The earliest culture in India of which we have archaeological evidence centered on Mohenjo-Daro and Harappa, chief cities of the Indus valley civilization, which flourished from about 2500 to 1500 B.C. An astonishing feature of this pre-Aryan urban culture was its advanced system of public sanitation. There were numerous wells, bathrooms, public baths, sewers, and chutes for collecting trash. Streets were laid out in regular fashion, and houses were well built and ventilated.
About 1500 B.C., an Aryan people invaded the Indus valley from the northwest and drove the earlier inhabitants down into the Indian subcontinent. These Aryan conquerors brought with them the basis for the subsequent religious and cultural development of India.
In the sixth century B.C., the Achaemenid Persian army of Darius I seized Gandhara and the Punjab region of northwest India, the easternmost extent of the Persian Empire. For a short time in the fourth century B.C., Alexander the Great, the Macedonian Greek leader, also occupied this northwest territory, but withdrew at the urging of his own army. Most of the rest of India was governed by the Maurya dynasty, which preserved the Aryan heritage. Asoka (273-232 B.C.), greatest of the Mauryan rulers, subsequently unified all of India except the southern tip. He was converted to Buddhism from the Hinduism of his ancestors and established it as the, state religion.
Hinduism is one of the oldest living religions, having evolved over a period of four thousand years. Initially it was a synthesis of the ancient religion brought in by the Aryans and the religious traditions of the Indus valley civilization. The body of literature of the Aryans known as the Veda (Sanskrit for knowledge) is the oldest scripture of Hinduism. The foundations of traditional Indian healing, called Ayurvedic (knowledge of life) medicine, rested on these ancient teachings together with a number of commentaries and later writings by healers such as Charaka, Sushruta, and Vagbhata.
Indian medical practices were gradually dispersed all over Asia, including the southeast, Indonesia, Tibet, and Japan. Furthermore, the translation of the Ayurvedic literature into Persian and Arabic in the eleventh century A.D. led eventually to further spread of Indian medical lore into Europe as writings in Arabic became part of European culture in the Middle Ages.
It is noteworthy that Indian religion and mysticism would permit a system of secular medicine which engaged in sound, rational practices, even though not completely free of magical and religious associations. Initially, illness was thought to result from punishment by the gods for sinning, but as belief in reincarnation developed the transgression itself would lead to retribution by nature. Humans were continually reborn until their karma (sum of actions in one existence which determined destiny in the next) entitled them to nirvana, or merging with the cosmic spirit. The universe was considered an eternal cycle of creation, preservation, and destruction.
Although there was a complex Vedic pantheon, the deities were but parts of the eternal whole, for Brahman, the power and spirit of the cosmos, permeated everything in the universe. The principal Aryan divinities were Indra (god of weather and war), Varuna (all-seeing god of justice and cosmic order), Agni (god of fire and sacrifices), and Soma (personification of the hallucinatory plant—no longer identifiable—used in Aryan rituals). As the Rig-Veda stated: They call it Indra, Mithra, Varuna, and Agni, And also heavenly, beautiful Garutman; The real is one, though sages name it variously.
In classical Hinduism, Shiva was a powerful and fierce deity. His consort was Kali. Together they personified fertility, creativity, and good, as well as destruction and evil, but Shiva alone was the conqueror of death. Vishnu, preserver of the world, with his consort Lakshmi (goddess of life, beauty, and good fortune), was gentler but just as majestic and powerful. The gods were often interchangeable; for instance, Shiva was sometimes Rudra, who shot arrows to produce pain and illness, as did Apollo in mythological Greece. Furthermore, the gods also took human incarnations, and thus Krishna and Rama were avatars of Vishnu on earth.
All of the gods affected health and illness, but Dhanvantari, one of the latest gods to appear, was most associated with medicine as its patron deity. He even appeared on earth as the king of Benares in one incarnation. In a legend Dhanvantari taught the sages the science of medicine. In another myth, it was Indra who imparted the secrets of life to the holy man Bharadvaja. His pupil Atreya, a great legendary physician, then transmitted this knowledge through the compilations of his disciples. Other medical gods were the twin Ashvins, who were patrons of eyesight and acted as doctors to the gods themselves.
The Vedas were the ancient hymns, prayers, and teachings of the Aryans, on which most of the religious and moral codes of India were based. The oldest, the Rig-Veda, as well as the Yajur-Veda and the Sama-Veda, were almost entirely religious. The Atharva-Veda, although also a collection of spells and incantations for the practice of magic, contained references to disease, injuries, fertility, sanity, and health.
Ayurvedic medicine was thus based on a vast literature which included not only the Vedas and their later commentaries (the Brahmanas, Aranyakas, and Upanishads) but also a body of medical writings by many contributors, of whom two stand out as the most influential: Charaka and Sushruta. Estimates have varied widely on their dates. Some have suggested the first century A.D. for Charaka and the fourth century for Sushruta, but there are also claims for more ancient times.
Inherent in Hinduism was the stratification of society into castes. Begun by the original Aryan invaders, the system later became more inflexibly structured by the doctrine of the Varna which divided all society into four distinct castes: Brahmins (priests and descendants of priests); Kshatriyas (warriors); Vaishyas (merchants, farmers, and artisans); and Shudras (the “untouchable” menial workers).
In the sixth century B.C. Buddhism arose chiefly as a reaction against the rigidity of Hindu teachings and the caste system. While retaining many of the Hindu rituals and gods, although they became less important, Buddhism preached through the “four noble truths” that suffering in life was due to the craving for bodily satisfactions from which one could be relieved only by doing away with desire. Nirvana, eternal peace, was achievable only by following the “eight-fold path.” The taking of life in any form was strictly forbidden. Although for a time Buddhism gained ground rapidly and was carried to Ceylon, Tibet, and China, by the thirteenth century it had largely died out in India.
Many other sects and offshoots developed from Hinduism and Buddhism. For example, there was Yoga, a theistic philosophy which taught its devotees through exercise to suppress all activity of body, mind, and will so that the self would be liberated. Virtually all Indian religions emphasized the spiritual rather than the material, and so the development of a rational, secular system of diagnostic and therapeutic medicine was all the more remarkable.
Methods of diagnosis included magical as well as rational approaches. Omens played an important role. The flight of birds, the sounds of nature, and many other observations were interpreted by the Indian physician as clues to the severity of the illness. Nevertheless, the patient was given intensive scrutiny, especially his sputum, urine, stool, and vomitus. Thus diabetes was detected by the sweet taste of a patient’s urine. The pulse, classified into an elaborate system, was also an important diagnostic and prognostic tool.
The pharmacopoeia was voluminous. Some ancient remedies have only recently been added to Western medicine, but there may be many more useful drugs among those not yet studied. Charaka listed five hundred remedies and Sushruta over seven hundred vegetable medicines. The plant now called Rauwolfia serpentina (to honor the sixteenth-century scholar who brought it to the West) was considered by the Indians to be especially potent against headache, anxiety, and snakebite. The physicians of India had a widespread reputation for being expert in treating poisonous snakebite. Certainly the prevalence of dangerous snakes, especially cobras, must have given the doctors considerable experience. Their procedures are illustrative of the therapeutic methods of Ayurvedic medicine. As soon as possible after the bite, a tourniquet was placed at a specified distance above the puncture marks, probably obstructing the spread of poison. A special mantra was recited, and then a bold cut was made to connect the punctures. The wound was sucked by the attending physician, and a plaster of special earths or plant decoctions was applied—most often Rauwolfia serpentina (reserpine, which was introduced in this century into Western medicine as an agent for controlling high blood pressure, is a derivative).
Since cutting off the nose was an official punishment for adultery and other transgressions, Indian surgeons had many opportunities to develop and refine reconstruction of the nose. Another plastic repair introduced in the Sushruta Samhita (Collection) was the treatment of torn ear lobes. The custom of piercing the ear lobes and then enlarging the opening, a folk magical means of affording protection against misfortune, led often enough to rips through the lobe by a pulled earring. The repair procedures described by the ancient Indians are essentially the same as in modern plastic surgery.
Operative methods were described for many different kinds of injuries and abnormal states, including harelip, hernia, and bladder stones. Cataract was treated by couching (displacing the opacifying lens of the eye down and away from the line of vision). Amputations were a regular part of surgical practice, and a large and varied number of instruments (over a hundred) were available to the surgeon: forceps, specula, scalpels, scissors, saws, needles, cauteries, syringes, trocars, catheters. They were usually given names according to their resemblance to animals: lion, cat, hawk, crocodile.
Caesarean section was performed with close attention to technique in order to save both mother and infant. For a dead child still in the womb, dismemberment through the vagina was painstakingly carried out to avoid the risks to the mother of opening her abdomen. Recognizing the hazards of abnormal presentations at delivery, writers gave instructions on how to turn a child into the proper position.
A unique Indian medical belief was the concept of marmas, special points on the body where injuries would prove fatal or seriously damaging. Some marmas were indeed directly over vital organs, blood vessels, and nerves, but, since the Indian physician knew little of anatomy (dissection was forbidden), their placement probably derived principally from many unfortunate results over the ages. Nevertheless, a good many marmas did not have subtending vital structures and were rarely life-threatening if punctured.
Of course not everyone died when a marma was injured; nor did everyone survive even when all precautions, omens, and procedures were carefully followed. According to the teachings there were two reasons for failure: the doctor had treated the wrong site in a patient or he had treated someone whose illness was incurable in the first place. Obviously neither the teachings nor the methods were acknowledged as faulty. However, this attitude did represent a contrast to the beliefs of earlier times and other ancient civilizations in that medical failures were due not to divine rejection but to incorrect assumptions by the physician. This attempt to assess secular responsibility contains the essence of rational medicine.
Early physicians came from the Brahmin, or priestly, caste; later, members of the second- and third-ranking castes also took on the healing profession, and the term vaidya came to be applied to all practitioners. Trained physicians, though from lowly origins, by their very professional status stood high in the social scheme, even gaining exemption from taxes. The court doctor stood highest on the ladder, often acting for the ruler in passing on the entrance of a student into practice. The ruler’s doctor was also an important political figure with considerable power and moral authority. He sat on the right hand of the sovereign during affairs of state. As in all times, doctors frequently exaggerated their own importance. Medical teachings pointed to the four foundations for cure: the physician, the patient, the medicine, and the nurse. Without the physician, said the teachers, the others were worthless.
The Laws of Manu—a body of rules for ritual and daily life compiled between 200 B.C. and A.D. 200—stated that physicians could be penalized for improper treatment. On the other hand, if the cured patient refused to pay, his property could be forfeited to the doctor. Ethically, Brahmin priests, friends, and the poor were supposed to be treated without charge. The finances of other patients were to determine the bills rendered. However, it is not certain how much medical attention was given the Shudras, the lowest caste, before Buddhism took their part.
The physician included both surgery and medicine in his practice. Sushruta wrote, “Only the union of medicine and surgery constitutes the complete doctor. The doctor who lacks knowledge of one of these branches is like a bird with only one wing.”
As in primitive societies and other ancient civilizations women were midwives and the possessors of drug lore, but they were not considered fit for higher learning. Charaka and Sushruta rarely referred to women and then only in connection with the management of women’s diseases and childbirth. A considerable amount of attention was given in the Vedic and medical writings to women, including their sexuality and illnesses. In all times a woman was supposed to be treated kindly. On the other hand, although the Laws of Manu forbade adultery for both men and women, extreme penalties for the transgression were prescribed only for the woman. Bearing and raising children and running the household were her functions. The Laws of Manu stated, “Wherever women are honored, the gods are satisfied, but when they are not honored, all pious acts become sterile.”
The behavior of practitioners of the healing arts was expected to conform to the highest ideals of professional and personal life. Even the appearance, dress, speech, and manners, must be above reproach. Therefore the student who wished to be apprenticed to a high-caste teacher had to present evidence of good moral character, satisfactory parentage (descent from a physician was a great asset), and the same attributes which the ideal physician should possess.
The teacher and the student had a high sense of responsibility to each other, and only four to six apprentices were permitted to each teacher. During storms, festivals, or catastrophes, the pupil was excused from classes lest he be unable to concentrate. Instruction in theory consisted of reciting and memorizing the Ayurvedic texts. Practical exercises included visiting the sick, collecting medicinal plants, preparing drugs, and performing procedures on dead animals or fruits, melons, leather bottles, and bladders. When the teacher found his pupil sufficiently trained, he submitted him for certification by the ruler, whose approval was necessary before the graduate could be considered a full-fledged physician. In many ways, the student’s final commitment resembled closely the Hippocratic Oath of Greece.
Dedicate yourself entirely to helping the sick, even though this be at the cost of your own life. Never harm the sick, not even in thought. Endeavor always to perfect your knowledge. Treat no women except in the presence of their husbands. The physician should observe all the rules of good dress and good conduct. As soon as he is with a patient, he should concern himself in word and thought with nothing but the sufferer’s case. He must not speak outside the house of anything that takes place in the patient’s house. He must not speak to a patient of his possible death if by so doing he hurts the patient or anyone else. In the sight of the gods you are to pledge yourself to this. May the gods help you if you follow this rule. Otherwise, may the gods be against you.
Public Health and Hygiene
Health and hygienic measures were different in various periods of Indian history. For instance the public baths and highly developed water systems during the early Indus valley civilization were not matched by succeeding peoples.
Judging from the written records, epidemics and illnesses must have been frequent throughout India’s history; there is evidence for malaria, dysenteries, cholera, smallpox, typhoid fever, plague, leprosy, tuberculosis, as well as a multitude of other catastrophic diseases such as mental illness, blindness, hepatitis, pulmonary affections, neurological disorders, parasitic infestations, and other pathologic conditions of the organ systems.
Traditional medicine recognized the dangers of remaining in an area where a plague or epidemic was raging, and caution was urged in choosing water and food. Smallpox was countered by inoculating people with pus from a smallpox skin boil by puncture or scarification to prevent the full-blown illness.
It is difficult to ascertain when hospitals were first begun. Among inscriptions dating from the third century B.C. by Asoka, the great ruler of the Mauryan dynasty, are statements that hospitals had been established, some for humans and others for animals. According to the scribe of the Asoka Samhita, there were elaborate dispensaries with their own compounds, set apart from the buildings of state. One building was usually a maternity facility where patients could stay throughout delivery and postpartum care. A second structure contained separate areas for apprentices to examine patients before reporting to the court physician, a pharmacy for the preparation and dispensing of medications, and an operating room set apart from areas sick patients frequented.
A century later, King Duttha Gamani is said to have listed among his good deeds the founding of eighteen hospitals for the poor. Whether these were true hospitals and not just facilities for custodial and outpatient care of the indigent is not clear. Certainly the account of Megasthenes, ambassador from the eastern Greek Seleucid king (inheritor of a segment of Alexander the Great’s empire) suggests that there were hospitals for the rich and royal in the great city of Pataliputra.
Charaka summarized all the attributes of a good hospital, including location in a breezy spot free of smoke and protected from the sun, smells, and objectionable noises. Details of equipment needed were described even to the extent of proper brushes and brooms. He also discussed an appropriate food supply and the availability of drugs, privies, and cooking areas. The personnel should be clean, well-behaved, and able to wash and care for the patients. The well-being of the ailing was also considered, with provision for attendants who could distract the patient by recitation, conversation, and entertainment. The hospital that he pictured was easily a model for all to emulate in any time, but we do not know whether Charaka’s principles represent an actual situation or simply an ideal to be hoped for.