This essay examines the treatment of menopausal syndrome by Chinese medicine as a window on how globalisation impacts on the development of the Chinese medical tradition. The treatment strategies for menopausal syndrome were invented in 1964 and betray a strong influence of biomedical thinking. Today, they are sold both at home and abroad as products of 2,000 years of clinical experience. Close examination of textual sources reveals that such attachment is achieved by way of skillfully patching selected elements of tradition onto each other, creating a narrative that appears coherent and fits biomedical models of menopause, but is intrinsically fragile. Not only can the patchwork that sustains this narrative easily be deconstructed (as for instance in this article) but having attached itself to a distinctive interpretation of ageing—universal, biological and chauvinist—it also opens itself up to all of the criticisms that have been made of biomedical models of menopause insensitive to local variations in women's experience. Furthermore, there is no evidence that modernising Chinese medical interpretations of menopause have increased its effectiveness in clinical practice. Whilst the essay itself does not seek to resolve these tensions, it demonstrates that the globalisation of Chinese medicine provides it not merely with opportunities but also with important new problems whose resolution may determine its ongoing development—and indeed survival—as a living tradition.
The processes of globalisation that are shaping the world today are still widely equated in both academic and popular imaginations with the dispersal of things western, modern and rational. In this view, epitomised in Fukuyama's (1992) notion of the end of history, natural evolution (of ideology, economics, technology) and the inevitable westernisation of the world are seen as congruent events. Yet, even as processes of globalisation are accelerating in the early twenty-first century, reverse currents carrying ideologies and practices from north to south and from east to west are becoming increasingly difficult to ignore. In the domain of medicine, for instance, both the Chinese and Korean governments actively promote the global-isation of traditional medical systems as part of a wider strategy aimed at projecting their national cultures onto a world stage and thereby gain economic advantage (Consortium for the Globalization of Chinese Medicine 2005; Kim 2007). Such flows undermine narratives that see globalisation moving in just one direction, and as being defined by just one logic or type of activity (Berger and Huntington 2002; Nederveen Pieterse 2004; Walters 2000), but they do not therefore escape the more comprehensive logics and contradictions that attach to all processes of globalisation. For irrespective of whether we examine McDonald's or Chinese medicine, successful global diffusion of goods, technologies or practices is predicated on integrating presumed universals into specific networks of practice and, vice versa, of detaching particulars sufficiently from whatever anchors them to a specific time and place in order to make them mobile and movable (Hsu 1943; Barnes 1998).
Such interactions of the local and the global have been examined in the humanities and social sciences from a wide variety of different perspectives (Appadurai 1996; Berger and Huntington 2002; Croucher 2004; Nederveen Pieterse 2004; Robertson 1992), including their relation to Chinese medicine (Stollberg 2001; Hsu 2002). The present article, which analyses the emergence of menopausal syndrome in Chinese medicine as a consequence of the globalisation of tradition, adds one more case study to an already large archive. In that sense, it is predominantly of local significance in that it ties the historiography of Chinese medicine to globalisation theories. Yet, it also moves into the other direction by bringing the critique of globalisation into Chinese medicine in an attempt at challenging the homespun histories of that tradition. I do this by explicitly addressing the problem of effectiveness, which I see as operating at different levels of practice at once.
On one of these levels, the invention of menopausal syndrome and its treatment in Chinese medicine—which, as I will show, is essentially a translation of biomedical theories about ageing into indigenous idioms—reflects a capacity for adaptation that has ensured its survival in mainland China in oftentimes extremely difficult conditions. At another, it has facilitated its expansion across the world. On these levels, the invention described here has been extremely effective. Yet, in as much as the translations on which it is based undermine core concepts of Chinese medical practice and subsume them to biomedical universals, and because they were motivated by political expedience and not merely clinical ends, their success may have been purchased at the expense of clinical effectiveness. Highlighting the inevitability of the gains and losses that accompany all processes of translation is therefore what my account of menopausal treatment and its invention can contribute to historiography and social science.
To enable readers not familiar with Chinese medicine to follow my narrative, I will first outline the broad contours of the historical context in which it unfolds. I will then examine in some detail the invention of menopausal syndrome in Chinese medicine and its discontents. In the concluding section, I will reconnect this discussion more explicitly to the problematics of globalisation and effectiveness raised above.
1 Con-texts: Chinese Medicine Practice and Chinese Medicine Textbooks
For the purposes of this discussion, I will differentiate the larger Chinese medical tradition from a more recent offshoot widely known under the label “traditional Chinese medicine” or “TCM”. If the former embodies a type of person-centred practice that has developed historically through a dialectic between clinical insight and scholarly learning, the latter is embodied most specifically in contemporary Chinese medical textbooks and in the institutional contexts in which these textbooks have been produced and in which they are used. From the first experimental attempts at condensing the essence of Chinese medicine into a single text in the mid-1950s, to the later series of educational materials for colleges and universities that is currently in its seventh edition, textbooks have been a cornerstone of state-directed efforts at modernising traditional medical education, integrating it into a larger modern health care system, and—from the very beginning—of diffusing it throughout the world. All of these objectives required standardising, regularising and systematising a hitherto loosely organised body of texts, practices and social relationships, producing in textbooks a set of objects from which the field of contemporary Chinese medicine—the processes of its emergence; its internal structure, tensions and contradictions; its complex relationships with biomedicine, science, the state, tradition, China and the world outside—can and has been analyzed (Farquhar 1994; Hsu 1999; Karchmer 2004; Scheid 2002; Taylor 2004a).
It was in the process of the production of these textbooks, for instance, that debates about the shape and place of Chinese medicine in contemporary China and about the nature of its modernisation were played out. Under political pressure to reconfigure traditional practice so as to accommodate to the contradictory imperatives of socialist modernisation and nationalist pride, their writers achieved the remarkable feat of defining Chinese medicine as a medical system whose essential characteristics (Chinese, dialectical and rooted in experience) distinguished it clearly from biomedicine, yet simultaneously allowed it to be integrated into a health care system organised by means of biomedical disease categories (Karchmer 2004; Scheid 2002).
If TCM textbooks facilitated the continued survival and transmission of traditional medical practice in China, the social space secured was not therefore entirely dominated by the systematised medicine they represented. Physicians and students continued to have access (sometimes more and sometimes less easily) to the entire corpus of literati medicine whose texts remained as important as ever for the cultivation of personal expertise. It is therefore impossible to draw a strict dividing line between the two forms of Chinese medicine—the older scholarly one centred on exegesis, commentary, apprenticeships and diverse currents of tradition, and the younger bureaucratic one taught and practiced in state-controlled institutions—I have outlined. The wider Chinese medical tradition encompasses TCM textbook medicine, even as the latter succeeds and develops it into a new direction. They can be seen as diametrically opposing each other, one firmly rooted in local contexts of practice and geared towards the development of personalised knowledge, the other seeking to develop Chinese medicine as a distinctive system that can be compared, contrasted or integrated with other such systems, or, alternatively, as different manifestations of a more comprehensive and continually developing living tradition (Scheid 2007).
TCM textbooks thus function as essential vehicles for globalising a local medical practice even as they appropriate concepts and practices imported from the West—including the very idea of textbooks and the institutional contexts in which they are used—into their own construction. I remember from my own days as a student of Chinese medicine in the UK in the early 1980s that it was precisely the systematic nature of these texts that made them so attractive to students in the West. What few of us knew at the time was that the “basic theory” (jichu lilun 基礎理論) we were studying was itself the result of efforts at making Chinese medicine more western in content and appearance so as to produce precisely the effect it had on us (Hsu 1999; Taylor 2004b).
The invention of menopausal syndrome as a problem for Chinese medicine I narrate below mirrors the crafting of TCM textbooks as hybrids of East and West, local tradition and global medical system. It is intended to deepen our understanding of these problematic articulations in order to develop a critique that moves from description and analysis to outlining, at the very least, the possible consequences of different types of assembling effective knowledge.
2 TCM Approaches to the Treatment of Menopausal Syndrome
TCM gynaecology textbooks in mainland China today all contain a chapter or section that discusses the diagnosis and treatment of menopausal syndrome.1 Whilst the length of these discussions and the number of formulae given to treat such patterns varies greatly from one text to another, their understanding of the aetiology and pathophysiology of menopausal syndrome is consistent throughout. Menopausal syndrome is understood as a problem of ageing and thus, in Chinese medical terms, defined to be a manifestation of declining kidney function. This is because Chinese medical doctrine has long associated the kidneys (shen 腎) with ageing, growth and development. Chinese Medical Science of Gynaecology and Obstetrics, one of the most recent and authoritative textbooks in this domain, states:
The title of these chapters, and therefore the name by which menopausal syndrome is referred to, varies. “Manifestation patterns associated with the cessation of menstruation” (jingduan qianhou zhuzheng 經斷前後諸證), “symptoms and signs associated with the cessation of menstruation” (jingduan qianhou zhenghou 經斷前後症候), “symptoms and signs associated with perimenopause” (juejing qianhou zhuzheng 絕經前後諸癥) and periomenopausal syndrome (juejingqi zonghezheng 絕經期綜合徵) are common terms found in the literature.
Generally, the occurrence of perimenopausal symptoms and signs cannot be linked to any concrete cause....[However,] around the cessation of menstruation women's physiology follows the general decrease of kidney qi whereby fertility declines, essence and blood become increasingly insufficient, and the yin and yang of the kidneys loses their balance....While a healthy body is generally able to regulate itself and gradually adjusts [to this decline], some women are more easily affected by internal and external influences so that the yin and yang of the kidneys lose their balance. As a result, they become either kidney yin deficient, kidney yang deficient, or kidney yin and yang deficient (Liu Minru 劉敏如 and Tan Wanxin 譚萬信 2001: 406).
Western TCM texts, which tend to be translations of mainland Chinese textbooks, follow such interpretations. They, too, define kidney deficiency (shen xu 腎虛) to be “always at the root of menopausal problems”. Secondary pathologies may need to be addressed, but it is kidney deficiency that constitutes the core of TCM treatment protocols. “Chinese medicine”, as one of TCM's most influential western teachers notes, “works by gently tonifying the kidneys and the kidney-essence to help the woman in this transitional time of life” (Maciocia 1998).
Given the strong association between hot flashes and menopausal syndrome in western understandings of menopausal syndrome, kidney yin deficiency (shen yin xu 腎陰虛) in particular has come to be seen as the defining feature of menopausal syndrome in TCM, and for western adepts of TCM even more so than for their colleagues in China. This is because in Chinese medicine yin deficiency is associated with yang excess (i.e. heat) symptoms. “While all patients with menopause will have kidney yin deficiency,” writes an influential TCM teacher in the widely read journal Acupuncture Today, “many will have other associated conditions that must be addressed (Chen 2002).” When these ideas are communicated to the wider public, they are simplified even further. “In Traditional Chinese Medicine, or TCM,” the University of Maryland Medical Center informs us on its webpage, “a woman is not generally referred to as ‘menopausal’. Rather, a practitioner of TCM might say that she exhibits ‘[K]idney yin deficiency (University of Maryland Medical Center 2008).
Research investigating how western TCM practitioners diagnose menopausal women with vasomotor symptoms shows that textbook discussion of menopausal syndrome consistently informs clinical practice (Zell et al. 2000). No similar research is available for China, but a review of over 800 articles on the treatment of menopausal syndrome in mainland Chinese medical journals published since 1979 shows kidney deficiency to be by far the most common diagnostic category used. Suggestions for the treatment of menopausal syndrome in the TCM literature in both China and the West, not surprisingly, are dominated by formulae and treatment protocols that tonify the kidneys and, in particular, kidney yin (Table 1). The same is true for research (Scheid 2009).
Based on this brief review of the literature, we thus can draw two conclusions: (1) TCM offers a clear and coherent understanding of menopausal syndrome and its treatment; (2) this understanding appears to be reflected in a broad consensus among TCM practitioners regarding core treatment protocols that, in turn, inform research. Without exception, TCM texts present this understanding as if it were ancient knowledge rooted in the classics and the “two thousand years of clinical experience” that we generally claim to be the foundation of the Chinese medical tradition. Nothing, however, could be further from the truth.
3 Chinese Medicine, Menopause and Alternative Medicine
Like many other conditions that patients bring to their Chinese medicine physicians today, menopausal syndrome is a biomedical disease category. There is no evidence that it was recognised as a medical problem in the classical Chinese medical literature. The influential Chinese Medicine Gynaecology, a text written specifically for teachers at TCM colleges and universities in China, admits as much.
The ancient literature does not contain any records of this disorder as a distinctive [medical problem]. But [descriptions of] symptoms [matching those of menopause] like ‘profuse uterine bleeding in old age’ (laoneng xuebeng 老年血崩), ‘recurrence of menstruation in old age’ (laonian jingduan fulai 老年經斷復來), ‘restless organ [disorder]’ (zang zao 臟躁), or ‘lily disorder’ (baihe bing 百合病) are widely scattered throughout [descriptions of various] manifestation patterns. Furthermore, this disorder was rarely seen in clinical practice. [It was only] from the 1960s onwards, that it began to be discussed in [Chinese medical] textbooks, and in dedicated chapters in works by modern [Chinese medicine] gynaecology specialists such as Selected Case Records and Medical Essays on Gynaecology by Ha Litian, A Selection of Qiu Xiaomei's Clinical Experience in Gynaecology, and [Han] Bailing's Gynaecology (Luo Yuankai 羅元凱 1988).
Whence, then, this modern interest among Chinese physicians in a hitherto apparently not very important medical problem? How did they go about defining treatment strategies for a condition for which, according to their own admission, they lacked clinical experience not just in treating it but also in recognising? And how was this new disorder integrated into the Chinese medical tradition?
At least three interdependent contributing factors can be distinguished: the creation of TCM textbooks embodying the imperatives of westernisation, scientisation and biomedicalisation of the Chinese medical tradition discussed above; an awareness among Chinese medicine physicians in China and perhaps of their patients, too, that symptoms of ill health occurring around menopause could be conceived of as a distinctive medical problem; and the demands of western patients, including menopausal women, for alternative medicines that, in turn, created a demand for practices like TCM that were sufficiently Chinese to pass as alternative yet also sufficiently western to make them useful for western patients experiencing modern diseases. Whilst it is impossible to determine the precise contribution of each of these factors to the invention of menopausal syndrome as a problem for Chinese medicine, an attempt can be made to describe their impact.
4 The Invention of Menopause as a Problem in TCM
Chinese commentators date the first discussion of menopausal syndrome in Chinese medicine to the publication in 1964 of the second revised edition of Lecture Notes for Chinese Medicine Gynaecology (Zhongyi fukexue jiangyi 中醫婦科學講義). This text was the culmination of a process that had begun in the late 1950s when the Chinese government, through the Ministries of Health and Education, embarked on a thorough investigation of teaching materials used at the newly established colleges of TCM. The review led to a decision in 1959 to commission a series of national textbooks for the teaching of Chinese medicine at all tertiary level educational institutions. If the primary goal of this process was the harmonisation of teaching practices across the country, its explicit subtext was more far-reaching. As the medical historian Kim Taylor remarks, it was a means of modernising tradition: “of mass-producing future doctors [...], of controlling their knowledge and practice.” With hindsight, it was an event that “fundamentally altered the dynamics [...] of any form of medical innovation” in the domain of Chinese medicine (Taylor 2004a).
The task of writing these textbooks was delegated to “teaching and research groups” (jiaoyanzu 椒研組) set up for this purpose at different Chinese medical colleges. The gynaecology textbook was compiled at the Chengdu College of TCM by a research group led by Prof. Zeng Jingguang 曾敬光 (b. 1918) drawing on teaching materials already in use at the college. These teaching materials included a series of handbooks published a year earlier in 1958 that had been edited by Prof. Zeng and other experts at the college. One of the most influential of these was Zhuo Qichi 桌啟墀, the biomedically educated son of the famous Chinese medicine gynaecologist Zhuo Yunong 桌雨農. Prof. Zeng herself had been trained at the Sichuan Tertiary School of National Medicine (Sichuan gaodeng guoyi xuexiao 四川高等國醫學校), one of the new colleges of “national medicine” (guoyi 國醫) established during the Republican era. In different ways, therefore, both Zeng Jingguang and Zhuo Qichi embodied in their own life histories the “integration of Chinese and Western medicine” that was the stated goal of government policy regarding the development of Chinese medicine at the time (Li Mingfu 李明富 1999: 386–420).
The first edition of the new national textbooks was published in 1960 (Chengdu College of Chinese Medicine 1960). Interestingly, for our purposes, the gynaecology text did not yet contain a discussion of menopausal syndrome or its treatment. This omission was representative of a more generalised shortcoming that policy makers identified in this first edition, namely the failure to move Chinese medicine more closely in the direction of modernity as defined by biomedicine. A new edition was thus commissioned more or less immediately. Published in 1964, the second revised edition of what were still termed “preliminary teaching materials” was deemed more acceptable. These textbooks outlined TCM as we know it today and their basic structure remains influential to this date. The revised Lecture Notes for Chinese Medicine Gynaecology, once more compiled in Chengdu, now discussed 44 (rather than as previously 34) different disorders (bing 病) according to the new paradigm of “pattern differentiation and treatment application” (bianzheng shizhi 辨證施治). One of these newly introduced disorders was menopausal syndrome, and Prof. Zeng Jingguang is thus rightfully credited with having introduced this disorder into the Chinese medical tradition (Chengdu College of Chinese Medicine 1964).
The various influences on Prof. Zeng's understanding of gynaecology—and thus menopause—are too complex to outline in detail here. Suffice to say that they focused on the physiology and pathology of the penetrating (chongmai 衝脈) and conception vessels (renmai 任脈), two functional entities that during the Qing dynasty had become increasingly closely associated with the uterus as the core concern of Chinese medical gynaecology. Another influence, undoubtedly, was biomedicine, assimilated during training programs run for Chinese medicine physicians in the early 1950s at the new Chinese medicine hospitals constructed in the late 1950s. These training programs constituted but one aspect of a concerted effort by the state to modernise Chinese medicine and integrate it in one way or another with biomedicine (Karchmer 2004; Scheid 2002; Taylor 2004a).
The early 1960s thus was a particularly exciting time for progressive physicians who embraced Mao Zedong's idea of creating a new medicine out of a merger of East and West. Not only was their project supported at the highest political level but initial research also suggested that it might indeed be possible to anchor the Chinese medical body in physics and biochemistry. While they were thereby not entirely detaching this body from problematic local metaphysical concepts such as yin/yang, the five phases and visceral systems of function (problematic, that is, for the scientist ideologues of Chinese modernisation), they succeeded in attaching it to an apparently objective and universal nature. The most influential work in this respect was that of the Shanghai physician Chen Ziyin 沉自尹 (b. 1928) who was able to demonstrate that patients diagnosed as suffering from kidney yang deficiency (shen yang xu 腎陽虛) had consistently low urine levels of 17-hydroxicorticosteroid (Chen Ziyin 沉自尹 and Wang Wenjian 王文健 1988). This led him to propose a correlation between kidney yang deficiency and adrenal insufficiency. A connection between the kidneys and hormonal function was thereby established in the Chinese medical imagination that persists to this day even if 40 more years of research have not fulfilled Chen's dream of matching Chinese and biomedical pathology (Ma Boying 馬伯英 et al. 1994: 584–596).
This still left the problem of seamlessly integrating the new disorder into the Chinese medical tradition by covering up the process of invention. Prof. Zeng achieved this by way of a two-pronged strategy. First, she replaced the biomedical term “menopausal syndrome” (gengnianqi zonghezheng 更年期综合症) with “manifestation patterns associated with the cessation of menstruation” (jingduan qianhou zhuzheng 经断前后诸证). This new term draws attention to the constellation of symptoms within patterns (zheng 证) and thereby anchors the treatment of menopausal syndrome firmly within TCM's core paradigm of pattern differentiation and treatment determination (bianzheng lunzhi 辨正論治). Furthermore, “cessation of menstruation” (jingduan 经断) is a term that occurs in the classical Chinese medical literature. “Menopause” (gengnianqi 更年期), on the other hand, is a direct borrowing from the Japanese term konenki, which in turn is a translation into Japanese of the German Klimakterium (Lock 1993). Having thus attached menopause as a concept to both ancient and modern Chinese medicine, Prof. Zeng filled its meaning by creating an implicit link to chapter one of the Inner Canon of the Yellow Lord, the foundational text of her medical tradition. This chapter discusses the development, growth and decline of human life in terms of 7-year cycles for females and 8-year cycles for males. Regarding women, it states:
When a woman is seven years old her kidney qi is vigorous. The teeth are replaced and the hair grows. At fourteen, fertility is established, the conception vessel is open, the great penetrating vessel is vigorous, the menses flow, and she therefore can have children. At twenty-one, kidney qi is fully developed. The wisdom teeth appear and [physical] growth is complete. At twenty-eight the sinews and bones are firm, the hair reaches its greatest length, and the body is luxuriant. At thirty-five, the yang brightness vessel declines, the complexion dries out, the hair begins to fall out. At forty-two, the three yang vessels decline above, the complexion is entirely dried out, the hair begins to turn white. At forty-nine, the conception vessel is depleted, the great penetrating vessel wanes, fertility is exhausted, menstruation ceases, the body has become old and she can no longer have children (Guo Aichun 郭靄春 1992: 4; Zhang Aifang 張愛芳 1995: 126–32).
Whilst Prof. Zeng does not quote this passage directly, she defines menopause as occurring after the age of 49 years aware that anyone who knows the Inner Canon will make an immediate connection (Chengdu College of Chinese Medicine 1964). However, a careful comparison between the original text and Prof. Zeng's outline of menopausal syndrome reveals a change of emphasis, or at least a subjective interpretation. The Inner Canon speaks of the penetrating and conception vessels when referring to menstruation and fertility, whilst the kidneys seem to govern ageing more generally and thus is also cited in a similar passage describing the 8-year cycles of physical growth, development and decline in males. Prof. Zeng speaks of “weakened kidney qi and deficiency and harm to the penetrating and conception vessels” (shenqi shuairuo, chongren xusun 腎氣衰弱, 衝任虛損), which was to be treated by supplementing kidney qi and regulating penetrating and conception vessels” (bu shenqi shuairuo, tiao chongren 補腎氣, 調衝任; Chengdu College of Chinese Medicine 1964: 61). Today's gynaecology textbooks, on the other hand, only cite the last sentence of the passage from the Inner Canon before proceeding to explain that kidney deficiency is at the root of all menopausal problems (e.g. Luo Yuankai 羅元凱 1988: 161). We thus find here a further stage in the development of the TCM understanding of menopausal syndrome. References to Prof. Zeng's personal focus on the penetrating and conception vessels are removed and replaced by a more simplified emphasis on kidney deficiency. This reduction of complexity in medical theorising makes sense to a biomedically trained doctor, in as much as kidney deficiency could be related to hormonal deficiency in biomedicine, whilst no such anatomical or physiological correlate could be imagined for the conception and penetrating vessels (Scheid 2002, Chapter 7; Karchmer 2004).
This narrowing of focus does, of course, have distinctive advantages. It suggests that TCM's understanding of menopause is systematic, coherent and nothing else than the logical extension of ideas contained in the earliest medical cannons to problems of the present. But in hiding the origins and intentions of the strategies that accomplish this construction within an apparently self-evident naturalist discourse of progress, TCM textbooks betray and misrepresent the rich and diverse Chinese medical tradition they claim to embody.
5 The Many Voices of Tradition
Even a very superficial examination of the passage on female development from the Inner Cannon shows, for instance, that the text does not link the cessation of menstrual flow to kidney function in any obvious way. Where the text speaks of the kidneys, it does so in relationship to the early years of a woman's development and to growth in general. In as much as it links specific bodily structures to the kidneys, it speaks of the teeth and the hair. With respect to menstruation and fertility, it speaks clearly and unambiguously only of the conception and penetrating vessels.
Certain currents within the Chinese medical tradition do, of course, link the kidneys to the eight extraordinary vessels (qijing bamai 幾經八脈), a group of functional units to which the penetrating and conception vessels belong. But many others do not. The famous Qing dynasty physician Ye Tianshi (1646–1727), for instance, believed that sweet and sticky herbs such as Rhemannia Radix (shu di huang 熟地黃)—listed in modern TCM textbooks as a main herb for tonifying the kidneys in the treatment of menopausal syndrome—do not enter into the extraordinary vessels (Luo Yuankai 羅元凱 1988). The reasons for this is the difference between channels (jing 經) and viscera (zang 臟) in Chinese medical thinking. The former are vessels that conduct qi and blood and that therefore get easily obstructed by herbs like Rhemannia that are believed to be sweet and sticky in nature. Viscera, on the other hand, store essences, which are replenished specifically by such sweetness. There is also a strong tradition that links the penetrating vessel more closely to function of the stomach than to that of the kidneys, as reflected, for instance, in the writings of the late Qing dynasty author Tang Rongchuan 唐容川 (1846–1897). In discussing the formula Ophipogonis Decoction (mai men dong tang 麥門冬湯), Zhou writes:
The penetrating vessel arises in the uterus and connects with kidneys and liver below, but [unfolds] its true majestic [nature] through the yang brightness (i.e. the stomach). In order to regulate the blood of yang brightness it enters into the uterus below. When the qi of yang brightness flows smoothly, the qi of the penetrating vessel also flows smoothly....This formula directs the qi of the penetrating vessel downwards by way of the stomach. This is a strategy for not letting fire ascend and interfere with the upper [burner]” (Tang Rongchuan 唐容川 1884).
I quote this passage because it emphasises not only the connection between the penetrating vessel and the stomach but also hints at a strategy for dealing with hot flashes discussed in more detail below that was advocated in Ming and Qing dynasty medicine but has been willfully ignored by TCM textbook writers.
The connection between menopausal symptoms and kidney deficiencies is even more tenuous in relation to “[descriptions of] symptoms [matching those of menopause]” that modern physicians claim to have identified in classical texts. Neither ‘restless organ’ (zang zao 臟躁) nor ‘lily disorder’ (baihe bing 百合病), for instance, are linked to problems of kidney deficiency in the Essentials from the Golden Cabinet 金桂要略, the Eastern Han dynasty text in which these disorders are first discussed. The consensus of commentators ascribes restless organ to some kind of nutritive qi deficiency and lily disorder to the presence of pathological (i.e. excess) heat in the body (Li Keguang 李克光 1989). Of course, establishing a precise match between these two disorders and the formulae that treat them on the one hand and kidney deficiency and menopausal syndrome on the other was not the primary goal of the TCM textbook authors who created these linkages. Their intention more simply was to suggest that if the ancients already had effective treatments for the symptoms of menopause, then they also must have perceived of a menopausal syndrome, even if in reality that syndrome was brought to China via Germany and Japan sometime in the early twentieth century (Lock 1993).
That, however, clearly was not the case. According to the medical historian Charlotte Furth, the body of the Inner Canon was essentially ungendered, meaning that not much attention was paid to gender differences when thinking about health and illness. In such a life-world, menopause as a problem specific of female ageing simply could not exist, even if it appears natural to us.
What moderns would understand as menopause is identified [in ancient Chinese medicine] in the same way as menarche, simply as an event in the life passage, similar in character if not in timing for males and females alike. Just as females cease to menstruate, males' ‘semen becomes scanty’, and these changes are not seen as a ‘pathology’ but ‘part and parcel of the ungendered feebleness of old age (Furth 1998: 45–46).
Over the course of subsequent centuries, Chinese medicine and its understanding of female physiology developed along a trajectory marked by several fundamental ruptures. The first text that discusses the treatment of specifically female disorders was Essentials from the Golden Cabinet by the Eastern Han dynasty author Zhang Zhongjing 張仲景 (ca. 180). Its three chapters on gynaecology and obstetrics discuss such disorders as manifestations of failure in the regulation of qi, blood and body fluids and their disturbance by outside factors like wind and cold. This approach continued to dominate physician's understanding of female bodies at least to the Song, where it organised Chen Ziming's (1190–1270) All-Inclusive Good Prescriptions for Women, widely considered to be the foundational text of gynaecology as a specialist discipline in the Chinese medical tradition (Furth 1998: 70–74).
It was only from the Jin-Yuan onwards, and particularly during the Ming (1368–1644), that organ systems began to assume a more prominent position within gynaecological writings. Furth sees this shift as being linked to a social reorganisation within elite medicine whereby physicians tried to distinguish themselves from each other by privileging one organ system over others in their choice of therapeutic strategies (Furth 1998: 144). Interestingly, most physicians between the Song and the Ming attached little or no importance to the role of the kidneys when treating women. Revised Good Prescriptions for Women (Jiaozhu furen liangfang 校註婦人良方), published by the imperial physician Xue Ji (1487–1559), thus seeks to divert its reader's attention away from Chen Ziming's focus on the channels (jingmai 經脈) as sites from where one could read of the circulation of qi and blood to one on organs and their metabolic functions. Among these, according to Furth,
...the spleen–stomach system controlling digestion was primary, closely followed by the associated liver and heart functions. When he [Xue Ji] mentioned the kidney system it was more often with reference to the function of discharge of body wastes (Furth 1998: 144).
Where physicians did envisage a role for the kidneys, it was associated with menarche and puberty rather than menopause. The influential Ming dynasty physician Wang Kentang 王肯堂 (1549–1613), for instance, writes:
During their childhood, before they menstruate [and are fertile], women's [physiology] is subordinated to the lesser yin [i.e. the kidneys]. When they menstruate [and are fertile] it is subordinated to the terminal yin [i.e. the liver]. When menstruation [and fertility] ceases, it is subordinated to the greater yin [i.e. the spleen] (Wang Kentang 王肯堂 1602–1608: vol. 6, 1).
Wang's statement is an almost verbatim copy of an earlier passage by the Jin dynasty author Zhang Yuansu 張元素 (1115–1231). Zhang, in turn, is considered to be the founding father of the influential Yishui current (Yishui xuepai 易水學派), one of the most influential schools of thought in Chinese during the late imperial period so named after Zhang's home town. The Yishui current strongly emphasised the pivotal role of spleen and stomach in health and disease, including disorders associated with symptoms of heat and fever (Qiu Peiran 裘沛然 and Ding Guangdi 丁光迪 1992: 145–146). One such disorder is “rebellious fire” (huo ni 火逆), a broadly defined disease category characterised by sensations of heat in the body that are not due to external causes and that manifest with fever. In biomedical terms, this might encompass heat sensations associated not only with, for instance, thyroid disorders but also, perhaps, menopausal hot flashes. Proponents of Yishui-style medicine advocated regulating spleen and stomach in order to treat this heat. This was in opposition to their main opponents, the followers of Liu Wansu 劉完素 (1120–1200) and Zhu Danxi 朱丹溪 (1281–1358), who emphasised tonification of the kidneys as suggested in the following quote from the writings of the Qing dynasty physician Huang Yuanyu 黃元御 (1705–1758), a follower of the Yishui current:
Due to the breakdown in the transmission of medical doctrine the pattern of rebellious fire with flushing of heat has been turned into one of yin deficiency. The regular use of [herbs like] Radix Angelicae (dang gui 當歸) and Rehmanniae Radix preparata (shu di huang 熟地黃) thereby destroys earth and harms the patients. As for the devilish use of [cooling herbs such as] Testudinis Plastrum (gui ban 龜板), Asparagi Radix (tian men dong 天門冬), Anemarrhenae Radix (zhi mu 知母), and Phellodendri Radix (huang bai 黃柏) that drain an already weakened yang, this surely must lead to death. This calamity is frightening and entirely due to the poisonous legacy of Liu Wansu and Zhu Danxi.” (Huang Yuanyu 1990, vol. 3, pp. 309–11).
The importance of this debate is that it draws our attention to the existence of an important alternative to kidney tonification within the Chinese medical tradition when treating hot flushes that is entirely ignored in contemporary TCM textbooks and even more so in the West. It is ignored in China, one must assume, because it gets in the way of a narrative that had discovered in the Inner Canon and the Essentials of the Golden Cabinet an understanding of menopausal syndrome that matches that of modern biomedicine. Admitting dissonance would call into question the entire TCM narrative. In the West, the debate is ignored because most practitioners lack the necessary linguistic resources to penetrate Chinese medicine beyond the modern textbook versions.
Interestingly, physicians able to read pre-modern texts and interested in clinical effectiveness rather than narrative consistency regularly approach the treatment of menopausal problems from perspectives that do not accord priority to kidney function. This includes the very physicians Chinese Medicine Gynaecology lists as having been responsible for bringing menopausal syndrome to the attention of a wider audience such as Ha Litian 哈荔田 (1912–1989) and Qiu Xiaomei 裘笑梅 (b. 1910). Ha notes that in the treatment of menopausal disorders, “...one must take the regulation of the penetrating and conception vessels as the foundation. But in order to regulate penetrating and conception vessels one must regulate the visceral systems, harmonise qi and blood (Ha Litian 哈荔田 1982).” Qiu, likewise, emphasises penetrating and conception vessels, which she links to yin deficiency and liver yang patterns. The treatment strategy, for which she is famous, focuses on ‘subduing yang’ (qian yang 潛陽) and ‘nourishing the spirit’ (yang shen 養神), combining two formulae in which not a single herb is used to tonify the kidneys (Anonymous 2005). And even Luo Yuankai 羅元凱, chief editor of Chinese Medicine Gynaecology, does not do in practice what he preaches in his textbook. In the one published case record of a menopausal woman treated by Luo I have found, his diagnosis was “qi and blood deficiency type” (qi xue liang xu xing 氣血兩虛型) for which he used a variation of Four Gentleman Decoction (si junzi tang 四君子湯) as his base formula (Zeng Lingzhen 曾令真 et al. 2004: 280).
Many other examples could be cited. My intention, however, is not to document in detail the diverse approaches to the treatment of menopausal syndrome that can be found in the modern and pre-modern case record literatures. Rather, I wish to call attention to the complex history of invention and reinterpretation that lies below the surface of the matter-of-fact narrative found in TCM textbooks. It should be clear by now that there is nothing within the Chinese medical tradition that naturally leads to the definition of menopausal syndrome as a problem of kidney deficiency. It is not what the texts say, nor is it the experience of 2,000 years of clinical practice. Substituting kidney deficiency for hormonal deficiency is, however, precisely that interpretation of those resources that makes Chinese medicine appear most similar to biomedicine whilst pretending that it has, in fact, an independent identity. These strategies can be interpreted as innovative and as succeeding in adapting Chinese medicine to a modern age (Scheid 2002; Karchmer 2004). One can also, however, take a more critical stance and view them as the product of an insidious process of colonisation—mediated through channels that include diffuse yearnings for modernity as much as explicit political directives—whereby this previously independent medical tradition has fundamentally reconfigured itself in the image of a dominant other. This has ensured its survival—for the moment at least—as a nominally independent tradition within China and greatly facilitated its diffusion throughout the world. Such colonisation does not come for free, however. At best, it implies a submissive position that inhibits independent development; at worst, it threatens the destruction of the colonised subject—though more on that later.
6 Menopause and Culture
If, like the Oxford English Dictionary, we define menopause as “the permanent cessation of menstruation”, it is a gendered species universal occurring sometime in the late 40s or early 50s without significant variations across cultures. If, on the other hand, we use menopause to mean “the period of a woman's life when this occurs”, which also is part of the dictionary definition, then the subjective dimensions of women's experience of midlife and their relationship to local cultures, ideologies and histories are moved to the fore (Lock 1993; OED Online 2004). Women in East Asian cultures like Japan, Singapore, Hong Kong, Taiwan and Malaysia for instance, do not generally associate the menopausal transition with the vasomotor symptoms (hot flashes) so emblematic of menopause in the West (Chen et al. 1998; Chim et al. 2002; Haines et al. 1995; Ismael 1994; Kagawa-Singer et al. 2002; Lam et al. 2003; Tsao et al. 2004). Muscle and joint pains, as well as depressed moods, tend to be frequently reported symptoms in these cultures, but most women do not consider menopause a problem requiring medical intervention. This is reflected in a relatively low uptake of hormone replacement therapy in countries like Hong Kong, Japan or Taiwan (Lam et al. 2003; Leung et al. 2004; Tsao and Huang 2004).
However, as Shea (2006a, b) demonstrates on the basis of her detailed studies of menopausal women in Beijing, oppositions between a western and Asian menopausal transition simplify a more complex picture. The women in Beijing Shea surveyed, for instance, were much closer to comparable cohorts in the USA than in Japan. The reasons for cultural differences in the experience of the menopausal transition thus appear to be complex, multi-causal and poorly understood. Besides possible genetic differences, diet and lifestyle, they include perceptions of what it means for a woman to become older and how she is to manage menopause in relation to her own personal life, cultural expectations of femininity and biologically shared processes and signs of ageing. Such perceptions are sites of contestation, shaped by diverse agencies and ideologies, and thus always in a process of transition themselves (Feher et al. 1989; Kuriyama 1999; Lock 1993). In a sample of American menopausal women interviewed by Martin in the 1980s, older women, for instance, experienced menopause as a potentiality, allowing them to face life free of the burdens of reproduction. Younger women, in contrast, appeared to have internalised the biomedical model of the menopausal body as being out of control and requiring support (Martin 1987). Contemporary middle-class Asian women increasingly report symptoms that match those of Western women. This could be related to a shift in bodily attention stemming from a desire to be modern (i.e. Western). It might equally denote a desire to escape from what Bulbeck calls the “midlife silence” of Asian women. Bulbeck sees this silence as arising from taboos concerning the discussion of sexual issues including menstruation, from fears of being criticised for failure of self-discipline or expressing ‘menopausal madness’ and from lack of information concerning how to name symptoms and lack of access to treatment—is open to question (Bulbeck 2001).
Whatever the reasons, such differences help to explain why until the 1960s menopausal problems did not constitute a topic of concern to Chinese physicians. What problems required treatment were classed under other disease categories, though which ones we cannot know. Alternatively, they would have been treated within the family by women knowledgeable about medicine, by midwives or by religious-based non-elite healers. Such healers left few written records, and their methods would be difficult in any case to integrate into the rationalistic framework of modern TCM.
Even in contemporary Chinese medicine clinics, women seeking help for menopausal problems are rare. The Shanghai gynaecology expert Cai Zhuang 蔡庄 estimates that less than one in six of menopausal women in this most westernised of Chinese cities suffer from symptoms serious enough to require treatment (Cai Zhuang 蔡莊 and Zhou Fengqing 周佩青 1997: 100). In the West, however, more than half of all women suffering from menopausal complaints such as hot flashes look towards alternative medicine for help (Hill-Sakurai et al. 2008). The ensuing demand for practices such as TCM may well have filtered back to China and influenced physicians there to design treatments specifically dealing with this problem.
How women in China experience menopause, however, differs significantly both from place to place and from what women experience in the West. Psychosomatic symptoms rather than hot flashes are the most commonly reported signs of distress. Zhao et al. (1996), for instance, found that 46% of menopausal women in China suffer from depressive symptoms, with 30% experiencing moderate or severe depression. The precise mode of presentation of what we would call depression seems to differ, however, in different regions and provinces. Whilst a large percentage of women in Fujian complain of symptoms such as restlessness, unhappiness, depression and negativity, Jiangsu women appear to suffer more from irritability, unstable moods and difficulty in concentration. In both groups, failing memory was the most common complaint, with hot flashes being prominent in Jiangsu but significantly less so in Fujian (Tables 2 and 3; Ge Meiyun and Meihua 1995; Li Songtao and Xi 1995).
Although methodological problems associated with these studies in terms of how data were elicited, sample sizes, inclusion of menopause due to surgery etc. have been pointed out by Shea (2006a, b), I haveincludedthemhereinasmuchasChinese medicine physicians might arrive at understandings of their female patients' symptoms by way of similar modes of questioning. Furthermore, from the symptoms that bother menopausal women in Jiangsu or Fujian, it would be difficult to ascertain kidney deficiency (flagged in any standard TCM textbook by symptoms such as aching and weakness of the back and knees, loss of hearing, urinary problems, oedema or dryness) to be the major problem for either group. Moreover, whereas Jiangsu women would appear to tend towards heart/liver excess patterns (irritability, palpitations, restlessness, heat, etc.), Fujian women seem to be more prone to deficiency/stagnation (slow reactions, unhappiness, depression, sweating, unable to make up one'smind, etc.). Admittedly, my attempts at large-scale diagnoses are nothing more than educated guesses. But the marked regional differences on which they are based call into question from yet another perspective the entire methodology by which TCM textbooks have constructed their strategies for treating menopausal syndrome. For rather than beginning with the symptoms actually experienced by women in the clinic (assuming this was accurately collected and assuming that sound comparisons could be made), the editors of these textbooks took biomedical theories of menopause as the starting point from which they devised their treatments. Not only are these treatments thus not experiential, they also embody—like biomedicine—an ideology of ageing as decline that privileges universal biology over local experience.
7 Conclusions: Towards a Critical Engagement with Chinese Medical Modernisation
I have shown that the TCM discourse and treatment of menopausal syndrome was invented in the 1960s by translating biomedical ideas of ageing into Chinese medical idioms. This newly invented discourse was then disseminated for both domestic and international consumption as “authentic” Chinese medicine. Yet even as Chinese medicine physicians were constructing universal treatments for a disorder hitherto unknown in their own culture and tradition, the unity of this disorder was challenged by western ethnographers working in Asia who defined it as reflecting distinctly “local biologies” of ageing. The term refers us to the fact that it is the co-production of biologies and cultures that contributes to embodied experience and, in turn, shapes our engagement with the body (Lock 2001; Lock and Kaufert 2001). The very modernity that the TCM discourse on menopause sought to construct has thus already been left behind by a post-modernity that seeks to undermine previous certainties regarding the articulation of global and local knowledge, practice and being.
Depending on which aspects of these encounters one moves into the foreground and what framework of analysis one employs for that purpose, the morale of this story can be made to appear in many different lights. One could choose, for instance, to celebrate Chinese medicine's ability to integrate biomedical disease categories such as menopause into its scope of practice as a sign of the continued vitality of that tradition. From this perspective, it is the achievement of Prof. Zeng and her colleagues to have made Chinese medicine relevant to a contemporary audience (of politicians, bureaucrats, patients and physicians in both China and the West) for whom menopausal syndrome is a reality. From the perspective of science and technology studies, their method of bricolage is no different in essence from the practices of scientists who create knowledge by simultaneously domesticating and adapting to the multiple other agencies with which they must engage at each concrete moment in time. For historians of medicine, Prof. Zeng may be said to merely continue what previous generations of physicians in her own tradition have been doing for centuries, namely to add to an ever enlarging medical archive her own ideas and commentaries.
There are also stories of resistance and accommodation here in the manner in which Chinese medicine allows itself to be assimilated to a global biomedical discourse on menopause yet continues to undermine its universality on the level of concrete clinical practice. For in writing a formula that draws on personal experience and the entire archive of their tradition, Chinese medicine physicians exploit a space that they can only occupy the authors of TCM textbooks created for them. We can furthermore identify the tensions between centre and periphery that widely accompany the diffusion of knowledge (Hwang 2008)—though where is the centre and where is the periphery once more changes with the perspective one adopts. From within the Chinese medical tradition, the fact that for Western practitioners of Chinese medicine the TCM view of menopause is the Chinese medicine view, whilst physicians in China, including textbooks authors, are able to accommodate more easily to multiple different understandings denotes China to be the centre. Yet, the centre is the West if we focus on the import of menopause into the Chinese medical tradition, or the more complex understanding of menopause as a problem of local biologies that is emerging at the interface of natural and social sciences but entirely absent yet from Chinese medical texts.
As a historian of medicine or globalisation, finally, one could focus on the interweaving flows of ideas and practices from East to West and back again, through which the discourse of menopause in Chinese medicine is being constructed. Here, one could highlight that what is marketed and consumed as authentic and traditional Chinese medicine is but a response to specifically western yearnings for authenticity, tradition and the East. One could also emphasise that in order to survive in contemporary China, Chinese medicine has had to adapt to both western knowledge and western desires. One could use the case of menopause to show how the diffusion of Chinese medicine around the globe is enabled by attaching it to the circulation of other kinds of knowledge and analyse the standardisations necessary for inserting it into the networks that facilitate such flows. Finally, one might want to highlight some of the ensuing paradoxes and unintended consequences, like that fact that in emphasising yin tonification for the treatment of hot flashes, Chinese medicine practitioners in the West are taking sides in a century-old debate of whose very existence most of them are unaware. After all, in preferring yin tonification over the tonification and regulation of spleen and stomach, they are associating themselves with Zhu Danxi and his followers against the Yishui current of Zhang Yuansu and Li Dongyuan.
The position I prefer to take myself is that of employing the resources of ethnography, history and science studies for critically interrogating contemporary Chinese medicine. Here, my investigation shows that if hitherto Chinese medical treatment strategies addressed pathophysiological processes that physicians deduced from their patient's presenting symptoms and signs (known as “patterns” or 證 zheng), their gaze—at least in the case of TCM and menopause—is now directed at something quite different: a biologically determined physiological change (meno-pause) that is interpreted via historically specific biomedical disease theories (estrogen deficiency) from which inferences are drawn about “deficiency patterns” (虛證 xu zheng) in the Chinese medical body. Whilst this is a strategy of survival, it is also one that refashions the Chinese medical body in the image of a dominant other. This reflects submission, but the real danger lies in admitting that Chinese medicine can only begin its work once biomedicine has defined the reality of a disease. As I have shown elsewhere, from the 1950s onward, TCM physicians defined themselves increasingly as being concerned with “patterns” vis-à-vis biomedicine, which they defined as being concerned with disease (Scheid 2002: chapter 7). In taking disease to be the first rubric in any process of diagnosis, TCM accepted its secondary status within the overall health care system but appeared to be able, at least, to protect its independent identity. The case of menopause shows, however, that biomedical definitions of disease have also invaded the definition of patterns and thus of what Chinese medicine is and how it knows. But if Chinese medicine can no longer know disease by itself, then perhaps it can also no longer effectively treat. This raises important questions about the effectiveness of Chinese medicine and, by implication, about its very right to exist.
8 Menopause and the Question of Chinese Medicine's Effectiveness
So far, the question of whether TCM treatments of menopausal syndrome are clinically effective has not been very important. If the treatment strategies textbooks recommend do not work, then physicians have always had many others to fall back on. That, however, is changing. As Chinese medicine everywhere comes under increasing pressure to legitimise itself by way of evidence-based research, research that demands and proceeds precisely from the standardisations found in Chinese medicine textbooks, the reality created in these textbooks may yet come to define the practice of Chinese medicine everywhere. And should their treatments be shown to have no demonstrable clinical effects, this research will then begin to delegitimise not merely TCM and the hybrids of East and West it embodies but all of Chinese medicine past, present and future.
Conversations I have had with experienced Chinese medicine practitioners in Europe, Australia and the USA strongly suggest such a possibility—at least for the case of menopausal syndrome. Very few of the practitioners I spoke with said that menopausal hot flashes were easy to treat. They stated that modern TCM treatments for menopausal syndrome are, at best, only sometimes successful and often not at all. Those practitioners who felt extremely confident about treating menopause almost all used non-standard treatments in a large majority of their cases.
As Adams (2002a, b) has shown for the similar case of Tibet, once traditional medicines allow themselves to be evaluated by biomedical research methods, the odds against receiving fair treatment are heavily stacked against them. Effective treatments are either reconfigured so that they can be assimilated into biomedicine or, at least assessed by means of biomedical research methodologies or, otherwise delegitimised. Modernised but clinically often less effective treatment strategies are then taken by researchers with little or no interest in history or culture to stand for the tradition as a whole. And when, as might be predicted, these treatments fail to show the effects practitioners claim for them, the entire tradition is being delegitimised.
It is not the responsibility of anthropology, history or science studies to challenge any of these processes. However, just as these disciplines seek to provide a critical perspective on biomedicine, they have the same responsibility with regard to other medical traditions. Change and transformation are inevitable; the direction of that change however is not. Knowing something about the history of a disease, the theories practitioners hold about it and how the strategies for its treatment came to be constructed creates a space in which practitioners, researchers and other stakeholders in the future of Chinese medicine can examine, discuss and evaluate the risks and pay-offs of different directions to be taken. My essay has been a small contribution to this critical interrogation of TCM and Chinese medicine.