General Principles of Diagnosis
Now let us talk about the diagnosis of disease in Tibetan medicine. This is done by a three-fold process. First is a visual examination, which entails examining the tongue and urine. Sometimes the eyes are observed for signs of secondary effects, such as yellowing of the white of the eye indicating the bile disorder of jaundice, but there is no system of diagnosis from the eyes such as in iridology. Second is the pulse examination and third is questioning the patient about symptoms.
The most common symptoms of a wind disorder in general are excessive yawning, shivering, sighing, stretching of the limbs, cold chills, pain in the hips and joints, particularly around the shoulder blades, empty heaves, dullness of the senses, depression, paranoia, restlessness and pain when hungry. Bile symptoms are a bitter taste in the mouth, headache, fever, burning sensation in the eyes, oversensitivity to bright light and sunlight, pain in the upper body and discomfort when eating. Some of the most frequent phlegm symptoms are no appetite, feeling bloated even with an empty stomach, constant burping, heaviness of body and mind, indigestion, nausea, one’s food having no taste, a sensation of being cold both externally and internally, and also discomfort after eating. Of course, one does not necessarily have all these symptoms, but they are interesting and useful to know.
During a Tibetan medical examination, the questioning is actually just minimal. This is because everything can be known simply on the basis of the urine and pulse analysis; and for skilled physicians, examining either the pulse or the urine is sufficient. The questioning about symptoms is often just added at the end to confirm the diagnosis. There have been Tibetan doctors who have gone to hospital clinics in the United States and Europe, and simply by examining the patients’ pulse, without asking any questions or being given any background information, have been able not only to diagnose their sicknesses accurately, but to tell their medical histories as well. The Western doctors have been amazed.
Also, it should be noted that a Tibetan medical examination is much shorter than a Western one. Western patients, often considering themselves very important and especially if they are paying a high fee for an examination, feel cheated if the doctor does not spend at least a half hour with them. They regard the doctor as almost a psychiatrist, and often will talk to him or her about their various personal, private problems concerning their marriage and so forth. Tibetan doctors, however, and spiritual teachers or Lamas as well, are not psychiatrists in a Western sense. A thorough Tibetan medical examination usually takes no more than five minutes, often less, and there is never a consultation fee. Furthermore, a Tibetan doctor does not usually give spiritual advice, even if the doctor is a monk. One goes to an experienced Buddhist master for that.
One important aspect that must be kept in mind when examining a patient is his or her basic constitution. This is most often seen from what is known as the constitutional pulse. Regardless of the gender of the person, a male constitutional pulse is like a wind one, a female one is like bile and a bodhisattva or neuter one is like phlegm. Bodhisattva, in this context, has no spiritual connotation.
These three constitutional pulses are reflected in the three basic body and personality types. A wind person has a weak constitution, talks a lot, looks nervous, unstable and not relaxed. A bile person is well-built, active and aggressive. A phlegm person is slow, fat and with a fair complexion. There are also combination types of any two or all three basic constitutions, making seven types of persons. One can also speak of wind persons having a fundamental predominance of the wind element, bile persons fire, and phlegm persons earth and water.
It gets rather complicated, actually, because it is not always the case that someone, for instance, with a bodhisattva pulse will be a phlegm type of person. He or she could be any of the seven types. All these factors about patients, then, their constitutional and basic body type, as well as age, environment, season of year and so on, must be taken into consideration when making a diagnosis, otherwise it is easy to make mistakes.
Urinalysis and Examination of the Tongue
First of all, there is the analysis of the urine. What is examined is the first urine of the morning, best is that which is voided just before dawn. If one has not urinated during the middle of the night, one should collect from only the latter portion of the stream. There are certain different features to look for as the fresh urine cools down from hot to lukewarm to cold. Nevertheless, since the urine should be the first excreted upon awakening, it is not the custom for patients to give urine samples at the doctor’s office later in the day. Therefore, most often the urine is examined not when it is first expelled, but after it has already cooled down.
Usually, then, a small amount of urine is carried to the doctor’s office in a clean container and then placed in a white porcelain cup so that the color can be easily seen. Since European vitamins affect the color of the urine, especially vitamin B, as well as strong tea, yogurt and alcohol, one should not take such things the night before. Also, one should refrain from any sexual activity the previous night as well.
Many variables are examined. The doctor can check the color, the amount of steam or vapor it emits, the odor, the bubbles it has, the viscosity or thickness, its turbidity, namely whether it is clear or opaque, and also whether it is oily, has any traces of blood or albumin in it, whether there is any sediment that settles from it, whether its color changes, how it changes, and so on. Although some of these factors can only be seen when the urine is hot, such as its vapor, or while it is cooling, such as its change in color, still one examines for whatever appears. The doctor then beats the urine with a wooden stick and once more examines the bubbles. One must look at the size of the bubbles, whether they are uniform or different in size, how long they remain and so on.
From all these variables, the doctor can diagnose a sickness very accurately and specifically, in terms of the humor and organ involved, whether it is a hot or cold disorder and so on. In general, the urine of someone with excessive wind is bluish-white in color, not very turbid, with a moderate amount of vapor when hot and, when stirred, has large bluish-white bubbles that remain for some time. With bile, it is dark yellow or orangey-red, quite turbid, with a lot of vapor when hot, a pungent odor and, when stirred, small, fast disappearing bubbles. With phlegm, the urine is whitish in color, with saliva-like bubbles of medium size and not so pungent an odor.
Urine analysis does not exist in Chinese medicine. Although it did exist in the Hindu Ayurvedic system, it has been lost. It has been developed the furthest and is found nowadays only in the Tibetan medical tradition. And even within the Tibetan system, it does not appear to be practiced at present any longer among the Buryats. It is still practiced in Mongolia to a certain extent, but the tradition is not strong. I do not know about the situation in Inner Mongolia.
There is a further feature about urinalysis that should be mentioned. The urine to be examined does not need to be even from the same day. There are many factors that must be taken into account when analyzing the data that one obtains from the urine. In general, the urine as well as the pulse will be affected by the sex and age of the patient, as well as the season of the year, weather and so on. But with the urine, another affecting variable is the age of the specimen. This is very useful in the context of Tibet or Mongolia where doctors would not be available in all areas and many days may often be required to reach a physician by caravan. A doctor would be able to diagnose the condition from old urine, taking into account its age. This also allows for Tibetan physicians to diagnose patients in foreign countries who send their urine samples by post, so it is very convenient.
As for the examination of the tongue, the doctor checks the color and texture. For wind disorders, the tongue is reddish in color, dry and with small pimples along the periphery. For bile, it has a yellowish coating and the patient has a bitter taste in the mouth. For phlegm disorders, the tongue has a slightly grayish, sticky coating and is smooth and moist in texture.
Diagnostic information can also be gained from other bodily fluids and excretions, namely sputum, nasal mucous, semen, menses, milk, sweat and solid excrement. The color and odor are examined for all of these; for most of them, the presence of blood or other foreign matter; and for the sputum, the bubbles and the way the person spits. The viscosity of the excrement and mucous is checked, and the places from which the person sweats and its profuseness. One can also tell something from the urine flow, ascertained from the marks and pattern left in the snow when a patient urinates there. In Tibet before 1959, when there were less patients and more time for thorough medical examinations, these various secondary diagnostic techniques were employed. Nowadays in exile in India, they are not commonly used. Urinalysis and pulse analysis suffice.
Pulse Analysis: General Technique
Next let us discuss the pulse analysis. Since the pulse is affected by the time of day, with it being slower and cooler at night and faster and warmer during the daytime, it is best to examine it as close to dawn as possible. Also, since food and especially a stimulant such as strong tea, coffee, alcohol or tobacco will affect the pulse, it is better to examine it before the patient has taken such substances, or at least not immediately afterwards. Also, the patient should wait a short while after arriving at the doctor’s office before having his or her pulse examined so that the pulse will settle down from the disturbing effects of the journey.
Pulse analysis is done with the doctor’s index, middle and fourth fingers placed on the radial artery (the one that goes toward the thumb) on the inside of both the right and left wrists of the patient. The doctor’s hand is placed such that his or her thumb is next to the patient’s thumb. The doctor’s right hand checks the pulse on the patient’s left wrist and left hand on the right wrist. For male patients, the left wrist is examined first, while for females, the right. The Tibetans usually examine each wrist consecutively, and occasionally then check both wrists together. The Mongolians most often examine both wrists at the same time.
The amount of pressure exerted by each of the doctor’s fingers is different. With the index finger, light pressure is exerted, just touching the skin. With the middle finger, stronger pressure is applied pressing into the muscle. With the fourth finger, the strongest pressure is exerted, pushing down toward the bone.
Each finger of the doctor tests for a different set of two organs within the body, one vital and one hollow, with the left and right kidneys being read separately. The doctor presses each finger onto the artery with first one side and then the other. The side of the doctor’s fingers closest to his or her thumb reads for the vital organs, while that away from the thumb for the hollow ones. The set of organs tested by the doctor’s index fingers are reversed for male and female patients. In other words, what the doctor reads with his left index finger on a man’s right wrist, he reads with his right on a woman’s left wrist. The organs tested with the doctor’s middle and fourth fingers are the same for men and women.
It is quite natural that someone with a background in European allopathic medicine might be skeptical about such minute differences existing and being detectable in a person’s pulse. But scientific evidence is being gathered. In Ulan Ude, in the Buryat Republic of the Soviet Union, at the Laboratory of Radio-Biophysics of the Institute of Biology of the Buryat Institute of Social Studies of the Siberian Branch of the USSR Academy of Sciences, they have developed a computer program and apparatus with probes to take and analyze the pulse according to the Tibetan method. Although this program is still in the experimental stage and quite primitive and incomplete, yet it indicates quite clearly differences in data gained from three probes applying different pressure at the three appropriate points on the two radial arteries of a patient.
Comparison with Chinese and Ayurvedic Pulse Analysis
The Tibetan system of pulse analysis is quite different from that found in Chinese medicine. Although the Chinese also examine the pulse on the radial artery of each wrist with the doctor’s same three fingers, yet in the Chinese system there is no examination of different organs with the right and left sides of the fingers. Nor does each of the doctor’s fingers exert a different degree of pressure from each other.
In the Chinese tradition, each finger tests with both superficial and deep pressure. With superficial or light pressure, the Chinese doctor reads what is called the yang pulse, which is for the organs equivalent to the hollow ones in the Tibetan system. With deep or strong pressure, he or she reads the yin pulse for the organs equivalent to the vital ones. And, as has been noted, since yang is hot and yin is cold, and in the Tibetan system the vital organs are cold and the hollow hot, the Chinese system has the reverse correlations of hot and cold with vital and hollow organs from that in the Tibetan.
Furthermore, in the Chinese system there is no distinction between the organs read by the doctor’s right and left index fingers on the left and right wrists of male and female patients. For everyone, the Chinese doctors test the organs on the right and left wrists with their index fingers the same as Tibetan doctors do for men. Other differences are that the Chinese doctors do not test each kidney separately, one with each fourth finger, but both together with one fourth finger, while testing for body heat and heart pace with the other. Also, the Chinese read the liver pulse on the left wrist with their middle finger and the stomach on the right, whereas with the Tibetans it is the reverse. When one Mongolian doctor in Ulaan Baatar reported to me that he obtains more information about the liver on the patient’s left rather than right wrist, although his manner of doing pulse analysis was Tibetan, this seemed to be an indication of the slight Chinese influence found in the Mongolian tradition of Tibetan medicine. This influence does not seem to appear so much in theory, but more in certain minor practical applications.
In the Ayurvedic medical system of India, there is yet another method for pulse analysis. A great deal has been lost in this system, so that what remains today is a gross simplification of what existed in the past. Both wrists of the patient are not examined, but just one. For male patients it is the right wrist and for female the left. The doctor’s index finger tests for wind disorders, the middle finger for bile and the fourth for phlegm.
There is a rough correspondence here, since in general one could classify the lungs, heart, and large and small intestines, examined by the index finger in Tibetan medicine, as wind-associated organs; the gall bladder, liver, spleen and stomach, examined by the middle finger, as bile-associated; and the urinary bladder, kidneys and reproductive organs, examined by the fourth finger, as phlegm-associated. One can see indications of a simplification process here.
Specifics of the Pulse Analysis
As for the analysis of the pulse, first there are the general characteristics of the pulse of someone with a disorder of each of the three humors. A wind pulse is generally empty and with intermittent beats. In other words, when pressed on a superficial level, it bounces back, but when pressed deeply, it disappears. A bile pulse is thin and twisting, while a phlegm pulse is sunken and very weak. These must be distinguished from and not confused with the person’s basic constitutional pulse – male, female or bodhisattva – which, as has already been discussed, will be similar to either one of these three or some combination.
From the general pulse found with all the doctor’s fingers, one can diagnose in general about the sickness. For instance, the rate of a healthy person’s pulse is five beats per breath cycle of the doctor. A breath cycle is one round of inhaling, exhaling and a small moment of rest afterwards. Constitutional factors may affect the normal pulse rate in each individual. But pulse that is slower than this indicates in general a cold disorder, while faster, a hot.
Then, for each organ one tests for several pairs of parameters. The first of each pair indicates a hot disorder, while the second a cold, with each parameter indicating different variables about the disease. One checks whether the pulse is strong or weak, overflowing or sunken, round and full in shape or flat, fast or slow, tight and twisting like in knots or loose, hard and bloated or empty, meaning when it is pressed does it bounce back or disappear, and so on. Obviously, it is necessary for the doctor to have very sensitive fingers and great concentration.
The season of year greatly affects the pulse and must be taken into consideration. Here, the year is divided into four seasons of seventy-two days each, with an intermediate season of eighteen days in between each of the four. This is as in one tradition of the Chinese calendar system. Each of these seasons has one of the set of five Chinese elements dominant. Spring is wood, summer fire, autumn iron, winter water and the intermediate seasons earth.
Each of the pairs of organs tested by each of the doctor’s fingers is associated with one of these five elements. The vital organ from each pair has a characteristic pulse, and that will be prominent under all the fingers of the doctor during the season of that organ’s element. Thus, in spring, for instance, the wood element predominates. The liver is the vital organ of the wood element, and so the liver-type of pulse, which is subtle and taut, will be strong in general for the entire pulse reading of all the organs. Thus, it affects each of the three constitutional pulses in any patient.
The age of the patient also affects the pulse. As was mentioned before, in childhood, phlegm predominates, in adulthood bile and in old age wind. This must also be taken into consideration, and as has been seen, the time of day and what the patient has eaten or drunk will also affect the pulse. Furthermore, the gender of the patient affects which organs are read by which index finger of the doctor.
Thus, interpreting the pulse, urine and tongue analysis and so on is a fine art and skill, in which the doctor must put together the voluminous amount of information he or she gathers, sort through what is more important and modify it according to many other affecting variables. It is parallel to the process a Tibetan astrologer must go through to come up with a sophisticated, experienced interpretation of someone’s horoscope. With babies and children under eight, Tibetan doctors do not check the pulse, but rather diagnose by examining the color and shape of the three veins on the back of each ear.
Comparison with Tuvinian Shamanistic Medicine
In the shamanistic medical tradition of the Siberian Turkic Buddhist region of Tuva, there was also pulse and urine analysis, but it is unclear if the theoretical basis was in terms of the three humors. The early morning urine was checked for smell, color and type of bubbles, and also beaten with a stick. It was also left standing for a day and then re-examined. The pulse was examined not only on the right and left wrists, but then also on the lymph nodes at the sides of the neck and temples, and then on the back of the neck.
Further techniques were also employed. The doctor would examine the eyes of the patient, place his palm on the right side of the patient’s temple and observe the movement of the temple when the patient chewed, and also poke his finger in back of the patient’s ears. Diagnosis was also made from examining the patient’s spittle and the way he or she spat, and from noting the marks left in the snow when a patient urinated there, as well as the way and places from which the patient sweated.
Treatment was done mostly by herbal medicine, but also moxabustion and blood-letting were used. The king of medicines was considered bear bile, and there was massage with wolf, bear and wildcat bile on a patient’s legs to help with poor circulation. Thus, most of the techniques of diagnosis and treatment were similar, if not borrowed from, Tibetan medicine, although differences do appear.
It seems as though this traditional Tuvinian shamanist system of medicine has been lost. Patients would go to either shamanist or Buddhist doctors for various disorders, but one doctor never mixed or practiced both systems. There was also a system of divination of the past, present and future by examining the shape and color of people’s face, the lines on their face and hands, and the shape of their teeth.