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.