From "Chinese Medicine," by Paul U. Unschuld,*
Paradigm Publications, 1998
Pgs. 111-123
 
 

6. Chinese medicine in the Western world at the end of the 20th century: Interplay of market and fears
 

Acceptance of acupuncture in the industrialized countries of the West over the last twenty years, as would appear now, has primarily been an acceptance of the notions of the nature and appropriate treatment of illness that allegedly underlie it. Only secondarily has this acceptance rested on clinical successes. In the 1960's, certain attitudes changed among a sector of the population in Western industrialized countries. Chemistry and technology, which previously had only positive connotations, now began to lose their attractiveness, despite the fact that almost any aspect of daily life was almost unthinkable without chemistry and technology.

Regular media reports about the negative effects of chemistry on the cleanliness of air, soil, and water, on animal life, and hence on the human body and its health, as well as equally regular reports about chemical disasters in Bophal or Seveso, in, Frankfurt-Hoechst, and many other places, caused chemistry to be seen in a new light, and provoked fears that extended to modern medicine. Chemical drugs come from the same factories whose products burden the environment-chemotherapy is the pride of modern medicine. It is easy to understand how the increasing detachment from the positive effects of chemistry were associated with a sense of alienation from a form of medicine that had closely relied on chemistry.

The same process of change is seen in attitudes toward technology. The impact of technology on daily life, once celebrated in world exhibitions as the solution to the millennia-old problems of humanity, now came to have a pale aftertaste for a certain section of the population. Technology is felt by many to destroy nature and also to destroy relationships between human beings. The picture of the railroad and freeway is no longer associated principally with communication between distant regions; it is equated with the carving up of stretches of land once intact.

Technology, and not least nuclear technology, is viewed as a threat, and this evaluation is carried over to medicine, whose whole pride rests on the application of technology in diagnosis and therapy. Technical diagnosis, though, can provoke fear and drive a wedge between patient and doctor. Many patients have the feeling that inexorably neutral machinery produces the diagnosis and informs the doctor with paper printouts or computer images. These patients wonder whether the dominance of technology in these areas allows any room for the perception of individual distress.

The advertising for Chinese medicine focuses precisely on these fears. The fuzzy concept of "natural healing," which in actual fact is barely applicable to Chinese medicine, offers an impression of security that their bodies will not be polluted with chemicals and suggests that the personal application of the needles guarantees a traditional doctor-patient relationship with the promise of sympathy and empathy. The diagnosis of inspection, listening and smelling, inquiry and pulse-taking aims to evaluate the suffering of the individual, not to compare the patient with standard values, any deviation from which is a priori considered morbid.

Important for the success of acupuncture and Chinese medicine has been the notion of qi. Acupuncture and Chinese medicine became attractive and plausible in Western countries overnight when shortage in oil supplies from the oil-producing countries in the 1970's made the Western world aware of the energy problem. Since those years, energy supply has come to be the most important existential problem of the industrial nations of the West. Securing energy supplies has repeatedly led to international conflicts culminating in military action. Domestic energy policy and the controversy about the best forms of energy for the future have led to violent squabbles in national politics. Even for the private household, concern about availability and affordability of energy since the energy crisis of the 1970's is not to be underestimated.

Against this backcloth, "Chinese healing," as interpreted by Western writers, at least serves to solve the issue of the energy problem within the individual's own body. By explaining disease in terms of energetic disturbances, Chinese medicine gains plausibility, but a plausibility that arises out of conceptual adaptation to Western fears, not out of the historical reality of Chinese thinking.

A further conceptual adaptation to the concerns of a section of the population enhances the attractiveness of Chinese medicine. Many metaphors of killing, defense and attack, which have be come prevalent since the 19th century with the development of bacteriology and more recently in the realm of popular descriptions of immunology, have been taken for granted in China since ancient times. This brand of figurative use of language does not appear in the version of Chinese medicine propagated in the West.

For the population of Europe increasingly disquieted by the threat of war, reports about the latest developments in immunity research in Western medicine presents a picture of war in the body in often quite drastic metaphors. The mass media report on "daily massacres, frightful carnage, and secret acts of sabotage," "hidden allies and the search for wonder weapons" in the battles between killer cells, and viruses, and so forth, on the one hand and antibodies supported by biochemistry and surgery on the other.

This kind of war reporting from the inner life of the body is understandable to some and frightening to others. Anyone afflicted by disease seeking rest and harmony finds it hard to come to terms with the fact that modern drugs are engaged in a belligerent struggle to destroy the enemy in the organism. Largely as a result of ruthless TV reporting, the general public is aware of unavoidable undesired side-effects on the civil population in real war, just as it is aware of the side-effects of drastic chemotherapy.

In contrast to reports from the battlefield of modern immunology, the theory of Chinese medicine freed of its martial metaphors gives the impression that it can lead patients back to the harmony of the great whole. It offers solace where modern medicine offers only the uncertainty of a murderous battle.

Quite a few patients experience modern medicine as a supermarket of possibilities, in which many specialists each investigate the organism from their narrow angle and recommend appropriate remedies based on their narrow view. The loss of a central authority guiding the patient toward an existentially meaning-fill understanding of his or her illness parallels the loss of "central meaning" within society in general. In daily life, a lack of central meaning, though enjoyed by those who are able to take full advantage of individual freedom, is bothersome for the many who find life hard to cope with and need guidance. Similarly, if modern medicine, which as any form of medicine is a reflection of the spirit of the times, falls to offer many patients any deep, innermost reason for their suffering-at least, this is what a certain sector of the population feels.

The systematic-functional approach of Chinese Medicine fills this gap. Of the heterogeneous mixture of different approaches that have arisen over the past two thousand years, the only approach to have found its way to the West is the one that appears to have been neglected by modern medicine or, to put it more accurately, one which is taken for granted in modern medicine at a theoretical level but which neither the general practitioner nor the specialist appears to be able to put into practice, and which for the patient might as well not exist at all.

The systematic approach in Chinese medicine and hence also in acupuncture interprets the body as a unity and the individual organism as a part of the whole universe. Chinese natural philosophy appears as an attractive alternative at a time when many people, consciously or unconsciously, suffer from the lack of reference to a whole, and are unable and unwilling to experience the whole in explanation models offered by the traditional churches. The notions of yin and yang and the five evolutive phases suggest answers to many questions and solutions to many problems that seem pressing today without having to resort to conventional religions.

The notions of the necessary harmony between man and his environment on the larger scale, and between the individual functional spheres of the body on a smaller scale address the doubts of many who cannot escape the impression that traditional politics and theology are either unable to adequately deal with the threats to future life or actually actively encourage the catastrophes in store.

The systematic and at the same time non-metaphysical approach of Chinese medicine, with regard to both the individual body and the universe, answers the needs of these people and has its primary justification in these needs.

Nonetheless, this attractive systematic approach is only a child of our times. It has secured for Chinese medicine and acupuncture a certain amount of popularity because it addresses the existential needs of a sector of the population at the end of the 20th century. The coincidence between the systematic approach and the existential needs has provided an initial push that has brought acupuncture into the limelight, yet for acupuncture to gain long-term recognition and avoid homeopathy's fate of being the eternal outsider, it requires substantiation, which in our Western civilization means the stamp of approval of science.

For a large proportion of users of acupuncture, it is of course of no direct consequence whether the application of acupuncture achieves scientifically demonstrable effects, The systematic approach is attractive because a preliminary cure for a wounded soul is achieved through its integration in a system of ideas that gives meaning to an individual illness, that traces the problems of the head or back, skin or mouth to an underlying cause in the body, and that relates, if necessary, the underlying cause in the body in turn to an underlying cause in the existential environment of the patient.

Given the multiple morbidity that ails our society in the eyes of a growing section of the population, it is reassuring to know that there exists an explanatory model at least for the multiple morbidity in the body that is capable of pinpointing the central problem and perhaps even of treating it. The fact that this central problem is expressed in unusual terms such as "kidney yang depletion" lessens fears, since such terms evidently cannot be construed as referring to biochemical or biophysical disturbances, which would have to be treated with chemical or technical methods that have increasingly fallen into discredit. Concepts such as kidney ping depletion refer to a deviation from an equilibrium in the great world plan that can be reversed.

All these factors alone might be reason enough for Chinese Medicine -even if it only fits this description in part-to be viewed as a meaningful complement, if not an alternative, to conventional Western medicine. It should also be added that, in contrast to the unsuccessful efforts in the 18th and 19th centuries, Chinese medicine in China has now come to be recognized as a lucrative export product, and in the Western commercial world is seen as a profitable investment.

It is particularly from this side (i.e., from the commercial world) that idealizing reports with cliche-coining titles such as "Healing from the Far East" are promoted in large-circulation magazines. This kind of reporting generates continuing interest among patients who originally may have had no affinity with such therapies, but who as a result of negative experiences in their dealings with contemporary biomedicine or as a result of unsatisfactory treatment in the past are now willing to give an allegedly Chinese alternative a chance.

The short air flights that have drawn Europe and America closer to China have brought more and more visitors into contact with Chinese medicine on its home ground. Chinese tourist managers have developed routines to show foreign travelers Chinese medicine in practice, especially Chinese drug therapy, which was hitherto only of marginal interest in the West, but which, for economic reasons, is a more viable export product. Tourists are given free diagnoses, which inevitably end with therapeutic suggestions. A considerable turnover is generated in this way. To what extent the medicines provided contain admixtures of highly effective substances from modern medicine not declared on the labels can scarcely be evaluated. The effects achieved cause many to seek Chinese medical health care on their return.

7. The spectrum of supply

Not all, but most of the books on acupuncture written for MD and non-MD students of acupuncture and general lay-audiences in Western countries place the systematic-functional approach of Chinese medicine in the foreground. They begin with an explanation of the doctrines of yin and yang and the five phases with lists of their correspondences. They show the system of the supposed meridians that for two thousand years provided the basis of needle therapy. The meridian system illustrates the way in which the functional spheres of the body are inter-linked, providing a graphic representation of the holistic view of Chinese medicine.

In this way, Western literature presents those elements of Chinese medicine that have a chance of providing a conceptual alternative to contemporary biomedicine and a complementary method of treatment. It would be impossible for Chinese medicine to be brought to the West in its entirety or in some purely original Chinese form. First, there is no Chinese medicine as a finished, closed healing system. Chinese medicine developed dynamically over two millennia much as medicine in the West did from its Hippocratic beginnings around the 500 B.C. The development of Chinese medicine within the framework of its traditional theoretical system came to a standstill long before the end of the cultural environment that made this medicine possible and made its conceptual basis plausible. None of the major areas -- theory acupuncture, or pharmacy -- have under- gone any significant innovation since the beginning of the 17th century.

In particular, acupuncture after a peak that was reached with the publication of the "Great Encyclopedia of Acupuncture and Moxibustion" in 1601, gradually degenerated to a folk medicine, prompting the famous physician Xu Dachun (1693-1771) in a detailed survey published in 1754 t o speak of the "loss of a tradition" and the nonexistence of able acupuncture practitioners. In 1822, the Chinese government classed acupuncture as a method of treatment that learned men should not be exposed to and forbade the imperial medical college to instruct students in its practice.

Against this background, the question arises as to what "Chinese medicine" should be transmitted to the West. The practices and theoretical conceptions that in the political climate of the People's Republic of China have been chosen from the heterogeneous heritage as meaningful? The varied practice free of political influence, based on personal interpretation of traditional opinion and techniques among representatives of Chinese, for example, on Taiwan? The pragmatic approach relatively free of theory that is widespread in Japan? Or any of the various Chinese approaches of the last two millennia? In trying to answer this question, one problem lies in the fact that there is no criterion for judging any one of these approaches in relation to another. They all have their effects. Practitioners of each of them can point to satisfied patients. Failure is of course also common to all.

Time and time again, each practitioner sees the astounding effect of the needles, but no explanatory model that would convince and completely satisfy at least a majority of practitioners is in sight. So far, the scientific approach to acupuncture has not followed satisfactory methodologies. Studies produ negative conclusions have no influence over practice, since such evaluations strengthen the conviction of those who would deny science the right to judge procedures whose conceptual basis lies outside scientific thought structures.

In this context, we should also consider the difficulties faced by medical faculties of universities confronted with demands to introduce Chinese medicine into the curriculum. Neither the theoretical basis, diagnosis or even the theory of Chinese medicine can be standardized. Graduates of modern medicine, even though they may later attain different levels of proficiency as physicians, have at least all had roughly the same training to the highest possible contemporary standards and have proven their knowledge through officially supervised examinations. This is not possible in Chinese medicine.

A medicine school or faculty that decides to include acupuncture in its curriculum has no criteria for the selection of teaching staff. If it has the idea to take on Chinese practitioners, it must decide first of all if preference is to be given to traditional practitioners who have no university education, who have learned their skills through self-study or a long teacher-student relationship, and who practice "classical" Chinese medicine, or to graduates from modern teaching institutions in the People's Republic of China who are trained to varying degrees in Western medicine, but who are no longer capable of practicing traditional medicine uninfluenced by modern anatomical, physiological, and pathological ideas.

Whichever option a medical school chooses, there are no objective criteria for evaluating the knowledge of prospective teachers in either group. Students attending one clinic in southern Germany are astounded to hear the therapies there are not spoken of flatteringly in another clinic in southern Germany, and vice versa. The reason for this is that the doctors in the one come from Peking, whereas those in the other are from Shanghai. Each group practices its own version of "Chinese medicine," and denies the other version any legitimacy even though it has no empirical or scientific grounds for doing so. The fact that these clinics are subject to no state or technical quality control is only one of the many ramifications of this situation.

Quite apart from the absence of an objective method of finding a skilled doctor in one or another group, the medical school, should it have reached the conviction that it has found a suitable candidate, cannot, given the nature of Chinese tradition, be sure that the candidate will be willing to pass on all his knowledge. Secret knowledge, to which only the mastermind has access, is still an important part of the prestige of an outstanding doctor in China. Even today, the best doctors refuse to pass on all of their knowledge either in medical colleges or to individual students assigned to them.

If the administration gives preference to Westerners, there would be a large number of different groups to choose from, most of which contest each other's competence. There are groups who, without any scientific evidence, say that getting the feeling of qi at the needle insertion point is the conditio sine qua non for the effectiveness of acupuncture treatment; other groups maintain precisely the opposite. There are groups who regard a strong electrical impulse as a prerequisite for successful treatment (which raises the question as to how acupuncture could have survived for two millennia without artificial electricity), while other groups of equally successful acupuncturists produce their effect through shallow needling whereby the needles penetrate the skin barely a millimeter. There are groups who state, again without any scientific proof, that acupuncture can only produce effects when ancient Chinese notions are followed, and these fundamentalists formulate their allegedly classical notions in a way that the ancient Chinese could not even have heard of. Other groups would rather discard all ancient Chinese concepts, believing that acupuncture's legitimacy can only be based on modern neurological or endocrinological theories.

It is not possible to make a reasonable choice from this plethora of options. Wherever a choice has been made, it has rested on local availability and personal recommendations. The students taught by such staff cannot be sure what quality of training they are getting since the chances are that in the nearest medical bookstore they will pick up a "standard work" of acupuncture that represents a completely different approach, or that they will come across an introduction to Chinese medicine whose terminology follows a completely different system of interpretation, translation, or transcription from the one to which they are accustomed. In either case, they will be confused. The same insecurity also affects patients.

The impossibility of objectively determining which of the old or modern approaches is the best and of standardizing this approach in theory and clinical practice is of course only one of the difficulties facing attempts not only to transfer Chinese medicine to the West, but also to anchor it in the Western academic framework. A second difficulty is closely related to this one, and is often overlooked. Irrespective of whether Western supporters of Chinese medicine take their notions of Chinese medicine from the older or more recent history of Chinese medicine, however hard they devise a purely Chinese alternative to Western medicine, they always fail because of the difference in attitude between Chinese and Western traditions to the stringency of thought systems.

The Western preference for thought systems that are free of internal contradictions and that constitute truth until a new truth provides better explanations with fewer contradictions is diametrically opposed to an East Asian tradition that judges thought systems by how well they prove themselves to be in practice rather than by how true they are. The yin-yang and five-phases doctrines are in many respects mutually exclusive, as when, for example, one assumes the existence of six and the other the existence of five depots in the body. The Western solution to the problem, which is to open the body and see whether there are five or six organs, stands in contrast to the Chinese tendency to reckon with six organs in the yin-yang doctrine and with five organs in the five-phase doctrine.

The yin-yang doctrine is legitimized by its being a logical system of correspondence and by proving itself capable of evaluating and influencing numerous processes in the body and hence in the human organism. The five-phase doctrine is legitimate for precisely the same reason: it too is logically derived from the notion of systematic correspondence and proves itself by being capable of evaluating and influencing numerous processes in the body and hence in the human organism. Consequently, traditional Chinese medicine bases itself on both doctrines, and sees no contradiction between them.

Another example is offered by pulse diagnosis. For those who are still capable of thinking in purely traditional categories, the various schemes for feeling the wrist pulse that are presented in ancient literature represent no contradiction. The physician has the choice of either feeling the pulse with three fingers or with one finger. Using three fingers, light pressure with the index finger above the imaginary line level with the styloid process allows him to feel the state of the lung and heart, greater pressure with the middle finger on the imaginary line enables him to feel the state of the spleen, and greater pressure still with the ring finger allows him to feel the liver and the kidney, which similarly lie in the depths of the body. Also in accordance with the doctrines of correspondence the physician can apply a little pressure to feel the lung and heart, a little more pressure to feel the spleen, and still greater pressure to feel the liver and kidney. According to a third (and certainly not the last) variant, he can, with one finger, apply a pressure equal to the weight of three beans to feel the lung, a pressure of six beans to feel the heart, a pressure of nine beans to feel the spleen, a pressure of twelve beans to feel the liver, and finally a pressure that brings the fingertip almost to the bone, to feel the kidney.

All three procedures are logically justified in themselves, since they are all based on systematic correspondence. Nevertheless, they go against Western thinking, which in the face of a "this-as-well-as-that" framework naturally poses the "is-it-this-or-that?" question. Authors writing for a Western public have no choice but to answer the "is-it-this-or-that?" question with regard to the number of organs, the pulse diagnosis schemes, and many other details.

Consequently, in all descriptions of Chinese medicine written for Western users, what is perhaps the only real alternative that Chinese medicine offers in comparison with Western thinking is adapted to the usual patterns of, precisely, Western thought. When one further considers the fact that the Western variant of Chinese medicine, by explaining the central concept of qi as energy and by selecting only those elements from the heterogeneous tradition that do not appear obsolete or scientifically absurd, is divorced from the original Chinese tradition, then it is easy to understand that the reception of Chinese medicine is not a mechanical, but a creative act, whose further development is conditioned more by the expectations and demands of a Western population than by the marshalling of scientific evidence.
 

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Professor Dr. Paul Unschuld (M.P.H.) is director of the Institute for the History of Medicine at the University of Munich. He is also the author of:

Medicine in China: A History of Pharmaceutics, Berkeley, Los Angeles, London: University of California Press, 1986

Medicine in China: A History of Ideas, Berkeley, Los Angeles, London: University of California Press, 1985

Nan-Ching: The Classic of Difficult Issues, Berkeley, Los Angeles, London: University of California Press, 1986

Huichun: Chinesische Heilkunde in historischen Objekten und Bildern, Munich: Prestel, 1995