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Thought, History and Critique: An appreciation of Chinese Medical Canon Relative to Pulse Diagnosis

(c) 2014 William R. Morris< PhD Pulse diagnosis. Thought, History and Critique provides a critical analysis of Leon Hammer’s article, Tradition and Revision (2002), republished as Discussion on Wang Shu He Pulse Classic, Parts One and Two (2009a, 2009b). In this critique, I adopt three vectors of rhetoric. First, I discuss medical epistemology (how we think and build knowledge) relative to pulse diagnosis. Second is an exploration of canonical lore and traditions relative to medical knowledge. Thirdly I discuss contributions that Hammer has made to the field. He is a teacher with whom I taught and studied between 1993 and 2000. This paper continues a debate and provides a critique of commentary contained in what I will call Tradition and Revision for the rest of this article and where I address the two pulses that the author highlights, the tight pulse and the choppy pulse (2002). The three points of view of knowledge, history and critique are woven throughout this piece. Matters of Thought: Can we really separate theory and practice? Pulse diagnosis is not a purely pragmatic discipline where philosophical considerations have no import. Rather, theory and philosophy are critical as theory and practice have informed each other throughout the history of Chinese medicine as a medical science. Theory helps people to make some sense of reality, enabling us to make assumptions and predictions about the world. It contains methods for selecting and arranging, prioritizing and legitimating what we see and do. The language of a theory can be used as a way of organizing and determining action (Smith, 1999). It helps us to interpret what is being told to us through the complex of signs and symptoms. Perhaps more importantly, theory helps us to deal with contradictions, uncertainties and resistances (p. 38). In his Discussion on Tradition and Revision, which is also presented in Chapter 1 Preliminary Reflections: Tradition and Revision (Hammer, 2001, p. 3), Hammer divides the transmission of Chinese medical knowledge into two paths. One “abstract and highly theoretical court medicine,” and the other, “based on experience and that could not be recorded for posterity by the written word unless approved by the Emperor’s court physicians” (p. 3). Resolving this dualism and the valuing of family practices over the canonical literature, I make the assertion that there is practical value in both literary and family traditions. We cannot separate abstract and concrete thinking for the purposes of valuing one form of knowledge over another. The act of pulse diagnosis involves both abstraction and pragmatic clinical applications. Correspondingly, it is important to acknowledge that the theoretical model is not the pulse, just as the map is not the territory (Korzybski, 1921). It is a form of naive materialism to assume a real external world that directly causes our perceptions (Petrilli & Ponzio, 2008). An example of this latter point is the way that a stick seems to bend when half is in water, and half out. Yet, we do use pulse models to inform inquiry and direct interpretation. Models can be useful tools, but the information obtained tends to be comprised of binary distinctions and are descriptive in a limited way. Further, knowledge evoked by models can become separated from experience and lost in reified concepts and theories. This may turn our attention away from direct inquiry and toward regarding the assumptions of the models themselves as more real than their subject (Tulku, 1984). The point here is that the risks and benefits of models are shared by both family practices and those rooted in literary traditions. Pulse diagnosis methods are subject to the same vulnerabilities as any other model or map, in that they are constructions of reality. The difference is that Hammer’s construct provides an anatomical map, whereas, the canonical literature is built in part from a plural conceptual framework that involves content such as the Shang Han Lun, five phases, six divisions, channel theory and the cycles of essence, nutrient and protective qi. It is important to have a critical understanding of the tools for inquiry, not just the obvious ones that fit our world view, but also to consider those that make us feel uncomfortable, which we avoid (Smith, 1999). For instance, if one were to have bias along the lines of this debate, Hammer’s construct has little capacity for analyzing the involvement of the eight extraordinary vessels or the six channels. By the same token, Wang’s eight extraordinary vessel methods are not very helpful for diagnostics relative to cardiopathology. The ability to select the correct tool for the job has impact on outcomes. Historical Considerations The canonical literature has provided a vital link to solving questions that remained unanswered by the Menghe-Ding family current as I learned it from both Shen and Hammer. In this section, I will build some background for the practices that inform the practical application of canonical tradition. The ‘theory and methods’ of classical literature are reconstructed and validated by practitioners, based upon clinical relevancy and efficacy. The time tested methods of scholar physicians sustain no matter the era or geographic location of their practice. The Difficult Classic (Nan Jing) was the first text to specify the radial artery at the wrist as the primary location for collecting pulse diagnosis data, and contains 22 chapters focused on pulse diagnosis. The Difficult Classic (Unschuld, 1986b) is a relatively homogeneous work when compared to The Yellow Emperor’s Classic (Huang Di Nei Jing) (Wu & Wu, 1996), which is an often self-conflicting and heterogeneous body of manuscripts. The Difficult Classic (Nan Jing), however, consistently applies a doctrine of correspondences in which seasons, organs, emotions, pulses, and other factors are correlated systematically (Unschuld, 1985). The Difficult Classic (Nan Jing) provides the core theoretical basis for contemporary Japanese acupuncture practices. During the late Han Dynasty (c. 200 CE), Zhang Zhongjing compiled one of the greatest formularies in the history of Chinese medicine. His manuscript, the Damage by Cold and Miscellaneous Disease Treatise (Shang Han Za Bing Lun) was eventually split into two documents, the Damage by Cold Treatise (Shang Han Lun) and the Synopsis of the Golden Chamber (Jin Gui Yao Lue). Although these two texts deal primarily in Chinese formulary, they are also representative of a highly skilled and experienced practitioner’s record of pulse diagnosis. In creating the Damage by Cold Treatise (Shang Han Lun), Zhang Zhongjing, combined the schools of medical thought that were based upon the Book of Changes (Yi Jing) with the oral traditions (Jing Fang). This led to a six-channel description of pathophysiology and a corresponding herbal formulary. Zhang’s work revolutionized practice. Zhang’s synthesis of family based knowledge and a literary tradition remains an important area of focus for contemporary scholar-physicians. Without a strong basis in both Book of Changes (Yi Jing) theory and access to the practices of oral traditions, Zhang Zhong Jing would not have compiled the Treatise on Damage by Cold (Shang Han Lun) and the Golden Cabinet (Jin Gui Yao Lue). The practices that are based upon literary traditions of Chinese medicine have strong ties to imperial traditions. State officials had the influence to collect manuscripts and information from family traditions and knowledge passed through apprenticeships. Wang Shuhe was such a state official working in the Han Dynasty (c. 200 CE). His writings were kept somewhat intact and received few changes from later authors because of the credibility his work enjoyed due to the wide-ranging and authoritative collection of work in that time frame (Miki Shima, personal conversation, March 2008). Some of the most significant contributions to Chinese pulse diagnosis literature were made during that period of time, including the Difficult Classic (Nan Jing) (Unschuld, 1986a) and the Pulse Classic (Mai Jing) (Wang, 1997). The Jin-Yuan Dynasty medical reforms sustained through a synthesis of canon and family lineage. We can locate similar stories regarding the family lineage attributed to Liu Wan Siu (Wu, 1993-94). In this article, Wu translates a quote from Liu Wan Su in the Su wen bingji baoming ji: When I was twenty-five I directed my aspirations to the Inner Canon. Day and night I never put the book aside. When I was nearly sixty I chanced to meet a celestial man, who gave me a beautiful wine to drink. I had only about a chestnut-hull’s full, but my face turned red as though I were drunk. After I awoke my eyes were perceptive and my mind keen; I had been greatly illuminated (p.40). Liu’s statement demonstrates a life steeped in classical lore prior to transmission from his teacher. His enlightenment had a foundation. Whether this foundation is contemporary state sanctioned programs, family practices or classical literature, there must be a basis for the illumined practice of medicine. The Yellow Emperor’s Classic (Huang Di Nei Jing), the Yi Jing and the Difficult Classic (Nan Jing), provided Li Dong Yuan a foundation for the creation of the Spleen Stomach Classic (Pi Wei Lun) in the context of family lineages. The flourishing of both direct transmission and the canons of Chinese medicine led to a new body of written lore. A contemporary example of synthesizing family lineage and classical lore is the work of Young Wei-jieh. He is the senior disciple of Master Dong and has a PhD from Beijing TCM University in Shang Han Lun. Young is a master of Yi Jing theory and remains influential for both Chinese and Western practitioners. There are many more contemporary practitioners who employ the canons of Chinese medicine safely and in an inspired fashion. Here is an incomplete account of the current standards of practice with respect to the use of canonical literature. There are the current lineages of Kanpo practitioners. This lineage is rooted in the Shang Han Za Bing Lun – the Treatise on Damage by Cold (Zhang, 1999) and Miscellaneous Diseases (Golden Cabinet) (Zhang, 1995). The Kanpo system is covered by government insurance programs in Japan. There are numerous Kanpo practitioners in Japan, US, Europe and other parts of the world such as Australia. As for the Japanese acupuncture tradition, it is rooted in the Nan Jing (Difficult Classic . Schools based on the Difficult Classic include the Toyo Hari and Shakuju systems (Kobayashi, 2001). There are other practitioners who base practice upon the canons such as Kiiko Matsumoto, Koui Kouahari, Shudo Denmai (Denmei, 2003), Ikeda Masakazu and Stephen Birch. Tran Vietduc’s students all practice on the basis of classics. The Academy of Oriental Medicine at Austin (AOMA) also has course work in the core curriculum that involves the Yellow Emperor’s Classic, the Treatise on Damage by Cold and the Golden Cabinet, taught by doctorally prepared faculty from Chengdu TCM University. Other US institutions that make classical studies available as core curriculum content: Southwest Acupuncture College (SWAC) and the New England School of Acupuncture (NESA) pursue classical studies in the Japanese traditions focused upon the Nan Jing. Further, The National College of Natural Medicine (NCNM) also has a program focused upon the classics. Thus, there appears to be a standard of practice in the field with respect to the application of the canon in clinical practice. Whether the knowledge presented is from state approved programs, classical literature or clan based thought, it is important for me to deconstruct that which is presented. My preference in subsequently building knowledges related to practice, is a triangulation between the three rivers of classical literature, family lineage and contemporary practices of medicine, identified by Volker Scheid in Chinese Medicine in Contemporary China: Plurality and Synthesis (2002). Through a participatory world view, I seek to validate the work by cycling between a contemplative hermeneutic analysis of the literature, practice, teaching, peer dialogue and publications. These processes protect against the many distortions that can occur from a mono-view in the transmission of knowledge. This shift of perspective provides depth of perception and reduces errors of assumption (Bateson, 1979). The Rough Pulse (sè mài 澀 脈) and the Tight Pulse (jǐn mài 緊 脈) We now turn to the literary and practical discussions of two pulse diagnostic images, the tight and the choppy pulses. Based upon my study and practice of pulse diagnosis since 1980, combined with a critical analysis of the literature, I present a perspective distinct from that put forth in Tradition and Revision. Hammer seeks to abandon the complex for the simple image of the rough pulse. In his words, “Based on Dr. Shen’s work I have attempted to make the differentiation that Wang found obviously so difficult as evidenced by his confused definition of the pulse associated with blood stasis.” Yet, Hammer does not address the same complexities that Wang Shuhe pursued for a pulse that represented qi, blood and essence depletion along with blood stasis. It would appear that Hammer is not using the same criteria for sign, symptom and pathology as Wang. This, the notion that Wang is confused becomes a matter of perspective. Lu Yubin is also an advocate of the simple rough pulse (sè mài 澀 脈) image, and Hammer turns to him for support, “though the uneven pulse is often seen together with the thready pulse, the slow pulse, the short pulse, the scattered pulse, etc. in the clinic, they are not the basic factors constituting the uneven pulse." These are important distinctions; not one of these features is salient to a rough pulse (sè mài 澀 脈). Lu goes on, "Since the uneven pulse is felt unsmooth, some doctors in the history have suggested that it has intermissions. But their suggestions are not accepted by most physicians, because the uneven pulse, unlike the pulses with intermissions such as the intermittent pulse, the running pulse and knotted pulse, has not abnormal intermission, although it is felt unsmooth” (1996, p. 70). This is also important since the rough pulse does not refer to the arrhythmias. Lu, however, uses a tautology, defining the uneven pulse as unsmooth, in the end providing no solution for the problem of definition for the rough pulse (sè mài 澀 脈). The question remains, what aspect of the pulse is rough? The historic use of the term rough had two common interpretations, blood stasis and depletion of essence, qi or blood. There are complexities that qi, blood and essence depletion with blood stasis bring to the event horizon. From my perspective and in my experience, such conditions affect the shape, state and timing of various features in the pulse and the state of unevenness may occur in any of these three domains. Wang’s depiction of the rough pulse is consistent with blood stasis and essence depletion. Hammer’s assumptions hold up only if the interpretations of the rough pulse are limited to certain forms of blood stasis. The debate remains, however, and the description of the rough pulse (sè mài 澀 脈) requires further dialogue within the Chinese medicine community. Here, we address the tight pulse (jǐn mài 緊 脈), which is an essential quality for identifying cold pathogens in pulmonary conditions, women’s health, gastro-intestinal and other conditions where cold pathogens may be latent or expressed. The tight pulse (jǐn mài 緊 脈) has these features: it strikes tightly, and with force, its strength is like a twisted rope, unevenly stretched, and snapping back and forth. Tietao Deng quotes from the Zhen Jia Zhi Jue suggesting that the cold evil causes the vessels to contract and the pulse becomes small and firm “shaking is a trembling movement, snapping back and forth, with a force like a twisted rope; with pressure it is like rolling, not even, but with bumps” (Deng, 1999, pp 128). The theme can also be found in the writings of Li Shizhen, “the tight (jin mai) pulse is either pellet revolving or twisted like a rope or without taking a side” (1999). Deng quotes Li Zhong Zi, “A tight pulse has force, it snaps left and right, like a large twisted rope, or a tight cutting string” (Deng, 1999, p 29). In my experience, the ability to identify the tight pulse (jǐn mài 緊 脈) is critical for the purposes of identifying the presence of cold pathogens. The ‘Tight’ pulse employed in Tradition and Revision is not the conventional tight pulse (jǐn mài 緊 脈). Hammer describes the ‘Tight’ pulse as a “totally new category which most clearly corresponds with wiry in the literature.” Further: The Tight quality may be best identified as feeling like the next to the thinnest A string on a violin. (The thinnest E string is descriptive of the wiry pulse.) It is harder, less resilient and flexible, and usually thinner than the tense quality. However, it still has both some flexibility and resilience, in contrast to the Wiry quality, which has neither. With pain, the Tight quality has a sharper, biting quality (Hammer, 2001, p. 337). The ‘Tight’ pulse that Hammer describes does not suggest the presence of a cold pathogen. Yet, a conventional tight pulse (jǐn mài 緊 脈) does suggest the presence of cold, even in a complex cases where heat transformations have begun. For the pulse that Hammer refers to as ‘Tight’, we might draw descriptors from the more common bowstring pulse (xián mài 弦 脈) series. Shen’s distinctions were more closely aligned with conventional practices. They are the replete bowstring pulse (shì xián mài 势弦 脈), deplete bowstring pulse (xū xián mài 虚弦 脈), and moderate bowstring pulse (huǎn xián mài 缓弦 脈). Hammer’s characterization poses a conundrum that is furthered by his interpretation, “The Tight pulse is no longer a sign of internal cold, in our time it is a sign of an overworking nervous system” (2001). If we take as a basis for practice, the tight pulse to be that which most clearly corresponds with the wiry pulse (xián mài 弦脈), then what image is used to identify the presence of a cold pathogen? What shall we use to translate the term jǐn mài (緊 脈), which is a common clinical presentation? Without the tight pulse (jǐn mài 緊 脈) to which Deng, Zhen and Zi refer, we do not have an effective method of identifying the impact of cold pathogens. This is a loss for clinical epistemology because cold is a common occurrence and can easily be identified by those who have experienced and understand the salient features of the tight pulse (jǐn mài 緊 脈). Hammer conceives of his project regarding classification and nomenclature as an attempt to relieve confusion and discouragement for the learner. His laudable goal is to “present a uniform nomenclature based upon sensations easily recognized by those familiar with the English language” (2001, p. 6). This project has similarities to the world view of logical positivism. Hammer’s method has integrity for those who operate in the clan, and poses problems for translation for those operating with the professional-technical language of Chinese medicine. Comparisons Hammer makes excellent points, such as verification of the therapeutic and diagnostic concepts derived from the classical lore. I agree with this point of view and extend it to both the family lineage and state approved medical approaches. I paraphrase the words of Karl Popper, The game of science is, in principal, without end. The person who decides that statements about Chinese medicine do not call for further test, and that they can be finally verified, retires from the game (2002). Hammer also makes significant contributions to the practice of pulse diagnosis. Among these are the “ropy” pulse for characterizing damaged vessel walls, the “cotton” or “sad pulse”, and Shen’s anatomical model. My purpose in this statement is not to be thorough, but rather to highlight a few of Hammer’s contributions. He seeks to clear up what he calls Wang Shuhe’s confusion regarding the “Choppy” pulse. He distinguishes what he considers to be a mistaken and dangerous amalgamation of distinctly different qualities and reduces them into one. The dangers that Hammer poses regarding Wang’s conception of the rough pulse (sè mài 澀 脈) require an assumption that professional practitioners of Chinese medicine make clinical decisions based upon a single sign. To do so, however, requires that the practitioner abandon standards of practice. While there are stories of practitioners who perform miraculously on the basis of a single sign, this is the exception rather than the rule. Were one to practice using Hammer’s assumption of diagnosis based upon the single sign, the medical-legal risks that Hammer identifies would remain for users of his system, just as they do for those who adopt the standards of practice as taught in the core curriculum of the major Chinese Universities and schools of acupuncture and Chinese medicine throughout the US. Rather, the single sign presents an opportunity for further inquiry in the critical analysis of a properly conducted history and physical. This with appropriate referral is the professional and safer way to practice. Additionally, there are findings for which Hammer has no discussion. Yet, there are methods that permit making meaning about those events. Take for example, distortions of the radial artery towards the radius in the right distal (cun) position. While Hammer does not interpret this finding, this event may be assigned meaning and has potential clinical benefit. Such a distortion may be interpreted as accumulations and depression in the tai yang channel (this can be musculoskeletal problems located along the trajectory of the Urinary Bladder and Small Intestine Channels), or an involvement of the yang wei mai if the trajectory of the vessel is transverse. Further, if we employ the compass model, the metal is assigned to this area, and since it correlates with the lung, it relates to a metal imbalance within metal, where one would select the metal point on the metal channel which is the “channel ditch” (jīng qú 經渠, LU 8), and the pulse tends to centralize (Morris, 2002a, 2002b, 2003). Single findings have meaning in the context of a larger field of assessment and are useful only to the degree that they improve clinical outcomes. Summary As both Hammer and I have established in different language, models are abstractions that are used to parse reality into meaning, yet, they are necessarily incomplete. This is true of the Menghe-Ding family anatomical model as taught by Shen and Hammer, just as it is true of the models located in the canonical traditions such as the eight extraordinary vessel and six division pulse systems of Wang Shuhe. Hammer has spent time on the teachings of John HF Shen, biomedicine and psychiatry. He admits no time to study the canonical literature, yet, claims the authority to affirm that, “clinically there is no contest between the efficacy of these verbally transmitted traditions and often mystifying classics.” In my opinion, such judgment has greater weight when rendered by scholars who have studied the relevant points of view. Thus, the voyage into commentary on classical literature by a practitioner who acknowledges no experience with or attention to the matter poses problems when it comes to a critique of the canonical literature. Hammer’s attempt to create a new nomenclature was performed without participation with stakeholders within the field of acupuncture and Chinese medicine. This is not a problem for pulse images that are unique to his system. Nor is it a problem for those who choose to think inside his methods. However, if we are to arrive at a nomenclature that functions for a wider community, there must be a public dialogue. What is needed here is a participatory and co-operative form of inquiry with respect to policy and knowledge building for the profession. The profession at large must have a voice in the development of the languages that compose practice. Through such methods, new knowledges can be built in a way that sustains the current dialogues. Biography Will Morris has a master degree in medical education, a doctorate in acupuncture and Oriental medicine and a PhD in transformative studies. He has developed two doctoral programs in acupuncture and Oriental medicine and two institutional review boards. As president of the AAOM, he was part of the unification movement that led to a single national professional association in the US. With an academic focus on the subject of pulse diagnosis since 1980, he is the founder of www.pulsediagnosis.com. Dr. Morris also serves as president of the Academy of Oriental Medicine at Austin (www.aoma.edu), where he has special programs and clinics devoted to the study of Chinese pulse diagnosis in early and contemporary forms. References Bateson, G. (1979). Mind and Nature, A Necessary Unity. Cresskill, NJ: Hampton Press. Deng, T. (1999). Practical Diagnosis in Traditional Chinese Medicine (M. Ergil & S. Yi, Trans.). New York: Churchill Livingstone. Denmei, S. (2003). Finding Effective Acupuncture Points (S. Brown, Trans.). Seattle, WA: Eastland Press. Hammer, L. (2001). Chinese Pulse Diagnosis, A Contemporary Approach. Seattle: Eastland Press. Hammer, L. (2002). Tradition and Revision Clinical Acupuncture and Oriental Medicine, 3(1). Retrieved from http://www.dragonrises.edu/articles/hammer-traditionrevision.pdf Hammer, L. (2009a). A Discussion on Wang Shu He Pulse Classic Part One. Chinese Medicine Times, 4 (1). Hammer, L. (2009b). A Discussion on Wang Shu He Pulse Classic Part One. Chinese Medicine Times, 4 (2). Kobayashi, S. (2001). Shaku Ju Chiryo: Treatment of Shallow and Deep Stagnation. Yokosuka, Japan: Ido-no-Nippon-Sha, Ltd. Korzybski, A. (1921). Manhood of Humanity: The Science and Art of Human Engineering New York: E.P. Dutton & Company. Li, S. (1999). The Lakeside Master's Study of the Pulse (B. Flaws, Trans.). Boulder, CO: Blue Poppy Press. Lu, Y. (1996). Pulse Diagnosis. Shandong: Shandong Science and Technology Press. Morris, W. (2002a). Eight Extra Vessel Pulse Diagnosis: A Path to Effective Treatment. Acupuncture Today(January). Morris, W. (2002b). Pulse Diagnosis Using the Elemental Compass Method. Acupuncture Today, 3(8). Morris, W. (2003). Neoclassical Pulse Diagnosis and the Six Channels. Acupuncture Today(April). Petrilli, S., & Ponzio, A. (2008). A Tribute to Thomas A. Sebeok. Biosemiotics, 1(1), 25-39. Popper, K. (2002). The Logic of Scientific Discovery. New York: Routledge. Scheid, V. (2002). Chinese medicine in contemporary China : plurality and synthesis. Durham, NC: Duke University Press. Smith, L. T. (1999). Decolonizing Methodologies: Research and Indigenous Peoples. London & New York: Zed Books. Tulku, T. (1984). Love of knowledge. Berkeley, CA: Dharma Press. Unschuld, P. (1985). Medicine in China: a history of ideas. Berkeley, CA: University of California Press. Unschuld, P. (1986a). Medicine in China : a history of pharmaceutics. Berkeley, CA: University of California Press. Unschuld, P. (1986b). Nan Jing: The Classic of Difficult Issues (P. Unschuld, Trans.). Berkeley, CA University of California Press. Wang, S. (1997). The Pulse Classic A Translation of the Mai Jing (S. Yang, Trans.). Boulder, CO: Blue Poppy Press. Wiseman, N., & Feng, Y. (1998). Practical Dictionary of Chinese Medicine. Taos, NM: Paradigm Publications. Wu, N., & Wu, A. (1996). Yellow Emperor's Canon of Internal Medicine (N. Wu & A. Wu, Trans.). Beijing: China Science and Technology Press. Wu, Y. (1993-94). A Medical Line of Many Masters: A Prosopographical Study of Liu Wansu and His Disciples from the Jin to the Early Ming. Chinese Science 11, 36-65. Zhang, Z. (1995). Synopsis of Prescriptions of the Golden Chamber (L. Xiwen, Trans.). Beijing: New World Press. Zhang, Z. (1999). Shang Han Lun: On Cold Damage, Translation & Commentaries (F. Ye, N. Wiseman & C. Mitchell, Trans.). Brookline, MA: Paradigm Publications

Flexner to Eisenburg: The Turning of a Nation

Medical Economics and Politics of Evidence

Let’s look at the problem of medical values in higher education, as they are essential to the current forms of care that are generally available and the consequent privileges available to a medical elite who are controlled by standards of care, whether those standards are in the best interest of a patient or not. because it is a post 1900 robber baron driven phenomena, and most people drank the Kool-Aid they were selling.

Essentially, there was a conspiracy between the AMA, Carnegie and the Rockefellers. AMA sought a monopoly on medical care and its education, and successfully gained it. Rockefellers sought 3 items, 1) a monopoly upon philanthropy as a business model 2) wash clean their sullied name and 3) control over oil based and chemically driven medicine. The Carnegies had similar motives to the Rockefellers.

Using the German medical education model as institutionalized at John’s Hopkins University, the AMA-Rockefeller-Carnegie patsy, Abraham Flexner, went on a series of site visits to medical schools. Five criteria were used by Flexner to develop his work. Here they are: a) entrance requirements and adherence to them (good!), b) the size and training of the faculty (biased) c) the sum and allocation of endowment and fees to support the institution (this criteria places power and control into the hands of the ‘philantrhopists’) d) the adequacy and quality of the laboratories as well as the training and qualifications of the laboratory instructors, (only chemically based medicines that are patentable are supported in this model) and e) the relationships between the school and its associated hospitals (another economic bias towards those institutions with philanthropic funding).

Abraham Flexner was a reformer of education, particularly in the area of medicine. His was a life devoted to education and the elevation of its place in society (“Abraham Flexner,”). It could be said that he changed the face of medical education in America with his 1910 report Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (Flexner, 1910). This article explores results on both sides regarding Flexner’s impact on medical policy and as a result, medical care. What is fascinating is that acupuncture and East Asian medical practices rose with the tide of the return beginning in the early 1970s.

The Background

Flexner ‘s report was likely part of the reduction of natural products in the US healthcare environment between 1910 and the 1960s. This is important because there is a difference between health and the need for chemical or surgical interventions.

The conditions after Flexner led to a gap between perceived and real use of natural products for health care purposes. It became obvious to policy makers when David Eisenberg’s study, Unconventional Medicine in the United States — Prevalence, Costs, and Patterns of Use, demonstrated the billions of dollars that Americans spent out of pocket on ‘complimentary and alternative healthcare’. We will explore this after considering Flexner’s work in more detail.

If one considers the centennial commemorative of Flexner’s work in a 2010 special edition of Academic Medicine, medical education improved. In it, Dr. Steven Kanter, the editor-in-chief, gave summary of the essays reflecting upon the past 100 years of a post Flexnerian world (Kanter, 2010). Kanter’s summary focused upon balance as a common feature among the essays. Dialectics ranged from curricular content and the length of medical training, to the contrast between a ‘disease management’ and an ‘population-based health improvement’ (Prislin, Saultz, & Geyman, 2010). Other areas of balance included professional or scientism and humanism, rural and urban care, lab time and patient time, and “the integration of formal knowledge of the basic, clinical, and social sciences with clinical experience (Irby, Cooke, & O’Brien, 2010).” Refreshingly, Lambert et al. argued for a balance between ‘standardized’ and ‘personalized’ scientific knowledge (Irby et al., 2010). The fundamental message was that Flexner was focused upon balance. We still find today, in acupuncture schools. A debate continues between liberal arts and the sciences as appropriate preparation for the acupuncturist as an independent medical provider in society.

Flexner also took strong positions. Consider this section of his report, this one justifiably addressing the Georgia College of Eclectic Medicine and Surgery of Atlanta:

The school occupies a building in which, in respect to filthy conditions, has few equals, but no superiors, among medical schools. Its anatomy room, containing a single cadaver, is indescribably foul. The pathological and histological “laboratory” contains a few dirty slides and ordinary microscopes . . . nothing more disgraceful calling itself a medical school can be found anywhere (Flexner, 1910).

Fortunately, the advent of acupuncture and East Asian medicine arose in an environment of accreditation and licensure that ensured certain levels of quality beyond the kind of schools that were removed from the terrain after Flexner’s report.

The Turn

Carnegie Foundation published and funded the 1910 Flexnor Report, which carved out and cleaned up national healthcare policy with respect to education and the medical profession, but at what cost? It was devastating for some. Medical care in the US was altered in such a way that indigenous knowledges as employed by eclectic physicians who used Native American traditional medicine were deleted.

Five criteria for evaluating schools were used by Flexner in order to develop his work. Here they are: a) entrance requirements and adherence to them, b) the size and training of the faculty c) the sum and allocation of endowment and fees to support the institution d) the adequacy and quality of the laboratories as well as the training and qualifications of the laboratory instructors, and e) the relationships between the school and its associated hospitals. There were other criteria used to develop the Flexner Report such as full-time teaching faculty, pathological analysis of the human body and a physiochemical analysis of the human body (Flexner, 1910). There are no records of who was involved with the process for developing these criteria. A model focused upon endowment favors institutions that reside within the good graces of philanthropists, creating control by certain economic interests.

As an educator, Flexner had no background in medicine and he investigated 69 medical schools in 90 days. Here are the results of his work. Within three years of the release of his Report, 25 medical schools closed. The total number of medical schools dropped from 650 to 50. Private hospitals declined in number from an estimated 2441 in 1910 to 1076 in 1946 (Mark D. Hiatt, 2003). The 22 homeopathic medical schools that flourished in 1900 dwindled to just 2 in 1923. By 1950 all schools teaching homeopathy were closed. If a physician did not graduate from a Flexner approved medical school, no job was to be had. New licensing laws required that medical schools be certified. Further:

Schools that admitted Afro-Americans did not pass (except for two that admitted only Afro-Americans). Schools admitting Jews got lower than average grades (resulting in a 30% reduction in Jews graduating). Schools that admitted women got lower than average grades resulting in a 33% reduction in women graduating [(Starr, 1982).]

Schools that were “commercial institutions” (able to function entirely by student fees) did not pass.By 1925 10,000 herbalists were out of business.

While Flexners ideals are espoused in reflection pieces upon him, it is also clear from the reults how the document was used. Conventional medical systems in America effectively excluded indigenous forms of medical knowledge from 1910 until the 1960s.

The Return

Acupuncture was part of the theme as the return of patient choice, or patient centered care became apparent. The patient’s view was made apparent to policy makers by Eisenberg’s study, Unconventional Medicine in the United States — Prevalence, Costs, and Patterns of Use (Eisenberg et al., 1993), showed that the US had began to recover from the losses created by the Flexner report. In 1990, there was an estimated 425 million visits to providers of unconventional therapy exceeding the 388 million visits to primary care physicians. Moneys spent were approximately $13.7 billion, three quarters of which ($10.3 billion) was paid out of pocket. $12.8 billion was spent out of pocket annually for all hospitalizations in the United States (Eisenberg et al., 1993).

Not long after Eisenberg published his landmark study, on Friday, December 6, 1996 the FDA announced the reclassification of acupuncture needles from class III (premarket approval) to class II (special controls). They identified the acupuncture needle as “a device intended to pierce the skin in the practice of acupuncture. The device consists of a solid, stainless steel needle. The device may have a handle attached to the needle to facilitate the delivery of acupuncture treatment (FDA, 1996).” Thus, the experimental status was removed from acupuncture needles.

Growth and change continued. On March 7, 2000, President William Jefferson Clinton gave executive order 13147, forming the White House Commission on Complimentary and Alternative Medicine Policy (CAM, 2002). Medical schools began including a consideration for nutrition and natural products. Further, in 2010, Rick Marinelli, ND, LAc, was appointed to the Institute of Medicine’s (IOM) Committee on Advancing Pain Research, Care, and Education. It is necessary for practitioners who are fully educated in CAM medicine practices such as acupuncture and naturopathy to be involved in the national policy dialogs for there to be any true integration of care in society.

The Summary

Carnegie Foundation published and funded the 1910 Flexnor Report (Flexner, 1910). Minutes from AMA meetings at that time express the need to have the report separate from the AMA in order to give an impression of neutrality and authority (Kirch, 2010) (can we say objective proofs?).

The Carnegie-Rockefeller-AMA conspirators effectively crushed an American free market in medicine and its education. Non-profit values serve as a cloak for this form of evil.

Flexner is arguably the grandfather of the “site visit” in medical education and higher education. The benefits of his work are clear, the US has one of the strongest medical education systems in the world. The American public was divested of a more rich a plural form of medical care. Powers that be noticed in 1990 after Eisenberg’s study that people have mode complex needs than the corporate-technological forms of medicine. That trend was present all along and gained momentum during the sixties. Later studies that Eisenberg conducted have demonstrated that the growth of a plural medical system continues. Lastly, We need to nurture and espouse patient centered care, which if pursued, clearly supports the use ‘alternative medical approaches’, “integrative medicine’ or in the case of this field, acupuncture and East Asian medicine.

Notes

Abraham Flexner. http://www.ias.edu/people/flexner

CAM, W. H. C. o. (2002). White House Commission on Complementary and Alternative Medicine Policy http://www.whccamp.hhs.gov/finalreport.html

Eisenberg, D. M., Kessler, R. C., Foster, C., Norlock, F. E., Calkins, D. R., & Delbanco, T. L. (1993). Unconventional Medicine in the United States — Prevalence, Costs, and Patterns of Use. N Engl J Med, 328(4), 246-252. doi: 10.1056/nejm199301283280406

FDA. (1996). Medical Devices; Reclassification of Acupuncture Needles for the Practice of Acupuncture. Federal Register 61(236). http://www.gpo.gov/fdsys/pkg/FR-1996-12-06/html/96-31047.htm

Flexner, A. (1910). Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. . In Updyke (Ed.). Boston, MA.

Irby, D. M., Cooke, M., & O’Brien, B. C. (2010). Calls for Reform of Medical Education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine, 85(2), 220-227 210.1097/ACM.1090b1013e3181c88449.

Kanter, S. L. (2010). A Letter to Those Who Read This Issue in 2110. Academic Medicine, 85(2), 181-182 110.1097/ACM.1090b1013e3181cfbf1096f.

Kirch, D. G. (2010). Commentary: The Flexnerian Legacy in the 21st Century. Academic Medicine, 85(2), 190-192 110.1097/ACM.1090b1013e3181c1099a1095d1091.

Mark D. Hiatt, M. D., M.S., M.B.A. and Christopher G. Stockton, M.S.M. (2003). The Impact of the Flexner Report on the Fate of Medical Schools in North America After 1909. Journal of American Physicians and Surgeons, 8(2).

Prislin, M. D., Saultz, J. W., & Geyman, J. P. (2010). The Generalist Disciplines in American Medicine One Hundred Years Following the Flexner Report: A Case Study of Unintended Consequences and Some Proposals for Post-Flexnerian Reform. Academic Medicine, 85(2), 228-235 210.1097/ACM.1090b1013e3181c1877bf.

Starr, P. (1982). The social transformation of American medicine. New York: Basic Books.

 

The Physician’s Pulse Watch

Or, an essay to explain the old art of felling the pulse, and to improve it by the help of a pulse-watch. In three parts. By Sir John Floyer.

Chapter 3 concerning the sensible alteration of the pulse, or the difference of the pulse.

If we consider the quantity of blood injected into the artery by the heart, and it also which is contained in it before the injection, the pulse is called great high or a full pulse, and the contrary a small, low or empty pulse: The great pulse we know by the great distention or protrusion of the artery, and that small by the small extension of the artery; In great pulses the artery appears like attends Circle and in small pulses like a small and more flaccid circle; by often feeling the pulse of the most healthful in the middle age, and in the spring, we must get the notion of a moderate distention or diastole of the artery, and soon that we must refer the preternatural, greater or smaller pulses, when they exceed the natural, moderate or middle magnitude of a pulse, or where that is deficient. Buy a long experience we may get the faculty of discerning the natural magnitude of the different constitutions, which no words can explain, and it is difficult to observe the full distention of the membranes of the arteries, and the several degrees of it’s flaccidity.

To a great holes not only a great quantity of blood is necessary, but also a strong temper of spirits to contract the heart with great force.

Great pulse also produced by a great rarefaction of the blood and spirits, and we may observe these several degrees of great pulses, if the spirits be much rarefied pulse becomes a little greater then it’s naturally, if the blood also be much rarefied the pulses much greater, and it is extremely great in fevers, where the blood and spirits are much rarefied especially if they’re also be a great quantity of blood.

A small pulse made depend not only on a small quantity of blood, but on cool or weak spirits, or cool, viscid blood, or obstructed arteries, or dyspnea, or stoppage in the lungs, which hinders the circulation.

We know a great pulse through fullness by the hardness of the artery in the interval of it’s pulsation.

William Morris, PhD, DAOM, LAc

William Morris, PhD, DAOM, LAc, is an internationally recognized expert in the area of Chinese pulse diagnosis. He has more than 30 years of concentration on the subject. His publications include: Li Shi-zhen Pulse Studies, an Illustrated Guide , Mai Dao: NeoClassical Pulse DiagnosisTransformation: Treating Trauma with Acupuncture and Herbs and a Comparative Materia Medica.

Classics and family lineages provide the foundation for his 30-year focus on the subject. He spent 7 of those years studying and teaching Chinese pulse diagnosis in the Ding family lineage. His current teachings include the Ding family lineage, weaving that work with a literate discipline that is rooted in the classics. With 20 years of experience teaching pulse diagnosis and a master degree in medical education from USC, Morris has developed a system of practice that weaves the knowledge systems of China into a comprehensive view.

He has built a contemporary application of six channel and Eight Extraordinary Vessel pulse methods presented in the Pulse Classic. These methods are verified through contemporary discourse and practice in the field of Chinese medicine. He has made original contributions to the anatomical methods of the Ding family as brought by Shen and Hammer. He has also reconstructed a comprehensive pulse diagnosis system that can be used to analyze the warp and woof of the channel systems, called NeoClassical Pulse Diagnosis.   Morris has designed and taught 2 year herbal programs, authored A Comparative Materia Medicine and has published numerous articles on the topic of Chinese herbal medicine. He is president of AOMA Graduate School of Integrative Medicine.

Morris has two doctorates focused upon problems of Chinese medicine. His PhD dissertation is entitled Chinese Pulse Diagnosis: Epistemology, Practice and Tradition and forms the basis of Mai Dao. It contains nermous contributions to the question of pulse diagnosis. While his DAOM is a specialty in pain, his portfolio contained a successful doctoral application to the accreditation commission, and an initial exploration into the potential interpretations of a distortion in the radial artery according to different traditions.

As a leader, he has focused nationally, state and institutionally. He served as architect of a single national professional association, now the American Association of Acupuncture and Oriental Medicine (AAAOM). He also organized 2 Institutional Review Boards and served as consultant to Children’s Hospital Los Angeles IRB.

As president of AOMA Graduate School of Integrative Medicine, he led the institution to regional accreditation with the Southern Association of Colleges and Schools and acquisition of its own property.  Under Will’s leadership, AOMA is now approved to operate a DAOM at regionally accredited level through the Southern Association of Colleges and Schools. Will was awarded Acupuncturist of the Year in 2008 for his work on uniting the AOM profession into one national association. That same year, across the profession, he was recognized as a Founder and Leader for his profession building efforts and work developing doctoral standards within the field, leading 2 other institutions to successful doctoral applications under the Accreditation Commission for Acupuncture and Oriental Medicine.

 

Mai Dao: Path of the Pulse Lineage

Body Image Pulse Diagnosis

The practice of pulse diagnosis eases when driven by inquiry. Here, the question pertains to anatomical location. In this method, one places the image of the body over the radial artery in order to explore specific anatomical locations.

The method is different than those that are used to assess a stage of disease process or the assessment of acupuncture channels. Body image pulse diagnosis

This section explores the contributions of the Ding family lineage as presented by Dr. John HF Shen.

Chinese medicine, as all medicine, articulates disease in terms of process, severity and location. The pulse may be explored in a limited fashion based upon the location of the problem for which the patient seeks care. The pulse may also be assessed in terms of a comprehensive record.

Ding Family Lineage

The late great John HF Shen influenced a whole generation of practitioners in America and Europe. The lineage he transmitted included a pulse diagnosis system that involved a ‘body image’ on the radial artery at the wrist. In his method, the fingers are rolled from one of the primary pulse positions into an area that is representative of a specific anatomical feature of the organ. For instance, to examine the esophagus, one rolls distal from the primary stomach position in order to get insight about the structure and function of the esophagus from the pulse.

Neoclassical Lineage

This lineage provides a comprehensive method for assessing the channel systems. It was created by Will Morris through a participatory model of research focused upon answering contemporary clinical questions through the canons of Chinese medicine. These are specifically, the Pulse Classic, Spiritual Axis, Cold Damage Classic, and Golden Cabinet.

Problems of Pulse Diagnosis Transmission

In this essay, I adopt three vectors of rhetoric in address of the problems of pulse diagnosis: appreciation, critique of works in the field, appreciation for unqiue contributions in the field. These three points of view of appreciation, recognition and critique recur throughout this piece.

Pulse diagnosis is not a purely pragmatic discipline where philosophical positions are not important. Rather, theory and philosophy are critical. Theory informs practice while practice informs theory: right here and right now, and throughout the history of Chinese medicine as a medical science.

The transmission of Chinese medical knowledge follows three paths. They are: family lineage, classical lore and state approved school curricula.

The classics often created by and served the royal court physicians, attracting  the attention of the privileged ‘best of the best’. They were fond of abstractions – which serve as the root of scientific inquiry – thus, the classics formed a theoretical court medicine. These canons of the discipline served to both capture oral traditions, transforming them into written form. An example is the Luo Shu diagram from the Yi Jing as a potential source for organizing thought about the different channel systems.

Family treatments were often created and sustained by itinerate physicians. This knowledge base accrued, often through clandestine secrecy, as trade secrets in medicine could easily affect survival. The conversion of family lineage knowledge into the classical lore were subject to approval by court physicians. We can see such courses of action in contemporary TCM where the pattern of Liver Qi Depletion is not discussed. Yet, architect of TCM, Qin Bo Wei, Jin-Yuan Dynasty physician Zhu Dan-xi and the Ding family lineage as represented by John HF Shen and Leon hammer recognizes such a pattern – and so do I and my students with distinctly positive patient outcomes.

The state-approved  committee based efforts provided the expertise to design the curriculum for TCM throughout China. This has had a strong influence upon the thinking and policies at western schools of Chinese medicine.

At no time in the history of practice, however, have the boundaries provided a discrete separation between these forms of knowledge accretion. That is, the canon, family practices and state approved doctrine have all influenced each other in a complex web. Consequently, accessing knowledge along each of these lines has benefits and challenges.

We cannot separate abstract and concrete thinking for the purposes of valuing one form of practice over another. The act of pulse diagnosis involves both abstraction and pragmatic clinical applications. Correspondingly, it is important to acknowledge that the model is not the pulse, just as the map is not the territory (Korzybski, 1921). It is a form of naive materialism to assume a real external world that directly causes our perceptions (Petrilli & Ponzio, 2008). An example of this latter point is the way that a stick seems to bend when have is in the water, and half out. Yet, we do use pulse models to inform inquiry and direct interpretation. Models can be useful tools, but the information obtained tends to be comprised of binary distinctions and are descriptive in a limited way. Further, knowledge evoked by models can become separated from experience and lost in reified concepts and theories. This may turn our attention away from direct inquiry and toward regarding the assumptions of the models themselves as more real than their subject (Tulku, 1984). The point here is that the risks of using models is one that is shared by both clandestine family practices and those rooted in literary traditions.

Pulse aficionados often hold the value of their world view as superior over that of others. Pulse methods are subject to the same vulnerabilities as any other model or map in that they are constructions of reality. Some methods focus upon anatomy and physiology while others focus upon channel based systems. Others focus upon stages of illness and others still, five elements. A path of the pulse will engage the appropriate inquiry method/s for the problem at hand.

The ability to select the correct tool for the job relates strongly to best outcomes. Anatomical methods have no capacity for analyzing the involvement of the eight extraordinary vessels or the six channels. By the same token, Wang’s eight extraordinary vessel methods are not very helpful for diagnosis cardiopathology.

Secret Transmission

The clandestine transmission of knowledge was especially common among family lineages. Such secrets were often the very basis of survival, and while knowledges gained in secrecy may provide for a power base and economic control, it does not provide for a flourishing of knowledge. The notion of secrecy as an ephemeral grasping of knowledge that can be difficult to grasp depends upon the readiness of the practitioner/learner to recognize and receive that knowledge.

For any number of reasons, there are teachers who refuse to write. They may lack the skill, feel they do not have the requisite knowledge and experience to justify the act of writing, or choose not to be accountable from one moment to the next in regard to what is said. Lastly, the sustenance of secret knowledge is a reason as much as the sensitivity to the delicate nature of high level expert knowledge which resists conversion into written dogma.

There is then the question of what is necessary for a writing to become a part of the canonical literature. If, based upon a given point of view, the book is considered ‘wrong’, it poses a problem for critical analysis and consideration for a body of knowledge to be verified in clinical practice, and to achieve the stature necessary to be sustained and republished millennia after millennia.

A critical eye must be cast upon all forms of transmission, and especially oral. Such knowledge could be easily be distorted by up to 40%. Can we rely upon such oral traditions as the pillar of knowledge against which to evaluate practice? My preference is a triangulation between the three rivers of classical, family lineage and contemporary practices of medicine East and West (Scheid, 2002). Through a participatory world view, I seek to validate the work by cycling between a contemplative hermeneutic analysis of the literature, practice, teaching, peer dialogue and publications. These processes protect against the many distortions that can occur from a mono-view in the transmission of knowledge. The shift of perspective provides depth of perception and reduces errors of assumption (Bateson, 1979).

Historical Considerations

In my experience, the canonical literature has provided a vital link to solving questions that remained unanswered in the Menghe-Ding family current as I learned it from both Shen and Hammer. In this section, I will build some background for the practices that informs the practical application of canonical tradition.

The Difficult Classic (Nan Jing) was the first text to specify the radial artery at the wrist as the primary location for collecting pulse diagnosis data, and contains 22 chapters focused on pulse diagnosis. In comparison to The Yellow Emperor’s Classic (Huang Di Nei Jing) (Wu & Wu, 1996), which is a heterogeneous body of manuscripts, the Difficult Classic (Unschuld, 1986b) is a relatively homogeneous work. It consistently applies a doctrine of correspondences in which seasons, organs, emotions, pulses, and other factors are correlated.

In a similar time frame during the Han Dynasty (c. 200 CE), Zhang Zhongjing compiled one of the greatest formularies in the history of Chinese medicine. His manuscript, the Damage by Cold and Miscellaneous Disease Treatise (Shang Han Za Bing Lun) was eventually split into two documents, the Damage by Cold Treatise (Shang Han Lun) and the Synopsis of the Golden Chamber (Jin Gui Yao Lue). Although these two formularies deal primarily in Chinese medicines, they are also representative of a highly skilled and experienced practitioner’s record of pulse diagnosis. In creating the Damage by Cold Treatise (Shang Han Lun), Zhang Zhongjing, combined the schools of medical thought that were based upon the Book of Changes (Yi Jing) with the oral traditions (Jing Fang). This led to a six-channel description of pathophysiology and a corresponding herbal formulary. Zhang’s work revolutionized practice (see Zhang, 1983, 1995, 1999).

Without a strong basis in both Yi Jing theory and access to the practices of oral traditions, Zhang Zhong Jing would not have compiled the Shang Han Lun and the Golden Cabinet. Without the Yellow Emperor’s Classic, the Yi Jing and the Nan Jing, Li Dong Yuan would not have been in a position to create the Spleen Stomach Classic. Each of these pieces of Chinese medical literature has reasonable translations in English, creating possibilities for the English language speaking practitioner to gain access. Yes, it is imperfect, and more desirable to gain direct access through reading the Chinese, this skill is not one that many successful practitioners outside China enjoy.

The practices that are based upon literary and canonical traditions of Chinese medicine have strong ties to imperial traditions. State officials had the influence to collect manuscripts and information from family traditions and knowledge passed through apprenticeships. Wang Shuhe was such a state official working in the Han Dynasty (c. 200 CE). His writings were kept somewhat intact and received few changes from later authors because of the credibility his work enjoyed due to the wide-ranging and authoritative collection of work in that time frame (Miki Shima, personal conversation, March 2008). Some of the most significant contributions to Chinese pulse diagnosis literature were made during that period of time, including the Difficult Classic (Nan Jing) (Unschuld, 1986a) and the Pulse Classic (Mai Jing) (Wang, 1997).

There are contemporary practitioners who employ the canons of Chinese medicine safely and in an inspired fashion. Here is an incomplete account of the current standards of practice with respect to the use of canonical literature. There are the current lineages of Kanpo practitioners. This lineage is rooted in the Shang Han Za Bing Lunthe Treatise on Damage by Cold (Zhang, 1999) and Miscellaneous Diseases (Golden Cabinet) (Zhang, 1995). The Kanpo system is covered by government insurance programs in Japan. There are numerous Kanpo practitioners in Japan, US, Europe and other parts of the world such as Australia. As for the Japanese acupuncture tradition, it is rooted in the Nan Jing (Difficult Classic) . Schools based on the Difficult Classic include the Toyo Hari and Shakuju systems (Kobayashi, 2001). There are others such as Kiiko Matsumoto, Koui Kouahari, Shudo Denmai (Denmei, 2003), Ikeda Masakazu and Stephen Birch. A classmate of mine, Khyung Kim is highly developed in the Korean classical styles and publishes on the subject. Tran Vietduc’s students all practice on the basis of classics . The students who choose to study with me at the Academy of Oriental Medicine at Austin (AOMA) practice on the basis of a deep discussion of classics. AOMA also has course work in the core curriculum at the master degree that involves the Yellow Emperor’s Classic, the Treatise on Damage by Cold. AOMA is not the only institution that makes classical studies available in core curriculum content, Southwest Acupuncture College (SWAC) and the New England School of Acupuncture (NESA) pursue classical studies in the Japanese traditions focused upon the Nan Jing. Further, The National College of Natural Medicine has a program with a focus on classical literature. It appears that Hammer’s best knowledge does not reflect the state of the field with respect to pragmatic and critically realistic application of classical literature in clinical life. Many of these schools have rigorous participatory system of knowledge building through peer communities.

Chinese Medicine in Early Communist China, 1945-63, a Medicine of Revolution

Chinese Medicine in Early Communist China, 1945-63, a Medicine of Revolution, Kim Taylor, 2005, RoutledgeCurzon, New York. 272 pages, appendices, notes, bibliography and index; hardcover. US $120 ISBN: 041534512X.

Chinese Medicine in Early Communist China, 1945-63 by Kim Taylor is the story of the people and a nation involved in the development of what is now known as Traditional Chinese Medicine.This book offers interesting insights into the clash and exchange of two worldviews in the context of medicine in China.  The agrarian medical traditions were confronted with Cartesian dualism and positivism. The political and social life of early communist China was the cradle of a new Traditional Chinese Medicine (TCM) based upon a new ‘science.’

The author, Kim Taylor is a Wellcome Trust Research Fellow based at the Needham Research Institute at Cambridge, England. Her areas of research include the history of disease, 19th and 20th century Chinese medicine, and the interaction between Chinese and Western medicines in China from the mid-19th century to the present day.

Chinese Medicine in Early Communist China is a ‘comparative historical’ and ‘critical social’ analysis that includes biographical studies of Mao Zedong and other influential party members.  The effect of these leader’s communications on their professional and political careers conveys the era’s tumult and mortal risk. Further, the exact documentation and research convey the effects of leadership and politics on the  transformation of medicine within an industrializing nation.

This book is focused upon the premise that “Chinese medicine in modern-day China is not so much a continuing tradition of the past, as a deliberate distillation of the ancient concepts according to the dictates of the twentieth century.” (p.1) This modern Chinese medicine developed according to Cartesian philosophical dictums under the guidance of Western physicians in China. For example, premodern texts on acupuncture discuss spirits entering and leaving the points. In general the spiritualistic components of the classical and family traditions were expunged from the doctrines under the influence of the materialistic view of communist ideology.  Rather, the Cartesian dualistic perspective was imparted into the new anatomical views and classification of diseases according to western medical concepts. For instance the diagnosis ‘endometriosis,’ never existed until the laporoscopic procedure was created, is now found in Chinese medical literature.

The role that Chinese medicine played in the revolution was passive, and at no time was the medicine developed on its own but rather it was at each moment led by state policies. (p. 8) The political, economic and social motives which drove this development are used to analyze the extraordinary role that Chinese medicine played in Mao Zedong’s revolutionary plan.

Dr. Taylor adopts medical historian, Paul Unschuld’s theorem that ‘the acceptance or rejection of concepts of disease by groups in society has rarely been independent of socioeconomic and sociopolitical determinants be they consciously considered or not’. (p5) She provides support for this idea by citing the politically driven slogans used during the development of TCM; ‘The Cooperation of Chinese and Western Medicine’ used from 1945-50; ‘The Unification of Chinese and Western Medicine’ from 1950-58;   ‘Chinese Medicine Studies Western Medicine’ from 1950-53; ‘Western Medicine Studies Chinese Medicine’ from 1954–58; and ‘Integration of Chinese and Western Medicine’ from 1958 – Present. (pgs. 12-13)  The net result of these campaigns is a highly synthesized practice of Chinese and Western medicine that is currently taught in the major university medical systems throughout China.

There are advantages to the integration of Chinese and Western medicine in terms of increased logical consistency for TCM and a more whole conceptual approach for Western medicine. However, at the same time there is a risk of losing the rich plurality of the Chinese medical traditions that are transmitted through both family lineages and classical literature.  After her six month internship at Dongzhimen TCM hospital in Beijing, Dr. Taylor stated, “the reduction of [Chinese medical] theories to a few easily identifiable syndromes, many of which have been designed to correlate with major western disease categories, has greatly undermined the potential to plumb the considerable depths of TCM theory.” (p. 149)

Furthering the sociological argument, she demonstrates that this process took place in China within a sociopolitical and economic environment. International economic forces prevented western medical substances and technologies from availability to the Chinese population. The traditional medical practices provided a low cost method of care that could be performed in hospitals or in the fields.

However, the needs of the integrated practice of Chinese medicine in the USA differ from China in terms of evidence based practices, systems based medicine, practice based improvement and professionalism. In addition, key to the development of acupuncture in the US was the socio-cultural environment of post 1960s with countercultural values and the use of acupuncture for purposes of personal evolution.

The first of four segments, A New, Scientific and Unified Medicine: Civil War in China and the New Acupuncture, 1945-1949 describes the ascendancy of the ‘new acupuncture’ under the influence of Dr. Zhu Lian, a Chinese woman of western medical training. Zhu Lian’s mission was formulated in the context of Chairman Mao’s definition of a ‘new democratic culture’ which used three words to describe the movement, new, scientific and unity. In this context, the word science refers to the Marxists ideal of a criterion for true knowledge. The term new refers to the elimination of feudal language, and the word unity referred to the necessary ideals to build China afresh. These ideologies became the essence of the slogan ‘cooperation between Chinese and Western medical practitioners.’ The movement was designed to bring Western and Chinese medicine together, but also the people of various socioeconomic strata into a common society constructed upon Marxist values.

The Chinese Communist Party was the first Chinese government to officially recognize acupuncture in over a century. However once the Chinese Communist Party took the Western-medicine based health care system over, the new acupuncture was an anachronism and already out of date. It became necessary to train western physicians in short courses.

In the second section, Pathway for the New Medicine: The Unification of Chinese and Western Medicine, 1949-1953, Taylor discusses another attempt by the Chinese Communist Party to synthesize western and Chinese medicine. The Cartesian logical world of Western medicine is further blended with Chinese medicine and acupuncture. This is important because it effectively filtered out significant information and practices which are clinically useful.

To fill the needs, Chinese medical practitioners were trained to provide inoculations. During this time, Mao stated “In the future there will be only one medicine; that is to say a [single] medicine guided by the laws of dialectical materialism, and not two [separate] medicines.” (p. 35) Dialectical materialism holds that change is the result of the struggle between opposing forces. This can be between physician and patient or constructed in medical concepts such as ‘the cause of disease is either internal or external or neither internal nor external.’ This principle has reverberated into the contemporary educational systems and beliefs regarding ‘best practices’ for Chinese medicine.

Modernizing the Old: The Creation of a ‘Traditional’ Chinese Medicine, 1953-1956, is the title of the book’s Section Three.  Taylor’s meticulous documentation of official communications within the Chinese administration creates a picture of the medical politic.

Chairman Mao became ill in early 1953 with no official high level communications forthcoming. Local practitioners of Chinese medicine gained influence as they were convened for the first time with their input the first hospital dedicated to Chinese medicine was built. However, Mao soon recovered, urging the official slogan, ‘doctors of Western medicine study Chinese medicine’. In an attempt to rehabilitate China’s past, Mao began pushing the development of Chinese medicine through training Western physicians under senior Chinese physicians. In 1956, four major academies of Chinese medicine were established within the university system. The period from 1953-7 is described as a period of ‘socialist transformation’ focused on a transition from an agrarian nation to an industrial nation. Earlier campaigns such as ‘Chinese Medicine Studies Western Medicine’ were minimized and the histories typically begin in 1956 when the full promotion of Chinese medicine took strength.

Forcing the study of Chinese medicine in order to achieve a world medicine was fraught with complexity. Seventy-nine of China’s youngest and brightest practitioners – many of whom had planned on careers as surgeons in the Western paradigm – were in the first class of Western physicians studying Chinese medicine. Seventy-six completed the program. In addition, senior Chinese medical practitioners were forced to come from around the country to teach, leaving high salaries to receive a government stipend of 200 yuan per month. This must have been devastating for both groups and created a difficult climate, with unwilling participants. The senior Chinese medical professors were unprepared to teach in classroom settings and insisted on an environment with no questions. The Western medical physicians and the culture at large still had to overcome the ideological biases against the ‘old’ medicine.

The formation of a Traditional Chinese Medicine progressed intensively under the last theme, Establishing a National Treasure Trove of TCM: The Standardization of Chinese Medicine, 1957-1963. In the early 1960s, the Western doctors in general were forced to leave their profession to study Chinese medicine in order to create the new medicine. This was to fulfill Mao’s intent was to create a new medicine rather than resurrect or protect the classical and family lineage based practices.

The net result is that the vast treasure house of Chinese medicine has been subject to reductionist and positivistic methods. Therefore, large numbers of practitioners can be trained to provide services to a massive nation. A disadvantage is that the fecund plurality of practices formerly transmitted via apprenticeships and in family traditions are at risk of dying out, or already have.

The book’s first appendix provides a list of the first Chinese medical practitioners brought to Beijing from around China to set up the new Research Academy of TCM in 1955. Appendix II provides TCM curricula for the period between 1981 and 1997. The latter may be of assistance to those who are involved in the development of TCM programs in the West. Chinese medicine in early communist china, 1945-63, a medicine of revolution by Kim Taylor, PhD. proved to be fascinating, informative and authoritatively documented. People involved in Chinese politics, social sciences, medicine and economics may very well find this text useful.

 

Book Review: Western Herbs According to Traditional Chinese Medicine

Western Herbs According to Traditional Chinese Medicine: A Practitioner’s Guide

by Thomas Avery Garran, Rochester, VT: Healing Arts Press. Hardcover; 257 pages. ISBN 13: 978-59477-191-0. $50.

The author of this book, Thomas Garran, comes by his credentials via mentorship with senior herbalists, Michael Tierra and Christopher Hobbs As an acupuncturist with a Master’s degree in Oriental Medicine from Pacific College of Oriental Medicine, he has served as chair of the Department of Herbal Medicine at the Institute of Clinical Acupuncture and Oriental Medicine in Honolulu, Hawai’i. Garran’s roots are in western herbal medicine which values the use of herbs that grow locally and regionally. He has endeavored to categorize western herbs according to traditional Chinese medical criteria, and admirably so.

Western Herbs According to Traditional Chinese Medicine: A Practitioner’s Guide feels smooth and well-built in my hands. Opening to the table of contents, I discover a well organized setup, allowing immediate use in a clinical setting. There are discussions about various herbal delivery methods including infusions, extracts and decoctions, also poultices, suffused oils, suppositories and special preparations.

Looking further, I discover that the materia medica section has 14 Chinese herbal categories based on the professional language of Chinese medicine, including herbs that have the following actions: resolve the exterior, clear heat, precipitate, drain dampness, dispel wind and dampness, transform phlegm and stop cough, aromatically transform damp, rectify qi, regulate blood, warm the interior and expel cold, supplement, stabilize and bind, calm the spirit and extinguish wind.

The herbal categories relate directly to treatment principles that lead to formulas. In the practice of Chinese medicine, the clinical data is aggregated into patterns from which treatment strategies are derived. These treatment strategies are categorically related to the materia medica sections which form the building blocks of an herbal formula.

Garran identifies primary sources for his work in the traditions of great herbalists of the early 20th century including the Eclectics and Physiomedicalists such as Lloyd, Felter, King and Cook. He pulls further information in from contemporary greats of western herbalism such as Simon Mills and Michael Moore.

The method Garran uses to develop the body of knowledge is both pragmatic and time honored: he triangulates personal experience, literature, and oral teachings. This method can be considered as a form of action research that employs cycles of phenomenological observations and the clinic hermeneutic analysis of the literature. Included in this loop of knowledge building is a participatory world view where the dialogues among teachers, students, and peers are used to further establish the credibility, dependability, and transferability of the knowledge about western herbs and Chinese medical thinking presented in the book.

58 herbal monographs and 40 briefs form the backbone of the book; they are constructed in a fashion similar to traditional Chinese materia medicas. From top down, each monograph contains the common name, Latin binomial, plant family, Latin pharmacopeial and other names that can be commonly found in China or the west. After the naming conventions, the flavor and qi—which are essential to the Chinese methods of organizing therapeutics—the entering channels are described, which often relate to the organ tropism but can also refer to tissue layers or anatomical zones. The actions are described using western botanical language. After these brief forms of information about the plant material are addressed—and this data is the traditional Chinese codified form which can be unpacked with contemplation—the functions and indications are discussed. Where appropriate, cautions are discussed. Dosages and preparations are addressed along with major combinations. In the commentary, Garran relates his clinical experience and where pertinent, he discusses the translation of source material for those plants with analogues in China.

The appendices are useful and include western analogues of Chinese herbs, an index of herbs by common name, and an index of herbs by Latin name and a glossary of Chinese medicine terms. I would liked to have seen a glossary of western herbal terms included since practitioners of Chinese herbal medicine may not be familiar with technical terms of western herbal practice such as demulcent, vulnerary, alterative, aperient, etc.

Garran photographed the images in the book with the exception of the damiana (Turnera diffusa, Turneraceae) image. His images have a bright presence that is clear, with excellent color and relief. The images make the book a pleasure to explore, bringing a touch of beauty to the pages. The qualitative methods of building knowledge used by Garran are employed well in terms of constructing a clinically useful collection of monographs.

This book is the best efforts of a mid-career professional herbalist. Garran approaches his craft with mindfulness and heart, and it shows. While the book has usefulness for the Chinese medical practitioner who is interested in Western herbs, the western herbalist who is interested in Chinese theory as a method of clinical thinking will find this book useful. I like having this reference. As the world becomes more globalized, creolized, and cosmopolitan, so does the cultural application of the herbal agents of healing. This book is a strong step in that direction.

 

 

Multiple Sclerosis: Treatment with Chinese Medicine and Nutrition

Acupuncture and Herbal Medicine in the Treatment of Multiple Sclerosis

Multiple Sclerosis is a chronic disorder of the CNS that causes the destruction of the myelin sheath over the  nerves. The course of the disease is variable; it may advance, relapse, remit, or stabilize. The demyelinating patches scattered  throughout the central nervous system interfere with neurotransmission and can cause a wide range of  neurological symptoms. As the disease progresses, the remissions become less complete and a permanent deficit can become apparent. Early diagnosis is difficult due to the vagueness of symptoms.

Symptoms

The symptoms of Multiple Sclerosis may vary greatly.

  • visual impairment including partial or total loss of vision; pain upon moving the eye; diplopia, or nystagmus.
  • impairment of speech
  • numbness or  tingling sensation in the limbs and ataxic gait
  • dysfunction of the  bladder such as hesitancy or urgency and
  • bowel may also be present.
  • depression, apathy, lack of judgment, hysteria.
  • increased deep reflexes, (+) Babinski, Charcot’s triad Others specific to the individual.

Etiology

The etiology of MS is idiopathic. In all likelihood, the cause is multifactorial. Theories about the cause include: autoimmunity, heredity, alteration of fatty acid metabolism,[i] environmental factors, slow viruses, myelinic enzymes, and more.

Temperate Zones

MS tends to be more prevalent in the colder latitudes, and is rarely seen in equatorial regions. The exceptions are regions with high dairy intake.

Postviral Sequela

Dr. Harold Manner reports 100% of his MS patients having a serious bout with measles or a recent inoculation with the vaccination. In animals, many viruses are capable of demyelination.  Studies are tending to show viral factors as adventitious rather than causal. Viral agents isolated from materials cultured from MS patients include: canine distemper, coranavirus, subacute myelo-opticoneuropathy, mumps, chickenpox, herpes simplex, as well as viral fractions.

Electromagnetic Field Disturbance

Dr. Hans Nieper claims an extremely high incidence of electromagnetic field disturbance and geopathic stresses among the some 1300 MS patients he has seen. Eureka California is a sight of high earthquake activity, close by, one must stand at an angle and not perpendicular to the earth to keep from falling. In that region there is an MS frequency 4 times the normal .1%. Given this information, it would be wise for MS patients to avoid microwave, heating blankets, heating pads and the like.

Heavy Metals

Other suspected culprits include heavy metals such as mercury, nickel, fluorine, platinum, aluminum, and chlorine. These metals interfere with the electrical potential across the phospholipid surfaces of cell membranes and myelin sheathing. There is a higher incidence of MS downwind from factories working with nickel, chromium and other heavy metals.

Li Chi Shen recommends the consumption of duck for metal poisoning.  Animal fat is commonly recommended in China for metal toxicity, high fat intake is less of an option here in the U.S for obvious reasons. Modern Study and Application of Materia Medica lists several antidotes for heavy metals according to Subhuti Dharmananda.

  • Arsenic: Angelica, Smilax, Onychium, and Siler.
  • Mercury: Smilax, Onychium, Lysimachia, Halloysite.
  • Lead: Lysimachia, Isatis, Osmunda, Tokoro, Codonopsis, Millettia, Chrysanthemum, Licorice, Equisetum.
  • Miso soup as well as the seaweeds Sargassum and Laminaria have also been shown to bind out heavy metals.

Blood-Brain Barrier

Another theory has to do with the blood-brain barrier and platelet aggregation or blood stasis. Modern researchers in China have been using Salvia miltiorrhiza (Dan Shen) with Astragalus membranaceous (Huang Qi) to potentize the effect of the Salvia.

Autoimmune Factors

During acute episodes, suppressor T-cell levels have been shown to fall just prior to an attack, and rise when the attack ends. Linoleic acid (Flax oil) supplementation has been shown to significantly reduce immune auto-aggression.

Epidemiology

Most cases begin between 20 and 40 years old, and rarely after 50. Females are affected slightly more than males. Siblings are at a 10-15% greater risk than the general populous whose risk is 0.1%. Daughters of mothers show a 5% increased risk. The disease is rarely seen in Native Americans, Eskimos and Bantus.

 Lab findings

Lab findings are used to rule‑out other diseases: CSF analysis, CT scan, brain scans, skull and spinal x‑rays. These diagnostic methods traumatize the dura mater, Hans Nieper considers these to be aggravants to the MS inflammatory phases.

Prognosis

Multiple Sclerosis is rarely fatal;  the average life expectancy is 93 percent of that of the general population. One in 5 Multiple Sclerosis patients experience one attack, followed by little or no advance in the disorder.  Two‑thirds of patients can walk independently 25 years after diagnosis.  Approximately 50 percent of those  with Multiple Sclerosis pursue most of the activities they engaged in prior  to their diagnosis. In some cases, however, paralysis of different severities may make it necessary to use a cane, crutches and other aids while walking. In a very small number of cases, the disease accelerates and may result in life‑threatening complications.

Differentiation and Herbal treatment of MS

MS falls into a category of TCM referred to as Wei Zheng, or flaccidity syndrome. A prime symptom of MS is loss of sensation; it is thought to be linked to the animal soul, or the Po. Spiritual exhaustion scatters the Po.

Differential diagnosis of MS includes the possible following:

Damp Heat, Spleen-Stomach deficiency, Lung Heat damaging body fluids, Liver-Kidney Yin Deficiency and Blood Stagnation.[ii],[iii]

Studies from China indicate that most patients fall into the deficiency categories.

 

Damp‑Heat: fever, slight swelling, fullness in the chest and stomach, and scanty dark urine. Abdominal palpation reveals pain upon pressure and can be warm to the touch. The tongue has a yellow greasy coat; the pulse is slippery and slightly rapid. These signs and symptoms are in addition to flaccidity of the limbs, especially the legs.

Phellodendron and Achyranthes Formula Plus (Jia Wei San Miao Wan):

Every herb in this formula drains damp; Phellodendron clears heat; Atractylodes, Lachryma jobi, Stephania and Tokoro all Dispel Wind Damp arthritic pains; Achyranthes strengthens the lower body tendons and ligaments, as well as nourishing the Liver and Kidney. Contents: Phellodendron (Huang Bai) 12g, Atractylodes lancea (Cang Zhu) 18g, Achyranthes bidentata (Niu Xi) 6g; add Lachryma jobi Sm (Yi Yi Ren) 10g, Stephania tetrandra (Fang Ji) 3g, Tokoro AKA Dioscorea hypoglauca (Bie Xie) 3g, Alisma (Ze Xie) 3g.

Another formula used for damp heat pictures is similar to Ching Hao and Scute Combination (Hao Jing Qing Tan Tang) in it: Rhubarb harmonizes the relationship between hot and cold, it also provides an avenue to eliminate heat through the intestines. Peony, Chih Shih and Bupleurum work together to harmonize the Qi level (Peony softens the Bupleurum action). Artemesia, Talc, Scutellaria, Akebia, Hoelin all drain damp. Pinellia, Bamboo and Chih Shih transform phlegm; with Bupleurum, these three herbs also impact the lymph system. Jujube renders the formula a little more palatable, it also sustains the Spleen/Stomach with the onslaught of these other herbs. Contents: Artemisia anua (Ching Hao), Talcum (Hua Shi), Peony alba (Bai Shao), Scutellaria baicalensis (Huang Qin), Bupleurum falcatum (Chai Hu), Bambusa en taenia (Zhu Ru), Akebia quinata (Mu Dong), Hoelen or Poria cocos (Fu ling), Citrus aurantium (Chih Shih), Pinellia ternata (Ban Xia), Rhei chinensis (Da Huang), and Zyziphus jujube (Da Zao).

 


Spleen-Stomach Deficiency: Poor appetite, shortness of breath, lack of energy to speak, pale complexion, loose stool, and sallow skin. Abdominal palpation reveals softness around Ren 12 and 8. The tongue is flabby with teeth marks; The pulse is weak and too elastic; in addition, there is a gradual weakening  of the legs.

Six Major Herb Combination is slightly modified (Jia Wei Liu Jun Zi Tang): Salvia invigorates the blood and dispels stasis. Astragalus, Codonopsis, Atractylodes, Hoelin, and Glycyrrhiza all tonify Qi. Pinellia and Citrus dissolve phlegm damp. Atractylodes and Hoelin dispel damp. Glycyrrhiza harmonizes the actions of the other herbs. Contents: Astragalus membranaceous (Huang Qi), Salvia miltiorrhiza (Dan Shen), Codonopsis pilosulae (Dang Shen), Atractylodes macrocephala (Bai Zhu), Poria cocos or Hoelin (Fu Ling), Pinellia ternata (Ban Xia), Citrus aurantium (Chih Shih), Glycyrrhiza uralensis (Gan Cao).

Blood Stagnation:

History of trauma, loss of strength and control in the limbs, muscle numbness and swelling. There may be patches of dry skin related to affected areas or channels. The shoulders can be tight, and the abdomen can have painful lumps. There may be a red flushed face, showing cardiovascular rigidity. The pulse can be deep or choppy; the tongue is dusky to dark purple, or there may be swelling and darkness in the vessels under the tongue.

Persica and Carthamus Combination (Xue Fu Zhu Yu Tang): The first 6 herbs activate blood; Bupleurum and Citrus harmonize and regulate Qi; Bupleurum, Raw Rehmannia and Red Peony balance the formula by cooling; Dang Gui, Rehmannia, and Ligustici tonify blood as components of the archetypal formula Dang Gui Four (red peony replaces the white). Contents: Persica (Tao Ren) 4g, Carthami flos (Hong Hua) 3g, Angelica sinensis (Dang Gui) 3g, Peonia rubra (Chi Shao Yao) 3g, Ligustici wallichi (Chuan Xiong) 2g, Achyranthes bidentata (Niu Xi) 3g, Bupleurum falcatum (Chai Hu) 2g, Platycodon grandiflori (Jie Geng) 2g, Citrus aurantium (Zhi Ke) 2g, Rehmannia glutinosa raw (Sheng Di Huang) 3g, Glycyrrhiza uralensis (Gan Cao) 2g.

Experimental Formula: Astragalus and Codonopsis supplement Qi; Raw Rehmannia nourishes yin; Peonia alba, Dang Gui and Raw Rehmannia nourish blood; Raw Rehmannia, Bupleurum and Scute clear heat; Salvia, Cnidium and Peonia rubra activate blood; Pinellia dissolves phlegm. Contents: Astragalus membranaceous (Huang Qi), Codonopsis pilosula (Dang Shen), Salvia miltiorrhiza (Dan Shen), Rehmannia glutinosa Raw (Sheng Di Huang), Peonia alba (Bai Shao Yao), Bupleurum falcatum (Chai Hu), Angelica sinensis (Dang Gui), Peonia rubra (Chi Shao Yao), Scutellaria baicalensis (Huang Qin), Cnidium or Ligustici wallichi (Chuan Xiong), Pinellia ternata (Ban Xia) and Glycyrrhiza uralensis (Gan Cao).

Liver and Kidney Yin Deficiency:

Heat sensations in the afternoon, dry skin, thirst, a tendency to restlessness and irritability. The low back and medial knee area can be quite warm to the touch. The pulse is thready and wiry, slightly rapid.The tongue is red with no coat. The muscles atrophy, and the limbs are without strength.

Eucommia and Achyranthes Formula (Wei Zhang Feng), the name of the formula translates as flaccidity decoction. Dang Gui, Peony, and Rehmannia nourish blood; Atractylodes lancea, Phellodendron, and Achyranthes drain damp; Anemarrhena and Phellodendron clear heat; Dang Gui and Achyranthes activate blood; Anemarrhena and Rehmannia nourish yin; Achyranthes and Eucommia strengthen the tendons and ligaments. This formula is an excellent example of using secondary herb functions to support and interleave therapeutic principles. Contents: Angelica sinensis (Dang Gui) 5g, Peonia alba (Shao Yao) 2g, Eucommia ulmoides (Du Zhong) 1g, Achyranthes bidentatae (Niu Xi) 3g, Astragalus membranaceous (Huang Qi) 2g, Atractylodes lancea Rx (Cang Zhu) 3g, Rehmannia glutinosae (Di Huang) 4g, Phellodendron amurense (Huang Bai) 1g, Anemarrhena asphodeloides (Zhi Mu) 3g.

Hu Qian Wan (Hidden Tiger Pill)

Testudinis, Anemarrhena and Rehmannia moisten yin. Phellodendron and Anemarrhena remove fire. Testudinis, Os Tigris and Cynomorii consolidate the muscles and bones. Chen Pi and Zingiberis regulate and protect the Spleen Stomach. Peony and Rehmannia nourish the blood. Phellodendron amurense (Huang Bai) 15g, Testudinis plastrun (Gui Ban) 12g, Anemarrhena asphodeloides (Zhi Mu) 6g, Rehmannia glutinosa cooked (Shu Di Huang) 6g, Citri pericarpium (Chen Pi) 6g, Peonia alba (Shao Yao) 6g, Cynomorii songarici (Suo Yang) 4.5g, Os tigris (Hu Gu) 30g, Zingiberis dessicata (Gan Jiang) 15g.

Lung Heat Damaging Body Fluids:

There is a fever at onset with a sudden weakness of the limbs. Other signs of lung heat are also present: restlessness, thirst, dry throat, cough, constipation; and dark, scanty urine; the tongue is red with a dry yellow coat; the pulse is thready and rapid.

Eriobotrya and Ophiopogon Combination (Qing Zao Jiu Fei Tang)

Mori Leaf and Gypsum clear heat in the lung; Mori also disperses wind; Armeniaca, Asini, Mori, and Eriobatrya stop cough; Asini, Ophiopogon and Sesame nourish Yin, Ginseng moistens and generates fluids. Licorice tastes good and harmonizes the formula.

Mori Folium (Sang Ye) 3g, Gypsum fibrosum (Shi Gao) 10g, Asini gelatinum (A Jiao) 2.4g, Ophiopogon japonica (Mai Men Dong) 3.6g, Sesami indici (Hu Ma Ren) 2.4, Panax ginseng (Ren Shen) 2g, Armeniacae amarae (Xing Ren) 2g, Eriobotryae japonica (Pi Pa Ye) 3g, Glycyrrhizae uralensis (Gan Cao) 2g.

A formula used with good success by Drs. Zhou and Lu[iv]

This formula nourishes essence, yin, and yang; it also clarifies consciousness and moistens the lung, thus benefitting the Po.

After a reduction of numbness, Hidden Tiger Pill was administered in a successful study.

Corni and Schizandra astringe essence; Acori and Polygala focus on the CNS and clear the mind while Acori opens orifices; Morinda strengthens muscles and bones; Ophiopogon and Eriobatrya benefit the Po; Morinda and Cistanches tonify Yang.

Contents: Rehmannia glutinosae (Shu Di) 18g, Corni officinalis (Shan Zhu Yu) 9g, Schizandra chinensis (Wu Wei Zi) 6g, Polygala tenuifolia (Yuan Zhi) 9g, Acori graminei (Chang Pu) 9g, Morindae officinalis (Ba Ji Tian) 9g, Cistanches 24g, Ophiopogon japonica (Mai Men Dong) 18g, Eriobotryae japonica (Pi Pa Ye) 12g.

Dr Mei Zhu, a practitioner with 50 years experience recommends tonifying the Spleen Liver and Kidney. This reflects more accurately the mixed syndrome picture usually seen in clinical settings.

This formula focuses intensely on replenishing vital essence.

Dr. Zhu’s Formula: P. sibericum, P. officinalis, Astragalus, and Korean Ginseng tonify the Lung (support of the Po) and Spleen. Scrophularia, Astragalus, Rehmannia cooked, P. sibericum, P. officinalis, Cornus and Placenta all replenish vital essence. Morinda strengthens bones and tendons. Scrophularia, and Rehmannia cooked, tonify the kidney Yin. Morinda, Cistanches, Red Ginseng and Placenta tonify Kidney Yang.

Contents: Polygonatum sibericum Rz (Huang Jing) 5g, Polygonati officinalis (Yu Zhu) 3g, Red Korean Ginseng (Hong Ren Shen) 5g, Placenta (Zi He Che) 3g, Morinda officinalis (Ba Ji Tian) 5g, Cistanches salsa (Rou Cong Rong) 3g, Corn officinalis (Shan Yu Ru) 3, Rehmannia glutinosa cooked (Shou Di Huang) 5g, Astragalus membranaceous (Huang Qi) 10g, Glycyrrhizae uralensis (Gan Cao) 5g, Scrophularia ningpoensis (Xuan Shen) 3g.

Food and Nutritional Therapy

Eat a very low fat diet, with fat at 12% of total calories. Use very low saturated fats. When treated early on, this diet can maintain an MS patient with no progression for up to 20 years[v].

A high fat diet impairs the conversion of linoleic acid to prostaglandin E1 (PGE1), this leads to an increase of inflammatory episodes and concomitant oxidative damage.

 

In general, decrease gluten and milk products. Use a hypoallergenic/rotation diet to reduce antigen-antibody responses and immune hypervigilance[vi].

 

therapeutic foods:

Increase omega‑3 and omega‑6 fatty acids: vegetable, nut, seed oils, salmon, herring, mackerel, sardines, walnuts, flaxseed oil, evening primrose oil, black currant oil, kale, celery, fish, raw goat’s milk, veal joint broth, cod roe, rice polishings, brewer’s yeast, nutritional yeast. Olive oil contains about 2% squalene, a substance receiving attention for cancer and MS in Europe (Olive oil itself does not contain sufficient sqaulenes to match the studies).

 

With weakness in the legs, use 5 oz. minced beef, 2 slices fresh ginger.  Boil for 10 minutes in 3/4 pt. water. Eat and drink while hot at night. This therapy is best for a deficient condition. Anthropological blood typing studies by Peter D’Adamo N.D. indicate that people with type O blood will tend to respond better to animal protein therapies due to a tendency to secrete more hydro-chloric acid.

Avoid: Black pepper, dairy, sugar, food intolerances, trans‑fatty acids, hydrogenated oils (margarine, vegetable shortenings, imitation butter spreads, most commercial peanut butters), oxidized fats (deep fried foods, fast food, ghee, barbecued meats)[vii].

 

Essential fatty acid (EFA) therapy provides substances which are necessary for myelin sheathing and cell membranes. Studies are contradictory as to the benefit, generally 2-1 in favor of EFA therapy. Dosages for EFA are: flax oil  2 tsp q.d., Max EPA  3 caps b.i.d., black current oil  2 caps q.d. People vary in there tolerance for these substances, adjust dosages accordingly.

 

Antioxidants can reduce the impact of oxidative damage due to inflammatory episodes. Vitamin E requirement increases with the use of unsaturated fats to reduce lipid peroxidation. Selenium is inexpensive and as the mineral portion of glutathione peroxidase can assist in reducing oxidative stress. Use: Vitamin E  800 I.U. q.d. and Selenium  200 mcg q.d.

 

Phosphatydal Choline is receiving attention for treatment of MS, primarily as a constituent of membrane phospholipids. It is found in high quantity in lecithin use: 2400 mg q.d., phosphatydal choline is available singularly, with the advantage of lower dosage quantity to get the desired phosphatides.

 

Calcium AEP is calcium bound to amino ethyl phosphoric acid, a neurotransmitter which improves electron transport across lipid membranes such as the myelin sheathing. It also reduces inflammation of the blood-brain barrier and reduces autoimmune aggression.

 

Bile salts and lipase assist gut uptake of the fatty acid therapy, reducing nausea. Digestive enzymes of the pancreas work best in concert with each other, rather than using simply lipase.

 

The treatment of MS require a long term diligent effort on the part of the patient as well as the practitioner. The consumption of materials can be tedious at times. Issues such as what the patient gains from the illness should be pursued in good time. The authors experience is that there is usually a payoff in MS as well as undefined demyelination patterns.

 

All tonification treatment should be stopped at the time of an external invasion of pernicious influences and appropriate treatment administered. It is important for the patient to understand this process as colds or flus can aggravate the inflammatory process of MS.

 

[i].Neu IS. [Metabolic aspects of multiple sclerosis] Stoffwechselaspekte der

Multiplen Sklerose. Wien Med Wochenschr (1985 Jan 31) 135(1‑2):20‑2.

[ii].Dharmananda S. Chinese Herbal Treatment for Multiple Sclerosis and Other Flaccidity Syndromes. Int.J.O.M., 1992;17:2,78-89.

[iii].Chen ZL, Chen MF. A Comprehensive Guide to Herbal Medicine. OHAI Press. 312-316.

[iv].Zhou XH, Lu LX. The Clinical Application of Tonifying and Benefiting The Kidney Essence on Multiple Sclerosis. JACTCM; 4, 1985; 65, 66.

[v].Swank RL. Multiple Sclerosis: Twenty Years on low fat diet. Arch. Neurol. 23:460-74, 1970.

[vi].Jones HD. Calif. Med. J. 70:376-80, November, 1953.

[vii].Extracted from IBIS software.

Book Review: What Is Medicine? Western and Eastern Approaches to Healing

By Paul U. Unschuld

Reviewed by William R. Morris, PhD, DAOM, LAc

Key Words: medical history, medical epistemology, Chinese medicine

A sociologist by training, Paul U. Unschuld has expanded his professional roles to that of sinologist and historian. Currently professor and director of the Horst-Goertz Institute for the Theory, History, and Ethics of Chinese Life Sciences, Charité Medical University-Berlin, Unschuld has authored many influential works on Chinese medical history such as Medicine in China: A History of Pharmaceutics and Huang Di Nei Jing Wen: Nature, Knowledge, Imagery in and Ancient Chinese Medical Text, both from UC Press. His works on the Nei Jing and the Nan Jing have influenced a generation of Chinese medical scholars in the West. His sociology background and role as a medical historian in the German University system prepare him well to explore the question: What is medicine?

As a sociologist, Unschuld presents a constructivist point of view which assumes that people build their knowledge of reality from the interaction of their experience and their ideas – and for Unschuld, medicine is no different. Thus, new practices in medicine are built from the beliefs of the social system in which a medical practice takes place.

In this work, Unschuld distinguishes medicine from noumanistic and spiritualistic healing practices and compares and contrasts medical scientific beliefs from the East and West in a historical triptych stretching back 2,000 years. In essence, Unschuld has created a tour de force that explores Eastern and Western medical practices, their history, and social construction. Therefore, one might read this book if seeking knowledge about medical history in the East and West and also to understand thinking processes in medical practice. This book works through medical anthropology as much as it does history and epistemology.

In ancient Greece and China, physicians observed the fact that people healed by themselves. In the canons of Chinese medicine, natural healing is only discussed in the Treatise on Damage bu Cold (Shang Han Lun). Further, the Chinese literature contains no discussion spontaneous healings. However, in ancient Greece, these notions of self-cure have existed for 2,000 years up to today. The external physician is necessary only if the inborn physician didn’t work, and the physician was to observe and intervene only if necessary: Natura Zanat Medica Cura.

Unschuld suggests that medicine is the attempt to understand and manipulate disease on the basis of science i.e., the development of science is a sole prerequisite to the development of medicine. What is science? He contends that it is the assumption that there are natural laws acting independently of person, time, or place, and that humans can recognize these laws. Unschuld believes that understanding these laws is sufficient to understand the universe and human existence in it, and that the development of medicine requires this set of assumptions. That is, science is the prerequisite to the development of medicine.

The basic questions that Unshuld pursues beyond “What is medicine?” are: Why do new thoughts emerge? Why are they adopted? And why are they convincing? How will people consider the concept 100 years from now?

In terms of politics, the Chinese world view that set the stage for the development and flourishing of medicine in China during the Han Dynasty (c. 001 CE) says that the images are in part connected to the efforts of the great unification that took place after the Warring States period.  Thus, Chinese medicine as we know it emerged in a unified empire whereas Western medicine developed in the Greek political environment that valued local and individualized government. In terms of process and relations, then, the tendency of Western medicine to explore objects in detail took place in distinction from the Chinese tendency to look at the whole.

Unschuld discusses China, where Confucianism, Legalism, and Taoism formed the three socio-political currents that affected thoughts and beliefs about medical practice. These are critical to understanding the medical practices of the era. Confucians state that man is basically “good-natured” and that this goodness needs to be reinforced through education, musical training, and behaviors appropriate to class with its rights and rules. If everyone behaves appropriate to class, there should be no problem. The emphasis was on strict sets of social norms for every social activity. Daoist philosopher, Chuan Zi, provided the basis for 2,000 years of imperial philosophy rooted in Confucian legalism. The movement emphasized control over man using strict laws rather than emphasizing good behavior. They did, however, promote education on a high order. Taoists emphasized ignoring rights, laws, and education, as they are all manmade, placing constraint on the people. Men will react, and this is why we have this mess. They said let’s look at nature—we don’t need laws, rules, and punishment. No manmade morality or laws.

Contrary to these three unifying threads in China, Greece sought to shut out monarchal rule. According to Unschuld, it was this very distinction in the sociopolitical climate between early Greece, the polis and the unified state of China the provided the metaphorical backdrop to the development of the medical worldviews. Part of Chinese society arrived at the belief in the necessity of social law, and the Greeks were focusing on the rights of the individual. In Greece the social dimension of law was established first, then natural law. Later, the in the Tang Dynasty, Chinese culture presented a complex pluralistic life compared to the simple depressed nature of European life in the Middle Ages.

Unschuld relates the story of Emperor Tian Chi Huangdi who conquered regions that used different writing, weights, cart track sizes. Within ten years he unified measures which increased commerce. The flow of goods, people, and money were served by the standardization. This is why the government established zang – the depots to store grains. Here we see the importance of zang and other terms. This example is a projection of the concept of circulation, a notion that was not able to be proved in China 2000 years ago, but this is what we see today, for example, in our understanding of the circulation of blood.

What Is Medicine? Western and Eastern Approaches to Healing provides a refined reading experience. Unschuld’s abilities in English, German and Chinese allows for a level of both depth and clarity in his writing style. In essence, Unschuld has created a work that is useful for both medical history and epistemology. His detailed account of the progression of European medical thought in comparison the development of Chinese medical thought is a must read for those who would explore medical history as it pertains to practice. This book could well be a resource in medical history courses.

What Is Medicine? Western and Eastern Approaches to Healing by Paul U. Unschuld
Berkeley, CA: University of California Press
September 2009
ISBN: 9780520257665
Paperback, 256 pages
$24.95

 

 

 

 

 

 

Acupuncture, Neurobiology and the Nitric Oxide Connection

Integrative Medicine and Acupuncture

William R. Morris

Research into the physiological effect of acupuncture is emerging at a rapid rate. From Calcium mediated signal transduction in meridian system and acupuncture where the pattern of magnetic field on the human scalp is mapped by SQUID (Superconducting Quantum Interference Device) showing that the Governor Vessel is a major pathway of magnetic flux on the scalp(14), to the gate-control theory put forth by Wall and Melzack in 1965 (8)(5) to functional MRI work mapping the brain body connection where a point needled in the toe causes the visual cortex to ‘light up.’

 Nitric oxide (NO) Functions

Nitric oxide research seems to show that acupuncture modulates nitric oxide activity in the brainstem somatic sensory paths (nucleus gracilis), basal ganglia striatum, and the cerebral cortex, as well as the hippocampus. Nitric oxide is a messenger molecule with biological actions that range from signal transduction to cell killing. Nitric oxide accounts for tonic relaxation of all types of blood vessels and non-adrenergic and non-cholinergic relaxation of the gastrointestinal tract. Nitric oxide acts as a neurotransmitter in the central and peripheral nervous system, contributes to the antimicrobial activity of macrophages, decreases platelet aggregation, and is involved in hormone release.

Current evidence indicates that, in the CNS, nitric oxide is produced enzymatically in postsynaptic structures in response to activation of excitatory amino acid receptors. It then diffuses out to act on neighboring cellular elements, probably presynaptic nerve endings and astrocyte processes. In several peripheral nerves, and quite possibly in parts of the CNS as well, nitric oxide might be formed presynaptically and thus act as a neurotransmitter(2).

Although the influence of NO on striatal neuronal activity remains to be thoroughly characterized, evidence has accumulatedsuggesting that NO signaling may mediate and/or regulate multipleaspects of striatal neurotransmission including the integration of convergent motor information within striatalnetworks. A major component of the cortical regulation of the nigrostriatal dopamine (DA) system is known to occur via activation ofstriatal efferent systems projecting to the substantia nigra through the intermediary role of striatal nitric oxide synthase(NOS). Striatal NOtone regulates the basal activity and responsiveness of DA neuronsto cortical and striatal inputs. In additionstriatal NO signaling may play an important role in the integrationof information transmitted to basal ganglia output centers viacorticostriatal and striatal efferentpathways(15).

 Acupuncture modulates NO concentration

Increased concentrations of NO were found on the skin adjacent to meridians and acupoints relative to surrounding areas. The hypotensiveand bradycardiac responses to EA ST36 are modified by influencesof L-arginine-derived NO synthesis in the gracile nucleus. It appears that NO plays an important role in mediating thecardiovascular responses to electro-acupuncture ST36 through the gracile nucleus(1).

The work of Dr. Sheng-Xing Ma at the Harbor-UCLA Medical Center suggests that at least some acupuncture effects involve transmission of biological information by nitric oxide.(7) In addition, enhanced NO in the acupoints/meridians is generated from multiple resources including neuronal NOergic system, and NO might be associated with acupoint/meridian functions including low electric resistance. He recently reported that stimulation of hindlimb acupounts (LB 64, 65) resulted in increased synthesis of the signaling molecule nitric oxide at a specific location of the brain stem of rats.

Other studies demonstrate the activity of nitric oxide modulation through acupuncture, needling Zusanli (ST 36) may modulate NOS activity in the hippocampus under diabetic conditions(3). In addition, Li et al investigated 42 people between the ages of age 55 and 70 were given the warm needling at Zusanli (ST 36), the results showed that IL-2 and NO contents increased significantly after the warm needling (P < 0.01)(6).

Hippocampal Function Related to Nitric Oxide Synthase (NOS)

The hippocampus is a central processing area at which meet the sensory and associative cortex, Learning and memory are essential to an animal’s ability to survive and thrive. In many species, including humans, a cortical structure known as the hippocampus is critical for the formation of long-term memory. Studies of long-term potentiation (LTP) in the hippocampus help to show how memories may be encoded and stored at the synaptic level. suggested that acupuncture treatment may modulate NOS activity in the hippocampus under diabetic conditions(3, 9). In addition, Kang et al showed that acupuncture modulates the expressions of NOS and c-Fos in the gerbil hippocampus post transient global ischemia(4).

The hippocampus matures postnatally, which means that the functions it serves are not available for some time after birth. According to Nadel, the role of the hippocampus is the core of a “spatial/cognitive mapping system.” and involves possible relations between space and language(11). In infant rats, stressful experiences can impact postnatal hippocampal development as well as the later development of the hippocampus in relation to unusual “fears and phobias”. It is generally assumed that in the adult organism the hippocampus interacts with the neocortex during memory “consolidation” so as to enable information to be permanently stored in cortical sites(10-13).

Since the hippocampus has connections with the hypothalamus and other structures dealing with somatovisceral, emotional, and endocrine functions where different parts of the brain combine to form a cognitive map, we can then understand the possibility of actual changes in all these areas, including the consolidation of pain memories.

 In Closing

The neurobiological connection is a promising area for the development of a deeper understanding about how acupuncture works. The changes that have been demonstrated in the hippocampal nitric oxide content in relation to acupuncture stimulation may present a fertile ground for the investigation of the psychosocial impact of acupuncture interventions. AS a speculation, it would seem to the author that memories in post traumatic stress syndrome that cause flashbacks of traumatic events could be modulated though acupuncture interventions.

Notes

1.         Chen S, Ma S-X. 2003. Nitric Oxide in the Gracile Nucleus Mediates Depressor Response to Acupuncture (ST36). J Neurophysiol 90: 780-5

2.         Garthwaite, Department of Physiology UoL, UK. 1991. Glutamate, nitric oxide and cell-cell signalling in the nervous system. Trends Neurosci 14: 60-7.

3.         Jang MH SM, Lim BV, Kim HB, Kim YP, Kim EH, Kim H, Shin MS, Kim SS, Kim CJ., Department of Physiology CoM, Kyung Hee University, Dongdaemoon-gu, Seoul, Korea. 2003. Acupuncture increases nitric oxide synthase expression in hippocampus of streptozotocin-induced diabetic rats. Am J Chin Med. 31: 305-13

4.         Kang J-E, Department of Acupuncture and Meridianology GSoE-WMS, Kyung Hee University, Yongin, Korea, Lee H-J, Department of Acupuncture and Meridianology GSoE-WMS, Kyung Hee University, Yongin, Korea, Lim S, et al. 2003. Acupuncture Modulates Expressions of Nitric Oxide Synthase and c-Fos in Hippocampus After Transient Global Ischemia in Gerbils. The American Journal of Chinese Medicine Vol. 31: 581-90

5.         Lewith G K, JN. 1984. Physiological and psychological explanations for the mechanism of acupuncture as a treatment for chronic pain. Soc Sci Med 19: 1367-78

6.         Li SJ, Tang J, Han JS. 1982. [Tolerance to 5-HT and its implication in electro-acupuncture tolerance and morphine tolerance]. Zhongguo Yao Li Xue Bao 3: 159-63

7.         Ma SX. 2003. Enhanced nitric oxide concentrations and expression of nitric oxide synthase in acupuncture points/meridians. J. Alt. Complement. Med. 9: 207-15

8.         Melzack R WP. 1965. Pain mechanism: a new theory. 150: 971-9

9.         Mi-Hyeon Jang M-CS, Baek-Vin Lim, Hyun-Bae Kim, Young-Pyo Kim, Ee-Hwa Kim, Hong Kim, Mal-Soon Shin, Sung-Soo Kim, Chang-Ju Kim. 2002. Acupuncture increases nitric oxide synthase expression in hippocampus of streptozotocin-induced diabetic rats. American Journal of Chinese Medicine

10.       Nadel L. 1994. Multiple memory systems: What and Why. In Memory Systems, ed. DSaE Tulving, pp. pp. 39-63. Cambridge, MA: MIT Press

11.       Nadel L. 1995. The psychobiology of spatial behavior: The hippocampal formation and spatial mapping. In Behavioural brain research in naturalistic and semi-naturalistic settings: Possibilities and Perspectives, ed. H-PL E. Alleva, L. Nadel, A. Fasolo and L. Ricceri: Kluwer Press

12.       Nadel LaJ, W.J. The role of the hippocampus in PTSD, panic and phobia. In Hippocampus: Functions and Clinical Relevance, ed. N Kato. Amsterdam: Elsevier Science B.V.

13.       O’Keefe JaN, L. 1978. The hippocampus as a cognitive map: Oxford: The Clarendon Press.

14.       Shang C. The Meridian System And The Mechanism Of Acupuncture.

15.       West AR, Grace AA. 2000. Striatal Nitric Oxide Signaling Regulates the Neuronal Activity of Midbrain Dopamine Neurons In Vivo. J Neurophysiol 83: 1796-808

 

 

Path of the Pulse: diagnosis and treatment