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Diagnosis in Chinese Medicine

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Diagnosis in Chinese Medicine

Imagine a new patient sitting in an acupuncturist’s waiting room. She suffers from headaches and has been given a conventional medical diagnosis of migraine, and is taking medication prescribed by her GP.

Going into the treatment room, the TCM practitioner asks her many questions.

Firstly about the nature of the headaches: how long have been occurring, when she gets them, where on the head get them, how do they feel. After this has occurred the practitioner then asks them a whole range of things about her day to day health, both physical and emotional.

He then asks her to poke out their tongue which he observes carefully. He then asks her present her wrists and he then spends a minute or two pressing the wrists on both sides.

What is going on here?

Well traditional Chinese medicine is truly holistic in nature. By this we mean that when a patient seeks acupuncture or herbal treatment the TCM practitioner will look at every aspect of the patients’ health and well being and not focus on symptoms alone.  When we treat patients we are seeking to find a pattern of disharmony. A syndrome, in other words group of symptoms that collectively indicate or characterize a disease, psychological disorder, or other abnormal condition.

How TCM practitioners get to this point is called Bian Zheng Comprehensive diagnosis based on the analysis, identification, and differentiation of symptoms and signs according to the data collection from the four examination methods and basic Chinese medicine theories of viscera, meridian, and pathology.

The 4 elements Bian Zhen

  • Questioning
  • Observation
  • Palpation
  • Listening and smelling

Diagnosis by Questioning

This is perhaps the most important of the four methods. Traditionally there were 10 questions asked about bodily function. These were:

  1.         Temperature
  2.         Perspiration

iii.        Digestion

  1.         Sleep/energy
  2.         Exercise
  3.         Urination

vii.        Thirst

viii.        Appetite

  1.         Bowel function
  2.         Fertility and sexual function

Today many more questions are asked. The number of and diversity of questions asked is often quite surprising for the new patient.

Returning to the example of our lady with headaches, the TCM practitioner needs to know where the headache is on the head. What is the nature of the pain (distended, stabbing, dull, tight etc), when is it better and worse. Is it associated with other symptoms?

In this case she mentions that the pain is on the temple and is stabbing in nature. It can occur any time of the month but is worse before her period. Generally the patient says she is stressed and this makes her feel tired. Already the practitioner is leaning toward a diagnosis but needs more information to confirm this.

Previous medical and family history will also be taken into account

Diagnosis by Observation

Observation is both specific and general. General observation can be such things as the overall demeanor of the patient. Are they restless and fidgety?  Do they seem subdued? What is the complexion like? Is it red, pale, waxen?  Are there dark rings around the eyes? Etc.

There may be cause to look at specific things such as skin lesions, quality of the hair and nails etc.

One of the unique diagnostic methods in TCM is tongue diagnosis. We believe that the health of the body is reflected in the condition of the tongue.  Firstly is the body of the tongue a healthy colour. Too pale may indicate deficiency, redness may be heat, and purple/darkness may be stagnation. Is the tongue an unusual shape thick or thin pointed?

The tongue coating may indicate pathogenic states. A thick yellow tongue coat may be a sign of heat for example. Certain areas of the tongue also relate to the organ systems so cracks, spots, or other signs in a specific area may be clinically significant.

Returning to our imaginary patient she has a tongue body that is darker than the normal especially on the sides. The tongue could be said to be somewhat pointed.

Diagnosis by Palpation

Often the Chinese medicine practitioners will physically examine a patient. Does a pain get better for pressure or is it aggravated. This might tell us if the problem is one of excess or deficiency. For the acupuncture treatment of pain the practitioner will seek out ashi (painful) points. Literally trying to pin-point the pain.

Next comes the taking of the pulse. This is felt on both wrists at three positions at three depths.  Traditionally the pulse was taken at various places about the body the throat or ankle for example. Today the pulse is only taken at the wrist. It is used to determine the current state of the organs and meridian function.  Basically the practitioner will seek to measure the speed and depth of the pulse and the relative force at each position.

There are 28 ways the pulse reflects pathological changes in the body correlated with Chinese medical pattern discrimination. These 28 pulse images are taught, like so much of Chinese medicine, using a yin-yang dichotomy. Thus we have the floating and deep pulses, the large and small pulses, the fast and slow pulses, the slippery and choppy pulses, the short and long pulses, etc. According to Hua Tuo, a late Han dynasty expert in Chinese medical diagnosis, the majority of these 28 pulse images can be grouped under four headings. These four headings are: floating, deep, fast, and slow. For instance, there are seven floating or superficial pulses: floating, vacuous, drum-skin, spring onion-stalk, scattered, soggy, and surging. The descriptions of these pulses are quite beautiful at times. The slippery pulse is likened to pearls rolling on a plate.  Our lady with the headaches has a choppy pulse one that feels like the back of a knife scraping along a piece of bamboo.

Diagnosis by Listening and Smelling

The TCM doctor might be interested in the Lung sounds, rattling of phlegm in the throat, the type of cough etc. There are more subtle things that may be heard. Each of the 5 organ systems has a particular voice associated with it. The Fire element voice is described as laughing the Water element as groaning.  This may not be quite so obvious and may show a general tendency to an element type. Smelling might relate to an overall breath/body smell or the smell of a particular discharge. Our patients’ voice seems to have a clipped shouting quality.

Bringing it all Together

If we look at what information we have gathered about our patient.

  • Migraine is on the temple and is stabbing in nature
  • It is worse before her period
  • She is stressed and this makes her feel tired
  • She has a tongue body that is darker than the normal especially on the sides. The tongue could be said to be somewhat pointed.
  • Choppy pulse
  • Clipped shouting quality to voice.

These signs and symptoms all point to the TCM diagnosis of blood stagnation.  Points will be selected on the head because this is main area of complaint. In this case a point on the temple will be used. The main TCM organ/meridians involved are the Liver/Gallbladder/Triple heater and point from these channels are selected especially ones which move blood or Qi (chee) and or affect the head or temple.  A herbal formula that moves blood and sedates the uprising Qi is used and this is given daily.

The success of the therapy depends on the ability of the practitioner to find the pattern of disharmony . In this sense TCM is truly holistic, patients are assessed and treated individually not handed a universal treatment based on one complaint alone.

If you would like to find out how TCM could help you please call me on 07724 899 833 or emaildudleykent@aol.com

Dudley Kent MBAcC MRCHM MRSS

Acupuncture & Chinese herbs in central London & Salisbury

www.city-acupuncture.com

A very big refresher course in Myanmar (Burma)

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In January 2010 I was privileged to be part of a small team of TCM practitioners who travelled to Sagiang in Myanmar (Burma). This was part of an ongoing project that has been teaching acupuncture to doctors of traditional Myanmar medicine (TMM). John Hamwee one of my colleagues has given me permission to publish this article detailing our time there.

This article first appeared in the spring 2010 copy of the acupuncturist the magazine of the British Acupuncture Council

JOHN HAMWEE MBAcC
Acupuncture Practitioner: Cumbria and Oxford

About 20 years ago a young American sat in meditation for long months in the hills of Sagaing, an important centre for Burmese Buddhism, overlooking the Ayeyarwady river near Mandalay. One day he came down to the village and a woman, a perfect stranger, seeing this westerner and apparently taking pity on him, gave him a bottle of Coca-Cola. He was deeply touched by the gesture and thought, I must give something back. He found many ways to do so, and one of those ways was to institute an annual visit of western acupuncturists to the nearby hospital. This was the tenth annual visit. There were five of us, four from the UK and one from the USA. For one of our party it was her fourth visit, for another the second. It was my first time, though it won’t be my last. I worked harder than I have ever worked in my life, I paid all my own expenses to get there and back, and I can’t wait to go again.

The set-up was that we worked for a week in the hospital where there are two rooms given over to acupuncture, one with about twelve beds in it and the other with about ten. Then we moved to work in a village where there were no beds, strictly speaking, so we worked on raised platforms in the monks’ dormitory, or outside. I didn’t count but I suppose there were about the same number of spaces available to patients.

And we needed them. There were almost 100 people the first day, more each day afterwards and, we were told, nearly 500 on the last day. That may have been an exaggeration but the patients certainly came in waves and we did have to find new spaces to work. That last day was all a bit of a blur, partly because we were so busy and also because we were all very tired by then, but as far as I can tell I treated 26 people myself and I supervised a further 40 or so treatments.

Which brings me on to how we worked. We had with us three local acupuncturists who had been qualified for some years and about sixteen young practitioners, in their twenties, who had qualified recently. It was a big part of our remit to act as teachers to the young people, mainly in
the clinic but also with a lecture each day.

They were all pretty good, so by the time the numbers really hit the roof we westerners were able to spend as little as five or ten minutes with each patient. We’d agree a diagnosis and treatment plan with one of the students and then leave it to her or him to do the treatment, coming back to check the pulses at the end. In that way, the five of us managed five or six patients at once all day long. Although some of the students were delegated to crowd control, and the senior people were usually otherwise occupied, there were still about twenty of us, each treating, say, three people an hour for about seven and a half hours. So that’s how we made up the numbers. Naturally, there were translation problems.Huge numbers of patients complained about ‘numbness’ for example but were normally sensitive as far as we could tell.We never really got to the bottom of what they were trying to tell us. More generally, because we couldn’t take much of a case history, we had to work with a simple diagnosis of the state of the patient’s energy system; it was refreshing to see how much we could do with very few words.

It was a very steep learning curve for me. Normally I have one-hour appointments, and rarely see more than eight people in a day. Also, in my own practice I tend to use zero balancing rather than acupuncture for musculo-skeletal problems, of which there were many, but it wouldn’t have been any use to the students if I had done so there. So I struggled to remember bi syndromes and shoulder points and was pretty rusty for the first day or two, which the students noticed and charmingly forgave. It felt like learning acupuncture all over again. All this reaffirmed my deep respect for this system of medicine. It really did work on conditions for which I would normally use zero balancing or recommend osteopathy. It also seemed to work on conditions which I never see at home and which, as a result, I had to treat simply from first principles.

After nearly 20 years in practice I hadn’t realised that I had become very limited in my thinking about acupuncture, assuming, in a rather lazy way, that it was good for what I used it for and a few specialisms like pediatrics and obstetrics but not much else. Wrong! Secondly, it taught me, as if I needed to learn, the value of having to explain a treatment before doing it. At the beginning of the work the students wanted to know why I was planning to do what I was planning to do. Sometimes, in explaining, I came to understand my rationale; one which I’d never spelt out clearly to myself and which I could then apply to other patients and other conditions. Very satisfying. And sometimes, of course, when pushed to explain myself I found that my thinking was woolly or inadequate, and it was a pleasure and a relief to be made to think again and to come up with a better treatment than the one I first thought of. By the end I made the students write down their proposed treatments before I would tell them what I would do, and I learned a lot from seeing two different but equally plausible sets of points. I often let the students do what they proposed, even when it didn’t seem to me ideal, and it was instructive to see the results of those treatments which, of course, I never do!

Finally, there was the whole process of working in a multi-bed setting. I loved it. I loved the noise and the bustle. I loved glancing up at one of the students taking pulses on the opposite side and seeing in her eyes an agreement about what we were noticing. I loved people coming round to have a look at me needling Liv 14, Lu 1 (not a treatment they knew) and their
interest in the resulting pulse change. I loved calling a colleague over to assess a hip joint which moved, or rather failed to move, in a way I’d never felt before. I liked having to talk less (it was tedious to wait for long translations) and having to senseqi more. And I liked the whole idea of seeing more people, more often, more quickly, for less money.

The whole experience has made me a much better practitioner and it will change the way I work from now on. I recommend it to those of you who feel like taking a very big refresher course.

Thanks to all at the Watchet JivitadanaSangha Hospital, especially U Win Ko and U Aung Min, and the students; to Kirsten Germann for leading us, and my colleagues Richard Graham, Dudley Kent and John Renna; and to Oxford Medical for their generous gift of supplies.
The hospital is run as a charity and receives no financial support from the Government. The programme I describe is run under the auspices of the MettaDana project which provides funds to local initiatives, including the hospital.
Contributions welcome
http://www.vipassanahawaii.org/mettadana_projects.php