MEDICINE

CHAPTER FIVE

Medicine

The Great Section on Virtue in the Sāmaññaphala Sutta (DN 2) lists the types of wrong livelihood from which a bhikkhu should abstain. Among them is the practice of medicine, or in the words of the sutta:

The Commentary to Pr 3 states that a bhikkhu should not act as a doctor for lay people unless they are:

In none of these cases, however, should he expect material reward for his services.

Bhikkhus are, however, expected to know enough medicine to care for their own and for one another’s illnesses. This point is beautifully illustrated by one of the most inspiring passages in the Canon:

The Buddha then sets out precise duties both for the sick and for those who nurse them:

Issues related to two of the last five qualities are discussed in detail in the Khandhakas: competence in mixing medicine and the question of material gain, i.e., the rewards given to nurses who have faithfully tended to the sick. The latter issue is a communal one, and so will be discussed in Chapter 22. Here we will discuss issues related to medicine, which fall under four main topics: the basic “support” medicine; general classes of edibles that count as tonics and medicines; medical treatments recommended for specific diseases; and medical procedures.

Support medicine

A bhikkhu’s basic medicinal support is pūti-mutta-bhesajja, which translates literally as “rancid urine medicine” (Mv.I.30.4). Strangely, none of the texts define the term. The commentaries to the Khuddakapātha, Udāna, and Sutta Nipāta give an example of this sort of medicine—rancid urine with yellow myrobalan—but without a formal definition to indicate the full range of the term. The Sub-commentary to the Vinaya defines rancid urine as any sort of urine at all, citing as a parallel the Pali expression pūti-kāya, decomposing body, which refers to any human body, living or dead, “even one with golden skin.” However, it does not say whether rancid urine medicine is the rancid urine itself or, as suggested by the example from the commentaries, rancid urine in which medicinal fruits are pickled.

Because the texts are vague about this term, various oral traditions have developed around it. In Sri Lanka, rancid urine medicine is interpreted as rancid cow’s urine, in which different types of myrobalan are sometimes pickled. In Thailand, some Communities interpret it as one’s own first urine in the morning, following the ancient Indian tradition of using this urine as a tonic. (Modern scientists have discovered that this urine contains a high level of melatonin.) Given the silence of the texts, the best policy here is to follow the traditions of one’s own Community.

The five tonics

The five tonics are discussed in detail under NP 23, but the issue of flour mixed with sugar bears repeating. The Canon states that if sugar is mixed with flour or ashes as a binding agent and is still called sugar, then it counts as one of the five tonics. Some have argued that this allowance extends to candies that have small amounts of flour or other food starch mixed in, but if the candies are not called sugar they do not meet the terms of the allowance and so should be classed as food.

Life-long medicines

Six types of edibles are classed as life-long medicines: root medicine, astringent decoction medicine, leaf medicine, fruit medicine, resin medicine, and salt medicine. The Canon lists specific examples for each type. Although some of the examples are hard to identify precisely, each of the classes when taken as a whole is clear enough to form a guideline for applying the Great Standards to similar medicines today. Thus I have made no effort to identify the more obscure examples. As the Canon itself makes clear, any medicine that would come under these six classes—as long as it does not serve as a staple or non-staple food—is allowed here.

Root medicine

The Canon defines life-long root medicine as follows: turmeric, ginger, sweet flag, white orris root, ativisa, black hellebore, khus-khus, nut-grass, or whatever other roots are medicines and do not serve as staple or non-staple food. With this, and all the remaining classes of life-long medicine, one may keep the medicine for life and consume it when there is a medicinal reason for doing so. If there is no such reason, there is a dukkaṭa for consuming it. As mentioned in the preceding chapter, there is a specific prohibition against eating garlic when not ill. In connection with the allowance for root medicine, there is also an allowance for a grindstone and a grinding wheel to reduce the medicine to a powder.

Astringent-decoction medicine

Here the Canon lists astringent decoctions from the neem-tree (Azadirachta indica), from the kuṭaja (Wrightia dysenterica), from the pakkava, from the nattamāla (Pongamia glabra), or any other astringent decoctions that are medicines and do not serve as staple or non-staple food.

Leaf medicine

The Canon’s list includes neem leaves, kuṭaja leaves, cucumber leaves (Trichosanthes dioeca), basil leaves, cotton-tree leaves, or any other leaves that are medicines and do not serve as staple or non-staple food. Aromatic oils made from such leaves would also fall under this category.

Fruit medicine

Here the Canon lists vilaṅga (Embelia ribes), long pepper (Erycibe paniculata), black pepper, yellow myrobalan (Terminalia chebula or citrina), beleric myrobalan (Terminalia balerica), embric myrobalan (Phyllantus embelica) (these last three form the triphala mixture still used in modern Ayurveda), goṭha-fruit, or any other fruits that are medicines and do not serve as staple or non-staple food.

Resin medicine

The Canon lists assafoetida, assafoetida-resin, assafoetida-gum, gum, gum-patti, gum-panni, or any other resins that are medicines and do not serve as staple or non-staple food.

Salt medicine

The Canon allows the following salts: sea salt, black salt, rock salt, culinary salt, red salt (which the Commentary defines as salt mixed with other medicinal ingredients), or any other salts that are medicines and do not serve as staple or non-staple food. The Parivāra (VI.2) mentions both natural and man-made salts as allowable. Modern medicines that are organic or inorganic salts would fit under this category.

Specific treatments

In addition to the general classes of medicines, Mv.VI lists allowable treatments for specific diseases. The stress here is on the word allowable: A bhikkhu is not required to use these treatments but he might want to familiarize himself with them so that he can apply the Great Standards to modern medicine in an informed way. Historically, this list, together with similar lists in the Vinayas of the other early schools, has played an important part in the spread of medical knowledge from India to the lands to which Buddhism spread in the rest of Asia. At present, it gives a fascinating picture of the state of medical art in the Buddha’s time.

For itch, small boils, running sores, an affliction of thick scabs, or bad body odor: One may use powders. To refine the powder, one may use powder sifters, including cloth sifters. As mentioned in Chapter 1, the Commentary states that for bad body odor all fragrant powders are allowable. The Canon allows the use of (powdered) dung, clay, and dye-dregs for one who is not ill. According to the Commentary, ordinary (unscented) chunam comes under “dye-dregs.”

For possession by non-human beings: Raw flesh and raw blood are allowed (!). The texts do not say whether this a medicine per se, or—if the non-human being is blood-thirsty—the bhikkhu should simply not be held responsible for eating such things.

For eye diseases: Ointments such as black collyrium, rasa-ointment (made with vitriol?), sota-ointment (made with antimony?), yellow orpiment (§), and lamp-black are allowed. Sandalwood, tagara (Tabernaemontana coronaria), benzoin gum, tālīsa (Flacourtia cataphracta), and nut-grass—all of which are fragrant—may be mixed in with the ointments. The ointments may be kept in boxes made of any of the standard ten materials (except for human bone, says the Commentary) but not in boxes made of fancy materials. The boxes may have lids, which may be tied to the boxes with thread or string. If an ointment box gets split, it may be bound together with thread or string. Ointment sticks may be used to apply the ointments, but again they must be made of one of the ten standard allowable materials. A bhikkhu may keep the ointment sticks in a case, and the ointment box in a bag. The bag may have a string for tying the mouth of the bag as a carrying strap.

For pains in the head: Apply oil to the head; give treatments (such as snuff medicine) up the nose; or have the patient inhale smoke. Nose-tubes (or nose-spoons), double nose-tubes (double nose-spoons), and smoke inhaling tubes are allowed but must be made from any of the standard allowable materials. One may keep lids, bags, and double bags for the smoke-inhaling tubes, and the bags may be tied at the mouth with a string for use as a carrying strap.

For wind afflictions: According to ancient Indian medicine, sharp pains in the body result from the provocation of the wind property. Dizziness is also counted as a wind affliction. The basic treatment is for the patient to drink a decoction of oil. The oil may be kept in a flask made of metal, wood, or fruit (e.g., coconut shell). Alcohol may be mixed in with the decoction, but not so much that the color, smell, or taste of the liquor could be detected. To drink oil mixed with excessive alcohol violates Pc 51. If too much alcohol has been mixed in with the oil, it may be determined for use as rubbing oil.

For wind afflictions in the limbs: Sweating treatments, sweating treatments with herbs, and a “great sweating” treatment are allowed. The Commentary gives directions for this last treatment: Use a hole dug lengthwise the size of a human being and fill it with burning embers, charcoal, or coals; cover it with sand or dirt, and then with various leaves that are good for wind diseases. Have the ill bhikkhu cover his body with oil and lie down on top of the leaves, turning over as necessary. Other treatments for wind afflictions in the limbs include hemp water (according to the Commentary, this means water boiled with hemp leaves; pour it over the body, cover the body with the leaves, and then get into a sweating-treatment tent) and a water tub, which the Commentary says is a tub big enough for a bhikkhu to get into. Hot tubs would come under here.

For wind affliction in the joints: Blood-letting and moxibustion are allowed.

For split feet: Rubbing-oil and foot salves are allowed. The Commentary states that the foot salve may include whatever liquor will help split feet to heal.

For boils: Lancing (surgery) is allowed unless the boil is on the genitals or near the anus (see below). Allowable post-operative treatments include astringent water, pounded sesame paste, a compress, and a bandage. The scar may be sprinkled with mustard-seed powder to prevent itching. It may also be fumigated, and the scar-tissue cut off with a piece of salt-crystal. The scar may also be treated with oil. An old piece of cloth is allowed for soaking up the oil, and every kind of treatment for sores or wounds is allowed.

For snakebite: A medicine may be made of the “four great filthy things”: excrement, urine, ashes, and clay (!). If there is someone present to make these things allowable, one should have him/her make them allowable. If not, one may take them for oneself and consume them. The Commentary notes that this allowance covers not only snakebite, but also any other poisonous animal bite. The Sub-commentary adds that for oneself here also includes cases where Bhikkhu X fetches these items himself for Bhikkhu Y, who has been bitten. Y, in such cases, is allowed to consume them. None of the texts mention this point, but an oral tradition in Thailand asserts that the excrement to be used in this medicine should first be burnt in a fire.

For drinking poison: Water mixed with excrement (!!) may be drunk. If one receives the excrement while excreting it, it does not need to be formally received again. The Commentary interprets this last statement by saying that if, while excreting, one catches the excrement before it falls to the ground, one need not have it formally offered. If it falls to the ground, one does. This, however, seems overly scrupulous. The parallel in the case of offering food is that if the food falls to the ground while being offered, it still counts as offered. The same principle should hold here.

For a sorcery concoction: According to the Commentary, a sorcery concoction is voodoo medicine made by a woman to put a man under her power. The antidote given in the Canon is to drink mud turned up by a plow. The Commentary recommends that it be mixed with water.

For constipation: The Canon recommends drinking alkaline liquid, and the Commentary gives directions for how to make it: Take cooked rice, dry it in the sun, burn it, and drink the liquid coming from the ashes.

For jaundice: Urine and yellow myrobalan are allowed, which the Commentary defines as yellow myrobalan pickled in cow urine. This raises the question: If this were the meaning of rancid urine medicine in the four supports, why would there be this special allowance?

For skin disease: A scented rubbing is allowed.

For a body full of bad humors: One may drink a purgative. After the purgative has worked, one may take clarified conjey (which, according to the Commentary, is the clear liquid from rice porridge, strained to remove all rice grains), clear green gram broth, slightly thick green gram broth (which the Commentary interprets as green gram broth that is not oily or greasy), or meat broth (which again, the Commentary says, is just the broth without any meat). Some Communities extend these last allowances for any occasion, but the Canon gives them in the context of an antidote to the effects of a strong purgative, so there are those who will extend the allowance only to cases where a bhikkhu is weakened by diarrhea or other similarly severe conditions.

As a general tonic: Loṇasovīraka (or loṇasocīraka—“salty sour gruel”), a fermented medicine, is discussed under Pc 37.

Medical procedures

A bhikkhu who has surgery (lancing) or hemorrhoid removal performed in the crotch or within the area two fingerbreadths around it incurs a thullaccaya. The word for crotch (sambādha) literally means “confining place,” and the area two fingerbreadths around it covers the anus and genitals.

It is interesting to note that brain surgery was known in the Buddha’s time (see Mv.VIII.1.16-20), and yet he did not regard it as dangerous as the procedures forbidden here. The Vinaya-mukha maintains that surgical technique has developed to the point where this prohibition is counterproductive, but post-operative complications from hemorrhoid surgery, for example, still arise fairly frequently. The Commentary states that if the scrotum is enlarged, one may apply medicines to it and warm it over the fire. None of the texts discuss alternatives to prostate surgery. Some Communities, following the Vinaya-mukha, would allow it whenever needed.

The Pali term translated here as hemorrhoid removal—vatthi-kamma—is a cognate of the Sanskrit term, vasti-karman, usually translated as the administration of an enema. However, the Commentary restricts its meaning to hemorrhoid removal, and it is possible that the Commentary is right, for Pali terms do not always have the same meaning as their Sanskrit cognates, and the idea of administering medicines through the anus may have first developed in the context of hemorrhoid treatment. The Commentary adds that even trying to remove a hemorrhoid by squeezing it with a piece of hide or cloth would come under this prohibition. However, it recommends as a safer alternative that one apply an astringent decoction to the hemorrhoid and tie off the end with string. If the hemorrhoid then falls off on its own, well and good. Furthermore, the Commentary allows any equipment, such as tubes, used to apply medicine through the anus—an explicit allowance for enemas.

As mentioned above, blood letting is allowed as a treatment for wind afflictions of the joints. For some reason, the PTS and Burmese editions of the Canon contain a separate general allowance for blood-letting at Cv.V.6. This passage is not in the Thai or Sri Lankan editions.

The Great Standards

Appropriately, the Khandhaka dealing with medicine ends with the Great Standards, as medical knowledge is so changeable over time, and variable from location to location, that there is a need for general principles to apply the rules of the Buddha’s time to our own. In this chapter, the rules about practicing medicine and the classifications of tonics and life-long medicines are timeless. In the sections on specific treatments and medical procedures, however, the only hard and fast rules are the prohibitions. Outside of the prohibitions, all modern medical procedures are allowed.

Rules