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A Concise History of Science in India c8.s5: Āyurveda: Practice and Application

A Concise History of Science in India c8.s5

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English

Contents

Āyurveda: Practice and Application

Ethics of the Medical Profession

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A practitioner in Āyurvedic medicine was expected to be a qualified person in all senses of the term. The qualities demanded for this calling were self-control, courage, compassion, integrity of character, keen intelligence, retentive memory, insight, acuteness of perception, purity of mind and body and, of course, a thorough knowledge of the theoretical, textual and practical branches of medical science. These qualities were assured as far as possible by limiting studentship to healthy, well-born youths who could be expected to have the proper potentialities and special aptitudes for learning. The student graduated into the profession only after a long period of study and practical training under competent, inspiring teachers. The intending physician was free to choose a particular branch of Āyurvedic knowledge as his special field, but was required also to have an adequate knowledge of the other branches and as much as possible of other sciences and philosophies which help in giving a comprehensive grasp of *Āyurveda* and the real significance of its diverse informations and its philosophical basis. Before starting practice he had to demonstrate beyond all doubt that he had thoroughly mastered his subject and had been properly trained in making independent observations and practical applications of his knowledge. Only then was he given permission to practise independently. A State licence was also required.a

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a *SS. Śa.*, **4**. 32-35.

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b *SS. Sū.*, **29**. 23-29.

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c *SS. Sū.*, **4**. 32-35.

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Aspirations to success, wealth and fame were considered normal on the part of a physician, but obligations to society and patients must always have prior claims. Desertion of, or injury to, patients under any circumstance was strictly forbidden. A physician’s duty is to treat all deserving persons to the best of his ability. But habitual sinners, morally degraded and depraved persons and professional killers (even of animals) were not considered deserving persons.b

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When a physician takes up a case, he should whole-heartedly apply all his skill, faculties and knowledge to his work. He should remember that patients trust their physicians implicitly to the extent of placing their lives unhesitatingly under his care. This is true even of patients who have no trust in their own relations, parents and children. Hence a physician should take as much care of each and every patient as he would of his own child.c He may, however, refuse to take up cases where the disease appears to be incurable.d

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The physician was expected to place the maximum facilities possible at the disposal of his patients, maintain a nursing home and dispensary, prepare medical prescriptions from raw materials under his own supervision and arrange for the services of nurses and qualified attendants.e In private practice, he must not enter a residential house without proper introduction, nor attend a woman in the absence of her husband or guardian. He must not also say or do anything which might give a mental shock to the patient or to the relatives and friends of the patients. He must not divulge any information he had learned in his professional capacity.f

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A physician should remain a learner all his life, gaining experience, knowledge and understanding all the time. He should discuss problems with other physicians and take part in debates and discussions. He is expected to lead a disciplined and unostentatious life, to be pleasant in his manners and speech, and considerate in all matters. Friendship towards all, compassion for the ailing, devotion to his noble profession and a philosophical attitude to cases with fatal endings—these are declared to be the four corner-stones of medical practice.g

Classification and Diagnosis of Diseases

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Diseases are the manifestations of the three humours, in their abnormal states, in an organism which already has a propensity for humoral aggravation due to inherent imbalance of humours. Hence *Āyurveda* has classified diseases by the humour affected (also in some cases by blood, which can be vitiated), and also by the causes which can trigger off such aggravations.

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a *CS. Vi.*, **8**. 3–13; *SS. Sū.* **2**, 4, 5 and 10.

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b *CS. Vi.*, **8**. 13, 20; *SS. Sū.* **2**. 5.

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c *CS. Sū.*, **25**. 24–25.

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d *CS. Sū.*, **10**. 8.

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e *CS. Sū.*, **15**.

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f *CS. Vi.*, **8**. 13.

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g *CS. Sū.*, **9**. 26.

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Classified according to humours (or blood), diseases are of the following types: due to *vāyu*, due to *pitta*, due to *śleṣman*, due to blood, due to two of them at a time, and due to three of them at a time. When all the three humours are deranged simultaneously, the disease is of the *sānnipātika* type and expected to be severe or even fatal. Classified according to the causes which aggravate the imbalance, all deviations from the healthy state are of three types. The first type, *ādhyātmika* (generated inside the organism or the mind), can be of three origins: *ādibalapravṛtta* (inherited from the stage of sperm-ovum), *janmabalapravṛtta* (acquired after conception but before birth, from the mother, her behaviour and other environmental factors) and *doṣabalapravṛtta* (caused during life by improper conduct, diet, etc.). The second type, *ādhibhautika* (due to adverse outside causes), can be of two origins: *saṁghātabalapravṛtta* (due to painful physical contacts, accidents, poisonous bites, etc.) and *kālabalapravṛtta* (due to abnormal or climatic conditions). The third type, *ādhidaivika* (due to fate, malign influences and other unknown reasons), can also have two origins: *daivabalapravṛtta* (providential, caused by 'acts of God', demoniac influences, charms, spells, natural calamities and epidemic diseases) and *svabhāva-balapravṛtta* (caused by factors which become inevitable with time, like sleep, hunger, thirst, senility and death).

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The above classification is found in the *Suśruta Saṁhitā*.a The *Caraka Saṁhitā* gives only three major origins: *nijaśarīradoṣaja* (of humoral origin, generated inside the body), *āgantuja* (communicated from outside) and *mānasa* (mental diseases).b The later texts by Vāgbhaṭa, Mādhava, Cakrapāṇidatta, etc., also give elaborate classifications and subclassifications on the general lines given by Suśruta but differing in details and nomenclature.

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All the major texts are also in agreement regarding the principles on which diagnosis is possible, though in some cases like the *Mādhavanidāna*, many chapters are devoted to a learned elaboration of the simple principles. In every case the aetiology, symptoms and prognosis are to be studied and compared to those described in the authoritative texts for different diseases. But, in diagnosis, the personal factors which cannot possibly be found in texts are of major importance. The patient's age, social status, heredity, usual residence, occupation, physical features, hardiness, vitality, habits, accustomed diet and usual appetite form the background which has to be filled in by interrogation and detailed personal examination by the physician who is advised to take the maximum help from his own trained senses. The physician should carefully observe the patient's present appearance, vitality, voice, acuteness of sense perceptions, clarity of mind, memory, any abnormality of behaviour, intestinal and other sounds, pulse, skin, bodily excretions, etc. When necessary, a sample of blood should be drawn and subjected to certain tests. Latent symptoms should be brought to the surface by provocative medication.a

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a *CS. Sū.*, 24.

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b *CS. Sū.*, 1, 19.

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Even with all the above knowledge at his command, the physician can make a correct diagnosis and decide upon a course of treatment, only if he has the mental calibre to apply properly his theoretical knowledge (which should be accurate and extensive) of all diseases and their different complications. He should have at his finger-tips the knowledge of the specific sources, exciting factors, preliminary indications, concomitant symptoms, possible complications and aggravations, variations of symptoms according to degrees of severity, period of duration and indications of recovery or imminence of a fatal end.b The physician should remember that some pathological symptoms are secondary effects of other diseases and may occur either simultaneously with the original disease resulting in a confusion of symptoms, or become apparent after the original malady subsides.c

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Though the above-mentioned personal factors are all important in diagnosis there are certain rational principles on which a diagnosis is to be based. These principles are too technical to be discussed here. The reader is referred to any reliable edition of *Rugviniścaya* by Mādhavakara, popularly known as Mādhavanidāna, for a masterly discussion of these principles.

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Though symptoms are generally valuable only as indicatives in diagnosis, the physicians should remember that in some cases the specific symptoms (or secondary symptoms) can become so violent and harmful that they should be checked first by any means, as otherwise they may prove more harmful than the disease itself. Symptoms are of three classes: *pūrvarūpa* (indicatory symptoms pointing to a future malady, latent in the system), *prāk-kevala* (specific symptoms appearing along with the onset of the disease) and *aupasargika* (secondary symptoms not specific to the disease, which may develop during the course of disease or after the latter has run its course).d

General Principles of Treatment

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Treatment in *Āyurveda* is fundamentally a process of restoration and building up, consisting largely of elimination of undesirable ingredients and replacing them (and also inherent deficiency) by desirable ingredients from outside. Except in emergencies, medical measures have always the long-term aim of restoring the lost equilibrium of *doṣas* and *dhātus*, or of stabilizing any imbalance which may be present in a state of apparent health. All drugs and medicinal measures, as also surgery, are employed to these ends; so also are diet and conduct recommended to the patient. In pursuance of these aims, *Āyurveda* makes no distinction between hygienic measures, preventive medication and therapeutics, or between items of diet and oral medicine.

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a *CS. Vi.*, **4.**

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b *CS. Vi.*, **4.**

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c *CS. Vi.*, **8.**

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d *SS. Sū.*, **35.** 13–15.

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Food, drugs, therapeutical and surgical measures, daily routine in health and medical measures in sickness—all are, therefore, oriented to the paramount need of creating an equilibrium of the *guṇas*, *doṣas*, *dhātus* and *malas*, individually and jointly. Only then it is possible to uproot the causes of the disease. These ideas apply equally to the mind and the body; for in the case of the mind the equilibrium can be similarly upset by an imbalance of the *guṇas* beyond normal levels. Mental treatment, therefore, requires psychic catharsis and spiritual rebuilding.

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As stated previously, the actual medical measures depend upon the disease; and diagnosis depends upon a host of variable factors most of which are individual. Though there cannot naturally be any hard and fast rules, there are certain common denominators in the Āyurvedic treatment of all pathological conditions. These are *saṁśodhana* (cleansing and evacuative processes), *saṁśamana* (tranquilization and rectification of humours and *dhātus*), *āhāra* (proper drugs taken orally, and diet) and *ācāra* (correct conduct and medical regime). All these apply equally to physical and mental processes, which also must be purified, tranquilized, fed with proper ideas and trained to think in proper lines. So in *Āyurveda* prayers, propitiation, spiritual guidance, exorcism of evil influences, etc., are of as much importance as medical measures.a

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Public hygiene is also not neglected in *Āyurveda*. People are urged to avoid all filth like offal, broken fragments and dirty grounds. Blowing or picking the nose in public and committing nuisance on a public road are forbidden. Dirty and inadequate dress, crude habits of eating, drunkenness, gambling and associating with prostitutes are considered unhealthy practices to be strictly avoided.b

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The dictum of Manuc not to pollute public waters is in conformity with Āyurvedic teachings. Contaminated waters and waters of public baths are recognized as major sources of ill health and epidemics, and the use of only clean and pure water from natural sources is recommended in all the texts.

Special Methods of Treatment in Āyurveda

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It has been said earlier that all substances are potentially medicinal drugs as they partake of the properties of the elements constituting them. But the selection of any food or drug in any disease, or for maintaining health, depend upon whether it contains the qualities sought for correcting the humoral state. The intrinsic qualities of all substances are taste, assimilability, potency, physical properties and specific physiological or therapeutic action. All these qualities have to be considered in selection; but taste, assimilability and therapeutic action are more important than the other two.d When a single substance is not available to satisfy all the desired qualities (as it is very often the case), more than one material is used in combination to meet the ends. Thus arise the *yogas* or prescriptions containing a multiplicity of drugs.

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a *Aṣṭ. Hṛ. Sū.*, 2; *SS. Sū.*, 1.

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b *CS. Sū.*, 8.

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c *MS.*, IV. 56.

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d *CS. Sū.*, 26.

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The four initial requirements of Āyurvedic treatment are good physicians, good nurse-attendants, good medicines and methods, and obedient patients.

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Among specific therapeutic methods, regular cleansing of accumulated bodily wastes and of internal organs get the pride of place in *Āyurveda*. Other methods (apart from oral medication which is the most common) include eye-drops, eye-salves; gurgles, fumigation of the ear, nose and throat areas;a liquid unguents, lotions, creams, skin salves, ointments, medicated oils, medicated clarified butter, etc., for the skin surface;b suppositories, tampons, soaked cotton swabs for the bodily openings; enemas, douches, etc., applied by catheter tubes, douche-cans, etc., for the rectal, vaginal and urethral passages;c sun-bath, steam, steaming decoctions, hot air and hot surfaces, hot immersion baths, hot fomentation, etc., for sudation and cleansing the skin pores;d and fomentation with absorbable drugs, mud-packs and poultices for local medication. The use of water sterilized by boiling or immersion of hot substances,e antisepsis by fumigation with benzoin group of drugs, arsenic compounds, use of hypertonic salt solutions for surgical dressings, astringents as styptics for bleeding wounds and abrasions, use of cautery, intense cold and tying blood vessels in uncontrollable haemorrhage and use of alcohol for inducing anaesthesia are found scattered in the texts.

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Psychiatric methodsf are also among the special methods of *Āyurveda*.

Āyurvedic Surgery

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The high achievements of Āyurvedic surgery have been described in an earlier section. The general excellence of Āyurvedic surgery is attested by the remarkably rational concepts and scientific methods found in the texts. Details of such methods are naturally out of place here.

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According to Suśruta, surgery is the best, quickest and generally the most successful method of treatment,g as it involves total removal of the diseased or morbid accumulations of *doṣas*, *dhātus* and *malas* and gives the organism a better chance to acquire a new equilibrium by post-surgical medication to replenish the removed tissues, fluids, secretions, etc. Surgical treatment, according to *Āyurveda*, is not limited to the use of surgical instruments alone but a complete course of treatment, including diagnosis, preparatory methods and measures, actual operation and post-surgical methods, to aid healing and restoration of health.h The *Suśruta Saṃhitā* recommends the use of bandages, splints, padding materials, plugs, lints, tourniquets, ligatures, horse-mane, human hair, silk and other threads, boiling and cold water, honey, milk, clarified butter, vegetable oils, pulverized cereals soaked in water, caustic and mild alkalis, heated metals, astringent pastes and solutions, setting plasters, ointments and alcoholic liquids as aids in surgical processes. For the different types of surgical processes (listed as incision, excision, scraping and softening of epidermic layers, puncturing, probing, extraction, draining and suturing) used for various conditions requiring surgery, 24 different manipulative methods (including sucking out, flushing, compression, wrenching, injections, etc.) are described. A great variety of surgical instruments including scalpels, razors, saws, probes, needles, hooks, forceps, pincers, hammers, tubular appliances, hollow hemispheres, horn instruments, speculums, etc., made of tempered hardened iron and other metals are described.a

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a *CS. Sū.*, 5.

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b *CS. Ci.*, 6 and 7.

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c *CS. Sū.*, 1, 9, 10 and 11.

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d *CS. Sū.*, 14.

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e *SS. Sū.*, 45.

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f *CS. Vi.*, 6.

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g *SS. Sū.*, 1.

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h *SS. Sū.*, 7.

Āyurvedic Materia Medica

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*Plant and Animal Substances*

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The *materia medica* of *Āyurveda* is extensive, and utilizes substances from the animal, vegetable and mineral kingdoms. The humoral conception of the diseases and their remedies together made this extensive *materia medica* logical and even compulsory. For, according to the basic theory, the different properties and constitutions of all different substances made them valuable in some condition or other. A study of the Āyurvedic texts makes it clear that the drugs included had each been selected after careful clinical experiments and long experience. The specific properties like taste, assimilability, potency, physiological actions are described in almost all cases.

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These experiments were naturally conducted mainly with materials available in the environment, which explains the strong preference shown by classical *Āyurveda* for plant remedies of the indigenous varieties. A second reason for this preference was that the plants being composed of all the five elements (according to the *pāñcabhautika* theory) had a natural flexibility and wider range of application, compared to inorganic matters composed of the earth element only. This advantage was shared by animal products but their use was limited by availability and variety, and possibly by lesser efficiency in actual application. A statistical break-up of the *materia medica* in the *Caraka Saṃhitā* shows 341 plant-substances, 177 drugs of animal origin and 64 mineral substances, metals, etc.b The corresponding numbers for the *Suśruta Saṃhitā* are 395, 57 and 64 respectively. The animal products are found less and less in the later works. These numbers no doubt reflect their tradition-*cum*-availability and also efficacy in comparison with each other. But in the case of inorganic remedies, the choice was limited to the few locally available metals and minerals, the synthesis of new inorganic compounds being still unknown.

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a *SS. Sū.*, 7 and 8.

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b Rāy and Gupta, pp. 38–85.

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Plants provided the natural and traditional drugs for most oral and non-oral medication. A clear understanding of their properties had led to their rational classification into different groups according to therapeutic actions. A list found in *Caraka* gives 50 different groups.a But in spite of the wide range of available varieties, many conditions required more than one drug, sometimes of different groups, sometimes in combination with animal and mineral matters also. This multiplicity of drugs for a single disease was based not only on theory but also on experience. If both (or all three, four, etc.) had been found valuable for various conditions, of a disease, it was quite logical to use all of them at the onset of a disease, when the prognosis was still not known. In this way, with new experiments and new clinical experience through centuries, more and more ingredients would enter into a single prescription, in the hope of possible benefit to the patient, due to inherent conservatism, and finally due to the supposed sanctity of written texts. Nothing would be dropped out against the new additions, and prescriptions sometimes grew to alarming proportions, containing literally hundreds of ingredients. To manage into homogenous form different solid, squashy, semi-solid and liquid substances, a great deal of compounding skill had to be brought into play. Even in the earliest texts we find elaborate directions for extracting the active constituents of organic substances and homogenizing them. Thus developed the remarkable and elaborate processes met with in the *saṃhitās*. Many of them have survived unchanged and form part of modern Āyurvedic pharmacological practice. They are named and sometimes described in detail in various passages while giving instructions for compounding prescriptions or extracting drugs from crude materials. They include the processes of solution, maceration, trituration, extraction with water, preparation of tinctures, preparation of emulsions, or solutions in oily liquids, extraction of essential oils and juices, pasting, coagulation, filtration, decantation, sedimentation, dilution, concentration, precipitation, gel formation, desiccation, dehydration, percolation, evaporation, distillation, fractionation, sublimation, steaming, combustion, chemical combination, etc. Actual weights and volumes were obtained by balances and measuring vessels, and a large number of other apparatus were used.b But all these methods were those of the pharmacy. There is little evidence of synthetic preparations of either inorganic or organic compounds. Processes for the dissolution of finely divided iron, gold, silver, gems, minerals, etc., in vegetable acids for medicinal preparations are found in some passages. The use of mercury is referred to in the *Suśruta Saṃhitā*, but only as an ingredient of a cosmetic preparation.c

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a *SS. Sū.*, **4.**

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b Rây and Gupta, p. 114.

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c *CS. Ci.*, **11, 12** and **21**; *SS. Ci.*, **25. 20.**

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Inorganic and Metallic Remedies

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After the age of Caraka and Suśruta we find a steadily increasing complement of inorganic substances among Āyurvedic medicines. The incoming materials differed from the readily available and naturally occurring inorganic substances mentioned in the earlier works; most of them were synthetic substances or minerals and ores transformed by chemical processes or metallurgical treatment. The beginning of this trend is found in Vāgbhaṭa’s works. These inorganic medicaments got a fillip from the researches of many generations of alchemists and iatrochemists who discovered many valuable chemical and metallurgical processes and devised new and workmanlike apparatus for their work. How these substances came to be used as medicines cannot now be ascertained with any accuracy, but the ‘philosophy of mercury’ and the prestiges of Vṛnda and Cakrapāṇidatta who first gave them a status as medicine must have helped. The advantages which gave these medicines an ever-increasing popularity among medical practitioners during the centuries have been recounted earlier. Another possible reason was that they often proved valuable in conditions which would otherwise have needed surgery, for which there was a growing distaste in the profession.

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The processes and apparatus devised during this age belong properly to the history of chemistry in India. The mercurial preparations, however, occupy a special position in this field and a short account of them will furnish a sample of the notions and methods of Āyurvedic chemistry of the *Rasacikitsā* school.

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Mercury of a pure variety was obtained by the dry distillation of pure *hiṅgula* (cinnabar, HgS) in a retort and collecting the vapours in cold water (*Rasaratnasamuccaya* quoted in Sir P. C. Ray’s work). Mercury obtained from impure cinnabar or imported from outside contained toxic matters, lead, tin and other impurities and required re-purification to make it fit for internal medication. This purification was done by trituration in a mortar with certain (named) vegetable juices in several repeated operations, each alternated with washing by portions of cold water. It was finally distilled thrice in a clean retort and receiver luted with clay.

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Mercury is said to be ‘solidified’ by rubbing with gold or silver giving a bright, brittle, solid product. It can also be ‘solidified’ by roasting in a covered crucible with its own weight of sulphur and one-eighth its weight of gold. (These processes would not really result in the solidification of the liquid metal; by the first process mercury will be converted into an amalgam and by the second into a pasty mixture of the metal and its sulphide.)a

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Mercury is said to be ‘incinerated into an ash’ by prolonged trituration with certain mixtures containing oils and juices of vegetables, followed by heating the mixture in a covered crucible.b (The ‘incineration’ of mercury into an ash is *prima facie* impossible; the metal may be converted into solid crystallizable derivatives by these processes.) Cinnabar, heated in a closed crucible with other plants, is said to give powdered ashes of mercury. By triturating the metal with yet other plant juices, alternatingly heating and cooling the mixture seven times, and finally heating in a closed crucible with fresh quantities of the plant juices is said to result in a salt-like ash of mercury.

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a Ray (P. C.), I, p. 54; II, p. 4.

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b *Op. cit.*, I, pp. 73–74.

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Mercury is said to be ‘killed’ by distilling with an excess of sulphur. The red-brown sublimate of mercuric sulphide is known as *rasasindūra* or *makaradhvaja* and is believed to be a highly potent remedy for many diseases and for senile decay. Mercury heated on a sand bath with twice its weight of resublimed sulphur, and one-eighth its weight of pure gold is known as *siddha-makaradhvaja* supposed to be comparable to ambrosia in its efficiency. Some later works of the same *Rasa* school are rightly sceptical about the incorporation of gold into the sublimed product. They believe that gold is simply left behind, and hence it makes no difference whether gold is used or not, and that there is no difference between the two varieties of *makaradhvaja*. The varieties of *makaradhvaja* are fairly representative examples of this class of medicines. After many centuries of experience, their efficacy is no longer open to question, though not all that it is claimed to be. Their use has survived up to modern times.

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