Traditional Chinese medicine

• 1. Introduction

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  Traditional Chinese medicine, usually shortened to TCM, gained a powerful sponsor in 1950 when Mao Zedong announced his support for it. His personal physician, Li Zhisui, later reported that Mao neither believed in it nor used it himself. That gap between public backing and private doubt runs through the whole subject.

  TCM covers herbal medicine, acupuncture, cupping, gua sha, tui na massage, bonesetting, qigong exercise and dietary therapy. It is widely used across the Sinosphere, and in adapted form in the West. Yet its reputation for unbroken antiquity is contested by historians. Its picture of the body describes channels and energies that investigators have struggled to locate. Its ingredients also reach well beyond the pharmacy shelf, into the survival of wild species.

  Where did this system really come from? How does a practitioner decide what is wrong with a patient? And what happens when its claims meet laboratory testing, state power and endangered animals?

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• 2. Canons and Commentaries

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  Carved bones and tortoise shells from the Shang dynasty, in the 14th-11th centuries BCE, hold the earliest traces of healing in China. Their oracle inscriptions mention illnesses that afflicted the royal family: eye disorders, toothaches and a bloated abdomen. Shang elites usually blamed such illnesses on curses sent by their ancestors. No evidence shows that the Shang nobility used herbal remedies. Stone and bone needles found in ancient tombs led Joseph Needham to speculate about acupuncture. Most historians now separate medical lancing, or bloodletting, from acupuncture in the narrow sense of stimulating points along meridians with metal needles. The earliest evidence for that narrower practice dates to the second or first century BCE.

  A tomb sealed in 168 BCE at Mawangdui held Recipes for Fifty-Two Ailments, excavated in the 1970s. Texts of that kind still made room for spirits and magic. The Yellow Emperor's Inner Canon, or Huangdi Neijing, did not. Compiled in the Han dynasty around the first century BCE from shorter texts of different medical lineages, it is the oldest received work of Chinese medical theory. It is written as dialogues between the legendary Yellow Emperor and his ministers. They range over the human relation to the environment and the cosmos, the contents of the body, the symptoms of illness, and how to reach diagnostic and therapeutic decisions. It was also among the first books to bring yinyang and the Five Phases into a mature synthesis.

  Between 196 and 220 CE, at the end of the Han dynasty, Zhang Zhongjing collated the Treatise on Cold Damage Disorders and Miscellaneous Illnesses. It focused on drug prescriptions rather than acupuncture. It was the first medical work to combine yinyang and the Five Phases with drug therapy. It was also the earliest public Chinese medical text to group symptoms into clinically useful patterns, called zheng, that could become targets for treatment. After many changes, the formulary now circulates as two books, edited separately in the eleventh century under the Song dynasty.

  The Classic of Difficult Issues, the Nan Jing, is ascribed to Bian Que of the eastern Han dynasty. It is built from 81 questions and answers, which is why it is also called the Eighty-One Nan. Questions one to twenty-two concern the pulse, and questions sixty-nine to eighty-one concern needling methods. It became one of four classics that practitioners study. The Shennong Ben Cao Jing, written between 200 and 250 CE, gathered the pharmacological experience of the Qin and Han periods. It was the first systematic summary of Chinese herbal medicine, and it has served as a textbook for medical workers in modern China.

  Huangfu Mi compiled the AB Canon of Acupuncture and Moxibustion between 256 and 282 CE, assembling a consistent body of acupuncture doctrine. The Canon of the Pulse, from around 280, presented itself as a comprehensive handbook of diagnostics and therapy. Another book, the Canon of Problems, probably from the second century CE, tried to reconcile divergent doctrines in the Inner Canon around needling therapy. Around 900-1000 AD, Chinese physicians were the first to develop variolation against smallpox. They had realised that healthy people exposed to smallpox scab tissue were less likely to catch the disease later. A common method was crushing scabs into powder and breathing it through the nose.

  Later scholars include Tao Hongjing, who lived from 456 to 536, and Sun Simiao of the Sui and Tang dynasties. Zhang Jiegu, who lived around 1151-1234, and Li Shizhen, who lived from 1518 to 1593, followed. The growth of drug records shows the accumulation. A few dozen drugs were described at first, close to 1,900 were documented by the end of the 16th century, and a modern count reaches 12,800.

  The literati physician Cheng Congzhou published a collection of 93 cases in 1644. Individually authored and published case histories became a prominent creation of the Ming dynasty. Physicians wrote them instead of books of prescriptions or advice manuals, because in their understanding no two illnesses were alike.

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• 3. An Assembled Tradition

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  Nathan Sivin looks at two thousand years of Chinese medicine and sees a "medical system in turmoil". He calls the idea of a single unchanging inheritance a "myth of an unchanging medical tradition". He also warns about translation. In his words, "Traditional medicine translated purely into terms of modern medicine becomes partly nonsensical, partly irrelevant, and partly mistaken; that is also true the other way around, a point easily overlooked."

  Paul Unschuld goes further and sees a "departure of TCM from its historical origins". On his account, what is practiced today in China and the West is not thousands of years old. It was recently constructed from selected traditional terms, some taken out of context and some badly misunderstood. He has criticised popular books in both languages for choosing only the works that seem to lead toward modern medicine. Those books ignore the elements that now look ineffective.

  The construction began in the early twentieth century. Chinese cultural and political modernizers were then working to eliminate traditional practices as backward and unscientific. Traditional practitioners responded by selecting elements of philosophy and practice and organizing them under the name "Chinese medicine".

  Even the English name has a disputed birth. J. A. Jewell and S. M. Hillier credit Dr. Kan-Wen Ma, a Western-trained doctor who was persecuted during the Cultural Revolution. He emigrated to Britain and joined the Wellcome Institute for the History of Medicine at the University of London. Ian Johnson says instead that "party propagandists" coined the term in 1955. Yet English-language newspapers in colonial Singapore were already using "Traditional Chinese Medicine" for Chinese ethnic medical practices by 1935.

  Colonial port cities show the blending in action. The Tung Wah Hospital opened in Hong Kong around 1870, founded on widespread rejection of Western medicine for older practices. Western medicine was still practiced there alongside Chinese methods. The Kwong Wai Shiu Hospital in Singapore, likely connected to Tung Wah, offered both kinds of care for similar reasons.

  Hong Kong's rulers left Chinese medicine alone. In 1841 the British government there pledged to govern residents according to their original rituals and customs, so traditional medicine went unregulated. Western medicine only grew popular from 1940, and by 1959 Hong Kong had researched using traditional Chinese medicine to replace it.

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• 4. The Body as Process

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  A sunlit hillside gave Chinese thinkers their oldest picture of yin and yang. The sun-facing side is yang and the shady side is yin. The concepts can be traced back to the Shang dynasty, and water and fire serve as two other common images. In this scheme the moon is yin and the sun yang, female is yin and male yang, inside is yin and outside yang. Cold is yin and heat is yang. The body divides the same way, with the upper part and the back counted as yang and the lower part as yin.

  Symptoms follow the pattern. Yin vacuity brings heat sensations, night sweating, insomnia, a dry mouth and a fine, rapid pulse. Yang vacuity brings an aversion to cold, cold limbs, pale and enlarged tongue and a slow, fine pulse. TCM also lists drugs believed to reinforce yin or yang to match each combination.

  The medical anthropologist Charles Leslie places Chinese medicine beside Greco-Arabic and Indian traditions. All three, he writes, were grounded in systems of correspondence that aligned society, the universe and the human body into an "all-embracing order of things". Qualities such as heat and cold, wet and dry, light and darkness also lined up the seasons, compass directions, and the cycle of birth, growth and death. Leslie credits these systems as a mnemonic device for storing empirical knowledge. He adds that they were also "subject to stultifying theoretical elaboration, self-deception, and dogmatism."

  The Five Phases of wood, fire, earth, metal and water extend the same logic. Wood belongs to the east, wind, the sour taste, the Liver and the eye. Water belongs to the north, cold, the salty taste, the Kidney and the ears. Strict rules govern how the phases generate and counteract each other. Numbers joined in as well. The count of acupuncture points has at times been put at 365, matching the days in a year. The twelve main meridians have been matched with the rivers of the ancient Chinese empire.

  The word shen, written 身, is the closest classical Chinese term to the English "body". Scholars read it as an "ensemble of functions" that includes the psyche and the emotions. That makes it very different from the European split between mind and body. TJ Hinrichs makes a related point. Modern Western societies divide healing among biomedicine for the body, psychology for the mind and religion for the spirit, and these divisions fit Chinese medical concepts poorly.

  TCM therefore cares less about anatomy than about function. Qi, often translated as vital energy, has five cardinal functions: actuation, warming, defence, containment and the transformation of food, drink and breath into other substances. Part of it comes from food, drink and breathing. Another large part is inherited from the parents and used up over a lifetime. Blood, called xue, is the one entity tied to a physical liquid, yet its concept is still defined by what it does. Body fluids, called jinye, nourish and moisten, and tears, saliva, sweat and urine are among their visible forms.

  At the centre sit the eleven zangfu. The five zang are the Heart, Liver, Spleen, Lung and Kidney, and the six fu are the Small Intestine, Large Intestine, Gallbladder, Urinary Bladder, Stomach and San Jiao. Their names are capitalised to show that they are functions rather than anatomical organs. Each zang pairs with a fu, and each pair belongs to one of the five phases. Meridians carry qi and blood from these interior systems out to the limbs. TCM counts 12 regular and 8 extraordinary meridians. There are six yin meridians but only five zang, so the sixth goes to the Pericardium, an entity close to the Heart.

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• 5. Reading the Patient

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  Two people with a common cold may leave the same practitioner with different treatments. In TCM a disease has two aspects, called bing and zheng. Bing is the disease entity, and zheng is the pattern of disharmony. One person's cold may show a wind-cold pattern and another's a wind-heat pattern. Therapy follows the pattern, not the entity. From a scientific viewpoint most listed disease entities, such as headache, cough, abdominal pain and constipation, are symptoms. Pattern discrimination is the most important step in TCM diagnosis, and it is also the hardest.

  Four pillars support it: inspection, listening and smelling, inquiry, and palpation. Inspection centres on the face and especially the tongue, with its size, shape, color, coating and any teeth marks. Inquiry covers topics such as chills, fever, appetite, sleep and menses. Different regions of the tongue are believed to correspond to the zangfu organs. Redness at the tip might point to heat in the Heart, and redness at the sides to heat in the Liver.

  The pulse is read at three places on the radial artery of each arm, named Cun, Guan and Chi. Each is felt at a shallow and a deep level, giving twelve pulses in all. Each is thought to correspond to certain zangfu. Practitioners describe qualities such as floating, slippery, feeble, thready and quick. Learning pulse diagnosis can take several years.

  A practitioner first sorts the signs by the Eight Principles. These are four pairs: exterior and interior, heat and cold, vacuity and repletion, and yin and yang. Heat and cold, and vacuity and repletion, carry the most clinical weight. Yin and yang carry the least. A sample finding reads: "Liver fire rushes upwards and scorches the Lung, injuring the blood vessels and giving rise to reckless pouring of blood from the mouth and nose." Treatment then aims to clear heat or supplement the Lung.

  Causes are sorted too. The Six Excesses of wind, cold, fire or heat, dampness, dryness and summerheat resemble climate effects, and they can also arise inside the body. The Seven Affects are joy, anger, brooding, sorrow, fear, fright and grief, and they are believed to damage the zangfu, especially the Liver. A third group includes irregular diet, fatigue, sexual intemperance, trauma and parasites.

  The method strained when the patient was a woman. Cheng Maoxian, born in 1581 and practicing medicine in Yangzhou, described the problem in his case studies. In one, the teenage daughter of Fan Jisuo could not be diagnosed because she would not speak of her symptoms. They involved discharge from her intimate areas. Custom required an adult man to call the doctor and stay present, and the physician discussed her condition only through him. Women often stayed behind curtains and screens, and the doctor might touch only enough of her to take the pulse. Doctors also used a medical doll, known as a Doctor's lady, on which female patients could point to the location of symptoms.

  Pregnancy made it harder. Seventeenth-century accounts describe a pregnancy emerging from menstrual irregularity, uneasy digestion and a sense of fullness, so diagnosis often came late. Women were often silent about suspected pregnancy, and some husbands and fathers learned of it only when complications arrived. After birth, the physician focused on restoring the mother's qi, with garlic, ginseng, medicine and rest. A check-in after a month followed, a practice known as zuo yuezi. Infertility was sorted into syndrome types, and patients were trusted to record the volume, color, consistency and odor of menstrual flow.

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• 6. Party and State

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  In the Yan'an Soviet, the Chinese Communist Party faced a shortage of Western-style medical resources. Its mass campaigns set two goals: to "scientize Chinese medicine" and to "make Western medicine Chinese". The 1950s then brought legal revival, including the legalizing of previously banned practices and state sponsorship for combining Chinese and Western medicine. In 1952 the president of the Chinese Medical Association promised that "This One Medicine, will possess a basis in modern natural sciences". It would absorb the ancient and the new, and the Chinese and the foreign, and become China's New Medicine.

  During the Cultural Revolution, from 1966 to 1976, the government stressed modernity, cultural identity and economic reconstruction, and set them against a colonial and feudal past. It built a grassroots health care system and made large investments in traditional medicine, hoping to provide affordable care. The Ministry of Health directed care across the country and set up primary care units. Physicians trained in Western medicine had to learn traditional medicine, while traditional healers received training in modern methods. That is why one account concludes that TCM was re-created in response to Western medicine.

  In 1968 the party backed a new rural system built around the barefoot doctor. Each village received a staff member with basic skills to handle minor illnesses. These workers blended traditional values with modern methods for poor farmers in remote areas, and they became a symbol of the era. The hybrid approach, often translated as Integrative Chinese Medicine, outlived the barefoot doctors. Nathan Sivin's 1987 translation of an outline from 1972, written for Western-medicine practitioners to learn Chinese medicine, shows it in practice.

  After relations between the United States and China opened in 1972, interest in the West grew sharply. China's State Intellectual Property Office, now CNIPA, set up a database of patents granted for TCM. By May 2011, China had signed TCM partnership agreements with over 70 countries.

  Xi Jinping called TCM a "gem". His government pushed to raise its use and the number of TCM-trained doctors. It also announced that TCM students would no longer need to pass examinations in Western medicine. Chinese scientists worried that TCM training and therapies would receive equal support with Western medicine. They also criticised reduced government testing and regulation of TCM production, since some products were toxic. Government censors have removed internet posts that question TCM. In 2020 Beijing drafted a local regulation outlawing criticism of TCM. According to Caixin, the regulation passed with that provision removed.

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• 7. Evidence on Trial

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  A 2007 editorial in the journal Nature judged that TCM "remains poorly researched and supported, and most of its treatments have no logical mechanism of action". It added that the field was "fraught with pseudoscience". A review of the literature in 2008 reached a blunter verdict. Scientists were "still unable to find a shred of evidence" for qi, meridians or acupuncture points by the standards of science-based medicine. The review concluded that acupuncture points and meridians are "merely the product of an ancient Chinese philosophy".

  Many in the acupuncture community hold that points and meridians are special conduits for electrical signals. No research has established a consistent anatomical structure or function for either. Stephen Barrett of Quackwatch adds that practitioners disagree among themselves about how to diagnose patients and which treatments match which diagnoses.

  Research on outcomes has not rescued it. A 2012 review of cost-effectiveness studies found low levels of evidence and no beneficial outcomes. Pharmaceutical research into new drugs from traditional remedies has produced few successes. A 2019 review of traditional herbal treatments found them widely used but lacking scientific evidence, and it urged a more rigorous approach to identify the genuinely useful ones. Proponents answer that research has missed key features of the art, such as unknown interactions among ingredients in complex biological systems. Many "natural" TCM remedies are effective, one account says, because they contain hidden allopathic drugs.

  In June 2019 the World Health Organization included traditional Chinese medicine in a global diagnostic compendium. A spokesman said this was "not an endorsement of the scientific validity of any Traditional Medicine practice or the efficacy of any Traditional Medicine intervention."

  The argument has also raged inside China. In 2006 the philosopher Zhang Gongyao set off a national debate with an article titled "Farewell to Traditional Chinese Medicine". He argued that it was a pseudoscience and should be abolished in public healthcare and academia. The government took the stance that TCM is a science and kept encouraging its development.

  Safety is a separate worry. Some plants, animal parts and mineral compounds used in TCM are known to be toxic, and some cause disease, including cancer. Trafficked and farm-raised animals used in TCM are also a source of several fatal zoonotic diseases.

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• 8. The Animal Toll

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  About 13,000 compounds are used in China, and the ancient literature records over 100,000 TCM recipes. Plants dominate. In the 1941 Handbook of Traditional Drugs, 517 drugs were listed, including 45 animal parts and 30 minerals. Animal substances include cow gallstones, hornet nests, leeches, scorpions, deer antlers, dog testicles and penis bone, and snake bile. Some textbooks still recommend preparations with animal tissue, yet little research supports their claimed effects. The demand for traditional medicines is a major generator of illegal wildlife smuggling, and Chinese authorities have tried to crack down on it.

  Rhinoceros horn is used for many ailments, though not as an aphrodisiac as is commonly misunderstood in the West. The black market for it is driven by TCM and also by unrelated status-seeking. It has cut the world's rhino population by more than 90 percent over the past 40 years. The Chinese Pharmacopoeia has adopted a substitute, a concentrate powder from buffalo horn.

  Tiger parts include bones, eyes and penis, the last believed to improve virility. There is no scientific evidence of efficacy for tiger medicines. The illegal trade has driven the species to near-extinction, and laws protecting even the critically endangered Sumatran tiger fail to stop open-market sales. Concern that China might legalize the trade in tiger parts prompted the 171-nation Convention on International Trade in Endangered Species to oppose any resurgence. One Chinese patent medicine approved as a prescription drug replaces tiger bone with bone powders from three livestock species.

  Fewer than 30,000 saiga antelopes remain, and organized gangs export their horns illegally to China for fever therapies. For seahorses, tens of millions are caught each year at unsustainable levels. Pangolin scales, turtle plastron and the gill plates of mobula and manta rays have also raised concern. Shark fin soup, long seen as healthful in East Asia, has seen huge demand as affluence rose in China. Sharp rises in donkey hide exports from Africa, to make the remedy ejiao, prompted export restrictions by some African countries. Australian scientists have developed methods to identify medicines containing DNA traces of endangered species.

  Captive animals carry their own cost. Because TCM recognises bear bile as a treatment compound, more than 12,000 Asiatic black bears are held in bear farms. Bile is drawn through a permanent hole in the abdomen leading to the gall bladder, which can cause severe pain. That can lead bears to try to kill themselves. As of 2012, approximately 10,000 bears were farmed in China, and the practice has spurred public outcry across the country. As of March 2020, bear bile in the Tan Re Qing injection remained on the list of remedies recommended by China's National Health Commission and the National Administration of Traditional Chinese Medicine for severe cases of COVID-19.

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