CHAPTER 17 The four methods of diagnosis

There are four traditional ways of diagnosing in Far Eastern medicine; namely, listening, observing, feeling and asking. When diagnosing traditional Chinese medicine (TCM) syndromes we should not rely on only one method; at least three should point towards a particular diagnosis. When diagnosing according to Zen Shiatsu methods, ‘feeling’ or palpation is the main method, but any of the other methods can be used to supplement the feeling diagnosis and establish a possible cause of the problem and a prognosis. Diagnosis can begin with the first moment of seeing or hearing the receiver. It is an ongoing procedure, which depends on objective, relaxed assessment of your own sensory impressions, as well as on interpretation of the receiver’s symptoms and signs.

Listening

In the ‘listening’ diagnosis the emphasis is not on listening to the receiver’s story; it is on listening to the receiver.

The sound of the voice

The sound of the voice can, if it attracts your attention, be significant in indicating a temporary or long-term imbalance in one of the Five Phases. Not all imbalances manifest in the voice; but enough do to make this a useful diagnostic tool. At a certain point in the taking of the case history, take time for a moment or two to disassociate your attention from what the receiver is saying, and to relax and widen your aural focus; in other words, open your hearing field and hear the receiver’s voice as if listening to music. Sometimes it is then possible to hear one of the five sounds described in Section Four under the individual Phases.

The appropriateness of the voice

The appropriateness of the voice can be a clue to an imbalance. When you become used to listening as described above you will be able to hear the sound of the receiver’s voice at the same time as listening to what she is saying. We would expect to hear a laughing voice when the receiver is happy, and so on. But if the sound of the receiver’s voice is not appropriate to what she is saying, there may be a weeping voice when she is talking about something that made her happy or a laughing voice when she is describing something sad. If you notice this there is an imbalance in the Phase corresponding to the sound of her voice.

Listening between the lines

Listening between the lines is a subtler technique to which some are more attuned than others. It has nothing to do with the sound of the voice, more with the quality of the receiver’s expression, his use of pauses or his eagerness to gloss over a particular subject. These signs indicate that some issue is significant to the receiver, and while they may not point immediately to a particular Phase or meridian, they can be helpful in suggesting the background to a condition or in indicating a significant time when it may have started. Tact and respect for the receiver mean that we should keep our conclusions to ourselves; the receiver usually opens up about the situation of his own accord, given time and space.

Observing

There are four visible diagnostic signs which can easily be observed; the receiver’s facial color and hue, demeanor and presentation, tongue, and energy or postural patterns.

Facial color and hue

Facial color and hue are two different things. The receiver’s facial color is related to his skin tone and is unlikely to vary substantially in the short term, although it may change gradually over time if it was caused by a pattern of disharmony which is being eliminated. Facial colors can indicate specific disharmonies in TCM terms, as follows:

• Bright pale, or shiny white – Ki Deficiency. If the skin is puffy and pasty, it is likely to be Spleen Ki which is Deficient, but otherwise the Lungs are usually involved.

• Dull pale, or ‘bloodless’ – Blood Deficiency. This appearance can often accompany the skin tone below.

• Sallow skin, with a brown or olive tint – Liver involvement, often Liver Blood Deficiency (unless this skin tone is a racial characteristic). Sometimes Liver imbalance is indicated by a brown or olive tone around the eye area.

• Red skin tone – Heat or Fire (pathogenic Fire, not the Fire Phase meridians necessarily).

• Red patches on the cheekbones indicate Empty Heat (Yin Deficiency).

• Blue-black circles under the eyes are a sign of Kidney Deficiency.

These skin tones are, of course, most easily seen on Caucasian faces, and can be discerned only to a limited extent on Asian or African skins. The facial hue, on the other hand, can be seen on any color of skin, since it is not a part of the skin, but a transparent overlay, like a reflection. The hues correspond to the colors of the Phases, as described in the chapters on the individual Phases and meridians; to recapitulate, they are:

• red – Fire

• yellow – Earth

• white – Metal

• blue-black – Water

• green – Wood.

It is impossible to see a hue when focusing narrowly on the receiver’s face. In the same way that the sounds of the Phases are most easily heard when ‘opening the ears’ with relaxed attention, so the colors of the Phases are best seen when opening the visual focus wide. When the receiver’s face is seen with this kind of openness and an expanded field, the colors manifest, sometimes as a flash, glimpsed out of the corner of our eye. The hues come and go, and rarely cover the whole face; they are most likely to be perceived around the eyes and the mouth.

Demeanor

Demeanor is the receiver’s Ki expressing itself in movement, facial expression and body language.

In TCM terms, the relevant aspects of demeanor are the strength of the receiver’s movements, the quality of his attention, the energy and appropriateness of his behaviour, and the strength of his voice.

• Strong movements, agitation and a loud voice are signs of Excess

• Lethargy, vacancy or absent-mindedness and a weak voice are signs of Deficiency

• Confusion, incessant talking and inappropriate behavior are signs of disturbed Shen.

From the Western standpoint considerably more subtle observations and interpretations can be made concerning both demeanor and presentation, especially if we can make connections with specific Phases or meridians. Underlying emotions can be perceived from the receiver’s intonation or the expression in her eyes. Often someone will make a particular movement when describing their condition, quite unconsciously.

CASE HISTORY

A young man complaining of multiple symptoms (but not lower back pain) continually rubbed his lower back when talking about his condition. He was not aware that he was doing it. His symptoms and general condition indicated Kidney Yin Deficiency and Kidneys/Bladder often came up in his Hara diagnosis. After a few weeks of treatment he stopped rubbing his lower back, but began again whenever his condition deteriorated over the course of treatments.

Since this kind of behavioral observation can include our own projections from our subjective experience, it is important not to base our entire diagnosis on it, but rather use it to confirm a diagnosis made from other signs and symptoms.

Presentation

Presentation includes the receiver’s style of dress and grooming, and his social manner; the veneer or appearance which, consciously or unconsciously, he presents to the world. All of these can be valuable diagnostic signs, when viewed from an objective standpoint.

This is not always easy, since we almost always have conditioned responses which can be triggered by any aspect of the receiver’s presentation. The person who makes us nervous, the person who complains, the person who exhausts us with his demands, the person who confuses us, the person who doesn’t wash; all are making statements with their presentation about the Phase or meridian which is out of balance in them. What is required of us as practitioners is that we observe our own reaction to the receiver and find its cause.

If we are irritated by someone because he reminds us of our primary school teacher, or because we are always irritated by people who wear cravats, we can notice our irritation and let it go. If we are irritated by a receiver because she is, for example, consistently late for her appointments, we need to look at the relevance of the continual lateness to her symptoms and signs. Does she simply have too much to do, and if so, why can’t she give herself this time? Is it Gall-Bladder over-responsibility, or Large Intestine lack of self-worth? Or is it general absent-mindedness and poor memory, part of a Blood Deficiency picture?

These signs can be particularly useful in determining a receiver’s motivation and orientation to life when the receiver does not supply much information about her own psychological or emotional state, for whatever reason.

The tongue

Inspection of the tongue is one of the main points of TCM diagnosis and we cannot confirm any TCM syndrome without it. The tongue should be observed, if possible, close to a good source of natural light. The receiver should not have to keep his tongue out for more than a minute without a rest, as the tongue changes color with the effort. Since hot food or drinks such as tea and coffee can alter the color of the tongue and coating, it is advisable to wait for 0.5–1 hour after food or drink is taken before inspecting the receiver’s tongue.

As a general rule, the shape and color of the tongue body is an indication of the condition of the receiver’s basic Ki, Blood and internal organs; the thickness and color of the coating shows any Excess that may be present. It is possible to pinpoint specific organs through tongue diagnosis by using the map (Fig. 17.1), which shows locations on the tongue which correspond to organs or areas of the body.

Fig. 17.1 Tongue map.

At the level of tongue diagnosis appropriate to Shiatsu, we need to observe:

• the color of the tongue body

• the shape and possible movement of the tongue body, and the location of any cracks

• the thickness and color of the tongue coating, or its absence

• the moisture of the tongue and coating.

Color of the tongue body

• A normal tongue is pale, fresh red, ‘like very fresh meat’.

• A pale tongue indicates a Deficiency of Yang or Blood, which may be accompanied by internal Cold.

• A red tongue body is a sign of Heat.

• A purple tongue shows Stagnation of Ki or Blood.

• A reddish-purple tongue shows Stagnation with Heat.

• A bluish-purple tongue shows Stagnation with Cold.

• Red spots in any area indicate Heat in that area.

• Pale or orange-tinted sides to the tongue indicate Liver Blood Deficiency.

• Any area of a particular color corresponds to a condition affecting a specific area or body organ, e.g. a red tongue tip indicates Heat in the Heart.

The tongue body color usually indicates a condition which has already lasted some time. It can, however, change over weeks or months, as the condition improves or deteriorates.

Shape of the tongue body

• A long tongue indicates Interior Excess Heat. Long tongues are usually pointed.

• A swollen (fat or puffy) tongue, when pale, usually indicates Deficiency of Yang, which causes Dampness. If there are teethmarks around the edges of a swollen tongue, they are a sign of Spleen Yang Deficiency.

• A red and swollen tongue shows Heat accompanying general Dampness.

• A thin or flabby tongue indicates Blood Deficiency.

Tongue shapes usually accompany a constitutional tendency towards a certain condition. They are therefore unlikely to change greatly during the course of treatment.

Movement of the tongue body

• A pale and quivering tongue indicates Deficiency of Ki.

• A red and quivering tongue shows that Heat is generating Interior Wind.

• A tongue that moves slowly and involuntarily from side to side indicates Interior Wind.

Cracks in the tongue body

• Short cracks around the edges of the tongue are a sign of Spleen Yang Deficiency.

• Cracks on each side of the midline of the tongue, just behind the tip, indicate a Lung problem, or can refer to a past lung disease, such as whooping cough, which has permanently affected the lungs.

• A central crack reaching right to the tip of the tongue indicates a constitutional imbalance in the Heart, although it may not imply any physical disease, but a tendency to a Fire psychological picture.

• A wide central crack which does not reach to the tip of the tongue is a sign of Stomach Ki Deficiency. If there is yellow fur inside the crack it indicates Heat and Phlegm in the Stomach.

• Many small cracks all over the surface of the tongue, like cracked glass or ice, indicate Deficiency of Yin.

Cracks usually indicate a deep-seated and long-standing condition, and do not often disappear, although they may become less marked.

The tongue coating

• A coating which is firmly rooted is a healthier sign than one which seems powdery and easily dislodged.

• A thin white coating is normal.

• A thick coating indicates that an Excess pathogenic factor is present, and the thicker the coating, the stronger the Excess.

• A white coating indicates Cold in the body area or organ corresponding to the coating.

• A yellow coating indicates Heat in the body area or organ corresponding to the coating.

• A slippery or sticky coating indicates Dampness or Phlegm in the body area or organ corresponding to the coating.

• Absence of coating is a sign of Deficiency. A tongue that seems peeled, or peeled in patches, indicates Yin Deficiency, either in the whole body (stemming from the Kidneys) or in the area corresponding to the peeled coating. A red, peeled tongue is a definite sign of Kidney Yin Deficiency.

The thickness of the tongue coating can vary from day to day, and may indicate a more short-term or recent condition, if the color and shape of the tongue body are normal. Absence of tongue coating indicates a long-standing condition.

The moisture of the tongue

• A wet tongue is a sign of Yang Deficiency or Cold.

• A dry tongue indicates Yin Deficiency or Heat.

Ki patterns

Training our visual sense to observe the receiver’s Ki patterns can be a useful adjunct to our trained capacity to sense the movement of Ki with our hands in the session. After an initial period of practice we do not have to make a special time for this during the consultation but can simply observe as we talk to the receiver beforehand. During the time when we are gaining practice and experience, however, it may be necessary to look at the receiver’s Ki at the start of the session when he or she lies down, and because this may make people feel nervous at the first session it is best left for receivers whom we have treated before, and we need to explain the observation with some phrase such as ‘I just need to observe your posture’.

Observing the condition and movement of a receiver’s Ki is surprisingly easy. Most of the students I have taught are able to see for themselves after being shown one or two examples, and are quite proficient after one lesson. It is, however, easier to demonstrate in class than to explain on paper, and, if possible, should be taught by an experienced teacher. (I was taught this technique by Pauline Sasaki, who made it both easy and fun.) It is not advisable to attempt to look at Ki before you have practiced Shiatsu and developed your sensitivity to Ki for some time.

When learning the rudiments of looking at Ki, it is ideal if two or more receivers can be observed at the same time, since the differences highlighted by comparison make the perception of what we are looking for very much easier. This is not always possible, however, and so I shall proceed assuming that only one receiver is available.

How to look at Ki

Stand at the receiver’s feet, with the receiver lying supine. It is possible after some practice to observe Ki with the receiver in the prone, sitting or side positions but supine is definitely the easiest position to begin with. If possible, the light should be evenly diffused over the receiver’s body, without strongly emphasizing one side or the other.

Make sure that you are grounded, and relaxed. Check that your breathing is soft and deep and your awareness field open and expanded. Then open your visual focus wide, as when observing the skin hue, and survey the receiver from that wide focus, without detailed scrutiny, but with relaxed attention. Looking at Ki is like looking at a painting, not like reading a book.

1. Begin with the question; ‘Is the receiver’s energy up or down?’ If the answer is not immediately clear, avoid the temptation to scrutinize more closely, which would contract your field, but instead go to the window or door, take a few deep breaths into Hara, relax again, tell yourself that it doesn’t matter (and mean it) and return for another wide, unfocused look. If you still cannot see whether the energy is up or down, it is possible that this receiver does not have a pronounced upper/lower discrepancy, and you can proceed to the next step. If the answer is immediately clear, but you then question it, or doubt what you are seeing; in a word, don’t. Proceed to the next step.

2. Now ask yourself, still keeping a wide, relaxed focus, ‘Is the receiver’s Ki strong or weak?’ It is a good idea, when asking this question, to maintain a feeling connection between your central core, which is the source of your ‘seeing’, and the receiver’s central core, which is the source of his Ki. (Do not focus visually upon the receiver’s center at this stage; this is a feeling connection which may tell you whether the receiver’s Ki is stronger or weaker than your own.)

If there is no answer immediately forthcoming (and it is difficult to assess relative strength of Ki without another receiver for comparison), move on to the next step.

3. Now ask yourself, ‘Is the receiver’s Ki flowing, or is it blocked?’ Still from the wide, relaxed focus, the movement of Ki can appear like the flow of water over the body surface, transparent yet perceptible:

• Blockages can be full, through concentration of Ki in an area, or empty, through weakness in an area, which prevents flow.

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