中医四诊信息采集的方法与原则

Methods and principles of information collection in four diagnosis of traditional Chinese medicine

关键词:  四诊  信息采集  全面  规范  准确

Key words:  four diagnostic methods  information collection  comprehensive  standard  accuracy

摘要:

四诊信息是疾病表现于外的信息的抽象概括，其质与量关系到对疾病的分析和判断。以整体观念为基础，中医诊断分别从望、闻、问、切4条不同途径诊察和收集病情信息，其原理是“司外揣内”。目前，临床四诊信息采集的不全面、不可靠已经成为影响中医辨证的突出问题，故在进行四诊信息采集时既要重视不同诊法的特殊性，又要强调诊法合参的“全面性”，更提倡借助于现代系统科学技术，实现中医诊断客观、量化，以保证信息采集过程的“规范性”和所采信息的“准确性”。因此，文章再次梳理中医四诊的含义，从不同角度、多个层次详细解释了四诊信息采集需遵循全面、规范、准确的原则，为进一步规范中医四诊信息采集、促进辨证的正确性提供理论与可实践思路。

Abstract:

Traditional Chinese medicine (TCM) diagnosis includes four aspects:looking,smelling and listening,asking and cutting. They are important means for TCM to obtain information about the four diagnoses. The four diagnostic information is an abstract summary of the disease information manifested. Its quality and quantity are related to the analysis and judgment of the disease. On the basis of the overall concept,TCM diagnoses and collects disease information is based on four different ways,namely,looking,smelling,asking and cutting. At present,the incomplete and unreliable collection of clinical four-diagnosis information has become a prominent problem affecting TCM syndrome differentiation. Therefore,when collecting the four-diagnosis information,we must pay attention to the particularities of different diagnostic methods and emphasize the "comprehensiveness" of combining diagnostic methods. We also advocate the use of modern system science and technology to achieve objective and quantitative diagnosis of TCM to ensure the "standardization" of the information collection process and the "accuracy" of the information collected. Therefore,this article sorts out the meaning of the four diagnosis of TCM again,and explains in detail from different perspectives and multiple levels that the collection of the four diagnosis information must follow the principle of comprehensive,standardized and accurate,which provides further standardization of the collection of the four diagnosis of TCM information and promotes the correctness of the syndrome theory and practical ideas.
Traditional Chinese medicine (TCM) is characterized by syndrome differentiation and treatment, and the premise and basis of syndrome differentiation is combination of the four diagnostic methods. Based on the holistic concept, the four diagnostic methods examine and collect disease information from four different ways: looking, smellingand listening, inquiring and feeling the pulse, and its principle is “conjecturing the interior by observing the exterior”. DanxiXinfa said: “If you want to know what is inside, you should look outside. If you are diagnosed outside, you will know the inside. If a disease exists in the body, it must be manifested externally by its surface characteristics.” Therefore, under the guidance of TCM theory, by comprehensively analyzing the symptoms and signs collected through four diagnostic methods, we can speculate the true cause and internal mechanism of the disease, and then give a result of syndrome differentiation[1]. It can be seen that the accuracy of the four-diagnosisinformation directly affects the results of syndrome differentiation and the corresponding treatment. Therefore, this paper focused on the methods and principles of collecting the four-diagnosisinformation, and made a systematic description in combination with the related researches on the modernization of the four diagnostic methods.
1 Methods and principles of four diagnosis
The occurrence and development of a disease is a complex process.The four diagnosis respectivelyexamine the disease and collect data from different angles, each with independent meanings and connotations[2]. Principle and Prohibition for Medical Profession says: “Looking, smellingand listening, inquiring and feeling the pulse, not a single one can be omitted”. However, due to the subjectivity and ambiguity in the collection process of TCMfour diagnosis, researchers gradually pay attention to modern scientific and technological means to promote the objectificationand quantification of TCMfour diagnosisin the modernization development of TCM diagnosis.
1.1Lookingdiagnosis
Among the four diagnosis in TCM, looking diagnosis is at the head of “shenshengGongqiao”, and Nan Jing says: “A doctor may be called a genius, who knows the cause of patient’s illness by lookingdiagnosis.” It refers to the method,by which doctors use vision to observe the external signs of the patient, such as spirit, color, shape, state, tongue picture and excreta,of collecting the disease information to diagnose the disease. Looking diagnosis, the most intuitive and convenient, the fastest and most sensitive method, is the earliest diagnostic method in the formation and development of the four diagnosis of TCM. Studies have shown that the information obtained by visual systemaccounts for about 80% of the information obtained by all human organs, so looking diagnosis plays an important role in objectively obtaining disease information. At present, TCM lookingdiagnosis method is continuously combined with rapidly developing system science and technology, especially in the research and development of face and tongue inspection systems.Generally speaking, the lookingdiagnosticsystem is mainly composed of animage acquisition system and afeature processing system. Among them, the image acquisition system usually consists of three parts of hardware: light source, photosensitive system and acquisition environment; while the face feature processing system is composed of facefeature recognition and analysis software such as face feature extraction, color correction and image segmentation. Taking tongue diagnostic instrument as an example, under the guidance of TCM theory, the objective quantitative index of tongue is extracted through digital tongue acquisition system and standardized tongue feature processing system, so as to study the correlation between disease syndrome and tongue images, tongue images and symptom index, which is of great significance to the objectification of TCM tongue diagnosis of specific syndromes in different diseases[3].
1.2Smelling and listening diagnosis
It is clarified that the specific content of smell and diagnosis is mainly "seeing wheezing, listening to sound". Smelling and listening diagnosisis one of the four diagnosis of TCM. Suwen:YinyangYinxiangDalun says: “Those who are good at diagnosis, check the color and feel the pulse with distinguishyin and yang first, judge the pure and turbid and know the part, and know the pain according to the seeing breathing and listening to sound.” It is clarified that the specific contents of the smelling and listening diagnosis are mainly “seeing breathing and listening to sound”. Nan Jing further inherits and develops the theory of smelling and listening diagnosis in HuangdiNeijing, and talks about the method of smellingodors. At present, the standard textbooks of TCM diagnostics are defined it as: smelling and listening diagnosis is a method of understanding health status and diagnosing diseases by listening to sounds and smellingodors[1]. Listening to sounds refers to examining and grasping the patient’s voice, breathing, speech, cough, vomiting, hiccup, yawn, bowel sounds and other sounds. Smellingodors refers to the abnormal odors of the sick body, the excreta and the ward. Because both sounds and odors are produced in the physiological activities and pathological changes of Zang-fu organs, the abnormal changes of sounds and odors can be used to diagnose diseases and syndromes.
Whether it is smelling diagnosisor listening diagnosis, most of them rely on doctors’ subjective judgment, and lack of clear qualitative and quantitativeobjective basis. In recent years, some scholars have proposed the use of physical methods and mathematical analysis methods of acoustic signals to detect and analyze TCM smelling and listeningdiagnosis[4], which is of great significance to promote the objectification and standardization of them. In the aspect of listening diagnosis, the common voice extraction methods are divided into two types: selectingvowels and selecting sentences, and then analyze the syndrome characteristicsby studying the most basic physical elements that reflect the voice characteristics, such as pitch, sound intensity, sound length and sound qualityand so on[5]. Themain research points ofsmelling diagnosis is mainly to measure or detect the physical amplitude or chemical products produced by the action of gas molecules on receptors, and then study them by using sensor array technology, infrared spectroscopy, gas-liquid chromatography analysis and so on[6].
1.3 Inquiringdiagnosis
Inquiringdiagnosis is the most important waytoobtaininformation about patients’ symptoms. We can catch the occurrence, development, treatment process, current symptoms and other conditions related to the disease through inquiring the patients or their accompanying patients purposefully, so as to diagnose the disease. Suwen:ZhengsiShilun says: “During the diagnosis, the patient is not inquired about the onset of the disease, whether there is mental stimulation, whether the diet is out of control, whether the daily life exceeds the normal rules, or whether he has been injured by poison, but just hastily feeling the pulse.It cannot correctly diagnose the disease, which makes the disease trapped by this rough treatment style.Thisis the fourthreason for the failure ofthe treatment.” It is emphasized that inquiry should ask about the cause and the development process of the disease. The ten Questioning Song written by ZHANGJingyue in Ming Dynasty comprehensively summarizes the contents, sequence and significance of differentiation.There are many factors affectingthe disease. The purpose of inquiry is to fully collect the disease data that cannot be obtained by the other three diagnosis. Especially in the early stage of the disease, the diagnostic clue can be grasped by inquirywhen the patient has not yet shown objective signs and only has conscious symptoms.
At present, an intelligent inquiry system of TCM has been successfully developed, which combines TCM theory with intelligent information processing technology to construct an inquiry training system of TCM with the functions of man-machine dialogue and interaction, so as to realize intelligent triage or clinical auxiliary diagnosis. The system is generally composed of front desk template, inquiry processing template, diagnosis template and database management template. Medical institutions can collect the basic information of users through the front desk inquiry template, and comprehensively judge the symptom information through the diagnosis template, and then the front desk template will display the diagnostic results and triage information [7].
1.4 Pulse diagnosis
Pulse diagnosis is a method for doctors to touch, fumble, push and press some parts of patients with their hands, so as to know the state of human body and examine their illness. Lingshu: CijieZhenxie says: “Anyone who uses acupuncture must first observe the sufficiency and deficiency of the meridian, thenfeel pulse and follow it, press and flick it, check the move condition of pulse qi, and finally take appropriate acupuncture points to cure the diseases.” The origin of pulse diagnosis is closely related to the meridian theory, and abnormalities can be diagnosed and treated by feeling the pulse and pressing along meridians. After that, people gradually discovered the abnormal pulsation of superficial arteries at the meridians, which can be used to analyze the state of zang-fu, qi, blood, yin and yang. Suwen:SanbuJiuhoulun points out that the upper, middle and lower three related arteries can be examined to judge the disease condition, so that thepulse diagnosis is gradually separated from meridian diagnosis.On the basis of this,Nan Jing initiated cunkou subdivision, dividing intocun, guan and chi, and the zang-fugoverning diseases, expounded the abnormal pulse condition of cunkou and the prediction of prognosis, which had a profound impact on the pulse diagnosis theory of TCM.
Regarding pulse diagnosis, there is a saying that "I feel it in my heart, but it is difficult to use".Compared with other diagnostic methods, pulse diagnosis is more difficult to master. However, due to the irreplaceable position of pulse diagnosis in the four diagnostic methods of TCM, there have been endless researches on it since ancient times. At present, researchers mostly focus on the “position, number, shape and momentum” of pulse condition, using sensors and pulse condition recognition technology to replace finger feeling, and obtain objective quantitative indicators by analyzing and processing the collectedpulse information[8]. In addition, the modernized research in pulse diagnosis also includes the research and development of acupoints instrument, which mainly relies on the electrical measurement technology of TCM to detect and identifyacupoints according to the difference in resistance between meridian points and non-meridian points[9].
2 Principles of information collection for four diagnosis
Clinically, in the four-diagnosis collection process,we should pay attention to the particularity of different diagnostic methods and the “comprehensiveness” of the combination ofdiagnostic methods to ensure the “standardization” of the collection process and the “accuracy” of the informationcollected. Therefore, the three core principles, comprehensiveness, standardization and accuracy, should be followed in the information collection of the four diagnostic methods.
2.1Comprehensiveness
The principle of "comprehensiveness" means that the four-diagnosis information needs to be collected from multi-angles, multi-aspects and multi-levels.
2.1.1 Collect information in multiple dimensions
The four diagnostic methods of TCM are to examine the disease from different aspects and ways, which are independent and complementary to each other. The collection of disease data should be based on the holistic concept of TCM, and paying attention to the completeness, richness and systematicness of informationrather than "knowing at a glance" or the practice of differentiation based on pulse[10]. Professor LICandong[1] proposed to collect patient information from macro, meso and micro dimensionsin order to fully grasp the disease.
2.1.2 Pay attention to negative symptomsand signs
It is necessary to identify the significance of negative symptomsand signsin clinical practice, such as not thirsty in mouth, normality of stool, warmth of hands and feet, reddish tongue, thin and white coating, etc., which are beneficial to the differential diagnosis. In Treatise on Febrile Diseases, it is often said that the body fluid is not injured by the mouth not thirsty, and the normality of stool means that the disease is not in the yangming intestines. For example, article 125 of Treatise on Febrile Diseasessaid: “The site of the disease is not blood if the syndrome of taiyangappeared with yellow body, deepand jie pulse, hard abdomen, and abnormalurination. The site of the disease is blood if urination is normaland the patient is manic.” It can be seen that the original text uses normal urination and abnormal urination to distinguish whether the site of disease is blood or not. Therefore, we should not only catch the negative symptoms of patients, as well as the positive symptoms, the four seasons’climate and so on to accurately grasp the etiology and pathogenesis, and realize “There was no fault in the treatment, because there is no error in the diagnosis”.
2.1.3 Pay attention to disease trends and continuously improve the four-diagnosis information
The comprehensive and systematic collection of four-diagnosis information is clinically emphasized, but it is difficult to cover everything in practice. Therefore, it is essentialto collect the information purposefully and methodically according to the actual situation.
The severity and urgency of the disease should be taken into consideration when collecting four-diagnosis information. For example, doctors are required to grasp the most prominent symptoms and signs of emergencypatients and make a preliminary diagnosis as soon as possible.Later on, doctors should pay close attention to the changes of the disease, and constantly collect information to modify and supplement the preliminary diagnosis, so as to achieve the comprehensiveness of syndrome differentiation.
2.2 Standardization
The principle of “standardization” mainly refers to standardizing the information of the four diagnosis and its collection process to realize the repeatability and feasibility ofsyndrome differentiation.
2.2.1 Description standardization
Due to the complexity and particularity of TCM and the richness of Chinese characters, the description of symptoms in TCM isvivid enough and lack of standardization. Furthermore, the description of symptoms of TCM still exists subjective ambiguities, multiple words representing the same meaning, inconsistent standards,new terminology and other irregularities, which undoubtedly limit the further promotion and application of the four diagnosisof TCM. Therefore, it is vitalto standardize the symptoms to overcome the shortcomings such as nonstandard name, unclear connotation and extension, vague expression of symptoms, indistinct quality difference between symptoms, and unclear differential diagnosis. In addition, the standardization of the four diagnosis of TCM should also be conducive to reflecting the nature of the disease. For example, the clinical significance of lack of appetite for a new disease is not significant, long-term lack of appetite often indicates weakness of the spleen and stomach. It is not conducive to clarifying the nature of the disease if all cases are called lack of appetite in general.
2.2.2 Collection standardization
Due to the intricacies of clinical work, the collection of some condition data is too hasty and not standardized, which affects the objectivity of the four-diagnosis information.Every diagnostic method must be carefully applied to make the information true and reliable. First of all, doctors need to master the basic methods of the four diagnosis of TCM, and avoid the hasty style. Secondly, we should try our best to avoid preconceived and subjective assumptions, and prevent subjectivity and one-sidedness in collecting the information from the four diagnosis. Furthermore, doctors are also required to have patience and professional ethics tocomplete the “predetermined actions” in a standardized way so as not to delay the disease. In addition, the development of TCM diagnostic instruments provides strong support for the standardized collection of TCM information from different aspects, and can well realize the repeatability and quantification.
2.3Accuracy
The principle of “accuracy” meansthat the disease data collected through the four diagnosismust reflect the disease objectively and truly.
2.3.1 Collect four-diagnosisinformation objectively
The factors affecting the accuracy of the four-diagnosisinformation mainly come from three aspects. First of all, the clinical manifestations of diseases are complex and diverse.On the top of that, the medical history and related information provided by patients will be inaccurate and incomplete, and even hidden and exaggerated due to the influence of age, education and other factors. Finally, the judgment and description of the four-diagnosisinformation is usually done by one doctor, so there must be some subjectivity in the information. Therefore, clinicians need to have extraordinary professional skills. Not only can they not be fooled by illusion in clinical practice, but also be able to listen patiently and carefully, ask repeatedly in many aspects, and eliminate all kinds of interference factors as much as possible, so as to ensure that the process of collecting symptoms and signsis objective and accurate and close to the actual situation of patients.
2.3.2 With modern science and technology
In response to the subjectivity and ambiguity of TCM, TCM can actively adoptmodern scientific instruments and technologies ofsound, light, electricity, and magnetism to improve the accuracy of diagnosis. On the one hand,it is crucial to develop and introduce new testing instrumentsactively; on the other hand, it is beneficialfor TCM to create effective unique diagnostic methods and local diagnostic methods based on modern artificial intelligence technology to further enrich the content of diagnosis, instead of staying in the traditional diagnosis of "three fingers, A pillow" level.
3 Summary
In a word, the patient’s condition changes intricately, and the clinical manifestations have the differences between obvious and hidden, true and fake, part and whole and so on.If doctors want to grasp the nature of the disease and diagnose the disease and syndrome correctly from the ever-changing and complicated manifestations, they should first proceed from the principle of combination of four diagnosis when dealing with clinical data, and secondly, carry out a comprehensive and systematic examination of patients in order to give full play to the leading role of doctors, and finally, they had better collect comprehensive, standardized and accurate four diagnosis information from multi-level and multi-angle with the help of modern instruments and equipment of TCM, and establish a standard and objective diagnosis model, so as to improve the correctness of syndrome differentiation and treatment and enhance the clinical curative effect.