Traditional Chinese Medicine—–What Are We Investigating? the Case of Menopauseଝ

Complementary Therapies in Medicine (2007) 15, 54—68

Traditional Chinese medicine—–What are we investigating? The case of menopauseଝ

Volker Scheid ∗

School of Integrated Health, University of Westminster, 115 New Cavendish Street, Westminster, London W1W 6UW, United Kingdom

Available online 9 February 2006

KEYWORDS Summary CAM researchers commonly treat traditional medicines as unchang- Traditional Chinese ing systems. This article questions the validity of this approach by examining the medicine; treatment of menopausal syndrome by traditional Chinese medicine (TCM). Such Kampo; treatment strategies were invented in 1964 and betray a strong inﬂuence of biomed- Traditional medicine; ical thinking. While they determine TCM treatment of menopausal syndrome in the Menopause; West, physicians in China and Japan use many other treatment strategies from within the wider Chinese medical tradition in clinical practice. Cultural variability in the Research design; manifestation of menopausal syndrome furthermore questions the usefulness of sim- Medical anthropology; ply importing treatment strategies from China to the West. This leads me to conclude History of medicine that Chinese medicine as such can never be evaluated by means of clinical research. What we can do is use Chinese medicine as a resource for thinking about illness, and for formulating clinical interventions that may then be assessed using methods of evidence based research. © 2006 Published by Elsevier Ltd.

Introduction ous efforts to find alternatives. This specifically includes the integration of complementary and Eighty percent of women in the UK experience alternative medicines (CAM) into treatment proto- menopausal symptoms and 45% find the symp- cols tailored to women’s individual needs.1—3 toms distressing.1 An increasing awareness among Traditional Chinese medicine (TCM) appears to both health care providers and patients regarding be a fruitful area to which such efforts might be potential adverse effects associated with hormone directed. It offers a clear and systematic approach replacement therapy (HRT) is leading to strenu- to the treatment of menopausal syndrome that might readily be evaluated with the help of inno- vative research protocols being developed in the ଝ The research on which this article is based was supported wider field of CAM research.4,5 These protocols by the DH-National Co-ordinating Centre for Research Capacity are committed to establishing an evidence base Development (NCC RCD). ∗ Tel.: +44 20 7689 4764; fax: +44 20 7689 4764. for CAM. They frequently group research sub- E-mail address: [email protected]. jects according to TCM diagnoses, or use TCM

0965-2299/$ — see front matter © 2006 Published by Elsevier Ltd. doi:10.1016/j.ctim.2005.12.002 Traditional Chinese medicine—–What are we investigating? 55 diagnoses in their analysis. This still leaves open ment strategies for menopausal syndrome as con- a host of unresolved methodological difficulties, tingent upon specific political factors in the Maoist i.e. whether or not clinical interventions should China of the early 1960s. It also provides us with an be standardized. But they do provide a platform understanding of the plurality of approaches to the from which such difficulties can be approached as treatment of menopausal syndrome within the Chi- ‘‘technical’’ problems by experts who share com- nese medical tradition. Steps three and four con- mon standards rather than as ‘‘conceptual’’ issues textualize TCM treatments further by exploring the that divide groups of researchers on the basis of cultural variability of menopausal experience and ideological commitments. by presenting some Japanese Kampo approaches to From a sociological perspective, the develop- menopausal syndrome. East Asian women experi- ment of such research protocols is indicative of a ence menopause differently to women in the West, maturing discipline. Some commentators, in fact, and Kampo physicians respond to these differences interpret them as signs that traditional medicines by utilizing traditional Chinese herbal medicine for- everywhere are ready to be integrated into a sin- mulas in ways that is entirely different from the gle, global, and progressive medical system.6 This TCM approach. In the final section I analyze what article seeks to challenge this analysis and the hid- the consequences of these observations are for CAM den ideologies and value judgments that sustain it. research on Chinese medicine and beyond. Using the Chinese medical treatment of menopause as an example, I argue that a collective unwilling- ness among practitioners and researchers to criti- cally examine the myth of tradition that underpins Traditional Chinese medicine (TCM) the discourse on TCM and CAM — even though this approaches to menopause critique is readily available in the anthropologi- cal and historical literature — invalidates much of For the purposes of this discussion I define TCM the research that is currently carried out and that as that interpretation of Chinese medical practice might be used to evaluate the TCM treatment of that is presented to us in contemporary Chinese menopausal syndrome. medical textbooks.8(pp6—8),9(pp107—150) Emerging in In particular, I wish to challenge the notion that the late 1950s, these textbooks have been a corner- CAM research is examining ‘‘Chinese medicine’’ or stone of state-directed efforts at modernizing Chi- that it will ever be able to do so. As we shall nese medicine and integrating it into a larger health see, Chinese medicine is a living tradition. Like care system. In China, TCM exerts a significant influ- biomedicine it offers multiple competing (if inter- ence on the practice of medicine through its dom- related) models for thinking about illness and suf- inance of educational curricula. Its influence on fering. Physicians and patients use these models to medical practice, however, is tempered by the con- develop treatment options that fit specific clinical tinued existence of alternative resources on which contexts and, in turn, shape the understanding Chi- clinicians can draw. These include direct access to nese medicine has of itself as a tradition.7 Gaining the classical medical literature, the transmission familiarity with the complex histories that generate of medical knowledge through personal master- specific treatment protocols, assessing the validity disciple networks and lineages, and the historical of these protocols in relation to local contexts of plurality of the Chinese medical tradition.8,10 In the clinical practice, and the ability to define new pro- West, where such alternative resources are lack- tocols through processes of creative development ing, TCM is thus widely perceived to constitute and translation thus emerge as urgent priorities in mainland Chinese medicine as such, even if on the the field of Chinese medical research. level of both teaching and practice TCM coexists I will develop my critique in four steps. I with a large number of hybrid practices created in first examine the TCM diagnosis and treatment of the course of the last 200 years by the complex menopausal syndrome in the west. This demon- diffusion of Chinese medicine to Europe and the strates significant consensus among TCM practition- West.56—59 This view is further enabled by a widely ers regarding patho-physiology, diagnosis and treat- shared cultural discourse that perceives of tradi- ment. It also shows that the further a practitioner tions as homogenous, stable and unchanging. CAM in either China or the west moves away from access research into Chinese medicine follows this trend, to primary sources, the more simplistic and system- as TCM practices become the object of research atic these theories and models become. In a second claiming to evaluate not singular interventions for step I compare TCM to Chinese medicine as prac- a given disorder, but ‘‘the TCM treatment’’ of this ticed in contemporary and late imperial China. This disorder. TCM theories about menopause, its diag- allows us to understand the development of treat- nosis and treatment of menopausal syndrome, and 56 V. Scheid

CAM research into these practices constitute a case us on its webpage, ‘‘a woman is not generally study that confirms these general observations. referred to as ‘menopausal.’ Rather, a practitioner Most Western TCM textbooks and TCM of TCM might say that she exhibits ‘[K]idney yin teachers11,12 state that Chinese medicine deficiency.’”14 Reversely, because hot flushes are attributes problems of menopause to Kidney such an emblematic and widely recognized symp- deficiency (shen xu ). In TCM the Kidneys tom, they can also be employed to communicate to (shen ) constitute a functional visceral system potential patients (i.e. menopausal women) how a (zang ) to which are ascribed the regulation and TCM practitioner may label their condition, namely sustenance of growth, maturation, and ageing. ‘‘yin deficiency’’ (Fig. 1). This system is sub-divided into two complementary Research investigating how TCM practitioners aspects. The actualizing dynamic of Kidney yang diagnose menopausal women with vasomotor symp- (shen yang ) is imagined as the driving forces toms shows that such understanding is not lim- of all metabolic process. The endpoint of this ited to discourse but that it consistently informs process, in turn, is the production of Kidney yin clinical practice. Zell et al.15 had a cohort of 23 (shen yin ), which constitutes the structive postmenopausal women suffering from hot flushes potential for the production of Kidney yang. Ageing independently successively examined by nine TCM in TCM is modelled as a diminishing vitality of this practitioners on the same day. Practitioners diag- transformative cycle caused by a decline of the nosed Kidney yin deficiency after 168 of 207 visits essence (jing ), which is stored in the Kidneys (81%). In 12 women (52%) the diagnosis Kidney yin and underpins the functions of both Kidney yin deficiency was made by eight of nine practitioners; and yang. The actual manifestations of ageing in 16 women (70%) by seven of nine; while in all are dependent upon the relative balance between 23 women (100%), at least five of nine practition- yin and yang. If yin (associated with substance, ers made this diagnosis. There was less agreement tranquillity, and moisture) declines more rapidly among practitioners regarding secondary patterns than yang, yang will be in relative excess produc- of disharmony and thus about the final specific ing symptoms of excess activity like hot flushes, diagnosis. However, because treatment of the core palpitations, insomnia, forgetfulness, or dryness. If pathology or ‘‘root’’ (ben) is considered the ulti- yang (associated with activity, warmth, dynamic, mate goal of treatment in TCM, such variation does and metabolic function) declines more rapidly than not tend to fundamentally change the basic direc- yin, symptoms like fatigue, depression, chilliness, tion of treatment in clinical practice. and oedema predominate.13(pp140—146,176—180) Suggestions for treatment of menopausal syn- Because the Kidneys sustain all metabolic pro- drome in the TCM literature, not surprisingly, are cesses, TCM assumes that Kidney pathology eventu- dominated by formulas and treatment protocols ally leads to dysfunction of other visceral systems. that tonify the Kidneys and in particular Kidney yin Hence, while Kidney deficiency is ‘‘always at the (Table 1). The only CAM clinical study that uses TCM root of menopausal problems’’11 it is often com- disease categories as determinants of treatment16 bined with secondary pathologies in practice. Those likewise sorted menopausal women into Kidney yin pathologies may need to be addressed in treat- and Kidney yang deficient treatment groups. It then ment but it is Kidney deficiency that constitutes employed Liu wei di huang wan , the the core of almost any TCM treatment protocol most widely used TCM formula for the tonifica- for menopausal syndrome. ‘‘Chinese medicine,’’ as tion of Kidney yin,17(pp263—266) as a base formula for one of TCM’s most influential teachers in the West treatment in both groups. notes, ‘‘works by gently tonifying the Kidneys and My overview of the TCM and CAM literature thus the Kidney-Essence to help the woman in this tran- allows me to draw three conclusions, which confirm sitional time of life.’’11 the claims made in the introduction: (i) that TCM Given the prevalence of hot flushes in the pre- treatment of menopausal syndrome it is informed sentation of menopausal syndrome in the west, Kid- by a distinctive understanding of patho-physiology ney yin deficiency has come to be seen as the defin- reflected in distinctive diagnostic categories; (ii) ing feature of menopause among western TCM prac- that this understanding is reflected in a broad titioners. ‘‘While all patients with menopause will consensus among TCM practitioners regarding core have Kidney yin deficiency,’’ writes an influential treatment protocols; and (iii) that these diagnostic TCM teacher,‘‘many will have other associated con- categories and treatment protocols are the most ditions that must be addressed.’’12 Communicating likely ones to orient CAM research. such ideas to the wider public, they are further sim- The TCM literature makes it appear that its plified. ‘‘In Traditional Chinese Medicine, or TCM,’’ understanding of menopause is an integral aspect the University of Maryland Medical Center informs of the Chinese medical tradition. In the follow- Traditional Chinese medicine—–What are we investigating? 57

Figure 1 Tongue diagnosis chart employed by Acumedic Centre, London, to explain Chinese medical methods of diagnosis to potential patients.

Table 1 The treatment of menopause in selected TCM textbooks Textbook title Total number of Formulas to treat Formulas to treat Formula(s) for formulas Kidneys Kidney yin Kidney yin main suggested formula(s) Lecture Notes for Chinese 321Yes Medicine Gynaecology20 Chinese Medicine 665Yes Gynaecology26 Understanding Chinese 221Yes Medical Gynaecology Through Tables28 Encyclopedia of Treatment in 888Yes Chinese Medicine Gynaecology29 My Sister the Moon: The 33 23 18 Yes Diagnosis and Treatment of Menstrual Disease by Traditional Chinese Medicine Obstetrics and Gynaecology 18 14 13 Yes in Chinese Medicine11 58 V. Scheid ing section, I will show that like TCM itself, the Like the treatment of menopausal syndrome, TCM understanding of menopause is a direct con- textbooks emerged very late in the history of Chi- sequence of Chinese medical modernization. nese medicine. In the late 1950s, the Ministry of Health embarked on a thorough investigation of teaching materials, which culminated in a decision The invention of menopause as a to edit a series of national textbooks for the teach- medical problem in TCM ing of Chinese medicine in 1959.9 The explicit goal of this policy was to systematise Chinese medicine In contemporary Chinese TCM textbooks dis- in a manner that would make it appear more orders related to menopause are referred to like biomedicine and thus legitimize its continued as ‘‘manifestation patterns associated with the existence in the modern world. However, in the cessation of menstruation’’ (jingduan qianhou words of the historian Kim Taylor who has exam- zhuzheng ) or ‘‘symptoms and signs ined this policy in detail, it was also ‘‘a means associated with the cessation of menstruation’’ of mass-producing future doctors of the medicine, (jingduan qianhou zhenghou ). In of controlling their knowledge and practice’’ that its visible difference from the biomedical term ‘‘fundamentally altered the dynamics ... of any ‘‘menopausal syndrome’’ (gengnianqi zonghezheng form of medical innovation.’’9 ), these terms seek to emphasize a The first edition of these textbooks was writ- difference of both focus and origin. In terms of ten in 1959 by ‘‘teaching and research groups’’ focus, the TCM terms draw attention to the individ- (jiaoyanzu ) set up specifically for this pur- ually specific constellation of symptoms into man- pose at various Chinese medical colleges. The Lec- ifestation patterns (zheng ) that constitute one ture Notes for Chinese Medicine Gynaecology20,21 of the core aspects of TCM self-definition.10 In were compiled at the Chengdu College of Chinese terms of origin, the wording ‘‘cessation of menstru- Medicine by a group led by Prof. Zeng Jingguang ation’’ (jingduan ) is a term borrowed from the (1918) building on teaching materials already classical Chinese medical literature. ‘‘Menopause’’ used at the College. These included a series of (gengnianqi ), on the other hand, is a direct handbooks published a year earlier jointly edited borrowing from the Japanese term konenki, with by Prof. Zeng and other experts from Chengdu.22,23 which it shares the same characters, which in turn One of the most influential of these was Zhuo is a translation into Japanese of the German Kli- Qichi , a son of the locally famous Chinese makterium from the early 20th century.18 As I have medicine gynaecology expert Zhuo Yunong shown elsewhere, such naming strategies estab- who had himself studied biomedicine. Prof. Zeng lish legitimizing attachments to past tradition for had been educated at one of the new colleges modern innovations even as they move the Chinese of ‘‘national medicine’’ (guoyi ) during the medical body of process ever more closely to the Republican era that sought to modernise Chinese biomedical body of structure.19 medicine while keeping its essentials in tact. In dif- In fact, neither of the two terms used to refer to ferent ways, therefore, both Zeng Jingguang and menopausal problems in TCM have any precedent Zhuo Qichi embodied the ‘‘integration of Chinese in tradition. The first occurrence of ‘‘manifestation and Western medicine’’ actively promoted by the patterns associated with the cessation of menstru- CCP during the late 1950s under the orders of Mao ation’’ — and thus the invention of menopause as a Zedong himself.b problem for Chinese medicine — can be dated pre- Having been compiled at break-neck speed, the cisely to the publication of the second revised edi- first edition of the new national textbooks was tion of Lecture Notes for Chinese Medicine Gynae- always intended to be provisional. It was there- cology (Zhongyi fukexue jiangyi )in fore replaced after only four years by a revised and 1964. The fact that the first edition of the same enlarged second edition. Published in 1964, these text, published in 1960, did not yet include a dis- new lecture notes provided a framework for the cussion of menopause allows us to link its invention teaching of Chinese medicine that remains influ- as a distinctive medical problem of concern to TCM ential to this date and that has been exported physicians to the historical process that guided the around the world as TCM. The revised Lecture compilation of textbooks — and thereby of TCM — Notes for Chinese Medicine Gynaecology, once in early Maoist China.a more compiled in Chengdu, now discussed 44 rather than as previously 34 different disorders (bing ) a The political emphasis on collectivity in early Maoist China prevented the attribution of textbooks to individuals. The edit- ing of both texts was thus ascribed to the Chengdu College of b My account in this and following paragraphs draws on the Chinese Medicine (Chengdu zhongyi xueyuan ). detailed biography of Prof. Zeng.21 Traditional Chinese medicine—–What are we investigating? 59 according to the new paradigm of ‘‘pattern differ- plementing Kidney qi and regulating penetrating entiation and treatment application’’ (bianzheng and conception vessels’’ (bu shenqi, tiao chongren shizhi ). One of these new disorders was , ). ‘‘manifestation patterns associated with the cessa- This still left the problem of supporting the tion of menstruation,’’ and Prof. Zeng Jingguang is new interpretation with references to the classics, today credited with its invention. without which it could not have been considered The various influences on Prof. Zeng’s under- authentic Chinese medical knowledge. Prof. Zeng standing of gynaecology are too complex for those did this by creating a link to chapter one of the Inner unfamiliar with the history of Chinese medicine to Canon of the Yellow Lord: Basic Questions (Huangdi outline in detail. Suffice to say that they focused neijing su wen ), the foundational text on the physiology and pathology of the penetrat- of the Chinese medical tradition.d Its first chapter ing (chongmai ) and conception vessels (renmai discusses the development, growth, and decline of ), two broad physiological functions that during human life in terms of seven-year cycles for females the Qing dynasty had become increasingly closely and eight-year cycles for males. Regarding women associated with the uterus as the core concern of it states: Chinese medical gynaecology. Another influence, ‘‘When a woman is seven years old her Kidney qi undoubtedly, was biomedicine, assimilated during is vigorous. The teeth are replaced and the hair training programs run for Chinese medicine physi- grows. At fourteen, fertility is established, the con- cians in the early 1950s and at the new Chinese ception vessel is open, the great penetrating vessel medicine hospitals constructed in the late 1950s. is vigorous, the menses flow, and she therefore can The early 1960s, furthermore, were a partic- have children. At twenty-one, Kidney qi is fully ularly exciting time for those progressive physi- developed. The wisdom teeth appear and [physicians who embraced Mao Zedong’s idea of creat- cal] growth is complete. At twenty-eight the sinews ing a new medicine. Not only was their project and bones are firm, the hair reaches its greatest supported at the highest political level but initial length, and the body is luxuriant. At thirty-five, research suggested that it might indeed be pos- the yang brightness vessel declines, the complexion sible to anchor Chinese medicine’s body of pro- dries out, the hair begins to fall out. At forty-two, cess in the more substantial realities of physics the three yang vessels decline above, the com- and biochemistry. The most influential work in this plexion is entirely dried out, the hair begins to respect was that of the Shanghai physician Chen turn white. At forty-nine, the conception vessel is Ziyin (1928), who established that patients depleted, the great penetrating vessel wanes, fer- diagnosed as suffering from Kidney yang depletion tility is exhausted, menstruation ceases, the body (shen yang xu ) had consistently low urine lev- has become old and she can no longer have chil- els of 17-hydroxicorticosteroid. This led him to pro- dren.’’25(p4) pose a correlation between Kidney yang depletion and adrenal insufficiency.24 A connection between Today’s gynaecology textbooks like the hugely the Kidneys and hormonal function was thereby influential Chinese Medicine Gynaecology (Zhongyi established in the Chinese medical imagination that fukexue ), generally only cite the last persists to this day even if 40 more years of research sentence of this passage before proceeding to have not fulfilled Chen’s dream of matching Chinese explain: ‘‘Around the cessation of menstruation and biomedical pathology.c the Kidney qi gradually declines, ... hence Kid- These observations help us to understand why ney deficiency is the root cause of this disor- menopause, which did not constitute a medical der.’’26(p161) The chief editor, Luo Yuankai problem in the classical literature suddenly became (1914—1995) from Guangdong, held a more narrow one in 1964 and why, given the biomedical focus view of menopause as Kidney deficiency than Zeng on menopause as hormonal decline, Chinese physi- Jingguang, who only was a deputy-editor, which cians were tempted to interpret it as a problem is duly reflected in this text.27(pp104—106) We thus of deficiency. In Prof. Zeng’s interpretation, how- find here a further stage in the development of ever, menopause was not yet merely a problem of the TCM understanding of menopausal syndrome. Kidney yin but one of ‘‘debilitated Kidney qi and Detached from Prof. Zeng’s personal focus on the deficiency and harm to the penetrating and con- penetrating and conception vessels, references to ception vessels’’ (shenqi shuairuo, chongren xusun , ). This was to be treated by sup- d The dating of this text is difficult. Most of the source material was probably written in the two centuries around the turn of c For an overview of Chen Ziyin’s research and his influence on the millennia [BCE/CE], with its final compilation perhaps not TCM see the accounts by Ma Boying.23 reaching maturity until the Song dynasty. 60 V. Scheid treating penetrating and conception vessels are cussions hide, too, is the plurality of approaches removed and replaced by the simplified emphasis of treating menopausal distress in contemporary on Kidney deficiency that we also find in western Chinese medical practice, which embody perspec- TCM texts.28(pp83—84),29(pp126—132) In broader histor- tives that differ from the narrow focus on Kidney ical terms, this reduction of complexity follows the deficiency cited above. If the transmission of Chi- new centring of Chinese medical practice on dis- nese medicine that underpins much of current CAM ease ‘‘types’’ (xing ) rather than ‘‘manifestation research continues to rely on a simplified under- patterns’’ (zheng ), first advanced by the above standing of menopausal syndrome as Kidney defi- mentioned Chen Ziyin in 1973 and widely applied ciency, then one of the reasons is the mistaken by modernising physicians since then.10 perception that textbooks prescribe actual clini- Not all Chinese medicine physicians, however, cal practice, as well as a lack of access to primary interpreted the passage from the Inner Cannon in sources of knowledge. the same way. For although it defines growth and Another important reason, however, could be development as emanating from the vigour of Kid- differences between China and the west in how ney qi, its account of decline emphasize beyond the women actually experience the menopausal tran- conception and penetrating vessels the yang chan- sition. For as much modern research shows, the nels, particularly yang brightness (yangming ). experience of menopause as a life event every- In clinical practice, therefore, many gynaecolo- where is shaped not only by a universal biology but gists emphasize treatment of the Kidneys only in also by the distinctly local factors of culture and younger women, while for older women the Spleen society. and Stomach visceral systems, which are associated with are associated with both the yang brightness and the penetrating vessel, are considered more Menopause and culture important. The influential Ming dynasty physician Wang Kentang (1549—1613), whose ideas If, like the Oxford English Dictionary,32 we define shape the practice of many contemporary gynae- menopause as ‘‘the permanent cessation of men- cologists, for instance writes: struation’’ it is a species universal, which hap- pens sometime in the late forties or early fifties ‘‘During their childhood, before they menstruate without significant variations across cultures. If, [and are fertile], women’s [physiology] is subordi- on the other hand, we use menopause to mean nated to the lesser yin [i.e. the Kidneys]. When they ‘‘the period of a woman’s life when this occurs’’32 menstruate [and are fertile] it is subordinated to — this, too, being part of the OED definition the terminal yin [i.e. the Liver]. When menstrua- — subjective dimensions of experience embed- tion [and fertility] ceases, it is subordinated to the ded in local cultures, ideologies and histories are ,p greater yin [i.e. the Spleen].’’30(vol.6 1) moved to the fore.e Women in East Asian cultures like Japan,33,34 Singapore,35 Hong Kong,36,37 The modern case record literature also provides Taiwan,38,39 and Malaysia,40 for instance, do not many examples of senior physicians approaching generally associate the menopausal transition with the treatment of menopausal problems from a per- the vasomotor symptoms (hot flushes) so emblem- spective that does not accord priority to Kidney atic of menopause in the west. Muscle and joint function. The gynaecology expert Ha Litian pains, as well as depressed moods tend to be (1912—1989), for instance, notes that in the treat- frequently reported symptoms in these cultures ment of menopausal disorders,‘‘... one must take but the majority of women does not consider the regulation of the penetrating and conception menopause a problem requiring medical interven- vessels as the foundation. But in order to regu- tion. This is reflected in a relatively low uptake of late penetrating and conception vessels one must HRT in countries like Hong Kong,37,41 Japan,18 or regulate the visceral systems, harmonise qi and Taiwan.42 blood.’’31 The reasons for such cultural difference are com- Many other examples could be cited. My inten- plex, multi-causal, and poorly understood. Besides tion, however, is not to document in detail the possible genetic differences, diet and lifestyle diverse approaches to menopausal syndrome that they include perceptions of what it means for a might be found in the literature. Rather, I wish to woman to become older and how she is to man- call our intention to the complex history of inven- age the menopausal transition. Such perceptions tion and reinterpretation that lies beyond the sur- face of matter-of-fact discussions of menopause e These issues have been discussed in detail by the anthropol- found in western TCM textbooks. What these dis- ogist Margaret Lock.18(pp32—38) Traditional Chinese medicine—–What are we investigating? 61 are sites of contestation, shaped by diverse agen- are rare. The Shanghai gynaecology expert Cai cies and ideologies, and thus always in a process Zhuang 46(p100), for instance, estimates that of transition themselves. In a sample of Ameri- less than one in six (17%) of menopausal women in can menopausal women interviewed by Martin in this most westernized of Chinese cities suffer from the 1980s, older women, for instance, experienced symptoms serious enough to require treatment. menopause as a potentiality allowing them to face A survey of 500 menopausal women in Beijing47 life free of the burdens of reproduction. Younger observed that while 47% of women experienced women, in contrast, appeared to have internalised menopausal symptoms, only 20% were taking treat- the medical model of the menopausal body as being ment. The same survey reports that hot flushes, out of control and requiring support.43 Contempo- experienced by 23% of women, were the most com- rary middle-class Asian women increasingly report monly reported symptom. This compares with a rel- symptoms that match those of Western women. ative high incidence of depressive symptoms among Whether this is due to a shift in bodily atten- perimenopausal women in China reported by Zhao tion stemming from a desire to be modern (i.e. et al.48 The authors of this study claim that 46% Western), or whether it denotes an escape from of these women suffer from depressive symptoms, what Bulbeck calls the ‘‘midlife silence’’ of Asian with 30% experiencing moderate or severe depres- women — stemming from taboos concerning the sion. The stigma attached to psychological disor- discussion of sexual issues including menstruation, der in China may explain the discrepancy between fear of being criticized for failure of self-discipline these figures. or expressing ‘‘menopausal madness,’’ and lack The high incidence of depressive symptoms also, of information concerning how to name symptoms however,calls into question the entire methodology and lack of access to treatment — is open to by which the TCM treatment for menopausal syn- question.44 drome was constructed. Rather than beginning with Whatever the reasons, such differences explain the symptoms experienced by women in the clinic, why until the 1960s menopausal problems did not this process took as its starting point a perception of constitute a topic of concern to Chinese physicians. ageing as decline that needed to be rectified. This As the medical historian Charlotte Furth observes, contrasts not only with the classical view as docu- these physicians did not even distinguish between mented by Furth,45 but also with the contemporary male and female where matters of ageing were con- approach to the treatment of menopausal prob- cerned: lems by other (i.e. non-TCM) currents of Chinese medicine. An exploration of how menopausal syn- ‘‘What moderns would understand as menopause is drome is treated by Kampo medicine, a Japanese identified [in ancient Chinese medicine] in the same medical tradition based on the use of clas- way as menarche, simply as an event in the life pas- sical Chinese herbal formulas, elucidates this sage, similar in character if not in timing for males difference. and females alike. Just as females cease to menstruate, males’ ‘semen becomes scanty’, and these changes are not seen as a ‘pathology’ but ‘part and parcel of the ungendered feebleness of old age.’’45 The Kampo treatment of menopausal Hence, what problems required treatment would syndrome have been classed under other disease categories such as ‘‘profuse uterine bleeding in old age’’ Kampo (lit. ‘‘formulas from the Han dynasty’’) (nianlao xuebeng ), or one of the many dis- designates a current of traditional medicine prac- orders with a psychosomatic manifestation.f Alter- ticed in contemporary Japan that evolved out of natively, they would have been treated within the Japanese reinterpretations of Chinese medicine. family by women knowledgeable about medicine, Like traditional medicine in mainland China, Kampo by midwives, or by religious based non-elite is multifaceted and multi-layered, consisting of medicine. These healers left few written records diverse competing currents and styles of practice, and their methods would be difficult in any case to often centred on charismatic teachers. The interre- integrate into the rationalistic framework of mod- lationship between Kampo and traditional Chinese ern TCM. medicine in China, too, is complex and involves 50 Even in contemporary Chinese medicine clin- centuries of exchanges flowing in both directions. ics women seeking help for menopausal problems Tables 2 and 3 list formulas recommended for the treatment of menopausal syndrome in two different texts: one from a Chinese survey of Kampo f This also is the opinion of modern Chinese TCM textbooks. medicine,49 and the second from a Kampo textbook 62 V. Scheid Deficiency Excess Mixed (mainly deficiency) Deficiency Mixed (mainly deficiency) Mixed (mainly excess) Excess Mixed disorder Joint disorder of the three yang warps Liver blood deficiency with heat from constraint Blood and qi deficiency with dampness Blood deficiency with phlegm and wind-heat Qi stagnationBlood stasis and water accumulation Excess Yang brightness warp excess heat Phlegm Excess Unstable qi in lower jiao due to excess water Strong constitution, restless mind, irritabilityrestlessness, and easily angered, palpitations, insomnia, tight distension in epigastric areapalpation that is painful upon Weak constitution, shoulder aches andtired, pain, irritability, easily easily angered, restlessvexation, mind, flushed heat red cheeks, dizziness, insomnia Agitated, easily angered, restless sleep,abdominal soft muscles, and hyperactive weak aortic pulsationleft on side the of the abdomen,pain resistance on to palpation pressure in or leftUprushing, even upper palpitations, abdomen, headache, dizziness, backlike feels burnt, intense heat, sweating,restlessness, depression, long-term insomnia, constipation Relatively weak constitution, cold boody,easily anaemic, tired, occasional sensations ofabdomen, pain heavy in head, the dizziness, lower shouldertinnitus, pain, palpitations, abdominal diagnosis revealsof lack strength Sad, cries easily, yawning, hysterical, insomnia Restless visceral system Strong constitution, red complexion, headaches, dizziness, abdominal pain, shoulder pain,abdominal palpitations, fullness, resistance to pressureon or palpation even of pain lower abdomen, irregular menstruation No decrease of physical power,red upflaring cheeks, of restless fire, mind, flushed constipation A sensation of something beingattacks stuck of in palpitations, the hurried throat, breathing,qi, uprushing chest of pain, a softthe abdomen, epigastric and area splashing sound in Attacks of palpitations in lowerqi abdomen, from uprushing the of lower abdomenaccelerated to breathing, the dizziness, heart sweating and fromhead, chest, the palpitations ˆ ao yi ˆ ao ) san ) ˆ uli ) nu ˆ an ) ) ˆ an ˆ um er chen tang ling gui gan z gan mai da z ban xia hou po ) Kampo formulas for the treatment of climacteric disorders ) two-cured ˆ an ˆ an ) ) ) ) gui zhi fu ling wan jia wei xiao yao s dang gui shao yao s chai hu jia long g ( tang shen s epigastrium decoction ( huang xie xin tang ( ( gan s decoction ( licorice, and jujube decoction ( tang and oyster shell decoction ( decoction ( decoction ( tang tang Cinnamon twig and poria pill Three-yellow and drain the Augmented rambling powder Tangkuei and peony powder Restrain the liver powder ( Female spirit powder ( Poria, cinnamon twig, Bupleurum plus dragon bone Licorice, wheat, and jujube Table 2 Name of formula Syndrome Pathophysiology Excess or deficiency Pinellia and magnolia bark From Ref. 49, p. 576. Traditional Chinese medicine—–What are we investigating? 63 Mixed Mixed (mainly deficiency) Excess with some deficiency Mixed Excess Excess Mixed (mainly excess) Excess Excess Phlegm-mucous from spleen deficiency; water dampness with cold Blood deficiency with water dampness Qi stagnationLiver yang transforming into wind with some spleen qi deficiency and phlegm damp Blood heat Excess or damp-heat and blood deficiency Joint disorder of the three yang warps Heat toxin flooding the triple burner Blood stasis and water accumulation Blood accumulation in the lower abdomen Palpitations; dizziness (orthostatic); mild oedema; tinnitus; shortness of breath; flushingsweating; and headache; profuse soft abdominal wallperiumbilical with sensation Dizziness; palpitations; shortness of breath;discomfort; substernal headaches; reduced urinary output; tinnitus; twitching; headrushes; substernal splashing sounds; mild upper abdominal rectus tension Dry lustreless skin; menstrual disorders;headrush bleeding; syndrome; skin problems markedredness by and dryness, itching; inflammatory conditions;irritability; anxiety; restlessness; insomnia; blood stasis signs muscular tension in neck andrubor shoulder tinnitus; area; thirst; ocular nervousness; irritability; insomnia; eye fatigue or pain; poor appetite Uprushing, palpitations, headache, dizziness, backlike feels burnt, intense heat, sweating,restlessness, depression, long-term insomnia, constipation Headrush syndrome; inflammatory conditions; irritability; restlessness; insomnia; thirst; badbitter breath; taste; distress in upperbleeding; abdomen unusual or warmth chest; may acute bechest palpable in centre of Strong constitution, red complexion, headaches, dizziness, abdominal pain, shoulder pain,abdominal palpitations, fullness, resistance to pressureon or palpation even of pain lower abdomen, irregular menstruation Signs of heat excess; tendencyheadrush towards syndrome; constipation; tendency toward skindark problems; coloured urine; firm abdomencontour with rounded Strong constitution, restless mind, irritabilityrestlessness, and easily angered, palpitations, insomnia, tight distension in epigastric areapalpation that is painful upon Hardness or palpable masses instools lower with abdomen; normal dark urination; mania;nosebleeds heat in head; ) Headrushes; headache or heavy-headedness; dizziness; ˆ an ) lian ) chai wen ) nu shen ) ˆ u li tang gou teng s ˆ um ling gui zhu gan fang feng tong sheng Kampo treatment of hot flushes ) ) ın ˆ ın ˆ ) tao he cheng qi tang ) ) ˆ ˆ an an huang lian jie du tang gui zhi fu ling wan zhu y qing y atractylodes, and licorice decoction ( tang s ( ( Qi ( powder ( s oyster shell decoction ( hu jia long g String of pearls beverage ( Uncaria powder ( Warm clearing beverage ( Poria, cinnamon twig, white Coptis toxin resolving decoction Cinnamon twig and poria pill Female spirit powder ( Table 3 Name of formulaPeach pit decoction to order the Syndrome Pathophysiology Excess or deficiency Ledebouriella sage-inspired Bupleurum plus dragon bone and 64 V. Scheid

on the treatment of menopausal disorders written for a western audience.50 While these texts do not represent an exhaustive listing of all Kampo styles, they suffice for the purposes of the comparisons I wish to make.g The precise indication of the formulas used cannot be discussed here in detail. Columns 3 and 4 clearly demonstrate, however, how the mainstream Kampo approach differs from that of mainstream Deficiency Mixed (mainly deficiency) TCM. These differences can be summed up in three points: (i) The Kampo approach does not focus on the treatment of Kidney deficiency; (ii) a significant number of formulas focus on the treatment of excess rather than deficiency; and (iii) the formulas used in Kampo medicine and those recommended in TCM do not generally overlap. This implies that even though it draws on the same medical literature and thus is part of the same larger medical tradition, Kampo and TCM treat menopausal syndrome in significantly different — and sometimes diamet- rically opposed — ways. Floating of empty yang with insufficiency of qi and blood Liver blood deficiency with heat from constraint Blood and qi deficiency Deficiency Besides differences in the experience of menopause by women in China and Japan, at least two other factors may be responsible. For historical reasons explored by Lock, many Japanese gynaecologists do not share the biomedical view of menopause as an oestrogen deficiency disorder. Instead, they perceive symptoms experienced by women during perimenopause as signs of autonomic nervous system imbalances. It is likely that this perspectives also shaped the views of Kampo physicians (all of whom are trained in conventional medicine before specializing in Kampo), particularly as there exists a close affinity between the idea of autonomic nervous system imbalance and the concern for harmony that underpins all styles of Chinese medicine.18 A second important factor are essential differences in how TCM and Kampo practitioners match formulas to presenting complaints. In TCM treatment protocols are formulated on the basis of theories that physicians hold regarding the patho- Fatigue; cold extremities; vasomotor symptoms; frequent urination; neurotic symptoms; periumbilical sensation; thin abdominal wall withrectus lower tension or general Weak constitution, shoulder aches andtired, pain, irritability, easily easily angered, restlessvexation, mind, flushed heat red cheeks, dizziness, insomnia Relatively weak constitution, cold boody,easily anaemic, tired, occasional sensations ofabdomen, pain heavy in head, the dizziness, lower shouldertinnitus, pain, palpitations, abdominal diagnosis revealsof lack strength physiology of a given condition. Kampo physicians, on the other hand, utilize a phenomenological approach that directly matches a patient’s symptoms and signs to the manifestation patterns

) deﬁned for speciﬁc herbal formulas. A Kampo ) ˆ an physician thus would simply determine a woman ˆ an )

) as exhibiting a ‘‘Cinnamon Twig and Poria Pill manifestation pattern’’ (Guizhi fuling tang zheng gui zhi jia ) with the diagnosis specifying the ˆ u li tang treatment. The ideal TCM practitioner, on the other Contunued ˆ um jia wei xiao yao s dang gui shao yao s plus dragon bone, and oyster shell ( long g ( ( g For another text that lists essentially the same formulas see Cinnamon twig decoction Table 3 ( Name of formulaAugmented rambling powder SyndromeFrom Ref. 50, p. 103. Pathophysiology Excess or deﬁciency Tangkuei and peony powder Ref.51. Traditional Chinese medicine—–What are we investigating? 65

Table 4 Formulas for the treatment of menopausal syndrome used at Kyung Hee University Oriental Medicine Hospital, Seoul Name of formula Predominantly excess Name of formula Predominantly deficiency Pinellia and magnolia Excess (qi and phlegm) Four substance decoction (si Deficiency (blood) bark decoction (ban wu tang) with additions xia hou po tang) Female spirit powder Excess (qi) Tangkuei and peony powder Deficiency (blood) (nu shen san) (dang gui shao yao san) Augmented rambling Mixed (blood and qi Rhemannia decotion with six Deficiency (Kidney yin) powder (jia wei xiao deficiency, qi stagnation) ingredients (liu wei di yao san) huang tang) Cinnamon twig and Excess (blood stasis with Rhemannia decotion with Deficiency (Kidney yang) poria pill (gui zhi fu damp-cold) eight ingredients (ba wei ling wan) di huang tang) Clear the heart drink Mixed (heart fire excess with lotus seed with qi deficiency) (qing xin lian zi yin) From Ref. 52, p. 45.

hand, would deduce from the manifestation pat- ing menopausal syndrome within the wider Chi- tern (zheng ) a patho-mechanism (bingji ) nese medical tradition. Table 4, which lists the caused by a specific disease cause (bing yin ). formulas commonly employed in the gynaecology They would then devise a treatment strategy (fa department of Kyung Hee University Oriental Med- ) to re-establish normality of physiological pro- ical Hospital in Seoul, provides just one additional cess and select a matching formula (fang ) for perspective as well as further proof for my general this purpose. In modern practice, they often sim- thesis. Only 2 of the 10 formulas treat Kidney defi- ply match a disease type (xing ) with a formula ciency, while at least 5 treat excess syndromes.52 (fang ). Many of these formulas match those used in Kampo The historical relationship between these two medicine, others correspond to the Kidney tonics styles of practice is complex and need not con- employed in TCM. This may reflect clinical experi- cern us here. What is important, however, about ence. As likely, it is an expression of the historical Kampo’s traditional disinterest in theory is that influence that both China and Japan have exerted it is less easily recruited to biomedical models on Korea and its medicine. of disease. Hence, even where Kampo physicians The diversity of different approaches to develop new formulas for specific disorders like menopause within the Chinese medical tradition menopausal syndrome, they do not feel obliged even this very superficial account has uncovered to do so via the detour of Kidney deficiency. A is clearly at odds with the naturalist depiction of phenomenological approach proceeding from the menopause as Kidney deficiency afforded by TCM actual manifestations of a disorder also will be textbooks. Such naturalism, by definition, is blind more sensitive to local variations in the experi- to the origins of its own vision. It claims to repre- ence of menopause than one positing universal pro- sent the body as it is without realising that bodies cesses. Hence, western TCM textbooks simply — and — or at least the bodies that we can become aware according to the inner logic of the system justifiably of as human beings — are shaped by a multitude of — export treatment protocols from China to the other factors beside biology: by local cultures and West. Kampo textbooks written for western prac- climates, dietary regimes and social mores. What titioners, on the other hand, are essentially list- menopause suggests, therefore, is that social, ings of formulas and their associated manifestation cultural, and physical differences among diverse patterns. populations create distinctive ‘‘local biologies,’’ in which disease is experienced differently and in which people are subject to different health risks.h Conclusions for TCM and CAM research The biomedical approach to menopause, which is informed almost exclusively by attempts to under- Lack of space prevents me from discussing in similar detail other contemporary approaches to treat- h The term ‘‘local biologies’’ stems from Ref.53. 66 V. Scheid stand its biology, takes scant account of such vari- changed. For what I have shown for the case of ability. Portraying itself as scientific and value- menopause is true for other conditions, too. All free, its definition of menopause as hormonal defi- of TCM, and not merely some isolated parts, is a ciency is nevertheless profoundly ideological. It is modern reconfiguration of a greater tradition. This informed by an intrinsic gender bias that many tradition offers multiple understandings on almost women experience as harmful,9 and a perception of anything, from the nature of disease to how a spe- ageing as pathological that reflects values and not cific problem like menopause should be treated, facts. When modern TCM textbooks in China thus even if its practitioners agree on a small num- celebrate the insertion of menopausal syndrome ber of core ideas and concepts. Rather than mis- into the Chinese medical tradition as an impor- construing Chinese medicine as a static tradition tant step ‘‘in the historical development of Chi- that offers specific treatments for specific condi- nese medical science,’’54 they also, willingly or not, tions, CAM research must embrace the realistic and embrace this ideology. For this reason they only see evidence-based view that it is a ‘‘tradition to think a lack where for reasons that at least deserve explo- with.’’ That Chinese medicine as a whole can thus ration physicians and patients hitherto had made never be proven right or wrong, beneficial or not. other choices. What we can do is to embrace the core principles Western TCM practitioners, in turn, chose to of the Chinese medical tradition in order to distil think of such modern inventions as traditional from them specific therapeutic options that then knowledge and present as an alternative to can be evaluated using the principles of evidence- biomedicine what, in effect, is a product of its based research. increasing domination of TCM. As long as this myth The person who has most clearly elaborated of tradition legitimised Chinese medicine among an these concepts and their value for contemporary audience sharing the same longings, such blindness practice is the twentieth century literatus physi- may have served its purpose. Now, that the efficacy cian Xie Guan (1880—1950). His definition of of Chinese medicine is subjected to increasingly the Chinese medical tradition is widely embraced stringent tests it may prove to be deleterious to its by the Chinese medical community and constitutes survival. Let us imagine for a moment that a clinical the basis even of official government definitions of study designed to test whether a given protocol for TCM.19 I therefore offer Xie Guan’s own words as a treating Kidney yin deficiency brings relief to west- fitting conclusion. Written almost a century ago its ern women suffering from menopausal syndrome affinity to the notion of local biologies that modern finds that this is not the case. What are the con- researchers have arrived at through the examina- sequences? In a context where it is accepted that tion of menopause could not be closer. How this Kidney yin deficiency is the Chinese medicine view agenda can be translated into a practical research of menopause we draw the conclusion that Chi- program is a work-in-progress whose results will be nese medicine offers no benefits to perimenopausal published at a later date. women. If, on the other hand, we accept that the definition of menopause as Kidney yin deficiency ‘‘To sum up [one can say that] the essentials of is the consequence of a complex historical process medicine do not lie outside the four characters into which clinical experience has constituted only principle, methods, patterns and drugs. The human one input our conclusions will be quite different. body may tend towards depletion or repletion, We will readily accept that the Chinese medical tra- heat or cold. In each [respective case] one decides dition offers many other possibilities for conceiving upon warming or cooling, attacking or supplement- of menopause and that some of these alternatives ing [methods] and administers [corresponding] pre- may offer more fruitful avenues for treatment and scriptions to return it to a [state of] balance. All research. Such research, furthermore, would then these principles and methods can be used through- not merely be a passive process of testing given out all provinces and [also] all other countries. treatment protocols. Rather, it would acknowledge A person’s body may be strong or weak, old or that a first step in developing treatment protocols young. Disorders may be recent or long-standing, is to adopt them to the contexts of specific local light or serious. Climates may [vary between] cold biologies: that protocols for women in Japan may and warm, dry and moist. 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