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

Traditional Chinese medicine—–Whatare we investigating?The case of menopause�

Volker Scheid ∗

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

Available online 9 February 2006

KEYWORDSTraditional Chinesemedicine;Kampo;Traditional medicine;Menopause;Research design;Medical anthropology;

Summary CAM researchers commonly treat traditional medicines as unchang-ing systems. This article questions the validity of this approach by examining thetreatment of menopausal syndrome by traditional Chinese medicine (TCM). Suchtreatment strategies were invented in 1964 and betray a strong influence of biomed-ical thinking. While they determine TCM treatment of menopausal syndrome in theWest, physicians in China and Japan use many other treatment strategies from withinthe wider Chinese medical tradition in clinical practice. Cultural variability in themanifestation of menopausal syndrome furthermore questions the usefulness of sim-

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History of medicineply importing treatment strategies from China to the West. This leads me to concludethat 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

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Introduction

Eighty percent of women in the UK experiencemenopausal symptoms and 45% find the symp-toms distressing.1 An increasing awareness among

both health care providers and patients regardingpotential adverse effects associated with hormonereplacement therapy (HRT) is leading to strenu-

� The research on which this article is based was supportedby the DH-National Co-ordinating Centre for Research CapacityDevelopment (NCC RCD).

∗ Tel.: +44 20 7689 4764; fax: +44 20 7689 4764.E-mail address: scheidv@wmin.ac.uk.

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0965-2299 © 2006 Published by Elsevier Ltd.doi:10.1016/j.ctim.2005.12.002

Open access under CC BY lice

erventions that may then be assessed using methods of

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us efforts to find alternatives. This specificallyncludes the integration of complementary andlternative medicines (CAM) into treatment proto-ols tailored to women’s individual needs.1—3

Traditional Chinese medicine (TCM) appears toe a fruitful area to which such efforts might beirected. It offers a clear and systematic approacho the treatment of menopausal syndrome thatight readily be evaluated with the help of inno-

ative research protocols being developed in the

Open access under CC BY license.

ider field of CAM research.4,5 These protocolsre committed to establishing an evidence baseor CAM. They frequently group research sub-ects according to TCM diagnoses, or use TCM

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raditional Chinese medicine—–What are we investi

iagnoses in their analysis. This still leaves openhost of unresolved methodological difficulties,

.e. whether or not clinical interventions shoulde standardized. But they do provide a platformrom which such difficulties can be approached as‘technical’’ problems by experts who share com-on standards rather than as ‘‘conceptual’’ issues

hat divide groups of researchers on the basis ofdeological commitments.

From a sociological perspective, the develop-ent of such research protocols is indicative of aaturing discipline. Some commentators, in fact,

nterpret them as signs that traditional medicinesverywhere are ready to be integrated into a sin-le, global, and progressive medical system.6 Thisrticle seeks to challenge this analysis and the hid-en ideologies and value judgments that sustain it.sing the Chinese medical treatment of menopauses an example, I argue that a collective unwilling-ess among practitioners and researchers to criti-ally examine the myth of tradition that underpinshe discourse on TCM and CAM — even though thisritique is readily available in the anthropologi-al and historical literature — invalidates much ofhe research that is currently carried out and thatight be used to evaluate the TCM treatment ofenopausal syndrome.In particular, I wish to challenge the notion that

AM research is examining ‘‘Chinese medicine’’ orhat it will ever be able to do so. As we shallee, Chinese medicine is a living tradition. Likeiomedicine it offers multiple competing (if inter-elated) models for thinking about illness and suf-ering. Physicians and patients use these models toevelop treatment options that fit specific clinicalontexts and, in turn, shape the understanding Chi-ese medicine has of itself as a tradition.7 Gainingamiliarity with the complex histories that generatepecific treatment protocols, assessing the validityf these protocols in relation to local contexts oflinical practice, and the ability to define new pro-ocols through processes of creative developmentnd translation thus emerge as urgent priorities inhe field of Chinese medical research.

I will develop my critique in four steps. Irst examine the TCM diagnosis and treatment ofenopausal syndrome in the west. This demon-

trates significant consensus among TCM practition-rs regarding patho-physiology, diagnosis and treat-ent. It also shows that the further a practitioner

n either China or the west moves away from accesso primary sources, the more simplistic and system-

tic these theories and models become. In a secondtep I compare TCM to Chinese medicine as prac-iced in contemporary and late imperial China. Thisllows us to understand the development of treat-

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ent strategies for menopausal syndrome as con-ingent upon specific political factors in the Maoisthina of the early 1960s. It also provides us with annderstanding of the plurality of approaches to thereatment of menopausal syndrome within the Chi-ese medical tradition. Steps three and four con-extualize TCM treatments further by exploring theultural variability of menopausal experience andy presenting some Japanese Kampo approaches toenopausal syndrome. East Asian women experi-

nce menopause differently to women in the West,nd Kampo physicians respond to these differencesy utilizing traditional Chinese herbal medicine for-ulas in ways that is entirely different from theCM approach. In the final section I analyze whathe consequences of these observations are for CAMesearch on Chinese medicine and beyond.

raditional Chinese medicine (TCM)pproaches to menopause

or the purposes of this discussion I define TCMs that interpretation of Chinese medical practicehat is presented to us in contemporary Chineseedical textbooks.8(pp6—8),9(pp107—150) Emerging in

he late 1950s, these textbooks have been a corner-tone of state-directed efforts at modernizing Chi-ese medicine and integrating it into a larger healthare system. In China, TCM exerts a significant influ-nce on the practice of medicine through its dom-nance of educational curricula. Its influence onedical practice, however, is tempered by the con-

inued existence of alternative resources on whichlinicians can draw. These include direct access tohe classical medical literature, the transmissionf medical knowledge through personal master-isciple networks and lineages, and the historicallurality of the Chinese medical tradition.8,10 In theest, where such alternative resources are lack-

ng, TCM is thus widely perceived to constituteainland Chinese medicine as such, even if on the

evel of both teaching and practice TCM coexistsith a large number of hybrid practices created in

he course of the last 200 years by the complexiffusion of Chinese medicine to Europe and theest.56—59 This view is further enabled by a widely

hared cultural discourse that perceives of tradi-ions as homogenous, stable and unchanging. CAMesearch into Chinese medicine follows this trend,s TCM practices become the object of research

laiming to evaluate not singular interventions forgiven disorder, but ‘‘the TCM treatment’’ of this

isorder. TCM theories about menopause, its diag-osis and treatment of menopausal syndrome, and

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CAM research into these practices constitute a casestudy that confirms these general observations.

Most Western TCM textbooks and TCMteachers11,12 state that Chinese medicineattributes problems of menopause to Kidneydeficiency (shen xu ). In TCM the Kidneys(shen ) constitute a functional visceral system(zang ) to which are ascribed the regulation andsustenance of growth, maturation, and ageing.This system is sub-divided into two complementaryaspects. The actualizing dynamic of Kidney yang(shen yang ) is imagined as the driving forcesof all metabolic process. The endpoint of thisprocess, in turn, is the production of Kidney yin(shen yin ), which constitutes the structivepotential for the production of Kidney yang. Ageingin TCM is modelled as a diminishing vitality of thistransformative cycle caused by a decline of theessence (jing ), which is stored in the Kidneysand underpins the functions of both Kidney yinand yang. The actual manifestations of ageingare dependent upon the relative balance betweenyin and yang. If yin (associated with substance,tranquillity, and moisture) declines more rapidlythan yang, yang will be in relative excess produc-ing symptoms of excess activity like hot flushes,palpitations, insomnia, forgetfulness, or dryness. Ifyang (associated with activity, warmth, dynamic,and metabolic function) declines more rapidly thanyin, symptoms like fatigue, depression, chilliness,and oedema predominate.13(pp140—146,176—180)

Because the Kidneys sustain all metabolic pro-cesses, TCM assumes that Kidney pathology eventu-ally leads to dysfunction of other visceral systems.Hence, while Kidney deficiency is ‘‘always at theroot of menopausal problems’’11 it is often com-bined with secondary pathologies in practice. Thosepathologies may need to be addressed in treat-ment but it is Kidney deficiency that constitutesthe core of almost any TCM treatment protocolfor menopausal syndrome. ‘‘Chinese medicine,’’ asone of TCM’s most influential teachers in the Westnotes, ‘‘works by gently tonifying the Kidneys andthe Kidney-Essence to help the woman in this tran-sitional time of life.’’11

Given the prevalence of hot flushes in the pre-sentation of menopausal syndrome in the west, Kid-ney yin deficiency has come to be seen as the defin-ing feature of menopause among western TCM prac-titioners. ‘‘While all patients with menopause willhave Kidney yin deficiency,’’ writes an influentialTCM teacher, ‘‘many will have other associated con-

ditions that must be addressed.’’12 Communicatingsuch ideas to the wider public, they are further sim-plified. ‘‘In Traditional Chinese Medicine, or TCM,’’the University of Maryland Medical Center informs

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s on its webpage, ‘‘a woman is not generallyeferred to as ‘menopausal.’ Rather, a practitionerf TCM might say that she exhibits ‘[K]idney yineficiency.’”14 Reversely, because hot flushes areuch an emblematic and widely recognized symp-om, they can also be employed to communicate tootential patients (i.e. menopausal women) how aCM practitioner may label their condition, namely‘yin deficiency’’ (Fig. 1).

Research investigating how TCM practitionersiagnose menopausal women with vasomotor symp-oms shows that such understanding is not lim-ted to discourse but that it consistently informslinical practice. Zell et al.15 had a cohort of 23ostmenopausal women suffering from hot flushesndependently successively examined by nine TCMractitioners on the same day. Practitioners diag-osed Kidney yin deficiency after 168 of 207 visits81%). In 12 women (52%) the diagnosis Kidney yineficiency was made by eight of nine practitioners;n 16 women (70%) by seven of nine; while in all3 women (100%), at least five of nine practition-rs made this diagnosis. There was less agreementmong practitioners regarding secondary patternsf disharmony and thus about the final specificiagnosis. However, because treatment of the coreathology or ‘‘root’’ (ben) is considered the ulti-ate goal of treatment in TCM, such variation does

ot tend to fundamentally change the basic direc-ion of treatment in clinical practice.

Suggestions for treatment of menopausal syn-rome in the TCM literature, not surprisingly, areominated by formulas and treatment protocolshat tonify the Kidneys and in particular Kidney yinTable 1). The only CAM clinical study that uses TCMisease categories as determinants of treatment16

ikewise sorted menopausal women into Kidney yinnd Kidney yang deficient treatment groups. It thenmployed Liu wei di huang wan , theost widely used TCM formula for the tonifica-

ion of Kidney yin,17(pp263—266) as a base formula forreatment in both groups.

My overview of the TCM and CAM literature thusllows me to draw three conclusions, which confirmhe claims made in the introduction: (i) that TCMreatment of menopausal syndrome it is informedy a distinctive understanding of patho-physiologyeflected in distinctive diagnostic categories; (ii)hat this understanding is reflected in a broadonsensus among TCM practitioners regarding corereatment protocols; and (iii) that these diagnosticategories and treatment protocols are the most

ikely ones to orient CAM research.

The TCM literature makes it appear that itsnderstanding of menopause is an integral aspectf 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 ofdiagnosis to potential patients.

Table 1 The treatment of menopause in selected TCM textbooks

Textbook title Total number offormulassuggested

Formulas to treatKidneys

Formulas to treatKidney yin

Formula(s) forKidney yin mainformula(s)

Lecture Notes for ChineseMedicine Gynaecology20

3 2 1 Yes

Chinese MedicineGynaecology26

6 6 5 Yes

Understanding ChineseMedical GynaecologyThrough Tables28

2 2 1 Yes

Encyclopedia of Treatment inChinese MedicineGynaecology29

8 8 8 Yes

My Sister the Moon: TheDiagnosis and Treatment ofMenstrual Disease byTraditional ChineseMedicine

33 23 18 Yes

Obstetrics and Gynaecologyin Chinese Medicine11

18 14 13 Yes

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ing section, I will show that like TCM itself, theTCM understanding of menopause is a direct con-sequence of Chinese medical modernization.

The invention of menopause as amedical problem in TCM

In contemporary Chinese TCM textbooks dis-orders related to menopause are referred toas ‘‘manifestation patterns associated with thecessation of menstruation’’ (jingduan qianhouzhuzheng ) or ‘‘symptoms and signsassociated with the cessation of menstruation’’(jingduan qianhou zhenghou ). Inits visible difference from the biomedical term‘‘menopausal syndrome’’ (gengnianqi zonghezheng

), these terms seek to emphasize adifference of both focus and origin. In terms offocus, the TCM terms draw attention to the individ-ually specific constellation of symptoms into man-ifestation patterns (zheng ) that constitute oneof the core aspects of TCM self-definition.10 Interms of origin, the wording ‘‘cessation of menstru-ation’’ (jingduan ) is a term borrowed from theclassical Chinese medical literature. ‘‘Menopause’’(gengnianqi ), on the other hand, is a directborrowing from the Japanese term konenki, withwhich it shares the same characters, which in turnis a translation into Japanese of the German Kli-makterium from the early 20th century.18 As I haveshown elsewhere, such naming strategies estab-lish legitimizing attachments to past tradition formodern innovations even as they move the Chinesemedical body of process ever more closely to thebiomedical body of structure.19

In fact, neither of the two terms used to refer tomenopausal problems in TCM have any precedentin tradition. The first occurrence of ‘‘manifestationpatterns associated with the cessation of menstru-ation’’ — and thus the invention of menopause as aproblem for Chinese medicine — can be dated pre-cisely to the publication of the second revised edi-tion of Lecture Notes for Chinese Medicine Gynae-cology (Zhongyi fukexue jiangyi ) in1964. The fact that the first edition of the sametext, published in 1960, did not yet include a dis-cussion of menopause allows us to link its inventionas a distinctive medical problem of concern to TCM

physicians to the historical process that guided thecompilation of textbooks — and thereby of TCM —in early Maoist China.a

a The political emphasis on collectivity in early Maoist Chinaprevented the attribution of textbooks to individuals. The edit-ing of both texts was thus ascribed to the Chengdu College ofChinese Medicine (Chengdu zhongyi xueyuan ).

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Like the treatment of menopausal syndrome,extbooks emerged very late in the history of Chi-ese medicine. In the late 1950s, the Ministry ofealth embarked on a thorough investigation ofeaching materials, which culminated in a decisiono edit a series of national textbooks for the teach-ng of Chinese medicine in 1959.9 The explicit goalf this policy was to systematise Chinese medicinen a manner that would make it appear moreike biomedicine and thus legitimize its continuedxistence in the modern world. However, in theords of the historian Kim Taylor who has exam-

ned this policy in detail, it was also ‘‘a meansf mass-producing future doctors of the medicine,f controlling their knowledge and practice’’ that‘fundamentally altered the dynamics . . . of anyorm of medical innovation.’’9

The first edition of these textbooks was writ-en in 1959 by ‘‘teaching and research groups’’jiaoyanzu ) set up specifically for this pur-ose at various Chinese medical colleges. The Lec-ure Notes for Chinese Medicine Gynaecology20,21

ere compiled at the Chengdu College of Chineseedicine by a group led by Prof. Zeng Jingguang

(1918) building on teaching materials alreadysed at the College. These included a series ofandbooks published a year earlier jointly editedy Prof. Zeng and other experts from Chengdu.22,23

ne of the most influential of these was Zhuoichi , a son of the locally famous Chineseedicine gynaecology expert Zhuo Yunongho had himself studied biomedicine. Prof. Zengad been educated at one of the new collegesf ‘‘national medicine’’ (guoyi ) during theepublican era that sought to modernise Chineseedicine while keeping its essentials in tact. In dif-

erent ways, therefore, both Zeng Jingguang andhuo Qichi embodied the ‘‘integration of Chinesend Western medicine’’ actively promoted by theCP during the late 1950s under the orders of Maoedong himself.b

Having been compiled at break-neck speed, therst edition of the new national textbooks waslways intended to be provisional. It was there-ore replaced after only four years by a revised andnlarged second edition. Published in 1964, theseew lecture notes provided a framework for theeaching of Chinese medicine that remains influ-ntial to this date and that has been exportedround the world as TCM. The revised Lecture

otes for Chinese Medicine Gynaecology, onceore compiled in Chengdu, now discussed 44 rather

han as previously 34 different disorders (bing )

b My account in this and following paragraphs draws on theetailed biography of Prof. Zeng.21

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raditional Chinese medicine—–What are we investi

ccording to the new paradigm of ‘‘pattern differ-ntiation and treatment application’’ (bianzhenghizhi ). One of these new disorders was‘manifestation patterns associated with the cessa-ion of menstruation,’’ and Prof. Zeng Jingguang isoday credited with its invention.

The various influences on Prof. Zeng’s under-tanding of gynaecology are too complex for thosenfamiliar with the history of Chinese medicine toutline in detail. Suffice to say that they focusedn the physiology and pathology of the penetrat-ng (chongmai ) and conception vessels (renmai

), two broad physiological functions that duringhe Qing dynasty had become increasingly closelyssociated with the uterus as the core concern ofhinese medical gynaecology. Another influence,ndoubtedly, was biomedicine, assimilated duringraining programs run for Chinese medicine physi-ians in the early 1950s and at the new Chineseedicine hospitals constructed in the late 1950s.The early 1960s, furthermore, were a partic-

larly exciting time for those progressive physi-ians who embraced Mao Zedong’s idea of creat-ng a new medicine. Not only was their projectupported at the highest political level but initialesearch suggested that it might indeed be pos-ible to anchor Chinese medicine’s body of pro-ess in the more substantial realities of physicsnd biochemistry. The most influential work in thisespect was that of the Shanghai physician Cheniyin (1928), who established that patientsiagnosed as suffering from Kidney yang depletionshen yang xu ) had consistently low urine lev-ls of 17-hydroxicorticosteroid. This led him to pro-ose a correlation between Kidney yang depletionnd adrenal insufficiency.24 A connection betweenhe Kidneys and hormonal function was therebystablished in the Chinese medical imagination thatersists to this day even if 40 more years of researchave not fulfilled Chen’s dream of matching Chinesend biomedical pathology.c

These observations help us to understand whyenopause, which did not constitute a medicalroblem in the classical literature suddenly becamene in 1964 and why, given the biomedical focusn menopause as hormonal decline, Chinese physi-ians were tempted to interpret it as a problemf deficiency. In Prof. Zeng’s interpretation, how-

ver, menopause was not yet merely a problem ofidney yin but one of ‘‘debilitated Kidney qi andeficiency and harm to the penetrating and con-eption vessels’’ (shenqi shuairuo, chongren xusun

, ). This was to be treated by sup-

c For an overview of Chen Ziyin’s research and his influence onCM see the accounts by Ma Boying.23

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lementing Kidney qi and regulating penetratingnd conception vessels’’ (bu shenqi, tiao chongren

, ).This still left the problem of supporting the

ew interpretation with references to the classics,ithout which it could not have been considereduthentic Chinese medical knowledge. Prof. Zengid this by creating a link to chapter one of the Inneranon of the Yellow Lord: Basic Questions (Huangdieijing su wen ), the foundational textf the Chinese medical tradition.d Its first chapteriscusses the development, growth, and decline ofuman life in terms of seven-year cycles for femalesnd eight-year cycles for males. Regarding woment states:

‘When a woman is seven years old her Kidney qis vigorous. The teeth are replaced and the hairrows. At fourteen, fertility is established, the con-eption vessel is open, the great penetrating vessels vigorous, the menses flow, and she therefore canave children. At twenty-one, Kidney qi is fullyeveloped. The wisdom teeth appear and [physi-al] growth is complete. At twenty-eight the sinewsnd bones are firm, the hair reaches its greatestength, and the body is luxuriant. At thirty-five,he yang brightness vessel declines, the complexionries out, the hair begins to fall out. At forty-two,he three yang vessels decline above, the com-lexion is entirely dried out, the hair begins tourn white. At forty-nine, the conception vessel isepleted, the great penetrating vessel wanes, fer-ility is exhausted, menstruation ceases, the bodyas become old and she can no longer have chil-ren.’’25(p4)

Today’s gynaecology textbooks like the hugelynfluential Chinese Medicine Gynaecology (Zhongyiukexue ), generally only cite the lastentence of this passage before proceeding toxplain: ‘‘Around the cessation of menstruationhe Kidney qi gradually declines, . . . hence Kid-ey deficiency is the root cause of this disor-er.’’26(p161) The chief editor, Luo Yuankai1914—1995) from Guangdong, held a more narrowiew of menopause as Kidney deficiency than Zengingguang, who only was a deputy-editor, whichs duly reflected in this text.27(pp104—106) We thusnd here a further stage in the development of

he TCM understanding of menopausal syndrome.etached from Prof. Zeng’s personal focus on theenetrating and conception vessels, references to

d The dating of this text is difficult. Most of the source materialas probably written in the two centuries around the turn of

he millennia [BCE/CE], with its final compilation perhaps noteaching maturity until the Song dynasty.

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treating penetrating and conception vessels areremoved and replaced by the simplified emphasison Kidney deficiency that we also find in westernTCM texts.28(pp83—84),29(pp126—132) In broader histor-ical terms, this reduction of complexity follows thenew centring of Chinese medical practice on dis-ease ‘‘types’’ (xing ) rather than ‘‘manifestationpatterns’’ (zheng ), first advanced by the abovementioned Chen Ziyin in 1973 and widely appliedby modernising physicians since then.10

Not all Chinese medicine physicians, however,interpreted the passage from the Inner Cannon inthe same way. For although it defines growth anddevelopment as emanating from the vigour of Kid-ney qi, its account of decline emphasize beyond theconception and penetrating vessels the yang chan-nels, particularly yang brightness (yangming ).In clinical practice, therefore, many gynaecolo-gists emphasize treatment of the Kidneys only inyounger women, while for older women the Spleenand Stomach visceral systems, which are associatedwith are associated with both the yang brightnessand the penetrating vessel, are considered moreimportant. The influential Ming dynasty physicianWang Kentang (1549—1613), whose ideasshape the practice of many contemporary gynae-cologists, for instance writes:

‘‘During their childhood, before they menstruate[and are fertile], women’s [physiology] is subordi-nated to the lesser yin [i.e. the Kidneys]. When theymenstruate [and are fertile] it is subordinated tothe terminal yin [i.e. the Liver]. When menstrua-tion [and fertility] ceases, it is subordinated to thegreater yin [i.e. the Spleen].’’30(vol.6,p1)

The modern case record literature also providesmany examples of senior physicians approachingthe treatment of menopausal problems from a per-spective that does not accord priority to Kidneyfunction. The gynaecology expert Ha Litian(1912—1989), for instance, notes that in the treat-ment of menopausal disorders,‘‘. . . one must takethe regulation of the penetrating and conceptionvessels as the foundation. But in order to regu-late penetrating and conception vessels one mustregulate the visceral systems, harmonise qi andblood.’’31

Many other examples could be cited. My inten-tion, however, is not to document in detail thediverse approaches to menopausal syndrome thatmight be found in the literature. Rather, I wish to

call our intention to the complex history of inven-tion and reinterpretation that lies beyond the sur-face of matter-of-fact discussions of menopausefound in western TCM textbooks. What these dis-

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V. Scheid

ussions hide, too, is the plurality of approachesf treating menopausal distress in contemporaryhinese medical practice, which embody perspec-ives that differ from the narrow focus on Kidneyeficiency cited above. If the transmission of Chi-ese medicine that underpins much of current CAMesearch continues to rely on a simplified under-tanding of menopausal syndrome as Kidney defi-iency, then one of the reasons is the mistakenerception that textbooks prescribe actual clini-al practice, as well as a lack of access to primaryources of knowledge.

Another important reason, however, could beifferences between China and the west in howomen actually experience the menopausal tran-

ition. For as much modern research shows, thexperience of menopause as a life event every-here is shaped not only by a universal biology butlso by the distinctly local factors of culture andociety.

enopause and culture

f, like the Oxford English Dictionary,32 we defineenopause as ‘‘the permanent cessation of men-

truation’’ it is a species universal, which hap-ens sometime in the late forties or early fiftiesithout significant variations across cultures. If,n the other hand, we use menopause to mean‘the period of a woman’s life when this occurs’’32

this, too, being part of the OED definitionsubjective dimensions of experience embed-

ed in local cultures, ideologies and histories areoved to the fore.e Women in East Asian cul-

ures like Japan,33,34 Singapore,35 Hong Kong,36,37

aiwan,38,39 and Malaysia,40 for instance, do notenerally associate the menopausal transition withhe vasomotor symptoms (hot flushes) so emblem-tic of menopause in the west. Muscle and jointains, as well as depressed moods tend to berequently reported symptoms in these culturesut the majority of women does not considerenopause a problem requiring medical interven-

ion. This is reflected in a relatively low uptake ofRT in countries like Hong Kong,37,41 Japan,18 oraiwan.42

The reasons for such cultural difference are com-lex, multi-causal, and poorly understood. Besidesossible genetic differences, diet and lifestyle

oman to become older and how she is to man-ge the menopausal transition. Such perceptions

e These issues have been discussed in detail by the anthropol-gist Margaret Lock.18(pp32—38)

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raditional Chinese medicine—–What are we investi

re sites of contestation, shaped by diverse agen-ies and ideologies, and thus always in a processf transition themselves. In a sample of Ameri-an menopausal women interviewed by Martin inhe 1980s, older women, for instance, experiencedenopause as a potentiality allowing them to face

ife free of the burdens of reproduction. Youngeromen, in contrast, appeared to have internalised

he medical model of the menopausal body as beingut of control and requiring support.43 Contempo-ary middle-class Asian women increasingly reportymptoms that match those of Western women.hether this is due to a shift in bodily atten-

ion stemming from a desire to be modern (i.e.estern), or whether it denotes an escape fromhat Bulbeck calls the ‘‘midlife silence’’ of Asianomen — stemming from taboos concerning theiscussion of sexual issues including menstruation,ear of being criticized for failure of self-discipliner expressing ‘‘menopausal madness,’’ and lackf information concerning how to name symptomsnd lack of access to treatment — is open touestion.44

Whatever the reasons, such differences explainhy until the 1960s menopausal problems did notonstitute a topic of concern to Chinese physicians.s the medical historian Charlotte Furth observes,hese physicians did not even distinguish betweenale and female where matters of ageing were con-

erned:

‘What moderns would understand as menopause isdentified [in ancient Chinese medicine] in the sameay as menarche, simply as an event in the life pas-

age, similar in character if not in timing for malesnd females alike. Just as females cease to men-truate, males’ ‘semen becomes scanty’, and thesehanges are not seen as a ‘pathology’ but ‘part andarcel of the ungendered feebleness of old age.’’45

Hence, what problems required treatment wouldave been classed under other disease categoriesuch as ‘‘profuse uterine bleeding in old age’’nianlao xuebeng ), or one of the many dis-rders with a psychosomatic manifestation.f Alter-atively, they would have been treated within theamily by women knowledgeable about medicine,y midwives, or by religious based non-eliteedicine. These healers left few written records

nd their methods would be difficult in any case tontegrate into the rationalistic framework of mod-

rn TCM.

Even in contemporary Chinese medicine clin-cs women seeking help for menopausal problems

f This also is the opinion of modern Chinese TCM textbooks.

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re rare. The Shanghai gynaecology expert Caihuang 46(p100), for instance, estimates thatess than one in six (17%) of menopausal women inhis most westernized of Chinese cities suffer fromymptoms serious enough to require treatment.

survey of 500 menopausal women in Beijing47

bserved that while 47% of women experiencedenopausal symptoms, only 20% were taking treat-ent. The same survey reports that hot flushes,

xperienced by 23% of women, were the most com-only reported symptom. This compares with a rel-

tive high incidence of depressive symptoms amongerimenopausal women in China reported by Zhaot al.48 The authors of this study claim that 46%f these women suffer from depressive symptoms,ith 30% experiencing moderate or severe depres-

ion. The stigma attached to psychological disor-er in China may explain the discrepancy betweenhese figures.

The high incidence of depressive symptoms also,owever, calls into question the entire methodologyy which the TCM treatment for menopausal syn-rome was constructed. Rather than beginning withhe symptoms experienced by women in the clinic,his process took as its starting point a perception ofgeing as decline that needed to be rectified. Thisontrasts not only with the classical view as docu-ented by Furth,45 but also with the contemporary

pproach to the treatment of menopausal prob-ems by other (i.e. non-TCM) currents of Chineseedicine. An exploration of how menopausal syn-rome is treated by Kampo medicine, a Japaneseedical tradition based on the use of clas-

ical Chinese herbal formulas, elucidates thisifference.

he Kampo treatment of menopausalyndrome

ampo (lit. ‘‘formulas from the Han dynasty’’)esignates a current of traditional medicine prac-iced in contemporary Japan that evolved out ofapanese reinterpretations of Chinese medicine.ike traditional medicine in mainland China, Kampos multifaceted and multi-layered, consisting ofiverse competing currents and styles of practice,ften centred on charismatic teachers. The interre-ationship between Kampo and traditional Chineseedicine in China, too, is complex and involves

enturies of exchanges flowing in both directions.50

ables 2 and 3 list formulas recommended for thereatment of menopausal syndrome in two differ-nt texts: one from a Chinese survey of Kampoedicine,49 and the second from a Kampo textbook

62V.

Scheid

Table 2 Kampo formulas for the treatment of climacteric disorders

Name of formula Syndrome Pathophysiology Excess or deficiency

Pinellia and magnolia barkdecoction (ban xia hou potang)

A sensation of something being stuck in the throat,attacks of palpitations, hurried breathing, uprushing ofqi, chest pain, a soft abdomen, and splashing sound inthe epigastric area

Phlegm Excess

Licorice, wheat, and jujubedecoction (gan mai da zaotang)

Sad, cries easily, yawning, hysterical, insomnia Restless visceral systemdisorder

Deficiency

Three-yellow and drain theepigastrium decoction (sanhuang xie xin tang)

No decrease of physical power, upflaring of fire, flushedred cheeks, restless mind, constipation

Yang brightness warpexcess heat

Excess

Bupleurum plus dragon boneand oyster shell decoction(chai hu jia long gu mu litang)

Strong constitution, restless mind, irritability andrestlessness, easily angered, palpitations, insomnia,tight distension in epigastric area that is painful uponpalpation

Joint disorder of the threeyang warps

Excess

Augmented rambling powder(jia wei xiao yao san)

Weak constitution, shoulder aches and pain, easilytired, irritability, easily angered, restless mind, heatvexation, flushed red cheeks, dizziness, insomnia

Liver blood deficiencywith heat from constraint

Mixed (mainly deficiency)

Tangkuei and peony powder(dang gui shao yao san)

Relatively weak constitution, cold boody, anaemic,easily tired, occasional sensations of pain in the lowerabdomen, heavy head, dizziness, shoulder pain,tinnitus, palpitations, abdominal diagnosis reveals lackof strength

Blood and qi deficiencywith dampness

Deficiency

Restrain the liver powder (yigan san) two-cureddecoction (er chen tang)

Agitated, easily angered, restless sleep, soft and weakabdominal muscles, hyperactive aortic pulsation on theleft side of the abdomen, resistance to pressure or evenpain on palpation in left upper abdomen,

Blood deficiency withphlegm and wind-heat

Mixed (mainly deficiency)

Female spirit powder (nushen san)

Uprushing, palpitations, headache, dizziness, back feelslike burnt, intense heat, sweating, depression,restlessness, long-term insomnia, constipation

Qi stagnation Excess

Cinnamon twig and poria pill(gui zhi fu ling wan)

Strong constitution, red complexion, headaches,dizziness, abdominal pain, shoulder pain, palpitations,abdominal fullness, resistance to pressure or even painon palpation of lower abdomen, irregular menstruation

Blood stasis and wateraccumulation

Mixed (mainly excess)

Poria, cinnamon twig,licorice, and jujubedecoction (ling gui gan zaotang)

Attacks of palpitations in lower abdomen, uprushing ofqi from the lower abdomen to the heart and chest,accelerated breathing, dizziness, sweating from thehead, palpitations

Unstable qi in lower jiaodue to excess water

Mixed

From Ref. 49, p. 576.

TraditionalChinesem

edicine—–What

arew

einvestigating?

63

Table 3 Kampo treatment of hot flushes

Name of formula Syndrome Pathophysiology Excess or deficiency

Peach pit decoction to order theQi (tao he cheng qi tang)

Hardness or palpable masses in lower abdomen; darkstools with normal urination; mania; heat in head;nosebleeds

Blood accumulation in thelower abdomen

Excess

Ledebouriella sage-inspiredpowder (fang feng tong shengsan)

Signs of heat excess; tendency towards constipation;headrush syndrome; tendency toward skin problems;dark coloured urine; firm abdomen with roundedcontour

Excess

Bupleurum plus dragon bone andoyster shell decoction (chaihu jia long gu mu li tang)

Strong constitution, restless mind, irritability andrestlessness, easily angered, palpitations, insomnia,tight distension in epigastric area that is painful uponpalpation

Joint disorder of the threeyang warps

Excess

Coptis toxin resolving decoction(huang lian jie du tang)

Headrush syndrome; inflammatory conditions;irritability; restlessness; insomnia; thirst; bad breath;bitter taste; distress in upper abdomen or chest; acutebleeding; unusual warmth may be palpable in centre ofchest

Heat toxin flooding thetriple burner

Excess

Cinnamon twig and poria pill(gui zhi fu ling wan)

Strong constitution, red complexion, headaches,dizziness, abdominal pain, shoulder pain, palpitations,abdominal fullness, resistance to pressure or even painon palpation of lower abdomen, irregular menstruation

Blood stasis and wateraccumulation

Mixed (mainly excess)

Female spirit powder (nu shensan)

Uprushing, palpitations, headache, dizziness, back feelslike burnt, intense heat, sweating, depression,restlessness, long-term insomnia, constipation

Qi stagnation Excess

Uncaria powder (gou teng san) Headrushes; headache or heavy-headedness; dizziness;muscular tension in neck and shoulder area; ocularrubor tinnitus; thirst; nervousness; irritability;insomnia; eye fatigue or pain; poor appetite

Liver yang transforminginto wind with somespleen qi deficiency andphlegm damp

Excess with some deficiency

Warm clearing beverage (wenqing yın)

Dry lustreless skin; menstrual disorders; bleeding;headrush syndrome; skin problems marked by dryness,redness and itching; inflammatory conditions; anxiety;irritability; restlessness; insomnia; blood stasis signs

Blood heat or damp-heatand blood deficiency

Mixed

Poria, cinnamon twig, whiteatractylodes, and licoricedecoction (ling gui zhu gantang)

Dizziness; palpitations; shortness of breath; substernaldiscomfort; headaches; reduced urinary output;tinnitus; twitching; headrushes; substernal splashingsounds; mild upper abdominal rectus tension

Phlegm-mucous fromspleen deficiency; waterdampness with cold

Mixed

String of pearls beverage (lianzhu yın)

Palpitations; dizziness (orthostatic); mild oedema;tinnitus; shortness of breath; flushing and profusesweating; headache; soft abdominal wall withperiumbilical sensation

Blood deficiency withwater dampness

Mixed (mainly deficiency)

64

Tabl

e3

(Con

tunu

ed)

Nam

eof

form

ula

Synd

rom

ePa

thop

hysi

olog

yEx

cess

orde

ficie

ncy

Augm

ente

dra

mbl

ing

pow

der

(jia

wei

xiao

yao

san)

Wea

kco

nsti

tuti

on,

shou

lder

ache

san

dpa

in,

easi

lyti

red,

irri

tabi

lity,

easi

lyan

gere

d,re

stle

ssm

ind,

heat

vexa

tion

,fl

ushe

dre

dch

eeks

,di

zzin

ess,

inso

mni

a

Live

rbl

ood

defic

ienc

yw

ith

heat

from

cons

trai

ntM

ixed

(mai

nly

defic

ienc

y)

Tang

kuei

and

peon

ypo

wde

r(d

ang

gui

shao

yao

san)

Rela

tive

lyw

eak

cons

titu

tion

,co

ldbo

ody,

anae

mic

,ea

sily

tire

d,oc

casi

onal

sens

atio

nsof

pain

inth

elo

wer

abdo

men

,he

avy

head

,di

zzin

ess,

shou

lder

pain

,ti

nnit

us,

palp

itat

ions

,ab

dom

inal

diag

nosi

sre

veal

sla

ckof

stre

ngth

Bloo

dan

dqi

defic

ienc

yD

efici

ency

Cinn

amon

twig

deco

ctio

npl

usdr

agon

bone

,an

doy

ster

shel

l(gu

izh

iji

alo

nggu

mu

lita

ng)

Fati

gue;

cold

extr

emit

ies;

vaso

mot

orsy

mpt

oms;

freq

uent

urin

atio

n;ne

urot

icsy

mpt

oms;

peri

umbi

lical

sens

atio

n;th

inab

dom

inal

wal

lwit

hlo

wer

orge

nera

lre

ctus

tens

ion

Floa

ting

ofem

pty

yang

wit

hin

suffi

cien

cyof

qian

dbl

ood

Defi

cien

cy

From

Ref.

50,

p.10

3.

ofrtw

ncKTptceuieatir

mlhgoIwntpmlito

efmtpclsdpam

t

R

V. Scheid

n the treatment of menopausal disorders writtenor a western audience.50 While these texts do notepresent an exhaustive listing of all Kampo styles,hey suffice for the purposes of the comparisons Iish to make.g

The precise indication of the formulas used can-ot be discussed here in detail. Columns 3 and 4learly demonstrate, however, how the mainstreamampo approach differs from that of mainstreamCM. These differences can be summed up in threeoints: (i) The Kampo approach does not focus onhe treatment of Kidney deficiency; (ii) a signifi-ant number of formulas focus on the treatment ofxcess rather than deficiency; and (iii) the formulassed in Kampo medicine and those recommendedn TCM do not generally overlap. This implies thatven though it draws on the same medical literaturend thus is part of the same larger medical tradi-ion, Kampo and TCM treat menopausal syndromen significantly different — and sometimes diamet-ically opposed — ways.

Besides differences in the experience ofenopause by women in China and Japan, at

east two other factors may be responsible. Foristorical reasons explored by Lock, many Japaneseynaecologists do not share the biomedical viewf menopause as an oestrogen deficiency disorder.nstead, they perceive symptoms experienced byomen during perimenopause as signs of auto-omic nervous system imbalances. It is likely thathis perspectives also shaped the views of Kampohysicians (all of whom are trained in conventionaledicine before specializing in Kampo), particu-

arly as there exists a close affinity between thedea of autonomic nervous system imbalance andhe concern for harmony that underpins all stylesf Chinese medicine.18

A second important factor are essential differ-nces in how TCM and Kampo practitioners matchormulas to presenting complaints. In TCM treat-ent protocols are formulated on the basis of

heories that physicians hold regarding the patho-hysiology of a given condition. Kampo physi-ians, on the other hand, utilize a phenomeno-ogical approach that directly matches a patient’symptoms and signs to the manifestation patternsefined for specific herbal formulas. A Kampohysician thus would simply determine a womans exhibiting a ‘‘Cinnamon Twig and Poria Pillanifestation pattern’’ (Guizhi fuling tang zheng

) with the diagnosis specifying thereatment. The ideal TCM practitioner, on the other

g For another text that lists essentially the same formulas seeef.51.

Traditional Chinese medicine—–What are we investigating? 65

Table 4 Formulas for the treatment of menopausal syndrome used at Kyung Hee University Oriental MedicineHospital, Seoul

Name of formula Predominantly excess Name of formula Predominantly deficiency

Pinellia and magnoliabark decoction (banxia hou po tang)

Excess (qi and phlegm) Four substance decoction (siwu tang) with additions

Deficiency (blood)

Female spirit powder(nu shen san)

Excess (qi) Tangkuei and peony powder(dang gui shao yao san)

Deficiency (blood)

Augmented ramblingpowder (jia wei xiaoyao san)

Mixed (blood and qideficiency, qi stagnation)

Rhemannia decotion with sixingredients (liu wei dihuang tang)

Deficiency (Kidney yin)

Cinnamon twig andporia pill (gui zhi fuling wan)

Excess (blood stasis withdamp-cold)

Rhemannia decotion witheight ingredients (ba weidi huang tang)

Deficiency (Kidney yang)

Clear the heart drinkwith lotus seed(qing xin lian zi yin)

Mixed (heart fire excesswith qi deficiency)

htcT

ctp(

scKiodmtpameca—Wtip

C

Ll

infdiptcMmeeio

meimtts—oocmcpiwhich people are subject to different health risks.h

From Ref. 52, p. 45.

and, would deduce from the manifestation pat-ern (zheng ) a patho-mechanism (bingji )aused by a specific disease cause (bing yin ).hey would then devise a treatment strategy (fa) to re-establish normality of physiological pro-

ess and select a matching formula (fang ) forhis purpose. In modern practice, they often sim-ly match a disease type (xing ) with a formulafang ).

The historical relationship between these twotyles of practice is complex and need not con-ern us here. What is important, however, aboutampo’s traditional disinterest in theory is that

t is less easily recruited to biomedical modelsf disease. Hence, even where Kampo physiciansevelop new formulas for specific disorders likeenopausal syndrome, they do not feel obliged

o do so via the detour of Kidney deficiency. Ahenomenological approach proceeding from thectual manifestations of a disorder also will beore sensitive to local variations in the experi-

nce of menopause than one positing universal pro-esses. Hence, western TCM textbooks simply — andccording to the inner logic of the system justifiably

export treatment protocols from China to theest. Kampo textbooks written for western prac-

itioners, on the other hand, are essentially list-ngs of formulas and their associated manifestationatterns.

onclusions for TCM and CAM research

ack of space prevents me from discussing in simi-ar detail other contemporary approaches to treat-

i

ng menopausal syndrome within the wider Chi-ese medical tradition. Table 4, which lists theormulas commonly employed in the gynaecologyepartment of Kyung Hee University Oriental Med-cal Hospital in Seoul, provides just one additionalerspective as well as further proof for my generalhesis. Only 2 of the 10 formulas treat Kidney defi-iency, while at least 5 treat excess syndromes.52

any of these formulas match those used in Kampoedicine, others correspond to the Kidney tonics

mployed in TCM. This may reflect clinical experi-nce. As likely, it is an expression of the historicalnfluence that both China and Japan have exertedn Korea and its medicine.

The diversity of different approaches toenopause within the Chinese medical tradition

ven this very superficial account has uncovereds clearly at odds with the naturalist depiction ofenopause as Kidney deficiency afforded by TCM

extbooks. Such naturalism, by definition, is blindo the origins of its own vision. It claims to repre-ent the body as it is without realising that bodies

or at least the bodies that we can become awaref as human beings — are shaped by a multitude ofther factors beside biology: by local cultures andlimates, dietary regimes and social mores. Whatenopause suggests, therefore, is that social,

ultural, and physical differences among diverseopulations create distinctive ‘‘local biologies,’’n which disease is experienced differently and in

The biomedical approach to menopause, which isnformed almost exclusively by attempts to under-

h The term ‘‘local biologies’’ stems from Ref.53.

cmomtacebcttewnWofcb

tpctbtTfiartapp

‘mpbhuistoAylabt

66

stand its biology, takes scant account of such vari-ability. Portraying itself as scientific and value-free, its definition of menopause as hormonal defi-ciency is nevertheless profoundly ideological. It isinformed by an intrinsic gender bias that manywomen experience as harmful,9 and a perception ofageing as pathological that reflects values and notfacts. When modern TCM textbooks in China thuscelebrate the insertion of menopausal syndromeinto the Chinese medical tradition as an impor-tant step ‘‘in the historical development of Chi-nese medical science,’’54 they also, willingly or not,embrace this ideology. For this reason they only seea lack where for reasons that at least deserve explo-ration physicians and patients hitherto had madeother choices.

Western TCM practitioners, in turn, chose tothink of such modern inventions as traditionalknowledge and present as an alternative tobiomedicine what, in effect, is a product of itsincreasing domination of TCM. As long as this mythof tradition legitimised Chinese medicine among anaudience sharing the same longings, such blindnessmay have served its purpose. Now, that the efficacyof Chinese medicine is subjected to increasinglystringent tests it may prove to be deleterious to itssurvival. Let us imagine for a moment that a clinicalstudy designed to test whether a given protocol fortreating Kidney yin deficiency brings relief to west-ern women suffering from menopausal syndromefinds that this is not the case. What are the con-sequences? In a context where it is accepted thatKidney yin deficiency is the Chinese medicine viewof menopause we draw the conclusion that Chi-nese medicine offers no benefits to perimenopausalwomen. If, on the other hand, we accept that thedefinition of menopause as Kidney yin deficiencyis the consequence of a complex historical processinto which clinical experience has constituted onlyone input our conclusions will be quite different.We will readily accept that the Chinese medical tra-dition offers many other possibilities for conceivingof menopause and that some of these alternativesmay offer more fruitful avenues for treatment andresearch. Such research, furthermore, would thennot merely be a passive process of testing giventreatment protocols. Rather, it would acknowledgethat a first step in developing treatment protocolsis to adopt them to the contexts of specific localbiologies: that protocols for women in Japan mayhave to look different than for those in China orthe US, and that they may have to be integrated

differently into different local contexts of healthcare delivery.

Once this is accepted, priorities of CAM researchin the field of Chinese medicine are drastically

t[ld

V. Scheid

hanged. For what I have shown for the case ofenopause is true for other conditions, too. All

f TCM, and not merely some isolated parts, is aodern reconfiguration of a greater tradition. This

radition offers multiple understandings on almostnything, from the nature of disease to how a spe-ific problem like menopause should be treated,ven if its practitioners agree on a small num-er of core ideas and concepts. Rather than mis-onstruing Chinese medicine as a static traditionhat offers specific treatments for specific condi-ions, CAM research must embrace the realistic andvidence-based view that it is a ‘‘tradition to thinkith.’’ That Chinese medicine as a whole can thusever be proven right or wrong, beneficial or not.hat we can do is to embrace the core principles

f the Chinese medical tradition in order to distilrom them specific therapeutic options that thenan be evaluated using the principles of evidence-ased research.

The person who has most clearly elaboratedhese concepts and their value for contemporaryractice is the twentieth century literatus physi-ian Xie Guan (1880—1950). His definition ofhe Chinese medical tradition is widely embracedy the Chinese medical community and constituteshe basis even of official government definitions ofCM.19 I therefore offer Xie Guan’s own words as atting conclusion. Written almost a century ago itsffinity to the notion of local biologies that modernesearchers have arrived at through the examina-ion of menopause could not be closer. How thisgenda can be translated into a practical researchrogram is a work-in-progress whose results will beublished at a later date.

‘To sum up [one can say that] the essentials ofedicine do not lie outside the four charactersrinciple, methods, patterns and drugs. The humanody may tend towards depletion or repletion,eat or cold. In each [respective case] one decidespon warming or cooling, attacking or supplement-ng [methods] and administers [corresponding] pre-criptions to return it to a [state of] balance. Allhese principles and methods can be used through-ut all provinces and [also] all other countries.

person’s body may be strong or weak, old oroung. Disorders may be recent or long-standing,ight or serious. Climates may [vary between] coldnd warm, dry and moist. The environment maye hard or soft, gentle or strenuous. All these fac-ors [can be classed] as changes of [local] situa-

ions, which [can be responded to] by collectingdifferent] drugs and composing [different] formu-as. For in [composing] formulas and combiningrugs one should follow what is appropriate to

T gatin

ep

R

raditional Chinese medicine—–What are we investi

ach given case and cannot [just] follow a givenrecedent.’’55(p62b)

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