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...

Medical Principles (In Early Buddhist Scriptures)

In addition to the above general perspectives on health and disease, there are also medical principles found in early Buddhist literature. These pertain to anatomy, physiology, aetiology, disease nomenclature, therapeutics, and advice for maintaining health. They will be described here respectively.

In relation to anatomy, bodily parts are enumerated in various discourses, such as the Mahāsatipaṭṭhāna Sutta (Greater Discourse on the Establishments of Mindfulness) of the Dīgha Nikāya, the Satipaṭṭhāna Sutta (Discourse on the Establishments of Mindfulness) and the Kāyagatāsati Sutta (Discourse on Mindfulness of the Body) of the Majjhima Nikāya, and the discourse on the ten perceptions instructed to the sick monk Girimānanda in the Aṅguttara Nikāya (V. 108-112). The anatomical parts listed in these Pāli discourses are: head hairs, body hairs, nails, teeth, skin, muscles, tendons, bones, bone marrow, kidneys, heart, liver, diaphragm,[1] spleen, lungs, intestines, mesentery, stomach content, excrement, bile, phlegm, pus, blood, sweat, fat,[2] tears, grease,[3] saliva, nasal mucus, joint fluid, urine.[4] In other texts, such as the Vijaya Sutta (Discourse on Victory) of the Suttanipāta (verse 199) and the Khuddakapāṭha (p. 2), brain (matthaluṅga) is also mentioned. There are also anatomical data found in the Āgamas, but differences in the listed items can be noted (because the Āgamas came from different Buddhist schools other than the Theravāda tradition). In the Madhyama Āgama, discourses corresponding to the Satipaṭṭhāna Sutta and the Kāyagatāsati Sutta are present at Taishō Tripiṭaka 26. 582b7 ff. and Taishō Tripiṭaka 26. 554c10 ff., respectively.[5] The anatomical parts given in these two discourses are: head hairs, body hairs, nails, teeth, coarse and fine thin-skin,[6] muscles, tendons, bones, heart, kidneys, liver, lungs, large intestine, small intestine, spleen, stomach, faecal lumps, brain and brainstem, tears, sweat, nasal mucus, spittle, pus, blood, fat, bone marrow, saliva, bile, and urine.[7] [8] A discourse in the Ekottara Āgama which is supposed to be a parallel of the (Mahā-) Satipaṭṭhāna Sutta gives a different list: body hairs, head hairs, nails, teeth, skin, muscles, tendons, bones, bone marrow, brain, grease, bowel, stomach, heart, liver, spleen, kidneys, faeces, urine, two unripe and ripe organs (?),[9] tears, spittle, nasal mucus, blood vessels, fat, and bile. [10] From these various discourses, it can be noted that anatomical knowledge had already been established at the time when the Nikāyas or the Āgamas were compiled.

In Section 2. 1. 2 of this thesis, it has been shown that during the Vedic phase of ancient Indian medicine, primitive knowledge of physiology had already been developed. In early Buddhist literature that represents the śramaṇ-ic phase, general information about this medical science is found. Ideology of physiology can be seen from the cases of diseases found in the Chapter on Medicine, such as the autumnal disease, the wind disease, and the disease of being moist in the body, which are related to the bodily humour of bile (pitta), wind (vāta or vāyu), and phlegm (Pāli: semha; Sanskrit: śleṣman or kapha), respectively.[11] No detail of physiology is found in the Chapter on Medicine. The discourses also briefly mention the four great elements in the body–earth-element (paṭhavīdhātu), water-element (āpo-dhātu), fire-element (tejo-dhātu), and wind-element (vāyo-dhātu)–without further elaboration. [12] An intriguing Pāli discourse, the Mahāhatthipadopama Sutta (Greater Discourse on the Simile of Elephant’s Footprint) of the Majjhima Nikāya (I. 184-191), has discussed the internal and external aspects of the four elements. According to this discourse, internal earth-element refers to anything “belonging to oneself, solid, solidified, and clung-to,” and examples of bodily parts which are in solid form, such as head hairs, body hairs, nails, etc., are given. Internal water-element is said to be anything “belonging to oneself, is water, watery, and clung-to,” and the bodily parts which are in fluid form, such as bile, phlegm, pus, etc., are exemplified. Internal fire-element is that “belonging to oneself, is fire, fiery, and clung-to; that is, that by which one is warmed, ages, and is consumed, and that by which what is eaten, drunk, consumed, and tasted gets completely digested”. Internal wind-element is that “belonging to oneself, is air, airy, and clung-to; that is, up-going winds, down-going winds, winds in the belly, winds in the bowels, winds that course through the limbs, in-breath and out-breath”.[13]

No clear definitions or examples of the four external elements are provided in this text, but the four external elements can be understood from the context that they refer to any solid things, any fluids, fire or heat, and wind or moving air in the external world. There is yet another similar passage found in the Ekottara Āgama (Taishō Tripiṭaka 125. 652a10-b3) which furnishes more information on external facet of the four great elements.

This text gives the description as follows:

“Now there are four types of element. What are the four? [They are] the earth-element, the water-element, the fire-element, [and] the wind-element. … Earth-element has two kinds: either internal earth[element] or external earth[-element]. What are those [things] called internal earth-element? Head hairs, body hairs, nails, teeth, body, skin, tendons, bones, bone marrow, brain, intestines, stomach, liver, gallbladder, spleen, kidneys–these are called internal earth-element. What is external earth-element? Things being firm and durable are called external earth-element. These are known as the two earthelements. What are those [things] as water-element? Water-element has two kinds: either internal water-element or external waterelement. [Things as] internal water-element [are]: saliva, spittle, tears, urine, blood, bone marrow–these are called internal water-element. Those external things, being soft and [able to] drown things, are called external water-element. These are known as the two waterelements. What are those [things] called fire-element? So, there are two kinds of fire-element: either internal fire[-element] or external fire[-element]. What is that called internal fire[-element]? The eaten food, without any leftover, is totally digested. This is known as internal fire[-element]. What is known as external fire[-element]? Those external objects [which can] heat and flourish things. These are known as external fire-element. What is called wind-element? Wind-element also has two: either there is internal wind[-element], or there is external wind[-element]. [The things] being termed as the wind inside the lips, the wind at the eye, the wind at the head, the out-breathing wind, the in-breathing wind, the wind between all joints–these are called internal wind[-element]. What are those called external wind[-element]? [They are] the things being termed as light, floating (in air), moving, shaking, [and] rapid. These are called external wind[-element].”[14]

From the above-mentioned discourses, it can be noted that physiological knowledge belonging to the śramaṇ-ic phase of Indian medicine is preserved in early Buddhist literature, especially in the discourses of the Nikāyas and the Āgamas.

In Section 3. 1 above, it has been demonstrated that ignorance and craving, in particular, are regarded as important factors for the arising of suffering. These can be considered as general causative factors of sickness. In addition, specific aetiological factors are also discussed in the discourses. Knowledge of causes of disease is a significant aspect in medicine. Without acquainting with the causes, accurate diagnosis and appropriate treatment are not possible. Certain causes of sickness are known from the cases of diseases recorded in the Chapter on Medicine. For example, bile humour is responsible for the autumnal disease, wind humour for wind diseases, and so on. These records of illnesses and their treatments will be examined in Chapter Five of this thesis. There is, however, no full delineation of the diseasecausing factors found in the Chapter on Medicine. Such information of aetiology, rather, can be discovered in the discourses. Eight factors are distinctly attributed as the causes of illnesses. Diseases can be caused by any of these factors which has/is: bile as the origination (pittasamuṭṭhāna); phlegm as the origination (semhasamuṭṭhāna); wind as the origination (vātasamuṭṭhāna); resulting from the combination of the (three) humours (sannipātika); arisen from seasonal change (utupariṇāmaja);arisen from wrong behaviour (of oneself) (visamaparihāraja); [15] pertaining to assault (opakkamika);[16] arisen from the result of (one’s) deed(s) (kammavipākaja) (Saṃyutta Nikāya IV. 230-231; Aṅguttara Nikāya II. 87, III. 131, V. 110). These factors are also mentioned in the Āgama, but without the one concerning the result of previous deed(s) (Pāli: kamma; Sanskrit: karma). In the Saṃyukta Āgama, there is a discourse which is the parallel of the Pāli discourse in the Saṃyutta Nikāya (IV. 230-231).

This discourse in the Saṃyukta Āgama (Taishō Tripiṭaka 99. 252c12-253a25), besides listing seven factors of disease, has more elaborations on some factors than the Pāli sources:

“… the suffering maybe has arisen from the wind humour–the sentient beings are aware of this, or has arisen from the phlegm humour, or has arisen from the saliva humour,[17] or has arisen from the equally contributing factors,[18] or [is due to] self-harm, or [is due to] harm from others, or is due to seasonal change. That [concerning] self-harm: [it is] either pulling head hairs, or pulling beards, or always standing with arms raised, or squatting on ground, or lying in ash or soil, or lying on thorns, or lying on rods, or [lying] on board, or lying on ground which is smeared with cow-dung, or lying in water, or having baths thrice a day, or standing with one leg [with] the body turned along with the sun. These sufferings are practised diligently. Sīvaka, they are called self-harm. [19] [Regarding] harm from others, [it is] either by another’s hand, stone, knife, staff, etc.–harming the body in various ways–this is called harm from others. Sīvaka, also, if it is harmed by seasonal change–it is very cold in winter, very hot in spring, [and] both cold as well as hot in summer[20] –this is called being harmed by seasonal change.”[21]

In the above-mentioned sources, there is no elaboration on karmic results causing illness. The Cūḷakammavibhaṅga Sutta (Shorter Discourse on Exposition of Action) of the Majjhima Nikāya (III. 202-206)[22] elucidates on this. According to this discourse, one is reborn sickly because of “injuring beings with the hand, with a clod, with a stick, or with a knife” in his/her previous life; one is reborn healthy by not doing these actions in his/her previous life (Ñāṇamoli 2001, 1054).[23] From these sources, therefore, aetiological factors have been identified in early Buddhist literature. Among these factors, maturation of previous actions is one of the causes for sickness according to Buddhist doctrine, though it is not the sole cause as some ascetics and brahmins thought, which is shown in the Buddhist texts such as the discourse in the Saṃyutta Nikāya (IV. 230-231).[24]

Many cases of diseases are recorded in the Chapter on Medicine, such as autumnal illness, wind diseases, water-element disorders, bowel problems, headaches, jaundice, snakebites, poisoning, eye problems, skin lesions, anal diseases, foot ailments, and psychiatric problem. These will be elucidated in Chapter Five. In the Buddhist discourses, it is stated that in ancient times, there was only three diseases, viz. desire (icchā), hunger (anasana), and old age (jarā); then, because of the killing of cattle, the number of diseases increased to ninety-eight (Suttanipāta verse 311),[25] though these ninety-eight diseases are not clearly enumerated in any discourse or commentary.

In addition, various diseases are listed in the Aṅguttara Nikāya (V. 110), the discourse mentioning the ten perceptions for the sick monk Girimānanda. These are:

“eye disease, inner-ear disease, nose disease, tongue disease, body disease, head disease, external-ear disease, mouth disease, tooth disease, cough, asthma, catarrh, burning, fever, abdominal disease, fainting, dysentery, colic, cholera, leprosy, furuncle, white leprous spot,[26] tuberculosis, epilepsy, rash, itch, scab, itchy pimples,[27] scabies, haemorrhage, diabetes, haemorrhoids, pustule, fistula; diseases with bile as origination, diseases with phlegm as origination, diseases with wind as origination, diseases resulting from the combination of the humours, diseases arisen from seasonal change, diseases arisen from wrong behaviour (of oneself), diseases pertaining to assault, diseases arisen from the result of (one’s) deeds, cold, heat, hunger, thirst, excrement, and urine.”[28]

Enumeration of diseases is also found in the Āgama. In the Madhyama Āgama (Taishō Tripiṭaka 26. 467c22-26), some diseases are named, though not as many as in the Pāli texts:

“Regarding disease, it means headache, eye-ache, earache, nose-ache, facial pain, lip-ache, toothache, tongue-ache, jaw pain, pharyngeal pain,[29] wheeze,[30] cough, belching and vomiting, laryngeal numbness, epilepsy, carbuncle and neck swelling, menorrhagia, haemorrhage,[31] high fever, wasting disease, [32] haemorrhoid and fistula, [and] dysentery. If there are other various diseases such as these [abovementioned], … these are known as disease.”[33]

From the above sources, it can be noted that many physical illnesses were identified during the phase of śramaṇ-ic medicine in ancient India. The listing of these morbid conditions, interestingly, has shown the attempt at systematically grouping the related illnesses, such as the various diseases of the head, respiratory problems, abdominal/bowel disorders, skin lesions, etc. This reveals that knowledge of diseases was already fairly advanced at this time.

Various treatments have been spoken of in early Buddhist literature. In the Chapter on Medicine, remedies include the use of medicinal substances, emesis, purgation, sweating therapy, bloodletting, smoke therapy, nasal douche, bathing, surgical intervention, wound dressing, fumigation, cauterisation, and so on. These will be discussed later in Chapter Five. Information of therapy is also present in the discourses. When talking about wrong livelihood by some ascetics and brahmins, certain forms of therapeutics were named, including those causing virility (vassa-kamma), impotence (vossa-kamma), mouth rinsing (ācamana), bathing (nahāpana), emesis (vamana), purgation (virecana), upward purgation (uddha-virecana), downward purgation (adho-virecana), purgation of head (sīsa-virecana);prescribing ear-oil (kaṇṇa-tela), eye-wash (netta-tappaṇa), nose-treatment (natthu-kamma), collyrium (añjana), counter-collyrium (paccañjana); performing eye-surgery (sālākiya), surgery (sallakattika), paediatric treatment (dāraka-tikicchā); administering root-medicine (mūla-bhesajjaṃ anuppādana) and remedy of medicines (osadhīnaṃ paṭimokkha), as stated in the Brahmajāla Sutta (Discourse on Brahma’s Net), the Sāmaññāphala Sutta (Discourse on the Fruit of Recluseship), and the Subha Sutta (Discourse about Subha) of the Dīgha Nikāya (I. 12; I. 69; I. 206, respectively).[34] The parallel of this discourse is in the Dīrgha Āgama (Dīrgha Āgama), but it gives only several examples of treatment such as helping women to have safe pregnancy and delivery (i.e. midwifery), chanting for the sick ones, prescribing medicinal formulae, performing acupuncture and moxibustion, and administering medicines (Taishō Tripiṭaka 1. 89b27-c4).[35] Another parallel of this discourse is Foshuo fanwang liushi’er jian jing 佛說梵網六十二見經 (Discourse on the Buddha’s Exposition of the Sixty-Two Views of the Brahma’s Net) (Taishō Tripiṭaka 21).

Several therapeutics are mentioned, such as treating young boys and girls (i.e. paediatrics), animals (i.e. veterinary medicine), and eye diseases (i.e. ophthalmology); midwifery; and administering emetic (Taishō Tripiṭaka 21. 265a13-20). [36] In relation to different fields of medical treatments, five are mentioned in the Mahāniddesa (II. 382): ophthalmology (sālākiya), surgery (sallakattiya), internal medicine (kāyatikicchiyā), that dealing with diseases due to supernatural beings (bhūtiyā), and paediatrics (komārakavejja). This reveals that specialisation into different medical disciplines occurred early in ancient India. Apart from merely naming the treatments (or their related fields) in the discourses, the use and effectiveness of certain remedies is also described (though only briefly) in the Aṅguttara Nikāya. Purgation or emesis is used for relieving the diseases having bile, phlegm, or wind as the cause;such treatments are sometimes successful and sometimes not (Aṅguttara Nikāya V. 218-219). In addition to these various kinds of remedy, it should be reminded that, as mentioned in the above Section 3. 1 on the general discussion of health and illness, certain Buddhist teachings and practices could have a therapeutic effect, such as the four establishments of mindfulness, the seven factors of enlightenment (as parittā), and the ten perceptions. But one important point about utilising medicines is stressed in the Buddhist doctrine: one consumes the medicines for the purpose of curing the illness and maintaining health, without any craving for or attachment to them. In the Majjhima Nikāya (I. 10), it is stated that “Reflecting wisely, he uses the medicinal requisites only for protection from arisen afflicting feelings and for the benefit of good health” (Ñāṇamoli 2001, 94).

A similar instruction is found in the Ekottara Āgama:

“Furthermore, [one] restrains one’s mind (when) coming close to the medicine, without arising any thought of clinging. Regarding that medicament, it is wanted only for the purpose of curing the illness, [so that] the body has ease and tranquillity.”[37]

Thus, from the above descriptions, various instructions in relation to treatments are present in the Buddhist discourses.

Medicine concerns not only curing disease, but also sustaining health. A healthy body can be supportive for spiritual development and attainment; conversely, a sick body can be obstructive to this goal. In the early Buddhist literature, there are numerous instructions which relate to health maintenance and hygiene, such as diet control, exercise, use of tooth-wood, sanitation, and so on. These will be described one by one below.

Food is an important element for life and health. [38] The Buddha has especially given instructions on consuming food in connection with health. It is suggested by the Buddha to control ones’ number, time, and amount of meals. In the Majjhima Nikāya (I. 124; I. 437) the Buddha taught the monks to eat only one meal daily for the purpose of health: “Bhikkhus, I eat at a single session. By so doing, I am free from illness and affliction, and I enjoy health, strength, and a comfortable abiding. Come, bhikkhus, eat at a single session” (Ñāṇamoli 2001, 218, 542).[39]

Moreover, another advice by the Buddha found in the Majjhima Nikāya (I. 473) is not to consume a meal at night:

“Bhikkhus, I abstain from eating at night. By doing so, I am free from illness and affliction, and I enjoy health, strength, and a comfortable abiding. Come, bhikkhus, abstain from eating at night” (Ñāṇamoli 2001, 577).

Instructions for the monks to have one meal a day for the sake of health are also present in the Madhyama Āgama (Taishō Tripiṭaka 26. 744b1116, 746b21-24, 749c4-8). In a discourse in the Saṃyutta Nikāya (I. 185-187), it is recorded that the Buddha uttered a verse to King Pasenadi, who had had a large meal before visiting the Buddha. The verse is: “When a man is always mindful, Knowing moderation in the food he eats, His ailments then diminish: He ages slowly, guarding his life” (Bodhi 2000, 176). From the above information, it can be deduced that controlling one’s diet in terms of quantity and time are important factors for staying healthy.[40]

In addition, certain foods with benefits for health are recommended by the Buddha. For example, rice-gruel (yāgu) is named in the Aṅguttara Nikāya to have five benefits: “It dispels hunger, subdues thirst, conforms to wind (humour), clears the bladder, [and] digests the undigested food.”[41] Similar lists of benefits of rice-gruel are found in various Vinayas.

In the Theravāda Bhesajjakkhandhaka, ten benefits are given:

Brahmin, these ten are the benefits of rice-gruel. What are the ten? One who is giving rice-gruel gives life, gives beauty, gives happiness, gives strength, [and] gives intelligence. The rice-gruel which is drunk dispels hunger, removes thirst, conforms to wind (humour), clears the bladder, [and] digests the undigested food.”[42]

The Dharmaguptaka Vinaya reports five benefits:

“There are five benefits of consuming rice-gruel: [it] removes hunger, settles thirst, digests overnight [undigested] food, eases passing of excrement and urine, [and] relieves wind.”[43]

The Sarvāstivāda Vinaya has a somewhat different list: “Rice-gruel has five things benefitting the body: One, [it] removes hunger; two, [it] dispels thirst; three, [it] moves the wind downward;four, [it] eliminates the coldness below the umbilicus; five, [it] digests the overnight [undigested] food.”[44] The Mahāsāṃghika Vinaya states (in a verse) that there are ten benefits: “Ten benefits for the practitioners: colour, strength, longevity, happiness, clear speech, eloquence, overnight [undigested] food [being digested], wind being removed, hunger and thirst being eliminated; this [rice-gruel] is called a medicine, as said by the Buddha.” [45] Therefore, food plays an important role in health, and particular instructions about control and type of diet can be found in early Buddhist literature.

Meditation in the form of “walking up and down” (caṅkama) is a common activity practised by the Buddha and his disciples. It can be regarded as a form of physical exercise.

Five benefits are expressed by the Buddha in the Aṅguttara Nikāya (III. 29-30):

“Bhikkhus, there are these five benefits of walking meditation. What five? One becomes capable of journeys; one becomes capable of striving; one becomes healthy; what one has eaten, drunk, consumed, and tasted is properly digested; the concentration attained through walking meditation is long lasting” (Bodhi 2012, 651).

Hence, walking can be conducive to health. Other walking activities–such as going for alms every morning, walking after meals, and wandering in long journeys–can be exercise which would be beneficial for health (Ratnapala 1993, 177-179).

Hygiene, both personal and public, is no doubt a significant factor for preventing illness and maintaining health. Relevant advice is given pertaining to oral hygiene, use of the lavatory, and tidiness of living and public places. Tooth-wood (Pāli: dantakaṭṭha;Sanskrit: dantakāṣṭha; Chinese: 齒木 or 楊枝) is used for cleaning teeth and maintaining oral health. [46] Disadvantages of not chewing tooth-wood and the benefits of chewing it are told in many Buddhist texts.

In the Aṅguttara Nikāya, such disadvantages and benefits are indicated:

“Monks, these five are the disadvantages in not chewing the toothwood. What are the five? It is bad for the eyes; mouth has bad smell; the taste buds are not cleansed; bile and phlegm cover up the food;[and] food does not give pleasure for this [person]. Monks, these five are the disadvantages in not chewing the tooth-wood. Monks, these five are the benefits in chewing the tooth-wood. What are the five? It is good for the eyes; mouth does not have bad smell; the taste buds are cleansed; bile and phlegm do not cover up the food; [and] food gives pleasure for this [person]. These five are the benefits in chewing the tooth-wood.”[47]

The same piece of information is found in the Cullavagga of the Theravāda Vinaya (Theravāda Vinaya Piṭaka II. 137-138), with further specification of the length of tooth-wood to be between four to eight finger-breadths. Vinayas of other schools also comprise such data on the benefits or disadvantages of using tooth-wood or not, but with minor differences.

In the Dharmaguptaka Vinaya, the faults and benefits of utilising toothwood are as follows:

“Not chewing tooth-wood has five faults: bad breath;tastes are not well discerned; bile and phlegm do not vanish; food is not appealing; eye[-sight] is not clear. Chewing tooth-wood has five benefits (the opposites of the above).”[48]

The Sarvāstivāda Vinaya provides a rather unique list only of benefits:

“Chewing tooth-wood has five benefits: one, mouth is not bitter; two, mouth has no bad smell; three, wind is eliminated; four, fever is relieved; five, phlegm is removed. Again, there are five benefits: one, wind is eliminated; two, heat is removed; three, taste is enhanced in mouth; four, one can eat; five, eye[-sight] is clear.”[49]

The Ekottara Āgama, unusually, lists the benefits obtained by giving tooth-wood, which are similar to the above benefits of using tooth-wood. The text reads:

“Giving others tooth-wood brings five benefits. What are the five? One, wind is dispelled; two, saliva and spittle are removed;three, [food in] the upper digestive tract gets digested; four, there is no bad smell in mouth; five, eye is purified. These are called, monks, ‘giving others tooth-wood brings five benefits’.”[50]

The Mahāsāṃghika Vinaya provides further information about the tooth-wood:

“Tooth-wood has two kinds: one, a torn (strip); two, a round mass. If a monk’s mouth has an ulcer arisen due to heat, [and] the physician says that ‘[one] should chew the tooth-wood and swallow the juice,’ [then one] should accept it.”[51]

From the above sources, it can be noted that oral hygiene is much stressed for the purpose of physical health.

Sanitation is a significant aspect for protecting health. According to the Vinaya, initially there was no fixed place for the monks to pass their urine and faeces. They did it anywhere in the monastery. This caused sanitary problems. The Buddha then gradually laid down rules about the use of the lavatory (vaccakūti) and connected things such as lidded urinal pots (passāvakumbhī), urinal shoes (passāvapādukā), cesspools (vaccakūpa), latrine-shoes (vaccapādukā), troughs for urine (passāvadonikā), wooden strips for scraping (avalekhanakaṭṭha), and so forth. Teachings of how to build and use these things and how to keep the lavatory clean are also given (Theravāda Vinaya Piṭaka II. 140-142). In addition, guidelines on maintaining tidiness of living quarters and public places (such as refectory, lavatory, and bathroom) are also found in the Vinaya (Theravāda Vinaya Piṭaka II. 208-210, 216-221), indicating the emphasis of sanitation and health protection.

In brief, in early Buddhist literature there are various pieces of advice pertaining to diet control, physical exercise, oral hygiene, and sanitation. These can be regarded as measures for health promotion. Besides, there are other instructions in the Buddhist scriptures, though not described for the purpose of health, that can be associated with hygiene and health, such as shaving hair, cutting nails, building and using bathrooms, washing robes, filtering water, etc. [52] These means are regarded as essential for achieving health and longevity, as per the medical teachings in the Āyuvedic texts such as the Sūtrasthāna of the Caraka Saṃhitā.

Footnotes and references:


In Pali-English Dictionary, kilomaka is rendered as pleura or right lung while the Sanskrit equivalent, kloman, is translated as right lung. Mitra (1985, 88-89) tells us that the meaning of this term has been uncertain for a long time. As Mitra has shown, the description in the Visuddhimagga seems to refer the term to fibrous sheaths, which cover internal organs (such as heart, kidneys, etc.) and muscles. According to modern anatomy, the diaphragm is a thin muscle with a central tendon separating the chest cavity and the abdominal cavity (Larsen 2002, 181). Thus it conforms to the description of the Visuddhimagga. Moreover, it is likely to be the diaphragm because the bodily parts preceding and following this term in the given source actually are organs adjacent to the diaphragm.


Meda, rendered as “fat,” is “the thick unguent to be found pervading the whole body of one who is stout, and on the shank flesh, etc., of one who is lean,” as explained in the Path of Purification (Visuddhimagga) (Ñāṇamoli 1991, 355).


Vasā, translated as “grease,” is “the melted unguent to be found on the palms and backs of the hands, on the soles and backs of the feet, on the nose and forehead and on the points of the shoulders, when heated by fire, and so on,” as per the Path of Purification (Visuddhimagga) (Ñāṇamoli 1991, 355).


This list is adapted from Bodhi’s translation of the terms (2012, 1412), with several modifications. The Pāli terms in the discourses are: “kesā lomā nakhā dantā taco maṃsaṃ nahārū aṭṭhī aṭṭhimiñjā vakkaṃ hadayaṃ yakanaṃ kilomakaṃ pihakaṃ papphāsaṃ antaṃ antaguṇaṃ udariyaṃ karīsaṃ pittaṃ semhaṃ pubbo lohitaṃ sedo medo assu vasā kheḷo saṅghāṇikā lasikā muttaṃ.”


Madhyama Āgama is believed by scholars to belong to the Sarvāstivāda school.


In the CBETA sources, it is given as “... 麁細薄膚、皮...”. It is strange to name two terms where both are referring to skin–the former can be rendered as “coarse and fine thin-skin” and the latter is just “skin”. If we consider the punctuation between the two terms as a mistake (which commonly occurs in the Taishō Tripiṭaka and sometimes in the CBETA, but not in the earlier canons–such as the Yongle beizang 永樂北藏 (Northern Tripiṭaka of Yongle) or Qianlong zang 乾隆藏 (Tripiṭaka of Qianlong)–because there was no punctuation in the earlier texts), then the two terms become one as “麁細薄膚皮” and it merely refers to “coarse and fine thin-skin,” since “膚皮” can be considered as a single term for “skin.” “Coarse” skin may refer to the superficial layer of skin (epidermis), and “fine” skin the inner layer of skin (dermis). My translation here takes “膚皮” as one term. In the rest of this thesis, any incorrect or inappropriate punctuation in the CBETA or Taishō Tripiṭaka sources will be corrected when necessary and my translations will then be made accordingly.


The list in the Madhyama Āgama is: “髮、髦、爪、齒、麁細薄膚皮、肉、筋、骨、心、腎、肝、肺、大腸、小腸、脾、胃、摶糞、腦及腦根、淚、汗、涕、唾、膿、血、肪、髓、涎、膽、小便” (Taishō Tripiṭaka


. 556a14-16; 583b6-9).


The term “the two unripe and ripe organs” (生熟二藏) seems to mean the upper digestive tract and the lower digestive tract (“人有生熟二藏,食在生藏,猶未變動,流入熟藏,即成糞穢”), according to Nanshan Vinaya Dictionary 南山律學辭典 (s.v. “不淨觀” (meditation on impurity) [accessed December 22, 2014,]).


Ekottara Āgama is thought to belong to the Mahāsāṃghika school. The list of bodily parts in the Ekottara Āgama is: “毛、髮、爪、齒、皮、肉、筋、骨、髓、腦、脂膏、腸、胃、心、肝、脾、腎... 屎、尿、生熟二藏、目淚、唾、涕、血脈、肪、膽” (Taishō Tripiṭaka 125. 568.a19-21). Many texts in the Chinese Buddhist canon include similar but not identical lists of the anatomical parts. There are too many to be all cited here.


These cases will be discussed in Chapter Five.


Examples of the Pāli discourses containing such information are the Mahāsatipaṭṭhāna Sutta, the Satipaṭṭhāna Sutta, and the Kāyagatāsati Sutta. The Chinese parallels of these texts also include this simple principle of physiology. However, the texts in the Madhyama Āgama mention two more elements in the body, viz. the space-element 空界 (ākāśa-dhātu) and consciousness-element 識界 (vijñānadhātu).


The quotations and explanations for these four internal elements are extracted from Ñāṇamoli’s The Middle Length Discourses of the Buddha (2001, 279-282). The parallel of this Pāli discourse is found in the Madhyama Āgama at Taishō Tripiṭaka 26. 464b17-467a26.


The original source in Ekottara Āgama reads thus: “今有四種之界。云何為四?地界、水界、火界、風界。... 地界有二種,或內地、或外地。彼云何名為內地種?髮、毛、爪、齒、身體、皮膚、筋、骨、髓、腦、腸、胃、肝、膽、脾、腎,是謂名為內地種。云何為外地種?諸有堅牢者,此名為外地種。此名為二地種。彼云何為水種?水種有二,或內水種、或外水種。內水種者:唌、唾、淚、尿、血、髓,是謂名為內水種。諸外軟溺物者,此名為外水種。是名二水種。彼云何名為火種?然火種有二,或內火、或外火。彼云何名為內火?所食之物,皆悉消化無有遺餘,此名為內火。云何名為外火?諸外物熱盛物,此名為外火種。云何名為風種?又風種有二,或有內風、或有外風。所謂脣內之風、眼風、頭風、出息風、入息風,一切支節之間風,此名為內風。彼云何名為外風?所謂輕飄動搖、速疾之物,此名為外風。”


According to the commentaries, this term refers to the wrong behaviour or activities such as prolonged sitting or standing, bearing heavy loads, or roaming around at an improper time, etc. See Saṃyutta Nikāya-Aṭṭhakathā III. 81-82; Aṅguttara Nikāya-Aṭṭhakathā V. 43; Mahāniddesa-Aṭṭhakathā I. 61.


According to the commentaries, this term means assaults such as striking, binding, imprisoning, beating by an elbow, knee, weapon, etc. See Saṃyutta Nikāya-Aṭṭhakathā III. 82; Mahāniddesa-Aṭṭhakathā I. 61.


Here saliva is mentioned as a factor, instead of bile.


It means that the three humours are equally contributing to the disease, and hence it refers to the combination of the three humours.


These behaviours obviously are the various ascetic practices in ancient India.


Here summer seems to refer to the rains season in India, where it is cool or cold during rain and it is hot without rain.


Taishō Tripiṭaka 99. 252c22-253a2: “或從風起苦,眾生覺知,或從痰起,或從唌唾起,或等分起,或自害,或他害,或因節氣。彼自害者,或拔髮、或拔鬚,或常立舉手,或蹲地,或臥灰土中,或臥棘刺上,或臥杵上、或板上,或牛屎塗地而臥其上,或臥水中,或日三洗浴,或一足而立,身隨日轉。如是眾苦精勤有行,尸婆!是名自害。他害者,或為他手石、刀、杖等,種種害身,是名他害。尸婆!若復時節所害,冬則大寒,春則大熱,夏寒暑俱,是名節氣 所害。” There is another discourse in the Saṃyukta Āgama-AT (Taishō Tripiṭaka 100. 452b4 ff.) which is supposed to be a parallel to the discourses in the Saṃyutta Nikāya and the Saṃyukta Āgama, but it differs in the minor details of the factors–there is no clear listing of those humoral factors, and the descriptions of the factors pertaining to self-harm, harm from others, and seasonal change are not identical to those in the Saṃyukta Āgama.


The parallel is found in the Madhyama Āgama (Taishō Tripiṭaka 26. 703c21 ff.), though the context is not identical.


This discourse also names actions such as killing living beings, being murderous, etc., leading to bad rebirth (even in hell) or being reborn with a short life in human form. By not doing such actions, one will be reborn in a happy state (even in heaven), or with a long life in human form.


In the Milindapañha (Questions of Milinda) there is a discussion relating to these disease-causing factors. In this passage, it is stressed that karmic retribution is only one of the causes and it can be a minor one (Milindapañho 134-138).


This account of only three diseases in ancient time is also found in the Cakkavattisīhanāda Sutta (Discourse on the Lion’s Roar of the Universal Monarch) of the Dīgha Nikāya (III. 75).


See A Sanskrit-English Dictionary, s.v. “kilāsa”.


It is not certain what rakhasā is. There is no definition found in the Pāli-English dictionaries. The Mahāniddesa-Aṭṭhakathā (I. 61) gives a non-specific explanation as “the disease is at the place scratched by nails” (nakhehi vilikhitaṭṭhāne rogo). Bodhi (2012, 1413) translates it as chickenpox. But Mitra (1985, 256-257), based on the Suśruta Saṃhitā (Nidānasthāna 5. 15), states that it “is identical with rakasā” which is a kind of minor leprosy, and it is “a sort of dry and non-exuding pimples characterised by excessive itching and appearing all over the body.”


Translation is modified from Bodhi’s translation (2012, 1412-1413). The Pāli source in the Aṅguttara Nikāya is: “cakkurogo sotarogo ghānarogo jivhārogo kāyarogo sīsarogo kaṇṇarogo mukharogo dantarogo kāso sāso pināso ḍaho jaro kucchirogo mucchā pakkhandikā sūlā visūcikā kuṭṭhaṃ gaṇḍo kilāso soso apamāro daddu kaṇḍu kacchu rakhasā vitacchikā lohitapittaṃ madhumeho aṃsā piḷakā bhagandalā pittasamuṭṭhānā ābādhā semhasamuṭṭhānā ābādhā vātasamuṭṭhānā ābādhā sannipātikā ābādhā utupariṇāmajā ābādhā visamaparihārajā ābādhā opakkamikā ābādhā kammavipākajā ābādhā sītaṃ uṇhaṃ jighacchā pipāsā uccāro passāvo.” The same list of diseases is also found in the Mahāniddesa (I. 13).


These above terms are all described as “痛”, which usually means pain or ache. But in classical Chinese, it can also refer to disease (病), as per the Kangxi zidian 康熙字典 (The Kangxi Dictionary). So these above terms can also be rendered as head disease, eye disease, etc.


This should refer to asthma.


赤膽 should be the transliteration of rakta-pitta, which refers to haemorrhage.


This may refer to tuberculosis (sosa) in the Pāli source.


The Chinese source is: “病者,謂頭痛、眼痛、耳痛、鼻痛、面痛、脣痛、齒痛、舌痛、齶痛、咽痛、風喘、咳嗽、喝吐、喉啤、癲癎、癕癭、經溢、赤膽、壯熱、枯槁、痔[病-丙+匿]、下利,若有如是比餘種種病... 是名為病。” My translation of some terms are based on the characters found in other earlier editions of Chinese Buddhist canon besides the Taishō Tripiṭaka, as provided in the CBETA; without taking into consideration these characters, the meanings of those terms are not recognisable. Some examples of such earlier characters are 噫 instead of 喝, 痺 instead of 啤, and 瘻 instead of [病-丙+匿].


In the original sources as mentioned, the act of appeasing a god/demon (santi-kamma) is another example of wrong livelihood. According to Dīgha Nikāya-Aṭṭhakathā (I. 97), santikamma is explained thus:

“Having gone to a temple, ‘if this [thing] by name takes effect for me, I will make offering with this and this to you.’ At the time [when it is] successful, the action of promise of the appeasement should be done” (santi-kamman ti, devaṭṭhānaṃ gantvāsace me idaṃ nāma samijjhati tumhākaṃ iminā ca iminā ca upahāraṃ karissāmīti,’ samiddha-kāle kattabbaṃ santi-paṭissava-kammaṃ). Moreover, according to Liyanaratne (1996, 60-61), the act of appeasement is part of the ritual stated in the Suśruta Saṃhitā (Sūtrasthāna 1. 4) as a means to deal with the disease caused by possession. It may then be considered as a kind of healing ritual for pacifying the possession by a deity or demon.


The Chinese source reads: “為人安胎出衣... 為人呪病... 或為醫方、鍼炙、藥石,療治眾病”.


The source in the Taishō Tripiṭaka (and the CBETA) is: “作男女小兒醫、作象馬牛羊之醫... 作自醫、作女人座醫... 持藥與人使吐”. Older editions of Chinese Buddhist canon wrote 目 醫 instead of 自醫, and this makes sense as “eye-medicine” or “eye-physician”, i.e. relating to ophthalmology. Also, 座醫 is 坐醫 in older editions, and this should refer to those physicians delivering babies, for there is a Chinese term 坐婆 which means the midwives.


Taishō Tripiṭaka 125. 741a9-11: “又復持心親近醫藥,不生染著之心;於彼醫藥,但欲使疾病除愈故,身體得安隱。”


According to Buddhist doctrine, there are four kinds of “food”, viz. material food, sensory contact, mental volition, and consciousness. In this present discussion, food refers only to material food.


The Pāli clause corresponding to “I eat at a single session” is “ekāsanabhojanaṃ bhuñjāmi”, which, according to the Venerable Professor Anuruddha, means “I eat one meal a day” (2004, 251).


At night, bodily functions slow down, including digestion. Digestion of food is less efficient at night and it is probably why a meal at night is not suggested by the Buddha. Moreover, if one takes a meal at night, he/she may easily become sleepy and it can hinder spiritual practice.


Aṅguttara Nikāya III. 250: “Khudaṃ paṭihanati, pipāsaṃ paṭivineti, vātaṃ anulometi, vatthiṃ sodheti, āmāvasesaṃ pāceti.”


Theravāda Vinaya Piṭaka I. 221: “das’ ime brāhmaṇa ānisaṃsā yāguyā, katame dasa. yaguṃ dento āyuṃ deti, vaṇṇaṃ deti, sukhaṃ deti, balaṃ deti, paṭibhānaṃ deti, yāgu pītā khudaṃ paṭihanati, pipāsaṃ vinodeti, vātaṃ anulometi, vatthiṃ sodheti, āmāvasesaṃ pāceti.”


Taishō Tripiṭaka 1428. 1005c26-27: “食粥五事好:除飢、解渴、消宿食、大小便通利、除風”.


Taishō Tripiṭaka 1435. 188c19-21: “粥有五事利身:一者除飢、二者除渴、三者下氣、四者却臍下冷、五者消宿食。”


Taishō Tripiṭaka 1425. 462c22-23: “十利饒益於行者 色力壽樂辭清辯 宿食風除飢渇消 是名爲藥佛所説”.


According to Āyurvedic texts, a stick of tooth-wood with one end crushed is used for brushing the teeth without injuring the gum. This removes the foul smell and dirt of the tongue, teeth and mouth, and brings out the taste of the food. Tooth-wood should be of astringent, pungent or bitter in taste.

Twigs of plants such as karañja, karavīra, arka, mālatī, kakubha, asana, nyagrodha, khadira, nimba, madhūka, etc. are recommended for use. A twig of the thickness of a little finger with the length of twelve finger-breadths can be used. See Caraka Saṃhitā Sūtrasthāna 5. 71-74; Suśruta Saṃhitā Cikitsāsthāna 24. 4-12; Aṣṭāṅga Hṛdaya Saṃhitā Sūtrasthāna 2. 2-3.


Aṅguttara Nikāya III. 250: “Pañc’ime bhikkhave ādīnavā dantakaṭṭhassa akhādane. Katame pañca? Acakkhussaṃ, mukhaṃ duggandhaṃ hoti, rasaharaṇiyo na visujjhanti, pittaṃ semhaṃ bhattaṃ pariyonaddhanti, battaṃ assa na cchādeti. Ime kho bhikkhave pañca ādīnavā dantakaṭṭhassa akhādane. Pañc’ime bhikkhave ānisaṃsā dantakaṭṭhassa khādane. Katame pañca? Cakkhussaṃ, mukhaṃ na duggandhaṃ hoti, rasaharaṇiyo visujjhanti, pittaṃ semhaṃ bhattaṃ na pariyonaddhanti, battaṃ assa chādeti. Ime kho bhikkhave pañca ānisaṃsā dantakaṭṭhassa khādane.”


Taishō Tripiṭaka 1428. 1005c24-26: “不嚼楊枝有五過失:口氣臭、不善別味、熱癊不消、不引食、眼不明,是為五。嚼楊枝有五事好(即反上句是)”.


Taishō Tripiṭaka 1435. 289b28-c3: “… 嚼楊枝有五利益:一者口不苦、二者口不臭、三者除風、四者除熱病、五者除痰廕。復有五利益:一者除風、二者除熱、三者口滋味、四者能食、五者眼明。”


Taishō Tripiṭaka 125. 703a11-14: “施人楊枝有五功德。云何為五?一者除風,二者除涎唾,三者生藏得消,四者口中不臭,五者眼得清淨。是謂,比丘!施人楊枝有五功德。”


Taishō Tripiṭaka 1425. 357b19-21: “齒木者有二種:一、擗,二、團。若比丘口中有熱氣生瘡,醫言:「應 嚼齒木咽汁。」者,應當受。”. Elsewhere in this Vinaya (Taishō Tripiṭaka 1425. 505a23 ff.) rules for using tooth-wood are given. Here, the length of tooth-wood is allowed to be from four to sixteen fingerbreadths.


Ann Heirman and Mathieu Torch have published a book, A Pure Mind in a Clean Body (2012), examining certain issues relating to hygiene in Buddhist monasteries, such as bathing facilities, toilet facilities, oral cleaning, hair shaving, and nail trimming. Their discussions are based mainly on the information in the Dharmaguptaka and Mūlasarvāstivāda Vinaya-s and various Chinese Buddhist sources (e.g. commentaries, compilations, travellers’ accounts, etc.).

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