On "Treating the Pattern" — Notes on Zhou Zhiyuan's TCM Anti-Cancer Studies (4)

There is a folk saying, "If the drug matches the pattern, a single bowlful cures." Many TCM classics also describe effects like "recovery as soon as the cup is turned upside down" or "effect as immediate as a drum to a drumstick."

"Recovery on turning the cup upside down" means the medicine is drunk, the cup washed and set upside down on the table, and the illness is gone. "Effect like a drum" means the drug's effect responds at the first stroke, like a drum.

From these sayings we can see that TCM was never a slow doctor. It is just that today's public deeply misunderstands TCM, habitually saying that Chinese medicine is only for "regulation" and works slowly.

I often feel sad at this. I have loved high efficiency since childhood. The reason I love TCM is that it works faster than Western medicine, not slower.

As a child I watched my father treat tonsillitis: a few drops of medicine dripped into the nose, running down into the throat, and the patient woke after a sleep cured. Because I was used to it, I did not think it remarkable. But later, seeing Western antibiotics treat similar diseases in at least a week—with patients often still at risk—I realized how remarkable that folk method was.

I also saw my father treat unexplained infectious swellings: he pounded a kind of root, mixed it with glutinous rice and egg white, and applied it; the swelling was gone by morning. Used to it, I did not think it remarkable. But growing up and seeing hospitals never achieve such speed for similar diseases, I was deeply impressed.

When young I studied science and engineering, doing extremely well in math, physics, and chemistry, basically full marks. I had read some Western medicine books and could not help looking down on my father's little tricks, thinking this countryside folk method was quite beneath notice—knowing nothing of anatomy or pathology, with no scientific grasp of disease, mere muddling.

That lasted until I was in my twenties, tormented by stubborn asthma, seeking doctors everywhere and seeing every top academician in the capital without improvement. Finally I studied Chinese and Western medicine myself, tried various methods, and cured myself—breaking my superstition of modern science. Only then did I believe that the accumulated experience of humans on Earth for millions of years is truly valuable.

Just as most foods we eat today were settled by our ancestors through countless trials, humans on Earth for millions of years had to fight not only cold, heat, hunger, and thirst but also disease. This experience of fighting disease, like the experience of finding food, is both reliable and precious.

Most of TCM's therapeutic experience was gained directly from such struggle, so its effectiveness is beyond doubt.

My father often told me: if three doses do not work, a hundred more will not either. This means that if a patient takes three doses of a TCM prescription and sees no effect, a hundred more of the same will not help. His point was exactly that TCM should work quickly; if it is slow, the prescription is wrong.

Of course this is somewhat absolute. I once treated a patient with cerebral-infarction sequelae, prescribing seven doses and telling the family to expect improvement in three to five days. After five days, the patient's nephew told me there was no improvement at all.

I told them to stop. A few days later, the patient's niece—an internal-medicine Western doctor—contacted me, asking why I had stopped the medicine. She said the patient had clearly improved: the leg that had been weak and clumsy was much better. It turned out that after five days the patient had not stopped as I instructed; having bought seven doses with two left, the frugal old man hated to waste them and kept on. By the sixth day, improvement was obvious.

So for major diseases, expecting obvious effect from three doses is a bit impatient. But for most common illnesses, Chinese medicine should show effect within two or three days; if not, the doctor's medication strategy is probably off.

How does TCM guarantee such speed? At root, only four words: use the drug for the pattern, or "match the medicine to the symptom."

The reason folk remedies work so fast and reliably is that some village healers who know unique folk methods have a strong ability to match drugs to particular diseases.

Nearly every Chinese person has blurted out "match the medicine to the symptom" on some occasion. Sadly, this plain, simple, effective principle has, in the development of TCM, gradually been replaced by various fanciful theories.

"Treating the pattern" is arguably the prescribing principle most consistent with evidence-based medicine. From this catchphrase we see that both traditional and modern medicine strive for precision of medication and reliability of effect.

I believe the most vexing problem for many TCM graduates or self-taught practitioners is the great uncertainty in the efficacy of the formulas they prescribe. Seeking a high effective rate is not only the wish of patients and families but of physicians too.

But through the ages, TCM materia medica (or bencao) texts rarely give clear, precise accounts of which symptoms a drug can relieve; most descriptions of a drug's effects and properties are vague. So when we clinically choose drugs, we easily feel lost.

Wu Youke, a Qing-dynasty warm-disease master, said every disease must have one drug; we simply have not yet found drugs for all diseases. His words are apt: the ultimate goal of human medicine should be "precise and effective" cure.

Li Dongyuan of the Jin-Yuan period, after losing his mother to an illness no doctor could name, felt the medicine of his time was too sunk in abstract theory and its clinical effective rate too low. So when teaching disciples, he first built a deep foundation in pharmacology before anything else.

The Japanese study TCM pragmatically, valuing the study of drug effects. Japan's most influential Kampo master, Yoshimasu Todo, wrote a book called Yakushin (Drug Evidences), summarizing the clinical effects of each herb drawn from Chinese medical works through the ages.

Traditional TCM describes herb properties using four qi, five flavors, channel entry, and floating/sinking/ascending/descending.

The four qi, or four natures, are cold, hot, warm, and cool. Ultimately they reduce to two: cold and hot. Cold-natured herbs treat hot diseases; cool is the lesser of cold. Hot-natured herbs treat cold diseases; warm is the lesser of hot. This follows TCM's basic theory that diseases are either cold or hot—treat cold with heat, treat heat with cold.

The five flavors are pungent, sweet, sour, bitter, and salty. Most bencao texts also list bland and astringent flavors—really seven in all. But because yin-yang and five-phase philosophy was so entrenched in ancient China, the number five mattered; dividing flavors into five made them correspond to five-phase theory.

Originally, people may have noticed that sour herbs like Wumei (Smoked Plum) astringe and stop diarrhea, while sweet herbs like Gancao (Licorice) relieve urgent pain, and so they inferred that different flavors have different effects and sought rules.

Later, once the five-flavor theory formed, "flavor" no longer meant actual taste but was assigned by a drug's effect.

By traditional TCM theory, the effects of the five flavors are as follows:

Pungent flavor disperses, moves qi, and invigorates blood. Pungent herbs include the exterior-releasing Jingjie (Schizonepeta) and Bohe (Mint), the qi-regulating Xiangfu (Cyperus), and the blood-activating Chuanxiong (Ligusticum). Pungent herbs generally consume qi and damage fluids, so those with qi, blood, or fluid deficiency should use them cautiously or combine them with qi- and blood-tonics.

Sweet flavor supplements deficiency, harmonizes the middle, and relieves urgency. Sweet herbs include Huangqi (Astragalus), Shudi (Prepared Rehmannia), walnut, and Gouqi (Goji) for deficiency patterns, and Gancao and Yitang (maltose) for spasmodic pain. Some sweet herbs also detoxify, such as Gancao and honey. Because sweet herbs are cloying, they hinder digestion; TCM says they clog the diaphragm, so patients with indigestion should use them cautiously.

Sour flavor astringes and secures, treating spontaneous and night sweating, emission and spermatorrhea, and chronic diarrhea. It also generates fluids and expels worms. Wuweizi (Schisandra), Wumei (Smoked Plum), and Shanzhuyu (Cornus) are sour. Traditional TCM holds that sour herbs retain the evil qi, so they should be used cautiously when the external evil is not yet resolved. Wuweizi can stop cough, but using it to stop cough when the exterior evil remains is mistreatment; first release the exterior.

Bitter herbs drain downward, clear heat, and harden yin and dry dampness. Bitter Dahuang (Rhubarb) drains heat and frees the stool; Xingren (Apricot Kernel) descends lung qi; Zhizi (Gardenia), Huanglian (Coptis), and Huangqin (Scutellaria) clear heat and drain fire. Huangbai (Phellodendron) and Kushen (Sophora Flavescens) also dry dampness and stop diarrhea. Bitter herbs mostly damage fluids and assault the stomach, so those with fluid deficiency or weak spleen-stomach should not use them in large doses.

Salty flavor softens hardness and disperses nodules, and purges and frees the bowels. Haizao (Sargassum), Kunbu (Laminaria), Muli (Oyster Shell), and Biejia (Turtle Shell), used for various benign and malignant masses, are salty; Mangxiao (Mirabilite) for heat-bound constipation is salty too. Many salty herbs are high in salt, so those with hypertension or arteriosclerosis should use them cautiously.

Astringent herbs resemble sour ones in securing and astringing, so many bencao texts group them with sour. Among astringent herbs, Longgu (Dragon Bone) treats TCM's various slippage patterns; Chishizhi (Halloysite) treats chronic diarrhea and prolapse of the rectum; Wuzeigu (Cuttlebone) treats uterine bleeding and leukorrhea in women. Both astringent and sour herbs retain the evil, so use cautiously when evil remains.

Bland herbs percolate dampness and promote urination; Fuling (Poria) and Zhuling (Polyporus), used for edema, are bland. Long use of bland herbs easily damages fluids, so those with yin deficiency and fluid depletion should use cautiously or combine with yin-nourishing herbs.

During the Song and Jin-Yuan periods, many aromatic drugs came to China via the Silk Road and gradually formed a new flavor: aromatic. Aromatic herbs scatter and move qi, transform dampness, ward off epidemic evils, open orifices, and awaken the spleen. Their effects resemble pungent herbs, as do their side effects: they consume qi and damage fluids, so use cautiously in qi and fluid deficiency.

By TCM yin-yang theory, pungent, sweet, and bland flavors belong to yang; sour, bitter, and salty belong to yin.

Ascending/descending/floating/sinking refer to a drug's directional action in the body. This direction is opposite to the tendency of the disease and matches the disease's location. It is another concept by which ancients tried to describe drug action precisely.

It is determined mainly by a drug's texture (light or heavy), odor, flavor/nature, and effect.

Light, clear substances ascend; heavy, turbid ones descend. Thick odor and flavor descend; thin, bland ones ascend. Warm/hot and pungent/sweet herbs mostly ascend and float; cold/cool and sour/bitter/salty herbs mostly descend and sink. Herbs that improve conditions tending downward and inward are ascending/floating; those that improve conditions tending upward and outward are mostly descending/sinking.

Channel-entry theory tries further to pinpoint the parts of the body a drug acts on, and must be understood together with TCM's zang-xiang (visceral manifestation) theory. For example, herbs entering the heart channel mostly calm the spirit in heart-channel diseases; herbs entering the kidney channel mostly improve urinary and bowel problems in kidney-channel diseases.

But as the Qing physician Xu Lingtai pointed out, once a drug enters the stomach and spreads through the blood throughout the body, to insist that a given drug enters only a given channel and treats only that channel's diseases is nonsense. Still, certain drugs do act more strongly on certain body parts. So channel-entry theory is a reference, not a straitjacket.

Traditional medicine also observed drug toxicity, dividing herbs into toxic and non-toxic, and among toxic ones into highly, moderately, and slightly toxic.

These foundational TCM pharmacology concepts, mostly derived from direct experience, help us judge indications and contraindications more accurately when prescribing.

But through all of TCM bencao, the core has always been drug effect—which symptom a given drug can relieve or eliminate. Manjingzi (Vitex) treats headache; Yinchen (Artemisia Capillaris) treats jaundice; Fuling promotes urination and reduces swelling; Renshen (Ginseng) greatly supplements original qi and strengthens the weak.

Traditional TCM descriptions of drug properties and effects can be called unscientific, some almost pure authorial guesswork. But when ancients prescribed, they too sought guiding principles, so they made these generalizations—unscientific yet highly practical.

If we study TCM but wallow in this theory, we easily become like a martial artist who has gone off the path, drifting into impractical talk and metaphysics. But to cast off the whole theoretical system is also unrealistic.

In fact, many pharmacologic actions found by modern pharmacology in Chinese herbs do not match the traditional effects. Prescribing by modern pharmacology is often less accurate than prescribing by the rules TCM summarized. This may be because some herbs are chemically so complex, with so many molecules, that we have not fully studied all their effects.

For now, and for a long time to come, the effects summarized by traditional TCM remain the standard we should respect and rely on in clinical prescribing.

Can the properties and effects summarized by TCM be improved? Certainly—and greatly.

We cannot let TCM stay vague. Studying TCM to reduce prescribing error, striving for precision and reliable effect, is the goal every TCM practitioner should pursue.

In this book, around the characteristics of the disease tumor, I will choose herbs that relieve the various symptoms of tumor patients and introduce each one's effects in turn.

The descriptions will be as precise as possible. Vague, ambiguous descriptions in ancient books will not be used, nor will the speculative "the physician's mind is the drug" talk the ancients often invoke.

When my late mother was alive, I bought nearly every Chinese- and Western-medicine book on tumors I could find, trying to solve her problem.

Unfortunately, most monographs by TCM experts lack precision. The more I read, the less I could decide. Many doctors choose formulas by subjective guesswork rather than objective "matching the pattern," so results are poor.

Following the map, I also sought out these authors as practitioners, based on their specialties. Results still disappointed me; I went hopefully and returned disappointed.

Though I now understand the uncertainty of medicine and the difficulty of being a doctor, I also lament how ancient and modern medical writings, "themselves confused, try to make others clear," hindering medical progress.

So this book must avoid that fault. I will strive to make things clear for readers—so that when they choose formulas and herbs, they do so with clarity. If I succeed, how would I dare shrink from the toil of completing it? May I, in this life, accomplish something on this road.