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A Tibetan Medical Perspective on Irritable Bowel Syndrome

Building A Means of Discourse for Integrative Medicine

Eliot Tokar and Ariana Vora

Introduction

A highly regarded Tibetan physician in West Bengal, India, recently said that he was wary of the negative effects when younger Tibetan doctors feel they must address Western medical diagnoses. He said that such information does not help the doctor to make an accurate Tibetan medical diagnosis and instead spreads the hegemony of Western medicine.

This is a persuasive argument. As economics and the influence of Western medical approaches endanger the more classic, holistic approach of traditional medical systems, the most important issue regarding Tibetan medicine is its complete preservation. Already, Tibetan medicine is beginning to be promoted as a hot new commodity in the new alternative medicine industry. In this environment the use of classic treatment protocols will increasingly give way to the use of Tibetan herbal pills as an oversimplification of Tibetan medical treatmen t. This crea tes a s cenar io e as i l y exploitable by the growing nutriceutical industry that is always looking for potential new products.

The active cooperation of various systems of medicine is an important goal, but a hasty integration will limit us to a "Disney World" version of these vast and varied medical approaches. That is, we will find ourselves using only some of the form and some of the substance of complex tra d Hi on al sys terns of na tural medicine squeezed into easily maketable and salable forms. "Complementary medicine" has already become a ubiqui-

tous term in current discussions of alternative medicine. Simply creating a field of "complementary medicine" as a new industrial category does not honor the intelligence expressed by the American people for the past three decades through their grassroots effort to investigate and use alternatives in healthcare.

However, adopting the isolationist perspective of the aforementioned Tibetan physician is not the only way to preserve Tibetan medicine. We must work to understand the system and teach its true meaning so that health care consumers can discern what is real and what is commercial. Before a system of truly complementary medicine can exist in the United States, the essence of traditional natural medicine practices needs to be properly understood by allopathic health professionals and more fully incorporated into American sensibilities. The first step in that process is developing a means of discourse 50 that lay people, allopathic physicians, and practitioners of traditional natural medicine can speak to and educate each other.

To begin establishing a complementary approach to medicine, we must create a common language through which traditional doctors and allopathic doctors can communicate clearly about their disciplines. For example, traditional Asian medicine is not about acupuncture points, herbal remedies, or other therapeutic devices. Rather, it is about the scientific, cultural, and spiritual knowledge that gives rise to and defines the clinical indications for those applications. Creating such a language is a complex but essential task that, at worst, is overlooked and at best is attempted in an intellectually and scientifically inadequate fashion.

The following example is offered as an illustration. A meeting was recently held at Columbia University New York, New York with two Ayurvedic physicians and a group of Western health professionals. In the question-and-answer session one Western practitioner, who was working at a hospital unit that utilizes complementary medicine, asked the Vaid yas if and how they treat multiple sclerosis (MS). They answered that they did treat MS and then attempted to explain their approach to treatment. As they spoke, the American practitioner posed numerous additional queries regarding the details of MS. As this happened, the discussion became progressively obtuse and frustrating.

Based on my experience in traditional Asian medicine, I offered the comment that the Vaidyas were actually not diagnosing or treating MS because it does not exist as a diagnostic category in A yurvedic medicine. I recommended that we share some case studies of their own patients with a Western diagnosis of MS and discuss in detail the condition they had diagnosed and the results of their treatment. The discussion immediately became a more organized and clear dialogue. It ceased to have the tone of an inquisition or the strain of a person struggling to fit the wrong size shoe onto the opposite foot. After the meeting the Indian doctors told me, "this often happens to us at meetings of this kind where we are asked about Western diagnoses. To accommodate the Western doctors we answer, but it is never adequate."

Western diagnoses such as irritable bowel syndrome (IES), cancer, and diabetes are not in fact illnesses; rather, they are conceptual descriptions of the etiology of illness with related treatment protocols. When we appreciate this point, the

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I BS is the most common

gastrointestinal disease in Western clinical practice.

Eliot Tokar (right) and his teacher, Dr. Yeshi Donden (left). Dr. Labsang Tenz in is seated left,

concepts of Tibetan medicine or any other system of medicine can be considered on equal terms with the concepts of the Western model. Only then can we create a language that enables meaningful dialogue among different medical systems. The development of such a language is an often ignored prerequisite for an effective integrative analysis.

This article contributes to this language of discourse with the long-term objective of creating such an analysis. As a starting point in building this language, the condition defined by Western medicine as IBS provides an example of a useful model for comparative analysis with the same condition as defined by Tibetan medicine.

IBS; Diagnosis and Treatment in Western Medicine

According to Harrison's Principles of Internal Medicine, irritable bowel syndrome (IBS) is the most common gastrointes t i n a l diseas e in Western clinica 1 practice.' Its etiology is not clearly understood by Western medicine, and it has no

known organic disease as its basis.? Psychological conditions ranging from stress and anxiety to deeper disturbances frequently trigger exacerbations of symptoms.1 Compared with the general population, patients with IBS have an increased frequency of psychiatric diagnoses including personality disorders, anxiety, depression.!

Symptomatically, IBS is experienced as either abdominal pain, intermittent diarrhea or constipation, bloating, and excess gas.3 IBS is a disorder of motility or sensory function in the gastrointestinal tract, often leading to rapid transit of food to the small intestine. 1,3 A diagnosis of 18S is supported by symptomology of a chronic and intermittent nature, an absence of physical signs of deterioration, and emotional str ess.? The rest of the diagnosis is esta b l ish e d based on the exclusion of other conditions, such as infection, neoplasia, thyrotoxicosis, obstruction, and malabsorption.'

IBS is considered treatable but not curable.1 Dietary treatment includes fiber supplements, osmotic laxatives, and easily digested carbohydrates} Symptoms can be medically controlled with antidiarrheals, prokinetic agents, tricyclic antidepressants and/or anxiolytics.! Because IBS is thought to be incurable, patients are advised to adapt to the sympt o ms.f In cases of great severity or where patients do not respond to treatment physicians often recommend psychotherapy, hypnotherapy, or biofeedback 1

Comparative Diagnosis

Figure 1 illustrates a basic difference in the diagnostic approaches of the Tibetan and Western systems. Consider two pyramids, one inverted and the other upright.

Western diagnosis can be graphically represented by the inverted pyramid. In the process of performing a Western diagnosis, the physician begins by considering the broad spectrum of a patient's chief complaints, history of present illness, past medical history, and social history. The Western physician then progressively narrows the differential, eliminating what is regarded as extraneous or secondary. Finally, a singular definition of disease is reached, such as IBS. Once this diagnosis is established, information about treatment options and expected prognosis can be accessed from statistical and experimental research tested in study populations. However, in this approach very little is understood about the difference between one individual with IBS and another individual with the same diagnosis. Beyond the subjective observation of the Western physician, no satisfying explanation is available regarding why individual patients experience the disease differently, with varying symptoms, course, prognosis, and quality of life.

Tibetan diagnosis can be graphically represented by the upright pyramid. At the apex of the pyramid is the individuaL The Tibetan physician places a particular emphasis on individuality because all illnesses are rooted in each patient's unique background and situation. This concept of the individual is then expanded to include the chief complaint, accompanying symptoms, and relevant medical, personal, dietary, and spiritual history. Through this process, the physician perceives the broader complex that characterizes the illness. Once the illness is diagnosed on such terms, the root cause of the entire complex of symptoms and conditions can be understood. It is this root cause of illness in addition to the

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The Tibetan physician places a particular emphasis on individuality because all illnesses are rooted in each patient's unique background and situation.

acute symptoms that Tibetan physicians diagnose and treat. In this approach, each patient's diagnosis, treatment plan, and prognosis are determined on an individual basis. Therefore, what might be perceived as one disease in Western medicine is actually perceived as a range of conditions in Tibetan medicine.

Diagnosis of the Condition in Tibetan Medicine

It follows that the etiologies and manifestations of illness can be understood within several diagnostic categories in Tibetan medicine. These categories relate to three principal systems that give rise to and regulate all functions of the body and mind: Lung (Wind), Tripa (Bile), and Biidken (Phlegm). Below is a rudimentary description of the three systems and a brief discussion of their relation to the diagnosis of IBS.

The three principal systems that create and sustain all the body's functions (Lung, Tripa, Biidken) are created at various stages of development in the womb by an interaction of the mind's developmental process and the Ii ve physical elements (discussed later in the section on diet). Embryologically, the mind acts as the basis for the creation of each individual's three principal physical systems. A materialist view of the world, based on ignorance of a spiritual perspective, is inherently related to Lung.

In Buddhism, stress can be defined at its most basic level as the conflict created between the pursuit of worldly desires and the inevitable limitations in fulfilling these desires. Therefore, stress is a reaction rather than a response to given circumstances. This reaction results in psychologic and physical reactions which

disturb Lung. The results of stress can include improper diet, harmful lifestyle (e.g., erratic sleep habits), and poor adaptation to one's physical environment (e.g., overexposure to cold in winter or to heat in summer).

-IBS is frequently triggered by an emotional stress reaction resulting in symptoms such as diarrhea and/or constipation. Therefore, a characteristic etiology of this condition is the disturbance of what in Tibetan medicine is called Lung (Wind). Lung gives rise to all circulation in the body. As the basis of circulation, it is associated with processes of the human organism characterized by movement, from the intangible (e.g., thoughts) to the physical (e.g., nerve impulse, blood, and lymphatic circulation and movement of chyme through the digestive and excretory systems).

A disturbance of Lung can occur alone or in combination with dysfunctions of one or both of the other principal systems. When it occurs alone, this disturbance is termed a Lung disorder. Typical symptoms of such a disorder incl ude erratic and diffuse pain, lower back and hip pain, dry skin, abdominal distention, constipation, diarrhea, anxiety, anorexia, depression, mood swings, insomnia, psychosomatic disorders, irregular blood pressure, and metastasis of tumors.

The second principal system is Tripa (Bile). Tripa is associated with thermoregulation, metabolism, vision, liver and gallbladder function, and blood production. It allows the mind to function with discriminating intelligence. A disturbance of this system can include such conditions as anger, hypertension, vomiting, gastric acidity, hepatic dysfunction, and the development of fast-growing tumors.

Eliot Tokar (left) and his teacher, the Tibetan lama and physician Dr. Trogawa Rinpoche (right).

Cases of IBS defined by the basic LUng disorder in combination with a Tripa disorder are called Lung /Tripa disorders. They can include symptoms such as erratic episodes of hypertension, sharp pains that move around the body, fluctuating fevers, reflux, regurgitation, and a combination of symptoms of both LUng and Tripa disorders.

Badken (Phlegm) is the third principal of physical and psychologic function. It is associated with the proper breakdown of food in the initial stages of digestion, the maintenance of the body's internal fluids, and the proper functions of the senses overall. Typical manifestations of Biidken disorders can include a sensation of physical or mental heaviness, kidney disor-

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The first consideration in treatment is the principle that all illness ultimately originates in the mind. This

does not mean that all illness is psychologic or psychosomatic.

ders, hypotension, slow metabolism, hypersensitivity to cold, weakness, diarrhea, the development of soft cysts, and slow tumor growth progression.

If the case of IBS is characterized by a Lung disturbance combining with the principal system of Biidken, it is called a Lung/ Badken disorder and is characterized by an inability to break down foods properly at the initial stages of digestion. In this case, the IBS is accompanied by symptoms such as hypersensitivity to cold, mucus or undigested food in the stool, excessive urination, and a combination of Lung- and Bli'dken-derived pathology.

Finally, if the condition derives from a complex dysfunction of all three main principal systems mentioned above (Lung, Tripa, and Biidken), it is termed a Badken Mukpo (literally brown phlegm) disorder and reflects a combination of liver and stomach dysfunction that chronically undermines digestive and assimilative processes. This results in a variety of symptoms, including intestinal pain, sour vomiting, indigestion, nausea, lack of appetite, blood in the stool, and constipation. In more severe cases, or if left untreated, this condition may lead to tumorigenesis.

Appropriate diagnosis of the condition is determined through an interview and physical examination, in which the patient's history and presenting symptoms are elicited. Next the physician analyzes a urine sample, feels the 12 distinct pulses on the radial artery of each wrist, observes the tongue and the sclera of the eyes, and, if necessary, applies pressure to appropriate points on the body. Treatment is then tailored to address the specific etiology of the individual's condition.

Treatment in Tibetan Medicine

Treatment is specific to each of the four diagnostic categories. The first consideration in treatment is the principle that all illness ultimately originates in the mind. This does not mean that all illness is psychologic or psychosomatic. Rather, it means that, due to ignorance, we misperceive the nature of reality and act in ways that create suffering, such as illness. Given this basic principle, when treating an illness, physicians begin by recommending specific behavioral and lifestyle modifications. If this is not sufficient, then physicians work at the level of dietary therapy. [f these are not enough to cure the problem, physicians use herbal medicines or, if needed, physical therapies such as acupuncture. As stated by Dr. Trogawa Rinpoche, the treatment ultimately must fit the patient; that is, treatment must be formulated in a manner that can and will be effective for that individual.

Behavioral Modification

Behavioral modification can include meditation instruction, spiritual advice, counseling, exercise, or the reorganization of habitual patterns such as sleep habits and eating schedules.

Initial stages of meditation generally include simple breathing practice and working with one's thoughts in a manner that calms the mind. Meditation then evolves beyond that point to include specific contemplations and visualizations, which begin a process leading to a new understanding and perception of the world. This aspect of the treatment may vary slightly with the diagnosis. For example, in the case of Lung disorders, meditation may be specifically directed

toward understanding the impermanent nature of physical phenomena as a cure for materialism and attachment. In the case of Tripa disorders, emphasis may be placed on generating a deep feeling of love and compassion as a cure for aggression and anger. In Biidken disorders, meditation will focus more on developing wisdom as a cure for ignorance.

What follows is a basic meditation for people experiencing anxiety and depression, which are fundamentally Lung disorders. Because it calms Liing, this meditation can be helpful in some etiologies of IBS. After awakening in the morning, patients are asked to sit with their backs to the sun in a place where they can look at the clear blue sky. If this is not possible, they can simply visualize the clear blue sky in their minds. Patients are then taught some simple breathing practice. When thoughts arise, they must not try to suppress them or to become involved with them; rather, they should allow them to arise in the mind and pass away. Such relaxing practices allow patients to focus and calm their minds. Patients are then asked to look at the sky, taking particular notice of its expanse into infinity. Next, they are told to focus on their minds and locate their consciousness. Then, on the exhalation, they are taught to project their consciousness out of the body and into the sky where the consciousness diffuses into an infinite blue expanse. Although it is very basic, this meditation begins to train patients who are gripped with mental turmoil to let go of their thoughts. In Tibetan medicine, this grasping onto thoughts is considered an exacerbating factor of anxiety and depression.

Physical activity, lifestyle, exercise, and habits are also considered. For example,

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Food is analyzed based on its qualities and nature as defined by a five-element theory~

patients with Lung disorders are told to pay special attenfion to regularity of lifestyle (e.g., eating, sleeping, and excretory function), find time for calm activities and socializing, and exercise in ways that promote good overall circulation, using techniques such as yoga. An individual who suffers from a Tripa disorder should stay away from situations causing conflict. Such people should avoid direct, excessive exposure to the sun and el"lgage in physical activities that relax them. Patients with Btidken disorders should keep warm and perform vigorous exercise such as running or dancing. Swimming is not a ppropria te if it invol ves immersion in cold water. In the case of a combined disorder such as Bddken Mukpo, behavioral modification is tailored to the particular form the illness takes.

Diet

In recommending an appropriate diet, Tibetan physicians consider which types of food are harmful and which might be beneficial, the amount of food to be eaten, the number of meals per day, and the proper meal times. Food is analyzed based on its qualities and nature as defined by a five-element theory. All of the material that makes up our universe is based on the qualities of five basic elements that are described in the ancient physics depicted in the texts of Tibetan medicine. Ancient Tibetans lived in direct contact with the natural environment. They understood through experience and study that the forces manifest in nature directly correlate with and influence the functioning of the human organism. In the theory of the five elements, we see an effort to define the qualities of the basic forces that exist in nature. Once defined they are named for their most identifiable

Patient

I ndividual

Direction

of diagn ostic analysis

Diagnosis of disease

Diagnosis of ill'ness complex and its r00[ cause

Direction of diagnosti c analiysis

Figure 1. Graphic description of difference between Tibetan and Western medical d'iagnosis.

manifestations: earth, water, fire, wind, and space. The characteristics and! therefore the nature of all matter then result from the qualities of these elements individually or in combination.

Specific arrangements of the five elements that occur during embryologic development form the three bask prmcrpIes of physical function (Lung, Tripa, Biidken), This is important because the taste of different foods, their resulting natures, and therefore their effects on the human organism are also dictated by the specific arrangements of elements that make up the food. This principle enables practitioners to think intelligent!.y about diet and health relative to each individual patient's lifestyle, environment, and health condition.

The recommended diet for IBS varies significantly depending on the specific etiology experienced by the individual patient. Because stress is a significant trigger in IBS, Lung is usually a contributing factor. Therefore, a proper therapeutic diet must usually treat Lung imbalances. Depending on the presence of imbalances of Tripa and/ or Biidk.en,

additio.nal foods must be addled to or removed from the diet.

lAing Diet. Patients benefit from a diet of heavy nutritious food's, such as meat, cheese, butter, and soups made with bones (e.g., chicken soup). In the case of a Lung I Tripa disorder, or some Btidken Mukpo disorders, or if the patient is a vegetarian, anf m a l-base d foods can be replaced with. other foods, Substitutes tnclude avocadoes, vegeta.bl,e-, legume-, or grain-based soups, onion, asparagus, and oats,

Foods that are irritating or "rough" in nature should be avoided because they would impede or distort the movement and circulation that is essential for the function of Lung. These include foods that are burned in cooking or processing (e.g., grilled meat, over-toasted bread, coffee, chocolate) because they induce stagnation of the circulatory energy; sugar, molasses, and artificial sweeteners; puffed grains such as rice cakes; monosodium glutamate; improperly processed foods (e.g., distilled vinegar, low-grade soy sauce); and green tea. These foods, which might otherwise be benign or useful, are con-

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Herbal treatments range from

simple to very complex, in a compound

using approximately 3 to 150 herbs per formula.

traindicated in this situation for two reasons: (1) because they are irritants causing an exacerbation of stress-related symptoms, and (2) because they impede proper circulation in the body.

Tripa Diet. These patients observe the Lung dietary guidelines when appropriate while incorporating additional principles that are tailored to the Tripa condition. In this case a simple vegetarian diet is suit-

able, including legumes, potatoes, cumin, coriander, fenugreek, artichoke, bitter vegetables (e.g., dandelion), and turnips. Foods that are heating in nature should be avoided. These include peanut butter, mustard, spices, garlic, ginger, onion, alcohol, meats (especially lamb), oily and greasy foods, and soups made with bones.

Biidke« Diet. These patients adopt a heating diet with respect to both the nature and the temperature of the food. For example, they consume hot water, cooked foods, pomegranates, sheep cheese, yogurt, radish, honey, ginger, and garlic. They avoid cold drinks and raw foods such as salads, potatoes, tomatoes, eggplant, bell peppers, and sugar.

Biidken Mukpo Diet. Badken Mukpo is the combined dysfunction of all three energies. This is a complex chronic condition in which each of the imbalances ultimately affects the digestive and metabolic functions. The diet includes fresh, cooked foods to facilitate the severely compromised digestion that is typical of this condition. Recommended foods include fresh meat, dairy products, vegetables, fruits, and whole grains. This condition is exacerbated by garlic, tomatoes, eggplant, bell peppers, and foods that are aged, fermented, cured, smoked, sour, chilled, oily, or processed.

Herbal Medicines

If the above approaches are not sufficient in relieving the condition, herbal medicines are prescribed. In Tibetan medicine, herbal treatments range from simple to very complex, in a compound using approximately 3 to 150 herbs per formula. Each formula or set of formulas is prescribed to fit the manifestation of the disease and the evolving condition of the individual patient. As a result, herbal medicines often need to be modified at each visit.

Typically, two to four formulas are prescribed, to be taken each day at specific

times. Morning remedies commonly in cl ud e those for Biidken disorders or digestive disorders. Afternoon remedies are typically used to treat Tripa disorders. Remedies given in the late afternoon or evening are usually given to treat Lung disorders. Ultimately, the organization of the prescription is based on both the doctor's judgment and the patient's lifestyle.

Although prescriptions are specifically tailored to each case, some herbs are more frequently found in formulas applicable to cases defined as IBS by Western medicine. For example, a set of three herbs (Terminalia chebula, Terminalia belerica, and Emblica ojficinalis) are often given together as a mixture or included as ingredients of a complex formula.

Additional herbs are typically prescribed for each individual's condition. Herbs such as Aquilaria agollocha, asofedita, Saussurea lappa, Areca catechu, cardamom, nutmeg, and clove are often found in Lung disorder mcd ications.f Swertia chirat a, Saussurea lappa, and Berberis are commonly used in Tripa disorder formulas.f Biidken disorders are commonly treated with pomegranate seeds, Piper longum, black salt, cardamom, and cirmamon.P Commonly used ingredients for relevant Badken Mukpa disorders are Saussurea lappa, Emblica ojjicinalis, pomegranate seeds, cardamom, Piper longum, Veronica ciliate, and calcite5

, Physical Therapies

Other therapies may also be used if the above approaches are not sufficient. They include:

Massage. Massage is calming and promotes good circulation. For cold conditions such as Lung and Bddkir: disorders, massage oils should be heating in nature, such as sesame oil or mustard oil.

Tibetan acupuncture. Tibetan medicine has its own unique acupuncture system. In addition to the application of needles

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Herbs such as Aquilaria agollocha, asofedita, Saussurea lappa, Areca catechu, cardamom, nutmeg, and clove are often found in Lung disorder medications.

Tibetan physicians also use moxibustion, which may be used in conditions such as Biidken and Lung.

Inhalation therapy. This modality is best illustrated by the medicinal use of incense formulated specifically to treat Lung conditions. When indicated, patients are prescribed such incense and asked to inhale the smoke as it diffuses into the air during times of the day when the Lung predominates, such as in the late afternoon and before bedtime.

Conclusion

The process of introducing new ideas regarding medicine and creating a new, integrative paradigm is already present in the history of Tibetan medicine. Centuries ago, before Buddhism entered Tibet, Tibetans like all ancient people had some degree of medical knowledge. According to traditional sources, in the beginning of the fourth 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 A yurvedic medicine, as well as more spiritual and psychologic systems from Buddhist and other sources. Around the 7th to 8th century, government-sponsored conferences were held in Tibet, where doctors skilled in the medical systems of China, Persia, India, and Greece came to present and debate their ideas on health and the treatment of illness. Those with superior abilities were invited to stay and contribute to the country's medical knowledge base. It was not until the 11 th century that this knowledge was integrated into a unified system. This system contained a synergy of various principles of physical and psychologic medicine imbued with a spiritual understanding.

For the past 30 years the American people have said that the medical system that has dominated this country for most of this

century is not wholly adequate. The recent explosion of interest in alternatives in health care from allopa t h ic doctors, researchers, the government, and industry creates two possibilities. One is a renaissance atmosphere in which doctors, researchers, and independent practitioners of natural medicine meet on equal ground, freely exchanging ideas, experience, and knowledge and thereby creating great benefit for patients. The other is evidenced by the new presence of people in the health care industry who are seeking to co-opt and control this renaissance through professional, political, legal, and commercial means.

People must learn to negotiate the landscape of alternative health modalities. However, Americans need a better understanding of the theory and practice of these disciplines before their efficacies can be truly understood. When understanding is achieved, Americans can gain benefit from Tibetan medicine's insights into how to maintain health and cure illness, based on centuries of accumulated knowledge of the spiritual, ecological, psychologic, and physical aspects of health.

Given the speed of developments in the modern world, it will probably not take us the seven centuries the Tibetans utilized to create a new paradigm of integrative medicine. However, we must not allow the agenda to be set by the rapid pace of economics and technology that has negatively affected our American health care system. The above material is an illustrative example of how diagnoses can be understood across two disciplines. Additional dialogue is required to explain the meaning of basic concepts such as "blood quality," "slow metabolism," or "sweet taste" in Tibetan medical terms. More work needs to be done to create a language that allows for clear and constructive dialogue between systems. Practitioners of natural medicine need to become more sophisticated in the Ian-

guage of allopathic medicine rather than using it as an inaccurate convenience or as a way to pass in the health care system. Allopathic physicians and researchers need truly to understand the approach of natural medicine rather than seeing it as a collection of therapeutic devices that can be cut and pasted into the existing paradigm. When this work is fully accomplished, we can reach a point where different systems of medicine can act independently or in a complementary fashion where appropriate for a patient's condition. Once freed from the dangers of hegemony and dedicated to equality, "complementary medicine" will fulfill its promise in broadening American health care. [J

References

1. Lynn, R. B., Freeman, L.S. Irritable bowel syndrome. In: Fauci, AS., et a1. (eds.), Harrison's Principles of Internal Medicine, 14th edition. New York McGraw-Hill, 1998, pp. 1646-1648. 2. Clanze, W., et a1. The Mosby Medical Encyclopedia. NE!w York: Penguin Books, 1992, p. 433. 3. Heuman, D., Mills, A., McGuire, H. Gastroenterology. Philadelphia: W.B. Saunders, 1997, pp. 121-122.

4. LaMont, T.J., Isselbacher, KJ Irritable bowel syndrome. In: Isselbacher, K.J., et al. (ed s.), Harrison's Principles of Internal Medicine, 13th edition. New York: McGraw-Hill, 1994, pp. 1421-1422.

5. Tsarong, T.J. Handbook of Traditional Tibetan Drugs: Their Nomenclature, Composition, Use and Dosage. Kalimpong, India: Tibetan Medical Publications, 1986, pp. 1-88.

Eliot Tokar is a New York City-based practitioner oftraditional Asian medicine. Ariana Vora was the 1997-1998 National Coordinator of the American Medical Student Association's National Project on Complementary and Alternative Medicine. She is currently a student at Mt. Sinai School of Medicine, New York, New York.