Chinese Medicine and the Internal Pharmacy

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Chinese Medicine and the Internal Pharmacy

Chinese Medicine And The Internal Pharmacy

 

Many years ago, I observed a panel discussion held by pharmacists at the University of California San Diego, who concluded that the future of medicine lies in what they called ‘the internal pharmacy.’ In other words, the next frontier in medicine is techniques that use endogenous medicinal substances, rather than adding medicines from the outside. In this light, modern researchers have examined biofeedback, meditation, yoga, qi gong, natural remedies, and diet as methods of activating these powerful substances. The internal pharmacy is similar to what the 19th century physiologist Claude Bernard called the milieu interieur, i.e. the internal environment or terrain.

[1] Bernard explains that the internal environment is of paramount importance for one’s health, and “the stability of the internal environment is the condition for the free and independent life.”[2] This concept is still used today by French physicians. The internal pharmacy has incredibly sophisticated self-regulating mechanisms. The brain (along with the vital organs, endocrine glands, and nervous system) produces myriad substances which are the same or similar to many pharmaceutical drugs. Various opioid-like substances, steroids, painkillers, and hormones circulate continuously through the body, maintained in a very delicate balance by what we can call the ‘bodymind intelligence,’ a regulatory system that is still not well understood by any modern explanation.[3] In Chinese medicine we understand these substances through their functional aspects as various expressions of qi—including defense qi (wei qi), construction qi (ying qi), essential qi (jing qi), source qi (yuan qi), and visceral qi (zang qi). These different qualities of qi, that circulate and communicate within the grid of channels and network vessels, provide a framework to understand how the body and mind regulate themselves and maintain their equilibrium.

To contribute to the dialogue of modern-day health care, we need to be able to understand the underlying principles and philosophy of Chinese medicine, as conveyed by its source texts. The foundations of Chinese medicine are to be found primarily in the Han dynasty medical classics: The Yellow Emperor’s Classic of Internal Medicine: Simple Questions (Huang Di nei jing su wen), Classic of Difficulties (Nan jing), and Treatise on Cold Damage and Complex Diseases (Shang han za bing lun). They are expressed through the rubrics of systematic correspondence, such as yin-yang, five phases (wu xing), defense and construction qi (wei qi and ying qi), channels and network vessels (jing luo), and the complex terminology of the subject matter. Chinese medicine, in contrast to modern biomedicine, is based on binary principles established in such canonical texts as the Classic of Changes (Yi jing), and a holistic view of the universe in which human beings are an integral part. Human health is considered to be a reflection of an orderly universe, and internal order reflects living with and adjusting to the external order of the universe. This is expressed through laws of season, climate, and environment, and adapting through clothing, diet, lifestyle, residence, moderated emotions, work, rest, and other human activities. Similarly, the Han dynasty source text the Difficult Classic (Nan jing), which has eighty-one difficulties in all, is clearly based upon this principle. Diagnosis by pulse and palpation, the theoretical application of yin-yang and five-phase theory, and the application of needles and moxibustion work to restore equilibrium to the systems represented by viscera, bowels, channels, and network vessels. What the Nan jing describes is a dynamic approach to a complex system, one in which activating self-healing mechanisms, restores homeostasis.

The two main and most visible technologies of Chinese medicine are acumoxa therapy and internal (herbal) medicine. This is not to undervalue counseling, dietetics, therapeutic exercise, and lifestyle as essential components of Chinese medicine. But these therapeutic modalities are the most active and professional of Chinese medical interventions, and ones that can be readily studied as therapeutic interventions in their own right. Acupuncture and moxibustion as described in the Yellow Emperor’s Internal Classic: Simple Questions (Huang Di nei jing su wen), Classic of Difficulties (Nan jing), and Divine Pivot (Ling shu) are treatment modalities designed to restore equilibrium of channel flow between left and right, up and down, inside and outside. Most importantly, these adjustments recalibrate the body clocks that regulate so many functions (including digestion, sleep, activity, thought, hormonal secretions, emotional states, and blood circulation) and their timing. For example, one method of treating irregular menstrual periods is to utilize points along or coupled with the eight extraordinary vessels (qi qing ba mai), specifically the generating and controlling vessels (chong mai and ren mai). Thus classical methods of acupuncture do not primarily focus on relieving symptoms, but rather they restore dynamic equilibrium to the body and mind by allowing self-healing mechanisms to take hold.

A terrain as it pertains to medicine is the landscape or environment in which specific patterns and phenomena occur. The view presented by Zhang Zhongjing in the Treatise on Cold Damage (Shang han lun), and later developed by the authors of the warm disease current (wen bing xue), is a topographical one: they are immunological maps, or maps of responses to invasion by evil qi. The six-channel pattern differentiation (liu jing bian zheng) describes a gradation of depth in the body, as it can be visualized as if laying out three-dimensional topographical maps of terrain illustrated by symptom patterns. In other words, tai yang or shao yang disease is a dynamic system in disequilibrium, and we introduce herbal treatment and acupuncture treatment to restore equilibrium. Even without attacks of evil qi, there are terrains of tai yang, yang ming, shao yang, etc., associated with the amount of blood and qi in the channels, the parts of the body they influence, and emotional aspects that they control. Channels are multi-dimensional in this sense; they are not just lines superimposed on they physical body. When the specific terrain of tai yang, for example, becomes imbalanced and therefore ill (as in damage by wind), one rebalances the terrain with an herbal prescription or combination of acupuncture points to make the terrain inhospitable to evil qi (wind, in this case). This strategy views disease as a moving target, and deals with not only the expulsion of pathogens or evils (xie), but also with the idea of a dynamic balance and equilibrium among the various layers and components of the body, including its emotional aspects.

By aiding transformation, the body takes care of itself; by resonantly aligning with heaven and earth, what the body produces what it needs. Shaoyin, taiyang, etc., are movements of yin and yang between heaven and earth. The medicines in the Treatise on Cold Damage and Miscellaneous Diseases (Shang han lun za bing lun) are designed based on direction and movement: in many ways, the formulas are about qi transformation (qi hua) and not about material substances (tissues, blood, viscera, or essence). Zhang Zhongjing’s formulas are not vitamin supplements—they are agents of transformation. Accordingly, Qi Bo explains the Su wen:

The spleen, that is the soil. It governs the center. Throughout the four seasons it tends the four depots. In each [season] it is entrusted with government for 18 days; it cannot rule an [entire] season by itself. (As for the spleen depot, it permanently stores the essence of the stomach, [i.e., of] soil. as for the soil, by generating the myriad beings, it takes heaven and earth as a law. Hence, in the upper and lower [parts of the body] it reaches head and feet; it cannot rule [only one specific] season).[4]

Thus the terrain of the body has first and foremost to do with earth. In Chinese medicine, this is the healthy functioning of the spleen and stomach. All the formulas of the Shang han lun have something to do with tai yin medicines, although tai yin is the shortest chapter of the book, it is quite influential. The ability to digest the herbs is paramount. Through qi transformation, the body demonstrates its innate ability to produce what it needs. Herbal formulas, like acupuncture, are a natural overlay that directs earthly matter toward healthier patterns.

For the most part, Chinese medicine works with the existing tools of the patient’s blood, qi, viscera, and channel system to resist and expel pathogens. Although there are toxic medicinal substances and powerful acumoxa treatments that do take a more militant approach to disease, it is more the exception than the rule. Although there was a school, the attack-evil current of thought (gong xie pai) founded by Zhang Zhihe that focused on forcefully eliminating evils from the body, Zhang’s approach never became mainstream. Systemic diseases, such as cancer, are best treated by prevention, rather than by chemotherapy, radiation, and surgery, which take such a toll on patients, often killing them faster than the cancer would. W. Daniel Hillis, the famous physicist, was recently funded to start an institute to research systems approaches to cancer treatment at the University of Southern California. In an interview in 2010, he says that modern biomedicine got stuck on one limited disease model in the 19th century (the infectious disease and pathogen model) and applied it to all diseases, including systemic ones such as cancer. He said Chinese and Ayurvedic medicine were examples of systems approaches that were perhaps more useful and could be adapted to modern proteomics approaches.[5] So even within biomedicine there is a trend toward researching systemic rather than reductionist approaches as the 21st century moves forward. It has much to learn from the wisdom of ancient medical systems. Indeed, we should also remember that until the early 20th century, all global medical systems such as Ayurveda, Greco-Arabic, and Tibetan medicine were based on a mind-body systems and an emphasis on humors that still survives in the modern era. Even modern biomedicine retains influences from its roots in Greco-Arabic medicine, with its four elements and four humors (black bile, yellow bile, blood and phlegm).

So what is equilibrium then, and how do patients attain it? In essence, the body remembers equilibrium that has been lost by habitual bias, i.e. by adapting to an unhealthy state. In other words, we get stuck in a lifestyle that is less than ideal, and begin to self-medicate blindly with aspirin, alcohol, too much (or too little) exercise, overeating, and other destructive behaviors. The strength of Chinese medicine is that it works not only on the physical body, or architectural body, but also on what medical anthropologist Elisabeth Hsu calls the ecological and sentimental bodies. According to Hsu, the Han dynasty Chinese conceptualized the human body in terms of health and disease in a threefold manner in terms of the clinical gaze. First, the architectural body, which is based on direction, depth, time and synchronization as expressed in the channel system; second, the ecological body of tissues, fluids, and blood, ideally seen as ‘solid, firm, and polished like a fresh plant, with shiny glossy leaves and stems full of water.’ This solid body was seen to be an ideal receptacle of qi and its transformations. And third, perhaps most significantly, the sentimental body: the Han Chinese saw the viscera (zang) as receptacles of emotions and qi. Paraphrasing the Su wen, ‘grief, fear, rage and anger harm the qi.’ As such, emotions in Chinese medicine are completely integrated with health and disease; when too extreme, they are considered part of pathology, and when balanced, are deemed an essential component of the healing process.[6]

Our duty to patients is not to treat symptoms with simple protocols, but rather to see clearly what made them ill in the first place and try to help them heal from within, if possible. Thus, as Elisabeth Hsu makes clear in her study of Yi Chunyu’s memoir of twenty-five case histories, it is clearly laid out in the classic texts that we must inquire about emotions since the viscera are depositories of emotions and qi. Yi Chunyu’s text is from the Han dynasty, and accordingly focuses on the synchronicity between phenomena occurring inside the body, emotions, and the macrocosm of the greater environment. Dr. Yi diagnoses by palpating the vessels, and in his medical universe, the viscera are not primarily physiological entities, but depots containing emotions and qi. He focuses on visceral qi and its specific qualities (color, scent, season, pulse image), and the primary disease factors are imbalanced emotions. As it says in Chapter 77 of the Su wen (“Discourse on Expounding the Five Faults”):

Whenever one wishes to diagnose a disease, it is essential to inquire about the [patient’s] drinking and eating [habits] and his place of living. Whether he has experienced violent joy or violent suffering, or whether he has experienced an initial joy that was followed by suffering, all this harms the essence qi. When the essence qi is exhausted and when [its flow] is interrupted, the physical body will be destroyed.[7]

Accordingly, Wang Bing comments, “Separation and interruption, dense compactness and knotting, anxiety, fear, joy, and anger, (whether they let) the five depots (viscera) be empty and depleted and (whether they let) blood and qi lose their guardian function, if the practitioner fails to know this, what art (of medicine) is there to speak of?”[8] It is quite an experience to look beyond the veil of Aristotelian causation (the finding of past factors that contribute to present illness) into an entirely synchronous worldview without past or future, but only an eternal present. Studying Han dynasty texts opens one up to a worldview that we’ve largely forgotten, but one that is essential to understand the foundation of Chinese medicine, for once without the overlay of our modern conceptions of reality.

Responsibility to the terrain of one’s body has another meaning in Chinese culture, in the imperative to nourish one’s life. In Confucian ethics, one’s body is a gift from one’s parents, and it is under our care and trust as long as we are alive. In addition, preserving our health is our obligation so that we may produce healthy offspring, who in turn will produce healthy offspring. In other words, health, like the environment is in our trust for future generations. When we speak of genetics in the Chinese medical context, we need to go beyond the random yet fixed view that most modern people seem to have. Genetics is not a roll of random dice, but a process that can be influenced by many things, including diet, environment, emotions, our mating partners, and lifestyles. A new scientific discipline is epigenetics that investigates whether the genetic code is not a fixed, arbitrary grouping of genes, but rather that our programming can be influenced by all of these factors. Chinese medicine does not endorse a rigid genetics unaffected by the environment or a person’s lifestyle, that a human being was just a cipher of a blind mechanism. Another ancient medicine, Ayurveda, has similar ideas, namely, that parents have a responsibility to future generations, and if they have any chronic illness, to do panchakarma therapy (with cleansing diet, herbs, steam baths, massage with oils, etc.) to clear their cells of the pathological factors. What our parents and previous generations thought, ate, the medicines they took, the events of their life, all were recorded into essence (jing), sperm and ovum. But they are mutable, changeable, and part of a continuing stream that is never fixed or rigid in time and space.

 

In Chinese internal medicine we primarily use polypharmacy (prescriptions that have multiple ingredients that work in concert). They herbal prescriptions can be said to treat not only presenting symptom patterns but the underlying terrain as well. Herbal prescriptions can be envisioned as complex external systems designed to interact with the internal environment in such a way that dynamic equilibrium is restored. Each ingredient of a prescription is chosen according to how it interacts with other ingredients to create a complex system that matches the specific pattern revealed through pattern differentiation (bian zheng). This approach also ensures that such relatively toxic medicinal substances such as aconite root (zhi fu zi) are always combined with medicinal substances such as ginger root (sheng jiang) or licorice root (gan cao) to reduce toxicity, in addition to the intensive processing (pao zhi) that medicinal grade aconite always undergoes before being used internally.

In the first definitive Chinese herbal text, The Divine Farmer’s Materia Medica (Shen Nong ben cao jing), medicinal substances are divided into three grades: superior, middle, and inferior. Superior medicinal substances are those that had no side effects, and like foods, could be consumed over an extended period with no harm. This included substances such as Jujube (da zao), prepared licorice root (zhi gan cao), and Chinese Ginseng (ren shen), designed for nourishing life. Middle grade medicinal substances, which had mild side effects and treated the personality and supplemented vacuity, such as Peony root (shao yao) and Scutellaria root (huang qin). Inferior medicinal substances are more potent and toxic, and were used to treat specific diseases; they include such herbs as Chinese rhubarb root (da huang) and aconite root (zhi fu zi). Chinese herbal medicine incorporates the idea of terrain, or terroir, at a fundamental level. Medicines come from certain regions where they have been grown and processed by locals for thousands of years, and are then traded as authentic or dao di medicinal substances. The classification and production of medicinal substances in China evolved as technology advanced, but the substances always remained intact, linked to their origin and raw form, always resonating with the earth and its material products. Although scholarly labs in China use HPLC machines and other technologies, the crude form of herbal, mineral, and animal substances has remained a cornerstone of Chinese medicine’s connection with nature.

It is a mistake to view Chinese herbal medicine through a biochemical lens—or, rather, we have not developed a sufficiently sophisticated lens through which to evaluate it. For instance, there are many studies that purport to show the estrogenic effect of dang gui (Rx. Angelica Sinesis), and that warn against giving it to patients with a history of breast cancer. However, any effect on such patients cannot be evaluated by reactions in a test tube. Pharmacological studies of Chinese medicinal substances must be in the proper context, with respect for the written history of dui yao and formula construction, which has to potential to dramatically alter the affect of any single herb. Dang gui, in itself, is a chemical chameleon; it has tendencies but behaves very differently depending on with what other herbs it is combined. In other words, Chinese herbs are always seen in relationship to everything else in a formula and to a patient’s pattern. All dang gui is not the same. Dang gui may be given raw, wine-fried, as a whole root, body only, or the rootlets (dang gui wei) may be used. Each part of the plant (and its processing) influences the clinical effect. Furthermore, was the plant decocted, made into a tincture, or is in in granule form? What is the dosage? There are only relative situations; Chinese medicine is best when practiced as an art as well as a science. We must practice it ethically and evaluate the risks and benefits via a model that acknowledges the internal safeguards that are part of herbal medicine’s history. Chinese medicine is a science of relationships among phenomena and this knowledge base is written in such tomes as the Shen Nong ben cao jing and Li Shizhen’s Ben cao gang mu.  These works contain the criteria that have been used in the field for centuries, and it is in this context that the safety of poly-pharmacy as it is used in Chinese medicine has been understood. Chinese herbal medicine is in fact a science with strict rules and protocols for preparing formulas to give to patients; it has proven safety record.

In contrast, modern pharmaceutical medicine is primarily based on the use of singular, molecular substances that interact with the body in a very direct, forceful way to achieve specific therapeutic effects. In any medical system, the more powerful a specific therapeutic effect, so is the greater the toxicity and potential for harm. Also, such an approach is one-sided and ignores the inherent complexity of the human organism. Recently a new approach, called combinatorial chemistry, has appeared. This approach uses combinations of drugs to treat various bodily systems, rather than just one targeted organ or tissue. While theoretically this is an advance over the ‘one drug, one disease’ model, and is closer to the clinical reality of patients on multiple medications, no solution has arisen to the increase of drug toxicity that usually occurs when combining many medications. As it stands, it is routine clinical practice to give drugs for side effects caused by other medications, or for patients with more than one defined disease at any given time.

Biomedicine and Chinese medicine have traditionally been different logical systems, with disparate clinical gazes and diagnostic systems. Whereas biomedicine determines treatment largely on a database of diseases defined by numbers on blood and saliva tests, specific tissue changes, MRI’s, EKG’s, etc., Chinese medicine uses other diagnostics (pulse, tongue, abdomen, sensory data, questioning) and a pattern-based approach to treatment that incorporates herbal formulas (rather than single herbs) in its treatments. Herbal formulas, like acupuncture, are complexes that activate the body’s innate healing abilities; although exogenous (and allopathic), they affect the endogenous substances of the body. One flaw of biomedicine is that it is often unable to see the rebounding effects of localized treatment with simple drugs or even natural substances to treat disorders. Allopathic medicines are defined as drugs that counter specific symptoms by interfering with natural biological processes, such as using anti-histamines to block histaminic reactions, anticoagulants, antacids, antibiotics, etc. This then shifts pathology to other parts of the bodily terrain. We should expect when we treat symptoms directly with substances, such as the single herb hai piao xiao (Sepiae endoconcha), which is used in modern China as an antacid, that there will be side effects as a result, even if they are more mild than with medications. It doesn’t mean we should altogether avoid allopathic methods, but rather, we must be clear about our intentions and motivations as physicians.

One can look at the biomedical technique of HRT (hormone replacement therapy) to see the difference between exogenous substances and endogenous ones, and how they affect the body in substantially different ways. Internally, hormones are produced and controlled by the source qi (yuan qi), which is a combination of essence (jing), food qi (gu qi), and air qi (da qi). They are definitely engendered by yang qi, which governs the transformation of all substances of the body. We are designed to ingest crude substances from nature, such as whole, unrefined foods and medicinal herbs, and our body’s process of qi transformation then separates clear yang from turbid yin, and manufactures its vital substances accordingly. With the example of HRT, injecting or ingesting a relatively pure substance—one that is pharmacologically fixed by fractionalizing, as in the case of estrogen and progesterone—reduces the involvement of the qi transformation processes relative to, for example, phytoestrogens from food sources. This problem is the same for all ‘replacement’ therapies, including giving insulin, thyroid, prednisone, and other purified essences that the body would normally synthesize by itself. When the body doesn’t need to make its own vital substances, the side-effect is that the yang qi is not engaged, and the body becomes flooded with purified essences that can lead to engorgement and yin accumulation (for instance, the side effects of birth control pills or HRT, including acne, weight gain, and blood circulation problems, specifically, blood stasis due to cold and damp-phlegm accumulation). Side effects are considered the cost of modern pharmaceutical technologies; Chinese medicine provides a lens through which to evaluate that cost on the body and its new normal or altered physiology.

In 2000, the Institute for Systems Biology opened in Seattle, Washington. Its mission is ‘analyzing biological complexity and understanding how biological systems function.’ While the language of this discipline comes from biology, chemistry, cybernetics, and other scientific disciplines, many of its observations can be related to the systems approach of Chinese medicine. While not based on channel theory and qi, systems biology recognizes that reductionism cannot finally explain the complex interactions between cells, tissues, organs, nerves, other structures, and the communications systems that keep everything functioning in balance. It is here, perhaps, where a mutual understanding of human health and disease between East and West can begin to flourish.

If we practice Chinese medicine (needle and moxibustion therapy, herbal medicine) with the aim to treat biomedical diseases, and then explain our treatment through biomedical logic, we are essentially practicing a second-rate Western medicine. Rather, we should be true to the foundation of Chinese medicine. How can our tools ever compete with the strength and precision of surgical interventions or the power of drugs? We must practice Chinese medicine according to its essential strengths, as has been done for two thousand years. Ultimately, there is a real Zen about the entire process of pulse diagnosis, palpation, questioning, and formulating a treatment plan. The treatment embodies both the practitioner and the patient, and creates a space for healing to occur. It is a gestalt that is greater than the sum of its parts, and both patients and practitioner know when they inhabit this sacred space. Furthermore, just as we study modern medicine and embrace its strengths and note its weakness, modern biomedical health professionals must also embrace and study traditional medical systems such as Chinese medicine.

 

[1] In the 19th century, there was a debate between Louis Pasteur and Jacques Beschamp about the nature of disease. Louis Pasteur, of course, was famous for the discovery of infectious agents including bacteria, which he considered to be the prime cause of disease, while Jacques Beschamp considered imbalances of the milieu interieur to be the prime cause. Interestingly, on his death bed, supposedly Pasteur said that Beschamp was correct, but Pasteur’s students went on to evangelize the doctrine of infectious disease agents with no regard for the patient’s terrain or internal environment. It is historical accidents such as these that often lead to predominant trends in science. Of course, Jacques Beschamp was in full agreement with Claude Bernard’s milieu interieur.

[2] Claude Bernard, Lectures on the phenomena common to animals and plants. Hoff HE, Guillemin R, Guillemin L, trans. Springfield (IL): Charles C. Thomas, 194.

[3] Neil Shubin, author of The Universe Within, describes the body’s self-regulatory mechanisms in a way that resonates with the chronobiology of traditional Chinese medicine:

We carry more than two trillion clocks inside of us. Our cellular clocks reside in the molecular machinery of DNA, which makes proteins that interact with one another and with DNA itself. Some combinations of these biological factors form a kind of molecular pendulum that swings back and forth between high and low levels of protein and gene activity, tuned to a virtual 24-hour day. (“January is the Cruelest Month,” The New York Times, January 25,1013).

[4] Paul U. Unschuld and Hermann Tessenow, trans. Huang Di nei jing su wen (Berkeley: University of California Press, 2011), 483-4.

[5] Daniel Hillis, “Edge Master Class 2010: W. Daniel Hillis on ‘Cancering’” http://edge.org/events/the-edge-master-class-2010-cancering-listening-in-on-the-body-39s-proteomic-conversation, retrieved December 3rd, 2010.

[6] Elisabeth Hsu, Pulse Diagnosis in Early Chinese Medicine: The Telling Touch (Cambridge: Cambridge University Press, 2010), 66-67.

[7] Paul U. Unschuld and Hermann Tessenow, trans. Huang Di nei jing su wen (Berkeley: University of California Press, 2011), 668-9.

[8] Ibid., 673, note 42:

Wang Bing: ‘離 is to say: to leave one’s loved ones. 絕 is to say: to part from what one has thought of. 菀 is to say: to focus one’s thoughts [on something]. 結 is to say: to contract great hatred. Now, when one is separated from a loved one, the hun-soul leaves. When one parts from what one has cherished, the sentiments are mournful. Excessive pondering exhausts the spirit; to contract hatred makes the mind suffer. In case of anxiety [the qi] is blocked and fails to move; fear makes one hesitant and lose control. In case of great anger one is confused and lacks order; in case of joy [the qi] disperses and cannot remain stored. All these eight states are the cause of depletion of the five depots; it is because of them that blood and qi leave their guarded [position]. If a practitioner fails to take this into regard, what else should one speak of!?

 

2017-09-20T16:35:19+00:00 February 25th, 2016|0 Comments