Modern Chinese medicine follows Western medicine in defining its specialties according to a patient's manifest pathology. This "common sense" approach classifies, for instance, a postmenopausal woman with heavy vaginal bleeding as a gynecology case and a patient with chief complaints of abdominal bloating and irregular bowel movements as a case for the digestive specialty.
While categorizing the physical expression of pathogenic process is familiar, it misses the peculiar power of classical and historical Chinese medicine.
The attempt to follow "scientific" standards leads modern Chinese medicine to mimic Western medicine in differentiating the physical expressions of pathology. Contemporary clinical doctrine classifies symptoms and signs as the manifestations of pathology into diagnostic categories. We are taught to focus treatment on these imbalances of the zang fu (vital and hollow organs) in managing physical humors (qi, blood and fluids). Successful treatments diminish the intensity and/or acuteness of symptoms and eventually restore balance.
Many students and practitioners choose to narrow their focus and specialize in treating patients with ailments of a particular system after learning this core doctrine. The basic zang fu imbalances express themselves somewhat differently in each of the physiological systems. Different herbs and acupuncture treatments are applicable for different ailments characterized by the same pattern discrimination so there is practical value in this type of specialty. These specialties generally include some training interpreting (Western) medical diagnostic tests, which technologically enhance perception of physical manifestations.
This emphasis on the physical manifestations of distress clearly is reflected in the many clinical handbooks organized according to key symptoms or Western medical diagnosis. While Chinese medical practitioners can learn from understanding how the dominant Western medical model perceives and analyzes various diseases, our greatest resource is the wealth of ideas explored during the long history of Chinese medicine. We must learn from Neijing (The Inner Classic) to differentiate pathogenic causes from intrinsic responses, rather than simply classifying physical manifestations. (See "Beyond Substance to Process," Acupuncture Today August 2007.)
The diagnostic differentiations of modern Chinese medicine are based on the "eight principles." The key functions of each zang fu in managing the humors are evaluated as either excess or deficient and characterized by either hot or cold. The pathology is located either at the exterior or the interior. While these yin-yang pairs date from the classical period, the method of classifying symptoms and signs according to such diagnostic standards was first articulated by Zhang Jingyue (1563-1640).
Though the clinical methodology of classifying zang fu syndromes dominates the contemporary clinical application of Chinese medicine, it departs radically from classical and historical traditions. The Shang Han Lun tradition recognizes that pathologies progress from the exterior to the interior and that heat is the embodied spirit's reaction to the penetration of cold and/or wind. Shang Han Lun inspires us to identify and address the progression of disease, rather than simply classifying clinical presentations according to the eight principles. Our familiarity with the symptom-sign complexes of the zang fu should not mislead us into thinking they have been universal or that they are the distilled wisdom of Chinese medical history.
While the ailments people exhibit express themselves as imbalances in the management of humors by the zang fu, the classical tradition of Neijing (The Inner Classic) recognizes that all those manifestations arise from blockages to the free flow of qi. Those blockages, and the accumulations that develop around them, are the focus of many historical traditions and specialties in Chinese medicine. Each of these identifies blockages in a different aspect of the human drama.
Blockages in the internal movement of wei qi lead to stagnation in the gut. In addition to being a central topic of the digestion specialty, several important authors outside the Imperial Academy focused on these internal blocks. Zhang Congzheng (1150-1228) was concerned with the accumulation of heat and focused on moving liver qi. While his "school of purging and elimination" may appear to be an outgrowth of the digestion specialty, Zhang was a military physician whose training and clinical thinking were heavily influenced by the Waike (external medicine) specialty.
Zhu Danxi (1281-1358) was also interested in identifying and resolving internal stagnations, but his focus was on their contribution to stagnation and depletion of jing (essence). His "school of nourishing (kidney) yin" included key formulas for preserving harmony (Bao He Wan) by eliminating food stagnation and for escaping restraint (Yue Ju Wan) of the five stagnations (food, damp, blood, qi, heat).
The Waike specialty focused on the penetration of perverse wind through the external anatomy. That wind embodies the confusing and distracting influences generated by the individual's interactions with the world. While the current doctrine seeks to guide patients back to normality through balancing the expression of distress, Waike does so through expelling stagnations. Although practitioners of this specialty stimulate and guide the embodied spirit to release stagnations in an orderly way through the natural avenues of elimination, there generally are some healing crises, which consist of intense periods of catharsis.
Patients of the Waike specialty may experience considerable distress at certain times during the healing process. This is related to the embodied spirit's resistance to releasing certain habituated patterns of behavior and/or reaction to the interactions of life. These cathartic events expel not only physical material, but also the patterning of wei qi that generated and tolerated that accumulation. Thus, these healing crises recondition the embodied spirit's intrinsic mechanisms (wei qi) for processing input. Such transformations create, and are able to sustain, profound healing.
Historically, a broadly trained physician was able to choose which facet of life to prioritize in diagnosing and treating a particular patient. Even a brief introduction to historical traditions and specialties can transform a practitioner's approach to devising treatment strategies and expected results. Decreasing the acuteness of symptoms is sometimes not the best short-term focus.
Although our modern clinical doctrine interprets symptoms and signs as direct expressions of pathology, the classical tradition of Neijing and most specialties required that practitioners differentiate between pathogenic factors and the intrinsic responses of the embodied spirit to life's challenges. The disparate tangle of theories that have contributed to clinical doctrines of the past doesn't satisfy the modern scientific standard of (logical) consistency, but it contributes to the peculiar power of Chinese medicine. We devise our most effective treatments when we draw freely from the vast marketplace of ideas that have arisen during the long and varied history of traditional Chinese medicine.
Click here for previous articles by Steven Alpern, LAc.
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