Internal Medicine (a): Autumnal Disease

Many cases are related to the discipline of internal medicine. What is internal medicine? In Āyurveda, it refers to kāyacikitsā, which mainly deals with generalised disorders relating to digestion and tridoṣas (translators’ notes to Caraka Saṃhitā Sūtrasthāna 30. 28; notes to Suśruta Saṃhitā Sūtrasthāna 1. 7). In modern medicine, internal medicine is defined as “the branch of medicine concerned with the study of the medical specialty dealing especially with the diagnosis and medical treatment of diseases and disorders of the internal structures of the human body” (Dorland's Illustrated Medical Dictionary, 32nd ed, s.v. “medicine: internal m.”). Various cases pertaining to internal medicine are grouped in the following subsections.

All extant versions of the Chapter on Medicine, with the exception of the Mahāsāṃghika Vinaya, possess this account of autumnal illness. This disease is presented as the starting case in the Chapters on Medicine, except the Dharmaguptaka Bhaiṣajyaskandhaka. These records tell us that some monks became sick during the autumn period, though there are some differences in the details.

The passages for this illness from different Vinayas are listed in the following:^[1]

Theravāda:—“At that time the Buddha, the Exalted One, lived in Sāvatthī, at Anāthapiṇḍika’s monastery in the Jeta Grove. At that time, for the monks affected by the autumnal disease, the rice-gruel which was drunk was vomited as well as the food which was eaten was vomited.^[2] Because of that, the monks became lean, coarse, of bad complexion, very pale/yellowish,^[3] [and] having veins showing all over the body. The Exalted One saw those monks who were lean, coarse, of bad complexion, very pale/yellowish, [and] having veins showing all over the body. Having seen [that], he addressed the Venerable Ānanda: ‘What is [the reason], Ānanda, [that] the monks at present are lean, coarse... [and] having veins showing all over the body?’ ‘At present, Venerable Sir, for the monks affected by the autumnal disease, the rice-gruel which has been drunk is vomited as well as the food which has been eaten is vomited. Because of that, they become lean, coarse, of bad complexion, very pale/yellowish, [and] having veins showing all over the body.’ Then, when the Exalted One had gone to a lonely place and was in solitude, a thought thus arose in [his] mind: ‘At present, for the monks affected by the autumnal disease... having veins showing all over the body. What medicine should I allow for the monks? Whichever medicine indeed is, [it is] considered as a medicine for this world. It could serve as food, and it should not be perceived as coarse food?’ Then this [idea] occurred to the Exalted One: ‘These five medicines, namely, ghee, fresh butter, oil, honey, [and] molasses; [these] medicines indeed are considered as medicines for the world, and they serve as food, and [each of them] is not perceived as coarse food. So now I should allow these five medicines for the monks, to use [them] in [proper] time after accepting [them] in [proper] time.’ Then the Exalted One had risen from solitude in the evening. Having given a dhamma talk against this background,^[4] he addressed the monks: ‘Here, monks, when I have gone to a lonely place... perceived [as coarse food]. Monks, this [idea] occurred to me: “These five medicines... So now I should allow these five medicines for the monks, to use [them] in [proper] time after accepting [them] in [proper] time.” I allow, monks, having accepted those five medicines in [proper] time, to use [them] in [proper] time.’ At that time the monks, having accepted those five medicines in [proper] time, consumed [them] in [proper] time. For them [the monks], whatever those ordinary coarse foods were, they did not seem good,^[5] not to speak of the greasy^[6] [foods]. Because of that indeed–affected by the autumnal disease and this loss of appetite^[7] –with both, those [monks] became exceedingly lean, coarse, of bad complexion, very pale/yellowish, [and] having veins showing all over the body. The Exalted One saw those monks exceedingly... having veins showing all over the body. Having seen [that], [he] addressed the Venerable Ānanda: ‘What is [the reason], Ānanda, [that] the monks at present are exceedingly lean... having veins showing all over the body?’ ‘At present, Venerable Sir, the monks, [having accepted] those five medicines in [proper] time... with both, they become exceedingly lean, coarse, of bad complexion, very pale/ yellowish, [and] having veins showing all over the body.’ Then the Exalted One, having given a dhamma talk against this background, addressed the monks: ‘I allow, monks, having accepted those five medicines, to use [them] in [proper] time and also in improper time.’”^[8]

Dharmaguptaka:—“At that time the Exalted One was in Śrāvastī. Then the monks became sick in the autumn months. [Their] complexions were wan; [their] bodies withered and were pallid. Then the Exalted One had such thought in [his] quiet room: ‘The monks become sick in the autumn months. [Their] complexions are wan, [and their] bodies are pallid and withered. Now what sorts of food should I allow the monks to eat, [which] act as foods [and] act as medicines without causing them to appear as coarse [foods]?’ [The Exalted One] at once thought: ‘There are five kinds of medicine which are commonly used by the world: ghee, oil, honey, butter, [and] rock sugar. Now I would rather let the monks eat these [which] act as foods [and] act as medicines, without causing them to appear as coarse [foods] like the things of rice [or] parched flour.’ Having made this thought, [the Exalted One] rose from solitude in late afternoon. [He] convoked the community of monks on this matter. [He] fully informed the monks what he thought of at seclusion a short while ago. [The Exalted One said:] ‘From now on, [I] allow the monks with a reason of illness to consume five kinds of medicine: ghee, oil, butter, honey, [and] rock sugar.’ Those sick monks obtained various excellent foods. [But] when time had come to noon they could not eat [such foods], let alone the five kinds of medicine which could be taken when time had come to noon. At that time, though there was a lot of medicines, the sick ones could not take [them] in time. The affliction of monks then enhanced, [and their] bodies withered [and their] complexions were wan. At that time the Exalted One knew [this] and purposely asked Ānanda: ‘Why are the monks having such [withered] bodies and [wan] complexions?’ Then Ānanda fully informed the above-mentioned cause to the Exalted One. The Buddha said: ‘From now on, if a monk has a reason of illness, [I] allow using the five kinds of medicine, whether it is in proper time or in improper time.’”^[9]

Mahīśāsaka:—“The Buddha was in Rājagṛha. At that time the monks got the autumnal disease. The Buddha, walking round the lodgings, saw [this and] had this thought: ‘The worldly people use ghee, oil, honey, [and] rock sugar as medicines. Now I should allow the monks to consume [them].’ Because of this matter, [the Buddha] convoked the community of monks [and] addressed: ‘From now [I] allow the monks to consume four kinds of medicine: ghee, oil, honey, [and] rock sugar.’ The monks consumed the ghee [and] were distressed by [its] bad smell. Because of this [they] informed the Buddha. The Buddha said: ‘[I] allow well-boiling [the ghee]: one boils it himself or makes another to boil [it]. If there is no appropriate place,^[10] [I] allow boiling [it] at an inappropriate place.’ The monks took the ghee [and] had retching and nausea. [They] informed the Buddha of this [matter]. The Buddha said: ‘I allow the use of yellow myrobalan, [or] emblic myrobalan, or honey, or garlic, or parched flour, [or] anything suitable for relieving the oral [discomfort] (?).’”^[11]

“There were monks who got the autumnal disease [and] they should take the root-medicine. [They] informed the Buddha of this [matter]. The Buddha said: ‘All root-medicines are allowed for use. So are fruitmedicines.’ There were monks who got the autumnal disease [and] they should use grass-medicine. [They] informed the Buddha of this [matter]. The Buddha said: ‘All grass-medicines are allowed.’”^[12]

Sarvāstivāda:—“The Buddha was in Rājagṛha. In autumn the monks had chill, fever, indigestion, [and] agitation of phlegm.^[13] They ate but could not be satiated. They were lean, pale and feeble. The Buddha saw [that] the monks were lean, pale and feeble. The Buddha knew [this] and purposely asked Ānanda: ‘Why are the monks lean, pale and feeble?’ Ānanda told the Buddha: ‘The Exalted One, during autumn the monks have chill, fever, ingestion, [and] agitation of phlegm. They eat but cannot be satiated. That is why [they are] lean, pale and feeble.’ At that time the Exalted One had this thought: ‘What medicine should be given [to the monks] for [their] consumption in order to [make them] recover and to restore [their] complexion and strength? If they eat coarse rice, parched flour, [or] parched rice which cannot benefit their bodies, [I] should allow them to consume the four kinds of soft and easily swallowed medicine: ghee, oil, honey, [and] rock sugar.’ The Buddha, on this account, convoked the community [of monks]. Having convoked the community, [the Buddha] addressed the monks: ‘From today [onwards], [I] allow the sick monks to use the four kinds of soft and easily swallowed medicine: ghee, oil, honey, [and] rock sugar.’ At that time the monks consumed [these medicines] before noon, [but they did] not consume beyond noon. As before, [they were] lean, pale and feeble. The Buddha, having seen [that], again asked Ānanda: ‘Why are the monks lean?’ [Ānanda] replied: ‘The Exalted One, although the Exalted One allows the sick monks to use the four kinds of soft and easily swallowed medicine, the monks use [them] before noon [but] do not use beyond noon. That is why, as before, [they are] lean, pale and feeble.’ The Buddha, on this account, convoked the community. Having convoked the community, the Buddha, [by means of] various reasons, extolled the precepts and praised the observation of precepts. Having extolled the precepts and praised the observation of precepts, [the Buddha] addressed the monks: ‘From today [onwards], [I] allow the four kinds of medicine which are easily swallowed to be used as one likes before noon and after noon.’”^[14]

Mūlasarvāstivāda (Sanskrit):—“The Buddha, the Exalted One, lived in Śrāvastī, at Anāthapiṇḍada’s monastery in the Jeta Grove. At that time the monks were afflicted with the autumnal disease. Those being afflicted with the autumnal disease became very pale/yellowish, lean, feeble, withered, [and] with frail body. The Buddhas, the Exalted Ones, [though] knowing [the answers], were asking [the questions].^[15] During which time the Buddha, the Exalted One, asked the Venerable Ānanda: ‘Why, Ānanda, at present the monks are very pale/yellowish, lean, feeble, withered, [and] with frail body?’ The Venerable Ānanda told [the Buddha]: ‘At present, Venerable Sir, the monks are afflicted with the autumnal disease. At present, [those who are] being afflicted with the autumnal disease become very pale/ yellowish, lean, feeble, withered, [and] with frail body.’ The Exalted One said: ‘On that account, Ānanda, I allow medicine to be used by the monks.’ It had been said by the Exalted One [that] medicine should be used by the monks. The monks made use of [the medicine] in [proper] time [but] they did not make use of [the medicine when] it had gone beyond [proper] time. They were very pale/yellowish, lean, feeble, withered, [and] with frail body. The Buddhas, the Exalted Ones, [though] knowing [the answers], were asking [the questions]. The Buddha, the Exalted One, asked the Venerable Ānanda: ‘Has it been said by me [that] medicine should be used by the monks? Nevertheless the monks are very pale/yellowish, lean, feeble, withered, [and] with frail body.’ [Ānanda replied:] ‘It has been said, Venerable Sir, by the Exalted One [that] medicine should be used by the monks. They, [thinking] “we are these who are eating in [proper] time”, make use of [medicine] in [proper] time [and] they do not make use of [the medicine when] it has gone beyond [proper] time. Because of that, [they are] very pale/yellowish, lean, weak, withered, [and] with frail body.’ [The Buddha said:] ‘On that account then, Ānanda, I allow four kinds of medicines to be used by the monks: those for [proper] time, those for a night-watch, those for seven days, [and] those for [consumption] as long as one’s life lasts.... That [medicine] for seven days is thus: ghee, oil, molasses, honey, [and] rock sugar....’”^[16]

Mūlasarvāstivāda (Chinese):—“At that time the Exalted One was in Śrāvastī, at Anāthapiṇḍada’s garden in the Jeta Grove. Then the monks were sick in the autumn period. [Their] bodies withered [and] were yellowish, lean, haggard, distressed, and feeble. The Exalted One, having seen [that], knew and purposely asked Ānanda: ‘Why the monks are withered, yellowish, lean, and feeble?’ Ānanda informed the Buddha: ‘Venerable Sir, since it is getting into autumn, the monks then are afflicted with diseases. [Their] bodies are withered, yellowish, lean, and feeble.’ The Buddha addressed Ānanda: ‘Because of the suffering of illness, I now allow the monks to take miscellaneous medicines.’ In this way the Exalted One had allowed [the monks] to take medicines. Then the monks took [medicines] in proper time [and] they did not take in improper time. Their bodies were still weak, lean, and feeble. At that time the Exalted One knew [this] and purposely asked Ānanda: ‘I have allowed the monks to take various medicines. These monks however are lean as before.’ Ānanda informed the Buddha: ‘The Exalted One allows the monks to take medicines, and these monks take [the medicines] in proper time. [But they] do not take in improper time. So [their] bodies are [still] withered, yellowish, lean, and feeble.’ At that time the Buddha addressed Ānanda: ‘I now allow four kinds of medicine for the monks: One, the medicine for proper time; two, the medicine for a watch of night; three, the medicine for seven days; [and] four, the medicine for one’s whole life.... Medicines for seven days are ghee, oil, molasses, honey, [and] rock sugar....’”^[17]

We can note from the above information on the autumnal disease that the monks affected by this disease were, in brief, emaciated, pale or yellowish, and feeble. There are also extra facts according to some versions of the Chapter on Medicine: the sick monks also had symptoms of vomiting and loss of appetite as per the Theravāda Bhesajjakkhandhaka; chill, fever, indigestion, agitation of phlegm, and non-satiation even with eating as described in the Sarvāstivāda Bhaiṣajyadharmaka. The treatment prescribed by the Buddha was the use of lipids and sweets as medicines for up to seven days (as described in Section 4. 1. 1 of the previous chapter), including ghee, butter, oil, honey, molasses, and rock sugar, which were allowed for use first in proper time and eventually in improper time as well.^[18]

What is “autumnal disease”? The Samantapāsādikā and Āyurveda treatises have provided us with explanations for this. The Samantapāsādikā explicates that:

“In the Bhesajjakkhandhaka, ‘by the autumnal disease’ [means] by the disease of bile arisen in the time of autumn. [It is] because at that time [the monks] get wet by rain water and they trample on the mud. From time to time the sun-heat is also harsh. Because of that, their bile has gone to the intestinal canal.”^[19]

Autumn, according to A Sanskrit-English Dictionary (s.v. “śarad”), refers to the period of two months after the rains period and it ranges from August to November depending on different parts of India. Āyurvedic texts contribute more detailed depictions: During the cool rainy season, a person’s body is moistened and the digestive fire is dampened by cold wind. This leads to an accumulation of bile humour. In autumn, with the return of sun-heat, bile humour becomes liquefied and aggravated, and causes disorders of bile humour (Suśruta Saṃhitā Sūtrasthāna 6. 11; Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 3. 49). Aggravated bile humour approaches the site of digestive fire (agni) in the stomach and small intestine (āmāśaya), follows the digestive tract, weakens the digestive fire because of its liquidity, dispels such fire from the digestive tract, and causes it to spread all over the body resulting in fever (Caraka Saṃhitā Nidānasthāna 1. 22-24). Hence, with impaired digestion and probable malabsorption, an afflicted person can become lean, withered, feeble, and pale. Such mechanism in accordance with Āyurveda also explains why the sick monks with the autumnal disease, as described in the Chapters on Medicine, can have fever and other digestive symptoms such as vomiting, loss of appetite, indigestion, and so on.

The medicines prescribed by the Buddha for this disease were those lipids and sweets, as described above and in Chapter Four. All these substances work chiefly by promoting bodily strength, weight, complexion, and functions. Ghee, fresh butter, and honey also have the effect of alleviating bile humour. Āyurveda suggests that, during autumn or while treating this disease, one should consume substances which are sweet, bitter, astringent, cooling, and easily digestible. Consumption of ghee prepared with bitter medicines, purgation therapy to eliminate the vitiated bile humour, and bloodletting to remove the likely conspicuous vitiation of blood are also some therapeutic measures (Caraka Saṃhitā Sūtrasthāna 6. 41-48 and the translators’ notes; 20. 16; Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 3. 49-57). Oil and fat are to be avoided (Caraka Saṃhitā Sūtrasthāna 6. 44-45); but the use of oil as a medicine for the autumnal disease in the Chapters on Medicine probably is due to its effects of enhancing digestion and promoting strength and complexion (Caraka Saṃhitā Sūtrasthāna 27. 286-288; Suśruta Saṃhitā Sūtrasthāna 45. 112, 129).

How can we understand this disease in terms of modern medicine? In this case, the common presenting features are emaciation, pallor, and weakness. These suggest the occurrence of weight loss, malabsorption, as well as possible dehydration. These–together with anorexia, vomiting, and indigestion–point to a gastrointestinal disease which affects digestion and absorption. Some important information–seasonal occurrence of this illness, along with fever and chill (as described in the Sarvāstivāda Bhaiṣajyadharmaka)–suggests that this is an infection of the digestive tract. It is, therefore, likely to be an infective gastroenteritis. The responsible pathogen can be a type of bacterium (e.g. Escherichia coli, Salmonella species, etc.), virus (e.g. rotavirus, enteric adenovirus, etc.), or parasite (e.g. amoeba, giardia, etc.) (Moss, Irving, and Anderson 2012, 119125, 133-135, 150-152; Patel and Shandera 2012, 1367-1368). Due to that there is vomiting without diarrhoea mentioned in the Buddhist sources, the group norovirus is highly suspicious in this case, causing “winter vomiting disease.” This viral infection mainly occurs in colder months, but can happen any time in the year. Patients of this infection usually present with acute onset of one or more of the symptoms such as nausea, vomiting, non-bloody diarrhoea, and abdominal cramps. They may also have fever, chills, headache, and muscle aches. Vomiting may be the only feature (Moss, Irving, and Anderson 2012, 104; Patel et al. 2009, 2-3). If we consider the term uppaṇḍuppaṇḍukajāta in the Pāli source (or utpāṇḍūtpāṇḍuka in the Sanskrit source) as “yellowish” rather than “very pale,” it would imply the presence of jaundice and thus the liver would have been affected. This suggests hepatitis, which is likely due to viruses (particularly hepatitis A or E viruses which are transmitted by contaminated food/water and associated with poor sanitation) (Burroughs and Westaby 2012, 316-326). Obinata (1965, 75 ff.) suggests that it was a bacterial infection, namely, leptospirosis (caused by Leptospira autumnalis), which is another possibility. Modern treatment for infective gastroenteritis is chiefly conservative measures such as rehydration and rest, and antimicrobial chemotherapy if bacterial or parasitic infection is involved. Hygienic measures such as personal hygiene, sanitation, clean food preparation, and so on would be necessary to prevent spread of pathogens causing the disease.

The autumnal disease recorded in the Chapters on Medicine is mainly presented with digestive disturbance, which is due to aggravation of bile humour according to Āyruvedic pathophysiology. This illness was treated by using certain sweets and lipids, including ghee, butter, oil, honey, molasses, and rock sugar. Most of these are mentioned in Āyurveda for treating this problem, except the use of oil and fat. In terms of modern medicine, this disease may be explained as a gastrointestinal infection. Treatment nowadays would chiefly be rehydration and rest, and antimicrobial drug therapy if necessary.

Footnotes and references:

[1]:

Like that in Chapter Four, the relating passages for a certain kind of disease will be gathered in a table for a better view of the illness and an easy comparison amongst the Chapters on Medicine.

[2]:

The verb uggacchati literally means “goes up.” The rice-gruel and food “go up” should imply that such things were vomited.

[3]:

The term uppaṇḍuppaṇḍukajāta, with its Sanskrit parallel utpāṇḍūtpāṇḍuka, is rendered as “very pale” in Pali-English Dictionary (s.v. “uppaṇḍuppaṇḍukajāta”) as well as in Edgerton’s Buddhist Hybrid Sanskrit Dictionary (s.v. “utpāṇḍūtpāṇḍu”). Horner has translated it as yellowish in The Book of Discipline (IV. 269). The Chinese translation of this term in the Mūlasarvāstivāda Bhaiṣajyavastu is also yellow(ish) 黄. The version in the Dharmaguptka Bhaiṣajyaskandhaka gives the description as pallid (癬白). Hence this term can mean either “very pale” or “yellowish”.

[4]:

The translation of this phrase is adopted from Anuruddha 2004, 256.

[5]:

The Samantapāsādikā (V. 1089) explains: “‘[They] do not seem good’ is [that] they neither are digested nor are able to cause the wind disease to subside” (nacchādentī’ti na jiranti, na vātarogaṃ paṭippassambhetuṃ sakkonti).

[6]:

The Samantapāsādikā (V. 1089) reads: “‘Those which are greasy’ are those which are soft” (sinesikānī’ti siniddhāni). But the Samantapāsādikā in the Pali Text Society version has the word sinesikāni while this text in the Chaṭṭha Saṅgāyana Tipitaka (Version 4. 0) gives senesitāni. Both words are not found in any Pāli dictionaries. The word seems to be senesikāni. See Pali-English Dictionary, s.v. “senesika”.

[7]:

The Samantapāsādikā (V. 1089) expounds: “‘By loss of appetite’ [means] by absence of appetite for food” (bhattacchādakenā’ti bhattassa anārocikena). Rocika or rocaka cannot be found in Pāli dictionaries. But according to A Sanskrit-English Dictionary, rocaka means appeptite.

[8]:

Theravāda Vinaya Piṭaka I. 199-200: “Tena samayena buddho bhagavā Sāvatthiyaṃ viharati Jetavane Anāthapiṇḍikassa ārāme. tena kho pana samayena bhikkhūnaṃ sāradikena ābādhena phuṭṭhānaṃ yāgu pi pītā uggacchati bhattam pi bhuttaṃ uggacchati, te tena kisā honti lūkhā dubbaṇṇā uppaṇḍuppaṇḍukajātā dhamanisanthatagattā. addasa kho bhagavā te bhikkhū kise lūkhe dubbaṇṇe uppaṇḍuppaṇḍukajāte dhamanisanthatagatte, disvāna āyasmantaṃ Ānandaṃ āmantesi: kiṃ nu kho Ānanda etarahi bhikkhū kisā lūkhā … dhamanisanthatagattā’ti. etarahi bhante bhikkhūnaṃ sāradikena ābādhena phuṭṭhānaṃ yāgu pi pītā uggacchati bhattam pi bhuttaṃ uggacchati, te tena kisā lūkhā dubbaṇṇā uppaṇḍuppaṇḍukajātā dhamanisanthatagattā’ti. atha kho bhagavato rahogatassa paṭisallīnassa evaṃ cetaso parivitakko udapādi: etarahi kho bhikkhūnaṃ sāradikena ābādhena phuṭṭhānaṃ–la–dhamanisanthatagattā. kiṃ nu kho ahaṃ bhikkhūnaṃ bhesajjaṃ anujāneyyaṃ, yaṃ bhesajjañ c’ eva assa bhesajjasammatañ ca lokassa āhārattañ ca phareyya na ca oḷāriko āhāro paññāyeyyā’ti. atha kho bhagavato etad ahosi: imāni kho pañca bhesajjāni seyyath’ īdaṃ sappi navanītaṃ telaṃ madhu phāṇitaṃ bhesajjāni c’ eva bhesajjasammatāni ca lokassa āhārattañ ca pharanti na ca oḷāriko āhāro paññāyati. yaṃ nūnāhaṃ bhikkhūnaṃ imāni pañca bhesajjāni anujāneyyaṃ kāle paṭiggahetvā kāle paribhuñjitun ti. atha kho bhagavā sāyaṇhasamayaṃ paṭisallānā vuṭṭhito etasmiṃ nidāne dhammikathaṃ katvā bhikkhū āmantesi: idha mayhaṃ bhikkhave rahogatassa … paññāyeyyā’ti. tassa mayhaṃ bhikkhave etad ahosi: imāni kho pañca bhesajjāni–la–yaṃ nūnāhaṃ bhikkhūnaṃ imāni pañca bhesajjāni anujāneyyaṃ kāle paṭiggahetvā kāle paribhuñjitun ti. anujānāmi bhikkhave tāni pañca bhesajjāni kāle paṭiggahetvā kāle paribhuñjitun ti. tena kho pana samayena bhikkhū tāni pañca bhesajjāni kāle paṭiggahetvā kāle paribhuñjanti. tesaṃ yāni pi tāni pākatikāni lūkhāni bhojanāni tāni pi na cchādenti, pag eva senesikāni. te tena c’ eva sāradikena ābādhena phuṭṭhā iminā ca bhattācchandakena tadubhayena bhiyyosomattāya kisā honti lūkhā dubbaṇṇā uppaṇḍuppaṇḍukajātā dhamanisanthatagattā. addasa kho bhagavā te bhikkhū bhiyyosomattāya–la–dhamanisanthatagatte, disvāna āyasmantaṃ Ānandaṃ āmantesi: kiṃ nu kho Ānanda etarahi bhikkhū bhiyyosomattāya kisā–la–dhamanisanthatagattā’ti. etarahi bhante bhikkhū tāni ca pañca bhesajjāni kāle … tadubhayena bhiyyosomattāya kisā lūkhā dubbaṇṇā uppaṇḍuppaṇḍukajātā dhamanisanthatagattā’ti. atha kho bhagavā etasmiṃ nidāne dhammikathaṃ katvā bhikkhū āmantesi: anujānāmi bhikkhave tāni pañca bhesajjāni paṭiggahetvā kāle pi vikāle pi paribhuñjitun ti.”

[9]:

Taishō Tripiṭaka 1428. 869b21-c9: “爾時世尊在舍衛國。時諸比丘秋月得病，顏色憔悴形體枯燥癬白。時世尊在靜室作如是念：「諸比丘秋月得病，顏色憔悴形體癬白枯燥。我今當聽諸比丘食何等味？當食常藥不令麁現。」即念言：「有五種藥，是世常用者，酥、油、蜜、生酥、石蜜。我今寧可令諸比丘食之，當食常藥不令麁現，如飯麨法。」作是念已，晡時從靜處起，以此事集比丘僧，以向者在靜處所思念事具告諸比丘：「自今已去，聽諸比丘有病因緣聽服五種藥：酥、油、生酥、蜜、石蜜。」諸病比丘，得種種肥美食，至中不能食，況復五種藥至中能食？爾時藥雖多，病人不能及時服，諸比丘患遂增，形體枯燥顏色憔悴。爾時世尊知而故問阿難：「諸比丘何故形體顏色如是？」時阿難具以上因緣白世尊，佛言：「自今已去，若比丘有病因緣，若時、若非時，聽服五種藥。」” In the Taishō Tripiṭaka and the

CBETA, the phrase “當食常藥” is given in the passage; but according to a footnote in the CBETA, older editions of Chinese Buddhist canon have the phrase as “當食當藥”. The present translation is based on the latter one.

[10]:

淨地 is kappiya-bhūmi (Pāli) or kalpiya-bhūmi/śuddha-bhūmi (Sanskrit). It refers to the appropriate or lawful place to store or manage food.

[11]:

Taishō Tripiṭaka 1421. 147b7-14: “佛在王舍城。爾時諸比丘得秋時病，佛行房見，作是念：「世人以酥、油、蜜、石蜜為藥，我今當聽諸比丘服。」以是事集比丘僧，告言：「從今聽諸病比丘服四種藥，酥、油、蜜、石蜜。」諸比丘服酥，苦臭。以是白佛，佛言：「聽熟煎，若自煎、若使人煎。若無淨地，聽非淨地煎。」諸比丘服酥，嘔逆欲吐。以是白佛，佛言：「聽以 呵梨勒、阿摩勒果、若蜜、若蒜、若麨，諸所宜物排口。」” The last term in this passage is 排口 in the Taishō Tripiṭaka and the CBETA; in older editions of Chinese Buddhist canon, it is 敗 口. Both of them are difficult for understanding the exact meaning. This possibly refers to the discomfort after consuming ghee and then the use of these substances to remove the discomfort.

[12]:

Taishō Tripiṭaka1421. 147b28-c2: “有諸比丘得秋時病應服根藥。以是白佛，佛言：「一切根藥聽服，果藥亦如是。」有諸比丘得秋時病應服草藥，以是白佛，佛言：「一切草藥聽服。」”

[13]:

According to Yiqiejing yinyi 一切經音義 (Pronunciations and Meanings in All Discourses) (Taishō Tripiṭaka 2128. 555c20), the Chinese character 癊 refers to the category of phlegm diseases (癊者痰病之類).

[14]:

Taishō Tripiṭaka 1435. 184b25-c11: “佛在王舍城，秋時諸比丘冷熱發癖癊患動，食不能飽，羸瘦少色力。佛見諸比丘羸瘦少色力，佛知故問阿難：「諸比丘何以羸瘦少色力？」阿難白佛言：「世尊！諸比丘秋時冷熱發癖癊患動，食不能飽，是故羸瘦少色力。」爾時世尊作是念：「當以何藥與服令差色力還復？若食麁飯、麨糒不能益身，當聽服四種含消藥：酥、油、蜜、石蜜。」佛以是因緣故集僧，集僧已，告諸比丘：「從今日聽諸病比丘服四種含消藥：酥、油、蜜、石蜜。」爾時諸比丘中前服，過中不服，猶故羸瘦少色力。佛見已復問阿難：「諸比丘何以故羸瘦？」答言：「世尊！世尊雖聽病比丘服四種含消藥，諸比丘中前服，過中不服，是以猶故羸瘦。」佛以是因緣集僧，集僧已，佛種種因緣讚戒、讚持戒，讚戒、讚持戒已，告諸比丘：「從今日聽四種含消藥中前、中後自恣服。」”

[15]:

The translation of this sentence is adopted from the Buddhist Hybrid Sanskrit Dictionary (s.v.

“jānaka”).

[16]:

Gilgit Manuscripts III. 1.i-iii: “buddho bhagavān śrāvastyāṃ viharati jetavane anāthapiṇḍadasyārāme | tena khalu samayena bhikṣavaḥ śāradakena rogeṇa bādhyante | te śāradakena rogeṇa bādhyamānā utpāṇḍūtpāṇḍukā bhavanti kṛṣālukā durbalakā mlānā aprāptakāyāḥ | jānakāḥ pṛcchakā buddhā bhagavantaḥ | yāvatpṛcchati buddho bhagavān āyuṣmantamānandam | kasmādānanda etarhi bhikṣavaḥ utpāṇḍūtpāṇḍukāḥ kṛṣālukā durbalakā mlānā aprāptakāyā iti | āyuṣmānānandaḥ kathayati | etarhi bhadanta bhikṣavaḥ śāradakena rogeṇa bādhyante | etarhi śāradakena rogeṇa bādhyamānā utpāṇḍūtpāḍukā bhavanti kṛṣālukā durbalakā mlānā aprāptakāyāḥ | (bhagavānāha) | tasmādānanda anujānāmi bhikṣubhirbhaiṣajyaṃ sevitavyamiti | (uktaṃ bhagavatā bhikṣubhirbhaiṣajyaṃ pratisevitavyamiti) | bhikṣavaḥ kāle sevanti kālātikrāntaṃ na sevanti | te bhavanti utpāṇḍūtpāṇḍukāḥ kṛṣālukā durbalakā mlānā aprāptakāyāḥ | jānakāḥ pṛcchakā vuddhā bhagavantaḥ | pṛcchati buddho bhagavān āyuṣmantamānandam | uktaṃ mayā bhikṣubhirbhaiṣajyaṃ sevitavyamiti | atha ca punarbhikṣavaḥ utpāṇḍūtpāṇḍukāḥ kṛpālukā durbalakā mlānā aprāptakāyāḥ | uktaṃ bhadanta bhagavatā bhikṣubhirbhaiṣajyaṃ pratisevitavyamiti | ta ete kālabhojinovayamiti kāle sevante kālātikrāntaṃ na sevante | tenotpāṇḍūtpāṇḍukāḥ kṛṣālukā durbalakā mlānā aprāptakāyāḥ | tasmāttarhyānanda anujānāmi bhikṣubhiścaturvidhāni bhaiṣajyāni pratisevitavyāni | kālikāni yāmikāni sāptāhikāni yāvañjīvikāni |... sāptāhikaṃ sarpistathā tailaṃ phāṇitaṃ madhu śarkarā | ”

[17]:

Taishō Tripiṭaka 1448. 1a10-b8: “爾時薄伽梵在室羅伐城逝多林給孤獨園。時諸苾芻秋時染疾，身體痿黃，羸瘦憔悴，困苦無力。世尊見已，知而故問阿難陀曰：「何故諸苾芻，身體痿黃，羸瘦無力？」阿難陀白佛言：「大德！諸苾芻等，既侵秋節遂染諸病，身體痿黃，羸瘦無力。」佛告阿難陀：「由是病苦，我今聽諸苾芻服食雜藥。」如是世尊既聽服藥，時諸苾芻遂於時服、非時不服，身體尚衰，羸瘦無力。爾時世尊知而故問阿難陀曰：「我已聽諸苾芻服食諸藥，然此苾芻猶故羸瘦？」阿難陀白佛言：「世尊聽諸苾芻服食諸藥，此諸苾芻並於時服、非時不服，所以身體痿黃，羸瘦無力。」爾時佛告阿難陀：「我今為諸苾芻，開四種藥：一、時藥；二、更藥；三、七日藥；四、盡壽藥。...七日藥者：酥、油、糖、蜜、石蜜。」”

[18]:

The Mūlasarvāstivāda Bhaiṣajyavastu does not mention these substances as specific remedies for the autumnal disease, but just states that these medicines are those for use in seven days while enumerating various substances of the four kinds of medicine in relation to the time of use (i.e.

medicines for proper time, those for improper time, those for seven days, and those for use in one’s duration of life).

[19]:

Samantapāsādikā V. 1089: “Bhesajjakkhandhake sārādikena ābadhenā ’ti saradakāle uppannena pittābādhena. tasmiṃ hi kale vassodakena pi tementi kaddamam pi maddanti, antarantarā ātapo pi kharo hoti, tena tesaṃ pittaṃ koṭṭhabbhantaragataṃ hoti.”