Volker Scheid Ph.D. and Dan Bensky D.O.

reprinted by permission of the European Journal of Oriental Medicine

As this years BAcC Conference demonstrates, defining with more precision what it means to be an acupuncturist, herbalist or practitioner of Oriental medicine is becoming an urgent question in the rapidly transforming world of medicine in the West. It is a question which contains within itself a number of important sub-questions such as: What contribution do we envisage Chinese medicine to make to the health care in the twenty-first century? How should Chinese medicine[1] be developed and transmitted? What are the similarities and differences between Chinese medicine and other medical traditions? Is it possible or desireable to integrate Chinese medicine and other medical traditions? How should Chinese medicine be organised professionally?

Each of these questions deserves a detailed analysis in its own right. They also demand of us to first answer an even more important question. A question to which we pretend we know the answer (for it is crucial to everything we do), yet which to the best of our knowledge has never been addressed in a satisfactory manner by any proponent of Chinese medicine in the West. This is the question of what Chinese medicine actually is.

In this article we shall provide an idiosyncratic response. While neither complete nor based on the kind of comprehensive investigation which would indeed be necessary, it reflects our current thinking. We believe that this response can act as a stimulus for future research, reflection and debate.

FROM DESCRIPTIVE TO NORMATIVE ACCOUNTS: HEALING POWER IN CHINESE MEDICINE

One way of looking at Chinese medicine is to examine how Chinese medicine is practised at a given place at a given time. Such studies are known as a descriptive accounts. All available descriptive evidence informs us that throughout the course of its history Chinese medicine has been characterised by two important characteristics, heterogeneity and plurality.[2]

The term heterogeneity implies that neither medical traditions nor medical practititioners constitute entities with clearly defineable boundaries. Biomedical knowledge, technology and research practices, for instance, are infiltrating contemporary Chinese medicine around the world[3], even as traditional poetry, painting and calligraphy continue to constitute powerful influences on Chinese physicians.[4] In Europe and the United States Chinese medicine is rehaped by its association with peculiarly Western understandings of concepts such as wholism and energy,[5] while in China it is redifined through particularly Chinese perceptions of science and processes of modernisation.[6] New practices like auricular acupuncture (which soon become `traditional') continually emerge in the ongoing commerce of ideas and technologies between East and West.[7] Even apparently immutable core concepts of Chinese medicine such as qi and practices such as pattern diagnosis are continually up for discussion as social, cultural, technological and economic factors penetrate into the medical domain.[8]

Plurality is a consequence of heterogenity. It indicates that at any one place and time we usually find a variety of different ways of thinking about the body, of diagnosing and treating it and of ideas about what constitutes good medical practice. We also can observe various types of practitioners, ways of transmitting knowledge and usually of competition between individuals and groups. Importantly, this plurality exists at any level of description, within as well as between medical traditions, and even with respect to individual physicians whose practices change over time or in different contexts.[9]

Immutable or bounded medical systems thus only exist in our imagination. Actually existing medicine emerges in and through an ongoing processes of borrowing, exchange and assimilation over which physicians have only very limited control. This is an important observation which undercuts a tendency, deeply engrained in Western thought, to think of objects of description as bounded phenomena whose attributes can easily be compared and contrasted to each other: Western medicine versus Chinese medicine, Chinese medicine in the Imperial era versus modern TCM, the Shanghan lun tradition versus the Wenbing tradition, scholar physicians versus shamans, science versus traditional knowledge, medicine versus art and so on.[10]

Reflecting on descriptive accounts of CM thus brings us face to face with a widely discussed issue of post-modern life, the problem of relativism. If we allow for the co-existence of a potentially unlimited number of different practices of Chinese medicine, how do we relate ourselves to them? This calls for a second type of inquiry: a discussion of the proper ways in which Chinese medicine should be practised. This is known as a normative account. Normative accounts are always political in nature and are always produced within the contexts of ongoing debates and struggles: inter-professional struggles between various medical systems, intra-professional struggles between various schools of thought and intra-personal struggles about how to develop one's own practice.

Descritpive and normative accounts unfortunately often get mixed up with each other. As a result we mistake our value-laden (normative) judgments of what we believe we should be doing for a (descriptive) account of what we think we actually are doing. When we are then confronted with the reality of Chinese medicine in all its complexity and all of its complications, we end up fighting each other about who represents true Chinese medicine. Or we reshape history, theory and practice so as to create the systems and traditions we imagine ourselves to represent rather than follow where our patients lead us.[11] This process not only causes us to lose respect for truth but also limits our potential for understanding and efficacy in the clinic.

We therefore suggest that any attempt to construct a normative account of Chinese medicine must be attentive to the following. First, that it is in fact a normative account. That it is an attempt to define for ourselves what Chinese medicine is and, by implication, also an attempt to define ourselves. That it is accordingly always a personal statement and never a statement of truth.

Second, that it should by guided by what we know from description to be true: that Chinese medicine is heterogeneous and plural. Many (but not all) physicians in the history of Chinese medicine have experienced this richness of tradition as empowering rather than as a hinderance. If, for us as Westerners, plurality and difference is more difficult to tolerate than this says something about ourselves, not about Chinese medicine. In that sense, our normative account should be therapeutic and encourage the development of an open-minded, tolerant and inquiring profession.

Third, that it should allow for heterogeneity and plurality not only on the level of tradition but also on that of personal development. That it should guide individual practitioners in attaining mastership of the craft they have chosen without surrendering their individuality in the process.

We suggest to draw for this purpose on Brodwin's concept of healing power. This is an attempt to collapse into a single analytic framework how actual medical practice emerges as a synthesis of the plural and heterogeneous actions of physicians and patients. Healing power is a deliberately inclusive term with a variety of interlocking meanings, connoting clinical effectiveness as much as the manner in which medical practice functions as a tool in people's search for personal identity.[12] It is a concept which, by its very definition, admits to the fragility of all knowledge and to the limited role played by physicians in the process of healing. Constructing a normative account of Chinese medicine thus becomes the task of formulating how we, as practitioners of Chinese medicine, might best move in the direction of healing power given the tools bestowed by the tradition to which we claim to belong.[13]

CHINESE MEDICINE AND THE NOTION OF YI

Normative discussions about what medicine is took place in China even before the compilation of the great medical classics. Throughout subsequent centuries many famous scholar-physicians made personal contributions to these debates, creating a large corpus of works referred to in contemporary China as yï dé writings.[14] The term yï dé is usally translated as "medical ethics", though the varied contributions to the genre relate themselves to the "character of medicine" as a whole, that is to practical as well as moral dimensions of medical practice without distinguishing categorically between the two.[15]

We shall examine one much discussed statement from this canon of yï dé writings. It is a play on words which in Chinese reads yï zhê yì yê , which for the time being we translate as "medicine is intention." The reasons for the choice of this phrase are straightforward. First, it is a statement about medicine. Second, it has served as the focus of yï dé debates for two thousand years. Many famous scholar physicians such as Sun Simiao and Zhu Danxi have written about it. This phrase continues to be deliberated upon in modern textbooks and commentaries and is discussed in contemporary schools of Chinese medicine. Third, while in these discussions (a number of which we shall translate below) the precise meaning of yì is contested, its importance for medical practice is never questioned. The concept of yì, simultaneously characteristic of Chinese medicine yet also plural and heterogeneous, fulfils all the conditions from where the kind of normative theory we desire might be developed.[16]

The importance of yì in the realm of medicine was elaborated upon for the first time in the literature by the Han Dynasty acupuncturist Guo Yu. Renowned for his needling skills, Guo Yu was asked by King He to explain to him the essence of his craft. This is his reply.

"As for doctors talking about intention, the interstices and pores have extremely subtle divisions, so to follow the qi requires skill. When inserting the needles and the the stone [probes] between them, being a hair off means failure.The knack exists in the connection between the heart-mind and hand. It can be understood, but it cannot be spoken of."[17]

Yì or intention here seems to refer to that which the physician desires and consciously conceives of, that which he wills, but also to that which comes about through a kind of focusing of consciousness. The present best guess as to the original meaning of this word is that it referred to what goes on in ones mind before speaking. According to Graham, it is the image rather than the concept of a thing, and the movement to action with which one responds to it.[18] In that sense, it is a practical activity which goes beyond conceptual knowledge or the application of a technical skill. Nevertheless, it is something the doer can identify and excecute and which allows him to bring about desired effects. This becomes even more clear in a subsequent passage where Guo Yu explains how intention is hampered by anxiety.

"Now when it comes to treating nobles, they look down on me from the heights of their distinguished places, and I am filled with anxiety that I might not please them ... Though the acupuncture needles demand precise measure, with them I am often in error. I am burdened with a heart full of trepidation, compounded by a will reduced in strength. Thus intention is not fully there. Consider what influence this has on treating the disorder. This is the reason I cannot bring about a cure."[19]

Intention, however, is a noun whereas Guo Yu is talking about a practice. Hence, translating yì verbally as "intending" to denote that which the physician does or, indeed, has to do in order to achieve a cure might be more appropriate. But what precisely is "intention" or "intending"? And why is it of such crucial importance for physicians?

To answer the first question we can explore some of the contexts in which yì was used in early Chinese philosophy. In pre-Han China yì , (here translated as intention) was considered a pre-requisite of the knowledge and understanding required for and derived from the divination practices based on the Yijing.

"Intention is what the sages used to search out profundity and study the all encompassing. As it is profound, it can penetrate throughout the purpose of the subcelestial realm. As it is all encompassing, it can penetrate throughout the affairs of the subcelestial realm. As it is divine, it is fast but never hurries and arrives but never travels."[20]

Yì , intention, here is that whereby one `searches out profundity' and `studies the all encompassing' to arrive at complete understanding. This process is a complex one which is `fast but never hurries', which `arrives but never travels'. It implies the utilisation of a logic which does not proceed from observation to conclusion in well defined steps as along a line or algorithm. It is a process with its own trajectory or natural flow that follows a path or dào by the exploration of subtle resonances and the weighing up of imponderables which result in complete and penetrating insight into the totality of a situation

Although in later texts, yì takes on exclusively mental connotations, in pre-Han texts such as the Guanzi, it still involves the meditation-like bodily practice of "intending", whereby one opens oneself to the universal flow of qi so as to acquire a luminous awareness of the world.

"Hence this qi, cannot be stayed by force, but can be stabilised by potency (dé); cannot be called by the voice, but one may go to meet it by intending as it comes. By reverence hold it fast, do not let it go: this is called maturing of the potency. Potency being matured, knowledge issues, and to the last one the myriad things are grasped."[21]

The nature of yì and its relation to knowledge is discussed by all major schools of Chinese philosophy. In the Great Learning, one of the five Confucican classics, the notion of chéng yì or "integrating the intentions" is an essential component of the process whereby the ideal Confucian person develops sincerity. Sincerity is displayed outwardly in the authenticity of one's words, an authenticity which ultimately effects the best possible order of things. Inwardly, it depends on a perfection of knowledge that comes from arriving at the things (gé wù ).[22] Although the Great Learning does not elucidate what it means `to arrive at the things', Graham argues that already in classical Confucianism it implied a valuation of knowledge as the foundation of authentic action.

"Only after the things have been arrived at is knowledge perfect, and only then is there integrity of intention, and only then are hearts correct, and only then are hearts cultivated, and only then are families regulated, and only then are states in order, and only then is the Empire at peace."[23]

Cultivation of one's person is the cultivation of one's heart, the bodily function from which appropriate action issues forth. Such action can only originate from a heart in which all intentions have been brought to integrity. Integrity (chéng ) here implies the wholeness or completeness of a person which manifests itself in speech. According to Hall and Ames it also refers to accurate, self-fulling forecasting.[24] According to Graham, intention (yì ) thus includes both the image or idea of a thing, our knowledge of it, and the intention to act which is inseperable from it and which manifests itself in what the heart does.[25]

This is the same association which the authors of the Neijing later translated into a medical context. In the Língshü we learn

"That which takes responsibility for things is called the heart. The heart has a place to focus its attention which is called intention (yì )."[26]

In the Nèijïng the heart is also the residence of spirit (shén ). And as we know from both reading and experience, spirit manifests itself simultaneously in the integrity of our actions and the clearity of our understanding. In both medical and philosophical contexts we can therefore speak of yì also as a kind of intelligence, an intelligence which comes from knowing and which manifests in doing, though an intelligence which goes beyond representational knowledge.

This latter point is emphasised by Zhuangzi, who provides us with a Daoist reading of yì .

"The bait is the means to get the fish where you want it, catch the fish and you forget the bait. The snare is the means to get the rabbit where you want it, catch the rabbit and you can forget the snare. Words are the means to get the idea (yì ) where you want it, catch on to the idea and you forget about the words. Where shall we find a man who forgets about words, and have a word with him?"[27]

For Zhuangzi words can never express reality as it is, even if they are uttered by a Confucian gentleman. Words or concepts are intrinsicaly unreliable because of their tendency to fix the complextities of the world. Ideas (yì ) come closer to how things really are because in our minds we can view different ideas and images all at the same time and thus grasp a thing from many perspectives at once. This is the reason why we can understand the world and act purposefully in it, even if that understanding is not always communicable. True knowledge and successful behaviour, thus are not rooted in accurate representations (as in Enlightenment positivism), nor do they presuppose counter-rational intuitions (as in Western Romanticism). For Zhuangzi they flow from a kind of unanalysable knack which manifests itself in all kinds of masterful craftsmanship.

In Imperial China medicine was one such craft. A craft, which because it implied a limited though nevertheless real power over life and death, was at once exalted but also demanded very special skills. Many physicians argued that yì (intention, intending, ideas, intelligence) was the basis for efficacious action in medicine. Sun Simiao, for instance, stated emphatically that "[m]edicine is yì . Those who are proficient at using yì are good doctors." In another passage, which deals with how to correctly select between different modes of administering medicinals he repeats that only

"...[t]hose who can match [the correct type of medicine with the appropriate condition] ... can be considered superior craftsmen. So it is said, `Medicine is yì '."[28]

Several hundred years later, the Ming dynasty physician Zhao Xuemin reiterates this view.

"Medicine is yì . It is not as good to use medicinals as it is to use yì . Whether or not a treatment works is based on yì . If yì can enter the fundamental subtleties [of the illness], one can achieve a penetrating understanding. After this, when one uses medicinals , none will not work as expected."[29]

Following Sun Simiao, Zhao Xuemin and many others we thus note that physicians move towards healing power by way of their yì - the ability to enter into the totality of a clinical situation, view it from different angles simultaneously, match it with ideas already present in the mind, compare and contrast them, weigh up different possiblities for action and then, and only then, do exactly what is appropriate. We therefore suggest to translate yì (at least in this medical context) as "signification." According to the Oxford English Dictionary, signification is the "act of signifying", where signifying implies both that something is important because it has a special meaning (a meaning, though, which is context specific and not absolute), that this meaning can be communicated (though often only with a loss of meaning) and that it is this special meaning which manifests in action. Medicine thus is signification - the process whereby the meaning of a set of symptoms and signs is understood and acted upon. How well it has been understood becomes immediately clear through the results produced. And superior skills at signification mark out the superior craftsman. Suwen Chapter 26 says as much.

"As for observing the obscure, this speaks of what is not manifested externally of the form, qi, nutritive, and protective but which the craftsman alone knows. Knowing about the differences of warmth and cold of the days, the waxing and waning of the moon, the floating and sinking of seasonal qi, and considering their various interactions so as to regulate them. The craftsman regularly is the first to see them. As these do not manifest externally, one speaks of observing the obscure....That which differentiates craftsmen is that which is not manifested to be observed externally and that all cannot observe. Therefore observing that which is obscure means seeing that which has no form and tasting that which has no flavour. This [capacity] seems to be divine."[30]

The differences between a medicine based on signification and one based on representational knowledge (as in modern biomedicine) or intuition (as in Romanticist perceptions of medicine as an expressive art) are once more thrown into relief. The healing power which flows from signification, like in modern biomedicine but unlike in Romaticist art, is grounded in an understanding which involves thinking and deliberating. Unlike in modern biomedicine, however, and more like in Romanticist art, this knowledge is context specific, personal and not readily communicable.[31] The following anecdote about the famous Tang physician Xu Yinzong makes this clear.

"Someone said, `Your medical skills are divine, why do you not write a book to bequeath to posterity?' Yinzong said, `Medicine is signification; it is in one's thoughts and deliberations. Moreover, the indicators of the pulse are murky and subtle and the difficulty in distinguishing them is distressing. That which is understood by intention cannot be disseminated by mouth. All of the famous practitioners of antiquity are so only [because of the abilities] to differentiate pulses. Once the pulse is clearly differentitated, one recognizes the disease. As for the disease's relation to the medicine, it is one of appropriate matching. It only requires the use of a single [medicinal] to directly attack that disease. When the force of the medicine is pure, the disease is cured immediately. Nowadays people cannot differentiate pulses and none recognizes the source of diseases. They use their feeling to speculate and set out a multiplicity of medicinals. This is like a hunter who does not know where the hares are and so sends out a multitude of men and horses to enclose an empty piece of land. Occasionally one hopes one guy will stumble onto something. If one treats illnesses in this manner won't the [results] also be haphazard? If one has one medicinal that happens to match the disease and other ingredients are added to "harmonize" it, the chiefs and the ministers will restrict each other's [effects] to that the force of the qi does not proceed. By this means it is difficult to get better and here lies the excuse. The profundity of the pulse cannot be spoken of. If one vainly sets out classic formulas, how can this add to [the knowledge of] old? I have thought about this for a long time and am not able to write anything.'"[32]

But where does one's significatory capacity come from? And how is it developed? In other words, how does one become a good physician? Chinese writers are clear about this. It is learned from teachers and the ceaseless study of books, both of which embody the medical tradition. However, that process in itself already also involves significatory ability. Zhu Danxi, for instance, writes that "[w]hen reading the texts of our predescessors, one should know the signification of the words they set out."[33] Zhang Shoukong is even more specific.

"The method for reading books [is as follows]. One should [first] read by following the characters one by one, then the sentences, then the sections. Then take up again the entire piece and in reading it achieve mastery of the subject. By thus also grasping the signification that [lies beyond the written] words one becomes a proficient reader."[34]

Becoming a physician thus is not the learning of facts or techniques produced by others in the laboratory and their replication in the clinic, nor is it a totally personal expression of intrinsic healing power. Rather, as both the Confucian and Daoist readings of yì imply, it is a process of self-cultivation. This process is guided by teachers and books, but what is learned from teachers and books provides only the basis for a more comprehensive and subtle self-determined agency that flows from signification.

THE DIALECTIC BETWEEN SIGNIFICATION (Yì ) AND METHODS (Fâ )

The force which drives this process of self-cultivation, which by implication also manifests in each clinical encounter, is perceived in the yï dé literature as a dialectic between personal signification (yì ) and the standards, principles and methods laid down by and embodied in the tradition to which one belongs. Such methods include prescriptions, treatment principles, diagnostic techniques, needling methods and so on. They, as much as written texts, are what a student has to master to become a competent practitioner.

"Medicine is signification, prescriptions are methods. The check - I think "divine" is probabetter here as it seems to be referring to the extraordinarily skilled spirits make clear their signification within the methods [transmitted by tradition]. How can these be grasped by [ordinary] human beings if not via transmission from father to son or via the imparting of skills from master to disciple?"[35]

As long as one is an inferior craftsman, one must be guided by the methods of one's teachers. However, as these methods are themselves derived from the significatory ability of previous masters, they are not immutable. Once one has become a superior craftsman, one is no longer bound by tradition but can add to it through one's own significatory capacity - a capacity which always remains grounded, however, in the knowledge of methods and principles one has previously acquired, that is in tradition.[36] The following anecdote about the famous Ming dynasty physician Hua Shou is a nice example.

Hua Shou'sa zi name was Boren and his hao name was Yingning. He crafted ci poetry using classical forms and was proficient in medicine. ... When treating people's ailments, he was not stuck in the formulary manuals but used his significatory [ability] to make prescriptions. When given out, each [of these] was effective. One autumn, the worthies of Gusu went on an outing to Tiger Mound Mountain. There a rich family had a case of difficult labor and asked for aid. The worthies could do nothing. Mr. [Hua] went up the steps and saw some newly fallen wutong leaves. He gathered some up and said, `Hurry back and drink these after decocting them.' Before he had finished his dinner the new baby had arrived. They all asked where this formula came from. Yingning said, "`Medicine is signification.' What formula could it be? If a pregnancy has gone on for ten [lunar] months and their is no delivery, the qi is insufficient. Wutong leaves fall when they get exposed to the autumnal qi, so I used them to help it along. Once the qi was sufficient, how could delivery not occur?"[37]

This special dialectic between yì and fâ , signification and method, bestows on medicine the character of a traditional craft without the constraints on development usually associated with traditional practices in the West. Signification is efficacious action based on penetrating insight in accordance with what is necessary and possible. To remain efficacious medicine must adapt and develop its methods according to circumstance. This occurs at any given time- synchronically and on a personal level from case to case, diachronically and on the level of living tradition by developing and adding to those methods that are transmitted from past to present. Zhu Danxi explains:

"Medicine is signification. Although [the medicine] one uses has been acquired through transmission and though its achievements may be profound, [changing] disease mechanisms in the clinic demand the transformation [of that medicine] just as if one was opposing an enemy general. If the craft of the boatsman is the subtlety of going against accepted methods as the situation demands even if he himself is not quite a gentleman, then why should physicians be ashamed to do so."[38]

The dialectic between yì and fâ , signification and method, intrinsically sets up the space for plurality and heterogeneity in Chinese medicine we have previously observed on the descriptive level. Regarding plurality, as the tradition develops its methods accumulate. Some methods may fall out of, though they can always be revived if demanded by circumstance. Physicians have different significatory capacities and vary in the comprehensiveness of their knowledge of the tradition. Hence, there are superior and inferior craftsmen. In contradistinction to Western positivist or realist accounts, this difference does not, however, derive from the difference between true and false knowledge but always remains grounded in the practice of signification. Debates in Chinese medicine therefore are not concerned with the truth of a method but with its efficacy.

Heterogeneity derives from the fact that signification is, as we have seen, a process of self-cultivation rather than mere knowledge creation. As such it can be fed by many domains: by poetry and calligraphy, by biomedical knowledge and by meditative contemplation. This makes it different from science. However, it is also not a personal, idiosyncratic or subjective process of self-realisation as in the Romanticist inspired psychotherapies that underpin much of contemporary alternative culture in the West. Rather, it is always a social process guided by and rooted in tradition. Unfortunately, this is not an easy process.

"That which is referred to as reading the ancient [classics] but not getting bogged down by them, adopting their methods [or prescriptions] without being controlled by them, this marvel of transfomative judgement, [unfortunately] is something of which people are capable only with difficulty."[39]

MOVING TOWARDS HEALING POWER: POSSIBILITES AND DANGERS

We are now in a position to define in broad outline a normative theory of Chinese medicine that meets the previously established criteria. We can do this by stating that for many leading physicians in the history of Chinese medicine, their ability to help their patients, their movement toward healing power, was located in and derived from yì or signification. We can further assert that the efficacious agency embodied in and flowing from signification is developed within a process of self-cultivation that is at once personal and social. And we can finally argue that this healing power develops out of and through the dialectic between yì and fâ , signification and method.

We pointed out at the beginning that we are interested, at this point, in nothing more than establishing a basis for discussion. Thus, rather than deepening our analysis by relating it to further writings from the yï dé literature, we want to conclude by shifting our focus first to comparative issues and then to the development of Chinese medicine in the West.

The very term `Chinese medicine' already presupposes comparison. Usually such comparisons imply binary oppositions between medical traditions, a view which blinds us to the pluralistic and heterogeneous character of all medical systems and, by implication, their very complex inter-relations. Our theory, instead, does not fix Chinese medicine by attributing to it a set of stable theories or practices, yet it still allows us to compare it to other medical traditions.

With respect to Chinese medicine itself we can note, for instance, that the inherent tension between yì and fâ , signification and method, is resolved differently at different times and by different schools and physicians. In other words, that this dialectic itself is contested and emergent. A pertinent historical example is the opposition between proponents of the jïngfäng "classical formula" school of thought, who favoured the use of classical prescriptions taken predominantly from the Han dynasty, and those of the shífäng "contemporary formulas" school, who favoured to treat contemporary problems with newly composed prescriptions. While in both cases the concrete choice of a formula was still determined by the yì fâ dialectic, the knack of the jïngfäng school was to determine which established method was best suited to a particular case. The knack of the shífäng school, instead, was to select medicinals in just the right manner to treat a particular pattern or illness.

A more recent example is the tension between modernisers and conservatives in the development of "pattern differentiation and treatment determination" (biànzhèng lùnzhï ) in contemporary TCM. While the former attempt to fix the nature of patterns and corresponding treatments in a manner purposefully reminiscent of biomedical diseases (thus shifting the tension towards the importance of fâ , methods) the latter argue firmly to retain subtle analyses based on personal experience (jïngyàn ) as the basis of healing power (thus retaining the importance of yì , signification).[40]

Western medicine, too, has struggled with the dialectic between yì and fâ by conceiving of medicine as both an art and a science. While the historical development of that tension and its changing historical resolution is beyond the scope of this discussion, we can nevertheless note a fundamental difference between Chinese and modern biomedicine. While in Chinese medicine yì and fâ are complementary (though it is clearly signification which drives development), the dominant view in biomedicine has been to separate art and science by reducing as much as possible all subjective elements from medical practice. Medical power is produced in the laboratory by scientists, while the clinic takes on more and more the character of an institution in which physician-technicians fit patients into appropriate boxes. Of course, the non-defineable can never be entirely removed from medicine and placebo effects surface everywhere, from the use of antibiotics to open-heart surgery. Whatever residues of the medical art remain, however, are either made subservient to science (such as when physicians use their skill to increase patient compliance) or defined in such a way as to allow their future scientific explanation (such as when everything that cannot yet be measured and thereby regularised is labelled a `placebo').[41]

The powerful influence of the biomedical model on Chinese medicine over the course of the last century can be examined, therefore, in how physicians' movement towards healing power has been reconceptualised. There is a powerful faction at work in both China and the West which no longer grounds that movement in signification but in experiment, and which considers the separation of art and science, entirely absent within the yì fâ dialectic, an example to be followed. We believe that this attitude may help Chinese medicine gain political acceptance, but that it will not help us to understand Chinese medicine better nor to practice it more effectively.

We wish to conclude, therefore, by pointing out three sources of danger for Chinese medicine which arise from not paying attention to the yì fâ dialectic as that which grounds the movement towards healing power in our tradition. The first of these is the belief, at the basis of all scientific inquiry, that the only valuable knowledge is that which is quantifiable and that which can be expressed in numbers and words. The uncritical adoption of positivist research methodologies as the foundation from which Chinese medicine should be developed should thus be resisted. Instead, we should focus on developing models of medical practice and strategies for research that resonate with the normative demands of medicine as signification.

The second danger is the uncritical import of fashionable Western philosophies (about holism, systems, personal self-realisation etc.) into Chinese medicine. Many of these philosophies share with biomedicine a fundamental conceptual division between theory and practice, the personal and the social, parts and wholes. Romanticist locations of healing power solely or above all within the subjectivity of charismatic individuals go as much against Chinese medicine as we have elaborated it, as do systems theories that remain wedded to the dream of an entirely explicit knowledge.

The third danger is insufficient access to the Chinese medical tradition. The movement towards healing power in Chinese medicine is grounded in the relation between individual physicians and the tradition they represent (where the latter is embodied by living masters and the texts of the medical archive). For reasons we all know, the connection of Western practitioners of Chinese medicine to either of these is particularly tenuous, though it is becoming more and more problematic also in China. Already in the 1970s, Yue Meizhong, one of the main architects of modern TCM, foresaw some of its contemporary pitfalls. As for him these were derived from paying insufficient attention to medicine as signification, his words eloquently summarise the purpose of this essay.

"Regarding symptoms one must analyse the [particular] synthesis between `disease' and `pattern' [they represent]. One must seek out the intrinsic character of [each specific] illness. One cannot [in this endeavour] limit oneself to a superficial [analysis in terms of] hot and cold, repletion and depletion....If one encounters a severe illness or a complicated pattern one must be even more particular. With meticulous care and great artistry one must [penetrate] in each case to the precise disease mechanism."[42]

CONCLUSIONS

The normative account we have presented emerges directly from the Chinese medical tradition. Given the relative strengths and weaknesses of that tradition, the utility of our account for study and self-cultivation will be readily apparent. It's implications for political and professional development are less obvious. However, we believe that our account provides not only a poweful vision statement but implies recomendations for action on all levels of Chinese medicine's existence. It is up to us, individually and collectively, to see and realise them.

ACKNOWLEDGEMENTS

Volker Scheid wishes to thank Cinzia Scorzon and Thomas Quehl for comments and criticisms on earlier drafts of this paper and everyone at the Northern College of Acupuncture for providing the supportive space in which some of the ideas presented here could mature. Dan Bensky would like to thank Paul Karsten for his sage observations.