Surgery (a): Perineal Diseases

Surgery is a major branch in modern medicine that deals with diseases and injuries which require surgical management or operation. It is one of the eight branches in Āyurveda known as śalyatantra or śalyapahartṛka. Cases pertaining to surgery are found in the Chapters on Medicine, and they are classified into two groups: one on perineal diseases and another on foot ailments. These will be examined respectively in this section.

A case of surgical treatment of a monk’s anal disease is found in the Chapters on Medicine of Sthavira Vinayas, while the Mahāsāṃghika Vinaya has the information kept outside the Chapter on Medicine parallel. From the context, all these accounts should belong to the same case, though there are differences in the descriptions.

These accounts show the presence of anal surgery early in the medical history of India.

Theravāda:—“The Exalted One stayed there in Rājagaha, at the place where the squirrels were fed in the Bamboo Grove. At that time a certain monk had a disease of [anal] fistula. The physician Ākāsagotta performed a surgical operation. Then the Exalted One, while walking round the lodgings, approached the dwelling place of that monk. The physician Ākāsagotta saw the Exalted One coming from afar. Having seen [that], he said this to the Exalted One: ‘Sir, let Gotama come. Let [him] see the anus of this monk, [which is] just as the mouth of an iguana.’ Then the Exalted One, [thinking] ‘this stupid person is making fun of me,’ was silent. Having turned back, against this background [and] on this matter, [the Exalted One] caused the community of monks to convoke and put a question to [the monks]: ‘Is there, monks, really a sick monk at such and such dwelling place?’ ‘There is, the Exalted One.’ ‘What, monks, is that monk’s illness?’ ‘Venerable Sir, that venerable has a disease of [anal] fistula. The physician Ākāsagotta performs a surgical operation [on him].’ The Buddha, the Exalted One, scolded intensely: ‘It is not befitting, monks, for that stupid person; it is not in conformity, not proper, not suitable for the recluseship, not permissible, [and] not to be done.^[1] How, monks, can^[2] that stupid person cause [the physician] to perform a surgical operation at the private parts? At the private parts, monks, the skin is fine, a wound is hard to heal,^[3] [and] a knife is difficult to move around.^[4] This is not, monks, for the faith of the unfaithful.’^[5] Having scolded intensely and given a dhamma talk, [the Exalted One] addressed the monks: ‘Monks, surgical operation should not be caused to be performed at the private parts. Whoever would cause [it] to be done, there is a grave offence.’ At that time the monks belonging to the group of six, [thinking] ‘surgical operation has been rejected by the Exalted One,’ they caused to undertake enema. Those monks, who were desiring little, criticised, voiced their anger, and condemned: ‘How can the monks belonging to the group of six cause to undertake enema?’ Then those monks informed this matter to the Exalted One. ‘Is it true, monks, [that] the monks belonging to the group of six cause to undertake enema?’ ‘It is true, the Exalted One.’ Having scolded intensely [and] given a dhamma talk, [the Exalted One] addressed the monks: ‘Monks, surgical operation or enema should not be caused to be performed [at] the vicinity of two finger-breadths of the private parts. Whoever would cause [them] to be done, there is a grave offence.’”^[6]

Dharmaguptaka:— “At that time the Exalted One was in Rājagṛha. Then Jīvaka Kumārabhṛta performed surgical operations for monks’ diseases at private parts and armpits. Then the Exalted One, with benevolent mind, addressed the monks: ‘This Jīvaka Kumārabhṛta performs surgical operations for monks’ diseases at private parts and armpits. [These diseases] should not employ surgical operations. Why is that? It is because the knife is sharp and it can cut deep into the flesh. From now on, [I] allow using tendon or woollen string to tie [the lesion] tightly; or grasping [it] to break [it] off the skin, and then applying medicine to [the wound].’”^[7]

“Then the monks belonging to the group of six used ghee [and] oil to perform enemas at [their] back passages. The Buddha said: ‘[You] should not perform the enema.’ They taught others to perform the enema. The Buddha said: ‘[You] should not teach others to perform the enema.’”^[8]

Mahīśāsaka:—“There was a monk [afflicted] with carbuncle at the private parts. The physician cut it open for [him]. The Buddha walked past [the site]. The physician told the Buddha: ‘The knife has cut to the anus. The Exalted One, have a look.’ The Buddha said: ‘This is the place where it is difficult to care for. If an ordinary person is caused to pass away, [he] then loses the great benefit. From now on, [I] do not allow cutting open by knife at the private parts. One who commits this, there is a grave offence.’”^[9]

Sarvāstivāda:—“The Buddha was still in Śrāvastī. There was a monk [who had] haemorrhoidal disease. The physician’s name was Adiliqudulu 阿帝利瞿妬路 (Atrigotra?). He cut [the monk’s] anus with a knife. At that time [he] treated [the sick monk] at an open place near the gate of the Jeta Grove. The monk suffered from pain in the whole body. At that time the Buddha wanted to enter the Jeta Grove. The physician saw the Buddha coming from a distance. He put his palms together and invited the Buddha to look at this [anal] place. The Buddha said: ‘Amongst the people with evil speech, this Adiliqudulu is the foremost. He even invited the Tathāgata and showed [the Tathāgata] such place. From now on, [a monk] should not show [and] speak of the anus. If [he] shows [and] speaks of [it], [he] commits an offence. From now on, [at] the anus, [one] should not allow surgical operation. If [a monk] is treated [thus], he commits a grave offence.’”^[10]

Mūlasarvāstivāda (Chinese):—“... [King Prasenajit] saw a monk [who was] afflicted with haemorrhoidal disease in [his] body [and] was lean and feeble. Having already seen that, the king then asked: ‘Noble one, why are you lean and feeble?’ The monk answered: ‘The great king, because of the affliction with haemorroidal disease, thus [I] am lean.’ Then the king returned [to his place and] ordered the physician Adiye 阿帝耶 (Ātreya?) to treat [the monk’s] illness. Then that physician received the instruction and went [to the sick monk]. However, this physician had no faith in the Three Jewels. He was not willing to treat that sick person. The king later went back to see the sick [monk]. He wondered and asked: ‘Noble one, hasn’t the physician treated [your illness]? [Your] body is still lean and wasted.’ The sick [monk] replied: ‘Although the great king has sent the physician, that [physician], unexpectedly, did not come to help [or] give treatment.’ Then the king heard that [and] hence [he] at once angrily chided [that physician]. He therefore sent a messenger to catch and bring [the physician]. The king said: ‘I at an earlier time caused you to care for the sick monk. Why have you, up till now, actually not treated [him]? If [you] do not treat [him], I shall deprive you of the official rank.’ This physician, however, did not have faith [in the Three Jewels] all along. Owing to the king’s scolding, [he] became angrier [and] reproached [the monks] with evil words: ‘How could I be deprived of the official rank because of you [this] group [of monks]!’ [He] caught the sick monk [and brought him] to [a place] outside the gate of the monastery, [and] then tied up [the monk’s] arms and legs so as to cut his piles. Meanwhile, that monk, having been compelled, experienced mind-disturbing pain. He then immediately screamed. Also, he had this thought: ‘I am experiencing extreme pain. The Exalted One has immense lovingkindness. How would he be pitiless!’ It is the Tathāgata’s usual practice: at all times there is nothing that he does not know or see. Due to the awareness of the great compassionate power, [he] went to [that] monk’s place. At that time, that physician saw the Buddha coming from a distance. [His] anger had not subsided, [and he] spoke such words: ‘You come here, son of a female servant. Have a look at how your disciple’s private parts are.’ At that time the Exalted One, having heard these words, left silently [and] returned to his own place.... At that time the Exalted One told Ānanda: ‘... because of that, a monk should not cause to send a faithless physician like Adiye to care for a sick monk. There are two treatments for haemorrhoidal disease: one, by mantra; two, by medicine. If a monk is sick, [one] should not send [a physician] from the faithless kind of people like Adiye to treat. If one causes [such physician] to treat, he gets an offence of transgression.’”^[11]

Mahāsāṃghika:—“[Regarding] surgical operation: The Buddha dwelled in Śrāvastī. Then there was a monk with haemorrhoidal disease. [He] spoke to the physician: ‘Sir, ^[12] can you perform surgical operation on me?’ [The physician] replied: ‘Yes.’ The physician then had this thought: ‘These recluses are clever and wise. Seeing my treatment they will then learn [it]. [They will] not request me [for it] again.’ [He] then sent away the monks. After [the monks] had left, [the physician] wanted to perform an unrighteous deed.^[13] Then this monk promptly had suspicion. He yelled to the monks: ‘Elders, [please] come here. The physician wants to perform an unrighteous deed.’ The monks heard that [and] then went into the place immediately. The physician was in fear. [He] discarded [his] knife and ran away. The monks went to [and] informed the Buddha on this account. The Buddha said: ‘Call that monk to come [here].’ The monk came [and] the Buddha asked him: ‘Is it true [about this matter of] you?’ The monk replied: ‘It is true, the Exalted One.’ The Buddha addressed the monk: ‘Why did you have surgical operation at [your] private parts? From now on, [I] do not allow surgical operation at the private parts. Private parts are: [the area within] four finger-breadths from each edge of the anus. If there is a carbuncle, a swelling, [or] a boil [at that area], [I] allow chewing wheat [or] chicken droppings [and] anointing [that to the lesion] to ripen [it]. [You] should ask [a fellow monk] of the same preceptor or [the same] teacher to scratch [and] break open [it]. If, at other places, there is a carbuncle, a swelling, a boil, and so forth [such] various diseases [and] there is a need of surgical operation, [I] allow employing [it]. [One who] employs surgical operation at the private parts, there is a grave offence.’ This is known as [the teaching on] surgical operation.”^[14]

“[Regarding] enema [by means of a] tube: The Buddha dwelled in Śrāvastī. There was a monk [afflicted] with wasting disease.^[15] [He] spoke to the physician: ‘Sir, can [you] perform on me an enema [to treat my] illness?’ [The physician] replied: ‘Yes’; [but he] then had this thought: ‘These recluses are clever and wise. [After] seeing me performing an enema, [they] will not call for me again.’ [Same as the above description and] up to [that he] discarded the tube and ran away. The monks went to and informed the Buddha on this account. [Same as the above and] up to [that] the Buddha said: ‘Why do you have enema [by] using a tube [to treat your] illness? From now on, [I] do not allow using a tube [to perform enema]. A tube is: a tube made of cowhide, a tube made of buffalo leather, [or] a tube made of sheepskin; such as these all [tubes] are not allowed to be used for enema. If the physician says “this illness requires enema with oil,” [one] should, in the bathroom, make a hole on a board, put oil [in the hole], lift [his] robe, [and] sit on [the oil while] holding a [piece of] sugarcane in mouth. Or [he] dips a woollen cloth, [a piece of] cotton, and so forth in the oil, [and then] press [this] at the anus to make the oil flow into [the anus]. [Doing thus,] there is no offence. If [one undertakes] an enema using a tube, there is a grave offence.’ This is known as the teaching on enema by tube.”^[16]

Perineal diseases mentioned in the Buddhist sources above are haemorrhoids, anal fistulae, and carbuncles. They were supposed to be treated by surgical operation, but such treatment was forbidden by the Buddha due to the danger of operations at the private parts. Enema was also banned, probably due also to the danger of causing injury at this part of the body or the bowel.

The Samantapāsādikā has provided extra information on these treatments at this area:

“‘Surgical operation or enema’ is: Just as in a small room, by whatever–by a knife, or by a needle, or by a sharp-pointed instrument, or by a small knife, or by a stone-splinter, or by a nail–[that] cutting, or splitting, or piercing, or scraping should not be done; every [of these] indeed is that surgical operation. By whatever leather or cloth, the pressing of a bladder should not be done; every [of these] indeed is enema. Here–‘the vicinity of two finger-breadths of the private parts’–it is said concerning just to this surgical operation. Enema at the private parts is also rejected. At that place, it is suitable to give a caustic or to bind with whatever cord. If it is severed by that, it is well-cut. Even in [the matter of] the disease of an enlargement of the testicle, surgical operation is not suitable. Therefore, having made the testicle split and removed the causing element, [one thinks] ‘I will bring health’–it should not be done. With regard to anointing with medicine and burning with fire, there is no objection. At the anus, a clinging rod or a bamboo stalk smeared with medicine is suitable; through which they perform caustic treatment or introduce oil.”^[17]

For these diseases, carbuncle has been discussed in the last section and it will not be covered again. Haemorrhoids and anal fistulae will be elaborated here. According to the classical Āyurvedic treatises, haemorrhoids (Pāli: arisa; Sanskrit: arśas) are morbid structures involving fat tissue, muscle tissue, and skin, which may obstruct the passage of the rectum. They occur in the area of four and a half fingerbreadths in the lower end of the alimentary canal. Piles can be congenital or acquired (after birth). Congenital piles are due to abnormalities of the seeds (sperm and ovum) of the parents, which in turn are due to improper diet and/or activities of the parents or sinful deeds of past lives of the person. Such abnormalities of the seeds cause aggravation of all humours resulting in the congenital piles (Caraka Saṃhitā Nidānasthāna 15. 56; Aṣṭāṅga Hṛdaya Saṃhitā Nidānasthāna 7. 1-3, 6-7). Acquired piles are of five types: three caused by aggravation of each humour, one by that of all three humours, and one by that of the blood (Suśruta Saṃhitā Nidānasthāna 2. 3; Aṣṭāṅga Hṛdaya Saṃhitā Nidānasthāna 7. 9). Various factors can lead to aggravation of humours and blood, such as inappropriate foods and drinks, activities, and treatments; excessive straining when opening bowels; injury to the anus by rubbing with objects or improper insertion of enema nozzle; suppression of natural urge; pregnancy; and so on. Aggravated humours then weaken the digestive power and cause accumulation of waste products. These humours (which may be associated with blood) and waste products are brought down by wind humour to the lower end of the digestive tract, where they vitiate the anal tissues resulting in the formation of piles (Caraka Saṃhitā Cikitsāsthāna 14. 9; Suśruta Saṃhitā Nidānasthāna 2. 4; Aṣṭāṅga Hṛdaya Saṃhitā Nidānasthāna 7. 10-15). Remedies for haemorrhoidal disease are surgical and medical. Surgical measures include excision and cauterisation (by caustic alkali and/or red hot metal probe). Medical means are applying medicated oil/fat, medicinal paste, poultice, or suppository at the lesion;sprinkling or bathing the piles with decoction of drugs; fumigation of drugs at the piles; use of enema; intake of decoction, medicated buttermilk, vegetables, medicated gruel, medicated ghee, vegetable soup, and meat soup; and so on. Bloodletting is undertaken if there is aggravation of blood. For bleeding piles, further treatments are required, such as elimination therapies, fasting, and haemostatic measures (e.g. consumption of bitter drugs and suitable diets, sprinkling or bathing the bleeding piles with decoction, external application with leaves or medicated ghee, and so forth) (Caraka Saṃhitā Cikitsāsthāna 14. 33 ff.; Suśruta Saṃhitā Cikitsāsthāna 6; Aṣṭāṅga Hṛdaya Saṃhitā Cikitsāsthāna 8).

Āyurveda enumerates five types of anal fistula (Pāli: bhagandala;Sanskrit: bhagandara): three due to each humour, one to the three humours together, and one to external factor (such as parasite, or injury to anus which occurs when an ingested bone is passed out) (Caraka Saṃhitā Cikitsāsthāna 12. 96; Suśruta Saṃhitā Nidānasthāna 4. 3). Those causative factors for piles can also lead to the formation of anal fistulae. The aggravated humours afflict the blood and muscle tissues around the anus, and this gives rise to the formation of abscess. When an abscess gets ruptured, it becomes a fistula (Suśruta Saṃhitā Nidānasthāna 4. 3-4; Aṣṭāṅga Hṛdaya Saṃhitā Uttarasthāna 28. 1-4). If the disease is in the early stage when the abscess is not ripened, it is treated with elimination therapy (such as purgation), bathing the lesion with decoctions, and so on. If the abscess has ruptured and the fistula has formed, it is chiefly managed surgically by means of probing, cauterisation (by caustic alkali or burning), incision, and/or excision depending on the lesion. Thereafter the cut-open wound is managed as an ordinary wound (Caraka Saṃhitā Cikitsāsthāna 12. 97; Suśruta Saṃhitā Cikitsāsthāna 8. 4; Aṣṭāṅga Hṛdaya Saṃhitā Uttarasthāna 28. 22-26).

According to modern anatomy, haemorrhoidal tissues are venous structures at the distal rectum and anal canal. They are filled with blood during defaecation and act as cushions to prevent direct trauma to the anal canal due to the passage of faeces. These tissues become pathologic haemorrhoids if they are enlarged and prolapsed into the anal canal, usually due to increased abdominal pressure–from factors such as straining at defaecation, pregnancy, obesity, lifting, and so on–leading to increased venous pressure and dilatation of these veins. Haemorrhoids are usually classified as internal or external according to whether the venous structures involved are above or below the mucodermal junction. Depending on the severity of the haemorroidal disease, it can be treated by medical and/or surgical measures. Medical treatments include dietary change to high fibre food, increased fluid intake, use of stool-softenig laxative, physical exercises, and so on. Surgical procedures commonly performed for such disease are elastic band ligation, injection sclerotherapy, infrared photocoagulation, excisional haemorroidectomy, and stapled haemorrhoidopexy (Welton et al. 2010, 707-709).

A fistula, in modern medicine, is defined as “an abnormal passage or communication, usually between two internal organs, or leading from an organ to the surface of the body,” and an anal fistula is “a cutaneous fistula opening on the body surface near the anus; it may or may not communicate with the rectum” (Dorland's Illustrated Medical Dictionary, 32nd ed., s.v. “fistula” and “fistula: anal f.”). An anal fistula commonly arises from an anorectal abscess, due to the infection of an anal crypt gland, which ruptures spontaneously or is surgically drained. Other causes include inflammatory bowel disease, mycobacterial infection, fungal infection, rectal tumour, and trauma (Rizzo, Naig, and Johnson 2010, 45-46). An anal fistula can locate at different anatomical tissues near the rectum and anal canal. Treatment for this disease is primarily surgical. A simple and superficial fistula can be cured by tracking and cutting open the fistular tract (fistulotomy), which is then managed as an open wound. Complicated fistulae which involve deeper tissues require special surgical procedures (Welton et al. 2010, 712-714).

Perineal diseases are mentioned in the Buddhist Vinayas. They were treated by surgery or enema. In Āyurveda, such diseases are also treated by various surgical and medical remedies. Haemorrhoids and anal fistulae are managed with medical and/or surgical measures in modern medicine, though much advanced treatments are being employed.

Footnotes and references:

[1]:

The translation for the phrase “ananucchaviyaṃ... ananulomikaṃ appaṭirūpaṃ assāmaṇakaṃ akappiyaṃ akaraṇīyaṃ” is adopted from Anuruddha 2004, 64.

[2]:

In the Pāli text, kārāpessati, a verb in future tense, makes strange sense in the English translation. Here the present writer adopts Horner’s translation in the Bhesajjakkhandhaka and renders the verb with “can” instead of “will”, which gives better meaning.

[3]:

The Samantapāsādikā (V. 1093) explains the clause “duropayo vaṇo” (a wound is hard to heal) thus: “the meaning is: [the wound] heals with difficulty, [and] it becomes the original state with difficulty” (dukkhena ruhati, dukkhena pākatiko hotī’ti attho).

[4]:

The Samantapāsādikā (V. 1093) gives explanation to this clause: “‘A knife is difficult to move around’ [means] the knife would hit with difficulty at the private parts” (dupparihāraṃ satthan ti sambādhe dukkhena satthaṃ pahareyya).

[5]:

The translation of “appasannānaṃ vā pasādāya” is adopted from Anuruddha 2004, 100.

[6]:

Theravāda Vinaya Piṭaka I. 215-216: “tatra sudaṃ bhagavā Rājagahe viharati Veḷuvane Kalandakanivāpe. tena kho pana samayena aññatarassa bhikkhuno bhagandalābādho hoti. Ākāsagotto vejjo satthakammaṃ karoti. atha kho bhagavā senāsanacārikaṃ āhiṇḍanto yena tassa bhikkhuno vihāro ten’ upasaṅkami. addasā kho Ākāsagotto vejjo bhagavantaṃ dūrato’va āgacchantaṃ, disvāna bhagavantaṃ etad avoca: āgacchatu bhavaṃ Gotamo imassa bhikkhuno vaccamaggaṃ passatu seyyathāpi godhāmukhan ti. atha kho bhagavā mamaṃ khv āyaṃ moghapuriso uppaṇḍetīti tuṇhibhūto’va paṭinivattitvā etasmiṃ nidāne etasmiṃ pakaraṇe bhikkhusaṃghaṃ sannipātāpetvā bhikkhū paṭipucchi: atthi kira bhikkhave amukasmiṃ vihāre bhikkhu gilāno’ti. atthi bhagavā’ti. kiṃ tassa bhikkhave bhikkhuno ābādho’ti. tassa bhante āyasmato bhagandalābādho, Ākāsagotto vejjo satthakammaṃ karotīti. vigarahi buddho bhagavā: ananucchaviyaṃ bhikkhave tassa moghapurisassa ananulomikaṃ appatirūpaṃ assāmaṇakaṃ akappiyaṃ akaraṇīyaṃ. kathaṃ hi nāma so bhikkhave moghapuriso sambādhe satthakammaṃ kārāpessatīti. sambādhe bhikkhave sukhumā chavi, duropayo vaṇo, dupparihāraṃ satthaṃ. n’ etaṃ bhikkhave appasannānaṃ vā pasādāya. vigarahitvā dhammikathaṃ katvā bhikkhū āmantesi: na bhikkhave sambādhe satthakammaṃ kārāpetabbaṃ. yo kārāpeyya, āpatti thullaccayassā’ti. tena kho pana samayena chabbaggiyā bhikkhū bhagavatā satthakammaṃ paṭikkhittan ti vatthikammaṃ kārāpenti. ye te bhikkhū appicchā te ujjhāyanti khīyanti vipācenti: kathaṃ hi nāma chabbaggiyā bhikkhū vatthikammaṃ kārāpessantīti. atha kho te bhikkhū bhagavato etam atthaṃ ārocesuṃ. saccaṃ kira bhikkhave chabbaggiyā bhikkhū vatthikammaṃ kārāpentīti. saccaṃ bhagavā. vigarahitvā dhammikathaṃ katvā bhikkhū āmantesi: na bhikkhave sambādhassa sāmantā dvaṅgulā satthakammaṃ vā vatthikammaṃ vā kārāpetabbaṃ. yo kārāpeyya, āpatti thullaccayassā’ti.”

[7]:

Taishō Tripiṭaka 1428. 871a13-18: “爾時世尊在王舍城。時耆婆童子，刀治比丘大小便處兩腋下病。時世尊慈念告諸比丘：「此耆婆童子，刀治比丘大小便處及兩腋下病。不應以刀治。何以故？刀利破肉深入故。自今已去，聽以筋、若毛繩急結之，若爪取使斷皮然後著藥。」”

[8]:

Taishō Tripiṭaka 1428. 877b8-10: “時六群比丘以酥油灌大便道，佛言：「不應灌。」彼教人灌，佛言：「不應教人灌。」”

[9]:

Taishō Tripiṭaka 1421. 147c10-13: “有比丘隱處癰，醫為刀破。佛經前過，醫白佛言：「刀已至大便門，世尊視之。」佛言：「此是難護之處，若使凡夫命過，便失大利。從今不聽刀破隱處，犯者偷羅遮。」”

[10]:

Taishō Tripiṭaka 1435. 187a28-b5: “佛故在舍衛國。有一比丘痔病，藥師名阿帝利瞿妬路，以刀割大行處。時近祇桓門間露現處治，苦痛切身。時佛欲入祇桓，藥師遙見佛來，合掌請佛看是處，佛言：「惡口人中，阿帝利瞿妬路此最第一，乃請如來示如是處。從今不應示語大行處，若示語犯罪。從今大行處不應聽刀治。若治，犯偷蘭遮罪。」”

[11]:

Taishō Tripiṭaka 1448. 6a1-19, b27-c8: “見一苾芻痔病嬰身羸瘦無力，王既見已遂便問曰：「聖者！何故羸瘦無力？」苾芻答曰：「大王！為患痔病，是故羸瘦。」時王還勅醫人阿帝耶為之療疾。時彼醫人奉教而往，然此醫人不信三寶，於其病者不肯療治。王於後時還見病者，怪而問曰：「聖者！醫人不為治耶？身尚羸損。」病者對曰：「大王雖遣醫人，彼竟不來相為救療。」時王聞已，即便瞋責，遂遣使者追捉將來。王曰：「我先令汝看病苾芻，何為至今竟不救療？若不治者，我當奪汝官位。」然此醫人素無信意，因被王責更加瞋忿，惡言毀罵：「豈為汝輩，奪我官耶？」捉病苾芻，至寺門外，遂縛手足，為割痔病。時彼苾芻既遭逼迫，苦痛纏心，即便大叫，復作是念：「我遭極苦，世尊大慈寧不哀愍？」如來常法，於一切時無不知見，由大悲力之所警覺，至苾芻所。時彼醫人遙見佛來，嗔猶未息作如是語：「汝來！婢兒！看汝弟子下部如何。」爾時世尊聞此語已，默然而去，還至本處... 爾時世尊告阿難陀曰：「...是故苾芻，如阿帝耶無信醫人，不應令遣看病苾芻。痔病有二種療法：一者以呪、二者以藥。若苾芻有病，不應於阿帝耶等不信之類而遣療治。若令治者，得越法罪。」” The Sanskrit parallel of this account in the Gilgit Manuscripts is lost.

[12]:

長壽 is āyuṣman in Sanksrit. It is usually rendered as “sir”. See Buddhist Hybrid Sanskrit

Dictionary, s.v. “āyuṣmaṃ”.

[13]:

We are not told what kind of unrighteous deed (adharma) it was.

[14]:

Taishō Tripiṭaka 1425. 488b12-25: “刀治者，佛住舍衛城，時有比丘痔病，語醫言：「長壽！能為我刀治不？」答言：「爾。」醫便作是念：「是諸沙門聰明智慧，見我治者便當學得，不復求我。」即遣諸比丘，去已，欲作非法。時此比丘即生疑，喚諸比丘言：「長老來此，醫欲作非法。」諸比丘聞即便來入，醫怖畏棄刀而走。諸比丘以是因緣往白世尊。佛言：「呼彼比丘來。」來已，佛問比丘：「汝實爾不？」答言：「實爾。世尊！」佛言：「比丘！汝云何用刀治愛處？從今已後不聽用刀治愛處。愛處者，離穀道邊各四指。若有癰痤癤，聽嚼小麥、雞屎塗上使熟，當令同和上、阿闍梨擿破。若餘處有癰痤癤等諸病，須刀治者聽用。用刀治愛處者，偷蘭罪。」是名刀治。” This passage is not within the Chapter on Medicine parallel in this Vinaya.

[15]:

乾痟病 should refer to śoṣa, which is usually rendered as tuberculosis.

[16]:

Taishō Tripiṭaka 1425. 488b26-c6: “灌筒者，佛住舍衛城，有比丘[病-丙+干]痟病，語醫言：「長壽！能為我灌病不？」答言：「可爾。」即作是念：「此諸沙門聰明智慧，見我灌者更不喚我。」乃至棄筒而走。諸比丘以是因緣往白世尊，乃至佛言：「汝云何用筒灌病？從今已後不聽用筒。」筒者，牛皮筒、水牛皮筒、羊皮筒，如是一切不聽用灌。若醫言：『此病須油灌』者，應在浴室中穿板盛油，褰衣坐上，口含甘蔗。若復以[疊*毛]衣絮等內著油中，臨孔上按之，令油流入者無罪。若筒灌者，偷蘭罪。」是名筒灌法。” This passage is not within the

Chapter on Medicine parallel in this Vinaya.

[17]:

Samantapāsādikā V. 1093-1094: “satthakammaṃ vā vatthikammaṃ vā’ti yathā paricchinne okāse yena kenaci satthena vā sūciyā vā kaṇṭakena vā santikāya vā pāsāṇasakalikāya vā nakhena vā chindanaṃ vā phālanaṃ vā vijjhanaṃ vā lekhanaṃ vā na kātabbaṃ, sabbaṃ h’ etaṃ satthakammam eva hoti. yena kenaci pana cammena vā vatthena vā vatthipīḷanam pi na kātabbaṃ, sabbaṃ h’ etaṃ vatthikammameva hoti. ettha ca sambādhassa sāmantā dvaṅgulā’ti idaṃ satthakammam eva sandhāya vuttaṃ. vatthikammam pana sambādhe yeva paṭikkhittaṃ. tattha pana khāraṃ vā dātuṃ yena kenaci rajjukena vā bandhituṃ vaṭṭati. yadi tena chijjati, succhinnaṃ. aṇḍavuḍḍhiroge’pi satthakammaṃ na vaṭṭati, tasmā aṇḍaṃ phāletvā bījāni uddharitvā arogaṃ karissāmī’ti na kattabbaṃ. aggitāpanabhesajjalepanesu pana paṭikkhepo n’ atthi. vaccamagge bhesajjamakkhitā ādānavaṭṭi vā veḷunāḷikā vā vaṭṭati, yāya khārakammaṃ vā karonti telaṃ vā pavesenti.”