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JOURNAL OF CHINESE MEDICINE NUMBER 38 JANUARY 1992

Thoughts on Acupuncture, Internal Medicine, and TCM in the West


by Bob Flaws, DOM, CMT, Dipl.Ac.
t the end of last summer, Peter Deadman sent me as this term is used in the PRC today, it is the proper a letter saying that the September 1991 issue of name of a specific style of Chinese medicine. As Paul The Journal of Chinese Medicine contained reUnschuld has stated in rebuttal to this modern PRC views of a number of Blue Poppy Press recent releases. usage of term zhong yi , Chinese medicine can (read He mentioned that he had taken exception to my preface should) only refer to a broad range of ideas and practices to Highlights of Ancient Acupuncture Prescriptions related to health care and illness intervention that were and invited me to rebut his argument. In his letter, he developed, or adopted from abroad, and practised in expressed the opinion that scholarly debate is good for China over the past few millenia.2 In other words, the profession and so I also believe. Therefore I would Unschuld is implying that the appropriation of such a like to take this opportunity to address some of Peter generic term is a misnomer. Likewise, Leon Hammer Deadmans criticisms concerning the opinions stated in states: According to my teacher Dr. John Shen, who has that books preface. By such public discussion, debaters been practising sixty years since his apprenticeship in and readers alike can hone and develop our ideas, exShanghai in the 1930s, every city, village, and clan, as pose our flaws, lacunae, and contradictions, and thus well as the Imperial Court and various philosophical clarify and improve our opinions and positions. Just as schools in China had their own often startlingly distinct Peter Deadman extended me an invitation to respond to variety of this healing art. At one time I counted twentyhis criticisms, I would also like to extend an invitation to five discrete methods of diagnosis and treatment within others within our profession to likewise address these my own files gathered over the past twenty years. China same issues in the pages of this journal. spawned the richest variety of healing methodologies For those who have yet to read my preface to Highever recorded in the history of medicine.3 lights of Ancient Acupuncture Prescriptions translated To understand why the current regime has elevated a by Honora Lee Wolfe and Rose Crescenz, basically I said particular style of Chinese medicine to the role of being that, as a teacher of TCM, I had found that only a the single legitimate and definitive style of zhong yi, one proportion of students can actually make TCM methodmust first understand that China is not a country but, ology work for them when they get into clinical practice. rather, to this day an empire. A country most successBased on that experience and on the history of Chinese fully encompasses a single ethnic group with a single medicine, I said that I felt TCM methodology might be language and relatively homogenous culture. China is better reserved as a post graduate study and that beginan empire which by military hegemony has bound toners might be better served learning and applying by gether within a single geographic perimeter literally rote such formulas as Highlights contains. Peter hundreds of different ethnic groups, languages, and Deadman, on the other hand, expressed the opinion that, cultures. based on his experience, anyone can learn to use TCM One of the main political agendas of the Communist methodology and that teaching only a formulaic apregime in 1949 was to transform such an empire, which proach to beginners in acupuncture would be a great is inherently difficult to rule centrally, into an unified step backward. country which is much easier to dictatorially command. In further clarifying my position, whose merit I still Therefore, the Communist regime instituted programs feel is worth exploring, there are a number of issues that of national standardization at every level. A national must each be addressed. First of language was imposed. Pu tong all, what is TCM? As I see it, hua or so-called common speech a single style of Chinese medicine TCM is a specific style of Chiis, in fact, only the indigenous was chosen and elevated to the nese medicine. Granted, it is the language of northern China dominant, state endorsed style position of supremacy and sole where the capital is located. Most of Chinese medicine in the PeoWesterners are now familiar legitimacy ples Republic of China today with the forced deculturation of and has been for the last 25-30 such minority groups in China years. Leon Hammer, in an article in a recent issue of the as the Tibetans. But such deculturation, i.e., genocide, American Journal of Acupuncture, states that as a selfalso extends to other minority ethnic groups, such as the conscious and deliberate style, it was adopted by the Miao, Yi, and everyone else who is not ethnically Han, Communist regime in the 1960s and early 70s1. Alpropagandist articles in China Today notwithstanding. though in Chinese it is simply referred to as zhong yi or In exactly the same way, a single style of Chinese mediChinese medicine, that should not obscure the fact that, cine was chosen and elevated to the position of su-

JOURNAL OF CHINESE MEDICINE NUMBER 38 JANUARY 1992

premacy and sole legitimacy, thus creating a single national standard binding even this aspect of Chinas multicultural society further together. Anyone who has studied in China should be aware that, during the Cultural Revolution, practitioners of politically incorrect styles of Chinese medicine were purged and persecuted, imprisoned, tortured, and even driven to commit suicide. As for the definition of TCM as a particular style of Chinese medicine, modern TCM textbooks are clear in stating that bian zheng lun zhi is the defining characteristic of this style. Bian zheng lun zhi means treatment based on a discrimination of patterns. Such patterns are based on signs and symptoms collected by the four diagnoses (si zhen) and analyzed by the eight principles ( ba gang). Discriminating damp heat ( shi re) from full heat ( shi re) from empty heat (xu ru) from depressive heat (yu re) or transformative heat (hua re) are examples of bian zheng. However, such a discrimination of patterns is only one style of Chinese diagnosis and only one methodology for erecting a treatment plan. Even though this style dominates Chinese medical literature, in fact, in terms of the numbers of Chinese healers employing it, this style of diagnosis and treatment strategizing is historically a minority style. This bian zheng style was created by the ru yi or Confucian scholar doctors, men such as Zhang Zhong-qing, Zhu Dan-xi, Li Dong-yuan, Zhang Jie-bin, Wu You-ke, Ye Tian-shi, etc. This is a highly discriminating style based on rigorous logic and an extremely sophisticated use of the Chinese language. These men were all wen ren or literati. They were also the men who wrote the scholarly books on Chinese medicine. Bruce Holbrook, medical anthropologist and lineal disciple of such a ru yi, refers to such doctors as yi sheng or true doctors4. ( Yi sheng is the term most commonly used in China today for a TCM practitioner.) They were both the intellectual and medical aristocracy. They wrote the vast majority of the great books or classics of Chinese medicine. But, in terms of sheer numbers, they were not the majority of persons practising healing in China during any historical period. The majority of practitioners in China were always what Lu and Needham refer to as ling yi5. These were the so-called bell-ringing doctors who travelled about the country practicing medicine for a living. These were also called zhou fang yi or itinerant formula doctors. Fang shi or masters of formulas is what Holbrook calls such practitioners6. Fang shi practised medicine as a trade, something Confucian gentlemen were loath to do. The ru yi practised medicine out of Confucian piety and an ethos of noblesse oblige. Fang shi were technicians practising what Confucians called a little dao or small path. Fang shi primarily memorized prescriptions based on bian bing lun zhi. These prescriptions were handed down in family lineages; therefore, such doctors often would advertise what generation of practitioner they were in their family. Such multigeneration doctors were also called shi yi. Since formulas were kept a secret in order to insure a particular familys lock on a market, formulas were passed down from male family member to male family member. The more generations, the more potential formulas and more clinical experience might be
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expected to be passed down. Such practitioners or fang shi tended to also specialize. This is because they were often illiterate and could only memorize a certain number of bits of information. By specializing in eye diseases, ear diseases, skin diseases, or whatever, a person only had to memorize a certain amount of information. Still to this day, in the countryside in China, one can see roadside practitioners treating eye diseases, ear diseases, and tooth diseases. As mentioned above, the methodology such practitioners used was mostly based on bian bing lun zhi or treatment predicated on disease category. For instance, such fang shi memorized a formula, be that acupuncture, herbal, massage, cupping, moxibustion, or whatever was ones family modality, for stomach ache (wei tong), toothache (ya tong), red eye (chi yan), headache (tou tong), etc. Every one with that same disease would receive the same memorized formula. Typically, there was little further pattern discrimination of the various manifestations of a single disease in various patients. Such pattern discrimination was the province for the ru yi or scholar doctors. One can still find many Chinese practitioners trained either before the rise of TCM or outside of the PRC, such as in Hong Kong, Singapore, and Taiwan, who still practise acupuncture, massage, cupping, moxibustion, and other such modalities according to bian bing. I have translated and published several examples of this style of formulaic Chinese medicine, both acupuncture and herbal medicine, in an attempt to document some of the other, historically identifiable alternatives to TCM7,8. That is not to say that the ru yi or scholar doctors did not also use bian bing lun zhi but that they used both bian bing and bian zheng lun zhi. They discriminated both their patients disease and their individual pattern and treated accordingly for both. For instance, although certain medicinals are known to be empirically useful for treating shao fu tong or lower abdominal pain, of those medicinals, some are further differentiated for the treatment of qi zhi or qi stagnation, others for xue yu or blood stasis, others for shi re, damp heat, and others for qi xue xu or qi and blood emptiness. This further discrimination was the great insight of the ru yi. And I would be the first to say that this insight leads to much more effective, holistic, and non-iatrogenic treatment. When the Communist regime instituted their program of standardizing and nationalizing Chinese medicine, they made certain choices in terms of authority figures. They made certain choices in terms of pragmatic considerations. And they made certain choices for purely political and philosophical reasons. All of these choices have participated in the modern development of what has become known as TCM. For instance, the ru yi were the medical intelligentsia. It was this group which was approached in order to design, set up, and be the professors at the various provincial colleges of Chinese medicine. This group of practitioners primarily practised internal medicine or the prescribing of polypharmacy formulas for internal administration. Although ru yi often also knew acupuncture/moxibustion, as Bruce Holbrook states, to be a yi sheng meant to prescribe internal medicine9. Acupuncture specialists were not

JOURNAL OF CHINESE MEDICINE NUMBER 38 JANUARY 1992

generally recognized as yi sheng or fully-fledged Chinese acupuncture/moxibustion (zhen jiu ke ), and tui na. Ted doctors. Therefore, the men tapped to set up and design Kaptchuk first referred to the practice of modern TCM New Chinas nationally standardized system were priacupuncture according to bian zheng lun zhi as the marily what we in the West refer to as herbal practitionherbalization of acupuncture in a previous issue of this ers. These practitioners then designed a system founded very journal 15. I find this term quite accurate in that a upon and modelled after their own style, a style which methodology and terminology which was developed grew up around the practice of internal medicine. for the writing of individualized herbal prescriptions For pragmatic reasons, only a system which tranwas applied to the composition of acupuncture treatscended local, clan, and individual idiosyncrasies could ments. In this sense, even tui na or Chinese remedial be the basis for a nationally standardized approach to massage has been herbalized. medicine. In establishing large hospitals and clinics, the Specifically in terms of acupuncture, I feel this moveChinese needed a methodology which all practitioners ment has been a great mistake. It tends to emphasize could use and agree upon. Family formulas for the zangfu physiology and pathophysiology over jing luo treatment of specific diseases theory. It tends to foster the could simply not provide notion that acupuncture I have personally found the treatments such a universal system. points have functions identiof TCM acupuncture to be both heavyThey were too idiosyncratic. cal to the functions of Chihanded in all senses of that word and By instituting the TCM bian nese herbal medicinals and zheng methodology, a doctor that these functions can be best suited for acute conditions which in one clinic on one side of activated similar to flipping may need such heavy-handed China could corroborate or a light switch. I am not familtreatment critique a diagnosis and treatiar with any Chinese book ment plan established by on acupuncture which atanother practitioner on the other side of China. The ru yi tributes such functions to points prior to the early sevenbian zheng methodology was both universal enough and ties. Prior to that time, points were not described accordprestigious enough to be able to fulfil this need. ing to functions but only according to indications couched However, in crafting this style as it exists today, politiin the terminology of bing, diseases, and zheng (a differcal considerations were also taken into account which ent zheng) meaning pathoconditions. I have previously had nothing to do with clinical efficacy. For instance, as published translations showing how acupuncturists Unschuld points out, the words bian zheng have been working in the late sixties and early seventies conemphasized in part because they are homologous to the sciously and deliberately mimicked the creation of acuwords bian zheng (second character different) which puncture protocols as if they were composing herbal mean dialectic as in dialectical materialism10. Western formulas16. 11 12 scholars such as Nathan Sivin , Ralph Crozier , and This TCM style of acupuncture was not the first one Manfred Porkert13, have all written about such political that I learned. I was first introduced to the Tao family and philosophical influences on the development of style of bian bing lun zhi acupuncture. This style as modern TCM apart from actual clinical exigencies. For practised by Dr. Eric Tao is also heavily influenced by the instance, wu xing xue or five phase theory has been down wu xing xue style of Wu Wei-ping of Taiwan, rememberplayed because of that theorys role in such outlawed ing that Taiwan was a Japanese colony throughout the arts as astrology and geomancy. Along with that, the wu latter years of the last century and the first half of this. I yun liu qi or five transports, 6 qi theory of Chinese then was influenced by Worsleyan five phase practice chronobiology has been either suppressed or allowed to and Vietnamese/French acupuncture as taught by flourish depending on the political mood of the ruling Nguyen Van Nghi, Soulie de Morant, and Chamfrault party. Yi Jing or Classic of Change influences have mostly and promulgated in the US by the Occidental Institute of been expunged from modern TCM. Recently the governChinese Studies (OICS). It was only after being exposed ment in the PRC has once again put that book on the to these styles and having practised an amalgamation of banned list. And yet its concepts form the basis of much them for several years that I went to China and studied of Neoconfucianism and, therefore, a great deal of ChiTCM acupuncture. Since that time I have also studied nese medicine. The concept of shen has been reduced to Japanese and Korean styles of acupuncture. As a clinithat of vitality as evidenced by that terms translation in cian, my opinion is that these other styles all hew more Health Preservation and Rehabilitation edited by Zhang closely to an acupuncturists acupuncture theory. They Enqin14. In general, all religious and spiritual concepts all tend to emphasize the flow of qi over the jing luo. They have been eliminated from modern TCM. This system is all tend to use some version of wu xing xue for deep, now a form of secular materialism, remembering that systemic balancing. And they all tend to incorporate a the concept of qi in Chinese does not necessarily imply great deal of palpation in both their diagnosis and treatan immaterial energy. ment. Nowadays in China at provincial TCM colleges, such In particular, I am especially impressed by modern as the Shanghai College of TCM, Beijing College of TCM, Japanese meridian acupuncture as taught by the late Nanjing College of TCM, etc., all treatment modalities Yoshio Manaka, Shudo Denmei, Kiko Matsumoto, Miki are taught from the perspective of bian zheng lun zhi: Shima, Stephen Brown, and Stephen Birch. Anyone who internal medicine (nei ke), gynecology (fu ke), pediatrics has had opportunity to witness the likes of Shudo Denmei (er ke ), external medicine (wai ke ), traumatology ( shang or Miki Shima work will immediately recognize the ke), orthopedics ( zheng gu ke), oncology (zhong liu ke ), sensitivity in their fingertips, the incorporation of mas-

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sage into their work, and their attention to the patients divided into at least three colleges, each with their own entire body and all their jing luo. Their needle technique students and curricula and each granting their own is simultaneously extremely sophisticated, rigorously degree. There is the acupuncture/tui na college which based on the classics of acupuncture, immediately trains only acupuncturists and tui na specialists. This is grounded in felt physical palpation, and extremely well typically a four year, bachelor program. Then there is the tolerated by even the most sensitive of patients. It also internal medicine college with its own four to six year works better, I think, than TCM acupuncture on a larger program which grants its own degree in the prescribing proportion of patients and especially in a Western setof internal medicine. And finally, there is the pharmacolting. ogy college which is likewise a four year program leadThat is not to say that TCM acupuncture does not ing to a degree as a TCM pharmacist. work. It does. However, I have personally found the Here in the West, we tend to want it all, to be all and treatments of TCM acupuncture to be both heavy-handed everything. We have begun down a path where the in all senses of that word and best suited for acute practice of acupuncture and internal medicine is taught conditions which may need and practised as if a single such heavy-handed treatprofession when, in fact, this ment. TCM acupuncture Therefore, I am saying that TCM as a style was and is not the case in treatments, I feel, tend to be most Asian countries. To be of acupuncture is not what I would less sophisticated in addressreally good at one or the other consider a very sophisticated ing wu xing , yin yang , and is a full-time practice requirand advanced style jing luo phenomenon and, ing different diagnostic therefore, also tend to be methodologies, different merely ballpark treatments. They work often only betheories, and different skills. In my experience, there is cause they are repeated so frequently (every other day in not the time in a single patient visit to do both really well, China). I think most Western TCM acupuncture practiand I further question the necessity of doing both to a tioners will have to agree that there is a significant single patient at the same time as an unspoken or percentage of patients who do not respond to this species unconsidered assumption. Should we indeed be doing of therapy. Because I have been exposed to a wide range both on a single patient at the same time? Why? Is this not of acupuncture styles from a number of different counanother example of if a little is good, more must be tries, when faced with a recalcitrant condition I have no better? Might not these two different modalities each problem in searching for a more effective methodology. excel at certain types of problems and conditions and, As far as acupuncture goes, I hold no particular alletherefore, best be employed in a more discriminating giance to any specific school and have come to the way by specialists who have a close working relationconclusion that TCM acupuncture is not all that good a ship with one another? style of that modality. I have personally given up doing much in the way of That is also not to say that there are not crackerjack acupuncture. For better or worse, I have decided to focus Chinese acupuncturists. There are. But in my experience on honing my skills specifically as a TCM internist and they tend not to do TCM treatments as contained in such gynecologist. That means that I mainly write polypharTCM acupuncture texts as Essentials, Comprehensive, macy, herbal prescriptions (as well as counsel patients etc. They are good precisely because they were trained in on diet, lifestyle, etc.) based on bian zheng diagnosis. In theories and techniques more germane and indigenous our clinic, we have a practitioner who just specializes in to acupuncture or have transcended through personal acupuncture, moxibustion, cupping, bleeding, and tui study and exploration the narrow confines of TCM na who has spent 15 years developing her touch and acupuncture. studying pre-TCM Chinese and Japanese theories and Therefore, I am saying that TCM as a style of acupunctechniques of cutaneous and subcutaneous stimulation. ture is not what I would consider a very sophisticated Some patients come to me and it is clear from their intake and advanced style. Personally, I would prefer to see that they would get better, more immediate, and cheaper Japanese or Korean acupuncture more widely promulresults from seeing this acupuncture specialist. Other gated. I feel the theories and techniques of these styles patients come to her and it is clear to her that really this are more sophisticated (as in sophia, meaning wisdom) patient needs internal medicine. In both cases, we make and more organic to the art at hand. However, such a the necessary referral and the patient, I believe, gets the style requires a different type of education than TCM best possible treatment from people who have really acupuncture training and also requires more time to focused on practicing their best modality. In some cases, master the very subtle palpation and needle technique we may also decide that the patient would benefit from skills employed. simultaneously receiving both acupuncture and internal Further, I question the wisdom of teaching both acumedicine, but even then it is from persons who have puncture and internal medicine to the same students in specialized in each individually. This is a big, multifaca single program as is done at least at the majority of eted topic of discussion and one which I think the time is American acupuncture schools. Although I agree with ripe for discussing before we willy nilly go down a path Sun Si-miao that the fully trained Chinese doctor or yi which later turns out to have produced both mediocre sheng should know something about the clinical practice acupuncturists and mediocre internists. of acupuncture, I do not necessarily think that all acuFurther, if we were to recognize that these are two puncturists should study and practise internal mediseparate, though historically related, healing arts, then cine. In the PRC today, most provincial TCM colleges are we would be free to chose the best methodologies for
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each. The geopolitical constraints of TCM in the PRC are relatively easy to teach students TCM to both do aculargely not operative here in the West. If we were to puncture and pass written exams. It is entirely a different divide these two professions as, I think, they deserve to matter to understand TCM well enough to be able to use be, then we would also be free to adopt the very best style it in the clinical practice of internal medicine. I make the of each and to design educational institutions for teachdistinction between TCM acupuncture and herbal mediing those best styles. Personally, in such a milieu, I cine again because in acupuncture there is less chance for believe that Japanese acupuncture would rise above iatrogenesis and a greater chance for a generalized sysTCM acupuncture but TCM herbal prescribing would temic effect even from wrongly or less than elegantly rise above kanpo yaku . Such a combination of Japanese chosen points. acupuncture and Chinese internal medicine is impossiSince the jing luo system is a closed loop and since, ble in Asia where cultural biases and downright racism from an acupuncturists acupuncture point of view, are so thoroughly entrenched. But that is not the case in there are only imbalances in qi, stimulating even the the West where we are free to chose whatever we think wrong points may have a generalized, systemic, and works the best. ameliorating effect on the patient. Further, certain points That Japanese acupuncture is coming to the fore in the are also so generally applicable that stimulating them United States is evidenced by the success of Drs. Manaka can benefit almost everyone regardless of the exactitude and Denmeis relatively recent, well attended seminars, of their TCM bian zheng diagnosis. In other words, in the perennial popularity of Kiko Matsumoto and Miki TCM acupuncture, the fact that the patient got better as Shimas seminars, the publication of Matsumoto and a result of a specific treatment or course of treatments Birchs several, well received books, the translation of does not necessarily validate the practitioners TCM bian Shudo Denmeis Japanese Meridian Acupuncture into zheng diagnosis. English, the production of an entire series of Japanese The fact that TCM is harder to do than to study and acupuncture instructional video tapes by Miki Shima, teach is borne out by the fact that even in China, it is and the opening of a branch of the prestigious Meiji difficult to effectively teach TCM to all students at TCM College in San Francisco. In comparison, I can think of no colleges. Nathan Sivin, in a very important article entiequivalent, recent important trend or event vis a vis the tled Reflections on the Situation in the Peoples Repubgrowth and spread of TCM acupuncture in the US. lic of China, 1987" published in 1990 in the AJA says: Already Japanese disposYoung doctors told me able needles dominate the It is relatively easy to teach students TCM again and again that they do practice of American acunot really grasp manifestato both do acupuncture and pass written puncture and I think it probtion type determination (bian exams. It is entirely a different matter to able that most American acuzheng) and prefer to diagpuncturists now use the nose by symptoms. Medical understand TCM well enough to be able Japanese insertion tubes school, they said, did not to use it in the clinical practice of that go along with these neegive them a deep enough internal medicine. dles. An interest in learning understanding of yin-yang the theories and techniques and the Five Phases to make for which these needles were designed seems logically them confident about using these concepts. They are inevitable. It is also my observation that there is so much thus driven to diagnose on the basis of what seems to interest in Japanese acupuncture in the United States them more concrete and objective Western criteria. They precisely because it is not based on an abstract, rational are aware that it is impossible to work out a traditional methodology but more on an empirical one in turn course of therapy on the basis of a biomedical diagnosis, founded on palpation. This system provides practitionbut that is the best they can do, and they do it someers with definite protocols and sequences, formulas if how.18 you will, based not upon analytical and abstract logic but This is exactly my own experience in China in 1983, 84, on palpation and biofeedback, and as a teacher it is my & 87. My TCM teachers told me over and over again perception that formulas are what students and neohow difficult most TCM undergraduates found TCM phytes want and need. methodology to apply in clinical practice and how most As stated above, TCM bian zheng lun zhi methodology of them preferred to do Western medicine. Western was the creation of ru yi (Confucian doctors) who were medicine is essentially a bian bing approach which prohighly educated wen ren (literati) and that, until approxiceeds not so much on the basis of mature and exceptional mately thirty years ago, such scholarly practitioners reasoning skills but on rote memorization. If even Chiconstituted the minority of all medical workers in China. nese professors of TCM at four year TCM colleges in I have also stated in my preface to Highlights that I China teaching in Chinese find it difficult to teach the believe only a proportion of all potential students are clinical application of TCM bian zheng lun zhi to native really capable of doing this style well. Peter Deadman Chinese speakers, it is reasonable to question the overall has taken exception to this statement and it is an imporsuccess of that attempt here in the West in part-time tant issue deserving further clarification. courses taught in often erroneous translation. In my This style is a highly rational one requiring greater experience, it is one thing entirely to teach TCM so that than average reasoning and verbal skills. As Peter students can pass written and oral exams. It is another Deadman has himself quoted Dr. Shen, Modern medifor students to be able to put that knowledge into praccine is difficult to study but easy to practise, but Chinese tice in terms of writing individually crafted internal medicine is easy to study and difficult to practise17. It is prescriptions based on both bian bing and bian zheng . I

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have seen any number of Western practitioners who bian zheng lun zhi as a prescriptive methodology. My have passed, for instance, the NCCA board exams in experience is that the other 80% feel more comfortable acupuncture, which are biased in favor of TCM bian with and tend to gravitate towards a bian bing lun zhi zheng lun zhi, who could not make this system work in approach. That does not mean such a methodology is not clinical practice. Even should Peter Deadman rebut that also effective. Homeopathy, for instance, is a very sohe has met many Chinese practitioners who could make phisticated and effective but nonetheless bian bing lun zhi this system work, I would remind him that he is mostly approach to prescribing internal medicine. It is interesttalking about his professors and other senior teaching ing to note that acupuncturists in California are pushing assistants who have been chosen precisely because of to have homeopathy added to their legal scope of practheir skills in this system. Dr. Sivin, however, is talking tice. about the Chinese rank and file and I likewise am talking I agree with Peter Deadman that the TCM bian zheng about Western rank and file, postgraduation ability in lun zhi approach, at least to the prescription of internal making this system fly in clinical practice. medicine, is a great art. I personally think it is the best Personally, I feel my TCM is up to the mark, nor do I and potentially safest methodology for doing internal feel I am any less capable teacher of TCM than anyone in medicine. However, to naively take the Chinese at their the West. I have taught TCM all over the US, in the UK, own words that TCM is the essence of everything timeand in Australia and New Zealand. In all those places, I tested and good within two thousand years of medical have had the same perception that although my listeners history does not tally with current scholarship nor with had passed their various courses and exams, a substanmy experience both in and out of China. The assumption tial percentage of them were not very capable of making that there is a best orthodoxy that should be adopted by this system work for them in their clinics. This is clearly everyone is both congruent with the current dictatorial and unmistakenly evidenced by the continuous asking regimes political thinking and characteristically paterof how to treat this or that disease in TCM when the nalistic. Recognizing that there are various levels of whole impetus of TCM is treating on the basis of patintelligence within humans and various levels of sophisterns. This is what is meant tication within various mediby the Chinese couplet: Tong cal methodologies and then bing yi zhi, Yi bing tong zhi allowing space for each to My feeling is that only about 20% of any (Same disease, different seek their own level is, to me, given population of practitioners is treatments; different disrealistic, compassionate, and intellectually comfortable with and eases, same treatment.) wise. That does not mean that capable of utilizing TCM bian zheng lun zhi proponents of their various The fact that many American practitioners at least have styles should not attempt to as a prescriptive methodology trouble doing TCM bian zheng demonstrate, advertise, and lun zhi in their clinics is evipromulgate the merits of denced by the great and growing popularity amongst their individual styles nor that practitioners of differing American acupuncturists of computerized diagnosis, styles should not debate between themselves, but I feel electronic diagnosis (such as EAV and Vegatesting), deeply that we should be careful not to create profesapplied kinesiology, and homeopathy even though TCM sional institutions which either unconsciously or delibbian zheng lun zhi dominates the curricula of almost every erately legitimize only a single approach to medicine. American acupuncture/Chinese medical school. Each What I was questioning in my preface and what I am of these methodologies or modalities are a way of ciragain questioning here is whether the professional insticumventing TCMs bian zheng lun zhi methodology which, tutions which have grown up in the West surrounding as Dr. Shen says, is easy to study but hard to practise. the practice of acupuncture and Chinese medicine are in There are relatively few postgraduate seminars given in fact the healthiest and best. What is wrong with a multithe United States in TCM methodology because this is tiered profession with some people doing primarily a not what the rank and file finds useful to them. What bian bing approach to acupuncture and herbal medicine they do find useful and what they flock to are workshops and others doing primarily a bian zheng approach? This, and seminars which teach empirical or formulaic apin a sense, merely recognizes what is the fact of the proaches to the practice of medicine. As a practitioner matter in the West. I feel fairly certain that the situation who can and does make TCM methodology work in in the UK is similar to that in the US with chiropractors, clinical practice I am somewhat saddened by this. On the naturopaths, and even MDs using acupuncture and other hand I also realize that not everyone has the certain Chinese herbs in their practice. When such intellectual proclivities necessary to really excel in this other practitioners do so, they primarily employ a bian style. bing lun zhi approach. Different people have different skills and propensities, Personally, I think a multi-tiered approach to the prodifferent intellectual capabilities. Although I agree with fessions of both acupuncture and Chinese internal mediPeter Deadman that TCM acupuncture is relatively easy cine not only makes pedagogic sense but also is truer to to teach, I do not feel that this is the most sophisticated human experience. Whether TCM be reserved as a graduapproach to acupuncture currently available. And when ate education or whether TCM schools simply screen it comes to the prescription of internal medicine, TCM is their applicants intellectual capabilities and proclivities not at all easy to practise. My feeling is that only about more carefully and increase the stringency of their cur20% of any given population of practitioners is intellecricula is a lesser issue. I still very much abide by my tually comfortable with and capable of utilizing TCM opinions that acupuncture would be better served di10 10

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vorced from TCM, that the practice of a TCM bian zheng lun zhi approach to internal medicine is not for everyone, that there is and always will be both yi sheng and fang shi and that there is a valid place for both in the health care marketplace. P.S. Highlights of Ancient Acupuncture Prescriptions is not a translation from the Zhen Jiu Da Cheng but is rather based on Liao Run-longs Qing dynasty Zhen Jiu Ji Cheng. I am also happy to say that with the publication of AIDS & Its Treatment by Traditional Chinese Medicine we will be routinely including the pin yin identifications of all traditional Chinese medicinals. And finally, we do feel that translations need to say what the Chinese says. If the Chinese says swelling like a silk cocoon, we believe that it is important to translate it such. Such descriptions function as technical terms in TCM and professional practitioners should be able to recognize them for what they are. If a Western practitioner writes a book on TCM in English, they may choose not to use such typically Chinese metaphors, but, in a translation, I think it is important to convey the original as closely as possible. The larger issue is why we in the West think that we can learn TCM without also learning the professional language of that medicine i.e., Chinese. But that is the subject of yet another essay. ENDNOTES
1 Hammer, Leon I., Duelling Needles: Reflections on the Politics of Medical Models, American Joumal of Acupuncture (AJA), USA, Vol. 19, #3, 1991, p. 262 2 Unschuld, Paul U. Traditional Chinese Medicine: Some Historical and Epistemological Reflections, Traditional Acupuncture Society Joumal (TASJ), UK, #9, April, 1991, p.5 3 Hammer, op.cit., p. 262 4 Holbrook, Bruce, Chinese Psycho-social Medicine: Doctor and Dang Ki: An Intercultural Analysis, Bulletin of the Institute of Ethnology Academia Sinica, No. 37, 1974, p. 86 5 Lu Gwei-djen & Needham, Joseph, Celestial Lancets: A History and Rationale of Acupuncture and Moxa, Cambridge University Press, UK, 1980, p. 157 6 Holbrook, op.cit., p. 88 7 Flaws, Bob, Secret Shaolin Acupuncture Prescriptions: A Glimpse of a Buddhist Lineage of Chinese Medicine, AJA, Vol. 16, #1, March, 1988, p. 27-35 8 Flaws, Bob, American Acupuncture Education: Has A Wrong Turn Been Taken? AJA, Vol. 19, #1, 1991, p. 63-71 9 Holbrook, op.cit., p. 86 10 Unschuld, Paul U., Medicine in China, A History of Ideas, University of CA Press, Berkeley, 1985, p. 258 11 Sivin, Nathan, Traditional Chinese Medicine in Contemporary China, Center for Chinese Studies, University of Michigan, Ann Arbor, 1987 12 Crozier, Ralph C., The Ideology of Medical Revivalism in Modern China, appearing in Asian Medical Systerns, ed. by Charles Leslie, University of CA Press, 1976, p. 341-354 13 Porkert, Manfred, The Intellectual and Social Impulses Behind the Evolution of Traditional Chinese Medicine, IBID., p. 6667 14 Zhang En-qin, chief editor, Health Preser~ation and Rehabilitation, Shanghai College of TCM Press, Shanghai, 1990, p. 44-48 15 Kaptchuk, Ted; Maciocia, Giovanni; Moir, Felicity; Deadman, Peter, Acupuncture in the West, Journal of Chinese Medicine (JCM), UK, No. 17, Jan. 1985, p. 22-31 16 Flaws, Bob; Chace, Charles, & Helme, Michael, Wang Leting on Acupuncture, Timing and the Times, Blue Poppy Press, Boulder, CO 1986 17 Shen, John, quoted by Peter Deadman, Starting Up, Joumal of Chinese Medicine (JCM), UK, #37, Sept. 1991, p. 36 18 Sivin, Nathan, Reflections of the Situation in the Peoples Republic of China, 1987", AJA, Vol. 18, #4, 1990, p. 343

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