Chapter contents

NATURE OF DIAGNOSIS BY INTERROGATION

We can distinguish two aspects to the interrogation: a general one and a specific one.

In a general sense, the interrogation is the talk between doctor and patient to find out how the presenting problem arose, the living and working conditions of the patient and the emotional and family environment. The aim of an investigation of these aspects of the patient’s life is ultimately to find the cause or causes of the disease rather than to identify the pattern; finding the causes of the disease is important in order for the patient and doctor to work together to try to eliminate or minimize such causes (Fig. 28.1). How to find the cause of disease is discussed in Chapter 48.

In a specific sense, the interrogation aims at identifying the prevailing pattern of disharmony in the light of whatever method of pattern identification is applicable, for example according to the Internal Organs, according to the channels, according to the Four Levels, etc.

Box 28.1 summarizes these aspects of interrogation.

It is important not to blur the distinction between these two aspects of interrogation; enquiring about the patient’s family situation, environment, work and relationships gives us an idea of the cause, not the pattern of the disharmony. Knowing that a patient is a business man with a heavy work burden, an antagonistic relationship with his employers or marital problems does not tell us which might be the prevailing pattern of disharmony but simply that stress and emotional tension are likely to be the cause of the disharmony; this knowledge is essential when working with the patient to try to eliminate or minimize the causes of disease.

During the course of the interrogation, we ask about many symptoms that may be apparently unrelated to the presenting problem; we do this in order to find the pattern (or patterns) of disharmony that underlie the presenting problem. For example, a patient may present with chronic backache which we suspect may be due to a Kidney-Yang deficiency with Dampness. By asking about bowels and urination, for example, we may find that there are other symptoms of Dampness in one of these two systems and this would confirm the original diagnosis of Dampness as the cause of the backache.

Not all symptoms and signs add up to one pattern of disharmony: indeed, most patients will suffer from at least two related patterns of disharmony. To use the above example again, in this case enquiring about urination and defecation may confirm to us that this patient does indeed suffer from Kidney-Yang deficiency with Dampness. These two patterns are related because deficient Kidney-Yang fails to warm, move, transform and excrete fluids properly, which may accumulate in the form of Dampness. Moreover, an enquiry about other areas of questioning beyond the lower back and urination is always important because it may reveal other patterns of disharmony, which may be unrelated to the patterns of disharmony causing a patient’s presenting symptoms. To continue the above example, it may be that an enquiry about bowels, urination and other systems reveals a condition of Qi stagnation, which may be unrelated to the presenting problem.

Diagnosis by interrogation is intimately related to pattern identification: one cannot be carried out without a thorough knowledge of the other. Without a knowledge of pattern identification, interrogation would be a meaningless and aimless process of asking questions without a clear idea of what to make of the answers and how to use these to arrive at a diagnosis. On the other hand, a knowledge of pattern identification without a thorough understanding of diagnostic methods would be useless as we would lack the skills and tools to arrive at a pattern identification. Thus, a knowledge of pattern identification is the essential prerequisite to form a diagnosis, but skill in the diagnostic art is the means by which a diagnosis is made.

NATURE OF “SYMPTOMS” IN CHINESE MEDICINE

Diagnosis by interrogation is based on the fundamental principle that symptoms and signs reflect the condition of the Internal Organs and channels. The concept of symptoms and signs in Chinese medicine is broader than in Western medicine. Whilst Western medicine mostly takes into account symptoms and signs as subjective and objective manifestations of a disease, Chinese medicine takes into account many different manifestations as parts of a whole picture, many of them not related to an actual disease process. Chinese medicine uses not only “symptoms and signs” as such but many other manifestations to form a picture of the disharmony present in a particular person. Thus, the interrogation extends well beyond the “symptoms and signs” pertaining to the presenting complaint. For example, if a patient presents with epigastric pain as the chief complaint, a Western doctor would enquire about the symptoms strictly relevant to that complaint (e.g. Is the pain better or worse after eating? Does the pain come immediately after eating or two hours later? Is there regurgitation of food? etc.). A Chinese doctor would ask similar questions but many others too, such as “Are you thirsty?”, “Do you have a bitter taste in your mouth?”, “Do you feel tired?”, etc. Many of the so-called symptoms and signs of Chinese medicine would not be considered as such in Western medicine. For example, absence of thirst (which confirms a Cold condition), inability to make decisions (which points to a deficiency of the Gall-Bladder), dislike of speaking (which indicates a deficiency of the Lungs), propensity to outbursts of anger (which confirms the rising of Liver-Yang or Liver-Fire), desire to lie down (which indicates a weakness of the Spleen), dull appearance of the eyes (which points to a disturbance of the Mind and emotional problems), deep midline crack on the tongue (which is a sign of propensity to deep emotional problems), and so on. Whenever I refer to “symptoms and signs” (which I shall also call “clinical manifestations”), it will be in the above context.

THE ART OF INTERROGATION: ASKING THE RIGHT QUESTIONS

Diagnosis by interrogation is of course extremely important as, in the process of identifying a pattern, not all the information is given by the patient. Indeed, even if it were, it would still need to be organized in order to identify the pattern or patterns. Sometimes the absence of a certain symptom or sign is diagnostically determinant and patients, of course, would not report symptoms they do not experience. For example, in distinguishing between a Heat and a Cold pattern, it is necessary to establish whether a person is thirsty or not, and the absence of thirst would point to a Cold pattern. The patient would obviously not volunteer the information of “not being thirsty”.

The art of diagnosis by interrogation consists in asking relevant questions in relation to a specific patient and a specific condition. A certain pattern may be diagnosed only when the “right” questions are asked; if we are not aware of a specific pattern and do not ask relevant questions, we will never arrive at a correct diagnosis. For example, if we do not know the existence of the pattern of “rebellious Qi of the Penetrating Vessel,” we will obviously not ask the questions which might lead us to diagnose such a pattern (see below).

The interrogation should not consist of blindly following the traditional list of questions; it should be conducted following a “lead” with our asking a series of questions to confirm or exclude a pattern, or patterns, of disharmony that comes to our mind during the exchange of question and response. Therefore, when we ask the patient a question we should always ask ourselves why we are asking that question. During an interrogation, we should be constantly shifting or reviewing our hypotheses about the possible patterns of disharmony, trying to confirm or exclude certain patterns by asking the right questions.

For example, a patient may present with chronic headaches and, even at this very early stage, we are already making a hypothesis about the possible pattern of disharmony on the basis of our experience and our knowledge, that is, we are thinking of Liver-Yang rising because we know it is by far the most common cause of chronic headaches. We therefore ask questions about the character and location of the pain: if the patient says that the pain is throbbing and is located on the temples, even these few details would almost certainly confirm the diagnosis of Liver-Yang rising. However, we should never stop there and reach premature conclusions. Instead we should ask further questions to confirm or exclude the existence of other patterns which also cause headaches. For example, Phlegm is another common cause of chronic headaches and we therefore ask this patient first about other characteristics of the headaches which may confirm Phlegm, and also about possible symptoms of Phlegm in other parts of the body: “Does the patient experience a feeling of muzziness in the head?” “Is the headache sometimes dull and accompanied by a feeling of heaviness?” If the answer to these questions is affirmative, we conclude that Phlegm might be a further cause of the headaches. We then ask other questions related to Phlegm in other parts of the body; in this particular case, we might ask whether the patient occasionally expectorates sputum or sometimes experiences a feeling of oppression in the chest. (Fig. 28.2).

Another example of the importance of asking the right questions to confirm or exclude our hypothesis about the pattern or patterns of disharmony is rebellious Qi of the Penetrating Vessel. Rebellious Qi in the Penetrating Vessel may cause a wide range of symptoms affecting the whole torso. These may include: lower abdominal fullness and pain, painful periods, umbilical fullness and pain, epigastric fullness and pain, a feeling of energy rising in the abdomen, a feeling of tightness of the chest, slight breathlessness, palpitations, a feeling of lump in the throat, a feeling of heat in the face, and anxiety (of course not all these symptoms need to be present). It may well be that the patient reports only the symptoms of painful periods and a feeling of lump in the throat: if we are not familiar with the pattern of rebellious Qi in the Penetrating Vessel we may not ask the right questions to uncover other related symptoms and we may therefore attribute painful periods to Cold in the Uterus (for example) and the feeling of a lump in the throat to stagnation of Liver-Qi. Even should we uncover other symptoms mentioned above, if we are not familiar with the pattern of rebellious Qi in the Penetrating Vessel we may wrongly attribute the above symptoms to a confusing number of patterns involving many organs instead of seeing that they are connected with the pattern of rebellious Qi of the Penetrating Vessel.

TERMINOLOGY PROBLEMS IN INTERROGATION

A potential problem for practitioners in the West is that the interrogation and the various expressions used to express symptoms are derived from Chinese experiences and culture and a Western patient would not necessarily use the same expressions. This is a problem, however, that can be overcome with experience. After some years of practice, we can learn to translate the Chinese way of expressing symptoms and find correlations more common to Western patients. For example, whereas a Chinese man might spontaneously say that he has a “distending pain”, an English-speaking Western patient might say that he feels “bloated” or “bursting”. The words are different, but the symptom they describe is the same. With practice and acute observation we gradually build up a “vocabulary” of symptoms as described by Western patients. For example, I have come to interpret the peculiar English expression “a feeling of butterflies in the stomach” as a symptom of rebellious Qi in the Penetrating Vessel.

The translation from Chinese of the terms related to certain symptoms may also present some problems. The traditional terms are rich with meaning and sometimes very poetic and are more or less impossible to translate properly because Western language cannot convey all the nuances intrinsic in a Chinese character. For example, I translate the word Men as a “feeling of oppression”; an analysis of the Chinese character, however, which portrays a heart squashed by a door, conveys the feeling of oppression in a rich, metaphorical way. What cannot be adequately translated is the cultural use of this term in China often to imply that the person is rather “depressed” (as we intend this term in the West) from emotional problems. As Chinese patients seldom admit openly to being “depressed”, they will often say they experience a feeling of Men in the chest.

Another example is the term Xin Fan, which I translate as “mental restlessness”: the Chinese characters contain the radical for “heart”, indicating an emotional cause of this feeling, and the radical for “fire”, indicating the heating effect of emotional stress on the Internal Organ; the translation cannot possibly do justice to the Chinese term and convey its rich inner meaning.

Yet another interesting example is the use of the word Ku to describe certain symptoms: Ku means “bitter” and is sometimes used to indicate a pain’s severity. However, the word Ku in China has also a definite emotional connotation implying that the person has had a “bitter” life and bitter life experiences.

We should not, however, overemphasize the terminology problems due to cultural differences between China and the West. Quite frequently, Western patients report symptoms exactly as they are in Chinese books. For example, a patient recently told me quite spontaneously “I am often thirsty but I do not feel like drinking”.

PATIENTS’ EXPRESSIONS

It is only after the patient has finished relating the main problems that we can start asking questions systematically on the basis of the “10 questions” (see below), but always following the lead given by what the patient has told us. Often patients have a good insight as to the main problem in their life; often this is the first “problem” they report. For example, when asked about what the main problem was, a 48-year-old man said that he was at a cross-roads in his life, that he felt dissatisfied with his work and that he was searching for something more meaningful in his life. This is a good example of how a patient spontaneously volunteers information about existential doubts which are obviously at the root of the physical problems. Of course, it is not always like this: very many patients cannot see or do not want to see the existential and spiritual problems in their life and present with a long list of physical symptoms which hide the true root of their existential dis-ease.

At the beginning of the interrogation, it is important to let patients speak freely and to make a note of the actual expressions they use; these are usually quite suggestive and indicative of the patient’s problem and sometimes also of the aetiology. For example, if a patient describes feeling “impotent” about a certain situation, it conveys the idea that the patient feels frustrated (and, in the case of a man, it may also indicate sexual impotence). It is particularly important to make a note of the actual expression used by a patient especially when this is repeated in the course of the interrogation. For example, a patient may use the expression “trapped” two or three times, clearly indicating that emotional frustration may be at the root of the problem.

In some cases patients refer to a particular part of the body several times in the course of the interrogation and this gives a strong indication of the possible pattern involved. For example, a patient suffering from chronic mental-emotional problems may refer to the “throat” three or four times during the course of the interrogation, saying things such as, “I feel a lump in the throat when I’m upset”, “My throat often feels dry”, or “I feel my heart in my throat”: this may suggest a condition of Qi stagnation in the Liver or Lungs.

The practice of Chinese medicine in the West presents us with new challenges which Chinese practitioners do not have in China. Western patients often seek treatment in search of an existential and spiritual balance, which is not the case in China. We therefore need to adapt our diagnosis and treatment to the needs of Western patients. For example, a woman said that she sought treatment because she wanted “more integration, rhythm and earthedness in her life”. We therefore need to develop a new knowledge of patterns and diagnosis which allows us to interpret the needs of our patients as they report them. In this particular example, I interpreted this patient’s lack of “earthedness” as being due to a severe Kidney deficiency which made her feel “without root” (it would have been a mistake to interpret her word “earthedness” in a literal sense as necessarily pointing to a deficiency in the Earth element).

PITFALLS TO AVOID IN INTERROGATION

The specific interrogation (as defined above), based on questions that concern the patient’s clinical manifestations, is aimed at finding the pattern of disharmony; the general interrogation (about the patient’s lifestyle, family situation, emotional environment, living conditions, etc.) is aimed at finding the cause of disease. It would be wrong to confuse the two and to deduce the pattern of disharmony from the enquiry about the patient’s lifestyle, work and family life. I have noticed this occurring in practice many times when a student or practitioner brings a patient to me for a second opinion: I frequently hear comments such as “Andrew is under a lot of stress at work and he therefore suffers from Liver-Qi stagnation”. This is an example of how a practitioner may confuse the general enquiry about the patient’s life to find the cause of the disease with the specific enquiry about clinical manifestations to find the pattern of disharmony. In other words, to go back to the above example, it would be totally wrong to assume that Andrew suffers from Liver-Qi stagnation on the basis of an enquiry about his lifestyle, work, etc.: such a diagnosis can be made only on the basis of a specific enquiry about his clinical manifestations. Patients might well have a lot of stress in their life, but this does not necessarily cause Liver-Qi stagnation as emotional strain may cause many other patterns.

Another possible pitfall is to make a diagnosis of a pattern of disharmony on the basis of vague and woolly concepts deduced from observation of the patient’s lifestyle – for example, “Betty seems to be a very “woody” person, so I thought there was Liver-Qi stagnation”. Of course, a diagnosis of a person’s prevailing Element on the basis of the body shape, mannerism, gait and voice is important (see Chapter 1), but this does not always coincide with the prevailing pattern; in other words, a Wood-type person will not necessarily suffer from a Liver pattern of disharmony.

A word of caution about the conducting of the interrogation is called for. As mentioned above, the interrogation is conducted with close reference to pattern identification and the questions are aimed at confirming or excluding the existence of a certain pattern of disharmony in the patient. The diagnostic process starts with observation skills as soon as a patient walks in; for example, if a woman patient looks pale, talks with a low voice, and complains of tiredness and poor appetite, we immediately think of Spleen-Qi deficiency as a possible pattern, and thus further questions aim to confirm or disprove the existence of this pattern. In Chinese medicine, however, it is easy to conduct the interrogation in a way that might influence the patient and elicit the symptoms that will force the clinical manifestations into a preconceived pattern; this is a real danger of Chinese diagnosis. The only way to eliminate this danger is to keep an open mind; this is extremely important. Going back to the above example, we must at all times be prepared to contemplate the real possibility that this patient might not suffer from Spleen-Qi deficiency, or that Spleen-Qi deficiency might not be the only or even the main pattern or problem.

Box 28.2 summarizes pitfalls in interrogation.