My Views on Several Fundamental Questions of TCM

I have long been engaged in TCM research on anti-cancer treatment. At the same time, around the problems of cancer patients, I have also studied cancer biology, modern oncology, psychology, and psychiatry, and have worked out some insights from clinical practice and reading. Today I write this essay to cast a brick to attract jade, inviting experts to correct me.

I believe the most crucial point in studying and practicing TCM is to know when to follow the principle of pattern differentiation and treatment (bianzheng lunzhi) and when to follow the principle of disease differentiation and treatment (bianbing lunzhi). These are two guiding schools of thought for clinical prescribing in TCM. From ancient times to the present, not many scholars have stated this clearly, and students of medicine are mostly bewildered, at a loss when prescribing. From years of clinical experience, I have worked out the following principles.

For acute illnesses with obvious symptoms, pattern differentiation and treatment should be the primary guide. Acute illnesses include acute exacerbations of chronic diseases and symptomatic infectious diseases. These have a series of symptom complexes, and some patients' pulses and tongue presentations are markedly abnormal; traditional TCM has many treatment protocols for them.

The six-meridian pattern differentiation in the Shanghan Lun, and the triple-jiao differentiation and defense-qi-nutrient-blood differentiation of the Warm Disease school, are all highly effective pattern-differentiation approaches for acute disease. These are foundational skills that TCM students should master. For acute illnesses, when pattern differentiation is used correctly and precisely, the patient's condition usually improves rapidly within one to three days, and may even be cured within hours (what the ancients called "recovery as the cup is set down").

My feeling is that Chinese medicine cures such acute illnesses faster than Western medicine. For such diseases, medication must be precise and bold. As long as the herbs are not extremely toxic, the dose may be larger to seek quick effect. Such patients usually do not take medicine for long, so there is no chronic cumulative poisoning; the dose can be large, and the medicine should be stopped as soon as the condition eases. Short courses like this, despite large doses, have few side effects.

For difficult-to-treat chronic illnesses with non-obvious symptoms, pulses, and tongue presentations—most asymptomatic cancer patients are in this state—disease differentiation and treatment should be primary. One may follow the principle of "Western diagnosis, Chinese treatment," and may also draw on modern pharmacological research, combined with the experience of ancient TCM formula composition, using the principle of "large formulas, small doses, multiple herbs combined" to build a prescription.

This is somewhat like the approach of the "Current Formulas" (Shifang) school of TCM; Li Dongyuan of the Four Great Masters of the Jin-Yuan period did this very well. The Shifang school is criticized by the Classical Formulas (Jingfang) school, who say their prescriptions are many and heterogeneous. In fact, for serious major illnesses like cancer that are also chronic and asymptomatic, even if Zhang Zhongjing himself returned, he could not solve the problem with a simple prescription.

Zhang Zhongjing's "Biejiajian Wan" (Turtle Shell Decocted Pill) is a classic prescription for liver cirrhosis and liver cancer, and it is very different from his other prescriptions. It uses many herbs, each in small dose, and is made as a pill rather than a decoction. This is because treating such major chronic diseases takes a long time; large doses are not appropriate, as they readily cause poisoning.

In modern times, we should not only avoid large-dose decoctions for such diseases but also remind patients to have periodic liver and kidney function checks to observe whether the herbs are damaging those organs. If damage appears, we must stop the medicine promptly and restore liver and kidney function to prevent further deterioration and medical accidents. Ancient practitioners did not worry about these things. But we live in the modern world, and must pay special attention to medication safety. Neglecting it can lead to medical accidents that threaten patients' lives and bring serious trouble to the physician.

For major chronic diseases, TCM has always followed the principle of slow treatment of chronic illness, favoring powders and pills rather than decoctions. An ancient TCM principle is: "Decoctions are for sweeping away; pills are for gradual easing." Decoctions are for acute problems: large doses, short courses, rapidly sweeping away disease. Pills, powders, plasters, and pellets are for chronic disease: small doses, long courses, gradual regulation. Most patients, unaware of this, blindly use decoctions long-term for diseases like cancer that require long treatment; many suffer drug poisoning, which is truly regrettable.

Of course, pattern differentiation and disease differentiation are not so sharply divided. Most chronic patients are not completely asymptomatic; they have mild symptoms, and these patients need a combination of both. When advanced chronic patients develop symptoms, their condition is usually critical. At that point, pattern differentiation should be primary, aimed mainly at relieving suffering and improving quality of life. We must clearly tell the family that the prognosis is poor, ask them to prepare psychologically, and urge them to remain rational and avoid losing both person and money.

Although there are successful rescue cases for advanced cancer patients with severe symptoms, the success rate is very low. The physician must communicate realistically with the family. Usually, when communication is adequate, the family forgives the physician when the patient dies. But if the physician is greedy, exaggerates efficacy, and—knowing treatment will not help—abuses expensive herbs, leaving the family with neither person nor money, disputes easily arise after the patient's death.

Cancer patients develop life-threatening symptoms during treatment, requiring multidisciplinary cooperation and hospitalization. Clinical TCM physicians should not overestimate themselves; they should require hospitalization and multidisciplinary cooperation, or they easily invite doctor-patient disputes.

The second question is that clinical TCM physicians' understanding of disease etiology must keep pace with the times.

Ancient TCM emphasized three causes of disease: external causes (the six excesses contracted externally: wind, cold, summer-heat, dampness, dryness, fire); internal causes (the seven emotions injured internally: joy, anger, worry, pensiveness, grief, fear, fright); and causes neither internal nor external (dietary injury, overexertion, trauma, insect and animal bites, drowning, etc.). As this theory developed later, it went somewhat astray. Many people attributed the causes of every disease to these three categories and assumed patients simultaneously had internal and external causes.

For example, many people believe diseases like cancer are related to the seven emotions injured internally. Are cancers related to internal emotional injury? To study this question, I looked at modern psychiatry, psychology, brain science, and cancer biology, and concluded that the great majority of cancers have nothing to do with internal emotional injury.

The seven emotions injured internally in TCM mostly refer to "emotional disorders," which correspond to modern psychological and psychiatric illnesses, mostly caused by inborn maladaptive genetic factors combined with poor postnatal rearing environments. Cancer, by contrast, is a disease mainly caused by disordered proliferation of somatic cells due to gene mutation. In most cases the two are completely unrelated.

It is only that many cancer patients have comorbid psychological and psychiatric disorders. For such patients, psychological and psychiatric illness may accelerate cancer progression, and treatment should adopt a mind-body healing approach. But this requires multidisciplinary cooperation. TCM can treat some mild emotional disorders, but not severe ones. For psychological and psychiatric illnesses such as schizophrenia, bipolar disorder, moderate/severe depression, and personality disorders, relying on TCM alone is very dangerous, because patients may at any moment self-harm or attempt suicide. Such patients should be treated jointly with psychiatrists.

TCM physicians need to learn the relevant knowledge and improve their ability to recognize such diseases. We must not, out of shallow past understanding, simplify the causes of these illnesses and rashly assume that a few simple TCM formulas can solve them—that easily causes medical accidents. For example, if a cancer patient has comorbid severe depression with strong suicidal ideation, without cooperating with psychiatrists and relying solely on Chinese medicine, treatment is not only ineffective but may readily lead to the tragedy of the patient committing suicide during treatment. This brings misfortune to the patient's family and incalculable professional risk to the physician. If, through a physician's inattention, a patient commits suicide, the physician himself will suffer anxiety, depression, panic, guilt, and self-blame.

Ancient TCM had a saying: "When emotions are extreme, medicine cannot treat them"—meaning traditional Chinese medicine is actually helpless against severe emotional disorders. Many psychiatric illnesses that could not be treated in the past can be solved by modern psychiatry. Recognizing a patient's psychological or psychiatric illness and giving appropriate advice—recommending multidisciplinary treatment—can also save the patient's life.

The third question is the approach to formula composition for treating major chronic diseases like cancer.

Traditional TCM usually uses compound formulas according to the patient's condition—a prescription composed of many herbs rather than a single-herb formula. This approach resembles modern combination antiretroviral therapy (the "cocktail" regimen). TCM describes the principles of herb pairing as the seven emotions of drugs: single effect, mutual reinforcement, mutual restraint, mutual assistance, mutual detoxification, mutual antagonism, and mutual incompatibility.

Looking at this today, these pairing principles are quite scientific. When we use multiple herbs to treat a disease, their combination must follow rules rather than be arbitrary. The seven emotions of Chinese-herb pairing are the rules traditional TCM worked out. In treating disease, herbs may act individually (single effect), synergistically (mutual reinforcement, mutual assistance), or together while counteracting each other's side effects (mutual restraint, mutual detoxification, etc.). Some herbs together increase danger (mutual antagonism, mutual incompatibility) and should be listed as contraindications.

I believe major chronic diseases like cancer can hardly be cured by a single herb. On the above principles, we should adopt multi-drug, large-compound, synergistic treatment. In composing formulas, we must fully consider the synergistic effects of the herbs and appropriate clinical doses.

In general, herbs that play the main role should be used in larger doses; secondary herbs in smaller doses; herbs that reduce a certain herb's side effects should be dosed in proportion to that herb's toxicity. Only thus can we fully exploit the advantage of a large compound combining multiple herbs. When using toxic herbs, we should draw on modern toxicology research, keeping extremely toxic herbs within a safe range—personally, I usually use one-hundredth to one-tenth of the LD50, which is much safer.

Moreover, doses should be increased gradually, not suddenly to a large amount. Suddenly using a large dose easily causes medical accidents. People differ individually; a few patients may die from an extremely tiny amount of a toxic herb. Ancient TCM physicians, when using toxic herbs, started with a trace amount, increased the dose if ineffective, and closely observed the patient's response to avoid fatal poisoning.

In treating diseases like cancer, our approach should build on the experience of our predecessors while making breakthroughs. I myself now use a large-compound, multi-target approach to cancer in composing formulas for patients. I have been exploring in this direction over the years and have achieved some breakthroughs in clinical outcomes. A few patients, after such treatment, have had tumors disappear with no recurrence observed over many years. Others have had their condition controlled: tumors stopped growing or slowed markedly in growth, expected lifespan extended, and clinical symptoms improved. I continue to work in this direction, hoping to gain more practical experience in the future.