medicine between science and religion chapter2

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Chapter 2

Biomedicine in Tibetat the Edge of Modernity

Alex McKay

Introduction The Tibetan medical world has never been closed to outside infuences. Inthe classical medical text o the Gyushi, or example, we may detecthistorical encounters with Greek, ersian, Chinese and Indian medicine.!

"ach o those traditions has contributed to the body o knowled#e in thatseminal text o sowa rigpa, $the science o healin#% in the Gyushi or the Four Tantras. "lements which are today seen as an inte#ral part o a $Tibetan%, ormore precisely Tibetan &uddhist system, have in actuality thus under#onea process by which they were adopted, synthesi'ed and eventuallyindi#eni'ed.2 This is, o course, entirely consistent with Charles (eslie%sconclusions that $)sian medical systems are intrinsically dynamic * +and* continually evolvin#% -(eslie and oun# !//2a0 1 and that syncretism isa $normative cultural practice% -(eslie !//2b0 !345/.6ver the last century the Tibetan world has a#ain been en#a#ed in anencounter with a body o orei#n medical knowled#e, known as$biomedicine%.7 8ince the !/9:s Tibetans have encountered this systemprimarily in the orm represented by the Chinese or Indian state, but theormative years o the encounter occurred durin# the &ritish colonialperiod in )sia. The biomedical system developed durin# the late nineteenthcentury, and its diver#ence rom earlier humoral understandin#s o thebody and reli#ious understandin#s o disease causation radically separatedit rom traditional medicine. The system was ully established within the&ritish imperial medical services, as well as missionary medicine practices,when &ritish orces invaded Tibet in !/:75:; and orced the Tibetans to

en#a#e politically 5 and to a lesser extent socially 5 with the <estern world.<hile the Tibetan medical world was radically transormed by thisencounter, in the historical perspective it doubtless replicates many aspectso earlier historical processes and areas o syncretism can be seen to haveemer#ed in line with (eslie%s dictum.

The &ritish impact on Tibet was lar#ely limited to the areas alon# theIndo=Tibetan trade route rom &en#al to (hasa, and the vast ma>ority o

Tibetans had little or no experience o biomedicine prior to the Chinesetake=over in the !/9:s. &ut a study o the initial sta#e o the encounter shedsconsiderable li#ht on the processes identi?ed by Charles (eslie and on theormative elements o the present Tibetan medical world. In what ollowswe will outline the process by which biomedicine was introduced into Tibetas a conse@uence o the &ritish political pro>ect there, discuss the encounterbetween the two medical worlds, and identiy initial steps towards adialo#ue between them in the orm o cultural concessions or practicaladaptations rom one world to the other.

The principle sources or this discussion are the records o the &ritishmedical pro>ect in Tibet, supplemented by interviews with relevant medicalpractitioners and &ritish and Tibetan memoirs o the period. It should benoted that the &ritish record=keepin# was oten poor and that their statisticscan only be accepted as a #eneral #uide. &ut while the colonial sourcesnaturally represent &ritish perspectives on the encounter, they also shedli#ht on Tibetan reactions to biomedicine and record milestones in the



structural development o the new system in Tibet.;

Medicine for a Political Purpose The primary a#ency responsible or the introduction o biomedicine into Tibet was the &ritish Government o India, more speci?cally the IndianAedical 8ervice oBcers who were attached to the Indian orei#n andolitical Department -the $oliticals%. This was the diplomatic corps o the&ritish Indian #overnment, which dealt with relations with the rincelystates and nei#hbourin# states such as Eepal and Tibet. <hile Christianmissionaries ostered the new medical system in border areas, where theyplayed a ma>or role in biomedical education and trainin#, the missionarieswere excluded rom Tibet by a#reement between the two powers. <hilethere were also private commercial initiatives, particularly with re#ard tothe importation o medicines into Tibet rom India, these were small scaleand overtaken by the imperial pro>ect. Individual "uropean travellers alsocontributed to Tibetan aith -or otherwiseF in <estern medical skill, butbiomedicine was primarily ostered there as a result o the northwardexpansion o &ritish power in India.

The search or a secure imalayan rontier, allied to real or ima#ined ears

o Hussian and Chinese power to the north, led &ritish Indian orces to invade Tibet in !/:75:;. The invasion, commonly termed the $oun#husbandAission% by the &ritish ater its leader, the olitical 6Bcer Colonel rancis

oun#husband, ou#ht its way to (hasa, the Tibetan capital. There it orcedthe Tibetans to enter into diplomatic relations with India and accept thepresence o &ritish Indian diplomats at Gyantse, !2: miles south=west o (hasa, atun# in the Chumbi alley and at Gartok in western Tibet. )ter!/71 a &ritish mission was also established in (hasa. 8eekin# ultimately toturn the Tibetans into allies 5 or accordin# to some plans, sub>ects 5 the&ritish used biomedicine as a political weapon with which to #ain Tibetan#oodwill, which they hoped would translate into political support.ree medical treatment was oJered to Tibetans o all classes by

oun#husband%s medical staJ, which ater a slow start attracted increasin#numbers o patients, particularly ater the mission reached (hasa. ollowin#the mission%s withdrawal, biomedical dispensaries were established alon#sidethe diplomatic posts. ) &ritish oBcer o the Indian Aedical 8ervice -IA8was stationed at the Gyantse Dispensary, while less @uali?ed sub=assistantsur#eons o Indian and later 8ikkimese ori#in were posted to atun# and toGartok -which was not staJed by the political department and was o onlyminor si#ni?cance. )ter the establishment o a &ritish mission at (hasain !/71573, a hospital was also opened there and in !/;: an IA8 oBcer wasappointed to a new position o Civil 8ur#eon or Tibet and &hutan, whichwas in eJect that o the (hasa mission medical oBcer.9

&ritish medical oBcers were posted to Tibet or two=year terms andwhile their primary duty was to ensure the health o the olitical )#ent,

the provision o medical services to the local population was o #reatsi#ni?cance. These medical oBcers #enerally submitted annual reports,which enable us to measure the #rowth o biomedical resort. or thecalendar year !/:1, Gyantse Dispensary had thirty=our in=patients andsaw 71/ out=patients -o whom thirty=one were Chinese. our decadeslater, in the year endin# on 7! Aarch !/;1, there were still only thirty inpatients,but there were a total o 9,9;; out=patients. In atun#, the ?rstyear or which ?#ures are available is !/22, when there were !9: outpatientsand no in=patients. In the year endin# Aarch !/;3 the reportaccounts or sixteen in=patients and 7,17! out=patients. There was,thereore, a si#ni?cant chan#e in resort patterns, with Tibetans increasin#ly



attendin# the IA8 dispensaries as out=patients, althou#h they remainedreluctant to become in=patients.1

The political purpose o the &ritish medical pro>ect was clearly articulatedthrou#hout the years until !/;3 -ater which the &ritish positions wereinherited by independent India. In recommendin# the establishment o theGyantse Dispensary, oun#husband had described it as $extremely desirable

on political #rounds%,3 and in the !/;:s the work o medical oBcers continuedto be described as $o #reat political value%.4 The primacy o their diplomatic rolewas also indicated by several periods in which, in the absence o a olitical6Bcer, the IA8 physicians acted in that role. <hile this could create certaintensions and ethical dilemmas, the doctors were always aware o their primaryduty 5 $a responsibility to our +political mission% -Aor#an 2::30 !7!.

Imperial and Biomedical Condence To ully understand the context in which biomedicine was introduced into Tibet, we must consider the wider imperial situation. Durin# theiceroyalty o (ord Cur'on -!4//5!/:9, &ritish power and presti#e inIndia reached its peak. In retrospect the seeds o its decline were alreadyclearK the rise o Indian nationalism, &ritish deeats in the &oer war and

subse@uent #rowin# anti=imperialism amon# &ritish voters were allpronounced by that time. The oun#husband Aission o !/:75:; actuallymarked a $hi#h tide% in &ritish imperial expansion in 8outh )sia. )ter thattime, the empire advanced no urther, and the subse@uent period was oneo consolidation and retreat. &ut in India under Cur'on, the prevailin#&ritish mood was one o #reat con?dence in the imperial pro>ect.&ritish medical oBcers were not only imbued with the con?dence o their empire, they were also ull o a new con?dence in their proession.8cienti?c and technolo#ical advances, to#ether with the discovery o theprinciple o disease causation a#ents -$#erms%, had revolutioni'ed thepractice o medicine in the <est durin# the last @uarter o the nineteenthcentury. )septic sur#ery was a radical advance in intrusive practice, whilea series o discoveries o speci?c causation a#ents seemed to su##est that theprospect o con@uerin# most common diseases was at hand. Aedicine wasat the oreront o the new scienti?c advances and proessional or#ani'ationand status had #reatly increased in the wake o these developments.

The IA8 and its provincial predecessor services were well aware romtheir experiences in other re#ions o 8outh )sia that the reception o theirmedical services was by no means socially unproblematic. et theirimperial and proessional con?dence seems to have dictated that the ormo biomedicine they oJered made no concessions to local culture otherthan those dictated by lo#istics and environment. In such areas as internalarchitecture, dress, hospital hours and routine, teachin# patterns, visitoraccess and determined secularism, the early IA8 dispensaries in Tibetemulated the model o hospitals in the L.M.

Imperial con?dence and the biomedical assumption that other medicalpractices would simply ade away in the ace o the new system%s power andeBcacy may explain why we turn in vain to the &ritish records whenseekin# studies or even comments on Tibetan medical theory and practice.It appears that none o the nearly thirty &ritish medical oBcers who servedin Tibet durin# the !/:;5;3 period ever undertook any serious study o the indi#enous traditions. "ven in the !/;:s when con?dence in bothempire and the potential o biomedicine had #reatly declined rom theCur'onian era, there were only brie and dismissive comments on thosepractices in private correspondence or diaries./

Dr H.8. Mennedy, medical oBcer in Gyantse in !/:35!:, and one o only a



handul o IA8 oBcers who learned Tibetan, did visit the Aentsikhan#, thehospital or Tibetan medicine and astrolo#y, while in (hasa in !/2:52!,accompanied by the olitical 6Bcer Charles &ell. &ut such encounters with thelocal system and its practitioners were the exception rather than the rule.

oun#husband%s chie medical oBcer, Dr (.). <addell, had met the head o theChakpori medical colle#e in (hasa, but dismissed his explanations o the

underlyin# philosophy o the Tibetan medical system as $saturated withabsurdity%,!:while Dr A.. Murian, an Indian Christian IA8 oBcer who servedin Tibet in the !/;:s, did not recall ever speci?cally meetin# a local practitioner.!!

Dr <.8. Aor#an, a hi#hly re#arded IA8 oBcer who served in Tibet in !/71573,displayed some interest in, and even sympathy or, local practitioners, but heultimately accepted the conclusions o his principal inormant, 8ikkimese subassistantsur#eon &o Tserin#, trained in biomedicine and hi#hly critical o thelocal system and its practitioners -Aor#an 2::30 !:/5!7, !!45!/.

Adapting Biomedicine for Tibetans<hile the IA8 oBcers were not concerned with the local system, they didseek to attract Tibetan patients and in that sense were in competition withindi#enous physicians. They undoubtedly had humanitarian motives which

we must consider. They were conronted by suJerin#, wanted to alleviate it,and in many cases knew they could do so #iven the opportunity. &ut therewas also the &ritish political pro>ect o which they were a part, and any Tibetanreluctance to attend the IA8 dispensaries was seen as refectin# poorly on&ritish presti#e and threatenin# the success o the diplomatic endeavour.

The result was that increasin# eJorts were made to attract Tibetans tobiomedicine. These emer#e clearly in the hi#hly politici'ed context o the!/7:s and !/;:s, althou#h there may have been earlier concessions to

Tibetan culture that are not recorded. 8ino=&ritish competition or Tibetansupport re=emer#ed stron#ly ater the death o the Thirteenth Dalai (amain !/77. Tibet had been eJectively independent under his rule since !/!7and Chinese oBcials had been lar#ely excluded rom Tibet in that period.&ut ater !/7;, ollowin# the arrival in (hasa o a Hepublican Chinese$condolence mission%, the &ritish took on a more active role to counter their#rowin# infuence. The buildin# o a new hospital in (hasa and theestablishment o the post o Civil 8ur#eon Tibet and &hutan weremaniestations o this active policy in the medical ?eld.

This political context was most clearly explicit when the Chinese openeda biomedical hospital in (hasa in !/;; which attracted many patients whohad previously attended the &ritish hospital. There seems to have been noparticular diJerence between treatment at the two institutions because atthat time China was ollowin# the <estern biomedical public health caremodelK the dispute was over status and infuence at (hasa. <hile theChinese hospital remained in existence the olitical 6Bcer in char#e o the &ritish positions in Tibet emphasi'ed that $Chinese competition in

medical work calls or a hi#h standard rom us%.!2 To counter the Chinese,the Gyantse medical oBcer Dr Murian was sent to (hasa to assist the newCivil 8ur#eon, Dr G.8. Terry, a civilian war=time appointee who was soonreplaced by the Tibetan=speakin# (ieutenant=Colonel Names Guthrie.) number o speci?c measures desi#ned to enhance the Tibetan uptakeo biomedicine were taken by successive IA8 physicians durin# this period.Eo evidence o any ormal discussion about this has survived, and themeasures were probably experimental initiatives by individual IA8 oBcers,doubtless takin# into account the opinions o the lon#=servin# 8ikkimesesub=assistant sur#eons, &o Tserin# and Tonyot Tserin# -or more on whom,see below. <hile there seem to be no examples o local medical curin#



strate#ies bein# incorporated into biomedicine at this time, no use o localherbs etc., concessions were made in re#ard to structures and biomedicalroutines. 6ne concession to Tibetan culture was to allow elective sur#ery tobe undertaken on a day chosen by the patient in consultation with a reli#iousadvisor, thus reco#ni'in# the Tibetan belie in auspicious days orindividuals. That practice survives today in parts o the &uddhist imalayas,

such as &hutan, and has been extended to the permanent postin# o reli#iouspractitioners within the hospital wards as staJ members.Aeasures were also taken to alter the hospital environment to suit

Tibetan traditions. Isolation was not a Tibetan practice -except in cases o smallpox and the con?nin# o sick individuals was similarly orei#n.

Tibetans ound <estern hospitals orbiddin#, sites o impurity that seemed$like a vision o hell%.!7 To counter this impression, the &ritish allowedpatients% relatives to camp in the hospital #rounds and permitted #reatlyincreased visitor access in order to reduce patients% sense o isolation. Theyalso turned a blind eye to dual resortK or example, Dr Guthrie allowed the

Tsaron# amily to administer powdered rhinoceros horn to a birthin#mother on the principle o $allowin# anythin# that would increasecon?dence provided it would not be harmul%.!;

<hat these measures had in common, rom the &ritish perspective, wasthat they did not threaten what the IA8 oBcers thus de?ned as an essentialcore o biomedical theory and practice. They were concessions in orm andpresentation, not least in allowin# a reli#ious dimension to a practice seenby the &ritish as entirely secular. Increased eJorts were also made to explainbiomedical practices, and the wives o the Civil 8ur#eons were permitted toaccompany them to (hasa, where they were able to explain biomedicalprinciples to Tibetan women. Ars Guthrie, a nurse, was also able to assisther husband%s practice. The increased Tibetan resort to the dispensariesdurin# this period su##ests that these concessions did help to attractpatients to biomedicine, which now took on external elements that werereco#nisably within Tibetan culture. The survival o these elements into

the post=colonial period su##ests they may represent permanent elementso the indi#eni'ation o biomedicine in this cultural re#ion.

Tibetan Adoption of BiomedicineIn addition to biomedical concessions to Tibetan culture, we may also traceaspects o that system that were #radually absorbed into indi#enousmedical understandin#s and practices. Despite the enormous conceptualdiJerences between the two systems, they shared a reco#nition o theimportance o the consultin# physician re#isterin# the patient%s pulse.8tethoscopes 5 the display o which became an obvious symbol o thebiomedical practitioner 5 were soon adopted by some Tibetan practitioners,partly we may su##est, because o their symbolic association withmodernity. In addition, another stron#ly visual symbol o biomedicine

became common in the Tibetan worldK the !/;:s Italian traveller oscoAaraini speaks o the $blind aith% o Tibetans in in>ections which wereapparently extremely popular by that time, and oten #iven by unskilledpractitioners.!9 This visual appeal has been noted as bein# avourable tobiomedicine in contemporary &hutan, with patients preerrin# that systemover indi#enous traditions because O=rays, C)T scans, etc. can be seen andunderstood by the patient, who thereore eels empowered.!1

The pharmacolo#y o biomedicine was also used by Tibetans outsidethe institutional settin#s o biomedicine, with antibiotics particularly indemand in the !/;:s. These were oten sold in ordinary shops, priced andprescribed by colour +F and kept and used in lar#e @uantities by ordinary



amilies.!3 ractitioners o sowa rigpa also made use o the new medicines.In (hasa in the !/7:s, i not earlier, amchi -lay Tibetan medicalpractitioners would visit &o Tserin#, describe their patients% symptoms,and he would provide stocks rom the &ritish dispensary or them todistribute to their patients -Aor#an 2::30 !!!5!7.<hat (eslie termed the$dynamic% aspects o local practice were thus clearly visible by this period,

as was an increasin#ly empowered patient base.&ut the introduction o <estern technolo#ies was not necessarily #reetedwith approval in Tibetan society. There were traditional avenues or theestablishment o orei#n technolo#ies0 &hutan, or example, was reerredto in early Tibetan sources as (ho>on# Aen>on# -$8outhern alleys o Aedicinal erbs%, but machinery could be considered anciul, $alseknowled#e% in the &uddhist sense -)ris !//;0 4. )s early as !32;, Capuchinmissionaries practicin# medicine in (hasa presented the then 8eventh Dalai(ama with a microscope -annini !/310 22!, and they were commonlyshown to Tibetans durin# the &ritish period, without this apparentlycreatin# any demand or them.It is assumed that the establishment o the Aentsikhan# hospital in (hasawas a Tibetan initiative that drew on the model o the <estern public healthsystem. Amchi do not seem to have ormed institutions outside amilylinea#es, and the concept o an in=patient hospital seems to have beenpreviously unknown, with patients normally treated in their own homes.

The traditional Tibetan model o the medical institution was the monasticcolle#e, o which the most prominent was Chakpori in (hasa. Its physiciansprimarily catered to elite patrons and public access to these colle#es appearsto have been limited. In the case o Chakpori, or example, ei#ht o itsphysicians were available to the public on aternoons durin# the annualGreat rayer celebrations -Aonlam Chenmo -Aeyer !/440 !!;, and notapparently durin# the rest o the year.)round !/!15!3, however, the Aentsikhan# hospital was opened in(hasa under the Chakpori=trained traditional physician Mhyenrab Eorbu

-!4475!/12. It apparently oJered ree sowa rigpa medical treatment to the#eneral public and secondary sources indicate that it was established aterthe Thirteenth Dalai (ama had been made aware o the &ritish Indianpublic health system durin# his Indian exile in !/!:5!2. Certainly itollowed the dispensary model o health care, which David )rnold called$one o <estern medicine%s most distinctive and eJective institutionalorms% -)rnold 2:::0 !34.&ut its history has not been sub>ect to academicen@uiry,!4 and there is no record that the &ritish had any involvement in itsconception. <hile the olitical 6Bcer Charles &ell -who was responsibleor the Dalai (ama durin# his Indian exile did advise his #uest onnumerous aspects o <estern modernity and #overnment, &ell makes nomention o this initiative in his writin#s,!/ and the Dalai (ama was open toother infuences.rom the Tibetan perspective, a ree public health system was clearly inline with &uddhist ideals o compassion. )nd in !/:;5:/ the Tibetan rulerhad also been exiled in Aon#olia, where the Hussians maintained a smallbiomedical dispensary in Lr#a, and China, where he may have been madeaware o biomedical hospitals that existed there. urther research in thisarea is necessary. <e would hope that more research would shed li#ht onthe choice o sowa rigpa over biomedicine as the prevailin# system at theAentsikhan#. <e simply do not know whether this stemmed rom a lo#icaldevelopment o the existin# structures, a nationalist statement, or a choicedictated by ?nancial considerations -or the Tibetan state lacked the



?nancial capital necessary or the development o many aspects o modernity, includin# biomedicine. Eonetheless, its location in the Tibetancapital was consistent with the Thirteenth Dalai (ama%s policies o centrali'ed control, and we may suspect that the Dalai (ama primarilyintended a system showcasin# sowa rigpa because the introduction o smallpox vaccination at the state level in the !/2:s -see below was the only

state=sponsored biomedical initiative under his rule. The only other such initiative in pre=communist Tibet came in !/;2,when the Tibetan #overnment unded the construction o a two=roomhospital block alon#side the &ritish hospital. This was intended or the useo Tibetan oBcials receivin# biomedical treatment and consisted o tworooms, each or two in=patients, with an attached kitchen and store=room. 2:

Its construction was a symbol o the #rowin# use o biomedicine by the Tibetan elites, with both o the re#ents who ruled Tibet between the Thirteenth and ourteenth Dalai (amas receivin# biomedical treatmentrom the IA8 physicians.ere we mi#ht note that ollowin# the practice in India, where )#encysur#eons were char#ed with attendance on the rulin# amilies o rincelystates, the &ritish dispensaries in Tibet always oJered private consultationsto certain members o the political elites. It is unclear which individualsand amilies were allocated this privile#eK presumably they were chosen bythe olitical 6Bcer. &ut scattered reerences to those attendin# thedispensary and the memoirs o Tibetans now in exile su##ests that theprivile#e was #iven more to the secular political elites rather than themonastic, which is consistent with #eneral &ritish eJorts that, until the!/;:s, ne#lected the monastic powers. Thus, while powerul lay oBcialssuch as Tsaron# Phape and his amily were entitled to private consultations,we read o the hi#hly respected 8akya lama attendin# the &ritish dispensaryto be vaccinated a#ainst smallpox and his amily complainin# o havin# to@ueue with the #eneral public or treatment there.2!

Eonetheless, while the &ritish system excluded powerul monastic

elements rom the ranks o the privile#ed, the lay authorities entitled toprivate consultations must have understood the biomedical system as onewhich would allow them to retain their status and privile#es. The supporto the lay authorities thus became an important pillar in the developmento biomedicine and the act that the system did not threaten existin# secularsocial hierarchies must have enhanced its appeal to that class.

Syncretism as Process<hile biomedicine was promoted within the imperial pro>ect in Tibet, >ust asit was promoted within a Christian a#enda by missionaries in the border areas,this does not imply that it was thus received by the indi#enous peoples. Therewas a certain paradox inherent in the promotion o biomedicine in thesecontexts. <hile it was explicitly used as a political -or missionary weapon, it

was also part o a packa#e o modernity that the imperial powers sou#ht tointroduce into local society. &iomedicine was thus to be transmitted to thatsociety throu#h #eneral explanation and education, the trainin# o localpractitioners, and the establishment o local structures. It was a power thatwas to be #iven away to the locals -not least because o economic constraintson the <estern a#ents, a point that challen#es an understandin# o imperialmedicine as a $tool o empire% -eadrick !/4!. The reality was more complexand multi=layered, with the encounter primarily ne#otiated at a local level.6nce it became clear to the indi#enous people that acceptance o biomedicine did not involve conversion to Christianity in the case o missionary medicine, or any speci?c commitment to supportin# &ritish



interests in the case o IA8 medicine, and it was understood that it couldbe controlled by, and did not threaten, certain existin# social hierarchies,many o the barriers to its adoption disappeared. <e can identiy threesta#es in a process o Tibetan uptake o biomedicine. The ?rst was theadoption o resort to biomedicine as a curin# strate#y or certain speci?cconditions -see below. The second was the adaptation o aspects o the

biomedical system to Tibetan cultural norms in order to increase its appeal. The third sta#e was the indi#eni'ation o biomedicine, in which controlover structures and processes passed to local hands, reliance on orei#nsupplies was diminished by the establishment o a local dru# industry, andlocal individuals took up the practice o biomedicine.

The ?rst sta#e o this process occurred durin# the &ritish colonialperiod. <hile biomedicine was only available to Tibetans in central Tibet,and in borderin# re#ions where missionary medicine could be obtained,the attendance statistics at the IA8 dispensaries indicate that it became acommon resort strate#y durin# this period. The second sta#e o the processwas underway by the time the &ritish let Tibet, and continued both in the

Tibetan re#ions o China and in the exile community. owever, the thirdsta#e o the process only occurred in the post=colonial period.

The process can be seen more clearly in its entirety in 8ikkim, wherebiomedicine was introduced in the late !4/:s and where 8ikkimese biomedicalpractitioners had #raduated at sub=assistant sur#eon level beore the irst<orld <ar, and at ull AD status by the 8econd <orld <ar. &iomedicine in8ikkim today is entirely indi#eni'ed, with 8ikkimeseQIndian control over thepublic health system, includin# structures and trainin#, a local dru# industryand 8ikkimese personnel at all levels o the process, with <estern practitionersentirely absent. There are o course #lobal system interventions and undin#with re#ard to conditions such as 8)H8 and IQ)ID8, and dual resortinvolvin# the continuation o traditional practices, but these aspects arecharacteristic o medical systems all over the world.

The 8ikkimese experience was o considerable importance to the

indi#eni'ation process in Tibet. &o Tserin# and Tonyot Tserin# -who werenot closely related, two o the ?rst three 8ikkimese to @ualiy as sub Alex

assistant sur#eons, were promptly posted to the IA8 dispensaries in Tibet.<ithin the wider context o encoura#in# the #radual moderni'ation o

Tibet, the olitical 6Bcer Charles &ell hoped that the si#ht o the culturallyclosely related 8ikkimese practisin# biomedicine would encoura#e Tibetansto take up biomedicine as a proession. <hile lar#ely unsuccessul in thatre#ard, the initiative was o considerable success in promotin# the uptakeo biomedicine. The two Tserin#s remained in Tibet or around thirty yearsand the &ritish ound that $in ?elds social, medical and politicalR +theycould inspire more trust, more con?dence, and oster more riendshipsthan perhaps any o us% -Aor#an 2::30 22.<ith the exception o Mhyenrab Eorbu, there are ew records o Tibetansdisplayin# particular interest in biomedicine. <e read o a monk who askedthe Gyantse medical oBcer to teach him sur#ery in the !/2:s, while the

Tibetan Trade )#ent in Gyantse assisted the &ritish medical oBcer on avaccination tour north o Gyantse in !/79, havin# $always shown a livelyinterest in <estern medicine%.22 In addition, at least one Tibetan, a youn#monk, received some medical trainin# rom the &ritish, spendin# threeyears at the (hasa dispensary rom !/73 to !/;:, while several others wereemployed as $dressers%, a &ritish colonial term or a basic health careprovider or assistant. &ut IA8 oBcers were only briefy present durin# thisperiod to supervise trainin#, and the monk let to ?nd employment at the



Aentsikhan#. There he stitched wounds and, in another example o broadenin# sowa rigpa, he provided basic treatment with <estern dru#s.27

Patterns of Resort The de?nin# characteristic o the Tibetan uptake o biomedicine was

selective resort. &iomedicine was not adopted wholesale, but its treatmento our particular conditions @uickly emer#ed as avoured curin# strate#iesamon# the Tibetan peoples. accination a#ainst smallpox, treatment orwounds and ractures, eye sur#ery, and biomedical curin# o venerealdiseases ormed this @uartet o treatments that rapidly #ained avour with

Tibetan patients. "ach o these treatments became embedded within Tibetan patterns o resort throu#h particular historical tra>ectories whichhad, however, certain commonalities, as will be seen.&iomedical treatment or most o the ma>or epidemic diseases that hadhistorically aJected the )sian and "uropean landmass derived rom thelate nineteenth=century discovery o biolo#ical disease causation a#ents.owever, vaccination a#ainst smallpox was an exception. It was adevelopment o the practice o variolation,2; widely known and practiced

in pre=modern )sia and introduced to the <est rom Turkey in the earlyyears o the ei#hteenth century. Despite various problems, such asdiBculties with maintainin# the eBcacy o lymph prepared or vaccinationdurin# stora#e and transportation, the improved system was stron#lypromoted by the imperial health services both in &ritish India and inChina, as well as by Hussia in Central )sia."arly Tibetan travellers to imperial centres such as &en#al and ekin# maywell have become aware o the bene?ts o vaccination, and we know that the"ast India Company sur#eon )lexander amilton explained the principleso the new system to the Third anchen (ama in !33;539 -(amb 2::20 !/45//, 214. ) century later, in !43/, the ith anchen (ama%s Chie Ainister,8en#chen (ama -(ob'an# alden Chophel, asked the visitin# &ritish Indian

a#ent 8arat Chandra Das to brin# smallpox vaccine to Tibet on his next visit.Chandra Das did return with lymph in !44!542, but it had spoiled on the

>ourney, and vaccination in central Tibet only commenced with the oun#husband Aission in !/:75!/:; -c., AcMay 2::1Q:30 !!/57:. Therehad, however, been an earlier, small=scale instance o vaccination within Tibetin !413, when the Aoravian missionary "duard a#ell was invited to western

Tibet to combat an outbreak o smallpox. a#ell vaccinated 17/ people intwelve villa#es at a time when "uropeans were #enerally unwelcome in Tibet-&ray !//20 73!K also see &ray !/490 2457!, 71573. is visit was apparentlyan initiative by local oBcials, the class who were later to play an importantrole in acilitatin# biomedical initiatives by the &ritish.

The trade routes rom Tibet to India oJered an entry point or smallpoxand ater the &ritish had established permanent diplomatic outposts in

Tibet as a result o the oun#husband Aission, systematic eJorts weremade to introduce vaccination in Tibet. There was a stron# economicimperative behind these eJorts. The imalayan epidemic o !/::threatened &ritish India, and cross=border trade was halted until theepidemic was controlled. The medical oBcers stationed at the &ritishdiplomatic outposts in Gyantse, atun# and Gartok thus promotedvaccination rom the outset, with !,72: local children vaccinated at Gyantseby the end o !/:9.29 This pro#ramme was carried out with the approval o the local district administrator -dzongpon, and elite acceptance o vaccination was urther con?rmed in Eovember !/:9, when the anchen



(ama and several hundred members o his court travelled to India. Theentire party, includin# the anchen, underwent vaccination beoredeparture rom 8hi#atse.<hile there is evidence su##estin# that Tibetans were reluctant to bevaccinated, particularly where smallpox was not present, &ritish Indianvaccinators were a#ain invited by local authorities, includin# the $head

lama% o uran# -Taklakot, to combat an outbreak o smallpox in western Tibet in !/:3. The Aanchu Dynasty Chinese oBcials in (hasa, the)mbans, also supported vaccination. In !/:4 they ordered all Tibetans tobe vaccinated, and brou#ht vaccinators to Tibet rom China -althou#h it isunclear i they actually carried out any vaccinations.21

&y !/!! the ma>ority o inhabitants o the Chumbi alley had beenvaccinated, as had lar#e numbers o people in Gyantse.23 )s smallpoxcontinued to break out in places such as (hasa where vaccination had notbeen introduced, the eBcacy o the new preventative became clearlyapparent. accination was provided without cost by the &ritish, but apopular demand or it is indicated by a !/!; report that Eepalesevaccinators, who char#ed a small ee, ound it pro?table enou#h to travelthrou#h southern Tibet.24

The Tibetan state%s acceptance o vaccination soon ollowed. In !/2:52!, durin# his meetin#s with Mhyenrab Eorbu at the Aentsikhan#, DrMennedy instructed the sowa rigpa physician in the collection andpreparation o smallpox lymph.2/ The ollowin# year the Tibetan army#arrison at Gyantse was systematically vaccinated,7: the ?rst entirelybiomedical state initiative in Tibet. )lthou#h relations between Tibet and&ritish India were deterioratin# at this time, and the Tibetan state wasre>ectin# most aspects o modernity, the Tibetan authorities continued toavour vaccination and, with &ritish assistance, subse@uently distributedlymph to outlyin# areas o the Tibetan state.) number o actors may be considered to explain the Tibetans% readyacceptance o vaccination. irstly, the #eneral principle o introducin# a

preventative into the body was amiliar rom the existin# practice o variolation, so the biomedical treatment mi#ht be accepted as adevelopment o an existin# practice rather than an entirely new strate#y.8econdly, vaccination had been established earlier in nei#hbourin# states,includin# culturally close re#ions such as 8ikkim, which acted as abrid#ehead or its acceptance into Tibet. Its eBcacy had already beenestablished there, and was soon empirically observable within Tibet, asvaccinated areas such as Chumbi and Gyantse remained ree o theepidemics that devastated other re#ions. The early acceptance o vaccination by elite individuals such as the anchen (amas and laterMhyenrab Eorbu was also si#ni?cant. Their traditional and institutionalauthority le#itimi'ed vaccination in Tibetan society, and local oBcials suchas the Gyantse dzongpon, who saw its advanta#es, subse@uently promotedit amon# their people. <e must also consider the role o intermediariessuch as the Eepal=born Dar>eelin# &uddhist, Marma aul, interpreter tothe early &ritish physicians in Gyantse. aul records that prior to his visitto India the anchen (ama had been araid o the in>ection but aulexplained the system, showed his own vaccination scar and even allowedhimsel to be vaccinated a#ain in ront o the (ama, who then accepted it-Hichardus !//40 43544.Hesort to biomedical treatment or wounds and ractures was alsorapidly established in areas o Tibet where it was available. Tibetans wereprobably made aware o its eBcacy by oun#husband%s medical staJ durin#



the !/:75!/:; invasion o Tibet. )ware o the need to ultimately cultivatethe riendship o the Tibetans in order to ensure the security o &ritishIndia%s northern rontier, oun#husband%s medical team treated Tibetansoldiers wounded in the ?#htin# a#ainst his orces. <hile there were bonesettersin Tibet and there were various treatments or wounds that involvedcoverin# the aJected area and applyin# herbal treatments to it, deormity

and restricted use were apparently considered almost inevitable ollowin#ractures and inection o wounds must have been more common in theabsence o aseptic treatment. )s a result, the biomedical treatment provedpopular, and throu#hout the &ritish period Tibetans o all classes resortedto the IA8 physicians or treatment o do#=bites, stab wounds, racturesand the like. 8uperior eBcacy was thus a ma>or actor in the Tibetan resortto biomedical practitioners, but as in the case o smallpox, Tibetans seemedmost likely to resort to treatments where they were amiliar with the #eneralcontours o the new practices, which were probably seen as improvements,rather than as innovations.

The Tibetan acceptance o eye sur#ery, principally the treatment o cataracts, was also prompt. These operations were ?rst oJered in Tibet by

oun#husband%s medical staJ and subse@uently by the IA8 oBcers atGyantse, who were well aware o the propa#anda value to biomedicine o the restoration o si#ht.7! )#ain, however, there are indications that cataractoperations were not unknown to the Tibetans. )lexander amilton hadcommented on the superiority o &hutanese sur#ical instruments over thosehe possessed or this practice -(amb 2::20 214. &ut by the &ritish period

Tibetan physicians do not seem to have been carryin# out these operations.<hile a more detailed study is necessary,72 it appears that there were severalmethods o treatin# cataracts practiced in )sia, and skilled practitioners o any one techni@ue may always have been rare. &ut the knowled#e that theoperation was possible a#ain su##ests that Tibetan amiliarity with the#eneral concept aided its acceptance, with the understandin# that thebiomedical physicians oJered an improved rather than a novel treatment.

&iomedical treatment or venereal diseases was the ourth therapy thatwas most rapidly accepted by the Tibetans. In this case an understandin#o the superior eBcacy o the new treatment appears to have developeddurin# the period !/:95!!, when Aanchu Dynasty troops were #arrisonedalon#side Tibetan orces in Gyantse. The Chinese troops, already amiliarwith the new treatments then emer#in# as a result o their use in China,re#ularly attended the IA8 dispensary there or venereal inections and itseems certain that, with Chinese women excluded rom Tibet, soldiers romboth nations patroni'ed the same reservoirs o inection. )#ain, the #eneralcontours o the treatment 5 the application o a speci?c -mercury=basedSpreparation 5 seems to have been common to both traditional andbiomedical curin#, acilitatin# the Tibetan uptake o the new treatment,which came to be heavily avoured when it proved more eBcacious.77

The evidence su##ests, thereore, that those aspects o the biomedicalsystem that were ?rst accepted by Tibetans were those in which the #eneralpattern o treatment was similar to that o the indi#enous treatment, butempirically indicated as bein# si#ni?cantly more eBcacious. In addition,the acceptance o a biomedical treatment by nei#hbourin# )sian cultureswould appear to have enhanced its uptake in Tibet. <hile the simple act o the availability o physicians and their oJerin# o ree treatment -as the IA8oBcers in Tibet did doubtless explains many cases o resort to biomedicine,other treatments were only accepted over time within the #radual process o indi#eni'ation o biomedicine and were thus dependent on the development



o new understandin#s, biomedical cultural concessions, etc. The #rowth o a small class o <estern=educated Tibetans and theirassociation with at least some aspects o modernity was also an importantactor at least in central Tibet, while novelty and indeed a @uestionin# o theprevailin# socio=cultural system must also be considered as actors.Eationalist based resistance to biomedicine o the kind identi?ed in India

by scholars such as David )rnold and Ian Catanach seems lar#ely absentrom Tibet -c., )rnold !/430 995/:, Catanach !/440 !;/53!, wherenationalism in the modern sense o identi?cation with a nation=state waspoorly developed in the colonial period.<hile the de?nin# attribute o the Tibetan uptake o biomedicine wasselective resort, it must be remembered that dual resort was 5 and still is 5also characteristic. This took various orms0 experimentin# ?rst with oneand then another treatment, selective resort to one system or particularconditions and simultaneous treatment under two systems or the samecondition. In the latter case this could be with the understandin# thatbiomedicine was eJective in the physical world, and indi#enous treatmenteJective in the other world.7; This pattern o resort, which was not promotedby any particular system or power structure, and which is diBcult i notimpossible to measure, su##ests that patients based their pra#matic selectionon what they perceived as the most eBcacious curin# strate#y available tothem rather than on the infuence o any particular power complex.

A Common round! The initial encounter between Tibetan and <estern medical worlds couldbe seen as a meetin# o two mutually incomprehensible traditions. Theirconceptual bases were undamentally incompatible. In the Tibetan system,or example, reli#ion and medicine were two sides o the same coin, withthe teachin#s o the Gyushi understood as derivin# rom the teachin#s o the &uddha in his Aedicine &uddha aspect. In stark contrast, biomedicinewas determinedly secular. Dialo#ue between the two systems was certainlyalmost entirely absent. <addell, as we have noted, concluded that the

Tibetan system was $saturated with absurdity%, and that underlyin# belie was never seriously @uestioned by the IA8 oBcers or their biomedicalassistants durin# the colonial period. 6nly in the case o Dr Mennedy andMhyenrab Eorbu in !/2:52! does there appear to have been any realattempt to exchan#e inormation, albeit apparently a one=sided exchan#e.

et we may identiy the existence o a dimension in which the two systemswere in communication 5 the social and ethical construct o thedoctorQhealer in society. In both traditions the practice o the doctorQhealerwas seen as morally #ood work or the bene?t o humanity. This wasparticularly the case when medical services were oJered without ?nancialbene?t, but even proessional medical services were seen in this li#ht.hysicians held hi#h social status partly as a result o the moral aspect o their

work, and the ideal o their callin# was that it was ultimately beyond materialreward0 the doctor was re#arded as duty bound to assist those in ur#ent need.Christopher &eckwith has pointed out the similarities between theippocratic oath and a very similar 5 perhaps derivative 5 medical oathcontained in an ei#hth=century Tibetan medical text which emer#es insimilar orm in later texts such as the Gyushi. It calls or physicians to behonoured with status, horses and #old, while counsellin# them0 $Do notexpound +medicine, to them or the sake o +their poor oJerin#sK +as youare pursuin# learned piety, do not do evil to householdersK +as you areupholdin# the noble method, do not #ive out evil dru#s * do not be indecentand hypocritical to patients% -&eckwith !/3/0 7:;. This cross=cultural



commonality may have assisted the development o Tibetans% understandin#o the IA8 physicians and ultimately the system they practiced. The Tibetanshad no experience o physicians as a#ents o the state, but do appear to haveavourably distin#uished the &ritish physicians rom their ellowcountrymen.or example, <addell @uotes the Tibetan He#ent -the abbot o Ganden monastery as statin# that $except you doctors, o whose humane

work I have heardK* all the others are utterly devoid o reli#ion% -(.).<addell, @uoted in )llen 2::;0 24/. <hile there is no evidence that this wasreco#ni'ed by the &ritish, the shared ideal o the doctorQhealer may thus haveassisted in the reception o biomedicine in Tibet.

Conclusions The indi#eni'ation o biomedicine in Tibetan societies was a process whichtook several #enerations. <hile it be#an durin# the colonial period, only apreliminary phase was completed when the &ritish withdrew rom Tibetat the end o the !/;:s. It may well be, however, that studies o the earlierindi#eni'ation o orei#n systems such as Greek and Indian medicine willindicate that these were also processes rather than events.<hile biomedicine was introduced to Tibet at a time o #reat con?dence

in both &ritish "mpire and the new medical system, syncretism in the ormo concessions to local culture proved necessary in order to attract Tibetanson a lar#e scale. Aost notably, the essentially secular claims to biomedicalauthority had to be mediated throu#h Tibetan reli#ious world=views. <hilea deep intellectual en#a#ement was lackin# in the colonial period, practicalconcessions acknowled#ed Tibetan cultural understandin#s, and paved theway or later explicit concessions to Tibetan belies. "ven then, the Tibetanuptake o biomedicine was selective, with continuin# dual resort, andincreased resort to biomedicine was slow and #radual. Eonetheless, theeventual post=colonial result was the creation o Tibetan biomedicalstructures -within Indian or Chinese state parameters.&iomedicine was introduced to Tibet by the &ritish or a politicalpurpose. <hether it served that purpose is an open @uestion, #iven thesubse@uent collapse o the &ritish colonial pro>ect. &ut the Tibetan receptiono biomedicine was a complex and multi=layered process, much o whichtook place outside state structures and was ne#otiated at a local level. Theexample o elite individuals such as the anchen (ama and the acceptanceo the new system by local oBcials were important in the move towardsbiomedical structural initiatives, but patient=driven demand was also aactor in its spread, particularly in re#ard to those elements o biomedicinethat were most rapidly resorted to by Tibetans. Aany examples o movestowards syncretism occurred outside ormal structures, with empiricalobservation o biomedical eBcacy bein# an oten underrated actor in theuptake o aspects o the new system. ) shared ethical basis in theunderstandin# o medical practice ormed an area rom which syncretism

could develop in the orm o blurred boundaries o theory and practice.inally we should emphasi'e that the history o biomedical development in

Tibet was not a uni@ue event. ) #rowin# number o studies o biomedicalbe#innin#s throu#hout the world indicate that many o the characteristiceatures o the introduction o biomedicine to Tibet are common to otherre#ions.79 ) #radual uptake eaturin# selective and dual resort, and a slow processo indi#eni'ation seem characteristic o the process re#ardless o location.

"otes!. 6n the ori#ins o the Gyushi, see "mmerick !/33, Marmay !//4, &eckwith !/3/.2. I use the term $indi#eni'ed% to indicate understandin#s and practices that haveunder#one a process o absorption into an indi#enous culture, and a system in which



the structures and personnel are entirely under indi#enous control -as much as ispossible under a world system. )mon# the characteristics o indi#eni'ed practicesand systems are that they are tau#ht and expressed in local lan#ua#es whereappropriate, are understood within a wider cultural world=view, possess a localhistory, and are transmitted within local teachin# linea#es or orms o instruction.7. &iomedicine is a system developed lar#ely in the <est in the late nineteenthcentury and known under various names includin# $allopathic%, $cosmopolitan%,

$scienti?c% or $<estern% medicine.;. Hesearch was carried out durin# a <ellcome Trust Centre or the istory o Aedicine research ellowship. Ay thanks are due to the Centre staJ and itsDirector, roessor al Cook, or their support. I am also #rateul to Aona8chremp or her encoura#ement with re#ard to this and related works. <herenot otherwise cited, this work draws on my mono#raph -AcMay 2::3.9. or a complete list o &ritish politicalQdiplomatic, medical and military oBcerswho served in Tibet durin# the period !/:;5;3, see AcMay -!//30 224573.1. The annual reports rom the &ritish dispensaries are #enerally attached to thereports o the olitical )#ency in the 6riental and India 6Bce Collection-hereater 6I6C (Q8Q!! and (Q8Q!2 series. The ?rst Gyantse reportcoverin# the period !/:;5:1 appears to survive only within the +(t=Colonel .A.&ailey collectionK A88 "ur !9357:;b. The attendance records are collated as anappendix in AcMay 2::3.3. Eational )rchives o India orei#n Department +hereater, E)I D, !/:1 "xternal

&, Aarch !/57!, ?le note by Colonel oun#husband, ; Eovember !/:;.4. 6I6C, (Q8Q!2Q;2:!593;3, (hasa mission report, week endin# 9 8eptember !/;7./. <hether Tibetans let any accounts o biomedicine is a @uestion that awaits a studyo the indi#enous sources.!:. (.). <addell, @uoted in )llen -2::;0 244 +no source #ivenK presumably <addell,Lhasa and its Mysteries, (ondon, !/:9.!!. )uthor interview with Dr A.. Murian, IA8, Coimbatore, !2 Nanuary !//;.!2. 6I6C, (Q8Q!2Q;2:15;47:, olitical 6Bcer 8ikkim to Government o Indiaorei#n Department, !9 8eptember !/;;. )s or Guthrie see AcMay -2::90 !24579.!7. 8ee or example, the comments by Namyan# 8akya in 8akya and "mery -!//:0 !44.!;. Ars H. Guthrie, $"veryday (ie in esterday%s Tibet%, unpublished manuscript inthe possession o Ar David Guthrie.!9. Aaraini -!//40 2;!K interview with Dr Ni#me and Dr Ars arku Eorbu, retired Ni#me Dor>i <an#chuk ospital 8uperintendents, Thimphu, 2! Nuly 2::;.

!1. Interview with Dr Tob#ye <an#chuk, )ctin# 8uperintendent, ND< ospital, Thimphu, 27 Nuly 2::;.!3. Interview with Dr Ni#me and Dr Ars arku Eorbu, 2::;.!4. The topic is now sub>ect to en@uiry by 8tacey van leet -Columbia Lniversity. 8eeher paper $Curriculum, eda#o#y, and Aodernity in the 8man rtsis khan#%presented at the International )ssociation or the 8tudy o Traditional )sianAedicine -I)8T)A IIth conerence, Thimphu, &hutan, 8eptember 2::/.!/. In particular, it is not mentioned in &ell%s Portrait of a Dalai Lama -!/43, wherehe discusses his advice to the Tibetan leader in exile. I have not seen any mentiono the Aentsikhan# establishment in &ritish recordsK no "uropeans visited (hasain the years between !/:; and !/2:.2:. 6I6C, (Q8Q!2Q;2:159227, report on the civil hospital, (hasa, !/;95;1.2!. 6I6C, (Q8Q!2Q;!1152:4:, Gyantse annual report !/21K 8akya and "mery-!//:0 29!, also see ibid0 2;2.22. 6I6C, A88 "ur D/4/, papers o rank (udlow, +Gyantse school headmaster

!/27521 and later ead o &ritish Aission (hasa, diary entry 2: Aarch !/29K(Q8Q!2Q;!115;913, Gyantse annual report !/79571.27. <.8. Aor#an, $!/71573 (hasa mission medical report%K appendix in &rad?eld !/7401;!5;7K 6I6C, (Q8Q!2Q;2:159227, Heport on the civil hospital (hasa, !/;95;1.2;. $accination% reers to inoculation with animal poxes containin# the vaccina virus,whereas $variolation% involves the introduction to the human body o mattercontainin# the variola virus.29. 6I6C, A88 "ur !9357:;b, Gyantse dispensary report, year endin# 7! December!/:9.21. 6I6C (Q8Q3Q22:5!129, Gyantse annual report !/:35:4, E)I, D, "xternal &, Nune !/!!, 24/, ?le note by $T.<.% 1 Nune !/!!K E)I, D, 8ecret ", ebruary !/:4,;135;42, ?le note by "..8. Clarke, 21 Eovember !/:3K E)I D, "xternal &,



6ctober !/:4, !/;52!1, Gyantse a#ency diary entry, !: 8eptember !/:4.23. 6I6C, (Q8Q3Q2;/5!!9!, Gyantse annual report, !/!:5!!.24. 6I6C, (Q8Q!:Q2!4527/1, Gyantse dispensary report or the year endin# 7!December !/!;.2/. 6I6C (Q8Q!2Q!;751/, Heport o Dr Mennedy, orwarded in Charles &ell toGovernment o India, 9 December !/2!.7:. 6I6C, (Q8Q!:Q2!452!2:, Gyantse annual report !/22527.

7!. 6I6C, (Q8Q!2Q;!11574;:, Gyantse dispensary report !/79.72. ) startin# point would be "lliot !/!3.77. 8o eBcacious was the biomedical treatment o venereal diseases that it seriouslyaJected the resort patterns at the IA8 dispensaries and led to a -alse understandin#o these conditions as endemic to Tibet, on which see AcMay -in press.7;. This understandin# appears common throu#hout the &uddhist imalayaK see orexample, Gaens'le -!//;0 9751:.79. or example, or two re#ionally extremely distinct studies showin# similarprocesses, see &retelle="stablet -!///0 !3!52:7 on rench colonial medicine insouthwest China, and Dirar -2::10 29!54: on the "ritrean reception o Capuchinmissionary medicine.

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Marmay, 8.G. !//4. $The our Tibetan Aedical Treatises and their Critics%, in 8.G.Marmay, The Arrow and the pindle$ tudies in -istory' Myth' 1itual and 8eliefs inTi#et . Mathmandu0 Aandala &ook rint, pp.224573.(amb, ). 2::2. 8hutan and Ti#et! the Tra2els of George 8ogle and Alexander -amilton(;;<6(;;;= 2ol$(' Letters' /ournals' and Memoranda. ertin#ordbury0 Hoxord&ooks.(eslie, C. and ). oun# -eds. !//2a. $Introduction%, in C. (eslie and ). oun# -eds,Paths to Asian Medical Knowledge. &erkeley0 Lniversity o Caliornia ress,pp.!5!4.RRR. !//2b. $Interpretation o Illness0 8yncretism in Aodern )yurveda%, in C. (eslieand ). oun# -eds, Paths to Asian Medical Knowledge. &erkeley0 Lniversity o Caliornia ress, pp.3352:4.Aaraini, . !//4 +ori#. !/9!. ecret Ti#et . (ondon0 arvill.AcMay, ). !//3. Ti#et and the 8ritish 1a>! The Frontier .adre ()?<6()<;. Hichmond0

Cur'on ress.RRR. 2::9. $UIt 8eems e Is an "nthusiast )bout TibetV0 (ieutenant=Colonel NamesGuthrie 6&" -!/:15!/3!%, /ournal of Medical 8iography !2-;0 !24579.RRR.2::1Q:3.$U)n "xcellent AeasureV0 the &attle )#ainst 8mallpox in Tibet, !/:;5;3%,The Ti#et /ournal 7:-;Q7!-!0 !!/57:.RRR. 2::3. Their Footprints 1emain! 8iomedical 8eginnings Across the &ndo@Ti#etanFrontier$ )msterdam0 )msterdam Lniversity ress.RRR.-in press. $Tibet, 8ikkim, &hutan0 the Ayth o enereal Disease%, in 8. Crai#, A.Cuomu, . Garrett and A. 8chremp -eds, tudies of Medical Pluralism in Ti#etan-istory and ociety . Proceedings of the ((th eminar of the &nternational Association for Ti#etan tudies' 8onn *??%. alle0 International Institute or Tibetan and &uddhist 8tudies Gmb.Aeyer, . !/44. Gso@#a rig@pa$ Le ysteme Medical Ti#etain. aris0 Centre Eational de laHecherche [email protected]#an, <.8. -.A. Hybicki, ed.. 2::3. Amchi ahi#$ A 8ritish Doctor in Ti#et ()%6;.

-Charlestown, A).0 privately printed.Hichardus, . -ed.. !//4. Ti#etan Li2es! Three -imalayan Auto#iographies. Hichmond0Cur'on ress.8akya, N. and N. "mery. !//:. Princess in the Land of nows! The Life of /amyang ha3yain Ti#et . &oston and 8hatsbury0 8hambala ublications.annini, . !/31. The 8ell of Lhasa$ -Eew Delhi0 privately printed.

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