The Buddhist–Medical Interface in Tibet: Black Pill Traditions in Transformation

: This paper introduces Tibetan pill traditions and examines two exceptional pill formulas that emerged from an early Buddhist–medical interface in Tibet, but followed di ﬀ erent trajectories due to the increased specialization of religious and medical knowledge. “Black pills” are the most revered consecrated healing compound of the Karmapas (the incarnate heads of the Karma Kagyü School of Tibetan Buddhism), while the “Cold Compound Black Pill”—a precious pill known as Rinchen Drangjor—is one of Tibetan medicine’s most complex formulas still produced today. Based on both textual research and ethnographic ﬁeldwork in India, I critically explore the principal factors that link these black pill traditions. I argue that parallels in the use of potent substances and their processing o ﬀ er examples of how strongly entangled medical and religious approaches are with respect to healing practices that include blessings, protection, spiritual support, and medical treatment. My ﬁndings reveal that although there are distinct areas of medical and religious specialized practices in the black pill traditions, consecrated multi-compounds are added to both types of black pills to enhance potency and ensure the continuation of lineage a ﬃ liations to certain Buddhist schools. I also show how political and sectarian conﬂicts within certain Buddhist schools may a ﬀ ect some of these rare pill practices. Fifth of Eighth Karmapa as a lid.


Introduction
Tibetan traditions are filled with practices that confer blessings and healing through a variety of pills that are ingested by people after birth, in case of illness, during the dying process, and to protect from poisons, weapons, spirits, and other forms of harm. For Tibetans, these pills are considered both medicine, called men (sman), and blessings, in Tibetan jinten or jinlap (byin rten or byin rlabs). Jinten is also a general term for a sacred pill or a relic. Men refers to both medicines and benefit. Something beneficial is also often considered a jinlap and vice versa. Thus, analytical categorization of whether these pills are "medicines" or "blessings" easily create artificial dichotomies, which should be avoided. This article will rather focus on overlaps, similarities, or shared concepts of potency, substances used, and processing techniques in the Tibetan pill traditions, as outlined below.
Tibetan pill traditions have been transmitted through specific lineages in Buddhist and medical schools, through smaller, often family-based medical houses (Hofer 2018), as well as through larger medical institutions that train practitioners in the Tibetan science of healing, or Sowa Rigpa (gso ba rig pa). Almost every Tibetan Buddhist master has made special jinten in his/her lifetime to pass on lineage blessings to future generations. They are part of Tibetan notions of "liberation through tasting" called nyongdröl (myong grol), which "liberate" beings through sensory contact and imbibing blessings by eating pills, letters inscribed on paper, or medicines (Gentry 2017, Garrett [2010 2011). They are closely One main characteristic emerging from the intersection of medicine and Buddhism in Tibetan pill traditions is the combined focus on both spiritual and physical well-being. This is especially the case with the "accomplished medicines," which in Tibetan are known as mendrup (sman sgrub) and contain about 100 medical ingredients, consecrated substances, and undergo elaborate ritual empowerments (Cantwell 2015;Garrett 2009). Mendrup rituals have been studied in terms of their manifold ingredients and elaborate nature (Sehnalova 2018), as tantric medicines, as a manifestation of lineage blessings shared by the community (Cantwell 2015), and in relation to amchi 5 making their own medicines and using mendrup to consecrate it (Blaikie 2013(Blaikie , 2014. Cantwell raises the important question of the overlaps between Buddhist ritual and Tibetan medicine in the past (Cantwell 2015, p. 88), pointing to the lack of research on the relationships between particular Buddhist pill traditions and specific medical formulas that also contain blessed substances. This paper starts addressing that gap.
In Sowa Rigpa, the formulas in question are nowadays for the most part collectively grouped under the category of precious pills, or rinchen rilbu (Gerke 2017). These are Tibetan medicines that contain between 25-160 plants and minerals as well as precious ingredients such as gold, silver, rubies, diamonds, corals, turquoise, pearls, natural agate beads (gzi), and sapphires. Many of them contain the processed organometallic mercury sulfide complex compound tsotel (btso thal), which is considered a very potent elixir 6 . Typically, they contain some form of ritually blessed substances. For centuries, precious pills have held a special place in Tibetan societies. They have been regarded as providing protection from epidemics and have been used to treat poisoning, fevers, malignant tumors, infections, neural disorders, strokes, and epilepsy (Sonam Dolma 2013).
This paper is a preliminary study of the black pill traditions in both Sowa Rigpa and Buddhist contexts. The main question that guided my research on the black pill traditions of the Karmapas and in Sowa Rigpa is whether we can find overlaps, similarities, or shared concepts related to potency, substances, and processing techniques in both pill traditions beyond their shared name of "black pill". I argue that while Tibetan pill traditions might appear as specialized fields of knowledge, there are significant corollaries and overlaps in terms of substances and processing techniques. I also argue that the traditions of pill making in institutionalized medical settings continue to manifest strong lineage ties to certain Buddhist schools.
Some of these pill traditions can be traced back to the 13 th century, while others emerged in specific lineage schools over time. While some pill traditions of specific Buddhist schools today face challenges of continuity because of political circumstances (such as the black pill tradition of the Karmapas), the production of precious pills in Sowa Rigpa medical settings has undergone reformulations due to new regulations and the industrialization of their production, as well as difficulties in procuring or using controversial ingredients (e.g., mercury, animal substances) 7 . Despite their pharmaceuticalization 8 , their ritual consecration remains closely linked to certain Buddhist schools, as I show with examples from India.
Through textual analysis and ethnographic research in northern India, I investigated the similarities and differences between particular medical and spiritual pill traditions in terms of some of the processing techniques as well as the use of powerful consecrated substances called damdzé (dam rdzas). These substances are passed on from Buddhist masters to medical practitioners to be added to precious pills in the form of a special "fermenting agent" called papta (phab rta) 9 . Papta emerges as a way to pass on spiritual tradition and potency over several generations, often bridging long decades of the absence of 5 Amchi is a Mongolian-derived term referring to a Tibetan physician. Tibetan terms are not pluralized in this paper. 6 For anthropological studies on tsotel, see Gerke (2013), and forthcoming. For recent toxicity studies on tsotel at the Men-Tsee-Khang in India, see Sallon et al. (2006Sallon et al. ( , 2017. See also Tidwell and Nettles (forthcoming). 7 See Czaja (2015) and Sabernig (2011)on substitutions and Schrempf (2015) on transnational formulation regimes of Sowa Rigpa in China and Europe. 8 Pharmaceuticalization here is different from commercialization in that it refers to a process that often includes the commodification of knowledge and is thus political in nature (Banerjee 2009). 9 Other spellings of papta are phab gta' or phab rgyun (Cantwell 2017, p. 193). a highly trained and realized master, and confirms association to a potent and authoritative lineage. Papta and the spiritual lineages through which medical knowledge and jinlap are transmitted still affect the making of formulas, even in terms of the larger pharmaceutical industry in which Sowa Rigpa is embedded in the Tibetan regions of the People's Republic of China (Tidwell unpublished), as well as in other areas where Sowa Rigpa is practiced today (see Blaikie (2013Blaikie ( , 2014 for examples from Ladakh).
For this study, the list of substances needed for the Karmapas' black pills could not be compared with the ingredients that are used to make the precious pill Rinchen Drangjor since they are kept secret (and are presumably currently sealed at Rumtek monastery in Sikkim). Thus, I relied on interviews with two attendants of the 16 th Karmapa, who prepared black pills in Sikkim in 1972/73. For the medical black pill, I relied on published Tibetan formula texts.
The following ethnographic vignette from a recent visit to Kalimpong, northeastern India, represents one of many pill traditions existing in Tibetan societies and illustrates their contemporary importance and rarity.

A Jinten Pill
Dikila carefully unraveled a folded piece of hand-made paper to show me what has been very precious to her ( Figure 1): a piece of an empowered substance pill called jinten rilbu (byin rten ril bu) which she received from the Second Domo Geshe Rinpoche Ngawang Jigme . In awe, I looked at the pill that the Rinpoche gave her in 1991 during the child-naming ceremony of her first-born son. At the time, her husband worked in the Tibetan army, and the pills were popular among soldiers to wear as a protective amulet. In order not to lose it, she kept it along with a Nechung seed, an orange-colored piece of wheat grain that was blessed and distributed to the public at the Namgyel monastery of the Tibetan Nechung oracle in Dharamsala 10 . It has been a popular practice among Tibetans to add such a seed to precious things in order not to lose them. The jinten pill has been Dikila's spiritual first-aid panacea. It is thought to help during times of illness, distress, and during the dying process. A few years ago, she broke off a little piece and gave it to her brother, who placed it in the foundation of his new house, together with other rinchen rilbu: a manifestation of a combined sense of medical and religious significance put into a popular Tibetan practice. At the end of our day spent together, Dikila broke off a tiny piece of the pill and gave it to me.
Religions 2019, 10, x FOR PEER REVIEW 4 of 31 industry in which Sowa Rigpa is embedded in the Tibetan regions of the People's Republic of China (Tidwell forthcoming), as well as in other areas where Sowa Rigpa is practiced today (see Blaikie (2013Blaikie ( , 2014 for examples from Ladakh). For this study, the list of substances needed for the Karmapas' black pills could not be compared with the ingredients that are used to make the precious pill Rinchen Drangjor since they are kept secret (and are presumably currently sealed at Rumtek monastery in Sikkim). Thus, I relied on interviews with two attendants of the 16 th Karmapa, who prepared black pills in Sikkim in 1972/73. For the medical black pill, I relied on published Tibetan formula texts.
The following ethnographic vignette from a recent visit to Kalimpong, northeastern India, represents one of many pill traditions existing in Tibetan societies and illustrates their contemporary importance and rarity.

A Jinten Pill
Dikila carefully unraveled a folded piece of hand-made paper to show me what has been very precious to her ( Figure 1): a piece of an empowered substance pill called jinten rilbu (byin rten ril bu) which she received from the Second Domo Geshe Rinpoche Ngawang Jigme . In awe, I looked at the pill that the Rinpoche gave her in 1991 during the child-naming ceremony of her firstborn son. At the time, her husband worked in the Tibetan army, and the pills were popular among soldiers to wear as a protective amulet. In order not to lose it, she kept it along with a Nechung seed, an orange-colored piece of wheat grain that was blessed and distributed to the public at the Namgyel monastery of the Tibetan Nechung oracle in Dharamsala 10 . It has been a popular practice among Tibetans to add such a seed to precious things in order not to lose them. The jinten pill has been Dikila's spiritual first-aid panacea. It is thought to help during times of illness, distress, and during the dying process. A few years ago, she broke off a little piece and gave it to her brother, who placed it in the foundation of his new house, together with other rinchen rilbu: a manifestation of a combined sense of medical and religious significance put into a popular Tibetan practice. At the end of our day spent together, Dikila broke off a tiny piece of the pill and gave it to me. Nechung is a protector deity associated with Guru Rinpoche, and thus the Nyingma School of Tibetan Buddhism, and was incorporated into the Gelukpa ritual system as the state oracle by the Fifth Dalai Lama in the 17 th century. We met in Kalimpong, in the northeastern Himalayas, in the Indian state of West Bengal, where Tibetans have settled since the 19 th century when there was a buzzing trade route between Kalimpong and Lhasa, turning Kalimpong into a "contact zone" in the eastern Himalayan Borderlands (Viehbeck 2017). Monasteries of all the Tibetan schools were established here over time, and many Tibetans settled here before and after 1959 11 .
When we met in December 2018, Dikila accompanied me to the newly established museum at the Tharpa Chöling Monastery on top of Tirpai Hill, which was established by the First Domo Geshe Rinpoche Ngawang Kalsang (1866Kalsang ( -1936 in 1912, following the Gelukpa School of Tibetan Buddhism. He became known to the West through Anagarika Govinda's The Way of the White Clouds (Govinda 1966). Ngawang Kalsang Rinpoche was trained at Tashilhunpo in Tibet, and spent years meditating in a cave in Domo, bordering Sikkim, where he also built his "White Conch" Dungkar Monastery. It is said that in Kalimpong he also collected plants and herbs for his famous pills.
The Second Domo Geshe Rinpoche, Ngawang Jigme, who was born in Sikkim in 1937, came to Kalimpong in 1961 after a period of imprisonment in Tibet during the Chinese takeover, which left him in ill health. In the 1970s, he moved to the Unites States, where he passed away in 2001. He visited Kalimpong once in a while and less during the mid-1990s when the Dorjé Shukden controversy peaked in Tibetan communities. At the time, the worship of the Gelukpa protector deity Dorjé Shukden was demoted by the 14 th Dalai Lama within its own Gelukpa school in an effort to become more inclusive of other Buddhist schools. 12 It turned into a question of loyalty when Shukden worshippers were requested not to receive tantric initiations by the Dalai Lama; this "effectively placed them outside the fold of the exiled Tibetan polity" (Mills 2003, p. 60). At the time, I lived in Kalimpong and noted how this issue led to religious confusion and split the Tibetan community. Dorjé Shukden was the main protector deity of Tharpa Chöling; consequently, many local Tibetans avoided the monastery. In 2018, Dikila assured me (as does the Wikipedia page of this monastery) 13 that the controversy was long over, no Shukden worship was carried out at the monastery, and local Tibetans were free to visit the monastery again. Moreover, the reincarnation of the Third Domo Geshe Rinpoche (b. 2003) was recognized by the 14 th Dalai Lama in 2005, and the monastery is now supervised by the Central Tibetan Administration.
The museum was established in one of the side buildings of the newly renovated monastery, adjunct to the small meditation room where the first and second Domo Geshe Rinpoches used to sit, practice, and see, heal, bless, and advise people, and also give out consecrated pills. In one of the museum showcases, we found the cover of a small notebook with the hand-written Tibetan title "Catalogue of Relics," or jinten karchak (byin rten dkar chag), which refers the list of ingredients used to make these jinten pills ( Figure 2). On inquiry, we found out that the notebook was empty and that the original pages were kept in secret with the current geshe of the monastery for future times, when the third reincarnation of Domo Geshe Rinpoche, currently a teenager, would be able to make these pills again. A few months earlier, a Tibetan doctor near Dharamsala, who is closely linked to the Rinpoche's family, told me that he had been asked to help procure the ingredients when the time comes to make the pills again. This is an example of a collaboration between medical and ritual specialists 11 See Gerke (2012) for a detailed description of this area as a fieldsite from 2004and Viehbeck (2017 on a recent edited volume on Kalimpong. 12 See Dreyfus (1998) for a historical analysis and in-depth overview of the Shukden controversy, which goes back to the 17 th century, circling around the vengeful spirit of a murdered Gelukpa lama who became a protector deity of the Gelukpa school, and whose main task became (especially in the 1930s) to protect the Gelukpa school from any "polluting" teachings of other schools. This created sectarian power struggles particularly with the Nyingma school of Tibetan Buddhism and the non-sectarian movement, but did not majorly disturb the unity of the Gelukpa School until 1975, when the issue began to flare up in exile. See Mills (2003) for a discussion of how the more recent Shukden controversy highlighted the discrepancy between Western discourse of religious faith as "individually held beliefs" and "human rights" as a product of modern nation-states, compared to the Tibetan case where religious relationships and ritualized loyalty is seen as integral to a state's constitution. 13 https://en.wikipedia.org/wiki/Tharpa_Choling_Monastery. Last accessed 9 March 2019. in the making of such pills across time and reincarnations. The historical contexts surrounding such collaborations will be explored in Section 3. Looking around the museum, we discovered two kinds of Domo Geshe Rinpoche's pills on exhibit as well as little statues made out of the jinten pill material (Figure 3). The pill called yangdzé rilbu (g.yang rdzas ril bu) 14 , which translates as "Good Fortune Pill", was black with silvery shiny flakes. The jinten rilbu was dark blackish in color. The one Dikila had at home seemed to be a black jinten pill. I had seen jinten material in the form of little statues before. It is a way to keep them in a revered and firm form. The material is stable and hard enough to resist decay through climatic influences. They can be used as a papta, by chiseling off little pieces of the statue and adding them to the next batch of pills. The idea is to enhance new batches of pills with the blessings of the lineage and previous masters by adding tiny amounts of papta to them 15 .
Lama Zopa, who studied at the First Domo Geshe's "White Conch" Dungkar Monastery, wrote about the pills made by the First Domo Geshe: The pills were very good for people who had eaten poison by mistake, and were good for many other things. They were very powerful in blessing the body, the chakras and of course, the mind. And if the pills were kept well, with good samaya, they also multiplied (Lama Zopa Rinpoche and Cameron 2010, p. 192).
Lama Zopa's last comment refers to the self-generating activities of pills explained later in this paper. Comments circulating online by Domo Geshe Rinpoche's disciples state that "Domo Geshe 14 Yangdzé is a general term for types of precious substances and grains (rin po che'i rigs dang 'bru sna sogs g.yang rdzas spyi'i ming (Zhang 1985(Zhang , p. 2614). 15 See (Blaikie 2014) for examples of papta used as accomplished medicine or as mendrup in rituals in Ladakh, Sehnalova (2018, n.d.) for papta used in Bonpo mendrup rituals, and Cantwell (2015Cantwell ( , 2017 for papta in Nyingma ritual contexts. Looking around the museum, we discovered two kinds of Domo Geshe Rinpoche's pills on exhibit as well as little statues made out of the jinten pill material ( Figure 3). The pill called yangdzé rilbu (g.yang rdzas ril bu) 14 , which translates as "Good Fortune Pill", was black with silvery shiny flakes. The jinten rilbu was dark blackish in color. The one Dikila had at home seemed to be a black jinten pill. I had seen jinten material in the form of little statues before. It is a way to keep them in a revered and firm form. The material is stable and hard enough to resist decay through climatic influences. They can be used as a papta, by chiseling off little pieces of the statue and adding them to the next batch of pills. The idea is to enhance new batches of pills with the blessings of the lineage and previous masters by adding tiny amounts of papta to them 15 .
Lama Zopa, who studied at the First Domo Geshe's "White Conch" Dungkar Monastery, wrote about the pills made by the First Domo Geshe: The pills were very good for people who had eaten poison by mistake, and were good for many other things. They were very powerful in blessing the body, the chakras and of course, the mind. And if the pills were kept well, with good samaya, they also multiplied (Lama Zopa Rinpoche and Cameron 2010, p. 192).
Lama Zopa's last comment refers to the self-generating activities of pills explained later in this paper. Comments circulating online by Domo Geshe Rinpoche's disciples state that "Domo Geshe Rinpoche's rilbus were precious pills made from medicinal herbs, sacred relics, and many different holy substances that he collected in the Buddha's hallowed places in India and in pilgrimages in the Himalayas and Tibet." 16 They protected against poisons and weapons, and guaranteed "at least seven human rebirths if administered at the right moment in the death process." 17 Religions 2019, 10, x FOR PEER REVIEW 7 of 31 Rinpoche's rilbus were precious pills made from medicinal herbs, sacred relics, and many different holy substances that he collected in the Buddha's hallowed places in India and in pilgrimages in the Himalayas and Tibet." 16 They protected against poisons and weapons, and guaranteed "at least seven human rebirths if administered at the right moment in the death process." 17

Snow Lioness Milk
A few days later, while attending a dance performance by the Tibetan cultural dance group of Kalimpong, a snow lion dance was announced. The master of ceremony, Tsewang Paljor, referred to the sacred substance of snow lioness milk during his announcement, which he said was also added to Domo Geshe Rinpoche's pills. I had seen a couple of the mythical snow lion figures on exhibit in the museum (Figure 4). 16 http://www.domogesherinpoche.org/domo-geshe-rinpoche-ngawang-kalsang.html. Last accessed 7 March 2019. 17 Ibid. Last accessed 7 March 2019. The reference to "at least seven human rebirths" might reveal links to the "seven-times born Brahmin flesh pills" discussed by Gentry (2017).

Snow Lioness Milk
A few days later, while attending a dance performance by the Tibetan cultural dance group of Kalimpong, a snow lion dance was announced. The master of ceremony, Tsewang Paljor, referred to the sacred substance of snow lioness milk during his announcement, which he said was also added to Domo Geshe Rinpoche's pills. I had seen a couple of the mythical snow lion figures on exhibit in the museum (Figure 4). When I asked Tsewang Paljor about the importance of snow lioness milk after the performance, he said: The snow lion represents the majesty, compassion, unity and strength of the Tibetan people. It also represents the strength of compassion and non-violence. It is the symbol on our national flag. Though the national animal is the yak, we consider the snow lioness precious, because it gives milk. About the snow lion, there is nothing in writing; these are oral stories. The snow lion is the mythical animal looking after the deities of the high snow-capped mountains.
Nyenchen Tanglha [gnyan chen thang lha] reaches into the Kham region where I was born. 18 There are so many mountains that are precious and sacred. We believe that snow lions live there and are protected by the deities. … The deities sometimes offer snow lioness milk to high lamas.
Of the two pills at the museum, the bigger one is the real one. Now it is not available. They say this pill can cure any disease. We say it contains the essence of the seven gems and snow lioness milk. This refers to the northern main peak in the Nyenchen Tanglha mountain range (7162 meters), west of Tsurpu monastery (Gamble 2018, p. 112). Most of the Nyenchen Tanglha mountain range is in U-Tsang, southeast of Namtso (north of Lhasa). 19 Unfortunately, I could not inquire further about how the controversy affected the perception of Domo Geshe Rinpoche's pills among other Tibetans in Kalimpong. Dikila did not think that it affected the potency of her pill. She was also unsure whether the First or Second Domo Geshe Rinpoche made the pill. More research is required to find out whether, and if so how, the Shukden controversy would have changed people's perceptions of these pills' potency. Tsewang Paljor's personal statement seemed to imply that they lost some of their authenticity, which could be linked to perceptions of breaking ties with a lineage, which would weaken their potency. When I asked Tsewang Paljor about the importance of snow lioness milk after the performance, he said: The snow lion represents the majesty, compassion, unity and strength of the Tibetan people. It also represents the strength of compassion and non-violence. It is the symbol on our national flag. Though the national animal is the yak, we consider the snow lioness precious, because it gives milk. About the snow lion, there is nothing in writing; these are oral stories. The snow lion is the mythical animal looking after the deities of the high snow-capped mountains.
Nyenchen Tanglha [gnyan chen thang lha] reaches into the Kham region where I was born. 18 There are so many mountains that are precious and sacred. We believe that snow lions live there and are protected by the deities. . . . The deities sometimes offer snow lioness milk to high lamas.
Of the two pills at the museum, the bigger one is the real one. Now it is not available. They say this pill can cure any disease. We say it contains the essence of the seven gems and snow lioness milk. The real one was made by the First Domo Geshe Rinpoche. It is his own pill, authentic. For us, it is now impossible to get Karmapa's black pill and Domo Geshe Rinpoche's pill. At the moment, both pills are not made. . . . They cannot be made. . . . You know about the controversy about the previous [Second] Domo Geshe [he refers to the Shukden controversy mentioned above]. Therefore, only the rilbu of the First Domo Geshe, which was kept very secret, is authentic. 19 The black one is the old and real one. The real one [from the First Domo Geshe Rinpoche] cannot change its color or taste. The real one will always be black. The shiny one seems to be a later one, but both were made during the First Domo Geshe Rinpoche's time. That's what I was told at the museum. (see Figure 5 In Kalimpong, I asked the Tibetan scholar Jampel Kaldhen about the use of snow lioness milk in Tibetan pill traditions. He said: The snow lion has two manifestations. Some say it really exists, some say it is mythological. With Domo Geshe Rinpoche, people say it is neither mythological nor physical. . . . When great rinpoches meditate, some transformation takes place and the snow lioness gives milk to such a rinpoche, and he puts that milk in that pill. That's why the real milk is in there. It is offered by a deity to that rinpoche by means of meditation, not by means of study. In Tibet we won't get it. It is very rare, and we have to give one yak for such a pill. 20 A few days later, I heard about the snow lioness milk in the form of a papta ingredient added to Tibetan medical precious pills made by the lama and Tibetan physician Samphel Norbu Trogawa Rinpoche  in Darjeeling. Teinlay Trogawa, who has been the director of the Chagpori Tibetan Medical Institute since Rinpoche passed away, told me a story that Trogawa Rinpoche told him, and which explains the importance of lineage substances and papta.
Trogawa Rinpoche got his papta from his root teacher Jamyang Khyentse Chökyi Lodrö, who got it from his teacher, Jamyang Khyentse Wangpo. It is said that Jamyang Khyentse Wangpo was a great teacher and he had the local deity Nyenchen Tanglha offer snow lioness milk to him. There are many stories about it. Rinpoche told me the story: Jamyang Khyentse Wangpo was in his room, and his attendant was just outside at his door, and he did not see anyone coming in, but he saw a man wearing a white woolen chupa with one sleeve [traditional Tibetan garment] coming out of the room, talking to himself and rushing out of the room.
The attendant thought: "OK, how did someone enter Rinpoche's room without my knowledge." . . . So he went in. "Oh Rinpoche, I saw someone just come out from your room!" Jamyang Khyentse Wangpo was sitting in his room, normal and natural. Casually, he said: "Oh, Nyenchen Tanglha brought some snow lioness milk in a leather pouch." Before, you did not have good containers. So, it was inside an animal hide that was used for carrying liquids. The milk was there inside the animal hide, which was lying on the floor. Jamyang Khyentse Wangpo was in the process of making precious pills, so it was at the correct timing to add it to the pills; so it is there in the pill form. This became the papta that was passed on to Chökyi Lodrö and then to Trogawa Rinpoche, who added some of it to his precious pills. 21 While it is currently impossible to get a complete list of the ingredients used in these Rinpoches' pills (or any of the other sacred pills mentioned in this paper), these introductory examples illustrate a shared use of precious substances across different pill traditions, especially by revered lamas who were also trained Tibetan physicians (e.g., Khyentse Wangpo and Trogawa Rinpoche). The medico-religious approaches to substances deemed specifically potent (e.g., snow lioness milk) cross any artificially boundaries that we might like to construct between medicine and religion in the context of Tibetan pill traditions, and highlight the combined spiritual and physical benefits attributed to such pills. The next section explores these interrelationships in more detail, as well as in their historical contexts.

Medical and Religious Entanglements in Tibet
Since the introduction and propagation of medicine to Tibet has largely been expressed in Buddhist terms (Garrett 2014), scholars have been exploring the multifaceted questions of whether medicine in Tibet was always Buddhist, how and when it was expressed in such terms, and what the relationship between Buddhism and medicine was like at different times in history. 22 I have used the words interface, interrelationship, intertwine, and (dis-)entanglement to grasp some of the complexities of the numerous elements that often appear inseparable despite their specialized techniques, puzzling researchers. Buddhism itself is a complex and heterogeneous term that is difficult to define. The ways in which Tibetan forms of Buddhism informed, guided, and enriched medical understanding and Sowa Rigpa practices was also contested and shaped by different political fractions that often had alliances with different Buddhist schools. Garret advocates "research on Tibetan medicine that is sensitive to the localized and historically contingent nature of the tradition" (Garrett 2014, p. 179), which is indeed deeply heterogeneous in character.
Overall, the relationship between Buddhism and medicine in Tibet has been complex. In the past, Buddhist monasteries often housed medical schools, and physicians were also monks with a Buddhist training (Gyatso 2015). At the same time, medicine was also passed down through family lineages and medical houses (sman grong) (Hofer 2018;McGrath 2017a). Institutionalization, such as the founding of Lhasa Mentsikhang in the early 20 th century, further separated medical and monastic education. Today, the large-scale institutionalization of medical training has led to very different manifestations of Buddhism within Sowa Rigpa both in India (Kloos 2017) and in the Tibetan regions of the People's Republic of China, where we find large urban (Saxer 2013) and rural differences (Hofer 2018). (Adams et al. 2010, p. 23) point to the diversity of religious influence on Tibetan medicine, including Bon, Buddhist, and various folk beliefs. Therefore, they argue that we cannot simply talk about "Tibetan medical theory to be purely religious, or purely Buddhist" (Adams et al. 2010, p. 14). argues "that instructions for healing illness, regardless of their empirical or historical pedigree, should be called Buddhist if a community agrees that they are the direct or inspired teachings of the Buddha." He draws attention to early Tibetan textual distinctions between Buddhist and non-Buddhist medicines, and compares them to recent distinctions by Western academics of empirical versus Buddhist medicine, referring to Gyatso's work (Gyatso 2015), which challenges Sowa Rigpa as a "Buddhist medicine" and emphasizes a "scientific sensibility" among Tibetan physicians in early modern Tibet.
We find some similarities here with the use of the term "Buddhist medicine" in China, which is a "convenient label for discourses about medicine that were introduced to China via Buddhist translations and that were elaborated on in Chinese Buddhist compositions," but are not necessarily "exclusively Buddhist" (Salguero 2014, p. 20). Likewise, medicine in Tibet was frequently expressed early on in a specific Buddhist literary trope (Garrett 2006), but developed its own specialized knowledge. Scholars have approached Sowa Rigpa as an empirically-based practice linked to materiality and distinguished from Buddhism (see Gyatso 2015), which the 14 th Dalai Lama keeps emphasizing in public discourse. Nevertheless, while ritual and medical substances might be perceived as distinct and are treated differently by religious and medical specialists, they are not separable as such, and to make a clear distinction between religion and medicine would be artificial (Adams et al. 2010). This inseparability is especially evident from the ways in which amchi are trained.
To illustrate this point: the Yutok Heart Essence Guru Sādhana is a core practice of the collection known as Yutok Nyingtik (G.yu thog snying thig) of the Treasury of Rediscovered Teachings, or Rinchen Terdzöd (Rin chen gter mdzod), which amchi have been practicing for centuries to develop therapeutic skills and meditative sensibilities for the doctor-patient encounter as well as to consecrate and empower their own medicines (Garrett 2009). Since the time of Yutok Yönten Gönpo (fl. 12 th century), such ritual manuals to consecrate medicines have been in place, especially in the Nyingma tradition of Tibetan Buddhism. They also played a part in the empowerment of pills 23 and in the administration of precious pills to patients (Czaja 2015). For example, in the early 18 th century, the famous physician and author Deumar Geshe Tendzin Püntsok (born 1672) included a visualization of a medicine goddess in the main practice of administering precious pills in his work The Practice of Administering Jewel Pills: The Definite and Profound Heart Essence (Rin chen ril bu gtong thabs lag len nges zab snying thig; Tendzin Püntsok 2006), which was analyzed in detail by Olaf (Czaja 2015, pp. 40-49). Czaja emphasizes that this visualization practice at the time was probably a part of the Yutok Nyingtik (ibid. p. 44, note 24).
When it comes to Tibetan pill traditions, as is the focus of this article, the complexity of medico-religious interrelationships between Sowa Rigpa and Buddhist ideas is strongly present, emerging from specific amchi training and practice. Even at present, amchi medical training deeply involves textual memorization, oral and secret transmissions by lineage teachers, as well as spiritual empowerments and practices, although with variations depending on schools and place (Tidwell 2017). This medico-religious education speaks of a religious-political landscape in which formulas are imbued with therapeutic potency that incorporate enlightenment ideologies and the need for spiritual guidance through critical phases of (re)birth, illness, and death. Pill traditions have been embedded in complex histories, of which some elements will be highlighted next.

Historical Background: Tibetan Pill Traditions and their Patronage
Some of the complex medico-religious interrelationships go back to the 12 th and 13 th centuries, when the key medical work Four Tantras (Rgyud bzhi) was compiled. Here, we find early references to precious pill preparations, which are further discussed in Section 4. Throughout Tibet's history, this seminal text, which is in part still memorized by Tibetan medical students today, was presented by some as the words of the Buddha, and by others as the written work of the famous medical and Buddhist master Yutok Yönten Gönpo. This debate has continued throughout Tibet's history (Gyatso 2015;Karmay 1998;McGrath 2017b). Each perspective developed its own spiritual practices passed down along medical and Buddhist sectarian lines, impacting and also competing with each other. Stacey van Vleet has pointed out that "contemporary scholarship has generally not acknowledged any relationship between Tibetan medical debates and Buddhist sectarian controversies" (Van Vleet 2016, p. 266).
By way of example, and based on the Medical History (Gso rig sman gyi khog 'bugs) written by the regent of the Fifth Dalai Lama, Desi Sangyé Gyatso (Sangyé Gyatso and Kilty 2010), van Vleet summarizes the alliances between medical and Buddhist schools: "[T]he rivalry between the Jang and the Zur medical traditions was tied to rivalries among Tibetan Buddhist traditions. While the [southern] Zur medical tradition had developed institutional ties to the Kagyüpa and later the Gelukpa orders, the [northern] Jang medical tradition held ties with the Jonangpa order" (Van Vleet 2016, p. 275). 24 Then, she presents a historical example that highlights how medicine was practiced and linked to Tibetan Buddhist schools, especially in terms of ritual and tantric practices, which will give us some insight into the historical contexts of black pill transmissions. During the 17 th century, in an effort to reconcile different tantric practices in a more systematized way of teaching medicine, the Fifth Dalai Lama in Lhasa promoted the sutra-based spiritual tradition of the Medicine Buddha more than the tantra-based, master-focused propagation of medical practice such as the Yutok Nyingtik, which had Yutok Yönten Gönpo as the focus of meditative visualization (Van Vleet 2016). Such efforts were officially framed as the "Fifth Dalai Lama's legacy to create a unified Tibetan medical tradition untouched by 'the demon of [sectarian] prejudice'" (ibid., p. 266). However, as van Vleet's analysis shows, the Fifth Dalai Lama's Guidelines (written in 1676) on how Sowa Rigpa should be practiced was an effort to make peace with and at the same time undermine heterodox views at the Tsarong medical school in Tsang after a period of warfare. This medical school followed the Kagyüpa school of Tibetan Buddhism and the Zur medical tradition (whose representative also published the black pill formulas discussed below) (ibid., p. 268). The Zur medical school was also more strongly associated with the Yutok Nyingtik practice (ibid., p. 268). In his effort to unify medical ritual practices as part of the new "state medical orthodoxy," the Dalai Lama also made a point to systematize medicine by distinguishing the "ordinary" medical practice from the "doctrinal view, meditation, and conduct", thus carving a separation between the medical and religious domains of Sowa Rigpa, which resulted in more distinct ways of classifying, standardizing, teaching, and controlling Sowa Rigpa, and at the same time unifying the various existing religious and ritual medical practices (ibid., p. 276).
As we shall see with the Tibetan pill traditions discussed here, the spheres of medicine and religion remain entangled: the making of precious pills are often sponsored by Buddhist patrons (Czaja 2013;Gerke 2017), and blessing pills are still made in both medical and Buddhist schools and are therefore vulnerable to sectarian politics. We saw how the Shukden controversy might have affected the perceived authenticity of a pill tradition. As we shall see later, the Karmapa controversy is currently impacting opportunities to make rilnak.
Profound intermingling of Buddhist and medical elements is characteristic of Tibetan pill traditions. We know that "accomplished medicine" practices from the early Buddhist Nyingma traditions significantly shaped the development of Tibetan medicine (Garrett 2009, p. 209). It comes to no surprise to find that powerful damdzé substances in the form of consecrated compounds (mentioned in the introduction) made their way into the compounding of special precious pills (rin chen ril bu), which form the pinnacle of Tibetan medicine preparations or menjor (sman sbyor) ( Figure 6). Precious pills are made by amchi, in the past often together with their lamas, and were generally sponsored by influential sections of Tibetan society (Gerke 2017). Even their recent institutionalized production in larger pharmacies is still connected to Buddhist lineages. To give an example from India: precious pills made at the Men-Tsee-Khang in Dharamsala, northwestern India, include consecrated substances, such as relics (see next section) from the 14 th Dalai Lama in the form of dütsi chömen. This is a multi-compound formula made at the pharmacy of the Men-Tsee-Khang, which is consecrated at the 14 th Dalai Lama's temple and added as a jinten to the precious pills produced back at the Men-Tsee-Khang. Dütsi chömen is a prime contemporary example of an institutionally made medical formula merged with the blessings of the Gelukpa Buddhist school. As we shall see later, it is also a key element of the overlap between the Karmapa black pills and precious pills.
The dütsi chömen made by the Men-Tsee-Khang follows a specific formula and contains more than 100 ingredients, and even includes small amounts of standard herbal medicine formulas made at the Men-Tsee-Khang pharmacy for the prevention of infectious disease, such as Norbu Dünthang and Pangyen 10. 25 Thus, consuming precious pills made at the Men-Tsee-Khang translates into taking a complex medical compound and at the same time ingesting the spiritual blessings of the 14 th Dalai Lama, and specifically the perceived potency related to this lineage as manifested in their jinten.
Consequently, other small-scale private pharmacies who affiliate themselves with the Men-Tsee-Khang and the Dalai Lama use these precious pills as a papta (through crushing one precious pill from the Men-Tsee-Khang into their own batch of the same precious pill during production) 26 to consecrate their own batches of medicines. This kind of medico-ritual collaboration between physicians and high-standing representatives of certain Buddhist schools in the making of medicines is not unique to Dharamsala, but has been widespread in Tibetan societies for a very long time. It is deeply linked to patronage. Janet Gyatso highlights two key historical themes of the confluences of Sowa Rigpa and Buddhism, emphasizing patronage: "One has to do with the long association between Buddhism and medicine in India. The other issues out of the close connection between the patronage of Buddhism and medicine in the story of the early Tibetan kings. The upshot, in the particular circumstances of Tibetan history, is that Buddhist symbols, discourse, and institutions directly facilitated the state's patronage of medicine" (Gyatso 2015, p. 98).
Historically, the Drangti medical school had a "longstanding intimacy with Buddhists of royal and political power" (Garrett 2014, p. 179), which dates back to Tibet's imperial times. The Drangti medical school provided the royal physicians to the Tibetan imperial court, and later to the Sakya leaders 27 , before the school branched off into the northern Jang, southern Zur, and Gongmen (gong sman) medical traditions during the 15 th century (ibid., pp. 180, 183).
Early medical texts abound with instructions blending medicines and ritual healing practices (ibid., p. 183). They also include details on mercury processing and the making of precious black pills (rin chen sman nag) (Czaja 2013, p. 79), including both local traditions and techniques imported from Tibet's neighbors (Gerke forthcoming). Furthermore, an enduring theme among Tibetan materia medica texts is the use of Buddhist relics or ringsel, outlined next, which became an integral part of pill traditions and whose perceived potency also dates back to Tibet's empire.

Relics in Medicine
"Supreme jewels" (mchog gi nor bu) are given a special status among other precious substances in many Tibetan medical texts. Already at the turn of the 14 th century, the Third Karmapa, Rangjung Dorjé (1284Dorjé ( -1339, who was also instrumental in the black pill tradition discussed below, opens his chapter on precious substances in his medical dictionary titled Ocean of Medical Terms (Sman ming rgya mtsho) with this statement: "The supreme jewels are the ringsel of the Victorious one [= the Buddha]. All your desires will certainly be fulfilled; the disciples themselves [will attain] Bodhicitta. Thus, the relics from a devoted yogin, even if offered, when tying it to the body [as an amulet], will keep all negativities away" (Karmapa Rangjung Dorjé 2006, p. 199/10-13) 28 .
Rangjung Dorjé does not mention eating ringsel as medicines. However, the idea of ringsel being supreme among precious substances is an enduring practice in Sowa Rigpa. Ringsel are mentioned throughout the literature, such as in Lozang Chödrak (1997) Ornament of the Forefather's Thoughts (Mes po'i dgongs rgyan) of 1680, Sangyé Gyatso's commentary on the Four Tantras, the Blue Beryl (Baid .ū rya sngon po), completed in 1688 (Sangyé Gyatso 1982), and in Deumar Geshe (Tendzin Püntsok 2009) early 18 th century Crystal Orb and Rosary (Shel gong Shel phreng) 29 . Even modern color-plated books on precious substances published by Tibetan medical institutes in the Tibetan regions of the People's Republic of China depict relics as "supreme jewels" at the beginning of chapters on precious substances (Gawé Dorjé [1995Dorjé [ ] 2018Kelden Nyima 2010, p. 8), and some include the Third Karmapa's quote mentioned above (e.g., Gawé Dorjé [1995. Ringsel are hard substances retrieved from the ashes after the cremation of high lamas. (Kelden Nyima 2010, p. 8) describes ringsel as being sourced from the dead body (sku gdung) of a great being. They can be small or large and often look like pills. They are mostly white, but pale blue or rainbow-colored designs also exist, and they have wondrous characteristics. They can also be retrieved from lake shores, such as Lake Namtso, and springs. In materia medica texts, spring-generated relics (chu tshan ring sel) are described as sweet in taste and having benefits for certain diseases, such as healing broken bones, providing essential nourishment (bcud), as well as eliminating harmful spirits (gdon) (Gawé Dorjé [1995] 2018, p. 34).
Ringsel embody the complex notions of the preciousness, vitality, and potency of the early Tibetan kings, who were often considered Buddhas or Bodhisattvas, and left relics (ibid., p. 67). We can see here how potency is partaken, imbibed, and offered in the form of jinlap, the 'wave of jin' (byin) 30 that is transferred to the receiver who partakes in the (royal) power and presence of such precious substances in the form of medicines or special pills. Based on ethnographic research with Tibetan lamas in India, Tanya Zivkovic argues that relics are "animate materials" and a "biographical extension of a lama's live" (Zivkovic 2010, p. 186) and carry the potency of "living agents" (cf. Germano 2004, p. 52). Since ringsel received the first place in the list of precious substances among the medical authors mentioned above, it is clear that its potency is considered very special, and has been highly valued over many centuries.
As explained above, at the Men-Tsee-Khang in India, ringsel are added in very tiny amounts to precious pill formulas (as part of the dütsi chömen). Thus, they carry a particular Buddhist lineage's potency. Every pill tradition has its own set of ringsel and other consecrated Dharma medicines, which are also an expression of the tantric bond (samaya) with the master who blessed them. In the context of a Nyingma mendrup ritual, Cathy Cantwell lays out this relationship between the master, disciples, and the consecrated substances taken: The efficacy of the medicinal pills is not only seen in terms of the proficiency of the lama and his team in producing an effective product, but more in terms of effectively transmitting the blessings of the practice and its lineage of masters. Thus, not only is it crucial to include the Dharma medicinal pills of the great teachers of the tradition, but it is equally important not to sully this special embodiment of their blessings with those with which one does not have the same personal connection. So, the medicinal substances should not include Dharma medicines of lamas from lineages which are not closely connected. Many practitioners avoid altogether medicinal pills from uncertain sources, or from lamas who represent lineages with which they are not personally connected. (Cantwell 2015, p. 55).
This issue of religious affiliation tends to be overlooked in the increasing industrialization and mass production of Tibetan medicines. However, a closer ethnographic look reveals that lineage and samaya are still at the base of Sowa Rigpa practice and impact the development of the industry in indirect ways (see Tidwell unpublished, on these issues in eastern Tibet). Rinchen Drangjor is the only precious pill that has a historical link to the Karmapas, who are known for their own black pill tradition. Therefore, Rinchen Drangjor is a good example to explore the medico-religious interface of Tibetan black pill traditions.

The Precious Cold Compound Black Pill (Richen Drangjor Rilnak)
The "Precious Cold Compound Black Pill" or Rinchen Drangjor Rilnak, which is also known as Rinchen Rilnak Chenmo, has become the most prestigious precious pill formula of Sowa Rigpa today. The Men-Tsee-Khang in India presents it as the "king of all precious pills." 31 Therapeutically, Rinchen Drangjor is given for complex chronic diseases such as cancer, and all kinds of poisoning and illness caused by environmental pollution (Bauer-Wu et al. 2014, p. 510). It is also taken as a tonic, worn as a protective amulet, and kept on Buddhist altars at home for emergencies. It is the most expensive Tibetan precious pill, also sold in the People's Republic of China (Figure 7), where precious pills drive a significant part of the Tibetan pharmaceutical industry, and where Rinchen Drangjor was listed under the name 'Renqen Changjor' in 2006 in the UNESCO-inspired "Intangible Cultural Heritage 30 Jin is one of the attributes associated with the old Tibetan kings. The pre-Buddhist divine king possessed jin as "a personal property or quality of his physical body" in the sense of "splendour" and "glory" (Huber 1999, p. 90). 31 rin chen kun gyi rgyal po lta bu yin. Men-Tsee-Khang leaflet on Rinchen Drangjor in Tibetan (Gerke 2017, p. 8).
List" (Gerke 2013, pp. 133-34;Saxer 2013, p. 205). Where does this pill tradition come from, and how did it evolve over time? The following explorations demonstrate how the use of processed mercury as a key ingredient of black pills has been intertwined with medical and religious domains in Tibet for a very long time.

The Lineage of Black Pill Traditions
In the 15 th century, the famous representative of the Zur medical tradition, Zurkhar Nyamnyi Dorjé (1439-1475), wrote extensively on mercury and included black pill instructions in his famous Relics of Countless Oral Instructions (Man ngag bye ba ring bsrel; Nyamnyi Dorjé 1993). More than 100 years had passed between him and the death of the Third Karmapa, who is claimed to be the first lineage holder of the tsotel mercury practice after the polymath Orgyen Rinchen Pel (1230-1309) from the Swat valley-today's Pakistan-introduced it to Tibet in the 13 th century (Czaja 2013;Gyatso 1991, p. 39; Gerke forthcoming) 32 . While the contemporary Tibetan author Sönam Bakdrö writes that the Third Karmapa received the mercury processing knowledge from Orgyenpa himself (Sönam Bakdrö 2006, pp. 31-32), Czaja maintains that there is no clear textual evidence to support this, even though the Third Karmapa included the "eight metals" (lcags brgyad), which are essential components of making tsotel in his list of precious substances in his Ocean of Medical Terms (Czaja 2013, p. 78, referring to Karmapa Rangjung Dorjé 2006). Nyamnyi Dorjé probably had access to the medical dictionary written by the Third Karmapa, since as a representative of the Zur medical tradition, he followed in the line of Karma Kagyü traditions (Gyatso 2015;Van Vleet 2016). However, we do not know exactly from where he received this lineage of black pills, but it seems that from the beginning, the black pill traditions were linked to the Karma Kagyü School of Tibetan Buddhism, while the mercury practices spread across several schools (Czaja 2013; Gerke forthcoming).
Nyamnyi Dorjé claims to be the first to write down the black pill formulas (Gyatso 1991, p. 39) following the request of his devoted student Trakwön Sönam Trashi, whom he instructed to pass it on only to trusted disciples who are "devoted, diligent, and very compassionate" (ibid., pp. 48, 52, note 59). Later, Nyamnyi Dorjé's student Kyempa Tsewang (born 1514) also wrote about a "major black pill" (ril nag chen mo) (Czaja 2013, p. 81). According to tradition, the lineage went on to the Drigung school, and then later to Situ Chökyi Jungné (1700-1774) in eastern Tibet (ibid., pp. 81, 90). 32 On the life of Orgyenpa based on his biographies, see Li (2011).

Drigung Rigzin Chökyi Drakpa (1595-1659)-briefly known as Drigung Chödrak or Drigung
Dharmakirti-was a trained physician and the 23 rd throne holder of the Drigung Kagyü, one of the sub-lineages of the Kagyü school of Tibetan Buddhism. In 1657, he taught Rinchen Drangjor manufacturing to "more than ten doctors in Drigung" (ibid., p. 82). He wrote/collated 11 short works on precious pills and mercury processing. 33 Among those, nine works deal specifically with rilnak, and two deal with precious pills in general.
Curiously, in the 14 th and 15 th centuries, mercury pills were collectively known as "black medicines" (sman nag) 34 , and several Tibetan medical texts treat cold compounds and black pills analogously (ibid., pp. 79, 88) 35 . The details of these overlaps still need to be researched, and the following analysis is preliminary. I begin by looking at the number of Rinchen Drangjor formula names and ingredients, and how cold compounds are explained in the Four Tantras.

Rinchen Drangjor Formulas
The number of ingredients of Rinchen Drangjor differ in the published literature: there are 140 ingredients according to the Men-Tsee-Khang website 36 , 152 ingredients in a contemporary Tibetan menjor book published in India (Dawa Ridak 2003, p. 366), and 119 ingredients in popular literature on precious pills (Aschoff and Tashigang 2009, pp. 63-67 (Gyatso 1991, p. 44;Nyamnyi Dorjé 1993, p. 292/10). Based on these counts, we can assume that extensive reformulations of Rinchen Drangjor Rilnak have taken place over the centuries, building on an early formula with 83 ingredients. 38 One of the works in the recently published collection of medical texts of the Drigung medical school frames all those 83 ingredients into a mythological story in which the king (representing mercury) "churned evenly" (bsrub pa'i sbyor bas) 39 with the queen (sulfur) that transforms him into a dark color, becoming more powerful than before (mercury sulfide) (Drigung Chödrak and Könchok Dropen Wangpo 2007, p. 76/14-16). The 83 royal court members of the formula include the queen, external and internal ministers, messengers, servants, supreme tantric practitioners, heroes, companions, sympathizers, external and internal security guards, personal attendants, and other followers of the great king. Together, they are able to completely extinguish the 404 collective diseases of hot and cold, 33 These 11 works are also listed in Czaja 2013, p. 81, note 32. They were also included in vol. 1 of the Drigung Collection of Sowa Rigpa ('Bri gung gso rig gces bsdus). See Drigung Chödrak and Könchok Dropen Wangpo 2007, pp. 76-114. 34 See, for example, Dorjé Pelzang's work Measure of Silver (Dngul bre), which flourished during the 15th and 16th centuries (Czaja 2013, p. 79); and Drangti Penden Gyeltsen's work of the 15 th century (Drangti Penden Gyeltsen 2005, pp. 143-57). 35 Czaja here refers to Yeshe Zangpo (2007, pp. 267-82). 36 https://www.men-tsee-khang.org/medicine/rinchen-pills/drangjor.htm. Last accessed 8 March 2019. 37 These additional ingredients are also found in vol. 2 of the Drigung collection (Pöntsang Yéshé 2007, p. 241/6-17). Note that this collection contains texts by various authors from different centuries. 38 These examples are not exhaustive. One would have to look at many more medical texts to trace the development of the formula. Moreover, not all reformulations are published in the texts. On the nature of Tibetan formulas, see Gerke (2018). 39 On a tantric level, this refers also to their sexual union. extend the lifespan, and increase merit and wealth (ibid., pp. 77/1-78/16). These kingdom-related categories are a method to mask the 83 ingredients listed by Nyamnyi Dorjé, who chose a simpler classification (explained further below).
When did Nyamnyi Dorjé's early black pill formulation become known as Rinchen Drangjor Rilnak? Drigung Chödrak gave us one possible answer in a short appendix written on black pills (ibid., pp. 90-91). There, he defined the traditional black pill formula as passed down by Nyamnyi Dorjé as the "medicine of the rilnak textual tradition" (ril nag gzhung gi sman) with 83 ingredients. If 20 herbal substances are added to those (kha bskong bsdoms), the resulting formula with 103 ingredients is presented as Rilnak Drangjor Chenmo (ibid., pp. 90/13-91/2-4).
Generally, added conscreated substances and papta are not counted as ingredients. If one would actually count all the ingredients of the dütsi chömen that are added as a jinlap to the Rinchen Drangjor at the Men-Tsee-Khang in Dharamsala, this precious pill would contain around 250 substances. The Men-Tsee-Khang is the only Tibetan medical institute in India that manufactures Rinchen Drangjor on a regular basis. 40 The Men-Tsee-Khang calls this formula "Rinchen Drangjor Rilnag Chenmo" (rin chen grang sbyor ril nag chen mo), which they translate as "The Precious Black Pill of Cold Compound." 41 In a medical text published by the Lhasa Mentsikhang, one also finds the name "Great Black Precious Pill" (rin chen ril nag chen mo) (Troru Tsenam [2011Tsenam [ ] 2012. The name of the pill merges several distinct ideas. First, there is the use of precious substances or rinchen. Second, there is the mercury processing technique called "cold compounding" or drangjor (grang sbyor), which refers to the use of processed mercury and a mercury processing technique not involving heat (see Section 4.3). Third, there is the signifier of a powerful pill, which is represented by the adjective "black" or nak (nag) (see Section 5.1), and "great" or chenmo (chen mo). Both adjectives allude to the inclusion of tsotel, which is the complex organometallic mercury sulfide compound added to many precious pills. Curiously, Rinchen Drangjor is the only precious pill that is also called "black pill." Other precious pills are known as, for example, "Precious Great Refined Moon Crystal" (rin chen btso bkru zla shel chen mo), "Precious Great Multi-Compound" (rin chen mang sbyor chen mo), or "Precious Wish-fulfilling Jewel" (rin chen ratna bsam 'phel). 42 The next section traces the early meanings of Drangjor.

Cold Compounding (Drangjor)
"Precious Cold Compounding" or Rinchen Drangjor (rin chen grang sbyor) is first described in the 12 th century Four Tantras as a technique to process mercury (chapter 12 of the Last Tantra) 43 . The question arises of how Drangjor became part of the name of a particular precious pill. In the Four Tantras, Drangjor is introduced as cold compounding along with a hot compounding, or Tsajor (tsha sbyor), both referring to techniques used in the transformation of mercury. Both Drangjor and Tsajor do not refer to treating either hot or cold disorders, as is often wrongly assumed. 44 Tsajor is a technique in which mercury is processed by heating it in a pot with sulfur and other substances on a coal fire (MTK 2015, p. 128). The resulting mixture is formed into pills and treats both hot and cold-natured illness, such as "hot natured tumors", and it "dries up ascites, localized edema, and pus 40 Gerke (2017, pp. 211-12) for a list of precious pills currently produced in India. 43 This chapter has been translated by (MTK 2011(MTK , 2015. For the Tibetan version, see Yutok Yönten Gönpo 1982, pp. 601/9-604/14. See also Gerke and Ploberger (2017, pp. 583-92) for a translation of and an introduction to this chapter. 44 The Men-Tsee-Khang loosely translates the phrase "sbyor ba tsha sbyor grang sbyor rnam pa gnyis" (Yutok Yönten Gönpo 1982, p. 601/14-15) as: "Compounds of precious medicines are of two types: compounds that cure hot disorders and compounds that cure cold disorders" (MTK 2015, p. 128 caused by cold disorders" (ibid., p. 129). 45 The cold compounding is described in nine steps. No heat is applied, but mercury is triturated and "smoothened" ('jam btsal) with various acids and medicinal substances. 46 The nine steps also involve steps on how to open and close the body channels in the patient in order to better absorb the mercurial medicine, how to take the pills, and how to better retain processed mercury in the body (ibid. pp. 129-31). The Drangjor technique reveals nothing specifically Buddhist at first glance. It describes nine steps to process mercury. The section is followed by 19 formulas, which when mixed with processed mercury "cure all diseases that are difficult to heal" 47 . However, Carmen Simioli recently discovered notable parallels between these nine Drangjor mercury processing steps and a Nyingma Treasure revelation or terma (gter ma) text, titled the Vase of Amrita of Immortality ('Chi med bdud rtsi bum pa), which has been preserved in the Rinchen Terdzöd (Simioli 2016). According to Simioli, mercury-containing medicines used during certain mendrup rituals "absorb the powers of nine special substances," which seem to parallel the nine processing methods of mercury in the Four Tantras. During the mendrup ritual, the nine steps are part of an internal alchemical visualization. Two of the nine steps refer to internal yoga practices to open and close the channels when taking mercury (ibid., p. 408). Simioli suggests that, "It could be plausible that the tantric ritual associated to mercury processing was omitted in the medical writing in order to be kept secret and be taught orally" (ibid., p. 40). This would correspond to the nature of Sowa Rigpa medical and ritual training, which is often kept secret, and transmitted only orally. While it is difficult to say when and how these two texts impacted each other, and which one was written earlier, it demonstrates a shared medico-ritual practice with a strong tantric Nyingma influence to process and take mercury (also ritually) in order to treat severe diseases, such as poisoning.
Zurkhar Nyamnyi Dorjé treated Drangjor as a particular mercury-processing technique rather than as the name of his black pill formulas. He actually stressed that the most profound mercury processing technique is the one introduced to Tibet by Orgyen Rinchen Pel. It involves the making of tsotel, including eight preprocessed metals and eight preprocessed minerals (Gyatso 1991, pp. 40-41). This practice was initially passed on through practitioners related to the Karma Kagyü Buddhist school and the Zur medical school. The nine-stage Drangjor mercury processing technique existed before Orgyenpa's more complex techniques of making tsotel came to Tibet, and seems to have been embedded in an early Nyingma context. The process of making Nyamnyi Dorjé's black pills, which will be introduced next, involves the hot trituration of mercury. Thus, it is strictly speaking not a cold compounding method in the way that Drangjor is introduced in the Four Tantras.

Nyamnyi Dorjé's Black Pill Formulations (15 th Century)
Nyamnyi Dorjé's Relics of Countless Oral Instructions contains several texts on mercury and mentions many formulas that contain processed mercury. To date, his black pill instructions are the only part of his work that has been translated into English. 48 His instructions begin with a section on the processing of mercury (attributed to Orgyen Rinchen Pel), followed by directions on how to preprocess the precious gems. Both are preliminary practices to be completed before actually making the black pill formulas. Nyamnyi Dorjé presents three versions of black pills: the major (with 83 ingredients), a medium (with 27 ingredients) and a minor formula (with 10 ingredients). Some of the ingredients that he listed are of human origin.
His three black pill formulations all contain mercury (dngul chu) and sulfur (mu si) as key ingredients. This is a step ahead when compared to the descriptions of the Drangjor processing technique described in the Four Tantras, which does not mention sulfur-a necessary ingredient to transform the elemental mercury into a stable and much less toxic mercury sulfide compound (Liu et al. 2008;Tidwell and Nettles forthcoming;Gerke forthcoming).
How similar are the 83 ingredients of Nyamnyi Dorjé's major black pill formula compared to the later published formulas of Rinchen Drangjor and those in circulation today? What is the nature of the substances used? How does that change over time, and what do the ingredients tell us about the inclusion or exclusion of certain types of substances? How were they reformulated by later practitioners? While this article cannot answer these questions in detail, I present some preliminary insights that might inspire future research to answer these questions. Nyamnyi Dorjé's major black pill formula contains several substances of metal, mineral, human, and animal origin, and represents an early medico-religious interface of what was deemed powerful and potent. Nyamnyi Dorjé's 83 black pill ingredients are classified into six groups: mercury, sulfur, and other precious substances (rin chen), rock medicines (rdo'i sman), distinguished medicines (bzang sman), herbal medicines (sngo sman), horns, feathers, and hair medicines (rva sgro spu'i sman), and indispensable secret medicines (med thabs med pa gsang sman) 49 .
His "precious substances" include preprocessed metals (gold, silver, copper, and iron) and gems such as old turquoise, amber, pearl, lapis, coral, ruby, and sapphire, among others. "Rock medicines" include, for example, calcite, iron ore, and lodestone. "Distinguished medicines" include herbs, but also bear's bile, musk, and "the unrotten liver of a 12-year-old girl who died suddenly," as well as the "fore-arm muscle of a middle-aged man who has been killed with a sword," 50 and the first stool of a human baby, a horse, and a dog (Gyatso 1991, p. 43). "Herbs" include white, red, and yellow types of aconite (bong nga dkar dmar ser) and about 19 different herbs and seeds. The section on "horns, feathers, and hairs" includes preprocessed rhino horn, peacock feathers, spines of porcupine, a set of tiger whiskers, and "hairs of the armpit and crown of the head of a clean girl born in the year of Tiger, which are calcined with the sun's heat through a convex glass" (Gyatso 1991, p. 43) 51 . The "indispensable secret ingredients" include human and deer fat (mi dang sha ba'i tshil) and refer to the further alchemical processing of black mica (a pa ra), golden-colored sulfur (mu zi gser 'dra), preprocessed mercury, and iron (lcags). Notably, Nyamnyi Dorjé's processing of iron, which is considered indispensable, parallels the ways in which the Karmapa's black pills are colored black, i.e., through soaking iron pieces in a decoction of myrobalan fruits. This processing and its relation to 'blackness' in pill traditions will be discussed later in the section on the Karmapa's rilnak.
Some of the human and animal products listed above are similar to the common "five nectar" (bdud rtsis lnga) tantric substances of Indian and Tibetan Buddhism described by Garrett (2010, p. 301) 52 . Following Garrett (2010), it makes sense to see the human fat, flesh, organs, stool, and armpit hair, or tiger whiskers, rhino horn, and peacock feathers as emerging out of a shared body of early tantric and medical literature that deemed substances not only as beneficial to cure illness, but also as enhancing 49 See (Chui forthcoming) on the category of "secret medicines" that might be human in nature and are mentioned in the medical works by Sangyé Gyatso and related commentaries. 50 Gyatso's translation of: bu mo lo bcu gnyis ma glo bur du shi ba'i mchin pa ma rul ma sungs pa'am/ and skyes dar ma grir shi ba'i lag pa'i nywa sha zho gang/ in Nyamnyi Dorjé (1993, p. 290/20 and p. 291/1). See (Chui forthcoming) for a discussion on human substances and potency, where he explains that the statement regarding humans or animals killed by a sword or knife refers to sudden or accidental deaths of which the flesh is deemed more potent, since it is considered generally more healthy, i.e., "without disease" (nad med). 51 Gyatso's translation of: bu mo stag lo ma gtsang ma'i mchan 'og dang spyi bo'i skra tshom pa gcig rnams me long nang du 'od bsreg bya/ (Nyamnyi Dorjé 1993, p. 291/15-17). 52 For the debate on the symbolic, literal, or semiotic interpretations of such tantric substances, see for example, (Chui forthcoming), (Garrett 2010;Wedemeyer 2007).
vital power and longevity. 53 Tantric substances are known to unfold their potency more fully when handled secretly (Chui forthcoming). Some of the human and animal substances are still listed in today's published formulas of the precious pill Rinchen Drangjor Rilnak, but they are probably not used in practice, or are substituted 54 . However, by the 17 th century, we see an interesting reformulation of Nyamnyi Dorjé's black pill, more than doubling the amount of herbal substances in this formula. Drigung Chödrak argued that if you make Rinchen Drangjor without these additional 20 herbs, it is like fighting a battle without arms; you need a quick acting (myur), sharp (rno), and very strong (tshan che) compound to fight disease. Therefore, these 20 plants should be added to the traditional black pill formula (Drigung Chödrak and Könchok Dropen Wangpo 2007, p. 90/5-7). Why would Drigung Chödrak more than double the amount of herbs? Did the previous black pill formula turn out too weak to fight the diseases of the time? Did they require more herbs to make larger amounts of pill material not having enough of the more expensive or rare precious ingredients? Further research is needed to answer these questions and to verify whether this demonstrates a development from earlier formulas based more on various tantric, metal, and mineral substances toward predominantly herbal formulas. If so, this might also parallel a change in what kind of substances and medical compounds were conceived as potent.

The Karmapa's Black Pills
The Karmapa's black pills, which are given to devotees as jinten, appear to be quite different from the precious pill Rinchen Drangjor Rilnak Chenmo described above, even though they share the same name: "black pill" or rilnak. However, these pills seem to have some parallels that are linked to nectar medicine practices and the processing of certain ingredients. I was fortunate to get the opportunity to interview two senior representatives of the Karma Kagyü lineage who were present at Rumtek monastery in Sikkim in 1972/73 when the 16 th Karmapa Rangjung Rikpé Dorjé (1924Dorjé ( -1981 last made his black pills. Khenpo Chödrak and Tsültrim Namgyel are brothers and related to the 16 th Karmapa, who was their maternal uncle. Tsültrim Namgyel became the sopön (caretaker of the 16 th Karmapa's private room) in 1962, and Khenpo Chödrak the Khenpo (a degree holder for one who has mastered Buddhist Studies) at Rumtek monastery. Both witnessed the making of black pills at Rumtek in the 1970s.
Traditionally, a Karmapa has to make black pills at least once in his lifetime. The 16 th Karmapa made them twice: once in the 1950s at Tsurpu, the seat of the Karmapas in Tibet, and once in Rumtek in Sikkim, where he settled in exile after 1959. Based on my interviews with the two brothers, I briefly summarize how the Karmapa's black pills are made 55 .
The altar is prepared with specific sacred statues of the Eighth Karmapa Mikyö Dorjé. A marble statue of the female deity Vajrayoginī is on the right side of the altar. On the left is a statue made by hand with the imprint of the fingers of the Eighth Karmapa, who mixed jewels into a dough and made this statue. Khenpo Chödrak said that it looks like a piece of tsampa (dough made from roasted barley flour) with a finger imprint, but on touch, it feels similar to strong and hard marble. Next to that statue is another white marble object, and several offerings.
Making rilnak requires a certain skill of rolling very small pills in equal size (about 1-mm diameter). At Rumtek, a selected group of fully ordained monks were especially trained and were tested on their pill-rolling skills before they were allowed to join the group of monks, who actually rolled the black pills. Lama Tsültrim Namgyel remembered that three days before making the pills, the Karmapa placed his empty cup on the throne overnight; in the morning, it was filled miraculously with snow lioness milk. This was an offering by the Tibetan mountain deity Nyenchen Tanglha (mentioned earlier in the paper), who with its close proximity to Tsurpu in eastern Tibet used to serve the Karmapas 56 .
The Karmapa himself prepares the dough from the Tibetan staple, tsampa. Then, he adds the special jinten, dütsi chömen, relics, and other damdzé and papta from his sacred collection. For around 50 spoons of tsampa, he adds one or two spoons of the damdzé, of which different kinds have been mixed together. Only the Karmapa himself can make the mother pills (a ma ril bu) of about three to four millimeters in diameter. They are said to self-generate ('phel dung), which means that a mother pill can give off many little baby pills. This notion of self-generation, which we find also in other contexts 57 , is based on the idea that authentic jinlap never diminishes. Khenpo Chödrak observed that when you chisel off a piece of a papta made of damdzé, the next day it grows back to its original shape. He explained: The damdzé have both the potency of blessing, jinlap kyi nüpa [byin rlabs kyi nus pa], and the potency of substances or dzé gi nüpa [rdzas gi nus pa]. It is a substance, but the power comes from the jinlap. It derives from the practice of not separating from the Bodhicitta mind for even one instance; the nüpa derives from that practice.
About the actual process of making the pills, Khenpo Chödrak recalls: They [the group of selected monks] 58 start in the morning. The first session takes four hours. They begin with the Guru Yoga [of the Eighth Karmapa], then they recite the Karmapa Chenmo mantra and start making the rilnak. Each monk receives the size of the tip of a thumb of dough material [which was made by the Karmapa himself]. It takes them about two and a half hours to roll the tiny pills. The monks have to be very clean and wash their hands and feet. Each time they enter the room, they have to wash themselves again. When they complete the pill rolling in the evening, whatever pills they have made they place them in the begging bowl of the seventh Karmapa. They cover the bowl with the Fifth Karmapa's yellow robe and use the robe of the Eighth Karmapa as a lid. 59 This practice continues for a few days. During the night, the mother pills might multiply and even spill over. Once enough pills have been made, it is time to blacken the pills.

The Meaning of Black
The Tibetan term for black is nak (nag). Nak also refers to something powerful and potent, but not necessarily black in color. A medical dictionary explains the meaning of black also as "a word for iron" (lcags kyi ming) (Jampa Trinlé and Bod rang skyong ljongs sman rtsis khang 2006, p. 415). In the pill traditions, we come across two meanings of nak. In Sowa Rigpa, the black pills seem to refer to the use of mercury. When mercury is triturated with sulfur, it results in a blackish paste; tsotel is known for its blackish color. We have seen that the early use of rilnak in medical texts is a synonym for mercury-containing pills. The mythological story of Rinchen Drangjor Rilnak told above also alludes to black as referring to the making of mercury sulfide, since the king (representing mercury) merges with the queen (sulfur) and transforms into a dark color (mercury sulfide), becoming more powerful than before (Drigung Chödrak and Könchok Dropen Wangpo 2007, p. 76/14-16).
The second meaning of nak refers to the black color of processed iron (lcags rtsi), which is used in Sowa Rigpa to color certain pills black (e.g., Dashel Dütsima). A similar technique appears to be used by the Karmapas to blacken the rilnak, although the pieces of iron they use have special religious and 56 See Ruth (Gamble 2018, p. 112) on the relationship between the Third Karmapa and Nyenchen Tanglha. 57 Other examples are: Ringsel self-generate in a way where larger ringsel produce smaller ones (Guidoni 2006). During the Bumchu festival at Tashiding monastery in Sikkim, self-generated sacred water is distributed to the public (see Dokhampa 1992). Personal Communication, Tashi Tsering, Dharamsala, December 2017. 58 The brothers remembered the numbers as somewhere between 16-25. The monks had to pass a test and were trained in forming equal-sized small pills with great precision. 59 Here, stories differ. Holmes wrote it was the Third Karmapa's begging bowl as well as his robes (Holmes 1995, p. 141). historical significance that is linked to their particular lineage masters. The emphasis on black within the Kagyü tradition also appears in a pun on the Karmapas in the biography of the 15 th century crazy yogi Drukpa Kunley, which circulates in several oral and written versions. Khenpo Chödrak recalled this humorous story as follows: Drukpa Kunley came one time to the Tsurpu monastery (seat of the Karmapa) and offered a handful of tea to the monks. When he was reprimanded by the cook that this was too little tea to offer to so many monks, Drukpa Kunley exclaimed: "Everything here is black! You have black hats, black pills, black tea water, monks are like black dogs, there is a black cliff behind Tsurpu, a black lake in front, and black willows growing along a black river, and you have a black protector!" Afterwards, the Karmapa was very friendly to him. 60 Khenpo Chödrak and Lama Tsültrim Namgyel both remembered how the black color of the pills is created. For this, three impressive metal pieces of the famous Kagyü masters of the past-Marpa, Milarepa, and Gampopa-are used: Marpa's iron trowel (which Milarepa used to work for Marpa), Milarepa's metal flint to make fire (me lcags), and the stirrup of Gampopa's horse 61 . These iron implements are boiled in water with specific myrobalan fruits (a ru ra rnam rgyal). The pills are soaked in this blackish iron-containing water and turn black. This technique is also known in Sowa Rigpa. In both traditions, this method is called "iron essence" (lcags rtsi), and both ritual and medical experts insist that the "detoxification" (dug 'don) has to be done properly to get the pills evenly colored black. Khenpo Chödrak mentioned that the Eighth Karmapa left detailed written instructions about how to make rilnak, including the processing of iron, so the help of amchi, who use the same method, was not required.
Let us briefly compare the description with Nyamnyi Dorjé's black pill instructions. Here, chaktsi is one step during the processing of mercury. Nyamnyi Dorjé writes: Mix the finely pulverized pulp of 21 unrotten, non-foul smelling fruits of Terminalia chebula with the urine of an eight-year-old child and put it in a new iron utensil, and cover with a clean cloth and when [the cloth] turns black and becomes dry, apply butter to the precious powder (the purified mercury powder), and cook. 62 There are many other descriptions of how to make chaktsi in medical texts, which cannot be explored here in detail. We can conclude that the basic formula of soaking iron with myrobalan and utilizing the blackish water for pill coloring is the same principle that is common across medical and ritual black pill traditions.

Medical and Ritual Collaboration during the Making of Black Pills and Rinchen Drangjor
It seems that at times, physicians and lamas collaborate to some extent in black pill making, but practices are principally carried out by different specialists. The collaboration appears as a flexible synthesis involving an exchange of potent substances while keeping specialized knowledge and practices distinct.
When I asked Lama Tsültrim Namgyel about the collaborations of amchi and monks in the making of black pills at Rumtek, he said: His Holiness the Karmapa had two senior physicians with him. Paljor studied with a student of Ju Mipham. The other one was called Dorjé Drakpa. He was a Tsurpu monk and trained by Tsurpu amchi. The two physicians were absolutely necessary to make the mendrup [in 1968], but they did not take part in the making of rilnak, which was done by a group of fully ordained monks and the Karmapa himself.
60 See (Dowman and Paljor 1980, p. 77) for a different version of this story, which does not mention the black pills. 61 Compare with Holmes, who writes that the metal implements of Milarepa and Marpa are used in the preparation of black pills to provide their black color (Holmes 1995, p. 141). 62 From the translation by Yonten (Gyatso 1991, p. 43) of (Nyamnyi Dorjé 1993, p. 292/2-5). See (Gyatso 1991, p. 50, note 32) for a different variation of this section in another edition of Nyamnyi Dorjé's Relics of Countless Oral Instructions.
The making of mendrup includes many more medicinal ingredients than used in rilnak, and requires the support of the amchi 63 . The 16 th Karmapa made dütsi chömen during an elaborate mendrup ritual at Rumtek in 1968, but according to Khenpo Chödrak, that dütsi chömen was not used to make the rilnak in 1972/73, since the 16 th Karmapa had plenty of jinten available at the time that were used for the rilnak. His two amchi had a clinic at Rumtek monastery and made medicines regularly. Khenpo Chödrak pointed out that since medicines used to be distributed for free to patients, amchi required the patronage of a high lama who would support them to pay for the ingredients. The practice of medicine as such was considered an act of charity. 64 This sense of patronage also extended to developing special lineage ties through pill traditions. We know from the autobiography of the Buddhist master and physician from eastern Tibet, Jamgön Kongtrül Lodrö Tayé (1813-99/1900)-also known as Kongtrül Yönten Gyatso-that during the New Year ceremony of 1838, the 14 th Karmapa, Tekchok Dorjé (1798Dorjé ( -1868, made rilnak. At the time, Kongtrül was preparing several kinds of precious pills, and the physician Karma Tsepel of Pelpung Monastery in eastern Tibet made the tsotel for them. The Karmapa's black pills were added as a papta to Kongtrül's precious pills, adding a special jinlap 65 . According to Khenpo Chödrak, this kind of collaboration was not a set requirement but happened twice, once again with the 15 th Karmapa. This must have established a papta tradition among amchi linked to the Kagyü school, in which future batches of precious pills would carry the jinten of the Karmapas through adding a papta with rilnak. This testifies to a certain collaboration between medical and ritual experts in the making of precious pills. At the same time, it demonstrates the separate fields of specialized knowledge that exist in each of these pill traditions.
To sum up, what can we conclude from the overlaps of the Karmapa's rilnak with the precious pill Rinchen Drangjor? Khenpo Chödrak explained where the Karmapa's black pills are similar and where they differ from the Rinchen Drangjor precious pill: Rinchen Drangjor is more a medicine. It is a medicine. The purpose of rilnak is two-fold: jinlap (blessing) and nyong dröl (liberation through taste). So this blessing and the nyong dröl are really different in the black pills. But rilnak is also similar to Rinchen Drangjor, because it has a medicine part. In rilnak there is a lot of dütsi chömen [Dharma Nectar Medicine]. To make dütsi chömen, they have to add all the herbs that are medicines and are not poisonous, and they have to consecrate them with a special practice, and they do it with these pills. Dütsi chömen are included in the rilnak and also in the Rinchen Drangjor; so this part is similar.
Among all the Buddhist schools, the Karmapas have the closest link to the tradition of precious pills, because the Third Karmapa Rangjung Dorjé was a disciple of Orgyen Rinchen Pel, who brought the tsotel mercury refinement practice to Tibet from the Swat valley, where he had received it from the Vajrayoginī. For Tibetan physicians, Orgyenpa is the father of the mercury practices, specifically tsotel, and the making of precious pills, including Rinchen Drangjor. Orgyenpa became a disciple of the Second Karmapa, and apparently recognized, raised, and trained the Third Karmapa, and passed on the black hat between the two incarnations (Gamble 2018, p. 2;Li 2011, pp. 274, 280-84). He could have passed on the tsotel practice to Rangjung Dorjé as well. Khenpo Chödrak explained that there is no written record that the Third Karmapa made rilnak, but oral tradition holds that this pill tradition was started by him. There is also no written record that he made precious pills, although he was trained in medicine (Gamble 2018, p. 2). However, Khenpo Chödrak was certain that the Karmapa's rilnak does not contain any mercury.

The Future of the Karmapa Black Pills
The Karmapa black pills also offer us a contemporary example of how sectarian politics can interfere with the continuity of a long-standing pill tradition. The future of the Karmapa black pill is linked to the future of Rumtek monastery and the outcome of the Karmapa controversy 66 . Khenpo Chödrak explained that there is a specific metal trunk called the rilnak box (ril nag sgam), which holds all the necessary ritual implements, such as the text, the "Catalogue of Relics" or jinten karchak, the three metal implements, and the special damdzé and papta that are required for the making of the rilnak. The moment the Karmapa returns to Rumtek, he will be able to make the rilnak again. To date, the room in which the Karmapa's implements are kept, including his famous black hat and the rilnak box, are under the seal of the High Court of Sikkim pending the outcome of the lawsuit filed by the Karmapa Charitable Trust upon the State of Sikkim and others. 67 On my question of whether it is possible to make rilnak without the implements held at Rumtek, Lama Tsültrim Namgyel replied that the power of the rilnak depends on the realization of the Karmapa. He cannot say for certain if he really needs the substances that are locked up in Rumtek. Khenpo Chödrak pointed to the self-generating capacity of the mother pills who multiply by themselves and could be used as a papta, should the rilnak box at Rumtek not become available. However, both agreed that it would be best if the rilnak box could be retrieved. It appears that currently, none of the rilnak texts or the jinten karchak are available to either of the two Karmapas. 68 The recent first-ever meeting of both Karmapas could be a step into a direction where the two lineage representatives themselves could decide about the future of the Karma Kagyü tradition, including its black pill practice 69 .

Discussion and Conclusions
Khenpo Chödrak's analysis of the distinctiveness of the two pill traditions, and the overlapping use of dütsi chömen emerging as a shared medico-religious element between rilnak and the precious pill Rinchen Drangjor (and others), brings me back to the discussions steered by Janet Gyatso on the endearing and challenging relationship between Buddhism and medicine in early modern Tibet (Gyatso 2015). Gyatso suggests that "Distinguishing between Buddhism as a civilizing force and Buddhism as a religion might help us better construe what is tempting to characterize as Buddhist elements in Tibetan medicine" (Gyatso 2015, p. 406). Throughout her book, she maintains that there are "key moments in Sowa Rigpa where distinctive emphases and orientations came into views, suggesting ways that medicine still constituted a separate knowledge system not reducible to formations of Buddhism" (Gyatso 2015, p. 100). 66 The controversy ensued around the two contenders Ogyen Trinley Dorjé (born 1985) and Trinley Thaye Dorjé (born 1983), who were both enthroned as Karmapa and have their groups of followers and lawyers who are involved in the Rumtek court case. The controversy is too complex to cover here, and the available literature is largely biased depending on which side is represented. 67 Currently, there appears to be no end in sight in the ongoing court case in Sikkim, which was filed in July 1998. 68 Tashi Tsering of the Amnye Machen Institute told me that he has seen a small text (around six to seven folios) by the Eight Karmapa on how to make rilnak. This text is kept separate, and is not included in the collected works of the Eight Karmapa.
In 2018 I have shown in the example of Rinchen Drangjor and the Karmapa's black pill that medical and Buddhist contexts are intimately intertwined. While they overlap in some regards, such as their ways of processing iron and the inclusion of consecrated substances, each tradition has its distinct texts, knowledge transmission, formulas, ways of making pills, and treating illness and misfortune. Sowa Rigpa developed strongly along the lines of Buddhist patronage and was infused with the blessings of religious lineages that were as potent as they were authoritative. In the pill traditions, they take the form of consecrated samaya substances called damdzé, such as the dütsi chömen or sacred substances such as snow lioness milk, which add to the power of jinlap to enhance the potency of specific medicines (especially precious pills), and ingest them with the continuity of lineage masters in the form of papta, which also bind those who take them to a specific place and Buddhist school. In Tibet's past, they also added additional benefits such as protection from poisons and from being hit by weapons, which were great concerns during Tibet's turbulent political times. The early formulas, such as Nyamnyi Dorjé's rilnak, also demonstrate the use of non-herbal substances that were considered potent for their shared tantric ideas of what was deemed a powerful substance, which is quite distinct from later reformulations of Rinchen Drangjor and other classical Sowa Rigpa herbal formulas. More research on Simioli's findings that mercury-containing medicines were used during early mendrup rituals might lead to discoveries of closer relationships between consecration rituals and mercury as an important damdzé substance.
What we have seen in this article is that techniques and substances merged in and across these exchanges between medical and ritual specialists, whether trained as amchi and/or monastics. They contributed to a heterogeneity of pill traditions still found in practice today. Future ethnographic research could focus on the shared and specific therapeutic usages of these pill traditions-precious pills, jinten pills, black pills, dütsi chömen, and so forth. Specifically, their use during end-of-life care could reveal shared therapeutic aims.
Moreover, the contemporary collaborations between amchi and lamas in the making of consecrated pills should draw more research attention (see for example, Sehnalova 2018). Depending on the complexity of the pill formulas, amchi are still involved in the procuring and compounding of their substances, also depending on their personal link to the lama and his lineage.
With two examples (Domo Geshe Rinpoche's jinten pills and the Karmapa's rilnak), I demonstrated that since pill traditions are so deeply embedded in Buddhist socio-political contexts, they are also vulnerable to political strife, and controversies taking place within a Buddhist school have the potential to disrupt their already very rare production.
Funding: This research was funded by the Austrian Science Fund (FWF) grant number P30804-G24.