Acupuncture Ecology

The Four Pillars of Diagnosis

Oriental medicine is a naturalistic art, having evolved before the advent of modern technology.

While the strength of technology is in its ability to heroically salvage human machinery, and to delve into tiny recesses and minutiae of human physiology, traditional, natural approaches derive their benefits from observation and integration of relationships.

Oriental or Chinese medicine rests on what is called the Four Examinations, or the Four Pillars of Diagnosis. They are:

  1. Looking
  2. Listening/Smelling
  3. Palpation
  4. Asking

This is deceptively simple. In Oriental medicine there is great variety; there are many, many systems and microsystems that can be examined and plundered for information, and nearly all of them rest on the assumption that the microcosm reflects the macrocosm.

That is, that a small area, like the ear or the pulse, is a holographic representation of the larger whole of the human body. This means that nearly any part of the body can be an image of the entire body. The methods that I list here are only a few of the major ones.


1. Looking

One thing that almost everyone has at least amateur training in is diagnosis of the face.

The simplest way to diagnose from the face is simply to notice the color on a face. However, even this simplicity is deceptive, because colors usually do not stand out in stark contrast. There are many subtle shades that layer themselves simultaneously in a face. This means that it requires a lot of visual sensitivity to see that color!

Along with color, the luster of the skin is also noted.

Things can get much more complicated, though, because every individual feature of the face indicates something about the health of the body. Large ears, for instance, indicate robust Kidney qi, and since the Kidneys in Oriental medicine are the root of one’s constitutional energy, that means that you were born with a lot of energy to spend, so to speak. Every feature correlates with something. The eyebrow area represents the Liver/Gall Bladder, the nose represents the Lungs, etc.

But one of the confusing things about Oriental medicine is that the same face can provide different information, depending on the map you’re using. For example, in addition to representing the Lungs, the nose can also represent the whole spine, and bumps along the nose can indicate where the spine is out of whack.

Additionally, there are whole systems of interpreting character from the face. For instance, a cleft in the chin is associated with a strong desire to be noticed—something noticeably common in Hollywood actors.

Face reading can reach even to the eerie realms of fortunetelling. Famous Chinese doctor John Shen was a master at this, and combined with the pulse, could sometimes tell someone within minutes of meeting them that they had had a traumatic experience at a certain age.

The sclera of the eye can also be examined, by looking at the veins under the eyes, which can tell you what side of the body has had trauma, whether there is toxicity present, etc.

Another microsystem is the ear. Some acupuncturists specialize in diagnosing and treating from the ear, and can tell instantly by looking at the ear where someone has pain, where a woman is in her menstrual cycle, etc. The whole body is often treated through the ear, using needles or seeds.

As you can see from the image, in this case the whole body is represented according to the image of an upside-down fetus mapped onto the ear, with the navel in the center.

But to make things more complicated, there is yet another system of looking at the ear that looks at the outer edge of the ear as representing events that happened in childhood. So if you have any notches at the edges of your ear, those represent traumatic events at particular ages in your life.

One of the most important methods of looking diagnosis in mainland Chinese medicine is the tongue. Many, many details of the tongue are examined, including qualities such as:

  • Color
  • Size
  • Shape
  • Depressions, swollen areas
  • Enlarged papillae
  • Moisture
  • Thickness and color of coating
  • Movement


2. Listening/Smelling

The voice is classified into roughly five types—shout, laugh, sing, weep, groan—according to the Five Element system of Chinese medicine, which correlates each Element with a set of organs; thus, the sounds heard in the voice can be used to determine which organ systems are disordered.

Smelling is classified with Listening as one of the “Four Pillars,” under a similar set of assumptions. Practically speaking, it is much less commonly used, in part because humans are not very odor-centric. However, I’ve heard anecdotal evidence of its effectiveness: There is a Chinese medical practitioner in California who has trained dogs to detect the odor of people who have cancer, and with highly accurate results.

Tasting, though also little-used these days, has had a history of diagnostic use in both the West and the East, although not in very palatable ways according to modern sensibilities—physicians in ancient cultures, from the Greeks to the Tibetans, practiced the tasting of urine for diagnostic purposes. Indeed, diabetes was known in the ancient world for the sweet taste of urine in diabetes sufferers.


3. Palpation

There are many ways to diagnose by palpation. The pulse at the radial artery is perhaps the most iconic of Chinese medicine, although this is ironic because most practitioners of Oriental medicine in today’s world have not had much training in these methods; the method I practice, Contemporary Chinese Pulse Diagnosis ®, is among the most comprehensive and the most rare, not being taught even in China. Yet, historically, there have been many different kinds of pulse diagnosis, but, again, they all rely on the principle of holographic representation—the idea that information throughout the body can be gathered by focusing attention within a small area of the body.

The picture on the left depicts six positions (three on each side) and two different depths or pressures at which you access the pulse, the superficial and the deep. This is the standard for many pulse diagnostic systems. Classically there are 28 different qualities that can be found on the pulse.

This is mostly consistent with the Japanese meridian therapy pulse system, which I am also familiar with.

Contemporary Chinese Pulse Diagnosis, however, incorporates those six pulse positions plus something like seventeen other positions. There are not three but eight depths, and not 28 but maybe over a hundred qualities.

These systems all yield different information. A comprehensive system of pulse diagnosis allows piercing insight into the whole organism, from physiological to psychological. A simpler method gives a broad view of the character of the organism at its root. Each works within the context of their respective diagnostic paradigms.

To make things more complicated, there are pulses to be found at many other sites throughout the body, such as on the foot and the head. These are rarely used today by the Chinese, but they are used by, among others, Japanese meridian therapists.

Another form of diagnosis is the palpation of the abdomen. Once again, there are many maps of the torso, and also many ways to palpate. Some doctors have learned to palpate the abdomen with rather strong, firm pressure, while others, like the Japanese style of Toyohari, emphasizes feather-light touch with only occasional pressure, and sensitivity to very slight changes in texture, temperature, and firmness of the skin.

Palpation of the acupuncture meridians is yet another method of diagnosis. This involves knowing all twelve of the main meridians (also called channels) and where they travel, and feeling the skin to sense, once again, changes in tone, texture, and temperature.


4. Asking Diagnosis

Traditional diagnosis centers around the “Ten Questions.” Oriental medical practitioners ask people about a broad variety of things, beginning with the main complaint, but branching out and including tension/pain, energy, sleep, digestion, thirst, menstruation, urine, bowel movements, sweating, mental functioning, emotional functioning, relationships, and even the birth history sometimes.

And every little area has other, related questions involved. Headache is a good example: Questions may be asked about the location of the headache on the head, the quality of the pain (sharp, dull, throbbing, etc.), how often it comes on, what time of day, if it’s associated with stress or food, and what makes it better or worse.


Putting It All Together

Despite the seeming complexity of all of these systems, the real work is in integrating all of this information. Because in real world situations, much of the information will not match! And this is why diagnosis is an art form: Medical practitioners are like Sherlock Holmes, gathering as many clues as possible, trying to notice the small details that everyone else misses, sifting through the information to determine what’s relevant and what’s not. The diagnostician journeys through the microcosms of the body, peer through the many different lenses, trying like hell to penetrate the veil of a person’s being.

The best physician sees to the roots of a problem and is able to pinpoint exactly where and how to treat a person, whether it is through an acupuncture point, an herbal formula, or a simple conversation.