KAMALIKA PIERIS

The College of Surgeons of Sri Lanka celebrated its 50 anniversary, by publishing, History of surgical services in Sri Lanka from the earliest times to 2021.”  The title itself shows that the College recognizes the existence of   a surgical service in the island, before the arrival of modern surgery.

 The book does not go straight into the medical systems of ancient times. It first looks at the political history of the island.   The reader is quickly directed to the most important historical discovery in modern times, the new dates for the Anuradhapura civilization. The book said, ‘Recently between Thuparama and the twin ponds, in the old city of Anuradhapura,      an area of about 250 acres 30 to 35 feet deep revealed a city dated to have been in existence around 900-500 BC. The pottery excavated showed brahmi script. This confirms the existence of a culture that dates to a period before what was believed previously.

Two historians, K.M. de Silva and W.I. Siriweera   were invited to   write the political and social history chapters of this book.  K.M de Silva’s chapter on the political history of ancient and medieval Sri Lanka was written specially for the book. The historical information he gives is, of course, well known, but this chapter has three items which I have not seen anywhere else.

Firstly, there is a pie chart of the royal capitals of Sri Lanka, indicating the period of time for each capital, starting with Anuradhapura and ending with Kandy. I have not seen such a pie chart before. It is original and very instructive. Secondly this chapter has two maps which I have not seen before. One is a map of the route taken by Dutugemunu, when he advanced from Magama to Anuradhapura to oust Elara. The other is a map of Vijayabahu I   campaign, to oust the Cholas, illustrating the pincer movement used. Both seem to be original to this book.

The presentation by WI Siriweera on sanitation and health in ancient Sri Lanka is probably the most recent information on the subject. Siriweera says there were four kinds of hospitals in the Rajarata kingdom, monastic, lay, maternity and outdoor.

According to the Mahavamsa there were 18 hospitals in existence during the time of King Dutugemunu, stated Siriweera. The chronicles continuously record the building of hospitals up to 1186 AD. For instance, Kukurumahandamana pillar inscription at Vavuniya dated to Kassapa IV   refers to   hospitals. Kassapa V had built a royal hospital Rajavedahala”   on the ‘ceremonial street’.  There is a complete Vedasala or hospital complex at Mihintale.  Arankele monastery   had a large hospital for outdoor patients, dated tentatively to the late Anuradhapura period. Remains of hospitals belonging to the late Anuradhapura period were found in Mihintale, Anuradhapura, Medirigiriya, Dighavapi, and Dombegoda.  In Polonnaruwa, the Alahana complex   is dated to 12 century.   .A special category of servants were appointed to hospitals to prepare drugs and food.

There were other medical centers. Pandukabhaya built a hall for the sick, sothisala” and a lying in home, sivikasala” in Anuradhapura. Kiribatvehera inscription of Kassapa IV records a behetge named Bamunu Kumbura. .Vessagiri slab inscription of Dappula IV also talks of a behetge.

There was a state health service. During the time of king Sirisangabodhi (247-249) a physician was appointed to every ten villages. There were vedas (physicians) and a maha Veda (chief physician). The disorders that were recognized for which evidence is available are paralysis, eye ailments, insanity, indigestion, pregnancy complications, and children’s diseases. Sinhala physicians had used leeches before the Europeans. Physicians who specialized in treatment with leeches are mentioned in the inscriptions.

Siriweera summarized the knowledge on hygiene. There was a high standard of town hygiene, he said. Pandukabhaya set up a settlement of 500 scavengers outside Anuradhapura to clean the sewers of the city, remove dead bodies and maintain graveyards.

There was emphasis on personal hygiene as well. Rules of hygiene prescribed for monks in Mahavagga, Samantapasadika, and Sikkhavalanda vinisa would have been applicable to lay society too.They include regular bathing, brushing teeth,   cutting finger nails, cleaning and sweeping the habitat, and surroundings. Kandavuruda sirita (Dambadeniya period)   said the king should take exercise and that monks should perambulate.

Numerous old wells are found in the ruined cities of Sri Lanka .they have their sides built either of brick, rubble or slabs of granite. Well carved basins of stone for washing purposes are seen among the ruins of Anuradhapura and Polonnaruwa, continued Siriweera.

Technique of building toilets developed in stages. At Abhayagiri the toilets and baths were constructed away from the residence of the monks.  At Baddaseema pasada in Alahana Pirivena, Polonnaruwa they have been built adjoining the residence. Extra toilets were built with ring well pits in the periphery of the hospital at Alahana, most likely for staff and visitors.

The urinary pits show the attention paid by the construction engineers to sanitary care. Water and urine have been diverted from toilet of Badddhasima Pasada at Polonnaruwa through terracotta pipes into a separate septic pit while excreta was diverted to anther septic pit. A stone seat with a central hole with four short legs probably used as a commode is seen in the quadrangle of the Dalada Maligawa in Polonnaruwa.

 The colour photographs in this section call for special comment. I have not seen such a profusion of photographs in any history book. They are a varied, interesting collection.  The earliest  potsherd with writing, a  pillar edict,  a copper plate ,a sannasa,  a  restored Samadhi Buddha, Lankarama  temple , a moonstone,  the Vatadage, a  stone bridge,   map of ancient irrigation works,  Jaya ganga, the ancient sluice discovered at Maduru oya and   a beautiful panoramic shot of Kalawewa taking up the full width  of the page.

The History of Surgery has three chapters on surgery in ancient Sri Lanka. The first is ‘Surgical anecdotes from the Culawamsa’. This chapter starts with King Buddhadasa (337-365 AD). King Buddhadasa has practiced operative surgery. According to the Mahavamsa he had treated a snake that had a tumor in its belly.  King slit open the belly of the snake, took out the tumor, applied medicine to the wound and cured the snake.

Buddhadasa is also credited with impossible operations. Buddhadasa had performed an operation for correction of a mal position of a foetus. He had split the cranium of a patient and removed a toad who had grown inside it, then reconstructed the bisected cranium.  Surgeons did not think these operations were likely. 

The chapter then drew attention to Parakramabahu I (1153-1186) who it appears, knew medicine, a fact which is rarely mentioned in accounts of this king.  Mahavamsa says Parakramabahu I   had done a ‘ward round’ surrounded by physicians. He had checked on the medicine given to patients, instructed on mistakes made and by his own hand skillfully showed the use of instruments.

Parakrama Bahu had encouraged the medical service .To those discerning and skilful physicians who were quick at identifying illness and were well versed in textbooks of medicine Parakrama Bahu gave a stipend according to their expertise and made them practice their art day and night.

When Parakramabahu sent a military expedition to Burma, he also sent physicians and nurses. Different kinds of medicine were preserved in cow horns for healing of venomous wounds caused by poisoned arrows. Iron pincers were used to extract arrowheads which had pierced deeply. He also sent remedies for curing disease caused by infected water in swamps, said the Mahavamsa.

The second essay written by archaeologist Leelananda Prematilleke and surgeon Arjuna Aluwihare is on Alahana Pirivena, Polonnaruwa. This essay adds to the information already known about ancient hospitals.  Alahana was more elaborate than the hospital ruins found in Anuradhapura, said the authors. It was well landscaped, with medicinal trees. The hospital was cordoned off with a wall.  Building was designed   for maximum ventilation and free circulation of air within it. This was achieved by two open courts and windows.

At Alahana they found medicine grinders and a micro balance.   The micro balance indicated that strong medicines had been used. Medicine troughs were also found. The writers had much to say on the medicine troughs. These unique granite medicine bath tubs standing on a granite base have not been found in any other ancient civilization, they said.  They had human shaped hollows. 

The granite is carved to repeat the shape of the head, expand at shoulder and slightly tapering at the place where the hands end, thereby showing the perfect proportions of the human body. There is much scientific merit in this design as the patient could be immersed in it with the minimum amount of fluid.  These troughs were intended for immersion therapy.

But the most important find at Alahana were the surgical instruments unearthed there.  They include probes, forceps, scissors, scalpels and lances. Probes were of different sizes. Forceps were made out of bronze or iron with a small percentage of steel. Forceps with short, strong jaws were found, perhaps for arrow head removal. Fine jawed forceps were not found. 

The third chapter in the book was on Surgery and surgical training in ancient Sri Lanka”. For the first time ever, scattered references available in the ancient literature on operative surgery were gathered together   and placed on record. This is a significant addition to the knowledge of medicine in ancient   Sri Lanka.

The authors looked for information on the surgical techniques of ancient times. One statement on surgical training was found. In Visuddhimagga, Buddhagosa had made an observation on how surgeons were trained. Pupils are trained in the use of the scalpel by learning to make an incision on a lotus leaf placed in a dish of water, he said. They must make the incision without cutting the leaf in two or pushing the leaf into the water.

Several books on the art of healing have been written, said the History. The Bessajja Manjusa written in 13th century refers to   surgical topics such as   fistula,       carbuncle, bladder stone, fractures, goiter and surgical treatment for intestinal obstruction.

Kankavitarani referred to 8 kinds of surgical operations and provides a list of instruments for each type. They are use in excision, rubbing and scarification, in opening blood vessels and flesh, in incision and drainage of body fluid, in removing, scaling and probing. There was mention of small drilling needles   and needles used in puncturing. There was also mention of scissors, thorn removers and an axe like instrument used for splitting.

Sararta sangrahaya carried diagrams of instruments available at the time for specific procedures. Yogarnavaya and Prayoga –ratnavaliya referred to almost 20 surgical instruments. Lastly, Historical Manuscripts Commission, 1933 found dozens of medical manuscripts in personal collections and temples. Purana vihara Pelmadulla had a manuscript dealing with surgical operations, copied in Sinhala, in 1862

The book then looked at the health service during Portuguese and Dutch rule. In addition to the Dutch Hospital in Colombo which everybody knows about, this book also carried an account of the lesser known Dutch Hospital for Leprosy in Hendala, with a photograph attached.This hospital was started by the Dutch in 1708, because the daughter of Dutch governor Van Imhoff was a victim of the disease.

The book has looked in great detail at the provision of operative surgery in the state hospitals. The book does not discuss the emerging private  sector which is also providing valuable services in operative surgery today, in Colombo, and in the outstations,  notably Kandy and  Galle..the private sector is also manned by    locally trained, PGIM qualified  surgeons. While some  are  employed full time in these hospitals, state sector surgeons also operate in these hospitals. The private sector  helps to ease the burden on the state hospital sector and is entitled to recognition.

The History of Surgery  published by the College of Surgeons of Sri Lanka  is the   definitive history of modern surgery in Sri Lanka . It is a book that the College of Surgeons can be very proud of. It  is very accurate .  I tested it using some facts  which I knew first hand.

 It has been well researched and each chapter has a long list of references at the end. It is well produced, on  high quality paper, and at the grossly under priced rate of Rs 7,500 a very  worthwhile purchase. The book ends with the hope that in the future we will  be able to both innovate and lead the world in the management of  the common surgical disorders  we see in Sri Lanka .

History of Surgery  published  by the College of Surgeons of Sri Lanka, priced at Rs   7,500. is available at the College of Surgeons  office , No    6, Independence Avenue, Colombo 7. ( CONCLUDED)