Principles of Treatment /TCM Dietary Therapy

ACR Class 7

Principles of Treatment

•After making a diagnosis and identifying the pattern, the next step is determining the principle of treatment.

•Rational and coherent plan of action

•What should be treated first, what is primary and what is secondary in the patient's condition, what is the relative importance of the acute or chronic condition and what method of treatment should be used.

• a. Upright Qi vs pathogenic factor: the Root is the Upright Qi and the Manifestation is the pathogenic factors.

• b. Etiology-pathology: the Root is the root of the disease and Manifestation is the clinical manifestations.

• c. Onset of the disease: the Root is the initial condition while the Manifestation is the later condition.

• d. Duration of the disease: the Root is a chronic disease while the Manifestation is an acute disease.

THE ROOT AND THE MANIFESTATION

• Generally speaking, the Root is primary and is treated first. However, sometimes the Manifestation can become primary and needs to be treated first, even though the ultimate aim is always to treat the Root.

• The decision to treat the Root or the Manifestation depends on the severity and urgency of the clinical manifestations. There are three possible courses of action:

• Treat the Root only

• Treat both the Root and the Manifestation

• Treat the Manifestation first, and the Root later.

•Sufficient to clear all clinical manifestations in most cases.

•Can be used in both interior or exterior as well as chronic or acute diseases.

•Applicable in cases when the clinical manifestations are not too severe. If the clinical manifestations are severe or even life-threatening, the approach should be changed.

1 TREAT THE ROOT ONLY

2 TREAT BOTH THE ROOT AND THE MANIFESTATION• Widely used in practice.

• When the clinical manifestations are severe and distressing for the patient, it is necessary to treat both the Root and the Manifestation simultaneously.

• Also applied when the clinical manifestations themselves perpetuate the original problem.

• Example: Qi deficiency leading to excessive menstrual bleeding.

3 TREAT THE MANIFESTATION FIRST AND THE ROOT LATER

• Applicable in cases when the clinical manifestations are very severe or even life-threatening, generally in acute cases.

• Example: productive cough with profuse watery sputum, breathlessness, chilliness, a thick-sticky coating and a Slippery pulse.

• Spleen‐Yang deficiency (Root) causing retention of Phlegm in the Lungs (Manifestation).

• If the clinical manifestations are severe and acute, the correct approach is to deal with the Manifestation first (resolving Phlegm and stopping cough). Later one can treat the Root (tonify and warm the Spleen).

MULTIPLE ROOTS AND MANIFESTATIONS

•Three possible situations:

•More than one Root, each giving rise to different Manifestations

•One Root giving rise to different Manifestations

•The Root coincides with the Manifestation.

More than one Root• Example: patient has Kidney-Yang deficiency

(Root) caused by excessive sexual activity.

• Later develops stagnation of Liver-Qi (another Root) caused by emotional problems.

• In this case there are two separate Roots from two different causes.

• The different Roots may also interact with one another, further complicating the picture. For instance, the stagnant Liver-Qi may invade the Spleen which could further aggravate the Kidney-Yang deficiency.

One Root with several different Manifestations• Example, if a patient suffers from Spleen-Qi

deficiency, this can give rise to edema (because Spleen-Qi is unable to transport and transform fluids) and also to deficiency of Blood (because the Spleen is unable to make Blood).

• There will therefore be two Manifestations (the edema and the deficiency of Blood) arising from the same Root.

• The treatment in this case is still simply directed at treating the Root.

Root and Manifestation coincide

•Can only happen when the clinical manifestations are caused by external physical trauma, such as in an accident.

•For example, if a person has an accident to the knee, this will cause stagnation of Qi and/or Blood in the knee channels leading to pain. In this case, the stagnation of Qi (the Root), coincides with the knee pain (the Manifestation).

WHEN TO SUPPORT UPRIGHT QI, WHEN

TO EXPEL PATHOGENIC FACTORS

•Closely related to the question of when to tonify and when to reduce.

•Upright Qi is the sum total of all of the body's Qi mostly in relation to its capacity to fight pathogenic factors. It is a term which is used only in relation and in contrast to pathogenic factors.

• Pathogenic factors indicate any disease factor, whether exterior (such as Wind, Damp, Cold, Heat) or interior (such as Phlegm, Fire, Interior Wind, Stasis of Blood or Stagnation of Qi).

• An Excess condition is characterized by the presence of a pathogenic factor, whether interior or exterior, while the Upright Qi is still relatively intact and fights the pathogenic factors.

• A Deficient condition is characterized by weakness of the Upright Qi and the absence of a pathogenic factor.

•A mixed Deficient/Excess condition is characterized by weakness of the Upright Qi, but also by the presence of a pathogenic factor.

•Although there is a pathogenic factor, the Upright Qi is weak and does not react adequately or successfully to the pathogenic factor.

•This is a very common situation in practice, probably more common than a purely Excess condition.

•Essential to have a clear idea as to the relative strengths of Upright Qi and pathogenic factors, or whether there is a pathogenic factor at all.

•The main question is whether the condition calls for tonification or sedation or both.

• If both are required, should they be applied simultaneously or in succession, and if so, which one should be applied first?

• Possible approaches:

• 1. Tonify Upright Qi

• 2. Expel pathogenic factors

• 3. Tonify Upright Qi and expel the pathogenic factors ->

• 3a. First tonify Qi, then expel pathogenic factors

• 3b. First expel pathogenic factors, then tonify Qi

• 3c. Tonify Qi and expel pathogenic factors simultaneously.

• Applicable in purely Deficient patterns.

• Can also be used in mixed Deficiency/Excess patterns but only if the pattern is predominantly Deficient. "Support Upright Qi, to eliminate the pathogenic factors".

• If pathogenic factor is strong, tonifying may make it worse.

• Only applicable in interior conditions, as exterior conditions are by definition of the Excess type, being characterized by the presence of a pathogenic factor.

TONIFY UPRIGHT QI

•Examples of purely Deficient patterns:

•Spleen-Qi Deficiency (manifesting with lack of appetite, tiredness, loose stools and an Empty pulse) or

•Blood Deficiency (manifesting with dizziness, blurred vision, poor memory, scanty periods, a Choppy pulse and a Pale tongue).

• Example of a mixed Deficiency/Excess pattern, but predominantly Deficient:

• Stomach and/or Spleen Deficient allowing themselves to be invaded by Liver-Qi (manifesting with tiredness, no appetite, loose stools, an Empty pulse, a slight dull epigastric pain and slight nausea). The last two symptoms are due to stagnant Liver-Qi invading the Stomach. In this case, there is a prevalence of Deficiency symptoms and signs. The (Liver) Excess signs are very slight.

• In this case, the correct course of action is to tonify the Stomach, so that when this is strengthened, Liver-Qi will not be able to invade it.

EXPEL THE PATHOGENIC FACTORS

• Applicable only in purely Excess patterns characterized by the presence of an exterior or interior pathogenic factor.

• Expelling the pathogenic factor will remove any obstruction caused by it and will indirectly contribute to strengthening Upright Qi (because it can circulate unhampered by the obstruction of the pathogenic factors).

• "Eliminate the pathogenic factors to strengthen Upright Qi".

• If the pattern is definitely of an Excess character, a reducing method is called for, even if the patient might be elderly or apparently weak.

• Especially true in Exterior conditions, where tonifying Qi tends also to "tonify" the pathogenic factor.

• We can later treat any underlying deficiency, but only after the pathogenic factor has been expelled.

• In rare cases if the patient is extremely weak, it might be necessary to combine the reducing method to expel the pathogenic factor, with the reinforcing method to tonify Qi.

TONIFY UPRIGHT QI AND EXPEL THE PATHOGENIC

FACTORS

• 3 options:

• a. First tonify Upright Qi, then expel the pathogenic factors

• b.First expel the pathogenic factors, then tonify Upright Qi

• c. Tonify Upright Qi and expel the pathogenic factors simultaneously.

First tonify Upright Qi, then expel the pathogenic

factors• Used when there is a pathogenic factor to be

expelled, but the Upright Qi is too weak to use a reducing method, as this would weaken it further.

• One can therefore first tonify Upright Qi, and then expel the pathogenic factor.

• It must be noted here that tonifying Upright Qi alone is not sufficient to expel the pathogenic factor.

• Does not apply to interior conditions, as in these cases one can tonify the body's Qi and expel the pathogenic factor at the same time.

First expel pathogenic factors, then tonify

Upright Qi• Use when there is a pathogenic factor and Upright

Qi is weak, but eliminating the pathogenic factor is called for due to the urgency or severity of the clinical manifestations.

• Widely used in both exterior and interior conditions. When there is a pathogenic factor and the body's Qi is weak, this is the standard procedure.

• Applicable in both exterior and interior conditions, but particularly in exterior ones. When tonifying the Upright Qi, make sure that there is no pathogenic factor left.

• In exterior patterns this is generally the approach adopted.

• In interior patterns this approach is used whenever the symptoms caused by the pathogenic factors are so severe or urgent that they need to be dealt with without delay.

• Example: chronic Kidney and Heart Yang deficiency leading to "Water overflowing" causing edema.

• One must first expel the pathogenic factor by using a reducing method (on SP-9, ST-28, Ren-9, BL-39 or BL‐ 22).

• After the edema is resolved and the urinary function restored, one can tonify Kidney and Heart Yang.

• This approach is not only applicable in acute and urgent cases such as those mentioned above, but also in chronic cases where the symptoms do not have a character of urgency but are nevertheless, very distressing and painful.

• For example, a patient may suffer from a chronic deficiency of Liver and Kidney Yin leading to the rising of Liver-Yang. This would cause severe headaches as well as dizziness, irritability, and so on. Although the symptoms are not acute or urgent, the headaches may nevertheless be extremely painful and distressing. It is therefore necessary to subdue Liver‐Yang first, and then tonify Liver and Kidney Yin.

Tonify Upright Qi and expel pathogenic factors

simultaneously

• Widely used in cases when there is a pathogenic factor and the Upright Qi is relatively weak, but not so weak as to need to be tonified first.

• This approach can only be used in interior conditions, as in exterior conditions it is usually necessary to expel the pathogenic factor first and then tonify the Upright Qi.

•Used in cases of mixed Deficiency/Excess interior patterns.

•Examples: Liver‐Yin deficiency with rising of Liver-Yang, one can simultaneously tonify Liver-Yin (tonify KI-3, SP-6, LIV-8) and subdue Liver-Yang (reduce LIV-2, G.B.-43).

•Spleen-Qi deficiency leading to the formation of Dampness, one can tonify Spleen-Qi (tonify BL-20, ST-36) and resolve Dampness (reduce SP-9, SP-6) at the same time.

TCM Dietary Therapy

Thermal property (Qi)

•Hot-Warm-Neutral-Cool-Cold

•Most foods are Warm-Neutral-Cool

•Hot = Some spices

•Cold = Some fruits

•More hot or cold = more potential toxicity

•May be modified by preparation methods

Taste (Wei)

•Acrid (pungent, spicy) - disperses, moves Qi & Blood

•Sour - contracts, tightens, restrains leakage

•Salty - softens, moistens and descends

•Sweet - tonifies, moistens, harmonizes

•Bitter - drains and dries

•Bland - promotes urination

Channel entry

•Based on function

•Examples:

•Ginger - ST: Nausea, low appetite

•Watermelon - ST: Thirst

•Persimmon - LU: Moistens dry cough

•Honey - LU: Moistens dry cough

•Mustard Greens - LU: Resolve phlegm

•Water Chestnut - LU: Resolve phlegm

•Lycium Fruit (Gou Qi Zi) - LR: Eyes

•Nuts - LI: Moisten dry intestines

•Most organ meats enter the pertaining channel - eg: Cow's liver enters LR channel

•Hot & Cold nature of food depends on:

•1) inherent property of specific food

•2) preparation methods

HOT / COLD

EXAMPLES OF THERMAL

PROPERTIES OF FOOD

HOT

•Beverages: Alcohol (high proof), chai

•Meat / fish: Lamb, venison

•Spices: chili, ginger, cinnamon, curry, garlic, cloves

WARM

•Beverages: Cocoa, coffee, red wine

•Dairy: Butter, goat's cheese

•Meat / fish: Beef, chicken, eel, salmon

•Fruit / vegetables: Cherry, fennel, leek, peach, onion

•Spices: Anise, basil, rosemary

NEUTRAL

•Condiments: Honey

•Dairy: Cow's milk, cheese

•Meat / fish: Carp, duck, chicken eggs, goose, pork

•Fruit / vegetables: Carrot, cauliflower, grape, fig, plum, potato

•Grains / legumes: Corn, lentil, millet, peas, rice, spelt

COOL•Beverages: Black tea, green tea, fruit

juices, peppermint tea, soy milk, wheat beer

•Dairy: Yogurt

•Meat / fish: Rabbit

•Fruit / vegetables: Celery, cucumber, soybean, sprouts, spinach, zucchini

•Grains / legumes: Barley, tofu, wheat

•Spices: Tarragon

COLD

•Beverages: Water

•Condiments: Salt, soy sauce

•Meat / fish: Shrimp, crayfish, crab

•Fruit / vegetables: Asparagus, banana, orange, rhubarb, seaweed, tomato, watermelon

•Spices: Dandelion, gentian

Preparation methods

•Generally use heat, which adds Yang

•Water adds Yin

•Most methods use either heat (BBQ) or heat + water (boiling)

Grilling / Broiling / BBQ

•strongest warming effect

•may develop toxic substances in foods

•avoid in heat patterns

Smoking

•adds Yang, less so than grilling

•smoked fish for Kidney Yang in cold climates

•use sparingly, esp if xs salt

Frying / Roasting

•More warming

•Blast frying / searing - balances yang and yin (fried outside, moist inside)

•avoid using too much oil

Baking

•gently supplies yang to foods

•ameliorating cooling effects of foods

•good for vegetarians who need more yang

Boiling / Simmering •dependent on cooking time

•prolonged boiling increases Yang

•"Master Soup"up to 36 hrs

•esp recommended for meat/bones

•Yang-boosting effect "offsets vitamin loss"

•vegetarian soups use spices instead of long cooking time

Blanching / steaming

•neutral methods

•make foods more digestible

Cooling

•Fruit / sprouts / lettuce - adding offsets Yang effects (e.g.: lettuce & tomato on a burger)

•Salting / pickling - Reduces Yang, increases Yin

Other methods

•Alcohol - warms, upbears, increases circulation

•Spices - generally have warming effect