Looking at the evidence: Notes on diagnosis and the evaluation of efficacy in TCM
European Journal, vol.5, n.1, 1995

Elisa Rossi
English translation by Emelia Mills and Kara Smith.

The small room is really crowded with people even for a Chinese clinic: two patients on trolleys against the wall, relatives, students, assistants, other patients. And Dr Zhang with his Mongolian-style moustache and sly smile, chain-smoking, sometimes leaving the needles in, sometimes not, and giving the impression that he only ever needles Taixi (KI-3). This article tries to explain at least part of our pressions gleaned from looking at the shen of Dr Zhang Shijie's eyes, from some of the clinical results his talks about dao, as well as from reading his article on theoretical and clinical aspects.
The encounter with Zhang Shijie also stems from a 'search for a master', from a curiosity for a teaching method different from that of the doctors of the Training Centres, whom we still admire and appreciate. The work of Zhang reminds one of that profound fascination for the simplicity of a gesture whìch has great effect; but also specifically connects with the current debate on the problem of diagnosis in Chinese medicine. It brings us back to the most recent scientific thinking surrounding the problem of the evaluation of traditional medicines to the crux of the debate on what constitutes scientific knowledge.
Zhang Shijie's article is in two parts: the first theoretical with a discussion on the method of establishing a diagnosis, referring to the physiological and pathological picture, followed by thirty clinical case studies in which this type of method is applied. Reference is made in this text to the classics.
We found it useful to present our article from a number of different angles: starting with the most theoretical part of Dr Zhang's article, extracting some points for critical reflection; then looking at some of the clinical case studies (which are presented in their original translation by Dr Zha Xiaohu and Elisa Rossi), and for a more thorough examination of the pathogenic interpretation we refer to the
`clinical case study'. In Zhang Shijie's work both the discussion on bianzheng (diagnosis through differentiation of syndromes) and the method of studying the clinical cases do not coincide with the system currently most used in China. These ideas have been published, however, and Dr Zhang is considered one among the forty ming lao zhong yi (famous Chinese doctors). His students are chosen, their selection made official in a ceremony, and at the end of their training they are allowed to specify in their title: 'student of Dr Zhang'. In other words these opinions are not considered marginal or even excluded from the contemporary Chinese `scientific community'.

Yuan wu bi lei - to reveal and compare

From the start, Zhang Shijie's article states very clearly that the knowledge and interpretation of a clinical case study through the various levels of reference that exist within traditional Chinese medicine are the minimum requisite for establishing a diagnosis; the real difficulty is in the following stage, when the various elements have to be unified. He identifies this process of synthesis in the principle of yuan wu bi lei. By examining modern commentaries to Suwen we find that yuan wu means 'to take/make one thing/fact evident' and bi lei means 'to make a comparison' (whilst lei bi is `analogy') but contains at the same time the idea of going back to the real cause, which does not necessarily reside where it is manifested.
In this paper Dr Zhang says 'This artic1e refers to thirty clinical case studies and demonstrates how in the practice of acupuncture not only the ba gang (the eight principles), the six jing (six pairs of meridians) the zangfu (internal organs), (the energies) wei qi and ying qi, xue (blood) and san jiao are necessary to come to a diagnosis through differentiation of syndromes, but that it is necessary to use the principle of yuan wu bi lei, which we find in 'Shi cong rong lun' (chapter 76) of Suwen as this method allows us to recognise the source of a hundred illnesses and to return therapeutic practice to a unitary whole'. And further on: `If there isn't a high analytical level there cannot be a high synthetic level, therefore the more detailed the diagnostic method of Chinese medicine is, the higher its level of synthesis will be. Otherwise our models would be like mist on the sea'. He becomes more specific with regard to the diagnostic method bianzheng when he talks about Zhang Zhongjing, how the term bianzheng first appeared in his Shang han lun, and how this method contributed to the development of Chinese medicine and has been honoured by doctors in every school. He recalls how Zhang Zhongjing referred to the concepts of Suwen and Nanjing, and whilst using the notion of jing luo and of acupuncture points, he preferred the study of prescriptions and pulses. And he stresses how, even then, the knowledge of jing mai constituted the basis of acupuncture, which is founded on `Zhong shi’, as is clear from the following quote: 'The li criterion of each puncture has its origin/beginning in the jing mai and the method of each puncture has its completion/end in Zhong shi.
And Zhang Shijie goes on: 'Yet yin and yang, qi and xue illnesses specific to the twelve channels (jing shi dong), six yang and related illnesses, course biao ben (knowing the manifestation and curing the source), gen jie (root-knot), the harmonisation and opening of the passages of qi (qi jie he kai), the notion of axis (shu) and connected pathological transformations, can be synthesised with difficulty through bianzheng, therefore the acupuncturist cannot avoid a method which uses comparison and analogy (bie yi bi lei).
By using this method one can arrive at a synthesis from a diagnosis through differentiation based on models (bianzheng fen xing), which are extremely detailed and subtle (xi). The subtler the analysis the higher the level of synthesis is necessary.
Zhang Shijie upholds this thesis by referring to the chapter ‘Shi cong rong lun' when he says that 'the evolution of an illness is so wide from high to low, that you cannot appreciate it by following the texts' and gives the example of a case discussed in the same chapter: `a person with a headache, contractions of tendons, feelings of heaviness in the bones, stomach swelling, regurgitation and belching, who gets easily frightened and is always on the look out (qie), with shortness of breath and restlessness, who does not like to lie flat. From which organ does all this originate? The pulse is floating, tense, as hard as stone on pressure (fu, xian, shi jian), I cannot explain all this and I ask again how can I understand the relationship (bi lei) with the three organs'.
He comments by saying that: 'If you analyse this case without using the method bi lei you can arrive at three conclusions: 1. The meridian of the liver has its origin in the point dadun, its qi links up to that of the kidney, arrives at the top of the head and controls the muscles. When there is a headache and muscle discomfort the illness depends on the qi of the liver channel. 2. The meridian of the kidney originates from the point yong chuan, it is the source of the production of qi and controls the bones. If the bones are heavy and there is shortness of breath then the illness originates from qi of the kidney meridian. 3. The meridian of the spleen has its origin in yinbai, is linked with the stomach by a membrane (mo). If there is regurgitation and belching, stomach swelling, jerky movements, and the patient is uncomfortable lying down, then all these are disorders of the spleen channel. In this way we would arrive at a therapy based on three meridians'.
Whereas Huangdi in Suwen replies: 'You are forgetting the eight winds and the building up of heat, the five organs are consumed and the xie (perverse external energies, pathogenic factors) go from one to the other. The floating pulse means kidney failure and the deep and hard pulse is the internal block of qi of the kidney. There are jerky movements and shortness of breath because the water passages are blocked and xing (shape, body) and qi are consumed; cough and the restlessness come from the qi of the kidney counter current. In this person the illness is in one organ. If you say that it is in three you are mistaken'. The article further reports a comment from Zhang Jiebin who confirms that 'these disorders are rooted in the kidney and it is wrong to talk of three organs that act at the same level' and concludes by repeating that 'this shows how it is possible to intervene only on the kidney, and if one did not proceed according to bi lei one would find oneself looking at a deep abyss or floating clouds'.
It then becomes necessary to understand both the key to reading signs and symptoms, and to have a deep understanding of the rules of underlying events and their development: 'the subtle analysis' constitutes the foundations of good medicine, but on this must be built the moment of synthesis. The synthesis would be represented as a vision that comprises and explains all the data consolidating them at a higher level (if wc think of the theories that periodically have upset the world of physics and mathematics, these solutions are generally simpler and more elegant). The concept of yuan wu bi lei takes us back to the principles of Chinese thought: wc know of a logic which proceeds by analogy and of a progression that evolves horizontally, and we recognise that they are fundamental elements like synchronicity and correspondence, but it isn't always easy to translate this into practice, to use them to reach a diagnosis and to choose the points.
But in the most theoretical part of the article by Zhang as well as in the clinical case studies, the method yuan wu bi lei is not explained in detail: as is often the case in the Chinese tradition, it is the occasional allusion that suggests the concept. As when, as if it were obvious, it is suggested that there is a relationship between a semiotic or pathogenic factor and macrocosmic elements like the qi of earth or sky.
On the other hand one appreciates the importance of the physiology and pathology of the meridian in diagnosis. We know the signs and symptoms 'of the meridian', though we don't always notice them: in Zhang Shijie's approach the anatomy of energies takes account of synthesis yuan wu bi lei.

On diagnosis

I would like to return to the current debate in the West regarding the diagnostic method bianzheng` by stressing that a possible critical examination of bianzheng cannot be made without recognition of its total value.
Those who studied in the European schools of acupuncture remember the enthusiasm and amazement of their first sojourns in China at the beginning of the 1980s, when suddenly everything seemed clearer. The texts, the articles, the translations, as well as dealing with Chinese pharmacology later confirmed the richness and usefulness of this diagnostic approach. I would also like to mention how the method bianzheng shows how complex and refined Chinese medicine was in the early centuries after Christ. And I would like to stress how this method contains such richness - in the late 1950s Mao defined traditional Chinese medicine as `a treasure' to be conserved and raised to a higher level - and such flexibility that in the debate in the 1970s traditional Chinese medicine was considered not `a residue of feudalism' but as already containing the seeds of dialectic materialism. If for us in the West moving within bianzheng means avoiding the risk of being vague, in
China taking bianzheng as a method of reference meant choosing a system of the highest standard, which is didactically transferable, unifying in mass practice, and one that could be used in controlled ways within research and clinical studies.
In this way Chinese medicine has been able to sustain competition against the biomedical Western system which has become dominant over other traditional medical systems. This dominance does not exclude the efficacy of many other traditional medical systems, but their value remains in general circumscribed within a specific cultural group: instead traditional Chinese medicine has official recognition within China, constituting a trans-cultural phenomenon (it is used in developing countries, present within `Western' medical literature, and the spread of its practice cannot be considered a temporary phenomenon).

On evaluating efficacy

It is said that bianzheng, as a very articulate method involving a different process of diagnosis through differentiation, is close to conventional medicine because it offers the possibility of building controlled clinical studies. Traditional Chinese medicine is an energetic medicine, which despite being founded on totally different presuppositions from conventional medicine, seems to offer the possibility of working through stages similar to those used in the West, especially in the initial formation of similarly diagnosed patient groups or in the final evaluation of results. When on the other hand the diagnostic approach is presented from the beginning in a less structured way, one is confronted with the problem of evaluating the results of nonconventional medicines, which I would like to discuss briefly.
Firstly, the risk that the positive results of therapy be considered a phenomenon of spontaneous recovery can be avoided by giving a diagnosis formulated on the basis of the modern biomedical standard, carried out on a rigid choice of cases, and using biomedical terminology. However the use of the observation protocols inherent in conventional medicine presents some difficulties: treatments are in fact the product of diverse and sometimes incompatible schools of thought. Besides, the comparison of clinical results favours the system that gives taxonomic criteria (and
thus defines the rules), and thus penalises non-conventional medicines that deviate.
Finally, the compared medical systems can differ not only in the intended therapeutic effects and results, but in the actual definition of the fundamental problem, that is in the diagnosis. In fact, not all medical systems differentiate diagnosis in a systematic way, and resorting to more diagnostic categories in interpreting illness could appear to be a sign of imprecision, inexperience, lack of clarity; whereas the use of diagnosis through differentiation, fundamental in the conventional approach, has in traditional and alternative medicines a limited, nonsystematic role.
In this sense the bianzheng method presents fewer problems since it is based on the rule of diagnosis through differentiation, despite a physiology and pathology which is different from biomedicine. Other diagnostic models, for instance in acupuncture, base their therapeutic efficacy on characteristics of variability, contingence, and flexibility, which makes their insertion in common protocols difficult.
There is a tendency to no longer identify the parameters which define scientism (= truth) for only the quantification or ability to reproduce an experiment opens the way to the introduction of new methods of evaluation. The concept of exactness is not the heritage of one single system of analysis or interpretation or of one single method of interaction.
These ideas have only been briefly outlined but wc decided to mention them because we believe that wc can all be involved in the search for new methodologies.
Wc have used a more theoretical approach than would generally be found in the practice of Chinese medicine, remembering that every clinical practice is connected in some way to a theory, and because even when Dr Zhang was talking to us, the various levels of discourse overlapped and were integrated. I was puzzled when he defined Chinese medicine as mo gu ('uncertain', the same term used in the Heisenberg principle), to then go on to say `like the theories of contemporary knowledge'.
Zhang refers to a complex hypothesis that he sees already present in the classics: in the article, referring to the `necessiry of taking into account a variety of disciplines', he again quotes chapter 76 of Lingshu when he says that 'one must observe the complexity of the disciplines and put them to an analogical comparison (lan guan za xue ni yu bi lei)'. For the modern commentator this means considering other texts besides Neijing, but more probably he refers to other fields of knowledge such as astronomy, Yi Jing (the book of changes) feng shui (wind-water, geomancy) since the value of a text also derives from the fact that it comprises alt the preceding texts. Other aspects in the article help to widen the debate. For example it is mentioned that 'Chinese medicine is a meeting of many disciplines and in practising it one needs an objective, dynamic and systemic view', and that `at present all scientific fields are following a new direction of thought characterised precisely by this systemic-organic approach and medicine too has to move along this development of disciplines', he again quotes chapter 76 of Lingshu when he says that 'one must observe the complexity of the disciplines and put them to an analogical comparison (lan guan za xue ni yu bi lei)'. For the modern commentator this means considering other texts besides Neijing, but more probably he refers to other fields of knowledge such as astronomy, Yi Jing (the book of changes) feng shui (wind-water, geomancy) since the value of a text also derives from the fact that it comprises alt the preceding texts. Other aspects in the article help to widen the debate. For example it is mentioned that 'Chinese medicine is a meeting of many disciplines and in practising it one needs an objective, dynamic and systemic view', and that `at present all scientific fields are following a new direction of thought characterised precisely by this systemic-organic approach and medicine too has to move along this development

SUMMARY: The following are a selection of some of the thirty cases reported in Dr Zhang Shijie's article. Beginning with a range of clinical problems, the diagnosis goes back to the pathology in the kidney and is treated with taixi point yuan of kidney.

Case No. 5 - Fu zhong gugu bian sou nan - Noises in the abdomen, with difficulty emptying the bowel and bladder.

A 70 year old female peasant, suffering for the last two years from noises in the abdomen, with difficult emptying of bowels and bladder and fullness and distension (pi zhang). When she exerts little effort to contract the abdominal muscles the noises increase. Scanty and painful diuresis, constipation.
Various examinations did not help to come to a clear diagnosis and treatments with Western and Chinese pharmacology did not have any effect. The two pulses are tense (xian), they come strong and become weakened (lai sheng qu shuai: it indicates a pathological excess and also an initial insufficiency of zhengqi). The tongue is without coating (guang)', deep red. On palpation of the abdomen there is the noise of water.
`Jue and abdominal noises, very cold (duo han qi, not specified whether it is a symptom or a diagnosis), gurgling noises, difficult bowel and bladder, one takes zu taiyin (meridian of the spleen)'. The abdomen is controlled by the spleen and is also where it is located. The qi of the spleen is exhausted which is why there are noises. The spleen controls the qi (in the sense of transformation and transportation), it is the extreme of yin (taiyin) which is why there is cold and the noise of water. The qi of earth when it rises makes clouds, the qi of sky when it descends is rain, the qi of earth does not rise, the qi of sky does not descend, so the tongue is without coating, the emptying of bowels and bladder are difficult. The symptoms of this case are of false heat and real cold, there is extreme emptiness (zhi xu), but manifestations of fullness. Illness of yin to be treated with yang. One uses the method of tonifying the origin of fire, the taixi point is needled, obtaining the qi like a fish being caught. The noise stops, at palpation there is no longer the noise of water.

Case No. 19 - Ben tun qi - Qi of the running pig.

From fin gui yao lue by Zhang Zhongjing, chapter 'Ben tun qi bing mai zhen zhi’ (illness, pulse, symptoms, prescriptions of qi of the running piglet), which says `In ben tun illness, qi starts in the lower abdomen", attacks the throat, the attack is such that one wants Lo die, then it stops (in the sense that it does not last long), all attacks come from tear (kong)'. You Zaijing (?-1749): `The kidney is struck (shang) with fear, ben tun is an illness of the kidney, the pig is a water animal (remember the analogies between the five elements and animals), the kidney, a water organ. The qi of kidney is disturbed inside, attacks the throat, like a running pig, for this reason it is called running pig. There are also cases where the beginning is a liver illness, because kidney and liver have a common origin (gan shen tong yuan, the same phrase used in case of yinxu) in the lower jiao, the qi of both organs goes up against the current (ni)'. Therefore I needle taixi to treat these illnesses with paroxysmal access (fa zuo xing), with considerable results.
A 58 year old male teacher, whose illness appeared during the ten years of unrest (the cultural] revolution) probably due to tear (kong), with frequent bouts throughout this period. In 1977 he came to the clinic complaining that he had qi (like a sensation of a current') which rose from the lower abdomen to the chest, feelings of restlessness and agitation in the middle of the heart (xin zhong fan luan), difficulty in breathing, cold limbs, with a desire to vomit but couldn't vomit, and pain that was out of the ordinary. The two pulses were deep and tense, the tongue pale red, the coating thin and white. The diagnosis was ben tun qi; the two taixi were needled, the symptomatology regressed immediately and there were no longer any attacks.

Case No. 20 - Mei he qi - Qi of the plum-stone

From fin gui yao lue by Zhang Zhongjing, chapter `Fu ren za bing mai zhen bing zhi' (`Various women's illnesses, pulse, symptoms, and prescriptions'): 'Women have Like a little piece of roast meat in their throat (zhi luan), the prescription in these cases is Banxia Houpo Tang'.
From Yizongjinjian 6: 'There is a Little piece of roast meat in the throat, with tan, which one cannot cough up nor swallow, which is like an illness qi of the plum stone'.
It is often caused by stagnation (yujie) of the emotions (qingzhi), and is also not infrequent in men. The channel Of the kidney goes along the throat and surrounds the tongue. Thus with taixi stagnation (san) can be dispersed, qi can be made to descend against the current.
A woman of 43, a relative of a hospital staff member, has had the sensation of a foreign body stuck in her throat for the last year, has taken a lot of Banxia Houpo Tang, even with variations, with no result. The two pulses are deep, a little tense (chen wei xian), the tongue a little red (wei hong), the coating thin and white. The diagnosis is of qi of kidney that rises high in the opposite direction (ni). I needled taixi and the symptomatology regressed more than 50% during the first session, completely after the second. In Yizong jinjian it is said that the illness mei he qi derives from stagnation of qi due to emotions, together with tan and, as Zhang Zhongjing advises, Banxia Houpo Tang is prescribed, in which banxia houpo and shengjiang are hot (xin), disperse the stagnation (san jie), and bitterness (ku) makes the counter qi
descend (only houpo is bitter); fuling assists (zuo) banxia, facilitates the fluids (li yin), moves tan; zisuye is aromatic and disperses the blocks of qi, if qi flows tan is removed, and the illness is resolved.
According to my experience if in this illness there are no symptoms of fullness (man) in the chest and of hardness in the epigastrium (xin xia fian) this prescription generally is not very useful. It is less effective than considering a different diagnosis, that of kidney qi which rises in the opposite direction, and to needle taixi.

Case No. 24 - Xuan yun - Dizziness.

A female student of 16, after a long and shaky bus journey starts to feel giddy, with nausea and excessive salivation. On examination she also presents with depression (jing shen yi yu), cannot think of eating or drinking, and vomits. The face is pale, the skin is cold and sweaty, BT. 80/S0. Pulse deep chen and slow chi, her eyes are rolling, standing is shaky (zhan li bu wen). The qi of the five organs, of the five elements, all have their root in water and in fire of anterior heaven (that is in the kidney). When qi of the five yin is exhausted (jue), the root of the eye' rotates and then there is dizziness (yun), when the zhi (spirit in the kidney) is dead then there is dizziness. The kidney controls zhi, the channel of the kidney goes up through the liver and diaphragm, along the throat, behind the nose (kang sang). It connects to the root o£ the eye, goes to the front, connects to dumai at the top. For these reasons I needled taixi and all the symptoms immediately disappeared.

Case No. 16 - Yi bing xing tan huang - Hysterical paralysis

From Suwen, chapter Wei lun, 'The qi of the heart is warm then the qi of the lower blood vessels rises, and the blood vessels become empty, and cause wei-atrophy, therefore the joints on which the body is supported break, the legs (jing)9 cannot support the body which becomes unsteady'. Because the heart is sovereign of the five zang and of the six fu, it governs all, hun, po, yi, zhi.
From Lingshu: 'Sadness, pain, anxiety and worry (bei ai you) disturb the heart and this shakes the five organs and the six viscera'. Therefore if emotions don't follow one's own wish (qing zhi bu sui) and the seven feelings are disturbed inside (nei dong), this leads to wei atrophy of the blood vessels, due to heat in the heart.
From Suwen, chapter Wei lun: 'Yangming is the sea of the five zang and of the six fu, it governs the lubrication of the tendons, the tendons bind the bones and make the joints mobile.
Chongmai is the sea of the blood vessels, which permeates and penetrates all the points'°, meets with yangming in all tendons. The meeting of all the tendons yin and yang is in the qijie (the area that corresponds to the precise point qichong, ST 30), governed by yangming, and all belong to daimai and connect to dumai. Therefore if yangming is empty all the tendons are flabby, if dumai does not conduct (yin) the feet have wei atrophy and cannot be used. All wei syndromes are then strictly connected with yangming and chongmai, that meet at qijie. Chongmai originates in the kidney, heart and kidney, fire and water exchange in turn, to needle taixi, point yuan, is to feed water and to assist fire, fill and feed all tissues, soften the tendons, warm the Legs. Therefore you can needle taixi not only for atrophy caused by heat of qi of the heart, but for all wei syndromes, in conjunction with other points.

Case No. 26 - Tong jing - Dysmenorrhoea

A woman of 32 has been suffering from dysmenorrhoea for the last three years and for the last year her periods have been scanty with dark clotty blood. She has cold limbs, nausea and a need to vomit. The pulse is deep, a little thin, the tongue is a little red with thin white coating, the face is greenish.
She was treated initially for stagnation of qi and of blood: reinforcing qihai (Ren 6) and dispersing sanyinjiao (SP 6) with a prescription to regulate qi and to move blood. The pain diminished, the other symptoms remained the same, the pulse was not so deep but tense (xian). In Suwen it is said that the floating pulse fu and tense xian is emptiness of the kidney. It the kidney is empty then chongmai and renmai are empty, that is they do not fill the abdomen and the menses are infrequent and painful. The blood vessels do not distribute and the limbs are cold;
they do not rise to the spleen, which then loses nourishment and there is nausea and vomiting. You needle taixi.
N.B. The approach 'according to the meridian' is expressed also by remembering that the qi of the kidney follows chongmai (menstrual disorders are an example) and rises: the superficial manifestation can then be in the lung (asthma, respiratory disorders) or in the stomach (the various instances of rising qi of the stomach), but the root is in the kidney.

An illness of the kidney meridian

Summary: this case offers points for theoretical and practical reflection on the issues raised by the diagnostic and therapeutic path of master Zhang and his idea of the principle yuan wu bi lei - to reveal and compare.
The case of a woman of 56, a peasant who for the last six years, from dawn to dusk could not open her eyes like when one is asleep. Also during the whole day she complained of constriction in her chest, xion men, feeling of hung heart", had dyspnoea duanqi, mesogastric fullness wanpi"- strong anxiety". All these symptoms were relieved by ingestion of food, to reappear shortly afterwards, with hunger and nausea, but without any desire to eat.
The pulse is floating fu, tense xian, taken in its depth it is a little slippery (chen qu wei hua). The tongue is pale, with white and quite thick coating.
The yinqiao and yangqiao meridians connect and enter one another in the inner corner of the eye, yin and yang interchange; if yin prevails the eyes close. Yinqiao is a ramification of the kidney meridian; if yin is strong and yang weak the earth-spleen is not heated, and there is a feeling of fullness and uneasiness in the stomach. The kidney does not receive qi (shen bu na qi), the breath is short and there is chest constriction; when there is illness of the kidney channel the symptoms are: hunger without desire to eat and heart suspended with feeling of hunger.
Thus wc treated taixi, point yuan source of the kidney, we obtained qi like catching a fish to bait, and all symptoms were immediately relieved. After four sessions the illness was very much improved.
With the normal diagnosis according to zangfu, that is bianzheng, it would have
been difficult to come to a conclusion, whereas by considering it an illness of the kidney meridian the result was easier.
With an excess of yin qi and a lack of yang qi it would seem that yang needs toning up whereas instead you need to regulate water": it tones up yang within yin, that is point taixi (KI 3), and it is much better than to needle yangqiao directly.
Here the original text ends. I have tried to run through the diagnostic journey in an autonomous way, using the symptoms and signs described in the clinical cases. I set out to collect case studies of master Zhang, incorporating only his point of view.
`From dawn to dusk the eyes would not open, like when one is asleep', the first symptom given in the case study can describe a relative or absolute excess of yin and therefore of the involvement of the extraordinary meridians yinqiao and yangqiao. It would be an excess of yin in yinqiao: in the morning the internal yang does not surface at point jingming UB 1, the wei qi do1~'s not flow as it should (from this derives the symptom of sleepiness).
But there can be other causes to the sleepiness, among them the build-up of moisture and of mucus.
The other symptoms can refer to the upper and middle heater, whereas there does seem to be no evidence of symptoms referring to the lower heater, especially to that of the kidney. The constriction in the chest, the shortness of breath and the feeling in the heart relate to the upper jiao; the mesogastric fullness, the nausea, the hunger without wanting to eat to the middle jiao. In relation to zangfu the hunger without wanting to eat can mean deficient yin in the stomach, but there is nothing to validate this. The mesogastric fullness and the nausea can be referred to the presence of mucus. The constriction in the chest and the shortness of breath can belong to different pathogenic pictures both of emptiness and of fullness: the lack of yuan qi of the kidney, yang qi that does not flow in the chest, presence of mucus and stagnation of blood, that are not confirmed by other signs. The fact that all these symptoms get better by eating can be ascribed to a deficit, particularly of qi.
Let us consider the tongue and the pulse: the tongue is pale, the coating is white and a little thick. The coating can be indicative of the mucus and the colour of the tongue with a deficiency of yang and so, in this case, it would be cold tan.
Let us analyse this hypothesis: if yang is deficient and/or has difficulty in flowing, there is an accumulation of mucus, because of alteration in the metabolism of fluids which is linked to the triple heater and to yang of the kidney, spleen and lung, whilst remembering that the root of yang is in the kidney. There are no signs of empty cold void or other deficiencies of yang, in particular of the kidney that would confirm such a lack. The pulse, which I would have expected to be deep, is instead floating and tense; in a similar chronic pathology that has been present for the last six years, this would indicate a deficiency in the kidney, despite the fact that the symptomatology and the look of the tongue do not validate this. The deep slippery pulse can indicate a yang in yin or mucus.
To summarise: it could be a relative excess of yin that originates in the deficit of yang, that is manifested in the yingqiao meridian, and is associated with a slowing down of the circulation of the yang in the chest with the formation of mucus.
On the basis of this diagnosis, by choosing the imbalance of yinqiao, I would have dispersed the key point or point xi of the meridian in conjunction with the toning of yang of the kidney and spleen and the transformation of mucus.
Master Zhang retrenches the involvement of yinqiao and yangqiao and the secondary vessels of kidney and bladder, demonstrating in fact the possibility of application of yuan wu bi lei. He revalues the importance of the knowledge of the meridian both in its pathway - thus in its anatomy of energies - and in its pathology15 He shows how the journey may recapitulate and bring together the pathogenic process through the appreciation of symptoms connected to the pathology of the meridian. It is the kidney together with its meridian, the pathogenic root that holds the relationship with the two heaters, where the symptoms are manifested.
In my opinion, in this clinical case, the meridian would function in the same way as described in chapter 76 in Suwen, Shicong ronglun. In fact it seems to me that the principle yuan wu bi lei is based on repeatedly distinguishing the original pathogenic root. The master also resorts to the same principle in order to create a unitary therapy: he supports the use of taixi to regulate the water by evoking the image of the ideogram kan, in which the central line yang refers to taixi as point yuan, the place where the yuanqi of the kidney emerges, the original yang. In this case the master refers to a text not strictly linked to medicine such as the Yi Jing.
All this leads back to the case studies and clinical semiotics. In fact I believe
that only in the first phase can the collection of symptoms and signs constitute a simple body of information; their destiny, as soon as wc ask questions and note the signs, is that of becoming more complex information16 and this happens when the information is related to the systems of reading" and these in turn become interrelated. During this journey we differentiate the information by evaluating the connections made and from the systems of reading prioritised. Perhaps the master is suggesting the idea that the system/s that allow/s us to obtain more coherence and to establish a unitary pathogenic root can really have priority, time and time again. In particular, in this case, this happens through drawing on the theory of meridians and a classic, but not medical, text such as Yi Jing.
Therefore let us consider Dr Zhang's experience as an important contribution and an invitation to reflect on the epistemological journey we follow each time we approach a clinical case. Through complex relationships wc are able to build a picture that corresponds to the diagnosis, and Ave find the pathogenic root from which Ave can derive unitary therapy. Highlighting this original root could reduce the multiplicity of points Of view that converge in building the final picture, which wc have seen results from the epistemological journey that each of us follows more or less consciously.