Hindu Medicine and India's Health

Competition between the ancient medical lore of India and Western medicine is here described by DR. CARL E. TAYLOR,who was born in the Himalayas and has spent half of his career in their shadow. His parents are medical missionaries, and as a boy he accompanied them on their extended tours of the Indian viliages each year. The Harvard Medical School, war experiences in tropical medicine, and specialization in internal medicine in Canada prepared Dr. Taylor for his return to India as a medical missionary for the Presbyterian Board in 1917. He is now at the Harvard School of Public Health, and next year will return to North India to teach Public Health at the Christian Medical College, Ludhiana.

by CARL E. TAYLOR, M.D.

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MOST Indians rely for their medical care on practitioners of the ancient Indian systems of medicine. Americans tend to dismiss these herbal doctors or vaidyas as little more than quacks. Their methods are sufficiently successful, however, to have gained for them the confidence not only of most of the unlettered villagers of India, but also of many of the most highly educated people. With the coming of independence for India, there has been a widespread revival of interest in indigenous medicine, and sharp competition has developed among the various systems of medical practice.

The clinical acumen of some of these vaidyas is surprisingly acute. Most of their information is obtained by general observation of the patient and “looking at" the pulse. In the remote Pokhara Valley of central Nepal, where only one white man had been previously, I found an acharya (Vedic specialist) who amazed me with the accuracy of his clinical evaluation of the patients we saw together. Having had vast experience with all kinds of fevers, he was particularly good at predicting the course of febrile illnesses.

I called him in for consultation when one of the members of our Chicago Museum of Natural History expedition came down with severe typhoid fever. Because this patient had had a complete series of inoculations just three months previously,

I failed to make the diagnosis until he was convalescing and we could get him to a hospital in India. With hospital and laboratory eight days’ hard march away over rugged mountain trails, it was good to have a clinician around who was used to relying exclusively on his own observations. One day this acharya said, “If our patient starts to sweat by tomorrow noon he will get well, but if his skin remains hot and dry he will die.”The acharya’s timing was perfect and I was greatly relieved when moderate perspiration did appear shortly before noon; and that did mark the beginning of the patient’s recovery.

Their performance is not always so successful, however, and this sort of clinical experience cannot take the place of teaching based on scientific observation. Funny things happen when these practitioners attempt to adopt modern techniques not included in their traditional training. The stethoscope in particular has caught their fancy, and they make a great show of using what they call their durbeen (literally translated, “telescope”). Many of them have never been taught how to use a stethoscope. I recall one occasion when I was seeing a patient seriously ill with pneumonia, in consultation with the family vaidya. After I had completed a chest examination, he pulled his stethoscope out of the folds of his flowing loincloth and went over the patient’s chest just, as carefully as I had done, mimicking many of my movements. The only difference was that he left the earpieces hanging around his neck instead of putting them in his ears.

For several years the government’s Chopra Committee has studied the place of vaidyas in medical practice in India. In their recent report they estimate that there are over 200,000 vaidyas as compared with 9000 doctors trained in the Western system of medicine. Most of these men practice in the villages, where it is difficult to get doctors to go. Many have had a bare minimum of training under the preceptorship of an experienced practitioner. The standards of training vary widely, however, and one also finds men practicing Ayurveda who are not only erudite Sanskrit scholars but also university graduates with degrees such as an M.A. in botany.

To Hindus, Ayurveda is more than a system of medicine. The word itself is derived from two Sanskrit words — Aayu, meaning “life,” and Veda, meaning “knowledge.”The emphasis, then, is on the whole of life and only incidentally on the intervals of ill health. The whole of the population is considered, and not just the diseased fraction. Hindus faithfully observe elaborate rules of hygiene which have considerable religious significance. They are more concerned with health than with illness, and prevention of disease is thought to be of greater importance than the treatment of disease. Only recently have we in the West developed the science of ecology, which has many of these same points of view. The traditional Hindu attitude is exemplified in the seventh-century textbook of Vagbhata, which ranks close to the two classics of Susruta and of Charaka as basic Ayurvedic reading. Of the thirteen chapters in this medical textbook, eleven are on health and only two deal with disease.

On a trek one summer to Kedarnath, one of the four main sources of the Ganges, I made friends with an idealistic young vaidya. He was a graduate of Benares University and had completed six years’ training in Ayurveda.He was serving a one-year internship in an isolated charitable dispensary for pilgrims, maintained by an order of Hindu priests. He was as interested in my ideas on medical subjects as I was in his, but we found that we just didn t. speak the same language medically.

In Ayurveda, health depends on a dynamic balance of the three dhattus, which are equivalent to the ancient Greek humors. These basic life-giving elements can be loosely translated as air, bile, and phlegm. The function of respiration of air is thought to be centered in the abdomen, whence it flows to every part of the body. Phlegm or the fluid principle is thought to be centered in the lungs, which have nothing to do with respiration. The bile centers in the upper intestines and controls digestion. The brain is thought to be mere bone marrow, and the seat of the consciousness is the heart. This oversimplified presentation of their physiology is the traditional one which is accepted by the bulk of the ordinary village vaidyas. More advanced scholars realize that these concepts cannot be verified by modern scientific methods. They therefore try to show that the dhattus have their counterparts in modern physiological findings. Or they maintain that the dhattus are even more fundamental elements of life than science has yet discovered. It would be difficult to scrap the whole theory without losing much that is good in Ayurveda because their analysis of symptoms and approach to therapy is based entirely on the balance of the dhattus.

The origin of these concepts, which are so similar to those found in medieval medical writings, becomes understandable when one realizes the handicaps under which ancient anatomists studied the human body. Susruta’s textbook, which is still a basic text, although written about the fifth century, stresses the importance of anatomic study and urges every Vedic student to perform dissections. He describes the following technique of anatomical study, which was developed because religious rules prohibited the use of cutting instruments on the dead. The body was wrapped in grass and submerged in a hidden spot in a river. “After an interval of seven days the thoroughly decomposed body should be taken out, and very slowly scrubbed with a whisk made of grass roots, bamboo, or bast. At the same time every part of the body, great or small, external and internal, beginning with the skin should be examined with the eye, one after the other, as it becomes disclosed in the process of scrubbing.”It is obvious t hat the tropical climate would in seven days make the lungs appear to be filled with fluid, the abdomen with air, and the skull with bone marrow.

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MY Vedic friend and I did, in the course of our discussions, get together on certain specific diseases for which we used the same Hindi name. I have since found that it was in the clinical recognition and description of disease that the ancient science of Ayurveda made a great contribution to civilization as we know it. The sweetness of the urine in diabetes is recorded in very old medical writings, and many of our modern ailments were recognized in India centuries ago. Susruta enumerated 1120 diseases, divided according to natural and supernatural causation. He gave a recognizable description of malaria and even attributed it to mosquitoes.

Other ancient texts warned people to desert their houses “when rats fall from the roofs, jump about and die.”Even today, riding through the endemic plague areas of North India it is easy to tell from quite a distance which villages are suffering a plague epidemic. The rats follow the grain from the fields to the villages after the harvest. If plague breaks out, the villagers just camp safely in neighboring groves. The rats take over the village and plague kills them off in large numbers.

The clinical knowledge of Ayurveda was carried to Greece by early travelers and by the survivors of the armies of Alexander the Great. The Moslem invaders of the thirteenth century, and later, transmitted this information to the famous Arab physicians of the Middle Ages. Men such as Avicenna and Rhazes kept alive the medical lore of the ages to pass it on to the Western world as our medical practice started to shake off the Galenic tradition at the time of the Renaissance. Today in Pakistan and India the Moslem practitioners of the synthesized Ayurvedie and Arabic systems of medicine are still numerous and are known as hakims.

Another contribution of Ayurveda has been in the field of treatment. Research workers are just beginning to appreciate and evaluate scientifically the extensive indigenous pharmacopoeia. Some of the practitioners make use of heavy metals such as mercury which are toxic and dangerous. For the most part, however, they rely on herbs. Commercial preparations of one plant known as Serpina are available in India for the treatment of high blood pressure. In using it on my own patients I have found it to be as good as almost any of the drugs in our own pharmacopoeia. It causes a significant though temporary lowering of the blood pressure, and patients can be kept for long periods on maintenance doses without apparent toxic effects.

A major part of a vaidya’s training is in botany. Many of them go on periodic collecting trips to certain ridges of the Himalayas. Before plucking the herbs, they are required to run through specified religious incantations to appease the spirit of the herb and thus persuade it to stay in the medication. Certain of the high Himalayan alpine meadows are thought to produce plants having a specific action.

While living in the Himalayas I heard repeatedly about the herbs that grew on the Panwali range in the northern part of what was then the native state of Tehri (Garhwal). One summer I made the rugged hundred-mile trek to this long ridge, which nestles against the major snow-clad peaks. I found miles of alpine meadows at an altitude of 10,000 to 12,000 feet which were literally carpeted by the greatest profusion of flowers I have seen anywhere. Panwali is famous as the home of the nussa-ke-pauda or intoxicating plant. It is claimed by local inhabitants that if any animal or human being approaches downwind of the plant when it is flowering in the fall, he will be rapidly and completely anesthetized. Without warning he will fall over in a deep sleep. There he will lie unless the wind changes in time or someone manages to drag him away. If removed from the influence of the plant he will soon wake up completely normal. At first I thought I was being kidded when I heard this story. But I found that across a 200-mile stretch of the Himalayas anyone who had ever heard of Panwali also spontaneously told the same story about this herb, and I then decided that it merits more investigation.

The results that vaidyas achieve wilh their herbs are sometimes hard to explain away. One day the eight-year-old daughter of an influential and wealthy Indian was brought to me. She had a grapefruit-sized tender swelling in her right side and had been under the care of Indian practitioners for a week. The findings resembled those of appendiceal abscess. I recommended surgery. The child’s mother insisted that before an operation was done, one more vaidya be consulted. This man was said to have a special medicine for reducing abdominal inflammation. I stressed the danger of medication, especially the strong cathartics which some vaidyas use, but finally had to let them leave.

The girl was taken home; the vaidya came to call and gave a single tiny pill of his own formulation. Two days later when the family triumphantly brought the girl to me the mass was gone. There was no tenderness and the girl was up and walking about. I tried to explain that they had been very lucky and that the abscess had apparently drained into the intestines, but they didn’t think I was being very sporting.

There is a sequel though. She remained well for several months but was finally brought back to me with a recurrence of a fluctuant abscess in the same position. This time the tiny pills had not helped. Incision revealed a tuberculous abscess which had its origin in a very early infection of the spine. We finally cured her after months of treatment with body casts and antibiotics. But our difficult and tedious therapy did not impress the family members nearly as much as the fact that the vaidya had apparently obtained a dramatic though temporary remission by using a single tiny pill.

3

A PROBLEM which arises in medical practice anywhere in the world is the tendency of patients to shop around from doctor to doctor. There is a feeling that if one doctor is good for a patient, then two will be better and three will be even better. Similarly, some patients think that if one drug is beneficial, multiple drugs may be even more effective. In Western countries this natural migratory instinct of patients can be somewhat held in check by the judicious use of consultants. In any case, the methods of treatment and the drugs are usually similar. Indian patients, however, have to choose between two completely different systems of medicine which have historically developed in distinct opposition to each other. Most vaidyas know little or nothing about Western methods or drugs. Western doctors have traditionally been so superior and condescending in their attitude that they have not bothered to find out anything about Vedic practices and herbs. The humble villager in his wisdom can see that there seems to be something of value in each system and he naturally tries to get all the help he can.

Early in my practice in India I began to realize that something peculiar was going on in the reaction of certain patients to some drugs. I would try to check a diarrhea in a hospital patient only to have it continue. Several days later I would think to inquire whether he was taking anything else, and would find that his family was bringing him potent purgative herbs prescribed by the village vaidya. I had to insist that patients being treated by me take only my prescription.

When a new doctor comes into a community, there is a tendency for chronically ill patients who have exhausted the resources of local physicians to flock in to give the new man a chance to show his skill. In one instance, a local doctor took me as a consultant to see a prominent zamindar, or wealthy landowner, who had suffered from asthma for years. I was warned that this man was being treated simultaneously by two doctors and three vaidyas but he insisted on having my opinion also. I found the man to be well educated, especially on the subject of asthma. Before I left his house he showed me his collection of medications, which could well have graced a medical museum.

I tried to get him to let me do skin tests to determine the allergens he was sensitive to, but he refused — as nearly as I could tell, on the score that he preferred experimenting with various therapeutic preparations. As we discussed the relative merits of several drugs, he informed me that although Western drugs were of value in relieving his symptoms, there were several herbs supplied him by vaidyas which were just as good. I assured him that this didn’t surprise me greatly, since one of our most widely used drugs for allergic conditions is ephedrine. This was originally discovered empirically by Chinese herb doctors and incorporated into our pharmacopoeia following the scientific establishment of its pharmacologic value. Similarly from the folk medicine of many lands we have got many useful drugs, such as digitalis, cocaine, quinine, caffeine, opium, cascara, squill, ipecac, and pyrethrum.

Reference to Lakshmipathi’s recent textbook of Ayurveda produces some intriguing items of information. A drug recommended for the eradication of intestinal parasites is horse dung which has been repeatedly dissolved in a special solution and dried in the sun some eight or ten times. An ancient solvent for certain medicines is the urine of the sacred cow. The well-known pipal tree, the most sacred of all trees to Hindus, is said to have a surprising therapeutic range. Seventeen different classifications of disease are listed as being improved by preparations of bark, leaves, shoots, or fruit. Included are diseases of the blood, urinary system, and the ears; also ulcers, vomiting, sterility, diabetes, the buboes of plague, and gonorrhea. Above all, it is said to be an effective aphrodisiac.

It has been interesting to observe the extent to which modern specific therapy has been incorporated into Vedic practice. Quite often now one finds that sulfadiazine powder has been added to decoctions of herbs. Some of the more modern vaidyas are also learning how to give injections of penicillin.

One therapeutic technique on which these practitioners place great emphasis is diet control and fasting. For certain kinds of fevers the approved treatment is a total fast. Each illness has a specialized diet directed toward righting the balance of the life-giving dhattus or humors. Patients coming to our hospital in North India were often more debilitated from their fast than they were from their original disease. Massage and special exercises are also widely used.

Originally, a fairly extensive system of surgery was part of Vedic medicine. Centuries ago Indian surgeons were famous for two operations, cataract couching and rhinoplasty. The latter is a plastic operation to rebuild an amputated nose. The need for this arose because, according to the ancient Laws of Manu, the penalty for adultery was amputation of the nose. Lithotomy, or removal of bladder stones, was also developed centuries ago. Susruta described 121 different surgical instruments and several operative procedures, such as tonsillectomy, extraction of the fetus, amputation of the extremities, setting fractures and dislocations, and anal fistulectomy. These techniques have become lost arts, having been almost completely replaced by modern surgery, in so far as it is available.

4

ONE fact which appeals greatly to the villagers is that the ethics of Vedic practitioners discourages them from collecting fees except when they have been successful in their treatment. If therapy fails to satisfy the patient, he is under no real obligation to pay. This guaranteed system of medical care relieves the family of paying fees after the breadwinner dies, unless they want to express their gratitude for the practitioner’s having done all that could be done. Fees are usually small and drugs inexpensive. The difference in the method of collecting fees often creates misunderstandings when a villager first comes into contact with Western-trained doctors. It has led some private practitioners to the expedient of taking payment for their services before seeing the patient. It has also caused other doctors to set up pharmacies in their medical offices. They see the patient and charge practically nothing for a consultation fee, but they collect their money when the patient pays for the medicine prescribed.

A practice that somewhat compensates vaidyas for the loss of fees when treatment is unsuccessful is their hesitancy in taking cases in which the chances of cure are doubtful. Wherever possible a vaidya is supposed to avoid treating diseases from which the patient has been suffering over a year. One of his first obligations in diagnosis is to determine whether the patient has Ayus or “strength of life”; and if this seems to be lacking, he is warned to be cautious in attempting treatment. Charaka’s dictum, dating from the first century, is taken seriously: “A physician who takes up the treatment of a disease that is incurable incurs loss of wealth, loss of knowledge, loss of prestige, censure of the world, and incapacity for practice.”

In determining curability the vaidya follows not only his clinical impressions but also the guidance of omens, lucky and unlucky, encountered en route to the patient’s house. The dreams of the patient and his relatives have a predictive value. The appearance of the messenger sent to call the practitioner provides a clue as to the outcome of the case. A good combination, for instance, is to have a man of the same caste as the patient, dressed completely in white, drive up for the raid if a in an oxcart. If en route to the patient the vaidya meets a virgin, a woman nursing a child, or two Brahmans, that is considered auspicious.

Since Ayurveda is essentially part of the Hindu religion, emphasis on the spiritual aspects of healthful living is only natural. A basic precept is that life is primarily a spiritual affair. The causation of disease is thought to be tied up with errors in religious living. Gods and goddesses are assigned to the major scourges such as smallpox. With this concept of etiology it is easy to see why many vaidyas rely heavily on charms, sacred incantations, and other religious rituals as therapeutic measures. As in the faith healing of the West, some seemingly miraculous cures are achieved by difficult pilgrimages to sacred spots. It is believed that if a man performs his religious duties and follows the prescribed hygienic rules he will remain free from disease. Specific ways of doing things, such as bathing and brushing the teeth with twigs of the neem tree, have through the years assumed considerable religious significance.

As practiced today, Ayurveda is an anachronistic collection of ancient beliefs which do not stand up in the light of modern knowledge. Imbedded in this matrix of superstition and tradition there are, however, jewels of empirical observation which should be added to our scientifically verified body of knowledge.

What can the government do about cleaning up the present hodgepodge of medical practice?

It is apparent to everyone that the medical needs of the 90 per cent of India’s people who live in villages are not being met. The Western-trained doctors and hospital facilities are concentrated in the cities. The government maintains rather high and rigid standards for the registration of doctors. For instance, it is impossible for an American physician to get a license to practice in India because Indian degrees do not receive reciprocity without examination in this country. An exception is made to permit medical missionaries to practice in philanthropic institutions if they refrain from private practice.

Bringing order out of the present welter of conflicting systems of medicine is made especially difficult by the cutthroat competition which now exists. Quackery thrives on confusion and can scarcely be checked as long as the present vacuum of medical care persists. A first essential would seem to be the setting up of some standardization of training within the several systems now in vogue.

There are significant political implications in the revival of interest in Ayurveda which has occurred since India gained her independence. A Hindu majority again controls India after centuries of Moslem and British rule. It is politically risky for any person in public life to criticize Ayurveda because it is so much a part of Hinduism. Orthodox Hindus claim that the Ayurvedic system is uniquely suited to India’s culture and economy and that it is a much more inclusive system of medicine than ours because of its spiritual implications. They concede that a few of the modern procedures and techniques should perhaps be added to the ancient arts.

No one is more aware of the need for improving the standards of Ayurveda than the group of enlightened vaidyas and acharyas. They are making strenuous efforts to systematize Vedic lore and interpret the traditional theories and empiric observations in the light of scientific knowledge. Annual conferences have this as a primary objective although much of their time and effort actually goes into the more immediate problem of fighting Western medicine. It has become evident to thinking vaidyas that the survival of Ayurveda depends less on political maneuvering against their allopathic counterparts than on setting their own house in order. There is little agreement among vaidyas from different places on even such basic matters as the theory of the three dhattus.

Until agreement can be achieved on basic concepts of physiology and pharmacology, uniformity of training and practice can scarcely be hoped for. The scientific method of experimentation creates unanimity of opinion by presenting proof. It seems obvious, therefore, that in order to survive, Ayurveda needs either to become a science or, better, to become a part of scientific medicine.

Recently a compromise proposal has been made suggesting that Ayurvedic schools be developed to train practitioners for rural service. In an abbreviated medical course the basic sciences would be taught as determined by scientific methods, but the clinical and therapeutic methods would be those of Ayurveda. There are obvious dangers in such an arrangement. However, if Ayurveda must be continued for political reasons, there is some hope that in this way the present dichotomy would gradually be eliminated.

One thing is to be hoped. In Ayurveda there has always been a strong emphasis on the prevention of disease. It should be possible, if Ayurveda is modernized with this training program, to continue this emphasis on the preventive approach. If modern scientific methods can be included in their training, these vaidyas can perhaps be trained to be rural health officers.