Traditional Chinese medicine

Traces of therapeutic activities in China date from the Shang dynasty (14th–11th centuries BCE).[18] Though the Shang did not have a concept of "medicine" as distinct from other health practices, their oracular inscriptions on bones and tortoise shells refer to illnesses that affected the Shang royal family: eye disorders, toothaches, bloated abdomen, and such.[19] Shang elites usually attributed them to curses sent by their ancestors. There is currently no evidence that the Shang nobility used herbal remedies.[18]

Stone and bone needles found in ancient tombs led Joseph Needham to speculate that acupuncture might have been carried out in the Shang dynasty.[20][21] This being said, most historians now make a distinction between medical lancing (or bloodletting) and acupuncture in the narrower sense of using metal needles to attempt to treat illnesses by stimulating points along circulation channels ("meridians") in accordance with beliefs related to the circulation of "Qi".[20][21][22] The earliest evidence for acupuncture in this sense dates to the second or first century BCE.[18][20][21][23]

The Yellow Emperor's Inner Canon (Huangdi Neijing), the oldest received work of Chinese medical theory, was compiled during the Han dynasty around the first century BCE on the basis of shorter texts from different medical lineages.[20][21][24] Written in the form of dialogues between the legendary Yellow Emperor and his ministers, it offers explanations on the relation between humans, their environment, and the cosmos, on the contents of the body, on human vitality and pathology, on the symptoms of illness, and on how to make diagnostic and therapeutic decisions in light of all these factors.[24] Unlike earlier texts like Recipes for Fifty-Two Ailments, which was excavated in the 1970s from the Mawangdui tomb that had been sealed in 168 BCE, the Inner Canon rejected the influence of spirits and the use of magic.[21] It was also one of the first books in which the cosmological doctrines of Yinyang and the Five Phases were brought to a mature synthesis.[24]

The Treatise on Cold Damage Disorders and Miscellaneous Illnesses (Shang Han Lun) was collated by Zhang Zhongjing sometime between 196 and 220 CE; at the end of the Han dynasty.[25] Focusing on drug prescriptions rather than acupuncture,[26][27] it was the first medical work to combine Yinyang and the Five Phases with drug therapy.[18] This formulary was also the earliest public Chinese medical text to group symptoms into clinically useful "patterns" (zheng 證) that could serve as targets for therapy. Having gone through numerous changes over time, the formulary now circulates as two distinct books: the Treatise on Cold Damage Disorders and the Essential Prescriptions of the Golden Casket, which were edited separately in the eleventh century, under the Song dynasty.[28]

Nanjing or "Classic of Difficult Issues," originally called "The Yellow Emperor Eighty-one Nan Jing", ascribed to Bian Que in the eastern Han dynasty. This book was compiled in the form of question-and-answer explanations. A total of 81 questions have been discussed. Therefore, it is also called "Eighty-One Nan".[29] The book is based on basic theory and has also analyzed some disease certificates. Questions one to twenty-two is about pulse study, questions twenty-three to twenty-nine is about meridian study, questions thirty to forty-seven is related to urgent illnesses, questions forty-eight to sixty-one is related to serious diseases, questions sixty-two to sixty-eight is related to acupuncture points, and questions sixty-nine to eighty-one is related to the needlepoint methods.[29]

The book is credited as developing its own path, while also inheriting the theories from Huangdi Neijing. The content includes physiology, pathology, diagnosis, treatment contents, and a more essential and specific discussion of pulse diagnosis.[29] It has become one of the four classics for Chinese medicine practitioners to learn from and has impacted the medical development in China.[29]

Shennong Ben Cao Jing is one of the earliest written medical books in China. Written during the Eastern Han Dynasty between 200 and 250 CE, it was the combined effort of practitioners in the Qin and Han Dynasties who summarized, collected and compiled the results of pharmacological experience during their time periods. It was the first systematic summary of Chinese herbal medicine.[30] Most of the pharmacological theories and compatibility rules and the proposed "seven emotions and harmony" principle have played a role in the practice of medicine for thousands of years.[30] Therefore, it has been a textbook for medical workers in modern China.[30] The full text of Shennong Ben Cao Jing in English can be found online.[31]

In the centuries that followed, several shorter books tried to summarize or systematize the contents of the Yellow Emperor's Inner Canon. The Canon of Problems (probably second century CE) tried to reconcile divergent doctrines from the Inner Canon and developed a complete medical system centered on needling therapy.[26] The AB Canon of Acupuncture and Moxibustion (Zhenjiu jiayi jing 針灸甲乙經, compiled by Huangfu Mi sometime between 256 and 282 CE) assembled a consistent body of doctrines concerning acupuncture;[26] whereas the Canon of the Pulse (Maijing 脈經; c. 280) presented itself as a "comprehensive handbook of diagnostics and therapy."[26]

Around 900–1000 AD, Chinese were the first to develop a form of vaccination, known as variolation or inoculation, to prevent smallpox. Chinese physicians had realised that when healthy people were exposed to smallpox scab tissue, they had a smaller chance of being infected by the disease later on. The common methods of inoculation at the time was through crushing smallpox scabs into powder and breathing it through the nose.[32]

Prominent medical scholars of the post-Han period included Tao Hongjing (456–536), Sun Simiao of the Sui and Tang dynasties, Zhang Jiegu (c. 1151–1234), and Li Shizhen (1518–1593).

In 1950, Chinese Communist Party (CCP) chairman Mao Zedong announced support of traditional Chinese medicine, but he did not personally believe in and did not use it.[17] In 1952, the president of the Chinese Medical Association said that, "This One Medicine, will possess a basis in modern natural sciences, will have absorbed the ancient and the new, the Chinese and the foreign, all medical achievements—and will be China's New Medicine!"[17]

During the Cultural Revolution (1966–1976) the CCP and the government emphasized modernity, cultural identity and China's social and economic reconstruction and contrasted them to the colonial and feudal past. The government established a grassroots health care system as a step in the search for a new national identity and tried to revitalize traditional medicine and made large investments in traditional medicine to try to develop affordable medical care and public health facilities.[6] The Ministry of Health directed health care throughout China and established primary care units. Chinese physicians trained in Western medicine were required to learn traditional medicine, while traditional healers received training in modern methods. This strategy aimed to integrate modern medical concepts and methods and revitalize appropriate aspects of traditional medicine. Therefore, traditional Chinese medicine was re-created in response to Western medicine.[6]

Apothecary mixing Traditional Chinese Medicine at Jiangsu Chinese Medical Hospital, Nanjing, China.

In 1968, the CCP supported a new system of health care delivery for rural areas. Villages were assigned a barefoot doctor (a medical staff with basic medical skills and knowledge to deal with minor illnesses) responsible for basic medical care. The medical staff combined the values of traditional China with modern methods to provide health and medical care to poor farmers in remote rural areas. The barefoot doctors became a symbol of the Cultural Revolution, for the introduction of modern medicine into villages where traditional Chinese medicine services were used.[6]

In the second decade of the twenty-first century, Chinese Communist Party general secretary Xi Jinping strongly supported TCM, calling it a "gem". As of May 2011, in order to promote TCM worldwide, China had signed TCM partnership agreements with over 70 countries.[33] His government pushed to increase its use and the number of TCM-trained doctors and announced that students of TCM would no longer be required to pass examinations in Western medicine. Chinese scientists and researchers, however, expressed concern that TCM training and therapies would receive equal support with Western medicine. They also criticized a reduction in government testing and regulation of the production of TCMs, some of which were toxic. Government censors have removed Internet posts that question TCM.[34]

At the beginning of Hong Kong's opening up, Western medicine was not yet popular, and Western medicine doctors were mostly foreigners; local residents mostly relied on Chinese medicine practitioners. In 1841, the British government of Hong Kong issued an announcement pledging to govern Hong Kong residents in accordance with all the original rituals, customs and private legal property rights.[35] As traditional Chinese medicine had always been used in China, the use of traditional Chinese medicine was not regulated.[36]

The establishment in 1870 of the Tung Wah Hospital was the first use of Chinese medicine for the treatment in Chinese hospitals providing free medical services.[37] As the promotion of Western medicine by the British government started from 1940,[38] Western medicine started being popular among Hong Kong population. In 1959, Hong Kong had researched the use of traditional Chinese medicine to replace Western medicine.[39]

Historians have noted two key aspects of Chinese medical history: understanding conceptual differences when translating the term 身, and observing the history from the perspective of cosmology rather than biology.[40]

In Chinese classical texts, the term 身 is the closest historical translation to the English word "body" because it sometimes refers to the physical human body in terms of being weighed or measured, but the term is to be understood as an "ensemble of functions" encompassing both the human psyche and emotions. This concept of the human body is opposed to the European duality of a separate mind and body.[40] It is critical for scholars to understand the fundamental differences in concepts of the body in order to connect the medical theory of the classics to the "human organism" it is explaining.[40]^: 20

Chinese scholars established a correlation between the cosmos and the "human organism." The basic components of cosmology, qi, yin yang and the Five Phase theory, were used to explain health and disease in texts such as Huangdi neijing.[40] Yin and yang are the changing factors in cosmology, with qi as the vital force or energy of life. The Five Phase theory (Wuxing) of the Han dynasty contains the elements wood, fire, earth, metal, and water. By understanding medicine from a cosmology perspective, historians better understand Chinese medical and social classifications such as gender, which was defined by a domination or remission of yang in terms of yin.

These two distinctions are imperative when analyzing the history of traditional Chinese medical science.

A majority of Chinese medical history written after the classical canons comes in the form of primary source case studies where academic physicians record the illness of a particular person and the healing techniques used, as well as their effectiveness.[40] Historians have noted that Chinese scholars wrote these studies instead of "books of prescriptions or advice manuals;" in their historical and environmental understanding, no two illnesses were alike so the healing strategies of the practitioner was unique every time to the specific diagnosis of the patient.[40] Medical case studies existed throughout Chinese history, but "individually authored and published case history" was a prominent creation of the Ming dynasty.[40] An example such case studies would be the literati physician, Cheng Congzhou, collection of 93 cases published in 1644.[40]

Yin and yang are ancient Chinese deductive reasoning concepts used within Chinese medical diagnosis which can be traced back to the Shang dynasty[61] (1600–1100 BCE). They represent two abstract and complementary aspects that every phenomenon in the universe can be divided into.[61] Primordial analogies for these aspects are the sun-facing (yang) and the shady (yin) side of a hill.[27] Two other commonly used representational allegories of yin and yang are water and fire.[61] In the yin–yang theory, detailed attributions are made regarding the yin or yang character of things:

The concept of yin and yang is also applicable to the human body; for example, the upper part of the body and the back are assigned to yang, while the lower part of the body is believed to have the yin character.[62] Yin and yang characterization also extends to the various body functions, and – more importantly – to disease symptoms (e.g., cold and heat sensations are assumed to be yin and yang symptoms, respectively).[62] Thus, yin and yang of the body are seen as phenomena whose lack (or over-abundance) comes with characteristic symptom combinations:

• Yin vacuity (also termed "vacuity-heat"): heat sensations, possible sweating at night, insomnia, dry pharynx, dry mouth, dark urine, and a "fine" and rapid pulse.[63]
• Yang vacuity ("vacuity-cold"): aversion to cold, cold limbs, bright white complexion, long voidings of clear urine, diarrhea, pale and enlarged tongue, and a slightly weak, slow and fine pulse.[62]

TCM also identifies drugs believed to treat these specific symptom combinations, i.e., to reinforce yin and yang.[27]

Interactions of Wu Xing

Strict rules are identified to apply to the relationships between the Five Phases in terms of sequence, of acting on each other, of counteraction, etc.[64] All these aspects of Five Phases theory constitute the basis of the zàng-fǔ concept, and thus have great influence regarding the TCM model of the body.[27] Five Phase theory is also applied in diagnosis and therapy.[27]

Correspondences between the body and the universe have historically not only been seen in terms of the Five Elements, but also of the "Great Numbers" (大數; dà shū)[67] For example, the number of acu-points has at times been seen to be 365, corresponding with the number of days in a year; and the number of main meridians–12–has been seen as corresponding with the number of rivers flowing through the ancient Chinese empire.[67][68]

Qi is a polysemous word that Traditional Chinese medicine distinguishes as being able to transform into many different qualities of qi (气; 氣; qì).[76] In a general sense, qi is something that is defined by five "cardinal functions":[76]

1. Actuation (推动; 推動; tuīdòng) – of all physical processes in the body, especially the circulation of all body fluids such as blood in their vessels. This includes actuation of the functions of the zang-fu organs and meridians.
2. Warming (温煦; 溫煦; wēnxù) – the body, especially the limbs.
3. Defense (防御; fángyù) – against Exogenous Pathogenic Factors
4. Containment (固摄; 固攝; gùshè) – of body fluids, i.e., keeping blood, sweat, urine, semen, etc. from leakage or excessive emission.
5. Inter-transformationel (气化; 氣化; qìhuà) – of food, drink, and breath into qi, xue (blood), and jinye ("fluids"), and/or transformation of all of the latter into each other.

A lack of qi will be characterized especially by pale complexion, lassitude of spirit, lack of strength, spontaneous sweating, laziness to speak, non-digestion of food, shortness of breath (especially on exertion), and a pale and enlarged tongue.[62]

Qi is believed to be partially generated from food and drink, and partially from air (by breathing). Another considerable part of it is inherited from the parents and will be consumed in the course of life.

TCM uses special terms for qi running inside of the blood vessels and for qi that is distributed in the skin, muscles, and tissues between them. The former is called yingqi (营气; 營氣; yíngqì); its function is to complement xuè and its nature has a strong yin aspect (although qi in general is considered to be yang).[77] The latter is called weiqi (卫气; 衛氣; weìqì); its main function is defence and it has pronounced yang nature.[77]

Qi is said to circulate in the meridians. Just as the qi held by each of the zang-fu organs, this is considered to be part of the 'principal' qi of the body.[lower-alpha 2]

In contrast to the majority of other functional entities, xuè or xiě (血, "blood") is correlated with a physical form – the red liquid running in the blood vessels.[78] Its concept is, nevertheless, defined by its functions: nourishing all parts and tissues of the body, safeguarding an adequate degree of moisture, and sustaining and soothing both consciousness and sleep.[78]

Typical symptoms of a lack of xiě (usually termed "blood vacuity" [血虚; xiě xū]) are described as: Pale-white or withered-yellow complexion, dizziness, flowery vision, palpitations, insomnia, numbness of the extremities; pale tongue; "fine" pulse.[79]

Closely related to xuě are the jinye (津液; jīnyè, usually translated as "body fluids"), and just like xuě they are considered to be yin in nature, and defined first and foremost by the functions of nurturing and moisturizing the different structures of the body.[80] Their other functions are to harmonize yin and yang, and to help with the secretion of waste products.[81]

Jinye are ultimately extracted from food and drink, and constitute the raw material for the production of xuě; conversely, xuě can also be transformed into jinye.[80] Their palpable manifestations are all bodily fluids: tears, sputum, saliva, gastric acid, joint fluid, sweat, urine, etc.[82]

The zangfu (脏腑; 臟腑; zàngfǔ) are the collective name of eleven entities (similar to organs) that constitute the centre piece of TCM's systematization of bodily functions. The term zang refers to the five considered to be yin in nature—Heart, Liver, Spleen, Lung, Kidney—while fu refers to the six associated with yang—Small Intestine, Large Intestine, Gallbladder, Urinary Bladder, Stomach and San Jiao.[83] Despite having the names of organs, they are only loosely tied to (rudimentary) anatomical assumptions.[84] Instead, they are primarily understood to be certain "functions" of the body.[63][69] To highlight the fact that they are not equivalent to anatomical organs, their names are usually capitalized.

The zang's essential functions consist in production and storage of qi and xuě; they are said to regulate digestion, breathing, water metabolism, the musculoskeletal system, the skin, the sense organs, aging, emotional processes, and mental activity, among other structures and processes.[85] The fǔ organs' main purpose is merely to transmit and digest (傳化; chuán-huà)[86] substances such as waste and food.

Since their concept was developed on the basis of Wǔ Xíng philosophy, each zàng is paired with a fǔ, and each zàng-fǔ pair is assigned to one of five elemental qualities (i.e., the Five Elements or Five Phases).[87] These correspondences are stipulated as:

• Fire (火) = Heart (心; xīn) and Small Intestine (小腸; xiaǒcháng) (and, secondarily, Sānjiaō [三焦, "Triple Burner"] and Pericardium [心包; xīnbaò])
• Earth (土) = Spleen (脾; pí) and Stomach (胃; weì)
• Metal (金) = Lung (肺; feì) and Large Intestine (大腸; dàcháng)
• Water (水) = Kidney (腎; shèn) and Bladder (膀胱; pángguāng)
• Wood (木) = Liver (肝; gān) and Gallbladder (膽; dān)

The zàng-fǔ are also connected to the twelve standard meridians – each yang meridian is attached to a fǔ organ, and five of the yin meridians are attached to a zàng.[88] As there are only five zàng but six yin meridians, the sixth is assigned to the Pericardium, a peculiar entity almost similar to the Heart zàng.[88]

Acupuncture chart from the Ming dynasty (c. 1368–1644)

The meridians (经络, jīng-luò) are believed to be channels running from the zàng-fǔ in the interior (里, lǐ) of the body to the limbs and joints ("the surface" [表, biaǒ]), transporting qi and xuĕ.[89] TCM identifies 12 "regular" and 8 "extraordinary" meridians;[71] the Chinese terms being 十二经脉 (shí-èr jīngmài, lit. "the Twelve Vessels") and 奇经八脉 (qí jīng bā mài) respectively.[90] There's also a number of less customary channels branching from the "regular" meridians.[71]

Yin and yang were critical to the understanding of women's bodies, but understood only in conjunction with male bodies.[98] Yin and yang ruled the body, the body being a microcosm of the universe and the earth. In addition, gender in the body was understood as homologous, the two genders operating in synchronization.[92] Gender was presumed to influence the movement of energy and a well-trained physician would be expected to read the pulse and be able to identify two dozen or more energy flows.[99] Yin and yang concepts were applied to the feminine and masculine aspects of all bodies, implying that the differences between men and women begin at the level of this energy flow. According to Bequeathed Writings of Master Chu the male's yang pulse movement follows an ascending path in "compliance [with cosmic direction] so that the cycle of circulation in the body and the Vital Gate are felt...The female's yin pulse movement follows a defending path against the direction of cosmic influences, so that the nadir and the Gate of Life are felt at the inch position of the left hand".[100] In sum, classical medicine marked yin and yang as high and low on bodies which in turn would be labeled normal or abnormal and gendered either male or female.[94]

Bodily functions could be categorized through systems, not organs. In many drawings and diagrams, the twelve channels and their visceral systems were organized by yin and yang, an organization that was identical in female and male bodies. Female and male bodies were no different on the plane of yin and yang. Their gendered differences were not acknowledged in diagrams of the human body. Medical texts such as the Yuzuan yizong jinjian were filled with illustrations of male bodies or androgynous bodies that did not display gendered characteristics.[101]

As in other cultures, fertility and menstruation dominate female health concerns.[92] Since male and female bodies were governed by the same forces, traditional Chinese medicine did not recognize the womb as the place of reproduction. The abdominal cavity presented pathologies that were similar in both men and women, which included tumors, growths, hernias, and swellings of the genitals. The "master system," as Charlotte Furth calls it, is the kidney visceral system, which governed reproductive functions. Therefore, it was not the anatomical structures that allowed for pregnancy, but the difference in processes that allowed for the condition of pregnancy to occur.[92]

Traditional Chinese medicine's dealings with pregnancy are documented from at least the seventeenth century. According to Charlotte Furth, "a pregnancy (in the seventeenth century) as a known bodily experience emerged [...] out of the liminality of menstrual irregularity, as uneasy digestion, and a sense of fullness".[93] These symptoms were common among other illness as well, so the diagnosis of pregnancy often came late in the term. The Canon of the Pulse, which described the use of pulse in diagnosis, stated that pregnancy was "a condition marked by symptoms of the disorder in one whose pulse is normal" or "where the pulse and symptoms do not agree".[102] Women were often silent about suspected pregnancy, which led to many men not knowing that their wife or daughter was pregnant until complications arrived. Complications through the misdiagnosis and the woman's reluctance to speak often led to medically induced abortions. Cheng, Furth wrote, "was unapologetic about endangering a fetus when pregnancy risked a mother's well being".[93] The method of abortion was the ingestion of certain herbs and foods. Disappointment at the loss of the fetus often led to family discord.[93]

If the baby and mother survived the term of the pregnancy, childbirth was then the next step. The tools provided for birth were: towels to catch the blood, a container for the placenta, a pregnancy sash to support the belly, and an infant swaddling wrap.[103] With these tools, the baby was born, cleaned, and swaddled; however, the mother was then immediately the focus of the doctor to replenish her qi.[93] In his writings, Cheng places a large amount of emphasis on the Four Diagnostic methods to deal with postpartum issues and instructs all physicians to "not neglect any [of the four methods]".[93] The process of birthing was thought to deplete a woman's blood level and qi so the most common treatments for postpartum were food (commonly garlic and ginseng), medicine, and rest.[104] This process was followed up by a month check-in with the physician, a practice known as zuo yuezi.[105]

Infertility, not very well understood, posed serious social and cultural repercussions. The seventh-century scholar Sun Simiao is often quoted: "those who have prescriptions for women's distinctiveness take their differences of pregnancy, childbirth and [internal] bursting injuries as their basis."[98] Even in contemporary fuke placing emphasis on reproductive functions, rather than the entire health of the woman, suggests that the main function of fuke is to produce children.

Once again, the kidney visceral system governs the "source Qi", which governs the reproductive systems in both sexes. This source Qi was thought to "be slowly depleted through sexual activity, menstruation and childbirth."[98] It was also understood that the depletion of source Qi could result from the movement of an external pathology that moved through the outer visceral systems before causing more permanent damage to the home of source Qi, the kidney system. In addition, the view that only very serious ailments ended in the damage of this system means that those who had trouble with their reproductive systems or fertility were seriously ill.

According to traditional Chinese medical texts, infertility can be summarized into different syndrome types. These were spleen and kidney depletion (yang depletion), liver and kidney depletion (yin depletion), blood depletion, phlegm damp, liver oppression, and damp heat. This is important because, while most other issues were complex in Chinese medical physiology, women's fertility issues were simple. Most syndrome types revolved around menstruation, or lack thereof. The patient was entrusted with recording not only the frequency, but also the "volume, color, consistency, and odor of menstrual flow."[98] This placed responsibility of symptom recording on the patient, and was compounded by the earlier discussed issue of female chastity and honor. This meant that diagnosing female infertility was difficult, because the only symptoms that were recorded and monitored by the physician were the pulse and color of the tongue.[98]

In TCM, a disease has two aspects: "bìng" and "zhèng".[111] The former is often translated as "disease entity",[27] "disease category",[107] "illness",[111] or simply "diagnosis".[111] The latter, and more important one, is usually translated as "pattern"[27][107] (or sometimes also as "syndrome"[111]). For example, the disease entity of a common cold might present with a pattern of wind-cold in one person, and with the pattern of wind-heat in another.[27]

From a scientific point of view, most of the disease entities (病; bìng) listed by TCM constitute symptoms.[27] Examples include headache, cough, abdominal pain, constipation etc.[27][112]

Since therapy will not be chosen according to the disease entity but according to the pattern, two people with the same disease entity but different patterns will receive different therapy.[106] Vice versa, people with similar patterns might receive similar therapy even if their disease entities are different. This is called yì bìng tóng zhì, tóng bìng yì zhì (异病同治，同病异治; 'different diseases', 'same treatment', 'same disease', 'different treatments').[106]

In TCM, "pattern" (证; zhèng) refers to a "pattern of disharmony" or "functional disturbance" within the functional entities of which the TCM model of the body is composed.[27] There are disharmony patterns of qi, xuě, the body fluids, the zàng-fǔ, and the meridians.[111] They are ultimately defined by their symptoms and signs (i.e., for example, pulse and tongue findings).[106]

In clinical practice, the identified pattern usually involves a combination of affected entities[107] (compare with typical examples of patterns). The concrete pattern identified should account for all the symptoms a person has.[106]

The Six Excesses (六淫; liù yín,[62] sometimes also translated as "Pathogenic Factors",[113] or "Six Pernicious Influences";[69] with the alternative term of 六邪; liù xié, – "Six Evils" or "Six Devils")[69] are allegorical terms used to describe disharmony patterns displaying certain typical symptoms.[27] These symptoms resemble the effects of six climatic factors.[69] In the allegory, these symptoms can occur because one or more of those climatic factors (called 六气; liù qì, "the six qi")[65] were able to invade the body surface and to proceed to the interior.[27] This is sometimes used to draw causal relationships (i.e., prior exposure to wind/cold/etc. is identified as the cause of a disease),[65] while other authors explicitly deny a direct cause-effect relationship between weather conditions and disease,[27][69] pointing out that the Six Excesses are primarily descriptions of a certain combination of symptoms[27] translated into a pattern of disharmony.[69] It is undisputed, though, that the Six Excesses can manifest inside the body without an external cause.[27][62] In this case, they might be denoted "internal", e.g., "internal wind"[62] or "internal fire (or heat)".[62]

The Six Excesses and their characteristic clinical signs are:

1. Wind (风; fēng): rapid onset of symptoms, wandering location of symptoms, itching, nasal congestion, "floating" pulse;[65] tremor, paralysis, convulsion.[27]
2. Cold (寒; hán): cold sensations, aversion to cold, relief of symptoms by warmth, watery/clear excreta, severe pain, abdominal pain, contracture/hypertonicity of muscles, (slimy) white tongue fur, "deep"/"hidden" or "string-like" pulse,[114] or slow pulse.[69]
3. Fire/Heat (火; huǒ): aversion to heat, high fever, thirst, concentrated urine, red face, red tongue, yellow tongue fur, rapid pulse.[27] (Fire and heat are basically seen to be the same)[62]
4. Dampness (湿; shī): sensation of heaviness, sensation of fullness, symptoms of Spleen dysfunction, greasy tongue fur, "slippery" pulse.[69]
5. Dryness (燥; zào): dry cough, dry mouth, dry throat, dry lips, nosebleeds, dry skin, dry stools.[27]
6. Summerheat (暑; shǔ): either heat or mixed damp-heat symptoms.[62]

Six-Excesses-patterns can consist of only one or a combination of Excesses (e.g., wind-cold, wind-damp-heat).[65] They can also transform from one into another.[65]

For each of the functional entities (qi, xuĕ, zàng-fǔ, meridians etc.), typical disharmony patterns are recognized; for example: qi vacuity and qi stagnation in the case of qi;[62] blood vacuity, blood stasis, and blood heat in the case of xuĕ;[62] Spleen qi vacuity, Spleen yang vacuity, Spleen qi vacuity with down-bearing qi, Spleen qi vacuity with lack of blood containment, cold-damp invasion of the Spleen, damp-heat invasion of Spleen and Stomach in case of the Spleen zàng;[27] wind/cold/damp invasion in the case of the meridians.[106]

TCM gives detailed prescriptions of these patterns regarding their typical symptoms, mostly including characteristic tongue and/or pulse findings.[62][106] For example:

• "Upflaming Liver fire" (肝火上炎; gānhuǒ shàng yán): Headache, red face, reddened eyes, dry mouth, nosebleeds, constipation, dry or hard stools, profuse menstruation, sudden tinnitus or deafness, vomiting of sour or bitter fluids, expectoration of blood, irascibility, impatience; red tongue with dry yellow fur; slippery and string-like pulse.[62]

The process of determining which actual pattern is on hand is called 辩证 (biàn zhèng, usually translated as "pattern diagnosis",[27] "pattern identification"[62] or "pattern discrimination"[107]). Generally, the first and most important step in pattern diagnosis is an evaluation of the present signs and symptoms on the basis of the "Eight Principles" (八纲; bā gāng).[27][62] These eight principles refer to four pairs of fundamental qualities of a disease: exterior/interior, heat/cold, vacuity/repletion, and yin/yang.[62] Out of these, heat/cold and vacuity/repletion have the biggest clinical importance.[62] The yin/yang quality, on the other side, has the smallest importance and is somewhat seen aside from the other three pairs, since it merely presents a general and vague conclusion regarding what other qualities are found.[62] In detail, the Eight Principles refer to the following:

• Yin and yang are universal aspects all things can be classified under, this includes diseases in general as well as the Eight Principles' first three couples.[62] For example, cold is identified to be a yin aspect, while heat is attributed to yang.[62] Since descriptions of patterns in terms of yin and yang lack complexity and clinical practicality, though, patterns are usually not labeled this way anymore.[62] Exceptions are vacuity-cold and repletion-heat patterns, who are sometimes referred to as "yin patterns" and "yang patterns" respectively.[62]
• Exterior (表; biǎo) refers to a disease manifesting in the superficial layers of the body – skin, hair, flesh, and meridians.[62] It is characterized by aversion to cold and/or wind, headache, muscle ache, mild fever, a "floating" pulse, and a normal tongue appearance.[62]
• Interior (里; lǐ) refers to disease manifestation in the zàng-fǔ, or (in a wider sense) to any disease that can not be counted as exterior.[65] There are no generalized characteristic symptoms of interior patterns, since they'll be determined by the affected zàng or fǔ entity.[62]
• Cold (寒; hán) is generally characterized by aversion to cold, absence of thirst, and a white tongue fur.[62] More detailed characterization depends on whether cold is coupled with vacuity or repletion.[62]
• Heat (热; rè) is characterized by an absence of aversion to cold, a red and painful throat, a dry tongue fur and a rapid and floating pulse if it falls together with an exterior pattern.[62] In all other cases, symptoms depend on whether heat is coupled with vacuity or repletion.[62]
• Deficiency (虚; xū), can be further differentiated into deficiency of qi, xuě, yin and yang, with all their respective characteristic symptoms.[62] Yin deficiency can also cause "empty-heat".[63]
• Excess (实; shí) generally refers to any disease that can't be identified as a deficient pattern, and usually indicates the presence of one of the Six Excesses,[65] or a pattern of stagnation (of qi, xuě, etc.).[115] In a concurrent exterior pattern, excess is characterized by the absence of sweating.[62]

After the fundamental nature of a disease in terms of the Eight Principles is determined, the investigation focuses on more specific aspects.[62] By evaluating the present signs and symptoms against the background of typical disharmony patterns of the various entities, evidence is collected whether or how specific entities are affected.[62] This evaluation can be done

1. in respect of the meridians (经络辩证; jīngluò biàn zhèng)[107]
2. in respect of qi (气血辩证,; qì xuè biàn zhèng)[107]
3. in respect of xuè (气血辩证; qì xuè biàn zhèng)[107]
4. in respect of the body fluids (津液辩证; jīnyè biàn zhèng)[107]
5. in respect of the zàng-fǔ (脏腑辩证; zàngfǔ biàn zhèng)[107] – very similar to this, though less specific, is disharmony pattern description in terms of the Five Elements [五行辩证; wǔ xíng biàn zhèng][106])

There are also three special pattern diagnosis systems used in case of febrile and infectious diseases only ("Six Channel system" or "six division pattern" [六经辩证; liù jīng biàn zhèng]; "Wei Qi Ying Xue system" or "four division pattern" [卫气营血辩证; weì qì yíng xuè biàn zhèng]; "San Jiao system" or "three burners pattern" [三焦辩证; sānjiaō biàn zhèng]).[106][111]

Although TCM and its concept of disease do not strongly differentiate between cause and effect,[69] pattern discrimination can include considerations regarding the disease cause; this is called 病因辩证 (bìngyīn biàn zhèng, "disease-cause pattern discrimination").[107]

There are three fundamental categories of disease causes (三因; sān yīn) recognized:[62]

1. external causes: these include the Six Excesses and "Pestilential Qi".[62]
2. internal causes: the "Seven Affects" (七情; qī qíng,[62] sometimes also translated as "Seven Emotions"[69]) – joy, anger, brooding, sorrow, fear, fright and grief.[69] These are believed to be able to cause damage to the functions of the zàng-fú, especially of the Liver.[62]
3. non-external-non-internal causes: dietary irregularities (especially: too much raw, cold, spicy, fatty or sweet food; voracious eating; too much alcohol),[62] fatigue, sexual intemperance, trauma, and parasites (虫; chóng).[62]

Examination of the tongue and the pulse are among the principal diagnostic methods in TCM. Details of the tongue, including shape, size, color, texture, cracks, teeth marks, as well as tongue coating are all considered as part of tongue diagnosis. Various regions of the tongue's surface are believed to correspond to the zàng-fŭ organs. For example, redness on the tip of the tongue might indicate heat in the Heart, while redness on the sides of the tongue might indicate heat in the Liver.[117]

Pulse palpation involves measuring the pulse both at a superficial and at a deep level at three different locations on the radial artery (Cun, Guan, Chi, located two fingerbreadths from the wrist crease, one fingerbreadth from the wrist crease, and right at the wrist crease, respectively, usually palpated with the index, middle and ring finger) of each arm, for a total of twelve pulses, all of which are thought to correspond with certain zàng-fŭ. The pulse is examined for several characteristics including rhythm, strength and volume, and described with qualities like "floating, slippery, bolstering-like, feeble, thready and quick"; each of these qualities indicates certain disease patterns. Learning TCM pulse diagnosis can take several years.[118]

There are roughly 13,000 compounds used in China and over 100,000 TCM recipes recorded in the ancient literature.[124] Plant elements and extracts are by far the most common elements used.[125] In the classic Handbook of Traditional Drugs from 1941, 517 drugs were listed – out of these, 45 were animal parts, and 30 were minerals.[125]

Some animal parts used include cow gallstones,[126] hornet nests,[127] leeches,[128] and scorpion.[129] Other examples of animal parts include horn of the antelope or buffalo, deer antlers, testicles and penis bone of the dog, and snake bile.[130] Some TCM textbooks still recommend preparations containing animal tissues, but there has been little research to justify the claimed clinical efficacy of many TCM animal products.[130]

Some compounds can include the parts of endangered species, including tiger bones[131] and rhinoceros horn[132] which is used for many ailments (though not as an aphrodisiac as is commonly misunderstood in the West).[133] The black market in rhinoceros horns (driven not just by TCM but also unrelated status-seeking) has reduced the world's rhino population by more than 90 percent over the past 40 years.[134] Concerns have also arisen over the use of pangolin scales,[135] turtle plastron,[136] seahorses,[137] and the gill plates of mobula and manta rays.[138]

Poachers hunt restricted or endangered species to supply the black market with TCM products.[139][140] There is no scientific evidence of efficacy for tiger medicines.[139] Concern over China considering to legalize the trade in tiger parts prompted the 171-nation Convention on International Trade in Endangered Species (CITES) to endorse a decision opposing the resurgence of trade in tigers.[139] Fewer than 30,000 saiga antelopes remain, which are exported to China for use in traditional fever therapies.[140] Organized gangs illegally export the horn of the antelopes to China.[140] The pressures on seahorses (Hippocampus spp.) used in traditional medicine is enormous; tens of millions of animals are unsustainably caught annually.[120] Many species of syngnathid are currently part of the IUCN Red List of Threatened Species or national equivalents.[120]

Since TCM recognizes bear bile as a treatment compound, more than 12,000 asiatic black bears are held in bear farms. The bile is extracted through a permanent hole in the abdomen leading to the gall bladder, which can cause severe pain. This can lead to bears trying to kill themselves. As of 2012, approximately 10,000 bears are farmed in China for their bile.[141] This practice has spurred public outcry across the country.[141] The bile is collected from live bears via a surgical procedure.[141] As of March 2020 bear bile as ingredient of Tan Re Qing injection remains on the list of remedies recommended for treatment of "severe cases" of COVID-19 by National Health Commission of China and the National Administration of Traditional Chinese Medicine.[142]

The deer penis is believed to have therapeutic benefits according to traditional Chinese medicine. Tiger parts from poached animals include tiger penis, believed to improve virility, and tiger eyes.[143] The illegal trade for tiger parts in China has driven the species to near-extinction because of its popularity in traditional medicine.[144][143] Laws protecting even critically endangered species such as the Sumatran tiger fail to stop the display and sale of these items in open markets.[145] Shark fin soup is traditionally regarded in Chinese medicine as beneficial for health in East Asia, and its status as an elite dish has led to huge demand with the increase of affluence in China, devastating shark populations.[146] The shark fins have been a part of traditional Chinese medicine for centuries.[147] Shark finning is banned in many countries, but the trade is thriving in Hong Kong and China, where the fins are part of shark fin soup, a dish considered a delicacy, and used in some types of traditional Chinese medicine.[148]

The tortoise (freshwater turtle, guiban) and turtle (Chinese softshell turtle, biejia) species used in traditional Chinese medicine are raised on farms, while restrictions are made on the accumulation and export of other endangered species.[149] However, issues concerning the overexploitation of Asian turtles in China have not been completely solved.[149] Australian scientists have developed methods to identify medicines containing DNA traces of endangered species.[150] Finally, although not an endangered species, sharp rises in exports of donkeys and donkey hide from Africa to China to make the traditional remedy ejiao have prompted export restrictions by some African countries.[151]

Dried human placenta (Ziheche (紫河车) is used in traditional Chinese medicine.[152]

Traditional Chinese medicine also includes some human parts: the classic Materia medica (Bencao Gangmu) describes (also criticizes) the use of 35 human body parts and excreta in medicines, including bones, fingernail, hairs, dandruff, earwax, impurities on the teeth, feces, urine, sweat, organs, but most are no longer in use.[153][154][155]

Human placenta has been used an ingredient in certain traditional Chinese medicines,[156] including using dried human placenta, known as "Ziheche", to treat infertility, impotence and other conditions.[152] The consumption of the human placenta is a potential source of infection.[156]

The traditional categorizations and classifications that can still be found today are:

• The classification according to the Four Natures (四气; sì qì): hot, warm, cool, or cold (or, neutral in terms of temperature)[27] and hot and warm herbs are used to treat cold diseases, while cool and cold herbs are used to treat heat diseases.[27]
• The classification according to the Five Flavors, (五味; wǔ wèi, sometimes also translated as Five Tastes): acrid, sweet, bitter, sour, and salty.[27] Substances may also have more than one flavor, or none (i.e., a "bland" flavor).[27] Each of the Five Flavors corresponds to one of zàng organs, which in turn corresponds to one of the Five Phases.[27] A flavor implies certain properties and therapeutic actions of a substance; e.g., saltiness drains downward and softens hard masses, while sweetness is supplementing, harmonizing, and moistening.[27]
• The classification according to the meridian – more precisely, the zàng-fu organ including its associated meridian – which can be expected to be primarily affected by a given compound.[27]
• The categorization according to the specific function mainly include: exterior-releasing[157] or exterior-resolving,[27] heat-clearing,[27][157] downward-draining,[157] or precipitating[27] wind-damp-dispelling,[27][157] dampness-transforming,[27][157] promoting the movement of water and percolating dampness[157] or dampness-percolating,[27] interior-warming,[27][157] qi-regulating[157] or qi-rectifying,[27] dispersing food accumulation[157] or food-dispersing,[27] worm-expelling,[27][157] stopping bleeding[157] or blood-stanching,[27] quickening the Blood and dispelling stasis[157] or blood-quickening,[27] transforming phlegm, stopping coughing and calming wheezing[157] or phlegm-transforming and cough- and panting-suppressing,[27] Spirit-quieting,[27][157] calming the liver and expelling wind[27] or liver-calming and wind-extinguishing[27] orifice-opening[27][157] supplementing[27][157] which includes qi-supplementing, blood-nourishing, yin-enriching, and yang-fortifying,[27] astriction-promoting[157] or securing and astringing,[27] vomiting-inducing,[157] and substances for external application.[27][157]

As of 2007 there were not enough good-quality trials of herbal therapies to allow their effectiveness to be determined.[44] A high percentage of relevant studies on traditional Chinese medicine are in Chinese databases. Fifty percent of systematic reviews on TCM did not search Chinese databases, which could lead to a bias in the results.[158] Many systematic reviews of TCM interventions published in Chinese journals are incomplete, some contained errors or were misleading.[159] The herbs recommended by traditional Chinese practitioners in the US are unregulated.[160]

• A 2013 review found the data too weak to support use of Chinese herbal medicine (CHM) for benign prostatic hyperplasia.[161]
• A 2013 review found the research on the benefit and safety of CHM for idiopathic sudden sensorineural hearing loss is of poor quality and cannot be relied upon to support their use.[162]
• A 2013 Cochrane review found inconclusive evidence that CHM reduces the severity of eczema.[163]
• The traditional medicine ginger, which has shown anti-inflammatory properties in laboratory experiments, has been used to treat rheumatism, headache and digestive and respiratory issues, though there is no firm evidence supporting these uses.[164]
• A 2012 Cochrane review found no difference in mortality rate among 640 SARS patients when Chinese herbs were used alongside Western medicine versus Western medicine exclusively, although they concluded some herbs may have improved symptoms and decreased corticosteroid doses.[165]
• A 2012 Cochrane review found insufficient evidence to support the use of TCM for people with adhesive small bowel obstruction.[166]
• A 2011 review found low quality evidence that suggests CHM improves the symptoms of Sjogren's syndrome.[167]
• A 2011 Cochrane review found inconclusive evidence to support the use of TCM herbal medicines for treatment of hypercholesterolemia.[168]
• A 2011 Cochrane review did not find improvement in fasting C-peptide when compared to insulin treatment for latent autoimmune diabetes in adults after 3 months. It is important to highlight that the studies available to be included in this review presented considerable flaws in quality and design.[169]
• A 2010 review found TCM seems to be effective for the treatment of fibromyalgia but the findings were of insufficient methodological rigor.[170]
• A 2008 Cochrane review found promising evidence for the use of Chinese herbal medicine in relieving painful menstruation, but the trials assessed were of such low methodological quality that no conclusion could be drawn about the remedies' suitability as a recommendable treatment option.[171]
• Turmeric has been used in traditional Chinese medicine for centuries to treat various conditions.[172] This includes jaundice and hepatic disorders, rheumatism, anorexia, diabetic wounds, and menstrual complications.[172] Most of its effects have been attributed to curcumin.[172] Research that curcumin shows strong anti-inflammatory and antioxidant activities have instigated mechanism of action studies on the possibility for cancer and inflammatory diseases prevention and treatment.[172] It also exhibits immunomodulatory effects.[172]
• A 2005 Cochrane review found insufficient evidence for the use of CHM in HIV-infected people and people with AIDS.[173]
• A 2010 Cochrane review found insufficient evidence to support the use of Traditional Chinese Herbal Products (THCP) in the treatment of angina.[174]
• A 2010 Cochrane review found no evidence supporting the use of TCHM for stopping bleeding from haemorrhoids. There was some weak evidence of pain relief.[175]

Artemisia annua, traditionally used to treat fever, has been found to have antimalarial properties.[2]

With an eye to the enormous Chinese market, pharmaceutical companies have explored creating new drugs from traditional remedies. The journal Nature commented that "claims made on behalf of an uncharted body of knowledge should be treated with the customary skepticism that is the bedrock of both science and medicine."[2]

There had been success in the 1970s, however, with the development of the antimalarial drug artemisinin, which is a processed extract of Artemisia annua, a herb traditionally used as a fever treatment.[2][176] Artemisia annua has been used by Chinese herbalists in traditional Chinese medicines for 2,000 years. In 1596, Li Shizhen recommended tea made from qinghao specifically to treat malaria symptoms in his Compendium of Materia Medica. Researcher Tu Youyou discovered that a low-temperature extraction process could isolate an effective antimalarial substance from the plant.[177] Tu says she was influenced by a traditional Chinese herbal medicine source, The Handbook of Prescriptions for Emergency Treatments, written in 340 by Ge Hong, which states that this herb should be steeped in cold water.[177] The extracted substance, once subject to detoxification and purification processes, is a usable antimalarial drug[176] – a 2012 review found that artemisinin-based remedies were the most effective drugs for the treatment of malaria.[178] For her work on malaria, Tu received the 2015 Nobel Prize in Physiology or Medicine. Despite global efforts in combating malaria, it remains a large burden for the population.[179] Although WHO recommends artemisinin-based remedies for treating uncomplicated malaria, resistance to the drug can no longer be ignored.[179][180]

Also in the 1970s Chinese researcher Zhang TingDong and colleagues investigated the potential use of the traditionally used substance arsenic trioxide to treat acute promyelocytic leukemia (APL).[181] Building on his work, research both in China and the West eventually led to the development of the drug Trisenox, which was approved for leukemia treatment by the FDA in 2000.[182]

Huperzine A, an extract from the herb, Huperzia serrata, is under preliminary research as a possible therapeutic for Alzheimer's disease, but poor methodological quality of the research restricts conclusions about its effectiveness.[183]

Ephedrine in its natural form, known as má huáng (麻黄) in TCM, has been documented in China since the Han dynasty (206 BCE – 220 CE) as an antiasthmatic and stimulant.[184] In 1885, the chemical synthesis of ephedrine was first accomplished by Japanese organic chemist Nagai Nagayoshi based on his research on Japanese and Chinese traditional herbal medicines[185]

Pien tze huang was first documented in the Ming dynasty.

A 2012 systematic review found there is a lack of available cost-effectiveness evidence in TCM.[51]

Galena (lead ore) is part of historical TCM.[186] Standard American TCM practice considers lead-containing herbs obsolete.[187]

From the earliest records regarding the use of compounds to today, the toxicity of certain substances has been described in all Chinese materiae medicae.[27] Since TCM has become more popular in the Western world, there are increasing concerns about the potential toxicity of many traditional Chinese plants, animal parts and minerals.[53] Traditional Chinese herbal remedies are conveniently available from grocery stores in most Chinese neighborhoods; some of these items may contain toxic ingredients, are imported into the U.S. illegally, and are associated with claims of therapeutic benefit without evidence.[188] For most compounds, efficacy and toxicity testing are based on traditional knowledge rather than laboratory analysis.[53] The toxicity in some cases could be confirmed by modern research (i.e., in scorpion); in some cases it could not (i.e., in Curculigo).[27] Traditional herbal medicines can contain extremely toxic chemicals and heavy metals, and naturally occurring toxins, which can cause illness, exacerbate pre-existing poor health or result in death.[189] Botanical misidentification of plants can cause toxic reactions in humans.[190] The description of some plants used in TCM has changed, leading to unintended poisoning by using the wrong plants.[190] A concern is also contaminated herbal medicines with microorganisms and fungal toxins, including aflatoxin.[190] Traditional herbal medicines are sometimes contaminated with toxic heavy metals, including lead, arsenic, mercury and cadmium, which inflict serious health risks to consumers.[191] Also, adulteration of some herbal medicine preparations with conventional drugs which may cause serious adverse effects, such as corticosteroids, phenylbutazone, phenytoin, and glibenclamide, has been reported.[190][192]

Substances known to be potentially dangerous include Aconitum,[27][53] secretions from the Asiatic toad,[188] powdered centipede,[193] the Chinese beetle (Mylabris phalerata),[194] certain fungi,[195] Aristolochia,[53] arsenic sulfide (realgar),[196] mercury sulfide,[197] and cinnabar.[198] Asbestos ore (Actinolite, Yang Qi Shi, 阳起石) is used to treat impotence in TCM.[199] Due to galena's (litharge, lead(II) oxide) high lead content, it is known to be toxic.[186] Lead, mercury, arsenic, copper, cadmium, and thallium have been detected in TCM products sold in the U.S. and China.[196]

To avoid its toxic adverse effects Xanthium sibiricum must be processed.[53] Hepatotoxicity has been reported with products containing Reynoutria multiflora (synonym Polygonum multiflorum), glycyrrhizin, Senecio and Symphytum.[53] The herbs indicated as being hepatotoxic included Dictamnus dasycarpus, Astragalus membranaceus, and Paeonia lactiflora.[53] Contrary to popular belief, Ganoderma lucidum mushroom extract, as an adjuvant for cancer immunotherapy, appears to have the potential for toxicity.[200] A 2013 review suggested that although the antimalarial herb Artemisia annua may not cause hepatotoxicity, haematotoxicity, or hyperlipidemia, it should be used cautiously during pregnancy due to a potential risk of embryotoxicity at a high dose.[201]

However, many adverse reactions are due to misuse or abuse of Chinese medicine.[53] For example, the misuse of the dietary supplement Ephedra (containing ephedrine) can lead to adverse events including gastrointestinal problems as well as sudden death from cardiomyopathy.[53] Products adulterated with pharmaceuticals for weight loss or erectile dysfunction are one of the main concerns.[53] Chinese herbal medicine has been a major cause of acute liver failure in China.[202]

The harvesting of guano from bat caves (yemingsha) brings workers into close contact with these animals, increasing the risk of zoonosis.[203] The Chinese virologist Shi Zhengli has identified dozens of SARS-like coronaviruses in samples of bat droppings.[204]

A 2013 editorial in the American journal Anesthesia and Analgesia stated that acupuncture studies produced inconsistent results, (i.e. acupuncture relieved pain in some conditions but had no effect in other very similar conditions) which suggests the presence of false positive results. These may be caused by factors like biased study design, poor blinding, and the classification of electrified needles (a type of TENS) as a form of acupuncture. The inability to find consistent results despite more than 3,000 studies, the editorial continued, suggests that the treatment seems to be a placebo effect and the existing equivocal positive results are the type of noise one expects to see after a large number of studies are performed on an inert therapy. The editorial concluded that the best controlled studies showed a clear pattern, in which the outcome does not rely upon needle location or even needle insertion, and since "these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work."[212]

According to the US NIH National Cancer Institute, a review of 17,922 patients reported that real acupuncture relieved muscle and joint pain, caused by aromatase inhibitors, much better than sham acupuncture.[213] Regarding cancer patients, The review hypothesized that acupuncture may cause physical responses in nerve cells, the pituitary gland, and the brain – releasing proteins, hormones, and chemicals that are proposed to affect blood pressure, body temperature, immune activity, and endorphin release.[213]

A 2012 meta-analysis concluded that the mechanisms of acupuncture "are clinically relevant, but that an important part of these total effects is not due to issues considered to be crucial by most acupuncturists, such as the correct location of points and depth of needling ... [but is] ... associated with more potent placebo or context effects".[214] Commenting on this meta-analysis, both Edzard Ernst and David Colquhoun said the results were of negligible clinical significance.[215][216]

A 2011 overview of Cochrane reviews found evidence that suggests acupuncture is effective for some but not all kinds of pain.[217] A 2010 systematic review found that there is evidence "that acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention" in the treatment of chronic low back pain.[218] Two review articles discussing the effectiveness of acupuncture, from 2008 and 2009, have concluded that there is not enough evidence to conclude that it is effective beyond the placebo effect.[219][220]

Acupuncture is generally safe when administered using Clean Needle Technique (CNT).[221] Although serious adverse effects are rare, acupuncture is not without risk.[221] Severe adverse effects, including very rarely death (5 case reports), have been reported.[222]

• Neigong: introspective and meditative
• Waigong: external energy and motion
• Donggong: dynamic or active
• Jinggong: tranquil or passive[227]

Acupuncture and moxibustion after cupping in Japan

Cupping (拔罐; báguàn) is a type of Chinese massage, consisting of placing several glass "cups" (open spheres) on the body. A match is lit and placed inside the cup and then removed before placing the cup against the skin. As the air in the cup is heated, it expands, and after placing in the skin, cools, creating lower pressure inside the cup that allows the cup to stick to the skin via suction.[228] When combined with massage oil, the cups can be slid around the back, offering "reverse-pressure massage".

Gua sha

Gua sha (刮痧; guāshā) is abrading the skin with pieces of smooth jade, bone, animal tusks or horns or smooth stones; until red spots then bruising cover the area to which it is done. It is believed that this treatment is for almost any ailment. The red spots and bruising take three to ten days to heal, there is often some soreness in the area that has been treated.[229]

Diē-dǎ (跌打) or Dit Da, is a traditional Chinese bone-setting technique, usually practiced by martial artists who know aspects of Chinese medicine that apply to the treatment of trauma and injuries such as bone fractures, sprains, and bruises. Some of these specialists may also use or recommend other disciplines of Chinese medical therapies if serious injury is involved. Such practice of bone-setting (正骨; 整骨) is not common in the West.

The concepts yin and yang are associated with different classes of foods, and tradition considers it important to consume them in a balanced fashion.

From 1 July 2012 Chinese medicine practitioners must be registered under the national registration and accreditation scheme with the Chinese Medicine Board of Australia and meet the Board's Registration Standards, to practice in Australia.[230]

TCM is regulated in five provinces in Canada: Alberta, British Columbia,[231] Ontario,[232] Quebec, and Newfoundland & Labrador.

The National Administration of Traditional Chinese Medicine was created in 1949, which then absorbed existing TCM management in 1986 with major changes in 1998.[233][234]

China's National People's Congress Standing Committee passed the country's first law on TCM in 2016, which came into effect on 1 July 2017. The new law standardized TCM certifications by requiring TCM practitioners to (i) pass exams administered by provincial-level TCM authorities, and (ii) obtain recommendations from two certified practitioners. TCM products and services can be advertised only with approval from the local TCM authority.[235]

During British rule, Chinese medicine practitioners in Hong Kong were not recognized as "medical doctors", which means they could not issue prescription drugs, give injections, etc. However, TCM practitioners could register and operate TCM as "herbalists".[236] The Chinese Medicine Council of Hong Kong was established in 1999. It regulates the compounds and professional standards for TCM practitioners. All TCM practitioners in Hong Kong are required to register with the council. The eligibility for registration includes a recognised 5-year university degree of TCM, a 30-week minimum supervised clinical internship, and passing the licensing exam.[237]

The Portuguese Macau government seldom interfered in the affairs of Chinese society, including with regard to regulations on the practice of TCM. There were a few TCM pharmacies in Macau during the colonial period. In 1994, the Portuguese Macau government published Decree-Law no. 53/94/M that officially started to regulate the TCM market. After the sovereign handover, the Macau S.A.R. government also published regulations on the practice of TCM. In 2000, Macau University of Science and Technology and Nanjing University of Traditional Chinese Medicine established the Macau College of Traditional Chinese Medicine to offer a degree course in Chinese medicine.[238]

In Macau, the legitimacy of Chinese medicine is not built upon "miracle making". Instead, it is achieved through a celebration of cultural tradition rejuvenated with discourses of nationalism and modernity, and through the mutual constructions of medical references between doctors and patients.[239]

In 2022, a new law regulating TCM, Law no. 11/2021, came into effect. The same law also repealed Decree-Law no. 53/94/M.[240][241]

The Chinese traditional medicine at one of Chinese traditional medicine shop at Jagalan Road, Surabaya, Indonesia.

All traditional medicines, including TCM, are regulated by Indonesian Minister of Health Regulation of 2013 on traditional medicine. Traditional medicine license (Surat Izin Pengobatan Tradisional – SIPT) is granted to the practitioners whose methods are recognized as safe and may benefit health.[242] The TCM clinics are registered but there is no explicit regulation for it. The only TCM method which is accepted by medical logic and is empirically proofed is acupuncture.[243] The acupuncturists can get SIPT and participate in health care facilities.[242]

Korea Institute of Oriental Medicine

Under the Medical Service Act (의료법/醫療法), an oriental medical doctor, whose obligation is to administer oriental medical treatment and provide guidance for health based on oriental medicine, shall be treated in the same manner as a medical doctor or dentist.[244]

The Korea Institute of Oriental Medicine is the top research center of TCM in Korea.

The Traditional and Complementary Medicine Bill was passed by parliament in 2012 establishing the Traditional and Complementary Medicine Council to register and regulate traditional and complementary medicine practitioners, including TCM practitioners as well as other traditional and complementary medicine practitioners such as those in traditional Malay medicine and traditional Indian medicine.[245]

The logo of the Dutch Association of Traditional Chinese Medicine (or 中 Zhong - Nederlandse Vereniging voor Traditionele Chinese Geneeskunde), the largest of the professional organisations that is recognised by private health insurance companies in the Netherlands.

There are no specific regulations in the Netherlands on TCM;[246] TCM is neither prohibited nor recognised by the government of the Netherlands.[247] Chinese herbs as well as Chinese herbal products that are used in TCM are classified as foods and food supplements, and these Chinese herbs can be imported into the Netherlands as well as marketed as such without any type registration or notification to the government.[247]

Despite its status, some private health insurance companies reimburse a certain amount of annual costs for acupuncture treatments, this depends on one's insurance policy, as not all insurance policies cover it, and if the acupuncture practitioner is or is not a member of one of the professional organisations that are recognised by private health insurance companies.[247] The recognized professional organizations include the Nederlandse Vereniging voor Acupunctuur (NVA), Nederlandse Artsen Acupunctuur Vereniging (NAAV), ZHONG, (Nederlandse Vereniging voor Traditionele Chinese Geneeskunde), Nederlandse Beroepsvereniging Chinese Geneeswijzen Yi (NBCG Yi), and Wetenschappelijke Artsen Vereniging voor Acupunctuur in Nederland (WAVAN).[248]

Although there are no regulatory standards for the practice of TCM in New Zealand, in the year 1990, acupuncture was included in the Governmental Accident Compensation Corporation (ACC) Act. This inclusion granted qualified and professionally registered acupuncturists to provide subsidised care and treatment to citizens, residents, and temporary visitors for work or sports related injuries that occurred within and upon the land of New Zealand. The two bodies for the regulation of acupuncture and attainment of ACC treatment provider status in New Zealand are Acupuncture NZ[249] and The New Zealand Acupuncture Standards Authority.[250][251]

The TCM Practitioners Act was passed by Parliament in 2000 and the TCM Practitioners Board was established in 2001 as a statutory board under the Ministry of Health, to register and regulate TCM practitioners. The requirements for registration include possession of a diploma or degree from a TCM educational institution/university on a gazetted list, either structured TCM clinical training at an approved local TCM educational institution or foreign TCM registration together with supervised TCM clinical attachment/practice at an approved local TCM clinic, and upon meeting these requirements, passing the Singapore TCM Physicians Registration Examination (STRE) conducted by the TCM Practitioners Board.[252]

National Research Institute of Chinese Medicine

In Taiwan, TCM practitioners are physicians and are regulated by the Physicians Act.They are able to diagnose, write prescriptions, and dispense Chinese medicine independently. Under current law, those who wish to qualify for the Chinese medicine exam must have obtained a 7-year university degree in TCM.[253]

The National Research Institute of Chinese Medicine, established in 1963, is the largest Chinese herbal medicine research center in Taiwan.[254]

As of July 2012, only six states lack legislation to regulate the professional practice of TCM: Alabama, Kansas, North Dakota, South Dakota, Oklahoma, and Wyoming. In 1976, California established an Acupuncture Board and became the first state licensing professional acupuncturists.[255]