Diseases in Antiquity

Apart from evidence derived from archeological research, the earliest available sources of information on disease in Southeast Asia are references in inscriptions and accounts appearing in traditional texts. Khmer inscriptions of the seventh and eighth centuries A.D., for example, make reference to lice, eye impairments, and "dermatitis" or "ringworm" (Jenner 1981). It is difficult to date some of these sources, especially texts, but it is clear that by the time of their appearance there had already been considerable contact between Southeast Asia and civilizations in other parts of Asia. Much of the language used, and the means of recording itself, were exotic in origin. Originally these descriptions were made using techniques probably borrowed from India or China. Inscriptions were made on stone, or on palm leaves trimmed and bound together with cord, or else written on paper. The scripts employed were similarly of Indie or Chinese origin (Guy 1982; Marr

Traditional Medical Texts

In addition to short references to disease in chronicles, or other official records, certain works were devoted solely to medicine. These appear to have been a feature of almost every major civilization in the region, including those of the Burmese, Thai, Lao, Khmer, Vietnamese, Malay, Javanese, and Bali-nese (La Loubere 1691; Sangermano 1833; Macey 1910; Pigeaud 1967; Pham Dinh Ho 1973; Martin 1983; Social Research Institute 1986; Lovric 1987; Reid 1988). Commonly, the contents of these books consisted of passages relating to theories of illness, lists, and descriptions of diseases, and details of the methods used in their treatment.

It is likely, however, that such texts provide incomplete accounts. One reason for this is their perishability. Being sensitive to decay and insect attack, traditional texts had to be continually recopied in order to preserve their contents. Not only did this introduce the possibility of human error through mistakes in transcription, but, more importantly, there was always the threat that disruptions caused by warfare or other adversity would result in the loss of large numbers of texts. For example, in 1767 the Siamese capital of Ayuthaya was sacked by the Burmese, an event which, in itself, resulted in the destruction of much of the court's medical library (Koenig 1894). Moreover, the loss was compounded by the slowness of the subsequent recompilation process, which was not completed until some 40 years later, around 1816.

Another difficulty in the use of traditional texts as source materials is in determining the extent to which their contents reflected diseases actually occurring in Southeast Asia, and their prevalence. It is quite possible that accounts of diseases contained in texts may be largely based on Indie, Chinese, or, later, Arabic medical treatises. This is certainly the case with other types of texts, such as literary or astrological works (Quaritch Wales 1983; Reid

1988). On the other hand, evidence suggests that, although Southeast Asian medical texts may incorporate disease terms and concepts derived from tradi tions outside the region, they are not simply translations of texts belonging to those medical systems. It appears that in the area of disease, as with other aspects of Southeast Asian culture, a process of localization took place, resulting in the selective emphasis of certain concepts of parts of theories, and changes in the meanings of words borrowed from languages outside the region. Some examples of these processes will be considered later in this essay.

Travelers' Accounts

A further important source of information on disease in Southeast Asia consists of the accounts written by early travelers to the region. These included the Chinese Buddhist monk Yi Jing, who passed through the region on his way to India toward the end of the seventh century A.D. (I Tsing 1896), Chou Ta-kuan (1951), who accompanied a Chinese ambassador to Cambodia in the thirteenth century, and the later European travelers such as S. de La Loubère (1691), and E. Kaempfer (1906). Kaempfer's account is of particular interest, because he represented a class of scholarly voyagers whose interests often extended to a number of disciplines. As a physician and botanist, he took care to record accurately what he saw and heard, including indigenous terms and descriptions. When compared with accounts obtained from indigenous texts, such information is extremely useful.

Ethnomedical Studies

Modern-day studies of indigenous perceptions of disease in the Southeast Asian region constitute another important kind of available information. As well as information on disease appearing in the context of more general anthropological or linguistic studies, a number of specific examinations of indigenous medical systems in Southeast Asia have been conducted. These include those of insular peoples, as well as those of mainland Southeast Asia (see, e.g., Frake 1961; Martin 1983; Boutin and Boutin 1987; Brun and Schumacher 1987; Gumpodo, Miller, and Moguil 1988; Bamber 1989). Although there have been far-reaching changes in Southeast Asian life, it is probable that, until quite recently, for a large number of people in the region, life was lived in much the same manner as it had been centuries ago (Hall 1981). It is thus likely that, for certain sections of the Southeast Asian population, present-day perceptions and treatment of disease bear a strong resemblance to those of the past. An analysis of such contemporary "folk" medical beliefs and disease classifications, made in conjunction with information derived from the other sources discussed above, may thus make an important contribution toward our understanding of disease in Southeast Asia in ancient times.

Indigenous Views of Disease It is clear from the information contained in the various sources described above that in the past, Southeast Asian peoples recognized a large number of diseases, and classified them in ways that were, in many cases, quite complex. One feature, which is immediately striking to an observer familiar with Western concepts, is that conditions that are understood to be diseases in modern medicine were not necessarily viewed as such by Southeast Asians. This is especially evident in the area of diseases affecting the gastrointestinal tract which, along with "fevers," occupy perhaps the most prominent place in accounts of illness in the region (see Dam-pier 1927; Chou Ta-kuan 1951; Schäfer 1967; Cook 1968).

A number of severe gastrointestinal diseases were well differentiated by Southeast Asians and elicited treatment responses. Symptoms and treatments for conditions such as cholera, dysentery, severe diarrhea, and certain types of parasitic infestations were, for example, described in traditional texts (Mulholland 1979; Lovric 1987; Terwiel 1987). However, certain other conditions that biomedicine would recognize as diarrhea were apparently not always considered to be diseases. Recent studies indicate, for example, that in certain areas of Southeast Asia infant diarrhea is not necessarily viewed as pathological. Thus, among some Northeast Thais one type of diarrhea (sw) may be regarded as a normal phenomenon, common to all infants (Earmporn, Pramote, and Stoeckel 1987). This would also appear to be the case for people in parts of northern Thailand and Laos. Similar findings have been reported for the Acehnese and other Indonesian peoples (Rahaijo and Corner 1989).

It is likely that such poorly defined boundaries between pathological conditions and "normal" bodily states are also to be found for other types of disease. Included in these are a number of Southeast Asian disease categories that are unrepresented in modern medicine. Examples of these that are better known because of their dramatic expression are the conditions of amok and latah, Malay behavioral syndromes that appear to have counterparts in other parts of Southeast Asia (Westermeyer 1973; Simons 1985).

Other conditions, lacking such overt behavioral symptoms, reflect classifications of illness that are equally different from those of modern medicine. One such disease is the Thai category saang (children's disease), which includes a range of symptoms mainly affecting the mouth and skin of young children (Mulholland 1987). The onset of this disease has strong links with Thai beliefs regarding "soul loss" (Hanks and Hanks 1955; Hanks 1963).

Shared Disease Terms

It is apparent from a comparison of disease terms in a number of Southeast Asian languages that certain categories were widely shared throughout the region. One explanation for this situation is the contact that resulted from the movement of large populations within the region, such as occurred with the establishment of the Tai peoples in the Chaophraya River valley and the Malay Peninsula from the mid-eleventh century A.D. (Wyatt 1984). Contact with peoples already established in the region, such as the Malay, Mon, and Khmer, was reflected in the adoption of disease terms from these languages. Thus, for example, the Malay disease sawan (convulsions), which affects small children (Wilson 1985), also appears, as saphan or taphan, in traditional Thai medical texts (Mulholland 1987).

A similar though more complex process seems to have taken place with respect to terms for certain types of skin diseases. This may be seen in the case of the ancient Mon-Khmer term mren, which probably referred to skin afflictions in general. This term appears to have undergone a change in meaning at some stage, possibly prior to contact with the Thai, to signify ulcer in Khmer, and superficial skin conditions in Mon (Shorto 1971).

Following contact with the Mon and Khmer, the term mren was adopted by the Thai, cognates appearing in traditional medical texts as mareng and baheng. In this case, however, because in Thai skin diseases appear to have been well differentiated prior to contact with the Mon and Khmer, there is evidence of an accommodation with existing terms (Li 1977). Thus in central Thai, which was in close contact with Khmer, mareng came to mean "deep-seated ulcer" (McFarland 1944). However, in northern Thai baheng refers to superficial skin diseases, indicating that the term was adopted from the neighboring Mon peoples (Brun and Schumacher 1987).

These examples also point to the existence of more complex processes within the Southeast Asian region which contributed to the sharing and interchange of terms and concepts related to disease. Medicine was an area of culture that was particularly amenable, for a number of reasons, to trade and exchange (Golomb 1985). These processes would have involved not only concepts and terms indigenous to the region but also those originating from outside Southeast Asia - in Chinese, Indie, or Islamic medicine. Perhaps the most well-known example of the integration and adaptation of foreign concepts of disease into the Southeast Asian framework is that of the so-called wind illness.

"Wind Illness,"Humoral Theories, and Therapeutic Practices

A type of illness common to most of the peoples of Southeast Asia has been termed wind illness (Hart 1969). The disease has been reported among Indonesian and Malay peoples, where it is referred to as masuk angin, literally "wind enters" (Gimlette 1939), among Filipinos (Hart 1969), Burmese (Sangermano 1833), Khmer (Headley 1977), Vietnamese (Eisenbruch 1983), and a number of Thai groups. The conditions represented by wind illness vary widely through the region, ranging from symptoms of the common cold among Indonesians and Malays, to fainting, dizziness, and, more rarely, leprosy, among mainland Southeast Asian peoples.

Most explanations for the phenomenon have been made in terms of theories derived from the major medical systems with which Southeast Asian peoples have come into contact. In Chinese medicine, for example, wind illness figures as part of a theory that sees disease arising through the entry of wind into the body (Unschuld 1982). Wind illness is similarly important in the humoral theories of Indie and Islamic medicine. Here, however, it refers to diseases of the wind element, one of the four elements (the others being earth, fire, and water) of which the body is said to be composed (Hart 1969; Ullmann 1978). According to the Indie version of this theory, the wind element denotes the quality of bodily movement, or sensation. Any disease that involves an impairment or abnormality in these faculties would thus be designated as a wind illness. Following from this rationale, wind illness includes a number of diseases or conditions, such as paralysis, epilepsy, and leprosy, which are considered in modern medicine to constitute quite separate disease entities (Caraka 1949).

Versions of both these theories are to be found in the Southeast Asian region. The Indie theory of the four elements is expounded, for example, in Thai medical texts (Mulholland 1979); Islamic humoral theory is widely known in peninsular Malaysia and Indonesia (Manderson 1986); and beliefs regarding the ill effects of the entry of wind into the body accompanied Chinese who settled in the region (Kwa Tjoan Sioe 1936). However, the wind illness of Southeast Asia does not always fit neatly with these theories. Early writers on Thai medicine commented, for example, on the prevalence of wind illness in comparison to diseases affecting the other three elements (Pallegoix 1854; Bradley 1967). Thai wind illnesses also appear to have encompassed a far wider range of diseases than one would expect on the basis of Indie theory (Muecke 1979).

Discounting the unlikely possibility that Thais, or other Southeast Asian peoples, are predisposed to diseases affecting bodily sensation or movement, it would seem that the Indie concept of wind illness has been reinterpreted to accord with indigenous concepts relating to the cause of illness. These concepts probably have more to do with beliefs linking disease to soul loss, or the spirit world, than they do with humoral theories (Laderman 1987). The resulting concept of wind illness represents a complex, incorporating elements derived from both within the Southeast Asian region and outside of it.

Similar interactions may be seen throughout the region in relation to other aspects of disease. For example, the etiological concept of hot and cold physical states is also widespread in Southeast Asia. Accordingly, certain diseases, foods, and treatment practices are regarded as heating or cooling (Hart 1969; Manderson 1981). As with wind illness, this concept appears to be the result of an integration of indigenous beliefs with Indie, Islamic, or Chinese theories (Manderson 1981; Marr 1987).

Therapeutic practices were also shared throughout the region. One well-known example is in the ritual ridding of a person, or community, of disease. Among the central Thai this was termed sia kabaan, and consisted of the symbolic transference of the disease to inanimate objects, such as dolls or animal images, which were subsequently floated away on streams, or otherwise removed from the locale of the patient (Anuman 1958). Similar rituals have been described for most other Thai groups (Terwiel 1980-1), and in several other regions of Southeast Asia, with variations according to the local culture (Snouck Hurgronje 1893; Skeat 1900; Reid 1988). Often these local variants included elements derived from Indie or Islamic tradition.

The picture that emerges from this brief look at some of the features of Southeast Asian views of disease prior to increased contact with the West is one of a dynamic state. Close contact among peoples within the region ensured that conceptions of disease and its treatment were frequently shared. The development of links with the major civilizations outside of the region meant that different perceptions of disease and therapeutic techniques continued to be introduced to Southeast Asia, and incorporated into indigenous systems (Owen 1987). The result was a matrix of classifications and strategies that could be brought to bear on the experience of illness.

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