Chinese medicine, a traditional system facing the test of the moderne world, by Eric MARIÉ (Faculty of Medicine of the University of Montpellier)

The  Lung Meridian of Hand Taiyin, Ming treatise.
Source : Zhang Jingyue, Leijing tuyi 類經圖翼
[Illustration for the Classic of Internal Medicine], 1624.

The medical system that has flourished for over two thousand years in China is extraordinary from both a historical and an anthropological perspective. During its long process of development it has maintained a remarkable epistemological continuity. China is the only country in the history of civilization that has preserved its traditional medical system, which was reinstated in the 1950s as a state-sanctioned health care system and accorded an official status comparable to that of biomedicine.

The principles of traditional Chinese medicine (TCM)) are mainly defined in its founding documents, which are still used today as standard reference works by all practitioners and researchers. The most important of these is the Huangdi neijing 黃帝內經 [The Yellow Emperor's Classic of Internal Medicine], a composite work whose most ancient texts are believed to date back earlier than 3 BC. Some of the work has been lost, and up to the seventh century the remaining texts underwent a series of amendments and were reorganized. Other “classic”  works and a  host of treatises and commentaries provide the main epistemological source of  Chinese medical theory, which is supplemented at the grass roots level by more popular forms of medicine based on oral tradition.  What emerges from all this is the concept that no life form can be examined in isolation from its universal organic context: the physical structures and functions of human beings form an indivisible and interactive whole that is constantly adapting to the  cosmic, climatic and psychological environment. Chinese doctors define life as the implantation of an organizing consciousness  (shen 神) in  an individual essence (jing 精), through which it conducts and personalises the flow of universal energy  (qi 氣) in a bodily form (xing 形). The theories of yin/yang 陰陽 (the interaction of opposing complementary forces) and of  wuxing 五行 [Five Movements] that inform all Chinese thinking underpin the entire system of connections and relations between  organs, feelings, body tissue  and physiological functions.
 

The human body, moreover, is envisaged as an empire, in which the intestines are not mere flesh but government ministries and departments. The terms emperor, chancellor, general, intendant and the names of various kinds of officials are frequently used to describe them. The information they receive and transmit is conveyed by means of a complex network of jingluo 經絡 [Meridians and Ramifications, also known as Channels and Collaterals] along which acupuncture points are plotted.

Acupuncture Meridians, Zhenjiu dacheng 針灸大成
[Grand Compendium of Acupuncture and Moxibustion]
by Yang Jizhou, 1601, published 1843.

Theories on the causes of illnesses have evolved and been defined throughout the history of Chinese medicine. At one important  stage they were divided into three etiological categories. Chen Wuze, in 1174, classified them according to external, climate-related causes, internal causes, related to the emotions, and other causes that did not fall into either of those categories. This thinking is still prevalent in current practice.

On the basis of these concepts, diagnosis takes place in two stages. The first  is the detection of signs and symptoms through four investigative methods traditionally known as sizhen 四診 [four diagnoses]: observation (of the complexion, tongue, etc), smelling/hearing (voice, cough, body  odours), inquiry (past history, subjective signs and symptoms) and palpation (particularly of the radial artery pulse). Using this set of data, the physician establishes a dual diagnosis: bianbing 辯病 [identification of the illness], which names the pathological state without considering its causes and development, and bianzheng 辯證 [identification of the syndrome] which establishes the etiopathogenic process that led to the clinical  condition. It is chiefly on the basis of these zheng 證 [syndromes], specific to TMC, that the therapist will devise  an appropriate treatment.

Chinese medicine consists of preventive measures and a group of branches of treatment. A crucial role is played by its very rich pharmacopoeia: about 6,000 substances and almost 100,000 formulas are listed (though in practice about 600 of these substances are used and the number of formulas used is somewhere between 500 and 1,000). Among the other therapeutic techniques, the most noteworthy are acupuncture and moxibustion, massage,  physical, breathing and mental exercises known as qigong 氣功 [Qi exercises], and “diet therapy”, based on recipes combining prescribed foods with drugs from the Chinese pharmacopoeia.

Until the early 20th century, medical knowledge in China was based on transmission of knowledge from master to disciple, frequently within a family-based system. At a very young age,  during childhood or adolescence, the pupil began his training by studying the classical texts, and then continued it by following his teacher in his work. However, medicine was not always the first profession chosen. Sometimes, unforeseen circumstances in the course of an official’s career, such as  illness or some other unexpected event, would induce a man of letters to take a passing or even a lasting interest in medicine. Several reference works were written by former magistrates and indeed by ministers who became respected, well-known doctors as a result of unforeseeable circumstances. This no doubt created or reinforced the image of the “body as an empire”  and guided therapeutic strategies, which were clearly influenced by political, economic or military concepts, as evidenced by the TMC lexicon. It might seem that the definitive transformation, over fifty years ago, of  ancient methods of apprenticeship into national university degree courses has replaced every traditional form of transmission of knowledge. This is not at all the case. On the contrary, traditional methods  were sanctioned by the Ministry of Health in the late 50s,  when it was decided to have a certain number of students trained by  laozhongyi 老中醫 [“ old” Chinese doctors] so that the ancient wisdom could be preserved and handed down.

Today, Chinese faculties of medicine provide training for students up to the level of xueshi 學士 (5 years), and then, after three more years, to the level of  shuoshi 碩士; finally, after a further three years of study they qualify as boshi 博士 , thus concluding their eleven-year training period. Training phases of the same duration are also envisaged for the study of Western medicine. The choice between the two disciplines, Western and Chinese, is made at the end of secondary school. Each system has its own hospitals, research institutes, national academy and central administration. During training to become a xueshi, students attend about 3,800 hours of lectures. 950 of these are devoted to general subjects (languages, sciences) and the rest are divided among TCM (about 70 %) and biomedicine (about 30 %). Finally, after basic training in one of the two main branches of medicine, some students opt for a course known as zhongxiyi jiehe 中西醫結合 [Integrated Chinese and Western medicine].

Organs and Entrails, Zhenjiu dacheng 針灸大成
[Grand Compendium of Acupuncture and Moxibustion]
byYang Jizhou, in 1601, published 1843.

But the desired institutional balance between Chinese medicine and Western medicine is very often uneven. The pharmaceutical industry, in China and in other countries, invests far more resources in biomedicine. This affects the material working conditions of practitioners and researchers. It is not easy to license drugs from the Chinese pharmacopoeia, which are essentially based on the TMC practitioners’ prescriptions for  natural substances. The strong tendency of TMC treatment to be tailored the individual is not compatible with the development of ready-made specialized drugs, which are available in China but account for only a very small proportion of  prescriptions. Since the drugs prescribed by TCM practitioners cannot  be exploited financially, the pharmaceutical industry, which is more interested in the testing of raw materials and in the economic potential of this type of medical treatment,  has preferred to focus on isolating  active agents from traditional drugs. In China, this work is done by an increasing number of  researchers and  it is encouraging to see that new drugs are being discovered in this way. However, biomedicine tends to be the dominant system. It hijacks and exploits TCM’s therapeutic tools,  which have proved effective in their specific context, and incorporates them into its own frames of reference, resulting in discrepancies  and poor performance. The positive contribution that TCM can make to biomedicine stems precisely from the fact that it encourages comparison between different sets of paradigms, thus enabling  Western medical science to reappraise its own  body of knowledge and methods by subjecting them to a more critical scrutiny that can be of benefit to TCM as well.

Throughout the Western world, TCM is  becoming increasingly  attractive. In China, however,  many doctors, teachers and researchers are faced with a dilemma. Should they allow TCM to become progressively insulated  through lack of the means and the right conditions for the knowledge to be developed and handed down, or should they accept its subservience to Western medicine, norms and objectives – leading to the loss not only of TCM’s  identity but also of its specific effectiveness? Some  practitioners perceive a third  way, envisaging the creation of teaching and research centres in the West managed by reputable TCM specialists who could initiate an effective and constructive dialogue with biomedicine and develop joint research by the  two systems, based on a rigorous scientific approach coupled with  respect for each other’s integrity and differences. This type of initiative has already been given a boost in two countries: according to the WHO (2001), in the western Pacific alone TCM is the subject of government policy documents in 75 %  of countries; 62.5 %  of  these countries offer university courses in TCM, and 69 % of them  have national institutions that conduct  research into TCM. In France, though some initiatives have been taken,  there is no significant teaching and research in the TCM area. Indeed, although academic cooperation with Chinese universities exists  in almost all branches of  knowledge,   TCM faculties in China and elsewhere have no institutional counterpart in France. The few projects that have been initiated are often  led by experts  in associated disciplines who rarely meet all the requisites for in-depth study of TCM, such as a knowledge of Chinese  and familiarity with TCM literature and thinking combined with clinical experience of its practice. This is a gap that urgently needs to be bridged, as the rich legacy of  medical knowledge and the increasing number of fields of inquiry that are engendered by TCM constitute a sector of research of international importance. It is a sector in which France must make its presence felt, sooner rather than later.

Éric Marié, head of university degrees in Chinese medicine 
at the Faculty of Medicine, University of Montpellier

Pulse testing in the oncology department
of a traditional Chinese medicine hospital in Shanghai (Photo © 2006 - E. Marié)

Pour aller plus loin :

- Éric MARIÉ, Précis de médecine chinoise, nouvelle édition, revue, corrigée et augmentée. éditions Dangles ; 488 pages ; 2008.

- Éric MARIÉ, « La médecine chinoise : mutations et enjeux d’un système médical traditionnel confronté à la modernité », Monde chinois, n° 5, 2005, pp. 101-124

- Éric MARIÉ : « Médecine chinoise : facteurs d’acceptation et de rejet en Occident au XX^e siècle », pp. 169-186. Thierry MARRES (ed.), Mondialisation et identité - Les débats autour de l’orientalisation et l’occidentalisation, Academia Bruylant, 2009.  

Site des diplômes d’université de médecine chinoise; à la Faculté de médecine de Montpellier