Clinical Thinking and Practice in TCM Ophthalmology
The clinical thinking and practice of TCM ophthalmology is, in fact, an inquiry into the law and practice of biàn zhèng lùn zhì applied to the eye. From the standpoint of Marxist epistemology and methodology, thinking-method is a scientific means of grasping the essence of things; it transcends medicine. Only by correct thinking-method can practice know the essence — that is, seize and resolve the main contradiction, attain in the clinic the aim of knowing and treating illness. This is a higher-level problem of adaptive law that every TCM ophthalmologist must explore.
The application of Marxist epistemology must take professional knowledge as its tool and base. Without TCM professional knowledge, thinking-method becomes empty metaphysics, unable to guide clinical practice.
I. The basic features of TCM theory
1. Unified-whole view. TCM holds the human an organic whole — an open system in continuous internal-external exchange of matter and information. The exchange runs through qi, blood, fluids; through jingluo as channels; through the yin-yang regulation of the zàng-fǔ. By the integral coordination of all storehouses-organs, a stable internal state is preserved. The body, in nature, maintains close organic ties with the external environment by such exchange (the human in correspondence).
**2. Biàn zhèng lùn zhì.** TCM's doctrines of yin-yang, zàng-fǔ, jingluo, qi-blood hold that among the body's many factors there are feedback-and-control relations of engendering, restraining, transformation that maintain health and stable state. When the body's ordered yin-yang relations are disturbed, a dynamic struggle of right and evil appears. If right qi suffices for self-adjustment, health is held; if evil is too strong and right cannot adjust, stable balance is lost — disease arises. By the four examinations the doctor learns the patient's signs; by yin-yang, surface-interior, cold-heat, vacuity-excess, zàng-fǔ, jingluo, and qi-blood-fluid theory he synthesizes and analyzes; finds the key disequilibrium; uses herbs, acupuncture (with tonification/drainage, channel-entry, ascending-descending/floating-sinking, principal-action and effect), and other means to restore steady state. This is biàn zhèng lùn zhì.
From these basic features one sees: TCM places the body in a great system, exploring its many-layered, multifactorial, multivariate cross-links, recognizing and handling relations through information, with the steady-state principle regulate yin-yang, take balance as the aim. These views accord with modern systems theory, control theory, and information theory.
(Schematic: the great system comprises outer information — four qi, yunqi, six excesses, pestilential qi — and inner information — zàng-fǔ, organs, qi-blood-fluids, jingluo; the body, as an organic whole, runs on yin-yang and five-phase, mutual engendering and restraining, over-activity and proper restraint. Diagnosis by four examinations and eight outlines; control by herbs, acupuncture, qigong, with synthetic analysis. Treatment: biàn zhèng lùn zhì.)
II. TCM ophthalmology is a branch of TCM
Before the Tang, no separate ophthalmology — eye diseases were discussed within general medical works. In the Tang, Mizhuan Yanke Longmu Lun came out as the first work; the official Imperial Medical Bureau had an "ear-eye-mouth-tooth" department. By the Song, the Bureau set nine departments, separating ophthalmology. Through long history, TCM ophthalmology matured. Its basic theory, perspective, and method are of one lineage with TCM as a whole. On TCM's theoretical base, ophthalmologists, by long clinical practice and the specialty's features, summed up pattern-discernment and treatment law for the eye. Beyond eight-outline, zàng-fǔ, wei-qi-ying-xue, and qi-blood-fluid discernment, TCM ophthalmology has the Five Wheels, the Eight Ramparts, internal-and-external-obstruction discernment, and discernment of common ocular symptoms.
The Five Wheels: TCM's unified-whole view holds the eye an organ in close organic tie with the whole. Eye pathology is never isolated — it can affect the whole and is affected by the whole. Eye disease is a manifestation of zàng-fǔ-jingluo-qi-blood disharmony (the liver opens at the eye; the eye-connector lodges in the brain; the essence-blood of liver and kidney ascends to fill the eye). TCM ophthalmology therefore looks both at local signs and at whole-body signs, synthesizes them, sees the essence. The body as organic whole is many-layered; whole and part are relative. The eye, as part, is itself many-layered — eye-connector, dark-eye (cornea), pupil-spirit, white-eye (sclera), inner-canthus blood-network, lid — each a different part. TCM ophthalmology's Five-Wheel localization to zàng-fǔ is grounded in the anatomy of the eye-part and the character of the symptom, judging zàng-fǔ specificity. Across long clinical history, using the body as model under zàng-xiàng theory, watching response after drug-signal input, they sought the regularity between local eye-pathology and zàng-fǔ dysfunction — and gradually formed the Five Wheels doctrine. Its basis is in the Neijing — Lingshu, Great Discourse on Confusion: "The essence-qi of the five storehouses and six bowels all ascends to fill the eye and becomes its essence. The essence's seat is the eye; essence of bone is the pupil; essence of sinew is the dark-eye; essence of blood is the network; the seat's qi-essence is the white-eye; essence of flesh is the lid…" Refined by the Tang Longmu Lun and the Song's Liu Hao, by the Northern-Song Taiping Shenghui Fang (CE 992) the Five Wheels doctrine was set: dark-eye is wind-wheel, inwardly tied to liver; inner-canthus blood-network is fire-wheel, tied to heart; lids are earth-wheel, tied to spleen; white-eye is metal-wheel, tied to lung; pupil-spirit is water-wheel, tied to kidney. The ancients had seen that eye disease ties to zàng-fǔ disharmony; by zàng-fǔ regulation eye-effects could be had. Under the unified-whole view, the Five Wheels summed up the general law of local-eye to whole-body (zàng-fǔ) relation — of great significance in pushing TCM ophthalmology forward, useful for zàng-fǔ localization, etiology-mechanism analysis, and treatment selection.
III. Clinical thinking-method in TCM ophthalmology
(One) Method. Start from the part; join with the whole; pattern and disease; whole-body and local; TCM diagnosis and Western diagnosis.
1. Through look-listen-ask-palpate of the eye, learn the local picture: chief complaint, vision, symptoms (appearance, site, etc.). Apply Five-Wheel, Eight-Rampart, internal/external-obstruction discernment, and common-symptom discernment, to set a tentative TCM ophthalmic disease-name (disease-discernment) and the related yin-yang/cold-heat/vacuity-excess/zàng-fǔ-jingluo-qi-blood localization and characterization (pattern-typing).
2. By modern detection (slit-lamp, fundus, B-ultrasound, visual field, electrophysiology, radiology, imaging), reach the Western diagnosis and the local picture — edema, congestion, exudate, inflammation, hemorrhage, proliferation, degeneration, atrophy, displacement, mass-effect, etc. (drawing on modern TCM ophthalmologists' clinical experience and research).
3. By look-listen-ask-palpate, learn whole-body conditions; by biàn zhèng lùn zhì, judge the whole-body yin-yang/cold-heat/vacuity-excess/zàng-fǔ-jingluo-qi-blood state (refining the pattern-type).
Synthesize the three streams in thinking.
(Two) Judgment. Generally use local signs to set the TCM ophthalmic disease-name, whole-body signs to set the type, refer to TCM ophthalmic formula-prescription rules, with the modern findings — value TCM-herb clinical experience.
1. Where all streams agree (Five-Wheels and Eight-Ramparts, zàng-fǔ, qi-blood, cold-heat surface-interior, eye signs by their wheel-position and zàng-fǔ tie, whole-body tongue-pulse and general symptoms, modern findings basically aligned): treat by the standard discernment.
2. Where whole and eye disagree: take the eye as principal, accommodate the whole-body in formula-selection. If eye-signs are typical and whole-body has only partial signs at variance, follow the eye, with a guide-herb nodding to the whole. If whole-body signs and tongue-pulse are typical, follow the whole-body, with an eye-side adjustment. Or: in acute states treat the branch; in chronic, the root.
3. Where no marked whole-body signs: discern by the eye alone — TCM ophthalmic pattern-method can give a conclusion.
4. Modern medical findings should be folded into TCM theory. TCM through continual scientific practice has innovated — e.g., on optic nerve, macula, fundus vessels, retina, choroid. For modern-detected retinal edema, exudate, hemorrhage, proliferation, much formula-experience deserves use.
5. In synthesizing, weigh many-sided, many-layered information; balance whole and part. Avoid mechanical formulas. The Five Wheels, under the unified-whole view, shows a general law of eye-to-whole-body tie; but mechanically applying it to derive diagnosis in a complex case will mislead.
IV. Examples
1. Case
Juxingzhang (cluster-of-stars obstruction):
- Eye: sudden fine black points on the dark-eye (cornea), grey-white, slightly raised or coalesced. (Wind-wheel, in liver.) Fluorescein-positive; photophobia and lacrimation; rough-painful sensation; circumlimbal red. (Heat.)
- Whole: (a) fever with chill; coating white; pulse floating. (b) Dizziness; bitter mouth; flank pain; red urine; coating slightly yellow; tongue-tip and -edge red; pulse string-like and rapid; dark-eye scars coalesced. (c) Chest oppression; lassitude; poor appetite; spirit-fatigue; muddy head; loose stool; tongue red, coating greasy; pulse soggy or slippery; hot-sticky tears; granular grey-white "erosive" star-spots; protracted course.
Diagnosis: juxingzhang; superficial punctate keratitis.
Typing and biàn zhèng lùn zhì:
- (a) Wind-heat surface-attack invading the dark-eye. (fits)
- (b) Liver-heat blazing within. (fits)
- (c) Damp-heat accumulating, attacking the eye-orifice; earth-excess oppressing wood. (does not quite fit)
Treatment principle:
1. Clear heat, dispel wind, brighten the eye.
2. Clear liver, drain fire, brighten the eye.
3. Clear heat, drain damp, brighten the eye. (Same disease, different treatment.)
Formulas:
1. Cool-pungent surface-releasing: Sangju Yin, Yinqiao San.
2. Clear-drain liver-fire and lower-jiao damp-heat: Longdan Xiegan Tang, Shijueming San.
3. Clear-damp-heat and unblock qi: Sanren Tang.
Modifications: For this disease, add scar-removing and wind-heat-clearing herbs — shijueming, chanyi, gujingcao, mimenghua, qingxiangzi, etc.
- Much eye-mucus, few tears: liver-and-lung heat — add yejuhua, jinyinhua, lianqiao, diding, gongying, daqingye.
- Many tears, little mucus: wind-strong — add fangfeng, jingjie, xixin, qianghuo, bohe.
- Vertex headache — add gaoben, manjingzi; lateral headache — fangfeng, xixin, mugua; brow-bone pain — baizhi; frontal — chuanxiong; nape — gegen.
- Heat-strong with constipation — add dahuang, yuanmingfen.
- Eye-red severe — add guiwei, chishao, danpi.
- Long use of wind-dispelling herbs — add yin-nourishing: shengdi, yuanshen.
- Protracted illness with right-vacuity — add qi-tonifying middle-supplementing herbs.
Chishizhi and shijueming used together promote corneal healing and reduce inflammation.
2. General rules of pattern and herb use
Under the unified-whole view and biàn zhèng lùn zhì, ophthalmologists have summed up rich rules of pattern and herb. Examples:
- For deficient, supplement the mother; for excess, drain the child. In eye, liver-deficiency → tonify kidney (yi-gui same source, son-vacuity → tonify mother). Liver-heat → drain heart; stomach-heat → drain lung — for excess, drain the child.
- In chronic eye disease, vacuity-patterns predominate; long use of kidney-tonifying greasy herbs requires aromatic-spleen-rousing herbs to prevent dampness-retention and stomach-injury.
- For yang-vacuity collapse with high eye-pressure (glaucoma), do not over-use yang-lifting tonics.
- Tonifying: from light to heavy. Draining: from heavy to light.
- In chronic eye disease where effects come and go: add qi-and-middle-tonifying herbs (sustain right to drive evil); release stagnation to unblock qi; quicken blood and regulate qi.
Schematic of TCM ophthalmic clinical thinking
- Eye signs — by look, listen, ask, palpate → TCM ophthalmic diagnosis → eye-symptom features, typing.
- Eye disease — modern testing — Western diagnosis → great treatment law.
- Whole-body signs — by look, listen, ask, palpate → surface-interior, cold-heat, vacuity-excess discernment → zàng-fǔ-jingluo-qi-blood typing → general herb rules → formula and modifications.
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