The mode of thinking in

Chinese clinical medicine:

characteristics, steps
and forms
Jiang Yong Guang

This past summer we visited with Prof. Jiang in his office at the Chengdu University of Traditional
Chinese Medicine. One of the topics of conversation was a programme which is underway at the uni-
versity to improve the clinical skills of senior students and graduates. Prof. Jiang shared with us that
one of the key factors that he and his colleagues have discovered underlies weakness in clinical skills
is the lack of instruction in how to apply theoretical material to clinical practice. Students master a
large amount of theoretical material in their early years of study, but once in the clinic they tend to
rely on following their supervisors and doing what the supervisors do, without going through a spe-
cific stage of training that teaches them how to apply the theory they have learned to clinical problem
solving. Focusing in on this key factor, Prof. Jiang has undertaken to develop a course as well as teach-
ing texts that are designed to guide senior students and graduates to a better understanding of the
methods of clinical thinking and problem solving. In the brief piece that follows, Prof. Jiang has outlined
some of the most fundamental issues pertaining to this endeavor. We thought it would be instructive
for readers to get a glimpse of how such situations are assessed and dealt with in one of the major
modern centers of Chinese medical education in the world. Readers who are unfamiliar with the style
of Chinese composition may find the following article terse or even stark. In fact, it represents a work
in progress that we feel is important enough to warrant input from as wide a range of perspectives
as possible. KPR and ZYH

THE MODE OF THINKING IN correct scientific mode of thinking in clinical prac-

CLINICAL PRACTICE – tice can improve the application of medical theory.
DEFINITION AND PURPOSE Therefore, this mode of thinking can be viewed as
essential to both theory and practice. For a clinician,
The phrase ‘mode of thinking in clinical practice’ the metaphor holds that if medical knowledge is the
refers to the cognitive processes by which doctors fulcrum, then the ability to think in clinical practice
Jiang Yong Guang, use the foundations of medical knowledge in concert is the lever. The leverage that develops from the
Professor, Chengdu with their clinical experience to understand and treat correct mode of thinking results in the ability to
University of traditional illness. These processes do not belong to the cate- bring the knowledge base to life. Thus the correct
Chinese Medicine
Translated by Zhang gory of scientific theory. They comprise a method- mode of thinking is an important element in inte-
Yu Huan ology of thinking based on scientific theory. The grating the entire process of medical education.

Clinical Acupuncture and Oriental Medicine (2001) 2, 23–28 © 2001 Harcourt Publishers Ltd
24 Clinical Acupuncture and Oriental Medicine
THE COGNITIVE BASES OF THE
MODE OF THINKING IN CLINICAL
PRACTICE OF CHINESE MEDICINE
The cognitive modes of traditional Chinese medi-
cine and modern Western medicine exhibit a large
difference. The core principles of Chinese medical
cognition are the key factors leading to what we
know as ‘naturalistic medical theory’ and its clinical
methodologies and characteristics.
The cognitive bases of
Western medicine
Western philosophy uses structuralism to view and
understand the innate characters of the objective
world (also called material world).
The ancient Greek philosopher, Empedokles,
(435 BCE) authored the theory of Four Origins. He
held that the ‘root of all things’ consists of Water,
Fire, Air, and Earth. According to this doctrine,
everything that exists in the universe is constructed
of these four elements, in varying ratios. As exam-
ples in medicine; the muscles were thought to be
constructed by these four elements in equal ratio.
Nerves were understood to be constructed of
Fire and Earth with double the quantity of the
Water element. Anakesagela was another ancient
Greek philosopher (428 BCE). His Theory of the
Essences did not concur with this understanding of
material objects as constructed by varying amounts
of these basic elements. This theory could not be
used to explain the relationship between simple and
complex structures. Anakesagela held that the world
is composed of essences with distinct natures in
non-specific quantities. For example, according to
this theory the hair contained the ‘hair essence,’ and
the muscles contained and consisted of ‘muscle
essence’.
Leukippos (400 BCE) and Demokritos (370
BCE) created the Atom Theory. Atom Theory asserts
that the origin of creation lay in the atom and the
void. Accordingly, the Atom was thought to be a
micro-substance that is indivisible and invisible. The
Void was conceived of as the field of action of the
Atom. The world results from the different sized,
shaped and positioned Atoms, their attraction and
repulsion.
These ancient theories reflect a proto-typical
view common in Western philosophical thought,
which is that the world is ‘constructed’ rather than
‘born’.1 Thus, as Western science developed, scien-
tists focused on the exploration and discovery of the
elements of which the universe is constructed. This
is the philosophical basis of reductionism that
provided impetus to the development of modern
science. This same reductionism has also directed
Clinical Acupuncture and Oriental Medicine (2001) 2, 23–28 © 2001 Harcourt Publishers Ltd
medical research at all levels, from the depths of the
microcosmic or microscopic level, to the systematic
arrangement of organic systems, organs, cells, and
individual molecules.
The cognitive bases of
Chinese medicine
Holism and Dynamism form the core of Chinese
Medical Cognition.
Holism
The philosophical origin of Chinese medical cogni-
tion is Lao Zi’s world view. Lao Zi says that: ‘Dao
gave birth to one, one gave birth to two, two gave
birth three, three gave birth to everything.’ This
passage from Lao Zi expresses the idea that the
world is ‘born’ rather than ‘constructed’. The notion
of ‘birth’ here carries an organic sense, while the
concept of the world as ‘construction’ implies a
mechanistic sensibility. Whereas reductionism pays
attention to the analysis of elements and structure,
the holism of Chinese medicine pays attention to the
interconnections and interactions of organic systems
and their functions. There are three levels in the
basic concept of holism:
1. The Theory of correspondence between
heaven and man: the natural biological
processes of man exist in close connection
with the natural environment
2. The Holism of five zang4 organs: the
complexity of the human organism and its
functions reflect an integrated and organic
whole
3. The Union of the body and spirit: the tissues
and organs of the human body are in
synchronistic coordination with the mental
activity.
Thus, in understanding illness (i.e. the practice
of Chinese medicine), Chinese doctors are always
looking for its causes by identifying impediments to
these various inter-relationships. The operant term
used to express these impediments is ‘imbalance’.
It follows that the therapeutic principle is ‘adjust-
ment’ of the abnormal inter-relationships (to restore
balance).
Dynamism
The Holism in Chinese medicine is based on the
theory of yin1-yang2 and the Five Phases. It uses
the yin1-yang2 theory to explain the innate nature
of unity of opposites of all things in existence. It
also uses the theory of Five Phases to explain the
complex relationships of both opposition and com-

plementarity between various aspects of the body.
It is opposite, but unified; it is opposite, but com-
plementary. Thus, movement and change are the
form in which the thing exists. Therefore, the Yellow
Emperor’s Classic of Internal Medicine says that:
‘The birth of things follows from the transformation.
The end of things comes about as a result of change.’
‘There is no object that does not possess rising
and falling, exiting and entering.’ This phi-
losophy describes the human body and diseases
dynamically, and conceives of clinical therapy as a
dynamic adjustment of harmonious activity and
processes.
This is the basic characteristic of the mode of
thinking in the clinical practice of Chinese medicine.
Determining treatment by patterns identified is the
concrete manifestation of this characteristic.
PATTERN – THE CORE AND
STARTING POINT OF THE MODE
OF THINKING IN CHINESE
CLINICAL MEDICINE
What is [meant by] ‘pattern?’ A pattern is an organic
arrangement of symptoms and constitutional signs,
which have many internal correlations. Patterns
are conceptions of various phases of the pathol-
ogical changes of a disease. A pattern is a synthetic
reflection of the pathological causes, stages, nature
and degree of the condition. A pattern is different
than disease. It possesses the characteristics listed
below.
The synthetic nature of pathology
Consensus holds that pattern in Chinese Medicine
implies a kind of pathological condition, i.e. the
reaction of the human body to pathological factors.
A pattern normally involves many organs and
systems. Thus pattern identification is difficult to
discern if only the bio-chemical markers of single
organs are used.
The changing nature of condition
Patterns display pronounced variations over time.
Thus, the diagnosis of a pattern in clinical practice
rarely stays the same. Especially in the case of the
more severe stages of externally contracted heat
(febrile) disease patterns, the diagnosis in terms of
the identification of pattern often changes by [incre-
ments of] hours of time. This differs entirely from
the relatively stable condition in merely identifica-
tion of disease.
Clinical Acupuncture and Oriental Medicine (2001) 2, 23–28 © 2001 Harcourt Publishers Ltd
The mode of thinking in Chinese clinical medicine 25
The superficial manifestations of
symptoms of a disease
The diagnosis of patterns is defined according to
signs. The meaning of ‘signs’ includes symptoms
and constitutional signs. It is a diagnostic method
[used] in judging [whether] biological and patho-
logical changes can be distilled into patterns through
analysis of external manifestations. The theoretical
bases of this method is ‘what is possessed inside
must manifest outside.’ In terms of modern science,
this method of reasoning is known as ‘black box’ or
‘gray box’.
The individualization of the patient
The pathological cause is the basis for diagnosis.
However, the pattern is affected by many factors. For
instance, the individual’s constitution, profession,
weather, emotional stimulation, living environment,
etc. The conclusion can be drawn that individualiza-
tion in diagnosis is the most prominent character of
pattern identification. According to the reasons cited
above, there are differences [in diagnosis] between
the approaches taken in Western and Chinese medi-
cine. Western medicine concentrates on taking group
statistics, and attention is closely paid to the study of
individual cases in Chinese medicine. The difference
between these two [medical systems] is not only
shown in quantitative terms. In fact, the former views
the individual as a biological sample. One [patient]
does not differ from another qualitatively. It [the
Western medical approach] only accounts for the
general trends through quantity. However, the latter
[Chinese medicine] finds that the individual dif-
ferences are intrinsic and inevitable. Therefore any
diagnosis and treatment must pay attention to the dis-
tinctions of each individual. Thus, in the thinking
mode of clinical medicine, what Western medicine
represents is well organized logical thinking; but
Chinese medicine tends to flexibility in thinking by
identifying patterns. This is the cause of the differ-
ence in understanding of diseases and the treatment
processes between the [Western and Chinese]
medical systems.
For example, a case study of exanthema.2
Case study
Patient: Liu, female, 38 years old, who suffered with
exanthema for last 9 years. The eruptions manifested
all over her body whenever she encountered wind
and rain or went swimming. Administration of
chlorpheniramine and other Western pharmaceuti-
cals had some effect at the beginning, but those
drugs lost their effectiveness over time. She began
taking Chinese herbs for the purpose of dissipating
26 Clinical Acupuncture and Oriental Medicine
cold and dispelling wind, but they did not take
effect. The pathological condition included gently
protruding patches of rashes on the four limbs.
These eruptions had a mild pink color. The patient
complained that the location of the irritations was
not stable. They appeared and disappeared irre-
gularly, causing extreme itchiness whenever they
appeared. They disappeared spontaneously when-
ever the weather turned sunny and warm causing her
body temperature to go up. The patient had a lus-
terless facial complexion and low energy level. The
tongue body was bland. The pulse was sunken and
fine.
• Pattern determination: kidney yang2 vacuity
• Treatment method: warming yang2 and moving
water
• Formula:
– True Warrior Decoction
– Fu2 ling2 (poria, Poria) 10 g
– Bai2 shao2 yao4 (white peony, Paeoniae
Radix Alba) 10 g
– Bai2 zhu2 (ovate atractylodes, Atractylodis
Ovatae Rhizoma) 10 g
– Shu2 fu4 zi3 (cooked rehmannia,
Rehmanniae Radix Conquita) 6 g
– Sheng1 jiang1 (fresh ginger, Zingiberis
Rhizoma Recens) 10 g
• Curative effect: the rashes disappeared after
nine packs of the formula. Six more packs were
added to stabilize the curative effect. The
patient was also instructed to take the same
formula, ten packs, whenever the seasonal
[weather] changes occurred in order to prevent
recurrence of the symptoms. The patient has
been followed up for 3 years, and the symptom
has not returned.
Analysis
There are many factors, including invasion of the
cold, that can cause exanthema. Its basic pathologi-
cal changes are an increase in the patency of the
blood vessels, smooth muscle spasm and increase
in glandular secretions caused by histamine and
other chemical mediators. Thus, the usage of anti-
histamine and both specific and non-specific anti-
allergenics in clinical treatment are commonly
indicated. Hitherto research findings have not yet
shown the formula True Warrior Decoction to have
those pharmacological effects, but the pathological
mechanisms of the emergence of this disease has a
complex immunological and genetic foundation.
True Warrior Decoction has obvious endocrine and
immunoadjusting effects. The curative effect could
be deduced from this analysis in this case of chronic
exanthema.
Clinical Acupuncture and Oriental Medicine (2001) 2, 23–28 © 2001 Harcourt Publishers Ltd
Usage of herbs in yang2 and heat category in this
case is also seen as an unorthodox treatment method
in Chinese medicine. Evidently, the decision to use
[True Warrior Decoction] accords principally to [the
diagnosis of] the patient’s constitution and tongue
body. Also, the patient’s case history indicated that
the orthodox treatment method had not produced
any curative effect. Thus we find a rationale which
is based in contradiction and results in a non-
standard selection of formulas; but why did the case
not respond to other kinds of yang2 warming for-
mulas, i.e. other than True Warrior Decoction, that
warm the yang2 and move water? The reasoning has
to do with the emergence of symptoms when the
patient encountered wind, rain, or went swimming.
Based on the point view of [clinical experience in]
Chinese medicine. True Warrior Decoction can
adjust the metabolism of body fluids. This raises the
question as to whether the emergence of symptoms
when the patient encountered water reflects some
kind of imbalance in body fluid metabolism. But
since True Warrior Decoction is a rather mild yang2
warming formula, it was safe to sue in this unortho-
dox treatment of exanthema.
Summing up
The research objective of both Chinese medicine
and Western medicine is the health of the human
body. Thus in treating the same disease, no matter
whether utilizing the approach of Chinese or
Western medicine, all [effective measures] should be
taken into consideration as long as they provide
curative effects. We should have some theoretical
basis where the two systems can communicate. The
difference lies in the different aspects of under-
standing and methods of treatment. To clarify these
differences and to promote progress towards this
theoretical basis on which all effective systems can
communicate and exchange workable theories and
methods, we present the following synopsis of
the steps and forms of clinical problem solving in
Chinese clinical medicine.
BASIC MODES OF THINKING IN
CHINESE CLINICAL MEDICINE
In the formal processes of thinking in Chinese
clinical medicine we can differentiate two general
categories: two steps and six forms.
Two steps
In clinical cognitive processes, there are two steps
to identifying patterns and determining treatments:

Step one: consider the disease
The central concern in considering the disease is
to understand the pattern. This is [accomplished]
through gathering the case history, four diagnostic
examinations, analysis of the mechanism of path-
ology, and inference of pathological causes. This
thinking process proceeds by deducing conception
[of the disease] by means of perception [of signs and
symptoms] and thereby reaches the final purpose of
‘determining the pattern.’
Step two, consider the medicine
The central concern in considering the medicine [i.e.
herb medicinals] is combinations of herbs. The
choice of treatment method, selection of the main
formula or the principal herbs in the formula, com-
binations of supplemental herbs, decisions on the
dosage and prohibitions according to the patterns
determined in step one are the main decision making
processes in medical thinking.
Six forms
Use manifestations to assess the viscera
The term Manifestation (xiang4) and Viscera
(zang4) refer to the external manifestations of inter-
nal essences and conditions. The understanding of
the correlations of those two terms is not only a so-
called Black Box method in Chinese medicine of
understanding the physiology of the human body, it
is also the basis of the study of patterns and signs
in clinical medicine. ‘What is inside must manifest
outside.’ In other words, the patterns and signs
(xiang4) in clinical medicine are the external mani-
festations of the internal viscera (zang4) that are
under the influence of pathological conditions. Thus,
identification of patterns in Chinese medicine is the
discerning and defining of the complicated and
diverse manifestations (xiang4).
Know the constant to achieve
the changes
The constant and changes are two extremely rich
philosophical concepts in the study of Chinese medi-
cine. Disease possesses both constant patterns and
changing patterns. Treatments have both constant
methods and changing methods. Medicines consist
of both constant formulas and changing formulas.
Between these two concepts, constant serves as the
basis of change; changes serve as the evolution of
the constant. With this kind of consideration of con-
stant and changes, they become most important con-
texts and formats in the clinical thinking of Chinese
medicine.
Clinical Acupuncture and Oriental Medicine (2001) 2, 23–28 © 2001 Harcourt Publishers Ltd
The mode of thinking in Chinese clinical medicine 27
Discuss the causes from the effects
Chinese medicine pays more attention to effects than
to causes. The reason may be that effects manifests
on the exterior and thus appear more ‘real,’ whereas
causes are complicated and entwined inside. Thus
the clear differentiation of disease patterns (i.e. the
effects) in order to infer all the possible causes con-
sists of investigating the patterns for the causes. This
is an important form of clinical thinking of Chinese
medicine.
Analysis of roots and tips
The concepts of root and tip pervade every aspect of
Chinese medicine. This concepts servers to differ-
entiate the primary and secondary [sources of] con-
flict. The conflicts between the doctors and patients,
righteous and evil, illness and causes, old disease
and new disease, exterior pattern and interior
pattern, etc. all need a clear differentiation between
what the root is and what the tips are. Thus, the
Classic of Internal Medicine says that: ‘The one who
knows the root and tip, can subdue ten thousand
rebellions in ten thousand attempts; for one who
does not know the root and tip, action is [bound to
be] impetuous.’
Dynamism in identification
and treatment
The process of (having) disease and treating disease
are both full of variables. The emergence and devel-
opment of disease has its own regularities as well as
the influences from outside causative factors. Thus,
Chinese medicine differentiates the process of
disease into different ‘patterns’. Chinese medicine
thinks that the same disease can have different
patterns and thereby can respond to different treat-
ments. Moreover, the treatment is also decided by
the particular individual, particular geographical
area and particular time of the year. ‘Diseases have
no constant form. Treatments have no constant
method. Doctors have no constant formula. Herbs
have no constant grade.’ This thinking is unique to
Chinese clinical medicine.
Flexibility usage of set formula
Chinese clinical thinking emphasizes awareness of
the influence in the process of diseases of all kinds
of variables. It fosters an individual approach to
cases along the three principal vectors [time, loca-
tion, and individual patient]. Chinese medicine thus
manifests a flexible dynamism in its clinical think-
ing. Nonetheless, Chinese medicine also includes
routine modes thinking [i.e. algorithms], which
manifest in the identification of pattern, selection of
28 Clinical Acupuncture and Oriental Medicine
formula, and combination of herbs. For instance, in
the diagnostic standard six channel pattern identifi-
cation from Shang Han [Lun], the relative formula
selection principle should match the diagnosed
pattern. Adjustment of the formula to fit individual
cases follows the same principle. The set methods
and set formulas in Chinese medicine are all flexi-
ble and adjustable to fit the specific conditions
[encountered] in actual clinical practice.
Clinical Acupuncture and Oriental Medicine (2001) 2, 23–28 © 2001 Harcourt Publishers Ltd
REFERENCES
1. Zhang Ju Sheng et al. The philosophical origins of
holism in Chinese medicine and reductionism in Western
medicine. Newsletter of Anhui Institute of Chinese
Medicine 1999;18(1):1–3.
2. Li Hong Dong. Correctly understand and grasp
the meaning of pattern-discussions begins at the using
True Warrior Decoction to treat rashes. Journal
of Shanghai Chinese Medicine and Herbal
1999;(2):28–29.