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Thoughts on Ben and Biao

Hiromi Matsumoto

by all the various symptoms, but should regulate the ba- sis of one's physical condition. Also, as to where to begin treatment, as long as there is no threat to life, the original (primary) symptoms are treated first. When there is im- mediate danger to life, one should disregard whether the symptom is original (primary) or a later occurrence (sec- ondary).

In the earliest classics, life threaten- ing symptoms were Zhongman (disten- sion and fullness in the abdomen) and the cessation of urination and bowel movements. In modern terms, it might be better to frame this differently, as any symptom which are a serious interrup- tion of life signs. In any case, the con- cepts of Ben and Biao, in instances where the symptoms were complex and transi- tory, were used to determine whether the symptoms required immediate attention or not. It helped decide where to place the emphasis in treatment. In some places, it is used to decide which meridians to treat. The following is a portion of the outline on the concept of Ben and Biao in the Suwen and Lingshu from Zhong Guo Yi Xue Da Zi Tian (The Dictionary of Chinese Medicine): 1 (1) The first disease is Ben and the latter disease is Biao (Suwen, Chap. 65 ) (2) The origin of the meridians (four limbs) is Ben, and the places they go to (head and trunk) is Biao (Lingshu, Chap. 52) (3) Diseases on the bottom are Ben, and diseases on the top are Biao (Suwen, Chap. 61 ) (4) The Six Influences of wind, cold, heat, dampness, dry- ness, and fire are Ben; the Three Yin and Three Yang (stages) are Biao (Suwen, Chap. 74) (5) The patient is Ben and the physician is Biao (Suwen, Chap. 14) (6) Receiving the Pathogenic Influence is Ben, and that manifesting the symptom is Biao. The Five Deficiencies are Ben and the Five Pathogenic Influences are Biao. When the Ben is more urgent than the Biao, treat the

1. The Origin of the Concept of Ben and Biao

The world view which originated in China also influ-

enced Chinese medicine, and the monistic principle of Yin and Yang is its central axis. The concept of Ben and Biao (i.e. cause and manifestation) occurred in Chinese medi- cine, along with the other Yin-Yang pairs: interior-exte- rior; cold-hot; deficiency-excess and tonification-dispersion. These concepts are different from the principles of modern ratio- nalism, in that they came from a world view of relative differences instead of one of abso- lute distinctions. The following are some ref- erences to Ben and Biao in Chinese classics, before the appearance of medical texts. It says in the Huainanzi that, “the sun is the master of Yang, the moon is the ancestor of

Yin

downward. Thus the birds move and are high while the fish move and are low. All things move in mutual rela- tion and there is a correspondence of Ben and Biao.” In this way, the workings of myriads of manifestations of nature are explained as each corresponding to cause and effect. Masawo Maruyama, a prominent scholar of Chi- nese medical classics, placed special importance on the Huainanzi as a work which set the precedent for the Neijing (Yellow Emperor’s Inner Classic of Medicine). In the Daxue it says, “Things have a cause and effect; events have a beginning and end; knowledge (has that which) leads and (that which) follows; thus the Way is approached. These passages express the Chinese world view which gave rise to the concept of Ben and Biao.

world view which gave rise to the concept of Ben and Biao. Fire burns upward and

Fire burns upward and water flows

2. References to Ben and Biao in the Medical Texts

1) The Suwen and Lingshu The concepts of Ben and Biao represent cause and ef- fect, or primary and secondary. In terms of disease, symp- toms and treatment, both of these terms express a relative relationship. These terms were used to deal with various aspects of medicinal practice. Applied to treatment, this concept came to mean that one should not be distracted

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Ben first. 2) Medical Texts after the Suwen and Lingshu There aren’t many texts after the Suwen and Lingshu which explain Ben and Biao clearly, but I have one text, Yi Xue Ru Men (Introduction to Medicine), which explains this as follows: 2 “Those who treat disease must know of Ben and Biao. Speaking about these in terms of the body, the exterior is Biao and the interior is Ben. Yang is Biao and Yin is Ben. Thus, the Six Fu are Yang so they are Biao, and the Five Zang are Yin so they are Ben. As regards the meridians of these Zangfu, those on the exterior are Biao, and those in the interior are Ben. Further, the Qi of the body is Biao and Blood is Ben. Speaking in terms of disease, that which first receives the disease is Ben, and the places the disease transmits to later is Biao. In general, to treat disease, first the Ben is treated and then the Biao is treated. If the Biao (disease) is treated first and the Ben (disease) is treated later, the Pathogenic Influence becomes stronger and that (Ben) disease goes even deeper. When the Ben (disease) is treated first and the Biao (disease) is treated later, even if there are over ten manifestations of the disease, they will all disappear An urgent situation is when there is Zhongman (dis- tension in the abdomen), and treatment is administered without considering Ben and Biao. If there is Zhongman, and then urination and bowel movement cease, this is most urgent. First, administer treatment to facilitate urination and bowel movement and then treat Zhongman, without regard to Ben and Biao In all cases, except those with Zhongman, and/or the cessation of urination and bowel movement, do not hesi- tate to treat the Ben (disease) first.” Also there is a passage about Ben and Biao in Jing Ye Quan Shu (Complete Works of Zhang Jie Bin, 1624):

“When it is said that there is Ben and Biao in disease, it means the origin of the disease is Ben and the changes of the disease are Biao. The root of a disease is only one, but this is hidden and difficult to bring to light. In addition, the changes in a disease are very many and varied. If it is apparent, it is easy to grasp. For this reason, many who treat diseases these days don’t understand Ben and Biao. Thus, they treat only what is obvious, and this is a big prob- lem Ben and Biao are mentioned so that (one may) know

about what is deep from what is superficial, and know about what is distant from what is close. While this may seem simple, it is difficult.” The Zhong Yi Xue Wen Dao (Questions and Answers on TCM) summarizes Ben and Biao as follows: 3 (1) Normal Qi is Ben and the Pathogenic Influence is Biao. (2) The etiology is Ben and the symptoms are Biao. (3) The internal organs are Ben and the body surface is Biao. (4) The initial or old disease is Ben and later or new dis- eases are Biao. (5) When treating disease, the Ben is addressed first.

(6) If the condition is urgent (acute), the Biao is treated; if mild (chronic), the Ben is treated.

A similar analysis is provided in Zhong Yi Xue Jie Nan

(Explanation of Complexities of TCM). 4 The following items, however, are different:

(1) Biao is (pathological) phenomena; Ben is the constitution. (2) The Zangfu are Ben and the meridians are Biao. These references give us a general sense of Ben and Biao, as they are understood in medical texts, from classical to modern times.

3. The Difference Between Western and Oriental Medicine With Ben and Biao

In dealing with diseases and symptoms clinically in Western medicine, diagnosis and treatment compromise the two aspects of therapy. Diagnosis is a concept for iden- tifying the pathological change occurring in the body. Once this is elucidated, knowledge of pathophysiology and pharmacology are applied to design a treatment. So, the

purpose of the diagnosis is to (1) elucidate the location and nature of the pathology, (2) provide a basis for a treatment plan, and (3) observe progress and make a prognosis. If we shift our perspective, however, under the current medi- cal system, the perception of a disease, with a few excep- tions, is based on the late stages. Diagnosis is made by means of various tests, and in most cases the existence of organic or histological change is indispensable. There is a climate in which changes on a functional level alone are not accepted as being a problem.

In Oriental medicine, balancing the whole is more im-

portant than the disease entity, and its attitude is one of resolving various diseases in this process. In principle,

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therefore, physiological functions are normalized through the attempt to balance the whole. This does improve a person’s physical condition, but it is assumed that this hap- pens primarily through the function of the autonomic ner- vous system (including somato-visceral reflex, and reflexes involving the endocrine and immune systems). In other words, we build up the condition of the body so that it can better recover from illness. This is a theme which is at the root of all acupuncture and moxibustion treatments. From the standpoint of treatment, it is obvious that tak- ing corrective steps as early as possible, before the patho- logical changes have become severe, is the best approach. Be that as it may, this is merely a rhetorical position and, when confronted by patients suffering from a disease, ob- viously it is important to do whatever we can to alleviate their suffering. This is because treatment is being sought to get relief. I think that the concept of Ben and Biao came about to address the issue of how to prioritize and take action, given the realities of clinical work, in which phi- losophy and practical concerns are intermingled.

The Practical Concerns of Patients

Our understanding of human beings, medical knowl- edge, and medical environment changes with the times. The position of practitioners and the standards and qual- ity of patient demands also change. In the period when medical approaches from China were dominant in Japan, treatments were based on that system. Today there is Western medicine along with Oriental medicine, and there are a large variety of treatment options. Therefore, even when we are performing acupuncture to treat a patient’s complaints, we have several possible kinds of treatment in mind, and we select the most appropriate one. Of course, the knowledge and experience of the practitioner plays a major role in the selection of treatment method. This, for example, affects decisions about whether to improve the overall condition of the patient as the complaints are ad- dressed, or to simply treat the symptoms. In addition, there is the choice of whether to apply the principles of Oriental medicine in treatment, or that of Western medicine, or both. The treatment is provided based on this decision, and natu- rally, the number of points used and the depth of needle insertion depend on it. In my case, for example, there are several ways in which I deal with cases of low back pain, which is a large portion

of my practice. For athletes in their teens, treatment of the local, lower back area is generally sufficient. For elderly patients, over seventy, however, in addition to the lower back area, I add treatment to the abdomen, upper back and essential points on the arms and legs. My reasoning is as follows: by treating the lower back area, I reduce tension in the tissues around the lesion. By treating ten- sion in the abdomen and back, I regulate the function of the digestive system and prevent recurrence. By treating points on the arms and legs, I increase the functional bal- ance of the autonomic nervous system. So, in considering our approach to clinical practice, the treatment a patient receives depends on the practitioner’s knowledge and re- lationship to his patients. The concepts of Ben and Biao are useful in defining our clinical stance.

4. Ben and Biao and Acupuncture in Modern Japan

We perform questioning and other examinations and, if we develop an understanding of the disease condition, we can decide if acupuncture and moxibustion are indi- cated, as well as what to use as an indicator of progress and the prognosis. We are also able to decide whether to use acupuncture or moxibustion, which points to use, the size of the needle, the depth of insertion and whether to retain or not. We can also explain the treatment strategy to the patient. From the patient’s standpoint, there are many things they want to know about: what is their physi- cal condition; will acupuncture be able to treat them; will they have to take time off of work; how many treatments

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will it take, and what will it cost? Many people do come in for health maintenance, but they still have their own reasons for coming for treatment. Therefore, they probably won’t be satisfied if the practi-

tioner gives a treatment without a clear objective. If their treatment is for health maintenance, it is important to ex- plain to the patient that you are regulating the function of the autonomic nervous system, improving their physical condition, and strengthening their body’s healing power.

It is important to create an environment and attitude where

people are motivated to come in for acupuncture treatment for prevention. The concept of Ben and Biao is valuable because it makes us consider what must be done first for the patient

in our clinical practice of acupuncture. It can help us to be more flexible in dealing in a variety of situations. There are those who understand Ben and Biao only from the per- spective of root and branch treatment, in which the former pertains to balancing the meridians and the latter to symp- tomatic treatment. This, however, is only one aspect of Ben and Biao, and it is important that we view these from

a wider perspective.

NOTES

1. Wujin, Xieguan, Zhong Guo Yi Xue Da Ci Dian (The Dic- tionary of Chinese Medicine), 1926.

2. Li Yan, Yi Xue Ru Men (Introduction to Medicine), 1575

3. Yang Yiya, et. al, Zhong Yi Xue Wen Dao (Questions and Answers on TCM), first of two volumes, Peoples Health Publishing, 1985.

4. Zhong Yi Xue Jie Nan (Explanation of Complexities of TCM), volume on acupuncture and moxibustion, Tianjing Science and Technology Press, 1987, p. 218.

REFERENCES

Takahashi, Kosei, Gendai Igaku Gairon (Synopsis of Mod- ern Medicine), Tokyo Univesity Press, 1968. Sato, Akio, et. al, Jiritsu Kino Seiri Gaku (Physiology of Self- regulation), Kimpo Do, 1995. Report of Science and Technology Agency, “Research on the Scientific Elucidation of Oriental Medicine”, Life Sci- ence Promotion Foundation, Tokyo, 1989.

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