Acupuncture in Medicine: A Metaphor for Therapeutic Transactions in History to the Present

By Moolamanil Thomas

An exponential growth to medicine and therapeutic procedure has been possible only in modern science. The sciences in general are a post-Renaissance development. The disciplines developed in its methods have superseded those of previous traditions. Therapeutic traditions progressed in human biology, their practices helping to cure or alleviate some of the ailments perceived in the lore of human constitution. Whatever its interpretation, bio-physiology has a substantial species continuity enabling a social use for Traditional Therapies. A rationale for them within medicine and its science must be established. Investigating Chinese Acupuncture may suggest an approach to the scientific potential of other Traditional Therapeutics and, importantly, address the issue of public safety.
Knowledge transmitted through European, Asian, Arab and Persian civilisations includes medical traditions that contributed to the Renaissance development of Medical Sciences. Acupuncture today is indeed a constructive metaphor for transacting and developing specific traditional therapeutic methods in Health Systems of nations, while acknowledging limitations and improving safe delivery.

• Language: English
• Publisher: AuthorHouse UK
• Release date: Jun 24, 2014
• ISBN: 9781496975751

Moolamanil Thomas

Qualified at the University of Madras 1952 and then worked in the National Health Service (NHS) of Great Britain from 1954-1968. Returned to India and General Practice in New Delhi in 1969. Spent 5 months in China in 1983, studying Acupuncture at the Traditional School in Beijing. From 1984 work included experimental and clinical Research into Acupuncture and related techniques for the relief of pain conducted at the Department of Physiology, Karolinska Institute Stockholm. Work in Sweden included teaching and lectures for doctors, dentists, physiotherapists, nurses and other para-medical workers, the bio-physiology and practice of acupuncture at courses organised through the Swedish Medical Council. Publications include a doctoral thesis on Acupuncture from the Karolinska Institute and Karolinska Hospital in 1995.

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Published by AuthorHouse   06/20/2014

ISBN: 978-1-4969-7574-4 (sc)

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Contents

INTRODUCTION

Acupuncture in the present culture of Medicine.

Historical interactions relating to medical knowledge (Ch. I, II)

Traditional therapeutics and access to Primary Health Care

Complementary and Alternative Medicine.

Hazards for patient and the practitioner

The Scandinavian experience to the promotion of acupuncture

Traditional therapeutics and Science

Acupuncture and Pain (Ch. V & VI)

Placebos and the Conditioned Response

A possible Determinant of Variable Response

Paradigms and the Problems of Acupuncture Research

Traditional Practice, Social Medicine. Caring and healing or commerce and cures.

Chapter 1     REDISCOVERING TRADITIONAL KNOWLEDGE IN SCIENTIFIC DISCIPLINES.

An Indian Folk Tale

Pursuing Acupuncture as medical science

Acupuncture Awareness in Europe

Fusing a tradition within a prevailing medical culture?

Therapeutic Traditions and Paradigms

Reservations relating to clinical trials

Biological Tracks from Tribal healing

The Placebo and Nocebo responses

The Enterprise of Knowledge. Beyond a Greek Heritage

Empirical and methodical priorities.

Science before Renaissance science.

Changing Societies and cumulative knowledge

Borrowing but excluding source knowledge

The Colonial Enterprise and Native knowledge

Social Contexts and Knowledge Exchange

The Industrial Age, Colonisation; Knowledge Enhancement in Civilisational Conflict and Ideological contention.

Reflections on disciplinary narrations of ‘the other’.

The Colonial interlude and its appraisals of local knowledge.

The advent of the Colonial into indigenous systems

Health Care and the dichotomy between traditional and modern medicine

Chapter 2     THERAPEUTIC SYSTEMS, KNOWLEDGE EXCHANGE AND ENHANCEMENT

Migration, war and demographic change. Biological endowment and advancing civilisation.

A few illustrative models

Slavery, Caste and Chattels. Identities and civilisations.

Civilisations. Restricting the sources to historical achievement.

India

Therapeutic Diversity

North America

Regional Cross Fertilisations and Interactions.

Europe

The flight of scholars and their sources of knowledge from war, violence and civil strife.

Transactions of value which followed in historical exchange

The Dark Ages

Non-European contributions to Science and Medicine

Medical tracks in History leading to Medical Science:.

The Heritage of Science

The Passage. Seats of Learning, Universities

Classical antecedents to Discovery. Developments to the Physiology of Blood Circulation.

Science and imperatives to Medical Discovery.

Experiment and methods of Discovery.

Aspects of West Asian contributions to the evolution of modern medicine and its universal significance have been discussed.

Heterodox Inputs and the development of Medical Disciplines

Transformations of Health Practices by Populist Perception

Popular cultures, Metaphysics and Universal science.

Alternative Systems and Health Care

Chapter 3     EPISTEMOLOGIES AND THERAPEUTIC ENHANCEMENT

Early Materialism and metaphysics: Ideas and Strengths

Evolving methodologies and heterodox approaches.

Metaphysics and Traditional Chinese Medicine

The Culture and Epistemology of Acupuncture.

The physician and patient problems. The medical culture.

A Summary of Examination procedure

Meridians (Channels, Collaterals) and the circulation of Blood and Qi

Meridians and Acupuncture Points

Table-I

Table-II

Acupuncture points

Acupuncture Points with Special Effects

Table-III

The Back Shu and Front Mu Points

Therapeutic Modes of Acupuncture

Evidence Based Medicine (EBM) and Modes of Acupuncture

Chapter 4    DICHOTOMISED MEDICINE AND SOCIAL IMPLICATIONS

The Clinic of Today and Traditional Practice

Science in clinical practice

Recompense for Health delivery.

Traditional Medicine (TM)

Continuity in application without development.

Traditional Therapeutics. The Need for Development as a Social Imperative.

Inherent Development of medical disciplines.

Empiricism in traditional epistemologies sustainable in scientific method

Implications for Safety WITH the Practice of Traditional Medicine

Traditional Therapies in the United Kingdom

Implications of Dichotomised Medical Practice and Safer Health with the Practice of Traditional Medicine

An early Swedish Model for treating Pain with acupuncture.

Case History

Acupuncture and traditionally discernible caveats.

The Need for Unitary Policies toward Patient Safety

Health Systems and Choices for the Patient

Chapter 5     ACUPUNCTURE MECHANISMS

Clinical Acupuncture

Neurophysiology of Inhibitory Controls

The Gate Control Theory

Acupuncture Mechanisms.

Components of the sensory response to the inserted needle: DeQi.

Dorsal Horn Cells. Segmental Effects of Acupuncture stimulation

Nonsegmental Effects of Acupuncture and evidence for its mechanisms

Descending Pathways

The serotenergic System

The noradrenergic system

The cannabinoid system.

Diffuse Noxious Inhibitory Controls (DNIC)

Summary of the evidence of neurotransmitters and pathways involved in acupuncture analgesia

Evidences of Cortical and Subcortical signal alteration following acupuncture using Brain Imaging Techniques and its functional implications.

Brain substrates in acupuncture modulation of pain.

Chapter 6     PAIN PHYSIOLOGY

Recent developments in Medicine and Pain

Physiological function of pain.

Pain pathophysiology

Investigatory tools and techniques

Pain Measurement

Morphology of Pain Transmission Primary afferent nerves

In the skin

Central Cells and Pathways Contributing to Pain Transmission

The Spinal Cord. The cytoarchitecture of the dorsal horn.

Functional attributes in development

Views on functional significance of the Laminar organisation of spinal gray

The organisation of the dorsal horn and sensory processing

Functional Morphology

Ascending spinal cord pathways for pain

Sites for further nociceptive projections from the dorsal horn. Thalamus and Cortex

Peripheral and Central Nociceptor processing signalling or inhibiting Pain.

The sensory-discriminative component of Pain

The affective-motivational component of pain

Peripheral Nociceptor and central pathological processing.

Peripheral nerve injury

Microglia and peripheral nerve injury

The sympathetic nervous system and pain

Pain, Neurophysiology and pitfalls to treatment

Chapter 7     TRADITION TO BIOLOGY

Traditional acupuncture. Historical Excerpts & Venerable skills.

Acupuncture therapy, biological attributes and clinical studies

Meridians, Acupuncture Points and Biological Significance

Biological Acupuncture

Six Studiesxiv.

Features of Pain pathology which determine outcome to Acupuncture treatment.

Study I

The parameters for study

Pathophysiological Differentiation of Pain

Study II

Summary of outcomes

Study III

Summary

Results of treatment

Study IV

Assessment procedure

Group Comparisons and Results

Study V

The Results

Discussion

Study VI

Patients and Methods

Acupuncture modes and treatment schedules

The Development of a Therapeutic Tradition

Chapter 8     Placebo; Beecher to Benedetti

Benedetti et al. The Placebov.

Evolution and the placebo response

Variant Pain Response and Research Implications

Reflections on the studies of Benedetti and Beecher

In conclusion

Notes

INTRODUCTION

Acupuncture is a specific therapeutic function which had its origins and progressed within a historical context, systematised in an epistemology relating to that history. We cannot ignore that context while arriving at the possibility of its development in clinical medicine. Clinical scientists visualise problems for a specific discipline and attempt solutions by its stipulated methods. But in this instance we attempt these methods to solve problems associated with a discipline that is from the past with its own therapeutic methods of practice. Should these be ignored for finding relevance to its therapeutic function, or are they necessarily irrelevant because seen to be so by the methods fashioned for present therapeutic products? To consider acupuncture as a function within scientific medicine and to survey it in relationship to the Science of Pain without its background to the knowledge as was transmitted in history or even a nodding acquaintance with the more specific epistemology of Traditional Chinese Medicine (TCM) can be done only by denuding acupuncture of a prospective and testable potential. The neurophysiology of Pain demonstrates a pronounced inhibitory response that can be activated endogenously by the organism from different environmental inputs. The acupuncture needle inserted into peripheral tissues of an organism is one such input, albeit, therapist controlled. A tradition which discovered that function some millennia ago, developed and phrased it in a therapeutic system for a wide range of ailments, is now rephrased by neuroscience and its clinicians, without making much allowance for its past.

Metaphysical theories that sustained acupuncture are not within this brief except to illustrate and discuss (Ch. III) a few of its concepts as empirical possibilities. There are many renderings of Chinese Acupuncture traditions in English. At least two pay close attention in translation to the metaphysical concepts rendered in the Chinese languagei, and Porkettii, states its functional principles by adhering closely to semantics. My acquaintance with Traditional Acupuncture suggests that some of its practical applications were based in an empiricism which could be investigated by clinical trial (Ch. IV). Researching acupuncture within scientific medicine is to necessarily contend with a tradition based in metaphysics. This has problems due to incompatibilities to their respective epistemologies. However the clinician/scientist assumes that regulations of method to obtain therapeutic validation should apply per se to any therapeutic modality, even those that have been with us from the past. Questions relating to the method for ascertaining the validity of traditional therapeutics need more answers.

The opportunity was fortuitous that brought me to TCM in China to the Beijing School for Traditional Medicine and a few months of sustained contact with the traditional teachings of acupuncture. The period was hardly sufficient for me to claim a deep knowledge of acupuncture and further, a scepticism of my medical background stood in the way of being a whole-hearted novice. We were told at the commencement of the course to put aside any baggage of modern medical science we might be carrying in order to understand traditional Chinese medical theory within its epistemology¹. The lectures on theory were delivered by esteemed academics of that School, and later applied to patients at a hospital clinic under the supervision of its doctor of TCM who was, within that tradition, unmistakably an inspired clinician. Based on physical, including variant pulse and tongue examination followed by due deliberation and discussion, a traditional diagnosis of disease was treated with appropriate acupuncture point selections within those theories.

Non medically qualified participants in the course were from a Traditional school for Acupuncture in Los Angeles, and there were as well doctors of Medicine from Iran, Africa, Europe and South America and physiotherapists from Scandinavia. The Californian therapists were the most impressed by the rational presentation of traditional theory. They had an impressive prior fluency to discussing proto-scientific theories. Many months later a visit to their school of Traditional Medicine in Los Angeles was an experience in the exegesis of TCM, but as a later Western interpretation of Chinese Medical thought it appeared to be losing out to the empirical content and continuous systematisation of the Chinese². However, the doctors were generally naive to this content, willing listeners, though most were sceptical. It was the daily clinical routine with patients at the hospital which gained us the most from the course.

At the Beijing School, I found that their Teachers and Scholars were dismissive of medical Science. The attitudes of the professional rank and file within either of today’s active health delivery systems is mutual, both stressing exclusivity and a conviction in the superiority of their own separate systems of learning. I must admit to not becoming a votary of acupuncture in the setting of TCM. But nor can present methods for clinical study be relied upon as a certain means to assessing worth. Prior to the Chinese experience my attitude was that of the many colleagues, that traditional therapeutics have little to offer, even may be hazardous to patients, and its teachings have no relevance, in this day and age.³

I have since been impressed by the variety of expression and opinions about acupuncture by teachers, colleagues and collaborators, views that are debated, often hypothesised and researched; in sharp contrast to my initial exposure to acupuncture, straight from the horse’s mouth, so to speak, from the Academic Chinese Traditionalist whose singular position maintains that dissent or another viewpoint was due to inadequate knowledge which needed improvement and correction. In this context one is also up against positions held by the practitioner/scientist in medicine with strongly held notions about the discipline of science and who often forgets that even those are held within socio-historical influences and the regulatory compulsions of his discipline. Attitudes do colour issues but debate is always possible. The progressive resolution to the subject of acupuncture in science in the final analysis is a testable proposition, although there are impossibilities about the metaphysics of traditional acupuncture which cannot be conveyed for scientific evaluation. Although in clinical trials the practices of acupuncture, or recent versions, are evaluated certain obvious empirical propositions that are evident in traditional theory, even as expressed in an original epistemology convey in interpretation to controlled studies. Neurophysiological research in basic experimental work demonstrates increased thresholds to pain, while experimental and clinical studies show that pain inhibition can be achieved by acupuncture needle stimuli in variant applications. Clinical responses relating to inflammatory, immune related and circulatory patient pathology continue to be widely investigated in clinical trials using acupuncture, and experimental work demonstrates responses at molecular levels in many biological speciesii.

Acupuncture in the present culture of Medicine.

For knowledge to develop into science, the revolutionary advance of a new investigatory paradigm is essential; the scientist is convinced that previous developments and knowledge lacking that authenticity may be no longer viewed as functional science, but appreciated for their history. This position applies to the many physical sciences but past and present therapeutic knowledge is established as functional when the ailment shows responses in human biology. The responses, objective or stated patient perceptions, are the measure of any therapeutic system. Additional to the alleviation or reduction of signs and symptoms from therapeutic inputs, substances or procedure, there is the evidence of conditioned responses which can reduce pain or ameliorate a subject’s physical or mental distress and which had a therapeutic role in tribal societies from pre-historic time (Ch. II). There remain today demonstrations of similar responses in the cultural lore of societies as they recall a tribal past⁴. It is the potential of a biological trait which in pre-history was used for therapeutic purposes, and a continuity of the response is furnished by the ‘placebo’ in the present medical culture. Medical research poses the response as a nullity, a therapeutic artefact in order to differentiate from a virtual therapeutic source. The amelioration or cure for disease are available in the records of history, for easing pain, recognising symptoms of ill health or reducing fevers. We have the extant tomes of therapeutics and pharmacopoeias from world sources (Ch. II). In the final analyses it is the response, either perceived and/or demonstrated in biological parameters of measurement, which has sustained therapeutic systems. The medical scientist accepts that position, provided there is consistent experimental evidence. For therapeutics a determination is made not only by science but in social choices as well, a factor that does not feature for other sciences. Experimental laboratory demonstrations, accepted or rejected by the small community in the practice of the latter disciplines, are the absolute benchmark of the functional value of the other physical sciences.

It was a repeated experience of the 19th century scientist as he was confronted by the various disciplines in other cultural contexts to consign the painstaking knowledge gathered over centuries to an irrelevance. Chapter I consider a few colonial compulsions which required new disciplinary institutions to promote their interests, and amongst them the health needs of the coloniser had to be catered to in the emerging disciplines of medicine. But, it also emphasised a predicament, further cultivated in undertones of race towards the native and his knowledge. Countries with a pronounced Colonial past, when today required to consider those therapeutic traditions of the Orient are still unable to do so with an objectivity sufficient to supplant attitudes. The British approach to the social relevance of traditional medicine is quite unlike that in Sweden where a subject like acupuncture is taken up in methods for objective study and use and concerned Swedish administrative organisations coordinate with scientific institutions in determining their value for research and to educate and train medical auxiliaries to the use acupuncture for their society.

The term ‘alternative’ medicine is a self-imposed hurdle in countries where these traditions have arrived, the impression being that like acupuncture they must remain outside the prevailing medical culture. While the epistemology will not assimilate, traditional applications may arrive in the practice of medicine as the evidences unfold. Presently its many practices are in the public domain without sufficient evidence substantiating a specific value from the treatment. Investigating them for evidence of therapeutic value, side effects and hazards in their use is not merely a research necessity but a social imperative. That position recognises the need to proceed from acupuncture as an ‘alternative’ therapeutic modality to exploring its diverse possibilities and defining the indications for its use for pathological categories or, if possible, for the complex patient pathology seen in clinics. If acupuncture can be established as useful for a particular pathological problem or a possible way to manage a chronic problem, at least for a while, in lieu of surgery, or provide immediate and spectacular relief for either prodromal aura or an attack of migraine, or likewise, for the intense muscular spasm, the acute pain and distress of trismus or lumbago, then it is not an alternative therapeutic mode but becomes part of a physician’s treatment armamentarium for specific indications.

Historical interactions relating to medical knowledge (Ch. I, II)

The epistemic passage of knowledge, therapeutics in this instance, has a fairly long history from tradition to Science. The chapters that relate to history are an acknowledgement of what medicine as science owes to that history; the general acquisition of knowledge through the ages, from many sources and traditions to their more systematic cultural applications. In sifting an application like traditional acupuncture through the sieve of clinical research the relevance of historical processes may help us to appreciate that the evidence we seek may not come about by a direct transposition to the epistemology of science, and beyond that, the looming social issue of therapeutic systems which are still widely used, despite the presence of Medicine and its science.

Science is apparent within societies when special groups test empirical knowledge by application or by the strictures of method and then systematise that knowledge in a theoretical structure. The displacement of populations in violent local strife, war and migrations brought them into foreign cultures, but for groups with special talents it was also a contact with those of a similar bent, and the exchanges inevitably enhanced the content of specialised knowledge. But knowledge systems also get debilitated in the short run in conflict, although hardly ever to extinction. More often than not they survive and quality is enhanced in newer inputs and fresh ideas from other peoples. The gains to civilisations and the quality of their achievements are reasonably obvious, but not usually attributed to foreign incursion, nor to the inevitable addition to the variety of biological attributes by mixing ethnic stock. Inevitably cognitive processes have the imprint of the mix, allowing a fresh look at older systems, whether of the arts or other forms of knowledge.

There is a marked tendency, on the contrary, for achievement to rest in Civilisations and be identified by: geographical spaces—Europe, China; ethnicity—the Incan, Aryan; religion—the Islamic or the Hindu, and so on. The tendency in history for culture and knowledge in their narration to be insulated within an identity bound culture offers greater appreciation for studies of literature and art. But, civilisational identity can also obscure the contribution either from the influx of other peoples or as achievements enhanced in the wealth of exchange. Civilisations gather momentum from the upheavals of war and from admixture, the considerable biological exchange across vast land spaces through history offering innumerable shades which are lost in identity. Migration was a process from antiquity, the movements of people and apparent in the borrowing, acquisitions and advances to the content of forms of knowledge, even while they developed distinctive cultural markings.

There is well-known evidence of movement, the trade route from the Chinese mainland across to the substantial civilisations of what is now N.W Afghanistan into West Asia, the routes of the Old Silk Road. But not merely a trade route, it was responsible for much exchange to stock; through nearly four millennia, the prior exchange was of the Europoid with peoples of the distant Far East, from what is now Xingjian in China; in later centuries the reverse flow was along the centres of the antique civilisations of Bactria and Sogdiana, transforming essentially into the Persian. By then peoples identified as Mongoloid or Caucasian and Europoid had in a considerable mix, attained physical features that were shared, now confirmed as genetic exchange from DNA studies of surviving mummiesiii. We have evidence of the mix to population but are yet to appreciate the full exchange between civilisations of culture and the transactions providing recognisable features between knowledge systems.

Knowledge develops in the absorption of extraneous peoples and in adaptation for the differing social needs, local problems, or in the older culture of an existing society. The present discussion lays stress on the medicine of West Asia and Persia, the transmission of the knowledge and achievements from their mediaeval civilisations and its influence and impact on Europe, despite all the turbulence of confrontation. It is unreal to read the period for Europe as the Dark Agesiv considering the scholarship conveyed by Arab and Jewish physicians aiding and working with scholars in Europe’s centres of learning. Lifetimes were expended in compiling and translating the not inconsiderable knowledge of the times sustained and developed largely in the Persian and Arab world. Large land areas of Europe were dominated by Arab or Moor who instituted centres of learning, and created cities with their unique architectural imprint. Medicine flourished from that contact followed by innovative institutionalised facilities for teaching students and treating patients.

The difficulty for historians in the past was not the dearth of knowledge or its applications which is suggested in Europe’s Dark Age but that in accepting its quality and its extent also required a concession to their origins. The age was one of achievement in technology, mathematics and medicine, largely outside an European space as we know it now. Discovery relating to therapeutics, in seepage across the worlds, revive, and the restitution has enhanced its content. Transformed knowledge in the past obscured its origins. It may be difficult to relate particular discovery to preceding ones until we seek that evidence in the past since acknowledgements to precedence was not required. An example in medicine is of small pox and its prophylaxis. There were methods of delivering an attenuated virus throughout the centuries. Variolation and inoculation in its variety of practices may be recalled before Jenner. Another, the commonplace attribution of a blood circulation to the pioneer of the 17th century, William Harvey, also requires examination for influences, if not precedence; there have been statements in China in antiquity and, much later, the definitive demonstration of a separate pulmonary circulation by Ibn Nafiz, in West Asia in the 13th centuryv. The availability of that knowledge to workers like Cesalpino who later still followed with discovery of a venous circulation and the valves of veins are hardly referred to in Harvey’s substantial discovery. The process of continuities to discovery, the knowledge that went before was likely to have been available to William Harvey before he stated the physiology of the Blood Circulation in the De Motu Cordis. Considering a period he spent in Italy, tutored by the eminent Fabricus, this may not be speculation. The period, ‘the Dark Ages’ of Europe was suggested in the backward look at history from a later period of her ‘Enlightenment’ and colonial dominance. The ravages of prolonged internecine wars, religious fratricide and devastating famine, the final collapse of the Crusades against the Saracen and the period of Moorish dominance over much of Mediterranean Europe, and then the cowering at the ceaseless thrust of the Ottoman to her East—those times were, indeed, bleak, but not ‘dark’ for the lack of intellectual lamps. Past the turbulence, seeping into Europe was the considerable knowledge from the East shaping her intellectual history. European history as a disciplinary exercise in the heyday of Europe’s later world dominance had a distinct predilection for the readings slanted to her conquests and Power. To the European historian of those times it was not Europe’s medieval crusades, her own barbaric incursions ostensibly to safeguard Christendom from the infidel, but Europe’s Colonial might and mercantile gains that leave its mark on standard narratives. Rather than acknowledge the debts she owes to others for her knowledge base, narration stressed debility as the preferred condition in the history of pre-mediaeval Europe. Transmission of knowledge and accretion occurred before the Renaissance. If readings confine the history of Medicine and European science as merely extending from Europe’s Greek forbears, it shows an insularity which obscures the immensity of the addition to that knowledge. Newer medical disciplines evolved form that contribution and influenced Renaissance medicine. But its evolution from Greek sources was not in Europe but West Asia. In antiquity the exchanges between Egypt and Greece, knowledge relating to mathematics and astronomy was transmitted from the former to the latter, and was barely acknowledgedvi; but by around the 7th century CE much of the recorded knowledge in Greece itself was lost possibly following an Arab onslaught. However, the works from Hippocrates (460-451 BCE) to Galen (170-189 CE) were available for scholars in Rome, Alexandria and Constantinople. In Alexandria, that learning was sequestered having been subject to Roman aggression and internal turmoil. Knowledge also passed in antiquity between many civilisations in the further East, China and much of the therapeutic systems of India across to West Asia with considerable enhancement in the two way exchange. But it was the medieval Civilisation of Persia where medicine made the greatest progress and many qualitative improvements that flowered in related disciplines.

It was a Syrio-Arab community, the Nestorians, and their translations of ancient learning into Syriac, a derived language from the Aramaic that preserved and developed Greek knowledge in the centuries that followed. Greek knowledge had already been conveyed in Latin, and was available to the community at Alexandria. They rendered the Latin into Syriac, a language into which Latin translated with particular felicity. It was these scholars, who carried the knowledge of the Hellenes as they fled Alexandria from persecution and found refuge in Byzantium. Their patriarch Nestorius had founded his Church at Constantinople but his theological interpretations came into conflict with Rome and its Church. High theology, interpretations of the nature of Christ, a principle of the Roman Catholic Church was disputed and the result was the Edict of Ephesus which pronounced the patriarch and the community heretics; expulsions and migration followed, initially to Edessa in Syria. As exponents of a theological position which was suppressed they were bound to propagate their ‘heresy’ with missionary zeal and conveyed it far into the East, to India and China. There were theological consequences to Christianity in the East and to South Indian Christian denominations in particular but for this discussion the importance are the pursuits of Nestorians relating to medicine and its practice. These scholar missionaries had transmitted medical knowledge which had a bearing on the future development of medicine across the globe. Their incessant travail was the gain toward an universal future for medicine.

Again, after Edessa, the respite was brief and not until they had reached Persia around CE 500 where medical institutions were already flourishing, did they finally find a welcome and reposevii. The Sassinian dynasty’s encouragement of these Syrian scholars helped bring in translation knowledge of the ancient medicine of Greece to Persian medicine. There were also remarkable conclaves and exchanges between physicians and scholars from Greece in the West and to the East, from India and China. It gained for Persian medicine universality in synthesis of their medical practices, later reworked to great sophistication and reaching a far wider civilisational space. Under Shapur I, 271 CE, an eminent ruler, Gundeshapur had already become an academic and medical power house with its ancient University, older than Bologna or the al-Azhar in Egypt. Syriac and Arabic scholarship flourished and the scholarship of the Nestorians, encouraged by Kobad a later Sassanian ruler, qualitatively improved medicine in the institutions for healing patients and teaching students. Much of their improved medical facilities were due to the work of their own renowned physicians but medical scholarship of Persia was with contributions from original Greek, Syriac and Arabic sources and recourse through extensive translations of Sanskrit medical texts and other sources into Pahlaviviii. We now know more of that medicine, but the extent of the influence of Islam on European culture and medicine is a comparatively neglected, though an increasingly investigated field. The various disciplines, including medicine, during this period of Persian renaissance are being explored, and the many Islamic libraries of Cairo, Damascus, Baghdad, and Suraj Kund near New Delhi, and also Spain’s Escorial, should all be fruitful sources for investigations with particular reference to transmission and influences.

Post Renaissance European science is now accessible by application of an universal culture of mathematics, and medicine has developed within that science. But the new culture of medicine is indebted to the traditions founded in West Asia and later in the development of knowledge in regions under Islamic influence. It evolved from the ancient Greek, and in a pre-Renaissance history of the, often turbulent, relationship between Mediterranean Europe and West Asia. The extent of transmission into Europe was quite considerable from the civilisations of West Asia; to them and then into Mediterranean Europe, almost certainly, farther from China, through the Asiatic civilisations centred around Bactria. The extent of the two-way traffic, material and information, to and from these lands across the ancient Silk Road in antiquity, is as yet not entirely appreciated. The scientific revolution relegated traditional medical systems and past medical epistemologies as of little value, and then further demoted them in the more recent history of colonialism with its racial overtones. In that period the study and passage of knowledge in and from past civilisations were of little consequence, and even less were the therapeutic systems to medical history and its science. Deconstruction has reached history, while the general trend is for increased specialist interest in traditional therapeutics, but with hardly any reference to the continuities of exchange and their historical context.

Medical history implies more than just an acquaintance with names and a nod in the direction of singular discovery. The Industrial Revolution was an impulse for the progress of the sciences and, for medicine, the social context in the ensuing problems of rapid urbanisation and altered social conditions. Industrialisation changed social relationships and brought unprecedented pressures on society and living conditions. In the wake of the large migrations from the countryside came the new urban conglomerations built around the factories and their appalling physical conditions. Folk unable to change from the habits of village life, now found themselves in overcrowded, dismal, smog-hazed industrial and mining towns, living in unparalleled pollution of air, earth and water.

The energies of medical practitioner/scientists were stimulated by the need for a newer approach in science, and its innovative methods for finding evidence for ill health related to the environment. Discovery followed as the beginnings of the epidemiological sciences put in place important sanitary and public health measures from the evidence that cholera was a water-borne disease. The consequent and effective control of that disease commenced quite simply by ensuring a strict separation of sewage from drinking water supplies, preventing contamination. From there on continued the further and consistent discoveries of the bacterial aetiology of diseases or the vectors for the transmission of others. The great killer diseases in the West for centuries, small-pox, cholera and plague, soon became diseases of the past until they surfaced again later with a different connotation, a scourge of the Tropics. Pathological classification now included Tropical Medicine, its previous decimating endemicity in Temperate Europe forgotten. Medical Science had arrived in the colonies.

The new paradigm of hypothesis and experimental evidence was in place. While influencing previous systems of medical thought and practice the impetus was social and community health. Using the changing paradigms of the discipline, concerned scientist/physicians, found evidence for initiating public health measures for the control of epidemics. It was a revolution of medicine in science that owed much to the social context, a ferment of the Industrial Revolution and the new disciplinary methods of the natural sciences that established medicine in science.

Traditional therapeutics and access to Primary Health Care

The history of Medicine, besides discovery and its great names, is also of exchange, borrowing, transmission and reinterpretation of knowledge from many sources. Within those substantial contributions one can discern in today’s science and medicine recognisable insights, its primacy hardly acknowledged. The recourse to a few of its offerings in the present approach to acupuncture is not an academic exercise but a perspective, a reinforcement of value of the heritage to modern therapeutic programmes. Programmes and projects hardly acknowledge the salience of traditional therapeutics in the formulation of health delivery systems. Yet they are a presence.

Looking beyond my own discipline at acupuncture, has necessarily to be from a point of view formed in the study of medicine in India; later in the different clinical routines of surgical and general practice in England and India, the sojourn in China, and, finally research in neurophysiology and Pain in Sweden. It offers a perspective of issues with a degree of familiarity but no claim to scholasticism, in separate cultural and social milieus, issues which are not merely restricted to establishing the validity of a therapeutic tradition. In many countries the use of traditional medicine is widespread. There is extensive dependence on them for primary health care rather than the esoteric alternative availed of for a developed world. The problems they pose are not just an issue of validity but of making the general public and practitioners aware of their possibilities, limitations and dangers within a more unified culture of medicine⁵. (Ch. IV)

Today, in a country like India, primary health care remains to a substantial degree with Traditional Medicine because there is insufficient institutional infrastructure for modern health delivery. The state of Kerala, (see footnote) is exceptional. In other States universal health care has not been achieved and health needs are served by various therapeutic cultures, state and private institutions for modern medicine and many forms of traditional therapeutics both authentic and questionable. The expenses for the most part are the responsibility of those in need. For the public the question of choice does not arise, due to their lack of education, deficiencies of infrastructure and inadequate trained manpower. The important question of scientific evidence for traditional therapy is not an administrative concern as it should be, especially when Traditional Medicine and innumerable ‘other’ practices using its epistemological terms are the only available health care for much of the populace. There is an economic drain due to improper or inadequate first line care and a strain on the services of secondary emergency and management centres. The wastage in economic terms would possibly be sufficient to initiate better supervised, collaborative efforts, including a basic medical educational discipline that exposes traditional practices to medical science. The needs are specified in the conclusions of many committees set up by a Central administration to examine health requirements of society. Basic medical education is thought to require an orientation to the context of society, but currently follows the norms laid out by a previous colonial administration over a century ago.

The most extensive use of traditional therapies remains in the lands of their origins where their disciplines are appreciated by the public as part of their culture, unlike the acceptance of Western societies. It possibly introduces another set of variables, patient responses dependent on their culture. Cultural appreciation of therapeutic rationale is an importance common to West and East. It is a support mechanism, the patient’s hope for succour. In the West public interest in the esoteric is often without substantiating evidence or cultural affinity, but the Western public is increasingly uneasy with pharmaceuticals and aspects of modern medicine, perceiving a remoteness and lack of empathy in medical personnel which affects patient/physician relationships. Complementary and Alternative Medicine in the context is an attraction because practitioners are accessible and communicative even if the explanations are not within a patient’s cultural orientation.

Complementary and Alternative Medicine.

The Medical Establishment in Britain is aware of the gathering plethora of unconventional therapies and often, while looking askance at them for the lack of regulated evidence for its efficacy, acknowledges their increasing popularity. Thus, in an attempt at impartiality towards all therapeutic procedure on their scene it characterises all practices as Complementary and Alternative Medicine (CAM). It is non-committal, all-encompassing and non-discriminatory. But using the term side steps issues relating to public health and the need for informed definition to therapies that epistemologically are not of medical science.

High powered committees in Britain appointed to