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Tuesday, October 07, 2014

MyView: Creative diagnosis

MyView: Creative diagnosis:

MyView: Creative diagnosis

October 21, 2013
By Jeffrey Camm, D.M.D.
There is no doubt that the dental profession is under assault from insurance companies—reduced reimbursements, decreased benefits and diminishing coverage for some procedures are all issues we have to face in our practices. Because of this, we all face financial pressures and threats to our bottom line. In response to these issues, I believe I've noticed an increase in the skill of what I call "creative diagnosis." I hope this is not a trend for our profession.
As a board certified pediatric dentist, who has practiced 34 years with both a military and civilian career, I feel I understand the wide range of differences in teaching programs and dental schools across the country. I realize that diagnosis of decay is somewhat subjective and recall the old joke about any two periodontists who agree on a patient should form their own society. But the disparity of diagnosis I have seen recently is alarming.
Consider the 16-year-old who graduated from my practice and sought care at her mother's general dentist. The phone call I received from that dentist asking how I could miss 16 cavities (with a treatment plan of more than $3,000) was alarming. The mother's call to me was also alarming—what had I been doing all these years? After inviting the mother and daughter back to my office and taking new radiographs I again came up with a diagnosis of no decay. There were a few incipient lesions in the enamel, some of which had been there five or six years. We reviewed the old radiographs and I showed the mother that some of these incipiences had actually decreased in size as the patient had aged and started mouth rinses and flossing. At this point, questioning my own skills I showed the radiographs to five fellow dentists representing three different specialties. The range of opinions was zero to four cavities they would restore. The number 16 was off the chart. The same diagnostician had recommended these restorations before the end of the year because of the imminent possibility of endodontics.
Another patient brought their daughter to our office for a second opinion. Her 2-year-old had a full mouth series of radiographs (six X-rays on a 2-year-old!) and was diagnosed with a cavity requiring restoration and sedation. To begin with, I can't envision a scenario where a 2-year-old with no visual decay requires full mouth radiographs. The American Academy of Pediatric Dentistry states, "Radiographs should be taken only when there is an expectation that the diagnosis will affect patient care." This child had no teeth with contact points, you could see all her interproximal surfaces—in fact, her maxillary second molars had not yet erupted. My board-certified partner and I found no decay. And speaking of radiographs, the criteria for panoramic X-rays is not: will the child stand still and is it a covered benefit? Referrals of 4-year-olds to us with panos is maddening—there is no indication for it.
Our practice is often referred children who are medically compromised or of a pre-cooperative age requiring general anesthesia for treatment. These are wonderful referrals and a great service to the parents and children. In the past six months, my partner and I have been referred three children with extensive treatment plans that we can find minimal or no decay. I have to wonder what the criteria for caries has become. Many parents come to us on their own seeking second opinions regarding general anesthesia. The majority have minimal decay.
Nowhere is creative diagnosis more evident than the occlusal surfaces of permanent first molars. I can identify a patient's prior dentist by the fact that all the first molars are always restored on every patient I see coming out of that office. I attended a lecture at a national meeting a few years ago on differentiating between sealants and occlusal caries. The take home message from the lecture was, when in doubt always do restorations. Seriously? Whatever happened to minimally invasive dentistry? There is ample evidence based literature that proves minimal decay (if in fact there was decay at all) with a sealant will not progress. If there is a question, I suggest placing a sealant with future evaluations expected. Maybe not as financially beneficial for the dentist but certainly less invasive for the child.
The difficult task for me with all this creative diagnosing is trying to explain to the parent why my treatment plan is hundreds (thousands?) of dollars different than someone else's treatment plan. I can only cover up so much with my explanation of different treatment criteria, sharper explorers, conservative vs. more aggressive therapy, blah, blah, blah.
My solution? Look in the mirror. Take radiographs that are necessary, not just covered by insurance. Find decay that another dentist looking over your shoulder would agree with. Treat your patient exactly as you would wish you or your family was treated. And as Hippocrates said, "First, do no harm." Are you increasing the creative diagnosis portion of your practice? Is creative diagnosing becoming a new skill in the dental profession? I hope not—for the sake of our patients and profession.
Dr. Camm practices at Fircrest Children's Dentistry in Fircrest, Wash. His comments, reprinted here with permission, originally appeared in the July issue of the Washington Dental Association News.

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Is Your Dentist Ripping You Off? | Mother Jones

Is Your Dentist Ripping You Off? | Mother Jones:



'

Is Your Dentist Ripping You Off?

You and your teeth could be victims of "creative diagnosis."

| Mon Oct. 6, 2014 6:00 AM EDT
dentist
Alison Seiffer
My household's level of confidence in dentistry is at an all-time low. About six months ago, my dentist informed me that my "bunny teeth" were likely getting in the way of my professional success, a problem he could correct with a (pricey) cosmetic procedure. If I let him fix my teeth, he told me, he was sure I would start "dressing better." A few months later, my husband scheduled a basic cleaning with a new dentist. Once they had him in the chair and looked at his teeth, they informed him that the regular cleaning wouldn't do at all: He would need to reschedule for an $800 deep cleaning. No thanks.
We were convinced we must look like suckers—until I came across an op-ed inADA News, the official publication of the American Dental Association. The article, by longtime pediatric dentist Jeffrey Camm, described a disturbing trend he called "creative diagnosis"—the peddling of unnecessary treatments. William van Dyk, a Northern California dentist of 41 years, saw Camm's op-ed and wrote in: "I especially love the patients that come in for second opinions after the previous dentist found multiple thousands of dollars in necessary treatment where nothing had been found six months earlier. And, when we look, there is nothing to diagnose."
Some toddlers treated at one chain underwent as many as 14 procedures—often under restraint and without anesthesia.
"In recent years, I have been seeing more and more creative diagnosis," Camm told me when I called him at his practice in Washington state. A dentist, he said, might think, "'Well, the insurance covers this crown, so I'm not hurting this patient, so why don't I just do it?' That's the absolutely wrong approach."
Poking around, I found plenty of services catering to dentists hoping to increase their incomes. One lecturer at a privately operated seminar called The Profitable Dentist ($389) aimed to help "dentists to reignite their passion for dentistry while increasing their profit and time away from the office." Even the ADA's 2014 annual conference offered tips for maximizing revenue: "Taking time to help our patients want what we know they need," notes one session description, "can drive the economic and reward engine of our practice."
Upselling in dentistry isn't a new phenomenon, but it's having a moment. One reason: Dental school tuition—and debt—has doubled since the '90s. According to the American Dental Education Association, students who graduated in 1996 were in the hole $112,000 (in 2013 dollars), on average, while 2013 grads were a whopping $215,000 in debt—28 percent were on the hook for $300,000 or more. By contrast, the average med school grad owed $170,000. ADEA executive director Richard Valachovic explained that one reason dental schools have jacked up tuitions is the rising costs of technology for student labs.
In any case, a generation ago, newly hatched dentists would join established practices as modestly paid associates, with the promise of eventually becoming partners. But these days, with dentists retiring later, there's less turnover in private practice. Instead, more and more young dentists are taking jobs with chains, many of which set revenue quotas for practitioners. This has created some legal backlash: In 2012, for example, 11 patients sued (PDF) a 450-office chain called Aspen Dental, claiming that its model turns dentists into salespeople.
That laser dentistry and whitening package may be a ploy to get you in the door so the practice can upsell you on more-profitable procedures.
Some corporate dentists appear to have crossed the line into fraud. In 2010, Small Smiles, a venture-capital-owned chain with offices in 20 states, was ordered to refund $24 million to the government after an investigation found that its dentists had been performing unnecessary extractions, fillings, and root canals on children covered by Medicaid. A new lawsuitalleges that some toddlers it treated underwent as many as 14 procedures—often under restraint and without anesthesia. (The group was banned from Medicaid this year.) Several other pediatric dentistry chains have been sued over similar allegations.
So what should you watch out for when you go for your next cleaning? First, beware of specials: That laser dentistry and whitening package may be a ploy to get you in the door so the practice can upsell you on more-profitable procedures. Van Dyk also advises caution if your dentist insists on replacing all your old fillings or always recommends crowns instead of fillings. And look out for excessive X-rays: The ADA says healthy patients need a full set (14 to 22) every two years at the most. If your dentist recommends a special "cone-beam" X-ray, get a second opinion, since, along with a 3-D picture of your mouth, it delivers a dose of radiation up to 18 times that of a traditional dental X-ray. While the Food and Drug Administration has approved cone-beam scanners, some radiation experts worry that dentists are using them when a standard X-ray would do just as well. Finally, when it comes to children's dentists, make sure to find a board-certified pediatric specialist, since not all dentists that cater to children have special training.
The practitioners I spoke to were quick to add that even dubious-sounding treatments are in some cases medically necessary. But if your gut says your dentist is going overboard on treatment, get a second opinion. "Will you have to pay a little more for another consult?" Camm asks. "Sure. But it could end up saving you a whole lot more in the long run."

Monday, October 06, 2014

The Greatest Ancient Picture Gallery by William Dalrymple | The New York Review of Books

The Greatest Ancient Picture Gallery by William Dalrymple | The New York Review of Books: "propitiated"



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The Greatest Ancient Picture Gallery



dalrymple_1-102314.jpg
Massimo Borchi/Atlantide Phototravel/Corbis
A statue of the Buddha in one of the Ajanta caves, India
In the winter of 1844, Major Robert Gill, a young British military draftsman, set off from Madras into the independent princely state of Hyderabad to record a major new archaeological discovery.
Some years earlier, in 1819, a British hunting party in the jungles of the Western Ghats had followed a tiger into a remote river valley and stumbled onto what was soon recognized as one of the great wonders of India: the painted caves of Ajanta. On the walls of a line of thirty-one caves dug into an amphitheater of solid rock lay the most beautiful and ancient paintings in Buddhist art, the oldest of which dated from the second century BC—an otherwise lost golden age of Indian painting. In time it became clear that Ajanta contained probably the greatest picture gallery to survive from the ancient world, and along with the frescoes of Pompeii, the fabulous murals of Livia’s Garden House outside Rome, and the encaustic wax portraits of the Egyptian Fayyum, Ajanta’s walls represented perhaps the most comprehensive depiction of civilized life to survive from antiquity.
The Ajanta murals told the Jataka stories of the lives of the Buddha in images of supreme elegance and grace. Unlike the flatter art of much later Indian miniature painting, here the artists used perspective and foreshortening to produce paintings of courtly life, ascetic renunciation, hunts, battles, and erotic dalliance that rank as some of the greatest masterpieces of art produced by mankind in any century. Most famous, perhaps, are the two astonishing images of the compassionate Bodhisattvas Avalokitesvara and Vajrapani, beings of otherworldly beauty, swaying on the threshold of enlightenment, caught in what the great historian of Indian art Stella Kramrisch described, wonderfully, as “a gale of stillness.” Even today, the colors of these murals glow with a brilliant intensity: topaz-dark, lizard-green, lotus-blue.
When they were first published in the Transactions of the Royal Asiatic Society in 1829, it was clear that these precious fragments of a lost classical world were themselves of great fragility and in danger of disintegrating into a cloud of dust. John Smith, the leader of the initial hunting party that had rediscovered the caves, had carved his name across the body of a Boddhisattva, and it did not take long for word to spread that here were unprotected treasures ripe for the attention of Victorian hunters, tourists, and assorted other graffiti artists. Nine years later, Dr. James Bird, in the course of preparing a report for the Asiatic Society, “notwithstanding protestations about defacing monuments…contrived to peel off four painted figures” from the zodiac or shield, one of the finest of the paintings at the site. Before long a self-appointed Indian caretaker had set up shop in the caves and, “for a small consideration,” presented tourists with “souvenir fragments” of fresco.
This was a relatively benign intervention by the standards of the time: in the same decade, forty newly discovered masterpieces of Gupta sculpture had been taken from the archaeological site marking the place of the Buddha’s First Sermon at the Deer Park in Sarnath in northern India and “thrown into the Barna river under the bridge to check the cutting away of the bed between the arches.” Many of the bricks of the great Sarnath stupa built by the Emperor Ashoka were also carted away to build a new suburb of Varanasi in the mid-nineteenth century.
Luckily, shortly after Bird’s visit, the painted caves of Ajanta came to the attention of James Fergusson, the pioneering archaeologist, art historian, and early scholar of Indian Buddhism. It was Fergusson who first realized the real importance of the Ajanta paintings and the danger they were in. After making a detailed study of the site and giving the caves the numbers they still possess today (“I numbered them like houses in a street”), he sent for the painter Major Robert Gill to make copies of the paintings before anyone else attempted to prise them off the walls or decorate them with records of their visit.
Twenty-two years later, in 1866, the great Indian Uprising of 1857 had come and gone, the vengeful British had murdered hundreds of thousands of suspected rebels, the East India Company had been removed from power, and instead Queen Victoria had been proclaimed empress of a now fully colonized India—but Major Gill was still in his beloved caves, hard at work. When he finally sent his painstakingly detailed oil paintings to London for exhibition in 1866 at the Crystal Palace, they were almost immediately destroyed in the fire that engulfed the exhibition center. Tragically, the paintings had not even been photographed. Gill knew what he had to do: with astonishing sangfroid, he packed his bags and returned to the site to begin work again. He died there, still absorbed by his copying, in 1875.
Gill’s place was taken by John Griffiths of the Bombay School of Art, who arrived in 1872 and worked away for a further thirteen years. Ajanta has always had this effect on people. Not only are the murals of unrivaled beauty, depth, and complexity, the site itelf is extraordinary: a steep horseshoe-shaped sickle of cliffs cut by the Wagora River, located in the wild mountain country of the western Deccan. But when Griffith’s pictures were sent to London, many of these too were destroyed when a wing of the Victoria & Albert Museum went up in flames.
Then, in 1916, the Japanese artist Kempo Arai arrived in India to teach Rabindranth Tagore calligraphy. Like Gill and Griffiths before him, he too spent many years tracing the murals through thin Japanese paper—the traditional Japanese method of making copies of artworks. On completion, Arai sent his work back to Japan, where they were stored at Tokyo Imperial University before they were destroyed by fire during the Taisho earthquake.”1
In our own time, the caves have lost none of this ability both to enrapture and entrap those artists and scholars who fall in love with them, and a whole sequence of modern academics have spent their entire careers studying the caves—Dieter Schlingloff,2Monika Zin, Naomichi Yaguchi, and perhaps most notably and prolifically, Walter Spink of the University of Michigan.
I first saw the caves when I was eighteen, on a backpacking trip to India exactly thirty years ago, in the summer of 1984. Staying the night in the modest tourist department rest house at Fardapur, a short walk from the caves, I happened to bump into Walter Spink. He had already lived in the rest house for as long as anyone could remember, and even then was recognized as a wonderfully enthusiastic and eccentric Ajanta obsessive. It was thirty years since he had published his first essay on Ajanta, in 1954, and the evening I met him he sat up under the stars regaling my companion and me with stories about the caves and his theories of how they were built.
Three decades later, Spink, now in his mid-eighties, is still resident in Fardapur for part of the year. In addition to bending the ear of any receptive passing traveler, he has just finished the seventh and final volume of his lifework—Ajanta: History and Development—while the handsomely bound and beautifully illustrated Volume Six is just off the presses.3
Spink’s long, lonely decades of work on Ajanta are one of the most remarkable examples of art historical focus and dogged scholarly obsession in the field, and Spink is widely respected for both his charm and tenacity. But probably inevitably, not everyone accepts Spink’s unorthodox version of the construction of the caves, and his conclusions about his beloved Ajanta are widely debated and, especially in India, the subject of some controversy.
The valley of Ajanta was first settled by Buddhist monks in the second century BC, about two hundred years after the death of the Buddha. It is probable that the Buddha envisaged his monks as leading a peripatetic life—the life of the wandering thinker that he had himself led: “You cannot travel on the path,” he said, “before you have become the Path itself.” Yet by the second century BC, when the great rock-cut monasteries of western India began to be constructed, Buddhist monks had already started to turn away from the road to embrace instead the more sedentary life of the hermit in his cell.
When the rains made travel impossible, the Buddha had allowed his followers a “rain-retreat.” During this time the bhikkhus—literally beggars—were allowed to congregate on higher ground and to live in huts of wattle and daub, or better still in natural caves in the Himalayas and the mountains of the Western Ghats. It was from these sites, in time, that the great Buddhist monasteries arose.
Excavated shortly after the collapse of Ashoka’s great Mauryan Empire (322–185 BC),which had once stretched from Kandahar to the Vindyas, caves nine and ten at Ajanta are some of the oldest extant rooms in the world: from the paleographic evidence, scholars believe the years between 90 and 70 BC to be the most likely period of construction. These long chaitya, or prayer halls, lined with tapering octagonal columns, ending in a rounded apse that encloses the perfect dome of a tall stone stupa, were thus probably already old when Augustus started the rebuilding of Rome.
The early rock-cut cave monasteries of western India also predate almost all the extant texts of Buddhism (written beginning in 100 BC but mostly surviving in much later copies), and all we know about them comes from the Sanskrit and Pali inscriptions left on the rock walls by the monks, their patrons, and devotees. By then the great monasteries of ancient India appear to have been as powerful as those in medieval Europe, and often had their own mints and owned landed estates, some of which were worked by slaves.
The second century BC was a period of great expansion of international trade, and these monasteries, remote as they may seem now, were originally built on the great trade routes of their time. The valleys they crown once saw the frequent passage of caravans bringing luxury goods—ebony, teak, and sandalwood, ivory and translucent Indian textiles, pepper and cinnamon—to the coast where they would then be shipped, usually by Jewish and Greek middlemen, to the Red Sea and thence to Rome.
The inscriptions show how surprisingly middle-class and mercantile early Buddhism was, and it is clear that the patrons of these early monks were often traders or their bankers. More surprising still, some of them designate themselves as Yavanas—“foreigners,” probably Greeks. As Walter Spink’s pupil Pia Brancaccio has pointed out, the Ajanta murals
portray a prosperous and multicultural environment filled with people wearing golden jewels and…enjoying imported goods. Even the pigments used in the paintings indicate international trade connections—the blue, for example, was obtained from lapis lazuli imported from Iran or Afghanistan…. Recognizable among the crowds are many foreigners, easy to spot because of their different clothes, hairdos, and in some cases even skin colors…. Foreign figures appear so commonly in the murals that they must surely have been part of the social scene at the time.4


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Charles and Josette Lenars/Corbis
Detail from a mural in Cave One at Ajanta, showing King Mahajanaka, at right
The scholar who has done more to open up the daily reality of the Buddhist monks who built Ajanta is Gregory Schopen. Schopen has apparently never been to India, but his brilliant essays, collected in four pathbreaking volumes, based on close study of the published inscriptions at the early Buddhist sites, have arguably done more to alter our understanding of the early Buddhist world than any other scholar since James Fergusson in the nineteenth century.5
He is a witty as well as a polymathically erudite and learned writer, and he delights in showing how readily scholars of Buddhism have romanticized their subject, relying on Buddhist texts that often date in their current form from many centuries after the early monasteries: most of the texts we use to study Buddhism today “may not even have been known to the vast majority of practicing Buddhists—both monks and laity.”6
Schopen shows how the inscriptions left at Buddhist sites tend to record a far less idealized picture of life in early Buddhist India than the later documents that have been the foundational texts of modern Buddhist scholarship. He points out, for example, that Buddhist monks, far from being the otherworldly creatures often imagined by Western scholars, were frequently extremely worldly and “men of considerable wealth,” running businesses and mints; many were clearly sleeping around, lending money, and writing treatises on such unexpected subjects as inheritance law, medicine, and eroticism; some were even getting into sectarian fights, hoarding weapons, destroying the stupas of rival orders, and abusing and occasionally trying to murder nuns. They were, in other words, not saints but normal human beings.
Moreover, Schopen has shown that though it may have been the ideal that Buddhist monks give away all their property and abandon their families, in practice this was clearly not happening, as is shown by inscriptions where the majority of large donations to the monastery are recorded as coming from monks and their relations.7 Inscriptions in cave ten, for example, record a variety of small donations from several monks with names such as Dharmadeva, Buddhinaga, and Sikhabhadra, the latter “in honor of his mother and father.” One pillar was “the meritorious gift of the teacher Sachiva. Whatever merit is in this, let that be for the good of all sentient beings.”
As Schopen has also shown, the chaitya halls executed around 200 BC were some of the first spaces in Asia specifically made for congregational worship. They were created as part of a momentous change in religious practice, and provided a setting for a new form of communal Buddhist worship directed at the stupa, the domed, moundlike structure containing Buddhist relics, which had come to be seen as the living embodiment of the Buddha, rather as later generations of Catholics would look to the tabernacle, the place where the Eucharist is stored, as the location of the Real Presence. In these halls, the monks of Ajanta would gather together to have a “direct, intimate contact with a living presence.” The cult of stupa worship, writes Schopen, was “monastically controlled and monastically dominated…a primary concern for the monastic community and a necessary prerequisite for its continuance.”8
The monks may have long gone, but reverence is still something these early caves invoke, and visiting them today you see crowds of chattering tourists instantly hushed by the dark, solemn splendor of their painted interiors. With some of these early images, particularly with the newly rediscovered and restored early cycles from cave ten, probably dating from the first century BC, we are in a world so astonishingly lifelike that even today they can still make you gasp as you find yourself staring eyeball to eyeball with a silent soldier who could have fought the Bactrian Greeks in Afghanistan, or a monk who may have seen the Buddha’s relics interred at Sanchi.
So realistic are the faces of the people depicted, so direct are their expressions, that you feel that these have to be portraits of real individuals, glowing still with the flame of eternal life. There is something deeply hypnotic about the soundless stare of these silent, often uncertain, ancient Buddhist faces. Their fleeting expressions are frozen, startled, as if suddenly surprised by, say, the decision of the king of Varanasi to loose an arrow on a hunting trip or by the nobility of a great elephant breaking through the trees of the jungles. The viewer peers at these figures trying to catch some hint of the upheavals they witnessed and the strange sights they saw in ancient India. But the smooth, intense, humane faces stare us down.
It is the second phase of activity in the caves under the Hindu Vatakata Emperor Harisena (circa 475–500 AD), ruler of the Deccan, that most interests Walter Spink. It was during this fifth-century period of construction—a full six hundred years after the first caves were carved—that twenty-six of the thirty-one caves, and all the most elaborate ones, were dug. Rejecting the conventional line that these caves were the work of many generations of laborers burrowing away into the hillside, century after century, Spink believes that with the exception of the five early caves, the rest were constructed in a mere sixteen years between 462 and 477 by Harisena, whom he describes as one of India’s greatest rulers.
This phase took place after a long period of decline in Indian Buddhism, when the religion was fast heading into extinction in South Asia—like a last bright flicker of the guttering Buddhist lamp. In contrast to the earlier period of community patronage, it is clear that in the age of Emperor Harisena each cave had one single very rich patron—a man like the monk Buddhabhadra, the chief donor of the opulently appointed cave twenty-six, who was clearly a man of considerable wealth: in his inscription he describes himself as “the friend of kings.” As Walter Spink has noted, it is unlikely “that he spent very much time humbly wandering from village to village with his begging bowl as his predecessors in the early days of Buddhism did.”
Built to commemorate powerful individual patrons, these later caves were contructed, if not for eternity, then at least for the foreseeable future: as one inscription puts it, thesechaitya halls were deliberately made to endure a kalpa—an entire cosmic age. The dedicatory inscriptions give a good indication of the motives of the patrons who paid for this work: “Realizing that life, youth, wealth and happiness are transitory,” reads one, Varahadeva, minister to Harisena, made “this magnificent dwelling to be occupied by the best of ascetics…. It resembles the palaces of the Lord of the Gods, clothed in the brilliance of Indra’s crown. As long as the sun [shines]…may this spotless cave…be enjoyed!” “Even a single flower offered here can yield freedom, the fruit known as paradise and final emancipation,” reads the inscription of Buddhabhadra, the donor. “The wise man will show reverence.” He adds: “A man continues to enjoy himself in paradise as long as his memory is green in this world. One should therefore set up such a memorial in the mountains that will endure for as long as the moon and sun continue.”
According to Spink, the work of construction was done at high speed by large numbers of workers: after carefully studying the excavations and conducting experiments with his own students, Spink has come to the conclusion that working continuously with no days off, one hundred workers could have excavated even a large cave in less than a month. Likewise, with a large number of painters—say fifty artists—collected from across India, Spink believes that the original 50,000 square feet of painting could have been done in around a decade. The fact that many of the caves are unfinished is, he believes, evidence that they were being excavated simultaneously and that work stopped suddenly owing to some political crisis—probably the death of Harisena in around 500 AD. A few piecemeal additions continued during the brief takeover of the site by the rule of the local Asmaka dynasty between 475 and 479 and the period of disruption that followed before the site was abandoned in the mid-sixth century.
During this time Spink assumes that the site may not have been a practicing monastery at all—merely a vast construction site: Ajanta, he concludes, “was never a proper and workable monastic establishment.” This would explain why several of the cave sanctuaries appear to have been almost unused, while the large number of different artistic styles in evidence would be owing not to changing tastes over many decades, but instead to the large number of different families of artists at work on a single site at the same time: close study, he believes, shows several hands with different styles at work simultaneously on a single wall.
Sixty years into his Ajanta project, it is clear that Spink has lost none of his detective-like eye for detail, and the latest volume, like its predecessors, bears witness to his astonishing inch-by-inch knowledge of every door jamb and window sill on the site. Even as he heads toward his nineties, Spink can spot details that anyone else would miss: for example, how a particular shrine may never have been used, since there was “no ritual soot,” and a “garland hook in its shrine antechamber” was never hung with flowers for worship, because “unlike its counterparts…the plaster around it remains unbroken”; or, conversely, he realizes by spotting the heavy “wear in the pivot holes in which the doors turned” that another cave was older and more frequented.
Many scholars, especially those in India, remain dubious that such an extensive body of work—excavation, painting, and sculpture—could all have been accomplished in so short a period of time; but even if you question Spink’s short chronology, there is no doubt that his work represents a huge contribution to the understanding of the site. His thesis remains unprovable, but his is certainly the most detailed study of the making of the caves ever conducted.
Walter Spink’s work is principally concerned with the construction of the site, but he has little to say about the theological world inhabited by the monks or the programs of painting they commissioned. In those fields, perhaps the most interesting new work has come from one of Schopen’s pupils, Robert DeCaroli, who has studied the persistence into early Indian Buddhism of earlier pre-Buddhist popular nature religions, and Vidya Dehejia, who recently has focused on the surprisingly sensuous nature of the Ajanta paintings.9
For the theological world of Ajanta is often very different from what we might expect, far from the pure and philosophically abstracted Buddhism sometimes projected onto the period by Western enthusiasts. Instead, it is clear that early Indian Buddhism was shot through with the cosmology of the animist cults that had existed in these hills before the arrival of the new teachings: all over the early Buddhist sites are inscriptions and carvings honoring the guardian gods and tutelary godlings who lived in the trees and stones and water around them and were capable of attacking, protecting, or possessing their human and monastic neighbors. Inscriptions reveal an imagined world full of hungry ghosts howling from the charnel grounds, voluptuous, nearly nakedyakshi tree spirits, and their royally attired and well-fed male counterparts who could be persuaded to act as guardians if properly propitiated.


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Universal History Archive/Getty Images
Detail of mural from the Ajanta caves
Nagas, or snake deities, are particularly prominent, and their cults were well integrated into the life and worship of the monasteries. This is made especially clear by the inscription left by Minister Varahadeva, which states that the mountain around the caves was home to a Naga king, and whose portrait sculpture, crowned with a wonderful plume of cobra heads, guards the stairs leading to cave sixteen.
The decoration of Ajanta may have been designed for monastic buildings constructed to house ascetics, but while the paintings do depict Buddhist themes, the stories chosen tend to depict the princely world of the courtly patrons rather than that of the monks. Here, beside handsome, bare-chested kings, narrow-waisted princesses decked with tiaras of jasmine languish lovelorn on swings, while dancing girls of extraordinary sensuousness, dressed only in jewels, perform beside lotus ponds.
While the choice of subjects may surprise us today, the Ajanta artists clearly saw nothing odd in this juxtaposition of monk and dancing girl: in the Indian tradition, whether Hindu, Jain, or Buddhist, the sensuous is seen as an integral part of the sacred. As Vidya Dehejia puts it, “the idea that [such sensual images] might generate irreverent thoughts did not arise; rather, the established association appears to have been with accentuated growth, prosperity, and auspiciousness.” The celibate Buddhist monasteries of Ajanta were filled with images of sensuous, half-naked women—because in the eyes of the monks and their patrons this was not just permissible, but completely appropriate decoration.
  1. 1
    Manager Singh and Balasaheb Arbad, “Chemistry of Preservation of the Ajanta Murals,” International Journal of Conservation Science, Vol. 4, No. 2 (April–June 2013). 
  2. 2
    Dieter Schlingloff is widely regarded as the greatest art historian of the Ajanta murals, and his work, assisted in many cases by Monika Zin, has revolved around minutely identifying the stories told in the murals. Many of his most important essays are translated into English in Studies in the Ajanta Paintings: Identifications and Interpretations(Ajanta, 1987). His recent Ajanta Handbook to the Paintings (New Delhi: Aryan Books International, 2013) is the best existing guide to them. 
  3. 3
    Walter M. Spink, Ajanta: History and Development: Volume 1: The End of the Golden Age (Brill, 2005 ), Volume 2: Arguments About Ajanta (Brill, 2006), Volume 3: The Arrival of the Uninvited (Brill, 2005), Volume 4: Painting, Sculpture, Architecture Year by Year (Brill, 2009), Volume 5: Cave by Cave (Brill, 2007), Volume 6: Defining Features(Brill, 2014). 
  4. 4
    Pia Brancaccio , The Buddhist Caves at Aurangabad: Transformations in Art and Religion (Brill, 2011), p. 80. 
  5. 5
    Gregory Schopen, Bones, Stones, and Buddhist Monks: Collected Papers on the Archaeology, Epigraphy, and Texts of Monastic Buddhism in India (University of Hawai’i Press, 1997), Buddhist Monks and Business Matters: Still More Papers on Monastic Buddhism in India (University of Hawai’i Press, 2004), Figments and Fragments of Mahayana Buddhism in India: More Collected Papers (University of Hawai’i Press, 2005), and the recent Buddhist Nuns, Monks, and Other Worldly Matters: Recent Papers on Monastic Buddhism in India (University of Hawai’i Press, 2014). 
  6. 6
    Schopen, Bones, Stones and Buddhist Monks, p. 2. 
  7. 7
    These themes and the question of how monks interacted with their families have been studied in a fascinating new book by one of Schopen’s pupils, Shayne Neil Clarke, Family Matters in Indian Buddhist Monasticism (University of Hawai’i Press, 2014). 
  8. 8
    Schopen, Bones, Stones, and Buddhist Monks, pp. 116, 34, 93, 126. 
  9. 9
    Robert DeCaroli, Haunting the Buddha: Indian Popular Religions and the Formation of Buddhism (Oxford University Press, 2004), Vidya Dehejia, Early Buddhist Rock Temples: A Chronology (Cornell University Press, 1972), and The Body Adorned: Dissolving Boundaries Between the Sacred and Profane in India’s Art (Columbia University Press, 2009).