The Physician in the Medical Texts

As we have seen, thus far, the brahmanical perspective on medical practitioners is extremely contemptuous of physicians and inimical to the profession. We shall now examine the perspective of medical authors on this question and how they viewed their own profession vis-a-vis the brahmanical notions of ritual impurity. In their eyes the medical profession is a highly respectable one. Suśruta says one who studies this eternal science described first by Brahmā and expounded by the king of Kaśī would be virtuous, who will be respected by kings on this earth and would attain heaven after death.^[1] The study of Āyurveda is a virtuous accomplishment (puṇyakarman) by which one earns great honour in this life and the next, ensuring both temporal and spiritual happiness. Sūtrasthāna ruta lays great emphasis on correct practice of medicine by which knowledge is brought to light, i.e., brought to fruition and one acquires friends, fame, virtue, wealth and pleasure (vidyā prakāśate, mitrayaśodharmārtakāmāṃśca).^[2]

Practitioners of this science are described as saviours of life in this world by both Suśruta^[3] and Caraka (prāṇābhisara).^[4] By saving patients of serious diseases from the noose of the Yama (the God of Death), physicians confer the greatest gift of all, the gift of life,^[5] and no other gift excels the gift of life (na hi jīvitadānāddhi dānamanyadviśiṣyate).^[6] He is described as a giver of righteousness and wealth (dharmārthadātā). Caraka unequivocally asserts the superiority of the physician when he comments that there is none equal to a medical practitioner who can help an individual with both dharma (righteousness) and artha (wealth).^[7]

It is significant that both Caraka and Suśruta strive to establish the respectable position of physicians and the honour of the medical profession which seems almost like an attempt to refute the brahmanical position. In a very significant verse occurring in the Cikitsā-sthāna, Caraka categorically states that a medical practitioner comes to be known as a “vaidya” only on the completion of his medical education, and he becomes a dvija.

Besides, the title of “vaidya” is not give to him because of his expertise in his previous birth:

vidyāsamāptau bhiṣajo dvitīyā jātirucyate.
aśnute vaiyaśabdaṃ hi na vaidyaḥ purvajanmanā.^[8]

The physician, thus, earns honourable title of vaidya by virtue of the formal schooling he undergoes under the guidance of a preceptor. More importantly, he experiences his second birth and the vaidya is ensured the elevated position of a dvija. This would imply that even Vedic education by itself does not ensure the honourable position of a dvija. There is further explanation of why the physician is worthy of the honour of the status of dvija and vaidya. On the completion of his medical studies, the physician is certainly endowed with either Brāhma sattva (the mental faculty of Brahmā) or Ṛṣi sattva (mental faculty of a ṛṣi): vidyāsamāptau brāhmaṃ vā sattvamārṣamathāpi vā.^[9] Therefore, he is known as a “vaidya” and a “dvija”. Moreover, Caraka contests the claim of Vedic education to grant the epithet of “dvija’. The second birth does not happen through into Vedic studies but through the completion (and not the initiation) into medical studies.^[10]

We may turn to some sūtras in the chapter on rejuvenation of the Cikitsā sthāna wherein Caraka explains why medical practitioners, especially the prāṇācāryas, are worthy of honour and high regard from the wise. A physician who is a dvijāti characterised by good conduct, intellect and scholarship, is known as a prāṇācārya.^[11] His erudition is not restricted to the medical field for he is learned in the Vedas as well. Hence, he deserves to be revered as a teacher just as the divine physicians, the Aśvins, were worshipped by the king of the gods Indra.^[12] Caraka then goes to recount the medical accomplishments of the twin deities. On the request of the gods, they had successfully joined the head of the Yajña to the body after it was decapitated. The medical texts make no references to the priestly ordination on the ritual pollution of physicians; rather Suśruta recounts the story to accentuate the importance of surgery in healing.^[13]

The texts record that the divine physicians cured many other deities of their afflictions: healing the loose teeth of Pūṣan, the affected eyes of Bhaga, the stiff arm of Indra, Soma’s tuberculosis and the loss of youth and strength suffered by sage Cyavana.^[14] It is for their numerous feats that Indra and other great souls offered prayers to the divine physicians.^[15] The dvijātis prescribe different types of graha (vessels for taking the soma), stotra (songs of prayers), mantra (incantation), havis (oblation to fire) and dhumra paśu (brown coloured animals for sacrifice). If the savana (oblation to the fire) is offered in the morning, then the soma (juice of the soma plant) is shared by Śakra (Indra) with the Aśvins. In the Sautrāmaṇī yajña, the almighty God rejoices with the Aśvins.^[16] Caraka even goes on to say that no other gods are respected as much as Indra, Agni and the Aśvins and the twice-born invariably recite Vedic incantations as prayers to them.^[17] When the deities who are immortal, free of the sufferings old age, learned and resolute, along with their king can offer prayers to the Aśvins, then why should pleasure-seeking mortals afflicted by the miseries of death, disease and old age not worship the physicians to the best of their ability? In other words, people must extend their respectful regard to physicians.^[18] The wise who long for happy lives should never covet the possessions of the prāṇācāryas, show anger or do them any harm.^[19]

Both Caraka and Suśruta, therefore, assert a high position for physicians and surgeons who are often mentioned along with brāhmaṇas. In the chapter on prognostication,^[20] the physician is acquainted with several physiological symptoms and such signs in the patient’s conduct, which are portentous of fatality. One such sign is the manifestation of hatred towards the gods, brāhmaṇas, teachers, friends and physicians in the patient.^[21] The import of the physician’s position is explained by Suśruta in the context of the responsibility he bears to the supreme authority of the land, i.e., the king.

The physicians familiar in use of drugs and minerals, and the priests well versed in the Vedas, should both carefully protect the king from death, which may be brought about by the vitiation of the doṣas or by external factors.^[22]

doṣāgantujam tyubhyo rasamantraviśāradau.
rakṣetaṃ nripatiṃ nityaṃ yatyau vaidyapurohitau.

The king desirous of victory, as he is marching along with his ministers, should be protected by all means, especially from poisons.^[23] Not only the king, the clinician also has to protect the army by ensuring that the roads, water, shadows, edibles, fodder and fuel are safe and devoid of poison.^[24] Further, Suśruta says that Brahmā Āyurveda with its eight branches which is an appendage of the Vedas, and as the priests (brāhmaṇas) are well versed in the latter, the physician should act according to the advice of the priests, which is to say, take a subservient position.

Thus:

brahmā vedāṅgaṣṭāṅgamāyurvedamabhāṣata.
purohitmate tasmādvarteta bhiṣāgāmavān.^[25]

The thrust of these sūtras is towards underlining the position of the physician vis-à-vis the king and the priest (brāhmaṇa). By describing Āyurveda as vedāṅga, the author accords the same sanctity to this branch of knowledge as is due to the Vedas. The second assertion is that the protection of the king is as much the responsibility of the physician as it is of the priest. In this sense, Suśruta asserts the entitlement of the medical practitioners to protect the person of the king, for which they derive sanction from their knowledge of drugs and minerals, and by virtue of medical science being a vedāṅga. At the same time, in a propitiatory gesture, the sūtrakāra concedes the ascendancy of the priest when he says that the physician should abide by the advice of the priest who is well versed in the Vedic mantra. Protecting the life of the king becomes almost a sacred duty when we are reminded of the grave danger to the social milieu from arising upon his death: all the castes get commingled, religious activities are eradicated and people are wiped out on account of the calamity overtaking the king.^[26] The role of the physician in upholding the social order, thus, becomes crucial to the brahmanical class itself, the class which has been always disapproving of the physician.

The deprecatory portrayal of medical practitioners in brahmanical normative literature made it necessary to impress upon the priestly class of the pivotal position of physicians in the perpetuation of the existing social order. Complete loyalty and devotion to the king is also enjoined on the intelligent physician for as Suśruta explains, despite the similarity in features, the king possess some attributes which set him apart from ordinary men: such as power, sacrifice, forgiveness, patience and superhuman valour. Therefore, the intelligent physician keen upon the welfare of the king, should always associate pious thoughts about him in his speech, thought and action, and consider him his god.^[27] Though at several places in both our texts the medical students and physicians are asked to be respectful to brāhmaṇas, they are mentioned along with and in the context of paying respect to teachers, sages, cows, etc.^[28] Proximity to the king is also revealed by recipes for special drugs meant only for the royalty. Suśruta prescribes only such drugs for the king which can taken be safely taken with known (good) results and which provide strength to the heart. They can be given in small dosages, are very effective and which have few side effects.^[29] A particular formulation containing gold is claimed to remove inauspiciousness, enhance longevity, bring good luck and is even auspicious for annexation of kingdoms.^[30]

There is a categorical statement of unqualified devotion to the royal authority, so much so as that the physician should consider the king as his god. Suśruta also asserts the proximity of the physician with the royalty. When the army sets up camp, the physician outfitted with all the necessary equipment, is required to establish himself close to the royal residence. Suśruta says any person suffering from poisoning or injury from a foreign body or disease unhesitatingly resorts to a surgeon possessing name and fame which is as conspicuous as a glorified ensign.^[31]

In the eyes of our classical medical authors, an expert in medical science with knowledge of the other branches of study earns admiration and respect of the king and other physicians and is honoured like the royal flag.^[32] The mention of physicians in our texts along with the venerable persons of society is an interesting point. In the context of building a cottage (kuṭīprāveśika) for rejuvenation therapy, one of the primary conditions of the location for its construction is that the site should be good and inhabited by the king, physician, brāhmaṇas, saints and those who perform virtuous acts.^[33] It is noteworthy that the physician is placed just after the king and ahead of the brāhmaṇas signifying the elevated position and high esteem that the medical practitioners accorded to their profession. The position taken by the medical texts is antithetical to that of the brahmanical priestly texts.

However, from certain references occurring in the classical texts make it apparent that condescension of physicians was very much a reality. The Soma creepers are invisible to those who insult the physicians (bhiṣajaścāpamānitāḥ), who are impious, who are ungrateful, who decry medicines and for those who look down upon brāhmaṇas.^[34]

Suśruta declares that patients do not recover in those houses where the physician is not respected; treatment is successful only where the physician is respected:

na sa sidhayati vaidyo vā gṛhye yasya na pujyate.
bhavana pujyate vā(a)pi yasya vaidya sa sidhyati.^[35]

It is evident, therefore, that the physicians of ancient India did not see themselves as members of any particular caste; rather they considered themselves to be a fraternity of men drawn from various castes and classes.^[36] Physicians are not identified as ambaṣṭhas in the medical treatises unlike in the law-books. Ambaṣṭha is identified as the name of some ancient Indian tribe on the basis of the evidence of the Greek historians who accompanied Alexander and the Mahābhārata.^[37] The objective of the law-givers like Manu to assign the profession of healing to this mixed group is to emphasize that the profession must be restricted to the base-born. The question arises if this was really the situation.

Contrary to the normative position of the law givers, the practice of medicine was not restricted to the lower castes. Members of any caste could choose to study the subject.^[38] The appellation used for Dhanvantari, Kāśi-rāja or king of Kāśi, is itself an instance of the engagement of upper castes in the study and teaching of medicine.^[39] It was sage Bharadvāja who went to Indra to receive the knowledge of Āyurveda^[40] who then taught the same to the sages who had gathered on the Himālayas. References to practitioners of the higher social orders occur in other texts. A brāhmaṇa physician is known to practice leechcraft in a Jātaka story.^[41] In another narrative, Ālambāyana describes himself as a brāhmaṇa doctor specializing in snakes and snake-bites.^[42]

Medical practice by brahmaṇas is hardly surprising for the mythical story of the Taittariya Saṃhitā itself explains how medicine can be practiced after purification though the profession is prohibited for them. It is said that after the ritual purification of the Aśvins, the gods deposited the healing powers of the two in three places: in fire (Agni), in the waters and a third in the Brāhmaṇa caste. “Therefore, having placed the water vessel to one side (and) having sat down to the right of the Brāhmaṇ, one should practice medicine. To be sure, as much medicine as he practices by this means, his work is accomplished.”^[43] Therefore, if individuals underwent a purification rite involving Bahiṣpavamāna, they could then be accepted at the sacrifice and practice medicine in the brāhmaṇic setting.^[44]

Evidence garnered from other literary works help to form some idea of the social position of physicians. According to the Arthaśāstra physicians could receive grants of land from the king though without the right of sale and mortgage.^[45] The royal physician is an important official of the state whom the king meets every morning.^[46] Besides, epigraphic data provides us evidence of physicians making donations and as land holders. Some were also appointed to high positions. The Kuḍā Buddhist cave inscription of the post-Mauryan period records the gift of a cave by a veja or vaidya named Somadeva.^[47] Land grants of a later period reveal that shares of land were allotted to vaidyas. The Somalapuram grant of Virupaksha (Śaka 1389) records the grant of valuable land yielding grain and fruit in favour of the physician and scholar Virupaksha.^[48] Physicians are also given significant duties; Vaidya Kṛṣṇadatta is mentioned as the dūta or executor of the grant in the Pedda-dugam plates of Śrī Sattrudamanadeva.^[49] The Velvikuḍi grant of Neḍuñjaḍaiya (regnal year 3) mentions Madavikalaṇ Māṛaṅgāri alias Mūvendamaṅgala-Peraiyaṇ, as the crest jewel of the Vaidyakas and a favourite of king Nedunjadaiyan.^[50] It is stated that Māṛaṅgāri fought bravely in the fight that ensued between kings of the eastern country and Vallabha. Another Vaidya Maṅgalarāja Madhuratara, known from the same source, was a master of śāstras, a poet and an orator.^[51] These evidences bear testimony to the respect and honour bestowed on physicians.

The early Smṛti texts do not refer to vaidyas as a caste but in the later Smṛti works medical practitioners are described as vaidyakas.^[52] In contrast to the inferior status in brahmanical literature, the vaidyas of Bengal emerged as a respectable caste along with the vaidiyans, a sub-division of the Nāmbūdiri brāhmaṇas of Kerala.^[53] The emergence of the vaidya caste in Bengal can be traced to the 12^th -13^th centuries CE.^[54] The caste pattern in Bengal differed from other parts of the country as there were no distinct kṣatriyas and vaiśyas castes. In their absence, the Bengal social structure was essentially bipolar, comprising brāhmaṇa and the non-brāhmaṇa castes; the latter included the śūdras along with antyaja classes and outcastes.^[55] This social pattern is reflected in the two Purāṇas composed in this region-the Vṛhaddharma and the Brahmavaivarta Purāṇas dated to about the 13^th century CE. The śūdra caste comprised 36 sub-castes of which the first and second positions are given to the karaṇas and the ambaṣṭhas (vaidyas).^[56] The terms vaidya and ambaṣṭha are used interchangeably in the Vṛhaddharma Purāṇa but in the Brahmavaivarta Purāṇa it is suggested that they are two distinct sub-castes.^[57] While vaidya is described as the offspring of Aśvinikumāra and a brāhmaṇa woman, ambaṣṭha is the issue a brāhmaṇa man and a vaiśya woman.^[58] What is important that both are included are listed as satśūdras who have a higher position in the hierarchy as they are entitled to offer water to the brāhmaṇa unlike the asatśūdras.^[59]

There is the view that the vaidyas of Bengal owe their origin to the south Indian vellala vaidyas who came to acquire the title of “vaidya’ by dint of their Vedic studies.^[60] Vaidyas are mentioned as a separate social group in three inscriptions of the 8^th century CE.^[61] They held high offices during the reign of the Cola kings though not as physicians. Those who did not take to royal service, generally, followed the medical profession. There is reference to Vaidyas in inscriptions of south Indian from the 7^th century CE. From Karṇāṭa or the Karanese country of the Deccan, they entered Bengal during the reign the Senas and were in all probability to be patronized by the rulers.^[62]

In the Ānulia Copper-Plate of Lakṣmaṇasena, the Sena kings take on the role of physicians.

The third verse reads:

“In that line of the Lord of Plants (Oṣadhinātha), i.e., the Moon, there flourished kings who cured their enemies of the fever arising out of power-poison by means of (medicinal) creepers.”^[63]

The metaphor of the physician’s skill of healing is used to exemplify the military prowess of the Sena kings. Sircar contends that it was the amalgamation of the physicians with the tribal Ambaṣṭha-Vaidyas of south India that led to the crystallization of the vaidya caste in Bengal.^[64] According to Majumdar the descendants of Senas are physicians by profession who wear the sacred thread and call themselves vaidyas. They claim the right to read the Vedas.^[65] According to H.H. Risley, the vaidyas of Bengal came to be identified with the ambaṣṭhas of Manu.^[66]

As compared to the physician, the position of the surgeon underwent gradual deterioration. Unfortunately, evidence on surgeons in inscriptions is very meager. From the pay structure given in the Tirumukkūḍal Inscription of Vīrarājendra, it is evident that the salary of the surgeon was lower to that of the vaidya indicating the inferior position of surgeons.^[67] According to Dominik Wujastyk, there is little evidence to show that the surgical practices described in Suśruta’s work persisted beyond the time of the compendium.^[68] This is hardly tenable as commentaries on the Suśruta Saṃhitā continued to be written even in the medieval period. Besides, even in the 11^th century Chalukyan record we get reference to a Jaina physician Aggalayya who was proficient in śastra-śāstra or surgery.^[69] He flourished under the patronage of the Chalukyan ruler Jayasimha II and the record shows that the practice of surgery was prevalent even among the Jainas who were advocates of non-violence.

Our study, therefore, shows that the normative brahmanical texts do not accurately reflect the stature of medical practitioners in society. There is sufficient non-canonical data and epigraphic evidence to show that physicians were honoured by kings. Idealization of the image of the physician as “a paragon of gentlemanly qualities”^[70] is evident in description of the prescribed code of medical ethics and social etiquette in our compendia. He was expected to be genial, modest and sincere. The physician’s code of behaviour was kind of self-regulation. More importantly, physicians looked upon themselves as members of a professional group and not as members of a caste. It is this professionalism which is reflected in the perception of what an ideal physician should be. There is deference towards brahmanical norms; nonetheless their perception of the medical practitioner is guided more by the needs of the profession.

Footnotes and references:

[1]:

Suśruta Saṃhitā Sūtrasthāna 1.41.

[2]:

Suśruta Saṃhitā Sūtrasthāna 2.8.

[3]:

Suśruta Saṃhitā Sūtrasthāna I.3.46.

[4]:

Caraka Saṃhitā Sūtrasthāna 9.18.

[5]:

Caraka Saṃhitā Cikitsāsthāna 1(4). 60.

[6]:

Caraka Saṃhitā Cikitsāsthāna 1(4).61/2.

[7]:

Caraka Saṃhitā Cikitsāsthāna 1(4).61/1.

[8]:

Caraka Saṃhitā Cikitsāsthāna 1:4.52.

[9]:

Caraka Saṃhitā Cikitsāsthāna 1:4.53/1.

[10]:

Wujastyk, Dagmar, Well Mannered Medicine: Medical Ethics and Etiquette in Classical Ayurveda, p.101.

[11]:

Caraka Saṃhitā Cikitsāsthāna 1:4.51.

[12]:

Caraka Saṃhitā Cikitsāsthāna 1:4.40.

[13]:

Suśruta Saṃhitā Sūtrasthāna 1.17.

[14]:

Caraka Saṃhitā Cikitsāsthāna 1:4.41-44.

[15]:

Caraka Saṃhitā Cikitsāsthāna 1:4.45.

[16]:

Caraka Saṃhitā Cikitsāsthāna 1:4.46-47.

[17]:

Caraka Saṃhitā Cikitsāsthāna 1:4.48.—indrāgnī cāśvinau caiva stūyante prāyaśo dvijaiḥ. stūyante vedavākyeṣu na tathānyā hi devatāḥ.

[18]:

Caraka Saṃhitā Cikitsāsthāna 1:4.49-50.

[19]:

Caraka Saṃhitā Cikitsāsthāna 1:4.54.

[20]:

Suśruta Saṃhitā Sūtrasthāna 32.

[21]:

Suśruta Saṃhitā Sūtrasthāna 32.4.

[22]:

Suśruta Saṃhitā Sūtrasthāna 34.7/2-8/1.

[23]:

Suśruta Saṃhitā Sūtrasthāna 34.4.

[24]:

Suśruta Saṃhitā Sūtrasthāna 34.5.

[25]:

Suśruta Saṃhitā Sūtrasthāna 34./2-9/1.

[26]:

Suśruta Saṃhitā Sūtrasthāna 34.9/2-10/1.—saṃkaraḥ sarvavarnāṃ ṇām. prajānāmapi cocchittirnṛpavyasanahetutaḥ.

[27]:

Suśruta Saṃhitā Sūtrasthāna 34.10/2-12/1.

[28]:

Caraka Saṃhitā Sūtrasthāna 8.18.

[29]:

Suśruta Saṃhitā Cikitsāsthāna 33.45.

[30]:

Suśruta Saṃhitā Cikitsāsthāna 28. 23-24.

[31]:

Suśruta Saṃhitā Sūtrasthāna 34.12-14.

[32]:

Suśruta Saṃhitā Sūtrasthāna 34.14/2-15/1.

[33]:

Caraka Saṃhitā Cikitsāsthāna 1.17.

[34]:

Suśruta Saṃhitā Cikitsāsthāna 29.32.

[35]:

Suśruta Saṃhitā Sūtrasthāna 29.52/2-53/1.

[36]:

K. Lochan, Medicines of Early India with appendix on a rare ancient text, Varanasi, 2003, p.110.

[37]:

D.P. Chattopadhyaya, Science and Society in Ancient India, p.217.

[38]:

Suśruta Saṃhitā Sūtrasthāna 2.5.

[39]:

Suśruta Saṃhitā Sūtrasthāna 1.3.

[40]:

Caraka Saṃhitā Sūtrasthāna 1.23.

[41]:

Jātaka, Vol. II, No.228.

[42]:

Jātaka, Vol.VI, No.543.

[43]:

K.G.Zysk, Asceticism and Healing in Ancient India,p.22.

[44]:

K.G.Zysk, Asceticism and Healing in Ancient India,p.23.

[45]:

Arthaśāstra 2.1.7.

[46]:

Arthaśāstra 1.14.18.

[47]:

S.Basu Majumdar, “Medical Practitioners, Medicines and Medical Institutions in Epigraphs”, in S. Basu Majumdar and N. Sharma Mukherjee, Essays on History of Medicine, Mumbai/Nasik, p. 12.

[48]:

S.Basu Majumdar, “Medical Practitioners, Medicines and Medical Institutions in Epigraphs”, p. 15.

[49]:

S.Basu Majumdar, “Medical Practitioners, Medicines and Medical Institutions in Epigraphs”, p. 16.

[50]:

S.Basu Majumdar, “Medical Practitioners, Medicines and Medical Institutions in Epigraphs”, p. 16.

[51]:

S.Basu Majumdar, “Medical Practitioners, Medicines and Medical Institutions in Epigraphs”, p. 16.

[52]:

N.R. Ray, History of the Bengali People (Ancient Period), translated with an Introduction by J.W. Hood, Calcutta, 1994, p.178.

[53]:

A.L. Basham, “Practice of Medicine in Ancient India”, p. 38.

[54]:

A.L. Basham, “Practice of Medicine in Ancient India”, p.178.

[55]:

N.R.Ray, History of the Bengali People, p.176.

[56]:

N.R.Ray, History of the Bengali People, p.18.

[57]:

N.R.Ray, History of the Bengali People, p.178.

[58]:

N.R.Ray, History of the Bengali People, p.196.

[59]:

N.R.Ray, History of the Bengali People, p.210, fn.1.

[60]:

B.C. Majumdar, The History of the Bengali Language, New Delhi, 2000 (Reprint), p. 51.

[61]:

S. Das, Socio-Economic Life of Northern India, c. A.D.550-A.D.650, Delhi, 1980, p.66.

[62]:

Sircar, D.C., Studies in the Religious Life of Ancient and Medieval India, Delhi, 1971, p.215.

[63]:

Majumdar, N.G. (Ed. and trans.), Inscriptions of Bengal, Vol.III, Rajshahi, 1929, Ānulia Copper-Plate of Lakṣmaṇasena, verse 3.

[64]:

Sircar, D.C., Studies in the Religious Life of Ancient and Medieval India, p. 215.

[65]:

B.C. Majumdar, The History of the Bengali Language, p.52.

[66]:

P.V.Kane, History of the Dharmaśāstra, Vol.2, Part 1, p. 72.

[67]:

S.Basu Majumdar, “Medical Practitioners, Medicines and Medical Institutions in Epigraphs”, p.15.

[68]:

Dominik Wujastyk, Roots of Ayurveda, p.107.

[69]:

P.V.R. Sastry, “Epigraphical Allusion to Surgery in Ayurveda”, Bulletin of Indian Institute of History of Medicine, Vol. VIII,1977, pp.127-130.

[70]:

G.S.Lavekar, Doctor-Patient Relationship in Ancient India (Ayurveda), Varanasi, 1996, p. 12.