ANCIENT HEALTH CARE IN SRI LANKA
The Sinhalese medical tradition harkens back to well over 2000 years. Besides a number of medical discoveries that are only now being acknowledged by western medicine, the ancient Sinhalese are perhaps responsible for introducing the concept of hospitals to the world. The history of medical care began early, for in the fourth century B.C. King Pandukabhaya (437-366 B.C.), in the course of sanitizing the town constructed a Traditional Ayurvedic hospital. At Mihintale there is a ruin of a hospital for traditional Ayurveda medicine built in the A.D. ninth century A.D. In the fourth century A.D. King Upastissa the second provided quarters and homes for the crippled and the blind. King Buddhadasa (337-365 A.D.) himself a physician of great repute, appointed a physician to be in charge of every ten villages. For the maintenance of these physicians, one tenth of the income of the fields was set apart. He also set up refuges for the sick in every village. Physicians were also appointed to look after the animals. King Kasyapa the fifth (914-923 A.D.) founded a hospital close to the southern gate of Anuradhapura. General Sena in the tenth century is believed to have built a hospital close to the ceremonial street (Mangala Vidiya). [Source: Sri Lanka Tourism Promotion Bureau srilanka.travel ]
Ancient and medieval Sri Lanka it should be noted, had a corporate social organization where the state provided welfare services to the people in return for the corvee labour provided by masses to build irrigation works, palaces and religious edifices. As such the state provided free medical care to all its citizens regardless of race, caste, sex, religion or status. Although traditional Sinhalese medicine has a number of distinctive features, it is primarily based on the science of Ayurveda (a Sanskrit term meaning "science of life") an essentially herbal system set forth in the medicinal texts (Sanhitas) of the great Indian physicians, Shushruta and Charaka who lived about the same time as the "Father of modern medicine" Hippocrates the Greek.
Ancient Sri Lanka"s extremely cordial relations with Mauryan India would have considerably helped facilitate the dissemination of the great Indian medicinal tradition amongst the local population. King Ashoka"s (3rd century B.C.) Girnar rock edict states that he provided medicines and medical aid for both men and animals as far as Tambaparni (The old Indian name for Sri Lanka).
However, in spite of the profound Indian influence, Sinhalese medical knowledge has developed on is own course with the passage of time and we note a number of distinctive features, which mark it out from other medical systems. We come across a number of references to medicines and medical treatment in the ancient Sinhalese chronicles. According to the Mahavansa, prior to the birth of her son Dutugemunu, Queen Viharamahadevi gifted medicines to the Buddhist clergy in order that she may conceive. The same work alludes to King Dutugemunu having donated food and medicine to the sick.
World’s Earliest Hospitals, in Sri Lanka
According to the Mahavansa, the ancient chronicle of Sinhalese royalty written in the 6th century A.D. King Pandukabhaya (4th century B.C.) had lying-in-homes and hospitals (Sivikasotthi-Sala) built in various parts of the country after having fortified his capital at Anuradhapura. This is the earliest literary evidence we have of the concept of hospitals (i.e. a special centre where a number of patients could be collectively housed and treated until they recovered) anywhere in the world.
Prof. Arjuna Aluvihare ("Rohal Kramaya Lovata Dhayadha Kale Sri Lankikayo" Vidhusara Science Magazine, Nov. 1993) contends that there is no evidence, literary or otherwise, to show that hospitals were known elsewhere before and during the time of King Pandukabhaya. According to Prof. Aluvihare, the oldest archaeological evidence we have so far of a hospital is in the ruins of Mihintale, where the remains of a hospital built in the ninth century could still be seen. The layout of the building and the discovery of a medicinal trough and surgical instruments proves this beyond doubt. Heinz E Muller-Dietz (Historia Hospitalium 1975) describes Mihintale Hospital as being perhaps the oldest in the world.
All medieval Sinhalese hospitals so far discovered appear to have comprised of a central courtyard surrounded by cells for the treatment of the sick and an adjoining second courtyard with surrounding rooms which were used for the storage and preparation of medicines, besides other purposes.
Sri Lanka’s Pioneering Doctor Kings
King Buddhadasa (A.D. 340-368) the country"s renowned physician- king was adept in general medicine, surgery, midwifery and veterinary medicine. The king"s surgical operation on an outcaste (Chandala) woman in order to deliver her child and the surgical removal of a lump in the belly of a snake are some of the feats narrated of this remarkable monarch in the sequel to the Mahavansa, Chulavansa. The chronicle states that the king constantly carried a set of surgical instruments with him on his journeys. It speaks well for the nobility of this king who casting aside ancient prejudices " unimaginable in those caste-ridden days " to have attended on an untouchable female.
This in itself shows that the Sinhalese medical establishment of yore considered service to humanity to be such a sacred and estimable duty as to even transcend caste barriers, which were otherwise strictly observed at the time. The king"s surgical feats on a helpless serpent also shows that not only humans, but also other creatures benefited from the medical skills acquired by the ancients. The king is also stated to have given medical professionals due remuneration for their services to the people. The Chulavansa states that the king "gave the physicians the produce of ten fields as livelihood."
The compilation of the " Sarartha Sangraha", a comprehensive medical treatise in Sanskrit is also attributed to King Buddhadasa. Although this work is similar in arrangement to the Sanhita of Shushruta, it contains much original information as well. The work deals with the preparation of drugs, clinical diagnosis, surgical instruments and operations, ear, nose and throat diseases, eye diseases, tuberculosis, insanity, epilepsy and obstetrics, besides a number of other subjects of medical importance.
King Aggabodhi VII (766-772 A.D.) even went to the extent of undertaking fresh research pertaining to medicinal substances. According to the Chulavansa, the king "studied the medicinal plants over the entire island of Lanka to ascertain whether they were wholesome or harmful to the sick." King Mahinda IV (956-972 A.D.) is said to have distributed beds and medicines to all the hospitals of his realm. King Parakrama-Bahu I (1153-1186 A.D.) who was also well versed in medicine helped qualified physicians practise their skills by providing them with due maintenance.
Ideas About Medicine in Medieval Sri Lanka
Sri Lanka land is full of medicinal herbs and many antidotes to poison, including remedies against snake-bites A slab inscription of Mahinda IV (956-972 A.C.) near Mihintale hospital alludes to physicians; physicians who apply leeches and dispensers of medicine..
Joao Ribeiro, a Portuguese soldier-historian who served in Sri Lanka from 1641-1658 wrote in "Fatalidade Historia de Ceilao": "They are great herbalists, and in case of wounds, tumours, broken arms and legs they effect a cure in a few days with great ease. As for cancer, which is a loathsome and incurable disease among us, they can cure it in eight days, removing all viscosity from the scab without so much as leaving a mark anywhere to show that the disease had been there. I have seen a large number of soldiers and captains cured during my residence in the country, and the ease with which this was done was marvellous.
Dr C.G. Uragoda ("A scientific basis for some traditional beliefs and practices in Sri Lanka". JRAS SL. 1989/1990) has shown that a good deal of traditional Sinhalese medical concepts, practices and drugs have a sound scientific basis.The concept of heaty (giniyam) and cooling (sitala) foods is one such example. Dr Uragoda has shown that a variety of fish such as skipjack (Sinh. Balaya) and tuna (Sinh. Kelavalla) which are traditionally regarded as heaty, have a high histamine content, a substance which causes allergic reactions amongst some people. Smoking of adhatoda vasica as treatment for excessive phlegm and use of coscinium fenestratum (Sinh. Venivel) as a prophylactic against tetanus are some of the traditional remedies cited by Dr Uragoda which have a sound scientific basis.
He has also shown that olden day Sinhalese folk knew that the malaria parasite was transmitted by the mosquito long before 1884 when Sir Patrick Manson propounded the theory that the malaria parasite was transmitted through mosquitoes. As evidence he has cited an interesting passage in Sir Emerson Tennent"s Ceylon (1859) which alludes to the Sinhalese of the time employing mosquito curtains as a precaution against malaria. This would indicate that the Sinhalese knew that the mosquito was the vector of malaria at least 25 years before Manson advanced his famous Mosquito-Malaria theory.
Hospitals in Ancient Sri Lanka
Prof. W. I. Siriweera said: “ The archaeological evidence as well as references in chronicles and literature indicate the existence of four types of hospitals during the period of the Rajarata civilisation. Their gradual growth cannot be traced in stages but it is certain that towards the late Anuradhapura period they had attained a fairly advanced stage. [Source: Prof. W. I. Siriweera, summary of lecture given at the sixth International Medical Congress organised by the Peradeniya Medical School Alumni Association and the Faculty of Medicine]
These hospitals can be broadly divided into four categories viz: (a) monastic hospitals where inhouse treatment was provided for ailing monks for short or long periods; (b) hospitals for laymen where inhouse treatment was provided (c) maternity homes and (d) hospitals where only outdoor treatment was provided.
Of these substantial amount of archaeological data is available pertaining to hospitals attached to monasteries. The remains of hospitals at Mihintale, Anuradhapura, Madirigiriya, Dighavapi and Dombegoda near Maligavila can be dated to the late Anuradhapura period. Those of the hospital at the Alahana Parivena Complex at Polonnaruwa can be assigned to the twelfth century. Besides these, the chronicle refers to a hospital for monks outside the city of Anuradhapura constructed by the Commander-in-chief of the army during the reign of Mahinda IV (956-972).
Excavations at Mediri-giriya, where a hospital is believed to have flourished in the ninth century, have revealed a stone medicine trough and querns for grinding medicine. Excavations at the Polonnaruwa hospital site have revealed medicine grinders, a pair of scissors, ceramic jars for the storage of medicines and a hooked copper instrument which was probably used for incising abscesses.
The construction of the hospital is assigned to King Parakramabahu I (12th century). institutions for the handicapped in existence in ancient and medieval Sri Lanka. According to the Chulavansa, the kings Buddhadasa and Upatissa II built institutions for cripples and hospitals for the blind. Upatissa II was probably also responsible for building the country"s first ever maternity home, while Kasyapa IV had specialized hospitals built in Anuradhapura and Polonnaruwa to combat Upasagga, which is believed to have been an epidemic disease.
An inscription attributed to King Kasyapa V (914-923 A.C.) records the establishment of "medical halls" in Anuradhapura. As borne out by the Kiribathvehera pillar inscription attributed to King Kasyapa IV (896-913 A.C.), the dispensary was such a hallowed institution that it had the privilege of affording sanctuary to offenders.
The ninth century Mihintale hospital which has the distinction of being the oldest hospital yet discovered in any part of the world as seen earlier, was quite a complex structure. The hospital is believed to have been founded by King Sena II (A.D. 851-885) on the basis of evidence in the Chulavansa. As shown by recent archaeological excavations the hospital complex comprised of an outer and inner court. The rooms used for the preparation and storage of medicines and the hot water bath were situated in the outer court. The discovery of stone querns used in the grinding of herbs in the outer court area suggests that the preparation of medicines took place thereabouts. The inner court in common with later hospitals, was surrounded by a number of cells where the patients appear to have been treated.
Prof. W. I. Siriweera said: “ The restored foundation indicates that the Mihintale hospital was a 68.6m x 38.1m rectangular building. The main entrance to the building was in the south. As one enters the building on the right hand side there is a 5.18m x 4.27m room. This may have been used as a dispensary. The large hall seems to have been the waiting hall for the patients. [Source: Prof. W. I. Siriweera, summary of lecture given at the sixth International Medical Congress organised by the Peradeniya Medical School Alumni Association and the Faculty of Medicine]
To the left and north of this hall are two rooms presumably used for examining patients. Beyond was the inner court at the center of which are found signs of an image house. Around the inner court was a corridor leading to 32 residential rooms for inhouse patients. Each of these measures 3.96m x 3.96m. The doors of all these rooms have been placed facing the image house. Presumably the resident monks meditated around the image house in the mornings and evenings. To the north-east of the building is a stone paved room where a medicinal trough externally measuring 213 x 74 x 60 centimeters used for immersion therapy was placed.
This room could be entered through a door from the eastern corridor near rooms of the patients as well as from outside the building through a door in the east. There had also been a jantaghara or a room where steam and hot water therapy was administered in the hospital building. The remains of a separate building which could be the kitchen of the hospital are visible in the northern side beyond the hospital.
Pieces of two large containers have been found in excavations done in 1954 at the Mihintale hospital complex. These pieces have been fitted together and the containers which are of West Asian origin are now displayed at the Anuradhapura museum. As some cement paste had been applied on the interior of these containers to make them air-tight it can be reasonably concluded that they had been used to store medicines at the hospital. Unfortunately the exact location in the hospital where these have been excavated have not been recorded. If it had been done so the identification of the storage room in the hospital could have been easier.
Prof. W. I. Siriweera said: “ The remains of the ancient Madirigiriya hospital are found about 50 meters to the north of the famous Madirigiri vatadage in Tamankaduwa in the Polonnaruwa district. This hospital is small in size when compared with the one at Mihintale. The foundation which has been restored suggests that it was a 15.8m x 15.8m square building. Encircling the centre court of the building is a corridor and beyond that are rooms of the inmates. The stone trough used for immersion therapy is now kept near the image house about 67 meters to the north of the hospital. The trough has been removed there by the Department of Archaeology for safekeeping. The external length of the trough is 230 centimeters and the breadth is 64 centimeters. The height is 58 centimeters. [Source: Prof. W. I. Siriweera, summary of lecture given at the sixth International Medical Congress organised by the Peradeniya Medical School Alumni Association and the Faculty of Medicine]
Near the Thuparama Stupa at Anuradhapura vestiges of a yet another hospital with a medicinal trough in situ are visible. As at the Madirigiriya hospital here too the main entrance is through a door located in the eastern side of the building. The foundation of the building has not been preserved well but existing remains indicate that as at Mihintale, a centre court around an image house and rooms for inmates were important aspects of this hospital as well.
The Ruvanvali Stupa complex contains remains of another hospital attached to the Mahavihara. The distance from the outer wall of the stupa to the hospital is approximately 46 meters. The stone medicinal trough (externally measuring cm. 224 x 75 x 60) found in situ is identical with that of the Thuparama hospital and there are signs of an image house and rooms for inmates. However the area is full of various other ruins belonging to different eras and therefore a correct picture of the plan of the hospital has not emerged so far.
The foundations of the hospitals at Dighavapi and Dombegoda have not been preserved well. But the layout of the hospital at the Alahana Parivena Complex at Polonnaruwa has been restored by the Cultural Triangle in 1982. The restorations indicate that it was smaller in size than the Mihintale Hospital. The total length of the building is 44.8 meters.
The breadth is 33.3 meters. The rooms of inmates are of varying sizes and each of them seems to have accommodated a number of inmates. There had been an image house at the center of the courtyard facing these rooms. Unlike in other hospitals, the baths and toilets for the inmates had been constructed just adjoining their rooms.
There had been two entrances to the hospital from the east and the south. The southern door led into a 9 x 4 meters room. The stone trough externally measuring 248 x 80 x 56cm. had been placed on the left of the room. The granite paved ground of this room has been sloped towards the north and water that led from it has been diverted into a drain.
The stone trough is slightly different from those at Mihintale and Anuradhapura but bears a close resemblance to the one at Medirigiriya. Not only the cavity in which a patient was laid but also the complete granite structure has been scooped out in the form of a human being both at Medirigiriya and Polonnaruwa.
Common Features of Ancient Sri Lankan Hospitals
Prof. W. I. Siriweera said: “ Several common features are discernible in all these hospitals. Walls had been erected around all of them so that they were isolated from the rest of the buildings in the monastic complexes. All the hospitals had been located in easily accessible plains. Similarly constructions have been designed to allow maximum ventilation in the buildings. [Source: Prof. W. I. Siriweera, summary of lecture given at the sixth International Medical Congress organised by the Peradeniya Medical School Alumni Association and the Faculty of Medicine]
As stated earlier there is a dearth of archaeological material pertaining to hospitals for laymen. A reference in the Mahavamsa suggests that there were eighteen hospitals at the time of Dutthagamani (161-137 B.C.). The chronicle also refers to the construction of hospitals in the reigns of Buddhadasa (337-365 A.D.), Upatissa I (365-406 A.D.), Mahanama (406-428 A.D.), Dhatusena (455-473 A.D.), Udaya I (797-801 A.D.), Sena I (833-853 A.D.), Sena II (853-887 A.D.), Kashyapa IV (898-914 A.D.), Kashyapa V (914-923 A.D.), Mahinda IV (956-972 A.D.) and Parakramabahu I (1153-1186 A.D.). The inscriptional evidence confirm some of these constructions.
The Kukurumahandamana Pillar inscription datable to the reign of Kashyapa IV refers to immunities granted to a land belonging to the hospital built by the Commander in Chief named Sen near the Ceremonial Street of the inner city of Anuradhapura. A slab inscription found at Abhayagiriya datable to the reign of Kashyapa V refers to a royal hospital (Rajvedhala) built by the king along the same street.
The Dorabavila Pillar inscription mentions grants made to the same hospital. It is reasonable to conclude that at least some of the above mentioned hospitals were residential hospitals for laymen.
The sources contain several references to maternity homes. The Pandukabhaya legend of the Mahavamsa refers to the construction of a building known by the term Sivikasala. According to the Vamsatthappakasini, the commentary of the Mahavamsa, it was either a hall where a Siva Linga had been placed or a maternity home.
This indicates that at the time of the writing of the Mahavamsa, there had been state maternity homes. Nevertheless references in the chronicles and literature to ordinary women or royal princesses ordinary women or royal princesses entering lying in homes (vijayanaghara, timbirige) should not be construed to mean that they entered common maternity homes for confinement.
The tradition of segregating the expectant mother on the eve of delivery, in a dark room of her own house, which was prevalent in ancient Sri Lanka continues in rural areas even at present. Moreover, it is most unlikely that in semi feudal ancient society the expectant princesses of royal households were sent to common maternity homes for giving birth to children.
Nevertheless there are at least two references which clearly point to the existence of public maternity homes in the country. The chronicle mentions the construction of maternity homes, Pasavantinamsala by king Upatissa I (365-406 A.D.). An inscription set up during the reign of Kashyapa IV (898-914 A.D.) refers to the construction of a maternity home (timibirige) by Senal Nakan, Chief Secretary of the state. According to this inscription several plots of land from an area to the north of Anuradhapura had been allocated for the upkeep and maintenance of this maternity home.
There were several places where treatment was provided for outdoor patients. Some of the hospitals erected by kings and key officials, referred to in the chronicles and inscriptions would have been hospitals for out-patients. Even hospitals to which patients were admitted for treatment consisted of out-patients' divisions as well. These establishments for dispensing medicine were known by the term behetge.
The Kiribatvehera Pillar inscription belonging to the reign of Kashyapa IV (898-914 A.D.) records donations made to a dispensary (behetge) named Bamunu Kumbara. The Vessaagiri Slab inscription of Dappula IV (924-935) too contains some information on a behetge.
Archaeological remains at Arankale monastery in the vicinity of Hiripitiya close to Wariyapola suggests the existence of a large out-door patients' hospital, possibly datable to the late Anuradhapura period. The length of the foundation of this hospital which has been restored is 26.1 meters. Its breadth is 12.2 meters.
Unlike in the hospitals at Mihintale, Medirigiriya etc. Here are no signs of the existence of rooms for inmates or of a medicinal trough in this location. On the other hand large grinding stones, pestles used horizontally and vertically and nearly sixty furnaces or kilns in situ suggests that Arankale behetge was a place where medicines were prepared and dispensed to a large number of outdoor patients and perhaps to dispensaries around the country. Grinders are wasted in the middle suggesting their use for a long time. [Source: CDN]
Image Sources: Wikimedia Commons
Text Sources: New York Times, Washington Post, Los Angeles Times, Lonely Planet Guides, Library of Congress, Sri Lanka Tourism (srilanka.travel), Government of Sri Lanka (www.gov.lk), The Guardian, National Geographic, Smithsonian magazine, The New Yorker, Time, Reuters, Associated Press, AFP, Wikipedia and various books, websites and other publications.
Last updated February 2022