Dermatology (a): Itching Lesions

Skin diseases and their remedies are another major scope of medical information found in the Vinayas. Some of these illnesses were treated with medical measures while others by surgical approaches. Among these skin diseases, itching lesions are the commonest. Other skin problems–for example, carbuncles, wounds, blisters, and leprosy–are also mentioned. In this section, these records on skin diseases will be organised into four categories: itching lesions; carbuncles; wounds; and miscellaneous skin problems. The last group embraces those accounts in which the skin diseases do not belong to the preceding three groups, and those in which different kinds of skin disease are listed together.^[1] These groups will be studied one by one in the following subsections.

Itching is a common experience. Records of itching skin diseases are found in most of the Chapters on Medicine.

They are collected in the table below.

Theravāda:—“At that time the Venerable Belaṭṭhasīsa, the preceptor of the Venerable Ānanda, had an extensive itching skin disease.^[2] The robes adhered on the body with his discharges. Those monks, having repeatedly moistened [the robes] with water, took [them] off [the body].... Then the Exalted One, having given a dhamma talk against this background, addressed the monks: ‘I allow, monks, medicinal powders for whom there is an itch, or pustule, or discharging lesion, or extensive itching skin disease, or the body with bad smell.^[3] For one who is not sick, [I allow using] animal dung,^[4] clay, [and] boiled dye.^[5] I allow, monks, the mortar and pestle.’ At that time, the sick monks had a need of sieved medicinal powders … ‘I allow, monks, a sieve for powder.’ There was a need of delicate [medicinal powders]. ‘I allow, monks, a cloth-sieve.’”^[6]

Mahīśāsaka:— “There was a monk afflicted with itching sores^[7] [and] he wanted a treatment. [The monk] informed the Buddha about this [matter]. The Buddha said: ‘[I] allow a treatment.’”^[8]

Sarvāstivāda:—“The Buddha dwelled in Vaiśālī. This place was salty and wet. The monks were afflicted with itches. Pus and blood were discharged [and] soiled the inner garments^[9] like water stains. The Buddha knew [this] and purposely asked the monks: ‘Why are the inner garments soiled like water stains?’ The monks said: ‘The Exalted One, we are afflicted with itches. Pus and blood are discharged [and these have] soiled the inner garments.’ The Buddha said: ‘From today [onwards], [I] allow the monks afflicted with itches to anoint with bitter medicines.’ The elder monk Upāli asked the Buddha: ‘What are the bitter medicines?’ The Buddha said: ‘Tellicherry bark, gouboluo-tree 拘波羅樹 (camphor tree, or box myrtle, or South Indian redwood?), guozhenlita-tree 拘真利他樹 (mountain ebony or Indian trumpet flower?), shiluo-tree 師羅樹 (siris tree?), boqieluo-tree 波伽羅樹 (bullet wood or trumpet flower?), boniwuqiluntuo-tree 波尼無祇倫陀樹 (?).’^[10] The monks did not know how to pound and grind [the bitter medicines]. The Buddha said: ‘[I] allow a grindstone.’ [While using] the grindstone, the medicine fell onto the ground. The Buddha said: ‘[I] allow mortar and pestle [made of] stone for pounding.’ The monks’ hands got hurt. The Buddha said: ‘[I] allow a wooden pestle.’ [The monks] did not know how to make a wooden pestle, [and] it slipped off the hand at the grasping site. The Buddha said: ‘Make the middle part [of the pestle] thinner.’ The pounded medicine was coarse. The Buddha said: ‘[You] should sieve [the medicine] to make it fine. Anoint the sores with oil, [and] sprinkle the medicine on [the sores].’”^[11]

Mūlasarvāstivāda (Sanskrit):—“The Exalted One stayed in Śrāvastī, at Anāthapiṇḍada’s monastery in the Jeta Grove. At that time a certain monk had a disease of itch arisen. He had approached the presence of the physician [and said]: ‘Good Sir, I have a disease of itch arisen. Please point out the medicine.’ That [physician] said: ‘Noble one, please use decoction. You will become healthy.’ ‘Good Sir, am I one enjoying sense-desires?’ That [physician] said: ‘This is the medicine for you monk. It is not possible to become well otherwise.’ The monks informed this matter to the Exalted One. As aforesaid up to ‘your teacher is omniscient; please go to him [and] ask him.’ The monks informed this matter to the Exalted One. The Exalted One said: ‘Five decoctions are: decoction of mango tree, [and so forth]’ as aforesaid.^[12] Having prepared the decoction by that monk, [his] body was embrocated [with that]. It had become hard. The Exalted One said: ‘Powder should be made.’ The monks pulverised [it] very damply. It had become a lump. The Exalted One said: ‘It should be caused to dry.’ Those [monks] made it dry up in the sun-heat. It became lacking in strength. The Exalted One said: ‘It should not be caused to dry in the sun-heat.’ They made it dry in the shade. Even so it became foul. The Exalted One said: ‘It should be caused to dry in the sun-heat with shade.’ The monks, having anointed the body with the decoction, took a bath. They did not do properly with the decoction. The Exalted One said: ‘As long as [the decoction] is being attached to [the body] by hand, it is to be cleansed. Then, after applying the decoction, it is to be bathed. One does what is proper with the decoction.’ For the monk, the disease had been allayed by the decoction. The remaining decoction had been thrown away by him. … The monks informed this matter to the Exalted One. The Exalted One said: ‘… By the monk who is the bearer of the decoction, the decoction which has been consumed and is remaining–whoever monk is having a need–should be given to him. Or it should be put aside in a house suitable for the sick. …’”^[13]

Mūlasarvāstivāda (Chinese):—“The place of the occasion was as [described] above. Then there was a monk afflicted with itching sores on his body. He went to the place of a physician [and] asked: ‘Good Sir, I am afflicted with itching sores. [Please] prescribe medicine for me.’ The physician replied: ‘Noble one, it is suitable to use astringent medicine [and you] will recover from the illness.’ The monk replied: ‘Good Sir, am I one indulging in sensedesires?’ The physician replied: ‘This astringent medicine can cure itching sores. Other medicines cannot heal.’ The monk asked: ‘What astringent medicine is to be used?’ The physician replied: ‘Noble one, your teacher is an omniscient one. [He] fully knows this matter.’ The monks went to inform the Buddha. The Buddha said: ‘There are five kinds of astringent medicine: one, [that of] mango [tree]; two, [that of] neem [tree]; three, [that of] black plum [tree]; four, [that of] siris [tree];^[14] [and] five, [that of] Kośambī’s neem [tree] (?). Monks, [you] should know: these medicines–either the barks or the leaves–should together be pounded into pieces. [These medicines] are boiled in water [and the decoction is used] for anointing the body.’ Having anointed [with the decoction], the [monk’s] body had further sores arisen. The Buddha told the monk: ‘[You] should make [the astringent medicine in the form of] powder medicine.’ The monk pounded [the medicines] damply, [which] became a lump but not shattered powder. The Buddha said: ‘[You] should not pound [the medicines] damply. [You] should expose them to sunlight to make them dry.’ The monks exposed the medicines to strong sunlight, [and] this thus caused the medicines to be lacking in strength. The Buddha said: ‘[You] should not expose the medicines to strong sunlight.’ The monks dried [the medicines] in shade. The medicines then had mould grown [on them]. The Buddha said: ‘[You] can expose [the medicines] in mild sunlight.’ The monks anointed their bodies with astringent medicine [and they] at once took bath. That medicine fell off [their bodies and hence the monks] did not receive the potency of the medicine. The Buddha said: ‘[You] wait till [the body] becomes dry [after bathing] and rub [the medicine onto the body] by hand. [When] that medicine has infiltrated into the skin, then [you] take a bath. After bathing, [you] again anoint [the medicine]. After anointing, [you] again take a bath. The illness with sores can be relieved.’ That sick monk had the sores relieved. The entire residual medicine was then discarded. … Then that monk informed the Buddha about this matter. The Buddha said: ‘… The residual medicine should not be thrown away. If there is another sick monk asking for it, [one] should give [it]. If there is no one asking for it, it can be sent to the sick quarter [and] stored [there] according with the rules. A sick one should be supplied [with it]. …’”^[15]

Mahāsāṃghika:—“The Buddha... saw a monk who had a disease of ringworm.... [The monk] replied: ‘The Exalted One, I have a disease of ringworm with an itch. [If I] can get scented powder for bathing, [the disease will] then be cured....’ The Buddha said: ‘From today [onward], [I] allow a sick monk to use scented powder. Scented powder is: powder of vetiver, powder of common gurjun tree, powder of Indian devil tree (?), powder of sandalwood, powder of costus, powder of anbaluo 菴拔羅屑 (nut grass or mango tree?), powder of yanfushili 閻浮尸利屑 (?), powder of azhun 阿淳屑 (powder of ashoka tree or arjun terminalia tree?), [or] powder of camphor tree–such as these examples, all are not allowed. If a monk has a disease of itching ringworm [and] there is a need of powder for anointing and bathing [so as] to cure [the illness], it can be used [and] there is no offence.^[16] [But I] allow using powder of jialuo 迦羅屑 (powder of grass pea?),^[17] powder of black gram, powder of lentil, powder of zedoary,^[18] [and] soil.’”^[19]

There are many chapters in the classical Āyurvedic texts dealing with various skin diseases and their treatments. But there is not a separate section or chapter for itching skin lesions. Many skin conditions can present with an itch (Pāli: kacchu or kaṇḍu; Sanskrit: kacchū or kaṇḍū). Examples are kakṣā, valmīka, padminīkaṇṭaka, vṛṣaṇakacchū, alasa, utkoṭha, koṭha, dadrukuṣṭha, carmadala, sidhma, vicarcikā, vipādikā, pāmā, rakasā, and so on. Some of these are regarded as leprous skin diseases (Sanskrit: kuṣṭha), and others as minor diseases (Sanskrit: kṣudraroga) (Suśruta Saṃhitā Nidānasthāna 5. 5, 8-19; 13. 3 ff.; Aṣṭāṅga Hṛdaya Saṃhitā Uttarasthāna 31). These itching diseases have their individual aetiology and pathogenesis. Their treatments, therefore, are different. In general, aggravated humours are alleviated by various measures (e.g. emesis, purgation, enema, bloodletting, etc.). Medicines in various forms (e.g. ghee, oil, pastes, decoctions, powders) are often ingested and/or applied externally on skin lesions. If a lesion becomes suppurated, it should be managed surgically (by knife or cauterisation), and then healed as a wound (which will be discussed later).^[20]

Modern medicine defines itch (pruritis) as “an unpleasant cutaneous sensation that provokes the desire to rub or scratch the skin to obtain relief” (Dorland's Illustrated Medical Dictionary, 32nd ed., s.v. “pruritis”). Causes of this distressing phenomenon are diverse. Common skin diseases causing pruritis are allergic dermatitis, atopic dermatitis, lichen planus, urticaria, psoriasis, xerosis (dry skin), lice infestation, scabies, skin infections (e.g. ringworm as a fungal infection), and so on. Besides, numerous systemic disorders can also give rise to itch, such as autoimmune diseases, liver diseases, kidney diseases, endocrine/metabolic diseases, haematological diseases, neurological diseases, psychogenic/psychosomatic diseases, infectious diseases, malignancies, and other conditions such as pregnancy (Leslie 2013, 368, table 1; Reamy, Bunt, and Fletcher 2011, 198, table 2; 199, table 3). In addition to diagnosing and treating the underlying cause(s), management of itching includes topical, systemic, and physical measures. Topical treatments are emollients to retain moisture and corticosteroids to reduce inflammation. Systemic medications may include antihistamines, immunosuppressants, antidepressants, and neuromodulatory drugs. Phototherapy is a physical measure which can be employed (Leslie 2013, 369-370; 370, table 4).

Itching skin condition was a common illness affecting the monastic members as recorded in the Chapters on Medicine. Such problems were treated with medicinal powders or decoctions. In Āyurveda, there is no distinct section discussing itching cutaneous diseases, but many skin lesions can cause an itch. They are treated accordingly. In modern medicine, an itch can occur not only in skin conditions, but also in various systemic problems. Apart from treating the underlying cause, pruritis may be managed with topical and/or systemic drugs, as well as physical measures.

Footnotes and references:

[1]:

Moreover, there are overlaps between these categories. For example, itching sores can be discussed as itching lesions or as sores/wounds. The cases are classified based on their major presenting problems and treatments involved.

[2]:

Thulla means “massive, coarse, gross, big,” and so on (Pali-English Dictionary, s.v. “thūla”). Kacchā means “enclosure, … veilings, ribbon, … belt, loin or waist cloth” and so forth (Pali-English Dictionary, s.v. “kacchā). The term thullakacchā thus means something unrelated to skin problem. Rather, kacchā seems to be a variant or corruption of kacchu, which refers to “itch, scab, a cutaneous disease” (Pali-English Dictionary, s.v. “kacchu”). Hence the term should be thullakacchu which is translated here as “extensive itching skin disease”. Pali-English Dictionary renders this term thullakacchā as thick scurf, which is incorrect.

[3]:

The Samantapāsādikā (V. 1090) explains “kāyo vā duggandho” as: “‘Or body with bad smell’ [means] the body smell of anybody is like [that] of horse and so on, and for him the powders of siris tree, Kosambī’s neem tree (?), etc., or scented powders–all are suitable” (kāyo vā duggandho’ti kassaci assādīnaṃ viya kāyagandho hoti, tassāpi sirīsakosambādicuṇṇāni vā gandhacuṇṇāni vā sabbāni vaṭṭanti).

[4]:

The Samantapāsādikā (V. 1090) expounds thus: “‘Animal dung’ is cow dung” (chakanan ti gomayaṃ).

[5]:

The Samantapāsādikā (V. 1090) gives annotation to this term: “‘Boiled dye’ is the dregs of dye. Having pounded the natural powder [and] moistened [it] with water, it is suitable to take bath [with]. This comes to know exactly [as] the definition of boiled dye” (rajananipakkan ti rajanakasaṭaṃ. pākatikacuṇṇam pi koṭṭetvā udakena temetvā nhāyituṃ vaṭṭati. etam pi rajananippakkasaṅkham eva gacchati).

[6]:

Theravāda Vinaya Piṭaka I. 202: “tena kho pana samayena āyasmato Ānandassa upajjhāyassa āyasmato Belaṭṭhasīsassa thullakacchābādho hoti. tassa lasikāya cīvarāni kāye lagganti. tāni bhikkhū udakena temetvātemetvā apakaḍḍhanti.... atha kho bhagavā etasmiṃ nidāne dhammikathaṃ katvā bhikkhū āmantesi: anujānāmi bhikkhave yassa kaṇḍu vā piḷakā vā assāvo vā thullakacchā vā ābādho kāyo vā duggandho, cuṇṇāni bhesajjāni, agilānassa chakanaṃ mattikaṃ rajananipakkaṃ. anujānāmi bhikkhave udukkhalaṃ musalan ti. tena kho pana samayena gilānānaṃ bhikkhūnaṃ cuṇṇehi bhesajjehi cālitehi attho hoti–la–anujānāmi bhikkhave cuṇṇacālanin ti. saṇhehi attho hoti. anujānāmi bhikkhave dussacālanin ti.”

[7]:

疥瘡 literally means itching sore(s). Nowadays this Chinese term specifically refers to scabies, which is a very contagious skin infection caused by a kind of tiny mite. But we cannot be certain that in ancient China, when the primary sources were translated from ancient Indian language to Chinese, this term had the meaning of parasitic infection. Thus the literal meaning will be used in the present writer’s translations of this term.

[8]:

Taishō Tripiṭaka 1421. 147c6-7: “有比丘患疥瘡欲治，以是白佛，佛言：「聽治。」” The information given is very brief and we are not told what treatment was allowed.

[9]:

安陀會 (Pāli: antaravāsaka; Sanskrit: antarvāsa) means inner garment.

[10]:

See “Decoctions/Astringent Medicines” in Section 4. 2. 7 of Chapter Four.

[11]:

Taishō Tripiṭaka 1435. 184c24-185a6: “佛在毘耶離國住，是地醎濕，諸比丘病疥，膿血流污安陀會如水漬。

佛知故問，問諸比丘：「何以污安陀會如水漬？」諸比丘言：「世尊！我曹病疥，膿血流出污安陀會。」佛言：「從今日聽諸病疥比丘用苦藥塗。」長老優波離問佛：「何等苦藥？」佛言：「拘賴闍樹、拘波羅樹、拘真利他樹、師羅樹、波伽羅樹、波尼無祇倫陀樹。」諸比丘不曉擣磨，佛言：「聽石磨。」石磨藥墮地，佛言：「聽石臼杵擣。」諸比丘手壞，佛言：「聽作木杵。」作木杵不曉作，捉處手上下脫，佛言：「中央令細。」所擣藥麁，佛言：「應簁令細，以油塗瘡，以藥坌上。」”

[12]:

The five decoctions mentioned earlier in the Mūlasarvāstivāda Bhaiṣajyavastu are: decoction of mango tree, decoction of neem tree, decoction of black plum tree, decoction of siris tree, and decoction of (possibly) neem tree in Kośambī.

[13]:

Gilgit Manuscripts III. 1.vi-viii: “bhagavān śrāvastyāṃ viharati jetavane'nāthapiṇḍadasyārāme | tena khalu samayenānyatamasya bhikṣoḥ kacchūrogaḥ samutpannaḥ | sa vaidyasakāśamupasaṃkrāntaḥ | bhadramukha me kacchūrogaḥ samutpanno bhaiṣajyaṃ vyapadiśeti | sa kathayati | ārya kaṣāyaṃ sevasva | svāsthyaṃ te bhaviṣyati | bhadramukha kimahaṃ kāmabhogī | sa kathayati | idaṃ te bhikṣorbhaiṣajyam | na śakyamanyathā svasthena bhavitum | etat prakaraṇaṃ bhikṣavo bhagavata ārocayanti | pūrvavadyāvacchāstā te (sarvajñaḥ | tameva gatvā pṛccheti | etat prakaraṇaṃ bhikṣavo bhagavata ārocayanti | bhagavānāha | pañca) kaṣāyāḥ | āmrakaṣāyāḥ pūrvavat | tena bhikṣuṇā kaṣāyaṃ kalpīkṛtya gātraṃ ghṛṣṭam | ekaghanībhūtam | bhagavānāha | cūrṇaḥ kartavyaḥ | bhikṣavaḥ ārdrameva cūrṇayanti | piṇḍī(bhūtaḥ | bhagavānāha | śoṣayitavyaḥ | te ātape śoṣayanti | nirvīryaṃ bhavati | bhagavānāha) nātape śoṣayitavyaḥ | te chāyāyāṃ śoṣayanti | tathāpi pūyyati | bhagavānāha | chāyātape śoṣayitavyaḥ iti | bhikṣavaḥ kaṣāyeṇa gātraṃ mrakṣayitvā snānti | kaṣāyakṛtyaṃ na (kurvanti | bhagavānāha | yāvad hastaparāmarśaṃ śodhayitavyam) | (atha) kaṣāyaṃ dattvā snātavyam | kaṣāyakṛtyaṃ karotīti | bhikṣoḥ kaṣāyeṇa rogo vyupaśāntaḥ | tenāvaśiṣṭaḥ kaṣāyaḥ choritaḥ |... etatprakaraṇaṃ bhikṣavo bhagavata ārocayanti | bhagavānāha |... (kaṣāyadhārakeṇa bhikṣuṇā upayuktaśeṣaḥ kaṣāyo yo) bhikṣurarthī tasya dātavyaḥ | glānakalpikaśālāyāṃ vā sthāpayitavyaḥ |...”

[14]:

夜合 is synonymous with 合歡, which refers to Albizia species which are commonly known as silk trees or sirises.

[15]:

Taishō Tripiṭaka 1448. 2a13-b11: “緣處同前。時有苾芻身患瘡疥，詣醫人處，問曰：「賢首！我患瘡疥，為我處方。」醫人報曰：「聖者！宜服澁藥，當得病差。」苾芻答曰：「賢首！我可是耽欲人耶？」醫人報曰：「此澁藥能治疥瘡，餘藥不差。」苾芻問曰：「當服何等澁藥？」醫人答曰：「聖者！汝師是一切智者，具知此事。」諸苾芻等往白世尊，佛言：「有五種澁藥：一者菴沒羅，二者絍婆，三者贍部，四者夜合，五者俱奢摩。苾芻應知，此等諸藥，或皮或葉，並應擣碎，水煮塗身。」塗已體更生瘡，佛告苾芻：「應作散藥。」苾芻濕擣，為作一團，不為碎粖，佛言：「不應濕擣，應曝使乾。」諸苾芻於盛日中曬藥，遂令無力，佛言：「不應於烈日中曝藥。」苾芻陰乾，藥便衣生，佛言：「可於微日中曝。」諸苾芻等，澁藥塗身，即便沐浴，其藥墮落，不得藥力，佛言：「待乾手摩其藥入皮膚，然後沐浴已更塗，塗已更浴，瘡病得差。」彼病苾芻瘡既差已，所有殘藥遂便棄擲。...時彼苾芻以緣白佛，佛言：「...所用殘藥，不應棄擲。若有餘病苾芻求者應與；若無求者，可送病坊，依法貯庫，病者應給。...」”

[16]:

See Section 4. 2. 10. 1 on scented substances; also footnote 132 of Chapter Four.

[17]:

迦羅 may be kalāya (grass pea), because the following items in the list are different kinds of pulse.

[18]:

沙坻 seems to be śaṭi (zedoary). It may also be a literal translation of sand islet, because the following item is soil. But it seems unlikely because it would then be sand and not exactly powder.

[19]:

Taishō Tripiṭaka 1425. 482c21-483a2: “佛...見比丘癬病。...答言：「世尊！我病癬瘙，得香屑末洗浴便差。...」佛言：「從今日聽病比丘用香屑。香屑者，於尸屑、馬耳屑、七色屑、栴檀屑、俱哆屑、菴拔羅屑、閻浮尸利屑、阿淳屑、伽比羅屑，如是比一切不聽。若比丘病癬瘙，

須屑末塗浴差者，得用無罪。聽用迦羅屑、摩沙屑、摩瘦羅屑、沙坻屑、塗土。」” This account is not within the Chapter on Medicine parallel in the Mahāsāṃghika Vinaya.

[20]:

These general principles of treatment are summarised from chapters dealing with skin diseases in Āyurvedic treatises.