THE TIBETAN MEDICAL HOUSE
A corporate body holding an estate made up of both material and immaterial wealth, which perpetuates itself through the transmission of its name, its goods, and its titles down a real or imaginary line, considered legitimate as long as this continuity can express itself in the language of kinship or of affinity and, most often, of both.
—Claude Lévi-Strauss, The Way of the Masks
THE transmission of medical knowledge among lay amchi has been conceived of as a flow of medical knowledge and practices passed on from fathers to sons, this continuity over time being known as “medical lineages,” or mengyü in Tibetan vernacular language and practice (Craig 2012; Hofer 2012; Schrempf 2007). My findings, however, lend themselves to broader anthropological analysis through the concept of the house, first coined and defined by the social anthropologist Claude Lévi-Strauss (1982) and then significantly developed and critically applied to ethnography of Southeast Asian societies (Carsten and Hugh-Jones 1995). Drawing on the reception of these debates in the study of Tibetan kinship and especially in social anthropologist Heidi Fjeld’s (2006) study of the house as an important form of kinship organization in Tsang, this chapter broadens and fine-tunes existing scholarship on the transmission of Tibetan medical knowledge. Findings on residence and marriage patterns of amchi, the symbolic and cosmological significance of their physical houses and how amchis’ socioeconomic position and medical authority were established and maintained within the broader social organization of central Tibetan society of the time likewise inform this inquiry. The concept of the Medical House is useful for tracing knowledge transmission as well as the practice of medicine outside of large, central medical institutions in the 1940s and 1950s. Particular medical practitioners were deeply affected when their houses were wholly or partially dismantled during the early Communist reforms.
Lévi-Strauss’s two characteristics of the house as a form of social organization are particularly pertinent to the transmission of medical knowledge and the establishment of authority in terms of Medical Houses in Tsang. One is a relatively flexible endorsement of social forms other than descent in selecting heirs to medical knowledge and skill within named and unnamed Medical Houses. This is despite the use of the rhetoric of patrilineage. Similar to the noble houses in Europe, houses among the Kwakiutl discussed by Lévi-Strauss, or the ie in Japan discussed by Chie Nakane (1970), Medical Houses have been remarkably enduring social units. The continuity of Medical Houses will be explored through discussion of two “male” Medical Houses, the Mentrong and the Térap in Ngamring, and one “female” Medical House in Sakya, the Nyékhang, followed by discussion of Medical Houses as moral persons.
REVISITING THE HOUSE
Yonten Tsering and I had known each other for several years, and during the winter of 2006–7 in particular, we spent many days and weeks together. In the early summer of 2007 we drove from Shigatse to Gye, his home village, nestled on the side of a fertile valley in lower Ngamring. The wind gently moved the browning tips of still largely green barley fields as we went bumping along dirt roads in a rented jeep. We had begun to plan the reestablishment of a Tibetan medical clinic in his birthplace, a rural farming village of about six hundred residents. It was his dear wish that it should be located in the Térap House that had belonged to the previous two generations of doctors in his family (figures 1.1 and 1.2). As usual, in the trunk of the car were his two aluminum chests filled with about one hundred Tibetan medicines to treat people on the way. The driver had put on music, and the backseat was crowded with Yonten Tsering’s students and supporters, myself included.
After several stopovers, we were in Gye by the next morning, in the house of Gyatso, an old acquaintance from previous fieldwork with whom I stayed. He is the father of Tashi Tsering, a young student of Tibetan medicine who was partway through a durapa, or BA course at the Tibetan Medical College in Lhasa, the most prestigious modern medical college in the TAR. Gyatso, a tax collector, was crucial to Yonten Tsering’s endeavor as he was the official owner of the Térap House that had belonged to the doctor’s family. Gyatso’s parents had moved there in 1960, when landless farmers benefited from the first Democratic Reforms (Mangtso Chögyur), especially the land reforms implemented in the area. The doctor’s family, by contrast, lost all rights to the house, its estate, and almost all personal belongings; they were relocated to a one-room shelter where they made do on less than the bare minimum over the following five years. With Yonten Tsering taking the lead, and Gyatso and his family present, we talked through the plans for the day: inspect Yonten Tsering’s former home with a carpenter, meet the village leader to get his approval for the project, and in the afternoon study and pick medical plants in the vicinity of the village to see whether the clinic could rely to some extent on local materia medica.
“This is where I studied medical texts with my father,” said Yonten Tsering as we entered his natal home in the central part of the village, peeping into a room where a thin shaft of light reached through the cracks of small wooden shutters. We opened them to let in light and air. The room was now used for storage, the walls blackened, but beyond several bags of clutter we began to make out a mural on one of the walls. It featured an amchi feeling the pulse of a patient (figure 1.3), someone grinding medicines, and another letting blood from a patient’s leg: “My father had this made—it is very dear to me. I am happy to see it! This is nothing fake—it is real. It is part of our history and my memory,” the doctor exclaimed as I quietly marveled over this almost forgotten treasure, only some time later pondering his use of the terms history and memory (logyü and trenpa). I then learned where the hearth had been—the center of sociality of the house, where medicines were made and his father once saw patients. Always practically inclined, Yonten Tsering continued, “However, it would be better to establish the new treatment rooms across the house, in the new northern court, as there is more light and warmth from the sun, also in the afternoons. This yard only gets the morning and midday sun,” displaying his intimate knowledge of the sun’s passage here, seemingly unbroken by the fifty-year hiatus.
MEDICAL LINEAGES: PAST AND PRESENT
Mengyü have so far been understood as major pathways for transmitting and reproducing Sowa Rigpa knowledge and skills in Tibet, and to lend authority, legitimacy, and status to medical practitioners.1 Similar ideas and patterns of transmission are found in Chinese medicine, Ayurveda, and Yunani Tibb (the Arabic healing traditions of South Asia), as well as in Buddhist and Hindu religious domains.2
Tibetan medical lineages are sometimes recorded in Tibetan textual and oral accounts. Accounts of who was granted the authority to study a medical text or practice a particular technique from a given teacher fill thousands of pages in Tibetan medical histories and biographies of noted, usually elite, practitioners.3
The prominence of medical lineages as sources for and constituents of authoritative knowledge was established in the early days of the Tibetan medical system, in the twelfth-century Four Treatises. Here we read that “a medical doctor without a lineage [rikgyü] resembles a fox seizing the throne of the king and will not be honored at all” (Men-Tsee-Khang 2008: 298). This phrase uses the Tibetan term rikgyü, which is usually translated as “lineage” or “descent” and emphasizes proper lineage credentials. The phrase, or at least the sentiment, is repeated endlessly in medical works. We also find a visual representation of the fox on the king’s throne in the famous Lhasa medical paintings (Parfionovich, Dorje, and Meyer 1992; figure 1.4). Such ideas on legitimacy and authority resemble wider Tibetan Buddhist and cultural ideals of who can become a scholar practitioner and how to be respected and successful in any of the ten Tibetan sciences, including Mahayana Buddhism (Barth 1990; Schaeffer 2003).
At the late seventeenth-century foundation of the Chakpori Medical College and other Buddhist medical institutions across eastern Tibet and Mongolia, the concept of mengyü continued to play a role. And mengyü is still important, even in secularized Tibetan medical institutions today, where classroom teaching, university exams, and degrees prevail.
In the historical and anthropological literature on Tibetan medicine, we find discussion of mainly two types of medical lineages. One, the prominent pathway within the family and along ties of kinship, is the so-called bone lineage or dunggyü. This refers to the ideal of transmitting medical knowledge along dung, an honorific term for rü, or what is translated into English as “bones” or “patrilineage.” The other type is the teaching lineage (lobgyü) or master-discipleship discussed in the next chapter. Here a student sought out a physician or medico-Buddhist master, whose teaching and practices often connected closely with medico-spiritual rituals, for instance those of the Yuthog Heart Essence. Empowerments (wang), oral transmissions of medical texts (lung), the transmission of “secret oral” knowledge (menngak) to selected disciples, and oral didactic instruction (tri) were practiced in both kinds of lineages. The ritualized presence of wang and lung was more common in teaching lineages, where teachers and students were not usually related through kin. Instead relationships had to be forged through rituals and other social practices that demonstrated respect for teachers and teaching, and in return legitimacy for the student. Both pathways of transmission featured in my conversations with and observations of amchi in Tsang, the first prevalent among lay and the second among mainly ordained Buddhist and Bon practitioners.
Yet to merely analyze empirical findings on the transmission of medical knowledge among lay amchi in terms of bone lineages (dunggyü) and associated medical lineages (mengyü) is to leave out of those who do not fit local conceptions of “bones” as constitutive elements of medical lineages. In practice, many Tibetans in Tsang have gained medical knowledge and authority, even when they did not inherit the bones or pass on the bones of their fathers (i.e., belong to a particular patrilineage). Instead, they were accepted on the basis of being members or residents in a medical household (mengyi kyimtsang), through marriage (what social anthropologists refer to as affiliation), or through birth or adoption into the household (or filiation).
Scholarship on kinship and social organization in Tibetan societies has long documented the coexistence of ideas of descent (bones and lineage), affiliation, and residency in determining and creating social differences and groups in Tibetan societies.4 In her analysis of social organization and domestic groups in rural Tsang, Fjeld (2006) applies and develops Lévi-Strauss’s anthropological house concept to reconcile the tensions in analyzing descent, affiliation, and residency. This analytical category of the sociosymbolic house is particularly relevant to understanding the transmission of medical knowledge in Tsang and the social position and rank of lay Tibetan medical practitioners there.
BONES AND FLESH: GENDERED IDEOLOGIES OF DESCENT
Tibetan understandings of a bone lineage are grounded in theories of procreation and accounts of corporeal formation and constitution, in which the two substances of rü (bones, of which dung is the honorific form) and sha (flesh) are fundamental (Levine 1981; Fjeld 2006: 155–61). In the medical literature, as well as in lay concepts, rü is thought to be transferred via the white reproductive substance (khuwa) of the father to the bones of a conceived child, while sha (or what is called trak, or “blood,” in medical texts and by Levine’s informants among the Nyinba in Nepal) is transferred via the red reproductive substance of the mother (khuwa or trak) to constitute the flesh (Fjeld and Hofer 2010/11: 181–83). Of these, the bones form the “matrix of the body”—that is, they constitute the foundation for the person’s physical and mental abilities—while the flesh has only limited implications for the constitution of personhood (Fjeld 2006: 158). While the bone lineage (rügyü, hon. dunggyü) is a direct and continuous line, the flesh lineage (shagyü) continues for no more than two generations. This is because the woman’s red reproductive substances result indirectly from her father’s bones (white substance) rather than directly from her mother’s flesh (red substance), and therefore from her patriline rather than her matriline (Fjeld 2006: 159; Fjeld and Hofer 2010/11: 181–83).
Common practice, either the source or the result of this ideology, has been to pass on medical (and other kinds of occupational) knowledge to a male heir. Tibetans explain this in terms of kinship ideology, in particular ideas of patrilineal descent such those as just outlined. In the words of one of my amchi informants from Ngamring, “The circulation of ‘flesh’ and ‘blood’ [sha khrag ’khor rgyug] means they always change. Over time they become lighter and weaker [sla ba]. The bones [rus] on the other hand are harder [mkhregs po]. This is the reason bone lineages [gdung rgyud] remain strong and do not disappear easily.” Another explained in a similar vein: “The color of the bone is white, and whatever happens, it will stay white; the color won’t change. The color of blood, on the other hand, becomes lighter and lighter, and in the end it disappears.”
This ideology of the transmission of medical knowledge from father to son is, however, not reflected in practice. Fjeld and I found that women born into medical households and in-marrying magpas (called-in son-in-laws), or adopted children, also inherited medical knowledge and passed it on to both male and female heirs (Fjeld and Hofer 2010/11: 181–83). The house concept from anthropology therefore provides an apt framework to reconcile the widespread coexistence of a rhetoric about the ideal of patrilineal descent in the transmission of medical knowledge, and indeed practice, with other situations not conforming to this ideal, especially when we looked at cases in which women inherited and transmitted medical knowledge in Medical Houses.
In line with these developments in the study of Tibetan kinship, the house concept offers new ways to analyze the transmission of Tibetan medical knowledge as well as the socioeconomic status and authority of practitioners in Tsang. Many of Fjeld’s findings regarding the social, symbolic, and economic aspects of houses in Panam in rural Tsang resonate with my findings on medical households in Ngamring, with the difference that none of the houses described below were to my knowledge polyandrous in the 1940s and 1950s (one however becoming so in the 1990s). At times these have even been referred to as Mentrong, literally “Medical Houses” (sman grong), while at other times they are called “medical households” (mengyi kyimtshang) or simply carry the name of a regular named House (Fjeld 2006: 126)—that is, without any explicit reference to men (medicine) but practicing and transmitting medicine across generations.
MEDICAL HOUSES IN TSANG
Despite the widespread verbal and practical insistence on the ideal of patrilineal descent for those who carry on medical lineages, medical knowledge has often been passed on to members of a family or a household who were not part of the bone lineage, such as magpas, adopted children, and women, the latter especially (but not exclusively) when there were no sons (Fjeld and Hofer 2010/11; Hofer 2015). These persons were subsequently seen as perfectly legitimate heirs to family medical traditions, by virtue of membership and filiation in Medical Houses.
In the following example of a Medical House, remarkable continuity was facilitated by mechanisms other than transmission along the bone lineage, which was considered to have been “cut.”
The Lhünding Mentrong
Situated in Lhünding Village at the foot of a hill topped by its local monastery is a named House widely known simply as the Mentrong, or “Medical House.”5 A seventy-year-old man, Rinchen Wangyal (affectionately and honorifically also called Rinchen-la or Mentrong Rinchen), explained the history of his Medical House to me in 2007:
Our bone lineage comes from Jangpa Namgyel Drazang. He was born here at the Mentrong about six hundred years ago. His palace was later established up there [points up the hill], and at some point it was turned into a monastery. He was an extremely distinguished doctor, who during his lifetime helped so many beings in extraordinary ways. He was also a great lama. That’s how it came about that people were saying that even eating the earth of the Mentrong would cure their coughs and colds. So famous and legendary was this place before its destruction! It is because of Jangpa Namgyel Drazang that we are called Mentrong. It means “the place where a doctor is born,” and that remained our household name.
The life and medical legacy of Jangpa Namgyel Drazang have been recorded in several of his works and in medical histories.6 His school, the Janglug (Jang School) was one of the dominant medical traditions in central Tibet (cf. Hofer 2012).
There is little doubt about the past medical achievement of the Mentrong. Medical works were written here, and its members tried and tested new techniques, some of which were subsequently propagated, such as the use of a uniquely shaped knife for bloodletting that is named after the Lhünding Mentrong.7 Lhünding as a place for teaching medicine is mentioned by name in a history of the reign of the Fifth Dalai Lama and his regent, Sangyé Gyatso, for the year 1680 (Ahmad 1999: 328; Hofer 2012: 106). It is also prominently noted in the Fifth Dalai Lama’s regent’s orthodox medical history, Khogbug. Aiming to legitimate the medical and political authority of the Fifth Dalai Lama and his regent, this work claimed that the Janglug was united with another medical tradition of the time, the Zurlug, by Sangyé Gyatso. Yet according to local and family history, the medical tradition of the Lhünding-lug (a branch of the Janglug) continued well into the late nineteenth century at the Mentrong. It was during the time of his grandparents, Rinchen Wangyal said, that “the doctor’s lineage was cut.”8
As the preferred line of transmission, the brother of Rinchen-la’s grandmother had received the medical lineage—that is, the texts, oral instructions on specific, sometimes secret practices (menngak), and practical teachings—from his father. He became a gifted doctor while still young—so much so that according to Rinchen-la’s account, he aroused the jealousy of other doctors in the area and was allegedly given poisonous medicine and died. Although Rinchen-la’s grandmother stayed in the house, married to an incoming magpa from an aristocratic family from Ruthog in western Tibet, she had not studied medicine. Due to the early death of her brother and their father, it was too late for this magpa to study in the direct teaching line of the Lhünding-lug tradition. After that no one could pass on the Lhünding medical tradition to either Rinchen-la’s father or Rinchen-la’s own generation. This is why he referred to the lineage as “cut.”
Nevertheless with the material and immaterial wealth of the Mentrong painstakingly preserved, when Rinchen-la reached twelve, it was decided that the family medical tradition should be revived in the Mentrong. He was sent to nearby Phuntsoling Monastery to learn to read and write. After obtaining the lung and wang to the Four Treatises—permission to study the text—he studied and memorized three of its volumes while receiving practical instructions from a lay teacher named Jedrung Dzi (Rje drung ’Dzi), who taught medicine to two lay students at the monastery.
When Rinchen Wangyal returned to the Mentrong after several years of training, he was ready to read and further study medical texts. These included a large copy of the Four Treatises and the works of Jangpa Namgyel Drazang and their Lhünding-lug, still kept safely in the house. He began to make his own medicines from materia medica the family had preserved, combining this with newly collected herbs. He treated patients at home and made visits to patients in nearby villages. The Mentrong once again had a medical practitioner. Rinchen Wangyal thus combined the authority of the Mentrong—using its accumulated medical materials, texts, medicines, and instruments and its immaterial ritual power and efficacy—with the teachings and practical application learned from his teacher in Phuntsoling.
By virtue of the long-standing reputation of this Medical House and its medical lineage, Rinchen-la was known as the Mentrong amchi, or Mentrong Rinchen. This was despite “offending” two classic ideals of medical transmission: He was not born in direct patrilineal descent (that is, from the bones of his grandmother’s father or her brother, the last amchi known in the patriline), as he was the son of the magpa from Ruthog. And he did not directly receive oral teachings of the Lhünding-lug (the Lhünding school). Yet he managed to reestablish the medical tradition in their Medical House and work as an amchi.
This shows how the indigenous concept of a named Medical House, when analyzed from an anthropological house perspective, allows us to account for continuity across generations, despite impasses in patrilineal descent. Members of Medical Houses, even decades later, on several occasions successfully sought out medical knowledge elsewhere and then continued work as a Medical House. This testifies to the importance Tibetans placed on maintaining the continuity of houses that were home to highly regarded professions, such as medicine. Due to subsequent political upheavals and reforms, Rinchen-la could not further develop as an amchi or recover the Lhünding-lug from the writings held at the Mentrong.
The Térap in Gye
In contrast to the Lhünding Mentrong’s historically recorded and longstanding medical tradition, Yonten Tsering’s medical lineage reaches back only four generations. Its members’ names and work are remembered primarily within the family. His is a more straightforward, classic transmission of medical knowledge in the patriline, through the bones, from father to son. Yonten Tsering’s grandfather established the Térap in Gye, moving it there from Napu, lower in the valley. Yonten Tsering’s wife Yeshe Lhamo explained to me that Térap, the name of the house, was the short form of Tégu Rabpa, which her grandson spelled out for me as “ste gu rabs pa.” As far as she was concerned, it meant “residence of good people.” Tégu rabpa can also be translated as “place of generations” or “place of lineage,” alluding perhaps to a desired continuity for this house.
At Térap, as far as Yonten Tsering remembered, there had been no shortage of male heirs, and in each generation they were trained at home, sometimes receiving additional scholarly and medical training elsewhere. He learned reading and writing at a nearby nunnery and then began to read and memorize the Four Treatises at home under the supervision of his father, studying every morning and then observing his father’s work with patients. In 1954 Yonten Tsering enrolled at the newly founded Kikinaka Medical School of the Shigatse Labrang at Tashilhunpo Monastery, joining a class of fifty male students, half lay and half ordained. After four years of training, the class was discontinued as a result of political changes, and he returned home.
As he had been chosen as the one in the family to study medicine, he remained at home after marriage, while his siblings left to marry or join monastic institutions.9 In 1956, during a school break, Yonten Tsering married Yeshe Lhamo, a woman from the named White House10 in Targyü, by arrangement of their parents. Yonten Tsering’s rank as a member of a trelpa, or taxpayer household, as well as the heir to a bone lineage of doctors—conveying high rank (rik thopo)—defined who was considered an appropriate marriage partner and thus future member of Térap.11 Yeshe Lhamo’s father served as a reserve soldier in the Tibetan army,12 and her family was also from a trelpa household. The couple’s socioeconomic status was similar, and during the land reform both families were labeled landlords and variously called phyadag or phyado. Yet there were several notable differences, chief among them that Yeshe Lhamo was and remains to this day illiterate, unable to even write her own name, and she is a few years older than Yonten Tsering.
I asked Yonten Tsering and his older sister, who had been ordained in Jonang as a nun, whether anyone considered passing the family medical lineage to her instead of one of her brothers. This prompted a great deal of laughter, followed by explanations that it had not been considered and would not have been right. Thus in their generation, Yonten Tsering was the sole recipient of his father’s medical lineage, the lineage holder (rikgyü dzinpa).
Yonten Tsering’s story follows the kinship ideal of patrilineal descent in the transmission of specialized, professional knowledge. Yet to this logic of patrilineality must also be added the differential perception of the mental capacities of men and women (Fjeld 2006: 159), in this case reflected in the reaction to my question. The preference of male heirs to medical lineages may also be related to the polha, the deity of the patrilateral kin group or bone lineage. Male heads of households worship the polha daily in the altar room, an activity Yonten Tsering carried out even after he moved out of the area in old age. Belonging to a bone lineage therefore not only embedded Yonten Tsering in particular social relations and professional expertise, but it entailed certain ritual obligations and the worship of deities related to the patrilateral kin group and the land (Blondeau and Steinkellner 1996).
As far as we know from current accounts, the transmission of medical knowledge over the past three generations at Térap neatly coincided with a patrilineally transmitted bone lineage. Marriage and educational choices ensured the continuity of both the social unit of the named house and the authority of the Medical House over time. In contrast to the Mentrong, the continuity of the bone lineage and the medical teaching associated with it had not been interrupted.
Both times I visited Sonam Drölma at her home in Tsarong District, Sakya County, she seemed surprised that a foreigner was interested in her story—and that I had made it to her house. In spring and summer the glacial melt carried away whatever had been rebuilt of the road in winter. The terraced fields and tiny hamlets, however, lay peacefully above the powerful pull of the river, as did the old footpath, which I followed along the upper part of the valley to reach her house. In 1941, Sonam Drölma was born into the Nyékhang, literally, “house dear and near [to oneself].” The Nyékhang was in a village at the base of the mountain, below the local Pusum Monastery of the Sakya order. Her grandfather and her parents lived in the household; she was the only child, and soon took great interest in her grandfather’s medical work. At thirteen she began to study medicine:
My grandfather was a layman, although with close connections to our Pusum Gonpa. He taught me to memorize the peja, mainly the Gyüshi [the Four Treatises], explained how to recognize the plants, how to make medicines, to read the pulse, and to check the urine. He explained everything. I watched what he was doing. He taught me, and I helped out. It was not like today’s school; it all took place in an informal way.
Grandfather let me collect plants, grind them, and give the medicines to the patients. They came to my grandfather, and he went to their houses. He also bought medicinal ingredients from India, via businessmen, or else we would collect them from the area. He made every single medicine himself—between sixty and a hundred types. He had a big wooden trunk full of raw materials, but that was burned during the revolution together with many other things.
Sonam Drölma’s studies and training in medicine lasted until she was in her late teens, about 1960, when family members, especially her grandfather, were targeted by the new regime during its first local campaigns. They had to stop practicing medicine entirely but were able to preserve medical texts and instruments.
Both Sonam Drölma and her nephew, a learned Sakya lama and Tibetan medical physician, described the family medical tradition as a khyimgyü, short for khyimtsang gyü, meaning literally “lineage of the household” or “home lineage.” This term emphasizes the corporate estate of the Nyékhang, the khyimtsang or “household,” as an important social and symbolic category. It contrasts “doctor’s or medical lineage” (amchi gyü or mengyü), which emphasizes the person or the medical craft; “bones,” which references the patrilineage; and the name of a medical tradition’s founder, usually men. The local term “household lineage” fits well with the anthropological concept of the house, which is wider and captures the idea that medical knowledge and skill was inherited and transmitted by and to men and women, to those affiliated by descent as well as by affiliation (i.e., birth, adoption, or marriage) and that they resided together in a household. Sonam Drölma was one of only a few lay Tibetan women to have inherited a Medical House, similar to, for instance, Lobsang Dolma Khankhar from Kyirong in southern Tsang (Norbu Chöphel and Tashi Tsering 2008; Hofer 2015).
Such an inheritance was possible to these two women as the only child in a household with no sons. They were given a solid education and medical training, receiving encouragement from their families and teachers as the perceived stand-ins for sons (or, at times, male students). As Sonam Drölma’s Medical House had an excellent reputation and several centuries’ standing, it is remarkable that it was inherited by a woman.
It was common knowledge among doctors in the area, and explicitly stated by Sonam Drölma and her nephew, that the Nyékhang’s khyimgyü went back to Tsarong Palden Gyaltsen (Tsha rong dpal ldan rgyal mtshan, b. 1535). Historical accounts tell us that he was a Buddhist monk from an aristocratic family who was drawn to study medicine after a childhood illness, and that his teacher was Gongmen Konchog Pandar of the Gongmen tradition.13 Sangyé Gyatso’s medical history discloses that the inheritors of Tsarong Palden Gyaltsen’s lineage, namely Tsarong’s son and his nephew, established their own medical school, Drangsong Düpai Ling, and that they acted as doctors to local rulers and wrote many literary medical works (Sangyé Gyatso 2010: 320, 326; Garrett 2014: 183, 185).
According to these accounts, Tsarong Palden Gyaltsen must have left the order at some point to start his own family and teach medicine to his son and nephew.14 The biographical account of an early twentieth-century Tibetan politician, whose estate was in Tsarong, mentions a “medical monastery” (Tsarong 2000: 86). This is described as located near the Tsarong estate, a “two-story temple dedicated to the Medicine Buddha” with the eight monks residing there “conducting prayers and taking care of the daily offerings.” I could not find out more about how the current Nyékhang was related to the Drangsong Düpai Ling medical school or the medical monastery mentioned in the historical accounts.
In the 1940s and 1950s, based on Sonam Drölma’s information, the only doctor in this area was her grandfather. Sonam Drölma inherited his Medical House, as well as its material and immaterial wealth, comprising medical knowledge, skills, and a text collection associated with it. Having received a medical training and been married by arrangement to an in-marrying magpa, she began to practice at home as an independent amchi shortly before the reforms radically changed the trajectory of the Nyékhang.
RELATIONS BETWEEN MEDICAL HOUSES
Despite the relative proximity of Gye and Lhünding (about a three-hour walk), there was in living memory no medical exchange between practitioners of the Mentrong and Térap. Rinchen Wangyal insisted that after his teacher in Phuntsoling died in 1958, “there were no more good amchi,” except at Tashilhunpo. This implies that he could not study with amchi from Térap in Gye. It is unclear whether this was due to distance and his own responsibilities, or perhaps due to medical households keeping their knowledge to themselves. At that time there would have been several amchi in the area who in principle could also have acted as teachers. Instead, when medical knowledge was sought outside one’s Medical House, it was almost always from a teacher who was also a Buddhist monk or nun.15 If Rinchen Wangyal’s account of the intentional poisoning of the doctor of the Lhünding Mentrong is to be believed, there may have been competition between Medical Houses.
Such a lack of exchange between Medical Houses as was seemingly the case in 1950s Ngamring contrasts starkly with what we know of pre-Communist social and medical networks of family practitioners of Chinese medicine.16 Furthermore, in Ngamring and Tsang more broadly Medical Houses rarely had more than one member per generation who inherited medical knowledge; thus usually only two, one parent and one child, practiced medicine at any one time.
Despite the social authority and continuity provided by lay Tibetan Medical Houses, difficulties in continuing Medical Houses across generations sometimes meant seeking knowledge from medical practitioners in monasteries, such as Phuntsoling or Tashilhunpo. This likely discouraged competition or sharing of lineage and family-specific secret knowledge, or menngak. One could also obtain Buddhist teachings from monastics, a commonly accepted and highly regarded practice.
MEDICAL HOUSES AS “MORAL PERSONS”
The second important feature of the anthropological house concept in relation to Medical Houses in Tsang concerns their status as “moral persons” (Lévi-Strauss 1982: 171–87). This concept opens up new ways to understand several phenomena usually studied and analyzed separately, such as the architecture and everyday social and medical practices related to houses. It allows material and immaterial wealth—economic position (in essence access to land) as well as the physical nature and cosmology of Medical Houses—to be included in the analysis. Material and immaterial wealth included primarily medical text collections, medical equipment, materia medica, medical knowledge and practice, as well as specific medico-Buddhist rituals intended to support the medical efficacy of practitioners and medicines.
To become a lay amchi in Tsang in the 1940s and 1950s implied significant interactions with the immediate physical, symbolic, and social aspects of Medical Houses. These were made and reproduced, establishing members as medical practitioners of a certain ilk: a particular, usually high rik (or kind), and their medical work’s authority and efficacy. My analysis of Medical Houses as moral persons is inspired by several anthropologists working in the region (especially Fjeld 2006) and beyond,17 and it follows Hsu’s suggestion that the house, like the body, is a prime agent of socialization (1998: 2).
Buildings with Authority
In summer 2003, during my first visit to the Mentrong in Lhünding, as I was seated with Rinchen Wangyal in the open courtyard on the first floor, I asked him, “What do you remember of the old Mentrong?” “I remember our old house very well!” he replied with a broad smile, his arms around his granddaughter, who was snuggled in his lap. “In our old house there was the menkhang, a small room solely devoted to medicine and the medical scriptures, though we ourselves did not practice medicine anymore. That had stopped two generations before. Nobody taught or practiced medicine in my parents’ generation when I was young, but all the different books of medicine were there. Some of them were also kept in the chökhang.” When I returned to the Mentrong with Yonten Tsering in summer 2007, Rinchen-la’s sister, also called Drölma and on a visit from her nearby home at the Nyingkhang, gave a similar account: “Every now and then, Rinchen Wangyal and I sneaked into the menkhang when we were small. All the different kinds of medicinal plants and ingredients were there—I loved the smell. There were beautiful medicine spoons as well. We played with them until we were told to stop. Medical bags with ready medicines were also kept, but at the time no one knew medicine any longer. Nobody used these things, but we kept them as blessings.” The siblings were remembering their childhood in the early 1940s, well before Rinchen Wangyal was sent to learn how to make use of the medicines he had played with. Their upbringing in the largest house of the village, Rinchenla’s education, and Drölma’s eventual marriage to a member of the Nyingkhang, an old and famous ngakpa household, all indicate the Mentrong’s privileged position compared to other households in Lhünding.
As mentioned earlier, the Mentrong comprised both the medical and the royal bone lineage of Jangpa Namgyel Drazang, the lay Buddhist scholar and teacher of the late thirteenth and early fourteenth centuries. These long-standing affiliations meant that the Mentrong enjoyed numerous socioeconomic privileges, including large landholdings, as well as certain ritual obligations.
The Mentrong building was located on the east side of the village, and its structure reflected this high sociosymbolic standing. It exemplified the symbolic ideal of Tibetan homes in Tsang, with the three floors of the house as a microcosm reflecting the tripartite macrocosm inhabited by humans and other beings: the lhayul (land of gods), miyul (land of people), and nyelwa (underworld) (Fjeld 2006: 265–99).18 Most Tsang houses today have only two floors, and many commoner or servants’ houses, like unnamed houses prior to the 1950s, have just one story.
The architecture and medico-ritual activities of Medical Houses corresponded to their socioeconomic position in the villages, together constituting the practical medical authority of each Medical House. The Mentrong’s exceptional role in ritual activities during the yearly cham dances in the 1940s and 1950s held at the house contributed to the house’s high moral and symbolic standing in Lhünding. On the other hand, owing to its structural survival to this day, the architecture of Térap in Gye is visible in more detail. Its socioeconomic standing was that of a trelpa, or taxpayer household, but because of its membership in a particular social subcategory, it was largely relieved from paying tax.
When Rinchen-la described the Mentrong as he had experienced it and remembered it again in the summer of 2007, a proud smile appeared as he described in his very polite way the size of the house: “Actually there was no need for it to be that spacious, but the house was really quite large. Yes, perhaps, it was even very large! [He laughs.]” He went on to detail its structure: Animals occupied part of the first floor. The second floor housed the all-important kitchen, bedrooms for members of the household and children, several storerooms, and the menkhang. Many rooms on the second floor were unused most of the time, reserved for guests when the need arose. The chökhang was located on the third, top floor, along with adjacent rooms used by visiting Buddhist monks.
Unusually for secular architecture in Tsang villages, the Mentrong featured a open central courtyard on the ground floor around which the whole house was constructed. It thus more closely resembled the houses of aristocratic families or Buddhist lamas in Shigatse or Lhasa, for instance the Lingtsang or Shatra mansions in Lhasa (Alexander, forthcoming; Larsen and Sinding-Larsen 2001: 119–21), which included up to three floors constructed around a central courtyard. It is not entirely clear why this was the case at the Mentrong but could be explained by the longstanding annual festival held there.
While it was common for monasteries throughout the region to hold cham dances at the end of each Tibetan calendar year, in Lhünding, rather than this taking place at the monastery, it was held at the Mentrong. Rinchen Wangyal explained:
Once every year, on the 28th of the eleventh month, we would go up to the monastery, and my father would invite the protector Yeshe Gonpo [Ye shes mgon po]. He would come down with us to our house. Beforehand from the Mentrong tsampa, we had prepared a special torma. It had to be made from our tsampa—not any tsampa would do. Not even the tsampa from the monastery! Then when the protector had arrived here, on the next day the monks came down and performed the cham on the 29th, for the whole day. The protector, for only once a year, would have the cloth covers over his eyes removed and looked over the dances. We would offer all the food and drink to the monks and make donations. The villagers all came to watch, and by the evening everyone had left again. On the 30th of the month we would invite and carry the protector back up to the monastery. The torma, however, was kept in our chökhang inside a special chest for the rest of the year. All this gave great blessings to our house and to everyone present.
As this account indicates, the Mentrong played a crucial role in ensuring the proper ritual to close the old year and ensure the support of the village protector, guaranteeing prosperity and fortune for the whole village for the coming year. Quite apart from the medical provisions this house could offer to villagers, it also played a prominent part in an important Buddhist ritual for the benefit of the whole community.
This unique relationship between the Mentrong and Lhünding Monastery as well as between the Mentrong and the village, together with their royal background (rgyal thog) and large landholdings, classified the Mentrong as a member of the two main “high ranks” (rik thopo) in Tibet’s traditional lay socioeconomic hierarchy. These comprised various kinds of lay nobility or kutra, the lowest of which was the gerpa category, and the trelpa, or taxpayers.19 The Mentrong was a gerpa household, which meant they had large landholdings for which they were, however, not required to pay taxes in the 1940s and 1950s. Hierarchically, they were lower than other Tibetan aristocracy, whose members served in the government and as administrators and tax collectors on behalf of the Tibetan government. Gerpa were, however, usually seen as higher than trelpa households, who effectively leased land from monasteries, aristocrats, or directly from the government, and in exchange paid them taxes (trel). Most of the Mentrong’s ancestral lands were found in and around Lhünding, while the land that had been inherited from the royal family of Ruthog in Ngari at the turn of the twentieth century was spread out in other places. In total the Mentrong had attached to their estate about seven landless farming households whom Rinchen Wangyal referred to as yokpo and who worked their land in the vicinity of the Mentrong in exchange for part of the yield and some payment; fields farther away were rented out and administered remotely. The landless farmers dependent on the Mentrong would later be termed serfs in Marxist parlance and “liberated” at the beginning of the Democratic Reforms in 1959–60 (cf. Shakya 1999: 247–48).
Social Status and Material Wealth
In contrast to the Lhünding Mentrong, the Térap in Gye was a trelpa household. This house was thus not technically a landholding estate in the traditional Tibetan organization but was required to pay taxes to the primary owners of the land, in this case the Khangsar Shekar, from which they had long-term leases.20 Being a comparatively small landholder, the Térap had three workers who plowed and tended to the fields in exchange for a share of the yield. The Térap differed from other trelpa households in Gye and the surrounding area, however, regarding tax payments. In local terms, they were considered a chödzé household,21 which was on a par and usually mentioned together with those of the rank of shabdrung and jedrung.22 Shabdrung referred to families of lay tantric lineages (ngakpa), chödzé to medical families, and jedrung to members of aristocratic families. These three kinds of professionally and socially ranked households all enjoyed individually agreed tax privileges, as they served the government in one way or another.23 In general their tax obligations were lower than those of regular trelpa households, and the shabdrung household of Nyingkhang was entirely exempted. In exchange for such privileges, the families of shabdrung, chödzé, and jedrung status—a seemingly Tsang-specific terminology—were expected to fulfill ritual duties and to serve the community through the activities of lay tantric households, for instance by carrying out protection rituals and averting hailstorms, providing medical treatment, or working as administrators for the government. This economic status and the associated tax privileges provided a financially stable existence for Medical Houses. Although no government health care was available in Ngamring, these tax levies allowed lay medical practitioners to work as doctors, which by all accounts required significant financial outlays for education and the purchase of materia medica, as well as long hours spent in medicine production and consultations.
Though the Mentrong building was destroyed by the Red Guards during the Cultural Revolution, the Térap remains in Gye, its physical (in this case two-floor) structure intact and its medical tradition kept alive by Yonten Tsering. A key architectural feature of the Térap and the Mentrong was their menkhang, or medicine room, which set it apart from other named houses in the area. Yonten Tsering and his father spent many hours together in the menkhang, engrossed in medical studies, the preparation of medicines, Buddhist rituals, and visits with patients. The menkhang was positioned on the second floor, in the quietest part of the house, its northeastern side (figure 1.5). It featured the aforementioned mural depicting various aspects of medical work and a Chinese Buddhist deity of longevity surrounded by auspicious symbols in a landscape.
In terms of ritual purity, the menkhang was similar to the family’s chökhang, which was located in the eastern part of the house. This is where most of the medical and religious texts as well as the lha (Buddhist deities) and thankas were kept. The Four Treatises states (in the chapter on the ethics of the physician) that “medicines should be regarded as precious jewels, nectar and sacrificial offerings [mchod rdzas]” (Men-Tsee-Khang 2008: 289). Medicines, instruments, and medical texts, as Buddhist works and ritual implements, had a status similar to that of Buddhist deities and were not to come in contact with impure practices (for instance, stepping over them). Similarly, they were to be kept out of impure locations (such as the ground floor) or highly “polluted” places or events and out of contact with certain groups of people, especially those of “impure rik” such as butchers and blacksmiths.24
The menkhang, rather than the chökhang, served as a place for Yonten Tsering’s father to perform certain medico-Buddhist practices. One such practice was the Yuthog Nyingthig, or Yuthog Heart Essence, a Buddhist practice of great importance to Sowa Rigpa practitioners since the twelfth century CE (Garrett 2009). For the torma preparation in the context of this cycle of teachings, his father, Tsering Norbu, had drawn a fine visual guide (figure 1.6). Once the torma were made, they were placed in a special wooden chest for torma and kept in the menkhang. A thanka of Yuthogpa also hung there. In front of these Yonten Tsering’s father practiced the Yuthog Nyingthig following a printed copy of the work from Lhasa’s Chakpori Printing House, thereby empowering both practitioner and medicines.
Another important aspect of the material wealth of Medical Houses were their medical libraries. Text collections in the Medical Houses from before the 1950s survived the reforms almost intact in the Térap and Nyékhang, while all were lost from the Mentrong.
The surviving collections that I encountered during my fieldwork always included a peja of the Four Treatises and at least one work on medical compounding. In the collection of the Térap House were two editions of the Four Treatises, two commentaries on them, one large independent medical work with an extensive collection of recipes, two fragments of manuscripts, and one manuscript of a commentary on the Third Treatise’s chapter on pediatrics.25 The collection of the female amchi Sonam Drölma had the most remarkable number and variety of medical and medico-religious materials. These ranged from illustrations to manuscripts and printed texts, and within the writings, from commentaries and original practical treatises (the so-called nyamyik, or “writings from experience”) to recipe collections, medical notes, letters, and medical mantras.26 Some of the titles clearly indicate a strong connection to the Gongmen medical tradition and to Tsarong Palden Gyaltsen’s medical lineage, in which they were probably passed on. For instance, there is an undated manuscript of the influential medical work A Hundred Verses Written from Experience (Nyams yig brgya rtsa), by the teacher of Tsarong Palden Gyaltsen, Gongmen Konchog Pandar (1511–1577).27 Tsarong Panden Gyaltsen himself was known for his expertise in treating drumbu and drumné (smallpox), on which he also wrote several works (Garrett 2014), some of them found among the surviving manuscripts and texts.
Two medical texts were saved from the collection of the Ruthog Amchi Tsewang, whose family practice is introduced in chapter 5. One of those was a unique menjordeb (see figure 5.2), a handwritten work on medical compounding that featured accumulated recipes and annotations in the hand of earlier members of this family medical tradition. These annotations suggest, for instance, how to substitute (tsab) medicinal ingredients of equivalent potency and effect for those that were not found locally.28
Since in the 1940s and 1950s medical texts were not commonly for sale or even printed in large numbers, these private medical text collections were simply the first port of call in the study and practical application of Sowa Rigpa. Because Sowa Rigpa was part of Buddhist learning, these texts gave equal blessings and prestige to Medical Houses compared with Buddhist scriptures, which were kept in the menkhang or the chökhang. Within Medical Houses, medical libraries were transmitted across generations. In some cases, even if the houses did not survive, these medical libraries were reinstated in the rebuilt homes of amchi.
Through ritual activities, socioeconomic position, and the physical houses, Medical Houses established and maintained their authority in a sociocultural nexus that resonates with Lévi-Strauss’s conception of houses as “moral persons.” Far from being inanimate physical structures, Medical Houses were made and maintained from within, through their symbolic order and associated rituals. These placed their members at the higher end of the traditional socioeconomic hierarchy in rural Tsang. Their inherited and actively maintained class status furthermore endowed them with responsibilities over specific village rituals or medico-spiritual practices, as well as medical work, which lies at the crossroad between material and immaterial wealth.29
THE MEDICAL WORK OF AMCHI
It was common practice at the Mentrong, Térap, and Nyékhang, my informants insisted, that amchis treated all patients, rich or poor. This had been a contentious issue, as during the Communist reforms many doctors were accused of having exploited their patients. Yonten Tsering and Mentrong Rinchen-la said there were no set prices for consultations and treatment; those who could afford it made donations, and these usually made up for those unable to offer anything. “Those who were seriously sick and recovered usually gave most!” Rinchen-la commented with a smile when we spoke about this topic. Sonam Drölma said that her grandfather had never asked for medical fees, but patients gave a donation, however much they could afford. One difference from the medical practitioners in the monasteries discussed in the next chapter is that lay amchi generally treated anybody in the laity, as well as monks and nuns at monasteries without a doctor, which was apparently often the case. By contrast, monks and nuns treated mainly other clergy.
At Térap, patients were seen on the first floor, either in the kitchen or the open courtyard, the social center in Tsang houses. Occasionally concessions were made and special patients were treated in the menkhang, which was otherwise used as a study and pharmacy.
Although the Four Treatises promises that the treatment of patients leads to Buddhahood (Clark 1995: 233), and compassion and generosity benefit amchis’ own Buddhist practice, allowing outsiders to enter the Medical House could threaten the household’s ritual purity. Resulting impurities had to be countered by appropriate purifications and rituals to avoid drib, or pollution. Drib was regarded as reducing the auspiciousness and efficacy of medicines but also caused illnesses and misfortune more broadly. Whether amchi also went to other people’s homes, and on what terms, differed from place to place and person to person, some saying they went to others’ homes only when specifically called, while others went to other villages voluntarily. Presumably social class was an issue here. Be that as it may, informants related that due to the scattered population, it was often necessary to diagnose at a distance, either through urine, which a family member of the sick person brought to the amchi, or by “stone diagnosis.” It is possible, however, that the grounds for such remote diagnoses related to the social background of patients.
Yonten Tsering was at first hesitant to explain stone diagnosis. He was worried about his credibility as a doctor today, as this was, in his words, “religion [chö] rather than medicine [men],” deflecting the thorny issue religion had become for amchi since the start of Communist reforms (cf. Adams 2001) by adding that “anyhow it cannot be compared to actually reading a patient’s pulse.” While discussing, with a monk at a remote Nyingma monastery, treatments that today fall outside strictly medical definitions—for example, the exorcism of a spirit through ritual, which was still recommended and practiced by monk and nun practitioners—Yonten Tsering became more willing to explain the technique of stone diagnosis:
A sick person first needed to make a prayer and then walk seven steps toward the east, close his or her eyes, and then pick up a stone from the ground. It might be any color, size or shape. Then this needed to be wrapped in a piece of cloth and brought to the amchi, since they might live far away. According to the shape, size, and color of the stone, the amchi would make a diagnosis and prescribe a treatment. One would still ask after problems of the sick person. This technique is close to a divination [mo]; it belongs to the realm of chö.
He considered this to have provided accurate diagnosis in many cases but nevertheless judged it to be no longer relevant. Medicine (men) and religion (chö) had to be separated, since the socialist transformation, he averred, attempted to separate the centuries-long tradition of “combined religious and medical traditions.”30
The core diagnostic technique used in Medical Houses was the classic ta rek dri approach of visual observation, palpation of the pulse, and questioning. Details are now hard to recover as practitioners have since passed away. However, judging from the subsequent generations’ accounts as well as some of the medical works they studied, it was likely personal virtuosity that made practitioners rely more or less on certain aspects, as all diagnoses have vast internal differences and repertoires. Among the works Yonten Tsering’s father had passed on to him, we find techniques not present in the classic Four Treatises work, such as ear vein diagnosis. This was used mainly in young children, where the pulse is difficult to determine at the wrist. This diagnosis is discussed in one of Yonten Tsering’s manuscripts, a handwritten commentary on the gynecology and pediatrics chapters of the Four Treatises, influenced by Khyenrap Norbu’s work on childcare and pediatrics.31
Apart from preparing medicines according to techniques and knowledge derived from classic and family-created works or specifically for patients, Yonten Tsering’s father applied external therapies, such as moxibustion, cauterization, golden needle therapy, and bloodletting. He had learned these mainly through hands-on practice with his father, rather than from Lamenpa Kachen Norbu, a doctor and teacher at Tashilhunpo and the personal physician to the Ninth Panchen Lama. He passed these skills on to his son, when he had returned from his education at Tashilhunpo.
Making Medicines: A Culture of Recipes
Almost all medicine prescribed in Medical Houses was compounded on site using both local and foreign ingredients. Collection of local raw materials either by the amchi or by their landless laborers took a lot of time as it involved journeys of several days to several weeks to places where the desired plants grew and minerals were found. A few were easily accessible in the immediate surroundings of the amchis’ residences or by exchange with people one knew. The same was true of animal ingredients, which were commonly used. These derived from domestic animals and hunted wildlife, including the musk deer (ladzi) for its gland and the Tibetan deer for its horn (sharu).
Foreign ingredients from warm climates in the south were essential to treat cold diseases. These account for many of the ingredients in many Tibetan medicines, and they were expensive as they came via trade or pilgrimage, mainly from India and Nepal. They included, for instance, the three dried fruits arura, barura, and kyurura, sandalwood (tsendan), the so-called six supreme medicines (sangbo druk or sang druk) of nutmeg, cloves, cardamom, saffron, cubeb, and bamboo pith, and animal parts such as rhinoceros horn (seru). The relative ease and cost of access to local versus foreign ingredients at the time appears to be the reverse of today’s situation, which is related to the great expansion of the Tibetan medicine industry. As one amchi explained, “In the old society the sang druk were really valuable and precious medicines, because they came from far away, from India and so on. Those included aru, baru, kyuru, dzati, sukmel, ka ko la, etc. Today it is the other way around! The plants from inside Tibet have become the sang druk.”
The principal place where medicines were prepared, ground, and mixed in Medical Houses was the menkhang. Raw and ready-made medicines were dried elsewhere, including on the roof and in covered parts of courtyards. Yonten Tsering still possessed and treasured several instruments in use at the time. He also kept an old three-layer wooden box to store raw materia medica and two large grinding stones in Gye. These bore the traces of several generations of doctors, a thick portion of the hard stone ground away through their efforts. Here medicines had been made according to classic formulas and the family’s own pharmacological traditions, as recorded in some of their manuscripts and practically learned as a craft. The whole medicine-making process was replete with adjustments factoring in the availability of raw materials and possibly their substitution (tsab); perceived efficacy and quality of the raw materials as defined by their taste (ro); and importantly, the individual patient’s condition.
Other medical items and instruments kept in the house were medical spoons, ideally made of silver, decorated with precious stones, and used for measuring the doses of powdered medicine, and a large medical bag made of snow leopard skin, filled with smaller leather bags. This bag was used primarily when visiting patients in their own homes, where ready-made medicines were relied upon and the amchi was unable to compound or adjust them en route.32
Named Medical Houses in rural Tsang were central social units and physical places for medical education and professional practice. State-sponsored health work (either Tibetan medical or biomedical) was mostly absent until well into the late 1960s and early 1970s. The fact that during the 1940s and 1950s private Medical Houses enjoyed tax benefits can be read as a form of Tibetan state support for their services. Medical Houses enjoyed economic wealth due to their trelpa and gerpa status, and this sustained the medical practice, as patients did not always pay for treatment. Although lay practitioners made up a relatively large percentage of Tibetan medical practitioners during the 1940 and 1950s, there has so far been little research on their work and history, which this chapter has gone some way to remedy. It describes and analyzes the transmission of knowledge, as well as the socioeconomic position and work of amchi in Ngamring and surrounding areas through the anthropological house concept. A combination of particular social relations, rank, professional knowledge, and ideas about moral purity worked to secure and maintain the authority and successful continuation of Medical Houses among lay practitioners over time. The Democratic Reforms and subsequent Communist reforms in Tsang from 1959–60 onward diminished, and in some cases permanently eroded, the hitherto long-standing medical and social authority of Medical Houses and their members.
Established Medical Houses were not the only places to learn, transmit, and practice Sowa Rigpa. New Medical Houses were formed, and medicine was practiced in other professional houses, for instance those of lay tantric priests. Importantly, medical teachings and practice were also present in monastic settings and among itinerant Buddhist teachers cum doctors.