Stagnant blood
Stagnant blood can cause pain. The painful area is fixed and has a stabbing, boring or colicky nature.

Stagnant blood causes hemorrhage. This produces deep purple blood, often with clots.

Stagnant blood causes ecchymosis or petechia.

Stagnant blood can cause a mass. This can be any sort of mass, tumor, splenomegaly or hepatomegaly.

Phlegm and humour
Phlegm and humour are formed when water metabolism is disordered; an accumulation of excess water then turns into phlegm or humour. Phlegm and humour in the lung causes cough, dyspnoca and excessive sputum.

Phlegm and humour in the stomach causes abdominal distension and a succussion sound.

Phlegm covering the heart orifice causes coma and a rattling sound from the sputum in the throat, such as in a stroke.

Phlegm blocking the channels and collaterals causes hemiplegia, numbness of the extremities and difficulty in speech, such as in a stroke.

Phlegm accumulating subcutaneously occurs when there is a subcutaneous lymph node.

VI. Differentiation of Disease According to the Eight Principles
This is the diagnostic system of Chinese traditional medicine. The notes in the ensuing section explain the broad principles of diagnosis, using the history and examination of the patient as a basis.

Diseases are either exterior or interior. If a pathogen such as cold invades the body then it may be superficial or exterior in its damaging effect, such as the common cold, or it may be deep or interior, such as septicaemia. Usually diseases of the exterior show mild fever, headache, generalized aches and pains, and a superficial pulse. Diseases of the interior are characterized by a high fever, thirst, restlessness, delirium, vomiting, diarrhea, a purplish-red tongue proper, with a white or yellow coating and a deep pulse.

Disease may be hot or cold. This means they may be due to the pathogen factors cold or heat. Diseases of heat show the signs of an acute infection or intestinal obstruction, whereas diseases of cold are more chronic in nature. Diseases of cold are characterized by a dislike of cold, pallor, loose stool, polyuria, a large flabby white tongue with a white coating, and a slow or deep and thready pulse. Diseases of heat show fever, dislike of heat, thirst, a red face, constipation, red scanty urine, and a red tongue proper with a yellow coating, associated with a rapid pulse.

Diseases may be xu or shi: Diseases of xu are usually more chronic in nature and are due to a deficiency of either the yin or the yang within the body. The patient is in low spirits, pale, emaciated, has palpitations and the tongue proper is light or red with a white or yellow coating, and there is a xu pulse. A shi disease is often more acute and is due to an excess of the yin or the yang within the body. This presents with irritability, distension and fullness of the chest and abdomen, scanty urine and dysuria, a red or white tongue proper with a yellow or white coating, and a shi or forceful pulse. There is a great deal of reference to xu and shi and it is important to realize that xu really means a deficiency, and shi really means an excess.

The last two principles are yin and yang. They are the generalization of the above ideas, which have already been discussed in Part I of this section.

VII. Methods Of Diagnosis

Inspection
Mental condition
See mental pathogens.

Facial complexion
A red face occurs with febrile diseases, a pale wizened face is due to anaemia or xu diseases, a yellow face occurs in jaundice and a purple face occurs in anoxia, severe pain or stagnation of blood.

Body build, posture and motion
In an obese person there is a chronic deficiency of qi with invasion of phlegm and damp, while in an emaciated person there is hyperactivity of fire due to a deficiency of yin. Paralysis of the limbs indicates insufficiency of qi and blood with blocked channels and collaterals. Convulsions and muscle spasm are often due to an invasion of the channels by wind, due to an insufficiency of yin.

Examination of the tongue
This is a most important diagnostic tool; the tongue is divided into the tongue proper and the tongue coating. A normal tongue has a pink tongue proper with a white clear coating over the tongue.

The tongue proper
A light coloured tongue proper: A light tongue proper indicates insufficiency of qi and blood, invasion of cold, and xu of yang.

A red tongue proper: A red tongue proper indicates diseases due to heat, or internal diseases of heat due to xu of yin.

A purplish-red tongue proper: This occurs in acute diseases of heat when heat has been transmitted from the exterior of the body to the interior, for instance septicaemia. It can also be seen in diseases that exhaust the body fluid, causing hyperactivity of yang due to an insufficiency of yin, for instance terminal carcinoma.

A purplish tongue proper: A purple or bluish-purple tongue proper indicates retardation of qi and stagnation of blood, causing internal cold due to xu of yang, for instance ischaemic heart disease or heart failure.

A large flabby tongue proper: A large and flabby tongue proper with teeth marks indicates xu of qi and xu of yang, for instance chronic enteritis. If there are purplish-red spots on the tongue then this means that there is an invasion of heat.

A streaked tongue proper: Some people have a congenital streaked tongue (this is called a geographical tongue in Western medicine) and it must be ignored. Streaks or red prickles on the tongue normally indicate hyperactivity of fire causing consumption of the body fluid and this is often found after infectious diseases.

Stiff and tremulous tongue proper: The tongue shows fasciculation and it may curl up. This is often accompanied by indistinct speech and mental disorders and indicates disturbance of the mind by phlegm and heat, or deficiency of yin of the gan-liver.

The tongue coating
A white coating: A thick white coating indicates stagnation of food, for instance dyspepsia.

A white greasy coating indicates invasion by the pathogen cold and damp, or phlegm, for instance chronic bronchitis.

A white powder-like coating indicates invasion by plague, for instance typhoid.

A yellow coating: A thick yellow coating indicates chronic indigestion.

A thin yellow coating indicates invasion of fei-lung by wind and heat, for instance a cold.

A greasy yellow coating indicates internal damp and heat, or phlegm and heat, for instance bacillary dysentry or a lung abscess.

A charring yellow coating indicates the accumulation of heat in the intestines which damages the yin, for instance infectious diseases of the intestine.

A yellow tongue coating may also be caused by smoking.

A greyish- black coating: A grayish-black slippery coating indicates excessive cold due to xu of yang, and this occurs in certain types of dyspepsia.

A grayish-black dry coating indicates exhaustion of the body fluids due to excessive heat, for instance dehydration.

A peeling coating: When the tongue coating is partially or completely peeled off the tongue proper can be seen. This indicates severe damage of the normal qi and an extreme deficiency of yin, for instance the late stages of terminal cancer.

Auscultation
Listening to the speech
Speaking in a low feeble voice indicates diseases of xu nature and sonorous speech indicates shi diseases. A partial loss of consciousness means that heat and phlegm are covering the heart orifice. Talking to oneself means that there is a derangement of the mind, and indistinct speech often means that the channels are blocked by wind and phlegm.

Listening to the respiration
Feeble respiration with dyspnoea and excessive sweating indicates xu of qi of the xin-heart and fei-lung. Heavy respiration, with a productive cough, indicates a shi disease of fei-lung due to an accumulation of phlegm and heat, or phlegm and humour, in fei-lung.

Listening to the cough
A heavy unclear cough is caused by invasion of fei-lung with wind and cold, or accumulation of cold and humour in fei-lung. A loud clear cough often indicates wind and heat, or phlegm and heat, in fei-lung. A dry cough with minimal sputum is often caused by a chronic xu of yin of fei-lung, for instance tuberculosis.

Smell
A rank foul smell of any discharge or secretion indicates a disease of shi nature (infection). A light smell indicates a disease of xu nature, for instance scanty red urine with a foul smell indicates a hot shi-disease, like cystitis, while clear profuse urine indicates a cold xu disease, like diabetes insipidus.

Interrogation
This is best summed up by the translation of an old Chinese text called the ten askings:

One ask chill and fever, two perspiration, three ask head and trunk, four stool and urine, five food intake and six chest. Deafness and thirst are seven and eight, nine past history and ten causes. Besides this you should ask about the drugs taken, and for women patients you should ask their menstrual and obstetric history. Finally, for infants, ask about the normal childhood diseases.

This section is included purely for interest as the method of taking a history so clearly corresponds with that used in Western medicine.

Palpation
Palpation of the pulse
The pulse provides a great deal of the information gained from palpation, although a mass or trauma will obviously have to be examined on a more Westernized basis. In classical Chinese medicine there are six pulses at each wrist. These pulses occupy three positions at each wrist over the radial artery, and each position has a deep and superficial pulse. Each of these pulses represents a different organ and in this way all twelve of the zang fu organs are represented by a wrist pulse. The character of the pulse indicates the state of health of each organ and also the balance between each organ. Although traditional pulse diagnosis is still used in China we were taught a much simpler form of pulse 'generalization' rather than the traditional pulse diagnosis, and it is this purse 'generalization' that will be discussed in the following section.

A superficial pulse: This pulse responds to the finger when pressed lightly and becomes weak on heavy pressure. It is often seen in the early stages of diseases caused by exogenous pathogens, such as infections.

A deep pulse: This pulse is not clear on superficial palpation but it is felt on deep pressure. It is often seen in interior diseases such as glomerulonephritis.

A slow pulse: This pulse is less than sixty beats per minute; it may be normal or it may be seen in atrio-venticular block, i. e. diseases of cold.

A rapid pulse: This pulse is greater than sixty beats per minute; it is often seen in diseases of heat.

A xu pulse: The pulse is weak and forceless and goes on heavy pressure. This is seen in diseases of xu nature, such as malnutrition or diseases of pi-spleen.

A shi pulse. The pulse is forceful and will not go on deep palpation; it is seen in shi diseases.

A large pulse: This is an abundant pulse; it is like a surging wave and is seen in diseases of shi nature and heat.

A thready pulse: This is like a thready flow of water and it is often seen in xu diseases