Diagnosis in Chinese Medicine - A Comprehensive Guide
Giovanni Maciocia Churchill Livingstone, Edinburgh, 2004 Hardback, with illustrations and colour plates, 1152 pages, £70
(Reviewed by Richard Blackwell, EJOM Vol. 4 No. 5)
This book is an essential clinical reference for all practitioners and it is surely the most important book on Chinese medicine to be published in the last ten years. The text is astonishing in its breadth and detail and it has something to offer everyone, from second year students to highly experienced practitioners.
The book is structured in parts. Parts One to Four deal in turn with diagnosis by observation, by interrogation, by palpation, and by hearing and smelling. Each part begins with general guidance and overview, followed by detailed chapters covering the whole field. For example, in Part One we find a chapter on Observation of the Skin, which takes us through the traditional concepts of the skin layers, discusses the relationship of the skin to the organs and channels, explains the diagnostic meanings of each skin sign in turn (macules, papules, vesicles, scales, erosion, ulcers and so on), and then explores the pathology and diagnostic patterns for 12 common skin diseases. The 26 other chapters of Part One cover observation of body shape and demeanour, excretions, all parts of the body, and of course the tongue. In Part Two there are 20 chapters on interrogation, ranging from pain to mental and emotional symptoms to diagnosing the causes of disease. Part Three covers palpation of the body and channels and includes an outstanding 76 pages on pulse diagnosis. Part Four deals with diagnosis by hearing and smelling, ranging from five element voices to stuttering and babies’ cries.
These parts are enormously helpful, not only in terms of diagnostic information but also in assisting us as practitioners to learn and further develop effective diagnostic processes. Particularly good are the chapters on interrogation, each of which starts with a discussion of what each group of questions tells us, when in the consultation it is best to ask them and how the author asks the questions. The author’s many years of clinical experience in the West shine through in these sections.
Throughout the book there are many bonuses. In Part One we find that in children we can diagnose not only by examining the veins on the index finger, but also by the creases on the index finger. In Part Two we find a brief discussion of yin fire, Li Dong Yuan’s theory which explains how qi deficiency can give rise to heat symptoms. Then in Part Three there is the best surprise yet. Maciocia, probably the West’s leading authority on Chinese medicine, has written here his first in-depth discussion of pulse diagnosis. He explores the historical development of the art, different ways of interpreting the pulse positions, guidelines for taking the pulse, application of pulse findings in practice, and 32 pulse qualities, including a discussion of the meanings of the qualities in different positions. The author brings his usual clarity to this complex area. I particularly liked the way he encourages the reader to adopt a flexible approach to interpretation of the pulse positions, drawing on a range of the systems developed during the history of Chinese medicine, rather than being wedded to just one system. These chapters on pulse diagnosis could easily have been marketed as a small book in their own right, instead they come as a further addition to this indispensable text.
In Part Five there is a change of gear. The next 300 pages contain a comprehensive listing of signs and symptoms for all parts of the body and body functions. For each sign or symptom there is a listing of all the patterns typically associated with it, with a description of the rest of the pattern as it will typically appear in connection with that particular symptom or sign. Helpfully, the patterns are listed with excess patterns first, with the most common of these first, and then deficiency patterns, again starting with the most common of these. This part of the book is a further treasure-trove of information. We would expect to find symptoms and signs such as feeling of heaviness of the head, inappropriate laughter, heavy periods, and frequent urination, but what a delight to also find nasal polyps, glaucoma, grinding of teeth, difficulty in swallowing, and ‘brain noise’ (like tinnitus but experienced in the centre of the head). All of these are signs and symptoms I have known in practice. There are also many others I have yet to encounter, such as itchy tongue, small red grains inside the eyelids, and yellow sweat. As an example of the comprehensive nature of the information, we learn that premature greying of the hair can be associated not only with various permutations of liver blood deficiency or kidney deficiency, but also with liver and heart fire (the hair turns white suddenly after a shock or intense emotional upset) or liver qi stagnation (premature greying in patches, maybe over a short period of time).
There are further bonuses in this part of the book, such as an interesting discussion of the role of the shen and the hun in depression. I was impressed too by the integration of key information from western medicine when appropriate and useful, for example in some of the signs and symptoms related to the eyes and heart.
Part Six presents a comprehensive summary of pattern identification, not only by eight principles and organs, but also according to vital substances, pathogenic factors, four levels, six stages, three burners, channels and five elements. For each pattern there are typical acupuncture points and herbal formulae. I especially liked the chapter on residual pathogenic factors, an important and often neglected subject, and the chapter on patterns of the eight extraordinary channels, which includes typical pulse findings for each channel.
In a work of this kind, it is crucial for the reader to be able to find the information they seek. This is helped enormously by the excellent index and by the clarity with which the text and illustrations are laid out. The use of two colours throughout helps a great deal, and the headings and sub-headings are clear and easy to navigate. There are nice ‘clinical notes’ boxes scattered through the text, plenty of clear illustrations and diagrams, and an excellent section of colour plates.
The collation of all this information is a huge task. The author has drawn on a wide range of modern and classical Chinese sources and has then enriched the information with his own experience of practising and teaching in the West. The result is an integrated work of great clinical value which will serve practitioners very well. The author is usually explicit about information which is derived from his own experience, but there are times when one wishes for a clearer sense of his other sources of information. An example of this is the mapping of the organs and body areas onto each individual fingernail. This is fascinating and I look forward to exploring its value in practice, but it looks like part of the modern development of holographic micro-systems, and this inclines me to treat it differently to most of the diagnostic perspectives in the book, which have survived and developed over centuries. This is a minor quibble though and should not detract from the scale of the achievement represented by this work. In any case, a full academic exploration of the historical development of Chinese medicine diagnosis from the classical sources through to the modern day would be another thousand page volume in itself!
Maciocia teaches widely throughout Europe and America and also receives many referrals from other practitioners, and this gives him the ability to anticipate the areas where his readers may become confused and to take them through these with clear explanations. One of many examples is his discussion of heavy menstrual bleeding. He notes that many practitioners have a strong bias to attribute this to spleen qi deficiency, when in fact around 50% of cases are due to blood-heat.
The greatest strength of this book to my mind is the way it helps the reader to integrate the information. As Maciocia observes ‘no symptom can be seen in isolation from the pattern of which it forms a part’. There is a danger that a dry listing of signs and symptoms and the patterns with which they are usually associated can encourage the reader to jump to conclusions and forget the holistic context. This book avoids this danger by examining each symptom and sign from several perspectives, by discussing the underlying pathology in detail, and by presenting numerous case histories. The latter are invaluable as they open a window into the mind of the author as he makes a diagnosis. He explains the avenues he is exploring with his questions, the way he attaches weight to the various items of information, and the way he integrates all the information in a holistic way.
In his preface, Maciocia reminds us of the enormous value of Chinese medicine diagnosis, with its focus on careful and detailed examination of the patient and its integrative and holistic perspective. He also notes ‘I feel that this [diagnosis] is an area that has been neglected in modern China. In their eagerness to ‘modernize’ Chinese medicine . . . modern Chinese doctors and teachers have tended to overlook the more subtle aspects of Chinese diagnosis, especially tongue and pulse diagnosis’. He tells us ‘it is my wish that the more subtle aspects of Chinese diagnosis be preserved’. This excellent work will greatly assist us all in making that wish a reality.
Richard Blackwell Richard Blackwell is Principal of the Northern College of Acupuncture in York. He graduated in medical science from the University of Nottingham before gaining the Licentiate in Acupuncture from the British Acupuncture College in 1982. He is a past president of the Register of Chinese Herbal Medicine and a regular contributor to the professional literature, with particular interests in asthma, arthritis and multiple sclerosis.