One diagnosis, two treatments

Two people arrive with the same diagnosis from their doctor: irritable bowel syndrome, IBS for short. A doctor asks: which disease is this? A TCM practitioner then asks a second question: how is the balance disturbed in this particular person? The answer is called a pattern, and that pattern decides the treatment, not the disease label.

Bian Bing versus Bian Zheng

Two words carry this lesson. Bing (病) is the disease: IBS, migraine, eczema. Zheng (证) is the pattern. Bian (辨) means to differentiate. So Bian Bing is differentiating the disease, as a doctor does; Bian Zheng is differentiating the pattern, the TCM practitioner's own work. The two do not map one to one, and you can see that in two directions.

You do not need to know these patterns yet; module 1, lesson 6 covers them one by one. Remember the principle: what gets treated is the pattern, not the disease label.

The Liver is not the liver

Patient A has a pattern with "Liver" in its name, while her complaint sits in the abdomen and her liver function tests are normal. That seems odd until you see how TCM understands an organ. Physiological thinking looks mainly for chains: what leads to what, via which mechanism. TCM orders mainly correlatively, by resonance: what goes with what, what changes together. The difference is one of emphasis, not a dividing line: medicine also recognises conditions by a cluster of findings, and TCM also has causes of disease, the subject of module 3.

So in TCM the Liver is not a gland that makes bile but a functional network. It stores the Blood, keeps the Qi of the whole body moving smoothly, and goes with the sinews, the eyes, the emotion anger and the season spring. One area of that smooth flow is digestion. When Liver-Qi gets stuck through stress, it presses on the Spleen, the organ of digestion. That is how patient A comes by her pattern, with perfect liver function tests.

Not two things, but a relationship

Under every pattern lies the same grammar: Yin and Yang. The characters refer to the shady side (陰, yin) and the sunny side (陽, yang) of a hill (textbook knowledge). It is one hill. So Yin and Yang are not two substances but two sides of one whole, and the sun keeps moving.

From that image TCM orders everything in pairs. The table gives the pairs you meet most often, and how you recognise them in a patient.

This is where a practitioner's work begins: every finding gets a place on these axes. Is it hot or cold, restless or slow, full or empty? Lesson 2 turns that into four fixed questions, the Eight Principles, with which you can order any picture.

How Yin and Yang relate to each other

The book describes four aspects of the relationship (ch. 1 p. 7). Together they explain how health stays in balance and how it goes off the rails. Other texts describe mutual consumption as the waxing and waning of Yin and Yang.

Not standing still, but a balance that moves

In TCM health is not a fixed position in the middle. Yin and Yang swing constantly with day and night, effort and rest, the seasons. Healthy means the relationship comes back after every swing.

Two Western words fall short here. Homeostasis sounds too static, as if the body stood still around a fixed value. "Allostatic load", the accumulated wear and tear of adapting again and again, is too broad. More useful: a push out of balance costs something in the short term, and sometimes brings adaptation in the long term.

Something to think about: what are you optimising for? TCM does not pick an optimum; it restores the relationship in this person, now.

From complaint to principle: IBS twice

The whole method is called Bian Zheng Lun Zhi (辨证论治): differentiating the pattern (bian zheng) and deciding the treatment from it (lun zhi). It is the common thread of this course, in four steps.

1. Findings. Gathered with the four examinations: looking (including at the tongue), listening and smelling, asking, and feeling (including the pulse). Module 1, lessons 10 to 12 work them out.
2. Pattern. Order the findings with Yin and Yang: hot or cold, empty or full, interior or exterior. Then ask: which organ, which substance? Lesson 2 gives you the four questions.
3. Principle. Follows from the pattern, often as its opposite: tonify what is empty, clear or move what is full or stuck, cool what is hot, warm what is cold.
4. Methods. Points, herbs and advice that serve that principle. They follow from the principle, never straight from the complaint.

What a practitioner means by "classical"

TCM is not a single block but two millennia of texts and schools. Four anchors in time help you place what a teacher or a book draws on.

The Six Stages and Four Levels come back in module 1, lesson 14: two models for following how an illness moves from the outside inwards.

Three currents in Chinese thought

Medicine grew up in a culture with three great currents of thought. You will meet their words in the classical texts.

Which tradition were you trained in?

Today, too, there are several traditions. Two practitioners can say different things about the same patient without either being wrong: they are reading a different map. That is why the first question to ask a practitioner or teacher is: which tradition were you trained in? This course follows the first tradition below, the system of the book. The sixth card is not a tradition within Chinese medicine, but a modern needling technique you often meet alongside it.

Spot it

Flashcards

Where it goes wrong

• Correlative is not illogical. TCM has a tight internal logic; it answers a different question.
• A pattern is not a diagnosis. It does not replace the medical work-up; red flags come first (step 7).
• Do not swap empty and full. The principle follows from the pattern: if you only move and clear an empty Spleen, you weaken it further (patient B).
• Yin and Yang are not substances. Equate Yin with "fluid" or Yang with "energy" and you lose the relativity.
• "Classical" is not "TCM". Standard TCM is a modern synthesis.
• A translation is not an equation. Qi is not ATP, Blood is not haemoglobin, Jing (Essence, lesson 3) is not DNA.

The translation, as a hypothesis

Discussion questions

Four imbalances, one dotted line

The book draws Yin and Yang as two bars side by side, and this course does the same. The dotted line is the norm: as much Yin and as much Yang as this body needs. When a bar rises above it, something has been added that does not belong there: Excess. When a bar drops below it, something is lacking: Deficiency.

1. Which bar is off, and in which direction? Above the line is Excess, below the line is Deficiency.
2. Which bar is now the higher one? If Yang is higher than Yin, the picture is warm (Heat); if Yin is higher, it is cold (Cold).
3. What do you do about it? What rises above the line, you take away; what drops below it, you top up. The treatment principle follows straight from the picture.

Who wins: a balance of power, not an amount

Deficiency and Excess are the concepts beginners get stuck on most often. They sound like a measure of how ill someone is: lots of complaints is Full, few complaints is Empty. That is not how they work. They describe a balance of power between two parties: what protects you, and what makes you ill.

A xie qi is not necessarily a microbe; you recognise it by the picture, not by a culture. Wind-Heat overlaps with a viral infection, but the name describes how the body reacts, not which virus it is (ch. 21 p. 269).

Excess means: a xie qi is present, and the zheng qi is still strong enough to fight back. You can see that battle: a sudden onset, intense complaints, fever or sharp pain, a forceful pulse. Deficiency means: there is no xie qi of any importance, but the zheng qi itself falls short. Nobody is fighting; something is missing. It creeps in, the complaints nag, the pulse is weak.

zheng qi, your own strength   xie qi, the invader   dashes: what would normally be there

Where it comes back. The treatment principle follows from who is winning. In Excess the practitioner expels the xie qi; in Deficiency they tonify the zheng qi; in a mixed picture they weigh up what comes first, or do both. A well-known image from the textbooks: tonify while the invader is still inside, and you shut the door with the thief in the house.

Empty-Heat is not mild Full-Heat

Empty-Heat often feels milder than Full-Heat, so beginners take it for a weak version of it. The difference is not in the amount, but in the cause. A picture from the kitchen makes it visible: think of Yang as the fire under a pan, and Yin as the water in it.

A picture to remember, not a classical text: Yang as the fire, Yin as the water. Schematic.

In Full-Heat the fire is too high: the water boils and everything is hot. In Empty-Heat the fire burns normally, but most of the water has boiled away; the pan becomes hot and dry because the water is missing. Turning down the fire under the second pan solves nothing: the water has to be topped up. In a patient you see findings; the highlighted rows carry the most weight.

Why?

Full-Cold and Empty-Cold, and two borderline cases

On the cold side the same logic applies. In Full-Cold, Cold has been added, from outside (cold weather, ice-cold food and drink) or from inside; Cold contracts and obstructs, and that gives sharp, cramping pain. In Empty-Cold the Yang is too weak to warm: the person feels the cold and is tired, and everything becomes slow and watery.

The same kitchen picture for the cold side; the dotted flames under Empty-Cold show the fire as it should burn. Schematic.

Textbook knowledge; check it in ch. 30 Heat-Cold, pp. 455 to 460.

The Eight Principles are four questions

The Eight Principles (Ba Gang) are not eight diseases, but four questions with two answers each. A practitioner asks them for every presentation, before naming an organ or a pattern. The book calls them Exterior-Interior, Heat-Cold, Excess-Deficiency and Yin-Yang. Tongue and pulse give a first clue for each question.

From finding to principle: warm, but Empty

1. Where? Interior: no acute onset, no shivering or aversion to cold, a pulse that is not floating.
2. What kind? Heat: hot flushes, red cheeks, red tongue, rapid pulse.
3. Who wins? Deficiency: a year already, no coating, a thin pulse. Nothing is fighting; something is missing.
4. Which pole? Yin deficiency: Yang is on the line, Yin has dropped, the Heat is relative. Timing (evening and night) and location (cheeks, soles) confirm it.
5. Pattern and principle. Interior-Deficiency-Heat. Once the organs come in, Kidney-Yin deficiency fits, one of the nineteen core patterns of lesson 7. Principle: nourish Yin and clear Empty-Heat; not just cooling.
6. Differential. Full-Heat more often shows a yellow coating, a forceful pulse, thirst for cold drinks and heat all day. None of these signs decides on its own; the picture as a whole counts. Liver-Fire adds a headache at the temples, a bitter taste and anger.

Try the combinations

Choose an answer for each question; you see which picture follows, with an example pattern, tongue, pulse and principle.

Empty or Full, and which label?

Flashcards

Where it goes wrong

• Empty-Heat is not mild Full-Heat. Cool and drain it as if it were Full-Heat, and you consume even more Yin.
• Excess is about the pathogen, not about intensity or duration. Blood stasis can nag for years and is still Excess; sudden exhaustion after heavy blood loss is Deficiency, however acute.
• Exterior is a layer, not an origin. Cold from an ice-cold drink that invades the Stomach comes from outside but is an Interior picture: the battle is no longer at the surface.
• Mixed pictures are normal. Prolonged Full-Heat consumes Yin: after a week of high fever someone is dry, with a red tongue on which the coating peels. And a weak zheng qi lets an invader in. The acupuncturist then treats both.
• Red flags come before the pattern. Weight loss, night sweating and fever together are also B symptoms, the classic warning signs of lymphoma; episodes of heat with sweating and palpitations call first for TSH, fT4 and, if needed, metanephrines.

The translation, as a hypothesis

Discussion questions

Five substances, from rarefied to dense

TCM does not describe the body as a machine made of parts, but as flows and reserves that feed each other. These are the vital substances: Shen, Qi, Blood, Body Fluids and Jing. They are not things you can put in a test tube; the traditional model sees them as five forms of the same thing, from rarefied to dense. It is a framework for ordering them, not a physical measurement of density. The more rarefied, the more function and movement (Yang); the denser, the more form and nourishment (Yin). This is the Yin-Yang logic of lesson 1, applied to the body.

A practitioner reads every complaint along these five: is it working (Qi), is it nourishing (Blood), is it moistening (Fluids), is there a reserve (Jing), and is the mind clear (Shen)? "Your Qi is stagnating" then means: the function is there, but it does not flow. "Your Blood is deficient": there is too little substance to nourish.

Qi: one substance that condenses and disperses

Qi is hard to translate. "Energy" is too rarefied, "matter" too dense; it is both, depending on how dense it is. The traditional character 氣 shows vapour rising above rice: something released from food that moves. When Qi condenses, form appears: tissue, Blood, fluids. When it disperses, you see function: warmth, movement, thought.

How Qi is formed: plate, breath and a spark

Qi has three sources: what you eat, what you breathe in and what you were born with. The Stomach receives the food and lets it "rot and ripen"; the Spleen extracts the Food Qi (Gu Qi) and sends it to the chest, where the Lungs add the air you breathe in. Together they form Zong Qi, the Gathering Qi of the chest. With the spark of Yuan Qi from the Kidneys this becomes Zhen Qi, the True Qi, which flows through the whole body: a nutritive part inside the vessels, a defensive part outside them.

Four kinds of Qi

Textbook knowledge, after Maciocia ch. 3; Yuan Qi as the motive force in ch. 4 p. 75. The numbers refer to the 19 core patterns worked out in lessons 6 and 7; here the name says enough.

Two additions from the textbooks: Jin flows with the Wei Qi, Ye with the Ying Qi (step 9); Yuan Qi and Jing are the Yang and the Yin side of the same reserve (step 10).

What Qi does: six functions in three pairs

You know what Qi is by what it does. The textbooks list six functions. Learn them in pairs, because each pair fails in a recognisable way: with the two Ts something builds up, with the two holders something leaks or sinks, with the two guards cold and illness get in.

Click a function: what it means, an example, and what you see when it fails.

Four directions: the Qi Mechanism

Qi never stands still. It ascends, descends, enters and exits; together this is called the Qi Mechanism (qi ji). Each organ has its own direction, and health means that each organ keeps to it. You can see it at the table: the Stomach sends food down, the Spleen sends the clear upwards. If Stomach-Qi rises, you feel sick; if Spleen-Qi sinks, the stools stay loose.

Textbook knowledge. Module 2, lesson 12 returns to this: there the Qi Mechanism is the interplay of all organs at once.

Four ways in which Qi falls ill

Twice too little, twice the wrong way. In deficiency there is too little Qi. Sinking is a further step of deficiency: the Qi has become too weak to lift, and it sinks. In stagnation and rebellion there is in principle enough Qi, but it does not go where it should: it stands still, or it rises where it should descend (or goes sideways, like a Liver pressing on the Stomach). In practice they often overlap; Qi too weak to move, for example, also comes to a standstill.

Textbook knowledge; the Qi patterns are in Maciocia ch. 31 (Qi p. 470).

Blood: made from food, stored and circulated

Blood (Xue, 血) in TCM is broader than the red fluid in the vessels: it is the dense, nourishing side of Qi. It comes from the same Food Qi as Qi itself. The Spleen sends it up, the Lungs push it to the Heart, and there it turns red: Blood. The Kidneys contribute through the Jing, which makes Marrow. Then three organs share the work: the Heart governs Blood and the vessels, the Liver stores it and releases it as needed, the Spleen holds it in the vessels.

Textbook knowledge; the Blood patterns are in Maciocia ch. 31 (Blood p. 471). Liver-Blood deficiency (pattern 4) and Heart-Blood deficiency (13) are Blood deficiency with the emphasis on one organ: in the Liver eyes, sinews and periods, in the Heart sleep and palpitations.

Qi and Blood sustain each other

Qi and Blood are a Yang-Yin pair: one is movement, the other substance. The textbook saying sums it up: Qi is the commander of Blood, Blood is the mother of Qi. The commander does three things: it makes the Blood (from the Food Qi), moves it (through the vessels) and holds it (in the vessels). The mother does two: she nourishes the Qi and carries it, because Qi without a carrier is scattered.

That is why an acupuncturist rarely treats Qi and Blood separately. In Blood deficiency they also tonify the Qi of the Spleen, because that is where Blood is made; in Blood stasis they also move the Qi, because Qi pulls the Blood along.

Body Fluids: thin and thick, and the route they take

All healthy fluids in the body are together called Jin-Ye (津液). Jin is thin and clear and moves quickly on the outside; Ye is thick and turbid and moves slowly in the depths. They come from food and drink: the Spleen separates the clear from the turbid, the Lungs spread the clear and send it down, the Kidneys vaporise what is still usable and excrete the rest via the Bladder. The Ling Shu 18 calls these three floors: a mist above, a soaking tank in the middle, a drainage ditch below.

Blood and fluids belong together: fluids thin the Blood, and according to the Ling Shu 18 Blood and sweat have one source. So you do not make someone who has lost a lot of blood sweat, and the other way round. The fluid patterns are in Maciocia ch. 31 (Body Fluids p. 476).

Jing and Shen: the reserve and the mind

The textbooks call Jing, Qi and Shen together the Three Treasures. The image of a candle shows why: the wax is the Jing, the flame the Qi, the light the Shen. Enough wax gives a steady flame, and a steady flame gives a clear light. When the wax runs low, the flame flickers and the light grows dim.

Jing: the reserve

Jing (精, Essence) is the densest substance: the basis of growth, reproduction and development, stored in the Kidneys. There are two kinds. Pre-Heaven Jing you receive from your parents at conception; it determines your constitution and can hardly be replenished, like an inheritance in the bank. Post-Heaven Jing you build up from food and breath, via Stomach and Spleen; that is your income. Living on your income spares the inheritance. Spending more than comes in for years, through overwork without recovery, chronic illness or many pregnancies close together, draws on the inheritance. Together they are called Kidney-Essence. Jing also makes Marrow, which fills the brain and the bones.

Tian Gui, the "heavenly water", matures from the Jing and brings fertility. Jing deficiency shows in children as slow growth and development, in adults as reduced fertility, early greying, loose teeth, weak knees and back and a poorer memory: Kidney-Essence deficiency.

Shen: the mind

Shen (神) is the most rarefied substance: awareness, thinking, memory and sleep. It resides in the Heart and rests in the Blood, the way a bird needs a nest. You see a clear Shen in the eyes: sparkle, attention, contact. For a practitioner "the Shen" is therefore not a vague notion but something they assess at once: how does someone look, how do they sleep, how coherently do they speak?

Classification: textbook knowledge.

From finding to principle: tired, pale and struggling to fall asleep

1. Eight Principles. Interior and Deficiency; no signs of Heat (pale, no thirst, no red tongue).
2. Which substances? Qi: tired, poor appetite, bloated, loose stools, teeth marks; the function of transforming fails. Blood: pale and dull, dizzy, dry skin, hair loss, scanty light periods, thin pulse; nourishing and moistening fall short. Shen: worrying, trouble falling asleep, palpitations; the mind lacks its anchor.
3. How does it fit together? Pregnancy and childbirth cost Blood. A weak Spleen makes too little new Blood, because Qi is the commander that makes the Blood. The Heart gets too little Blood, and the Shen finds no rest in the evening.
4. Pattern. Spleen-Qi deficiency (6) turning into Heart-Blood deficiency (13).
5. Principle. Tonify Spleen-Qi and nourish Blood, calm the Shen. Textbook knowledge: the classical formula is Gui Pi Tang, Restoring the Spleen Decoction; the name says where the root lies.
6. Differential. Liver-Blood deficiency (4) shows mainly in eyes, sinews and nails; Heart and Kidneys not harmonised (14) gives waking at night, night sweats and a redder tongue; Heart-Fire (15) is red, hot and thirsty; Kidney-Essence deficiency affects growth, fertility and ageing.

This is how the building blocks work together: one function of Qi fails, a substance runs low, and the most rarefied substance notices it first.

Which substance, which problem?

Flashcards

Where it goes wrong

• Qi is not ATP, Blood is not haemoglobin, Jing is not DNA. The golden rule of this course: a translation into physiology is always a labelled hypothesis (step 14).
• Blood deficiency is not anaemia. It overlaps with a lack of iron, B12 or folate, but Blood deficiency can occur with a normal Hb, and the other way round. Do have the blood tested.
• Dampness is not a body fluid. Jin-Ye are healthy; Dampness is fluid that has stood still and become pathogenic.
• Stagnation is not Blood stasis. Qi stagnation gives distension that comes and goes, Blood stasis a fixed, stabbing pain. The first can turn into the second.
• Deficiency and stagnation can occur together. The balance of forces decides the treatment (step 6).
• Red flags come first. Bleeding and prolapse are called "Qi not holding" and "Qi not raising", but they call first for a medical assessment.

Four translations, as hypotheses

Discussion questions