4. The Constitutional Factor
Chapter contents
The concept of the constitutional imbalance in Chinese medicine18
What do we mean by the Constitutional Factor?18
How does a practitioner diagnose the CF?19
Elements within Elements21
How does our Constitutional Factor affect us?22
Treating the CF23
The concept of the constitutional imbalance in Chinese medicine
The notion that people have a particular constitutional imbalance is very old and widespread in Chinese medicine. Ling Shu Chapter 64 is devoted to an exploration of Five Element constitutional types, based mainly on physical shape and aspects of a person’s character. Another system given in Ling Shu Chapter 72 outlines a four-fold yin/yang system that divides people into taiyang, shaoyang, taiyin and shaoyin types (see Flaws and Lake, 2000, p. 27). In Japan there is a strong tradition of treating people according to constitutional type. For example, there is a style based upon the six-fold system outlined in the late Han dynasty classic, the Shanghan Lun. Using somewhat different criteria it divides people into six types, taiyang, shaoyang, taiyin, shaoyin, yangmimg and jueyin (Schmidt, 1990). Master practitioners such as Fukushima and Honma (Eckman, 1996) have also developed styles that diagnose and treat constitutional types. In Korea, Kuon Dowon teaches yet another constitutional style (see Eckman, 1996, p. 209).
The phrase that is currently used in Chinese medicine today to describe a person’s constitution is chang ti, which means ‘bodily type’. This is an appropriate phrase to describe diagnosis that is primarily based upon the physical shape of the person’s body (see Maciocia, 2005, pp. 292–298, or Requena, 1989, pp. 81–93, for discussion of these systems). J. R. Worsley, however, developed his style based upon completely different diagnostic criteria, which are set out in the Nei Jing and Nan Jing. The practitioner’s focus is on certain signs that arise as a patient’s qi goes out of balance.
What do we mean by the Constitutional Factor?
The Constitutional Factor, known as the CF, is one of the most important concepts in Five Element Constitutional Acupuncture. J. R. Worsley used the phrase ‘Causative Factor’ because, as it is the primary imbalance, it ‘causes’ other Elements to become imbalanced. Although this is true there are also other causes. Along with many other practitioners of this style we prefer, for clarity, the term ‘Constitutional Factor’. The word factor is used, partly because it is the word used by J. R. Worsley and partly because it is commonly used in Chinese medicine, as in ‘pathogenic factor’. It is the main focus of the practitioner’s diagnosis and much of the patient’s treatment is centred on it. Because it is the patient’s most underlying imbalance it creates much of the imbalance that can be detected in other Elements. For this reason, as it returns to a better state of health through treatment, it in turn enables many other imbalances to respond and improve. Many of the most dramatic and profound changes that patients can experience from acupuncture treatment are achieved by focusing treatment on it.
The word constitution is defined in the Oxford English Dictionary as: ‘The character of the body as regards health, strength, vitality, etc. Condition of mind; disposition; temperament.’ The concept of a person’s constitution covers both the physical body and the mind and temperament. The word gives a sense of a person’s constitution having lifelong characteristics that may manifest in their physical health or psychological make-up.
There is some debate amongst practitioners of Five Element Constitutional Acupuncture about whether the CF is always inherited or whether it can be acquired in early childhood. Examining the occurrence of the same CF in several members of different generations in a family suggests that many constitutional imbalances are carried in the genes. The person’s responses to subsequent traumatic life situations further imbalance that Element. Other Elements are also affected over time but the CF is the person’s Achilles heel and is the most vulnerable.
Just as people can inherit diseases or weaknesses in particular Organs, people can also inherit imbalances in their temperament or disposition depending on the balance of the Five Elements. The ‘nature versus nurture’ debate is probably irresolvable and will continue wherever people study humanity, whether they are psychologists, educationalists, acupuncturists or anyone interested in the formation of character. The key task of the acupuncture practitioner is to diagnose the pattern of the person’s imbalances and to assist them to achieve a better state of health.
According to Chinese medicine theory the jing is the main vehicle by which imbalances are handed down from generation to generation. Jing is governed by the Kidneys and determines people’s constitutional strength or weakness. This is different from the CF. It is obvious that not all congenital imbalances are found in people’s Kidneys. Just as, for example, heart problems or skin problems can be inherited, so also are imbalances in any of the Elements or Organs.
How does a practitioner diagnose the CF?
The four diagnostic signs
The four diagnostic signs are:
• the emotion that has the most inappropriate expression in the person
• the colour can be observed on the face, particularly on the lower temples beside the eye
• the odour that is emitted by the body
• the sound present in the voice, particularly a tone that is not congruent with the emotion being expressed.
As well as focusing on these four signs, a practitioner also concentrates on assessing the nature of the person’s character in the light of the Five Elements and twelve Officials (see Chapters 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22, this volume, for a discussion of the Elements). The idea that imbalance of an Organ or Element produces these energetic signs comes from both the Nei Jing and the Nan Jing.Chapter 34 of the Nan Jing, Su WenChapters 4 and 5 and Ling Shu Chapter 49, amongst others, outline the emotion, colour, sound and odour that ‘resonate’ with each Organ. The odour, colour, season and climate are also given in the Huainanzi, a non-medical Han dynasty text.
Chapter 16 of the Nan Jing says that when a person’s Organ becomes distressed the emotion and colour associated with that Element will manifest themselves. The Ling Shu laid down the basic idea by stating, ‘Examine the external resonances of the body to know the body’s inner viscera’ (Wu, 1993, Chapter 47). These four signs enable practitioners to use their senses and intuition to discern which Elements have become dysfunctional.
The importance of diagnosing by signs
This emphasis on diagnosing purely by signs is a distinctive feature of this style. (The use of pulse diagnosis and palpation of the body to reveal signs is discussed in Chapter 28, this volume.) Chronic physical symptoms are usually regarded as merely a manifestation (biao) of the primary underlying imbalance (ben), and should not distract the practitioner. Even if a patient has obvious signs or symptoms of a congenital or constitutional imbalance in a particular Organ, for example, a heart abnormality or being born with only one kidney, this offers no clue to the person’s CF. Diagnosis by signs always takes precedence over physical symptoms when diagnosing the CF. In practice, a significant physical dysfunction is often in the CF Element, but it cannot be relied on diagnostically.
Su Wen Chapter 54 and Ling ShuChapter 3 both stress that the practitioner should not rely only on symptoms for making a diagnosis. In fact, hoping to reach a diagnosis of the person’s CF by questioning patients about their physical symptoms or even their own perception of their emotional tendencies is regarded as missing the point. As it says in Nan Jing Chapter 61:
To be able to make a diagnosis by observation alone is to possess divine power. To be able to make a diagnosis by hearing alone is to be a sage. To be able to make a diagnosis by questioning alone is to be skilled physician.
(Lu, 1972)
That said, there is no doubt that basing nearly all of the diagnosis on signs and virtually none on symptoms is an extremely difficult path to follow. Practitioners who practise Five Element Constitutional Acupuncture without integrating it with another style pay little attention to the information that can be gained from questioning the patient. This places huge demands on the practitioner. Depending on their inclination, this style suits some practitioners more than others.
Practitioners of Five Element Constitutional Acupuncture need to hone their senses in order to become adept at diagnosis using only signs. Liu I Ming writes of the ‘encrustation of the senses’ (Cleary, 2001, p. 66). It is this numbing of our sensory perception that has to be transcended. Much of an acupuncturist’s training, both while a student and throughout their career as a practitioner, is devoted to refining sensory and intuitive faculties.
Diagnosis by assessing the emotion
Of the four diagnostic signs the emotion is probably the most reliable indicator of the CF. The ability to use the intuition (zhiguan) to gain insight into the patient’s emotional life is therefore one of the most important skills that the practitioner needs to develop. As the Huainanzi stated, ‘The external is manifest, the internal is concealed’ (Major, 1993, Chapter 7).
Practitioners need to develop the ability to understand the balance of the qi of the Five Elements. To do this they interact with the emotions of the patient. As emotions arise, they create movements in the patient’s qi
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