About half way into the school year at ACTCM, we began learning tongue and pulse diagnosis. Of the two, tongue diagnosis was easier than pulse diagnosis.
We looked at the tongue size, shape, color, and texture. Any motion, such as quivering, and the appearance of the tongue coating are also important aspects of the examination. A Western physician looks at the tongue merely for signs of dehydration, anemia, and perhaps fungal infections. In TCM, a discipline that uses no invasive techniques, observation of the tongue plays a far greater role in diagnosis. For the TCM practitioner, it is a window to the internal condition of the body.
I was amazed at all the clues tongue diagnosis offered the clinician. From the size and shape, one could diagnose not only dehydration but also fluid retention or edema. Tongue color is very important. As in Western diagnosis, pallor means anemia. In TCM, an excessively dark red color also has significance—it is a sign of either organ congestion or Heat. A yellowish coating signifies an infectious or inflammatory state. A thick wet coating often signifies a dysfunction in digestion.
TCM includes in its paradigm a system like reflexology in which different organs of the body have their representative locations on the tongue. The same applies to the French Ear Acupuncture system and the Korean Hand Acupuncture system. Discoloration, such as a dark spot, on a certain area of the tongue might signify a disease in the represented area of the body. As I became more proficient, I was even able to find signs of past surgery in the lines and indentations of the tongue.
We were also taught to feel the pulses at the wrist. In addition to noting the rate and rhythm of the pulse, already familiar from my Western training, we were taught to note the quality of the pulse. We felt the pulse in three locations along about an inch and a half length of the radial artery at the wrist, using our right hand for the patient’s right wrist and our left for the patient’s left wrist. We felt with index, middle, and ring fingers respectively. Changes in the quality of the pulse at a particular location on the wrist reflect changes in the corresponding body zone. The location of the index finger corresponded to the Upper Burner, the middle finger to the Middle Burner, and the ring finger to the Lower Burner (see chapter 2).
Pulse diagnosis has always intrigued me. Diagnosing an ailment by the quality of the pulse took on meaning as I correlated these qualities with Western physiology. A slippery pulse is one in which the pulse wave seems to begin before the previous one has a chance to fall all the way to baseline. TCM practitioners often take pride in their ability to diagnose early pregnancy. A pregnant woman will typically have a slippery pulse because during pregnancy, there is a marked increase in blood volume and cardiac output, accounting for the characteristic change.
When a patient is stressed or in pain, he has a wiry or Liver-type pulse, indicative of blood vessel constriction. The description of Liver-type pulse validated my interpretation of the TCM Liver being the sympathetic nervous system. With stress or pain, the sympathetic nervous system acts by constricting the blood vessels, causing them to feel wiry.
When the body mounts an immune response and blood rushes to the part of body being attacked, the pulse to that region of the body becomes floating . The pulse is close to the surface, and it seems to float up to meet the examiner’s finger. The explanation is that with infection or inflammation, the blood vessels in the affected area dilate, bringing the needed immune cells to do battle in defense of that body zone.
For many years I had wondered how, by feeling the pulse at three locations on the wrist, TCM physicians were able to correlate what they found with the three zones of the body. One day, the explanation dawned on me. As the heart pumps blood into the main blood vessel, the aorta, its branching vessels send blood to various parts of the body. With each heartbeat, there is a series of waves along the radial artery, or any blood vessel for that matter. The first wave is from the initial branches sending blood to the brain, heart, and lungs. The second wave is from branches sending blood to the visceral organs, and the third and last is from branches to the urogenital region and lower limbs in sequential order. Feeling the three great waves created in the blood flow along the length of the radial artery, the Chinese physicians could determine the condition of the three zones of the body. Pulse diagnosis required sensitivity and skill. I seized every available opportunity to practice on any willing subject.
Fig. 3. Pulse Taking. The examiner’s three fingers are, with each pulsation, palpating the three waves, representing the three body zones.
Fig. 4. The Three Great Waves of the Chinese Pulse.
The ER: My Virtual Lab
While I was attending ACTCM, I continued to work in the emergency room. The ER became my virtual laboratory. I tried to apply what I had learned in the evenings and weekends to various situations at work. My subjects were roughly divided into two groups. Those in the horizontal group were patients wheeled in on gurneys; those in the vertical group were the ER staff, who, when there was a lull at work, would describe their symptoms to me, asking for my TCM diagnosis. As I applied TCM to the ER scene, I began to sort out which conditions were candidates for the Eastern approach and which were not.
For the ER patients who were brought in comatose, once they were given the appropriate Western emergency care, I tried the Chinese emergency acupuncture technique of needling them briefly above the upper lip to awaken them from coma. I found this method ineffective. In fact, I found no true medical emergencies in which I could apply the TCM treatments I had learned. If patients required intravenous fluids or drugs, the Eastern way of brewing herbs just could not compare to rapid Western methods.
On the other hand, as I used my newly learned tongue and pulse diagnosis to see how “balanced” the ER staff was, I discovered almost all of them had, by TCM standards, some abnormalities. Some were symptomatic, others were not. Paula had recently given birth to twins and returned to work on the evening shift as a ward clerk after only a short maternity leave. Although she had no symptoms, her tongue showed signs of Spleen Deficiency, indicating that her immune system was weakened. Darlene, a nurse, had a skin cancer taken out of her leg and, shortly thereafter, had a miscarriage. Her pulses and tongue showed Blood Deficiency, indicating that her body had not totally made up for the blood loss from her miscarriage. From the TCM perspective, it was rare to find anyone completely normal. Yet they were all well enough to be working in the ER. I wondered if they were walking time bombs.
I began to realize that every disease progresses in stages. Generally, a disease begins with certain imbalances, barely detectable, and only later does it become symptomatic. The duration of the stages varies depending on the disease. In an acute infection, the stages are short. A patient with strep throat will develop fever and painful swallowing in a matter of hours. With other diseases, like cancer or heart disease, the early stage might last for years. Eastern medicine works best in the early stages of a disease because it can help reverse the imbalances in the host and promote self-healing. It can also be effective in the intermediate stage, when there are symptoms. In advanced stages, TCM methods of working on imbalances in the host are no longer enough. At this point, a Western approach should be chosen. After the critical problem is taken care of with a Western approach, Eastern medicine may again have a role during the recovery period.
Some skeptics explain the popularity of complementary medicine by saying that the patients who feel helped by it were actually not that sick and that it is the practitioner’s attentiveness rather than the treatment that made the patient feel better. From the Western perspective, that may appear to be. Complementary care practitioners do spend more time with patients and go into detail getting their history. The patients seeking this kind of care are not severely ill, but they usually have problems that do not seem to completely resolve using Western methods. Nevertheless, their problems are real and not just imagined. Success with using Eastern treatments is also real and not just a placebo effect. Western skeptics try to explain it away because they do not understand the paradigm. The difference between Western medicine and TCM is that TCM diagnosis focuses not just on disease but also on the person’s own ability to fight disease. This entails detailed history taking. Although they lack specificity, pulse and tongue diagnosis are extremely sensitive tools. Sometimes they can pick up diseases before symptoms appear. Often they can detect deficiencies in the patient’s ability to heal and work on improving the host’s recovery. The West has an aphorism: “If it isn’t broken, don’t fix it.” TCM may be able to detect small cracks and mend them before they actually break.
The sensitivity of TCM diagnosis became apparent to me during the course of treating a physician’s wife with acupuncture for a musculoskeletal condition. As I was contemplating giving her herbs for another problem she had, I happened to feel her pulses. The lung position pulse was floating, a sign that the body is mounting an immune response, typical in the early stage of a viral infection. At the end of the session my patient said, “I’ll see you next week.” “No,” I told her, “you are probably coming down with the flu, and I shall probably see you in two weeks.” After two weeks, she returned. She had indeed come down with the flu. Her husband was amazed at my prescience. Actually, it was a simple diagnosis to make using TCM methods.
I used to think that the only treatment for acute appendicitis was surgery. When my teacher, Dr. Lai, told me that he had treated a man for appendicitis by using acupuncture, I was skeptical. The patient had been experiencing pain in the lower right region of his abdomen, and my teacher had acupunctured him until the pain was relieved. This cannot be true, I thought. Perhaps the diagnosis of appendicitis was in error. There are abdominal pains that could mimic appendicitis. The only absolute proof is when a surgeon operates and can actually see the inflamed appendix. As I look back with the perspective that diseases evolve in stages, and I think about how appendicitis develops, the account of my teacher’s treatment becomes more plausible.
The appendix is a small worm-like tube branching out from the intestines. It is situated at the junction of the small and large intestine. If stool passing down to be eliminated is hard, sometimes a small stone-like piece, called a fecolith, will be stuck at the opening of the appendix, thereby blocking it. At this stage, if there is no intervention, the appendix wall becomes inflamed and swollen, worsening the obstruction. The secretions of the appendix, which normally empty into the large intestine, have nowhere to go and therefore stagnate and become infected. The appendix becomes a closed tube containing infected fluid whose volume continually increases. If there is no intervention, the appendix will eventually rupture. Before that happens, surgery is needed. At the early stage, when the fecolith is just beginning to block the opening of the appendix, intervention with acupuncture could work. If the smooth muscles of the appendix wall could be relaxed and allowed to dilate, then the opening might become wide enough to let the fecolith pass into the large intestine. Acupuncture and some herbs can act to relax the smooth muscle and dilate the wall of the appendix, stopping the progression to appendicitis.
In my dual role as both TCM student and ER physician, I observed a certain pattern of events. Often, patients who came to the ER with an acute catastrophic condition had undergone a recent invasive Western procedure. Two cases come to mind. One was an older man who had had recent cataract surgery and was brought to the ER with a stroke. Another case was a young boy who had had dental surgery the day before and came in with acute appendicitis. Later on in my practice, I observed other similar cases.
I began to realize that the “walking well” have a certain balance that we in Western medicine call homeostasis, the intrinsic ability of the body to keep itself in equilibrium. For some, like the older man, homeostasis might have been tenuous, and the balance was tipped by the stress of the surgery. Although cataract surgery is not considered a major operation, we know that with any surgery, the body usually mobilizes its clotting mechanisms to prepare for blood loss. In a man whose arteries to the brain were already narrowed, that extra increase in the blood clotting function might have been enough to tip the balance and cause his stroke.
As for the young boy with appendicitis, I could see how his disease evolved. The codeine his dentist prescribed for pain made him constipated. Because his mouth hurt, he probably did not drink enough fluids, and this caused dehydration. Constipation and dehydration led to fecolith formation, which then progressed to appendicitis.
When I was a first-year anesthesiology resident at Columbia Presbyterian Hospital, we used to have rounds (mini-conferences) in which dramatic cases were discussed. There was a plethora of these cases characterized by near-disaster and rescue among the trainees. One of our attending physicians remarked, “My days are rather dull. I never seem to encounter all this drama you people report.” His comment made me think about what distinguished him, a seasoned anesthesiologist, from us, the neophytes. The experienced, competent anesthesiologist anticipates disaster and takes measures to avert it before it happens. The measure of a good doctor should not be how many dramatic rescues he performs on his patients but how stable and “not sick” he can keep them.
In addition to detecting early stages of disease, TCM has a role in treating conditions of a chronic nature. Western medicine often reaches an impasse when treating certain people whose conditions plateau. In these cases, Eastern medicine plays a significant role. By infusing energy with herbs, or improving blood flow to a diseased area using acupuncture, the body can be induced to heal itself.
One day while working a shift in the emergency room, I bumped into Bill, an ER orderly, in the hospital corridor. He told me he had missed nearly three weeks of work because of a painful condition. His affliction was epididymitis, which is an inflammation of the tube around the testicle. Despite being on nonsteroidal anti-inflammatory drugs and the second course of antibiotics prescribed by his urologist, he was no better. After consulting with my teacher, Dr. Lai, I offered to treat Bill with acupuncture and herbs. Since he seemed to have reached an impasse with Western treatments, Bill agreed to try.
I began with acupuncture. Bill was palpably anxious. He watched my every move as I needled (no, I did not needle the organ, but close to it) along the pubic area and inner thigh. Because he had confidence in my competence as an ER physician, he gritted his teeth and was willing to let me continue. I hooked up the needles to the electrical machine Aunt Teresa had given me. (This time I remembered to turn the dials the Chinese way.) At the end of the twenty-minute treatment, Bill arose from the stretcher and looked a bit puzzled. He said, “The pain isn’t there anymore. Is it supposed to go away right away?” “I don’t know, this is the first time I’ve done this,” I answered. The next day was my day off. I called the emergency room to find out how Bill was. They said he was back at work. He never required any further treatment. Imagine, with the best modern medicine had to offer, this man suffered for weeks and lost time at work from his illness. Then with an ancient remedy consisting of a few needles hooked up to electricity, he was cured in a matter of twenty minutes. The implications were tremendous. More than ever, I was convinced there was validity to TCM.
Being a female in a male-dominated field, I am often mistaken for a nurse. One patient referred to me as “that nurse” when I was training in intensive care. I assumed it was the usual mistake because of my gender. When the nurse told her I was the doctor, the patient said, “I know, but sometimes she’s a nurse, too.” I considered that a compliment. Over the years, I have found that nurses in general are very receptive to Eastern medicine. Unlike the doctor, who pops in once or twice a day for a matter of minutes to see the patient in the hospital, nurses have ongoing contact with their patients daily. They are often more in touch with how patients feel than doctors are. One ER nurse told me she was enthusiastic about my studying Eastern medicine, saying, “I bet it will make you an even better doctor.” I think she was right.