Traditional Chinese Medicine Diagnosis

The use of sight in traditional Chinese medicine diagnosis is crucial. By examining the face, the body, and the tongue, a practitioner can recognize signs and symptoms that indicate illness. Treatment cannot begin until observation using sight has been made and other methods of diagnosis have been employed.

The Face

An experienced practitioner often develops an initial idea of a patient's health just by observing him or her walking into the office. Inspecting the quality of the spirit (shen) is an important aspect of this first impression, since the shen gives a good indication of the overall vitality of a person. The shen especially shows in the eyes: An ancient maxim states, "If there is shen, there is life." A person with healthy shen has a gleam or sparkle of life in the eyes.

The face is bright with some color, breathing is regular, and movements and speech are normal and logical. A person with unhealthy spirit has dim eyes with a vacant look. The face is dull with no shine; breathing is slow, weak, or irregular; movements appear abnormal or unusual; and speech is illogical or the voice is at an inappropriate volume.

Changes in facial skin color can provide the traditional Chinese medicine practitioner with a number of diagnostic clues. A bright (shiny), white face can indicate deficiency of qi or a cold condition, while a dull, pale face with no shine is a sign of blood deficiency.

Redness in the face indicates heat: If the entire face is red, it is a sign of excess heat, while red cheeks alone are a sign of deficiency heat. A bright yellow skin tone can indicate damp heat, while pale yellow is a sign of damp cold due to deficiency. Finally, areas of black usually indicate kidney deficiency.

The location of color on the face also has diagnostic significance as in the example of kidney deficiency: The black appears below the eyes and is often seen in people who don't get enough sleep or push themselves too hard, both practices that deplete the kidneys of qi, yin, and yang. Another example of the importance of the location of color is when it appears on the tip of the nose, an area affected by the spleen. Alcoholics often have redness in this area due to damp heat in the spleen caused by the heat generated in that organ by alcohol.

The Body

A lot of information can also be accumulated by looking at the overall physique. Overweight people have a tendency toward dampness or phlegm, while thin people are inclined to be yin deficient. A person with internal heat may be scantily clad in the winter, while a person with internal cold might wear a sweater in the summer. Somebody who is active and energetic tends to experience yang syndromes, while yin syndromes are more common in quiet, sedentary people.

Faded, sparse, and dry hair indicates weak kidney qi or blood, while lustrous, thick, and shiny hair is a sign of strong kidney qi and sufficient blood. Finally, the lips can tell a lot about the condition of the body. Bright red lips can indicate heat, pale lips can be a sign of qi or blood deficiency, and blue lips can be due to cold or blood stagnation. Dry and cracked lips are a sign of depleted body fluids, and twitching lips are an indication of liver wind.

The Tongue

The most important and richest source of visual diagnostic information is the tongue. Entire books have been written to illustrate the amount of information that can be garnered simply by carefully observing the tongue.

The surface of the tongue is divided into areas that correspond to the organs. The tip of the tongue corresponds to the heart, while the entire front area applies to the lungs. The middle area reflects the condition of the stomach and spleen, while the sides of the tongue are related to the liver and gallbladder.

Finally, the back of the tongue corresponds to the lower burner, which includes the kidneys, the urinary bladder, and the large intestine. These assigned areas reveal a wealth of information, and they repeatedly prove accurate when applied to clinical practice.

The colors of the tongue body and coating also enhance the clinical picture. When the body of the tongue is much redder than normal, it is a sign of excess heat, while a slightly redder tongue body is a sign of deficiency heat. A pale tongue body indicates a syndrome of deficiency or cold. A purple tongue can indicate qi or blood stagnation, while a blue-tinged tongue indicates stagnation and severe deficiency of qi and blood.

The consistency and shape of the tongue are also significant. A puffy tongue with teeth marks on the sides is seen in a person with deficient qi, while a puffy tongue that appears wet indicates deficient yang. A shriveled, atrophied tongue is seen in deficient conditions; this sign appears sometimes in cancer patients. Finally, cracking in the tongue body occurs when body fluids have been depleted due to heat or yin deficiency.

The movements of the tongue also tell their own story. When the tongue shakes, it is a sign of deficiency or liver wind. (Of course, it can also indicate nervousness.) When a person has difficulty sticking the tongue out, it can indicate deficient qi, blood, or yin. When the tongue is turned to one side, as in stroke patients, it is a sign of internal wind or phlegm blocking the meridians. Finally, a person who leaves his tongue out, or whose tongue moves in and out, has heat in the heart.

Another important aspect of diagnosis through observation of the tongue is the appearance of the coating on the tongue. In a healthy person, the coating is thin, moist, and white. A change in the color or distribution of the coating indicates some sort of pathologic process occurring in the internal organs; for example, if there is heat in the stomach, that area of the tongue will have a yellow coating.

A thick coating is related to excess conditions, while a thin coating is seen in deficiency. With yin deficiency, there is little or no coating, since the tongue coating is created by the stomach yin. An excessively moist coating is a sign of excess fluids and occurs when yang is insufficient to transform fluids (in other words, if yang is weak, fluids accumulate). A dry coating indicates fluid deficiency or dehydration; a greasy coating indicates dampness; and a patchy coating occurs when phlegm blocks the acupuncture meridians.

The color of the tongue coating can tell a lot about the nature and progress of a disease. Often, an acupuncturist requests that patients avoid brushing the tongue before an office visit, since it can take a few hours for the coating to reappear.

Similarly, foods that discolor the tongue should also be avoided before an appointment, since they can make it difficult or impossible for a practitioner to read the true coating color. Although a white tongue coating is normal, it can also appear in external conditions, as well as conditions of cold or deficiency. A yellow tongue coating is always a sign of heat; as the heat increases, the intensity of the color also increases. A gray or black tongue coating can appear in conditions of extreme heat or cold, depending on the other symptoms.

The progress of a disease can actually be monitored by observing the tongue over the course of an illness. A person with a high fever might have a thick yellow coating; as the fever subsides, the coating becomes more white as the excess heat leaves the body. In fact, there are actually even more sophisticated visual diagnostic cues. However, the above descriptions illustrate that a wealth of information is available to the observant practitioner before hearing a single word of complaint from a patient.

On the next page, learn how other senses, such as smell and hearing, are used to make a diagnosis in Chinese medicine.

For more about traditional Chinese medicine, treatments, cures, beliefs, and other interesting topics, see:

The use of sound and smell in traditional Chinese medicine can garner information when diagnosing a patient. The two diagnostic tools are grouped together because the same Chinese word is used for both of them. In this diagnostic area, the practitioner listens to the various sounds emanating from the patient and pays attention to any unusual smells. A wealth of information can be gleaned from these perceptions, and they give the physician some clues to pursue later on during the initial interview.

Speaking

A person under attack by an external pathogen speaks softly at first, with the voice gradually becoming louder. With an internal deficiency, the voice gets softer over time due to a lack of energy. People with cold syndromes tend to be quiet, while heat syndromes are associated with excessive talking. It is the nature of cold to slow functions and movement, while heat speeds them up.

A person with an excess condition tends to have a loud, strong voice, while a soft, weak voice is associated with deficiency patterns. Repeated sighing is often a sign of liver qi stagnation; it is an attempt by the body to release pent-up emotion while expanding the chest muscles that tighten due to the stagnation.

Breathing: Weak and shallow breathing that is difficult to hear is associated with deficiency, especially of the lungs and kidneys. Loud and heavy breathing indicates an excess condition that constricts the air passages. The source of asthmatic wheezing can also be differentiated by its sounds. In a deficiency pattern, the sound is soft and the patient experiences difficulty inhaling due to the kidneys' inability to "grasp the qi."

In a lung excess syndrome, the wheezing is coarse and loud and the patient has difficulty exhaling. A loud cough is a sign of excess, while a weak, slow cough is due to deficiency. A dry, hacking sound can indicate dryness or yin deficiency, while gurgling sounds are a sign of phlegm.

Gastrointestinal Signs: Vomiting due to an excess condition is loud and strong, while a deficiency condition causes vomiting that is weak and painful. Hiccups are known as "rebellious stomach qi" in traditional Chinese diagnosis. If they are due to excess, the sound is loud and short, while deficiency hiccups have a weak sound and last longer. If hiccups show up in an illness after a few days, it is an indication of a collapse of stomach qi. Loud belching is a sign of excess; if there is heat, a sour smell accompanies the belching. Deficiency belching has a softer sound with no sour smell.

Smelling

In general, strong smells are due to heat, while a lack of aroma is a sign of cold. This applies to the breath, urine, stools, vomit, sweat, and any discharges. Some specific smells are linked to organs; for example, a sweet smell is linked to the spleen, a urine-like smell is associated with a kidney problem, and a smell like rotten apples is a sign of diabetes ("wasting and thirsting syndrome").

Asking

This is an exceptionally important aspect of diagnosis, for Western as well as traditional Chinese practitioners. When interviewing the patient, the traditional Chinese practitioner accumulates enough information to formulate a diagnosis based on the condition of the internal organs, pernicious influences, and vital substances.

The traditional Chinese practitioner also delves further into information that he or she uncovered while "looking, listening, and smelling." In addition, the practitioner attempts to get an accurate picture of the person's past medical history, lifestyle, and present area of complaint, gradually building a complete diagnostic picture.

On the next page, learn more about how a practitioner observes physical factors, such as perspiration or eye movements, in order to help make a diagnosis.

For more about traditional Chinese medicine, treatments, cures, beliefs, and other interesting topics, see:

Evaluating physical factors in traditional Chinese medicine is important to making a diagnosis. These factors can indicate the type and level of an illness.

Chills and Fever

It is important to remember that these terms refer more to the patient's perceptions of cold or heat, rather than an actual elevated body temperature or shivering. Chills and fever that occur simultaneously indicate an external condition: If the chills are worse than the fever, the condition is wind cold; if the fever is worse than the chills, it is wind heat.

In either case, if the fever persists after the chills disappear, it is a sign that the condition has penetrated to the interior of the body. If the fever persists and is accompanied by sweating, thirst, and constipation, the interior heat has penetrated to the stomach and intestines, which is an even deeper level.

A chronic low-grade fever can occur after an illness accompanied by a fever has "burned out the yin." This sort of fever can also be a sign of qi deficiency associated with a collapse of the body's immune system. Feeling cold can be a symptom of either wind cold or yang deficiency. In wind cold, it can be difficult for a person to get warm, even when he or she is bundled up in warm clothes. Wind cold is an acute ailment of short duration, while yang deficiency is a long-term, chronic condition.

Perspiration

Perspiration is regulated through the opening and closing of the pores, a function of the defensive qi (wei qi). When qi or yang deficiency occurs, the pores remain open due to weakness, and the person experiences spontaneous sweating during the day. This can occur even if the person has not become overheated. Sensations of heat in the evening with night sweats are considered a sign of yin deficiency. This condition is called "stealing sweats" because it steals fluids from the body like a thief in the night.

In an external disorder, perspiration is an important indicator of the final diagnosis: With wind heat, the person perspires, while with wind cold, the pores are closed from cold, causing a lack of sweating. If sweating occurs with an external condition, and the person feels better afterward, it is a sign that the body has successfully expelled the pathogen. If sweating doesn't break the fever or make the person feel better, the pathogen is successfully fighting against the wei qi.

Head and Body

Headaches that have an acute onset with severe pain are usually due to an external pernicious influence, such as wind cold or wind heat. Milder, more chronic head­ache pain suggests an internal influence such as qi or blood deficiency. Severe, intermittent pain is likely due to liver fire, which rises up to the head, often from an outburst of anger.

The location of the headache also has clinical significance, since it helps the physician select herbs and acupuncture meridians that run through the area of pain. For example, a frontal headache is considered a disorder of the stomach meridian. Treatment involves needling acupuncture points on that meridian and prescribing herbs with an affinity for that area of the body. Pain at the top or sides of the head is related to the liver and gallbladder, while pain at the back of the head is related to the bladder meridian.

Dizziness is another important diagnostic aspect associated with the head. If dizziness is due to qi deficiency, the symptoms are mild and get worse when the person is tired. Blood deficiency dizziness is also mild and gets worse when the person stands up suddenly. Dizziness from dampness is associated with a heavy feeling, which patients often describe as a "wet blanket wrapped around the head." Liver fire can create a severe form of dizziness in which the person loses balance as if on a rolling ship. If the head itself is shaking, it is a sign of internal wind moving.

Since many people turn to traditional Chinese medicine for the treatment of pain, this is often the first symptom mentioned to a practitioner. The practitioner can accumulate an abundance of information by asking about the location, severity, frequency, and causes of pain in the patient's body. Pain that comes and goes is due to wind or qi stagnation, while pain in a fixed location is a result of cold or blood stagnation. If pressure relieves the pain, it is a deficient type; pressure always makes excess type pain feel worse. Pain in specific areas of the body can also serve as a sign of problems in an internal organ.

For example, pain in the rib area is a symptom of stagnation in the liver and gallbladder. Lower back pain is a cardinal sign of kidney deficiency: Since it is due to depletion, it gets worse after exertion. When low back pain is due to cold and dampness, a stagnant condition, it gets worse after rest.

Ears and Eyes

Since the kidneys open up into the ears, poor hearing or deafness is usually from kidney deficiency. Sudden deafness is usually due to heat and fire rising up to the ears, which is an excess condition. Similarly, ringing in the ears (tinnitus) is a sign of an excess condition if it comes on suddenly as a loud, high sound. Most often this is a condition of liver yang rising up to the head. Development of tinnitus over a long time is a sign of depletion of the kidneys. One diagnostic test is to press on the ears. If the sound gets stronger, it is due to excess; if it gets weaker, it is due to deficiency.

The eyes can also tell a lot about the patient. As previously mentioned, a practitioner looks into the eyes to assess the state of a person's shen (spirit) and thus acquire a general picture of the overall vitality and the potential for healing. Pain in the eyes can be due to liver fire or wind heat, while dry eyes can be caused by blood deficiency. Poor vision in general is associated with kidney jing or liver blood deficiency, as is night blindness. Itching in the eyes is a symptom of external wind or blood deficiency. Abnormal eye movement is a sign of internal wind.

Stools and Urine

The stools and urine are important sources of information but may be signs overlooked by the patient. Stools that are sticky or cause burning with a strong smell are a sign of heat, while watery diarrhea with little smell is a sign of deficiency or cold. Damp heat causes frequent urges to defecate, but only a small amount is expelled each time. Stools that are watery with undigested food indicate spleen yang deficiency; if the same symptoms occur early in the morning ("cock's crow diarrhea"), it is due to kidney yang deficiency.

When constipation occurs, other diagnostic signs must be taken into account. If constipation accompanies dark urine, bad breath, and a yellow tongue coat, heat is the cause. Qi stagnation is the cause if the constipation occurs when the person is upset; qi deficiency is implicated if a person feels fatigued after a bowel movement. In blood or yin deficiency, the stools are exceptionally dry, making them difficult to pass.

Frequent passing of clear urine indicates kidney deficiency; if the urine is concentrated (dark yellow), it is a sign of heat. Bed-wetting can also occur in kidney deficiency; in children, the cause of the bed-wetting is usually emotional. Lack of urination can arise from very deficient kidneys or occur due to severe heat, blood stagnation, or a stone.

Whatever its cause, lack of urination is a life-threatening condition, since the body can quickly become overwhelmed by its own toxins. In general, pale urine is a sign of cold, dark urine is a sign of heat, and cloudy urine is a sign of dampness. Sharp pain or blood in the urine can result from a stone or heat in the urinary bladder. Blood without pain could be a sign of cancer.

On the next page, learn about how lifestyle factors, such as the amount of sleep you get or how much you eat, can help a practitioner diagnose an illness in Chinese medicine.

For more about traditional Chinese medicine, treatments, cures, beliefs, and other interesting topics, see:

Lifestyle factors can help a practitioner make a diagnosis in Chinese medicine. These factors, such as the amount of sleep you get each night, play a role in your overall health. The practitioner should also evaluate your past medical history to get a clearer picture of your health.

Thirst, Appetite, and Taste

No desire for fluids at all is a sign of excess cold, while a desire for small amounts of hot liquids can indicate deficiency cold from yang depletion. A craving for large amounts of water is a sign of excess heat. If a person has a dry mouth and wants small amounts of water, it is a sign of deficiency heat due to depleted yin.

If dampness is present, a person may want to drink but is unable to do so and may even vomit small amounts of water. A person with an excessively strong appetite may have stomach heat; he or she might even eat a lot but remain thin.

A person who has an appetite but no desire to eat could have stomach yin deficiency. In this case, the deficiency heat causes a false appetite, but the deficiency in stomach yin itself prevents true hunger. On the other hand, a complete lack of appetite indicates spleen qi deficiency; when the person does eat, he or she often feels bloated or tired afterward. When the appetite is low and the person has an aversion to oily foods, the cause could be damp heat in the liver and gallbladder.

Another set of diagnostic indicators unique to Chinese medicine is the presence of various tastes in the mouth. For example, a bitter taste in the mouth indicates heat, usually in the heart, liver, or gallbladder. A sweet taste can occur with damp heat in the spleen, and a salty taste can arise from a deficiency in the kidneys. A sour taste is associated with heat in the liver or food stagnation in the stomach, while a complete lack of taste can occur with spleen qi deficiency.

Sleep

A restful night's sleep depends on a healthy balance of yin and yang. The yin and blood are the aspects of the heart that provide a solid foundation for the mind and spirit. If yin and blood are deficient, yang will be out of control. Yang is fire and activity and is kept within normal ranges by cool and calm yin. When yin is deficient, it can't control yang, and too much heat and activity results, producing such symptoms as restlessness and insomnia.

On the other hand, if qi or yang is insufficient, the person experiences an overabundance of yin, leading to fatigue and excessive sleepiness. A person who has difficulty falling asleep but then sleeps soundly may have a deficiency of heart blood. Difficulty staying asleep can be a sign of deficient heart yin: The deficiency heat disturbs sleep. Insomnia that is accompanied by a bitter taste in the mouth and angry dreams is associated with liver fire, while sleeplessness due to irritability and sexual dreams can be a result of heat due to kidney yin deficiency.

A person who wakes up easily, is forgetful, and experiences heart palpitations can have a pattern of insufficient heart blood and spleen qi. In children, crying at night can often be due to heat in the heart or liver. A practitioner also attempts to determine whether a person gets too much sleep, since this could be due to qi or yang deficiency. If the person claims his whole body feels heavy, especially when the weather is rainy, the excessive sleep is caused by dampness.

Lifestyle and Medical History

Many imbalances are due to the patient's lifestyle. It is very difficult to treat a case of cold dampness in the spleen successfully in a person who eats a quart of ice cream every day -- no matter how much ginseng and ginger the person consumes. Ice cream is classified as a cold, damp food. On the other hand, the same person can assist the healing process by consuming hot soups containing ginger root and pepper.

Foods are also strong medicines with their own hot or cold energies, and selecting the proper foods for a given body type or disease pattern is an impor­tant part of the healing process. Similarly, a person who walks around barefoot in the winter might complain about frequent colds. This person would be better off dressing in warm clothing, rather than trying to stimulate the immune system.

A complete medical history is just as important in traditional Chinese medicine as it is in Western medicine. Important clues might be uncovered that could shed light on the cause of current problems. It's important to note the use of any prescription medication, since a patient's symptoms could be due to side effects of these medications.

Gynecologic Signs and Symptoms

A female patient is always asked about her menstrual cycle, since it can provide abundant information about the condition of the internal organs and vital substances. A cycle that is longer than normal might be a sign of blood deficiency or cold stagnation, while a short cycle can occur with heat.

A scanty menstrual flow with light-colored blood is associated with deficiency of qi and blood, while a strong flow with dark color can be a sign of excess heat. Cramping before the menstrual flow is a symptom of excess, while cramping after the flow begins is a sign of deficiency. Blood clots with sharp pains occur with blood stagnation. If there is no cycle at all, the primary causes are qi and blood deficiency or stagnation.

On the next page, learn about how the sense of touch can help a practitioner determine a person's health. From palpitation to pulse, sense of touch indicates whether a person is ill or not.

For more about traditional Chinese medicine, treatments, cures, beliefs, and other interesting topics, see:

The use of touch in making a diagnosis in Chinese medicine is integral. The art of touch in traditional Chinese medicine is highly sophisticated and includes the palpation of areas of pain and diagnostic points and the reading of the patient's pulse.

For example, an area of the body that feels hot to the touch is experiencing a heat condition, while a place that is cold to the touch is under the influence of cold or dampness. Tumors or swellings that are hard with a well-defined border are due to blood stagnation, while soft nodules with an indistinct border are a result of qi or phlegm stagnation.

Diagnostic points on each acupuncture meridian can be palpated to assess the condition of an internal organ. When there is an imbalance in the organ, the point is painful or has a flaccid feeling. For example, there are points on the back known as transporting points, each one corresponding to an internal organ. If an imbalance occurs in one of these organs, the transporting point for that organ might be tender or sore.

The treatment would include needling that point in order to heal the organ that is associated with it. The Japanese have also developed a highly sophisticated system of abdominal palpation; entire books have been written on the subject.

By far, the most important form of palpation in Chinese medicine is the art of pulse diagnosis. This highly sophisticated system provides abundant information about the entire body, and it can easily take an entire lifetime to become truly proficient in this ancient diagnostic method.

In an ideal situation, the pulse is taken in the morning while the person is still calm and rested. In actuality, however, the procedure usually takes place in the clinic during the initial interview. It is important to let patients who have just arrived rest for a while to allow the pulses to settle down. Otherwise, it would be easy to mistake a rapid pulse for a heat condition when it is actually due to the person's hurrying to make the appointment. This is one situation when sitting in the waiting room is to the patient's advantage!

Although the pulse can be felt in a number of locations, the primary location is at the radial artery in the wrist. Each wrist has three positions that correspond to different organs. The left wrist corresponds to the heart, liver, and kidney yin. The right wrist gives information about the lungs, spleen, and kidney yang.

These six positions are also felt at three different depths: deep, middle, and superficial. In addition to the information that can be gleaned from these 18 locations, the experienced practitioner can identify 28 different types of pulses. It's not hard to understand why it takes a lifetime of practice to become truly proficient at pulse-taking.

A normal pulse is strongest at the middle depth. In patterns of deficiency, the pulse is only palpable at the deepest levels. A person fighting off a cold will have a strong pulse at the superficial level due to the defensive qi rushing to the surface of the body. This "floating" pulse is fairly easy for a beginner to identify, and it can be very useful clinically.

Many times, this pulse appears a couple of days before a person experiences any cold symptoms, making it possible to practice early intervention. Since a rapid pulse is a sign of heat and a slow pulse is a sign of cold, a floating, rapid pulse occurs if the condition is a case of wind heat. In this case, the pulse is also strong, since wind heat is an excess condition. A weak pulse, on the other hand, indicates a deficient condition. For example, a person with kidney yang deficiency has a deep, weak pulse, especially in the area on the right wrist that corresponds to kidney yang.

Since learning the pulses requires hands-on experience, a detailed description is beyond the scope of this book. In a clinical setting, however, students are trained to discern the following types of pulses: floating, sinking, slow, fast, empty, full, wiry, slippery, flooding, hollow, leather, soggy, hidden, confined, moderate, choppy, knotted, intermittent, hurried, spinning bean, tight, sick, scattered, small, minute, short, long, and frail.

Each one of these pulses is associated with a variety of imbalances, and an experienced practitioner can learn an enormous amount of information from the pulse alone. In clinical practice, however, the physician always combines the pulse information with the whole picture derived from looking, listening, smelling, and asking. Through this process, traditional Chinese practitioners are able to accurately diagnose the patterns of imbalance in their patients without the help of laboratory tests or expensive diagnostic equipment.

For more about traditional Chinese medicine, treatments, cures, beliefs, and other interesting topics, see:

ABOUT THE AUTHORS:

Bill Schoenbart has been practicing traditional Chinese medicine (TCM) since 1991, when he earned a Masters degree in TCM. He teaches TCM medical theory and herbalism at an acupuncture school in California, and also maintains a clinical practice.

Ellen Shefi is a licensed massage technician, licensed acupuncturist, and registered dietician. She is a member of the American Association of Acupuncture and Oriental Medicine, the American Herb Association, and the Oregon Acupuncture Association.