GANANATH OBEYESEKERE

THE THEORY AND PRACTICE OF PSYCHOLOGICAL M E D I C I N E IN T H E A Y U R V E D I C T R A D I T I O N

ABSTRACT. In this paper I attempt to elucidate and render intelligible to a non-Western reader the internal logic and the consistency in both theory and Practice of Ayurvedic psychological medicine. In Part 1, I deal with the classical metaphysical base (S~mkya philosophy) on which the Ayurvedic concept of mind rests. I also deal with the theory of psychological medicine as stated in ancient Sanskrit texts. In Part II, I deal with the manner in which the classic theory is implemented in contemporary practice in Sri Lanka, while Part III deals with case studies of two patients taking Ayurvedic therapy.

INTRODUCTION The classical Sanskrit theory o f Indian medicine known as Ayurveda (lit. the science o f long life) has dominated the medical traditions o f all o f South Asia, and to a lesser extent Southeast Asia. Its concepts o f illness and formulations o f b o d y functioning are coded into the thinking and formulation o f experience o f Asian peoples. Ideas derived from the classical medical tradition are extended into the realm of ritual and religion, a metamedical extension of medical concepts (Obeyesekere 1976). Concepts and ideas regarding the healthy individual - b o t h physical and psychological health - are largely derived from Ayurveda. Without some awareness of the theory o f Ayurvedic medicine it is not possible for us to understand much of what goes on in the minds o f men in the South Asian world. Western-trained physicians and psychiatrists who are generally contemptuous o f this tradition do so at the risk o f failure to grasp popular ideas o f bodily and mental well-being and illness in South Asian cultures.

PART I

The Philosophical Background of Indian Medicine

To properly understand mental illness in Ayurveda we must know the philosophical assumptions o f Ayurveda, including its concept o f mind. Many of these assumptions, including the concept o f mind, are derived from s~m.kya, one o f the six o r t h o d o x systems o f Indian philosophy, and to a lesser extent from nydya-vaises.ika. In view o f its importance, I shall deal very briefly with s~mkya and its relation to Ayurveda and omit discussion o f ny~ya-vaisesika. Sdmkya is an extremely original, complex, and unusual philosophical system. 1 It postulates

Culture, Medicine and Psychiatry 1 (1977) 155-181.All Rights Reserved. Copyright 1977 by D. Reidel Publishing Company, Dordrecht-Holland.

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two primary principles: puru.sa (spirit) and prakrti (primordial matter or nature). Purus.a is a passive principle whereas prakrti is an active principle which gives the phenomenal world its dynamism and evolutionary direction. Both principles are deduced from the nature of reality as perceived by us;prakrti as the primordial substance from which the world evolved, and purus.a the teleological rationale for evolution (parinama). Prakrti itself is constituted of three guna or fundamental components: sattva, that which is pure, fine, or as Dasgupta says, 'intelligence stuff'; rajas, the active principle or 'energy stuff'; and tamas, the stolid, gross principle or 'mass stuff' (Hiriyanna 1956: 108; Dasgupta 1963: 244). Prakrti, consisting of these three gunas, develops into mahat or buddhi; 'intellect' and ahamk~ra, 'ego-consciousness' or 'self-consciousness'. It is interesting to note that these principles which are viewed in other philosophies as spiritual are here seen as material. Though derived from prakrti they are infused with a predominance of sattva guna. In that sense one could say that these principles evolve, in the teleological sense, to the needs of purus.a, the spiritual entity. From ahamk~ra (ego consciousness) there develops two further sets of evolutes. The first set dominated by sattva are: (a)manas, mind or consciousness; (b) the five sensory organs; and (c) the related motor organs, viz. speech (yak), handling (pani), walking (pada), evacuation (payu) and reproduction (upastha). The second set, dominated by tamas, is known as bhatadL From bh~ttadi, assisted by rajas, emerge the five subtle elements (tanrn~tras): elementary sound, touch, colour, taste and smell. From these tanrndtras or subtle elements are derived the gross dements (bhfaas), the basic constituents of the universe, i.e., wind, fire, earth and water, and ether. These 25 principles could be conveniently seen as 'primary evolution', to use Hiriyanna's term, i.e., new levels or differentiating principles have evolved from primordial matter or prakrti (1956). Secondary evolution refers to the manifestation of these principles, or their combination, in the objects of the phenomenal world. The evolution of the phenomenal world has not produced new principles; only combinations and transformations of the highly differentiated primary evolutes into various forms that make up the phenomenal world. Thus the body, or any other object in nature, could be seen as constituted of the five atomic bh~tas; it may also contain different proportions of the three gunas, depending in this case on the person's karma, or his good or bad actions in previous births. 1. MIND AND ITS FUNCTIONS IN AYURVEDA The concept of mind in Ayurveda is developed from s~m.kya and ny?tya-vaises.ika philosophy. We noted that rnanas was one of the 25 principles that form the sam.kya system and is a derivative of the sattva aspects of ahamkara, connecting

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buddhi (where self is located), to the external sense and motor organs. The classic work on Ayurveda by Caraka says that "the rnanas, the self and the body
are connected together like a tripod on which life rests; if any of the components are missing the unity is broken" (Dasgupta 1968:368). The mind has four fundamental functions according to classic Ayurveda, very much like the ego-functions of psychoanalytic theory. (1) lndriya bhigraha: the direction of the indriyas or sensory (and the motor) organs. The view is that the indriyas are inert and can only be activated by manas. When manas acts in conjunction with the sense organs it perceives the external world, the indriya arthas constituted of the five elements. "lndriya bhigraha can be translated as the direction or coordination of the senses" (Dissanayake 1969:28). (2) Svasya nigraha: control of itself. Manes is said to be active and ever-moving from one object to another while it is also in control of itself (Dissanayake 1969:29). (3) Uha: reasoning or "the capacity of the mind to produce perception by combining with the sensory organs on the one hand and the soul on the other" (Dissanayake 1969:30). (4) Vicara: deliberations, judgement, discrimination, i.e., "to consider the usefulness and uselessness of a thing according to its merits and demerits" (Dissanayake 1969:30). Symptoms of psychopathology are due to the malfunctioning of the mind, so that Ayurveda would argue that emotional conflicts such as the oedipal one are not the cause but rather a result of mental malfunction. How then are the functions of the mind impaired? According to Ayurveda this is fundamentally due to physiological factors. Practically all classical theorists assert that the mind and self are located in the heart rather than the brain. The only exception to this view in the whole of Sanskrit literature is Bhela, who considered the brain as the locus of mind (Dasgupta 1968:340). Mental illness arises when the heart does not function efficiently, because the ducts (sira) and channels (dhamani) that carry the dOsas (humours) and vital elements (dh~tus) to that organ have failed to function satisfactorily. (It should be noted, however, that contemporary Ayurveda in Sri Lanka locates the mind primarily in the brain, and only secondarily in the heart.) 2. AYURVEDIC THEORY OF PHYSIOLOGICAL FUNCTION AND PATHOLOGY: THE PARADIGM While both Yoga and Ayurveda were influenced by : s ~ y a philosophy, Ayurveda took its own course and developed a theory of physiological function and dysfunction suited to its own needs as a system of medicine. Unlike Yoga,

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which had a symbolic view of the human body, Ayurveda had a clear notion of body physiology and functioning (Dasgupta 1968). It had highly detailed descriptions of human anatomy and physiology, much of which was based on observation. Yet, fundamental to the theory is not so much practical anatomy but the physiological theory of the three humours. The basic paradigm on which the theory of illness r e s t s - the five bh~tas and three dOsas- has been unquestionably accepted right through the ages by all practitioners of Ayurveda. 'Experimentation' could exist within the paradigmatic set of assumptions, so that controversy and debate could occur regarding the manner in which the dOsas operate to cause disease; or the efficacy of ingredients used in medical prescriptions. The paradigm itself remains unaltered to this day. A highly sophisticated and aesthetically elegant theory has been constructed on the basis of these fundamental assumptions. The fundamental principles (mFda dharma) of Ayurveda include the doctrine of the five bhfttas or basic elements (atoms) of the universe, the tridOsa, or three humours, and the seven dh~tus, or components of the body. The five elements are ether (~k?tsa), wind (v~yu), water (ap), earth (prthvi), and fire (agni or t~jas). These elements are constituents of all life and as such also make up the three humours and the seven physical components of the body. As the five elements contained in food are 'cooked' by fires in the body they are converted into a fine portion (~hara-praetda) and refuse (kitta or maD). The body elements are produced by successive transformation of the refined food substance into food juice (rasa), blood (rakta), flesh (mamsa), fat (medas), bone (asthi), marrow (mafia) and semen (sukra). Semen is said to be the most highly refined element in the body, the 'vital juice' that tones the whole organism (Filliozat 1964:27). Physical health is maintained when the three humours are in harmonic balance, but when they are upset they become dOsas, or 'troubles' of the organism. The universal element (bh~ta) of wind appears in the body as a humour, also called wind (vayu); fire appears as bile (pitta); and water as phlegm (kapha or sles.man). ~llness is due to upsetting the homeostatic condition of these three humours (tridOsa). The more serious condition is one in which all three humours are upset (sannip~ta). When a dOsa is 'angry' or excited it increases in proportion to the other humours. The aim of medication is to reduce or control this excess. The excited dOsa may also damage one or more dhdtu (blood, flesh, fat, etc.) so that treatment must aim to restore the affected body substance. These assumptions have several consequences: (a) If the five elements are found in nature then nature itself can be a factor in the cause of disease and also in its cure. This has special relevance to the intake and consumption of foods. Thus, for example, an excessive consumption of heat-producing foods may lead to excess of bile in the organism thereby producing illness. In the case of a person with a congenital heated bod-y the

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consumption of such foods may lead to serious consequences: he would be advised to avoid such foods and generally have a diet of cooling foods that can counter the congenital pitta (bile produced by heat) in his body. (b) If the five elements pervade all nature and if they are essential for curing and prophylaxis then all substances are ausada (curative). This applies specially to vegetable substances (herbs, roots, bark, flowers) which are specially used in Ayurvedic decoctions. (c) Flowing from the same logic is the view that both seasons and climates can have therapeutic or pathogenic effects. Thus, Susruta has elaborate classifications of seasons and climates in terms of the d6sas/bhfttas they contain. There is therefore an Ayurveda eco-medicine. (d) Finally, there are two views of temperament in Ayurveda based on these assumptions. The first pertains to the relative preponderance of one of the three humours in the human body as a result of congenital factors. The resulting temperaments are discussed by Susruta at some length (Susruta 1963:154). The other type of temperament is due to the predominance of any one of the gunas. Thus, Susruta discusses the mental traits and physical characteristics of those affected congenitally by either sattva, rajas, or tamas (Susruta 1963a:157). Prognosis and diagnosis of both mental and physical health may depend on temperament. For example, if a patient has temperamentally an excess ofpitta (bile) he may be specially susceptible to physical illness as a result of this humour; he should be careful of heat-producing foods since this may raise the level of pitta in his body. Again, a person with a predominance of sattva may be better able to resist mental illness from psychological shock, than a person with a tamas temperament. Hence, Susruta's maxims: "A physician should take in hand a patient with an eye towards these mental traits." And, "A physician should coolly deliberate upon the different types of temperament described herein and their characteristic features" (1963a: 158). 3. PSYCHOPATHOLOGY IN CLASSICAL AYURVEDA THEORY In the classical theories of Susruta and Caraka the major cause of mental malfunction is the upsetting of the humours, as in all diseases. Thus, the major cause of mental illness is somato-psychic, rather than psychosomatic. The humours can be upset owing to a variety of causes. Susruta says that there are four types of madness due to humoural upset. In addition, a fifth type of psychosomatic origin may directly affect the mind as a result of sorrow and shock (sokaya), and a sixth due to the effects of poison (Susruta 1963b: 386-391). The premonitory symptoms of unmada (madness) are as follows: "Fits of unconsciousness, agitated state of mind, ringing of the ears, emaciation of the body, excessive energy of action, aversion to food, eating filthy things in

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dreams, perturbation due to v~yu, and vertigo or giddiness are the symptoms in a patient which forebode a speedy and impendin~ attack of insanity" (Susruta 1963b:387). After discussing the general and premonitory symptoms Susruta discusses the symptoms produced by each of the three humours, and finally the fourth and incurable form of madness resulting from sannip~ta or the upsetting of all three humours. Note that the same causes can produce imbalance and bring about diseases which do not affect the mind. Psychopathology occurs when the upset humour (or humours) reaches the area of the heart, where the mind is located, and blocks the ducts (sira) and channels (dhamani) that carry the dSsas and dhdtus. Susruta and particularly Caraka have elaborate discussions of the symptoms of each type of insanity. They also have discussions of therapeutics. Basically, the principle of cure is the same in all diseases: the upset humour has to be controlled by ingredients that have the right counteractive properties. I shall discuss symptoms and therapeutics in detail when I deal with the contemporary practice of Ayurvedic psychiatry. However, it is worth mentioning that the classic texts have harsh measures to control intractable and extreme cases of unm~la, such as threatening patients with flogging, piercing the patient with pointed instruments, or putting the patient in a dry well with a cover over it. Yet Susruta does have more humane treatment for those patients suffering from sorrow or shock. "In the case of the fifth kind of insanity the cause of grief should be first removed." Also: "In all forms of insanity the restoration of serenity of mind should be first attempted. Mild and gentle forms of these remedies should be resorted to in the case of maria (preliminary stage of insanity)" (Susruta 1963a:391). The almost identical set of causes may produce both insanity (unm~da) and apasm~ra (epilepsy). In both the mind is affected by the blockage or malfunctioning of the ducts and channels leading to the heart. However, apasm~ra is distinguished from unm~da in that the upset humour results in unconsciousness rather than mental malfunction. In apasmdra the morbid humours lie dormant near the heart. When roused by a sudden, emotional shock like desire, anger, fear, greed, infatuation, excitement, grief, worry or anxiety, they block the channels of the heart and sense organs causing thereby an epileptic fit (Caraka 1960: 246-253). We also noted that similar causes can produce different diseases: the crucial fact again is the manner in which the intervening humours are affected. In this sense Ayurveda recognizes strictly psychosomatic illnesses, though they do not receive conceptual formulation as such. Emotional conditions like sorrow and excitement can not only produce madness and epilepsy; they can also produce, through a radically different effect on the dOsas (humours), diseases which have nothing to do with mind, but are entirely organic or physical. These

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psychosomatic ailments are not treated as a special category; they are nevertheless referred to right through the whole corpus of Ayurveda. Let me give a few examples: (I) Even fevers can be caused by emotional conditions such as grief and anxiety. They produce an excess of heat in the body which finds lodgement in the rasa (lymph-chyle) and causes fever. (2) Atisara (diarrhea, dysentery, indigestion) can be caused by grief, fright, change of seasons, aquatic sports, and suppression of natural urges. The natural urges referred to are the following: evacuation, flatus, micturation, yawning, lachrymation, sneezing, eructation, vomiting, discharge of semen (Susruta 1963b :344). (3) Aversion to food (arocaka). "The derangement of the dbsas either several or combined or an apathetic state of mind (through grief, etc.) tends to block the food carrying channels, viz. the esophagus as well as the region of the heart causing aversions to all sorts of foods" (Susruta 1963b:357). According to Susruta somatic illnesses caused by the emotions, atisdra in this case~ require emotional therapy, generally consolation and the fulfillment of the patient's wishes (Susruta 1963b :360). In addition physical therapy may also be required to alleviate any humoural upset. (4) Kusta: eczema. Ayurvedic physicians have insightfully noted that eczema can be caused not only by unwholesome food but also injudicious living, suppression of the natural urgings of the body, and the dynamics of sinful acts (guilt?) done by a man in this or in some previous life (Susruta 1963a:346). (5) Sexual incapacity can also be emotionally caused by (a)bitter thoughts arising in the mind and (b) forced intercourse with a disagreeable woman! These conditions, says Susruta, can produce 'mental impotency' (1963a:311). Remedies for impotency are exclusively physical medicine, in this case aphrodisiacs or va/ikarana. Nowhere in Ayurveda is there a psychodynamic theory to explain these phenomena. By contrast, the somatic theory of the three d6sas is always systematically spelled out.
PART H The Contemporary Practice of Psychological Medicine in Ayurveda

In this section I shall consider the application of the classic Sanskrit paradigm in the treatment of mental illness in contemporary Sri Lanka 12,a I have interviewed three major practitioners in Sri Lanka and see very little difference in their treatment techniques. For convenience I shall focus on Dr. Indrasena de Alwis, a lay pupil of a famous Buddhist monk, now deceased, of Nilammahara. Nilammahara is a Buddhist temple about 20 miles from Colombo and a

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long-established center for a local tradition (d~siya cikitsa) of Ayurvedic psychiatry. Dr. Alwis is a highly educated person thoroughly familiar with the Sanskrit as well as his own local (d~siya) tradition. He has also a working knowledge of English. He is a dedicated physician with a high sense of duty and well developed standards of professional ethics. He makes his own medicines and also dispenses them. He has no facilities for warding patients; but he has trained attendants who look after patients in their (the attendants') own homes. The theory of illness in the Nilammahara tradition is based entirely on classic Ayurveda, which has been sketched earlier. I shall therefore deal with the local application of this theory in respect of nosology, diagnostics and therapy. The Nilammahara tradition is based on the following: (a) a medical text belonging to this tradition and written in Sinhala verse, (b) the practical experience of four or five generations of physicians, and (c) familiarity with Sanskrit and Sinhala medical texts. Prescriptions from these texts are used for treating patients. The Nilammahara psychiatrists follow their own medical text with reference to classification and symptomatology. According to Nilammahara there are 22 types of psychopathology, but in this paper I shall deal with eight types based directly or indirectly on the Sanskrit paradigm.

1. Vata Unm~la: Madness from Wind (vdta, vdyu) Causes: Consumption of bad foods, indigestible foods, revulsive foods; also lack of adequate food intake. Extremely 'cool' foods are also bad. So are conditions that can weaken the. body like excessive work or exercise or excessive sexual intercourse. These cause v~ta to be excited; if the rata affects the brain and heart, rata unmada may develop. Symptoms: The patient sees dreams and illusions: serpents, elephants, non-humans, horses, royal officials. He hears the sound of flutes and of firearms. Some patients shout in fear, or try to scare people. Others try to run away, or abuse people. Very often they wake up in fright. Comment: Foods that have the property of wind are generally dry and hard to digest like most cereals and dried meats. When food is ill-digested (it cannot get 'cooked' in the stomach) it forms a 'vapour' (i.e., wind). Flatus is one symptom of this condition. Even excessively cool foods may produce v~ta since they are often difficult to digest, producing flatus. Some kinds of foods have excess of both wind and phlegm and as a result of bad digestion can produce excess wind (rata) in the body. Piping-hot foods also produce vata perhaps through the vapour they exude. The major effect of vdta is edema as well as diseases involving pains and swelling of the joints as a result of trapped air. Vdta affects the mind when the upward moving currents of air hit the brain and heart. The symptoms are clearly based on Sanskrit texts. In interviews the doctor

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pointed out some of the connections between theory and symptoms. V~ta (wind) is the principle of movement; thus, when vdta increases the patient becomes hyperactive or manic. Such symptoms as shouting, abusing, attempting to run away clearly indicate the effect of vdta. The patient's dreams are also of animals and royal officials in movement (e.g., pursuit). When elephants appear in dreams they are seen as breaking or shaking trees and branches. Vdta-based mental illnesses are always serious.

2. Pit-unmdda: Madness from Pitta (bile) Causes: Eating of sour and harsh (katuka) foods to excess; excess foods with giniguna (the property of heat); sleepless nights and irregular food habits can
also cause this condition. Symptoms: The premonitory symptoms are the following: the patient attempts to run away; he may experience great anger; his face may turn yellow and eyes red. When full blown illness develops the patient experiences sleeplessness and a gnawing hunger. His hands and feet 'burn' and his mind hankers after cool things. Behavioral symptoms include obstinancy and attempts to frighten those around him. Comments: Here the relationship between causes and symptoms with the upset pitta or bile is even clearer: sour, harsh foods contain excess of the element of heat (fire). This increases the bile in the body, and could cause any type of pitta disease. Factors like a weak mind or temperament, or a physiological factor like a current of air in the body may force the pitta upwards towards the brain (and heart) thereby producing madness. The symptoms of excess heat are also clear. Heat=red=rage is one symbolic equation. Thus the patient has red eyes and sees red, causing fright in others. When the body is heated there is a craving for cool things. Burning sensations in the hands and feet are also clearly related to heat or pitta. So is hunger since heat 'cooks' the food in the digestive system; hence, more and more food is needed. Some symptoms are not immediately related to pitta, like attempts to run away. In general such symptoms are due to 'wind'. But emotional heat produces impatience and can cause motor activity also.

3. Sem unm~da: Madness from Phlegm

The most important cause of madness from phlegm is due to excess consumption of 'nutritious' foods. When this is combined with little exercise the patient becomes a candidate for phelgm (sema) diseases, including those affecting the brain. The symptoms are a distaste for food and an aversion for 'cool' things including water. Excess phlegm oozes from the nose and mouth. The patient cannot sleep; he has rigid, fixated body movements. He also has an excessive desire for sex.

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Comment: Here as elsewhere the local texts lay more emphasis on symptoms than causes as befits their purpose as handbooks of practical medicine. However, even here the importance of food in the etiology of disease is clear. According to Ayurvedic thinking the most nutritious foods are those containing the cooling principle. Thus, sweet foods are invariably cooling and invariably nutritious, and phlegm producing. Therefore, too much good food and lack of exercise lead to excess phlegm. If and whenlphlegm clogs up the passages to the brain and heart you have madness from phlegm. Most of the symptoms are once again clearly related to the cause of the disease. If wind causes movement, then water (phlegm) is the static principle. Thus, rigid, lethargic, lazy behavior is the result of sem unm&ta. The excess of phlegm also leads to a natural bodily aversion for cool things. It also produces' symptoms of excess phlegm like coughs, colds, sneezing, hypersalivation and expectoration. Furthermore, sweet, cooling foods have aphrodisiacal properties (vafikarana); they increase sukra dhatu (semen) and stimulate the sex drive. The next three types of psychopathology are combinations of the three humours: 4. va-pit unm~da: madness caused by v~ta and pitta;

5. va-sem unm&ta: madness caused by v~ta and sema (phlegm) and 6. pit-sem unm~tda: madness caused by pitta and sema. 7. Tundos or sannip~ta unmada: madness caused by all three humours or a concatenation of the three humours. According to classic Ayurvedic theory any sannip~ta type disease is very serious and in general incurable. All our classic authorities ask the physician to give up as incurable madness which is caused by all three upset humours. The rationale for this is clear from the theory of Ayurveda. If all three humours are upset then attempts to control one by administering medicines with its opposed properties wiU only excite another. For example, if I give cooling medicines to control heat or pitta, these cool medicines will also increase the quantity of phlegm in the patient's body, which is already in excess owing to his sannipata condition. Thus, the incurability of sannipata conditions is based on the logic of Ayurveda theory. In practical medicine, however, this is not easy, for contemporary physicians feel that they must do the best they can for the patient. Dr./kiwis says that his tradition has prescriptions that will not cause these oppositions. I shall deal with their therapy later. Dr. Alwis insists that in spite of the bleak prognosis one must not give up hope. One of the patients he was treating while we were there was a sannip~ta case.

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8. Rat-pit unmada: Madness caused by rakta (blood) and pitta (bile) In Ayurvedic theory the dhdtus or body elements are very important. If these body elements are disturbed you can have serious illnesses. Thus, loss of semen may cause anorexia since semen is the quintessence of the dh~tus. Another crucial body-element is blood. Excess of heat and air can also affect the blood causing rakta-pitta and rakta-vdta (blood-wind) type diseases. In rat-pit blood gets directly affected as a result of excess heat in the body; alongwith this is a general increase in pitta. Madness results when these conditions 'rise to the top': (udakuru, urgata) and block the channels of the brain (and heart). The causes are similar to madness from excess pitta; in addition to these, exposure to the sun's heat and the consumption of alcohol and narcotics can produce this condition. The symptoms are almost identical with pit-unm&ta (No. 2). Comment: The primary cause of this disease is heated blood; since blood permeates the whole body, you have the characteristic symptoms of bodily burning sensations. Also, the heated blood escapes from body orifices. The rest of the symptoms are as in pit-unm~da. Note that alcohol and narcotics are heated substances that directly affect the blood. The Ayurvedic psychiatrist told me that though these symptoms look very serious, rat-pit unm~la is easiest to cure. He said 75% of all patients visiting him are of this type. He further explained to me in English that this disease was 'like hysteria'. This statement has considerable implications. Rakta-pitta is a well-known disease in classic Ayurveda, but there it is not seen as a special type of unm~l~ This type of madness is, however, a crucial one in the Nilammahara tradition. I suspect that this is due to the recent massive increase in hysteria, itself apparently caused by an increase in sexual puritanism (Obeyesekere 1974). There is also a widespread tendency among modern Sinhala people (especially females) to somatize their psychological conflicts. Hence, the burning sensations in the body noted in the symptoms. Rat-pit is a convenient category for incorporating the increasingly large number of hysterical and hypochondrial patients in contemporary Sri Lanka. The illnesses listed thus far arise from the upsetting of dOsas (humours) and dhatus (body elements), particularly blood. The rest of the 22 types largely deal with the side effects of other kinds of illnesses (e.g., asthma, epilepsy); or due to neglect of internal cleanliness (e.g., 'childbirth psychoses', from the womb's impurities after childbirth); or external causes like demonic intrusion (bhf4ta dbsa) which requires ritual curing. Dr. Alwis proudly claims that the Nilammahara tradition with its 22 types of psychopathology is an improvement on the five or six types recorded in the Sanskrit texts. The local tradition must be given the credit for two things: (a) extending the logical implications of the Sanskrit trid~sa theory and (b) reclassifying the scattered references in the Sanskrit literature to other

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conditions which affect the functioning of the mind. Regarding the former, the logical implications of the tridOsa theory are explored in the first seven types of illnesses based on upset humours. The illness due to the blood (rakta) being affected is also consonant with classic Ayurvedic theory. The practical and humane ethic of treating patients affected with the upsetting of all three humors (sannip~ta) is, however, different from the classic Sanskrit position which enjoins the physician to consider the disease as incurable. The remaining mental illnesses are not alien to the classical tradition either. Classic Ayurveda also recognizes that the mind can get upset in a variety of other diseases or due to other causes. But these are not classified as unm~da. The local tradition has brought together these references under a larger rubric. Thus, in local usage, unm~da can be glossed as "all those conditions that produce an upset or disturbed mind." 1. AYURVEDIC THERAPY FOR PSYCHOPATHOLOGY In classical Sanskrit as well as in Sinhala, humoural disequilibrium is referred to as 'excitement' or 'anger' of the dOsas. Another technical term in Sanskrit is dOsa vaisamya, 'disturbance of the dOsas'; its opposite is samya, which is rendered in current Sinhala as samanaya. Thus dos samanaya is the goal of therapy: 'the calming of the dOsas', 'the evening out of the dOsas', 'the restoration of the balance or equilibrium of the dOsas'. All therapy of somato-psychic diseases are directed to this goal. In psycho-somatic diseases (like diarrhea caused by emotional factors) emotional therapy (generally consolation) must be accompanied by medication to restore humoural balance. To effect humoural homeostatis in unm~da the following therapies are essential: (a) Kas~ya: decoctions. (b) Hisa giilma or hisa kuditchi: head pack. (c) Nasna: draining of phlegm through the nose. Decoctions are essential for all diseases in Ayurveda, including unmada. The vegetable ingredients used have certain guna, 'essential properties', and vip~ka or effects. Guna here could refer to the three gunas of s~.mkya philosophy; more importantly they refer to the preponderance of the five elements in each ingredient, particularly wind, water and heat. The vip~ka is the effect of the guna on the body. Thus the ingredient dried grapes has the guna or property of 'coolness' (water); its effect or vip~ka is to calm excess bile or pitta (heat): i.e., pitta samanaya in Sinhala. In general, the property of heat counters excess cold (phlegm) and renders the latter sarnanaya, and vice-versa. The problem becomes more complicated in the case of excess wind (v~ta) since there is no binary opposite involved here. However, Sinhala doctors have several ingredients that

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have the property of calming (samanaya) excess of wind. Furthermore, an excess humour cannot only be calmed (samanaya) but totally destroyed (n(staka) by certain ingredients. Such ingredients must be carefully used, and matched with others in order to counter the drastic effects of the former. The careful 'matching' of the various ingredients used in any particular decoction is known as sam.yOga, a critical word in the vocabulary of Ayurvedic therapy. The sa.myOga or matching or combination of properties in any decoction can be quite complicated, and depends on the nature of the disease. Let us say that a certain ingredient 'x' mayhave the property of 'coolness' and also some 'heat'; if the patient suffers from excess of bile (heat) then this ingredient may only be partially successful, since the property of 'coolness' may be nullified by the 'heat' in the same ingredient. In which case the sam.yOga requires another ingredient 'y' in the prescription to counteract the 'heat' in ingredient 'x'. The contraindication of certain ingredients is known as viruddha (opposition). But, as we noted, a particular sam.yOga(matching or combination of ingredients) neutralizes an otherwise contra-indicated ingredient. Neutralization of ingredients often results in sama-sitos.na, 'balanced hot-cold'. Thus, when you have a high fever you are often given coriander which is 'cool', combined with 'ginger' which is 'hot'. The combination of the two (i.e., its sa.m_yOga)renders i t neither hot nor cold, i.e., sama-sitos.na, which is good for the fever which has to be brought to normal. All ingredients are measured in terms of kalam (k) andtmanc~di (m ), the seed of the adenanthera pavonia. Each m is about 1 grains; 20 m = 1 k. In general the ingredients used in one decoction must add up to 12 k; in the case of a decoction containing an unusually large number of ingredients 24 k can be used. These ingredients are generally boiled in water which is measured in terms of pata (Sanskrit, kudaha). Each pata contains about nine ounces of water. In general all decoctions aIe reduced to ~ the original volume by boiling. I shall now illustrate the Ayurvedic idea of samyOga, combination and balancing of ingredients, and its therapeutic principles by examining one prescription for a decoction (kasdya) 4 (see Table 1). Sannip~ta illnesses, we noted earlier, are difficult to cure since all three humours have been upset. This affects medication since, very often, an ingredient that controls one humour (e.g., phlegm) may increase another (e.g., bile). Thus, in this case the yoga, yoking or combining of ingredients, or sa.rnyOga 'balanced combining', is crucial. This means that: (a) the prescription must use ingredients that do not rouse another humour; (b) in case another humour is roused counterative ingredients must be employed to neutralize it. This can be illustrated by negative examples, i.e., why certain powerful ingredients are not used. Thus, no tippili (piper longum) is prescribed here, for

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TABLE I Prescription for tun dos or sannipitta unmdda - madness from 'all three humours'. Name of Ingredient
1. midi (dried grapes)

Latin Term -

Vipaka - Effect Sema samanaya; evening out of phlegm (it's loosened and expeUed);pitta also controlled by its cooling properties. Neutral in respect of vffta (wind). Pitta samanaya: evening out of pitta. Neutral in respect of phlegm and vffta (wind).

2. sudu handun

santalum album

3. nelun yams 4. nelun stalks 5. nelun filaments 6. kalanduru yams (ala)

nelumbius speciosum

Phlegm is expelled and made samanaya; destroys pitta (bile); neutral in respect of vffta (wind). The excited pitta can affect the stomach (ffma); this ingredient loosens and expels stomach impurities. Neutral in respect of all three d~sas. When the three humours are excited the patient may suffer 'stomach block' (mala badda; constipation). This is an emetic which clears this condition. It also destroys vffta and sema; neutral in respect of pitta. One of the most important ingredients in Ayurvedic medicine, a 'friend' of all three humours; emetic, expels feces and stomach impurities; cleanses blood. Saying: 'aralu is like the mother, she never punishes you.' Another crucial ingredient. Blood is purified; also a nutrient (ahara) for the blood. Helps in the equilibrium (samanaya) of all three humours. Flushes kidneys; and helps samanaya of pitta. Not against vffta and sema.
Sema is evened out; destroys pitta; not bad for vffta.

cyperus rotundus

7. katukar~sana

picrorhiza kurrooa

8. aralu

terminalia chebula

9. nelli

phyUanthics emblica

10. iriv&iya

plectranthus zeyhnicus

11. s~v~ndarff roots

andropogon murieatus

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Table I cont. Name of Ingredient 12. unuvarana bark Latin Term crataeva roxburghii

Vipaka - Effect
Helps pass urine thereby expelling impurities; destroys sema; evens out (samanaya) v~ta. Illustrates samySga very well. KatukarSsana (7) and aralu (8) are powerful emetics; fkelinda seeds are anti-diarrhea and reduce the strength of the earlier ingredients. Th.us the sa.mySga or combination of the three ingredients produces moderate bowel movemerlts. Not opposed to any of the three humours, Destroys pitta; has cool property but does not rouse sema (because it expels it); not against vffta. Helps even out vffta and sema; not opposed to pitta. (Incidental effects: good for the throat (urgura) and for coughs produced by excess pitta). Not opposed to the three humours but the physician could not explain positive effects of this ingredient. Excellent in evening out vffta; expels sema and evens it out; also not against pitta. Another popular ingredient often used for pitta and heated blood (and coughs and fevers). Helps the evening out of all three humours. Sema is loosened and expelled. Loosening and expulsion of sema (phlegm); its cooling properties help control of pitta. Not opposed to vffta. Belongs to the group/class of virecana (purifiers, emetics); cleanses and purifies the stomach. Helps even out all three d6sas by expelling impurities.

13. kelindaseeds

holarrhena anti dysenterica

14.patpadagan

oldenlandla corymbosa

15. uguriissa fruits

flacourtia ramontchi

16. ruk flowers

myristica horsfieldia

17. valkahambiliya roots

tragla involucrata

18.adat6da roots

adhatoda vasica

19. val mi (liquorice)

glycyrrhiza glabra

20. dummalla

triehosanthes cucumerina

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Name of Ingredient 21. bin kohomb~

Latin Term munronia pumila

Vipaka - Effect

Destroys v~ta and sema. Normally, it tends to increase pitta, but this effect is neutralized in this samy~ga since there are many pitta destroying medicines (ausada) here. Helps pass out urine:and loosens the impurities of the stomach. Sema is loosened (p~savanava) and expelled. Helps even out vffta and pitta.

22. kottamalli (coriander)

Dosage: 24 k (1 k 2 m each ingredient); 16 pata reduced to 1 by boiling; three times daily. Also hisa kuditchi (head packs), nasna (nasal draining) and oil for the head.

while it is good for phlegm, helping its expulsion, it rouses a great deal o f p i t t a (bile, heat). Inguru (ginger) is good for serna and v~ta but it causespitta to rise to the top (urgata) and therefore can increase the symptoms of madness. Aratta ala (vanda roxburghii) is excellent for v~tta but bad for pitta, and also dries up sema, and hence is not used in this prescription. 2. HISA KUDITCHI AND NASNA: HEAD PACKS AND NASAL DRAINING Head packs and nasal draining are used in almost all types of mental disorders in Sinhala medicine, much more so than in classic Ayurveda. These therapies are certainly known in classical Ayurveda, but they are given prime importance by Sinhala practitioners of Ayurvedic medicine. Indeed, local practitioners view this as the special Sinhala contribution to Ayurvedic therapy. The reason for their importance in Sinhala medical theory is not difficult to seek. In the local Sinhala tradition, the head is viewed as the primary locus of the mind. The heart is treated as important because it is so considered in classic Ayurveda: the Sinhala tradition only pays lip service to this idea. Sinhala beliefs, probably derived from Buddhism, treat mental illness as caused by the 'head going bad', or 'the brain going bad'. Otherwise, the classic theory is unchanged; mental illness is caused by the humours affecting the dhamanis and s i r a s channels and ducts - leading to the brain. Hisa kuditchi and nasna are important when there has been an excess of heat and phlegm which has risen to the top (urgata). Heat, invariably produced in mental illness, may dry the phlegm which then may clog up the channels and

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ducts leading to the brain. The aim of these therapies is to loosen the dried phlegm and expel it from the head via the nasal passage. However, if the patient has a cold or fever, or has excess loose phlegm, these therapies, especially head packs, should not be given. The head pack, or hisa kuditchi, is also known as hisa-gdlma, 'head-flooding', which better indicates its purpose. The pack itself is a towel tied around the circumference of the head, with a strap to hold it firmly in place, to form a kind of 'basin'. The medicines are poured into the basin. The patient keeps the medicines on his head for three hours, generally 8:00 a.m.-11:00 a.m. If the patient has loose phlegm already, no hisa gdlma is required, because the idea of the pack is to 'flood' the head with cool substances and thereby create artificial 'cold', i.e., loosen the dried-up phlegm. Sometimes no nasna is required for the phlegm comes out easily with the flooding. Some patients may experience a fever after a head pack, but this is not of a serious nature. Head packs must be followed by 'head-bathing'. There are several types of prescriptions for head packs. The following is a very popular one: Unripe limes - cleanses the head Bdbila (sida cordifolia)(whole plant) - destroys v~ta Powdered white sandalwood (santalum album) - cooling; controls pitta. Sdvdndara (andropogen muricatus) powdered - cooling; controls pitta. Take about eight ounces of each; boil all the ingredients in 1 bottles of cow's milk until it is reduced to one bottle. Grind into a paste with some breast milk and fill the pack. This is good for rat-pit unm~da. In other prescriptions the ingredients may be left overnight in the open to be cooled by dew drops (pinna). Very often the water of the yellow coconut (ti~mbili), a prime cooling substance, is added. The general rule is a decoction for 4 - 6 days, followed by a head pack and bath, and decoctions once again. One or two nasna may also be given to the patient during a period of a month. Nasna expels the loose phlegm collected in the region of the head (and heart). The most common prescription for nasna is as follows: 1 seeds of mT(bassia latifolia), 6 seeds of white pepper. These two ingredients must be ground with a little breast milk on a clean grinding stone. This paste must then be dissolved in about an ounce of breast milk. This is poured into a nasnayuda (instrument used for nasal draining), a small silver instrument with two funnels which are placed just outside the nasal passages. The patient lies on his back and his head is firmly held by an assistant while the doctor pours the mixture into the nose with a funnel; he then takes the funnel out, and blows twice with his mouth into the patient's nose. It is

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apparently a sudden, painful experience. Immediately afterwards the patient goes into the garden and blows out or expectorates the loose phlegm into a box (bakki). After about one hour when the loose phlegm has been fully expelled he bathes in cold water. He then has a lunch which must not consist of extremely cool or hot foods. If the patient has a fever he should be given only a liquid diet at night; otherwise the lunch meal could be repeated at night. The following day the patient is expected to rest in bed; the day after decoctions could be resumed.

PAR T III
Case Studies and Conclusions Since my research on psychopathology in Ayurveda has been only recently initiated, I do not have in-depth case studies of patients. I have, however, ten patient interviews in the doctor's office and many discussions with Dr. Alwis regarding his mode of diagnosis and treatment of these patients. The two cases described below are based on one or two interviews with either the patient or family members or both. These cases, however, will help illustrate that the theory and practice of Ayurveda is not a psychodynamic one, though individual physicians may have personal sensitivity to the psychological problem of their patients. Furthermore, these cases will illustrate the manner in which illness is diagnosed and treated by Ayurvedic physicians in specific cases. Finally, they will help us draw some very tentative observations regarding the nature of Ayurvedic psychological medicine. CASE I: HEMACHANDRA: RAT-PIT UNMADA We noted earlier that rat-pit unmRda, produced by a combination of rakta (blood) and pitta (bile), constituted, according to Dr. Alwis, 75% of his cases. He also vaguely equated these illnesses with 'hysteria'; his diagnosis may not be entirely wrong in the two cases discussed below. The first patient, Hemachandra, is the eldest in a family of seven siblings. His father is employed as a mason in the Government Steel Corporation, and the mother is a housewife. The mother was neat, well-dressed; I felt, however, that she never did have much time for her children owing to the large family she had to look after. The patient is twenty; he was extremely polite and cooperative with the interviewer, but openly hostile to the mother, constantly contradicting her. He went to school up to Grade 8, but left school two years ago largely owing to his illness. He was treated by Dr. Alwis then, but he did not complete the full course of treatment. Consequently, Dr. Alwis told us that he had a relapse two months ago.

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The patient says that the symptoms of his illness are burning sensations in the stomach, aches and pains in the shoulders, back and joints (common enough complaints in the culture). His mother says that he manifests extreme rage against his parents and even outsiders. According to her, the "madness' started with a severe stomach disorder. Even as a child hot foods like beef and pork were bad for him, she said; excessively cool foods also produced diarrhea. As a result of diarrhea the boy became thin. This was a great cause of anxiety to the parents who consulted both Western and Ayurvedic doctors. The boy was subsequently hospitalized and the diarrhea was cured. The boy's 'madness' developed soon after this. In the height of his illness he used to yell out in pain, complaining of stomach cramps. He became restless, and couldn't remain still. In his sleep he would get frightened and would wake up with a jerk. His eyes would often smart, so that he couldn't even see a film. He complained of back-aches and seeing demons (bhOtas)in his dreams. All this occurred two years ago at age 18. He took a course of treatment from Dr. Alwis for three months; the symptoms subsided and t h e parents discontinued the treatment. Hemachandra then got a job as salesman, with a meagre salary, in a vegetable stall owned by a friend of his father. When he had his relapse two months ago he had to give up his job. Some of Hemachandra's complaints are common both in the culture and among Dr. Alwis' patients, these being the somatization of conflicts, and burning sensations in the stomach, and even the diarrhea which sometimes is psychogenic in origin. He was 18, and like many in the culture, had no heterosexual outlets. But beyond these problems there was a deep-rooted hostility to the father. Hemachandra openly stated his intense dislike for his father; constantly 'fighting' with him. Hemachandra says that his father retaliates by humiliating him, calling him pissa, 'madman'. The familial conflict came out on one occasion in a most interesting fashion. The boy's family, like many others in the culture, tended to give a supernatural explanation for his illness. The father interpreted the boy's hostility to him as due to spirit incursion by his own deceased paternal grandfather whom he disliked! They thus consulted diviners who suggested curing rituals. But Hemachandra strenuously objected to these interpretations as hocus-pocus. After one of his arguments with his father, the latter took him to a Buddhist monk who was also an exorcist (a monk-exorcist is rare in this culture). The father-son conflict came out into the open in the interpretation of the disease: the father insisting on its demonic origin, the boy insisting on its physical nature. The monk, apparently sensing the nature of the conflict, uttered a mantra, and placed a charmed 'bag' against the boy's forehead. If the cause of the disease was demonic, the charm would excite the spirit and the boy will shake. This did not happen and the monk affirmed the boy's interpretation of the case as due to

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upset humours. He then gave the boy a long sermon, with edifying examples, of how to get on with elders and be tolerant of their weaknesses. DR. ALWIS' INTERPRETATION OF THE CASE The familial conflict as far as Dr. Alwis is concerned is a symptom, not in any way causally related to the illness. "Frightening others," he says, "is a common symptom among pitta and rat-pit patients", quoting from a medical text to illustrate this. For example, the doctor said that he saw Hemachandra threatening (i.e., 'frightening') his own father. "When I firmly but also kindly forbade him to do so h e desisted. My experience is that patients, even intractable ones, obey us, because they know that we are not afraid of them." I have all the medical prescriptions given by Dr. Alwis for Hemachandra. I shall, however, briefly deal with the doctor's medications during Hemachandra's second visit. Initially Hemachandra was given three decoctions for controlling pitta during a period of about two weeks. Then followed another consultation: he was given another decoction to samanaya (even out) the 'blood' (rakta) for six consecutive days. This was followed by three days of head packs; and one nasna (nasal drainage). After this the doctor said that about 75% of the patient's symptoms were gone. This was followed by another cooling decoction and another head pack. After this another standard decoction was given for six days: but tippili (piper longum), an ingredient normally used in this prescription, was omitted because of its hot properties. This was followed by two other decoctions given consecutively; at the conclusion of which he was given a vireka (emetic) to cleanse the bowels. This vireka consisted of tamarind, raw arecanut and sent kola (senna leaves), combined with sugar and taken two times in the morning. The patient has to be prepared for this. The night before he eats a light meal at 7:00 p.m. with a few mildly cooling, easily digestible vegetables. The next morning he is given some 'bed tea', followed by the emetic, in turn followed by a meal of rice cun]ee (light porridge) minus salt. In the afternoon and the next morning he has light rice meals. He must not bathe for two or three days; after which he can resume his normal regimen. By this time the disease was practically cured, the doctor told us. I saw Hemachandra soon afterwards in the doctor's office; he seemed much better, more cheerful, relaxed, and told me that he felt very much better, and ready to go back to work. CASE II: SIRIMATHIE: RAT-PIT UNMADA I met Sirimathie at the doctor's office only once. It was clear to me that she was suffering from a severe depression. She practically refused to speak to me and all the information I have is from her voluble younger sister. Sirimathie (aged 23)

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was one of five siblings; one sister (unemployed) and three brothers, one of whom (age 22) was also unemployed. The father died recently and the eldest brother, an electrician, looks after them. Owing to poor economic circumstances they have divided their small house in two and rented one half; they also collect rent from another small house. The patient is unemployed, a high-school graduate; she desperately wants a job, but none is available. She therefore does some housework and cultivates manioc in her small garden plot. Sirimathie's case clearly illustrates our doctor's tendency to treat psychodynamic factors as symptoms of deeper physiological malfunction. According to the doctor, the patient developed her symptoms of withdrawal and depression seven days after the father's death, when a remembrance ritual for the dead was held in the house by Buddhist monks. Therefore, he argued, sorrow has little to do with the cause of the illness. If she felt sorrow and shock immediately after the father's death he would have interpreted the case as mdnasika (mental). But, he said ironically, it is not hitta (mind), but pitta (bile). One has to be careful before one rushes into an interpretation ofmanO dukkha, 'mental suffering'. The patient's head was bowed, and slightly slanted to a side; this again was only peripherally due to her sorrow, the real cause being the action of humoural energies moving upwards. Dr. Alwis' interpretation is that Sirimathie had a temperamental excess of heat, pitta, or bile. During the period of her father's death she kept up late nights, which aggravated this condition and also affected the blood (rakta). As a result of upset routine, she also developed an excess of phlegm manifest in a serious case of cold (pratis. yaya) and cough and asthma. Her unm~da (madness) was due to the fact that the excited pitta heated the blood; these humours then moved up, disturbing the brain and heart and also clogging the ducts and channels leading to the brain and heart with dried phlegm. Ultimately this must affect the mind (hitta). "Mind is not an organism; its seat is the heart and its 'office' (executive functions?) is in the brain", he said, combining the ancient Sanskrit and Buddhist theories of mind. From a psychodynamic view I got a different impression of the case from Sirimathie's sister. Sirimathie's father loved her greatly and was very concerned about a marriage for his eldest daughter. He had initiated arrangements for a match for his daughter with a son of a friend. Soon after this he went to Navalapitiya, about 100 miles from his residence, to talk to his brother about the proposed match. There he had a heart attack, but decided to come home straight away, where he died. The daughter was greatly distraught, particularly after the father's 'remembrance-day' events; she used to cry, laugh, brood, looking constantly at the father's photograph. But the other members of the family hoped that these symptoms would pass away. After a week they consulted a ritual specialist who tied a talisman on her wrist, but this had little

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effect. Oftentimes she refused to eat and clrink; her head became bowed to one side. After a month she developed other symptoms. She often scolded and threatened to hit her younger sister and mother. She became even more depressed after the 'remembrance alms-giving' for monks, which is given three months after the death of a person. Three weeks after this she was taken to Dr. Alwis. Some of the psychodynamics of the case seem reasonably clear. She was a twenty-three year old woman, and if her case is typical for urban Sri Lanka, she would have had little or no heterosexual experience. Repression seems to be the common defense, and hysterical propensities are common in these women. Marriage is a crucial event, since in modern-day Sri Lanka, it is difficult to get a woman married unless she has reasonable dowry or good job, owing to massive under employment and unemployment. Her father whom she loved arranged a marriage for her: he died suddenly, and the marriage proposal fell through. Her depression is expectable in these circumstances; her displaced rage is directed at her sibling rival and, given her feelings for her father, against her own mother. Her asthmatic condition was also probably triggered by her emotional state. I shall not describe the enormously complicated set of decoctions and other medications given to Sirimathie by the doctor, but only his attempt to practically implement his diagnosis of her case. The first problem was the cold, cough and asthma, i.e., excess phlegm which then had dried up owing to excess heat. Three decoctions were given to loosen the phlegm (pasanava, lit. 'ripen'), one at 6:00 a.m. and 2:00 p.m.; the other at 10:00 a.m. and 6:00 p.m. In the standard prescription inguru (ginger) is added to the decoction, but the samyOgahere did not permit it since ginger is hot and she has excess of it anyway. The third decoction given once daily at 10:00 p.m. was mostly medicinal herbs to flush the kidneys, help her to pass urine, and cool the blood. These decoctions were given for four days. Much of the phlegm had gone by then, but there was still some left. The symptoms of madness were still there but the doctor was not concerned about them at this time. So he gave her two other decoctions, with more complicated matching of ingredients (sam. yOga) to be taken daily at 6:00 a.m. and 2.00 p.m. Decoction No. 3 given at 10:00 p.m. was continued. After four days, the phlegm condition was very good but the doctor was not satisfied since the-asthma still remained. He gave her three more decoctions, and on the twelfth da3~her phlegm was restored to normalcy, and no symptoms of asthma remained. Thus, one of the causes of her illness - the dried up phlegm - was successfully treated. Now the doctor treated her for the symptoms of madness (unm?Tda). Two mild decoctions were given; after four days the patient tended to respond verbally and the slant of her head was better. Then (after the sixteenth day), more drastic remedies were given. Cold baths were initiated (these couldn't be

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given earlier owing to her phlegm (i.e., cold) condition). Along with this were two decoctions, 'with great power of sam. y6ga', directed to the symptoms of unmdda. The immediate effect of such powerful decoctions was to make the unrrada worse, but only temporarily, because the dOsas (humours) were being attacked directly. Patients are warned about this reaction. In Sirimathie's case she was 'normal' after eight days. Then she was given three days of head packs, followed by a nasna. In the doctor's opinion these latter prescriptions were follow-up remedies, to ensure the final cleansing of her system. When we saw the patient she was 'cured', as far as the doctor was concerned. Her depression and refusal to talk to me were minor symptoms which will pass away with more medications. Earlier she had been almost totally mute; now she talks to members of her family and friends and in time she will behave normally, he predicted. Unfortunately I had to leave Sri Lanka soon afterwards, so I could not follow up this case.

CONCLUSION In this paper I have tried to render intelligible to a Western reader a radically different system of medicine which continues to influence the lives of millions of people in South and Southeast Asia. I have not attempted to evaluate the system in terms of its therapeutic efficacy. This is a difficult task which requires experimental and laboratory studies of Ayurvedic medicines and an attempt to understand Ayurveda theory in terms of modern physiolozy, both tasks being outside of my competence. Such a task, however, must take the theory seriously, so that experimental studies of Ayurvedic drugs should not only deal with the therapeutic value of individual ingredients, but more importantly, consider the crucial concept of samyOga, the balancing or matching of the ingredients. On the other hand, a therapeutic system may be efficacious for reasons other than those postdated by its theory. This is the case in Western psychiatry where competing and often theoretically irreconcilable therapies may be effective in curing some types of mental illness. In Ayurveda also there are psychological and cultural reasons for success, over and above those postulated by the indigenous theory. I shall refer to three such reasons. (1) The Ayurvedic theory of the mind and body, the causes and cure of illness are shared by the physician and his clients, insofar as they are part of a larger shared culture. They do not share identical views: the physician's views are more abstract, specialized, and full of technical expertise. But the patient can grasp and comprehend the doctor's treatment of his illness, whereas an interpretation of his illness in a Western psychiatric idiom will be 'culturally alien', and

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psychologically implausible to him. The sharing of a common belief system facilitates communication and rapport between patient and physician, which in turn enhances the patient's confidence in his doctor. The relationship between doctor and patient, particularly in the case of mental illness, can be complicated by the intra-psychic conflict of the patient as well as by such processes as transference and counter-transference. Take the case of Hemachandra, who hated his father and resisted his father's interpretation of his illness as an evil, demonic incursion. He has a positive motivation to get well with Dr. Alwis' medicines and the theory of the physical causation of his illness. It helps him to triumph over his father, to prove that he was correct in his views. It also enhances his self-esteem, since a theory of demonic incursion, in his case, would be severely ego-dystonic. I know of another female patient, whose father was somewhat emotionally remote and distant to her; as her therapy progressed she called Dr. Alwis, veda mama, 'doctor-uncle'; the avuncular relationship continued even after she was successfully treated. The mother's brother (m~ma) has a warm, affectionate role in the culture. However, such transferences can obviously have, in some cases, negative effects. (2) Some of the medicines may have direct beneficial effects as a result of the shared idiom. Almost universally in South Asia people believe in the five bhfttas, the seven dh?ttus, the three humours, and the importance of foods in the causation of disease. Thus a preoccupation with foods in terms of hot-cold properties is standard in this region. The patient can therefore be easily persuaded that his illness is, for example, due to 'excess of heat reaching the brain'. Once he accepts this view, he can, and will want to, take counteractive cooling medicines. Such actions are psychologically therapeutic, irrespective of the chemical action of the ingredients used in the prescriptions. (3) Some therapeutic effects may be related to psychological factors which have little to do with shared views. For example, Dr. Alwis told us that 75% of his patients were suffering from 'hysteria'. This may indeed be the case since hysteria and the somatization of intra-psychic conflicts are common in the culture. These tendencies have increased within the last twenty years owing to economic pressures and mass unemployment. Two consequences of these economic conditions are relevant: the existence of a large number of unmarried persons, and also an increase in the age of marriage. Given the puritan-type sexual ethic, particularly in the urban 'middle-class', the existence of sexual segregation, and lack of opportunity for heterosexual expression, there would be an increase in sexual frustration leading to widespread hysterical tendencies in the population, particularly among females, as in the Europe of Freud's time (see Obeyesekere 1974, for a detailed discussion of this problem). Some of the therapies employed may have beneficial effects on hysterical patients, especially head packs and nasal draining, where the patient perceives noxious evil

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substances being drawn out of his body. Yet it must be noted, in respect of hysterical patients, Ayurveda has to compete with expressive and cathartic type healing rituals also institutionalized and widely prevalent in the culture. Nevertheless, the success of ritual curing depends once again on the idiom of communication: the patient must accept the view that his illness is caused by demonic possession (or a similar theory), and be able to accept an interpretation of his illness and symptoms in these terms (Obeyesekere 1970, 1975). For those who like Hemachandra resist such an interpretation, Ayurvedic therapy must perforce be a reasonable alternative. Some Ayurvedic practitioners are aware of the recent increase in demonic possession and supernatural interpretations of illness among the general population (psychodynamically viewed, as a result I think of the increase in hysteria). One Buddhist monk who is a famous Ayurvedic physician has had for many years his own facility for hospitalizing his patients. Like Dr. Alwis he used to give the classic somato-psychic explanation of illness. He prescribed similar medications and kept seriously ill or intractable patients in chains or stocks in cells outside his residence. If he occasionally saw a patient with possession symptoms, he referred him to a practitioner of ritual medicine (bhata vidya, 'science of demonology'). However, a few years ago he started his own shrine for curing patients afflicted with supernatural forces. The shrine is separate from the main temple, and the curer is a shaman-type ritual specialist, trained by the monk, since it is considered unethical for a monk to engage in supernatural curing. The monk is present at the beginning and at the end of these curing sessions: he withdraws into his temple residence when the actual exorcism takes place. In conclusion, it should be remembered that some medical ideologies and therapies may themselves be anxiety-producing and help create psychological tensions which may not have otherwise existed. Often medical ideologies define the body and its functions in ways which are false from a scientific point of view; for example, the Chinese view that blood once lost can never be replenished, or the Ayurvedic view that semen is the quintessence of bodily vitality. In such cases loss of blood or night-emissions and masturbation with consequent 'semen loss' may create great anxiety in the patient and produce certain psychosomatic reactions like weight-loss, debility, etc. This is a complicated problem and the reader is referred to an article where I discuss at length these forms of 'cultural illness' generated by the Ayurvedic theory of body functioning and physiology (Obeyesekere 1976).

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GANANATH OBEYESEKERE NOTES

1. For a more detailed discussion of sa.mkya refer to the excellent work by Dasgupta (1963). Hiriyanna (1956) has a fine summary of both s~mkya and ny~ya-vaises.ika. Dasgupta (1968) also has an extended discussion of the relationship between Ayurveda and the philosophical schools. 2. This part of the paper is based on field work undertaken in Sri Lanka during summer, 1975 with the aid of a research grant from the Academic Senate, University of California, San Diego. I thank the following individuals who helped me in this research: Mr. Wewegama, Commissioner of Ayurveda, Government of Sri Lanka; Dr. JayatiUeke, Principal, College of Ayurveda; Dr. D.M.R.B. Dissanayake, Lecturer, College of Ayurveda, who loaned me his thesis on Ayurvedic psychopathology. Above all, I am grateful to Dr. Indrasena de Alwis who was not only an informant but also practically a collaborator in this research. This paper could not have been written but for his cooperation. 3. The Sinhala equivalents of Sanskrit terms are as follows: sema, sem = slesman, kapha (phlegm) pitta, pit = pitta (bile) unm~da, umatuva = unm~da (madness) vata, v~ = v~yu, vitta (wind) 4. The botanical terms employed are from Roberts (1931).

REFERENCES Caraka. 1960 Caxaka Samhita. R. Buddhadasa, trans. Colombo: Government Press. Dasgupta, S. 1963 The Kapila and the Patajali Sfimkya (Yoga), In A History of Indian Philosophy. Vol. I. London: Routledge; pp. 2 7 4 - 3 6 6 . 1968 Speculation in the Medical Schools. In A History of Indian Philosophy, Vol II. London: Routledge; pp. 2 7 3 - 4 3 6 . Dissanayake, D.M.R.B. 1969 Applied Psychopathology: a Post-Graduate Thesis. Jamnagar, India: Gujerat Ayurvedic University, Filliozat, J. 1964 The Classical Doctrine of Indian Medicine. Dev Raj Chanana, trans. Delhi: Munshiram Manohadal. Hkiyanna, M. 1956 The Essentials of Indian Philosophy. London: Allen and Unwin. Obeyesekere, G. 1970 The Idiom of Demonic Possession. Soc. Sci. & Med. 4 : 9 7 - 1 1 1 . 1974 The Firewalkers of Kataragama: the Rise of Bhakti Religiosity in Buddhist Sri Lanka. (Paper read at the American Anthropological Association meetings in Mexico City, 1 9 - 2 4 November 1974, to appear in Journal of Asian Studies). 1975 Psycho-cultural Exegesis of a Case of Spirit Possession in Sri Lanka. Contributions to Asian Studies 8: 4 1 - 8 9 . 1976 The Impact of Ayurvedic Ideas on the Culture and the Individual in Sri Lanka, In Asian Medical Systems: A Comparative Study. Charles Leslie, ed. Berkeley: University of California Press. Roberts, E. 1931 Vegetable Material of India and Ceylon. Colombo: Plat6 Limited.

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Susruta. 1963a Susruta Samhita, Vol. II. K.L. Bhisagratne, ed. and trans. Varansi: Chowkamba Sanskrit Series Office. 1963b Susruta Samhita, Vol. IlL Bhisagratne, ed. and trans. Varansi: Chowkamba Sanskrit Studies 30. (Received 15 July, 1976)