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by Dr. Godofredo U. Stuart Jr                  
 

Pasma is a malady unique to Philippine folk medicine, bound to elements in its physical world, and like na- bales, is one of the favorite go-to diagnosis by the albularyos, hilots and medico. It is accepted as a disease entity in many provinces and tribal cultures, differing in the regional variations and contributions of myth and superstition, but sharing in the belief that it is most commonly brought about by exposure to "cold" and water in its varied presentations. Water is believed to be the vehicle by which this unhealthy coldness enters the body – through skin pores, through the vagina, cervix and uterus, or through other avenues of entry imagined by folklore or rural science, and if the exposure is repetitive enough, it eventually manifests as "pasma" in the variety of ways it can present.

Rural physics
Rural physics and the quirky provincial ways are often looked upon with urban derision and burgis incredulity, but as often, with tolerant amusement. It is a world inhabited by elves, good and bad, black and white (duwendeng itim o puti), tikbalangs and kapres, and countless other creatures of regional mythologies. The rural folk whistle to summon the wind to grace the heavy stillness of a warm day with a breeze. They slaughter a chicken, its neck spurting blood, praying as they circle the house to drive the evil spirits away. They predict tomorrow's weather by the night skies. They believe earth-dwellers inhabit the termite mounds (nuno-sa-punso) who will inflict illness on those who disrespect or disturb their earth mounds. They go to their village healers who diagnose their illnesses from imagined signs in a slaughtered pig's liver or configurations made by raw eggs or melted candles in water. In this setting of folklore, pasma finds a welcome and believable position in the health care beliefs of rural folk.

HOT-COLD DISEQUILIBRIUM
In pasma, they draw upon their abundant collection of lore and version of rural science to distill a hot-cold belief system. They believe in the contributions of the physical elements in the causation of disease, in the imbalances of hot-and-cold, and how water facilitates the entry of negative or "cold" energy through traditional pathways or mysterious and imagined conduits. Cold water is believed to be harmful to health if one is exposed to it after physical exertion. Washing the hands or feet when tired is ill-advised. Showering or even a sponge bath after a hard day' s work is avoided, as this can cause the cold to enter the body through the skin pores. Showering or washing after sexual intercourse is not advisable, as cold may enter the body through the vagina, cervix and uterus. Baths are generally avoided after childbirth, as long 14 to 21 days, strongly advised in the old world hilot's manual of postnatal care (Suob). Washing clothes after ironing is a big rural no-no; but to the rural housewife's possible dismay, it is acceptable to iron after washing clothes. Any kind of prolonged and repetitive activity that causes undue tiredness and trembling of the extremities is avoided for fear it might eventually lead to a more permanent tremulous condition.

VENGEFUL EARTHFOLKS
Although chronic and recurrent disruptions of the "hot-cold" equilibrium is the cause most often blamed for pasma, in some regions mythologies and superstitions enter into the mechanisms of causation. Local healers, through diagnostic "tawas," may attribute "pasma" to vengeful earth folks – duwende or nuno-sa-punso, whose dwelling places might have been wittingly or unwittingly disrupted or disrespected by rural pedestrians.

Manifestations
Pasma is a cumulative condition that covers a wide spectrum of complaints – from a simple tremor, numbness or swelling to a constellation of symptoms and signs – usually attributed to a chronic repetitive habit or behavior, especially one that causes recurrent "unhealthy cold exposure" or imbalances of the hot-cold elements.

Inevitably, in its motley ways of presentation and cause, pasma has its own diagnostic nomenclatura: pasma, the classic all-inclusive diagnosis, includes the common tremors of the hands, excessive sweating and swelling of the hands and feet, numbness, pain in the distal extremities and knees, prominent veins in the hands and feet. Some are more system- or cause-specific diagnoses: pasmang bituka, pasmang matanda, pasmang sapatos, pasmang mata.

Tremors or shakiness (pangangatal), especially of the hand, in traditional rural notion of health and disease, is almost always initially attributed to pasma.
Numbness (pagmamanhid) and swelling (pamamaga) and pain (kirot) of the hands and feet, and sometimes of the knees, commonly blamed on too frequent washing, invariably pass through the "pasma" diagnosis.
Abdominal pains for those who take baths during their menstrual periods or wash after sexual intercourse.
Unsightly veins in the hands and legs, are attributed to the too frequent exposure of the body to cold water after hot or washing when tired or physically exhausted.
Pasmang-bituka, abdominal pains and flatulence attributed to drinking cold water when tired and coming from the heat.
Pasmang-sapatos, sweating of the feet from tired and shod feet getting wet in the rain.
Pasmang-matanda, a common arthritic affliction of the hands, feet and knees in older patients, is often attributed to frequent practice of the tired-cold bathing.
Pasmang-mata, the frequent blinking and visual blurring in someone who spends the good part of the day inside a hot and sweaty environment, and washing the face at day's end with cold water.

Coping ways
From the still prevalent belief in pasma as a common rural malady caused by certain lifestyle habits and behavior, a hand-me-down list of DO's-and-DON'Ts endures in folkloric therapeutics. Many cases of "pasma" never make it to the local healers; many resolve with tincture of time or with adherence to a preventive rural regimen of behavior modification.
• Tiresome repetitive movements of the upper extremities should be avoided.
• Washing clothes after ironing is pasma-inducing.
• Showers and bathing should be done in the mornings. Most men go to bed without bathing, the dirt and grime of the day's work usually brushed or rubbed off with a dry towel.
• And many of the rural womenfolk, equally observant, avoid bathing or washing after sexual intercourse, during menses, and for 14 to 21 days postpartum. (see Suob) If they bathe or wash, they do so with great care, using warmed moist towels.

Folkloric treatments
Massage
Ginger, coconut oil and alcohol: A concoction of ground or mashed ginger (luya) is mixed with a little alcohol and coconut oil, for massage to the tremulous, painful or swollen extremities.
Ginger, garlic, camphor, onions, etc: Another preparation used for massage therapy is a concoction of ginger, coconut oil, onions, garlic, camphor, wintergreen and a small amount of scrapings from naphthalene balls.

Ginger, litlit or ikmo, and coconut oil: Another herbal preparation used for massage therapy is a concoction of juice from pounded ginger and litlit or ikmo to which is added coconut oil.
Hugas-Bigas: More easily accessible is the use of hugas-bigas (water from the washing of uncooked rice) for use in massage treatments.

Wash and soaks
Salt soaks: For sweating of the hands or feet, soaking into lukewarm decoctions of salted water for one-half to one hour.
Salt and Bayabas Leaves The salt residue from home ice-cream makers is mixed with water and bayabas leaves, boiled and used as a healing wash to the extremities.
Salt and Gas: The ice-cream maker salt residue is mixed with "gas" (used for rural lighting) and used for washing the extremities.
Hugas Bigas (rice-water) is saved and used for washing or sponge-baths.
Tawas: Bath water is prepared with tawas boiled and dissolved in it.
Urine: In some provinces, the warm first morning urine, is used as a soak-and-wash for tremors, numbness and excessive sweating.
Others

Sand-and-Sweat Therapy: Seaside treatment – digging and lying covered with sand for 3-5 hours.
Herbal-Steam Therapy:
Steam from boiling decoction of lagundi leaves (with or without kalamansi leaves) is funneled toward the body, like a modified steam bath, for a half hour, daily as needed.
Pasmang-bituka:
Daily salted decoctions of solasi (Holy basil).
Tawas: In regions where pasma is sometimes attributed to vengeful earth folks, tawas is the folkhealer's favorite modality, not uncommonly supplemented with a bulong or orasyon.

Misdiagnosis
• Many of the tremulous maladies and sundry of complaints attributed to pasma never make it to the albularyos. Many are self-limited complaints resolving with tincture of time or with some hand-me-down self treatment. Many of those who consult the albularyos will often have their complaints attributed as complications of some past malady or as consequence of one of many pasma-inducing behavior. Many of these complaints, ministered to by the albularyos and hilots, likewise resolve with tincture-of-time, placebo or one of many folkloric treatments, concoctions, or massage.
• Of course, modern medicine views pasma's pathophysiology as folksy hogwash. The persistent and worsening cases that eventually make it to the physician, stripped off its layers of myth, reveal them to belong to a wide spectrum of medical conditions – extremity edema from renal or cardiac diseases or venous insufficiency, numbness of the hands from carpal tunnel tunnel syndrome or ulnar entrapment neuropathy, extremity numbness from diabetes or lumbosacral disease, distal tremors which could be benign essential tremor or parkinson's disease, and a whole slew of underlying conditions–hypertension, diabetes and inflammatory diseases.
• One case was a 47-year old woman who has been suffering eight years with progressive tremors, diagnosed as "pasma" and treated with this-and-that rural herb and a variety of concoctions for massage. Four years later, it was diagnosed as Parkinson's disease. Alas, the diagnosis, finally made, did not matter; the treatment, at 40 to 60 pesos a day, was unaffordable.
• Recently, I looked into a 70-year old woman with acute onset left sided weakness. On exam, she manifested with significant systolic hypertension, neurologic findings of left hemiparesis and a right carotid bruit that strongly suggested a stroke syndrome. A week later, on follow up, I learned the family has stopped my prescriptions and, in lieu, has started on a albularyo hilot's regimen who diagnosed it as pasmang-ugat.

Pasma is a Filipino folk diagnosis shared by most indigenous cultures, handed down from generation to generation, high on lore and zilch on science, borne on ignorance and so embedded in their notions of health and disease, perpetuated by the faith and reliance on their albularyos and hilots who minister to their maladies with doses of bulongs and orasyons and a motley of concoctions, occasionally finding relief through tincture of time, placebo or some mysterious benefits of alternative rural modalities.

And it will not be surprising to find in this group of patients—self-diagnosed or diagnosed by albularyos, medicos and hilots to have pasma—many who will turn out to have various other medical conditions (cardiovascular, circulatory, neurologic, rheumatic, osteoarthritic, inflammatory and degenerative)–amenable to some form of treatment, but unfortunately delayed by folklore from the benefits of medical therapies. Fortunately, most of the conditions are chronic and treatment merely delayed. However, sometimes, acute and serious conditions are erroneously labeled as pasma, and appropriate treatments are sadly delayed with unfortunate consequences to health and outcome.


April 2012
Last Update August 2014
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by Godofredo U Stuart Jr, MD



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