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By Misha Ruth Cohen
http://www.docmisha.com
from
The Chinese Way to Healing: Many Paths to Wholeness
 Evaluation and Diagnosis
When you go to a Chinese medicine practitioner, whether for treatment
of an illness, acute pain, or to begin a program of preventive care, the
doctor will follow a system of evaluation and diagnosis that depends on
observation and questioning. In accordance with the philosophy of the Tao,
diagnosis is a process of perceiving signs and symptoms and relating them
to one another to reveal how they form patterns of harmony or disharmony.
Each symptom or sign has meaning only in relationship to other signs and
symptoms and to the whole of your mind/body/ spirit.
The Four Examinations
In order to begin to develop an accurate picture of your whole being,
the Chinese medicine practitioner examines you, using the traditional Chinese
method, called the Four Examinations: inquiring, looking, listening/smelling
(these two seemingly different acts are grouped together--in Chinese they
are the same word) and touching. This process of examination reveals which
of the Eight Fundamental Patterns of disharmony are at work and what type
of disharmony of the Essential Substances, Organ Systems and channels you
may have.
The Four Examinations are sometimes done formally, but often the practitioner
uses intuition and casual observation to create a vivid profile of a patient.
Every gesture, word and attribute provides clues to a person's health and
well-being.
Let's look at each step in the diagnostic process in more detail, breaking
down the Four Examinations into their components, so you'll know what to
expect.
INQUIRING
Step One: Asking Questions
The Chinese medicine doctor takes a great deal of time to ask you about
yourself. Your answers allow the practitioner to benefit from the knowledge
that you have, for no one can know your body as well as you do. Questioning
allows the practitioner to observe your emotions, voice and self-presentation.
Basic questions focus on:
- Your reaction to heat and cold
- Your patterns of perspiration
- If and when you experience headaches or dizziness
- What type of pain, if any, you may have
- Your bowel and bladder function
- Your thirst, appetite, and tastes
- Sleep patterns
- Your sexual functioning, sexual activity, and reproductive history
- General medical history
- General physical activity
- Emotions
LOOKING
Step Two: Evaluation of the Tongue
The tongue is the mirror of the body. Harmony and disharmony are reflected
in the tongue's color, moisture, size, coating and the location of abnormalities.
Healthy Organ Systems and a lack of External Pernicious Influences produce
a healthy tongue, which is pinkish red, neither dry nor too wet, fits perfectly
within the mouth, moves freely and has a thin white coating.
Imbalances in the Organ Systems and/or invasion by Pernicious Influences
produce an unhealthy tongue. External Pernicious Influences produce changes
in the tongue coating. Interior problems, such as Organ System or Essential
Substance disharmonies, produce changes in the tongue body.
When examining the tongue, the Chinese medicine doctor looks at the
color of the tongue body, its size and shape, the color and thickness of
its coating or fur, locations of abnormalities, and moistness or dryness
of the tongue body and fur. These signs reveal not only overall states
of health but correlate to specific organ functions and disharmonies, especially
in the digestive system. To evaluate the tongue accurately, always do the
examination in natural light.
Tongue Body
The tongue body is a fleshy mass and has color, texture, and shape independent
from the apparent qualities ofthe tongue coating. A pale tongue body indicates
deficient Xue, Qi, or Yang or Excess Cold. An overly red tongue body indicates
Excess Heat. A purple tongue indicates that Qi and/or Xue are not moving
harmoniously and are stagnant. Pale purple means the Stagnation is related
to Cold. Reddish purple is related to Stagnation of Heat. When the tongue
is black or gray, it indicates extreme Stagnation; if black and dry, that
indicates extreme Heat Stagnation; if black and wet, that indicates extreme
Cold Stagnation. Bright red indicates Deficient Yin or Excess Heat. Dark
red indicates Excess Heat. Cracks in a red tongue indicate Deficient Yin
or Heat Injuring the Fluids. If the tongue is pale and cracked, there is
Deficient Qi or Xue. Thorny eruptions of the buds on the tongue alert the
doctor to Heat or Stagnant Xue.
Tongue Fur
The tongue's coating is best described as moss or fur. It arises when
the Spleen causes tiny amounts of impure substances to drift upward to
the tongue. When the Spleen and stomach are in balance, there is a uniform
density of fur, with a slightly thicker area in the center of the tongue.
Thick fur indicates excess. Thin fur is related to deficiency during illness,
but is normal if you are well. Fur that is wet indicates Excess Jin-Ye
(fluids) and/or a Deficient Yang. Dry fur is a sign of Excess Yang or Deficient
Jin-Ye. A greasy fur is a sign of mucus or dampness in the body. If the
fur looks peeled off or missing, it reveals Deficient Spleen or Yin or
fluids. White, moist fur indicates Cold. Yellow fur means Heat. However,
white fur, resembling cottage cheese, points to heat in the Stomach. Gray/black
fur with a red body is associated with extreme Heat; gray/black fur with
a pale body is a sign of extreme Cold.
Size and Shape
The healthy tongue rests comfortably in the mouth. It is neither too
small nor too large. If a tongue is enlarged and flabby, it indicates Deficient
Qi. If, in addition to being enlarged and flabby, the tongue has scalloped
(or tooth marked) edges, then it indicates dampness due to Deficient Qi
or stagnation of fluids. If the tongue is enlarged and hard, it is a sign
of Excess. If it swells so that it fills the mouth and is deep red, that
means Excess Heat in Heart and Spleen are a problem. A small, thin tongue
can indicate Deficient Yin or Xue.
Movement
A trembling, pale tongue indicates Deficient Qi. A flaccid tongue that
is pale often reveals extreme Qi or Xue Deficiency. A flaccid tongue that
is deep red reveals severe Yin Deficiency. A trembling, red tongue indicates
interior Wind. If the tongue sits off-center in the mouth, early or full-blown
Wind stroke may be present. A rigid tongue accompanies an Exterior Pernicious
Influence and fever. This may indicate the invasion of the Pericardium
by Heat and Mucus Obstructing the Heart Qi.
Location of Abnormalities
The location of disturbances on the tongue are vivid indications of
where disharmonies in the mind/body/spirit are located. Certain organs
are associated with the Upper, Middle and Lower Triple Burner, which are
in turn associated with the front, middle and back sections of the tongue.
For example, if there are red spots on the front third of the tongue, which
is associated with the Upper Burner, this indicates that there is Heat
in the Lungs. If the tip of the tongue is red, that indicates Heat in the
Heart. Menstrual cramps, when associated with Stagnant Xue, are often accompanied
by purple spots on the edges of the tongue in the Liver/Gallbladder area.
The Role of Tongue Diagnosis
Not all tongue irregularities are indications of disharmony, however.
Food and drugs may change the coating or color of the body of the tongue.
For example, coffee yellows the coating and Pepto-Bismol turns the tongue
black.
Furthermore, some people have minor, unchanging cracks on their tongue,
which are considered normal. Others are born with what is called a geographic
tongue, which is covered with severe cracks and covered with hills and
valleys. This is considered normal by some practitioners, but a sign of
congenital disharmony by others.
The way a tongue appears is not an absolute indicator of the location
of the disharmony, but when taken as part of an overall pattern that includes
a complete evaluation, it offers strong clues to the location of disharmony.
Step Three: Evaluation of Body Language--Styles of Movement, Posture
and Self-Presentation
Seeking clues to possible Pernicious Influences, the practitioner looks
for signs of heat or Cold influences, Excess or Deficiency, Yin or Yang
disharmonies. If a person has a heavy-footed walk, loud voice and sits
in a sloppy, spread-out posture, that may indicate Excess. If a person
acts frail and weak, sits with shoulders slumped and is shy and receding,
that may indicate a Deficiency. On the other hand, fast, jerky, impulsive
movement and an outgoing personality indicate Heat. If combined with a
full, red face, high energy and a loud voice, then both Heat and Excess
may be at work. Cold, as you might suspect, is associated with slow but
not sloppy movements and a pale face. When coupled with a low voice, shortness
of breath, or passivity, Cold and Deficiency may be at work.
Step Four: Evaluation of Facial Color
When you are feeling off-balance or have a specific disharmony, facial
colors offer clues to the nature and the severity of the imbalance.
There are several different methods of facial diagnosis: Korean, Japanese,
Worsley School, even macrobiotic. The following evaluation of facial colors
is derived from a combination of Traditional Chinese Medicine and Five
Phases principles. I have found this system provides accurate analysis.
TIP In order to obtain a clear idea of what the various facial
colors look like, always use natural light when examining your face in
a mirror.
The Significance of Facial Colors
- If facial color is bright and fresh, then the disease is called floating
and is on a superficial level.
- If the color is moist, neither wet nor dry, the disease is not severe
and will be easy to treat.
- If the color is shallow and scattered over a large area, the number
of days of the disease will be short.
- If the color is dark and cloudy, then the disease is sinking into the
inner organs.
- If the color is dark, cloudy and dry, the disease is severe and will
be difficult to cure.
- If the color is deep and accumulated in one spot, the disease is a
long-term one.
Reading Between the Lines
Five colors appear on the face: red, green, yellow, white and black. Depending
on a person's constitution, a healthy face may have one color that is more
predominant than others, but several may be visible. To determine what
colors are present in your face, always examine it in natural light. Look
for the overail color tone; study the skin to see what tones appear from
under the surface; look at any visible veins. For contrast, hold your hand
up alongside your face.
Red is the color associated with the Heart Organ System and Xue.
If the face is a fresh red, the Xue is Hot. If the face is dark red, the
Xue is Stagnant. If it is light red, the Xue is Deficient.
Green is the color associated with the Liver System and circulation
of the Xue. If veins on the face appear greenish purple, the Xue is Hot.
If the veins appear greenish black, the Xue is Stagnant. If the condition
is severe, the veins on the face appear black.
Yellow is the color associated with the Spleen System. If the
face appears light yellow, then the Spleen system is Damp and Hot. If the
face appears deep yellow, Heat has accumulated. If it is dark yellow, Heat
is the result of Xue Stagnation. Withered yellow indicates a Heat Deficiency.
White is the color associated with the Lung System, which regulates
Qi, the breathing in of oxygen, and the exhalation of carbon dioxide. If
a person is not able to exhale completely-as in emphysema-his or her face
will take on a grayish white color. If the person inhales inadequately,
then the face will appear pale and lusterless.
Black is the color associated with the Kidney System. If the
face is cold and black, the Kidney System is not filtering Xue properly.
If the face color is black but bright and moist, the condition can be treated.
If the face is not shining, the condition is not good. If the face is withered,
the Kidney System Yin is dry. If the face is cloudy and dark, the Kidney
System Yang is dying.
Occasionally, there are combinations of colors. This further refines
the evalua tion. For example, if the color is red and white, both the Heart
and Lung channels are involved.
LISTENING AND SMELLING
Step Five: Evaluation of Voice
Listening to the sound of a person's speech, breathing and cough can
help identify a disharmony that results from one or more pernicious influence
and pattern of disharmony. For example, if the voice is too loud and strident,
that indicates Excess, as does the sudden onset of a violent cough. A weak,
low voice that doesn't project and a weak cough indicate Deficiency. Losing
your voice or hoarseness can indicate either Deficiency or Excess. Wheezing
arises from Dampness.
Step Six: Evaluation of smell
According to TCM theory, there are two main odors that clue a doctor
to the origin of disharmony. A strong stench from secretions or excretions
indicates Excess and Heat. A weaker odor indicates Deficiency and Cold.
Five Phases practitioners generally rely on smell more than TCM practitioners
do. Each smell is associated with a phase and can indicate disharmony with
the associated organ or among organs that are related through the Five
Phases cycle. The smells used in Five Phases diagnosis are: goatish, associated
with wood; burning, associated with fire; fragrant, associated with earth;
rank, associated with metal; and rotten, associated with water.
TOUCHING
Step Seven: Evaluation of Pulses
There are twenty-eight pulse qualities that are essential to Traditional
Chinese Medicine's process of evaluation and diagnosis. Learning to read
pulses requires years of study and practice and is not something that can
be done at home on yourself. However, your Chinese medicine practitioner
will talk to you about your pulse diagnosis, and you will want to have
a passing familiarity with the terminology that's used. The most common
descriptions are: floating, slippery, choppy, wiry, tight, slow, rapid,
thin, big, empty and full. (For a more detailed explanation of pulse diagnosis,
see The Web That Has No Weaver,
by Ted Kaptchuk.)
Pulses are evaluated on a superficial, middle and deep level. The normal
pulse resides at the middle level and is usually about four or five beats
for each complete inhalation and exhalation of breath.
Disharmonies of the pulses indicate: the condition of Qi, Xue and Fluids;
Organ System imbalance(s); the location of the imbalance(s); and the nature
(Heat or Cold) of the disease, along with many other qualities.
For example, a wiry pulse may indicate that the Liver System has Stagnant
Qi. However, there are no absolute meanings to pulses. They contribute
to a diagnosis only when viewed in context with other diagnostic techniques.
Step Eight: Evaluation of Sensitivity to Touch
Palpation of acupuncture points and channels can trigger, increase,
or reduce pain and indicate disharmony in the associated channels and Organ
Systems.
- If you have a pain you can't pinpoint, that indicates Stagnant Qi.
Stagnant Qi is also indicated by a pain that moves around.
- If the pain is fixed, it may indicate Stagnant Xue.
- Pain that feels better with pressure is due to Deficiency.
- Pain that feels worse with pressure is due to Excess.
- Pain that feels better with warmth is associated with Cold.
Palpation of the body does not have to be confined to the twelve channels',
fifteen collaterals' or eight extraordinary channels' acupuncture points.
Ear acupuncture points are also powerful tools for diagnosis and provide
refined clues to the sources of disharmony. They are also useful for self-massage.
Reflexology, while not a traditional Chinese method of diagnosis and treatment,
is another useful tool at this stage of diagnosis.
THE NEXT STEP
Now that you have an understanding of the basics of Chinese medicine
and what to expect if you go for acupuncture or herbal therapy, you may
be ready to make an appointment to see a Chinese medicine practitioner.
The following guidelines may help you find a qualified practitioner.
SELECTING A PRACTITIONER
When you are selecting an acupuncturist, herbalist, or a Chinese medicine
doctor, the two most important factors to consider are the doctor's training
and your goals.
Training
In order to gain the full benefit of Chinese medicine therapy, the practitioner
who administers the treatment(s) should have reputable training and a keen
sense of the philosophical underpinning of Chinese medicine.
The best way to determine if a practitioner meets those standards is
to ask a lot of questions about his or her training, length of practice,
scope of practice, specializations, attitudes about wellness and disharmony
and understanding of Chinese medicine philosophy.
Meeting Basic Standards
The Taoist system of belief is not some fancy window dressing that can
be cast aside. It is part and parcel of Chinese medicine treatments. No
particular Chinese medicine therapy, such as acupuncture or herbal remedies,
can deliver its full healing potential if it is separated from the philosophical
context of the Tao.
In addition, you want to find a practitioner who is schooled in the
Chinese medicine therapies that you want to use. There are practitioners
who are licensed acupuncturists (L.Ac.) but who do not offer herbal therapy;
there are others who are herbalists but provide no acupuncture; there are
licensed acupuncturists who also have training as herbalists; and there
are doctors of Oriental medicine who provide acupuncture and herbal therapy.
Every acupuncturist should be licensed (in
states
with licensing requirements) or certified. In more than half the states
there are state licensing boards and nationally there is the National Commission
for the Certification of Acupuncturists (NCCA).
You may call the commission for a listing of certified
acupuncturists in your area.
If you live in a state without a state licensing board, it is particularly
important that your acupuncturists have a certificate from the NCCA. Acupuncture
degrees in this country come from
accredited
schools of acupuncture and Traditional Chinese Medicine schools and colleges.
Your herbalist (who may also be your acupuncturist) should have either
a certificate of training or a long-standing reputation and years of experience.
Many schools train people in herbal medicine, but there is no independent
licensing for Chinese herbalists. Since 1982, California
is the only state that requires practitioners to take an exam in both acupuncture
and herbal therapy to be licensed to practice acupuncture. The NCCA does
offer an herbal certification, but it doesn't lead to licensure.
Your Goals
You also want to decide if you are looking for a primary care physician,
someone to work with your primary care doctor, or simply someone who can
provide shortterm treatment for a specific complaint.
If you are looking for a primary care physician, I recommend someone
who is knowledgeable about all aspects of Chinese medicine and Western
medical procedures; someone who will know when to refer you for Western
evaluations and testing, and someone who is willing to work with a Western
doctor, if doing so provides you with the best therapy.
To sum up what to look for in a primary care Chinese medicine practitioner:
- Someone who does not make promises to cure disorders and diseases for
which there is no cure (applies to all practitioners, no matter what you
use them for)
- Someone who understands that there may be many different modalities
that work for an individual and does not insist that his or her way is
the only right or good way to go
- Someone who has a bedside manner that pleases you (What pleases some
people most is ability, and they don't care about personality at all. That's
fine. For others, a more personal relationship is important. You should
make that individual decision.)
- Someone who is able to explain what she or he is doing from both a
Chinese and a Western viewpoint-or is at least willing to find out about
the alter native perspective when necessary
- A practitioner who is not unconditionally opposed to any drug therapy
in conjunction with acupuncture or herbal treatment, and who understands
the interactions of drugs and herbs
- Someone who will work with medical doctors and other practitioners
In cases of serious illnesses, you want to select a practitioner
who understands Western medical terminology and concepts of the immune
system, viruses and cancer, as well as Chinese concepts, if you are going
for treatment of these problems.
If you have HIV, chronic hepatitis, or CFIDS (chronic fatigue immune
defi ciency syndrome), be sure that the practitioner's attitude is that
you can live with this chronic, manageable viral infection and that acupuncture
and herbs may help you be more successful in that process.
Receiving Treatment
When you select a practitioner and go for treatment, you don't surrender
control of your health. Chinese medicine recognizes that we each possess
the tools we need to preserve or reclaim good health. The good (or excellent)
practitioner simply acts as the guide, helping to coax the body's own defenses
to prevent or mend disharmony.
There are four basic healing techniques that the practitioner may suggest
as treatments:
acupuncture and
moxibustion, herbal therapy,
dietary therapy, and
Qi Gong exercise/meditation.
A brief description follows here, and each therapy is discussed in detail
in the following chapters.
Dietary Therapy
Chinese dietary therapy uses foods to strengthen digestion, increase
energy and balance the body's energy. Dietary therapy is often used prior
to or in conjunction with other therapies to increase the effectiveness
of these treatments.
Acupuncture and Moxibustion
Classic acupuncture is the art of inserting fine, sterile, metal filiform
needles into certain points along the channels and collaterals (tributaries
of the channels) in order to control the flow of the Qi. These days, practitioners
also use electrostimulation of the needles, lasers and even ultrasound
to stimulate the points.
Acupuncture is well-known for its effectiveness as a painkiller. Even
more powerful is its ability to alter the flow of the Qi so that the body
can heal itself when attacked by pathogens that trigger disharmony. Acupressure
and massage are subsets of acupuncture.
Moxibustion, the burning of the herb moxa (Chinese mugwort) over channel
points and certain areas of the body, is used to warm, tonify and stimulate.
It also induces the smooth flow of the Essential Substances, prevents diseases
and preserves health. Doing moxa regularly on specific acupuncture points
is said to promote strength and longevity. In fact, an old Chinese saying
is, "Never take a long journey with a person who does not have a Moxa
scar on (the acupuncture point called) Stomach 36."
Chinese Herbal Medicine
Herbal medicine is actually a misnomer. Although the ovenwhelming majority
of medicinal substances come from plants, some are derived from minerals
and animals. Whatever their origin, they are used to balance the mind/body/spirit
as well as to reverse disease processes. Most Chinese herbs should only
be taken under the supervision of a trained herbalist.
Qi Gong Excercise/Meditation
Qi Gong, the Chinese art of exercise/meditation, uses dynamic movements
and still postures in combination with mental and spiritual concentration
to influence the flow ofQi. It is a powerful preventive therapy and can
help remedy disharmony in the Organ Systems and the channels.
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