Dermatology (b): Carbuncles

This subsection examines the few cases on carbuncles. The accounts found in the Chapters on Medicine/Vinayas are as follows:

Theravāda:—“At that time a certain monk had a disease of carbuncle.^[1] ‘I allow, monks, surgical operation.’ There was a need of astringent water. ‘I allow, monks, the astringent water.’ There was a need of sesame paste. ‘I allow, monks, the sesame paste.’ There was a need of wound dressing. ‘I allow, monks, the wound dressing.’ There was a need of a cloth for wound bandage. ‘I allow, monks, the cloth for wound bandage.’ The wound was itchy. ‘I allow, monks, to sprinkle [the wound] with mustard powder.’ The wound festered. ‘I allow, monks, to fumigate [the wound].’ The flesh of wound protruded. ‘I allow, monks, to cut [the protruded flesh] with a piece of salt-crystal.’ The wound did not heal. ‘I allow, monks, oil for the wound.’ The oil trickled. [The monks] informed this matter to the Exalted One. ‘I allow, monks, a linen bandage [and] all cures for a wound.’”^[2]

Mahīśāsaka:—“There was a monk afflicted with a carbuncle. It should be cut open with a knife [and] anointed with medicine. [The monks] informed the Buddha about this [matter]. The Buddha said: ‘[I] allow [such treatment].’”^[3]

Sarvāstivāda:—“The Buddha was in Rājagṛha. There was a monk with a disease of carbuncle. [He] went to and told Jīvaka: ‘[Please] treat this disease of mine.’ Jīvaka replied: ‘[You] soak [the carbuncle] with grease to ripen it.’ The monk said: ‘The Buddha has not allowed [us] to soak [the carbuncle] with grease to ripen it.’ The monks informed the Buddha about this matter. The Buddha said: ‘[I] allow soaking [the carbuncle] with grease to ripen it.’ Jīvaka again said: ‘[You] should break open [the carbuncle].’ [The monk] replied: ‘The Buddha has not allowed [us] to break open the carbuncle.’ [The monks] informed the Buddha about this matter. The Buddha said: ‘[I] allow breaking open [the carbuncle].’ Jīvaka again said: ‘[You] should press [at the carbuncle] to remove the pus.’ The monk said: ‘The Buddha has not allowed [us] pressing [at the carbuncle].’ [The monks] informed the Buddha about this matter. The Buddha said: ‘[I] allow pressing [at the carbuncle].’ Jīvaka again said: ‘[You] should apply object which absorbs pus.’ The monk said: ‘The Buddha has not allowed [us] applying [object to absorb pus].’ [The monks] informed the Buddha about this matter. The Buddha said: ‘[I] allow applying various medicines for treating pus.’”^[4]

The Samantapāsādikā has provided explanations for some of the terms mentioned in the Pāli source, which are in relation to wound care:

“‘A need of sesame paste’ [refers to] a need of crushed sesame seeds. ‘Wound dressing’ [means] to put a lump of parched flour on the wound surface. ‘With mustard powder’ [means] with crushed mustard seed. ‘Increased flesh’ [refers to that] the exceeding flesh rises like a pin. ‘Linen bandage’ is a small piece of cloth covering with oil. The meaning [of] ‘all cures for a wound’ is: whatever by name a cure for a wound is, I [the Tathāgata] allow all [of them].”^[5]

In Āyurvedic treatises, carbuncle (Pāli and Sanskrit: gaṇḍa) is not separately discussed. A related condition, boil (Pāli: piḷakā;Sanskrit: piḍaka), similarly is not examined in detail. In the Caraka Saṃhitā (Sūtrasthāna 17. 83-89), seven types of boil with different presentations are enumerated. In the chapters on minor diseases in the Suśruta Saṃhitā (Nidānasthāna 13) and the Aṣṭāṅga Hṛdaya Saṃhitā (Uttarasthāna 31), certain forms of boil are briefly mentioned (e.g. yavaprakhyā, andhālajī, panasikā, and so on). Rather, the associated conditions–inflammatory swelling and abscess–are well covered in these texts. Inflammatory swelling (Sanskrit: śopha or śotha) is defined as “elevation caused by doṣas, localised and situated between skin and muscles, widespread, knotty, even or uneven” (Suśruta Saṃhitā Sūtrasthāna 17. 3). Swellings are divided into two types: endogenous and exogenous. Endogenous swellings are due to aggravation of each of the humours, the combination of three humours, and the blood. Exogenous ones are due to trauma, force;irritating or poisonous substances of plants, insect, or animals; snow, wind, and fire (Caraka Saṃhitā Sūtrasthāna 18. 3-4; Suśruta Saṃhitā Sūtrasthāna 17. 4). Swellings can also be classified as three stages: immature, maturing, and matured. If an immature swelling is not properly cared, it aggravates and suppurates. The suppurated swelling then becomes deep-seated, causes further damage to surrounding tissues, and is difficult to be cured (Suśruta Saṃhitā Sūtrasthāna 17. 4, 14-16). Treatment for inflammatory swellings includes various measures such as fasting, application of paste to swelling, sprinkling at the lesion with water or decoction, anointing with ghee or oil, fomentation, softening by gentle pressure, applying poultice, bloodletting, lubrication by intake of oil, emesis, purgation, opening of the swelling, cleaning of the wound, healing, and anti-scar remedies (Suśruta Saṃhitā Sūtrasthāna 17. 17-18; Cikitsāsthāna 1. 10).

Boils and carbuncles are associated with abscess (Sanskrit: vidradhi) in pathology. According to Āyurveda, there are six types of abscess: three due to each humour, one to the combination of three humours, one to the blood, and one to trauma. By various causative factors and trauma, humours are aggravated. They cause vitiation of various body tissues such as skin, muscle, fat, bone, ligament, tendon, and so on, and this leads to swelling and abscess formation (Suśruta Saṃhitā Nidānasthāna 9. 5-6; Aṣṭāṅga Hṛdaya Saṃhitā Nidānasthāna 11. 1-3). An abscess can be external (located at skin, muscles, or ligaments) or internal (at deeper tissues or internal organs) (Caraka Saṃhitā Sūtrasthāna 17. 90-95; Aṣṭāṅga Hṛdaya Saṃhitā Nidānasthāna 11. 4-6). It is divided in terms of the level of suppuration into the stages of unripe, ripening, and ripened, similar to those of inflammatory swelling mentioned above (Aṣṭāṅga Hṛdaya Saṃhitā Nidānasthāna 11. 16). Treatment of abscess should start early when the lesion is at early unripe stage. An unripe abscess is treated like an inflammatory swelling (as mentioned above). If an abscess is ripened, incision is made and the pus is removed. The wound is then cleansed with decoction of drugs or medicated ghee (or oil or fat), pasted with drugs, and bandaged. Medicated ghee/oil or decoction is used for cleansing and healng purposes. Intake of decoction of drugs or medicated ghee/oil and administration of enemas are used for treating internal abscesses (Suśruta Saṃhitā Cikitsāsthāna 16; Aṣṭāṅga Hṛdaya Saṃhitā Cikitsāsthāna 13. 1-27).

The modern medical term for boil is furuncle. Both furuncles and carbuncles are skin abscesses. Furuncles arise from infection of hair follicles, or from injuries to skin or foreign bodies in the skin. The infection of boils can proceed to subcutaneous abscesses, or can spread along the subcutaneous tissues as cellulitis. Furuncles can be multiple and recurrent. They manifest as itching and/or painful inflamed swellings with surrounding redness and induration. The chief treatment for boils is drainage of the abscess. Carbuncles arise from furuncles but the infection is more extensive in the dermal and subcutaneous tissues, with many connecting fistulae formed between infected hair follicles. The severe infection often results in many openings at the skin surface, while the skin overlying the lesion becomes necrotic. Carbuncles require immediate extensive excision with electrocautery to remove all the fistular tracts. Antibiotic therapy is also needed for this serious infection (Mundy and Doherty 2010, 79-80).

Several accounts of carbuncle with description of its cure are noted in the Vinayas. They were treated surgically with incision and then by wound care with drugs and bandaging. Āyurvedic treatises do not have a specific section on boil or carbuncle. But such lesions are well discussed in sections of related conditions of inflammatory swelling and abscess. According to modern medicine, a boil (furuncle) is an infection of hair follicle, and a carbuncle is the more severe and extensive form of furuncle, which requires immediate surgical treatment.

Footnotes and references:

[1]:

Gaṇḍa is one of the five diseases with which a person is not allowed to become a monk (or nun) (Theravāda Vinaya Piṭaka I. 71). The Chinese parallel is 癰, which is translated as a carbuncle (Shu et al. 2005, 924).

[2]:

Theravāda Vinaya Piṭaka I. 205-206: “tena kho pana samayena aññatarassa bhikkhuno gaṇḍābādho hoti. anujānāmi bhikkhave satthakammaṃ. kasāvodakena attho hoti. anujānāmi bhikkhave kasāvodakan ti. tilakakkena attho hoti. anujānāmi bhikkhave tilakakkan ti. kabaḷikāya attho hoti. anujānāmi bhikkhave kabaḷikan ti. vaṇabandhanacolena attho hoti. anujānāmi bhikkhave vaṇabandhanacolan ti. vaṇo kaṇḍuvati. anujānāmi bhikkhave sāsapakuṭṭena phositun ti. vaṇo kilijjittha. anujānāmi bhikkhave dhūmaṃ kātun ti. vaṇamaṃsaṃ vuṭṭhāti. anujānāmi bhikkhave loṇasakkharikāya chinditun ti. vaṇo na rūhati. anujānāmi bhikkhave vaṇatelan ti. telaṃ galati. anujānāmi bhikkhave vikāsikaṃ sabbaṃ vaṇapaṭikamman ti.”

[3]:

Taishō Tripiṭaka 1421. 147c7-8: “有比丘患癰，應以刀破藥塗。以是白佛，佛言：「聽。」”

[4]:

Taishō Tripiṭaka 1435. 288a4-11: “佛在王舍城。有比丘病癰，往語耆婆：「治我此病。」耆婆答言：「膒令熟。」比丘言：「佛未聽膒熟。」諸比丘是事白佛，佛言：「聽膒令熟。」耆婆又言：「應破。」答言：「佛未聽破癰。」是事白佛，佛言：「聽破。」耆婆又言：「應捺去膿。」比丘言：「佛未聽捺。」是事白佛，佛言：「聽捺。」耆婆又言：「應著食膿物。」

比丘言：「佛未聽著。」是事白佛，佛言：「聽著種種治膿藥。」” This account is not in the

Sarvāstivāda Bhaiṣajyadharmaka.

[5]:

Samantapāsādikā V. 1092: “tilakakkena attho ti piṭṭhehi tilehi attho. kabaḷikan ti vaṇamukhe sattupiṇḍaṃ pakkhipituṃ. sāsapakuḍḍenā’ti sāsapapiṭṭhena. vaḍḍhamaṃsan ti adhikamaṃsaṃ āṇi viya uṭṭhahati. vikāsikan ti telarundhanapilotikaṃ. sabbaṃ vaṇapaṭikamman ti yaṃ kiñci vaṇapaṭikammaṃ nāma atthi, sabbaṃ anujānāmī’ti attho.”