The Greatest Benefit to Mankind: A Medical History of Humanity. Roy Porter

the way to extract arrowheads and splinters, suturing, and the examination of human corpses as part of the study of anatomy. The text maintains that surgery is the oldest and most useful of the eight branches of medical knowledge, and elaborate surgical techniques are described. However, there is little evidence to confirm that these practices persisted. A description of the couching operation for cataract exists in the ninth-century Kalyanakaraka by Ugraditya, and texts based on the Susruta Samhita copy out the sections on surgery with other material. But medical texts give no evidence of any continuous development of surgical thinking; no ancient or even medieval surgical instruments survive; nor is surgery described in literary or other sources. A parallel may be found in the apparent fate of surgery within the Islamic tradition.

      One possible explanation for this apparent waning of surgery is that, as the caste system grew more rigid, taboos concerning physical contact became stronger and, a little like Hippocratic doctors, vaidyas may have shunned therapies which involved applying the knife to the body, transferring their attention to less intrusive approaches, including examination of the pulse and the tongue. Whatever the reasons, the early sophistication of surgical knowledge seems to have been an isolated phenomenon in the development of the Indian medical tradition.

      There is, however, one well-documented historical event which suggests that surgery akin to the Susruta Samhita remained widely known. In March 1793, an operation was undertaken in Poona of significance for the later course of plastic surgery. A Maratha named Cowasjee, a bullock driver with the English army, having been captured by Tipu Sultan’s forces, had his nose and one hand cut off – a customary punishment for adultery. He turned to a man of the brickmakers’ caste to have his face repaired. Thomas Cruso (d. 1802) and James Trindlay, surgeons in the Bombay Presidency, witnessed this operation, publishing in 1794 an account of what they had seen, with an engraving of the patient and diagrams of the skin-graft procedure. The obscure brick-maker, reported the English surgeons, had performed a superb skin-graft and nose reconstruction using a technique superior to anything they had ever seen. It was taken up in Europe and became known as the ‘Hindu method’.

      This may seem to be proof of the persistence of Susruta’s surgery during the course of well over a thousand years, but there are puzzling elements to the tale – notably the fact that rhinoplasty of this kind is not delineated in any detail in the Susruta Samhita. Furthermore, as a member of the brickmakers’ caste, the surgeon who performed the Poona operation was not himself a vaidya. He probably knew no Sanskrit: his skill lay in his hands, not in his head. It is conceivable that this represents a survival of a procedure from Susruta’s time, but if so it seems to have been passed down independently of the practice of educated physicians. There is no evidence from other written sources of the practice of such operations in the intervening period.

      A similar puzzle is posed by smallpox. Before the nineteenth century, inoculation was popular knowledge and widely used for protection against the disease, with the expectation that a mild episode would follow. After the graft the patient was kept quarantined in a controlled environment. A detailed account by an English surgeon, dating from 1767, describes the practice and states that it was widespread in Bengal. No trace of inoculation appears, however, in any Sanskrit medical text. The disease was undeniably identified in Ayurvedic writings, where it is called the ‘lentil’ disease, but again the link between theory and practice is tenuous. It seems that techniques recorded in texts, though still related in the learned tradition, fell into disuse, while new developments were widely practised without being inscribed in approved medical learning.

      In this light it is easy to fall into the trap of assuming that the Ayurvedic tradition was static and ‘timeless’ – that later texts did no more than to elaborate a coherent and comprehensive set of teachings set out, once and for all, in the Caraka Samhita and the Susruta Samhita. This supposition is given some support by the fact that these two texts do present themselves as unchanging bodies of knowledge; moreover, it is in line with native and foreign stereotypes of India as the fountain-head of eternal truths. But while the canonical texts present the appearance of homogeneity, research into the development of Sanskrit Ayurvedic literature has revealed that numerous authors dissented from orthodox viewpoints. In the course of time new diseases were reported and identified. From the sixteenth century syphilis (known as ‘foreigners’ disease’ in Sanskrit) was described in texts (mercury, brought to India by Islamic physicians, was used to treat it); and from the eighteenth century writings embraced disease descriptions evidently borrowed from western medicine.

      There were also innovations in diagnostics. Close attention to urine, and techniques for its inspection, stem from the eleventh century. Before the thirteenth century there is no mention of pulse examination in Sanskrit texts, but it subsequently developed into a key diagnostic method. A technique called ‘examination of the eight bases’ (astasthanapariksa) – the routine diagnostic method for examining the patient’s pulse, urine, faeces, tongue, eyes, general appearance, voice and skin – emerged in the sixteenth century. Novel prognostic techniques also came into use. For example, from about the same time, a procedure was taught whereby a bead of oil was dropped on the surface of a patient’s urine. The remaining span of his life was read from the way the oil spread.

      In therapy, a discernible shift lay in the rise of standardized compound medicines (yoga). Consisting of a large number of ingredients, yoga is regularly described in terms of its specific effectiveness against a particular ailment; this brings into question the conventional western view that Ayurvedic medicine was invariably holistic.

      Though Ayurveda is the most familiar tradition of indigenous Indian medicine, others have flourished in the subcontinent, notably the Siddha system of the Tamils and the Yunani medicine of Islam. Other assorted therapies are also visible, from folk medicine and shamanism to faith-healing and astrology.

      In south India, the form of medicine evolved in the Tamil-speaking areas was dissimilar in certain aspects to Ayurveda. Known as Siddha medicine (Tamil: cittar), this was basically an esoteric magical and alchemical system, presumably heavily influenced by tantric ideas. It was characterized by a greater use of metals, in particular mercury, than in Ayurveda, and prized a substance called muppu, credited with possessing great powers for physical and spiritual transformation. Pulse taking was highly valued for diagnosis. The semi-legendary founders of Siddha medicine include Bogar, who is said to have journeyed to China, teaching and learning alchemical lore, and Ramadevar, who supposedly travelled to Mecca, teaching the Arabs the arts of alchemy.

      From earliest times, Ayurvedic medicine handled and treated a range of children’s maladies, blaming them on the evil influence of celestial demons (graha, seizer), believed to attack children. The Sanskrit term graha was subsequently used to mean ‘planet’, and although grahas are clearly described as celestial beings in the Susruta Samhita, later rites for planetary propitiation are targeted at the same types of influence. Indian astrology and religious ordinances contain texts for placating heavenly bodies, as well as astrological prognostications regarding such matters as pregnancy and the sex of unborn children, dream interpretation, sickness and death. According to an early and significant legal work, ‘one desirous of prosperity, of removing evil or calamities, of rainfall [for farming], long life, bodily health and one desirous of performing magic rites against enemies and others should perform sacrifice to planets.’

      A work exemplifying the close relationship between medicine and astrology as therapeutic systems is the Virasimhavaloka by Virasimpa, written in AD 1383, probably in Gwalior. It deals with diseases from three points of view: astrology, religion, and medicine. The body parts are matched to the constellations and planets in an intricate scheme of influences and associations, and it is the astrologer’s task to read this pattern of symbols to understand the patient’s problem before advising remedies such as charms, expiations, prayers and herbs.

      The Bower manuscript, one of the oldest surviving Indian works, contains a text on divination by dice. It reveals the outlook of a fifth-century healer interested in the therapeutic powers of garlic, in elixirs for eternal life, in the treatment of eye diseases, herbal medicines, butter decoctions, aphrodisiacs, oils, the care of children, and spells against snake-bites, as well as divination.