Cambodian Society
in the United Kingdom

Introduction
The Indian epic, Ramayana, said to have been written somewhere between 200 BC and 200 AD in 25,000 verses by Sage Valmiki (Buck 1976, p. xv), has exerted a more profound influence on various aspects of Cambodian culture than perhaps any other source from outside Cambodia. Along with its twin epic, the Mahabharata, and many spiritual and ritualistic features of Hinduism, the Ramayana came to Cambodia during the pre-Angkor or Angkor periods.

The Ramayana dominated Cambodian culture so overwhelmingly that it inspired a Cambodian version of the epic. The story of the Ramayana, and of what is considered its sequel, were written anonymously in the Khmer language between the 16th and 19th centuries (Pou 1979, p.xii), and called the Reamker (or Ramakerti). The two Indian epics represent the most important source of dramatic materials in South-East Asia including Cambodia. Most court dramas derived from these two epics and popular and folks play derived from them as well ( Brandon 1967, Leclère 1911, Thiounn 1956, Pech 1995).

Though the Reamker is taken directly from the Indian Ramayana, various aspects of the story were modified to suit Cambodian culture. The Reamker retained some elements of the Hindu belief system upon which the Ramayana was based, but was adapted to incorporate Buddhism. While in the Ramayana, Ram is believed to be an incarnation of Vishnu, a Hindu god, in the Reamker, Ram is seen as Bodhisatva, or an incarnation of Buddha. (Pou 1979, p. 22) One of the most significant effects of the arrival of the Ramayana in Cambodia was the transmission of the wealth of information it carried, including the wisdom of traditional systems of healing.

The main system of medecine in India, Ayurveda, as well as most of the knowledge content in the Ramayana, were based on the sacred scriptures, the Vedas (composed approximately between the 15th and 5th century BC). Ayurveda was practiced in Cambodia by the elite in the royal court,until it was extended to all strata of the population in the 12th century AD (Chhem 2000, p.25), and became an integral part of Cambodian medical practice.

Medical Education
Although the methods used to hand down knowledge from one generation to the next have changed a great deal from the time of the Reamker to the present, education was considered as essential then as it is now. Particularly before writing became widespread, considerable importance was placed upon the memorization of all necessary teachings, so that the information in these teachings would survive the test of time.

The Reamker seems to have been written in the transition period between the oral tradition and the use of written manuscripts. It often mentions books or “treatises” from which characters read out instructions for a particular task (Pou 1979, p. 166-167).

It is clear from the narration of the Reamker, however, that regardless of the modes of preserving knowledge, the methods of healing were central to teaching and learning, and were ingrained in every individual who underwent the process of education. The art of healing, along with other areas of learning, was taught in hermitages. The hermits were believed to have “increased their great state of blessedness and their power...through the practices and prescribed regime of ascetics” (Pou 1979, p. 26).

The regime required the hermits to practice the discipline of intense meditation and fasting, while the task of teaching required of them a considerable scholarship and intimate knowledge of the sacred scriptures. The knowledge that the ancient Indian sages imparted to their students was held in such high esteem that the process of education was considered as a “birth…superior to physical birth from the mother’s womb.” (Sharma 1971, p. 119)

There is not sufficient evidence in the literature to assume that the hermits of the Reamker held such high ranking in the Cambodian society. However, according to the translator’s comments on the Reamker, “supernatural power which hermits acquire, through the wisdom gained by contemplation and ascetic practices, must command our great respect.” (Pou 1979, p. x).

The Indian Ramayana “speaks of a network of asramas (hermitages) which were spread all over the country, most of them situated in the forest along the banks of rivers.” (Sharma 1971, p. 119)

The system of education “ensured compulsory education for everyone and at the same time harnessed the energies of the entire nation for the preservation of the veda, the national treasure of learning.” (Sharma 1971, p. 119).

It may be assumed that the Cambodian hermitages operated in a similar fashion, and held the same significance for the country and its culture for two reasons. Firstly, the education described in the Reamker was based on the system in ancient India. Secondly, and more reliably, there is evidence throughout the Reamker of a strongly positive attitude towards learning; the highest praise accorded to someone was to be “learned in the scriptures.” (Pou 1979,p. 23).

The Vedas and Medecine
As mentioned earlier, Indian traditions heavily influenced the beliefs and practices, both religious and academic, in Cambodia. The Hindu religion, as well as the accepted knowledge/doctrines in ancient India, had as its foundation the four sacred scriptures, the Vedas. The use of the Vedas travelled with the story of the Ramayana to Cambodia, and was deemed as essential to education in Cambodia as it was inIndia.

In the Reamker, the sage Vajjaprit takes on the task of educating the sons of Ram, saying: “They do not yet know the treatise on the Supernatural Arts…It shall be my task to instruct and train the princes in the whole of the three Vedas…divine incantations, the Pali sayings…the art of the bow and of the sharp arrow…” (Pou 1979, p.216). The three Vedas that are referred to here form the “trayi-vidya (“threefold knowledge”)”1 , Rg Veda (Veda of Verses), Sama Veda (Veda of Chants), and Yajur Veda (Veda of Sacrificial Formulas). The fourth scripture, Atharva Veda, is the most relevant to the study of medecine.

It functions as a pharmacopoeia for Ayurveda, the principal form of traditional Indian medecine. Ayurveda has remained widely accepted and practiced system of medecine in India through the centuries, validating the information about medecine in the Atharva Veda at least to some extent.

Traditionally, this fourth Veda was relegated to a position of lesser importance than the other three Vedas, because it represented a more popular aspect of religion, remaining partly outside the Vedic sacrifice,2 to the extent that it is not even mentioned in the text of the Reamker. However, the Atharva Veda, as well as the system of medecine it yielded, must have been transmitted to Cambodia, since the highly educated doctors of the Royal court were trained in Ayurvedic medecine. (Chhem 2000,p. 25)

The Healing Art
The system of medecine in the Reamker includes herbal medecine, surgery, magic medecine, and crystal therapy, though this last method of healing is not mentioned as prominently as the others are. It is very likely that many components of the medecine in the Reamker are of relevance even today to the practice of traditional Khmer medecine.

Medicinal Plants and Herbs
The Reamker refers to names of specific plants and herbs only occasionally. Typically, at the points in the story when someone is being healed, the narration becomes vague, and the names of the healing substances are rarely mentioned. Even there, the medicinal properties of the plants are absent. (Pou 1979, p. 20).

This makes it difficult to accurately identify the medicines and the modes used to prepare and administer them. However, while the healing in the Reamker itself is not explicit, theAtharva Vedais exhaustive in its details of the remedies, and one may speculate that the treatment described in the Reamker stays within the Ayurvedic framework. Some of the instances in the Reamker that do contain some relevant information on the remedies are the following:

• Ram’s passing through a forest is likened to “a divine balm…blown…on the body attacked by sickness,” (Pou 1979,
  p. 25); here, the translator’s note explains that “traditionally in Cambodia magic men have blown spittle over sick people to heal them.” (Pou 1979, p.293) The use of spittle is not restricted to Cambodian medecine, but can be found in many traditional cultures including aboriginal American medecine, and Christian and Muslim religious stories, among others. Furthermore, modern research findings support the idea that saliva has healing properties.
• Another example of healing remedies in the story is the repeated use of “flower perfumed water” (Pou 1979, p. 31) to revive an unconscious person. This is reminiscent of smelling salts4 in modern times, likely to have been adapted by the authors of the Reamker, using poetic license.
• Finally, the most relevant part of the Reamker for our purposes is the information available in the description of Lakshman’s wound, and his recovery. Because of its significance, a discussion of the details is reserved for a later section.

Surgery
A study of the Indian Ramayana states that “accompanying the army of Bharata were surgeons and experts in the extractions of extraneous substances, and poison-doctors.” (Sharma 1971, p. 428) It would not be surprising, therefore, for surgery to be an essential part of the Cambodian version of the story as well.

There is, however, no immediately obvious mention of treatment through surgery in the Reamker, unlike the clear reference to use of plants for remedies. One possible instance of surgery that one might reconstruct from the story is the incident in which a pike is removed from Laksm(n)’s foot.

Magic Medecine
Magic medecine is another major component of healing in the Reamker. It includes spells and incantations, or the chanting of mantras, and is used even more frequently than herbal remedies, and not only for healing but also for a variety of other purposes. There is a mantra to accompany any task to do with healing or battle. There are those who believe that certain sounds have the ability to heal.5 Although this has not been proven systematically, incantations are found around the world, perhaps because of the element of comfort their use provides.

Furthermore, there are other compelling reasons why incantations are so ubiquitous across cultures. One reason for the prevalence of mantras in the Reamker is that they are available to even those who have not been educated in the hermitages, for example, an ogre who recites “incantations from the books” (Pou 1979, p. 55). Another advantage is that unusual events are easily attributable to and explained in terms of the use of incantations.

Hanuman’s spell to put Mahajambu and his people to sleep (Pou 1979, p. 124) might be explained in terms of the effects of a gas that causes drowsiness, rather than as magic. It is difficult to determine whether there is any factual basis for the chants; and if they do indeed have healing power, their effectiveness has no rational explanation. The belief held by the healers at the time was that the purpose of the chants was to invoke the help of the gods.

The intervention of the gods and spirits is another element of healing mentioned often in the Reamker. Similarly, the intervention of the gods explains, for example, Ram-Laksm(n)’s relative comfort in captivity (Pou 1979, p.240), Laksm(n)’s ability to exist with little nourishment or sleep, and even the simple recovery of consciousness after fainting.

Crystal Therapy
The use of crystal therapy, which is prevalent, for instance, in the Chinese culture, is suggested occasionally in the Reamker as well. A specific stone, “an emerald, the exact requirement for the cure” (Pou 1979, p. 167) is needed to grind together the ingredients for the remedy for Laksm(n)’s wound. Whether there is any substance underlying the belief, the emerald stone can be found as a “generally healing and protective stone in the beliefs of many people.”6 Another instance of possible crystal therapy is the “sunstone ring” which Sita gives to her son to protect him against Ram’s army (Pou 1979, p. 242).

Examination of Specific Parts of the Reamker
Lakshm(n)’s Injury
As mentioned earlier, one of the most relevant events in the Reamker in the context of medicinal practice is Laksm(n)’s injury caused by a “magic pike” from which a strychnine plant grows. The remedy is described as “a beautiful lotus bloom with stamens…clear, pure water from the nine pools, and some urine from the king of the oxen” as well as an emerald stone to grind the ingredients together. (Pou 1979, p. 166).

The most relevant part of this section of the story is the strychnine, which is widely known to be toxic. A modern treatment for contact with strychnine is to “administer 100% oxygen by positive pressure to provide as much pulmonary gas exchange as possible”. The treatment given in the Reamker does not provide for an explanation of how the injury was treated. However, an account of the same incident in a Laotian version of the story states that the remedy includes “part of the pillow of Kalanaga” (Sahai 1996, p.12) which is found in the depths of the ocean.

This “pillow” may be the poet’s description of a sea plant which holds pure oxygen, and could therefore be used as an antidote to strychnine. As mentioned, the emerald grinding stone in the Reamker is suggestive of crystal therapy. However, while crystal therapy is normally associated with the energy of the crystal and its molecular vibrations9 , this is not the only possible aspect of the stone’s healing properties. It is also possible that the grinding process crumbles the crystal which reacts with the other ingredients to form the remedy.

The descriptions of the details of Laksm(n)’s injury are different in each of the various versions of the story of the Ramayana. In some versions, it is Ram who is injured, in others, Ram’s entire army. The exact ingredients of the remedy are also different across texts. However, one detail remains constant in every version, namely, that part of the cure is brought from a far away mountain. The reoccurrence of this detail suggests that the ingredient is essential for the cure. Unfortunately, the exact substance is not specified in the Reamker, where it is simply described as a lotus bloom. Nor is it identifiable from other versions of the story, where it is referred to vaguely as “medicinal herbs”.

The other ingredient of the cure given in the Reamker that might be of relevance is the urine of a bull. The “excrement of the bull-king” appears in the Laotian version of the Ramayana as well, though this in itself does notprove its healing power. The appearance of the healing properties of urine in various other stories and cultures, however, does suggest a degree of factual basis for the idea.

The Birth of the Twins
While many of the incidents in the Reamker that involve magic medecine might not have rational explanation in terms of modern medecine, there are a few that might be explained. The sage Vajjaprit believes he has lost Sita’s son and creates an exact replica of him with a drawing of the infant in association with the recitation of mantras. (Pou 1979, p. 214). This might have been the poet’s interpretation of the birth of twins. This is an interesting incident in the Reamker because it is reminiscent of the recent scientific explorations of cloning.

Monkey’s Blood
A group of monkeys waiting for the result of the fight between a bull and another monkey notice that the blood flowing forward is light, “exactly like that of a monkey” (Pou 1979, p. 80) and assume that the bull was victorious.

This suggests a certain amount of study and comparison of the blood of different animals. The care and knowledge of animals is demonstrated in both the Ramayana (Brockington 1985) and the Reamker.

Khmer traditional medicine is a form of naturopathy and combines differing roots, barks, leaves of various trees, some minerals and other natural ingredients. In total this branch of medicine can treat more than 100 different diseases. Practitioners of this therapy are known as Kru Khmer.

About 40 to 50 percent of the population in remote areas are using traditional medicine because they are poor and it is cheaper than Western medicine. It also cures them of their ailments all the same.

The ancient Khmers first formulated this medical lore, during and around the Angkor period. From the turn of the first millennia until the present day, this system of treatment has served the people of Cambodia.
Using traditional remedies has no side effects: an advantage natural remedies have over their more chemical orientated counterparts.

The National Center of Traditional Medicine of Cambodia is interpreting books from Pali into Khmer, these texts describe traditional medicine and have been gathered from pagodas and even as far a field as the Middle east. "We have already interpreted 50 percent of the books, the young generations don't understand the Pali language," he said. "We will produce booklets about traditional medicine when we finish translating them."

The horseshoe crab, starfish and sea cucumber are common ingredients in traditional medicine.

Nowadays, Khmer traditional medicine is available in market places as well as in traditional doctors’ surgeries in Phnom Penh.

In Cambodia, most traditional doctors take tree bark, roots and herbs from trees to compound as Khmer medicine. These can be found on many mountains across the nation. To make the traditional medicine very effective, before cutting each tree they have to light incense sticks and ask permission from the Neak Ta (Mountain spirit), who is believed to be the owner of the trees. Moreover, it is also believed that in order for the herbs to be truly effective, they have specific times of cutting them. Some trees should be cut at the trunk only in the morning, the leaves in the afternoon and the roots at night. A more controversial ingredient is animal parts. These have for centuries provided alleged cures.

It seems that people are more willing to try local medicine, both out of economic causes and due to its traditional role in society. So it is both cheaper and an old habit that is hardly dying.

Osteoarchaeology and Angkor
RESEARCH REPORT Stuart Anderson
RESEARCH REPORT Rethy K Chhem
History of medicine
I became interested in the history of Khmer medicine about four years ago and initiated independent research in this field in order to answer several questions: What was the cultural foundation of medical practice in ancient Cambodia?

• How did the Khmer perceive his/her natural environment and his/her own body?
• What were the medical theories of the Khmer?
• Who were the doctors? What were their practices?
• What types of tools did they use for the diagnosis of diseases?
• What were the different types of treatments available?

Despite the numerous research projects on medical anthropology in Cambodia conducted since the mid-1970s, published information on the history of Khmer medicine is limited. In order to understand this lack of information and interest, it is important to examine the background of the field of Khmer studies in general.

Khmer studies include all scholarly works related to the investigation of Khmer culture such as history, archaeology, linguistics, art history, architecture, religious studies, literature, etc. Khmer studies were inaugurated at the end of the 19th century by French ‘scholars’, who worked for the French colonial administration in Indo-China. Most were senior administrators, doctors or army officers, but a few others were historians of art, architects, epigraphers and Sanskritists.

The ‘re-discovery’ of Angkor by Henri Mouhot, a French naturalist, in 1860 during his expedition to Cambodia, Siam and Laos, boosted research in archaeology, epigraphy and art history.The most urgent task for those scholars was to establish the chronology of temples and reigns of Khmer kings.The study of epigraphy shed light on the lives of the Khmer elite at the expense of that of the commoners. Also, social history was not fashionable in the early 20th century. All these factors explain why there are so few publications on the history of Khmer medicine.

To answer these research questions many sources have been exploited, including written sources, such as inscriptions on stone, royal chronicles and palm-leaf manuscripts; and unwritten sources, such as archaeological finds (temples, sculpture, artefacts and skeletal remains). In addition to these data, I have also used results from medical anthropological research in contemporary Khmer society. Finally, a comparative approach was applied using data from the history of medicine of ancient India and China as well as the history of indigenous medical practices in the South-East Asian region.

Under the guidance of a French archaeologist of the French School of the Far East, digital photography of medical scenes from bas-reliefs and temple pediments of Bayon temple and the Neak Poan temple as well as the chapels of hospitals were taken and stored on CD to serve as sources for my study.

Osteoarchaeological research
For historians of Cambodia, pre-Angkor means the period before the establishment of the Angkor capital in AD 802 by King Jayavarman II. Before the 1970s, most research projects on early Khmer civilization were conducted by the French and were focused on the Angkor period (AD 802–1432). Since the mid-1990s, scholars from several other countries have conducted research on ancient Khmer culture.

At the same time, the historical period covered by such studies has gone beyond the Angkor era to include both the pre-Angkor and post-Angkor periods. At a conference on the pre-Angkor period, held at the Center for Khmer Studies in Siemreap, Cambodia, I presented a preliminary report on the investigation of the two skeletons recovered from the pre-Angkor site of Prey Khmeng by Dr Christophe Pottier.

Carbon dating of charcoal found in the same stratum suggested that these two skeletons are approximately 2000 years old, pre-dating the construction of the Prey Khmeng temple which was founded in the eighth century according to epigraphic data.

One of the skeletons is an adult and the second is a child. Despite the destruction of both the skull and pubic bone during excavation, we were able to confirm, with anthropometric measurements, that the adult skeleton was a male and approximately 40–50 years old. The child skeleton is undergoing the same type of investigation. X-rays and CT (computerized tomography) scanner investigations allow the study of palaeopathology (disease that occurred in the past) and the imaging of the skeleton itself for physical anthropological evaluation.

Our radiological tests confirmed the diagnosis of a healed fracture of the distal right femur, with an anterior bowing. As no findings suggest any underlying tumour or infection, this fracture was most likely the result of a trauma and had occurred before death. In addition, scoliosis of the thoracic and lumbar spine was either an idiopathic deformity occurring before death, or post-mortem alteration.

Here again, there was no tumour or infection. In terms of procedural information, we were able to demonstrate that CT scanning of the specimen before the removal of its soil matrix preserved data that may be lost after cleaning.Therefore we believe that there may be no need for a thorough cleaning of the skeleton for anthropological study, as has been done in the past. However, this is anecdotal evidence as a study of a larger series must be done in order to validate these preliminary findings. If further studies support these current results, CT imaging may open the door to a ‘virtual osteoarchaeology’.

A mitochondrial DNA study of the skeleton’s bone and teeth is underway.There are many potential applications of ancient DNA study, including study of kinship, identification of gender and, rarely, detection of the presence of pathogens such as tuberculosis or malaria. It must be emphasized that valid conclusions cannot be drawn from a study that includes only two skeletons. In addition, a comparison of these findings with DNA from different populations of South-East Asia is necessary in order to investigate the migration of ethnic groups and/or infer the distribution of Austro-Asiatic linguistic groups in the region.

Finally an analysis of the microstructure of the bone itself was performed, using an electron microscope.The histological pattern of a normal ancient bone was demonstrated with the identification of its ultrastructure such as the Haversian system and vascular grooves. In addition, some unidentified microorganisms were demonstrated within the bone that may represent contamination from the soil. A pathogen affecting the bone itself is less likely.

Our investigation has shown that medical high technology is useful in the investigation of the human past. Osteoarchaeological findings may also soon become an additional historical primary source that will alter the historiography of the history of medicine in general and the history of disease in particular.

There has been a surge in interest in Khmer studies in the last five years. After three decades of armed conflicts there is now free and safe access to the region of Angkor Wat and many other archaeological sites scattered over the rest of Cambodia. Soon, new findings will shed light on many unknown historical facts concerning this once flourishing and powerful empire of South-East Asia.

Acknowledgement
Thanks to Dr Christophe Pottier and APSARA Authority for sending the Prey Khmeng skeletons to the Osteoarchaeological Research Group (ORG) in Singapore for a bioarchaeological investigation.The author thanks also members of the ORG who participated in the investigation of the skeletons.

Rethy K CHHEM
Associate Professor of Radiology and Director of the Medical Education Unit National University of Singapore Hospital chapel atAngkor Thom. One of the 102 hospitals built under King Jayavarman VII. (Image courtesy of R Chhem)

Courtesy of the Nginn Karet Foundation for Cambodia