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encountered an elephant. In tbLis story fl'acb man. f~e[mg only (me part of the e1~phant, draws ,acoropleteJy diffenmt and erroneous conclusion ~bout what be holds: jj) his bands. None {If them perceives that he ~s touching an elephant. Instead, judging from limited experience, each decides that the part he is ,axp erlencing mus t equal the whole: the leg is though t to be a tree trunl<:,tbetail a TOpe, the trunk a snake, andiso on.

In medical d(agnosi$we healthcare practitioners begin with eur own biases" which are based on our personal. <'.UlturaL and professional. worldview, thlJis forming the basis either for our blindness OJ our insight. We obtain a limited set ofinronnatio'll that is derived from testsandjor other tecbni.qu,es defined by our tradition's medical science. Through this analysis, which is based 'In our understanding, experieaeeand awareness, we atteillpt to comprehend the truth of the condition .

Ifwe are to succeed we must do better than the bllnd men (lithe tale, By experlencing the trunk, leg, or tusk, we must be able finally to perceive the whole. We must ultimately have the insight and skill tosee the entire elephant. HoweveJ; because of the blindness inherent in the pliejudices and limitations of any wm;ldview, we will inevitably see a slightly or even. a radically

dlfferentelephaet. .



Eliot Tokar

OriginaUy presentt'd to the Roundtable on Traditional Medicine, Columbia Presbyterian Hospital; New York, NY; April 2'9, 1997; Modified for Aiter:natiWJ Therapies in Hralth ,and Medicin(.

Eliot Thku pnctices traditional Asian medicine lO New York, NY:. From 1983 to 1986, be studied Tibetan medicine as a student of Dr VesM Donden. From 1985 to the present he has been a student of Dr Trogawa Rinpoche,and from .il990 to tb.e fuseat he has been a stude.nt of Dr Shakya DoIj4!. He j~ one of the only Nortb Americans to have received. such trainin.g, Trained in Chlnese and Japanese traditional medicine as welL Mr Tokar lias leetared extensivelY on Tibetan medicioe and nawra.ll nealthcare alternatives. He advises the American Medical Students As:socia tion's National Project on Complementary and Alternative Medicine.

1c make usq if IJ):I anae!111raditi_ mmliC4J 3J$tem, we mriStjirsJ. tI)wprthend the singular C'CflceplJ and itmguage that ;system uses to . wukrsi£m.d' and descn'he heaithl1l1d iilflm1lle diagnostic Pl0tedu.rt is ike method by which a pet$on~s medicol tonJitWll is inkrpreted m.wthe conceptualjramewnfk ami language oj medical sr:icnce. This article provides a dc,scription oj tra'dltlfmal Tibetan medical diagnosis a.nd apJaif/!J how a Twetan physician perceives and Gna{yze.s a pmenting iD, nas. It disclJSSts Ihe spirilW, psycJI<Jiogical, l111d physiffll aspects oj the Tibetan medical tq1ptrXich 10 diagn()$~ Addressing these issues can hiip wulmtaml what is ltIlique about this tystem of altemtdive medicine and how it can infol11l ather madels o/medical practiCe. (Altem Tho HtUtl~h MM. 1999;5(2):50-58)

ben moot patients seek a doctor fer a medical! diagnosis, they geIlerallyasSliltme that the process will clearly and directly reveal the ·truth .1i:lI)1Jt their condition. Their assumption is that the diagnostic procedure will rev·eal! their illness in much the same way that cutting open an apple bears its tore. In most cases, however, nothing could be fiu· tiler from the truth.

In exam.ining the nature of diagnostic prccedures, it is worthwhile to recall the lndlan t.ale of the bHnd men who

JIlpDm RfNf1i4:1)hI~V!JifJf OmmWtkmkn. 1m C~.mbia, AiIJil !!lip, WI (esse; pir-. (tDW ~mllil" (MfJ) 14~·7!J;7il (W 515);for.. ~) 3fi2·m.,>: l--mllit JW ~j'.~!.i'fmI.


In the teachings of TIbetan medicine there is a metaphor that !("erers to the stages ofdevelopmenr of the diagnostician. At the first levela student is liken~d to a person standing ona mountain top who isunable to perceive whati.s on the top of the oppositepeak. At the next level ,the student cansee that something is. there, At a higher level the stedent can perceive that someone is standing on the opposite peak but he or she sdlll,3Cks the ability to perceive anythingaoout that person. At many Slilcceedillg levels, more and ~OJ:e can beperceived ahQl,lt this person until, oltim;ltely, at the most a deanced degree of ability, the student reoog",~zes. p:reds:cly who isthere,

This metaphor descnb es the eve I u tien of pereeptlveablllties in leaming Tibetan medkaldiagnosls. Its meanin.g U:D also apply to precess that prsctltleners of different: medicalsystems musil: undergo to truly perceive wha~'.11 doctor from

SO AI.TERNAT!V£ IH £ AAflf S, MARCH 1999, VOL. S, NO.2

another scientific worldview sees, Performing a medical diagnosis requires an understanding of the technique and language of the system withln which one is eperating. The foundation of diagnostic skill. however, is the development of a. capacity of awareness that leads to clear and precise perceptlen,

The following artidewill explain. the basic tools and langusgeof Tibetan diagnosis and begin to dear the mist that stands between the peal!. of Tibetan medicine and that of other medical traditions. To begin establishing a complementary to medicine, there must be a common language created through which traditional and allopathic doctors can effec~ively commenicete about tbeir disciplines. Medical tradaions are not the sum. total of their diagnostic or treatment techniques; instead, they are the result of the ~denilik, cultural, and spiritual knewledge that gave rise to those therapeutic applic:a.t~olls< lb esteblish 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 Ricbard Seize., MD.l In this book Dr Selzer recounts a diagnosHc session performed by my first teacher; Dr Yeshi Donden, The session was part ofa demonstration conducted at all Americannospitai. Dr Donden was shown a patient about whom he was told nothing, Before an audience of skepelcal Western physletans, Dr Donden perfermed tile Tibetan pulse diagnosis and urinalysis. To the amazement of his audience he was able toacc:w:ately diagnose that the patient had a chronic heart problem, He diagnosed an imbalance ln the basic dxcubtory principle of the body-as it relates to bleed and heart function. This disorder had progressed to a stage in whkh it affected the patient's preexistingiheart irregularity, which had developed durrung a s.pecifi( stage ofembryo.logica~ development. Dr Selzerl recounted the diagnosis in mhis manner:

'[Dr Donden] .speaks of winds coursing through the body of the woman, curren ts that break against barriers, eddying. These vortices are in her blood, he says. The last spendings of an imperf£ct 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 fun wa~ers of her river, as the mountain stream cascades in the :springtime, battering, knocking loose the land and flooding her breath.

The allopathic diagnosis had been "congenital be art disease," all ""interventricular septal defect, with Iresultant heart fail-

I ure, ~ To Dr Seber, who was used to the worldview, technique, and jargon of his profession, th e Ti betan diagnosis seemed remarkably poetic. Dr Selzer described this diagnosls as a.large:Iy divine mystical experience accessible to priests but not to mere doctors}' Interest, fascinarion, and perhaps even respect were engendered, but little understanding be~ween the doctors seemed to develop. In fact, wha.t Dr Donden was doing was not magic. He was d()ing what was expected ttl a properly trained Tibetan physiclan, albeit at its highest level.


In describing how he worked as a phySician, my teacher,. Dr Trogawa Rinpoche," remarked: "My external activity is the practice of medicine, and in mty inner thoughts 1 meaittlteon the Medicine Buddha." This comment does not simply tell us that Dr Trogawa is a religious or pious mall. Properly understood, this remark displays the first step in the process and pracnee of Tibetan medica! diagnosis. It is an ongoing practice toward spiri. tual development and! its resultaut awareness and intenrlen, toward which the physician continually s~rives. Given the. differ' ing Levels of practice and development that exist among Tibetan doctors, there is no quantitatively preseribed standard fur thiS aspect of medical practice. Still. the primary classic principle of Tibetan rnedicel practice is that the bedrock ofene's appccech to diagnosis lies within. ~he doctor's spiritual pra€tice.

In describing the Tibetan approach to diagnosis it is vital to understand how the propedy trained Tibetan doctor sees the woiJd. After all, it is always within a doctor's subjective understanding of the nature ,of the phenomenal world that the relatively o bjective work of obtaining a diagnosis occurs. How, then, do Buddhist teachings determine the basis for making a dear diag· nosis of illness?

Because the historical Buddha described his role and teaching in a fimdamentaly medical fashion" this connection is very direct .. In fact, .. because the Buddba's teachings were meant to cure suffering. he was known as the "Supreme iPhysiciaril:'~ The Buddha. ~ ttlerefore a direct inspiration fur libetan doctors, who attempt to emulate this model of a spiritually realized being who makes a conscious choice to care 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 doctors conscious intention. Buddhist teachings delineate Tibetan doctors' image of themselves and their patients as well as the doctorpatient relationship. Buddhism's central teachings and practices place great emphasis on (1) understanding and dis<:overing the nature of one's mind, and thereby transcending ego; (2) developlng a practice of compassion toward all <other conscious beings; and (3) developing a sense of equanimj~!y< Therefcre, fur the dottor of Tibetan medicine there is IlQ psychological ox profes!;ioool dilemma in directly idenHfyill~ with his or her patient-as tl.lere can be, for instance. in Western medicine .. In a sense, the TIbetan physician. illtention:a1ly seeks to identify with the patient. It is important for illS as physicians to intimately understand the basic namre of suffering-both the patient's and the doctor's-« as well as to understand that our relationship to the patient has bollia prefesslonal and spirituaJ significance.

Throug'&l spitjtuaru practice the: Tibetan doctor is trained i.o emulate a higblyspiriluallyevolv,ed person. A direct connectlon develops between the doctor's perception of the patient and a Bodhlsetsva's perception of all beings. The term "Bodbisateva" literally means "hero of enlightenment." Bodhlsattvas art spiritual trainees who strive to generate an altraistle mind {If l!JiVe and compassion.' They are basically Buddhas in the making who


have dedicated th.eir PUl,"swt of spuiroal awareness to the single goal of bfinging about the welfare of all.

We can get a gllmpse of the professional ethic Dr trogawa endeavors to prsctice in an instruction from the 8uddbist sage Vimalakirti:

I am ill because all sentien.t beings are ill. If the illness of all sentient beings were ito come In an end, then my i1Iness woold be ended. Why is this so? Because when the Bodhisattva. enters into th~ realm ofbirth and duth for the sake of beings. be becomes subjed to the laws of this realm and th~upon becomes UI. If all sentient beings: were 00 be cured of their diseases, then the Bodhisattva would never be ill again.

It is like the rich man who only has one child. Wheu his child becomes ill. his parents become ill, If the son b. 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. Wben all beings are cured, then the Bodhisattva will be eured ..•. '

B.efor~ seeing their first patient. Tibetan doctors practice all archetypal diagnosis that becomes a basis fur all the diagnoses they wiD perform throughout Ufe. This diagnosis is visualized in II medimtion practice used by traditioua1ly trained Tibetan doctors.

In this meditation physicians visualize the "Buddha of Medkine," seeing all beings before him, with their particular sufferiog and all of the Jnnumerable diseases they may have. The Medicine Buddha. feels anguish fur them and wishes them freedom from suffering. Through the power ofbis realized mind, this Medicine Buddha diagnOlles the illnesses a$ symptomatic of fundamental spiritual disharmony caused by ignorance. This ignorance is a lack of understanding of the basic naUireof reallty, as understood from the Buddhist perspective.

The resultant confaslon leads to activities of our body and mind that di~ctly or indirectly lead to suffering and illness. Given this diagnosis, the Medicine Buddha understands the te.mporary.lUusory nature of illness. Pushing through his sense of anguish. he delves deeper into this and sees that wi.thin every atom of every being who appears as suffering, there exists a Medi(ine Buddha. He experiences inner joy in the knowledge that despite suffering. there is the potential for boundless happiness. HaWlg completed bls diagnosis, the Medicine Buddha projects a purifYing energy from himself to those before him that reveals the inherently healtby state. S

At this point in the rnedltatlon. practitioners merge their own selves with the being of the Medicine Buddha and become indistinguishable from him. They then proceed til a state of meditative emptiness derived from the understanding of the Buddhist aea(hings. In relatiM eo this emptiness. all the forms and concepts we o~upy in illness--are understood as iIIusory~ dream-like, and therefore highly changeable. Thus it follows that illness is made worse or berter 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 perreptiQn. These ql.lalities, aJong with his resultant capadty to heal, makes the Med.i.cine Buddha the role model for the physician of Tibetan medidae, By vtsuaiWng themselves as M.tdicine Buddha, doc-tors of Tibetan medicine pursue an aspiration to develop the same capacity for compassion, awareness, and skMlfulness. Tbis proces!t is the root from which diagnostic skill develops, 11 is establisbed even before the first patient walks In ,the door.

TIm ROOT, 'fBE TREI!. TIm .lJ.RAN(:}lES, nm LEAves. TlmF.lWlT

All medical systems grow from 3 roots: (1) faith and belief, (2) experience and perception, and (3) objectivity and analysis.ft Westem medidae generally claims to need only the third root, excluding tbe sjgniacant;'eof faith and bdief and imagining that experience and perception at:e superseded by an assumption of scientific objectivity and analYSIS. Fo.rtU!n3tely, as the gtassroots alternative medicine movement becomes a prominent force, Western medicine ls beginning to grant SO.ol(.' sijgnificance to these 2- other roots. Examples of this are Larry lDossey's} and He~t Bemon'-J work on the value offaith and be.Uefln treatment, and Oliver Sacks's~ assertion that the su~jec;tive experience of the pa1ient is a useful tool in dlagnosis. Practitioners of Tibetan medicine have always depended on all 3 roots to properly perceive and analyze .an i!Jness ,Qnd its cause in the diagnostic ~.

By synthesizing knowledge from various medical systems.

Tibetans creased .a systEmatic approach to medical science drawing frem thousands of years of accumulated empirical knowledge and intuition about the nature of health and illness. Centuries ago, before Buddhism entered Tibet, TIbetans, like an andent people. bad a significant degree of medical knowledge. Attording to traditional sources, in tbe beginning of the 4th century 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 mere spiritually and psychologically based! systems from Buddhist and other SOUTWl.

Around tbe 7th to 8th centuries the Tibetan govermnent 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 iIIness. Those with superior abilities in the diagnosis, treatment, and understandlngeflllness were Invited to stay and eontrlbute to the country's medlcal kaowledge base, In the 11th century this knowledge:W$ codified into a unique system.Ml'

To properly perform TIbetan medical diagnosis, a doctor must have an understanding of the theodes ofTWetan medicine and their unique description efthe body-its creati.on, prinCipal energies, functions, and processes=es ~nas: an understanding ofbealth lind the etiology of illness. As wi~h Western medicine. the q uantltarive aspect of kn owJ edge in medicine must be understood and lnternalleed SQ it can be readily drawn upon In the diagnostic session. Through instruction from a roaster and through their own practice, Tibetan doctors in trainIng also gain experience with the qualitative understanding and analysis that

are essentlalln Tibetan medicine. This qualitative dimension clearly differe.ntiates Tibetan medicine from the mechanistic vIew of Wester til medicine. Tibetan medicine views the human boo)' as an ecological system. a microcosm directly .r·elated to the macrocosm oftbe natural world,

All of the m~eriaL that makes up our unIverse is based on me qualities of 5 basic elements, which are described in the ancient physics and depicted inTIbttan medicine. Ute slltradicional people. Tibetans lived in direct contact with the nataral environmen(.'T1u~y understood through experienee and study lhat na[lIral environmental forces directly correlated with and influenced the functioning of the human organismJTibetans defined the qualities of the basic forces exis.tmg in nature in the theory of the 5 elements. These forces are ruun«i fur their most identlilable manifestations; Earth, water, ]lIre, Wind. and Space. The characteristics (such 3S a substance's taste) and therefore the nature of all matter result from the qualities of r hese elements individually or in combination.

Eanb has qualifiES offumness and stability and therefore provides the basis of physical existence and development. water creates moisture, giving lise to all fluids. Wind creates movement aad so enables aU aspects of circoliUion and movem.ent. FIre creates transformation, metabolic fUllctions, and activity, Space provides the potenttal for existence to be ereated in the first place. Combinations of these qualities make up the pbys[cal aspect of our bodies as well as the body's distinct physiologieal energies.~

As wfth any medical system, understanding the various functions of the body is important in TIbetan medicine. Howtver, the underlying physiological principles that create and maintain those functions IIIre of primal"}' importance. TIMWI medicine defines 3 main systems dl9.t eontrol all the body's functions, These 3 systems oft~ body, or Nycpa in TIbetan, are created at various stages of development in the womb by an i.nt«action of our mind's deveJ~opmentai process and the 5 physkalelements.

The first, Liing (Wind), creates an enormous number of functions, the best ex3ropl.f! of which is circulation. LUng gives .rise to and regulates the movement of blood. nerve jOlpl,Ilses, thoughts in our minds, and food through the dj,gestive tract and eliminative ()rgans. The mind expressed as attachment, desin. or a materialist worldview is manifested during the prenatal period through the deveJopment of the system ofLiing,

the second, 7'ripa {Bile), gives rise to and controls such functions as metaboltsm, liwr fun,tion, and vision.. allowing our mind to function witb discriminating inte11ed. The mind expres.'I£d as aggressiQn •. hatred, or anger is nuuifeste.d. during the prenatal period through the diVelopment of the system of1ripa.

Finally, Dddkin (phlegm) creates the physkll principle by which tnergy can be used to produce a function, provide our body's lubr~tion. break down food at the inifull stages of digeseJon. create the will. and facilitate roemOl'}'. the Inind ~ressed as ignorante or iuoomprehmsion is manifested during the PI[ena.tal period through the development of the system of lJlidf.iin.f.U

Good diagnostic skills in thf:Tibetan Systc!Ul require both

an jntellect:ual understanding of the genesis and nature of the 3 Nyepa as well as a subjectiveapp~e.dation of their qualirles and funcHo·ns. Such grounding in the SYSEeM allows us [0 avoid a fotmulakust 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 so(utions-such as changes In behavior, Hfestyle, ocr diet-can be most effective.

It is batmful 110 create a significant dichotomy bet.weeo what we ptarnce in our own life and what we preach in a profess.ional context. It Is most beneficial to patients when doctors develop a healthy .lifestyle consistent with tbeir undemanding ofmedldne. Such a pemonal pl"actke leads to a deeper understanding ofhow thf- action of the mind-maBi.fested in one's p:s.ychologieal state or behavi.or, including dietary habits-is the primary cause ofUlness: and therefore should be the primary basis: of treatment.

The practitioner of natura! medicine who is ideological]y tonStra!ned by a pure1yquantitaliJVe .approach will often think in I a disease-oriented model more appropriate to the Western medical. system, A cleat understanding of and personal experience; with the principles of health and illness are necessary to develop Ehe to make a discriminating diagnosis. When the doc- ~ tor aehleves tlUs capacity. treatment will be appropriate to the condition. It will be based on [be lise of spiritual, behavioral, psyehologic3I, and dietary approacbes [0 affect the root canse of the condition. Then, ifitis relevant to the individual case, herbal medicines Of pbysical 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 (rGyuJ bZJri" the structure of a tree Is used as a teaching metaphor, Adopting that metaphOI here, the roots of Tibetan doctors' pracUee consist of their spiritual practice, tbelr understanding and study of the medical teachings. and their oWl) personal life txperienee. The trunk of the tree is ehecapadty to fully 1,I~rsta.nd the nature of health and illness. The bnIJnches and the le-avtls are the spedfic details of medical th~OIy and practice, and the fruit i$ tile ability to makeagood diagnosis.


Th~ spMitual practice, intellectual tr.ming, and ~ the doctor CreMes the fuundation for Ite prartiee of diagnosis. The TIbetan medica! diagDosis con:s!sts 013 main phases, The:ant is the patient interview; the second is the obretvatiMl of the urine; the ahird is the taking oftbe 1:2 pulses. after which the doctor may look at the selera of the ~. aIld the sur.face of theto:ngue, and rnay feel for sensitiw.ty on certain points of the bod)'. (Jigurlt 1, from a 17thcentuly woodcut, shows a Tibetan doctor·taldng a pulse.)

Pulse reading and tllI'inalysls reqaire years of thCOl""etlcll study along with direct instruction by a master. Both ef these diagnostic praetkes combine the are and the science of medicine. The reading of the 12 pulses is a subtl.e proc-es3 that is best


FIGURE 1 Tibetan do«or raking II. pulse (l7th·c~ntuzy woodclilt)

conducted if the patient has not done anything to grossly disturb his or her physical energles, The patient should prepare fur the pulse reading by avoiding foods and behaviors Ibat art excessively heatirlg or [ooUng (0 the body as well as anything that disturbs the circulation. Behaviors or dietary practices tbat distort or discolor the urine l>-ampJe should be 3V{)k\ed as well,

Por 24 hours before the appointment, patiencs should take no medication (except prescription pharmaceuticals, which sheuld not be stopped abruptly}, red meat, alcohol, beets, toffee (If 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 m.orning of the appointment. Patients are advised not to ingest anything except water on the day of the appointment; or, if they muse eat, to eat light. easy-to-digest foods at least 10~ hours pOor to tb~

The patient is asked to bring a urine sample that should be taken from the second urination after mjdnigM. Although most doctors ask simply for the fust morning's urine, my teacher Dr Trogawa Rlnpoche states that such a sample could have too many iofl:l,lellces from the food! consumed the prevleus evening. lf the patien t goes to bed aftt1' midnight and/or wakes up during th.e night to urinate, the first safllph: taken in the morning upon arlsing can be used. Otherwise, the person should be asked to bring in the second sample taken .in the morning. Because of the signin<:ant effects of temperature on the urine, the patient is asked not to refrigerate the sample. n

When the patient arrives, the physkian tries to discover as much as possible about the problem. through listenlng and observation. The first step in (he lnterview is observation of the patient's physical appearance and manner of speaking. this is most useful if OM understands the nature of the 3 Nyepa and the classical physkal and psythologital types that can result from a constltuttcnsl predominance of one or a. pa:rtkular oombinalJon


of these energies (Table it). The pbyskian inquires about the patient's current medical condition as well as how the patient feels personally. J t may be useful Ito investigate the patient's medical history, heakh relative to the seasons, dietary pattern, or to engage in a more detailed discussion of persoeal or spiritual issues, Iii is useful. to ask femaJe patients about tbeiIgyneco!ogical 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-IJis the 5 elements and 3 Nytpa.

The patient's dietary history can be especially revealing for 2. reasons. First, follawing behavior, diet is a primary determinant of bealth, Second, there is a great amount in the Tibetan medicalliteratu:re 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 .. Understanding a person's dietary habits and! reactions to different foods can reveal tile basis of his or her condition as well as tbe circumstances leading to illness (Table 2).

The manner in which these factors can ieSul tin illness wiU be more or Less complex depending on the acute or chronic nature .0{ the problem. All illnesses must be seen as individual and based on a patient's background. There is a widespread notion that allopathit'medicine only addresses symptoms, whereas llatural medicine only addresses tlte root cause of illness, This Ii incorreet-e-an exhaustive list of Symptoms is <1.'Ucial fOf achieving a proper diagnosis in Ttbetan medicin~. If a practitioner sees 10 different cases of what aUopatnic medicine woold .regard as 1 disease, the additional aooompanymg symptoms (physical and/or psychological!) will determine the specific diagnOSIS in terms ofTibe~an medicine. Once the ftill range of symptoms in the context of the patient's history is discovered, tbe root cause of the litem can begin to be uudexsoood. Within the 1 djs~ defined by allopathic medicine, the TIbetan physician. might in fact define 10 djffer· ent sets of symptoms, 10 differ.e:nt etiologies, and therefore 10 different illnesses, the root cause of the patient's entlre complex of symptoms is uLtimately diagnosed and. treated (Figure 2), .

A&"" . ... thoo r .L.......hy ..

... rrer IDterVl.ewJng. e pa n,.e. ~r.><; .... n p sieian ana-

Iy2es a urine sample [n a white opaque container, They begin by observing the sample's odor. Spec.i6c odors described in the t~ correlate with speci.6.c oonditiQns. If it is a fresh sample, 'h~ presence or lack of vapors helps to define the reliatl,VEl he3itlexcess or wWinsufficiellCY Rlanifestrui in the to»ditioo. The S:p1!cime~ is then observed to determine w!IIether it has a watery appearance or shows degrees of ilbe colors yellow, brown, red, or white.

Nm: the physician will determine whether the sample has particular characteristlcs such as a watery appearance or whether a reddish ring appears around the surface of the sampie, A blackish hue, for example, indicates specific conditions such as the presence of eJ(teptional toxic::ity in the system. Any deposits in the urine are noted for their speeifie appearance, location in the sample, and persistence. Numerous types of deposits and their specific pathologic s.lgnitkance are described in the texts"~

TABLE 1 Examples of characterlstles corresponding to specific constitutional typd

Wind na~ore person

Bile nature person

Phlegm nature petson

Slightly hunched over

Thirsty often

Often luIs cold

Tendency ro In! thin

Heshyandl or fat body

I Bluish complexion

Good digestive capacity

Small bone structure

Exctssillely talkatillf

Red or blonde hair

Pale complexion

Complains e-asily

ShaJ'iP m.ind


Good memory

Can endoresutfering

I Capable of maliciousnESs

Not ma~.ri.a1istk

Pirood and confident

long life spa!')

Sho~t life span

Materially well,.olf

Light sleeper

Strong body odor


Pbyskally small

I Likes music aad dancing Laughs a let

Medimn-,!ength life span

Can control feelings of hatred or aggresslon

Moderately materialistic

Stable temperament

Dees IlOto\!twa.rdly betray fufJing.s held

intemaily .

Ukessweet, bitter, astringent, and cooling foods

Holds grudges

Doesn't like to be alone skill

Likes ~f and SOO!: and hot tastw Hat«d

Moves around easily

Likes, hot, SO\lr, utringenr, and stiml,llant foods

Comfortable at heights

Tends (0 have a good physiqut' and physical beauty

I Sly or sneaky

Not discrl minating

Can be telred on in matters ofimportance

DiffiClllty otganizing and priorifi.2ing

Moves around :Ii kit to either different places or situations

The sample is then vigorously stined with a sUck; the size, color, placement, amount, and perslstenee of bubbles are observed, The observation of the bubbles provides valuableinfor-

mation regartliog the natllre of the illness, the presence of infection, and w localization of the iUness. The 4 foundational texts QfTibetan medicine, the rGyud hZhi, and their eommencaries


Irritant food:; that can be hannfill to liiflg Heating foods that can be harmful to 1'ripa

Ceding foods that can be harmill to BitINn

TABLE 2 Example$ offoods with natures similar to and having the potential to cause imbalance in the 3 NJepaI<

Coffee Nuts


Strong tea Meat (except goat)

Goat meat

Mint Pataand oils


Poo~de soy sallee Spi<:es (txeqlt parsley. cumin, coriaom:r. anise)


Rabbit and hare

Sheep milk products

Cold liquids and dI illed food

Pood burned in cooking or processlng




Cooked food eaten coI.d or at room temperature





Pepper {black, white, gray) Salt






AI! alcoholk beW!rajeS

describe in d.etlil how the diagnO$lic signs listed. a~ relate to specific imbalances of the Nytpt1. individually or in combination.

The e.fftcts ()f organle homeostasls are reflected in the pattent's pulse. There ate 12 distinct pubes at the radial artery of each wrist. The site of pulse taking should be the distance from the

first crease below the wrist on the distal forearm measured down the. length of the fu:st phalanx of tht patient's lhu:rnb. 11te doctoi's. fioget'S are placed flat on the pa1ien.t's wrist. parallel and spaced wUh approdmately the wi.dth of a grain of nee between mem. This placement is chosen because of its rdaIion to the other arteries in.


Dim:tiono{ diagtlOSlic walj1$i~

Direc:ticn of di~ an.alysis

FlGUR;E 2 GraphiC delqiption oJ diff' be~ W~rn (left) and Tibe~n (right) medical diagt)osis.

&prinwllroro Taka!: E, Vora A. "A Th"batan. Me.di~l Pmpe«i"W! an Jrrl«lbl.e i!.owel Syndrome: B1.Iilding a. Means ·ofOis~e ror ~ Madkine" (A/lI!m ~!npkment 1hcr. 1998;4(5):347). l.!$ed wi.thpetmission of M:r.ry Ann llibett. Int.

the is a proper dmanceftom the heart and liver and therefore does not have too much or too little influena: on energy or blood pressure. Blood and the circulatory energy aiinj) from all the organs flow through the distal nelial artery, providing information about the patient's oonditi.on. Analogous to the wave; that affect tM 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 Nyep!i that oonstitute the body."

Specific pressure is applied by each finger and each ftngeI' is divided in halflongitudinalLy with each side feeling a distinet pulse (Table 3). Pulse taking jnvoives the assessment of the pulse's width, depth, strength, speed, and response to pressure. In the texts tbere are detailed descriptions of all these qualities and their indication of health, iJ.J.ness, and impending death. The speed of the patient's pulse is couoeed relative to the physician's re$piratiOll rate .. Consequently, in performing pulse diagnosis attention to the breath is as significant as it is In meditation.

The pulses are influented by the seasons, because all physi· cal phenomena reflect their composition ill the 5 elements described above. Each season has a dear elemental nature that rtl:l:tes to the nature of the individual organs. As the function of each orgam is affected by the stasons, tbe pulse takes on 3pecific eharaeteristlcs during different times oflhe year. Tibetan physicians must be aware ofthose changes when takil1lg the pulse,

When tHe differenf pulses are properly understeod and eoordlnated with the other Investigations: described above, one can clearly define the ty-pe of illness, its Jocasion, its duonkity. its hidden complications, .and other meaningful aspec~ of its

Male: small intestines Femalt: large intestine

TABLE 3 Placement of fingers in Tibetan puke fa'king

Finger Upper po.>iittlln Lower poIlition

Rigbt index: Male: Heart

, Readlll8lelt arm of Female: Lung


Right middle: Spleen

Read;ng left arm of


" Rigbt ring: Left kldney

; ReadingJefJ: ann of


Left index:: Male:LlIlIg

. ReatUng right arm of lIe:male: Heart

\ patient

Left Qlidd,ht livex

. Rtading right arm of


Mate: large intestine Pem.ale: small intt'stines


; Left ritlg: Rigbt kkImy

Reading:right arm of


'--"'---------- --- ---

Urinary bladder


etiology. To further ·ronfirm the diagnosis we can look at the color, shape, and coatings of the tongue: the sclera of ~e eye: and the seMitivity of certain pressu~ points {In the body.


With the doctor soMly rooted in 1he koowledge and practice of the ecologital and spiritual underntanding of medicine. and the paDen!: ~ to clearly ~ the nature of his or her oondltion. diagnosis in Tibetan .medicine becomes an elegant I.nvesdgatkm into the root causes af llI:ness.. The goaJ of diagnosis, 1$ in meditation, is to gain iosJght rnto the true nature of parliculat phenomena.

This article is Dot ao exhaustive description ofthe techniques ofTibetan medical diagnosis. Such desaiptions are available from published translations and. summaries of Tibetan medical texts. (Additional reading.s on Tibetan medicine are recommended below.~ Mastery of the diagnostic ~niques described in these texts reqtJil'e$lifelong study and pJ'&Clice. In £his article I ~provided an overview and analysis of an approach to investigating m~ ness as it bas been taught to me over the past 15 years.

In Dr Trogawa Ri'npoche's clinical approach, the. physidan arrives at an individualized, complex diagnosis explaining the systemic Imbalances that have manifested as illness. A multilevel I therapeudc approa(his mated to treat this imbalance (and sig-

nific:aQ.t acute sYlUptoms) to achieve a. truly curative clfut. As modernisM affects Tibetan medkine, this more classica~ hollstic approaf:h ttl TIbetan medicine is at risk of being lost. The «onomy of time and! eommerce can encQutage even Tibetan doctou to think in dinkal terms Influenced by the hegemony GfWestem medieal and techm;llogical culture. This type of clinical shorteuttins (an lead, for ewnple, to an excessive emphasis on the use of medicines to cure a more narrowly defined model of illness.

AJ, practitioners. it is ODr job to properly diagnose and treat illness as e1fecti~Ly as possible. But that process should be an educational experience fOJ: both doctors and patients. Tibetan medicine describes a logical structure foe understanding a complex matrix offactoJs It$Ulting In health or illness. It provides a set of diagnostic took to find the caLmeS of .imbalances that result in poor health. Both of these functions af(! based on .a centuries-old tradition of contemplation paired with empirlc:al observation, majntained by a long. unbroken lineagt of teachers. TIbetan medicine reminds us what tradltlonal peeple know: that illness must be understood on the basis of the inherent relationship between physical health, psychology, behavior, diet, environment, and our spiritual existence.


[am inddJted 1o·"'Y ~[S, Dr'lhlgawa Rinpedw and D, Yem!i DendeB, for fum rare andpIictksstmbing, as vrelIM to my ct:&1,gue. Shakya Do!jt. 1 would abo 100: I .. thank Kenneth 2yik, I'tII), &r bI:s support and org,tftinlioD III the Roo.MIt3Ne 00 1Rdition3I Medidne at CoI\1mbia Presbvterlan Howibll Nelf Y4.rk. NY. at whicb this pape[ wa$6rst delivered. I am most grateful ~ Amu:tw Tokar,. and Brian Tokar fur their inwlllable: a~I~Jlrein. ~"iling Ibis work. FitWly, tbanb to the Hinduja FouncialiOtl alld die ltomIth31 Centtr IW Medicine fur fuo.ditlg the fbrum at which tim pape: was origi:naDy prm!ntcd.


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4. CoIeouuG.A~~CIJJIIm. ~Meoss=~19t3=2M.

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lO. .Yolitt:tI P. A ~ cfthe 1ibet8a lMdkal ~.II'I: 11lrtt01 MtJkfllt. iO'-lrI.

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ShambNla ewer; JoIy 1&8$; NtwYw\l. NY.

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13. RtnpochBT.~~Jbwd 8eadl.NVl~Coxp;H1I9.

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16. KhIllF lJ). f.«wt;s _ TIIlI1l1J> MUkIJIG Dbuarnsala,lndb: Ubmy Qi'lIb1hn Wo:rb lind AlCld\rts: 19$6.

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n. Tiboetln med\clnI! Wllb~ile. ~at. biqxI;-ttbmcun~.