Contributions of ancient Indian physicians - Implications for modern timesJ Singh1, MS Desai2, CS Pandav3, SP Desai1
1 Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, USA
2 Department of Anesthesiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
3 Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
Ayurveda traces its origins to contributions of mythological and real physicians that lived millennia earlier. In many respects, Western medicine also had similar origins and beliefs, however, the introduction of anatomical dissection and progressive application of scientific evidence based practices have resulted in divergent paths taken by these systems. We examined the lives, careers, and contributions made by nine ancient Indian physicians. Ancient texts, translations of these texts, books, and biographical works were consulted to obtain relevant information, both for Indian traditional medicine as well as for Western medicine. Ayurveda has retained principles enunciated by these physicians, with minor conceptual advances over the centuries. Western medicine separated from ancient Indian medicine several hundred years ago, and remains the foundation of modern medicine. Modern medicine is evidence based, and randomized clinical trials (RCTs) are the gold standard by which efficacy of treatment is evaluated. Ayurvedic medicine has not undergone such critical evaluation to any large extent. The few RCTs that have evaluated alternative medical treatment recently have shown that such therapy is no better than placebo; however, placebo treatment is 30% effective. We suggest that foreign domination, initially by Mughals, and later by the British, may have contributed, in part, to this inertia and protracted status quo.
Keywords: Ancient medicine, biographical study, evolution of medicine
Ancient Indian medical traditions span millennia, and its legendary physicians are known for many contributions to traditional as well as modern medicine. Information about individuals who lived several thousand years ago is not easy to obtain, especially when records of births, deaths, educational institutions, and case records do not exist. However, much may be gleaned from texts attributed to them, and from written historical and biographical treatises.
We examined the lives of nine legendary Indian physicians, with three objectives. Firstly, to describe their medical contributions; secondly, to determine if Indian and Western medical traditions share similarities in their evolution; and thirdly, to determine the contribution of these physicians to modern medicine. Since some of these physicians have mythological references, it is not possible to verify when and whether they existed. References to medicine in the Rig Veda and the Atharva Veda are largely theurgic, and rely on divine and supernatural remedies to treat bodily ailments. It is only during the post-Vedic period (800 BC to 1000 AD) that ancient Indian medicine began to develop and take on the form as it is known today. ,,,,,,
An elegant story illustrates both the charm and the difficulty in obtaining accurate information about these ancient physicians, and also in deciphering fact from myth. During a conference of ancient rishis it was determined that someone should obtain medical knowledge to cure the many ills that plagued humanity. This knowledge had been imparted by the divine creator Lord Brahma, first to Daksha, then to the Ashwini twins, and finally to Indra, Lord of the heavens. Bharadwaja volunteered for this mission and brought back the necessary information from Indra. Bharadwaja's pupils included Atreya, and it was Agnivesha (circa 800 BC), a student of Atreya who is credited to be the author of the first Indian treatise on medicine. ,,,
[Table 1] displays the meanings and derivations associated with the names of the nine legendary physicians, real or mythological, who lived and worked between 6 th century BC and 7 th century AD.
Ashwini twins: (Mythological)
These celestial physicians  are referred to repeatedly in the Rig Veda, but it is most likely that they were mythological entities, not physicians. There are many stories about a variety of cures brought about by these heavenly twins, and also about their divine status. Their origin is described in the story of Sharanyu (their mother) who assumed the form of a mare, and Vivasvat (their father), who had assumed the form of horse. Their union gave birth to twins with the form of a human head and trunk but a horse's lower torso, and thus the name Ashwin. They are similar in many respects to the Centaur in Greek mythology, and references to the Ashwins are made in the Zoroastrian holy book Zend Avesta. In addition, cuneiform tablets found in Mesopotamian archeological excavations have suggested that Ashwins were worshipped in that region as far back at 1600 BC. They are also mentioned in the Bower manuscript, a c. 350-AD manuscript made up of a collection of 51 bark leaves, purchased in 1889 by Lieutenant Hamilton Bower from Haji Ghulam Qadir, just off the Silk Road in China.  Medical texts ascribed to the Ashwins include the Ashwin Samhita, Cikitsasar Tantra, Dhaturatnamala, Nadi Nidana, among others. The Charaka Samhita as well as the Sushruta Samhita describe an important role played by the Ashwins. Numerous ayurvedic preparations are credited to the Ashwins-matulanga gutka, gulma powder, ashwagandha enema, amruta guggula, haritaki avaleha, and various oils and churna. Despite the existence of these products and texts, it is most likely that these were prepared by others, but attributed the Ashwini twins. Reasons include a means of gaining credibility or as a sign of respect.
This ancient rishi (sage) and the father of the great Dronacharaya (Mahabharata), was one of the greatest rishis of his time, known to be one of the seven great rishis (saptarishis) of India. The others being Atri, Gautama, Jamadagni, Kashyapa, Vasishtha, and Vishvamitra. He was famous for his insatiable appetite for learning and scholarship. Another story depicts him as an orphan adopted by Bharata, son of King Dushyanta and Shakuntala. As mentioned earlier and referred to in the Charaka Samhita, Bharadwaja was selected by the rishis to go to Indra and learn the science of life (Ayurveda). After returning from the heavens, Bharadwaja in turn taught Ayurveda to his disciples, a group that included Divodasa Dhanvantari, a king from Benaras (not to be mistaken for the physician to the Gods who also carried the same name, and is discussed next).
An ancient physician by this name lived before the time of Sushruta. He is mentioned in the Sushruta Samhita, , the Kashyapa Samhita, , and also the Bower manuscript.  Dhanvantari is also the physician of the Gods who appeared after samudramanthan (the churning of the oceans) by the Gods and Demons using the snake Vasuki, while Lord Vishnu in his kurma (turtle) form allowed the churning rod to rest on his back. ,,, After the Gods ingested amrit (elixir of immortality), Dhanvantari arrived on Earth where he taught medical skills to practitioners.
Although a celestial physician, Dhanvantari was taught Ayurveda by none other than Bharadwaja, and he taught his disciples the Shalya Tantra (Surgery). He is credited with the discovery of the antiseptic properties of turmeric and the preservative properties of salt, principles which were incorporated in his cures. He has several ayurvedic preparations named after him (Dhanvantari ghritam, rasa rajendra, among others), and he is also credited as being the author of Chikitsa Tatva Vigyan, Dhanvantari Nighantu, among others.
Jivaka (Bihar, 6 th century BC)
Born in Rajgriha (Rajgir, Bihar) near Nalanda and Gaya, Jivaka became one of the most celebrated physicians of his time. , Abandoned at birth (next to roadside garbage) by his courtesan mother, he was the illegitimate child of King Bimbisara of the Magadha Empire. In a strange turn of events he was rescued and adopted by Prince Abhaya, the son of King Bimbisara. He was given the name Jivaka, meaning 'life', for successfully surviving the harsh environment prior to his rescue.
Upon learning of his humble origins, Jivaka sought to earn respect by becoming a great physician. He traveled along the established trade route to Taxila University (near Islamabad, Pakistan) to study medicine under the tutelage of the famous teacher Atreya. He studied for seven years and his powers of observation and deduction were similar to those of the legendary Sherlock Holmes. There are many stories written about various episodes in his career, and we would be remiss without narrating two of the very best.
Prior to graduation, Jivaka and his classmates were asked to go to a nearby hill and bring back plants that did not possess medical properties. Most of the students returned with a variety of plants, but a disappointed Jivaka returned much later without any and said 'O teacher, all things (i.e. plants) are remedies; there exists nothing which is not a remedy'. , Another fascinating episode occurred when the students and Atreya encountered large animal tracks on a road on which they were traveling. Jivaka remarked, 'Those are footprints of an elephant, not male but female, blind of the right eye, and about to bring forth young today. On it a woman was riding. She too is blind of the right eye, and she will bear a son today.' , Asked by Atreya and his astonished students to explain, Jivaka mentioned, 'being brought up in a royal family, I know that footprints of male elephants are round, whereas those of female elephants are oblong'. He explained further that, 'she had eaten grass only from the left side of the road, and that she was pressing hardest towards the right side, suggesting that the foal would be a male'. Lastly, he explained, 'the woman riding the elephant was blind in the right eye because she picked flowers that grew on the left side upon descending, and the heels of her feet made deeper than usual impressions, the backward lean suggested that she was pregnant'. The incredulous students went towards the inn where the group was staying, and verified that all the predictions were in fact correct. There are many other stories about Jivaka successfully treating the rich and the powerful. His fame spread far and wide, and he became a physician to the royal family that had adopted him, and he was also appointed as the personal physician to Lord Buddha.
Jivaka's contributions include the use of purgatives for constipation, abdominal surgery for intestinal obstruction, and the use of herbal remedies for wound healing. He is best known for his amazing powers of observation and intuition. Illustrations of Jivaka's work have been detailed in the Bower manuscript, and in Buddhist chronicles such as Deepvamsa and Mahavamsa.
Sushruta (Benaras, 4 th century BC to 3 rd century AD)
Perhaps the most prominent of all ancient Indian physicians, Sushruta is considered to be the father of Indian surgery as well as the first plastic surgeon in the world. ,,, Very little is known about the period when Sushruta lived. He is believed to be the son of the great sage Vishwamitra, and he studied medicine and surgery under Divodasa Dhanvantari, King of Kashi (Benaras), and founder of Ayurveda.  The ancient Greeks knew about him, and called him 'Sucruta'. Ethical principles introduced to the West by Hippocrates,  (Greek physician, father of Western medicine, (circa. 460 BC - 370 BC)) bear close resemblance to the principles promulgated initially by Sushruta, and later by Charaka. He emphasized the importance of balancing theoretical knowledge with practical experience in order to achieve good results.
The text attributed to him, though not available in its original form, is called 'Sushruta Tantra'. It was subsequently revised and expanded by Nagarjuna into the work we now know as Sushruta Samhita. , It contains chapters on recognition and treatment of diseases, surgical instruments, surgical procedures, and the management of poisoning. Topics of specific interest include fistula-in-ano, hemorrhoids, intestinal obstruction, care of wounds, application of dressings, earlobe-piercing, cataract surgery, bladder catheterization, the use of leeches, as well as treatment of women and children. ,,, Sushruta was the first to suggest that malaria was caused by mosquito bites. ,
Sushruta is most famous for introducing rhinoplasty, a procedure performed commonly since mutilation of the nose was often the punishment accorded to criminals and prisoners. The procedure described by him is as follows, 'Now I shall deal with the process of affixing an artificial nose. First the leaf of a creeper, long and broad enough to fully cover the whole of the severed or clipped part should be gathered, and a patch of living flesh, equal in dimension to the preceding leaf, should be sliced off (from below upwards) from the region of the cheek and, after scarifying it with a knife, swiftly adhered to the severed nose.' ,,,, There follows a description of how to control bleeding, keep the nasal passages patent, and application of a suitable dressing. Alcohol and other plant-based sedatives were used to provide pain control, amnesia, and for controlling patient movement, as were able-bodied assistants. Sushruta was the first physician to advocate physiotherapy for patients recovering from surgery. The techniques described by him were used by British surgeons in India in the 18 th century and by Italian surgeons two centuries earlier. 
Charaka (Northern India, 1 st century AD)
There is considerable disagreement about the period during which Charaka lived. ,, The figures range from before 500 BC to 200 AD, and not much is known about the man. It has even been suggested that the name Charaka was adopted as a non-specific label for wandering physicians. Scholars suggesting the earlier periods note that Charaka is quoted in the works of the famous Sanskrit grammarian Panini (520-460 BC) and Patanjali (circa 250 BC) while those suggesting later periods observe that Chinese Buddhist documents indicate that Charaka was a court physician to King Kanishka (1 st and 2 nd centuries AD), a Kushan Buddhist King who ruled a wide region that included parts of India (Mathura), Pakistan (Peshawar and Taxila), Afghanistan (Bagram), and Tibet (Xinjiang in Uygur, China). His relatively modern approach to medicine suggests that he perhaps lived in the 1 st and 2 nd century AD. However, it is also possible that the court physician for King Kanishka was merely a namesake of the ancient physician Charaka. Charaka is credited with re-writing and editing Agnivesha's text, while Charaka's own text was later revised by Dridhbala (Kashmir, 8 th century AD).  This is the document currently available as the Charaka Samhita. ,,, It contains 120 chapters and is divided into eight sections. English translations of the original Sanskrit text exceed 1000 pages in length, and the material covered includes anatomy, physiology, diagnosis, and treatment. Dridhbala's is the only surviving text and we do not have access to the original Sanskrit text by Agnivesha, that by Charaka, or translations thereof.
Charaka emphasized a rational approach to the etiology and treatment of diseases and relied heavily on physical examination and direct observation. He believed that success required a team approach - emphasizing that the skill of the physician needed to be complemented by appropriate nursing care, dietary and therapeutic interventions, and participation by the patient.
He introduced the concept of digestion, immunity, metabolism, and the genetic basis of inherited characteristics. He believed that genetic defects were transmitted by either the sperm or the ovum. He attributed a central role to the heart, and taught that the body contained 360 bones (including the teeth). He is credited with proposing a revolutionary idea - that prevention was as important, if not more so, than treatment. He emphasized the importance of cleanliness, exercise, and a healthy diet and lifestyle. He advocated professionalism, laying down a strict code of ethics, warning against malpractice by incompetent or unscrupulous physicians who merely wished to profit from the illness of their patients. Moreover, he believed that treatment should be customized for each patient since the conditions under which the illness occurred varied between one patient and another. Charaka's approach was a major milestone in the advancement of ancient Indian medicine, away from the belief that illness was caused by supernatural forces that needed treatment by prayers, rites, and rituals. He believed that disease was caused by natural phenomena, and therefore natural, rather than spiritual, means were necessary to enable a cure.
Nagarjuna (1 st century BC to 4 th century AD)
Famously recalled in ancient Indian texts as 'Bodhisattva Nagarjuna', the father of chemotherapy, considerable doubt exists about the period during which he lived, and it is more than likely that we are dealing with more than one person when we consider all that is attributed to Nagarjuna.  He is believed to have been an alchemist who worked extensively with mercury, and advocated the use of chemical cures rather than preparations made from herbs and vegetables. He was associated with the Madhyamik school of Buddhism and also with a splinter cult movement called 'Shunyavad'. The places he is associated with range from Vidarbha or Berar (Maharashtra), Patna and Nalanda (Bihar), and Srisailam (Andhra Pradesh). His works include Mul Madhyamika Karika (religious), Vigraha Vyavar Vartika (therapeutics), Suhrilekha (letters to the king), Lauha Shashtra (treatise on iron), and Rasa Ratnakar (alchemy), among many others. As mentioned earlier, Nagarjuna redacted Sushruta's text into what we currently know as the Sushruta Samhita. He described details of the circulatory system, and referred to blood as rakta dhatu. An alchemist par excellence, he compounded many specially concocted chemicals referred to as bhasmas. 
Vagbhatta (circa 4 th to 7 th century AD)
It has been argued that Vagbhatta lived during the reign of King Samudragupta (AD 325-375), or at a much later period in the 7 th century AD. , His son was also named Vagbhatta, and each of them is credited with authoring a medical text, Vagbhatta I with Ashtanga Sangraha (a collection with eight sections)  and Vagbhatta II with Ashtanga Hridaya Sangraha. , These scholars were followers of the Charaka School, and their works, along with those of Charaka and Sushruta, are referred to as Brhat Trayi (a triad of great compositions). The earlier composition Ashtanga Sangraha is larger and less specific than the later Ashtanga Hridaya Sangraha which is condensed and more focused. These texts are more a compilation of the existing knowledge of the times, rather than new information being added to the existing body of knowledge. One of his disciples was Indukar, whose son Madhavkar became a famous physician, and is discussed separately in this article.
Vagbhatta broke with tradition by questioning the concepts and ideas behind kapha, pitta and vayu. He emphasized the importance of personal hygiene to good health, and introduced the importance of combating pollution by elaborating the role of contaminated river water in adversely affecting health. He prepared numerous antidotes and worked on their formulae, some of which are in use today (e.g. asafetida churna). 
Madhava (circa 7 th century AD)
Not much is known about Madhava, perhaps owing to the fact that this was a very common name. Historians have identified several dozen prominent individuals with the same name, and this has added to the difficulty and confusion that arises when one studies Madhava.  Nonetheless, he is credited to be the author of one of the most famous ayurvedic texts, Madhava Nidanam, or Madhava Nidan. , The period during which this text was compiled has been derived with the help of other texts that quote his work, and texts that his work quotes. By the 8 th century AD, his works had already been translated into Arabic, while Vagbhatta (6 th century AD) does not mention Madhava Nidan.
Madhava is famous for being the best pathologist and diagnostician of his time. He was the son of Indukar (a disciple of Vagbhatta) and an astute pathologist in his own right. Madhava's text includes chapters on the pathology of a wide variety of ailments such as fever, hemorrhage, asthma, diarrhea, worms, anemia, jaundice and much more. His systematic approach included five methods of evaluating a disease - etiology, the prodromal or preclinical stage, main presenting signs and symptoms, complications, and progression of the illness. He developed astute diagnostic criteria for these diseases at each stage of the illness. He suggested that each disease was an independent entity and other diseases may follow as complications. However, he emphasized the importance of distinguishing one illness from another, and introduced the concept of differential diagnosis. He also popularized the notion of symptom clusters and specificity.
Before 800 BC, illness and disease were felt to be a result of divine or supernatural influences. , The Rig Veda and Atharva Veda are full of such references, and it was felt that prayers and rituals would be effective treatment. In pre-Hippocratic Greece too, it was common to attribute sickness to supernatural causes, and attempt cure by appealing to deities such as Aesculapius, the son of Apollo, the god of healing. Gradually, experience taught ancient practitioners the importance of herbal medications, diet, physical fitness, and hygiene, rather than a reliance on rituals and prayers. In the West, the initial transformation in approach to treatment began with the Greek physician Hippocrates (460-370 BC), while in India it likely began with Jivaka (6 th century BC). Hippocrates taught that since sickness arose from the environment, cure too must be sought using natural methods, not by prayers. In the absence of direct anatomic study using dissection, a concept of body fluids and gaseous elements developed, both in India and also in the West. Disease was thought to occur as a result of an imbalance in these elements, and the practitioner strove to correct such imbalances. In Ayurveda (Ayu meaning life), the three doshas (vata or prana in the form of air, agni or pitta in the form of heat, and soma or kapha in the form of water) form the basis of the desired equilibrium. ,, Hippocrates and his followers believed in 'innate heat' generated in the heart, and four fluids (blood that caused a person to be sanguine or full of energy; yellow bile that resulted in someone to be bilious or choleric (quick to get angry); black bile which caused depression or sadness; and phlegm, an excess of which causes someone to be phlegmatic, i.e. of slow temperament). ,,,,,,,,
Although the extent to which cadaveric or animal dissection occurred in ancient India is not known, this practice began in the West with another Greek physician, Galen (131 - 201 AD). ,,, While Sushruta was the first and foremost ancient Indian surgeon, his teachings were likely continued, though to a lesser extent, by other physicians. It is not known if Sushruta conducted human dissection to learn anatomy, especially since many of the procedures he performed were on superficial structures. Galen studied anatomy and conducted physiological experiments on animals, especially on the neuromuscular, respiratory, urinary, and cardiovascular systems. He wrote extensively, and his reputation spread throughout the Greek and the Roman empires. Such was Galen's influence, that it was only after the passage of over a millennium that the earliest seeds of scientific medical thinking were sown when Andreas Vesalius (Belgian, 1514-64 AD) ,,, began a rigorous study of human anatomy and wrote his treatise de Humani Corporis Fabrica. At this important juncture, we observe the steady, sometimes rapid, advances made by Western medicine. Just as Western medicine remained static for over a thousand years after Galen, Indian medicine too suffered from such stasis, an observation only partially explained by foreign rule, first by the Mughals, and later the British; traditional Indian medicine continued to develop, but without any significant conceptual advances in the understanding or treatment of disease. Western medical approaches reached India under the influence of colonial rule, however, those influences mainly affected urban populations. Further developments ,,, in Western medicine occurred with William Harvey (England, 1578-1657 AD) who conducted pioneering work on the circulation of blood, and Giovanni Morgagni (Italian, 1682-1771) who showed that specific pathological processes within tissues cause specific diseases. The invention of the stethoscope by René Laennec (French, 1781-1826), and the successful public demonstration of anesthesia by William T. G. Morton (American, 1819-1868) accelerated the pace of medical progress. Joseph Lister (English, 1827-1912) introduced the concept of germ theory and antiseptic surgery, while Alexander Fleming (Scottish, 1881-1955) introduced modern medicine with the discovery of penicillin in 1928. Discussion about more recent developments in modern medicine is beyond the scope of this article. Traditional Indian medicine failed to incorporate these giant advances into its armamentarium, and has taken only limited steps to scientifically validate the efficacy of its pharmacopoeia. Currently, in India, traditional Ayurvedic medicine coexists peacefully with its modern counterpart, providing relief in at least three sets of circumstances. First; it is most commonly sought when modern medicine does not offer satisfactory palliation of chronic conditions; second, it is used in the treatment of non-critical minor illnesses; and third, it is used as a supplementary or preventive treatment.
Many aspects of the origins of traditional Indian and Western medicine bear close resemblance. Prayer and holistic approaches predominated thinking until supernatural causes gave way to natural ones. Here too, the concept of balancing various body fluids and gases (ethers) prevailed for centuries, until dissection and experimentation gave a scientific basis to medical practice.
What remains amazing is that ancient practitioners were able to achieve so much even in the absence of what we now consider scientific knowledge. Performing simple as well as complicated cosmetic surgical operations, Sushruta is accepted as the first surgeon and the father of plastic surgery. It is remarkable that he was able to describe a malaria-like illness attributable to mosquito bites. The code of ethics enforced by Hippocrates, Sushruta, and Charaka had many similarities. The elaboration of specific diagnostic criteria by Madhava predates those used by modern clinicians by centuries. Yet, despite these advantages, while Western medicine continued to make steady progress, traditional Indian medicine remained firmly entrenched in the status quo. As indicated earlier, the attitudes of Mughal and British rulers may have played a role, but even today, in the absence of outside rulers, few investigators carry out rigorous scientific examinations to validate the efficacy of various Ayurvedic treatments. Two recent books have examined the benefits of alternative complementary medicine of various origins. , In both instances the authors have used as the gold standard the randomized controlled trial. While exceptions certainly exist, their overall consensus is that their efficacy was, at best, equal to that of placebo treatment (i.e. approximately 30% effective). An unfortunate observation was that many Ayurvedic preparations were found to contain toxic amounts of heavy metals. Moreover, alternative complementary medicines containing herbal preparations of ephedra have resulted in cardiovascular complications, and gingkoa biloba has recently been implicated in causing seizures. These and other toxic side-effects of herbal preparations have led the authors to warn users that not only are many alternative medical treatments only as effective as placebo therapy, but also that they may expose the patient to significant risk. The difficult challenge to practitioners of Ayurveda is to conduct randomized controlled trials to prove the efficacy of their remedies, and thereby overcome objections attributed to the placebo effect. Once efficacy is proven, it will be necessary to determine the active ingredient and confirm whether or not the other accompanying chemicals from the plant are necessary for the therapeutic effect. These monumental tasks are most essential for the discipline of Ayurveda to gain acceptance in the modern era. Such action would allow continuance in the interrupted rich tradition begun millennia earlier by the ancient Indian physicians we have described. In the absence of such work, the contributions of our legendary physicians, with the exception of Sushruta, will be limited to prevention, exercise and control of diet, striving for balance in life, and also in the diagnosis and classification of diseases based on principles that are not based on scientific anatomic, physiologic, and pharmacological principles. There is no reason why the finest traditions of ancient medicine cannot supplement those of modern medicine.
We are deeply indebted to Dr. Bhanu Shankar Mehta, Birdopur, Varanasi, an eminent historian and prolific writer on ancient Indian Medicine for his valuable advice and comments.