2. The Practice of TCM

2.1 What is Traditional Chinese Medicine?

Traditional Chinese Medicine (TCM) is as diverse in its practice as western medicine. It is employed in both acute and chronic illnesses, and it includes:

  • internal and external pharmacological therapy. Chinese herbal medicine includes the use of plant, animal and mineral substances. Preparations are administered, similar to western medicine, via a number of routes:
    • oral consumption (such as pills, teas and powders)
    • nasogastric administration
    • topical applications
    • intravenous, intramuscular, subcutaneous injections
    • vaginal and rectal preparations
    • ear and eye preparations;
  • acupuncture, including:
    • traditional manual needle stimulation
    • modern usage of laser and electrical stimulation
    • embedding needles;
  • Chinese massage;
  • dietary and lifestyle advice;
  • specific techniqes including:
    • moxibustion
    • cupping
    • scraping
    • point injection therapy;
  • breathing, movement and meditation; and
  • orthopaedic manipulations and surgery.
  • TCM is based on an understanding of health and illness which differs substantially from that in western medicine. Clinical phenomena are interpreted by reference to theories of bodily operation which are alien to the western-trained scientific eye. A brief overview of the key differences between Chinese and western medicine is provided.

2.1.1 Chinese Medical Theory

Chinese medical theory is a formulation of concepts based upon empirical observation, and provides a basis for clinical practice. TCM adopts fundamental theories that are markedly different from their western scientific counterparts. For example, in TCM, health is defined by specific characteristics. These include not only the absence of discomfort and pain and the regularity of sleep, sexual and other behaviours, but also characteristic qualities in the tongue and the radial pulse.

TCM shares some common ideas with other forms of complementary medicine, including belief in a strong interrelationship between the environment and bodily function, and an understanding of illness as starting with an imbalance of 'energy' (a concept central to some alternative medical practices). The TCM diagnostic process is claimed to be particularly holistic in nature and is usually contrasted to a reductionist approach in western medicine. Western medicine often defines disease at an organ level of dysfunction and is increasingly reliant on laboratory findings. In contrast, TCM defines disease as a whole person disturbance.

The diagnostic categories of TCM describe recurring clinical patterns of both subjective symptoms and objective signs. They have been used with relative consistency over the twenty centuries of recorded clinical practice.

While western medicine focuses on diagnosis at the molecular level, traditional Chinese diagnosis focuses on the macromolecular level, using the subjective symptoms and visually objective signs of the patient to categorise these patterns. For example, to understand certain features of heart disease it is possible to focus at the microscopic level on the state of coronary blood vessels, however, to investigate whether specific clinical patterns are correlated with increased incidence of heart disease, one would need to shift focus to the macroscopic level. What Chinese medicine claims to identify and work with is a series of recurring patterns in the clinical signs and symptoms of patients at the broader macroscopic level.

'Pattern identification' is the irreducible basis for treatment using TCM techniques. While TCM will, like western medicine, employ tactics aimed at eradicating pathogens, the emphasis on restoration of normal physiological functioning remains the essential feature.

Kaptchuk (1983:15) highlights the differences between western and eastern clinical approaches1. In a typical study a western physician may diagnose by endoscopy six patients with stomach pain as having peptic ulcers. Each patient is then examined by a Chinese physician who finds the following (only the first two cases are reported):

  • The first has pain that increases on touch, but diminishes with cold compresses; a robust constitution, a reddish complexion, and a full, deep voice. He is assertive, even a little aggressive, with constipation and dark yellow urine. His tongue has a greasy yellow coating and his pulse is described as full and wiry. The diagnostic label given by the Chinese doctor is 'damp-heat affecting the spleen'.
  • The second patient is thin, with an ashen complexion, though her cheeks are ruddy, and she is constantly thirsty, sweats easily at night, and tends to constipation and insomnia. She is restless, her tongue is dry, slighthly red without any coat, and her pulse is described as thin and a little fast. This patient carries the label of 'stomach yin deficiency'.

And so on for the remaining four patients. In TCM, the treatment for each patient differs based on their unique clinical picture. Even though these six patients all have peptic ulcers, no two are likely to receive the same Chinese medication.

TCM is considered as complementary to conventional western practice. It rooted in its cultural tradition and is capable of generating therapeutic options for a range of illnesses. It is used by large numbers of the Australian population of south-east Asian origin and increasingly by those of European origin. In this sense, TCM is an important component of Australia's multicultural mix. Its practice in Australia is influenced by its interpretation through western modes of scientific assessment and the restrictions placed upon it by the Australian legal system.

2.2 Extent of Use of TCM

2.2.1 China

In China, Chinese herbal medicine (CHM) and acupuncture play a significant role in the treatment and prevention of a wide range of common and chronic diseases. Chinese statistics in the mid-eighties revealed that 80% of the one billion population used varied forms of herbal preparations in the treatment of a wide range of diseases and for preventative purposes2.

In Shanghai, 160,000 herbal prescriptions were estimated to have been dispensed every day using 1,076 different medicinal substances from the Chinese materia medica2. Similarly, acupuncture is used widely in most Chinese hospitals and in a large number of public health clinics. In China, all TCM techniques are employed in in-patient and out-patient settings in public hospitals and in private practices. A number of large public hospitals are dedicated principally to the provision of TCM.

2.2.2 Australia

The flow of Chinese migrants to the Australian goldfields in the 19th century brought with it a distinct medical culture. One estimate is that by 1887 there were 50 Chinese herbal medicine (CHM) practitioners on the Victorian goldfields, although not all would have had more than a rudimentary knowledge of the field3, and by 1911 Chinese herbal remedies were available with English labels and directions.

The recent growth in the practice of TCM in Australia is significant:

  • Australian distributers of Chinese medicines estimate that importation of raw and proprietary Chinese medicines has grown four-fold since 19924. Currently, approximately 600-800 raw medicinal substances are imported for use in Australia, principally from China, and imported prepackaged herbal preparations amount to approximately 300-400 individual medicines.
  • In 1986 it was estimated that at least 20% of the Victorian public used some form of unconventional therapy5.
  • A 1992-93 survey reported in the Lancet concluded that half the South Australian population has used alternative medicines and one fifth visit alternative medical practitioners each year6. This study estimated that $621 million was spent by Australians on alternative medicines in 1992-93, compared with the $360 million of patient contributions for all pharmaceutical drugs purchased in the same year.
  • Thirty percent of the respondents to a survey of alternative medicine usage in the Northern Rivers of NSW had been consumers of TCM7.
  • Similar findings were noted in the United Kingdom, the United States, Germany and Europe in general, where at least as much appears to be spent out of pocket on alternative medicines as on pharmaceuticals or hospitalisations8,9.

Public attidudes to alternative medicine are invariably positive, with findings in Australia being consistent with those in Europe5,9.

Approximately 4,500 practitioners of TCM have been identified in NSW, Victoria and Queensland. This includes western medical practitioners and other therapists who use any modality of TCM. (See Chapter 5)

The majority of TCM practitioners in Australia are trained primarily as acupuncturists, although a significant number have knowledge of Chinese herbal medicine. TCM association representatives interviewed have identified a steady growth in the numbers of TCM practitioners, along with an increase in the number of medical practitioners, chiropractors, osteopaths, physiotherapists, naturopaths, homoeopaths, nurses, shiatsu therapists and others using TCM modalities.

A range of traditional therapeutic approaches other than acupuncture and Chinese herbal medicine, are used considerably less frequently in Australia than China. According to the Workforce Survey conducted as part of this project they are nevertheless used to some degree by Australian TCM practitioners. The methods include scarring moxibustion, point injection therapy, scraping, embedding needles or cat-gut sutures, bleeding and orthopaedic manipulation. It is unlikely that they are used by Australian-trained practitioners, but they are taught to TCM students who may spend additional time studying in China.

2.3 TCM Diagnostic Methods

TCM practitioners use Chinese medical theory to identify clinical 'patterns of dysfunction'. The practitioner is guided by four classic diagnostic methods that were systematised in Chinese medical literature around the 4th century BC:

  • observing the patient's expression, colour, appearance and tongue coating;
  • listening to the patient's voice and smelling body odour;
  • inquiring about the disease condition and duration, etc.; and
  • feeling the pulse to find out its quality, power, rate, and rhythm, and palpating the body for any abnormality.

Data gathered is then ordered and structured using one or more of the conceptual templates of TCM theory, for example:

  • the 'Eight Principles' (Ba Gang Bian Zheng);
  • 'Six Divisions' (Liu Jing Bian Zheng);
  • 'Four Stages' (Wei Qi Ying Xue); and
  • 'Organ System Disharmonies' (Zang Fu Bian Zheng).

These templates are used to organise the patient's signs and symptoms into specific 'patterns of dysfunction' which, once identified, will guide the practitioner to defined therapeutic approaches using acupuncture, herbal medicine, dietary changes, or other traditional techniques.

Diagnostic principles in TCM are significantly more complex in their application than can be described in this report. The Chinese medical schools of thought are well-established, have formed substantial theories that relate to specific classes of disease, generate practical guidelines for the administration of therapy, and have a long history of publication and clinical debate.

The examination of the clinical benefits of acupuncture and Chinese herbal medicine (Chapter 3) proceeds by isolating these therapeutic practices from the integrated body of TCM. However, a TCM practitioner will usually adopt more than one TCM therapeutic intervention in the treatment of a patient (selecting any combination from acupuncture, herbal medicine (internal and external), dietary, lifestyle advice and other ancillary practices). The total therapeutic benefit will be an amalgamation of the individual benefits of these techniques.

2.4 The Practice of Chinese Herbal Medicine (CHM)

Chinese herbal medicine involves the use of medicinal substances in the treatment and prevention of disease. The Chinese materia medica includes:

  • plant components;
  • mineral substances (such as gypsum and talc); and
  • animal products (such as deer antler and cuttlefish bone).

These substances frequently undergo initial processing before clinical use. This may be simple cleaning or washing of the substance, or may involve more complex methods of soaking in wine or vinegar, or toasting in honey. In this processed form, the medicinal substances are made available in herb shops for use by TCM practitioners.

In TCM theory, the concept of therapeutic action for both medicinal substances and acupuncture points developed hand in hand with the concept of patterns of dysfunction. This led to the linking of therapeutic action to a particular clinical problem, and substances within the Chinese materia medica are prescribed to address particular clinical patterns. For example, ginseng's therapeutic action is to tonify a deficient 'Qi' or 'energy' in a deficient clinical pattern.

Individual herbs were used to deal with certain ailments, then, as the practice developed, combinations of substances were used to deal with more complicated conditions, and the practice became more systematised. Eventually, this evolved to become formulas of herbs (usually 4 to 12 different medicinal substances) used to treat specific clinical patterns.

A system of classification was devised which defined the attributes of particular agents. Every medicinal substance is 'inclined' toward being hot, cold, warm, floating, sinking, moistening, drying, tonifying, sedating, sweet, bitter and other qualities, and it is the consideration and combining of these inclinations during therapy that brings about equilibrium or balance to a pattern of clinical dysfunction. The fundamental principle is to restore balance and harmony: when the patient's pattern is hot, cool it; when cold, warm it; when deficient, tonify it, when dry, moisten it.

The four Qi (energy) attributes, the five flavours (of herbs), the four directions (of action) and the acupuncture channels entered (by the herbs) determine the therapeutic actions of medicinal substances. Individual substances may also be ascribed specific actions that relate to particular illnesses. Herbal formulae are designed with combinations of individual herbs specifically selected to address the general pattern of disharmony, with each herb adopting a specific role in the formula. The omission of any one substance from the formula would alter (and may well compromise) the overall effect.

CHM is applied to a very broad range of illnesses, from minor skin ailments to life-threatening cancers. It is used in the treatment of burns, chronic hepatitis, haemorrhagic diseases, angina, acute and chronic infections; in paediatric and obstetric care and many other areas. CHM has played a principal role in health care over many centuries for one-quarter of the world's population, and it continues to be widely used within the Chinese hospital system. Its range of applications should be considered to be similar to modern pharmaceutical medicine.

2.4.1 CHM Practitioners in Australia

Some TCM practitioners are trained specifically as Chinese herbal medicine practitioners and have little or no knowledge of acupuncture. Chinese herbal medicine practitioners are generally experienced in the use of the full range of medicinal substances that comprise the Chinese materia medica. Oral consumption is primarily of pills, tablets, syrups, powders, and boiled teas. Herbal preparations are also administered topically and prepared as pastes or douches. On rare occasions Chinese herbalists in Australia have accessed public hospital patients and provided herbal preparations through nasogastric administration. No cases of intravenous administration of Chinese herbs have been identified in Australia to date, however point injection therapy of herbs is used by some practitioners.

A wide range of conditions are treated by both Chinese herbalists and acupuncturists. These are described in Chapter 6.

2.5 The Practice of Acupuncture

Acupuncture in Chinese hospitals is used in both acute and chronic care of patients for a wide variety of clinical presentations. It has been applied to regulate physiological functions, treat infectious conditions and for psychological disturbances. Acupuncture has also had a short period of use in surgical anaesthesia, but is currently only used where chemical anaesthetics pose unacceptably high risks.

Unlike CHM, modern acupuncture is distinctly different from practice 100 years ago. The boundaries of the practice have changed. Clinical practices of traditional acupuncture in Chinese hospitals in some instances are based upon modern neurophysiological concepts, and therefore have neither a traditional empirical base nor are they especially of Chinese origin (examples include scalp and ear acupuncture).

The flexible form of acupuncture and the range purposes for which it is used are likely to have generated some confusion in the West as to its appropriate applications.

At the crudest level, acupuncture may be claimed to be a technique for initiating, controlling or accelerating physiological functions of the body. Acupuncture theory incorporates an elaborate set of models which are claimed to permit the precise calculation of acupuncture points to use, when and how to stimulate them, and which points to combine together all based on observations of the symptoms and signs of the patient.

However, acupuncture is derived from theories and diagnostic schema very different from those of western medicine, and it adopts distinct terminology (such as the concept of 'Qi' and the routes or 'channels' of Qi flow). This has hindered communication between traditional Chinese doctors and western medical practitioners. There exists a problem of no common standard of measurement between the two medical paradigms.

2.5.1 Acupuncturists in Australia

Acupuncturists in Australia are generally experienced in the use of a variety of techniques including:

  • manual insertion and stimulation of needles (from just beneath the dermis to depths of 7 to 8 cms, according to location);
  • embedding (and retaining) of needles in the dermis for up to seven days;
  • electrical stimulation of needles;
  • laser and manual stimulation of acupuncture points;
  • moxibustion, the burning of the leaves of artemisia vulgaris over an acupuncture point;
  • cupping, the use of suction cups that draw blood to the surface capillaries and usually result in a degree of bruising;
  • scraping the skin with a coin or spoon;
  • drawing a drop of blood from specific acupuncture points;
  • point-injection therapy, where substances are injected subcutaneously or intramuscularly at the site of an acupuncture point; and
  • gentle skin tapping with a plum blossom needle, which results in slight bleeding of the skin capillaries.

Dietary and lifestyle advice (including exercise) are also often dispensed. Some practitioners use Chinese massage. The workforce survey showed that a number of practitioners use point injection therapy, scarring moxibustion, bleeding and needle embedding, and occasionally orthopaedic manipulation, or although none reported to engage in surgery within the context of TCM practice.

Each of the techniques used in the stimulation of acupuncture points carries distinct risks, some of which are higher than simple manual needle stimulation.

Transcutaneous electrical nerve stimulation (TENS) may be considered a western medical approximation of traditional acupuncture. Specific trigger points or loci of tenderness are stimulated with surface electrodes applied to the skin.

Qualifications in acupuncture have been established in the West longer that qualifications in CHM, and in Australia, acupuncture education is more standardised than that of CHM. However, there is still considerable variability in content and form in all TCM qualifications. These issues are addressed fully in subsequent chapters.

TCM practitioners trained primarily as acupuncturists have variable knowledge in the application of medicinal substances in the Chinese materia medica. Some have no experience, others have significant levels of training in China and elsewhere, although may not have completed a formal qualification.

Whilst pain clinics attached to some public hospitals employ medical practitioners with some training in acupuncture, acupuncturists without medical qualifications generally have little access to patients other than through private clinics.

References

1. Kaptchuk T. Chinese Medicine: the web that has no weaver. London:Rider; 1983.

2. Hu SL. Exploring the future of CHM. Acta Medica Sinica 1986; 1(2):9-12.

3. Loh M. Victoria as a catalyst for western and Chinese medicine. Journal of the Royal Historical Society of Victoria 1985:39-46.

4. Personal communication (AB) with importers of Chinese medicines. May 1996.

5. Dixon J (Chairperson). Parliament of Victoria, Social Development Committee. Inquiry into alternative medicine and the health food industry. 1984-86, report Vol 2.

6. MacLennan A, Wilson D, Taylor A. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347:569-573.

7. Public Health Research Group 1996 Southern Cross University.

8. Eisenberg DM, Kessler RC, Foster C et al. Unconventional medicine in the United States: prevalence, costs and patterns of use. New England Journal of Medicine 1993; 328(4):246-252.

9. Fisher P, Ward A. Complementary medicine in Europe. British Medical Journal 1994 ;309:107-111.