SUSHRUTA :

The Sushruta samhita is in two parts, the Purva-tantra in five sections and the Uttara-tantra. Those two parts together encompass, apart from Salya and Salakya, the other specialities like medicine, pediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs and psychiatry. Thus the whole Samhita, devoted as it is to the science of surgery, does not fail to include the salient portions of other disciplines too. In fact, Sushruta emphasises in his text that unless one possesses enough knowledge of relevant sister branches of learning, one cannot attain proficiency in one's own subject of study. The Samhita is thus an encyclopaedia of medical learning with special emphasis on Salya and Salakya. The Sutra-sthana, Nidana-sthana, Sarira-sthana, Kalpa-sthana and Chikitsa-sthana are the five books of the Purvatantra containing one hundred and twenty chapters. Incidentally, the Agnivesatantra known better as the Charaksamhita and the Astangahrdaya of Vagbhata also contain one hundred and twenty chapters in all. The Nidana-sthana gives the student the knowledge of aetiology, signs and symptoms of important surgical diseases and those ailments, which have a bearing on surgery. The rudiments of embryology and anatomy of human body along with instructions for venesection (cutting of veins), the positioning of the patient for each vein, and protection of vital structures (marma) are dealt with in the Sarira-sthana. This also includes the essentials of obstetrics. Principles of management of surgical conditions including obstetrical emergencies are contained in the Chikitsa-sthana, which also includes a few chapters on geriatrics and aphrodisiacs. The Kalpa-sthana is mainly Visa-tantra, dealing with the nature of poisons and their management. Thus the Purva-tantra embraces four branches of Ayurveda. The Uttara-tantra, contains the remaining four specialities, namely Salakya, Kaumarabhrtya, Kayacikitsa and Bhutavidya. The entire Uttara-tantra has been called Aupadravika since many of the complications of surgical procedures like fever, dysentery, cough, hiccough, krmi-roga, pandu, kamala, etc., are briefly described here. The Salakya-tantra portion of the Uttara-tantra contains various diseases of the eye, the ear, the nose and the head. Thus the whole Samhita is one comprehensive treatise on the entire medical discipline.

Sushruta

On the whole, the entire Samhita is a complete work on medicine with special attention to Salya and Salakya tantras. The succinct and sombre style and the overall superiority of the Sushrutasamhita led to the extinction of other treatises which preceded this compilation or were contemporary. As a text-book, it is unrivalled in respect of composite teaching of the subject of surgery with reference to all allied branches of medical learning required by a surgeon. It is a forerunner of Vagbhata's Astanga-sangraha.

Sushruta has pointed out that haemorrhage can be arrested by apposition of the cut edges with stitches, application of styptic decoctions, by cauterisation with chemicals or heat. That the progress of surgery and its development is closely associated with the great wars of the past is well known. The vrana or injury, says Sushruta, involves breakdown of body-components and may have one or more of the following seats for occurrence, viz., skin, flesh, blood-vessels, sinews, bones, joints, internal organs of chest and abdomen and vital structures. Classically vrana, the wound, is the ultimate explosion of the underlying pathological structure. It is, in Sushruta's words, the sixth stage of a continuous process, which starts with sotha (inflammation). Sushruta says that in the first stage, the ulcer is unclean and hence called a dusta-vrana. By proper management it becomes a clean wound, a suddha-vrana. Then there is an attempt at healing and is called ruhyamana-vrana and when the ulcer is completely healed, it is a rudha-vrana. Sushruta has advocated the use of wine with incense of cannabis for anaesthesia.^[3] Although the use of henbane and of Sammohini and Sanjivani are reported at a later period, Sushruta was the pioneer of anaesthesia.

Sushruta describes eight types of surgical procedures: Excision (chedana) is a procedure whereby a part or whole of the limb is cut off from the parent. Incision (bhedana) is made to achieve effective drainage or exposure of underlying structures to let the content out. Scraping (lekhana) or scooping is carried out to remove a growth or flesh of an ulcer, tartar of teeth, etc. the veins, hydrocele and ascitic fluid in the abdomen are drained by puncturing with special instrument (vyadhana). The sinuses and cavities with foreign bodies are probed (esana) for establishing their size, site, number, shape, position, situation, etc. Sravana (blood-letting) is to be carried out in skin diseases, vidradhis, localised swelling, etc. in case of accidental injuries and in intentional incisions, the lips of the wound are apposed and united by stitching (svana).

To obtain proficiency and acquiring skill and speed in these different types of surgical manipulations, Sushruta had devised various experimental modules for trying each procedure. For example, incision and excision are to be practised on vegetables and leather bags filled with mud of different densities; scraping on hairy skin of animals; puncturing on the vein of dead animals and lotus stalks; probing on moth-eaten wood or bamboo; scarification on wooden planks smeared with beeswax, etc. On the subject of trauma, Sushruta speaks of six varieties of accidental injuries encompassing almost all parts of the body.

Sushruta also gives classification of the bones and their reaction to injuries. varieties of dislocation of joints (sandhimukta) and fractures of the shaft (kanda-bhagna) are given systematically. He classifies and gives the details of the six types of dislocations and twelve varieties of fractures. He gives the principles of fracture treatment, viz., traction, manipulation, appositions and stabilisation. Sushruta has described the entire orthopaedic surgery, including some measures of rehabilitation, in his work.

As war was a major cause of injury, the name Salya-tantra for this branch of medical learning is derived from Salya, the arrow of the enemy, which in fights used to be lodged in the body of the soldiers. He emphasises that removal of foreign bodies is fraught with certain complications if the seat of the Salya be a marma.

Sushruta also discusses certain surgical conditions of ano-rectal region, he has given all the methods of management of both haemorrhoids and fistulae. Different types of incision to remove the fistulous tract as langalaka, ardhalangalaka, sarvabhadra, candraadha (curved) and kharjurapatraka (serrated) are described for adoption according to the type of fistula.

Sushruta was well aware of the urinary stones, their varieties; the anatomy of urinary bladder along with its relations is well recorded in the chapter on urinary stones. Varieties of stones, their signs and symptoms, the method of extraction and operative complication are given in detail. Apart from the above, surgery of intestinal obstruction (baddha-gudodara), perforated intestines (chidrodara), accidental injuries to abdomen (assaya-bhinna) in which protrusion of omentum occurs are also described along with their management.

Though the contributions of Sushruta are mainly in the field of Plastic and Cataract surgery,^[1] a number of his other contributions to medicine are listed below:

Plastic Surgery

Sushruta lays down the basic principles of plastic surgery by advocating a proper physiotherapy before the operation and describes various methods or different types of defects, viz., (1) release of the skin for covering small defects, (2) rotation of the flaps to make up for the partial loss and (3) pedicle flaps for covering complete loss of skin from an area. He has mentioned various methods including sliding graft, rotation graft and pedicle graft. Nasal repair or rhinoplasty has been described in greater detail, which to this day has stood the test of time and is mentioned as the Indian method of rhinoplasty in the books of plastic surgery. Lastly, labioplasty too has received his attention. In short, all the principles of plastic surgery, viz., accuracy, precision, economy, haemostasis and perfection find an important place in Sushruta's writings on this subject.

list of ancient doctors in India.

CHARAK :

Charak, sometimes spelled Caraka, born c. 300 BC in a Maga Brahmin family was one of the principal contributors to the ancient art and science of Ayurveda, a system of medicine and lifestyle developed in Ancient India. He is sometimes referred to as the Father of Anatomy.

Acharya Charak & Ayurveda

The term Caraka is a label said to apply to ‘wandering scholars’ or ‘wandering physicians.’ see Charaka Samhita.

According to Charaka's translations health and disease are not predetermined and life may be prolonged by human effort and attention to lifestyle. As per Indian heritage and science of Ayurvedic system, prevention of all types of diseases have prominent place than treatment, including restructuring of life style to align with the course of nature and four seasons, which will guarantee complete wellness.

The following statements are attributed to Acharya Charak:

A physician who fails to enter the body of a patient with the lamp of knowledge and understanding can never treat diseases. He should first study all the factors, including environment, which influence a patient's disease, and then prescribe treatment. It is more important to prevent the occurrence of disease than to seek a cure.

These remarks appear obvious today, though they are often not heeded, and were made by Charaka, in his famous Ayurvedic treatise Charaka Samhita. The treatise contains many such remarks which are held in reverence even today. Some of them are in the fields of physiology, etiology and embryology.

Charaka was the first physician to present the concept of digestion, metabolism and immunity. According to his translations of the Vedas, a body functions because it contains three dosha or principles, namely movement (vata), transformation (pitta) and lubrication and stability (kapha). The doshas are also sometimes called humours, namely, bile, phlegm and wind. These dosha are produced when dhatus (blood, flesh and marrow) act upon the food eaten. For the same quantity of food eaten, one body, however, produces dosha in an amount different from another body. That is why one body is different from another. For instance, it is more weighty, stronger, more energetic.

Further, illness is caused when the balance among the three dosha in a human body is disturbed. To restore the balance he prescribed medicinal drugs. Although he was aware of germs in the body, he did not give them any importance.

Charaka knew the fundamentals of genetics. For instance, he knew the factors determining the sex of a child. A genetic defect in a child, like lameness or blindness, he said, was not due to any defect in the mother or the father, but in the ovum or sperm of the parents (an accepted fact today).

Charaka studied the anatomy of the human body and various organs. He gave 360 as the total number of bones, including teeth, present in the body. He wrongly believed that the heart had one cavity, but he was right when he considered it to be a controlling centre. He claimed that the heart was connected to the entire body through 13 main channels. Apart from these channels, there were countless other ones of varying sizes which supplied not only nutrients to various tissues but also provided passage to waste products. He also claimed that any obstruction in the main channels led to a disease or deformity in the body.

Under the guidance of the ancient physician Atreya, Agnivesa had written an encyclopedic treatise in the eighth century B.C. However, it was only when Charaka revised this treatise that it gained popularity and came to be known as Charakasamhita. For two millennia it remained a standard work on the subject and was translated into many foreign languages, including Arabic and Latin.

Contributions

According to the Charaka tradition, there existed six schools of medicine, founded by the disciples of the sage Punarvasu Ātreya. Each of his disciples, Agnivesha, Bhela, Jatūkarna, Parāshara, Hārīta, and Kshārapāni, composed a Samhitā. Of these, the one composed by Agnivesha was considered the best. The Agnivesha Samhitā was later revised by Charaka and it came to be known as Charaka Samhitā. The Charaka Samhitā was revised by Dridhbala.

Āyurveda is traditionally divided into eight branches which, in Charaka's scheme, are:

1. Sūtra-Sthāna, general principles
2. Nidāna-Sthāna, pathology
3. Vimāna-Sthāna, diagnostics
4. Sharīra-Sthāna, physiology and anatomy
5. Indriya-Sthāna, prognosis
6. Chikitsā-Sthāna, therapeutics
7. Kalpa-Sthāna, pharmacy
8. Siddhi-Sthāna, successful treatment

Charaka Samhita

The Charak Samhita contains 120 adhyayas (chapters), divided into 8 parts.

1. Sutra Sthana
2. Nidan Sthana
3. Viman Sthana
4. Sharir Sthana
5. Indriya Sthana
6. Chikitsa Sthana
7. Kalpa Sthana
8. Siddhi Sthana

Plastic Surgery in Ancient India

From 1769 AD to 1799 AD, in a period of thirty years, four Mysore Wars were fought between Hyder Ali and his son Tipu Sultan and the British. As a result of these wars the British learnt two very important Indian techniques --- rocketry and plastic surgery. Both these Indian techniques were further improved first in England and then in other European countries (see 'Story of Indian Rockets', DREAM, October 1999). How the British learnt the art of Indian plastic surgery is a fascinating story.

A Maratha cart-driver, Kawasajee, who had served the British, and four tilanges (Indian soldiers of British army) had fallen into the hands of the Sultan of Srirangapattam. Their noses and right arms were cut off as a punishment for serving the enemy. Then they were sent back to the English command.

After some days, when dealing with an Indian merchant, the English commanding officer noticed that he had a peculiar nose and scar on his forehead. On inquiry, he learnt that the merchant's nose had been cut off as a punishment for adultery and that he had a substitute nose made by a Maratha Vaidya of the kumhar (potter) caste. The commanding officer sent for the Vaidya and asked him to reconstruct the nose of Kawasajee and others.
The operation was performed near Pune in the presence of two English doctors, Thomas Cruso and James Findlay. An illustrated account of this operation, carried out by an unnamed Vaidya, appeared in the Madras Gazette. Subsequently, the article was reproduced in the Gentleman's Magazine of London in October 1794. The operation is described as follows :
"A thin plate of wax is fitted to the stump of the nose so as to make a nose of good appearance; it is then flattened and laid on the forehead. A line is drawn around the wax, which is then of no further use, and the operator then dissects off as much skin as it had covered, living undivided a small slip between the eyes. This slip preserves the blood circulation till a union has taken place between the new and the old parts.

"The cicatrix of the stump of the nose is next paired off, and immediately behind the new part, an incision is made through the skin which passes around both alae, and goes along the upper lip. The skin, now brought down from the forehead and being twisted half around, is inserted into this incision, so that a nose is formed with a double hold above and with its alae and septum below fixed in the incision. A little Terra Japonica (pale-catechu) is softened with water and being spread on slips of cloth, five or six of these are placed over each other to secure the joining. No other dressing but this cement is used for four days. It is then removed, and cloths dipped in ghee are applied. The connecting slip of skin is divided about the twentieth day, when a little more dissection is necessary to improve the appearance of the new nose. For five or six days after the operation, the patient is made to lie on his back, and on the tenth day, bits of soft cloth are put into the nostrils to keep them sufficiently open. This operation is always successful. The artificial nose is secured and looks nearly as well as the natural nose, nor is the scar on the forehead very observable after a length of time."

This description fired the imagination of the young English surgeon J.C. Carpue, who after gathering more information on the "Indian nose" performed two similar operations in 1814 with successful results. After Carpue published his account, Graefe, a German surgeon, performed similar plastic operations of the nose using skin from the arm. After this plastic surgery became popular throughout Europe. All replacement operations which use a flap of skin in the immediate vicinity of the loss are known as Indian plastic surgery.

Plastic surgery has little to do with plastics, the synthetic substances so common today. The term 'plastic', derived from the Greek plastikos, means to mould or shape. The task of plastic surgery is to restore the appearance and function of parts of the body destroyed or damaged by disease or injury. Contrary to popular belief, plastic or reconstructive surgery is not merely cosmetic surgery but an important discipline that aims at correcting all sorts of physical deformities. Though a very old technique, plastic surgery has made great strides only after the First World War.

The Bible contains no reference of plastic operations. There is no mention of plastic surgery in the ancient Greek literature. Homer (9th century BC) has described various types of wounds and their treatments but did not mention the possibility of replacing parts of the nose or other features. Roman legends vaguely mention plastic surgery. Genuine records of plastic operations are not found in Europe until the middle of the fifteenth century. These come from Italy. Many European scholars are of the opinion that reports of Indian plastic operations reached Italy by way of seamen and merchants, who used to undertake long journeys to the Far East at the beginning of the Middle Ages. Like other methods Indian mathematics and medicine, the Italians might have learnt the techniques of Indian plastic surgery from the Arab Moors.

From Italy we have the record that in 1442, Branca, a surgeon of Catania in Sicily, carried out plastic operations of the nose, using flap from the face. His son Antonio continued his work and was the first to use a flap from the arm for reconstructing the nose. The work was carried on by the Boinias, another Italian family. The plastic operations carried out by the Boinia brothers are described in a book published in 1568 by Fioravanti, a doctor of Bologna.

However, it was in the hands of Gasparo Tagliacozzi (1546-99), a professor of surgery and of anatomy at the Bologna University, that plastic surgery attained wide fame in Europe. His book De curtorum chirurgia per insitionem (The surgery of defects by implantation), printed in 1597, was the first scientific treatise on plastic surgery. Tagliacozzi has described a method of plastic substitution of the nose by skin from the arm and of replacement of the ears and lips, demonstrating his work by a large number of illustrations.

The Church dignitaries regarded plastic surgery as an interference in the affairs of the Almighty. They not only excommunicated Tagliacozzi but later got his corpse exhumed from its church grave and placed in an unconsecrated ground !

In the 17th and 18th century not much importance was attached to plastic surgery in Europe. The great Voltaire (1694-1778) wrote a satirical poem on Tagliacozzi and his operation on the nose, using flap from the buttocks. Many gentlemen who lost their nose in duel or through other misfortunes had substitutes made of gold, silver or ivory. The Danish astronomer Tycho Brahe (1546-1601) once became involved in a dispute with another young Danish nobleman over who was the better mathematician. The dispute led to a duel in which Tycho lost part of his nose. This he replaced with a mixture of gold, silver, and wax, of which he was very proud.

In ancient Europe, as we have seen, there was no tradition of plastic operations.
The plastic operation on nose done by Branca in 1442 was very similar to the one described in the Sushruta-Sanhita, an Ayurvedic compendium composed in the early centuries of the Christian era. In India, from ancient times to the early nineteenth century, we find a living tradition of plastic operations of the nose, ear and lip. The Kangra (correctly pronounced as 'Kangada') district in Himachal Pradesh was famous for its plastic surgeons. Some scholars are of the opinion that the word 'Kangada' is made from 'Kana + gadha' (ear repair). The British archaeologist Sir Alexander Cunningham (1814-93) has written about the tradition of Kangra plastic operations. We have information that in the reign of Akber a Vaidya named Bidha used to do plastic operations in Kangra.

The Charaka-Sanhita and the Sushruta-Sanhita are among the oldest known treatise on Ayurveda (the Indian science of medicine). Chronologically, Charaka-Sanhita is believed to be an earlier work, and deals with medicine proper containing a few passages on surgery. The Sushruta-Sanhita, a work of the early centuries of the Christian era, mainly deals with surgical knowledge. The extant Sushruta-Sanhita is, according to its commentator Dalhanacharya (twelth century AD), a recension by Nagarjuna. The original Sushruta-Sanhita was based on a series of discourses of Kashiraj Divodas (or Dhanvantari) to his disciples, Sushruta and others.

There has been a tradition to divide the Ayurveda works into 120 chapters. The Susruta Sanhita also contains 120 chapters, grouped into five sthanas (books): Sutrasthana, Nidanasthana, Sharirasthana, Chikitsashana and Kalpasthana. Besides, the compendium contains an appendix, called Uttaratantra, consisting of 66 chapters.

The plastic operations of otoplasty (plastic surgery of the ear) and rhinoplasty (plastic surgery of the nose) are described in the 16th chapter of the first book (Sutrasthanam) of the compendium. First, methods are described for piercing the ear-lobes of an infant which still is a widespread practice in India. Often these ear-lobes, due to the use of heavy ornaments, get considerably expanded and ultimately sunder. Sushruta has described 15 methods of joining these cut-up ear-lobes. For these plastic operations, called Karnabandha, a piece of skin was taken from the cheek, turned back, and suitably stitched on the lobules. Further treatment of the operation, periodic dressing of the wound and the use of various ointments is elaborately described.

In describing the method of rhinoplasty (Karnabandha), Sushruta says that the portion of the nose to be covered should be first measured with a leaf . Then a piece of skin of the required size should be dissected from the living skin of the cheek, and turned back to cover the nose, keeping a small pedicle attached to the cheek. The part of the nose to which the skin is to be attached should be made raw by cutting of the nasal stump with a knife. The physician then should place the skin on the nose and stitch the two parts swiftly, keeping the skin properly elevated by inserting two tubes of eranda (the castor-oil plant) in the position of the nostrils, so that the new nose gets proper shape. The skin thus properly adjusted, it should then be sprinkled with a powder composed of liquorice, red sandal-wood and barberry plant. Finally, it should be covered with cotton, and clean sesame oil should be constantly applied to it. After some days the wound heals up and the grafting is successful. Sushruta also mentions the reconstruction of the broken lip and hare-lip (Oshtha-sandhana).

Thus, plastic surgery is a very old science. It is, however, difficult to say when the first plastic operations on man were performed. Primitive man knew how to do grafting in plants. This might have given him the idea of transferring tissues in man and animals. The necessity arose when he lost such parts of his body as the nose, which has been a common form of injury in all periods of history. In olden days, removal of the nose was also one of the most common form of punishment. Manu, the famous lawgiver, mentions the ears and the nose among the ten parts of the body on which punishments are to be executed (Manusmruti : 8.125), Thus it became a social necessity to find a substitute for the lost nose. The development of plastic surgery is closely connected with the operative techniques used in the field known as rhinoplasty.

After getting fresh impetus from India, plastic surgery has made great progress in the past two hundred years. In 1933 the first international congress of plastic surgery was held in Paris. Basically, the task of plastic surgery is to restore the parts of the body destroyed or damaged by disease or injury. But in recent years "cosmetic surgery" as beauty treatment has become very fashionable. Anyway, we should always remember that the sources of modern plastic surgery are the Sushruta-Sanhita and it was from India the Europeans learnt the technique of rhinoplasty.

Illustrations : 1. In 1793, a Maratha Vaidya reconstructed the nose of a cart-driver. Illustration from "Gentleman's Magazine" (London), Oct.1794. 2. Italian method of plastic surgery of the nose taking flap from the arm (two illustrations from Tagliacozzi's work).
3. Present type of Indian flap from forehead used for nasal plastic surgery.
4. Sushruta doing plastic surgery of the ear.
5. Some surgical instruments (Yantra and Shastra) as described in the
Sushruta-Sanhita.

ORIGIN

Archaeologists in Mehrgarh in Balochistan province in the present day Pakistan discovered that the people of Indus Valley Civilization from the early Harappan periods (c. 3300 BC) had knowledge of medicine and dentistry. The physical anthropologist who carried out the examinations, Professor Andrea Cucina from the University of Missouri-Columbia, made the discovery when he was cleaning the teeth from one of the men. Later research in the same area found evidence of teeth having been drilled, dating back 9,000 years.^[31]

The Atharvaveda, a sacred text of Hinduism dating from the 10th to the 12th centuries B.C.E., is the first Indic text dealing with medicine. It identifies the causes of disease as living causative agents such as the yatudhāna, the kimīdin, the krimi or kṛmi and the durṇāma. The Atharvans seek to kill them with a variety of incantations or plant based drugs in order to counter the disease^[32]. This approach to disease is quite different compared to the trihumoral theory of Ayurveda. Remnants of the original atharvanic thought did persist, as can be seen in Sushruta's medical treatise and in the Garuda Purana — Garuḍa Purāṇa, karma kāṃḍa, chapter 164. Here following the Atharvan theory, the Purāṇic text suggests the germs as a cause for leprosy. In the same chapter Suśruta also expands on the role of helminths in disease. These two can be directly traced back to the Atharvaveda saṃhitā. The hymn AV I.23-24 describes the disease leprosy and recommends the rajani auṣadhi for its treatment. From the description of the auṣadhi as a black branching entity with dusky patches, it is very likely to have been a lichen with antibiotic properties. Thus the Atharva Veda may be one of the earliest texts to record uses of the antibiotic agents.

Ayurveda (the science of living) is the literate, scholarly system of medicine that originated over 2000 years ago in South Asia. Its two most famous texts belong to the schools of Charaka, born c. 300 B.C.E., and Suśruta, the 6th century B.C.E. physician of Varanasi. While these writings display some limited continuities with very ancient medical ideas known from the religious literature called the Vedas, historians have been able to demonstrate direct historical connections between early āyurveda and the early literature of the Buddhists and Jains. The earliest foundations of āyurveda were built on a synthesis of selected ancient herbal practices dating back to the early second millennium BC, together with a massive addition of theoretical conceptualizations, new nosologies and new therapies dating from about 400 B.C.E. onwards, and coming out of the communities of thinkers who included the Buddha and others. ^[33].

According to the compendium of Charaka, the Charakasamhitā, health and disease are not predetermined and life may be prolonged by human effort. The compendium of Suśruta, the Suśrutasamhitā defines the purpose of medicine to cure the diseases of the sick, protect the healthy, and to prolong life. Both these ancient compendia include details of the examination, diagnosis, treatment, and prognosis of numerous ailments. The Suśrutasamhitā is notable for describing procedures on various forms of surgery, including rhinoplasty, the repair of torn ear lobes, perineal lithotomy, cataract surgery, and several other excisions and other surgical procedures.

The āyurvedic classics spoke of eight branches of medicine: kāyācikitsā (internal medicine), śalyacikitsā (surgery including anatomy), śālākyacikitsā (eye, ear, nose, and throat diseases), kaumārabhṛtya (pediatrics), bhūtavidyā (spirit medicine), and agada tantra (toxicology), rasāyana (science of rejuvenation), and vājīkaraṇa (aphrodesiacs, mainly for men). Apart from learning these, the student of Āyurveda was expected to know ten arts that were indispensable in the preparation and application of his medicines: distillation, operative skills, cooking, horticulture, metallurgy, sugar manufacture, pharmacy, analysis and separation of minerals, compounding of metals, and preparation of alkalis. The teaching of various subjects was done during the instruction of relevant clinical subjects. For example, teaching of anatomy was a part of the teaching of surgery, embryology was a part of training in pediatrics and obstetrics, and the knowledge of physiology and pathology was interwoven in the teaching of all the clinical disciplines.

At the closing of the initiation, the guru gave a solemn address to the students where the guru directed the students to a life of chastity, honesty, and vegetarianism. The student was to strive with all his being for the health of the sick. He was not to betray patients for his own advantage. He was to dress modestly and avoid strong drink. He was to be collected and self-controlled, measured in speech at all times. He was to constantly improve his knowledge and technical skill. In the home of the patient he was to be courteous and modest, directing all attention to the patient's welfare. He was not to divulge any knowledge about the patient and his family. If the patient was incurable, he was to keep this to himself if it was likely to harm the patient or others.

The normal length of the student's training appears to have been seven years. Before graduation, the student was to pass a test. But the physician was to continue to learn through texts, direct observation (pratyaksha), and through inference (anumāna). In addition, the doctors (vaidyas) attended meetings and seminars where knowledge was exchanged. The physicians were also enjoined to gain knowledge of unusual remedies from hillsmen, herdsmen, and forest-dwellers. ^[34]