In Exile From the Land of Snows

by John Avedon

  Mendzekhang lay on the west side of Lhasa, next to the Tibetan government’s newly built post and telegraph office. It was centered on a flagstone courtyard, with dormitories for students, both lay and monk, occupying two long wings, at the head of which, facing the main gate, stood the classrooms, assembly hall and the Master’s quarters. Outside, the college walls were lined with display beds of frequently used medicinal plants. Inside, life at Mendzekhang followed a spartan schedule. At four each morning a bell sounded in the main temple at the head of the courtyard. Yeshi Dhonden had a few minutes to wash and roll up his bedding before hurrying to his classroom to begin memorizing by the soft light of butter lamps. As the mind was believed to be most fresh on waking, the first three hours before sunrise were given over to the memorization of the 1,140 pages of the four medical tantras, the root texts, preached by the Buddha, which, together with hundreds of commentaries and pharmacological catalogues, were the basis of Tibetan medicine. At seven o’clock instructors quizzed their students on the morning’s work, after which they would return to their rooms for the day’s first bowl of tea. A second bell then rang, and the whole college gathered to pray in long seated rows running the length of the pillared assembly hall, its walls hung with thankas illustrating herbs, anatomy, embryonic development and surgical instruments. On the way back to his room, Yeshi Dhonden would pass patients lined up for treatment beneath the apartments of Kenrab Norbu, the Master of Mendzekhang. Under their instructors’ observation, senior students examined the sick while other professors, along with all the doctors of Chokpori, fanned out into the city on morning house calls, visiting those too ill to come to the colleges. As always in Tibet, medical treatment was free, only the medicines themselves having to be paid for.

  Although Yeshi Dhonden’s day was spent mainly in memorization, he often looked in on Mendzekhang’s chief pharmacist and his staff. Two doors east of the front gate, they carried out the first step in the preparation of medicines, pounding into a fine powder the various roots, stems, leaves and branches as well as the numerous gems, minerals and animal products used in the 2,000 drugs routinely made by the college. The demands of their work were so great that Mendzekhang was covered with the raw materials of the trade. Hundreds of pungent medicinal plants, collected on expeditions into the mountains, were laid out to dry throughout the school’s hallways, classrooms and rooftops. Subsequently they were administered either in powder form or as shiny black and brown pills.

  Following an early dinner at five o’clock, the student body once again assembled, this time to practice debate. Seated by class in the courtyard, the college would, on the Master’s signal, break into a cacophony of shouts, claps and loud retorts as attackers queried their respondents on the correct interpretation of the tantras’ description of the causes, conditions and treatments of various illnesses. Often debates became so heated that when the five-hour session had concluded, individual pairs, a small group of entranced onlookers seated around them, their sens or outer robes wrapped tightly against the chill, continued debating far into the night.

  After two years and four months, Yeshi Dhonden completed memorizing the medical tantras. He then recited for a full day before his teacher, declining to divide his first test over a period of time, as was customary. Promoted, despite his youth, to be senior student among the five in his room, he went on to take his official examination. The mornings of four days were set aside. His parents came from Namro to attend, while his home monastery, Shedrup Ling, offered a tea service at each session. Yeshi Dhonden, aged thirteen and a half, then appeared in the Assembly Hall before the Master of Mendzekhang, the faculty and the entire student body and after prostrating three times to the images of the Medicine Buddha and Tibet’s most famous doctor, Yuthok Yonten Gonpo, on the main altar, recited verbatim the one hundred fifty-six chapters of the four tantras—in and out of sequence—as he was requested. Only minor mistakes were accepted—a lapse of any kind being considered grounds for failure. On the afternoon of the fourth day Yeshi Dhonden was informed that he had passed in good standing. Rewarded with a white scarf and a set of brocade book covers, he was admitted into the college to commence his formal education.

  Dr. Dhonden spent the next four years absorbed in eleven divisions of study. To provide an overview of the medical system, Mendzekhang’s curriculum began with the Illustrated Tree of Medicine, a diagram wherein each field of learning found its proper place in relation to the whole. Yeshi Dhonden and his fellow students spent long hours laying out on the large flagstones before their rooms the three roots, nine trunks, forty-two branches, two hundred twenty-four leaves, three fruits and two flowers of the tree, using colored thread, sticks and bright plastic buttons from the Barkhor or marketplace. After they had mastered the diagram, they were taught how to collate the appropriate chapters of the tantras with the various parts of the tree, following which they entered into the study of root one, trunk one, branch one, explaining the most important topic in Tibetan medicine, the theoretical basis for the entire system, that of the three bodily humors.

  As explained by the Buddha in the First or Root Tantra, three humors govern the condition of all sentient beings: wind, bile and phlegm. Wind is described as rough, hard, cold, subtle and motile in nature; bile as light, oily, acrid and hot; phlegm as sticky, cool, heavy and gentle. Five kinds of each orchestrate the human organism. The five winds control movement, respiration, circulation, secretions and the joining of consciousness to the body; the five biles, digestion, sight and skin tone; the five phlegms, among other functions, the body’s cohesiveness. The quantity of wind in an average adult is said to fill a bladder, that of bile a scrotum, that of phlegm, three double handfuls. Although active throughout the body, wind predominates in the pelvis, bile in the middle torso and phlegm in the upper torso. Wind moves through the skeleton, bile in the blood, phlegm in the chyle, flesh, fat and regenerative fluid. Phlegm prevails in youth, bile in adulthood, wind in old age. When all the humors are in balance, health exists. The smallest imbalance, however, produces disease. Every illness—of which the tantras account for 84,000 in 1,616 divisions—owes its cure to the correction of a humoral imbalance. Equipped with such an all-inclusive theory, the medical system could address itself to any disease, known or unknown, including mental illness, as not just the body but also the personality of each individual was said to be governed by the balance of humors in his makeup.

  With a working knowledge of the humors, Dr. Dhonden went on to study embryology, anatomy, metabolic function, signs of death, pathology, treatment and diagnosis. In embryology, conception, followed by the weekly growth of the embryo (including the nature of its consciousness at critical stages of development), was described in texts predating Western medicine’s own findings by 2,000 years. Techniques for determining the sex of the child prior to birth were demonstrated, along with medicines which would reduce labor to between two and four hours, guard against postpartum infection and ease pain. Anatomy was the next subject. As autopsies were performed only if attending physicians disagreed on the cause of death, Mendzekhang’s students obtained their anatomical knowledge from detailed charts first drawn up late in the eighth century when the practice of surgery in Tibetan medicine was at its height. At that time Tibetan surgeons had routinely performed heart and brain surgery until the mother of King Muni Tsenpo, Tibet’s thirty-eighth monarch, died during an operation to lessen swelling from water retention around the heart. Following her death, surgery was officially banned. Nevertheless, minor operations continued to be performed and the use of surgical instruments as well as that of anesthetizing drugs remained part of the Mendzekhang program. While metabolic function and signs of death were relatively brief topics, pathology, treatment and diagnosis were immense undertakings, requiring Yeshi Dhonden’s greatest efforts. Pathology alone, dealt with in the ninety-two chapters of the Third or Oral Tradition Tantra, entailed individual descriptions of the categories, causes, symptoms and complications of thousands of diseases, s
upplemented by their treatments under varying conditions. It was here that memorization of the tantras proved invaluable as, equipped with commentaries written by Tibet’s long line of physicians, Yeshi Dhonden gradually built up an intricate picture of the entire range of human illness through its expression in single, double and triple humoral imbalances. The study of diagnostic procedure, though, was even more difficult. Unlike academic topics, the three trunks, eight branches and thirty-eight leaves of the Diagnostic Root of the Tree of Medicine could be thoroughly understood only through actual practice. Questioning the patient and analyzing nine aspects of his urine were essential to diagnosis. But it was mastery of the third trunk, pulse diagnosis, that was the hallmark of a leading physician.

  Although pulse diagnosis was taught for an entire year in Mendzekhang, it was believed to take a decade or more to fully comprehend. The basics were laid out in thirteen sections of the Last Tantra. The first four detail eight guidelines for the evening before an examination. To prepare themselves, both patient and doctor should refrain from the consumption of tea, alcohol and overly nutritious food, also avoiding exercise, sex and any anxiety-producing encounter. The following morning, after the sun has risen but, as the Tantra says, before “its rays have fallen on the mountaintop,” the pulse should be read. In this brief period, two definitive factors characterizing every pulse, disease and medicine—the forces of hot and cold—are believed to be most in equilibrium. Prior to dawn, lunar influences, manifested in an enhanced cold or negative pulse, accentuate wind and phlegm; after dawn, solar influences augment the hot or positive pulse of bile and blood (sometimes spoken of as the fourth humor). Because the patient has not yet eaten, digestion does not obscure other functions, while all the winds have subsided during sleep into the heart of the central channel, where, according to tantric theory, the mind and body are joined.

  The best place to read the pulse is said to be on the patient’s wrist, just over the radial artery. The Last Tantra queries itself: “Why is the radial artery used?” It replies that listening to arteries close to the vital organs “is like talking to someone by a waterfall,” whereas using those in the extremities is like receiving “messages brought by distant merchants.” The radial artery is the optimum position and is likened to “a voice in summer shouting across an open field.” “How is it possible to read the quality of the twelve organs at the radial artery?” the tantra continues. “Just as a successful businessman can discern the place of origin and make of wares at a marketplace, so the pulse if read at the radial artery can exhibit the condition of the hollow and solid organs.” Only in children below the age of eight and terminally ill patients is the pulse to be read elsewhere: in the former, on the blood vessels in the lobe of the ear; in the latter, to determine how many days of life remain, at the posterior tibial artery behind the ankle.

  The doctor is now instructed in the technique for taking the pulse. If the patient is male, the left arm is examined first; if female, the right. Switching hands, the physician then examines the patient’s other arm. In both cases he uses the three middle fingers of either hand spaced apart the width “of a grain,” while to overcome the thickness of the forearm’s muscle, his index finger presses the skin, his middle finger the flesh and his ring finger the bone. The essential ingredient of pulse diagnosis is explained next. Each of the six fingers used is to be divided into an “inner” and “outer” half. These twelve positions monitor the organs; hollow organs are read on the outer half, solid on the inner. For example, the outside of the physician’s right index finger reads the heart; the inside, the small intestine; the outside of his middle finger, the spleen; the inside, the stomach. The correspondence of all six fingers is the same for both men and women save for one instance. In a male patient the doctor’s right index finger registers the heart; his left, the lung. With a female patient the reverse applies. They are switched because the consciousness of a woman is believed to enter the center of the ovum and sperm at a slightly different position than that of a man at the time of conception. The text then admonishes the doctor to always keep his fingertips “smooth, sensitive, without scars and pliable.”

  There is one final consideration before the pulse can be read. One of three “constitutional pulses,” corresponding to the three humors, is said to dominate every person. The male pulse, similar to wind, is bulky and prominent; the female, similar to bile, subtle and rapid; the neuter, similar to phlegm, slow and smooth. Unless the patient’s particular type—any of which can be had by either a man or a woman—is known to the physician (either by examining the patient when healthy or by being told), a diagnostic error can easily be made. Furthermore, once the constitutional pulse is known, it is crucial to factor in the “seasonal pulse”—each season manifesting an influence on the characteristic pulse imprint of a particular organ, such as heat in summer, which affects the heart, and cold in winter, which affects the kidneys.

  The doctor begins by ascertaining whether the illness is hot or cold in nature. He does so by using his own respiratory cycle, to determine the rate of the patient’s pulse. If the pulse beats five times per breath, the person is in perfect health. More than five beats denotes a hot disorder; less than five, a cold. Above eight in a hot disorder or below three in a cold disease means an extremely severe, usually incurable problem.

  One of twelve general pulse types is now sought. The six hot beats are strong, ample, rolling, swift, tight and hard. The six cold beats are weak, deep, declining, slow, loose and hollow. If the moment all his fingers touch the radial artery a hot beat is superficially felt, the physician knows that the disorder is new and minor. If, after pressure is applied, they are felt deeply, the illness is chronic and complex. The reverse holds true for cold disorders; superficial pulses reveal old, serious ailments; deep ones indicate new, minor imbalances. From this second step the history of an ailment is known.

  The state of the three humors in the body is now explored. Each humor, as well as its combinations, possesses a characteristic pulse type. When it has been identified, the individual pulse of one of a huge number of conditions is sought. If the patient is pregnant, the “pregnancy pulse” will reveal it, as well as, after the sixth week, the sex of the child. If worms are present, the pulse is “flat” and seems to knot as it beats; if bacteria, it is incomplete, with “sudden, irregular and unpredictable cessation in the rhythm of the beat.” In leprosy, the pulsebeat is “quivering,” and contracting at its conclusion “like a person who limps.” Wounds manifest a “bulky, hard and quick” pulse. A bullet lodged in the body produces a “limping and double” pulse as if there were two arteries, not one, being read. After describing tests to distinguish pulse types, the tantra instructs the physician to investigate the individual organs through the twelve positions on the fingertips. His exam complete, over a period of roughly one hundred breaths, the doctor knows what the humoral imbalance is, its severity, which organs are affected and in what manner.

  As Yeshi Dhonden and his classmates discovered, however, the topic of pulse diagnosis was far from exhausted. In the remaining sections numerous exceptions to the rules were cited as well as the uses of the pulse in determining lifespan, spirit possession and, in an extremely complex section known as the “Seven Amazing Pulses,” the future course of an illness. In the eleventh section, those pulses which reveal that a disease will be terminal are described, showing how vivid the tantra’s descriptions can be.

  The “changing” death pulse is said to “flutter like a flag in the wind”; while the “irregular” death pulse appears “like a vulture attacking a bird, who stops, plunges, beats its wings quickly, stops again and then resumes flight.” In a combined wind-bile disorder, the patient’s pulse will resemble “a fish leaping out of water to catch a fly, who quickly shimmers back.” Accumulation of phlegm and wind producing death are like “the pecking of a hen eating grain”; that of a triple humoral imbalance, like “the saliva of a drooling cow, moving in the wind.” The text then enumerates d
eath pulses unrelated to the humors. If a healthy person who has had an accident has a thin pulse, he will die shortly. If in a person who has been sick for some time the pulse suddenly turns strong or violent, death is imminent. The amount of time left to live, within a period of eight days, is shown by the absence of pulse. Death will occur in three days if the liver or gallbladder pulse is missing; in two if the lung or large intestine pulse is absent; in one if the tongue is black, the eyes are in a fixed stare and the pulse of either the heart or the small intestine is gone.

  Dr. Dhonden’s true education in pulse diagnosis came only after his studies were completed. At the age of eighteen he was sent by Kenrab Norbu, Mendzekhang’s principal, to undertake a four-year internship with a master physician practicing in Lhoka, who was already surrounded by many disciples. During this second stage in his training, Dr. Dhonden rose before dawn each day to take pulse, analyze urine and present his diagnosis of patients’ ailments to his new teacher. While his understanding of the myriad pulse types grew, he came to have a profound regard for the efficacy of the entire medical system. Although patients in advanced states of illness could not be cured, others, afflicted by a number of usually fatal degenerative diseases, such as cancer and diabetes, responded with complete remission. In the case of diabetes, seen in one out of every two to three hundred patients, he witnessed many cures occurring within six to nine months. When medicine proved ineffective, he and his teacher used accessory treatments: emetics, purgatives, moxabustion, cauterization, bloodletting and acupuncture or “Golden Needle” therapy, which, according to Tibetan medical histories, originated in Tibet and spread to China via Mongolia. Among the most successful treatments Yeshi Dhonden found were those for senility (employing memory pills), those included in the divisions covering women’s and children’s diseases as well as those in the eight branches of infertility, itself an entire category of medical practice. Although rarely prescribed, due to Buddhist ethics, two types of birth-control pill existed. One had to be taken for a few consecutive days, whereafter its effect lasted for a year; the other eliminated fertility for life.