Chinese diagnosis involves the reading of basic physical indicators of health and disease such as complexion, eyes, color and texture of tongue and tongue fur, the patient’s personal habits, pulse, and so forth. To this data, the physician applies the medical theories of disease to form a diagnosis and recommend a treatment. Neither the diagnosis nor the treatment remains static: the doctor must keep in close touch with the patient throughout the course of treatment and constantly review both diagnosis and treatment ac- cording to the directions taken by the disease. These directions are reflected in symptomatic changes. Herbal prescriptions are thus regularly revised according to the requirements indicated by the latest developments and symptoms.
Chinese physicians use four basic methods of diagnosis: interviewing, observing, listening, and feeling. Interviews take the form of comprehensive, and detailed dialogue be- tween the doctor and patient. The interview must be well-organised and systematic focusing on the major symptoms of the disease and background factors which may have contributed to its development. Above all, the interview must be objective and frank.
The order of business in such diagnostic interviews is first for the patient to describe the chief complaints and more obvious symptoms of his ailment. This is followed by an explanation of how, when, and where he first felt ill, followed by a description of the history of the illness from its onset right up to the day he visits the doctor, noting especially symptomatic changes, specific pains, and other manifestations unique to the ailment. Six indicators are emphasized during this part of the interview:
Chills And Fever
Intermittent fever and chills usually indicate an ailment which affects both the internal and external parts, or is moving from one to the other. Fever and thirst with no chills indicates an internal ailment, chills without fever reflects yang-deficiency, and fever without chills indicates an ovei -abundance of yang-energy. Other factors, such as what time of day chills and fever occur, further refine the reading of this indicator.
The amount and viscosity of perspiration, when it occurs and on what parts of the body it appears, are the main questions regarding this sign.
Stool And Urine
Constipation accompanied by hard stools is a sign of “hot” and “solid” disease. Loose stools containing partially digested food indicates a “cold” and “empty” ailment. The presence of blood or mucus in the stool must also be re- ported. Scanty, dark urine reflects “heat-excess,” while profuse, clear urine is a sign of “cold” and “empty” disease. Cloudy urine indicates “moist-heat excess.”
Food, Drink, And Taste
An inclination for hot drinks reflects a “cold” disease, while a preference for cold drinks and food indicates a “hot-type disease. A revulsion towards drinking water is a sign of “moist” disease. The presence of a flat, bitter, sweet, or other dominant taste in the mouth must be reported. A strong desire for spicy, deep-fried foods or strange materials (such as dirt, candle-wax, coffee-grounds etc) usually indicates the presence of parasites in the system.
Excessive sleep indicates yang- deficiency, while insomnia is a sign of poor circulation, excessive worry, or spleen-deficiency. Fitful sleep indicates emotional disturbance or over-indulgence in food and drink. Unusually early rising often indicates an over-active hearts.
Sex, Menstruation, And Pregnancy
For men, the vital questions in this area involve sexual vitality, impotence, incontinence, nocturnal emissions and spermatorrhoea, and frequency of coitus. For women, frequency of menstruation, its color and texture, other vaginal discharges such as leukorrhoea, past pregnancies and/or abortions, childbirths, and frequency of coition are vital indicators of the nature of disease in the body.
In addition to the history of the specific disease based on the above indicators, a comprehensive past history of the patient himself is also taken. Besides stressing past illnesses, living habits, enviromental surrounding, allergies, and so forth, the general health history of the patient’s family is also covered. In cases involving infants, the deaf and dumb, and others who are unable to conduct the interview for themselves, the relevant information is provided by the patient’s spouse, parent, close family member, or friend.
Methodical Visual Observation
Methodical visual observation of the patient is the second diagnostic technique used by traditional Chinese doctors. Changes in the body’s skin coloring and form, tongue color and tongue fur, eyes, secretions and excretions, all reflect the state of disease inside. First, the doctor notes the patient’s mood and movements. If he is spirited and alert, with regular breathing and normal coloring, the illness is not yet serious and can be easily treated. If he is depressed and moody, with irregular breathing, wan complexion, and list- less eyes, the disease has reached a serious stage and the treatment will be more complex. The color and flesh-tone of a patient’s facial complexion are direct indicators of pathological changes in the vital organs. The physician observes the patient’s general physical condition by noting the way he walks, talks, sits down, lies, breathes, and moves his limbs.
One of the most important methods of observation-diagnosis is visual examination of the tongue. Such factors as muscular form and color of the tongue and the color and texture of the tongue fur reveal the empty-full nature of disease as well as its severity. Normal tongues are soft and moist, light-pink in color and neither thick nor thin. If the tongue appears tight and shrivel- led, the disease is of the “full” type; if it appears thick, porous, and tender, the ailment is of the “empty” type. A fat and swollen tongue indicates “moist-heat” excess inside the body. A light, pallid color instead of the normal soft-pink indicates “blood- empty” and “qi-empty” disease, while a bright-red color reflects “hot” and “full” disease. Normal tongues have a thin, white, clear fur coating that is neither too moist nor too dry. Dis- ease in the body usually thickens this fur coating. A raw, white fur results from “cold” and “moist” disease, while a yellow fur indicates “hot” and “full” disease. In observing tongue- fur, care must be taken not to confuse symptomatic color changes with residual coloring from food and drink. The accompanying chart gives a detailed account of the diagnostic indications of tongue structure, color, and fur.
The listening technique includes examination by ear and stethoscope as well as by smell (one Chinese character for “hear” also means “smell“). The physician listens to the patient’s speech, breathing, coughing, and to the sounds emanating from the visceral organs. He uses his nose to check the smell of the patient’s body excretions, which helps to determine the nature and location of disease. “Empty” ailments are indicated by low, weak speech, shallow, weak-sounding respiration, and a weak, low-pitched cough. “Full” ailments are reflected in restless, confused speech, rapid and noisy breathing, and a heavy, loud cough. Examination of the internal organs by stethoscope is performed over the heart, lungs, and abdomen. The various sounds or murmurs made by the heart during various stages of heart beat, and the sounds produced by the lungs during inhalation and exhalation are all important diagnostic indicators of energy imbalances and dysfunction in those organs.
Tactile examination includes traditional Chinese pulse diagnosis and other manual methods such as mass- age and acupressure. In pulse diagnosis, the physician places his first three fingers along the radial artery of the patient’s wrist, feeling for three special points. Light pressure on these points reveals three separate pulses, while heavy pressure reveals yet three different ones, a total of six pulses on each wrist. Each of the twelve pulses reflects the condition of one of the twelve vital organs. With skilled, sensitive fingers, the Chinese doctor can detect over thirty different pulse qualities on each of the twelve pulses. The pulse qualities —such as “floating,” and “sunken,” “weak,” “bounding,” —indicate the condition of the related organ. Past, as well as current diseases sustained by the organ are revealed by this method. It may also indicate inherent weakness which may lead to disease in the future. Chinese pulse diagnosis is a delicate art, difficult to master and requiring many years of practice. Its proven ability to trace the sources and courses of disease in the vital organs —past, present and future — seems almost miraculous to those unfamiliar with the technique.
Other tactile techniques include light massage examination and palpitation of the internal organs. Massage reveals the temperature of the skin, flesh, and extremities, “full” and “hot” or “empty” and “cold” disease. Massaging the spinal column often indicates where a disease is located because the spinal nerves associated with the diseased organ will be knotted and tight to the touch. Certain vital points along the meridians, called “alarm points,” will be tender and painful under acupressure when the related organ is diseased or weak. Palpitation involves applying finger and palm pressure to the body’s surface directly over vital organs to check their consistency and tone. Similar to this method is percussion: the physician uses the middle finger of one hand to hit the mid-joint of the middle finger of the other hand, which is placed palm down over the organ. The resonance of this percussion indicates the condition of the organ below.
Determining the nature and location of disease is only the beginning of Chinese diagnosis. To treat patients effectively with herbal medicines, the physician must next make a “differential diagnosis” based on symptomology. Differential diagnosis determines in which direction the disease is moving and the nature of its symptoms. Symptoms sometimes seem to disappear during treatment. In actual fact, they have usually transformed and moved elsewhere, following, for better or worse, the course of the disease. Halting treatment at this juncture, when the disease is still inside, may permit the disease to recur at some time in the future. Continuing the same herbal treatment, when the symptoms and disease have already changed form, is not effective in the long run. Herbal prescriptions must be regularly adjusted to meet the ever- changing symptomatic situation. Since no two patients are exactly alike in their reactions to disease and to medications, differential diagnosis is vital to the successful application of Chinese herbal medicine in individual patients.
There are eight categories of ba gang, differential diagnosis: yin/ yang, internal /external, cold/hot, and empty/full. These categories ultimately overlap, and all disease falls into one of the two great categories of yin and yang, according to the clinical manifestations of all the eight indicators. The principles of differential diagnosis are indispensable guides for prescribing herbal treatments which match the requirements of the disease and its symptoms.
Yin-yang designates whether the disease is primarily injuring the patient’s yin- or yang-energy and whether to treat with yin or yang herbs. Based on the four diagnostic techniques, the general symptoms indicate yin or yang disease, as outlined below:
Internal-external indicators differentiate the site, extent, and seriousness of the disease, revealing in which direction it is moving. As diseases get worse, they tend to move inward toward the bones and vital organs. Movement towards the exterior usually indicates that the cure is working. Cold-hot manifestations are used to differentiate the nature of the disease itself, while empty-solid indicators reflect the nature and extent of the illness, as well as the body’s resistance to the specific disease.
The following chart lists the broad indications drawn from the eight principles of differential diagnosis.
There are, of course, many different combinations of the above factors, and their manifestations are different for every patient and disease. The important point is to match the medications directly to the actual symptoms at hand, regardless of the original diagnosis. Some of the more common combinations of the eight principles are charted below.
Chinese diagnosis involves a three-step process: The four diagnostic techniques, (si zhen), are first employed to determine the general type, location, and cause of the disease. Next, differential diagnosis based on the eight principles, (ba gang), is applied to reveal to what extent the disease has developed ; in which direction it is moving and exactly how the symptoms are affecting the individual patient. Finally, based on the latest differential diagnosis, an herbal prescription is prepared which takes the body in the opposite symptomatic direction of the disease and redresses the energy imbalances caused by it. Regular reevaluation of the data and diagnosis, followed by re-adjustment of the herbal formulas prescribed, continues until a complete cure is effected. Having briefly covered the essential principles upon which traditional Chinese medicine is founded, we now return to the ben cao itself to see how this vast treasure-house of Chinese herbal knowledge is actually used in the practical application of Chinese herbal medicine.