Buddhist Monastic Medicine

Summary

Buddhist monastic medicine is the medical tradition that developed within the early Buddhist sangha between the fifth century BCE and the fifth century CE. It was codified into the Vinaya Pitaka (the Buddhist code of monastic discipline) under a small set of doctrinal warrants: the Middle Way’s teaching that the body is to be neither indulged nor mortified, the Buddha’s instruction that monks must nurse one another, and the practical fact that lay donors expected the sangha to care for its sick. The tradition gave India some of its earliest hospitals and infirmaries, trained physicians at monastic universities like Taxila and Nalanda, codified a materia medica that overlapped extensively with the classical Ayurvedic compendia, and traveled along the Silk Road into Central Asia, Tibet, and China. The historian Kenneth Zysk has argued that it was within Buddhist monasticism that classical Indian medicine first acquired institutional form.

Why Medicine Became Monastic

Indian medical practitioners were excluded from brahmanic ritual life, as the Taittiriya Samhita declares that “medicine is not to be practiced by a Brahman, for he, who is a physician, is impure, unfit for the sacrifice.” (Zysk, 1991) Excluded from the orthodox social structure, physicians gravitated toward those who shared their alienation: the orthodox mendicants and the heterodox wandering ascetics, the sramanas, who had a penchant for more empirical and rational modes of thought. (Zysk, 1991) The Greek ambassador Megasthenes, writing around 300 BCE and quoted later by Strabo, confirms that physicians were a recognized subgroup of the sramanas, ranked second in honor after the forest-dwelling Hylobii; he reports they relied primarily on grain and diet rather than drugs, and that among their drugs they held ointments and poultices in highest esteem, testimony to an empirico-rational therapeutic practice current among ascetic physicians already at the Maurya court. (Zysk, 1991)

Among these sramana groups, it was the Buddhists who codified medicine into religious doctrine and monastic discipline. (Zysk, 1991) Zysk reads this as a doctrinal fit. Jainas knew medical theories and practices, but the severity of their ascetic discipline made the relief of suffering operate as a hindrance to spiritual progress; the Buddhist Middle Way, by contrast, made medical care doctrinally consistent. (Zysk, 1991) The Buddha’s teaching of the Middle Way between indulgence and self-denial required maintaining a healthy bodily state: equilibrium within the organism and between the body and its environment. (Zysk, 1991) Wujastyk notes the parallel: through all the classical Sanskrit medical texts, moderation in food, sleep, exercise, sex, and dosage is the central practical ethic, “a fundamentally Buddhist ideal, embodied in the Buddha’s Middle Way teaching.” (Wujastyk, 1998) The Pali canon also preserves the earliest Buddhist integration of humoral theory: in the Sivaka Sutta, the Buddha tells the wandering ascetic Sivaka that human suffering has eight causes: bile (pitta), phlegm (semha), wind (vata), their combination (sannipata), seasonal change, irregular activities, external agency, and karma; this formula directly parallels the Ayurvedic etiological scheme centered on the three dosas. (Zysk, 1991)

A second warrant came from the Vinaya itself: the Mahavagga records that the Buddha, coming upon a sick monk lying in his own urine and feces who had not been nursed because he was not useful to the others, nursed the monk himself and then propounded the rule: “You, O bhikkhus, have neither a mother nor a father who could nurse you. If, O bhikkhus, you do not nurse one another, who, then, will nurse you? Whoever, O bhikkhus, would nurse me, he should nurse the sick.” (Zysk, 1991) The institutional consequence was that nursing became a constitutive activity of monastic life. (Zysk, 1991) The Mahavagga lists the qualities of a competent nurse: he provides medicine, knows what is beneficial, nurses with kindly thought rather than greed, is not unwilling to remove feces, urine, mucus, or vomit, and gladdens the sick from time to time with talk of the dhamma. (Zysk, 1991) Zysk observes that Caraka’s fourfold lists of physician and patient qualities stand close to the Buddhist pattern, while Susruta’s lists use stock brahmanic vocabulary such as satya (truth), dharma (duty), and astika (orthodox piety), which he reads as a later Hindu veneer applied over an earlier codification shared with the Buddhist tradition. (Zysk, 1991)

Zysk rejects one popular but unsupported claim about how this medical orientation was structured. It is sometimes suggested that the Buddha’s Four Noble Truths were modeled on a medical schema of cause, symptom, cure, and non-recurrence. The fourfold division does occur in the Caraka Samhita, but it is not the dominant mode of systematized medical knowledge there, and its formulation differs from the Four Noble Truths in content; the analogy is, in Zysk’s reading, untenable. (Zysk, 1991)

The Vinaya Pitaka as Medical Source

The Vinaya Pitaka, the basket of monastic discipline, exists in six recensions across the major early Buddhist schools. The Indologist Erich Frauwallner, examining all of them, concluded that the medical chapter (Bhesajjakkhandhaka in Pali, Bhaisajyavastu in Sanskrit) belongs to the oldest stratum of the Vinaya, composed shortly before or after the second Buddhist council in the early fourth century BCE. (Zysk, 1991) This makes it, in Zysk’s reading, the earliest extant codification of Indian medical doctrine. (Zysk, 1991)

The medical material in the Vinaya is structured as a series of case histories (eighteen stories of sick monks and the treatments permitted to them) interleaved with rules that establish the basic resources of monastic medicine. (Zysk, 1991) One of the four basic resources (nissaya) provided to a new monk was putimuttabhesajja, putrid cattle urine as medicine, alongside alms food, dustheap robes, and tree-foot lodging, establishing medicine as one of the four life necessities of the order. (Zysk, 1991) Buddhaghosa’s fifth-century commentary on the Vinaya remains the principal source for understanding what these terms meant in practice. (Zysk, 1991)

The Vinaya recognized five basic medicines (clarified butter, sappi; fresh butter, navanita; oil, tela; honey, madhu; and molasses, phanita), sanctioned, the Mahavagga recounts, after monks at Savatthi suffered an autumn disease that Buddhaghosa identifies as an affliction of the bile humor pitta arising in autumn. (Zysk, 1991) As the sangha grew, the materia medica expanded into a full pharmacopoeia of fats, roots, extracts, leaves, fruits, gums, and salts. (Zysk, 1991) (Zysk, 1991)

The monk Pilindavaccha suffered from head-heat (sisabhitapa) treated with oil-on-the-head, nasal therapy, and medicated smoke inhalation, (Zysk, 1991) and from wind-in-the-joints (pabbavata) treated by bloodletting with horn-cupping. (Zysk, 1991) A certain monk, according to Buddhaghosa, suffered from being “body-filled” (abhisannakaya) with peccant humors (dosas), the first implied use of dosa in Buddhist monastic medicine. (Zysk, 1991) A monk with morbid pallor or jaundice (panduroga) was given a solution of cow’s urine and yellow myrobalan (haritaki), a treatment Caraka prescribes specifically for the same condition, evidence of direct continuity between the early Buddhist and Ayurvedic traditions. (Zysk, 1991)

The Vinaya prohibits surgical treatment within two finger breadths of the private parts and prohibits enema therapy (Zysk, 1991). This prohibition arose after the physician Akasagotta of Rajagaha lanced a monk’s rectal fistula and the Buddha objected (Zysk, 1991). Alternative treatments using bamboo splinters with caustic medicines or oil suppositories were established instead (Zysk, 1991).

The Vinaya’s toxicological material reflects what Zysk identifies as an ascetic stratum below even the Buddhist layer. The four “great foul things” specified for snakebite treatment — dung, urine, ashes, and clay — are associated by Zysk with extreme ascetic groups such as the Ajivikas, and only one or two of the four substances appear together in Caraka or Susruta, never the full quartet under that designation. (Zysk, 1991) That putimuttabhesajja (putrid cattle urine) was simultaneously one of the four basic monastic resources given to every new monk indicates that the sangha had absorbed practices from the furthest margins of the sramana world, then reframed them within a disciplinary code accessible to ordinary monastics.

Materia Medica

Zysk has shown that the Vinaya materia medica initially included five basic medicines, to which were added seven additional groups: fats, roots, extracts, leaves, fruits, gums or resins, and salts. (Zysk, 1991) The medicinal roots permitted to monks were turmeric (haridra), ginger (srngavera), sweet flag or orris root (vaca), white variety of sweet flag (vacattha), Indian atees (ativisa), black hellebore (katukarohini), vetiver (usira), and nut grass (bhadramusta); none of these appears in the Caraka and Susruta classification of root groups, indicating an independent classificatory tradition. (Zysk, 1991) The medicinal extracts were made from neem (nimba), kurchi (kutaja), pakkava, and Indian beech (naktamala); three of the four appear in Caraka’s antipruritic group (kandughna). (Zysk, 1991) The medicinal leaves included neem, kurchi, wild snake gourd (patola), holy basil (sulasi), and cotton tree (kappasika); Caraka and Susruta have no equivalent category of leaves, instead listing leaves diffusely as ingredients of various drugs. (Zysk, 1991)

The medicinal fruits include embelia (vidanga), long pepper (pippali), black pepper (marica), and the three myrobalans (chebulic, haritaki; beleric, vibhitaka; and emblic, amalaka) already grouped together in the Pali, the well-known triphala combination of later Ayurveda. (Zysk, 1991) The medicinal gums (jatu) include three types of asafetida (hingu) and three resins; a separate category of laksa resins appears in Susruta but not in Caraka, evidence of a Buddhist-Susrutan continuity not shared with the Caraka tradition. (Zysk, 1991) The five Buddhist medicinal salts (ocean, black, rock, culinary, and red) are essentially identical to Caraka’s fivefold list, with one minor synonymy difference. (Zysk, 1991)

The pattern across all eight categories suggests that the earliest classification of drugs in India was rooted in culinary tradition: the parallels with Caraka and Susruta’s chapters on foods and drinks (annapana) are, in Zysk’s reading, more striking than parallels with the more theory-laden later pharmacology, suggesting an original understanding of these substances as forms of nourishment and only secondarily as medicines. (Zysk, 1991) Where the Vinaya classifies fats by their animal source (bear, fish, alligator, swine, donkey), Caraka and Susruta classify them by ecological habitat, wetlands (anupa) versus drylands (jangala); this, Francis Zimmermann has argued, is a typically brahmanic systematization superimposed on the older source-classification, providing further evidence of a sramanic substrate beneath the brahmanic surface of classical Ayurveda. (Zysk, 1991)

Anatomy by Different Means

Buddhist ascetic anatomy was acquired through two practices closed to brahmanic practitioners by purity rules. The first was satipatthana, the meditative contemplation of bodily parts, in which the monk reflects on the body as a “skilled butcher of cattle” reflects on a slaughtered cow divided into parts at a crossroads, a method that suggests anatomical knowledge was acquired by observing animal dismemberment. (Zysk, 1991) The second was meditation on a decomposing corpse on a charnel ground. (Zysk, 1991) Susruta describes a more clinical version of the same practice: a corpse, intact and not severely poisoned, is wrapped in muñja or kusa grass, placed in a cage in a flowing stream for seven nights, then scraped layer by layer with grass-bunches. Because this method required contact with extreme impurity, it could not have originated in brahmanic settings. (Zysk, 1991) Hsuan-tsang in the seventh century and Albiruni in the eleventh both confirm that Buddhists disposed of dead bodies in flowing water, providing practical context for the dissection technique Susruta preserves. (Zysk, 1991)

Hospitals, Infirmaries, and Universities

Excavations at Kumrahar (Pataliputra) have uncovered a structure dating from around 300 to 450 CE with four rooms, two potsherds bearing the inscriptions “in the auspicious health house” (arogyavihara) and “of Dhanvantari,” and is read by Zysk as a Buddhist arogyavihara whose attached physician practiced in Dhanvantari’s surgical tradition. (Zysk, 1991) Fa-hsien in the early fifth century reported that at Pataliputra heads of Vaisya families established houses for dispensing charity and medicine, where the poor, the destitute, the maimed, and the diseased could resort and receive food, medicines, decoctions, and physician examination, and depart when recovered. (Wujastyk, 1998) (Zysk, 1991) Wujastyk treats this as one of the earliest descriptions of an organized civic hospital system anywhere in the world. (Wujastyk, 1998)

King Asoka’s second rock edict at Girnar (ca. 269-232 BCE) proclaims kingdom-wide medical treatment for humans and animals, importing and planting medicinal herbs, roots, and fruits, and digging wells and planting trees along paths. (Zysk, 1991) When Buddhism was submerged in India after 1200 CE, Hindu religious centers followed the Buddhist model and established infirmaries, hospices, and hospitals, and appear to have assumed the provision of medical services previously carried by the Buddhist monasteries. (Zysk, 1991) (Zysk, 1991)

Monastic universities formalized medical education. Taxila was the principal medical education center of ancient India: the lay Buddhist physician Jivaka studied seven years there, by Sanskrit and Tibetan accounts as apprentice to the semi-legendary Atreya whose teachings underpin the Caraka-samhita. (Zysk, 1991) By the seventh century CE, both Hsuan-tsang and I-tsing reported that Nalanda’s curriculum included medicine (cikitsavidya) as one of the five sciences, alongside Buddhist sastras, the Veda, logic, grammar, Atharvavedic magic, and Samkhya. (Zysk, 1991) By the fourteenth century, Tibetan Buddhist monasteries had inherited this curriculum from the Indian mahaviharas before the latter were destroyed; the Tibetan historian Bu-ston records that Vagbhata’s Astangahrdaya-samhita was the principal text for medical instruction. (Zysk, 1991)

Jivaka

The most renowned physician of the early sangha was Jivaka Komarabhacca, a lay practitioner who provided free medical care to the Buddha and the monks and donated his mango grove at Rajagaha (the Jivakarama) for use as a monastic site. His free service to the order is said to have attracted so many people to join the sangha that it created administrative problems. (Zysk, 1991) Legends about his medical feats survive in nearly all Buddhist scriptural traditions: Pali, Sanskrit, Tibetan, and Chinese.

Comparison of the Theravada and Mahayana versions of Jivaka’s life is itself a methodological tool. (Zysk, 1991) (Zysk, 1991) The Theravada Pali version emphasizes the pragmatic side of his career: three cases including a merchant’s wife’s seven-year head disease cured by nasal therapy with clarified butter, King Bimbisara’s rectal fistula cured by ointment applied with a fingernail, and the Buddha’s peccant humors cured by gentle purgations including a bath, lotus inhalation, and a restricted diet of mild foods. (Zysk, 1991) The Mahayana versions add esoteric magical elements, including a magical diagnostic device. (Zysk, 1991)

Spread Along the Silk Road

Theravada Buddhism, preserving the Pali canon, dominated in Sri Lanka and western Southeast Asia. (Zysk, 1991) Mahayana Buddhism, carried along Central Asian trade routes from the first century CE, became the official religion of Tibet in the eighth century. (Zysk, 1991) Indian medicine was assimilated nearly verbatim in Central Asia and Tibet. (Zysk, 1991) In China it had to be modified, with a four-element etiology overlaid on the threefold humoral theory and a threefold classification of treatment (religious, magical, and proper-medical) that incorporated Chinese acupuncture, moxibustion, and pulse-lore; the magico-religious aspects of esoteric and Mahayana Buddhism, especially the bodhisattvas of healing, were well-received because of the existing Taoist tradition of magical medicine. (Zysk, 1991) (Zysk, 1991)

The most striking single artifact of this transmission is the Bower Manuscript, found in 1890 by Lieutenant Hamilton Bower in Kuqa during a Great Game manhunt and dated to the late fourth or early fifth century CE. (Wujastyk, 1998)(Wujastyk, 1998) It originally belonged to a senior Buddhist monk named Yasomitra at the rock-cut monastery of Qum Tura on the Silk Route. (Wujastyk, 1998) The seven treatises it contains (three on Ayurvedic medicine, two on dice divination, and two of incantations against snakebite) confirm that Sanskrit-language Ayurvedic medicine was already in practical use across Central Asia in the first centuries CE. (Wujastyk, 1998) Among its contents is the Navanitaka medical recipe collection, a practical handbook transmitted along the trade route to China. (Zysk, 1991) The Chinese Buddhist Tripitaka preserves another trace of this transmission: a short text known as the Kasyapaprokta-stricikitsa-sutra (“The Sutra of Women’s Medicine Declared by the Sage Kasyapa”), lost in Sanskrit but surviving in a Chinese translation made by the Buddhist monk Dharmadeva who traveled to China in AD 973. Wujastyk uses this transmission date to place the lost Sanskrit original of the Kasyapa-samhita tentatively in the seventh century. (Wujastyk, 1998)

The Buddha Bhaisajyaguru, the “Teacher of Healing,” emerged as a figure of cult devotion in Central Asia or Kashmir during the third century CE and was important in China by the fourth. (Zysk, 1991) [GAP: The paragraph previously included unsupported claims about Bhaisajyaguru’s iconography (lapis lazuli and yellow myrobalan) which are not found in the cited source.]

What the Tradition Bequeathed

Zysk’s central interpretive claim is that the Buddhist monastery functioned as the institutional bridge between magical and rational Indian medicine. Sramana physicians wandering with mendicant ascetics formed the first repository of empirically-grounded medical knowledge, accumulating lore from different healing traditions across India unhindered by brahmanic strictures. Buddhism’s contribution was to give that knowledge institutional form: codifying medical doctrines in monastic rules, training monk-healers, establishing infirmaries and hospices, and aiding Buddhism’s diffusion throughout the subcontinent during and after Asoka. (Zysk, 1991) Zysk argues that Buddhist monasteries played the same institutionalizing role for Indian medicine that Christian monasteries played in medieval Europe — codifying practices, training healers, running infirmaries, and integrating medicine into monastic universities. (Zysk, 1991) The codification of medical practices within the monastic rules accomplished what Zysk treats as probably the first systematization of Indian medical knowledge and likely served as the model for the later medical handbooks; the monk-healers’ extension of care to the wider populace and the building of hospices and infirmaries also increased lay support of the monasteries. (Zysk, 1991) Hindu monastic institutions that succeeded the Buddhist ones inherited and continued the institutional pattern. (Zysk, 1991)

This is a revisionist thesis. (Wujastyk, 1998) It runs counter to traditional Ayurvedic teaching, which presents Indian medicine as a brahmanic science from inception. (Wujastyk, 1998) Wujastyk has argued the textual side of the same claim more cautiously, locating the emergence of classical Ayurveda in the sramana milieu of fifth-century-BCE North India and treating the Vedic-descent claim as a bid for social acceptance rather than evidence of historical lineage. (Wujastyk, 1998) On the question of why Vagbhata, the great seventh-century synthesizer of Caraka and Susruta, was probably from Sind and was taught by a teacher with the Buddhist name Avalokita and may himself have been a Buddhist, Wujastyk concedes that the evidence is inconclusive. (Wujastyk, 1998)

The blending of medicine and religion in Buddhism, Zysk concludes, remains an essential feature of Asian Buddhism today, a feature that distinguishes Buddhism from Western traditions in which medicine and religion separated. (Zysk, 1991)

See Also

• ayurvedic-medicine
• kenneth-zysk
• dominik-wujastyk
• susruta-samhita
• charaka-samhita
• middle-way
• tridosha
• panchakarma

Sources

• Zysk, K. (1991). Asceticism and Healing in Ancient India: Medicine in the Buddhist Monastery. Oxford University Press. [zysk-asceticism-healing-ancient-1991]
• Wujastyk, D. (ed. and trans.) (1998). The Roots of Ayurveda: Selections from Sanskrit Medical Writings. Penguin Classics. [wujastyk-roots-of-ayurveda-1998]