Pattern Differentiation Plus Target Therapy: A New Approach to the Practice of Chinese Medicine
By Dr. Greta Young Jie De (Ph.D)
One of the future developments of Chinese medicine is Target Therapy which applies the traditional herbal formula based on pattern differentiation as well as adding target herbs (i.e., selected herbs) that have the properties of targeting a specific disease identified by laboratory tests as in Western medicine. Distinct from Western medicine, the system of Chinese medicine encompasses the four diagnostic techniques, and various kinds of differentiation, such as the eight guiding principles, the theory of six meridians, and the theory of wei, qi, ying and xue, and others. The concept of Target therapy consists of three aspects i.e. symptoms, pattern and disease (WM disease). It must be noted that symptoms incorporates the chemical indicators of western medicine In order to identify the key symptoms, one must invoke the strategy of "Focus on the chief symptoms or 抓主症" On the other hand, Western medicine heavily relies on laboratory blood tests and medical instruments to provide further information for diagnosis of many diseases. In recent years the practice of Chinese medicine is incorporating more and more such Western laboratory information in the diagnosis and treatment of diseases. It is in this background of both traditional Chinese medicine pattern differentiation and conventional Western laboratory diagnosis and laboratory test indicators that target therapy is gradually becoming more prevalent by adding specific herbs as an adjunct to the traditional prescription formulated based on differentiated pattern.
Significance of "Focus on the Chief Symptoms" 抓主症
There is a degree of difficulty to grasp the real essence of Jing Fang. This is because often many TCM practitioners are mainly focused on the patients' "chief complaints", which can be regarded as the tip. In reality, the chief complaint is the result of careful analysis by the practitioners via the four Examinations. In accordance with the TCM theory, disease is the result of the patient's loss of yin and yang balance while pattern (证) is a summery of the practitioner's analysis via the "Four Examinations". The patient's chief complaint is the process of abnormal manifestations resulting from the imbalance of yin and yang. It is through the symptoms to understand the disease; and also from the symptoms to understand the pattern. Thus, "disease, pattern and symptoms" are interrelated to form a triology of diagnosis. Pattern (证) reflects the nature of disease and it is the result of the diagnostic skill of the practitioner, and whether the diagnosis is accurate is totally dependent on the TCM level of the practitioner. There are three essential elements correlated to the pattern ie., aetiology of the disease, disease location and nature of the disease while the "chief complaints" reflect these three essential elements. Suffice to say that the chief complaints are associated with the tip of the disease instead of the root. In reality, the detection of the chief complaint hinges on the practitioner's ability and accumulated clinical experience.
Differences between Pattern Differentiation and Target Therapy:
Broadly speaking, the traditional method of formulating a prescription is to select herbs according to their traditional classifications of pharmacological properties, which fulfil the treatment principle. The theory of herbal properties and hence their classifications is primarily based on the components of “Five Tastes and Four Qi as well as Attributive Meridians” of the herb. However, in the concept of Target Therapy, specific herbs are chosen based entirely on researched outcome of the herb’s clinical indications for a particular disease as diagnosed by Western medicine and laboratory tests. Knowledge of these target herbs and their specific clinical indications has been accumulated over past 60 years through modern pharmacological researches mainly done in China. It should be pointed out that some disease-specific indications of many of these target herbs had also been recognised empirically and taken advantaged of in the traditional practice of Chinese medicine for a very long time. Thus modern researches not only confirm and lend credibility to their application as target herbs, but also have expanded our knowledge of many more such target herbs. In other words, modern clinical and laboratory investigations of many herbs and/or their chemical components have demonstrated specific pharmacological properties that are effective in treating certain diseases as identified by Western medicine and indicated by Western biochemical or haematological indicators. For example, Hong Qu 红曲, Jiao Gu Lan胶股兰 and Wu Gu Chong 五谷虫 can effectively lower the serum cholesterol; Huang Lian, Zhi Mu, Chi Shao can lower serum glucose; Wei Ling Xian 威灵仙, Tu Fu Ling 土茯苓 can reduce urinary urea; Lei Gong Teng 雷公藤 and Chuan Shan Long穿山龙 can regulate the auto immune system etc.
Based on this concept, Professor Tong Xiao Lin of Guangan'men Hospital suggests regular use of Western diagnosis and biochemical indicators in the practice of Chinese medicine of employing the traditional Chinese medicine diagnosis and pattern differentiation. Furthermore, he advocates the wider application in Chinese medicine practice of combining Pattern Differentiation and Target Therapy by formulating the traditional prescription to address the identified pattern, and at the same time adding the target herb(s) to specifically home in on the Western-diagnosed disease and/or its biochemical indicator(s). This approach will likely potentiate the effectiveness of the traditional approach of differentiation and expedite recovery of health. Below are two cases that involved such combined approach:
Case Study 1:
Diabetes with hyperlipedemia
Li xx 42-year-old-male
Chief complaints: Elevated blood lipid for 5 years and elevated blood sugar for one year.
S/S: Dry and parched lips; facial acne, right chest oppression, sloppy stool, dark stasis spots on the back of tongue, submerged pulse.
Fasting blood glucose :10.96 mmol/L; TG 4.41 mmol/L; Total cholesterol 5.46 mmol/L; GPT 117 u/L; GOT 61 u/L. Abdominal ultrasound : Fatty liver
Prescription: Xiao Xian Xiong Tang modified
Huang Lian 30g; Ban Xia 15g; Gua Lou 30g; Zhi Mu 30g; Sheng Shan Za 30g; Hong Qu 12g; Wu Wei Zi 30g; Hong Hua 0.5g (to be mixed with decoction); Jiu Da Huang 6g (wrapped); Sheng Jiang 5 pieces.
Second consultation (one month later): Improved dry and parched lips and oppressed sensation in the chest; normal bowel movement; TG1.96 mmol/L; GPT: 27 u/L; GOT: 18 u/L. Weight Loss 5 kg.
Three months later: Improvement of fatty liver, normal blood lipid and normal bowel movement.
Discussion: (Comment: Irrelevant! Focus on and clearly discuss the role of target herbs – which one is target herbs in this formula? If without knowledge of target herbs, a practitioner can still arive at such a prescription including the herbs you mentioned based on traditional knowledge, then this case is not exactly a good example for this topic. So, must SPECIFICALLY point out the target herbs.) The cause of hyperlipedemia can be attributed to improper diet, thus by adding Sheng Shan Za, Hong Qu combined with Wu Wei Zi and Hong Hua can effectively improve the fatty liver disorder as well as reducing the liver transaminase. (Ref: Tong Xiao Lin Jing Fang Xin Yong)
Case Study 2:
Guo x 39-year-old male
Chief complaints: Elevated blood glucose for one year; Uric acid 480 µmol/L
S/S: Serum glucose is stabilized; FBG: 5.5 mmol/L, 2h PG 6.4mmol/L; occasional stomach distension; yellow, thick and greasy tongue coating; dull tongue body with sublingual stasis spots, and a submerged and slightly slippery pulse.
Prescription: Ge Gen Qin Lian Tang + Wei Ling Xian 30g; Qin Pi 15g. Cang Zhu 30g; Hou Po 15g.
Second consultation: (Two months later)
His distended stomach improved, and his UA was reduced to 412 µmol/L. The core formula was modified with addition of Qin Pi 30g. However, the patient consumed some seafood and his UA was raised to 794µmol/L. Hence Qin Pi was added as a target herb to reduce the UA.
After further two months of medication, his UA was 425µmol/L.
Discussion: Abnormal uric acid is a chemical indicator of gout. From the Chinese medicine perspective an attack of gout can be treated as Bi Syndrome hence the recommended herbs such as Wei Ling Xian and Qin Pi are herbs for treatment of Bi Syndrome in Chinese medicine. High uric acid can cause the TCM disorder of "Shi Lin (Kidney stones), edema, kidney failure etc. Recent findings reveal that hight uric acid is intimately associated with cardiac and kidney diseases. Asymtomatic hyperuricemia can be attributed to improper diet resulting in phlegm damp turbidity. Hence the selection of disinhibiting dampness and eliminating turbidity can be regarded as a basic treatment principle for abnormal uric acid. Many herbs, which expel turbidity and removing dampness have been proved to be effective in enhancing the excretion of uric acid. (. (Ref: Tong Xiao Lin Jing Fang Xin Yong)
Case Study 3:
Wang x 76-year-old female
First consultation: 1st June 2009
History: Type 2 diabetes for one year. She had been taking Acarbose Tablets
S/S: Difficulty in falling asleep; sweating in the upper part of the body with cold limbs in the lower part. occasional heart palpitations; nocturnal urination 3 times at night. Her tongue was dull and purple with thick tongue coating and her pulse was submerged and slightly rapid. Fasting blood sugar: 4-9 mmol/L; serum glucose after meals (2hPG) 5.7 - 10mmol/L.
Pattern identification: Yin deficiency with non-interaction of heart and kidney
Prescription: Chao Zao Ren 120g; Huang Lian 30g; Rou Gui 6g; Shan Yu Rou 30g; Wu Wei Zi 15g; Duan Long Gu 30g (decoct first)
Second consultation: 14th June 2009
After taking 14 packs of the medication, the patient was able to get 3 hours sleep per night but still suffered from difficulty to fall asleep with easy awaking; her sweating was reduced and so was her heart palpitations. Her nocturnal urination improved and her bowel movement was sloppy with two movements daily. Her tongue was dull and had thin yellow tongue coating and her pulse was submerged, thready and wiry. FBG 4-10 mmol/L; 2h PG 5.7-8.8 mmol/L. Increase Chao Zao Ren to 150g.
Third consultation: 30th June 2009
After taking four packs of the modified prescription, her sleep was substantially better with 4-5 hours sleep per night. She complained of slight fatigue but there was no other discomfort. Her tongue was dull with thin, yellow tongue coating and her pulse was submerged, thready and wiry. Add Huang Qi 45g; Wu Wei Zi 15g and switch Duan Long Gu to Yuan Zhi 30g; reduce the dosage of Huang Liaqn to 6g and Rou Gui to 1g.
Discussion: The above case study was diagnosed as suffering from insomnia hence the large dosage of Suan Zao Ren was prescribed. It must be noted that Suan Zao Ren was used to improve sleep however, in this instance, the large dosage was used to improve the patient's insomnia. Therefore the target herb is Suan Zao Ren. According to "Ben Cao Bei Yao 本草备要 which said: "Suan Zao Ren is a tonifying and moistening herb, it can astringe sweating, calm the heart. It is sweet and sour and moistening specialising in tonifying the liver and gallbladder especially deficiency of gallbladder with inability to sleep. " Suan Zao Ren Tang is a formula from :Jin Gui Yao Lus" for treatment of insomnia. Suan Zao Ren contains Suan Zao Ren saponins, flavonoid glycosides. Irrespecitve of water or ethanol extractions both have sedative, hypnotic and inhibitory effect on the CNS. The prescribed formula is supplemented by Jiao Tai Wan to exert heart and kidney interaction to augment the sedative. Please note the dosage of Chao Zao Ren is 120-150g which is relatively large compared to the standard dosage of 15-20g. (Ref: Tong Xiao Lin Jing Fang Xin Yong)
The contemporary approach of Chinese medicine by incorporating specific targeted herbs can serve the purpose of treating many diseases.
It is hoped that Traditional Chinese Medicine can take full advantage of the modern scientific researches of many Chinese herbs in an endeavour to improve the bio-chemistry parameters.
Dr. Greta Young will share with you in depth the concept of "Contemporary Applications of Jing Fang" such as the targeted herbs, the optimum dosage for the targeted herbs and how to focus on the Chief complaints etc, in the forthcoming live webinar scheduled for 18th and 19th September 2021. For more details please visit 2021 Contemporary Applications of Jing Fang