Why We Do Not Diagnose In
Chinese Medicine 

Chinese medicine challenges the Western mind.
Western authors of Chinese medical texts warn against reductionist logicⁱ, while using reductionist languageⁱⁱ. Teaching from these texts as though practice springs from theory, as one might expect in the West, I have heard frustrated senior instructors lament that students are lackingⁱⁱⁱ. Of course a teaching approach based on this attitude authorizes the superior instructor and undermines student practice. The problem is not the students, but the Western hierarchical teaching approach that privileges authority: usually white, usually male, and texts written by same^iv. That tradition of authority silences other voices, discards contradictory information, and ignores other 'ways of knowing'.

Diagnosis is a good example. Our texts concede the only constant in Chinese medicine is change. Yet how do we diagnose what is always changing? How do we treat the un-diagnosable?

In the West, to know how to treat an illness, we must diagnose it. In Chinese medicine we do not diagnose.

First Appearing in
Anglo-Dutch Institute of Oriental Medicine Magazine
Spring, 1999

Texts say we bianzhen, 'differentiate syndromes '. Why can't we just say 'diagnose' syndromes? After all, 'differentiation' implies there are a finite number of syndromes from which to choose. But this is not true. Syndrome differentiation is not a diagnostic end, in and of itself, but a method of associative thinking. The problem confronted in clinic every day is that patients almost never fit the text and can rarely be reduced to a syndrome. 'Lacking' students are confounded while the adept practitioner knows how to forge ahead. That forging ahead is based on knowing from experience and practice, not, as it would appear, from correct diagnosis. It is this 'knowing practice' (Farquhar), or 'knowing doing" (Scheid) that needs explaining.

Many of us fall sway to the image of a Western clinical encounter where the doctor is expected to know, to diagnose based on a priori knowledge of science (patterns, syndromes?). The doctor (subject) examines the patient (object) and orders labs that will reveal some deeper 'truth' that becomes diagnosis. The deeper 'truth' of the MRI or blood work is rarely the same 'truth' told by patients directly. So the patient's own report is discouraged; they are talked out of their own experience of illness. This is one way that biomedicine disembodies the patient. It follows that recovery cannot be accurately assessed by the patient either. While both doctor and patient may feel relief from diagnosis, assured by knowing what to call 'the problem', the image of recovery starts sometime later with a prescription, or therapy intervention.

The diagnosed patient consumes not only the medicine but also the diagnosis and disease^v. When I meet a patient who has migraines, their every head pain or sensation gets interpreted through that diagnosis. Not only do they have migraines, migraines have them. The diagnosis becomes part of personal identity that crosses time, place and context. Obviously every head sensation is not a migraine nor does it lead to one. Yet nuances of sensation are pathologized by diagnosis. So too, by the way, patients and practitioners can consume Chinese 'diagnoses' of Liver fire or deficient Kidneys long after context and patient have changed.

What is the nature of your pain? How does it respond to movement or rest? Do you feel hot or cold? These questions require patient participation and body location. In Chinese medicine the doctor and patient examine the patient's problem together, called kanbing^vi. "The doctor does not have the power to reject any sign reported by the patient. Patients retain a sense of being expert, the authority of last resort, on their illness." ^vii

What do you feel as I press here? Does the sensation change when I press.....there? The patient and practitioner have moved beyond a cognitive discourse and join in somatic rapport. Palpation facilitates co discovery of sensory association. Treatment comes directly from/with it: The 'asking' in palpation folds into treatment that continues asking. The most important question is confronted within the session itself: not what is wrong with me, what do I call it, but can it change: can/will I get better?^viii The central question is risked in that very moment: How do you feel? Better, worse, the same? This evaluation and treatment, treatment and evaluation are active inquiry that follows feminist, scientific methodology as expressed by Mies (1991) "in order to understand a thing, one must change it". ^ix

Changes in the patient's tongue, pulse and other signs within the session and over time, direct acupuncture treatment, herbal prescribing, recommendations and follow-up. The practitioner forges ahead even when a pattern is not obvious; guided by the somatic rapport and skill that recognizes things are already changing. Is the pulse more even, less wiry? Has the tongue become less red, the coat more rooted, the shape less puffy, less scalloped? ("What do mean the tongue changes?" one student demanded: "I thought I could rely on the tongue." The answer is, of course, you can.) Is the patient more mobile, with less pain? All of this can happen within the session. 'Knowing practice' comes not from texts (only) but from the practitioner's ability to be present and co produce with the patient those first inches of change that build recovery.

Together practitioner and patient convert illness, and the conversion begins with the examination. So we say: evaluation is treatment; treatment is evaluation^x. That is the 'knowing doing' of our practice.

The next question is how do we explain, teach or write about this ‘knowing doing’? Can we separate out a theory from this practice?^xi Nowhere in looking, listening, asking, touching, or treating do we diagnose.^xii But we do locate. And describe. And push to change.^xiii

The practitioner of Chinese medicine locates the problem by naming physical place: the outside or inside....or more specifically at the channels, organs, jiaos, phases, substances, stages, or levels.^xiv One location approach may prove to be more advantageous than another for a given patient, and location vantage may change at any time. Location stimulates descriptive qualities, as channel activity differs from jiao activity. Yet every description revolves around stasis or free flow and associated possibilities. Descriptions fall within the dyads of full/empty, hot/cold, damp/dry, yang/yin. Differentiation cannot be reduced to diagnosis because patterns are always moving and changing.

Our ways of knowing in Chinese medicine are fluid, vitalized by the unique presentation of the patient in the present moment: that day that way. So, in constructing theory, the challenge is change: becoming, declining, quiescence. It is change that affords the possibility for healing. The practitioner looks for the ebb and flow, the wax and wane, the range of change inherent in any disorder. What helps it, what hinders? The inherent flux is always exploited, encouraged, or redirected. Locate, describe, change. And so on.

Finally, our allusion to theory must include another operative that strikes terror in the heart of Western diagnostism: practitioners also differ, change. They are unique. They bring to bear, on the clinical encounter, their own sagacity. One doctor might emphasize the spleen more than the liver, where another might view the same case as kidney, not spleen or liver at all. One enters at the lower jiao when another might treat only spirit. Yet the patient heals.

In fact, there may not be a 'correct' or 'fundamental' view for a given case, only co creating that serves the immediate patient-practitioner somatic interaction. The practice is to welcome every nuance the patient experiences, and to welcome ourselves to be present and attentive: locate, describe, to push here, watch there: change. To forge ahead in that most exquisite 'knowing doing'.

The author is grateful to Judith Farquhar whose work Knowing Practice provided the theoretical foundation for this piece; to Volker Scheid who recommended her work to me, and for his own careful contribution to the anthropology of Chinese medicine; and to Ted Kaptchuk whose non hierarchical style of teaching, albeit white and male, authorizes that 'forging ahead'. Thank you to Anne Marie Hemken and Velia Wortman for first welcoming this piece for the Journal of the Anglo-Dutch Institute for Oriental Medicine. To my students who teach me how to teach; to my patients who teach me how to practice.

 

Bammer A 1991 Mastery, (En)Gendering Knowledge: Feminists in academe. Hartman and Messer-Davidow eds. University of Tennessee Press. Knoxville

Beinfeld H, Korngold E 1992 Between heaven and earth. Ballantine Book New York, NY

Cohen M 1996 The Chinese way to healing, many parts to wholeness. Berkeley Pub. Group, Berkeley CA

Cohen M 1998 HIV Wellness Sourcebook: an east/west guide to living well with hiv/aids and related conditions. Owl books

Connelly D 1979 Traditional acupuncture: the law of the five elements. Center for Traditional Acupuncture. Columbia, MD

Farquhar J 1994 Knowing practice. The clinical encounter of Chinese medicine. Westview Press, Boulder, CO

Finando D, Finando S 1999 Informed touch. Healing Arts Press, Rochester, Vermont

Hartman J, Messer-Davidow E, eds. 1991 (En)Gendering knowledge: Feminists in academe. University of Tennessee Press. Knoxville

Kaptchuk T 1983 The web that has no weaver. Congdon and Weed, New York

Maciocia G 1989 Foundations of Chinese medicine. Churchill Livingstone, Edinburgh

Matsumoto K, Birch S 1988 Hara diagnosis: reflections on the sea. Paradigm Press, Brookline MA

Messer-Davidow E 1991 Know How (En)Gendering Knowledge: Feminists in academe. Hartman and Messer-Davidow eds.University of Tennessee Press. Knoxville

Mies M 1991 Women's research or feminist research? The debate surrounding feminist science and methodology. trans. Andy Spencer in Beyond methodology: feminist scholarship as lived research. ed. M Fonow, J Cook Indiana University Press

Ni, Yitian 1996 Navigation the channels of traditional Chinese medicine. Oriental Medical Center. San Diego, CA

Nielsen A 1995 Gua sha. a traditional technique for modern practice. Churchill Livingstone, Edinburgh

O'Connor J, Bensky D 1981 Acupuncture: a comprehensive text. Shanghai College of Traditional Medicine, Shanghai

Ross J 1984 Zang Fu. The organ systems of traditional Chinese
Scheid V 1998 TheAnglo-Dutch Institute for Oriental Medicine Magazine, Interview by Velia Wortman Spring issue

Unsculd P Nan Ching, the classic of difficult questions. University of California Press, Berkeley

Wolfe H 1990 Second spring. a guide to healthy menopause through traditional Chinese medicine. Blue Poppy Press, Boulder, CO

 

i

logic that reduces a thing to its smaller constituent parts, valuing the activity of the parts as an explanatory model for the whole, while ignoring the whole and its context. Reductionism is the dominant mode of thinking in biomedicine.

ii

O' Connor, Bensky (1981) advise that we "...in the West are accustomed to viewing events in a linear fashion. "..A causes B which with C causes D...but Classical Chinese thought interrelates phenomenon as a pattern, treatment is centered on the person, not the disease." p.2 Their Comprehensive Text refers to 'channel and point diagnosis' via touch p551-555. and theory and practice p 30

In the Web, Kaptchuk (1983) sites the Aristotelian law of contradiction, the cornerstone of Western logic: "...the truth....the same thing cannot at one and the same time be and not be...A cannot be not A" compared to Lao Tzu: "To be empty is to be full". p 139 The Web refers sparingly to Chinese diagnosis, emphasizing differentiating patterns.

Similarly, Ross(1984) details the differences in Western and Chinese patterns of thought. He warns against "...forcing Chinese concepts into Western molds" He does not use the term diagnosis.

Unschuld's first chapter of the Nan Jing is entitled "Movement in the Vessels and its Diagnostic Significance" while the same text's prolegomena admonishes European and Western attempts to characterize Chinese medicine into a "...kind of homogeneous, logically coherent system of ideas and practices that is so attractive to the Western mind ..under the pseudo-scientific guise of Greco-Latin terminology." p 6 The term diagnosis itself descends from Greek.

In his Foundations text Maciocia uses 'pattern differentiation' and diagnosis interchangeably. He has an entire chapter entitled "Diagnosis". Relying on the logic of cause and effect in asserting the universality for Chinese medicine: "causes of disease(climate, emotion, diet, and so on) are basic and can apply to any society at any time. p viii

By contrast, in Knowing Practice, Farquhar states 'neither weather conditions, such as heat, cold, or damp, nor extreme internal states are malignant in and of themselves. Illness factors are not powerful causes (italics are mine) p88...Possibly the recent elevation of illness factors to a mode of diagnostic analysis prominent in textbooks reflects a comparison with Western medicine, in which action is often organized around the identified cause of illness p90."... "all illnesses always manifest themselves from a root or source condition (which) is always a dynamic relationship among a variety of factors."

In Gua Sha, I also essentialize causative factors as pernicious via the medical definition of 'sha syndrome', finding comfort in linear reductionism. However, for the 48 cases I did not give a ' TCM diagnosis' letting signs, symptoms, treatment and outcome speak, for which I have been criticized. Farquhar (1994) notes (in China)"...diagnosis; treatment principles;, and other categories of information discussed in teaching texts often do not appear in the case record booklets of outpatient clinics..." p43

iii

from private conversations

iv

In the US the gender distribution of licensed acupuncturists is more even than published authorship represents. With an exception of a handful of female authors,(Connelly, Matsumoto, Beinfeld, Nielsen, Wolfe, Cohen, Ni) men dominate the profession. Female patients outnumber male, however. In China "The vast majority of doctors of Chinese medicine are men; Chinese medical gynecology is now heavily populated by women, although its oldest practitioners are almost all men; and the overall predominance of men in the field may be changing somewhat with the youngest generation of school trained doctors...Patients are more evenly distributed by gender..." Knowing Practice p 41(n1)

v

A Foucaultian concept, I first heard spoken by Jeanette Armstrong, a native American environmental activist, in her presentation on Native American resistance to the Genome Project. Bioneers conference San Fransisco 1997

vi

Knowing Practice. p 45-46

vii

Ibid. p45

viii

The 'change within the session' is an immediate somatic shift characteristic of acupuncture, more so when palpation is used. In an exclusively herbal prescribing encounter the 'change with in the session' occurs via the doctor patient co-labour-ation where the patient's subjective experience is valued, in fact centrified. The patient, embodied and allied with, is empowered as an authority and agent in illness and recovery.

ix

"In order to understand a thing, one must change it' is the fourth of four "Methodological Postulates of feminist science proposed by Maria Mies. See "Women's Research or Feminist Research? The Debate Surrounding Feminist Science and Methodology", trans. Andy Spencer in Beyond Methodology: Feminist Scholarship As Lived Research. ed. M. Fonow, J. Cook

x

see forthcoming Informed Touch by Donna and Steve Finando

xi

According to Farquhar, '...the textbook divide between 'theory' and 'clinical practice' is maintained rather more briefly in China than it is in the discourses of the Western natural sciences. p.38(n29)

xii

I concede that most Western instructors of Chinese medicine teach the necessity for diagnosis and that many Western practitioners make diagnoses using Chinese disharmony patterns or syndromes, and that patients in the West expect a diagnosis. Still I think that adapting Chinese medicine to the Western diagnostic ritual makes rigid what is fluid and changing, and diminishes its potential.

xiii

Knowing Practice p 72

xiv

These locations, also known as jingluo , zang fu, san jiao, five phase, substances: i.e. Qi, Blood, Phlegm, Food, Fluid, 6 stages or 4 levels are in common use in the West but I would venture do not exhaust possibility.