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Dermatology in India and Indian dermatology: A Medico-Historical perspective

2016; Medknow; Volume: 7; Issue: 4 Linguagem: Inglês

10.4103/2229-5178.185460

2249-5673

AmiyaK Mukhopadhyay,

Medicine and Dermatology Studies History

"India suffers today in the estimation of the world, more through the world's ignorance of her achievements than in the absence or insignificance of these achievements." H. W. Rawlinson, 1951[1] During the process of evolution of human civilization, few places in the world emerged as the centres of immense development. India was one of these cradles of civilization that witnessed the advancement in various fields of knowledge including science and philosophy. Though the present form of civilization throughout the globe is the fruit of yesteryears' accumulated knowledge, the story is somewhat different in the Indian scenario. In a sharp contrast to other civilizations, the lifeline of Indian civilization has never seen any disruption.[2] Even the present day daily activity in every household, if analyzed critically, is the reminiscent of the ancient social culture. It is unique as it is not orthodox but at the same time bears the relics of the past that are in the interest of the betterment of the human progress. Among all other branches of knowledge, the development of medical science was probably the earliest. Man had suffered injury for various reasons and had to face various bodily discomforts. So, he had to find out the remedies to continue the lifeline and win over unfavorable situations. Historically, in the beginning, any disorder of the body was regarded as either the curse of the God or conspiracy of the demons. So, the responsibility of alleviating the wrath was left in charge of the Shamans or Priests who used their magical and religious capacity to treat the ailments by appeasing the supernatural power(s) they imagined and believed. Medicine in the beginning was, thus, magico-religious by nature and practice. But, only chanting incantations and wearing amulets did not help in all cases. Hence, the utilization of substances in the form of plant, animal, and other non-living matters came in to use. though empirically. With the passage of time, some rationality was experienced and the next phase was that of empirico-rational medicine. This method slowly matured with time and scientific experiments led to the rational medicine, which formed the cornerstones on which the edifice of modern day medicine was built. This history of evolution of dermatology and other branches of medical science is almost universal, and India is no exception. In India, the story of history and evolution of medicine in general and dermatology, in particular, is interesting as it has some distinctive features. The medical practice (including dermatology) in India today in a broader sense is not only the fruit of one method of medicine (e.g., Allopathic), but is widely supported and contributed by various other branches starting from Ayurveda to Acupuncture and many more. The entire thing becomes even broader if one considers the indigenous medical system of the native tribal populations. For example, various Negrito and other aboriginal tribes living for more than 50000 years in Andaman and Nicobar islands, an important part of the Indian archipelago, and maintaining the heritage of the Paleolithic era have their own method of medicine, and in some cases they are surprisingly more effective than present day modern Western medicine.[3] Hence, if considered critically, dermatology in India and Indian dermatology are not exactly one and the same. Historically, dermatology in India and Indian dermatology at times seems something different, though at one point they become rather complementary. In many instances Indian dermatology deviates from contemporary dermatology practiced elsewhere. The dermatology practiced in India today is in essence the modern method developed and designed in the Western countries based on the Western medical philosophy, observations, experience, and research findings. With the advancement of research and observations done in this country, it becomes evident that the Western scenario is not universal, rather considerably differs from India. Hence, the subject needs to be modified and tailored to meet the needs of the country. Indian dermatologists are working under the banner of the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) in this direction. Few examples such as framing of therapeutic guidelines on various important dermatological disorders such as Stevens–Johnson syndrome, psoriasis, acne, and vitiligo, establishing a drug formulary and drug policy in reference to the Indian context, and setting up various Special Interest Groups (SIGs) on subjects like atopic dermatitis, psoriasis, contact dermatitis, occupational dermatoses, dermatopathology, vitiligo, geriatric dermatology, teledermatology, and others may be mentioned in this connection.[456] Thus, the subject has evolved in its own way with contributions from its own researchers, both Indian and foreigner, working on the Indian soil, especially since the beginning of the British era. This has given modern dermatology a distinct color which may be termed Indian dermatology though it basically emerged from Western dermatology. Before we move any further, we must resolve some issues regarding semantics. Semantically, the word "dermatology" may only be used to the part of the subject that has developed at some stage in the third and fourth quarter of the eighteenth century during which the term Dermatology came in vogue.[7] So, anything before that period should rather be termed as "Subject of skin and its diseases." Hence, in this article, anything in relation to the skin that happened before eighteenth century will be termed as Diseases of the skin. and not dermatology. Even only two centuries back, dermatology was treated as a part of general medicine and some of its appendages such as nail as a part of surgery.[8] Hence, an evolutionary history of dermatology will always be accompanied by a discussion on the history of medicine. In the Indian context, the discussion on the development of the subject of skin and diseases may be divided into four broad time frames: (i) the prehistoric to Vedic period, (ii) the post-Vedic period, (iii) medieval period, and (iv) modern period. These periods are not separate watertight compartments but one is the continuation of the other—much more improved and contributed by various new developments, both scientific as well as philosophical, from indigenous as well as imported knowledge from lands afar. From the early days of the human civilization, the Indian subcontinent witnessed the development of the subject of medicine. Though nothing much is known to us about the prehistoric medicine in India, few examples like the treatment of dental diseases by drilling the molar crown discovered in a Neolithic graveyard at Mehrgarh of Baluchistan that dates back to 7500–9000 years and the trepanation of the skull from the cemetery R37 of Harappa and cemetery area KLB 8 of Kalibangan are the earliest evidence in this regard.[910] It may be assumed that these "operations" definitely needed postoperative care of the skin and mucosa. What was the situation of care of the skin and its diseases during Indus valley civilization that most likely flourished during 2500 BC to 1500 BC, was not very comprehensible to us, but it might be assumed from the presence of scientific sewerage system, including the highly organized town planning with the Great bath, that some kind of medical science including any system of taking care of the skin diseases was prevalent. The well-known female figurine is an emblem of aesthetic consciousness of that period. The first ever historical material about skin and its diseases are available in the Rig-Veda—the earliest texts of Indo-Iranian Aryans, compiled probably during or prior to the 14th century BC but originated long back. The mention of skin diseases in the riks 117.7, 117.19 of the Book I and that of the hair in riks 126.7 of the book I and 80.5-6 of the Book VIII are few illustrations worth mentioning in this regard.[11] Among the four Vedas, the Atharva Veda deals more with the various diseases prevalent during that period. The mention of jaundice (verses 22.1, 22.4 Book I), leprosy (or some other disease) (verses23.1-4 and 24.1-4 of Book I), disease of the nail (verse 33.6 of Book II), and many other verses dealing with wound healing (verses 12.4, Book IV, 57.1 of Book VI etc.) are also noteworthy.[12] In the next period of the great Indian epics of the Ramayana and the Mahabharata, the mention of various ailments of skin and care of the skin and its components are elaborately mentioned. In this connection the role of Draupadi, the central character of the Mahabharata as Sairandhri (a lady who used to be an expert and employed in the royal families for taking care of the hair care of the queens and other noble ladies), provide us with specialized beauty management that prevailed about 3000–4000 years back. In this connection, it may be mentioned that the daily care of the normal skin such as oil massage, trimming of hairs, beards and nails, and use of perfumes and toiletries have been mentioned in various Ayurvedic texts such as Charaka Samhita, Astangahridaya, and Samhita of Vagbhata (as Dinacharya).[1314] With the passage of time, the philosophy of Tridosa emerged that formed the foundation of the Ayurveda, the science of life that became the systematized base of the Indian medical system. The entire subject of medicine was compiled and composed into various treatises in the name of Ayurvedic Samhitas. Of these great works, only Susruta Samhita (c. 6th century BC), Charaka Samhita (c. 2nd century BC?), and Bhela Samhita are available, rest are either lost or available in either incomplete or corrupted forms. These Samhitas not only dealt with various skin diseases but also gave an insight into the conceptual aspect of the anatomical structure including various layers of the skin. Charaka Samhita mentioned that skin formed the outer boundary of the body and composed of six layers and also pointed out skin to be the residence of touch sensation.[1315] Among the various diseases, the dialogues on leprosy, vitiligo, cellulites, small pox, acne, melasma, fungal infections of the skin, etc., are fascinating. If Charaka Samhita can be considered as the tome predominantly dealing with the medical treatment, then the other famous treatise of Susruta deals with the surgical aspect of the disease management. It mentioned approximately 121 surgical instruments and more that 300 procedures that included different types of incision and drainage procedures of abscesses and infected wounds, rhinoplasty, repair of the cleft lips, palate, restoration of the severed ear lobes, various types of cauterization, etc.[16] As far as the management of skin diseases are concerned along with herbs and inorganic and organic substances, surgical procedures (as already mentioned), cauterizations, dermabrasion, fomentation, and fumigation etc., were in practice [Figure 1]. A special mention may be made regarding the term Kustha. Like other ancient medical texts in other parts of the world, the term was probably used to represent a number of skin ailments along with leprosy of the modern sense. Three words "svitra," "kilasa," and "kustha" were used. The classification of kustha into seven types in the Charaka Samhita and 18 (seven Mahakustha and 11 Kshudrakustha) in the Susruta Samhita represents the astute observation of the ancient Indian physicians. Interestingly, Kustha and Kilasa (be it leprosy or vitiligo) was clearly declared not to be an inheritable disorder.[13] The use of malapu (Ficus hispida) with Sun exposure and treatment with Bakuchi or Bavachi and even scrapping the lesion (dermabrasion) in the treatment of svitra and kustha is worth mentioning. These Samhitas also mentioned symptoms, signs, their basic etiologies, management, as well as prognoses. One may take the example of vitiligo in this regard.[1718] With respect to the prognosis, the samhitas clearly say that white spots evolved in an area that is devoid of hairs such as palms, soles, anal orifices, or the area where the hairs also have turned white or a white patch that developed as a result of burn injury that are difficult to treat.[18] It is also interesting to note that care of the skin was not limited to the diseases only but was concerned with the normal healthy skin too [Figure 2]. In the post-Vedic period, the contribution from the revolutionary philosophy of the Gautama Buddha and Vardhaman Mahavira not only changed the social scenario but also influenced the course of the medical science. The speed of the surgical approach to various disorders faced some resistance due to the influence of the philosophy of Ahimsa, but the treatment offered to the common people by the Bhiksus and Arhats made better distribution of the medical care to the lowermost strata of the society.[19] This was further supported by royal patronage. Various stone inscriptions of the king Asoka (304–232 BC) mentioning the import of a variety of medicinal plants from distant lands and cultivating in this country to provide them to the common people is an example in this regard.Figure 1: Fumigation therapy in ancient Indian medicine (Konark, 13th century AD)Figure 2: Use of pumice-like stone for sole care in ancient India (Indian Museum, Kolkata)It is interesting to note that this entire development was not restricted within the boundaries of the Aryavarta, the area briefly located on the northern side of the Vindhya. A separate and equally systemized medical subject developed in the southern region too. This system was known as Siddha and had some similarities with the classical Indian system, including alchemy and Tantrism, and also had some philosophical similarities with the Yang and Yin concept of the Chinese Medical system and its Taoist philosophy.[20] In the Siddha system, skin diseases are grouped under the term Kuttam. There are ample discussions on various skin ailments such as thinvup-pun (urticaria), paru (acne), and sarumap-pun (dermatitis).[21] The subject of systemized medicine in the form of Ayurveda and Siddha were further improved till the period of the Islamic invasion. The period of the Islamic invasion saw a big shift in the faith and flavor in the culture of the Indian social system. The Indian traditional system suffered a jolt but the new system of the Arabic world which evolved in Egypt, Babylon, and curetted carefully under the care of the great scholars of Alexandria, Jundishapur, Baghdad, Shiraj, and other places, accompanied the invaders and added a new tint and aroma to the Indian art and science [Figure 3]. They were also mutually influenced. the translation of the Susruta Samhita to Kitab-Samural-Hindi or Susrud, Charaka Samhita to Sarag and Nidan to Badan under the patronage of the Abbasid kings and Caliphs are few examples of this. Various treatises such as Hidayat-al-Muttalimin fiz-Tibb, and Donisnamoi maisari clearly mention the influence of Ayurveda on the Arabic system of medicine. These entire phenomena led to the commencement of the journey of the system of the Unani and Tibb. The system got patronage from the Muslim rulers and reached to a very high level that could match the standard of Baghdad and Alexandria. The management of Amraze zild or skin diseases got a very new approach. This phase lasted for a period of approximately eight centuries when the Indian soil was further invaded by the Westerners during 15–16th century AD. With the arrival of Vasco da Gama at the Malabar Coast on 17th May, 1498, a new chapter of the Indian history began.[22] He was followed by many others, the French, Portuguese, Danes, Dutches and others, but the battle of capturing political and economic power finally went in the favor of the British Empire. And thus, an entirely new era started.Figure 3: A handwritten book of magic and medicine of the Islamic period (date not mentioned)It is a well-known historical phenomenon that any system or religion or philosophy that does not enjoy the royal patronage usually either perishes or its development gets marred. This happened in the case of Ayurvedic, Siddha, as well as Unani and Tibb system in India. In the beginning, the British administration was reluctant about any developmental activity in this country and they were in dilemma regarding the "Anglicist-Orientalist controversy." On 15th January, 1784, The Asiatic Society of Bengal was established which created a platform for discussing diverse topics related to India and other colonies under the British Crown.[23] Medical problems and related topics such as small pox, leprosy, treatment of ulcers, filariasis, syphilis, and scurvy were an integral part of these discussions; this could be seen from the records of the Society.[24] The scenario changed after the "First Indian Revolt" of 1857. The ruling power of the East India Company was revoked and India was attached to the Royal Crown. This led to the introduction of the Western system of medicine and the voyage of the modern medicine including dermatology started. Many medical institutions were established to impart formal education in the Western medical system. These saw the influx of the modern medical treatises [Figures 4 and 5]. Formation of different medical societies encouraged the culture of discussion, debate, and formation of new scientific researches. As far as the dermatology in India is concerned, Dr. Henry Vandyke Carter was appointed by the British government to gain a clear view of the situation of skin diseases in the country and his epidemiological study was published in 1876.[2526] In the year 1872, Fox and Farquar were given the charge to report the prevalence of skin diseases in India. In 1895, the first chair of dermatology was established at the Grant Medical College, Bombay, and Major C. Fernandez was appointed for the post. The second department was established in the School of Tropical Medicine at Calcutta under the auspices of Prof. Ganapati Panja and Col. HW Acton in 1923.[27] In the year 1935, "Indian Journal of Venereal Diseases," first ever journal in this field in India, was published by Dr. UB Narayan Rao. This was rechristened in 1940 as the "Indian Journal of Venereal Diseases and Dermatology," and after the formation of the Indian Association of Dermatologists and Venereologists in 1947, this journal was proposed to be the organ of the association in the second All India Conference in April 1951. Finally, the official journal of the association was published in 1955 with the new title of the Indian Journal of Dermatology and Venereology.[28] In 1976, the journal's[29] subject was not restricted to the management of skin disease only but also enriched itself with researches on the subjects of sexually transmitted diseases and leprosy.Figure 4: "Seborrhoea." (Source: Walker N. An introduction to Dermatology, Bristol: john Wright & Co; 1904)Figure 5: "Pellagra." (Source: Manson P. Tropical diseases: A manual of diseases of the warm climates. London: Cassel & Co. Ltd; 1914)As far as the evolution of Leprology in India is concerned, it has already been mentioned that leprosy was prevalent in the country, as can be seen from the mention of the disease in major ancient Indian Ayurvedic treatises such as Charaka Samhita, Susruta Samhita, Astangahridaya of Vagbhata, and others. Its social impact was so marked that various laws have been mentioned about the dealing of the lepers in the Manu Samhita, an ancient Indian law book compiled before 2nd century BC.[30] In modern period, the work of leprosy probably started with the observation of two types of leprosy by Francis Buchanan Hamilton (1762–1825) of Bengal medical Service. During 1873–1874, Henry Van Dyke Carters visited the Hansen's laboratory at Bergen.[31] After this visit, Carter became an ardent pleader of the "contagion theory" and advised the then British Government ruling the country about the segregation of the leprosy afflicted persons. He also described a mixed variety of leprosy "Lepra leprosa" in his book entitled On Leprosy and Elephantiasis. The German bacteriologist working in Mumbai reported the presence of plenty of lepra bacilli in the nasal smears of the leprosy patients in the first leprosy Congress held in Berlin in 1897. In the next period, Sir Leonard Rogers and Ernest Muir described lepra reaction and advocated the use of hydnocarpus oil in the management of leprosy[32] The "Mission to Lepers" was established by Wellesley Bailey at Chamba in 1875 to ameliorate the poor situation of lepers in the country. With the establishment of the Indian Council of the British Empire Leprosy Relief Association (ICBELRA) in 1925, a methodical approach of "Propaganda, Treatment, and Survey" was initiated which became the backbone of leprosy control programme of India. In 1941, Dharmendra described "Lepromin" antigen. A number of luminaries like Carter, Rogers, Muir, Lowe, Dharmendra, Paul Brand, and others enriched the subject and India became the forerunner in leprosy work throughout the globe. Finally, in 1955, the National Leprosy Control Programme was launched, which in 1982 reformed and upgraded to the National Leprosy Eradication programme. The history of venereal diseases in India is also quite old. The mention of different types of genital ulcerative disorders in the Chikitsa Samgraha of Chakrapanidutta (11th century) and Chikitsa Paddhati of Sarangdhaara (13th century) is worth mentioning.[3334] The first mention of syphilis is found in the Bhavparakasha as "firangaroga." The organized work started with the recognition of Donovanosis in Madras in 1881 by Kenneth Mcleod. He named it "serpiginous ulcer." In 1902, Lymphogranuloma venereum was described by Caddy as "Climatic bubo."[35] Though the scenario of venereal disease management was reported to be gloomy even during 1933, the whole picture gradually witnessed a tremendous change with the beginning of the National STD Control Programme in 1946. In 1975, a number of towering personalities in Venereology like Drs RV Rajam, PN Rangiah, CW Chacko, Vasudev Rao, among others formed an association for the scientific progress of the subject and named it the Indian Association of Sexually Transmitted Diseases. In 1993, the name was changed to the Indian Association of Sexually Transmitted Diseases and AIDS to encompass the newly emerged dreaded disease of AIDS.[36] The subject of Dermatology, Venereology, and Leprology was thus progressed from a mere insignificant topic confined to a small chapter in medicine to a full-fledged subject in its own regard. The subject got a fresh start after the Independence in 1947. This is evidenced by the ample quotations of Indian works in the international texts all over the world. The description of various entities like "Kangri cancer," "Madura foot," "mudichud," lichen planus pigmentosus, cerebriform tongue, etc., to name a few, have got their places in the subject of dermatology. The research and further progresses received additional momentum with the establishment of the "Indian Association of Dermatologists and Venereologists" on 28th December 1947.[27] This was followed by the further establishment of specialized organizations like the "Indian Association of Sexually Transmitted diseases and AIDS," "Contact Dermatitis Forum of India," "Indian Society for Pediatric Dermatology," "Association of Cutaneous Surgeons of India" and many more sister organizations working for the improvement of the subject in a focused manner. The detailed picture of this development is beyond the scope of this brief editorial. The history of evolution of the IADVL has been recently compiled in a book by the IADVL History book team.[37] It may be summarized that today's Indian dermatology is respected for its high standard and newer contributions. The organs of the associations of Indian dermatology like the "Indian Journal of Dermatology, Venereology and Leprology," "Indian Journal of Dermatology," "Indian Dermatology Online Journal" etc., are now places for publication of highly acclaimed scientific research from various countries across the globe. This entire story that began its journey from time immemorial has reached the state of highly developed science now Table 1. The science and art of dermatology practiced today mainly follows the Western medicine but the international guidelines and methodologies are now reviewed and redesigned by the Indian authorities to suit the need of Indian populations. Here, lies the transition of dermatology in India to the Indian dermatology. To further strengthen the subject, emphasis should be laid on the scientific researches, and in this process, researchers in India should explore their own treasure trove that has been enriched with knowledge of the last few millennia to improve the subject. This may be done by scientific analysis on the platform of modern concepts instead of ignoring the old traditional system and branding it as "obsolete." This will manifest the true colour of Indian dermatology and should be the base for dermatology in India.Table 1: Time line of major events of dermatology, venereology, and leprology in India[5 38 39]