by Z'ev Rosenberg, L.A.c

" When the ancients treated patients, they became familiar with the cycles of yin and yang and of time, and with the exhalations of qi from mountain, forest, river and marsh.  They discerned the patient's age, body weight, social status, style of life, disposition, likes, feelings, and vigor. In accordance with what was appropriate to these characteristics, and avoiding what was not, they chose among medicines, moxa, acupuncture, lancing with the stone needle, decoctions and extracts.  They straightened out old habits and manipulated patterns of emotions.  Feeling their way, missing no opportunity and constantly adapting, in their reasoning there was not a hair-breadth's gap.  They would go on to regulate the patient's dress, rationalize his/her diet, change his/her living habits, and follow the transformation of his/her emotions, sometimes treating according to environmental factors, sometimes according to individual factors."

Shen Kuo, Su Shen liangfang/Good Prescriptions by Su and Shen, 12^th century

Approaches to Time in Chinese Medicine:

We live in a time where reforming health care is a central issue in the United States.  Some of the most pressing problems include the insufficient time that medical professionals spend with their patients, and an over-emphasis on pharmacological or surgical solutions to complex health issues.  Chronic, long-term illness has become an increasing demand on health care professionals, requiring more in-depth approaches to care that demand increased time and attention. A small but increasing group of health care professionals are organizing their practices to emphasize more time with patients, and offering tools such as education, lifestyle and dietary counseling, and alternative approaches to managing chronic illness.  Chinese medicine has a large role to play in this sector as well, as one of our chief strengths is the comprehensive approach to health care delineated by Shen Kuo in the above quote, nine centuries ago.  Even in modern times Chinese medical practitioners tend to spend a greater amount of time with patients and address many of the issues that contribute to their complaints.

When discussing Chinese medicine and its role in modern life, it can be argued that one of its essential strengths is its comprehensive medical philosophy, and specifically its approach to time.  In classical Chinese thought, the understanding of change and its transformations in time are a common thread in such texts as the Classic of Change, and expressed in such areas of study as astronomy, agriculture, calligraphy, military strategy, and self-cultivation practices.  The view of phenomenal nature as movement and pattern rather than a fixed viewing point is pervasive throughout Chinese history, and is at the core of how the Chinese traditionally viewed medicine before Western medicine and science became a major influence on Chinese culture.

When we study the classical medical texts, we find an emphasis on patterns and cyclic nature of symptoms, leading to stasis, decay, inflammation, exhaustion of yang, depression, accumulation, and distortion of channel flow.  In the life cycle of most plants, there is the movement from the core seed stage to sprouting in springtime, to leaves and flowers in summer, to fruition in late summer/early fall, and to decay or death in late autumn/winter, returning back to the original seed state.  All living beings, whether plant or animal, follow similar patterns of growth, fruition, and decay.  Chinese medicine is based upon observation of these life cycles and their associated transformations, the human being seen as a microcosm and reflection of the greater dynamics in nature.  Each living being has a particular life span, heart and breathing rate, metabolism, digestion suitable for specific foods, waking/sleeping cycle that distinguishes it from every other species.  In addition, each living organism interacts with the environment in specific ways, and must maintain both internal and external equilibrium in order to prosper, reproduce, and remain healthy.  For all life forms other than humanity, this is an automatic process governed by instinct and natural law.

 Human beings, gifted with free will, paradoxically must choose to live with or against natural cycles, therefore, we can choose to be healthy or ill.  Chinese medicine first and foremost teaches a philosophy of health based on safeguarding and prolonging health.  The first three chapters of the Su wen/Simple Questions are based on instructions for living in harmony with the seasons and harmonizing emotions to avoid damage to the body and mind.  In Ling shu 71 below, the human being is envisioned as a microcosm of heaven and earth, and subject to the same laws:

"Heaven is round, earth is square.  Man's head is round, his feet are square.  Heaven has sun and moon; man has a pair of eyes.  Heaven has wind and rain; man has joy and anger. Heaven has the four seasons; man has the four limbs.  Heaven has five tones; man has the five yin viscera (zang).  These are the mutual correspondences between humanity and heaven and earth." Ling Shu (Evil Guests)

Human beings also are influenced by time within the society and culture where they live.  For example, whether a society uses a solar or lunar calendar, agricultural rhythms (sowing, cultivating, harvesting), animal herding (nomadic societies), industrial societies (clocks, transportation, assembly lines) and our own informational, post-industrial society in which we live, with its rapid movement of digital information, contributing to excessive speed, stress, and anxiety.  One can never catch up in this culture because digital rhythms move faster than biological time.  The body clocks become confused and distorted, as in jet lag or night shifts at work, as we become more divorced from natural rhythms.

The Nan Jing and Diagnosis:

The Nan Jing, in Difficult Issue 50, speaks about the transference of internal evils according to five phase cycle via channel between the viscera and bowels.  Each viscera/bowel has a terrain of emotions, functions, physiology, etc. that is healthy when operating harmoniously with other visceral systems, and unhealthy when overacting on other systems or weakened so that other systems dominate them.  The Nan Jing speaks of five types of internal evils as follows:  weak evils, thief evils, replete evils, vacuous evils, and correct evils.  Correct evils are defined as those that are contracted by a specific channel or viscera according to predictable evils, such as wind damaging the liver, or fire damaging the heart.  The other evils have to do with the generating and controlling cycles of the five phases, and may develop due to emotional, seasonal, or other evils that are transferred according to phase, constitutional factors, or disharmonies of the viscera and bowels that become entrenched.  When emotions or functions of the five yin viscera are disturbed by external or internal aberrations, illnesses may follow (see chart).

In Difficult Issue 8, it states "All the channels are connected with the yuan qi/source qi".  This source qi fills all of the channels, and circulates through the body, communicating jing/essence from one region to another.  The channel system coordinates, supplies, and drains the viscera and the bowels, maintaining a harmonious balance.  When there is a loss of communication between the viscera and bowels, due to the channels being blocked, depleted, or shunted in a different direction, this may lead to what we may describe as "illnesses of compensation".  In other words, the necessary checks and balancing mechanisms are distorted, leading to over-activity in some viscera, and chaotic flow in the channels.  Since the body must always maintain systemic balance, the patient develops a chronic disease of many facets, and because underlying it is a deep-set pattern, it is difficult to resolve without a treatment plan that addresses the underlying complex pathomechanisms.  These undesirable patterns can then be addressed through herbal medicine, acumoxa, therapeutic exercises, and diet, along with regulation of daily activities, rest, and emotions.

Just as we humans develop coping strategies emotionally/psychologically, we may also develop these strategies at a physiological level as well.  Many of these coping strategies may work temporarily, but end up being damaging to both emotional and physiological health in the long run. The body often serves as a conduit for the emotions, in such symptoms as skin rashes, hemorrhoids, recurrent urinary tract infections, irritable bowel syndrome, or abdominal pain.  Thoughts and emotions are sometimes mirrored in physiological processes (and vice versa) in an auto-feedback loop.  Fixations and false strategies become embedded in the body, seen in abnormal posture, contracted muscles, arthritis, abnormal bowel rhythms, or marked weight gain.

Just as people develop strategies to deal with emotional overload, they also self-medicate, using coffee, alcohol, recreational drugs, sex, hyper-exercise, over-eating, and special diets to try to find balance or relief, but it is often done in an unconscious or unproductive fashion.  It is the job of the Chinese medical physician to replace false strategies with healthy ones, to rectify past issues with the present, and help project healthy new directions for the future. 

 "The Emperor asked: ‘by what qi are the one hundred illnesses produced?  When there is anger, the qi counterflows upwards.  When there is elation, the qi becauses relaxed.  When there is sadness, the qi disperses.  When there is fear, the qi descends.  When there is fright, the qi is in chaos.  When there is fatigue, the qi is consumed.  When there is obsessive thought, the qi is bound."  Su Wen 39

The CM physician looks for patterns in handwriting, mode of dress and hairstyle, movement (walking, sitting, loud or soft movements), speech, perfume and makeup.  What is the patient projecting about oneself?  Is it a true picture of what is inside, or a projection of an ideal?  How does the patient approach their treatment?  Do they take responsibility for their own health? How many doctor visits have they had?  How many procedures?  How much medication do they take?

When I treat complex cases, I often will draw a ‘flow chart' for my patients, showing how the condition developed over time, often beginning with an initial, often overlooked, trauma.  The homeopaths call this "never been the same since. . ." (fill in the blanks).  For example, a woman in her forties whose health never recovered after a bout of mononucleosis in college, suffering from irregular menstrual cycles, severe fatigue, bloating after eating, poor digestion, and disturbed sleep.  A number of factors combine from climate, season, emotional stress, constitutional weakness, diet, and unresolved symptoms to create ‘the perfect storm', which manifests as a disease.  This can be drawn as a ‘time-line', extending as a string of symptoms/disease factors from the past, to the present pattern, utilizing five phase, viscera/bowel, six channel or other types of pattern differentiation that can be used as a relational model.  This model allows both the physician and the patient to intervene in the body/mind system providing new stimuli to open communication in the channels and restore homeostasis.

The value of the above methodology recorded in the Nan Jing is that it allows the physician to view a patient's health and disease patterns as a process, a movement in time, rather than just a snapshot taken at one point in time, and then trying to base a diagnosis and treatment plan on it.  The physician, by observing the past, is able to project the future course of health and illness.

In the Nan Jing, acupuncture treatment is designed to restore disturbed order to the channel and visceral systems through sophisticated five phase treatment strategies.  Please see Bob Damone's article for more details on use of five phase transporting points (wu xu xue) in Nan Jing acupuncture.

Chronobiology in the Su Wen and Nan Jing/Introductory Thoughts:

"The Chinese applied cyclic ideas of time (to the microcosm of) the life-maintaining order of the human body, in phase with the environment and with the individual's emotional and rational processes.  This seemed to constitute a remarkably articulated nest of cycles, with the life trajectory of the mayfly or the diurnal rhythm of the human body representing the smallest wheel, and, as the largest, the practically infinite great cycle-----from the beginning until the end of time-----integrating all the astronomical periods, all the small cycles turning within it like a superbly complicated train of gears".

Nathan Sivin, "On the Limits of Empirical Knowledge in the Traditional Chinese Sciences"

The next aspect to investigate is the periodicity of symptoms.  In zi wu liu zhu xue/chronobiology theory, the Chinese recognized that all sentient beings and phenomena had internal clocks that measured cycles of change, birth, growth, decay, and death.  Symptom patterns were recognized as being dependent on the variables of the twenty-four hour clock of the internal viscera, seasons, year, and other cycles.  Symptoms such as heart palpitations were observed to see when they occurred to associate them with the rise and fall of qi in specific channels and viscera/bowels.  Medicines and acupuncture points were chosen to coordinate with the best times vis a vis the rise and fall of qi in treatment.  The pulse was also seen to vary at different times of day, season or other natural cycles.  As the sun rose from dawn to its zenith in the sky, the yang qi would increase and strengthen in the pulse.  As it sank in the sky towards dusk, yang qi would decrease and the yin quiescent qi of nighttime would increase. 

In the next section, we will discuss how chronobiology and the ‘time line' of case histories described in such texts as the Nan Jing can be used to develop comprehensive diagnosis and treatment strategies.

Scheid, Volker, Currents of Tradition 1626-2006, Eastland Press, Seattle, Wa. 2007