Chinese medicine: history, features, influences, and perceptions

Origins

Chinese medicine as we know it today began to emerge, with the birth of efforts to understand the natural world in terms of laws a few centuries BCE, healers began to develop a theory-based understanding of health and sickness. Through careful observation and deduction, medical scholars realized that the body was composed of different organs each of which performed some vital function and that physical nature of each organ provided clues as to its function. They began to explain illness in terms of disturbances of functions caused by environmental influences, dietary irregularities, or internal imbalances between body substances and functions.

Natural, Supernatural, and Magical Causality

In the earliest times, medical interventions took the form of symptomatic treatments. Vegetable, animal and mineral products were ingested or applied to the body for their symptomatic effects. Sharpened stones and bamboo were used for lancing abscesses and for bloodletting (the presumed origin of acupuncture). This is natural causes.

Sudden afflictions with no obvious natural cause were attributed to ancestors and spirits and were treated by placating the offending beings in the supernatural world. Magical practices designed to combat demonic forces were also applied to many illnesses that had no apparent physical causes. This is supernatural causality.

There was also a belief that similar things could affect each other, so that, for example, stabbing an effigy of a person can harm the person it is intended to represent) or that eating an animal’s penis could enhance male sexual vigor. This is magical causality.

With increasing efforts to find explanations in terms of natural laws, supernatural causes of illness tended to be replaced with natural causes. Magical causality did not disappear entirely, but it underwent change.

Analysis vs Analogy

The notion that phenomena have natural causes guides attention to the observable phenomena to discover the natural laws they follow. This entails isolating different possible factors giving rise to a particular thing or phenomenon and observing which factor or factors are the most likely cause. In other words, the search for natural causes involves analytical reasoning. To understand the workings of the body, medical scholars thus focused on the internal organs. They deduced that the lung absorbed air, the kidney produced urine, the heart was responsible for moving blood around the body, and the stomach was a collecting place of food from which nutrients were absorbed.

Qì, yīn-yáng, and the five phases: The products of natural philosophy at the time reveal not only analytical reasoning but also a strong influence of analogical reasoning, whereby the similarity of disparate things and phenomena were deemed to be of explanatory significance. Analogical reasoning is seen on the one hand in the concepts of qì and on the other in the yīn-yáng and five-phase systems of correspondence, which were developed by natural philosophers and adopted by medical scholars as the foundation stones of a theory-based medicine. As Paul U. Unschuld points out in his Medicine in China (University of California Press, 1985), the Chinese systems of correspondence bear strong similarities to magical causality.

• Yīn-yáng is a system where a whole host of phenomena that can easily be classified as complementary opposites such as cold/heat, night/day, dark/light, female/male, moon/sun, down/up, etc. This paradigm largely rests on physical connections, such as the connections between cold, night, and winter. However, the broader the yīn-yáng net is cast, the more tenuous the physical connections become. Down/up, male/female, moon/sun have only associative connections.
• The five phases operate in the same way as yīn-yáng, but classify things according to five properties rather than two. Wood, fire, earth, metal, and water represent not physical elements, but types of activity evinced in five seasons of the year, birth in spring, growth in summer, transformation in late summer, withdrawal in autumn, and storage in winter. In five-phase theory, strong physical connections between corresponding phenomena are less apparent than in yīn-yáng theory, to the point where some are far-fetched (e.g., the correspondence of animals with the phases.
• Qì was posited by natural philosophers as the basic stuff of the natural world on the basis of the properties of water. Qì originally meant clouds, mist, vapor, steam, air, i.e., something that could take on different forms. From this it was deduced that qì was the basic substance of the universe that simply appeared in different forms. Steam from boiling water is invisible and wind in the environment are invisible but powerful forms of qì, thus allowing the basic building block of the material world to also explain all activity. Under the influence of the yīn-yáng doctrine, solids and liquids were classed as yīn qì, while the motor force of activity and transformation in the university was yáng-qì.

These doctrines and analogical way of thinking that underlines them explain how the Chinese medical model did not develop a model of the body that completely accord with that of modern biomedicine.

The authors of the Huáng Dì Nèi Jīng (黄帝内经 The Yellow Emperor’s Inner Classic), the earliest extant seminal text of a theory-based approach to medicine in China, appear to have been quite aware of the importance of analogy in the model of health and sickness they presented. They explicitly stated that analogy was indispensable to a comprehensive understanding of health and sickness.

Qì provided medical scholars with a framework for understand the material and non-material aspects of the body. Solids (flesh, bone, sinew), and liquids (the blood and other fluids) were classed as yīn qì, while the forces of movement and transformation seen only by their effects on matter, were classed as yáng qì. Qì is understood by many Westerners as being this force of activity and transformation, but it is important to note that, strictly speaking, this is the yáng manifestation of the qì that the whole universe is made of.

Yīn and yáng provided a framework for understanding physiological and pathological process in terms similar to fire and water. The solids and fluids of the body are yīn, standing in complementary opposition to warming and activating force of yáng qì. When, for example, yīn qì, i.e., the solids and especially fluids are abundant, it keeps yáng qì in check, and if it for any reason becomes insufficient, yáng qì is becomes disproportionately strong, giving rise to pathological heat in the body.

The movement of water through the body conceived in terms of the yīn-yáng cycle of water in the environment. Yīn and yáng represent not only different forms of qì of differing density but also directions of movement. Downward movement is yīn, while upward movement is yáng. By the power of the lung, fluids in the body descend to the kidney as rain falls from the sky, while the yáng qì of the kidney warms the fluids, causing them to steam upward to upper part of the body, as the sun causes water to evaporate from the surface of the earth.

Yīn-yáng also offered a framework for understanding the internal organs of the body by classifying them according to whether they stored substances (a yīn quality) or allowed them to flow through them (a yáng quality). The heart, liver, spleen, lung, and kidney were deemed to store substances, i.e., to retain or promote absorption of them, while the stomach, large and small intestines, gallbladder, bladder and an additional organ called the triple burner were deemed to discharge substances, i.e., allow them to flow through and out of them, as food flows through and out of the digestive tract, bile flows out of the gallbladder, and water flows through and out of the triple burner.

Because the yīn-yáng doctrine only incorporates paired phenomena, the two kinds of internal organs had to be paired. The liver was naturally paired with the gallbladder, while the kidney was paired with the bladder. The spleen, lying next to the stomach, was considered to absorb and thus store the nutrients from the food. The heart with the small intestine and the lung with the large intestine are not so readily explicable.

The storing organs, which we refer to as bowels or, to emphasize their original conception, as storehouses, are five in number, allowing a categorization according to the five phases, which made a monumental contribution to their understanding. Thus, the liver was paired with wood, the heart with fire, the spleen with earth, the lung with metal, and the kidney with water. The reasons for these pairings in two cases are quite obvious: the kidney was paired with the water phases on account of its producing urine; the spleen, identified as the yīn-yáng partner of the stomach, was assigned to earth because just as earth provides the sustenance for humans and animals, so the spleen produces the nutrients that keep the body alive. The reasons for these and the other less obvious three pairings are discussed under the following links.

• analogy in Chinese medicine: heart, fire, Sovereign
• analogy in Chinese medicine: lung, metal, Minister-Mentor
• analogy in Chinese medicine: spleen, earth, Office of the Granaries
• analogy in Chinese medicine: liver, wood, General
• analogy in Chinese medicine: kidney, water, Office of Forceful Action

Since potentially all phenomena in the universe could be categorized according to the yīn-yáng and five-phase systems of correspondence, medical scholars used the five phases to classify not only the major internal organs but also other organs and tissues of the body, as well as fluids, psychic components, and sounds, as the table below shows.

The systems of correspondence constitute a paradigm pervading all aspects of Chinese medicine. Yīn and yáng classify body parts such as upper body/lower body, exterior/interior, the bowels and viscera, and the channels and network vessels (the pathways of qì). They provide a diagnostic framework for evaluating complexion colors, sounds, pain and for categorizing patterns. In treatment, they classify the nature of medicinal effects on the body (warm-hot/cool-cold) and medicinal actions (upfloaters/downsinkers).

The five phases classify the viscera and all their associated domains indicated in the table above: the five humors, the five spiritual entities, the five body constituents, the five voices, the five aversions. It is no coincidence that the word five appears in a substantial slough of disease category names: the five impediments, five taxations, five stranguries, five wheels, five unmanlinesses, five unwomanlinesses, five limpnesses, five accumulations.

Analogical reasoning goes far beyond the systems of correspondence: Analogies appearing in the physiological model of the body were not limited to those implicit in the systems of correspondence. As can be seen from the links and the table above, governmental analogies also figured in the model, reflecting how ancient medical scholars viewed the body by analogy to the administration of the then newly united empire of the time. Thus, since the heart is understood as storing the spirit (i.e., as the seat of consciousness), it is like the sovereign of a nation. Since the spleen is understood as a digestive organ responsible for absorbing nutrients from the stomach, it given the epithet of official of the granaries.

Analogies are found outside physiology. The attribution of certain illnesses to environmental conditions including wind, cold, heat, dampness, and dryness reflects a belief in natural causes and analytical reasoning. External cold obviously causes cold conditions in the body; external heat obviously causes hot conditions. Yet, even here, analogical reasoning creeps in. Wind is considered to penetrate the skin and, under certain circumstances is capable of producing convulsions or tremors, as wind causes the branches of to bend and sway. Since, according to our modern understanding, wind is a moving air, it cannot enter the body, so that the relationship between wind and spasm is purely analogical in nature.

The treatments offered by the Huáng Dì Nèi Jīng involved acupuncture and moxibustion. It was only much later that medicinal therapy was incorporated into this corpus, although the acupuncture and medicinal modalities remained, as they still do, distinct traditions. Nevertheless, analogical reasoning played an important role in the investigation of the effects of medicinals, reflecting the fact that analogical reasoning was not limited to natural philosophy and medicine. Plant stems with tubular structures (e.g., mutong) promote urination; animal penises promote virility; red things act on the heart (fire phase); white things act on the lung (metal phase).

Modern Chinese-language textbooks do not highlight or categorically ignore the analogical aspects of Chinese medicine, probably because they wish to avoid the impression that Chinese medicine is primitive. Many Western-language texts do not either. This is because Westerners have been provided with textbooks from the PRC and few learn Chinese to a level that makes access to the primary Chinese medical texts possible. However, scholars of medical history are well aware of the role of analogical reasoning in the creation of the Chinese medical model. In recent years, the analogical approach has attracted new interest among Chinese medical scholars as a result of the findings of linguistic and neuroscientific research in the West.

Historical Evolution

Formative Period

Medicinal therapy was originally applied symptomatically. Early literature on the subject reveals little or no theory about specific actions of agents on specific functions of the body. It was with the development of acupuncture that a theory-based medicine first developed. The earliest extant text presenting these ideas was the Huáng Dì Nèi Jīng (Yellow Emperor’s Inner Classic), written in the Early Hàn era (first and second century BCE). Similar ideas are presented in the Nàn Jīng (难经Classic of Difficult Issues), published slightly later. Many of the core ideas of the Nèi Jīng form the basis of physiology and pathology to this day.

Soon after the appearance of the Nàn Jīng, Zhāng Jī (张机), better known to many as Zhāng Zhòng-Jǐng (张仲景), incorporated medicinal therapy into the theory-based medicine for the first time. His work survives in the form of the Shāng Hán Lùn (On Cold Damage), which discusses febrile diseases, and the Jīn Guì Yào Lüè (Essential Prescriptions of the Golden Cabinet), which covers other diseases. Nevertheless, Zhāng’s work did not gain a following for centuries. Only in the Sòng dynasty (10th to 13th century) did theory-based medicinal therapy become mainstream.

The Medieval Period (220–960 CE)

The medieval period saw a gradual development of the existing framework. The appearance of the Zhēn Jiǔ Jiǎ Yǐ Jīng (Systematic Classic of Acupuncture and Moxibustion) by Huáng-Fǔ Mì reveals that the number of treatable acupuncture points had doubled since the appearance of the Nèi Jīng. In the Mài Jīng (Pulse Classic), Wáng Shū-Hé developed a system of standard pulses that are still used in modern clinical practice. Cháo Yuán-Fāng wrote the Zhū Bìng Yuán Hòu Lùn (The Origin and Indicators of Diseases), which is the earliest book to systematically enumerate the causes and symptoms of diseases.

The Sòng-Jīn-Yuán Period (960–1368 CE)

From the Sòng dynasty (960–1279 CE) onwards, clinical experience flourished to produce new ideas about the underlying causes of medical conditions, giving rise to the Cold-Cool School, the Offensive Precipitation School, the Spleen-Stomach School, and the Yīn-Nourishing School. This period also saw the systematic investigation of the flavors of medicinal and their five-phase correspondence and the emergence of tongue diagnosis.

The Míng–Qīng Period (1368–1911 CE)

The Míng-Qīng period was marked by two main highlights. One is the Běn Cǎo Gāng Mù (本草纲目 Comprehensive Materia Medica) by Lǐ Shí-Zhēn (李时珍), a monumental summarization of the pharmaceutical knowledge of the time. The other was the development of the warm-disease theory, a new system of analyzing and treating external contractions that placed the emphasis on heat (warm disease theory). This system did not replace the older cold damage system developed by Zhāng Jī in the Hàn dynasty but provided an alternative way of understanding and treating febrile disease.

Modern Era

In the 20th century, underwent many changes. After almost being outlawed by the Kuomingtang (KMT) government in the 1920s, Chinese medicine was revived by the Communist Party, who believed it had a vital role to play in health care at a time when biomedical care was not available to a large segment of the population.

Scholars collected the most valuable elements of the medical tradition, sifting out any magico-religious elements considered unsuitable in the modern age. They created a large range of textbooks that could efficiently provide instruction, which now took place in large classrooms rather than in the traditional master-apprentice setting. Even though basic theories including yīn-yáng, the five phases, qì, the channels were considered unscientific, these were nevertheless retained in the interests of preserving the theoretical integrity of the discipline. The only major change was to make the diagnostic procedure more efficient, the ancient notion that a specific disease could arise by different pathomechanisms was developed into a complex system of pattern identification.

In the West, China’s healing art attracted great attention in the second half of the 20th century. This was fostered by dissatisfaction with modern biomedicine on account of numerous perceived failings. Despite this new popularity, Chinese medicine as a healing art originating in the distant past of a distant culture faced major problems in transmission and translation, the greatest single factor being the West’s failure to gain linguistic access to the primary Chinese sources of the tradition.

External Influences

Chinese medicine has been subject to numerous influences from outside medicine over its history. As previously explained, the concepts of qì and the systems of correspondence were borrowed from natural philosophy. More generally, healing practices based on a theoretical model evolved with philosophical ideas held by social elites.

Confucianism

Confucianism, the philosophical doctrine that has been most influential for the last 2,000 years, has left the largest imprint on Chinese medicine. As a doctrine intended principally to promote benevolence, virtue, and harmony within a strict social hierarchy, it was uninterested in the supernatural world beyond reverence for ancestors. Viewing medicine as a benevolent art, it propagated the notion of disregard for profit and provision of care regardless of the social or economic status of patients. As a pragmatic doctrine, it espoused a deterministic view of the world and served to move medical thought away from supernatural and magical causes to natural causes. The physiology of Chinese medicine, modeled on the natural world and the Chinese empire, strongly reflects the Confucian world view.

Confucian respect for elders, ancestors, and teachers created an intellectual atmosphere of reverence for the foundational medical texts. Although Confucianism welcomed new ideas, it expected these to be added to the corpus of old ideas rather than replacing them.

Daoism

Daoism was a new philosophy pioneered by Lǎo Zǐ and Zhuāng Zǐ that came on the scene slightly later than Confucius’s doctrine. Initially, Daoism tended to consider medical treatment of illness as an interference in the course of nature, although prevention of illness was considered acceptable. The precedence of prevention over treatment was reflected in the early materia medica literature, in which medicines that nourished life and the body were labeled as rulers and ministers, while those that treated illness were classed merely as assistants and considered to be toxic.

With the rise of a new religious form of Daoism, there developed a cult of immortality, which involved the consumption of toxic substances that shortened rather than prolonged life. This left no imprint on the future development of medicinal therapy. However, physical exercise and breath control practices evolved over the centuries and were adopted into religious Daoism. These survive as keep-fit practices to this day.

Buddhism

Buddhism arrived in China in the first century CE. Inspired by compassion and relief of suffering, Buddhism has always viewed the practice of medicine positively as a means of gaining good karma. However, Buddhism concretely contributed to Chinese medicine only by the introduction of certain medicinals and surgical techniques for cataracts, the latter being too invasive for Chinese taste.

Modern Challenges

In modern times, the need to resist the challenges of biomedicine and adapt education to the modern environment brought about major changes in the presentation of the subject. Nevertheless, the basic theories of Chinese medicine have remained untouched.

Western Perceptions

To this day, perceptions of Chinese medicine in the West, despite a considerable increase in translations, are still quite different from those that prevail in the Chinese world.

Chinese medicine is widely understood in the West as a natural and holistic medicine. Although this is not entirely incorrect, it is useful to understand the origins of this characterization in the Western world and to see precisely how well they apply to Chinese medicine.

Acupuncture is widely believed amongst Westerners to have always been the main modality in the Chinese fight against sickness. In fact, it has not been for centuries. Its use was even banned in the Qīng dynasty court.

The notion of patterns is often identified as a major distinguishing feature of Chinese medicine. This statement is true only if it is carefully qualified. Chinese medicine has traditionally recognized a wide range of diseases, more than a hundred of which are regularly discussed in modern Chinese-language textbooks introducing basic theories. English-language writers for many years only mentioned a handful of diseases. The notion of patterns can be traced back to the principle stated in the Huáng Dì Nèi Jīng that any disease can manifest in different ways requiring different treatments. However, this principle was originally simply understood to mean that treatment should reflect the operant pathomechanism. The idea that pathologies could be viewed in terms of a large array of patterns did not appear until the Míng-Qīng period (1368–1911 CE) and only in the 20th century did pattern identification gain primacy over disease identification.

Many characterize Chinese medicine as a practical skill, principally mastered through interaction with patients. However, this notion, which stems from a dissatisfaction with biomedicine’s reliance on complex science and technology rather than on physician-patient interaction, ignores the fact that the Chinese tradition stresses reading and re-reading of the classics and the famous latter-day physicians.

The belief that Chinese medicine is Daoist art has been widespread over recent decades in the West. It stems from two misconceptions. One is that yīn-yáng and the five phases so widely applied in Chinese medicine are of Daoist origin. This constitutes a fallacy because the appearance of the systems of correspondence antedates the development of Daoism. The other misconception concerns the importance of Daoism in China. Confucianism has been the dominant philosophy for 2,000 years that even Marxism-Leninism in the 20th century did little to change. The tendency to attribute Chinese medical theories to Daoist sources is explained by the great appeal that Daoism holds for modern Westerners and the lack of appeal of the more authoritarian doctrines of Confucianism, which did much more to shape the development of China’s healing arts.

Chinese medicine is often understood to be a spiritual form of healing. This again is attributable to Western interest in Daoism as a philosophy that has helped to fill the vacuum left by the decline of Christianity in the West. While the Five Elements school, which is the main focus of spiritual applications of Chinese medicine, has produced an interesting variant of Chinese medical practice, it would be wrong to think that it in any way faithfully reflects any of the various traditions of China.

All misconceptions of Chinese medicine are essentially attributable to a lack of familiarity with Chinese culture, Chinese history, and the Chinese language.