Chinese Traditional Medicine: Methodological Problems and New Perspectives

 

The new approach to the study of Traditional Chinese Medicine focuses on two main issues: a further definition of the subject matter and the research methodological aspect. Since the choice of the most suitable method depends on what is meant to be included in the field of TCM, the two issues are obviously interconnected.

A reconsideration of traditional heritage

Traditional Chinese Medicine’s (TCM) history starts from the inscriptions on oracular bones of more than four thousand years ago. Obviously only a fraction of such an old tradition has survived up to our times; just to give an example, almost all the books quoted by Ge Hong, a very famous physician of the IV century AC., have disappeared. This is due partly to deterioration of materials and accidental losses (such as the fire of the Imperial Library in 206 BC. and again in 190 a. C.) ; partly to indiscriminate damages produced for ideological reasons, from the famous fire of books ordered by the First emperor of the Qin in 213 BC. to the recent losses caused by the red guards during the Cultural Revolution. We do not know what percentage of the original heritage is represented by the over 9.000 titles quoted in literary and medical works; however, taking as sample the over 2700 works listed in the first tome of the bibliographic catalogue of Shanghai’s Academy of Traditional medicine, we can roughly estimate that the extant works represent more or less the 63% of the titles collected in different sources. Further analysing the same sample, we see that only about the 17% of the extant works are available in relatively recent editions; of these last ones less than the 0.4% have been translated into foreign languages and are now available for non-Chinese readers.

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It must be said that editions of traditional medical classics have undergone an exponential growth from the founding of the Chinese People’s Republic to our days; Ma Kanwen has estimated that medical classics re-published in the seven years between 1975 and 1982 have doubled those published in the sixteen years between 1949 and 1965; an even more significant increase took place in these last ten years. In the western world, the number of publications on TCM has also been rapidly increasing in the last times; unfortunately, only a very small percentage of these works are written by sinologists (M. Porkert, N. Sivin, P. Unschuld, C. Despeux, C. Larre and E. de la Valle just to quote some names); most of the works on TCM in western languages have been written by authors that do not have access to primary sources and that are unaware of the methodological and contextual implications connected with the study of ancient Chinese literature.

Medical classics are often written in archaic or cryptic language; they present frequent omissions, wrong annotations, disarrangement and miswritten characters, due to the long process of transmission and to the many different versions of a same text produced by ancient copyists. Ancient sources and successive commentaries have been combined together in the transmission process; as a result, single texts are usually composed by fragments belonging to different epochs and several authors; they often present a contextual heterogeneity which is difficult to unravel. Moreover the traditional dating found in written sources is absolutely untrustworthy; the gap between the historical date (established by philological studies) and the traditional date (attributed to the same text by Chinese ancient sources) might exceed the thousand years, as it happens with the Huangdi Neijing, traditionally placed around the 3000 BC. Most of the ancient classics we own, including the Neijing, are often Song (960-1279) editions of Tang (618-907) versions of Eastern Zhou (770 BC.- 221 BC.) fragments collected and reorganised in Han-Jin dynasties (206 BC. - 420 a. C.). For these reasons, a previous critical editing work is necessary to make these texts understandable even for Chinese non specialised readers.

Our partial and often misleading view about TCM is not only due to accidental or technical reasons; but also to a voluntary discriminating process of selection.

The two most important schools of thought in China’s antiquity are the Literati (Confucians) and the Taoists. The Literati were strictly involved into the feudal political system and mainly concerned with ethical and social aspects of culture. The Taoists can be considered as a self-alienated intelligentsia, mainly concerned with natural sciences (including medicine). The cultural heritage of ancient China has reached us especially through imperial editions, which were obviously edited by integrated intellectuals. Most of the practical aspects of Taoist science, especially certain aspects involving alchemy, Yangsheng (nourishing of vital principle or ‘long life’ techniques) and Daoyin (guiding of Qi, including both Taoist gymnastic and sexual alchemy), were transmitted orally into esoteric and non-integrated circles. Only after the introduction of Buddhism into China, around the third century a.C., these teachings took a written form. Of the almost 1500 extant Taoist works collected in recent editions of Daozang (Taoist Canon), less than ten are integrally or partially available for non-Chinese readers.

From the catalogue of the Han’s Imperial Library we know that around the first century AC. medical classics were divided under four main headings: general manuals (Yishu), recipes (Jing Fang), sexual techniques (Fangzhong) and transcendental techniques (Shenxian). The basic classical texts presently studied by Chinese physicians majoring in TCM are the following: the Neijing (including Suwen and Lingshu) which can still be considered as the most important theoretical manual of TCM; next comes the Shanghanlun, a technical treatise specialised in exogenous pathological factors diseases, the Bencao, a treatise of materia medica and the Jinguiyaolue a collection of indications concerning 38 inner diseases, 10 external and various ailments and twenty gynaecological illnesses: as we can see, all of them can be roughly placed into the first two headings of Han library’s index. In other words, the actual concept of TCM covers just a half of the original subject matter. The remaining half, connected with the last two headings Fangzhong and Shenxian; was absorbed into Yangsheng and Daoyin Taoist techniques, excluded from medical science and confined to religious-philosophical studies and martial arts.

The texts unearthed in 1973 at Mawangdui, not far from Changsha, provide us with written sources that have preserved the original form they had at inhumation date (168 a.C.). For this reason, they are of extreme value to understand how matters really stood at that time. Mawangdui’s texts cover a wide range of subjects; the 15 medical works recognised by the archaeologists represent about one sixth of the total: three deal with prescriptions, four describe the net of Qi channels in the body with diagnostical and moxa therapy indications; a fifth text, almost identical with one of the preceding four, describes the Qi channels into a different context: it is written on a silk scroll together with an illustrated description of Daoyin exercises and a text on ‘esoteric’ dietetics, explaining how it is possible to gradually substitute material food with Qi absorbed from the environment. This is a fact of the utmost importance since, for the first time, we can see that the channels net of Qi flowing, which constitutes the real ‘interface’ between the micro inner system of the human body and the macro outer system of the world, does not originate - as often believed - from linking of acupuncture points (acupoints are not even mentioned in Mawangdui texts) but was born in Yangsheng-Daoyin context. Sexual techniques, also belonging to the same context, are the main subject of four texts, to which another one on pregnancy can be added, representing, all together, one third of the unearthed medical texts.

From Mawangdui’s medical corpus, we can assume that among the four divisions of ‘classical’ medical theory in Han times, sexual and transcendental techniques were prevailing.

One of the texts dealing with sexual techniques’, the Tian Xia Zhi Dao Tan ("On reaching the Dao from the sublunary world") presents one passage also included in the 5th Chapter of the Neijing Suwen: the introductory remarks are almost identical but the description of sexual techniques found in the Mawangdui text is omitted in the Neijing. This is a striking example of the selection process that characterised the imperial compilation of the classics. This selection process has completely modified the intrinsic axiology of TCM up to our times: technical notions connected with therapy were promoted to self-training techniques detriment.

We might say that originally pharmacopoeia, rebalancing techniques such as acupuncture and moxa, enhancing and preventive techniques such as massage and dietetics, self-training and transcendental techniques (including sexual alchemy), non strictly therapeutical use of drugs, and other paranormal features of Daoyin - Yangsheng, were all part of a single science of man, that we might call ‘Classical Chinese Medicine’ to distinguish it from the narrower realm of today’s Chinese Traditional Medicine. The therapeutical part was intended to bring back an individual into the average state of health; the Daoyin Yangsheng aspect was meant to develop the psycho-physical potentialities of man beyond the average level.

Stability of political power usually depends on a certain homogeneity in cultural context, there’s no need to go back to Chinese antiquity to establish that centralised power tends to promote mass mediocrity and to minimise every factor inducing personal growth beyond the average level accorded to the individual’s social class. Chinese imperial power was no exception, the literati concept of ‘fen’ (social divisions) by which everybody was asked to act in accordance to his or her social position and never try to change it, is an example of this tendency. The actual concept of medicine does not collide with the intent of preserving individuals into mass mediocrity: when somebody falls outside the average state of health because of an illness, one is treated and eventually recovers his or her previous healthy state but no big effort is made to promote the maximum possible development of individual potentialities. The classical concept of TCM was only partially concerned with therapy. In the Neijing itself there’s a strong accent on prevention: the real goal of medical science was to avoid illness, to re-balance the inner energy-information system of the body by acting on its passageways (channels) as soon as an exogenous or endogenous pathogenic factor was detected and, only as an extreme remedy, if the unbalance had already taken a material form or had already attained the inner organs, medicaments were prescribed. The ultimate factor of unbalance of the body system is to be found in what we might call ‘spiritual impairment’, this in turn determines a loss of coherence between the natural rhythms and life style that is bound to lead to illness; this conception is resumed in chapter XIII of Neijing Suwen:

"[Men of the ancient times] did not let lust or envy strain their interior, nor unrestrained ambition exhaust their exterior. They lived in a peaceful and quiet world and could not be affected by evils; for this reason they did not need medicines to heal their interior, nor stone needles to cure their exterior; they just enhanced their essence and prayed. Today men do not live in the same world; anxiety and sadness strain their interior, overwork harms their exterior, moreover they do not respect the four seasons..."

Both prevention and self-training were based on the same requirement: keeping the microsystem of the body in tune with the macrosystem to which it belongs. According one’s lifestyles to natural rhythms means to preserve health; increasing the degree of coherence between the dynamics of micro and macro systems means to enhance individual growth towards transcendental dimensions. Because of its stress on the system of correspondences between man and universe, the Neijing is relatively closer to the ‘classical’ idea than Shanghanlun, which expresses a more therapy-oriented conception based on pulse-diagnosis and pharmacological therapy. Since in the transmission process clinical aspects are dominant and ‘classical’ aspects are recessive, these last ones are not visible even when available: despite the fact that today’s TCM theory is still based on the Neijing, most aspects of micro-macrocosmic interaction - such as the cronobiological indications based on the ancient calendrical system (to which about one third of Neijing Suwen is devoted) - are normally neglected and dismissed in clinical practice.

Among factors hindering the full understanding of surviving classical knowledge, we must consider the evolutionist and rationalistic approach of philological studies, particularly strong among Chinese scholars. One example of this tendency is the common statement by which the old world of ‘magic medicine’ would have been overcome by the ‘rational’ approach (prevalent in the Neijing) from the Han dynasty onwards. It is enough to consider the work of later great physicians belonging to the Taoist current, such as Ge Hong (283-343), Tao Hongjing (456-536) and Sun Simiao (581-683), to see that those ‘magic’ or paranormal elements, found in Mawangdui’s texts, have been developed and used by relatively non-integrated "naturalist physicians" up to the present times. From the evolutionist point of view, the differences between Mawangdui’s texts and the Neijing are attributed to a process of theoretical development from ‘superstitious beliefs’ to ‘medical science’. Many historical factors contribute to this view, as, for example the structure of the Chinese character for ‘physician’ into which, during the western Zhou, the sign for ‘shaman’ was substituted by the sign for ‘alcohol’ (probably with reference to medicated wine). Until Han times, the single sign for ‘Shaman’ (Wu) and the later character for ‘doctor’ (Yi) were often used in compound to indicate a physician; most probably they were just meant to distinguish two separate set of skills: the first included the ability to channel (through dance, gestures and vocal emissions) certain healing energies directly on the body of the sick person or on a material support (such as water, rice or grain) which was then ingested by the patient; the second was mainly based on the use of stone and metal needles. In pre Han sources, the simple word Wu was often inclusive of both skills, while from the beginning of centralised imperial power, around the III sec. BC., the term Wu started to be used with deprecatory intent (it must also be considered that most of the Wu were women). Official’s culture compilers placed shaman’s physicians in the ancient past, to delegitimize those that were acting at the time. This delegitimization was necessary since imperial power was supported and granted by ritual performances, assuming that the emperor was the only intermediary between cosmic forces and human kind. The evolutionist approach of present studies seems to comply with the official version by which the dismissal of ‘superstitious beliefs’ was the first step of Chinese medicine towards ‘science’; without taking into due account the fact that ‘magic’ conceptions had an independent evolution in Taoist environment and greatly contributed to those scientific discoveries by which ancient China was ahead of the rest of the world. In our opinion, their influence on medical conceptions was not outdated but simply gradually dismissed by a dominating cultural mainstream, as it still happens in present times. To accomplish the task of recovering lost traditions it is necessary to overcome the influence of the uniforming process of Chinese transmission. Modern scholars engaging in Chinese studies have developed great skills in dating single fragments of a given text, but there’s not much concern in recognising and reconstructing the different cultural backgrounds to which they belong.

Due to the compilation and anthological nature of Chinese texts, elements belonging to this ‘parallel traditions’ are still recognisable in the Neijing and they could give us useful hints to further research into the subject. Just to make an example, Shao Shi and Bo Gao, that only seldom appear as interlocutors of the Yellow Emperor, seem to represent a different trend by comparison to the usual conversation partner Qi Bo. This trend stresses the morphological analogies between earth and human body on the one side and is strongly concerned with biotypology on the other. In Chapter 71 of Lingshu, Bo Gao enumerates the morphological analogies between human body and the planet earth which are also to be found in Chapter 51 of the Huainanzi, a Taoist philosophical treatise. The analogies between earth and the human body have been considered purely metaphorical up to present times; recent studies however - particularly by J. Lovelock - show that this conception might have solid scientific grounds. Another point of interest is the comparison between the 25 human types described by Qi Bo in Chapter 47 and the 25 described by Bo Gao in Chapter 72 of Neijing Lingshu. Despite the common pattern "five times five is twenty-five" (drawn from common cosmological background) their approach is dramatically different: Qi Bo uses a sequence drawn from a metaphorical pattern of similarity between inner organs’ organisation and Imperial Court’s hierarchy; his main concern is how to deduce the morphological aspects of inner organs from somatic features. Bo Gao’s conception is strongly rooted into the holistic system of correspondences between micro and macrocosm; the first peculiarity distinguished for each of the five basic ‘types’ is the pentatonic tone that constitutes its ‘resonance frequency’; each of these tunes has Yin and Yang, high and low modulation variations which give the 25 typologies; each variation is related with a peculiar tract of the Qi channels net (and, most probably, with a certain period of the year). While Qi Bo stresses the somatic features and gives very little indications about connected psychological attitudes, Bo Gao gives somatic description only for the five basic types but provides 25 psychological distinctions. His fundamental concern with the ‘vibratory’ aspect of reality applies also to pharmaceutical context: in Chapter 71, before even mentioning the ingredients to be used for a decoction, he explains that the water to be used needs to have been flowing for at least 500 Km; that the vessel containing it must be agitated myriad times from side to side before boiling it and only then he tells us the ingredients to be added to boiling water. Bo Gao’s view provides striking similarities to some modern homeopathic conceptions, not found elsewhere in the Neijing.

The therapeutical utilisation of herbal, animal and mineral substances as described in Mawangdui’s texts (and in later Taoist literature) was not necessarily depending on their consumption; the simple direct or mediated contact with a certain substance could produce a healing effect. This fact is not to be understood as a simple apotropaic belief; it was rooted in a ‘vibratory’ conception of reality by which the healing properties of a given object were not identified with its material structure but with its ‘De’ or with its ‘Qi’ that is to say with its peculiar modulation of the common matter-energy by which everything is made. This ‘information’ could be transmitted through another vehicle (such as water or smoke -in the case of moxibustion-) or induce ‘resonance’ in the sphere of the body by simple contact. It might be significant that the phonetic part added to the graph of ‘herb’ to form the Chinese character for ‘medicine’ means ‘music’.

 

The impact with western science: new perspectives

The progressive impoverishment of ‘classical’ medicine was only partially compensated by the developments of ‘clinical’ notions until the Ming dynasty. The great Ming physician Xu Dachun (1693-1771) was keenly aware of this situation when he wrote in 1775: "The tradition of [true] teachings of medicine has been lost. If even such shallow principles [as the one discussed above] are no longer known, how much more this applies to subtle [doctrines]". TCM’s situation at that time was still good if compared to what happened to it at the time of its first impact with western medical thought. Under the Manchurian Qing domination (1644-1911), Chinese culture in general underwent a period of great decadence. Military defeat aroused a certain scepticism about the superiority of native culture compared to the invader’s one, while missionary hospitals, opened by Jesuits and surgeons of the West India Company, at the beginning of 19th century, proved that the primacy of western science was not limited to military technologies. In 1822 the teaching of acupuncture and moxibustion was banished from the Imperial College of Medicine. With the establishment of the First Republic in 1911, the supporters of western thought gained absolute prevalence in the governmental environment: most of the leaders of the New Republic had studied abroad and the President Sun Yat-Sen (Yi Xian 1866-1925) himself graduated in (allopathic) medicine. As a result of this new trend, the practice of Chinese Medicine was on the verge of being forbidden on the whole national territory - a petition in these terms was presented to the National Board of Health in February 1929 - and only through the Central Physical Culture Bureau, native medicine gained itself a minimal survival.

This situation changed after the second World War: at the beginning of the People’s Republic, western medicine was not developed enough to meet the needs of the masses, particularly in the countryside; most of the western medicaments were too expensive to be broadly employed. The pragmatic nature of the new Marxist ideology brought to a temporary revaluation of TCM, which, during the fifties, enjoyed a period of great revival. The study of Traditional Medicine, integrated with notions of western disciplines, was reintroduced into university education, a basic knowledge of native practice was included in the training of allopathic physicians and new research projects - based on the integration of traditional and western notions - were launched to open what, in 1981, will be called the ‘third way’ of Chinese Medicine. This spirit of co-operation and integration between the two systems of thought produced important results, such as the electroacupuncture for analgesia in major surgery. Reports from western doctors, that could speak with Chinese patients during surgery, started to gain the interest of the western world.

However this revival was purely utilitarian; only practical aspects of TCM were taken into consideration; research was aimed at selecting the most efficacious medicines and therapeutical techniques to be included into the body of international medical science, provided their mechanism to be explainable by western scientific standards. This means that the evaluation method, by which certain features of Chinese Medicine were selected, was not merely grounded on the proven clinical effectiveness of a given therapy, but took western interpretative patterns as standard. For example, the analgesic effects of acupuncture, being explainable as direct action on the nervous system, are now broadly recognised, while its action on the internal organs activity or on the psychical sphere is denied, even if both results are observable in clinical practice and considered just different applications of a same principle in traditional theory. The utilitarian approach does not require any change of paradigms; it simply selects what can be integrated in western biomedical conceptions. Beside the shortness of studies on primary sources, this evaluation method is one of the main causes of the very narrow understanding of TCM in the western world.

This narrow interpretation of Chinese Medicine is now still prevalent not only in the western world but, in different degree, in China itself. Judith Farquahr has recently monitored a hospital of Traditional Medicine in Guangzhou; in her interesting work she points out how the usual praxis consists in formulating a western style diagnosis on the basis of which Chinese herbs are prescribed. The best consideration that western medicine enjoys in China can be easily detected by the fact that physicians majoring in allopathic medicine are nowadays about the double of those majoring in traditional medicine.

An increasingly strong opposition to this reductionistic approach comes from scientists engaged in researches on the Qigong (Qi-skills) field. Qigong represents the modern heritage of Daoyin Yangsheng techniques and the common field of ‘classical’ medicine, martial arts and transcendence. Qigong therapy involves two aspects: the therapeutical effects that can be obtained by making patients practice this ancient exercises (mainly based on a triple co-ordination and control of body, breath and mind) and the healing effects that can be produced through a voluntary emission of Qi by Qigong masters. The first aspect was tested for the first time in a public hospital of Chengdu by doctor Liu Guizhen in 1954. The encouraging results caused the spread of Qigong therapy in other public structures, as attested in a convention, organised by the Public Border of Health at Shanghai in 1960. At the same time Qigong masters were starting to be used as guinea-pigs for a research project aimed at establishing the existence and eventually the physical structure of Qi, and to investigate about the neurophisiological modifications induced by Qigong practice. These experiments were mainly held in Nuclear medicine research institutes, in High-Energies Physic and Nuclear Physics Departments of Shanghai’s and Beijing’s Universities. The results started a process with great epistemological implications. First of all research projects on TCM went beyond the mere pathology-therapy utilitarian conception; some scientists, as professor Qu Yanggang - whom in 1959 formulated one of the earliest scientific hypotheses to explain some aspects of Qigong training - were not interested anymore in its mere therapeutical utilisation but were starting to explore, through lab appliances, the psyco-physiological development that this practice could induce in common sound individuals (Qigong masters and Qigong trainees). In the second place because researches were carried out by scientists not necessarily belonging to the medical environment using a different evaluation method. Thirdly because important assumptions of ‘classical’ traditional theory, previously rejected by scientific medicine as ‘superstitious beliefs’ were proven to be true. The results of these experiments started to threaten the reductionist approach to traditional science and imposed a reconsideration of TCM (and of its cultural background) from the point of view of Physics, a science that had already dismissed the mechanistic conceptions on which the biomedical model is still based. Most of the phenomena detected by lab appliances were not explainable by usual standards and brought to divisions in the scientific world: some scientists just ignored the results, others found theoretical hypothesis to make the new data fit the old pattern (a new utilitarian approach started by constructing appliances that could reproduce a sort of "Synthetic Qi") a minority claimed that the results obtained by analysing Qigong phenomena pushed to a general reconsideration of human body-mind system model; the famous astrophysician Qian Xuesen leaded the last group and started facing the opposition of the conservative academic world especially for inquires conducted on the taboo field of paranormal faculties.

While in China scientists involved in the research on Qigong were divided between those trying to reduce the new data to the old pattern and those maintaining that the new discoveries pressed for a ‘Scientific Revolution’, in the western world leading physics of the ‘quantum generation’, starting with the Nobel prize Schrödinger, were exploring biology and physiology from a quantum physics perspective. It is interesting to notice that a common feature of some ‘new physics’ leading figures, including Schrödinger, is their great interest in the ancient oriental knowledge which, in their opinion, has very much in common with the world described by quantum physics. The human model considered from quantum physics perspective is the energy-information system as it is described in ancient Chinese classics, including its relations with psycho-physiological activity on the one side and its possible interactions with the global matter-energy-information system of the universe on the other. Nobel prize Prigogine quotes the ancient Taoist philosopher Zhuangzi and declares that the new science is moving toward a synthesis of western experimentation (and quantitative data) and traditional Chinese thought. Qian Xuesen believes in a new ‘science of man’ that will include TCM, scientific study of paranormal phenomena and Qigong. Many others are following the same trend, of which the best known is probably Fritjof Capra, who has clearly pointed out how this neo-paradigmatical science cannot set aside ecology and spiritual development.

However, this ‘Scientific Revolution’ is still far to come; the dominating trend remains mechanistic and reductionist, new data are not taken into consideration if they cannot be explained by usual paradigms. To get round this problem, Qian Xuesen has advocated the adoption of the so-called phenomenological approach, which mainly consists in gathering experimental data and informations without applying any interpretative evaluation method. This means that it is possible to use modern technologies and collect quantitative data to establish if and how a given phenomena takes place, without being obliged to rule it out if we cannot explain by current standards why it happens. Waiting for the next ‘Scientific revolution’ we can temporarily accept its traditional explanation.