Why Should We Bother with Treatment Principles?
Why Should We Bother with Treatment Principles?
The statement of a treatment principle (zhi ze) is a standard step in the practice of professional Chinese medicine in China. These principles are written down right after the patient’s presenting patterns and before the treatment plan. As such, they are a part of the patient’s written file for every visit (or at least every time the patient’s pattern discrimination and, therefore, treatment changes). It is said that the treatment principles are the bridge between the pattern discrimination and the treatment. Unfortunately, in the West, we do not always have a good understanding of the hows and whys of using these treatment principles. On the one hand, this may be due to linguistic issues. On the other, it may be due to a lack of understanding the clinical utility of this extra step between the diagnosis and the treatment. However, if we understand how to state treatment principles correctly and then how to use them as the directions for erecting our treatment plan, they become an extremely useful tool for insuring that our treatment truly represents or manifests our pattern discrimination. The pattern discrimination tells us what is out of balance in our patient. The treatment principles tell us what we need to do in order to restore balance. Once we understand what, in theory, we need to do with the patient, then it should be relatively easy to create a concrete method of achieving those ends using whatever modality is most appropriate. In terms of acupuncture-moxibustion, once we have stated the treatment principles, we know that we should use 1-2 points to accomplish each stated principle. We may also know whether needling, moxa, bleeding, tuina, or some other modality is the best approach. Then, when looking back over our treatment plan or formula, we can check whether each point or method is or is not warranted by the stated treatment principles. Basically, stating treatment principles is a method for turning the abstract pattern discrimination into a concrete treatment plan. It allows for more precision in point/method choice and administration technique as well as for peer review by our teachers, mentors, and co-professionals.
In Chinese medicine in China, patterns and their related treatment principles are professionally agreed upon can only be stated in only a few standard ways. As such, there are right and wrong treatment principles for each pattern and there are standard ways of stating each of these principles. Further, the method of stating these principles is based on the idiosyncracies of the Chinese language. This means that the ways Chinese state these principles in Chinese is a function of the structure and rhythms of the Chinese language. For instance, treatment principles are most commonly stated in four word phrases where each phrases has two parts, each part made up of two Chinese words. Thus, jian pi bu qi (fortify [the] spleen [and] supplement [the] qi) is the most commonly used treatment principle for remedying the pattern of spleen qi vacuity weakness (pi qi xu ruo). In this case, the words in brackets [ ] have been added to the English translation to make the principles grammatically correct In English. However, literally, the phrase reads, “fortify spleen supplement qi.”
Then, if there is more than a single pattern present, the next pattern stated is given its own treatment principles in the same way. Thus we move from the predominant or most important pattern to the least dominant or important pattern. For instance, if we say that a patient’s presenting patterns are a combination of spleen qi vacuity weakness complicated by damp accumulation along with blood vacuity and blood stasis, then there is the assumption that spleen qi vacuity weakness is the most important pattern or the root of the condition, damp accumulation is second in clinical importance, blood vacuity is third in importance, and blood stasis is fourth in importance. This ranking in descending order of importance is then faithfully reflected in the statement of the treatment principles which then become: (1) fortify the spleen and supplement (or boost) the qi,
(2) eliminate dampness,
(3) nourish the blood, and
(4) quicken the blood.
This ranking gives the practitioner a very clear understanding of how much weight they should give to each part of the treatment when it comes to selecting points or methods of treatment. In general, we will tend to select more points (or herbal medicinals) for the most important treatment principles and fewer points for the least important treatment principles.
In some cases, we may need to add an extra treatment principle to the end of the list, which is related to an acute or serious symptom. Commonly, these treatment principles call for the immediate stoppage of an outflow of pure substance which, allowed to continue, would lead to a relatively speedy decline in qi, blood, yin, and/or yang. Such outflows include massive sweating, diarrhea, vomiting, bleeding, persistent vaginal discharge, polyuria, and spermatorrhea. Stopping pain (zhi tong) also warrants its own acute terminal treatment principle. When such an acute terminal treatment principle is added at the end of a list of treatment principles, then we must be sure that one or more points in the treatment plan or formula do, in fact, directly and reliably address that symptom or condition.
This whole process, tied as it is so closely to the Chinese language, is often not well understood by Western students and practitioners of Chinese medicine. However, it is my experience that the more we try to understand this professional terminology and apply this step-by-step methodology of moving from pattern discrimination to treatment principles to treatment plan, the easier it becomes to compose acupuncture-moxibustion or herbal medicinal formulas and the more clinically accurate and effective those formulas are. Therefore, I highly recommend always stating the requisite treatment principles after stating the patient’s pattern discrimination and before erecting a treatment plan. I always try to state the treatment principles in the same order as the patterns, and also try to use professionally accurate standard terms for the treatment principles.
In order to help all of us learn this process, below is a partial list of common Chinese medical patterns with standard treatment principles. In the book Sticking to the Point, we give a much longer list, followed by two chapters that give commonly used acupoints for most of these treatment principles. I hope readers find this to be helpful. Just a note: all terminology used here is based on A Practical Dictionary of Chinese Medicine by Nigel Wiseman and Feng Ye. Thanks for reading!
Treatment principles correlated to patterns
Qi vacuity: Supplement the qi
Blood vacuity: Either supplement or nourish the blood
Yin vacuity: Either supplement, nourish, or enrich yin
Yang vacuity: Either supplement, warm, or invigorate yang
Blood vacuity: Nourish or supplement and regulate the blood
Blood stasis: Quicken the blood and transform or dispel stasis
Blood stasis in the network vessels: Quicken the blood and free the flow or open the network vessels
Blood heat: Clear heat, cool the blood, and stop bleeding
Phlegm dampness: Transform phlegm and dry dampness, rectify the qi and harmonize the center
Phlegm nodulation or binding: Transform phlegm, scatter nodulation or binding, and/or soften the hard
Damp heat: Clear heat and eliminate dampness
Heat toxins: Clear heat and resolve toxins
Cold striking the channels and network vessels: Warm the channels and scatter cold
Wind damp impediment: Dispel wind and eliminate dampness, free the flow of impediment and stop pain
Damp heat impediment: Clear heat and eliminate dampness, free the flow of impediment and stop pain
Cough: Stop coughing
Diarrhea: Stop diarrhea
Bleeding: Stop bleeding
Vomiting: Stop vomiting
Sweating: Stop sweating
Pain: Stop or stabilize pain
Irregular menstruation: Regulate the menses
Restless fetal stirring: Quiet the fetus
Constipation: Free the flow of the stools
Disquieted spirit: Quiet, calm, still, and/or settle the spirit
Insomnia: Quiet the sleep
Syncope: Arouse the spirit
Dampness: Eliminate, transform, dry, seep, or disinhibit dampness
Dryness: Moisten dryness and/or engender fluids
Exterior contraction: Resolve the exterior
Interior repletion: Drain the interior
Interior cold: Warm the interior
Externally contracted wind: Course or dispel wind
Internally engendered wind: Extinguish or track down wind
Liver depression qi stagnation: Course the liver and rectify the qi
Liver-spleen disharmony: Harmonize the liver and spleen
Liver-stomach disharmony: Harmonize the liver and stomach
Liver depression-depressive or transformative heat: Course the liver and rectify the qi, resolve depression and clear heat
Liver-stomach depressive heat: Clear the liver and stomach, resolve depression and downbear counterflow or harmonize the stomach
Liver depression and blood vacuity: Harmonize the liver
Ascendant liver yang hyperactivity: Clear the liver and subdue yang or subdue yang and downbear counterflow
Upward flaming of liver fire: Clear the liver and drain fire
Internal stirring of liver wind: Settle the liver and extinguish wind
Liver blood insufficiency or vacuity: Relax or emolliate the liver and nourish the blood
Liver blood-kidney yin vacuity: Nourish the liver and enrich the kidneys
Yin vacuity-yang hyperactivity: Enrich yin and subdue yang
Liver-gallbladder damp heat: Clear heat and eliminate dampness from the liver and gallbladder
Cold stagnating in the liver vessels: Warm the liver and scatter cold, rectify the qi and stop pain
Heart qi vacuity: Supplement the heart qi
Heart blood vacuity: Supplement heart blood
Heart-spleen dual vacuity: Fortify the spleen and nourish the heart, supplement the qi and blood
Heart-gallbladder qi vacuity: Fortify the spleen and nourish the heart, transform phlegm and rectify the qi
Heart fire effulgence: Clear the heart and drain fire
Phlegm confounding the heart orifices: Transform phlegm and open the orifices
Spleen qi vacuity: Fortify the spleen and supplement or boost the qi
Spleen qi downward fall: Fortify the spleen, boost the qi, and lift the fallen
Spleen vacuity with stomach heat: Fortify the spleen and clear the stomach and/or harmonize the center
Spleen-kidney yang vacuity: Fortify the spleen and boost the qi, supplement the kidneys and invigorate yang
Spleen vacuity with damp encumbrance: Fortify the spleen and eliminate dampness
Damp heat smoldering in the spleen: Clear heat and disinhibit dampness
Food stagnation in the stomach duct: Disperse accumulation and/or abduct stagnation
Stomach qi counterflowing upward: Harmonize the stomach and/or downbear counterflow
Wind cold raiding the lungs: Course wind and scatter cold, diffuse the lungs and stop coughing
Wind heat attacking the lungs: Course wind and clear heat, diffuse the lungs and transform phlegm
Wind dryness damaging the lungs: Course wind and clear the lungs, moisten dryness and stop coughing
Phlegm heat depressing the lungs: Transform phlegm and clear heat, loosen the chest and resolve depression
Lung heat smoldering and exuberance: Clear the lungs and drain fire
Phlegm turbidity obstructing the lungs: Transform phlegm and dry dampness, fortify the spleen and stop coughing
Lung qi vacuity: Supplement the lungs and boost the qi
Lung-spleen dual vacuity: Fortify the spleen and boost the qi, supplement earth to engender metal
Lung dryness with simultaneous phlegm: Moisten the lungs and clear heat, rectify the qi and transform phlegm
Lung yin vacuity: Enrich yin and moisten the lungs
Lung qi and yin dual vacuity: Clear heat and moisten dryness, supplement the qi and nourish yin
Large intestine damp heat: Clear heat, transform dampness, and free the flow of the stools
Large intestine fluid dryness: Nourish the blood, moisten dryness, and free the flow of the stools
Kidney qi vacuity: Supplement the kidneys and boost the qi
Kidneys not securing the essence: Supplement the kidneys and secure the essence
Kidney yang vacuity: Supplement the kidneys and warm or invigorate yang
Kidney yin vacuity: Supplement the kidneys and enrich or nourish yin
Kidney essence insufficiency: Supplement the kidneys and fill, foster, or boost the essence
Urinary bladder damp heat: Clear heat, disinhibit dampness, and free the flow of strangury
This article was excerpted and condensed from Sticking to the Point: An Approach to TCM Acupuncture Therapy by Bob Flaws and Honora Lee Wolfe, Blue Poppy Press, 2008.
Thanks so much for helping to make students(and the rest of us) more clinically careful.
On a personal note, I handed over my practice recently to a colleague because I had to have some surgery. Had I not clearly identified my treatment prinicples and strategies, I would have had hours of work preparing my files for my colleague, rather than using my time to mentally, spiritually and physically prepare for my own healthcare.
So thanks again for stating it so eloquently.
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