Professional Chinese medicine bases its treatment on two diagnoses (liang zhen). There is the disease diagnosis (bian bing) and the pattern discrimination (bian zheng). Today, the disease diagnosis is also divided into two types. There is the modern Western medical diseases diagnosis, such as poliomyelitis and rheumatoid arthritis, and the traditional Chinese disease diagnosis of wilting condition (wei zheng) and impediment condition (bi zheng) respectively. Although, these days, treatment is predicated to some degree on all three of these diagnoses, treatment is mainly based on the patient's personal pattern discrimination. Thus it is said, Yi bing, tong zhi; Tong bing, yi zhi--Different diseases, same treatment; Same disease, different treatments.

For example, one patient may present with systemic lupus erthymatosus (SLE), while another patient may present with rheumatoid arthritis (RA). In Western medicine these are two different diseases. However, in Chinese medicine, if both patients present with a pattern of wind damp heat impediment, then they will receive identical treatments regardless of the fact that they suffer from different diseases. Conversely, two patients may both present with rheumatoid arthritis. However, if one of these presents a pattern of wind damp cold impediment and the other presents a pattern of wind damp heat, these two patients will receive markedly different treatments. Although some of the Chinese herbal medicinals they receive may be the same, others included for one patient may actually worsen the condition of the other.

Therefore, pattern discrimination is extremely important in standard professional Chinese medicine. There are more than 300 professionally agreed upon, standard patterns in Chinese medicine, and real-life patients often manifest multi-pattern presentations. For instance, patients with chronic diseases rarely present less than three patterns simultaneously and sometimes up to 10. At the moment, the criteria for establishing the presence of a Chinese medical pattern are the so-called four examinations (si zhen). These are visual inspection, auscultation-olfaction, questioning, and palpation. Visual inspection means inspection of the facial complexion, the bodily constitution, carriage and gait, any diseased or painful areas, and especially the tongue. (I will talk about Chinese tongue examination in next month's column.) Palpation means manual palpation of any diseased areas or regions of pain but mainly refers to palpation of the pulse on the radial side of both wrists. These four streams of information are then analyzed into three groups of information: 1) general signs and symptoms, 2) tongue signs, and 3) pulse signs. This means that pulse examination (mai zhen) is one third of the criteria used to establish the presence of a particular pattern in contemporary standard professional Chinese medicine.

The Inch Mouth

There are many pulses in the body, but the place where Chinese doctors take the pulse is called the "inch mouth" (cun kou). This refers to the radial artery at the styloid processes of the wrists. Chinese doctors have been feeling the pulses diagnostically at this location for at least 2,000 years. It is believed that pathological changes in the entire body are reflected in changes in the pulses at this position. In practice, this pulse is first divided into three sections (san bu), the inch, bar, and cubit. The practitioner begins by resting their middle finger directly over the patient's styloid process. This is called the guan or bar position because it separates the other two positions. Then the practitioner's index finger falls into the space between the styloid process and the hypothenar eminence. This is called the cun or inch position because it is one inch wide. The practitioner's ring finger then falls just proximal to their middle finger. This position is called the chi or cubit position because there is one cubit in length between this position and the crook of the elbow.

The Three Positions Correspondences with the Rest of the Body

Since at least the late Han dynasty, 200 AD or CE, Chinese doctors have believed that the changes in the pulse at the inch position reflect changes in the area of the body from the diaphragm to the top of the head, including the two arms. This area is called the upper burner (shang jiao). Changes in the bar position correspond to changes in the area of the body from the diaphragm to the level of the navel. This area is called the middle burner (zhong jiao). Changes in the cubit position correspond to changes in the area of the body from the level of the navel to the soles of the feet. This area is called the lower burner (xia jiao). Since the late Ming dynasty (circa 1575), most

Chinese medical practitioners believe they can "read" the heart in the left inch, the lungs in the right inch, the liver-gallbladder in the left bar, the spleen-stomach in the right bar, and the kidneys, bladder, and large and small intestines in the two cubits. Therefore, a pathological change in the pulse of the right inch may reflect a lung disorder or a problem with the right arm or right side of the head. This depends on the corroboration of the patient's main complaint and other signs and symptoms. One of the first rules of Chinese medical diagnosis is that no one sign or symptom means anything by itself. It is only meaningful when compared with other signs and symptoms.

The Normal Pulse

In Chinese medicine, the normal healthy adult pulse comes at 60-90 beats per minute. It has a slippery, flowing quality, can be felt in all three positions on both sides, and does not skip any beats. It is neither too superficial nor too deep, to thin or too wide, nor is it hard or tense. This is called the ping mai, level or normal pulse. Such a normal pulse suggests that yin and yang within the body are in balance, the five viscera and six bowels are working in a healthy, coordinated fashion, and there are no evil qi present, whether externally contracted or internally engendered.

The Constitutional Pulse

In old China, when Chinese medicine was mostly village medicine, the family doctor would take the constitutional pulse of the patient when they were healthy so that they would have a baseline to compare to when the patient was ill. This constitutional pulse was taken in the early morning just before daylight and before the patient had eaten or drunk, moved about, or had sex. This is similar to taking the basal body temperature (BBT) to assess the basal metabolic rate. However, as far as I know, this is no longer done. Today, patients come to the doctor when they are sick. Therefore, the main emphasis in learning how to examine the pulse is on the diseased pulse or bing mai.

The 28 Pulse Images

Chinese doctors learn that there are 28 diseased pulse images. These 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, drumskin, scallion-stalk, scattered, soggy, and surging; and four deep pulses: deep, hidden, confined, and weak. Similarly, there are five slow pulses: slow, bound, regularly intermittent, choppy, and moderate (meaning slightly slow); and there are four rapid pulses: rapid, skipping, racing, and stirring. The skipping, bound, and regularly intermittent pulses all skip beats. The skipping pulse is rapid and skips beats irregularly, while the bound and regularly intermittent pulses are both slow. The bound pulse is slow and skips beats irregularly, and the regular intermittent pulse is slow and skips beats at regular intervals with frequently alarmingly long pauses between beats.

Each of these 28 pulse images typically has two descriptions within the Chinese medical literature. There is a poetic or metaphorical description, such as the choppy pulse feeling like a knife scraped over bamboo or the slippery pulse feeling like pearls rolling in a dish. There is also a very precise definition made up of a string of tactile adjectives. Thus, the choppy pulse is fine in size, moderate in speed, and speeds up and slows down but never actually misses or skips a beat (i.e., sinus arrhythmia). If one memorizes these very precise tactile definitions and understands exactly what they mean in terms of the pulse, then learning how to examine the pulse is relatively easy. Only the bowstring and slippery pulses simply have to be pointed out in live clinical practice by a mentor. It is my experience that students can memorize, understand, and, therefore, feel all 28 of these pulse images with a high degree of inter-rater reliability after only 12-15 hours of instruction.

While it is possible to feel more than 28 different tactile feelings in the pulse, Chinese medicine has long ago decided on these 28 pulse images as the basis for its pedagogy and practice. Although one might feel the pulse as if it were a chirping cicada or a grinding cam-shaft, since there is no established, broadly based professional agreement on these feelings and their relationship to Chinese medical patterns, they are diagnostically meaningless in Chinese medicine. It is these 28 pulse images and the modifying terms of "very," "a little," and "not" that have been correlated to the 300 plus patterns of Chinese medicine by 20 centuries of practitioners, and, in my 20 plus years of clinical experience, these 28 terms and their modifiers get the job done.

Interpretation

It is not feeling the tactile sensations that must be felt that is the most difficult thing in Chinese pulse examination. It is the interpretation of what one feels in light of all the other signs and symptoms, including the tongue signs. Prior to Zhang Jing-yue (circa 1575), many Chinese doctors would establish their credentials as professionals by attempting to impress their patients by how much they could know simply by taking the pulse. Thus we have stories of doctors diagnosing their patients from the pulse alone. However, such a practice lends itself to quackery. After all, basing one's diagnosis on pulse alone is something akin to "channeling." Who's to say one is wrong when there's no objective way to peer review? Therefore, it was Zhang Jing-yue who relegated pulse examination merely to confirmatory status within Chinese medical pattern discrimination, a status it has maintained ever since. Since the time of Zhang Jing-yue, the pulse is felt after the practitioner has visually examined the patient, asked many questions, palpated any painful or diseased areas, and looked at the tongue in that order. Therefore, once again I would emphasize that the pulse images in the various of the three positions are interpreted only in the light of all this other information.

Nevertheless, we can say certain things about the qi, blood, yin, and yang of the body from the 28 pulse images. For instance, if the pulse is floating, then we know that the yang qi is located preponderantly in the upper and outer parts of the body. However, we do not know why until that finding is corroborated and explained by all the other findings. Conversely, if the pulse is deep, we know the yang qi of the body is located in the lower and inner parts of the body. Whether this is because of lack of yang qi to upbear and exit (i.e., move outward) or because of some evil qi forcing the yang qi down and in, we do not know until we gather other information. Similarly, a fast pulse means that there is either a lot of yang qi or yang has come apart from its controlling yin, while a slow pulse either means there is not enough yang qi or some evil qi is preventing the yang qi from moving along at a normal pace.

Unfortunately for practitioners, patients with chronic conditions rarely manifest a single pulse image in all three positions on both hands. The norm is for patients to manifest two or more pulse images in any given position, with the possibility of different combinations (within certain limits) in different positions on the two sides. Once we begin to combine pulse images and also identify different images in different positions on the two sides of the body, one can see that there is a lot of room for complexity. At this point, correct interpretation depends on two things: first and foremost, corroboration; and secondly, depth and breadth of Chinese medical theory.

For instance, a pulse may be slippery and bowstring. It may be slippery, bowstring, and deep or slippery, bowstring, and floating. It may be soggy and rapid or soggy and bowstring. It may be choppy, bowstring, and deep. A not uncommon multifaceted pattern of pulse found in perimenopausal North American females is to have a normal or slightly rapid pulse rate overall with a floating, fine pulse in the left inch, a bowstring, fine pulse in the left bar, and floating, fine pulse in the left cubit. In the right inch, the pulse is surging (meaning floating, large, and forceful), is floating, bowstring, and forceful in the right bar, and deep and bowstring in the right cubit. By itself, this suggests that there is liver blood-kidney yin and yang vacuity with vacuity heat floating upward, liver depression, and spleen with an exuberant stomach vacuity. Whether this is true or not depends on the patient's other signs and symptoms. If this were truly the case, then we would expect there to also be night sweats and/or hot flashes, fatigue, irritability, possible depression, cold feet, nocturia, low back pain, and possible low libido but a strong appetite. If a preponderance of these other signs and symptoms do not present, then we are probably wrong in our interpretation.

As stated above, correct interpretation of the pulse also depends on the depth and breadth of one's knowledge and understanding of Chinese medical theory. The more Chinese medicine one knows, the easier the interpretation of the pulse becomes. For instance, if one well understands the Chinese medical spleen's role of upbearing the clear and one feels that the pulse is absent in the right inch, extremely fine and forceless in the left inch, and bowstring, fine, and forceless in the right bar, then it is relatively easy to hypothesize that there is a chest qi vacuity due to a spleen qi vacuity associated with liver depression. In that case, one should also know the questions to ask and tongue to look for to corroborate this hypothesis. If one does not know or understand this particular Chinese medical theory, then it is less likely they would come easily or quickly to this interpretation. Thus, although learning how to feel the 28 pulse images can be accomplished in days, it typically takes years to learn how to correctly and reliably interpret what one feels.

Patterns vs. Diseases & the Importance of Pulse Examination

In modern Western (and, therefore, modern Chinese) medicine, diseases can be asymptomatic. For instance, a patient may have herpes genitalia or herpes zoster and be in remission. Thus they present no signs or symptoms of herpes. However, in Chinese medicine, it is axiomatic that patterns are presentations of standard collections of signs, symptoms, tongue and pulse signs.

Therefore, there are no asymptomatic patterns. Patterns are nothing other than patterns of signs and symptoms. If patterns are defined by the three elements of signs and symptoms, tongue signs, and pulse signs, then pulse examination is an extremely important part of Chinese medical pattern discrimination. While pulse examination has been relegated in the last 300 years to mostly confirmatory status, it is still an important, indispensable diagnostic modality within Chinese medicine. In antiquity and even to this day, some Chinese doctors believe that they can diagnose asymptomatic disease via the pulse. Why bother? We have many other, more reliable and objective methods of examination, such as serum analysis, X-rays, CT scans, and MRIs. But, when it comes to Chinese medical pattern discrimination, pulse examination is still a crucial part, and it should be remembered that, in Chinese medicine, treatment is primarily predicated on the patient's pattern.

Tongue Proper

Pale Tongue: Indicates xu and cold syndromes or symptoms due to yang qi deficiency and insufficiency of qi and blood.

Red Tongue: Indicates heat syndromes, mostly shi types of disease caused by interior heat, or symptoms of fire preponderance due to yin deficiency.

Deep Red Tongue: Denotes the excessive heat seen in febrile disease due to invasion of exogenous pathogenic heat which as been transmitted from the exterior to the interior of the body. It also can be seen in miscellaneous diseases due to a preponderance of fire caused by yin deficiency, or seen in diseases of accumulated fire in the liver channel.

Purplish Tongue: Shows the syndrome of blood stagnation. A tongue with purplish spots or petechiae also indicates blood stagnation.

Tongue Appearance

Flabby Tongue: A flabby tongue body with teeth marks on the margin and pale in color indicates a yang deficiency of the spleen and kidney leading to accumulation and obstruction of phlegm-dampness. A flabby tongue with a deep red color indicates excessive pathogenic heat attacking the heart and spleen.

Thin and Small Tongue: This indicates consumption and deficiency of blood and yin. A thin and small tongue with a pale color denotes deficiency of both qi and blood. A thin dry tongue with a deep red color is mainly due to a preponderance of fire and great exhaustion of body fluids.

Rigid Tongue: Seen in febrile diseases due to the invasion of exogenous pathogenic heat transmitted into the pericardium or due to an obstruction of pathogenic phlegm. It may also be seen in high fever leading to consumption of body fluids and preponderance of pathogenic heat. It is a prodrome of wind-stroke (cerebral stroke).

Deviated Tongue: This is a prodrome of wind-stroke.

Cracked Tongue: Cracks on the tongue with deep red color indicate excessive heat. A cracked pale tongue indicates insufficiency of yin and blood. However, a cracked tongueof long term duration without any other symptoms can be considered normal.

Tongue Coating

In the first place, the properties of tongue coating should be examined.

Thinness and Thickness: Generally, if substantial pathogenic factors such as damp, phlegm or food accumulation occur and cause obstruction, they further affect the spleen and stomach leading to the ascent of turbid qi and forming of a thick tongue coating. A white thin tongue coating is formed if nonsubstantial pathogenic factors such as wind, heat, dryness, or cold attack the body; or if the pathogenic factors stay on the body surface; or if body resistance is weak during the disease development.

Moistness and Dryness: The normal tongue coating is moist, which indicates that plenty of body fluid is flowing upward. If the tongue coating is dry, it is due to body fluids failing to moisten the tongue. A dry tongue coating may also be present in some febrile diseases where pathogenic heat consumes the body fluid. A slippery tongue coating may be due to pathogenic damp-humor floating over the tongue surface.

Sticky and Curdled Tongue Coating: A sticky coating is due to hyperactivity of endogenous pathogenic phlegm and damp rising to the tongue, and is mostly seen in diseases caused by pathogenic damp-heat or phlegm-humor. A curdled tongue coating is the outcome of food accumulation in the stomach leading to the ascent of turbid qi to the tongue surface. It is also seen in disease caused by phlegm-damp.

Peeled Tongue Coating: Mostly due to deficiency of qi and yin. If peeled tongue is accompanied by a sticky coating, it indicates a complicated disease condition to which the body resistance is weakened.

No Tongue Coating: Changes in the tongue coating indicate fluctuation in the disease condition. For example, if a qi deficiency of the stomach is manifested by no tongue coating at an early stage, the tongue coating will reappear after the stomach qi is recovered. If a disease has no tongue coating, then suddenly appears, this indicates a perversive flow of stomach qi, or excessive pathogenic heat. If a disease has a tongue coating at the beginning which disappears abruptly, this indicates stomach yin fluid has decreased. If a thick coating gradually turns into a thin white coating, this indicates that pathogenic qi is being gradually weakened, and the disease condition is becoming milder.

Generally, an observation of the thinness and thickness of the tongue coating will indicate the depth of pathogenic qi. The tongue's moistness or dryness shows the body fluid condition. The degree of curdling and stickiness of the tongue coating indicates the dampness of the stomach and spleen. The appearance or disappearance of tongue coating signified the cure or worsening of the disease condition.

Color of Tongue Coating

White Coating: Indicates exterior-cold syndromes. A white and thin coating is seen mostly in exterior syndromes, while a white and thick coating appears in interior-cold syndromes. If there is a powder-like whitish coating covering the tongue surface, it is caused by the internal accumulation of summer-humid heat and is usually seen at the onset of pestilential diseases.

Yellow Coating: Indicates interior and heat syndromes. A light yellow tongue coating is seen in cases of slight fever. A deep yellow color indicates high fever. Brownish tongue coatings represent an accumulation of pathogenic heat.

Grayish Coating: Denotes interior-heat syndrome or interior-cold syndrome. A grayish black and slippery coating on the tongue usually indicates symptom-complex due to cold-damp in the interior. A grayish, yellow, and sticky tongue coating usually indicates the accumulation of damp-heat. Grayish and dry tongue coatings are usually due to the consumption of body fluid by excessive heat.

Black Coating: This is often seen at the serious and dangerous stage of disease, and indicates extreme heat or cold. A black, yellow, and dry coating with thorns on the tongue surface usually denotes consumption of body fluid by extreme heat. A black and slippery tongue coating shows excessive cold due to yang deficiency.

Methods of Diagnosis

 In TCM there are four diagnostic methods, namely :

Inspection is a method of diagnosis in which the doctor understands and predicts the pathological changes of internal organs by observing abnormal changes in the patient ' s vitality, colour, appearance, secretions and excretions. In their long - term medical practice, the Chinese physicians realized the close relationship between the external part of the body, especially the face and tongue, and the zang - fu organs. Any slight changes appearing in these areas can tell pathological conditions in various parts of the body. Inspection of the exterior of the body, therefore, is of much help in diagnosis.

• Observation of the vitality
• Observation of the color
• Observation of the appearance
• Observation of the five sense organs
• Observation of the tongue

Listening and smelling.

Inquiring is asking the patient or the patient ' s companion about the disease condition in order to understand the pathological process. Inquiries are made systematically with questions focused on the chief complaint of the patient according to the knowledge necessary in differentiating a syndrome. Inquiring covers a wide range of topics.

• Chills and fever
• Perspiration
• Appetite
• Thirst
• Taste
• Defecation
• Urination
• Pain
• Sleep
• Menses
• Leukorrhea

Palpation is a method of diagnosis in which the pathological condition is detected by palpating, feeling and pressing certain areas of the body. It is discussed under the headings of feeling the pulse and palpation of different parts of the body.

• Feeling the pulse
• Palpation of the epigastrium
• Palpation of the abdomen
• Palpation of the acupuncture points

As human body is an organic entity, its regional pathological changes may affect the whole body, and the pathological changes of the internal organs may manifest themselves on the body surface. The Medical Book by Master of Danxi says : " One should observe and analyse the external manifestations of the patient in order to know what is happening inside the body, for the disease of internal organs must have its manifestations on the body surface. " Inspection, auscultation and olfaction, inquiring and palpation are the four approaches to understand the pathological conditions. They can not be separated, but relate to and supplement one another. In the clinical situation, only by combining the four can a comprehensive and systematic understanding of the condition of the disease be gained and a correct diagnosis made. Any inclination to one aspect while neglecting the other three is one - sided, therefore, is not suggested.

The best crockery to use

The pot used for decoction should be made of something other than iron or bronze in order to prevent chemical changes; usually, an earthenware pot is used instead.

The best crockery to use are those made of ceramics as they will not have any chemical reaction with the drugs. As they conduct heat slowly, the medicine will not get burnt and stick to the bottom of the pot. Stainless steel and glass pots will also do. But you must not use bronze, aluminium and iron pots. These metal pots will have chemical reactions with the drugs and affect their effectiveness. They may even cause side-effects!

The way to decoct Chinese medicine

Place the herbs in the pot, add cold water so that the water will be about half an inch higher than the herbs. Stir a little bit and let the herbs soak in the water for about 20 minutes. Then bring the water to boil; as soon as the water begins to boil, reduce the heat to low, both to keep the water from overflowing and to prevent its premature exhaustion.

The quantity of the water used varies with the herbs and the heat, because some herbs absorb more water than others and thus need more water for decoction and high heat consumes more water than low heat.

The total decoction time depends upon the herbs being decocted. For instance, herbs for inducing perspiration can be decocted over high heat for less than 10 minutes after the water starts boiling and herbs for strengthening the body, traditionally called tonics, can be decocted for as long as an hour over low heat. After decoction, the herbs are strained. In most cases, you can get the first decoction  20 minutes after boiling, then add some cold water, reduce the heat to low after it starts boiling, get the second decoction  20 minutes later, mix with the first one. The total decoction you get usually is between 300-600ml. Usually you take the decoction twice daily: Half after breakfast and half after supper.

When a Chinese patient gets a prescription from a doctor, he or she usually brings it to an herb shop for filling. The clerk at the herb shop will wrap up the herbs in small paper bags and give instructions about decocting and taking. 

Sometimes it may be necessary to decoct the heavy or hard herbs, like minerals, wood or roots, over low heat for 20 minutes first, so that their constituents will become fully soluble in boiling water. Clinical experiences have shown that such heavy herbs can be decocted repeatedly to produce good results. After heavy and hard herbs have been boiled for 20 minutes, add the aromatic herbs and then the very light herbs, such as leaves and flowers, which should be decocted for only about five minutes or so in order to prevent evaporation of some constituents like essential oils.