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Emotions are far more than just the causes of disease envisaged by Chinese medicine. Far from obscuring our human nature, as the Neo-Confucianists tell us, they define our human nature and give meaning to our life. (p 569)
Neurotransmitters are the symptoms rather than the cause of a mental-emotional imbalance. (p 568)
This is the latest of Giovanni Maciocia's six blockbuster tomes from Churchill Livingstone, comprising 688 pages in 22 chapters and four appendices (that's over 6440 textbook pages currently in print, a major achievement for any author).
The author begins with a lengthy philosophical discussion of the psyche in the West (‘spirit and soul’) and in China (‘spirit, soul and mind’), exploring the traditional aspects of the person: ‘mind’ (shen, associated organ being the heart), ‘ethereal soul’ (hun, liver), ‘corporeal soul’ (po, lungs), ‘intellect’ (yi, spleen), ‘will-power’ (zhi, kidneys) and the gui (ghost, or ‘movement’ of the hun and po). He goes on to discuss the relationship of the 12 internal organs (zangfu) to the psyche, and the emotions (adding guilt and shame to those traditional in Chinese medicine). Next he looks at the aetiology and diagnosis of ‘mental-emotional’ problems (by this time we are more than a quarter through the book), their treatment ‘with herbal medicine and acupuncture’ (note the change in emphasis), and then focuses on the main acupoints used (40 pages). In his own practice he comments that he uses acupuncture particularly to ‘nourish’ the five aspects of the person listed above, herbal medicine more to treat the ‘patterns’ or ‘syndromes’ of disease—a welcome statement from someone who has often been seen as fostering the ‘herbalisation’ of acupuncture so evident in the simplified but so-called ‘traditional’ Chinese medicine advocated and taught as a unified system alongside herbal medicine in China.
At this stage, although already feeling quite overwhelmed by the amount of information wrestled with in the preceding 13 chapters, I expected to be able to move on to read about the treatment of particular conditions. However, Maciocia now includes more philosophy, with chapters on ‘emotions and concept of self in Western philosophy’ and ‘the influence of Confucianism on the Chinese view of the mind and spirit’. Finally though, he does finally get to the disorders of the psyche he considers treatable with Chinese medicine. These are surprisingly few: depression (including ‘lilium’ and ‘plum-stone’ syndromes, but with a de-emphasis of the Chinese diagnosis of depression as frequently attributable to liver qi stagnation), anxiety, insomnia (with appendices on excessive dreaming, somnolence and poor memory), bipolar disorder, night terrors and attention deficit disorder (and attention deficit hyperactivity disorder). It is puzzling that dementia, schizophrenia, obsessive-compulsive disorder (OCD) and other obvious candidates like hysteria, personality disorders or psychosexual problems barely get a mention, despite a long history of treatment using Chinese medicine.
The book is completed by an epilogue on the role of Chinese medicine in disorders of the psyche, two appendices on herbs, another on the most frequently mentioned classical texts (rather light, given the in-depth writing in the rest of the book), glossaries and chronologies (including a somewhat sparse comparative timeline of Western and Chinese philosophers and doctors), a reasonable bibliography and a frustrating index (with many entries, but insufficient cross-referencing of particular topics).
The author's perspective
Personally, I find Maciocia's often skilfully written background material on the psyche, the self and Confucianism fascinating and much more interesting to read than the more formulaic writing on the conditions that follows. In particular, he redresses the balance for those who consider Chinese medicine simply as some kind of romantic outgrowth of Daoist mysticism, arguing convincingly that this is far from true, and that much Chinese medicine is in fact based on the stricter model of the Legalist school and the tenets of (Neo-) Confucianism with its ‘objectivising’ of the emotions as distinct from the self. He is a thoughtful man, and has clearly spent long hours sorting out for himself the similarities and differences between Western and Chinese views (one major difference, eg, being that between ‘substance-oriented’ and ‘process’ thinking; another being between the Western self as individual and autonomous, as against the ‘connected’ self of Confucian and contemporary China, defined much more in relation to society and family—in the words of the fourth century Neo-Confucian Ge Hong, ‘the body of a person is the image of a state’).
Maciocia, as a Westerner who has read deeply (but not trained) in the field of psychotherapy, willingly admits that “Chinese medicine does not provide a framework for interpreting the emotional suffering of patients with complex emotional histories stretching back to childhood”, and in his analysis he tends to fall back on James and Lange, Sartre and Jung, Damasio and MacLean as much as on the Chinese classics. As a result he has definitely reinterpreted some Chinese terms in language that is going to be more acceptable to other Westerners than to the Chinese themselves. At times his thinking is quite idiosyncratic (for instance, his analogy between the hun and the Jungian anima), his associational logic the result of his own arduous personal journey through the landscape of the psyche. Often he does not distinguish clearly enough between ‘traditional’ and contemporary interpretations in China, often he presents rationales without stating that they are his own, occasionally they appear quite arbitrary, and sometimes—probably inevitably—the mass of information presented has not been well digested or integrated. For someone of Maciocia's stature, this is a risky game—too many who read his book may take his words as gospel.
The book is presented in the style Elsevier has used for Maciocia's previous works, with many illustrations (some superfluous and distracting), and summary boxes (very useful, if somewhat repetitious). The one colour used in both is a rather strident pink, which I for one found rather unrelaxing. There are also quite a number of case histories, although these sometimes involve diagnosis only, without any account of treatment or outcome (similarly for the audits of depression and insomnia patients from the author's own practice), which is somewhat frustrating. Sometimes the cases used in different chapters are very similar (eg, those on pages 95 and 125), but apparently do not refer to the same patient, which makes one suspect that they have been cobbled together from different records rather than representing ‘real’ people. This is a shame, as it may lead the reader to doubt other aspects of the book. In addition to presenting case studies, Maciocia also summarises the results of clinical trials. However, this is not done methodically: old studies are mixed in with new ones and reviews, the acupuncture points and methods of treatment used are not described (although of the 11 depression studies included, four are stated as having used electroacupuncture, which was also used in one study on autism), and no conclusions are drawn, leaving one wondering rather why the trials were mentioned at all. Finally, and probably inevitably in a book this size, there are occasional mistakes in the figures and their captions. But these are definitely minor issues.
Other literature in the field
Given the size of this book, it is hardly surprising that few others have taken up the challenge of writing comprehensively on the psyche in Chinese medicine. In 2001, Flaws and Lake compiled an impressive 512-page textbook on Chinese medical psychiatry1 (fewer pages, but larger and actually heavier than the Maciocia tome). In a fairly traditional presentation, with few diverting illustrations, this offers detailed but down-to-earth parallel reviews of the conditions covered from both Western and Chinese medical perspectives, and is divided into three parts: introductory theory and fundementals (sic) (more basic and much less philosophical than Maciocia), Chinese essence spirit diseases (21 conditions, including ‘plum pit qi’, ‘lily disease’ and the wonderfully named but unpleasant ‘running piglet’), and the treatment of Western psychiatric diseases with Chinese medicine (12 conditions, including ‘somatoform disorders’ and ‘psychological disturbances due to erroneous qigong’ as well as more obvious candidates such as schizophrenia, OCD and senile dementia). This simple division, together with a brief account of the common side effects of Western psychiatric medications, a useful glossary and bibliography, and a good index, means that it is easier to locate clinically relevant material here than in Maciocia's book, although the greater emphasis on herbal medicine by Flaws and Lake may deter some acupuncturist readers. This emphasis is particularly evident in the case studies and material culled from published clinical trials, the exception being depression, where the focus is very clearly on acupuncture.
More recently Zhang has written ‘an ethnographic account of emotion-related disorders’ in Chinese medicine,2 but apart from these two, books in the field tend to be smaller and concentrate on specific conditions such as depression3 or schizophrenia (Bosch and van den Noort 2008,4 reviewed recently in this journal).
Maciocia's is an ambitious, vast and sprawling book, which might better have been divided more neatly into two—one on the writer's own philosophical approach to Chinese thought and medicine; one on the diagnosis and treatment of psychiatric disorders. By the end, the author's exhaustion is almost palpable (and probably would be, to someone experienced in Chinese pulse taking). Nonetheless, the book is also a goldmine of information, with many thought-provoking nuggets. It is a challenge to read, but worth it if you take your time and do not expect to find quick answers to your clinical questions. I certainly feel richer for the experience.
Research Methods in Complementary and Alternative Medicine An International Summer School Supported by the Robert Bosch Foundation
For the fourth time Claudia Witt and Klaus Linde offer the practical training course providing the necessary skills to design, organize and plan your own clinical study
September 15 to 19, 2010
Venue: Seminaris Seehotel Potsdam, Germany (near Berlin)
Course instructors: Claudia Witt (Berlin); Klaus Linde (Munich)
Course fee: 400 € (max. 18 participants)
Application deadline: June 13, 2010
Further information: http://www.charite.de/epidemiologie/english/ag_witt_news.html
Know which types of studies are best suited to which research questions
Be able to design a study on efficacy or effectiveness taking into account specific problems in CAM
Understand the statistical findings of clinical studies, and be able to perform simple sample-size calculations and basic statistical analyses
Have basic knowledge of a variety of study designs
Competing interests DM is the editor of Electroacupuncture: a practical manual and resource, published by Churchill Livingstone, and of Energy medicine east and west (in which the notion of ‘soul’ is also explored), to be published by Churchill Livingstone in 2011.
Provenance and peer review Not commissioned; not externally peer reviewed.
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