Diagnosis


Just as we can predict that when we see smoke in the distance we know there is a fire, similarly we can predict disease or illness through observing signs and symptoms. However, we need to be cautious when diagnosing illness; when we see a small dark cloud in the sky and predict it is going to rain we might be wrong. Therefore the physician should take time and make their diagnosis only when they are absolutely sure.

In Tibetan medicine diagnosis is divided into three sections –

Visual observation
Touch
Questioning
1. Visual Observation

The physician must use all of his or her senses in diagnosis and also closely observe the five senses of the patient in order to diagnose any imbalance of the internal organs. For example weakness of eyesight means that the liver is weak, if the patient has dry lips and sores it means there is heat in the spleen, if the patient has a hearing problem it might be connected with the kidneys, it there is difficulty in speech it might be connected with the heart, if the patient has nasal problems they might be connected with the lungs. The physician also has to observe the height and weight of the patient and their skin complexion. Also, from my experience, sometimes as soon as a patient enters my consultation room I am able to observe through their body language signs of stress, anger and unhappiness.

The most important methods of visual observation for the Tibetan physician however, are tongue diagnosis and urinalysis.

Tongue Diagnosis

The table below lists symptoms of the three Nyes-pas that are found through tongue diagnosis.

Disease of the three Nyes-pas and Tongue texture

Nyes – pas    Tongue
Loong    Reddish, coarse, dry texture
mKhris-pa    Thick yellowish coating
Bad-kan    Pale, smooth and whitish coating, moist texture
Urinalysis

This is one of the most unique features of Tibetan medicine in comparison to other forms of ancient medical science. For the Tibetan physician, the urine is like a mirror through which they can observe the internal imbalance and bodily temperature of the patient. The majority of patients think that I take their urine into a lab and send the results later, however that is not the case, I check the urine on the spot by stirring it, checking the consistency, the size of the bubbles, colour, smell, and sediment.

The best time for the physician to inspect the urine is first thing in the morning under natural light, however this if often impractical for me as I see patients throughout the course of the day and often in the evening when in winter of course there is no natural light at all.

2. Touch

Diagnosis through touch in Tibetan medicine is performed by pulse reading. This is one of the most sophisticated methods of diagnosis in Tibetan medicine. It takes years to learn and decades to fully master. The pulse is like a messenger between the physician and the disease. The preliminaries to be observed on the part of the patient for a proper pulse reading are the same as those for urinalysis. In the Tibetan medical texts pulse reading is divided into thirteen sections, and here I will just give a general overview.

The proper time to read the pulse is first thing in the morning. The patient should not move from their bed and their stomach should be empty. In the human body there are three main subtle channels known in Tibetan as roma, rkyang-ma and Bu-ma. The rkyang-ma channel is influenced by the moon, roma by the sun and Bu-ma by neutral energy. At night the pulse beat is slower because the lunar influence is stronger, and in the daytime the pulse is faster and stronger because the solar influence is stronger. At dawn, however, when the lines on the palms are visible, these influences are in a dynamic state of equilibrium and therefore this is the best time to read the pulse.

These days of course it is very impractical to read the pulse at such an early time in the morning, however pulse reading can be accurately performed at any time during the course of the day. When I see patients I always tell them to relax for at least ten minutes before I read their pulse. This is because people often arrive to see me for a consultation after having travelled for many miles and suffered from the stresses caused by the unpredictability of our modern forms of transport, and simply from life in general. It is also very important for the physician to be as relaxed as possible at the time of performing pulse reading.

The pulse can read from any part of the body, such as the jugular pulse in the neck, the abdominal pulse in the abdomen, the dorsal pulse on the ankle, or the heart pulse on the heart. However if a pulse such as the heart pulse is read at a location too close to the heart organ it will be like trying to hold a conversation with people whilst sitting next to a television which is on at full volume. The physician will simply be unable to understand what the conversation is about. Similarly if the pulse is read at a location which is too far from the organs of the body, such as reading the dorsal pulse on the ankle, it will be like watching the television when the volume is too low to understand anything.

Therefore the most accurate location of pulse reading is on the radial artery on the first crease of the wrist; this location is neither too far from the major bodily organs or too near. This is like sitting comfortably on your sofa and watching your favourite movie with the volume just right. The radial artery is like a newsroom from where reporters have been despatched to many different parts of the country to gather all kinds of news, and they will sometimes bring good news, funny news, serious news and bad news. In a similar way the radial artery is connected with the five vital organs and six hollow organs in our body, and it is read in order to see what imbalance there is in these organs.

Two other pulses are also read by the Tibetan physician. These are the ulna artery to read the life span of the patient and the dorsal artery which is read to confirm death.

As the radial artery lies deep within the wrist, the Tibetan physician will use the six fingers of the index, middle and rings of hands of both hands to read it. The index finger is pressed lightly to feel the skin, the middle finger is pressed with medium pressure to feel the muscle tissue and the ring finger is pressed hard to feel the bone.

How to read the pulse

For pulse reading the fingers of the physician should be supple and at the right temperature. If the patient is male the physician’s right hand reads the left arm of the patient. The index finger reads the heart and small intestine (fire element), the middle finger reads the spleen and stomach (earth element) and the ring finger reads the left kidney and reproductive organs (water element). The physician’s left hand then reads the right arm of the male patient. The index finger reads the lung and large intestine (metal element), the middle finger reads the liver and gall bladder (wood element) and the ring finger reads the right kidney and urinary bladder (water element). If the patient is female the right arm is read first and the left arm afterwards.

Pulse reading is the most complicated and subtle method of diagnosis in Tibetan medicine and in Tibetan medicine it is known as che pa thun gyi rigpa or intuitive knowledge of diagnosis.

3. Questioning

The physician needs to have a sympathetic ear and realise the fact that the patient will have come to visit them full of hope that they might be cured, and at the same full of anguish because of their illness. It is best if the physician is a good listener and open minded, whilst fully realising that the relationship between a physician and patient is a confidential one. The patient must feel comfortable and relaxed in order for there to be good communication between the patient and the physician. Trust and understanding between the physician and patient is crucial if the patient is to be helped.

From my own experience this method of diagnosis is the most informative. When I see a patient I ask about their medical history, how their illness began, the location of the illness and signs and symptoms of the illness.

How can I best prepare for a consultation?

    It is important to understand the current, natural state of our humors.  Certain behaviors and dietary choices can temporarily aggravate the humors, and therefore promote an inaccurate reading.

    It is best to refrain from the following for 24 hours prior to the visit In order to obtain an accurate assessment:

  1.    alcohol use

  2.    excessive or deficient fluid intake 

  3.    over or under eating

  4.    excessive exertion (physical, mental or verbal)

  5.    sexual intercourse