An introduction to nonwestern medical systems Lawrence Berk, MD, PhD ABSTRACT This paper will discuss the basic concepts of three alter native medical systems: Ayurvedic medicine, traditional Chinese medicine (TCM), and homeopathic medicine, Alternative medical systems are dilficult to understand using westem standards ofscience. The basis of western medicine is the cell theory, which presents the body as a clockwork sys- tem and is organized around learning the functional parts of the cell. Ayurvedic medicine from India, TCM, and home- opathy start with a holistic philosophy. They see disease as representative of the imbalance of internal enemies and look to cure the disease by restoring the balance. These altemative systems also have a yreater emphasis on preventive medicine than westem medicine By understanding the basis oftheir own medicine and Jeaming altemative approaches, physicians can become more aware of the biases of westem medicine. This can lead to new approaches, or atleast an appreciation of the limitations of western medicine. Alternative medical systems, such as Ayurvedic medicine, TCM, and homeopathy, are sellcon- tained, internally logical systems that present alternative ways to look at health, disease, and medical treatment. Key words: alternative medicine, Ayurvedic medicine, traditional Chinese medicine, homeopathy, philosophy of INTRODUCTION Complementary and alternative medicine (CAM) is bolten represented as the unscientific use of herbs, vitamins, and New Age mind-body techniques. This depiction of CAM is an oversimplification of an extremely complex area. CAM is defined by the National Institutes of Health's National Center for Complementary and Alternative ‘Medicine (NCCAM)' as a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine. Tagae Oreobgy Reseach Grup LB) Nena Of, While some scientific evidence exists regarding a number of CAM therapies, for most there are key questions that are ‘yet to be answered through well-designed scientific studies: Guestions such as whether they are safe and whether they work for the medical conditions for which they are used, (Note: The list of what is considered to be CAM changes con- tinually, as therapies proven to be safe and effective become adopted into conventional healthcare and as new approaches to healthcare emerge.) ‘CCAM classifies CAM therapies into five categories: 1, Akternative medical systems. These are built ‘upon complete systems of theory and practice and have often evolved apart from and eaulier ‘than the conventional medical approaches used in the US. Examples of alternative medical systems that have developed in western cultures include homeopathic medicine and naturopathic medi- cine. Examples of systems that have developed in nonwestem cultures include traditional Chinese medicine (TCM) and Ayurveda 2. Mind-body interventions. These use techniques esigned to enhance the mind's capacity to affect bodily function. Some techniques once consid- ered CAM have become mainstream, e., patient support groups and cognitive-behavioral therapy. Mind-body techniques still considered CAM include meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance. 3. Biologically based therapies. This approach ‘uses substances found in nature, such as herbs, foods, and vitamins. Examples include “natural but as yet scientifically unproven therapies (for example, using shark cartilage to treat cance). 4, Manipulative and body based methods. These involve manipulation and/or movement of one or JOURNAL OF CANCER INTEGRATIVE MEDICINE, FALL 2108 VOL. 1,N¢ ‘more parts of the body. Examples include chico- practic or osteopathic manipulation and massage, 5. Eneny therapies. Biofield therapies are intend. ed to affect energy fields that purportedly sur: round and penetrate the human body (the existence of such fields has not yet been scientifi cally proven). Energy therapies that manipulate biofields by applying pressure and /or manipulat- ing the body by placing the hands in, or through these fields include qi gong, Reiki, and therapeu- tic touch. Bioelectromagnetic-based therapies involve the use of electromagnetic fields, such as pulsed fields, magnetic fields, or AC/DC fields, ‘This article is an overview of these alternative medical ‘systems. It will describe the basis for the western medical sys tem, then review Ayurvedic medicine, TCM, and homeo- pathic medicine. My goal is only to give an introduction to these systems. General references are provided at the end of the article for those who would like a more in-depth study. ‘The western medical system One misconception of western physicians is that their ‘medical system the only “scientific” medical system. This is predicated on the supposition that itis scientific because itis based only on proven facts. According to this belief. western medicine, unlike other medical systems, is deductive (arising from proven facts) rather than inductive (derived from basic principles). However, it has always been difficult to deline “scientific.” Among modem philosophers of science, there is no universally accepted standard definition ofthe term. I pre- fer to use the approach of Imre Lakatos, whose definition employs the concept that a research methodology or system is scientific if t generates a postive heuristic; that is it explains present knowledge and yenerates new hypotheses that can be subsequently confirmed, There are many other approaches to the definition of “scientific,”? but they almost all agree that no system is trly inductive. All systems must have certain underlying principles that allow classification and under: standing of the experimental data as they arise ‘Madera western medicine began to assume its preseat shape with the emergence of the cell theory in the mid-19th ‘century. Prior to this, Western Hippocratic/Galenic medi cine saw the body as a holistic system, based ona balance of the four humors functioning as an integrated wile. Disease resulted from the loss ofthis balance. As the laws oF physics evolved from Aristotelian physics, upon which Galenic ‘medicine was based, into Newtonian physics, medical scientists were driven to develop a Newtonian (and therefore “scientil= ic" and clockwork) approach to medical scienc For example, Herman Boerhaave (1668-1738) explained disease in terms of pneumatic theories; it was due to excessive pressure in the arteries and veins £ Thomas Sydenlnam (1624- 1689) attempted to generate a purely inductive system of dis- case by formulating a Linnaean compendium of all symptoms and the diseases they represented However, these approaches were unsuccessful because they did not account for known facts and dic not have a positive research heuristic Cell theory succeeded because it provided a research pro- ‘gram with both explanatory power and some predictive power, and because it was harmonious with Newtonian theory, at that time the dominant scientific research program. The premise of Newtonian paysics is that everythingcan be explained with the understanding of a few physical laws and knowledge of the starting conditions (a clockwork universe), Cell theory, as well asits derivatives (which have culminated inthe current enthusi- asm for gene theory), also predict a clockwork universe in life Ifthe starting principles ofthe cell, perhaps the genes, can be defined, then the entire functioning of the cell, and ultimately the whole body, can be defined. In Newtonian physic, part- es willinteract with each other, butas long as each particle is known, the system s defined. Incell theory, the parts ofthe cell interact bat as long as each part can be defined, the entire cell ‘an be understood. Newtonian physics was subsequently shown tobe correct ata general level but inadequate asa com- plete system. This is exemplified within Newtonian physics itself by chaos theory and outside of classical Newtonian physics by quantum mechanics and relativistic physics Bucno such evolution has as yet occured in medicine, the basis of modern medical science is still the Newtonian clockwork universe, This i seen inthe use of idealized mod- els, such as the nude mouse, in cancer research. The use of simplified models is only productive if there isa linear rela- tionship between simple and complex systems, which is pre- dicted by Newtonian physics but not modern physics ‘The emphasis on cell theory (and its derivatives) and the testing of derived hypotheses is the face of western medicine. ‘This must be taken into consideration before there can beany understanding of alternative medical systems such as TOM ‘or Ayurvedic medicine. These systems donot wilize the same underlying scientific program, Most alternative medical sys- tems take a holistic approach to the body, assuming tis filled with vital forces that must be kept in balance. These systems must be understood within their own frameworks. Attempts to explain or justify their principles in terms of western medicine are misguided; just as Aristotelian physics cannot be explained with Newtonian physics, TCM cannot be 8 JOURNAL. OF CANCER INTEGRATIVE MEDICINE, FALL. 08 YOE. 1,N0.1 deserbed using western medicine's terms. Alternative medi ‘eal systems can only be understood as derived from their basic principles. The flow of qi may seem fantastic to a western physician, But then, worrying about the genetic makeup of a ‘tumor cell may seem fantastic toa TCM physician. Overview of altemative medical systems ‘The two largest active alternative medical systems are Ayurvedic medicine in India and TCM, Their prewriten his- tories date back at least 2000 years. The written histories go back about 1000 yea between the two cultures, the two systems probably shared some of their basic knowledge, A third medical system devel ‘oping at about the same time was Hippocratic, or Galenic, ‘medicine, Again, there was contact between the Greek cu ture and India (Alexander the Great invaded India in 325 ‘BC), and many ideas may have been shared. All these systems share a belief that the body is made up of vital forces and that illness is due to imbalance. In Hippocratic/Galenic medicine, the balance is betwee four humors—black bile, yellow bile, blood, and phlegm. which represent the four elements, earth, fire, air, and phlegm, respectively. Each humor has a particular combina tion of qualities associated with it: black bile with cold and dry, yellow bile with hot and dry, blood with hot and moist ‘and phlegm with cold and moist. Thus, an excess of one humor could be corrected by applying the appropriate herbs having counteracting qualities. Similarly, avoiding environ ‘ments that were excessively cold, moist, ete, would prevent disease and counteracting environments could cure disease.”* ‘This westem tradition is remarkably free from religious and philosophical influences. Hippocrates stressed the role of ‘observation in determining how to treat patients, However, he also said, “Life is short, artis long, opportunity fugitive, experience delusive, judgment difficult. ‘Ayurvedic medicine is a product of the philosophy and religion of ancient India. The original teachings of Ayurvedic medicine come aot from observation or derived physical Jaws, but from meditation and divine revelation, The books of this attained knowledge, covering all areas including health and medicine, are the Vedas. Ayurveda comes from the Sanskrit words ayur (life) and veda (knowledge) The ‘Ayurveda was derived from the Veda's philosophical writings and then was extensively supplemented. However, it wetains its basis within the Vedie philosophy.” Ayurvedic philosophy is extremely complex (for an into: duction to Ayurvedic medicine, see Ninivaggi"). To greatly simplify, the life force of all nature, Prana, gives rise to the first bioenergetic force, or dosha, called Vata, Vata, which Given the extensive interactions means wind and represents motion, in turn gives rise to the other two doshas, Pitta and Kapha, which Vata transports where they are needed. The doshas are analogous to the bumors of Hippocratic/Galenic medicine, They have com- ‘ponents of both energy and matter. Because the doshas havea material aspect, they are composed of the five elements space, air, fire, water, and earth. The doshas maintain physi- ‘al and psychological homeostasis. Vata is composed of space and air, itis cold, dry, mobile, hard, and sharp. Pitta represents fire, and is identified with digestion and transfor- mation, [tis composed of fire and water, andis flowing, clear, soft, and smooth. Kapha represents water, and is cohesive. It gives substance to the body, and is composed of water and. earthy it is cold and heavy. “Health isthe balance of the doshas. But the doshas can be ‘out of balance due to inheritance (parents giving an excess of one type over another), or the seasons, the weather, diet, or behavior, Disease can arise out of three factors: failure to maintain oneness with the universe; the natural variation of the quantities of the doshas over a person's lifetime, over the seasons, and over the day; or the senses being exposed to, ‘unhealthy sensations, such as smells and sights. Initially, dis- ease arises as an imperfection in the doshas, usually an excess or deficit. This leads to impairment of the digestive fire, which causes an unbalanced metabolism, which then causes impurities to accumulate in the system. Finally, a disease as ‘we recognize it occurs. A good doctor prevents disease by fos- tering a healthy lifestyle and recognizing an imbalance early in the pathogenesis of disease. It is the poor doctor who must ‘treat an established disease, because this means the early. stages of the disease were missed, ‘The treatment options for an Ayurvedic physician reflect the mot causes of disease. They include “dietary, herbal, lifestyle, behavioral, psychological, meditative, exercise, Yoga and Panchakarma therapeutic interventions." Panachak- arma are five techniques—emesis, purging, enemas, nasal installation of herbal oils, and bloodletting (using a syringe or leeches}—used to remove toxins and impaired doshas, ‘Traditional Chinese medicine ‘TCM's written history is approximately 1000 years old, ‘with many subsequent revisions. The acknowledged primal text is the Yellow Emperor's Classic of Internal Medicine." ‘The Yellow Emperor was the third of the five legendary first emperors of China, reputed to have ruled from 2697 to 2597 BC. The earliest reference to the work was during the Han Dynasty 206 BC to 25 AD); prior to this, it is assumed to have existed in oral form, The currently available text is based ona revision, reputedly from an older text, by Wang JOURNAL. OF CANCER INTEGRATIVE MEDICINE, PALL 208 VOL, 1.0.1 » Ping, finished in 762 AD during the Tang Dynasty ‘The philosophic basis of TCM is less complex than Indian medicine. It focuses on the Tao, or the Way? The pri mary aspect of the Tao is the balance between yang and yin Evaluation of the written characters for yang and yin suggest that their original meaningy reflect the sunny and shady sides of a mountain, respectively. This is also reflected in their attributes. Veith! writes, "Vang stands for san, heaven, day fe, heat, deyness, light, and many other related subjects; ‘Yang tends to expand, to flow upwards and outwards. Yin stands for moon, earth, night, water, cold, dampness, and darkness; Yin tends to contract and flow downwards.” ‘Yang is male and yin is female. The body, like all material ‘objects, is composed of the five elements: earth, fre, water, vwood, and metal, The elements regulate eachother, which is important for maintaining homeostasis, Bach element creates ‘one element and contols another. For example, fire controls ‘metal and creates earth, Wate, in turn, control fire. Chinese anatomy and physiology are one and the same Chinese anatomy is representative not of the body, but of the theoretical functions of the organs, The primary function of the organs is to process qi (chi), the vitalizing fTuid of the body, It is constantly consumed by the body and reabsorbed fiom food. The organs are classified as ive zang organs and six fu organs. The five zang organs-the heart, lung, spleen, kidneys, and liver—transform the absorbed qiand store gi ‘The six fu organs—the gallbladder, large intestine, small intestine, urinary bladder, stomach, and “triple burner" (not physically identifiable organ)—digest, absorb, and excrete nutrients and waste. The zang organs are consicered yin and the fu organs are yang, although all things contain both yin ‘and yang. Yin and yang are two parts of a whole and don't exist in isolation Qi flows between orguns through channels, or meridians. ‘These meridians cometo the surface at specific points it sat these points that acupuncture and moxibustion can be used 10 stimulate or inhibit the ow of qi. Acupuncture ithe insertion ‘of needles to change the flow of qi. Moxibustion isthe use of burning moxa (shredded artemesia) to stimulate qi flow Disease can arse from internal or external disturbances ‘External disturbances often focus on the weather, especially ‘wind. External diseases can become internalized as they progress. Other diseases start internally, tom an imbalance caused by food or improper behavior. Similar to Ayurvedic belief, loss of understanding of the Tao leads to imbalances and illness, Moderation maintains health Herbs can also be used to restore the balance of yin and yang and maintain gi flow. Herbs ae classified by their taste (or flavors). The five favors are pungent, sour, sweet, salty and bitter. Different flavors will affect different organs and, the herbs are choven based on theis exciting or calming prop- erties Diagnosis is made by careful observation of the patient, particularly by measuring the pulse. The pulse is measured at three points at the distal end of the radial artery atthe wrist ‘The strength and texture of these pulses determine the nature ‘of the disease. Palpation of both the right and left pulses must be made, because they represent different organs. The mea- surement of the pulse is supplemented with observation of the patient, including such details as the color and texture of the tongue and the color of the skin, and by learning of the patient's present and past symptoms ‘The following diagnosis and wreatment of burns (an area of interest to radiation oncologists) comes from a modern TCM textbook" + Etiology. Burns by such agents as fire and heat may lead t decay of the skin and flesh. Extensive burns can injure vital energy, blood and body fluid, and internal organs. Serious complications include inward attack of toxic heat, which may invade the cardiac and nervous system, depletion of body fluid, derangement of vital essence, and collapse due to depletion of vita energy and + Essentials of diagnosis and treatment, In treating, burns, drugs are given orally to help replenish vital essence and enrich body fTuid, remove toxic ‘beat, restore vital function from collapse, and/or strengthen body resistance and speed up healing. Drugs cool in nature are applied externally to help eliminate toxic heat. In emergency cases, burns must be treated with both traditional and modern, medicine, + Treatment based on differentiation of symptom- complexes. Burns caused by exposure to fire and resulting in injury of vital essence (usually moder ate burns). Manifestations: Fever, restlessness, thirst, dry mouth, concentrated urine, constipa- sion, yellow and reddened tongue with or without coating, taut, rapid or thready, rapid pulse Principle of treatment: Removing toxic heat and replenishing vital essence to enrich body fluid. Prescription: Decoction of five detoxicants in combination with decoction for enriching the body fiuid, with modifications. 20 JOURNAL OF CANCER INTEGRATIVE MEDICINE, PALL 24 VOL. 1,N0.1 The text goes on to describe the herbal constituents and quantities, Different treatments are given for different symp- ‘tom seis from burns, such as “Collapse Due to Depletion of Vital Essence and Vital Energy,” “Inward Attack of Toxic “Heat,” and “Deficiencies of Both Vital Energy and Blood.” Homeopathy Homeopathy is often confused with naturopathy, an herbal approach to western medical diagnosis and treatment ‘Homeopathy also uses herbs, as well as metals and salts, but has a unique underlying belief system: the principle of simik fars. When this term is used outside of homeopathy, it means that a plant with a certain shape, for example a heart, will be effective for treating the heart. In homeopathy, it means that an hetb or other compound that at full dose causes a symp: tom, eg, headache, will atower doses cure that symptom. ‘The more the compoundis diluted, the more potent it willbe, However, the dilution must be made using prescribed tech- niques for this “potentization,” with particular care to vigo ‘ously shake the solution at each step. The process of testing what the fll strength compound will eause, and therefore in dilution cure, is called proving. The provings are published in a homeopathic materia medica. For an introduction to ‘homeopathy, see Cummings and Ullman.'® ‘A basic tenet of homeopathy is thatthe person must be tveated holistically. A symptom is only a sign of the undesly- ing illness and the whole person—physically and psychologi ccally—must be treated. Rarely is more than one disease present, so multiple illnesses probably represent a deeper, ‘nderiying single iliness. Hering’s Law of Cure says that the ‘cure will progress from the deeper levels, where i is more severe, tothe superficial level. Another tenet of homeopathy js that single agents, ather than compounds, should be used. Often the agent needs only to be used once. The agent acts as ‘a catalyst to start the body's natural healing properties and doesn't need tobe reintosced, ‘Bvidence-based evaluations of alternative medical systems ‘No systematic investigations of the efficacy of home opathy, TCM, or Ayurvedic medicine have taken place. Evaluations of Ayurvedic or TCM herbal preparations and homeopathic preparations have been performed, but do not representa testing of the systems, Such systems require that ‘each patient be diagnosed and treated using the precepts of that system, not western medicine (as exemplified by the earlier quotation on buras), In western medicine, itis the disease rather than the person that is treated, so all persons with the same disease are treated the same, Randomized clin» ical trials cannot be run when there may not be agreement among practitioners as to the nature of the diagnosis. Some supporters of alternative medical systems deny the need for research trials, citing the centuries of years of use as proof of ellicacy. This approach is fallacious, as early trials of bloodletting showed."” Common acceptance doesn’t neces- sarily equate with objective proof. Therefore other ap- proaches are needed. Parallel treatment studies have been suggested. These trials would not be randomized but would have western and alternative physicians separately diagnose the same patients, This would allow a common basis for ‘comparison of the outcome of the treatments. Patients ‘would select the approach they want t9 use. This would be a type of case-control study, and although not as rigidly con trolled asa randomized tral, it would supply a level of rigor to efficacy trials. ‘Traditional Chinese medicine and the oncology patient Because Iam most familiar with TCM, I will discuss the uses and risks of TCM among cancer patients. Many TCM techniques have a place as complementary treatments for ‘cancer patients. For example, a National Cancer Institute ‘consensus committee in 1997 recommended acupuncture for ‘nausea during chemotherapy." Acupuncture has been stud~ ied for xerostomia induced by radiation therapy. Several trials ‘have shown thatit increases salivary Function, even in pilo- carping resistant patients"? During treatment, some patients use tai chi or i-gong, gentle exercises used to redirect ‘energy flow and maintain internal balance. A Medline search showed no trials showing efficacy in humans. At least two studies have shown that alteration of qi by a qi-gong master ‘ean inhibit tumor growth in vive22* Utilization of TCM herbs represents more of a chal- lenge. One problem is that Chinese herbs, especially those imported from China, may be adulterated with allopathic medications. Chinese herbs have been shown to be toxic in their own right, causing, for example, anticholine symptoms The popular Chinese herbal mixture Ma Huang contains ephedra and ean interact with standard medications However, the data discussing the toxicity of herbals are patchy and often anecdotal. Attempts have been made to set ‘up a comprehensive database,2 but there is a tremendous. number of Chinese heths and mixtures, and many are mar= keted under proprietary names, Any patient taking Chinese heibs (or any herb) must exercise caution, Patients must real- ize they are taking a risk of unknown maunitude when mix- ing modern and traditional medicines, and that most practitioners and lay people recommending these herbs have litle to no insight into their potential toxicity. JOURNAL OF CANCER INTEGRATIVE MEDICINE, PALL. 2003 VOL. 1, 2 CONCLUSION ‘Western medicine's research paradigm for cancer treat ment is based on cell theory and derivatives, such as the ‘genome and more recently the proteome. It has been slow to embrace the systemic nature of many cancers, and still defines this systemic involvement as ces spreading to various locations rather than a susceptibility of the body to the cancer cells, Alternative medical systems look at disease as primarily systemic with local manifestations of the systemic disease. ‘The Western approach focuses treatment on removing the pathogen. The altemative approach focuses on strengthening and rebalancing the host. Both approaches may benefit the ‘cancer patient, The lack of understanding of the scientific basis and philosophy of alternative medical systems should ‘not cause western physicians to arbitrarily dismiss them as incorrect. An appreciation of what they have to offer may lead to treatment advances that cannot be foreseen in the pre- sent research heuristic. 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