Practice of Therapeutics

Application of spiritual therapy is recommended in exogenous (āgantu) type of fever that is distinct from the other seven types of febrile conditions by way of its etiology and the specific symptoms. Daivavyapāśrayacikitsā or performance of religious rites is the most desired therapy (sarvamauṣadham-iṣyate) for this kind of fever attributed to curses, imprecations, emotional turmoil or some entities.^[1] Its treatment comprises a mix of non-clinical therapy like oblations, auspicious acts and yajñas along with dietary prescription of fasting, light diet, gruels, and decoctions.^[2]

Suśruta also advises that fever caused by evil spirits (bhūtas) should be treated with bandha (binding with ropes sanctified by charms), āveśana (sprinkling with mustard seeds while chanting texts) and pūjā (hymns and making offerings);^[3] while fever originating from spells and curses are treatable with performance of homa (sacrificial rites).^[4] The general line of treatment associated with fever is not followed in cases of tṛtīyaka and caturthaka types of intermittent fever (viṣama jvara), as etiologically they are also belong to the exogenous (āgantu) category.^[5]

Hence, along with certain medicinal recipes, the patient is directed to offer prayers to Lord Īśvara along with Ūmā, their retinue and Mātṛs; recite the thousand names of Lord Viṣṇu; offer prayers to Brahmā, the Aśvins, Indra, Agni, Himalaya, Gaṅgā, and the retinue of Maruts. Devotion to parents, payers to gurus, observance of celibacy, practice of penance (tapa), truthfulness (satya), religious rites (niyama), incantation (japa), offering of oblations to the sacred fire (homa), listening to the recitation of the Vedas, and visiting saints (darśana) are also prescribed which are said to have immediate effect.^[6]

Spiritual therapy is recommended in cases whose treatment is difficult or where it is believed that extraneous factors are involved. These extraneous agents are not physiological as we have seen earlier. Intermittent fever presents a difficult clinical condition to the physician as it does not ever quit the body of the patient.^[7] Its pathophysiology may not have been well understood. Though the seasonal and the diurnal pattern, the disturbance of doṣa or doṣas and the mental condition of the patient are cited as factors for the periodicity of fever, Caraka adds that the result of the action in previous life is also a determinant of the nature of the fever pattern.^[8] Thus, virtuous actions in this life or the maturity of the results of deeds in the past life can free a patient from the miseries of fever, but sinful acts lead to more misery.^[9] Hence, recourse to spiritual therapy is recommended.

In the treatment of cases of poisoning, we notice the precedence of spiritual therapy. Caraka enumerates twenty four therapeutic measures among which the first place is given to the recitation of mantras. Significantly, it is cited prior to other procedures like tying of ariṣṭa (amulet or tourniquet), utkartana (excision of the afflicted part), niṣpīḍana (squeezing out blood from the place of the bite), cūṣaṇa (sucking out the poison), agnikarman (cauterization) etc.^[10] Cakrapāṇi explains that recitation of mantras is the best measure to counteract the effects of poison; hence, it is listed at the beginning. One type of ariṣṭa is an amulet fortified with mantras, and the other type is a simple tourniquet.^[11] Recitation of mantras helps to occlude the blood vessels (dhamanī-bandha) that causes downward movement of poison (avamārjana) and prevents further infection (ātma-rakṣā).^[12]

According to Caraka, the exogenous type of vraṇa (ulcer) brought about by stab wound (vadha), caused by tight fastening (bandha), fall or injury can be cured by mantra, agada (talisman) along with external application of drugs cure.^[13] It is prescribed for consumption^[14] and exogenous type of mental disorders. Pharmaceutical treatment is deemed inadequate for seizures (āgantu unmāda). Therapeutics here consist of bali (sacrifices), maṅgala (recitation of auspicious mantras), homa (offering of oblations to the sacred fire), wearing talismans containing antitoxic herbs, truthfulness (satya), maintenance of good conduct (ācāra), practice of penance (tapa), recourse to knowledge (jñāna), charity (dāna), observance of scriptural rules (niyama) and religious vows (vrata), offering prayer to the gods, cows, brāhmaṇas and preceptors, mantras and medicines.^[15] Propitiation of the Lord of all supernatural beings (Bhūtānāmadhipa), i.e., Lord Śiva and his attendants (pramathas) is said to ensure deliverance from the dreaded disease.^[16]

Suśruta, too, advises that the physician should start the treatment very cautiously by proper recitation of hymns (japa), observing religious austerities (niyama) and rites offering oblations to the sacred fire (homa) to pacify the grahas followed by offerings of fragrant red garlands, seeds, honey, ghṛta and all types of eatables. Besides, garments, garlands, flesh and blood of animals, especially preferred by a particular graha should be offered on specific days.^[17] Should these measures as instructed in bhūtavidyā (bhūtavidyānidarśita) prove ineffective, the physician is advised to resort to medicinal recipes,^[18] through fumigation (dh ma), nasal insufflations (nasya), eye salve (añjana) and sprinkling (pariseka), etc.^[19] Spiritual therapy is the only line of treatment for paediatric diseases which are sought to be managed through sacrificial rites, chanting of hymns and offerings to appease the graha.^[20]

In the management of graha seizures, therefore, pharmaceutical therapeutics is considered secondary to rites and offerings despite the proclamation that the drug formulations given in the text when used in therapy with oils, etc., methodically eradicate all mental disorders in a very short time.^[21] We may postulate that the perception of such ailments being brought about by formidable malevolent elements that need to be appeased was well entrenched in the popular mind and among the clinicians. This seems a distinct possibility as the physician is advised to proceed carefully without making mistakes lest the infuriated grahas kill the patient as well as the physician. Besides, we have noted above that these malevolent forces attack individuals who stray from the path of truth and righteousness. Consequently, it is not unexpected that prayers and religious ceremonies receive precedence over medical treatment in the management of graha seizures but they are not specifically recommended in psychological disorders of humoral origin.

The use of ritualistic/spiritual therapy is noticeable in those disorders that do not admit of easy cure. No other disease is as serious (dāruṇa), as complicated (bahūpadrava) and as difficult to cure (duścikitsyā) as jvara. It is crowned the king of all diseases (sarvarogādhipati) by both Caraka^[22] and Suśruta. Consumption is termed a very serious disease (vyādhirmahābala), difficult to diagnose (durvijñeya) and very difficult to cure (durnivāra)^[23] which clearly establishes the problematical nature of the disease. In the Harṣacarita, it is termed as a“dīrgha roga’ (chronic disease) that is known to be fatal.^[24]

The patient of skin disorders is advised to perform daily rituals, good deeds and religious austerities.^[25] Kuṣṭha is among the few disorders with visarpa (erysipelas and herpes) whose pathogenesis manifests the involvement of the seven dhātus, i.e., rakta (blood), lasīkā (lymph), tvak (skin) and māṃsa (muscle tissue) apart from the doṣas (vāyu, pitta and kapha).^[26] Leucoderma (śvitra), among skin disorders, is a particularly obstinate condition. In very rare cases, leucoderma patients may be cured through drugs and clinical measures provided they are emancipated from the effects of their sinful deeds.^[27]

Here, we notice that Caraka does not speak of offering of prayers or conduct of rituals for patients of visarpa (erysipelas and herpes) though it is regarded as serious (dāruṇa) ailment that spreads like cobra venom through the various parts of the body.^[28] Neither the actions of the patient (past or present) nor extraneous agents are etiologically responsible for its causation.^[29]

The primary thrust of yuktivyāpāśraya is pacification of the vitiated doṣa/doṣas through diet and regulation of the daily regimen. The most important factor for growth and maintenance of health is diet^[30] for wholesome nutrition maintains the equilibrium of the dhātus and pacifies their disequilibrium.^[31] The other factors are various aspects of daily regimen such as sleep, physical exercise, massage, bath, habitat, sexual behaviour, therapeutic procedures (fomentation, enema, etc.), mental state, etc.^[32] The selection of therapeutic measures would depend on the consideration of the following factors: Human physiques differ on basis of age, strength and physical features. Hence, patients are of innumerable types.^[33]

The physician should examine the patient on the following items before initiating treatment:

1. vitiated doṣa;
2. auṣadha (drugs);
3. deśa (habitat);
4. kāla (time);
5. bala (strength);
6. śarīra (physique)
7. sāra (excellence of dhātus);
8. āhāra (diet);
9. sātmya (wholesomeness);
10. sattva (will-power);
11. prakṛti (constitution);
12. vyayas (age).^[34]

Some conditions require administration of combination of therapies that is well exemplified by the management of consumption. It requires pacification by a host of curative measures that we have classified as below:

A. Pharmacological: massage, unction, taking medicated bath according to the temperature of the season, external cleansing, medicated enema;

B. Dietary: consumption of milk, ghṛta, meat, food mixed with meat soup, agreeable alcoholic preparations;

C: Non-pharmacological: new and pleasing garments, bath (without medication), application of pleasing perfumes, observing friendly and beautiful ladies, listening to vocal and instrumental music as well as to invigorating and consoling talk, paying regular obeisance to preceptors, observing celibacy, making donations, performing penance, offering prayers to the gods, maintaining truthfulness and good conduct, performing auspicious and non-violent activities, and offering respect to physicians and learned brāhmaṇas,^[35] and performing yajñas enjoined by the Vedas.^[36] Worship of physicians, dvijas, gods and the teachers and listening to religious discourses by the brāhmaṇas is also advised by Suśruta.^[37]

The employment of Sattvāvajaya treatment or psychotherapy in mental disorders has been mentioned. Its use is also noticed in some somatic disturbances brought about by psychic factors. When intermittent fever is attributed to some extrinsic factor,^[38] shock therapy such as, the use of non-poisonous snakes or trained elephants or bringing false charges of theft to instill fear is advocated for its management.^[39] Fever of traumatic or psychic origin is managed with psychological measures (vijñānādyaiśca mānasam).^[40] In case of vomiting caused by contact with disgusting or loathsome objects (dviṣṭārtha-yogaja-chardi), the measures recommended are those to overcome mental affliction with pleasing talk, solace, encouragement, narration of popular folk tales and mythological stories, company of congenial companions, and participation in games (vihāra).^[41]

The management of mental disorders in the classical texts embraces a curious mix of various therapies, medication, physical segregation and psychotherapy in the form of both sympathetic and punitive measures-all intended to stimulate the mind, intellect, memory and consciousness. Treatment incorporates emesis and purgation^[42] as well as pradeha (application of thick ointment), utsādana (unction), abhyaṅga (massage), dhūma (fumigation), regulated diet, administration of ghṛta^[43] and medicinal preparations^[44] as well as blood-letting.^[45] Psychotherapeutic measures include shouting with anger, terrorizing, exhilaration, giving gifts, consolation, fear, and exhibition of surprising acts.^[46] The nature of psychotherapy is determined by the source of the mental disturbance. Thus, if the cause is identified as the loss of something dear, efforts are made for him to regain a similar object. Simultaneously, he is consoled with pleasing assurances of friends^[47] or with religious and moral lessons^[48] so as to help him overcome the ailment.

Similarly, the causative factor, be it passion, grief, fear, anger, exhilaration, jealousy or greed needs to be determined so as to subject the patient to just its contrary situation.^[49] To strike fear in his heart Caraka prescribes exposure to faux attacks by snakes, lions, elephants, criminals or armed enemies, though with precautions to prevent actual harm by removing the fangs of the reptiles, and using fierce animals well trained to refrain from attacking the person. Another ploy is to employ the royal guards to arrest him with the threat of execution on the orders of the king.^[50] Such methods of terrorizing are believed to be effective. Caraka goes on to say that the danger to life is taken more seriously than the fear of injury to the body.^[51]

When such measures intended to alter the distortion of the cognitive process of the mentally ill do not produce desirable results, harsher methods are resorted to. The body is subjected to considerable physical brutality. The patient is smeared with mustard oil, tied with rope and he is made to lie down in the sun. He is again rubbed with kapikacchū or branded with hot iron rods or burnt with hot oil or water. Thereafter he is subjected to the lashings of the whip, tied up and kept confined to a lonely house by which the perturbed mind gains composure.^[52] It is believed that the perverted mind, thereby, gets detracted from all sides and regains composure.^[53]

While on the one hand there is sympathy and understanding for the patient, on the other, physical methods of brutalizing the patient appear to be an integral part of Caraka’s methodology. It is, however, recommended in certain situations, as for instance, when the initial clinical therapies are unsuccessful. Thus, should cleansing of the body be ineffective, procedures like inhalation, application of collyrium and beating are recommended for stimulating the mind, body and intellect (…tāḍanaṃ ca manobuddhidehasaṃvejanaṃ hitam).^[54] Again, when a physically strong patient refuses to abide by the instructions, he can be tied up with pieces of cloth (without causing hurt) and kept confined to a dark room devoid of iron rods and wooden pieces.^[55] The precautions to be taken in dealing with such patients are clearly spelled out for the physician. Depending on the behaviour and response of the mental disorders patients to medical intervention, their treatment varied from kindness and insensitivity to harshness. The objective of psychotherapy is to overcome the perversion of mind and loss of memory so that the patient regains consciousness^[56] whereby he is relieved of the perversion or distortion of intellect, mind and memory that defines the condition of unmāda.^[57]

The physician can consider the course of action complete with the appearance of symptoms of normal functioning of the physiological processes in the patient. These symptoms are spelled out clearly in the texts. The physician is advised to identify the symptoms of well-being. Subsidence of fever is marked by the observation of these symptoms in the patient: a feeling of lightness in the head (laghutva śira), perspiration (sveda), slight facial pallor (mukhapāṇḍu), stomatitis (mukhapāka), sneezing (kṣavathu) and appearance of appetite (annakāṅkṣā).^[58] A patient is cured of unmāda if he manifests symptoms of clarity of sense faculties, clarity of intellect, spirit as well as of the mind, and normalcy of the tissue elements.^[59]

Footnotes and references:

[1]:

Caraka Saṃhitā Cikitsāsthāna 3.317-318.

[2]:

Caraka Saṃhitā Nidāna-sthāna 1.31.

[3]:

Suśruta Saṃhitā Uttaratantra 39.265.

[4]:

Suśruta Saṃhitā Uttaratantra 39.265.

[5]:

Caraka Saṃhitā Cikitsāsthāna 8.292.

[6]:

Caraka Saṃhitā Cikitsāsthāna 3.310-315.

[7]:

Suśruta Saṃhitā Uttaratantra 39.63.

[8]:

Caraka Saṃhitā Cikitsāsthāna 3.75.

[9]:

Cakrapāṇidatta on Caraka Saṃhitā Cikitsāsthāna 3.75.

[10]:

Caraka Saṃhitā Cikitsāsthāna 23.35.

[11]:

Cakrapāṇidatta on Caraka Saṃhitā Cikitsāsthāna 23.35.

[12]:

Caraka Saṃhitā Cikitsāsthāna 23.61.

[13]:

Caraka Saṃhitā Cikitsāsthāna 25.7-8.

[14]:

Caraka Saṃhitā Cikitsāsthāna 8.180.

[15]:

Caraka Saṃhitā Cikitsāsthāna 9.93-94.

[16]:

Caraka Saṃhitā Cikitsāsthāna 9.91-92.

[17]:

Suśruta Saṃhitā Uttaratantra 60.28/2-31/1.

[18]:

Suśruta Saṃhitā Uttaratantra 60.37/2-38/1.

[19]:

Suśruta Saṃhitā Uttaratantra 60.38/2-53/1.

[20]:

For eg. Suśruta Saṃhitā Uttaratantra 28.8, 10-14.

[21]:

Suśruta Saṃhitā Uttaratantra 60.53/2-54/1.—eṣa sarvavikārāṃāstu mānasānaparajitaḥ. hanyādalpena kālena snehādirapi ca kramaḥ.

[22]:

Caraka Saṃhitā,Nidāna-sthāna 1.35.

[23]:

Suśruta Saṃhitā Uttaratantra 41.3.

[24]:

P.V. Sharma, Medicine in the Classical Age, p. 60.

[25]:

Suśruta Saṃhitā Nidāna-sthāna 5.32.

[26]:

Caraka Saṃhitā Cikitsāsthāna 21.15.

[27]:

Caraka Saṃhitā Cikitsāsthāna 7.172.

[28]:

Caraka Saṃhitā Cikitsāsthāna 21.6.

[29]:

Caraka Saṃhitā Cikitsāsthāna 21.16-22.

[30]:

Caraka Saṃhitā Sūtrasthāna 25.31.

[31]:

Caraka Saṃhitā Sūtrasthāna 25.33.

[32]:

Caraka Saṃhitā Sūtrasthāna 25.40.

[33]:

Caraka Saṃhitā Cikitsāsthāna 30.321.

[34]:

Caraka Saṃhitā Vimānasthāna 1.3.

[35]:

Caraka Saṃhitā Cikitsāsthāna 8.184-188.

[36]:

Caraka Saṃhitā Cikitsāsthāna 8.189.

[37]:

Suśruta Saṃhitā Uttaratantra 41.58.

[38]:

Suśruta Saṃhitā Uttaratantra 39.56.

[39]:

Suśruta Saṃhitā Uttaratantra 39.259.

[40]:

Suśruta Saṃhitā Uttaratantra 39.265.

[41]:

Caraka Saṃhitā Cikitsāsthāna 20.41.

[42]:

Caraka Saṃhitā Cikitsāsthāna 9.26.

[43]:

Caraka Saṃhitā Cikitsāsthāna 9.25-28, 32.

[44]:

Caraka Saṃhitā Cikitsāsthāna 9.34-77; Suśruta Saṃhitā Uttaratantra 62.22-24.

[45]:

Caraka Saṃhitā Cikitsāsthāna 9.78; Suśruta Saṃhitā Uttaratantra 62.33/1.

[46]:

Caraka Saṃhitā Cikitsāsthāna 9.30.

[47]:

Caraka Saṃhitā Cikitsāsthāna 9.85.

[48]:

Caraka Saṃhitā Cikitsāsthāna 9.79.

[49]:

Caraka Saṃhitā Cikitsāsthāna 9.86.

[50]:

Caraka Saṃhitā Cikitsāsthāna 9.82-83.

[51]:

Caraka Saṃhitā Cikitsāsthāna 9.84.

[52]:

Caraka Saṃhitā Cikitsāsthāna 9.80-81. Similar measures are also given in Suśruta Saṃhitā Uttaratantra 62.17-20/1.

[53]:

Caraka Saṃhitā Cikitsāsthāna 9.84.

[54]:

Caraka Saṃhitā Cikitsāsthāna 9.29.

[55]:

Caraka Saṃhitā Cikitsāsthāna 9.30.

[56]:

Caraka Saṃhitā Cikitsāsthāna 9.78.

[57]:

Caraka Saṃhitā Cikitsāsthāna 9.8.

[58]:

Suśruta Saṃhitā Uttaratantra 39.322.

[59]:

Caraka Saṃhitā 9.97.