Diagnosis:
Finding the Root of the Problem
If you’ve never been to a Chinese medical practitioner, this chapter and the next provide some insight into what you may expect. They outline various common procedures and go into some detail about exactly what they are and how they work. This will help you have an informed dialogue with your physician, and it offers a few tips you can use for assessment in your self-care.
Diagnostic Methods
The first and most crucial step in achieving the best therapeutic outcome from a Chinese medical course of treatment is a complete and accurate diagnosis. For reasons previously stated, a Western medical diagnosis is of limited help toward that end. It should be common sense that if you are seeking acupuncture or a more fully integrated Chinese treatment, you’ll get the best results by using the diagnostics intrinsic to that medical paradigm.
Chinese diagnosis does not rely on technology. Even here, its methods are holistic, utilizing all of the physician’s senses. Visual examination of the tongue (many physicians also examine their patients’ eyes, complexion, and Shen/spirit) and tactile examination of the pulse points (some systems also palpate the abdomen, primarily in Japanese-style hara diagnosis) are standard. Sometimes acupoints are palpated for tenderness, and body parts may be palpated to determine Ah Shi points, painful regions of nonstandard points. Classically, the physician’s senses of smell and taste were employed, with the patient’s scent and the taste of some body fluids, chiefly urine, being diagnostically significant. While scent may still be surreptitiously included by some—few if any contemporary physicians in the Western world actively smell their patient, primarily out of social convention and prevailing sense of propriety—taste is no longer used due to hygienic concerns. Hearing is used for additional corroboration, as the sound quality and strength of a patient’s voice and breathing are significant. Inquiry gathers specific information relevant to the patient’s medical history, lifestyle, and constitution.
Inquiry
Inquiry is usually the first part of a medical intake. It allows the patient to talk about concerns and is useful in building a rapport. On a first visit, the questions may be very extensive, inquiring about occupation, diet, level and type of activity, aspects of familial and personal medical history, former surgeries, illnesses and injuries, problems with any sense organs, possible problems in every Organ System, number of pregnancies and possible complications, and other factors that fill in the patient’s background and current life circumstances. This is where the physician learns of the patient’s main medical concerns—the reasons they decided to come for treatment. That focuses most of the rest of the intake so that the patient’s distress may be alleviated most quickly and effectively. The physician asks questions in order to expand on the patient’s main concern, helping to arrive at the most accurate diagnosis.
The next aspect of inquiry is most detailed on a first visit but is included on all subsequent visits as a way to monitor the patient’s progress and alert the physician to any possible new health challenges. These standard questions help evaluate the state of balance in a person’s daily life and provide clues about which Organ Systems are most involved. These include the quality and amount of sleep, perceived energy throughout the day, appetite, regularity of bowel and urine functions, emotional states or changes, the regularity of menstrual cycles, length and quality of menses, any premenstrual discomforts, and any discomforts arising from perimenopause or menopause. If pain is present, questions are asked about the nature, location, and duration of the pain. If suffering from a cold, flu, or something similar, a patient is asked about fever, chills, perspiration, body aches, and other symptoms. Other relevant questions are asked about any new immediate concern that may arise.
Pulse Diagnosis
After the verbal intake, a pulse diagnosis usually follows. Chinese pulse diagnosis is more extensive than its Western counterpart of checking blood pressure and pulse rate.
Physician and patient sit facing each other across the interview table. (Some physicians prefer to have their patient laying on the treatment table; their fingers will still be placed on the pulse points exactly as described below, and they will make the same evaluations.) The patient’s arms extend across the table, usually resting palm-up on a small cushion both for comfort and to open their wrists for unobstructed blood flow. The physician places their index fingers on both of the patient’s wrists, just below the thumb, and then place their middle and ring fingers down just beyond their index finger. Each fingertip is now on one of six discrete pulse positions.
The first thing a physician may do is to take the pulse rate, exactly as a Western physician would do. Next, an assessment of the overall state of the patient’s pulses may be made. The right wrist indicates the state of Qi throughout the body, and the left wrist indicates the Blood. The qualities of the overall pulses are determined, revealing the general state of the whole body. These two steps, rate and overall quality, may be taken in any order.
Next, the functionality of each organ is examined. Each of the six pulse positions has two depths (one close to the surface, the other deeper), yielding twelve positions in all (Figure 10.1 on next page). The superficial pulses indicate the Yang organs, since they are more superficial, and the deeper pulses indicate the paired deeper Yin organ. On the right wrist, moving from wrist toward elbow, the first position indicates the condition of the Large Intestine superficially, and the Lungs, deeper; the second position includes the Stomach and Spleen; and the third position, the Urinary Bladder and the right Kidney. On the left wrist, the first position is the Small Intestine and Heart, the second position is the Gall Bladder and Liver, and the third position is the Urinary Bladder (again) and the left Kidney. The positions are frequently colloquially called by their Yin organ association, since those are most closely examined except in cases of suspected Yang organ pathology.
At each position, the physician feels for (sometimes called “listens to”) specific qualities of diagnostic significance. A normal pulse feels smooth and even, has moderate force, with sixty to seventy beats per minute. There are volumes written on pulse diagnosis alone, so an exhaustive catalogue of those qualities is impractical, but here are some common qualities, their descriptions, and what they indicate.
Figure 10.1 (Pulse Positions)
Pulse Qualities
• Floating (Superficial): This pulse is felt most distinctly at the superficial level, is discernible with a very light touch, and may be weaker or absent at deep levels. This most often indicates a superficial pathology, such as Invasion of Wind Cold. In this case, the Qi rises to the surface of the body to fight off the EPF, causing the floating quality.
• Sinking (Deep): This pulse is felt most distinctly at the deep level, often requires a heavier touch to feel, and may be weaker or absent superficially. This indicates a deeper pathology, such as Kidney Yin Deficiency.
• Slippery (Rolling): This pulse has a smooth and bumpy quality that feels “like pearls rolling under the fingers,” indicating “something extra” in the body. Most often, that something extra is Damp, either from an EPF or from an internal cause generating Damp, common in Spleen Qi Deficiency. This pulse is normal during pregnancy, as the fetus is seen as something extra in the mother’s body.
• Deficient: A generally forceless pulse in all pulse positions, indicating Qi and blood deficiencies.
• Excess: A generally forceful pulse in all positions, indicating excess syndromes. Often seen when the body’s normal or defensive Qi is strongly fighting a pathogenic Qi.
• Bowstring (Wiry): This pulse feels strong and hard, like the thump of a bowstring against the fingertips. This indicates excess, as in Liver Qi Stagnation, where the buildup of Liver Qi causes the obstruction that typically creates this pulse. This is also common in pain syndromes, as almost all pain is caused by obstruction of Qi, Blood, body fluids, or combinations of those.
• Thready: This pulse feels very fine, like a thread, yet distinct. It indicates deficiency, most often of Blood or Yin, but can indicate Qi deficiency especially when accompanied by Blood deficiency. Commonly found in Heart Blood Deficiency, with or without Spleen Qi Deficiency.
• Slow: A slow pulse is less than sixty beats per minute and usually indicates Cold syndromes. The Cold can be due to either deficiency or excess.
• Rapid: A rapid pulse is more than ninety beats per minute and usually indicates Hot syndromes. The Heat can be due to either deficiency or excess.
• Leisurely: A normal pulse of between approximately sixty and seventy beats per minute.
These pulses can be found in combination, giving a broader set of diagnostic indications. It’s common for a pulse to be thready, bowstring, and rapid or floating and slippery, for example.
These qualities, and the many others that exist, can be subtle and difficult to distinguish. Most physicians spend years, even decades, refining their pulse-taking abilities while examining hundreds of patients. As an aid to your self-assessment, you can begin with the easiest pulse qualities of rate and general deficiency and excess. If you’d like to try, check your pulses in the following way.
Assessing Your Pulse
Place the back of your left wrist on the palm of your right hand at a right angle. Curl your right fingers so that the tips touch your left pulse points, with your right index finger closest to your thumb in the first position and your ring finger farthest from your thumb in the third position. Let your middle finger fall comfortably between. Check your rate by counting beats for fifteen seconds and multiplying the number of beats by four. Then get some sense of the strength of your pulse. If it feels strong and forceful, it may be an Excess pulse. If it feels weak or difficult to distinguish, it may be a Deficient pulse. Repeat on your right hand. Check these qualities at the same time every day for a week or so, preferably while you are feeling well, to establish a baseline of what is normal for you.
You can use this simple method to make some crucial distinctions if you become sick. For example, if you catch a cold, in the early stages you can note if your pulse feels stronger, indicating your Qi is strong and fighting off a strong EPF. If it feels weaker, that may mean the EPF is too strong for your Qi to effectively combat. In that case you will need to rest, nourish yourself, and work to build stronger Qi once the cold has passed. If your pulse feels faster than normal, that will tell you the EPF is Hot. If slower than normal, the EPF is Cold. That can help you determine which acupressure points and herbs will best address your condition.
With practice over time you will begin to distinguish some of the other qualities introduced above. You may begin to notice differences in pulse position qualities. For example, the Liver pulse (the middle position on your left wrist) commonly feels thin or thready and bowstring, especially in times of stress or pain, while the Heart and Kidney pulses may not.
Tongue Diagnosis
The tongue provides a wealth of visible information outside the scope of Western medical thought. The Heart, Spleen, and Kidney meridians have branches that directly end in the tongue, and most of the other organs connect with the tongue through collateral branches. Many aspects of the functional energy of the organs are thereby reflected on the tongue. Other factors that contribute to evaluating the tongue include the tongue body (size, shape, color, moisture, regions of organ correspondence), the coating, also referred to as “moss” or “fur” (its thickness, color, possible absence), and its mobility. A normal tongue fits comfortably in the mouth, is neither enlarged nor small, moves freely, is light red in color, is slightly moist, and has a thin, white coating.
As with pulses, there are volumes written on tongue diagnosis, but here are some common attributes and what they indicate.
The tongue body can be most simply divided into four regions: the tip, middle third, rear third (or “root”), and the sides (Figure 10.2 on the next page). The tip of the tongue reflects the state of the Heart and Lungs, the middle third reflects the state of the Stomach and Spleen, the rear third reflects the state of the Kidneys, and the sides reflect the state of the Liver and Gall Bladder. It’s possible for each of those regions to manifest entirely different changes, indicating different pathologies in the respective organs. Some possible changes include the following.
Tongue color can change. A pale color indicates Cold syndromes or Blood deficiency; red indicates Heat, from either Deficiency or Excess (a deeper red indicates stronger Heat); a light purplish color (“dusky”) indicates Qi stagnation, where the obstructed Qi is less able to move Blood, causing mild Blood Stasis; and a purple or blue color indicates more significant Blood Stasis. A purple or reddish purple color indicates Stasis due to Heat, while a blue color indicates Stasis due to Cold. Different colors may appear on different portions of the tongue, giving clues about the state of the related organs.
The tongue body may be thin, indicating a deficiency of body substance, either Blood or Yin. It may be swollen or enlarged, indicating Damp. If swollen and pale, the Damp comes from Spleen or Kidney Yang Deficiency or both. If swollen and red, Damp Heat is present.
Figure 10.2 (Regions of the Tongue)
The tongue may have cracks or lines in it. This is caused by Dryness, which may come from Heat consuming fluids or from Yin Deficiency.
There may be uncontrollable tongue movement. A trembling tongue occurs in Qi Deficiency. A rigid, inflexible tongue may be caused by Heat attacking the Pericardium. Both a rigid and a deviated tongue (moved to one side or the other) indicate Internal Wind and may precede a stroke.
The tongue coating is equally important diagnostically, indicating the presence, absence, nature, and intensity of various pathological factors. It is produced by Stomach Qi, although the Qi of the other Yang organs also influence it. A normal tongue coating is thin and white, so the tongue body is clearly visible beneath.
A white coating can be from either exterior or interior Cold. A yellow coating indicates Heat, usually from interior syndromes.
A thick coating always indicates an excess condition, whether Hot, Cold, or Damp. So a thick, yellow coat indicates Excess Heat, while a thick, white coat indicates Excess Cold. A thickening of the coat indicates a worsening condition, while a thinning coat indicates improvement. If it is thick and greasy or sticky, the Stomach’s digestive functions are weak, possibly indicating food retention and causing the dirty-appearing Damp residue.
A dry, coarse-looking coating lacks moisture, due to excess Heat (especially if yellow) or Yin deficiency. An absence of coating, a “peeled” tongue, indicates Yin deficiency, primarily of the Stomach or Kidneys or both. If only parts of the tongue are peeled, this is called a geographic tongue, indicating a Stomach Qi and Yin deficiency.
While there are many more possible presentations of the tongue body and coating, these provide numerous diagnostic clues to pattern identification.
Simple Self-Diagnosis
If you’d like to use basic tongue diagnosis to help assess your health, begin by examining your tongue at the same time each day, preferably first thing in the morning before you’ve had anything to eat or drink and before brushing your teeth. Eating changes the appearance of the tongue, bringing more blood to it and making it appear redder, and the coating often absorbs some of the color of the food you eat. Coffee always turns the tongue coating yellow for a time. If you can’t examine your tongue in the morning, wait at least two hours after a meal, so it returns to normal.
Look for all the tongue qualities in its body, coating, and movement. For now don’t be too concerned with organ correspondences to tongue regions, but you may notice that the tip of your tongue is redder than the rest of the body. While not “normal” (it indicates Heat in your Heart and Lungs), it is fairly common and an easy observation to make if it’s there. Examine those qualities for a week or so to note possible changes and to establish a baseline frame of reference.
Follow the instructions from the section “Assessing Your Pulse.”
If you do become sick, see how your pulse and tongue change. Ideally, as you incorporate the self-care practices found in this book, you’ll see the positive changes reflected there.
For example, you know that if your tongue is consistently red with a thick, yellow coating, and your pulse is rapid and forceful, you likely have some syndrome of Excess Internal Heat. You can use the information in PART 1 to help refine that assessment.
In this case, you may select acupoints from Chapter 13 that sedate (to clear the Excess) and clear Heat. You might select herbs from Chapter 15 that nourish Yin and are cooling and moistening. However, if you have other troublesome symptoms, look through the index of conditions in Chapter 18 and see if there are any that are a good match for an Internal Excess Heat presentation. (Under “Digestive System Disorders,” Constipation from Excess is one likely choice.) If so, select those acupoints and herbs, as they’ll be the best choice for you. Include the recommended Qigong exercises(s) and foods. After a few weeks or a month, note the changes in your pulse, tongue, and overall health.
Remember, pulse and tongue diagnosis is challenging for health professionals too. Even with this simplified approach, take plenty of time, give yourself permission to make mistakes—you’ll make a lot of them in the beginning—and eventually it will become clearer, easier, and immensely rewarding.