By Various Authors
Translated by Heiner Fruehauf P
National University of Natural Medicine, College of Classical Chinese Medicine
rior to the process of treating disease, the sage (superior doctor) must be able to distinguish the Yin and Yang of Heaven and Earth. S/he must know the rhythmic flow of the four seasons and the intricate relationships between the five organ networks and the six bowel systems. S/he must be able to distinguish the Yin/Yang and exterior/interior quality of the meridians, and know what kind of diseases to treat with acupuncture, what kind with moxibustion, and what kind with herbs. S/he must understand the relationship between health and social interaction, master the standard procedure of diagnosis and treatment, and discern the constitutional differences in rich and poor people. S/he must inquire about the age of the patient and analyze whether the patient tends to be outgoing or withdrawn. S/he must examine the parts afflicted by the disease while at the same time figuring out the root of the disease, and s/he must relate his/her knowledge of the eight seasonal dates to the information gained from the nine pulse positions. Only in this way a diagnosis can be called complete!
From Inner Canon of the Yellow Emperor (Neijing Suwen), Chapter 77: “Analyzing the Five Mistakes in Diagnosis” (fl.200 B.C.)
mong all diagnostic methods, none is superior to the examination of the pulse. But just as there are cases in which the disease profile and the pulse picture match, there are also cases in which they differ, and this is were the logic of the mysterious unknown comes in. Therefore, whenever we encounter a case that appears difficult to diagnose, we must use the four-fold method of diagnosis: we also have to inquire about the history of the disease in detail and differentiate the face color and the voice. In this way, we approach the patient from the root and from the branches, from front and from behind. Finally we put all the pieces together, interpret them, and everything will be clear.
If we fail to examine all of these aspects and rely only on one single method of diagnosis, chances of treatment failure are great. How could we, knowing full well that the pulse sometimes has a tendency to convey misleading signals, calmly trust that we will not make a mistake even though the general pictures of pulse and disease do not match? This insight comes easy to the experienced doctor, but may be hard to understand for the beginner.
For all of these reasons, we cannot bypass the four-fold method of diagnosis. The Classic of Difficulties (Nanjing), by the way, listed the examination of the pulse at the end of the four methods of diagnosis, and there is a deep purpose in this arrangement. In exactly this sense, Tao Jieyan (1369-fl.1450) has once said: “Getting to know the surface by asking, and getting to know the interior by examining the pulse–success of this procedure depends entirely on how flexibly the various diagnostic methods are applied.” This, indeed, should be our guideline in clinical practice!
From Zhang Jingyue: Jingyue’s Collected Writings (1637)
he Four Methods of Diagnosis (si zhen) are Looking (wang), Listening and Smelling (wen), Asking (wen), and Touching (qie). They constitute standard procedure for every doctor. By working with them and interrelating them, the doctor will get to understand the source of the disease, just as the carpenter needs to abide by certain standards in the process of manufacturing his commodities.
Looking, that is looking whether the face is glowing or lackluster, whether there is a tongue coat or not, in order to judge the severity and the progressive tendency of the disease.
Listening, that is listening whether the voice is frail or strong, whether the speech is coherent or not, in order to determine how weak or strong the patient’s spirit (shen qi) is.
Asking, that is asking about the history of the disease and where the problem is located, in order to differentiate between internal and external afflictions, between organ and meridian layers. This feature is particularly important.
Touching, that is feeling whether the pulse is floating, sunken, slow, fast, powerful, or weak, in order to discriminate deficiency and excess and Yin and Yang; and also, to see whether the general pulse profile matches the patient’s symptoms or not, and thus determine the favorable or life threatening disposition of the disease.
From Zhang Nan, Enlightening Whacks to Waken from Foolishness in Medicine (1825)
ooking, that is observing physical shape and color. Listening, that is listening to the sounds emitted by the patient. Asking, that is asking about the details of the disease. Touching, that is examining the six pulse positions.
We need them all, these four, but it is really only the processes of looking and asking that are absolutely essential. I will tell you why: When listening to the sounds a patient makes, there really is only the volume of the voice indicating deficiency and excess, and the fluidity of a cough informing us about ascending and descending motion (of qi) that is of value. Otherwise, there is not much else that we could listen to.
When examining the pulse, we can really only distinguish between a floating and a sunken quality to determine whether we are dealing with an internal or an external problem, between a slow pulse and a fast pulse to determine cold or heat, and between a powerful and a weak pulse to determine excess and deficiency. Anything else is clearly subjective and hard to verify with just the fingers. Also, the pulse can change very fast from big to small, from floating to sunken and vice versa, and the six positions are not all that clearly delineated. Therefore, the theory that a doctor can know all of the patient’s symptoms just by feeling the pulse is clearly a hoax.
Only by inquiring about the history of the disease can we know about its development, and only by interviewing the patient about his recent symptoms do we get a clear idea about the severity of the problem. And if we then take a look at the color of the diseased body part, the color of the tongue and the lips, and the color of urine and stool, we are already 80-90% there.
From Jiang Hantun: Reflections on Medicine (1824)
All Translations © 2007 Heiner Fruehauf