Essential traditional Chinese medicine: Western scientific medicine
perspective*

E C L Yu 余秋良

H K Pract 20 0 1;2 3 :2 0 -2 7

Summary

An attempt has been made to briefl y describe the framework of Tradi tional Chinese Medicine and i ts original intent and meaning. Thi s has been contr asted wi th the demands of current scienti fic medicine while provi sions to understand its concepts by an expanded pl atform have b ee n i l l us t r a te d . T h e ph y si c al s i gn s, di ag n os ti c techniques as well as the principles of Chinese Medicine, when further defined and formal i sed can be an asset to di agnosis and treatment in mainstream medicine.

摘要

本文描繪了傳統中醫學的框架，簡述了其實質和 涵意。並與現代西方醫學的要求相互對比，在拓展的 層面來解釋中醫學的概念。如果能夠將中醫學的臨床 病徵，診斷方法及治療原則更準確的界定和規範化， 則可以增加主流醫學在診斷治療的寶貴資產。

There is a wide gap between Traditional Chinese Medicine (TCM) and Western Scientific Medicine (WSM), even in conceptual framework,terminology, and practical clinical methods. In an earlier article, why they evolved differently was addressed by comparing the differences of the two cultures as these shaped their own medical worlds in concept formation, instrumentation, knowledge acquisition methods, practice behaviour, and evaluation standards. ¹ All these wide gaps were the results of the long history of separate development between Eastern and Western thoughts and philosophy. In essence,WSM culture promoted science,its methodology, and the use of scientific technology to identify and treat diseases. On the other hand, the culture that embodied TCM favoured a perfectionistic approach, viewed the universe and body philosophically and developed inductive tools and methodswith such principlesto guide restoring the total balance of the body.

In this era, when TCM practice is coming out of its veil and obscurity, workersin mainstream medicine may like to know how the wa y that TCM rea ches its therapeutic goals can be justified in current WSM perspective. No easy job, and depending on the amount of understanding and experience with TCM as well as WSM,the gap unfilled by adequate work and efforts could raisemuch difficulty for different individuals. This article is an attempt to guide the initiated readers to view TCM along a path the author experienced,so that hopefully they will be able to see that medicine can be practised with both TCM and WSM like resources, from left and right pockets, each with their strengths and weaknesses.

A different way to practise medicine

TCM started in the days before science. While current workers in medicine emphasise the need of a scientific basis, TCM emphasis was based on another world view the Chinese then treasured. The scholars of China, even Confucius, prioritised the basis offered by Yijing (易經), the Book of Cha nges. Simp ly, as everything in the universe is changing,Yijing depicts a mechanism to describe such patterns of changes. The origin of such principles hasbeen attributed to Fu Xi (伏 羲), while metaphorical and mathematical methods to evaluate its applications in estimating directions and changes have been developed by later workers.

TCM developed in such an environment. In the days of Shen Nong (神農), theDivine Farmer, agriculture was dominant, and people began to systematically document plants which were toxic, and medicinal effects were identified and classified under such framework. The classic Huangdi Neijing (黃帝內經) using a dialogue between Huangdi and QiBo, described naturalistic observations of life and ways of living, and applied these to man. Though not a mature practical clinical method, it founded the roots of TCM: the integral perspective, application of yin-yang and 5-phases principles in pathogenesis, and a framework for diagnostic and therapeutic methods. Debates during the wisdom boom around the era of Warring States established the philosophy and methodology of knowledge acquisition. Later in the Eastern Han Dynasty, in the Discussion of Cold-induced and Miscellaneous Diseases (傷寒雜病論), Zhang Zhonging developed a systematic practical clinical method which dominated the treatment of febrile illnesses for centuries.

From these and later developments, TCM used its basic framework as an evaluational tool (Figure 1). Throughout the centuries, the framework allowed accumulation of clinical observations. Its emphasis on mechanism of changes probably led those early workers to develop formats and intelligence instruments that describe functional changes better. Indeed, it may be said that TCM often is more useful than WSMto describe and categorise functional problems in diseases.

The TCM framework

Huangdi Neijing described man and his functional adaptation a nd reactions to the environment. It emphasised how health and longevity could be improved when the body and mind harmonize with the ways of life according to nature. Projecting from this, it explained how observations of the functional reactions of living things can be a way to observe man in his environment. The TCM framework developed intelligence tools to evaluate. In the framework, the body can be assessed by the 8 states, using opposites: yin-yang, inner and outer, deplete or replete, hot or cold (陰陽表裏寒熱虛實). Furthermore, the pattern of interactions inside the body is taken as similar to the universe and can be assessed in relation to the zang-fu, blood circulation and qi (臟腑氣 血). Important though often under-emphasised, an assessment of the harmony between the body and the environment ismade, where the environment is evaluated in terms of seasonal changes, climate and soil. This framework (Figure 1) became the evaluational tool.

To describe the changes in the universe, the use of characteristics and properties to depict changes had become useful. Thus the universe was described by its yin-yang properties, and there being so many elements that may change, a simplified model with five elements which portray the phases or their functions interacting with each other in a balanced whole was used. It was believed that man would function in that same pattern, and the body needed to achieve that same balance inside in order to achieve balance with the environment.

TCM continued to say more. For example, where could such body framework, apart from balance, derive its energy and momentum. This drove the search for the body stem or core (本). Initially in Neijing, the zang heart was taken as the driver of the body. This probably took it as analogous to the heart-felt feelings that drive the mind and body. The continued search took much discussion and controversy. Finally in the Ming dynasty, the body stem that subserved the basis of the body was taken as coming from two zangs. 2 The zang spleen which essentially means the absorptive and assimilation system provides the energy as it constantly takes in. The zang kidney, likened to the neuroendocrinal axis, gives the body the born energy capital that supports its life.

The current demands from scientific medicine

So much for the TCM framework. The worldview framed by science demands validity to any such reality to be understood on a more solid basis. Scientific medicine has evolved far in the last few centuries and has gone deeper into understanding of cellular biochemistry and physiology, cellular pathology including cancer, embryology and developmental science, and others. The most dramatic development of WSM in the last half a century has been supported by the vast and extensive development ofscience and technology. Whatscience has developed, medicine has used to its advantage. The hot topic may have been laser technology then, or DNA techniques now, or at another time another scientific development. These have added on power to look into the body with more and more specific details.

Such biomedical worldview has created wider and wider gaps with the naturalistic observations of everyday life, and even more so with the evaluational perspective of TCM. It may be presumptuous to call TCM scientific. However, this once important methodology can not be wholly discounted by modern science. For thosewho rely on nothing except the biomedical approach as scientific medicine, much work would be needed to transform the concepts and basis behind TCM into its frame.

Provision of understanding by other scientific developments in medicine

While the above went on, WSM developed into other streams. Some of these developments might lend strength to bridge the gap,particularly towardslooking at the body as an integral unit. In social medicine, man is seen as interactive with his environment including social, poli tical, e conomica l and te chnical issues. The understanding is that a better social environment helps health. There are studies to show how the body and the mind are linked to such social phenomena. For example, it was found that a socially isolated person compared to one well supported socially has a higher blood cortisol level ³ analogous to a higher idling machine speed to cater for life. An equivalent thinking may be used in TCM to similarly view the core or state of body reacting to its physical environment. The overexposure of glucocorticoids and catecholamines meant for short term mobilisation of energy, when extended over time, can produce myopathy, fatigue. ⁴ In fact, the development of psychological medicine ⁵ is also towards these directions. Identification of the determinants of positive outcomes in individuals at risk has been useful to uncover healthprotecting factors, both constitutional or intrinsic (biologically based) or extrinsic (social-contextual). ⁶

The body and environment in TCM

While WSM studied mostly the chemical and biological environment around the body, the TCM observations and emphasis were on the physical and bio-ecological environment. It thus took a careful look at the body reactions to heat and humidity and other climatic changes. It even looked at hair changes and skin changes with environment. Reviewing the use of TCM framework as an intelligence instrument to assess the body state and changes, it can be noted that the assessment is on such body ties with the physical environment. The idea is to assess how much a body that is maladapted to climatic changes would have poorer function similar to the cortisol example above. While WSM used cortisol and other experiments to document validity, TCM essentially tried to assess the body core and used other experiential observations to justify itself.

The scenario and clinical methods developed by Zhang Zhonging is one such example. It derived its heritage from the Neijing observation that after being chilled by a very cold Winter, a person would have febrile illness in Spring. 7 Using the then current clinical methods of pathogenetic classification with 6 major body meridians and aided by the diagnostic modality with assessing the 8 states, the illnesses could be classified and treated accordingly. Examples of treatment methods in TCM would be like: warm the chilled, cool the hot, expel what comes in, etc. As long as t he rig ht me di cin e w it h suc h c ou nte rac ti ve properties could be tailored right, then treatment is likely to be successful.

How such an idea, incomprehensible to the present world, that a body chilled could develop months later a feb rile illne ss now ca lled a viral syndro me or in fect ion , c ould do mina ted TCM in th e p ast is interesting. What seems like simple truth, it took centuries before other TCM workers advocated that there could be a new infliction apart from the winter chill to cause a febrile illness in spring. Thus, it was but not too long ago in Qi ng d ynast y, th at t his observation finally matured and Ye Tianshi developed the other important practical clinical method on febrile illness, on Discussion on Febrile Illnesses (溫熱論), de scr ibin g a mo del of dif fer ent bo dy laye rs or reacting compartments to assess the body reactions to infection.

A note on signs of heat

Excess body heat can be assessed by raised tongue spots (Figure 2). There are many signs (and symptoms) of a hot state including dry furred tongue, crusted lips, and dry scaly skin according to TCM diagnostics in the same patient (Figures 3, 4). Though it may be argued that the association may be pure coincidence, such combination does occur to varying degrees in different patients. Treatment of such patients with the TCM category of drugs against hot states (cold herbs) alleviates the signs (and symptoms) which could otherwise have been there for a long time.

To take this further, many eczematous patients also have such signs of hot states. Attention to this aspect would alleviate their eczema. Combined with other signs and managed accordingly, even psoriasis can be treated. My other dissertation 8 may illustrate how treatment along such principles could help these patients. Signs of hot states in general can be defined, reproducibly identified and treated. It seems to be a physical sign of its own right, not to be ignored, only the interpretation seems out of bounds or without applications for WSM practice.

The diagnostic platform of TCM

It should be understood that TCM assesses the core integral unit of the body, and diseases could be the maladaptations of such. With this framework, TCM evaluates the whole integral body and its reactions to the environment with the 8 states perspective and assessment of the zangfu, blood circulation and qi. It would arrive at an evaluation or diagnosis of the SystemicClues of the body (証) (Figure 5), or the conglomerate evidence of core functional changes. ⁹

Taken together (Figure 7), the “disease” at the centre overlaps issues that the two disciplines are assessing. Along the linear arrow, WSM methods continue to add on factorial analysis of the disease. On top, TCM also assesses the deviations in reactions of the whole body as a form of health disturbance, which may amount to disease production.

A full diagnosis in academic medicine needs to account for pathological diagnosis, symptomatic diagnosis, biomedical diagnosis, cellular diagnosis, and similar definable issues. Now these are defined against tangible issues. TCM could extend this to diagnose body changes related to less tangible issues like weather. For examp le, in WSM, aller gy to chemicals m ay be recognised but not allergy to weather. TCMon the other hand describes the abnormal reactions (analogous to allergy) to weather changes. TCM diagnosis adds to the unfinished spectrum of assessing the body.

The importance to practise academic medicine

What we need with academic medicine is a firm foundation to allow effective and well based decisions. The development of research techniques like double blind studies helps to define effectiveness and what good medicine is. The evolution to use outcome research facilitates TCMdevelopment. Evidenced based medicine is important to show what is necessarily valid to be useful. Not all TCM is necessarily valid and useful, but understanding of the limitations of WSM and the strength of TCM allows further growth of mainstream medicine using both. TCM by itself is a great resource. Scientific efforts used to validate what has been noted to be useful through the ages would be tiring, but careful selection should lead the way to tremendous assets. Documentation helps to lay ground for further development to best utilise the resources. Drug research needs to be done on how TCM herbs are useful to the current understanding of the body and il lness includi ng, cel lular, organ, and immunological changes. However, one should not be blinded by the old habits of WSM and forget to assess scientifically how these also affect the core state. How to evaluate the scientific structure and effectiveness of TCM and the difficulties to do so will be addressed in later articles.

Final remark

It is helpful to understand TCM practice in its own right and in consideration of its assets to WSM. For example, along with the principle of Winter Storage, TCM advocates that helping the asthmatic patient’s body reserve in winter is better than at other times of the year. I have tried using even simple WSM tonics according to tailored counteractive properties assessed by 8 states to help such patients in winter and found that some aged patients suffering from asthmatic attacks throughout the years weremuch relieved for a few years. There are other examples where simple TCM principles helped and guided WSMpractice. While strength and dominance of WSM is established, TCM concepts and understanding perfused into the mainstream will expand the domain of medicine.

Acknowledgment:

I am grateful to Professor Chen Keji,Academician, Chinese Academy of Science, and President, Chinese Association of the Integration of Traditional and Western Medicine, for his gracious help to review this article.