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TCM Reconsidered

by Todd Luger, L.Ac.

I have wanted to discuss the distinctions between so-called Traditional Chinese Medicine (TCM) and Classical Chinese Medicine (CCM), as I remain unclear in this regard.  I am most interested in how the clinical process may differ between the two approaches.  My understanding of TCM is as follows:

1.  that it attempts to integrate into one systematic framework a wide variety of diagnostic frameworks and theoretical concepts, which developed independently over the course of Chinese medical history.

2.  It is based on the principle of treatment selection according to differentiation of patterns (bian zheng lun zhi).

3.  It is mainly influenced by the "secular" practice of herbal medicine, rather than acupuncture or Daoist arts.

In many ways it is a continuation of the scholarly Confucian style of medicine.  The antecedents of TCM can be seen in much earlier works, like those of Zhu Danxi and Fu Qingzhu, as well as modern precommunist works like Qin Bowei.  Thus, Chinese Medicine was apparently drifting in a rationalistic, materialistic direction before the communists came in and accelerated the process.  I have heard Heiner Fruehauf suggest this himself, pointing out that tongue inspection is a later, more materialistic addition to Chinese diagnostics, not being prominent in ancient texts.

Of course, there is no doubt that the communists radically purged official textbook TCM of politically unacceptable ideas.   However, it is also Paul Unschuld's thesis that political constraints have impacted the nature of mainstream publication about Chinese Medicine since the Han dynasty.  Even the Neijing has not so subtle political overtures being made to the state in the overt metaphorical relationships between the feudal aristocracy and the organs of the body, for instance.  Since many scholars were being executed and books being burned at this time, it would seem to me that the Neijing would have to been written in a particular way to avoid a similar fate.  While modern TCM texts can hardly be compared to the Neijing, the modern codification of Chinese medicine did allow it to survive in an uncertain political climate, as ancient medical systems faded in the rest of the world.

The main Confucian scholars who have dominated the written literature of Chinese Medicine for the last 1000 years were also not very keen on psychotherapy, spiritual practice or shamanism, according to Needham, Sivin, Unschuld and Flaws.  Thus,  such omissions from the TCM literature cannot be blamed completely on the modern cultural reformers.  The tendency to downplay these areas was already inherent in the classical medical literature when the old masters sat down to write the first textbooks of TCM in the fifties.  Personally, I have no doubt that yoga and shamanism were the foundations of ancient medical practice (Needham, Flaws and Unschuld also agree with this position).  It is also true that Buddhists and Taoists, as well as the many Confucian doctors who were also closet adepts, continued to give such approaches prominence in their own medical practices through the ages.  Unfortunately, these styles of medicine have not been made nearly as accessible to the western reader as modern TCM, for such information and approaches would be of great value to our practice of Chinese medicine.  There is much written about Daoism in English, including many respected translations and one adequate journal, but it still remains unclear how to integrate this information into our practices.  It would be nice to know what the Daoist doctors wrote about their medical practices,  Apparently much of this information remains untranslated at this time, though Heiner Fruehauf provides frequent glimpses in his lectures and writings.

As I see it, the problems with TCM are not so much that it continued the historical trend towards materialism evident in all literate world cultures in the last 2000 years or that it's development was constrained  by local political factors.  There is nothing new about these processes, which are probably beyond the control of individuals or even governments.  TCM thus cannot be criticized for being part of the times in which it was codified.  What must be remembered about TCM is that it was created as a system of teaching, more so than as a system of practice, which can be evidenced by watching dedicated modern practitioners from the PRC practice their craft.  Many travelers to China (including Fruehauf, Bob Flaws and Volker Scheid, for example) contend that many, if not most, practitioners of TCM in modern China are not interested in what they do, nor do it seriously or well.  I believe this is not true of all those who come to America to teach.  While some practice in a very uninspired textbook fashion, others are constantly drawing on sources and explanations drawn from the entire history of Chinese medicine to inform their clinical decisions.

Unfortunately, most students are not prepared to receive these gems and thus uninspired textbook TCM is what usually gets practiced by interns and also by many graduates of American schools.  However, many students don't really like TCM or have heard it is "bad", but since they do not grasp the classical ideas, there is a tendency to gravitate to much, much worse simplifications of Chinese medicine.  So-called 5 element, jin shin do, and Mark Seem's Acupuncture Osteopathy are popular among acupuncturists.  Yet, TCM is actually much truer to tradition than any of these other styles, so what is its flaw?

I believe the main flaw of textbook TCM is the way it has apparently reduced the therapeutic process to something akin to a computer flow chart.  Rather than understanding basic theory and evaluating each patient individually (with reference to the classics, of course, as well as case studies, if appropriate),  the typical TCM doctor begins his evaluation assuming a limited range of possibilities for a given disease and focuses his questioning to differentiate between these.  Such a method of practice could actually be programmed into a normal binary computer.  Thus, if one was not taught to consider dampheat as a cause of nightsweats, for instance, one will never arrive at that diagnosis, using the TCM shortcut method.  Countless times, I have seen patients pigeonholed into prechosen categories, despite a preponderance of evidence contradicting their diagnoses when they are thoroughly and openmindedly questioned.  While the formulas are usually modified to correct gross digestive upset or treat specific symptoms, the process is still very circumscribed.   If one is unable to see beyond these TCM boxes, one may easily miss the obvious.

However, is it not true that TCM and what Heiner Fruehauf calls CCM share in common the approach of bian zheng lun zhi and both rely on the process of gathering information via the four methods, determining the nature of disharmony according to zang-fu, six pathogens, liujing, wenbing, wuxing, jing luo, sanjiao, etc., selecting and prioritizing treatment principles, choosing formulae and modifying them for the patient?  Is it possible that the suposed dichotomy between these styles of practice is actually an artifical one? To elaborate, modern sinoanthropologist Judith Farquhar refers frequently in her writings to a concept she labels the "archive of Chinese medicine".  It is her thesis that theory and practice are linked in classical Chinese medicine by the archive of accumulated medical lore.  The best doctors are the ones who have broad access to the classical archive.  They may very well use textbook TCM patterns as a pivot point from which to enter this archive.  The nature of this archive is very individual and is both learned from teachers and developed from one's own explorations into the archive (keeping in mind that historically, most new ideas in Chinese medicine have been rooted, at least tenuously, in older ideas.  They are not usually drawn from thin air).  Every new encounter with a patient thus stimulates and guides one's path through the archive, fresh and different each time.

According to Farquhar, who spent much time in China  studying TCM herself, this is the highest method of practice in TCM, but is often eschewed by students in favor of the much easier "cookbook" method illustrated in the basic textbooks.  Thus, TCM tends to look oversimplistic both on paper and in practice, these days.  Is there more to it than that?  I have observed many Chinese doctors closely for many years, both in school and at Chinatown herbal shops and they all seem to use the same basic method, whether they are TCM university trained or not.  However, that last step that leads them to the formula is never completely transparent to me, though, unless they are obviously practicing textbook TCM (you know, give tian ma gou teng yin in high blood pressure, ha-ha!).  I know they are wandering well-trod paths through the archive, but I can only discover their routes by close questioning.  They are rarely obvious.  This style of practice has been called Classical Chinese Medicine by Heiner Fruehauf, though Farquhar just calls it TCM and Flaws now rejects the term classical altogether as being artificial?  Personally, I agree with Flaws and Farquhar. This is because my long observation suggests that the clinical process of those who promote CCM is no different than those who promote TCM?  Some of my TCM teachers tell me that there are a limited number of etiologies and pathogeneses for any given symptom or disease.  Yet others seem to be much less circumscribed in their clinical process, drawing liberally from the classics.

So-called CCM is nothing more than TCM practiced in a sophisticated fashion, open ended and unfixed in its possibilities.  It is a realm easily accessed by those trained in cookbook TCM, if they are willing to cast off their blinders.  Textbook TCM provides an adequate framework for the presentation of basic concepts (albeit with considerable room for a reinfusion of spirit and creativity).  It  falters when it defines disease in a static, finite form (like western medicine, I might add).  Patterns of disharmony (zheng) in the classics and later texts by great physicians seem usually to be described in a dynamic context, generally in relation to real cases.  Description of these patterns was never meant to limit one's choices, but rather to guide one's creative process.  As my teacher Li Wei always said to me as a student, it is the way of thinking that is revealed in the classical formularies that is their greatest value, moreso than the formulas themselves.  A formula is an idea developed from experience, never used in exactly the same way.  It should be such ideas that guide us in practice; one should avoid rigid use of both words and herbs.  Similarly, the old masters who created TCM under the watchful eye of communist demagogues could only have meant for it to point the way.  They couldn't have meant for it to be the way, because that is never possible.


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