Learning Processes in a Tibetan

Medical School

Colin Millard

Ph.D. Thesis
University of Edinburgh 2002
 Thesis Abstract

The focus of this research is learning processes in a Tibetan medical school in the Tibetan
refugee settlement ofNorzinling at Dhorpatan in the Baglung district of West J',;epal. The school
in Dhorpatan has the special quality of being the only Bon medical school outside of Tibet. Part
of the thesis compares the Buddhist and the Bon medical systems of Tibet and the way medicine
is taught in the school in Dhorpatan with other contemporary Tibetan medical schools, Tibetan
monastic education, Brahmanical schools in South India, Islamic education in Yemen and
Morocco, and modes of knowledge in Medieval and Renaissance Europe. The distinctive
features of Tibetan medical education will be discussed such as the strong emphasis on
memorisation and lineage.
The process of acquiring competency as a Tibetan medical practitioner is a process of
acquiring new ways of perceiving and knowing. The Tibetan medical system, like all medical
systems has its own rules of pathology, nosology, diagnosis and therapeutics, which accord to a
specific cultural cosmological scheme. A discussion will be made of the various elements of
Tibetan medical theory and practice and the way that they relate to Bon and Buddhist
cosmological notions. The research shows how the students pass through various stages of a
journey into a new world of meaning. They are introduced to modes of perceiving, knowing, and
practice, that are initially strange and unfamiliar, with the aim that as they go deeper into this
journey, the students will gradually come to inhabit this new world of meaning; what was
initially strange and unfamiliar becomes taken for granted - an unquestioned mode of being in
the world.
The research focuses on how the students learn medicine in the three main areas of medical
activity in the school: the classroom, the pharmacy, and clinical interaction. In the context of the
classroom, the research focuses on the various elements of the course syllabus and the techniques
that the students and the teacher use to facilitate understanding. In the pharmaceutical context,
the focus is on the ways in which the students learn about the medicines, and the way that
ingredients should be processed and combined to make medicinal compounds. In clinical
interaction, the focus is on how the students are inducted into the practice of diagnosis, and
therapeutics. A discussion will also be made of the use of ritual in the healing process.
Rather than adopting a simple propositional view of knov,;ledge transmission, whereby the
students are taught the facts of the system in a purely cognitive \vay, the research will consider
wider techniques involved in the learning process. The research presents the ways in which
through clinical interaction the students develop performative memory. The approach taken
draws on a body of recent literature on learning that moves away from the acquisition of
propositional knowledge and focuses on the situated nature of learning
 Acknowledgements

I would like to give my gratitude to all the numerous people who have made this research
possible by their kind assistance. In particular I would like to thank Lopon Tenzin Namdak,
Lopon Tenpa Yundrung, and Norbu Lama of Triten Norbutse Bonpo monastery in Kathmandu. I
would also like to thank the Dhorpatan Tibetan Settlement officer Jigme Wangduk for his
assistance and his great sense of humour. Above all I would like to thank Amchi Gege, Geshe
Tenzin Dargye, Nyima Samphel, and all the medical students at the school in Dhorpatan for their
help. I am also very grateful to Fernand Meyer for his comments on the ideas presented in
various sections of the thesis. I am also deeply grateful to my two supervisors, Jonathan Spencer,
and Roger Jeffery, for their invaluable assistance. Finally, I would like to thank Isabelle Henrion-
Dourcy for her support and companionship throughout this research.
 Thesis Chapters

Introduction

Themes and Methodology 1

Dhorpatan: The People and the Place 6

Chapter 1. Tibetan Medicine: Origins, Institutions, and the School in

Dhorpatan 16

1.1 Contending Medical Histories 16

1.2 Contemporary Tibetan Medical Institutions 23
1.3 Tashi Gyegay Thartenling Bonpo Medical School 25
1.4 The Teacher 27
1.5 The Students 30
1.6 Principal Texts Used in the School 33
1.7 The Course Syllabus 37
1.8 The Daily Routine 39
1.9 Exams and Course Assessment 40
1.9.1 Memorisation Assessments 41
1.10 Legitimation 42

Chapter 2. Learning Processes: Theoretical Orientations 46

2.1 The Culture of Acquisition: Knowledge as Proposition 49

2.2 The 'Social Being' and the 'Individual Being' 51
2.3 Situated Learning 52
2.4 Innate Knowledge: The 'Knowing Subject' 55
2.5 Non-discursive knowledge 59
2.6 Embodied Meanings 62
2.7 Knowledge as a Mode of Being: 'Knowing How' 64
2.8 Knowledge as a Mode of Being: Dispositions and Explanatory Models 68
2.9 Knowledge as a Mode of Being: The Past in the Present 70

Chapter 3. The Role of Memory in the Medical School 80

3.1 The Method of Memorisation in the Medical School 80

3.2 The Method of Memorisation in Other Contemporary Settings 84
3.3 Memorisation in Medieval and Renaissance Europe 88
3.4 The Technologies of Memory 91
3.5 From Memorisation to Performative Memory 93
3.6 Performative Memory in Clinical Practice 96

Chapter 4. Synthetic and Analytic Modes of Knowing and Learning 103

4.1 Modes of Thought: a Series of Dichotomies 104

4.2 The Synthetic Mode of Knowledge and Learning 111
4.3 Lineage 114
4.4 Modes of Thought: the Effects of Literacy 117
4.5 Cognitive Syncretism 120

Chapter 5. Learning Medicine in the Classroom 126

5.1 The Teaching Method 128

5.2 Learning Medicine through the Tree Metaphor 137
5.3 Anatomy 138
5.4 Physiology 143
5.5 The General Principles of Disease Causation 147
5.5.1 Concepts of 'Infectious' Disease in Tibetan Medicine 150
5.6 Learning about Specific Diseases 151
5.7 Diagnostic Theory 162
5.8 Learning the Theory of Pulse Diagnosis 165
5.9 Learning the Theory of Urine Diagnosis 170
5.10 Learning Therapeutic Methods 172

Chapter 6. Learning Medical Practice 178

6.1 Learning Pharmacology 179

6.2 Data on Patients attending the Clinic and Clinical Interaction 186
6.3 Learning Through Clinical Interaction 188
6.3.1 Learning the Practice of Pulse Diagnosis 193
6.4.2 Learning the Practice of Urine Diagnosis 198
6.3.3 Learning the Practice of Therapy 200
6.3.4 Learning About Tren Through Clinical Interaction 202

Chapter 7. The Relationship Between Tibetan Religion and Medicine 209

7.1 Tibetan Cosmology 210
7.1.1 The Gods of the Bonpo and Tibetan Buddhist Heavens 212
7.1.2 The Tantric Deities 213
7.1.3 The Gods of this World 213
7.1 .4 Malevolent Spirits 215
7.1.5 Harmful Spirits as Pathogenic Agent 216
7.2 Dhorpatan Spirit Stories 218
7.3 Setting the Ground for Prosperity 226

Chapter 8. The Use of Ritual in Healing 236

8.1 Napa 237

8.2 Drib 241
8.3 Divination 244
8.4 Divination through the Patient's Urine 247
8.5 Ransom Rituals and Rites of Exorcism and Destruction 250
8.6 The Angry Widow 252
8.7 The Ritual of the La Lil - a Case of Soul Loss 256
8.8 Lu Napa 260

Conclusion 263

Appendix A The Bon and Buddhist Religions of Tibet 269

Appendix B The Contents of the Gyu Shi 277
Glossary of Tibetan Words 283
Bibliography 291
 List of Maps and Plates

Maps

Opposite page 1
Map 1 - Dhorpatan
Map 2 - The Area of Dhorpatan
Map 3 - The Valley of Dhorpatan

Plates

Opposite page 1
Plate 1- The Gompa Compound
Plate 2- The Gompa Compound on a Snowy Day in October
Plate 3- The Gompa Compound and Surrounding Forest
Plate 4- A Typical Meadow on the Valley Side
Betweeen page 25 and 26
Plate 5 - The Medicine Store
Between pages 28 and 29
Plate 6 - Amchi Gege and Geshe Tenzin Dargye
Plate 7 - Amchi Gege Drying Out Medicinal Plants
Plate 8 - Geshe Tenzin Dargye
Plate 9 - Geshe Tenzin Dargye, Nyima and Tsering Lhamo
Between pages 29 and 30
Plate 10 - Nyima
Plate 11 - Chunsom Preparing Medicinal Compounds
Plate 12 - Tundup, Yungdrung and Sonam
Plate 13 - The Jamma Ritual
Between pages 136 and 137
Plate 14 - Root of the Condition of the Body
Between pages 162 and 163
Plate 15 - Root of Diagnosis
Between pages 171 and 172
Plate 16 - Root of Treatment
Between pages 188 and 189
Plate 17 - Patients Waiting to see Amchi Gege
Plate 18 - Cleaning Out an Abscess
Between Pages 210 and 211
Plate 19 - Mount Meru World System
Plate 20 - The Wheel of Existence
Between Pages 229 and 230
Plate 21 - Setting Up a Lungta Flag
Plate 22 - Jamma Ritual Offering
Between Pages 250 and 251
Plate 23 - Namkha
Plate 24 - Namkha offering
Plate 25 - Three ritual objects: mo dong, dadar and gyangbu

Between Pages 253 and 254

Plate 26 - La Offering
Plate 27 - La for the Woman Suffering from Napa
 List of Tables and Figures

Tables

Table 1.1 The Course Syllabus 37

Table 2.1 Four Modes of Knowledge in the Learning Process 64
Table 4.1 The Attributes of the Synthetic and Analytic Modes of Knowledge 106
Table 5.1 Root of the Condition of the Body between pages 136 and 137
Table 5.2 The Five Types of Wind, Bile and Phlegm between pages 146 and 147
Table 5.3 The Locations of Disease According to the Pathological Humour 149
Table 5.4 Root of Diagnosis between pages 162 and 163
Table 5.5 The Twelve Pulses in Tibetan Medicine 167
Table 5.6 The Influence of the Seasons and the Five Elements on the Pulse 168
Table 5.7 Root of Treatment between pages 171 and 172
Table 5.8 The Elemental Nature of the Six Tastes 174
Table 6.1 Table of Patients by Ethnic Group, Gender and Age Group between pages 186 and 187
Table 6.2 Table of Disease Classifications between pages 187 and 188

Figures

Fig. 2.1 Diagram of Classifications of Memory 75

Fig. 5.1 The Seven Bodily Constituents and their Residues 146
Fig. 8.1 The Locations of Spirit Caused Disease Reflected in the Patient's Urine 248
c
ro
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a.
~

o
..c
o
/
 /

Plate 1 - The Gompa compound. Amchi Gege's room, which served as the clinic
and classroom, is the building with the sloping roof just below the centre of the
picture at the top right hand corner of the stone courtyard. The new clinic and
school is the building in the top right hand corner with the orange gate.

Plate 2 - The Gompa compound on a snowy day in October.

Plate 3 - The Gompa compound and surrounding forest.

Plate 4 - A typical meadow on the valley side containing many diffe rent types of
medicinal plants.
 Introduction

Themes and Methodology

This thesis is about the learning process in a Tibetan medical school situated in
the valley of Dhorpatan in the Baglung district of west Nepal. The school was
founded in 1990 by Tsultrim Sangye, a Bonpo monk and Tibetan medical doctor. He
had left Tibet several years before coming to Dhorpatan, and had been staying at the
Menri Bonpo Monastery at Dolanji in Himachel Pradesh. Tsultrim Sangye is the
name he received when he became a monk, but he is known to everyone as Amchi
Gege (see Plates 6 and 7). He studied Tibetan medicine with his grandfather and
other local Tibetan doctors in his home in Khyungpo in the Kham region of east
Tibet.
There are a number of reasons why I chose this location to carry out my research.
I first heard about the school on a visit to Triten N orbuste Bonpo monastery in
Kathmandu, from the head teacher of the Bonpo religion, Lopon Tenzin Namdak. He
stressed that the school in Dhorpatan is a Bonpo medical school, and that the main
text that is used in the school is not the Tibetan Buddhist medical text, the Gyushi,
but a Bonpo medical text, the Bumshi. Intrigued by this I wanted to discover the
nature of Bonpo medicine and how it compares to Tibetan Buddhist medicine. A
further point of interest was the extent to which Amchi Gege's method of teaching
reproduced the traditional pattern he had experienced in Tibet, and whether or not he
had incorporated new elements into the medical education. Another advantage of the
school in Dhorpatan was that Amchi Gege's ten students were at different stages in
the course curriculum, and I thought this would be helpful in gleaning insights into
the learning process. The school has the additional interest of having a clinic which
serves the medical needs of both the Tibetan and Nepalese communities living in the
valley, and a pharmacy, where locally gathered plants, and raw medicinal substances
that are brought from Kathmandu, and occasionally Tibet, are processed into
medicines.
The research is based on fieldwork, which I conducted in Dhorpatan between
September 1996 and August 1998. During this period I also visited the Tibetan
Medical Schools at Dharamsala, Sarnath, Darjeeling, and the Lhasa medical institute,
for comparative material. In addition I spent short periods of time at the Menri
Bonpo Monastery at Dolanji in Himachel Pradesh and Triten Norbutse Bonpo
monastery, gathering information about the Bonpo religion.
In the medical school in Dhorpatan, learning occurs through a threefold process in
three separate arenas: the students first memorise the main medical text , and then
they receive teaching on it from Amchi Gege in the classroom; along with this the
students learn by engaging in medical practice in clinical and pharmaceutical
contexts. During my research I carried out participant observation in each of these
arenas of learning. I observed teaching in the classroom, and in the pharmacy I
recorded the ways the students learn how to make medicinal compounds. I also
attended several medicine gathering trips in the local hills. In clinical contexts, I
observed and recorded the ways that the students were inducted into clinical practice.
In addition to gathering information about the community, the school, and the
medical world, through informal interaction, I also formally interviewed all the
students and Amchi Gege on several occasions, and selected people within both the
Nepalese and the Tibetan communities.
The person who provided me with the most assistance during my research was the
young head lama ofDhorpatan, Geshe Tenzin Dargye (see Plates 6 and 8). He helped
me with most matters to do with medicine in the school, the clinic and the
community, and with numerous other research concerns. Although he had not
specialised in Tibetan medicine, he was reasonably familiar with its theories and
practices. He had also worked in the clinic situated in the Dolanji Tibetan refugee
settlement, and for six months as an assistant in the hospital at the nearby town of
Chandigarh, and had thereby acquired a familiarity with the procedures and concepts
of biomedicine. These characteristics, taken in combination with the fact that he
speaks good English, meant that he was invaluable to me in my attempts at
understanding the Tibetan medical worldview. As a Bonpo Geshe, he also has a very
extensive knowledge of Tibetan religion and ritual. A significant number of diseases
that I witnessed in Dhorpatan were thought to be caused by various classes of
harmful spirits. As the treatment of these disorders usually involved the performance
of ritual, in these instances it was Geshe Tenzin Dargye who assumed the central role
in the healing activities. This will be discussed fully in chapters seven and eight. I

2
also benefited greatly from the assistance of the senior medical student in the school ,
Nyima Samphel (see Plate 10).
The thesis has two broad themes: it looks at the way the students learn medicine
in the school, and it considers the nature and status of the knowledge that they learn.
The model that I have used to understand the learning process moves away from the
view of learning which emphasises the internalisation of propositional forms of
knowledge. In the course of the thesis I demonstrate that the learning process also
involves non-discursive, tacit forms of knowledge, which are essential to the
development of expertise; these forms of knowledge by their very nature can not be
transmitted in a discursive form, but are acquired through practice. I draw on a body
of recent literature on learning, which emphasises the situated nature of learning. The
central mechanism of situated learning is what Lave and Wenger (1991) refer to as
'legitimate peripheral participation'. In the medical school in Dhorpatan the students
are gradually inducted into medical practice by engaging in medical practice under
Amchi Gege's supervision. The training in the medical school is thus a form of
apprenticeship. But if we are to understand how the students develop practical skills
in medicine, we should avoid reducing apprenticeship to a process, which consists
exclusively of imitation, repetition, and the internalisation of a fixed body of
knowledge. Learning should not be viewed strictly as a cognitive process occurring
in the heads of individuals; it is a wide-ranging process involving the interaction of
the mind, body, agency, and social context.
In my analysis of the learning process In the school I follow Dreyfus and
Dreyfus's (1986) study of the acquisition of skills, which lead to expertise. They
identify a process, which involves five stages from novice to expert. For the novice,
knowledge is primarily propositional and decontextual. As the student moves
through the various stages towards expertise, knowledge becomes increasing non-
discursive and situated. In the context of the medical school, what was once
memorised, studied and recollected, becomes the performative memory of medical
practice. At the level of expertise, knowledge is a mode of being in the world.
The approach that I have taken to understand the learning process in the school in
Dhorpatan parallels similar research carried out by Byron Good on the way the
medical world is constructed at the Harvard medical school (Good 1994 1993). For

3
over four years Good carried out a study of 'The New Pathway to General Medical
Education' at the Harvard medical college. It involved interviewing 50 students from
the graduating class of 1990, interviewing faculty staff, and participant observation
in several of the basic science classes. Good also moves away from the traditional
concern of studies of medical education with the reproduction of medical knowledge
as propositional knowledge. His aim is to concentrate on the phenomenological
dimensions of medical knowledge, 'how the medical world, including the objects of
the medical gaze, are built up, how the subjects of that gaze - the students and the
physicians - are reconstituted in the process, and how distinctive forms of reasoning
about that world are learned' (Good 1993:83). Good adopts Foucault's notion of
medical discourses, 'as practices that systematically form the objects of which they
speak' (Foucault 1972:49). But his aim is to expand on this notion by bringing
subjective agency back into the world of discourses. He quotes the charge made by
Dreyfus and Rabinow that Foucault's discussion of discursive practices presents a
picture of 'intentionality without a subject, a strategy without a strategist' (1982: 187
quoted in Good 1994:69). In a like manner, my aim in this thesis is to document the
power of discursive practices, which I experienced in the medical school in
Dhorpatan.
As with Good, part of my methodology was to go through the learning process
myself. On most days I had a lesson at lOa. m. for one hour with Amchi Gege.
During each of my lessons, Geshe Tenzin Dargye acted as translator, and Nyima who
also knows a little English helped out whenever necessary. It must be said, however,
that even with the help of these two very competent people, and three Tibetan
dictionaries, the lessons were often far from easy. Sometimes we could spend half of
the lesson trying to understand the meaning of one word. However, in the time that I
spent at the school I did manage to make some reasonable headway into the
teachings, and a large part of what I will say about the way the students learn
medicine in the classroom, draws on my own experience of being taught by Amchi

Gege.
The learning process for the students begins with memorising the main medical
text, they then receive explanations on it from Amchi Gege in the classroom; in this
way the students build up their store of medical knowledge. Initially this knowledge
is mostly of a propositional, decontextual nature. Performative memory is developed
when the students situate this knowledge in pharmaceutical and clinical contexts.
Therefore, a major focus of my research in Dhorpatan was how the students are
inducted into medical practice through clinical interaction. From the outset of my
stay at the school I noticed that Amchi Gege nearly always used one or two of his
students as his assistants when he was consulting a patient. This was partly because
most of the patients who came to the clinic were Nepalese, and Amchi Gege needed
the student to serve as translator. But Amchi Gege also used this opportunity to
demonstrate to the student aspects of medical practice. In the first period of my stay,
Amchi Gege's clinical assistant was whoever was the nearest student at hand. After
some months, he formalised this by developing a rota system where each student
served as his assistant in turn for a period of two weeks.
As each student served in this capacity, I asked him or her to explain to me what
occurred in the clinical interactions. For every patient, I recorded a set series of
information. I began with the patient's ethnic group, age, sex, religion, and abode. I
then recorded what the patient said about his or her condition, details about the
diagnosis, the disease category that was finally decided upon by Amchi Gege, and
the forms of treatment that were adopted. By asking the student to give me this
information I was able to assess their experience of the clinical interaction, and the
extent to which they had learned through it.
As Lave (1988) has indicated, patterns of learning can only be fully understood by
considering the social, political, and cultural contexts in which they occur. This
brings me on to the second major theme of the thesis, the nature and status of Tibetan
medical knowledge. Tibetan medical knowledge is considered to derive from the
enlightened insight of the Medicine Buddha; it is therefore perfect, complete, and
beyond dispute. Consistent with this view of the sacred nature of Tibetan medical
knowledge, are the particular modes in which it is passed on: the strong emphasis on
memorisation, oral transmission, the personal relationship of the master and the
student, and the importance of the medical lineage. These themes recur throughout
the thesis, but I will discuss them in detail in chapter four.

5
Dhorpatan: The People and the Place

Dhorpatan is the name given to a valley in the Baglung district of west ~epal

lying south of the Dhauligiri mountain range (see map 1). The bottom of the valley is
some 3000 metres above sea level, the surrounding hills reaching up to 4500 metres.
Despite this altitude, the region for most of the year is green and luscious. This is due
to the high levels of precipitation in the area, the northern limit of monsoon rains
being the Dhauligiri mountain range situated just to the north. From June to August
there is almost incessant cloud cover and rain during the day, which invariably clears
by nightfall leaving a bright starry sky. Often, during the spring and autumn months,
convection currents draw clouds up from the lower foothills which come
intermittently swirling in to the large plain lying at the western extremity of the
valley; they crawl and twist along the plain, eventually dispersing again into the sky.
The valley itself marks the southern boundary of the Dhorpatan Royal Hunting
Reserve, this being one of Nepal's nine National Parks (see map 2). The region is
host to an abundance of fauna and flora, including many types of medicinal plants
(see Plate 4). The valley sides are largely forested, mostly with coniferous trees, but
deciduous trees are also strongly present. In the summer, a soft pleasant smell of pine
resin wafts through the valley. There are also many rhododendron groves, which
when in full blossom impart spectacular threads of colours through the forest.
Until quite recently the quickest way of getting to Dhorpatan across land was to
walk from Pokhara. Since the construction of the roads to Baglung and to Tansen,
people now start their trek from one of these towns. Most commonly, people take the
bus from Pokhara to Baglung. Outside the monsoon season it is possible to travel a
little further to the small town of Beni. From there one takes the footpath north west
along the Myangdi River passing through the villages of Tatopani, Dharpang, and
Takam, and after three days arriving at the village of Lumsum. At this point one
leaves the river and climbs up the densely forested mountain path up to the Jaljala
pass. In this forest it is rumoured thieves and spirits lie in wait for unsuspecting
travellers. The long haul up the Jaljala takes about four hours. At the top is a small
Tibetan shrine heavily adorned with prayer flags and the small offerings of Tibetan
passers-by. Unless one has met other Tibetans on the route, this is the first yisible

6
indicator on the path of the Tibetan settlement. From here Dhorpatan lies a further
four hours along a thickly wooded path.
Less frequently people take a southern route to the valley. This involves walking
through the southern foothills from the town of Tansen. It takes about the same time.
Approaching Dhorpatan from this direction affords spectacular views of the plains at
the bottom of the valley and the surrounding hills. The valley runs east west along
the Uttaraganga River. The large flat plain along the valley floor makes it highly
suitable for grazing animals. The plain is broadest at the western end of the valley,
and up until the 1980s an airstrip situated here was frequently in use; now it is
overgrown and hardly noticeable. The National Park Office is located at this end of
the valley. Surprisingly few tourists visit the region. Occasionally trekkers used to
pass through the valley on their way to Dolpo, which is another two weeks walk
from Dhorpatan. Also a few times each year helicopters used to bring tourists with a
penchant for hunting, but there was certainly nothing in Dhorpatan like the tourist
industry that exists in some of Nepal's other National Parks. In 1998 Dhorpatan was
closed to foreigners due to the escalation of Maoist activity in the area.
The valley is host to six Nepalese ethnic groups and a Tibetan refugee settlement,
which up to now have had a peaceful coexistence. The Tibetan refugee settlement in
Dhorpatan is known as Nor dzin ling, which means' The Place of Wealth'. It was one
of the first four Tibetan refugee settlements to be established by the International
Committee of the Red Cross and the Swiss Association for Technical Assistance
between 1961 and 1962. The other three settlements were lawalakhel in
Kathmandhu, Hyanga in Pokhara and Chialsa in Solu-khumbu. There are currently
13 Tibetan refugee settlements spread through eleven districts in Nepal. About half
of the refugee population live independently outside of the settlements, mostly in
Kathmandu valley. Hagen (1994) and Forbes (1989) have given accounts of the early
history of the settlement at Dhorpatan.
The refugee settlement consists of five camps situated at various locations along
the valley (see map 3). It takes approximately one hour to walk from the first to the
last. There are presently around 250 Tibetans living in the five camps in Dhorpatan.
Throughout the valley there are also many Nepalese homesteads, but on the whole
these are only used from spring to autumn when the Nepalese come from the lower

7
 valleys to grow crops and graze their animals. During these months the valley is very
active, as in addition to the 250 Tibetans it is host to around 1000 Nepalese.
The Tibetans have been living in Dhorpatan for over forty years now. Many of
them were born and educated in Nepal. This is the case for nine of Amchi Gege's ten
students. However, the long years in exile have not diminished in any way their
sense of national identity, and there remains a strong feeling that their stay in
Dhorpatan is temporary and that at some point they will return to Tibet. When the
Tibetans first arrived in India and Nepal they brought with them their old religious
and political affiliations, and these were mostly organised along regional lines. As
Goldstein (1978:396) puts it, '(t)he obstacles facing the Tibetans were not just
external ones. They came from widely disparate regions in Tibet where they spoke
mutually unintelligible dialects, operated under different socio-political systems, and
were traditionally hostile'. One of the main tasks of the Dalai Lama's government -in-
exile has been to break down these old allegiances and instil in the Tibetans a shared
sense of national identity. There are a number of reasons why it should want to
pursue this initiative: to consolidate its own power; to attract international support for
the Tibetan cause; and to present a more effective opposition to the Chinese.
The government was set up in 1960 at Dharamsala in Himachel Pradesh and
comprises four ministers chosen by the Dalai Lama (the Kashag), and an assembly of
seventeen elected deputies who represent the refugees according to the three main
l
regions , and the five principle religious sects (Furer-Haimendorf 1990). The Tibetan
refugee settlements have a democratically elected hierarchy of leaders whose
responsibility it is to liase between the people and the representative of the Dalai
Lama's government responsible for that settlement, known as the 'settlement
officer'. The government does not have legislative powers and Tibetans are not
obliged to follow its policies. Though in 1969 the Tibetan administration
implemented a voluntary program of taxation, it still relies heavily on international
aid. In addition to catering for the material needs of the refugees, it is also
responsible for the preservation and regeneration of Tibetan religion and culture.
This is the responsibility of the Council for Religious and Cultural Affairs. Through
its publications, and its control over education in the Tibetan refugee settlements, the

I Central Tibet (U-tsang), northeast Tibet (..J.mdo), and east Tibet (Aham).

8
government has successfully generated and maintained a sense of Tibetan national
identity.
About a third of the Tibetans in Dhorpatan follow the Bon religion of Tibet, the
2
rest are Buddhist. Of the 120, 000 Tibetan refugees who came to Nepal and India,
about 1000 are followers of the Bon religion. As the administration set about the task
of constructing the new national identity for the Tibetans, the Bonpo found
themselves increasingly peripheral to this definition.
In 1967 a Bonpo settlement was established at Dolanji near Simla in the Shiwalik
hills. This is the location of the new Menri 3 monastery. Cech (1987) has carried out a
detailed study of the history, and social and cultural identity of this settlement. In the
early years the Bonpo had no political representation in Dharamsala. This changed in
4
1977 when the Bon religion was officially recognised as a sect of Tibetan religion ,

and the Bbnpo were allowed one representative in the Assembly of the Tibetan
People's Deputies. A further embracive gesture was made by the Administration in
1978 when Sangye Tenzin, the thirty-third abbot of Menri monastery, officially
received the title of 'throne bearer' (tridzin) from the Dalai Lama; this title is
traditionally bestowed on the heads of the four Buddhist sects (Cech 1987).
Although a notion of a common Tibetan identity was strongly evident among the
Tibetans in Dhorpatan, residential patterns indicate that regional and religious
affiliations remain important. There is a clear distinction between the two camps on
the eastern side of the valley, where the residents are mostly from the Tewa region of
Tibet and follow the Bon religion, and the three camps on the western side of the
valley, where the residents mostly originate from Kham and are Buddhist. The
majority of the Buddhists follow the Karma Kagyu sect. I never witnessed any
conflict in Dhorpatan amongst the Tibetans deriving from regional or religious
affiliations. From conversations I had with refugees who had lived in the settlement
since the early days, it appears that this has been the general pattern in the settlement.
Throughout the time that I was there the only monks and lamas in Dhorpatan were
Bonpo. The Buddhist families had no qualms about using their services. There

2 See appendix A for an outline of the Bon and Buddhist religions of Tibet.
3The original Menri monastery was located in Central Tibet. It was destroyed by the Chinese in the
eriod following the 1959 occupation. Menri remains the principal monastery of the Bon religion.
f Although this is a positive development. the Bonpos consider themselves to be a completely separate
religion and not merely a fifth sect of Tibetan Buddhism.

9
appeared to be a consensus amongst the lay people that Buddhist and Bonpo
practices amounted to very much the same thing.
In recent years the new settlement officer had implemented a number of
innovations to improve living conditions and opportunities for the Tibetans. Up until
recently biomedical provision in the valley had been somewhat erratic. In the early
years of the camp a Swiss doctor was in permanent residence at the Namdru Tang;
now all that remains of this are the ruins of the building, which housed the clinic.
There is also a Nepali clinic situated at the Namdru Tang, but I never saw or heard of
anybody in it. Usually when people needed biomedical treatment they had to walk
down to clinics in the larger villages in the lower valleys. In response to this
situation, one of the first things that the present settlement officer did was to send a
Tibetan girl to be trained as a nurse in Dharamsala. Now she runs a daily clinic at the
Namdru Tang providing care for both the Nepalese and the Tibetans. This provides
an alternative form of treatment, should people wish it, to Amchi Gege's clinic of
traditional Tibetan medicine, which he has been running since he arrived in
Dhorpatan in 1990.
Along with the 250 Tibetan refugees, from the spring to the end of the autumn,
the valley is host to about 1000 Nepalese from six ethnic groups. Dhorpatan is
situated in the western reaches of Baglung district. The 1991 census lists the Magar
ethnic group as the numerically dominant group in the district, constituting 28.20/0 of
the population (Gurung 1998:58). The largest group in Dhorpatan is the low caste
Bishwakarma, then in roughly equal proportions there are the Magar and the Nauthar
groups; there are also a few members of the Parbatiya, Chantel and Thakali groups.
The untouchable Bishwakarma group can be found throughout the valley. About
thirty Bishwakarma live in a small settlement a short distance from the medical
school. The Bishwakarma are a low caste group who are the odd-job men of the
valley. When the possibility of some sort of work arises, such as building a wall, a
new house, or collecting timber, it is usually the Bishwakarma who provide the
labour. For instance, as I have mentioned, throughout the time that I was in
Dhorpatan, many people were replacing the old wooden roofs of their houses with
slate, and it was a group of Bishwakarma labourers that were doing the arduous
quarry work to provide this slate.

10
 After the Bishwakarma, it is difficult to say which of the Nauthar or the Magar is
the next largest group in the valley; some people say one, some the other. Like the
Bishwakarma, the Nauthar are not listed in the 1991 census, nor in the 1854 Muluki
Ain Legal code. De Sales makes a passing comment to them (1993 :92) in her article
on the origins of the Chantel group. The Nauthar have their permanent homes in the
cluster of villages of the Bowang and Adhikarichaur Village Developent Commitees
in the valleys just south of Dhorpatan. The total population of the Nauthar is around
2500. 'Nauthar' means 'nine castes' and refers to the original number of subcastes
that constituted the group. Two of these castes have now ceased to exist.
The Magar are found distributed throughout Nepal, but their highest concentration
IS in the western hills. Like many other Nepali caste and ethnic groups, in the
changing political climate in Nepal over the last few decades the Magar are
becoming increasingly self-conscious and politicised. In 1986 an association called
Nepal Langhali Sangh was formed in Kathmandhu. In 1993 it became the Nepal
Magar association, which has the prime aim of representing the interests of the
Magar as a united group. The Parbatiya, Chantel and Thakali groups are present in
only small numbers in the valley.
Before coming to Dhorpatan I heard conflicting accounts about the safety of the
place. On the 13 February 1996, the Communist Party of Nepal (Maoist),
disillusioned by the failure of Parliamentary democracy to solve Nepal's social and
economic problems, formally announced the beginning of the 'people's war' with the
aim of overthrowing the state and replacing it with the 'new people's democracy'
(naulo janbad). Rukum and Rolpo districts just to the west of Dhorpatan are the
districts were the Maoist insurgents have their strongest presence. Certainly everyone
living in the valley is aware of the close proximity of the Maoists, but up to now,
with the exception of a few minor incidents, the conflict has not entered the valley in

any substantial ways.

It is very easy to distinguish the Tibetan camps in the valley due to the abundance
of coloured prayer flags that flutter around them. As one approaches the valley from
the east, the first Tibetan camp one arrives at is called Gompa (see Plates 1, 2 and 3).

5 I have written about the Maoist insurgency and how the Nepalese in Dhorpatan view it. and the
changes that have been wrought since democracy was established in 1990 (Millard in press).

11
The local Nepalese refer to it as ek kutta ('one-legged'), a name deriving from a one
legged spirit that has sometimes been seen in the vicinity. As this is the location of
the medical school and clinic, this is where I stayed. During the time I was there, the
residents of the settlement included six monks, Nyima Samphel (the senior medical
student), Geshe Tenzin Dhargye (the head lama), Amchi Gege (the Tibetan doctor
and head of the medical school), two old men (one of them being Tsawo), and two
families, all of whom were Bbnpo.
Continuing westward for about fifteen minutes along the valley, one arrives at a
mixture of stone and wooden houses dispersed randomly along the valley bottom~

this is the Nepalese settlement of Chendung. Adjoining this is the Tibetan camp
called Khangpa Gyepa, which means 'eight houses'. Although the Tibetan phrase
literally means 'eight houses', the convention is for Tibetans to refer to it in English
as 'eight camp.' (This convention also applies to the names of the other camps.) The
names of the Tibetan camps derive from the number of houses that were originally
established there, which bears no relation to the present day situation. There are
fourteen families staying here, mostly originating from Tewa region of Tibet. Almost
all of the people residing in this camp are Bbnpo. Adjoining Khangpa Gyepa to the
south is the Nepali settlement of Barde.
Continuing further west there is a large area of open fields running along the river
with small pockets of woodland. After passing a small Nepali shrine one arrives at
the Dhorpatan School and a cluster of blacksmith dwellings, which mark the
beginning of the Nepalese settlement of Bagata. The homestead of one Tibetan
family can be seen marked by a circle of prayer flags in the middle of this settlement,
this is the only exception to the usual pattern of Nepalese and Tibetan houses being

separate.
Ten to fifteen minutes beyond Bagata, a few straggling Nepalese houses lead on
to the next Tibetan camp, referred to as Khangpa Shiwa, meaning 'four houses'. This
camp comprises eight families, all of whom are Buddhist, mostly of the Karma
Kagyu sect. The majority of the families residing here originate from the Kham
regIOn of east Tibet. A Tibetan sakya6 temple, established by Taru Rinpoche is
situated here, a little distance away from the settlement in a pine forest. Near the

6 The name of onc of the four main sects of Tibetan Buddhism.

12
temple is a large wooden building in the style of a Swiss chalet; up until recently this
was used as a carpet factory.
The next Tibetan camp is a little further along the path and is almost contiguous
with Khangpa Shiwa, this is known as Khangpa Chugsum, 'thirteen houses'.
Thirteen families live here, again mostly originating from Kham; four of these
families are Bonpo, the rest are Buddhist. Shortly after this settlement one passes the
buildings of the National Park Office and enters the large open plain at the western
end of the valley. Ten minutes further on, nestled at the bottom of the steep sided
valley is the last of the Tibetan settlements, called Namdru Tang, which means
'airport', this being the location of a now overgrown airstrip. It is a small settlement
comprising only four families, one of which is Bonpo, the others Buddhist. The
office and residence of the Tibetan settlement officer is situated here as well as a
small clinic, three Tibetan lodges and two shops. When the valley was open to
tourists, trekkers usually stayed here before heading north towards Dolpo or south
towards Tansen.

In chapter one I begin by outlining the history of Tibetan Buddhist and Bonpo
medical traditions, I then move on to make a brief discussion of contemporary
Tibetan medical institutions. Following this I give information about the Tibetan
medical school in Dhorpatan. I discuss the students, the course curriculum, the
principal texts that are used, and the way that student progress is assessed. I also
discuss the problem that the school faces in getting itself officially recognised by the
Tibetan government in exile in Dharamsala.
Chapter two presents the model of learning that I have used to understand the
learning process in the school. This serves as a foundation for later chapters where I
give information on how the students learn medicine in the classroom and in
pharmaceutical and clinical contexts.
Chapter three focuses on the role of memory in the school. I explain why
memorisation is so highly valued, and I compare the techniques of memorisation
used in the school with techniques used in Tibetan monastic education, Brahmanical
schools in South India, Quranic education in Yemen and Morroco, and medieval and
renaissance Europe. I conclude that the ideal is that far from being a passive form of

13
rote learning, memorisation paves the way to the development of perfonnative
memory.

In chapter four I discuss the writings of Goody and Horton on modes of thought.
The attributes that Goody lists for non-literate societies, and which Horton lists for
'cognitive traditionalism' have many similarities with what I encountered in the
Tibetan medical school; I have referred to this as the synthetic mode of knowledge. I
compare this with the modem scientific form of knowledge, which developed during
the period of the enlightenment in seventeenth and eighteenth century Europe. This is
the form of knowledge, which underpins biomedicine; I have referred to this as the
analytic mode of knowledge. I conclude that although there are important differences
between the two modes of knowledge, in practice the boundary between them is not
so clear-cut.
Chapters five and six cover specifically the way that the students learn medicine.
Chapter five focuses on learning in the classroom. I discuss how the students learn
Tibetan medical theory related to anatomy, physiology, pathology, diagnosis, and
therapeutic methods. In this chapter I also summarise Arnchi Gege's teachings on the
section of the third volume of the main medical text, which deals with tren
(tumours). Chapter six focuses on how the students are inducted into medical
practice in pharmaceutical and clinical contexts. I gIve examples of clinical
interactions involving the students learning pulse and unne diagnose, therapeutic
methods, and as a complement to the tren section of chapter five I give examples of
the students interacting with patients who were diagnosed as suffering from this
disorder.
Chapters seven and eight cover related themes. In chapter seven I give a general
overview of the Tibetan medical world that the students are being inducted into. The
word 'medicine' in a Tibetan cultural context has a wider semantic scope than it does
in a biomedical context. There is a large degree of overlap between Tibetan religion
and Tibetan medicine. A key feature of Tibetan medicine is the notion of harmony~

health is a product of the harmonious relationship of the three humours within the
microcosm of the human body, and between the human being and the macrocosmic
environment. In Dhorpatan much ritual attention was devoted to maintaining a
beneficial relationship between the human community and the various classes of

14
local deities and spirits; this relationship is considered essential to human health and
the general prosperity of the community. When this relationship breaks down,
misfortune may arise, and this usually takes the form of disease. This type of
sickness requires a ritual response and this is dealt with in detail in Chapter eight,
where I give examples of the kind of healing rituals that were performed in
Dhorpatan.
The purpose of chapter six and eight is to give examples of the way that the
students develop performative memory through clinical practice: chapter six focuses
on clinical interactions involving disorders with endogenous causative factors,
chapter eight, disorders with exogenous causative factors.

A Note on Tibetan Spelling

Most of the Tibetan words that appear in the text have been written phonetically
and put in italics. The sound of 'ng' in the phonetic spelling is formed at the back of
the mouth as in the English 'going'. The Tibetan spelling of the word, using the
Wylie (1959) method of transliteration, can be found in the glossary at the end of the
thesis. On a few occasions it has been necessary to give the transliterated form in the
text.

15
 Chapter 1 Tibetan Medicine: Origins, Institutions, and the
School in Dhorpatan

Before I move on to consider in detail different aspects of Tibetan medical

knowledge and the processes that are involved in learning medicine, in this chapter I
will present relevant background information about Tibetan medicine and the school
in Dhorpatan. I will begin by outlining the history of Tibetan medicine from both the
Bonpo and the Tibetan Buddhist perspectives, and then I will make a brief discussion
of contemporary Tibetan medical institutions. Following this I will tum to the medical
school in Dhorpatan, I will discuss the teacher, the students, the course syllabus,
principal texts used in the school, and forms of assessment.

1.1 Contending Medical Histories

Both the Bon and the Tibetan Buddhist religions have their own principal medical
text: for the Bon tradition it is the Bumshi; and for the Buddhist tradition it is the
Gyushi. One of the reasons why I chose the medical school in Dhorpatan was because
I knew that Amchi Gege was using the Bumshi as the main text in the school and I
wanted to know how this differed from the Gyushi. When I arrived in Dhorpatan I
found that the medical knowledge, which Amchi Gege was imparting to his students,
was no different from that which I had witnessed in Tibetan Buddhist medical
contexts, and in time I came to realise that the Bumshi, which he was indeed using, is
virtually identical to the Gyushi. Amchi Gege had no problem explaining this. In his
opinion Tibetan medicine was first taught by the founder of the Bon religion, T onpa
Shenrab, and the Gyushi is a Buddhist reworking of the Bumshi; for this reason he is
quite happy to use both texts in his medical school. In order fully to contextualise
Amchi Gege's opinion, in what follows I will briefly outline the history of Tibetan
2
medicine,l and discuss the various accounts of the origin of these texts.
Both the Bonpo and the Tibetan Buddhist historical traditions claim that their
medical traditions were established prior to the reign of the Tibetan King, Songtsen

I Tibetan medicine is known in Tibetan as Sowa Rigpa. 'The Art of Healing'.

~ For further information on the history
. of Tibetan Medicine. see Meyer
. (1995. 1988). Parfionoyitch.
Dorje & Meyer (1992). Rechung (1973). and Karmay (1989).

16
Gampo, in the seventh century, but there is no evidence to substantiate these claims.
The earliest Tibetan manuscripts date from the late ninth century to early tenth
century. These were sealed in a chamber of a cave at Dunhuang in north west China,
around 1035AD, and discovered at the beginning of the twentieth century (Bacot et
al: 1940, Thomas 1935-63, Lalou 1939-61). From what is written in these
manuscripts it appears that in this early period medicine was very much bound up with
religious notions; disease was related to the activity of spirits and required a ritual
response.
Tibetan historical sources speak of a great efflorescence of medical learning during
the period of the Royal Dynasty from the seventh to the ninth centuries. At this time
Tibet was a powerful imperial force in the region, and as such was open to the
influence of the neighbouring regions of Iran, China, Nepal, and India. Cultural
influence also came from the Central Asian oasis towns along the Silk Route where
Tibet had a strong military presence. Physicians from different medical traditions were
invited to Tibet, and the medical works of their traditions were translated into
Tibetan. This pattern was initiated by King Songtsen Gampo who invited three
doctors to Tibet: Galenos from Throm (the Greek Byzantine Empire), Hen-weng
Hang-de from China, and Vajradhvaja from India (Stein 1972:61).3 Of these three,
Galenos went on to become the king's physician. At the same time the medical text
Great Medical Practice (Menche chenmo), which had been brought to Tibet by
Wengcheng, the Chinese wife of King Songtsen Gampo, was translated into Tibetan.
The predominance of the Galenic tradition in Tibet appears to have persisted for at
least the first century of the Royal Dynasty. During the reign of King Me'agtsom
(704-54), we are told that the physician Bi-chi-tsha-ba-shi-Ia-ha, who had been invited
to Tibet from Throm, was appointed the kings physician. Later, during the reign of
King Trisong Detsen (755-797), doctors were invited from India, Kashmir, Nepal,
Iran , and China, and texts were translated from their traditions into Tibetan; but again
the Galenic tradition appears to have been dominant as it was the three students of his
'Greek' physician who served as the king's physicians, before Yuthog Yontan Gompo

3 As Meyer (1995) has pointed out. the names of these physicians denote not thc historical figurcs but
the respectiyc medical traditions, which they represent.

17
the elder was appointed to the position. Beckwith (1979) relates the predominance of
Galenic medicine and Chinese medicine in Tibet during this period, to the pervasive
influence of the Islamic Caliphate and the Chinese Tang Empire; all the early court
physicians came from either Throm or Tazig (the Arab Persian Caliphate). Tibetan
historical sources give the titles of many medical Texts, which are said to have existed
during the Royal Dynasty;4 very few of these texts are extant. s
It was during the reign of King Trisong Detsen that the main medical text of the
Tibetan Buddhist tradition, the Gyushi, was brought to Tibet. It is said to have been
transmitted to Vairocana by the Kashmir pandit Candranandana. Vairocana translated
the text into Tibetan and passed it on to Padmasambhava, who, thinking that the
people of Tibet were not ready for it, hid it in a pillar in Samye Monastery. Another
important figure in the history of Tibetan medicine around this time is Yuthog Yontan
Gompo the elder. His biography has been translated by Rechung (1973) and is a
typical account of an accomplished Tantric practitioner (siddha). As I have
mentioned, he served as the personal physician for King Trisong Detsen. Like
6
Vairocana he also visited India and studied with Candranandana. He is said to have
been competent in Chinese medicine, which in the opinion of Emmerick (1977) makes
him a possible source for the Chinese medical material found in the Gyushi.
The period of the later propagation of Buddhism in Tibet also marked a new wave
of activity in the medical domain; now the focus was on the connection with Indian
teachers and the translation of Sanskrit medical texts. In the eleventh century
numerous Ayurvedic texts were translated and included in the Tibetan Buddhist
Tanjur 7 (Cordier 1903, Dash 1975, Fenner 1996).8 Amongst these texts are the

--1 Rechung (1973) gives a long list of these medical texts.

5 Amongst the Dunhuang manuscripts there are three short medical texts, a medical drawing

showing moxibustion points, and six texts dealing with diseases of horses that can be dated to the
period of the Royal Dynasty (Meyer 1995:112, Lalou 1941, Blondeau 1972).
6 Emmerick (1977) notes that this could be the Candranandana who wrote the Padarthacandrika, a
commentary to Vagbhata's Astangahrdayasamhita; both of these texts were translated by Rinchen
Zangpo and were included in the Chapa Tanjur. For Emmerick this indicates that the
.. lstangahrdayasamhita could have been a major source for the Gyushi.
7 Both the Tibetan Buddhist and the Bonpo canons are divided in two large collections of texts: the

Kanjur, which contains the words (ka) of the Buddha. and a large selection of commentaries know as
the Tanjur.
8 Dash gives the names of 21 Ayurvedic texts.

18
translations made by Rinchen Zangpo of the famous Collection of the Essence of the
Eight Branches (Astangahrdayasamhita) by Vagbhata, his own commentary to it, and
the commentaries of Candranandana. Medicine was also influenced in this period by
the new influx of Tantric cosmological notions; the Kalachakra Tantra, the text that
has had the greatest influence on Tibetan medicine and astrology, was translated in
1027. Also at this time translations where made by Orgyenpa Rinchenpal (1230-
1309) of Indian medical texts dealing with mercury based medical compounds.
In 1098 the Gyushi was taken from Samye monastery by the Terton 9 Drapa Ng6n
She,lO who transmitted it to his disciple O-pa Dardrag. Eventually the text was passed
on to Yuthog Yontan Gonpo the younger who lived in the twelfth century; he was the
thirteenth generation descendant of Yuthog Yontan Gompo the elder. Yuthog Yontan
Gompo the younger visited India several times in search of medical knowledge. As
well as revising the Gyushi, he wrote numerous medical works, the best known of
which is the Practice in Eighteen Chapters (Chalag Chogye). The earliest textual
account which connects Vairocana with the Gyushi is the Namthar kagyachen, of
Sum ton Teshezung, a disciple of Yuthog Yontan Gompo the younger. In this account
the Gyushi was first taught by an emanation of the Medicine Buddha, Rigpe Yeshe in
Oddiyana, it was eventually written in Sanskrit and passed on to Candranandana. No
mention is made in this text of Yuthog Yontan Gompo the elder; Karmay concludes
from this that it is possible that he is a transposition of the Yuthog Yontan Gompo
who definitely lived in the tweltfth century. 11
In the Tibetan literary genre known as khogbub that developed from the thirteenth
century, which deals specifically with the history of Tibetan medicine, the view of the
Gyushi as a canonical text (Gyuzhi karu drub pa, or in short the kadrub literature),
eventually became the standard opinion. But in the early period, there was another
Tibetan historical tradition, which took a different stance; namely that the Gyushi was
not a translation of a Sanskrit original, but was composed by Yuthog Yontan Gompo

9 Terton ('treasure discoverer') is the title given to individuals who discover termas (hidden objects.
usually books).
10 This date is based on information given in the Rinchen Terdzo text (Kvaerne 1975).

lIOn the confusion in the Tibetan historical tradition on the two Yuthogs. see Meyer (1990: 209-11).

19
the Younger. This tradition, which was started by another one of Yuthog's close
disciples (Karmay 1989:21), produced a large volume of writings known as tsod yig;
unfortunately very few of these texts have survived, and the tradition is mainly known
about from arguments made against it in the kadrub literature. Karmay (1989:25) lists
sixteen arguments from one tsod yig text, which aim to prove that the Gyushi is a
Tibetan work. Many of these arguments point to specifically Tibetan customs found in
the Gyushi that could not have been part of a Sanskrit original, such as the line in the
Gyushi which reads 'the best diet is tsampa made of old barley' (1889:25). Since the
Gyushi was first made known to the west by Csoma de Koros who presented an
outline of its contents in 1835, western scholars have also been divided into those
who have followed the mainstream Tibetan tradition that it is a translation of a lost
Sanskrit original, and those who have tried to disprove this claim. Meyer (1988:90)
concludes from his reading of the Gyushi that as it contains Indian, Chinese and
Tibetan elements, which are seamlessly integrated into the coherent structure of the
text, it could not have been a translation of a Sanskrit original.
The Bonpo have a different account of the origin of the Gyushi. For them it is
based on the Bonpo medical text the Bumshi, which was first taught by Tonpa
Shenrab to his son Tribu Trishi. Amchi Gege explained to me that from Tribu Trishi
the text was passed on through the medical lineage in Tazig and Zhang Zhung,
eventually to be translated into Tibetan by Tongyung Thuchen, Gyimtsha Machung,
Chetsha Khorwa, and Shari V-chen, at the time of the second king of Tibet Mutri
Tsenpo. Later, when the Bon religion was persecuted, the Bumshi, along with many
other Bonpo texts was hidden. There are three different accounts of the way the text
was discovered. One account states that the text was found by the Bonpo Terton,
Khutsa da-a 12 in Bhutan. A second account holds that it was one of the texts that
were rediscovered at Samye monastery in 913 AD by three Nepalese monks; the
Terton is named as A-tsa-ra. The third account is given in Shardza Tashi Gyaltsen's
history of the Bon religion (Karmay 1972: 170). He writes that in 1037 AD, Butsho
Sipai Gyalpo, found several medical texts in western Tibet, amongst which was the

12 Khutsa da-a is identified by the 8onpo with Yuthog Yontan Gonpo the younger.

20
Bumshi. In Nyima Tenzin's catalogue (karchag) of Bonpo texts, nine medical texts
are listed in the Bonpo Kanjur (Kvaerne 1974:101); these he states were all
discovered by Butsho Sipai Gyalpo. The first of these texts is the Bumshi. Nyima
Tenzin adds to his entry that the four parts of the Bumshi were 'transformed'
(gyurpa) by Vairocana into the four parts of the Gyushi. He gives as evidence of this
that the mantras in the text have been left in the language of Zhang Zhung, and the
Bonpo word for a fully ordained monk, drangsong 13 has also been left unchanged.
Other Bonpo accounts claim that it was Yuthog Y ontan Gonpo the younger who
transformed the Bumshi into the Gyushi.
Though the kadrub thesis that the Gyushi is a canonical text was generally
accepted, because it is a lerma, 14 it was not included in the Chapa Kanjur or Tanjur
collections. The Bonpo on the other hand, as nearly all of their Kanjur consists of
lermas, had no qualms about including the Bumshi. With the dominance of the
Buddhist kadrub tradition, and particularly with the ascendancy of the Gelugpa
administration from the seventeenth century, we hear very little about the Bonpo
medical tradition until relatively recently. Amchi Gege told me that when he was
studying medicine in Tibet, he knew about the Bumshi, but he had never seen a copy
of it; he carried out his training using the Gyushi. Lopon Tenzin Namdak informed me
that while he was the head teacher in Menri monastery in Tibet, before the Chinese
invasion in 1959, there was a copy of the Bumshi in the monastery library.
The next major event in the history of the Buddhist medical tradition was the
founding in the fifteenth century of two medical lineages: one based on the teachings
of Changpa Namgyal Dragzang (1395-1475), known as the Chang-pa tradition; and
one based on the teachings of Zurkharwa Nyamnyi Dorje (1439-1475), known as the
zur-Iug tradition. After the political reunification of Tibet in 1642 under the fifth Dalai
Lama, Tibetan Medicine again underwent major developments. These developments
received their initial impetus from the fifth Dalai Lama, who attempted to establish
medical institutions and produce a new xylographic edition of the Gyushi. When the

13 The corresponding Tibetan Buddhist tenn is gelong.

14 The Tibetan word means 'treasure'. It denotes hidden objects. usually texts which have been

rediscovered.

21
fifth Dalai Lama died, the work that he had initiated was continued by his Regent,
Sangye Gyamtso (1653-1705). In 1696 Sangye Gyamtso established Tibet's first
medical college known as Chagpori (,iron hill'), after the name of the hill it was
situated on near the Potala Palace in Lhasa. Some of the doctors who had trained here
went on to establish other medical institutions, such as Labrang in 1784, Kumbum in
1757 and Yonghegong in Beijing in 1750 (Meyer 1995: 118). Also in the same period,
in the Kham region of eastern Tibet, Situ Choki Jungne established a medical school
at Palpung monastery.
With the aim of clearly establishing the principles of Tibetan medicine, Sangye
Gyamtso, after studying many medical texts and consulting practitioners, revised the
Gyushi, composed his famous commentary to it, the Blue Beryl (Vaidurya Ngonpo),
and had seventy-nine paintings (thangka) made to illustrate its contents
(Parfionovitch, Dorje & Meyer 1992). Meyer (1988:92) draws attention to the
colophon of the Lhasa edition of the Gyushi, were it is written that Sangye Gyamtso
revised the Gyushi after first consulting a wide range of sources: tantras, sutras,
translations of Zhang Zhung and Chinese medical works, and ancient Tibetan texts.
The edition of the Gyushi he produced appears to have involved a complete rewriting
of the text; this would account for the high degree of concordance between his edition
of the Gyushi and his commentary to it, as he is the author of both texts.
Since the founding of the Chagpori medical school in 1696, Tibetan medicine has
been increasingly taught in schools of medicine. Up until relatively recently these
schools have all been based on the Tibetan Buddhist medical tradition. However,
medical knowledge continued to be passed on in family lineages or by doctors taking
on private students, by this means, aspects of Bonpo medical knowledge have
survived to the present day. From the many conversations I had with Arnchi Gege, it
was clear that even though his early medical studies were based on the Gyushi, he
identified this text with the Bumshi and viewed Tibetan Buddhist medicine to derive
ultimately from the teachings of the founder of the Bon religion, Tbnpa Shenrab.
By the turn of the twentieth century Tibetan medicine was again in need of
revitalisation. The thirteenth Dalai Lama responded to this by establishing a new
medical institution in Lhasa in 1915, and placing it under the authority of his personal

22
physician Khyrenrab Norbu (1883-1962); this institution was known as the building of
medicine and astrology (Mentsikhang).

1.2 Contemporary Tibetan Medical Institutions

Following the Chinese invasion of Tibet in 1959, the fourteenth Dalai Lama fled
the country eventually to set up residence in Dharamsala in India. As part of his
efforts to preserve Tibetan culture in exile, the Dalai Lama established a dispensary
and medical school in Dharamsala in 1961,15 also known as the Mentsikhang; it is
referred to in English as The Tibetan Medical and Astrological Institute (TMAI). At
the outset there was only one doctor and one astrologer. The first group of three
medical students graduated in 1966, to be followed in 1968 by the first group of three
astrological students. By 1970 there were seven doctors and six astrologers working
at the institute. In 1980 a research and development department was added and its
employees had expanded to twenty-three doctors, seven astrologers and twenty-three
support staff. By 1997, one-hundred-and-fifty-five students had graduated in
medicine, and twenty-eight in astrology. Currently, the institute has thirty-five
branches in various locations in India and Nepal, mostly located in Tibetan refugee
settlements.
In 1997, Dr Thokmey Paljor of the institute told me that the tenth batch of students
was about to begin the medical curriculum. Each batch of students consists of
between twenty and twenty five students. To be accepted on the course the students
must have sat the twelfth class of the Indian school curriculum, and they must also
take an entrance exam. This exam has sections in Tibetan and English. The twelfth
class requirement is not applicable to applicants from outside India, or to monks and
nuns. Four places are reserved in each batch of new students for new arrivals from
Tibet, monks and nuns, and students from the Himalayan region. The course in the
school lasts for five years, after this the students must study for a further year in one
of the branch clinics. As well as studying Tibetan medicine, the students also take

15The following infonnation about the Tibetan Medical and Astrological Institute in Dharamsala
comes from interviews I carried out with one of the teachers in the institute. Dr Thokmey Paljor. and
the Infonnation Guide. published by the Institute in 1997 (Men-Tsee-Khang 1997).

23
classes in Tibetan grammar, poetry, and western sClence (this includes lessons in
biology, human anatomy and physiology, infectious and parasitic diseases, disease
prevention, nutritional diseases, and the immune system). Dr Thokmey Paljor told me
that the students are encouraged to memorise all of the Gyushi, but they are only
required, for the course, to memorise important sections of the text. Periodically they
have written and oral examinations. On graduating, the students have the choice as to
whether they would prefer to work in a clinic, in the research department, or in the
pharmacy; most students choose the clinical option.
Recently, two new Tibetan medical schools have been established in India. The
first was established in 1992 in Datjeeling by Trogawa Rinpoche. When I visited the
school in 1996, two groups of students were studying there. The course consists of
five years of study in the school, followed by two years of study in a clinic. Trogawa
Rinpoche taught in the TMAI in Dharamsala from 1964 to 1967. As one of the few
remaining lineage holders of the Chagpori system, he established the school, which is
also named Chagpori, to preserve this lineage. In addition to their lessons in medicine,
the students are also taught the spiritual practices related to this lineage. The school is
associated with the TMAI in Dharamsala; the two teachers at the school are both
graduates from the TMAI, and the final exam for the Chagpori students is organised
by it. The second school is part of the Central Institute of Higher Tibetan Studies in
Sarnath. The medical department was established in 1993. The teacher, Lobsang
Tenzin Rinpoche, studied medicine privately in Lhasa. The course again involves five
years in the school and a further two years of clinical training. As the Sarnath Institute
is an Indian University, at the end of their course the students will receive a medical

degree.
In Tibet itself, shortly after the Chinese invasion in 1959, the Mentsikhang in Lhasa
was temporarily closed and the future of Tibetan medicine, as for Tibetan culture in
general, became extremely uncertain. In the political climate that ensued, Tibetan
medicine was lumped together with Tibetan religion and derided as little more than
superstition by the Chinese authorities. During the Cultural Revolution nearly all of
Tibet's medical institutions were destroyed along with most of its monasteries. This
situation changed after the Third National Assembly, when the Chinese authorities,

24
 realising that Tibetan Medicine could provide cheap and effective remedies, began to
support it (Tsenam 1995). The Menstsikhang was enlarged to include a hospital with
150 beds and a medicine factory. Like the schools in India, the medical course at the
Institute in Lhasa involves five years of theoretical training followed by two years of
clinical practice. There are now numerous Tibetan Medical Institutes in towns in Tibet
and China. Amchi Gege explained to me that there is also a large Bonpo medical
school situated near Mount Kailash, based at the monastery of the famous Bonpo
scholar Khyuntrul Jigme Dorje (b 1897).16

1.3 Tashi Gyegay Thartenling Bonpo Medical School

The medical school in Dhorpatan is known as Tashi Gyegay Thartenlillg Bonpo

Medical School. It was established in 1990 by TsuItrim Sangye, a Bonpo monk and
Tibetan medical doctor (menpa) from the Khyungpo area of the Kham region of east
Tibet, who is commonly referred to as Amchi 17 Gege. It is situated in the Gompa
camp, the first of the five Tibetan camps as one approaches the valley from the east.
Although very few Tibetans reside at the Gompa camp, it is important as it houses the
only functioning Tibetan temple in the settlement, and the monks and lamas who
minister to the community's religious needs.
The school is part of a medical complex, which includes a pharmacy and a clinic.
When I first arrived in September 1996 these three areas of medical activity took
place in and around Amchi Gege's living quarters. His small room served as both the
classroom and clinic (see Plate 17). Leading off from his main room is a small
anteroom, which was used variously as a kitchen, waiting room and pharmacy
workshop. His room was only just big enough to accommodate his ten students. The
space provided a conducive atmosphere for learning about medicine, as arranged
around the room there was an abundance of medicinal compounds and raw
ingredients. When patients arrived, they would either be seen in this room or in the

16 His monastery, founded in 1936. is called Gur gyam do nge drag gye ling. Khyuntrul Jigme Dorje
is the author of'several important Bonpo medical texis, one of which, as will be discussed shortly. is
one of the most important commentaries used in the medical school in Dhorpatan.
17 'Amchi' is the Mongolian title for a doctor, also commonly used in Tibet.

25
 Plate 5 - The Medicine Store, which is located next to Amchi Gege's room, was
also where Nyima and Yungdrung stayed.
enclosed grassy area in front of it. Patients most often came early in the morning,
either before the first lesson of the day or during it. These two activities taking place
in the same location resulted in an amorphous boundary between the clinic and the
classroom; a formal classroom teaching context could quickly be transformed into a
direct clinical experience. Next door to Amchi Gege's room was another room, which
served at the same time as a medicine store, pharmaceutical workshop, and bedroom
for two of the students (see Plate 5).
All the activities of the clinic and school are sponsored by the French charity, aide
a l'enfance Tibetaine through the Swiss Snowlion Foundation in Kathmandu. The
sponsorship pays for the clinic and the education of the students. Financial support
had also been given to construct a new medical building. When I arrived in September
1996, work on this new building was well underway. It was finally completed and
inaugurated according to Tibetan custom in September 1997. As a consequence of the
building activity much of the normal routine of the school was disrupted during the
time I was in Dhorpatan. The new building is situated close to Amchi Gege's room. It
has been constructed in a traditional Tibetan style with a large walled garden at the
front where a wide selection of medicinal plants is grown. The building has two
storeys. The ground floor includes a pharmaceutical workshop, a dispensary,
schoolroom and two rooms for in-patients. The upper floor contains two rooms:
Amchi Gege's cho khang, this is the room he uses for ritual and religious activity, he
has also now moved his collection of medical books here; next to this is a large room,
which is used as a medicine store and for drying freshly harvested medicinal plants.
When I left Dhorpatan in November 1997 most medical activities still occurred in and

around Amchi Gege's room.

The medical school is ideally located. The area of Dhorpatan is very rich in
medicinal flora; about 150 plants that are used in the Tibetan pharmacopoeia can be
found in easy walking distance from the medical building. More types of medicine can
be found if one goes further afield, as the students do during the summer and early
autumn months. However, some important common medicinal ingredients must be
bought in Kathmandhu. This is sometimes a costly affair, for instance one do/a (a
Nepalese measurement equivalent to about eight grams) of musk currently costs

26
around four thousand rupees (£40) in Kathmandu. As very little is charged for the
treatment provided at the clinic, it relies on the sponsorship of the French organisation
to fund its activities.

1.4 The Teacher and the Head Lama

Every evening between seven and eight I ate thugpa18 in Amchi Gege's room with
the other students and monks staying in the Gompa camp. This was always served
shortly after the evening prayers, which took about an hour to complete. Before the
prayers, Amchi Gege would commence spinning his large hand-held prayer wheel and
continue until the prayers were finished and food was served. After eating he would
either continue to spin the prayer wheel and chat with the others, or he would become
engrossed in some religious or medical text. Quite often, when the mood took him,
Amchi Gege would question me about life in Britain.
On one such evening, we were all sat around amidst the shadows cast by the
kerosene lamp and I was responding to a question about the British royal family.
Afterwards there was a period of silence. This was broken by Amchi Gege saying that
his king was born from an egg. This story refers to Khyungpo, the area of Kham in
east Tibet, where Amchi Gege comes from. Khyung is the Tibetan word that
corresponds to the Indian mythological eagle known as the Garuda. The Khyung
eagle is featured in both Tibetan Buddhist and Bon Tantric texts, but it is especially
important in the Bon religion. I was told that in Tibet there are two lineages
connected with the Khyung, one white and one red. The red khyung lineage is
connected with kingship in the Kbyungpo region. 19
In Khyungpo there is a high concentration of Bonpo communities. Before taking
monastic vows Amchi Gege lived in Tibet as a Bon ngagpa practitioner, that is a class
of non-celibate Tantric practitioners. When he took monastic vows he received the

18 A traditional Tibetan stew.

19 On the origin of the Khyung lineage, see Jackson (l98~: 13 7-8).

27
name Tsultrim Sangye. His mother always called him 'Gege' which he told me means
'virtue'; this is the name that everyone still uses. He was born in 1938. He comes from
a family medical lineage (gyu pa). His father was more interested in business than
medicine so he studied under his grandfather and other Amchis in Tibet. When he was
young he wanted to study at Drepung medical college, but the Chinese would not
allow Tibetans from Kham or Amdo to do this. He became a practising Tibetan
doctor after six years of study, but since then he has continued to increase his
knowledge and refine his practice. He has a very high reputation amongst Tibetans for
his medical knowledge. Before coming to India he was imprisoned by the Chinese for
nine years for activities opposing their political regime in Tibet. In prison he found
himself amongst a number of other prominent Tibetan doctors, including Khenpo
Troru Tsenam, the present head of the Lhasa medical school.
He has a reputation amongst Tibetans in Dhorpatan for being truculent and quick
tempered. Quite often I saw him in heated arguments with Tibetans over various
issues relating to the community. On the first day that I met him, the Tibetan girl who
escorted me to the school told me that she would have like to have studied Tibetan
medicine but she was afraid of Amchi Gege. There was a tinge of humour in her
voice, but her comments were not entirely without foundation; Amchi Gege maintains
a very strict hand of discipline in the school. During one conversation I had with
Nyima, the senior medical student, he told me that Amchi Gege believes that men
should have their hair either completely shaved off, or very long. This reflects Amchi
Gege's origins in the Kham region of Tibet where it is the custom for laymen to grow
their hair long and wrap it around their head with coloured string attached to it.
Khampa men generally have a reputation for being stern and wild to the point of
belligerence, and Amchi Gege is no exception to this.
On the other hand, Amchi Gege, as well as being a Tibetan medical doctor is a
devout monk, and as such his head is always closely shaven. Whenever he had a spare
moment he would usually take the opportunity to read religious texts, and there was
hardly ever an occasion when he missed his evening prayers. He has a strong belief in
the Bon religion, and he is a staunch upholder of Tibetan values and customs. He has
a great generosity, and if it is was within his power he would often help people out

28
Plate 6 - Amchi Gege and Geshe Tenzin Oargye.

Plate 7 - Amchi Gege drying out medicinal plants.

Plate 8 Geshe Tenzin Dargye.

Plate 9 - Geshe Tenzin Dargye, Nyima and Tsering Lhamo , drying medicines.
with their problems, both Tibetans and Nepalese. He also proved on many occasions
to be a great raconteur, usually after the evening meal, holding those present captive
with stories about lamas in Tibet or anecdotes from his experiences in Kham.
Of almost equal importance to Amchi Gege in the area of health care was the
young head lama ofDhorpat~ Geshe Tenzin Dargye (see Plates 6, 8 and 9). He had
studied in the dialectics school at Menri Bonpo monastery at Dolanji, and after
passing his final examination and achieving the title of Geshe, he had been sent to
serve as the lama in Dhorpatan by the abbot ofMenri, Sangye Tenzin. Tenzin Dargye
is the name he acquired when he passed his Geshe examination, before that his name
was Tamdrin, a name which many people still use.
His mother and father met as refugees in the Jomsom area of lower Mustang,
where Geshe Tenzin Dhargye was born and spent the first years of his life, mostly
looking after his family's goats. At the age of nine he was sent to Dolanji and
ordained as a monk. His mother was born in west Tibet, and his father in the Amdo
region of northeast Tibet; Geshe Tenzin Dhargye always identified himself with
Amdo.
In 1998 he was thirty-one years old. The position of head lama in Dhorpatan is not
an easy task and requires a person who combines a considerable knowledge of
Tibetan religion and ritual with a certain capacity for diplomacy. From my experience
of him not only did he have these qualities, but he also had a dynamic and strong
willed nature and infectious sense of humour. Although Amchi Gege was considerably
senior to Geshe Tenzin Dargye in terms of age, he always deferred to his superiority
in terms of the monastic scale, but not always without some tension.
As Tibetan medicine to a large extent overlaps with Tibetan religion, Geshe Tenzin
Dargye played an important role in clinical contexts, sometimes overshadowing that
of Amchi Gege. Amchi Gege, as a senior Bonpo monk, was thoroughly conversant
with Tibetan rituals that are used in healing contexts, but he usually passed on all
these kind of activities to Geshe Tenzin Dargye who was assisted in this task by
Amchi Gege's monk students. Chapters seven and eight are devoted to the use of
ritual in healing that I observed in Dhorpatan and the way that the students \vere
involved in these rituals.

29
Plate 10 - Nyima

Plate 11 - Chunsom preparing medicinal compounds .

Plate 12 - Amchi Gege's three monk students pounding medicinal ingredients,
Tundup (left), Yungdrung (centre), and Sonam (right).

Plate 13 - Amchi Gege's students reciting the ritual texts of the annual Jamma
ritual. Behind the monk holding the text on the left, from left to right are Nyima
Sonam, and Yundrung . Tundup is holding the text on the right, beh ind him is
Phuntsok.
1.5 The Students

F or most of the time that I was in Dhorpatan there were ten medical students, four
girls and six boys (see Plates 10, 11, 12 and 13). The reason they entered the school
seems partly because of their own interest and partly the prompting of their parents.
The high representation of female students derives from the stipulation of the school's
sponsor. Amchi Gege told me that traditionally in Tibet there were female Amchis,
but very few. Initially three of the boys were monks, but after about a year of my stay
at the school they gave it up. They had become monks after they had entered the
medical school. Although there is no rule that students at the school should be monks,
there is no doubt that this is Amchi Gege's preference, this is because of the large area
of overlap between the Tibetan medical and religious domains. When they decided to
give up their robes, for a period of time it was uncertain whether Amchi Gege would
allow them to continue with their studies. He agreed, but only after the earnest
intervention of their parents. The eldest male student in the school comes from a
ngagpcl° lineage in Mustang and as such he is well versed in Tibetan religion and
ritual techniques. The two other male students, though not ordained as monks, were
expected to don the monk's habit at times of important rituals. Through serving as
assistants in the ceremonies in the temple they had also acquired a good practical
knowledge of Tibetan ritual.
When I asked the students why they had taken up medicine, the usual reply was
that they wanted to be able to help people. Some of them also answered that they
were doing it to support the Bon religion. None of them had any idea about what the
future might hold for them as medical practitioners. Nobody had entered the school
with a solid idea about making a living from practising medicine after they had
finished their studies. They were all of the opinion that whatever might unfold in the
future, in terms of a medical vocation, would be determined by Amchi Gege, when the

occaSIOn arose.

~ll For a detailed discussion of a ngagpa lineage in the \'iUage of Lubra in lower Mustang. see Ramble
(1985).

30
 All the students, with exception of the eldest student, Nyima, were born and
brought up in Dhorpatan. The six male students were as follows. Thundup Gyaltsen,
aged twenty-two,21 who in 1998 had been studying for eight years. The families of all
the male students are Bonpo with the exception of Thundup; his family are Buddhist
but they were quite content that he had become a Bonpo monk. He is the tallest of the
students and I was always taken aback by his great appetite for the simple Dhorpatan
food. He also seemed to have a great capacity for memorisation, and a disposition
towards laughter and joking at slightest possible opportunity.
Yundrung Lhazon, aged nineteen, who had been studying for five years. He told
me that his maternal grandfather had been an Amchi, but as he himself pointed out,
this does not mean he is from a medical lineage (gyu pa) because for this to be the
case, the lineage should be on the father's side. Although Yungdrung had not studied
as long as some of the other students, from conversations I had with him it seemed he
had acquired a good grasp of the principles of Tibetan medicine. He was definitely
keen to learn Tibetan medicine but at the same time he was also the student who was
most openly critical of the teaching method in the school. Yungdrung had also taken
up monk's robes when he entered the school.
The third of Amchi Gege's monk students was Sonam Tenzin, aged twenty-three,
who had been studying for eight years. He was of a more sober disposition than
Yungdrung or Tundup and less given to joking around. Yungdrung and Sonam were
particularly prone to telling me stories about supernatural phenomenon they had
encountered or heard about in the valley. I will recount some of these stories in
chapter seven. Amchi Gege's two youngest male students were Tsultrim Tenzin, aged
seventeen, and Phuntsok, aged sixteen, both of whom had been studying for three

years.
The senior medical student in the school in terms of age and experience in medicine
was Nyima Samphel, aged twenty-eight. He had been studying in Dhorpatan for five
years. Nyima is different from the other students in that his family come from the
village of Iharkot in Mustang. He belongs to both a Bonpo ngagpa and a medical

The Tibetan convention is to include in the age the time the child was in the womb, therefore
21
when I asked him his age. he said twenty-three.
lineage and had been taught medicine by his father before he was sent for education at
the Bonpo settlement at Dolanji near Simla in North India, where he studied to eighth
class at school. During his stay at Dolanji he also studied medicine with Sangye
Tenzin, the thirty-third abbot of the famous Menri Bonpo monastery, which has been
re-established here. He had been sent to Dhorpatan to complete his medical training
with Amchi Gege. He had a very good knowledge of medicine and proved immensely
useful to me in my attempts to understand the learning processes in the school.
The following were the four female students. Tsering Lhamo and Lhasom, both of
whom were aged eighteen, had been studying for seven years, and came from
Buddhist families. Tsering Lhamo whose name was generally contracted to Tsela was
one of the most outspoken of the girls. She was also generally thought of as being one
of the most attractive Tibetan girls in the settlement, and had many admirers. The
other two girls were Monlam, aged twenty-two, who had been studying for eight
years and Chunsom, aged seventeen, who had been studying seven years. Monlam's
family is Bonpo; Chunsom's father is Buddhist and her mother, who had died some
years before, was Bonpo. Nyima, Tsultrim and Phuntsok all dressed in western style
clothing, the girls all wore traditional Tibetan style clothing.
Both Tsela and Chunsom had quite outgoing natures, Monlam and Lhazom by
contrast were quite shy, at least when they were near older Tibetans and me. When all
the girls were together and Amchi Gege was away the scene could verge on the
riotous. Whenever the opportunity arose they would seize it to tease the male
students. I remember one afternoon hearing some commotion outside. Looking
through my window I saw one of the local goats wearing Sonam' s underpants that he
had washed and left hanging to dry outside his room. The girls were some distance

away having a good laugh at his expense.

The primary school in Dhorpatan can only cater up to fifth class. Prior to entering
the medical school this was the only formal education most of the students had
undergone. Chunsom and Lhazom had only completed second class at the school in
Dhorpatan. The subjects they had studied at school were Nepalese, English, Tibetan,
Science and Maths. Only Nyima, who had studied in India, had some reasonable
ability in English. All the students were totally fluent in Nepalese.

32
1.6 Principal texts used in the school

The Bumshi and the Gyushi

By far the most important medical text in the school is the so rig bum shi, 'the four
fold treatise on the hundred thousand healing arts'; it is usually referred to in short as
the Bumshi. The Tibetan word bum, 'one hundred thousand', in this context, serves as
an idiom to express great quantity. According to the Bon tradition the subject matter
of the text was taught by the founder of the Bon religion, Tonpa Shenrab to one of his
eight sons, Tribu Trishi, who then wrote it down in the language of Tazig. As such
the Bumshi is a canonical text and is included in the Bonpo Kanjur. The Bumshi
corresponds to the principal Tibetan Buddhist medical text, the Gyushi, 'the fourfold
tantra'. As we have seen, the Bonpo and the Tibetan Buddhists both claim their text
to be authentic and the text of the other tradition to be plagiarised.
With the exception of a few minor differences in detail, the two texts are essentially
the same. Where they diverge substantially is in the material that deals with the history
of the medical teachings and the medical lineage. The Bumshi originates in
Olmolungring where Tonpa Shenrab first taught it to his son Tribu Trishi. The whole
of the text is structured as a dialogue between them; each section begins with Tribu
Trishi requesting the teachings from his father. The Gyushi, on the other hand, was
taught by the Medicine Buddha, Bhaisajyaguru, 'the master of remedies', in his
palace, in the city of Tanaduk (,beautiful to behold'). Here, from his body he
magically emanates two sages. Yile Kye as the embodiment of his speech requests the
teachings, which are given by the emanation of his mind, the sage Rigpe Yeshe. The
Gyushi is structured as a dialogue between these two sages.
Both texts consist of four volumes, which deal with different aspects of the medical
lore. The Bumshi has one hundred and sixty-six chapters, and the GYlIshi has one
hundred and fifty-six 22 . This disparity arises from the few occasions when material
that is covered in one chapter in the Gyushi is divided into separate chapters in the
Bumshi. As the sequence of the course is related to the structure of the text, I will

~~ See Appendix B for an outline of the contents of the Gyushi.

--,
JJ
first outline the contents of each volume before moving on to discuss the sequence of
the teachings.

Bumshi Volume 1

Volume one of the Bumshi is called Tsawa Thug Bum Kha Ngon, 'The Root One-
hundred-thousand Essence of the Blue Sky'. It has seven chapters. The text begins by
explaining the origin of the teachings in Olmolungring, it describes the different
locations of Olmolungring and relates them to qualities of medicines. It then goes on
to summarise the whole of the medicine teachings through the metaphor of a tree with
three roots: the condition of the body, diagnosis and treatment.

Gyushi Volume 1

Volume one of the Gyushi is called Tsa Gyu 'The Root Tantra'. This consists of
six chapters. The subject matter is the same as volume one of the Bumshi with the
exception of the preliminary chapter, which describes the teaching of the Gyushi by
the Medicine Buddha in city of Tanaduk.

Bumshi Volume 2

The name of the second volume of the Bumshi is Che Bum Trawo 'The One-
hundred-thousand Multi-coloured Examinations'. This consists of thirty-one chapters.
It covers anatomy and pharmacopoeia.

Gyushi Volume 2

The second voume of the Gyushi is called She Gyu, 'The Explanatory Tantra'.
This consists of thirty-one chapters. The subject matter is the same as volume two of

the Bum shi.

Bumshi Volume 3

The name of the third volume of the Bumshi is So Che Ne Bum Nagpo 'The Black
One-hundred-thousand Remedies for Disease'. It has ninety-six chapters and deals
entirely with Tibetan disease categories, how they come about, and how they should
be diagnosed and treated.

Gyushi Volume 3

The third volume of the Gyushi is the Men Nag Gyu 'The Instruction Tantra'. This
consists of ninety-two chapters. The subject matter is the same as the third volume of
the Bumshi.

Bumshi Volume 4

The fourth volume of the Bumshi is Namgyal Men Bum Karpo 'The White One-
hundred-thousand Victorious Medicines'. It comprises of twenty-seven chapters,
which give instructions on diagnosis and the different forms of therapeutic techniques.

Gyushi Volume 4

The fourth volume of the Gyushi is called Chi Ma Gyu 'The Final Tantra'. This
consists of twenty-seven chapters. The subject matter is the same as Bumshi volume
four.

As the texts are virtually identical it makes little difference whether the students
study the Bumshi or the Gyushi, and indeed both texts are studied at the school; some
students use one of the texts and some the other. Amchi Gege himself originally
studied and memorised the Gyushi. The copies of the Bumshi that are used in the
school are photocopies of a text written in the Tibetan U-me script, brought from
Tibet by Lopon Tenzin N amdak in 1989. He told me that although most copies of the
Bumshi had been lost or destroyed, a few copies did remain sequestered in various
locations. As have I mentioned in the previous section, he informed me that there had
been a copy in the Library of Menri monastery in Tibet.
Outside the Bonpo community, very few people have seen the text. When I asked
about the text to Dr Thokmey Paljor, who teaches Tibetan medicine at the Tibetan
Medical Institute at Dharamsala, he told me that he had heard of it but had never seen
a copy. In 1999 the BlImshi was printed for the first time in v,/estern style book form

35
In the U-Chen Tibetan script. As Amchi Gege is a devout follower of the Bon
religion, the main medical text used in the school is the Bumshi, when the Gyushi is
used it is done with an awareness that it is an almost exact copy of the Bumshi.

Khyungtrul Men Pe

The second most important medicine text used in the school is the commentary to
the Bumshi written by the famous Bonpo lama and scholar Khyungtrul Rinpoche.
Khyungtrul Rinpoche, whose full name is Khyungtrul Jigme Namkhai DoIje, was born
in the Ngari region of West Tibet in 1897. He passed away in 1956. Khyungtrul
Rinpoche was a renowned scholar and wrote many texts, his medical work is
23
generally referred to as Khyungtrul Men Pe. It consists of four volumes, the first
three are commentaries to the various sections of the Bumshi, and the fourth discusses
the manufacture of medicine.

These are the main texts that are used in the school by the students. The students
have access to other medical texts such as commentaries and pharmacopoeias, but the
main body of their studies is based on the Bumshi, the Gyushi, or Khyungtrul
Rinpoche's commentary. Amchi Gege has a large selection of texts dealing with all
aspects of Tibetan medical practice. Whenever he is teaching from the Bumshi, he
always has several commentaries at hand to bring lucidity to the terse passages of the
main text. He often uses Sangye Gyamtso' s famous commentary to the Gyushi, The
Blue Beryl. On several occasions I observed the head lama in Dhorpatan and Amchi
Gege totally bemused at the way that what they considered to be Bonpo medical
knowledge had been incorporated into this primarily Tibetan Buddhist medical text.
As we saw in the previous chapter, this could be due to the wide range of sources that
Sangye Gyamtso consulted before he made his edition of the Gyushi.

Most of his texts appeared as lithographic editions printed in Delhi between 19-15 and 195(). His
:!3
four mcdical works were published by the Tibetan Bonpo Monastic Ccntre at Dolanji in 1972.
 1.7 The Course Syllabus

As can be seen from Table 1.1 the course syllabus at the medical school lasts for nine
years. However, in an information leaflet about the college that Amchi Gege made, it
is explained that the duration of the course is related to the student 's capacity to learn.

The student with the highest capacity would take five years, for a medium
capacity student it would take seven years, and for someone of the lowest capacity it
would take nine years. This is a typical Tibetan cultural idiom. The time sequence of
the programme is not kept to so rigidly; if other work arises then the students must

y . . . :••• ):.: :B iJiiSilf text

..................
........ .......
··::··:ear.::: . :·. . Chapters
.
.... .. ...
....................
. ............. .. . . . . . . . . ..
................ .
.... .. ... .. . ...
...... . ... . ....
. . .
...
. ..
..
.. ... . . ..
..
..
-. Length of Subject
.... . . . . ............
.
.. .. .. .. .. .. .. .....,
,.
.... ...
.. .. ........
. .. ... . . ...............
. . . . . . - . . . ............. ..........
.. . ..
. . .... Study
1st Tsawa Thug Bum Kha 1-7 6 months Condensed summary
NKon of medical teachings
Namgyal Men Bum Karpo 1 and 2 4 months Urine and Pulse
diagnosis
nd
2 Namgyal Men Bum Karpo 3,4 and 5 6 months Medicine
composition
So Che Ne Bum Nawo 1-10 4 months Specific diseases
rd
3 So Che Ne Bum Nawo 11-23 10 months Specific diseases
4th So Che Ne Bum NaKPo 24-48 10 months Specific diseases
th So Che Ne Bum NaKPo 49-73 10 months Specific diseases
5
th So Che Ne Bum Nawo 74-90 10 months Specific diseases
6
th So Che Ne Bum Nawo 91 and 92 10 months Specific diseases
7
Namgyal Men Bum Karpo 6-19 Medicine
composition
th Namgyal Men Bum Karpo 20-27 10 months External treatments
8
and conclusion
Che Bum Trarvo 1-21 Various
th Che Bum Trawo 22-31 10 months Various
9
Table 1.1 The Course Syllabus

assist with this . In practice what this amounts to is all the students taking nine years or

more to finish their studies.

A major source of disruption, which prevailed throughout most of the time I was in

Dhorpatan, was work on the new medical building. Other tasks entailed carrying out

37
odd jobs within the school and clinic, and helping out with the various rituals that had
to be done for the community or for patients. As we will see in chapter seven, in the
spring and in the summer, certain annual rituals must be performed to ensure the
health and prosperity of the community. Amchi Gege, in his capacity as a senior
monk, together with his monk students, must help with these rituals. As well as the
annual rituals, there are other rituals that need to be performed in the community as
need arises, and these also usually require the services of Amchi Gege and his monk
medical students. For instance, during the two-year period that I was in Dhorpatan,
five Tibetans died, and lengthy rituals had to be performed on each occasion. Another
major disruption to the students' lessons came from the demands of the clinic.
Patients usually came early in the morning, but they also turned up at all times during
the day. A further time-consuming activity was the gathering of medicinal plants and
the manufacturing of medicines; these activities happened periodically throughout the
year. The powdering of raw medicinal material can be a long, arduous process.
All this extracurricular activity meant that the normal routine of the school often
went by the wayside. This largely explains the disparity between the years the students
had been studying and the stage they had arrived at in the official course syllabus.
When I left Dhorpatan in August 1998, three of the students had been in the school
for eight years; this however does not mean that they had completed eight years of
study. Sometimes days, even weeks went by when hardly any teaching occurred in the
classroom. This was extremely frustrating for the students.
The approach of the medical school straddles that of the modern, Western-style
school method, and that of the traditional Tibetan approach. In keeping with Tibetan
tradition, in return for receiving teachings from Amchi Gege the students must help
out with any work he needs doing. The sequence of the teachings was also broken by
Amchi Gege deciding at a certain point to teach about specific diseases in the morning
lesson and the chapters on medicines and external treatments found in the fourth
volume in the afternoon lesson. Every year there are ten months of lessons; the school
is closed for two months during the winter.

38
1.8 The Daily Routine

Most days at the school follow the same pattern. The school is open from Monday
to Saturday; Sunday is holiday. Each week one of the students served as cook. The
day began at five 0' clock in the morning when the students staying at the school (the
three monk students and the eldest student Nyima) awoke and began to memorise
their texts. The students who lived with their families were also supposed to do this.
At 7 a. m. the students staying at the school gathered in Amchi Gege' s room and
recited various prayers with him: the Bonpo lineage prayers, prostration prayers,
bodhicitta prayers, guru yoga prayers, the twelve requests of Tonpa Shenrab, the
Medicine Buddha prayers, and prayers for the religious protectors. At about 7.30 a.m.
breakfast was served.
After breakfast the students had free time until 9 a.m. when the first lesson of the
day commenced. The other students would arrive shortly before it. After the lesson at
ten 0' clock, for fifteen minutes the students got together in pairs, and revised what
they had learnt in the lesson. It was supposed to be a process of verification through
discussion, but usually entailed one of the students going through what had been
taught in the lesson while the other listened and made the occasional comment. The
Tibetan name for this is go duro After this they had a fifteen minute break, and then
from 10.30-12.00 they had to memorise the text. Beginning around noon they had a
two hour lunch break.
The next lesson began at 2 p.m., which was followed at 3 p.m., like the morning
lesson with fifteen minutes discussion. From 3.15-5 p.m. the students again had to
memorise their texts. At 5 p.m. the students who stayed with their families went
home; the students who stayed at the school congregated in Amchi Gege' s room and
had tea and tsampa. They returned to his room at 6 p.m. to recite various prayers for
about an hour. Between 7 and 7.30 p.m., the evening meal was served. After this the
students were expected to return to their rooms and again set about the task of
memorising their texts. The students who were staying with their families were also
expected to do this in the evenings.

39
 At 10 a.m. every day I also had a one-hour lesson with Amchi Gege, which the
students often attended by way of revision. When I first arrived in Dhorpatan the
students were also being taught Tibetan astrology in the mornings by the head Lama
of the B6npo community, Geshe Tenzin Dhargye, but Amchi Gege stopped this after
some time, as he thought it was detracting from their medical studies. The same fate
befell the English lessons that I was giving to the students at the beginning of my stay.
The above routine was the standard pattern of events, though as I have said, this was
often disrupted by various types of work that required to be done.

1.9 Exams and Course Assessment

Student progress is assessed in three different ways: their theoretical knowledge is

assessed formally through written examinations, and informally during the classes;
their memorisation is assessed formally by frequent examinations; and their ability to
apply what they have learned is assessed informally in clinical contexts. Amchi Gege
teaches his students in a way that he considers faithful to Tibetan tradition. He
explained to me that he teaches in the same manner as he himself was taught. Having
said this, he admits that there are a number of differences between the traditional
Tibetan approach that he experienced and what occurs in the school. Amchi Gege was
not part of a cohort of students and there was no set routine to the way he was taught
and assessed. In the school much of the teaching and assessment occurs according to
a routine, at least this is the ideal. The normal procedure is for there to be two written
exams every year: one in the summer and one towards the end of the teaching year. If
the students fail the exam they are given a chance to do it again; in principle they must
pass the exam before they can continue with the course material. During my stay in
Dhorpatan the regularity of all exams was disrupted by the students having to help
with the building of the new school and clinic.
The students understanding of the medical knowledge and their ability to apply this
knowledge practically were constantly being assessed in various informal ways. Whilst
Amchi Gege was teaching he would spontaneously ask students questions, sometimes
only remotely connected with the subject matter he was teaching at that time.
Whenever patients came, after Amchi Gege had first made a diagnosis, he would often

40
ask one or two of the students to attempt to verify his findings. Sometimes all the
students would be brought together to give their opinion about something of
particular interest, such as a symptom, or a certain type of urine.

1.9.1 Memorisation Assessments

The students were frequently tested on the level they had reached in memorisation,
and their retention of previously memorised sections. Usually at the end of each week
Amchi Gege tested the students on the level of their memorising. There is a big
memorising exam every six months where the students must recite a large section of
the text in front of Amchi Gege. What follows are my observations of one such exam.
On the morning of the exam all the students were sat in the grass courtyard outside
Amchi Gege' s room, memorising their texts with an uncommon fervour. The exam
was not to begin until later in the afternoon and so the students were taking any
chance they could to bring their memorising up to standard. During the morning there
was a tangible nervous tension in the air. At three 0' clock I was called to Amchi
Gege's room. He had given consent to my request to be able to sit in on the exam.
The first student arrived and sat cross-legged adjacent to him. The student explained
which section he was going to recite, and after a short pause he began. He was
reciting a section of the third volume of the Gyushi. He had his head slightly down all
the time, and he recited the memorised section very quickly. Occasionally he had
lapses in his memory. To overcome this he would start his recital from an earlier
section, each time he did this he managed to overcome the problem. As the student
carried out the recitation, Amchi Gege followed the section in the text looking for any
deviation from the original, occasionally he made a quick comment, but most of the
time he remained in attentive silence.
The second student recited a section from the fourth volume of the Bumshi. He
made more mistakes than the first student, but by adopting the same technique of
retracing his steps, and continuing, he managed to complete the section. The third
student was the youngest student in the school. He had memorised a section from the
third volume of the GYlIshi. He started well, but after some time he began to lose his
concentration. A few lapses of memory were overcome by the method of retracing his

41
steps, but eventually he hit a complete block and could not continue. He began to
laugh nervously; this was soon brought to an end by Amchi Gege's stem look.
The recitation of each student lasted between five to ten minutes. In order to
complete the full recitation it was essential that the student remained fully
concentrated. This was made all the more difficult with the awareness that they were
being meticulously scrutinised, and on top of this there was the constant repetitive
chorus of the other students outside rehearsing their sections. The recitations were
conducted at great speed; the student could only have been vaguely aware of the
meaning of what they were saying. The recitation appeared to occur on a level at
some remove from the conscious mind. Whenever the conscious mind intervened ,
whenever there was a shift, however fleeting, back to the level of consciousness, this
was accompanied by a disruption in the flow. When each student finished, Amchi
Gege left a piece of paper in the text, as an official marker of the stage where each
had reached.

1.10 Legitimation

A major problem that the school faces is how it can legitimise its newly graduated
medical practitioners according to some commonly accepted criteria. Broadly
speaking, there are two requirements that must be fulfilled: it must be recognised as a
genuine medical school with the power to confer a medical qualification by the
Tibetan authorities; and the qualification must be recognised in the country were the
newly graduated students wish to practise. For the Tibetan medical school at the
Institute of Higher Tibetan Studies at Samath, as it is an Indian educational institute,
the qualifications it confers are fully recognised by the Indian Department of
Education. The qualifications given at the TMAI at Dharamsala are not officially
recognised by the Indian Department of Education; however, recognition by the
Tibetan Government in Exile is enough sanction for the new doctors to practise in one
of the Institute's thirty-five branch clinics. Through its association with the TMAI, the
same also applies to the students who graduate from the Chagpori medical school.
According to the traditional Tibetan approach, medical students who were trained
through family lineages, or through apprenticeship with a doctor, were examined by

42
recognised doctors at the end of their studies. This examination sometimes took place
in front of the local community, as it still does today in Ladakh.24 On passing this
exam, the newly graduated doctor did not receive a formal qualification or certificate,
but the sanction to practise through the recognition of established doctors and the
local community. Amchi Gege had come through such a system. Although he is
widely acknowledged for the depth of his medical knowledge and clinical experience,
he has no formal qualification in medicine. It would be possible for his students to
practice within Tibetan communities, but if they want to widen their career options,
they need to have recognised qualifications.
According to Carr-Saunders and Wilson's (1933) classic study, professions are
occupation groups whose practitioners are bonded together through formal
associations. Through the professional association, institutional structures are
established with the aim of: improving technical knowledge; educating novices;
regulating standards of practice; excluding the unqualified; and improving the
standards of qualified practitioners (Leslie 1972:40). According to this definition, up
to the present, Tibetan doctors have never formed a professional group, though it
could be argued that the new emphasis on acquiring qualifications and the dominance
of medical institutions such as the Medical Institute in Lhasa and the TMAl in
Dharamsala are indications that Tibetan medicine is presently undergoing a process of
professionalisation. 25 Whereas before it was not necessary to acquire formal
recognised qualifications to practise medicine, now it is becoming increasingly the

standard pattern.
The medical students at TMAI, Chagpori, and Samath, have an occupational
structure lying ahead of them. The Sarnath students, because they will have an
officially recognised Indian qualification in Tibetan medicine, will be able to find
employment in Tibetan medical clinics or in Indian clinics. The students from
Chagpori and TMAI, could either work in one of the branch clinics or in

24 For a study of Amchi practice in Ladakh see Millard (1992).

25 The classi~ study of medicine as a profession is Freidson' s Profession of.\Iedicine (1970). On the

process of professionalisation amongst Ayurvedic and Unani practitioners in India, see Leslie (1972);
for similar processes in Africa, see Last and Cha\unduka (1986).

43
pharmaceutical or research contexts. For the school in Dhorpatan the picture IS

different and the legitimation process is not going to be simple. When I asked Amchi
Gege about this, he replied that Sangye Tenzin, (the present abbot of Menri
monastery at Dolanji, and the spiritual head of the Bonpo community), or Lopon
Tenzin Namdak (the head teacher of the Bonpo), both whom are highly respected and
widely recognised authorities on the Bon religion and Tibetan culture in general, will
prepare and assess the final exam. But he realises that this in itself will not solve the
problem of legitimation. By 1998 no students had graduated from the school and the
issue remained to be solved.
One obvious solution to the legitimation problem facing the medical school in
Dhorpatan would be to get it fully recognised by TMAI and the Tibetan Government
in Exile. The present settlement officer had already enquired about this possibity. It
appears that if the school is to be recognised by TMAI, it would have to have some
say in the assessment of the students, as it does with the Chagpori school. But this
would be difficult because, unlike the students at Dhorpatan, the students at TMAl
have mostly studied to the twelfth class at school, and in their medical exams they are
assessed on their understanding of Tibetan grammar and English. In addition to this,
given the history of the predominantly Buddhist Tibetan administration's attitude
towards the Bon religion, there is likely to be some reluctance to officially recognise a
Bonpo medical school.

My aim in this chapter has been to give relevant background information about the
medical school in Dhorpatan, before I move on to consider different aspect of the
medical knowledge that is taught in the school and the manner in which it is
transmitted. I have introduced the teacher, the head lama and the students and the
arena of learning: the pharmacy, clinic and classroom. I have outlined briefly the
contents of the main medical text and when its different sections are taught in the
course syllabus. I have also briefly introduced the daily routine in the school.
We have seen that Tibetan historiography presents three views on the origin of the
principle medical text of Tibetan medicine: the first view holds that it originally
existed in Sanskrit and was translated into Tibetan by Vairocana in the eighth century;
the second view contends that the Gyushi is of Tibetan origin and was composed by
Yuthog Yontan Gontan Gompo the Younger in the twelfth century; the third view is
that the Gyushi is a 'transformation' of an original Bbnpo medical text known as the
Bumshi. This third perspective is that held by Amchi Gege and consequently as the
Bumshi and the Gyushi are virtually identical he uses both texts in his school.
We have also seen that like other contemporary Tibetan medical schools Amchi
Gege has made some concessions to modernise the teaching of Tibetan medicine, such
as having a set curriculum, timetable and formal assessments. But as we will see he
still strongly values the way that he was taught in Tibet, for instance unlike the other
contemporary Tibetan medical school that I have discussed, the students in Dhorpatan
have to memorise all of the main medical text. We also saw that there is no strong
demarcation between Tibetan religion and medicine in the school. In certain medical
contexts the role of the head lama of Dhorpatan, Geshe Tenzin Dargye, supersedes
that of Amchi Gege.

45
 Chapter 2 Learning Processes - Theoretical Orientations

'Now, what I want is, Facts. Teach these boys and girls nothing but Facts. Facts alone are wanted in
life. Plant nothing else, and root out everything else. You can only form the minds of reasoning animals
upon Facts; nothing else will ever be of any service to them. This is the principle on which I bring up my
own children, and this is the principle on which I bring up these children. Stick to the Facts, sir!'
The scene was a plain bare, monotonous vault of a schoolroom, and the speaker's square foretinger
emphasized his observations by underscoring every sentence with a line on the schoolmaster's sleeve.
The emphasis was helped by the speaker's square wall of a forehead, which had its eyes for its base,
while his eyes found commodious cellarage in two dark caves, overshadowed by the wall. The emphasis
was helped by the speaker's mouth, which was wide, thin and hard set. The emphasis was helped by the
speaker's voice, which was inflexible, dry and dictatorial. The emphasis was helped by the speaker's
hair, which bristled on the skirts of his bald head, a plantation of fus to keep the wind from its shining
surface, all covered with knobs, like the crust of a plum pie, as if the head had scarcely warehouse-room
for the hard facts stored inside. The speaker's obstinate carriage, square coat, square legs, square
shoulders - nay, his very neckcloth, trained to take him by the throat with an unaccommodating grasp,
like a stubborn fact, as it was - all helped the emphasis.
'In this life, we want nothing but Facts, sir; nothing but Facts!'
The speaker, and the schoolmaster, and the third grown person present, all backed a little, and swept
with their eyes the inclined plane of little vessels then and there arranged in order, ready to have
imperial gallons of facts poured into them until they were full to the brim (Dickens [1854] 1966:1).

This thesis is about learning processes in a Tibetan medical school. In the following
chapters I will consider the various elements of medical education and the manner in
which the students are gradually inducted into medical practice. In this chapter I will
outline the model of learning that I have used to understand this process. The process
of acquiring competency as a Tibetan medical practitioner is a process of acquiring
new ways of perceiving and knowing. The Tibetan medical system has its own rules of
pathology, nosology, diagnosis and therapeutics, which accord to a specific cultural
cosmological scheme. The students pass through the various stages of a journey into a
new world of meaning. They are introduced to modes of perceiving, knowing, and
practice, that are initially strange and unfamiliar; as they go deeper into this journey,
the aim is that the students will gradually come to inhabit this new world of meaning.
What was initially strange and unfamiliar becomes taken for granted, an unquestioned

mode of being in the world.

As a worldview Tibetan medicine is consistent with wider Tibetan cosmological
notions; within this cultural framework, there exists a very clear idea of what is
considered to be valid knowledge and how it is acquired and should be passed on.
This is not something exclusive to the Tibetan tradition, it is often the case that forms
of knowledge and methods of how that knowledge should be reproduced are deeply
interrelated. Lave (1991, 1988, 1990) has pointed out the error of studying education

46
in a decontextualised manner. Education must be considered in its social, cultural ,
historical and political context. In the medical school there are three main areas of
activity where learning takes place: the classroom, the pharmacy, and in clinical
contexts. By pharmacy I mean the range of activities involved in finding and preparing
medicines. My observations of the learning process in the classroom will be dealt with
at length in chapter five. Clinical contexts include interaction with patients at the
school and within the community. A discussion of the ways in which the students
learn through clinical practice will be made in chapter six and eight.
The model of learning that I have developed to interpret the progression of the
students is holistic; rather than adopting a view of learning as a cognitive process
happening in the heads of the students, I will look at how mind, body, action and
social world, are simultaneously involved in the generation of meaning. What I discuss
in connection with education in the medical school has wider general application as a
theory of social reproduction.
In the passage quoted at beginning of this chapter, Dickens is aiming his critical
comments at the approach to education in the Victorian age, and particularly to the
then prevalent utilitarian philosophy, which provided it with a theoretical basis.
Utilitarian writers such as Jeremy Bentham, John Stuart Mill, and James Mill combine
a self-seeking understanding of the individual based on the economic ideas of Adam
Smith, with the Lockean view that the human mind is born as an empty slate. The
passage spells out many of the features of what Jean Lave has referred to as the
'cultural of acquisition' (1990:310). This understanding of human nature and
knowledge has been in the ascendancy since the nineteenth century and is still widely
influential. It is a view founded in a number of firmly entrenched dichotomies: that of
knowledge as fundamentally propositional, immutable and transposable, in contrast to
the position that knowledge is changeable and has multiple forms; that of subject and
object; and that of mind and body. Another component of this perspective is an
extremely restricted view of subjective agency. These are the basic elements of the
standard modernist version of human nature, knowledge, and the process of learning.
The perspective on learning that will be presented in this chapter attempts to
transcend these dichotomies by understanding learning as a process involving all levels

47
of human experience. Individuals, far from being the passive vessels of pre-existing
social forms, will be shown to be the active 'orchestrators' or 'authors' of meanings
generated in the learning context (Cohen 1994). The learning process whereby
novices become experts, involves far more than the mere acquisition of knowledge;
expertise comes about not through accumulation, but through appropriation.
With regard to the medical education in the school in Dhorpatan, the first point to
make is that what the students are undergoing is a form of apprenticeship, that is to
say a large part of what is learned comes about through engaging in medical practice.
Apprenticeship has assumed many different cultural forms (Lave 1990). Common to
all these forms is the situated nature of the learning process; the novice learns by
participating in varying degrees in the practices of the master. Recent studies on
apprenticeship have tended to move away from previous unilinear models of
internalisation through imitation and repetition (Engestrom 1987; Goody 1982;
Jordan 1989; Lave and Rogoff 1984; Lave and Wenger 1991; Benner 1984). The new
concern is with the dynamic interrelationships between the individual, social action
and the social world.
Any theory of learning or social reproduction must be founded in specific
understandings of the nature of knowledge and human understanding. There are
broadly two opposing views on this, and the debate on them runs through the full
length of the Western philosophical tradition. On the one hand there is the tradition of
nativism or as it is sometimes called, rationalism. According to this tradition the
individual is born with some form of innate knowledge. Our understanding of the
world is made possible by this pre-existing knowledge. Key thinkers on this side of the
argument are Plato, Descartes, Leibniz, and more recently Chomsky and Fodor
(Cowie 1999). The opposing view is that of empiricism, which holds that all
knowledge derives from experience through the senses. Some of the most celebrated
exponents of this position are Hobbes, Hume, and the nineteenth century utilitarians
such as John Stuart Mill, who, as we have seen, were so much the focus of Dickens'
satirical contempt. Perhaps the most famous and influential protagonist of the
empiricist tradition is Locke, who represented the human mind as a tabula rasa. By

this he means:

48
 Let us then suppose the mind to be, as we say, white paper, void of all characters, without any
ideas; how comes it to be furnished? Whence comes it by that vast store, which the busv and
boundless fancy of man has painted on it with an almost endless variety? Whence has it ~l the
materials of reason and knowledge? To this I answer in one word, from experience: in that all
our knowledge is founded, and from that it ultimately derives itself (Book II chap i sec 2).

Kant's philosophy attempts to bridge these two opposing views by showing that
although knowledge starts with experience, it is through the mind's innate categories
of understanding and perception that the world is constructed. These opposing
streams of thought are also represented in anthropological and sociological theory.
Structuralist perspectives such as functionalism and Marxism follow the empirical
tradition. The structuralism of Levi-Strauss accords with the tradition of nativism, as
do the phenomenological and ethnomethodological perspectives with their emphasis
on the role of the individual in constructing the 'life-world'.
It follows from this that any understanding of learning must first address the
question of the locus and nature of knowledge, and the role of the mind. Bloch
succinctly expresses our problem:
If culture is the whole or a part of what people must know in a particular social em·ironment in
order to operate efficiently, it follows first that people must have acquired this knowledge,
either through the development of innate potentials, or from external sources, or from a
combination of both, and secondly that this acquired knowledge is being continually stored in
a manner that makes it relatively accessible when necessary (Bloch 1990: 184).
The view that will be proposed here is that culture is a combination of both; the
individual is always actively present in the generation of meaning as the 'knowing
subject'.

2.1 The Culture of Acquisition: Knowledge as Proposition

Every morning the day at the schools starts with memorisation of the main medical text. At 9
a.m. the students have their first lesson of the day with Amchi Gege. When he is ready to
begin the lesson, the students assemble in his room and sit on mats behind small Tibetan tables
(chotse) situated around the periphery of the floor. They begin by reciting the prayer to the
medical lineage, after which they open their copies of the Bumshi or the Gyushi at the section
that they had arrived at in the previous lesson. First Amchi Gege reads a section of the text and
then using various commentaries he has open in front of him he elaborates on what is said in
the main text in great detail. The students listen attentively. making occasional notes in their
copies of the text or in exercise books. They seldom ask questions, but occasionally Amchi
Gege asks them questions about what he is teaching. This is the basic pattern that occurs in
every lesson in the classroom.

The 'culture of acquisition' 1S best typified by the functionalist approach to

education. The functionalist approach holds that the individual is the passive

49
receptacle of structures of pre-existing knowledge present in the external social
world. Children are born as empty passive vessels and through the process of
socialisation are filled with the shared norms and values of society - in this way social
stability is maintained. According to Durkheim, within each person there exist two
beings: the individual being and the social being. The individual being is made up of
various personal mental states; the social being comprises of 'systems of ideas,
sentiments and practices which express in us, not our personality, but the group or
different groups of which we are a part' (Durkheim 1938: 71). For Durkheim the
purpose of education is to constitute the social being. Innate qualities are written off
as 'vague and indefinite tendencies' and we are told that, 'society finds itself, with
each new generation, faced with a tabula rasa, very nearly, on which it must build
anew' (Durkheim 1938:72).
The functionalist understanding of knowledge and education has been highly
influential in the disciplines of cognitive psychology and anthropology. Culture is
viewed as an accumulation of knowledge, which is stored in the heads of individuals.
Memory is likened variously to a warehouse, a digital computer, or an encyclopaedia
of accumulated information, and culture is reduced to factual mental contents. Culture
consists of various 'knowledge domains', each constituted by an abundance of
'chunks' of knowledge (Simon 1980). According to the theory of 'learning transfer'
(Thorndike 1903), knowledge acquired in one situation can be easily transferred
across domains, regardless of the change in context.
There are a number of problems with this view of education: culture is considered
to be a body of facts that are internalised and stored in the heads of individuals in an
unproblematic way; in the process of transmission the body of knowledge is
considered to remain constant; and culture is viewed as immutable and existing
outside of social contexts. Social reality does not bear testimony to any of these
issues. The general criticisms of the functionalist perspective, which derive from the
passive role it allots to the individual, are also applicable to this understanding of
education: it does not account for social change, and there is no explanation for the
historical origin of culture or 'social facts'. In addition, as 'we have no justification for
supposing that our mind bears within it at birth, completely formed, the prototype of

50
this elementary framework of classification' (Durkeim and Mauss 1963: 8), there is the
problem of the logical origin of cultural categories. Another shortcoming of the
functionalist perspective is the entirely positive role it attributes to education. More
critical perspectives view education in an entirely different light: it is an act of
'symbolic violence' (Bourdieu and Passeron 1977), which justifies and thereby
perpetuates existing relations of power and social inequality. For Chomsky (1989,
1988) the institution of education works alongside other institutions in creating
'necessary illusions' which lead to a 'manufactured consent'; this serves the interest of
global corporations.
Recent theories of education have tried to overcome the inadequacies of the
functionalist perspective by broadening the scope of the learning experience. The new
view perceives it as a result of processes occurring at the interactive interface between
the mind, body, agency and social context; this is the approach I have taken to the
learning process in the medical school. It is an approach that hits head on to what has
been, up until recently, the firmly entrenched divide between the disciplines of
psychology on the one hand, and sociology and anthropology on the other. Before
proceeding to discuss this holistic view of education, I shall first consider this
disciplinary divide.

2.2 The 'Social Being' and the 'Individual Being'

We have seen how Durkheim understood each person to be a composite of two

beings: the 'social being' and the 'individual being'. Durkheim played down the role
of the 'individual being' in society. For him, the subject of sociology is the social
being and the collective representations to which it owes its nature.
Collective representations, emotions, and tendencies are caused not by certain states of the
consciousness of individuals but by the conditions in which the social group in its totality is
placed. Such actions can, of course, materialise only if the individual natures are merely the
indeterminate material that the social factor moulds and transforms (Durkheim 1938: 106).

This perspective is at the root of the long-standing rift between, the domain of
psychology, which is concerned with the individual, and the domain of anthropology
and sociology, which focus on culture and society. It is not that there have never been
attempts to bridge this divide. From the 1970s there has been the sub-discipline of
psychological anthropology (Hsu 1972), which grew out of the culture and

51
personality school rooted in the ideas of Edward Sapir. Also, even in the heyday of
functionalist perspectives, culture was occasionally explained in terms of
psychological conditions; a case in point is Malinowski (1954). Within psychology, a
parallel process occurred with the development of social psychology. Yet the divide
has never been successfully bridged.
As Lave points out (1988), from the 1960s cognitive anthropologists began to take
a critical view of the psychological validity of their cognitive analyses (Burling 1964,
Romney & D' Andrade 1964). In cognitive psychology a parallel development
occurred as questions were raised about the ecological and social validity of theories
that were often tried and tested only in laboratory settings (Barker 1968, Neisser
1976). The same division has been brought into question by Obeyesekere (1981,
1990), who criticises the anti-psychological stance of anthropology and the anti-
institutional stance of psychology. He cites Leach (1958) as an example of the classic
anthropological position on public and private symbols.
He clearly recognises the importance of individual psychology; but he adopts the classic social
anthropological position that individual psychology cannot have cultural significance or that
publicly shared symbols cannot have individual psychological meaning (Obeyesekere
1981:14).

For Leach, private symbols have emotional meaning and are amenable to
psychological analysis, but public symbols operate in an arena of an entirely different
order. Obeyesekere attempts to bridge the divide by showing how symbols have
motivational significance at the level of the personality and culture simultaneously. An
illustration of this from medical anthropology is Dunn's idea that disease occurs
simultaneously in three realms of meaning (1976: 143). A disease involves, in varying
degrees, biophysical, psychological and socio-cultural components. Take the case of
smallpox in India for instance. On a biophysical level it is an extremely infectious
disease, on a socio-cultural level it is the action of a goddess, and on a psychological
level it is the experience of the afflicted individual. Any fully adapted response to the
disease must be related to these three realms of meaning.

2.3 Situated Learning

A 28-year-old Tibetan woman came to the clinic complaining of a sharp pain in the left side of
her chest. Whilst Amchi Gege was diagnosing her condition two of his students. Yungdrung
 and Nyima were present. Amchi Gege took her pulse and without saying an}thing about what
he understood from it, he asked both Nyima and Yungdrung to attempt to diagnose the
disorder. After taking the pulse, which they said was strong and fast, they concluded that the
patient was suffering from a fonn of fever. Amchi Gege said that the woman's husband had
died a month before, and her distressed emotional condition had upset the humours of wind
and bile. He said that the pulse did not denote a fever condition but a disturbance in the bile
humour, and it was this that was causing the pain in her chest.

From what has been said so far it is clear that a comprehensive theory of learning
and social reproduction must bridge a number of traditional dichotomies: that of the
body and the mind; that of individual psychology and the external socio-cultural
environment; and that of knowledge as fixed, immutable and transposable, and
knowledge as generated in interactional contexts. Lave goes along these lines when
she says that the everyday practice of cognition 'is distributed - stretched over - not
divided among mind, body, activity and culturally organised setting' (Lave 1988: 1).
Traditionally, learning has been construed as fundamentally cerebral in nature and
unaffected by agency and context. Knowledge is understood as so many propositions
that the learner must internalise. The nature of the individual and the process of
transmission are left as unproblematic. I don't mean to imply that a propositional view
of learning is completely invalid; it is just one element within a wide-ranging process.
Learning is not something purely cerebral in nature; it is a process involving the
reciprocal interaction between the whole person and the social environment. As the
above example shows expertise is developed as propositional knowledge is
increasingly situated in practice. In chapter six I give a further twenty examples of
clinical interactions involving the students attempting to situate the knowledge that
they had learned in the classroom into medical practice.
I have mentioned that there are three main arenas of learning within the medical
school: the classroom, the pharmacy and clinical interaction. Every day the students
have two hours of formal classroom education with the doctor: one hour in the
morning and one in the afternoon. In the classroom, knowledge is presented as a
series of propositions. In order for these propositions to become fully relevant they
must be realised in medical practice. Knowledge becomes a reflexive part of the
student's sphere of competency through an act of appropriation carried out whilst the
student is engaged in medical activity. For this reason a large part of my research
focuses on how the students come to inhabit the medical world by engaging in

53
practice. My approach draws on a body of recent literature on learning that moves
away from the acquisition of propositional knowledge and focuses on the situated
nature of learning (Lave and Rogoff 1984, Lave 1988, Lave and Chaiklin 1993, Lave
1990, Lave and Wenger 1991, Jordan 1989).
The chief exponent of this approach is Jean Lave. At the basis of her view is
Ortner's (1985) contention that recent anthropological theory no longer accepts a
simple internalisation view of social reproduction; the new emphasis is on socialisation
occurring in everyday practice. For Lave, learning is not confined to the acquisition of
a body of self-contained facts that can be transferred across contexts; rather it is
situated in moments of social co-participation. The central mechanism of situated
learning is what she refers to as 'legitimate peripheral participation' (Lave and
Wenger 1991). The idea is that the individual is gradually inducted into the practice of
the master by being allowed to participate in that practice in varying degrees and with
varying responsibilities. In her words 'apprentices learn to think, argue, act, and
interact in increasingly knowledgeable ways, with people who do something well, by
doing it with them as legitimate peripheral participants' (Lave 1990:311). As we shall
see in chapters six and eight, this is very much how learning occurs in the medical
school as the students progressively move towards full participation in the community
of medical practice.
Situated learning shifts the emphasis away from the acquisition of a fixed body of
propositional knowledge to meaning generated through negotiation in social
interaction. Emphasis is placed on the various transformations that are brought about
through the learning interaction~ transformations that affect the student, the master,
and the body of knowledge transmitted. Zimmerman (1978) draws attention to this
issue when he says that research which focuses exclusively on the classical Ayurvedic
texts gives a distorted picture of the tradition as static and unchanging, whereas actual
Ayurvedic practice draws on certain elements within the texts and neglects others.
Eickelman mentions a similar point (1978) in his discussion of Islamic education,
which stresses the importance of memorising Islamic religious texts. It has often been
thought that this leads to an unchanging and inflexible body of knowledge, whereas

54
Eickelman claims that there has been considerable flexibility over what has to be learnt
at different times and in different places.
Some forms of apprentice learning are entirely oral, others, such as Tibetan
medical education make extensive use of texts. But it is important to note that
wherever there is a fixed codified body of knowledge that the student must learn, it is
not through this that the community of practitioners reproduces itself; it is through the
preservation of the prescribed pattern of the student-master relationship, in other
words it is the framework of participation (Lave and Wenger 1991). This is clearly
demonstrated by the relationship between the doctor and the students in the medical
school, and the general importance of lineage in Tibetan culture.

2.4 Innate Knowledge: The 'Knowing Subject'

To return to Bloch's remark that the ability to perform competently within a given
cultural sphere requires that the individual has either developed an innate potential, or
received the relevant knowledge exclusively from external sources, or a mixture of
both. Learning cannot be confined exclusively to acquisition, nor is it centred
exclusively in social negotiations. Learning occurs at the interface between the active
individual as what the idealist tradition refers to as the 'knowing subject' (Bourdieu
1977:2) and the social and natural environment. I agree with Lave's contention, 'that
there is no such thing as '''learning'' sui generis', not because, as she claims, that there
is 'only changing participation in the culturally designed settings of everyday life'
(Lave 1993: vii), but because there is always the 'knowing subject'. Having said this,
Lave's view of situated learning as a process of negotiation, spread over mind, body,
activity and cultural setting, does by necessity involve the 'knowing subject';
negotiation can only occur if there is a person doing it.
There is now a large body of theory about learning and social reproduction that
attempts to bridge the divide between the individual and structures existing externally
in the social world. The aim has been to develop a theory of social practice (Bourdieu
1977) or what Giddens refers to as 'structuration' (1976, 1984). Situated learning is
intimately related to these theories. I have said that a comprehensive theory of
learning and social reproduction must transcend various entrenched dualities. As the

55
aIm of Bourdieu' s theory is to transcend the divide between objectivism and
subjectivism which has bedevilled the social sciences, and as E P Thompson has
spoken of him as an antidote to the errors of Marxist structuralism, and to theorists
who view, 'history as a process without a subject and concur in the eviction from
history of human agency' (Thompson 1978:366), this would seem like a good place to
begin.
At the centre ofBourdieu's understanding of learning and social reproduction is
the habitus:
The structures constitutive of a particular type of environment ... produce habitus, systems of
durable, transposable, dispositions, structured structures predisposed to function as structuring
structures, that is as the principles of the generation and structuring of practice, which can be
objectively 'regulated' and 'regular' without in any way being the product of the obedience to
rules ... (BoUTdieu 1977:72).
In the same way that from a Marxist perspective certain material conditions produce
specific class conditions, the same relationship holds between the habitus and what
Bourdieu calls a 'field'. The field is network of relations (Bourdieu and Wacquant
1992: 97) in which the individual circulates. For the students in Dhorpatan, the field is
the institution of Tibetan medicine as a body of knowledge and prescribed social
relationships. The Tibetan medical habitus is what the students need to be competent
practitioners in the 'field' of Tibetan medicine. Chapters three, five, six, and eight all
present different ways in which the students acquire the habitus of Tibetan medical

practice.
Bourdieu's quest is to establish 'an experimental science of the dialectic of the
internalisation of externality and the externalisation of internality, or more simply of
incorporation and obj ectification' (Bourdieu 1977: 72). By shifting the focus from
fixed representations of social structure and agency - the opus operatum - to social
practice as the unfolding of a continuous process - the modus operandi - he aims to
break away from subjectivist and objectivist perspectives which he views as 'opposed
to practical knowledge' (Bourdieu 1977:3). But in the end this is never achieved.
Bourdieu for all his subtle circumlocution never manages to leave the objectivist camp
(Jenkins 1992: 175). We are back at the functionalist tabula ra.. .-a and social
reproduction as the internalisation of pre-existing social structures. The habitus is
'history turned into nature' (Bourdieu 1977:78). Human agency exists in the form of

56
strategies, but ultimately the objective structures, which have been internalised as
dispositions, tend to reproduce themselves. Thus many of the criticisms that were
raised earlier against functionalism are equally applicable here. The logical and
historical origin of social forms, and social change remain problematic.
However, the habitus does serve as an important tool in understanding learning.
The whole question he raises of shifting the emphasis from fixed representations to
the process of social practice is important. The habitus is also useful for an
understanding of the situated nature of learning, particularly the way dispositions
become embodied and 'the second natures of the habitus' (Bourdieu 1977:79). The
'internalisation of externality' side of his formula is insightful, yet the picture is
incomplete. The individual is elided and the role of the mind remains vague (Jenkins
1992:93), if not almost completely absent, except as an empty vessel. Dispositions are
at times referred to as 'cognitive and motivating structures' (Bourdieu 1977:76), but
these owe their existence entirely to the social environment.
At this point I would like to look closer at the other side of Bourdieu's formula:
the externalisation of internality. The question is, what does the individual bring to
the learning process and what is the role of the mind? Bourdieu accuses the
anthropologist who searches for objective meanings as the 'knowing subject'. Thus
we have what he describes as the 'pernicious' problem of the model being taken for
reality. 'The "knowing subject", as the idealist tradition rightly calls him', performs
interpretations, and in so doing 'constitutes practical activity as an object of
observation and analYSiS, a representation' (Bourdieu 1977:2). But this is equally
true of any person engaged in social practice. There can be no doubt that there is a
symbiotic relationship between the internal and the external, but it is the individual
who carries out the act of interpretation. Ultimately, knowledge is constituted not by
the social environment but by the 'knowing subject'.
This all relates to the question of the role of the mind in social reproduction: is it
plastic and malleable, as Durkheim would have us believe - an empty slate to be
written on? Or does it play a much more active role in the learning process and the
construction of culture? What exactly is the nature of the 'cognitive and motivating
structures'? In his introduction to Durkheim and Mauss's book Primitil't!

57
Classification ((1903) 1963), Rodney Needham likens the experience of ethnographic
fieldwork to the first visual sensations of a congenitally blind perso~ who through
surgery is given the power to see. Initially, everything is a chaos of swirling colours
and shapes until the newly sighted person makes the immense effort to give them
ordered form. Needham's reflections are based on von Senden's accounts of
numerous cases where this operation was actually performed. Ironically there is
enough evidence within von Senden's book to refute Durkheim and Mauss's basic
position, that the human mind has no innate capacity to classify. Von Senden' s
assessment of the cases he uncovered is highly suggestive.
In the initial stage of pure sensation, vision is confined to the purely physiological process of
the reception and conveyance of stimuli to the visual centres. For the individual, it remains a
quite passive influx of visual impressions, which do nothing, as yet, to induce him to emerge
from his passive state and to try, for his own part, to take up some sort of mental attitude
towards the colours presented to him (von Senden 1960: 129).
What is important here is the stage of 'pure sensation' remains until the newly sighted
person assumes a mental attitude towards the chaos; again we return to the' knowing
subject' .
Numerous theorists claim that the ability to classify and give meaning to external
sensations is already present in the mind from birth. In anthropology the main
inspiration for approaches that adopt this position has been linguistics. For Levi-
Strauss, culture, like language, derives from structuring processes inherent in the
human brain. Levi-Strauss, solves the functionalist problem of the logical origin of
cultural classifications by ascribing them to the human mind's inherent capacity to
classify.
Like Levi-Strauss, Chomsky focuses on innate linguistic capacities, but he adopts
quite a different approach. In his attempts to understand language, he draws on
Plato's notion of innate ideas. Plato's poses the problem of how people can come to
understand so much if they are born devoid of all knowledge. Plato's solution to this
problem is to claim that people are born with pre-existing ideas from past lives, and
learning entails a process of recollecting (amamnesis) this knowledge. Chomsky's
theory of language is a modified version of Plato's position. For Chomsky, acquisition
of language can only be explained if children are born with what he calls the 'universal
grammar'. What we know must be in some sense innate as 'people lack evidence for
even simple aspects of what they know' (Chomsky 1996:27). Children are not born
with the capacity to speak only one language; they have the innate potential to speak
any. For Chomsky, 'the ability to acquire language is basically a fixed uniform species
property' (Chomsky 1996:27). What is remembered from previous existences
becomes in a modem version of Plato, our 'genetic endowment'; Lyons refers to this
process as 'genetic anamnesis' (1991: 165).

2.5 Non-discursive Knowledge

There is evidence that knowledge should not be confined to linguistic and

propositional forms. Research done on neonatal and infant consciousness points to the
presence of forms of knowledge, even conceptual knowledge (Brown 1973), before
the acquisition of language. Furthermore, studies have shown that babies in the first
years have a very well developed innate ability to give meaning to their perceptions,
and information from the social environment (Bower 1977).
Attempts to understand learning, or culture for that matter, using linguistic models,
or to be essentially propositional in nature, miss the mark (Bloch 1990). As Bourdieu
points out a large part of what we learn is, 'something which communicates, so to
speak, from body to body, i.e. on the hither side of words or concepts' (Bourdieu
1977:2). 'Schemes', as he calls them, can be passed from practice to practice at a tacit
level, without ever entering discursive or propositional forms. This does not mean that
all learning is a matter of imitation and trial and error. Every culture has its own way
of transmitting knowledge in a structured, propositional way, but this forms only a
part of the learning process. In forms of situated learning, such as apprenticeship,
much that is learned occurs outside the conscious awareness of the student and the
master. Even in cases where there is a highly structured, institutionalised form of
knowledge transmission, tacit knowledge is still fundamentally at work.
From what has been said so far, it is evident that learning involves the acquisition
of two types of knowledge: explicit knowledge and tacit knowledge. Explicit
knowledge has a discursive nature and as such it can be stored and transferred in
propositional forms, involving a variety of impersonal media such as books, tapes and
computers, and so on. In contrast tacit knowledge has a non-discursive nature and

59
therefore cannot be stored in a propositional form; it is transferred by personal means
through interaction in learning contexts (Mackenzie 1995). In chapter six I have
given twenty examples of students learning through clinical interaction. In most of
these interactions the students have acquired the explicit propositional knowledge
relevant to the patient's condition but they have some difficulty situating this
knowledge in clinical practice. However in a number of the interactions the students
demonstrate considerable practical proficiency, and appear to have developed the
non-discursive knowledge that underpins expertise.
The learning process involves constant moves between these two modes of
knowledge. In the process of apprenticeship, the propositions of the master are
transformed into the non-discursive, taken for granted assumptions of the student; this
is how the students themselves become masters. The implicit knowledge of forms of
practical mastery can be rendered into discourse, but in so doing the knowledge is
transformed from one mode into another of a radically different order. Dreyfus and
Dreyfus (1986) refer to the discursive knowledge, the rules and facts of a body of
practice as a 'knowing-that'; this is to be distinguished from practical mastery which
they refer to as a 'knowing-how', which cannot be put into words. Whilst an
individual is engaged in practice (,knowing-how'), thinking about the practice
(,knowing-that'), can in certain instances diminish the quality of the performance.
A celebrated proponent of the distinction between discursive and non-discursive
thought is Susanne Langer. After discussing the importance of the 'laws of discursive
thought', she points to 'the unexplored possibility of genuine semantic beyond the
limits of discursive language' (1957:86). The ability to impose meaning on sensory
experience is for Langer inherent in the organs of perception, and this ability is
primarily non-discursive. Propositional thought, by its nature, must be strung out in a
linear temporal zone. This is not true of sensory experience, which involves giving
unified meaning to a mass of sensations simultaneously, in order that what is
experienced takes the form of a coherent unified sensation. For Langer, this process
can only be achieved by the application of non-discursive forms of awareness.
Numerous authors have stressed the role of tacit knowledge in the learning process
(Polanyi 1958, 1967; Bourdieu 1977; Collins 1985, 1975, Ferguson 1977; i\lackenzie

60
1995, Lave 1988; Bloch 1990). One of the examples Polanyi gives of tacit knowledge
is an experiment, which involved presenting a series of nonsense syllables to a person
(1967). Each time a certain syllable recurred, the person was given an electric shock.
In time the person showed signs of anticipating the shock when the syllable was
heard, but on being asked afterwards could not identify it (1967:7). Less drastic
examples of the operations of tacit knowledge are the acquisition of motor skills. A
person can be told in intricate detail how to ride a bicycle, drive a car, to ski, how to
feel a pulse, or mix medicine; but the actual skill is developed non-discursively
through practice. It is only when a person can drive a car reflexively, without
'thinking about it', that expertise can be said to have been truly achieved (Bloch
1990: 187).
In fact, in sharp contrast to traditional views of education that have emphasised the
importance of propositional knowledge, evidence seems to suggest that this must take
second place to tacit knowledge. Even if all the propositional knowledge of a body of
practice has been codified in some form or other, if the social co-participation
network through which this knowledge is passed on is broken, re-establishing the
practice solely from the propositional knowledge is no simple matter. Propositional
knowledge is embodied in the community of practice; therefore if codified versions of
it are lost, it is of no great matter. On the other hand if tacit knowledge is lost, this has
severe implications for the continuity of the community of practice. On this issue
Mackenzie suggests that if a long period of time passed during which nuclear
weapons were not made, important tacit knowledge could be lost. It would be still
possible to make nuclear weapons, but this would amount more to a re-invention than
reproduction (Mackenzie 1990).
R D Laing's depiction of the internalisation of tacit knowledge within the family
has important implications for any situation of group learning. Interaction within the
family involves a process of 'reciprocal interiorisation', whereby the attributes of
relationships within the family are internalised by each family member. For Laing,
'(T)o be in the same family is to feel the same family inside' (1971: 13). Lai ng' s
concern is with the dysfunctional nature of families: how reciprocal interiorisation
within the family can lead to pathological psychological conditions. Be that as it may.

61
what is of interest here is the mechanism of reciprocal interiorisation. It is common
knowledge that when people spend a long time together, the process of reciprocal
interiorisation occurs; unconsciously, character traits of others are picked up.
Through reciprocal interiorisation knowledge is internalised without any conscious
intention or awareness. Apprenticeship has often been characterised as learning
through imitation, but in the light of what has been said this idea needs to be clarified.
Imitation is certainly important, but knowledge acquired through imitation often
occurs without any conscious aim to imitate, or to teach. The mechanism of reciprocal
interiorisation shows that learning is not something that occurs only as an outcome of
the student and master relationship, it is a process occurring continuously within the
learning group.

2.6 Embodied Meanings

As I said earlier, a comprehensive theory of learning and social reproduction must

override a number of traditional dichotomies. So far I have focused mainly on the
relationship between individual psychology and the socio-cultural environment. Now I
want to turn to the division between the body and the mind. Traditional
understandings of learning have ignored the body, and focused on cognitive processes
occurring in the heads of individuals. Already what has been said about the acquisition
of motor skills shows this position to be fundamentally flawed. Meaning that is
generated in situated activity becomes inscribed simultaneously in the mind and the
body. What Bourdieu says of honour in Kabyle illustrates the pervasive nature of this
process .

.. . Honour is a permanent disposition, embedded in the agents' very bodies in the form of
mental dispositions, schemes of perception and thought, extremely general in their application,
such as those which divide up the world in accordance with the oppositions between the male
and the female, east and west future and past, top and bottom, right and left, etc .. and also. at
a deeper level, in the form of bodily postures and stances, ways of standing, sitting, looking,
speaking, or walking (Bourdieu 1977: 15).
This is not a new idea. In an article originally written in 1936 (1972), Mauss gives
numerous examples of how social forces are reflected in the body. After noticing how
French women were beginning to walk like American women, he sets himself the task
of understanding the social basis of how the body is used. One of the many examples

62
he gives of this is the social origin of gendered behaviour as reflected in the different
ways in which women and men throw stones. As he perceives it, the female throw is
generally weak and in a horizontal plane; this contrasts with the male throw, which is
strong and in a vertical plane. Young, writing on the same issue from a feminist angle,
points out that this has nothing to do with innate female characteristics, but 'the
particular situation of women as conditioned by their sexist oppression in
contemporary society' (Young 1990:153). Timidity as a mental and bodily trait is
something that a girl learns.

There is a specific positive style of feminine body comportment and movement, which is
learned as the girl comes to understand that she is a girl. The young girl acquires many subtle
habits of feminine body comportment - walking like a girl, tilting her head like a girl,
standing and sitting like a girl, gesturing like a girl, and so on. The girl learns actively to
hamper her movements. She is told that she must be careful not to get hurt, not to get dirty, not
to tear her clothes, that the things she desires to do are dangerous for her. Thus she develops a
bodily timidity that increases with age (young 1990:154).
Mauss refers to the process whereby society becomes inscribed in bodily forms,
postures and use, as 'techniques of the body'. Interestingly, in this article, Mauss
anticipates many of the foregoing arguments by stressing that education must consider
all of the three elements of 'total man': the sociological, the physiological and the
psychological, which we are told are 'indissolubly mixed together' (Mauss 1972:74).
Mauss presents the body as, 'man's first and most natural instrument' (Mauss
1972:75). This view of the body highlights one of the important components of how
students are inducted into a body of practice; through the learning process, students
learn the specific 'techniques of the body' that they need to be competent
practitioners. In the medical school these techniques include: learning to feel the
pulse; learning to observe the patient's tongue, complexion, urine, and eyes; learning
to diagnose pathological conditions through feeling the patient's body; learning how
to carry out various forms of external treatment; learning how to compound
medicines, learning to identify medicinal qualities of substances through taste; and so

on.
Having acknowledged that meanmgs generated in social interaction become
inscribed in the body, we should not make the objectivist error of considering these
inscriptions to be of an entirely social origin. Embodiment is a dual process involving
both the psychological reactions of the individual and determinants \vithin the social

63
environment. Embodiment, where the emphasis is on the point where society meets
the individual can be called social inscriptions; embodiment where the main effective
focus is the point where the individual meets society can be called psychological
inscriptions. Psychological inscriptions are forms of embodiment that arise from an
individual's psychological temperament. Inner states such as anger, timidity,
senousness, apathy, dejection, can all be reflected in bodily comportment, as can
deeper pathological psychological conflicts (Freud 1987; Laing 1971; Sacks 1985).

2.7 Knowledge as a Mode of Being: 'Knowing How'

So far we have seen that the learning process involves four modes of knowledge.
This is summarised in Table 2.1.

Mode of Form of knowledge Learning Activity

knowledge

Propositional Discursive
Acquisition
Knowledge Explicit

Tacit
Non-discursive
Emotional Acquisition
Knowledge
Intuitive

The Knowing Subject Developing Innate

Innate Knowledge
The Authorial Self Potentials

Know ledge as a Reflexive, taken for granted

Appropriation
Mode of Being practical knowledge of the master

Table 2.1 Four Modes of Knowledge in the Learning Process

I have discussed the first three of these modes of knowledge. Now I will elaborate on
what I mean by knowledge as a mode of being. It goes without saying that the ability
to carry out with expertise common everyday social activities, or more specialised
roles such as a surgeon, tennis player, aeroplane pilot, lawyer, plumber, needs to be
learnt. Dreyfus and Dreyfus (1986) through studying the process of skill acquisition
amongst aeroplane pilots, chess players, car drivers, and adult learners of a second
language, identify a process, which involves five stages of development from novice
to expert. At the outset knowledge is primarily propositional and de-contextual. As

64
the novice acquires more experience, knowledge becomes increasingly non-discursive
and situational. At the stage of full mastery, practice 'flows'; it is 'intuitive' and
reflexive, and on the whole done without conscious deliberation (1986:30).
Knowledge at this level is embodied second nature knowledge. It is no longer a
proposition or representation, but a way of being in the world. What was acquired has
been appropriated into the modus operandi of social practice through the crucible of
experience. In the following discussion of the learning process in the medical school in
Dhorpatan, I will use the Dreyfus and Dreyfus model to help identify the various
stages that the students have arrived at on the journey from novice to expert. In each
of the clinical interactions, which I have discussed in chapter six, I have assessed the
students level of ability according to this five-fold scale.
The five stages Dreyfus and Dreyfus identify are: nOVIce, advanced beginner,
competence, proficiency, and expert. At the stage of novice, the student acquires
context free objective facts and rules of behaviour. The advanced beginner, alongside
acquiring more context-free elements, begins to situate knowledge by engaging in
practice. Competence is achieved as more and more context-free elements are situated
in practice; at this stage there is still a need to work through situations rationally, by
devising plans and analysing possible modes of action. The two higher stages in the
learning process are quite similar. Whereas the earlier stages involve the following of
rules, and conscious deliberations over various possible options, proficiency and
expertise involve behaviour that is fluid and intuitive. 'Intuition' here is not to be
understood in its usual cognitive sense:
Intuition or know-how, as we understand it, is neither wild guessing nor supernatural
inspiration, but the sort of ability we all use all the time as we go about our everyday tasks
(Dreyfus & Dreyfus 1986:29).
What distinguishes the stage of proficiency from that of the expert is that the
proficient performer has lapses from the intuitive level to moments of uncertainty and
conscIOUS deliberation. The expert on the other hand generally does not make
conscIOUS deliberations over performances. The expertise of a great actress, a
ballerina, a violin virtuoso, or the expertise of everyday activities such as walking,
talking and social etiquette, is not the product of conscious analytical thought.
Benner, who used the Dreyfus model of skill acquisition in her study of clinical

65
nursing, found that expert nurses often spoke of their perception, using terms like 'gut
feeling', a 'sense of uneasiness' or a 'feeling that things are not quite right'
(1984 :xviii). This is not to say that the expert never deliberates over issues, but when
it does occur it is more an adjunct to intuition than a form of analytic problem solving.
The fivefold learning process illustrated by the Dreyfus model demonstrates that
intelligence should not be confined to deductive reasoning. Experts act not by
constant recourse to a set of rules or by calculative assessment, but because they have
an intuitive feel for their area of expertise. As this feel is neither rational nor irrational
Dreyfus and Dreyfus refer to it as 'arational'. Of the three higher levels on the
learning scale they say, 'Competent performance is rational; proficiency is transitional;
experts act arationally' (1986:36).
I have already made frequent references to two types of knowledge: discursive or
propositional knowledge, and tacit or non-discursive knowledge. Knowledge as a
mode of being occurs when these two forms of knowledge, through an act of
appropriation, become a part of a person's sphere of practical expertise; this is what I
have referred to as 'knowledge as a mode of being' . Dreyfus and Dreyfus refer to this
mode of knowledge as 'knowing how.' Everyone has the know how to perform
certain activities such as constructing sentences, walking or dining in a socially
acceptable manner, but being able to articulate this know how is another matter.
Knowledge that can be articulated in propositional form they refer to as 'knowing
that'. For Dreyfus and Dreyfus the learning process involves the transformation of the
discursive knowledge of 'knowing that', into the non-discursive 'knowing how' of
expertise.
Gilbert Ryle (1949) also makes the same distinction between 'knowing how' and
'knowing that'. He rejects the long established view that the prime activity of the
mind is cognition through intellectual processes. For Ryle, the view that intelligent
behaviour is the result solely of intellectual mental processes is mistaken; this would
be to confuse the practical knowledge of 'knowing how' with the discursive form of
'knowing that'. In his view, if we want to understand how people become experts, we
should shift the emphasis from what people say about learning and practice to how
people perform these activities. For Ryle, human activity can be coherent and

66
intelligent without being the result of intellectual activity or some conscious aim to
follow rules. Ryle's opinion on the relationship between rules and social behaviour
accords with the Dreyfus Model of Learning; rules are useful for the beginner, but the
expert performs without conscious recourse to guidelines.
The practical knowledge of 'knowing how' should not be confused with habit.
Expertise is not the automatic unreflective repetition of tasks that have been carried
out many times before. The expert performer is fully focused and aware of what is
happening, alert to variations, and ready to respond; responses are not made out of
habit; as circumstances arise the expert is able to innovate. Another important quality
of expertise is the ability to be able to make judgements. Dreyfus and Dreyfus view
judgement as a quality of the higher levels of expertise. According to their fivefold
scale, at the stage of competence, judgements are made through conscious
deliberation; at the higher levels of proficiency and expertise, judgements are made
from experience, without rational calculation.
Some of the students were capable of making judgements in this way. As I discuss
in chapter six, occasionally patients came to the clinic when Amchi Gege was not
there, in which case it was left to one of his students to make a diagnosis and choose
the appropriate medicine. Nyima, the senior medical student, who was very close to
being a fully trained medical practitioner, was often able to make informed judgments
on medical matters, without the help of Amchi Gege.
Ryle's example of the activity of an intelligent reasoner, gives a good portrayal of
the mood that is present in skillful performance.
The rules that he observes have become his way of thinking, when he is taking care: they are
not external rubrics with which he has to square his thoughts. In a word, he conducts his
operation efficiently, and to operate efficiently is not to perform two operations. It is to perform
one operation in a certain manner or with a certain style or procedeure, and the description of
this modus operandi has to be in terms of such semi-dispositional. semi-episodic epithets as
'alert', 'careful', 'critical', 'ingenious' 'logical', etc., (1949:48).

The position that expertise involves innovation and inventiveness, lends further
weight to the argument against the view that traditions where knowledge is located in
specific sacred texts, such as Tibetan Medicine, Ayurvedic medicine, or Islamic
education, are static and inflexible.
I have said that the skill of knowing how to do something well, what I have
referred to as knowledge as a mode of being, should not be considered the product of

67
deductive reasoning. Nor is it the outcome of the mind directing bodily activity like
some Cartesian invisible rider on a horse. Knowledge as a mode of being overcomes
what has been variously called 'Descartes' myth' (Ryle 1949) or 'Descartes' Error'
(Damasio 1994), which presents the mind and the body as two different orders of
existence. For Ryle the Cartesian duality is based on a category mistake: the
difference is not quantitative but qualitative, it is one of degree, not kind. Mind should
not be opposed to matter, it does not exist outside of space and time; the location of
mind is in what people do.

2.8 Knowledge as a Mode of Being: Dispositions and Explanatory

Models.

R yle highlights the difference between habitual behaviour and intelligent behaviour
by relating both to different forms of dispositional concepts. As he explains, 'to
possess a dispositional property is not to be in a particular state, or to undergo a
particular change; it is to be bound or liable to be in a particular state, or undergo a
particular change' (1949:43). Dispositions can be simple and unilinear, like to be
'brittle' is to be disposed to break; or they can be complex, disposing towards any
number of possible outcomes. 'Knowing how' is a complex dispositional state,
producing results that are 'indefinitely heterogeneous' (1949:44); habit is a simple
unilinear state. Geertz also adopts this dispositional view of the nature of mind. For
him, "'mind" is a term denoting a class of skills, propensities, capacities, tendencies,
habits ... and as such, it is neither an action nor a thing, but an organised system of
dispositions, which finds its manifestation in some actions and things' (1993: 58).
All that has just been said on the dispositional nature of 'knowing how', resonates
very much with Bourdieu's notion of habitus. The habitus, we are told, is made up of
dispositions that are, 'embedded in the agents very bodies in the form of mental
dispositions, schemes of perception and thought' (Bourdieu 1977: 15). These
dispositions are 'cultivated' and 'inscribed'; their existence derives from 'objective
structures'. How people conceive and behave is due to dispositions providing
'cognitive and motivating structures' (1977:83). In the sense that Bourdieu uses it,
the word 'disposition' has a broad range of meanings: it is a result of 'an organising

68
action', it approximates to 'structure', it is also 'a way of being', a 'predisposition',
'tendency' or 'propensity' (1977:214).
One of the criticisms that has been made of the habitus, is the lack of a causal
mechanism; it is not clear how the habitus generates practices (Elster 1983). Jenkins
makes this point when he says, 'we still do not know what the habitus is or how it
works to generate practices' (1992:93). In order to fully assess this claim we need to
look more closely at the nature of dispositions. From the array of meanings Bourdieu
attributes to the word, it can be seen that they have two distinct aspects: as 'cognitive
and motivating structures' they have both representional and operational valencies. In
this sense they are similar to what Geertz calls 'culture patterns' which are 'systems
or complexes of symbols' (1993 :93). Like dispositions 'culture patterns' have both
operational and representational aspects, they can function as models of 'reality' or
models for 'reality'. In other words, 'dispositions' or 'culture patterns' generate social
practice in that they are simultaneously models of and for social behaviour. Jenkins
(1981) himself provides the same causal mechanism in a paper where he attempts to
develop a model of 'cognitive practice'. But I would contend that this is already
present in the habitus as the principle that generates practice.
There is a strong relationship between much of what I have said about medical
practice as knowledge as a mode of being, and Kleinman's theoretical framework of
explanatory models. Kleinman (1980) along with Good (1977, 1994) are the two key
figures of what is referred to as the 'meaning centred' approach in medical
anthropology. This approach focuses on the ways the medical world is constituted
through meanings and interpretive practices. According to this perspective illness and
disease are not considered to be natural entities but cultural constructions anchored in
specific social realities. Kleinman adopts an 'ethnomedical approach' which 'studies
medicine as an inherently semantic subject, inseparable from the conceptualisations of
it held by patients, communities and practitioners (Kleinman 1980:84). For Kleinman
disease and illness are not entities but explanatory models.
I will say more about the nature and various sources of medical explanatory models
later. What is of interest here is how the medical reality is constructed through the
employment of practitioner explanatory models. For Kleinman explanatory models

69
provide the theoretical framework for understanding 'the cognitive and
communicative features of health care' (Kleinman 1980:83). Explanatory models are
the dispositions, which provide the 'cognitive and motivating structures' of the
habitus of medical practice. As dispositions they are not confined to representation of
illness; they are both models of and for 'reality' (Kleinman 1980:26). ). Like the
habitus, explanatory models are part conscious and part tacit. Drawing on Polanyi and
Prosch's (1975) ideas about tacit knowledge, Kleinman says, 'as part of our cognitive
orientations, beliefs about illness and care are deeply embedded in our tacit systems of
"personal knowledge", to which we are strongly committed (1980:99).
In the process of medical practice explanatory models address five main questions:
etiology; time and mode of onset of symptoms; pathophysiology; course of sickness;
and treatment. As we shall see, the students in Dhorpatan encounter all of these
elements in the medical school and during medical practice. Medical knowledge and
behaviour develops out of explanatory models and the explanatory model sets up the
conditions for its own reproduction or revision (Young 1980). In other words there
is dialectical relationship, or feedback loop between the explanatory model and given
instances of medical practice. The same dialectical relationship pertains to the habitus,
but the usual outcome of the feedback loop is the same social reality reproducing
itself. As Bourdieu puts it, 'the virtuoso finds in the opus operatum new triggers and
new supports for the modus operandi from which they arise, so that his discourse
continuously feeds of itself like a train bringing along its own rails' (1977:79).
According to Kleinman the same is true of explanatory models in medical practice;
popular explanatory models used by non-specialists are flexible enough to be adapted
to experience, practitioner explanatory models can be tenaciously maintained even
when contrary evidence is present (1980: 110).

2.9 Knowledge as a Mode of Being: The Past in the Present

Memory plays a fundamental role in the learning process in the school. As we will
see in the next chapter the students have to memorise all of the main medical text.
Ideally this should not be a form of rote learning. In Amchi Gege's opinion,
memorising the text relates directly to expertise in medical practice. Before I move on

70
to discuss the role of memorisation in the school, in what follows I will consider the
relationship between memory and learning.
In Matter and Memory Bergson makes the claim that, 'the whole of our past
psychical life conditions our present state' (1911: 191). Much of what I have said
about the various levels of the learning process involve different types of memory;
some that can be recalled and articulated and some that remain at a non-discursive
tacit level. It is evident from what has been said in the previous section that memory
has a central role in the workings of the habitus and explanatory models. In this
section I would like to take a closer look at the ways in which memory relates to the
learning process and social practice. If what Bergson says is true, then the question to
be answered is: in precisely what way does the past condition the present? Bourdieu
goes deeper than the individual life, for him the habitus is 'history turned into nature'
(1977:78). He cites Durkheim on the same theme, ' ... in each of us in varying
proportions is part of yesterday's man' (Durkheim 1938: 16 cited in 1977: 78). He
could have quoted Marx with equal poetic effect, 'the legacy of the dead generations
weighs like an alp upon the brains of the living (Marx 1926:23). Though the poetry
might be equal, the sentiment is not. For Durkheim, social memory carried on through
the generations is the collective representations, which contain the norms and values
that are necessary for social cohesion and stability. For Marx the legacy of the dead
generations is the legacy of the class struggle. My concern here is not with the role of
power in determining what is to be remembered (Asad 1993 :35, Bloch 1989), but the
role of memory in determining social life.
The first point to make is that memory is not univocal; several authors have
pointed to the wide array of phenomena that is conveyed by the word. Casey (1987:
49-64) identifies fifteen distinct forms of memory, which include: 'remembering how',
'remember that', 'place memory', 'commemoration' and 'body memory'. Tulving
(1983 :6) also stresses the wide range of meanings embraced by memory, from past
experiences having a direct bearing on ones present state, such as language learning,
acquiring preferences, skills and habits, to subjective experiences derived from
recollections of past events. A recent edited volume on forms of memory in Buddhism
bears equal testimony to the spectrum of meanings both in Buddhism and Western

71
 thought (Gyatso 1992). In her introduction, Gyatso follows Kapstein in the same
volume and adopts the adjective 'mnemic'! to represent phenomena falling within this
wide semantic range.

Although the word 'memory' is popularly thought of as the recollection of past

events, of equal importance are the various types of memory that are non-recollective.
This relates to the distinction I made earlier between tacit, non-discursive knowledge,
and propositional knowledge. In the process of learning and acquiring skills, whether
they are the skills needed in everyday life, or the specialised skills of a specific type of
practice, all forms of memory work together. The question that needs to be
understood is exactly how memory sustains practice. In order to shed some light on
this I will present some of the typologies of recollective and non-recollective forms of
memory that have been identified by several influential authors, and discuss how these
types of memory relate to social practice. The only one of the four modes of
knowledge in my model of learning that does not have a mnemic counterpart in the
following discussion on memory is innate knowledge; but I have already accounted
for this in mnemic terms by identifying it with what Chomsky calls 'genetic
. ,
amamneSlS.
I shall begin with Bergson's (1911) typology of memory as it is of direct relevance
to an understanding of the way recollective and non-recollective forms of memory
work in social practice. For him the past survives in two distinct forms: independent
recollections and motor mechanisms. He gives the example of a person who is
learning a poem by heart. The person memorises the poem by repeating it many times
until it is fixed in the memory until it can be recited with ease. At the same time as
being able to recite the poem from memory, the person also has recollections of each
occasion when they tried to memorise the poem. Bergson gives this example to
demonstrate the existence of two distinct forms of memory. When the person
remembers learning the poem, what appears in the mind is a representation of a past
event. Memory here is like a store that collects all our past experiences in the form of
'memory images' (1911:92). The type of memory that is used to recite the poem is of
quite a different order; for Bergson it has all the characteristics of habit. Although

I First coined by Semon (1921).

72
learnt in the past, it is not represented as a past event, it is lived in the present. This
form of memory is present in all our habitual patterns of behaviour, such as walking.
bodily composure, riding a bicycle or writing. Bergson refers to these two forms of
memory as 'representative memory', which he considers to be 'true memory' as it
'truly moves in the past' (1911: 195), and 'habit memory', which is present orientated.
Though Bergson does not consider habit memory to be 'true memory', there is a
remarkable similarity with what he has to say about how it functions and what
Bourdieu tells us about the habitus:
... the one, fixed in the organism, is nothing else but the complete set of intelligently
constructed mechanisms which ensure the appropriate reply to various possible demands. This
memory enables us to adapt ourselves to the present situation: through it the actions to which
we are subject prolong themselves into reactions that are sometimes accomplished, sometimes
merely nascent, but always more or less appropriate. Habit rather than memory, it acts our past
experience but does not call up its image (Bergson 1911: 195).

For Bergson the two forms of memory exist side by side and give each other
mutual support. This relates to what I said earlier about the interrelationship of
different forms of knowledge in the learning process. Another connection with what I
have said earlier about the learning process is the parallel between Bergson's two
types of memories and Ryle's distinction between 'knowing that' and 'knowing how'.
Ryle (1949:40) presents a very good illustration of how these two types of knowledge
are related, which resonates strongly with what Bergson has to say on memory. Ryle
gives the example of a boy learning to play chess. The boy begins by learning the rules
and strategies that are necessary to play the game. In the initial period the boy will
play by mentally referring to this body of rules. As expertise develops the rules
become second nature and it is no longer necessary to make conscious recourse to
them. Indeed, as the rules become more and more internalised, the boy may lose the
capacity to formulate them discursively. Bergson's comments on the example he gives
of a person memorising a poem, strike the same chord. He says that if the person
could not remember the various attempts that were made to memorise the poem, he
or she might believe it to be innate. This is so because once acquired, habit memory
exists independently of the lessons that were used to achieve it.
There IS considerable overlap between what different authors have said on
memory. In Figure 2.1, I have attempted to bring together a number of different
classifications in one schematic diagram. The basic structure of the diagram deri\"es

73
from Tulving's classifications, which appear in bold type. What Bergson refers to as
representative memory has an exact counterpart in what James identified as secondary
memory. Secondary memory is the experience of a past event or state that has been
stored in memory and has returned to consciousness; this is to be distinguished from
primary memory which is the retention of an impression of an event that is retained
for a short period of time before it gradually leaves consciousness (James 1890, see
also Husserl 1962). A classification that has been widely adopted by psychologists is
the distinction between long-term memory, which is the reservoir of all our past
experiences, and short-term or working memory that is essential to how we use
memory in everyday activities (Atkinson and Shiffrin 1968, 1971).
From an anthropological point of view, the obvious issue that needs to be attended
to is the relationship between memory and culture. For Bloch (1996: 361), what
anthropologists have referred to as culture can be equated with the shared knowledge
that is stored in the long-term memories of people belonging to a given society. I
would argue that culture should not be equated entirely with propositional memory;
culture is not only something that is thought and said: it is also something that is done.
Take football for instance, a game played all over the world, but one could argue that
each country has its own style. Another example would be the way Indian women sit
on motorbikes in India, and the way that women do it in Britain. Theories of
representation abound, but as Bourdieu quite rightly observes, what is required is a
theory of practice.
There seems to be a general consensus amongst writers on the validity of the two
types of memory identified by Bergson, though more recent authors have refined the
classification. Tulving (1983) renders them as 'propositional memory' and 'procedural
memory'; for Connerton (1989) the same distinction is referred to as 'cognitive
memory' and 'performative memory'. Tulving's category of propositional memory
derives its name from his contention that all knowledge contained here can be
represented in a propositional form. Propositional memory can be sub-divided into
what Tulving calls episodic memory and semantic memory. Episodic memory we are
told is 'concerned with unique, concrete, personal experiences dated in the
rememberer's past (1983 :v); semantic memory is 'a person's abstract, timeless

74
 knowledge of the world that is shared with others' (1983 :v)... 'it is about rules,
formulas, and algorithms for the manipulation of symbols, concepts, and relations'
(1983: 21). Episodic memory relates to a specific time in the past; semantic memory,
such as our knowledge of maths, grammar and logic, is not contextualised in time in
such a way.

Memory

Propostional Procedural
Memory Memory
I I
Knowledge Skills
I I
(Bergson - Representative Memory) (Bergson - Habit Memory)

I
(Connerton - Performative
Memory)
Episodic Semantic I -
Memory Memory (Casey - Habitual Body
(James - Secondary (Connerton - Cognitive Memory)
Memory) Memory)
(Connerton - personal
Memory)

James (Primary Memory)

Fig 2.1 Diagram of Classifications of Memory

Tulving (1983: 3 5) lists a wide range of differences between semantic and episodic
memory. Information in episodic memory comprises of units of events or episodes,
which are organised temporally and are personal; information in semantic memory is
divided up into units of facts, ideas or concepts, which are organised conceptually and
are universal.
The other broad type of memory that Tulving identifies is procedural or
operational memory. This is acquired in a way that differs markedly from semantic
and episodic memory; whereas they may be acquired quickly, procedural memory

75
often requires a lengthy period of training. Like Bergson's habit memory, procedural
memory is the type of memory, which is present in our habits and skills. Other authors
also speak about this type of memory. Casey (1987) calls it 'habitual body memory',
which he says is 'pre-reflective and presupposed in human experience' (1987:149).
For Casey, habitual body memory is constantly at work sustaining human activity:
As presupposed, habitual body memories serve as our jamiliaris in dealing \\ith our
surroundings - as a constant guide and companion of which we are typically only subliminally
aware. They are always in operation in our ongoing lives (1987:149).

Connerton, as we have seen, refers to this same form of memory as 'performative

memory' (1989), which he says relates to our ability to reproduce performances.
A number of points I have raised in this discussion of memory are in conflict with
what I have said earlier about the nature of non-discursive knowledge and expert
performance. For Tulving, what semantic and episodic memory have in common is
that they can both be rendered into discursive form, in contrast to procedural memory
which can not, it can only be demonstrated by performing the action it relates to. Yet
what I have said earlier about the boy acquiring expertise in chess shows that what
starts off as propositional knowledge, as explicit rules and guidelines, can become the
tacit knowledge of expertise. For this reason the generic label 'propositional' is
something of a misnomer. Another problem is the association of the word 'habit' with
the type of memory that is involved in performance. It may well be that this form of
memory finds expression in habitual behaviour, but as Ryle is at pains to point out,
expertise and habit are two different types of activity. It is self evident that anybody
who needs a medical examination would prefer the doctor to do the examination
skilfully rather than habitually. To overcome this elision of human creativity, perhaps
the best term that has been coined so far is Connerton's 'performative memory';
certainly it is far more appropriate than 'habit memory', and for this reason I have
adopted this phrase to denote the type of memory which relates to expertise.
On a final note I would like to say something about one particular mechanism that
has been suggested to account for how memory is able to affect what we feel and
experience, and how we behave. This mechanism must be sufficiently flexible to
explain the type of phenomena spoken about in the above quotations of Bergson on
the functioning of habit memory and Casey on the functioning of habitual body

76
memory. It must also be able to accommodate for the way that different forms of
memory work together to produce the modus operandi of social practice. What
Bourdieu says about the relationship of the habitus to social practice clearly illustrates
the question that needs to be addressed. On one side we have memory (my term, not
Bourdieu's) as the 'socially constituted system of cognitive and motivating structures'
(1977:76), which are 'embedded in the agents' very bodies' (1977:15); and on the
other side we have 'the socially structured situation' (1977: 76). In between these
there is the habitus, which Bourdieu tells us, 'accomplishes practically the relating of
these two systems' (1977:78). The question which naturally arises from this is, how
the habitus, whatever it might be, accomplishes this.
Psychologists have developed a number of theories that give some idea of the type
of mechanism that may be involved. One such mechanism that has been influential in
cognitive anthropology is schema theory. Although the term was used by Kant
(1781), its first modern usage is usually ascribed to the Cambridge psychologist
Bartlett (1932). Bartlett's book Remembering documents a series of experiments he
carried out using Cambridge undergraduate students as subjects. The experiments
involved giving the subjects a story (usually a North American Indian folk tale), or a
drawing, and then observing the transformations that occurred as the subject
attempted to remember the information on different occasions at increasing time
intervals. Bartlett found that the subjects' pre-existing cultural knowledge influenced
what they remembered. The mechanism of schemas that he proposes is an attempt to
account for such experimental results. 'Schema', he says, 'refers to an active
organisation of past reactions, or of past experiences, which must always be supposed
to be operating in any well-adapted response' (1932:201). Because schemas are in a
state of flux, he finds the word 'schema' to be too rigid. He suggests the phrase
'organised setting' as more appropriate, which is interestingly reminiscent of what
Bourdieu says about 'dispositions'; though, after sounding his reservations about the
appropriateness of the term, he finds it good enough for his purposes. For Bartlett,
schemas are not static; being adapted to experience they are continuously being
revised as an outcome of it. The capacity for change and adaptation is fundamental to
the psychological process. As Bartlett expresses it, '(a)n organism has someho\v to

77
acquire the capacity to tum round upon its own "schemata", and to construct them
afresh' (1932:206)
D' Andrade (1995: 122), in a recent overvIew of the growth of schema theory
points to the increasing interest from the mid 1970s in linguistics, anthropology,
psychology and artificial intelligence in the role of structures in human cognition.
After some initial uncertainty about the term, eventually the consensus veered towards
'schema'. D' Andrade cites Schneider's (1968) influential work on American kinship
as an example of the application of schema theory in an anthropological context.
Schneider's aim is to understand the cultural patterns that lie behind American notions
of kinship. These patterns include ideas about 'blood', 'marriage', 'love', 'the family',
and so on. Although Schneider uses the word 'symbol' rather than 'schema', the
cultural patterns he identifies perform the same function.
Since the 1970s there has been an increasing tendency towards understanding
memory and cognition in terms of computer metaphors. This is clear in the
explanation of schema theory given by Cohen (1993 :26). Incoming 'data' from the
external world (Bourdieu's 'socially structured situation'), is referred to as 'bottom-
up processing'. When we receive this 'data', information already stored in the
memory (Bourdieu's 'cognitive and motivating structures') comes into play, and
through it the 'current input' acquires meaning~ this is referred to as 'top-down
processing'. Thus schemas are the 'top-down' information that give meaning to
experIences. Cohen explains that although for a long time Bartlett's ideas about
schemas were criticised for being too vague, they now have wide currency amongst
psychologists. Recent versions of schema theory have incorporated Bartlett's notion
that schemas are not fixed but are amenable to change according to the nature of what
is experienced.
To return to the question of how the habitus 'accomplishes practically the relating
of these two systems'. From the foregoing discussion it is clear what these tv-,o
systems are in psychological terms, but it remains obscure exactly how the habitus, in
itself, can accomplish anything. If we are to understand the habitus as Bourdieu

defines it:

78
 The structures constitutive of a particular type of environment ... produce habitus, systems of
durable, transposable dispositions, structured structures predisposed to function as structuring
structures ... {Bourdieu 1977:72).
This rendition of the habitus involves only 'top-down processing', and sits very
comfortably with what has just been said about schemas. What accomplishes the
relationship between the 'two systems' is not the habitus but subjective agency, so
again we arrive back at the authorial self, the knowing subject. Just as I said earlier,
that learning as a process involving negotiation can only occur if there is a negotiator,
so too must there be a subject who remembers.
By way of summary, my general argument has been that the learning process
involves four modes of knowledge: propositional knowledge, non-discursive
knowledge, innate knowledge, and knowledge as a mode of being. I have related
these modes of knowledge to different forms of memory. Following the Dreyfus and
Dreyfus model, in the early stages of the learning trajectory the emphasis is on
acquiring propositional knowledge, which takes the form of context free objective
facts and rules that govern behaviour. Expertise develops as this knowledge is
increasingly situated in practical contexts, and propositional memory is transformed
into the performative memory of expertise. In the following chapters I will discuss the
nature of Tibetan medical knowledge, the forms of learning in the medical school, and
I will apply the model of learning, which I have presented in this chapter to interpret
of how the students learn medicine.

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 Chapter 3 The Role of Memory in the Medical School

Memorisation has played a key role in the education of doctors in many different
medical traditions; this is true not only of medical systems such as Tibetan medicine,
Ayurvedic medicine, Yunani medicine and Chinese medicine, but it is also true of
biomedical education. Unlike the traditional form of education in Asian medical
systems, the student of biomedicine does not have to memorise whole medical texts;
but in the same manner as the student of Asian medical systems, they must memorise
vast lists of diseases, symptoms and medicines, many of which they will never
encounter in clinical practice. In this chapter I will assess why memorisation is so
highly valued, and discuss the role that memory has in the learning process in the
medical school in Dhorpatan.
As a major part of their study the students are expected to memorise all the
principal text. There is hardly a day goes by when the sounds of the students
repeating passages cannot be heard. It is a hypnotic repetitive sound. They repeat the
phrases in a rhythmical manner, causing the tone to rise slightly before dropping it on
the last syllable. The aim is that the combined effect of the rhythm, repetition, and
melody, will forge the phrase indelibly into the student's memory.
In what follows I will assess why memorisation is so highly valued in the school
and present Amchi Gege's and the students own feelings about it. I will begin by
presenting the method of memorisation in the school, and then I will compare this
with the techniques used in Tibetan monastic education, Islamic education in Yemen
and Morocco, Brahmanical education in South India, and medieval and Renaissance
Europe. Through considering the role of memory in these various settings, I conclude
that far from being a passive form of rote-learning, memorisation plays a
fundamental role in the development ofperformative memory.

3.1 The Method of Memorisation in the Medical School

There appears to be no doubt in Amchi Gege's mind about the importance of

memorising the principal medical text. As he told me, this is the way he was taught
in Tibet and this is the way he is teaching his students. From conversations I had \\'ith
the students, they seemed certain that he knows at least all of the Gyushi by heart. On
several occasions during the lessons, I witnessed him recite from memor\, the

80
relevant section of the text when students were unable to answer his questions. When
I was just beginning to familiarise myself with the procedures in the school, I asked
him whether the students had to memorise all of the main medical text, to which he
replied with unwavering conviction, 'yes, this is not like Western medicine'.
In principle, every day the students should have one hour of teaching in the
morning and one hour in the afternoon. During the lessons Amchi Gege would
explain sections of the text, drawing on his own experience and the explanations
found in various commentaries. Meanwhile the students would follow what he was
saying with their medical text open at the relevant location in front of them. As most
of the students don't have the habit of taking notes (an issue I will return to in
chapter five), if they are to understand at all, they must immediately consign to
memory Amchi Gege's explanations.
As can be seen from the daily timetable, there are certain times of the day that
are specifically allocated for memorising: early in the morning, between lessons, and
after the evening meal. At these times the students either sit around the Gompa
compound, or in Amchi Gege' s room, or in their own rooms, and set about the task
of repeating over and over again the part of the text they are memorising. The fact
that the recital must be done aloud, allows Amchi Gege to keep a check on whether
any student is shirking their duties. One evening I was in my room helping a student
with his English, when a torchlight flashed outside my window. When we looked to
see who was there, the light vanished only to reappear again a few minutes later. We
became anxious as we thought that perhaps a thief was trying to break into the
building, as had happened on two separate occasions the year before. In the end it
turned out to be Amchi Gege, angrily searching for the student who should have been
memorising in his room.
A memorising session can last up to two hours. Whether there is a group of
students memorising together or a student sat alone, the sound is always the same
hypnotic rhythmical pattern of repeating nine-syllable phrases, with the first and last
syllables stressed. As all the students are at different stages in memorising the text,
they never repeat the same phrase together, nor do they ever appear to be
synchronised in their rhythms. Nevertheless, a group of students memorising
together can produce quite a melodious sound. The fact that the recitation is done

81
aloud allows Amchi Gege to survey which students are engaged in memorising and
who is not~ but this is only strictly true when he and the students are within the
Gompa compound at the same time. When he is away on an errand, the students tend
to take the opportunity for a moment's respite. Between six and seven in the evening,
when their duties at the medical school have been completed, the three female
students and two of the male students return to their homes. In principle, they are
supposed to continue memorising in the evening, but in practice Amchi Gege has
very little control over what they actually do.
For the three monk students and the eldest student, Nyima, who stay in the
Gompa compound, it is another matter; the same rigorous discipline that Amchi
Gege executes during the day in the school is carried over into the night. The
students, if they have not been assigned another task, must memorise, and Amchi
Gege can hear whether they are memorising or are not.
The order in which the texts have to be memorised follows the order in which the
texts are studied in the course syllabus. Unlike in other schools where students have
to memorise only important sections of the Gyushi, in Dhorpatan the students have to
memorise all of the main text. Some of the students are memorising the Bumshi, the
others the Gyushi; as the texts are virtually identical it makes little difference. In
place of the third volume of the Bumshi, some of the students have to memorise the
Men Jor Dong Tsa, Khyungtrel Rinpoche's commentary on it. The text of the Gyushi
and the Bumshi is structured in verse according to the classical style of units of nine
syllables lines (tshig kang). Each day the students are supposed to memorise fifteen
such lines from the text; this would be equivalent to about seven lines on this page.
The normal procedure is to copy the fifteen lines they have to memorise into an
exercise book and they repeat them over and over again, until the section is fixed in
their memory. Once they have accomplished this, the next fifteen lines are copied
and memorised. There is no specific technique used for memorising the text other
than perseverance and repetition. The nine-syllable verse form of the text, and the
abundant use of lists, which I will say more about later, serve the purpose of
facilitating memorisation. Material that has been previously memorised must be
occasionally gone over to prevent it lapsing from memory.

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 The standard routine in the school is that at the end of the week the students are
examined by Amchi Gege on how much they have memorised. By means of this
exam he is able to keep a check on how well the students are progressing. For most
of the time whilst I was there, due to the large amount of work that had to be done on
building the new medical school and clinic, this routine was virtually non-existent.
Memorising exams did occur, but in a very intermittent fashion. I received
contradictory information from the students about whether they could still remember
what they had memorised a long time before. One student told me that he never
forgot what he had previously remembered, another student told me that due to the
amount of time he had spent doing other things, such as helping with the building
work on the new medical school, he had forgotten large sections of what he had
previously memorised.
One of the key issues that kept arising during my time at the school was the
distinction between memory and knowledge. The students themselves kept
complaining that they spent too much time memorising and not enough time
receiving explanations. Due to the disparity in the amount of years the students had
been at the school, they were all at different stages in their memorisation of the text.
The students who had been at the school for eight years had memorised almost all of
the text, the others were part way through either the third or the fourth volume. With
the exception of Nyima and Phuntsok, the stage the students had arrived at in their
memorisation was beyond the stage that they had arrived at in Amchi Gege's
explanations. The last time I was there in August 1998, in their lessons the students
had arrived at the seventy-second chapter of the third volume of the medical text, the
section dealing with children's diseases (chi pi mi so wa).
The students could not have understood very much of what they had memorised
before Amchi Gege's explanation. The medical text is replete in details but does not
in itself provide a complete exposition of Tibetan medical knowledge; like all Tantric
texts, it requires commentary. The constraint of the nine-syllable verse form means
that passages are elided and detailed explanations are either absent or rendered in a
terse manner. The text contains many details about disease symptoms, forms of
diagnoses and medicines, but does not give all the information that is required to
practise medicine. For example, in the section dealing with medicines, the text

83
contains the names of each medicinal ingredient, but not how much should be used,
or which part of the plant is used, or how ingredients should be prepared and
compounded. The structure of the text may well serve the purpose of memorisation,
but it certainly does not facilitate ease of understanding. What should be borne in
mind here is that the students are not memorising a detailed self-explanatory
exposition of the medical system, but a framework which allows them to bring to
mind any of the multifarious topics dealt with in the text, and associated expositions
they have received on it. In a certain manner, what they are memorising is an
elaborate mnemonic device.

3.2 The Method of Memorisation in Other Contemporary Settings

Now we have seen the way that memorising is done in the school, to enable a
deeper understanding of the processes that are involved I will present the methods of
memorisation as they are found in three other contemporary educational contexts:
Tibetan monastic education, Islamic education and Brahmanical education in South
India.
Both the Gelugpa tradition of Tibetan Buddhism and the Bonpo tradition have
schools of dialectics (tshen nyi) where the monks follow a long structured course of
teaching leading to the title of Geshe. As the course progresses, the students come to
an understanding of the teachings through logical argument in debate. The Gelugpa
programme takes place in the three main Gelugpa monasteries, Ganden, Sera and
Drepung, which have been re-established in South India. The course follows the five
classes of Buddhist teaching: logic (tshe rna), the Prajnaparamita texts (phar chin),
Madhyamika philosophy (u-rna) and Abhidharma (ngon par dzo) (Tucci 1980). The
study involves three components: memorisation of the basic texts, teachings on the
texts by a teacher of their choice (Strom 1997), and debate. It usually takes thirteen
years to complete the programme, but can take up to twenty-five, after which the
student may have to wait several years before the final exam.
Most of the information I shall present here will document the education as I
observed it in the Bonpo dialectic school at Triten Norbutse monastery in
Kathmandu. This is the monastery where Amchi Gege and his monk students come
to stay during the winter months when the medical school is closed. During the

84
Bonpo dialectic programme, which is run at the monastery in Kathmandu and at
Menri monastery at Dolanji in Himachel Pradesh, the students study three groups of
texts: the sutras, the Tantras and meditation texts (do ngag sem sum). The
programme thus differs from the curriculum in the Gelugpa tradition, which covers
only the sutras (do). As with the Gelugpa schools, the method of study involves three
components: the memorising of the basic text for each subject, explanations using
commentaries on these texts, and dialectical debate. The course of study can be
completed in eight years (Cech 1986), but in practice it can take a good deal more.
Again like the Gelugpa tradition, on completing the full programme and passing the
final exam, the student is awarded the title of Geshe.
From this discussion it can be seen that education In the medical school is
consonant with the wider cultural pattern of Tibetan education, where a premium is
placed on the memorisation of texts before they are explained. In the dialectic school,
the monks have to memorise a great quantity of texts, far more than what the
students have to memorise in the medical school. This involves an intense effort on
the students' behalf I asked the junior head teacher (ponlob 1) Tenpa Yungdrung at
Triten Norbutse monastery whether the monks use any special techniques to help
them memorise the texts. He told me that some monks prefer to recite the text aloud
and other monks prefer to do it in silence. He said that a popular device to aid the
memory is to remember certain marks near a word or somewhere on the page. He
explained that above all, the students must be fully concentrated. None of the
students in the medical school mentioned anything to me about remembering
sections of the text by recalling marks on the pages, but it seems in both the monastic
setting and the medical school, the main method is the same; the constant repetition
of the text over and over again.
Another example of a form of education that stresses the importance of
memorisation is found in the work of Fuller (1984, 1993, 1996, 1997) on the
education of Brahman Saivite temple priests in South India. The function of the
priests is to conduct the rituals in the Minaksi temple in Madurai, Tamil Nadu,
according to the prescriptions believed to have been given by Siva, found in the
agama texts. Recently the priests have been subject to the reformist campaign of the

I In the Bon religion the title for head teacher can either be pan/ob or /opon.

85
Tamil Nadu government's Hindu Religious and Charitable Endowments Department.
The reformist premise is that the priests would be better able to perfonn the rituals if
they first receive a good education in the texts. The priests themselves are fully in
accordance with this view, and as a consequence there has been a steady increase in
priests educated in the texts.
Most of the priests receive their education in one of three schools. The full
agamic education lasts for six years, though the Minaksi temple runs one-year
refresher courses. Education in the schools follows the gurukula system, which
involves the students (si~a) living in the guru's house and showing total respect and
obedience towards him. This entails the students having to carry out various tasks for
the guru, whether they are directly related to the school or not. Exactly the same type
of relationship exists between Amchi Gege and his students in the medical school,
although it would be wrong to imagine that they are always obedient.
Over the six years the main focus of the programme in the Minaksi temple
schools is the memorisation of the Sanskrit texts. Memorisation of the texts is carried
out by means of a twofold process. The first stage, referred to as cantai, involves the
Guru reciting the section of the text and the students repeating it twice after him.
This is done because the sound of the words is believed to contain a certain power;
hence it is important that the students learn how to pronounce them correctly. The
second stage, referred to as tiruvai, involves a process of the constant repetition of
the text that they received in the cantai. The process of memorising in the
Brahmanical schools has a number of features in common with memorisation in the
medical school in Dhorpatan: the Brahmanical students do not use mnemonic devices
to help them memorise the texts, the technique is constant repetition; and the
Brahmanical students copy the section of the text they are to memorise in a
notebook.
The reformists' vIew is that the education in the schools is a professional
training. Fuller tells us that priests and gurus liken agamic education to the kind of
training that a lawyer or medical doctor needs to undergo. But evidence suggests that
what is actually happening is quite different. The students do receive explanations
about the texts, but we are told that, 'all the gurus insist that memorisation is far
more important than understanding' (Fuller 1997: 13). Though some of the best

86
students are eventually able to explain the mearung of the texts, Fuller tells us,
'education in the religious schools is not primarily about acquiring the kind of
formal, substantive knowledge that doctors or lawyers have to apply to a range of
different cases' (Fuller 1997: 17). The main aim of the schools is that the students
memorise the texts to enable them to recite the relevant passages during the ritual;
the acquisition of 'formal, substantive knowledge' about rituals is superfluous to that
performative role. Fuller's later writings on the education consider it to have been a
success, not in the sense that the temple priests now understand the content of the
agamic texts, but they now know what to say during the ritual, and this sets them
apart from the uneducated priests.
One further relevant comparison is with Quranic schools. Although the two
sources I have used, Eickelman (1978) writing about Quranic schools in Morocco,
and Messick (1993) on Quranic Schools in Yemen, provide historical accounts; the
form of education they describe resonates with the previous examples. Eickelman
tells us that in the Quranic schools in Morocco the teacher (jqih) would begin by
writing verses from the Quran on the students' wooden slates (luh). The students
would then spend the rest of the day memorising the text on their slate and sections
of text that they had previously learnt. On the following day the students had to recite
the text in front of the teacher; if this was done successfully, the teacher would rub
the verse from the slate and write a new one to be memorised. Thus, as in the
medical school in Dhorpatan, progress III memonsIllg the text is achieved
incrementally. The students did not use any mnemoruc devices to help them
memorise the texts, though they did remember sections of the text by recalling the
shape of letters or events that occurred around the time of memorising specific
sections. Eickelman tells us that in the Quranic schools in Morocco, the strong
emphasis on memorising the Quran was accompanied by a, 'lack of explicit
explanation of memorised material' (Eickelman 1978: 493). Messick (1993)
describes exactly the same method of the teacher writing the text on the student's
lesson board and replacing it with another once the student had memorised it, in his
study of Quranic schools in Yemen.

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3.3 Memorisation in Medieval and Renaissance Europe

The method of memorisation in the medical school and the method used in the
other examples I have given share certain characteristic features: in each case the text
that is memorised is considered to be sacred and is written entirely in verse~ the
method of memorisation involves the constant repetition of sections of the text;
furthermore, in a few of the examples there is an apparent emphasis on memorisation
over and above explanation. Taken together these features can be taken to be typical
attributes of pre-modern forms of learning; in the following chapter I refer to this as
the synthetic mode of knowledge. By now turning to the role of memory in medieval
and renaissance Europe, I hope to be able to shed light on my original question of
why memorisation has been so highly valued.
Carruthers (1990) begins her study of memory in medieval culture by contrasting
a contemporary account of Einstein with a similar account of St. Thomas Aquinas.
Although both accounts agree on the high intellectual stature of each person, they
differ in the list of qualities that are deemed worthy of esteem. In the description of
Einstein we hear of his 'tremendous imagination', 'originality', and his 'intuition
which leads to unexplored regions' (Infeld 1980 cited in Carruthers 1990:2). The
account of St. Thomas Aquinas takes a different approach: we are told that '(h)is
memory was extremely rich and retentive: whatever he had once read and grasped he
never forgot~ it was as if knowledge were ever increasing in his soul as page added to
page in the writing of a book'. Later in the passage the author eulogises his great
powers of dictation, 'he seemed simply to let his memory pour out its treasures ... '
(Gui cited in Carruthers 1990:3).
At the first glance it seems that what we have here is a dichotomy between the
modernist view of knowledge, which values originality and creativity, and a pre-
modern view which values rote learning and the faithful reproduction of traditional
knowledge. Eickelman tells us that the French historian Levi Provenyal (1922: 11 )
made the following assessment of traditional Islamic education: 'he claimed that it
deadened the student's sense of inquiry to the point that the knowledge and
comportment of twentieth century men of learning could be assumed '\vithout fear of
anachronism" to be exact replicas of their predecessors of four centuries earlier'
(Eickelman 1978:490). In Carruthers's view, an examination of the value ascribed to

88
memory, and the role it played in medieval culture, allows us an understanding of
how scholars of the time viewed the nature of 'creative activity'. In her account she
shows that the strong emphasis on memory is not at all incompatible with creativity
and originality. Eickelman raises the same issue in his response to Proven~al' s
comment, by pointing to the 'considerable flexibility' of traditional religious
knowledge (1978:490).
We have presently three tasks at hand: first, to assess how memory was
understood in medieval culture; second, to compare that understanding with the role
of memory in the various educational contexts I have given; and finally, to compare
the medieval understanding with the prevalent view of memory in contemporary
Western culture. In Carruthers' view, 'medieval culture was fundamentally
memorial, to the same profound degree that modem culture in the West is
documentary' (Carruthers 1990:8). Implicit in the distinction that Carruthers makes
here is that medieval culture relied on memory because of the rarity of texts. In fact
this does not appear to have been the case. Written material became increasingly
available from the eleventh century, but this does not seem in any way to have
dislodged the culture of memory, which prevailed up to and beyond the period of the
renaIssance. During the renaissance the arts of memory reached their highest
expressIOn. Carruthers suggests the culture of memory prevailed, despite the
increasing presence of documentary technology, because of the identification of
memory with morality and virtue (Carruthers 1990: 156). By embodying the text
through memorisation, an individual embodies the values contained within it.
We can conclude from this that the medieval understanding of memory is not
confined to the modem passive recollective usage of the word, which restricts its
meaning to the exact reproduction of past experience. To the medieval frame of
mind, memory, far from being a passive system of rote repetition or iteration is, as
we shall shortly see, an active system of techniques used for retrieving and
manipulating what has been previously set aside. This distinction is important, as it
was precisely this partial view of memory as a passive mechanism, which stores and
reproduces past events, which obfuscated Provenc;al' s view of the subtleties present
in Islamic education. As Carruthers puts it,
This is not at all what pre-modern writers meant by "memory'. The distinction is clear in
Albertus Magnus's commentary on Aristotle's De memoria et reminiscentia. Albcrtus says that

89
 iteration, or rote repetition, of knowledge is not at all the task of memorial recollection or
'memoria'. He defines reminiscence or recollection as the 'tracking down' (investigatio) of
what has been 'set aside' (obli/i) through and by means of the memory; this process differs in
nature from 'rote repetition' (iterata scientia) (1990:20).
'Memory' in the medieval sense has an active role and a character which IS

essentially compositional and hermeneutical, for this reason I will call it

'compositional memory' to distinguish it from passive recollective forms. I don't
mean to say that in pre-modern western civilisation rote memory and iteration did not
exist amongst scholars; it most certainly did, but this was not considered to be 'true
memory' (Carruthers 1990:20).
Perhaps the easiest way to demonstrate the nature of medieval compositional
memory is to consider some accounts of its activity that were made in the medieval
period. One relevant account is Carruthers' discussion of St Augustine's reflections
on a school friend who had memorised all of Virgil and most of Cicero. The point of
interest for St Augustine is not the fact that his school friend had memorised so
much, or that he could manipulate what he had memorised, but the great extent to
which he could do it (Carruthers 1990: 18). An ability to memorise large amounts of
text was not something in itself particularly worthy of note, rather it was the
command that a person had of memorised material that was accorded high respect.
Contemporary accounts of St Thomas Aquinas suggest that he composed his
works mentally and then dictated them from memory. This certainly appears to have
been true of his Summa Theologica, and of the compilation of patristic texts on the
gospels, the Catena Aurea (Carruthers 1990:5). We are told by Bernardo Gui that the
Catena Aurea was composed from diverse texts he had committed to memory while
staying in various religious houses. Gui also refers to a number of firsthand
testimonies, which describe St Thomas Aquinas dictating from memory to three or
four secretaries 'on different subjects at the same time' (Gui cited in Carruthers
1990:3). This description demonstrates the active compositional role that memory
played in medieval culture. A similar process of composition must have occurred in
the construction of the early Vedic texts and amongst the early Buddhists who appear
to have composed the Buddha's teachings mentally in a textual form in a manner
suitable for oral transmission (Gombrich 1987:24).

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3.4 The Technologies of Memory

Thomas Aquinas did not carry out such great feats of memory unaided. He was
well versed in the classical arts of memory (mnemotechnics) as his discussion of
them in the Summa Theologica shows (Yates 1966:73). Traditionally the origin of
these arts is ascribed to the Greek poet Simonides (477 BC). The first written account
of how Simonides invented the art of memory appears in the Roman politician
Cicero's De Oratore. As a politician, Cicero is interested in memory as one of the
five branches of rhetoric. For him the arts of memory are the techniques that enable
an orator to make long accurate speeches. The full story is given by Yates (1966: 1)
and Rose (1993 :63) but the main point is that in the story, Simonides is able to
remember all the guests who were present at a banquet by bringing to mind their
location at the table. It follows from this that the technique involves the orderly
arrangement of what is to be remembered in a sequence, which is easy to recall. The
classical technique is to place images of what is to be remembered in various
locations of a familiar structure. The device most often used was an architectural
structure. This technique was used throughout the middle ages and is found in the
famous 'memory theatres' in the renaissance period (Yates 1966). Even in recent
times the technique has been used to great effect. Perhaps the best example of this is
Luria's (1968) Mind of a Mnemonist.
The students in the medical school do not consciously make use of such
mnemotechnics. The only technique that they use is the constant repetition of the
text. The same is true for the way memorising is conducted in the other examples I
have given. This is not to say that mnemonic devices are absent from Tibetan culture.
As we saw, one technique that is used by the monks is to recall marks on pages of the
text: in medieval Europe this is one of the main reasons for the careful layout of

illuminated manuscripts.
Though the students do not consciously make use of mnemotechnics, the text is
itself a kind of elaborate mnemonic device. Two main mnemonic devices have been
inbuilt into the fabric of the text to facilitate ease of memorisation. The first is the
abundant use of lists. Various authors have pointed to the widespread occurrence of
lists used as a mnemonic device in the oral traditions of Brahmanism, Buddhism and
Jainism (Gethin 1992, Collins 1982, Gombrich 1987). The use of lists begins

91
immediately with the first volume of the medical text, which presents a summary of
the medical knowledge using the metaphor of a tree with three roots, nine stems,
forty-seven branches, two-hundred-and-twenty-four leaves, two flowers and three
fruits. The tree metaphor is itself a mnemonic device, which contains all the
fundamental knowledge of Tibetan medicine. Three of the seventy-nine pictures
(thangkha) that the regent of the fifth Dalai Lama, Sangye Gyamtso had made to
illustrate his famous Blue Beryl commentary, give precise pictorial representations of
the various elements of the tree metaphor (see plates 14, 15 and 16). Reproductions
of these pictures are still used in Tibetan medical schools, the school in Dhorpatan
being no exception.
Although the tree metaphor is meant only to summarise the basic principles of
the medical teaching, the metaphor of the tree is also well suited to the way that
information is organised in the text. Time and time again we are given lists within
lists, like the divisions of branches on a tree. Take for example the explanation given
in the first chapter of the fourth volume on medicinal decoctions. First we are told
that there are two broad types of decoctions: decoctions for hot illness and decoctions
for cold illnesses. The text proceeds further to subdivide decoctions for hot diseases
into a fourfold classifications according to: location of fever, types of fever, scattered
fevers, and single ingredient decoctions. It then lists the seventeen decoctions for the
first type, seven for the second, nine for the third and fifteen for the fourth. Needless
to say the same kind of scheme is then given for the decoctions for cold sicknesses.
The text abounds in such forms of presentation.
The second main mnemonic device that is made use of in the text is the use of
verse. The Gyushi comprises of 156 chapters, which all in all contain 5900 verses. As
I have said, the standard meter of the verse is the tshig kang, the nine-syllable line.
Ayurvedic texts, though still in verse, differ somewhat in form from the Tibetan
medical text. The texts Zimmerman (1978: 101) worked with in South India are
composed in the karika style of four octosyllabic quarters. As with lists, verse is a
standard technique used in oral traditions to facilitate memory. Brahmanical,
Buddhist and Jain literature has been composed in verse form with this purpose in
mind. The same is true of Islamic tradition; Eickelman (1978 :489) points to the

92
rhymed verse form in which Islamic treatises were purposefully composed with the
aim of facilitating memory.
The idea of the text as a mnemonic device rather than a repository of knowledge
seems to be very much the view that was taken in all of the examples of oral
traditions that I have given. A closer look at Thomas Aquinas's text the Catena
A urea (' golden chain') is insightful in this respect. Carruthers (1990: 5) tells us that
the Catena ('chain') was a genre widely used by monks, which involves the linking
together of various religious authorities around certain biblical phrases. There is an
exact parallel to the medieval Catena genre in the Tibetan tradition in the ten rim
(' stages of the doctrine') and the lam rim (' stages of the path') textual genres, which
layout the stages of the path of a Bodhisattva (Jackson 1996). One of the best known
works in this class is Gampopa's Jewel Ornament of Liberation (Guenther 1971). As
Guenther points out in his preface, the work is full of quotations from inside Tibetan
collections of Buddhist sutras and sastras and from outside, all given by Gampopa
directly from memory. Another example is Tsong kha pa's celebrated Lam rim chen
mo.
Finally we should not overlook the act of writing itself as a technique of
memory. We have seen how in Dhorpatan, the Quranic schools, and the Brahmanical
schools in South India, the sections of the texts to be memorised were first written
down. Writing here serves as an aid to memory, not a substitute for it~ the same
reasoning applies to written texts. In the medieval period, memory itself was likened
to a book. Earlier we heard about Thomas Aquinas's knowledge, which was 'ever
increasing in his soul like as page added to page in the writing of a book' (Gui cited
in Carruthers 1990:3). By first writing out a section of the text, and then constantly
repeating it, the idea is that the text will be indelibly imprinted in the memory of the
student.

3.5 From Memorisation to Periormative Memory

During my time at the school I often questioned the students about their
knowledge of the medical system, such as how they understood the various disease
classes, or anatomy. On several occasions the students responded to my questions by
saying that they had memorised the relevant section but it had not yet been explained

93
to them. It would be easy to conclude from this that the large amount of time and
effort that the students put into memorising the text amounts to little more than rote
learning. I mentioned this to Tempa Yungdrung, the junior Lopon at Triten Norbutse
Bon Monastery in Katmandhu. He said that memorisation and understanding should
go together, but often within the Tibetan tradition they do not. He added that in Tibet
it was common for monks who could barely write to memorise large texts with little
understanding of what they were memorising. Although it is less common today, the
situation still persists, and this is so not only in Tibet but also amongst Tibetan
refugees.
Time and time again whilst he was explaining to me about understanding the
contents of Bonpo texts, Tempa Yungdrung stressed the need of 'single minded
concentration'. He used the English phrase, but the idea is congruent with the
Buddhist and Bonpo notion of 'mindfulness' referred to in Tibetan as dran-pa
(Sanskrit smrti)2. He said that when reciting a text in a ritual, whether it is a mantra
or a prayer, it is single-minded concentration that is needed. He said that monks who
recite prayers and mantras without this presence of mind are likened to parrots.
Contrary to what has been said about the importance of the sound of words in the
Brahmanical tradition (Fuller 1997 Parry 1985), it seems in the Tibetan tradition that
what takes precedence over this is the 'mindfulness' of the practitioner.
At the medical school, Amchi Gege takes great pains to inculcate in the students
this presence of mind. If he notices that students are not fully concentrated in their
lessons or when they are engaged in other medical activities, they will be
admonished. The students know that they must respond to what he says or risk a
beating. Every day before the evening meal, the monk students would sit with Amchi
Gege in his room and recite prayers for about an hour. Even though it was the end of
the day and everyone would normally be tired, the monk students still had to recite
the prayers with a strong presence of mind. One of the students told me that a couple
of years previously he had been so tired during the prayers that he had begun to fall
asleep. This did not happen for very long as he was abruptly returned to wakefulness
by Amchi Gege striking him on the head with a stick.

2For a discussion of the relationship between this word and cognate forms, with ditTerent types of
memory in Indian and Tibetan Buddhism, see Gyatso (1992).

94
 A similar form of discipline has been documented in Quranic schools. Messick
tells us that teachers in Quranic schools in Yemen were given a 'legally recognised
capacity for discretionary discipline' (1993 :77). This usually involved a thrashing
with a rod or a 'pole-and-strap bastinado device' used to beat the soles of the
student's feet. The aim of this discipline was to instil into the students the quality of
adab, which we are told is, 'a complex of valued intellectual dispositions and
appropriate behaviours' (1993: 77).
Though initially memorisation is a process of rote learning, the aim is that in
time this knowledge will be appropriated into the students' sphere of competency.
Amchi Gege would not expect his students to be able to understand what they had
memorised until it has been explained to them. But if they can't answer his
questions, either during the lessons or during clinical practice, on subjects that have
been explained to them, then he has cause for concern. What I said earlier about the
role of memorising in medieval culture is equally applicable in the medical college.
In memorising the text the students are inscribing its content not on a page but in the
fabric of their mind. The aim is that gradually, through exegesis and practice, what
they have memorised will be appropriated and made an inalienable part of their
sphere of competency. The text is not viewed as something that should be picked up
off a shelf and consulted; it is something that the student must become. In a sense the
student becomes a practitioner of Tibetan medicine by gradually embodying the
medical text. In the Tibetan medical tradition this process is not only about acquiring
the knowledge that is contained in the text, it is also about embodying the vision and
capacities of the Medicine Buddha who is considered to be the source of its contents.
On several occasions I questioned Amchi Gege about the origin of different
facets of the medical system. His answer was always the same; all the teachings
came from the enlightened vision (ngon) of the Buddha Tonpa Shenrab. By
memorIsmg the text, along with acqUlrIng the knowledge necessary to practise
medicine, they are setting up the conditions for acquiring the same vision within
themselves.
For some time now I have been talking about the role of memory in Tibetan,
Indian, Islamic, and Medieval culture. My main point has been that to understand the
role of memory in these cultures, it is necessary to move away from the narrow view

95
of memory as the reproduction of past events. As we have seen in the previous
discussion of memory in medieval culture, what was valued was the active role
memory was seen to play in the generation of meaning. Memory was valued amongst
the educated class, because in its active compositional and hermeneutic modes it was
seen to be fundamental to scholarly creativity.
Although the general experience in western culture has been one of a progressive
devaluation of human memory, as I have previously indicated, there has been an
increasing interest amongst scholars in the manifold ways in which memory works.
The passive reproduction of previous experience, what Tulving (1983) calls 'episodic
memory', is only one of numerous forms of memory (see Figure 2.1). Memory is not
simply a passive vessel of accumulated information; through the processes of
memory, acquired knowledge is actively present in the generation of meaning in
social action. Skilled performance in any sphere of activity involves the dynamic
synthesis of propositional and procedural forms of memory. It is this synthesis,
which underpins skilled performance and is at the basis of what I have called
knowledge as a mode of being. For this reason I have chosen to call this active mode
of syncretic memory, 'performative memory'. Connerton (1989) uses the phrase to
apply specifically to procedural forms of memory, but my argument is that expert
performance often involves both procedural and propositional forms of memory.

3.6 Performative Memory in Clinical Practice

If the students are to become competent medical practitioners they must acquire
some theoretical and practical mastery over the material that they have memorised.
The same is true of education in Tibetan monasteries; it may be commonplace for
Tibetan monks to memorise texts without any understanding of their meaning, but
the ideal is that they should understand. Unlike in the Brahmanical schools described
by Fuller, or the general pattern described by Eickelman, the students in Dhorpatan,
like all medical students must acquire 'formal and substantive knowledge' of
medicine and be able to bring that knowledge to medical practice.
The students are explicitly encouraged to engage with the material in the text in
an active way. After each lesson they were given fifteen minutes to 'debate' in pairs
what they had been taught. As we have seen, there is a long-standing tradition of

96
debate in Tibetan culture. Although the session was commonly referred to by the
English word, 'debate', very little actual debating occurred. The session is more
correctly referred to in Tibetan as gotur, 'a disussion'. This is much more befitting as
what usually happened is one of the pair of students would attempt to summarise
what had been said in the lesson while the other student would relax in the sun and
listen, perhaps making the occasional comment.
In a conversation I had with Amchi Gege about the role of memorising, he
related it directly to medical practice. He explained that memorising the text is
essential as, during the process of examining a patient and prescribing a course of
treatment, many different elements of medical knowledge must be brought together
at the same time. The idea is that this can only be done if all this knowledge is
already present in the memory of the practitioner. In an unusual moment of
enthusiasm for the method of memorisation, one student confided in me his
conviction of its worth. He said that it is especially important for volume three of the
Bumshi, which gives abundant details concerning the various classes of disease. The
practitioner of Tibetan medicine must have all this knowledge to hand when
examining a patient, if a correct diagnosis and therapeutic assessment is to be made.
The ordered structure of the medical text with its reams of lists within lists,
serves as a mnemonic device for medical practice; once memorised, it acts like a
semantic web of layers of associated meanings. For this reason it would not be too
much of an exaggeration to liken it to a textual 'memory palace' or 'theatre of
memory' (Yates 1966). This interpretation of the generation of meaning through
processes of associative memory was very much a part of techniques of memory in
medieval culture. The idea is that if what is memorised is imprinted strongly in the
mind, according to a clear pattern, no mistake can be made in remembering. If this is
done, as Quintillian observes, 'however large the number of [things] we learn all are
linked to one another like dancers hand in hand' (cited in Carruthers 1990:62). A
further metaphor that is used is fishing, whereby associative material is 'hooked' like
fish caught on a line. Carruthers suggests a further piece of evidence, which links the
idea of texts with memory. The word texta, which literally means 'something
woven' , seems to be highly suggestive of medieval conceptions of memory
(Carruthers 1990:62). The same Latin root is also present in the word 'textile'.

97
 How this works in the medical school is that through memorising the text, the
students set the elements of medical knowledge in their mind according to an ordered
framework. Gradually through exegesis in the classroom and through engaging in
clinical practice what they have memorised will be understood and appropriated into
their sphere of competency. Once they have achieved this level of competency, the
idea is that in clinical practice what a patient says, taken in combination with any
observations made in the diagnosis, will set in motion a gathering of associated
elements in the student's mind through which meaning will be generated in the
clinical setting. In a sense, the process of carrying out the diagnosis and deciding on
the appropriate treatment is an act of composition which creates a coherent order
through the selection of associated elements of medical knowledge in the
practitioner's mind which relate to the patient's condition. In the previous chapter I
have described three theoretical mechanisms that have recently been developed to
account for this process: schema theory, the habitus, and explanatory models.
The programme in the medical school is not incremental in the sense that the
students start at the beginning of the medical text and gradually learn the material in
the order that it is set down. One logical way to structure the course would be for the
students to memorise a chapter of the text and then receive the explanation, and
finally when they have gathered enough knowledge in this way they can attempt to
put it to practice. This is not the way that it happens in the medical school. First as
can be seen from the course syllabus (see Table 1.1) the programme does not follow
the sequential order of the text. After studying the condensed version of the medical
system, which is provided in the first volume of the medical text, the students go
directly to the first and second chapters of the fourth volume on pulse and urine
diagnosis; after this they continue with the following three chapters on medicinal
decoctions, powders and pills. Once this foundation has been laid they then move on
to study the descriptions of diseases listed in the third volume.
Memorising follows the sequence in which the subjects are taught, but most of
the students were much further ahead in their memorising than the stage where they
had arrived in their lessons. Furthermore, by acting as Amchi Gege's helpers, the
students are actively involved in clinical practice almost from the beginning of the
course. Having memorised and studied pulse and urine diagnosis at the beginning of

98
the course, all the students could attempt to do it in clinical practice. Usually what
happened was when a patient arrived, first Amchi Gege would do the diagnosis and
then after this he would ask the student who was helping him to try~ occasionally he
would let the student try first.
In order to understand why Amchi Gege and the student who I have just
mentioned, should feel that memorising the text is essential to medical practice, in
what follows I will present one episode of clinical practice in which the students
were involved. This episode demonstrates the way that elements of medical
knowledge, which the students had previously memorised and had explained to them,
are brought together to generate meaning in the clinical setting. In the following
chapters I will give further examples of the way that performative memory is
developed in medical practice.
One morning a Nepalese woman arrived at the clinic. While she was consulting
Amchi Gege about her sickness, two of his male students were present. She
explained that she had been feeling generally unwell and had been suffering from
bouts of fever. She complained specifically of pain in her knees, a pulsating pain in
her back, and a general feeling of 'laziness'. She added that doing work exacerbated
her condition. I was told that she had come to the clinic with exactly the same
problem the year before, and at that time her condition had been diagnosed as 'old
fever' (nying tshe). First Amchi Gege asked her a few questions and asked both of
the students to take her pulse. From this they concluded that she was suffering from a
condition known as 'hiding fever' (gab tshe). Following this, Amchi Gege took her
pulse and corrected their diagnosis to 'old fever' (nying tshe), the same condition that
had been diagnosed the previous year. She was given the medicinal powder Saffron
twenty-five (gapur nyernga), which was measured out into individually packaged
single dosages by one of the students.
This example clearly shows the way in which performative memory is developed
as all the different elements of the learning process in the school are brought together
in clinical practice. As I have said, pulse diagnosis is one of the first subjects that the
students memorise and are taught by Amchi Gege. I will discuss the theory
underlying pulse diagnosis and how the students learn about it in chapter five.
Suffice it to say here, the students have to learn a large amount of different types of

99
pulse. The chapter on pulse diagnosis gives the qualities of the pulse for forty-six
types of disorder, but the list doesn't stop there: characteristically, many of these
classes are further subdivided into subclasses. For example the class of 'fever pulses'
contains pulses for six different types of fever; the class of 'cold pulses' contains
pulses for six different types of disease that are of a cold nature. On top of this there
are separate sections dealing with types of 'death pulse', pulse indicating the action
of malevolent spirits, and the 'life force pulse'.
From my own experience of trying to take the pulse, as a beginner it is difficult
enough to find even the twelve basic pulses. As for discerning the subtle qualities of
the pulse, this must come after some considerable experience. By the time I arrived
at the medical school, all of the students had acquired some practical competency in
pulse taking, indeed a few of them seemed to be exceptionally good at it. But a high
level of competency in pulse taking is in itself insufficient. As the qualities of the
pulse for some diseases are very similar, or even in some cases the same, it is not
enough for the students to learn just the pulse, they must have a thorough working
knowledge of the specific symptoms of each type of disease.
In the above example both the students found the pulse to be a little fast, slightly
twisting, and not very prominent. From this they concluded that the patient was
suffering from a condition known as 'hiding fever' (gab tshe). The condition of 'old
fever' (nying tshe), which is characterised by a very similar kind of pulse was finally
decided on by Amchi Gege, partly due to his greater abilities in discerning the
qualities of the pulse, but also because of the way he related the pulse to the patient's
symptoms.
The main source of information about symptoms is the third volume of the
medical text. This consists of ninety-two chapters, which give extensive information
about the various classes of disease. Information for each class of disease is given
according to a fivefold scheme: primary cause (gyu), contributory factors (kyen),
types (rig), symptoms (ne tag), and treatment (cho thab). Expertise in pulse diagnosis
requires that the practitioner has a knowledge of the techniques of pulse diagnosis
along with a comprehensive understanding of the symptoms of different types of
disease. Once the diagnosis has been made an appropriate treatment must be decided
upon, and this knowledge, as well as being found under the relevant disease

100
classification in the third volume, is dealt with at some length in other locations in
the medical text.
We can now see why Amchi Gege considers memorising the text to be essential
to medical practice. For him, so much knowledge must be brought together at one
moment. Memorising the text is a necessary stage on the way to clinical competency.
The type of memory that is at work in expertise in clinical practice is what I have
referred to as performative memory; at this level, knowledge that was first
memorised and learnt is not merely recalled it is enacted. Through performative
memory in clinical practice, meaning is generated by a process of the linking
together of associated elements within the mind of the practitioner. To use the old
metaphor, in clinical practice through associative memory, various elements of
relevant medical knowledge arise 'like dancers hand in hand'.

In the previous discussion we have seen that the high value that is placed on
memorisation in the medical school in Dhorpatan, as in the various other contexts
that I have described, relates to the student developing the skills that are necessary to
competent performance. Memorisation, though initially taking the form of rote
learning, through explanation and increasing practical experience is gradually
appropriated into the students' sphere of practical competency. We have seen that
there are many similarities between the role of memory in Western medieval and
Tibetan culture, but there is one big difference: the students in the school are not
learning how to compose texts, they are learning how to practice medicine. From the
vast store of knowledge that they memorise and learn, certain elements will remain
passive and others will become part of the performative memory of clinical practice.
Many of the diseases they learn about in the text they will perhaps never encounter in
clinical practice, and consequently this knowledge will never become performative.
Though the nature of medical knowledge in Tibetan medicine and biomedicine is
different, both medical systems place great emphasis on memorisation as a
fundamental precursor to clinical practice. If the learning process is successful,
memorisation is not a passive form of rote learning; the student must develop the
'single minded concentration' or 'mindfulness' that is necessary to bring together

101
relevant medical knowledge in clinical practice. This is as true for the biomedical
student as it is for the Tibetan medical student.

102
 Chapter 4 Synthetic and Analytic Modes of Knowledge and
Learning

Lave has stressed the importance of fully contextualising patterns of learning. As

she puts it, '[I]t is impossible to analyse education - in schooling, craft
apprenticeship, or other form - without considering its relations with the world it
prepares people' (Lave 1988:xiii). And again on the same theme, 'any given attempt
to analyse a form of learning through legitimate peripheral participation must involve
an analysis of the political and social organisation of that form, its historical
development, and the effects of both of these on sustained possibilities for learning'
(1991: 64) . We have seen that the learning process in the medical school III

Dhorpatan has certain characteristic features: the sacred indisputable nature of

medical knowledge; the importance of memorisation; and the emphasis on lineage,
that is to say the teacher pupil relationship as a medium by which the knowledge and
skill of past masters is perpetuated. This view of the nature of knowledge, and related
notions about how it should be transmitted, is widely present in Tibetan culture. We
have also seen that these features are not unique to traditional Tibetan education, but
have broad currency in pre-modem forms of knowledge transmission, such as in
Islamic education, Brahmanical education, and in medieval and renaissance Europe.
In what follows I will consider more closely the relationship between modes of
knowledge and learning and the contexts in which they are found.
The following discussion is founded on two premises: the first is that there exists
a direct relationship between forms of knowledge and methods of transmission, and
any study of a particular cultural form of education must take both into
consideration; the second is that a full appreciation of modes of knowledge and
related forms of learning can only be made by considering the social, political and
cultural setting. I will begin by assessing the form of knowledge and the method of
learning in the medical school in Dhorpatan in the light of the anthropological debate
on modes of thought. In this chapter I will focus mainly on the nature of modes of
knowledge, in the following chapters I will relate these modes of knowledge to
notions about the body and disease.

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--------
4.1 Modes of Thought: a Series of Dichotomies

Like all medical systems, Tibetan medicine has its own notions of pathogenesis.
diagnosis and therapy which accord to a specific cosmological scheme. This
cosmological scheme defines not only what is considered to be valid knowledge, but
also the proper method by which it should be transmitted. This method of
transmission flows logically from the Tibetan mode of knowledge, which is based on
Buddhist, and in the medical school in Dhorpatan, Bonpo cosmological notions. The
knowledge contained in the main Tibetan medical text, whether it be the Gyushi or
the Bumshi, is considered to derive from the enlightened vision (ngon) of the
Medicine Buddha; it is thus sacrosanct and beyond dispute, and by attempting to
understand and achieve practical mastery of this knowledge, the student is aspiring to
acquire the qualities of the Medicine Buddha: the high value that is placed on
memorising and lineage flow logically from this view.
In contrast, students of biomedicine learn a body of knowledge, which is derived,
at least in principle, through scholarly ingenuity, and is amenable to change. Existing
medical knowledge is extolled, but so too is the capacity to improve upon it.
Memorisation, and to a certain extent lineage, are still important, but the approach
taken is explicitly one of progress rather than preserving intact the revealed
knowledge passed down through the medical lineage. In a manner of speaking, the
ideal of Tibetan medical education is for the student to become the master, whereas
the ideal of biomedical education is for the student to surpass the master's
understanding. Depicted in this way, it appears that these two medical systems
involve contrary modes of knowledge and learning. For reasons that will in due
course become clear I will refer to these two idealised approaches as synthetic and
analytic modes.
In my assessment of the method of learning medicine in the medical school in
Dhorpatan, my aim is to identify three kinds of learning processes: processes that are
universal; processes that are common to a variety of similar learning contexts; and
processes that are specific to Tibetan culture and the medical school in Dhorpatan.
Although I concur with Lave when she emphasises 'the diversity of historical forms,
cultural traditions, and modes of production in which apprenticeship is found (in
contrast with research that stresses the uniform effects of schooling regardless of

IO.f
location), (1991: 63), I believe there is a need to consider the diversity of forms and
also unifying features. As evidence for her claim, Lave refers to the work of several
authors whose writings present different forms of apprenticeship in a variety of
settings (Goody 1982, Coy 1989, Cooper 1980, Geer 1972, Jordan 1989, Medick
1976). Her remarks are directed specifically toward apprenticeship, but her
comments are equally applicable to other forms of learning. By showing similarities
between the mode of knowledge and learning in the medical school in Dhorpatan
with that found in other cultural contexts, my aim is to shed light on the learning
process in general.
The debate on modes of knowledge does not present a diversity of cultural forms
but in a broad sweep all forms are conflated into one or other of two modes of
thought. There have been various renditions of the formula all revolving around the
modern/pre-modern, or modern/traditional layout. To mention a few of the most
influential of these dichotomies, there is: logical/pre-logical (Levy-Bruhl 1926),
rational/irrational (Wilson 1970), logico-empirical thinkinglmythopoeic thinking
(Cassirer 1944), open/closed (Popper 1959), wild/domesticated and hot/cold (Levi-
Strauss 1962). Here I will focus on the ideas of two authors in particular: Robin
Horton and Jack Goody. The reason for doing this is that what Goody lists as the
typical attributes of non-literate societies, and what Horton says of cognitive
traditionalism, appears to strongly resonate with what I have said about the mode of
knowledge and the method of learning in the medical school in Dhorpatan.
Horton's position began in an article in 1970 where he lays out what he
considers to be the difference between African traditional thought and Western
science. First he clears the ground by stating that the difference is not that Western
science is rational and African traditional thought is not. His stance is a development
of Evans-Pritchard's notion that the Azande, 'reason excellently in the idiom of their
beliefs, but they cannot reason outside, or against their beliefs because they have no
other idiom' (cited in Horton 1970:154). Horton combines this view with Popper's
(1959) distinction between open and closed societies. The outcome is a view of
traditional societies as closed, in that they lack scepticism and a developed awareness
of alternative views to established doctrine; and a view of societies where modern

105
science is prevalent as open, in that scepticism, and the concomitant awareness of
alternatives is highly developed.

Increased ratio
Increased 10
Increase in cumulative knowled
Personal transmission of knowled ersonal transmission of knowl
ical notion of time Durational notion of time
Knowl is malleable Knowled e has semi form

.:: .

Closed - no awareness of alternatives

Lack of inter-theoretic v'U"uu

clsm
Traditionalistic co of knowled e Pro sivist co
Present knowledge passed on from Present knowledge is an improvement on
ancients the knowled of the ancients
Table 4.1 The Attributes of the Synthetic and Analytic Modes of Knowledge

In response to criticism, in an article published in 1982 Horton reformulated his

position; the closed and open dichotomy was dropped and the theory of alternatives
and scepticism was refined . But much of the original argument was retained . In the
new formulation ' cognitive traditionalism ', which involves an incontestable form of
knowledge, that is passed on from the ancestors through an unbroken lineage of
person-to-person transmission, is opposed to ' cognitive modernism', which is
marked by 'inter-theoretic competition' . It follows from this that cognitive
traditionalism has a 'consensual mode of theorising ', which is done within the
framework of established knowledge, whereas cognitive modernism is marked by a
'competitive mode of theorising ' and a ' progressivist concept of knowledge ' . We are
told that through the activity of inter-theoretic competition, knowledge graduall
progresses through increasingly better formulations .

106
 Goody's argument began in a joint article with Watt in 1963, and went through
various permutations in the ensuing decades (1968, 1977, 1980, 1986, 1987). His aim
is to understand the effects of writing on modes of thought. Like Horton he does not
hold the view that people in traditional, pre-literate societies are irrational. He also
has his own views about the lack of scepticism in pre-literate societies; as he puts it,
they 'are marked not so much by the absence of reflective thinking as by the proper
tools for constructive rumination' (1977:44 cited in Parry 1985:201). In Goody's
opinion the proper tool for constructive rumination is literacy.
In 1962, Levi-Strauss made the distinction between two modes of thought, which
he classified as 'savage' and 'domesticated'. For Goody the problem with this
formulation is that Levi-Strauss makes no attempt to account for the transition from
one to the other, nor for the fact, as he puts it, that 'modem man is emerging every
day in contemporary Africa' (1977: 16). In Goody's opinion, it is the advent of
literacy in society, which brings about the domestication of the savage mind. With
literacy, oral knowledge takes on a 'semi-permanent form' (1977: 37); this leads to an
accumulation of knowledge and an increase in scepticism, rationality and critical
activity. For Goody this inevitably leads to: the breakdown in the need for person to
person transmission; the growth of individualism; a steady increase in bureaucracy;
and a durational as opposed to a cyclical notion of time. All these features, Goody
tells us, are characteristic of modern society. There are a number of similarities
between Goody's framework and that of Horton's. Like Goody, Horton sees oral
transmission as conducive to the persistence of the traditional mode of knowledge.
He also takes a similar view to Goody on literacy as a causative factor that brings
about the transformation from the traditional to the modem mode, but to this he adds
the factors of social and environmental change. Table 4.1 summarises the attributes
Goody and Horton ascribe to the non-literate/literate, and the cognitive
traditionalism/modernism dichotomies, and relates them to what I have called
synthetic and analytic modes of knowledge.
I would now like to broaden the discussion by briefly considering Foucault's
(1970) work on modes of thought which he calls 'epistemes'; this \vill lend further
evidence to the relevance of the 'synthetic' and 'analytic' classification. An episteme
is an overarching world view prevalent in a given historical period which serves as a

107
ground plan for all human actIVIty. In this sense the episteme appears similar to
Kuhn's (1962) concept of 'paradigms', the prevalent guiding models that are
followed by scientific communities.
Although there is some similarity between Foucault's ' epistemes' and Kuhn's
concept of 'paradigms', there are also important differences. For Kuhn, paradigms
are 'exemplars', as he puts it, 'some accepted examples of actual scientific practice -
examples which include law, theory, application, and instrumentation together -
provide models from which spring particular coherent traditions of scientific
research' (Kuhn 1962: 10). A paradigm is 'an accepted model or pattern' (1962:23)
shared by a scientific community, which is used by scientists as the basis of their
work. Though Kuhn acknowledges that paradigms have a tacit component,
particularly at the level of scientific practice (1962: 191), they operate primarily at a
conscious level; that is to say scientists are aware of the paradigm upon which their
work is founded.
Unlike paradigms, Foucault's 'epistemes' are not exemplars; they are active at
an unconscious level, structuring thought and behaviour, and as such are present, not
only in the natural sciences, but in all areas of life. Though Foucault identifies a
number of historical epistemic phases, for him the most decisive change in European
life was marked by the historical watershed of the seventeenth and eighteenth
centuries, which saw the birth of science and the period of the enlightenment. The
attributes he gives for the 'epistemes' on either side of this divide correspond closely
to what I have previously listed for the synthetic and analytic modes.
The synthetic mode corresponds to the attributes that Foucault lists for the
Renaissance episteme. Weare told that the key principle in the Renaissance episteme
is 'resemblance'. Through one of the forms of 'resemblance', cOllvennientia, all
things near to one another were seen to be interconnected into a continuous
hierarchy. Lovejoy (1936:59) tells us that throughout the Middle Ages, up to the
eigteenth century, the structure of the world as it was understood by 'most educated
men' was one of a 'Great Chain of Being', which ranked all living beings into an
infinite hierarchy from the Absolute Being through decreasing increments to the
lowest forms of existence. Each level of existence is considered to be distinct but at
the same time part of an indivisible continuous hierarchical series, separated by 'the

108
least possible degree of difference' (1936:59). Through other fonns of resemblance
such as analogy and sympathy, everything in the world was understood to be built
upon layers and layers of reflections and analogies. According to Renaissance
understanding, the resemblances between things is not of an arbitrary nature. The
doctrine of signatures held that God had marked things with a special signature,
which pointed towards a universal hannony.
In Europe in the seventeenth century, the world of resemblances and affinities
was gradually replaced. According to Foucault, in place of unity there developed the
principal of discrimination, and in place of analogy and resemblance the crowning
principles became, designation, representation and analysis. Foucault was not the
first to characterise the distinction between pre-modern and modern knowledge in
this way. Heidegger (1977) had already identified 'correspondance' as the guiding
principle of premodern knowledge and opposed this to the representational mode of
modern thought (Merquior 1991 :44), and a similar distinction is to be found in Levy-
Bruhl (1926).
Two other important changes also occurred around this time. Whereas the word
'belief had once signified valid knowledge, in the Enlightenment it became
associated with ignorance and superstition. Good (1994), following the ideas of
Smith (1977, 1979) and Needham (1972), has brought into question the use of the
word in the literature of medical anthropology. Following along the lines of
enlightenment reasoning, if the disease categories of Biomedicine are taken to be
universal natural categories existing outwith of culture, medical knowledge that does
not accord with this must be considered in some way invalid. The outcome of this is
the devaluation of culture as belief, where belief is the incorrect representation of the
world. A similar transfonnation also occurred to the relationship between nature and
culture. To the medieval mind, nature and culture were unified in one Great Chain of
Being, in the Enlightenment they were rent apart and opposed to each other.
Throughout the literature of medical anthropology two images of medicine recur
that reflect the divide between the synthetic and analytic modes of thought. This is
epitomised in a publication by Fabrega and Silver (1973) where they contrast the
system of medicine of the Zinacanteco of the Chiapas region of Mexico with
biomedicine, each are presented as holding diametrically opposed medical vie\vs

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 The Zinacanteco view, which relates to the synthetic mode, has many similarities
with other medical systems, including Tibetan, Chinese, Ayurvedic, and Yunani
medicine. It is characterised by a view of the body as an integrated holistic system
that is interrelated with other systems existing within society and the universe. The
emphasis is on the functions of the system as a whole (Porkert 1976). Body and mind
are not thought of as separate. Here Meyer's comments on the conceptions of Asian
medical systems are appropriate when he says that they, 'conceive body and mind as
two interdependent poles of the same somatic and psychic continuum. Furthermore,
this body-mind, the world and society, are interrelated, reflecting one another in a
complex system of polysemy, parallels and metaphors' (Meyer 1995: 14). Disease
arises through dissonance occurring within the interrelationships between these
systems and treatment involves restoring balance and harmony.
This was also the view of Galenic medicine, which was the orthodox form of
medicine in Europe throughout the Middle Ages up until the ascendancy of the
biomedical model in the early nineteenth century. For the Zinacanteco, the healing
process focuses not only on the body, but social relations and supernatural agents,
and the relationship between the afflicted person and the specialist who is trying to
restore health is characterised by informality, closeness and shared meaning (Good
1994:27). Leslie has pointed to the same mode of thought in the great traditions of
Asian medicine. As he puts it '(g)reat tradition medicine conceived human anatomy
and physiology to be intimately bound to other physical systems. The arrangement
and balance of elements in the human body were microcosmic versions of their
arrangement in society at large and throughout the universe' (1976:4).
Porkert's (1976) comments on the approach taken by Chinese medicine are
generally applicable here. In his view the approach taken involves a perception,
which is synthetic and inductive; it focuses on the functioning of the system as whole
as opposed to the biological substratum. He contrasts this with a rational perception
of sub stratums, which is causal and analytic. This approach is typified by
biomedicine where the image of the body is one of a complex biological mechanism
and the concern is with biological substrata.
The scientific revolution that occurred in the sixteenth and seventeenth centuries
and the mechanistic view of the universe that is represented in the writings of

110
Descartes and Newton, had very little impact on medicine in the early period. Up
until the eighteenth century doctors continued to uphold Galenic views about the
nature of health and disease. Gradually as more evidence accrued which contradicted
Galenic physiology, the new science gained ever more ground. Such publications as
the anatomical studies of Vesalius in 1543, and William Harvey's discovery of the
circulation of the blood in 1628, were two of the first stirrings of the new medical
paradigm, which would eventually replace Galenic orthodoxy. As I have mentioned,
scientific methods are based on enlightenment notions of knowledge and language.
Scientific methodology is about acquiring knowledge about natural categories, which
are considered to be universal; such knowledge is acquired objectively, in a value
free manner.
The current biomedical model views disease as a pathological entity deriving
from somatic lesions or dysfunctions in biological systems. The disease entity
produces physical signs that can be clinically assessed, and symptoms, which are the
expressions of suffering individuals. The signs and symptoms must be interpreted as
indicators of the somatic pathological condition. It is acknowledged that symptoms
may be expressed in specific cultural idioms but the disease itself is taken to be an
event existing outside of its social or cultural context; it is a pathological entity in the
nature-based framework of human biology. The image of the body is one of a
complex biological mechanism and the concern is with biological substrata (Pokert
1976). Body and mind are considered as separate. Treatments are mechanical and
impersonal and symptoms are codes which the trained medical gaze can read as
reflections of somatic dysfunctions.
As the mode of knowledge and learning in the Tibetan medical school in
Dhorpatan has many of the attributes of the synthetic mode of knowledge, I will now
take a closer look at these attributes and compare them with similar elements found
in other systems of traditional knowledge.

4.2 The SynthetiC Mode of Knowledge and Learning

There is a strong relationship between Buddhism and medicine. The most

fundamental teaching of the Buddha is couched in terms of a medical metaphor. The
four noble truths begin with suffering as the condition of existence, the second truth

11 1
identifies the cause as desire, the third truth states that it is possible to eradicate the
cause of suffering, and the fourth truth gives the method to do this - the eightfold
path. Zimmer (1948) has shown that this has a direct parallel with the four successive
problems the doctor of Indian medicine looks for when consulting a patient.
At the very foundation of Tibetan medical notions about health and disease lies
the Buddhist concept of the three mental poisons (dug sum), which lead beings to
successive rebirths in the six realms of existence. The three mental poisons of
ignorance (timug) , desire (dochag) , and aggression (zhedang) are the root cause of
the three humours of wind (lung), bile (tripa) , and phlegm (peken) in the human
constitution. I mention all this to emphasise the point that the dividing line between
medicine and religion in the Tibetan medical context is often very tenuous; medical
knowledge and ideas about how it should be transmitted are suffused with Tibetan
Buddhist and Benpo religious notions. The way that Tibetan religious notions
overlap with the domain of medicine will be discussed in detail in chapters seven and
eight. Both the Bon and Tibetan Buddhist religions have the same view about the
nature of knowledge and how it should be transmitted, and the approach taken has
many of the characteristics I have listed for the synthetic mode of knowledge. Before
moving on to assess the validity of Goody and Horton's dichotomies, I will fIrst
consider these attributes as they are found in Buddhism, Brahmanism and Islam.
The Buddhist scriptures fall into two categories: the canon (sutras), which
contains the texts ascribed to the Buddha, and the commentaries (sastras) of various
Buddhist scholars. As I mentioned in chapter one, by the fourteenth century most of
these texts had been translated into Tibetan and were compiled by the Tibetan
scholar Buton into the collection of canonical texts known in Tibetan as Kanjur and
the collection of commentaries known as Tanjur. The Tibetan Kanjur includes
Hinayana and Mahayana sutras and also Tantric texts. The canonical texts contain
the teachings of the Buddha on the nature of existence and the path to liberation; this
knowledge derives from his enlightened awareness, and as such, it is complete and
beyond dispute. It is left to the Buddhist aspirant to strive to a full understanding of
what the Buddha said and by following his methods achieve the same realisation.
However, new knowledge can be appended to this in the form of scholarly
commentaries. The Indian Buddhist commentaries, which form the biggest part of

112
the Tibetan Tanjur collection, were written between the second and the tenth century
AD. The Tibetan medical text itself has been the source of many commentaries of
this nature. All of this is equally applicable to the Bonpo who also have their own
Kanjur and Tanjur collections.
We should also note that many texts that are contained in the Tibetan canon
originated a long time after the Buddha's final paranirvana, though tradition
maintains that he originally first taught them. The new sutras that began to appear
from around the first century Be formed the basis of the Mahayana vehicle of
Buddhism. Buddhists claim that the world was not ready for the Mahayana teachings
at the time of the Buddha, so he entrusted this knowledge to the safe keeping of
nagas1 and other deities, until the time when competent people had the power to
retrieve and teach them. Perhaps the most celebrated scholar to have done this is
Nagarjuna, who brought the largest collection of Mahayana texts, the
prajiiiipiiramitii sutras, from the naga realm. The Tantric texts which developed later
and contain the doctrines that form the basis of third vehicle of Buddhism, the
Vajrayana or 'diamond vehicle' are ascribed to the historical Buddha in the same
manner.
From what we have seen so far it is clear that Tibetan medicine and Buddhism
have many of the attributes listed above under the synthetic mode of knowledge.
This is true of many pre-modem forms of education. Take for instance what
Eickelman tells us of Islamic education in Yemen. We are told that the 'text and
commentary type relation is also part of a much wider pattern, one that goes to the
heart of the general understanding of the growth of the Shari' a' (1978:33). The
original revelation in the Quran was commented on by Muhammad in the Sunna, and
these two works acted as the source for the corpus of further interpretation that
became the Shari' a. Along with the text and commentary form of knowledge,
personal transmission is the standard form in which knowledge is passed on. In a
manner reminiscent of the Tibetan oral transmission (lung) of tantric texts, students
in the quranic schools received licenses to give the oral transmission (riwaya) of
particular texts (Eickelman 1973 :22).

1 Tibetan III (klu). a class of spirits often in the fonn of a serpent.

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 A further example of this two-fold classification of knowledge into a revelatory
form and commentaries has been given by Parry (1985) in his work on Sanskrit
pedagogues and Brahman sacred specialists in Benares. All of his informants make
the distinction between two forms of knowledge: shastrik, which is based on the
revelation of the gods found in the scriptures, and as such is eternally valid and
beyond dispute; and laukik knowledge, which is 'a mere matter of local usage'
(1985: 204). This distinction relates to a much older twofold classification of
knowledge that was present in the original oral tradition, which classified the Vedas
into those that were 'heard' sruti, and those that were 'remembered' smrti.
Parry tells us that though technically the word shastra in the Brahmanical
tradition refers to the 'law books' and compilations written after the Vedic period,
the word shastrik in common usage is applied to practices and beliefs validated by
various texts including Vedas, Puranas and Dharmasastras. As the absolute truth has
already been revealed by the gods and now exists in written form, 'knowledge then is
not something to be discovered, as in the western scientific tradition, but something
to be recovered from texts' (Parry 1985:205).
This is not to imply that shastrik knowledge is unscientific, Parry informs us that
the traditional approach to knowledge in India made no divide between religion and
science; indeed the shastras themselves have been considered as a form of science.
F or this reason in modern Hindi the word shastra acts as suffix equivalent to the
English '-ology', so sociology becomes samaj-shastra. The Tibetan equivalent of
this is the word rig-gnas meaning 'culture' or 'auxiliary science' or occasionally rig-
pa, meaning 'intelligence', or 'science'. The word is a used in this way in the Tibetan
name for Tibetan medicine, sowa rigpa, 'the science of healing' .

4.3 Lineage

We have seen that three of the key features of Buddhist education in Tibetan
monasteries are: an emphasis on oral transmission and memorisation, person-to-
person transmission, and debate. These three features have been, and remain, very
much a part of Buddhist education in general. Though Buddhism is a literate
tradition, the style in which Buddhist texts are written and the manner in which they
are taught display many characteristics of an oral tradition. The main purpose of the

I 1.+
Sangha, the collective monastic order, is to preserve and teach the Buddhist
doctrines. The principal method of monastic education is person-to-person
transmission. Traditionally after the 'Going Forth' (pravrajya) ceremony that marks
entry into the monastic order, the candidate acquires two new relationships: he
becomes the companion (sardhaviharin) of a preceptor (upadhyaya), and the pupil
(antevasin) of a master (acarya) (Lamotte 1984: 55).
In Parry's study on the transmission of Brahmanical knowledge in Benares, he
tells us that 'without the guidance of a guru, book learning is an obstacle to the
acquisition of knowledge' (Parry 1985 :209). The guru also plays an important role in
relating what is said in the texts to how people are supposed to behave. The same
emphasis on the role of the guru was found by Fuller in the Brahmanical schools
where he carried out his research in South India. Here the students follow the
gurukula system of education. This involves the students living with the guru and
receiving his teachings on the Sanskrit text; in return they must carry out work for
him (Fuller 1997). Both Parry and Fuller tell us that the personalised transmission of
the texts, in part relates to Brahmanical notions about the power of the sound of
words, and the importance of knowing how to say the words in the right way. Many
of the texts are believed to contain the words of the gods and they are replete with
mantras, which are considered to be charged with the deity's power. The guru's
crucial role in this respect is not to explain the mantras, but to impart to the students
the knowledge of how to pronounce them correctly in order to achieve their full
magical potency.
The Vajrayana vehicle of Buddhism, which forms a major component of Tibetan
Buddhism, gives even greater stress to the personal relationship between the guru
and the student. The following comments are equally applicable to the Bon religion,
which also has a strong Tantric component. The Tibetan equivalent of the Sanskrit
term 'guru' is 'lama'. In the context of Tantric practice it is the lama who has the
power to pass on to the student the knowledge and realisation embodied in the
lineage of practice. Each Tantra centres on a particular deity (yidam). By assuming
the role of the Tantric deity, the lama is able to carry out the appropriate
empowerments that are necessary to do the practices associated with the particular
Tantra. These empowerments are accompanied by the oral transmission of the text

115
(lung) and by explanations about the practices (tri) (Samuel 1993: 244). Through
receiving the appropriate empowerments and the oral transmission of the text, the
novice is connected to the lineage of the practice. In Tantric practice, the lama is
identified with the Tantric deity, and is therefore looked upon as a fourth object of
refuge.

Both the Bumshi and the Gyushi are classed as Tantric texts, and as such they
can only be learnt by establishing a connection with a qualified teacher. The medical
teacher does not have to be a lama and the students do not need to take a Tantric
empowerment to begin their studies, but there is an awareness that the teachings have
been preserved by a lineage of practitioners stemming back to the Medicine Buddha.
The word 'Tantra' is related to the notion of lineage. The Tibetan word for 'Tantra'
is gyu, which Das (1995) gives as 'a tantrik treatise; a string; a chain; that which joins
things together; a connection whether physical or mental'. In Tibetan medicine the
student attempts to connect with the lineage of the teachings. Every morning and
evening the students in the medical school in Dhorpatan recited together the prayer to
the masters of the medical lineage. Amchi Gege often explained to them about the
history of the Bumshi and the medical lineage.
Tibetan medical knowledge is presented as revelation. On several occaSIOns
Amchi Gege explained to me that it derives from the spiritual insight (ngon) of
Tonpa Shenrab. It is the purpose of the lineage to pass this insight on to future
generations of practitioners. Through connecting with the medical lineage the
medical student aspires to a VISIOn of the completeness of Tibetan medical
knowledge and by so doing the past is merged into the present. This represents a
completely different view of the status of knowledge from the way it is generally
perceived in the West. A student of biomedicine is not learning a finished, static
body of knowledge; the student may hope that in time he or she may improve upon
what they are learning. Thus lineage in the West is concerned with a continuous line
of individuals who have nurtured or contributed to a certain trajectory of thought.
The lineage of practice is essential to the teaching of Tibetan medicine. In the
main text, explanations are often given in a very terse form. Sometimes only a few
words are given to represent a complex idea; this would be very difficult to
understand without the teacher who can give the required commentary. Furthermore,

116
the medical text which is used in the school is written in the u me Tibetan script, and
many words are hidden or contracted in ways that again require the knowledge of a
qualified teacher. Another example of the importance of personal transmission is
pharmaceutical practice. The manufacture of some medicines involves a long
complicated procedure, and if everything is not done correctly, the medicine will be
ineffective, or even harmful. I asked one Bonpo doctor if he could make the type of
Tibetan medicine known as precious pills (rinchen rilbu) , some of which contain
detoxified metals such as mercury. He replied that he had read the relevant texts but
he did not have the oral transmission (gyu rim). One monk who was nearby at the
time explained, 'it is like driving a car, knowing about the brakes and the steering
wheel is not sufficient to be able to drive, somebody proficient in the technique is
needed to demonstrate'. This relates with my point in chapter three on the importance
of tacit knowledge in the learning process. On another occasion, Geshe Tenzin
Dhargye was explaining to me that in the Bonpo tradition there are many old texts,
which contain practices that are no longer done. When I asked him if it would be
possible to re-establish these traditions, he replied that if someone had received the
oral transmission (lung) of the practice, it would be possible, but if not it would be
very difficult.

4.4 Modes of Thought: the Effects of Literacy

One of the main criticisms of Foucault's work on 'epistemes' is that he makes no

attempt to account for the causes which bring about epistemic change. Following the
French historian of science, Gaston Bachelard, he avoids any attempt to establish
links between epistemic phases; what we get are discontinuous gaps between
incommensurable historical modes of knowledge. We have seen that Goody levied
the same charge against Levi-Strauss concerning the lack of an explanation of the
cause of the shift between the 'savage' and 'domesticated' modes of thought. As we
saw, for Goody the primary causative factor that brings about this change between
pre-modem and modem modes of knowledge is the introduction of writing. For him
it was this event that eradicated the problem of memory storage and 'the human mind
was freed to study the static "text'" (Goody 1977:37), leading to increased rationality
and critical activity. The same view is presented by Horton \vho sees oral

I 17
transmission as conducive to cognitive traditionalism, and the introduction of writing
as weakening its hold (Horton 1982:251). I would now like to look more closely at
this claim and assess why it is that with the existence of writing in Tibetan culture
2
since at least the seventh century, the learning process in the Tibetan medical school
in Dhorpatan has retained many of the features of the synthetic mode of knowledge.
Akinnaso (1992), in a review of the literature on the relationship between
literacy and forms of knowledge, identifies two principal schools of thoughts: one
school views literacy as a powerful causative agent in bringing about changes in
forms of knowledge and communication; the other school, though agreeing that
literacy brings about social-cultural change, views this not in terms of a radical
transformation of knowledge but as an adaptation of pre-existing forms. As far as the
first view is concerned, that literacy will inevitably lead to modem forms of
knowledge, what we have seen so far of the form knowledge and learning in the
Tibetan medical school in Dhorpatan does not provide evidence for this. The high
value that has been traditionally placed on memorisation and personal transmission
has remained intact, even though Tibetan medicine has been a literary tradition for a
very long period of time. There are also other examples of this. Parry's (1985)
discussion of knowledge and learning amongst Brahman ritual specialists in Benares
has much in common with the medical school in Dhorpatan. Though he
acknowledges that literacy has the potential to bring about impersonal forms of
communication, he points out that the Brahmanical tradition has gone out of its way
to prevent this from happening. Though it is uncertain exactly when the Vedic texts
were first committed to writing, there is general agreement amongst scholars that
they had been transmitted orally for a long time before this, and that it was not for
the lack of literacy that they were not written down.
If literacy is not the prime causative agent in bringing about the change from
cognitive traditionalism to cognitive modernism then what other factor could account
for the transformation? Parry points to the work of Eisenstein (1969, 1981, 1983) as
a possible answer. For her the crucial cognitive distinction is not between literate and
non-literate cultures, but between scribal and print cultures; in her view it was the

Traditionallv the Tibetan alphabet was created by Thomi Sambhota. modelled closely on the
::!
Kashmir San~krit script around 6~2 AD (Stein 1972:59). But as I ha\"e explained in chapter L the
B6npo claim that many of their texts had been written down for a long time before that.

118
shift from script to print which brought about the revolution in modes of knowledge.
But Eisenstein herself indicates that new forms of technology in themselves are
insufficient to bring about this revolution, what is also essential is a favourable
institutional context. As Parry notes, the printing press can be as easily used as an
instrument of oppression as a means of spreading liberating knowledge. The
importance of taking into consideration the wider institutional context of cognitive
change is shown by Merton's (1949) study on the development of science in Europe
in the sixteenth and seventeenth centuries. In Merton's view it was the religious
values that arose from the Protestant revolution, which paved the way for scientific
enquiry. As he puts it:
... the positive estimation by Protestants of a hardly disguised utilitarianism, of intra-mundane
interests, of a thoroughgoing empiricism, of the right and even duty of libre examen, and of the
explicit individual questioning of authority were congenial to the very same values found in
modem science. And perhaps above all else in the significance of the ascetic drive which
necessitated the study of Nature that it might be controlled (Merton 1949:346 quoted in
Tambiah 1990: 13).
Carruthers informs us that in the late Middle Ages books were more readily
available than ever before, but this had little effect on the value and practices of
memorial culture for many centuries (1990:8). For Carruthers medieval European
culture 'was fundamentally memorial, to the same profound degree that modem
culture in the West is documentary' (1990:8). Each of these two cultures has its own
technology: for the former it is the various arts of memory (arts memorativa); for the
latter it is the printing press. Furthermore, I would argue that the corresponding
medium for conveying information in memorial culture is the text, and in
documentary culture it is the book. Certainly books and texts are not thought about in
the same way in Tibetan culture. The word for religious texts in Tibetan is the
honorific pecha; the word for book is deb. Deb also has the honorific form cha deb,
but it would be inappropriate to use either form for religious texts. Carruthers also
makes the distinction between texts and books, as she views it, '(a) book is not
necessarily the same thing as a text. 'Texts' are the material from which human

beings make literature (1990:8).

In the Brahmanical tradition as 10 the Tibetan tradition the institutional
framework favours personal transmission and memorisation, and consequently rather
than the advent of literacy causing changes in the form of knowledge and
transmission in the manner outlined by Goody, precisely the opposite has occurred;

119
the literary tradition has been adapted to the requirements of the oral tradition. From
his work with Brahmans in Benares, Parry concludes that rather than leading to the
breakdown in the traditional features of Brahmanical knowledge and methods of
transmission, such as the emphasis on memorisation, personal transmission, and the
notion that knowledge has been revealed by the gods and is beyond dispute, literacy
has tended to reinforce these features. Thus rather than leading to cognitive
modernism, literacy has contributed to a process of cognitive conservatism.
We have already seen that the Bumshi and the Gyushi, the principal medical texts
used in the medical school in Dhorpatan, have been composed, using stylistic
features such as the verse form, terse phrasing, and the abundant use of lists in order
to facilitate oral transmission. Most texts in the Brahmanical, Buddhist and the Bon
tradition have been composed in such a way, with the same purpose in mind. Thus
the written form of the text has not in any way undermined the oral tradition, on the
contrary the written text has lent further support to it; the ideal remains to be that the
text should be no more than a support for the personal transmission of the lineage.

4.5 Cognitive Syncretism

So far I have discussed two modes of knowledge. These modes of knowledge,

which I have referred to as synthetic and analytic modes, have been variously
typified by other writers as: cognitive modernism and cognitive traditionalism, print
culture and scribal culture, and documentary culture and memorial culture. The
impression given from this series of dichotomies is that of self-contained cognitive
worlds. But in practice the dividing line is not so clear-cut. We have already noted
that memorial culture existed for many centuries in medieval Europe after the
introduction of new forms of book technology, and that Buddhist and Brahmanical
texts were not written down until a long time after the introduction of writing in
India. Furthermore, empirical evidence shows that modes of knowledge are not
exclusive domains; elements of cognitive modernism and traditionalism often exist
side by side within the same system of knowledge. It is to these inter-epistemic
elements, and particularly to forms of cognitive syncretism that I found in the
medical school in Dhorpatan, that I will now tum.

120
 Merquoir (1991: 62) criticises Foucault's presentation of epistemes as fixed
bounded all encompassing units. For him such a portrayal overlooks a range of
transepistemic phenomena such as: anachronistic ideas in an epistemic phase, which
foreshadow later modes of thought; the resurgence of concepts from previous
epistemes; and 'epistemic lags' where fragments of previous epistemes linger and
persist in succeeding periods. In each of Foucault's four epistemic periods, there is
only one episteme that determines the possibilities of knowledge. It may be that in
each of these periods there was only one prevalent episteme, but there have always
been voices of dissent. For instance, Merquiour (1991:58) points out that during the
Renaissance there was a humanist tradition in France that looked upon signatures,
correspondence, magic and hermeticism with considerable disdain. Tambiah (1990)
raises the same issue by citing E P Thompson's (1972) criticism of Thomas's (1971)
notion that in second half of the seventeenth century it became possible to make a
new clear-cut distinction between science and religion. Thompson is doubtful that
the intellectual views of scientists and philosophers were taken on board by the
masses. For him it is more likely that they withdrew into their own religious
symbolism and he presents the rise of Wesleyanism as such a counter-enlightenment
movement.
The point I wish to make here about trans-epistemic elements of knowledge has
an illustrative parallel in economic theory. What I have referred to as the synthetic
view, connects with Mauss's (1970) ideas on the wide net of interrelationships
established in non-market based exchange systems and Karl Polanyi' s (1971) notion
of embedded societies. The analytic view corresponds to Mauss's atomised society
based on market exchange and Polanyi' s notion of disembedded societies. But again
this division masks important overlaps, such as the importance of money in pre-
capitalist societies and that in both capitalist and pre-capitalist societies the objects of
exchange are equally fetishised (Parry and Bloch 1989).
The idea that modes of thought are not unified all-encompassing phenomena has
been pointed out by several authors in the context of medical anthropology. For
example recent research has show that the idealised form of biomedicine that has
been adopted as a comparative category in much research is far from a true picture.
Hahn and Gaines (1985) have shown how biomedical knovv'ledge and practice varies

121
 within one society, and Lock (1980) has shown variations at an international level.
The same epistemological inconsistency appears to be true of the opinions of
patients~ as Young (1982) points out, patients sometimes give different
epistemological accounts of their sickness at the same time.
So far I have presented the mode of knowledge and learning in the Tibetan
medical school in Dhorpatan as representative of the synthetic mode of knowledge.
Though to a certain extent this is a valid characterisation, what is actually happening
in the school is more complex. Amchi Gege, like so many Tibetans of his generation
is a stalwart of traditional Tibetan culture. Yet it must be said he is not wholly
centred in memorial culture; he has many books as well as texts, and he frequently
consults them with vigorous scrutiny, comparing what he reads in one book with
what is written in another. This is especially true if different books present
contrasting Buddhist and Bonpo treatments of the same subject matter. But if the
tinge of modernism that has come his way has not been sufficient to bring into
question the high value he places on memorisation, this is not true of his students.
They, like many Tibetans have been influenced by modem values, and this has led
them to question the merits of the way things were traditionally done in Tibet.
Generally the students have a very low estimation of the value of memorising.
This is not just because of the immense amount of work it involves, but also they can
not see the point of it. On several occasions students told me of their frustration with
having to do so much memorising, in their view it did not help them understand
medicine. The students' feelings are also shared by other Tibetans in the community.
Whilst discussing the medical school with the settlement officer, he told me that the
students will only learn through study and practice. He said that all too often in the
past, monks would memorise many texts and afterwards not be able explain anything
about what they contain.
It is the only Tibetan medical school that I am aware of where the students still
have to memorise all of the main medical text. In 1997 I had the opportunity to meet
one of the teachers from the medical school in Lhasa. He told me that the students in
Lhasa now have to memorise only important parts of the text. He thought that the
traditional approach of having to memorise all of it involved much work and was not
essential to being a good doctor. Likewise, the students at the Tibetan \ 1edical

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Institute at Dharamsala, the medical school at Sarnath, and the Chagpori Medical
Institute at Darjeeling, have to memorise only important parts of the texts. When I
told this to one of the students at Dhorpatan he was surprised and thought their
course must be very easy.
The main complaint that I heard repeatedly from the students was the relative
lack of time devoted to explanation compared to memorising. What the students
wanted was more exegesis and practice, and less memorising and miscellaneous
chores. The period of my stay in Dhorpatan was a particularly difficult time for the
students. In addition to the regular chores they had to carry out for Amchi Gege, they
also had to help with the building of the new school and clinic. On top of all this,
within the same period five Tibetan people died, which meant more work for the
three monk students performing the necessary rituals. Even when the workload was
such that there were no lessons for days on end, still the students were expected to
memorise. This was a big strain for them, especially the monk students who had the
extra religious work.
The following accounts give a feeling of the prevailing mood. I was sitting one
evening with Nyima in the room he shares with Yungdrung, working on the qualities
of medicinal plants. Around 9 o'clock, Yundrung returned from the Namdru Tang
camp, where he had been helping Geshe Tenzin Dargye carry out a puja for an old
Tibetan woman who had recently died. He looked exhausted. He sat down on his bed
and, with sweat still falling down his forehead from the long walk back, he
immediately set about the task of memorising the text. He was so tired his head
would occasionally drop forward with the weight of sleep, then he would instantly
straighten his posture and continue repeating the section, until his head fell again.
After some time he stopped memorising and told us that he was not happy with the
way things were going in the school, particularly that the lessons were being
constantly disrupted with other activities. He said that he had been studying for five
years and he thought that his knowledge was not very good. (Actually from my
experience his knowledge was very good). He was contemplating leaving the school,
but he was afraid that if he did, he would get a beating from his older brother. He
complained about having to do so much memorising, which he said involved much
work but was of little use. What he wanted was more explanations and these were
not happening quickly enough.
On another occasion around this time, I was sitting in the afternoon sun drinking
Tibetan tea with Geshe Tenzin Dargye, when we were joined by Lhazom, one of
Amchi Gege's female students. The constant disruptions in the lessons and the heavy
workload seemed also to be taking their toll on her. She complained that she had
spent six years at the school, and like Yungdrung she felt she knew very little about
medicine. Curiously, a few days after this incident Amchi Gege told Geshe Tenzin
Dargye that he was very happy with Lhazom's progress. The incongruence between
the feelings of Amchi Gege and those of Lhazom derived from their different
criteria: Lhazom was dismayed at how little she thought she understood, Amchi
Gege was impressed at how much she had memorised.
Amchi Gege was born in Tibet and had spent most of his life living there. He is a
firm believer in the traditional ways of Tibet, yet all around him he sees threats to the
survival of his culture, from within Tibet and from outside. He told me that his
method of teaching is the same as that used by his own teachers. But this is not
entirely true. His teachers taught him whenever they had time, and he did not have to
do written exams on what he had learnt. Already he has made some concessions to
the modernist approach to education with the fixed daily schedule in the school, and
the routine of the oral and written exams. Other Tibetan medical schools have gone
further down this line.
Though the students were apt to question the methods of learning and even the
authority of Amchi Gege, I never heard them question the knowledge they were
being taught. At the same time as holding what they were taught in high value, they
did not disparage other approaches to healing. The students were generally aware of
the strengths of biomedicine, but they had also acquired opinions about its
weaknesses, such as its' side effects' and its cures not always being of a permanent
nature. They were also generally positive about the work of traditional Nepalese

healers.
We have seen that the form of knowledge and learning in the medical school in
Dhorpatan has many of the attributes of the synthetic mode, and that literacy far from
eroding these features, as Goody and Horton suggest, has reinforced them. Some of

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the common themes that have occurred during the discussion are: an emphasis on
personal transmission and memorisation; a division between sacred revealed
knowledge which is beyond question, and scholarly commentaries upon it; the
mystical power of the sound of words; and a blurred division between the domains of
religion and science. But there are two qualifying comments that I should add here.
First, the students are often questioning the value of the learning methods in the
school, particularly the large amount of memorising they have to do. Finally, modes
of thought are not exlusive and elements of different modes of thought often exist
side by side. In Dhorpatan features of documentary culture exist quite comfortably
side by side with memorial culture. In almost every lesson in the school Amchi Gege
would consult books, sometimes two or three at the same time, to get a clearer
understanding of some medical issue related to clinical practice or a subject in the
main text. At the same time there was no doubt in his mind that the students had to
memorise all the main text if they wanted to be good medical practitioners. For him
consulting books is something to be done after this has been completed.

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 Chapter 5 - Learning Medicine in the Classroom

There are three main contexts in which the students learn medicine: the
classroom, pharmaceutical activities, and clinical interaction. In this chapter I will
present the ways in which the students learn medicine in the classroom. As the
course last for nine years, I only experienced a relatively small section of the course.
On the subjects of the tree metaphor, diagnosis, therapeutics, and certain diseases
classes of the third volume, I can speak from direct experience of what happened in
the classroom. At the stage the students were at in the course when I was there,
certain sections of the text, such as the anatomy and physiology sections of the
second volume had not been taught by Amchi Gege, but the students were aware of
these topics from Amchi Gege's teachings on other sections of the text. In what
follows I will outline Tibetan medical theory related to anatomy, physiology, disease
causation, diagnosis and therapeutic methods, as it is presented to the students from
the text. Where possible I will draw on my own experiences of the learning process.
The information presented here prepares the ground for the sections of the following
three chapters which all relate in various ways to medical practice.
My understanding of the learning process in the school draws on two areas of
experience. First, most mornings I had a one hour lesson with Amchi Gege~ by this
means, during the time I spent in Dhorpatan, I completed the first volume, the first
five chapters of the fourth volume on pulse diagnosis, urine diagnosis, decoctions,
medicinal powders, and pills, and several chapters of the third volume on nosology.
Second, I sat in on the students' lessons, discussed with them their understanding of
Tibetan medical knowledge, and observed them engaging in medical activities.
The following discussion of the learning process in the school accords with the
theoretical framework, which I have outlined in chapter two. I move away from the
view of learning as a simple unilinear cognitive process, which involves the
transferral of transposable, immutable propositions into the passive repository of the
student's mind. This restricted view of learning, has been criticised by Lave
(1990:310) who refers to it as the 'culture of acquisition' (1990:310). The view that
is taken here is that learning is something that occurs on numerous levels; it is the
result of an interaction between mind, body, agency and social context. Knowledge
often starts off as a series of propositions that are impersonal and isolated from social

126
context. But with increasing practical expenence, propositional knowledge is
gradually incorporated into the student's sphere of competency. In this way learning
is not simply a matter of the acquisition of knowledge; more importantly it involves a
process whereby knowledge becomes a mode of being in the world through an act of
appropriation.
The process of becoming a Tibetan doctor, takes the student through progressive
stages of a path leading to new ways of knowing and perceiving. As the students are
gradually inducted into the medical practice, if the process is to be successful,
knowledge, which was initially strange, unfamiliar, and decontextual, becomes taken
for granted and second nature. If the students are to become competent medical
practitioners, the cognitive memory of acquired knowledge must be transformed into
the performative memory of medical practice. It is difficult to identify precisely what
the stages are between the two poles of novice and expert. As I mentioned earlier,
Dreyfus and Dreyfus (1986), based on their study of aeroplane pilots, chess players,
car drivers, and adult learners of a second language identify five stages: novice,
advanced beginner, competence, proficiency, and expert. At the level of novice,
knowledge that is acquired takes the form of context-free objective facts, and rules of
behaviour. Competency and expertise develop as this context-free knowledge IS

situated in practice. At the levels of proficiency, and expertise, knowledge IS

increasingly intuitive, and reflexive, and is carried out without conscious

deliberation.
Broadly speaking, the learning process involves two forms of knowledge: explicit
knowledge, which has a discursive nature and can be stored and transferred in
propositional forms; and tacit knowledge, which is non-discursive and as such cannot
be rendered in a propositional form; it is acquired in person-to-person interaction in
situated contexts. As we will see, the classroom in the medical school is the arena
where the students learn Tibetan medical knowledge as a series of propositions. The
higher levels of competence are developed when this knowledge is situated in
pharmaceutical practice and in clinical interaction, both of which will be discussed in

the following chapter.

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5.1 The Teaching Method

As I have discussed in chapter one, the students have two one-hour classes every
day, except Sunday; one in the morning and one in the afternoon. Amchi Gege
expected the students to attend all the lessons; he did not repeat material because of
student absence. If students miss lessons then it is up to them to get the information
from other students. The students are aware that the nine-year programme is longer
than the curriculums followed by other schools of Tibetan medicine, and they are
generally of the opinion that things could be speeded up. Amchi Gege does not share
this opinion. One evening, shortly after we had eaten, he was reading a book written
by Thupten Phuntsok, a Tibetan doctor who lectures at the University of Beijing. In
the book, Thupten Phuntsok explains that he had studied Tibetan medicine privately
in Kham for twelve years before becoming a doctor. Amchi Gege gave this as
evidence of how fortunate the students were to have to study for only nine years.
In August 1998 the students were still studying the final chapters of the third
medical text, which gives detailed information on Tibetan nosology. According to
the official syllabus this should have been finished by the end of the sixth year.
Another disparity between the official course syllabus and what was actually
happening in the school was that for some time whilst I was there, during their
afternoon lesson, the students studied chapters six to nineteen of the fourth text,
which give detailed information on different forms of medicines and their correct
use; this according to the official syllabus should have commenced after the
completion of the third text.
There is a further issue about the length of the course that reqUlres some
explanation. Amchi Gege's ten students started at different times yet they were all at
the same stage in the syllabus. The reason for this is that when new students start,
Amchi Gege teaches them at a free time in the day, and the other students attend the
lesson by way of revision. This is in fact what occurred during my lessons. The first
text of the Bumshi I was taught alone. This was presumably because Amchi Gege felt
that the other students were already thoroughly conversant in the knowledge found in
this volume of the text. When I moved on to the other volumes, the students were
expected to attend all my lessons. During the lessons, Amchi Gege would

128
occasionally ask them questions to make sure they had understood the subject the
first time round.
Amchi Gege told me that he was teaching in the same way that he had been taught
and as such in a way consistent with Tibetan tradition. As a rule the students must
first memorise the text before it is explained to them. As we have seen in chapter
three, memorising is highly valued by Amchi Gege and as such it is a fundamental
part of learning medicine in the school. It is the only school that I am aware of where
the students are still obliged to memorise all the main medical text.
Amchi Gege always teaches in the same manner. He first reads to himself the
passage of the Bumshi he is teaching, and then he elaborates on the information in
the text, drawing from his own experience, and where necessary information in
various commentaries. The two main commentaries he uses are the Bonpo
Khyungtrul Menpe, and the Blue Beryl (Vaidurya ngonpo), the famous Buddhist
commentary written by the regent Sangye Gyamtso in the seventeenth century.
Sometimes he draws from three or four books to give different angles on the same
point. All the students have their texts open in front of them and follow what he is
saying. Amchi Gege responds sternly and with vigour to student distraction or lack
of concentration, if it is noticed. He wields a very firm hand of discipline during the
lessons, and indeed at all other times the students are in his vicinity. Where
necessary, he shows the students plants or minerals, either the real item or an
illustration. He also uses as teaching aids, anatomical diagrams with Tibetan names
for body parts, and illustrations of Tibetan medical implements that are mentioned in
the text, even though many of these instruments are no longer used. Time and time
again throughout the lessons, the sacred nature of Tibetan medicine is emphasised.
The very act of learning medicine accumulates karmic merit, and each lesson finishes
with a short prayer dedicating this merit to the benefit of all sentient beings.
My lessons were facilitated by the good nature of the young head lama of
Dhorpatan, Geshe Tenzin Dhargye. I have mentioned earlier that his work in the
clinic in the Bonpo monastery at Dolanji, in the Himachel Pradesh state of North
India, and in the nearby hospital at Chandigarh for six months, meant that he had
acquired a familiarity with the procedures and concepts of biomedicine. As the head
lama, he also has a wide ranging knowledge and expertise in Tibetan ritual and as we

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will see in chapter eight he assumed the central role in the healing process when
disorders were thought to be caused by harmful spirits. These characteristics taken in
combination with the fact that he speaks good English meant that he was invaluable
to me in my attempts at understanding the Tibetan medical worldview. During each
of my lessons, Geshe Tenzin Dhargye acted as translator, and Nyima who also
knows a little English helped out whenever necessary. It must be said however, that
even with the help of these two very competent people, and three Tibetan
dictionaries, the lessons were far from easy going. Sometimes we could spend half of
the lesson trying to understand the meaning of one word.
Only a few of the students have acquired the habit of taking notes, and those that
have, do it with a certain reserve. As most of the students do not own their medical
texts, they make notes during the lesson in school exercise books, but this only to a
very limited extent. A premium is placed on collecting information directly in the
mind rather than storing it on paper. The senior medical student, Nyima, who had
received a western style education in the Bonpo settlement at Dolanji, was something
of an exception; he wrote copious notes in his own copy of the Gyushi. His notes
were to serve as a mnemonic device enabling him to recall Amchi Gege' s
explanation. As far as I could understand, the note-taking disposition is something
new to Tibetan education, and is a skill not easy to acquire. One Bonpo Geshe I met
in Kathmandu told me that although there is a modem tendency for monks to take
notes, usually this is done only to a very limited extent. He himself had tried to take
notes when lamas gave important teachings, but afterwards he had difficulty
understanding what he had written. A Tibetan scholar who had studied at the
University of Beijing told me that from his experience, modern Tibetan scholars do
take many notes, but this is a recent innovation.
Every morning I also had one hour of teaching and the students had to sit in on
my lessons by way of revision. From my observations in the student's classes, and
from how the students behaved in my classes, there was a stark contrast between how
they approached learning medicine and how I did. I have internalised the Western
predilection for acquiring knowledge through the medium of taking layer upon layer
of notes. Through these notes I wrote down almost verbatim what Amchi Gege said

130
during the lessons; the idea being that ultimately it would not remain in my notes but
would eventually be transplanted into my memory.
Another big difference with my approach to the teachings and the approach of the
other students was when it came to clarifying what Amchi Gege intended to convey.
During their lessons, the normal pattern is for the students to remain attentive to what
Amchi Gege is saying; they hardly ever ask questions,l either during the lesson or at
the end of it. When they do it is only to clarify minor points of detail. There was
never debate or critical analysis during the lesson; the atmosphere was generally
antipathetic to such approaches. There seemed to have been a tacit agreement that
asking questions reflected, not the unclear way in which the teaching was expressed,
but the unclear mind that was unable to comprehend. The students are accustomed to
this manner of approaching knowledge, and though they might have their doubts
about its merits, it is more or less natural to them.
On one occasion Geshe Tenzin Dhargye told me he thought that the biggest
difference between the Tibetan and Western approaches to education had to do with
the attitude to asking questions. Whereas the Western style approach to education
encourages the student to ask questions, the traditional Tibetan approach discourages
it. He gave me the example that when he was studying in the dialectics school at the
monastery in Dolanji, one teacher severely reprimanded him for asking too many
questions, calling him a donkey. The view appears to be that if a student doesn't
understand on the first explanation, the problem is with the student, not the teacher.
On several occasions this approach led to tension during my lessons. The cause of
this was my predilection for questioning all that I did not feel that I fully understood.
Geshe Tenzin Dhargye was in the awkward position of having to relay my questions
to Amchi Gege sometimes three or four times before I finally understood. Meanwhile
Am chi Gege became irate due to Geshe Tenzin Dhargye asking my questions over
and over again, then this anger would rub off on Geshe Tenzin Dhargye, who after
some time would direct it at me. There would never be the smallest vestige of anger
after the lesson, but when such occasions arose, the lesson became even more of a
struggle. Certainly, when I realised what was happening, I made an extra effort to
understand what Amchi Gege was saying straight away.

1 On the issue of student questioning in apprenticeship, see Goody 1978.

13 1
 Towards the end of my stay in Dhorpatan, Amchi Gege told me that he had found
my constant questions very useful in that it deepened his own understanding of what
he was teaching. The tacit prescription against the asking of questions seems to apply
mainly to the period of the lesson. It appeared to be quite acceptable to ask questions
about the teachings at other suitable times, such as in the evening during and after
dinner, or at lunchtime. Quite often at these times general discussion would occur
about the condition of particular patients who had recently visited the clinic, or
Amchi Gege would provide some anecdote that illustrated what had been discussed
in the lesson or related to some aspect of recent clinical practice.
The discipline in the school is very strict. If the students are playing around when
they should be studying or working, Amchi Gege is quick to respond. He usually
vents his anger by shouting at the students; normally this is enough, as they know
from experience that if they don't immediately amend their action they are likely to
be beaten. I only saw Amchi Gege beat one student, but I heard that it had happened
on several occasions. Geshe Tenzin Dhargye said that this is the traditional Tibetan
approach, and was the way he was taught in the monastery. During their lessons the
students must remain quiet and fully focused on what Amchi Gege is saying. If they
do not, they will suffer the consequences. Even outside lesson time, discipline in the
school is enforced. On an evening, when the students are supposed to be memorising,
if no sound is coming from their rooms, it is highly likely that Amchi Gege will visit
to find out why. One night he went to Nyima and Yungdrung's room enraged by the
sound of talking instead of the sound of memorising. He angrily accused them of
being possessed by a spirit and said that he was going to get two of the monks to
perform a ransom ritual.
In return for the privilege of being taught medicine the students must be respectful
to Amchi Gege, carrying out whatever work he needs doing, and usually there is
much to be done in and around the gompa compound. As I indicated earlier, exactly
the same form of relationship between the master and his students was observed by
Fuller (1997) in Brahmanical schools in South India, were it is referred to as the
Gurllkliia system. Above all, the students in the medical school must work hard at
their studies, or as Amchi Gege occasionally threatens, they will not be allowed to
stay at the school. Their studies in medicine must come before everything. For

132
instance, for some months after I first arrived, I gave the students lessons in English.
During this period some of the students were also being taught Tibetan astrology (tsi)
by Geshe Tenzin Dhargye. Amchi Gege soon put a stop to all of this when it seemed
to him that the students' interest in these subjects was detracting from their studies in
medicine.
The students were not entirely happy with the way things were proceeding with
their studies. This was not due so much to the tight discipline they had to undergo in
the school; although the students did work hard in their studies, they always found
time to enjoy themselves, even when they were under Amchi Gege's close
surveillance. Authority in the school resembles what Weber (1968) classified as
traditional authority. In the refugee context, a high premium is placed upon the
preservation of Tibetan tradition, and as Amchi Gege is a pillar of this tradition, his
authority is thus justified and legitimated.
The main gripe that the students had concerned the amount of work which they
had to do that was not directly related to their studies. The monk students were often
asked to perform religious services either in the temple or the community. Whenever
this occurred it inevitably meant that there would be no lessons for them or the other
students. Geshe Tenzin Dargye told me that in the monastery at Dolanji this problem
is overcome by concentrating all the major rituals and prayers during one month
when the monks are given a break from their studies. At all other times, except in
emergencies, they must devote their time to their studies.
For the students in the medical school, in addition to the demands of religious
activities, there are all manner of other types of work that need to be done: cooking,
working in the fields, taking care of the horses, work on the new medical building,
and so on. The main problem for the students was that they wanted to learn, but more
often than not their time was consumed by having to do other activities. Feelings ran
high over this issue and as a consequence, in the two-year period that I was there,
four of the male students left. Two of them returned after a two-month absence, but
when they returned they had given up being monks and resolutely refused to take up
robes again. After long and difficult discussions involving the students' parents,

Amchi Gege accepted them back.

133
 Most of the learning that happens in the classroom is concerned with acquiring
propositional knowledge about Tibetan medical theory and practice. It is the kind of
knowledge that Ryle (1949) refers to as 'knowing that', rather than 'knowing how'.
In terms of the Dreyfus model, the classroom is where the novice medical students
acquire context free objective facts about Tibetan medicine. For the students in the
medical school, the lessons in the classroom are not the first stage in the learning
trajectory. Before they receive lessons in the classroom, they should have first
memorised the relevant section of the medical text. As I have suggested in chapter
three on the role of memorisation, the structure of the main medical text, the
repeating nine syllable phrase, the constant use of lists, and the terse elided syntax,
amount to it being more of an elaborate mnemonic device, than a self contained
teaching on Tibetan medicine.
The students already have the relevant parts of this mnemonic device in their
minds before they receive teachings. In the lessons, what they have memorised is
rendered into a coherent, intelligible form through Amchi Gege's explanations. As
more sections of the text are illuminated in this way, new propositions can be
contextualised into the emerging overall pattern of the teachings. In this way what is
happening in the classroom is something more than a simple passive process of the
accumulation of propositional knowledge. The students are not empty vessels, but
bring to the classroom what they have memorised and a developing understanding of
medical theory and practice. It is possible that what is presented in the lessons will be
passively absorbed, but if the student is attentive, new teachings will be interpreted in
the light of what they have already learnt. The students are given fifteen minutes at
the end of each lesson to clarify their understanding of what they have been taught
through discussion in pairs. As far as their knowledge of Tibetan medical theory
goes, I would estimate that all the students have reached the third stage of
'competence' in the Dreyfus model, some of the senior students seem to have
developed the next stage of 'proficiency' in certain areas of medical knowledge.
As we have seen, unlike in other Tibetan medical schools, the course curriculum
(see section 1.7) does not follow the sequence of the text. The students begin with the

134
 2
first volume, which gives a summary of the whole medical teaching using the
metaphor of a tree with three roots. The first root covers the condition of the body; it
provides a summary of the factors, which lead to health and disease. The second root
covers diagnosis, and the third root presents the various forms of treatment. The first
3
volume provides the ground plan for all that follows in the three subsequent
volumes. The second volume presents detailed information about anatomy,
physiology, pathology, the qualities of medicines, methods of treatment, and
4
diagnosis. In the medical school in Dhorpatan this is the final text that is studied.
The third volume contains ninety-two chapters on Tibetan nosology5. This is by far
the largest volume of the medical text and takes the students more than four years to
complete, according to the official course syllabus. Before commencing the third
volume, the students study the first five chapters of the fourth volume, 6 on pulse and
urine diagnosis, medicinal decoctions, powders and pills. The rest of the fourth
volume is completed immediately after the third volume. It is entirely dedicated to
forms of treatment. It includes a further seven types of medicinal compounds,
cleansing medicines such as suppositories, enemas and emetics, and the external
treatments: moxibustion, bloodletting, hot and cold compresses, medicinal massages,
steam baths, and minor surgery.

2 The Gyushi consists nominally of four 'tantras': the Root Tantra (tsa gyu), the Explanatory Tantra
(she gyu), the Instruction Tantra (men ngag gyu), and the Final Tantra (chi ma gyu). The titles of the
corresponding parts ofthe Bumshi do not include the word tantra (see chapter 2). As the four parts
taken together form a coherent and comprehensive explanation of the doctrines and practice of
Tibetan medicine, and as Amchi Gege mostly uses the Bumshi in the school, I have referred to them as
volumes.
3 The contents of the first volume of the Gyushi, the Root Tantra, can be found in Clark (1995),
Tsarong (1981), Donden (1986), Donden and Kelsang (1983), and Parfionovitch, Meyer and Dorje
(1992).
4 The contents of the second volume of the Gyushi, the Explanatory Tantra, can be found in Meyer
(1988), Clark (1995), Donden ( 1986) Donden and Ke1sang (1983), Parfionovitch, Meyer and Dorje
(1992), Rechung (1973).
5 There are very few publications that contain translations of material in the third volume of the
Gyushi. Clifford (1984) provides translations of chapters 77-79 on diseases caused by harmful spirits,
Badaraev et al. (1981), chapter 49 on lang thab, a disease affecting the abdominal region, Emcrick
(1987) has also translated chapter 79, as well as Chapter 90 (1990) on rejuYenation and extraction of
essences. In addition, the chapters on Diabetes, Tumours, and Virilification and Rejuvenation, in
Donden (1986), provide summaries of information found in the third volume ofthc G.vushi.
6 The fourth volume of the Gyushi consists of 27 chapters. Meycr (1990) has translated the first
chapter on pulse into French. The pulse chapter, and chapter 2 on urine analysis. can be found in
Rechung (1973). Both Donden (1986) and Rabgay (1994a, 1994b) proyide outlines of urine and pulse
diagnosis based on information taken from the first two chapters of the fourth volumc.

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 As Amchi Gege explained to me, he is teaching the text the way that it was taught
to him. Amchi Gege comes from a family medical lineage; he was taught mainly by
his grandfather, but he also learned from other Tibetan doctors in the Kham district
of east Tibet. In this context his study of the text went hand in hand with his
induction into medical practice. The same situation pertains in the school in
Dhorpatan. For the students, when patients arrive a classroom lesson can be quickly
transformed into a clinical experience. The students learn medical practice by acting
as Amchi Gege's assistants. Because they are involved in clinical practice from very
early on in their training it is necessary that they have some understanding of
diagnosis, medicines, and pathology as soon as possible. This explains the structure
of the teachings. In medical schools such as the Chagpori Institute at Datjeeling, the
Tibetan Medical Institute at Dharamsala, and the Tibetan medical school in Lhasa,
the students first study medicine in the school for a number of years, and only after
this are they placed in clinics to gain practical experience of what they have learnt. In
these schools the four volumes of the main medical text are taught sequentially.
During my lessons with Amchi Gege, I studied the first volume, the first five
chapters of the fourth volume and selected chapters of the third volume. In the
following sections on how the students learn anatomy, physiology, the general
principles of disease causation, diagnosis, and therapeutic techniques in the
classroom, I will first outline the summary of the subject found in the first volume as
it was taught to me and the other students in the school. I will then give further
details on each of the subjects drawing on the relevant sections of the following
volumes. Most of what follows is based on a combination of the lessons I had with
Amchi Gege, my observations of the students' lessons, and discussions I had with
them about the teachings.
Although neither the students nor myself had formally studied the second volume
with Amchi Gege, as this presents a detailed exposition of a large part of what is
summarised in the first volume, I will also draw on this based mostly on the
references given above. I should add that by the time the students arrive at this text
they will have already acquired a considerable knowledge of anatomy, physiology',
pathology, diagnosis and methods of treatment through their studies of the third
volume of the medical text,

136
Plate 14 - Root of the Condition of the Body.
 --

Root 2 Stems 12 Branches Leaves (£]0\ ers and fruits)

I life ho lder wmd
2. upward mo-.ring wind
3. pervading wind
4 . fire companion wind
5 dO....'Tlward expe ll ing wind
6. d igestive bil e
7. col ouring bile
Branch 1. The Humours 8. stimulating bile
9. eyesight giving bil e
10 . complexion clearing bile
II . supporting phlegm
I 2. mix.ing phlegm
13. gustatory phlegm
Stem 1. The I 4. salis fying phlegm
15. joining phlegm
Condition of the I . chyle
2. blood
Healthy Body 3. flesh
Branch 2. The Bodily
4 . fat
Constituents 5. bone
6. marrow
7. regenerative fl uid
I . faeces
Branch 3. The Excreta 2. Urine
3. Sweat
Flower of longevity
2 Flowers
Flower o f good health
Fruit o f spirituality
3 Fruits Fruit of happiness
Fruit o f wealth
I . desire / wind
Branch 1. The Primary 2. anger / bile
Causes of Disease 3. stupidity / Phlegm
I . seasons / time
Branch 2. Contributory 2. harrnfu I sp irits
Causes 3. diet
4 . behaviour
I . skin
2. fl esh
Branch 3. The Entrances 3 . channels
4. bones
of Disease
5. 5 so lid organs
6. 6 hollo w organs
I . phlegm - top of the head
Branch 4. The Locations 2. bile - nuddle part o f body
Root 1. The of Disease 3. wind - lower part of body
I . bones
Condition of 2. ear
the Body 3. body hair
4. heart and related blood vesse ls
5. large intest ine
6. bl ood
7. sweat
Branch 5. The Pathways 8. eyes
of Disease 9. liver
10. gall bladder / sma ll lfltestlfle
II . chyle, fl esh, fat, marrow, reproductive flUId
12. faeces, urine
I 3 . nose, tongue
Stem 2. The 14. lungs, spleen, kidneys
IS . stomach, bladder
Pathological I . o ld age - wind
Condition of the 2 . prime oflife - bi le
3. childhood - phl egm
Body Branch 6. The Time of 4. cold place - wind
5. dry place - bile
Predominance 6. moist and lush place - ph legm
7. surrtnler. early everung. dawn - wlfld
8. autumn, midday, midrught - bue
9. spring, late everung, morrung - phlegm
I . exhaustion o f Itfespan
2. humo un disturbed in sp ite of treatment
3. other facton ai!l!T<lvate dISease
Branch 7. The 4 c.lam.age to Vital organs
Conditions Having Fatal 5 irreven ib le wind sickness
6 . fatal hot disease
Issue 7 fat.e.l cold disease
8. incurab le disease
9. fatal harmful Splf1t tniluence
I wind lowered, tnp 8 rwsed
2 wind dUlllfllShed. peken raISed
3 wind nuse<i tnpa dunlfllShed
4 wlfld ralSed, peken dlffilfllShed
5 Bile l o wer~d. wmd raISed
Branch 8. The Humoural 6 Bil e lowered, phle!!J1l ra l!!ed
7 B ue raISed, wlfld lowered
Reactions 8 Bile ra ISed. phl e!!J1l lowered
9 phl egm lowered. WU1d raISed
10 phlegm lowe red. bile raISed
I I phl egm raISed. wmd lowered
I 2 p hl C!!J1l I1l1sed. bile 10\\ ered
I Cold dlSeases wmd and phle~
Branch 9. Swrunary :! Hot dlSeases blood and bile

Root of the Condition of the Body

5.2 Learning Medicine Through the Tree Metaphor

Medical teaching in the school begins with the first volume of the medical text
which summarises the whole of the medical teaching using the metaphor of a tree
with three roots, nine trunks, forty-seven branches, two-hundred and twenty-four
leaves, two flowers and three fruits. In drawings of this tree, the three roots give rise
to what appears to be three separate trees, but they are in fact joined together below
the ground symbolising the intimate interrelationship of all the different elements of
the medical teaching. During Amchi Gege's lessons he often made use of
illustrations of the tree found in various books. Most often he used the Lhasa edition
of the seventy-two thangkas that the regent Sangye Gyatso had made in the
seventeenth century to illustrate his commentary, the Blue Beryl. During the time that
I was there he arranged for the whole of the tree diagram to be painted by a Tibetan
artist living in Dhorpatan. This was then put up on the wall of the classroom in the
new medical building.
In respect to anatomy, physiology, and pathology, what concerns us here is the
first root, which represents the condition of the body (see Plate 14). It has two trunks:
the first trunk summarises the condition of the healthy body; the second summarises
the pathological condition of the body. The first trunk has three branches and twenty-
five leaves (see Table 5.1). Amchi Gege first gave the names of each of the branches
and leaves and then he went on to explain each in turn.
One of the basic principles of Tibetan medical theory is that everything in the
macrocosmic environment and the microcosm of the human body is made up of
various combinations of the five elements (chungwa) of earth, water, fire, air and
space. Another fundamental principle is the notion that all psycho-physical processes
in the body can be divided into three categories. Each of these series of processes is
co-ordinated and maintained by a certain force, which drawing on Galenic
terminology, is usually rendered as a 'humour'. Though there is some justification in
using this word, the Tibetan word nyepa that is usually translated as 'humour',
actually means 'fault' or 'wrong doing'; a point I will return to shortly. In Tibetan
medicine, the three humours are: wind (lung), bile (tripa) and phlegm (peken). Wind
has the elemental nature of air, bile that of fire, and phlegm that of earth and water

137
(Tsarong 1981 :9). The humours are referred to in Tibetan by names, which have
specific physical referents, but the term refers to much more than this. According to
Tibetan medical theory there are five forms of each of the humours, which govern
specific functions in the body. The first branch of the first trunk has fifteen leaves,
which represent each of these humours. During the lessons on the first volume,
Amchi Gege gave the name and the principle location in the body of each of these
fifteen humours, and a short explanation of their function. This is summarised in
Table 5.2 along with more detailed information given in the second volume.
The next branch has seven leaves, which represent the seven bodily constituents
(Iii zung diin): the essential nutrient (chyle), blood, flesh, fat, bone, marrow, and
regenerative fluid. The final branch of this trunk has three leaves, which represent the
three forms of excreta: the stool, urine and sweat. At the top of the first trunk are two
flowers representing health and long life, and the three fruits of spiritual life, wealth
and happiness. These fruits and flowers can only be attained if the humours, the
bodily constituents, and three forms of excreta remain in a state of homeostasis: for
the three humours this means that they remain in the correct location and proportion.
Thus within the first few lessons the basic principles of Tibetan medicine are
established. As I have mentioned in chapter two, the pattern of the medicine tree
whereby all the basic principles of Tibetan medicine are laid out in a coherent
structure, serves the purpose of providing a framework upon which layer upon layer
of associated material can be brought together as the students expand their
knowledge of medicine.

5.3 Anatomy

The second volume of the medical texts has thirty-one chapters, and eleven
sections, which are further subdivided into four broad parts: the subject of medicine,
modes of treatment, therapeutic methods, and the healer. Each of the chapters has
further subdivisions; this is in keeping with what I said earlier about the use of lists
as an aid to memorisation; this manner of structuring information is found
throughout the text. The first of the four parts has two sections, which deal with the
subject of medicine, namely the body and disease. The section on the body provides
the most detailed account of anatomy and physiology in the main medical text. This

138
 section comprises of chapters two to six of the second volume which expand on the
basic outline that is given by the leaves and branches on the first trunk of the first
medicine tree, giving a much deeper exposition of the body and its components.
Chapter four deals specifically with anatomy. It begins by outlining the parts of
the body and their quantities in proportion to the size of the body. For instance the
amount of wind should fill the bladder, and the amount of bile should fill the
scrotum. The components that are listed are: the three humours, the seven bodily
constituents, the excreta, the five solid organs7 (don nga), and the six hollow organs
(no druk)8.
The text then moves on to describe the various 'channels' in the body. Here the
medical teachings clearly overlap with wider Bon and Tibetan Buddhist notions
about the nature of the mind and the body and the relationship with the macrocosmic
environment. The highest yoga (annuttarayaga) Tantric texts speak of a subtle
anatomy, which is permeated by a vast network of channels (Tib. tsa, Skt. nadI)9 -
traditionally 72, 000 are spoken of There are three main channels, which run down
the centre of the body. At various points on the central channel there are seven
centres (Tib. Karla, Skt. Cakra), which are confluence points for the other
channels. to The mind is related to 'winds', or 'subtle energies' (Tib. lung Skt. prana)
that flow through these channels. Certain yoga practices (tsalung) involve the
manipulation of these 'winds' (Samuel 1993 :236) with the aim of gaining spiritual
insight. Some of these 'winds' are related to physiological functions and are
mentioned in the main medical text (Meyer 1995: 127).
The text lists four classifications of channels. 11 The first class consists of the three
'channels of formation' (chagpe tsa). These are the first channels to be formed in the
human embryo. The nature of these channels and the three humours is intimately
related to Buddhist and Bonpo notions about the causes that lead human beings to be
constantly reborn into samsaric existence. As it is explained earlier in the section on

7 Heart, liver, lungs, spleen, and kidneys.

8 Intestine, stomach, seminal vesicle/ovaries, colon, gall bladder, and bladder. Meyer (1995: 129)
views this classification of 5 solid and 6 hollow internal organs as pointing to early Chinese influence.
9 The Tibetan word tsa. denotes 'channeL 'vein', 'artery', 'nerve', and 'pulse'.
10 The central channel is called, uma (sushumna), the left channel. kyangma (ida), and the right
channel roma (pingala). See Meyer (1988:60) for an illustration of the three channels and the chakras.
II See tangkas 9-13 in Parfiono\'itch, Meyer and Dorje (1992) for illustrations of the channels

described here.

139
the body, conception occurs when certain factors come together: the non-defective
sperm and menstrual blood, the five elements, and the consciousness that is swept by
the force of karma to be reborn. The root cause that leads beings to be born into
samsaric existence is a deep, fundamental ignorance (Tib. ma rigpa, Skt. avidya) of
their own nature, this leads to a false sense of self (dagzin), which in tum leads to the
three afflictive emotions of ignorance (timug), desire (dochag), and aggression
(zhedang). As I have discussed earlier it is these so called 'three mental poisons'
(dug sum) that generate the karma, which impels beings to be born into one of the six
realms of samsaric existence.
The power of the afflictive emotions and karma, which carries the consciousness
into rebirth, is carried through into the embryo, and has a causal affect on how the
body subsequently develops. Each one of the mental poisons has a direct causal
relationship with one of the three humours: desire is the cause of wind, aggression
brings about bile, and ignorance generates phlegm. In a like manner, the three mental
poisons are related to the 'three channels of formation'. The first channel has the
nature of the water element. It rises from the umbilical region moving up the left side
of the body passing the heart and the throat and finally forming the brain, and
thereby mental confusion and dullness; it is related to phlegm and as such this
humour is associated with the upper body. The second channel of formation is
related to the fire element and the blood. It passes through the middle of the body
carrying the essential nutriment of the digested food to the liver, from there it heads
to the tenth vertebra and forms the 'black life channel' (sogtsa nagpo); this channel
is the source of anger, which is situated in the black life channel and the blood. As
we have seen, anger is the cause of the bile humour and consequently this humour is
associated with the middle of the body. The third channel of formation is associated
with air, it goes downwards and forms the genital organs, which are the seat of
desire , and thus the humour of wind is associated with the lower body. From this we
can see that unlike the biomedical perspective, which tends to view consciousness as
an epiphenomenon of physiological processes, in Tibetan medicine quite the opposite
view is taken.
The second series of channels, are called the 'channels of existence' (. . . ipe Isa).
There are four principal channels of existence. The first is situated in the brain and is

140
surrounded by 500 small channels; these provide sensory experience. The second is
situated in the heart, it is called 'good mind' (yizang wa), it is surrounded by 500
small channels; these provide various mental functions such as the sense of self,
memory and intellectual processes. What the brain perceives is rendered intelligible
by the heart centre. In discussions I had with Amchi Gege on the subject, he was
firmly of the opinion that the seat of the mind is the heart and not the brain. The third
channel is situated at the navel, it is surrounded by 500 small channels, it functions to
develop and maintain the body. The fourth channel, which is surrounded by 500
small channels is situated at the genitals and is responsible for procreation.
The connecting channels are of two sorts: black and white. The vital channel
(roma) that is at the right side of the body has a dark colour because of the presence
of blood and bile; it gives rise to the 'black channels' of the blood vessels. The
channel in the left of the body (kyangma), is of a lighter colour due to the presence of
phlegm and wind, it gives rise to the 'white channels' of the nervous system.
The final series of channels that are mentioned in the text are the three 'life
channels' (tshe yi tsa). Although they are described as channels, what is actually
referred to in the text is the movement of the life force (la) in the body. The first,
which is described as the 'one that penetrates the whole of the head and body', 12 is a
life force, which circulates round the body according to the lunar cycle. On the first
day of the cycle it is located at the feet, it gradually moves up the left side of the
female body, and the right side of the male until the full moon on the fifteenth day of
the Tibetan month when it reaches the head. It is important to know the location
(lane) of this 'life force' before doing moxibustion or bloodletting. The second life
channel is called the one 'that accompanies the breath'; this relates to the wind (lung)
that is drawn in through the breath.
The third life channel requires some explanation as it relates directly to certain
forms of illness and the use of ritual in healing, which I will discuss in chapter eight.
The text says this channel, 'is like the soul (la) and roams about'. Both Buddhist and
Bonpo philosopy have the same view of the nature of the self. The individual
consists of the five aggregates (Tib. phungpo, Skt. skandha) of form, feelings,
perceptions, mental formations, and consciousness. The aggregates give the

1~ I have used Meyer' s translations of the titles of the three life channels (1988: 12.5).

141
appearance of an abiding self, but in reality s~ch a self does not exist. What
transmigrates from life to life is a stream of consciousness propelled by the force of
afflictive emotions and the karma they generate.
However, in the medical school the three human components that were most often
spoken about were the body (Iii), the consciousness (namshe) and the soul (la). The
la acts as a kind of vital principle essential to the healthy functioning of the body. It
can leave the body of its own volition, usually through the channel at the ring finger,
or it can be taken by harmful spirits. Its absence is potentially fatal. The condition of
the la can be diagnosed by palpating the ulna artery. On several occasions during my
stay in Dhorpatan patients were diagnosed as suffering from an absent la; I will
describe some of these incidents in chapter eight.
The la was spoken about in different ways, sometimes it appeared to be a soul that
could survive death; sometimes it was talked about as a vital energy that circulated in
the body. Amchi Gege, when he was teaching me about the la pulse, explained that it
originates from the consciousness; he said the namshe is like the mother and the fa is
like the son. He added that it is the support (ten) of the body. He said that after death
the la should 'go with the namshe. It may remain behind in the place where the
person died, but this is not propitious. Nyima, the senior medical student, following
what he had been taught by Amchi Gege, described it in physiological terms as the
most refined nutrient of the metabolic process.13 When I asked Geshe Tenzin Dargye
for clarification, he said the la should be thought of along with another two aspects
of the mind: the sem and the yi. He explained that the mind that consists of
constantly shifting thoughts is the sem; the yi is a deeper layer of mind in which the
thoughts circulate. He gave the metaphor of yi as a village and sem as people
wandering about in it. He said that the la provides the energy for all this to happen.
He added that when a person dies the la, yi and sem are separated and this causes
great mental turmoil for the deceased person. In the Bbnpo ritual that is carried out
for the dead, the la, yi and sem are first brought back together, to give the deceased
person peace and mental clarity. 14

\3 The phrase he used was 'the nutrient of the nutrient' (dangrm? dangma). In the text the most refined
nutrient produced from the metabolic process is the vitality fluid (dang).
\1 A short description of the ritual is given in Norbu (1995:87): a full account of it can be found in

Kvaerne (1985).

142
 When I discussed all this with Lopon Tenzin Namdak at Triten Norbutse Bonpo
monastery in Kathmandu, he said that the notion of the la, yi and sem is important in
the Bonpo religion. He explained that sem is the mind; he likened it to 'a lame man
who can see'. Yi, he said, is a subtle wind, which supports the mind; the metaphor he
used for this was 'a blind horse'. He explained that the la is the karmic traces
(bagchag), which sets everything in motion; he said the la is like the food for the
lame man and the horse. This is how the la is conceptualised in Bonpo philosophy,
but as we will see in chapter eight, from a ritual point of view it is treated like a soul
I5
or a vital life force. Lopon Tenzin Namdak also pointed to this aspect of the la
when he explained that traditionally in Tibet, objects in the natural environment
could be used as its support, such as a tree (fa shing), a lake (fa tsho) , a piece of
turquoise (la yu) or a mountain (fa ri). He said that the early kings of Tibet had Mt.
Kailash as the support of their lao It was thought that if the snow melted it showed
the weakening of their vital energy; he added that now there is much less snow on
the mountain.

5.4 Physiology

Having outlined the components of anatomy, in chapter five of the second

volume, the text moves on to expound the principles of physiology. The emphasis in
the text is not so much on how the bodily components and the three humours
function to produce health; rather the explanation is couched in terms of how
pathological conditions can arise. The various components on the leaves of the first
branch of the first tree on the condition of the non-pathological body are presented in
negative terms as either objects of harm or the agents of that harm. Thus the chapter
on physiology is divided into two parts: the human constitution that is the object of
harm (nocha kham) , namely the seven bodily constituents and the three forms of
excreta; and the pathogenic agents that cause the harm (nocha nyepa), the three
humours.
According to Tibetan medical theory the metabolic process has seven stages.
After the food is ingested it is transported to the stomach by the 'life sustaining wind'
(see Fig. 5.1). In the stomach the metabolic process is set in motion by the 'fiery

15 For more infonnation on the fa as the souL see Tucci (1980:190) and Stein (1972:226).

143
heat' (medro), of the 'digestive bile'. The 'digestive bile' provides the heat that is
necessary to break down the food. The' decomposing phlegm' breaks down the food,
and the 'fire companion wind' operates to support the heat of the digestive bile and
separate the nutrients from the residues in the digested material. This process,
whereby the food is broken down into nutrients and residues through the combined
action of the three humours, is repeated during each of the seven metabolic stages.
The nutrient that is produced from the digested food is the first bodily constituent,
the chyle (dangma). This passes along 'nine channels' from the stomach to the liver,
where it is transformed into blood. As Meyer (1988: 131) notes, there is a relationship
here with the second channel of formation, the roma. In the above section on
anatomy we saw that it is responsible for carrying the chyle to the liver. Near this
location it forms the 'black vital vessel', which is the source of the blood vessels in
the body.
At each stage of the metabolic process a nutrient is formed as one of the body's
constituents. The process that produces the nutrient also generates a residue; in this
way all the components of the body are generated according to a sequential pattern.
The seven-stage sequence of the metabolic process can be seen in Figure 5. 1. The
digested food in the stomach produces the nutrient chyle, and the residues of the
stool and urine. The nutrient of chyle is blood, and the residue is the 'mixing
phlegm'. The nutrient of blood is the flesh; and the residue is bile. The nutrient of
flesh is adipose tissue, and the residues are the secretions of the body's nine orifices.
The nutrient of the adipose tissue is bone, and the residues are sebum and sweat. The
nutrient of bone is marrow, and the residues are the teeth, nails and body hair. The
nutrient of marrow is the regenerative fluid (kuwa) , and the residues are the oiliness
of the body and eye mucus. The regenerative fluid has two parts: a residue, which
forms the sperm and menstrual blood; and a refined part referred to as the 'vitality
fluid' (dang), this resides in the heart but its presence permeates the whole body,
giving long life, vitality, and a bright sheen to the body's complexion.
In order that the metabolic process will function well it is necessary that the 'fiery
heat', which provides the energy for all the transformations is neither too intense nor
too weak. If this is the case and nothing disrupts the natural process of the
metabolism, then health will be experienced. But as we have seen it is the three

144
humours that are ultimately responsible for bodily processes, and if these are
disturbed, this will manifest as a disruption in the body's constituents. For this reason
the humours are presented in the text as the agents of harm rather than health.
As we have seen, what is said in the medical text about the moment of conception,
entirely accords with Buddhist and Bonpo philosophical notions about the nature of
existence. Through the fundamental ignorance of the true nature of the mind, the
three mental poisons of ignorance, desire, and aggression arise; these generate the
karma that impels beings to be born into one of the six realms of existence. The three
mental poisons that are present in the consciousness generate the three humours that
govern all physiological processes in the body. Meyer (1995: 128) has noted that
Tibetan medicine is following a tradition here that can be found in certain Mahayana
texts where the three mental poisons are related to the three humours of Indian
Ayurvedic medicine.
The three humours have a dual nature: if they are in their right proportions and
locations, they are the cause of health; but if by some means they are disturbed then
pathological conditions will arise. Indian Ayurvedic medicine, with which Tibetan
medicine shares many of its theories,16 uses two separate terms to refer collectively
to the humours, depending on whether they are in an healthy state, in which case they
are referred to as dhiitu, 'constituents', or in a disturbed state, when they are referred
to as dosa, 'defects' (Meyer 1995: 128).17 In Tibetan medicine, on the other hand,
following the Buddhist and Bonpo view that suffering is innate to all forms of
samsaric life, the humours are named only according to their negative aspect as
'faults' (nyepa) or sometimes 'illness' (ne). The text graphically likens the inherent
disposition of the humours to generate sickness to an insect becoming poisoned as a
consequence of feeding on a poisoned tree.
Each of the three humours is responsible for a range of psychophysical functions.
Wind is responsible for: breathing, movement, circulation in the body, the passage of
the bodily wastes, making the senses sharp, and sustaining the body. Bile is
responsible for: hunger and thirst, digestion, body heat, the clearness of the
complexion, courage and intelligence. Phlegm is responsible for the firmness of the

16 Mever has noted that Tibetan medical notions of physiology (1988: 133) and its humoural theory

(1988-: 136) corresponds almost exactly to that of Ayurvedic medicine.

\7 The three dosas are. viita. pilla. and kapha: these correspond respectiyely to lung. tripa and peken.

145
body and the stability of the mind; it enables sleep, allows the body's articulations,
gives patience, and makes the body soft and lubricated.

Vitality Fluid

i
.
NUTRIENTS

~ ~---.~ ---. Regenerative

Fluid

l l l
BI 'Ie "'-s-e"':'-cc-re-ti-on-s--' Teeth,
Body Spenn,
Mixing Sebum, nails,
of the nine oil, eye menstrual
phlegm Sweat body
orifices mucus blood
hair

RESIDUESIWASTES
Fig. 5.1 The Seven Bodily Constituents and their Residues

As we have seen on the first branch of the first tree each humour has five principal
forms. Table 5.2 gives the names, functions, and locations of these humours; for the
five winds there is the additional information of the pathways through which each
circulates. All this information can be found in the second volume of the medical
text. The text also gives a list of qualities for each humour that relate to its elemental
nature. The qualities of wind are: rough, light, cool, subtle, firm and mobile; the
qualities of bile are, oily, sharp, hot, light, strong-smelling, purgative and moist; and
the qualities of phlegm are, cool, oily, heavy, smooth, dull, firm and adhesive. Types
of behaviour or food that have the same qualities of a humour will tend to increase it.
Tibetan medical therapy is of an allopathic nature; if a humour is disturbed,
medicines, food and behaviour are proscribed with the opposite qualities.
From Table 5.2 it can be seen that it is the three humours that are responsible for
all psycho-physiological processes. The focus in Tibetan medical notions of anatomy
and physiology is not so much on biological substrata but the functioning of the
system as a whole, which is governed by the three humours. I asked all of the
students about what they knew about the function of organs in the body, such as the
liver or the kidneys. Their response was to either attempt some explanation in terms

146
 The Five Winds Life Holding Wind Upward Moving Pervading Wind Fire-Companion Downward
(Sogdzin lung) Wind (khyabche lung) Wind Expeller Wind
(Gyen du gyuwe lung) (me dang nyampe lung) (thur du selwe lung)

Location Top of the head Chest Heart Stomach Geni talslrectum

Pathway Throat and breastbone Nose, tongue, and throat All the body Hollow organs Colon, bladder, genitals,
thighs, small intestine

Function Swallowing, breathing, Speech, body strength, Capacity for movement Separates the nutrients Retentions and expulsion.
sheds tears, sneezing, body colour, gives from the wastes during Flow of sperm, menstrual
, belching, gives clarity to strength to mind, gives digestion and helps form blood, urine and stool.
, the senses clear memory the body's constituents Helps during birth. I

~~

I The Five Biles Digestive Bile Colouring Bile Accomplishing Bile Eyesight Bile Complexion
I
(tripa juche) (trip a drubche) (tripa dangyur) (tripa thongche) Clearing Bile
.~
-
(tripa dogsal)

Location Between digested and Liver Heart Eyes Skin

indigested food

Function Digests food, provides Provides colour of bodily Provide Body heat, Provides eyesight Gives a clear complexion.
body heat and strength, Constituents courage, pride,
and supports the other bi Ie intelligence, will power
humours

The Five Phlegms Supporting Phlegm Decomposing Phlegm Experiencing Phlegm Satisfying Phlegm Connecting Phlegm
(peken tenche) (peken yeche) (peken yongche) (peken tSimche) (peken jonhe)

Location Chest Stomach Tongue Head Articulations

----~

, Function Provides body moisture Breaks down the food in Provides tastes Provides the sensation of Connects the body's joints
and supports the other the stomach satisfaction from the and enables movement of
phlegms senses the limbs
-~---

Table 5.2 - The five types of Wind, Bile and Phlegm

-- -~ - - ----
of the three humours or more usually to say that they did not know because this
information is in the second volume of the medical text, which they had not yet
studied. In fact most of the information that is contained in the second volume on
physiology has been outlined above, and as we have seen it is entirely oriented
towards the function of the three humours rather than specific physiological
components.
From what has been said so far about Tibetan medical notions of anatomy and
physiology it can be seen that they are an expression of what I described in chapter
four as the synthetic mode of knowledge. This is equally true of the great medical
traditions of Chinese and Ayurvedic medicine and Galenic medicine in its medieval
European form, and its contemporary South Asian form of Yunani medicine. Tibetan
medicine shares many features with these other systems of medicine; they are all
based on humoural theories, they view the human body as a microcosmic reflection
of the wider environment, and health is produced through the balanced functioning of
the humours.

5.5 The General Principles of Disease Causation

There are three main locations in the medical text where the nature of disease is
presented: it is summarised in the first volume, explained in detail in the third section
of the second volume, and the whole of the large third volume is dedicated to Tibetan
nosology. The students had studied the first volume with Amchi Gege and had
arrived up to chapter seventy-three of the ninety-two chapters of the third volume,
the last time I was in Dhorpatan. Although they had not been taught the chapter on
disease in the second volume, they were certainly well aware of Tibetan medical
notions concerning it.
The second stem of the first medical tree provides a schematic layout of the
principles involved in pathology. It has nine branches and sixty-three leaves. The
three leaves of the first branch give the primary cause of illness: the three humours.
The four leaves of the second branch give the factors that lead to a disturbance in the
humours: season, spirits, diet, and behaviour. The six leaves of the third branch give
the various locations where disease enters the body. The three leaves of the fourth
branch give the main locations in the body of each of the humours: phlegm in the

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upper body, bile in the middle region, and wind in lower area. The fifteen leaves of
the fifth branch cover the various points traversed by the three humours: these cover
the seven bodily constituents, the excreta, the senses, and the five solid and six
hollow organs. The nine leaves of the sixth branch give the age in the person's
lifespan, place, and time during the day and season where each humour
predominates. The seventh branch has nine leaves, which give circumstances that
have fatal outcomes such as an intractable fever or wind disease. The twelve leaves
of the eighth branch give the effects that lowering or increasing a humour has on the
other two humours. The ninth and final branch has two leaves, which classify all
diseases of the humours as either cold (wind and phlegm), or hot (bile and blood)
diseases. When Amchi Gege teaches about this tree he elaborates on the subject of
each leaf so that by the time he has finished the students have a solid foundation for
what is to follow in subsequent sections of the text and what they will encounter in
clinical practice.
What is said in the first volume on the nature of disease is elaborated on In

chapters eight to twelve of the second volume. Chapter eight expands on the first
branch on the primary causes (gyu) of diseases, which it divides into remote and
close. The remote cause is the fundamental ignorance, which generates the three
mental, poisons. In turn the three mental poisons lead to the three humours in the
body, which are listed as the close cause of disease. Chapter nine expands on the
second branch on the contributory causes (kyen) of disease. The leaves on this branch
list four contributory causes: season, diet, behaviour, and harmful spirits. In chapter
nine these appear amongst a list of general causes of disease: season, harmful spirits,
incorrect treatment, poison, diet, and negative karma; the text then goes on to
describe specific causal factors for each of the three humours; these relate to the
humours properties. For example wind is said to be: rough, light, cool, subtle, firm
and mobile. If any contributory cause is present which has any of these properties,
and this cause is sustained for a prolonged period of time, this will bring about
pathological conditions in the wind humour.
Chapter nine of the medical text gives three forms of modification that a humour
goes through when it is disturbed. The first stage is 'accumulation' (.'log). When a
cause is present that has similar properties to the humour this will first lead it to

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accumulate in its own location. As the humour accumulates, a natural process ensues
where one begins to desire forms of behaviour or diet, which have the opposite
qualities of the humour. The following stage is 'arising' (dang), when the humour
becomes pathogenic and spills over into the pathways of the other humours; it is at
this time that symptoms of the pathological condition manifest in the body. The third
stage is 'calming' (zhi); this refers to the time when the disturbed humour is returned
to a state of balance in its own location by appropriate diet, behaviour and therapy.

Wind Bile Phlegm !

Intestines Between the navel and the Chest
stomach
Hip articulation Stomach Throat
Bones Blood Lungs
Skin Perspiration Head
Ears Chyle Chyle
All the body's articulations Serum Flesh
Colon Eyes Adipose tissue
Skin Marrow
Between the digested and Semen
undigested food
Stool
Urine
Nose (sense of smell)
Tongue (sense of taste)
Upper stomach (the place of
'undigested food')

Table 5.3 The Locations of Disease According to the Pathological Humour

The way that disease enters the body is explained in chapter ten of the second
volume. The contributory causes of disease are likened to an archer who shoots the
arrow of the qualities (coarse, rough, smooth etc.) at the target of the three humours.
The way disease manifests depends on the interrelationship between the three
humours, the bodily constituents and the excreta. First the humour accumulates in it
own location: wind in the bones, bile in the blood and perspiration, and phlegm in the
chyle, flesh, adipose tissue, marrow, the regenerative fluid, and the stool and urine.

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 When it overflows from its own location, a process ensues whereby disease
manifests as the pathological humour follows six pathways. As it is explained in the
Blue Beryl commentary:18 the humoural disturbance first 'disperses' (dram) to the
skin; then 'extends' (gye) to the flesh; then 'passes' (gyu) in the channels, then
'attaches' (zhenpa) to the bones, then it 'descends' (bab) on the five full organs, and
'falls' (lhung) on the six hollow organs. Once the disease has entered the body
through the six passageways it manifests in certain locations depending on the
pathological humour: these locations can be found in Table 5.3. It can be seen that
the locations of the disease relate to the various physiological functions of each of
the humours in their five forms, which are shown in Table 5.2.

5.5.1 Concepts of 'Infectious' disease in Tibetan medicine

Although the students had not studied the section in the second volume on disease
causation, they had acquired an extensive knowledge of it from their studies of
specific diseases in the third volume. From conversations I had with the students
about the nature of disease, their view was generally in accordance with what is said
in the text. But on occasions they would try to interpret Tibetan medical notions
according to well-known biomedical concepts.
The Tibetan word sin or sometimes sinbu, mearung 'insect', 'worm', or
'parasites', which occurs in the medical text, was frequently identified by some of
the students as 'germs' or 'bacteria'. Sometimes the fit between the two categories
worked well such as when one patient came to see Amchi Gege with toothache
(sinbu ne), which was described to me as caused by sin eating at the tooth. On
another occasion, Nyima, the senior medical student, accounted for the infectious
nature of the two groups of diseases collectively known as nyene and rim, by sin
carrying it from person to person. The original cause of nyene is the nyen class of
spirits~ by saying that they created the sin that transports the disease from person to
person he managed to embrace both Tibetan and biomedical theories of disease
causation.
Meyer has commented on this tendency amongst Tibetans to modernise the
Tibetan medical system by using biomedical terms. He criticises Rechung Rinpoche

I~ I have relied here on Mcycr' s ( 1988: 141) French translation of the Tibetan passage.

150
for using words such as 'lupus', 'typhoid', and 'germs' without giving the original
Tibetan word (Meyer 1988:39). On the subject of rim, although he acknowledges
that the text describes it as a contagious disease he feels it inappropriate to translate
rim tshe as 'infectious disease' as Yeshi Donden (1986:96) has done, as it 'lends to
Tibetan medicine a pathogenic conception that is foreign to it' (1990:240). For the
same reason he objects to Lobsang Dolma Khangkar's (1986: 166) translation of
sinbu as 'bacteria' (Meyer 1990:239).
Tibetan medicine is referred to in Tibetan as sowa rigpa, the 'science of healing',
but much of what is said in the text can be used as guidance for maintaining good
health. As we have seen the key to good health in Tibetan medicine is diet and
behaviour. The students knew about this, but when I questioned them about the cause
of good health most of them prioritised good hygiene practices. Not because Amchi
Gege had told them this, but because it had been instilled into them by the teacher at
the local school in Dhorpatan. Almost all of them were firmly of the opinion that
good health was related to having clean water, clean food, clean body and clothes,
and going to the toilet in a place far away from where people live. Amchi Gege never
presented me with a Tibetan medical germ theory of disease, though he himself
carried out practices that related to it such as putting iodine solution and elastic
plasters on wounds.

5.6 Learning About Specific Diseases

Tibetan nosology is first outlined in the last part of section three of the second
volume, where diseases are enumerated according to various different criteria. In this
place very little is said about the nature of the disease; the purpose appears to be to
enumerate the various forms of disease according to a pattern of lists and sub-lists.
As I have mentioned this is a typical device for a tradition that values memorisation
and the oral transmission of knowledge.
The text commences by listing three broad classifications of disease: by cause, by
host, and by the type of disorder. There are three types listed for the classification by
cause: disorders arising when contributory factors disturb the three humours in this
life; disorders arising from negative karma accrued in a previous life; and a mixture
of the two. Disease that results from the effect of negative karma can only be

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remedied with a religious approach, which is directed at neutralising the kanna.
Disorders that arise from causes in this life are of two sorts: endogenous (rangzhin
ne), that is to say internal disturbances of the three humours; and exogenous (chi
kyen), for which the text lists, poisons, weapons, and harmful spirits.
F or the classification according to host, the text enumerates seventeen male
diseases, thirty-two female diseases, twenty-four diseases affecting children, and
diseases specific to old people. For diseases that are common to all people it gives
101 affecting the humours, 101 principal (tsowo) disorders, 101 diseases classified
by location, and 101 classified by type. This gives a total of 404 diseases. The
number 404 is cited in a number of different locations in the medical text as
representing the entire range of Tibetan nosology. For example at the beginning of
the first volume we are told that the Medicine Palace, where the Medicine Buddha
19
gave the teachings, is made of precious gems that heal the 404 diseases arising
from the three humours. This number should not be taken literally. As it is stated in
the last part of the section on nosology in the second volume, the three humours and
their fifteen forms can act singly or combine to affect the seven bodily constituents
and the excreta in countless different ways.
The third volume is by far the largest part of the medical text. It gives details
about the wide range of diseases known to Tibetan medicine, their causes, symptoms
and treatment. It is through studying this volume that the students learn about the
different forms of diseases, which they may encounter in clinical practice. It
comprises of ninety-two chapters divided into fifteen sections. The first chapter
begins with the standard formula found at the beginning of each of the four tantras
with the request for the teachings. The broad classes of disease dealt with in the
fifteen sections are as follows: section one has four chapters on humoural diseases;
section two has six chapters on chronic internal disorders; section three comprises of
sixteen chapters on fevers; section four has six chapters on disorders of the upper
body; section five comprises of eight chapters on disorders of the solid and hollow
organs; section six has two chapters on genital disorders; section seven has nineteen
chapters on miscellaneous disorders; section eight has eight chapters on internal
sores and ulcers; section nine has three chapters on paediatrics; section ten has three

Mcyer (1995: 130) has noted that though the number 4-04- does not appear in Ayurvedic texts. it is
19
mcnti'oncd in several carly Mahayana texts as the total of 101 diseases amplified by thc four clcments.

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chapters on gynaecology; section eleven has five chapters on disorders caused by
spirits; Sections twelve comprises of three chapters on poisons; section fourteen has
one chapter on geriatrics; and finally section fifteen comprises of two chapters on
fertility treatment. The disease classification of each of the ninety-two chapters can
be found in Appendix B.
Each of the chapters follows the same structure, giving the primary and secondary
causes of the disorder, its different types, the symptoms, and the forms of treatment.
Throughout the entire period of my stay in Dhorpatan, the students were studying
this volume of the medical text. The last time I was there in August 1998, the
students had arrived at chapter seventy-three on child disorders caused by spirits. In
my own lessons with Amchi Gege, after I had been taught the first Tantra, and the
first five chapters of the fourth Tantra, I also went on to study several chapters in the
third volume.
Based on the expenence of my lessons and my observations of the students
lessons, Amchi Gege always taught in the same way. He would read a passage of the
text to himself, and then elaborate on it drawing on information in commentaries.
The commentary he relied on mostly for explaining the contents of the third Tantra
was Khyuntrel Rinpoche's Men Jor Tongtsa. The students listened to him and took
the occasional notes in their text or in exercise books. On rare moments they would
ask Amchi Gege to clarify points. Sometimes he would ask the students questions
about the subject he was teaching, which related to things he had taught in previous
lessons.
One word that I heard Nyima and Geshe Tenzin Dhargye use many times was
'cancer'. They were familiar with the English term and used it frequently to translate
the Tibetan disease category of tren. From the outset of my stay, Nyima informed me
that 'cancer' was very common in the valley of Dhorpatan, and indeed from records
that I kept of patients who came to the clinic, tren was by far the most frequently
diagnosed disease (see Table 6.2). Both Nyima and Geshe Tenzin Dhargye were of
the opinion that given time Tibetan medicine could treat 'cancer' very effectively. In
order to clarify all this, when I moved on to the third volume in my lessons, the first
chapter I asked Amchi Gege to teach me was the chapter on trell. In what follows I
will summarise the teachings that I was given. This will serve two purposes: first, it

153
 will provide an example of how the disease categories that are found in the third
tantra are presented as propositional knowledge in the classroom; and second, in the
following section on clinical practice I will show how the students engage with this
knowledge in interactions with patients who were diagnosed as suffering from this
condition. As the word tren refers to various types of growths in the body I will
adopt the more appropriate translation of 'tumour'. 20
Amchi Gege based his teachings, as usual, on the main Bon medical text the
Bumshi. The chapter begins in the standard way by saying that it was taught by
Tonpa Shenrab after his son Tribu Trishi requested the teachings. It then situates tren
as one of the 'five great chronic diseases'21 (chong chen de nga) covered in section
two of the third tantra. Amchi Gege explained that these diseases are listed together
because they all share the same cause of poor digestion (ma zhu ba). The text then
goes on to discuss tren according to seven subjects: primary cause (gyu) ,
contributory causes (kyen) , types (chewa), location (nepa), how they develop
(gyurtshill), symptoms (tagpa), and treatment (cho thab).

1. The primary causes of tren

The primary causes of tren are: the three humours, blood, sin,22 serum (chu ser),
and hair. Amchi Gege said that a problem arising in the digestive process combines
with one or a combination of these causes to produce the tren.

2. Contributory causes of tren

The contributory causes of tren are: karma (Ie), spirit (don), dysfunctional
digestions (ma zhu), weapon (tshon), falling (dram),23 a disturbance (thrug) caused

20 Some of the tumours that patients had may well have been cancer, but it seems that this was not
always the case. Nyima mentioned that 'cancer' is also described in other sections of the third
volume.
21 Chapters six to eleven: digestive disorders (ma zhu wa), tumours (tren). first stage oedema
(kyabab), second stage oedema (or ne), and third stage oedema (mu chu). Consumption (zad byed).
which is also listed in this section of the text, is according to Amchi Gege, considered to be separate
from the first five.
22 Following what I mentioned earlier I have declined to translate this word by the biomedical tenns
'genn', or 'bacteria' as Nyima, and Geshe Tenzin Dhargye translated it to me. However the tenns
'wonn', 'insect' or 'vennin' given by Das (1995) are also inappropriate in this context. consequently I
have left the word untranslated.
~3 The word means 'to hurt', but what seems to be meant here is the effects of a hefty blow. Whencvcr
this word came up in my lessons. Amchi Gege always gave the examples of falling from a horse or a
hill.

154
by incorrect diet or behaviour, giving birth (bu tse), a wet place, and a cold place.

3. Types of treD

The text lists eleven types of tren: phlegm tren, tren of the upper stomach (then)
region, stone tren (do tren) , wind tren, blood tren, bile tren, channel tren, hair tren,
water tren, sin tren, and pus tren (nag tren).

4. Locations of the treD

The text gives twelve locations which tren affect: the lungs, heart, liver,
diaphragm (chin tri), kidneys, spleen, gall bladder, stomach, colon, intestines,
bladder, and womb.

5. The process by which the treD develops

The text describes how seventeen forms of tren develop. In most cases this
involves a breakdown in the metabolic process whereby the undigested nutrient
(dangma mazhu) stays in the liver and creates impure blood, which then mixes with
it. If this mixture stays in the liver it will in time, through the action of the wind
humour, be rendered hard like 'stone', and transformed into a {ren. When this
mixture passes to other locations of the body listed in the text, tren are formed there
in the same way. In two cases it is the undigested residue (nyigma mazhu) that is
transformed into the tren, this occurs in the stomach and colon, and in the area just
under the sternum (lhen).
All this information came from Amchi Gege's commentary on what is found in
the main text. As is often the case the main text gives an elided phrase, which
summarises the information, but cannot be understood unless the teacher explains it.
The relevant nine-syllable phrase for what I have just said about the 'liver blood
(ren' and the possible affects on the spleen, stomach, colon or womb, can be
translated, 'blood tren liver spleen stomach colon womb' (khrag. skran. mchin.
mtsher. pho. long. mngal. du. 'ong). No explanation is given in the main text to give
meaning to this string of words in the context of the medical teachings.
A stone like (ren may also be formed in the gall bladder if the undigested nutrient
passes into it from the liver and wind acts upon it, which seems to be the Tibetan

155
medical explanation for gallstones. The tren can also be formed by blood staying in a
location and being transformed by wind; the text lists wounds as a possible cause of
this problem, and also childbirth when blood remains in the womb. If the undigested
nutrient enters the channels it may mix with serum and form what is referred to as a
'water tren' (chu tren), which clings to the side of one of the hollow or solid organs;
because of the presence of the serum it is not hard like the other tren. The only tren
amongst the list given in the text that is not formed by the action of the wind humour
is the sin tren; in this case it is the sin that form the tren in the stomach or the colon,
in a process that Amchi Gege likened to 'winding up a ball of wool' .
Quite often after my lesson with Amchi Gege I would discuss what I had been
taught with Nyima, in an unintentional parallel to the students' discussion groups. He
invariably showed a good understanding of what he had been taught in the lessons.
He described the process whereby the undigested nutrient and impure blood mix in
the liver, to smoke arising from a fire. When he was describing the nature of the
'water tren ' to me he gave the graphic image of frog's spawn.
Amchi Gege concluded his commentary on the section on the development of tren
by saying that all tren can be classified into two groups: 'hot tren', which are caused
predominantly by blood and bile; and 'cold tren', where phlegm and wind playa key
causative role. He then added a threefold classification of tren according to their
location: 'outer tren' (chi tren) are situated between the flesh and the skin; 'middle
tren' (bar skran) are situated on the surface of the solid and hollow organs; and
internal tren (nang tren), are situated inside the solid and hollow organs. Outer tren
can be seen easily, middle tren can be felt with the hands, and internal tren are
known through the symptoms.

6. The symptoms of tre"

The text gives a range of general symptoms that are relevant for most forms of
tren, and then lists twenty-three groups of symptoms for specific forms of tren.
Amchi Gege explained that there are four methods of diagnosing tren: pulse, urine,
investigation of the signs (tshen nyi fa tag pa), and questioning the patient.
The general pulse for tren is 'faint' and 'weak' (zhen); this is felt on all the pulse
locations. When examining the urine the doctor should look at the appearance, colour

156
and location of the bubbles: if the patient is suffering from tren, the bubbles will look
like fish eyes; if they are white, yellow or red, this indicates respectively a tren of a
phlegm, bile or blood nature; their location in the bottom, middle or upper area of the
urine is a sign that the tren is located in these regions of the body.
The text gives fourteen general characteristic signs of tren, which may be present:
wherever the tren is located, nearby there may be a dark mark on the skin (Amchi
Gege joked that people wash so much these days that it is difficult to see this mark);
pain in the area where the tren is located; difficulty to digest food; cold body;
belching; vomiting; loss of weight; chant4 and fresh butter exacerbate the problem;
diarrhoea; a sensation of wind in the bowels which can never be evacuated;
constipation due to the dryness of the stool; eating 'bad meat' (sha ra25 ) exacerbates
the problem; after eating only a small amount of food the stomach feels full and
hurts; after eating one feels cold and ill; and finally, any form of exertion makes the
condition worse. Amchi Gege explained that the doctor should elicit information
about these fourteen general characteristics and the specific symptoms by asking the
patient about their experience.
The text then goes on to list twenty-three groups of symptoms according to types
of tren and the various locations where they are found. For example, for the 'liver
blood tren' (chinpi tra tren) , which occurs in the liver due to wind acting on the
mixture of the undigested nutrient and impure blood, Amchi Gege gave the following
commentary. First he explained that the location of the liver can be found by
touching the tips of the finger of the right hand on the right ear lobe with the arm
kept close to the chest; the liver is located next to the elbow. He then gave the
following symptoms: red urine; fever; thin and quick pulse; when the body is hot or
cold there is pain in the back and in the area of the chest; the skin goes a bluish
colour; loss of weight; drinking chang or eating liver meat causes vomiting; as the
liver becomes inflamed this compresses the gall bladder and bile is leaked into the
body causing the eyes and the urine to become yellow. Another example is the
'brown blood tren' (mugp6 tra tren) , which is the name give to the tren which forms
in the stomach after the mixture of the undigested nutrient and impure blood has

~·1A traditional Tibetan alcholic drink made from fennented barley.

~5 Amchi Gege explained that this tenn means meat that comes from an animal that has died of a
disease.

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passed into it from the liver. For this type of tren, Amchi Gege explained the
symptoms as: a sharp pain (tsha) in the stomach~ when the stomach is pushed a beat
can be felt; when the body is hot or cold the condition worsens; difficulty to eat food;
and when the stomach is full pain is felt.

7. Treatment of treD

Amchi Gege began by summarising that there are four methods of treatment that
are used for tren: medicines, external treatment, diet, and behaviour. The text first
lists six general treatments; these relate to the outer, middle and inner types of tren in
their hot and cold forms. It then goes on to outline the treatments for fifteen specific
forms of tren. As these treatments involve sometimes numerous stages, and
medicinal compounds that often consist of a large number of ingredients, I will
restrict my explanation here to only two of them: the treatment for 'internal hot tren'
(tsha nang tren); and for the 'brown blood tren located in the stomach and colon'
(Pho long ne su mug pe tra tren). This will give an impression of the way the
students are taught about therapeutic methods for specific diseases in the classroom,
and the knowledge they bring with them to clinical practice.

'internal hot treD '

For an internal tren that is of a hot nature, the treatment begins with the medicinal
compound tigta chuchig. The name follows the pattern I described earlier giving the
name of the principle ingredient of the medicine, in this case tig ta, followed by the
total number of ingredients, which is here, eleven, chuchig. The ingredients are:

1. tig ta (plant) [Swertia chirayta]

2. serji metog (plant) [Herpetospermum pedunculosum]
3. duma nyung (plant) [Holarrhena antidysenteriaca]
4. sil sum, 'the three cool ones': chu gang (bamboo pith), gllr kum (saffron) and Ii shi
(cloves) 26

5. dragzhun (bitumen)
6. ru ta (plant) [Sallssurea lappa]

~6 Amchi Gege explained that these three medicines are used for fevers of the upper body: for the
lower body" shi should be replaced by slig mel (green cardamon).

158
 7. pi pi ling (plant) [Piper longum]
8. tsha la (borax)
9. a ru ra (fruit, chebulic myrobalan) [Terminalia chebula]
10. dron thai (ash made from dron bu, cowrie shell)
11. chongzhi dragtiil (ash made from chong zhi , calcite)

The following three medicines are added to the above ingredients. Amchi Gege
explained that they have the specific task of 'melting' the tren. They are prepared
together by heating them in a sealed metal container: 27

1. dong ro (mineral) [realgar] Amchi Gege explained this is a red stone that smells of
sulphur.
2. hong len (plant) [Picrorhiza scrophulariaefolia]
3. da Ii (plant) [Rhododendron anthropogon]

All these medicines are mixed together with cane sugar (kara) , and ground into a
powder and made into pills; these are then given to the patient. If the medicine is
having a healing effect, certain signs will manifest: the tren will gradually become
soft, the fever will become stronger, and the patient's appetite weaken. For the
patient it feels like the condition is becoming worse; but this is sign that the medicine
is working.
At the time when the signs appear that the medicine is taking effect, the doctor
should do bloodletting on the point connected with the effected organ: either the liver
point on the forearm, or the colon point on the foot. Amchi Gege explained that
before doing the blood letting, a medicine should be given which separates the pure
and impure blood. This has 5 ingredients:

1. drebu sum - three fruits that are often used together in medicinal compounds: a ru
ra (chebulic myrobalan) [Terminalia chebula], ba ru ra (beleric myrobalan)
[Terminalia belerica], kyu ru ra (emblic myrobalan) [Emblica officinalis].
2. ma nu pa Ira (plant) [fnufa racemosa]
3. pi pi ling (plant) [Piper fongum]

~7
Heat is a method commonly employed tn Tibetan phannacology to change the properties of
medicinal substances. usually as a process of detoxification.

159
After making a slight incision on the vem, the first blood to appear will be the
discoloured, impure blood. After a short time clean blood will begin to flow marked
by the colour changing to a clear red. Amchi Gege said that this change is very easy
to see. When the change occurs, the bleeding must be stopped; this can be done
either by reciting a mantra, or by putting some medicine on the wound. Amchi Gege
explained that the reason why bloodletting is done is because if the impure blood is
not eliminated, though the tren may be cured by the medicine, there is a possibility
that the condition will return.
As the third volume contains information that relates to medical practice, it
provides a synthesis of information found in the other three volumes of the medical
text. By the time the students move on to study this volume, they have a thorough
theoretical knowledge of diagnosis, but only a partial knowledge of therapies and
pharmacology. Therefore, whenever necessary, Amchi Gege must explain about
subjects that are found in the second and the fourth volumes, which the students had
not at that time studied. For instance, bloodletting is explained in detail in chapter
twenty of the fourth volume; the students had not studied this chapter, but they were
reasonably familiar with the principles involved from Amchi Gege's lessons on the
third volume, such as here in the chapter on tren. In their studies of the third volume,
the students develop an awareness of how the theories and practices that they had
studied in other sections of the text relate to specific disease; as this awareness
develops, so too does the potential for clinical competency.
The next stage in the treatment of the 'internal hot tren' involves adding certain
medicines to the medicinal compound given above, which cleanse the five solid
organs, and the six hollow organs and all the channels associated with them. By
adding these medicines all the extraneous material will be cleared out through the
urine and the stool. This subject is dealt with in detail in chapter seventeen of the
fourth volume on gentle enemas, and chapter nineteen on channel cleansing
The final treatment that is listed in the text is to take a hot bath (chu lam). Amchi
Gege said that for tren the best kind of hot bath is one that has a predominance of
calcite (chongzhi). The patient should stay in the water for as much time as possible
over the period of a week. If the patient feels a sensation like the \vater is pushing
them up and they want to vomit, this indicates that the wind humour is becoming

160
disturbed, in which case they should stop the bath. For each of the three forms of hot
tren, the recommended food and behaviour is the same: the food should be cool and
light, and one should avoid becoming too hot or cold, and physical exertion.

'brown blood treD located in the stomach and colon'

The section on the treatment of specific forms of tren begins by outlining

procedures according to five locations of the tren: heart, lungs, liver, spleen, and
kidneys. The text then moves on to discuss the treatment of ten specific types of tren.
In what follows, to give an example of how Amchi Gege teaches this part of the text,
I will give his commentary to the section on the 'brown blood tren located in the
stomach and colon'.

The first medicine that should be given has five ingredients:

1. tarbu (40g) (plant) [Hippophae rhamnoides]

2. gyam tsha (20g) (rock salt) [Sallucidum]
3. 'u su (coriander seeds)
4. manu patra (plant) [lnula racemosa]
5. bu ram dkar po (white molasses)

The first four ingredients are ground into powder, and then a small amount of white
molasses is added. Amchi Gege explained that as the medicine must be taken as a
powder, care must be taken not to add too much molasses. The powder should be
taken in the morning and evening with hot water that has been boiled and allowed to
cool. The next stage is to make a hot compress from:

1. chulo [Rheum spiciforme royie]

2. dragkya hawo (plant) [Corallodiscus kingianus]

The plants should be first cleaned then ground into a powder to which is added a
little salt (preferably len tsa). This is then wrapped inside a cloth and used as a hot
compress on the location of the tren, either the stomach or the colon; this should
make the Ire 11 become soft.

161
 After the hot compress, the tsha Ie jong, cleansing medicine is given. This consists
of five ingredients:

1. domtri (bear's bile)

2. hong Ian (plant) [Picrorhiza scrophulariaefolia]
3. durji (plant) [Euphorbia]
4. tsha la (borax)

Amchi Gege explained that the salt tsha fa is used in many tren medicines; it is
usually first detoxified by subjecting it to extreme heat in a metal container.
However, for this cleansing medicine it is not heated in this way but dissolved in
boiling water, at which point the other ingredients are added to the liquid. The
purpose of the first medicinal compound and the hot compress is to soften the tren.
When this has been accomplished the cleansing medicine is used to eliminate it from
the body. If the tren is not eliminated, the text gives a stronger medicinal compound
and cleansing medicine that should be used.
The pattern of the teaching that we can see here for tren is repeated in each of the
ninety-three chapters of the third volume. The students learn the causes of the
disease, its various forms, the part of the body affected, the symptoms and the
methods of treatment. The third volume of the medical text is a veritable handbook
of medical practice. In his teachings on it Amchi Gege weaves together into a
coherent whole, elements of medical knowledge that are covered in the other three
volumes of the medical text, and relates them to specific instances of disease that the
students may encounter in medical practice.

5.7 Diagnostic Theory

We have seen that when a cause is present with the same qualities of a humour,
this will cause it to increase in its own location, and if the cause is sustained it will
become pathogenic and spill over into the sites of other humours. When this occurs,
symptoms of the underlying pathological condition will become present. These
symptoms are manifest in the experience of the patient, the appearance of the body,
and the qualities of the urine and pulse. Learning diagnosis involves two stages: first,

162
Plate 15 - Root of Diagnosis.
 Root 3 Stems 8 Branches 38 leaves
1. \Vind tongue
Branch 1. Tongue
2. Bile tongue
Stem 1. Visual Diagnosis 3. Phlegm tongue
Diagnosis 1. Wind urine
Branch 2. Urine
2. Bile urine
Diagnosis 3. Phlegm urine :
Branch 1. Wind pulse 1. Wind pulse
Stem 2. Pulse Diagnosis Branch 2. Bile pulse 2. Bile pulse
Branch 3. Phlegm pulse 3. Phlegm pulse
1. light and rough food and
behaviour
2. yawning
3. stretching and sighing
-t.. shivering
5. aching hips, waist. lumbar
Branch 1. Questions for
area, joints.
wind disorders 6. sharp shifting pains
7. vain attempts to vomit
8. dulled senses
9. worried mind
10. worse when hungry
Root 2. 11. rich and nutritious diet
Diagnosis 1. fast acting and hot
behaviour and food
2. bitter taste in mouth
3. headache
Stem 3. Diagnosis Branch 2. Questions for
4. raised temperature
through questioning bile disorders 5. pains in upper body
6. pain after digestion
7. cool place diet and
behaviour
1. heavy and oily food and
behaviour
2. poor appetite
3. difficult digestion
4. vomiting
5. bad breath
Branch 3. Questions for
6. bloated stomach
phlegm disorders 7. belching
8. physical and mental
heavines
9. feeling cold
10. feeling unwell after eating
11. wann behaviour and diet
~

Table 5.4 Root of Diagnosis

during their lessons in the classroom the students learn the symptoms of specific
pathological conditions; then in clinical practice they must develop the skills
necessary to perceive these indicators. Learning to relate what is said in the text to a
patient's urine sample, or an actual sensation of the pulse, requires considerable
practical experience. In the following chapter I will consider the students attempts at
diagnosis. Here I will outline the way the students learn diagnosis in the classroom.
The students spend a considerable part of their first year in the school studying
diagnosis. They are first taught the general principles of diagnosis summarised by the
branches and leaves of the second root of the tree metaphor. After finishing the first
volume of the medical text, they then move on to the pulse and urine chapters of the
fourth volume; this, according to the official course syllabus should bring them to the
end of their first year of study. The second root, the root of diagnosis, has three stems
(see Plate 15 and Table 5.4), which provide a general outline of the methods of
diagnosis used in Tibetan medicine. The first stem summarises the methods of visual
examination. It has two branches, each with three leaves representing wind, bile and
phlegm disorders: the first branch gives the appearance of the tongue; the second
branch describes the appearance of the urine. The second stem summarises the
method of pulse diagnosis; it has three branches, each with one leaf representing the
qualities of the pulse for each of the humours. The third stem is the stem of
questioning. It has three branches, one for each of the humours. The first leaf gives
the type of food and behaviour that disturbs the humour, and the last leaf gives food
and behaviour that have a positive therapeutic effect. The range of leaves in-between
these, represent the specific symptoms associated with each humour. By making
reference to this knowledge the doctor can elicit information from the patient that
will contribute towards an accurate diagnosis.
Before moving on to discuss the techniques of pulse and urine diagnosis I will
briefly consider what is said in the second volume on the subject of diagnosis. In a
like manner to the pattern we saw for the first root on the condition of the body, the
second volume expands on the knowledge that is summarised by the root of
diagnosis, thereby building on the students' existing knowledge. The second volume
does not give information on specific diagnostic techniques, rather it gives general

163
guidelines on diagnosis, and a list of symptoms related to pathological conditions in
the humours and the seven bodily constituents.
The symptoms of disease, which are mentioned on the branches of the stem of
questioning, are expanded on in chapter eleven of the second volume. As we have
seen, health derives from each of the humours being in the correct quantity, and
location. The text lists symptoms for each of the humours, the seven bodily
constituents and the three excreta when they are in a state of 'increase' (phel) ,
'decrease' (ze), and for each of the three humours when they are 'disturbed' (trug).
The symptoms, which indicate a disturbance of the wind humour, are: the pulse is
empty (tong) and floating (kyel); the urine looks like water and as it cools down it
becomes thinner; the tongue is dry, red and rough; insomnia; yawning; dizziness;
pain when one attempts to move; shifting pains; light-headedness; sighing;
restlessness; goose pimples; pain in the hips and in the region of the waist; and so on.
The symptoms of a disturbance in the bile humour are: a fast (gyog) , thin (tra), and
taut (gye) pulse; urine which is a reddish yellow colour, foul smelling, and gives off a
large amount of steam; the tongue is thickly coated; headaches; insomnia; bitter and
sour tastes; yellow eyes; high temperature; thirst; diarrhoea with blood; unpleasant
smelling sweat; vomiting blood and bile; and so on. The symptoms of a disturbance
in the phlegm humour are: a sunken (chin), indistinct, slow (del), pulse; pale
coloured urine that has hardly any odour or steam; the tongue and the gums are a
pale colour; abundance of mucus in the throat and nose; a sensation of heaviness;
poor digestion; swollen body; itchy skin; stiff limbs; intellect not clear; pains in the
kidneys and lumbar area; lethargy; mental dullness; and so on. Certain conditions
such as the times of the day when the humour is ascendant, or the stage of the
digestive process exasperate the symptoms: the early evening, at dawn, and after
digestion for wind; midday, midnight and during digestion for bile; and at dusk and
shortly after eating for phlegm.
Diagnosis is also the focus of the sixth part of the second volume, which
comprises of chapters twenty-four to twenty-six. The subject of chapter twenty-four
is diagnosis of the humoural condition of the patient. It begins by reiterating what
was established on the stem of questioning, that diagnosis must take into
consideration three aspects of disease: the cause, the symptoms, and the factors that

164
have a positive or negative affect on the condition. The text then proceeds to explain
that the focus of diagnosis is the three humours in all their pathological modes. The
diagnosis should also take into consideration the constitutional humoural
characteristics of the patient, and environmental influences, such as the nature of the
place and the season. The chapter concludes by making some general observations
about visual diagnosis, diagnosis through feeling, and questioning. Chapter twenty-
five gives a series of procedures to be followed if the doctor fails to understand the
nature of the disease; the approach taken is one of beguiling the patient rather than
confessing one's shortcomings. Chapter twenty-six gives a series of criteria to enable
a doctor to decide if treatment should be undertaken or not.
Though the students had not studied the second volume, they had acquired a very
good working knowledge of diagnosis from their studies of the third and fourth
volumes combined with their experience of clinical practice. The third volume
comprises of ninety-two chapters on Tibetan nosology. Each chapter gives detailed
information about a class of disease, relating to causal factors, symptoms and
treatment. As the students had arrived to chapter seventy-three of this volume they
had acquired a wide-ranging knowledge of symptoms.
After finishing the summary of medical theory and practice glven 10 the first
volume, the students move directly on to the first and second chapters of the fourth
volume on pulse and urine diagnosis. As these chapters are quite long, in what
follows I will present a summary of their contents,28 with the twin aim of outlining
the basic principles of diagnostic knowledge that the students bring to clinical
practice, and presenting the way the students learn this knowledge in the classroom.

5.8 Learning the Theory of Pulse Diagnosis

Amchi Gege began by saying that the chapter on pulse is divided into thirteen
topics. In the first lesson he gave the titles of these topics and a brief explanation. He
then went on to discuss each topic in detail drawing where necessary on his favourite
commentaries: the Khyungtrel Menpe and the Blue Beryl. The first topic gives advice
on how the patient should behave prior to the diagnosis. Amchi Gege said that during
this period the patient should avoid any kind of behaviour or food, which might

~8 See note three for translation of these chapters.

165
agitate the humours and thereby confuse the diagnosis. He gave the examples of rich
food such as meat and alcoholic drinks, and behaviour such as sexual intercourse,
and hard physical or mental activity. This is the ideal, but in the clinic in Dhorpatan
it seems that generally people did not modify their behaviour very much prior to the
diagnosis.
The second topic concerns the ideal time to take the pulse. Amchi Gege explained
that this should be done at sunrise. We saw earlier that this is the time when the wind
humour comes into ascendancy. Amchi Gege said that if the pulse is to be felt in a
state that most closely reflects the condition of the body, it should be done before the
wind humour rises. Again this is an ideal that to my knowledge was never carried out
in Dhorpatan. Sometimes patients arrived to the clinic very early in the morning, but
Amchi Gege rarely saw them before 8 a.m.
The third topic focuses on the location where the pulse should be felt. The pulse is
felt with the index finger (tsh6n), the middle finger (ken), and the ring finger
(chag).29 The index finger is positioned on the radial artery, at the distance of one
thumb phalanx from the first crease on the wrist just below the thumb. The other
fingers are placed next to it gently touching one another. The fourth topic describes
the pressure that should be applied by each finger. The index finger should press
gently at the level of the skin. A little more pressure should be applied with the
middle finger allowing it to penetrate to the level of the flesh. The ring finger should
press the hardest so that it penetrates to the level of the bone.
The fifth topic describes the method of taking the pulse. Each finger takes two
pulses: the pulse on the upper section of the finger relates to one of the solid organs;
the pulse on the lower section of the finger relates to one of the hollow organs. This
can be seen in Table 5.5. The information given in the table is relevant for a male
patient; for a female patient the heart and lung pulses are swapped to the same
location of the opposite hand. Amchi Gege explained that before taking the pulse,
one should ensure that neither the patient nor the doctor is unduly hot or cold. If the
patient is male, the doctor begins by examining the pulse on his right wrist, if the
patient is female the doctor begins with her left wrist pulses. As the heart and lung
pulses are located on the opposite arms of a man and woman, this means that in both

~<J These terms are not Tibetan but Chinese (Meyer 1990:221): Amchi Gege was aware of this. but he
still insisted that Tibetan pulse diagnosis did not derive from Chinese medicine.

166
 cases the doctor begins with the heart pulse. At this point, Amchi Gege said that
these first five topics are known as the preliminary topics (ngondro) , as they deal
with the method of taking the pulse; the following eight topics discuss the qualities
of the pulse .

.:::::·i:.··::F~~~~r:~A~i*igltiL::::::: .:: :!:~~~:~e~le~i~r9~n$ · ; : i : .FiVe solid organs

:: . . :.: ....

:;t#.~~#~ . . :.... : ..•:..•.• :.::.::.: . . : ..... .

................ .... .

Top of tip of first finger Lungs

Bottom of tip of first finger Colon

Top of tip of second finger Liver

Bottom of tip of second finger Gall Bladder

Top of tip of third finger Right Kidney

Bottom of tip of third finger Bladder

. :~~t::~~~ :: . : · : :· .:.:.:·: :.:.: .: :.:

Top of tip of first finger Heart
Bottom of tip of first finger Intestine

Top of tip of second finger Spleen

Bottom of tip of second finger Stomach

Top of tip of third finger Left Kidney

Bottom of tip of third finger Seminal Vessicle/Ovaries

Table 5.5 The Twelve Pulses in Tibetan Medicine

The sixth topic concerns the three types of constitutional pulse : the male pulse, the
female pulse, and the Bodhisattva pulse. These are the three classifications of pulse
that relate to the type of constitution a person may have : the male pulse is thick
(born) and rough (ragpa) ; the female pulse is thin (tra) and fast (nyurpa) ; and the
bodhisattva pulse is long (guling) , smooth (jam) , and supple (nyen) . Arnchi Gege
explained that it is necessary to understand the constitutional pulse of a perso n in
order that it is not mistaken for a pathological pulse. He said that the male female

167
and bodhisattva pulses are very similar respectively to the wind, bile, and phlegm
pulses, and these constitutional pulses should not be misunderstood as a pathological
condition of the humour.

Pulse

1 (Feb) tiger tapaLike the call of

36 days liver and the lark
1-------1
2 (Mar) rabbit wood gallbladder wo (chokha)
36 days New leaves thin (tra) and
Spring ~-----+------_4------~appearon ~ ______ -+__________ ~ta=u=t~(=dr ~i"~l~)__~
3 (Apr) dragon earth trees spleen and nag pa Like the cal l of
18 days stomach the sparrow
short (thung)
and
smooth O"am)
4 (May) snake fire sag a Like the call of
36 days heart and the cuckoo
1-------1
5 (lun) horse fire intestines non (khu chug)
36 days thick (bom ) and
Leaves
long (ring)
Summer I---------+-------_+---------l grow and
6 (luI) sheep earth flourish spleen and chu to Like the call of
18 days stomach the sparrow
short (thung)
and
smooth O"am)
7 (Aug) monkey Iron dro zhun Like the sound
36 days of a locust 's
colon and 1 - - - - - - - 1
8 (Sept) bird lron !rum to wings (khyung
lungs
36 days trug)
Wheat short (thung)
and rough
Autumn harvest, (rtsub)
~9-(-O-c-t)--~--d-og---4---ea-rth--~fiuitripens~sp-I-ee-n-an--d-+---c-h-ug-p-a--~L-l-· k-e~t-he-c-a-ll-o~
f
18 days stomach the sparrow
short (thung)
and
smooth ('jam)
10 (Nov) plg water mindrug
36 days
11 (Dec) mouse water
36 days

Table 5.6 The Influence of the Seasons and the Five Elements on the Pulse

168
 The seventh topic presents the influence of the seasons and the five elements on
the pulse. According to the Tibetan system each season consists of three months: two
months of thirty six days, and a transitional month of eighteen days. Each of these
months corresponds to an astrological sign, one of the five elements,30 one solid and
internal organ, an event in the environment, a constellation, and a certain type of
pulse; this information can be seen in Table 5.6. As each element is associated with
one of the hollow and solid organs, at the time of the year when that element
predominates, those organs have an influence on the constitutional pulse. Thus if the
doctor is to make an accurate pulse diagnosis, the possible influence of the time of
the year must be taken into consideration.
The eighth topic explains the seven extraordinary pulses, these are the pulses of:
the household, the traveller, the enemy, wealth, harmful spirits, fire-water inversion,
and the pregnancy pulse. Pulse reading here is more an act of divination than medical
diagnosis. By discerning subtle qualities in the pulse, the doctor is able to give
information about a person's household, enemies, or the sex of the child of a
pregnant woman, and so on. Amchi Gege said that these pulses are very difficult to
understand and require what is now a rare level of expertise.
The ninth topic relates to information that is conveyed about the state of the body by
the frequency of the pulse. Amchi Gege began by explaining that a healthy pulse
should have five beats for each breath cycle of the doctor: two during inhalation, two
during exhalation, and one in-between. A pulse that has six beats or above indicates a
fever condition; a pulse that has below five beats indicates a cold sickness.
The tenth topic describes the pulses of various classes of disorders. It begins by
giving twelve general pulses, six for hot disorders and six for cold. The six hot pulses
are: strong (dragpa) prominent (gyepa) fast (gyogpa) twisting (drilwa), hard
(thrangpa), and taut (drimpa). The six cold pulses are: weak (zhen) , deep (ching),
impaired (gii), slow (bul), loose (lh6d) , and empty (tong). The text then goes on to
describe the specific pulses of forty-six different kinds of disorders.
The eleventh topic discusses pulses that indicate imminent death. The topic is
divided into three subjects: changes in the pulse, missing pulses, and stoppages. The
text lists several types of change in the pulse that signify death. For instance, the

30 The five clements and the twcl\'e astrological signs here correspond to those of Chinese astrology.

169
wind death pulse changes like 'wind blowing a flag', and the phlegm death pulse
changes from quick to slow like 'water dripping off the roof of an old house'. The
text then gives a list of missing pulses, which indicate imminent death; each of these
should also be accompanied by other symptoms. For example death is signified if the
heart and intestine pulse is missing and the tongue is dark, and the eyes are aslant.
On the subject of stoppages, Amchi Gege explained that death is indicated only if
there is a regular pattern to the stoppage, such as a repeating pattern of ten beats and
a pause; this is known as the 'death stoppage' (chi do).
The twelfth topic gives details about the characteristics of the pulse indicative of
disorders caused by harmful spirits. The text lists a range of different disorders which
have this cause, but in each case the pulse is the same: the main indicator is the
irregularity of the pulse; there may also be breaks in the frequency, but unlike the
death pulse they occur in an irregular manner; it is taut (ten), and in some cases feels
like two beats are occurring at the same time (chamdre l).
The thirteenth topic concerns the pulse of the life force (fa). Amchi Gege
explained that the fa has three 'pathways' in the body. He said it circulates round the
body in monthly cycles; this is the first life channel, which is discussed above. The
second 'pathway' is the twelve pulses that are taken on the radial artery. The third
'pathway', which is the focus of this topic is life force pulse taken on the ulnar
artery; the text relates the qualities of this pulse to the condition of the patient's lao

5.9 Learning the Theory of Urine Diagnosis

The first lesson on urine diagnosis began in the same way as the first lesson on
pulse diagnosis. Amchi Gege said that the chapter is divided into eight topics; he
gave the title of each topic and a short summary. During the lessons on urine
diagnosis, again he made use of the two commentaries: the Khyungtrel Menpe and
the Blue Beryl. He began the lessons by saying that urine is like a mirror that reflects
the condition of the body.
The first topic concerns the preparations that should be undertaken prior to the
diagnosis. On the night before the diagnosis, the patient should avoid foods that
affect the colour of the urine such as: tea, buttermilk, or alcohol. The patient should
also avoid sexual intercourse, and any excessive physical or mental activit\' The

170
urine, which is to be diagnosed, should be passed at the latter part of the night (!lam
me). Amchi Gege explained that this means in the early morning, in order that the
urine is not contaminated by food from the previous evening. The second topic gives
the time when the examination should be done, which is just after dawn.
The third topic describes the qualities of the container in which the urine should
be examined. Amchi Gege personally uses a white porcelain cup, but he said that a
tin (/eags dkar) container would also be suitable. The main issue is that the container
must show the colour of the urine clearly and reliably; therefore a coloured container
should not be used.
The fourth topic concerns how the urine is formed in the body. After the food is
digested in the stomach, the residue passes to the intestine and there it is separated
into the stool, which passes to the colon, and the urine, which collects in the bladder.
The nutrient of the digested food passes from the stomach to the liver where, as we
have seen in the above section on physiology, it is transformed into blood. The
residue that is produced here passes to the gall bladder where it is broken down into a
nutrient, serum (chu ser), and a waste, which passes to the bladder and appears as the
sediment (ku ya) in the urine.
The fifth topic discusses the qualities of the urine of a healthy person. Eight
characteristics are considered. The text says that the colour should be that of the
melted butter of a female yak (dri). Amchi Gege described this as pale yellow. The
smell should be like the smell of urine found in places where goats or sheep stay; it
should not be strong or weak, but moderate. The steam should also be moderate in
both its quantity and the time it is visible. The bubbles should be moderate in size
and quantity. The sediment should also be of a moderate quantity, and it should be
evenly distributed throughout the urine. The surface film (drima) on the urine should
be neither thick nor thin. When the steam dissipates, the urine should change colour
(dog); this change should progress from the outer part of the urine to the centre. The
colour of the urine after the change should be a pale yellow. Amchi Gege added here
that one must take into consideration the age of the patient, the season, and the
environment, all which affect the colour of the urine.
The sixth topic details the qualities of the urine of a sick person. Nine qualities of
the urine should be observed over three periods of time. When the urine is hot and

171
Plate 16 - Root of Treatment
 ~

---
.n .UVI. '+ ~tems 27 Branches 98 Leaves
I horse flesh
2 donkey
3. marmot
4. one year old <!ned meat
5. hwnan flesh
Branch I . Foods for wind diseases
6 grain oil
7. one year old butter
8. raw cane sugar
9. garlic
10. onion
I. milk
2. beer made from angelica roo
Branch 2. Drinks for wind diseases
3. molasses
4. bone wine
I. fresh butter
2 .~em eat
3. goat 's meat
Stem 1. Diet Branch 3. Foods for bile disease 4. meat of tole (yak, dz.o cross)
5. tsampa pom dge
6. Boiled white dandelion leves
7. Boiled dandelion
I. cow or goat yoghurt
2. cow or goat buttermilk
Branch 4. Drinks for bile diseases 3. hot water
4. cold water
5. water boiled ~tedly
I. mutton
2. wild yak meat
3. wild beast ' s meat
Branch 5. Foods for phlegm diseases 4. fish
5. honey
6. warm doughball made from old grain
I. female yak yoghurt and butter mill<
Branch 6. Drinks for phlegm diseases 2. strong beer
3. boiled water
I. warm place
Branch I . Behaviour for wind disorders 2. company of good friends
Stem 2. Branch 2. Behaviour for bile disorders
I. cool place
2. peaceful actIVIty
Behaviour I. warm £lace
Branch 3. Behaviour for phlegm disorders 2. strong exercise
I. sweet
Branch 1. Tastes of medicines for lung disorder 2. sour
3. salty
I. oily/rich
Branch 2. Potencies of medicines for lung disorders 2. heavy
3. smooth
I. sweet
Root 3. Branch 3. Tastes of medicines for bile disorders 2. bitter
3. astringent
Therapies I. cool
Branch 4. Potencies of medicines for bi Ie disorders 2. thin
3. slow acting
I. hot
Branch 5. Tastes of medicines fo r phlegm disorders 2. sour
3. astringent
I. fast-acting
Branch 6. Potencies of medicines for phlegm disorders 2. rough
3. lighl
I. Bone broth
Branch 7. Broths fo r wind disorders 2. broth of meat, butter, molasses or chang
3. broth made from sheep 's head
I. nutmeg medicinal butter
2. garlic medicinal butter
Branch 8. Medicinal butters for wi nd disorders 3. 3 fruits medicinal butter
Stem 3. 4 5 root medicinal butter
5. black acorule medtcmal butter
Medicines I. Inula racemosa decoction
2. Tinospora sinensis decoctJOn
Branch 9. Medicinal decoctions for bil e disorders 3. swertia decoction
4. 3 fruits decoction
1 camphor
2. wrule sandalwood
Branch 10. Medici.nal powders fo r bi le disorders 3. saffion
4. bamboo Pith
I. Black acorute
Branch I I . Medicinal pi lls for phlegm disorders 2. various salts
1 pomegranate
2. pale pmk rhododendron
Branch 12 . Medici.nal powders for phlegm disorders 3 very hoI compound
4. sail calemales
5 calcite
1 gentle
Branch 13 . Enemas: cleansing treatment for wind disorders 2 c1eansmg
3 forceful
1 general
2 speC1al
Branch 14. Purgati ves : cleansing treatment for bile di orders 3 forceful
4 gentle
1 forceful
Branch 15 . Emetics: cleansing treatment for phlegm
2 gentle
disorders
Im~e
Branc h I. Ex1ema l treatment f r wind di orders 2 ha l appucaoon
Stem 4. 1 U1ducmg sweat

External Branch 2. Ex1emal treatment for bile di rde 2

3
blood lemng
shower
treatment Bran h :>.1emal treatment for phlegm di rde -
I
2
holicold appucatlons
mJ'.\']bustlon

Ta ble 5.7 Root of Treatment

fresh the doctor should note its colour, steam, smell, and bubbles. When it is
lukewarm, the sediment and the surface film should be obseIVed. Finally, when the
urine has cooled down, the doctor should note the time of the change, the manner in
which it occurs, and the appearance of the urine after the change. The text then goes
on at some length describing the various possible attributes of these nine qualities
and relates them to specific pathological conditions. For example: if the colour of the
urine is bluish, this indicates a disturbance of the wind humour; if it is yellow this
indicates bile; and white indicates a phlegm disorder; if there is a large amount of
steam this denotes a fever condition; if the bubbles are big and bluish this indicates a
wind disorder. Usually the urine is stirred with a stick to create the bubbles. If this is
done and the bubbles created are small and disappear very quickly this indicates a
bile disorder. The seventh topic describes the qualities of the urine, which signify the
imminent death of the patient. The eighth topic describes the qualities of the urine,
which signify the action of harmful spirits; an outline of the contents of this section
can be found in chapter eight.

5.10 Therapeutic Methods

The students are first introduced to therapeutic methods by Amchi Gege' s

teaching on the third root of the tree metaphor given in the first treatise. The third
root has four stems which cover the range of therapeutic methods used in Tibetan
medicine: diet, behaviour, medicines, and external treatments (see Plate 16 and Table
5.7). The first stem has six branches, the leaves of which give foods and drink that
are used for disorders of the three humours. The second stem has three branches,
which give the recommended behaviour for disorders of three humours. The third
stem has fifteen branches, which describe the various characteristics of medicines.
Finally, the fourth stem has three branches, which give different types of external
treatment that are used for disorders of the three humours. The root of treatment with
its ninety-eight leaves provides the students with a detailed foundation in therapeutic
techniques, which is expanded on in chapters thirteen to twenty-one of the second
treatise and in the whole of the fourth treatise.
Food, like medicine, has certain properties that can affect the functioning of the
humours. In the root treatise numerous foods and drinks are given, which are

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beneficial for disorders of each of the humours. The logical corollary of this is that
foods that are beneficial for one humour are likely to have the contrary affect on
another humour. The second treatise gives detailed information about the types of
food and drink that Tibetans commonly eat. Examples from five classes of food are
discussed: grains, meat, oil, vegetable, and cooked foods. Information is also given
about foods that should be avoided, about how to recognise food that contains
poison, and about the correct quantity of food that should be eaten.
Behaviour can also affect the humours in a positive or negative way. As both
wind and phlegm disorders are by nature cold, the root treatise recommends that the
patient should stay in a warm place. For patients with bile disorders, due to its hot
nature, they should stay in a cool place. The root treatise also gives a certain type of
activity that is suitable for disorders of each humour; for wind, the patient should
stay in pleasant company, calm activity is recommended for bile, and for phlegm,
physical exercise is beneficial. The second treatise discusses behaviour according to
three categories: routine behaviour, seasonal behaviour, and occasional behaviour.
The first category gives advice about general behaviour, such as exercise, sleep, sex,
and moral and religious attitudes. The second category deals with how behaviour
should be modified at different times of the year to suit changing seasonal influences.
Finally, the third category explains that the natural processes and needs of the body
such as, vomiting, yawning, sneezing, sleeping, hunger, urinating, and so on, should
not be impeded.
The reason why a substance has medicinal properties according to Tibetan
medical theory is summarised in the first treatise by the first six branches of the stem
of medicines. Each branch has three leaves, which give the tastes and potencies of
medicines that cure each of the three humours. For each of these tastes and potencies
the text gives a substance as an exemplar of these properties. When Amchi Gege
teaches this subject, he has these substances ready at hand for the student to observe
and taste.
The theory that underlies this is explained in section six of the second treatise. As
I have discussed earlier, according to Tibetan medical theory everything that exists is
made up of various combinations of the five elements: earth, water, fire, air and
space. The healing properties of a substance derive from its constituent elemental

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nature, and this is reflected in its taste. The text identifies six tastes, which are
produced by six pairs of elements; this can be seen in Table 5.8.

Taste Elements
Sweet Earth and Water
Sour Fire and Earth
Salty Water and Fire
Bitter Water and Wind
Hot Fire and Wind
Astringent Earth and Wind

Table 5.8 The Elemental Nature of the Six Tastes

Medicines with a sweet, sour, salty, and hot taste cure wind disorders; bitter, sweet
and astringent tastes cure bile disorders; and hot, sour and salty tastes cure phlegm
disorders.
During the process of digestion, the tastes of the medicine are transformed
producing three so-called 'post-digestive tastes' (zhuje): sweet and salty medicines
produce a sweet post-digestive taste; sour remains sour; and bitter, hot and astringent
medicines, in the post-digestive stage, become bitter. Each of the post-digestive
tastes cures disorders of two of the humours: sweet cures wind and bile; sour cures
phlegm and wind; and bitter cures phlegm and bile.
Chapter twenty of the second treatise explains that the properties of a medicine
derive from the element, which predominates in its makeup. If the element is earth,
the medicine will have heavy (chiwa), firm (tenpa), blunt (tii!), smooth (jampa), oily
(num) and dry (kampa) properties; it is used to cure wind disorders. If the element is
water, the medicine will have liquid (lawa) , cool (sifwa), heavy, blunt, oily and
pliable (nyen) properties; it is used to cure bile disorders. If the element is fire, the
medicine will have hot (tshawa), sharp (nowa), dry, coarse (tsub pa), light (yang ba),
oily and mobile (yowa) properties; it is used to cure phlegm disorders. If the element
is wind, the medicine will have, light, mobile, cold (drangwa) , coarse, and dry
properties; it is used to cure phlegm and bile disorders.
Medicines are effective because they have the opposite properties to those of the
humours; these qualities are referred to in the text as the eight potencies (niipa).
Medicines with heavy and oily potencies cure wind disorders; cold and blunt
potencies cure bile disorders, and light, coarse, hot and sharp potencies cure phlegm

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In addition to this: light, cold and cool potencies increase wind; hot, sharp and oily
potencies increase bile; and heavy, oily, cool, and blunt potencies increase phlegm.
After making these general comments on the potencies of medicine the chapter
then goes on to give details about the qualities of a large number of specific
medicines according to eight classifications: precious medicines (rinpoche yi men),
stone medicines (do yi men), earth medicines (sa yi men), tree medicines (shing
men), mucilaginous medicines (tsi men), plant medicines (thang men) herbal
medicines (ngo men) and animal medicines (sog chag men).
As we saw earlier when conditions are present which adversely affect the
humours, a process ensues whereby the humour first accumulates in its own location
and then spills over into the locations of the other humours. If the disorder is at the
first phase, medicines are used, which pacify the humour in its own location. If the
condition has reached the second phase, before the humour can be pacified in its own
location, medicine is first given which gathers the humour from the pathways it has
wrongly infiltrated. In certain cases, the pathological condition may have to be
ejected from the body. The whole range of Tibetan medicines thus falls into two
categories: pacifying, and cleansing. These form respectively the second and third
sections of the fourth treatise. In their studies in the classroom the students had
completed both of these sections.
External treatments (che) are first presented by the fourth stem of the root of
treatment. It has three branches: the first branch gives massage and hot applications
as treatments for wind disorders; the second branch gives inducing sweat, and blood
letting for bile disorders; and the third branch gives hot and cold applications, and
moxibustion31 (me tsa dregpa) for phlegm disorders.
Hot and cold applications, involve pressing on certain areas of the body, with
objects such as a warm or cold stone, or fennel seeds wrapped in a cloth and dipped
in hot oil. Bloodletting (tar) involves making a small incision in a vein and allowing
pathological blood to leave the body. The incision is made on one of seventy-nine
locations, depending on the nature of the disorder. For several days before it is done,
the patient is given a decoction, which serves to separate the pathological blood (lUi
Ira) from the healthy blood. Moxibustion involves the burning of small cones of the

31Moxibustion is practised in Chinese medicine. but the name comes from Japan (Meyer 1988:66
n.l ).

175
herb gerbera (trawa) on one of seventy-one locations on the body that are related to
various disorders. Another form of heat treatment used in Tibetan medicine is
cauterisation with a metal instrument. Amchi Gege explained to me that there are
numerous different types of medical baths classified according to their mineral
content; such natural hot pools are commonly found in the mountains in Tibet and
throughout the Himalayan region.
If all other forms of treatments have been ineffective, for some disorders the text
recommends surgery, indeed the whole of chapter twenty-two of the second treatise
deals with types of surgical instruments. However, nowadays, with the exception of
minor problems, surgery is not practised.

From the foregoing discussion it can be seen that there is a logical pattern to the
way the students learn medicine in the classroom. This pattern partly relates to the
way medical knowledge is presented in the text, but also partly relates to the way that
Amchi Gege has chosen to teach it. The lessons begin with the first treatise which
through the tree metaphor lays the structural foundation for the entire medical
teaching, thus by the end of the first six months the students have a basic
understanding of all aspects of Tibetan medical theory and practice. All subsequent
teachings can be related to the basic pattern that is laid out in the first treatise.
After completing this, the students immediately move on to the pulse, unne,
medicinal decoctions, powders, and pills chapters of the fourth volume. Amchi Gege
approaches the text in this way because the students are involved in the practice of
medicine from a very early stage in their studies: either in a clinical context as Amchi
Gege's assistants, or in a pharmaceutical context, collecting medicinal plants,
preparing raw ingredients, or compounding medicines according to his instructions.
After studying the fifth chapter of the fourth treatise on medicinal pills, they then
begin the long study of the third treatise on Tibetan nosology, which again accords
with the early emphasis on medical practice in the school. The second volume, which
as we have seen, concentrates on medical theory, is the final volume to be studied in
the school at Dhorpatan. By the time the students reach this volume, they will
already be familiar with much of its contents, as an outcome of Amchi Gege' s

176
teachings on the causes, diagnosis, and treatments of the large number of specific
diseases discussed in the third treatise.
To a certain extent, it is not necessary to have studied the theoretical material
contained in the second volume in order to practise medicine. In fact, Nyima told me
that many practising amchis in Mustang had only studied the first and the fourth
treatises; a circumstance which also applies to Ladakh. The students study a large
amount a material in the third treatise, which they will almost certainly never
encounter in clinical practice, and as such it is likely that this will never reach the
stage of performative memory.
Learning medicine in the school in Dhorpatan involves three simultaneous
processes: the students memorise the text; receive teaching on what they have
memorised; and engage in medical practice. As they progress through the various
stages of increasing competency from novice to expertise, the structural framework
that they learn during their studies of the first treatise is built upon with layers and
layers of new explanations and experiences in the clinic and the pharmacy. All of the
students in Dhorpatan had been studying medicine for more than four years, some for
as many as eight years. As such they all knew a great deal about Tibetan medical
theory and practice, at least at the level of propositional knowledge. In the next
chapter I will present how the students learn through medical practice, this is the
arena where the propositional knowledge they acquire in the classroom is
appropriated and made a part of their sphere of practical competency.

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 Chapter 6 - Learning Medical Practice

We have seen from the Dreyfus model of learning that expertise develops as
knowledge, which was initially presented as a series of decontextualised and
impersonal propositions, is increasingly situated in practice. In the previous chapter
we saw how the students learn the theory, which underlies medical practice; in this
chapter I will give examples of how this knowledge is brought to medical practice.
We have also seen that the transformative process whereby the students pass from
novice to higher levels of knowledge and expertise, involves various forms of
memory. The students begin by memorising the text. I have explained that this is not
simply a passive form of rote learning; it provides a structural framework, which
facilitates understanding and provides a matrix whereby associated elements of the
medical teachings can be seen to form part of a coherent whole. The students had
studied a large part of the medical text in the classroom with Amchi Gege and from
the many conversations I had with them they displayed a very good knowledge of
medical theory. However, much of this understanding remained at the level of a
mode of knowing rather than a mode of being. In what follows I will present
examples of how practical competency develops III clinical interaction; how the
propositional knowledge acquired in the classroom is appropriated and thereby
transformed into the performative memory of medical practice. This chapter forms a
unit with chapter eight, which also focuses on how the students learn medicine by
engaging in medical practice, but the main focus in chapter eight will be on the use
of ritual in healing. Chapter seven prepares the way for this by presenting
information on the relevance of Tibetan religious notions to Tibetan medicine.
The central mechanism in the development of performative memory in the school
is what Lave refers to as 'legitimate peripheral participation'. From very early on in
their medical studies, the students are gradually inducted into the practices of
medicine by carrying out various tasks for Amchi Gege, either under his supervision
or according to his instructions. The principal method through which the students
develop competency in clinical practice is by acting as Amchi Gege's assistants I
will begin by looking at how the students learn the practice of pharmacology
collecting and identifying medicinal plants; preparing the raw material; and
compounding medicines. I will then move on to summarise the chapter of the third

178
volume, which describes the classification of disease referred to as tren. Finally I will
give examples of how the students learn medicine through clinical interaction.

6.1 Learning Pharmacology

As we have seen in the last chapter, the students first receive an introduction to
the properties of medicinal substances during their studies of the first volume.
Though they had not studied the sections of the second volume, which give extensive
details on the subject, over the course of their studies they had acquired most of this
information from Amchi Gege's commentaries to other sections of the medical text.
The students are engaged in medical practice in both the clinic and in the pharmacy
almost from the outset of coming to the school; as such they are involved in medical
practice some considerable time before they fully understand the theory, which
underlies that practice. Because of the practical orientation of the course in the
school in Dhorpatan, after studying the first volume, the students move on to study
the chapters of the fourth volume on pulse and urine diagnosis, medicinal decoctions,
powders, and pills. As the students often assist Amchi Gege to make medicinal
compounds, it is important that they have a basic grasp of practical pharmacological
knowledge as soon as possible.
Dhorpatan is an ideal place to learn about the Tibetan pharmacopoeia as many of
the medicinal plants that are commonly used can be found in and around the valley
(see Plate 4). About 150 medicinal plants grow in the immediate vicinity, and many
more can be found within a few days' walk. There are many Tibetan
pharmacopoeias; the most famous is Dilmar Geshe Tenzin Phuntsok's The Pure
Crystal Orb and Crystal Rosary,l composed in 1717, which lists 2294 drugs.
Although Tibetan medical texts list thousands of drugs, in practice only a few
hundred are regularly used. Amchi Gege used about 200 drugs in his range of
medicinal compounds. Most of the ingredients used are plant products, but animal
and mineral products are also commonly used. As I mentioned in chapter one, some
important ingredients cannot be found in Dhorpatan, and these must be bought in
Kathmandu. As it is impossible to gauge how many patients will come to the clinic

1 Drinlf! She/gong She/rrrng. The Crystal Orb is the main text and the Crystal Rosary is the author's
own commentary.

179
in one year, or the kinds of diseases that will occur, occasionally stocks run out~ in
which case one or two students are sent to Kathmandu to buy more.
Most of the plant collecting takes place in the late summer and the autumn. Amchi
Gege divides the students up into three or four groups, gives them a list of plants that
are required, and sends them off in different directions. The last time I went out with
the students, just before we set off, he reeled off a list of about twenty plants, and
finally he said 'bring wild pig excrement, and make sure you don't mistake it for
dog', which is apparently what they had done before. Usually they go early in the
morning and come back in the evening; occasionally a few of the students are sent
collecting in distant areas, which can take several days.
Amchi Gege rarely goes looking for plants with the students; he had already
imparted enough knowledge to the students for them to manage well without him.
On the few occasions when he did go, there seemed hardly a plant that he did not
recognise. Whenever he points out a medicinal plant, he always explains about its
characteristics: which part is used, the time of the flowers and the fruit, whether it is
poisonous, what taste it has, how many types there are, and so on. Although it is
mostly plant products that are gathered around Dhorpatan, a few mineral and animal
products can also be found, and he is quick to point these out whenever the occasion
anses.
By the time I arrived in Dhorpatan, the students had already acquired an
impressive knowledge of local medicinal plants. They could all recognise at least 80-
100 plants, some students many more. As Nyima had spent many years studying with

his father in Mustang, his knowledge of plants far surpassed the other students. He
was always keen to expand his knowledge. Every time I went out looking for plants
with him, he would return with several plants that he did not recognise, and ask
Amchi Gege about them. As we saw in the previous chapter, all medical substances
display one or more of eight different potencies. The main indicator of the potency of
a medical substance is its taste, which can be one or more of six different types.
Amchi Gege, when introducing the students to a new medical substance, usually asks
them to taste it. Frequently when I was out looking for medicines with Nyima, his
first response, when he found a plant that he did not recognise, was to taste it.

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 In the medical text, information about medicinal compounds is found in chapters
three to nineteen of the fourth volume, and throughout the third volume, which is a
compendium of Tibetan disease classifications, covering pathogenesis, diagnosis and
therapeutics. Usually the main text says nothing about the quantities of the different
ingredients, or how specific ingredients should be prepared, or which part of a plant
should be used. It is the responsibility of the teacher to provide the extra information,
which will bring texture and detail to the basic fabric of the text. This information is
found in commentaries, or remains strictly part of the oral transmission.
When he is teaching about medicinal compounds, Amchi Gege expands on the
basic information found in the main text, giving detailed information on the various
ingredients, and how they should be prepared and compounded. During the lessons,
whenever a medical substance is mentioned for the first time, Amchi Gege either
shows the students the real thing, if he has it, or if not, a picture of it. The
pharmacopoeia he most often uses in this context is one recently published in Lhasa
entitled 'The Book Born from the Pure Crystal Mirror'. 2 This book includes 861
coloured photographs of medicinal substances.
Hardly any information is given about medicinal plants in the main text; almost
every time a plant is mentioned, some further explanation is needed. A plant referred
to by one name in the text can have several different types, and the specific type
which is referred to in the context described, is not specified. For example a very
commonly used ingredient in medicinal compounds is gentian (tigta); Amchi Gege
told me that it has twelve types of which three are commonly used. Saffron (gurgum)
has three types: only the petals are used of two them, and only the leaves of the third.
Usually nothing is mentioned about the part of the plant that should be used; Amchi
Gege supplies this knowledge. Whenever I saw the plant kyerpa written in the text, I
knew from what Amchi Gege had taught me that only the thin yellow skin that lies
under the bark is used. Moreover, many medicinal ingredients that are listed in the
text are poisonous, and before they are used they must undergo a process of
detoxification: this is also not specified. What is written in the text would be
impossible to put into practice without receiving the essential information of the oral
transmission.

~ Khyung pe drime shel g\'l melong (dka' b'i rdo rjes brtsams 1995).

181
 There are ten basic types of Tibetan medicinal compounds: decoctions, powders,
pills, pastes, butters, ashes, concentrates, beers, herbal preparations and precious
medicines. In the course of their studies, the students gain experience in making all
of these forms, with the exception of precious medicines; this is because the
ingredients, which include, gold, silver and precious stones, are too expensive to be
purchased by the school.
When he is teaching about medicinal compounds in the classroom, Amchi Gege
does not normally specify the exact quantity of each ingredient that is used; the
students learn this when they make the compound. Usually there will be one main
drug, which is the principle ingredient, combined with a variety of other drugs. The
names of Tibetan medicinal compounds reflect this. For example gentian eight (tigta
gyepa) has gentian as the principle drug along with seven auxiliary drugs. Some of
the auxiliary ingredients support the action of the main drug; others balance out any
iatrogenic effects. The main side effect is disturbances caused to the non pathological
humours; we have seen from the branch of humoural reactions, the eighth branch of
the second stem of the first tree, that a medicine, which lowers or raises a humour, is
likely to have a counter effect on one or both of the other humours.
During my lessons, in response to my request, Amchi Gege always specified the
type of plant, and the part that should be used. He also always gave the quantities of
each of the ingredients in grams. Whenever he was uncertain of the exact
proportions, he would refer to various commentaries, where the amount is given in
the traditional Tibetan units of weight measurement, the karma and the zho. Amchi
Gege explained that there are ten karma in a zho, and by his reckoning a zho is more
or less equivalent to a gram.
The students are given plenty of opportunities to put what they learn into practice.
One technique that Amchi Gege used was when the stocks of a medicinal compound
ran low he would ask a few of the students to collect together all the ingredients for
the compound in the correct proportions by consulting various medical texts, he
would then verify what they had done before the ingredients were ground into a
powder. The only potential difficulty here for the students was getting the right
proportions; they could easily recognise many of the ingredients and they knew
where to find them in the storeroom (see Plate 11).

182
 The students also had to prepare specific ingredients before they could be used in
the medicinal compounds. The method most often used was subjecting it to intense
heat. For example, garlic is put inside a sealed metal container and heated until it
becomes black; calcite is heated for a long time in fire until it is reduced to ash; the
stool of wild pigs is also transformed through a heating process before it is used. This
process is undertaken to either eliminate the toxic properties of the substance or to
render it in a form that is more suited to the properties of the compound. For the
students many of these activities have now become routine.
In the previous chapter we saw how the students learn medicine in the classroom.
Before receiving teachings from Amchi Gege, the students should have first
memorised the relevant section of the medical text. Even if they reflect upon what is
written in the text, it is unlikely that they will understand very much. As I have
previously discussed, to facilitate memorisation and the oral transmission of the
medical knowledge, syntax and clarity of meaning have been sacrificed in favour of
preserving the verse form of the text. Phrases are often elided or rendered in a terse
style, which make it almost impossible to understand the exact meaning that is being
conveyed. The text does not provide detailed explanations of medical theory and
practice, it provides the basic elements that must be illuminated by the explanations
of the teacher; the text serves as a support for the oral transmission of the medical
lineage.
From what I have been saying it should be clear that learning medicine in the
school involves three phases: the memorisation of the medical text, Amchi Gege's
explanations based on his own experience and his familiarity with various
commentaries, and engaging in medical practice. To understand how the students
develop competency as medical practitioners, we need to focus on the manner by
which these three levels of learning converge to bring about the transformation of
propositional knowledge into the performative knowledge of medical practice. In
order to give an idea of how these three levels work together in pharmaceutical
activities, I will present Amchi Gege's commentary to the section of the medical text,
which describes one medicinal pill, and my observations ofNyima making it.
The medicine is called Khyullg Nga, and is found at the beginning of the chapter
on medicinal pills, which is chapter five of the fourth volume of the medical text.

183
The name of this medicine does not follow the usual pattern of giving the name of
the principal ingredient followed by the total number of ingredients in the medicine.
Nga is the Tibetan for 'five' and denotes the total number of ingredients, but
'khyung' is not the name of the principal ingredient. Khyung is the Tibetan word,
which equates with the Sanskrit garuda, both words referring to the same
mythological eagle. I say 'mythological', but it must be stressed that many Tibetans,
including Amchi Gege, do no think of it in this way. For Amchi Gege, the khyzmg is
an emanation of the Buddha, and as such it is a very real healing power. The
medicine is named after this creature because, as we will see, it is considered to have
a special relationship with it.
The main text condenses all the information concerning this medicine into ten
3
lines. The only information given in the text is the names of the medicines, the part
of the khyung's body they are associated with, and the names of the diseases the
medicine is used for. In what follows I will give Amchi Gege's commentary, which
accompanied these ten lines. As we will see, he gave considerably more information
than is contained in the main text.
He began by saying that the medicine is associated with the khyung, it comprises
of five medicines, each of which is a part of the khyung's body. The first medicine,
men chen (black aconite), is the heart of the khyung; twenty grams of the root are
used. Many Tibetan medicinal substances have several names, and Amchi Gege
sometimes uses them interchangeably. When he gives the name of a medicinal
substance for the first time he always mentions other names that are used to refer to
it. Another common name for this medicine is bong nga nagpo. Only the root is
used, which Amchi Gege stressed is poisonous. The second medicine, latsi (musk), is
the blood of the khyung; three grams are used. The third medicine, ruta (costus root),
is the bones of the khyung; ten grams of the root are used. The fourth medicine,
chudak nagpo (acorus calamus), is the ligaments of the khyung; six grams of the root
are used. The fifth medicine, arura fruit (terminalia chebula), is the flesh of the

3Dang po spyi 'jom gtso bo ha Ia nag po dang / gia rtsi ru rta chu dag a ru ra / snying Ia bong nga
khrag Ia gia rtsi dang / rus par ru rta elm rgyu ras chu dag dang / sha Ia a ru ra' i nad scI bas / tshad du
sbvur ba dri elms ril bu dril / 'du ba Inga 'joms khyung gi ri lu 'de / nam gyi srod la Inga bdun dgu rim
ru'btang / gag lhog gzcr gsum gnyan srin glang thab dang / khyad par chu ser md.lc nad 'joms pa'\
mchog (folio .t9).

184
 kbyung; forty grams are used. Amchi Gege always gave an exact number of grams
for each ingredient, but this is meant only to indicate the correct proportions.
At this point Amchi Gege then told the following story about the origin of this
medicine, which he took from a Bonpo commentary4 to the Bumshi written by
Kongrong Menlha Dundrub. In the east of India there was a kingdom ruled by a king
called Sangha Pala. At some point, the king and all his people were beset by a series
of virulent diseases. These were sent by various types of spirits such as the lu and the
sinpo. The people responded by praying fervently to the three jewels (konchog Slim),
and the Tantric deities (yidam). The Buddha answered their supplications by
appearing in an emanation body (tulku) in the form of the khyung, and curing all their
diseases. The khyung informed them that when he dies, they must make medicines
from his body to use to cure these diseases in the future. The five parts of the
khyung's body correspond to the five elements: the heart is fire, the blood is water,
the bones are earth, the ligaments are wind, and the skin is the sky element.
Amchi Gege then went on to explain how the medicine should be made. This is
best demonstrated by describing my observations of Nyima, the senior medical
student, making it. To begin with, the four plant ingredients must be ground into a
fine powder; as a general rule, the finer the powder, the more powerful the medicine.
The powder is then put into a metal pan, containing water and a little butter. Nyima
said that initially the consistency should be like thugpa, the traditional Tibetan stew.
The mixture is then brought to boiling point and allowed to simmer for a long time.
Nyima stipulated that the heat applied to it should be gentle and constant. After about
two hours of simmering and constantly stirring the mixture, it eventually became a
thick dark paste. At this point Nyima added the musk. The following day, Nyima and
a few of the other students, spent hours painstakingly rolling the mixture into little
balls about a centimetre in diameter. On the third day, the pills had hardened and
they were rolled continuously for an hour or so, in wide gently concaved metal
dishes, until their exterior became smooth. Finally they were rolled in a cloth, to
further smoothen and harden the exterior; the purpose of this is to trap the aromatic
and medicinal qualities of the medicine inside the pill.

kong rong sman bla don gmb kyis mdzad pa'i rig zeg re'u le'j rkyal pa phyi r~ud Ihan thabs rin po
-I

che 'gor 10 las.

185
 The number of pills given should be adapted to the strength of the illness and the
size of the patient: a small dosage is five, medium is seven and large is nine. They
should be taken in the early evening. Amchi Gege explained that the quantity of
menchen to be used should be adapted to the strength of the patient, on a scale
between five and forty grams. The medicine is used for several different types of
diseases: gagpa and lhogpa, disorders affecting the area of the throat; nyenser and
nyensin, classes of infectious fever; lhangthab, a disease involving pains in the
stomach and abdomen;5 and a disorder of the serum (chuser) leading to leprosy
(dzem!).
As we can see there is a large difference between what is said in the main text and
what Amchi Gege teaches on the subject. Sometimes his explanations are concise
and straightforward, at other times, as with this medicine, they are long and
discursive. All of the students had gained experience at making medicines. In fact,
making medicines in the school had become something of a routine matter. By the
time that I arrived in Dhorpatan, the longer standing students had already been
inducted into the practices of preparing raw ingredients and combining them into
medicinal compounds. When stocks of a medicine needed replenishing, Amchi Gege
would ask the students to make some more, usually they already knew how to do
this, in which case his role would be not so much to teach them as to verifY that they
were doing things correctly.

6.2 Data on Patients Attending the Clinic and Clinical Interaction

It was rare for a day to go by when no patients came to see Amchi Gege. On
average about three patients came daily. It was quite common for eight patients to
come. The most I witnessed in one day was fifteen. In order to shed light on the
method Amchi Gege used to induct his students into clinical practice, I recorded the
procedure, which occurred for 153 patients. This figure does not represent all the
patients who came in a given period, I was not always at the clinic when patients
arrived, and for the first period of my stay I did not record any details about the
patients who arrived. Most of the patients listed below were recorded in the last ten
months of my stay in Dhorpatan.

5The name gives a graphic image of the nature of the illness. Lhang is the Tibetan word for 'ox' ~ the
pain of the illness is likened to being penetrated by an ox's horns.

186
 Age Bishwa
Magar Nauthar Tibetan Chettri Thakali Babun Nepali Chantel European Total Age
Group Karma Group,
M F M F M F M F M F M F M F M F M F M F M F Total I
Below
3
1 3 2 3 3 6 l
3-10 2 0 2 2

11-20 1 1 1 1 3 1 3 1 1 2 2 1 6 12 18

21-30 2 3 2 4 3 4 3 4 1 1 4 i
3 1 10 25 35 i

31-50 1 1 6 3 15 7 2 3 1 6 2 7 4 1 32 27 59

51-60 1 8 3 1 2 2 1 12 6 18
Above
1 4 2 1 1 6 3 9
60
Total
Male/ 4 8 3 10 2 10 31 21 5 8 1 0 1 1 11 11 10 8 1 1 69 78
Female

Bishwa
Age not Karma Magar Nauthar Tibetan Chettri Thakali Bahun Nepali Chantel European Total Age
recorded M F M F M F M F M F M F M F M F M F M Group
F M F Total

1 2 3 2 .t 6

Totals 12 14 12 52 13 1 2 27 18 2 71 82 153

Group
12 13 12 52 13 1 2 22 18 2 1.t7
Total

Table 6.1 Table of Patients by Ethnic Group, Gender and Age Group
 For each of these patients I noted a set sequence of information: gender; age;
ethnic group; domicile; religion; symptoms; diagnosis; disease classification;
therapy; and the medicines used. The first group of items in this list aimed to
ascertain who used the clinic. The exact figures for each ethnic group, and for a
range of age groups can be seen in Table 6.1. The category 'Nepali' comprises those
patients for whom I did not know their exact ethnic group. At the bottom of the table
I have included the patients for whom I did not record any age. The table lists the
ethnic groups in the order of their numerical presence in the valley: Bishwakarma
being the highest and European the lowest. In the summer months, when I recorded
this data, there were around 1000 Nepalese living in the valley, and 250 Tibetans.
We can see from the table that all the ethnic groups present in the valley use the
clinic. Taken together the Nepalese constitute sixty-six percent of the total number of
patients that I recorded. The Tibetans, who form only twenty percent of the total
population, constitute thirty-four percent of the total number recorded; this high
proportion can be accounted for due to reasons of cultural affinity. The only other
figures in the table that require explanation are the disproportionately high numbers
of Chettri and Chantel patients. This can be explained by the fact that many of these
patients did not live in Dhorpatan, but in various locations in the surrounding valleys.
It was quite common for people to come to the clinic from villages that were located
up to one day's walk from Dhorpatan.
The second group of data relates specifically to clinical interaction. My aim in
recording the symptoms was two-fold: the prime aim was to understand how the
symptoms were interpreted as indicators of predefined disease classifications by
Amchi Gege and his students; in addition to this I was following Meyer's suggestion
of using elementary symptoms as a possible means of making comparisons between
the disease categories of different nosological systems. As he expresses it:

If elementary symptoms are indeed transcultural, this cannot apply to their classification as
nosological entities. It is thus \'cry difficult to establish direct equi\'alents between different
nosological systems, except when the association of symptoms is so obvious that it is
universally recognised (1995: 13).
The symptoms that I recorded can be grouped into two types: the first type were
the symptoms that the patient first said to Amchi Gege and his students, without any
prompting on their behalf; the second group of symptoms were reported in response

187
No. Disease Description I No. of I

I
I
cases
Classification I
Various types of tumour - in most cases the location was I
1 tren 29
the stomach or the intestines
2 drumbo Rheumatic condition -+
3 mentruation dorders Various types 6
4 mewal Itchy rash I
Various disorders caused by the phlegm humour effecting
5 peken -+
the throat and stomach
6 lung General wind disorder 1
7 tripa General bile disorder 2
8 tra lunf( Disorder caused by a combination of blood and wind I
9 pe lung Combined phlegm and wind disorder 5
10 pe tri Combined phlegm and bile disorder 3
11 pe tshe Phlegm and fever mixed 2
12 drangwa General cold disorders -+
13 tshawa Various types of general fever disorder 8
14 po ne General stomach disorder 9
15 so ne Toothache 2
16 wound Various types of cuts, bites and abrasions -+
17 /if(luf( Hydrocele (swollen scrotum) - [chap. 68 of the 3ra treatise] -+
18 peken mugpo Chronic digestive disorder 13
19 dram tshe Fever caused by a physical blow like falling from a horse 3
20 diarrhea General diarrhea condition of various causes -+
21 kyabab First stage oedema 2
22 mu chu Second stage oedema 1
23 menbu Disorder effecting the neck glands 1
24 nyen ne Infectious fever 2
25 champa Common cold 3
26 zhang drum Haemorrhoids 2
27 tsa karpo This patient had a trapped nerve in his neck I
28 ~ne Intestinal disorder 2
29 lonka natsha Colon disorder 2
30 drib Pollution causing disturbance in the humours (see ch. 7) 2
31 sa drib Disorder caused by planetary influence (see ch. 7) -+
32 kha lang Rash inside the mouth I
33 dzerpa Warts 1
3-+ sin thor Acne 1
35 sin ne Disorder caused by genn-like organism 1
36 khalne Male and female kidney disorders -+ I

37 chu ser Disorder of the serum 3

38 sha tra Skin disease I
39 poor hearin~ I
40 tra ne Blood disorder 3
-+1 chin ne Liver disease 1
-+2 napa Disease caused by malevolent spirits -+

Table 6.2 Table of disease classifications diagnosed for patients recorded

to Amchi Gege's questions. The normal procedure during diagnosis in Tibetan
medicine is that the doctor should ask questions to verify the nature of the condition.
We have seen that these questions are given as the twenty-nine leaves of the third
stem of the tree of diagnosis. But these twenty-nine leaves serve only as a summary;
Amchi Gege could also formulate innumerable questions based on his knowledge of
the symptoms of disease described in the third volume of the medical text.
F or the diagnosis I recorded which form was used, who did it, and how Amchi
Gege inducted the students into the practice. The most common forms of diagnosis
were asking questions and taking the patient's pulse. Of the 153 patients that I
recorded, urine diagnosis was carried out only seven times. For each patient I also
recorded the name that had been applied to the disorder. In total, for my sample
group I recorded forty-two disease classifications, each of these classifications can be
seen in Table 6.2 along with the number of patients who had been diagnosed as
suffering from the condition. Finally I recorded the therapeutic method that was
applied, and the specific medicines that were used.
In the process of studying the third volume the students memorise and receive
teachings on a huge range of diseases, symptoms, and medicinal compounds.
Through engaging with this knowledge in clinical practice, certain elements will be
appropriated and made a part of the student's sphere of practical competency.
However as I have said of the 153 patients, there were only forty-disease
classifications and most of these occurred very few times, from this we can conclude
that a large amount of what they learn in the classroom will seldom or never be
experienced in practice and as such this knowledge will remain at the propositional
stage. In the next section I will describe the various ways that the students develop
performative memory through clinical interaction.

6.3 Learning Through Clinical Interaction

Now we have considered how the students learn medicine in the classroom and in
the pharmacy, what remains is the third area of the schools activity clinical practice.
I am using the word 'clinical' here, not in its restricted biomedical sense, but in
Kleinman's sense of the word as a cross-cultural category. As he explains it:
'Clinicar. in the sense that I haye discussed it. is not a Western category, but a category
intrinsic to all societies. The problem with most ethnomedical studies is not that they impose an

188
Plate 17 - Patients waiting outside Amchi Gege's room.

Plate 18 - Amchi Gege and Nyima cleaning out an abscess .

 alien clinical category on indigenous materials, but rather that they fail to apprehend a profound
cross-cultural similarity in clinical interest and praxis' (1980:83).

F or Kleinman this similarity in clinical interest lies in what he refers to has the core
clinical functions of health care systems, these include: the cultural construction of
illness; explaining and categorising illnesses; therapeutic methods; and managing
therapeutic outcomes (1980: 71). In Dhorpatan, these core clinical functions are
carried out by Amchi Gege and his students during clinical interaction.
Meaning is generated in clinical practice through the use of specific cultural
explanatory models. As I have discussed in chapter two, Kleinman identifies five
principal questions that explanatory models seek to address: etiology, time and mode
of onset of symptoms; pathophysiology; course of sickness; and treatment. Through
Amchi Gege's guidance, the students acquire the skill to employ what they have
learnt in the classroom as explanatory models to give meaning to what they
experience in clinical practice.
The adjective 'clinical', used In the above sense, refers to medical practice
whereby symptoms are interpreted and understood as representative of certain types
of disorder, this will then dictate the therapeutic approach that is to be taken. Clinical
activity is thus not confined to a specific space in the medical school, it occurs
wherever Amchi Gege and his students attend to patients. For most of the time that I
was in Dhorpatan, a new medical building was being constructed. This building had
rooms designated for certain types of activity such as: the clinic, the classroom,
religious activities, caring for inpatients, and drying and storing medicines. Even
though this building had been completed about three months before I left Dhorpatan,
Amchi Gege rarely used it to see patients or to teach his students. He continued to
use his own room as the classroom and to consult with most of his patients in the
small courtyard outside his door (see Plate 17).
It was quite common for patients to arrive in the middle of the students' lesson, in
which case Amchi Gege would either let them wait until he had finished teaching, or
if there was some degree of urgency he would disrupt the lesson. As I have
mentioned earlier, for the students, this meant that a formal classroom-learning
context, could quickly shift into a clinical session. This was the general pattern of
learning in the school: the pharmacy, classroom and clinic, were not bounded zones
of learning, there was a great deal of fluidity between them.

189
 As my main objective in recording the details of the clinical interaction was to
learn how the students were inducted into clinical practice, most of the time I asked
the students to explain to me what occurred. The students who had been assisting
Amchi Gege, always knew about the diagnosis, the disease category, and the
medicines that had been given to the patient, even if they were merely reporting to
me what Amchi Gege had said and done. As in most cases the students had been
actively involved in the clinical interaction, I was able to ascertain their own
understanding of the patient's condition.
On the few occasions when I asked Amchi Gege to explain to me about patients
who he had seen that day, he gave me much more information than the students did.
He went into detail about the diagnosis, and the disease classification he had
identified. He explained to me that when carrying out diagnosis it should always be
done in a certain manner: first, the doctor should observe the patient's body, whether
there is anything unusual about its colour, if there are any marks, protuberances,
rashes, and so on; second, the doctor should take the pulse; and third the doctor
should ask questions to refine the diagnosis.
Amchi Gege was taking for granted here that as soon as a patient arrives, the first
thing they will do is explain their condition, as they perceive it. For example, on one
occasion, a patient arrived at the clinic when there were no students around, so
Amchi Gege attended to him on his own. The patient was a forty-five-year-old
Nepali man. First, he explained to Amchi Gege that he was suffering from pains in
his chest. Amchi Gege looked at the patient's tongue, took his pulse, and asked him
about his condition. He explained to me that: if the pain is on the right of the
patient's chest, it could be a blood disorder; if it is on the left side, the cause could be
an 'infection' (nyene); and if the pain moves into different locations in the chest, the
cause could be the wind humour. The patient had said that the pain moved around.
The diagnosis of wind as the principle cause of the disorder was confirmed by the
patient's inflated pulse, and the appearance of his tongue, which was red, dry and
rough.
Before moving on to consider examples of how the students learn through clinical
interaction, I will first summarise the key features of the learning process \\"hich I
discussed in chapter two. The model of learning that I have adopted to understand

190
how the students learn medicine, involves four modes of knowledge; these four
modes of knowledge are summarised in Table 2.1. The first mode is propositional
knowledge. This mode of knowledge has a discursive form. In chapter five I have
discussed how the students acquire the propositional knowledge of Tibetan medicine
through Amchi Gege's teachings on the main medical text.
The next three modes of knowledge are related to practice. By engaging with
propositional knowledge in practice, the student begins to acquire competencies
which involve the non-discursive mode of knowledge; by this means 'knowing that'
is transformed into the 'knowing how' of practice. In chapter two I have also
discussed the Dreyfus and Dreyfus model of learning which involves a scale of five
stages in the development of expertise: novice, advanced beginner, competence,
proficiency, and expert. The student progresses on this scale as knowledge is
increasingly situated in practice; in this way the student acquires the tacit forms of
knowledge, which underpin expertise. The innate mode of knowledge relates to the
'knowing subject', or 'authorial self who brings coherence and meaning to what is
experienced in clinical practice.
Through Amchi Gege' s teachings In the classroom, all of the students had
acquired a large range of explanatory models related to specific diseases. The task in
clinical interaction is to relate these explanatory models to the symptoms which they
encounter. At first, the knowledge they have acquired in the classroom is difficult to
situate in practice, but with increasing experience a shift occurs, at which point
knowledge is no longer simply known, it is enacted; the propositional knowledge
acquired in the classroom is transformed into the performative memory of clinical
practice. As expertise develops, knowledge is appropriated into the individual's
sphere of competence and becomes a mode of being in the world. The transformation
of propositional knowledge into the performative memory of clinical practice
pertains to the two highest levels on the Dreyfus and Dreyfus scale: proficiency, and

expert.
On most occasions when Amchi Gege saw patients, he had one or two of his
students acting as his assistants. As Amchi Gege speaks very little Nepalese, he
needs the students to act as translators. At first I thought that this would be a very
difficult task, because it would involve translating between Nepalese and Tibetan

191
medical concepts; but this was not an issue as the Nepalese patients never described
their condition in medical terms, they described only the specific ways in which they
were suffering.
About half way through my stay at the school, Amchi Gege set up a rota system,
which involved each student serving as his assistant for a period of two weeks. I
mentioned earlier that the mechanism by which the students develop performative
memory in clinical practice in Dhorpatan is what Lave refers to as 'legitimate
peripheral participation'. Through this method the students develop expertise by
being allowed to participate in varying degrees and with varying responsibilities in
the practice of the master. In clinical interaction the students are inducted into
medical practice by practising alongside Amchi Gege as supervised legitimate
peripheral participants. As their expertise develops they are given more
responsibilities and brought increasingly closer to the centre of medical practice.
Amchi Gege used the method of legitimate peripheral participation to induct the
medical students into clinical practice in two different ways. The first way involved
him carrying out the diagnosis in front of the student, he then told the student what
the patient's conditions was, and asked him or her to verify his findings, this is the
method he used during most clinical interactions. The second method involved the
same procedure, but this time Amchi Gege said nothing about what he had perceived
in the diagnosis, nor about how he had interpreted the condition; he allowed the
student to first attempt to come to their own conclusions, and after this, if it was
necessary, he corrected them.
I have already given one example of this method in chapter two in the section on
the development of performative memory in clinical practice, where the students,
Yundrung and Nyima, mistook 'old fever' for 'hiding fever'. Another example of
this method, which involved the same two students, was the case of a 28-year-old
female Tibetan patient. She said that she was suffering from fever, and pains in the
left side of her chest. Nyima explained to me that about two weeks before, she had
come to see Amchi Gege complaining of a similar condition. A few weeks prior to
this her husband had died and Amchi Gege had concluded that her distraught
emotional condition had caused a disturbance in the wind and bile humours. A.fier
taking her pulse, Nyima and Yungdrung could not decide on the exact nature of the

192
condition. To them it seemed like fever, but it could also have been a disturbance in
the bile humour. Amchi Gege confirmed the problem to be the latter.
In what follows I will give twenty examples of clinical interaction that I observed
in Dhorpatan, from four areas of clinical activity: pulse diagnosis, urine diagnosis,
and treatment. I will also give examples of how the students learnt medical practices
related to tren, the most common disease amongst the group of patients that I
recorded; this will enable an understanding of the ways in which Amchi Gege' s
teachings on the tren chapter of the Bumshi, which I discussed in chapter five, relate
to instances of clinical practice involving this disease. In my discussion of each of
these clinical interactions, I will attempt to interpret the event in terms of the various
modes of knowledge and the Dreyfus and Dreyfus scale of developing expertise.

6.3.1 Learning the Practice of Pulse Diagnosis

Patient 1

I will begin with one of Amchi Gege's female students, Tsering Lhamo. She had
been studying medicine for five years and in that time had acquired much experience
in clinical practice. Though she had achieved some mastery of pulse diagnosis, still
on occasions, as the following three examples will show, she experienced difficulty
understanding the pulse.
The first patient I shall discuss was a forty-eight-year-old Tibetan woman who
complained of poor appetite, and fever. Amchi Gege first took the patient's pulse and
explained the condition to Tsering Lhamo as a disorder caused by the combination of
the phlegm and bile humours. He then asked her to verify for herself his diagnosis.
She took the patient's pulse, which she said was 'deep'. Afterwards, she told me that
the pulse was difficult to feel and she could not understand how Amchi Gege had
concluded from it that the disorder was a disturbance in phlegm and bile.
Even though Amchi Gege had told her what the condition was, she still had
difficulty in relating her perception of the pulse to this disorder. Tsering Lhamo
knew in terms of propositional knowledge about the nature of the disease, but she
could not fully situate this knowledge in clinical practice. Her pulse diagnosis was
not clear, and appeared to involve much conscious deliberation, and very little
intuitive, tacit understanding. We can conclude that Tsering Lhamo in this clinical

193
interaction has the attributes of an 'advanced beginner' on the Dreyfus and Dreyfus
scale.

Patient 2

This patient was a 50-year-old male Tibetan. He complained of recurrent

headaches, stomach-ache and poor appetite. Amchi Gege first took the patient's
pulse and told Tsering Lhamo that the patient's condition was peken mugpo, which is
a chronic digestive disorder. He asked her to take the pulse and verify this for herself
As can be seen in Table 6.2, Peken Mugpo was the second most prevalent disease
amongst the group of patients that I recorded. All of the students had received Amchi
Gege's teachings on the chapter of the third volume which deals with this disease. In
addition, because of the prevalence of the disorder in Dhorpatan, all the students
knew of people who had been diagnosed with this disease.
The characteristic pulse for peken mugpo is that the pulse on the second finger is
either absent or very faint compared to the pulse of the other two fingers. When I was
discussing the disorder with Yungdrung, one of Amchi Gege's students, he directed
me to feel his pulse, because he himself had recently suffered from it. He said that
although he was then much better, the disorder could still be felt in his pulse. The
pulse on the middle finger did feel vaguely faint compared to the pulse of the other
two fingers. Tsering Lhamo told me that she could feel the pulse very clearly and had
no problem in relating it to the disorder of peken mugpo. Although in this instance it
appeared that Tsering Lhamo was able to situate her knowledge of peken mugpo into
medical practice in an intuitive way with very little conscious deliberation, because
she was first told by Amchi Gege what the disease was, we can conclude that in this
interaction she has the attributes of 'competence' on the Dreyfus and Dreyfus scale.

Patient 3

On most occasions when patients came to the clinic, Amchi Gege inducted his
students into medical practice through the method of legitimate peripheral
participation, but there were occasions when the students attended to patients on their
own. If Amchi Gege was not around when patients arrived at the clinic, one of the
more experienced students would attend to them. Usualh the student would attempt

194
a diagnosis, and if they felt confident about the nature of the patient's condition, they
would give the appropriate medicine; if they were uncertain, then they would tell the
patient to come back and see Amchi Gege. Sometimes the sick person would be
unable to come to the clinic, and a message would be sent to Amchi Gege about the
sickness. He would then either go himself to visit the patient or he would send one of
his students. The students would have to report back with information about the
patient's symptoms, and an assessment of their condition. It was usually the more
experienced students that were entrusted with this task: more often than not, Nyima.
In this way, by giving the students more and more responsibility, they were brought
gradually closer to centre of practice.
On one occasion whilst Amchi Gege was away, I had the opportunity to observe
Tsering Lhamo attend to a patient alone. The patient was a ten-year-old Tibetan girl.
She said that she had stomach-ache and no appetite. Tsering Lhamo took her pulse,
which she found to be slow and weak. She concluded from the pulse and the
symptoms that she was suffering from a cold disorder, and she gave the girl one
medicinal powder to take (sugme/ chupa).
From my observation of Tsering Lhamo attending to this patient, there seemed to
be no doubt in her mind about the veracity of her diagnosis and that the medicine she
had given was entirely appropriate. In this interaction she was able to situate her
knowledge in practice with some ease and fluidity. Whether this would have been the
case if Amchi Gege had been present is not certain, but in this instance it seemed that
Tsering Lhamo was approaching the 'proficiency' stage on the Dreyfus and Dreyfus
scale.

Patient 4

During this and the following clinical interactions, Tundup Gyaltsen served as
Amchi Gege' s assistant. He had been studying medicine for seven years and his
knowledge and experience of pulse diagnosis were about the same as Tsering
Lhamo's. This patient was a fifty-year-old Tibetan man who complained of
headaches, a bloated stomach, and no appetite. Amchi Gege first took the patient's
pulse and told Tundup that the condition was peken mugpo. He then asked Tundup to

195
take the pulse and verify this for himself. Tundup told me that he had no difficulty in
discerning the characteristic pulse of the disorder.
The comments I made above for Tsering Lhamo, for patient two, are also
pertinent here. Tundup was thoroughly conversant with the medical theory related to
peken mugpo and had no difficulty situating this in practice. However, because
Amchi Gege first told Tundup that the condition was peken mugpo, I will class his
level of medical practice on the Dreyfus and Dreyfus scale as that of' competence' .

Patient 5

This patient was a sixty-year-old Tibetan man. He complained of a swollen

painful throat, stomach-ache, back pains and that his stool was dry. Amchi Gege took
the patient's pulse, which he said felt like two beats occurring at the same time
(chamdrel). All the time, Tundup was listening and watching. He concluded from
what the patient said, and the pulse diagnosis, that the disease was a form of
'infectious' fever (nyene). He then directed Tundup to take the patient's pulse.
In the classroom, Tundup had already studied the characteristics of the chamdrel
pulse during Amchi Gege's teachings on the pulse chapter in fourth volume of the
main medical text. Tundup had also received teachings on the nyene section of the
third volume of the main medical text. Therefore, he could relate very well to what
Amchi Gege was saying from a theoretical point of view. Certainly the patient's
symptoms taken in combination with the chamdrel pulse, indicated the condition of
nyene.
When Tundup took the pulse he told both Amchi Gege and myself that he could
clearly discern the chamdrel pulse. Thus it appeared that Tundup was able to situate
his theoretical knowledge in practice. However, again because Amchi Gege first told
Tundup about the pulse and the related disorder, I will classify Tundup's level of
skill on the Dreyfus and Dreyfus scale, in this interaction, as one of 'competence'.

Patient 6

The following three clinical interactions all involved the senior medical student,
Nyima. As in all other areas of medical practice, Nyima displayed the highest level
of skill in pulse diagnosis. He very rarely seemed to have any doubt about the

196
quality of a pulse. Pulse diagnosis had become almost second nature to him. He
seldom made mistakes, but on the odd occasion it did happen, as in the example I
gave in chapter two where he mistook 'old fever' for 'hiding fever'. In most areas of
medical practice he was able to situate his knowledge with ease into medical
practice, and his high level of skill suggested that he had a well developed intuitive
and tacit knowledge of medicine. On the Dreyfus and Dreyfus scale, in many areas
of medical practice he had reached the level of 'proficiency', this is certainly true in
my estimation for the following three example of clinical interaction.
On one occasion a group of French people were passing through the valley. Out of
curiosity, one of them asked Nyima and myself to take his pulse. We had no reason
to believe that he was unhealthy in any way. I took his pulse first, and could not
perceive anything unusual. Then Nyima attempted the diagnosis, and after a few
minutes deep concentration he said that there seemed to be a problem with the pulse
for his lungs. Afterwards, the French person told us that he suffered from asthma.

Patient 7

On another occasion a thirty-eight-year-old man from the Chantel ethnic group

came to see Amchi Gege. He said that for more than a year he had been suffering
from an itchy rash all over his body. He had been to the hospital in Pokhara, but the
medicine they had given him had not helped. First Amchi Gege took his pulse and
told Nyima that the man was suffering from a cold disorder affecting the serum
(chuser). He then directed Nyima to verify his diagnosis. Nyima said that all his
pulses were slow, and he fully concurred with Amchi Gege's diagnosis.

Patient 8

This patient was a forty-five-year old Nepali man. Amchi Gege was not present
when he arrived at the clinic, and Nyima attended to him on his own. He complained
of a poor appetite and a bloated stomach. Nyima took his pulse and concluded that
the man was suffering from an early stage of peken mllgpo~ he gave him the
appropriate medicines for this disorder. Nyima had no doubt about his diagnosis. He
was able to situate his knowledge of this disease in practice with considerable ease
and fluidity. Due to his high levels of skills in medical practice, in this clinical

197
interaction Nyima behaved not so much as a legitimate peripheral participant, but as
a full member of the body of practice.

6.3.2 Learning the Practice of Urine Diagnosis

The students had all studied the second chapter of the fourth volume of the
medical text on urine diagnosis, they therefore knew very well about it from a
theoretical point of view. In chapter five, I have described how the students acquired
the propositional knowledge related to urine diagnosis in the classroom. Urine
diagnosis was carried out only once, or occasionally twice a month, and as such the
students had very little opportunity to situate this knowledge in practice and thereby
develop practical expertise in this area. On numerous occasions I saw students
attempt pulse diagnosis without the aid of Amchi Gege, but I never saw any of the
students doing urine diagnosis alone. A large section of the chapter on urine
diagnosis deals with the characteristics of the urine, which denote the action of a
harmful spirit. This form of diagnosis is akin to divination and I will discuss it in
detail in the divination section of chapter eight. Urine diagnosis was always done
early in the morning. Whenever it occurred, Amchi Gege would call all his students
to observe and learn about the procedure.
In each of the following examples Amchi Gege inducts his students into the
practice of urine diagnosis in the same way: he demonstrates the techniques of urine
diagnosis; he points out the characteristics of the urine; and he relates the
characteristics of the urine to the patient's condition. When he identified a
characteristic of the urine, he would try his best to ensure that all the students could
clearly see what he was talking about. Occasionally he would ask the students
questions about the urine that related to information they had been taught in the
classroom. Most Tibetan medical knowledge can be found in the main medical texts
or in the commentaries, but some knowledge remains strictly part of the oral
tradition. With patients one and four below, we can see the way that during practice
Amchi Gege imparts to his students knowledge that is not contained in the medical

text.

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Patient 1

On one occasion, the wife of a fifty-eight-year-old Tibetan man brought a sample

of his urine. She did not say very much about her husband's symptoms apart from
that he was feeling generally unwell in an unspecified way. Amchi Gege called all
the students to observe the urine. He first pointed out its orange colour. He then
stirred the urine with a stick, generating much froth. He pointed out to the students
that the urine looked 'dirty', and said that this was because it was not fresh. As we
saw in chapter five, the urine must be observed at three times: when it is hot, when it
is cooling down, and when it has cooled down. Amchi Gege explained, if the urine is
a few hours old, it can be warmed to enable the doctor to observe its qualities during
these three phases. This technique is not mentioned in the main medical text. After
this was done, he concluded that the patient was suffering from a cold disorder.

Patient 2

On this occasion one of the female students brought a sample of her uncle's urine.
Amchi Gege called all his students to observe the diagnosis. On the day before, they
had seen another sample of the patient's urine, which looked like water~ the
characteristic urine of a wind disorder. Amchi Gege had concluded that the wind
humour had spread out of its own pathways into other areas of the patient's body. He
had given a medicine to gather the humour. The patient's new urine sample had no
pathological qualities; this proved that he had responded well to the medicine. Amchi
Gege explained that the humour had been gathered in the patient's stomach and
another medicine was needed to remedy this situation.

Patient 3

The following example demonstrates the way in which Amchi Gege draws the
student's attention to specific details in the qualities of the urine. Whilst observing
the urine of a woman who was suffering from aches and pains all over her body,
Amchi Gege pointed out to all the students that there was no sediment, and that the
bubbles disappeared very quickly after the urine was stirred. He also indicated that
the colour was yellow, denoting a fever condition. He concluded that the patient was

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suffering from lungtse (rlung tshad), a disorder involving both the humours of bile
and wind.

I remembered from Amchi Gege's lessons on unne diagnosis that with fever
conditions there should be some sediment, and I questioned him about this. He
reminded me of the section in the medical text, which speaks of wind descending on
bile like an eagle scattering a flock of pigeons. This was the case with this disorder.
Through the action of the wind humour, the bile humour had been scattered
throughout the patient's body, this was signified by the absence of suspended
material and the quickly vanishing bubbles.

Patient 4

On this occasion, a girl brought a sample of her mother's urine to Amchi Gege.
She was also suffering from aches and pains all over her body. Amchi Gege pointed
out to the students its strong yellow colour. Then he stirred the urine with a short
stick and indicated that the bubbles, which had accumulated on the surface, stayed
for a long time. He then directed the students' attention to the sediment, which was
suspended high up in the urine. Finally he sprinkled a medicinal compound on the
urine and observed how this affected the bubbles and the urine when it was stirred.
This technique, which Amchi Gege also uses in 'The Angry Widow' section of
chapter eight, is also not mentioned in the main medical text. When I asked him
about it, he said that it was a 'secret' technique that was passed on to him by his
teachers.

6.3.3 Learning the Practice of Therapy

By far the main therapeutic method used by Amchi Gege is to give the patients
medicines. Measuring out the required amount of each of the medicines to be used
was always the task of the student who was assisting Amchi Gege at that time. The
student also had to explain to the patient how and when the medicine should be
taken. By repeatedly carrying out this task, the students learn to associate medicines
with specific disorders and the ways that they should be taken. We have seen that in
certain instances, if Amchi Gege is not present, some of the more experienced
medical students will assume the responsibility for this task. We can conclude from

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this that with certain disorders, the more experienced students had acquired the level
of 'competency' in the Dreyfus and Dreyfus scale. As other fonns of therapy are
seldom used in the school, the students have little opportunity to get experience of
them. Whenever Amchi Gege did carry out some fonn of external therapy, he always
asked a few of the students to attend and observe. The following two examples
involve students learning external therapies.

Patient 1

One morning I noticed one of Amchi Gege' s students, Yungdrung Lhazon,

preparing a moxibustion application. As I have said in chapter five, this form of
treatment involves the burning of the herb gerbera on specific locations on the body.
Amchi Gege had taught all his students how to roll the herb into the required cone
shaped fonn, and Yungdrung was doing it evidently with some previously acquired
expertise.
The moxibustion application was for a twenty-one-year-old male Tibetan who had
slipped and dislocated his ankle whilst he had been out collecting wood. When
Yungdrung had finished rolling the moxibustion application, Amchi Gege directed
him to place it on a certain location on the patient's ankle, where it was fixed in
position with a sticky substance made from garlic. Yungdrung then lit the cone
causing it to smolder. He then gently blew on it until it had burnt down to the
patient's skin. He did all this with the expertise of a person who was thoroughly
conversant in the practice. After this, an ointment was applied on the location. I was
told that the purpose of the application was to reduce the inflammation and speed up
the healing process.
Yungdrung carried out most of this treatment on his own. Amchi Gege supervised
the procedure but Yungdrung appeared to know exactly what he was doing. He was
able fully to situate his knowledge in practice, and required very little instruction
from Amchi Gege. For this reason I would situate Yungdrung's level of ability in this
clinical interaction at the 'proficiency' level on the Dreyfus and Dreyfus scale.

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Patient 2

Another form of external therapy, which I witnessed Amchi Gege demonstrating

to his students, was cleaning out an abscess with a small surgical knife (see Plate 18).
The abscess, which was very inflamed, was on the patient's right index finger. All
the students observed as first Amchi Gege made a small incision into the inflamed
area, and then Nyima used a pair of tweezers to extract the abundant purulent matter
that had accumulated inside. Eventually, buried deep in the abscess, he found what
looked like a very small sharp piece of wood. The patient looked in great discomfort
throughout the proceedings, as did most of the students. Afterwards, Amchi Gege
washed the wound with iodine solution.

6.3.4 Learning About Tren Through Clinicaiinteraction

Table 6.2 shows the disease classification of tren to be by far the highest disease
amongst the patients that I recorded. The unusually high figure of twenty-nine
occurrences demands explanation. Unfortunately nobody was certain of the reason
why this disease was in such abundance. Some people said it was due to the fertiliser
that was used on the potatoes; other explanations I heard were that it was due to
people having sexual intercourse during menstruation or shortly after the woman had
given birth, or that it was because people worked too hard. Amchi Gege thought that
it might be related to people's diets, but he was not certain about this. Whatever the
cause, its abundance in Dhorpatan meant the students had plenty of opportunity to
gain practical experience of diagnosing and treating it.
In chapter five we saw how Amchi Gege teaches about {ren in the classroom. All
the students had memorised and studied this chapter, but not all the students had
developed the same level of practical competency. To demonstrate this I will give
examples of clinical interaction, which involved three students attempting to
diagnose patients with {ren; in these instances each student exhibits a different level
of practical competency.
As we saw from Amchi Gege's teachings, there are three types of Irell classified
according to location: outer, middle and internal {ren. Most of the Ire II of the patients
I recorded were of the middle variety, that is to say, the {rell was situated not inside

202
an internal organ, but on the surface of it. All of the examples I give below were
middle tren. Also in each case, the tren was located in the region of the patient's
stomach. By this I mean the area above the navel and below the chest, not the organ
of the stomach. The tren may have been on the surface of the stomach, but it also
might have been on the surface of the intestines.
The text describes four methods of diagnosis for tren: pulse, urine, symptoms, and
questions. I never witnessed Amchi Gege using the urine method to diagnose tren;
the pulse and the symptoms were always sufficient. For most cases of tren, the pulse
is faint and weak; this was the case with all of the following examples. As we will
see, if the student had not developed high sensitivity in his or her pulse taking, very
little could be discerned of the tren pulse.
Quite often the patients complained of a beating sensation in the area of the tren.
Nothing is said about this in the main medical text, but in the clinic in Dhorpatan it
was taken as one of the key symptoms. The text lists four methods of treatment for
tren: medicines, external treatment, diet, and behaviour. I never witnessed Amchi
Gege using any form of external treatment with patients who had been diagnosed
with tren; the principal treatment was a series of medicinal compounds, which the
patient had to take over a long period of time.

Patient 1

In the following two examples, Chunsom, one of Amchi Gege's female students,
served as his assistant. She had studied medicine for seven years and had acquired a
high level of competency in medical theory, but still needed to perfect her abilities in
medical practice. The patient was a forty-year-old Nepali woman. She said that for
three years she had suffered from a growth in the region of her stomach, and that she
could feel pain and a pulsating sensation in the location of the growth. She added that
whenever she did hard work her condition became worse.
These symptoms were partly elicited by Amchi Gege's questions and partly from
her own account of her condition. She had come to the clinic a few weeks before and
Amchi Gege had given her some medicines to take. She said that this had helped, but
a few days before, her condition had resurged after she had been chopping wood.
Amchi Gege felt the growth, which he said was about eight centimetres long ...\fter

-'0'-'
taking her pulse, he asked Chunsom to try the diagnosis. She explained to me that the
pulse did not convey anything to her. Chunsom was then asked to measure out more
of the same medicines the patient had been given before.
In this interaction Chunsom seemed not to fully understand what Amchi Gege was
doing. With this patient she had some difficulty situating her knowledge about (ren
in clinical practice. If she had carried out the diagnosis on her own, she would have
most likely understood the condition to be tren from the symptoms, especially the
beating sensation, which many patients with tren complained about in Dhorpatan, but
she could not understand anything about the condition from the patient's pulse.
Following from this we can see that on the Dreyfus and Dreyfus scale, Chunsom, in
this interaction has the attributes of an 'advanced beginner'.

Patient 2

This patient was a fifty-year-old Nepali woman. She explained that she had
suffered from a growth in her stomach for twenty-five years, which had
progressively worsened. She said that often she could feel a pulsating sensation in
the region of the growth, and sometimes immense pain. Amchi Gege first pointed out
to Chunsom that the skin on her stomach was covered in discoloured blemishes. He
then felt the growth. He said that the condition was so old that the tren was now
almost as big as her stomach. After taking her pulse he directed Chunsom to first feel
the growth and then to take her pulse. She told me that the pulse was very difficult to
discern, she thought 'maybe it was deep'. She was then instructed to measure out
three medicines and explain to the patient how they should be taken.
As with patient one above, with this patient Chunsom understood the nature of the
problem from a theoretical view. She also had no difficulty when it came to
measuring out and administering the medicines. The main problem for Chunsom was
situating her knowledge in practice; in this case relating the symptoms to the specific
form of tren the patient was suffering from. Generally speaking she had acquired a
reasonable level of competency in clinical practice. On numerous occasions I had
observed her read a patient's pulse with confidence, but in this interaction, again she
has the attributes of an 'advanced beginner'.

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Patient 3

In the next two examples Tundup was Amchi Gege's assistant. This patient \vas a
seventy-three-year-old Nepali man. He said that for the last seven years he had
suffered from: poor appetite, difficulty breathing, fever, and pains in his stomach.
Amchi Gege took his pulse and felt his stomach. When he had finished, he directed
Tundup to do the same. Tundup told me that he could feel a large growth in the
man's stomach, and he said that his pulse was very weak. He was then instructed to
measure out and give three medicines to the patient.
In this interaction Tundup closely followed Amchi Gege's instructions and
assessment. He didn't appear to have any problem in understanding the patient's
symptoms, nor did he appear to have any difficulty in feeling the pulse, but as this
was all done under the direction supervision of Amchi Gege I will categorise his
level of ability in this interaction as 'competence' on the Dreyfus and Dreyfus scale.

Patient 4

This patient was a twenty-three-year-old Nepali girl. She had exactly the same
symptoms as patient three above, except she did not have a fever. The same
procedure ensued whereby Amchi Gege felt the girl's stomach and took her pulse
and then directed Tundup to do the same. Tundup said that he could feel a small
growth in her stomach and that her pulse was weak. Amchi Gege explained that the
girl was suffering from the same condition as the old Nepali man, only her condition
was in a much earlier phase; he then instructed Tundup to give her the same
medicines.
Both Tundup and Chunsom had been studying medicine for the same amount of
time. From discussions I had with them, and from my observations of their skills in
clinical practice, I would estimate that they had both achieved the same level of
ability in medical theory and practice. Though, in these four examples I have given
of them attempting to diagnose patients with tren disorders, Tundup demonstrated a
higher level of skill.

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Patient 5

The student who showed the highest level of competence in dealing with tren was
Nyima. I will give two examples of him diagnosing and treating patients suffering
from tren. The first patient was a sixteen-year-old Nepali boy who had been brought
by his father to the clinic. He said that although right at that moment he was feeling
quite well, for the past three years he had been suffering from recurring health
problems, these included: a beating sensation in the region of his stomach; diarrhea;
poor appetite; and occasionally, difficulty to move. Amchi Gege began by feeling the
boy's stomach and then he took his pulse; he asked Nyima to do the same. Nyima
told me that he could feel a hard growth in the boy's stomach about seven
centimetres long, and that all his pulses were weak, but those on his left hand were
weaker. This is exactly what Amchi Gege had felt. Nyima, following Amchi Gege's
instructions, gave the boy three medicines.

Patient 6

The second patient arrived at 6.30 am, when Amchi Gege was in the middle of his
regular morning puja, and as such Nyima attended to him on his own. The patient
was a twenty-five-year-old Nepali man. This was his third visit to the clinic with the
same disorder. On his first visit he had been diagnosed with a tren in the region of
his stomach just above his navel. At that time he felt so weak that he was unable to
work. After a month of taking the medicines that Amchi Gege had given him, he had
noticed a marked improvement in his condition, and was again able to resume work.
He had returned because he had run out of the medicines. Nyima felt the growth,
which he said was a little smaller, and was not pulsating as strongly as before. He
also took his pulse, which he said was still weak. He measured out and gave the

patient more of the same medicines.

Although Nyima had not spent as much time at the medical school as some of the
other students, he had studied with his father in his home at Jharkhot in !\lustang, and
with Sangye Tenzin, the Abbot of Menri Yungdrung Bon monastery at Dolanji near
Simla. He had acquired a high level of competency in both medical theory and
through his extensive experience of clinical practice much of this had reached the

206
 level of performative memory. He was the closest amongst the students to becoming
a fully trained Tibetan doctor.

During their lessons in the classroom, the students learn about a large number of
diseases and their related symptoms. They also learn the range of subtle qualities of
the pulse and urine, which represent different pathological conditions in the human
organism. In the classroom this knowledge is presented as a series of propositions.
For example, the twelve general pulses are described in the text as: strong (dragpa),
prominent (gyepa), fast (gyopa), twisting (drilwa), hard (trangpa), and taut (drimpa);
weak (zhen), deep (ching), impaired (gil), slow (bur), loose (lh6d), and empty (tong).
It is one thing to have memorised this section of the text and to have received Amchi
Gege's commentary to it, but it is a different order of knowledge to be able to relate
these words to medical practice. Some of the words appear straightforward, such as
'slow' and 'fast', but it is not exactly clear what the difference is between a 'hard'
and a 'taut' pulse, or what exactly is meant by 'loose'. This can only be understood
through experience. Whenever students described what they felt from a patient's
pulse, either they would say that they could not understand anything, or they would
use one of the categories from the text.
On a few occasions, students said to me that they had learnt a great deal by acting
as Amchi Gege's assistants. As Yungdrung explained to me, in the middle of his two
week practical induction, 'This is very good work, I have studied much in the
medical text, but some things I can't understand, now I can see patients and listen to
what Amchi Gege says, and then I can go back to the text and finally understand it'.
What Yungdrung is articulating here is his own awareness of a transformation in his
medical knowledge; his understanding of the theories and practices presented in the
medical text, was gradually being transformed through clinical interaction into the
performative memory of medical practice.
As I have mentioned, the development of performative memory during clinical
interaction occurs when theoretical knowledge is appropriated and made a part of the
student's sphere of practical competency. For the students in the medical school in
Dhorpatan, the propositional knowledge that they have acquired consists of two
layers: that which they have memorised, and the knowledge they have acquired from

207
Amchi Gege's explanations. In chapter three on the role of memorisation in the
medical education I have discussed the way that it provides the basis for associative
elements in various locations in the text to be brought together simultaneously to
generate meaning in clinical interaction. In fact this associative pattern is built into
the structure of the text. All the topics of the medical teaching are summarised by the
tree metaphor given in the first volume of the medical text. As the students go deeper
in their studies of the medical text each subject is elaborated upon in increasing
detail. In their studies of the third volume all the elements of the medical teachings
are brought together in the explanations on specific disease. As their experience of
clinical practice increases, more and more propositional elements are brought to the
performative level. Though it seems likely that not all of what they learn in the
school will reach this level. The development of performative memory requires
considerable practical experience and many of the diseases that the students learn
about in the text, may seldom or never be encountered in clinical practice.
All the students had acquired a good theoretical knowledge of medicine, some of
them had also developed high levels of competence in certain areas of clinical and
pharmaceutical practice, but with the exception of Nyima they still all had a long
way to go in developing the performative memory of medical practice. Nyima, on the
other hand, was well on his way to becoming a fully trained medical practitioner. He
seldom showed any signs of difficulty in situating what he knew in clinical practice.
Much of what he had learned in the classroom had become a part of his practical
sphere of competency.

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 Chapter 7 - The Relationship Between Tibetan Religion and
Medicine

In the last chapter I have given twenty examples of the students learning medicine
through clinical interaction. All of these disorders could be understood to a large
extent without taken into consideration Tibetan religious notions. However, many of
the clinical interactions that took place in Dhorpatan whilst I was there were directly
related to Tibetan religion and cosmology. In chapter eight I will discuss these illness
episodes and the ways in which the students were involved in them. Before doing
this, in this chapter I will first discuss the relationship between Tibetan medicine and
Tibetan religious notions. In the domain where Tibetan medicine overlaps with
Tibetan religion, it was Geshe Tenzin Dargye who assumed the central role, and the
medical students served as his assistants.
Dunn (1976:134) gives four causative factors that lead to health or disease:
exogenous, endogenous, behaviour, and human population. He further subdivides the
category of exogenous factors into: biotic and non-biotic. For the endogenous factors
he gives: genetic. This accords well with the biomedical view of disease causation,
but a cross-cultural study of medical systems shows considerable divergence in what
is classed under these various headings. For example the endogenous factors of
Asian medical systems relate primarily to the proportions and flows of humours; and
exogenous factors, could include a range of factors, such as astrological influence
and disruptions caused by harmful spirits. Under behaviour, Dunn lists
psychological, social and cultural factors; where biomedicine might downplay these
components of disease causation, in other cultures these are deeply related to health
concerns. For instance the Ayurvedic, Chinese, and Tibetan medical systems view
health as arising from the harmonious interrelationship of physiological,
psychological, social and environmental factors. It is breakdowns in this
interrelationship that is the cause of disease.
The aim of what follows is to present the exogenous factors of Tibetan disease
causation, which includes a range of phenomena such as seasonal change, adverse
environmental conditions, astrological influence, and harmful spirits I will outline
the basic elements of Tibetan cosmology and the kinds of ritual practices that

209
Tibetans carry out to maintain harmony in their environment and cultivate prosperity
in their lives.

7.1 Tibetan Cosmology

As I have mentioned, the Tibetan medical text is classed as a Tantra and as such
there is much in Tibetan cosmology that is of direct relevance to medicine. Tibetan
notions about the nature of the universe and the beings that inhabit it have a number
of different sources. For Tibetan Buddhists these sources are principally Hinayana,
Mahayana and Tantric Buddhist texts that were brought to Tibet from India. The
Bonpo also have equivalent texts, which they claim were translated from the
language of the Central Asian kingdom of Zhang Zhung. Another significant source
is Tibetan folk tradition.
Tibetans have two main overlapping cosmological systems. The first is found in
the Abhidharma text of the Hinayana Buddhist tradition. The Bonpo also have a
version of this text. According to this account, the universe is described as one of an
infinite number of world systems (Brauen 1997 Sadakata 1997), which came into
existence through the karma of earlier living beings. Our world system is set upon a
golden earth disk in the centre of which is a four-cornered mountain known as Mount
Meru. Around this are seven mountain ranges, each half the size of the one closer to
Mount Meru. Some depictions of these mountain ranges show them as concentric
circles, but in the text they are described as situated in concentric squares. Between
them is the 'inner ocean'. Beyond these mountain ranges is the 'great outer sea' with
twelve continents: one large continent in each of the four cardinal points flanked by
two smaller subcontinents. The world system is encircled by a range of iron
mountains situated around the perimeter of the golden earth disc.
Humans live on the southern continent known in Tibetan as dzambuling (skt.
jambudvipa). As the southern side of Mount Meru is made of lapis lazuli, the sky
above dzambuling appears blue. On the top of Mount Meru, which is shaped like a
truncated pyramid, is the city of Sudarsana (Skt. 'beautiful to see'); this is the abode
of a group of thirty-three gods. Ascending above Mount Meru there are twenty-five
heavens: four of the desire realm, seventeen of the form realm, and four of the
formless realm. Each ascending heaven has a higher degree of purity than the one

210
Plate 19 - The world system of Mount Meru and the 12 continents.

Plate 20 - The wheel of existence.

below it. In contrast to this, for beings that have accumulated a high level of
negative karma, below the southern continent of dzambuling, there are eight hot and
eight cold hells.
A common religious practice In Tibetan Buddhism and the Bon religion for
accumulating karmic merit is for the practitioner to build up this mandala universe
using an ornamental metal plate and rings and piles of rice. Each time it is made, it is
visualised as perfect and complete, and offered to the three jewels (kon chog sum):
the Buddha, the dharma and the spiritual community (Kongtrul 1986).
The second main Tibetan cosmological scheme complements the above model; it
focuses specifically on the transmigratory nature of life (skt. samsara). This second
scheme depicts the universe as a wheel of existence (sipe khorlo) with six sectors
representing six forms of samsaric existence: the three higher realms, of the gods,
asuras, and humans; and the three lower realms, of animals, hungry ghosts and hells.
Beings, through their personal store of karma, are constantly born in one or other of
these realms until they can escape this cycle of death and rebirth through realising
Buddhahood.
Traditional paintings of the wheel of existence usually include twelve symbols
equally spaced around the outer circumference, which represent the Buddhist
philosophical scheme of the twelve links of the chain of interdependent origination.
This explains the successive stages of how beings become ensnared in the cycle of
death and rebirth. In the centre of the diagram there is a drawing of a pig, snake and
cock, which represent respectively, ignorance, aggression, and desire; the three
mental poisons that are at the root of samsaric existence. According to Tibetan
medical theory, the three mental poisons are the root cause of the three humours in
the body, and consequently they are the fundamental cause of all forms of disease. In
place of these three animals, at the centre of the Bonpo version of the wheel of
existence, is a monstrous beast with the body of a cow, the tail of a snake, and three
heads: that of a pig, cock and serpent. As with the Buddhist version, the symbolism
relates to the three mental poisons (Kvaerne 1995: 143). These two cosmological
schemes are widespread in Tibetan culture. Plates 19 and 20 show the mandala world
system and the wheel of life that are painted on either side of the main door of the
temple at Triten Norbutse Yundrung Bonpo Monastery in Kathmandu.

211
 Having given some idea of the structure of the universe according to Tibetan
conceptions, I shall now turn to the different classes of beings that are said to inhabit
it, and the nature of their relationship with humans. Some beings are considered
inherently ill disposed to humans, some are always helpful, but most can veer in
either direction depending on the circumstances. For this reason it is important that
measures are taken to maintain, as much as possible, a positive relationship with
beings living in the natural environment. In Dhorpatan, as in other locations where
Tibetans live and have retained their traditional culture, spirit beings are an everyday
reality. According to Tibetans living in Dhorpatan, the spirits living in the area of the
valley are particularly strong and of a capricious and truculent nature. On numerous
occasions during my stay in Dhorpatan diseases were diagnosed as caused by the ill
intent of spirits. For this reason hardly a day went by without a Tibetan coming to
Geshe Tenzin Dargye and asking him for a blessing and some form of protective
amulet.
Tibetan religion recognises a huge range of divinities and spirits, many of them
referred to by the same Tibetan word, fha. These can be best understood by grouping
them into four classes (Samuel 1993: 166): the Tantric deities known as yidam, the
gods of the Buddhist heavens (jigten Ie depe fha) , the gods of this world (jigten pe
lha) , and malevolent spirits (dre). An important distinction to be made here is
between beings that are still part of samsara, and beings that have passed beyond it,
such as the gods of the Buddhist heavens, and the Tantric yidams. In what follows I
will give a brief description of these four classes of beings.

7.1.1 The Gods of the Bonpo and Tibetan Buddhist Heavens Uigten Ie
depe Iha)

The Gods of the Bonpo and Tibetan Buddhist heavens are those deities that
through meritorious acts have passed beyond samsaric existence; they have realised
the enlightened nature, which is inherent to all beings. Some of the higher worldly
deities are said to be on the verge of achieving enlightenment and passing into the
heaven realms; for instance Pehar (Nebesky-Wojkowitz 1956). These gods reside in
the various heavens that exist above Mount Meru. Some of them act as high-level
religious protectors. In this class we can also include divine Bodhisattvas such as:
Chenresi (skt. Avalokitesvara) and Jampel (skt. Mafijllsrf) in the Buddhist tradition.

212
and the corresponding Kunzang Gyalwa Gyatso and Mawe Senge in the Bon
tradition. Though not strictly speaking, 'gods' (lha) , Tibetans approach them like
divinities.

7. 1.2 The Tantric Deities (Yidam)

The deities of the Tantric texts are expressIOns of enlightened conSCIOusness.

Within Tibetan Buddhism and the Bon religion there are numerous Tantric lineages.
Each Tantric deity has one, or sometimes a cycle of texts associated with it. The texts
explain the attributes of the principal deity, the subsidiary deities connected with it,
its mandala, and the rituals associated with it. The principal Tantric deities are
referred to as yidam. This is the shortened version of yi kyi damtshig, which means
'the sacred bondage of the mind' (Trungpa 1982:228). The idea is that the yidam is
the means by which the practitioner can experience their own enlightened nature. In
Tantric practice, the practitioner assumes the form of the yidam, and by so doing,
through the power of the ritual, his or her consciousness is transformed into that of
the Tantric deity; by this means the lama acquires the power of the deity and is able
to control the activities of the gods of this world, and malevolent spirits.
It is common for Tibetans to have a special relationship with one particular yidam,
due to them receiving the appropriate empowerment (wang) from a lama, or it may
be that the yidam has been passed down through their family line. Geshe Tenzin
Dargye's family has a special relationship with the Bonpo yidam, Walchen Gekhd. It
was this deity that he most often resorted to when he was carrying out healing rituals.
The main yidam of the Bonpo temple next to the medical school at Dhorpatan is
Takla Mebar.

7.1.3 The Gods of this World aigten pe Iha)

There are abundant classes of gods of this world found in Bonpo and Buddhist
texts. Most of them are associated with locations in the natural environment such as
the sky, mountains, mountain passes, rocks, caves, rivers and lakes. The more
powerful deities usually have a retinue of helpers. The relationship between the main
deity and the entourage is likened in the texts to a court with the main deity as chief,
with generals and ministers and a range of lesser attendants in service. Tibetans

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sometimes make use of another cosmological scheme which divides the Universe
into three levels, according to the specific abodes of various classes of beings: in the
heavens or the sky there is the white lha; in the intermediate realm there is the red
tsen and yellow nyen; and under the earth there is the blue lu (Tucci 1980: 167, Stein
1972:204).
A well-known Nyingmapa classification is the 'eight classes of deities' (lha sin
degye). There are various renditions of this classification. Samuel (1993: 162)
following Cornu (1990) gives ten deities whose names often appear in this list. The
lu often have a serpentine appearance, they live in rivers, lakes, or streams, but can
also be found on the land in caves and trees and so on. The lu have been identified
with the Indian nagas. The lu can be helpful or harmful towards humans; they are
particularly vengeful if their habitat is damaged. Nyen live in the atmosphere and in
various locations on the land, such as in forests and trees; if they are disturbed they
quickly seek retribution. A whole class of virulent infectious diseases, nyene, is
attributed to them. The tsen class live in rocks. They are noted for their red colour,
and their martial nature. The gyalpo, are a powerful class of deities who often act as
protectors. The leader of the gyalpo is Pehar. They are white and carry armour and
are often associated with mountains. The dud are black malevolent spirits. The mamo
are fierce female deities. The sa are deities of the planets who cause various types of
disease, particularly epilepsy. Finally there is the nodjin, the deities who reside over
the wealth of the soil, and the lha who generally have a positive attitude towards
humans.
This eightfold classification is only one of numerous classifications. One
Nyingma text cited by Nebesky-Wojkowitz (1956) lists thirty classes of deities. A
few important classes of deities are missing from the above eightfold classification.
There is also the sadag, the 'owners of the land'; these deities are intimately related
to Tibetan astrology. In Dhorpatan, I was told that rivers are the blood of the sadag,
stones are the bones, and the earth is the sadag's body. If harm is done to any of
these environments, the sadag will seek retribution. One important group of local
deities is the gowe lha (Nebesky-Wojkowitz 1956). This is a collection of five deities
that are associated with an individual from birth: the sog fha, 'the god of life' who
resides in heart, the po lha~ 'the male god' who resides in the right armpit~ the mo

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fha, 'the female god' who resides in the left armpit; the dra fha, 'the enemy god'
(that is to say the god that provides protection against enemies), who resides at the
right shoulder, and the yuf fha 'the god of the village', who resides at the crown of
the head. The yuf fha is also an important local god in its own right, being the
protective deity of a given locality.
The worldly gods, as well as having the potential to cause harm, can also be
bound to serve as religious protectors (cho kyong, 'protectors of Buddhism', Bon
kyong 'protectors of Bon' , srung ma, 'guardians'). Tantric deities and the gods of the
Buddhist heavens can also serve in this capacity, but an important distinction must be
made between their motivation and that of the worldly protectors. The higher class of
protectors are known as 'the divinities that have passed beyond samsaric existence'
(jigten fe depe srung ma) (Nebesky-Wojkowitz 1956), and as enlightened beings
their motivation is aligned with that of the Buddha. A famous group of Buddhist
protectors of this class is the drag she gye, 'the eight fierce destroyers'. 1 The most
important protector of this class in the Bonpo tradition is Sipai Gyafmo who has three
faces and six arms and rides a black mule. She also manifests in a form with two
arms and one face as the fierce protector Yeshe Wafmo. Protectors belonging to the
lower group are known as worldly protectors (Jigten pe srung ma), these are deities
that are still within samsaric existence who have been bound by oath (damtshig) by a
lama to protect the Buddhist or the Bonpo teachings.

7.1.4 Malevolent Spirits (dre or don)

The fourth general group of spirits are referred to by the generic name dre or don.
This term covers a wide range of malevolent spirits that are always trying to cause
harm and create obstacles for people. Stories about dre abound in Dhorpatan. I will
recount some of these stories in the next section. Geshe Tenzin Dargye told me that
there are many dre in the vicinity of the valley, and he is often called upon to
perform rituals to counteract the harmful effects of their activity.

1 Palden Lhamo. Gonpo. :Vall/tho sre. Shinje. Cham sing. Tshang pa karpo. Tamdrin. shinje she.
These protectors all belong to the higher class except Tshang pa karpo who belongs to the lower class,
and the last two deities who are .yidams. See Nebeskv-Wojko"itz
. (1956) for a discussion of their
appearance and attributes.

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 Some dre are spirits of the dead that, because of some unfulfilled task, such as an
existing vendetta, remain attached to the place where they lived. Geshe Tenzin
Dargye said that in such a case it is the consciousness (namshe) of the person, which
lingers after the death of the body. He told me that about two years before, he and
another Bonpo lama were called to a village near Jomson to try and help a sick
woman. They recognised the sickness as spirit possession, and in response they tied
blessed cords around the third finger of each of her hands. The reason for this is these
are the channels spirits often use to enter and take possession of somebody; by
blocking them with blessing cords they effectively trapped the spirit inside the sick
woman's body. They then proceeded to question the spirit about its motives. It turned
out that the spirit causing the harm was a person from a nearby house who had died
three years before in a hospital in Kathmandu. They found out that the cause of the
problem was the dead person's relatives had not performed the correct ritual after the
woman's death. The two lamas then taught the dead woman how to do the ritual.
After this they removed the blessed cords and the sick woman returned to
consciousness, having no recollection of what had happened. Such a spirit is known
as a shindre. Another type of dre that I was told about by Geshe Tenzin Dhargye is
the songdre. This is a person, usually a woman, who has an inherent power to cause
harm, This power is passed on through the family line. A short account of both these
classes of dre can be found in Tucci (1980: 187).

7.1.5 Harmful Spirits as Pathogenic Agent

As can be seen from the descriptions given above, many deities are of a
temperamental nature and have the potential to cause harm if they are disturbed. In
numerous locations in the medical texts diseases are attributed to various classes of
spirits. Often the only way to treat these diseases is by resorting to ritual. The first
chapter of the fourth volume of the Bum Shi, which deals with pulse diagnosis, has a
section, which details pulses indicative of the action of malevolent spirits. It begins
by explaining the qualities of the pulse, which indicate harm by malevolent spirits to
the five solid organs (don nga)2, and it lists the types of spirits involved. It then goes
on to describe the qualities of the pulse of various specific diseases that are caused by

:2 Hearl. liver. lungs, spleen. and kidneys.

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 the action of spirits. Some of the spirits named in the text are: the kordag, gyalpo,
lutsen, jangmen, mu, lu, sadag, and nyen, along with numerous others. The following
chapter on urine diagnosis also has a section on the qualities of urine, which denote
the action of malevolent spirits. It contains a long list of classes of spirits that are
known to cause disease. In the third volume of the medical text, which details
Tibetan nosology, spirits often appear in the list of contributory causes of specific
diseases. Section eleven of the third volume has five chapters that are entirely
devoted to diseases caused by harmful spirits. 3
There are also whole groups of infectious diseases, which are attributed to the
action of spirits. I have already mentioned the class of diseases known as nyene after
the nyen class of spirits that cause them. Das (1995) gives the Tibetan name and a
short description for fifteen of these diseases. Nyima, the eldest medical student in
the school, told me that the Khyungtrul Rinpoche's commentary to the main medical
text lists eighteen. Usually, what prompts the nyen to act in this is way is human
activity that causes damage to the environment, such as quarrying work or cutting
down trees. Another class of infectious diseases caused by spirits is rim: this includes
flu (cham rim), and typhoid fever (rim mi zepa). Amchi Gege told me that in the past,
that is to say during the time of Tonpa Shenrab, none of the nyene class of diseases
existed. He said that Tonpa Shenrab, through the power of his deep insight (ngo she)
knew that these diseases would arrive in the future. He said that even in his
grandfather's time these diseases were hardly encountered in Tibet. According to
Amchi Gege's teachers this situation changed after W orId War I.
Tibetan medical theory holds that the primary cause of disease is disruption in the
function of three humours and the seven bodily constituents. In cases of diseases that
are due to the action of harmful spirits, they are listed in the medical text not as the
main pathogenic cause but as secondary causes. For instance, in the first volume of
the medical text, which summarises Tibetan medical theory and practice using the
metaphor of a tree, the primary causes of disease are listed as the three humours, and
4
harmful spirits are listed as one of the four main contributory factors. The same
pattern is also found with specific types of disease. For example chapter seven of the

3 Parts of this section have been translated and commented on by Clifford (l98~) .
.j The others are: seasonal influence, diet, and behaviour.

217
third volume of the medical text dealing with types of tumour (tren) gIves
dysfunction of the three humours as the primary cause along with a few other factors,
and again harmful spirits are found amongst the list of nine contributory factors.
Spirits are not just something that are spoken about in Tibetan religious texts. For
the people in Dhorpatan they are an everyday reality. There was hardly a week went
by when I did not hear of their presence in the valley in some form or other. As many
diseases that occurred in Dhorpatan were viewed as an outcome of their activity, an
understanding of the nature and of how people relate to them is of direct relevance to
medicine. As I said earlier, 'medicine' in a Tibetan cultural context has a wider
semantic scope than in a biomedical context. It overlaps to a great extent with
Tibetan religious notions, and the students if they are to be good medical
practitioners must also develop competence in this area. Even if the students do not
know how to perform the rituals that are necessary to counteract the activity of
harmful spirits, they should at least be able recognise the disease and know what type
of ritual should be performed. In fact, all of Amchi Gege's male students have a very
good knowledge of Tibetan ritual. In the context of health, there are two types of
ritual that are performed by Tibetans in Dhorpatan: ritual that is carried out to
maintain a positive relationship with the local deities and spirits; and ritual that is
performed to bring about health when disease arises as a consequence of a disruption
in this relationship. In what follows I will discuss both of these forms of ritual
behaviour. Before doing this, I will I will try to evoke an impression of how spirits
were experienced by people in the valley, by recounting some of the stories that were
told to me.

7.2 Dhorpatan Spirit Stories

There are two main routes that people take to walk to and from Dhorpatan: one
passes through the valleys between Dhorpatan and the small town of Tansen to the
south; the other route passes through the valleys between Dhorpatan and Baglung to
the east. Both routes take about four days. On a few occasions I had to leave
Dhorpatan for short periods of time, usually to organise extensions for my visa in
Kathmandu. After one such occasion, I was walking back up to Dhorpatan along the
Baglung route, accompanied by a Sherpa friend. We had ended our day's walk in the

218
village of Dharpang in the Myagdi Khola valley, and had taken a small room in a
lodge at the top of the main street of the village. After nightfall, shortly after we had
finished our evening meal, I went for a stroll up the street. As I was returning to the
lodge, I saw what at first appeared to be a bright star. Then I realised that what I was
looking at was not a star but a large bright light situated about 80ft above the river.
The light was moving in what seemed from my perspective to be in the same
direction as the river. After about five seconds three or four small lights split away
from it for a few seconds and then merged back into the main light. Shortly after this
it seemed to change direction and then disappear.
I was left somewhat bewildered. Tibetans in Dhorpatan had recounted similar
experiences to me, but this was the first time that I had seen anything like this
myself. In the following two days walk to Dhorpatan, I didn't discuss the experience
with anybody, but I often thought about it. One thought that arose was of Evans-
Pritchard's (1976: 11) description of a bright white light that he saw late one night
whilst he was staying in an Azande village. The light he saw was moving behind his
servant's hut in the direction of the homestead of a man called Tupoi. Later that same
morning an old relative of Tupoi living in the same homestead died. The Azande had
no doubt that what Evans-Pritchard had seen was witchcraft. Evans-Pritchard did not
know what the light was but thought it might have been someone carrying a grass
torch. I don't know what it was that I saw above the river at Dharpang that night, but
when I told Tibetans in Dhorpatan about my experience, there was no doubt in their
mind about what it was.
On the night that I arrived in Dhorpatan after that journey, a group of people who
live in the medical school compound congregated in the room in the Labrang were
Geshe Tenzin Dargye and I stayed. I told everyone about the light that I had seen,
and almost immediately there was a consensus amongst all in the room that what I
had seen was a dre me. There was nothing remarkable about seeing it. All the
Tibetans in the room had either personally experienced them, or knew of someone
who had. In fact there existence was taken to be so commonplace that the
conversation quickly moved on to something else.
The Tibetan word, dre me, literally means 'spirit fire'; this derives from their fire-
like, luminous appearance. As we have seen, the word drt! is a generic term for' a

219
demon' or 'an evil spirit'. The word dre me was used in Dhorpatan not to refer to one
class of spirits, but to a series of different kinds of spirit-related occurrences. Geshe
Tenzin Dargye explained to me that different kinds of spirits can appear in this way,
he said that quite often they appear as blue lights. He had seen dre me on several
occasions in different areas in the Himalayas. He said that it is rare to get close to
them; sometimes when one does get close to them their form can be discerned to be
that of a woman. He also said that people who have died and who have got stuck in
5
the bardo can take the form of a dre me, in which case they are known as shindre.
Most Tibetans and Nepalese who live in the valley have a firm conviction in the
reality of spirits. For them, the environment in which they live is replete with such
entities, and the health of the community and the individual depends on maintaining
an harmonious relationship with these beings. Many people claim to have seen spirits
or witnessed their presence in some form or other.
Only a small number of Tibetans within the community, invariably amongst the
few who have received a Western-style education, are sceptical of such claims. For
instance, one night I was with the settlement officer, and another two Tibetans, in the
settlement officer's house. His house is situated in the Namdru Tang settlement at the
western extremity of the valley. In this area, the valley opens forming a large plain.
The plain runs into another valley leading down into the lower hills to the south. At
this point, as they are obstructed by high hills everywhere else, clouds frequently
issue into the valley skirting above the tops of the homesteads. Often on a nighttime,
jackals can be heard howling in the surrounding forest. In this location of the valley,
the strong and powerful presence of the natural environment is especially striking.
We were drinking a few beers and generally chatting about things, when the
conversation swayed towards the subject of spirits. One of the Tibetans, who had
arrived in Dhorpatan from Tibet as a young child with his family, and had been
brought up there, remarked about the abundance of spirits in the valley, and how
often people encountered dre me. The settlement officer jovially replied that this was
nonsense, he had been there a year and had never seen anything; the notion of dre me
was just an old Tibetan superstition with no basis in reality. The gauntlet was quickly

5The intennediate realm that the consciousness passes into after death, from which in due course it
will either achieve liberation or be reborn into one of the six realms of existence.

220
taken up and the person who had made the first comment said that there was no
doubt that they existed, many people had experienced them. He said that we could
experience them at that time. He knew a valley nearby, where dre me were often
seen, and if we were to go we would be sure to see one or even more. The settlement
officer remained unconvinced, but wasn't prepared to go up the valley to corroborate
his opinion.
On several occasions during the time that I was in Dhorpatan I heard that people
had encountered spirits of the class of dre. Early one morning shortly after everyone
staying in the gompa compound had awoken, I was aware of some commotion. It
turned out that the night before, one of the monks had got up about one in the
morning and left the monks' residence to go to the toilet. In the field, just beyond the
new medical building, he had seen what to him looked like a fire. He also noticed
that there were a number of dogs near the fire, barking at it. In the morning he had
gone to the area were he thought he had seen the fire but could see no trace of it. The
following night, again he left the monks' residence to go to the toilet, this time about
midnight. As on the night before he saw the 'fire' in the same field. This time he
called Sonam, one of Amchi Gege's monk medical students. What they saw, as they
described it, was a ball of fire, hovering some distance above the field. At a certain
point it split into three fires, which stayed separate for a while and then merged back
together. It stayed hovering for some time and then quickly flew off into the forest.
Early the following morning when we were all discussing what had happened,
there was no doubt for the Tibetans that this was a dre me. Tenzin Dargye said that if
it came again people should not go near it, as it could be dangerous. By that time I
had heard numerous stories about spirits in Dhorpatan. I asked Tenzin Dargye why it
was that whenever somebody encountered a spirit, there was always talk of danger~
wasn't it possible that the meeting could be of no consequence, or even propitious?
He replied that classes of spirits like the sadag, lu, and nyen, were not inherently
malevolent or benevolent, they could sway in either direction. He told me about one
spirit of the class lu that lived in a juniper tree in the garden of his family house near
Jomsom. The III was generally well disposed to his family, but to preserve this
beneficial relationship, the juniper tree and the area around had to be treated with
great respect. Sometimes his family would recite prayers and make offerings to the

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lu. He added that many types of spirits could be either helpful or harmful, but dre
were different, they are always inclined to harm.
On another occasion, earlier in the evening the same two monks thought they
could see a dre me some considerable distance away on the other side of the river.
Several people gathered, including myself to watch the spectacle. We all watched
bemused as the light danced and flickered and seemed to change colour. As time
went on it became increasingly evident that what we were watching was the light of a
fire in a Nepalese homestead. This time, to everyone's disappointment, it was a real
fire.
Although the Tibetans in Dhorpatan were quick to interpret strange phenomena or
untoward events in terms of the activity of spirits, this was not always the case. One
young Tibetan told me that he had once seen a large light shoot across the valley.
Some Americans had told him about UFOs, and he thought that what he had seen
could have been one of them. After he told me this, he explained to me about another
bizarre and unfortunate event that had just happened in the valley. I had just come
back from one of my visa renewing sorties, and the event had occurred while I was
away. He said that a Nepalese woman had gone up into the mountains with her child
to collect firewood. When she returned to her father's house, she put the basket down
and to everyone's horror it contained not firewood, but the body of her child who she
had hacked to death. He said that when the police arrived she suddenly became
aware of what had happened, and became hysterical having no memory of killing her
son. In her hysteria, she frantically demanded that people kill her the way that her
son had been killed. He accounted for her behaviour by attributing it to spirit
possession. Later I discussed the event with Geshe Tenzin Dargyey, and asked him to
explain how the alleged spirit possession had occurred. He replied, that in his opinion
there had been no spirit possession, what had happened was a case of 'mind crack' as
he put it, using the English phrase.
Often nothing arises as a consequence of an encounter with a dre. But as I have
said, they are looked upon as being of a malevolent nature and as having the
potential to cause harm. Towards the end of my stay in Dhorpatan, Sonam, one of
Amchi Gege's monk medical students was afflicted by a dre me, which he had
encountered near his house. He said that, as he was walking down a path, the spirit

222
shot past him in front of where he was walking. It appeared as a big white light, and
as it moved it had a tail like a shooting star. It stopped at the other side of the river,
and hovered there for a while and then disappeared. Shortly afterwards, Sonam
started to feel ill, and by the next day he had a strong fever. Within a few days a large
boil appeared on his neck. Boils (nyen bur), are traditionally viewed as resulting
from the retributive activity of the nyen class of spirits, though the aftliction is not
confined to them alone. He received medicines from Amchi Gege, and the monks
carried out appropriate rituals at his house. He was away from the medical school for
about two weeks as a result of the illness. He remained certain that the cause was the
dre me, which had passed in front of him that night.
As we have seen, dre me are just one class of spirits amongst many that exist in
Tibetan cosmology. The question is not whether such beings exist or not, rather
given the fact that they do exist, the issue is how best to preserve a harmonious
relationship with them. Yungdrung, another of Amchi Gege's monk students told me
that, when he was about ten, he was out playing with some friends at a place where a
spring emerges from under a large rock at the bottom of a hill. This place is
acknowledged as being the dwelling place of lu and is surrounded by Tibetan prayer
flags. As young children this was of little concern for Yungdrung and his friends.
They found a frog in the water, and took it out because it seemed very colourful.
After playing with it for a while they killed it. The next day Yundrung could hardly
move his legs at all. The lama who was there at the time discovered that by killing
the frog he had offended the lu that lived in the spring. Frogs are thought to have a
close association with this class of spirits. Yundrung told me that the lama performed
the appropriate ritual and shortly afterwards he could walk again.
On another occasion, Yungdrung told me about an event that had happened the
previous year when a spirit had almost killed a Tibetan man. At that time Yungdrung
was staying in his house at Khangpa Chugsum. The house of the Tibetan man is
nearby. That night the man was sitting alone when a Tibetan woman walked into his
house. He said she was very beautiful and she was wearing his wife's clothes. She
approached him and grabbed him by the throat and said that she was going to kill
him. He could remember nothing else because at this point he became unconscious.
As a monk and a medical student, Yungdrung was called to help, but as he explained

223
to me he had very little experience of how to deal with such events and did not really
know what to do. First he did some mantras and blew on the afflicted man, but this
seemed to have little effect. Then he took some pieces of hair that he had from a
powerful lama and burnt them with some incense and wafted the smoke towards the
man. At this point, the man tried to move away from the smoke and Yungdrung had
to struggle with him to allow some smoke to go into his face. Finally, when the man
breathed the smoke, he let out a cry and suddenly became conscious again.
Many people in Dhorpatan have stories to tell similar to Yundrung's. One day I
was discussing spirits with a young Tibetan woman. She told me that about ten years
before, her uncle had had a terrifying experience with a spirit whilst crossing a bridge
near the school at Bagata. She told me that ever since then she has felt uncomfortable
crossing the bridge. He had been out all day and was on his way home when he
reached the bridge at about seven in the evening. As he was crossing the bridge a
black mass appeared before him totally obscuring his foreground vision. Then
something grabbed his arm and he heard a voice say, 'What did you do with the
money I lent you this morning?' He hadn't borrowed any money from anyone and in
a state of terror he automatically started reciting the mantra of the main protector of
the Bon religion Sipai Gyalmo. As he did this, the path ahead of him became visible
and he managed to make his way home. The next day he became ill, and rituals had
to be performed to help him return to health.
The Nepalese who live in the valley perceive the environment in a very similar
way. They also have many tales to tell about spirits, some associated with specific
locations in the valley, others living in the surrounding forest and mountains. One
person that I spoke to told me that before the Tibetans arrived, in the location where
the gompa and medical school are now situated, a one-legged spirit had been seen on
a few occasions; for this reason the Nepalese call the Gompa compound ek kulla,
'one leg'. He also said that further down the valley on the edge of the forest on the
other side of the river from Chendung, on a few occasion people had seen a spirit in
the form of a naked women with her hair hanging down to the ground. I also heard
that in the areas near the school at Bagata many people, both Nepalese and Tibetan,
had encountered a small stout immensely hairy spirit. At the far western end of the
valley there is a large hill, which is considered to be the residence of a local goddess.

224
Every year the Nepalese gather at the shrine at the foot of the hill to carry out a large
ritual in her honour, involving the sacrifice of hundreds of goats. The ritual is
referred to as the Uttara Ganga Puja, after the name of the river that runs through the
valley, which is turned red with the flow of sacrificial blood.
When problems arise as a result of the activity of spirits, the Nepalese have their
own traditional shamanic healers whose aid is sought. In the area of Dhorpatan they
are known as jhiinkri. 6 When a sickness is deemed to have been caused by some kind
of spirit, a jhiinkri is called to the house. In full ceremonial costume, aided by his
drumming and dancing he will go into trance, in which state he is able to
communicate with spirits and find out the cause of the disease and how it can be
remedied.
One day I heard that a young boy in a nearby Nepalese settlement was suffering
from an unusual illness and a jhiinkri was on his way to treat him. The boy was
twelve years of age, and had been ill for five days. He had a fever and had almost
completely lost the capacity to move his legs. I went with Tenzin Dhargye. By the
time we had arrived the event was well underway. We could hear the jhiinkri
drumming and singing in the house, and we waited outside with a group of people to
see what would happen. After some time two Nepalese men emerged up the path
from the back of the house. Each man was clasping on to a stick in front of him with
both hands. The sticks were held vertically and one end bounced up and down on the
ground erratically as if it had a life of its own. The jhiinkri was walking behind them
singing and playing his drum. He had ascertained that the cause of the boy's sickness
was a naga (the same class of spirits that the Tibetans refer to as lu).
Through his spirit helpers the jhiinkri was using the sticks to find the exact
location of the naga. The men carrying the sticks wandered far and wide in the large
field next to the settlement. One of them kept coming back to a small area just next
to the boy's house. Eventually, in this location, with a dramatic gesture he stuck the
stick in the ground in the middle of a large bush. Immediately the jhiinkri went to the
bush, crouched down and started drumming and singing. Within a few minutes he
was fully possessed by the naga who was then questioned by the jhiinkri 's assistant.

6On the subject ofjhiinkri in this region of Nepal see Maskarinec 1989, 1990, 1993, and Sales 1991.
On the subject ofjhiinkri and in other areas of Nepal see Hitchock & Jones 1976, Miller 1997,
MacDonald 1983.

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 The naga told the father of the child, and the thirty or so people present that this is
where he lived and the boy had come and used the place has a toilet. It said that if a
puja was not promptly done, involving the sacrifice of three chickens, the child
would be dead within ten days. At this point the father, now in great distress,
apologised profusely to the naga, saying that it would never happen again, and
promising to provide the three chickens for the sacrifice. The jhiinkri then quickly
climbed about thirty feet up the steep sided hill and clambered into a small nook in
the rook. The naga who still possessed the jhiinkri said 'I live here', and then in an
instant the consciousness of the jhiinkri returned.
He climbed down, looking somewhat shaken. As we walked back to the house he
was evidently fully aware of everything that happened. He knew Tenzin Dargye was
the head lama in Dhorpatan and he greeted him. Amongst many of the Nepalese,
Tenzin Dargye had acquired a strong reputation for his ability to deal with this kind
of disease. The jhiinkri asked him if he thought the boy would get better. He replied
that he did not know. He said first you do your puja and if he doesn't get better I will
try. In the end he did not need to as within a few days the boy was feeling well and
had fully regained the use of his legs.
I have tried to give an impression of the prevalence of ideas about spirits amongst
the people living in Dhorpatan. Before the students enter the medical school they are
already well versed in notions about spirits and the ways in which they can cause
disease. Later I will discuss a series of patients who came to the clinic whose
illnesses were interpreted in this way. This class of disease, known as napa, occurred
on several occasions whilst I was in Dhorpatan. Tibetans try to prevent the
occurrence of this kind of disease by constantly carrying out rituals with the aim of
maintaining a harmonious relationship with the local deities and spirits. The
following section presents an overview of this kind of ritual behaviour.

7.3 Setting the Ground for Prosperity

As we have seen, Tibetans in Dhorpatan, as in other Tibetan communities that

have retained traditional cultural forms, share their world with a host of gods and
spirits, many of which, in their view, have the potential to cause harm. These beings
are commonly associated with locations in the natural environment such as mountain

226
passes, rivers, springs, caves, trees, rocks, and so on. Hannony, health and prosperity
within the community are considered to derive from the maintenance of the correct
relationship to the environment and the beings that inhabit it. This entails behaving
with respect towards the environment and the periodic perfonnance of rituals
connected with the gods and spirits of this world, the religious protectors, and the
enlightened beings and Tantric deities.
From a Buddhist and a Bonpo perspective, the prescribed attitude that should be
taken towards worldly deities is one of respect, not devotion. The rubric is that one
should take refuge only in the three jewels of the Buddha, Dhanna, and the spiritual
community. Yet from a practical point of view, Tibetans direct much attention to the
maintenance of the correct relationship with the local deities and spirits. This is so,
because if this relationship is in any way disturbed, all manner of harmful
consequences, including disease, may ensue. Thus Samuel (1993) has characterised
the religious motivation of Tibetans, and this is applicable to followers of Buddhism
and the Bonpo religion, as having a three-fold nature: 7 the bodhi orientation involves
activity dedicated to achieving enlightenment; the kanna orientation involves activity
that aims to accumulate positive karmic merit; and the pragmatic orientation relates
to success and prosperity in this world through maintaining a positive relationship
with the environment and the local deities and spirits.
Some rituals are done only by monks and lamas, but there are many that are also
done by lay people. Before arriving in Dhorpatan from the Baglung direction, apart
from the likelihood of encountering Tibetans on the path, the first visible sign of the
Tibetan community is on the top of the Jaljala pass, four to five hours walk from the
settlement. Here there is a small pile of stones, mostly painted white, with different
coloured prayer flags hanging from it, and from ropes tied between it and a nearby
tree. The path leading up to the pass is a four hour-long steep climb through dense
forest, which, so it is believed, is a popular hiding place for thieves. The forest
finishes at the top and the path continues along a spacious open valley. Arriving there
is both a physical and psychological relief. Every time I arrived there, Tibetans threw
a stone, or tied a new prayer flag on to the structure shouting out, 'ki ki so so Iha gyal

7This is a reworking of Spiro's (1971) three fonns of Buddhism: kammatic Buddism. nibbanic
Buddism. and apotropaic Buddhism.

227
10', 'the gods are victorious', or sometimes just the syllable 'so' several times in loud
succeSSIOn.
These cairns are known as Ihatho, and are set up on mountain passes in honour of
the mountain deities. Sometimes the structure also includes the horns of animals such
as ram, ibex, or yak. Stein (1972:206) interprets the 'ki ki so so lha gyallo' phrase as
a battle cry, which relates to the martial nature of the mountain gods, and to the
strategic importance of the mountain pass. He points to the fact that other strategic
crossing places such as bridges and fords are also often covered in prayer flags.
In the valley of Dhorpatan, the Tibetan settlement can be clearly distinguished
from the Nepalese homesteads by the prayer flags, hanging from the roofs of the
Tibetan houses and from flag poles scattered around the houses. Prayer flags also
adorn a point at the eastern end of the settlement marking the point were a stream
emerges from under a rock; this is the abode of the lu, which I discussed earlier in
connection with Yungdrung becoming ill after killing a frog. Along the main
pathway leading to the different parts of the settlement are mani stones, with mantras
carved on them. In the Buddhist areas it is the mantra, Om Mani Padme Hum, of
Chenresi, the Bodhisattva of compassion; in the Bonpo areas it is the mantra Om
Matri Muye Sale Du. By circumambulating these mani stones in the right direction, 8
people generate positive karmic merit. In the gompa compound there is a building
with a large prayer wheel (mani khorlo), which people set in motion for the same
purpose. Some of the older generation Tibetans also use hand held prayer wheels
(mani lag khor).
Already within the first few months of my stay in Dhorpatan I witnessed a range
of ritual activity that related to the activity of local deities and spirits in the valley,
particularly to diseases that were thought to have been caused by them. In response
to my questions on the nature of these rituals, Geshe Tenzin Dhargye, who was
directing most of this activity, set his explanation in a traditional Bonpo framework.
He explained to me that all Bonpo knowledge is classified into nine ways (thegpa
gu) (see appendix A) and what he had been doing was mostly part of the first way,
the 'Way of the Shen of the Cha' (cha shen thegpa). This encompasses four types of

~ Buddhist circumambulate sacred objects in a clockwise direction; Bonpo do it anticlockwisc

228
activity: divination (mo), astrological calculation (tsi) , ransom rituals (to), and
medicine (men), which is sometimes listed as medical diagnosis (che).
Popular ritual practice has a number of related aims: to bring about prosperity and
auspiciousness (tashi, dele), long life (tshering), health (ne me), and wealth (long
cho) (Tucci 1980: 172). Generally, 'auspiciousness' is signified by the Tibetan word
tashi, though, as in the title of the first of the nine ways the word cha can also be
used. Geshe Tenzin Dhargye explained to me that cha is the potential for prosperity
that can be invoked in rituals to bring about actual prosperity (yang). Thus in his
view, yang and cha, though both referring to prosperity, one refers to a potential
whilst the other refers to a tangible expression. I asked him whether yang was the
same as accrued positive karma (sonam). He said that yang and cha are similar to
positive karma, but they are not the same.
Tempa Yundrung, the junior Lopon of Triten Norbutse monastery in Kathmandu,
explained to me that the reason why the first way, is called the way of cha, is because
it deals with the methods used to find out the causes of problems that we have in this
life, and the techniques that are used to eradicate them. He said that the rituals
connected with it are based on the principle that everything is interconnected, that
everything in the external world is reflected in the microcosm of the human body.
The five elements in the outer world have their counterpart in the human
constitution; they permeate the whole of the physical constitution, but also have a
particular association with the five mental poisons, the five solid organs, the five
orifices, and so on. He said that this is explained in detail in the Tantric teachings of
the higher ways. It follows from this that the actions people make in the external
world are inextricably related to their physical and psychological well-being.
In the Bon texts, cha is related to two other concepts: wangthang and lungta.
Wangthang refers to a person's charisma and personal power; it relates to the ability
to perform in some capacity to the highest order, for this reason Norbu translates it as
'ascendancy-capacity' (Norbu 1995:62). Lungta is the name given to prayer flags
that are usually found in abundance on the roofs of Tibetan houses and on the tops of
surrounding hills. In the centre of the prayer flag there is a picture of a horse carrying
a jewel on its back. Around the horse are four animals, one in each of the four
corners: a tiger, a lion, a dragon, and an eagle. The first syllable of the Tibetan word

229
Plate 21 - Geshe Tenzin Dargye, Nyima and another Tibetan from the community
setting up a lungta flag on a nearby hill top.

Plate 22 - Geshe Tenzin Dargye making offerings at the culmination of the Jamma
ritual.
lungta is commonly spelt in two ways, giving either rlung rta, 'wind horse' or klung
rta, 'river horse'. Both spellings are pronounced in the same way. Karmay opts for
the rlung rta spelling, as the ideal horse (ta chog), due to its speed, is traditionallv
associated with the wind (1993). In his discussion he connects the four animals with
the four great nyen, the four divinities of the rLung rta, and the four elements. Norbu
prefers the klung rta spelling. The reason he gives is that in ancient texts klung had
the meaning of 'space', which is now represented by the word klong. In his view the
four animals represent the four elements of earth, water, air and fire; the horse
represents the fifth element of space. In his view, as everything depends on the five
elements, the symbolism relates to the speedy transformation of negative
circumstances into beneficial ones.
Both authors concur that the symbolism is concerned with prosperity and well-
being. Lungta also come in the form of small squares of thin paper with the symbols
printed on them. The ritual of the lungta is concerned with increasing ones good
fortune, and can be done at any time, but is usually done when embarking upon a
new venture. On one occasion I went up into the hills looking for medicinal plants
with Geshe Tenzin Dargye and Nyima. When we reached the highest point he
planted a large stick firmly in the ground and fastened a lungta prayer flag on the top
of it. We were all given a handful of barley grains and after he had finished the
prayer to the local divinities, we threw the grains in the air in a gesture of offering
(see Plate 21). With the small lungta, the same ritual is done and the papers are
thrown into the wind usually in great quantities. The mechanism that underpins the
efficacy of this ritual can be understood according to Tenpa Yundrung's explanation
about the relationship between outer and inner elements. He said that by throwing the
lungta papers into the wind, or by setting up lungta prayer flags, this in turn affects
the inner winds and brings about good fortune.
The interrelationship between the outer and inner elements also forms the basis of
Tibetan medical theory. The five elements of earth, water, fire, air, and space are the
fundamental components of everything that exists. Disease arises when these
elements are in a state of disequilibrium (Tsarong 1981). Cures are affected by
counteracting imbalances in the body by using medicines that have the opposite
potency to the disease; for instance hot diseases are treated by cold medicines. The

230
interrelationship between the outer environment and the human constitution can also
be seen in the way the body responds to seasonal change; each of the three humours
and the five elements rises and declines at different times of the year. For this reason,
as I have discussed in chapter five, chapter one of the fourth volume of the medical
text, which deals with pulse diagnosis, contains a section that deals with the rising of
the five elements at different times of the year and the affect this has on the quality of
the pulse.
Geshe Tenzin Dargye told me that the mam Bonpo ritual that is used to
accumulate cha and yang is the cha khug yang khug, which is connected with the
deity Nor gyi dzamfa fha. This can be done at any time that seems appropriate. He
explained that one occasion when it is often performed is during marriages. The
ritual is carried out on behalf of the bride's family. The reason for this is that the
bride will usually go and live with the husband's family. In effect this means that her
own family will lose a daughter and this could be harmful to their chao Some of their
cha could go with their daughter, having a positive effect for her husband's family,
but a possible negative effect for them; the ritual is done to strengthen their chao
He gave another related example. If somebody has a special horse, this will attract
other horses to the owner. But if this special horse is lost in some way or other, so
will the yang that it embodies. Some Tibetans in Dhorpatan have up to forty horses.
They use these horses for carrying out trade between the mountain communities.
Some people carry out trade between Tibet and Nepal. One of the Tibetans who does
this has a horse that is renowned for its strength and beauty. At a certain point when I
was in Dhorpatan, I got news that he had just arrived back from a trading journey to
Tibet. I heard that when he was in Tibet a rich nomad had taken a fancy to his horse
and offered him twenty yaks for it. Even with such a generous offer, he refused to
part with the horse. In his view this horse was his wealth god (norlha) , and to part
with it would be tantamount to losing his capacity to accumulate wealth.
Some other activities that are done to set up and maintain the conditions for
prosperity are: decorating chorten;9 repainting sacred buildings, or images, carving

9The Tibetan equivalent of the Sanskrit stupa: these are structures that represent Buddhahood: they
often contain sacred writings or relics of accomplished lamas.

231
mantras into rocks; setting animals free (tshethar) that otherwise would be
slaughtered; and the recitation of sacred texts, either by oneself or by sponsoring
others to do it.
Examples of most of the above can be found in Dhorpatan. In the part of the
settlement where I stayed, there was an old goat that wandered around freely. This
had been set free by a Tibetan living nearby in an act to bring good fortune to his
family. At a certain point during my stay, everyday for about two months an old
Tibetan man could be seen sitting outside the medical school carving the Bon mantra
Om Matri Muye Sale Du on flat pieces of stone; this had been sponsored by Amchi
Gege. Geshe Tenzin Dargye and the other monks, including Amchi Gege's three
monk students, were frequently called upon to go to houses and recite religious texts.
Depending on what was to be recited this could take up to a week and sometimes
longer.
Most of the Tibetan houses have an altar with religious statues on it, and pictures
of deities hanging on the wall above it. Here, water is offered in small dishes every
morning; butter lamps are also frequently burned in front of the images. Another
common practice carried out by monks and lay people alike is the sang offering. This
is usually done early in the morning but can be done at any time. It entails the
burning of aromatic plants; juniper is usually used as it grows in abundance in the
high Himalayan valleys, and creates large clouds of smoke. As the drifting aromatic
smoke wafts into the air, a prayer is recited offering it to the local deities. This has
the effect of clearing obstacles and maintaining a harmonious relationship in the
environment.
Along with the general ritual activity that is carried out in an intermittent fashion
throughout the year by monks and lay people with the aim to maintain a positive
relationship with the local deities and spirits, every year the monks and lamas carry
out three large rituals for the benefit of the community. The first ritual is dedicated to
the three classes of beings: the sadag, lu and nyen. 10 I was told that the best time to
perform this ritual is in the spring, as this is the time when these beings awake. The
ritual I observed was carried out at the beginning of June and lasted for a week.

10A short description of a similar Bon ritual dedicated to the sadag. III and nyen has been giYcn by
Norbu (1995: 131).

232
Before the ritual began there were several days of preparations, which involved
making the butter lamps, drawing the mandala 11 with coloured sand, and making the
12
appropriate tormas. During the ritual, different types of objects are placed as
offerings on specific locations of the mandala, this includes: sweet smelling herbs,
branches of juniper, various types of torma, gyangbu,13 pho dong and mo dong, 14 and
15 16
namkha and dadar (see Plate 25). During the ritual, the Ill, sadak, and nyen are
called to the mandala to receive the offerings. At the close of the ritual, the mandala
is dismantled and the offerings are gathered together in four big metal dishes and
placed some distance from the temple in each of the cardinal directions next to an
object representing the element of that direction, such as next to a stream for water,
or a stone for earth. In this way the spirits are appeased and a positive bond is struck
between them and the human community.
The next ritual occurred around the middle of August and again lasted for a week.
Whenever I asked Geshe Tenzin Dhargye about this ritual, he always referred to it as
the 'gompa puja'. The generic Tibetan term for ritual is shabten, but most often he
used the Sanskrit term puja. This ritual is the annual ritual of the Bonpo temple
(lhakhang) that is situated next to the medical school~ it focuses on the Bonpo
protectors, Nyipangse, Midii, Gyalpo Sheltrab, Tong Gyung, and the class of the tsen.
The third ritual, which Geshe Tenzin Dhargye referred to it as the 'people's puja'
commenced a few days after the end of the ritual of the Bonpo protectors. The ritual
involved the reading of two sets of texts: the bum, the sixteen volumes of the Bonpo
prajnaparamita sutras, and the Ziji, the long biography of Tonpa Shenrab. After the
monks had done this they performed a lengthy ritual dedicated to the Bonpo goddess

II The mandala is a concentric diagram representing the palace or environment of a Tantric deity. and
the deity's emanations and attributes.
I ~ An offering cake made from barley. Tormas come in many different shapes and colours.

corresponding to types of ritual and deity.

13 A wooden stick with three strings tied on it; I was told the strings represent. life (srog). body (Iii)

and ascendancy-capacity (wangthang).

14 Wooden sticks with pictures of men (Pho) or women (mo) on them. some gvangbu also show

pictures of animals; they are offered to the local deities. a~d s?irits as representatives of the real thing.
-1 Sticks, \vith coloured threads wrapped around them m mtncate patterns. There are many different
types of namkha. The types used here symbolise the the elements: red thread. fire: white thread. air:
green thread. water: yellow thread. earth; and blue thread. sky.
15 Sticks. with coloured threads \\Tapped around them in intricate patterns. There are many different
types of namkha. The types used here symbolise the five elements: red thread. fire: white thread. air:
green thread. water; yellow thread. earth: and blue thread. sky (see plates 23 and 2ot).
16 Ritual arrow used in rites of prosperity.

233
Sherab Jamma. The merit that is accumulated from the reading of the texts is
dedicated to the benefit of the community for the coming year. Sherab Jamma is
invoked as a guardian deity to bring prosperity and eliminate obstacles (see Plates 22
and 13).
The four principal peaceful deities of the Bon religion are the 'four transcendent
lords' (der she fso zhi) which includes a mother goddess; and three male deities: the
god (lha) , the procreator (si pa) and the teacher (tonpa). In the present age these are
respectively: Satrig Ersang, Shenlha Okar, Sangpo Bumtri, Shenrab Miwo. Sherab
Jamma is a form of the great goddess Satrig Ersang. Her name means 'the Loving
Lady of Wisdom' (Kvaerne 1995:24-28). Though she is primarily a peaceful deity
the Bonpo consider her to be extremely powerful. The principal wrathful protector of
the Bon religion, Sipai Gyalmo, is considered to be an emanation of her.
The ritual culminated in her forma being carried beyond the gompa compound
and cast into a fire of burning juniper branches. Most of the Tibetan people of the
settlement came to witness this, along with many Nepalese, and there was a strong
contrast between the solemnity of the ritual and the party atmosphere amongst the
people who were watching it. Though most of the valley of Dhorpatan lies above
3000m it is still engulfed by the monsoon rains before the clouds dissipate in face of
the indomitable Dhaulagiri mountain range situated a short distance to the north. At
this time of the year, the monsoon rains are beginning to thin out, but it is still
unusual to have a day without rain. Geshe Tenzin Dargye said that after he had
finished the same ritual on the previous year, the rains stopped, which he attributed
to the power of the ritual. The same thing happened after the ritual I observed.
Within a few hours of the culmination of the ritual, the skies cleared and the rain
stopped; however they did ensue again incessantly on the following day.
We have seen that the Tibetans and Nepalese who live in the valley of Dhorpatan
believe that they share their environment with a host of local spirits and deities, and
that the health and prosperity of the community depends on maintaining a positive
relationship with them. Numerous rituals are carried out throughout the year with the
aim of preserving this positive relationship. In their studies of the main medical text
the students learn about how to identify disorders that arise due to breakdowns in this
relationship It is unlikely that medicinal compounds alone will cure such diseases; it

234
is necessary to perform the appropriate ritual. In the next chapter I discuss some of
the rituals that I observed in Dhorpatan that were resorted to when such diseases
were diagnosed. I will focus specifically on the way that students in the medical
school were involved in these incidents.
 Chapter 8 - The Use of Ritual in Healing

In chapter five we have seen how the students learn about Tibetan medicine in the
classroom, and in chapter six I have discussed how the students develop performative
memory by engaging in medical practice. All of the disorders that we saw in the
twenty clinical interactions I gave in chapter six, were diagnosed in terms of Tibetan
medical theory as deriving from endogenous and behavioural pathogenic factors~ as
such, the therapeutic course of action involved either administering medicines or
external therapies such as moxibustion. However, during my stay at the medical
school in Dhorpatan, I witnessed a significant number of patients whose disorders
were attributed to exogenous pathogenic factors. It is to these factors, and
specifically to diseases caused by harmful spirits that I will now turn.
When the cause of a disease is known to be harmful spirits then medicines alone
will not suffice to bring about a cure, the spirit causing the harm must be addressed
directly through ritual. In Dhorpatan, the person who was in charge of all this activity
was Geshe Tenzin Dargye. As a senior monk, Amchi Gege knew how to perform the
rituals, but once he had diagnosed a patient with a disorder caused by harmful spirits,
he would pass the patient on to Geshe Tenzin Dargye. All of Amchi Gege's students
knew about the ritual techniques pertinent to healing and every time that Geshe
Tenzin Dargye performed such a ritual, he was always helped by a number of the
medical students.
Healing rituals are not described in detail in the mam medical text, but with
certain diseases they are mentioned as a therapeutic method. However, as we will see
in the following section on the disease known as sa drib, detailed descriptions of
healing rituals can be found in medical commentaries. In the classroom the students
learn about the various types of disease that are caused by harmful spirits, and how to
diagnose these diseases. Learning about the ritual techniques that are used to cure
these diseases is also very much a part of their induction into medical practice.
In what follows I will begin by discussing various types of diseases that are
caused by spirits. I will then move on to discuss forms of diagnoses and divination
that are employed when a patient is thought to be suffering from such a condition.
The chapter concludes by discussing three illness episodes involving patients who

--,
"''''6
had been diagnosed as suffering from a disorder caused by harmful spirits. I also
discuss the rituals that were employed in these episodes.

8.1 Napa

During my stay in Dhorpatan there were many instances of napa, indeed a large
portion of Geshe Tenzin Dargye' s time was taken up doing rituals to either prevent
or cure it. Generally napa arises as a consequence of human activity that causes harm
in the environment, such as polluting streams or ponds, cutting down trees, or
carrying out quarry work. Spirits also take offence at action, which they consider to
be polluting, such as food spilling out of a pot onto the hearth, or human corpses
being disposed of in ways that offend them. For example, Amchi Gege told me that
when he was young and living in Khyungpo, in the Kham district of east Tibet, he
heard of a village where there were many cases of napa. A lama was sent to ascertain
the cause of the problem, which turned out to be the people of the village burying
their dead in an area of land, without consulting the sadag, the spirit that lived in this
land. Traditionally when a person dies, a lama or a monk or some other specialist
will consult the astrological texts (tsi) to ascertain the appropriate way to dispose of
the body.l This had not been done in the village, and in an act of retribution the
sadag had caused the disease. In response, the spirit had to be appeased through
ritual, and from then on people disposed of their dead with more care.
Tibetans living in Dhorpatan take measures to avoid causing offence to the local
spirits and deities. As we have seen, they commonly carry out rituals such as the
lungta, and the sang, offering to appease them. Offerings are also made at the outset
of a new undertaking, such as a business venture, or constructing a building. The
Nepalese are also careful not to disturb the spirits in the surrounding environment.
For example, when I was in Dhorpatan, close to the medical school there was a
quarry, where a group of Nepalese from the Bishwakarma ethnic group worked every
day cutting slate to be used as roofing tiles. Just next to the place where they were
working, they had set up a little shrine where every morning they made offerings and
said prayers before commencing work, in order to appease the local spirits.

1 The are four methods. which correspond to the four elements: burial (earth), cut up and placed in a
riYcr (water), cremated (fire), fed to yultures (air).

237
 Dhorpatan has a reputation amongst Tibetans as a place where napa frequently
occurs. Geshe Tenzin Dargye told me that this reputation stems from when the
Tibetans first arrived in the 1960s, as at this time the valley was densely forested and
there were many strong unruly spirits in the vicinity. In time their power to cause
harm was curtailed by vanous Tibetan lamas, but particularly by one powerful
Bonpo lama, Tsultrim Nyima. But napa had by no means been completely
eradicated, and Tibetans and Nepalese often came to Geshe Tenzin Dargye for
blessings to protect themselves against it. This usually involved him wafting them
with incense and sprinkling them with blessed water while he recited prayers and
mantras. Sometimes he would also give them blessed cords (srung dud) or amulets
made from folded paper inscribed with mantras and wrapped with different coloured
threads (srung khor).
Geshe Tenzin Dargye's account of the valley of Dhorpatan as a place of wild
unruly spirits, until they were subdued by the ritual power of Tibetan lamas, is a
common Tibetan theme. The environment is something wild and potentially
dangerous, which needs to be tamed by the power of religion. The best known
accounts in this genre are the numerous tales of the eighth century Tantric adept,
Padmasambhava, who was instrumental in establishing the Vajrayana form of
Buddhism in Tibet, travelling through the countryside subduing local spirits and
binding them by oath (dam cha, dam tshig) to uphold the Buddhist doctrine. Samuel
(1993: 167) views the taming of the environment theme as part of the mythological
history of Tibet. One account he gives is found in the Mani Kabum text, which
describes the land of central Tibet as the body of a wild demo ness (sinmo) that was
subdued by being pinned down by a series of three concentric temples; in the centre,
situated on the heart of the demoness is the famous Jo khang temple in Lhasa. The
Bonpo have similar accounts. When Tonpa Shenrab came to Tibet he found the
people not ready for the higher teachings, and so he imparted to them at this time
only the knowledge of the lower ways concerned with controlling the local spirits

(Karmay 1972).
In the early years of the settlement, the Bonpo lama, Tsultrim Nyima, carried out
much of the work of taming the environment of Dhorpatan. Although he passed
away almost thirty years ago, he is still spoken of with reverence by people in the

238
Bonpo community, both in Dhorpatan and beyond. One local spirit that he subdued
has a shrine in the centre of the valley. The shrine belongs to the Nauthar ethnic
group. I was told that during the early years of the settlement the spirit frequently
caused problems for people. In response to this, Tsultrim Nyima ritually controlled
its activity, and as a result, for many years it was unable to cause harm. Recently,
people have recommenced giving offerings in the shrine, and consequently the spirit
has re-established itself; it is now frequently suspected of causing napa.
On one occasion Geshe Tenzin Dargye and one of Amchi Gege's monk students
were on their way back from carrying out a ritual at the Namdru Tang. When they
reached Khangpa Shiwa, the closest Tibetan camp to the Nauthar shrine, they were
called to the house of a Tibetan man who had suddenly been taken ill. When they
arrived, the man was having difficulty breathing and was unable to speak. The illness
had assailed him quickly. Before he had lost the ability to speak he had complained
of pains in his chest. Geshe Tenzin Dargye started to invoke his yidam, Walchen
Gekha. As he was doing this, the man cried out and jerked about violently. Then
Geshe Tenzin Dargye attempted to tie a blessed cord around the third finger of one of
the man's hands, and he told Amchi Gege's student to do the same with the other
hand. This would effectively trap the spirit inside the man's body, and it could be
then forced to reveal its identity. But this was no easy matter, as the man's hands
were tightly clenched into fists. Geshe Tenzin Dargye managed to pry one of his
hands open, but as he did, the spirit possessing the man promptly left. The student
confessed to me afterwards that he was unable to act efficiently in the situation
because he was afraid. The man quickly came back to consciousness and had no
recollection of what had passed. He was questioned about what had happened to him
before he became unconscious. He explained that the last thing he remembered was
walking near the Nauthar shrine. Geshe Tenzin Dargye took this as evidence that the
spirit connected with the shrine had caused the affliction. A few days later he came
to the clinic and Amchi Gege gave him medicines, and Geshe Tenzin Dargye tied
blessed cords around his third fingers, which he was told to wear for a few days.
Earlier I mentioned the dre me, that Amchi Gege's student Sonam experienced as
ball of light that passed in front of him and hovered at the other side of the river from
where he was standing. Shortly after this, Sonam became ill. At first no connection

""""9
--'
was made between his illness and the dre me. It was only after Geshe Tenzin Dargye
had done a divination about the nature of the illness that they knew it was the dre me.
As Sonam encountered it near the Nauthar shrine, again this spirit was the prime
suspect.
During the period of my stay in Dhorpatan, Geshe Tenzin Dargye treated a large
number of young children who were thought to be afflicted by napa. One Tibetan
woman came to the clinic complaining that her young son could not sleep at night,
and claimed to keep seeing a black figure. Geshe Tenzin Dargye did a divination,
which identified the problem as a dead woman coming from the north east, who was
harming the child's life-force (sog). He did the appropriate ritual, the boy's name
2
was changed (ming gyur), and his family set free one of their chickens (tshethar).
Geshe Tenzin Dargye's ritual healings of child napa were not confined to the Tibetan
community. At one point after Geshe Tenzin Dargye had cured a Nepali baby of
what seemed to be an intractable case of napa, his reputation spread and a stream of
Nepali woman came in the ensuing months, bringing with them their sick children to
be healed.
Sometimes the spirits that were identified as the cause of an incident of napa were
not local, but were connected with the area of Tibet that the family originally came
from. For instance, one morning, Tsering Lhamo, one of Amchi Gege's female
students, came to Geshe Tenzin Dargye and asked him to do a divination because her
brother was suffering from insomnia, and recurring bouts of fear for no apparent
reason. The divination said that the cause of the problem was a particular type of
female demon (dremo) with a pig's head. When Tsering Lhamo's father heard about
this, he remembered that in his village in Tibet there had been such a demoness with
a pig's head that had caused much napa.
On another occasion, a Tibetan man came to the medical school concerned that
his wife had fallen from her horse and gashed her head. As his wife was very
competent at riding horses, he suspected that some insidious influence had been at
play. He asked Amchi Gege to do a divination, which he did, and received the reply
that the fall had been caused by the tsen spirits. Amchi Gege then directed him to
Geshe Tenzin Dargye to verify this. The result of his divination also pointed to the

~ A traditional Tibetan practice to avoid harmful influence.

240
tsen. He asked the man whether he had ever had any relationship with the tsen, to
which he replied no, but he thought that the relationship could go back to when his
family lived in Tibet.

8.2 Drib3

A concept that I came across time and time again amongst Tibetans in Dhorptan
was drib, which is a form of pollution associated with certain kinds of activities.
When drib accumulates sufficiently in a person it can bring about illness. Geshe
Tenzin Dargye explained that drib arises from carrying out impure activities or
coming into contact with something that is thought to be impure. He gave the
following activities as examples: working with dead bodies; breaking social taboos
such as incest; eating garlic or onions if one has a connection with certain yidams;
using dead people's possessions; and mixing with low caste people such as
blacksmiths, cobblers and musicians. He also explained that a major source of drib is
carrying out sinful activity (digpa) or associating with sinful people.
Notions about drib are widespread amongst the older generation of Tibetans in
Dhorpatan. For example, one morning a Tibetan woman came to ask Geshe Tenzin
Dargye to ask his advice about a problem she had with her eyes. The problem had
persisted for two years and consisted of soreness and impaired vision. She said that it
had started shortly after the death of a Tibetan man who she had been close to. In the
period prior to his death she had been in constant contact with him, offering him
assistance whenever he needed it. She thought that she was suffering from drj b
arising from this contact.
Dri b can also come about as a consequence of offending the local deities and
spirits by carrying out inappropriate behaviour in their dwelling places such as
shouting or lighting fires in the mountains (Tucci 1980: 173). Much of the ritual
activity, which I described in the previous section, which is dedicated to preserving
harmony between the human community and the spirits that inhabit the natural
environment, can also be viewed as a means to prevent drib (Samuel 1993: 161). Drib
can accumulate in a person, and a person who has a high level of drib may
contaminate others. Geshe Tenzin Dhargye told me that vultures will not eat a human

3 For further information on drib see: Daniels (1994). Lichter and Epstein (198)). and Schlickl.l!rubcr
( 1989).

241
corpse if it is defiled with drib. He was also of the firm conviction that drib can be
fatal. He said that he knew of a lama that had come into contact with many human
corpses, and as a consequence of the drib he had accumulated in the process, he had
become fatally ill. According to Tibetan medical theory, drib may lead to a range of
pathological conditions, but it can be cured if the appropriate therapy is administered,
which may involve a mixture of medicines, ritual and behaviour modification.
Towards the beginning of my stay in Dhorpatan, Amchi Gege went to visit an old
Tibetan woman. He took one of his monk students, Yundrung, along with him. She
had been sick for seven years and had received repeated medical treatments. Some
months before, her condition had worsened and she was unable to speak or walk. At
that time Amchi Gege gave her some medicines and a moxibustion4 treatment, which
improved her condition, but in the ensuing months she had regressed. Amchi Gege
had diagnosed her condition a long time before as drib. Nyima, the senior medical
student, told me that the pulse indicative of drib, is similar to the 'blood' (tra) pulse 5 .
Now she had completely lost all movement down one side of her body. I never saw
the woman, but from what I heard about her symptoms, it seemed like apoplexy.
However, they were of no doubt that she was suffering from a condition called sa
drib.
On a few occasions when I was in Dhorpatan I heard about or directly witnessed
patients whose illness had been diagnosed as sa drib. Each time the symptoms
seemed to denote what in biomedical terms would be called apoplexy or epilepsy.
Curious about the evident disjuncture between the two medical systems I asked
Amchi Gege to teach me what Tibetan medicine has to say about the disease. Sa drib
is dealt with in chapter eighty of the third volume of the main medical text. I was
taught all of this chapter of the text and the relevant sections of Khyungtrel
Rinpoche's commentary. What follows is a brief synopsis.
The chapter on sa drib is one of the five chapters of the tenth section of the third
volume, which deal with diseases arising from the action of harmful spirits. The
chapter focuses on diseases associated with the planetary spirit called sa (Sanskrit:

4 A treatment similar to acupuncture. which involves the burning of a herb on specific locations of the
bod\'.
5 This pulse indicates a pathological condition of the blood: the pulse is swollen (bur) and twisting
(drif).

242
Rahu). The subject is covered under five topics: the time when the disease occurs;
the types of the disease; the symptoms; protection against the disease; and treatment
and measures to be taken to prevent the return of the disease.
Sa drib can only occur on eight specific days in the Tibetan month. These are the
days when the planetary spirit sa has influence. There are five kinds of the disease
corresponding to the five elements of: water, earth, fire, air, and space. There are two
sets of symptoms. The first are general symptoms that are present in all cases of the
disease: the eyes look very clear as if the person is healthy; there is paralysis of the
left or right side of the body; and the mouth is twisted to one side. The second set of
symptoms corresponds to the five types of disease according to the five elements.
For instance if the sa spirit affects the fire element in the body: the person's right
side is paralysed; the left side of their tongue protrudes longer than the right side;
they have a strong fever; and the nails have a yellow appearance like they have been
burnt in a fire. If it is the water element that is affected: the left side of the body is
paralysed; the right side of the tongue protrudes longer than the left side; when
touched the left side of the body feels cold and the right feels hot; and the ligaments
of the body tighten. In the section on protection against the disease, Amchi Gege
gave a number of mantras, and following Khyungtrel Rinpoche's commentary he
explained how to make various kinds of amulets (srung wa). The section on
treatment mostly deals with rituals that should be performed to counteract the
influence of the sa spirit, but it also gives information about medicines, and advice
on diet and behaviour.
Amchi Gege explained that the main cause of sa drib is negative karma, accrued
in the present life or in previous lives. This may be the case for sa drib but from
conversations I had with Geshe Tenzin Dhargye, negative karma is not the only
cause of drib. As we have seen, there are two ways in which it can arise: non-
virtuous actions, and coming in contact with something that is classified as impure.
The first of these causes is directly related to karma, but the second is usually not.
The Tibetan people in Dhorpatan said that the old woman, who had been diagnosed
with sa drib, had committed many bad deeds in Tibet. Her husband was a notorious
Tibetan bandit who had robbed many people, and she had assisted him in his
exploits. Yundrung told me that night, after he and Amchi Gege had visited the

243
woman, that while he was there she was semi-conscious and muttering things to
herself. One thing he heard her say repeatedly was 'they are coming', 'they are
coming'.
Yungdrung also told me that he had taken her pulse, which he said was the death
pulse (chi do). This is when the pulse makes a pattern of beats then stops and then
repeats the same pattern. The next day Geshe Tenzin Dhargye and Yungdrung went
to her house and performed the appropriate ritual for her condition. She seemed to
get a little better after this, but her improvement was short lived. A few days later
Yundrung was sent to see how she was getting on. He told me that her body had
become bloated with fluid, and when he tried to take her pulse it made an indent in
her skin. He said that her pulse seemed then to be that of a blood condition, but this
could also be interpreted as drib. Some of her friends had taken a sample of her
urine, which they were about to bring to Amchi Gege, when they had dropped it.
They had noticed that the urine was a reddish colour. Yungdrung relayed all this
information to Amchi Gege, who thought she was now suffering from kya bab,
which in biomedical terms is most likely oedema. Kya bab is the first stage of a
condition were the body swells with serous fluid; there are two more stages listed in
the third volume of the medical text. Within a week the woman had died, having
gone through all three stages.

8.3 Divination (mo)

Every time somebody was suspected of suffering from napa, Geshe Tenzin
Dargye was invariably asked to do a divination to verify the cause of the affliction.
The diagnosis would always begin with the patient's pulse. The first chapter of the
fourth volume of the Bumshi on pulse diagnosis gives various characteristics of the
pulse, which indicate the action of harmful spirits: the beat is irregular, the pulse
stops at sporadic intervals, it is taut (thenpa) like a rope, the pulse feels like two beats
(chamdrel) occurring simultaneously. These qualities may be present on their own or
in combination. If the pulse appeared to denote napa, then divination would always
be done to confirm the nature of the disease.
There are numerous forms of divination listed in Tibetan texts. In the nine-fold
classification of Bonpo teachings, divination forms part of the first way, the 'Way of
the Shen of the Cha' (cha shen thegpa). Tibetan Buddhists also have many forms of
divination. One form that Nebesky-Wojkowitz (1956:454) mentions is scapulimancy
(sagmar). This involves laying the shoulder blade of a sheep in a fire and interpreting
the cracks that appear in it. The Bonpo have a method of divination, which involves
interpreting knots in ropes (juthig), but it seems very few lamas have much practical
knowledge of this now. Nebesky-Wojkowitz also mentions a form of divination
known in ancient Tibet of interpreting bird song. A few years before, whilst I was
staying at Menri Yungdrung Bon monastery at Dolanji, near Simla, I remember
commenting to the Abbot of the monastery, Sangye Tenzin, about the beautiful
sound of all the birds singing around the monastery. He replied in a jocular manner,
'but can you understand what they are saying? There is one Bonpo text which
explains how to do this. '
Another common method of divination in Tibetan culture is through oracular
pronouncements made by men or women possessed by a spirit. Such people are
known as lha pa, lha ma or pawa (Day 1989, Nebesky-Wojkowitz 1956:398-443,
Prince Peter 1978, Berglie 1976). The possessing agent may be a god, goddess, or a
being from one of the many spirit classes. The person possessed can be a monk or a
layperson. Perhaps the most famous Tibetan oracle of this nature is the Nechung
oracle. Nechung is the name of a small Nyingmapa monastery near Drepung
monastery located a short distance west of Lhasa. This monastery housed the oracle
of the chief protector of Tibet Pehar. The Dalai Lama and the Tibetan government
consulted the oracle on state matters. In 1959 the oracle moved with the Dalai Lama
to Dharamsala in Himachel Pradesh where he continues to be consulted.
The two most common forms of divination used by lamas and monks are
divination using dice (sha ma) and divination using rosary beads (treng ma). The
number generated from throwing the dice corresponds to an entry in a book, which
gives the relevant response to the question. Treng ma is the method that Geshe
Tenzin Dargye most often used to verify cases of napa. He told me that there are
three main systems of doing this form of divination in the Bonpo religion: one that is
governed by the main Bonpo protector Sipai Gyalma; another that relies on MClli'e
Senge, the Bonpo deity that corresponds to the Buddhist Mafijusri~ and a third
system, which draws on the Bonpo protector Gyafchen Dragpa Senge. Geshe Tenzin

2-l5
Dargye uses the latter system. When he needs to consult the oracle, he begins by
burning incense, reciting a prayer to Gyalchen Dragpa Senge, and then he formulates
the question clearly in his mind. Once he has done this, he places his fingers
randomly on his rosary and counts groups of nine beads with each hand, until he is
left with a number of beads between one and nine. He then consults the text under
the relevant heading such as: travel, business, child illness, theft, and so on.
He confided in me that he had never wanted to do divination. Before coming to
Dhorpatan he had been advised to take it up, which he did, but very reluctantly. His
reason was that when people know that you can do divination they are always
coming with questions, and sometimes the answers to those questions are not what
people want to hear. Indeed every week at least two or three people came to him and
asked for divination to be done.
Sometimes the question concerned the prospects of a new business venture. One
Tibetan man had the possibility of doing some trekking work with an American
group who were shortly to arrive in Kathmandu. Although he would have been
happy to earn some money, he was uncertain about going because his mother was not
well. The divination replied that if he went, the prospects were neither good nor bad,
but by having a ritual performed the circumstances could be swung to his advantage.
Another man came to ask about a business project that he wanted to set up in
Kathmandu. The outcome of the divination was not favourable and the man left
somewhat dismayed.
Most often the questions that people asked referred to illnesses. One morning a
Tibetan woman came and asked for a divination. She said that her son had suffered
from a painful swollen area behind one of his ears. She had consulted doctors in
Kathmandu and Pokhara, and eventually surgery had been carried out. The divination
identified the cause of the problem as the dremo spirit class. On another occasion one
of Amchi Gege's female medical students asked Geshe Tenzin Dargye to do a
divination about the sickness of one of her friends. The response was that the (sen
class of spirits had caused the condition. He told me that her family had been doing
rituals to the (sen for protection, and then they had stopped, and the (sen do not take
kindly to this.

246
 Geshe Tenzin Dhargye's qualms about the problems of doing divination are
clearly indicated in the following account. One Tibetan boy aged 18 had been taken
seriously ill with some kind of intestinal disorder. He was well known in the
settlement. He was in the hospital in Kathmandu and the doctors had decided to
operate on him. His mother was very upset. She came to Geshe Tenzin Dhargye,
offered him a bag of potatoes, and asked him to do a divination about her son's
condition. He did the divination, and he told her that the sickness was serious, but if
prayers and ritual were performed her son should be well. That evening prayers were
done and I could hear the bell of the large prayer wheel in the gompa compound
ringing all night. A few days afterwards, we received news that the boy had died. For
some days this cast a dark shadow over everybody. Geshe Tenzin Dhargye told me
that he had done divination several times and it had repeatedly given a negative
response and he had not known what to say to the boy's mother.

8.4 Divination through the Patient's Urine

The second chapter of the fourth volume on urine diagnosis is divided into eight
sections. I have discussed the first seven sections in chapter five. The eighth section
deals with the qualities of the urine, which denote the action of harmful spirits.
Unlike in the earlier sections of the chapter, the techniques explained here relate
strongly to Tibetan cosmological notions; the practices that are described take
Tibetan medical diagnosis clearly into the domain of divination.
When Amchi Gege explained this section to me he gave abundant details about
types of spirits that cause disease, and how this is reflected in the urine. Most of this
information is not provided in the main medical text but in commentaries to it such
as Sangye Gyamtso's Blue Beryl (Vaidurya Ngonpo) or Khyuntrel Rinpoche's
Khyungtrel Menpe, which was the text Amchi Gege used as a basis for his lessons on
the subject. The following description is based entirely on Khyuntrel Rinpoche's
commentary.
The patient's urine is collected in a flat-bottomed round bowl. A male patient
urinates into the bowl in a west direction, as this is the direction of the wood

247
 6
element , which is male; the bowl is then turned 180 degrees so that the point where
he urinated is in the west. A female patient does the opposite, she urinates in the east
direction, as this is associated with the iron element; again the pot is turned 180
degrees. The bowl is placed very carefully on the ground, and four thin sticks are
placed across the brim dividing the surface of the urine into nine sections of equal
size. The nine sections are shown in the medical text as sections of the shell of a
turtle. The head of the turtle is south and the tail is north. Male urine is shown by the
front of the turtle and female urine is shown by the back. For this reason the
categories found in the east and west columns are reversed for male and female. The
nine sections correspond to various locations or categories associated with the
afflicting class of spirits; this information can be found in Figure 8.1.

Male Urine Female Urine

south south
Paternal Maternal
Gods Cemeteries Cemeteries Gods
Ancestors Ancestors
(lha) (dur) (dur) (lha)
(Pha ma)
e w e w
People Self Home Home Self People
a e a e
(mi) (rang) (khang) (khang) (rang) (mi)
s s s s
One's One's
t t t t
children, children,
Spirits Land Land Spirits
nephews nephews
(don) (shing) (shing) (don)
nieces nieces
(bu tsha) (bu tsha)

north north

Figure 8.1 The locations of spirits causing disease reflected in the patient's urine

The main items that should be observed in ascertaining the cause of the disease
are: the shape and location of the material suspended in the urine (kuya); the shape
and location of the surface film (drima) and if there are any cracks (sub) in it~ and the
location of the bubbles. If any of these items are found located in one of the nine

6Chinese and Tibetan astrology use the same five elements: wood. fire. earth. metal and water.
Tibetan texts that are of an Indian origin use the earth. water. fire. "ind. and space classification.

248
sections this indicates that the disease has been caused by a particular class of
harmful spirit. For each section the text gives various classes of spirits and the type
of ritual that should be done to remedy the condition.
Specific kinds of design in the suspended material and the surface film also give
information about the spirit that is causing the affliction. Khyuntrul Rinpoche' s
commentary gives eight specific designs found in the suspended material and twenty-
three for the surface film, which signify the action of classes of spirits. For example,
if the shape of a scorpion can be discerned in the surface film, this denotes the action
of the spirit classes lu and dii, if it is a deer antler then it is the gyalpo and the
yamshii, if it is a fish, conch shell, turtle, frog or spider, then the cause of the
affliction is the sadag. The text goes on to describe another type of turtle, again with
nine sections, but this time the sections are ascribed to: the self (rang); the patient's
parents (pa ma) relatives (nyen); the god of the locality (yullha); religious protectors
(srung ma); the yidam; the senmo class of female spirits; the dn?bo class of male
spirits; and the class of the gyalpo. The text begins by describing designs for each
section, which indicate auspicious conditions (sang), it then moves on to describe
designs for each section, which signify a possible fatal outcome. Designs are then
described for each section that indicate harmful spirits affecting one of the three
humours of wind, bile and phlegm.
Other divinatory techniques are described in the text that call upon the power of
the Medicine Buddha, or the doctor's yidam to reveal the spirit, which is causing
harm. In one section the doctor first prays to his yidam and then with eyes closed he
spits into the urine. Whichever of the nine sections the spit falls into, reveals the
cause of the disease. In another section the doctor again begins by praying to his
yidam, or the medicine Buddha, then with eyes closed he drops one grain into each of
the nine sections. One of these grains is coloured black, and the section that this grain
falls into reveals the cause of the affliction.
Although napa frequently occurred whilst I was in Dhorpatan, urine diagnosis
was seldom used to ascertain the cause of the disease; usually this was done by the
pulse and divination. I only witnessed one patient whose disease was diagnosed as
napa by the urine method. The patient was a Tibetan man in his late fifties. He came
to the clinic early in the morning. He explained that he was feeling generally unwell

249
and sometimes he would lose the capacity to speak and move. I was told that this was
the third time he had come in recent weeks complaining of these symptoms. Amchi
Gege took his pulse followed by his student Nyima, which they found to be
prominent and beating in an erratic manner. His condition was diagnosed as a
mixture of drib and napa. He was given three types of medicinal powders to take.
A few days later as his condition had not altered, Amchi Gege decided to do a
urine diagnosis to ascertain the type of spirit that was causing the condition. The
examination occurred early in the morning. I was called to see the fresh urine, which
was already in a porcelain bowl and placed on the ground next to the Amchi Gege' s
room. All the students were gathered around it. Amchi Gege explained to me that the
man had urinated into the bowl in a west direction. He said that this method of
diagnosis is resorted to if the spirit is hiding the cause of the affliction. First, Amchi
Gege and his students recited prayers to the medical lineage and to the medicine
Buddha. Four thin sticks were then placed across the brim of the bowl, dividing the
surface of the urine into nine sections as prescribed in the text. Amchi Gege then
recited more prayers and after some time, starting in the east direction he dropped
one grain into each of the sections. The grain that had been marked black fell into the
north section, which identified the najin class of spirits as the cause of the sickness.
Amchi Gege pointed out small bubbles in the urine that in his view looked like fish
eyes; he explained that this is another symptom of napa. Then after painstaking
scrutiny on behalf of all present, one of the students discerned a scorpion shape in the
bubbles; some agreed, but after a little time the general consensus disavowed it.
Shortly after this, another student noticed a frog shape in the surface film. After some
time this was accepted by most of the others, including Amchi Gege. The text
explains this to indicate the harmful influence of the sadag class of spirits. Within the
next few days the appropriate rituals were performed.

8.5 Ransom Rituals and Rites of Exorcism and Destruction

Tenpa Yungdrung the junior Lopon of Triten Norbutse Yungdrung Bon

monastery in Kathmandu told me that when a problem arises as a result of the
activity of don (malicious spirits), such as a sickness, ritual must be used. He said
that milder forms of treatment described in the first way of Bon will be attempted

250
 Plate 24 - Namkha offering at the
periphery of the gompa compund.

Plate 23 - Namkha

Plate 25 - Three ritual objects: mo dong (top) , dadar(middle) , gyangbu (bottom ).

first. If the problem persists, then the more severe types of ritual described in the
second way of Bon will be used; these are the rites of ransom and exorcism. He
explained that in these rites the spirit causing harm is given offerings in a gesture of
making peace. The Tibetan medical precept that one starts with milder forms of
therapies and moves on to progressively more severe treatments only if occasion
should demand it is equally applicable to ritual intervention. If the Iii rite does not
work then the powerful rituals of destruction that are explained in the third way are
carried out. In these rituals the yidams and protectors are invoked to capture the spirit
and prevent it from causing harm.
There are many different kinds of rites of ransom, all referred to by the Tibetan
word Iii. 7 These consist of various ritual techniques of offering ransoms to appease
harmful spirits and thereby clear disturbances and create favourable circumstances.
There are ransom rites to protect the life of animals, to bring back a person's soul (fa
Iii), or life force (sag Iii), ransoms done to prevent death (chi lu), and to cure sickness
caused by harmful spirits. Lii is both the collective name given to all ransom rituals,
and the name given to the effigy that is offered in the rituals (see Plates 26 and 27).
In this second sense the word means the 'substitute' that is meant to take the place of
the afflicted person or animal. I often heard the Tibetan word tshab, meaning
'representative', used interchangeably in this context, but this word does not have the
ritual connotations of Iii (Norbu 1995: 77).
The most common form of ransom rituals are referred to as do rites. During these
rituals a representative (ngar mi) of the afflicted person or animal is made from
barley dough (tsampa), this is surrounded by other offerings such as pieces of the
person's clothes, bits of their hair, barley grains, and ritual objects such as gyangbu,
pho dong and mo dong, and namkha. These are offered to the spirit or deity with the
hope that it will be satisfied and cease its harmful activity. In Dhorpatan sometimes
only namkha were offered to the spirits. They could be found lying on the ground in
various locations on the periphery of the settlement and at crossroads (see Plates 23
and 24).
Ritual is very much a part of Tibetan medicine and Amchi Gege teaches all his
students to recognise the kinds of disease that require ritual intervention. In the

7These rituals ha\'c been discussed by Tucci (1980). Snellgrove (1967), 'icbcsky-Wojkowitl (19:'()
Norbu (1995) Beyer (1973), and Kannay (1998).
section of Khyungtrel Rinpoche's commentary on sa drib, which I mentioned earlier,
the rituals that are required are explained in intricate detail. Amchi Gege teaches all
his students the appropriate rituals that need to be performed for specific diseases.
Although there is no rule that his male students should be monks, he certainly prefers
this. In any case, all of his male students had been trained in the techniques of
Tibetan ritual; the three monk students and Nyima are very competent in this sphere
of activity.
Incidents of napa sometimes lasted two to three weeks. After Amchi Gege had
seen the patient, and Geshe Tenzin Dargye through divination had confirmed the
sickness to be napa, the patient would undergo a course of treatment involving ritual
and medication. Geshe Tenzin Dargye would usually carry out the ritual, assisted by
Amchi Gege, his three monk students, and the eldest student Nyima. In what follows
I describe three accounts of napa that occurred during my stay. They clearly show
the importance of divination, the use of ritual in the healing process, and the ways in
which the students were involved throughout the proceedings.

8.6 The Angry Widow

The first I knew about this case of napa was when I saw Geshe Tenzin Dargye
sitting in the courtyard outside his residence consulting his astrological text (tsi) for
an old man from Khangpa Gyepa. Afterwards he told me that the problem concerned
the old man's daughter who had fallen ill that morning in a sudden and mysterious
way. Earlier in the morning his daughter had been feeling quite well. She was a
forty-two-year-old strong healthy Tibetan woman, with two children, and no history
of medical problems. Shortly after breakfast she complained of a pain behind her left
ear and in her throat. From that moment her condition quickly worsened, she became
feverish, and the pain in her throat made it impossible for her to swallow. Her father,
suspecting that this was the action of some kind of spirit, came immediately to the
medical school in search of help.
Tsi is the Tibetan word for enumeration or counting, and by logical extension it is
8
used to refer to the various types of astrology to be found in Tibetan culture. The lsi
texts should be consulted on important occasions, such as for births, marriages,

8 For a description of the system of Tibetan astrology sec Cornu (1990).

deaths, embarking on a Journey, building a house, commencmg a new business
venture. Tsi can also be consulted to find out the cause of certain kinds of illnesses
and for advice on methods of treatment. On this occasion Geshe Tenzin Dargye did a
divination with the text to determine the source of the problem. The tsi reading had
confirmed the old man's suspicion, giving the cause of the illness as napa, caused by
either a widow, or the spirit of a dead person. At this stage the exact cause was not
clear.
Around midday Amchi Gege sent Yungdrung, one of his monk medical students,
to attempt a diagnosis. Yungdrung had heard that the problem was possibly napa, but
he did not know anything of Geshe Tenzin Dargye's tsi reading. When he arrived
back, to my surprise, he told me that the problem was indeed one of napa, which had
been caused by an old Nepali widow. He said that the afflicted woman had been
feeling fine in the morning and had made and served breakfast to her family.
Afterwards she went to a nearby stream to wash the dirty pots. At the same time,
some distance downstream, the old Nepali widow was collecting drinking water. The
dirt from the Tibetan woman's dishes flowed down to her; this caused her great
irritation and she came and vented her disapproval. The Tibetan woman's illness
started shortly after this. He took her pulse, which he described as 'slow like a peken
pulse' .
The term that had been used for widow in the tsi text was yug sa mao The word is
associated with impurity and has pejorative overtones. Geshe Tenzin Dargye
explained that the pejorative sense of the word derives from the notion that widows
have the potential to cause napa, but this rarely happens. The Tibetan word khyoga
drongpi kyeman also means 'widow', but does not have derogatory connotations. As
I have mentioned, the appropriate therapeutic response to instances of napa involves
various types of ritual. After lunch, Geshe Tenzin Dargye with Yundrung as his
assistant went to visit the sick woman and work out what should be done. The first
thing he did was give her an amulet (srung khor) to protect her against malevolent
spirits. He decided to return later in the afternoon and perform one of the Iii ransom
rites.
At around six in the evening Geshe Tenzin Dargye and Yungdrung returned to the
house to carry out the ritual. This time I accompanied them. When \ve arrived, the

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 Plate 26 - Geshe Tenzin Dargye making a /0 offering.

Plate 27 - Geshe Tenzin Dargye and Yungdrung making the f{j for the woman
suffering from nopa thought to be caused by the angry widow.
woman was lying down in a smoke filled room, clearly in great discomfort, groaning
and occasionally spitting into a cloth. Immediately work commenced on making the
Iii (see Plate 27). Various medicinal substances had been mixed into the barley flour
that are known to be pleasing to the lu class of spirits. Small fragments of the sick
woman's clothes and bits of her hair had also been mixed into the barley dough.
Geshe Tenzin Dargye made the figure, while Yungdrung made tormas to be offered
along with it. When the figure was finished it was a reasonably good likeness of a
female human form. The right hand of the figure was held upwards and the left
down. This I was told was meant to be a gesture of 'please accept this because the
real one is not coming'. The figure was then placed on a metal tray, with the tormas
surrounding it. A butter lamp made of tsampa was placed in front of the figure. The
tormas were then daubed with a red paint made from the root of the tso plant;9 this is
also thought to be especially pleasing to the spirits. Next, various types of food were
scattered around the figure and the whole thing was wrapped by a new white
ceremonial scarf (khata) 10 and a red woollen scarf belonging to the sick woman.
By this time it was almost sunset. I was told that the offering would be made at
dusk, as this is a suitable time for such an activity according to Tibetan tradition. At
this point something strange and unexpected occurred. The widow who was
suspected of causing the illness came to the door of the house. She said that she had
come for her 'wages'. Geshe Tenzin Dargye told her that she had to wait a little time,
as everything was not yet ready. The widow left, and the ritual began with the
reciting of the Iii text. The chanting went on for about thirty minutes as darkness
gradually descended outside. At certain points rice was scattered around the room as
an offering, and now and then, dense clouds of incense were wafted around the sick
woman. During the chanting, Tsultrim, one of Amchi Gege's lay students, turned up
and joined in with the ritual. The chanting reached a climax with Geshe Tenzin
Dargye leaning over the sick woman and after a short time reciting mantras, he blew
on her and gently touched the ritual text on her head. The Iii was taken outside and

9 Rubia Cordifolia.
10 The Khala is a ubiquitous Tibetan cultural object. It is exchanged between people as a token of
respect. Whenevcr Tibetans approach a lama. the custom is to givc a khata and the lama will then
return it with a blessing. Calkowski (1986) draws an interesting parallel between anthropological
understandings of the nature of the gift and the Khala.

254
left at the side of a bridge at the nearby stream where everything had begun in the
mormng.
After the ritual, food was served and considerable effort was made to get the sick
woman to eat. With some difficulty she managed to take Amchi Gege' s medicine
and eat a little Tibetan stew (thugpa), grimacing in discomfort as she did it.
Yungdrung took her pulse and said it had changed since the morning, now she had a
fever pulse. He also noted that her 'second tongue' (uvula) as he put it, was swollen.
Shortly after finishing eating we left and set off back to the gompa. As we passed the
bridge, we looked at the place were the Iii had been placed. To our surprise all that
remained on the plate was the sick woman's red scarf Whatever happened to the
offerings is anybody's guess, but Yungdrung and Geshe Tenzin Dargye were of a
single mind about it; for them there was no doubt that the widow had taken
everything.
The next day the sick woman's father came to the gompa and informed us that her
condition had only slightly improved. That evening Amchi Gege offered another Iii
on her behalf. The following day Amchi Gege was teaching me about the fa pulse. At
the end of the lesson he said that I was lucky because a few of the monks were just
about to begin a ritual for the sick woman. It was now thought that her soul (fa) had
been abducted by some spirit. Some of the monks and Nyima, the senior medical
student, were going to perform a special ritual known as la Iii, the purpose of which
is to bring back the sick woman's la. The various elements of this ritual are identical
to the ritual I will describe in the next account of napa.
The next morning the mother of the sick woman brought a sample of her urine.
She said that the sickness had changed. The pain in the woman's throat was now
accompanied by an itching sensation and something like a boil was beginning to
appear. All the students gathered around the urine. Yungdrung remarked that the
colour was the reddish colour of Tibetan tea; this indicated the presence of a fever
condition. Amchi Gege stirred the urine and watched the transformations as the urine
settled. Then following his instructions Nyima brought two medicine powders, which
were poured separately into the urine. As each powder was added, Amchi Gege
stirred the urine and observed the effects. A third medicine was brought which when
added made the bubbles produced by Amchi Gege's stirring disappear quickly; from
this information he ascertained which medicine should be prescribed. Amchi Gege
told me afterwards that he had noticed a rainbow-like iridescence on the bubbles
floating on the surface of the urine. This he said denotes the possible presence of
poison. He added that this effect sometimes occurs if the patient has taken
biomedical drugs.
Two days later the sick woman's father brought another sample of her urine. All
the students gathered around it as Amchi Gege explained what they should be
looking for. He reminded them to pay particular attention to the colour, the
suspended material, the steam and the smell. He stirred the urine and told the
students that the medical text likens the urine to a forest and the bubbles to flowers
growing inside it. The colour of the urine was a little lighter in shade than last time,
thus a fever condition still prevailed but it seemed to be abating. Amchi Gege
brought attention to the faint cloud of suspended material that was floating towards
the upper region of the urine. The location of the suspended material was related to
the illness being centred in the woman's throat. As before, Amchi Gege added
medicines and observed the effects in the urine as he stirred. Within a few weeks the
woman had returned to full health.

8.7 The ritual of the La Lii- a case of soul loss

This case of napa occurred within a week of my arrival in Dhorpatan in

September 1996. In the early afternoon Geshe Tenzin Dhargye asked me if I would
like to see a special ritual that was at that moment being performed in the temple, for
a sick Nepalese man. The Magar group, which the man belonged to, have their own
ritual specialists known as jhiinkri, who deal with illnesses caused by spirits. But as
with so many other Nepalese I was to observe in the valley, he was very much open
to the Tibetan medical approach.
When we arrived the ritual was already well underway. The sick man was sat
cross-legged on the floor in the middle of the temple. In front of him was a large
metal bowl about a metre in diameter and thirty centimetres deep. The bowl was full
to just below the brim with a milky coloured liquid with various plant substances
floating in it. Geshe Tenzin Dargye told me that this liquid was a mixture of water
milk and medicines. Amchi Gege had supplied the medicines, which were the 'six

256
 good medicines' (zang drug) that are often used together in ritual and medicinal
compounds. 11 Just to his side, one of the elder monks was sat chanting from a ritual
text whilst simultaneously beating a large round drum hanging from the ceiling.
On inquiring about the man's condition, I was informed that about a week before
he had been taken ill and had come to the clinic to consult Amchi Gege. He had
complained of sickness that kept moving into different locations in his body. This is
one possible symptom of napa. Amchi Gege's reading of his pulse confirmed this to
be the correct diagnosis. Some time after this initial diagnosis, Geshe T enzin Dargye
elicited the cause of the affiiction to be the spirit of a man who had recently died
within the patient's community. As we have seen, when somebody dies and their
consciousness remains firmly attached to the places and events of their previous life,
they remain behind as a spirit known as a shindre. This particular spirit had seized
the man's soul (fa).
At a certain point during the recitation of the fa Iii text, Geshe Tenzin Dhargye set
an object floating on the liquid in the bowl. The object was made of tsampa dough,
and consisted of a human-like figure standing in a boat. The figure had been
constructed so that its arms were held out directly in front of it. One hand was
holding a small khata scarf, the other, a small piece of turquoise on a piece of string.
Geshe Tenzin Dargye then set the liquid spinning by stirring it with a stick. The
figure floating in the water span round and round, for what seemed like a very long
time. Throughout all this the chanting continued unremittingly.
The figure had been set spinning to divine whether or not the man's fa had been
returned during the ritual. When the figure settled motionless the key feature that had
to be observed was the position of the hands. If they settled pointing directly at the
sick man or to his right, this would indicate that the fa had returned and that the
adverse action of the shindre had stopped. If the figure settled with the hands
pointing in any other direction, this would indicate that the problem persisted. In this
instance, the arms of the figure settled to the man's right.
To confirm that the shindre had stopped causing harm, another divination \vas
then done. Two stones were placed in the liquid, a white one and black one, and in
the same manner as before it was set spinning. While the appropriate section of the

II The six medicines ofbzang drug are: chu gang (bamboo pith). gur gum (saffron). Ii shi (clO\·cs). dza
Ii (nutmeg). ka ko la (black cardamon) and sug mel (green cardamon).

257
ritual text was chanted, Geshe Tenzin Dargye fished out one of the stones. If he had
taken the black one, this would have boded ill for the outcome of the ritual , but in
this instance he had taken the white one. A few days after, I asked about the man and
I was told that he was well.
A number of studies have been done on the la Iii ritual. Two early studies were
done by Lessing (1951) and Bawden (1962); these were primarily textual accounts of
the ritual. More recent accounts have been given by Mumford (1989), and Namkhai
Norbu (1995). Mumford's description is of particular interest as it gives an
ethnographic account of the ritual he observed performed by Tibetan Lamas in the
Gyasumdo region of Nepal. The ritual he describes is structurally very similar to the
ritual that I observed in Dhorpatan. All of these accounts, with the exception of
Lessing's are based on Nyingmapa Buddhist versions of the ritual text. Lessing used
a Gelugpa text, but Karmay (1998:310) points out that this is also based on a
Nyingmapa original. The large collection of terma texts known as the Rinchen
Terdzo collected by the lama Kongtrul Yonten Gyatsho (1818-1899) includes a
number of texts on the ritual. 12
The study of the ritual that I will discuss is that given by Karmay (1998). It is of
direct relevance here as it is based on his observations in 1983 of the same Bonpo
ritual carried out at Menri Yundrung Bon monastery in Dolanji, Himachel Pradesh.
The account he gives is a blend of textual analysis and ethnographic description. The
text used in Dolanji and in Dhorpatan is called 'swastika of life' (tshe yi yungdrung);
it is a nineteenth century text composed by the Bonpo lama, Nyima Tenzin. Karmay
points out that although the text is of relatively recent origin it is based on a much
older Bonpo tradition. The Nyingmapa texts are considerably older, but Karmay
points to textual evidence within them that suggests an earlier Bonpo influence.
Lessing believed the ritual he studied to be based on a Sanskrit original, and thereby
originating in India. Karmay denies this by pointing to the fact that the fa Iii ritual
texts do not form a part of the Tibetan Buddhist Tanjur.
The main deity of the ritual is the Bonpo master, Tsewang Rigzin. According to
Bonpo tradition he is the son of the celebrated eighth century Bonpo lama, Drenpa
Namkha; amongst his many accomplishments he is said to have mastered the long

12 See Karma\' ( 1998: 32 I) for the titles of four of these texts.

258
life practices. The lama begins by visualising himself in the form of Tsewang Rigzin
and supplicating his power to achieve the purpose of the ritual. In a discussion about
the ritual with Tenpa Yungdrung, I was told that the ritual draws on both the higher
and lower ways of Bon. Dzogchen and Tantric practices found in the five higher
ways of the 'the bon of the fiuit' (drebu'i bon), are used to give power to the rituals
of the lower ways (gyu'i bon).
Karmay identifies eight stages in the procedure of the ritual. The ritual begins
with a long invocation of Tsewang Rigzin. The lama then visualises himself in his
form and summons the demons that are responsible for the abduction of the lao The
ritual text refers to the chief demon as tshe dii, 'the demon of life'. Various types of
offerings are given to the demon and its entourage, in return it is asked to give back
the fa. At this point an effigy of the sick person made of tsampa dough, is taken
outside and offered to the demon. In the ritual described above, this had occurred just
before I arrived. Initially, the demon is asked in a more or less pleasant way to accept
the offerings and the ransom and return the lao The ritual text then takes a more
vigorous turn and declares that if this is not done, the lama as Tsewang Rigzin, will
emanate thousands of wrathful deities and reduce the demon to dust. In the second
stage of the ritual, the lama calls on the combined power of the Buddha Tonpa
13
Shenrab, the Bonpo yidams, khadroma and Tsewang Rigzin, to bring the fa into
the tsampa figure floating on the liquid. This figure is known as the 'figure of the
soul' (fa zug); its head should be that of the emblem of the man's clan, if this is
unknown then the text says the head should be that of a deer. The liquid upon which
it floats is known as the 'lake of the soul' (fa tsho). The third stage of the ritual
involves invoking the five aspects of Tsewang Rigzin; these correspond to the five
Buddha families of Tantric philosophy and practice. The aim of this invocation is
threefold: to bring the fa into the figure and into the turquoise which it holds in its
left hand, and to bring life into the 'arrow of life' (tshe da) which it holds in its right
hand.
The next stage involves various forms of divination to determine whether the la
has returned. The lama calls on the same divinities to reveal through the divination
the status of the lao The' lake of the soul' is stirred anti-clockwise, and the' figure of

13 A class of female deities (Skt. Dakini).

259
the soul' is set spinning. The text says that the figure can be set in motion up to nine
times until receiving a positive outcome. The divination of fishing out the \vhite
stone can be repeated only three times. A third divination occurred in the ritual that
Karmay observed which was absent from the Dhorpatan ritual. A game of dice was
enacted which represented symbolically a battle between gods and demons. The dice
of the demons was black and the dice of the gods was white. The dice were thrown at
the same time and the highest score won. Both the ritual I observed, and the ritual
Karmay observed, had positive outcomes, and they culminated in the fa being
symbolically returned by the lama tying the 'turquoise of the soul' around the sick
person's neck.

8.8 Lu Napa

One afternoon I was sitting in the Gompa compound when a Nepalese girl ran
past me in great distress. She was shouting something to the Nepalese men who were
working on the new medical school building. One of the men put down his tools and
left with the girl. Shortly afterwards, Geshe Tenzin Dargye told me that the girl's
sister had been suddenly beset by a strange illness. The man she had left with was a
jhiinkri, a local healer. The following day Geshe Tenzin Dargye said that he had been
searching for me because he had done another do ritual. He had been to the house of
the sick Nepali woman. He said that she was sat in the house, not conscious of
anything that was happening around her, and shaking all the time. The day before,
the jhiinkri had done a ritual, during which two chickens had been sacrificed. Geshe
Tenzin Dargye explained about the sacrifice with evident distaste. The jhiinkri's
ritual had not improved the condition of the girl and her family had asked Geshe
Tenzin Dargye for help.
On the following day, two of Amchi Gege's monk medical students told me that
they had been to see the sick Nepalese woman. They gave the same description of
her condition as Geshe Tenzin Dargye, but added that her eyes were turned back so
that the cornea could not be seen. They were totally convinced that she was suffering
from napa. As I heard more about the condition of the woman, I began to think that
she might be suffering from epilepsy.

260
 The following day I accompanied Geshe Tenzin Dhargye to visit her. She was sat
in the corner of the house, seemingly oblivious to what was happening in the room,
with her head nodding up and down to a steady rhythm. She looked to be in her early
twenties. Geshe Tenzin Dargye lit some incense and began reciting a prayer. As he
did so he occasionally threw barley grains around the room and wafted the incense
into the woman's face. I asked her family if she had ever suffered from something
like this before. They said this was the first time. It had all begun five days before
when she had been up in the hills with their buffaloes. She had been in a place where
there is a small lake. Geshe Tenzin Dhargye thought it was possible she had washed
in the lake and thereby offended the lu spirits who reside there. He had asked one of
her relatives to go up to the lake and burn some juniper and set up a prayer flag and
apologise to the lu. This had not yet been done, but they said it would be done
quickly.
The next day another jhankri was brought from a nearby village. He was reputed
to have more power than the first jhankri. I didn't see the ritual he performed, but
within a few days the woman was well again. Around this time I met her father at the
gompa compound. He was very happy about his daughter's recovery and had brought
a bag of meat as a gift for the' doctor lama'. I asked him which treatment or ritual did
he think had brought about the cure. He replied that he did not attribute it to anyone
particular cause, but to the combination of everything together.

For the students in the medical school in Dhorpatan, Tibetan religion is not a
separate knowledge domain from medicine. In their lessons with Arnchi Gege, in
each of the three main areas of medical activity - the classroom, the pharmacy, and
clinical interaction - the students learn elements of Tibetan religion that are directly
related to medical practice. Because of the intimate relationship between Tibetan
religion and Tibetan medicine, Arnchi Gege prefers his male students to be monks.
Tundup, Sonam, and Yundrung all became monks on entering the medical school,
but gave it up towards the end of my stay. In almost every healing ritual that I saw
Geshe Tenzin Dargye perform, a number of the medical students served as his
assistants. For instance in the Angry Widow illness episode, which I discussed
earlier, Yundrung served as Geshe Tenzin Dargye's principal assistant, and about

261
half way through the ritual Tsultrim turned up and joined them in reciting the ritual
text. A few days later, when it was thought that the patient's fa had been abducted,
Nyima, the senior medical student, was one of the principal participants in the fa Iii
ritual that was performed to bring it back.
Although all the medical students know in varying degrees about Tibetan healing
rituals, in the context of the medical teachings it is only necessary that the students
learn how to identify whether a disease has been caused by a harmful spirit. It is then
the function of a monk or a lama to perform the appropriate ritual. With Amchi
Gege's three monk students, and Nyima, who as I have mentioned in chapter one,
comes from a nagpa lineage, they were legitimate peripheral participants in the
healing practices of Geshe Tenzin Dargye.

262
 Conclusion

Throughout the thesis I have focused on two principal themes: learning processes
that I observed in the Tibetan medical school, and the nature and status of Tibetan
medical knowledge. These two themes are related in the sense that any form of
learning must be considered alongside the social, political, and cultural context in
which it occurs. Although these two main themes are addressed in various ways
throughout the thesis, certain chapters focus specifically on one of them. In chapter
one I have given relevant background information about the research location and the
medical school. Learning processes are the main subject of chapters two, three, five
and six; the nature and status of Tibetan medical knowledge is the principal focus of
chapters four, seven and eight.
The model of learning, which I have adopted to understand the learning processes
in the medical school, emphasises the situated nature of learning. I draw on the
scheme developed by Dreyfus and Dreyfus (1986), which identifies five stages of
progress from novice to expert. As a novice, the student learns context free object
facts and rules of behaviour. Progress is made through the next two stages of
advanced beginner and competence as more and more knowledge is situated in
practice. At the two higher stages of proficiency and expertise, knowledge becomes
second nature; it is fluid and intuitive. It follows from this that the learning process
should not be confined to the acquisition of propositional forms of knowledge. As
increasing knowledge is situated in practice the students acquire non-discursive
forms of knowledge that are essential to expertise. In order to move on to the higher
levels of competency, the decontextual, propositional knowledge that the student has
acquired must be transformed into the performative memory of skilled practice. At
this level knowledge is not simply something that is consciously known, rather it is
something that is enacted; for this reason I have referred to it as 'knowledge as a
mode of being' .
As we have seen, there are three aspects to the method of learning in the school in
Dhorpatan: first the students memorise the main medical text, then they receive
explanations on it from Amchi Gege; alongside this the students are inducted into
medical practice by engaging in pharmaceutical and clinical activity. In chapter two,
I have outlined in detail the model of learning, which I have adopted to understand

263
the learning process. In chapter five, I have used this model to show how the students
learn about medicine in the classroom; this is the main arena where they acquire the
propositional, decontextual knowledge of medicine. In chapters six and eight I have
shown how the students engage with this knowledge in pharmaceutical and clinical
contexts and thereby develop the performative memory of medical practice.
In chapter seven I have discussed the relevance of Tibetan religious notions to
Tibetan medicine. I presented the various kinds of rituals that were performed with
the aim of cultivating prosperity and maintaining a balance between the human
community and the natural environment. In chapter eight, I have discussed various
disorders which occurred in Dhorpatan that were diagnosed as caused by harmful
spirits, and the healing rituals that were performed to cure these afflictions. Although
Amchi Gege was thoroughly conversant in these rituals it was Geshe Tenzin Dargye
who directed all these healing activities. In the course of their studies the students
learn to identify diseases that have been caused by harmful spirits, and they all
assisted Geshe Tenzin Dargye in carrying out the healing rituals. By participating in
the rituals, Amchi Gege's three monk students and the senior medical student, Nyima
were being actively inducted into this area of medical practice by Geshe Tenzin
Dargye.
In my discussion of memorisation in the medical school, I have concluded that it
should not be equated with rote learning. Carruthers's comments on the role of
memory in European medieval culture, which I have discussed in chapter three, are
of relevance here; in medieval culture memorising was not considered to be a form
of rote learning, rather it was a necessary stage in the development of creativity and
originality. In the same way, in the medical school in Dhorpatan, memorising the
main medical text contributes to the development of performative memory. One of
the key mechanisms involved here has also been identified by Carruthers (1990:62).
The idea in medieval culture was that if what is memorised is done according to a
clear coherent structure, there will be no problem in bringing back to the conscious
mind what has been previously set aside, along with associated forms of knowledge.
We have seen that the medical text, with it verse form, tree metaphor, and abundance
use of lists was deliberately structured in this way to serve the purposes of memory,
in a similar manner to European medieval texts. This is equally true of Buddhist and
Hindu texts, which still rely heavily on oral transmission.
Another key component in the process was identified to me by Tenpa Yundrung,
the junior Lopon of Tritsen Norbutse Bonpo monastery. He explained to me that
ideally memorising should not be a passive form of rote learning; the students should
develop the 'single minded concentration' or 'mindfulness' to forge the material
indelibly into their mind. It is by cultivating 'mindfulness' that the student is then
able to retrieve relevant associated medical knowledge during instances of clinical
practice.
In the school in Dhorpatan, the students are engaged in medical practice from the
outset of their studies. As I have mentioned, patients can tum up at any time, and a
formal classroom teaching session can quickly be transformed into clinical
interaction. Usually Amchi Gege had one or two of his students assisting him when
he consulted patients. For this reason Amchi Gege had structured the way he teaches
in a way that quickly provides the students with knowledge that is useful for medical
practice. He begins by teaching the first volume of the medical text which gives the
students a general overview of the medical teaching, and then he moves on to the
first five chapters of the fourth volume on pulse and urine diagnosis, and medicinal
decoctions, powders and pills. After this he moves on to the third volume of the
medical text on Tibetan nosology. In the school the students have ample opportunity
to gain practical experience of medicine. In certain areas of medical practice, I would
estimate that most of the students have acquired the third stage of 'competence' on
the Dreyfus scale. In a few areas of medical practice, Nyima, the senior medical
student, had almost certainly reached the fourth stage of 'proficiency'.
I have said that memorisation in the school is not a form of rote learning. But as I
have mentioned in chapter two, Tenpa Yungdrung told me that in the past it was
common for monks to memorise texts and have very little knowledge of their
contents, even in the present day this sometimes still occurs. However the ideal has
always been that monks should memorise and understand. In chapter three, we saw
in Fuller's study of agamic education in Brahmanical schools in South India, the
reformists likened education in the schools to the kind of training that a lawyer or a
doctor needs to undertake, but Fuller points out that this is not the case. Education in

265
the Brahmanical schools is not about 'acquiring the kind of formal, substantive
knowledge that doctors or lawyers have to apply to a range of different cases'
(1997: 17). The main aim of the agamic education is to enable the students correctly
to recite the relevant passages during the ritual. However, as the ultimate aim of the
education in the medical school in Dhorpatan is that students will be medical
practitioners, they do need formal and substantive knowledge of medicine, as they
will be confronted with a range of different cases in clinical practice.
This is not to say that everything that the students memorise and are taught by
Amchi will reach the level of performative memory. The development of
performative memory requires considerable practical experience and as we saw in
chapter six, the students had only experienced in clinical practice a small selection of
the diseases that they had learnt about in the classroom. It is likely that they will
never encounter some of the diseases that are discussed in the third volume of the
medical text. The same reasoning applies to the external therapies of cauterisation,
and bloodletting; as these were rarely resorted to in Dhorpatan, the students had little
opportunity to develop the necessary performative memory.
In chapter four, I have discussed the two images of medicine that recur throughout
the literature of medical anthropology. One, which includes amongst a range of
traditions, Tibetan, Chinese, Ayurvedic and Yunani medicine, presents the body and
the mind as a unified integrated system that is interrelated with other systems in the
environment and the universe. Disease occurs when the interrelationship within and
between these systems breaks down; treatment involves restoring balance and
harmony. This is contrasted with biomedicine, which presents the body as a complex
mechanism. Disease arises as a consequence of lesions and breakdown in biological
systems. Treatment is mechanical and impersonal and focuses on dysfunctions in
biological substrata.
The first approach relates to what I have called the synthetic mode of knowledge,
the second approach is what I have termed the analytic mode of knowledge. In
chapter four I have also discussed various other typologies that have been used to
explain these two modes of knowledge, there have been various rendered as: scribal
culture and print culture (Eisenstein 1969, 1981, and 1983), non-literate and literate
culture (Goody 1977), and cognitive traditionalism and cognitive modernism (1982).

266
We saw that the way Tibetan medical knowledge is viewed and the manner in which
it is passed on in the school in Dhorpatan has may similarities with the attributes that
Goody lists for non-literate cultures and Horton for cognitive traditionalism. Tibetan
medical education emphasises memorisation of the main text, alongside the personal
transmission of teachings on it by a fully qualified practitioner. The medical
teachings are thus preserved in an unadulterated form by means of the medical
lineage. For the Bonpos, the main Tibetan medical text is considered to derive from
the enlightened insight of Tonpa Shenrab, and for the Tibetan Buddhists from the
Medicine Buddha; it is therefore looked upon as sacred, complete, and beyond
dispute. The text has spawned a large number of commentaries over the centuries.
We have seen that this two-fold pattern of knowledge of canonical texts and
scholarly commentaries is an expression of a wider cultural pattern: the same
division exists in the Islamic tradition between the Quran and the Sharia
commentaries, in Hinuduism between shastrik and laukik knowledge, which relates
to the older Vedic distinction between knowledge classified as sruti and smrti, and in
Indian Buddhism between the sutras and the sastras, which has its counterpart in the
Tibetan Kanjur and Tanjur collections.
Though it appears that specific cultural forms of the synthetic mode of knowledge
are bounded self-contained units and can be sharply contrasted with the analytic
mode of knowledge, in practice there is considerable overlap. In chapter three, I have
discussed that memorial culture in Europe and India existed a long time after the
introduction of writing. In fact, as we have seen from Parry's discussion of Brahman
priests in Benares, and with the transmission of Tibetan medical knowledge, literacy
far from contributing to a process of cognitive modernism has been co-opted by
exponents of the oral tradition to enable a process of cognitive conservatism.
Amchi Gege, although firmly valuing the importance of memorising the text and
the personal transmission of medical knowledge, has made some concessions in the
programme at his school to modem forms of education, such as the structured daily
timetable, course syllabus, and regular assessments and written exams. The students
also continuously criticised the way that they were being taught; on the whole they
couldn't see the point of having to memorise all of the main text, and they thought

267
that the constant chores they had to carry out for Amchi Gege considerably distracted
from their medical studies.
The long-standing tradition In medical anthropology of contrasting medical
traditions, which I have typified as involving the attributes the synthetic mode of
knowledge, with biomedicine, masks important similarities. Although students of
biomedicine do not have to memorise whole texts, they do have to memorise long
lists of drugs, symptoms, and disease classifications. Furthermore personal
transmission and lineage are by no means absent from biomedical education.
I was last in Dhorpatan in August 1998. Since that time only one of Amchi Gege's
students has completed the course. Nyima, the senior medical student took his final
exam in the summer of 2000 and is presently trying to establish a clinic in his village
of Jharkhot, in lower Mustang. The other students are now close to completing the
course. Amehi Gege has recently taken on one more female student.

268
 Appendix A - The Bon and Buddhist Religions of Tibet

The two religions have coexisted in Tibet since at least the tenth century AD.
Although, following common usage I have referred to them as Buddhism and Bon, as
we will see, the use of the word 'Buddhism' here is misleading. Adopting the more
appropriate Tibetan designations, the distinction is between the vast majority of
Tibetans who are Chapa, followers of the religion of Cha, and a substantial minority
who are Bonpo, followers of the religion of Bon I . Both Snellgrove (1967: 1) and later
Kvaeme (1972:23) have pointed out that there is no word for Buddhism in Tibetan.
The closest approximation is the word nangpa, which means 'insiders', but as
Kvaerne has indicated, this word designates both the Chapa and the Bonpo.
Of the 120,000 Tibetan refugees who came to Nepal and India, about 1000 are
followers of the Bon religion. The first Bonpo refugee settlement was established in
1967 at Dolanji near Simla in the Shiwalik hills. This is the location of the new
Menri monastery and the seat of the thirty-third abbot Sangye Tenzin. Cech (1987)
has carried out a detailed study of the history, and social and cultural identity of this
settlement. In the early years the Bonpo had no political representation in
Dharamsala. This changed in 1977 when the Bon religion was officially recognised
as a sect of Tibetan religion2, and the Bonpo were allowed one representative in the
Assembly of the Tibetan People's Deputies. A further embracive gesture was made
by the Tibetan administration in 1978 when abbot Sangye Tenzin officially received
the title of 'throne bearer' (tridzin) from the Dalai Lama; this title is traditionally
bestowed on the heads of the four Buddhist sects (Cech 1987).
About a third of the Tibetans in Dhorpatan are Bonpo and the rest are Chapa.
Although there is no doubt that these two groups feel themselves to be part of
separate religious communities, in terms of doctrine and practice both religions have
much in common: both are based on the doctrine that life is marked by
impermanence and suffering, and that through the force of karma, beings are bound
into a constant cycle of death and rebirth into one of the six realms of existence, until
through religious practice and virtuous actions they can achieve liberation.

1 In keeping with the main body ofthe thesis I haye not put the Tibetan words Bon or Bonpo in italics.
:! Although this is a positive deyelopment. the 8onpo consider themselves to be a separate rcligion and
not mercly a fifth sect of Tibetan Buddhism.

269
 Furthermore, both religions use the same word Sangye 3 to refer to the one who has
accomplished this state of emancipation, and both religions are based on the
teachings of such an individual; for the followers of Cha it is the Buddha Sakyamuni;
and for the followers of Bon it is the Buddha Tonpa Shenrab. The Tibetan words Cha
and Ban refer at the same time to the teachings of these two respective Buddhas, and
to the unchanging nature of reality, which these teachings express; thus they have the
same semantic scope as the Sanskrit term, dharma. Due to the manifest similarities
between the two religions a number of authors have brought into question the
common practice of translating the term Cha as Buddhism, and leaving the tenn
'Bon' untranslated, as though it is an entirely different religion (Martin 1994;
Kvaerne 1972). Some scholars have gone as far as to argue that Bon is in fact not a
separate religion but an unorthodox form of Buddhism (Snellgrove 1967, 1987;
Kvaeme 1972).
A good deal of confusion about the word Ban stems from the way that it has been
used to signify a diverse range of meanings. Kvaeme (1995:9) gives three common
meanings that are associated with it in the writings of western scholars: among one
group of writings, the word 'Bon' is used to denote the religion that existed in Tibet
prior to the arrival of Buddhism in the eighth and ninth centuries; a second group of
writings associates the word with Tibetan folk tradition, and fonns of pre-Buddhist
shamanic practice; the third way that the term is used is to refer to an organised
religion known in full as Yungdrung Bon, which developed in Tibet in the tenth and
eleventh centuries alongside various forms of Buddhism that were imported from
India at this time. When I use the word 'Bon' in the context of the people in
Dhorpatan it is this third signification that I wish to convey.
There are three different accounts of the development of the two religions: one
version is found in Bonpo texts, another version is found in Chapa texts, and western
scholars present a third perspective. For the Chapa, the Bonpo religion is little more
than a plagiarised version of their own religion; the Bonpo make the same
counterclaim. There is a long tradition of Chapa polemical writings on the 8onpo
religion going back to the thirteenth century AD4. A good example of the approach
taken in this polemical literature is the eighteenth century gelllgpa scholar Thubten

3 The Tibetan word means one who has been completely purified. and is used to refer to a Buddha.
·1 See Martin (1991) for a detailed study of this polemical tradition.

270
Losang Chokyi Nyima's 'Crystal Mirror of the doctrinal System', which presents the
5
Ban tradition to have passed through three phases : the first phase, 'original Ban'
(dol bon) consisted of an unsophisticated primitive popular religion with no
literature; the second phase, 'deviating Ban' (khyar bon), involved a new focus on
funerary rites and a development in doctrine through contact with other religious
practitioners and centres; the third phase 'transformed ban' (gyur bon) was the
period when Buddhist texts were transformed and made to appear as Bon texts. The
most intense activity of the third phase would have been during the tenth and
eleventh centuries AD, resulting in the Ban tradition in its present shape.
The Banpo themselves would readily acknowledge that events occurring in Tibet
in the tenth and eleventh centuries marked a major changing point in their religion,
but they firmly believe that their religion predates cho by a long period of time.
According to the chronology of the Banpo lama, Nyima Tenzin (b 1813), T onpa
Shenrab was born in 16016 BC (Kvaerne 1971). In the Banpo canon there are three
versions of his life story: the short version is the Dodii which comprises of twenty-
one chapters in one volume; the medium length version is the Zermig6 , which has
eighteen chapters in two volumes; and the long version is the ZUF, which has sixty-
one chapters in twelve volumes.
Tanpa Shenrab taught the doctrines of Ban primarily in Olmolungring. He visited
Tibet only briefly, in quest of his seven prized horses that had been stolen by the
demon Khyaba Lagring; at this time he taught only the lower ways of Bon, finding
the people not ready for the higher teachings. The Banpo canon contains a huge
volume of literature, which is said to be the word of Tanpa Shenrab. Like the
scriptures attributed to Sakyamuni, Tanpa Shenrab's teachings were collected by his
close disciples shortly after his death. He entrusted to each of his sons certain aspects
of the Banpo doctrine. The most important in the context of this study is his second
son, Tribu Trishi, to whom Tanpa Shenrab passed on all his medical knowledge.

5 These three phases have been discussed by Tucci (l980:22-l). Kvaerne (197229). and Martin
(1994).
6 The first seven chapters havc been translated by A H Francke (l92-l. 1926. 1921. 1928. 1\)30. 19)0).
The text was also used as the basis of Hoffman's (1961:85-97) account of Tonpa Shenrab's life.
7 Snellgrovc (1967) has translated and edited the relevant sections (chs. 7.8.9, 1O.12.ll.I-L 15. and 16)

dealing with the nine ways of 80n.

271
According to Bonpo accounts there were six great translators 8 who were responsible
for translating and spreading the doctrines of Bon in the surrounding countries. The
disciples of Mucho Demdrug of Tazig translated the teachings into the language of
Zhang Zhung, and it was from here that the teachings were brought to Tibet during
the reign of the legendary first King of Tibet, Nyatri Tsenp09.
Zhang Zhung plays the same role for the Bon religion as India does for Cho.
According to Bonpo sources, Zhang Zhung was a large kingdom stretching from
Gilgit in the west and encompassing all of western Tibet. Its capital was Khyunglung
Ngulkhar, which was situated in the region of Mt Ti-se (Kailash). Tradition
maintains that the second king of Tibet, Mutri Tsenpo, invited 108 Bonpo scholars
from Zhang Zhung to Tibet, and thiry-seven religious centres were established
during his reign (Cech 1987). The Bonpo claim that most of their texts were
originally written in the language of Zhang Zhung, and on the first page of many
their texts the title has been left in this language, in a like manner to the way chos-pa
texts have retained their original Sanskrit title.
The religion of Bon is said to have flourished in Tibet up to the reign of the eighth
King of Tibet, Drigum Tsenpo, who persecuted the religion, and banished the Bonpo
from the land. In response to this the Bonpo hid many of their texts for safety. For
the Bonpo, this persecution marks the beginning of their tradition of rediscovered
texts (terma). This state of affairs was resolved when his son re-established Bon as
the state religion. In the seventh century, during the reign of Songtsen Gampo
(accession 634 AD), through the influence of his Chinese and Nepalese wives, Chd
(i.e. Buddhism from India and China) was brought to Tibet. However, Bonpos
maintain that their religion remained the state religion of Tibet until the time of king
Trisong Detsen (accession 755AD) during whose reign the Indian Tantric saint
Padmasamhava was invited to Tibet, and Same, the first Tibetan monastery was
established. In this period, the Bonpo were again persecuted and banished from
Tibet, and for the second time they were compelled to hide their texts for
safekeeping. According to Bonpo historical sources, it was also during Trisong

8 These translators are ,\/utsha Trahe of Tazig, Trithog Patsha of Zhang-zhung. Ifulu Pale of Sum-pa.
Lhadag :\~'o!.agdro of India, Legtang .\fangpo of China, and Serthog Chejam of Throm (Karmay
1972:16)
9 Sec Haarh (1969) for an account of the early kings of the Yarlung dynasty.

272
Detsen's reign that Zhang Zhung was annexed to Tibet, after the assassination of its
king, Ligmigya.
There is a wealth of information in Tibetan historical texts concerning the history
of Tibet prior to the reign of Songtsen Gampo, but as very few of these texts date
from before the tenth century, they cannot be taken as reliable sources. Tibetan
history based on reliable sources - inscriptions, accounts of Tibet by historians of
neighbouring countries, and the literature of later Tibetan historians - begins from the
reign of King Songtsen Gampo. The earliest Tibetan manuscripts date from the late
ninth century to the early tenth century. These were sealed in a chamber of a cave at
Dunhuang in north west China, around 1035AD, and discovered at the beginning of
the twentieth century (Bacot et al: 1940, Thomas 1935-63, Lalou 1939-61). Based
mainly on material found in the Dunhuang manuscripts, some recent western
scholars have given an account of the Bon religion in the early period that differs
from that found in Bon texts.
As we have seen, according to Bon and Buddhist historical sources, the Bon
religion existed in Tibet prior to the introduction of Buddhism in the seventh century.
Despite the lack of references to it in the stone inscriptions, Karmay (1983)
concludes from his reading of Dunhuang manuscripts that an organised religion
known as Bon did exist in Tibet at this time. But the extent to which it was
organised, the nature of its doctrines and practices, and the way in which it relates to
the organised religion called Yungdrung Bon that emerged in the eleventh century, is
not clear. The Dunhuang manuscripts speak of a class of priests in Tibet known as
Bonpos or sometimes shen. These priests performed funerary rites and rituals
connected with the king. Snellgrove (1967: 1) points out that the word Bon is the
Tibetan equivalent of the Zhang Zhung term gyer, meaning 'to chant'; he therefore
translates the term 'Bon' as 'priests who invoke' (1967:21). From his reading of the
early Tibetan manuscripts, the Bon were just one amongst several types of priests.
Karmay has also noted that the word gshen-rab appears several times in the
Dunhuang manuscripts as a type of priest.
After the collapse of the Royal dynasty in 842, for a period of around 150 years,
very little is known about Tibetan cultural life. It appears that the Bon and Chij

273
traditions were maintained through hereditary lineages of religious practitionersl0.
Tibet emerged from this 'dark age' in the eleventh century when the Bon and Chd
religions entered a major period of revitalisation known as the 'Later Propogation'
(Chi dar). For the Chapa this period involved re-establishing the connection with
Indian Buddhist teachers, and a new wave of translations of Indian Buddhist texts.
This activity began with a scion of the old Royal Dynasty sponsoring a group of
young Tibetans to go to study in Kashmir. The most notable of these was the famous
translator Rinchen Sangpo. The Tantric cycles that that were introduced at this time
led to the formation in Tibet of the Sakya and Kagyu Buddhist religious sects.
The later propagation of Bon, which was the third dissemination of Bon teachings
in Tibet, was founded, as it was for the nyingmapa, the oldest sect of Tibetan
Buddhism, on rediscovered texts (terrna). The first Bon texts to be rediscovered were
found by three monks from Nepal in Same monastery in 913 AD, but the later
propagation of the Bonpo doctrine did not really get underway until 1017 AD, when
Shenchen Luga rediscovered a larger number of texts, which eventually went to form
a major part of the Bonpo canon. He entrusted the knowledge contained in these texts
to three of his main disciples (Karmay 1975: 119), each of whom went on to establish
religious centres. One of these centres was the famous monastery of Yeru Wensakha,
in central Tibet.
Traditionally, the doctrines and practices of Bon have been classified according to
two main systems: the Four Doors and the Treasury as the Fifth (Go zhi dzd nga) 11 ,
and the Nine Ways (thegpa gu). There are three versions of the Nine Ways: the
'northern treasure' (chang ter) , the southern treasure (tho gter) , and the central
treasure (u ler). The nine ways are explained in the Ziji, 'The Glorious', the long
biography of Tonpa Shenrab~
the relevant sections have been studied by Snellgrove
l3
(1967)12. In brief the Nine Ways are :

1. The 'Way of the Shen of the Cha' (cha shen thegpa): covers the four activities of:
divination (rno), astrology (rtsis), ritual (gto), and medical diagnosis (dpyad).

10 According to the Bon tradition there are six main Bonpo family lineages: gShen, Brn. sPa, rMe'u.
Zhu, and Khyung. On the subject of these families see Cech (1987) and Karmay (1975).
liOn this classification see Karmay (1975) and Norbu (1995: 37).
I ~ His study represents only the southern treasure; the other two versions have not yet been studied by

western scholars.
13 I have followed the English translation of the titles of the ninc ways given in Norbu (19<)5)

274
2. The 'Way of the Shen of the Phenomenal Universe' (nang shen thegpa): deals
with classes of malevolent spirits and local deities, and rituals associated with them,
rites of exorcism, and ransom rites.
3. The 'Way of the Shen of Magic Power' (trul shen thegpa): explains how to carry
out rituals of destruction against harmful beings.
4. The 'Way of the Shen of Existence' (sri shen thegpa): comprises of funerary rites.
5. The 'Way of the Virtuous Ones' (genyen thegpa): covers the rules of behaviour for
the lay practitioner.
6. The 'Way of the Ascetics' (drang song thegpa): deals with the rules of monastic
discipline.
7. The 'Way of the White A' (a kar thegpa): covers Tantric theory and practice.
8. The 'Way of the Primordial Shen' (yeshen thegpa): gives further details on Tantric
practice.
9. The 'Supreme Way' (yangtse la me thegpa): the teachings of the great perfection
(dzogchen).

The Nine Ways are divided into two groups. The first four are collectively
referred to as the 'Bon of Cause' (gyu-i bon) and involve knowledge and practices
that are of practical benefit for worldly ends. This group of practices is sometimes
further subdivided into 'twelve lores of Bon', which according to Tibetan historical
sources were prevalent during the reign of the first king of Tibet, Nyatri Tsenpo, who
reigned around 126BC (Norbu 1995:xv). The last five ways are referred to as the
'Bon of Fruit' (drebu-i bon); these include the teachings found in the Bonpo Tantras
and Dzogchen texts, which deal with the methods of liberation from this world. As
Snellgrove (1967: 12) points out this classification covers the whole range of Tibetan
religious culture. The only thing that is missing is the pattern of learning that occurs
in Buddhist and Bonpo dialectic schools; this is because this form of study developed
after the compiling of the nine-fold classification.
In the present day, the Bonpo religion is still practised by a sizeable minority of
Tibetans both in Tibet and in refugee communities. The largest Bonpo communities
in Tibet are found in the regions of Kham and Amdo, but there are also smaller
communities in the regions of Chadur, Tewa and Dromo in the Chumbi valley.
Bonpo influence also stretched beyond Tibet into Nepal and Sikkim, and into the
Yunnan province of China were it is found in the religious practices of the Na-khi
people (Jackson 1978, 1979; Rock 1952). Though there may be many points of
similarity between Cho and Bon in doctrine and practice, the two religious groups
consider themselves to be followers of separate religions. As K vaerne (1995: 10) has
suggested, this sense of a separate identity, is founded not on metaphysical doctrine

275
or religious practices, but on different notions of history, legitimation and religious
authority.

276
 Appendix B - The Contents of the Gyu Shi

Chapters Tibetan Name English Name

The Root Tantra (rtsa rgyud)

1 f(linf(-f(zhi Introduction
2 gling-glong Enumeration of Topics
3 gzhi The Condition of the Body
4 ngos'dzin Diagnosis and Symptoms
5 f(so-thabs Treatment
6 rtsis Summary of Chapters 3,4
and 5

The Explanatory Tantra (bshad rgyud)

1 bshad-pa 'i sdom Summary of Explanatory

Tantra
2 chags-tsul Embryology
3 'dra-dpe Similes of the Body
4 gnas-Iugs Anatomy
5 mtsan-nyid Physiology
6 dbye-ba Types of Body
7 'jig-Itas Signs of Death
8 rKYU Causes of Disease
9 nad kyi rkyen Immediate Causes of
Disease
10 zhugs-tsuI Mode of Entry of Disease
11 mtsan-nyid The Symptoms of Disease
12 dbye-ba Classifications of Disease
13 rgyun-spyod Regular Behaviour
14 dus-spyod Seasonal Behaviour
15 gnas-skabs-spyod Incidental Behaviour
16 zas-tsul Diet
17 zas-bsdam Dietary Restrictions
18 zas-tsod ran-pa Correct Amount of Food
19 sman KYi ro Tastes of Medicines
20 sman gyi nus-pa Potency of Medicines
21 sman KYi sbyar-thabs Compounding of Medicines
22 cha-byad Medical Instruments
23 me-na-gnas Maintaining Health
24 nyes-pa dngos-ston Diagnosis
25 ngan-gyo skyon-brtag Examination by subterfuge
26 spallg-blang mu-bzhir Four Diagnostic T\1ethods to
Verify Whether a Patient
Should Be Accepted or :\ot
27 Kso-t~l"spyi General Therapeutics
~

28 khyad-par gso-thabs -----

Specific Therapeutics I
i

29 gso-thahs gnyis Two forms of Treatment

-"
~~

30 gso-thahs dngos Direct Therapeutics

277
 31 sman-pa 'i Ie 'u The Qualities of the Doctor

The Instruction Tantra (man ngag rgyud)

I

1 man nKaK rf{YUd zhus pa Requesting the Teachings I

Section 1 - Humoural Diseases

2 r/unK Ki nad Wind Diseases

3 mkhris p 'i nad Bile Diseases
4 bad kan gyi nad Phlegm Diseases
5 'dus nad bad kan smug po Disorders Involving
Combinations of the Three
Humours

Section 2 - Chronic Internal Disorders

6 KonK nad thams cad kyi r:<J!U ma zhu ba Digestive Disorders

7 gcong chen skran nad Tumours
8 skya rbab First Stage Oedema
9 'or nad Second StaEe Oedema
10 gcong chen dmu chu Third Stage Oedema
11 Gcong chen zad byed Consumption

Section 3 - Fever Conditions

12 tsha ba spyi General Fever

13 'grul gzhi gsal ba tsha drang gal mdo Distinguishing Hot and
Cold Disorders
14 tsha b 'i ri thang mtshams bstan pa Condition Where Wind
Manifests fever, but
Treatment is for Wind
15 tsha ba rna smin pa Unripened Fever
16 rKYas P 'i tsha ba High Fever
17 stongs p 'i tsha ba Empty Fever I

18 gab p 'i tsha ba Hidden Fever l

19 tsha ba rnyinf(s pa Chronic Fever
20 tsha ba rnyogs pa Turbid Fever ,

21 'wams kyi tsha ba Spreading Fever ~

22 'grugs kyi tsha ba Disturbed Fever

23 rims kyi tsha ba bal nad Infectious Fever
24 'brum p 'i rims Pox Diseases
25 rgyu gzer gyl rims Infectious Disease of the I

Intestine (C otic)
26 gag Ihog Fever Associated with
Infectious Disease of the
Throat
27 cham rims Common cold and Flu -- .
- ---

278
Section 4 - Disease of the Upper Body i i

I
28 mgpnad Head Disorders i
I

29 mignad Eye Disorders I

30 rna b 'i nad Ear Disorders

31 sna nad Nasal Disorders iI
32 ganad Mouth Disorders
33 lba ba Goiter

Section 5 - Diseases of the Internal Organs

34 snying nad Heart Disorders

35 glo nad Disorders of the Lungs
36 mehin nad Liver Disorders
37 meher nad Spleen Disorders
38 mkhalnad Kidney Disorders
39 po b'i nad Stomach Disorders
40 rgyu m 'i nad Disorders of the Small
Intestine
41 long nad Disorders of the Colon

Section 6 - Genital Disorders

42 pho mtshan gyi nad Male Genital Disorders

43 Mo mtshan gyi na Female Genital Disorders

Section 7 - Miscellaneous Diseases

44 skad 'gags Voice Disorders

45 yi ga 'ehus pa Loss of Appetite (Including
Anorexia)
46 skom nad gso ba Thirst
47 skyigs b 'u nad Hiccups
48 dbugs mi bde ba Respiratory Disorders
(Including Asthma)
49 glang thabs beos pa Sharp Pains in Stomach
50 srin nad beos pa Parasites
51 skyugs p 'i nad Vomiting
52 'khru p 'i nad Diarrhoea
53 dri ma 'gags pa Constipation
54 ehu 'gags Urinary Retention .
55 gehin snyi b 'i nad Polyuria
56 tshad p 'i 'gu ba F ever with Diarrhoea ,

(Dysentery )
~
57 drig nad gso ba Gout I

58 grllm bll 'i Rheumatoid Arthritis ~

:

59 ehll ser gyi nad Disorders of the Serous

Fluid . ---------1

60 rlsa dkar gyi nad Neurological Disorders ~. .

61 Ipags p 'i nad Skin Disorders

279
 62 Phran bu 'i nad Miscellaneous minor ;
I

Disorders

Section 8 - Sores

63 'bras nad Cysts and abscesses

64 gzhang 'brum Haemorrhoids
65 me dbal Skin Disease (Erysipelas,
Eczema)
66 sur y'i nad Blood Disorder Causing
Sores/Tumours on Internal
Organs
67 rman bu beos pa Disease of the Glands
68 rliK rlugs Hydrocele
69 rkang bam gyi nad Disease Causing Swelling
of Legs (elephantiasis)
70 mtshan bar rdol ba Anal Fistula

Section 9 - Pediatrics

71 byis pa nyer spyod Caring for the Foetus

72 byis p 'i nad Children's Disorders
73 byis p 'i gdon Children's Disorders
Caused by Spirits

Section 10 - Gynaecology

74 mo nad keo bo spyi General Gynaecology

75 mo nad bye brag Specific Gynaecology
76 mo nad phal pa Common Gynaecological
Disorders

Section 11 - Diseases Caused by Spirits

77 'byung p '0 gdon Diseases Caused by Spirits

related to the Elements
78 smyo byed kyi gdon Madness Caused by Spirits
79 Brjed byed kyi nad Spirit Caused Amnesia
80 gza 'i gdon nad Diseases Caused by
Planetary Spirit Rahll (skt.)
(Apoplexy, Epilepsy)
81 gdug pa klu 'i gdon nad Diseases caused by the III
spirits
I

Section 12 - Wounds and Lesions -,

82 rma spyi 'i gsa thabs bstan pa General Wounds - -

83 mga bo 'i rma KSO ba Head \ Vounds

84 ske 'i rma gso ba Neck Wounds
85 hvallf.{ khof.{ stad smad g-so ba Abdominal \Vounds

280
 86 Yan laf,( f.(i rma Limb Wounds

Section 13 - Poisons

87 sbyar p 'i dug Compounded Poisons I

,i
88 gyur p'i dug Food Poisoning ,!
89 rf!YU ba danf,( ma rgyu b 'i dug Natural Poisons I
I
Section 14 - Geriatry "

90 rgas pa gso ba bcu len Rejuvenation Treatment

Section 15 - Virility and fertility

91 ro tsa bar bya ba Aphrodisiacs and Virility

Treatments
92 bu med pa btsal ba Fertility Treatment for
Women

The Final Tantra (phyi rna rgyud)

Section 1 - Pulse and Urine Diagnosis

1 rtsa Pulse Diagnosis

2 chu Urine Diagnosis

Section 2 - Calming Medicines

3 thang Decoctions
4 phye-ma Powders
5 ril-bu Pills
6 Ide gu Pastes i

7 sman mar Butters I

8 thai sman Ashes

j

9 khanda Concentrates
10 sman chang Medicinal Brew
11 rin-po-che Precious Medicines
12 sngo sbyor Herbal Compounds ,

Section 3 - Cleansing Medicines ---- - .

-----<

13 snum 'cos Medicinal Oils - .

14 bshal Purgatives I

15 skyugs Emetics
16 sna sman -----
Nasal Medicines
1

17 'jam rtsi - - --
\ 1ild Suppository
18 ni-nl-ha -- ---
i Strong SUQQositorv - - - .
19 Rtsa sbyong I Channel Cleansing ---- ----------~

!
--- ------- --- ---

281
Section 4 - External Treatments

20 gtar Bloodletting
21 me btsa' moxibustion
22 dugs Hot and Cold Compresses
23 lums Steam Baths
24 byugs-pa Massage/Ointments
25 Thur-dpyad Minor Surgery

282
 Glossary Of Tibetan Words

(This glossary contains the spelling of Tibetan words used in the thesis using the Wylie
method of transliteration)

a kar thegpa - a dkar theg pa chang ter - byang gter

Amdo - a-mdo Changpa Namgyal Dragzang - byang pa
arura - a ru ra mam rgyal grags bzang
bab - 'bab che - dpyad
bagchag - bag chags Che Bum Trawo - dpyad 'bum khra bo
bar tren - bar skran chenresi - spyan ras gzigs (skt.
bardo - bar do Avalokitesvara)
barura - ba ru ra chetsha khorwa -lee tsha mkhor ba
bom- sborn chewa - dbye ba
bom - sbom chi dar - phyi dar
Bon - bon chi da - 'chi 'dod
Bon kyong - bon skyong chi kyen - phyi rkyen
bong nga nagpo - bong nga nag chi lu - 'chi bslu
po Chi Ma Gyu - phyi rna rgyud
Bonpo - bon po chi pi ne so wa - byi p'i nad gso ba
bu tse - bu btsas chi tren - phyi skran
bu tsha - bu tsha chin - byin
bul- bul chin ne - mchin nad
bul- bul chin Iri - mchin khri
bum - 'bum ching - bying
Bumshi - 'bum bzhi chinpi Ira Iren - mchin pi' khrag skran
bur - 'bur chiwa - lei ba
buram karpo - bu ram dkar po Cha - chos
Butan - Bu ston Cha khang - chos khang
Butsho Sipai Gyalpo - bu mtsho Cha kyong - chos skyong
srid pa'i rgyal po Cha thab - bcos thabs
cha - phywa (sometimes spelt chokha - cho kha
phya) chong chen de nga - gchong chen sde lnga
cha deb - phyag deb chongzhi - chong zhi
cha khug yang khug - phya khugs chongzhi dragtill - cong zhi drag btu I
gyang khugs Chapa - Chos pa
cha shen thegpa - phywa gshen chorten - mchod rten
theg pa chotse - chog tse
Chadur - bya dur chu gang - cu gang
chag- chag chu ser - chu ser
chag kar - Icags dkar chu ta - chu stod
chagpe tsa - chag pa'i rtsa chu tren - chu skran
chalag chogye - cha lag bco chuchig - bcu gcig
brgyad chudak nagpo - chu dag nag po
cham rim - cham rims chugang - chu gang
cham sing - learn sring chugpa - dbyug pa
chamdre I - learn dral chlilam - chu lam
champa - chams pa chulo - chu 10
chang--chang chllllgwa - 'byung ba
chang pa - byang pa cllIIser - Chu ser

- .)
')8'
da Ii - da Ii drebu sum - 'bras bu gsum
dadar - mda' dar drebu-i bon - 'bras bu'i bon
dagzin - bdag 'dzin dremo - 'dre mo
dal- dal drenpa - dran pa
dam bea' pa - dam cha pa Drenpa Namkha - dran pa nam rnkha
dam eha - dam bca' dri - 'bri
dam tshig - dam tshig drib - sgrib
damtsig - dam tshig Drigum Tsenpo - gri gum bstan
dang - mdangs dril - 'gril
dangma - dangs rna drilwa - 'dril ba
dangma mazhu - dangs rna rna drim - grims
zhu drima - spris rna
dangme dangma - dangs m'i Drime Shelgong Sheltreng - dri med shel
dangs rna gong shel phreng
deb - deb drimpa - grims pa
del- dal driwa - 'dril ba
dele - bde-Iegs dro ZhUll - gro zhun
Der she tso zhi - bder gshegs gtso Dromo - gro mo
bzhi dron bu - 'gron bu
digpa - sdig pa dron thaI - 'gron thaI
do - mdos drll - bru
Do-mdo drum bo - grum bo
do ngag sem sum - mdo sngags dii - bdud
sems gsum dug sum - dug gsum
do tren - rdo' skran duma nyung - dug mo nyung
do yi men - rdo yi sman dur - dur
doehag - 'dod chags durji - dur byid
doehag - 'dod chags dza ti - dza ti
Dodii - mdo 'dus Dzambliling - dzam bu gling
dog-Idog dzene - mdze nad
dol bon - brdol bon dzepa chunyi - mdzad pa bell gnyis
domtri - dom mkhris dzerpa - mdzer pa
don - gdon dz6 - mdzod
don nga - don lnga dzogchen - rdzogs chen
dong ro - Idong ros dzogphug - mdzog phug
drag she gye - drag gshed brgyad gab (she - gab tshad
dragkya hawo - brag skya ha bo gagpa - gag pa
dragpa - drag pa gapur nyernga - ga phur nyar lnga
dragzhun - brag zhun gelong - dge slong
dralha - dgra lha gelug - dge lugs
dram - 'grams genyen thegpa - dge bsnyen theg pa
dram - gram geshe - dge bshes
dram Ishe - 'gram tshad go- mgo
drang song thegpa - drang srong go zhi dz6 nga - sgo bzhi mdzod Inga
thegpa gonpo - mgon po
drangsong - drang srong gollir - dgo-btur
drangwa - grang ba gmnJ Iha - 'go ba'i lha
Drapa Ngon She - grva pa mngon gil - gud
shes gliling - rgud ling
dre - 'dre gllr gum - gur gum
dre me - 'dre me gur gyam do nge drag gye ling - gur gyam
dnjbo - ' dre bo - '- -
mdo sngas ......grags rgvas
-. ......gling
 gurkum - gur kum karchag - dkar chag
gyal- rgyal karma - skar rna (weight measurement)
Gyalchen Dragpa Senge - rgyal Kashag - bka' shag
chen grags pa seng ge ken - kan
gyalpo - rgyal po Kha lang - kha lang
Gyalpo Sheltrab - rgyal po shel khadroma - rnkha 'gro rna
'khrab Kham - khams
gyam tsha - rgyam tsha khang - khang
gyangbu - rgyang bu khata - kha btags
gye - rgyas Khogbub - khog 'bubs
gyen gyu lung - gyen rgyu rIung khu chug - khu byug
gyepa - rgyas pa Khutsa Da-o - khu tsha zla 'od
Gyimtsha Machung - gyim tsha Khyaba Lagring - khyab pa lag ring
rma chung khyabche lung - khyab byed rIung
gyog - mgyogs khyar bon - 'khyar bon
gyogpa - mgyogs pa khyoga drongpi kyeman - khyo ga grongs
gyu - rgyu (primary cause) pa'i skye dman
gyu - rgyud (tantra, connection) khyung - khyung
gyu ne - rgyu nad khyung - khyung
gyu pa - brgyud pa khyung nga - khyung lnga
gyu rim - rgyud rim Khyung Pe Drime Shel Gyi Melong -
gyu-i bon - rgyu' i bon 'khyungs dpe dri med shel gyi me long
gyur bon - gyur bon khyung trug - khyung 'phrug
gyurpa - bsgyur-pa Khyunglung Ngulkhar - Khyung lung
gyurtshiil - 'gyur tshul dngul rnkhar
Gyushi - rgyud bzhi Khyungtrul Men Pe - khyung sprul sman
Gyuzhi karu drub pa - rgyud-bzhi dpe
bka' -ru bsgrub-pa Khyuntrul Jigme Dorje - khyung sprul
hong len - hong Ian 'jigs med nam mkha'i rdo rje
Hulu Pale - hu lu spa legs ki ki so so Iha gyal 10 - ki ki bswo bswo
jam - 'jam lha rgyallo
jam - 'jam kon chog sum - dkon mchog gsum
jampa - 'jam pa Kongrong Menlha Dundrub - kong rong
jampel- 'jam dpal sman bla don grub
jangmen - byang sman Kongtrul Yonten Gyatsho - kong sprul yon
jigten Ie depe Iha - 'jig rten las tan rgya tso
'das pa'i lha kordag - dkor bdag
jigten Ie depe srung ma - 'jig rten korlo - 'khor 10
las 'das pa' i srung rna Kunzang Gyalwa Gyatso - kun bzang
jigten pe Iha - 'jig rten pa'i lha rgyal ba rgya mtsho
jigten pe srung ma - 'jig rten pa'i kuwa- khu ba
srung rna kuya - ku ya
jllthig - ju thig kyabab - skya rbab
ka - bka' kyangma - rgyang rna
ka ko la - ka ko la# kyel- rkyal
kadrllb - bka' -bsgrub kyen - rkyen
kagyu - bka' brgyud kyerpa - skyer pa
kal ne - mkhal nad kyu nl ra - skyu ru ra
kampa - skarn pa la - bla
kang - rkang la Iii - bla bslu
kanjl/r - bka' -' gyur la Iii - bla glud
kara .. ka fa la ri bla ri
285
 la shing - bla shing Mawe Senge - smra ba' i seng ge
la tsho - bla mtsho me nyam lung - me mnyam rlung
la yu - bla g.yu me lsa dregpa - me btsas bsreg pa
la zug - bla gzugs medra - me drod
lam rim - lam rim men - sman
Lam Rim Chen Mo - lam rim men chen - sman chen
chen mo Men Jor Tongtsa - sman sbyor sdong rtsa
lane - bla gnas Men Nag Gyu - man ngag rgyud
lang thab - glang thabs men lsi khang - sman rtsis khang
latsi - gla rtsi Menbu - rman bu
lawa - sla ba menche chenmo - sman dpyad chen mo
Ie -las menpa - sman pa
. .
legtang mangpo - legs tang menrz - sman-n
rmang po meii - rme'u
lha - lha mewal - me dbal
lha mo - lha mo mz-nu
lha pa - lha pa Midii - mi bdud
lha sin degye - lha sin de gyed mindrug - smin drug
. .
Lhadag Ngagdro - lha bdag mzng gyur - nung gyur
sngags dro mo- mo
lhakhang - lha khang mo dong - mo-sdong
lhatho - lha tho molha - mo lha
Ihen -lhen mu-dmu
lho ter - lho gter mu chu - dmu chu
Ihad -lhod Mucho Demdrug - mu cho Idem drug
Lhogpa - lhog pa muchu - dmu chu
Ihung - lhung mugpd tra tren - smug po'i khrag skran
Ii shi - Ii shi Mutri Tsenpo - mu khri btsan po
Liglug - rlig rlugs Mutsha Trahe - dmu tsha tra he
Ligmigya - lig myi rhya nag pa - nag pa (constellation)
long cha - longs spyod nag tren - rnag skran
Lonka natsha - long ka na tsha nam me - nam smad
Lopon - slob dpon Namgyal Men Bum Karpo - rnam rgyal
Iii - glud (ransom rites) sman 'bum dkar po
lu - kIu namkha - nam mkha
Iii - Ius (body) namshe - mam shes
Lu - kIu Namlhar Kagyachen - rnam thar bka' rgya
Iii zung diin - Ius zungs bdun cen
lung - rlung namthd sre - rnam thos sras
lung -lung (oral transmission) nang shell thegpa - snang gshen theg pa
lung - rlung (wind) nang trell - nang skran
lungta - rlung Ita nangpa - nang pa
lungtse - rlung tshad Ile - nad
Lutsen - klu btsan ne me - nad med
ma rigpa - rna rig pa 1U? tag - nad rtags
ma zhll - rna zhu Ile tra - nad khrag
ma zhll lva - rna zhu ba nechung - gnas chung
mamo- rna mo nepa - gnas pa
Malli Kabllm - rna ni bka' 'bum ngagpa - sngags pa (class of religious
malli khorlo - rna ni 'khor 10 practioner)
malli lag khor - rna ni lag 'khor ngar 1111 - ngar ml
mallupatra - rna nu pa tra "go men - sngo sman
286
ngo she - rnngon shes peken jorche - bad kan 'byor byed
ngon - mngon peken mugpo - bad kan smug po
ngon par dzo - mngon par rndzod peken tenche - bad kan rten byed
ngondro - sngon 'gro peken tsimche - bad kan tshirn byed
no druk - snod drug peken yeche - bad kan rnyad byed
nocha kham - gnod bya kharns peken yongche - bad kan rnyong byed
nocha nyepa - gnod bya nyes pa pha ma - pha rna
nodjin - gnod sbyin phar phyin - phar chin
nojin - gnod sbyin phel- 'phel
non - snron pho dong - pho sdong
nopa - gnod pa pho long ne su mug pe Ira Iren - pho long
nor dzin ling - nor 'dzin gling gnas su smug pa'i khrag skran
nor gyi dzamla lha - nor gyl phungpo - phung po
'dzarn bla Iha pi pi ling - pi pi ling
norlha - nor Iha po ne - pho nad
nowa - rno ba polha - pho Iha
num - snurn ponlob - dpon slob
niipa - nus pa ragpa - rags pa
Nyame Sherab Gyaltsen - mnya rang- rang
rned shes rab rgyal rntshan rangzhin ne - rang bzhin gnas
Nyalri Tsenpo - gnya' khri btsan rangzhin ne - rang bzhin nad
· .
po rzg- ngs
nyen - gnyen (relatives) rig lam pa - rig glarn pa
nyen - gnyan rigne - rig gnas
· .
nyen - mnyen (pliant, supple) rzgpa - ng pa
nyen bur - gnyen 'bur Rigpe Yeshe - rig-pa'i ye-shes
· .
nyen gyu - snyan brgyud rzm - nrns
nyene - gnyan nad rim mi zepa - rims rni zad pa
nyenser - gnyan gzer rim tshe - rims tshad
nyensin - gnyan srin rinchen ri lbu - rin chen ril bu
nyepa - nyes pa rinchen sangpo - rin chen bzang po
nyigma mazhu - snyig rna rna zhu rinchen terdzo - rin chen gter mdzod
· .
Nyima Tenzin - nyi rna bstan rmg- nng
'dzin rinpoche yi men - rin po che yi sman
nying tshe - mying tshad roma - ro rna
nyingma - mying rna ru - rus
nyipangse - nyi pang sad ruta - ru rta
nyurpa - rnyur pa sa - gza'
Olrnolungring - '01 rno lung ring sa drib - gza' grib
or ne - 'or nad sa yi men - sa yi sman
Orgyenpa Rinchenpal - Orgyan sadag - sa bdag
pa Rin chen dpal saga - saga
pa - spa sakya - sa skya
Palden Lhamo - spalldan Iha rno same - bsam yas
pawo - dpa' bo sang - bsangs (incense ritual)
pe lung - bad rIung sang - bzang (auspicious)
pe tri - bad rnhris Sangpo Bumtri - sangs po 'bum khri
pe tshe - bad tshad sangye - sangs rgyas
pecha - dpe cha Sangyl! Gyamls(}· sangs rgyas rgya mtsho
pehar - pe har Satrig Ersang - sa trig er sangs
pekeJl - bad kan sem - sems
. . .l!l1nlO - bsen mo
287
serji metog - gser gyi me tog sogtsa nagpo - srog rtsa nag po
serthog chejam - gser-thog lee sonam - bsod nams
'byams songdre - gson 'dre
sha - sha Songtsen Gampo - srong btsan sgam po
sha ra - sha ra sowa rigpa - gsa ba rig pa
sha Ira - sha bkra sri shen thegpa - srid gshen theg pa
shabten - zhabs brtan srung dud - srung mdud
Shardza Tashi Gyaltsen - shar srung khor - srung' khor
rdza bkra shis rgyal mtshan srung ma - srung rna
Shari U-chen - sha ri dbu chen srung wa - bsrung ba
She Gyu - bshad rgyud sub - srubs
shen - gshen sug mel- sug smel
Shenchen Luga - gshen chen kIu Sugmel chupa - sug mel bcu pa
dga' Sum ton Teshezung - sum stan te shes
Shenlha Okar - gshen Iha 'ad gzung
dkar ta chog - rta chog
shenrab - gshen rab tagpa - rtags pa
Shenrab Miwo - gshen rab mi bo Takla Mebar - stag la me 'bar
Sherab Jamma - shes rab byam tamdrin - rta mgrin
rna tanjur - bstan 'gyur
shindre - shi' dre tapa - rta pa
shing - zhing tar - gtar
shing men - shing sman tarbu - star bu
shinje - gshin rje tashi - bkra shis
shinje she - gshin rje gshed Tashi Gyegay Thartenling - bkra shis dge
sho mo - sho rna rgyas mtha' brtan gling
si pa - srid pa Tazig - stag gzig
sil sum - bsil gsum ten - 'then
silwa - bsil ba ten - rten
. . ten rim - bstan rim
sin - snn
sin ne - srin nad tenpa - brtan pa
sin thor - srin 'thor terma - gter rna
sinbu - srin 'bu terton - gter stan
sinbu ne - srin 'bu'i nad Tewa - kre wa
sinmo - srin rna thang men - thang sman
Sipa Yesang - srid pa ye sangs thangka - thang ka
Sipai Gyalmo - srid pa'i rgyal rna thegpa gu - theg pa dgu
sipe khorlo - srid pa'i 'khor 10 thenpa - 'then pa
sipe tsa - srid pa'i rtsa thi/pa - mthil pa
Situ Choki Jungne - si tu chos kyi thingri / - mthing ril
chung nge thrangpa - mkhrangs pa
So Che Ne Bum Nagpo - gsa byed Throm - phrom
nad 'bum nag po thrug - 'khrugs
so ne - so nad thugpa - thug pa
so rig bum shi - gsa rig 'bum bzhi thung - thung
sog - srog (life force) thur se//ling - thur sel rIung
sog - gsog (empty) tigta - tig ta
sog chag men - srogs chags sman tigta - tig ta
sog Iii - srog glud tigta chllchig - tig ta bcu gcig
sogdzin lilng - srog 'dzin rIung tigta gyepa - tigta brgyad pa
soglha - srog lha timllg - gti mug
sogmar - sag dmar to - gto
288
tong- stong tshang pa karpo - Tshang pa dkarpo
Tongyung Thuchen - sdon rgyung tshawa - tsha ba
rnthu chen tshe da - tshe rnda'
tonpa - sTon pa tshe dii - tshe bdud
torma - gtor rna tshe ma - tshad rna
Ira - khrag (blood) tshe yi tsa - tshe yi rtsa
Ira - phra (thin) tshe yi yungdrung - tshe yi g. yung drung
Ira lung - khrag rIung tshen nyi - rntshan nyid
Ira ne - khrag nad tshen nyi - rntshan nyid
Irangpa - mkhrangs pa tshen nyi la tag pa - rntshan nyid la brtag
Irawa - spra ba pa
Iren - skran tshering - tshe ring
Ireng mo - 'phreng rno tshethar - tshe thar
Iri - khrid tshig kang - tshig rkang
Tri bu Trishi - dpyad bu khri shis tshil - tshil
Iridzin - khri 'dzin tshon - rntshon (index finger)
Iripa - mkhris pa tshon - tshon
Iripa dangyur - mkhris pa rndang tsi - rtsis
sgyur tsi men - rtsi srnan
Iripa dogsal - mkhris pa rndog tso - btsod
gsal tso ba - rtsod ba
tripa drubche - rnkhris pa sgrub tsod yig - rtsod yig
byed tsowo - gtso bo
Iripa juche - mkhris pa 'ju byed tsub - rtsub
Iripa thongche - mkhris pa tsub pa - rtsub pa
rnthong byed tiil- rtul
Trisong Detsen - khri srong Ide tulku - sprul sku
btsan u me - dbu rned
Trithog Patsha - khri thog spa ii ter - dbus gter
tsha u-ma - bdu rna
Irug - 'khrugs V-pa Dardrag - dbus pa dar grags
trul shen thegpa - 'phrul gshen usu - 'u su
theg pa V-Tsang - dbu-gtsang
trum to - khrurn stod Vaidurya ngonpo - Vaidurya sngon-po
tsa - rtsa walchen gekho - dbal chen ge khod
Tsa Gyu - rtsa rgyud wang - dbang
tsa kalPO - rtsa dkarpo wangthang - dbang-thang
tsalung - rtsa rIung wo - dbo
tsampa - tsarn pa yamshii - yam shud
tsang - gtsang yang- g.yang
Tsawa Thug Bum Kha Ngon - rtsa yangtse la me thegpa - yang rtse bla med
ba thugs 'bum mkha' sngon theg pa
tsen - btsan yangwa - yang ba
Tsewang Rigzin - tse dbang rig Yeru Wensakha - g. yas ru dben sa kha
'dzin Yeshe Walmo - ye shes dbal mo
tsha - tsha (sharp pain) yeshen thegpa - ye gshen theg pa
tsha la - tsha la yi - yid
tsha la- tsha la yi kyi damtshig - yid kyi dam tshig
tsha Ie jong - tsha las sbyong vidam - yi dam
tsha nang tren - tsha nang skran Yile kye - yid las skyes
tshab - tshab yizang wa - yid bzang ba
yowa - g yo ba
289
yug sa ma - yugs sa rna zhedang - zhe sdang
yulha - yullha zhen - zhan
yungdrung bon - g.yung drung zhenpa - zhen pa
bon zhi - zhi
Yuthog Yontan Gonpo - g.yu thog zho - zho
yon tan rngon po zhu - zhu
za - gza' zhuje - zhu rjes
zang drug - bzang drug Ziji - gzi brjid
ze - zad zur lug - zur lugs
ze che - zad byed Zurkharwa Nyamnyi Dorje - zur mkhar ba
Zermig - gzer mig mnyarn nyid rdo rje
zhang drum - gzhang 'brurn

290
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