Charles Chace article

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An article of interest, perhaps

 

 

http://www.paradigm-pubs.com/html/natural.html

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

On Natural Selection: Ruminations on the Roles of Insight & Rationality in Clinical Practice.

by Charles Chace, Dipl. Ac., Dipl. C.H., FNAAOMCOMP Designation: Original workAbstract: In this article, the author discusses the relationship between rationality and intuition in the Western practice of . The author supports his opinions by a case history and quotes from Huangfu Mi's Systematic Classic of Acupuncture & Moxibustion.IntroductionAt this point in my life, I am realizing that it has taken me 10 years to develop a genuine appreciation of just how little I really know about practicing Chinese medicine. I think this is because after 10 years, I have gained a certain facility and achieved at least a modicum of success with the basic tools of medicine (whatever those might be), and yet anything approaching true mastery of the art seems as far off today as it did when I first began my studies. It is not so much that there are still many diseases that strike me as pretty mysterious. It is more the act of actually practicing that is so unfathomable. Clinical practice is that place where everything we think we know is filtered through one's own set of insights, biases, and delusions in an attempt to come up with something which will adhere itself in a meaningful way to a real person who thinks you might have something to offer them. As clinicians we are called upon to apply all of our faculties in a judicious manner which requires both crisp rational consideration and a fair amount of intuition. This is what brings the practice to the practice.If I pay attention, just about any client I see teaches me something about the nature of practice. it is not just the precariously balanced HIV patient or the person with multiple chemical sensitivities. Even the most mundane case will raise some very basic questions for me regarding who I am, what it is I do, and how I do it if I am not too preoccupied to notice. When I stop to think about it, my life does not get much more instructive than this. I think the following case is a good example. It's not terribly dramatic, but it has brought many of the issues of clinical practice into focus for me.Case HistoryIn the spring of 1994, one of my patients approached me about treating her daughter who at 7 years of age continued to wet her bed nightly. This problem had persisted since the little girl had been toilet trained and, at this point, the condition was beginning to have social ramifications beyond soaked sheets at home. I confidently assured the mother that this was something I treated routinely and which responded well to Chinese medical intervention. When I examined my young patient, she appeared quite healthy, although she had a slight malar flush. She had a pleasant disposition and seemed well adjusted. The young girl was clearly growing up in a loving home environment and appeared to have no other developmental shortfalls. Her mother reported that the girl would wet her bed a few times at night and would typically sleep quite soundly through till morning. She reported that she tended to be thirsty and that the girl's urine and body odor smelled more strongly than that of her siblings. The girl's mother also mentioned that her daughter had a history of polyuria but that this was no longer an issue. Her tongue tip was quite red, and her cun and guan pulse positions on the left were noticeably stronger than the chi position which was fine and deep.I surmised that this was a case of heat in the heart above and vacuity of kidney yin below causing a failure of the securing function of the kidneys. My treatment principles were to clear heat from the heart and upper warmer in general while enriching heart and kidney yin and to secure kidney function and astringe the essence. I administered the following prescription in bulk herb form: Semen Nelumbinis Nunciferae (Lian Zi), 15g, Radix Panacis ginseng (Ren Shen), 12g, Tuber Ophiopogonis Japonicae (Mai Men Dong), 9g, Sclerotium Pararadicis Poriae Cocos (Fu Shen), 9g, Radix Scutellariae Baicalensis (Huang Qin), 9g, Radix Astragalus Membranacei (Huang Qi), 6g, Semen Plantaginis (Che qian Zi), 6g, Radix Glycyrrhizae (Gan Cao), 3g, Fructus Schizandrae Chinensis (Wu Wei Zi), 9g, Rhizoma Coptidis Chinensis (Huang Lian), 3g, prepared Radix Rehmanniae (Shu Di), 6g, Semen Cuscutae (Tu Si Zi), 6g. This was decocted in 4 cups of water and 1 oz. was administered 3 times per day.One week later the family reported that the girl's condition was essentially unchanged, although her bedwetting had possibly lessened somewhat in the previous 2 nights. However, she was now quite irritable. I administered the same prescription with the addition of Radix Bupleuri (Chai Hu), 6g, to course the liver qi.After the youngster took this for 10 days, the family reported that she was now generally waking up to urinate and she was no longer cranky. We all felt confident that we were making progress. Unfortunately, things went nowhere from there. I subsequently tried a wide variety of strategies ranging from simply enhancing the astringency of the prescription with medicinals such as Oothecha Mantidis (Sang Piao Xiao) to reinterpreting the red tipped tongue as lung heat and prescribing Ephedra, Armeniaca, Gypsum and Licorice Decoction (Ma Xing Shi Gan Tang).When none of this worked, we tried a series of acupuncture treatments which included warm needle technique. My young patient enjoyed the sensation of qi coursing through her body and looked forward to her acupuncture sessions, but this approach was ultimately unproductive as well.At this point I was stumped and told the family as much, now regretting the cockiness with which I had made my initial prognosis. We discontinued treatment and I told them that if I came across anything in the future that might be helpful I would let them know.When I hit a wall, I most often simply back off and wait until a new avenue of pursuit presents itself. A few weeks later, while going through a stack of Chinese medical journals on some other quest, I came across an article on the use of medicated moxa threads in treating pediatric enuresis. Needless to say, I read on. In the interim, I had reviewed a number of other discussions of pediatric enuresis from various sources, but I had gleaned little new theoretical or practical information which struck me as apropos to this case. The collection of points prescribed for moxibustion in this study did not suggest any specific diagnosis. There were points to supplement and regulate kidney function, regulate water metabolism both above and below, points to calm the spirit, and points to raise clear yang. There were also points which are specific to enuresis and which have some local influence on this problem. While this shotgun approach lacked the satisfying elegance that some new, previously unconsidered theoretical framework might have provided, I was content with any empirical approach that provided results.It has been my experience that not all of the protocols published in Chinese medical journals, many of which appear to border on the miraculous, translate into viable treatments here in the U.S. Sometimes, for whatever reason, the protocol is simply not as effective in my patient population, and sometimes it is an issue of patient compliance. (For instance, a retained medicated enema may sound like a good adjunctive therapy in the treatment of ovarian cysts, but getting a patient to do this regularly is another matter.) The protocol in the moxa study called for the moxibustion to be done daily with 1 course of treatment lasting 2 weeks. So a certain consistency in administering the therapy was an obvious priority. While the profile of the enuresis patients fit my client nicely and the results were predictable impressive, the actual process of medicating the moxa and applying it to the 20 or so prescribed points struck me as patently unrealistic for my patient and her family. It seemed pointless to prescribe a protocol that would not be likely to be administered consistently.In casting about for alternatives, I remembered a moxibustion protocol for hypertension which involved indirect moxa on 2 points using a pecking technique. This technique had apparently proven quite effective in the hypertension study. Therefore I decided to have my patient administer moxa to the prescribed points using this pecking technique rather than struggling with the elaborate moxa technique that the enuresis study called for. The article listed the points in no particular order. Therefore I arranged them roughly from top to bottom in the following sequence so that they would be easy to administer and remember: Nao Hu (GV17), Bai Hui (GV20), Si Zhen Cong (Extra), Feng Chi (GB20), Qu Chi (LI11), Shou San Li (LI10), Nei Guan (Per6), Shen Men (Ht7), Shi Niao (Loss of Urine; on the small finger 0.5 cun distal to DIP joint), Xia Guan Yuan (Below Origin Pass; 3.5 cun below the umbilicus), Si Feng (ExtraMUE9), Fei Shu (Bl13), Shen Shu (Bl23), Ba Liao (Bl3134), Chang Qiang (GV1), Yin Ling Quan (Sp9), San Yin Jiao (Sp6), Yong Quan (Ki1).I showed the mother how to locate all of the points and how to warm each of them with the moxa stick must enough for her daughter to feel the heat but now enough to burn her. The girl would simply say " hot " and they would move on to the next point. Each point was warmed once per treatment. Once they had learned the technique, the entire process took about 10 minutes.At this point, given my divergence from the prescribed protocol and my previous failures with what I believed were much more potent interventions, my expectations were low. On the other hand, the moxa was simple, it was easily administered, and it was essentially costfree. So it seemed like a good idea. When the family reported back 2 weeks later, I was rather surprised to hear that my young patient had ceased to wet her bed and had been dry for over a week. I suggested that they continue with the regimen for another fortnight to consolidate the therapeutic effect in keeping with the protocol in the article. This they did and, at that point, I suggested that they resume the therapy at any sign of relapse. Happily, 9 months have passed and the problem has not recurred.DiscussionThe reader may glean from this discussion a nifty protocol for pediatric enuresis that is both effective and easy to administer. Indeed, the original study and my own clinical experience suggest that it is worth considering, at the very least as an adjunctive therapy. This protocol could be the key to treating one of your patients with pediatric enuresis. On the other hand, it might not, and this reality raises some intriguing issues for me. While I may have cobbled together an effective therapy, it is not immediately clear why it worked in this case when others did not. It would seem that my initial diagnosis was at least peripherally correct since there was some improvement. One would also assume that if a simple yang vacuity were ultimately at issue here and the essential warming function of the indirect moxibustion addressed this, the kidney yang boosters and the warm needle technique which indeed focused on yang fortification below would have yielded a more tangible response. It would seem that I had already addressed the components which might contribute to a reasonable explanation of why the indirect moxa worked.Although written case histories are generally composed in a manner intended to convince the reader that the physician knew what she was doing, they are invariably open to second guessing, and the above case is no exception. While a more insightful administration of theory and practice may have yielded a more immediate response, whether or not the initial diagnosis and therapies were correct is almost secondary to the larger questions at hand. In the context of this discussion, it is pointless to assert that, had I been a better practitioner, I would have most likely gotten it right sooner and perhaps even with my original herbal modality. This is true of us all, regardless of where we are on the path. The fact remains that a very mild and general treatment produced a cure when a wide variety of more specific modalities and diagnoses did not. I am confident that I brought to bear the full range of skills that I had available to me at every stage of this process and that is all one can ask of any physician. In any case, let us assume that there were no overt technical flaws in my therapy and we can consider another possible factor in the happy resolution of this case.I believe that I finally selected the most natural, i.e., appropriate, influence to effect a positive change in my young client. Unschuld translates the word qi not as energy or life force, but as influence. It seems to me that this translation of a concept we as acupuncturists and herbalists often take for granted sheds a fresh light on just what it is that we do. In actuality are we not simply trying to provide the correct qi or influence for our clients, whatever that might be? Perhaps the influence we select is transmitted via a needle, perhaps by a medicinal,or perhaps even by the right thing said in the right way at the right time. It is all qi. I believe that the function of any healer can be understood in terms of selecting and then administering the most natural influence which will effect a positive change in one's patient. We may have what we believe should be the perfect prescription or the ideal point for a given client, but if that influence is not one which resonates with that individual, we are both wasting our time.Sometimes a simple influence is best and sometimes we need to cover every base. Even in complex cases, a patent medicine, which at best only broadly addresses a patient's pattern, may sometimes yield a result far beyond the most crisply honed bulk herb prescription. These occasions tweak the noses of bulk herb snobs such as myself and remind us that technical prowess is only a tool and not a solution in and of itself. The similarities between this phenomena and the case at hand are not lost on me. Like everything else in nature, the most natural influence for a given individual is not a fixed quantity. I cannot count how many times I have readministered the same treatment which worked so miraculously the week before on the same patient only to have it backfire. I either believed that I was playing it safe in going with a known quantity or I was simply too lazy to carefully evaluate the most appropriate influence for the moment. Of course, the converse may be true as well. One must also know when not to fiddle with something that is working nicely.Selecting the Most Natural InfluenceIt seems to me that the question of just how to select and deliver the most natural influence is perhaps the central issue in the practice of Chinese medicine or, for that matter, in the practice of any system of medicine. This is a difficult thing to know and there are few guideposts for us as practitioners. Certainly, it is not the exclusive province of rational thought. Decisions such as these also require some other, perhaps rightbrained organization of information as well. This is often referred to as intuition.For the purposes of trying to understand intuition in the context of clinical practice, I believe that it is useful to describe it in the following way. Intuition is a hypothesis based on experience for which no existing rule is adequate. If we test this hypothesis in practice and it turns out to be valid, then it is intuition. If this hypothesis turns out to be false, then it is merely whimsical thinking. For example, a practitioner may decide not to put a patient on an herbal medication despite the fact that the patient's condition suggests that this would be appropriate. Instead, they elect to do only acupuncture until the practitioner feels the patient is ready for herbs. In this case, the hypothesis is that it is a bad idea to give this patient an herbal medication. There is typically very little, if anything, apparent to suggest the above decision. In other words, there is no existing rule that dictates this course of action. Indeed, a student sitting clinic with this practitioner will likely have a difficult time understanding her motives. Nonetheless, a decision such as this does not arise out of a vacuum but is the product of clinical experience that has been so internalized that it essentially bypasses rational examination. The information is apparently processed or organized at some other level. In hindsight, the practitioner may be able to look back and give some tangible reasons for administering only acupuncture. For instance, the emotional makeup of the patient might suggest that he would balk at the odd taste of the medication, and his tongue coat was a little slimy, suggesting that his digestion was impaired. This, however, is simply a result of reorganizing the information on a more rational level.In the case of my young patient, while I can look back and rationally defend each of my actions, I cannot say that they were arrived at in an entirely rational manner. At many of the junctures in this case, I simply made a decision. I would more accurately say that I knew I was not going to get any further with this patient till I backed off and that I knew the protocol I discovered had to be modified to fit this patient's situation. However, this knowing was the product of experience, it is not only clinical experience we are talking about. Simply experiencing life itself and people in particular in a mindful manner is as important as running a lot of patients through one's clinic.I do not pretend to really understand intuition, but I have seen my experience of it and my application of it improve throughout the course of my practice, almost in spite of myself. However intuition actually works, it is clear to me that the selection of the most natural influence requires both sides of the brain. I do not believe the solutions to my difficult cases will invariably lie in simply figuring out the right prescription, in reevaluating some diagnostic parameter, or in learning some new trick. On the other hand, I am quite clear that it is equally unwise for me to slam the door on my cognitive abilities and simply adjourn to my pendulum or my yarrow stalks. The above case is not a tale of the dramatic resolution of a lifethreatening disease, nor is it an example of mystical insight. It is, however, an example of how multiple aspects of one's consciousness are brought to bear on a case encountered daily in the clinic. In many ways, the fact that it is mundane is what I feel is so illustrative of the complexity and mystery of the therapeutic process. Consider how much is going on even in this case.Rationality and IntuitionContemporary discussions on the various styles and approaches to Chinese medicine often tend to dichotomize rational thought and intuitive processes. It seems that practitioners are pigeonholed as eggheads or airheads, as TCM bean counters or as featherwaving shamanic acuflakes. It also seems to me that students entering the field tend to gravitate toward one extreme or another and that the education that the schools provide tend to reinforce this. I rarely hear of a practitioner who is regarded by his or her peers as being both an incisive thinker and an intuitive healer. Yet one cannot be a truly skilled physician without both attributes.TCM practitioners often take the brunt of this sentiment since it is undoubtedly the most cerebral of the Chinese medical styles practiced in the U.S. today. In addition, I think that it is fair to say that students trained in other styles often resent having to learn enough pattern discrimination to pass a national board exam but then do not learn enough about TCM to make it work clinically. This situation does not tend to breed a positive outlook on TCM. It is important to remember that TCM is much more a teaching style than a practice style. It is a means of stringing all of the most important theoretical beads of Chinese medicine on a single thread and conveying that to a student. One need only consider the variety with which TCM is practiced by physicians both here and abroad to realize this. Having said this, I acknowledge that in order to practice any flavor of TCM, one has to know how to think rationally, and some practitioners find this an abhorrent concept, smacking of the very Cartesian biomedical patriarchy they have fled in the first place.It is fashionable to talk about one's rational mind getting the way of one's intuitive processes, and I would certainly agree that it is best to avoid a cognitive freeforall in one's cranium. However great intuitive leaps must be predicated upon some preexisting information. For instance, a healer may have an intuition that a patient needs a needle stuck in them to move their qi. I would argue that having some idea about how and where that needle might best be placed will greatly enhance the effectiveness of that influence. The greater the information, the greater the range of available options. The options are useless if not skillfully employed, and that is where the oftmaligned left side of the brain comes in. Chinese medicine has its origins in the Dao. We all understand that the Dao cannot be rationally known, but this does not suggest to me that in working with the Dao we must abandon our capacity to think rationally. How can rational thought be somehow outside the Dao? Can one experience yin without yang?Clearly the Chinese medical classics demand an intimate familiarity with both modes of understanding. The first real textbook of acupuncture, The Systematic Classic of Acupuncture & Moxibustion (Jia Yi Jing), is a collection and reorganization of the original primary sources of Chinese medicine including the Inner Classic (Nei Jing). It is unparalleled in the literature as an example of how all of these ancient and arcane texts were interpreted by a physician of that time in terms of actual practice. An observant reader can readily see the seeds of whatever the style of Chinese medicine one may be practicing already lying in the rich soil of this preeminent classic. As such, it serves as an ideal basis for this discussion.The Systematic Classic opens with the statement, " All methods of needling must first have their basis in spirit " , setting the tone of the entire book. The book is virtually littered with statements of this sort, The key to proper needling is to first attend to one's spirit. In this way, the condition of the five viscera and the nine indicators are made clear and only then may the needle be inserted. As if perched above a fathomless abyss with one hand grasping a tiger, (when holding a needle,) the spirit must not be distracted by anything. Prior to needling, (the practitioner should) retire to a quiet place and commune with his spirit with doors and windows shut. (The practitioner's) ethereal and corporeal souls must not be scattered, his mind must be focused, and his essence qi undivided. Undistracted by human sounds, he must marshal his essence, concentrate his mind, and direct his will entirely toward needling.This is pretty subtle stuff. Huangfu Mi is not talking about book learning here. In between these passages, however, is arranged some of the most articulate information on the nuts and bolts of acupuncture practice in the entire Chinese literature. These passages also suggest how one actually goes about accessing this other aspect of understanding. We cannot simply think real hard. Whether intuition is a surpassing wisdom or simply the totality of experience locked in cold storage in our brains, it is clear that it is not tapped in the same way one might remember baseball statistics. A certain core level quietude is required. In addition, I firmly believe that this is as necessary in the practice of herbal medicine as it is in the practice of acupuncture.I am a zazen practitioner and it would be nice if I could say that I went and meditated and the solution to my particular clinical conundrum appeared before my eyes. It did not. Indeed, if I took the time to go and sit before making every clinical decision, I quite literally would not have the time to actually practice. I am finding, however, that my clearest clinical insights arrive following periods of momentary emptiness. In these instances, information is clearly being processed, but my mind is not churning. Perhaps these instances of emptiness are just a symptom of an old head injury, but I like to think otherwise.Huangfu Mi goes on to say: The essentials of needling are easy to explain but difficult to master in practice. The mediocre practitioner abides by the form, but the superior practitioner abides by the spirit...(But) without a study of the illness, how can one understand its source? One must have a clear understanding regarding the five transporting points and be well informed regarding the slow, and rapid (manipulation of the needle in supplementing and draining therapies)...and all this knowledge should be systematic.These excerpts show that Huangfu Mi had no preference for one aspect of understanding over another. Rather, I believe that he is telling us we must use all of our faculties. It is clear that he is advocating a rigorous and rational understanding of available information and that this information must then be applied with both heart and mind. For me, the magic and mystery of practicing Chinese medicine lies in learning to make yin and yang dance together in creating and guiding a natural selection. Sometimes I am more successful at this than others.ConclusionThe above was not one of my more skillfully executed cases. That I hit upon the correct influence in this case may reflect either an intuitive leap on my part or a series of blind but lucky stumbles. Perhaps I was just thrown a bone. It may simply have been time for my young charge to stop wetting her bed, and time for me as an agent of this process to once again experience practice in the larger sense of that word. It is impossible to say. If some nonrational process was indeed a factor in the resolution of this case, it is only because I had managed to provide my clients with the proper tools. And these tools were definitely derived from rational processes. Perhaps it was the nourishment and intimacy of mother administering the moxa to daughter that was the deciding factor in this case, or maybe it was the milder but more constant stimuli of daily indirect moxibustion. Either way, the influence that worked was ultimately natural selection.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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