Reflection-10

Dr. Azad’s clinic, late evening. The clinic is quiet, the last patients already gone. A dim lamp glows on the desk, where books and notes lie scattered. Kabir, Aarav, and Rohan walk in with their text still in hand and sit across from Dr. Azad, eager to ask their questions.

Kabir (leaning forward): Uncle, we finished reading the chapter on seven dhātus. This time it is not Charaka, but it is Sushruta who teaches his students. It places seven dhātus—Rasa, Rakta, Māṃsa, Meda, Asthi, Majjā, and Śukra—in that order. We have so many questions.

Dr. Azad (smiling): It had to be Suśruta because he performed surgeries and dissected human cadavers. Who else would justify teaching the dhātu sequence? But before we come to your questions, let me remind you: even modern anatomy struggles with defining “tissue” precisely.

Aarav: Is it? I never thought of this!

Dr. Azad: In standard sources such as Britannica, a tissue is described as “a level of organization in multicellular organisms; it consists of a group of structurally and functionally similar cells and their intercellular material.” But here lies the difficulty: if the notion of similarity in structure and function is stretched broadly enough, then all human cells can be considered similar, and by that logic the entire organism itself could be called a tissue. Similarly, even semen could qualify as a tissue, as it is made up of cells that are structurally and functionally similar and suspended in intercellular matrix. That seems inappropriate, right?

Aarav: I don’t think your argument makes sense. A tissue should form a component within the assembly of the body, not the whole body itself. A book that I recently read, described that cells and matrix must share a common embryonic origin. That would render such extrapolations impossible.

Dr. Azad: But if you take that strictly, blood will fall outside the category of tissue—yet no one denies that blood is considered a tissue in medicine!

Aarav: Oh! Now I get where you are taking us! Interesting!

Dr. Azad: This shows that “tissue” is not a purely descriptive word, but part of a theory about how the body is organized. Different definitions yield different theories, and the best theory is the one that explains the most. Suśruta’s dhātu theory was his own attempt to impose such order on the body as he observed it.

Aarav: So, Suśruta’s sevenfold scheme must have been his way of bringing order to what he observed.

Dr. Azad: You are right! He was not working with microscopes or imaging techniques, but with the body as it appeared to his senses—in health, disease, and dissection. His “tissues” are functional and clinical categories, not histological ones.

Kabir: I want to know – is the narrative we just read authentic?

Dr. Azad: Classical Ayurveda proposes that one dhātu is converted into the next. However, this author has changed the narrative to focus on sequence and to negate the theory of conversion. It appears that the author wanted to correct major errors in certain Ayurvedic propositions. In this chapter, all the arguments are this mysterious author’s creation, but reasoning is faithful to Ayurvedic way of thought. The author has tried to reconstruct the dhātu theory, which is often described as speculative, by using clinical and other observations.

Kabir: What about the translation of dhātus as tissues? Is it all right to translate it like that?

Dr. Azad: Sushruta’s classification of the seven dhātus was, in many respects, similar to the concept of tissues. However, it was not based on histology. Instead, it drew on observable features in health and disease. For instance, bones, teeth, and nails were all grouped under Asthi because they shared the property of being resistant to rapid decomposition. Similarly, Śukra referred primarily to semen, but since secondary sexual characteristics manifest throughout the body, physicians postulated another form of Śukra present throughout the body.

Aarav: If Śukra stood for semen, what about Śukra in women?

Dr. Azad: The existence of Śukra in women was debated. Many considered that though Śukra was present in women, it wasn’t responsible for reproduction. Instead, they considered menstrual blood to be the female counterpart of semen which was called Śoṇita or Ārtava. The observation that menstruation ceases during pregnancy must have been the basis of this belief. What they could not yet comprehend was the complex physiology of oogenesis, even though they had accurately documented the occurrence of monthly cycles. Similarly, Māṃsa stood for flesh in general. Māṃsa-peśī stood for muscles, especially skeletal and cardiac.

Kabir: Even though Sushruta placed Māṃsa before Meda, there was some amount of uncertainty, right?

Dr. Azad: Yes. In modern anatomy, beneath the skin there is indeed superficial fat in the subcutaneous layer. But beneath that lies the deep fascia and then the bundles of muscle fibers. There is intermuscular fat as well. The author has Suśruta admit openly that this point could be contentious. What Sushruta says about gradually decreasing mobility is indeed an interesting argument, though debatable.

Aarav: What does modern histology say?

Dr. Azad: Histology confirms that adipocytes are interspersed in muscle tissue, but they do not give muscle its structure or strength. Suśruta’s reasoning reflects clinical observation rather than literal anatomical layering. And where subcutaneous fat is very thin, as in the forearms, his placement of Māṃsa before Meda was in fact correct.

Aarav: Ketana’s statement made sense. When there is conflict between spatial arrangement and temporal replenishment, they adjusted their sequence to fit with what was clinically most relevant.

Dr. Azad: Yes. Sushruta lacked a microscope, but he noticed that muscle rebuilding occurred earlier than fat restoration. In modern terms, dietary proteins are used first to repair muscle, while fat deposits accumulate only afterwards.

Rohan: Suśruta says the embryo is first fluid, then red, then muscle, then fat, then bone, marrow, and finally reproductive essence. Does modern embryology really follow that order?

Dr. Azad: No! Development of the embryo is overlapping rather than strictly step-by-step. By the third week of gestation, primitive blood cells appear in the yolk sac, and by the sixth week the liver begins blood production. Muscle precursor cells emerge around weeks five to six, while fat cells differentiate only much later, mainly in the second trimester. Ossification of bone begins around week seven in certain regions but continues into adolescence. Marrow cavities develop only after bone matrix is laid down. Germ cells are present in the fetal gonad, but they remain immature until puberty.

Kabir: So Suśruta was right about Māṃsa before Meda, and about blood appearing before bone, but he could not have known the precise timings.

Dr. Azad: Yes, he observed broad stages: blood before bone, muscle before fat and bone, bone before marrow, and reproductive capacity last. He did not know the microscopic processes, but his sequence was broadly correct as a clinical heuristic. How he arrived at this is not recorded. The author imagines that he may have drawn on observations from miscarried fetuses, which is plausible, but not certain.

Aarav: Was his claim about medical ethics—respecting aborted fetuses—actually documented in the classical texts?

Dr. Azad: No. Intentional abortion was generally discouraged in ancient times, but no explicit ethical framework about studying aborted or miscarried fetuses is documented. That part is the author’s imaginative reconstruction.

Kabir: But if muscles need bones for movement, shouldn’t bones form before muscles? I think Ketana’s argument had a strong point there.

Dr. Azad: This is indeed interesting. But development does not always follow the logic of adult anatomy. In the embryo, mesoderm first produces muscle cells (myogenesis). Bones come later, as cartilage models ossify. So muscles begin to shape the limbs before bones harden enough to anchor them.

Rohan: Then Suśruta’s explanation, even without microscopes, was remarkably close to what modern embryology shows.

Dr. Azad: Indeed. His reasoning reveals careful observation and inference. He missed details that only modern science can detect, but his sequence captured essential patterns of development and provided a useful framework for clinical thinking.

Kabir: In the chapter, Suśruta says that during starvation you lose fluids first, then blood, then muscle, then fat, then bone, marrow, and finally reproductive vitality. Does modern medicine agree with this order?

Dr. Azad: Why don’t you read for yourself? Search on the internet!

Kabir (surfs the internet and reads): “In the early stages of starvation, individuals typically experience weakness, irritability, and fatigue as glycogen stores are quickly depleted and gluconeogenesis becomes the primary source of glucose. As starvation progresses, fat reserves are mobilized through lipolysis and muscle proteins are broken down through proteolysis, leading to marked wasting of both fat and muscle tissue. With more prolonged deprivation, endocrine and micronutrient-related complications appear, including bone demineralization, anemia, and reproductive dysfunction such as amenorrhea or loss of libido. In the terminal phase, the body can no longer sustain vital functions, resulting in multiorgan failure, severe immunosuppression, and ultimately death.”

Kabir: What about bone marrow?

Dr. Azad: During extended periods of inadequate nutrition, the bone marrow becomes hypoplastic. This is largely due to severe protein–energy deficiency and deficiencies in micronutrients such as iron, folate, and vitamin B12, which are essential for hematopoiesis. The result is reduced production of red blood cells, white blood cells, and platelets. Clinically, this may present as anemia, leukopenia, and thrombocytopenia, which in turn contribute to pallor, recurrent infections, and increased bleeding tendency. However, it is a feature of the advanced stage.

Aarav: So his model isn’t highly accurate. For example, anaemia doesn’t seem to appear in the early stages, and loss of fat and muscles seem to overlap. But does it still make some sense clinically?

Dr. Azad: Yes. Suśruta’s sequence roughly reflects what a physician might notice at the bedside: first dehydration and weakness, then wasting of muscle and fat, later bone weakness. It is more heuristic than biochemical.

Rohan: And his treatments—water, gruels, iron preparations, goat liver, meat soups, oils—do they make sense today?

Dr. Azad: Broadly, yes. He prescribed fluids for dehydration, iron-rich remedies for anemia, proteins for muscle wasting, and fats and oils for energy and tissue repair. Modern care is more precise, but the principles remain relevant.

Kabir: But why not just feed starving patients quickly with rich food? Wouldn’t that rebuild everything faster?

Dr. Azad: That’s where modern medicine has identified a serious risk called refeeding syndrome. Do you know what that is?

Kabir (shaking his head): No.

Dr. Azad: Look it up on your phone.

Kabir (reading aloud): It says “refeeding syndrome is a dangerous shift in fluids and electrolytes that can happen when severely malnourished patients start eating again. It can cause low phosphate, potassium, and magnesium levels, leading to heart failure or even death.”

Dr. Azad: Exactly. Suśruta did not know the molecular details, but he was cautious. He advised starting with thin gruels and soups before richer foods. That slow reintroduction of nourishment protected patients in much the same way we now prevent refeeding syndrome.

Aarav: So his cautious stepwise feeding was a safeguard, even if he didn’t know the chemistry.

Dr. Azad: Yes. That shows how empirical observation, even without modern physiology, could anticipate sound medical practice.

Rohan: Despite the gaps, I admire how he combined direct observation, inference and teacher testimony to build his theory.

Dr. Azad: That triad—pratyakṣa, anumāna and āptopadeśa—was central to the Ayurvedic method of knowledge. In this narration, however, the author urges us to reconsider what counts as āptopadeśa. He reimagines the logic behind the sequence of dhātus in a way that challenges the old sequential conversion hypothesis.

Aarav: Apart from conversion, do the ancient texts record any other explanations?

Dr. Azad: Yes. Some commentators proposed that the sequence reflects the time taken for nourishment to reach each tissue—Rasa first, then Rakta, then Māṃsa, and so on—based on their relative proximity within the body. Others employed the irrigation model, comparing Rasa to a water reservoir whose canals irrigate distant fields. These were powerful metaphors for their time, but without a complete knowledge of systemic circulation or biochemical pathways, the hypotheses remained incomplete.

Kabir: And what do you find most striking in this narration?

Dr. Azad: His intellectual humility. In the classical texts it is often only implicit, but here the author makes it explicit. He has Suśruta tell his students, “If new observations contradict my theory, we will revise it.” That willingness to adapt makes him sound more scientific than some modern researchers I know. No theory is sacred. We test, we question, we refine. That is how knowledge grows.

Aarav: Is there anything that modern medicine can learn from this?

Dr. Azad: Yes, very much. Not the categories themselves, but the method behind them. Suśruta worked with what he could see, touch, and reason about—without microscopes or lab tests. He relied on careful clinical observation: the skin’s dryness as a sign of fluid loss, pallor as a sign of weak blood, wasting as a sign of muscle depletion. He then built bold hypotheses to explain these patterns, like arranging the dhātus in a sequence. Some details were wrong, but the process was sound.

Kabir: Isn’t that the same logic modern doctors use when they build a hypothesis at the bedside and then test it with investigations?

Dr. Azad: Yes, this is exactly how modern science grows too: first by attending closely to patients, then by proposing explanations, and finally by testing and revising them as new evidence arrives. Suśruta’s lesson shows us that careful observation, combined with the courage to frame a big hypothesis and the humility to revise it later, is the engine of medical progress.

Kabir: Thank you, Uncle. We will keep questioning, and maybe one day refine these theories ourselves.

Dr. Azad: And that is exactly how medicine advances—through curious minds willing to challenge and build upon what came before.

[The boys step out into the quiet night, their minds alive with questions, carrying Suśruta’s spirit of inquiry into their own time.]