Facing reality: Today, all TCM is "Combined Chinese and Western Medicine" (ZHONGXIYI JIEHE).
It is a popular illusion that there is still something like "pure TCM" today. Even in China, all TCM is combined Chinese and Western medicine. Or, more precisely: There is a small part admitting this fact, calling themselves "ZHONGXIYI JIEHE". And there are the majority of teachers, authors and TCM training centers not admitting it. But if admitting or not, modern medicine is present everywhere. Any suspicion of a contagious disease? Send the patient to the Westerns-style colleagues! Heart attack? Stroke? Severe trauma? Infection with high fever? Back pain with paralytic symptoms of the legs? Vomiting blood? Severe fainting? Any suspicion of cancer? Just the same: Cases for the Western-style colleagues! Or, more precisely: Cases for the colleagues of modern international medicine.
A TCM doctor failing to have the blood checked or an X-ray made when necessary might soon face a law suit. But this doesn't happen frequently. The TCM doctors doing clinical work know about their responsibility and usually act accordingly. Only the book authors and the teachers of the international training centers dislike talking about it. But the fact that TCM has become a secondary system even in China cannot be denied. Anyone who doesn't believe it might have a look at the patients' documentations in the TCM departments: 90 percent written in terms of modern medicine, with TCM diagnosis and therapy added in some short lines.
This is nothing to be sad or ashamed about. There are so many diseases and conditions which modern medicine still cannot cure, that TCM (as well as the "natural healing methods" of Western countries) has more than enough work left: Pain, chronic diseases, psychosomatic syndromes, allergies, functional diseases ... relieving the side effects of radiation therapy or chemotherapy ... and many, many more.
TCM should face reality, not only in clinical practice, but also in teaching and theory.
The reality is that medical thinking today starts from modern anatomy, physiology and pathology.
The reality is that TCM even in China has become a complementary system, dealing mainly with the cases which modern medicine still cannot treat adequately.
The reality is that most TCM doctors themselves think in terms of modern medicine and translate them into TCM terms afterwards.
Teaching TCM should acknowledge these facts. At least this should be done in Western countries. And it must be done when we try to integrate some TCM therapy into the medical curriculum of our countries.
So, we have to ask: Is it justified to demand a reform of TCM theory, TCM teaching and TCM examinations, at least when dealing with foreigners? Or are we asking too much? Should we be just thankful that wise TCM teachers are sharing their wisdom with us?
A simple test to check medical concepts (including TCM concepts). - There is in fact a big difference between modern medicine and TCM. If Harvey hadn't found the blood circulation, someone else would have found it sooner or later. In TCM, this is different. Let's take the "8 Influent Points" (BAHUIXUE) of acupuncture, which are not mentioned in the HUANGDI NEIJING, but in the NANJING and later scripts. What if these scripts had been lost? We are quite sure that no one would find or miss this strange point category today.
Or take the HUANGDI NEIJING itself, classifying the gallbladder first as a FU organ, then as an "extraordinary FU organ" (QIHENGZHI FU) as well. What if this chapter had been lost? Nobody would ever imagine such a strange classification. And if the chapters describing the "5 SHU Points" had been lost, modern TCM would never think about such a concept.
This shows that much of TCM's foundation does not reflect the reality of the human body. Big parts of it seem to be a rather arbitrary collection of ancient speculation. So, if we really want to integrate some TCM into the general medical curriculum, we think it justified to make a test. This test is very simple. To do it, we don't need any equipment. All we need is a little thinking.
And this is the test: Let's imagine a certain element of TCM had been lost. Now we ask: Could we find this element today, either by observation or by logical deduction? Do we need it for our understanding? Or for some clinical application? Does it explain things as well or better than other explanations? Does it really help us? - If not, this element it should be eliminated from our teaching.
Or does anyone see any reason why the ancient people were able to discover things we don't see anymore today?
Did the ancient TCM creators, when speaking about "Spleen", "Kidney" etc. really mean anatomical organs? - Some decades ago, there has been a fierce fight about this question among Western TCM friends. Mr. Porkert, one of the most ardent missionaries of TCM in the west, was eager to declare: The ancient creators of the TCM system never really meant anatomical organs when they spoke of "Spleen", "Heart" or "Kidney", but "functional circles" (though Porkert preferred using Latin names). We don't agree, because what TCM thinks today is not necessary the same as the ancients thought 2000 years ago. Still, we should like to pass the question to our Chinese friends: What did, according to your opinion, the ancient doctors and philosophers really mean when talking about the ZANG-FU?
ZANG-FU (1): What do modern TCM experts mean when talking about the ZANG-FU? - When presenting the ZANG-FU or ZANGXIANG, our TCM teachers like to talk about "holism", which, as everyone knows, sounds very pleasant to Western ears. And they tell us that the ancient Chinese were more interested in functional aspects than in anatomical details. But what do they themselves - China's modern TCM experts - think the ZANG-FU are? Organs? Organ systems? Or just functional units?
Whatever they mean, we cannot but laugh when even the newest books start their presentation of the "Spleen" telling us: "The spleen, located in the abdomen, governs digestion and absorption". Do they really believe this? Or do they use "Spleen" only as a metaphoric name for a functional system without a clear location, representing functions like being "the source of qi, blood and body fluid"? But if they do not mean the biological organ, why do the acupuncture books and charts tell us that the "Meridians" really pass through the regions where these organs are located anatomically (though always symmetrical, even in case of asymmetric organs like heart, stomach, liver and gallbladder)?
ZANG-FU (2): Supposing we talk of functional systems. - The bigger part of the TCM descriptions concerning structure and functions of the inner organs cannot be confirmed by modern science. The Spleen does not "govern digestion and absorption". The Heart does not "play a role in the production of blood", nor is it "storing spirit". The Lung does not "govern skin and hair". The Liver does not "govern the tendons". And the Kidney does neither "store essence" nor "govern reproduction".
But this is not the decisive aspect. Even if the anatomical organs don't have these qualities, there might be functional systems working this way. And the question must be: Are there really such functional units in the body? Are their clinical qualities really as described by TCM theory? And is, by any chance, their direction of mutual influence really in the sense of the WU XING? With the "Heart nourishing the Spleen and controlling Lung", the Spleen "nourishing Lung and controlling Kidney", and the Kidney "nourishing Liver and controlling Heart"?
Again, we have to ask the question: How could the ancients possibly find it? By clinical observation? We doubt. Or by philosophical speculation? Yes, probably. And we have to ask and to prove, in every given situation: Which of these descriptions are really clinically useful? Which of them are worth to use them together with scientific medicine, or in some cases even to replace it?
But to prove this, we need more than just repeating the statements of the classics. We need courage, confidence and open discussion. If we consider ourselves not as preachers but as teachers, there must be an end presenting TCM like some kind of religion. We have to change our books, our attitude and our teaching. We must encourage our students to present their questions and objections. If TCM goes on like today - avoiding any fundamental discussion and considering itself an export article more than an object of science and public service - it will appear still strong in the West, but weaker and weaker in China herself.
The "extraordinary FU-organs" (QIHENGZHI FU). - Apparently, the organs or tissues put into this category were those the ancient TCM creators had no real use for, but thought they should mention them: brain, marrow, bones, vessels, gallbladder and uterus. About these, we are told: "The extraordinary FU-organs are characterized by hollowness, similar to the six FU-organs in morphology, and storage of essence, similar to the five ZANG-organs in function." But this is not correct. Where is the "hollowness" of brain and marrow? And what do the vessels or the uterus "store"?
And why was the gallbladder in one chapter counted as FU organ, but in another one as "extraordinary FU organ"? Really because "it is hollow inside and excretes bile to promote digestion, similar to the functions of the six FU-organs, but it also stores bile which is part of the essence, similar to the functions of the five ZANG-organs."? But then the heart, too, should have been counted as FU organ, because it was hollow. And if the ancients believed that the heart "stored" anything, it should also have been counted as an "extraordinary FU-organ".
We believe the explanation is much easier. When the HUANGDI NEIJING was compiled, there were probably two or more older manuscripts from which the authors cited, some describing the gallbladder as FU-organ, other ones as "extraordinary FU-organ". And as the authors did not know which was the authentic statement they kept them both. Maybe they hoped that this question might be decided later ... not knowing that no one afterwards would have courage or competence to do so.
Or ist there any better explanation?
Some more organs: well known, but forgotten. - There are more questions connected with this strange category of QIHENGZHI FU. Several organs, although surely known at this time, were forgotten again, even in this collection of structures without clear function. Forgotten was the deplorable XINBAO, whose only purpose seemed to be to obtain symmetry in the acupuncture system. And if the uterus was integrated, the logical question is: Why not the female breast, giving milk to the babies? Why, again, not the testicles and the penis? And why did no one discover that pancreas and spleen were two different organs?
Do the JINGLUO belong to the "extraordinary FU organs"? Did they mean arteries and veins? - It is obvious that all the organs or tissues in the group of “extraordinary FU organs” meant structures which could be clearly seen and identified when a corpse was cut open (for example in a battle). So, what about the "vessels"? MAI stands for "channels and vessels, passages through which QI and Blood circulates". Apparently, the creators of ancient TCM considered the JINGLUO as structures clearly visible in the corpse. But the structures to be found 2000 years ago must have been the same as today. Which would mean (not really surprising): When the ancients spoke of JINGLUO, JINGMAI or LUOMAI, they meant arteries and veins.
There is another aspect confirming this. Recently published Chinese books, when dealing with pulse taking, state that “CUNKOU is located on the pulsation of the lung meridian whre QI and blood in the lung meridian flows by.” In other words: At the CUNKOU position, the “Lung Meridian” is identical with the radial artery. So we see reasons to suppose that the whole JINGLUO concept started with celarly felt arteries, but became speculative when describing regions where the arteries could not be felt.
If this is true, any hope that some day a new anatomical structure might be found which confirms the supposed course oft the JINGLUO should be given up.
Or ist there really anyone in the world still hoping that some day an anatomical equivalent of the JINGLUO might be found?
A different spectrum of diseases: Which consequences for TCM theory and TCM teaching? - As stated above, the ancient doctor was usually called in severe or dangerous cases. So we should suppose that most of the conditions mentioned in books like SHANGHANLUN meant such severe conditions. Nowadays, these diseases are treated by modern medicine, at least in the initial stage. As a result, the spectrum of pathological conditions being treated by TCM has changed deeply.
Acupuncture in modern China treats mainly pain syndromes, arthritis, head ache and neurological diseases including paralysis and hemiplegia. In Western countries, strangely enough, this spectrum is broader, including allergies and many functional and psychosomatic conditions. TCM pharmacology today has a wide range of applications "strengthening" the body and its resistance to pathological influences. It is very useful in many chronic diseases, and it is often (as is acupuncture) able to ease side effects of modern therapies, e.g. increasing appetite and wellness under chemotherapy or radiation therapy. Thus, the spectrum of diseases is very different from the situation in the past.
We think that the changed situation of TCM should be reflected in TCM theory. We have to ask: Which of the old diagnostic criteria and which of the old syndrome patterns are still relevant today? Which ones not?
And there is another question: Do we have to establish a special etiopathology for functional and psychosomatic conditions?
Talking about hypertension without mentioning blood pressure. - In some aspects, the actual situation of TCM is rather schizophrenic. On one hand, every acupuncture book describes the positions of the acupoints mentioning bones, muscles, nerves, arteries, veins or inner organs. But most of this knowledge is switched off when the same authors deal with etiopathology, diagnostics and therapy. The result are TCM books which talk about hypertension without mentioning blood pressure, about bronchial asthma without mentioning allergic reactions, about dysmennorrhea without mentioning hormones, or about stomach ulcer without mentioning acid production. But this is a childish hide-and-seek. And we think this attitude is by no means "traditional", because never in the history of TCM did doctors or teachers intentionally switch off parts of their own knowledge.
For anyone dealing with hypertension it is natural to ask: Is it useful to describe this condition in traditional terms? How can we do this, considering clinical reality, and integrating as much as possible of our modern knowledge?
To answer such questions, it is not enough to state that hypertension was called XUANYUN by the ancient doctors. First, this is not correct, because XUANYUN (dizziness) may result from hypotension as well. Second, the teacher shouldn't be content just to name some ancient term or explanation, but use his own brain and make his explanation as reasonable as possible. Is hypertension always a YANG condition? Always a SHI condition? BIAO or LI? Hot or cold? And if it is a SHI condition, how can it remain for years without becoming a XU condition? Is there a relationship between blood pressure and certain traditional symptoms?
Again, the annoying thing is not the lack of answers, but the lack of questions.
Is it useful to explain Apoplexy as "ZHONG FENG"? - As stated above, there are still diseases which modern medicine can neither cure nor explain. But there are many conditions which it explains very well. One of them is apoplexy: A critical condition of the brain, caused by a loss of oxygen supply due to a ruptured or blocked vessel. As a result, the respective brain areas do not function correctly, causing neurological defects like hemiplegia.
Although a similar term ("Stroke") is still existing in Western popular medicine, we don't see any advantage in speaking of ZHONGFENG ("wind stroke"), which implies, for example, that the symptoms start from the outside, only afterwards entering the inside, and so on. Neither the etiopathology nor the syndrome description of ZHONGFENG seem to add any relevant aspects, if comparing it with the scientific explanation. So we think that in a case like this one the TCM description is useless, as well as in a majority of infectious diseases, including malaria.
Even in these cases TCM methods can often be helpful. But this doesn't mean that the traditional explanation is helpful, too. If it really is, this has to be proved in each case, because the patient needs not only the best possible treatment, but also the best possible explanation. The only aspect that matters should be the patient's health, not the preservation of certain ideas. And the correct description of his disease helps the patient to regain his health.
So we think that the use of traditional syndrome descriptions has to be thoroughly reconsidered, at least if we want to use TCM methods in Western countries. Or does anyone believe that the TCM description is useful even in cases like apoplexy or malaria?
"Organ Clock", Chronobiology, ZIWULIUZHU (1). - The HUANGDI NEIJING is full of chronobiological statements. There is the theory of 7 x 7-year-cycles in women and 8 x 8-years-cycles in men, which makes it hard to explain why women generally become older than men. There are all these statements about certain conditions getting worse in summer and better in autumn, and if not better in autumn resulting in death in winter, and so on. There are suggestions which JINGLUO or which point category should be needled on which day in summer or winter, culminating in the ZIWULIUZHI theory. If these concepts really had any foundation in the changes of climate according to the seasons, there should be a difference between hot and cold regions. But there aren't any, so we consider most of these concepts clinically irrelevant and purely speculative.
Moreover, there is a chronobiological concept which is called "Organuhr" ("Organ Clock") in German. It states that the 12 organs (or their corresponding "Meridians") each should have a "maximum flow of QI" at a certain time, for example "Liver" from 1-3 A.M, "Lung" from 3-5 A.M. and so on, following the triple cycle of the "Meridians". The 12 "organs" are supposed to form a circle, so that opposite to the "maximum" organ or "meridian" there is the organ supposed to have its "QI minimum". A symptom occurring at a certain time might be caused by hyperfunction of the "QI maximum" organ or by hypofunction of the opposite organ. E.g., a symptom between 7-9 A.M. might be caused by hyperactivity of the Stomach or by hypofunction of the "Pericardium".
This concept is missing in most Chinese books for foreigners, maybe because of its contradiction to the "50 cycles of QI" a day also stated in the HUANGDI NEIJING. But there might be another reason: If we took this concept serious, the logical consequence would be not to needle any disease at any time. Maybe we should really needle a lung disease early in the morning and gallbladder pain late at night. But we cannot expect the doctors and nurses to work at these hours, so it can't be done.
The question is: are thes concepts neglected because they are speculative and useless? Ore only because the circumstances do not allow doctors to make full use of these chronobiological aspect?
"Organ Clock", Chronobiology, ZIWULIUZHU (2). - The concept of the so-called "Organ Clock" is presented in many Western TCM books. And many TCM friends in our countries are happy that some of its aspects might have a clinical foundation. For example, attacks of bronchial asthma frequently occur between 3-5 A.M. But again, a coincidence in part is no proof of the whole. It doesn't make sense that basic organs like "Liver", "Spleen" or "Kidney" should have the same two hours of "energetic maximum" as secondary organs like Bladder and Gallbladder, or even a non-existent organ like "Pericardium". It is rather unlikely that a heart attack at 11 A.M. might be caused (apart from hyperfunction of the "Heart") by hypofunction of the Gallbladder. It is unlikely that an asthma attack at 4 A.M. might be caused by hypofunction of the Urinary Bladder, or a stomach symptom at 8 A.M. possibly caused by "hypofunction of the Pericardium". So we are convinced that this system, too, is mainly speculative.
This may answer one question, but only to raise another one: Are there really no chronobiological aspects which should be considered when using acupuncture or herbs?
In fact, we believe that there are such aspects. But we think they cannot be revealed in a simple system like the "Organ Clock" but have to be checked in systematic tests. In other words: We are afraid that speculative concepts like ZIWULIUZHU or the "Organ Clock" have two negative effects. First, most of them are probably clinically useless. Second, and making things worse: The existence of these systems prevents or harms the research of these chronobiological aspects which really might be clinically helpful.
To believe that a certain acupoint might be "open" on May 1st, but "closed" on May 2nd is ridiculous. But the question if acupuncture has a better result in the evening or in the morning or vice versa is not yet sufficiently researched. Neither is the question which conditions should be preferably needled at which time of the day.
Urban society, heating, air conditioning. - HUANGDI NEIJING and SHANGHANLUN don't care about the differences between urban and agricultural society. But it seems logical that most of the "climatic influences" lose their importance in an environment of heating in winter and air conditioning in summer. The natural effect of "Dryness" - that people don't drink enough and don't have enough water for hygienic purposes - vanishes if everybody, at least in the cities, has access to running water. Modern TCM should think about the consequences. Or, if anyone is taking these concepts seriously, there should be some discussion about them.
The limited amount of JING and semen. - This is a TCM concept which still has a great influence upon Chinese thinking. "SHEN CANG JING" includes the notion that there is a limited amount of "Essence" stored in the kidney(s), becoming less and less each time the male has an ejaculation, like coins in a money bag which are gone forever once the bag is empty.
The results of this concept are partly good and partly doubtful. That the male shouldn't be too eager to reach orgasm and ejaculation is indeed good for the relation between husband and wife. However, the TCM panic concerning "wet dreams" and spermatorrhea seems exaggerated. From the point of view of modern physiology it is clearly wrong, because the ability of the testicles to produce semen is not reduced by a regular sexual life, but prolonged.
According to medical reason, this concept is clearly obsolete. But did or do the old and reactionary professors in China’s “TCM universities” ever have the courage to tell anything written in the HUANGDI NEIJING obsolete?
What about QI and Blood? - Do the Chinese TCM experts really believe there is "QI and BLOOD" flowing in other vessels than arteries, veins and lymph vessels? - This is what some TCM books seem to tell us. But do the authors really believe what they are writing? We doubt it.
What about "body fluids", "phlegm" etc.? - The "body fluids" play an important part in TCM theory and in the explanation of diseases. But most of these descriptions don't sound very convincing. We doubt if these concepts of fluids and QI being transformed and going up or down or being blocked and turning into pathogenic "phlegm" have been really based upon clinical observation. And we doubt if they are really necessary for the use of acupuncture or other TCM methods.
But again, there might be some reasons why these elements cannot be dismissed - and we’d really like to know them.
What about "Blood Stasis" (XUE YU) and "QI Stagnation" (QI ZHI)? - Like many other terms, "Blood Stasis" and "QI Stagnation" are frequently used but seldom explained. Anyone working in the field of TCM seems to know what they mean. But as we have proved already that we have been unable and inattentive pupils, we might as well ask another stupid question. Please, dear teachers, could you tell us once again: What in heaven do these terms really mean? Is this real Blood and substantial QI being obstructed somewhere? But where? Inside or outside some vessels? In front of or behind a bone or a joint? Under the skin? Between some muscles? Inside or outside an inner organ? And if obstructed in some vessels: Does this Blood or QI just move slower, or not at all? So that the obstructed area becomes bigger and bigger? Resulting in thrombosis? Or even in necrosis of some tissue? Could this "Blood stasis" or "stagnated QI" be discovered by means of sonography or MRT? Which forces keep it from moving? And where does this "Blood" or QI go when treated - back into the vessels? Disappearing through the hole of an acupuncture needle? Just spreading around? Or being transformed into something else?
Of course, this is all described in the books. But maybe there is someone who can explain it in a way that even stupid pupils like us can understand.
TCM and Feudalism. - When the HUANGDI NEIJING was written, feudalism seemed as natural as sun and moon, rain and wind. So the ancient author(s) of the HUANGDI NEIJING believed that body functions followed the same principles as society. Today, however, we know that society as well as nature functions like networks. There should be some consequences even for TCM theory. But to admit these consequences, we need courage, controversy, discussion - and daoes anyone believe that “courage” might be found among China’s TCM professors?
What about TCM elements not mentioned in the HUANGDI NEIJING? - To understand the actual role of the HUANGDI NEIJING in TCM history is not easy. Sometimes it seems to be considered as a holy bible, even in aspects not conform to common sense. Sometimes the position of the HUANGDI NEIJING seems reasonable, but TCM prefers to ignore it.
Pulse taking according to the HUANGDI NEIJING should not be done at the radial artery only, but at different parts of the body, including the carotid artery. This sounds reasonable even today, but in later times TCM preferred to restrict pulse taking to the CUNKOU position, and modern TCM still sticks to this habit.
Other elements like the "8 influent points" (BA HUIXUE) are not mentioned in the HUANGDI NEIJING; nevertheless they became part of the TCM theory.
How can we explain this? Has TCM in its history just been a huge bag, where everybody could put anything into it he wanted, and where certain things sometimes were forgotten, but never definitely thrown away? (Yes, of course, but maybe there is someone objecting.
TCM and the absence of local diseases. - One thing in TCM which we think should be corrected is admitting that there is something like a limited local happening. Take tennis elbow, for example. Most doctors agree that this is usually caused by overstrain, combining pushing and turning strain, resulting in local irritation and inflammation. Unfortunately, TCM theory doesn't seem to acknowledge something like a local happening. But can we apply the traditional etiology of NEIYIN (caused by emotions) or WAIYIN (caused by climatic influences) in this case? We don't think so.
When treating this disease with acupuncture, most TCM doctors treat it locally, using mostly local acupoints and ASHI points. But when the books try to give a theoretical explanation, they still put this ailment into the category of BI syndrome, thus making it a systemic thing. As a consequence, we should expect some special kind of pulse as well as some hints for tongue diagnosis ... we don't believe it. We never found a special pulse or tongue image indicating tennis elbow. - Or did anyone find it, prove it, publish it?
TCM and the self-healing body. - Sometimes we are amazed about how much some TCM friends overestimate the effect of their doing. There are many case reports like the following: A patient with some pain or disease, the doctor using some herbs or needles, and the pain disappears. Then, the doctor is happy and writes a case report, taking what happened as a proof of what he did. We don't remember having read a Chinese case report considering the question if in fact it hadn't been the therapy which made some pain disappear but just the self-healing power of the body.
What should be done if you catch a cold? In Western countries, we say: Take some pills, and you'll be okay in seven days - take none, and you'll be okay in a week. Sometimes it is the wisdom of the doctor to give the body time to heal itself. So we really think TCM should pay more attention to this aspect.
Things disappearing by themselves. - Quite different from China, in Western countries acupuncture is often used for psychological or psychosomatic cases. In certain TCM books we find case reports like the following: A boy is unable or unwilling to speak after being scolded by the parents. The doctor sticks some needles with no result, so next time he switches to different acupoints, and in the evening, the boy starts speaking again. From now on, the doctor is convinced this was the effect of his point combination ... which we think is quite ridiculous.
Some things disappear by themselves. And if TCM were really as self-confident as it should be, it wouldn't have to tell such doubtful success stories. Real confidence leads to sound judgment and modesty, and it gives courage to speak frankly about one's possibilities, but also one's limitations.
TCM, psychology and the QI QING (seven emotions). - Defining excess or imbalance of emotions as the "inner causes" (NEIYIN) of disease is part of TCM's "holism" which makes it so popular among Western friends of alternative medicine. However, what sounds so amazing in theory seems to be rarely used in clinic. When we analyzed the clinical parts of 35 Chinese acupuncture books we found that the emotional aspect was nearly non-existent. Even in case of bronchial asthma, which according to modern understanding has an important psychosomatic component, the emotional aspect was hardly ever mentioned.
And reading about "depression" in these books sometimes made us depressive. In Western countries, this state of mind is quite frequent and threatening. In Chinese books, it is usually described either as "Hysteria" (ZANG ZAO), "Melancholia" (YU ZHENG), "Schizophrenia" or "Manic-Depressive Disorder" (DIAN KUANG). And the books explain: "There are stagnant liver qi and accumulated fluid due to impaired transportation, which turns into phlegm. Then the phlegm pervertedly goes upward to invade the mind" ("Chinese Acupuncture and Moxibustion") ... Well, well.
These lines are typical: The emotions, if mentioned at all, are immediately changed into some somatic process. As a result, the treatment is strictly somatic. Nothing about personal conflicts or social stress ... so that we ask ourselves: Could it be that we praised our TCM teachers too emphatically and too early? With the result that they think it unnecessary to study a little bit of modern psychology?
Which is the real clinical value of the emotions considered as NEIYIN? - Analyzing these 35 Chinese acupuncture books brought some unexpected findings. For example, in clinic nobody seems to care about the association of heart and joy, spleen and sorrow, lung and sadness, kidney and fright. Again, theory and therapy are two different worlds. In the clinical parts of these books, any emotional disturbance seems to affect the liver - and that's it.
Now, we have to admit that these seven emotions as "inner causes" (NEIYIN) never made us happy. For example, we seldom met a patient whose heart disease might have been the consequence of too much joy. And in general, we found the association of organs and emotions not convincing. Some Western TCM friends enthusiastically point at the relationship between sadness and tuberculosis which has been known long ago. But again, a coincidence in one part is no proof the whole. Even in case of sadness it seems evident that sadmess affects not only the lung, but appetite ("Spleen") and general vitality ("Kidney") as well. The same in case of sorrow, fright and anger: Each of them affecting all the inner organs, not just one.
Then, there is another question: Some of the most powerful emotions are missing in this system. What about love and hate? Envy and jealousy? Greed and ambition?
As usual, our TCM books not only give no answer, but don't even see the question. But we have to insist: how useful and applicable is such an arbitrary and fragmentary system in everyday clinic?
Moreover, modern etiology and pathology have revealed quite a lot of real NEIYIN. We know about genetic defects, immunopathy, autoimmune reactions, hormonal disorders, degeneration of cells and tissues, neoplasms, persisting microbes, and many more. All these are real "inner causes". And the question is: How can we make full use of all this knowledge when using TCM methods? Why should we just stick to these incomplete emotions - for no reason but to preserve the system?
Which is the clinical value of the "climatic influences" (LIU YIN)? - There can be no doubt that 2000 years ago people were much more subject to climatic influences than nowadays. Though there were some means for the rich, even the emperor suffered more from heat in summer and cold in winter than an average Shanghai businessman today in his air-conditioned car and office. When there was no rain, only the rich could buy enough water, so "dryness" really became an important factor. And when there were weeks of rain, the water was everywhere.
Today we have heating, air conditioning, canalization and running water. Naturally, this change of environment should affect importance and usability of the "climatic influences", which were considered the most important "exogenous pathogenic influences" (WAI YIN). Unfortunately, we read nothing about this aspect in our TCM books.
If we need a new evaluation of the LIU YIN in present China, then even more in foreign countries. If these climatic influences were really considered essential, doctors in cold or moderate regions should have to deal with diseases quite different from these in hot regions. But is this true? Even in China?
Again, this question can be answered easily: Just compare one year's TCM patients in a Harbin hospital with these in a Guangzhou hospital and see how much of their respective diseases were really caused by climatic influences.
The HUANGDI NEINJING states that “rheumatism” were more frequent in the southern parts of China than in the north. We have some doubts about this, so we’d like to ask you about the statistics in your hospital.
Concerning foreign countries, we’d like to ask the Chinese doctors who have been working there: What about their experiences? Did they find differences concerning diseases due to climatic influences?
How can TCM develop further without development of the theoretical foundations? - At present, we have a rather disparate situation. Our TCM books present a theory which in wide parts is not used at all. At the same time, there are clinical methods like ear acupuncture or other microsystems which are widely used but have no foundation in TCM theory. Besides, we have an environment of modern medicine which permanently interferes with TCM thinking, but of which most TCM teachers don't like to speak. TCM seems to flourish, if we think of it as a merchandise product. But TCM's spirit is in a crisis. In parts, we Westerners are guilty of this crisis, too. For decades, we praised TCM so loudly that tendencies in China to reconsider TCM theory were entirely stopped - at least in front of the foreign TCM customers.
But the actual situation is far from satisfying. Any responsible teacher - no matter if Chinese or foreign - has the duty to teach theory and practice as coherent as possible. What is medical theory, after all? It should be foundation and essence of clinical practice, nothing else. If our TCM reality gets us constantly switching between modern and traditional medicine, this kind of switching must sooner or later become part of our theory. A responsible teacher shouldn't teach statements of the classics which he himself doesn't use in clinical practice. Even in China, acupuncture training courses should not teach points or point categories which are hardly ever used in clinic. (Neither should you check the respective knowledge in your examinations). But did China’s TCM professor ever care about reality?
Clinical value of the classics. - Every true TCM friend must hope that all the syndromes and clinical cases described in the classics are still clinically relevant today. However, this is no realistic hope. The majority of acute diseases like plague, cholera, typhoid, smallpox etc. can be prevented or cured, as well as chronic diseases like leprosy, tuberculosis and many more. So, the question about the clinical value of the classics has to be answered not ideologically, but statistically: How many of the syndromes described in the HUANGDI NEIJING or SHANGHANLUN have been recently found in Chinese hospitals, comprising which percentage of all patients?
Shortcomings of the classics. - Why not admit that ancient Chinese charts of the body and its organs were full of errors? The concepts in Western countries at this time weren't any better. Or take all these disease descriptions of the HUANGDI NEIJING: getting worse in winter or better in summer, and if not better in summer, patient will die in autumn ... most of it clinically not useful any more (if it has ever been).
Some TCM friends still believe that some day all of these apparently speculative elements will be proved as being correct or at least useful, even in terms of modern science. We don't share this optimism. We think it's time to admit that the HUANGDI NEIJING is full of statements which have may have been a marvelous step forward two thousand years ago, but are just a relic of medical history today.
Which parts of TCM theory are really essential? - If only considering China, we might leave the TCM system without any substantial change and say: Well, that's tradition - all these theoretical foundations, though doubtful and arbitrary in many aspects, are just what makes traditional medicine part of a "cultural heritage".
This is true. But as we said above: We, doctors in foreign countries, have no obligation towards TCM. We only have an obligation towards our patients and our students. So we should not only have the right to ask fundamental questions, but even the duty. And this is a fundamental question indeed: How much of the theoretical foundation of TCM, incoherent and contradictory as it is, is really necessary to use acupuncture, Chinese herbs or other TCM methods?
Again, we believe that this question cannot be answered ideologically. We can't say in general: "We need it all" or "We don't need it at all". Maybe, we shouldn't even ask: "How much is necessary?" But the question must be: "Which parts of the TCM theory are definitely useful?"
And the answer has to be found pragmatically and in detail. Is it necessary or useful, to define the task of the ZANG organs (or maybe organ systems) as "storing JINGQI (essence)"? We doubt, but we are open for the opinion of experts who know better.
Is it useful or necessary to teach the existence of a strange organ named XINBAO (Pericardium) for no other purpose but to make the acupuncture system symmetrical?
These questions have to be asked in detail, concerning each and every aspect of TCM theory.
Do YIN-YANG and WU XING have equal philosophical and clinical value? - For more than 2500 years, the concept of YIN and YANG has been part of Chinese thinking. At first sight, the concept of the "5 elements" ("5 phases", WU XING) doesn't seem to be much younger. But if you ask some Chinese if they think that the WU XING concept is of equal rank and importance as YIN and YANG, the majority won't agree. So, if we ask which parts of TCM theory are essential and which ones not, we cannot avoid this question: Do the YIN-YANG concept and the WU XING concept really have equal rank and value?
Even the applications of the YIN-YANG concept are sometimes doubtful. Just because the Chinese, when thinking of the earth, are accustomed to look south (different from the Westerners, who are looking north), they see the sun rising at the left, thus making the left side YANG and the right one YIN, although the majority of the Chinese are right-handed, too. Even more doubtful is the association of the front side as YIN and the back side as YANG. Still, we consider the concept of YIN and YANG as a fundamental discovery, applicable to philosophy and society as well as to nature, science and medicine.
The theory of the five phases (WU XING), however, seems to be just one speculative system among several others - sometimes interesting, sometimes amusing, but often useless or even annoying. As a clinical guideline, it still has to be proved, if only considering the necessities of common sense.
So, does anybody believe that YIN-YANG and WU XING have equal philosophical rank and equal clinical value? That the WU XING cannot be eliminated from TCM theory without making the whole system collapse?
Or could we agree about the fact that only the YIN-YANG concept is vital for TCM theory, including the BA GANG as diagnostic criteria, but not the WU XING doctrine and all its implications?
ZANG-FU, YIN-YANG and WU XING: How could they possibly find it? - This simple question is always a useful tool. How could the ancients possibly find out that the Spleen was related to "Earth", and the Lung related to "Metal"? How could they possibly find that "Spleen" had a nourishing effect upon the "Lung" according to the SHENG-Cycle, and a controlling effect upon the "Kidney" according to the KE-Cycle? We really see no way.
It must have been the other way round. First, there was the philosophical concept. Then, some literate men (probably not the practitioners offering medical service in streets and markets) were sitting at their desks, convinced that the same principles like in philosophy should be applied to the human body. They did not know much about the body and how it worked, but a lot about YIN and YANG and the WU XING. For thousands of years peasants and eunuchs in China had known that the organs responsible for reproduction were the testicles. But these wise men at their desks either did not know it or did not like to mention it. So they preferred to make the "Kidney" responsible for this noble task, although no peasant or emperor ever thought of castration by means of taking away the kidney.
The results of these wise men's thinking were in many aspects arbitrary. If classifying organs according to "solid" and "hollow", it was not correct to consider heart and lung as "solid". If classifying according to "storing" and "transporting", they were wrong again, because the only organs really "storing" should have been gallbladder and bladder. No matter where they started, the organ most YANG of all should have been the heart, and second the lung, because the position of both organs is the highest, and both of them are in permanent movement, especially the heart.
If applying YIN and YANG to the human body had to be arbitrary in many ways, the classifications according to the WU XING was even more. Why was the "Lung" classified as "Metal" and related to "Dryness"? It would have been much more logical to see a relationship between the ever-breathing Lung and the ever-blowing wind. How could the ancients possibly find that it was the Liver, instead, being related to Wood and Wind? How could they possibly find that the Heart "nourishes the Spleen and controls the Lung", that the Spleen "nourishes the Lung and controls the Kidney", and that the Kidney "nourishes the Liver and controls the Heart"?
We think that these classifications had no clinical base at all, but were the result of philosophical speculation. Why did the ancients think that each of these organs "nourished" one and only one ZANG organ, as well as it "controlled" one and only one ZANG organ? Surely not by means of clinical observation, but according to what they thought were the principles of the WU XING theory.
So, we ask our Chinese friends: Which is today, according to your point of view, the clinical value of the classification of the "ZANG organs" according to the WU XING, including all these endless "systematical correspondences" concerning directions, seasons, grains, fruit, tastes, sounds, numbers etc.?
Progress, Science and the Elimination of Obsolete Concepts. - There are many TCM experts trying to prove that TCM always has been "scientific" in some way. They forget that this term can never be applied to some knowledge or concept as such, but only to the way we deal with it. First there is a problem, then there is a concept to solve it. If it turns out useful, it is used, but if it cannot answer new questions, it has to be replaced by a better concept. This is called "progress". Progress obtained by means of scientific methods - observing, comparing, developing a hypothesis and checking it, mainly by experimental study - is called "science". But there can be neither "progress" nor "science" without eliminating antiquated or useless concepts.
This, however, has been and is still one basic problem of TCM: It has never been able to get definitely rid of obsolete concepts. Any concept ever presented by an important TCM authority can return at any time, even if it has not been used for centuries.
Maybe, this is "culture", indeed. But to use TCM in Western countries, we'd prefer to eliminate those aspects which are not conform to modern knowledge - unless there is evidence that they are absolutely necessary for the proper use of TCM therapy.
So, ist there any possibility that certain ancient ideas might be eliminated from modern TCM? Or do are all these concepts to be considered as part of the same tradition, so that they should remain in TCM thinking forever?
Which parts of TCM theory could be replaced by modern concepts? - Of course, we should never propose to do this in China, where TCM must remain without substantial change forever because it is part of the "cultural heritage". But in our countries, it isn't. Although we love China and cherish her rich culture, our reasons for dealing with TCM are not cultural, but medical. It is our "culture" to check everything again and again, and reject it if we don't find it useful. As there are very few Western doctors believing in the existence of the "Meridians", we would be glad if the concept of the JINGLUO could be replaced by nerves, arteries or veins, but we know that this hope might be in vain. There are very few people believing that herbs could have a connection not only to certain organs or functions, but also to certain "Meridians" (always considering the question "How could they possibly find this by clinical observation?"). Very few believe that the human organs might do us the favor to influence each other exactly the way the WU XING concept suggests, just because it is such a nice theory. So we'd like to get rid of this whole concept in medicine.
Reading ancient descriptions like "bone steaming" (GU ZHENG), we often get the feeling: Interesting observation, ridiculous explanation. So, how can we possibly get rid of such explanations, maintaining the value of the observations?
Unfortunately, there was no Li Shizhen in TCM theory. - TCM pharmacology was lucky: Li Shizhen had enough courage and authority to criticize errors and correct them. Other parts of TCM were not so lucky. There was no one with enough authority to decide that the gallbladder should be either considered as a FU organ or a QIHENGZHIFU organ. In acupuncture, no one had the authority to declare that YINTANG, located exactly on the DU channel, definitely had to be considered as a regular point of this channel. No one had the authority to make clear that the concept of the "5 SHU points", always starting from the distal extremities, was a contradiction to the concept of QI and Blood in the 12 regular JINGMAI flowing in a triple circle, so that one of these two concepts had to be given up. No one had the authority to make clear that the idea of turning a needle to the right meaning BU and to the left meaning XIE was absurd, because "to the left" on one side of the body means turning towards the outside, whilst on the other side towards the center. TCM theory is full of such contradictions, and the HUANGDI NEIJING is full of purely speculative concepts. But even today many of these things are mentioned in the books without being properly discussed.
To this day, we haven't met anyone able to judge the condition of Heart and Small Intestine, Liver and Gallbladder, Kidney and Urinary Bladder separately at the Inch, Bar and Cubit position of the left hand, and of Lung and Large Intestine, Spleen and Stomach, Kidney and Urinary Bladder at Inch, Bar and Cubit of the right hand. Nevertheless, it is printed in the books. Some of these books even today declare that it's not the second kidney to be felt at the Cubit position of the right hand, but "Vital Gate" (MINGMEN). Nobody believes it; nevertheless it is printed in the books. Does this mean that modern TCM isn't able to substantial discussion any more, and even less to substantial change?
If this would concern only China, we might say: Well, if they think it okay to teach a theory which is mostly neglected in clinical practice, that's their affair. But things are not so easy anymore. TCM has become an important part of world medicine. So the world has a right to ask questions and hope for answers. In Western countries, we hope to integrate TCM therapy into the normal medical curriculum some day. But if we can't even get rid of the most obvious contradictions and absurdities, we'll only be laughed at.
We do hope that our Chinese friends might help us to get rid of some of the most severe contradictions which make it difficult to teach TCM to modern medical students.