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UNDERSTANDING CHINESE MEDICINE
Chinese medicine is a vast entity involving more than 2,000 years of history, thousands of renowned scholars, tens of thousands of modern practitioners, a collection of classic texts, modern journals, private reports, and a wealth of ideas. It is beyond anyone's capability to fully grasp and understand such a huge human enterprise. Rather, one can seek its principal trends and characteristics, and then try to elucidate them with the hope of shedding light on as much of the rest of it as possible.
Most people who have some understanding of Chinese medicine are its practitioners: those who have learned the techniques of diagnosis and treatment and the theory of disease causation. One aspect of comprehending the medical system is to know the six climatic and seven emotional factors; master the patterns of the pulse, tongue, and symptomatic indicators; learn the meridians and their acupuncture points and how to select and stimulate them; and to recognize the herbs and be able to combine them to match the diagnostic pattern. But another, equally important aspect is to understand what makes Chinese medicine unique among medical systems and to understand the challenges it faces in its current context. This article reveals four underlying features of Chinese medicine that will aid practitioners and their patients in understanding the system of therapy with which they are now involved. The four features are:
In a book subtitled Understanding Chinese Medicine, Ted Kaptchuk briefly explained some of the tensions between the Chinese and Western medical systems and then launched into a detailed description of the doctrines of yin-yang, five elements, internal organs, causes of disease, a review of acupuncture meridians and points, and the like. For years, this book, with the main title The Web That Has No Weaver, was the first text for most practitioners. Other books aimed at explaining Chinese medicine cover the same basic subjects and may add a discussion of herbs and formulas (which was not in Kaptchuk's book), as well as survey typical treatment strategies. The current article, which takes a different approach, is based on the assumption that the reader either already has familiarity with those other subjects or is about to undertake a study of them. The focus, instead, is on the processes that drive the growth and development of Chinese medicine and define its underlying nature. For each of the features listed here, advantages and disadvantages will be described in relation to the situation faced by the modern practitioner. Certain difficulties and dilemmas will be pointed out; it is not the purpose of this article to propose solutions to the highly complex problems.
The world's major religions have a fundamental book or collection of books that contain the absolute knowledge that forms the religious base. In addition, they all have one or more divine human figures of the past who are representatives of potential that is beyond normal human limitations. These divine human figures have generally delivered the books or the teachings contained in the books. Participation in the religion involves, as a minimum, undertaking some activities and having some thoughts that refer to the contents of the fundamental book(s) and to the divine human figure(s). The devotee aims, through religious practice, to come in contact with the ultimate truth and to lead a better and more meaningful life. A greater level of participation in the religion is attained by carefully studying the teachings, interpreting them for oneself and others, and putting them to practice in daily life; in other words, embracing the teachings.
Chinese medicine has much of this religious character, as do the other major traditional medical systems, such as Ayurvedic medicine and Tibetan medicine. However, although it was sometimes done in the past, Chinese doctors usually do not make prayers nor call upon the images of the divine beings as an essential part of their practice of traditional medicine. Rather, they give the divine beings due respect as founders of the medical tradition. In Tibet, which is now part of China, the traditional medical system does call upon Buddha (in particular, the Medicine Buddha) as part of the medical practice, but this is different from what takes place in China in relation to traditional Chinese medicine.
In the Chinese system, there are the three god-like figures of ancient times:
While today these ancient god-like figures may be regarded as mythological beings, until the 20th Century, most Chinese simply viewed them as divine historical individuals (see Figure 1 for a depiction of the medicine god, Sun Simiao, along with the above three gods). In relation to medicine, these three form the tripod of all medical practice: acupuncture, herbalism, and essential medical theories, respectively.
Many of the ancient texts are presented as a question and answer session between a divine figure and someone who represents an accomplished human seeking to gain further knowledge. In particular, Huang Di carries out a dialogue with his chief associate, Qi Bo, an accomplished physician, in the Huangdi Neijing (Yellow Emperor's Classic of Internal Medicine). In this case, Huang Di asks the questions and Qi Bo gives his answers, as if he is being tested. The Neijing is the central book of Chinese medicine, its "bible." This book is divided into two volumes, one is the Suwen (Plain Questions) and the other is the Lingshu (Spiritual Pivot). Any doctor or scholar who wishes to expound upon a medical treatment-and give his exposition authority-will refer to a statement in the Neijing in support of what is being said.
In the Neijing Suwen, the key to healthy living that will result in attainment of an old age is outlined. There is a story explaining the origins of this view of how to be healthy:
The Yellow Emperor had ruled for 15 years but he worried because the world was not well-ordered; so he withdrew, resting himself in the Palace of the Great Court. He purified his heart and submitted his body (to plain living). For three months he himself had nothing to do with carrying out the affairs of state. Once he had a daytime dream about traveling around the state of the Huaxu clan. This was a natural place, where people had no cravings and did not die prematurely. They did not think about clinging to life, nor did think about the fear of death. (Ideas about) beauty and ugliness did not grow in their hearts, mountains and valleys did not cause them to stop walking, and they lived happily. When the Yellow Emperor awoke he felt happy and contented; he now understood the greatest Dao. For the next 28 years the world was very well regulated, resembling the state of the Huaxu (in his dream).
The Neijing is the first and oldest of all existent medical books referenced in the Chinese tradition; it is the source book for virtually all of the important medical commentaries in subsequent centuries. It focuses on Fu Xi's systems of describing nature in terms of yin-yang and the five elements, and his method of therapy: acupuncture. Although archeologists have dug up pre-Neijing writings on medicine, such writings are not mentioned at anytime throughout the recorded history of traditional Chinese medicine. In other words, they were superceded by the Huangdi Neijing. In the Neijing itself, former classics are mentioned, but these did not survive other than in the retained quotations.
Even today, in modern Chinese medical journals, articles about treatment methods will sometimes refer to what was said in the Neijing (sometimes described simply as: "the ancients said..."). Before the introduction of Western science and its reporting style, talking about the Neijing was an essential part of medical discourse. In the modernization of China and Chinese medicine, efforts have been made to purge such references from the publications, or to only make them in passing, not as a focal point of discussion.
The first and the most central materia medica of China is attributed to Shen Nong (see Figure 2) and is known as the Shen Nong Bencao Jing (Classic of Materia Medica by Shen Nong). When discussing individual herbs, it is natural to refer to whether or not the herb is mentioned in the Shen Nong Bencao Jing, since its inclusion in this work demonstrates a certain additional positive aspect of the herb. The brief description of the herb in this ancient text is usually quoted. In essence, all Materia Medica books that followed this one were modeled after it and considered expansions of it, at least until the Bencao Gangmu (Great Compendium of Herbs) written during the 16th Century (see: Li Shizhen: scholar worthy of emulation), in which some innovative forms of organization and presentation were introduced.
In the Chinese medical system, herbal medicine is based on use of formulas, and the central guide to formulas appears to have been written by an historical figure, a doctor named Jiang Zhongjing who lived at the end of the Han Dynasty period (his book is typically dated at the end of the Han Dynasty, about 220 A.D.). The book, Shang Han Lun, was later divided into two works, one called Shang Han Lun (Treatise on Diseases Caused by Cold) and Jin Gui Yao Lue (Prescriptions of the Golden Cabinet). Despite its possible basis in an historical figure who was an ordinary human, the doctor, his work, and, in particular, his formulas, have attained a divine nature. Zhang might be described, borrowing from the Catholic religion, as a Patron Saint of herbal formulas. For centuries afterward, doctors who strayed from Zhang's work were warned by others that they needed to study it in order to avoid dangerous therapies. Xu Dachun, a well-known medical commentator of the 18th Century (see Figure 3) said:
The wisdom of the sages of antiquity was truly identical with the essentials of Heaven and Earth; it can not be reached by the mind and by the thoughts of ordinary men....Then, Zhang Zhongjing provided clear instructions about using the ancient prescriptions. He clarified various difficult issues and he offered instructions on the main pathoconditions cured by these prescriptions. His works Shang Han Lun and Jin Gui Yao Lue combined the great achievements of thousands of sages preceding him. Those books carry on what was before to instruct those who come later. Their scope is so encompassing that even ten thousand generations will not be able to transcend it. They are so-called ancient prescriptions. Together with the Neijing, they will never cease to flourish.
He proceeded next to complain about contemporary physicians who loosely referred to their use of ancient prescriptions. He cautioned that: "If one speaks of the prescriptions of high antiquity, there are almost none except those transmitted by Zhang Zhongjing." In Japan, where traditional medicine was revived after the second World War with government assistance, many of the leading physicians express true wonder at the prescriptions of this ancient text, stating that the formulas cannot be improved upon: one can only endeavor to better understand them. One of Japan's most famous herb doctors, Keisetsu Otsuka, explained the situation in the introduction (written in 1959) to his book 30 Years of Kanpo:
After the Tokugawa era [ended 1867], Chinese herbal medicine in Japan subdivided into several schools. Among them, the main ones are the school of old formulas, the school of classic formulas, and the school of posterity formulas. Mr. Yumoto was representative of the school of old formulas during the Showa era [1926-1989], and following him I learned the old formulas. The school of old formulas asserts that only two works need to be consulted: the Shang Han Lun and Jin Gui Yao Lue. Further, the school stipulates that to learn Chinese medicine, one need read nothing later than the Song and Tang Dynasties.
The Tang Dynasty was when Chinese medicine first came to Japan and the Song Dynasty was when the Shang Han Lun and Jin Gui Yao Lui were rescued from being lost (with only damaged copies having been retained at the Imperial library).
While the Chinese medical system has other great historical figures and historical works, its treatment of the above-mentioned divine figures, books, and the contributions attributed to them, has a defining role in the development and practice of the medicine. The importance of these individuals highlights the religious nature of Chinese medicine: to which, it is a system based on looking to the past. A scholar or practitioner of Chinese medicine looks back in time, a thousand years or more, but at least a century or two, for guidance, refreshment, knowledge, wisdom, and authority. In the Chinese system, one would barely contemplate considering that the ancient teachings may have been wrong or are now irrelevant. It is possible to expand upon the original teachings and to interpret them in light of modern developments, but not to contradict them or to ignore them.
Just as a religious system has its central book(s) and central divine figure(s), it also has its essential doctrines that these individuals and books have elucidated. In the Chinese medical system, there are certain fixed doctrines that are essential to learning and applying it. These include: yin-yang; three essences (qi, shen, jing; that is, qi, spirit, essence); three humors (qi, blood, moisture); five elements; five zang and six fu; six environmental influences; seven emotions; and 14 meridians. These doctrines define how the body works and how the therapeutic methods that are applied will interact with the body and its diseases. They are fixed ideas that yield the medical system itself. It is not possible, by modern scientific means, to alter the system; for example, one cannot conduct some studies that would show that the ancients omitted a sixth element that should now be included, or that there were only five environmental influences because one of them is redundant with another. One can add new meridians and new points, add new herbs and new formulas, but one cannot say, on the other hand, that the old meridians and points, the original herbs (of Shen Nong) and formulas (of Zhang Zhongjing) were not correctly chosen and presented. Similarly, a scholar during any period of Chinese history might argue that one of these doctrines was being interpreted incorrectly, but could not change the essential doctrine.
In outlining the basic theoretical framework of Chinese medicine, the well-known Japanese doctor Yakazu Domei quoted from The Outline of Chinese Medicine Sciences (1980): "The theory of yin-yang and the five elements connects every aspect that is important to the theoretical system." Quoting from the Neijing Suwen: "Yin-yang is the law of the universe. It rules all-it is the parent of transformation, the origin of life and death, and the house of the gods." He also points out that "Throughout the Shang Han Lun, the yin-yang theory is the governing principle....The five elements and yin-yang theory also dominate the Jin Gui Yao Lue." Further, "The descendent medical schools [four schools of the Jin-Yuan period] emphasized the theory of yin-yang and the five elements." The details of these doctrines (which are beyond the scope of the current article) are described in numerous works.
As the major religions each have one or more mystical sects (one can think of the tantric yogis of Tibetan Buddhism or the Kabbalic mystics of Judaism), Chinese medicine has its own mystical sects. These tend to involve the bagua (eight triagrams) or the five elements. Indeed, for Western practitioners, there is a well-established sect of "Five Element Acupuncturists," with the leading figure being a British acupuncturist: Worsley. This sect focuses intensively on the relation of emotions to the internal organs and on the inter-relationship of each of the five elements, as it influences the selection of acupuncture points; it is largely based on one segment of the Neijing. This orientation to Chinese medicine is contrasted to the somewhat standardized Chinese medicine taught in mainland China that is sometimes referred to as the "Eight Entities" sect (yin/yang, cold/hot, interior/exterior, deficiency/excess), because of the emphasis on diagnosis via study of opposing pairs of qualities, a reflection and expansion of the basic yin/yang doctrine. This doctrine is seen, by certain Chinese authorities, as being reasonably consistent with both modern science and dialectical materialism, and, therefore, can be emphasized within the current political structure of China. As occurs in religious practice, each sect believes that it has found the most essential and vital doctrine within the religion. New sects arise from time to time. Recently, in the U.S., Dr. Tan has introduced a form of acupuncture treatment that relies on treatment of distal points that correspond (in a systematic way) with the area of the body where the disease is localized. The selection of distal (rather than local) points is justified on the basis of ancient teachings.
In his book, Kaptchuk relays some underlying impressions of Chinese medicine that exist among Westerners who view it. He describes one group that is
…deeply and often justifiably disturbed by many of the products of Western science and culture. They assume that the Chinese system, because it is felt to be more ancient, more spiritual, or more holistic, is also more 'true' than Western medicine. This attitude threatens to turn Chinese medicine from a rational body of knowledge into a religious faith system.
While one can imbue the Chinese system with a greater degree of religious character than it already has, the fact is that it is not correct to depict the system as a "rational body of knowledge." It is described here as "quasi-religious" in that it is not purely a faith-based practice (as would be miraculous healings attributed to a few individuals who have been given the power by God), but a system that incorporates several aspects of religion. The idea that Chinese medicine is more "true" than Western medicine is, indeed, one that has been held by many practitioners in the West and is based on a system of beliefs and personal observations.
The fixed nature of the various doctrines that characterized traditional Chinese medicine from its inception has had a defining role in how the medicine developed over the centuries. The fixed doctrines prevented each subsequent generation of doctors from reinvestigating the basis of medical practice, and, instead, direct them to fit their experiences into the patterns described by the doctrines. Thus, if a patient presents a set of symptoms and signs that does not seem, at first glance, to fit into the fixed patterns that have been described in the essential texts, it is the role of the experienced doctor or scholar to see through the confusion and find an explanation of how the doctrine fits perfectly well. Similarly, if a therapy has not worked well, it is important to consult the basic doctrines to determine where an error might have been made; failure is not attributed to any fundamental limitation of the doctrines themselves, only their incorrect application.
New developments in Chinese medicine can take place where the original texts are relatively silent. Thus, for example, in the Ming Dynasty period it was proposed that "where there is mental disorder there is phlegm." The Neijing gives some clues as to causes of mental disorders (in relation to pathologies of the heart and the stomach), but doesn't go into much detail, so there is room for pronouncing a seemingly new principle. Of course, any such new principle can be accepted or rejected by subsequent doctors simply because it is not firmly grounded in the Neijing. In this particular case, it is supported. The Neijing says:
When the stomach qi rebels upward, the transformed products of the stomach stagnate. Over time, they turn into phlegm. The phlegm courses upward with the stomach qi, congesting the lung and heart....If the phlegm disturbs only the heart (and not the lung), there is trouble sleeping....As the ancient classic Xia Jing (Classic of Medicine) stated, 'when the stomach is in disharmony, one cannot sleep peacefully at night.'
Thus, there is already a precedent for the situation of phlegm congesting the heart and disturbing the sleep (which is evidence of it disturbing the spirit). One can delete the specific reference to the stomach qi and to the sleep, and retain the problem of phlegm congestion and spirit disturbance.
The quasi-religious nature of traditional Chinese medicine is one of its great appeals to some, while it represents a key obstacle to others. In particular, for those who find modern medicine and modern science objectionable, due to unappealing descriptions of living organisms and treatments that appear too technological and not human or natural enough, a religious type of medical system can be quite attractive, as Kaptchuk had noted. Many people feel that the body is more than a mechanical system; that it may be infused with various forces that cannot be explained by modern science. The traditional Chinese medical system, with its description of the mysterious qi and its reliance on a system of correspondence (with five elements and yin/yang) where the internal organ systems can be linked to external phenomena, provide an attractive alternative.
By contrast, to someone who finds scientific progress appealing, the attachment to old ideas (such as the common cold and a cerebral infarction each being caused by invasion of wind) and to mythical figures (or poorly defined but revered historical figures) can be objectionable. It is possible, in the modern era, to simply reject the historical and religious aspects of traditional medicine and begin the scientific study of the herbs and acupuncture therapies that have come down to the present, with the objective of finding what parts of the system are effective and which parts are not. Such rejection of old concepts and materials is standard practice in the West. Modern medicine constantly re-evaluates its treatment methods and simply tosses out old ones in favor of ones that are shown, by scientific evaluation, to be superior; or, it subdivides treatment and limits the old treatments to certain situations and provides new treatments for other situations. A modern physician would hardly look to a book a few decades old for inspiration or information, but would rather read the latest medical journal and attend the conferences where ground-breaking accomplishments are revealed. In this sense, modern medicine is forward looking, always hoping for an unanticipated improvement (e.g., gene-splicing solutions that could not have been imagined a century earlier); one looks back mainly to experience the wonder of how we could have been so naive.
There is a strong drive now, even among many practitioners of traditional Chinese medicine, to discard the reverential and ancient aspects and simply focus on what seems to work, regardless of its origins. For example, in the introductory article to the 2001 issue of the Journal of Traditional Chinese Medicine (the premier traditional medical journal of China), the Vice Minster of the Health Ministry (who is also Director-General of the State Administration of Traditional Chinese Medicine) wrote on the subject of promoting the development of traditional Chinese medicine in the new century. Regarding the ancient aspects of the system, he was careful to avoid any religious undertones, but mentioned the importance of looking to the past, describing it as "inheritance:"
Traditional Chinese medicine and pharmacology is a great treasure house. With the development of science and technology, people will derive constant new ideas and discoveries from the treasure house. It is the value and basis of inheritance. Inheritance is mainly involved in TCM's profound theories, therapeutic principles for prevention and treatment of disease, rich clinical experience, and unique methods of diagnosis and treatment. The purpose of relying on inheritance is development. We will try to make a breakthrough in the study of TCM theory by organizing scientific research personnel from TCM and other related disciplines and utilizing the technology of bioengineering, bioinformation, and microscopic investigation, in combination with epidemiology. TCM clinical researches are aimed at improving the ability to prevent and treat common diseases....Discovery of new phenomena and revelation of new law will provide mankind with a new train of thought and new approaches in disease prevention and treatment. The process of TCM modernization is picking up speed.
The end result of such a process will be the isolation of a few therapeutically viable items (the few that can be adequately tested by increasingly cumbersome research protocols) with eventual disposal of everything else. From such an exercise, we can obtain some useful drugs from the active ingredients of herbs, and may find that specific acupuncture treatments treat certain specific diseases in a way that is as good as or better than other existing therapies. Such modernization will not yield a revitalized traditional Chinese medicine. To retain traditional Chinese medicine, one has to retain its quasi-religious nature, otherwise, one has to dispose of the tradition and absorb small parts only. A third route-to view Chinese medicine as a rational body of knowledge and simply overlook its religious aspects-is unlikely to have an end different from the proposed modernization. This is because Chinese medicine must exist within the dominant modern medical system that increasingly can replace the small niches that have been carved out for its practice in the West (e.g., modern medicine can develop immune regulating therapies, an area where Chinese medicine has been briefly viewed as a unique resource).
Here then is the dilemma for the practitioner of Chinese medicine in the 21st Century: one may accept the religious qualities of the tradition, but then has to face its incongruity with the overwhelming modern medical system; or one may reject the religious qualities of the tradition, but then has to face the question of whether or not much of the system really works, since so much of it is based on ancient teachings and not confirmed by modern investigations. One of the great disappointments to those who have been involved with Chinese medicine during this transitional period (the past few decades) is that the concept that something which has been done for a long period of time is necessarily justified by that historical experience. In actuality, practitioners now view some remedies that were relied on for many centuries to be toxic (e.g., use of cinnabar that contains mercury, as one of the essential ingredients of many formulas) and other remedies that were deemed highly effective to be of limited value (e.g., traditional acupuncture is being replaced by new ways to perform it).
Sometimes, modern practitioners accept the religious aspects of the system when they go through their initial training, but then gradually reject or simply let go of those aspects while living in a community in which few other persons accept it. All religions emphasize the importance of having a religious community and of having public ceremonies that bring together adherents. If a person simply goes off on his own, it is natural for the religious teachings to be lost in the absence of such reinforcement. Similarly, practitioners who are not involved in intensively interacting communities with other practitioners or, at the least, with others who live within a Chinese cultural context, may easily adopt heretical viewpoints and practices. Soon, they are no longer practicing traditional Chinese medicine, but some amalgam of theories and practices that are unrelated to one another.
In a background of highly conservative medical ideas, with emphasis on referring to the knowledge, wisdom, and practices recorded in a small number of essential texts, Chinese medicine allows for a tremendous amount of diversity via personalization of medical practices. Each practitioner may specialize in some aspect of Chinese medicine, not just a medical specialty like gynecology or dermatology, but a focus on one particular portion of the theory or one particular technique. It is even conceived that there are hidden niches in the ancient wisdom that can be accessed only by extraordinary methods, allowing one to pursue concepts that appear, at first glance, to fall outside the tradition. Therefore, there are an unlimited number of potential avenues within the larger matrix of the medical tradition that can be pursued.
Paul Unschuld, in his book Chinese Medicine: History of Ideas, wrote:
The common underlying conceptual basis of all these practitioners [those who were well-educated in the tradition] was exceedingly narrow, being limited to the acknowledgement of certain surviving works as classic texts and a belief in the fundamental truth of the central theories of the five phases and the all-encompassing dualism of yin-yang. But, even the interpretation of the universally revered classics, as well as the application of these theories to the concrete realities of daily life, gave rise to numerous contradictions, fragmenting the large community of private scholars and professional medical practitioners seeking solutions to health-related problems into countless individuals, groups, and traditions.
Thus, for example, doctors could specialize in acupuncture or moxibustion, in herb therapies of various types (topical applications, internal remedies, pills, alcoholic preparations, decoctions, etc.), or in various physical exercises, each of which could follow a number of divergent pathways. Within one disciple, such as acupuncture, each practitioner could rely on different parts of the doctrine and different techniques. A patient who sequentially visited two doctors for treatment might well receive two entirely different therapeutic regimens; and visiting ten doctors, receive ten different treatments. Although those differences might merely reflect different levels of skills, most often it represents a different way of applying the fundamental doctrines and reliance on various personal (sometimes secret) techniques.
Throughout the history of China, it was common practice for individual doctors to retain secret treatment methods, typically involving unique herbal preparations or unique acupuncture combinations or techniques, that would only be passed on generation to generation, but not readily revealed to others. Xu Dachun pointed out that such a practice was encouraged by the Yellow Emperor (in the Ling Shu); the widespread practice of keeping secret prescriptions was further elaborated by Xu:
The prescriptions that are kept secret have a meaning that cannot be explained, and their working mechanism is not entirely accessible. Their transmission, often enough, originated from strange persons, scholars living in seclusion, hermits in the mountains, Bodhisattvas, demons, or spirits. To meet such a being is quite difficult, and therefore, these prescriptions are extremely well guarded. If they are handed on to others carelessly, they will only generate a disrespectful attitude. Hence, most prescription masters guard them as a most precious belonging....In secret prescriptions, the herbs are composed in accordance with extraordinary patterns. The way the herbs are combined is ingenious. Such prescriptions usurp all the authority of yin and yang, and they look deeply into the workings of creation. It is utterly imperative to be sincere and devout. Even the slightest violation of any prohibitions renders the herbs ineffective. If, therefore, someone lightheartedly teaches such prescriptions to others, the influences of the prescriptions leak away, and their application no longer yields miraculous results.
The personalization of medical practice was rarely discouraged by leading members of the medical community unless it was noted that too many patients died under the doctor's care. Then, it would be argued that the doctor with this poor patient survival record had veered too far away from the central doctrines and had become reckless. One could turn to the classics and find that the doctor had not paid attention to some key element in the diagnosis or understanding of therapeutic principles, explaining the harm that came to the patients.
Personalization of medical practice was expected. On a broad scale, it had been observed that, due to geographic and climatic variations, people in different villages would suffer from different diseases. For example, they might be influenced by the cold in northern climates or the heat of southern climates, by the diet of salted fish in coastal areas, or by the particular mineral content of a stream used for drinking water in inland areas. As a result, certain therapies would be emphasized and would develop separately in these areas. In China, it is common for people to talk about the specialties of their province, their region within the province, or their own village; this sense of local uniqueness carries over to the medical system. Further, China had numerous philosophical systems vying for the hearts and minds of the people, including Confucianism, Taoism, and Buddhism. Such strong cultural forces could lead doctors to different conceptions of how medicine was to be applied. On a more limited and personal scale, it was understood that each physician had certain talents, and that the expression of these talents included a particular approach to administering medical care. Thus, for example, one person would become a pulse master; another could diagnose just by looking at the face; still another would turn to finding the sensitive (ashi) points on the body, having an uncanny ability to aim straight for those points on the first try.
The personalization of medical practices brings both advantages and disadvantages. For the practitioner, a primary advantage is the sense of ownership over the medical practice, while being able to still count oneself a member of the larger community by sharing in the basic traditional medical doctrines. Doctors working with very diverse approaches to treatment of disease could still claim to be working within the same core of yin-yang and five elements. For the patient, the diversity of practices provides an opportunity to make an important selection choice from among well-respected practitioners and to have an alternative should one fail.
A disadvantage of this diversification is the inability to develop any consensus on an effective therapy. Each practitioner comes to believe that his or her therapies are particularly successful, so that, in essence, each and every therapy of every doctor is described as an effective one. If a young practitioner becomes concerned that his or her techniques are not, in fact, adequate, the remedy is to take on the techniques of someone else who is viewed as being successful, and later, to personalize it.
The concept that the combined extensive experience of thousands of practitioners could yield a single superior therapy didn't arise until the modern era when Western medicine influenced the system. Even with this idea being present, it is rare for two doctors to use the same therapy: a standard herb formula will still be modified to make it unique to the practitioner's work. By contrast, the ideal in modern medicine is to have a multi-centered trial involving a single treatment and to determine if it works significantly better than another widely used and tested treatment. If this treatment is found to be superior, it will then displace the other. An ideal in modern medicine is to have a patient receive the same state-of-the-art treatment by a doctor working in a major hospital in a big city as would be received by another doctor in a small hospital in a rural town. If this is not possible, patients with serious ailments are recommended to travel to the major hospital, to assure the state of the art diagnostics and therapeutics.
For the modern practitioner of Chinese medicine, the unique position of being able to practice according to one's sense of what is right and what works best rather than according to what is deemed state-of-the-art is often viewed as one of the most attractive aspects of the career. Each patient can be treated individually and receive highly personalized services. Indeed, whenever adequate training has been received-so as to permit the practitioner to develop his or her own therapies-that practitioner will object to reliance on any set formulas (point formulas or herb formulas), stating that the superior method is to make each and every treatment unique. From time to time, a particular formulation (of herbs or acupuncture points) may be recommended and adopted widely, but it is soon displaced by others. In other words, no centralization of medicine is accepted.
For the modern consumer of health care services, the personalization is at once an attraction and also a concern. Western medical practices are often seen as being highly impersonal. Individuals are given treatments based on the statistical outcomes of huge studies, and the person can easily feel like just one of the statistical components. Doctors seem to be all the same. Thus, when turning to a Chinese medical practitioner, the attention the consumer gets, the personalized practices of the practitioner, as well as individualized treatments, all appear attractive. On the other hand, the modern consumer of medical services may have become used to the ability of doctors to clearly inform them the current state of the art. It may be confusing to find that each practitioner of Chinese medicine has a different diagnosis and a different therapy to offer. The question then arises: which one is correct?
Paul Unschuld, in his book on medical ethics in China, described the problem with personalization that was recognized during the Ming Dynasty:
Gong Xin (ca. 1600 A.D.) distinguishes his group [of Confucian practitioners] from that of 'common physicians' by the fact that he discourages his colleagues from soliciting patients by emphasizing individual skills. Here again we encounter a very important element in the efforts directed at professionalization, and one which is still found in our present society. Patient solicitation, through emphasis on individual skills by one member of the group, implies that he is better than at least some of his colleagues. This kind of patient solicitation is therefore injurious to the group as a whole, because the public's attention is drawn to differences in performance. Differences in performance, in their turn, cause a lack of trust, and thus lessen the readiness of the public to entrust the same tasks to every member of the group.
In other words, the public can quickly become skeptical of practitioners of Chinese medicine, because each practitioner is implying, through adopting and promoting the highly personalized approaches, that many of the other practitioners are not as valuable to visit. Worried by the apparent lack of consistency and implied inferiority of many members of the profession, this situation reduces the number of people who will try or who will continue to utilize Chinese medical services. By contrast, the message with modern medicine is that the most important thing is simply to go to a doctor and follow the advice. Therefore, "see your doctor" may be the most commonly used phrase, and the result is intensive use of the medical system.
Throughout the history of Chinese medicine, inspiring stories are told of famous doctor-scholars that spent years, often several decades, collecting information-from medical books and from current doctors-to produce a new compendium of treatment strategies. Often, the Emperor himself would order such projects be undertaken by his large staff of medical scholars. As a result of these efforts, many large collections of knowledge have been published.
The collection activities result in marked expansion of the Materia Medica guides. Starting with the 365 herbs of the Shen Nong Bencao Jing, the number doubled to 730 herbs with the revision by Tao Hongjing, reached over 1,000 in the books of the Song Dynasty, then growing to 1,892 herbs in the Bencao Gangmu, arriving finally at the modern books that boast over 6,000 medicinal materials. Dr. Chen Keji, one of the prominent researchers and authors of modern Chinese medicine said in a recent article: "China has about 12,807 kinds of medicinal materials; there are 11,146 kinds of botanical materials, 1,581 kinds of medicinal animals, and 80 kinds of medicinal minerals." There is clearly a great pride in maximizing the number of materials and enumerating them precisely.
Herbal prescriptions also would be gathered together, so that the initial group of just over 200 formulas in the Shang Han Lun would grow to collections of over 10,000 prescriptions by the Ming Dynasty (Li Shizhen's Bencao Gangmu had over 11,000, of which about 8,000 were added by Li to earlier collections). Acupuncture meridians and points grew in numbers, and acupuncturists began collecting entire zones of treatment, so that there was a specialty of hand/wrist acupuncture, foot/ankle acupuncture, nose acupuncture, and so on, with the most modern additions being ear acupuncture and scalp acupuncture. For each treatment zone, a basic set of points would grow to include numerous new ones, often within just a few years or decades. In a recent Chinese book on ear acupuncture, a chart is presented with the main points, showing 103. One of the popular subjects in acupuncture books today is the study of the so-called "extra meridians." As occurred with herb formulas, acupuncturists developed therapies based on particular sets of points-point formulas-for which there were thousands recorded. Many acupuncture books today do little more than relay numerous such formulas based on the unique practices of respected physicians.
The collecting of knowledge characteristic of this medical system is illustrated by the following brief descriptions of two works written at about the same time Li Shizhen was compiling his great herbal. This is relayed in the book History and Development of Chinese Medicine:
Guijin Yitong Daquan (A Great Collection of Medical Works, Ancient and Modern) was written in 1556 by Xu Chunfu, a famous physician in the Jiaqing age of the Ming Dynasty who once worked in the Institute of Imperial Physicians. The book consisted of 100 volumes, which quote the medical contents of 390 sources from Confucian classics, history, philosophy, and other important contributions before the middle Ming. It is a comprehensive collection with an overall summary of the basic theories and clinical departments of traditional Chinese medicine, including physician's biographies through the ages, different schools, pulse-taking methods, doctrine on five elements and six natural influences, channels and collaterals, acupuncture and moxibustion, materia medica, health preservation, and treating in clinical practice of different departments and medical cases.
Jingyue Quanshu (Complete Works of Zhang Jingyue) was compiled in 1624 by Zhang Jiebin, a famous physician of the Ming. The works consist of 12 parts, 24 volumes, and 64 books with more than one million characters. The works includes basic theories of traditional Chinese medicine, diagnosis and treatment, various clinical departments, herbs and formulas, etc.
The attempts to collect, and, thereby, preserve all kinds of medical techniques had the advantage of retaining a wide range of knowledge that might be otherwise be lost. However, it also had the disadvantage of being non-selective: vast numbers of things were being recorded, but there was little basis for determining which statements and which formulas were truly of value. As described above, personalization of the medical practices essentially conferred equal value to all therapeutics; the drive to collect all treatment techniques and substances reflected the equal value assigned to all the collected items. Although some attempts were made to weed through the literature and get rid of items deemed to be of lesser value, it was often difficult to determine which items to delete, because there was little theoretical basis for valuation; the determination was highly personal.
The situation stands in contrast to modern medicine. Even though the number of therapies grows year by year, there is a continual process of comparative evaluation, so that certain therapies remain in the foreground and others drop out. A medical researcher might review the therapies that were developed over the years to provide an historical perspective, but would not expect readers to give a value to the older therapies that equals that of the newer ones. The rare exceptions, such as on-going use of aspirin, morphine, or penicillin, are remedies that are only about a century or two old; even so, their dosage form, indications, and method of use have been significantly altered. Similarly, even though Western medicine was at one time characterized by its unique development of surgery (based on careful anatomical studies), modern surgical practices are very different than past ones that made it famous, such as replacement of the large-incision abdominal surgeries with small-incision laparoscopic surgeries, and modern use of fiber optics and lasers. No one bothers to collect or refer to the prior surgical techniques.
Collecting therapeutic patterns is partly a response to the personalization of medical practices-aimed at assuring retention of the valuable individual experiences-and partly a response to the high respect for things that belong to the past. Key medical documents had formerly been lost (as occurred during the great book burning of the Han Dynasty) and others nearly lost (as occurred with the Shang Han Lun). To avoid any further tragedies to the medical record, the reports of leading physicians have been kept intact during recent centuries. Modern capabilities of book publication make it possible to continue the process of recording more and more medical techniques, substances, and frameworks for their use.
A medical system that looks back to ancient times, that is highly personalized, and that collects vast numbers of suggestions that have no true hierarchy, could easily become diffused and lifeless. One can imagine it degenerating into a collection of individuals working at virtual odds with each other, relying on rote repetition of principles personally selected out of a sea of possibilities. Indeed, substantial periods of relative stagnation and decline can readily be identified in the history of the Chinese medical system, such as the 750 year interval between the end of the Han Dynasty and the beginning of the Song Dynasty. Further, one can observe this negative outcome as a characteristic of some parts of the existing Chinese medical system today. However, traditional Chinese medicine has retained considerable vigor into the modern era by its inclusion of a healthy debate about how it is to be best applied. In this, it is unique as a traditional medical system. For example, stagnation in the neighboring Indian Ayurvedic tradition, where critical debate about medical issues has been lacking, has left it dulled and difficult to revive.
A key vitalizing element of the Chinese system is that which serves as a counterbalance to personalization: critical evaluations undertaken from time to time by highly respected scholars. Attempts to reign in practitioners who go too far off from a central zone of unifying principles is critical in preventing the medical system from disintegrating into an incoherent mass of activities. Xu Dachun made the following comments, among others, critical of his contemporaries that illustrate this concern that physicians must be chastised for going too far from the basics:
In other words, he was appalled at the extent to which the doctors had deviated from the core of the tradition: ignoring the true teachings of the ancients, not learning the basics, and adopting all kinds of unfounded medical principles and erroneous facts. This is precisely the problem to be expected from the personalization of medical practice, and is something that he, and certain other scholars working in a position of respect, hoped to counter by pointing out the deficiencies.
Concerns about how medicine was being practiced have been illustrated by Paul Unschuld's examination of medical ethics in China. Quoting from a number of famous physicians, it becomes clear that there were certain failings that were constantly the subject of complaints. The leading problems had nothing to do with the medical system itself, but with the context in which practitioners applied it, such as the recurrent tendency of doctors focusing their efforts on getting paid (i.e., not treating poor people, only treating the rich); the solution was to remind physicians that they must first and foremost be humane and compassionate. At a second level, the complaints had to do with the lack of attention physicians were giving to the task at hand. As with Xu Dachun's concerns above, this involved observations that physicians didn't adequately study the basic doctrines and techniques; further, they didn't give adequate time to correctly diagnose the patient and didn't think enough about the correct principles of treatment. As a result of these flaws, patients would suffer. To remedy this, some physicians devised mandates that any principled practitioner should follow.
Those who study traditional Chinese medicine today are unlikely to be exposed to the part of the historical record that includes such criticisms and demands for reforms. This is because there has been a concerted effort to show the achievements of traditional Chinese medicine, as if there has been a continuous progress towards a highly effective system that is purported to exist today. Indeed, Paul Unschuld is one of the few who has quoted those who complained about the status of Chinese medicine. That medical practices fall short of the ideal is not unusual and should not be hidden; the fact that the faults were vigorously addressed is a key element of the Chinese system, keeping it on track as a viable method of health care.
The Imperial examination system served as a stabilizing force. It led to growth of a class of Confucian doctors who could work in official positions (mainly the Imperial Medical Academy) after passing the examinations. This procedure maintained the basic medical system by assuring that the practitioners had a common knowledge and understanding of the classics. While some individuals who were interested in medicine could become itinerant doctors or folk practitioners who did pretty much as they pleased (using a combination of amulets and other demon dispellers, secret pills, and various physical therapies), others could gain a higher social status by becoming official doctors who would have a uniform basic training. Working in the Imperial Medical Academy, the highest position in China, was also a more formal and restrictive setting than doctors would experience anywhere else.
In addition to keeping practitioners on track in their individual practices, the Chinese system also involves constant work at reinterpretation of the basic doctrines. Unschuld illustrates this best in his translation of the Nan Jing (Classic of Difficult Issues, ca. 260 A.D.), in which he incorporated comments of several physicians who lived in subsequent centuries. The Nan Jing is itself a book about interpreting the Nei Jing , and these commentators then carried on the process. Two well-known attempts at aiding interpretation of the Nei Jing during the Ming Dynasty were Ma Shi's explanatory texts on the Su Wen and Ling Shu, and Zhang Jiebin's Lei Jing (Organized Classic; 1624 A.D.). Similarly, further work on the Shang Han Lun was carried out during the Qing Dynasty, starting with Shang Han LunTiao Bian (Systematic Differentiation of the Shang Han Lun; 1589 A.D.). Rather than merely passing on the ancient texts, the Chinese system encouraged and rewarded efforts to make the texts more accessible and understandable to practitioners of later generations. The doctrines could not be changed, but the ancient texts were often so cursory and poorly organized that they were ripe for elaboration and reshuffling.
Another way to improve Chinese medical practices was by carefully observing the current medical conditions, and recommending practices were consistent with these conditions that differed from the past. For example, Zhang Yuansu (13th Century A.D.) noted that practitioners were using ancient formulas to treat diseases that were different than the pathologies for which the formulas had been designed; he therefore recommended that new formulas be written to suit the current conditions. His contemporaries and students became famous as leaders of the Jin-Yuan Medical Reform by directing physicians to look at alternative explanations for the cause, development, and treatment of contemporary diseases, rather than relying on a sole theory that had been dominant since the end of the Han Dynasty (based on the Shang Han Lun). During the latter part of the Ming Dynasty, Wu Youxing wrote the Wenyi Lun (Treatise on Acute Epidemic Feverish Diseases) and described the concept of a transmissible pathologic agent that was responsible for epidemics. Such diseases were devastating much of the Chinese population, in a similar manner to the Black Plague that reduced Europe's population by two-thirds in earlier centuries. Previously, this concept of transmissible elements had been poorly developed. As a result of Wu's work, numerous authors expounded upon the theory (see Figure 4), which eventually led to a certain degree of consistency between traditional Chinese medicine and modern medicine in the field of infectious diseases.
During the modern era, from the Qing Dynasty until now, the greatest challenge to Chinese medicine has been the introduction of Western medicine to China (followed, much later, by the introduction of Chinese medicine to non-Oriental countries). From the 18tth Century to the present, the role of each of the medical systems has been one hotly debated. Some Chinese argued vigorously against the use of any Western medicine; others argued that it was superior to Chinese medicine and should supplant it, while still others wanted to pick and choose among the two systems to retain the best of each. One of the famous medical reformers during this time was Wang Qingren. He relied heavily on traditional treatment principles, but wanted to adopt Western anatomical descriptions, based on dissection of cadavers. Many of his contemporaries were not impressed, saying: "the more he corrected our past mistakes, the more mistakes he introduced." They meant to say that, in fact, they were not mistaken in the past at all and such revisionism is uncalled for.
A variety of attempts have been made to integrate traditional Chinese medicine and modern medicine in a way that is respectful of each. One well-known effort was that of Zhang Xichun (1860-1933) who wrote the book Yixue Zhongzhong Canxi Lu (which has been interpreted as meaning "Chinese at Heart, with Western Practices"). Zhang's view was that it should not be difficult to combine Chinese and Western medicine, as most Western medical therapies were implicit in traditional Chinese ones. This view was popular in China during the 1930s and 1940s, and led to free intermixing of traditional and Western medical diagnostics and therapeutics. After the Chinese communist revolution, a slogan was adopted in relation to the development of traditional Chinese medicine: "Weed through the past to bring forth the new." The implication was that the traditional medical system was full of extraneous matter that must be left behind, but that it contained certain gems that should be retained. It was referred to as a treasure house, a place where one could find great things. Although coarse in its meaning and application, this slogan really differed little in basic intent compared to earlier efforts by famous physicians to correct numerous mistakes in the literature, toss out suggestions that no longer made sense, and make room to add new items. Among the new items to be introduced were Western medicines and natural resources in China that had not yet been fully exploited.
Although there will remain a tension between the two systems, more than their coexistence is essential if traditional Chinese medicine is to survive: they must eventually become integrated, if not as a single medical system, then integrated into the social system in which medical practice exists. Most Chinese medicine practiced in China today is a form of integrated medicine. Only in foreign countries has there been an attempt to keep the two systems isolated, largely based on the adoption of Chinese medicine as a rebellion against the existing medical system.
The ongoing re-evaluation of Chinese medicine and its practical applications is advantageous, in that it prevents stagnation and disintegration. However, there are some evident disadvantages in the manner in which this process has been carried out in the past. In particular, there is rarely a good basis for determining who is right when one physician criticizes another or when one scholar offers a different interpretation from that given by the other. Unlike modern medicine, in which the re-evaluation of the system is based on research efforts (which, themselves, can yield considerable controversy), the Chinese attempts at re-evaluation are usually philosophically based and argumentative: there is no well-established factual base for the opinion that has been rendered. Therefore, upon reading medical works, it becomes obvious that there is a lot of criticism, but not a conclusion to it: there is no evident consensus outside the basic tenet that practitioners must be humane and must pay attention to the performance of their craft.
The continuing efforts to criticize and reevaluate helps keep practitioners thinking about what they are doing, as opposed to allowing rote action on the basis of a past practice or allowing one's personal ambitions and problems get in the way of proper administration of medicine. The practitioner of Chinese medicine is expected to respect the past and turn to it for guidance, but not be blind to the current situation, which requires an attentive, and sometimes revised, application of the principles and methods of the past.
Chinese medicine is a quasi-religious system relying heavily on ancient doctrines and a small number of ancient texts. Doctors personalize the medical system to suit their own orientation and they treat each patient uniquely, thus making a system that has tremendous diversity, to the point that it is not expected to present a uniform appearance. It is an expansive system that collects techniques and substances and fits them into the underlying medical framework. Chinese medicine retains knowledge of as many of the past experiences and recommendations as possible. Several medical scholars have attempted to define the central core of traditional medicine by clarifying the basic theories and pointing out practices that appear to be inconsistent with them. The Chinese medical system typifies diversity and expansion based on a limited set of basic principles. The tension between its expansive qualities and its conservative philosophy, along with the influence of critical thinkers who question its excesses, keeps the system vibrant.
A crossroads stands before the traditional Chinese system as Western medicine shows rapid progress. Not wanting to appear inferior, practitioners portray certain advantages to the traditional system. In particular, they point to the naturalist philosophy embodied in yin-yang and five elements, the non-invasive and non-toxic qualities of its therapeutic techniques, and the aim of holistic health care rather than repair of individual diseases or alleviation of individual symptoms. However, these apparent advantages are challenged by questions of how useful such basic philosophies are in the complex modern world, how effective the mild therapeutics can be (and how safe they really are), and whether or not the way Chinese medicine is applied is actually holistic or merely a one-to-one substitute for Western medical approaches.
To respond to the challenges, it is necessary first to grasp the unique features of the Chinese medical system and observe their positive and negative features in relation to the modern situation. Therefore, one must look beyond the doctrines and practices themselves and observe the organizing principles that make the system work. This essay is one attempt at promoting an understanding of Chinese medicine that may aid in developing a valuable dialogue.
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