In 1941, Ho Kai Cheong (何繼昌), a Guangdongese herbalist born in Malaya, established a modest tea stall in Ipoh, which eventually grew into Ho Yan Hor (何人可), today’s most iconic Chinese herbal tea brand in Malaysia. Rooted in a multi-ethnic community and shaped by an industry-driven economic context, the brand has evolved over 84 years from a local enterprise into a heritage icon and a leading pharmaceutical company with a global presence (Ho Yan Hor Museum, 2025). Despite the long-standing presence of Chinese herbal tea in Malaysia, research on its cultural heritage and social impact remains limited.

Tin and Tea: Creating Wealth and Health in Perak

Located on the west coast of the Malay Peninsula in Malaysia, Perak’s prominence began with the discovery of tin in Larut in 1848. This discovery catalyzed rapid development as mining activities proliferated throughout the 19th century, attracting significant Chinese immigration (Khoo and Abdur-Razzaq 2005, 15–20). Under colonial administration, Perak emerged as a leading tin producer, contributing over half of Malaya’s tin output and accounting for a quarter of global production. Tin mining brought significant prosperity and population growth to the region. In addition to tin, rubber played a crucial role in shaping Perak’s economy and attracting a large influx of laborers. By 1947, the Chinese diaspora in Perak had reached 444,509, constituting 46.6% of the state’s total population and surpassing both the Malay and Indian populations (Economic History n.d.). The Chinese maintained a high percentage among the ethnic groups for the following decades.

The 19th century witnessed the concurrent development of traditional and colonial healthcare systems in Malaya. Indigenous and folk medicine practices were prevalent throughout the peninsula. Traditional Chinese medicine (TCM) has long been an integral part of local community in Malay Peninsula. In 1879, Eu Kong, a native of Guangdong, established the first Chinese herbal medicine shop, Yan Sang, in Gopeng, Perak. It subsequently evolved into Yu Yan Sang (餘仁生), a highly esteemed listed company specializing in the production and sale of traditional Chinese herbs and medicines (Yeung 2004, 138). The practice of traditional Chinese medicine continued to grow, and in 1925, the Perak Chinese Herbal Medicinal Hall was established in Ipoh, further advancing its accessibility and influence in the region (Wong et al. 2019).

During World War II, Malaya, which included the state of Perak, underwent significant economic, social, and political transformations. The conflict resulted in widespread poverty, scarcity of resources, and severe health issues, burdening the population’s access to healthcare services. Government records show that public health deteriorated seriously in 1940s. Malaria was the great killer, although dysentery and malnutrition probably contributed to a significant portion of the mortality (Annual Report 1947, 68). After the war, the Perak Chinese Physicians Association and the Perak Chinese Physicians and Druggists Association were established, reflecting the growing demand for traditional Chinese medicine (Wong et al. 2019). In 1947, the Perak Choong Wah Hospital (霹靂中華醫院) was established by the Association to provide charitable, non-profit healthcare for the underprivileged (Perak Choong Wah Clinic 2025).

Chinese herbal tea, a folk healing tradition also known as “cooling teas,” was introduced to British Malaya alongside the introduction of Chinese medicine. Typically, a Chinese physician prescribes a remedy in the form of a formula consisting of multiple components. These formulas are usually boiled for a specified duration to produce a medicinal liquid known as a tang (湯), or decoction. In contrast, Chinese herbal tea uses much simpler formulas with only a few ingredients, which are typically local and readily available plants (Zong and Liscum 1996, 2). Chinese herbal tea has been popular in Southern China for centuries and are celebrated for their distinctive abilities to clear heat and detoxify. These teas come in a variety of formulations, each containing a broad spectrum of bioactive compounds (Liu et al. 2024). It is tailored to address common ailments such as dyspnea, rapid breathing, cough, or phlegm-related conditions. In early 20^th century, Chinese herbal tea shops were promoted in Southeast Asia and other countries. Among these, the most renowned was Wong Lo Kat herbal tea (Guo 2024).

The Legacy of Ho Yan Hor

The history of Ho Yan Hor herbal tea traces back to the 1940s, originating on Treacher Street in Ipoh, Perak. Ho Kai Cheong, the founder of Ho Yan Hor, was born in 1910 in Kati, Perak. His parents, who hailed from Panyu, Guangdong, operated a dim sum café in Kuala Kangsar. Ho was sent to his ancestral hometown, Panyu, in 1918 to further his education, returning to Malaya in 1924 (Ho Yan Hor Museum 2025). His early exposure to traditional learning and subsequent experience working at a Chinese medical hall nurtured his lifelong interest in Chinese medicine. Inspired by his passion for Chinese Medicine, Ho pursued further studies at the Ganton Wah Lam National Physician’s School in Hong Kong, from which he graduated in 1940, obtaining professional training in Chinese medicine (Fig. 1).

Ho began his career as a Chinese physician in 1941, but ceased due to the Japanese occupation. Following the war, miners in Perak began rehabilitating their mines and sought workers to resume operations. Ho Kai Cheong realized that many Chinese colliers suffered from colds, runny noses, and fevers due to body heat. This rekindled his passion for Chinese medicine, and he developed a flu remedy based on a carefully formulated blend of Chinese herbs, including those for dispelling body heat and Eight Formula sugar cane extract, which helps to dispel exogenous influences.

With an initial modest capital of $4, Ho Kai Cheong established his first tea stall on Teacher Street, offering the herbal remedy as a natural solution to alleviate these conditions (Fig. 2). Timing his sales to coincide with the return of coolies and workers in the afternoon and into the night, he was surprised when the herbal tea sold out at 5 cents a glass within less than an hour. His tea went on to eventually gain widespread popularity in the community.

Typically, Chinese herbal preparations involve processing dried herbs into powdered, coarsely ground, sliced, or fragmented forms, while fresh herbs are sliced or torn to maximize their surface area (Wu et al. 2018). In 1947, Ho Kai Cheong introduced an innovative concept: packaging Ho Yan Hor Herbal Tea for sale in coffee shops and Chinese medical halls (Fig. 3). Priced at ten cents per pack, the tea became a popular remedy among the local residents. Ho soon became known publicly as the “King of Herbal Tea.”

As indicated in Table 1, Ho Yan Hor herbal tea is formulated with a combination of various herbs traditionally used in Chinese medicine. Unlike common herbal cooling teas in Guangdong, such as Wong Lo Kat and the popular “Twenty-Four Flavors,” which mainly include herbs like chrysanthemum, honeysuckle, prunella vulgaris, and licorice, the Ho Yan Hor formula features a broader array of potent medicinal ingredients (Guo 2024). The formula incorporates potent heat-clearing and detoxifying agents, such as scrophularia, gardenia, and rhubarb, as well as herbs that dispel wind and dampness to alleviate symptoms of external colds and body aches. Additionally, it contains ingredients like atractylodes lancea, which dries dampness and supports the spleen, and licorice root to harmonize the potent medicinal properties. This creates a balanced remedy that maintains wellness by addressing both acute external symptoms and chronic internal imbalances. In times when aspirin and antibiotics were not readily available, it served as a highly effective treatment for such ailments (Ho 2009, 691).

Table 1. Ho Yan You Herbal Tea Formula in the 1940s.

Commercialization and Globalization

Building on the success of Ho Yan Hor herbal tea, the Ho Yan Hor Medical Hall was officially established in 1948. Several signature Chinese medicine products had been developed, including Ho Yan Hor Oil (何人可油), Ching Tim Kam Jik San (清甜疳積散), and Ko Kou Tan (可口丹). The continual growth reflected the local demand for traditional remedies.

In 1957, the Asian Flu spread rapidly across the globe (Honigsbaum 2020). During this time, Ho Yan Hor herbal tea gained popularity as an alternative remedy to Western medicine, valued for its perceived effectiveness in relieving symptoms such as fever and dizziness, promoting self-healing, and providing accessible household relief from influenza. The Ho Yan Hor factory, established in 1954, employed workers in the manufacturing process, marking the beginning of its modern commercialization. Recognizing the importance of marketing, Ho utilized innovative strategies, such as equipping his distribution vehicle (a Fordson van) with loudspeakers to advertise the benefits of his products across neighborhoods.

In the 1960s, Ipoh was home to numerous herbal tea vendors, many of whom hired young women known as “herbal tea ladies” (leong char mooi) to attract customers. Large Ho Yan Hor tea stalls also sprouted across the country. Leveraging his strong connections with Hong Kong, Ho Kai Cheong capitalized on the widespread popularity of Guangdongese opera and Hong Kong cinema among Chinese communities in the 1950s and 1960s. Famous performers from Hong Kong, including actress Tang Pik Wan (鄧碧雲) and TVB actor Cheng Gwan-Yin (鄭君綿), were invited to visit Ipoh for promotional events. Ho Yan Hor has consistently produced a series of advertisements in major newspapers across the country, with small-sized ads that consistently convey a continuous message to reinforce consumers’ brand recognition (Vijayan 2022). It registered its trademark and officially established its first overseas brand in 1960. By the 1970s, the brand had expanded its sales to include other countries such as the United States, the United Kingdom, and New Zealand (Fig. 4).

Since the 1980s, the depletion of Perak’s tin reserves and the global downturn in natural rubber demand have ushered in a period of economic transition. In response, the state government pursued diversification by promoting manufacturing as a new growth engine, supported by expanded infrastructure and industrial development. Industrial estates were progressively established across Perak (Perak Investment Management Centre 2025). Ho Yan Hor has responded by introducing new herbal varieties tailored to specific health needs, modernizing packaging, and rebranding to attract younger consumers while maintaining its heritage.

The original recipe has since undergone systematic refinement and expansion to include 31 herbs to maximize the therapeutic value and health benefits of the herbal tea (Table 2). The new formula is crafted to clear heat, dispel dampness, regulate qi, and alleviate pain. It is conveniently packaged in aluminum cans. Additionally, the introduction of these new products and packaging has reinforced the brand’s message of promoting herbal wellness among all Malaysians.

Table 2. Ho Yan Hor Herbal Tea New Formula

The Malaysian herbal tea market has experienced significant growth in recent years, fueled by consumers’ increasing preference for natural, health-promoting alternatives to caffeinated drinks. The market showcases innovations in herbal blends, sustainable packaging, and convenient wellness products (Mobility Foresights 2025). Amidst growing competition and changing consumer lifestyles, Ho Yan Hor has adapted by introducing functional teas such as Gold Tea, Night Tea, and the Everyday Series, thereby maintaining its position as Malaysia’s leading brand with the most diverse range of herbal teas, the evolution of its manufacturing and packaging not only demonstrates the brand’s progression through different historical stages but also reflects Malaysia’s broader industrialization and shifting consumer market trends.

Cultural Heritage and Medical Transition

Malaysia, with its rich biodiversity and multicultural traditions, fosters the development of a dynamic Chinese herbal tea and medicine sector. Remedies based on local flora are still prevalent in households and present significant potential for the creation of new herbal products. After the war, Perak experienced significant political and economic transformations that facilitated modernization and rapid development. The ascent of Ho Yan Hor, established in Perak during the 1940s and later expanding nationwide, coincided with these broader economic and industrial changes. The increasing popularity mirrored robust local demand for healthcare and the adaptation of traditional remedies to evolving social contexts. Despite the creation of Western health institutions, traditional medical practitioners maintained a dominant role within local communities (Mohd Sukri 2020). By 2024, the number of Chinese medicine practitioners had continued to grow, with 402 Chinese medicine halls and 482 registered physicians, though the actual figures are likely even higher (FCPMDAM, 2016).

Herbal tea remains highly popular in Malaysia, reflecting both enduring cultural traditions and increasing health awareness among consumers. Market analyses project that Malaysia’s herbal tea industry will expand from USD 1.2 billion in 2025 to USD 2.7 billion by 2031, registering a compound annual growth rate of 14.3% (Mobility Foresights 2025). Rich in bioactive compounds, herbal teas possess antioxidant, anti-inflammatory, antiviral, and hepatoprotective properties, and are traditionally valued for their ability to clear heat, reduce fever, soothe the throat, and relieve coughs (Lin, Li, and Huang, 2024).

Notably, significant ethnic differences exist in the knowledge and consumption of Chinese herbal tea across Malaysia. A survey in Kedah, northern Malaysia, found that many Chinese consumers maintain this practice as a cultural tradition, motivated by its perceived safety and health benefits (Teh, Jaafar, and Asma 2020). Over the past century, herbal tea has become not only a cultural emblem but also a prosperous business sector. Chinese entrepreneurship has been pivotal in shaping Malaysia’s societal and economic development. Perak has rapidly evolved from its traditional economic foundation of tin mining and related industries to a diversified array of manufacturing and service sectors, ranking as the seventh-largest by economic size and contributing 5.5% to the national GDP in 2020 (Zafri and Morhalim 2022). As of 2020, the Chinese community in Perak numbered 643,627, constituting 27.22% of the state’s population, with the highest concentration in Ipoh (Jiao and Singh 2024).

Since the 1980s, the narrative of Ho Yan Hor has embarked on a new chapter, characterized by a shift from traditional remedies to modern pharmaceutical manufacturing. Following the succession from Ho Kai Cheong to his son, David Ho, the family business evolved into a research-driven pharmaceutical enterprise. Upon his return in 1980, equipped with professional training in pharmacy, David Ho established Hovid Berhad, bringing innovation, scientific production, and modern management practices. By the 1990s, Ho Yan Hor had evolved from a traditional herbal brand into a GMP-certified and Halal-accredited pharmaceutical manufacturer with an expanding international presence. Importantly, while numerous traditional herbal products exist, few have successfully transitioned from folk remedies to high-value modern biomedical brands. Thus, the case of Ho Yan Hor and Hovid presents a particularly significant and insightful example of this evolution.

Conclusion

The historical trajectory of Ho Yan Hor embodies the post-war evolution of Chinese herbal tea cultural heritage in Malaysia within the socio-economic transformation of Perak. This traditional herbal beverage adapted to processes of industrialization and commercialization, reflecting the broader modernization of traditional Chinese medicine in the country. The sustained success of Ho Yan Hor demonstrates how traditional Chinese medical knowledge can be reinterpreted and institutionalized within modern pharmaceutical frameworks. By fusing heritage-based practices with Western scientific production, marketing strategies, and regulatory standards, the company has evolved from a local family enterprise into a modern pharmaceutical corporation of both national and global relevance, serving as a model of cultural continuity amid technological and economic change.

As one of Malaysia’s most prominent functional herbal teas, Ho Yan Hor’s legacy extends far beyond being “just a cup of tea”; it is a testament to the enduring value of Chinese herbal medicine and its seamless integration with modern consumption advancements. Its evolutionary journey reflects how traditional remedies can evolve through innovation while retaining their cultural essence. This synthesis not only strengthens the brand’s position in the industry but also serves as an inspiring model for the broader healthcare sector, offering insights into how traditional and modern medicine can work in harmony to meet evolving health needs.

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Authors

Corresponding author: Dr. Su Qiuyang, mysunnysu@gmail.com

Su Qiuyang (https://orcid.org/0009-0005-4541-0681; BA, Sun Yat-sen University; MBA, Peking University; PhD Candidate, University of Malaya) has worked in the healthcare sector for many years as a senior manager and has authored a series of articles, interviews, and in-depth reports on culture and healthcare reform. Her current doctoral research at the University of Malaya focuses on the history of traditional Chinese medicine and its development among Overseas Chinese communities in Malaysia.

Prof. Danny Wong Tze Ken (https://orcid.org/0000-0002-4357-7753) is Professor of History at the Department of History, Faculty of Arts and Social Sciences, Universiti Malaya where he teaches history of Southeast Asia and History of China. His research interests include the Chinese in Malaysia, China’s relations with Southeast Asia and History of Sabah. He is currently Dean of the Faculty of Arts and Social Sciences, Universiti Malaya. He was Director of Global Planning & Strategy Centre, Universiti Malaya and former Director of the Institute of China Studies and former Head of the Malaysian Chinese Research Centre at the same university.

Dr. Tan Miau Ing (https://orcid.org/0000-0001-9129-6641; PhD Saharan Cina Malaysia, Universiti Malaya; M.Econ and B. Econ, Universiti Kebangsaan Malaysia) is Senior Lecturer of Department of History, Faculty of Arts and Social Sciences, University of Malaya. She is also the Head of Malaysian Chinese Research Center (MCRC) of UM.

Herbal drugs have long been valued not just for their effects, but where they come from. The origins of drugs are thought to be important indicators of their quality and their efficacy, and scholars and pharmacists around the world have paid attention to this for centuries. It is thus rare to find new data that allows us to rethink the early tradition in fundamental ways. An article of mine titled Mapping the Bencao, recently won an academic prize, so I thought I would write a brief summary of the article and its implications.

The study uses Digital Humanities to produce new data that challenges long-held assumptions about the origins and geography of Chinese materia medica. By digitally tagging a critical edition of an early Chinese pharmacological text, I was able to analyze its contents in new ways. In particular, by tagging it with historical GIS points, and rendering them in open-access platforms, I was able to produce maps of the locations where drugs were produced in early imperial China.

The practice of reading maps is very different from the way we encounter drug locations in a text. When reading a text, names pop up that may sound familiar or jog the memory, but for the most part, they fall into the background. You don’t get a sense of where they’re from, just the significance of the name of the place. The digital map however, reveals the geographic distribution of Chinese drug cultures in a way never before seen. It brings the drug locations into relationship with one another, and also in relationship to the local landscape. In particular, it showed a surprising fact—that almost all sites of production described in the texts were located on rivers or lakes, not on mountains, as imagined in the tradition.

At the heart of this study is the bencao 本草 tradition — China’s vast pharmacopoeia literature — and its multiple textual layers, especially the Materia Medica of the Divine Farmer, the Supplementary Records by Famous Physicians, and Tao Hongjing’s 陶弘景 Collated Annotations. Together with a team of colleagues, students and research associates, at the Max Planck Institute for the History of Science, National Taiwan University, Dharma Drum Institute of Liberal Arts and Nanyang Technological University, we created a digital, searchable edition of this layered text with the MARKUS and DocuSky platforms. Each entry is tagged for properties like taste, temperature, toxicity, preparation, and—crucially—place of origin. These tags were then matched to historical maps and GIS data from Academia Sinica, allowing researchers to visualise where drugs were sourced over time.

The resulting images tell a story that textual readings alone cannot. While scholars like Yamada Keiji had previously identified the loess plateau as the origin of Chinese drug lore, this map reveals a dense corridor of medicinal activity stretching along the Yellow River from the Bohai Sea through Chang’an (modern Xi’an), and into the Sichuan basin. This “Yellow River Corridor” turns out to be a riverine highway of drug trade and knowledge, connecting regions once thought peripheral to the canonical centers of Chinese medicine.

This view allowed me to rethink early drug lore not as a product of isolated Daoist mountain sages, but as a vibrant, decentralised network of drug production and exchange along rivers, mountains, and trade corridors. Because these sites were locations of trade rather than fixed points of botanical origin, the paper reimagines these locations as “drug production” sites — nodes of social-technological activity where wildcrafting, preparation, and trading translated these “wild objects”, or raw materials, into culturally legible medicinal products. Some places, like Taishan and Songshan, have long been famous in Daoist or medical traditions, but others — such as Hanzhong and Jianping — emerge in this study as waypoints in the drug trade. These places acted as bottlenecks or crossroads, showing that pharmacological knowledge flowed along human routes of exchange rather than solely sprouting from mountain hermitages or elite academies.

One particularly important case study is the recently excavated medical texts from Laoguanshan 老官山, near Chengdu in southwestern China. Though geographically distant from the central plains, the herbal repertoire of this tomb text is particularly concentrated in east and northeast China, especially Shandong province. This challenges assumptions about regional isolation and suggests that even in the 2nd century BCE, medical knowledge travelled widely. By comparing drug names in the Laoguanshan text with those found in the digitised bencao corpus, the paper argues that the Laoguanshan text reflects an eastern herbal vocabulary, perhaps preserved through trans-regional networks that may have navigated along the Yellow River.

One takeaway is that digital tools can radically transform how we understand traditional medical knowledge. Not only do they allow for granular philological tracking of drug names and their changes over time, but they also help visualise sociotechnical systems of exchange. I argue for moving beyond elite literary imaginations that saw drug knowledge as flowing from Confucian doctors or Daoist adepts. Instead, I encourage readers to see pickers, traders, sellers, and users — actors often marginalised by Confucian social mores —as part of a complex polyglot system where knowledge was dynamic, negotiated, and deeply embedded in place.

I also argue that this open-source data could be used for other kinds of research. For example, to look again at concentrations of regional trade, or to geo-locate literature, like poems or strange tales, that favour drugs from particular regions.

This work also speaks to present-day concerns in ethnopharmacology, bioprospecting, and data equity. Just as ancient Chinese physicians debated drug authenticity, modern researchers must wrestle with how traditional knowledge is extracted, named, and validated — often by those with the most institutional power. Through careful data stewardship and open-access publication, we can provide a more ethical and inclusive way to explore and share historical medical data.

Ultimately, Mapping the Bencao is more than a historical study. It’s a compelling case for how digital humanities can not only preserve the past but reconfigure our understanding of it. The rivers and roads that once carried herbs and recipes are now mirrored by data pathways and linked ontologies — but the questions remain the same: who knows what, where does knowledge live, and how do we value it?

The twenty-minute film Traditional Medicine in Southern Laos: A Documentary tells the stories of traditional medicine practitioners in the lowlands of Champasak Province in the far south of Laos, mainly through their own words. It features the places and people where I conducted ethnographic fieldwork during 2015–16 as part of my PhD in anthropology.^[1] Since then, I have regularly visited, shooting this video footage in 2019 and eventually completing the documentary in 2023.

The three elderly men featured in the film are at the center of both the research and the film—as teachers, guides, and collaborators. While staying in their homes or the nearby village or health facility, I learned about their medical practices, recorded herbal prescriptions, collected plants during trips to the forest and in their gardens, observed them create medicines, interact with patients, and conduct rituals—and had long talks about their approach to work and life.

All are from the same generation, born before the revolution when Laos was still in the process of gaining independence from French colonial rule. Po Nueang and Ajan Vilaysack^[2] describe themselves as traditional healers (mo ya phuen mueang), while Dr. Outhai is a retired medical doctor who previously managed the small traditional medicine department in the provincial hospital. The film highlights the similarities and differences in how they approach and think about traditional medicine and examines several intersecting issues through their words and practices. These include the role of traditional medicine for people seeking care, the various methods of creating medicines, formulating treatments and transmitting knowledge, approaches to medicinal plant conservation, the incorporation of magical or spiritual principles into treatment, and the urgent need for more research and documentation.

The first scene, shot at the home of Po Nueang, features a young girl who is receiving treatment for a sprained ankle and has also taken medicine for diarrhea. Po Nueang explains that the girl and her mother had traveled from several villages away and had already tried going to the hospital to receive injections and intravenous fluids (popular forms of allopathic medicine). However, it had not helped, so she had come to consult him. This story is representative of the often complex treatment-seeking routes taken by people and their families to deal with illness, where they may use multiple medical modalities to deal with uncertainty.^[3]

Indeed, although traditional medicine has long been used as primary healthcare for simple ailments in Laos, it is now more commonly turned to in cases of chronic illness. Later in the film, Ajan Vilaysack describes his journey as a traditional medicine practitioner, explaining that “in the past, we didn’t have enough medicine or doctors—people lived in the forest and had to help themselves.” But these days, he mainly sees patients with illnesses such as liver disease (a common problem due to high rates of hepatitis and alcohol and raw pork consumption), thyroid, digestive and skin disorders, weakness, and paralysis. He argues that he can treat these conditions more effectively and cheaply than the hospital, which sometimes even sends him patients.

While healthcare integration is government policy, this shows how, in reality, integration still happens primarily at an individual, informal level. In Laos, traditional medicine was, as in neighboring revolutionary nations, promoted as an inexpensive, low-tech, and culturally appropriate medicine.^[4] In the context of an under-resourced state biomedical system and given the weak influence of colonial healthcare, there was perhaps less impetus to create a national medicine, and so locally practiced medical forms in Laos have undergone little transformation or standardization, with no centralized knowledge source and few official treatment facilities or training courses.^[5] In the far south of Laos, traditional medicine may incorporate Tai, Buddhist, Ayurvedic, Khmer, and even Chinese influences.^[6] Southern medical practices are closely linked to those in culturally similar areas of northeastern Thailand and northern Cambodia.^[7]

These influences are shown in the healers’ use of medicines. The combination of plant parts shown by Po Nueang, including roots, woods, barks, and other woody parts, together with some shells and animal horns, make up the ingredients of ya fon, a common medical practice of southern Laos that may be linked to ancient Khmer influence.^[8] This is a technique in which a root, bark, mineral or animal product is ground against a smooth stone (hin sa) into cool water, creating a thick brown liquid that is drunk without boiling. As Po Nueang describes, it is considered a cooling medicine and is thus especially useful for fever, an ever-present condition in the heat of the southern lowlands. He demonstrates how he combines these medicines into recipes for different symptom patterns, including fever types such as chronic intermittent fever (khai sam huea), shivering cold fever leading to convulsions (khai nao san), fevers with gastrointestinal issues such as vomiting and diarrhea, those described as malaria that descends to the intestines (khai nyung long lamsai), and fever with yellow skin (khai piu lueang nang lueang). Po Nueang describes these as being forms of “the disease we now call malaria,” showing how he incorporates both traditional and biomedical explanations of disease and reflecting the variable symptom patterns of malaria that have been endemic during his lifespan, including when he was a military health worker in the 1970s.^[9]

Collecting and formulating personalized prescriptions is crucial to treating illness successfully. However, while healers may follow similar principles, Lao traditional medicine knowledge is highly heterogeneous; even the oldest textual sources, such as palm-leaf manuscripts (bailan), contain discrete sets of information.^[10] Po Nueang shows a book of herbal recipes (tamla) that belonged to one of his teachers and describes the learning process. Traditionally, this involves apprenticing to one or more older healers and learning certain spiritual practices to maximize the efficacy of the medicine. Ajan Vilaysack explains, “This is our secret—we use medicine and also magic to treat patients.” He demonstrates the technique of blowing (pao) to treat a man with a headache, who describes the effect afterward as “I feel cool, and I have more strength.” When blowing, the healer also mouths a healing mantra (mon).^[11] In the southern lowlands, these incantations are usually spoken in Pali and, if written, inscribed in tham script. Still, they may also include Sanskrit, Khmer, and Lao words, reflecting the multidimensional origins of healing power and the layered religious history of the south of Laos, including the expansion of the Khmer empire and the relatively late arrival of Theravada Buddhism and its absorption of Hindu/Brahmanical and indigenous spiritual practices.^[12]

Another distinguishing characteristic of traditional medicine in Laos is its reliance on wild harvested plant materials. Laos is highly diverse, with an estimated 8000–11,000 plant species, of which ethnobotanical studies have identified a significant number showing promising actions against disease^[13] and with no previous medicinal uses recorded.^[14] While Po Nueang uses mainly small pieces of roots or bark to make ya fon, Ajan Vilaysack’s medicine store contains large quantities of plant materials used for making decoctions or steam sauna, some of which he has harvested in high altitude areas; an apprentice healer “must love to go to the forest,” but it is not easy. He explains that it is very important for this medicine to be used when fresh (no more than a month old) for maximum potency, which presents a challenge because of the difficulties involved in sourcing materials. However, while walking around his land, he also observes that “everything here is a medicine,” pointing out the many uses of each herb, demonstrating how using plants as medicine is also flexible and circumstantial. This ability to recognize plants is the first step in learning traditional medicine. Po Nueang says, “If I have an apprentice, I must take him to dig up the plants first; he must collect and sort all kinds of plants.”

Traditional principles prohibit the overexploitation of plants; as Po Nueang explains, it is very important never to cut the main root so the tree does not die and can continue growing—and based on astrological principles, only one part of the plant can be harvested at a time. This approach is related to a wider “grammar of healing”^[15] in which astrology is applied to diagnosis and treatment, and an ethical framework based on local cosmologies that governs how the healers interact with patients and medicines. Ajan Vilaysack says, “You must avoid destroying or selling plants without a good reason.” This refers to the rule that the healers cannot directly charge money for their services and must rely on donations given according to Buddhist principles, in comparison to medicine sellers (mo khai ya), who they regard as inferior, and non-Buddhist practitioners, who are not subject to the same restrictions.^[16] The healers explain that adherence to these rules is essential for their medicine to be effective and for them to practice safely.

However, factors outside the healers’ control, such as deforestation and illegal exports, have led to a loss of plant biodiversity, a matter of great concern for them as it is becoming increasingly difficult to find the materials they need. Dr. Outhai recommends creating medicinal plant gardens and teaching students how to cultivate and use them. Some conservation efforts are in place; the Institute of Traditional Medicine oversees a network of medicinal plant preserves across the country, although lack of funding and protection makes these difficult to maintain.^[17] Ajan Vilaysack has dedicated part of his land to cultivating medicinal plants, but the difficulty of ensuring water sources limits it. He has also created a small house for people with chronic illnesses to stay free of charge. Despite being in high demand by his patients, he also farms rice, coffee, and cassava with his family and has responsibilities as the village head; like most healers, he cannot depend on practicing traditional medicine to make a living.^[18]

These combined challenges mean that transmission of medicinal knowledge through apprenticeship is now very low, and as these are likely the last generation of traditional healers in Laos, new forms of learning and practice will need to emerge for the future. Dr. Outhai describes his education on medicinal plants during his time at medical college “using books and a system,” which he says is a more sustainable learning method than the long process of memorization required by apprentice healers. Lao government institutions such as the Institute of Traditional Medicine and the Faculty of Pharmacy are making efforts to research, document, and create training programs, but there is much more to be done. These institutionalizing processes will inevitably alter the forms in which Lao medicine is taught and practiced; for example, the influence of staff trained in China, Thailand, or Vietnam and the emphasis on pharmaceutical evaluation and production. However, perhaps contrary to stories of resistance against state power, the healers are not against government regulation but instead frequently express the desire for their medicine and work to be recognized and documented.^[19] Ajan Vilaysack advocates for a scientific approach to discover the full potential of Lao medicine; “I would like Lao medicine to be recognized internationally and researched so that we know what each part of the plant is good for . . . how many diseases can one tree treat?” He concludes with his hopes for the future: “This is my idea of how to preserve medicines for the rest of my life.”

Bibliography

Alvesson, Helle M., Magnus Lindelow, Bouasavanh Khanthaphat, and Lucie Laflamme. 2013. “Coping with Uncertainty during Healthcare-Seeking in Lao PDR.” BMC International Health and Human Rights 13, no. 1: 28. https://doi.org/10.1186/1472-698X-13-28.

Brun, Viggo, and Trond Schumacher. 1994. Traditional Herbal Medicine in Northern Thailand. Bangkok: White Lotus.

Coderey, Céline. 2017. “The Buddhist Grammar of Healing: Building Efficacy in the Pluralistic Therapeutic Context of Rakhine, Myanmar.” Asian Medicine 12, nos. 1–2: 233–64. https://doi.org/10.1163/15734218-12341394.

Dubost, Jean Marc, Chiobouaphong Phakeovilay, Chithdavone Her, Audrey Bochaton, Elizabeth Elliott, Eric Deharo, Mouachan Xayvue, Somsanith Bouamanivong, and Geneviève Bourdy. 2019. “Hmong Herbal Medicine and Herbalists in Lao PDR: Pharmacopeia and Knowledge Transmission.” Journal of Ethnobiology and Ethnomedicine 15, no. 1: 27. https://doi.org/10.1186/s13002-019-0307-2.

Elkington, Bethany G., Kongmany Sydara, John F. Hartmann, Bounhong Southavong, and D. Doel Soejarto. 2013. “Folk Epidemiology Recorded in Palm Leaf Manuscripts of Laos.” Journal of Lao Studies 3, no. 1: 1–14.

Elliott, Elizabeth M. 2021. “Potent Plants, Cool Hearts: A Landscape of Healing in Laos.” PhD thesis, University College London, UK.

Elliott, Elizabeth M. 2024. “Protecting the Body, Living the Good Life: Negotiating Health in Rural Lowland Laos.” In “The Good Life in Late Socialist Asia: Aspirations, Politics And Possibilities,” edited by Minh T. N. Nguyen, Phill Wilcox, and Jake Lin. Special issue, positions: asia critique 32, no. 1: 151–70.

Elliott, Elizabeth, François Chassagne, Agnès Aubouy, Eric Deharo, Outhay Souvanasy, Phaiboun Sythamala, Kongmany Sydara, et al. 2020. “Forest Fevers: Traditional Treatment of Malaria in the Southern Lowlands of Laos.” Journal of Ethnopharmacology 249 (March): 112–87. https://doi.org/10.1016/j.jep.2019.112187.

Finot, Louis. 1917. “Recherches sur la littérature laotienne.” Bulletin de l’École française d’Extrême-Orient 17, no. 1: 1–218. https://doi.org/10.3406/befeo.1917.5323.

Grabowsky, Volker. 2007. “Buddhism, Power, and Political Order in Pre-Twentieth Century Laos.” In Buddhism, Power and Political Order, edited by Ian Harris, 121–42. London: Routledge.

Libman, Amey, S. Bouamanivong, B. Southavong, K. Sydara, and Djaja Djendoel Soejarto. 2006. “Medicinal Plants: An Important Asset to Health Care in a Region of Central Laos.” Journal of Ethnopharmacology 106, no. 3: 303–11. https://doi.org/10.1016/j.jep.2005.11.034.

Monnais, Laurence, C. Michele Thompson, and Ayo Wahlberg. 2011. Southern Medicine for Southern People: Vietnamese Medicine in the Making. Newcastle upon Tyne: Cambridge Scholars Publishing.

Pottier, Richard. 2007. Yû dî mî hèng. Etre bien avoir de la force : essai sur les pratiques thérapeutiques lao. Monographies 192. Paris: Ecole française d’Extrême Orient.

Salguero, C. Pierce. 2016. Traditional Thai Medicine: Buddhism, Animism, Yoga, Ayurveda. 2nd rev. ed. Bangkok: White Lotus Press.

Soejarto, Djaja Djendoel, C. Gyllenhaal, M. R. Kadushin, B. Southavong, K. Sydara, S. Bouamanivong, M. Xaiveu, et al. 2012. “An Ethnobotanical Survey of Medicinal Plants of Laos toward the Discovery of Bioactive Compounds as Potential Candidates for Pharmaceutical Development.” Pharmaceutical Biology 50, no. 1: 42–60. https://doi.org/10.3109/13880209.2011.619700.

Soejarto, Djaja Djendoel, Kongmany Sydara, Bethany G. Elkington, Bounleuane Douangdeuane, Onevilay Souliya, and Mouachan Xayvue. 2023. “Conservation of Medicinal Plants of Laos.” In Medicinal Plants of Laos, edited by Djaja Djendoel Soejarto, Bethany G. Elkington, and Kongmany Sydara, 52–71. Boca Raton: CRC Press.

Sweet, Kathryn Dawn. 2015. “Limited Doses: Health and Development in Laos, 1893–2000.” PhD thesis, National University of Singapore.

Thompson, C. Michele. 2015. Vietnamese Traditional Medicine: A Social History. Singapore: National University of Singapore Press.

Vidal, Jules. 1958. “La thérapeutique par les plantes au Laos.” Journal d’agriculture et de Botanique Appliquée 5, no. 10: 601–16.

Acknowledgments

The author would like to acknowledge the assistance of the Faculty of Pharmacy at the University of Health Sciences, the Institute of Traditional Medicine, and Champasak Regional Hospital for administrative support during fieldwork. The Asia Research Institute of the National University of Singapore provided financial support to edit the documentary, and the Institut de Recherche pour le Développement in Laos provided videomaking equipment. This documentary was funded by the Global Traditional Medicine Grant (Award 73578).

^[1] Elliott 2021.

^[2] Po and Ajan are titles meaning “Father” and “Teacher/Scholar,” respectively.

^[3] Alvesson et al. 2013.

^[4] Monnais, Thompson, and Wahlberg 2011; Thompson 2015.

^[5] Sweet 2015.

^[6] Salguero 2016.

^[7] Brun and Schumacher 1994.

^[8] Vidal 1958.

^[9] An analysis of the plants used in these recipes showed a high use correlation with species used cross-culturally to treat malaria, several of which have shown promising results in pharmacological studies such as Amorphophallus paeniifolius (Dennst.) Nicolson and Alocasia macrorrhizos (L.) G. Don. See Elliott et al. 2020.

^[10] Elkington et al. 2013; Finot 1917.

^[11] Pottier 2007.

^[12] Grabowsky 2007.

^[13] Soejarto et al. 2012.

^[14] Libman et al. 2006.

^[15] Coderey 2017.

^[16] For example, ethnically Hmong medicine sellers (Dubost et al. 2019).

^[17] Soejarto et al. 2023.

^[18] Elliott 2024.

^[19] This is likely also to reflect their status as Buddhist, lowland, male practitioners; this may be different for other healers from non-Buddhist minority groups.

The standard Chinese word for efficacy is yan 驗 or xiao 効/效. In premodern sources, it carries a strong sense of "having been tested." The word started to appear in the titles of medical works during the Six Dynasties (220-589), especially in the genre of "formula books" (fangshu 方書). The bibliographical records of the official histories offer us the following examples: "Personally Tested Formulas" (shenyan fang 身驗方), "Collected Tested Formulas" (jiyan fang 集驗方), and "Efficacious Formulas" (xiaoyan fang 效驗方).[1] What were the criteria to consider a formula effective is unclear, yet it is evident that medical writers at the time paid attention to the therapeutic outcomes of their remedies.

To further understand yan, I now turn to a formula book in early Tang titled “Essential Formulas Worth a Thousand in Gold for Emergencies” (Beiji qianjin yaofang 備急千金要方, 650s), written by the famous physician Sun Simiao 孫思邈.[2] The book contains thirty scrolls organized by the types of illness. In each scroll, Sun starts with a theoretical discussion of the illness, expounding its causes, symptoms, and bodily dynamics. This is followed by a large number of formulas that treat the illness, ranging from single-drug therapies to enormous prescriptions that use as many as 64 ingredients. Altogether, the book includes a massive number of 4,200 formulas.

In general, Sun follows a set structure in the writing of each formula in his book. He starts with the name of the formula, often with the typical symptoms associated with the illness. He then lists all the ingredients in the formula, specifying the dose for each one. Finally, he advises on how to prepare and administer the medicine. Intriguingly, the formula sometimes ends with the confirmation of the efficacy of the prescription, presented in short phrases such as "numinously efficacious" (shenyan 神驗), "extremely good" (shenliang 甚良), "having efficacy" (youxiao 有效), and "as if to pour hot water onto snow" (rutang woxue 如湯沃雪). These “efficacy phrases” are terse, generic, and formulaic, which probably carry more rhetorical force of boasting the value of the formula than serving as evidence of the remedy’s actual usage.[3] Likely, Sun incorporated certain formulas from earlier sources, including these set phrases, without inserting his own voice. Efficacy was an artifact of copying.

Besides these generic phrases, Sun also offers more specific accounts to show the efficacy of some of his formulas, as exemplified by 25 medical cases spread throughout the book. Significantly, Sun was the first person in Chinese history who included medical cases in formula books, manifesting physicians' rising consciousness of using personal experience to validate the efficacy of medicines during the Tang.[4]

In general, each medical case in Sun's book appears at the end of a formula where Sun presents a specific situation to testify to the efficacy of the remedy. These cases contain some or all of the following components: time, place, the identity of the physician, the identity of the patient, diagnosis, prescription of the formula, and the therapeutic outcome. In what follows, I present three cases to show different meanings of yan in Sun's writing.

Case 1: To cure the illness of dragon (jiaolong bing 蛟龍病)

On the eighth day of the second month of 586, someone ate celery and became sick. The symptoms of the person resemble those of bloated abdomen, with the face turning bluish yellow. Upon ingesting cold food and strong sugar, the patient spat out a dragon with two heads and a tail. Greatly efficacious.[5]

The case confirms the efficacy of a food remedy to eliminate a pathological animal inside the body. Sun did not identify who the patient was; he only used the generic phrase “someone” (youren 有人) to refer to him or her, which implies that he had no direct experience of the event described. He may have heard of the story from others and felt the need to include it in his book to validate the formula. Efficacy was disembodied knowledge bolstered by word of mouth.

Case 2: To cure sudden turmoil of abdomen (huoluan 霍亂)

During the Wude period (618-626), a virtuous nun named Jingming had this illness for a long time. Sometimes the illness erupts once a month; sometimes more than once a month. Every time the illness erupts, she almost died. At the time, great court physicians such as Jiang Xu and Gan Chao failed to recognize the disorder. I treated it as sudden turmoil of abdomen and prescribed this formula, which cured her. I thus isolate and record the formula.[6]

Unlike the first case, Sun directly involved in treating the patient. This case particularly emphasizes Sun’s ability to offer correct diagnosis. Revealingly, Sun contrasts his superb skills with the clumsiness of the court physicians, which is a strategy that he uses regularly in his book to elevate his status as a superior healer. Sun’s effective treatment of the patient implies that he had an excellent understanding of the symptoms of the illness and the rationale of the formula. Efficacy was based on personal experience guided by reasoning.

Case 3: To cure sores caused by the urine of earwigs (qusou chong niao 蠼螋蟲尿)

In the sixth month of a year during the Wude period (618-626), I contracted this illness and felt oppressed at the heart after five or six days. I tried other methods to treat it but to no avail. Someone taught me to draw the shape of the bug on the ground, take the soil enclosed by its abdomen, mix it with saliva, and smear the paste onto the sores. It cured me immediately.[7]

This is an example of self-healing, which appears frequently in Sun's medical cases (10 out of 25 cases). The physician regularly tried medicines on himself and used his experience as compelling evidence of a formula's efficacy. After recounting the case, Sun confesses that “myriad things under the heaven resonate with each other, and I do not fathom the reason.” Despite this, he cherished the formula because of its undeniable efficacy.

We find a similar sentiment from another case where Sun tried a panacea called the powder of daphne (yuanhua san 芫花散), a massive formula consisting of 64 ingredients. Physicians at the time did not sanction the use of the medicine, yet upon trying it, Sun found it “numinously efficacious” especially for treating emergencies. He then muses:

“I then realize that the efficacy of numinous things is not bound by common rules. The highest principle and the resonance [between things] cannot be understood by intellect. … This is without understanding why it is so—even sages cannot discern the reason.”[8]

What is striking here is Sun’s ready recognition of the inadequate understanding of why the medicine works (buzhi suoyiran 不知所以然). Yet as long as it could effectively save lives, Sun found no reason not to include it in his collection. Efficacy was based on personal experience without doctrinal understanding.

To sum up, we encounter a wide range of meanings of efficacy in Sun Simiao's formula book. It could be simply a copying artifact manifesting the physician's respect for past knowledge, or word of mouth without direct observation, or attestation based on firsthand experience, or therapeutic success even devoid of understanding the logic behind. In Sun's text, he juxtaposes these various presentations of yan without establishing a clear hierarchy. The new phenomenon of integrating medical cases into formulas in the 7th century, though, does indicate the fledgling effort of using experience, especially personal experience, to verify the efficacy of remedies.

Which brings back the question I raised at the beginning: Does Chinese medicine work? Well, it depends on a miscellany of factors, as Sun Simiao's text reveals. To be clear, 7th-century China is very different from our world today: physicians during Sun's time did not identify themselves as an autonomous, well-defined, and institutionalized social group; they competed with diverse types of practitioners in society such as ritual therapists, drug peddlers, and itinerant healers to gain the trust of patients. Their authority, unlike that of modern doctors, was not a given, but something to strive for. If our understanding of therapeutic efficacy today is heavily informed by scientific evidence and the approval of professionally-trained doctors, we see a different set of criteria used by Sun to promote his formulas and establish his authority. Therefore, what we can learn from Sun's writing is not just a more open, inclusive way of perceiving efficacy but also to understand efficacy as characterized through a dynamic process that ties to text, experience, and the building of a healer's identity.[9]

[1] Suishu 隋書 [Book of Sui], juan 34.

[2] For more information on Sun Simiao, see https://www.happygoatproductions.com/sun-simiao-

[3] On "efficacy phrases," see Claire Jones, “Formula and Formulation: ‘Efficacy Phrases’ in Medieval English Medical Manuscripts,” Neuphilologische Mitteilungen, 99, 1998: 199-209.

[4] On the history of medical cases in China, see Christopher Cullen, “Yi’an 醫案 (Case Statements): The Origins of a Genre of Chinese Medical Literature,” in Innovation in Chinese Medicine, ed. Elisabeth Hsu (Cambridge; New York: Cambridge University Press, 2001), 297-323; on the analogous history of medical cases in Europe, see Gianna Pomata, “The Medical Case Narrative in Pre-Modern Europe and China: Comparative History of an Epistemic Genre,” in A Historical Approach to Casuistry: Norms and Exceptions in a Comparative Perspective, eds. Carlo Ginzburg and Lucio Biasiori (London: Bloomsbury Academic, 2019), 15-43.

[5] Beiji qianjin yaofang, juan 11.

[6] Ibid., juan 20.

[7] Ibid., juan 25.

[8] Ibid., juan 12.

[9] For more discussion on the issue of efficacy in Chinese medicine, see Nathan Sivin, "The Question of Efficacy," Asian Medicine, 10(1-2), 2015: 9-35.

Source of image: https://www.taiwannutrition.com/blog/intermittent-fasting/. Accessed August 5, 2019.

Trendy though it is today, the idea is hardly new . I’ve been reading Chinese and Japanese books from the early twentieth century, and I came across one that radiates very similar enthusiasm for very similar advice: Jiang Weiqiao 蔣維喬’s On Skipping Breakfast for Health and to Prevent Aging (健康不老廢止朝食論). I’ll just call it On Skipping Breakfast from here on, for simplicity. This book claims that by eating only two meals per day, one slightly before noon and one in the early evening, anyone can improve his health and extend his lifespan. Following this advice, it says, can strengthen cases of weak nerves and prevent conditions such as depression, diabetes and obesity, constipation, and even cholera and typhoid. And, as if that weren’t enough, it gives the eater more time, improves his mental clarity, and makes him more successful in his career. When Twitter CEO Jack Dorsey says that intermittent fasting “helps him save time, stay focused, and sleep better at night,” it’s almost as if he’s quoting Jiang.[1]Or actually, quoting Mishima Kin’ichirō 美島金一郎,since Jiang’s book is a modified translation of a Japanese book published a year earlier.

But On Skipping Breakfast is not just an example of biohacking before Silicon Valley. While Mishima’s original text does celebrate the potential to lighten the body and boost productivity, Jiang’s version has higher aims: his ambition is to “arrive at a world of great harmony” by promoting moderate eating.

When the Commercial Press published the book in 1915, Western scientific ideas about eating were beginning to permeate China. Increasingly, diets were defined, measured, and quantified as the concepts of calories, vitamins, and minimum daily requirements took root. Underpinning much of this knowledge was a conviction that Western diets were superior to what people ate in East Asia. Scientists as well as political and cultural leaders decried Chinese diets as deficient—in proteins, in calories, in micronutrients and in just about every other way. Modernizers in China, like those in other weak countries, wanted their people to adopt what Rachel Laudan has called the “power cuisine” of the West, a high-calorie feast featuring meat, wheat, and dairy.[2]The goal was to create a taller, stronger, and generally more “fit” population that could better compete in the nations’ struggle for survival.

On Skipping Breakfast, though, approaches the question of national diet very differently. It’s not that Jiang rejects modern knowledge. By choosing to translate Mishima’s tract in all its scientistic glory, Jiang demonstrates his fascination with then-current physiological and anatomical ideas. The body described in this book is clearly the body of Western science, not the one of classical Chinese medicine: it has blood but no qi, yingyang (營養, the neologism “nutrition”) but no yin 陰 or yang 陽, and a mind-hosting brain instead of a heart-mind (xin 心), among many other marks. The book revels in mechanistic descriptions of digestion and excretion. But Jiang harnesses these ideas to a very different goal from the usual one of bulking up to better compete.[3]

Jiang Weiqiao, from his book 因是子靜坐法 (Shanghai: The Commercial Press, 1922). Available through Hathi Trust.

In a preface added to Mishima’s original text, Jiang affirms the Darwinian premise that all living beings are locked in a struggle for survival. But his response sounds like a Buddhist one:

“if there were a way to make living things able to not rely on food to live, then their conflict and killing one another perhaps could be stopped. If there were a way to … make living things return and not be reborn and not die … [t]he conflict and mutual killing could forever not be aroused.”

Unfortunately, he writes,

“there is not yet a good method of not eating. So we will use eating in moderation to save [people]. When there have been generations who have practiced healthy, anti-aging [practices like these] for a long time, this can build up their self-cultivation and produce wisdom, and engrave the truth of no-rebirth.”[4]

Here the goal is not to win the competition but to transcend it. Rather than improving their stock by eating more animal protein and calories, nations can improve their moral essence by eating in a disciplined and economical pattern. Jiang’s perspective echoes not only Buddhist ideals but also Daoist practices like abstaining from grain. It resonates, too, with what Chinese medical classics say about moderating what you eat and drink.

Despite (or perhaps because of) its ties to traditional culture, On Skipping Breakfast clearly remained a contrarian piece. China did indeed absorb Western “power cuisine.” A century later, the attendant problems of a calorie-dense diet heavier in meat, wheat, and dairy have cropped up there, including rising rates of obesity, diabetes, and high blood pressure. No wonder, then, that these days intermittent fasting is attracting attention in Chinese societies too. Today, though, you’re less likely to hear about its potential to save humanity.

[1] Aria Bendix and Julia Naftulin, “Twitter CEO Jack Dorsey says he eats only one meal a day and fasts all weekend,” Business Insider April 12, 2019 (https://www.businessinsider.com/jack-dorsey-intermittent-fasting-diet-risks-2019-4)

[2] Rachel Laudan, Cuisine and Empire: Cooking in World History (Berkeley: University of California Press, 2013), 255-257.

[3] Hilary A. Smith, “Skipping Breakfast to Save the Nation: A Different Kind of Dietary Determinism in Early Twentieth-Century China,” Global Food History vol.4, no.2 (2018): 152-167.

[4] Jiang Weiqiao, Jiankang bulao feizhi zhaoshi lun [Skipping Breakfast for Health and to Prevent Aging] (Taipei: Xin wen feng, 1980), author’s preface 2 and 5.

This post first appeared on BiblioAsia. It is syndicated here with permission.

Malay ubat-ubatan (medicine) and healing – which spans many centuries and has been passed down through generations either orally or in written form – is a complex and holistic practice.

Traditional Malay medicine incorporates principles and practices of pharmacology that are highly dependent on indigenous flora and fauna found in the wild.¹ Age-old literature and manuscripts – although scarce in number – document the ways in which plants, animals and minerals² native to the Malay Archipelago have been part and parcel of its healing practices. At the heart of Malay ubat-ubatanis the amalgamation of complex Islamic and Hindu beliefs and practices presided over by traditional or faith healers.

Colonial scholars and administrators in 20th-century Malaya were invariably conflicted in their perceptions of traditional Malay medicine. Local sources and interpretations were frequently overlooked, and this has in turn affected the way in which traditional Malay medicine has been studied and understood for decades. Some defined ubat-ubatan as remedies administered according to the principles of chemistry and scientific evidence, while others dismissed such healing practices as belonging to the realm of magic and the supernatural. For the most part, the British regarded traditional Malay medicine with suspicion and antithetic to its Western counterpart.

As a result, the practice and form of traditional Malay medicine underwent dramatic changes under colonial rule. Legislations, for instance – shaped by altruism or bigotry, but more likely a combination of the two – were introduced by the British to stamp out traditional Malay healing practices and regulate village healers.

The Spread of Islam and Malay Medicine

The adoption of Islam in the Malay Archipelago from the 13th century onwards not only introduced a new religious doctrine to the region, but also fostered a pan-Islamic identity and defined new parameters for the spiritual, social and economic way of life of its inhabitants. Gradually, Islam became syncretised with the prevailing belief systems of the Malay world.

Western scholars of the time held the view that the Malay community adopted a hybridised form of Islam. In his address before the Straits Philosophical Society in 1896, English orientalist and linguist Charles O. Blagden postulated that Malays were “only superficially Muhammadan” as their folk rituals were “unorthodox” and “pagan” in relation to the basic tenets of Islam.³ Such an assertion, however, simplifies the complex understanding and expressions of a dynamic and multifaceted faith.

Medicine in Islam is characterised by a history of enquiry, innovation and adaptation. This is reflected in the ease in which indigenous healers adopted and adapted Islamic symbolism in their practices. In the Malay Peninsula, ceremonies overseen by the pawang (or shaman) include Quranic incantations and prayers addressed solely to God, even though most other aspects of the rituals are Hindu-Buddhist or pre-Indic in character.

Although the origins are unclear, the Malay method of healing is mainly administered by the traditional medicine man or bomoh (see text box), who derives his knowledge from either ilmu turun (inherited knowledge) or ilmu tuntut (apprenticeship) and, in some instances, complemented by the Kitab Tibb (The Book of Medicine).

There are numerous versions of Kitab Tibb manuscripts found in the Malay Archipelago. Mostly written between 1786 and 1883, these broadly outline three main types of healing practices: those using natural resources such as plants and herbs; those relying on wafaq (written symbols or amulets); and healing practices using Quranic verses, supplications and salawat (blessings to the Prophet). All these techniques can be used simultaneously or separately.⁴

The earliest edition of the Kitab Tibb was written on 12 wooden sheets, and prescribed medications based on plants, herbs and spices commonly found in the region. The manuscript also includes a list of dietary restrictions and a variety of taboos (pantang larang) the afflicted should observe.⁵ By the 19th century, surviving copies of the Kitab Tibb in the Malay Peninsula were known to contain detailed observations by the bomoh, including visual representations of disease symptoms as well as the appropriate incantations.

Types of Healing

Traditional Malay healing offers a holistic, multifaceted and ecological solution to a multitude of illnesses and ailments. It comprises aspects of the spiritual, such as magic, shamanism and the supernatural, and the empirical, such as dietetics and herbalism, which can be scientifically explained.

Although Islam may have encouraged the use and incorporation of nature in traditional Malay medicine, natural remedies were already widely used in local healing practices and rituals prior to the arrival of Islam in the Malay world. For example, common plants, herbs and spices like bonglai (Zinggibar cassumunar) had been used to treat migraine, cough and gastrointestinal problems for centuries.

As observed by British physician John D. Gimlette in his book, Malay Poisons and Charm Cures (1915),⁶  bomohs used rattan splints for simple fractures and wood ash as an antiseptic dressing. When a baby was delivered by a bidan or midwife, the umbilical cord is cut with a bamboo stem and the stump dusted with wood ash or a paste made of pepper, ginger and turmeric.

Islamic medical science introduced new concepts to the pre-existing knowledge of the human body and the environment. The seeds of Islamic medicine and healing can be traced back to the Quran, the underlying philosophy of using flora and fauna in natural remedies grounded in the belief in Allah as the Creator of Nature. As such, tapping on the healing properties of the earth has been a long-standing aspect of the Islamic medical tradition. One of the verses from Surah An-nahl (16:69) of the Quran reads thus:

“Then eat from all the fruits and follow the ways of your Lord laid down [for you]. There emerges from their (bees) bellies a drink, varying in colours, in which there is healing for people. Indeed, in that there is a sign for people who give thought.”

Ancient medical texts in the Malay world did not have specific titles but were generally referred to as Kitab Tibb and primarily consisted of translations from Persian and Indian sources. Different manuscripts prescribed different courses of treatment even for the same ailments. Interestingly, the vast array of natural sources described in these manuscripts are likely still in use today in the Malay Peninsula, either as supplements or natural remedies.

The Andalusian botanist and pharmacist Ibn al-Baytar’s pharmacopeia, titled Compendium of Simple Medicaments and Foods and published in the 13th century, is still a widely consulted text in the world of Malay healing today. It lists 1,400 plants, foods and drugs, and their uses, organised alphabetically by the name of the plant or plant component.

Apart from their knowledge of humoural theory (see text box) and botany, traditional Malay healers also offered spiritual healing to cure the sick. The belief is that animate and inanimate objects, including the physical body, possess semangat (a vital force or soul). The loss of semangat can be detrimental to one’s physical and mental well-being.

A healer is purportedly able to manipulate and revive the semangat of the sick – particularly those suffering from mental and spiritual ailments. To treat patients who might have been “disturbed” by unseen forces, healers invoke supernatural entities through jampi (incantations), spells and elaborate rituals. Such ceremonies may sometimes take the form of a public event, witnessed by the entire village and accompanied by loud music. The public nature of such rituals was often derided by colonial administrators and scholars, who saw these practices as primitive and irrational or, as Gimlette puts it, “circumvent[ing] Muhammadan tenets”.⁷

The Cultural and Scientific Divide

There is a paucity of comprehensive written records of traditional Malay healing as much of it have not survived the ravages of time. Whatever extant Malay manuscripts – mostly inherited and passed down orally from one generation to the next (ilmu turun) or by way of apprenticeship (ilmu tuntut) – along with books and documents authored by colonial scholars, provide the only window into the ancient practices and beliefs of the Malay world.

In striving to achieve a balance of the body, mind, health and spirit, traditional Malay medicine does not differ much from Ayurvedic, Chinese and Hippocratic traditions that emphasise the same – especially with regard to humoural theory. Colonial writings, however, have tended to focus on Malay folk religion and animism, centering their writing around the use of amulets, incantations, charms and sorcery by the community.

The late 19th to early 20th centuries saw a significant output in research by colonial scholars who studied Malay belief systems and healing practices. The body of ideas and literature generated by these early observers were often biased, filled with racist sentiments or tinged with romanticism, although some scholars were of the view that the sudden rise in writings on Malay magic and medicine was simply an effort at documenting the “primitive” and vanishing aspects of the social and cultural lifestyles of the Malays.⁸

The use of magic and the fervent belief in religion among Malays have often been cited as stumbling blocks to the development and progress of the community. In his September 1896 report from Kuala Langat, Selangor, where he worked in the Straits Settlements civil service, English anthropologist Walter W. Skeat made the overtly racist remark that “indolent and ignorant Malays” needed to be “saved from themselves”, and attributed the “many crippled lives and early deaths” to the “evil influence of the horde of bomors”.⁹ In fact, Skeat believed that increasing “contact with European civilisation” by the local Malay tribes had diminished their use of charms and spells.¹⁰

Biased perceptions of traditional Malay society, such as its healing practices, could have been used by the British to justify its political domination and imperialist motives.¹¹ There were, however, several scholars such as Thomas N. Annandale and John D. Gimlette, who acknowledged the benefits and scientific merit of traditional Malay medicine.¹² Both men were heavily involved in fieldwork and were well known for their research on traditional Malay medicine. Gimlette referenced local sources, including Kelatanese manuscripts, for his book Malay Poisons and Charm Cures (1915), which today remains a classic and definitive reference guide to the practices of Malay healers. As the use of some herbs and plants could lead to fatal consequences, Gimlette’s study of the wild varieties of vegetation in the Malay Archipelago opened up a new field of study for physiologists and pharmacologists.¹³

An attempt to comprehend the Malay pathological framework for medicine and disease is also evident in Percy N. Gerrard’s medical dictionary, A Vocabulary of Malay Medical Terms (1905).¹⁴ As a medical professional, Gerrard’s efforts were borne out of the desire to understand his patients’ medical ssues from a scientific and cultural point of view. This enabled him to treat his patients using Malay herbal medicine whenever necessary. Gerrard drew parallels to Western medicine and, in doing so, lent credibility to Malay practices and beliefs – at least in the eyes of the colonial administrators.

Like Gimlette, Gerrard praised the Malays’ profound understanding of plants and herbs, and highlighted the medicinal value of these untapped sources and the native knowledge of local medicine. Despite his affirmations of the scientific value of herbs in Malay healing, Gerrard felt that the community’s belief in the supernatural was an impediment to British acceptance of traditional Malay medicine and healers.

It is clear that colonial observers of 20th-century Malaya have largely contexualised their understanding and knowledge of Malay medicine against Western markers. This cultural chasm was mainly due to a lack of empathy and the inability to comprehend the complexities behind the religious rituals and healing systems of indigenous groups. For the most part, Malay healing practices were regarded as superstitions and folklore that could not be explained by scientific theories. Hence over time, some traditional Malay healers co-opted the language of religion¹⁵ and, eventually, science into their practice in order to gain wider acceptance by their Western critics.

Legislating Malay Medicine

Although Western medical services were gradually introduced to the local population, most Malays continued to consult their community healers as they allegedly had “complete faith in their own particular charms and cures” and “dread[ed] hospitals, doctors and western medicines”.¹⁶ As traditional healers were also involved in non-medical matters such as state, social and cultural affairs, they occupied an esteemed position in the indigenous communities they served.¹⁷

Healing Practices 

One of the most notable Malay medical manuscripts translated into English is Ismail Munshi’s The Medical Book of Malayan Medicine. Originally written in Jawi (c. 1850), it contains over 550 remedies for maladies ranging from migraines to depression, bloatedness and leprosy.

For Violent Headaches and Loss of Energy For Dizziness and Vertigo For Night Chills Ingredients Cumin seeds (5 cents)Garlic (10 cents)

Indian hemp

Ginger

Smilax china

Mace (35 cents), Nutmeg (5 cents)

Henbane

Javanese ginger

5 young shoots of betel vineRed onion

Fennel seeds

Daun medan (root of an unidentified plant)7 kernels of the fruit of the candle nut Method Pound all ingredients together and mix with honey to form into tablets. Patient to take tablets until course of treatment is complete. Grind finely. Place the pulp on a piece of cloth. Squeeze the juice into the patient’s eyes for three days. Reduce both ingredients to fine pulp. Apply to patient’s head.

Reference

Burkill, I.H., & Ismail Munshi. (1930). The medical book of Malayan medicine. Singapore: Botanic Gardens. (Call no.: RCLOS 615.3209595 MED)

By the turn of the 20th century, the British had become more receptive to Malay healing practices. Although dismissive of the efficacy of traditional Malay medicine, the British were aware that traditional healers formed the backbone of a long-established support system that locals could turn to in times of physical, emotional and spiritual distress.

A significant example would be the role of the bidan, or midwife, in the community. Before the colonial government set up a maternity hospital in 1888, the demands of pregnancy – ranging from prenatal care to actual delivery and postpartum care – were handled by bidans.

Although colonial medical officers acknowledged the importance of bidans, they were concerned that these midwives were operating under unsanitary conditions. In the early 20th century, a surge in the infant mortality rate was mainly attributed to traditional midwifery practices: many babies died from Tetanus neonatorum (umbilical infection).¹⁸  The authorities thought it imperative that bidans be trained and supervised to reduce maternal and infant mortality rates, and to develop trust and spread awareness of Western medical services among Malay mothers.

Under the Midwives Ordinance enacted in the Straits Settlements in 1915, all bidans had to be registered with the Central Midwives Board and undergo in-service training. Local women were also trained in biomedicine, midwifery and nursing in order to replace the traditional role of the bidan. The intention was not to encourage women to deliver in hospitals (due to a lack of beds and facilities), but rather to establish a pool of trained and licensed midwives who could recognise complications during pregnancy and refer the women to the hospitals if necessary. By the 1920s, mobile dispensaries as well as home and school visits were available to communities living in rural areas, and public campaigns were mounted to ensure that people had access to medicine and healthcare.

By 1936, there were 720 trained midwives in Singapore, 574 in Penang and 224 in Malacca. Despite these efforts, traditional bidans were still sought after by Malayan women in the subsequent decades due to the personal nature of the antenatal and postnatal services they provided, including up to six weeks after delivery.

Two other legislations introduced by the colonial government further threatened the existence of traditional healers and the provision of traditional medicine. Under the Sale of Food and Drugs Ordinance that came into force in 1914, the sale of adulterated drugs was deemed an offence “if the purchaser [was] not fully informed of the nature of adulteration at time of purchase”.¹⁹ The second legislation, the Poisons Ordinance of 1938 “regulate[d] the possession and sales of potent medicinal substances, to prevent misuse or illicit diversion of poisons”.²⁰

These laws compromised the role of traditional Malay healers in the community, especially given the latent suspicions surrounding Malay medicine. However, due to the high costs involved in establishing an islandwide public healthcare system, the British authorities were rather lax at enforcing these legislations, and allowed itinerant and home-based traditional healers to continue practising their craft.

With the introduction of Western-style healthcare, including clinics and hospitals, and the increasing availability of over-the-counter medications from the turn of the 20th century onwards, traditional Malay healing played a smaller role in the lives and rhythms of the community.

State controls and the exposure to Western education further put paid to the services of traditional Malay healers. Although their numbers have drastically dwindled over the years, traditional Malay medicine continues to play an ancillary – and occasionally complementary – role to Western medicine today for those who recognise its efficacy in providing ritual care and treating spiritual ailments and conditions not yet acknowledged in Western medical science.

Humoural Theory and Malay Medicine Humoural theory, which is one of the oldest theories of medicine, is organised around the four humours – blood, phlegm, yellow bile and black bile – and is associated with the four elements of earth (flesh), water (phlegm), air/wind (temperament), and fire (blood). The four elements are in turn paired up with the four qualities of cold, hot, moist and dry. Each individual has a particular humoural makeup, or “constitution”. As optimal health is attained when the humours are in harmonious balance, any imbalance of the humours may result in disease and sickness.In one of the earliest Malayan accounts of humoural theory, English scholar Thomas J. Newbold describes Malay medicine as being based on the fundamental “principle of ’preserving the balance of power’ within the four elements, specifically, air, fire, water and earth”.²¹ This ranges from the consumption of certain hot or cold foods (such as meat and fruit respectively), hot and cold temperatures, wind, micro-organisms and supernatural forces. Dry chills and dizzy spells arise when the “earth” element is too strong and from ailments such as cholera and dysentery, which are caused by excessive heat and moisture from the “air”.²² Consuming large amounts of food that contain “air” may cause feebleness in some. The plants and herbs prescribed by Malay healers help to revitalise and restore these imbalances in the human body.

Pawang, Bomoh And Bidan

Traditional Malay healers are the main providers of Malay medicine. To achieve the necessary credentials, some have resorted to living in solitude, spending their time meditating, fasting or putting themselves through strict dietary regimens – all in the name of spiritual cleansing. Healers are also expected to have an extensive knowledge of botany and nature so that they can classify and identify the right plants and herbs as well as their healing properties, and prescribe the correct remedies.

Pawang

A pawang is commonly defined as a shaman or general practitioner of magic who incorporates incantations into his craft. He is usually involved in conducting agricultural rituals and divination ceremonies to sanctify the village. Pawangs have also been referred to as “wizards” by scholars such as Richard J. Wilkinson for their ability to manipulate the course of nature through the use of incantations and divination practices.

Dukun/Bomoh

A dukun or bomoh is a general practitioner who treats fevers, headaches, broken bones, spirit possession and various ailments. The skills and reputation of a dukun/bomoh stem from the person’s knowledge of humoural medicine, the healing properties of local flora and fauna as well as syncretic ritual incantations. Some were well known for their treatment of victims of sorcery. The bomoh akar kayu (the latter words meaning “roots” in Malay) is known for his expertise in gathering and preparing ubat-ubatan from plants and herbs In his book, A Descriptive Dictionary of British Malaya (1894), Nicholas B. Dennys compares the dukun to “being on par with witch doctors of history”. Although the dukun has been generally described in disparaging terms by Western scholars, a small minority saw the merits of these traditional healers. Percy N. Gerrard defines the “doctor” as a bomoh, dukun or pawang in his dictionary, A Vocabulary of Malay Medical Terms (1905).

Bidan

Also known as “Mak Bidan” or “dukun beranak”, these midwives specialise in women’s health matters, including fecundity, midwifery and contraception, along with a variety of beauty-related disorders. Up till the 1950s, it was common for mothers in Singapore to deliver their babies at home with the help of village midwives. Today, the role of these women is limited to providing antenatal and postnatal care, such as confinement services for new mothers or general massage therapies.

References

Dennys, N.B. (1894). A descriptive dictionary of British Malaya (p. 104). London: London and China Telegraph. [Microfilm nos.: NL7464, NL25454].

Gerrard, P.N. (1905). A vocabulary of Malay medical terms (p. 24). Singapore: Kelly & Walsh. (Microfilm no.: NL27512)

Skeat, W.W. (1900). Malay magic: Being an introduction to the folklore and popular religion of the Malay Peninsula (pp. 424–425). London: Macmillan and Co., Limited. (Call no.: RCLOS 398.4 SKE-[GH])

Wilkinson, R.J. (1908–10). Papers on Malay subjects. [First series, 4], Life and customs (p. 1). Kuala Lumpur: Printed at the F.M.S. Govt. Press. (Microfilm no.: NL263).

References

Bala, A. (Ed.) (2013). Asia, Europe, and the emergence of modern science: Knowledge crossing boundaries. Singapore: Institute of Southeast Asian Studies. (Call no.: RSEA 509.5 ASI)

Haliza Mohd Riji. (2000). Prinsip dan amalan dalam perubatan Melayu. Kuala Lumpur: Penerbit Universiti Malaya. (Call no.: Malay RSEA 615.88209595 HAL)

Harun Mat Piah. (2006). Kitab tib: Ilmu perubatan Melayu. Kuala Lumpur: Perpustakaan Negara Malaysia: Kementerian Kebudayaan, Kesenian, dan Warisan Malaysia. (Call no.: Malay R 615.880899928 HAR)

Manderson, L. (1996). Sickness and the state: Health and illness in colonial Malaya, 1870–1940. New York: Cambridge University Press. (Call no.: RSEA 362.1095951 MAN)

Matheson, V., & Hooker, M. (1988). Jawi literature in Patani: The maintenance of an Islamic tradition. Journal of the Malaysian Branch of the Royal Asiatic Society, 61(1)(254), 1–86. Retrieved from JSTOR via NLB’s eResources website.

McHugh, J.N. (1955). Hantu hantu: An account of ghost belief in modern Malaya. Singapore: Donald Moore. (Call no.: RCLOS 398.47 MAC-[RFL])

Mohd. Affendi Mohd.Shafri & Intan Azura Shahdan. (Eds.). (2017). Malay medical manuscripts: Heritage from the garden of healing. Kajang, Selangor, Malaysia: Akademi Jawi Malaysia. (Call no.: RSEA 610.95 INT)

Muhamad Zakaria & Mustafa Ali Mohd. (1992). Tumbuhan dan perubatan tradisional. Kuala Lumpur: Fajar Bakti. (Call no.: Malay RSING 615.88209595 MUH)

Ong, H.T. (Ed.). (2011). To heal the sick: The story of healthcare and doctors in Penang. Georgetown: Penang Medical Practitioners’ Society. (Call no.: RSEA 362.1095951 TO)

Owen, N. G. (Eds.). (1987). Death and disease in Southeast Asia : explorations in social, medical and demographic history. Singapore: Oxford University Press. (Call no.: 301.3220959 DEA)

Mohd. Taib Osman. (1989). Malay folk beliefs: An integration of disparate elements. Kuala Lumpur: Dewan Bahasa dan Pustaka, Kementerian Pendidikan Malaysia. (Call no.: RSEA 398.4109595 MOH)

Tuminah Sapawi. (1997, January 8). Bidan kampung now offers massage and other rituals. The Straits Times, p. 17. Retrieved from NewspaperSG.

Wilkinson, R.J. (1908–10). Papers on Malay subjects. [First series, 4], Life and customs (p. 1). Kuala Lumpur: Printed at the F.M.S. Govt. Press. [Microfilm no.: NL 263].

Notes

1. The World Health Organization defines traditional medicine (also known as folk, indigenous or alternative medicine) as “the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness”. Herbal medicines include “herbs, herbal materials, herbal preparations and finished herbal products that contain as active ingredients parts of plant, or other plant materials or combinations”. See World Health Organization. (2018). Traditional, complementary and integrative medicine. Retrieved from World Health Organization website.

2. The Kitab Permata from 19th-century Patani (southern Thailand) discusses the characteristics and medicinal properties of gemstones, minerals and metals. The text is commonly used by traditional healers in the north coast of the Malay Peninsula.

3. Blagden, C.O. (1896, July). Notes on the folk-lore and popular religion of the Malays. Journal of the Straits Branch of the Royal Asiatic Society, 29, 1. Retrieved from JSTOR via NLB’s eResources website.

4. Malay healers used Quranic verses to supplement the efficacy of herbs and medicinal plants. Supplications remain at the heart of Malay healing. A healer may choose to use only plants and herbs with supplications but without wafaq, while another may use fewer plants and herbs and more wafaq in his practice.

5. A prominent Patani scholar, Sheikh Ahmad al-Fathani, laboured his discourse in Islamic knowledge with the science of medicine. His manuscript, Tayyib al-Ihsan fi Tibb al-Insan, which was produced in 1895, was widely consulted by traditional healers in 20th-century Malaya.

6. John D. Gimlette was a physician who resided in the Malay state of Kelantan for many years and was extremely interested in the subject of Malay poisons, sorcery and cures. See Gimlette, J.D. (1915). Malay poisons and charm cures. London: J. & A. Churchill. (Call no.: RRARE 398.4 GIM-[JSB])

7. Gimlette, 1915, p. 106.

8. Winzeler, R.L. (1983). The study of Malay magic. Bijdragen Tot De Taal-, Land- En Volkenkunde, 139 (4), 435–458, p. 436. Retrieved from JSTOR via NLB’s eResources website.

9. Malay “doctors”. (1896, September 22). The Singapore Free Press and Mercantile Advertiser, p. 4. Retrieved from NewspaperSG.

10. Skeat, W.W. (1900). Malay magic: Being an introduction to the folklore and popular religion of the Malay Peninsula (pp. 424–425). London: Macmillan and Co., Limited. (Call no.: RCLOS 398.4 SKE-[GH])

11. Winzeler, 1983, p. 447.

12. Thomas N. Annandale was a Scottish zoologist, entomologist, anthropologist and herpetologist, who became interested in Malay animism, related magical lore and curers.

13. From pineapples (Ananassa sativa) and keladi (Alocasia denudata) to cheraka (Plumbaginasea), the poisons Gimlette examined have been described to contain active ingredients useful in the study of modern medicine.

14. Gerrard, P.N. (1905). A vocabulary of Malay medical terms. Singapore: Kelly & Walsh. (Microfilm no.: NL27512)

15. Anthropologist Thomas Fraser notes that in village processions led by the pawang who is healing a physically ill or possessed patient, the imam(Islamic worship leader) is also involved to officiate the ritual from a religious perspective. This prevents any possible conflict with Islamic beliefs that may border on shirk (idolatory or Polytheism).

16. Why fewer babies are now dying in Singapore. (1935, July 21). The Straits Times, p. 13. Retrieved from NewspaperSG.

17. In the Malay villages, traditional healers were involved in sanctifying the village via ceremonies and rituals, and were also involved in the affairs of the state. Known as the Maharaja Lela in Selangor or Sultan Muda in Perak, a bomoh enjoyed unfettered entry into the palace compounds.

18. Owen, N.G. (Ed.). (1987). Death and disease in Southeast Asia: Explorations in social, medical and demographic history (p. 258). Singapore: Oxford University Press. (Call no.: RSING 301.3220959 DEA)

19. Singapore. The Statutes of the Republic of Singapore. (1987, March 30). Sale of Drugs Act (Cap 282, 1985 Rev. ed.). Retrieved from Singapore Statutes Online website.

20. Singapore. The Statutes of the Republic of Singapore. (1999, December 30). Poisons Act (Cap 234, 1999 Rev. ed.). Retrieved from Singapore Statutes Online website.

21. Newbold, T.J. (2015). Political and statistical account of the British settlements in the Straits of Malacca, viz. Pinang, Malacca, and Singapore, with a history of the Malayan states on the peninsula of Malacca vol, 2 of 2 (p. 242). London: Forgotten Books. (Call no.: RSING 959.5 NEW)

22. Squeamishness, heartburn and fevers arise when the “fire” element is too strong. The “water” element causes damp chills and vomiting.

Many scholars and practitioners of Chinese medicine now consider the Tang Ye Jing 湯液經 (Classic of Decoction) as the basic reference for Zhang Ji’s 張機 (style name: Zhongjing 仲景, c. 150-219 AD) Shang Han Lun 傷寒論 (Discourse on Cold Damage). But is such an opinion on the relationship between the two texts unquestionable?

On the Anonymous Text Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction)

The Tang Ye Jing (Classic of Decoction) has long been lost since the Eastern Han Dynasty (25-220 AD). The ‘Yiwen Zhi 藝文志’ (Bibliographical Treatise) of the Han Shu 漢書 (History of the [Former/Western] Han Dynasty, c. late 1st century and early 2nd centuries AD) simply records the Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction, in 32 juan 卷 [volumes], without author information), and groups it with the other ten medical works under the title of jing fang 經方 (classical prescriptions). Many later authors mentioned the bibliographic record of this text in the Han Shu (Book of Han); but none of them reported his/her reading of the text (strictly under the title of ‘Tang Ye Jing Fa’, or under a similar title [e.g. Tang Ye Jing 湯液經] but containing the same number of volumes), or introduced the content of the text.

On the Text Tang Ye Jing 湯液經 (Classic of Decoction) by Yi Yin 伊尹

At least from the Southern Song dynasty (1127-1279 AD) onward, so far as known, authors of Shi Wu Ji Yuan 事物紀原 (Origins of Things and Matters, first printed in 1197 AD), Yi Shui 醫說 (Discourse on Medicine, 1224 AD) and other works attributed the text entitled Tang Ye Jing 湯液經 (Classic of Decoction; NOTE: lacking the character fa 法) to Yi Yin 伊尹 (c. 1649- c. 1549 BC), without offering any reasons or additional information, without basing such a claim on the above bibliographic record in the Han Shu (History of the [Former/Western] Han Dynasty). But similarly, no one in pre-modern China left a bibliographic record of this text, and/or spoke of any specific content of the text. Did this Tang Ye Jing 湯液經 (Classic of Decoction) ever exist? If so, is it the same as the Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction)? If so, why does the above bibliographic record in the Han Shu (History of the [Former/Western] Han Dynasty) not ascribe authorship to Yi Yin?

On Yi Yin’s 伊尹 Authorship of Tang Ye 湯液 (Decoction), Tang Ye Jing 湯液經 and Tang Ye Jing Fa 湯液經法

Modern proponents of the Tang Ye Jing 湯液經 (Classic of Decoction) as the progenitor of Zhang Ji’s Shang Han Lun 傷寒論 (Discourse on Cold Damage), as mentioned above, often invoke the following words in Huangfu Mi’s 皇甫谧 (215-282 AD) preface to his own work Zhen Jiu Jia Yi Jing 鍼灸甲乙經 (Classic of Acupuncture and Moxibustion, Selected and Arranged):

Zhong Jing Lun Guang Yi Yin Tang Ye Wei Shi Shu Juan, Yong Zhi Duo Yan.

仲景論廣伊尹湯液為十數卷, 用之多驗.

[Zhang] Zhongjing expanded Yi Yin’s Decoction into more than ten volumes, which were mostly effective in practice. Lin Yi’s 林億 (active in the 11 century AD) preface to Zhang Ji’s Shang Han Lun (Discourse on Cold Damage) adopts the above words of Huangfu Mi, and adds that ‘Zhong Jing Ben Yi Yin Zhi Fa 仲景本伊尹之法’ ([Zhang] Zhongjing’s [medical knowledge] is rooted in Yi Yin’s norms). The proponents often acquiesce in the equation of the Tang Ye 湯液 (Decoction) with the Tang Ye Jing 湯液經 (Classic of Decoction) or Tang Ye Jing Fa 湯液經法(Models of the Classic of Decoction). In this way, Tang Ye (Decoction) becomes an abbreviation of the latter text title; and Yi Yin also becomes the author of Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction).

However, Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction) consists of 32 juan 卷 (volumes); while Zhang Zhongjing’s expanded edition of Yi Yin’s Tang Ye 湯液 (Decoction) merely contain more than ten juan 卷 (volumes). How could Yi Yin’s Tang Ye 湯液 (Decoction) or Tang Ye Jing 湯液經 (Classic of Decoction) be the same as the anonymous Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction)? Why do extant editions of Zhang Ji’s preface to his own work Shang Han Lun (Discourse on Cold Damage) contain no words of the text Tang Ye 湯液 (Decoction), Tang Ye Jing 湯液經 (Classic of Decoction), or Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction)?

Copyright page A, showing the book title Tang Ye Jing 湯液經 (Classic of Decoction), the words ‘Yang Shao Yi Fu Zi Kao Ci 楊紹伊夫子考次’ (Compiled by Teacher Yang Shaoyi) and ‘Di Zi Li Ding Jing Shu 弟子李鼎敬署’ (Respectfully Signed by [Yang’s] Student Li Ding).

On the Reconstruction of Yi Yin’s Tang Ye Jing 湯液經 in 1948

In 1948, Yang Shiyin’s 楊師尹 (style name: Shaoyi 紹伊, 1888-1949) reconstruction of Yi Yin’s Tang Ye Jing 湯液經 (Classic of Decoction), supplemented by Liu Fu 劉復 (style name: Minshu 民叔, 1897-1960), was published by Liu’s Yiqian Ge 一錢閣 (One-Coin Pavilion). This is the only reconstruction of the text Tang Ye Jing 湯液經 (Classic of Decoction), which is believed by some people to be written by Yi Yin, and/or to have truly existed and given birth to Zhang Ji’s Shang Han Lun (Discourse on Cold Damage). Its main text has 160 pages.

The book title printed on the front cover of this reconstruction is ‘Yi Yin Tang Ye Jing 伊尹湯液經’ (Yi Yin’s Classic of Decoction); while the title shown on the copyright pages and the first page of the main text is ‘Tang Ye Jing 湯液經’ (Classic of Decoction).

All images here are from the original edition (1948) of the reconstruction of the Yi Yin Tang Ye Jing 伊尹湯液經 (Yi Yin’s Classic of Decoction) or Tang Ye Jing 湯液經 (Classic of Decoction) in 1948.

The 1948 reconstruction of the Tang Ye Jing 湯液經 (Classic of Decoction) now has the following two modern versions (the latter one has adjusted the original title to another):

• Yi Yin Tang Ye Jing 伊尹湯液經 (Yi Yin’s Classic of Decoction), in: Liu Min Shu Yi Shu He Ji 劉民叔醫書合集 (Collection of Liu Minshu’s Medical Works), Chen Guangtao et al. (eds.), Tianjin: Tianjin Kexue Jishu Chubanshe, 2011, pp. 201-345.

• Tang Ye Jing Gou Kao 湯液經鈎考 (A Study of the Collected Text of the Classic of Decoction), Chen Juwei and Guo Yujing (eds.), Forewarded by Qiu Hao, Beijing: Xueyuan Chubanshe, 2011, Pp. 242.

Yang Shiyin’s 楊師尹 (style name: Shaoyi 紹伊) name indicates Yang’s admiration of Yi Yin. Literally, Shiyin 師尹 means imitating [Yi] Yin; and Shaoyi 紹伊 means introducing Yi [Yin]. According to Yang Shiyin’s own introductory chapter in the reconstructed text,

The first page of the main text, showing the following information: ‘Shang Yi Yin Zhu 商伊尹著’ (Written by Yi Yin of the Shang Dynasty), ‘Cheng Du Yang Shi Yin Shao Yi Kao Ci 成都楊師尹紹伊考次’ (Compiled by Yang Shiyin of Chengdu, whose style name is Shaoyi), and ‘Hua Yang Liu Fu Min Shu Bu Xiu 華陽劉復民叔補修’ (Supplemented by Liu Fu of Huayang, whose style name is Minshu).

1. the full title of the text Tang Ye 湯液 (Decoction) mentioned by Huangfu Mi should be Tang Ye Jing 湯液經 (Classic of Decoction);

2. the author of the Tang Ye Jing 湯液經 (Classic of Decoction) was Yi Yin of the Shang dynasty (c. 1600-1046 BC);

3. the Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction, 32 volumes) was a later text composed on the basis on Yi Yin’s Tang Ye Jing 湯液經 (Classic of Decoction) and containing all the content of the latter;

4. the Tang Ye Jing 湯液經 (Classic of Decoction) still existed in the Eastern Han dynasty, and enabled Zhang Ji to read it and expand its content; Shang Han Lun (Discourse on Cold Damage) was not ‘written’ by Zhang Ji, but an expansion of the Tang Ye Jing 湯液經 (Classic of Decoction);

5. Yang Shiyin’s reconstruction of the text Tang Ye Jing 湯液經, alleged by Yang to be comprised of Yi Yin’s Tang Ye Jing 湯液經 (Classic of Decoction) and extended words by Zhang Ji, was reconstructed on the basis of Wang Shuhe’s 王叔和 (c. 210-285 AD) Mai Jing 脈經 (Classic of the Pulse) and Sun Simiao’s 孫思邈 (581-682 AD) Qian Jin Yi Fang 千金翼方 (Supplement to Prescriptions Worth a Thousand Gold, c. 682) (Wang and Sun’s texts contain words from Zhang Ji’s Shang Han Lun [Discourse on Cold Damage]).

The above points are arbitrary and speculative. None of them is solidly convincing. In particular, the Mai Jing (Classic of the Pulse) adverts to neither Yi Yin nor the Tang Ye Jing 湯液經 (Classic of Decoction). And only the 26th chapter of the Qian Jin Yi Fang (Supplement to Prescriptions Worth a Thousand Gold) mentions ‘Gu Ren Yi Yin Tang Ye 古人伊尹湯液’ (the ancient man Yi Yin’s Decoction), which, however, is not connected with origins of the content of the Qian Jin Yi Fang. Moreover, as mentioned above, extant editions of Zhang Ji’s preface to his Shang Han Lun (Discourse on Cold Damage) also makes no mention of the text Tang Ye 湯液 (Decoction), Tang Ye Jing 湯液經 (Classic of Decoction), or Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction). Some scholars also treat Yang’s opinions, methodology and reconstruction with caution, as evidenced by Qiu Hao’s foreword to the Tang Ye Jing Gou Kao 湯液經鈎考 (A Study of the Collected Text of the Classic of Decoction, Chen Juwei and Guo Yujing eds., Beijing: Xueyuan Chubanshe, 2011, pp. 1-16) and Feng Shilun’s foreword to the Jie Du Yi Yin Tang Ye Jing 解讀伊尹湯液經 (Interpreting Yi Yin’s Classic of Decoction, Feng Shilun 馮世綸 ed., Beijing: Xueyuan Chubanshe, 2009, pp. i-iv).

On the Manuscript Fu Xing Jue Zang Fu Yong Yao Fa 輔行訣臟腑用藥法要 (Auxiliary Knacks of Essential Drug Usage for Viscera)

A text often associated with academic discussions of the Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction) is the manuscript Fu Xing Jue Zang Fu Yong Yao Fa 輔行訣臟腑用藥法要 (Auxiliary Knacks of Essential Drug Usage for Viscera, hereinafter FXJ), which is now included in, for example, the Dun Huang Gu Yi Ji Kao Shi 敦煌古醫籍考釋 (Commentary and Research on Ancient Medical Texts Excavated in Dunhuang, Ma Jixing 馬繼興, ed., Nanchang: Jiangxi Kexue Jishu Chubanshe, 1988, pp. 115-137), Dun Huang Shi Ku Mi Cang Yi Fang 敦煌石窟秘藏醫方 (Secret Medical Prescriptions from Dunhuang Grottoes, Wang Shumin, ed., Beijing: Beijing Yike Daxue & Zhongguo Xiehe Yike Daxue Lianhe Chuban, 1998, pp. 1-28), Fu Xing Jue Zang Fu Yong Yao Fa Jiao Zhu Kao Zheng 《輔行訣臟腑用藥法要》校注考證 (Textual Studies, Collation and Annotations of the Auxiliary Knacks of Essential Drug Usage for Viscera, Wang Xuetai, ed., Beijing: Renmin Junyi Chubanshe, 2008, pp. 3-62), and Fu Xing Jue Zang Fu Yong Yao Fa Jiao Zhu Jiang Shu 《輔行訣五臟用藥法要》校注講疏 (Interpretation, Collation and Annotations of the Auxiliary Knacks of Essential Drug Usage for Viscera, Yi Zhibiao, et al., eds., Beijing: Xueyuan Chubanshe, 2009, pp. 250-307).

According to the introductory remarks on FXJ in the above modern publications, FXJ was initially preserved at the Mogao Grottoes of Dunhuang, and then flowed into the hands of a Daoist, who later sold it to the Chinese physician Zhang Wonan 張偓南 at the beginning of the Republican period (1912-1949). Zhang passed the original manuscript of FXJ down to his grandson Zhang Dachang 張大昌, also a Chinese physician. In the summer of 1966, unfortunately, the original manuscript was destroyed in the Cultural Revolution. In 1974, Zhang Dachang sent a copy of the manuscript to the Zhong Guo Zhong Yi Yan Jiu Yuan 中國中醫研究院 (China Academy of Chinese Medicine). Later, the manuscript began to receive increasing attention from historians of medicine. Until now, 21 copies of the original manuscript of FXJ, transcribed by different people in the second half of the 20th century, have been found in China and included in the Fu Xing Jue Wu Zang Yong Yao Fa Yao Chuan Cheng Ji 《輔行訣五藏[臓]用藥法要》傳承集 (Collection of the Circulated Manuscripts of the Auxiliary Knacks of Essential Drug Usage for Viscera, Beijing: Xueyuan Chubanshe, 2008, pp. 3-400).

FXJ, originally authored by Tao Hongjing 陶弘景 (456-536), is a controversial manuscript. Two historians of Chinese history, namely Zhang Zhenglang 張政烺 and Li Xueqin 李學勤, had examined FXJ, and concluded that it could not be counted as an early writing composed by Tao Hongjing, nor could it be a modern forged text. The original manuscript of FXJ is now lost; and available information on the origin of FXJ originates from Zhang Dachang, whose narrative might be unreliable (say, FXJ might be forged or might not be a manuscript from Dunhuang Grottoes). The title of FXJ also does not appear in extant records of Tao Hongjing’s writings. Some scholars treat FXJ a forged text, see, for example, Tian Yongyan 田永衍, ‘Fu Xing Jue Zang Fu Yong Yao Fa Yao Fei Cang Jing Dong Yi Shu Kao——Cong Wen Ben Xing Shi Yu Wen Xian Guan Xi Kao Cha 《輔行訣臟腑用藥法要》非藏經洞遺書考——從文本形式與文獻關係考察 (A Study of the Auxiliary Knacks of Essential Drug Usage for Viscera as a Text not from Dunhuang Grottos——From the Perspectives of Textual Forms and Relationships)’, Nan Jing Zhong Yi Yao Da Xue Xue Bao (She Hui Ke Xue Ban) 南京中醫藥大學學報(社會科學版) (Journal of Nanjing University of TCM [Social Science]), 2015, 16(4): 232-237.

FXJ mentions ‘Tang Ye Jing Fa 湯液經法’ (Models of the Classic of Decoction) three times, and claims that it was written by Yi Yin of the Shang dynasty. Because of this, some historians, such as Ma Jixing 馬繼興, consider that FXJ incorporates some words from the Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction). Further, because some prescriptions recorded in FXJ (not associated with the Tang Ye Jing Fa 湯液經法 [Models of the Classic of Decoction]), bear resemblance to their counterparts in Zhang Ji’s Shang Han Lun (Discourse on Cold Damage), some historians of medicine, such as Qian Chaochen 錢超塵, think that FXJ proves Shang Han Lun (Discourse on Cold Damage) to be composed on the basis of Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction). Even if FXJ is not a forged text, such an opinion is still too arbitrary.

Concluding Remarks

Copyright page B, showing the publisher information ‘Liu Shi Yi Qian Ge Zeng Fu Zhen Juan Zhuan Chuan 劉氏一錢閣曾福臻鐫傳’ (Engraved and Issued by Zeng Fuzhen at Liu’s One-Coin Pavilion), and the information on the transcriber and the collator: ‘Di Zi Li Ding Lu Gao 弟子李鼎録稿’ (Transcribed by [Yang’s] Student Li Ding) and ‘Wu Zi Nian Dong Chu Ban Hai Men Shen Dan Jiao Zi 戊子年冬初版海門沈旦校字’ (First Published in the Winter of 1948, Collated by Shen Dan of Haimen).

After a brief review of related issues on the Tang Ye Jing 湯液經 (Classic of Decoction), we can confirm that:

1. There had been an anonymous text entitled Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction, in 32 juan [volumes]) in the Western Han dynasty;

2. It is unknown whether there truly existed a text written by Yi Yin of the Shang dynasty and entitled Tang Ye 湯液 (Decoction) or Tang Ye Jing 湯液經 (Classic of Decoction);

3. It is unknown whether the Tang Ye Jing Fa 湯液經法 (Models of the Classic of Decoction) was Yi Yin’s Tang Ye 湯液 (Decoction) or Tang Ye Jing 湯液經 (Classic of Decoction);

4. It is unknown whether Zhang Ji’s Shang Han Lun (Discourse on Cold Damage) was an expansion of Yi Yin’s Tang Ye 湯液 (Decoction) or Tang Ye Jing 湯液經 (Classic of Decoction);

5. Yang Shiyin’s reconstruction of Yi Yin’s Tang Ye Jing 湯液經 (Classic of Decoction), published in 1948, can only represent his own faith in the existence of Yi Yin’s Tang Ye Jing 湯液經 (Classic of Decoction).

Treatment periods are rarely discussed in Classical Chinese medical literature.  While classics like the Shanghan Lun meticulously describe formula preparation and administration over the course of a day, the number of days a formula should be used for is never plainly described.  Due to this ambiguity, many physicians apply a saying that originates in the Huangdi Neijing to classical formula use, “after one dose one knows, after two doses there is resolution.”[i]

However, by examining powder and pill formula dosage, we can gain more specific insight into classical treatment timeframes.  Whereas with liquid decoctions the written herb weights compose a single day’s worth of formula, with powders the daily dose is fixed at a few grams and the herb weights define a formula’s projected treatment period.

This article is an exploration into the treatment periods and patterns for four foundational classical formula powders, accurate weights and measures based on Han period archeological evidence, and the drinks traditionally used to aid powder consumption. The goal is to provide insight into how and why classical clinicians used medical powders.

Classical Weights

A liang (兩) is the core unit of weight used in classical Han dynasty formulas.  Though there has been some debate as to the exact weight of a classical liang throughout Chinese history, and a great deal of inaccuracy in modern texts, recent archeological findings indicate that a liang weighed between 13.8 and 15.6 grams.  Contemporary doctors in mainland China generally simplify a classical liang’s weight to 15g.  A classical Liang can be subdivided into 24 zhu (銖) or four fen (分).  16 Liang combine to make one jin (斤)[iii].  The table below describes the weight of each measurement unit:

Table 1.  Han Period Weight Units

Measure Unit Approximate Weight Simplified Weight Jin 斤 220.8g to 249.6g 240g Liang 兩 13.8g to 15.6g 15g Fen 分 3.45g to 3.9g 3.75g Zhu 銖 0.575g to 0.65g 0.625g

Single doses of powdered formulas were most commonly dosed by heaping powder onto a fangcunbi (方寸匕, Square Inch Spoon) or a qianbi (錢匕, Coin Spoon).  The cun (寸), a classical unit of measurement, is 2.32cm long.[iv]  Therefore, a square cun measures 5.4 cm² in area.  The Zhongyao Da Cidian (中藥大辭典, Great Encyclopedia of Chinese Medicine) states that a fangcunbi weighs 2g for metal and stone powders and 1g for plant powders.  However, the actual tested weights are somewhat heavier, causing researcher Li Yuhang (李宇航) to conclude that plant powders should be dosed at 1-2g and mineral powders at 3-4g[v].  A portion of his findings is translated on the following table:

Table 2. Actual Fangcunbi Powder Weights

Formula Actual Weight Wu Ling San 五苓散 1.59g Muli Zexie San 牡蠣澤瀉散 1.27g Banxia San 半夏散 1.46g Sini San using Baishao 四逆散（白芍） 1.66g Sini San using Chishao 四逆散（赤芍） 1.68g Chishizhi (in Taohua Tang) 赤石脂（桃花湯） 3.31g Wenge San 文蛤散 3.33g

The qianbi dose was measured using the Han Dynasty wuzhuqian (五銖錢, five zhu coin).  The coin’s radius measures 2.5cm and it has an approximately 1 cm² square hole in the center.  Assuming a finger is used to plug the square hole in the center of the coin when used as a scoop, the area measures 4.9 cm², giving it roughly 10% less area than the fangcunbi.

For the purposes of this article, I simplified unknown formula powder weights to 1.66g per dose for a fangcunbi and 1.5g for a qianbi.  Given that most formulas suggest three daily doses this works out to 5g total per day for the fangcunbi and 4.5g per day for the qianbi.

Intake Methods

Classically, powders are stirred into a warm liquid and drank.  The choice of liquid gives additional insight into the formula’s purpose and should be considered an essential part of powdered formula construction.  The main liquids used for powder administration in the Shanghan Lun and Jingui Yaolue are baiyin (白飲, the water from boiled rice[vi], also called miyin 米飲), maizhou (麥粥, wheat porridge), jiangshui (漿水, fermented millet water), jiu (酒 rice wine, likely analogous to modern huangjiu 黃酒) and water.  In formulas that don’t specifically mention what drink to use, Ge Hong and Sun Simiao suggest that any of the above can be used[vii], presumably leaving the choice of liquid assistant to the practitioner.

Table 3. Liquid Assistants for Powder Administration

Liquid Function Formulas Baiyin (白飲, boiled rice water) Sweet, balanced.  Strengthens earth harmonizes the middle qi, separates clear from turbid, generates fluids;stops thirst; promotes urination. Sini San, Wu Ling San, San Wu Xiao Bai San, Muli Zexie San.Rice is also used in Baihu Tang, Taohua Tang, and Zhuye Shigao Tang. Maizhou (麥粥, wheat porridge) Sweet, slightly bitter, cool.  Eliminates heat, stops thirst and dry throat, promotes urination, nourishes liver qi. Zhishi Shaoyao San, Baizhu San (modification).Wheat is also used in Gan Mai Dazao Tang. Jiangshui (漿水, fermented millet water) Sweet, sour, cool.  Regulates the stomach, dissolves food obstructions, stops thirst. Chixiaodou Danggui San, Shuqi San, Banxia Ganjiang San, Baizhu San (modification).Jiangshui is also used in Zhishi Zhizichi Tang. Jiu (酒, rice wine) Bitter, acrid, warm.  Invigorates the channels, unblocks obstruction syndrome, warms the blood, scatters blood stasis. Danggui Shaoyao San, Danggui San, Baizhu San, Tianxiong San, Zishi Han Shi San, Tuguagen San.

A Selection of Powdered Formulas

According to Dr. Li Yuming,[viii] Zhang Zhongjing uses internal powdered formulas primarily to treat diseases of the lower jiao, especially recalcitrant conditions that involve blood deficiency and or fluid accumulation.  Below I have selected four representative formulas that each demonstrate a specific lower jiao pathology and can be considered foundational building blocks for individualized powdered formula construction.

Sini San 四逆散, Frigid Extremities Powder

SiniSan SHL Text Weight Gram Weight Zhi Gancao 炙甘草 10 Fen分 37.5g Zhishi 枳實 10 Fen分 37.5g Chaihu 柴胡 10 Fen分 37.5g Shaoyao 芍藥 10 Fen分 37.5g Total Formula Weight 40 Fen分 150g (138g-156g) Single Dose Weight 1 Fangcunbi 1.66g-1.68g Daily Dose Weight 3 Fangcunbi 5g (4.98g-5.04g) Treatment Period 30 Days (27.3-31.3days) Administered With Baiyin白飲 (Boiled Rice Water)

Sini San treats Liver qi stagnation that manifests with cold hands and feet, possibly with cough, palpitations, inhibited urination, abdominal pain, or diarrhea with tenesmus, emotional distress, depression, chest and rib distention or pain, or breast distention pain, with a white tongue coat, and a thin wiry pulse.[ix]

According to the Shennong Bencao Jing (《神農本草經》The Divine Husbandman's Classic of Materia Medica), Chaihu’s bitter, balanced nature has the ability to eliminate knotted qi and food accumulations from the GI tract.[x] Zhishi’s bitter, cool, slightly acrid and sour nature assists Chaihu by breaking up stagnant qi, reducing distention and pain from accumulation and directing the qi of the GI tract downwards.  Shaoyao’s bitter, sour and slightly cool nature nourishes the liver, preserves yin, and according to the Mingyi Bielu (《名醫別錄》Miscellaneous Records of Famous Physicians) eliminates blood stasis, expels water, and benefits the bladder and intestines.[xi] Zhi Gancao’s sweet, warm nature nourishes the middle qi.  Rice water’s bland, sweet and balanced nature is used to administer the formula to build thin fluids, regulate fluid metabolism, and benefit the spleen and stomach.

The Sini San pattern shows signs of dryness, blood deficiency, qi knotting, and food accumulations in the GI tract, and resultant lower jiao yang qi depression.  The formula is overall cool and bitter, with hints of acrid, sour, and sweet and should be considered a light purgative with elements of qi and blood building.  Sini San’s light dose and ability to enter the lower jiao is aimed at slowly purging the intestines without stressing the body’s upright qi.  Due to the purgative nature, caution should be used when exceeding the projected treatment period of 30 days.

Wu Ling San 五苓散, Five Poria Powder

Wu Ling San SHL Text Weight JGYL Text Weight Gram Weight Zexie 澤瀉 1 Liang 兩 6 Zhu 銖 1Liang兩1Fen分 18.75g Zhuling 豬苓 18 Zhu銖 3Fen分 11.25g Fuling 茯苓 18 Zhu銖 3Fen分 11.25g Baizhu 白術 18 Zhu銖 3Fen分 11.25g Guizhi 桂枝 ½ Liang兩 2Fen分 7.5g Total Formula Weight 4 Liang 60g (55.2g-62.4g) Single Dose Weight 1 Fangcunbi 1.59g Daily Dose Weight 3 Fangcunbi 4.77g Treatment Period 12 days (11.6 – 13.1 days) Administered With Baiyin白飲 (Boiled Rice Water)

Wu Ling San treats a number of symptom patterns, all of which revolve around dampness accumulation in the lower jiao resulting in some degree of yang qi depression and heat.  The primary acute pattern manifests with headache, low fever, irritability, aversion to cold, dry mouth and thirst, possibly with vomiting upon drinking, and urinary obstruction.  Other variants include diabetic thirst and edema patterns.

Zexie, Zhuling, and Fuling’s overall bland and cool natures act to leach out dampness, promote urination, and gently clear lower jiao heat.  Baizhu’s bitter warm nature strengthens the spleen by drying dampness and dissolving food and phlegm liquids[xii]. Guizhi’s acrid warm nature disperses yang and promotes the movement and ascent of yang out of the lower jiao.  Rice water’s bland, sweet and balanced nature is used to administer the formula to build thin fluids, regulate fluid metabolism, and benefit the spleen and stomach.

When taking the Wu Ling San the patient is advised to drink plenty of warm water and that the condition will resolve through gentle sweating which indicates that upright qi has regained control of the surface.  Presumably, the 12 day dose period is the expected term of resolution for the acute symptom pattern.

Danggui Shaoyao San 當歸芍藥散, Angelicae and Peony Powder

Danggui Shaoyao San JGYL Text Weight Gram Weight Danggui 3 Liang 45g Shaoyao 1 Jin 240g Fuling 4 Liang 60g Baizhu 4 Liang 60g Zexie ½ Jin 120g Chuanxiong ½ Jin (3 Liang*) 120g (45g*) Total Formula Weight 43 Liang (38 Liang*) 645g (593.4g – 670.8g)

570g* (524.4g – 592.8g)

Single Dose Weight 1 Fangcunbi ~1.66g Daily Dose Weight 3 Fangcunbi ~5g Treatment Period 129days (118.7 days – 134.2 days)

114 days* (104.9 days – 118.6 days)

Administered With Jiu 酒 (Rice Wine)

*One Jingui Yaolue version states a 3 liang dose for Chuanxiong, all other versions state ½ jin.

Danggui Shaoyao San primarily treats blood deficiency with fluid accumulation in the lower jiao resulting in abdominal pain or cramping.  Though the pattern is more common among women, the formula can also be used for men.  Other possible symptoms include rib distention or pain, lack of appetite, dizziness, emotional constraint, and weakness of the limbs with a pale tongue, white tongue coating, and a deep, wiry pulse.[xiii]

The formula is composed of two main elements: Danggui, Chuanxiong and Shaoyao to nourish the blood and gently disperse blood stasis; and Fuling, Zexie, and Baizhu to regulate water metabolism, dry dampness, promote urination and fortify the spleen.  Together the two groups somewhat resemble a combination of Wu Ling San and Sini San but with a greater focus on blood level movement and nourishment.  To further promote blood movement, rice wine’s acrid, bitter and warm nature is used to administer the formula.  The Mingyi Bielu notes that Rice Wine has the specific ability to circulate a medicine’s strength[xiv] by unblocking the channels and invigorating the vessels.

While the formula is best known for treating acute stomach cramping during pregnancy, modern text books urge cautious use during pregnancy, “specifically because too high a dosage of Chuanxiong Rhizoma can affect the fetus, particularly in mothers who have deficient and weak Kidney qi”.[xv] The question of whether Danggui Shaoyao San’s daily dose of Chuanxiong at 0.93g is considered high must be left to the practitioner and further research. But clearly, it was classically thought of as a safe formula as it was dosed for around four months of use during pregnancy and is suited for long term blood and fluid regulation in the lower jiao.

Chixiaodou Danggui San 赤小豆當歸散, Adzuki and Angelicae Powder

Chixiaodou Danggui San JGYL Text Weight Gram Weight Chixiaodou (adzuki bean, sprouted and dried) 3 Sheng* 510g Danggui 10 Liang** 150g Total Formula Weight 660g Single Dose Weight 1 Fangcunbi ~1.66g Daily Dose Weight 3 Fangcunbi ~5g Treatment Period 132 days Administered With Jiangshui 漿水 (Fermented Millet Water)

* A Sheng is a unit of volume that measures approximately 200ml.

** Some Jinggui Yaolue versions write 3 liang, others write 10 liang.

Chixiaodou Danggui San treats damp heat in the lower jiao which can lead to hemorrhoids, anal prolapse, excessive menstrual bleeding, ulceration, intestinal abscess, red eyes, rashes, irritability and other symptoms associated with damp head leading to blood toxicity presenting with a red tongue, yellow, greasy tongue coat, and rapid pulse.

Chixiaodou has a sweet/bland, slightly sour, and balanced nature, promotes urination, drains damp heat, stops bleeding and, as noted in the Shennong Bencao Jing, has the ability to expel the blood and pus from carbuncles and welling-abscess.[xvi]  Danggui’s sweet, acrid and warm nature nourishes the blood, disperses stasis, and promotes the healing of sores.  Fermented millet water is used to administer the powder and supports Chixiaodou by dissolving food accumulation and regulating the stomach with its sweet, sour, and cool nature.

Like Danggui Shaoyao San, Chixiaodou Danggui San has an intended dose period of around four months and aims to nourish blood in the lower jiao while simultaneously eliminating fluid accumulation.  Chixiaodou, a common food in China, is a particularly safe medicine for the slow, long term elimination of damp heat and blood toxicity.

Conclusion

From the above formulas, we can clearly see that Zhang Zhongjing favored using powders for the long-term treatment of recalcitrant lower jiao and gastrointestinal diseases that present with mixed excess and deficiency patterns.  According to the Jingfang Xiaopin （《經方小品》A Small Collection of Classical Formulas), powders and pills were used after a decoction formula had eliminated the primary pathogenic factors, presumably as a long term regulatory treatment, which could then be periodically assisted with decoction formulas.[xvii]  Sun Simiao believed powders were appropriate for slowly driving out pathogens, particularly wind and damp obstructions with symptoms that come and go without a static location,[xviii] as is characteristic with many gastrointestinal disorders.

Unfortunately, formula powders are rarely used in the modern clinic.  When used, they are often decocted as liquid formulas with little concern for difference in administration form or dose.  I hypothesize that powdered formulas may offer a better, cheaper, safer, and more convenient treatment method for the long-term resolution of many gastrointestinal and other lower jiao associated disorders, especially when used in conjunction with periodic decoction formula treatments.  As renewed interest in classical formula theory and application continues to grow in China and around the world I hope that modern practitioners will also renew research into formula powders for modern clinical use.

Endnotes

[i]《黄帝内经素问·腹中论篇第四十》云，“一剂知二剂已”。

[ii] 王付.经方用量秘旨. 人民军医出版社, 2015.62-64，98-100

[iii]《汉书·律历志·权衡》云，“权者，铢、两、斤、钧、石也……一龠容千二百黍，重十二铢，两之为两，二十四铢为两，十六两为斤”。

[iv] 李宇航.《伤寒论》方药剂量与配伍比例研究. 人民卫生出版社, 2015. 64

[v] 李宇航.《伤寒论》方药剂量与配伍比例研究. 人民卫生出版社, 2015. 68

[vi] 朱西杰、晋学仁、樊恒茂. “《伤寒论》“白饮”新解”，来源：《国医论坛》2000年第02期

[vii]《千金要方·论服饵第八》云，“凡服丸散，不云酒水饮者，本方如此，是可通用也”。《肘後備急方·華陽隱居《補闕肘後百一方》序》云，“凡下丸散，不雲酒水飲者，本方如此，而別說用酒水飲，則是可通用三物服也”。

[viii] 李宇铭.伤寒治内方证原意. 中国中医药出版社, 2014.

[ix] 王付《历代经方方论》.人民军医出版社, 2013. 515

[x]《神农本草经》云，“柴胡味苦平，主心腹，去肠胃中结气，饮食积聚，寒热邪气，推陈致新”。

[xi]《名医别录》云，“芍药味酸微寒有小毒，主通顺血脉，缓中，散恶血，逐贼血，去水气，利膀胱、大小肠，消痈肿，时行寒热，中恶，腹痛，腰痛”。

[xii]《神农本草经》云，“消食”。《名医别录》云，“消痰水……消谷嗜食”。

[xiii] 王付《历代经方方论》.人民军医出版社, 2013. 574

[xiv]《名医别录》云，“酒，味苦甘辛大热有毒，主行药势，杀邪恶气”。

[xv] Bensky Chinese Herbal Medicine - Formulas & Strategies, 2nd Ed. page 588

[xvi] 《神农本草经》云， “ 味甘、酸，平。主下水肿，排痈肿脓血。生平泽”。

[xvii]《小品方·述看方及逆合备急药决》云，“病源宜服利药治取除者服汤之后宜将丸散也时时服汤助丸散耳”

[xviii]《千金要方·论诊候第四》云，“散能逐邪风气湿痹表里移走居无常处者散当平之”

Traditional systems of medicine in countries such as Nepal, Sri Lanka, Bangladesh, Pakistan, Tibet, and Mongolia appear to be derived from Ayurveda. In Indian, Tibetan, and Mongolian traditional medicine, the mind, emotions, and body are not seen as separate but as a continuum. A person’s emotional and mental states are seen as having a significant impact on the body and vice versa. Mongolian, Tibetan, and Indian traditional medicine use a number of modalities or therapies for both prevention and treatment of disease. Many medicinal herbs are usually used in combination.

Mongolia has a severe climate with four seasons, throughout which nomadic Mongolians move from place to place tending to their domesticated animals. Their way of life and medical treatments are very peculiar. The methods of medical treatment are derived from their simple lives. Medicinal herbs, the limbs of animals, and minerals are used as natural forms of medical treatment. They are sometimes used individually and sometimes used together for medicinal purposes. Mongolians combine medicine with psychological therapy and use sayings, such as mantras, shamanic charms, and prophecy. There are certain influences of Buddhism in Mongolian medical treatment, such as the use of spells and the stating of one’s requests and mantra expressions.

In the 4th and 5th centuries, monks of Tibet, Nepal, and China were studying Buddhism in India, and it provided the opportunity for Buddhism to spread in Tibet. Medical books from India were translated from Sanskrit into Tibetan. When Mongolia tried to make Buddhism the official religion in the 13th century, Indian and Tibetan medical books came to Mongolia as well.

The book “Four Tantras” (Jud Shi) was written in the 11th century, a classic creation of Indian and Tibetan medicine. “Jud Shi” was the main textbook of Mongolian doctors when it arrived in the 14th century. In Mongolia, it was read in Tibetan and was also translated into Mongolian. The Mongolian version has been published many times. German scholar Walther Heissig wrote that Choiji Odser translated “Jud Shi” in the 14th century, and during Ligden Khan’s time (1604-1634), “Jud Shi” was revised and re-translated.

The five elements theory of Indian philosophy started to hold an important position in the basic principles of Mongolian traditional medicine and this is related to the popularity of “Jud Shi” in the 16th century and its translation into Mongolian. “Jud Shi” is the amalgamation of Tibetan and Mongolian medicine and the Indian sutra.

“Jud Shi” has four volumes, identified by tantra:

1. Basic Tantra- The Basic Tantra has four parts and is the basis of the other three tantra volumes. It contains all the general meanings of the Four Tantras and is a basic overview of the theories of Indian and Tibetan medicine.

2. Explanatory Tantra – This tantra has 31 parts. The root of Indian and Tibetan medicinal theory is defined briefly here.

3. Oral Instruction Tantra – This tantra has 92 parts and is the largest part of the book. It describes how diseases and disorders of the body and organ systems are generally understood in Indian and Tibetan medicine.

4. Subsequent Tantra – This tantra has 27 parts and draws conclusions on the therapies in the other 3 volumes.

Jambaldorj was one of the greatest doctors in Mongolia during the 19th century. He wrote a 174-page sutra called “Zetsermigjan”. During this time, there were errors and mistakes in identifying medicinal ingredients. He researched the work of the best ancient doctors of India, Tibet, and Mongolia, and defined the shape, form, features, and potency of the medicinal ingredients used. He also wrote a book about ingredients in Sanskrit, Tibetan, Chinese, Manj, and Mongolian, complete with 576 images. This book has attracted the attention of national and foreign scholars and has been published in foreign countries.

Luvsanchultem was a Mongolian doctor of the 19th century. He wrote about the Indian “five elements” theory used in Indian and Tibetan medicine. Mongolians enriched the ancient books on medicine that were passed on from India to Tibet. In Mongolian traditional medicine, anatomy, diseases, and the effects of medicine are explained on the basis of the five elements theory.

Five elements theory and three types of combinations

The five elements theory and the three types of combinations of these elements are the main parts of Indian, Tibetan, and Mongolian traditional medicine. Everything in the universe, including human beings, is composed of five basic elements. The five elements are earth, water, fire, air, and space. These five elements form the metabolism of the body.

– Earth controls the physical structure of the body: bones and flesh. All life forces become inert and inactive in this element and more energy is used to keep a body active.

– Water controls the kidneys, male and female reproductive organs, and produces antibodies. Water keeps the body and life flowing.

– Fire controls the spleen, liver, pancreas, and keeps all the organs active. It creates fire in the body. It heats water. It regulates sight, provides strength to the body by digesting food, induces hunger and thirst, maintains the suppleness of muscles, and a beautiful complexion.

– Air controls the chest, lungs, and heart and forms the purity of the mind and heart. Air is life itself. It is strength and guides every part of our body. It moves bile and phlegm, which cannot move in the body by itself.

– Space controls the entire body, thyroid, parathyroid, tonsils, saliva, cerebral and spinal fluid, the nervous system, and eliminates poison from the body. In order for air to circulate in the body and maintain a proper balance, there has to be space. If such circulation is blocked, it creates pain, even leading to heart attacks and loss of consciousness.

All these elements should be maintained in proper proportions. Any disturbance (and excess or deficiency) of one element leads to disturbances in other elements, and is considered the root cause of disease. If these five elements are maintained in proper proportions in the body, a proper metabolism is ensured and the body remains healthy. However, due to heredity, as well as eating and living habits, we can disturb one or two of these elements and upset the metabolism. When there is an illness present there is a predominance of one or more of three types of combinations of the five elements. In Indian, Tibetan, and Mongolian traditional medicine, people are diagnosed as being one of these three types of elemental combinations.

1. Kapha (Bad-kan) – the combination of excessive earth and water These elements occupy the largest areas of our body. Kapha people have a regular appetite with relatively slow digestion, and prefer warm drinks and like pungent, astringent, and bitter foods.

2. Pitta (Tri-pa) – the combination of excessive fire and air Pitta people have a strong metabolism, and a good appetite and digestion. They like large quantities of food and water, and like bitter, sweet, and astringent foods and cooling drinks.

3. Vata (Lhung) – excessive air Vata people have a variable appetite and crave salty, sweet, and sour foods, and prefer warm or hot drinks. Their hands and feet are usually cold and dry with cracked skin.

In Indian, Tibetan, and Mongolian traditional medicine, all foods are divided into six tastes: bitter, astringent, pungent, sweet, sour, and salty.

Mongolian diet therapy

Mongolians eat the following five kinds of food:

White – dairy products Red – meat products Green – plants and vegetables Yellow – butter and oil Black – water and distilled milk vodka

The five kinds of food of the Mongols include milk and milk products, such as curds, fermented mare’s milk, clotted cream, butter, sea buckthorn oil, cedar nut oil, apricot oil, and sheep tail fat.

The oil from sheep tail fat contains calcium, magnesium, iodine, and fluorine. It is also rich in vitamins D, C, A, K, E, B, and is good for fatigue, allergies, poisoning, and the eyes. Sheep tail fat has many medicinal qualities and is very nutritious, and has been considered beneficial “food” for infants and elders since ancient times. It enhances the metabolism and digestion, provides energy, prevents weakness and fatigue, and is thought to speed up the growth of infants. It moisturizes, softens, regenerates, and rejuvenates the skin. Sheep tail fat contains nutrients that cannot be found in any other food. The tip of the sheep tail, which is called uurag suul, is the best nourishment for the liver and supports the brain.

In Mongolian traditional medicine sutras, it’s written, “Fresh white butter is of cool quality and cures lung diseases and coughing, and treats fever. Old butter cures mental disorders, hangovers, and diseases of the eyes, brain, and womb.” In ancient sutras, it’s written “Yellow butter kept for years is good at treating diseases when applied to the skin. It has many diverse curative qualities if mixed with other ingredients. Yellow butter enhances intellectual capability, relaxes the mind, and refreshes one’s sight. It makes elders younger and makes voices melodious. It also improves fertility and cures diseases of the ears, lungs, and mind, and burns, frozen wounds, or cold weapon injuries.” The sutras also say, “Cow’s milk butter is very nutritious and good at healing any illness. The butter of goat’s milk is of cool quality and treats fevers. Yak or sheep milk is of hot quality and produces energy.”

In Indian, Tibetan, and Mongolian medicine, it is said, “Unsuitable food is poison to one’s body. Perfect food nourishes and keeps the body fit, healthy, and energetic. If the food is too little, the body weakens, beauty fades, and illness appears. If the food is too much, the body gets tired from over-consumption and is invaded by sickness. Thus, two quarters of the stomach should be full of food, one quarter of drink, and one quarter left empty.”

Nomadic Mongolians had a healthy lifestyle. During the winter time, meat products were mainly eaten, and during the summer time, dairy products, vegetables, and fruits were mainly eaten. The four conditions of climate, evil spirits, diet, and lifestyle act together to affect disorders. The four remedial measures for disorders are diet, lifestyle, medicine, and external therapies.

The following disorders are treated in Indian, Tibetan, and Mongolian traditional medicine: hot and cold disorders, pediatric disorders, gynecological disorders, wounds, geriatric disorders, infertility, indigestion, tumors, edema, fever, smallpox, and the common cold. They also treat disorders of the head, the eyes, the ears, the nose, the mouth, the goiter, and genital disorders; disorders of vital vessels and organs, such as the heart, lungs, liver, spleen, kidneys, stomach, intestines, and colon. Miscellaneous disorders, such as laryngitis, anorexia, hiccups, asthma, vomiting, diarrhea, constipation, diabetes, gout, arthritis, skin diseases, nervous disorders, and minor injuries are also addressed.

For centuries, Indian, Tibetan, and Mongolian medicinal practices were used not only to diagnose diseases but also to prescribe medicine based on individual conditions, using a unique system of evaluating the pulse, eyes, tongue, skin, and smell. The botanical formulas used thousands of years ago continue to be in use today. The Indian, Tibetan, and Mongolian traditional medicine systems are fond of using formulas involving multiple herbs. The treatments include decoctions, powders, pills, paste, medicinal butter, calcinated powder, gems, herbal compounds, oil therapy, purgation, emesis, nasal drops, enemas, channel cleansing, venesection, moxibustion, cauterization, compression, medicinal baths, natural spring baths, massage, and surgical therapy.

The diagnostic techniques are visual study, pulse taking, and interrogation. The visual study involves the examination of the tongue and urine. Touching with the fingers is like receiving information transmitted by the patient’s pulse. Interrogation involves the patient’s medical history, looking at the signs and symptoms of illness, as well as dietary factors.

For centuries, Mongolians have utilized traditional methods for surviving the harsh winter season. During the winter months, Mongolians eat “hot” foods that are rich in vitamins and minerals, and abstain from eating “cold” foods. Eating hot foods has the positive effect of increasing blood flow, energy level, improving the functions of the main organs of the body (including the digestive system), and has been scientifically proven to prolong life expectancy to an average of 70 years. However, in recent years, the life expectancy of the population has been decreasing, due to improper dress during the winter season and spending too much time in cold places, therefore not being able to maintain internal body heat. The long-term effect of this is a decrease in the immune system’s functions, cold sweats, and lower blood levels. Daily consumption of cold starters and salads, coffee, soft drinks, juices, beers, and other drinks that are below room temperature and straight from the refrigerator can lead to “cold” digestive ailments.

Cold water, drinks, and ice cream reduce body heat and increase the burden placed on the digestive system. In Indian Ayurvedic medicine, it is said that heat is life, while cold is death. Due to these practices in recent years, and particularly among young people, intestinal inflammation, stomachaches, stomach ulcers, the feeling of fullness or bloating, constipation, and the removal of gall bladders have been much more common.

There are cases where toxic vegetation is used to make medicines. Those toxic plants need special care, and there are specific methodologies for drying and removing the plant’s poison. A branch of a toxin-containing tree must be cut in half before drying. If the plant has a poisonous surface, the outer layer must be scraped away. To release the toxins in spar, it needs to be placed in a covered dish and set on fire.

Indian, Tibetan, and Mongolian traditional medicine is based on a philosophy that guides the practitioner to serve his patient according to special needs at a special time, and under special circumstances. They are extremely individualized, personal, and flexible, dependent on a person-to-person and expert-to-client relationship. Treatments and prescriptions are tailor-made for the patient, and take into account the individual’s constitution, age, gender, syndrome, primary complaints, accompanying signs and symptoms, the season, and the geographic location.

Nomin Galsandorj is a freelance writer and translator, translating texts from English to Mongolian, including the Dalai Lama’s official website. She can be contacted at nomin1994@yahoo.co.uk.

For centuries, Kou’s comment was repeatedly quoted as the dominant theory over lactation in the realm of learned medicine. It also coincides with parallel attempts to speculate on the metaphysical foundation of sex differences in women, and the consolidation of women’s medicine (fuke) and pediatrics (erke) as medical specialties.[1]

However, Kou’s original aim was to make sense of medical recipes. In particular, he was trying to figure out why do so many recipes for eye medicine use human milk to mix up powdered mineral drugs: a practice that has parallels in different cultural contexts. Since blood is essential for the five senses to function and human milk is essentially blood, Kou reasoned, this makes it an excellent medicine for eye diseases. Another recipe that may have been on his mind is the recommendation to drink “three portions of human milk” to help with obstructed menses. It makes sense if they were considered of the same origin. Like cures like.

Let’s pause here to consider what this means. Working with Chinese materia medica texts often means untangling different strands of thought, modes of compilation and miscellaneous quotations. The entry on each substance (e.g. human milk, renru or ruzhi) often begins with a learned survey of previous literature, including passages from classical literature and histories, and ends with a large (and often unwieldy) body of recipes. The problem is that the prescribed uses of the substances in the first part do not always sit well with the recipes, which are messy, opaque, and often outright strange.

In fact, Kou Zongshi’s work could be understood as a scholar-physician’s attempt to impose order and coherence on the unruly recipes, which were becoming increasingly available in print. [2] The incongruities and tension between theory and recipes, however, allows us to follow the intricate dance between empiricism and rationalism in such texts: when did authors equate recipes with real-life experiences, and when did they treat them as exemplars of theory and formulaic principles? When did book culture begin to shape the ways in which medicines were prepared, consumed, and invented?

Back to Kou Zongshi’s ingenious, if somewhat contrived, speculation over the nature of lactation. It did not seem to have caught much attention immediately. The twelfth and thirteenth centuries witnessed a growing suspicion among medical experts to discipline and curb wet nurses’ sway over childcare, and pediatric treatises abound with warnings against drunken, naughty wet nurses whose milk turns unwholesome to the infant.[3] Again, the female body’s power to nourish but also intoxicate with her transformed milk resonates with similar discourses discussed elsewhere on this blog; notably, alcoholic drinks were seen to be a bad thing that excites her passions, in contrast to ancient Roman recommendations.

In addition, the conquest of Mongols brought about increased consumption of cow and goat’s milk.[4] A leading physician active in the fourteenth century advised consuming those over human milk, which is easily “tainted with poisonous passions.” It looks like the arrival of more abundant dairy products would transform the existing pharmacopeia once and for all.

But not so simple. By the sixteenth century in China, human milk had become a “super food” of sorts, especially among elite families. Kou Zongshi’s dusty theory became a dominant trope, fanning the imagination of the female body as a machine of alchemical wonders, and her milk a sort of elixir that revitalizes the frail and depleted bodies. In the sixteenth-century encyclopedia Systematic Materia Medica(Bencao gangmu), Li Shizhen, the erudite naturalist and capable physician, criticized the excessive fetishizing of human milk. The prudent Li nevertheless included twelve “new recipes” that involve human milk as medicine. Li’s encyclopedia was first printed in 1596; soon after the turn of the century, dietary manuals began to teach people how to prepare dried milk powder at home, after collecting fresh milk from “strong women who just gave birth to boys”. Presumably, women sold their milk not as wet nurses, but directly to pharmacists (as depicted in the picture above).

So did people in imperial China consume human milk as medicine? Quite likely. But was it ubiquitous? Probably not. Recipes can be practical and fantastic, and theorists can explain and inspire. What matters is that human milk as medicine gradually came to be taken out of the context of nursing and acquired a more abstract quality as commodity.

[1] Charlotte Furth, A Flourishing Yin: Gender in China’s Medical History: 960–1665 (Berkeley, CA: University of California Press, 1999).

[2] Asaf Goldschmidt, The Evolution of Chinese Medicine: Song Dynasty, 960-1200 (London ; New York: Routledge, 2009).

[3] Ping-Chen Hsiung, “To Nurse the Young: Breastfeeding and Infant Feeding in Late Imperial China,” Journal of Family History, 20, 3 (1995), pp. 217-38.

[4] Paul D. Buell, E.N. Anderson, and Charles Perry, A Soup for the Qan : Chinese Dietary Medicine of the Mongol Era as Seen in Hu Sihui’s Yinshan Zhengyao, 2nd Rev. and Expanded ed. (Leiden, The Netherlands: Brill, 2010).

This one, Xianfang huoming yin (仙方活命飲, Immortal-Formula Life-Saving Beverage), is the representative formula for the dispersing method (xiaofa 消法) used in treating the early stages of welling abscesses (yong 癰). Historically it's been highly respected, but I haven't had call to use it myself (though I do get to use Wuwei xiaodu yin 五味消毒飲, Five Flavor Toxin-Dispersing Beverage, on occasion). The notes hand-written in the text is my mnemonic. This is one of my favorite ways to remember longer formulas that don't break down into neatly analyzable divisions. I make a rhymed verse from the names of the herbs. I thought I'd share this one for fun. In pinyin it goes (I've made one change since this photo was taken):

Yin, zao, hua, fang, zhi, gan, bei./Chen, mo, ru, jia, chi, guiwei.

Which means:

Jinyinhua, zaojiaoci, tianhuafen, fangfeng, baizhi, gancao, beimu./Chenpi, moxiang, ruxiang, chuanshanjia, chishao, dangguiwei.

Part of how I make this work for me is by grouping the herbs roughly by function (when the rhyme allows it). So the first three (jinyinhua, zaojiaoci, tianhuafen) are all herbs that address the toxic swelling rather directly (I could have put chuanshanjia in this group too, but it didn't fit). The second four (fangfeng, baizhi, gancao, beimu) are a more loose group that assists with that function. The second line is all movers, starting with one qi mover (chenpi) and finishing with a whole mess of blood movers (moxiang, ruxiang, chuanshanjia, chishao, dangguiwei). I'm very oral-aural--and I've always loved poetry--so that's probably partially why this works well for me. But I've been shocked at how well it works. I've remembered some of these rhymes for years without using the formula or reviewing the rhyme.

I find that some formulae, however, can be easily divided into parts based on the function of the herbs. So in the example above I've broken down Hao-qin qingdan tang (蒿芩清膽湯, Sweet Wormwood and Scutellaria Gallbladder-Clearing Decoction) into four pairs of herbs:

Qinghao and huangqin: The  lords of the formula that clear gallbladder damp-heat. Qinghao is the source for the artemisinin malaria medicines that earned Tu Youyou the nobel prize recently. From a Chinese medicine point of view it has the useful ability to clear heat that is hidden inside dampness in the same way the ashes of a fire can look cold but still hide glowing-hot embers.

Banxia and zhuru: These two herbs resolve phlegm and stop vomiting--a common symptom in this formula's pattern.

Chenpi and zhike: This pair move the qi, which is often obstructed by dampness leading to problems like glomus in the epigastrium.

Fuling and Biyu san: This pair is a bit of a cheat since the second member is actually a small formula containing huashi, sheng gancao, and qingdai. Nevertheless, that's how the formula is usually written. Both these ingredients disinhibit the urine, draining dampness downward and out of the body.

Finally, there are formulae that belong to formula families. These are best understood by understanding the family's basic structure and how each formula is a modification of that structure. Generally speaking, there are four basic ways in which the basic structure of a formula family can be modified: adding ingredients, removing ingredients, replacing ingredients, and adjusting the dosage of ingredients. The Guizhi tang 桂枝湯 family provides good examples of all three of these methods. The basic structure of the this family is the formula Guizhi tang itself (guizhi, shaoyao, zhi gancao, shengjiang, dazao), which is built from three formula elements (small formulae of one to four ingredients that act as the building blocs of larger formulae):

guizhi + zhi gan cao: This combo supplements the yang--particularly of the heart and spleen--and the defense (wei 衛). On its own, it is a formula called Guizhi gancao tang 桂枝甘草汤 used to warm and supplement the heart yang. It embodies the principle "acrid and sweet produce yang (xin-gan hua yang 辛甘化陽)."

shaoyao + zhi gancao: These two herbs together nourish the yin-blood--especially of the liver--and construction (ying 營). As a formula it is called Shaoyao gancao tang 芍藥甘草湯. It emobides the principle "sour and sweet produce yin (suan-gan hua yin 酸甘化陰)."

zhi gancao + shengjiang + dazao: This combination is frequently used by Zhang Zhongjing 張仲景 and serves to protect and nourish the stomach. It is particularly important in Guizhi tang because this formula acts primarily through the spleen and stomach--hence the saying that it "releases the flesh (jieji 解肌)."

The first Guizhi tang modification seen in the Shanghan lun (傷寒論, Treatise on Cold Damage) is an example of adding ingredients: Guizhi jia fuzi tang (桂枝加附子湯, Cinnamon Twig Decoction with Aconite Accessory Root Added). In this formula, fuzi is added to more strongly supplement the defense yang. It is used when a patient's defense yang is weak or damaged by improper promotion of sweating. The second modification of Guizhi tang in the Shanghan lun is a classic example of removing an ingredient: Guizhi qu shaoyao tang (桂枝去芍藥湯, Cinnamon Twig Decoction with Peony Root Removed). In this formula, the removal of shaoyao removes the second, yin-nourishing, formula element. This results in a formula that more strongly emphasizes warming and supplementing the heart yang. In the Shanghan lun it is used when incorrect purging damages the heart yang, allowing a cold evil to fall into the heart, but the Guizhi tang pattern persists. The third modification of Guizhi tang is an example of replacement (or removal and addition, same difference in this case): Guizhi qu shaoyao jia fuzi tang (桂枝去芍藥加附子湯, Cinnamon Twig Decoction with Peony Root Removed and Aconite Accessory Root Added). Here fuzi is added to the previous formula, increasing yet further its ability to warm and supplement the heart yang. It is used in the same patterns as the previous formula, but when stronger cold is present. Not all examples of replacement can also be described as removal and addition. The Ma-Xing family is an excellent example. This family has three representatives in the works of Zhang Zhongjing: Mahuang tang (麻黄汤, Ephedra Decoction), Mahuang xingren gancao shigao tang (麻黄杏仁甘草石膏汤, Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction), and Mahuang xingren yiyiren gancao tang (麻黄杏仁薏苡甘草汤, Ephedra, Apricot Kernel, Job's Tears, and Licorice Decoction). All three formulas contain the core two ingredients of the family--mahuang and xingren--as well as gancao, but by replacing the third ingredient and adjusting the doses of the remaining ingredients very different formulae are produced. To return to Guizhi tang, one of its most famous modifications is an excellent example of how altering dosage can produce new formulae: Guizhi jia shaoyao tang (桂枝加芍药汤, Cinnamon Twig Decoction with Additional Peony Root). In this formula the dosage of shaoyao is doubled. This greatly increases the strength of the shaoyao + zhi gancao formula element, allowing the formula to more effectively soothe the liver and the sinews, treating the cramping pain that often accompanies diarrhea (in this case a taiyin-spleen vacuity diarrhea). Understanding how the formulae of a family are related to one another--how they are constructed and modified--makes remembering their ingredients far simpler. Many such formula families exist in Chinese medicine, and understanding them is a key method of formula memorization. All herbalists, whether just starting to learn or with many years of experience, have to keep memorizing and reviewing formulae. It's just part of the process of being a good herbalist. Many people find memorization difficult, but everyone is capable of tremendous feats of memory--it's part of our human skill set. We just have to learn how to use that capacity. These three methods have been very useful for me, and I hope that others may find them useful as well.

This three-day workshop (May 8-10, 2015) at EASTmedicine, University of Westminster, London brought together international expert physicians and scholars of Tibetan medicine – medical anthropologists, historians, ethno- and medical botanists, pharmacologists – working with and/or on Tibetan medicine, and also experts in Chinese medicine as well as IT specialists. Organised by Mona Schrempf, the author of this report, the workshop was funded by the British Academy/Small Leverhulme Research Grant, the Sino-British Fellowship Trust and IASTAM (International Association for the Study of Traditional Asian Medicine). It had the aim to discuss and contribute to what an interdisciplinary and multilingual digital knowledge base should look like that could be used in the future as a tool for documenting and analysing Tibetan medical formulas for a variety of scholarly users worldwide, including physicians of Tibetan medicine working in many different national contexts in Asia and the West.

Such an ambitious endeavour requires complex processes of re-translation and re-contextualisation of and between Tibetan medicine and biomedicine (and partly Chinese medicine) in the relevant languages Tibetan, English, Latin, and Chinese, and also between different disciplines involved. Therefore, we focused on a common global ailment of our time that many of us universally suffer from – stress. We approached the topic from different angles, starting with a set choice of multicompound Tibetan formulas containing as main ingredient eaglewood. They are prescribed for specific types of ‘wind’ (Tib. rlung)[1] disorders in Tibetan medicine that are characterised by common stress symptoms – insomnia, restlessness, lack of concentration, light depression. ‘Wind’ is the principle of movement within the body and governs the functions of thought, breathing, and other physical movements, such as bowel movement, etc. in Tibetan medicine. Stress-related ‘wind’ disorders are usually caused by and located in or around the heart, i.e. by an imbalance of the ‘heart wind’ (Tib. snying rlung) or the ‘life-sustaining wind’ (Tib. srog ’dzin rlung).

Such ‘wind’ disorders are generally treated – next to using other treatment methods (nutrition, behaviour, massage, moxibustion) – with a specific set of Tibetan formulas containing as main ingredient eaglewood or agar wood (Lat. different types of Aquilaria; Tib. a ga ru or a gar)[2], in the following shortly called Agar-formulas (Agar 8, Agar 15, Agar 20, Agar 35, Sogdzin 11). Eaglewood is both a potent medicinal and fragrant resinous wood, also used in medicinal incense against insomnia (Agar 31). Its use is problematic because of the unresolved botanical identification of Aquilaria malaccensis that is endangered and CITES-listed[3]. Nevertheless, Agar-formulas are very popular and frequently prescribed in Tibetan medicine. They are produced and prescribed as compounded formulas by physician-cum-pharmacists or by physicians administering readily manufactured pills; however, they might be also directly taken as a dietary supplement.

We looked at different Agar-recipes and their various formulations, their ingredients and indications. At the workshop, Tibetan scholars also presented classical Tibetan medical texts and certain pharmacopoeias used for producing these formulas. It quickly became evident, however, that both the complexity of different disease categories and understandings of causes of illness in Tibetan medicine are not easily translatable into European biomedical or even ‘alternative medical’ understandings. On the other hand, it is possible and practiced already. Researchers at one pharmaceutical company in Europe producing Padma Nervetonic based on the Tibetan formula Sogdzin 11 explained at the workshop how and why they had to adapt or omit certain ingredients of the original formula which is administered for stress to European patients, how its overall efficacy is maintained and understood, as well as proven and regulated within European frameworks of production and distribution (on such a process of translation, see Schwabl and Vennos 2015).

Processes of cultural translation are intrinsic to correlating and making sense of illness and treatment between different languages, of medico-cultural concepts of health and disease, and of various disciplinary approaches and interests, yet they are vexed and problematic and therefore often ignored or glossed over. We tried to do the opposite in this workshop by carefully translating together the same formulas from different disciplinary perspectives and retranslating ‘in-between’ those. Prepared by a one-month pilot study by visiting scholar-physician of Tibetan medicine, Dr Cairang Nanjia from the Tibetan Medical College, Qinghai University, PRC, and the author of this report, Mona Schrempf – at the time Wellcome Trust Research Fellow at EASTmedicine, University of Westminster (2012-2015) – this ensuing workshop proved a fruitful platform for discussing some of the outcomes and issues involved. It is hoped that the initial results from this workshop will serve as a basis for future international research cooperations on the topic of Tibetan materia medica and formulae (Schrempf forthcoming a,b).

Our pilot-study examined Agar-formulas based on their original recipe texts and documentations as well as different application contexts in China and Europe. From a Tibetan medical point of view, it is impossible to narrow down the efficacy of a particular formula or even of a single ingredient within a formula to one specific disease only (usually defined in biomedical terms). Rather than perceiving this gap in translation between different medical principles as a loss, it can also open up a space for research examining how careful correlations between different medical principles can allow for a more complex and complete view of disease in relation to a particular formula, and maybe even shed light on possible causes and explanations on how disease can originate. Tibetan formulae are conceptualised in a way that they balance internally the different efficacies of single ingredients as to avoid side-effects while multitargeting connected imbalances in the body.

Traditionally, Tibetan formulae are not only prescribed for a particular imbalance in the body but individually according to the constitution of an individual patient and according to the stage of a disease or combination of disease(s), etc. For this subtle individual prescription, pulse diagnosis is necessary. It is the only way to know which particular imbalances are present or dominate and therefore in need of immediate treatment within a patient’s body. So how can this aetiological and epistemological complexity be translated into a fixed biomedical disease entity required to prove biomedically defined efficacy that is, for example, necessary for producing industrialised, quality approved and licensed pharmaceuticals? This is just one of the many questions of translation that we were addressing in this workshop[4].

The individual workshop presentations

Cairang Nanjia (Tib. Tsering Namgyal) began by documenting Agar-formulas in Tibetan medical, botanical and pharmacological texts used at present in Qinghai, China. He was focusing on the structure of the formulas, comparing the single ingredients and their relations to each other. We also looked at the different translations of these formulas into Chinese and English as well as German languages and prescription leaflets, adaptations that were sometimes also altering the actual composition of the formulas. The author of this report, Mona Schrempf, related her ethnographic material on different styles of production and prescription practices of Agar-formulas in both China and parts of Europe (Schrempf, in press, forthcoming a). With the advice from IT specialist Kapetanios, Cairang and Schrempf developed a possible multi-level digital knowledge base structure of synonyms and homonyms in order to deal with the complexity of different languages, concepts and terminologies connected with the Agar-formulas in an adequate way using different disciplinary approaches as access points to the digital knowledge base envisioned. The preliminary results were presented at the workshop for discussion and have benefitted, among others, specifically from the input by Bob Allkin, IT-specialist for digital Plant Names Services at the Royal Botanic Gardens Kew, London. He explained why plant names matter and how he organises Kew’s digital knowledge base using authoritative international naming and taxonomic resources, what the obstacles are for appropriate naming and use, how things can go wrong, and the role of the food and drug administration in deciding what is toxic and what not.

Workshop participants used different sources for looking at the Tibetan Agar-formulas and analysed them following up on specific questions, such as: Which texts are important for understanding Tibetan materia medica and formulas produced today? Who produces these formulas using what kind of knowledge and production technology, and how is this connected to (biomedically defined) efficacy and safety issues? Which ingredients are we actually talking about in a specific formula and how do we identify them botanically while addressing their regional diversity at the same time? How and why are certain materia medica ingredients in a formula substituted? How does a formula work and for what kind of disorders, related to which organs etc.? How can we understand ‘wind’ (Tib. rlung) disorders in Tibetan medicine correctly, and in particular, ‘heart wind’ and ‘life-sustaining wind’ treated by Agar-formulas? Is a translation between these specific wind-disorders and what we call ‘stress’ possible at all? Is it effective to prescribe an Agar-formula for stress symptoms without a prior detailed pulse diagnosis of the individual constitution of the patient and his or her specific disease by a physician of Tibetan medicine?

These are complex issues without doubt that we tried to address by re-translating between Tibetan, English and Chinese languages and inherent health and disease concepts in Tibetan and biomedicine as well as – at least where China is concerned – also in relation to Chinese medical concepts. The latter appear on package leaflets of Tibetan medicines in China, written in Chinese. Sources used and topics addressed at the workshop ranged from analysing Tibetan historical medical and botanical texts for developing a feasible structure for Tibetan formulas (Olaf Czaja) to Chinese publications on minority medicines and how information on their materia medica is collected in China (Lena Springer); how the seminal Tibetan medical text, the Four Tantras or rGyud bzhi explains the classification and treatment of rlungdisorders (Mingji Cuomu); how specific rlung disorders, specially ‘heart wind’ (Tib. snying rlung) and ‘life sustaining wind’ (Tib. srog ’dzin rlung), are taught to Tibetan medical students in Xining (Sanjijia); and what the experiences with treating rlung disorders at the Tibetan medical hospital in Xining are, demonstrated by the eminent 84 year old co-founder, teacher and physician-cum-pharmacist, Akhe Nyima.

Colin Millard presented patient case studies and related prescription practices by Lobsang Dhonden Soktsang for ‘wind’ disorders at the Tara Clinics, UK, in which, however, no Agar-compounds were used. IT-specialist Bob Allkin and medical botanist Christine Leon from the Royal Botanic Gardens Kew gave stunning presentations of the complexity of identifying just one single plant in a botanically correct way. In contrast, the ethno-botanist van der Valk asked questions on whether the fixation on a specific botanical identity of, for example, ‘eaglewood’, does not counteract or limit the diversity and regional flexibility of this particular medicinal plant.

This flexibility is also connected with the sustainability of these plants used in many Tibetan formulas whose ingredients mostly grow in the wild in the Himalayas and on the Tibetan Plateau – and are often locally not accessible for small scale producers, such as private physician-cum-pharmacists. Padma Gurmet from the Sowa Rigpa Institute in Ladakh demonstrated the ongoing efforts to cultivate and sustain medicinal plants growing in the wild in Ladkah. Brion Sweeney demonstrated the important work by the eminent scholar and teacher Akong Rinpoche in both his home area of Kham and the UK for Tibetan medicine focusing on the sustainability of medical plants and Tibetan medical education. Florian Ploberger discussed the Tibetan materia medica of Agar-formulas from the point of view of TCM-phytotherapy. Herbert Schwabl, director of research at Padma AG, and Cecile Vennos, head of regulatory and medical scientific affairs, explained how they had adapted the Tibetan formula Sogdzin 11 into becoming Padma Nervotonin (Schwabl & Vennos 2015). Last but not least, Michael Stanley-Baker, Chen Shi-Pei, and Brent Haoyang Ho from the Max Planck Institute for the History of Science, Berlin, explained what a digital data base can offer if one is interested in mapping drugs across time and space.

Perspectives

The aim of the workshop was to sound out what kind of information is important in order to fully document and analyse Tibetan medical formula in a multidisicplinary and multilingual digital knowledge base. Only careful translations will allow to properly correlate different concepts used and applied to these formulas, from Tibetan, Chinese and bio-medical knowledge, the impact of regulatory regimes on the formulas in each national context. It would be desirable if in the future we could pursue an integrative and synthesising approach to Tibetan Medicine with a sensitivity to various interpretations in this multi-lingual endeavour and one which adequately represents the varying involved disciplines and therapeutic practices. The aim would be to explore careful and meaningful ways of representing Tibetan cultural and medical knowledge and develop suitable key search terms in different semantic networks as to make such a digital knowledge base a useful tool for researchers and practitioners alike.

On the workshop, see the website of EASTmedicine, University of Westminster.

Footnotes

[1] ‘Wind’ or loong (rlung) in Tibetan is one of three complex bodily principles in Tibetan medicine, the other two being ‘bile’ or tripa (Tib. mkhris-pa) and ‘phlegm’ or peken (Tib. bad-mkan), resembling Ayurvedic principles with which they are historically connected. An imbalance of these three bodily principles causes disease. For more information, see http://tibet-medicine.org/de/tibetische-medizin/grundlagen/die-grundprinzipien/

[2] One of the problems we are facing is the botanical identification and regional variety of this plant. It can be, for example, Aquilaria agallocha Roxb., Aquilaria sinensis, Cinnamomum pharthenoxylon Tack.

[3] On the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES), see https://cites.org/eng/disc/what.php. On Aquilaria mallacensis, see http://www.iucnredlist.org/details/32056/0

[4] Medical anthropological research publications on Tibetan medicine alias Sowa Rigpa (Tib. gso ba rig pa), the ‚Science of Healing‘, mainly as practiced in Asia, are growing. See Adams, Schrempf & Craig 2010; Blakie 2013, 2015; Craig 2012; Janes 2002; Hofer 2012; Kloos 2013; Pordié 2008; Saxer 2013, Schrempf 2007, in press, forthcoming a,b.

References

Adams, Vincanne, Mona Schrempf & Sienna Craig (Hgs). 2010 (2013). Medicine Between Science and Religion – Explorations on Tibetan Grounds. London, New York: Berghahn Publishers.

Blakie, Calum. 2013. Currents of Tradition in Tibetan Medicine Pharmacy. In: East Asian Science, Technology and Society 7 (3), 425-451.

—— 2015. Wish-fulfilling Jewel Pills: Tibetan Medicines from Exclusivity to Ubiquity. In: Anthropology and Medicine22 (1), 7-22. DOI: 10.1080/13648470.2015.1004504

Craig, Sienna. 2012. Healing Elements: Efficacy and the Social Ecologies of Tibetan Medicine. Berkeley: University of California Press.

Janes, Craig. 2002. Buddhism, Science, and the Market: The Globalisation of Tibetan Medicine. In: Anthropology and Medicine 9 (3), 267-289.

Hofer, Theresia. 2012. The Inheritance of Change. Transmission and Practice of Tibetan Medicine in Ngamring. Wien: Arbeitskreis für Tibetische Buddhistische Studien Universität Wien, Wiener Studien zur Tibetologie und Buddhismuskunde, Heft 76.

Kloos, Stephan. 2013. How Tibetan medicine in Exile Became a „Medical System“. In: East Asian Science, Technology and Society 7 (3), 381-395.

Pordié, Laurent (Hg). 2008. Tibetan Medicine in the Contemporary World. Global Politics of Medical Knowledge and Practice. London & New York: Routledge.

Saxer, Martin. 2013. Manufacturing Tibetan Medicine. The Creation of an Industry and the Moral Economy of Tibetanness. Oxford, New York: Berghahn Publishers.

Schrempf, Mona. 2007. Soundings in Tibetan Medicine. Historical and Anthropological Perspectives (Proceedings of the 10th Seminar of the International Association for Tibetan Studies (PIATS), Oxford 2003). Leiden: Brill Academic Publishers.

—— (2015, in press). ‘Formulation Regimes and Styles of Practice in Transnational Tibetan Medicine – a Comparative Perspective on Efficacy and Safety between China and Europe. In: Mona Schrempf & Lena Springer (Hgs). Efficacy and Safety in Tibetan and Chinese Medicine: Historical and Ethnographic Perspectives (special issue) Asian Medicine – Tradition and Modernity 10 (1-2), 35 p.

——(forthcoming a) A Tibetan Medical Root Formula and its Derivatives: Cultural Translations in Transnational Styles of Practice.

——(forthcoming b) Transnational Tibetan Medicine – Formula Regimes, Therapeutic Networks and Styles of Practice between China and Europe (Berghahn Publishers)

Schwabl, Herbert & Cecile Vennos. 2015. From Medical Tradition to Traditional Medicine: A Tibetan Formula in the European Framework. In: Journal of Ethnopharmacology 167 (5), 108-114.

In the Song (960-1279), although the term “medical cases” was not yet in use, records of clinical interactions first began to be compiled as a major or sole component of books. The reasons for this development are complex and beyond the scope of this post. Instead, I would like to query the hermeneutics of the Song case record literature. How were these records meant to be understood? What purposes did they serve?

To begin answering these questions, I look at an example from one of one of the pioneers of this genre, Xu Shuwei (許叔微, 1080-1154)—a member of the literati-elite, holder of the prestigious jinshi degree, and avid proponent of the Han Dynasty (206 BCE-220 CE) medical text, the Treatise on Cold Damage (Shanghan lun 傷寒論). Xu produced the first book completely devoted to case records, Ninety Discourses on Cold Damage 傷寒九十論, and included many such records in his other works, most notably Efficacious Formulae for Universal Aid (Puji benshifang 普濟本事方). The case I translate and examine below is taken from the ninth fascicle of Efficacious Formulae. It follows a description of a formula from the Treatise on Cold Damage, Minor Bupleurum Decoction (Xiao chaihu tang 小柴胡湯). Throughout this book, Xu frequently followed a formula with a case record including its use. Their position clearly indicates that their purpose is explanatory and pedagogical, but their content is often far from straightforward.

Translation and Commentary

Xu opens this case record by describing the circumstances in which he found the patient:

            I recall that there was a person who had suffered from cold damage for five or six days. He was sweating from his head, but from the neck downward there was no sweating. His hands and feet were cold; he felt fullness and oppression in his epigastrium, and he was constipated. Another [physician], seeing the cold extremities and also the sweating and fullness, took it to be a yin pattern [of illness]. I diagnosed the patient’s pulse and found it to be sunken and tight.

            I said, “This pattern can certainly give rise to doubt. However, the stool is bound, and it is not a vacuity-bind. How can take it as a yin [pattern]? Although a sunken and tight pulse indicates a lesser yin pattern, they are mostly patterns of spontaneous diarrhea. There has never yet been a case of constipation [with this diagnosis]. Know that this pattern is half in the interior, half in the exterior. Prescribe Minor Bupleurum Decoction and you will obtain a cure.

A common feature of Xu’s cases is the attention he pays to his arguments with other physicians present. Well-off families frequently consulted more than one healer and often made use of more than one healing modality. Even a very elite physician like Xu had to argue down the other physicians present in order to win the confidence of the patient’s family, but unlike some of Xu’s other case records, the emphasis here is not on the ignorance of his opponents so much as it is on content of Xu’s resolution of the “doubts” surrounding this case:

            “Zhongjing said, ‘In cold damage after four or five days, there is sweating from the head, slight aversion to cold, cold hands and feet, and fullness of the epigastrium. [The patient’s] mouth does not wish to eat, and his stool is hard. The pulse is fine. This is debilitation and binding of the yang. There must be [illness] in both the exterior and the interior. A sunken pulse also indicates [an illness in] the interior. Sweating indicates debilitated yang. If it were completely binding of the yin, it could not also have an external pattern. It would completely enter into the interior. This is half in the interior and half in the exterior. Even if the pulse is sunken and tight, it cannot be taken as a lesser yin [pattern]. Why is this so? Yin [patterns] cannot have sweating. Now the head is sweating, therefore we know that it is not a lesser yin [pattern]. You can give Minor Bupleurum Decoction. If [the patient] does not recover completely, obtain a bowel movement and [the illness] will resolve.’ This pattern of illness is the same; therefore, if we obtain a bowel movement [the illness] will resolve.

In defense of his position, Xu quotes from the Treatise at length (this is line 148). Throughout his case records this is the most common tactic he uses to overcome objections to his proposed treatments. In this case, the match between the patient’s symptoms and the line from the Treatise on Cold Damage is precise and nearly complete. In the original Chinese, the similarity is so pronounced the reader could be forgiven for thinking a scribe had accidentally copied the same passage twice. Xu’s reading of this particular line, however, is somewhat idiosyncratic. The terms I have translated as “debilitation and binding of the yang (yang wei jie 陽微結) are read by most commentators as “mild binding of the yang.” Both readings are grammatically possible, but I have found no other commentator who agrees with Xu’s interpretation.

            One person objected, “Zhongjing said, ‘If the yin and yang of the patient’s pulse are both tight, but contrary to expectations he is sweating, the yang has perished, this pertains to lesser yin.’ How can you now say that ‘Yin patterns cannot have sweating?’ How is it that [seeing] sweating from the head you can then know that it is not a lesser yin pattern?”

In most of Xu’s case records, his opponents are depicted as ignorant and unable to quote the medical classics—particularly the Treatise on Cold Damage. In this record, however, at least one of his opponents has a solid knowledge of the Treatise and accurately quotes from it (line 283) disputing Xu’s conclusions.

            I said, “This passage is truly one of the places where Zhongjing critically analyzes [a clinical situation]. The significance [of this passage] is that cold of the four limbs, a sunken and tight pulse, and fullness are all similar to lesser yin [patterns]; however, hard stools and [only] sweating from the head cannot be lesser yin [patterns]. Since the head is where the three yang [channels] gather together while the three yin [channels] turn back on reaching the chest, it must be that when there is sweating from the head [alone], it is naturally [due to] yang vacuity. Therefore, [Zhongjing] says, ‘Sweating indicates debilitated yang.’ This is [the meaning of] ‘Yin cannot have sweating.’ As for a lesser yin [pattern], if there were sweating from [only] the head, [the patient] would die. Thus, in the ‘Treatise on Evaluating the Pulse’ [chapter of the Treatise on Cold Damage], Zhongjing says, ‘[In the five phases], the heart is fire. It is named lesser yin. … If there is no sweating from the head, [the patient] can be treated; if there is sweating, he will die.’ It must be because the heart [channel] is hand lesser yin and the kidney [channel] is foot lesser yin. Relative to one another they are above and below. Only by using judgement to trace it back can you obtain it.

“Critical analysis (yilun 議論)” refers to a discussion of the finer points of what is and is not so in a given situation (in Chinese shi zhi shifei 事之是非), and Xu immediately delves into just such an analysis. The problem, he informs us, with this clinical situation is that some of the signs and symptoms seem to clearly indicate a lesser yin pattern while others equally clearly argue against it.

A key issue was why sweating from the head alone cannot be present in a yin pattern. Xu’s explanation draws on the fundamental ambiguity of the terms yin and yang within the Treatise on Cold Damage. The Treatise labels the primary six diseases or stages of cold damage with the names of the six categories of acupuncture channels. While many later authors drew a clear distinction between the diseases of the Treatise and the acupuncture channels that shared the same name, Song authors like Xu did not. For them, cold damage diseases were diseases of the channel for which they were named. Xu could therefore freely conflate diseases, patterns of illness, and channels. Xu reasons that since only yang acupuncture channels directly reach the head, only an illness of the yang channels could cause sweating from the head alone. Thus, this could not be a lesser yin pattern, as his interlocutor had suggested. To secure his victory, Xu quotes from the Treatise again, noting that in illnesses of the heart, patients who sweat from the head will die. Lesser yin disease in the Treatise is usually associated with the kidneys, but both the heart acupuncture channel and the kidney acupuncture channel are named lesser yin (one for the hands and one for the feet).

Xu's final comment, "Only by using judgement (yi 意) to trace it back can you grasp it 惟以意逆者，斯可得之," is somewhat vague. It closely resembles a passage from the Mencius (Mengzi 孟子) in which Mencius gives instruction on how to understand one of the Odes (Shi 詩): "We use our understanding (yi 意) to trace it back to what was [originally] in the writers mind (zhi 志)—this is how to grasp it 以意逆志，是為得之." (Mencius V.A.4.ii, translated by Stephen Owen [1]). This quote was one of the mainstays of Chinese literary theory, and Xu would certainly have been familiar with it. The parallel is interesting. It suggests that Xu is giving advice for understanding medical texts in general, and that advice is very similar to the traditional method for understanding literature: use your judgement/understanding (yi 意) to understand the author's intention (by Xu's time also written yi 意). This advice would be given and applied more explicitly two centuries later by Zhu Zhenheng (朱震亨, styled Danxi 丹溪, 1281-1358, e.g., Gezhi yulun 格致餘論, "Douchuang Chenshi fang lun 痘瘡陳氏方論") and his student Wang Lü (王律, fl. mid-late 14th c., e.g., Yijing suhui ji 醫經溯洄集, "Zhang Zhongjing shanghan lifa kao 張仲景傷寒立法考“).

Discussion

What are we to make of this case record? The clinical details of the case receive far less space than the argument between Xu and the opposing physicians, but given the pedagogical intent of the record, attention to the reasoning behind Xu’s choices is understandable. It is also typical of Xu’s cases in general. Likewise, citing the medical classics in medical arguments—though less common than it would become—was not uncommon in the Song and was almost ubiquitous in Xu’s cases. However, the particular quotation chosen and the way in which Xu used it reveal important aspects of Xu’s general approach and his purposes in writing this case record. To understand what Xu was doing in this case record, we need to answer three questions. First, why does Xu’s description of the patient’s signs and symptoms match almost word for word the quotation from the Treatise? Second, this quote is one of the most difficult and debated lines of the Treatise. Commentators have argued over it’s meaning from Xu’s time to today and failed to reach consensus. If this case record was meant to illustrate the use of Minor Bupleurum Decoction, why did he choose such a problematic example? Finally, why in this case—unlike almost all of Xu’s others—are his opponents depicted as being conversant with the text of the Treatise on Cold Damage?

For Xu, the words of the classics, properly understood, correspond exactly to clinical reality. They are not merely doctrinal principles but detailed clinical guidance. In looking to them, he did not seek general ideas but concrete diagnoses and treatments. We see this throughout his medical writings, but most especially in his case records, where he goes to great length to demonstrate that what one sees in clinical practice is identical to what one reads in the classics—particularly in the Treatise on Cold Damage. The line Xu quoted, obscure and difficult to explain, was therefore a challenge. If his approach was sound, Xu had to be able to show that even this line could be understood in a way that would make it’s clinical application straightforward. Presenting a case record in which he used this line as the basis for his treatment was an ideal way of demonstrating its clinical utility. Unfortunately, part of this line—the statement, “Yin [patterns] cannot have sweating”—appears to directly contradict other parts of the Treatise, which, in fact, frequently mention sweating as a symptom of lesser yin disease. Xu had to resolve this contradiction in order to maintain his claim that the classics were sources of practical clinical advice. A knowledgeable opponent provided the perfect opportunity to both raise this objection and defeat it.

Xu’s analysis thus emphasizes the similarity of the illness pattern described by this line to lesser yin patterns of disease—cold limbs, abdominal fullness, a sunken and tight pulse—but reveals how a handful of symptoms—constipation and sweating from the head—guide us away from that diagnosis and towards a very different one. In so doing, he not only rescues this line but also gives it a proper place in the system of cold damage diagnosis and treatment. It has become one of the many lines that discuss patterns that superficially appear to be one kind of illness but on deeper investigation are found to be something else entirely.

Taken as a whole, this case record vindicates both the clinical applicability of this line and the overall usefulness of Xu’s approach to medicine. An obvious question is whether this is really a case record at all. Did Xu present events that actually occurred or did he just invent them to suit his purposes? We have no way of knowing with certainty. Xu’s cases include a large amount of clinical and social detail that seem unlikely to be completely fictional. At times he identifies his patients and surely would not have falsified the basic details of their cases in so public a fashion. However, the dialogues between himself and other physicians often appear somewhat too convenient for the arguments Xu wants to make. It is possible that these debates were embellished or invented by Xu to suit his purposes. Regardless, what this example shows us is that case records could be used for a variety of purposes: self-promotion, instruction, doctrinal polemics, clinical innovation, or even exegesis.

Notes

[1]: Stephen Owen, Readings in Chinese Literary Thought (Cambridge: Harvard University Press, 1992), 24.

In this report, I would like to share what I have learned about an indigenous ethnic minority group, the Karen people of Burma, focusing primarily on the condition of their traditional herbal medicine. By drawing information from my experiences in the refugee camps and from conversations I've had with people about life inside Karen State, I will conclude with what I know about the current work being done to preserve the herbal traditions of the Karen; specifically the courageous and visionary efforts of the Karen Environmental Social Action Network (KESAN).

As a result of the long-term refugee situation of the Burmese Karen population, I have seen an overall loss of herbal traditions combined with an unsustainable reliance upon modern medicine distributed in camp.

History and Introduction

The Karen are an ethnic minority living in Burma (now Myanmar) and Thailand. They trace their ancestry to Mongolia and Tibet, and claim to have been the first inhabitants of what is now Myanmar, arriving sometime in the 5th century B.C. Not long afterwards, the more aggressive Burman ethnic group moved into the central plains and pushed the Karen up into the mountains of what is now Karen State. They assumed control of the country, established great kingdoms and subjugated the ‘lesser’ hill tribe Karen. Thus the seeds of the current conflict were sown centuries ago.

In the early 1800s, British colonialism took place and the Karen fared quite well; they were thankful to see the Burman conquered by the British and so were quite loyal to the crown. Missionaries, especially American Baptists, were popular among the Karen. Along with conversions to Christianity, these missionaries brought education and literacy to the Karen.

As a result, an improved and sophisticated determination to stand up to the Burman began to grow. In 1949, the country gained independence, leaving the Burman ethnic group in control and the Karen began fighting a revolution that continues to this day.

The present military regime in Burma, the State Peace and Development Council (SPDC), perpetrates abuse on a mass-scale against their people -- including ethnic Burmans. However, they have a particular hatred for the Karen and their 56 year old revolution. In the 1970’s, after two decades of unsuccessful fighting against the guerilla warfare of the Karen, the military regime began specifically targeting civilians. Since then, many have sought refuge in neighboring Thailand. Despite this continuous movement, though, the majority of the Karen struggle to live in their homeland, the Karen State of Burma, along the Thai border.

The Kingdom of Thailand has responded to the plight of the Karen by establishing camps along its border, but Thai Authorities severely limit the actions and movements of both the refugees and the International Non Governmental Organizations (INGOs) that support them. The first official camp was founded in 1980, and over the years, numerous others have been established, consolidated, and relocated. Currently there are 7 Karen camps offering safety to over 100,000 legally registered refugees. The largest camp has over 40,000 inhabitants. The Karen are safe here, have access to clean water, shelter, food, and basic medical services. However, they now face a new psychological struggle as they have been trapped in camps for years with little hope of going home.

There are also Karen villages in Thailand. Many of these Karen are Thai citizens, either being born in the Kingdom or having lived there long enough to obtain papers. These villages serve as accurate models of what Karen villages might be like in Burma when there is peace and freedom. An herbal medical tradition still exists, but the rapid growth of Thailand’s economy is severely threatening its survival. In the meantime, many have attempted to study this traditional medicine, but little has been translated into English.

My experience in the last two years has primarily been with the refugee population. My wife and I spent almost one year living with the refugees in a remote camp. I taught English classes, trained local English teachers, and participated in a variety of other developmental activities. Through my experience with my students and day to day life in the camp, I learned a lot about refugee life and the Karen in general.

The transformation that the refugees have undergone during their time in camp is enormous. Most notably, I observed an unhealthy dependency on INGOs. These INGOs provide emergency food rations, basic necessities like mosquito nets and clothes, and education in the form of teacher subsidies, textbooks, notebooks, pens and pencils. In addition, several medical INGOs offer basic health care and training.

In my opinion, the refugees' reliance on camp healthcare has become the most threatening impedance to the survival of the Karen in the future, especially after repatriation. For example, at any indication of not feeling well, a “para” is prescribed. This is the status quo throughout the community. Paracetemol (called acetaminophen in the U.S.) is the cure-all, handed out like candy by the INGOs in camp. I had no idea how widespread this treatment was until another English teacher told me that the clinic has been nicknamed the “paracetemol hospital.” He mentioned that every illness is treated similarly.

In addition to this unhealthy reliance on western medicine, the Karen continue to look at the British, or “white skinned” as their potential saviors; a direct effect of colonialism and missionary work from years ago. We have returned to the area in the form of development workers, teachers, doctors, and missionaries. Basically, in the eyes of the Karen, we offer hope for a better future. By adopting our ways, young Karen believe that they can potentially leave behind the nightmare that is their reality. Sadly, it is this type of extreme vulnerability in the refugee population that threatens their cultural identity and ultimate survival upon repatriation.

It saddens me to see the Karen in camps losing their rich herbal tradition. When I look at their future repatriation to the mountains of their homeland, I see a major obstacle in terms of healthcare. The INGOs will be gone, and there will not be any “para” available for free. At the moment, their knowledge of traditional herbal remedies remains stronger than their understanding of the pills that they are given. However, what they are unwilling to admit is that they will have to rely on these traditional remedies when they return home, and this knowledge is fading with time.

In contrast to life at camp, the Karen struggling to survive in Burma continue to practice a traditional livelihood out of necessity. They live off of their land by farming, hunting,

gathering wild plants, fishing, and then trading what they have grown and collected. They possess a working understanding of traditional medicine based on the rich biodiversity of the forests because they have no other options. This type of necessity for survival is nonexistent in the refugee camps because the INGOs continue to provide basic necessities, including western medicine.

The Refugee Population

As mentioned above, my main concern within the Karen refugee community is the unhealthy reliance on INGOs. Though I respect the services they are providing and understand the need for food rations and other basic necessities, as time passes, it saddens me to see the Karen unable to provide for themselves. I truly believe that it is the very nature of the long-term refugee situation that has produced this unhealthy reliance.

Years ago, refugee camps were created as a temporary relief from an emergency situation. The Karen arrived with no food or shelter. The INGO’s were successful in meeting the needs of the refugees and have continued to this day in the same capacity. Unfortunately, the Karen are still unable to return home. It has been more than 20 years since the establishment of these refugee camps. In my opinion, the emergency has stabilized, and the greater need has evolved into one of development. The refugees need skills to prepare themselves for successful reintegration in Burma.

In 1984, the BBC (Burmese Border Consortium) was set up to respond to the needs of the refugees. Currently they provide bamboo and wood posts for house construction, mosquito nets, sleeping mats, and food rations in the form of rice, chili peppers, salt, oil, yellow mung beans, and fish paste. They are also working to relieve the Karen of their heavy reliance on INGO's by developing programs aimed at empowering the refugees with sustainable life skills. For example, efforts are being made to create more gardens, thus providing more nutrition while at the same time reinforcing self reliance skills which will prove necessary upon repatriation.

Malnutrition is not as large a problem as is often seen within refugee situations, but nutrition continues to concern the BBC because it supports an unhealthy reliance on and consumption of “para.” The ultimate issue is the lack of space for growing vegetables, especially leafy greens. There is little room to grow farm vegetables or herbs like garlic, onions, lemongrass, basil, or cilantro, and many families cannot afford to buy them elsewhere. Thus even the most basic preventative herbs are not being used.

I admire the volunteer doctors that travel to the camps and spend their time working for the refugees. Their hard work is certainly needed and well-received. However, it is my experience that many of the numerous medical INGOs seem to be “imperialistic” when it comes to their health care. There is no effort on their part to maintain the Karen's traditional knowledge of medicine. Most symptoms are remedied with a good dose of “para,” even though there may be equally effective traditional remedies available in camp to cure and/or prevent illness. “Para” will often eradicate these symptoms of disease, but there is little education among the Karen about the effects of a daily regimen of these pills. In addition, those that rely on this medication believe that it is a “cure-all,” when in reality, the cause of illness is rarely found.

There is another aspect of the relationship between the Karen and modern pills that concerns me. In their minds, and their vocabulary, there is no difference between medication such as “para” and vitamin supplements that are often prescribed and provided for them. For example, many women are given iron to combat a fairly common anemic condition. Ironically, most are reluctant to take these vitamins because they believe that it is unhealthy to take “medicine” everyday. The irony is that they do not mind taking “para” when they feel dizzy or unwell, a condition that usually occurs as a result of not taking daily vitamins. The pills, both medication and vitamins, are provided free by the INGOs.

Unfortunately, Karen traditional medicine, along with most alternative treatment options, is overlooked and even frowned upon. One experienced Karen medic I spoke with told me that he knew some traditional remedies, but that his faith in them had diminished. There is little effort directed towards empowering the people to develop and pass on their traditional practices, all of which have the potential to be invaluable upon repatriation.

Many Karen refugees are now posing the question, “Where will the INGOs be when the Karen are once again living in the remote mountains of their homeland?” They have voiced their concerns regarding the lack of health and medical education in camp. They understand western medicine is necessary at present, but also know that it will not prepare them for when

they return to the mountains. Several Karen are passionate about reviving their herbal traditions and feel it is their best tool for survival after repatriation. They are also aware of the rich preservation of Thai herbal tradition, including massage, preventative herbs in the diet, and other more practical techniques practiced in remote villages, and hope to employ something similar within their own villages.

I would like to mention one incredible program in the camps, and elsewhere along the border, that has tapped into the rich herbal traditions of Burma. A drug rehabilitation and addiction education program called the Drug and Alcohol Recovery and Education (DARE) Network was created in the Mae Hong Son Province of Thailand. DARE utilizes a remarkable blend of traditional herbs to help in the detoxification treatment of patients. The treatment they have created involves the use of Burmese herbal traditional medicine, herbal sauna, traditional massage and acupuncture (darenetwork.com). They have had astounding success in detoxification treatments for dependencies on everything from alcohol to opium. Most of the herbs are obtained in the forest and mixed by local Burmese herbalists in one of the camps.

Karen Youth

Another primary limitation in the perpetuation of the practice of Karen traditional medicine can be found in the youth in the refugee camps. Since some families have been in camps for over 20 years, and most for around ten, there is now a substantial population of children born in camp. These children spend their days in crowded classrooms and continue to eat poor quality rice and rations. They know little of their parents’ lives back in the homeland and many have no idea where rice comes from, other than on trucks. Since the Karen were traditionally farmers, and their homeland remains undeveloped, it can be assumed that growing rice will be a necessary skill upon repatriation. Without the knowledge of how to live off of the land and provide for themselves, their future remains unclear.

Karen youth also grow up accustomed to going to the Out Patient Department (OPD) at the slightest feeling of illness for some sort of pill. Reliance upon herbal tradition has been neglected and the community members that practice this type of medicine are generally looked down upon as “less developed” than the medical INGOs.

On the other hand, there still remains a lingering interest in Karen traditional medicine within the youth population. Some understand the importance of this wisdom and are motivated to learn more about it. I would often speak of the positive effects of learning this type of healing modality as opinions in these matters carry far more weight when spoken by a foreigner than when taught by their own community members.

Although the youth deny it, and the elders exaggerate it, there is certainly a loss of respect towards elders as well as the Karen traditions. Students look to the outside world for education and miss out on the valuable wisdom that their elders possess. Unfortunately, most of this wisdom cannot be transferred through practical hands-on experience.

Additionally, Thai law prohibits refugees from leaving the camps. In a few camps located in the remote mountains, it is possible for them to go into the forests to collect what is available, but this is a rare benefit. In fact, the refugee situation has tightened significantly in recent years. There are now barbed wire fences around the two largest camps and travel outside is almost completely forbidden. That being said, I was fortunate enough to be able to join a group of my students for an early rainy season forest vegetable collection. We collected several varieties of wild vegetables. Each contained a preventative or curative property that my students had learned from their parents and I was thoroughly impressed with their knowledge. Afterwards, I noticed more and more of these wild medicinal vegetables and fresh roots being carried and eaten throughout the camp.

Fortunately, the Karen that have migrated into smaller semi-secret villages in Thailand are more knowledgeable of the local medicinal herbs. One man I know cured his hepatitis with a traditional remedy, mostly containing a fresh green leaf translated as “horse hoof leaf,” which is quite common to the area. Similarly, these Karen use many other herbs for preventative and curative measures. Some are collected from the forests, but many are found along the road or trail. They have no access to the clinics in the refugee camps and so have employed their traditional medicine as a case of necessity. However, even here, the youth are not interested, especially since they have established contact with mainstream Thai culture which looks down on “hill tribes.”

Karen in Burma

If we look at the Karen in the refugee camps, we can see that their suffering is primarily psychological. However, the Karen in Burma face both extreme mental and physical suffering. Most are struggling to survive with little money, food, and almost no medicine. In addition to this, they continue to suffer under an abusive military regime that denies them basic human rights. Mandatory labor, forced relocation, extrajudicial killings, torture and rape are only a few of the injustices that the ethnic minorities face in Burma.

The Karen in Burma generally consist of two main groups, although throughout the year it is common for people to be a part of both. One group lives in villages, mostly high up in the remote mountains of Karen State. The other group is known as the Internally Displaced People (IDPs). It is estimated that there are over 2 million IDPs in Burma with almost one million hiding in the most remote mountains of Karen State. The SPDC regularly patrols the ethnic minority areas and continues to relocate remote villages in order to control them better. At the sight of the SPDC, villagers will flee into hiding and become IDPs. Some remain IDPs for a few days or weeks, but some live as IDPs for years, constantly moving from one hiding site to another.

A friend of mine from a village in Karen State explained to me the situation in his village. He said that there is little modern medicine, and even less money to buy it. As a result, they have an extensive working knowledge of traditional remedies. In many cases it is all they have. For example, malaria is quite common among his students and the villagers. To treat it, one must go into the forest to search for a specific tree to use its bark. According to my friend, the tree is rare and it takes a lot of time to collect the needed remedy, which is an effective treatment. This is a desperate use of the traditional knowledge, and according to my friend, they would prefer having modern medicine. He has asked foreign volunteers for medicine or money to purchase it.

IDPs

As mentioned above, the other group of Karen in Burma is the Internally Displaced People. Their lives are total desperation. They are homeless, in hiding, and barely surviving. They face the worst situation of all, surviving for months on what they can find in the jungle. Malaria and diarrhea, two easily curable conditions, are slowly killing IDPs because they have no access to treatment. They have some knowledge of forest medicine, but are limited to what is growing around them and/or in season. Even more problematic though, is that they do not have any food, clean water, or shelter.

There are organized groups of Karen medics braving the mountains to provide basic care to the IDPs, but they are severely limited to what they can carry on their backs. Their work is all modern, having received medical training in Thailand, so there is little effort to utilize the available resources in the jungle as medicine. The situation is entirely desperate, and most emergency help is overwhelmed by the need and the danger. Volunteers do their best to offer basic hygiene training to prevent disease, but their knowledge and/or use of available herbal remedies is almost nonexistent.

SDPC

Interestingly enough, the ruthless military regime in Burma encourages the use of traditional herbal medicine. Since the colonial era, the Burman have been obsessively anti-imperialistic. They continue to dismiss western medicine and embrace their own and Chinese medical traditions. They encourage the population to continue to use these traditional remedies both directly and indirectly by having one of the worst health care systems in the world. In 2000, the World Health Organization (WHO) ranked Burma's overall health system 190th out of 191 countries.

The mentality of the Karen is to oppose just about everything about their oppressors, the Burman. In the past they accepted the British, mainly because they defeated the Burman, and assumed better leadership for Burma. Now they try to follow our western ways, whatever they are. In rejecting the Burman culture, traditional herbal prescriptions included, and embracing western concepts of medicine, the Karen are expanding the distance between themselves and their oppressors.

KESAN

A shining light that I have been lucky enough to see is the grassroots Karen Environmental Social Action Network (KESAN). In fact, I can say that my whole inspiration for this work has been from them. They are a highly motivated and dedicated group of young Karen working to educate their community and the world about the importance of re-establishing the link between the natural environment and their livelihood. They contribute their research to numerous international environmental groups to raise awareness on a global scale of the environmental destruction in Burma that is leading to loss of livelihood for countless people. In addition, they strongly believe in the local knowledge and empowerment of villagers to create their own futures. While the Karen struggle to protect their homeland from the ruthless military regime, KESAN works hard to reinforce sustainable community development.

One of their current projects involves educating the Karen in the importance of protecting their community forests. I participated in one of their trainings in the camp. It involved me facilitating a discussion about the role of traditional cultural medicine, especially in Karen State. The conclusion was that there were several reasons why it needs to be preserved and many ways in which it can be done. I have also explained to students the hazards of modern medicine and the terrific value of their traditional practices.

My students and colleagues have been quite open and genuinely interested in our classroom discussions about preserving traditional medicinal knowledge. Some in the camp have taken it to the next level by going to their elders and learning about their traditional medicine. There is an evident pride in these actions; a pride that I typically do not see among them. This is something that is culturally theirs; something to be passionate about during a time of insecurity and sadness where there is little or nothing to be proud of.

KESAN is now in the process of recording what traditional herbal knowledge remains, both in the camps and in Karen State. They understand the importance of traditional medical knowledge and they are dedicated to preserving it. Their plan is to create a reference book to distribute throughout communities both in the camp and in Karen State.

KESAN recently initiated another traditional medicine project in Karen State as well. Members of one local village came together to create and encourage traditional medical educational programs for their youth population. The project gained incredible momentum and has received support from the village authorities and local Karen leaders. They were allotted ten acres of protected forest area to use for identifying, collecting, and replanting medicinal plants. As a result, local herbalists are now able to teach and produce natural treatments for malaria, tuberculosis, acute respiratory disease and menstrual problems, all of which are common to the area. News of this project has spread to surrounding villages, along with a renewed interest in the preservation of traditional medicine and its practical applications.

KESAN is now seeking funds to build an herbal clinic and store-house for their growing number of supplies. They hope to attract villagers from surrounding areas with treatment and/or available training upon its completion. We hope to inspire a similar interest within the camps.

In conclusion, although the herbal traditions of the Karen are alive, especially in Burma, there are severe threats to the continuation of it. This is particularly true among the refugee population. Traditional herbal medical training and herbal reference books are perhaps the best means to facilitate the continuation of Karen herbal traditions, both in camp and in Karen State. In addition, the role of the “white-skinned” must not be underestimated. Visiting herbalists and/or volunteers must continue to emphasize the validity of traditional herbal medicine. We also have a financial responsibility to support and expand the efforts of KESAN and small village initiatives in their struggle to keep Karen traditional medical knowledge alive.