Problem Solving in Chinese Medicine

Evidence Based Medicine (EBM) has not eliminated the need for the somewhat elusive clinical mental activity called “problem-solving.” Every systematic review presents the interpretation of an “expert,” whose biases remain largely invisible to the consumer of the review. In addition, meta-analyses cannot generate evidence where there are no adequate randomized trials, and most of what clinicians face will never be thoroughly tested in a randomized trial. For the foreseeable future, excellent clinical reasoning skills and experience supplemented by well designed quantitative tools and a keen appreciation for individual patient preferences will continue to be of paramount importance in the professional life of medical practitioners. (Harrison’s Principles of Internal Medicine)

When Chinese medicine began over 2,000 years ago there were neither simple nor complex diagnostic quantitative tools, such as thermometers and laboratory blood analyses. Problem solving was qualitative; it was based on signs and symptoms alone. In this regard, it was and still is a very pragmatic medicine. The goal of diagnosis in Chinese medicine is not to explain the etiology of the disease, but to correctly identify a treatment strategy. If a patient complains of feeling hot, or the doctor feels that the patient’s skin is warmer than it ought to be, the appropriate treatment is to “clear the heat.” Doctors treat the phenomenological aspects of the disease they encounter. If the signs and symptoms change, the treatment protocol changes as well.

Diagnosis in Chinese medicine is based on clinical reasoning skills; it is multi dimensional and ‘holistic’ in that it takes into account the whole patient, their present condition and their constitution. A robust patient might be treated with stronger herbs and more acupuncture points than a weaker patient. Pregnant patients are not given certain herbs or treated with certain acupuncture points. Children are not treated like adults, and disease is known to progress differently in children as compared to adults.

Chinese medicine aims to understand the interdependence of individual components within the human body, a complex, dynamic and nonlinear system. Chinese medicine has a solid systematic foundation of disease pattern recognition, and a corresponding treatment strategy. Pattern recognition takes into account multiple simultaneously occurring signs and symptoms, a “top-down approach,” with treatment being of primary importance. This differentiates Chinese medicine from Western medicine, which uses a “bottom-up approach”, in that it attempts to identify and treat a single etiological factor in a linear fashion. These different approaches make Chinese and Western medicine complementary.

The terminology that was used to describe the signs and symptoms, in the classical texts of Chinese medicine dating back to the Han era (206 BC-220 AD), continues to be used today. Doctors trained in both Chinese and Western medicine make great effort to translate traditional terms into standard biomedical language. However, not every single phenomenon recognized in Chinese medicine is easily translatable. The descriptor “heat” can mean the patient is febrile or that the patient reports feeling hot without a quantitative elevation in body temperature. One of the most difficult terms I had to come to terms with, as a Western practitioner studying Chinese medicine, is the term “wind.”

What does “wind” mean in Chinese medicine? One of the definitions of a disease characterized in Chinese medicine by “wind” is what we now call an “airborne disease.” We can catch the common cold and influenza this way. Considering that microbes weren’t discovered until the 1670’s, and the use of antibiotics wasn’t started until 1928, it is remarkable that Zhang Zhong-Jing (150-219), the author of the Shang Han Lun, observed that “wind” contributed to these “externally contracted diseases”. Zhang Ji lost two thirds of his family to epidemic diseases, and he dedicated his life to the study of the origin, development and treatment of such diseases with herbal medicine. He wrote the Shang Han Za Bing Lun (Treatise on Febrile and Miscellaneous Diseases) consisting of 16 scrolls. These were later divided into two separate volumes; the Shang Han Lun (On Cold Damages), and the Jin Gui Yao Lue (Essential Prescriptions of the Golden Cabinet). These texts are the first known dissertations on the signs, symptoms and progression of disease that, beyond theory, used systematic clinical methods, to determine the prescription of herbal medicine.

There are many characteristics of wind in nature; wind affects the upper body more because it is light and buoyant in nature, it is very mobile and moves suddenly from place to place, wind is always changing, it has tension associated with it and it always combines with other pathogenic factors. In Chinese medicine, a disease with a very sudden onset affecting the upper body, such as a migraine or a stroke can be described with the word wind. A disease with symptoms that tend to move from place to place, such as migratory joint pain, or a rash that shows up on one body part and then on another, can be described with the word wind. Muscle tightness that, upon palpation exhibits rubbery tension, can be described as wind in the channels or collaterals. Muscle spasms, twitches or tremors are described with the word wind. Wind always combines with other pathogenic factors such as heat, cold, dampness, phlegm or dryness. Conditions associated with wind can be made worse by being outside in climactic factors.

The reason why these descriptive factors are so important in Chinese medicine is that these diagnostic details, like puzzle pieces, together create a pattern, which determines the acupuncture point and herbal medicine prescription. Acupuncture points that clear heat and expel wind are appropriate to treat a pattern of “wind heat” such as in a case of influenza. And, specific herbs are also used to treat a wind heat pattern.

The inherent strength in treating the qualitative signs and symptoms of a disease is that treatment can be effectively rendered, even when the etiology is unknown. It is always helpful to know the cause of a disease, and this is not lost on modern practitioners of Chinese medicine, but it is not a prerequisite for treatment in Chinese medicine. The goal of pattern differentiation is not necessarily to determine the etiology of the disease. The goal of pattern differentiation is to determine the appropriate treatment. It is the clinical reasoning skills and experience of the practitioner in identifying the pattern of the disease that will likely determine the success of the treatment protocol in the Chinese medicine model.

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