Traditional Chinese medicine

Traditional Chinese Medicine(simplified Chinese: 中医; traditional Chinese: 中醫; pinyin: zhōng yī: "Chinese medicine") refers to a broad range of medicine practices sharing common theoretical concepts which have been developed in China and are based on a tradition of more than 2,000 years, including various forms of herbal medicine, acupuncture, massage (Tui na), exercise (qigong), and dietary therapy.[1] These practices are a common part of medical care throughout East Asia, but are considered alternative medicine in the Western world.[1]

The doctrines of Chinese medicine are rooted in books such as the Yellow Emperor's Inner Canon and the Treatise on Cold Damage, as well as in cosmological notions like yin-yang and the Five Phases. Starting in the 1950s, these precepts were modernized in the People's Republic of China so as to integrate many anatomical and pathological notions from scientific medicine. Nonetheless, many of its assumptions, including the model of the body, or concept of disease, are not supported by modern evidence-based medicine.

TCM's view of the body places little emphasis on anatomical structures, but is mainly concerned with the identification of functional entities (which regulate digestion, breathing, aging etc.). While health is perceived as harmonious interaction of these entities and the outside world, disease is interpreted as a disharmony in interaction. TCM diagnosis consists in tracing symptoms to an underlying disharmony, mainly by palpating the pulse and inspecting the tongue.

Contents

History

The Compendium of Materia Medica is a pharmaceutical text written by Li Shizhen (1518-1593 AD) during the Ming Dynasty of China. This edition was published in 1593.
Acupuncture chart from Hua Shou (fl. 1340s, Ming Dynasty). This image from Shi si jing fa hui (Expression of the Fourteen Meridians). (Tokyo: Suharaya Heisuke kanko, Kyoho gan 1716).

The first traces of therapeutic activities in the territories that are now considered China date from the Shang dynasty (14th-11th centuries BCE).[2] Though the Shang did not have a concept of "medicine" as distinct from other fields,[3] their oracular inscriptions on bones and tortoise shells refer to illnesses that affected the Shang royal family: eye disorders, toothaches, bloated abdomen, etc.,[4] which Shang elites usually attributed to curses sent by their ancestors.[3] There is no evidence that the Shang nobility used herbal remedies.[5]

Stone and bone needles found in ancient tombs have made Joseph Needham speculate that acupuncture might have originated in the Shang dynasty.[6] But most historians now make a distinction between medical lancing (or bloodletting) and acupuncture in the narrower sense of using metal needles to treat illnesses by stimulating specific points along circulation channels ("meridians") in accordance with theories related to the circulation of Qi.[7] The earliest evidence for acupuncture in this sense dates to the second or first century BCE.[8]

The Yellow Emperor's Inner Canon, the oldest received work of Chinese medical theory, was compiled around the first century BCE on the basis of shorter texts from different medical lineages.[9] Written in the form of dialogues between the legendary Yellow Emperor and his ministers, it offers explanations on the relation between humans, their environment, and the cosmos, on the contents of the body, on human vitality and pathology, on the symptoms of illness, and on how to make diagnostic and therapeutic decisions in light of all these factors.[10] Unlike earlier texts like Recipes for Fifty-Two Ailments, which was excavated in the 1970s from a tomb that had been sealed in 168 BCE, the Inner Canon rejected the influence of spirits and the use of magic.[11] It was also one of the first books in which the cosmological doctrines of Yinyang and the Five Phases were brought to a mature synthesis.[10]

The Treatise on Cold Damage Disorders and Miscellaneous Illnesses was collated by Zhang Zhongjing sometime between 196 and 220 CE, at the end of the Han dynasty. Focusing on drug prescriptions rather than acupuncture,[12] it was the first medical work to combine Yinyang and the Five Phases with drug therapy.[13] This formulary was also the earliest Chinese medical text to group symptoms into clinically useful "patterns" (zheng 證) that could serve as targets for therapy. Having gone through numerous changes over time, it now circulates as two distinct books: the Treatise on Cold Damage Disorders and the Essential Prescriptions of the Golden Casket, which were edited separately in the eleventh century, under the Song dynasty.[14]

In the centuries that followed the completion of the Yellow Emperor's Inner Canon, several shorter books tried to summarize or systematize its contents. The Canon of Problems (probably second century CE) tried to reconcile divergent doctrines from the Inner Canon and developed a complete medical system centered on needling therapy.[15] The AB Canon of Acupuncture and Moxibustion (Zhenjiu jiayi jing 針灸甲乙經, compiled by Huangfu Mi sometime between 256 and 282 CE) assembled a consistent body of doctrines concerning acupuncture;[16] whereas the Canon of the Pulse (Maijing 脈經; ca. 280) presented itself as a "comprehensive handbook of diagnostics and therapy."[16]

Famous historical physicians

These include Zhang Zhongjing, Hua Tuo, Sun Simiao, Tao Hongjing, Zhang Jiegu, and Li Shizhen.

Philosophical background

Traditional Chinese medicine (TCM) is based on Yinyangism (i.e., the combination of Five Phases theory with Yin-yang theory),[17] which was later absorbed by Daoism.[18]

Yin and yang symbol for balance. In Traditional Chinese Medicine, good health is believed to be achieved by a balance between yin and yang.

Yin and yang

Yin and yang are ancient Chinese concepts which can be traced back to the Shang dynasty[19] (1600-1100 BC). They represent two abstract[20] and complementary aspects that every phenomenon in the universe can be divided into.[19] Primordial analogies for these aspects are the sun-facing (yang) and the shady (yin) side of a hill.[21] Two other commonly used representational allegories of yin and yang are water and fire.[20] In the yin-yang theory, detailed attributions are made regarding the yin or yang character of things:

Phenomenon Yin Yang
Celestial bodies[22] moon sun
Gender[22] female male
Location[22] inside outside
Temperature[22] cold hot
Direction[23] downward upward
Degree of humidity damp/moist dry

The concept of yin and yang is also applicable to the human body; for example, the upper part of the body and the back are assigned to yang, while the lower part of the body are believed to have the yin character.[24] Yin and yang characterization also extends to the various body functions, and - more importantly - to disease symptoms (e.g., cold and heat sensations are assumed to be yin and yang symptoms, respectively).[23] Thus, yin and yang of the body are seen as phenomena whose lack (or overabundance) comes with characteristic symptom combinations:

  • Yin vacuity (also termed "vacuity-heat"): heat sensations, possible night sweats, insomnia, dry pharynx, dry mouth, dark urine, a red tongue with scant fur, and a "fine" and rapid pulse.[25]
  • Yang vacuity ("vacuity-cold"): aversion to cold, cold limbs, bright white complexion, long voidings of clear urine, diarrhea, pale and enlarged tongue, and a slightly weak, slow and fine pulse.[26]

TCM also identifies drugs believed to treat these specific symptom combinations, i.e., to reinforce yin and yang.[27]

Interactions of Wu Xing

Five Phases theory

Five Phases (五行, pinyin: wǔ xíng, sometimes also translated as the "Five Elements"[28] theory presumes that all phenomena of the universe and nature can be broken down into five elemental qualities - represented by wood (木, pinyin: ), fire (火pinyin: huǒ), earth (土, pinyin: ), metal (金, pinyin: jīn), and water (水, pinyin: shuǐ).[29] In this way, lines of correspondence can be drawn:

Phenomenon Wood Fire Earth Metal Water
Direction[30] east south center west north
Color[31] green/blue red yellow white black
Climate[30] wind heat damp dryness cold
Taste[32] sour bitter sweet acrid salty
Zang Organ[33] Liver Heart Spleen Lung Kidney
Fu Organ[33] Gallbladder Small Intestine Stomach Large Intestine Bladder
Sense organ[34] eye tongue mouth nose ears
Facial part[35] above bridge of nose between eyes, lower part bridge of nose between eyes, middle part cheeks (below cheekbone)
Eye part[36] iris inner/outer corner of the eye upper and lower lid sclera pupil

Strict rules are identified to apply to the relationships between the Five Phases in terms of sequence, of acting on each other, of counteraction etc.[29] All these aspects of Five Phases theory constitute the basis of the zàng-fǔ concept, and thus have great influence regarding the TCM model of the body.[28] Five Phase theory is also applied in diagnosis and therapy.[28]

Correspondences between the body and the universe have historically not only been seen in terms of the Five Elements, but also of the "Great Numbers" (大數, pinyin: dà shū)[37] For example, the number of acu-points has at times been seen to be 365, in correspondence with the number of days in a year; and the number of main meridians - 12 - has been seen in correspondence with the number of rivers flowing through the ancient Chinese empire.[38][39]

Old Chinese medical chart on acupuncture meridians

TCM model of the body

TCM's view of the human body is only marginally concerned with anatomical structures, but focuses primarily on the body's functions[40][41] (such as digestion, breathing, temperature maintenance, etc.):

"The tendency of Chinese thought is to seek out dynamic functional activity rather than to look for the fixed somatic structures that perform the activities. Because of this, the Chinese have no system of anatomy comparable to that of the West."

—Ted Kaptchuk, The Web That Has No Weaver

These functions are aggregated and then associated with a primary functional entity - for instance, nourishment of the tissues and maintenance of their moisture are seen as connected functions, and the entity postulated to be responsible for these functions is xuě (blood)[42] - but this is mainly a matter of stipulation, not anatomical insight.[43]

The primary functional entities used by traditional Chinese medicine are qì, xuě, the five zàng organs, the six fǔ organs, and the meridians which extend through the organ systems.[44] These are all theoretically interconnected: each zàng organ is paired with a fǔ organ, which are nourished by the blood and concentrate qi for a particular function, with meridians being extensions of those functional systems throughout the body.

Qi

TCM distinguishes not only one but several different kinds of qi (氣).[45] In a general sense, qi is something that is defined by five "cardinal functions":[46][47]

  1. Actuation (推動, tuīdòng) - of all physical processes in the body, especially the circulation of all body fluids such as blood in their vessels. This includes actuation of the functions of the zang-fu organs and meridians.
  2. Warming (溫煦, pinyin: wēnxù) - the body, especially the limbs.
  3. Defense (防御, pinyin: fángyù) - against Exogenous Pathogenic Factors
  4. Containment (固攝, pinyin: gùshè) - of body fluids, i.e. keeping blood, sweat, urine, semen etc. from leakage or excessive emission.
  5. Transformation (氣化, pinyin: qìhuà) - of food, drink, and breath into qi, xue (blood), and jinye (“fluids”), and/or transformation of all of the latter into each other.

Vacuity of qi will especially be characterized by pale complexion, lassitude of spirit, lack of strength, spontaneous sweating, laziness to speak, non-digestion of food, shortness of breath (especially on exertion), and a pale and enlarged tongue.[26]

Qi is believed to be partially generated from food and drink, and partially from air (by breathing).[48] Another considerable part of it is inherited from the parents and will be consumed in the course of life.[48]

In terms of location, TCM uses special terms for qi running inside of the blood vessels and for qi which is distributed in the skin, muscles, and tissues between those. The former is called yíng-qì (營氣), its function is to complement xuè and its nature has a strong yin aspect (although qi in general is considered to be yang).[49] The latter is called weì-qì (衛氣), its main function is defence and it has pronounced yang nature.[49]
Qi also circulates in the meridians. Just as the qi held by each of the zang-fu organs, this is considered to be part of the ‘’principal‘’ qi (元氣, pinyin: yuán qì) of the body[50] (also called 真氣 pinyin: zhēn qì, ‘’true‘’ qi, or 原氣 pinyin: yuán qì, ‘’original‘’ qi).[51]

Xue (blood)

In contrast to the majority of other functional entities, xuě (血, "blood") is correlated with a physical form - the red liquid running in the blood vessels.[52] Its concept is, nevertheless, defined by its functions: nourishing all parts and tissues of the body, safeguarding an adequate degree of moisture,[53] and sustaining and soothing both consciousness and sleep.[54]
Typical symptoms of a lack of xuě (usually termed "blood vacuity" [血虚, pinyin: xuě xū}) are described as: Pale-white or withered-yellow complexion, dizziness, flowery vision, palpitations, insomnia, numbness of the extremities; pale tongue; "fine" pulse.[55]

Jinye (bodily fluids)

Closely related to xuě are the jīnyė (津液, usually translated as "body fluids"), and just like xuě they are considered to be yin in nature, and defined first and foremost by the functions of nurturing and moisturizing the different structures of the body.[56] Their other functions are to harmonize yin and yang, and to help with the secretion of waste products.[57]
Jīnyė are ultimately extracted from food and drink, and constitute the raw material for the production of xuě; conversely, xuě can also be transformed into jīnyė.[58] Their palpable manifestations are all bodily fluids: tears, sputum, saliva, gastric juice, joint fluid, sweat, urine, etc.[59]

Zàng-fǔ

The zàng-fǔ (simplified Chinese: 脏腑; traditional Chinese: 臟腑) constitute the centre piece of TCM's systematization of bodily functions. Bearing the names of organs, they are, however, only secondarily tied to (rudimentary) anatomical assumptions (the fǔ a little more, the zàng much less).[60] As they are primarily defined by their functions,[61][62] they are not equivalent to the anatomical organs - to highlight this fact, their names are usually capitalized.

The term zàng (臟) refers to the five entities considered to be yin in nature - Heart, Liver, Spleen, Lung, Kidney -, while fǔ (腑) refers to the six yang organs - Small Intestine, Large Intestine, Gallbladder, Urinary Bladder, Stomach and Sānjiaō.[63]

The zàng's essential functions consist in production and storage of qì and blood; in a wider sense they are stipulated to regulate digestion, breathing, water metabolism, the musculoskeletal system, the skin, the sense organs, aging, emotional processes, mental activity etc.[64] The fǔ organs' main purpose is merely to transmit and digest (傳化, pinyin: chuán-huà)[65] substances like waste, food, etc.

Since their concept was developed on the basis of Wǔ Xíng philosophy, each zàng is paired with a fǔ, and each zàng-fǔ pair is assigned to one of five elemental qualities (i.e., the Five Elements or Five Phases).[66] These correspondences are stipulated as:

  • Fire (火) = Heart (心, pinyin: xīn) and Small Intestine (小腸, pinyin: xiaǒcháng) (and, secondarily, Sānjiaō [三焦, "Triple Burner"] and Pericardium [心包, pinyin: xīnbaò])
  • Earth (土) = Spleen (脾, pinyin: ) and Stomach (胃, pinyin: weì)
  • Metal (金) = Lung (肺, pinyin: feì) and Large Intestine (大腸, pinyin: dàcháng)
  • Water (水) = Kidney (腎, pinyin: shèn) and Bladder (膀胱, pinyin: pǎngguāng)
  • Wood (木) = Liver (肝, pinyin: gān) and Gallbladder (膽, pinyin: dān)

The zàng-fǔ are also connected to the twelve standard meridians - each yang meridian is attached to a fǔ organ and five of the yin meridians are attached to a zàng. As there are only five zàng but six yin meridians, the sixth is assigned to the Pericardium, a peculiar entity almost similar to the Heart zàng.[67]

Jīng-luò (meridians)

Acupuncture chart from the Ming Dynasty (c. 1368-1644)

The meridians (经络, pinyin: jīng-luò) are believed to be channels running from the zàng-fǔ in the interior (里, pinyin: ) of the body to the limbs and joints ("the surface" [表, pinyin: biaǒ]), transporting qi and xuĕ (blood).[68][69] TCM identifies 12 "regular" and 8 "extraordinary" meridians;[44] the Chinese terms being 十二经脉 (pinyin: shí-èr jīngmài, lit. "the Twelve Vessels") and 奇经八脉 (pinyin: qí jīng bā mài) respectively.[70] There's also a number of less customary channels branching off from the "regular" meridians.[44]

Concept of disease

In general, disease is perceived as a disharmony (or imbalance) in the functions or interactions of yin, yang, qi, xuĕ, zàng-fǔ, meridians etc. and/or of the interaction between the human body and the environment.[71]
Therapy is based on which "pattern of disharmony" can be identified.[72][73] Thus, "pattern discrimination" is the most important step in TCM diagnosis.[72][73] It is also known to be the most difficult aspect of practicing TCM.[74] In order to determine which pattern is at hand, practitioners will examine things like the color and shape of the tongue, the relative strength of pulse-points, the smell of the breath, the quality of breathing or the sound of the voice.[75][76] For example, depending on tongue and pulse conditions, a TCM practitioner might diagnose bleeding from the mouth and nose as: "Liver fire rushes upwards and scorches the Lung, injuring the blood vessels and giving rise to reckless pouring of blood from the mouth and nose.".[77] He might then go on to prescribe treatments designed to clear heat or supplement the Lung.

Disease entities

In TCM, a disease has two aspects: "bìng" and "zhèng".[78] The former is often translated as "disease entity",[79] "disease category",[80] "illness",[78] or simply "diagnosis".[78] The latter, and more important one, is usually translated as "pattern"[79][81] (or sometimes also as "syndrome"[78]). For example, the disease entity of a common cold might present with a pattern of wind-cold in one patient, and with the pattern of wind-heat in another.[82]
From a scientific point of view, most of the disease entitites (病, pinyin: bìng) listed by TCM constitute mere symptoms.[79] Examples include headache, cough, abdominal pain, constipation etc.[83]

Since therapy will not be chosen according to the disease entity but according to the pattern, two patients with the same disease entity but different patterns will receive different therapy. Vice versa, patients with similar patterns might receive similar therapy even if their disease entities are different. This is called 异病同治,同病异治 (pinyin: yì bìng tóng zhì, tóng bìng yì zhì,[73] "different diseases, same treatment; same disease, different treatments").

Patterns

In TCM, "pattern" (证, pinyin: zhèng) refers to a "pattern of disharmony" or "functional disturbance" within the functional entities the TCM model of the body is composed of.[84] There are disharmony patterns of qi, xuě, the body fluids, the zàng-fǔ, and the meridians.[85] They are ultimately defined by their symptoms and "signs" (i.e., for example, pulse and tongue findings).[86]
In clinical practise, the identified pattern usually involves a combination of affected entities[87] (compare with typical examples of patterns). The concrete pattern identified should account for all the symptoms a patient has.[88]

Six Excesses

The Six Excesses (六淫, pinyin: liù yín,[89] sometimes also translated as "Pathogenic Factors",[90] or "Six Pernicious Influences";[91] with the alternative term of 六邪, pinyin: liù xié, - "Six Evils" or "Six Devils"[92]) are allegorical terms used to describe disharmony patterns displaying certain typical symptoms.[93] These symptoms resemble the effects of six climatic factors.[91] In the allegory, these symptoms can occur because one or more of those climatic factors (called 六气, pinyin: liù qì, "the six qi"[94]) were able to invade the body surface and to proceed to the interior.[95] This is sometimes used to draw causal relationships (i.e., prior exposure to wind/cold/etc. is identified as the cause of a disease),[96] while other authors explicitly deny a direct cause-effect relationship between weather conditions and disease,[97][98] pointing out that the Six Excesses are primarily descriptions of a certain combination of symptoms[99] translated into a pattern of disharmony.[91]
It is undisputed, though, that the Six Excesses can manifest inside the body without an external cause.[95][100] In this case, they might be denoted "internal", e.g., "internal wind"[100] or "internal fire (or heat)".[101]
The Six Excesses and their characteristic clinical signs are:

  1. Wind (风, pinyin: fēng): rapid onset of symptoms, wandering location of symptoms, itching, nasal congestion, "floating" pulse;[102] tremor, paralysis, convulsion.[95]
  2. Cold (寒, pinyin: hàn): cold sensations, aversion to cold, relief of symptoms by warmth, watery/clear excreta, severe pain, abdominal pain, contracture/hypertonicity of muscles, (slimy) white tongue fur, "deep"/"hidden" or "string-like" pulse,[103] or slow pulse.[104]
  3. Fire/Heat (火, pinyin: huǒ): aversion to heat, high fever, thirst, concentrated urine, red face, red tongue, yellow tongue fur, rapid pulse.[105] (Fire and heat are basically seen to be the same)[106]
  4. Dampness (湿, pinyin: shī): sensation of heaviness, sensation of fullness, symptoms of Spleen dysfunction, greasy tongue fur, "slippery" pulse.[104]
  5. Dryness (燥, pinyin: zaò): dry cough, dry mouth, dry throat, dry lips, nosebleeds, dry skin, dry stools.[107]
  6. Summerheat (暑, pinyin: shǔ): either heat or mixed damp-heat symptoms.[108]

Six-Excesses-patterns can consist of only one or a combination of Excesses (e.g., wind-cold, wind-damp-heat).[102] They can also transform from one into another.[102]

Typical examples of patterns

For each of the functional entities (qi, xuĕ, zàng-fǔ, meridians etc.), typical disharmony patterns are recognized; for example: qi vacuity and qi stagnation in the case of qi;[109] blood vacuity, blood stasis, and blood heat in the case of xuĕ;[110] Spleen qi vacuity, Spleen yang vacuity, Spleen qi vacuity with down-bearing qi, Spleen qi vacuity with lack of blood containment, cold-damp invasion of the Spleen, damp-heat invasion of Spleen and Stomach in case of the Spleen zàng;[111] wind/cold/damp invasion in the case of the meridians.[112]
TCM gives detailed prescriptions of these patterns regarding their typical symptoms, mostly including characteristic tongue and/or pulse findings.[113][114] For example:

  • "Upflaming Liver fire" (肝火上炎, pinyin: gānhuǒ shàng yán): Headache, red face, reddened eyes, dry mouth, nosebleeds, constipation, dry or hard stools, profuse menstruation, sudden tinnitus or deafness, vomiting of sour or bitter fluids, expectoration of blood, irascibility, impatience; red tongue with dry yellow fur; slippery and string-like pulse.[115]

Basic principles of pattern discrimination

The process of determining which actual pattern is on hand is called 辩证 (pinyin: biàn zhèng, usually translated as "pattern diagnosis",[116] "pattern identification"[117] or "pattern discrimination"[81]). Generally, the first and most important step in pattern diagnosis is an evaluation of the present signs and symptoms on the basis of the "Eight Principles" (八纲, pinyin: bā gāng).[117][118] These eight principles refer to four pairs of fundamental qualities of a disease: exterior/interior, heat/cold, vacuity/repletion, and yin/yang.[117] Out of these, heat/cold and vacuity/repletion have the biggest clinical importance.[117] The yin/yang quality, on the other side, has the smallest importance and is somewhat seen aside from the other three pairs, since it merely presents a general and vague conclusion regarding what other qualities are found.[117] In detail, the Eight Principles refer to the following:

  • Exterior (表, pinyin: biaǒ) refers to a disease manifesting in the superficial layers of the body - skin, hair, flesh, and meridians.[119] It is characterized by aversion to cold and/or wind, headache, muscle ache, mild fever, a "floating" pulse, and a normal tongue appearance.[119]
  • Interior (里, pinyin: )refers to disease manifestation in the zàng-fǔ, or (in a wider sense) to any disease that can not be counted as exterior.[120] There are no generalized characteristic symptoms of interior patterns, since they'll be determined by the affected zàng or fǔ entity.[121]
  • Cold (寒, pinyin: hàn) is generally characterized by aversion to cold, absence of thirst, and a white tongue fur.[122] More detailed characterization depends on whether cold is coupled with vacuity or repletion.[122]
  • Heat (热, pinyin: ) is characterized by absence of aversion to cold, a red and painful throat, a dry tongue fur and a rapid and floating pulse, if it falls together with an exterior pattern.[123] In all other cases, symptoms depend on whether heat is coupled with vacuity or repletion.[124]
  • Vacuity (虚, pinyin: ) often referred to as "deficiency", can be further differentiated into vacuity of qi, xuě, yin and yang, with all their respective characteristic symptoms.[125] Yin vacuity can also be termed "vacuity-heat", while yang vacuity is equivalent to "vacuity-cold".[126]
  • Repletion (实, pinyin: shí) often called "excess", generally refers to any disease that can't be identified as a vacuity pattern, and usually indicates the presence of one of the Six Excesses,[127] or a pattern of stagnation (of qi, xuě, etc.).[128] In a concurrent exterior pattern, repletion is characterized by the absence of sweating.[123] The signs and symptoms of repletion-cold patterns are equivalent to cold excess patterns, and repletion-heat is similar to heat excess patterns.[129]
  • Yin and yang are universal aspects all things can be classified under, this includes diseases in general as well as the Eight Principles' first three couples.[130] For example, cold is identified to be a yin aspect, while heat is attributed to yang.[130] Since descriptions of patterns in terms of yin and yang lack complexity and clinical practicality, though, patterns are usually not labelled this way anymore.[130] Exceptions are vacuity-cold and repletion-heat patterns, who are sometimes referred to as "yin patterns" and "yang patterns" respectively.[130]

After the fundamental nature of a disease in terms of the Eight Principles is determined, the investigation focuses on more specific aspects.[117] By evaluating the present signs and symptoms against the background of typical disharmony patterns of the various entities, evidence is collected whether or how specific entities are affected.[131] This evaluation can be done

  1. in respect of the meridians (经络辩证, pinyin: jīng-luò biàn zhèng)[87]
  2. in respect of qi (气血辩证, pinyin: qì xuě biàn zhèng)[81]
  3. in respect of xuě (气血辩证, pinyin: qì xuě biàn zhèng)[81]
  4. in respect of the body fluids (津液辩证, pinyin: jīn-yė biàn zhèng)[81]
  5. in respect of the zàng-fǔ (脏腑辩证, pinyin: zàng-fǔ biàn zhèng)[81] - very similar to this, though less specific, is disharmony pattern description in terms of the Five Elements [五行辩证, pinyin: wǔ xíng biàn zhèng][132])

There are also three special pattern diagnosis systems used in case of febrile and infectious diseases only ("Six Channel system" or "six division pattern" [六经辩证, pinyin: liù jīng biàn zhèng]; "Wei Qi Ying Xue system" or "four division pattern" [卫气营血辩证, pinyin: weì qì yíng xuě biàn zhèng]; "San Jiao system" or "three burners pattern" [三角辩证, pinyin: sānjiaō biàn zhèng]).[85][133]

Considerations of disease causes

Although TCM and its concept of disease do not strongly differentiate between cause and effect,[134] pattern discrimination can include considerations regarding the disease cause; this is called 病因辩证 (pinyin: bìngyīn biàn zhèng, "disease-cause pattern discrimination").[87]

There are three fundamental categories of disease causes (三因, pinyin: sān yīn) recognized:[71]

  1. external causes: these include the Six Excesses and "Pestilential Qi".[71]
  2. internal causes: the "Seven Affects" (七情, pinyin: qì qíng,[71] sometimes also translated as "Seven Emotions"[135]) - joy, anger, brooding, sorrow, fear, fright and grief.[135] These are believed to be able to cause damage to the functions of the zàng-fú, especially of the Liver.[136]
  3. non-external-non-internal causes: dietary irregularities (especially: too much raw, cold, spicy, fatty or sweet food; voracious eating; too much alcohol),[137] fatigue, sexual intemperance, trauma, and parasites (虫, pinyin: chóng).[71]

Herbal medicine

"The method of appropriately using herbs in accordance with the symptom and sign presentation of the patient entails determining substances with the correct qi, taste, yin and yang, and thick and thin properties as well as the pathogenic factor involved and the meridian it has entered." - Zhang Jiegu
Dried plants and animals parts are used in traditional Chinese medicines. In the image are dried "Supernatural mushrooms" (Lingzhi), dried curled snakes, turtle shell underbelly (plastron), Luo Han Guo, and species of ginseng.
Chinese red ginseng roots
Artemisia annua, one kind of wormwood, is used to treat fevers. It has been found to have antimalarial properties.

Raw materials

There are roughly 13,000 medicinals used in China and over 100,000 medicinal recipes recorded in the ancient literature.[138] Plant elements and extracts are by far the most common elements used.[139] In the classic Handbook of Traditional Drugs from 1941, 517 drugs were listed - out of these, 45 were animal parts, and 30 were minerals.[139]

Animal substances

Some animal parts used as medicinals can be considered rather strange such as cows' gallstones.[140] Some can include the parts of endangered species, including tiger penis[141][142] and rhinoceros horn.[143] The black market in rhinoceros horn reduced the world's rhino population by more than 90 percent over the past 40 years.[144] Concerns have also arisen over the use of turtle plastron[145] and seahorses.[146] In general, Chinese traditional medicine emphasizes the penis of animals as therapeutic.[141] Snake oil, which is used traditionally for joint pain as a liniment,[147] is the most widely known Chinese medicine in the west, due to extensive marketing in the west in the late 1800s and early 1900s, and wild claims of its efficacy to treat many maladies; however, there is no clinical evidence that it is effective.[147][148] Since TCM recognizes bear bile as a medicinal, more than 12,000 asiatic black bears are held in "bear farms", where they suffer cruel conditions while being held in tiny cages.[149] The bile is extraced through a permanent hole in the abdomen leading to the gall bladder, which can cause severe pain; the bears are known to regularly try to kill themselves.[149]

Human body parts

Traditional Chinese Medicine also includes some human parts: the classic Materia medica (Bencao Gangmu) describes the use of 35 human body parts and excreta in medicines, including bones, fingernail, hairs, dandruff, earwax, impurities on the teeth, feces, urine, sweat, organs, but most are no longer in use.[150][151][152]

Traditional categorization

The traditional categorizations and classifications that can still be found today are:

  • classification according to the Four Natures (四气, pinyin: sì qì): hot, warm, cool, or cold (or, neutral in terms of temperature).[153] Hot and warm herbs are used to treat cold diseases, while cool and cold herbs are used to treat heat diseases.[153]
  • classification according to the Five Flavors, (五味, pinyin: wǔ wèi, sometimes also translated as Five Tastes): acrid, sweet, bitter, sour, and salty.[153] Substances may also have more than one flavor, or none (i.e., a "bland" flavor).[153] Each of the Five Flavors corresponds to one of zàng organs, which in turn corresponds to one of the Five Phases.[32] A flavor implies certain properties and therapeutic actions of a substance; e.g., saltiness drains downward and softens hard masses, while sweetness is supplementing, harmonizing, and moistening.[153]
  • classification according to the meridian - more precise, the zàng-organ including its associated meridian - which can be expected to be primarily affected by a given medicinal.[154]
  • categorization according to the specific function. These categories mainly include:
    • exterior-releasing[155] or exterior-resolving[156]
    • heat-clearing[155][156]
    • downward-draining[155] or precipitating[156]
    • wind-damp-dispelling[155][156]
    • dampness-transforming[155][156]
    • promoting the movement of water and percolating dampness[155] or dampness-percolating[156]
    • interior-warming[155][156]
    • qi-regulating[155] or qi-rectifying[156]
    • dispersing food accumulation[155] or food-dispersing[156]
    • worm-expelling[155][156]
    • stopping bleeding[155] or blood-stanching[156]
    • quickening the Blood and dispelling stasis[155] or blood-quickening[156]
    • transforming phlegm, stopping coughing and calming wheezing[155] or phlegm-transforming and cough- and panting-suppressing[156]
    • Spirit-quieting[155][156]
    • calming the Liver and expelling wind[155] or Liver-calming and wind-extinguishing[156]
    • orifice-opening[155][156]
    • supplementing:[155][156] this includes qi-supplementing, blood-nourishing, yin-enriching, and yang-fortifying.[156]
    • astriction-promoting[155] or securing and astringing[156]
    • vomiting-inducing[155]
    • substances for external application[155][156]

Efficacy

Regarding Traditional Chinese herbal therapy, only few trials of adequate methodology exist and its effectiveness therefore remains poorly documented.[157] For example, a 2007 Cochrane review found promising evidence for the use of Chinese herbal medicine in relieving painful menstruation, compared to conventional medicine such as NSAIDs and the oral contraceptive pill, but the findings have to be interpreted with caution due to the generally low methodological quality of the included studies (as, amongst others, data for placebo control could not be obtained).[158]

Acupuncture and moxibustion

Needles being inserted into a patient's skin.
Traditional moxibustion set from Ibuki (Japan)

Acupuncture means insertion of needles into superficial structures of the body (skin, subcutaneous tissue, muscles) - usually at acupuncture points (acupoints) - and their subsequent manipulation. TCM claims that it relieves pain and treats (and prevents) various diseases.[159] The term “acupuncture” is sometimes also used to refer to insertion of needles at points other than acupoints, or to applying an electric current to needles in acupoints.[160][161]

Acupuncture is often accompanied by moxibustion, which involves burning mugwort on or near the skin at an acupuncture point.[162] There are three methods of moxibustion: Direct scarring, direct non-scarring, and indirect moxibustion. Direct scarring moxibustion places a small cone of mugwort on the skin at an acupuncture point and burns it until the skin blisters, which then scars after it heals.[162] Direct non-scarring moxibustion removes the burning mugwort before the skin burns enough to scar, unless the burning mugwort is left on the skin too long.[162] Indirect moxibustion holds a cigar made of mugwort near the acupuncture point to heat the skin, or holds it on an acupuncture needle inserted in the skin to heat the needle.[162] The Chinese character for acupuncture means "acupuncture-moxibustion".

Auriculotherapy (耳灼疗法/耳燭療法) applies acupuncture or moxibustion to the ear. It is believed that a part of the ear (the auricle) is a microsystem with the entire body represented on it.

The effectiveness of acupuncture beyond the placebo effect is not well established.[163] There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles.[164][165][166] The World Health Organization (WHO) has compiled a list of disorders for which acupuncture might have an effect; adverse reactions to chemotherapy and radiation, induction of labor, sciatica, dysmenorrhea, depression, hypertension, rheumatoid arthritis, and low back pain.[167]

Tui na

Tui na (推拿) is a form of massage akin to acupressure (from which shiatsu evolved). Oriental massage is typically administered with the patient fully clothed, without the application of grease or oils. Choreography often involves thumb presses, rubbing, percussion, and stretches.

Qigong

Qigong (气功 or 氣功) is coordinated breathing, movement, and awareness used for exercise, healing, and mediation. Traditional Chinese medicine practioners believe that qìgōng (气功/氣功) and related practices prevent, heal, and treat diseases.

Other therapies

Cupping

Acupuncture and moxibustion after cupping

Cupping (拔罐) is a type of Chinese massage, consisting of placing several glass "cups" (open spheres) on the body. A match is lit and placed inside the cup and then removed before placing the cup against the skin. As the air in the cup is heated, it expands, and after placing in the skin, cools, creating lower pressure inside the cup that allows the cup to stick to the skin via suction. When combined with massage oil, the cups can be slid around the back, offering "reverse-pressure massage".

Gua Sha

Gua Sha

Gua Sha is abrading the skin with pieces of smooth jade, bone, animal tusks or horns or smooth stones; until red spots then bruising cover the area to which it is done. It is believed that this treatment is for almost any ailment including cholera. The red spots and bruising take 3 to 10 days to heal. It is believed that most people can tolerate the pain of treatment, but there is often some soreness in the area that has been treated.[168][169][170][171]

Die-da

Diē-dá (跌打) or bone-setting is usually practiced by martial artists who know aspects of Chinese medicine that apply to the treatment of trauma and injuries such as bone fractures, sprains, and bruises. Some of these specialists may also use or recommend other disciplines of Chinese medical therapies (or Western medicine in modern times) if serious injury is involved. Such practice of bone-setting (整骨) is not common in the West.

See also

Notes

  1. ^ a b Traditional Chinese Medicine, National Center for Complementary and Alternative Medicine, Traditional Chinese Medicine: An Introduction [NCCAM Backgrounder]
  2. ^ Unschuld 1985, p. 17
  3. ^ a b Unschuld 1985, p. 19
  4. ^ Unschuld 1985, p. 18; for detailed explanations of these ailments in Chinese, see Peng 2008, pp. 193–217
  5. ^ Unschuld 1985, p. 22
  6. ^ Lu & Needham 1980, pp. 69-70; Harper 1998, p. 5, note 2.
  7. ^ Harper 1998, p. 5, note 2; Lo 2002, p. xxxiii; Epler 1980.
  8. ^ Unschuld 1985, pp. 93-99; Liao 1991, pp. 272–74; Harper 1998, p. 5, note 2; Lo 2002, p. xxxiii
  9. ^ Harper 1998, p. 4; Sivin 1993, pp. 193-94; Lo 2002, p. xxix
  10. ^ a b Sivin 1993, p. 198
  11. ^ Harper 1998, p. 11
  12. ^ Sivin 1987, p. 179; Ergil & Ergil 2009, p. 30
  13. ^ Unschuld 1985, p. 169
  14. ^ Goldschmidt 2009, pp. 100-101.
  15. ^ Sivin 1987, p. 89
  16. ^ a b Sivin 1987, p. 90
  17. ^ "Zou Yan". Encyclopædia Britannica. http://www.britannica.com/EBchecked/topic/607826/Zou-Yan. Retrieved 1 March 2011. 
  18. ^ Liu 1999, p. 38-39
  19. ^ a b Men & Guo 2010, p. 60
  20. ^ a b Men & Guo 2010, p. 62
  21. ^ Ergil et al. 2009, p. 56
  22. ^ a b c d Ergil et al. 2009, p. 57
  23. ^ a b Wiseman & Ellis 1996, p. 6
  24. ^ Wiseman & Ellis 1996, p. 5
  25. ^ Kaptchuk 2000, p. 230
  26. ^ a b Wiseman & Ellis 1996, p. 142
  27. ^ Ergil et al. 2009. p. 58
  28. ^ a b c Ergil et al. 2009, p. 60
  29. ^ a b Aung & Chen 2007, p. 8
  30. ^ a b Aung & Chen 2007, p. 8 (table)
  31. ^ Deng 1999, p. 13 (table)
  32. ^ a b Ergil et al. 2009, p. 61
  33. ^ a b Maciocia, Giovani (2005) The Foundations of Chinese Medicine, p. 26
  34. ^ Deng 1999, p. 18
  35. ^ Deng 1999, p. 19
  36. ^ Deng 1999, p. 21
  37. ^ Matuk 2006, p. 6
  38. ^ Camillia Matuk (2006). "Seeing the Body: The Divergence of Ancient Chinese and Western Medical Illustration". Journal of Biocommunication 32 (1). http://www.sesp.northwestern.edu/docs/publications/6074956944509ac426aaa6.pdf. 
  39. ^ "There are 365 days in the year, while humans have 365 joints [or acu-points]... There are 12 channel rivers across the land, while humans have 12 channel", A Study of Daoist Acupuncture & Moxibustion, Cheng-Tsai Liu, Liu Zheng-Cai, Ka Hua, p.40, [1]
  40. ^ Matuk 2006, page 5
  41. ^ "Chinese medicine ... emphasizes function. Little emphasis is placed on structure, especially internal structures." As seen at: Ross 1984, p. 6
  42. ^ Ross 1984, p. 13 (table)
  43. ^ "For example, [the term] Xue is used rather than Blood, since the latter implies the blood of Western medicine, with its precise parameters of biochemistry and histiology. Although Xue and blood share some common attributes, fundamentally, Xue is a different concept." As seen at: Flaws 1984, pp. 12-13
  44. ^ a b c Aung, S.K.H. & Chen, W.P.D. (2007): Clinical introduction to medical acupuncture. Thieme Mecial Publishers. ISBN 978-1-58890-221-4, p. 19
  45. ^ Aung & Chen 2007, pp 11-12
  46. ^ Aung & Chen 2007, pp 11-12
  47. ^ "氣的生理功能...(一)推動作用...(二)溫煦作用...(三)防御作用...(四)固攝作用...(五)氣化作用 [Physiological functions of qi ... 1.) Function of actuation ... 2.) Function of warming ... 3.) Function of defense ... 4.) Function of containment ... 5.) Function of transformation ...] as seen at 郭卜樂 (24t October 2009). "氣 [Qi]" (in Chinese). Archived from the original on January 8, 2009. http://web.archive.org/web/20090108191112/http://www.zgxl.net/sljk/imgbody/zyrt/qi.htm. Retrieved 2 December 2010. 
  48. ^ a b "What is Qi? Qi in TCM Acupuncture Theory". 20 June 2006. http://www.yinyanghouse.com/theory/chinese/what_is_qi#jing. Retrieved 3 December 2010. 
  49. ^ a b Elizabeth Reninger. "Qi (Chi): Various Forms Used In Qigong & Chinese Medicine - How Are The Major Forms Of Qi Created Within The Body?". http://taoism.about.com/od/qi/a/Qi_Forms.htm. Retrieved 6 December 2010. 
  50. ^ "...元氣生成後,通過三焦而流行分布於全身,內至髒腑,外達腠理肌膚... [After yuan-qi is created, it disperses over the whole body, to the zang-fu in the interior, to the skin and the space beneath it on the exterior...] as seen in 郭卜樂 (24t October 2009). "氣 [Qi]" (in Chinese). Archived from the original on January 8, 2009. http://web.archive.org/web/20090108191112/http://www.zgxl.net/sljk/imgbody/zyrt/qi.htm. Retrieved 6 December 2010. 
  51. ^ "1、元氣   元氣又稱為"原氣"、"真氣",為人體最基本、最重要的氣,..." [1. Yuan-qi Yuan-qi is also known as "yuan-qi" and "zhēn qì", is the body's most fundamental and most important (kind of) qi ...] as seen at 郭卜樂 (24t October 2009). "氣 [Qi]" (in Chinese). Archived from the original on January 8, 2009. http://web.archive.org/web/20090108191112/http://www.zgxl.net/sljk/imgbody/zyrt/qi.htm. Retrieved 6 December 2010. 
  52. ^ "Blood from a TCM Perspective". Shen-Nong Limited. http://www.shen-nong.com/eng/principles/blood.html. Retrieved 4 April 2011. 
  53. ^ "The Concept of Blood (Xue) in TCM Acupuncture Theory". 24 June 2006. http://www.yinyanghouse.com/theory/chinese/blood_theory_and_disharmonies. Retrieved 3 December 2010. 
  54. ^ "Blood from a TCM Perspective". Shen-Nong Limited. http://www.shen-nong.com/eng/principles/blood.html. Retrieved 3 March 2011. 
  55. ^ Wiseman & Ellis, p. 147
  56. ^ "Body Fluids (Yin Ye)". copyright 2001-2010 by Sacred Lotus Arts. http://www.sacredlotus.com/theory/substances/jinye.cfm. Retrieved 9 December 2010. 
  57. ^ "三、津液的功能 ...(三)调节阴阳 ...(四)排泄废物 ..." [3.) Functions of the Jinye: ... 3.3.)Harmonizing yin and yang ... 3.4.)Secretion of waste products ...] As seen at: "《中医基础理论》第四章 精、气、血、津液. 第四节 津液 [Basics of TCM theory. Chapter 4: Essence, qi, blood, jinye. Section 4: jinye]" (in Chinese). http://www.zysj.com.cn/lilunshuji/jichulilun/44-4-4.html. Retrieved 9 December 2010. 
  58. ^ "Body Fluids (Yin Ye)". copyright 2001-2010 by Sacred Lotus Arts. http://www.sacredlotus.com/theory/substances/jinye.cfm. Retrieved 3 March 2011. 
  59. ^ "津液包括各脏腑组织的正常体液和正常的分泌物,胃液、肠液、唾液、关节液等。习惯上也包括代谢产物中的尿、汗、泪等。" [The (term) jinye comprises all physiological bodily fluids of the zang-fu and tissues, and physiological secretions, gastric juice, intestinal juice, saliva, joint fluid etc. Costumarily this also includes metabolic products like urine, sweat, and tears, etc.] As seen at: "《中医基础理论》第四章 精、气、血、津液. 第四节 津液 [Basics of TCM theory. Chapter 4: Essence, qi, blood, jinye. Section 4: jinye]" (in Chinese). http://www.zysj.com.cn/lilunshuji/jichulilun/44-4-4.html. Retrieved 9 December 2010. 
  60. ^ "Cultural China - Chinese Medicine - Basic Zang Fu Theory". http://kaleidoscope.cultural-china.com/en/118Kaleidoscope4651.html. Retrieved 8 January 2011. 
  61. ^ Ross 1984, p.6: "... the Zang Fu, the organ systems of TCM, do not refer so much to structures as to functions."
  62. ^ Kaptchuk 2000, p. 76: "The Chinese Liver is defined first by the activities associated with it, the Western liver by its physical structure"
  63. ^ by citation from the Huangdi Neijing's Suwen: ‘’言人身臟腑中陰陽,則臟者為陰,腑者為陽。‘’[Within the human body's zang-fu, there's yin and yang; the zang are yin, the fu are yang]. As seen at: "略論臟腑表裏關係 [outline on the relationships between the zang-fu]" (in Chinese). 22 January 2010. http://www.yixuesheng.com/lunwen/zhongyi/zyjc/201001/5090.html. Retrieved 13 December 2010. 
  64. ^ "Cultural China - Chinese Medicine - Basic Zang Fu Theory". http://kaleidoscope.cultural-china.com/en/118Kaleidoscope4651.html. Retrieved 26 February 2011. 
  65. ^ "六腑:膽、胃、小腸、大腸、膀胱、三焦;“傳化物質”。 [The Six Fu: gallbladder, stomach, small intestine, large intestine, bladder, sanjiao; "transmit and digest"] as seen at "中醫基礎理論-髒腑學說 [Basics of TCM theory - The zangfu concept]" (in Chinese). 11 June 2010. http://www.notedyy.com/news/html/?341.html. Retrieved 14 December 2010. 
  66. ^ Aung, S.K.H. & Chen, W.P.D. (2007): Clinical introduction to medical acupuncture. Thieme Mecial Publishers. ISBN 978-1-58890-221-4, pp 15-16<
  67. ^ Aung, S.K.H. & Chen, W.P.D. (2007): Clinical introduction to medical acupuncture. Thieme Mecial Publishers. ISBN 978-1-58890-221-4, p. 16
  68. ^ "经络是运行全身气血,联络脏腑肢节,沟通表里上下内外,..." [The jingluo transport qi and blood through the whole body, connecting the zang-fu with limbs and joints, connecting interior with surface, up with down, inside with outside ...] as seen at "中医基础理论辅导:经络概念及经络学说的形成: 经络学说的形成 [guide to basic TCM theory: the jing-luo concept and the emergence of jing-luo theory: the emergence of jing-luo theory]" (in Chinese). http://www.diyifanwen.com/kaoshizhuanti/fuxizhidao1/0781614101641980_497.htm. Retrieved 13 January 2011. 
  69. ^ Aung, S.K.H. & Chen, W.P.D. (2007): Clinical introduction to medical acupuncture. Thieme Mecial Publishers. ISBN 978-1-58890-221-4, p. 20
  70. ^ "(三)十二经脉 ...(四)奇经八脉 ..." [(3.) The Twelve Vessels ... (4.) The Extraordinary Eight Vessels ...] as seen at "经络学 [meridian theory]" (in Chinese). http://www.pharmnet.com.cn/tcm/knowledge/detail/100044.html. Retrieved 22 February 2011. 
  71. ^ a b c d e Wiseman & Ellis 1996, p. 77
  72. ^ a b Ergil et al. 19, p. 148
  73. ^ a b c Flaws & Finney 1996, p. 1
  74. ^ Flaws 1990, p. 5
  75. ^ “Tongue Diagnosis in Chinese Medicine”, Giovanni Maciocia, Eastland Press; Revised edition (June 1995)
  76. ^ Maciocia, Giovanni (1989). The Foundations of Chinese Medicine. Churchill Livingstone. 
  77. ^ Peter Deadman and Mazin Al-Khafaji. "Some acupuncture points which treat disorders of blood", Journal of Chinese Medicine
  78. ^ a b c d Clavey 1995, p. xxx (30 of the introduction)
  79. ^ a b c Ergil et al. 2009, p. 146
  80. ^ Flaws 1990, p. 6
  81. ^ a b c d e f Flaws 1990, p. 7
  82. ^ Ergil et al. 2009, p. 126
  83. ^ Ergil et al. 2009, p. 147
  84. ^ Ergil et al. 2009, p. 122: "... Chinese medicine does not diagnose a disease, but rather a 'pattern of disharmony'... the concept of disharmony ... refers to the functional disturbance of any bowel, viscus, or vital substance."
  85. ^ a b Clavey 1995, p. xxxi
  86. ^ "The ground, however, is the total pattern. The ground is made up of all the other signs and symptoms that are not necessarily pathognomonic of the diagnosed disease." As seen at: Flaws & Finney 1996, p. 3
  87. ^ a b c Flaws 1990, p. 8
  88. ^ Flaws & Finney 1996, p. 3
  89. ^ Wiseman & Ellis 1996, p. 78
  90. ^ Marcus & Kuchera (2004). Foundations for integrative musculoskeletal medicine: an east-west approach. North Atlantic Books. ISBN 9781556435409. http://books.google.com/?id=WbThUt45ZXgC&pg=PA159&dq=tcm+six#v=onepage&q=tcm%20six&f=false. Retrieved 22 March 2011.  p. 159
  91. ^ a b c Ross 1984, p. 39
  92. ^ Ross 1984, p. 27
  93. ^ Ergil et al. 2009, p. 88: "The six evils are not detected in a lab, but are known through distinctive signs."
  94. ^ Deng 1999 , p. 185
  95. ^ a b c Ergil et al. 2009, p. 88
  96. ^ Deng 1999, p. 185: "Or, abnormal changes in the weather, at inappropriate times for that weather condition, can cause the emergence of disease."
  97. ^ Ergil et al. 2009, p. 88:"Whether the patient had a specific encounter with a cold wind shortly before the onset of the symptoms is not necessarily relevant."
  98. ^ Ross 1984, p. 39: "The situation is not so much a linear chain of cause and effect,..."
  99. ^ Ergil et al. 2009, p. 88: "It is the patient's presentation that determines the nature of the evil."
  100. ^ a b Wiseman & Ellis 1996, p. 79
  101. ^ Wiseman & Ellis 1996, p. 81
  102. ^ a b c Deng 1999, p. 186
  103. ^ Wiseman & Ellis 1996, pp. 80 & 142
  104. ^ a b Ross 1984, p. 38
  105. ^ Ergil et al. 2009, p. 89
  106. ^ Wiseman & Ellis 1996, p. 80
  107. ^ Ergil et al. 2009, p. 127
  108. ^ Wiseman & Ellis 1996, p. 82
  109. ^ Wiseman & Ellis 1996, p. 145-146
  110. ^ Wiseman % Ellis 1996, p. 147-150
  111. ^ Ergil et al. 2009, p. 139 (table)
  112. ^ Flaws & Finney 1996, p. 169-173
  113. ^ cf. Flaws & Finney 1996, pp. 9-133, 137-151, 169-174
  114. ^ cf. Wiseman & Ellis 1996, pp. 145 et sqq.
  115. ^ Wiseman & Ellis 1996, p. 173
  116. ^ Ergil et al. 2009, p. 122
  117. ^ a b c d e f Wiseman & Ellis 1996, p. 127
  118. ^ Ergil et al. 2009, p. 124
  119. ^ a b Wiseman & Ellis 1996, p. 128
  120. ^ Deng 1999, p. 167
  121. ^ Wiseman & Ellis 1996, p. 130
  122. ^ a b Wiseman & Ellis 1996, p. 132
  123. ^ a b Wiseman & Ellis 1996, p. 141
  124. ^ Wiseman & Ellis 1996, p. 133
  125. ^ Wiseman & Ellis 1996, p. 135
  126. ^ Kaptchuck 2000, pp. 230-231
  127. ^ "...if it not that the right is vacous, then it is that the evil is replete." As seen at: Deng 1999, p. 165
  128. ^ Tierra & Tierra 1998, p. 108
  129. ^ cf. Wiseman & Ellis 1996, pp. 80, 142, 193, 197
  130. ^ a b c d Wiseman & Ellis 1996, p. 138
  131. ^ "For instance, if by eight-principle pattern identification a heat pattern is detected, qi-blood pattern identification will show whether the heat is located in the blood or qi; organ pattern identification will determine what organ or organs are affected; and disease-evil pattern identification will identify any evil present." As seen at: Wiseman & Ellis 1996, p. 127
  132. ^ Flaws & Finney 1996, p. 7
  133. ^ Flaws & Finney 1996, p. 6
  134. ^ Ross 1984, p. 26
  135. ^ a b Ross 1984, p. 40
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