Introduction to Diagnosis in Chinese Medicine

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1 PART A

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3 CHAPTER 1 Introduction to Diagnosis in Chinese Medicine DEVELOPMENT HISTORY Diagnosis in Chinese medicine helps to diagnose medical conditions, identify specific patterns, predict the prognosis and thus provide the basis for treatment. As early as the Zhou dynasty ( B.C.), The Rites of Zhou: Offices of Heaven (Zhou Li: Tian Guan, 周礼 天官篇 ) recorded, A patient s prognosis can be predicted by five odors, five sounds and five colors, coupled with changes in the nine orifices (two eyes, two noses, two nostrils, mouth, urethra and anus) and the nine organs (heart, liver, spleen, lungs, kidneys, stomach, large intestine, small intestine and urinary bladder). This indicates that inspection, olfaction and pulsetaking were employed at that time. Bian Que ( BC), a legendary physician, was amazingly excellent in diagnosis via observation and pulse-taking. The Records of the Grand Historian (Shi Ji, 史记 ), completed in the Western Han dynasty (202 B.C. 9 A.D.), recorded the case studies of Bian Que and commented, Bian Que is the very initiator of pulse-taking. In addition, Zhang Zhong-jing ( ) mentioned in his preface to Treatise on Cold Damage and Miscellaneous Diseases (Shang Han Za Bing Lun, 伤寒杂病论 ), Bian Que left a lasting admiration with his amazing diagnostic skills in observation and pulse-taking. The Yellow Emperor s Inner Classic (Huang Di Nei Jing, 黄帝内经 ), completed during the Warring States Period ( B.C.), contains texts on specific methods of observation, auscultation and olfaction, 3

4 4 Introduction to Diagnosis in Chinese Medicine inquiry and palpation coupled with theoretical explanations. Discussions on Yin and Yang with Natural Phenomena in the Basic Questions (Su Wen Yin Yang Ying Xiang Da Quan, 素问阴阳应象大论 ) states, Skillful physicians identify yin from yang first by observing the facial complexion and feeling the pulse, then identify the affected location by examining the five colors and be aware of the suffering by observing the breathing and listening to the voice. After that, they analyze the involved zang fu organs by examining the colors and pulse conditions and further understand the causative factors by feeling the cunkou (radial artery) pulse (floating, deep, slippery or hesitant). In this way, they can make a correct diagnosis and subsequently an appropriate treatment plan. Regarding observation, The Yellow Emperor s Inner Classic especially highlights the observation of spirit, color, shape and tongue conditions. For olfaction, the text initiated the theory on five notes (sounds) corresponding to the five zang organs. For inquiry, the text states, It is necessary to inquire into the primary and current conditions. In addition, the text emphasizes the importance of pulse-taking. It covers the methods of three positions and nine subdivisions for pulse-taking, as well as more than 40 pulse conditions. Classic of Difficult Issues (Nan Jing, 难经 ), completed in the Eastern Han dynasty (25 220), established the methods of taking the cunkou pulse. If also discussed normal and abnormal pulses and their clinical significance. Treatise on Cold Damage and Miscellaneous Diseases developed the principle of syndrome differentiation (or pattern identification) by combining diseases, pulse and symptoms to differentiate the cold damage condition by the six meridians and differentiate miscellaneous diseases by the zang fu organs. With treatment principles as well as formulas, the text has been influential even until today. Pulse Classic (Mai Jing, 脉经 ) by Wang Shu-he ( ) of the Jin dynasty ( ), is considered the first monograph on the pulse. The text standardizes the terminology for the pulse conditions and summarizes them into 24 pulses. It clearly defines the six positions in both hands corresponding to the zang fu organs. Also in that period, Emergency Formulas to Keep up One s Sleeve (Zhou Hou Bei Ji Fang, 肘后备急方 ),

5 Introduction to Diagnosis in Chinese Medicine 5 by Ge Hong ( ), recorded the method of urine staining on a piece of white paper to diagnose jaundice. Arcane Essentials from the Imperial Library (Wai Tai Mi Yao, 外台秘要 ) by Wang Tao ( ) of the Tang dynasty ( ), recorded the method of urine staining on white silk fabrics to test the urine color. The text mentioned that sweet urine is necessary for the diagnosis of diabetes. In addition, it recorded diagnosis and differentiation of typhoid, pulmonary tuberculosis, malaria, smallpox and cholera. The Song ( ), Jin ( ) and Yuan ( ) dynasties witnessed a development in pulse studies. Other than books including Cui s Verse on Pulse Diagnosis (Cui Shi Mai Jue, 崔氏脉诀 ), Verse on Pulse Diagnosis (Mai Jue, 脉诀 ) and Essential Points in Pulse Diagnosis (Zhen Jiao Shu Yao, 诊家枢要 ), pulse graphs were also present to illustrate various pulse conditions. Guide to Disease Examination (Cha Bing Zhi Nan, 察病指南 ), completed in the year 1241 by Shi Fa of the Song dynasty, covered 33 types of pulses. Ao s Golden Mirror Records for Cold Damage (Ao Shi Shang Han Jin Jing Lu, 敖氏伤寒金镜录 ), completed in the year 1341 by Du Ben, a physician of the Yuan dynasty, remains the earliest monograph on tongue examination, including 36 types of tongue conditions. In addition, this era witnessed great progress in the diagnosis of pediatric conditions by observing the color and shape of the index finger. Key to Diagnosis and Treatment of Children s Diseases (Xiao Er Yao Zheng Zhi Jue, 小儿药证直诀 ), completed in the year 1119 by Qian Yi, also recorded the diagnosis by observing the face and eyes. The four masters in the Jin Yuan period ( ) expressed distinctive points in diagnosis and treatment: Liu Wan-su emphasized the role of pathogenesis, Zhang Cong-zheng differential diagnosis, Li Dong-yuan combination of the four diagnostic methods and Zhu Dan-xi external manifestations. Physicians in the Ming dynasty ( ) favored combination of the four diagnostic methods, which had been mentioned in [Li] Bin-hu s Teachings on Pulse Diagnosis (Bin Hu Mai Xue, 濒湖脉学 ), completed in the year 1564 by Li Shi-zhen and Simple and Concise Measures for Common Conditions (Jian Ming Yi Gou, 简明医彀 ), completed in the year 1629 by Sun Zhi-hong. Introduction to Medicine (Yi Xue Ru Men, 医学入门 ), completed in the year 1575 by Li Chan, listed 55 questions for

6 6 Introduction to Diagnosis in Chinese Medicine inquiry. The Complete Works of [Zhang] Jing-yue (Jing Yue Quan Shu, 景岳全书 ) completed in the year 1624 by Zhang Jing-yue, listed rhymes of 10 questions. These question items are still influential today. Physicians in the Qing dynasty ( ) valued the significance of diagnosis by inspection. Tongue Inspection in Cold Damage (Shang Han She Jian, 伤寒舌鉴 ), completed in the year 1699 by Zhang Deng, presented 120 tongue pictures. Differentiation of Tongue Conditions (She Jian Bian Zhen, 舌鉴辨证 ), by Liang Yu-yu, presented 149 tongue pictures. Additionally, Ye Tian-shi ( ) paid much more attention to the tongue conditions in the diagnosis of externally contracted febrile conditions. In regard to the syndrome differentiation of febrile conditions, Ye Tianshi developed the method of examining the teeth, assuming that the luster of teeth is closely associated with the medical conditions. He also predicted the prognosis by observing the maculae or white patches. Differentiation and Diagnosis by Inspection (Wang Zhen Zun Jing, 望诊遵经 ), completed in the year 1875 by Wang Hong, collected the data of generations on inspection, including the color, luster and changes of sweat, blood, moustache and urine. Numerous books on diagnosis have been published over the past hundred years. They include the Guide to Tongue Diagnosis by Illustrations (Cai Tu Bian She Zhi Nan, 彩图辨舌指南并 ), by Cao Bing-zhang, Study on Tongue Diagnosis (She Zhen Yan Jiu, 舌诊研究 ), by Chen Ze-lin, Diagnosis Based on Signs and Symptoms (Zhong Yi Zheng Zhuang Jian Bie Zhen Duan Xue, 中医症状鉴别诊断学 ) and Syndrome Differentiation in Chinese Medicine (Zhong Yi Zheng Hou Jian Bie Zhen Duan Xue, 中医证候鉴别诊断学 ), by Zhao Jin-duo; and Diagnosis in Chinese Medicine (Zhong Yi Zhen Duan Xue, 中医诊断学 ), by Fei Zhao-fu. These texts have greatly enriched diagnosis in Chinese medicine. QUESTIONS 1. What are the two diagnostic methods Bian Que was especially excellent at? 2. When did the pulse graph and tongue pictures appear in history?

7 Introduction to Diagnosis in Chinese Medicine 7 MAIN CONTENTS Diagnosis in Chinese medicine mainly covers two aspects: collection of the signs, symptoms and case histories by inspection, auscultation and olfaction, inquiry and palpation; then evaluation and differentiation of the disease, syndrome and prognosis prior to treatment. This book will mainly focus on syndrome differentiation (or pattern identification), namely the pattern identification of the eight principles, etiology, qi, blood and blood fluids, zang fu organs, meridians, and the six meridians, wei (defense), qi, ying (nutrients) and blood, and Sanjiao. The four diagnostic methods are inspection, auscultation and olfaction, inquiry, and palpation. Inspection aims to understand a medical condition by observing the patient s spirit, color, shape, five sense organs, tongue and secretions or discharges. Auscultation and olfaction aims to identify a medical condition by listening to the patient s voice and breathing as well as smelling the patient s odor of the body, breathing and discharges. Inquiry aims to get an idea of the patient s health status, case history and symptoms by asking either the patient him/herself or his/her relatives. Palpation aims to understand the internal conditions by feeling the patient s pulse and palpating other body areas. The above four methods are always combined in the examination of a patient. The pattern identification of the eight principles aims to generalize the data collected through the four diagnostic methods into eight principles. The eight principles are exterior, interior, cold, heat, deficiency, excess, yin and yang. Regarding a specific medical condition, cold and heat tell about the nature, exterior and interior tell about the location and depth, deficiency and excess tell about the strength between antipathogenic qi and pathogenic factors, and yin and yang tell about the general category. The pattern identification of etiology aims to analyze causative factors and pathological changes. The causative factors mainly include six external pathogens, seven emotions, an improper diet and overexertion. The pattern identification of qi, blood and body fluids aims to identify disorders of qi, blood and body fluids in specific conditions. The pattern identification of the zang fu organs aims to identify the involved zang fu organs (locations), nature and strength between antipathogenic qi and pathogenic factors.

8 8 Introduction to Diagnosis in Chinese Medicine The pattern identifications of the six meridians, wei, qi, ying and blood, and sanjiao, are mainly indicated for acute externally contracted febrile conditions. CHARACTERISTICS AND PRINCIPLES Examining the Interior and Exterior The interior refers to the five zang and six fu organs especially the former. The exterior refers to the external manifestations, such as mental activities, emotions, daily life activities, the five sense organs, the seven orifices, the torso and the extremities. Chinese medicine holds that the human body is an organic whole. The interior and the exterior are interconnected through the meridian system. The body and nature are interconnected through the five sense organs on the body surface. Environmental or natural changes can affect the five zang organs through the body surface and meridians. For example, seeing or hearing horrifying things may cause palpitations; a cold stimulus may cause nasal obstruction and sneezing. Likewise, disorders of the five zang organs may manifest in the exterior. For example, dysfunctions of the spleen and stomach may cause a foul breath and a greasy feeling in the mouth with a bitter taste; dysfunctions of the liver may cause chest or hypochondriac discomfort, blurred vision and tinnitus. A local medical condition may affect the whole body, and a systemic condition may manifest in a specific area. An exterior condition may be transmitted into the interior, and an interior condition may manifest in the exterior. Mental stress may affect the functions of the zang fu organs, and dysfunctions of the zang fu organs may affect mental activities. As a result, for example, eye problems can be caused by a local lesion, such as a foreign body injury, but can also result from ascending of liver fire or heart fire. In diagnosing medical conditions, it is important to evaluate the functions of the zang fu organs by the external manifestations. It is also necessary to pay attention to the external environment, such as the season, geographical locations, life habits, living area and mental or social surroundings.

9 Introduction to Diagnosis in Chinese Medicine 9 Identifying Patterns to Determine Causes Patterns refer to the differentiation conclusions on the basis of signs and symptoms. Causes here can be causative factors, such as the six external pathogens, the seven emotions, an improper diet or overexertion, or pathological products, such as stagnant blood, phlegm fluid and qi stagnation. These factors can trigger or aggravate the patient s discomfort. Take a subjective fever, for example. Other than fever, the onset and accompanying symptoms need to be understood through the four examinations. Fever with a short duration and a history of contracting cold and chills is often caused by an external contraction. A floating pulse and a thin tongue coating indicate an exterior syndrome. A white and moistening tongue coating indicates cold, a dry scanty or yellow coating or a red tongue with a sore throat indicates heat, and a thick greasy yellow or brown tongue coating indicates other concurrent conditions. Comprehensive Analysis of the Four Examinations The four examinations are equally important in diagnosing medical conditions. Overexaggerating one method but neglecting the other methods can be misleading. For example, by observing the patient s constitution, age and gender, some physicians can get a general idea of deficiency, excess cold or heat. Then, by the local epidemic or seasonal conditions as well as the patient s external manifestations (such as coughing or the clothes he or she wears), they can make a preliminary diagnosis. After that, they just claim that they diagnosed by inspection or pulse-taking alone. As far as the four examinations are concerned, some physicians may be more skillful at inspection, while others may be more skillful at pulsetaking. However, combination of the four examinations is always necessary for a complete and correct diagnosis. RECOMMENDED LEARNING METHODS Be Familiar with the Basic Theory of Chinese Medicine As the basic theories of Chinese medicine run through the whole process in diagnosis, it is important to be familiar with theories such as yin, yang,

10 10 Introduction to Diagnosis in Chinese Medicine the five elements, qi, blood, body fluids, zang fu organs, meridians, etiology and pathogenesis. It is also necessary to learn clinical subspecialties so as to facilitate ability in diagnosis. Participate in Practice Diagnosis requires practice. Reading books alone is far from enough. For example, one can never understand a red or pale tongue without actually seeing it, and one can never experience a wiry or slippery pulse without actually feeling it. Pay Attention to Details As the saying goes, Details determine outcomes. Only by attentive and rigorous examinations can one make a correct diagnosis. Acquire Good Thinking Skills Since diagnosis in Chinese medicine requires both theoretical foundation and actual practice, it is essential to equip oneself with substantial knowledge and good thinking skills. QUESTIONS 1. What are the main principles of diagnosis in Chinese medicine? 2. Why is comprehensive analysis of the four examinations important?