Liver and liver disease in Hinduism

HINDUISMHinduism is often considered the world’s oldest religion that is still being practiced today by at least 1.1 billion followers (15% of the world’s population), compared to 2.2 billion Christians (31.5%), 1.6 billion Muslims (23.2%), 1.1 billion nonreligious people (16.3%), and 15.7 million Jews (0.2%). Thought-provoking data like these are accessible online from at least 2 reliable websites.1,2 The first is devoted to the demography of world religions. It uses an interactive online map1 drawn from a 2010 Pew Research Centre demographic study of more than 230 countries and territories, which relied on more than 2500 synthesis surveys and population registers. This map can be used to investigate the prevalence of any or all religions in a specific geographic location or worldwide. The second website is devoted solely to ancient religions.2 Hinduism, with its roots deeply embedded in the Indian subcontinent, is an ancient tradition that has evolved over thousands of years, predating recorded history. Rather than being founded at a specific time, it represents a complex amalgamation of cultural and spiritual practices that have developed since the dawn of civilization in the region. Hinduism’s practices and philosophical concepts bear a deep connection to the Indus Valley Civilization, one of the world’s earliest urban cultures, which flourished around 2500 bce in what is now Pakistan and northwest India. This civilization is often considered a precursor to key aspects of Hindu society, reflecting early forms of Hindu cultural and religious expressions.3 A follower of Hinduism is known as a “Hindu,” a word derived from the river Indus in the northwestern part of the Indian subcontinent, from where this religion originated. Although often viewed as a polytheistic faith, Hinduism is actually henotheistic — a term coined by Frederich Max Müller (1823–1900), who was a British Philologist and Orientalist of German origin and one of the founders of the Western Academic disciplines of Indian studies and Religious studies.4 Müller was elected to a life fellowship at All Souls’ College, Oxford, and, according to him, henotheism means devotion to a single primary God while accepting the existence or possible existence of other deities or other forms of this supreme God. Simply put, henotheism means “Monotheism in principle and Polytheism in practice.” Apart from Hinduism, prominent examples of other henotheistic religions are Zoroastrianism and the religions of ancient Greece and Rome. Unlike the Abrahamic religions (chronologically: Judaism, Christianity, and Islam), wherein there is the monotheistic concept of a single well-defined god, in henotheism, one God is supreme out of several others or several other forms of the first one, as in Hinduism. The concepts in henotheism are often quite abstract, but fortunately, the charge here in these essays on the history of hepatology is not to resolve this challenge. In Hinduism, there is the concept of Brahman, the Ultimate Reality related to the soul or self, through which each individual is connected; there is an embodiment of the universe and force that is in all things, which is a metaphysical concept of an unchanging Ultimate Reality. In other words, there is a unity behind diversity in all that exists, or a supreme being — even a supreme God that may have several forms. It is sometimes difficult for nonadherents of Hinduism to discern who is considered to be the Supreme Being of the gods; it seems that the answer depends on where the question is directed. (Lord) Brahma is sometimes considered the “first among equals” of the Trimurti or 3 forms (Figure 1), the trio of supreme deities that includes his other forms, that is (Lord) Vishnu and (Lord) Shiva. Brahma, the “Creator,” is depicted as a golden-complexioned bearded individual with 4 heads and 4 arms, holding a silver bow, an alms bowl, prayer beads, and a book, and he is seated on a lotus throne or mounted on a goose. Since Brahma is too immense a concept for the human mind to comprehend, he presents himself in many different versions, which people recognize as deities, such as Vishnu and Shiva — the preserver and protector, and the destroyer, respectively — and there are others.FIGURE 1: Three Hindu Gods—The Trimurti. Trimurti means “Three Forms or Images.” Three of the most significant forms (Murti) of Brahman (the Ultimate Reality) are (A) Brahma, the creator, (B) Vishnu, the preserver, and (C) Shiva, the destroyer. In a Hindu temple, there are no images of Brahman. However, there are many images of murtis of gods and goddesses, which are aspects of the Divine One. © muchmania/Adobe Stock.Murtis of Vishnu express splendor and power. His 4 arms carry symbols of power — a discus, a lotus flower, a conch shell, and a mace. Vishnu, the god of light and enlightenment, has appeared on Earth through avatars. Murtis of Shiva vary. He is often pictured dancing and with 4 arms. He holds a drum and a flame, and he points to his dancing feet with one hand and holds in the other hand a pen, meaning “fear not.” His necklace of cobra snakes is another sign of power. Once the most popular deity, Brahma was later eclipsed by Vishnu (and his avatars, including Krishna) and Shiva, both of whom are worshipped by many millions of Hindus today. According to the Vedas — the 4 collections of shlokas (hymns), philosophy, and ritual guidance that form the earliest body of Indian scripture (probably composed between 1500 and 700 bce) — it seems that Indra, who had power over storms in the heavens, and whose weapons of choice were thunder and lightning, was once considered the supreme of the Hindu gods. It appears that “He who pays the piper, calls the tune,” an aphorism that predates the Pied Piper legend that Robert Browning epitomized in the narrative poem “The Pied Piper of Hamelin,” which was published in 1842. The Hindu belief system includes 330 million gods — figuratively meaning a great number — and these range from those who are very well known (such as Shiva, Rama, Krishna, Durga, and others) to lesser-known deities worshipped at the village level. The primary understanding of Hinduism is that there is an order in the universe and that every person on the planet has a specific place in that order. Accordingly, each person has a duty (dharma) that only he/she can perform. The performance of this duty is known as karma, which, if executed correctly, is rewarded by moving the person closer to the supreme God and eventually becoming one with that God. If, however, one does not perform karma well, then she/he is reincarnated as many times as it takes finally to come closer to union with the supreme God.2 SYSTEMS OF MEDICINE IN HINDUISM Traditionally, there are 2 recognized systems of medicine in Hinduism: Siddha and Ayurveda.5 In addition, there is Yoga, which is a healing system in the form of breathing exercises, physical postures, and meditation, practiced since 3000 bce.6 Siddha, a traditional system of healing that is practiced in south India, is based on a combination of ancient medicinal practices and spiritual disciplines, as well as alchemy and mysticism. Siddha is thought to have developed during the Indus civilization (which flourished between 2500 and 1700 bce) and came to south India when the Dravidians (speakers of the family of Dravidian languages in southern India, northeast Sri Lanka, and southwest Pakistan), who may have been the original inhabitants of the Indus valley migrated to south India. The most commonly practiced system of medicine in Hinduism is Ayurveda,5 literally meaning the Science of Life, which originated in India more than 5000 years ago. According to Hindu mythology, Ayurveda is attributed to Dhanvantari,7 the physician of the gods, who received the teachings of Ayurveda from Brahma himself, the supreme God (Brahma’s biographical details are discussed below). Initially, Ayurveda was taught for many thousands of years in an oral form by accomplished masters and their disciples. During the Vedic era (starting from c.1500 bce), some of this knowledge was written down in one of the Vedas known as the “Atharvaveda,” which has numerous hymns relating to health, diseases, fertility, herbal drugs, and anatomy.8 This period of Vedic Ayurveda medicine started in 1500 bce and lasted until about 800 bce. The next period in the history of Ayurveda is often considered its “Golden Age” (800 bce until 1000 ce), with the production of many great medical treatises by prominent physicians and surgeons of India. Among these famous individuals are the “The Trinity of Ayurveda,” as follows: Susruta or Sushruta (born around 800 bce) — a surgeon from Varanasi, known as “The father of surgery,”, was the author of the treatise Sushruta Samhita9,10 — in Sanskrit: सुश्रुतसंहिता, literally “Suśruta’s Compendium,” or according to the International Alphabet of Sanskrit Transliteration (IAST) Suśrutasaṃhitā. Charaka (born 300 bce) — was a physician from the ancient University of Taxila who was known for the treatise “Charaka-Samhita.”11 Vāgbhata (born 800 ce) — a physician from Sind who composed 2 treatises (1) “Ashtāṅgasaṅgraha” and (2) the ”Ashtāngahridayasaṃhitā.”12 All later writings on Ayurveda are based on the works of this Trinity. Intriguing evidence of cross-fertilization between peoples in medical traditions may be found in a System of Medicine in Islam,13,14 known by its Arabic name Unani or Unani Tibb, which translates as Greek or strictly Ionian Medicine, and indicates its origin in Greek Medicine, which also explains why medicine in Islam is defined a Greco-Arabic.15 These days, however, Unani or Unani Tibb is an alternative holistic medical system that has been practiced in the Indian subcontinent and elsewhere in South Asia since its introduction there in the 8th century CE. It has even been rumored that Greek medicine may have arrived in India with the Asian campaign (327–325 bce) of Alexander the Great. The cross-fertilization referred to above has been the transposition of the Greco-Roman Medicine of Buqrat and Jalinoos (Urdu for Hippocrates and Galen), respectively, influenced by Indian medical teachings. The derived doctrines promote 7 basic physiological principles, the so-called the Umoor-e-Tabiya, which include, among others, influences of the 4 Hippocratic humors, written in Urdu and transliterated here: dam (blood), balgham (phlegm ie, mucus, from the lungs), safra (yellow bile, from the liver), and sauda (black bile, in the gall bladder) that are responsible for sanguine, phlegmatic, choleretic, and melancholic dispositions — and the 4 usual corresponding physical elements — air, water, fire, and earth, respectively (but no ether, see below) and the “temperaments” (or qualities) — cold, hot, wet, and dry, which is so familiar to students of the Hippocratic school and Galen16 (Figure 2), and which has been discussed many times elsewhere in this series.15FIGURE 2: (A) Image of woodcut from Physiognomische Fragmente, zur Beförderung der Menschenkenntnis und Menschenliebe (1775–1778) by Johann Caspar Lavater, depicting the 4 humors: phlegmatic (upper left, ie, mucus phlegm, phlegma φλέγμα), choleric (upper right, ie, yellow bile, xanthe chole ξανθη χολή), sanguine (lower left, ie, blood, haima αἷμα), and melancholic (lower right, ie, black bile, melaina chole μέλαινα χολή). (B) The association between the 4 elements — fire, earth, water, and air (depicted on the outside of the figure) — and the 4 Hippocratic humors (yellow bile, black bile, blood, and phlegm), enveloped in the inside by the 4 qualities: dry, moist, hot, and cold. The natural state (physis, φύσις), that is good health (eucrasis/eucrasia, εὐκρᾶσις/ία), is achieved when there is a proper blending and balance of the elements, qualities, and humors in amount and strength. When these are disproportionate, disease, that is, dyscrasia (δυσκρασία) ensues. Reprinted with permission from Rothschuh.16.It is remarkable that despite the influence of Western medicine on medicine in India, as we have seen above transmitted through Islamic medicine,15 the contribution of Ayurveda masters to the discovery of blood circulation has not been recognized.17 PRINCIPLES OF AYURVEDA Ayurveda describes 5 basic elements and 3 bio-elements constituted from the former 5 basic elements18 (Figure 3). The 5 basic elements are air, fire, water, earth (reminiscent exactly of the Hippocratic humors), as shown in Figure 2, with the addition of ether — a substance formally postulated to permeate all space and to transmit light but not the pleasant-smelling, volatile, highly inflammable liquid used as an anesthetic and a solvent; everything in the universe is presumed to be made up of these basic elements. The 3 bio-elements are vaata, pitta, and kapha that are composed of various combinations of the 5 basic elements of the universe. The bio-elements, known as dosha in Sanskrit, not only compose the body but also govern all functions of the body.19 The vaatadosha, composed of air and ether, is a bio-element that governs all motion within the body (such as breathing, blinking, muscle and tissue movement, pulsation of the heart, and all movements in the cytoplasm and cell membranes). The kaphadosha, composed of water and earth, is a bio-element that governs the growth of the body. The pittadosha, composed of fire and water, is a bio-element that governs all the digestive and metabolic functions of the body, including hunger, thirst, digestion, absorption, assimilation, nutrition, metabolism, and body temperature. The body type of a person (known as prakriti in Sanskrit) depends on which dosha predominates in his/her body. Ayurveda divides the different body types into 7 categories: vata body type, pitta body type, kapha body type, vata-pitta body type, pitta-kapha body type, vata-kapha body type, and tridosha body type. However, there is no “best” or “perfect” body type. Each of the categories has its own advantages and disadvantages. For example, since pitta is composed of fire and water, persons having pitta as predominant bio-element are strong-willed and determined and tend to have leadership qualities, while those dominated by kapha bio-element are said to be thoughtful, calm, and steady. While the body type of a person is permanent, depending on which bio-element predominates in him/her, there could be a transient imbalance of his bio-elements from his natural constitution, which leads to diseases.20 Hence, while correcting these imbalances is actually treatment, it is essential to know the patient’s original body type.FIGURE 3: The 3 Doshas (bio-elements: vaata, pitta, and kapha) and the 5 basic elements (air, fire, water, earth, and ether) from which they are composed. Source: Wikimedia Commons (https://creativecommons.org/publicdomain/zero/1.0/deed.en).THE LIVER IN AYURVEDA In the Vedas, the liver is referred to as Takima or Yakna. Some of the other ancient literature use words like Kalakhanda, Jyotisthana, Yakritkhanda, Yakritpinda, Raktadhara, and Raktashaya for the liver. But the most common word for the liver in Ayurveda is yakrut derived from yaha, that is, one, and krut, which literally means does.21 Thus, the word yakrut means an organ that is always active and performs important metabolic functions in the body. Ayurveda’s understanding of the anatomy, physiology, and pathology of the liver is quite different from conventional Western medicine. However, although comprehension of liver embryology is similar in both systems,22 Ayurveda’s approach to the diagnosis and treatment of liver diseases is not conventional.23 The treatment in Ayurveda is more symptom-based rather than organ-based, so we don’t find a on liver or diseases in Ayurveda the concept of is based on that is, the imbalance of vaata, pitta, and in a to the humors in Hippocratic and medicine. the of pitta is the most important bio-element since most of it is by the and it governs the digestive and metabolic functions of the body. literally means bile, but since pitta dosha governs a of functions (and not as in Ayurveda pitta dosha into 5 in in the and the the primary of digestion, absorption, and of in the gall and the to all the body, the in the is for is in the where its primary functions the of and and in the and the heart, is responsible for and of pitta dosha and their the of which is down into and the of blood to blood and and of the such as and of Apart from pitta, the pitta, the liver also has a metabolic Ayurveda describes the liver as a organ of the it literally means fire, and in the term is used in the of of and metabolic Ayurveda describes at least specific physiological 5 of known as the 5 which are in the liver. the are responsible for into The digestive down into its most basic the 5 basic elements water, fire, air, and ether) and the for each these elements into a form that the body can these more are actually made to the through Ayurveda like Charaka Susruta the diseases in the of or in the of A significant number of liver diseases are in the like — with and 2 diseases in Ayurveda diagnosis with liver medicine is still to find for many of its liver diseases, such as metabolic liver and many The system of medicine by the world’s oldest Hinduism, has a of for many liver diseases and may some of its tradition in to find for some of the liver diseases of However, these to be by such as and then into medicine. the author of this introduction to the world of Hinduism and Hindu is an accomplished and who practices in at one of the in the was a Indian and who during the British — he founded the in is for his contribution to the of in including the of and His was as it on the when the in is of the of and where he also heads the having a liver fellowship at the he was from both the of in and in if hepatology and were not to he is also a who performs and all types of with is an with in and cell and he has a highly had the of for the first a years when was to at one of his hepatology It was a to in this highly where first of the concept of Indian referred to by the This Indian is of a to who why basic and are not was when of the their times by several which to the by several was even more to that in the by the not even the the of Indian was the and to to later this and to In this is by a and in at and a of the of in the of of the on in this does not a of numerous the of and in hepatology in India, it is that of a Indian have to this The contribution as a introduction to the of Hinduism and the of liver diseases in the ancient of medicine in Hinduism, which is not always as we have