SURGERY, ANATOMY, AND DISSECTION | Kickoff

SURGERY, ANATOMY, AND DISSECTION

11 May

Perhaps  the  most  striking  aspect  of ancient  Indian  medicine  was the range of surgical interventions and  the level of success claimed by the disciples  of  Susruta   and  Caraka. Vedic  myths  speak  of  remarkable operations on  men  and  gods,  such  as a cure  for  impotence  achieved by transplanting the testes of a ram  to the afflicted god Indra.  Ayur- vedic texts describe more  prosaic  but  still formidable  operations such as cesarean  section,  lithotomy  (removal  of bladder  stones),  couching the cataract, tonsillectomy,  amputations, and plastic surgery. Thus, the Ayurvedic surgical tradition offers an interesting  challenge to Western assumptions  that  systematic  human  dissection,  animal  vivisection, and the rejection of humoral  pathology  are essential for progress in surgery. In  ancient  India,  surgeons  mastered  many  major  operations without these supposed  prerequisites.

While the therapeutic use of the knife was accepted  in India,  for the upper castes contact  with cadavers and use of the knife on the dead were prohibited by custom  and  religion.  Nevertheless,  Susruta  taught that physicians and surgeons must study the human body by direct observation in order  to gain essential knowledge  of the structure  and function of its parts. While acknowledging religious prohibitions against contact  with dead bodies,  Susruta  justified the study of anatomy—the science of being—as a form of knowledge linked to higher phenomena, including the relationship  between humans  and gods.

Ingeniously working his way around religious prohibitions against the use of the knife on dead bodies, Susruta  proposed  an unusual  form of  anatomical investigation.  If  a  body  was complete  in  all its  parts, neither too old nor too young, and if death had not been caused by pro- tracted  illness or poison,  it was suitable for dissection.  After removing the excrements from the intestines, the anatomist should cover the body with grasses, place it in a cage made of fine mesh, and leave it to steep in a quiet  pond.  Seven days later  the anatomist could  gradually  remove successive layers of skin and  muscle by gently rubbing  the body  with soft  brushes.  According  to  Susruta,   this  process  rendered  the  most minute parts of the body distinct and palpable.  There is, however, little evidence that teachers of Ayurvedic medicine followed Susruta’s prescription  for human  dissection.

One aspect of human  anatomy  that  all students  were expected to have mastered  was the complex  system of ‘‘vital points,’’ or  marmas, distributed  throughout the body. The marmas appear  to be sites where major  veins, arteries,  ligaments,  joints,  and  muscles unite  and  where injuries  are  likely to  be  incapacitating or  fatal.  The  classical  system included  107 points,  each  of  which  had  a  specific name  and  special properties.  When examining an injured patient,  the physician’s first task was to determine whether a wound corresponded to one of the marmas. If injury to a marma would lead to death,  the surgeon might amputate the limb at an auspicious  site above the marma. In venesection, or any form of surgical intervention, the surgeon had to avoid damage  to the marmas.

Bleeding and cauterization were among  the most routine  surgical operations. Cauterization, Susruta  taught,  was the  method  of choice for treating  hemorrhages and diseases that  resisted medicinal remedies. Moreover,  he believed that  the healing properties  of the actual  cautery (red-hot  irons)  were vastly superior  to  those  of the  potential  cautery (chemically  induced  burns).  Bloodletting  was considered  an  excellent remedy, but it had to be done cautiously  because blood was the source of strength,  vitality,  and  longevity. Leeching was recommended  as the most propitious form of bleeding, because leeches were thought to have a preference for vitiated  blood  rather  than  healthy  blood.

According to Susruta,  all surgical operations could be described in terms of their most basic techniques.  That is, all operations were varia- tions  on  excising, incising,  probing,  scarifying,  suturing,  puncturing, extracting solid bodies, and evacuating fluids. Preparations for any sur- gical operation were exacting, involving special attention to the patient, the operating  room,  and  the ‘‘one hundred  and  one’’ surgical  instru- ments. One reason  for the large number  of surgical tools was the pref- erence for  instruments  resembling  various  animals.  If the  lion-mouth forceps did not fit the task,  the surgeon  could try the hawk, heron,  or crocodile-mouth  version.   Surgeons   also  needed   tables   of  different shapes  and  sizes for  particular operations and  a  ‘‘fracture-bed’’  for stretching  fractured  or  dislocated  limbs. Above  all, the surgeon  must see to it that the room used for surgery was carefully prepared  to insure cleanliness and comfort.

Medical  care  of pregnant  women  encompassed  efforts  to  ensure male  offspring,  management of  diet,  easing  the  pains  of  labor,  safe delivery, and the postnatal care of mother  and child. Normally,  child- birth  was managed  by midwives, but  in difficult deliveries, a surgeon might be needed to perform  operations in which the fetus was turned, flexed, mutilated,  or destroyed.  If natural delivery was impossible, or if the mother  died in childbirth,  Susruta  recommended  cesarean  section. Certain  signs foretold  the outcome  of pregnancy.  If, for example, the mother  was  violent  and  bad-tempered, the  child  might  be  epileptic, while the child of an alcoholic woman would suffer from weak memory and constant  thirst.  Failure  to gratify the wishes of a pregnant  woman might cause the child to be mute, lame, or hunchbacked. A malformed child might  also be the result  of misdeeds in a prior  life, physical  or emotional  injury to the mother,  or an aggravated condition  of the three humors.

Indian  surgeons apparently developed techniques  for dealing with the major  problems  of surgery, that  is, pain and infection.  Fumigation of the sickroom and the wound before surgery in the pursuit  of cleanli- ness might have reduced the dangers  of infection,  but the effectiveness of such techniques is an open question. Claims that the ancients had dis- covered potent  and reliable anesthetic agents are likely to be somewhat exaggerated,  since both Caraka and Susruta  recommended  wine before surgery to prevent fainting and afterwards to deaden pain. In some cases, patients  had  to  be bound  hand  and  foot  in preparation for  surgery. Burning  Indian  hemp  (marijuana) may  have  released  narcotic  fumes, but  references  to  drugs  called  ‘‘producer  of  unconsciousness’’  and ‘‘restorer of life’’ remain obscure.

The Susruta  Samhita  describes many difficult operations, such as couching  the cataract, lithotomy,  opening  the chest to drain  pus, and the repair  of torn  bellies and  intestines.  Various  kinds  of threads  and needles were used for closing wounds, but when the intestines were torn, large  black  ants  were recommended  as  wound  clips. Plastic  surgery, especially the art  of reconstructing noses, lips, and ears, was probably the most remarkable aspect of the Indian  doctor’s achievements. Noses and ears were at risk among Indian warriors, who worked without protec- tive masks or helmets, and among the general run of sinners and criminals. In India,  as in Mesopotamia, justice was meted out by mutilation and amputation. Even those who led peaceful, blameless lives might need a plastic surgeon. For example, earlobes were sometimes stretched beyond endurance by the large, heavy earrings worn to ward off misfortune.

Repairs of noses, lips, and ears were made with the ‘‘sensible skin-flap’’ technique.  Using a leaf as his template,  the surgeon  would tease out  a  patch  of  ‘‘living flesh’’ (now  called  a  pedicle  flap)  from  the patient’s cheek or forehead in order to create a new nose. After scarify- ing the patch, the physician quickly attached  it to the site of the severed nose and covered the wound with an aesthetically pleasing bandage. Because a pedicle flap used as a graft must remain attached  to its origi- nal site, the free end can only be sewn to an area within easy reach. After the graft had grown attached  to the new site, the base of the flap was cut free. If the surgeon had superb skill, steady hands, and sharp razors, the operation could be completed  in less than  two hours.

During  the nineteenth  century,  British  colonialism  gave Western doctors  the opportunity to  investigate  traditional Indian  medical  and surgical practices.  While working  at the Madras  Ophthalmic  Hospital in  the  1910s, Dr.  Robert   Henry  Elliot  assembled  a  collection  of  54 eyeballs in a study  of the Indian  operation for cataracts.  Elliot  found evidence of  many  serious  complications,   but,  since all the  eyes were collected from  blind patients,  these cases represented  only the failures of traditional surgeons.  Unfortunately, Elliot  never observed  a tradi- tional  practitioner at  work,  but  his  informants claimed  that  practi- tioners often told the patient  that surgery was unnecessary. Then, while pretending  to examine the eye, the operator suddenly  pushed  a needle through  the cornea  and detached  the lens. Immediately  after the oper- ation,  the surgeon  tested  the patient’s  vision, bandaged  the eyes, col- lected  his fees, and  advised  the  patient  to  rest  for  at  least  24 hours. Scornfully,   Elliot   noted   that   this   would   allow   the   operator  to disappear  before the outcome  of the case could be ascertained.

Although  cleanliness was a major precept for Susruta  and Caraka, Elliot  claimed  that  it was of no  concern  to  contemporary traditional practitioners. Moreover,  unscrupulous practitioners recklessly operated on patients  suffering from optic atrophy or glaucoma  rather  than  cata- ract.   Reports   by  colonial   observers   might   provide   some  valuable insights  into  traditional Indian  surgical  practices,  but  these  accounts cannot  be directly related to the ancient Indian  science of life. The wan- dering empiric, crudely performing  illegal operations in the shadow  of colonial power, had only the most tenuous links to the scholarly practi- tioners envisioned by Susruta  and Caraka.

Unfortunately, although  in theory India has a vast primary  health care  system,  with  public   clinics  for  every  three   thousand  to  five thousand people,  the  clinics are  often  closed  because  of  the  lack  of doctors,   nurses,  medicines,  safe  water,  and  electricity.  Villagers  are forced  to  rely on traditional healers  and  private  ‘‘doctors’’ who have no formal  medical training.  Such healers give injections  of antibiotics and intravenous glucose drips, despite the lack of sterile equipment.

Western science and medicine have won a place in India, but Ayur- vedic medicine  and  religious  healing  traditions still bring  comfort  to millions of people suffering from physical and mental illnesses. In much of rural  India  today,  treatment for mental illness is more likely to take place in a traditional ‘‘healing temple’’ than in a clinic or hospital. When Western-trained psychiatrists evaluated patients treated at such temples, they found some cases of paranoid schizophrenia,   delusional disorders, and manic episodes. After an average stay of five weeks, many patient had improved significantly, as measured on a standard psychiatric rank- ing. Psychiatrists  attributed the improvement  in symptoms  to cultural factors,   expectations,   and   the  temple’s  supportive,   nonthreatening, and reassuring  setting.

As demonstrated by the popularity of health spas and resorts featur-ing traditional Ayurvedic  principles  of health,  healing,  and  nutrition, Ayurvedic concepts have now reached a global audience. Instead of dismissing Ayurveda as ‘‘mere superstition,’’ scholars in India are finding valuable  medical  insights  and  inspiration   in  the  ancient  texts.  Like students of traditional Chinese medicine, followers of Ayurveda see their ancient traditions as a treasure-house of remedies and healing practices. Indeed, at the end of the twentieth  century, there were more than 6,000 licensed Ayurvedic pharmacies in India, about 1,500 Ayurvedic hospitals, and  over 100 Ayurvedic  colleges registered  in the New Delhi  Central Council of Indian  Medicine. The Council continues to issue regulations that  govern  Ayurvedic education  for undergraduate and  postgraduate students.

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