The Art and Practice of Diagnosis in Chinese Medicine PDF

Nigel Ching is a lecturer in Chinese Medicine and course director at the Nordisk Akupunktur Uddannelse, Denmark. With over 25 years of clinical experience, Nigel lectures widely in Scandinavia, Germany, the UK, Greece and Finland and is the author of The Fundamentals of Acupuncture, also published by Singing Dragon. SINGING DRAGON Nigel Ching Divided into two parts, it is a comprehensive diagnostic manual. The first part explains how to collect and collate the information required to formulate a diagnosis and is divided into four approaches: visual, palpation, interrogation and listening/smelling. The second part describes the various diagnostic models in Chinese medicine, including the Eight Principles; zangfu organ patterns; the Six Stages, Four Levels and san jiao; the 12 regular channels and eight extraordinary vessels; and the Five Phases. The Art and Practice OF This textbook on diagnosis in Chinese medicine is unique in its clarity and accessibility. DIAGNOSIS IN Chinese Medicine ‘What Nigel Ching has achieved in this thorough and detailed study of traditional Chinese diagnosis is to outline and explain clearly both the methodology and, perhaps more importantly, the thinking behind it. It is especially this that I am convinced will prove to be indispensable to both students and interested readers.’ – from the Foreword by Jeremy Halpin, acupuncturist, Zen-shiatsu therapist and teacher The Art and Practice OF Diagnosis Chinese Medicine Nigel Ching Fore word by Je re my Ha l pin www.singingdragon.com Cover design: Black Dog Design in The Art and Practice of Diagnosis in Chinese Medicine by the same author The Fundamentals of Acupuncture Nigel Ching Foreword by Charles Buck ISBN 978 1 84819 313 0 eISBN 978 0 85701 266 1 of related interest Acupuncture and Chinese Medicine Roots of Modern Practice Charles Buck ISBN 978 1 84819 159 4 eISBN 978 0 85701 133 6 The Acupuncture Points Functions Colouring Book Rainy Hutchinson Forewords by Richard Blackwell, and Angela Hicks and John Hicks ISBN 978 1 84819 266 9 eISBN 978 0 85701 214 2 The Spark in the Machine How the Science of Acupuncture Explains the Mysteries of Western Medicine Dr. Daniel Keown MBChB MCEM LicAc ISBN 978 1 84819 196 9 eISBN 978 0 85701 154 1 The Acupuncturist’s Guide to Conventional Medicine Second Edition Clare Stephenson ISBN 978 1 84819 302 4 eISBN 978 0 85701 255 5 Intuitive Acupuncture John Hamwee ISBN 978 1 84819 273 7 eISBN 978 0 85701 220 3 The Art and Practice of Diagnosis in CHINESE MEDICINE NIGEL CHING Foreword by Jeremy Halpin LONDON AND PHILADELPHIA Disclaimer: The author and the publisher assume no responsibility for the treatments carried out in relation to the instructions in this book. English language edition first published in 2017 by Singing Dragon an imprint of Jessica Kingsley Publishers 73 Collier Street London N1 9BE, UK and 400 Market Street, Suite 400 Philadelphia, PA 19106, USA www.singingdragon.com First published in Danish as Kunsten at diagnosticere med Kinesisk medicin by Klitrose Publishers, Copenhagen, Denmark, 2009 Copyright © Nigel Ching 2017 Foreword copyright © Jeremy Halpin 2017 All rights reserved. No part of this publication may be reproduced in any material form (including photocopying, storing in any medium by electronic means or transmitting) without the written permission of the copyright owner except in accordance with the provisions of the law or under terms of a licence issued in the UK by the Copyright Licensing Agency Ltd. www.cla.co.uk or in overseas territories by the relevant reproduction rights organisation, for details see www.ifrro.org. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher. Warning: The doing of an unauthorised act in relation to a copyright work may result in both a civil claim for damages and criminal prosecution. Library of Congress Cataloging in Publication Data Names: Ching, Nigel, 1962- author. Title: The art and practice of diagnosis in Chinese medicine / Nigel Ching. Description: London ; Philadelphia : Singing Dragon/Jessica Kingsley Publishers, 2017. | Includes bibliographical references. Identifiers: LCCN 2016056990 (print) | LCCN 2016058175 (ebook) | ISBN 9781848193147 (alk. paper) | ISBN 9780857012678 (ebook) Subjects: | MESH: Medicine, Chinese Traditional--methods | Diagnostic Techniques and Procedures Classification: LCC R601 (print) | LCC R601 (ebook) | NLM WB 55.C4 | DDC 610--dc23 LC record available at https://lccn.loc.gov/2016056990 British Library Cataloguing in Publication Data A CIP catalogue record for this book is available from the British Library ISBN 978 1 84819 314 7 eISBN 978 0 85701 267 8 Dedicated to my granddaughter ‘5316’, my parents and all the family and friends between them. If a man will begin with certainties, he shall end in doubts; but if he will be content to begin with doubts, he shall end in certainties. Francis Bacon 1561–1626 CONTENTS Foreword by Jeremy Halpin........................... Acknowledgements............................... Preface...................................... The Art of Diagnosis or How to Diagnose in Chinese Medicine. Diagnostic prerequisites............................ Western diagnosis............................... The diagnostic process............................. Diagnostic models............................... Treating complex patients with many patterns of imbalances.......... 11 13 14 17 21 26 28 33 34 Part 1: The Diagnostic Pillars Introduction to the Diagnostic Pillars................ 36 Section 1: The Diagnostic Pillar: Visual Observation........ 39 Introduction.................................. Visual diagnosis of a person’s shen........................ Visual diagnosis of the body shape and posture................. Visual diagnosis of a person’s movements.................... Visual diagnosis of a person’s clothing..................... Visual diagnosis of the face........................... Visual diagnosis of the eyes........................... Visual diagnosis of the area around the eyes................... Visual diagnosis of the forehead, the root of the nose and the area between the eyebrows........................... Visual diagnosis of the nose.......................... Visual diagnosis of the ears........................... Visual diagnosis of the lips........................... Visual diagnosis of the mouth......................... Visual diagnosis of the gums.......................... Visual diagnosis of the tongue......................... Visual diagnosis of the hair........................... Visual diagnosis of the body hair........................ Visual diagnosis of the throat.......................... Visual diagnosis of the chest and the back................... Visual diagnosis of the back.......................... Visual diagnosis of the limbs.......................... Visual diagnosis of the joints.......................... Visual diagnosis of the hands.......................... Visual diagnosis of the skin........................... Visual diagnosis of veins............................ Visual diagnosis of skin lesions......................... Visual diagnosis of acupuncture points and channels.............. Visual diagnosis according to micro‑systems such as ear acupuncture..... 39 41 44 49 52 55 61 65 66 68 69 70 72 73 73 94 96 97 98 98 99 100 101 104 108 109 112 113 Appendix to Section 1: Visual Diagnosis of Children............ 117 Section 2: The Diagnostic Pillar: Listening and Smelling..... 124 Section 3: The Diagnostic Pillar: Palpation............. 148 Section 4: The Diagnostic Pillar: Interviewing........... 195 Introduction.................................. Auditory diagnosis............................... Auditory diagnosis of the person’s voice.................... The Five Phases in the voice........................... Quality of the voice.............................. Auditory diagnosis of other sounds coming from the mouth, nose and chest.. Diagnosis of sounds from the abdominal cavity................ Olfactory diagnosis............................... Introduction.................................. Pulse diagnosis................................. Palpation of the abdomen, including Hara diagnosis.............. Palpation of the thorax............................. Palpation of the skin.............................. Palpation of the hands and feet......................... Palpation of acupuncture points, channels and micro-systems......... Introduction.................................. Interviewing techniques............................ The 10 questions................................ General questions............................... Disease history................................. Temperature.................................. Energy levels.................................. Sweating.................................... Thirst, appetite and taste............................ Stools and urination.............................. Heart, thorax and Lung............................. Dizziness.................................... Skin, hair and nails............................... The ears and eyes................................ Sleep...................................... Pain...................................... Headache.................................... Enquiry that is specific to women....................... Enquiry that is specific to men......................... Enquiry with regard to the emotions and mental state............. Lifestyle and diet................................ 124 125 126 129 136 138 141 143 148 150 183 187 188 190 191 195 196 199 200 204 206 209 212 214 220 224 228 229 231 234 235 239 241 248 251 254 Part 2: The Diagnostic Models Introduction.............................. 258 Section 5: Diagnosis According to the Eight Principles...... 261 Interior and exterior imbalances........................ Exterior imbalances.............................. Interior imbalances............................... Hot and Cold imbalances........................... 263 263 268 270 Heat...................................... Cold...................................... Combined Hot and Cold patterns....................... Xu and Shi imbalances............................. Xu conditions................................. Shi conditions................................. Yin and yang imbalances............................ 271 280 288 289 289 300 301 Section 6: Diagnosis According to Xie Qi.............. 305 Section 7: Diagnosis According to Qi, Xue and Jinye Imbalances. 355 Section 8: Diagnosis According to Zangfu Organ Patterns..... 393 Section 9: Diagnosis According to the Six Stages, Four Levels and San Jiao....................... 641 Wind...................................... Invasion of exogenous Wind.......................... Internally generated Wind........................... Cold...................................... Dampness and Damp-Heat.......................... Exogenous Dampness............................. Internally generated Dampness......................... Summer-Heat................................. Heat and Fire.................................. Shi Heat and Fire................................ Xu Heat.................................... Dryness.................................... Exogenous Dryness............................... Internal Dryness................................ Phlegm..................................... Xue stagnation................................. Food stagnation................................ Qi imbalances................................. Xue imbalances................................. Jinye imbalances................................ Lung imbalances................................ Large Intestine imbalance........................... Stomach imbalances.............................. Spleen imbalances............................... Heart imbalances................................ Small Intestine imbalance............................ Urinary Bladder imbalances.......................... Kidney imbalances............................... Pericardium and san jiao imbalances...................... Gall Bladder imbalances............................ Liver imbalances................................ Diagnosis according to the Six Stages...................... Diagnosis according to the Four Levels..................... Diagnosis according to San Jiao theory..................... 310 311 314 315 319 320 324 328 331 333 336 337 338 339 340 347 352 356 367 380 393 427 437 459 487 524 532 546 577 580 590 642 669 696 Section 10: Diagnosis According to the 12 Regular Channels... 712 Section 11: Diagnosis According to the Eight Extraordinary Vessels...................... 722 Section 12: Diagnosis According to the Five Phases........ 729 Lung channel imbalances............................ Large Intestine channel imbalances....................... Stomach channel imbalances.......................... Spleen channel imbalances........................... Heart channel imbalances............................ Small Intestine channel imbalances....................... Urinary Bladder channel imbalances...................... Kidney channel imbalances........................... Pericardium channel imbalances........................ San jiao channel imbalances........................... Gall Bladder channel imbalances........................ Liver channel imbalances............................ Du mai imbalances............................... Ren mai imbalances.............................. Chong mai imbalances............................. Dai mai imbalances.............................. Yin qiao mai imbalances............................ Yang qiao mai imbalances............................ Yin wei mai imbalances............................. Yang wei mai imbalances............................ Sheng phase patterns.............................. Ke phase dominating patterns......................... Ke phase ‘insulting’ patterns.......................... Appendix 1: Supporting the Treatment of the Patient through Yangshen.. Appendix 2: The Energetic Properties of Certain Foods........... Appendix 3: Herbal Formulas.......................... Glossary...................................... References.................................... Further Reading................................. Endnotes..................................... Index........................................ 715 715 716 717 717 718 718 719 719 719 720 720 723 724 725 725 726 727 727 728 729 732 735 738 754 758 768 770 771 773 775 FOREWORD Another way of seeing things One of the most important contributions that Chinese medical diagnosis has given to the collective medical knowledge is the unique way it comprehends and describes conditions of disease. Chinese medicine does not use polarised belligerent metaphors that try to identify internal and external ‘enemies‘ that must be destroyed. Neither does it see the body as a dissociated and isolated island on which this ‘war‘ is waged. Chinese medicine’s focus is more on the constant adaptation to change. To understand why this is so, it is necessary to understand the underlying medical model, or the logical principles that form the basis for this approach. To use a modern metaphor, the approach in this model focuses on ‘software data flow‘ and not ‘hardware’, i.e. on what is happening inside and not on the physical structure. The model is energy based; it is not an anatomical/physiological model. It does not involve the study of dead bodies or the deconstruction of the body into ever smaller components in an attempt to describe the whole. Chinese medicine always sees everything in the context of the whole. The Dao that can be named is not the Dao1 The attentive reader will note that all the diagnostic models in this book describe the body’s response to change and not separate and arbitrary disease symptoms as such. This is because the state of balance in the body is in a state of constant flux and a skilled therapist will be able to track the signals that the body is emitting. In this context, to name something is to fossilise it. People are not their ‘diabetes‘ or ‘migraine’. They are unique individuals whose conscious and unconscious responses have brought them to this place. The art of diagnosis is to identify these unique patterns of response in each individual. In other words, it is the patient who is diagnosed and not the disease. An exchange of stories So what is diagnosis? In the late 1800s the meeting between the patient and practitioner was called an ‘exchange of stories’. This is where the patient presents their problem (‘story’) as best they can, based on their subjective experiences. They can also present their story in more subtle and non-conscious ways, for example their posture, movement and other factors that can be observed by the clinician. Diagnosis, which is the subject of this detailed book, forms the therapist’s story – the therapist’s interpretation and response to the patient’s history through the filter of their knowledge and experience. It will include aspects such as observation, palpation and the use of other senses, such as the sense of smell or noting the way the 11 The Art and Practice of Diagnosis in Chinese Medicine person’s shen is manifesting, to expand the practitioner’s perspective of the whole. All these factors are sorted in the diagnostic process through the various sub-models (the Eight Principles, Four Levels, Six Stages, etc.) to differentiate the possible diagnoses. This does not, however, mean that the diagnosis ends here. For example, it is common to recheck the pulse diagnosis during the treatment to measure the response. In fact, treatment and diagnosis are never separated. They are constantly influencing each other and are two sides of the same coin. When looking at new models such as this one, it is easy to drown in the volume of cultural references that permeate it. What Nigel Ching has achieved in this thorough and detailed study of traditional Chinese diagnosis is to outline and explain clearly both the methodology and, perhaps more importantly, the thinking behind it. It is especially this that I am convinced will prove to be indispensable to both students and interested readers. Jeremy Halpin Acupuncturist, Zen-shiatsu therapist and teacher Stockholm, June 2008 12 ACKNOWLEDGEMENTS I would like to express gratitude to the practitioners and scholars of Chinese medicine who have developed and documented this unique medical system. The world is a much better place to live in thanks to their knowledge, wisdom and efforts. I am deeply indebted to all of my teachers through the years, the authors of English language Chinese medicine textbooks and the doctors and practitioners who I have had the pleasure and honour of working with. I would also like to thank the people directly involved in the genesis of the original Danish version of the book. Primarily my thanks go to Ole Bidsted from the Klitrose publishing house who published the original version of this and all my other books. Thank you for your tireless idealism and enthusiasm in publishing unprofitable but indispensable textbooks. My gratitude and appreciation is also sent towards Singing Dragon for their support and belief in my books. A special thanks to Claire Wilson, Jane Evans and Victoria Peters. Thanks to Aske Ching for tweaking the illustrations and making them presentable. Thank you to the various students who have made valuable comments to the book, both when it was still only in the form of teaching handouts and later on after it was published in Denmark. There is a lot of proofreading talent gone to waste out there! Thanks to friends and colleagues who have helped with their encouragement. I would particularly like to thank Wendy Norris for shelter, encouragement and support, both before and during the writing of the original version of the book. 13 PREFACE An experienced Chinese medicine doctor can often diagnose a patient before the patient has even begun to tell the doctor what their disorder is. This may sound fantastic, as if the doctor has supernatural abilities, something that only a few people with special powers can do. This ability, though, depends on years of experience and a thorough understanding of the body’s physiology and pathology. The doctor will have consciously and subconsciously picked up on a myriad of small and sometimes extremely subtle signs, such as the expression in the patient’s eye, the facial complexion, the tone of the flesh, how the movement of the person is, how their posture is, the strength of their handshake and whether the hand feels clammy or dry, whether the hand is cold or hot and if it is warm whether it is the whole hand or only the palm that feels hot, how their attire is, the smell of their body, the sound of their voice, etc. All these individual small signs and signals will create an overall impression in the doctor’s mind, enabling the doctor to identify the patterns of imbalance that the patient is presenting with. Charlie Buck once said that this ability which experienced Chinese doctors possess is the same ability that a good ornithologist possesses. If a novice like me is going to be able to identify a bird in my garden, the bird must stand still and I must also have sufficient time to take note of the size of the bird’s body, its wingspan, the colours in the plumage, the colour and length of the legs and beak, how it moves and so forth. Furthermore, I must then compare this information with the descriptions presented in an ornithology manual to see which bird it is that has precisely these colours and characteristics. However, an experienced ornithologist will immediately recognise which bird it is that is sitting on the bird table. An experienced ornithologist will not only recognise the bird when it sits on the bird table outside the window, but will also be able to identify the bird at a distance, even when it flies quickly past. Where others will barely have noticed the bird at all, just a few fleeting impressions will enable the experienced ornithologist to identify the bird with certainty. This ability is the result of many years of experience of studying the bird both through binoculars and with the naked eye, as well as having studied pictures and read descriptions of the bird in ornithological manuals. This will have resulted in an ability to recognise birds quickly from a minimum of signals. This is also the case with an experienced Chinese medical doctor. The doctor will have gathered sufficient information before the patient talks of their problem to be reasonably certain of their diagnosis. The rest of the consultation is then used to confirm the diagnosis and to identify the aetiology and whether there are contributing patterns of imbalance. This might give the impression that diagnosis goes from being analytical to being simply intuitive, but this is not so. Diagnostic intuition is nothing other than the rapid, subconscious analysis and interpretation of impressions and signals and 14 Preface relating these impressions to all the previous experiences of these signs. At the same time, these signs and impressions are subconsciously compared with the theoretical knowledge that has been gleaned from books and teachers. The subconscious is much quicker at analysing and sorting information than the conscious brain. Intuition is therefore not a supernatural ability but something that most of us are capable of. It just requires experience and a sound theoretical foundation. What Chinese medical doctors have done over the centuries is to observe all the changes that occur in a person when a person’s body is out of balance – both which symptoms there are and what other signals the body emits in these situations. They have been aware of the relationships between these symptoms and signs or the patterns that they constitute. Chinese medicine developed methods to collect and collate this information and these models systematically, and to classify and differentiate the symptoms and signs so that an accurate diagnosis can be determined, thereby creating a solid foundation for the treatment strategy. The purpose of this book is to enable the practitioner to gather the necessary information from the patient to make an accurate and correct diagnosis through the use of traditional Chinese diagnostic methods. The book is divided into two parts. The first part of the book is a summary of the four diagnostic approaches or diagnostic pillars. This part of the book covers the methods used to collect information from the patient – through observation and palpation and by listening to and smelling the patient – and the information that can be gathered through interviewing the patient. The clinical significance of what these signs represent in Chinese medicine is also detailed and explained. The second part of the book examines the various diagnostic systems or diagnostic models used to classify and rationalise the information that has been collected through the four diagnostic pillars. It is only by making an accurate diagnosis that one is able to give the correct treatment to each individual patient. As well as reviewing the various patterns of imbalance, this part of the book also gives suggestions for their treatment. It is important to remember that the acupuncture points and herbal formulas that are mentioned in the text are suggestions and not a rulebook. Excellent results will also be obtained using other relevant combinations of acupuncture or herbal formulas. Furthermore, the acupuncture points suggested are just a starting point and only some of the points listed will be used. These points will often be combined with other points that are relevant to the individual symptoms or other imbalances that are to be addressed concurrently. The herbal formulas presented should also be modified in practice so that they are tailored to match the individual patient’s presentation. It should also be noted that treatment with herbal prescriptions should only be administered by practitioners who have a relevant herbal medicine training. Acupuncture needles forgive mistakes, but herbal prescriptions can be merciless and one can easily worsen a patient’s condition if the diagnosis and herbs do not match each other. Furthermore, there is a risk that even if the prescription is suited to the diagnosis, it can still create new imbalances in the body. Only when you have 15 The Art and Practice of Diagnosis in Chinese Medicine learned what signs you should be aware of do you know how to intervene and adjust the treatment in time. It should also be made clear that this book is an analysis of Chinese medical diagnosis as a complete system. This means that some of the diagnostic categories are a reflection of life-threatening conditions that you will rarely meet in the clinic. Even if you work exclusively with Chinese medicine, it is important not to forget which signs and symptoms to be aware of in Western pathology and to know the limits of your competence and when to send a patient on to a Western medicine doctor for further examination or hospitalisation. In keeping with Fundamentals of Acupuncture (Ching 2016), I have as far as possible used Chinese words, such as qi, xue, xu, shi, shen, instead of an English translation of these terms. The reason for this is that English words will usually either be too specific, representing only one of the multiple meanings or interpretations of the term, or they will not express the connotations that are present in the Chinese character. Xue, for example, is something other and more than blood is in the Western definition of the word. Furthermore, terms such as shen or qi cannot be adequately translated into a single English word. These Chinese words are therefore written in italics. Furthermore, organ names, pathogens, pulse qualities, etc. are capitalised when the Chinese understanding of this term is inferred. This is done in order to emphasise that it is the Chinese medicine concept that is being referred to and that the word is not to be understood in the usual definition of the word in English. I hope that this book can help the reader to develop a systematic approach to the diagnosis of their clients and that it gives the reader a thorough understanding of how and why pathological changes arise in the body. This book will never be able to replace practical instruction or teach the more tactile aspects of the diagnosis, but it is my hope that the book can be a guide to what needs to be felt, seen, smelt or heard and how these sensations are often experienced. I am indebted as a practitioner, teacher and author to the Chinese doctors and scholars who have developed the theories and methods that are described in this book, as well as to the teachers and authors who have transferred this knowledge on to me. My hope is that I can be a medium or pathway so that their knowledge can be of benefit to you and your patients. Nigel Ching Copenhagen 16 THE ART OF DIAGNOSIS OR HOW TO DIAGNOSE IN CHINESE MEDICINE Before we even start to look at how to diagnose in Chinese medicine, it is appropriate to consider the following questions. Why do we diagnose at all? What is the aim of the diagnosis? In what way are we going to use the diagnosis? We use the diagnosis as one of several steps that must be taken when we want to move from point A, which is a person who has some form of disorder or suffering, to point B, which is the same person who no longer has a disorder or is no longer suffering. Traditional Chinese Medicine (TCM)2 has a logical and linear approach to enable the practitioner to get from point A to point B. Patient with a problem Diagnostic techniques to reveal the patient’s symptoms and signs Classification of these symptoms and signs into the various diagnostic models Creation of an appropriate treatment strategy Choice of relevant acupuncture points and needle techniques, appropriate herbal formulas and appropriate dietary and lifestyle advice Patient without a problem By diagnosing and identifying the underlying pattern or patterns of imbalance, we have not only a treatment strategy in relation to acupuncture and Chinese herbs, but we have also created a foundation from which we can give relevant advice to the client. This advice will often, but not always, have a direct relationship with the aetiology of their disorder. When we know which patterns of imbalance are present, we will also have an idea of the probable aetiology. These aetiological factors can often still be a part of the person’s life. In this case, they are something that must be altered if the patient is to have a long-term benefit from the treatment. At the same time, when we know which other aetiological factors can negatively affect the imbalance, we can also give the client advice with regards to these factors. Chinese medicine usually diagnoses on two levels at the same time: bian bing lun zhi (differentiation of symptoms and signs in relation to the disease category) and bian zheng lun zhi (differentiation of symptoms and signs in relation to the patterns of imbalance). Bian bing lun zhi is very similar to a Western medicine diagnosis in that it classifies the symptoms and signs with respect to a specific disease 17 The Art and Practice of Diagnosis in Chinese Medicine category, for example headache, menstrual cramps, vomiting, etc. Although the bian bing diagnosis is characterised by the name of a specific disorder, it is still important to remember that you must still think of this pathological process from a Chinese medical perspective. This means that we must understand the disorder through the pathomechanisms that have generated it. We must think of qi, xue, Phlegm, zangfu, etc. and not through the lens of lymphocytes, antibodies and hormone receptors. We do this even if the bian bing category has the same name as a Western disease category. Dizziness, for example, is a disease category in both Chinese and Western medicine, yet the understanding of how and why dizziness arises is very different. In both Chinese and Western medicine there are several causative factors and various subcategories of dizziness. These pathomechanisms cannot simply be translated from one system into another. Dizziness can, for example, be diagnosed in Western medicine as being caused by a virus on the balance nerve. If we just translate this into Chinese medicine, we may think that we have to expel invasions of exogenous xie (pathogenic) qi. There will only be a few situations in which this would be a relevant treatment strategy. Dizziness in Chinese medicine can arise from many factors, such as internally generated Wind, xue xu or yin xu. Although the disease names and the underlying aetiology can sound similar, the treatment focus will often be decidedly different. This is because it is with the Chinese medical system that we will be treating the disorder. There is a linear progression in all medical systems from physiology, pathology and diagnosis through to treatment. Each stage is determined by the previous stage and these stages cannot be separated from each other. The bian zheng lun zhi approach to diagnosis is radically different from Western medicine concepts. Bian zheng lun zhi is the classification of symptoms and signs in relation to the various patterns of imbalance, such as Liver qi stagnation, an invasion of Wind-Damp or shaoyin Stage Cold. Chinese medical diagnosis is not a choice between either bian bing lun zhi or bian zheng lun zhi. For the treatment to be truly effective, we must in reality use both differentiations. This can be illustrated with the following example. The acupuncture point GB 20 and the extra point taiyang (Ex-HN 5) are effective acupuncture points that can be used to treat headaches (bian bing lun zhi diagnosis). This is because these acupuncture points move and circulate qi and xue, as well as being able to drain xie (pathological) qi downwards from the head. GB 20 and taiyang are not, though, indicated in the treatment of nausea, which is a separate bian bing lun zhi diagnosis. The reason for this is precisely because the actions of these points is in the head. If the headache was the result of Phlegm (bian zheng lun zhi diagnosis), then St 40 and Sp 3 would be obvious points to combine with GB 20 and taiyang. This is because St 40 and Sp 3 can transform Phlegm, which in this case is underlying the headache. If, on the other hand, the headache had arisen from an invasion of Wind-Cold (bian zheng lun zhi diagnosis), then St 40 and Sp 3 would not be relevant, because they do not ‘open to the exterior and expel invasions of xie qi’. St 40 and Sp 3 would, though, be relevant when treating nausea (bian bing lun zhi diagnosis) if the nausea is due to the presence of Phlegm 18 The Art of Diagnosis or How to Diagnose in Chinese Medicine (bian zheng lun zhi diagnosis). In this situation, these two points could be combined with Ren 12 and Pe 6, as these points are effective in regulating Stomach qi so that it descends. Ren 12 and Pe 6 are, however, not suitable for draining Phlegm down from the head. It is for this reason that an adage in Chinese medicine states, ‘A single ailment can have many causes; a single cause can result in many ailments.’ Western medicine trains practitioners to distinguish symptoms separately and to understand them individually or as part of a particular disease or disorder. In Chinese medicine it is the opposite. Here one is trained to try to see patterns in the symptoms and signs and to see how these are related and what they can be an expression of. A Dutch lecturer, whose name I have unfortunately forgotten, once gave a good illustration of the difference between the two systems’ approaches to analysing a client. He said that the two systems both look at the same scene through a telescope. Western medicine views the body through the focus of the telescope, so when you look through it, you can, for example, see a hand. Western medicine can even see through the skin and can zoom in on the tendons, the muscles and bones in the hand and how these interact with each other. The telescope can zoom even closer in and see how the nerves affect the muscle fibres and how various neurotransmitters can activate the nerves. It can see into the cells themselves and see how the various components in the individual cells operate. Chinese medicine reverses the telescope. Chinese medicine sees the same hand, but it also sees what is going on at the same time. It observes that the hand is on an arm that belongs to a woman, who is waving to her husband, whilst a train is pulling out of a station. Both images are correct. To stop the hand moving, you could, for example, sever the muscles and tendons, break the bone or inject a chemical that disrupts the nerve signals. You could also, though, stop the train. Both approaches will result in the same result: the cessation of the hand waving. In Western medicine, the focus is on the physical causes and effects. In Chinese medicine it is more the context and the relationship that are the most important, and not the individual components. For example, migraine headaches, menstrual pain, alternating diarrhoea and constipation, hypochondriac tension, a sensation of having a lump in the throat, the voice having a slight staccato quality and the pulse having a Wiry quality in the left middle (guan) position are not coherent symptoms in a Western medicine perspective and they will be seen as being expressions of several disparate disorders. Chinese medicine sees these symptoms and signs collectively as a clear indication that the person is presenting with Liver qi stagnation. Chinese medicine will therefore not treat these individual symptoms separately but instead treat them as a single pattern. Chinese medicine will also try to identify the underlying aetiology that has resulted in the development of Liver qi stagnation, because the pattern of imbalance itself must also be seen in a context. Imbalances do not arise by themselves. The adage ‘a single ailment can have many causes; a single cause can result in many ailments’ means, therefore, that there are no standard treatments for specific diseases. There will, of course, be particular acupuncture points that are often used 19 The Art and Practice of Diagnosis in Chinese Medicine in the treatment of certain ailments, but there will also be utilised acupuncture points that treat the specific patterns of imbalance that have resulted in the disorder. In order to do this, one must be able to differentiate the individual patterns of imbalance from each other. Patterns of imbalance can be differentiated according to various diagnostic models. These models can be used individually and they can be used together. They are, in fact, overlapping. Liver xue xu for example is both a diagnosis based on the Eight Principles and a zangfu diagnosis, as well as being a diagnosis according to qi, xue and jinye. The bian zheng lun zhi diagnosis will not only identify the root cause of the disease manifestation, it will also identify where or at which level in the body the imbalance is. At the same time, it will give an indication of the relative strength of the body in relation to the imbalance. For example, the diagnosis ‘invasion of the Wind-Cold’ indicates that the imbalance is to be found in the taiyang aspect, which means that it is in the exterior aspect of the body, and implicit in this diagnosis is that there is a relatively strong pathogenic assault on the body – a shi or excess condition. Liver xue xu diagnosis, on the other hand, indicates that the imbalance is in the interior aspect of the body and that it is specifically the functioning of the Liver that is disturbed. Liver xue xu further implies that xue is deficient, and therefore the organ is weakened, so the Liver is xu or deficient. A Chinese medicine diagnosis is the foundation of the treatment strategy, i.e. how to restore balance in the body. The treatment strategy is already indicated in the diagnosis. If there is an invasion of xie qi, xie qi must be expelled. If there is a shi condition, then that which is shi must be drained, spread or expelled. If there is a xu condition, then that which is xu should be tonified, nourished or strengthened. By differentiating patterns of imbalance, the clinician is not only able to develop an appropriate treatment strategy and thus utilise relevant acupuncture points or herbal prescriptions, but also will have an idea of what the aetiology of the imbalance could be. It is vitally important to remember that patterns of imbalance are not the causes of the disease. Diseases are certainly manifestations of patterns of imbalance, but the real causes lie in the aetiological factors that result in the pattern of imbalance. This will be factors such as environmental influences, a person’s diet, lifestyle or emotional influences. Liver qi stagnation, for example, can manifest with the symptoms and signs described earlier. However Liver qi stagnation is not the cause of these symptoms and signs. Liver qi stagnation is, like all other patterns of imbalance, a related collection of signs and symptoms. The pattern of imbalance is exactly this – a ‘pattern’ the patient presents with. The underlying cause of the pattern in this case will often be related to a person’s emotional situation. If we are able to recognise patterns, we can have a logical idea of the underlying aetiology. When we have an idea of the aetiology, we have an opportunity to give relevant advice to the client. This is in reality the most important part of the treatment. By administering herbs or inserting needles, we can rectify an imbalance and relieve its symptoms. By giving relevant advice, we can help a person to prevent the imbalance from arising again. 20 The Art of Diagnosis or How to Diagnose in Chinese Medicine To be able to detect which patterns of imbalance are present requires a comprehensive and thorough diagnosis. This entails the gathering of large amounts of disparate information from the client. This information has to be gathered through several sensory organs at the same time. Gathering and processing so much information simultaneously can appear to be overwhelming, but Chinese medicine is very logical in its approach from having developed specific diagnostic models and, especially, from having a very systematic approach to the collection of this information. This foundation for this systematic approach to the gathering of diagnostic information was laid 2000 years ago in the classical text Nan Jing (The Classic of Difficulties). This book initiated the diagnostic approach that we use to this day: the four diagnostic pillars. In the book it says that one must first see and observe the patient. Then you should listen to and smell the patient. Next you have to ask the patient questions. Finally, you should palpate the patient. This requires that you are systematic and logical, whilst being sensitive and aware. This is because much of the information that needs to be gathered and utilised is something you have to perceive through your fingers, nose, eyes and ears, rather than simply asking questions. To observe and absorb this much information at the same time, you need to be centred and focused when the patient comes through the door and free from all mental distractions so that your senses are open and receptive. This is obviously easier said than done when you are already behind schedule with your clients. Nevertheless, it is important to try at all times to be as focused and present as much possible. However, being sensitive and receptive is, in itself, not enough when diagnosing. You also need to have an intellectual understanding of the material. You need to learn which signs and symptoms you should be aware of and what these symptoms and signs mean. This can done by learning either the various signs and symptoms and what these are a manifestation of by heart, and what the pathomechanisms behind these signs and symptoms are – how these symptoms and signs arose. Organising and structuring our approach and the way we process this information means it becomes more manageable and easier to access the relevant information. This frees you up so you can be more intuitive. Intuition that is not based on a strong fundamental understanding of theory will always only be speculation and guesswork. Diagnostic prerequisites A strong theoretical foundation and understanding of Chinese medicine physiology and pathology By having a solid understanding of both the Chinese medicine physiological and pathological models, you will be able to understand the pathomechanisms (the pathological dynamics) behind the various symptoms and signs. Let us look at an example. The Stomach sends its qi downwards. When a person vomits, this will be due to a rebellious movement of Stomach qi, which has sent the 21 The Art and Practice of Diagnosis in Chinese Medicine contents of the Stomach upwards and out of the mouth. We do not yet know why the Stomach qi is rebellious, but we know that Stomach qi is moving in the opposite direction to the direction in which it should when the Stomach is in balance. We know this, because we have studied the Chinese medicine physiological model and we therefore know that the correct movement of Stomach qi is downwards. Having also studied Chinese medicine pathology, we will already have several ideas of how and why this disturbance of Stomach qi could have arisen. There could, for example, be something that is blocking the Stomach qi from descending (such as exogenous Cold, Phlegm, qi stagnation, xue stagnation or food stagnation). We also know that Stomach qi could be too weak to be able to send the food downwards (Stomach qi xu) or there may be Heat present, causing the Stomach qi to rise upwards (Stomach Fire or an invasion of exogenous xie qi). This means that we can start looking for relevant symptoms and signs that relate to these particular patterns of imbalance and we can ask the patient relevant questions: Is there anything that provokes the vomiting? Is there anything that ameliorates it? When and how did the vomiting start? And so on. All these things will give an idea of why the person’s Stomach qi has become rebellious. Observe and analyse deviations from the ‘norm’ A concept that is central to the art of diagnosis is the norm. The norm is that which we expect to observe. It is that which we should observe when the body functions perfectly and is completely harmonious. This condition is also known as the utopian state! If we constantly maintain a clear image in our minds of how the body should be, we can recognise signs which indicate that the body is not in balance. At this point, it is very important to be constantly aware of the crucial difference that there is between what is normal and what is common. It is common to have a pale tongue with teeth marks, a greasy yellow coating on the root and a red tip. This is seen in a lot of people, perhaps the majority of Northern Europeans, but it is not what a normal tongue should look like. A normal tongue should be pink, without tooth marks and with a thin, pale, even coating. We must train ourselves to spot deviations from the norm, and to think about and determine what has caused the change. There will often be nothing, or very little, to observe. The closer you are to the norm, whether this is the strength and speed of a person’s voice, the colour of the tongue or something else, the fewer signs of imbalance there will be to observe. By observing the deviations from the norm, and by understanding pathomechanisms behind these changes, you are in fact liberated from having to learn long lists of symptoms and signs, as well as having to remember what these signs and symptoms signify diagnostically. This is not the typical Chinese approach to learning how to diagnose: in China, it is more common to learn things by heart, which is also a valid way of learning the significance of the various signs and symptoms. I personally think, though, that it is easier to learn and remember 22 The Art of Diagnosis or How to Diagnose in Chinese Medicine the relevance of diagnostic signs and symptoms, by thinking of qi dynamics and pathomechanisms. This also has the advantage that you become more flexible in your thinking and comprehension of problems when they present themselves differently from the textbooks. By learning to understand the pathomechanisms, you become accustomed to thinking: ‘This is not as it should be. How and why is it not as it should be?’ When you have done this, you can start to figure out why something has deviated from the norm. As always, it is easiest to use an example. Normally, a person’s respiration is gentle and rhythmic. If a person has difficulty breathing gently, quietly and rhythmically, and if their respiration is very shallow, this is a sign that the Lung3 is not descending and spreading qi as it should. We must then try and determine why the Lung is not able to perform this function optimally. Is it because the Lung is qi xu? Is it because there is a stagnation of qi in the upper jiao? Is there exogenous xie qi, such as Wind‑Cold, obstructing the Lung so it cannot spread and descend qi? Is there Phlegm in the Lung and the upper jiao that is blocking the qi? Has the person been exposed to a shock, and qi in the upper jiao has become chaotic? This way of thinking can be used with any symptom or sign. This approach also means that we then start to look for other relevant signs and symptoms that may confirm our hypothesis. Study and become adept at using the various diagnostic techniques In order to practise Chinese medical diagnosis, it is a prerequisite that you have learned the various diagnostic techniques – the observational skills required to be able to utilise the techniques involved in the four diagnostic pillars. This means that you must have learned to palpate the pulse, observe the tongue, palpate the channels and interview the client. This is something that is taught in basic training, but it requires constant practice to become adept at it. I often meet former students who ask me for advice about a client they are treating. Unfortunately, when I ask about the tongue and pulse diagnosis, it is not uncommon that the practitioner says that they have not checked the pulse. When I ask why, the answer is that they think it is difficult and they do not feel that they are competent enough to be able to utilise the pulse. Learning diagnostic skills is no different from learning to play the guitar or learning a foreign language. Some people have natural talents and they are adept right from the beginning. These people will only improve with time if they practise. Others, myself included, are less gifted. I could learn to play some simple chords on a guitar if somebody showed me where to put my fingers. However, I would never become a virtuoso who could play in a concert hall, although I might become competent enough to sit around a fire and entertain my friends. However, even this will take practice – a lot of practice! The same is true of pulse diagnosis, tongue diagnosis, observation techniques and palpation. Diagnostic techniques are something that must be practised every day or at least every time you have a patient. You may well feel that you are not feeling or observing anything, but it is important 23 The Art and Practice of Diagnosis in Chinese Medicine to keep on practising. It is often easier, when diagnosing, if you deconstruct the process and analyse each aspect separately. If we take the pulse as an example, you might ask yourself, whilst your your fingers are palpating the patient’s artery: Is the rate of the pulse fast or slow? Does the pulse feel strong or weak? Wide or narrow? Shallow or deep? Rhythmic or not? Has the pulse got qualities that could be perceived of as being ‘Slippery’, ‘Choppy’, ‘Wiry’ or ‘Tight’? Are there variations between the individual pulse positions? You can also reverse the process. If you know which patterns of imbalance are present in a patient, you can search for the relevant pulse qualities and see if you can recognise them in the patient’s pulse. When you have felt the same quality several times, you may start to recognise this same quality in a new patient’s pulse. Study the various patterns of imbalance There are, unfortunately, no short cuts here. The various patterns of imbalance should be learnt by heart. You should be able to classify the various symptoms and signs you experience and categorise them into the various patterns of imbalance. However, there is the loophole that I described above: if you have a firm grasp of Chinese medicine physiology and understand the dynamics of the various forms of xie qi (pathological qi) and other disruptive factors, you will be able to assess which organs, substances or aspects of the body are affected and in what way. For example, if a person freezes, especially suddenly, and they cannot get warm even though they put on thick clothes and tuck themselves under a duvet, our thinking will be as follows. We know that it is yang qi that heats the body, so if they had yang qi xu – a condition where there is too little of the warming yang qi – the person ought to be able to keep warm by putting on sufficient clothing or by tucking themselves under a duvet. This is not the case here, so it is probably not a yang xu condition. If, on the other hand, the person has been invaded by exogenous Wind-Cold, which blocks the wei qi whose function it is to warm the skin, then even though they pack themselves into warm clothes and bedding, they would still feel cold. Therefore, this is probably a shi Cold condition – an invasion of exogenous xie Cold. Further confirmation that their wei qi is being blocked by exogenous xie qi will be found if the person does not sweat and has muscle aches. This is because all these signs either relate to the functions of wei qi (warming the skin and controlling the pores) or they are signs of a stagnation of qi in the exterior aspect of the body, where the wei qi circulates (muscle aches). We know that the wei qi can be blocked by exogenous xie qi and that Cold, due to its contracting dynamic, will cause the pores in the skin to close. Cold will also inhibit the free movement of wei qi. The other option is, of course, to learn everything off by heart. You can memorise the various symptoms and signs that define the individual patterns of imbalance. By studying the textbooks, we know that all of the above symptoms and signs can be found in the diagnostic category ‘invasion of Wind-Cold’. This is similar to how a computer works. The computer does not understand why the symptoms occur, but 24 The Art of Diagnosis or How to Diagnose in Chinese Medicine it can nevertheless recognise a pattern when it is presented with a particular group of symptoms and signs. This is because it has been programmed to recognise these symptoms and signs as being representative of this pattern of imbalance. An alternative approach is to learn the importance of the individual symptoms and signs by heart. In the example above, when a person freezes, you can look at all the possible imbalances that manifest with a sensation of cold or an aversion to cold. You can then collect additional information to see whether the person has other symptoms and signs that can confirm the presence of one or more of these patterns of imbalance. Experience The main difference between an experienced practitioner and a novice with regards to diagnosis is simply a question of experience. An experienced practitioner has had more years to read books and study other practitioners’ case histories. More importantly, the experienced practitioner has had more years of experience in visually observing, interviewing, listening to, palpating and smelling patients and subsequently comparing what they have read about in books with what they meet in practice. This means that the experienced practitioner knows what is probable in certain situations, but also has experienced situations where the opposite is the case. An experienced practitioner has also learned to place more emphasis on certain symptoms and signs than others in particular situations. Moreover, the experienced practitioner, through practice and experience, just becomes better at recognising characteristic signs of an imbalance in certain people. They have, however, also become better at not latching onto, and sticking with, the first idea that comes to mind. They have become more flexible in their approach. In general, an experienced practitioner is often quicker at diagnosing a patient than a novice. This is because the experienced practitioner does not need to think for as long about things. When observing a symptom or a sign, the experienced practitioner automatically know what questions they will subsequently ask or what signs they should observe in this situation. They do not need to think about it. Neither do they need to look things up in books or search the corners of their memory when they want to find out what the various symptoms, signs and observations signify. It is something that they just know. Intuition Another major difference between experienced and less experienced practitioners, is how much they trust their intuition and, especially, how trustworthy their intuition is. Intuition must be based on a solid theoretical understanding coupled with practical experience, otherwise it is nothing more than just guesswork. Intuition is one of the most important skills an experienced practitioner possesses. Intuition, however, is nothing other than a person’s ability to let their 25 The Art and Practice of Diagnosis in Chinese Medicine subconscious brain recognise and process the information that they, at some point, have had to collect consciously and think about. Their subconscious brain can more rapidly sort this information into useful conclusions than the conscious processes of the mind can. Western diagnosis There can be a tendency amongst some practitioners to use a Western medicine diagnosis as their starting point. A question that I often meet, both when I talk to other acupuncturists and when I read online discussions is: Which acupuncture points should you use to treat some Western named disorder? This raises several issues. Western diagnoses can be incorrect. There is a significant risk involved in relying on another person’s diagnosis. It is not uncommon for a patient to receive different diagnoses from different doctors. This is not a critique of Western doctors, but a fact when different people subjectively analyse objective material. If you treat according to another doctor’s diagnosis, there is a risk that you will administer an incorrect treatment if the initial diagnosis was wrong. This is only made worse by the fact that the Western medicine diagnosis is based on a completely different physiological and pathological model than that of the Chinese medicine diagnoses and treatments. I will expand on this below. However, it is not only the Western medicine diagnosis that we must be wary of. We should also be wary of Chinese medicine diagnoses made by other acupuncturists or herbalists. I regularly receive clients from other practitioners who want me to either treat their patient with herbs or continue their acupuncture treatment. It is not uncommon that my and the other acupuncturist’s diagnoses do not match. If I prescribed herbs or inserted needles based on another acupuncturist’s diagnosis, I would often be giving the patient the wrong treatment (assuming that my diagnosis is correct). Likewise, if I gave an acupuncture treatment on the basis of a Western doctor’s diagnosis, I cannot be sure that the doctor’s diagnosis was correct in the first place. A Western medicine diagnosis is based on the Western medicine physiological and pathological model. The acupuncture points that are recommended in Chinese medicine textbooks for the treatment of certain organs, bodily substances, pathological factors, etc. are usually selected based on an understanding of the actions that they have in Chinese medicine. It is not certain that they have the same effect when viewed from a Western medicine analysis of their physiological actions. A very obvious example of this is when a Western medicine diagnosis says that a person has a problem with their spleen. It is far from certain that a point such as Sp 3 will have any effect on the physical spleen in this situation. This is because the same pattern of symptoms and signs in a patient will often not be diagnosed as a Spleen 26 The Art of Diagnosis or How to Diagnose in Chinese Medicine pattern of imbalance in Chinese medicine. We need to translate diagnoses to our own diagnostic models. It is only in this way that the treatment will match the diagnosis perfectly. This also applies to other complementary medicine diagnostic methods, such as iris diagnosis or a homoeopathic diagnosis. In these cases, the diagnosis of organs and their functions will again be based on another physiological and pathological model. Treatments and the physiological and diagnostic foundation must match each other. We would not expect a Western medical doctor to treat a patient based on our diagnosis. They would immediately exclaim that what we are saying does not make sense in relation to their way of understanding the body. Likewise, we should not treat the body from a diagnosis based on a Western medicine understanding of the body but through a Chinese medicine interpretation of the symptoms and signs. The same disorders can have many causes. A Western diagnosis will always be a bian bing lun zhi diagnosis. The foundation of Chinese medicine is the differentiation of disorders both in relation to the disorder or disease and in relation to the patterns of imbalance. This means that even if we diagnose multiple patients with the same bian bing lun zhi diagnosis, we may well treat each of these patients differently, precisely because their patterns of imbalance or bian zheng lun zhi diagnosis are different. In what way can we then use a Western medicine diagnosis? As written above, a Western medicine diagnosis is basically a bian bing lun zhi diagnosis that is based on a Western medicine understanding of the body. This means that the Western diagnosis will often relate to aspects of the body that are not found in the Chinese medicine model, such as hormones, neurotransmitters or intestinal bacteria. We know that intestinal flora, for example, has many of the functions that we relate to Spleen qi, but we also know that Spleen qi is much more than just the functions performed by the intestinal flora. Similarly, the intestinal flora also have functions that do not relate to Spleen qi. When we are informed of a Western medicine diagnosis, we need to deconstruct this into its component symptoms and pathological processes. We should then reconstruct the individual symptoms and signs, as well as the pathological processes, into a Chinese medicine diagnosis using a Chinese medicine understanding of the body. Unfortunately, we cannot just say that oestrogen, for example, is equivalent to Kidney yin and thereby treat an oestrogen imbalance with the acupuncture point Kid 3. It may well be that the treatment will work, but not all of the functions of oestrogen in the body can necessarily be interpreted as being Kidney yin. There may well be individual processes that we will interpret differently, and if we are to treat these processes then there may be a greater physiological effect if we warm Kidney yang or move Liver qi or something else altogether. This is especially relevant if there are other symptoms and signs that also point in this direction. What we must find 27 The Art and Practice of Diagnosis in Chinese Medicine is a pattern – a relationship between the various symptoms and signs and how they relate to the Chinese medicine model of health and illness. A Western medicine diagnosis will give us an idea of which direction we should look in. We can definitely examine the Western medicine diagnosis and try to analyse the symptoms and the pathological processes that lead to these symptoms from a Western medicine perspective, but we should always be thinking: How would I interpret this from a Chinese medicine perspective? Which organs or types of qi perform these functions? How could this process be disturbed, for example, by qi stagnation, Phlegm, Heat, etc.? We should also look at the individual patient and ask ourselves: Do they actually have these symptoms and signs? At the same time, we need to correlate these symptoms and signs with all the other symptoms and signs that the patient manifests. This is because Chinese medicine often places emphasis on signs and symptoms that are not viewed as being relevant in a Western medicine diagnosis of a disorder. This could, for example, be that the person talks rapidly and gesticulates a lot with their hands whilst they are talking, indicating the presence of Heat in the Heart. The diagnostic process As previously written, diagnosis is part of a process where we proceed from point A, where a patient has a problem, to point B, where the same patient does not have a problem any longer. This is most easily achieved by having a structured approach where you are aware of what the aim of each step is. This is especially true in the diagnostic part of the process. The diagnostic process starts at the first contact We start the diagnosis the moment we first see the patient or at the first moment of contact that we have with the patient. This process can actually start even before the patient enters the room, when we talk to them on the phone or read their email. From the moment we are in contact with them, and certainly from the moment they step into the room, we must constantly gather information from them and begin to form a diagnostic hypothesis. We will subsequently continue to verify and check this hypothesis in an attempt to confirm or refute our assumptions. We must then constantly investigate all the various diagnostic clues that reveal themselves. At times, it is something of a difficult balancing act. We must trust our first impressions. This is because the first impression can often be of great diagnostic importance, especially as it is at this moment that we are usually most intuitive and least rational in our thinking. We must, however, simultaneously have and maintain a flexibility in our thinking and our approach to the patient. We must not stubbornly cling to a diagnosis and thereby become blind to the diagnostic signs that point in other directions. We must be aware of the risk of interpreting symptoms and signs exclusively from the perspective of our first hypothesis. It’s like being a detective. We must follow a hunch, but not become blind to other possibilities or exclude other suspects. 28 The Art of Diagnosis or How to Diagnose in Chinese Medicine Have a structured approach Having a structured approach is very important. Moving from the metaphorical point A (the patient has a problem) to point B (the patient no longer has a problem) is most easily achieved when taking deliberate steps, where you are conscious of what you want to achieve with each individual step. A structured approach is also important, because our clients often present us with many, varied and sometimes conflicting symptoms and signs. It is therefore essential that you constantly have a clear idea in your head of where you are going and what you want to know. You must not let yourself be driven around like driftwood in a sea of symptoms and signs. You must have a clear direction and deliberately paddle using your eyes, ears, mouth, nose and fingers as oars and your theoretical foundation as a rudder. This can be especially difficult when new pieces of information constantly keep emerging, each of which must be investigated. You will have to travel down each diagnostic track one at a time, but at the same time remember to come back and investigate the remaining tracks. In these situations, having a pen and a piece of paper is invaluable, so that you can jot down notes and key words whilst the patient is talking to make sure you do not forget to investigate everything thoroughly. A good intake sheet with boxes and rubrics that list various qualities is a diagnostic essential that enables you to investigate all relevant areas thoroughly. Complex patients, where there are many signs and symptoms, will always be a challenge. Unfortunately, these clients are not uncommon. This is because many of the clients who seek Chinese medicine are clients who have chronic conditions that have not been helped in the conventional medical system. These conditions are called ‘difficult to treat, knotty diseases’ in China. In these cases, there will typically be many patterns of imbalances at the same time – at least six or seven – and often in excess of ten patterns. There will also be a tricky mixture of xu and shi and Hot and Cold imbalances. This means that there will be a myriad of symptoms and signs to discern and decipher. These signs and symptoms will often be contradictory, pointing in opposite directions at the same time. There is a vast amount of information that we have to keep track of whilst we diagnose. At the same time, we must be open and attentive on several levels, both intellectually and intuitively. We need to listen to what the patient says and at the same time listen to how they are saying it, what qualities their voice has, how fast they talk and how structured their conversation is. We must observe their appearance, their movements and their body language while we ask them questions and mentally analyse their responses. A structured approach is also important when interviewing clients who have a tendency to take over the interview. There are definitely some clients who are more difficult to interview than others. This is usually an important diagnostic sign in itself. As the practitioner, we should try to maintain control of the conversation. After all, it is us who is the therapist. When this control is challenged by the client, we can try and interpret diagnostically why and how they cause us to lose control. We must, of course, be conscious of our own patterns of imbalances and how these 29 The Art and Practice of Diagnosis in Chinese Medicine might be involved in us having difficulty in controlling the interview. If it is not our own patterns of imbalances that result in us losing control, then we can try to see how the patient makes us lose our footing. For example, some patients with Heart Fire will often be very garrulous and we will have difficulty getting succinct answers to our questions. Patients with Phlegm-Heat blocking and agitating shen will also often talk a lot and much of what they say may be completely irrelevant, because Phlegm is blocking their shen. Liver qi stagnation patients may have a tendency to want to control the situation and the conversation. Phlegm-Dampness patients may be slightly confused and have difficulty keeping their focus, and so on. It can also be difficult when patients have a lot of ideas about what is wrong and why they have a disorder. These people tell you a lot of things that to us are not necessarily relevant to the diagnosis. They could, though, have been treated by other acupuncturists or have read things on the internet or in an acupuncture textbook and believe that they know which Chinese medicine patterns of imbalances they are manifesting. It is important that it is us who interprets the information we gather and the information they tell us. What they conclude or what they have been told may not be correct. It is important that it is us who makes the diagnosis. A structured approach is more than just a checklist As written above, all the information that we need to collect and process simultaneously can be overwhelming and confusing, especially with a client who takes control of the conversation. A well-designed diagnostic journal or intake sheet is a massive help here. It ensures that we collect all the information that we need to use. A diagnostic journal must never become a checklist where you just tick boxes. I have often experienced in exam situations and school clinics that some students tend to ask a question – often a yes or no question – and then they just move on to the next question. Each and every answer we get is a springboard for further investigation. It is a door that we should walk through to see if there is more information inside that room. For each answer we get, or for each sign we observe, we must look for further signs or ask clarifying questions. This is both in order to understand the mechanism behind this sign or reply and to see if there are other symptoms and signs that these are connected to. We must see whether the sign or the answer is part of a pattern. An example could be that the patient has replied that yes, they do suffer from headaches. We then need to know: When do they have headaches? How would they describe the pain? Whereabouts in the head is the pain? What makes the headache better or worse? When did they begin to suffer from headaches and what happened in this period of time? We must ascertain what type of headache they have. If we have the impression that the headache is possibly a manifestation of, for example, ascending Liver Fire, we must then look for further signs of Liver Fire to confirm or refute our hypothesis. Furthermore, we also know that many patterns of imbalance may be a consequence of the other patterns of imbalance. We should therefore also investigate whether there are signs and symptoms of these patterns. 30 The Art of Diagnosis or How to Diagnose in Chinese Medicine Use all four of the diagnostic pillars If we have a structured approach, we should consciously utilise all four diagnostic pillars. A skilled diagnostician will also utilise as much information as possible from each pillar. A pillar is not just built from one or two blocks of stone, it also consists of sand and mortar. Palpation is more than just pulse diagnosis, and observation is more than just tongue diagnosis. Furthermore, there can be a tendency to prioritise the diagnostic pillar of interviewing or questioning the client. This is often at the expense of the other three approaches. This is mainly due to the way we have been educated, since we started in primary school when we were children. This has resulted in the development of an intellectual bias. We feel secure and trust an intellectual approach based on questions and verbal responses. It is relatively easy to translate a verbal response to intellectual knowledge. This is something the education system trained us to do for more than a decade. There are, however, a lot of pitfalls in this diagnostic approach. We must be very conscious of what the questions are and how we ask them. We need to know what their response implies. We also know that patients do not always respond truthfully. It could well be because it is something that they are not conscious of. Also, clients sometimes, for various reasons, deliberately answer misleadingly or use words that you can interpret in a different way from them. More typically though, they comprehend the question in a different way from the practitioner. For example, if you ask a woman if she has regular menstrual periods, she may well answer yes, even if her menstrual cycle is only 21 days long or is 35 days long. Another woman might answer yes – it is regular, because it comes about once a month. The problem for us is that ‘about once a month’ is not regular in Chinese medicine if it’s 25 days in one month and 33 days in the next month. Similarly, regular bowel movements can be interpreted by a client as being once every three days or four times each day. Some of these problems can be minimised by having a good interview technique with unambiguous questions and constantly ensuring that you have asked additional and clarifying questions and not let yourself be satisfied with simple yes and no answers. The fact that we are so conditioned to be intellectual by the education system means that we actually have an intellectual handicap. We blindly trust our intellect at the expense of our other senses. We must learn to retrain and hone our observational abilities. This is also a challenge, because it is much easier to translate verbal responses to intellectual knowledge that can be analysed and categorised than it is to transform sensory information to something we can rationally analyse and intellectually classify. Each of the four diagnostic pillars has their inherent strengths and their weaknesses. These will be investigated in Part 1. Conflicting information It is, unfortunately, not uncommon for there to be a conflict in the information, and thereby diagnostic conclusions, obtained from the different diagnostic approaches or within the same aspect of the diagnosis. It is quite common, for example, for the 31 The Art and Practice of Diagnosis in Chinese Medicine tongue to exhibit signs of certain imbalances, whilst the pulse manifests something else and the patient’s voice and demeanour something else again. In reality, we must not think of these discrepancies as being conflicts but more as puzzles to be solved. These discrepant signals will usually just reflect different aspects of the diagnosis, i.e. different patterns of imbalance, all of which are present at the same time. We just need to understand how to separate them from each other and see whether they interact with each other or are independent of each other. We must also be aware of other factors that may have blurred these diagnostic signs, for example medicine, the fact that the patient just ran up the stairs or that they are angry. Time constraints A major problem we have is a lack of time. It can take a long time to gather all the information, especially when you are not experienced and therefore as quick to spot what is relevant and important in this situation. This means that you have to either allot an appropriate period of time to the diagnosis of clients or learn to prioritise information and make sure that you have control of the dialogue with the client. Different processes, different strategies Some teachers believe that you should only investigate the patterns of imbalance that are relevant to the specific disorder that you are asked to treat. This means that, for example, you do not start asking questions about signs of a Lung imbalance, if a person has chronic diarrhoea. Bob Flaws, an American author of numerous Chinese medicine textbooks, is an advocate of this approach and considers that you must learn all the relevant patterns of imbalance for the different bian bing lun zhi categories and only investigate these when diagnosing a bian bing condition. Personally, I do not agree with him. First, the relevant pattern of imbalances that can manifest with a specific disorder can in itself be the consequence of other patterns of imbalance. For example, Liver qi stagnation can be a consequence of Liver xue xu, which itself may be a consequence of Spleen qi xu. It is important to understand the dynamics involved in the genesis of the patterns of imbalance. I personally, therefore, do not think that it is enough only to investigate the patterns that are relevant to the specific bian bing lun zhi conditions. Furthermore, the patterns of imbalance that are presently manifesting may be precursors to other patterns of imbalance. It may therefore be relevant to investigate whether these patterns of imbalance are evolving. Furthermore, it is not uncommon to uncover other disorders through the diagnostic process that are more serious than the disorder that the client has sought help for. It may be that the patient is not aware that you could also treat this problem but would actually want this problem addressed. For example, a patient may come to you because they want to have treatment for their weak immune system, but through your thorough and 32 The Art of Diagnosis or How to Diagnose in Chinese Medicine extended diagnosis you find out that they suffer from anxiety and insomnia, which is something that is a serious problem for them. Diagnostic models It is an advantage to memorise the various symptoms and signs of all the various bian zheng lun zhi categories, i.e. all the various pattern of imbalances. You can, of course, look these up in your textbooks or on the computer, but this is much more time consuming in the long run. Once you have learned the different diagnostic models and categories, you can quickly recognise patterns in the symptoms and signs that are in front you. The diagnostic models are templates that we can place on top of all the information we have collected. We can then see if the information we have gathered fits into a particular template. Some diagnostic models are only used in specific situations, for example diagnosis according to the three jiao or the Four Levels; others are used constantly and in combination with other diagnostic models, for example diagnosis according to zangfu and diagnosis according to qi, xue and jinye. One of the typical mistakes that I made when I started was that I believed that all the symptoms and signs that were listed as being representative of a specific pattern of imbalance should be present. Often, we diagnose a pattern of imbalance from the presence of as little as three or four key symptoms and signs. The trick is to learn which of the various symptoms and signs are important and essential and in which situations. Furthermore, I thought that the symptoms and signs that were listed in the textbook were the only signs and symptoms that were manifestations of this particular pattern. The signs and symptoms listed in textbooks are the most probable symptoms and signs of this pattern. There will often be other symptoms and signs that are not in the textbook but are created by this pattern’s qi dynamic. When you suspect the presence of certain patterns of imbalance, you have to ask yourself whether all the things that you are observing can be interpreted as being manifestations of these patterns, even though they are not listed in the textbook. This is where you really benefit from the hours spent studying Chinese medicine physiology and pathology. These studies have, in reality, enabled you to determine for yourself what symptoms and signs can be manifestations of a particular imbalance. You are now capable of seeing a symptom or a sign in different context from that described in the textbook. Another mistake that I made was to think that when diagnosing a particular disorder, the disorder was the result of either one or other of the imbalance patterns that were listed as being the root of the problem. In reality, a disorder is usually the consequence of multiple patterns simultaneously. For example, spontaneous bleeding will very often be the result of Spleen qi xu, xue stagnation and Heat simultaneously. Individually, these three patterns of imbalance may not have been sufficient to result in bleeding in this patient. This can also sometimes be the reason that a treatment has 33 The Art and Practice of Diagnosis in Chinese Medicine not succeeded. This is because you have not treated all the aspects of the problem. At other times there will only be the one underlying pattern of imbalance. Treating complex patients with many patterns of imbalances Keep it simple When things seem complex and confusing, it is always a good idea to keep things simple and only diagnose and treat what you are certain is present. The diagnostic picture may well become clearer with time. The situation may seem daunting, because there are so many symptoms and signs all mixed in with each other. This is further complicated by the fact that some of these symptoms and signs are also contradictory. In these situations, the diagnostic model of the Eight Principles is a blessing. This is a solid rock that we can step back onto when we start to drown in a rough sea of multiple symptoms and signs. We can simplify the whole situation or the individual symptoms and signs momentarily and ask ourselves: Is this xu or shi? Cold or Hot? Interior or exterior? Yin or yang? This can then be used as a springboard to refine the diagnosis. If the diagnosis will not or cannot be further refined, we can always treat the patient from these principles alone. If we treat only from the Eight Principles, we can be reasonably confident that we will not harm the patient, but, on the contrary, we will probably benefit them. This is despite the fact that it would have been optimal to further refine the diagnosis. Make inventory boxes and flowcharts One technique that I utilised a lot in the beginning was to make inventory boxes and ‘flowcharts’ on a sheet of paper. I distributed all the symptoms and signs of the patient in various diagnostic boxes. The individual symptoms and signs could usually be listed in multiple boxes. Boxes that had many symptoms and signs in were probably relevant patterns of imbalances, whereas boxes with only one or two signs or symptoms were less probable, especially if these symptoms and signs could be seen and explained better in other boxes. However, it is important not to write off a pattern of imbalance simply because there are only one or two signs or symptoms in the box. This is because some signs and symptoms are definitive signs of particular patterns of imbalance or these signs are simply the only two signs that are manifesting at this point in time. When you have made these boxes, you can then see how the dynamic is in this patient – how these patterns of imbalance affect and create each other. You can also continue the exercise by including the aetiological factors. 34 Part 1 THE DIAGNOSTIC PILLARS INTRODUCTION TO THE DIAGNOSTIC PILLARS The first half of this book concerns itself with the so-called ‘diagnostic pillars’. These pillars are all the information that can be gathered through visually observing, listening and smelling, palpating and interrogating the client. The pillars are the systematic approach that Chinese medicine has developed over the years to gather and analyse all the information from a patient that has diagnostic relevance. The four pillars enable the practitioner to construct as precise and solid a diagnosis as possible. Through the use of the practitioner’s eyes, hands, ears and nose, as well as their intellect, Chinese medicine has over the millennia developed a diagnostic system that is both coherent and logical. This is because any change in the physiology of the body will not only affect the functioning of the body, but it will also manifest with tangible signs that can be seen, felt, heard and smelt. By systematically organising the collection and categorisation of this knowledge, Chinese medicine has developed a very precise and scientific diagnostic system. While modern Western medicine has chosen to focus more and more on less and less, Chinese medicine historically chose a different approach. Chinese medicine has focused on collecting as much information as possible about a person. This includes not just the individual symptoms and signs themselves, but also information about the person as an individual and the world around them. By gathering as much information as possible, the picture becomes more defined and precise. In the beginning, the sheer volume of the information that is presented in the following chapters can appear to be overwhelming and intimidating. The intention is not that you should slavishly follow the contents of each chapter section by section when diagnosing a client. Instead, you should train yourself to be aware of when and how a patient differs from what is normal or to be expected, i.e. the norm. There will always be an ideal norm – the norm being what we ought to see or hear, all things being equal, if the body is physiologically harmonious – and then there is the reality that is in front of us. This reality will be an aggregate of various deviations from the norm. Each of these deviations will usually be linear movements away from a midpoint. There will often be too little or too much of each individual variable. Each norm or midpoint is, of course, itself variable and is dependent on many factors, such as gender, age, season or time of day. It is, for example, normal to be wide awake at three o’clock in the afternoon but not at three o’clock in the morning. Whenever there’s a change in a person – a deviation from the norm in how they look or smell or the sounds they emit – it will be a manifestation of an imbalance in their physiology. Every sign and every change is significant. What Chinese medicine has done is to document the systematic observation of how imbalances manifest themselves and the diagnostic significance of these physiological changes. 36 Introduction to the Diagnostic Pillars We must therefore constantly ask ourselves the following questions every time we observe something in a patient. What should I expect to be seeing, hearing, smelling or feeling right now? In what way does this manifestation differ from the norm? Which mechanisms and dynamics could be the cause of this change? Which pathological process can be the cause of this dynamic? How can this be interpreted in Chinese medicine terms? What imbalance and which pathological processes could be the cause of this manifestation? Something imperative that is important to be constantly aware of is the crucial difference between what is normal and what is common. Being common does not make something normal. This is evident, for example, when considering the tongue. Most of my clients present with tongues that are pale and swollen, with teeth marks on the sides, a red tip and a greasy coating. Is this therefore a normal tongue? No, this is a common tongue, manifesting signs of very common patterns of imbalance. I have tried, wherever possible, to provide physiological explanations of how and why changes in the body arise in pathological conditions. This is because I, personally, think that it is easier to learn the diagnostic significance of these changes if you understand how and why they have arisen, rather than just learning the signs and symptoms by heart and blindly accepting that things are as they are. Furthermore, by developing a comprehension and understanding of how changes occur, you will be able to figure out why a body presents as it does without having to remember the importance of all the symptoms and signs by heart. Some signs and symptoms are, of course, more important than others; some will be seen more frequently and others more rarely. However, I have chosen in this part of the book not to weight some signs and symptoms as being more important than others or as being ‘key symptoms’. Even though the signs and symptoms are themselves objective, the diagnostic process itself is subjective. Some therapists weight certain signs as being more important than others. I know from my own experience that the signs and symptoms that I weight most now are somewhat different from the ones that I weighted ten years ago. Where ten years ago I relied much more on the interrogative approach to diagnosis, my focus is now much more on the visual and auditive signs that the patient is manifesting. On the other hand, a person trained in Japanese acupuncture will often place more emphasis on palpable signs, and a Five Element acupuncturist may well focus more on smelling and listening to the client. It is not because one area is more important than others. All information has a value and ought to be involved in the diagnostic process. There will, however, often be a personal and subjective weighting of which information is deemed to be most relevant or reliable. What is crucial is to keep an open mind whilst diagnosing. Even though there may be a clear sense of what the diagnosis is from the outset or during the initial stages of the diagnosis, one must consciously 37 The Art and Practice of Diagnosis in Chinese Medicine search for evidence that can confirm this thesis or assumption. It is also important not to focus blindly on this thesis. This is because most signs and symptoms can mean different things in different contexts. This is the core of Chinese medicine and oriental philosophy in general. It is the context that the object is observed in that provides the definition, not the object itself. A sign or symptom should be comprehended as a part of a whole and it is this whole we are trying to determine, not the individual components. This is the reason that the Chinese medicine diagnostic process is so comprehensive and the reason that each of the four pillars comprises of so many elements. It’s also why you have to use all four pillars together and not neglect the use of any of them. A roof is only stable if there are four pillars supporting it. A diagnosis is no different; it relies on four pillars. There are also some aspects of these diagnostic approaches that are indispensable. They should not be forgotten or omitted. This is especially true of tongue and pulse diagnoses, which are such important cornerstones in their respective columns that the pillars, and therefore the diagnostic roof, would be unstable if they are not present. 38 Section 1 THE DIAGNOSTIC PILLAR: VISUAL OBSERVATION Introduction Visual diagnosis is something that people constantly utilise without necessarily being aware of it. What you must learn, as a practitioner, is to refine this ability. When someone who is angry or distressed enters a room, you are usually in no doubt about their mood. Similarly, if a person is exhausted or has a heavy cold, you will usually also pick up on this, both by seeing them and when talking to them. This is because there is a multitude of signs and signals, some more subtle than others, that we pick up on. We perceive and mentally record these signs without even thinking about it. What we, as therapists, must do is refine this ability to observe relevant signs and see them as part of a pathological pattern. The above examples are, of course, fairly obvious and the signs are easy to spot, but the difference between these examples and the signs that we encounter in the clinic when interviewing clients is only a matter of degree. The signals are always there. They’re just not always as pronounced. The trick is to refine and train one’s perception. This is an ability that virtually everyone possesses, but they are not accustomed to using it in such a refined way or, importantly, using it systematically as part of a structured diagnostic system. Visual diagnosis in Chinese medicine has two prerequisites: you must learn what the different visual diagnostic signals are a manifestation of in a Chinese medical context, and you must train your observational skills – your visual attentiveness. The former is a matter of understanding and remembering how changes in the body’s internal physiology will manifest on the exterior of the body. The latter requires honing your visual awareness and focus so you are able to perceive these signals. Something that is also vital when utilising visual diagnosis is good lighting. This is especially relevant when observing the complexion in the face and the tongue. A great many details can be overlooked because the lighting conditions are poor or the signs can be misinterpreted because the light source causes the colours to have a different hue. What are the signs and symptoms that we will be looking for in this diagnostic pillar? Which signals from the body should be observed and what is the diagnostic significance of these signs? In the moment a client steps through the door, we immediately start to form an impression of the person. We do this based on their body shape, their posture, their way of moving, the colours in their face, the complexion of their skin, the expression in their eyes, their body language, how they sit down on the chair and much more. 39 The Art and Practice of Diagnosis in Chinese Medicine During the diagnostic procedure, we actively observe specific areas of the body – including the tongue, the fingernails and the skin. This is because certain aspects of the body manifest a lot of relevant information that can give us vital information about the patient – information that can often determine the diagnosis. In Chinese medicine visual diagnosis, this information is utilised in a structured manner. We consciously focus on and interpret the signals that are being radiated by the patient. We process the information and relate it to our understanding of the body’s physiology. Within the first three to four minutes, an experienced Chinese doctor may well have determined the fundamental aspects of the diagnosis. The rest of the consultation is then used to confirm and further refine the diagnosis. Having said that, it does not mean that you should blindly adhere to your initial diagnostic impression or solely approach the diagnosis using intuition. At times this becomes a difficult balancing act. We must learn to trust the first impression we have received. This is because this first impression can often be of great diagnostic importance, especially because it is in this moment that we are often most intuitive and least rational in our thought processes. However, we must simultaneously maintain a flexibility in our thinking and our approach to the patient. Our mind must not get stuck on a diagnosis and thereby become blind to the diagnostic signs pointing in other directions. We must be aware of the risk of interpreting symptoms and signs only from the perspective of our initial hunch. It’s like being a detective. We must follow a lead, but not get stuck trying to pin the evidence on our initial suspect. Intuition without a theoretical foundation is nothing other than guesswork. Intuition requires that you have a strong theoretical basis that you subconsciously utilise. Most of us, at least to begin with, have to look systematically and consciously for each visual sign. We must consciously ask ourselves questions whilst we observe the patient: How is their facial complexion? How are their body movements? How do they dress? And so on. Later on you will begin to answer these questions subconsciously and just say to yourself when you see a client: ‘Liver qi stagnation and Heart yin xu,’ without having consciously thought about it. Some diagnostic areas are more straightforward than others. Diagnosis of body movements is usually fairly straightforward and can be observed from a greater distance than, for example, the skin in the area around the eye. Several signs that have relevance must be consciously sought out, for example skin lesions that are covered by clothing. They will first be seen only when the relevant area is uncovered. J. R. Worsley advises practitioners to set up their practices so that they can see their patients when they arrive in their car and walk towards the clinic. This means you will have time to see the client and their natural posture and body movements, etc. without the client being aware that they are being observed (Worsley 1990, p.77). As stated, good lighting is crucially important in visual diagnosis. You shou

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