The training of the Surgeon

The most vital aspect of the surgeon‘s schooling training is acquiring dexterity and confidence in various procedures through practice. After the student has thoroughly mastered the interpretations of the entire scripture, instructions are given in practical methodology and he is required to practice experimental surgery (yogyā).^[1] The identification of different instruments, the correct method of handling them,^[2] the characteristics of good instruments,^[3] recognition of their defects,^[4] and testing of their sharpness^[5] are included in the practical curriculum. There are other aspects of handling surgical instruments: tempering the steel^[6] and maintaining the sharpness^[7] which the surgeon is also required to know. He also had to get them manufactured by the blacksmith according to specifications.^[8] Handling of the instruments correctly is emphasised and the surgeon who injures himself during procedures is rebuked by Suśruta.^[9]

The Milindapañha (VI.10) records the procedures that the student of surgery is taught: holding the lancet (satthagahana), cutting (chedana), curetting (lekhana), piercing (vedhana), extracting foreign bodies (salludharana), cleansing wound (vaṇadhovana), causing them to dry up (sosana), application of ointments (bheṣajānulimpana), as also administration of emetics, purges and oily enemas.^[10] The text also refers to the student undergoing a period of apprenticeship before attending to patients.

We have a good idea of how students practised their hand at various surgical procedures from the chapter entitled ‘yogyāsūtrīyamdhyāya’ of the Sūtra-sthāna in the Suśruta Saṃhitā. The procedure of excision or complete removal of a tissue or organ is demonstrated on various kinds of fruits of the gourd family, such as pumpkin, bottle gourd, water-melon, cucumber, eravāruka (Cucumis utilissimus or a variety of cucumber known as kakri), and karkāruka (Benicasa cerifera/ash gourd). For demonstrating the method of incision or making a cut in a tissue or an organ, a leather bag, urinary bladder of an animal or a leather bottle filled with water and slush are used. The appropriate material for scraping is hairy animal skin, and for puncturing animal corpses and lotus stalks. Hollow objects such as moth-eaten wood, bamboo, nala-nali (reed-tubes) and the mouth of a dried gourd are suitable for probing; while extraction is experimented on fruits having embedded seeds like jackfruit, bimbī (Coccinia grandis Linn.), the pulp of bilva or wood apple and on the teeth of dead animals.

A piece of śālmali or silk cotton wood is coated with beeswax is the chosen material for conducting experiments in drainage that is, removing pus, blood or fluids from wounds. The choice of silk cotton wood is interesting as experiments demonstrate it has high moisture content or water holding capacity.^[11] Students are taught to practice suturing on fine or thick cloths or soft leather and bandaging on cloth dummies. Practical demonstration of application of cautery and caustics is given on soft muscle pieces, and the corrective surgery of the external ear (karṇasandhibandhana) on soft leather, muscles and lotus stalks. An earthen pot with a side hole or a gourd is suitable for demonstrating the application of the enema nozzle and wound irrigation.^[12]

There is emphasis on repeated experimentations which alone can help the student to gain confidence and not lose his nerve during actual operations. The surgeon can devise his experiments on similar objects and it is recommended that such practice should continue even after he has entered the profession.^[13] The student without adequate practical work is declared by Suśruta to be unfit for the profession despite being well read (subahuśrutopyakṛtayogyaḥ karmasvayogyo bhavati).^[14]

For a surgeon it is absolutely essential to undertake a study of the human body in order to understand its structure and avoid injury to the vital parts of the body that could be fatal.^[15] Textual learning alone is considered inadequate and could in no way prepare a student for surgery. Suśruta recognises the importance of dissection and examination of the cadaver for an aspiring surgeon. It helps the student to clarify his doubts and supplement the textual with practical knowledge.

Thus it is said:

sarīre caiva śāstre ca syādviśaradaḥ.
dṛṣṭasrutābhyāṃ saṃdehamvāpohyācaret kṛyā.

“One can be considered an expert (surgeon) only when he is well versed in practical anatomy and in the knowledge of classical literature. Therefore, one should start the procedure (of surgery) after clearing away the doubts by actually seeing (the surgical anatomy concerned) and consulting (the appropriate literature).”^[16]

An examination of all parts of the dead body after its proper preparation (avagharśana) is considered essential for an exact knowledge of surgery by Suśruta.^[17] The method of preparation and dissection of cadavers is described in the treatise. First a corpse in satisfactory condition, that is with all the body parts intact, had to be procured. Victims of mutilation or poisoning, patients of chronic ailments and the very old (according to the text those who had attained a hundred years) are not suitable for dissection. As we had noted in Chapter 3, medical students possibly procured corpses from the cemeteries. After the faecal matter is removed from the intestines, the cadaver, is wrapped in muñja grass, tree bark, kuśa grass or flax. It is then placed in a cage and immersed in slow flowing water to decompose in an unlighted area. After seven nights, it is removed from the cage and rubbed with a brush made of either uśīra (the fragrant root of Andropogon Muricatus), hair, bamboo or balvaja (a species of coarse grass, Eleusine Indica). All the external and internal parts are then carefully examined.^[18]

According to K.L.Bhishagratna, Suśruta‘s avagharśana is now considered by many as the only perfect mode of dissection ever known.^[19] However, such procedure had its limitations for it has been pointed out that it could only produce skeleton, bones, tendons and muscles before a naked eye.

“It was not possible to get into the interiors of the body and gain knowledge about visceral anatomy.”^[20]

We may conjecture a word that corpses were possibly procured from the charnel grounds for dissection. It is known from the early Buddhist texts that dead bodies of ordinary persons were disposed of in a cemetery (sīvathikā or āmakasusāna) unlike deceased persons of distinction or public teachers who were cremated.^[21] Dismembered and cut up corpses were to be found in battlefields, in forests where kings slaughtered robbers or wild animals took the life of men as well as and on charnel grounds.^[22] The term āmakasusāna refers to a spot in the charnel ground where corpses are thrown to be eaten by wild animals.^[23] Such uncremated corpses would have been sought by students and teachers of surgery and as we have noted in Chapter 3, the cemetery is one of the places where studies is prohibited by Suśruta. It is known from Buddhist texts that experiments in dead bodies were undertaken.^[24] The Rāmāyaṇa (Ayodhyākāṇḍa 66.14-16),^[25] Viṣṇupurāṇa^[26] and the Aṅguttaranikāya^[27] contain references to the preservation of the dead in oil and fragrant substances.

Handling of corpses certainly did not meet with the approval of the legists and the Dhanvantari school of physicians would be well aware of defilement and ritual pollution incurred by working with decaying cadavers. According to Vasiṣṭha Dharmasūtra (23.24-25) touching a human bone with soft tissue attached to it causes impurity for three days; but if there is no soft tissue attached to it, then period of impurity is a day and a night.^[28] Baudhāyana (1.11.32-33) says that if someone accidentally touches the corpse of an outsider, he becomes pure after immediately taking a bath with his clothes on; whereas if he does so deliberately, he remains impure for three for three days.^[29] Basham suggests that it would have been theoretically possible for the vaidya to hire the untouchables to work as executioners and cremation attendants to dissect the corpses for him^[30] to avoid physical contact with cadavers. Nevertheless, it is in the background of the social disapproval that this school of physicians had to build up a case in favour of dissection of cadavers.

The actual observation of the body parts, internal and external as described in the text, has been emphasised by Suśruta.^[31] In the mind of the author, it would be deficient for a student to know the various body parts and their locations only from a text book.^[32] It is also remarkable that the authors are in no way apologetic about this recommendation, and neither is there an attempt to seek exculpation through performance of purification rites.

Zysk has drawn our attention to the penultimate verse of the chapter on anatomy in the Suśruta Saṃhitā that appears to sanction the use of the body for scientific purposes, which says:

“It is not possible to perceive the pervading and subtlest consciousness (vibhu) in the body with the eye. It is only possible to see the same by the eyes of knowledge and by the eyes of penance”.^[33]

Thus, the body contains a fundamentally sacred part which is invisible but at the same time, it is implied, that scientific observation of the body will never reveal its most subtle part. As he never comes in contact with the sacred, the physician has no fear of retribution for his action.^[34]

Footnotes and references:

[1]:

Suśruta Saṃhitā Sūtrasthāna 9.3.

[2]:

Suśruta Saṃhitā Sūtrasthāna 8.5.

[3]:

Suśruta Saṃhitā Sūtrasthāna 7.20; 8.8.

[4]:

Suśruta Saṃhitā Sūtrasthāna 7.19; 8.9.

[5]:

Suśruta Saṃhitā Sūtrasthāna 8.14.

[6]:

Suśruta Saṃhitā Sūtrasthāna 8.12.

[7]:

Suśruta Saṃhitā Sūtrasthāna 8.13.

[8]:

Suśruta Saṃhitā Sūtrasthāna 8.19.

[9]:

Suśruta Saṃhitā Sūtrasthāna 25.41.

[10]:

J.Mitra, History of Indian Medicine from Pre-Mauryan to Kuṣāṇa Period, Varanasi, 1974, p.16.

[11]:

P.K. Aggarwal, et al., “Water Repellent Treatments for Catamaran Grade Bombax Ceiba Linn. (Spermatophyta/Dicotyledoneae) Wood” Indian Journal of Marine Sciences, Vol. 32(4), Dec. 2003, pp.340-343.

[12]:

Suśruta Saṃhitā Sūtrasthāna 9.4.

[13]:

Suśruta Saṃhitā Sūtrasthāna 9.5-6.

[14]:

Suśruta Saṃhitā Sūtrasthāna 9.3.

[15]:

Suśruta Saṃhitā Sūtrasthāna 25.33.

[16]:

Suśruta Saṃhitā Śārīrasthāna 5.51.

[17]:

Suśruta Saṃhitā Śārīrasthāna 5.47.

[18]:

Suśruta Saṃhitā Śārīrasthāna 5.49.

[19]:

J. Bhattacharya, “Encounter in Anatomical Knowledge: East and West”, in Indian Journal of History of Science, 43.2 (2008), pp. 163-209.

[20]:

J. Bhattacharya, “Encounter in Anatomical Knowledge”.

[21]:

T.W.Rhys Davids, Buddhist India, Delhi, 1997 (Reprint), pp.78-80.

[22]:

Bhikkhu Nānamoli (translated from Pāli), Visuddhimagga: The Path of Purification, Kandy, 2011, VI.72.

[23]:

A.P.B.Mahathera, Concise Pali-English Dictionary. Electronic source: Accessed at http://www.budsas.org/ebud/dict-pe/dictpe-02-aa.htm on 26.12.2014.

[24]:

K. Upreti, India as Reflected in the Divyāvadāna, New Delhi, 1995, p.77; S. Das, Surgical Heritage of Early India in S. Das, Medical Heritage of Early India: An Anthology, Kolkata, 2014, p. 153.

[25]:

P.V. Kane, History of the Dharmaśāstra, Vol. IV, Poona, 1941, p. 233-234.

[26]:

P.V. Kane, History of the Dharmaśāstra, Vol. IV, pp.233-234.

[27]:

J. Mitra, A Critical Appraisal of Āyurvedic Material in Buddhist Literature with special reference to Tripiṭaka, Varanasi, 1985, p. 65.

[28]:

P. Olivelle, annotated text and translation Dharmasūtras: The Law Codes of Āpastamba, Gautam, Baudhāyana and Vasiṣṭha, Delhi, Reprint 2003.

[29]:

P. Olivelle, Dharmasūtras.

[30]:

A.L.Basham,., “The Practice of Medicine in Ancient and Medieval India,” in Charles Leslie, (ed.), Asian Medical Systems: A Comparative Study, 1976, p.28.

[31]:

Suśruta Saṃhitā Śārīrasthāna 5.49.

[32]:

K.G.Zysk, ‘Some Observations on the Dissection of Cadavers in Ancient India’, Ancient Science of Life, Vol.2 (4), 1983 (April-June), pp.187-189.

[33]:

Suśruta Saṃhitā Śārīrasthāna 5.50.

[34]:

K.G.Zysk, ‘Some Observations on the Dissection of Cadavers in Ancient India’, pp.187- 189.