Guidelines for Formulating a  

TCM Diagnosis, Treatment Principle and Treatment

Michael Tierra

One of the most challenging obstacles for an advanced East West Course students is to learn how to make and write a TCM styled diagnosis and formulate Treatment Principles and  Treatment  -- all derived from applying the Four Diagnosis. This sequence is the defining cornerstone of Traditional Chinese Medicine and for Planetary Herbology and the students of the East West Course. The most noticeable lack in the education of Western herbalists in myriads of Western herb books, courses, schools and so forth is an appropriate method of assessment that logically flows to treatment strategy and herbal treatment. Without this, clinical herbal medicine simply cannot happen. We are an East West Herb Course, promoting principles of Planetary herbology using TCM and Ayurvedic diagnostic principles and herb classifications to the use of herbs from around the world. Out goal is to educate qualified clinical herbalists and amateur herbalists who have an understanding of clinical herbal methodology. For this it is simply not enough to know the herbs, their uses, biochemistry, etc one must also know an appropriate system for assessing patients attendant to the practice of clinical herbology. The East West Course and Planetary Herbal Practitioner uses Traditional Chinese Medicine (TCM) assessment methods and diagnostic terminology specifically because the diagnosis if done systematically flows smoothly from diagnosis, treatment principle to herbs and formula treatments in one classification continuum.
           A diagnosis should be organized so that the patient’s primary complaint is prominently listed, then any secondary symptoms.  To begin assess the patient in terms of Eight Principles, then Triple Warmer, possibly Six Stages but most important Symptoms-Sign Diagnosis described as described in Lesson 33 of the the East West Course and in book 1 of Traditional Chinese Herbal Medicine.
           In complex cases and most chronic conditions there is usually more than one disease going on and these must be defined in terms of Primary, Secondary and Tertiary complaints. Sometimes and quite often these relate to each other but their individual patterns must first be understood. and then related to the primary complaint and any other complaints. 
   
Diagnosis

Let's take a named disease: ASTHMA for instance.
    Asthma would be the primary disease but based on relevant questioning, this should be elucidated in terms of  -- whether it is particularly aggravated by cold weather (it would be a cold-wind type condition), whether is brought on or accompanied by fatigue and exhaustion (it could be related to a deficiency Qi condition), is there a pattern to the season or time it occurs? (This relates to the five elements and the biological clock  indicating other organs besides the lung is involved with the primary complaint)– is there mucus? (in which case it would be Wind Damp or if dry it would be only Wind). Remember that Phlegm is a further condensation of Dampness in TCM  so while Dampness relates to the excess of the Spleen, Phlegm is its result in the lungs.  The manifestation of phlegm and dampness would be the branch of the disease while possibly the Lungs, Spleen, Kidneys or any other of the six yin organs would be the root. Upon questioning, perhaps the asthmatic symptoms occur after sex  so that depending on the other signs and symptoms, this type of asthma might be seen as a result of  yin or yang deficiency Kidney Deficiency (indicating hormonal (essence) or adrenal insufficiency . Has it been since childhood? – again this points to original Qi or Kidney as the root cause. To corroborate one might ask if parents or others in the family have had asthma or chronic lung problems. Given these considerations one should treat this asthma from the perspective of Kidney deficiency whether or not directly treats the lungs. Now suppose from your questions, observations and so on you notice a number of liver signs then look to liver and lung patterns  -- or spleen signs associated with appetite and eating , then look to lung-spleen patterns. For every disease, one can virtually find several underlying patterns .
           If it is a damp Spleen qi and yang deficient cause the TCM diagnosis might be:
"Asthma with spleen cold dampness and Qi deficiency:”  Supposing the patient has listed rheumatic pains of the joints and lower back and knee pains. These would be secondary complaints pointing to a second disease pattern. For this, the diagnosis is modified as follows: “Asthma caused by spleen, cold dampness and qi deficiency with deficiency of Kidney yang.” If the patient also says they have frequent clear urination and lack of libido your diagnosis does not need to be altered because these symptoms are included with ‘deficient kidney yang.”  So review your diagnosis and see if it reflects most of the important signs and symptoms associated with your evaluation.
    Now what if the patient complains of severe depression and mood swings – this is a third disease category and based on Signs and Symptoms in lesson 33, this would come under the category of Liver Qi Stagnation. Neither of the previous diagnostic patterns would catch this tertiary disease. So one must add "regulate Liver Qi" in the third place (it is third in importance according to the patient's report). 
    With all of these seeming distant and conflicting signs and symptoms it is still of primary importance to keep track of the various complaints in order of importance and severity. 

Most of us are not good enough diagnosticians to base our entire treatment on taking the Chinese pulse and observing tongue diagnosis. These two methods are, however, invaluable as a confirming diagnosis based on interrogation and observation.

The diagnostic pattern that would encompass all of the above is:
Asthma caused by cold dampness obstructing of the lungs with spleen qi deficiency and kidney yang deficiency with liver qi stagnation.
   
 Treatment Principle
    What of the Treatment Principle? While this may seem to be purely theoretical since the Treatment Principle just describes the strategy of treatment based an assessment of the patient and consequent diagnostic pattern previously given.
    Some may think formulating the treatment principle is obvious and therefore redundant. What if after carefully interviewing the patient we decided that regulating liver qi by discouraging those aspects in the patient's life that cause stress, perhaps more rest and recreation. Our Treatment Principle outlines priorities of what needs to be done first or even by itself before the primary complaints associated with the asthmatic symptoms are treated. So in that case, the Treatment Principle would read:

Regulate Qi (with herbs, diet, lifestyle adjustments) and secondarily warm and dry Lung and Spleen dampness and tonify Kidney yang.


Based on the original diagnosis the treatment principle for this patient is congruent as follows:
Warm and dry Lungs, dispel and transform phlegm, tonify Spleen and Kidney yang and regulate Liver Qi.

Treatment
Finally from all of the above we arrive at our herbal treatment by finding a representative formula. This could be any number of formulas one is most inclined to use but lets say it will be modified Citrus and Pinellia (Er Chen Tang) because of wise use of our reference materials. Page 262  of Chinese Traditional Herbal Medicine Book 1  gives Citrus and Pinellia Combination (Er chen tang) as the representative formula. major associating condition is cold phlegm dampness. This dries and clears dampness and phlegm (this type of dampness is not urinary dampness) and Citrus and Pinellia can be used to prevent and treat some types of asthma. However if there Wind (symptoms that change) associated with asthma, one might include an antispasmodic like lobelia inflata from Western herbal traditions or a low dose of ma huang (ephedra) which works in a completely different way to treat asthma (it is like herbal adrenaline) especially during an acute phase. We also see that coldness associated with yang deficiency is an issue in which case we would find a Kidney yang substance. Gecko lizard is specific Kidney yang substance that helps the Kidneys grasp the Qi of the Lungs  (like the Gecko grasps the ceilings and walls or branches of trees. Generally, whenever possible it is good to add two herbs for every associated symptom you are try to treat. The reason is simply that two will have a positive synergistic effect with each other and affect a wider range of the condition. For this I recommend purchasing the book called “Dui Yao” published by Blue Poppy Press. Its very useful for clinical practice.
           One may not find all the two herb combinations and in this case I might choose gecko and cinnamon twig because cinnamon twig also relieves external cold wind and joint pains and its warming action complements the use of gecko. For deeper low back pains we might add or substitute cinnamon bark as well. Finally for greater kidney yang warming cinnamon with prepared aconite can be combined but for many aconite is too heating.
           No let’s assume we have the liver qi stagnation accompanying the previous two conditions. Our studies should point to the use of xiao yao wan or Bupleurum and Peony Combination. This can be given as a separate formula or following dui yao principles, you may simply add bupleurum and white peony to the formula.

In any case the treatment should follow the strategy declared in the Treatment Principle.

The benefit of this systematic approach are many not least of which is that if we know our herbs well and we have reasonable trust in our diagnosis. If any part of that logical process was in error, we have a good sense of what to change and alter. Usually if our diagnosis and treatment is precise, we can expect a positive result even of a chronic problem within a week or so.

THE ORDER OF DIAGNOSIS

Carefully review lessons six and seven in the herb course and learn how to frame your questions in terms of the Five Elements and the Eight Principles. Similarly read chapters three through seven in the first book of Chinese Traditional Herbal Medicine (CTHM).

Lessons 32 and 33 should be carefully studied as these lessons go more deeply into Disease patterns with corresponding formulas.

There are actually ten diagnostic methods in TCM as follows:

1.      Eight Principles

2.      Symptom – Sign or Viscera and bowel pattern discrimination (as described in lesson 33 and Chapter 10 in Book 1 of CTHM).

3.      Six Stages of disease based on the Shan Han Lun as described in Lesson 31 and chapter 6 of CTHM.

4.      The Four Radicals or methods of treating heat described in Lesson 33 and Chapter 6 in Book 1 of CTHM.

5.      Triple Heater pattern diagnosis

6.      Disease cause pattern discrimination which is the named disease and associated patterns.

7.      Qi and Blood

8.      The Three Humours of TCM described in lesson 32 and in chapter 6 of CTHM.

9.      Five Element Discrimination found in lesson 6 of the herb course and chapter 3 of CTHM.

10.  Channel and Connecting Vessel pattern discrimination based on an understanding of the acupuncture channels which is especially relevant to acupuncture therapy but an herb student should make it a point to know these because they are commonly referenced in formulas and clinical diagnosis. I believe that every serious herb student who wishes to become a professional herbalist should concomitantly study some form of Asian physio-therapy such as Japanese shiatsu or Chinese Tuina massage, acupuncture as well as Chinese yoga called “”Qi Gong.” At this point, for most, it would be difficult to make a living only through herbal consultations because clients tend to come less frequently when they are undergoing herbal therapy but if the practitioner establishes themselves in one of the above disciplines, it is possible to develop  a patient flow which is better for the practitioner as well as the patients.

Let’s face it for most of us, mastery of the above could require a lifetime or many lifetimes of diligent study and review so don’t be discouraged if after going over it once or twice you still may not have a consummate grasp of all the elements involved.

Next one should evolve a number of representative Traditional Chinese Formulas and then consider how the desired therapeutic effects can be accomplished to a greater or lesser extent with a Western or Ayurvedic protocol or simply by adding elements along with the TCM treatments and formulas. This can be confusing but ultimately is what frees the practitioner to integrate healing herbs and substances from around the world .i.e. Planetary Herbology. Most of the representative formulas are presented in the third part of the herb course and the second book of CTHM. Believe it or not through in depth mastery and understanding of a few formulas advanced herbalists often time will rely on a relatively small number of formulas say 30 or so with an understanding of how to vary them according to individual patterns. Bringing a desired therapeutic effect down to two herbs, I recommend the book Dui Yao published by Blue Poppy Press.

 

Following are some of the common disease patterns and treatment principles used in making a TCM diagnosis. See chapter 10 in CTHM for more details and possible representative formulas.

 

1.                  Qi Deficiency
Tonify qi

2.                  Stagnant Qi
move liver qi

3.                  Rebellious Qi
regulate Qi

4.                  Blood Deficiency
nourish blood

5.                  Blood Stagnation
regulate and move blood

6.                  Heat in the Blood
cool blood heat

7.                  Fluid deficiency (dryness)
moisten dryness

8.                  Phlegm
Depending on the type of phlegm: transform, expectorate phlegm, scatter nodules, clear phlegm from the Heart,  etc

9.                  Essence deficiency
protect and nourish essence

10.         Yin deficiency
nourish yin

11.         Yang deficiency
tonify yang

12.         Collapse of Yang
Raise yang

13.         Heart Blood Deficiency
nourish Heart blood

14.         Heart Yin Deficiency
supplement Heart Yin

15.         Heart Qi deficiency
tonify Heart Qi

16.         Deficiency Heart Yang
tonify Heart yang

17.         Collapse of Heart Yang
restore and warm Heart yang

18.         Heart Fire
cool Heart fire

19.         Cold Mucus (Phlegm) obstructing the Heart Orifices
warm and dispel cold mucus

20.         Hot mucus (Phlegm) Obstructing the Heart Orifices
cool and resolve hot mucus

21.         External Cold Wind Invasion of the Lungs
dispel cold wind with warming diaphoretics

22.         External Wind Heat invading the Lungs
Cool and dispel external wind heat with cooling diaphoretics

23.         Cold Dampness Obstructing the Lungs
Warm and Clear dampness from the lungs

24.         Phlegm Heat Obstructing the Lungs
cool and expel Phlegm from the lungs

25.         Deficient Lung Qi
tonify Lung qi

26.         Deficient Lung Yin
moisten and supplement Lung yin

27.         Deficient Spleen Qi
tonify Spleen qi

28.         Deficient Spleen Yang
tonify Spleen yang

29.         Spleen Unable to Control the Blood
Tonify Spleen to contain Blood (tonify and astringe)

30.         Cold Dampness Invading the Spleen
warm the Spleen and dispel dampness

31.         Damp Heat invading the Spleen
cool and dispel Spleen dampness

32.         Stagnation of Liver Qi
 Regulate and Move liver qi

33.         Liver Fire Blazing Upwards
cool and purge Liver fire

34.         Internal Liver Wind
transform Liver wind

35.         Deficient Liver Blood Generating Wind
nourish Liver blood

36.         Deficient Liver yin with Liver yang Rising
nourish Liver yin, subdue Liver yang

37.         Damp Heat in the Liver
dispel and cool Liver damp heat

38.         Cold Stagnation in the Liver
warm and remove cold Liver stagnation

39.         Deficient Liver Yin
supplement and nourish Liver yin

40.         Arrogant Liver Yang
cool and subdue Liver yang

41.         Kidney Yang Deficiency
 warm and tonify Kidney yang, nourish the Liver

42.         Kidney Yin Deficiency
nourish Kidney and Liver yin

43.         Kidneys Failing to Receive the Qi
tonify Kidney yang, assist the Kidneys to receive Qi

44.         Deficient Kidney Jing
nourish Kidney jing

45.         Heat in the Small Intestine
clear heat from the Small intestine

46.         Stomach Fire
quell Stomach fire

47.         Rebellious Stomach Qi
regulate Stomach qi

48.         Food Stagnation
disperse food stagnation

49.         Heat in the Large Intestine
purge heat from the Large Intestine

50.         Cold Invading the Large intestine
Warm and expel cold from the Large Intestine

51.         Large intestine Cold
Warm the Large Intestine

52.         Collapse of the Large Intestine
Tonify the Spleen and raise the Large Intestine

53.         Damp Heat in the Gall Bladder
clear damp heat from the Gallbladder

54.         Deficiency of the Gall Bladder
assist the Gall Bladder to overcome deficiency

55.         Damp Heat in the Bladder
cool and clear damp heat from the Bladder

56.   Damp Cold in the Bladder
Warm the Bladder and tonify Kidney yang

 

Different authors may have somewhat different patterns but these are the primary ones described in the herb course and in volume 1 of CTHM. In addition there are important interactive organ disharmonies that one should learn. As much as possible, when making a diagnosis and treatment principle, try to be consistent with terminology as these have specific meanings.

 

I believe in self quizzes with file cards. Write the pattern on one side of a card and its description on the other with some possible western diseases and the representative herbal formula.

 

Two of the most useful if not the most useful references for a serious student to have are A Practical Dictionary or Chinese Medicine by Nigel Wiseman and Feng Ye published by Paradigm and Diagnosis in Chinese Medicine by Giovanni Maciocia published by Churchill Livingstone.