The Student of Āyurveda (3c): Practical Knowledge

We have noted earlier both Caraka and Suśruta have stressed the importance of learning the theoretical and the practical aspects of the subject. It is said that Āyurveda must be studied first, and having done so, it is essential that the student should practice it. The king respects only such a physician who has mastered both.^[1]

Suśruta quotes an older verse to make his point more emphatic:

yastu kevalaśāstrajñaḥ karmasvapariniṣṭhitaḥ.
sa muhyatyāturaṃ prāpya bhīrurivāhavam.

One who possesses theoretical knowledge only and is not so expert in its practical application, gets bewildered when confronted with a patient, just as a coward (loses wits) in the battlefield.^[2]

One who has not observed practical demonstrations suffers from the lack of knowledge of practical application (karmasvapariniṣṭhitaḥ).

There is no actual description of a practical class in the Caraka Saṃhitā but the text gives an exposition on the ten factors that need to be examined by the physician before deciding on a course of therapeutic action:

1. kāraṇa (the cause), i.e., the physician;
2. karaṇa (the instrument), i.e., the medicaments;
3. kāryayoni (the source of action), i.e., disequilibrium of the doṣas;
4. kārya (the action itself), i.e., maintenance of equilibrium of the doṣas;
5. kāryaphala (the fruits of action), i.e., freedom from disease;
6. anubandha (subsequent manifestation), i.e., longevity;
7. deśa (habitat), i.e., both the locale where the patient resides and the body of the patient;
8. kāla (time), i.e., season of disease occurrence and the state of the disease;
9. pravṛtti (initiation), i.e., therapeutic action; and
10. upāya (means of action), i.e., excellence of the physician and correctness of the therapy.^[3]

It has commented that the examination of the ten topics was essentially a bedside exercise.^[4]

There is a detailed exposition on how each of the above items has to be examined in their specificity.^[5] For instance, the patient is examined in considerable detail with reference to his physical constitution (prakṛti), morbidity (vikṛti), condition of the dhātus or tissue elements (sāra), compactness of organs (saṃhanana), physical measurement (pramāṇa), homologation (sātmya), mental status (sattva), digestive power (āhāraśakti), capability to perform exercise (vyāyāmśakti) and age (vyayas) so as to determine his strength and the intensity of the disease. These factors along with the suitability of the time (including the season) and the state of the patient determine the nature and strength of therapy to be employed or not to be employed at all. The importance of these ten topics lay in the fact that whatever was learnt in the gurukula was complemented by the bedside experience in perfecting the training process.^[6] It must have mandatory for students of the Ātreya school to attend and practice the procedures of pañcakarma that are an essential component of Āyurvedic therapeutics.

The treatise of Suśruta, however, gives an interesting account of practical classes of experimental surgery (yogyā) for the medical student. Suśruta says that one who has not practiced experimental surgery remains incompetent in operations even though he may be well read.^[7] Practical lessons consist of demonstrations in surgical procedures of excision (chedya), incision (bhedya), scraping (lekhya), puncturing (vedhya), probing (esya), extraction (aharya), drainage (visravya), suturing (sivya), bandaging (bandhana), use of caustics and cautery, oleation,^[8] enema, irrigation, etc. It is immensely important for the medical student to work on his skills till he attains proficiency in these procedures.^[9] Besides, students also had to be acquainted with the 101 types of yantras (blunt instruments) and 20 types of saśtras (sharp surgical instruments).

It can only be expected that the two core subjects of medicine, anatomy and physiology, would be included in the curriculum. The physiological functioning of the human body and its correlation to the aetiology of disease has well elucidated in both our sources but anatomy has been given relatively greater importance in the Suśruta Saṃhitā. This is not unexpected considering that knowledge of anatomical structure and function is absolutely vital for a student of medicine surgery. Suśruta, in fact, claims that the importance of description of the structure of the human body and its parts is recognised and taught by the Dhanvantari school of surgery alone. Students of surgery are advised to thoroughly examine all parts of a cadaver through dissection.^[10] For the surgeon it is extremely important to know the location of the various organs so as to prevent injury during procedure.

The earliest body of anatomical knowledge is contained in the Vedic corpus. The sections of the exegetical Brāhmaṇas, which detail the horse-sacrifice, enumerate the anatomical parts of the animal. These texts have also preserved similar lists for humans as well. This understanding was developed further in the classical medical texts. The systematic arrangement of the anatomical data in the Suśruta Saṃhitā suggests a more scientific attitude towards the subject.^[11] It is evident that by the time of the composition of the surgical text, the systematization of anatomical knowledge was considerable. Kenneth G. Zysk comments, “The most impressive aspect of the earliest phase of anatomical knowledge is the precision with which the lists of anatomical terms are recorded.”^[12]

There are three ways by which anatomical knowledge could be obtained as Ludwig Edelstein suggests in the context of his study of ancient Greek anatomy: sacrifice, chance observations and dissection. This probably holds good in the Indian context too, though Zysk believes sacrificial practices played a key role in the accumulation of anatomical knowledge. However, the role of dissections on animal and human corpses in the enhancement of anatomical knowledge was probably substantial when we recall the prohibition imposed by Suśruta on medical study in cemeteries and slaughter-houses. We may assume that students were in the habit of visiting these places to procure corpses for dissections. Here, we have a word of caution from Suśruta himself forbidding medical students from regularly carrying out experiments there. It may also be noted that these are the only two places specifically prohibited in the surgical treatise.

As regards scientific dissection, Zysk is of the view that it was initiated in India only at a considerably later time, sometime after Alexander of Macedon set foot on its soil in 326 B.C, but his view has been contested. Bhattacharya refutes this argument for Āyurveda does not have any loan word from the Greeks for dissection; so the question of Hellenistic origin does not arise.^[13]

We have dealt with the details of experimental surgery and dissection in Chapter 9 of our thesis in the context of the training of the surgeon. It is significant that among the four sources of knowledge (pramāṇa) Suśruta gives precedence to direct observation (pratyakṣa) over authoritative texts (āgama), inference (anumāna) and analogy (upamāna)^[14] signifying the importance of practical work in surgery. As we have already noted in Chapter 2 Suśruta mentions that it is essential for the physician to observe the operations and perform them experimentally to become eligible to practice.

Footnotes and references:

[1]:

Suśruta Saṃhitā Sūtrasthāna 3.47.

[2]:

Suśruta Saṃhitā Sūtrasthāna 3.48.

[3]:

Caraka Saṃhitā Vimānasthāna 8. 68-78, 84.

[4]:

M.S.Valiathan, The Legacy of Caraka, p. lxxxiv.

[5]:

Caraka Saṃhitā Vimānasthāna 8.85-151.

[6]:

M.S.Valiathan, The Legacy of Caraka, p.lxxxiv.

[7]:

Suśruta Saṃhitā Sūtrasthāna 9.3.

[8]:

Suśruta Saṃhitā Sūtrasthāna 9.4.

[9]:

Suśruta Saṃhitā Sūtrasthāna 9.6.

[10]:

Suśruta Saṃhitā Śārīrasthāna 5.46-47.

[11]:

K.G. Zysk, “The Evolution of Anatomical Knowledge in Ancient India, with Special Reference to Cross-Cultural Influences”, Journal of American Oriental Society, 106.4, 1986, pp. 687-705.

[12]:

K.G. Zysk, “The Evolution of Anatomical Knowledge”, pp. 687-705.

[13]:

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

[14]:

Suśruta Saṃhitā Sūtrasthāna 1.16.