Divyen Shah
Centre of Jaina Studies Newsletter: SOAS - University of London
In the earliest Śvetāmbara canonical scripture, the Ācārāṅga, is found a list of 16 diseases, interpreted as associated with a rise in karmic particles.[1] Disease and human suffering is a product of and also results in karmic particles that stick to the soul and form a barrier that has to be shed before a perfect body and kevalajñāna is obtained. The question of how to deal with disease was not only of soteriological importance to the Jainas but would also have been of practical importance to the Jaina mendicant in everyday life. Of interest for the modern medical professional are views on disease and treatment as found in the scriptures, the understanding of health and disease at the time, and how they compare to our understanding of health and disease today. This essay focuses on aspects of ancient Jaina concepts of health and disease from the point of view of modern medicine not yet discussed in the modern commentary literature.[2]
Health and Disease in Canonical Scriptures
The list of sixteen diseases first appears in the Ācārāṅga I.1.6.1.3.2-3, the first of the 12 Angas and representing content dating back to perhaps 300 BCE:
Boils and leprosy, consumption, falling sickness, blindness and stiffness, lameness and humpbackedness. Dropsy and dumbness, look! apoplexy (?) and eye-disease, trembling and crippledness, elephantiasis and diabetes.... [B]esides them many illnesses and wound occur.[3]
Why has this group of sixteen diseases been singled out in the scriptures? Many of these conditions are progressive and have a propensity to become chronic. In the absence of effective treatment they cause prolonged suffering, e.g. tuberculosis, leprosy and diabetes. Other conditions may result in visible disfigurement or disability such as goiter, boils, paralysis (possibly due to cerebral palsy if present in early childhood or stroke in later life), 'dropsy' (oedema from heart, kidney or liver failure) and elephantiasis. Individuals would also have been affected by more acute (short duration) illnesses, not mentioned in this list, from which they would have either recovered completely or would have died.
(Detail) Folio 115v from a Prakrit Kalpasūtra Manuscript: Mahāvīra preaching to the universe c. 1503 Asian Collection: MS INDIC GAMMA 3 © Wellcome Library, London
Epilepsy, or the tendency to suffer from fits or seizures included here, demonstrates a sophisticated approach as it is regarded as a disease rather than simply as a strange or even supernatural phenomenon. Bollée (2003:166) gives a description of epilepsy from the Ṭīkā (213a 2f.):
[T]he corresponding distinction between reality and the opposite disappears and a living being experiences a condition of confusion, faintness and the like, for it is said: 'Intense confusion and possession, excessive repugnance and loss of memory should be known as the four-fold characteristics of the horrible disease called epilepsy.
This is a relatively accurate description of our present understanding of the symptoms of a grand mal epileptic seizure or fit; 'possession' may refer to the seizure itself consisting of eyes rolling back, tonic back arching, clonic jerking and loss of consciousness. We know that the post-ictal state is accompanied by memory loss and confusion.
The Causes of Disease
In her eloquent cultural study of the Niśītha Cūrṇi, a 7thcentury commentary on the fourth of the Cheda Sūtras, Madhu Sen (1975: 182) describes how the Vejjasattha, an ancient treatise on medicine attributed to the sage Dhanvantari, who is regarded as the patron of Ayurveda, would have been studied by physicians in training and was also followed by the author of the Niśītha Cūrṇi. The basis of this system was the three fundamental body elements or humors which were required to be in balance during good health: vātita caused by disturbance of vāta (air or wind), pittiya caused by disturbance of pitta (bile) and siṃbhia caused by disturbance of siṃbha or kapha (phlegm). Disturbance of this balance was thought to result in disease, and treatments and remedies were based on restoring balance of any or all the humors. As to the cause of ill health, the Sthānāṅga II.9.13, the third Aṅga of the Śvetāmbara canon, outlines nine sthānas or reasons.[4] These are:
- Atyāsanasitting for prolonged periods or overeating
- Ahitāśanasitting in 'harmful' posture or eating 'harmful' foods
- Atinidratoo much sleep
- Atijāgaranatoo little sleep, or literally staying awake too long
- Ucchāra-nirodharestraining the urge to pass stool
- Prasravaṇa-nirodharestraining the urge to pass urine
- Adhvagamanaexcessive walking
- Bhojana-pratikulataunsuitable meals
- Indriyārtha-vikopanaexcessive sensuous pleasures
Through the ages and even today, many of these would be regarded as common and accepted adages as contributors to poor health even though as yet there may be no scientific evidence. It is commonly believed that many diseases may be precipitated, if not actually caused by, factors of increased stress and overindulgence.
On Giving and Receiving Medical Treatment
Ācārāṅga I.1.8.4 tells us that Mahāvīra did not accept medical treatment:
The Venerable One was able to abstain from indulgence of the flesh, though never attacked by diseases. Whether wounded or not wounded, he desired not medical treatment. Purgatives and emetics, anointing of the body and bathing, shampooing and cleansing of the teeth do not behove him, after he learned (that the body is something unclean).[5]
The use of medication in this instance is regarded as indulgence of the flesh.
Sen explains that according to the Niśītha Cūrṇi there were broadly two sorts of treatments available at the time.[6] One involved cleansing of the body (saṃsohaṇa) by means of emetics and purgatives and the other involved the use of medication (saṃsamaṇa) by 'the pacification of the deranged elements' and humors. The regular use of purgatives and emetics would have been an important part of the health maintenance ritual. Given that medical treatment involves hiṃsā, and that Mahāvīra did not accept medical treatment, it is not surprising that the giving of medical treatment by a physician and receiving of medical treatment by a mendicant is also viewed with ambivalence:
'Knowing that these diseases are many, should the afflicted search after (remedies)?' See! they are of no avail, have done with them! Sage! see this great danger! Do not hurt anybody! (Ācārāṅga I.1.6.4).[7]
The inference is that the suffering of disease should be endured rather than seeking remedies and relief. By seeking remedies, hiṃsā may be committed and further karmas will be acquired. However, later in Ācārāṅga II.2.2.13, passive acceptance of this basic surgical management is acceptable:
One should neither be pleased with or prohibit.... (a householder) if he extracts or removes a splinter or thorn from (the mendicant's feet); If he extracts or removes pus or blood from them.... If he incises it with any sharp instruments; if after having done so, he extracts pus or blood from it. If he rubs a boil, abscess, ulcer, or fistula.[8]
As an aside, incision and drainage still remain the mainstay of surgical management for large abscesses. In the Jaina landmark non-canonical Tattvārtha Sūtra,[9] Umāsvāti clarifies that merely inflicting pain does not cause the inflow of pain-producing karmas but the evil motive behind inflicting the pain does, thus helping save the soul of the surgeon who inflicts pain to help treat his patient, from acquiring these karmas!
Conception, Embryology and Birth
Ideas about conception and embryology are present in the earliest Jaina canonical texts. There is an understanding that the presence of semen in the uterus is necessary for conception to take place:
Man is born...through seminal effusion into the woman's uterus, and composition of pre-foetal flesh and muscle (i.e. embryo five days old), and development of various limbs. After birth he gradually grows and matures.[10]
These ideas are further elaborated in the Bhagavatī (BS), the fifth of the 12 Agamas.[11] The mixing of the male semen with female menstrual discharge has the potential to give rise to up to 900,000 offspring.[12] The semen implanted in the womb is thought to be viable for up to 12 muhūrtas and the duration of pregnancy can last for up to 12 years' duration in humans.[13] The Tandulaveyāliya goes into greater detail such as sex determination of the fetus.[14] When the male and female germ cells come together, a preponderance of sperm cells brings about a male fetus whereas a preponderance of female germ cells brings about a female fetus. This Jaina model of conception is closer to that accepted by modern science than an earlier 5th-century BCE model postulated by Hippocrates in ancient Greece that both men and women are capable of producing either 'strong' germ cells or 'weak' germ cells.[15] When germ cells from the two parents come together, a preponderance of strong germ cells produces a male whereas a preponderance of weak cells produces a female.
According to Umāsvāti's commentary, the soul absorbs the zygote or mass of cells produced by the combination of the semen and the blood in the womb of the mother and builds it into a physical body.[16] The embryo was believed to receive nourishment secondary to the liquids that the mother consumes,[17] and there was also the notion that the fetus receives nourishment through the two (umbilical) cord connections between the mother and the fetus.[18] However, according to the Jaina scriptures the fetus did not produce stool, urine, phlegm, bile and vomit.
Our present understanding is that sperm probably survives a matter of hours in the uterus. In terms of fetal development, urine production in-utero is an important sign of functioning and normal kidney development. Fetal urine production, which starts before the second trimester continues throughout gestation and makes up an important component of amniotic fluid that the fetus drinks.[19] In cases of abnormal or absent kidney development, diminished amniotic fluid production is associated with lung hypoplasia and may be incompatible with life. We also know that under certain circumstances, the fetus is capable of passing stool just prior to birth.
The Bhagavatī goes on to elaborate that in the newborn, the soft components, i.e. the flesh, blood and brain, are of maternal derivation whereas the hard components such as bone, hair and nails are of paternal derivation.[20] The fetus in utero lies in various positions and seems to share many of the mother's states of mind, being awake, asleep, happy or sad when the mother is the same.[21] Even today, the notion that maternal wellbeing reflects fetal wellbeing remains a popular adage.
Interestingly, at the end of this section of embryology there is a recognition that a child born cephalically (head first) or by breach (feet first) will survive whereas a child born "sideways" will die.[22] Modern midwifery and obstetric recognizes that such a fetus in "transverse lie" or compound presentation commonly requires delivery by Caesarian section in order to avoid serious birth injury or death of the infant.
Conclusion
Notions of health and disease would have been of soteriological importance as well as of practical importance to Jaina mendicants. There is a sophisticated understanding of embryology. There are ambivalent views in the scriptures on accepting medical treatment. With a very limited number of effective treatments available, people may have died of acute illnesses that are easily cured today. This review demonstrates that the sixteen diseases listed in the Acārāṅga are chronic diseases and hence ideal to illustrate the lasting negative effects of karman.[23]
Divyen Shah is a consultant neonatal paediatrician at the Royal London Hospital with a special interest in brain injury and neuroprotection in the newborn. He is also an associate student in the Non Violence in Jaina Literature, Philosophy and Law course at SOAS.