Seeing to the distant mountain: diagnosis in Tibetan medicine. more

ALTERNATIVE THERAPIES IN HEALTH AND MEDICINE A PEER-REVIEWED JOURNAL • MARCH 1999 ■ VOL 5, NO. 2 HYPNOSIS TO ACCELERATE HEALING • CONTROL IN MIND-BODY MEDICINE ' PATIENT-PHYSICIAN COMMUNICATION - TIBETAN MEDICAL DIAGNOSIS - TOLERANCE - PRAYER CIRCLE • NCCAM • SYMPOSIUM ABSTRACTS • CONVERSATIONS/MICHAEL MURRAY te-o. ...... ORIGINAL PAPEF SEEING TO THE DISTANT MOUNTAIN: DIAGNOSIS IN TIBETAN MEDICINE EliotTokar Originally presented to the Roundtable on Traditional Medicine, Columbia Presbyterian Hospital; New York, NY; April 29.1997. Modified for Alternative Therapies in Health and Medicine. Eliot Tokar practices traditional Asian medicine in New York, NY. From 1983 to 1986 he studied Tibetan medicine as a student of Dr Yeshi Dondeu. From 1986 to the present he has been a student of Dr Trogawa Rinpoche, and from 1990 to the present he has been a student of Dr Shakya Dorje. He is one of the only North Americans to have received such training. Trained in Chinese and Japanese traditional medi- cine as well, Mr Tokar has lectured extensively on Tibetan medicine and natural healthcare alternatives. He advises the American Medical Students Association's National Project on Complementary and Alternative Medicine. To make use of an ancient traditional medicalsystem, we must first comprehend the singular concepts and language that system uses to understand and describe health and illness. The diagnostic procedure is the method by which a person's medical condition is interpreted into the coneeptualframework and language of medical science. This article pro- vides a description of traditional Tibetan medical diagnosis and explains how a Tibetan physician perceives and analyzes a presenting ill- ness. It discusses the spiritual, psycltological, and physical aspects of the Tibetan medical approach to diagnosis. Addressing these issues can help us to understand what is unique about this system of alternative medi- cine and how it can inform other models of medical practice. (Altern ■JherHealth Med. 1999;5(2):S0-58) When most patients seek a doctor for a med- ical diagnosis, they generally assume that the process will clearly and directly reveal the truth about their condition. Their assumption is that the diagnostic procedure will reveal their illness in much the same way that cutting open an apple bears its core. In most cases, however, nothing could be fur- ther from the truth. In examining the nature of diagnostic procedures, it is worthwhile to recall the Indian tale of the blind men who Reprint/equals: bif9V!sio» Comamialiont, 101 Columbia, Aliso V/eja, CA 8265$;pfiofie, (800) S99-l?i2 i>r (949) 448-7370 (ai SIS):fax. (949)362-2049; e-mail, m RtpmlQaolxtm. encountered an elephant. In this story each man, feeling only one part of the elephant, draws a completely different and erroneous conclusion about what he holds in his hands. None of them perceives that he is touching an elephant. Instead, judging from limited experience, each decides that the part he is experiencing must equal the whole: the leg is thought to be a tree trunk, the tail a rope, the trunk a snake, and so on. In medical diagnosis we healthcare practitioners begin with our own biases, which are based on our personal, cultural, and professional worldview, thus forming the basis either for our blindness or our insight. We obtain a limited set of information that is derived from tests and/or other techniques defined by our tradition's medical science. Through this analysis, which is based on our understanding, experience, and awareness, we attempt to comprehend the truth of the condition. If we are to succeed we must do better than the blind men of the tale. By experiencing the trunk, leg, or tusk, we must be able finally to perceive the whole. We must ultimately have the insight and skill to see the entire elephant. However, because of the blindness inherent in the prejudices and limitations of any worldview, we will inevitably see a slightly or even a radically different elephant. LEARNING TO SEE In the teachings of Tibetan medicine there is a metaphor that refers to the stages of development of the diagnostician. At the first level a student of medicine is likened to a person stand- ing on a mountain top who is unable to perceive what is on the top of the opposite peak. At the next level the student can see that something is there. At a higher level the student can per- ceive that someone is standing on the opposite peak but he or she still lacks the ability to perceive anything about that person. At many succeeding levels, more and more can be perceived about this person until, ultimately, at the most advanced degree of ability, the student recognizes precisely who is there. This metaphor describes the evolution of perceptive abili- ties in learning Tibetan medical diagnosis. Its meaning can also apply to the gradual process that practitioners of different med- ical systems must undergo to truly perceive what a doctor from 50 ALTERNATIVE THERAPIES, MARCH 1999. VOL S. NO. 2 Swing lo the Distant Mountain: Diagnosis' in Tibetan M«Kcfcie another scientific worldview sees. Performing a medical diagno- sis requires an understanding of the technique and language of the system within which one is operating. The foundation of diagnostic skill, however, is the development of a capacity of awareness that leads to clear and precise perception. The following article will explain the basic tools and lan- guage of Tibetan diagnosis and begin to clear the mist that stands between the peak of Tibetan medicine and that of other medical traditions. To begin establishing a complementary approach to medicine, there must be a common language creat- ed through which traditional and allopathic doctors can effec- tively communicate about their disciplines. Medical traditions are not the sum total of their diagnostic or treatment techniques; instead, they are the result of the scientific, cultural, and spiritu- al knowledge that gave rise to those therapeutic applications. To establish a common language of communication, we must begin by seeing clearly. This point is demonstrated in the book Mortal Lessons by the surgeon and Yale professor Richard Selzer, MD.1 In this book Dr Selzer recounts a diagnostic session performed by my first teacher, Dr Yeshi Donden. The session was part of a demonstra- tion conducted at an American hospital. Dr Donden was shown a patient about whom he was told nothing. Before an audience of skeptical Western physicians, Dr Donden performed the Tibetan pulse diagnosis and urinalysis. To the amazement of his audience he was able to accurately diagnose that the patient had a chronic heart problem. He diagnosed an imbalance in the basic circulatory principle of the body as it relates to blood and heart function. This disorder had progressed to a stage in which it affected the patient's preexisting heart irregularity, which had developed during a specific stage of embryological development. Dr Selzer' recounted the diagnosis in this manner: [Dr Donden] speaks of winds coursing through the body of the woman, currents that break against barriers, eddy- ing. These vortices are in her blood, he says. The last spend- ings of an imperfect heart. Between the chambers of her heart, long, long before she was born, a wind had come and blown open a deep gate that must never be opened. Through it charge the full waters of her river, as the moun- tain stream cascades in the springtime, battering, knocking loose the land and flooding her breath. The allopathic diagnosis had been "congenital heart dis- ease," an "interventricular septal defect, with resultant heart fail- ure." To Dr Selzer, who was used to the worldview, technique, and jargon of his profession, the Tibetan diagnosis seemed remarkably poetic. Dr Selzer described this diagnosis as a largely divine mystical experience accessible to priests but not to mere doctors.1 Interest, fascination, and perhaps even respect were engendered, but little understanding between the doctors seemed to develop. In fact, what Dr Donden was doing was not magic. He was doing what was expected of a properly trained Tibetan physician, albeit at its highest level. LIKE A RICH MAN WITH ONE CHILD In describing how he worked as a physician, my teacher, Dr Trogawa Rinpoche,2 remarked: "My external activity is the prac- tice of medicine, and in my inner thoughts 1 meditate on the Medicine Buddha." This comment does not simply tell us that Dr Trogawa is a religious or pious man. Properly understood, this remark displays the 6rst step in the process and practice of Tibetan medical diagnosis. It is an ongoing practice toward spiri- tual development and its resultant awareness and intention, toward which the physician continually strives. Given the differ- ing levels of practice and development that exist among Tibetan doctors, there is no quantitatively prescribed standard for this aspect of medical practice. Still, the primary classic principle of Tibetan medical practice is that the bedrock of one's approach to diagnosis lies within the doctor's spiritual practice. In describing the Tibetan approach to diagnosis it is vital to understand how the properly trained Tibetan doctor sees the world. After all, it is always within a doctor's subjective under- standing of the nature of the phenomenal world that the relative- ly objective work of obtaining a diagnosis occurs. How, then, do Buddhist teachings determine the basis for making a clear diag- nosis of illness? Because the historical Buddha described his role and teach- ing in a fundamentally medical fashion, this connection is very direct. In fact, because the Buddha's teachings were meant to cure suffering, he was known as the "Supreme Physician."1 The Buddha is therefore a direct inspiration for Tibetan doctors, who attempt to emulate this model of a spiritually realized being who makes a conscious choice to cure others. To appreciate how a particular medical system approaches diagnosis, one must discover how a doctor trained in that system perceives the patient. It is important to comprehend the doctor's conscious intention. Buddhist teachings delineate Tibetan doc- tors' image of themselves and their patients as well as the doctor- patient relationship. Buddhism's central teachings and practices place great emphasis on (1) understanding and discovering the nature of one's mind, and thereby transcending ego; (2) develop- ing a practice of compassion toward all other conscious beings; and (3) developing a sense of equanimity. Therefore, for the doc- tor of Tibetan medicine there is no psychological or professional dilemma in directly identifying with his or her patient—as there can be, for instance, in Western medicine. In a sense, the Tibetan physician intentionally seeks to identify with the patient. It is important for us as physicians to intimately understand the basic nature of suffering—both the patient's and the doctor's— as well as to understand that our relationship to the patient has both a professional and spiritual significance. Through spiritual practice the Tibetan doctor is trained to emulate a highly spiritually evolved person. A direct connection develops between the doctor's perception of the patient and a Bodhisattva's perception of all beings. The term "Bodhisattva" literally means "hero of enlightenment." Bodhisattvas are spiri- tual trainees who strive to generate an altruistic mind of love and compassion.4 They are basically Buddhas in the making who Seeing 10 the Disiani Mountain: Diagnosis in Tibeian Medicine ALTERNATIVE THERAPIES. MARCH 1999, VOL. 5. NO. 2 51 have dedicated their pursuit of spiritual awareness to the single goal of bringing about the welfare of all. We can get a glimpse of the professional ethic Dr Trogawa endeavors to practice in an instruction from the Buddh ist sage Vimalakirti: T am ill because all sentient beings are ill. If the illness of all sentient beings were to come to an end, then my illness would be ended. Why is this so? Because when the Bodhisattva enters into the realm of birth and death for the sake of beings, he becomes subject to the laws of this realm and thereupon becomes ill If all sentient beings were to be cured of their dis- eases, then the Bodhisattva would never be ill again. Jt is like the rich man who only has one child. When his child becomes ill, his parents become ill. If the son is cured of disease, so also are the parents. It is the same for the Bodhisattva: he loves all beings as if each of them were his child. When all beings are cured, then the Bodhisattva will be cured....* Before seeing their first patient, Tibetan doctors practice an archetypal diagnosis that becomes a basis for all the diagnoses they will perform throughout life. This diagnosis is visualized in a meditation practice used by traditionally trained Tibetan doctors. In this meditation physicians visualize the "Buddha of Medicine," seeing all beings before him, with their particular suffering and all of the innumerable diseases they may have. The Medicine Buddha feels anguish for them and wishes them free- dom from suffering. Through the power of his realized mind, this Medicine Buddha diagnoses the illnesses as symptomatic of fundamental spiritual disharmony caused by ignorance. This ignorance is a lack of understanding of the basic nature of reali- ty, as understood from the Buddhist perspective. The resultant confusion leads to activities of our body and mind that directly or indirectly lead to suffering and illness. Given this diagnosis, the Medicine Buddha understands the temporary, illusory nature of illness. Pushing through his sense of anguish, he delves deeper into this and sees that within every atom of every being who appears as suffering, there exists a Medicine Buddha. He experiences inner joy in the knowledge that despite suffering, there is the potential for boundless happi- ness. Having completed his diagnosis, the Medicine Buddha pro- jects a purifying energy from himself to those before him that reveals the inherently healthy state.* At this point in the meditation, practitioners merge their own selves with the being of the Medicine Buddha and become indistinguishable from him. They then proceed to a state of meditative emptiness derived from the understanding of the Buddhist teachings. In relation to this emptiness, all the forms and concepts we occupy in life—including illness—are under- stood as illusory, dream-like, and therefore highly changeable. Thus it follows chat illness is made worse or better by changes in the mental perception we give it. The Medicine Buddha's profound diagnostic skills are derived from wisdom based on deep awareness and perception. These qualities, along with his resultant capacity to heal, makes the Medicine Buddha the role model for the physician of Tibetan medicine. By visualizing themselves as Medicine Buddha, doc- tors of Tibetan medicine pursue an aspiration to develop the same capacity for compassion, awareness, and skillfulness. This process is the root from which diagnostic skill develops. It is established even before the first patient walks in the door. THE ROOT, THE TREE, THE BRANCHES, THE LEAVES, THE FRUIT All medical systems grow from 3 roots: (1) faith and belief, (2) experience and perception, and (3) objectivity and analysis.6 Western medicine generally claims to need only the third root, excluding the significance of faith and belief and imagining that experience and perception are superseded by an assumption of scientific objectivity and analysis- Fortunately, as the grassroots alternative medicine movement becomes a prominent force, Western medicine is beginning to grant some significance to these 2 other roots. Examples of this are Larry DosseyV and Herbert Benson's8 work on the value of faith and belief in treat- ment, and Oliver SacksV assertion that the subjective experience of the patient is a useful tool in diagnosis. Practitioners of Tibetan medicine have always depended on all 3 roots to properly per- ceive and analyze an illness .and its cause in the diagnostic setting. By synthesizing knowledge from various medical systems, Tibetans created a systematic approach to medical science draw- ing from thousands of years of accumulated empirical knowl- edge and intuition about the nature of health and illness. Centuries ago, before Buddhism entered Tibet, Tibetans, like all ancient people, had a significant degree of medical knowledge. According to traditional sources, in the beginning of the 4th cen- tury many new ideas regarding medicine began to enter the country. At first, influences came from India in the form of what is now called Ayurvedic medicine, as well as more spiritually and psychologically based systems from Buddhist and other sources. Around the 7th to 8th centuries the Tibetan government began sponsoring conferences at which doctors skilled in the medical systems of China, Persia, India, and Greece presented and debated their ideas regarding health and the treatment of ill- ness. Those with superior abilities in the diagnosis, treatment, and understanding of illness were invited to stay and contribute to the country's medical knowledge base. In the 11th century this knowledge was codified into a unique system." To properly perform Tibetan medical diagnosis, a doctor must have an understanding of the theories of Tibetan medicine and their unique description of the body—its creation, principal energies, functions, and processes—as well as an understanding of health and the etiology of illness. As with Western medicine, the quantitative aspect of knowledge in medicine must be under- stood and internalized so it can be readily drawn upon in the diagnostic session. Through instruction from a master and through their own practice, Tibetan doctors m training also gain experience with the qualitative understanding and analysis that 52 ALTERNATIVE THERAPIES. MARCH 1999, VOL. 5, NO. 2 Seeingio iheDtsiara Mountain: Diagn&js in Tibetan Medicine are essential in Tibetan medicine. This qualitative dimension clearly differentiates Tibetan medicine from the mechanistic view of Western medicine. Tibetan medicine views the human body as an ecological system, a microcosm directly related to the macrocosm of the natural world. All of the material that makes up our universe is based on the qualities of 5 basic elements, which are described in the ancient physics and depicted in Tibetan medicine. Uke all tradi- tional people, Tibetans lived in direct contact with the natural environment. *Tbey understood through experience and study that natural environmental forces directly correlated with and influenced the functioning of the human organism*Tibetans defined the qualities of the basic forces existing in nature in the theory of the 5 elements. These forces are named for their most identifiable manifestations: Earth, Water, Fire, Wind, and Space. The characteristics (such as a substance's taste) and therefore the nature of ail matter result from the qualities of these elements individually or in combination. Earth has qualities of firmness and stability and therefore provides the basis of physical existence and development. Water creates moisture, giving rise to all fluids. Wind creates movement and so enables all aspects of circulation and move- ment. Fire creates transformation, metabolic functions, and activity. Space provides the potential for existence to be creat- ed in the first place. Combinations of these qualities make up the physical aspect of our bodies as well as the body's distinct physiological energies.5 As with any medical system, understanding the various functions of the body is important in Tibetan medicine. However, the underlying physiological principles that create and maintain those functions are of primary importance. Tibetan medicine defines 3 main systems that control all the body's functions. These 3 systems of the body, or Nyepa in Tibetan, are created at various stages of development in the womb by an interaction of our mind's developmental process and the 5 physical elements. The first, Lung (Wind), creates an enormous number of functions, the best example of which is circulation. Lung gives rise to and regulates the movement of blood, nerve impulses, thoughts in our minds, and food through the digestive tract and eliminative organs. The mind expressed as attachment, desire, or a materialist worldview is manifested during the pre- natal period through the development of the system ofLiiag. The second. Trips (Bile), gives rise to and controls such func- tions as metabolism, liver function, and vision, allowing our mind to function with discriminating intellect. The mind expressed as aggression, hatred, or anger is manifested during the prenatal period through the development of the system of Tripa. Finally, Badken (Phlegm) creates the physical principle by which energy can be used to produce a function, provide our body's lubrication, break down food at the initial stages of diges- tion, create the will, and facilitate memory. The mind expressed as ignorance or incomprehension is manifested during the prena- tal period through the development of the system ofBadken^1 Good diagnostic skills in the Tibetan system require both an intellectual understanding of the genesis and nature of the 3 Nyepa as well as a subjective appreciation of their qualities and functions. Such grounding in the system allows us to avoid a formulaic use of the theoretical and practical aspects of the diagnostic technique. To take a simplistic or ideologically bound approach is a mistake, because it weakens our capacity to diagnose illness properly, especially in cases of complex or chronic illnesses. It also prevents us from seeing where simple solutions—such as changes In behavior, lifestyle, or diet—can be most effective. It is harmful to create a significant dichotomy between what we practice in our own life and what we preach in a professional context. It is most beneficial to patients when doctors develop a healthy lifestyle consistent with their understanding of medicine. Such a personal practice leads to a deeper understanding of how the action of the mind—manifested in one's psychological state or behavior, including dietary habits—is the primary cause of illness and therefore should be theprimary basis of treatment The practitioner of natural medicine who is ideologically constrained by a purely quantitative approach will often think in a disease-oriented model more appropriate to the Western med- ical system. A clear understanding of and personal experience with the principles of health and illness are necessary to develop die capacity to make a discriminating diagnosis. When the doc- tor achieves this capacity, treatment will be appropriate to the condition. It will be based on the use of spiritual, behavioral, psychological, and dietary approaches to affect the root cause of the condition. Then, if it is relevant to the individual case, herbal medicines or physical treatments (eg, acupuncture) can be employed. This procedure allows the doctor and the patient to avoid overdependence on therapeutic techniques or devices. In the 4 primary Tibetan medical texts (rGyud bZbii7) the structure of a tree is used as a teaching metaphor- Adopting that metaphor here, the roots of Tibetan doctors' practice consist of their spiritual practice, their understanding and study of the medical teachings, and their own personal life experience. The trunk of the tree is the capacity to fully understand the nature of health and illness. The branches and the leaves are the specific details of medical theory and practice, and the fruit is the ability to make a good diagnosis. SPEAKING, TOUCHING, AND LOOKING Through spiritual practice, intellectual training, and intuition, the doctor creates the foundation for the practice of diagnosis. The Tibetan medical diagnosis consists of 3 main phases. The first is the patient interview; the second is the observation of the urine; the third is the taking of the 12 pulses, after which the doctor may look at the sclera of the eyes and the surface of the tongue, and may feel tor sensitivity on certain points of the body. (Figure 1, from a 17th- century woodcut, shows a Tibetan doctor taking a pulse.) Pulse reading and urinalysis require years of theoretical study along with direct instruction by a master. Both of these diagnostic practices combine the art and the science of medi- cine. The reading of the 12 pulses is a subtle process that is best Seeing to the D&iaw MouniaircOiagiWi&inT&etari Medicine ALTERNATIVE THERA1>1 IS. MARCH 1999. VOL S. NO. 2 S3 FIGURB1 Tibetan doctor taking a pulse (17th-century woodcut) conducted if the patient has not done anything to grossly disturb his or her physical energies. The patient should prepare for the pulse reading by avoiding foods and behaviors that are excessive- ly heating or cooling to the body as well as anything that dis- turbs the circulation. Behaviors or dietary practices that distort or discolor the urine sample should be avoided as well For 24 hours before the appointment, patients should take no medication (except prescription pharmaceuticals, which should not be stopped abruptly), red meat, alcohol, beets, coffee of any kind, black tea, or foods that are unusual to their normal diet. They should also abstain from strenuous physical activity and sexual activity. No vitamins should be taken for 2 days prior to the appointment. Hot showers and baths should not be taken on the morning of the appointment. Patients are advised not to ingest anything except water on the day of the appointment; or, if they must eat, to eat light, easy-to-digest foods at least 10'^ hours prior to the appointment." The patient is asked to bring a urine sample that should be taken from the second urination after midnight. Although most doctors ask simply for the first morning's urine, my teacher Dr Trogawa Rinpoche states that such a sample could have too many influences from the food consumed the previous evening. If the patient goes to bed after midnight and/or wakes up during the night to urinate, the first sample taken in the morning upon arising can be used. Otherwise, the person should be asked to bring in the second sample taken in the morning. Because of the significant effects of temperature on the urine, the patient is asked not to refrigerate the sample.15 When the patient arrives, the physician tries to discover as much as possible about the problem through listening and observation. The first step in the interview is observation of the patient's physical appearance and manner of speaking. This is most useful if one understands the nature of the 3 Nyepa and the classical physical and psychological types that can result from a constitutional predominance of one or a particular combination of these energies (Table 1). The physician inquires about the patient's current medical condition as well as how the patient feels personally. It may be useful to investigate the patient's med- ical history, health relative to the seasons, dietary pattern, or to engage in a more detailed discussion of personal or spiritual issues. It is useful to ask female patients about their gynecologi- cal health and history and their experience with childbirth. Each of these items provides a quantity of health information as well as a basis for understanding the nature of a patient's condition vis-a-vis the 5 elements and 3 Nyepa. The patient's dietary history can be especially revealing for 2 reasons. First, following behavior, diet is a primary determi- nant of health- Second, there is a great amount in the Tibetan medical literature about the meaning and significance of foods and the 6 tastes (salty, pungent, sour, bitter, astringent, sweet) with respect to the theory of the 5 basic elements. Under- standing a person's dietary habits and reactions to different foods can reveal the basis of his or her condition as well as the circumstances leading to illness (Table 2). The manner in which these factors can result in illness will be more or less complex depending on the acute or chronic nature of the problem. Ail illnesses must be seen as individual and based on a patient's background. There is a widespread notion that allo- pathic medicine only addresses symptoms, whereas natural medi- cine only addresses the root cause of illness. This is incorrect—an exhaustive list of symptoms is crucial for achieving a proper diag- nosis in Tibetan medicine, If a practitioner sees 10 different cases of what allopathic medicine would regard as 1 disease, the addi- tional accompanying symptoms (physical and/or psychological) will determine the specific diagnosis in terms of Tibetan medi- cine. Once the full range of symptoms in the context of the patient's history is discovered, the root cause of the illness can begin to be understood. Within the 1 disease defined by allopath- ic medicine, the Tibetan physician might in fact define 10 differ- ent sets of symptoms, 10 different etiologies, and therefore 10 different illnesses. The root cause of the patient's entire complex of symptoms is ultimately diagnosed and treated (Figure 2). After interviewing the patient, the Tibetan physician ana- lyzes a urine sample in a white opaque container. They be$n by observing the sample's odor. Specific odors described in the texts" correlate with specific conditions- Tf it is a fresh sample, the pres- ence or lack of vapors helps to define the relative heat/excess or cold/insufficiency manifested in the condition. The specimen is then observed to determine whether it has a watery appearance or shows degrees of the colors yellow, brown, red, or white. Next the physician will determine whether the sample has particular characteristics such as a watery appearance or whether a reddish ring appears around the surface of the sam- ple. A blackish hue, for example, indicates specific conditions such as the presence of exceptional toxicity in the system. Any deposits in the urine are noted for their specific appearance, location in the sample, and persistence. Numerous types of deposits and their specific pathologic significance are described in the texts." 54 ALTERNATIVE THERAPIES. MARCH 1999, VOL. 5. NO. 2 Secwigto rhe O&ani Mountain: Diagnosis in TibWan Mwfidne TABLE 1 Examples of characteristics corresponding to specific constitutional types5 Wind nature person Bile nature person Phlegm nature person O It Slightly hunched over Thirsty often Often feels cold Tendency to be chin Hungry often Fleshy and/or fat body Bluish complexion Good digestive capacity Small bone structure Excessively talkative Red or blonde hair Pale complexion Complains easily Sharp mind Doesn't experience strong hunger or thirst Cracking joints Good memory Can endure suffering Not materialistic Proud and confident Long life span Short life span Can be rigidly opinionated, arrogant Materially well-off Light sleeper Strong body odor Sound sleeper Physically small Medium-length lifespan Can control feelings of hatred or aggression Likes music and dancing Moderately materialistic Stable temperament Laughs a lot Quarrelsome Doesn't like to be alone Likes sweet and sour and hot tastes Moves around easily Comfortable at heights Medium-sized physically Ukes sweet, bitter, astringent, and cooling foods Physical skill Hatred Flexible and agile body Ooes not outwardly betray feelings held internally Holds grudges Once made angry is intractable Ukes, hot, sour, astringent, and stimulant fo Tends to have a good physique and physical beauty Always hungry Large body Sly or sneaky Can be relied on in matters of importance Not discri ruinating Difficulty organising and prioritizing Affected by even trivia) events Moves around a lot to either different places or situations Capable of maliciousness The sample is then vigorously stirred with a stick; the size, matron regarding the nature of the illness, the presence of infec- cotor, placement, amount, and persistence of bubbles are tion, and the localization of the illness. The 4 foundational texts observed. The observation of the bubbles provides valuable infor- of Tibetan medicine, thtrGyud bZhi, and their commentaries Swing to tli c Distant Mountain: Diagnosis in Tibetan Medkinc ALTERNATIVE THERAPIES. MARCH 1999, VOL. S. NO. 2 55 TABLE 2 Examples of foods with natures similar to and having the potential to Irritant foods that can be harmful to Lung Heating foods that can be harmful to Tripa cause imbalance in the 3 Nyepa* Cooling foods that can be harmful to Badlm Coffee Nuts Pork Strong tea Meat (except goat) Goat meat Green tea Fish Goat milk products Mint Fats and oils Potatoes Poor-c rade sov ssuce Snicts fexcent narslsv cumin coriander dku peppers frnnorppW a nisei Distilled vinegar tvaw tomatoes Sninach ftiiflfvvhe^t Eggplant Mustard Rabbit and harp ujcumDers Sheep milk products C.ril led food Cold hqutds and chilled rood Radishes Food hiirntvi in cookhii? or nrooessinff Sugar Watercress Chips __■___i f__i _______M___j_____,_____.____ Cooked food eaten cold or at room temperature Onion Suphy and artificial swptteiwfs Yam Garlic Goat chfifls^ _ ■ Turnip Peouer {black, white ffrav) Chili Villi! Salt Puffed rice/rice cakes Peanut butter Whiskey Avocado Sake Mango Chocolate Cofa Eggs Eriedfood AU alcoholic beverages Celery Sesame Molasses describe in detail how the diagnostic signs listed above relate to specific imbalances of the Nytpa, individually or in combination. The effects of organic homeostasis are reflected in the patient's pulse. There are 12 distinct pulses at the radial artery of each wrist. Hie site of pulse taking should be the distance from die first crease below the wrist on the distal forearm measured down the length of the first phalanx of the patient's thumb. The doctor's fingers are placed flat on the patient's wrist, parallel and spaced with approximately the width of a grain of rice between them. This placement is chosen because of its relation to the other arteries in 56 ALTERNATIVE THERAPIES, MARCH 1999. VOL 5. NO. 2 Swing ro (he Distant Mountain: Diagnosis InUbWanMedEdw Patient Individual Di agnosis of disease Diagnosis of illness complex an d its too t cause FIGURE 2 Graphic description of difference between Western (left) and Tibetan (right) medical diagnosis. Reprinted from Tokar E, Vora A- "A Tibetan Medical Perspective on Irritable Bowel Syndrome: Building a Means of Discourse for Integrative Medicine" {Allcrn Complement Tber. I99$;4[5]:347). Used with permission of Mary Ann Liebert, Inc. the body. It is a proper distance from the heart and liver and there- fore does not have too much or too little influence on circulatory energy or blood pressure. Blood and the circulatory energy (£w$ from all the organs flow through the distal radial artery, providing information about the patient's condition. Analogous to the waves that affect the flow of the ocean, the energy that flows along with the blood exercises its effect in direct relation to the balance or imbalance of the basic 3 Nyepa that constitute the body,11 Specific pressure is applied by each finger and each finger is divided in half longitudinally with each side feeling a distinct pulse (Table 3). Pulse taking involves the assessment of the pulse's width, depth, strength, speed, and response to pressure. In the texts there are detailed descriptions of all these qualities and their indication of health, illness, and impending death. The speed of the patient's pulse is counted relative to the physician's respiration rate. Consequently, in performing pulse diagnosis attention to the breath is as significant as it is in meditation. The pulses are influenced by the seasons, because all physi- cal phenomena reflect their composition in the 5 elements described above. Each season has a clear elemental nature that relates to the nature of the individual organs. As the function of each organ is affected by the seasons, the pulse takes on specific characteristics during different times of the year. Tibetan physi- cians must be aware of those changes when taking the pulse. When tfte different pulses are properly understood and coordinated with the other investigations described above, one can clearly define the type of illness, its location, its chxonictty, its hidden complications, and other meaningful aspects of its TABLE 3 Placement of fingers in Rnger Upper position Tibetan pulse taking Lower position Right index: Reading left arm of patient Male: Heart Female: Lung Male: small intestines Female: large intestine Right middle: Reading left arm of patient Spleen Stomach Right ring: Readingleftarmof patient Left kidney Reproductive organs Left index: Reacting right arm of patient Male: Lung female: Heart Male: large intestine Female: small intestines Left middle: Reading right arm of patient Liver Gall bladder left ring: Reading right arm of patient Right kidney Urinary bladder Seeing 10 the DUtem Mountain: DJagnosfc ia Tibeten Medicine ALTERNATIVE THERAPIES. MARCH 1999. VOL 5, NO. 2 57 etiology. To further confirm the diagnosis we can look at the color, shape, and coatings of the tongue; the sclera of the eye; and the sensitivity of certain pressure points on the body. SEEING TO THE DISTANT MOUNTAIN With the doctor sofidty rooted in the knowledge and practice of the ecological and spiritual understanding of medicine, and the patient prepared to clearly reveal the nature of his or her condition, diagnosis in Tibetan medicine becomes an elegant investigation into the root causes of illness- The goal of diagnosis, as in meditation, is to gain insight into the true nature of particular phenomena, This article is not an exhaustive description of the techniques of Tibetan medical diagnosis. Such descriptions are available from published translations and summaries of Tibetan medical texts. (Additional readings on Tibetan medicine are recommended below.*41) Mastery of the diagnostic techniques described in these texts requires lifelong study and practice. In this article I have pro- vided an overview and analysis of an approach to investigating ill- ness as it has been taught to me over the past 15 years. In Dr Trogawa Rinpoche's clinical approach, the physician arrives at an individualized, complex diagnosis explaining the systemic imbalances that have manifested as illness. A multilevel therapeutic approach is created to treat this imbalance (and sig- nificant acute symptoms) to achieve a truly curative effect. As modernism affects Tibetan medicine, this more classical, holistic approach to Tibetan medicine is at risk of being lost The econo- my of time and commerce can encourage even Tibetan doctors to think in clinical terms influenced by the hegemony of Western medical and technological culture- This type of clinical shortcut- ting can lead, for example, to an excessive emphasis on the use of medicines to cure a more narrowly defined model of illness. As healthcare practitioners, it is our job to properly diag- nose and treat illness as effectively as possible. But that process should be an educational experience for both doctors and patients. Tibetan medicine describes a logical structure for understanding a complex matrix of factors resulting in health or illness. It provides a set of diagnostic tools to find the causes of imbalances that result in poor health. Both of these functions are based on a centuries-old tradition of contemplation paired with empirical observation, maintained by a long, unbroken lineage of teachers. Tibetan medicine reminds us what traditional peo- ple know: that illness must be understood on the basis of the inherent relationship between physical health, psychology, behavior, diet, environment, and ourspiritual existence. I am indebted to my teachers, DrTrogawa Rinpoche and Dr Yeshi D widen, for their rate and priceless teaching, as well as to my colleague, Shakya Dorje, I would also like to thank Kenneth 2ysk ph>, for his support and organization of the Roundtabte on Traditional Medicine at Columbia Presbyterian Hospital, New York, NY. at which this paper was first delivered. 1 am most grateful to Annette Tokar, and Brian "fbkar for their invaluable assistance in editing this work. Finally, thanks to theHinduja foundation and the Rosenthal Center for Alternative/Complementary Medicine for funding the forum at which this paper was originally presented. References J. Se^ft.A&rf^&s*^M>teMfte^rt#&ri^ 2. Rinpoche T. vt» Dr Trogawa BSnpocHe: In His Own Words. Howard Beach, NY: Chakpori;l992. 3- BimtaamR. The Hwilni Buddha. Boston, MsssrSharobhab; 1989:1+16- 4. CokmanG. A RondboeltfVbttan Qdiurt Boston, Mass: Shambhak 1393:285. 5. Dondeo Y. Tibetan medicine seminar, lectures presented at: American Institute £» Buddhist Studies; fctfl 1943; Amherst, Mass. 6. Tatar E. Seminar in Tibetan medicine- Urtute presented at: New York Botanical Garden; Nwmber 2,1996; New York. NY, 7. Coasey L Prayer Is Goad MedJeJnt: How to Reap ike Heating Starts of Prayer. Sa n francbcftOlrf: HarperCollins; 1996. 8. Benson H. FmetatHeating The¥t**trordBk&w <tfBelief. New York, NY: Saloon 159$. 9. Sacks O. Recycling old ideas, new form. lecture presented at: New York Public library; April 20,1994; New York. MY. 10. Yemen P. A history of the Tibetao medical system, to fibetao Mcdla'M. Dhanmak, India: library of Tibetan Works and Archives; 1969,12^51. It Rinpoche T. Introduction to Tibetan roedii^. Lecture r^esestedai: New York ShambhaUC«ter;JrJyl98S;N*wYorb,Ny, 12. rGyadbtkt. Dharamsala, India: Tibetan Medical and Astrological hvstimte; 1994. 13. RtnpotheT. Prtamuhatloa tostruetiau. Howard Beach, NY: Chakpori Oxp; 1989. 14. KnpocheT. Tteaa MedkdDksay Cviddim. Howard Besch, NYrOafcporlCoip; 1992. 15. TbondupT. ThiHcaKn^Pi^rr^lheMifid. Bo$*on,Ma$$:Sharnbhala; 1996. 16. Khangkar LD. Letter* on T&tlan Medicine. Dbaramsala, India: library of Tiberar. Works and Archives; 1986. 17. Tibetan Medfeme^o-rig). Vo\ hl% Dharamsala. In dia: library of Tibet in Wortsand Archives 1989-1959. 18. Parfkwovitch Y, Don'e G, Meyer P. Tibetan Mtdked Palming lUsstratim to the Hue Beryl Treatise o/Sangye Gya&tso. Neiv York, NY: Ha rryNAbnms;1992. 19. CE/Totd T. TlArfae BuifdilstMedklae <md fty&kary York Beach, Me: Weter; 199a 20. Donden Y. Htahh Throng Balance 4a ImioduaJoa to Wetan Med/eJse, Ithaca. ny: Snow Line PubHcattons; 1988. 21. Tibdan meoHdr* Web she. Available at: http://Ww. ttbewm edid n?-com. 58 ALTERNATIVE THERAPIES, MARCH 1999. VOL S, NO. 2 Seeing re. the Distant Mountain: Diagnosis in Tibetan Marine