Tibetan medicine, also known as Sowa Rigpa (gso ba rig pa), or the “science of healing” in Tibetan, is one of the great scholarly medical systems in Asia and the dominant health care system for many regions, particularly Tibet, Himalayan communities, Bhutan, Ladakh, Nepal, Mongolia, Buryatia, various regions of China, and areas of Tibetan refugee settlements throughout India. It has served the Tibetan people as the only health care system for over one thousand years. The roots of Tibetan medicine stem from pre-Buddhist, and even pre-Bön, indigenous healing practices in Tibet that further developed through a rich shared intellectual history, textual corpus and practice repertoire with the antecedents of medical traditions from India, China, Persia, Dolpo, and Central Asia through the Greco-Islamic cultural world.
Tibetan medicine emerged as a coalesced tradition in Central Tibet between the seventh and twelfth century, standardizing its medical canon in the form of a singular treatise called the Gyüzhi (rGyud bZhi) or Four Medical Tantras. Between the thirteenth and seventeenth centuries CE, it spread together with Tibetan Buddhism, throughout the Tibetan plateau, Mongolia, Himalayan range, and surrounding border regions.
It is classified as one of the five major Tibetan sciences, and has a rich theoretical corpus with hundreds of commentaries, formularies, and medical notes. It relies on a complex formulary of multi-ingredient compounds, using herbs, minerals, metals and animal products. It served as the sole therapeutic, medicinal, and health resource for an area roughly the size of Europe until the early/mid-twentieth century when biomedicine was introduced.
Decades of devastating official conditions in Tibet, Mongolia and Siberia, and neglect in Himalayan areas, almost eradicated its existence. In the 1980s and 90s, changing circumstances allowed Tibetan medicine to reemerge as a valued primary health resource. Tibetan medicine’s growth and development since then has culminated in a major force throughout Asia with clinics, hospitals, education and research institutes, and even major pharmaceutical industries forming from the late 1990s and early 2000s.
With the manifestation of national boundaries and identities, as well as the specificity of its medicinal ingredients to geographic and socio-ecologic contexts, it is now known by numerous names such as Amchi medicine, Bhutanese medicine, Mongolian medicine, and simply Sowa Rigpa to unify the diverse sociopolitical contexts. It is one of the few traditional medical systems that has been able to remain rich and diverse in its medical knowledge and practice, and retain its traditional modes of transmission, inheritance and lineage preservation.
Today it reaches globally across the world with clinics throughout North America and Europe, southeast Asia, eastern Europe, across mainland Russia, and now emerging in Latin America, and even parts of Africa. Pharmaceutically it has become a $1 billion industry.
Menjor (sman sbyor), or “medicine compounding” is its pharmacological theory and practice. It is a rich discipline of how medicinal substances combine. Such rigorous practices have led Tibetan medicine to treat the full range of disease that humankind experiences, and compared to biomedicine, to become particularly successful at treating chronic digestive and degenerative disorders, nervous system conditions, autoimmune cases, and even some types of cancer. Its sophisticated diagnostics rely on the physician as embodied instrument to assess tongue, urine, pulse and numerous aspects of the patient physique, behavior and experience to direct its complex therapeutic methods.
The concept of health in Tibetan medicine engages a view of mind and body that is intimately integrated at the subtlest level, and experiences disassociations at more coarse levels. The body and mind is animated by five elements corresponding to properties of energy and matter: earth (solidity), water (cohesion), fire (heat), wind (motility), and space (interactive context). Three major physiologic systems called nyépa (nyes pa) delineate function of organs, fluids, pathways and energetic signaling dynamics of the body: rlung (pronounced lōōng, rlung), tripa (mkhris pa), and béken (bad kan). Rlung is responsible for motility and psychophysiologic signaling in the body; tripa for metabolic heat, blood production, and thermoregulation; and béken for fluid-nutrient cycling, filtration, joint lubrication, and solidity/cohesion of tissues, cells and mass of the body. Rlung exhibits properties of the wind dynamic, tripa of the elemental fire dynamic, and béken of the elemental earth and water dynamics.
Rlung is, in turn, animated by the afflictive emotion of desire and attachment (’dod chags), tripa by hatred and aversion (zhe sdang), and béken by delusion and obscuration (gti mug). The integral relationship of body, mind, and consciousness in its function and dysfunction demonstrate how Tibetan medicine and Buddhist philosophy are deeply integrated as a single theoretical infrastructure.
The Four Medical Tantras characterizes the healthy body as a specified composition, flow and balance of rlung, tripa and béken, as well as seven bodily constituents and three excretory substances to create a balance of mind, body, inflow and outflow.
Rlung, tripa and béken in balanced form are known as the three düwa (’du ba), and have five subdivisions each characterized by their functional roles for the body.
Rlung (Wind Dynamic)
Like the wind, rlung is rough, light, cool, subtle, mobile, and “hard” in the sense it imparts force that can move things. The general function of rlung is to facilitate growth and movement of the body, exhalation and inhalation, and mobilize other functions of body, speech and mind. Rlung helps to separate nutrients from waste products in digestion, and accentuates influences of both heating or cooling depending on context, like wind inflaming a fire or transmitting the chill of a frozen lake.
The five types of rlung are Life-Sustaining rLung, Upward-Ascending rLung, All-Pervasive rLung, Fire-Accompanying rLung, and Downward-Voiding rLung. Each has its own location, pathway, and function.
- Life-Sustaining rLung (Srog ’dzin rlung) is primarily seated in the brain. It travels down the throat and chest cavity, and facilitates the swallowing of food and the spitting of saliva. This wind also assists breathing, sneezing, and belching. It provides a special clarity to the mind and sense organs, and binds the mind and body together.
- Upward-Ascending rLung (Gyen rgyu’i rlung) resides primarily in the chest cavity. It travels through the nose, tongue, and larynx, and assists with speech. It generates strength, perseverance, and good memory. This wind provides brightness and radiance (“colorfulness”) to the body.
- All-Pervasive rLung (Khyab byed rlung) is found mainly in the heart, but travels to all parts of the body. It is responsible for most bodily movement, such as movements of the limbs, closing and opening the eyes, mouth, etc., and animating minor winds throughout the body.
- Fire-Accompanying rLung (Me mnyam rlung) is seated in the stomach and travels to all inner organs. It assists the digestion of food, extracts nutrients from food and transforms nutrients into blood, enriching the seven bodily constituents.
- Downward-Voiding rLung (Thur sel rlung) resides primarily in the rectum, but travels to the large intestine, urinary bladder, sexual organs and inner thighs. The function of this wind is to regulate the passing of stool, urine, sperm, menstrual blood, and fetus.
Tripa (Fire Dynamic)
There are five types of tripa: Digestive Tripa, Color-Transforming Tripa, Accomplishing Tripa, Sight Tripa, and Complexion-Clearing Tripa. Each has their own location and function.
- Digestive Tripa (Mkhris pa ’ju byed) is located between the stomach and the intestine. It digests food, separates nutrient and waste products, and generates body heat. It is also comprised of a type of bile that supports and increases the rest of bile.
- Complexion-Clearing Tripa(Mkhris pa mdog gsal) is found in the liver. Its function is to supply color to the seven basic bodily constituents, such as that which provides red tones to blood and flesh.
- Accomplishing Tripa (Mkhris pa sgrub byed) resides in the heart. It gives confidence, pride, and wisdom. It also encourages people to achieve their desire.
- Sight Tripa (Mkhris pa mthong byed) is located in the eyes and generates vision.
- Color-Transforming Tripa (Mkhris pa mdangs sgyur) resides as part of the skin and is responsible for skin color.
Béken (Earth & Water Dynamics)
There are five types of béken, which are Supporting Béken, Decomposing Béken, Experiencing Béken, Satisfying Béken and Connecting Béken. Each of them has its own location and function.
- Supporting Béken (Bad kan rten byed) is located in the chest. Its function is to support the other four types of béken and regulate bodily fluids.
- Decomposing Béken (Bad kan myag byed) is situated in the upper part of abdomen. It breaks down ingested solids into a semi-liquid state.
- Experiencing Béken (Bad kan myong byed) resides in the tongue. It tastes and experiences the six tastes.
- Satisfying Béken (Bad kan tshim byed) is located in the head. It is responsible for the sensorial satisfaction of the sense organs.
- Connecting Béken (Bad kan ’byor byed) is found in the interstices of the joints. Its function is to maintain interconnectivity and lubrication of the joints and to move appendages.
When rlung, tripa and béken are balanced, then what are called the seven body constituents are also balanced.
The body is comprised of seven constituents without which it could not exist: 1) nutritional essence; 2) blood, 3) muscle tissue, 4) fat tissue, 5) bone, 6) bone marrow, and 7) regenerative fluids.
The production of the bodily constituents is traced from ingested contents to final produced constituent. When we eat or drink something, it enters the stomach, where Decomposing Béken mixes it, Digestive Tripa breaks it down and the Fire-Accompanying rLung separates and facilitates absorption of nutritional essences and mobilizes expulsion waste products. The nutritional essences form blood, the essence of blood forms muscle tissue, the essence of muscle tissue forms fat, the essence of fat forms bones, the essence of bones forms bone marrow, and the essence of bone marrow forms regenerative fluid. Waste products comprise primarily three excretory substances: 1) bowel excreta (feces), 2) urine, and 3) sweat. This process shows how important it is for rlung, tripa and béken to be kept in balance.
Imbalanced rLung, Tripa, and Béken
The Tibetan term nyépa refers to the tendency for rlung, tripa, and béken to be the instigators of disease and imbalance in the body, like a weakness or fault that befalls the Achilles heel and results in systemic debilitation. In this way, the can be known as “faults” in imbalance and disease, and “defaults” in balance and health. The fundamental causes of imbalanced normal rlung, tripa, and béken are the three afflictive emotions: desire and attachment (’dod chags), tripa by hatred and aversion (zhe sdang), and béken by delusion and obscuration (gti mug). The immediate causes of imbalance are time and season, the influence of non-human external influences called dön (gdon), improper diet, and improper behavior.
With regard to changes of the nyépa with time of day and season, rlung arises at dawn, in the evening and in the summer. Tripa arises at midday, midnight and in autumn. Béken arises in the morning, dusk, and in the spring. The harmful influence of non-human external influences depends upon a variety of material and emotional conditions. As for improper diet, if someone eats excessive amounts of light foods such as pork, goat’s meat, goat’s milk and yogurt, strong tea, strong coffee, and vegetables they will suffer from rlung problems. If someone drinks excessive cow’s milk and alcohol, and eats large quantities of meat, fatty cheese, nuts, sugar, ice cream, butter, chocolate, and oils – tripa problems will arise. Excess raw food consumption such uncooked meat, salad, raw fish, as well as cold water and milk, will cause béken imbalances to arise.
With regard to improper behavior that causes rlung aggravations, engaging in excess fasting and meditation, minimal sleep, improper timing of meat consumption, excess sex, forced or strained induction or retainment of bowel and urinary functions, excess mental pressure and tension, and prolonged speaking, exacerbates rlung. Tripa aggravations arise from intense exertion and strain of the body, such as carrying heavy loads, digging hard soil, running in hot weather, and experience sudden shock or trauma from falls, collisions, or other sudden accidents. Béken aggravation is induced from prolonged sedentary behaviors, no physical exercise, sleeping through the day, sleeping after eating a heavy meal, taking cold showers routinely, excess exposure to cold temperatures through inadequate clothing, and remaining in damp and cold areas for prolonged durations.
There are three methods of diagnosis in Tibetan medicine: 1) Observation, 2) Palpation, and 3) Questioning.
Observation is done by urine analysis and looking at the tongue. For a urine sample, the patient should refrain from eating spicy foods, drinking alcohol, or having sexual intercourse the night before, and then, the sample itself should be taken first thing in the morning. In Tibetan medicine urine analysis uses eight characteristics for assessment: urine color, vapor, odor, bubbles, and sedimentation, and three forms of transformations. The color of the urine is determined by the quality and suitability of ingested food and drink, appropriateness of seasons, and diseases processes.
If there is excessive rlung, the patient’s urine is very clear, like water, and has big bubbles. If there is excessive tripa, the patient’s urine is a reddish-yellow color, there is a lot of vapor and a very strong odor. If there is excessive béken, the patient’s urine appears white in color and has little odor or vapor. Generally, a reddish color indicates a hot disorder, whereas white and clear appearances indicate a cold disorder.
When observing the tongue, the patient with excessive rlung will have a very red, dry and rough tongue. The patient with excessive tripa will have a tongue which is yellow with thick coating. The tongue of a patient with excessive béken disorder will be white, smooth and moist.
The second method of diagnosis is by assessing the pulse. In Tibetan medicine pulse analysis provides an invaluable source of information – the pulse is like a messenger traveling throughout the body of the patient to assess and carry news of the patient’s condition to the doctor. To read the pulse, it is very important for the patient to be as rested as possible. The physician places the index, middle and ring fingers on the radial arteries. The space between each of the three fingers is the width of a grain of rice, and the fingers are placed half an inch from the crease of the wrist. The physician will use both hands to examine the pulse; the left wrist of a male patient is read first, while for the female patient it is the right wrist which is read first.
The third and final method of diagnosis is by questioning— asking the patient how and when the problem started, its location and which foods, situations, seasons, times of day and so forth worsen or relieve symptoms.
Four modes of treatment are employed in Tibetan medicine: 1) diet recommendations, 2) lifestyle and behavioral advice, 3) oral and/or topical medicine, and 4) external therapy applications.
If the illness is not serious, we only provide advice for dietary and behavioral modifications. Generally the patient with excess rlung must try to eat foods which are rich in nutritional content, such as lamb, butter, alcohol, milk, soup and broth, chicken, garlic and onions. The patient with excessive tripa will be advised to eat beef, vegetables, fresh butter, fresh low fat cheese, cow’s yogurt and buttermilk, drink weak tea and spring water and have less oily food. The patient with excessive béken will be advised to have honey, mutton, fish, barley, wine and plenty of hot water and cooked vegetables.
For behavior, the rlung patient will be advised to relax in dimly lit, warm places like next to a hearth fire; with quiet surroundings, beautiful scenery, and good company, such as close friends and loved ones. The patient will be advised to rest both physically and mentally minimizing any worries. For excess tripa patients, lifestyle advice focuses on cold baths and showers, sitting in shade, walking by the sea and using cooling fragrances such as sandalwood. The béken patient is advised to have lots of sun, warm fires in their home, and engage in regular exercise such as prostrations, walking and running.
Medicinal formulations in Tibetan medicine consist of ten different forms: liquid, powder, pill, medicinal paste, medicinal butter, medicinal ash, concentrated liquid, medicinal beer, precious substance medicine, and herbal compounds. External therapeutic techniques include purgatives, forced vomiting, nasal medication, suppository, enema, and vessel cleansing techniques. Medicine is identified by its taste and functions. There are six tastes: sweet, sour, salty, bitter, pungent and astringent. There are eight functions, namely, heavy, oily, cool, blunt, light, coarse, hot and sharp. In general, patients with a rlung disorder will be treated by sweet, sour, and salty tastes; those with a tripa disorder are treated by medicines with sweet, bitter or astringent tastes; and patients with a béken disorder will be treated with medicines with bitter, sour, or astringent tastes. Patients who have rlung problems should be treated by medicines which contain oily and heavy functions; those with tripa disorders should take medicines which have dull functions; béken patients should have medicines with sharp, coarse and light functions. Patients who have rlung problems should be treated by medicinal butters and mild suppositories; patients with tripa disorders should take liquid, powered medicine and purgative medicines; béken disorder patients should be treated with pills, powdered medicine and emetics.
The final treatment approach is external therapies, which are divided into smooth and rough types. Smooth physical therapies indicated for rlung patients, which include massage with year-aged butter and oil compresses. Rough physical therapies indicated for rlung patients are hot moxibustion applications on selected rlung points (e.g., crown of head, and first, fifth and sixth vertebrae of spinal cord, sternum, etc.). For tripa patients, indicated smooth physical therapies comprise water therapies that induce sweating and sitting beneath waterfalls. Rough procedures indicated for tripa patient include bloodletting. For the béken patient, an indicated smooth physical therapy is hot fomentation; and an indicated rough physical therapy is moxibustion.
According to the Tibetan medical tradition, the physician must have an insightful and intellectual rigor of mind and deep compassion. Intellectual astuteness, deep comprehension and swift and incisive understanding are important qualities for Tibetan doctors. Compassion entails a particular depth and breadth. One who wishes to be a doctor must practice The Four Immeasurables of immeasurable love, immeasurable compassion, immeasurable joy and immeasurable equanimity towards their patients.
The physician must also hold specific vows, and pay great respect to his or her master, the medical teachings, the medical art and science and his/her colleagues. The doctor must also cultivate skilled compassion toward patients, with a lack of aversion to any bodily fluid, excrement or condition. The doctor must regard medical experts as the guardians of health, flourishing and longevity, medical instruments as sacred implements, and medicine as a precious nectar and supreme offering to the medicine Buddha.
Although we recognize innumerable disease and disorders in Tibetan medicine, they can all be condensed into disorders related to rlung, tripa and béken imbalances. All diseases are located in the seven bodily constituents and three excretory substances. Diseases are diagnosed through observation, palpation and questioning. Pulse analysis and urine evaluation are critical modes of diagnostics in Tibetan medicine. The treatment approach uses dietary and lifestyle recommendations, as well as medicine and external therapies. The physician plays an important role in a patient’s life, diagnosis and treatment of disease; this requires that physicians not only have good knowledge about medicine, but also cultivate a particular medical ethics. The training for Tibetan medicine is rigorous and long with the bare minimum as four years of coursework with detailed study of the Four Medical Tantras, its commentaries, materia medica identification and compounding, and external therapy applications, along with a one year internship to qualify for clinical practice evaluation. The methods of diagnosis and treatment rely on training rigor to be accurately and effectively applied.