Fundamentals of pattern analysis
for classical Chinese medicine (CCM)
— part 3

[[[Click on the link shown at right.
The window that pops up will be used to display links to diagrams, tables, or references throughout this lecture.]]]

It's a natural tendency for any profession to evolve by inventing new protocols to handle problems that fail to respond to old methods. Illnesses that fail to respond to standard, tried-and-tested remedies may require creative modification of old methods, experimentation, and careful observation to derive effective remedies. However, adding new illnesses and diagnostic categories inevitably increases complexity.

In modern scientific medicine, thousands of different diseases have been described, with textbooks outlining criteria for their diagnosis and treatment. Only about 120 basic symptom-sign patterns are described in the most detailed CCM textbooks. However, as any honest, experienced practitioner of CCM will acknowledge, accurate differentiation of even these 120 patterns can be exceedingly challenging; only a tiny percentage of practitioners ever acquire the ability to accurately differentiate these 120 patterns from each other, especially in complex clinical cases with multiple simultaneous patterns and when only partial subsets of the defined symptoms are present. Accurate allopathic medical diagnosis, with its thousands of distinct diseases, is even more difficult, and erroneous diagnoses are acknowledged to be a major problem, which is why artificial intelligence software for general medical diagnosis remains an elusive goal. Consequently, expert systems for allopathic medicine have typically limited their scope to narrow sub-specialties of medicine, such as the interpretation of radiology x-rays or the classification of respiratory illnesses, of rheumatology diseases, etc.

A number of prominent artificial intelligence researchers have complained that Western medicine is often confounded by its very complexity, and its frequently ambiguous, indefinite diagnostic criteria hinder developing successful algorithms for general diagnosis. In other words, we have a seeming paradox. By increasing the total number of diseases that must be differentiated from each other, diagnosis in general becomes so difficult that high error rates become a serious problem. That's not what we'd like to see. It's commonly assumed that increasing sophistication will improve our quality of life. However, as any corporate manager knows, the greater the number of parts in any consumer product, the greater the risk of product failures.

To avoid these pitfalls, early in its history Chinese medicine devised a simple 3-dimensional system for classifying diseases according to fundamental qualities that should seem intuitively obvious to most people.

• The first dimension is Depth (Exterior vs. Interior):
  (To be consistent with the format of the I Ching hexagrams, I've placed it at the bottom of the chart here.)
  Is the condition mild, superficial, and acute in nature (e.g: early stages of upper respiratory illnesses, skin rashes, tension headaches)? Or does the illness affect internal organs, and is it chronic? Or does it lie somewhere between these two polar extremes? At whatever depth an illness lies, we will need to choose herbs and remedies that penetrate to that level. Herbs for the Exterior are generally mild and light in nature. Herbs for the Interior can span a wide range of qualities, from pleasant-tasting to harsh and intense in their effects; most people can readily sense these effects penetrating to deeper levels.
      In this table, each pattern is defined as a set of symptoms, tongue, and pulse signs. We always organize these by symptom category, to make it easier for our students to learn and memorize. For example, under Excess, the categories listed are: SYSTemic, RESPiratory, PAIN, MOTN (motion), SPCH (speech), BEHAVior, TCOAT (tongue coating), and PULSe.
      Exterior patterns are usually acute and are typical of the earliest stages of a cold or flu. Symptoms focus on head, sinuses, and shoulders, and with only slight changes to tongue appearance and a radial pulse that seems to float near the surface.
      Interior patterns affect chest, abdomen, and deeper levels of the body. Most chronic illnesses are Interior in nature, as are acute illnesses that become more severe. The symptoms and signs can vary widely depending on other qualities.
• The second dimension is Thermal (Heat vs. Cold):
  Is the disease condition characterized by symptoms of overheating, burning sensations, flushing, or inflamed, reddish areas? Or by hypothermia, perception of cold, chills, with pale-bluish skin? Or perhaps a combination of fever plus chills which often occurs in the early stages of acute infectious illnesses? The Heat/Cold aspects of an illness will generally be counteracted by choosing remedies of an opposite nature, just as you might instinctively choose to take a hot bath to relieve body coldness and the aches and pains associated with cold, or to drink cool liquids on a hot summer day.
      For Heat patterns, think Hot-Red-Rapid:
  in addition to sensations of heat; skin and body tissues tend to be redder than normal; movements, behaviors, & pulse tend toward rapid.
      For Cold patterns, think Cold-Pale-Slow:
  sensations of cold; skin and body tissues pale; movements, behaviors, and pulse sluggish and slow.
• The third dimension is Strength (Excess vs. Deficiency):
  Is the condition characterized by an over-accumulation of something — like edema, constipation with distention and fullness, blockages, infected tissues, swelling, or tightness? Or by a lack of something — a perceived emptiness, fatigue, weakness, or laxness? Excess conditions require purging, draining, and/or unblocking actions. Deficiency conditions require nutritive tonics and other types of restorative therapies.
      For Excess patterns, think Strong-Forceful.
  Here, the overall pulse strength is an especially useful indicator of Excess conditions.
      For Deficiency patterns, think Weak-Passive.

For complicated cases, there can be simultaneous presence of both Heat and Cold, Excess and Deficiency, Exterior and Interior.

While the preceding criteria are admittedly crude, this schema establishes general guidelines within which all the other 120 CCM syndromes can be classified. It's especially useful for spotting serious errors. And it's applicable not only to herbs, but to understanding how diet, massage therapy, hydrotherapy, the weather, and other therapies and environmental factors may affect each of us differently based on our unique strengths, weaknesses, and vulnerabilities.

Some of you may now be thinking: "But you've so far outlined only six patterns, not eight!" I'll give you a hint: Yin and Yang form the basis of the very notion of polar opposites, measurement scales, dimensions, etc. In other words, in Daoist cosmology, the universe is spontaneously generated from the Dao by an interplay of Yin and Yang, and these are implicit in any measurement or classification system based on this principle.

The diagram at right displays the 3-dimensional vector space defined by the Eight Principal Patterns. The three axes effectively divide the space into eight sectors, which results in eight combination patterns — shown on the right as trigrams.

In this diagram I've displayed only the major Interior patterns, which allows me to collapse the 3-D space into a 2-D space of Thermal vs. Strength.
I've also added four patterns:

• Interior Heat Evil has definite qualities of Excess, so I've placed it somewhat to the right of the mid-point of the Excess-Deficiency axis.
• Interior Cold Evil is neutral with respect to Excess vs. Deficiency.
• The patterns Interior-Deficiency and Interior-Excess are neutral with respect to Heat vs. Cold.

One very useful feature of vector spaces is that to determine how similar or different two patterns are, we simply measure the distance between two points. Contraindications for a given pattern can often be identified by considering patterns in opposing quadrants. Let's look at a few examples:

 
Example #1.   Liu Wei Di Huang Wan, or Rehmannia Six, is one of the most popular and widely sold Chinese herbal formulas. It's appropriate for Deficiency of Kidney and Liver Yin, which is a sub-type of Interior-Heat-Deficiency.
For Deficiency patterns, we use nutrient-tonics, and for Deficiency-Heat we use Yin tonics, which are typically moistening, sweet, and slightly bitter to taste. These will relieve symptoms of thirst and overheating that occur due to the systemic dehydration that is a key aspect of this pattern.
    However, for Interior-Heat-Excess conditions, which also share the symptoms of thirst and fever or overheating, it is inappropriate and may actually aggravate the overall condition. Many people frequently misuse this formula by failing to observe its many contraindications.
    It's also inappropriate for conditions of Deficiency of Spleen and Kidney Yang, which is a sub-type of Interior-Cold-Deficiency. In such cases, this formula may result in abdominal bloating and nausea and will be difficult to digest. For Interior-Cold-Excess conditions, it will be even worse and may result in nausea and vomiting.

As a general rule, the most important contraindications will almost always correspond to regions that are most distant from the pattern of interest.

In fact, this remedy has a somewhat narrow range of use and should be precisely targeted to its intended pattern, or it's likely to create problems for its users. The primary detail that spares many from such problems is the fact that Rehmannia Six is often sold in the form of small pills, so the typical dose is relatively tiny; however, if the formula is contraindicated, side effects may creep up so gradually that the individual may not make the association. (I first discovered this unpleasant fact when I was a beginning student of Chinese medicine and tried this myself, so don't try to tell me I'm exaggerating.) On the other hand, if this formula is truly indicated, it can have quite beneficial effects, thus its continuing popularity.

 
Example #2.   Dry ginger is hot and spicy in nature, is appropriate for many types of Interior-Cold, and has a much broader range of application than does example #1. Although not specifically prohibited for use for Interior-Heat-Excess, it must be combined with plenty of bitter-cold herbs in order to counteract its hot nature and to create a net cold action in the body.

 
Example #3.   Coptis root is a bitter-cold herb similar to the Western herbs gentian root, goldenseal, and oregon grape root, which all have broad-spectrum antimicrobial properties. Its bitter-cold nature strongly resolves Damp-Heat and Heat-Toxins, which are patterns located in the Interior-Heat-Excess sector. Coptis root is contraindicated for Interior-Cold of all types and for Interior-Heat-Deficiency, although it might be usable in the latter condition if it's combined with plenty of moistening-lubricating herbs that tonify the Yin.

 
(Also relevant here is that we have so far focused only on the 2-dimensional plane representing the Interior disorders. But for all Exterior patterns, these three preceding remedies are also inappropriate or contraindicated. The exception is dry ginger, which has a greater range of acceptable uses, although for Exterior patterns, fresh ginger would be more appropriate.)

 
The vast majority of instances of contraindicated uses (like the three examples given here) occur directly as a consequence of attempting to answer the remedy-for-disease-X question and then trying things at random — like the results of Internet searches. And as for those TCM colleges that follow the Communist Chinese educational model, their graduates often fall into this same unfortunate trap. Accurate pattern analysis is crucial to the CCM paradigm.

To learn how the flavor of specific herbs and foods reveals important clues about their physiological effects, see the reference link at right. Individuals afflicted by various CCM patterns of disharmony will typically experience flavor preferences and aversions unique to those patterns.

Now that we understand the importance of targeting the right patterns and avoiding contraindications, let's explore some of the challenges of correctly identifying patterns in real life.

In this table, all three Interior-Heat and all three Interior-Cold patterns are defined. I've omitted Interior-Deficiency and Interior-Excess, because these two patterns are still too general to pin down by specific lists of symptoms.

To make it more convenient as a reference and learning tool, I always format the pattern definitions by organizing the symptoms and signs by category.

Here I've listed each of the standard categories included in a typical pattern definition. It should be clear from this list that an initial clinic appointment requires far more than 10 minutes to obtain the information necessary for an accurate pattern analysis of an individual's state of health. It's not unusual for the initial interview to require several hours. For many complex cases, this extra effort ultimately saves much wasted time later trying ineffective remedies because of an incorrect pattern analysis.

While it's possible for rare master herbalists to accurately assess a patient in 10 minutes palpating the pulse, inspecting tongue, and intuiting the personality, this is a skill acquired with decades of practice. In my opinion, fewer than one in a thousand experienced herbalists can pull this off. The rest of us mortals are being unforgivably sloppy when we take shortcuts.

There's another important reason to spend more time. Due to the crucial importance of diet, lifestyle, and environmental toxicity, it's not enough for you to understand an individual's patterns. Patients must be actively involved in their own care, and education is an important part of the process of restoring them to health.

To distinguish these patterns from each other may seem like a daunting task, because there are so many items in each definition. However, let's see if we can simplify the task by remembering a few rules of thumb.

Here, I've highlighted all the clues suggesting Heat in red, and all the clues suggesting Cold in blue. Distinguishing Heat patterns from Cold turns out to be relatively easy, at least much of the time. It's also one of the most crucial, as mistakes can lead to the worst side effects resulting from incorrect remedies.

For Heat, think Hot-Red-Rapid. Regarding red, this means that any shift toward red, or orange or yellow from normal. For example, the tongue coating and sclera of the eye are normally white, so if these become yellowish, that can be a sign of Heat.

For Cold, think Cold-Pale-Slow.

Each symptom or sign by itself is rarely definitive, but merely suggestive of possibilities, which is why we should obtain multiple confirmations of a pattern before we conclude that it's really present. For example, pale tongue tissue can signify Cold, but it also may signify Deficiency of Qi and/or Blood, with or without presence of Cold.

Correct diagnosis in CCM is very much like the job of a private investigator. Individual clues at a crime scene rarely prove the culprit's identity. But collect lots of clues, piece them together in a logical framework, then make a hypothesis and see if the details fit. If not, try again.

Now let's focus only on the three Interior-Heat patterns. Suppose we have an individual with the following symptoms and signs: feels and dislikes heat, thirsty and prefers drinking cold liquids, dark scanty urine, rapid body movements and speech, reddish tongue tissue. These clues are common to all three patterns, so without more clues, we are still uncertain how to assess this person.

The most common error that inexperienced herbalists make is jumping to conclusions with inadequate or ambiguous information, as we have here. Countless times I've heard TCM practitioners confidently, though erroneously, declare that the preceding five symptoms and signs point to Interior-Heat-Deficiency, or what is commonly known as Deficiency of Yin.

I've now just added highlighting to all clues for Excess and Deficiency.

Now let's carefully compare Interior Heat Evil with Interior-Heat-Excess. They both share many clues that indicate Excess. However, Interior-Heat-Excess has the additional clues of:

• PAIN: aggravated by pressure/touch
• SPCH: loud voice
• BEHAV: aggressive

The last two additional clues of Excess are attributes of "Spirit", which encompasses character and personality and which is why the pattern Interior-Heat-Excess is placed further to the right than Interior Heat Evil. Moreover, CCM theory states that if the Spirit is disturbed, this is an indication the illness has penetrated to the deepest levels of the Interior.

So how many clues do we need before we can be reasonably sure of our pattern assessment?? There is no magic number that answers this question, just as there is no magic number of clues a private investigator needs to identify the perpetrator of a crime. Instead, it always depends on context. We must continue to obtain clues until we have uniquely identified a specific pattern, eliminating all patterns that are very different in quality, so that we minimize the risk of giving a contraindicated remedy.

Because this rule is so critical, let me repeat it:
We must obtain enough clues to reliably identify each pattern present in given individual,
being especially careful to distinguish them from patterns that are very different in quality
— so that we minimize the risk of giving a contraindicated remedy.

In other words, just because we have a few symptoms that seem to match a given pattern, does not necessarily mean that that pattern is really there. There might be other patterns that also share those same symptoms, and our job as health detectives is to determine which pattern is really responsible.

Given how crucial it is to accurately distinguish Excess vs. Deficiency, are there any indicators that are consistently reliable that will allow us to quickly make this determination? The answer is emphatically yes — the tongue and pulse data, more so than any other categories of symptom clues, almost always provide us with a clear measure of Excess vs. Deficiency — and not only in general, but for each Organ and body sector. Thinner than normal tongue coating, lack of tongue coating, and randomly-oriented fissures in the tongue tissue are all reliable indicators of Deficiency. Thick tongue coating is a reliable indicator of Excess. And the overall strength of the pulse is almost always an accurate measure of the degree of Excess vs. Deficiency.

If we compare the definitions of the three types of Interior-Heat in this table, we can see that the pulse and tongue clearly help to distinguish the degree of Excess vs. Deficiency.

In order to help our students learn the art of pattern identification, we created TCM Herbal Tutor, which is a collection of interactive games. Multiple choice exam questions typically used by most schools to test students' skills do not even begin to approach the types of challenges posed by accurate evaluation of a patient's clinical patterns. At its most challenging, TCM Herbal Tutor presents random sequences of symptoms and signs to the user. Closely mirroring what happens in a real patient interview, users must decide when they have enough symptom clues to reliably identify a mystery pattern and then to choose the answer from a list of possibilities. At any time they may ask for specific categories of information instead of randomly provided clues, just as the practitioner in real life might interrupt a patient's narrative to ask specific questions.

This screenshot shows a new Syndrome Game window. At this point, the game software has chosen a mystery syndrome, which the user must determine by requesting clues. The buttons in the left column allow the user to request specific types of clues. The  All Clues  button results in the easiest game: a user is presented with the entire textbook definition. To simulate the challenges of real life, though, let's try requesting a sequence of random clues.

Shown in this view are the four clues that resulted from requesting  Random Clue  three times and then a  PULS  clue.

Let's try guessing the answer. I've selected  Interior-Heat-Deficiency , to show you what will happen when the user chooses a wrong answer.

The bottom frame indicates that a wrong answer was chosen, and the top frame displays all the clues. Clues highlighted in red do not match, those in blue do.

Let's try again. This time I've chosen  Interior-Heat-Excess , which is revealed to be the correct answer.

After a student has reached a level of mastery in these beginner-level syndrome games, the software gradually begins to introduce new material. Ultimately, the goal for each of our students is to achieve mastery in pattern identification of all 120 or so patterns defined in the most detailed traditional diagnostic texts.

A typical syndrome game at this advanced level might look like the two instances shown here. A refined level of skill is required to select the correct answer from among a list of possibilities, many of which are very similar in quality.

 
To recall all the details of 120 syndrome-patterns may seem an overwhelming task to the beginner. My co-developers and I extensively tested the TCM Herbal Tutor on ourselves before making this a requirement for all our students. After spending hundreds of hours playing syndrome games and questioning our volunteer users, I began to realize that almost all successful users gradually and instinctively developed internal mental models of the pattern identification task that were considerably more sophisticated than the 3-D vector-space model outlined earlier in this lecture. Eventually, we incorporated the best aspects of these mental strategies into a 10-D model that provides the foundation for AutoSage-TCM, our artificial-intelligence system, which I discuss in the next lecture of this series.