main topic Wien Klin Wochenschr (2020) 132:260–273 https://doi.org/10.1007/s00508-020-01625-w A critical examination of the main premises of Traditional Chinese Medicine Michael Eigenschink · Lukas Dearing · Tom E. Dablander · Julian Maier · Harald H. Sitte Received: 9 December 2019 / Accepted: 26 February 2020 / Published online: 20 March 2020 © The Author(s) 2020 Summary Traditional Chinese Medicine (TCM) con- and agreement to current guidelines to achieve high- sists of a plethora of therapeutic approaches aiming quality research are of utmost relevance. Thereby, an- to both characterize and treat diseases. Its utiliza- cient knowledge of herbal species and concoctions tion has gained significant popularity in the western may serve as a possible treasure box rather than Pan- world and is even backed by the World Health Organi- dora’s box. zation’s decision to include TCM diagnostic patterns into the new revision of the International Classifica- Keywords Qi · Meridians · Acupuncture · Pulse tion of Diseases code, the global standard for diagnos- diagnostics · Tongue diagnostics tic health information. As these developments and potentially far-reaching decisions can affect modern Introduction healthcare systems and daily clinical work as well as wildlife conservation, its underlying factual basis must The origins of Traditional Chinese Medicine (TCM) be critically examined. This article therefore provides date back more than 4000 years. A first written compi- an overview of the evidence underlying the basic TCM lation of TCM was published as The Yellow Emperor’s concepts, such as Qi, meridians, acupuncture, pulse Inner Classic (Huangdi Neijing). This publication and tongue diagnostics as well as traditional herbal served as one of the first dogmatic sources for the ap- treatments. Moreover, it discusses whether scientific plication of TCM. The Huangdi Neijing comprises two literature on TCM reflects the current standard for ev- books which contain a number of treatises reflecting idence-based research, as described in good scientific on the basic and theoretical principles of TCM, as well practice and good clinical practice guidelines. Im- as its approach to diagnosis, acupuncture and thera- portantly, misinformation regarding the therapeutic peutic applications. Over the millennia, the Huangdi efficacy of animal-derived substances has lead and Neijing has been annotated and revised numerous currently leads to problems with wildlife preservation times; furthermore, it has been partly translated into and animal ethics. Nevertheless, the (re-)discovery of English to make the principles and foundation of artemisinin more than 50 years ago introduced a novel TCM available to interested practitioners and health- development in TCM: the commingling of Eastern and care professionals worldwide [1, 2]. Western medicine, the appreciation of both systems. A first western account of TCM was published in The need for more rigorous approaches, fulfilment of the eighteenth century, when the East Indian Com- pany brought both physicians and medically trained priests to China [3]; however, the communication be- M. Eigenschink · L. Dearing · T. E. Dablander · J. Maier · tween the evolving western medicine and TCM was H. H. Sitte () Institute of Pharmacology, Medical University Vienna, not exhaustive as an exchange of medicinal concepts Vienna, Austria rarely took place. Indeed, as noted by Nakayama [4], [email protected] anatomical studies and surgical operations were rela- tively uncommon in Chinese medicine because of the H. H. Sitte Center for Physiology and Pharmacology, Institute of Confucian tenets of the sacred body. With the princi- Pharmacology, Medical University Vienna, Waehringer ples of yin and yang, the five elements, the universal Straße 13A, 1090 Vienna, Austria energy “qi”, the meridians, the inclusion of environ- 260 A critical examination of the main premises of Traditional Chinese Medicine K main topic mental factors, such as wind, damp, hot and cold, tics: it is believed by TCM practitioners that the in- TCM appears as a philosophy that attempts to inte- terior of the human body is connected to its exterior grate mind, body, health and disease prevention by and therefore, tongue and pulse diagnosis serve as diverse practices. reference points to determine pathological changes The main principles of TCM have evolved over within the organism. TCM views the human body thousands of years and TCM practitioners also refer as a holistic unit where all parts are connected by to this vast and longstanding experience as a seal so-called channels and collaterals, the meridians, in of trust. TCM’s fundament is based on its holistic which the vital force Qi is believed to be distributed view, the principle of harmony, individuality, and the through the entire body. Qi has its roots in a philo- prevention and treatment of disease. Following these sophical theory, first described in The Analects of Con- principles, TCM uses unique diagnostic and thera- fucius [7]. The meridian system historically consists of peutic techniques, such as acupuncture, Tai Chi and 12 main meridians and, while subjected to many stud- Qi Gong as well as a plethora of plant and animal ies, has remained unmodified throughout the last two derivatives to restore health and prevent illness. millennia [8]. The rationale behind acupuncture treat- After World War II, a TCM modernization campaign ment builds on the philosophical foundations of Qi was set up: the leaders of “New China” put major and the meridians, which has been controversially dis- efforts into founding universities, hospitals and re- cussed since its inception. Nevertheless, acupuncture search institutes for the promotion of TCM [5]. The is a widely known and broadly applied TCM method, first phase led to a rapid increase in popularity and and therefore we discuss arguments regarding its effi- general importance of TCM, resembling a harbinger cacy, safety and utilization. for the larger changes that were about to follow. The Historically, the therapeutics used in TCM derive second phase was heralded in the 1980s by Deng Xi- from the Guidelines and details of materia medica (= aoping’s implementation of the Chinese economic re- Bencao gang mu), a book published during the Ming form, leading to the consolidation and continuous dynasty by the Chinese herbologist Li Shizhen. The growth of national networks as well as the beginning Bencao gang mu describes approximately 11,000 dif- of international recognition. Nonetheless, the acme ferent therapeutics and contains information about was reached during the third phase: in 2015, You- 1892 herbal remedies [9, 10]. Whilst mostly focus- you Tu was awarded the Nobel prize for the discov- ing on herbal remedies, evaluating their therapeu- ery of artemisinin [6]. Furthermore, TCM diagnostic tic potential and risk for pharmacointeractions, we patterns were included into the 11th revision of the In- also tried to provide a brief overview about ethical ternational Classification of Diseases1, which was ac- considerations regarding the utilization of therapeu- cepted by the WHO on 25 May 2019 and will come tics, deriving from endangered species such as the into effect on 1 January 2022. rhinoceros and the pangolin [11, 12]. The utilization We ascertained evidence in the field of TCM on the of these products, their inhumane production condi- basis of the following topics: (i) TCM publications, tions(e.g.retrievalofbeargall),aswellasthevio- (ii) TCM diagnostics, (iii) meridians and acupuncture, lation of the Convention on International Trade in En- and (iv) TCM remedies. It was our intended goal to dangered Species of Wild Fauna and Flora have been examine the most obvious and publicly visible ones. matters of recent animal welfare debates [13, 14]. First, we evaluated the increase in publication rates The critical analysis of TCM, its historical back- related to TCM, using data derived from the publicly ground and philosophical basis also encouraged available database PubMed2.Then,wesearchedfor us to evaluate our own, western, evidence-based highly cited TCM literature and analyzed their content medicine (EBM). This was insofar of importance, as for logical reasoning and scientific justification. In or- (i) we needed to compare TCM to “our” science- der to elucidate the quality of published articles we based medicine, (ii) it broadened our view for weak- performed a substantive analysis of the 100 most cited nesses in our own medical system and (iii) led us TCM publications available on PubMed. By using the to ascertain the evolution and development of EBM software Publish or Perish (Harzing, London, UK) we over time. Historically, Scotsman George Fordyce were able to constrain the publications between 2015 proposed the combination of evidence and medicine and 2019. Next, we assessed TCM’s most commonly in the middle of the eighteenth century; however, the applied diagnostic tools—tongue and pulse diagnos- first clinical studies were conducted in 1747 by an- other Scottish doctor, James Lind, who examined the use of vitamin C in scurvy in a systematic manner; the 1 World Health Organization: WHO. ICD-11 International Classi- Hungarian Ignaz Semmelweis solved the etiology of fication of Diseases in 11th revision. (homepage on the internet; childbed fever roughly 100 years later [15]. Lind, Sem- accessed Dec. 02.2019); available from: https://icd.who.int/en melweis and others in succession converted empirical 2 PubMED is a database of the National Center for Biotechnol- observation