The following is the second part of a two-part interview I conducted with Dr. Paul Unschuld, Director of the Institute of the History of Medicine at the University of Munich and one of the world's foremost authorities on the history of Chinese medicine. Part one can be found in last month's issue.
Dr. Unschuld's most recent English work, Huang Di Nei Jing Su Wen: Nature, Knowledge, Imagery in an Ancient Chinese Medical Text, is a remarkably detailed deconstruction of the Huang De Nei Jing Su Wen. His actual translation of that classic text is due to be published next year.
Matthew Bauer (MB): You have made reference in the past to misconceptions supporters and practitioners of Chinese medicine in the West have about Chinese medical history. Could you cite some of the most common misconceptions?
Dr. Paul Unschuld (PU): The major misconceptions held in the West have to do with: A. the definition of "TCM"; B. the world views underlying Chinese traditional medicine; C. the nature of Chinese pharmaceutical therapy; and D. the role of acupuncture in Chinese medicine. Let's talk about them.
With regard to part A, few people are aware that TCM is a misnomer for an artificial system of health care ideas and practices generated between 1950 and 1975 by committees in the People's Republic of China, with the aim of restructuring the vast and heterogenous heritage of Chinese traditional medicine in such a way that it fitted the principles - Marxist-Maoist type democracy and modern science and technology - on which the future of the PRC was to be built. TCM, as it came to be known in the West beginning with the late 1970s, reflects only a portion of the tremendously variegated body of knowledge accumulated in the preceding two millennia. While it is entirely understandable and legitimate for the Chinese leadership to select from this tradition, and to reinterpret those elements it considers helpful to build a future meaningful coexistence of modern Western and traditional Chinese ideas and practices, it is not clear whether populations in Western countries wish to make the same choices when they are confronted with the legacy of the past. It is therefore that I distinguish between TCM and "CTM," the latter referring to the entirety of health care knowledge, beliefs and practices prior to the 20th century.
In terms of world views, before serious historical research on the origins and conceptual basis of Chinese medicine had been conducted, much of Western secondary and tertiary literature claimed a Daoist underpinning for TCM. This is incorrect for two reasons. First, TCM is a product, as indicated above, of Communist China. Kim Taylor's meticulous study of the origins of what she calls "medicine of revolution", i.e. of the formative period of TCM in the early decades of TCM, will soon be published (Chinese Medicine in Early Communist China, 1945-1963. A Medicine of Revolution) and is mandatory reading for everybody in the field. Second, even if we were to apply the term TCM to pre-revolutionary Chinese medicine, the Daoist impact should be considered minimal. As I have shown in my recent Huang Di Nei Jing Su Wen: Nature, Knowledge, Imagery in an Ancient Chinese Medical Text, and even more so in my most recent German book What is Medicine?, Chinese civilization, two millennia ago supported two initially (that is, for the first one thousand years, until the Song-Jin-Yuan era of the 12th through 15th century) separate traditions of health care. One, i.e. Chinese medicine in a narrow sense, was legitimized by Confucian and Legalist world views. The other, i.e. Chinese materia medica, was informed by Daoist notions. Acupuncture and dietetics were based on the former; there is hardly any Daoist, or even spiritual, element in their early theoretical foundation. Thus, to be able to appreciate the conceptual nature of Chinese health care traditions, a careful look at their history is essential.
As for Chinese pharmaceutical theory, its history may be divided into two periods: the first dating from its first magnificent literary document (i.e. the Mawangdui manuscript Wushier Bingfang, translated with all other medical Mawangdui manuscripts by Don Harper in his seminal Early Chinese Medical Literature) to the early Song dynasty, and the second from the Song-Jing-Yuan era to the present. In the first period, Chinese materia medica remained untouched by the yin-yang and five-agents doctrines of Chinese medicine. The Shanghan Lun by Zhang Ji was an early attempt at providing materia medica with a theoretical basis, but it remained an isolated attempt and found no successor prior to the Song era. From the Han dynasty to the Song era, over a period of more than one thousand years, an ever increasing number of pharmaceutical substances was described in materia medica literature, and if a theoretical link was indicated, it was with demonology. Also, an ever increasing number of fixed recipes was collected by physicians and periodically published, as for example in the works of Sun Simiao and Wang Tao.
Beginning with the Song dynasty, several authors contributed to the formation of a pharmacology of systematic correspondences. It was only in this context that the individualistic approach at curing diseases was developed that is considered characteristic of Chinese pharmaceutical therapy today. Still, historical evidence suggests that this approach remained marginal. Even after the Song-Jin-Yuan era, Chinese pharmacy preferred ready-made medications mass-produced and marketed by apothecary shops addressing a region- or even a nation-wide clientele. Advertisements aiming at creating product loyalty and other strategies known from modern Western pharmaceutical industry were widely applied in China for many centuries before the 19th century. An interesting compromise developed between the individualistic approach and ready-made medications based on proven recipes. In particular, in the treatment of women's diseases, proven core recipes that could be modified by taking one or two ingredients away or adding one or two others according to individual conditions of a patient, were very popular during the Qing dynasty, and well into the 20th century.
Now, to part D. Acupuncture, it appears, at no time played a dominant role in Chinese health care. No reliable history of acupuncture is available in Western languages or Chinese. However, the close proximity of the conceptual origins and basis of acupuncture to Confucianism and Legalism resulted in ups and downs of this health care approach following the fate of these two social ideologies. From early Chinese medical literature, it is quite obvious that the Confucian-Legalist tradition of health care emphasized prevention and, if a crisis emerged, early intervention. Confucianism promised to prevent social crisis if a ruler and his people adhered to certain morals. Thus, acupuncture in its beginnings was meant as a tool to correct early physiological deviations from a correct course of events, not to treat manifest disease. Dietetics was recommended for the same purpose. In contrast, the materia medica tradition of health care acknowledged, in true Daoist and Buddhist fashion, the unavoidability of disease. Thus, the pharmaceutical approach emphasized both prevention and therapy. However, in the course of time, acupuncture proved to cure numerous ailments. Hence, physicians drew their own conclusions and used needle therapy to treat a wide range of illnesses. Nevertheless, from the 17th century on, acupuncture lost much appeal in Chinese society, in the same way as heroic pharmaceutical therapies were no longer applied by most Chinese physicians. Tuina massage instead of acupuncture, and "harmonizing" rather than "attacking" pharmaceutical recipes, became the new ideals of Chinese health care.
MB: I wanted to follow up on two points you raised. First, you stated that, in their early stages, acupuncture and dietetics had little to do with Daoist notions, but doesn't the Su Wen repeatedly extol the virtues of "the Dao" and even begin by identifying the loss of Dao as the source mankind's health and longevity problems?
PU: The notion of Dao is not restricted to Daoist philosophy. In its meaning of "the Way" it was accepted and used widely to signify what we would call fundamental principles, even laws, underlying the course of events and the nature of things. Confucians tended to emphasize the social Dao; Daoists focussed on the Dao underlying man's embeddedness in his natural environment. In my Huang Di Nei Jing Su Wen: Nature, Knowledge, Imagery in an Ancient Chinese Medical Text , I have discussed the proximities between the Su Wen doctrines and Confucianism, and I have pointed out why they conflict with Daoist world views. For example, the Su Wen promises, at its very beginning in treatise 1: "When essence and spirit are guarded internally, where could a disease come from?" Disease, the reader of this rhetorical question is informed, can be avoided as long as a person's behavior serves to guard the organism's central material and nonmaterial constituents, that is, essence and spirit. The advice to follow "rules" or "laws" is linked to the promise of health. This is, of course, in contrast to a Daoist conviction that the material body cannot escape illness. A later, albeit pre-Tang commentary introduced this notion into Su Wen treatise 68: "Without physical appearance there is no suffering." That is to say, the fact that human life is tied to a physical appearance, i.e. to a body, makes illness an unavoidable facet of life.
The fact that both these views, diametrically opposing as they are, can be found in the Su Wen offers some evidence of the dynamics, and also of obvious controversies, among scholars in ancient China. Thus, when I speak of the Confucian/Legalist legitimation of early Chinese acupuncture medicine, one might wish to add that this medicine underwent a manifold development in subsequent centuries. The science of systematic correspondences and materia medica health care that eventually merged beginning with the 11 th and 12 th centuries did not come about from nothing. As pointed out, acupuncture soon was discovered to have curative strength, not only preventive potential, as some early authors had claimed. Similarly, in the 8 th century, a physician named Wang Bing edited the Su Wen and laid the foundation of the text as it is known today. Wang Bing was a Daoist. In his commentaries he referred to Laozi and Zhuangzi. He moved the Su Wen sections on the "nourishment of life" from a later chapter to a much more prominent position in the beginning. Much later again, these sections, in turn, were incorporated into the Daozang, the grand encyclopedic collection of Daoist texts. Also, Wang Bing believed in the existence of demons and included such notions in his comments to the Su Wen. All of that is to draw attention to the complexity of ancient Chinese medical history. This complexity is in stark contrast to the simplistic and often naive historical accounts found in modern Western secondary literature on acupuncture and Oriental medicine.
MB: Thank you. Your answer underscores how complex the background factors can be when you are considering shifting ideals over centuries of time. Earlier, you also stated that acupuncture was not initially used to treat manifest disease, but isn't one of the earliest references to the use of acupuncture an account of it being applied to revive someone in a coma who was thought to have died? Wouldn't that indicate an early use of acupuncture in the treatment of a manifest disease?
PU: My point was that acupuncture was described in early Chinese medical literature not as a therapeutic approach to be used for treating acute/manifest diseases, but rather as a means able to correct early signs of deviation from an ideal state of health. This, then, was the ideological basis for its recommendation in the context of a medicine designed to maintain health, not to cure full-fledged disease. However, the Su Wen was not written by a single hand, and it is such a valuable source because it reflects much of the dynamics of the development of Chinese medicine and health care in Chinese antiquity. Many of its treatises recommend bloodletting, and there is also enough acupuncture for treating ailments such as cholera, convulsions, or conceptual diseases such as "heat in the liver." Tracing the history of Chinese medicine, we need to distinguish between conceptual sources and affiliations on the one side, and daily reality on the other. The Su Wen is such a wonderful gift from the past because it permits us to see both: conceptual affiliations and daily reality. The revival of a patient from a coma, as you refer to in your question, was recorded by the historiograph Sima Qian in his Shi Ji circa 90 B.C. It does not tell us much about acupuncture's role in treating disease; it simply relates a technique of piercing an unconscious person at the back of his head and bringing him back to consciousness.
MB: Are there any individuals or universities in the U.S. working on translating ancient Chinese medicine works?
PU: Nigel Wiseman is continuing his work on ancient Chinese medicine works. Sabine Wilms has translated a major section from the works of the Tang physician Sun Simiao. And Paul Buell and his collaborators plan an annotated translation of a rare manuscript from Mongol times reflecting the impact of Arabic pharmacotherapy on Chinese materia medica.
MB: What other projects are you working on now?
PU: Together with Profesoor Zheng Jinsheng, I am working on an analysis of Chinese medical manuscripts from the 17th through the middle of the 20th century. The outcome will be published by E. Brill, Leiden, Netherlands, under the title: Chinese Medical Manuscripts: A Window on Knowledge and Clinical Reality. This study focuses on approximately 600 manuscripts held by the Ethnological Museum and the Staatsbibliothek Preussischer Kulturbesitz in Berlin. In contrast to well-known and widely disseminated printed medical literature, which may have reached only a small portion of the Chinese people in Imperial times, the manuscripts reflect the knowledge and clinical practices of perhaps 90 percent of pre-modern Chinese population. A survey of their contents has brought to light many most fascinating aspects of Chinese traditional health care, many entirely unknown in the West today. This includes physiological notions of blood circulation, therapeutic approaches believed to have vanished during the Tang dynasty but carried on in folk healing, and others more.
MB: I look forward to reading that and other future works of yours as well. Thank you, Dr. Unschuld, for consenting to this interview and for your decades of work in this field.
PU: You're welcome. And thank you, Mr. Bauer, and the people at Acupuncture Today, for allowing me the opportunity to share some of my thoughts. I hope your readers will find them of interest.
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