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JOURNAL OF CHINESE MEDICINE NUMBER 38 JANUARY 1992

Thoughts on Acupuncture, InternalMedicine, and TCM in the West

by Bob Flaws, DOM, CMT, Dipl.Ac.

as this term is used in the PRC today, it is the propername of a specific style of Chinese medicine. As PaulUnschuld has stated in rebuttal to this modern PRCusage of term zhong yi, Chinese medicine can (readshould) only refer to a broad range of ideas and practicesrelated to health care and illness intervention that weredeveloped, or adopted from abroad, and practised inChina over the past few millenia.2 In other words,

Unschuld is implying that the appropriation of such ageneric term is a misnomer. Likewise, Leon Hammerstates: According to my teacher Dr. John Shen, who hasbeen practising sixty years since his apprenticeship inShanghai in the 1930s, every city, village, and clan, aswell as the Imperial Court and various philosophicalschools in China had their own often startlingly distinctvariety of this healing art. At one time I counted twenty-five discrete methods of diagnosis and treatment withinmy own files gathered over the past twenty years. Chinaspawned the richest variety of healing methodologiesever recorded in the history of medicine.3

To understand why the current regime has elevated a

particular style of Chinese medicine to the role of beingthe single legitimate and definitive style ofzhong yi, onemust first understand that China is not a country but,rather, to this day an empire. A country most success-fully encompasses a single ethnic group with a singlelanguage and relatively homogenous culture. China isan empire which by military hegemony has bound to-gether within a single geographic perimeter literallyhundreds of different ethnic groups, languages, andcultures.

One of the main political agendas of the Communistregime in 1949 was to transform such an empire, whichis inherently difficult to rule centrally, into an unified

country which is much easier to dictatorially command.Therefore, the Communist regime instituted programsof national standardization at every level. A national

language was imposed.Pu tonghua or so-called common speechis, in fact, only the indigenouslanguage of northern Chinawhere the capital is located. MostWesterners are now familiarwith the forced deculturation ofsuch minority groups in China

as the Tibetans. But such deculturation, i.e., genocide,also extends to other minority ethnic groups, such as theMiao, Yi, and everyone else who is not ethnically Han,propagandist articles in China Today notwithstanding.In exactly the same way, a single style of Chinese medi-cine was chosen and elevated to the position of su-

t the end of last summer, Peter Deadman sent mea letter saying that the September 1991 issue ofThe Journal of Chinese Medicine contained re-

views of a number of Blue Poppy Press recent releases.He mentioned that he had taken exception to my prefaceto Highlights of Ancient Acupuncture Prescriptionsand invited me to rebut his argument. In his letter, heexpressed the opinion that scholarly debate is good for

the profession and so I also believe. Therefore I wouldlike to take this opportunity to address some of PeterDeadmans criticisms concerning the opinions stated inthat books preface. By such public discussion, debatersand readers alike can hone and develop our ideas, ex-pose our flaws, lacunae, and contradictions, and thusclarify and improve our opinions and positions. Just asPeter Deadman extended me an invitation to respond tohis criticisms, I would also like to extend an invitation toothers within our profession to likewise address thesesame issues in the pages of this journal.

For those who have yet to read my preface to High-lights of Ancient Acupuncture Prescriptions translated

by Honora Lee Wolfe and Rose Crescenz, basically I saidthat, as a teacher of TCM, I had found that only aproportion of students can actually make TCM method-ology work for them when they get into clinical practice.Based on that experience and on the history of Chinesemedicine, I said that I felt TCM methodology might bebetter reserved as a post graduate study and that begin-ners might be better served learning and applying byrote such formulas as Highlights contains. PeterDeadman, on the other hand, expressed the opinion that,based on his experience, anyone can learn to use TCMmethodology and that teaching only a formulaic ap-proach to beginners in acupuncture would be a great

step backward.In further clarifying my position, whose merit I still

feel is worth exploring, there are a number of issues thatmust each be addressed. First ofall, what is TCM? As I see it,TCM is a specific style of Chi-nese medicine. Granted, it is thedominant, state endorsed styleof Chinese medicine in the Peo-ples Republic of China todayand has been for the last 25-30years. Leon Hammer, in an article in a recent issue of theAmerican Journal of Acupuncture, states that as a self-conscious and deliberate style, it was adopted by theCommunist regime in the 1960s and early 70s1. Al-though in Chinese it is simply referred to as zhong yi orChinese medicine, that should not obscure the fact that,

a single style of Chinese medicinewas chosen and elevated to theposition of supremacy and sole

legitimacy

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premacy and sole legitimacy, thus creating a singlenational standard binding even this aspect of Chinasmulticultural society further together. Anyone who hasstudied in China should be aware that, during the Cul-tural Revolution, practitioners of politically incorrectstyles of Chinese medicine were purged and persecuted,

imprisoned, tortured, and even driven to commit sui-cide.As for the definition of TCM as a particular style of

Chinese medicine, modern TCM textbooks are clear instating that bian zheng lun zhi is the defining characteris-tic of this style. Bian zheng lun zhi means treatment basedon a discrimination of patterns. Such patterns are basedon signs and symptoms collected by the four diagnoses(si zhen) and analyzed by the eight principles (ba gang).Discriminating damp heat (shi re) from full heat (shi re)from empty heat (xu ru) from depressive heat (yu re) ortransformative heat (hua re) are examples ofbian zheng.However, such a discrimination of patterns is only one

style of Chinese diagnosis and only one methodology forerecting a treatment plan. Even though this style domi-nates Chinese medical literature, in fact, in terms of thenumbers of Chinese healers employing it, this style ofdiagnosis and treatment strategizing is historically aminority style.

This bian zheng style was created by the ru yi or Confu-cian scholar doctors, men such as Zhang Zhong-qing,Zhu Dan-xi, Li Dong-yuan, Zhang Jie-bin, Wu You-ke,Ye Tian-shi, etc. This is a highly discriminating stylebased on rigorous logic and an extremely sophisticateduse of the Chinese language. These men were all wen renor literati. They were also the men who wrote the schol-

arly books on Chinese medicine. Bruce Holbrook, medi-cal anthropologist and lineal disciple of such a ru yi,refers to such doctors as yi sheng or true doctors4. (Yisheng is the term most commonly used in China today fora TCM practitioner.) They were both the intellectual andmedical aristocracy. They wrote the vast majority of thegreat books or classics of Chinese medicine. But, in termsof sheer numbers, they were not the majority of personspractising healing in China during any historical period.

The majority of practitioners in China were alwayswhat Lu and Needham refer to as ling yi5. These were theso-called bell-ringing doctors who travelled about thecountry practicing medicine for a living. These were also

called zhou fang yi or itinerant formula doctors. Fangshi or masters of formulas is what Holbrook calls suchpractitioners6. Fang shi practised medicine as a trade,something Confucian gentlemen were loath to do. Theru yi practised medicine out of Confucian piety and anethos of noblesse oblige. Fang shi were technicians prac-tising what Confucians called a little dao or small path.Fang shi primarily memorized prescriptions based onbian bing lun zhi. These prescriptions were handed downin family lineages; therefore, such doctors often wouldadvertise what generation of practitioner they were intheir family. Such multigeneration doctors were alsocalled shi yi. Since formulas were kept a secret in order to

insure a particular familys lock on a market, formulaswere passed down from male family member to malefamily member. The more generations, the more poten-tial formulas and more clinical experience might be

expected to be passed down.Such practitioners orfang shi tended to also specialize.

This is because they were often illiterate and could onlymemorize a certain number of bits of information. Byspecializing in eye diseases, ear diseases, skin diseases,or whatever, a person only had to memorize a certain

amount of information. Still to this day, in the country-side in China, one can see roadside practitioners treatingeye diseases, ear diseases, and tooth diseases.

As mentioned above, the methodology such practi-tioners used was mostly based on bian bing lun zhi ortreatment predicated on disease category. For instance,suchfang shi memorized a formula, be that acupuncture,herbal, massage, cupping, moxibustion, or whateverwas ones family modality, for stomach ache (wei tong),toothache (ya tong), red eye (chi yan), headache (tou tong),etc. Every one with that same disease would receive thesame memorized formula. Typically, there was littlefurther pattern discrimination of the various manifesta-

tions of a single disease in various patients. Such patterndiscrimination was the province for the ru yi or scholardoctors. One can still find many Chinese practitionerstrained either before the rise of TCM or outside of thePRC, such as in Hong Kong, Singapore, and Taiwan,who still practise acupuncture, massage, cupping, moxi-bustion, and other such modalities according to bianbing. I have translated and published several examplesof this style of formulaic Chinese medicine, both acu-puncture and herbal medicine, in an attempt to docu-ment some of the other, historically identifiable alterna-tives to TCM7,8.

That is not to say that the ru yi or scholar doctors did

not also usebian bing lun zhi but that they used both bianbing andbian zheng lun zhi. They discriminated both theirpatients disease and their individual pattern and treatedaccordingly for both. For instance, although certainmedicinals are known to be empirically useful for treat-ing shao fu tong or lower abdominal pain, of thosemedicinals, some are further differentiated for the treat-ment ofqi zhi or qi stagnation, others for xue yu or bloodstasis, others for shi re, damp heat, and others for qi xuexu or qi and blood emptiness. This further discrimina-tion was the great insight of the ru yi. And I would be thefirst to say that this insight leads to much more effective,holistic, and non-iatrogenic treatment.

When the Communist regime instituted their programof standardizing and nationalizing Chinese medicine,they made certain choices in terms of authority figures.They made certain choices in terms of pragmatic consid-erations. And they made certain choices for purely po-litical and philosophical reasons. All of these choiceshave participated in the modern development of whathas become known as TCM. For instance, the ru yi werethe medical intelligentsia. It was this group which wasapproached in order to design, set up, and be the profes-sors at the various provincial colleges of Chinese medi-cine. This group of practitioners primarily practisedinternal medicine or the prescribing of polypharmacy

formulas for internal administration. Although ru yioften also knew acupuncture/moxibustion, as BruceHolbrook states, to be a yi sheng meant to prescribeinternal medicine9. Acupuncture specialists were not

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generally recognized asyi sheng or fully-fledged Chinesedoctors. Therefore, the men tapped to set up and designNew Chinas nationally standardized system were pri-marily what we in the West refer to as herbal practition-ers. These practitioners then designed a system foundedupon and modelled after their own style, a style which

grew up around the practice of internal medicine.For pragmatic reasons, only a system which tran-scended local, clan, and individual idiosyncrasies couldbe the basis for a nationally standardized approach tomedicine. In establishing large hospitals and clinics, theChinese needed a methodology which all practitionerscould use and agree upon. Family formulas for thetreatment of specific diseasescould simply not providesuch a universal system.They were too idiosyncratic.By instituting the TCM bianzheng methodology, a doctor

in one clinic on one side ofChina could corroborate orcritique a diagnosis and treat-ment plan established byanother practitioner on the other side of China. The ru yibian zheng methodology was both universal enough andprestigious enough to be able to fulfil this need.

However, in crafting this style as it exists today, politi-cal considerations were also taken into account whichhad nothing to do with clinical efficacy. For instance, asUnschuld points out, the words bian zheng have beenemphasized in part because they are homologous to thewords bian zheng (second character different) which

mean dialectic as in dialectical materialism10. Westernscholars such as Nathan Sivin11, Ralph Crozier12, andManfred Porkert13, have all written about such politicaland philosophical influences on the development ofmodern TCM apart from actual clinical exigencies. Forinstance,wu xingxue or five phase theory has been downplayed because of that theorys role in such outlawedarts as astrology and geomancy. Along with that, the wuyun liu qi or five transports, 6 qi theory of Chinesechronobiology has been either suppressed or allowed toflourish depending on the political mood of the rulingparty.Yi Jing or Classic of Change influences have mostlybeen expunged from modern TCM. Recently the govern-

ment in the PRC has once again put that book on thebanned list. And yet its concepts form the basis of muchof Neoconfucianism and, therefore, a great deal of Chi-nese medicine. The concept ofshen has been reduced tothat of vitality as evidenced by that terms translation inHealth Preservation and Rehabilitation edited by ZhangEnqin14. In general, all religious and spiritual conceptshave been eliminated from modern TCM. This system isnow a form of secular materialism, remembering thatthe concept of qi in Chinese does not necessarily implyan immaterial energy.

Nowadays in China at provincial TCM colleges, suchas the Shanghai College of TCM, Beijing College of TCM,

Nanjing College of TCM, etc., all treatment modalitiesare taught from the perspective of bian zheng lun zhi:internal medicine (nei ke), gynecology (fu ke), pediatrics(er ke), external medicine (wai ke), traumatology (shangke), orthopedics (zheng gu ke), oncology (zhong liu ke),

acupuncture/moxibustion (zhen jiu ke), and tui na. TedKaptchuk first referred to the practice of modern TCMacupuncture according to bian zheng lun zhi as theherbalization of acupuncture in a previous issue of thisvery journal15. I find this term quite accurate in that amethodology and terminology which was developed

for the writing of individualized herbal prescriptionswas applied to the composition of acupuncture treat-ments. In this sense, even tui na or Chinese remedialmassage has been herbalized.

Specifically in terms of acupuncture, I feel this move-ment has been a great mistake. It tends to emphasizezangfu physiology and pathophysiology over jing luo

theory. It tends to foster thenotion that acupuncturepoints have functions identi-cal to the functions of Chi-nese herbal medicinals andthat these functions can be

activated similar to flippinga light switch. I am not famil-iar with any Chinese bookon acupuncture which at-

tributes such functions to points prior to the early seven-ties. Prior to that time, points were not described accord-ing to functions but only according to indications couchedin the terminology ofbing, diseases, and zheng (a differ-ent zheng) meaning pathoconditions. I have previouslypublished translations showing how acupuncturistsworking in the late sixties and early seventies con-sciously and deliberately mimicked the creation of acu-puncture protocols as if they were composing herbal

formulas16.This TCM style of acupuncture was not the first one

that I learned. I was first introduced to the Tao familystyle of bian bing lun zhi acupuncture. This style aspractised by Dr. Eric Tao is also heavily influenced by thewu xing xue style of Wu Wei-ping of Taiwan, remember-ing that Taiwan was a Japanese colony throughout thelatter years of the last century and the first half of this. Ithen was influenced by Worsleyan five phase practiceand Vietnamese/French acupuncture as taught byNguyen Van Nghi, Soulie de Morant, and Chamfraultand promulgated in the US by the Occidental Institute ofChinese Studies (OICS). It was only after being exposed

to these styles and having practised an amalgamation ofthem for several years that I went to China and studiedTCM acupuncture. Since that time I have also studiedJapanese and Korean styles of acupuncture. As a clini-cian, my opinion is that these other styles all hew moreclosely to an acupuncturists acupuncture theory. Theyall tend to emphasize the flow of qi over thejing luo. Theyall tend to use some version of wu xing xue for deep,systemic balancing. And they all tend to incorporate agreat deal of palpation in both their diagnosis and treat-ment.

In particular, I am especially impressed by modernJapanese meridian acupuncture as taught by the late

Yoshio Manaka, Shudo Denmei, Kiko Matsumoto, MikiShima, Stephen Brown, and Stephen Birch. Anyone whohas had opportunity to witness the likes of Shudo Denmeior Miki Shima work will immediately recognize thesensitivity in their fingertips, the incorporation of mas-

I have personally found the treatmentsof TCM acupuncture to be both heavy-handed in all senses of that word and

best suited for acute conditions which

may need such heavy-handedtreatment

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sage into their work, and their attention to the patientsentire body and all theirjing luo. Their needle techniqueis simultaneously extremely sophisticated, rigorouslybased on the classics of acupuncture, immediatelygrounded in felt physical palpation, and extremely welltolerated by even the most sensitive of patients. It also

works better, I think, than TCM acupuncture on a largerproportion of patients and especially in a Western set-ting.

That is not to say that TCM acupuncture does notwork. It does. However, I have personally found thetreatments of TCM acupuncture to be both heavy-handedin all senses of that word and best suited for acuteconditions which may needsuch heavy-handed treat-ment. TCM acupuncturetreatments, I feel, tend to beless sophisticated in address-ing wu xing, yin yang, and

jing luo phenomenon and,therefore, also tend to bemerely ballpark treatments. They work often only be-cause they are repeated so frequently (every other day inChina). I think most Western TCM acupuncture practi-tioners will have to agree that there is a significantpercentage of patients who do not respond to this speciesof therapy. Because I have been exposed to a wide rangeof acupuncture styles from a number of different coun-tries, when faced with a recalcitrant condition I have noproblem in searching for a more effective methodology.As far as acupuncture goes, I hold no particular alle-giance to any specific school and have come to the

conclusion that TCM acupuncture is not all that good astyle of that modality.

That is also not to say that there are not crackerjackChinese acupuncturists. There are. But in my experiencethey tend not to do TCM treatments as contained in suchTCM acupuncture texts as Essentials, Comprehensive,etc. They are good precisely because they were trained intheories and techniques more germane and indigenousto acupuncture or have transcended through personalstudy and exploration the narrow confines of TCMacupuncture.

Therefore, I am saying that TCM as a style of acupunc-ture is not what I would consider a very sophisticated

and advanced style. Personally, I would prefer to seeJapanese or Korean acupuncture more widely promul-gated. I feel the theories and techniques of these stylesare more sophisticated (as in sophia, meaning wisdom)and more organic to the art at hand. However, such astyle requires a different type of education than TCMacupuncture training and also requires more time tomaster the very subtle palpation and needle techniqueskills employed.

Further, I question the wisdom of teaching both acu-puncture and internal medicine to the same students ina single program as is done at least at the majority ofAmerican acupuncture schools. Although I agree with

Sun Si-miao that the fully trained Chinese doctor oryisheng should know something about the clinical practiceof acupuncture, I do not necessarily think that all acu-puncturists should study and practise internal medi-cine. In the PRC today, most provincial TCM colleges are

divided into at least three colleges, each with their ownstudents and curricula and each granting their owndegree. There is the acupuncture/tui na college whichtrains only acupuncturists and tui na specialists. This istypically a four year, bachelor program. Then there is theinternal medicine college with its own four to six year

program which grants its own degree in the prescribingof internal medicine. And finally, there is the pharmacol-ogy college which is likewise a four year program lead-ing to a degree as a TCM pharmacist.

Here in the West, we tend to want it all, to be all andeverything. We have begun down a path where thepractice of acupuncture and internal medicine is taught

and practised as if a singleprofession when, in fact, thiswas and is not the case inmost Asian countries. To bereally good at one or the otheris a full-time practice requir-

ing different diagnosticmethodologies, different

theories, and different skills. In my experience, there isnot the time in a single patient visit to do both really well,and I further question the necessity of doing both to asingle patient at the same time as an unspoken orunconsidered assumption. Should we indeed be doingboth on a single patient at the same time? Why? Is this notanother example of if a little is good, more must bebetter? Might not these two different modalities eachexcel at certain types of problems and conditions and,therefore, best be employed in a more discriminatingway by specialists who have a close working relation-

ship with one another?I have personally given up doing much in the way of

acupuncture. For better or worse, I have decided to focuson honing my skills specifically as a TCM internist andgynecologist. That means that I mainly write polyphar-macy, herbal prescriptions (as well as counsel patientson diet, lifestyle, etc.) based on bian zheng diagnosis. Inour clinic, we have a practitioner who just specializes inacupuncture, moxibustion, cupping, bleeding, and tuina who has spent 15 years developing her touch andstudying pre-TCM Chinese and Japanese theories andtechniques of cutaneous and subcutaneous stimulation.Some patients come to me and it is clear from their intake

that they would get better, more immediate, and cheaperresults from seeing this acupuncture specialist. Otherpatients come to her and it is clear to her that really thispatient needs internal medicine. In both cases, we makethe necessary referral and the patient, I believe, gets thebest possible treatment from people who have reallyfocused on practicing their best modality. In some cases,we may also decide that the patient would benefit fromsimultaneously receiving both acupuncture and internalmedicine, but even then it is from persons who havespecialized in each individually. This is a big, multifac-eted topic of discussion and one which I think the time isripe for discussing before we willy nilly go down a path

which later turns out to have produced both mediocreacupuncturists and mediocre internists.

Further, if we were to recognize that these are twoseparate, though historically related, healing arts, thenwe would be free to chose the best methodologies for

Therefore, I am saying that TCM as a styleof acupuncture is not what I would

consider a very sophisticated

and advanced style

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relatively easy to teach students TCM to both do acu-puncture and pass written exams. It is entirely a differentmatter to understand TCM well enough to be able to useit in the clinical practice of internal medicine. I make thedistinction between TCM acupuncture and herbal medi-cine again because in acupuncture there is less chance for

iatrogenesis and a greater chance for a generalized sys-temic effect even from wrongly or less than elegantlychosen points.

Since the jing luo system is a closed loop and since,from an acupuncturists acupuncture point of view,there are only imbalances in qi, stimulating even thewrong points may have a generalized, systemic, andameliorating effect on the patient. Further, certain pointsare also so generally applicable that stimulating themcan benefit almost everyone regardless of the exactitudeof their TCM bian zheng diagnosis. In other words, inTCM acupuncture, the fact that the patient got better asa result of a specific treatment or course of treatments

does not necessarily validate the practitioners TCM bianzheng diagnosis.

The fact that TCM is harder to do than to study andteach is borne out by the fact that even in China, it isdifficult to effectively teach TCM to all students at TCMcolleges. Nathan Sivin, in a very important article enti-tled Reflections on the Situation in the Peoples Repub-lic of China, 1987" published in 1990 in the AJA says:

Young doctors told meagain and again that they donot really grasp manifesta-tion type determination (bianzheng) and prefer to diag-

nose by symptoms. Medicalschool, they said, did notgive them a deep enoughunderstanding of yin-yangand the Five Phases to make

them confident about using these concepts. They arethus driven to diagnose on the basis of what seems tothem more concrete and objective Western criteria. Theyare aware that it is impossible to work out a traditionalcourse of therapy on the basis of a biomedical diagnosis,but that is the best they can do, and they do it some-how.18

This is exactly my own experience in China in 1983, 84,

& 87. My TCM teachers told me over and over againhow difficult most TCM undergraduates found TCMmethodology to apply in clinical practice and how mostof them preferred to do Western medicine. Westernmedicine is essentially a bian bing approach which pro-ceeds not so much on the basis of mature and exceptionalreasoning skills but on rote memorization. If even Chi-nese professors of TCM at four year TCM colleges inChina teaching in Chinese find it difficult to teach theclinical application of TCM bian zheng lun zhi to nativeChinese speakers, it is reasonable to question the overallsuccess of that attempt here in the West in part-timecourses taught in often erroneous translation. In my

experience, it is one thing entirely to teach TCM so thatstudents can pass written and oral exams. It is anotherfor students to be able to put that knowledge into prac-tice in terms of writing individually crafted internalprescriptions based on both bian bing and bian zheng. I

each. The geopolitical constraints of TCM in the PRC arelargely not operative here in the West. If we were todivide these two professions as, I think, they deserve tobe, then we would also be free to adopt the very best styleof each and to design educational institutions for teach-ing those best styles. Personally, in such a milieu, I

believe that Japanese acupuncture would rise aboveTCM acupuncture but TCM herbal prescribing wouldrise above kanpo yaku. Such a combination of Japaneseacupuncture and Chinese internal medicine is impossi-ble in Asia where cultural biases and downright racismare so thoroughly entrenched. But that is not the case inthe West where we are free to chose whatever we thinkworks the best.

That Japanese acupuncture is coming to the fore in theUnited States is evidenced by the success of Drs. Manakaand Denmeis relatively recent, well attended seminars,the perennial popularity of Kiko Matsumoto and MikiShimas seminars, the publication of Matsumoto and

Birchs several, well received books, the translation ofShudo Denmeis Japanese Meridian Acupuncture intoEnglish, the production of an entire series of Japaneseacupuncture instructional video tapes by Miki Shima,and the opening of a branch of the prestigious MeijiCollege in San Francisco. In comparison, I can think of noequivalent, recent important trend or event vis a vis thegrowth and spread of TCM acupuncture in the US.

Already Japanese dispos-able needles dominate thepractice of American acu-puncture and I think it prob-able that most American acu-

puncturists now use theJapanese insertion tubesthat go along with these nee-dles. An interest in learningthe theories and techniquesfor which these needles were designed seems logicallyinevitable. It is also my observation that there is so muchinterest in Japanese acupuncture in the United Statesprecisely because it is not based on an abstract, rationalmethodology but more on an empirical one in turnfounded on palpation. This system provides practition-ers with definite protocols and sequences, formulas ifyou will, based not upon analytical and abstract logic but

on palpation and biofeedback, and as a teacher it is myperception that formulas are what students and neo-phytes want and need.

As stated above, TCM bian zheng lun zhi methodologywas the creation ofru yi (Confucian doctors) who werehighly educatedwen ren (literati) and that, until approxi-mately thirty years ago, such scholarly practitionersconstituted the minority of all medical workers in China.I have also stated in my preface to Highlights that Ibelieve only a proportion of all potential students arereally capable of doing this style well. Peter Deadmanhas taken exception to this statement and it is an impor-tant issue deserving further clarification.

This style is a highly rational one requiring greaterthan average reasoning and verbal skills. As PeterDeadman has himself quoted Dr. Shen, Modern medi-cine is difficult to study but easy to practise, but Chinesemedicine is easy to study and difficult to practise17. It is

It is relatively easy to teach students TCMto both do acupuncture and pass writtenexams. It is entirely a different matter to

understand TCM well enough to be ableto use it in the clinical practice of

internal medicine.

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have seen any number of Western practitioners whohave passed, for instance, the NCCA board exams inacupuncture, which are biased in favor of TCM bianzheng lun zhi, who could not make this system work inclinical practice. Even should Peter Deadman rebut thathe has met many Chinese practitioners who could make

this system work, I would remind him that he is mostlytalking about his professors and other senior teachingassistants who have been chosen precisely because oftheir skills in this system. Dr. Sivin, however, is talkingabout the Chinese rank and file and I likewise am talkingabout Western rank and file, postgraduation ability inmaking this system fly in clinical practice.

Personally, I feel my TCM is up to the mark, nor do Ifeel I am any less capable teacher of TCM than anyone inthe West. I have taught TCM all over the US, in the UK,and in Australia and New Zealand. In all those places, Ihave had the same perception that although my listenershad passed their various courses and exams, a substan-

tial percentage of them were not very capable of makingthis system work for them in their clinics. This is clearlyand unmistakenly evidenced by the continuous askingof how to treat this or that disease in TCM when thewhole impetus of TCM is treating on the basis of pat-terns. This is what is meantby the Chinese couplet: Tongbing yi zhi, Yi bing tong zhi(Same disease, differenttreatments; different dis-eases, same treatment.)

The fact that many Ameri-can practitioners at least have

trouble doing TCMbian zhenglun zhi in their clinics is evi-denced by the great and growing popularity amongstAmerican acupuncturists of computerized diagnosis,electronic diagnosis (such as EAV and Vegatesting),applied kinesiology, and homeopathy even though TCMbian zheng lun zhi dominates the curricula of almost everyAmerican acupuncture/Chinese medical school. Eachof these methodologies or modalities are a way of cir-cumventing TCMsbian zheng lun zhimethodology which,as Dr. Shen says, is easy to study but hard to practise.There are relatively few postgraduate seminars given inthe United States in TCM methodology because this is

not what the rank and file finds useful to them. Whatthey do find useful and what they flock to are workshopsand seminars which teach empirical or formulaic ap-proaches to the practice of medicine. As a practitionerwho can and does make TCM methodology work inclinical practice I am somewhat saddened by this. On theother hand I also realize that not everyone has theintellectual proclivities necessary to really excel in thisstyle.

Different people have different skills and propensities,different intellectual capabilities. Although I agree withPeter Deadman that TCM acupuncture is relatively easyto teach, I do not feel that this is the most sophisticated

approach to acupuncture currently available. And whenit comes to the prescription of internal medicine, TCM isnot at all easy to practise. My feeling is that only about20% of any given population of practitioners is intellec-tually comfortable with and capable of utilizing TCM

bian zheng lun zhi as a prescriptive methodology. Myexperience is that the other 80% feel more comfortablewith and tend to gravitate towards a bian bing lun zhiapproach. That does not mean such a methodology is notalso effective. Homeopathy, for instance, is a very so-phisticated and effective but nonetheless bian bing lun zhi

approach to prescribing internal medicine. It is interest-ing to note that acupuncturists in California are pushingto have homeopathy added to their legal scope of prac-tice.

I agree with Peter Deadman that the TCM bian zhenglun zhi approach, at least to the prescription of internalmedicine, is a great art. I personally think it is the bestand potentially safest methodology for doing internalmedicine. However, to naively take the Chinese at theirown words that TCM is the essence of everything time-tested and good within two thousand years of medicalhistory does not tally with current scholarship nor withmy experience both in and out of China. The assumption

that there is a best orthodoxy that should be adopted byeveryone is both congruent with the current dictatorialregimes political thinking and characteristically pater-nalistic. Recognizing that there are various levels ofintelligence within humans and various levels of sophis-

tication within various medi-cal methodologies and thenallowing space for each toseek their own level is, to me,realistic, compassionate, andwise. That does not mean thatproponents of their variousstyles should not attempt to

demonstrate, advertise, andpromulgate the merits of

their individual styles nor that practitioners of differingstyles should not debate between themselves, but I feeldeeply that we should be careful not to create profes-sional institutions which either unconsciously or delib-erately legitimize only a single approach to medicine.

What I was questioning in my preface and what I amagain questioning here is whether the professional insti-tutions which have grown up in the West surroundingthe practice of acupuncture and Chinese medicine are infact the healthiest and best. What is wrong with a multi-tiered profession with some people doing primarily a

bian bing approach to acupuncture and herbal medicineand others doing primarily a bian zheng approach? This,in a sense, merely recognizes what is the fact of thematter in the West. I feel fairly certain that the situationin the UK is similar to that in the US with chiropractors,naturopaths, and even MDs using acupuncture andcertain Chinese herbs in their practice. When suchother practitioners do so, they primarily employ a bianbing lun zhi approach.

Personally, I think a multi-tiered approach to the pro-fessions of both acupuncture and Chinese internal medi-cine not only makes pedagogic sense but also is truer tohuman experience. Whether TCM be reserved as a gradu-

ate education or whether TCM schools simply screentheir applicants intellectual capabilities and proclivitiesmore carefully and increase the stringency of their cur-ricula is a lesser issue. I still very much abide by myopinions that acupuncture would be better served di-

My feeling is that only about 20% of anygiven population of practitioners isintellectually comfortable with and

capable of utilizing TCM bian zheng lun zhias a prescriptive methodology

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vorced from TCM, that the practice of a TCM bian zhenglun zhi approach to internal medicine is not for everyone,that there is and always will be bothyi sheng andfang shiand that there is a valid place for both in the health caremarketplace.

P.S. Highlights of Ancient Acupuncture Prescriptions

is not a translation from the Zhen Jiu Da Cheng but israther based on Liao Run-longs Qing dynastyZhen Jiu JiCheng. I am also happy to say that with the publication ofAIDS & Its Treatment by Traditional Chinese Medicinewe will be routinely including the pin yin identificationsof all traditional Chinese medicinals. And finally, we dofeel that translations need to say what the Chinese says.If the Chinese says swelling like a silk cocoon, we believethat it is important to translate it such. Such descriptionsfunction as technical terms in TCM and professionalpractitioners should be able to recognize them for whatthey are. If a Western practitioner writes a book on TCMin English, they may choose not to use such typically

Chinese metaphors, but, in a translation, I think it isimportant to convey the original as closely as possible.The larger issue is why we in the West think that we canlearn TCM without also learning the professional lan-guage of that medicine i.e., Chinese. But that is thesubject of yet another essay.

ENDNOTES1 Hammer, Leon I., Duelling Needles: Reflections on the

Politics of Medical Models, American Joumal of Acupuncture(AJA), USA, Vol. 19, #3, 1991, p. 262

2 Unschuld, Paul U. Traditional Chinese Medicine: SomeHistorical and Epistemological Reflections, Traditional Acupunc-ture Society Joumal (TASJ), UK, #9, April, 1991, p.5

3 Hammer, op.cit., p. 2624 Holbrook, Bruce, Chinese Psycho-social Medicine: Doctor

and Dang Ki: An Intercultural Analysis, Bulletin of the Instituteof Ethnology Academia Sinica, No. 37, 1974, p. 86

5 Lu Gwei-djen & Needham, Joseph, Celestial Lancets: AHistory and Rationale of Acupuncture and Moxa, CambridgeUniversity Press, UK, 1980, p. 157

6 Holbrook, op.cit., p. 887 Flaws, Bob, Secret Shaolin Acupuncture Prescriptions: A

Glimpse of a Buddhist Lineage of Chinese Medicine, AJA, Vol. 16,#1, March, 1988, p. 27-35

8 Flaws, Bob, American Acupuncture Education: Has A WrongTurn Been Taken? AJA, Vol. 19, #1, 1991, p. 63-71

9 Holbrook, op.cit., p. 8610 Unschuld, Paul U., Medicine in China, A History of Ideas,

University of CA Press, Berkeley, 1985, p. 25811 Sivin, Nathan, Traditional Chinese Medicine in Contempo-

rary China, Center for Chinese Studies, University of Michigan,Ann Arbor, 1987

12 Crozier, Ralph C., The Ideology of Medical Revivalism inModern China, appearing in Asian Medical Systerns, ed. byCharles Leslie, University of CA Press, 1976, p. 341-354

13 Porkert, Manfred, The Intellectual and Social ImpulsesBehind the Evolution of Traditional Chinese Medicine, IBID., p.6667

14 Zhang En-qin, chief editor, Health Preser~ation and Reha-bilitation, Shanghai College of TCM Press, Shanghai, 1990, p. 44-48

15 Kaptchuk, Ted; Maciocia, Giovanni; Moir, Felicity; Deadman,Peter, Acupuncture in the West, Journal of Chinese Medicine(JCM), UK, No. 17, Jan. 1985, p. 22-31

16 Flaws, Bob; Chace, Charles, & Helme, Michael, Wang Le-ting on Acupuncture, Timing and the Times, Blue Poppy Press,Boulder, CO 1986

17 Shen, John, quoted by Peter Deadman, Starting Up,Joumal of Chinese Medicine (JCM), UK, #37, Sept. 1991, p. 36

18 Sivin, Nathan, Reflections of the Situation in the PeoplesRe ublic of China, 1987", AJA, Vol. 18, #4, 1990, . 343

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