Class and Gender (Introduction)

[Full title: Class and Gender: Discrimination and Distinction in the Process of Treatment]

The medical profession provides the practitioner with an extensive sphere for interaction with patients of diverse socio-economic strata and of all genders. The physician operates within in a stratified milieu wherein the ubiquitous issues of hierarchy are likely to impact the human factors involved in therapeutics. Both the clinician and the patient approach each other with pre-conceived notions of their respective social status. We need to remember that the archaic state was both a class state and a patriarchal state; in the case of India, there has been a close connection between caste, class and the state, which together functioned as the structural framework of institutions within which gender relations were framed.^[1] Historians of ancient Indian medicine have looked at doctor-patient relationship from the perspective of medical ethics by focussing on the idealized norms of behaviour described in the medical texts,^[2] but keeping the questions of the patient’s class or gender position outside their purview.

In this chapter, we shall attempt to address the issue of how far was the patient-physician interaction conditioned by the issue of class -if there was any noticeable differential treatment of patients of the disadvantaged section. The other question which will be addressed here is that of perception of gender in the medical world and the treatment of female diseases. However, we are handicapped in this discussion by the absence of any testimony of the patients, particularly of those belonging to the economically weak sections. Since the Āyurvedic practitioner of the classical treatises was always a male, we get only one-sided perspective on this subject of gender. Despite such shortcomings, we able to get gather evidence from the Saṃhitās on class and gender issues.

At the outset both the Caraka and Suśruta Saṃhitās assert that Āyurveda is meant exclusively for the care of the human being for he occupies the foremost position among all living beings (tatra puruṣaḥ pradhānaṃ, tasyopakaraṇamanyat). The concern for the well-being of mankind in this world well and beyond impelled the sages as well as Suśruta and others to seek the knowledge of medicine. Caraka describes the sages (maharṣis) who had gathered in a Himalayan valley to deliberate on the calamitous effects of diseases on human life as being “full of compassion for all creatures” (bhūteṣu-anukrośam)^[3]. Their objective of acquiring the knowledge of longevity was the well-being of all creatures (prajāhitam).^[4] Suśruta and his fellow students too approached Dhanvantari with the request to discourse on Āyurveda to relieve people of their sufferings arising from different types of diseases.^[5] Thus, one may construe that the origin of the practice of this medical science derives from its principle of providing succour to all persons irrespective of social rank or gender, and the practitioner is idealized as the genuine embodiment of this ideal.

Friendliness to all creatures is one of the aspects of ethical behaviour that Caraka enjoins upon an individual as also mercifulness to the poor and solace to the fearful.^[6] The physician is advised to be kindly and honest and have friendly attitude to all (kalyāṇābhivyāhāreṇākuhukena bandhubhūtena bhutānāṃ).^[7] The disposition of the physician towards his patients as described by Suśruta should be friendly, compassionate and caring on the one hand; on the other, the clinician is expected to be protective and caring as a father who is reminded of his duty to care for the patient like his son.^[8] How far this ideal was realized is the question we shall try to explore in this chapter.

As we have already noted, the patient is one of the quartet that constitute the four pillars of treatment along with physician, the medicines and the attendant.^[9] Caraka mentions good memory, obedience, fearlessness and uninhibited expression as the desirable characteristics in the patient without reference to his resources.^[10] Suśruta, however, includes financial well-being (dravyavān) as one of the qualities that go into the making of a good or suitable patient.^[11] It has been noticed in previous chapter that cases with good prognosis alone are recommended to be taken up by the physician. Suśruta explains that curability is determined by the following prognosticative factors: whether the locality, the constitution, the suitability (of diet and habits) of the patient and the season of affliction are contradictory to the disease itself; whether the disease is newly arisen, of single origin and uncomplicated; the physician’s competence; the patient’s vitality, mental strength, longevity and metabolic power.^[12] The patient’s ability to bear expenses is not specifically mentioned here but from other observations, it is evident that this factor did affect the therapeutic process.

Caraka’s exposition on prognosis of treatment^[13] concurs with Suśruta’s with the addition of a few points, one of them being the availability of the four-fold therapeutic measures (catuṣpāda)^[14] comprising the physician, medicament, the attendant and the patient. The unavailability of proper equipment (including medicine) and attendants is cited some physicians as a cause of failure of treatment.^[15] Caraka acknowledges that all prescribed medicament may not available to all human beings (na hi sarvamanuṣyāṇāṃ santi sarva paricchadāḥ). At the same time diseases cannot but attack even the poor (na ca rogā na bādhante daridrānapi dāruṇāḥ)^[16] Therefore, patients in case of emergency have to make do with whatever drugs, cloths and diets are easily available according to their ability.^[17] Though the frame of reference here is to a situation of emergency, this proposition could well be applicable to a wider context (i.e., non-urgent situations) insofar as Caraka acknowledges the non-availability of every prescribed drug to all patients. One without adequate resources had to make do with whatever is available to him for certain medicines were beyond his reach. Curable diseases become difficult to treat in patients who are needy, miserly or orphaned.^[18]

Suśruta, therefore, instructs the medical student to provide free medication to a poor person (daridra) and to such other persons without resources or possessions like a religious mendicant (pravrajita), one who is dependant (upanata), a sage (sādhva)^[19] and an orphan (anātha). They should be treated as his family members with his personal medicines so that goodwill may prevail.^[20] Therefore, ideally the disadvantaged could expect gratuitous treatment from the physician.

Before initiating therapeutic action, the physician had to take into consideration the age, the constitution and chronic ailments of the patient so as to determine of his/her physical ability to undergo a particular treatment. Children, aged persons, those of tender health (sukumāra), those brought up in luxury (sukhocita)^[21] and women (especially the pregnant) are generally categorised as patients mandating medical precautions before administering drugs or surgical procedures. It, therefore, appears that the patient’s constitution and the progress of the disease are as much factors of concern to the physician as the monetary status of the patient. Had the latter been the major concern, Suśruta would not have made the incisive observation that kings and royal servants are among some categories of patients who are difficult to treat.^[22] Consequently, the physician or surgeon had to be discerning to the needs of the patients unaccustomed to suffering or intolerant of pain. Selective use of surgical instruments and procedures is indicated in Suśruta’s compendium. Among the sharp instruments, the trikūrcaka is singled out for those of delicate constitution, women, kings and crown princes.^[23] Among the various procedures of blood-letting, the gentlest method by the application of leeches is preferred for the same patients.^[24]

A detailed examination of both the medical treatises reveals the tendency to highlight the needs of a particular class of individuals. This is evident in the discussion on treatment of certain diseases as well as the rules of dietetics and the regimen prescribed for the seasons. If we consider the regimen as described for summer, the picture becomes clear. Caraka advises that physical exercise should be avoided and during the day, one should sleep in a cool apartment (śītagṛha). At night, it is appropriate to apply sandal paste to the body and sleep on the open airy roof of the house which is cooled by rays of the moon. Having put on pearl ornaments and seated comfortably on a chair, he should enjoy the breeze of the fans and the cooling touch of tender hands dipped in sandal water. Abstaining from sexual intercourse, one should take delight in gardens, cold water and flowers of the season.^[25] In winter, a few of the recommendations are residence in an underground dwelling or inner heated apartment,^[26] use of heavy wrappers, skin, silk cloth, blankets, etc., to keep warm^[27] and the application of aguru (aloe) on the body.^[28] A house devoid of humidity is advised for residence in the rainy season.^[29] For those unable to afford such luxuries, the texts do not have any alternatives.

The texts also describe therapies that are designed essentially for the affluent sections of society. The rejuvenation therapies have multiple benefits of enhancing longevity, memory, intellect, youthfulness, lustre, complexion, voice, functioning of the body and the sense organs and provide relief from sickness. The recipient achieves vāk-siddhi (what he says comes true), respect and brilliance.^[30] Many of these procedures are of long duration: one type of Viḍaṅga Rasāyana is completed in five months. It ensures a superhuman body, sun-like lustre, ability to hear sounds and see objects from a distance, eradication of rajas and tamas states of the mind and creation of sattvic psyche, ability to recall anything heard only once, as well as the aptitude for poetry writing. The therapy also gives the strength of an elephant and the speed of a horse.^[31] Similar results are also the expected from the Balāmūla Rasāyana.^[32]

Therapies for achieving such phenomenal qualities could hardly be the aspiration of those who had to struggle for a living. Besides, the preparation process of rasāyanic formulations is complex involving several drugs of the best quality. For example, when haritakī and āmlaki are used, the mature fruits are gathered from the Himālayas in the proper season as they are rich in rasa and potency, ripened naturally and unblemished.^[33] Use of copious quantities of ghī,^[34] and occasional addition of gold, silver, copper, coral, iron,^[35] crystal, pearl, cat’s eye,^[36] etc., in some formulations are also known. The preparation time of these formulations varies and can be as long as six months (āmalaka avaleha)^[37] or a year (lauhādi rasāyana).^[38]

The rasāyanic therapies are conducted in specialised structures. The kuṭīprāveśika type of treatment requires a cottage, located in a good habitation site, with high roof and three concentric courts and equipped with all necessary appliances.^[39] Restorative therapy is said to be popular among the great sages.^[40] Suśruta also says that brāhmaṇas of unblemished character who regularly carry on the practice of rasāyana, penance (tapas) and silent prayers (japa) are able to ward off the riṣṭas, i.e., the fatal omens.^[41] The action of the (celestial drugs) divyauṣadhis cannot be easily withstood, especially by those who do not practice self control.^[42] Hence, they are not meant for all.

Other than the intellectual stratum, the patrons of such rasāyanic treatments must have been those with the leisure and the means for long-winded therapies and the craving for the extraordinary scholastic attributes. This would include the royalty, and in all probability, the affluent sections as well. The second type of Indraokta rasāyana, for instance, apart from enhancing physical and mental attributes, endows one with good complexion and voice, alleviates all diseases including poisoning, helps in the accomplishment of objects, makes one endearing to the people and is conducive to worldly name and fame^[43] -attributes that would be beneficial for the royalty. Kuṭīprāveśika therapy is described as useful for those who have sufficient time to spare, and have adequate resources (monetary and human).^[44] However, the full potential of the treatment is realised only in persons of with unlimited life span who are given to penance, celibacy, meditation, tranquility.

Overall, rasāyana is an elitist brahmanical male-centric therapy that is extremely restrictive in its administration. The presence of brāhmaṇas is mandatory during the period of rasāyanic treatment^[45] making it admissible only to dvijātis.^[46] Faith in the Vedas and regularity in study of the scriptures are also said to be beneficial for the therapy. Non-dvijātis (śūdras) and women are categorically excluded from the purview of rasāyana. Women are debarred from entering the cottage (kuṭī) during the therapy.^[47] These anti-aging rejuvenating formulations must have been prized classified knowledge for they are safeguarded against their revelation to undesirable persons.

Thus, the physician is cautioned against their disclosure to a person of evil nature, to one who is not free from disease, who is not a dvijāti and to one without faith in the therapy:

tadetanna bhavedvācyaṃ sarvameva hatātmasu.
arujebhyo(a)dvijātibhyaḥ śuśrūṣā yaṣu nāsti ca.^[48]

We can surmise that even a dvijāti may be denied administration of treatment if he is found deficient in the mental and physical attributes.^[49]

Another male-oriented therapy for the affluent is vājikaraṇa or aphrodisiac treatment. Aphrodisiac treatment helps in attaining manliness (pauruṣa)^[50] and is beneficial for the luxurious, the rich, those who have handsome features and youthfulness, and for those having many wives (bahubhāryāṇāṃ yogā vajīkarā hītāḥ).^[51] The description of the desirable ambience of this treatment is evocative of a wealthy dwelling: a comfortable furnished home filled with chirping of birds and tinkling of ornaments; use of fragrances, garlands, ornaments and clothes that are fresh and attractive; and presence of beautiful women.^[52]

It is in keeping of the needs of this social stratum that the Caraka Saṃhitāhas an elaborate set of rules for the consumption of alcohol. The description of the locale, the attire of the gentlemen, the deportment of the trained young women who wait on them and the cuisine to be served at such a drinking session are testimony enough to the class of individuals ministered to:

(i) Before its consumption, the body of the person should be purified (both externally and internally—externally in the form of bath, dress, etc., and internally in the form of taking unctuous, hot food, etc., in accordance with seasonal requirements);

(ii) He should apply the most pleasing perfumes and have a pleasant disposition;

(iii) He should wear clean clothes perfumed with strong scents in accordance with the requirements of the season;

(iv) He should wear different types of garland of variegated colours, jewels and ornaments;

(v) He should offer prayers to the gods and the dvijas or the twice-born;

(vi) He should touch auspicious objects of excellence;

(vii) Alcohol should be consumed in a place appropriate to the season of the year which is surrounded by trees with flowers scattered all around, which is exceedingly liked by beloved ones, which is perfumed with the aroma of incense and provided with beds and seats spread out with pillows;

(viii) The person sitting comfortably or lying in an recumbent posture on the bed or the seat should drink alcohol served to him in a beaker of gold, silver or costly stone or in other clean and well prepared vessels;

(ix) While taking alcohol, he should be pleasantly massaged in different parts by a retinue of beautiful, youthful and passionate damsels, adorned in beautiful clothes, ornaments and garlands appropriate to the season, having the spirit of service and love, and who are specially trained;

(x) He should eat delicious refreshments like fruits, haritaka (green salads) which are salted and aromatic, and which go well with the type of alcohol and are suitable for the season;

(xi) Along with alcohol, he should take different types of roasted meat dishes prepared from birds and animals inhabiting land, water and the sky as well as other types of fare prepared by expert cooks.^[53]

The regimen to be followed prior to consuming alcohol is determined by the nature of one’s constitution. A person of vātika type needs to prepare himself by taking massage, unction, bath, fumigation, application of ungent, and consuming food that unctuous and hot. Different types of cooling regimens and partaking of sweet, unctuous and cooling food is advised for one of pattika constitution. An individual of kapha constitution is counselled to go for heating regimen as well as to consume food prepared of barley, wheat and meat of animals inhabiting the arid zone mixed with black pepper.^[54] Further, the selection of the alcoholic drink must be in accordance with the appropriateness for the constitution: alcoholic preparation of jaggery and piṣṭa (paste of wheat flour, etc.,) suits the vātika, that of honey suits the kaphaja while a preparation of grapes is useful for the paittika individual. The company of good friends and the presence of objects pleasing to the senses provide the ideal a congenial environment. Therefore, Carakas’s advice is that one should consume alcohol with the happiness of mind (soul), at an appropriate place, and (at an appropriate) time with the pleasing environment represented by the most enjoyable objects of the five sense organs.^[55] It can be hardly expected that such guidelines were written for those other than the royalty or the nobility. The text, in fact, admits that these rules of consuming alcohol are meant for those wealthy persons or for those who are going to attain wealth in the near future.^[56] The considerably detailed exposition of management of alcoholism (madātyaya) in the Caraka Saṃhitā lends credence to this view.

The hearty fare recommended to such patients consists of a great variety of preparations, including delectable snacks and appetisers, and is an essentially meat based diet. The patient of vātika alcoholism is recommended the following preparations: meat soup of lāva, tittiri, hen or peacock, or that of birds, animals and fish of marshy land, or burrowing animals, or meat of prasaha category of animals (who eat their food by snatching) with śali rice;^[57] delicious veśavāra (a type of appetiser) with gh , hot (pungent) ingredients, salt and sour articles; preparations of wheat with addition of vāruṇī (a type of alcohol), pūpa-vartis (rolls) stuffed with meat and ginger with gh , and pūpalikās (fried sweet cake) made of māṣa;^[58] meat of fatty animals (indicated above) with black pepper and ginger accompanied by juice of dāḍima,^[59] pastries smeared with sugar syrup with the addition of spices like trijātaka, dhānya, marica and ārdraka.^[60] Paittika alcoholic patients are given dry roasted meat with other necessary ingredients.^[61] Prescription of a diet high in meat and fat content would be suitable for those habituated to it. Apart from prescribing a diet high in animal protein content, the medical authors also suggest additives like aṣṭāṅga-lavaṇa to preparations of wheat, barley or meat to make them very delicious.^[62] Designed to gratify the discerning palate, such exotic food preparations could have been affordable to none other than the affluent.

We also notice the liberal use of extremely expensive and rare commodities like aguru and saffron. The application of the thick paste of aguru (aloeswood/agarwood) and thick fumigation with its smoke,^[63] embracing women whose pleasant limbs are smeared with saṅkoca (saffron)^[64] and pleasant massage with warm hands by well-trained women are advised as therapeutic measures for such patients.^[65]

The patient of paittika type alcoholism is prescribed the following measures: use of cooling beds and seats (according to Suśruta it is a bed of blooming lotuses or of padmini petals covered with water droplets^[66]); walks in cool gardens;^[67] use of silk garments, lotus, water-lily, gems and pearls; and the application of sandal paste.^[68] Patients are advised to touch vessels of gold, silver and bronze filled with cold water and of leather bags containing ice,^[69] and embrace women smeared with sandal paste.^[70] The use of jala-yantra (instrument for sprinkling water), vāta-yantra (instrument for blowing air in the room),^[71] and dhāragṛha^[72] (a room where water is sprinkled from the roof) are deemed beneficial.

Suśruta’s prescription is similar. The patient is recommended to bathe in a pond which has been cleaned, filled with fresh water and made fragrant with padma and utpala.^[73] Hereafter, we have the description of the house where the patient should retire. Apart from being cooled by the artificial fountains (dhāragṛha), its floor are sprinkled with fragrant water and flowers; its walls pasted with patra, ambu and candana water and decorated with flowers of jātī, utpala, priyaka, keśara, puṇḍarika, punnāga, nāga and karavīra. The abundance of lotus pollen imparts a reddish hue to the interiors while the flower garlands waft in the carefully fanned breeze.^[74]

These prescriptions would befit the very affluent section of society alone, and alcoholism was possibly habitual among the royalty. While our two medical compendia treat alcoholism as a disease of the affluent few, consumption of alcohol was quite common among the lower classes as well. In Jātaka society consumption of alcoholic drinks is common across people of different strata. We learn of goldsmiths organizing a festival with fish, meat and strong drinks.^[75] Drinking seems to have been a vice specially associated with the śūdras, for the list of words for spirituous liquor and various stages of its preparation and for intoxication are enumerated by Amarasimha in the śūdra-varga.^[76] In the Pañcatantra a drunken weaver is represented as beating his wife.^[77] Remedial measures for those lower down in the social scale are not alluded to in either medical compendium. A decoction of mud turned up by the plough is the cure recommended in the Mahāvagga for those suffering from gharadiṇṇaka (alcoholism).^[78]

Similar cooling measures are also described for relief from fever with burning sensation.^[79] The patient is advised to reside in a house cooled by the leaves of puṣkara, padma, utpala, kadal or kṣauma or by sandal water or by sprinkling of snow water or a dhāragṛha (cooled by water streams from the roof). The cooling touch of gold, conch shell, coral, jewels and pearls dipped in sandal water, provision for fanning with different types of fans, the soothing touch of bejewelled ladies smeared with sandalwood paste, etc., are again meant for the upper stratum. Perhaps others had to make do with bathing in water bodies (rivers, ponds etc.) which is also one of the measures suggested in the text for alleviating burning sensation, morbid thirst, fatigue and fever.^[80]

Parallels with these therapeutic measures can be drawn from the Harṣacarita that describes the condition of Prabhākaravardhana as Harṣa approaches him:

“There he saw his sire preparing by a camp-lustration, as it were, of burning fever for the conquest of the next world…As they touched him, the hands of the attendants engaged in ceaselessly smearing him with sandal were as white in the palm as if turned to ashes by contact with his burning limbs; while in the guise of the sandal ointment his abiding glory seemed to be saying farewell on his departure to another sphere. Incessantly applied petals of red, white, and blue lotuses seemed to blot his body with the falling glances of death.”^[81] …

“The physicians gone, he (Harṣa) lost all fortitude, and at nightfall went up again to his father’s cries such as, “The heat is terrible, bring pearl necklaces, Hariṇī! -place jewelled mirrors on my body, Vaidehī! -anoint my brows, Lilāvatī! with bits of ice -give me camphor powder, Dhavalākṣī! -apply a moonstone to my eye, Kāntāmatī! -set a blue lotus on my cheek, Kalāvatī! -give me a rubbing with sandal, Cārumatā! -make a brisk breeze with a cloth, Pāṭalikā! -assuage the heat with lotuses, Indumatī! -refresh me with wet clothes, Mandirāvatī! -bring lotus fibres, Mālatī! -wave a palm leaf, Āvantikā! -bind tight my whirling head, Bandhumatī! -support my neck, Dhāraṇikā! -place an ice-cooled hand upon my bosom. Kuraṇgavatī! -shampoo my arms, Valāhikā! -squeeze my feet, Padmāvatī! -clasp my body, Anaṇgasanā!-what hour? Vilāsavatī! -sleep will not come, tell stories, Kumudvatī!”^[82]

The discourse on toxicology in our texts also shows a predilection for attending to the needs of the royalty. The Crown often had to face grave danger from political intrigues and attempts at murder through the administration of poison in food and drinks as also in articles of daily use. This necessitated deliberation on preemptive and therapeutic measures for safeguarding the physical person of the king by the physicians. An exposition on toxicological considerations finds a place in the Kalpa-sthāna of our Saṃhitās that includes detection of poisoned articles, the agents and nature of various types of toxins, symptoms of poisoning and their antidotes. The first chapter of this section of the Suśruta Saṃhitā titled “The Doctrine of Protection of Foods and Drinks” (annāpānarakṣākalpa) is primarily concerned with protective measures for the king (and members of the royal household) which gives guidelines on the construction of the royal kitchen; the selection of a physician and a superintendant as well as other staff for this establishment and their duties;^[83] procedure for detection of poison and their remedies in edibles and articles including armour, foot-cushions, ornaments and riding animals, all of which can be identified as royal appurtenances.^[84] The protection of king apart, management of such situations of mass poisoning is also dealt with by Suśruta. Contamination of pastures, water bodies, food stuff, smoke, the soil and the atmosphere enemies would affect the population and domesticated animals.^[85] For mass treatment of animals affected by poisoned fodder, Suśuta advises beating of drums and playing other musical instruments after smearing them with anti-venomous drugs.^[86] Kṣārāgada is one such formulation applied on dundhubhi, banners and gates (of houses) whose antidotal effect can be absorbed through hearing, sight and touch.^[87] In all probability the state provided for the remedial procedures in these situations, for in case of poisoning of water bodies, it is said that these disorders (in men and animals) should be immediately attended to and every effort should be made to purify such poisoned water.^[88]

The treatment of diseases is not dependent on medication alone; in practically every condition, the patient is advised a particular regime which is evocative of his or her social situation. Many of the therapeutic measures, it appears, are designed keeping the needs of the royalty and affluent section of society. We may take into consideration the treatment of tuberculosis (rājayakṣmā) and prameha (diabetes with urinary disorders).

Special recipes are also suggested by Suśruta for pleasing the palate of a rich or a royal patient suffering from prameha or urinary abnormalities who dislikes medicines. Such a patient’s diet consists of āsavas (fermented bevarages) as well as meat roasted with mādhvīka and liberal use of honey, kapittha and black pepper in food and drinks.^[89] The recommended daily regimen for the affluent and the needy gives us an insight into the dissimilitude in treatment methods for patients of differing social strata. The royalty, in advanced cases of prameha, are advised physical exercise, wrestling, sports, riding on horse, elephant or chariot, walking, touring and practice with weapons.^[90]

Those who are needy and without relatives are advised to walk a hundred yojanas or more without shoes and umbrella, live off alms spending the night only in a village, and practise self-control like an ascetic.^[91] Withdrawal from comfort and luxury and a life of hardship is recommended for the affluent. He has to live amongst the deer and subsist on grains of śyāmāka and nīvāra and fruits of āmalaki, kapittha, tindūka and aśmantaka. He should constantly follow the cows and take their dung and urine.^[92]

A brāhmaṇa should be engage in śila vṛtti (i.e., live only on the grains that have fallen from plants) or uñcha vṛtti (i.e., live solely on the grains strewn on the floor during cleaning) and in the recitation of the Vedas.^[93] The farmer should constantly be occupied in farming and digging of wells (kṛṣet satatamitaraḥ ā kūpaṃ).^[94] A variant reading of this line would be kṛṣet satatam itaraḥ ā kūpaṃ which would imply that if the patient be a śūdra, then he is advised to dig wells.^[95] Special care is, however, advised for weak patients (kṛśaṃ tu satatam rakṣet).^[96] Without a doubt prameha was of common occurrence among all sections of the population which necessitated the ancient Indian medical physician to take cognizance of the needs of the patients. According to the Vinaya Piṭaka, all the diseases are said to be low except madhumeha which is considered a major disease (ukkaṭa ābādha).^[97]

The divergent methods of management of this disease, all aimed at incorporating physical exertion in the regimen, are indicative of how the physician dealt with patients of differing socio-economic backgrounds. Alms-seeking would be acceptable to the poor but hardly suitable for the well-to-do. No dietary restrictions are spelled out for patients of the labouring class unlike the regimen of cereals and fruits that is specified for the affluent. Of two kinds of grains mentioned nīvāra is a variety of wild rice (Oryza nivara) with red grains used as food and medicine.^[98] Its cultivation was very easy, and hence, it was used by landless people.^[99] The other grain śyāmāka is a kind of millet. As these cereals and grains were probably regularly consumed by those of poorer sections of society, it was not felt necessary to specify the same to the patients of meager means. Both nīvāra and śyāmāka are included in the list of food articles that are always beneficial to all living beings.^[100]

The cornerstone of treatment of prameha is depletion through physical exertion which is incorporated in the course of therapy keeping the lifestyle of the patient in consideration. Exposure to the sun and the wind, abstention from food and physical exercise are some of the constituents of reducing therapy (laṅghanam).^[101] A brāhmaṇa or an affluent person unaccustomed to physical activity can hardly be expected to carry out the kind of hard toil advised for cultivator or a member of the laboring class. However, the poor patient is reassured that if he follows the directions of the physician, he gets cured of prameha within a year or less.^[102]

Special recipes that are formulated exclusively for the royalty, the well-to-do or other special persons are frequently mentioned in our texts. One such formulation is the balā vāta disorders, is useful in women during puerperium and for those who are desirous of conception (garbhārthinī narī), as also in the following cases: impotent men (kṣīṇaśukra), debilitation caused by vitiation of vāta, injury to the vital parts or crush injury or any other trauma, fractures, exhaustion due to hard labour, convulsions, hiccough, cough, glaucoma, abdominal swellings, severe asthma and hernias.^[103] Its use gives nourishment to the tissues and youthfulness to the individual.^[104] The physician is advised to prepare this oil for kings, king-like persons (rājamātrāśca), the delicate (sukumārāśca) and the wealthy.^[105] Lākṣādi ghṛta, which is a cure for kuṣṭha and vipādikā, is meant for kings and ladies as well as similar delicate persons.^[106]

The cure for all types of fever, the Mahakalyāṇaka ghṛta, is acclaimed as a panacea for all diseases (sarvarogahara) by its very sight and touch, a cure for wrinkles and grey hairs with the potency to confer welfare, invincibility and longevity of five hundred years.^[107] Before its administration to the patient it is sanctified by brāhmaṇas by mantras on an auspicious day.^[108] Such a valuable formulation prepared with gold and gems^[109] and consecrated by the priests would be prepared for royal use only. A medicinal preparation like Mahā-gandhahastī which is an instantaneous antidote to the effects of poison of animal or pant origin, comprises no less than sixty ingredients.^[110] It is not unreasonable to presume that its use is meant for a particular class of individuals.

Certain other remedies not of common occurrence may be presumed to set aside for notable patients. Complex preparations with multi-pronged intervention capability are described as having the potential of increasing longevity by hundred years or more. Thus, one tulā of ayaskṛti cures skin diseases including leprosy, urinary disorders, obesity, general anasarca, anaemia, insanity and epilepsy besides adding a hundred years to one’s life. Each subsequent tulā adds to longevity.^[111] It is no surprise that the teacher advises some of these precious recipes, such as khadira sāra and medicated ghṛta of black sesamum oil, bhallātaka oil etc. for cure of skin diseases, should be stored safely, i.e., in a protected place.^[112]

Among the precious ingredients of the āyurvedic pharmacopoeia are śilājatu and mākṣika considered efficacious in the treatment of madhumeha or glycosuria. Obtained as an exudation from mountain rocks in the summer months, śilājatu is known to cure all diseases (sarvavyādhivināśanam),^[113] while mākṣika (pyrite ore of copper and iron)^[114] is a cure for senility, skin diseases (including leprosy), urinary abnormalities, anemia and consumption.^[115] It may be presumed that these expensive drugs were not readily available for the all patients. As balā oil is an important medication in the puerperal stage, it may be presumed that its use was exclusive to women of upper society.

Not only was the preparation of exclusive drugs was class-specific, Sūtrasthāna ruta clearly specifies that their management would be restrictive. The king of antidotes, the mahāsugandhi agada, composed of eighty-five ingredients should remain in the hands of the king (rājāgadānāṃ sarveṣāṃ rājño haste bhaveta sada).^[116] Its use is not is not confined to cases of poisoning; when smeared on the skin after bathing, the drug imparts a special effect which ensures that he attains the liking of all his subjects and attains brilliance even among his enemies.^[117] A collyrium, meant for the king’s eyes, has the same impact -the beloved of his subjects (sarvajanapriya), unconquerable by living beings (adhṛṣya sarvabhūtānāṃ) and free from eye diseases (dṛṣṭirogavivarjita).^[118] This highly efficacious eye salve that enhances visual power and is capable of curing relievable diseases is fit to be used by the kings.^[119] It is noteworthy that the salve is an expensive one containing eight parts of śrotāñjana (black antimony) and one part each of copper, gold and silver,^[120] and its preparation entails a protracted process. The ingredients are mixed in a mūṣā (crucible) and heated. Thereafter, the mixture is immersed in the liquidized cow dung. The process of heating and immersion is repeated with several liquids and drugs separately. The resultant mass is wrapped in a cloth, suspended in rain water for a month, dried and finely powdered with pearl, sphaṭika (crystal), vidruma (coral) and kālānusārivā (tagara or Valeriana wallachii).^[121] Similarly, the collyrium, bhadrodaya, is also appropriate for royal use (sadaivārhati bhūmipaḥ).^[122]

Certain medical procedures described in our texts demand special and elaborate arrangements which would have been out of reach of the lower classes. We may consider the therapeutic measures of purification like oleation (snehana), fomentation (svedana) and elimination (vamana and virecana). Fomentation follows oleation,^[123] and elimination therapies always follow oleation and fomentation therapies.^[124] Thirteen types of fomentation are described by Caraka, each of which require different arrangements. For jentāka sveda, a circular building of given dimensions is first constructed facing a pond on fertile land of black, sweet or golden colour soil. A special oven of clay in prepared inside for heating.^[125] A thick walled round windowless cottage with furnaces is built for another kind of fomentation- kuṭī sveda.^[126] Eliminative therapy is conducted in a separate structure designed by an expert architect to accommodate certain medical specifications. It should provide comfortable moving space and prevent exposure to the wind (except through one passage), the sun, smoke, water, dust, noise, etc. The other requirements are a water reservoir, latrine, bath and kitchen;^[127] various categories of attendants (paricārakas) including musicians and bards; specified animals,^[128] milch cow and cowshed; utensils, furniture, linen, mortars, pestles, sharp instruments, accessories, weighing scales, measuring vessels and various drugs required during and after treatment.^[129]

That such a well equipped facility was meant exclusively for the royal class is acknowledged in no uncertain terms in the text itself. When the patient happens to be the king or someone of similar status, the physician is advised to assemble all the above equipment and arrange for attendants prior to the treatment.^[130] The entire treatment process of purification as explained by Caraka is a prolonged process extending over several days. Following the successful administration of oleation and fomentation, the patient is given a dose of emetics and rested. He is then put on dietary programme for seven days. The entire therapeutic process of oleation, fomentation and elimination is repeated and the patient is released after he has rested and regained normalcy.^[131] This programme is meant for kings and others of equivalent status alone who have adequate resources.^[132]

A needy person in the event of an emergency necessitating the administration of elimination therapy, should take the prescribed drugs available without caring to collect all the rare medicaments in advance.^[133] All prescribed medicament are not available to all human beings (na hi sarvamanu āṇāṃ santi sarva paricchadāḥ). At the same time diseases cannot but attack even the poor (na ca rogā na bādhante daridrānapi dāruṇāḥ)^[134] Therefore, in case of emergency, whatever drugs, cloths and diets are easily available should be used by patients according to their capacity.^[135] Though the advice here is meant for an emergency situation, this proposition could well be applicable to a wider context (i.e., to all situations) insofar as Caraka acknowledges the non-availability of every prescribed drug to all patients. One without adequate without resources had to make do with whatever is available to him for certain medicines were beyond his reach. From the above discussion it also emerges that it is the responsibility of the physician to collect all the essentials well in advance of the therapy when attending on members of the royalty or the affluent section of society, while the common people had to gather the necessary medicines and other necessities themselves. We do not get any mention of drugs being made available from a state charitable establishment for the needy.

Considering the importance given to the management to some diseases and patients from the upper sections of society, the same level of concern is hardly perceptible in certain other disorders common among the lower classes. The correlation between disease and class is only implicative in our medical treatises. There is no attempt to associate a disease or correlate its frequency of occurrence to the living or working conditions of those at the lower end of the social ladder.

Footnotes and references:

[1]:

Chakravarti, Uma, Conceptualizing Brahmanical Patriarchy in Early India: Gender, Caste, Class and State in U. Chakravarti, Everyday Lives, Everyday Histories: Beyond the Kings and Brahmanas of ‘Ancient’ India, New Delhi, 2007 (second edition), p.153.

[2]:

To cite a few works: G.D. Singhal and D. Sharma Gaur, Surgical Ethics in Āyurveda, Varanasi, 1985 (second edition); G.S. Lavekar, Doctor-Patient Relationship in Ancient India (Ayurveda), Varanasi, 1996.

[3]:

Caraka Saṃhitā Sūtrasthāna 1.7.

[4]:

Caraka Saṃhitā Sūtrasthāna 1.27.

[5]:

Suśruta Saṃhitā Sūtrasthāna 1.4.

[6]:

Caraka Saṃhitā Sūtrasthāna 8.18.

[7]:

Suśruta Saṃhitā Sūtrasthāna 10.3.

[8]:

Suśruta Saṃhitā Sūtrasthāna 25.44.

[9]:

Caraka Saṃhitā Sūtrasthāna 9.3; Suśruta Saṃhitā Sūtrasthāna 34.15/2-16/1.

[10]:

Caraka Saṃhitā Sūtrasthāna 9.9.

[11]:

Suśruta Saṃhitā Sūtrasthāna 34.21/2.

[12]:

Suśruta Saṃhitā Sūtrasthāna 35.46-47.

[13]:

Caraka Saṃhitā Sūtrasthāna 10.11-13.

[14]:

Caraka Saṃhitā Sūtrasthāna 10.13.

[15]:

Caraka Saṃhitā Sūtrasthāna 29.9.

[16]:

Caraka Saṃhitā Sūtrasthāna 15.20.

[17]:

Caraka Saṃhitā Sūtrasthāna 15.21.

[18]:

Caraka Saṃhitā Sūtrasthāna 13.38.

[19]:

P.V. Sharma translates this as “gentleman”. See Sharma (Ed. and trans.), Suśruta Saṃhitā, Vol. I. p.33.

[20]:

Suśruta Saṃhitā Sūtrasthāna 2.8.

[21]:

Caraka Saṃhitā Sūtrasthāna 13.38.

[22]:

Caraka Saṃhitā Sūtrasthāna 13.38.

[23]:

Suśruta Saṃhitā Sūtrasthāna 8.5. It is also meant for patients of tender age, the old and the timid.

[24]:

Suśruta Saṃhitā Sūtrasthāna 13.3.

[25]:

Caraka Saṃhitā Sūtrasthāna 6.29-32.

[26]:

Caraka Saṃhitā Sūtrasthāna 6.14.

[27]:

Caraka Saṃhitā Sūtrasthāna 6.15.

[28]:

Caraka Saṃhitā Sūtrasthāna 6.16.

[29]:

Caraka Saṃhitā Sūtrasthāna 6.40.

[30]:

Caraka Saṃhitā Cikitsāsthāna 1(1).7.

[31]:

Suśruta Saṃhitā Cikitsāsthāna 26.8.

[32]:

Suśruta Saṃhitā Cikitsāsthāna 26.10.

[33]:

Caraka Saṃhitā Cikitsāsthāna 1(1).38-40.

[34]:

For example, the recipe for āmlakaghṛtra requires the ghī to be boiled consecutively for a hundred or a thousand times with three types of juices and pastes; Caraka Saṃhitā Cikitsāsthāna 1(1).4.

[35]:

Caraka Saṃhitā Cikitsāsthāna 1(1).58.

[36]:

Caraka Saṃhitā Cikitsāsthāna 1(4).22.

[37]:

Caraka Saṃhitā Cikitsāsthāna 1(2).7.

[38]:

Caraka Saṃhitā Cikitsāsthāna 1(3).15-19.

[39]:

Caraka Saṃhitā Cikitsāsthāna 1(1).17-20.

[40]:

Caraka Saṃhitā Cikitsāsthāna 1(1).59.

[41]:

Suśruta Saṃhitā Sūtrasthāna 28.5.

[42]:

Caraka Saṃhitā Cikitsāsthāna 1(4).8.

[43]:

Caraka Saṃhitā Cikitsāsthāna 1(4).24-26.

[44]:

Caraka Saṃhitā Cikitsāsthāna 1(4).27.

[45]:

Caraka Saṃhitā Cikitsāsthāna 1(1).20.

[46]:

Caraka Saṃhitā Cikitsāsthāna 1(4).38.

[47]:

Caraka Saṃhitā Cikitsāsthāna 1(1).20

[48]:

Caraka Saṃhitā Cikitsāsthāna 1(4).38.

[49]:

These are specified in Caraka Saṃhitā Cikitsāsthāna 1(4).30-35.

[50]:

Caraka Saṃhitā Cikitsāsthāna 2(2).32.

[51]:

Suśruta Saṃhitā Cikitsāsthāna 26.5.

[52]:

Caraka Saṃhitā Cikitsāsthāna (3).24-25.

[53]:

Caraka Saṃhitā Cikitsāsthāna 24.11-19.

[54]:

Caraka Saṃhitā Cikitsāsthāna 24.21-23.

[55]:

Caraka Saṃhitā Cikitsāsthāna 24.84.

[56]:

Caraka Saṃhitā Cikitsāsthāna 24.24.—vidhirvasumatāmeṣa bhaviṣyadvibhavāśca ye.

[57]:

Caraka Saṃhitā Cikitsāsthāna 24.123-124.

[58]:

Caraka Saṃhitā Cikitsāsthāna 24.125-126.

[59]:

Caraka Saṃhitā Cikitsāsthāna 24.127.

[60]:

Caraka Saṃhitā Cikitsāsthāna 24.128.

[61]:

Caraka Saṃhitā Cikitsāsthāna 24.173.

[62]:

Caraka Saṃhitā Cikitsāsthāna 24.179.

[63]:

Caraka Saṃhitā Cikitsāsthāna 24.133.

[64]:

Caraka Saṃhitā Cikitsāsthāna 24.187.

[65]:

Caraka Saṃhitā Cikitsāsthāna 24.188.

[66]:

Suśruta Saṃhitā Uttaratantra 47.56.

[67]:

Caraka Saṃhitā Cikitsāsthāna 24.152.

[68]:

Caraka Saṃhitā Cikitsāsthāna 24.153.

[69]:

Caraka Saṃhitā Cikitsāsthāna 24.154.

[70]:

Caraka Saṃhitā Cikitsāsthāna .24.155.

[71]:

Caraka Saṃhitā Cikitsāsthāna .24.158.

[72]:

Caraka Saṃhitā Cikitsāsthāna 24.159; Suśruta Saṃhitā Uttaratantra 47.60.

[73]:

Suśruta Saṃhitā Uttaratantra 47.58.

[74]:

Suśruta Saṃhitā Uttaratantra 47.60-62.

[75]:

The Jātaka: V.228.

[76]:

R.S.Sharma, Śūdras in Ancient India, Delhi, 1990 (third revised edition), p.285.

[77]:

R.S.Sharma, Śūdras in Ancient India, p.285.

[78]:

J. Mitra, A Critical Appraisal of Āyurvedic Material in Buddhist Literature with special reference to Tripiṭaka, Varanasi, 1985, 247.

[79]:

Caraka Saṃhitā Cikitsāsthāna 3.260-266.

[80]:

Caraka Saṃhitā Cikitsāsthāna 3.264.

[81]:

Harṣacarita, p.139.

[82]:

Harṣacarita, pp.144-145.

[83]:

Suśruta Saṃhitā Kalpasthāna 1.8-18.

[84]:

Suśruta Saṃhitā Kalpasthāna 1.25-85

[85]:

Suśruta Saṃhitā Kalpasthāna 3.6.-17.

[86]:

Suśruta Saṃhitā Kalpasthāna 3.14.

[87]:

Suśruta Saṃhitā Kalpasthāna 6.4.

[88]:

Suśruta Saṃhitā Kalpasthāna 3.8.

[89]:

Suśruta Saṃhitā Cikitsāsthāna 11.11.

[90]:

Suśruta Saṃhitā Cikitsāsthāna 11.11.

[91]:

Suśruta Saṃhitā Cikitsāsthāna 11.12.—adhanastvabāndhavo vā pādatrāṇātapatravirahito bhaikṣyāṣ saṃyatātmā yojanaśatamadhikaṃ va gaccheta

[92]:

Suśruta Saṃhitā Cikitsāsthāna 11.12.

[93]:

Suśruta Saṃhitā Cikitsāsthāna 11.12. brāhmaṇo vā śilocchavṛ

[94]:

Suśruta Saṃhitā Cikitsāsthāna 11.12.

[95]:

Anant Ram Sharma (Ed.), Śuśruta Saṃhitā of Maharṣi Śuśruta with “Śuśrutavimarśinī” Hind Commentary along with Special Deliberation etc., Varanasi, 2001, Vol.II, Cikitsāsthāna 11.11.

[96]:

Suśruta Saṃhitā Cikitsāsthāna 11.12.

[97]:

J. Mitra, A Critical Appraisal of Āyurvedic Material in Buddhist Literature with special reference to Tripiṭaka, p.255.

[98]:

Uma Ahuja, et al., “Red Rices-Past, Present and Future”, http://restore.org.in/downloads/redrices-umaahuja.pdf (Accessed on 10.08.2013).

[99]:

B.P. Roy, “Vṛkṣāyurveda in Ancient India” in L. Gopal and V.C. Srivastava (Eds.), History of Agriculture in India (Upto c.1200 AD), New Delhi, History of Science, Philosophy and Culture in Indian Civilization series, Vol.V, Part I, p.579.

[100]:

Suśruta Saṃhitā Sūtrasthāna 20.5.

[101]:

Caraka Saṃhitā Sūtrasthāna 22.18.

[102]:

Suśruta Saṃhitā Cikitsāsthāna 11.13.

[103]:

Suśruta Saṃhitā Cikitsāsthāna 15.35-38.

[104]:

Suśruta Saṃhitā Cikitsāsthāna 15.38/2.

[105]:

Suśruta Saṃhitā Cikitsāsthāna 15.39.

[106]:

Suśruta Saṃhitā Cikitsāsthāna 25.42.

[107]:

Suśruta Saṃhitā Uttaratantra 39.238-239.

[108]:

Suśruta Saṃhitā Uttaratantra 39.237.

[109]:

Suśruta Saṃhitā Uttaratantra 39.235.

[110]:

Caraka Saṃhitā Cikitsāsthāna 23.77-80.

[111]:

Suśruta Saṃhitā Cikitsāsthāna 10.11.

[112]:

Suśruta Saṃhitā Cikitsāsthāna 10.13,15.

[113]:

Suśruta Saṃhitā Cikitsāsthāna 13.4-5.

[114]:

Mohapatra, S.D., et al., “Makshika in Ancient Literature”, AYU, Vol. 30, No.2, (April-June) 2000, pp.194-200.

[115]:

Suśruta Saṃhitā Cikitsāsthāna 13.17/2-18.

[116]:

Suśruta Saṃhitā Kalpasthāna 6.26.

[117]:

Suśruta Saṃhitā Kalpasthāna 6.27.

[118]:

Suśruta Saṃhitā Kalpasthāna 18.93.

[119]:

Suśruta Saṃhitā Kalpasthāna 18.84.

[120]:

Suśruta Saṃhitā Kalpasthāna 18.85.

[121]:

Suśruta Saṃhitā Kalpasthāna 18.86-91.

[122]:

Suśruta Saṃhitā Kalpasthāna 18.97.

[123]:

Caraka Saṃhitā Sūtrasthāna 15.67.

[124]:

Cakrapāṇidatta’s commentary on Caraka Saṃhitā Sūtrasthāna 15.1-2.

[125]:

Caraka Saṃhitā Sūtrasthāna 14.46.

[126]:

Caraka Saṃhitā Sūtrasthāna 14.52-54.

[127]:

Caraka Saṃhitā Sūtrasthāna 15.6.

[128]:

Caraka Saṃhitā Sūtrasthāna 15.7.

[129]:

Caraka Saṃhitā Sūtrasthāna 15.7.

[130]:

Caraka Saṃhitā Sūtrasthāna 15.3.

[131]:

Caraka Saṃhitā Sūtrasthāna 15.8-17.

[132]:

Caraka Saṃhitā Sūtrasthāna 15.18.

[133]:

Caraka Saṃhitā Sūtrasthāna 15.19.

[134]:

Caraka Saṃhitā Sūtrasthāna 15.20.

[135]:

Caraka Saṃhitā Sūtrasthāna 15.21.