Ancient Indian Medicine 152 WIM yeaq qpeap juejsuy yeep pue jyooqfoyur Jo ssoy “Teay quourayioxe — yeyuoUr sosned SAOGE Se oLeS syNsoy PeAourar st Joyuyds yr ynsex ACUI Yyeap osMIAIIO “Tosyt JO jNO suI0D 0} pamorfe 30 UPCWSr 0} Pamore st royuT|ds oy} Se BuO] se oyes sy our ‘ujerey paspoy kpoq, usraI0,7 Aint fo 1nsay peoy 9Y} Jo yorq amt We POyM-qey om Jo Joasy oY} Jnoge ye yoour ses ayy oroyM soovjd oy} ye 100 SH @Aoge pue TNys oy UIETA jeour afo ayy pue asou om} ‘Ie9 aM) ‘qynour oy} Wor savessed imoz oxy sroya. xuAreyd 043 Jo qpem Jorraysod pue saddn om) uO winner “BID Oy JO sommns cay ony. 80 aq} Jo y00r at} 38 sMoIq-ofe oy} Toamjog uonrlod Arey oy jo AapIog oy) 78 sofdma; oq eroge jods ouL uoyn207 T "W lypues y ‘Wiupueg Ss "Wi lqpueg T W Bg ZW nkeug daquinn P Sapo, pedpy. “eq eqewsang “cy emRWg “TT medemg ‘or uredaimn *6 Dudu ay} {o aunSurgery in Ancient India 153 Susruta gives detailed instructions as to the sites at which incisions are to be made in connection with some of the important marmas. An incision should be made at the spot of a finger’s width remote from the urvi, kircha-sira, vitapa, kaksa and parsva-marma ; whereas, a clear space of two fingers from it should be left in making any incision about the stanamula, mani- bandha or gulpha-marma. Similarly a space of three fingers should be left from the Ardaya, vasti, kiarcha, guda or nabhi marma ; and a space of four fingers from the four sringdtakas, five simanthas, and ten marmas of the neck ; a space of half a finger is the rule with the remaining 56. Men versed in the Science of surgery have laid down the rule that, in a surgical operation, the situation and dimension of each local marma should be first taken into, account and the incision made in a ‘way so as not to affect it, inasmuch as an incision which extends or affects the edge or side of the marma in the least may prove fatal. Hence all the marma-sthanas should be carefully avoided in a surgical operation. (S.S. III. 6. 81). A marma is a junction or meeting place of the five organic ‘structures, that is, of ligaments, blood vessels, muscles, bones and joints. Susruta thus explains the result of injury to the various marmas and links it to the tri-dhatu theory. The marmas belong- ing to the sadya-pranahara group are possessed of fiery virtues ; as these are easily enfeebled, they prove fatal to life (in the event of being injured in any way). Those belonging to the kalantara-pranahara group are fiery and lunar (cool) in their properties ; and as the fiery virtues are enfeebled easily and the cooling virtues only after a considerable time, the marmas of this group prove fatal in the long run (in the event of being injured in any way), if not instantaneously like the preceding ones. ‘The visalyaghna marmas are possessed of vataja properties (i.e., they arrest the escape of the vital vdyu) ; so long as the dart does not allow the vayu to escape from the injured interior, life is prolonged ; but as soon as the dart is extricated, the vayu escapes from inside the injury and this necessarily proves fatal. ‘The vaikalyakaras are possessed of saumya (lunar properties) and they retain the vital fluid owing to their steady and cooling virtues ; hence they tend only to deform the organism in the event of being hurt, instead of bringing on death. The rujakara marmas of fiery and vataja properties become extremely painful when injured inasmuch as both of them are pain-generating in their properties. Others, on the contrary, hold the pain to be the result of the properties of the five material components of the body (pancha-bhautika). (S.S. iii 6. 23).154 Ancient Indian Medicine But this opinion was not universally held and some authorities tried to explain the effects of injury on marmas by the varying composition of the latter. Taking the five varieties of effects, some assert that marmas, which are the firm union of the above~ mentioned five structures (ligaments, blood vessels, muscles, bones and joints) belong to the first group (sadya-pranahara) ; and that those which form the junction of four such, or in which there is one in smaller quantity, will prove fatal in the long run, if hurt or injured (Adlantara-pranahara). Those which are the junction of three such factors belong to the visalya-pranahara group ; those of two belong to the vaikalyakara group; and those in which only one exists belong to the pain-generating type (rujakara). (S.S. iii. 6. 24-25). There is no mystery about these marmas. From the results produced by injury it can easily be inferred that they are danger spots which surgery discovered during operations. They consist of arteries and veins, nerves, tendons and ligaments, and. bones and joints. The thoracic and abdominal marmas include in addition the intestines, the bladder, and the ducts such as the ureters, seminal vesicles, fallopian tubes, etc. We have seen that the marmas are divided into 5 distinct groups : fatal in 24. hours, within a fortnight or a month, as soon as a dart or any other imbedded foreign matter is extracted, or maiming and deforming, or painful, according as an injury produced the aforesaid results. The marmds are arteries, veins, nerves, ten- dons, and ligaments. A clear knowledge of the anatomy of the vascular system, the nervous system, the muscles, their origin and insertions, the ducts and their courses, would have enlighten- ed the surgeon as to what. artery, vein, nerve or duct he is likely to meet during the course of his operation. As we have seen, this knowledge was lacking. Indian physicians since the time of Susruta were convinced that anatomy securely based on autopsy dissection is requisite for true medical knowledge. In Practice, however, Indian anatomy was utterly unable to rise to the achievement one might have expected from the keen interest of surgeons in the structure of the human body. “The methodi- cal dissection of a well preserved corpse after the manner of modern research and training was excluded bythe tabus of religion in subtropical’ India. They had to have recourse to the most unsatisfactory method of dissection which was only possible under those conditions. The results to be gained by this sort of gently scrubbing asunder a soaked body on the verge of melting away, were exactly what one would expect from such an exami- nation of an object, preserved and decomposing at the same eo oe BeSurgery in Ancient India 155 time ; an almost perfect osteology, based on the bony structure left intact for unlimited inspection ; a fair enumerative know- ledge of the muscles, sinews and ligaments still sufficiently preserved ; but no real insight into the intricacies of the nervous system, the blood vessels, or into the exact course and purpose cf the various canals and organs essential for metabolism.” * What anatomy was expected to supply and did not, left no option to the surgeon but to rely on his own experience. A knowledge of the anatomy and physiology of the nervous and vascular systems would have dispelled all the mystery surrounding the marmas and made the task of the surgeon less hazardous and dangerous and more certain. The concept of marmas is the crystallisation of the wide experiences gained by the surgeons of the dangers and hazards of inadvertently cutting vital structures like the arteries, veins, nerves, tendons and ligaments. What anatomy failed to do for him, he out of his own experience mapped out with his theory of the marmas, the danger spots of the body. It is this that made the surgery of ancient India possible and enabled it to attain such an eminent position among the ancient civilizations. It has always been a matter of speculation how the ancients ever carried out major surgery in the absence of anaesthetics, haemostatics and antiseptics. “Surgical achievements are not inconsiderable among the primitive people; considering the paucity of anatomical knowledge, the boldness of operations undertaken is surprising. Foreign bodies are extracted and ab- scesses opened with thorns or other sharp pointed gbjects; in the treatment of wounds suction is employed, sometimes even a species of drainage by means of sections of bamboo; suture or tight bandaging, to promote union, is not unknown amongst some tribes. Stitching of small wounds is carried out by means ._ of thorns, which are used to transfix the edges of the incision, the ends being then wrapped round. Among some Indian tribes of Brazil it is customary to allow both edges of a wound to be seized by the sharp head-nippers of certain ants, whose bodies are then rapidly cut off; one ant after another: being used, the wound is closed. In the treatment of ulcers cauterisation with hot ashes, heated blades and irons are favourite methods. Arrest of haemorrhage presents great. difficulties to aborigines; for the most part they do not know how to attack it. It is sometimes brought about by means of vegetable and mineral styptics, less often it is attempted by means of circular pressure (tightly bound bandages). The treatment of dislocations is baséd upon no rational method, but we have astonishing reports of intelligence 14156 Ancient Indian Medicine with which fractures are set. Not only splints (of wood, bark and bamboo) are employed, but even immobilising apparatus, made of clay. Of operations the majority concern the sexual sphere. Circumcision, male and female ; and the Mika opera- tion (external urethrotomy from the orifice of the glans to the scrotum, in order to limit the progeny), the Caesarean section and ovariotomy, have all been performed by the primitive tribes. “Cupping, blood-letting, in various forms were widespread methods of treatment. Scarification was performed with thorns. Venesection was performed upon various veins with splinters of stone or knives. The instruments used were bone tubes, oxen or buffalo-horns for cupping, thorns, fish-bones, splinters of stone, mussel-shells, pieces of bone and glass or knives for scari- fication, splinters of stone or knives mounted or unmounted were used for venesection. Trephining and scraping of hollow bones were undertaken. Intoxication or stupefaction by narcotics and by hypnotism are the necessary preliminaries for severe measures. “The not infrequent successful outcome of such operations, done regardless of all antiseptic precautions, can only be explained by the supposition that the aboriginal races have a greater power of resistance against wound infection than highly civilized nations. “ Obstetrics, which lies almost exclusively in the hands of the women, shows a very variable stage of development in different races; thus among the Malays an attempt is made to rectify unfavourable positions of the foetus in utero, whilst in Cochin- China retained placenta is treated by trampling upon the abdo- men.” $ The above observations on the art of primitive surgery enable us to understand how the ancient Indians cultivated and perfected it within their available means and attained a very great profi- ciency in it. The range of their surgery was not wider than that of the primitives, but their methods were vastly improved, sup- plemented by newer knowledge and acquisitions. It is curious to note that no reference has been made in Indian surgical treatises to trephining. Susruta classifies surgical operations into eight different kinds: (1) excision (bhedya); (2) incision (chhedya) ; (3) scarification (lekhya) ; (4) puncture (vedhya) ; (5) probing (eshya) ; (6) extraction (Gharya) ; (7) Drainage or evacuation of fluids (visravya) ; and (8) suturing (sivya). ASS. I. 5, 4). A surgeon called upon to perform any of the above operations should equip himself with such accessories as surgical appliances -and instruments, viz., blunt instruments, cutting instruments,