Bhesajjakkhandhaka (Chapter on Medicine)

by Hin-tak Sik | 2016 | 121,742 words

This study deals with the ancient Indian Medicine (Ayurveda) in Early Buddhist Literature and studies the Bhesajjakkhandhaka and the Parallels in other Vinaya Canons. The word Bhesajja means “medicine” and is the sixth chapter of the Khandhaka, which represents the second book of the Pali Vinaya Pitaka. Other works consulted include the Bhaisajya-s...

(b) Basic Principles of Āyurveda

The term Āyurveda is a compound word made of two parts: āyus means life or longevity, and veda denotes knowledge or science. Thus Āyurveda refers to the knowledge/science for life or longevity, which is a rational and naturalistic system of medical knowledge and practice (Filliozat 1966-1968, 477). Its purpose is to prolong life–it not only cures the sickness of people, but also prevents them from getting sick (Basham 1976, 21-22). It provides physicians with practical information for treating patients, as well as for advising people on proper ways to maintain health and to live long (as mentioned at the beginning of Section 2. 3). As Zysk (1996, 8) has stated: in many cultures of the world, having a long life is a criterion for being considered healthy. More importantly, longevity allows people more opportunity to achieve their goals or fulfil duties. In Indian culture, four goals (puruṣārtha) are known, as mentioned in the Caraka Saṃhitā (Sūtrasthāna 1. 15): accomplishment of virtues (dharma), attainment of wealth (artha), fulfilment of desire (kāma), and liberation from the world (mokṣa). The achievement of these goals relies on having good health and a long life–that is, the science of longevity.

There are eight branches (aṣṭāṅga) in Āyurvedic science, namely (Benner 2005, 3853; Mitra 1985, 22):

  1. kāyacikitsā (internal medicine),
  2. śalyatantra or śalya-pahartṛka (general surgery),
  3. śālākyatantra or ūrdhvāṅgacikitsā (dealing with diseases above the clavicle),
  4. bhūtavidyā or grahatantra (relating to possession by supernatural beings),
  5. kaumārabhṛtyaka or bālacikitsā (paediatrics),
  6. agadatantra or viṣagaravairodhikapraśamana or daṃṣṭrā (toxicology),
  7. rasāyana or jarācikitsā (geriatrics and life prolongation), and
  8. vājīkaraṇa or vṛṣa (pertaining to aphrodisiacs).[1]

Anatomical and physiological principles are important in Āyurveda for understanding physical health and disease (Weiss 2005, 715). The anatomical knowledge in the classical Āyurvedic texts is thought to come principally from Vedic sources, which contain long lists of body parts from dissecting animals during religious sacrificial rituals (Chopra 2003, 75). Anatomical data were also obtained from examination of bodies of the injured or killed. Dissection of human corpses, though a strong taboo in ancient India, was not unknown in early times (Basham 1976, 27-29).[2]

The fundamental physiological principles of Āyurveda include the theories of pañcamahābhūtas, doṣas, dhātus, and malas. The doctrine of pañcamahābhūtas forms the very basis of Āyurvedic science (Chopra 2003, 75). Doṣas, dhātus, and malas are recognised in the classical Āyurvedic treatises as the “root” of the body (Suśruta Saṃhitā Sūtrasthāna 15. 3; Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 11. 1). These concepts will be concisely introduced as follows.

Pañcamahābhūtas (or simply pañcabhūtas), the five great elements, are earth (pṛthvī), water (ap), fire (tejas), wind or air (vāyu), and space (ākāśa). These five are the elemental substances of all physical matter in the universe, including the human body. By adopting this ideology of the Sāṃkhya school, the Āyurvedic system holds that humans as microcosms of the universe can interact with nature (Chopra 2003, 75; Filliozat 1964, 26-27). Each of these five elements, according to the Āyurvedic (and other Indian philosophical) literature,[3] has its special qualities. Moreover, each predominates in certain bodily components and manifests certain functions.

Mitra (1985, 55) has extracted such information from a passage in one of the Āyuvedic texts (Caraka Saṃhitā Śārīrasthāna 7.16) and given the translation as follows:

“Whatever is predominently [sic] gross (sthūla), firm or static (sthira), solid (mūrtimat), heavy (guru), rough (khara), and hard (kaṭhina) part of the body, viz., nails, bones, teeth, flesh, skin, faeces, hair of the head, face and body, tendons as well as odour and the sense of smell, belongs to Pṛthivī bhūta [sic]. Whatever is predominently [sic] liquid (drava), diffusive (sara), sluggish (manda), viscous (snigdha), soft (mṛdu) and pasty (picchila), viz., body nutrient fluid (rasa), blood, fat, kapha [sic] or phlegm, pitta [sic] or bile, urine, sweat, etc., belongs to Ap dhātu. Whatever in the body is of the nature of Pitta, heat and radiating lustre (bhā) as well as colour and complexion is referable to tejas dhātu. Whatever in the body is of the nature of inhalation and exhalation, opening and closing the eyes, contraction and extension, movement, impelling and holding, etc., as well as touch and the sense of touch are referable to vāyu [sic]. Whatever in the body is of the nature of porosity (vivikta), utterance and the channels that are gross and minute, as well as sound and the sense of hearing, are referable to ākāśa dhātu.”[4]

The three doṣas (tridoṣa) are wind (vāta or vāyu), bile (pitta), and phlegm (kapha, śleṣman; Pāli: semha),[5] which are thought, like all matters in the world, to evolve from the pañcabhūtas.[6] They are often rendered as “humours” because of the similarity of this theory to the Greek humoral theory of Hippocrates and Galen. The term doṣa can literally mean “vitiator”, from the root duṣ (to spoil or to corrupt). It is because when the doṣas are in balance or in proper proportion they lead to a good state of health; otherwise they can cause various diseases and even death. Although these humours carry a sense of negative implication, they are essential to all bodily functions.[7] They are thought to be semi-fluids circulating in the body via special channels, but each of them predominates in certain part of the body: vāta in the lower abdomen, pitta in the upper abdomen, and kapha in the chest and head. They have their own qualities: vāta is dry, cold, light, mobile, non-slimy, and coarse; pitta is greasy, hot, sour, pungent, sharp, and fluid; kapha is heavy, cold, viscous, soft, sweet, and slimy (as described in the Caraka Saṃhitā Sūtrasthāna 1. 59-61, as well as in the Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 1. 11-12).[8] The three doṣas have their individual functions. Vāta, as wind, mainly exerts its function characterised by “movement”, such as body/limb movement, mental activation, speech utterance, respiration, intestinal peristalsis, bowel evacuation, etc. Pitta is responsible for functions such as digestion, metabolism, body heat, as well as making the body soft and flexible. It also induces psychological activities such as understanding, intelligence and courage. Kapha makes the body firm, smooth and stable, lubricates the joints, and refreshes the sense organs (Benner 2005, 3854-3855; Chopra 2003, 77-78).[9] The three doṣas undergo fluctuation and each of them dominates at a different period during the daytime and night-time. Variations of the three also occur at different seasons and at different stages of life. Conditions–such as habitat, food, lifestyle, and so on–can have influences on the functions of the doṣas (Chopra 2003, 78; Thakar 1992, 383). The three doṣas are already present at the start of life for each person, until the end of life. Moreover, every person has his/her unique constitution of the doṣas at birth, forming his/her prakṛti. This constitution determines the individual physical and psychological characteristics; it also influences pathogenesis of disease and hence the treatment (Chopra 2003, 77-78; Thakar 1992, 382-385). In brief, the three doṣas together regulate all phases and activities of growth, maintenance and decay. Their balance is responsible for health, and their imbalance for illness and death.[10]

The term dhātu, though literally means “constituent part” or “element”, represents certain body substance or tissue in Āyurvedic science. There are seven dhātus: chyle (rasa), blood (rakta), muscle (māṃsa), fat (medas), bone (asthi), marrow (majjā), and semen (śukra). Each of these seven, according to the Āyurvedic physiology, is derived one by one from each other, starting from the ingested food. Food undergoes the process of digestion, which assumes a very significant role in Āyurveda and is regulated by doṣas. Food is digested–viewed as being “cooked” by “digestive fire” (jāṭharāgni)–and this results in chyle. Then chyle is transformed by bile into blood, blood into flesh, flesh into fat, fat into bone, bone into marrow, and marrow into semen (Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 1. 13; Caraka Saṃhitā Sūtrasthāna 28. 4, Cikitsāsthāna 15. 16; Chopra 2003, 76-77). Through this process of digestion and metabolism, the seven dhātus are sustained and restored (Thakar 1992, 384).[11] These dhātus have their specific functions: chyle supplies nu[12] trients, blood helps maintain life activities, meat covers the bones, fat provides lubrication, bones support the body, marrow fills the bone, and semen is responsible for reproduction (Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 11. 4).[13]

Mala, another “root” of body, refers to any bodily excretion; among which urine, faeces, and sweat are the major ones. Other examples of wastes are earwax, tears, nasal discharge, and so on (Caraka Saṃhitā Cikitsāsthāna 15. 18-20). Being the waste products of the process of metabolism, they are passed out of the body. According to the Aṣṭāṅga Hṛdaya Saṃhitā (Sūtrasthāna 11. 5), the malas have their functions: the faeces sustain the strength of the body, the urine eliminates the moisture, and sweat retains the moisture.

According to the teachings of the Āyurveda, health is achieved by the balance of the doṣas, the dhātus and the malas; sickness occurs when one or more of them are out of balance (Thakar 1992, 377). Doṣas play an important role because their change can vitiate the balance of dhātus and malas, and the doṣas can cause imbalance of the dhātus and/or the malas resulting in disease (Benner 2005, 3855; Zysk 1991, 29). Most of the diseases (and even death) are explained by the imbalance of one or more of the three doṣas. When there is “causative factor” (nidāna) acting on the doṣas, the balance of the doṣas can be upset with the increase or decrease of one or more of the doṣas, and this leads to various symptoms and diseases (Weiss 2005, 714; Zysk 1996, 1). Causative factors can be diet, time, seasonal change, habitat, lifestyle, conduct, physical and/or emotional stress, suppression of natural urges, effect of previous actions (karma),[14] and so on (Suśruta Saṃhitā Sūtrasthāna 21. 19-26; Filliozat 1964, 29; Weiss 2005, 714). If a doṣa is increased, it first accumulates at its dominant area and causes pathology there; if further increased it overspreads from its area, causing morbid features (symptoms and signs) at other parts of the body.[15] Thus, as Thakar (1992, 386) clearly summarises, disease is conditioned by nidāna (external aetiological factor), doṣa (internal physiological factor) and dūṣya (the body parts to be affected). In addition, sickness can also be due to āma, which is considered as a harmful product of improperly digested food. It can cause blockage of the channels through which doṣas and dhātus flow, and subsequently disturbs their normal circulation and leads to disease (Benner 2005, 3855).[16] Other external factors such as injuries, poisons, and supernatural beings are also recognised as disease-causing in Āyurveda.[17]

In order to make a diagnosis of the patient’s illness, a six-fold examination (ṣaḍvidha rogiparīkṣā) of the patient will be carried out: the physician uses the five senses to observe the symptoms and signs, together with the interrogation (of the patient’s complaints) to make diagnosis (Suśruta Saṃhitā Sūtrasthāna 10. 4-5). Then the diagnosis is made by the Āyurvedic physician (vaidya) in terms of five criteria (nidāna pañcaka): aetiology (nidāna), prodromal features (pūrvarūpa), clinical features (rūpa), therapeutic trial (upaśaya), and pathogenesis (samprāpti) (Aṣṭāṅga Hṛdaya Saṃhitā Nidānasthāna (Nidānasthāna) 1. 2-8).[18] Apart from these, special diagnostic skills have been added and utilised in the long history of Āyurveda, for instance: examination of urine (mūtraparīkṣā) came into practice from about the eleventh century Common Era; examination of the pulse (nāḍīparīkṣā)[19] appeared in the Śārṅgadhara Saṃhitā (circa the fourteenth century); examination of the eight bases (aṣṭasthānaparīkṣā)–which examines the patient’s pulse, urine, faeces, tongue, eyes, general appearance, voice, and skin–began to be used from the sixteenth century. Furthermore, prognostic methods were also developed in Āyurveda. For example, a technique in which an oil-drop was placed on the surface of the patient’s urine, to determine his/her remaining lifespan, has been employed from about the sixteenth century (Wujastyk 1993, 767).

Āyurveda includes both therapeutic and preventive aspects. In respect to therapy, it employs many different measures such as medicinal substances, diet, emesis, enemas, purgation, massage, bloodletting, douches, sweating, surgery, and so on (Wujastyk 2005, 1411). The chief goal of various therapies in Āyurveda is to restore the balance–especially that of the doṣas. After diagnosing which humour or humours are increased or decreased, different drugs or treatments are prescribed to counter the pathogenic factor(s) and to correct the imbalance (Weiss 2005, 714).[20]

The materia medica recorded in the ancient Āyurvedic treatises is vast, containing various vegetal, animal and mineral substances with specific healing properties (Wujastyk 1993, 761). The body of medicinal substances was enlarging with new drugs being introduced, such as opium and metallic compounds (from the development of alchemy in the second millennium of the Common Era, especially for rejuvenation and extraordinary powers) (Chopra 2003, 80-81; Mazars 2006, 11-12).

Apart from using drugs, other modes of treatment were used. Five specific therapies (pañcakarma) have been described in the early medical texts. For instance, in the Caraka Saṃhitā these are emesis, purgation, oily enema, watery enema, and nasal catharsis (while the Suśruta Saṃhitā replaces one enema with bloodletting). Moreover, preparatory measures–such as consuming oil or applying oil externally (i.e. oiling), and causing sudation by various methods (i.e. sweating) in order to open the channels, mobilise the problematic humour/waste, and eliminate it–are often carried out before these treatments.[21]

Surgery was emphasised in the Suśruta Saṃhitā, but not in the other Āyurvedic texts. Various types of surgical techniques have been described in detail in this treatise, such as cataract couching, bone-setting, suturing, and so on. However, the practice of surgery seemed to have lost its importance very soon in the history of Āyurveda, for there is almost no evidence of this practice in the historical sources of India in the medieval times (Wujastyk 1993, 763-765; 2005, 1411).

Apart from the above commonly employed remedies of Āyurveda, there are other therapeutic measures. Dietetics has an important role in Āyurveda. It is based on the doctrine that there is an association between taste (rasa) in foods and five mahābhūtas, and through such a principle that the six tastes–sweet, sour, salty, pungent, bitter, and astringent–assert different effects on the doṣas (Caraka Saṃhitā Sūtrasthāna 1. 6466). Preparation and consumption of various foods and drinks are taught in Āyurveda. In addition, a meat diet and alcohol sometimes are prescribed as medicines when necessary. [22] Another type of treatment is the magico-religious measures of the Vedic medicine. Some forms of Vedic medicine survive in the Āyurvedic medicine, though the latter is empirico-rational and emphasises on pharmaceutical/surgical cures. Magico-religious remedies such as ritual offering and spell chanting were used in Āyurveda for certain diseases, especially in the possessed conditions and paediatric diseases (Zysk 1991, 19-20).

Maintenance of health–for the purpose of long life–is another important aspect of Āyurveda. There are many practical advices–what to do and what not to do–for this purpose according to Āyurveda (e.g. Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 2-4), such as personal hygiene (tooth-brushing, bathing, cutting hairs and nails, etc.); non-suppression of natural urges (e.g. passing urine, faeces, flatus); suitability of and moderation in foods and drinks; physical exercises to control weight; time and place for sleep; ethical conduct (good deeds of body, speech and mind, e.g. no harming of other sentient beings, no stealing or robbing, no sexual misconduct, compassion, thinking of the benefits of others, etc.); appropriate occupations; suitable etiquettes and activities;good clothing and footwear; wearing talismans or amulets; usage of eye collyria, nasal drops, mouth gargles, etc.; body massage; regimens during different seasons; suitable living environment; and so on.

Footnotes and references:


These eight branches are listed in the classical Āyurvedic texts, though different terms have been used for the branches (Caraka Saṃhitā Sūtrasthāna 30. 28; Suśruta Saṃhitā Sūtrasthāna 1. 6; Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 1. 5).


In the Suśruta Saṃhitā (Śārīrasthāna (Śārīrasthāna) 5. 49), there is a passage describing the way to handle a corpse and to observe the body parts while it is decomposing.


Karunadasa (2002, 392) points out that Buddhism (as well as Jainism) only recognises four great elements–earth, water, fire, wind–but not space (as the fifth mahābhūta), even though space is sometimes listed with the four elements in the Pāli Nikāya. Likewise, consciousness (viññāṇa) is sometimes enumerated with the five items in Pāli discourses but it is not regarded as the sixth mahābhūta. However, the Caraka Saṃhitā (Śārīrasthāna 1. 16) groups the five great elements with consciousness (cetanā) and term them as six dhātus.


There are many similar descriptions of the qualities and functions of these great elements found in the Āyurvedic treatises, and it is impossible to quote them all here. Mitra has composed a good chapter on the mahābhūṭas, providing many references from Āyurvedic texts as well as Buddhist scriptures. See his book (1985, 40-56).


Vāta, pitta and kapha are sometimes glossed as wind, fire, and water respectively, because of the properties of these elements in the doṣas (Benner 2005, 3854).


Blood is sometimes listed as the fourth doṣa in some Āyurvedic texts. See, for example, Suśruta Saṃhitā Sūtrasthāna 21. 28.


This general depiction of the three doṣas is based on information gathered from Basham 2004, 501; Benner 2005, 3854; Chopra 2003, 77; Thakar 1992, 382; and Wujastyk 2005, 1411.


In the description of the Caraka Saṃhitā, it also states that medicines having opposite qualities can relieve the qualities of these humours.


Each doṣa is further divided into five kinds. Details of these kinds can be found in Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 12. 4-18. See also Jolly 2012, 49-50.


These three doṣas are commonly referred to in the Āyurvedic texts as pathogenic factors of physical body. Rajas (emotion) and tamas (darkness) are mentioned in the Caraka Saṃhitā (Sūtrasthāna 1. 57) as the pathogenic factors of the mind causing vitiation of the mind. But these two are much less emphasised while discussing aetiology in Āyurveda.


The metabolic process, if functioning well, results in the production of ojas (rendered as energy or vitality, which is the essence of the seven dhātus) which serves as the support of life and gives strength, courage and immunity to the body; without it, life vanishes (Chopra 2003, 76; Jolly 2012,


; Thakar 1992, 384). For more information on ojas (also known as bala in the Suśruta Saṃhitā), see Caraka Saṃhitā Sūtrasthāna 30. 8-14; Suśruta Saṃhitā Sūtrasthāna 15. 19-28; Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 11. 39-41.


In the metabolic process, upadhātu (secondary dhātu) and mala (excretion) are also formed. Upadhātus refer to bodily tissues or fluids such as skin, hair, tendons, breast milk, menses etc., which are regarded as side-products of the dhātus (Caraka Saṃhitā Cikitsāsthāna 15. 17). Malas will be described in the following paragraph.


According to Zysk (1991, 30-31), the classical Āyurvedic texts have little regard for karma as a cause of illness, though it is listed as a theoretical cause. And it seems to have more importance in the area of embryology.


Caraka Saṃhitā (Sūtrasthāna 17. 114) and Aṣṭāṅga Hṛdaya Saṃhitā (Sūtrasthāna 12. 22-24) state two pathological stages for the doṣas: accumulation (caya) and aggravation (prakopa or kopa); Suśruta Saṃhitā (Sūtrasthāna 21. 18-37) describes six abnormal stages: accumulation (saṃcaya), aggravation (prakopa), spread (prasara), localisation (sthānasaṃśraya), manifestation (vyakti), and specification (bheda).


According to Āyurveda (e.g. Aṣṭāṅga Hṛdaya Saṃhitā Uttarasthāna (Uttarasthāna) 6. 4-6), mind is transported via channels; blockage of the channels can also lead to mental illness such as insanity. Moreover, mental stress can aggravate the doṣas (the physical body), while dysfunction of doṣas (and channels) can lead to insanity and epilepsy (mental and neurological disorders), as Thakar (1992, 385) has commented.


Supernatural causes (e.g. deities or demons) are usually accounted for psychiatric and paediatric problems.


There are different diagnostic principles in Āyurveda, such as the ten-fold examination mentioned in the Caraka Saṃhitā (Vimānasthāna (Vimānasthāna) 8. 94), which includes: physical constitution (prakṛti), morbid manifestations (vikṛti), excellence of the dhātus (sāra), compactness of the body (saṃhanana), measurement of bodily parts (pramāṇa), suitability of food (sātmya), mental strength (sattva), capacity for intake of food (āhāraśakti), physical capacity for exercise (vyāyāmaśakti) and age (vayas).


According to Chopra (2003, 79), the appearance of the examination of the pulse in Āyurveda was probably influenced by Chinese medicine or Arabic medicine. He also mentions that scholars have suggested the possible influence by Tantric yoga.


However, it is known that in Āyurvedic practice this principle is not necessarily followed. Often treatment is given based on empirical data rather than on theory (Benner 2005, 3855; Chopra 2003, 80).


This description on the pañcakarma has the information collected from Chopra 2003, 80; Wujastyk 2003b, xx; 2005, 1411.


There is much material on dietetics in the classical Āyurvedic texts, such as Caraka Saṃhitā Sūtrasthāna 23, 25-28; Suśruta Saṃhitā Sūtrasthāna 45-46; and Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 5-10.

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