Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.1: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont.)

Rave Reviews

In 1983, Ted Kaptchuk, the senior author of the recent “albuterol vs. placebo” article, and soon to become the long-time Second-in-Command of the Harvard Medical School “CAM” program, published The Web that Has No Weaver:

The book received rave reviews:

A major advance toward the synthesis of Western and Eastern theory. It will stimulate all practitioners to expand their understanding of the causes and treatment of disease.

–Paul Epstein, MD, Harvard Medical School

A lucid and penetrating exposition of the theory and practice of Chinese medicine. While the book’s rich detail makes it of great use to practicing healers, it is in its entirety very simply written, enjoyable reading for the layman…it brings a demystifying balance…Instructive, profound, and important!

Professor Martin Schwartz, University of California, Berkeley

…demystifies Oriental medicine in a remarkably rational analysis…

—Science Digest, Nov. 1982

…an encyclopedia of how to tell from the Eastern perspective ‘what is wrong.’

—Larry Dossey

Dr. Kaptchuk has become a lyricist for the art of healing…

—Houston Chronicle

Although the book is explicitly detailed, it is readable and does not require previous knowledge of Chinese thought…

—Library Journal

The 2nd edition was published in 2000, to more acclaim:

…opens the great door of understanding to the profoundness of Chinese medicine.

—People’s Daily, Beijing, China

…weaves a picture…that is eminently understandable from a Westerner’s point of view…adds a valuable analysis of the current scientific understanding of how the therapies work and their effectiveness.

—Brian Berman

Ted Kaptchuk’s book was inspirational in the development of my acupuncture practice and gave me a deep understanding of traditional Chinese medicine…

Dr. George T. Lewith

…a gift for all who share an interest in deep understanding of healing. This new edition is essential reading…

—Michael Lerner, President, Commonweal

Even Edzard Ernst, still in his foggy period, called the 2nd edition “a brilliant synthesis of traditional and scientific knowledge…compulsory reading…”

Andrew Weil, who wrote a forward for the 2nd edition, praised Kaptchuk for “merg[ing] the insight of a Taoist sage with the skepticism of a modern, inquiring scientist,” and asserted that

…the emphasis of Chinese practitioners on energy and its balanced flow throughout the body is a stumbling block for Westerners who cannot see beyond the limitations of the paradigm of materialistic science.

Margaret Caudill, who wrote forwards to both editions, praised Kaptchuk for having written

…an important exposition of the ancient art of Chinese medicine in terms that can be understood by a Western audience. The author has deftly avoided, as much as possible, the pitfall of interpreting Chinese theory through Western terminology, thereby leaving the central Chinese concept of medical patterns and disharmonies undisturbed.

(One wonders if Caudill had read the book that she introduced. Kaptchuk himself, on the third page of his own introduction, states that he tried to “explain Chinese concepts with a Western vocabulary,” although he’d found that “at times [this] was a very great problem.”)

What readers might expect to find, then, is a book that is easy to read and understandable to Westerners, that is rational, that ‘demystifies’ its subject, that will provide a ‘deep’ understanding of healing, that will “expand their understanding of the causes and treatment of disease,” and that heralds a ‘synthesis’ of Eastern and Western medicine.

I perused the first edition of The Web around 10 years ago, when I was trying to learn something about acupuncture for my work on the Massachusetts Special Commission on Complementary and Alternative Medical Practitioners. A friend had it on his bookshelf, and let me borrow it; he hadn’t read it himself. A few days later I reported back to him: “there is sophistry on nearly every page.”

This review is mostly concerned with the first edition; I’ll mention some things about the 2000 edition in the subsequent posts.

“A Coherent and Independent System of Thought”

Kaptchuk begins by dismissing two, presumably dominant Western notions of Chinese medicine:

Some…see it as hocus-pocus—the product of primitive or magical thinking. If a patient is cured by means of herbs or acupuncture, they see only two possible explanations: either the cure was psychosomatic or it was an accident, the happy result of hit-or-miss pin-sticking that the practitioner did not understand. They assume that current Western science and medicine have a unique handle on truth—all else is superstition.

Other people have an equally erroneous view of Chinese medicine. Deeply and often justifiably disturbed by many of the products of Western science and culture, they assume that the Chinese system, because it is more ancient, more spiritual or more holisitic, is somehow more “true” than Western medicine. This attitude threatens to turn Chinese medicine from a rational body of knowledge into a religious faith system. Both attitudes mystify the subject—one by arrogantly undervaluing it, the other by setting it on a pedestal. Both are barriers to understanding.

But no more a barrier to understanding than the passage just quoted. We who ‘arrogantly’ undervalue Chinese medicine do so not because we see only two possible explanations for its apparent successes; we see many explanations, none involving hit-or-miss pin-sticking, accidental or otherwise. We deny that science is ‘Western,’ any more than the physics of Einstein was ‘Jewish’ (I confess to having used this quip repeatedly, but in my opinion it can’t be repeated enough). We immediately detect, in the phrase “current Western science,” the Galileo Gambit, and we reject that bit of sophistry. We’ve seen precious little evidence of cures by means of herbs or acupuncture, and 28 years later we’re still waiting. Those who think Chinese medicine is more true than ‘Western medicine’ have a problem with science other than merely being disturbed by its “products.” They are, er, deeply ignorant of it.

What, then, is Kaptchuk’s view of Chinese medicine?

Actually, Chinese medicine is a coherent and independent system of thought and practice that has been developed over two millennia. Based on ancient texts, it is the result of a continuous process of critical thinking, as well as extensive clinical observation and testing. It represents a thorough formulation and reformulation of material by respected clinicians and theoreticians. It is also, however, rooted in the philosophy, logic, sensibility and habits of a civilization entirely foreign to our own. It has therefore developed its own perception of the body and of health and disease.

If you’re bracing for an onslaught of the usual sCAMbits—unfalsifiable assertions, propaganda language devices, arguments from ignorance, arguments from tradition, special pleading, changing the rules ad lib, breezy contradictions, and all the rest—you’re on the right track. Right off the bat, Kaptchuk asks that you check your own critical thinking skills at the door:

In order to understand it, we must first accept two principles: that another perspective, though different from our own, can be logical and have predictive validity, and that there can exist another method of healing. In other words, the world can contain two rational and effective medical systems, both describing the same phenomena, but describing them differently. Once we accept these premises, we can begin to understand the Chinese view of physiology.

I’ll give you a taste of that ‘physiology’ below, but first know that for Kaptchuk, Western medicine suffers from a severe case of reductionism, whereas Chinese medicine is far more interested in you as a whole person:

Western medicine is concerned mainly with isolable disease categories or agents of disease, which it zeroes in on, isolates, and tries to change, control, or destroy. The Western physician starts with a symptom, then searches for the underlying mechanism—a precise cause for a specific disease…

The Chinese physician, in contrast, directs his or her attention to the complete physiological and psychological individual. All relevant information, including the symptom as well as the patient’s other general characteristics, is gathered and woven together until it forms what Chinese medicine calls a “pattern of disharmony.”…Oriental diagnostic technique does not turn up a specific disease entity or a precise cause, but renders an almost poetic, yet workable, description of a whole person.

“An Effective Healing Method”

Kaptchuk asserts that Chinese medicine considers some things important that Western medicine does not, and vice versa:

…Chinese medical theory does not have the concept of a nervous system. Nevertheless, it has been demonstrated that Chinese medicine can be used to treat neurological disorders. Similarly, Chinese medicine does not perceive an endocrine system, yet it is used to treat what Western medicine calls endocrine disorders. Nor does traditional Chinese medicine recognize the bacteria Streptococcus pneumoniae as a pathological cause of pneumonia [sic], yet often it effectively treats the disease.

The first two claims are trivially true, of course, but beg the relevant question: the humoral system of medicine was also used to treat all sorts of diseases, as has every pre-scientific form of medicine. The pneumonia claim is another matter, for which Kaptchuk doesn’t offer particularly convincing evidence:

…the Chinese performed thousands of experiments and clinical studies during the fifties. The result was that in 1958 the Central Committee decided to give traditional and modern medicine equal respect and place in China…

The pages of such studies fill entire libraries, yet it is not their quantity that is important, but rather their conclusions: that traditional Chinese medicine can hold its own, that it does work clinically.

It is now evident that Chinese medicine is an effective healing method.

Kaptchuk proceeds to cite numerous, presumably positive or at least promising studies from China, involving heart disease, cancer, kidney disease, asthma, encephalitis, diphtheria, acupuncture anesthesia, and more. He points out that when these are “diseases recognized by the West,”

the actual application and methodology are clearly Western in orientation. The theory of Yin and Yang and other traditional concepts are left behind…

Fortunately for its future, however, the results of the studies generally demonstrate that traditional Chinese medicine does work best when left in the context of Chinese logic.

He continues to plead the case for the unfalsifiable:

…the Chinese view of health and disease as inseparable from a specific person means that the treatment will be well tailored to that person. Such personal shaping seems to maximize the effectiveness of the therapies.

Nevertheless,

Western clinical studies (done in China) of traditional Chinese medicine, by proving its practical efficacy, have helped it win its battle for survival in the twentieth century, and promise it a place in the future of medicine.

Later, in a footnote, Kaptchuk mentions that those weren’t, like, real studies: they weren’t controlled, and many used “imprecise assessment methods. They would most properly be called clinical observations.” Throughout the book he continues to cite them in support of various unlikely cure claims.

Sometimes he just makes stuff up without even attempting to justify it:

Chinese remedies are often more effective than Western ones, and they are always gentler and safer. Chinese prescriptions, for example, do not produce side effects because they are balanced to reflect a patient’s entire state of being.

Chinese medicine, because it emphasizes balance and relationship more than measurable quantity, can also frequently discover and treat a disorder before it is perceptible by the most sophisticated Western diagnostic techniques. Chinese medicine is capable of touching those places that evade the microscope…

Woah. Dr. Epstein, did you even read this stuff? Dr. Ernst? OK: Dossey, Weil, Berman, we expect them to quack right along, but really. Dr. Delbanco? (He’s not one of the reviewers quoted above, but one of my former mentors at Harvard. He told me a few years ago that he’d been Kaptchuk’s patron. Did he read this book?)

Kaptchuk never explains the real reasons that “the Central Committee decided to give traditional and modern medicine equal respect and place in China,” previously discussed here. In that post I also showed how one of the passages quoted above morph’d from the 1983 edition to the 2000 edition of The Web; it isn’t flattering to the ideal of intellectual honesty.

“Images of the Macrocosm”

What about that Chinese view of physiology? It turns out that Kaptchuk, who coined the phrase, asserts only a few pages later that there is no such thing. We already suspected that, but let’s play along:

The highly developed constructs [sic] of chemistry, biochemistry, anatomy, and physiology that form the groundwork for modern Western medicine are of little importance to the Chinese…Chinese medicine therefore has a very limited theory of the human organism itself.

But didn’t he tell us that the Chinese physician directs his or her attention to the complete physiological and psychological individual? I guess it depends on what your definition of “truth” is:

The essential ideas of Chinese medicine…are cultural and speculative constructs that provide orientation and direction for the practical patient situation…The ‘truth’ of these ideas lies in the way the physician can use them to treat real people with real complaints.

Maybe we’re getting somewhere, because the essential ideas are certainly cultural and speculative constructs; but there are those real complaints again, such as pneumococcal pneumonia. I thank Kaptchuk for now having made it clear that I needn’t go into excruciating detail about what I’d imagined he meant by the “Chinese view of physiology,” even as I cringe when I consider that he probably hadn’t intended to insult Chinese people in general.

But wait:

For the Chinese, Qi is not a metaphor; it is a real phenomenon that makes possible integrative descriptions of bodily changes.

Such contradictions are rampant throughout the book (and ya gotta love those “integrative descriptions”):

Chinese medicine is not primarily quantitative.

But:

It has standards of measurement that allow practitioners systematically to describe, diagnose, and treat illness.

Aren’t measurements quantitative? Silly, Western me:

Its measurements, however, are not the linear yardsticks of weight, number, time, and volume used by modern science but rather images of the macrocosm.

Hmmm. Images of the macrocosm: simple, lucid, rational, understandable, demystifying—and each one a measurement to boot! Heck, no less a measurement than Dolores Krieger’s, and the macrocosm’s been around for a helluva lot longer.

The “Chinese View of Physiology”

The ancient Chinese, according to Kaptchuk, were totally into Functions and Relationships. I had therefore imagined that by “physiology” he must have meant the “Fundamental Substances”—Qi (“we can perhaps think of Qi as matter on the verge of becoming energy, or energy at the point of materializing”), Blood (“not the same as what the West calls blood”), Jing (“Essence”), Shen (“Spirit”) and Fluids (“bodily liquids other than Blood”)—; and the Organs (“The Harmonious Landscape”: Yin Organs are Heart, Lungs, Spleen, Liver, and Kidneys; Yang Organs are Gall Bladder, Stomach, Small Intestine, Large Intestine, Bladder, and Triple Burner; Curious Organs are Brain, Marrow, Bone, Blood Vessels, Uterus, and Gall Bladder again); and, of course, how they all work together to get things done. That’s physiology!

The Chinese view, according to Kaptchuk? Let’s see:

The Heart:

‘rules the Blood and Blood vessels’

‘stores the Shen [Spirit]’

‘opens into the tongue’

The Lungs:

‘rule Qi’

‘move and adjust the Water channels’

‘are the upper origin of water’

‘rule the exterior of the body’

‘open into the nose’

The Spleen:

‘rules transformation and transportation’

‘governs the blood’

‘rules the raising of the pure’

‘rules the muscles, flesh,’ and the four limbs

is the origin of Qi and Blood

‘opens into the mouth’

Organs vs. organs

It goes on and on, but I think you get the point. Kaptchuk insists that the ancient Chinese did not seriously intend to portray those Organs as real:

…the Chinese have no system of anatomy comparable to that of the West.

In China, internal anatomy is generally irrelevant to clinical practice.

The Heart, Lung and Kidneys of this volume are not a physical heart, lung, or kidneys; instead they are personae in a descriptive drama of health and disease.

The Organs of the body, defined as they are by their functions and relationships, are another part of the bodily web. They cannot be discussed out of context. The Chinese notions about Organs (or anything else) are not meant to be hard pieces of a theory that can be proved or disproved. They are part of an organizing network to be used when convenient. The Chinese would be indifferent to proof in our accustomed scientific sense.

China’s lack of an anatomical theory like the West’s does not mean its system is unscientific; it means only that there exist alternate systems of thought, one Eastern, one Western.

What are the differences between the two? Here is the remainder of the paragraph partially quoted above:

The tendency of Chinese thought is to seek out dynamic functional activity rather than to look for the fixed somatic structures that perform the activities. Because of this, the Chinese have no system of anatomy comparable to that of the West. Thus, for example, the Organ known as the Liver is for the Chinese very different from the Western liver. The Chinese Liver is defined first by the functions associated with it, the Western liver by its physical structure. This divergence makes it possible for Chinese medicine to identify Organs not recognized by the West—such as the Triple Burner—and for it not to recognize organs and glands clearly identified by Western medicine—such as the pancreas and the adrenal glands.

So it seems that in the West, physicians view organs in much the same way that butchers do: as mere “somatic structures,” without regard to their functions and relationships. This is nonsense, of course. I’m sure that every MD who was trained at least since the Flexner Report has thought of organs as being part of an anatomical and physiological whole, with countless, real functions and functional relationships among them, more of which are being discovered all the time. That’s physiology!

In reality, the ancient Chinese rarely dissected cadavres, so a straightforward explanation for their Organ confusion is the same as that for the centuries-long persistence of Galen’s erroneous anatomy in the West: prior to the last few hundred years the Chinese, like the Europeans, didn’t know any better. What anatomical information they had likely came from fleeting observations of mangled soldiers on battlefields, by extrapolating from the butchery of farm animals or occasional dissections of primates, and from very rare, mostly secretive dissections of human cadavres. Because such dissections were frowned upon, and Arguments from Authority were ‘privileged’ in both cultures until recently, even legitimate challenges to conventional wisdom, if there were any, were not appreciated.

Kaptchuk knows some of this but, once again, you have to go to the small print of a footnote at the end of the chapter to find the relevant passage:

China…had Confucian religious and ethical prohibitions against dissection…

The straightforward explanation is supported by some of Kaptchuk’s Organ descriptions being crudely accurate (the lungs really do “open into the nose”; the Stomach does “receive and ripen” food) and by some being inaccurate in ways that are understandable from a simplistic, purely anatomical point of view. For example, according to Kaptchuk, the “Kidneys are called the ‘root of life’…the source of reproduction,” and dysfunctions thereof are responsible for “sterility or impotence…or lack of sexual maturation.” Well, no, the kidneys have almost nothing to do with those things, but you might think otherwise if you knew only that there are tubes that connect them to the bladder and the bladder to the external genitalia. So much for an understanding of function and relationships.

An “Important Taoist Notion”

There is nothing shameful about a pre-scientific history; all cultures have gone through it. So why the subterfuge? Apparently the straightforward explanation evokes a Pattern of Disharmony with Kaptchuk’s central claim:

Chinese medicine is a coherent system of thought that does not require validation by the West as an intellectual construct. Intellectually, the way to approach Chinese concepts is to see whether they are internally logical and consistent, not to disguise them as Western concepts or dismiss them because they do not conform to Western notions. And the system is internally consistent—it is an organization of all the observable manifestations of the body into an integrated set of functions and relationships. Understanding of these functions and relationships enables the practitioner to identify and treat a disharmony in them.

And finally, his absolute, you-got-no-answer-for-this trump card:

The important Taoist notion—that the Tao (or Dao, the balanced and harmonious Way) that can be talked about and described is not the Tao—pervades medicine.

Ya gotta love the Gish Gallop. You also gotta appreciate how that important Taoist notion morphs, almost seamlessly, into current Quantum Quackery, with its own purported trump cards, misplaced versions of the Observer Effect and of Quantum Entanglement. This is no mere coincidence: Quantum Mysticism was all the rage during the 1970s, especially with the publication of Fritjof Capra’s annoying book, The Tao of Physics. Kaptchuk had apparently read another such book, The Dancing Wu-Li Masters, from which he borrowed this quotation attributed to physicist David Bohm:

Parts…are seen to be an immediate connection, in which their dynamical relationships depend, in an irreproducible way, on the state of the whole system (and, indeed, on that of broader systems in which they are contained, extending ultimately and in principle to the entire universe). Thus, one is led to a new notion of unbroken wholeness which denies the classical idea of analyzability of the world into separately and independently existent parts…

That works perfectly for someone who is hell-bent on dissing “reductionism” in Western medicine. There is that little problem of physiology, though…ya gotta wonder how all those wise reviewers missed it and just about everything else.

But back to ‘observable manifestations of the body’: doesn’t their being ‘observable’ imply that they are real, not just ‘internally logical and consistent’? Which, by the way, sounds awfully ‘Western’ to me. Oops, I stumbled again: throughout the book Kaptchuk refers to “Chinese logic”; that must be different from Western logic.

OK, I’ll try to be a little less snide. It’s possible that a system of thought can be coherent and internally logical and consistent, and yet still not be valid. Astrology, or at least some schools of it, could be such a system. Homeopathy could be another. So could the activities of the Tooth Fairy. There is also the question of just how coherent and logical and consistent Chinese medicine is. I hope this is becoming evident throughout this review.

Meridians: Interior vs. Exterior

Meridians are another important part of the Chinese view of anatomy and physiology:

Meridians are channels or pathways that carry Qi and Blood through the body. They are not blood vessels. Rather, they comprise an invisible network that links together all the Fundamental Substances and Organs…The Nei Jing says: ‘The Meridians move the Qi and Blood, regulate Yin and Yang, moisten the tendons and bones, benefit the joints.’

Are we to take such pronouncements literally? After all, “The Chinese notions about Organs (or anything else) are not meant to be hard pieces of a theory that can be proved or disproved.” Remember, there are many contradictions in this book:

In Chinese Meridian theory, these channels are unseen but are thought to embody a physical reality—the Substances Qi and Blood move along them, carrying nourishment and strength.

The Meridians connect the interior of the body with the exterior. (As has been said earlier, the distinction between inner and outer has more to do with significance than with place—the interior is more important than the exterior.)

Huh? But we were just told that the Meridians embody a physical reality. So do they or don’t they?

This is the basis for acupuncture theory, that working with points on the surface of the body will affect what goes on inside the body, because it affects the activity of the Substances that are traveling through the Meridians. Most acupuncture points relate to the Meridians and most herbs a doctor prescribes will enter one or more Meridian pathways.

Well, the ‘exterior’ seems to really mean the exterior, i.e., the surface. But does “inside the body” not mean the “interior”? After all, “the interior is more important than the exterior.” But “the distinction between inner and outer has more to do with significance than with place,” and elsewhere Kaptchuk tells us that “in China, internal anatomy is generally irrelevant to clinical practice.” This is making me dizzy.

Kaptchuk next discusses the number of meridians and the number of acupuncture points, without mentioning their relation to astrology. Throughout the book he also fails to deal adequately with the abundance of military, political, geographical, and meteorological metaphors in pre-scientific Chinese medicine, as well as the conspicuous numerology (the number 5 recurs over and over again).

More rigorous historians, such as Paul Unschuld, have made compelling arguments that the Chinese actually thought of those entities as offering important insights—not merely convenient terms—for medical ‘theory.’ Unschuld reports that what Kaptchuk calls “Yin and Yang Organs,” the Chinese call “depot and palace organs,” respectively, even if they are “yin-yang pairs.” Unschuld does not agree with Kaptchuk’s mythologic view of Chinese ‘organs’; he (Unschuld) states that they were “understood as actual morphologic entities.” He also spells them in the lower case. According to Unschuld, such concepts as “stagnant qi” or “blocked qi” were likely derived from irrigation systems in farming. Such views would be an embarrassment to the claim that

…the world can contain two rational and effective medical systems, both describing the same phenomena, but describing them differently.

Patterns of Disharmony

Kaptchuk tells us that the Chinese are (were) not concerned with ultimate causes, but with patterns:

There is no distinction between the illness itself and the factor that “caused” it. The question of cause becomes incidental. In this sense, the word ’cause’ is almost a synonym for ‘effect.’ In Chinese pattern-thinking, what might at first seem to be a cause becomes part of the pattern, indistinguishable and inseparable from the effect. Pattern-thinking subsumes the cause, defining it in terms of the effect and making it part of the total pattern. What we in the West call a cause has little importance in Chinese thought. The lines of causality are bent into circles.

This concept is the basis for the title of the book: The Web that Has no Weaver. I have no reason to doubt that such circular thinking was true for some periods or for some aspects of pre-scientific Chinese medicine, because I don’t really know all that much about it other than what I’ve read in Kaptchuk’s book, in a couple of Unschuld’s books, and in a few essays here and there. I do suspect that Chinese physicians who held this view would have nevertheless jumped at the chance to learn about the real causes of disease, as they did in the late 19th century when the Germ Theory reached them, and as modern Chinese physicians are now doing through scientific research.

It seems, moreover, that not all pre-scientific Chinese physicians subscribed to the “cause has little importance” doctrine. According to Unschuld,

When a doctor who felt bound to the tradition of the medicine of systematic correspondence treated a patient, it was necessary for him to determine categorically which evil was afflicting the patient, via what organ the evil (if of exogenous origin) had found its way into the body, where it was currently located in the organism, what damage it had already caused in the economy of qi, and what other spheres it could possibly move into.

Back to Kaptchuk. Here are some of the “signs” that he would call ‘both cause and effect’ in Patterns of Disharmony: the Six Pernicious Influences (also called the Six Evils)—Wind, Cold, Fire or Heat, Dampness, Dryness, Summer Heat; the Seven Emotions—joy, anger, sadness, grief, pensiveness, fear, fright. Here are the Eight Principal Patterns of Disharmony: Yin/Yang, Interior/Exterior, Deficiency/Excess, Cold/Hot. According to Kaptchuk, the Eight Principal Patterns “are the fundamental model for mediating between [the] two realms” of Yin/Yang and the “signs of disharmony.”

Various combinations of these, which are countless, are beyond my patience to attempt to comprehend. The book is sprinkled with “clinical sketches,” however, which can help to give a flavor of how such Patterns are used. I’ll reproduce a couple of them shortly.

Tongue Diagnosis, Pulse Diagnosis and the $1 Million Challenge

Of the Four Examinations in Chinese medicine—Looking, Listening and Smelling, Asking, and Touching—there are two “pillars”: observing (Looking) at the tongue and feeling (Touching) the pulse. Kaptchuk writes that one of his own teachers “described the tongue as a piece of litmus paper that reveals the basic qualities of a disharmony.” Let’s see if this is credible. The following is a small sample of nearly four pages of tongue descriptions:

A scarlet tongue is deeper red than a red tongue, and points to an extreme Heat condition. In a disharmony characterized by External Heat, it indicates that Heat has entered the deepest levels of the body.

A purple tongue usually indicates that the Qi and Blood are not moving harmoniously and that there is a pattern of Stagnant Qi or Congealed Blood…A purple tongue may also be associated with the Liver’s failure to flow or spread properly.

Moss that is puddled with moisture is a sign of Excess Fluids, usually due to Deficient Yang (or Fire, the body’s internal Heat), but is also a possible sign of other patterns, such as Dampness.

A moss that appears firmly implanted on the tongue body, like grass sprouting from the ground, signifies strong Spleen and Stomach Qi. Moss that appears to be floating on the surface of the tongue is a sign of weak Spleen and Stomach Qi.

A greasy moss appears to be a thick, oily film covering the tongue or a portion of it. It can resemble a layer of white petroleum jelly or butter, and is a sign of Mucus or Dampness in the body.

A peeled tongue may be a sign of Deficient Yin or Fluids, or of Spleen Qi too weak to raise smoke.

A stiff tongue lacks flexibility…This type of tongue usually implies a Wind Pernicious Influence or Mucus obstructing the Heart Qi.

A trembling tongue seems to wiggle uncontrollably. When this type of tongue is pale, it is a sign that Qi is insufficient to regulate proper movement. If the tongue is red, the diagnosis is usually Internal Wind moving the tongue.

…particular areas of the tongue are said to correspond to particular Organs…which are helpful but are never considered absolute.

I quoted those passages not so much to demonstrate their absurdity—though absurd they most certainly are—as to demonstrate their obvious hopelessness as repeatable, agreed-upon physical findings (remember that there are many more where those came from). They remind me of the 35 or so shades of sputum that are listed in homeopathic repertories, each one requiring a match with about the same number of sputum textures, that must further be matched to each of hundreds or thousands of other multi-faceted “symptoms”; and even one little “mistake” among all those choices will purportedly make the crucial difference between choosing the simillimum and choosing a dud. (Look here, pp. 79-81)

Has a study ever shown inter-rater reliabilty for Chinese tongue diagnosis? Not that I know of. A couple of abstracts suggest the opposite, as you’d expect.

What about pulse diagnosis? This is the most important of all the Examinations, and is “far more complex than what we know in the modern West.” Kaptchuk takes it quite seriously. He spends about 16 pages describing “the 28 basic pulses.” They are categorized according to Depth, Speed, Width, Strength, Shape, Length, and Rhythm; some of them are the Floating Pulse, Sinking Pulse, Thin Pulse, Big Pulse, Full Pulse, Empty Pulse, Slippery Pulse, Choppy Pulse, Tight Pulse, Short Pulse, Long Pulse, Knotted Pulse, Flooding Pulse, Soggy Pulse, Leather Pulse, Spinning Bean Pulse. If these weren’t trouble enough, according to Kaptchuk they “are more often found in combination than in their pure form…”

Thus, writes Kaptchuk,

…pulse taking approaches the subtlety and complexity that bespeaks an art. It requires thorough training, great experience, and the gift of sensitivity. When the physician takes a pulse, he or she is alert to a tremendous array of sensations that must be expertly understood and arranged as a unity—the “feel” of an individual pulse…

…it is clear that the system is extremely complex, capable of infinite refinement. Pulse diagnosis is a very sophisticated art. It demands sublety and wisdom on the part of the physician to discern the relative importance of each variable and to make of them all an intelligent and precise diagnosis—to weave a useful pattern.

How is the pulse taken and what can it tell the physician? Rather than quote Kaptchuk, I’ll turn to Unschuld, who explains it in a clearer fashion, complete with a topographical metaphor that the ancient Chinese apparently took seriously. He notes that there are several methods:

One method was based on the notion that at the high point of the styloid process below (medial to) the wrist there was an imaginary line, called the “pass,” as a narrow passage through mountains. When a finger feels the pulse with light pressure above the “pass,” i.e., toward the wrist, the pulse offers evidence about the state of the lung and heart. The connection lies in the fact that the imaginary line, the “pass,” corresponds to the diaphragm in the human body. The lung and heart are located above this separation, in the yang area of the body. The lung and heart therefore manifest in pulse above the “pass” in the yang region. Below the pass, in the yin region, the pulse reflects the condition of the liver and kidney, organs which lie below the diaphragm in the yin region of the body. Right on the pass, the middle of the three fingers feels the state of the spleen, the organ that lies closest to the diaphragm.

A second method of pulse taking uses the pressure of a single finger. The finger exerts a light pressure in the area of the pass and feels the pulse just below the skin, that is, in a yang region, which provides information about the lung and heart. Somewhat greater pressure allows the finger to penetrate the level where the pulse of the spleen can be felt. Applying still greater pressure so that the fingertip enters the yin region and almost reaches the bone, the level of the liver and kidneys is reached.

This method stands alongside yet another by which the finger, by application of different degrees of pressure, feels the state of the five organs each at five different levels.

The “states” of the organs include the same possibilities that we saw for tongue diagnosis, e.g., dampness, cold, heat, congealed blood, stagnant qi, etc. It should be obvious to anyone with even a passing knowledge of anatomy and physiology, and with even a passing sense of reality—which apparently excludes the reviewers quoted above, assuming that they read the book—that the claims made for ancient Chinese pulse-taking are ridiculous. Dampness aside, if I were in charge of the Randi $1 million challenge, I’d offer it to anyone who could demonstrate that the maneuvres described above can repeatably yield information distinctly referable to each of the named organs, other than, of course, the heart.

The reports of dismal inter-rater reliability for tongue diagnosis also apply to pulse diagnosis.

“Clinical Sketches”

A patient suddenly gets a high fever and a severe sore throat. She has a red face, a dry, hacking cough, and no fear of cold. A Western physician takes a throat culture and discovers the presence of Group A beta hemolytic streptococcus. Antibiotics are prescribed, with good results. If the same patient had gone to a Chinese physician, he very likely would have diagnosed a Heat Pernicious Influence. Herbs like Coptis and Scutellena, which disperse and cool Fire, would have been prescribed. The results would have been adequate though perhaps slower to achieve than with the antibiotic treatment. Modern research shows, incidentally, that both Coptis and Scutellena inhibit the growth of streptococcus bacteria. Acupuncture treatment, such as needling Large Intestine 4 (He-gu, Adjoining Valleys), to cool Fire, would in this case have offered some symptomatic relief and heightened the body’s resistance, but would have been less effective than herbs.

Oh really? I haven’t pursued the claim made for the two herbs, but I suspect it goes something like this. Acupuncture would have “heightened the body’s resistance”? Spare me. The bigger problem is the blithe, ignorant dismissal of effective medicine: antibiotics don’t shorten the duration of uncomplicated acute streptococcal pharyngitis, so the ‘results’ of Chinese intervention, at least the results that Kaptchuk seems to be talking about, would have been no “slower to achieve.” What antibiotics do in this case—and the entire reason for taking them—is to prevent complications, most importantly post-streptococcal rheumatic fever. And you can bet, dollars to donuts, that neither the herbs nor acupuncture will accomplish that. Oops.

Here’s another Clinical Sketch, “taken from the author’s private practice”:

A woman, aged twenty-six, complained of wheezing, difficulty in breathing, and coughing, especially in the middle of the night. The pattern had begun suddenly when the patient was sixteen years old and had gotten steadily worse. The patient constantly felt tightness in her chest, unrelated to seasonal changes, and when an attack started, there was much sneezing and coughing. Phlegm with a thick and yellow quality was produced. The patient’s medical history was otherwise insignificant. Her appetite was good and her stools and urination were normal. She was very thin, with dark rings under her eyes. Her energy level was good except during an attack, and she did not report any emotional stress but seemed jumpy and anxious. Otherwise, her Shen was harmonious and clear. Her tongue was red and cracked in the middle and had scattered red dots. Her pulse was rapid (ninety-six beats per minute) and also slippery and slightly thin.

When she came for treatment, she was taking Western medication but wanted an alternative because the drugs made her dizzy, tired, and nauseated.

Many of the signs pointed to the pattern of Heat in the Lungs: yellow phlegm, rapid pulse, red tongue, and thirst. Other signs, such as the thin body, the chronic nature of the disorder, the peeled and cracked tongue, and thin pulse, pointed to Deficient Yin. The wheezing, thick phlegm, and slippery pulse indicated that Mucus was present. A combination of acupuncture and herbal treatments was administered to cool the Lung Heat, nourish the Yin of the Lungs, and eliminate Mucus. This therapy brought the symptoms under control within two weeks.

Although the patient is still subject to occasional attacks, they are much less frequent and intense. When needed, she takes herbs or uses an herbal inhalator [sic].

Kinda sounds like asthma, no? You’d think he might’ve asked about cigarette smoke, or maybe cats or dust in her abode. How about listening to her lungs, or maybe even considering (gasp) an objective test? Wasn’t he expected to gather “all relevant information?” (No matter, he nailed the tongue and pulse exams.) An “herbal inhalator”?

Conclusion

How does the Web that Has No Weaver measure up (in the macrocosmic sense, of course) to the reviewers’ promises? Let’s see: is it a book that’s easy to read and understandable to Westerners, that is rational, that ‘demystifies’ its subject, that will provide a ‘deep’ understanding of healing, that will “expand [our] understanding of the causes and treatment of disease,” and that heralds a ‘synthesis’ of Eastern and Western medicine?

Wow. No. In a nutshell, there is sophistry on nearly every page. It continues to astound me that such drivel could have been taken seriously by academic physicians. I suppose the two most likely explanations are, in this order, that they didn’t read the book—can’t say I blame’em, it was like wading through molasses—or that they were utterly fooled by the rampant, misleading language. This post could have been the rilly advanced course in that little bundle, and let’s face it, most academics have just not had the privilege of learning about such esoterica. Whatever else you can say about Kaptchuk, he’s a Master of Misrepresentation.

Some might quibble with my not having cited some reasonable or even insightful passages in the book. It’s true that there are a few, and if taken out of context they can make the author look quite respectable, if you’ll excuse the tongue-in-cheek Bostonian observation. Put’em back in context, however, juxtaposed with all the meaningless adjectives, fallacies, contradictions, unsupported claims and the rest, and it’s ever more clear: sophistry. Ya gotta look at the whole.

I heard Kaptchuk speak at the 2001 Harvard Medical School “CAM” conference. Early in his talk he recounted, in a defiant and triumphant tone that brought cheers from the partisan audience, an episode during the 1980s—perhaps at about the time that he’d treated the woman in the second clinical sketch—when he’d been under threat of arrest for practicing medicine without a license. Go figure.

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In subsequent parts: Dialectical materialism, PoMo gibberish, and an academic career built on sand.

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The Dummy Series:

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The Harvard Medical School series:

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Kimball Atwood

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