Zen training in the U.S.: tradition, modernity, and trauma

Mushim and son at Green Gulch Farm Zen Center in 1990 when she was a penniless single mother, following six years of monastic practice under a vow of poverty. (Photo credit: Jack Van Allen)

Moderator’s note: Many practitioners of Asian medicine and Asian-based health modalities are grappling with questions concerning the historical roots and cultural status of their disciplines today as never before. In response, Asian Medicine Zone is launching a new series of practitioner essays exploring how changing conceptions of “tradition” and “modernity” are impacting their practice and field in the 21st century (these are organized under the tag “tradition/modernity”). If you’re interested in contributing to this seriesplease email a short description of your proposed essay to the moderators. Here, we’re pleased to share our first offering, which artfully explores the encounter between traditional patriarchal authority and contemporary social justice commitments in the author’s life, practice, and community.

Having spent over 30 years of my adult life as a Buddhist practitioner in the U.S., I’m certain of only one thing, which is this: in the process of spiritual maturation, the path is not always clear and straightforward. In my personal experience as a practitioner, there’s been a lot of both/and – a particular experience can be abusive and traumatic, and it can lead to insight and breakthrough. Necessary spiritual surrender can mix potently with what Western psychology calls poor boundaries. And, it seems to me, some people will always be drawn to take paths of greater risk in varying degrees, up to so-called crazy wisdom. Others will develop by staying true to conventional mores with quiet patience.

In 1984, I was living as a renunciant under a vow of complete poverty in a Buddhist community in the United States. Our teacher, a strong-willed Asian man, resided most of the time in Canada, with periodic visits to our startup temple in the Midwest. Probably like most of our convert Buddhist community, I had moved into the temple full-time with a great deal of hope and projection that the teacher, who was described by his senior students as a Zen master and enlightened being, would be my major role model of elevated qualities of compassion and wisdom as I somehow imagined them to be.

I had immediately been appointed office manager and treasurer when I moved into the temple. I started the office with a landline phone, a cardboard box for petty cash and receipts, a checkbook, and a small wooden bench that could be used as a tiny desk if one sat cross-legged on the wooden floor. There wasn’t enough money in the bank to pay our utility bills and mortgage when I moved in, so we cut every corner and pinched every penny.

It was under these pressured circumstances that I was quietly working in the office when the “Zen master” suddenly walked in and began screaming at the top of his lungs at me for making a long- distance phone call for business reasons during a time when rates were higher. As Zen students, we were taught to “eat the blame,” so I did, and simply apologized until he went away. A few days later, having complained to the temple director who told him that the reduced rate times for calling were different in the U.S. than in Canada, he sheepishly reappeared in the office and said he hadn’t had full information. This was somewhat short of an “I’m sorry I unfairly vented my rage on you.” But it was the best I could get under the circumstances.

I couldn’t talk to anyone outside our temple system about such incidents because they would immediately say, “Why don’t you leave?” And the fact was, I was also learning a great deal. There were so many beautiful aspects of our communal temple life of meditating together and manual work, cooking and cleaning and eating together. The teacher was also immensely talented and caring in many ways. It was confusing, and in the Buddhist practice we were doing, it was okay not to know everything at once.

Traditional Zen stories and Zen lore are full of anecdotes that involve hitting and yelling and enduring unfair accusations. By the time I became a renunciant, I was an adult woman with a master’s degree. I’d been married and divorced. I had worked various jobs in the secular world. And I’d been exposed to the women’s movement and lived through the civil rights era in the U.S. I was open to going through some strong, and even traumatizing experiences for the sake of spiritual training.

Things continued to be a dynamic mess. I ended up in an Asian monastery for 8 months in 1987-88. There, my life and identity as I had known them continued to be blown up. As I said some time after I returned, I felt as though I got completely chewed up by the patriarchy.

It is also completely possible that if I had been smarter and had better boundaries, I wouldn’t have ended up as badly as I did.

But I survived. I got back to California, and, struggling continuously with extreme poverty, raised a Buddhist child, and continued my practice. I promised my son and myself that I would find a way to live in Buddhist community where power was more equally distributed, and codes of ethics and democratic structures were in place. Buddhist life might continue to be a mess. But I wanted, at minimum, a more workable mess that aligned with my cultural values. I distinctly remember thinking, upon returning to the U.S. from the Asian monastic system, “I don’t have to get my way, but I will be damned if I don’t at least get to vote. I am an American, and I want my vote!”

I didn’t want to overthink any of this. All systems and forms have limitations, and attachment creates suffering – this is a universal principle of Buddhism which I personally have never found to be untrue. That being said, the reason I began Zen meditation in the first place was because I wanted to find a situation in which I could live with other people with forms of practice that encourage well-being, kindness and justice, while at the same time providing support for Awakening. And I’ve been fortunate, because I’ve spent the last eleven years working with others to create a diverse and social justice-centered urban meditation center in Oakland, California, where I live. For me, and for many others, East Bay Meditation Center has been the intersection of Dharma practice and community-based social justice activism and awareness where I can constantly explore Liberation in ways that don’t separate the spiritual world from the real experiences of structural violence that I experience or witness every day.

As a Buddhist teacher at East Bay Meditation Center, I teach in trauma-informed ways that I have learned as a yoga student from the social justice-based Niroga Institute in Oakland, California. The traditional forms of spiritual training that require students to withstand humiliation and abuse from those above them in a hierarchical model are, I’m convinced, not essential to a 21st century Eightfold Path. Why? Because for most people, especially those in communities targeted for oppression, life is already full of traumatic humiliation and abuse. What we need are ways to become resilient, whole, and wise in seeking environmentally sustainable ways to coexist nonviolently and joyfully.

My Bodhisattva vows, the same as millions of others who have taken these vows, are “to save the many beings.” Where the rubber meets the road is that we are different from one another, love is not always the answer, and conflict is inevitable. I’m fine with this particular dynamic mess of imperfection, as long as it’s worked with in the service of systemic justice and equity.

Water Blog, Part Three: Li Shizhen on Terrestrial Waters

The first part of my blog on the Therapeutic Use of Water in the Bencao gangmu (click here to read it) contained an introduction and brief survey of the content of the whole text, and the second part (see here) covered the first section of Li Shizhen’s volume on Water: the thirteen entries on “celestial waters” 天水, or in other words, on the various kinds of water that fall from the sky. The following information concerns the second, and considerably bigger section, namely the thirty entries on “terrestrial waters” 地水. As in the previous post on celestial waters, the historical illustrations below come from Vivienne Lo’s wonderful collection of images from the Shiwu bencao (Materia dietetica), a dietetic herbal in four volumes dating from the Ming period (1368-1644) found here (https://wellcomecollection.org/works?query=Vivienne+Lo). For other illustrations relevant to medical history, visit the Wellcome collection here https://wellcomecollection.org/works and type in your search terms.  If you are more interested in my personal thoughts and a less nerdy approach, you might enjoy my personal blog here.

After covering the thirteen types of water that come out of the sky (rain water, downpour water, dew, sweet dew, sweet dew honey, brightness water, winter frost, snow from the dead of winter, hail, summer ice, divine water, half sky river, and leaky roof water; for explanations and details, read my earlier blog post), let us now look at the waters that come from, pool on, or run over the earth. Given that this section is more than twice as long as the section on celestial waters, I will not cover each entry, nor completely translate the ones I do discuss, but pick and choose based on entertainment value, clinical applicability, historical relevance, or my personal whim. If I have omitted a type of water that you urgently need to know about or additional explanations, indications, or attached formulas, post your question as a comment to this blog, and I promise to answer it. I may eventually publish a complete translation in book form….

Terrestrial Waters

Running Water


The explanations found in this entry offer valuable insights into Li Shizhen’s understanding of medicinal efficacy and the way in which a substance is affected by its surroundings. I believe that most of us modern people, used to eating lifeless greenhouse strawberries in February and heavily processed food from distant continents out of plastic containers, cannot even begin to comprehend the reasoning expressed here. It is just one more expression of this notion of “resonance” (ying 應) that strikes me as the foundation of the classical Chinese way of living in harmony with the universe. In the initial general explanation to this section, Li Shizhen himself comments that flowing water refers to rivers, streams, creeks, and brooks, which all share the characteristics of moving on the outside but being still by their inner nature, and of being soft in substance but hard in Qi. He then emphasizes the importance of distinguishing running water from the stopped water of lakes, marshes, ponds, and reservoirs. In addition, the muddy waters in the larger rivers differ from the clear waters in smaller streams. As proof for the importance of these differences, Li reminds us of the drastic difference in the nature and color of fish living in each, in the outcome of tempering swords or dying cloth with each, and in the flavor of rice porridge or tea cooked with each. So how could we not take this into consideration when preparing medicinals!

Known to traditional medical practitioners and contemporary translators by the technical terms “thousand-mile water” 千里水, “east-flowing water” 東流水, and “sweet-billowing water” 甘爛水,” Li claims that these substances are the most efficacious for decocting medicinals and keeping spirits at bay. They are indicated for the Five Taxations and Seven Damages–a common term referring to debilitating conditions of emptiness taxation, with the seven damages explained in the Zhubing yuanhou lun 《諸病源候論》 as food damage, anxiety damage, drinking damage (i.e., due to alcohol), bedchamber damage (i.e., due to sexual intercourse), hunger damage, taxation damage, and damage from taxation of the channel and network vessels and ying wei 營衛 provision and defense Qi damage)–; for kidney vacuity and spleen weakness; for Yang exuberance and Yin vacuity; for inability to close the eyes; as well as for dysentery, vomiting and diarrhea and for threatened bentun Bolting Piglet syndrome after cold damage. Water that is moving countercurrent, on the other hand, is indicated for wind strike, sudden reversal, head wind, malaria, all sorts of throat conditions, and vomiting of phlegm rheum.


In the following “Elaboration” section of the entry on Running Water, Li Shizhen quotes various authorities to make sense of the above indications: Thousand-Mile Water and East-Flowing Water flush out and rinse away evil and filth and hence are good for restraining and exorcising spirits and ghosts. According to our friend Sun Simiao, river water has journeyed far from its spring and thus homes to the sea with the force of its current instead of flowing upward. Thus it is perfect for treating conditions like headache by inducing a downward movement. “Sweet-Billowing Water” is explained as water that has been whipped up a thousand times with a ladle until it appears frothy. This process changes the nature of the water from being salty and heavy to being sweet and light. As a result, it no longer assists the kidney Qi but instead boosts the spleen and stomach. Water that moves in the direction of the current flows downward by its nature and therefore treats patterns in the Lower Jiao and lumbus and knees, while also promoting defecation and urination. Rapidly flowing water with its fierce urgency and downward pull can treat conditions like stopped urination and defecation or wind Bi syndrome. Water that is moving countercurrent, such as in eddies, is by its nature upward-moving contrary to its regular flow and is therefore indicated for promoting the ejection of phlegm rheum. As the greatest proof for the efficacy of running water, Li cites a story about Zhang Congzheng 張從正 successfully treating a patient suffering from urinary block that other practitioners were unable to cure. After decocting the same medicinals in urgently flowing water from long rivers, one drink restored urination!

Well and Spring Water, Well Blossom Water, and Freshly Drawn Water

As anybody who works with historical formulas knows and as Li Shizhen demonstrates with the 29 new and old formulas he has attached to this topic, well and spring waters are important ingredients for a wide range of conditions. Indications range from cleaning dog and insect bites or infected wounds with it, to inducing vomiting and diarrhea to treat arsenic poisoning by drinking freshly drawn well water; consuming large amounts of plain water to counteract alcohol poisoning or sudden retching from taking excessive doses of medicine; drinking a bowl of water with honey mixed in for heart oppression with sweating and loss of consciousness; using the first water drawn from a well at dawn to treat bad breath by holding it in the mouth and then spitting it out in the outhouse or to induce childbirth by having the woman drink it; and making newborn babies cry out by sprinkling them with cold water. 

The information in the introduction to Well and Spring Water and the two following entries on Well Blossom Water 井華水 and Freshly Drawn Water 新汲水 explains the reasoning behind these usages: First off, Li cites Wang Ying 汪穎, author of  the Shiwu bencao 《食物本草》 (“Materia Dietetia”), as his authority: “Freshly drawn well water treats illness and benefits people, and the first water drawn at dawn, called Well Blossom Water,  is extremely broad in its applications and different from all other water. Well water that comes from far away in the earth’s veins is best; water that has seeped in from nearby rivers and lakes is second. Water in the cities that is close to ditches and canals and has sewage mixed in forms must be boiled vigorously….” Li Shizhen continues: All water under heaven functions identically in extinguishing fire and irrigating withered plants. And yet, its nature is transformed by the earth and its material quality changed by things, until it is no longer identical. For example, brocade is brilliant in color when washed in Sichuan water; spring water from the mountains in Shanxi cure abscesses because of the alum; and bathing in the sulfurous hot springs in the foothills of Western China cures pestilence. 

Even the water coming out of a single well is different in effect and must be chosen carefully: For example, Well Blossom Water, drawn at dawn, is indicated for alcohol-induced heat dysentery while Freshly Drawn Water is indicated for heat dysentery and strangury, and red and inhibited urination. Well Blossom Water is used for treating bleeding in the extremities and all orifices due to extreme fright, for settling the heart and calming the spirit, for fermenting alcohol and vinegar to avoid spoilage, and for decocting Yin-supplementing medicinals and for medicinals for phlegm, fire, Qi, and blood. Freshly Drawn Water, on the other hand, dispels evil and attunes the center, brings down heat Qi, disperses welling abscesses, and resolves various toxins.


The “Elaboration” section (fa ming 發明) on Well and Spring Water provides fascinating background for Li Shizhen’s thinking, mostly supported by other textual authorities: Always use freshly drawn clear spring water when using water to treat illness, and avoid stagnant, muddy, warm water. Freshly Drawn Water and Well Blossom Water contain the One Genuine Qi of Heaven 天一真氣 floating on the water’s surface and are therefore used to decoct Yin-supplementing medicinals and to prepare alchemical substances. They are equal in their quality and flavor to snow water. Wells and springs are the veins of the earth 地脈, and the blood in human veins resembles this. So you must use deep water from dense earth, from distant sources and of pure quality. Humans are produced from the earth and their natural endowments are mutually linked with and affected by the Qi of the mountains and rivers. Thus their beauty or ugliness, longevity or premature death are all mutually affected. Metals and stones, herbs and trees, all adapt to the inherent nature of the water and soil, so how could this not be true for humans, as the most divine of the ten thousand things, as well? Each region and soil create humans of its type: Mountain Qi means more males and Marsh Qi more females; water Qi more muteness and wind Qi more deafness; forest Qi more infirmity and tree Qi more hunchback; Qi below cliffs means more swelling, stone Qi more strength, and Qi in dangerous and obstructed places more goiters; summerheat Qi means shorter life and winter-cold Qi means longer life; valley Qi more bi Impediment Syndrome and hill Qi more mania; and so on and on.


After all this evidence to show the intimate relationship between humans and their environment and the resulting importance of choosing water for medicinal uses carefully, Li Shizhen abruptly changes the topic to discuss hydrotherapy. He tells the following story: A woman had been suffering for years from a chronic illness identified as an “influx of cold and heat” 寒熱注病. At the height of winter, the famous Han dynasty physician Hua Tuo instructed her to sit in a stone trough, and at dawn began a treatment of pouring cold water over her, stating that this treatment must be repeated a hundred times. After receiving seventy cold showers in this manner, the woman was shivering and close to death. The person pouring the water was scared and wanted to stop, but Hua Tuo would not permit this. When she had received eighty pourings, the hot Qi finally exited with great noise from the top of her head in a cloud of steam two to three feet high. When she had received the full treatment of a hundred pourings, Hua Tuo made her lie down on a warm bed over a burning fire, covered with a thick quilt. After a good long while, cold sweat came out, and she was dusted with powder and was cured.

In a similar story, a general had taken too many preparations of “Five Stone Powder” 五石散, an addictive and toxic mind-altering mineral-based drug popular in medieval China that purportedly consisted of five minerals like fluorite, quartz, red clay, stalactite, and sulfur. As a result, he was suffering from cold, forcing him to wear warm clothing even in summer. Diagnosing this condition as “latent heat,” the physician Xu Sibo 徐嗣伯 insisted that it could only be treated by effusing it through hydrotherapy in winter. So he waited until a time of abundant snow and ice at the height of winter and then made the general sit naked on a stone. He had a total of twenty bushels of freshly drawn cold water poured over his head until his patient’s mouth clenched shut and his Qi expired. The general’s relatives wailed and cried, asking the doctor to stop, but he seized and struck the person who had criticized him. After he had used a hundred bushels of water, the general began being able to move, with a great display of Qi on his back. After a while, he sat up, complained of unbearable heat, and begged for a cold beverage. The physician gave him a pint of water to drink, and his illness was cured. Thereafter he often felt hot, only wore thin clothing in winter, and was generally stout and strong. 

Li Shizhen explains that both of these treatments are cases of latent fire, which was effused by dousing the patient with cold water at dawn around the time of the solstice, when Yang Qi is inside but just starting to break out. Breaking the fire by cold causes it to be stimulated and released through the sweat.

Miscellaneous Other Waters

 Pig trough and urine ditch water

Pig trough and urine ditch water

In the following entries, Li Shizhen covers a range of waters to be found on the earth, from waters drawn during specific seasons to water from special springs, caves, seawater, or springs in cliffs. Lastly, he discusses various poisonous waters and their medical applications. Without going into details here, it makes sense, as Li states, that the specific Qi in each of the 24 seasonal nodes 節氣 affects the quality of the water drawn at this time. In a universe where everything is related to everything else and where Heaven and Earth resonate with each other, not only the time of day when the water is collected but also the time of year affects its Qi and therefore its potential effect as a medicinal. Thus, water drawn on the first day of spring or during the “tomb-sweeping” (Qingming) festival two weeks after the spring equinox is indicated for all sorts of wind conditions, for the spleen and stomach, for deficiency, and for alchemical preparations and medicinal liquors. Water drawn in the seasonal nodes of winter is best for supplementing the five Zang organs and treating phlegm fire, accumulations, and worms and toxins. Drinking just one cup of water drawn before noon on the first day of autumn can treat malaria and dysentery and the “hundred diseases in both old and young people.”


Following this section are a number of entries of water from special springs. For example, water from springs in mountains that contain jade will make the body hair black and increase longevity, just as the vegetation in these mountains is luxurious because it is exposed to this treasure. Water from caves with stalactites is greatly beneficial. It is concentrated and heavier than normal water. Consuming this water will make the person fat and healthy and stave off aging, just like the effect of consuming stalactites (shizhongru 石鐘乳) directly. Concerning hotspring water, the sulfur deep down makes the water hot and causes it to have a foul-smelling odor. Sulfur is indicated for all sorts of sores, so this water has the same effect. Bathing in it causes the Qi of sulfur to enter the skin. Arsenic hotsprings, however, are poisonous to bathe in. In general, bathing in hotsprings is indicated for spasms and contractions in sinews and bones due to wind, for bi Impediment in the flesh and skin, paralyzed limbs, lack of eyebrows and hair on the head, for scabies and for problems in the skin, joints, and bones. When done with the bath, one is greatly deficient and fatigued and can take medicine in accordance with the condition or supplement and nourish health with food and drink. Healthy people should not lightly enter hotsprings.


Next there is a fascinating line that might actually refer to the phenomenon of bioluminescence, which I myself got to experience last summer while swimming under a new moon in the Puget Sound: The entry for “Jade-green Sea Water” 碧海水 explains that when one stirs the water while moving in the sea at night and there are fiery stars, this is saltwater. Because its color is jade-green, it is called “jade-green sea.” Reinforcing my own love of the sea and practice of immersing myself in it almost daily, Li Shizhen comments: “The sea is the meeting of the hundred rivers. Heaven and Earth and the four directions are all connected with each other by the waters of the sea, with Earth in its center.” Bathing in it gets rid of wind-related itchy and scabby skin conditions. 

 dish washing water

dish washing water

Let me finish this blog with a few curiosities: Water from old burial mounds is toxic and will the person if drunk, but can treat all sorts of sores by washing them in it. Water in earthen grain jars from old tombs is good for treating ghost Qi, being struck by malignity, and demonic infixation, for heart and abdominal pain, nightmares of ghosts and spirits, and for killing roundworm. In the interest of scientific objectivity, Li notes that rinsing the eyes with it will cause one to see ghosts, but that he has not personally tried this. It is, however, divinely effective for treating hiccup. Drinking one bowl of pig trough water may be disgusting but will treat gu poisoning! It can also be used for washing out snake bites. For serious cases of dispersion thirst, you can make a patient drink a small bowl of city latrine water, but do not let them know (for obvious reasons). Lastly, this volume concludes with some general rules that are good to know: Water houses the palaces of dragons, and you must be cautious not to offend them. Washing the face with old cooking liquid, as I have personally done in the steppes of Mongolia when fresh water was too precious a commodity to waste on bathing, will cause one to lose color. Washing the head with cold or hot water creates wind in the head, which is particularly dangerous for women. Here I may add that this warning is still heeded by traditionally minded women in Asia and elsewhere who avoid swimming in cold water or washing their hair during menstruation and the postpartum recovery period. Bathing in cold water after a seasonal disease injures the pericardium, bathing in it in exuberant summer-heat causes cold damage. Entering cold water after sweating causes bi Impediment Syndrome in the bones. Bathing after childbirth causes convulsions and often death. Drinking cold water when intoxicated causes tremor in the hands. Drinking tea after drinking alcohol causes liquor aggregations. Drinking water and then going right to sleep causes water aggregations. Finally, when walking long distances in the summer months, do not immerse the feet in cold water, and when walking far in the winter months, do not immerse them in hot water. So much for dipping your feet in an icy mountain stream or cool ocean while playing at the beach this month…




Water Blog, Part Two: Li Shizhen on Celestial Water


The first part of my blog on the Therapeutic Use of Water in the Bencao gangmu (found here) contained an introduction and brief survey of the content of Li Shizhen’s grand opus in general. Now we are finally ready to jump into the blue stuff itself! The pictures below come from Vivienne Lo’s wonderful collection of illustrations from Shiwu bencao (Materia dietetica), a dietetic herbal in four volumes dating from the Ming period (1368-1644) found here. For other illustrations, visit the Wellcome collection here and type in your search terms.

The section on Waters is the first of 16 major parts (bu 部) in this text, and the second shortest section, about twice as big as the one on Fires and just a bit shorter than the one on Earths, which are the next two sections in the text. After these three innovative sections, the main body of the Bencao gangmu follows a more traditional format with sections on Metals and Stones, Herbs, Grains, Vegetables, Fruits, Trees, Clothes and Utensils, Bugs, Scaly Creatures, Shelled Creatures, Birds, Quadrupeds, and, last but most definitely not least, Humans. The section on Water is divided into two large categories (lei 類): Celestial Water 天水 and Terrestrial Water 地水, which are further subdivided into 13 and 30 “types” (zhong 種) respectively. Because this text is just so much fun to read, I couldn’t help translating or excerpting much of it here. Let us first look at Part One, namely water that comes from Heaven, or in less poetic terms, falls out of the sky:

Celestial Water 天水

The category of Celestial Water is comprised of various types of natural precipitation that fall from the sky, from different kinds of rain to dew, hail, snow, frost, condensation gained by exposing a large clam shell or copper and tin vessel to the moon (mingshui 明水 or fangzhushui 方諸水), and even “leaky roof water,” which refers to water that comes dripping through a leaky roof in a rainstorm.

 Plum rain water (aka rainy season rain)

Plum rain water (aka rainy season rain)

  1. Rain Water: As a general introduction to Celestial Water in the first entry on “Rain Water” 雨水, Li Shizhen cites a famous Suwen 5 line and relates it to human sweat: “Earth Qi ascending constitutes clouds; Heaven Qi descending constitutes rain. Hence the sweat of humans is named the rain of Heaven and Earth.” 地氣升為雲,天氣降為雨,故人之汗,以天地之雨名之。Classified as salty, balanced (between cold and heat), and non-toxic, rain is then further subdivided into three varieties with different properties:
    1. Rain at the beginning of spring has the two main indications of being “divinely efficacious” for making babies when husband and wife each drink a cup and then retire to the bedroom, and of being suitable for decocting dispersing medicines and those that supplement the center and boost Qi. Because it is imbued with the uplifting, generative, and effusing Qi of spring, another quote states in the paragraph marked as “Explanations,”, it can be used to decoct medicine for insufficiency of center qi and for failure of clear Qi to ascend. The reason why It was used for fertility in ancient times, this text explains, is because it provides for the initiation and development of the myriad things.
    2. Rainy season rain is good for washing scabs and making scars disappear. But Li Shizhen comments that this substance comes from warm-damp places in the south and makes people sick. 
    3. Early winter rain is indicated for killing the hundred bugs and is thus an appropriate substance to use for decocting medicinals that kill bugs and disperse accumulations. When the hundred bugs drink this sort of rain, the text explains, they go into hibernation underground until they hear the thunder of the next spring.

2.     Downpour Water: This substance is classified as sweet, balanced, and non-toxic. It is indicated for decocting medicines to attune the spleen and stomach and get rid of damp heat. To explain this effect, Li Shizhen quotes the famous hereditary physician Cheng Wuji 成無己 (1063-1156): “The reason why Zhang Zhongjing uses Downpour Water for decocting the ingredients in Mahuang Lianqiao Chixiaodou Tang 麻黃連翹赤小豆湯 to treat cold damage from static heat in the interior with generalized yellowing is that its flavor is thin and it therefore does not assist the damp Qi.”

 Autumn dew water

Autumn dew water

3.     Dew: Being sweet, balanced, and non-toxic, dew is the fluid of Yin Qi. It is the Qi of the night that adheres to things and moistens them. Collected in a bowl in autumn and simmered down to a syrupy consistency, it extends people’s years and alleviates hunger. Because it is “endowed with the Qi of austere killing” (due to its association with the season of autumn), it is suitable for decocting lung-moistening and evil-killing medicinals and for mixing into the various powders for treating scabies, ringworm, bugs, and leprosy. Collected in autumn from the tips of herbs before the sun has started shining on them, it cures the hundred diseases, stops dispersion thirst, and makes the person’s body light and without hunger and the flesh glistening. Collected on the first day of the eighth lunar month, used to grind up ink, and painted on the Taiyang points, it stops headaches. Painting a spot on Gaohuang treats taxation sickness. This is called Heavenly Moxibustion. Dew from on top of the hundred flowers gives the person a beautiful complexion.

 Profuse dew water

Profuse dew water

4.     Sweet Dew: Listed as a separate category, this auspicious substance is also known as “heavenly liquor” or “spirit sauce” and is described as “the essence of divinity, sheen of humane auspiciousness, congealed like lard, and sweet like syrup.” According to one text, it descends onto pine and cypress trees when the king reveres and nurtures the elderly, and onto bamboo and reeds when he reveres the paragons of virtues and treats the masses with magnanimity. According to other sources, it descends when the star Tianru 天乳 (Heaven’s Nipple) shines with bright luster or is found in special locations such as on Mount Kunlun 崑崙. Either way, it is an auspicious omen and is indicated, when eaten, for “moistening the five Zang organs, lengthening years, avoiding hunger, and turning the person into a spirit immortal.”


5.     Sweet Dew Honey: This is another rare syrup-like substance. It is a sugary “frost” that is purportedly produced in Arabia in autumn by collecting dew and exposing it to the sun. It is indicated for all sorts of heat in the chest and diaphragm, brightening the eyes, and quenching thirst.

 Fangzhu water, aka "brightness water"

Fangzhu water, aka “brightness water”

6.     Brightness Water: An alchemical substance with different explanations in various textual sources, it is a fluid of a Yin essence that is gained by exposing a mineral, a large clamshell, or a metal (copper or tin) object to the moon. It brightens the eyes, settles the heart, gets rid of vexing heat in small children, and quenches thirst.


7.     Winter Frost: Being “congealed dew when Yin is exuberant,” it kills things, as opposed to dew, which moistens and thereby enriches things. Sweet, cold, and non-toxic, you can consume it to resolve the heat from liquor, cold damage nasal congestion, and generalized heat and a red face after drinking.


 snow from the dead of winter

snow from the dead of winter

8.     Snow from the Dead of Winter: Related to the fact that snow is cleansing, this substance “washes away miasms, epidemics, bugs, and locusts.” It is indicated for resolving all poisons and treating medical conditions like seasonal warm epidemics, small children’s heat seizures with manic crying, adult people stirring due to cinnabar and mineral [poisoning], fulminant heat after drinking alcohol, and jaundice. It can also be used to prepare tea or cook porridge to resolve heat and stop thirst. It treats all the diseases mentioned above because it is the water of great cold.


 hail water

hail water

9.     Hail is the Qi of Yin and Yang struggling with each other and therefore categorized as poisonous. Alternately, it is described as Yin wrapped around Yang, as opposed to sleet, which is Yang wrapped around Yin. Eating it will make you sick.


 summer ice

summer ice

10.  Summer Ice: Li Shizhen explains that ice (bing 冰) is the essence of Taiyin and, as the extreme state of water, resembles earth in that the transformation of softness becomes hardness, which is a case of the extremes of things changing entirely into their opposites. Hence the Chinese character for ice consists of water plus two ice crystals. It is indicated for getting rid of heat vexation, for effusing heat and swelling from “stones” in the breast, and for resolving vexing thirst, summer-heat toxin, yang poison in cold damage, and heat stroke, which you treat by placing a piece of ice on the center of the chest.  It also resolves alcohol poisoning. In the Explanation section of the entry on Summer Ice, we find the stern warning that eating ice in the abundant heat of summer is the opposite of the season and not recommended because heat and cold strike each other as they enter the abdomen, causing all sorts of illness. Li Zhizhen offers a story about Song emperor Huizong eating too much ice and contracting spleen disease that numerous physicians were unable to cure as a warning example. Finally, Yang Jie cured the condition by giving Da Lizhong Wan, which he prepared by decocting the ingredients with ice, to treat the source of the illness by using the cause of the illness.

11.  Divine Water: This ingredient is collected by catching the drops trickling out of the center of a bamboo pole cut quickly when it rains at noon on the fifth day of the fifth month. Citing no secondary source, Li Shizhen states that it treats masses in the heart and abdomen and worm disease and should be taken by mixing it with otter liver into pills. Alternatively, you can drink it to clear heat, transform phlegm, settle fright, and calm the spirit.

12.  Half Sky River: According to a citation from the illustrious alchemist and commentator on the Shennong bencao jing Tao Hongjing, this substance, which is also called “upper pool water,” refers to water found on top of bamboo fences or in tree hollows. Li Shizhen then cites a story that Bian Que gained his X-ray vision, allowing him to see patients’ internal organs after drinking this substance. It is indicated for ghost infixation, mania, malign poisons, Gu toxin, killing spectral entities, and insanity, and should be drunk in secret, without telling others about it.

 leaky roof water

leaky roof water

13.  Leaky Roof Water: Even though this substance is classified as toxic and inedible, it is suitable for washing out dog bites, spreading on warts, and for rubbing on cinnabar toxin.


The third part of this blog on Water will cover the second half of Li Zhizhen’s information, on Terrestrial Water, 地水.

The Therapeutic Use of Water in the Bencao gangmu, Part One: Introduction to the Text




This post is written in preparation for a lecture I will be giving while soaking in the hot springs at Ojo Caliente in New Mexico, in the framework of a retreat on Chinese herbs and the Chinese medicine classics taught by Z’ev Rosenberg and myself in Taos on August 19-23, 2018. For more information on that retreat, see here. My interest in water is obviously also inspired by my current life on the Puget Sound on Whidbey Island where I go wade, swim, and play in the blue stuff almost every day.

 Thanks to my daughter for modeling as a mermaid.

Thanks to my daughter for modeling as a mermaid.

While late Imperial China is not my specific area of expertise, I have always been intrigued by Li Shizhen 李時珍 and his grand masterpiece, the Bencao gangmu 本草綱目 “Classified Materia Medica,” and consult it frequently in my research in medical history. Anybody interested in the natural sciences in Chinese history needs to read Carla Nappi’s wonderful book on the subject, titled The Monkey and the Inkpot: Natural History and Its Transformations in Early Modern China! If you haven’t, the following information is meant to give you a little taster.

To provide a bit of historical background, this text was composed in the late Ming 明 dynasty and was perhaps influenced by three developments relevant to natural history in China:

1.     The Ming dynasty (1368-1644) was a return to indigenous Chinese rule that followed after the Yuan 元 dynasty (1279-1368) when China was under Mongol control. While undoubtedly traumatic and associated with a horrendous loss of Chinese lives and cultural treasures, China’s incorporation into the Mongol empire also resulted in the creation of a multicultural, multiethnic society with a vibrant exchange of knowledge, substances, languages, religions, artefacts, and peoples all over central Asia, connecting Europe to India to China. As part of this diverse culture, medicine in China became more exposed than ever to the theories, clinical techniques, and medicinal substances of Greek, Arabic, Tibetan, Mongolian, and Indian medicine. In addition, the Mongols eventually succeeded in reunifying the north of China with a much more developed south.


2.     The cultural openness, confidence, and dynamism of the early Ming dynasty, exemplified by the famous seven voyages of Admiral Zheng He in his fleet of “treasure boats” between 1405 and 1433 was abruptly replaced with xenophobia and isolationism, especially after a humiliating defeat of the imperial army at the hands of the Mongols in 1449. Rather than collecting tributes in the Indian Ocean and bringing home giraffes from Africa, the Ming rulers turned their focus to defending against Northern invaders by fortifying what would become known as the Great Wall.

3.     The cultural and economic development of the Jiangnan region south of the Yangzi from the Song period on introduced different diseases into mainstream Chinese medicine. Consequently, both medical theory and clinical therapy expanded, as exemplified by the School of Warm Diseases 溫病 and an emphasis on supplementation of weak deficient Southern bodies. From the Ming dynasty forward, famous literati physicians tended to come from medical lineages in the Jiangnan area.

Against this backdrop, Li Shizhen 李時珍 lived and worked in the late Ming dynasty (1511-1593). Descended from a medical family, he ended up becoming a doctor like his father after he failed the highest level of the civil service examination. Besides being an accomplished physician and compiling one of the greatest books of Chinese natural history and eleven other medical texts, he was a voracious reader, skillful poet, and dedicated scientist and naturalist who spent decades traveling throughout China for his textual, oral, and clinical research. In his relentless pursuit of knowledge, he interviewed countless local sources and interacted with people from all backgrounds. He is reported to have poisoned himself repeatedly by experimenting on his own body and investigating the objects of his research directly by dissection, close observation, and even smelling and tasting. The reader should be warned that Li’s passion for research in his subject matter may be contagious and that it is easy to get lost in the plethora of mind-bending stories in his book.


The Bencao gangmu is undoubtedly one of the greatest books ever written in Chinese history, published posthumously by Li’s sons in 1603. Based on 27 years of research, it summarizes 40 bencao (materia medica) texts and 361 other medical sources, consulting a total of 932 texts, as listed in the bibliography! In the spirit of the Neo-Confucian “investigation of things” 格物, Li Shizhen embraced direct empirical research in combination with thorough studies of all relevant literature, to examine all sorts of natural phenomena and their effect on humans. In 53 volumes, almost 2 million characters, and 1892 main entries or categories (綱 gāng), which are further subdivided into specific entries (目 ), it classifies 1892 substances (plants, animals, “stones,” and objects employed, derived from, or otherwise related to humans) and offers 11,000 formulas for their medical use. The entries include clearly marked subsections identified as

·      “Elucidation of names” 釋名: Including sometimes lengthy lists of alternate names and discussion thereof, this philological preoccupation with naming can be traced back to the Confucian emphasis on “rectifying names” 正名 as an important aspect of scholarly activity.

·      “Collected explanations” 集解: A collection of quotations from a wide range of literature and contemporaneous local informants, with a critical discussion by Li Shizhen himself, on the object and its natural history, lifecycle, varieties and distinguishing features, myths and stories, and other general information. This is a goldmine of facts and fiction for any natural historian;

·      Separate entries on the specific parts used and their preparation and processing as a medicinal substance 修治;

·      Qi (i.e., thermodynamic quality) and flavor 氣味, including information on toxicity and substances to avoid while taking it, also faithfully quoting disagreements in the literature;

·      Indications 主治: The clinical uses of the substances, as traced through the bencao literature up to Li Shizhen’s time;

·      Elaboration 發明: Perhaps the most useful part for clinically inclined readers, this section elaborates on the reasons why the substances has the effect on the body described in the “Indications” section.

·      “Attached formulas”: This section not only cites earlier sources, written and oral, but also includes Li’s personal experience, thereby providing great insight into the actual clinical use of the substance in the late Ming period.




Probably the most innovative feature of the Bencao gangmu is the classification of substances: In the earliest edition of the earliest transmitted bencao text, the Shennong bencao jing 神農本草經 (“Divine Farmer’s Classic of Materia Medica,” translated and published by yours truly here), contains 365 substances categorized into three levels associated with Heaven, Humanity, and Earth in that order, based on their effect on the body and with generally increasing levels of toxicity. This text does employ the system of the Five Dynamic Agents 五行 to classify the substances according to flavor, but not as an organizing principle for the text itself. In his later edition from 492 CE, Tao Hongjing uses the distinction between minerals, plants, and animals, in that order as his main organizing principle, and then subdivides each of these categories into the three classes of Heaven, Humanity, and Earth. Subsequent materia medica text followed this general organization but changed the order to start with plants, followed by minerals, then animals, and ending with human substances.


In sharp contrast to his predecessors, Li Shizhen used the Five Dynamic Agents wuxing 五行 as the overarching paradigm for organizing all substances that affect the human body and therefore created the following major “parts” 部: Waters, Fires, Earths, Metals and Stones, Herbs, Grains, Vegetables, Fruits, Trees, Clothes and Utensils, Bugs, Scaly Creatures, Shelled Creatures, Birds, Quadrupeds, and Humans. Of these major parts, the first three (waters, fires, and earths) are a radical departure from previous bencao literature! The order of the wuxing here does not follow either the cycle of creation or the cycle of control, but instead is subordinated to what Carla Nappi describes as progressing “from the most fundamental to the most exalted.” These large “Parts” 部 are then subdivided further and further into “Categories” 類 and individual Entries 種. For example, we go from “bugs” to “egg-born bugs” to “bees,” or from “herbs” to “mountain herbs” to “gancao.” Besides this emphasis on correct classification and rectification of names, the organization of substances in this text also reflects the Confucian preoccupation with hierarchical ordering of the natural world, especially in the progression from plants to animals (and therein from bugs to scaly to shelled creatures to birds and then quadrupeds) and lastly to humans.

Among the main parts, the section on Fires is the shortest, with no separate “Categories” and only twelve Entries. The first of these is titled “Yin Fire and Yang Fire” and offers an introduction to the topic of fires. Here, Li states that Fire can be categorized into three “Guiding Principles” 綱 , namely Heaven Fire, Earth Fire, and Human Fire, and 12 “Entries” 目, perhaps because it “has Qi but no substance.” Part Two of this blog on the therapeutic uses of water in the Bencao gangmu will discuss the section on Waters in this text in greater detail. Stay tuned….. because right now the tide is high and it’s time for a swim…


Curing Illness with Meditation in Sixth Century China

This is a syndicated post that first appeared on BuddhistDoor
By C. Pierce Salguero

Buddhistdoor Global | 2018-06-29 |


Though he lived in the sixth century, Zhiyi (538–597) has a lot to teach the modern practitioner of meditation, whether Buddhist or secular. He is best known as the founding patriarch of the Tiantai school of Buddhism, widely considered to be the first native East Asian school, and thus a precursor to Chan and other later developments. Among the foundational writings of Tiantai are several treatises on meditation composed by Zhiyi.

Although it is popular to think of meditation as a solution for all kinds of illness, Zhiyi knew it was more complicated. In his Shorter Treatise on Samatha and Vipasyana (in Chinese, Xiao zhiguan), Zhiyi suggests not only that not all illnesses can or should be treated with meditation, but that meditation itself can be a cause of illness: one might be unskillful in harmonizing the mind, body, and breath, and thus fall ill. But he does advise eight different healing meditation practices.

These eight practices are divided into two categories. First are the calming meditations, or, as he calls them, employing the Chinese translation of the Sanskrit samatha, “stopping” meditations:

1. Settle the mind on the location of the illness.
2. Settle the mind on the dantian,* one inch below the navel.
3. Settle the mind on the soles of the feet.
4. Abiding calmly, remain aware that all phenomena (including the illness) are empty.

Next, Zhiyi introduces what he calls “seeing” meditations. Here he uses the Chinese translation of the Sanskrit vipashyana, although most are quite different from what contemporary meditators mean by the term vipassana. There are four practices in this category:

1. The Six Breaths, a Chinese exercise in which the practitioner makes the sounds “chui,” “hu,” “xi,” “he,” “xu,” or “si,” while exhaling in order to regulate internal processes.
2. The Twelve Respirations, which are different types of Indian breathing exercises (pranayamas) intended to regulate various symptoms of illness.
3. Visualization techniques in which one concentrates on one type of qi in order to counteract ailments caused by others. (He gives the example of concentrating on fire-like qi to cure cold in the body.)
4. Finally, Zhiyi mentions using both samatha and vipasyana together to “analyze the non-existent nature” of physical and mental illnesses, resulting in their spontaneous healing.

painting of Sramana Zhiyi, founder of the Tiantai school of Buddhism. From wikipedia.org
Painting of Master Zhiyi, founder of the Tiantai school
of Buddhism. From wikipedia.org

Lamentably, Zhiyi does not give us much detail on specifically how to practice the techniques mentioned in this particular chapter. (Zhiyi did write instructions on samatha and vipasyanameditation, much of which has been translated into English. [Chih-i 1997; Zhiyi 2009]) The most detailed descriptions he gives concern the specific medical applications of the Six Breaths and for the Twelve Resiprations.

For example, each of the Six Breaths should be used as follows:

Imagine each of the Six Breaths revolving around inside your mouth and between your lips, and then make [the sounds]. If you are in meditation, use chui when you are cold and hu when you are hot. In the treatment of illnesses, chui is for eliminating cold, hu is for eliminating heat, xi is for eliminating pain and treating wind, he is for eliminating mental troubles and also flatulence, xu is for breaking up phlegm and relieving congestion, and si is for replenishing exhaustion. If you are treating the Five Viscera, the two breaths of hu and chui can treat the heart, xu is for treating the liver, he is for treating the lungs, xi is for treating the spleen, and siis for treating the kidneys.

For the Twelve Respirations, he instructs:

Now, to explain how the Twelve Respirations relate to the treatment of symptoms: the upward respiration cures weight gain, the downward respiration cures feeling spent, the falling respiration cures emaciation, the scorching respiration cures bloating, the increasing respiration cures depletion [of the Four Elements], the dissipating respiration cures [their] excess, the warming respiration cures cold, the cooling respiration cures heat, the forceful respiration cures blockages, the retained respiration cures trembling, the harmonizing respiration completely cures disharmony of the Four Elements, and the nourishing respiration nourishes the Four Elements. One who is good at using these respirations can cure any and all afflictions—but, as you can infer from this, doing them wrong can cause even more afflictions to arise.

In closing the chapter, Zhiyi offers general reflections on the practice of healing using meditation. Advising the practitioner to become skilled in all of the eight techniques, he notes that he has only provided an overview, and that we should seek out more complete instruction. Above all, Zhiyi is emphatic that healing meditations help us cultivate various good qualities. He explicitly states that if one follows 10 “dharmas,” then one’s “treatments are guaranteed to be effective and will not be in vain:”

1. Faith in the effectiveness of the methods outlined in the text.
2. Regular practice.
3. Sustained effort.
4. Staying entirely focused on the object of the meditation one chooses.
5. Clearly discriminating the causes of illness (presumably in order to apply the correct meditation).
6. Using skill in choosing the right practice for the ailment in question.
7. Maintaining a long-term perspective and not giving up when results come slowly.
8. Knowing when to continue with a beneficial practice and when to abandon a non-beneficial one.
9. Avoiding mental distractions and moral transgressions.
10. Avoiding hindrances to practice such as pride and frustration.

Zhiyi lived in a very different religious and medical culture than we do today. Throughout the essay, we see that his notion of illness revolves around traditional Asian medical concepts, such as qi and the “five viscera” from Chinese medicine and the “four elements” from Indian classical medicine. However, it is quite possible that Zhiyi’s essay is describing contemplative techniques that can be proven to be efficacious in the modern context. At the very least, he is pointing out avenues beyond the current fixation on mindfulness meditation that merit further medical research and exploration.

* Qi or energy center.

C. Pierce Salguero is an interdisciplinary humanities scholar interested in the role of Buddhism in the cross-cultural exchange of medical ideas. He has a PhD in the history of medicine from the Johns Hopkins School of Medicine, and teaches Asian history, religion, and culture at Penn State University’s Abington College. He is the author of numerous books and articles on Buddhism and medicine, including Buddhism and Medicine: An Anthology of Premodern Sources.


Chih-i. 1997. Stopping and Seeing: A Comprehensive Course in Buddhist Meditation. Translated by Thomas Cleary. Boulder, CO: Shambhala Publications.

Zhiyi, Shramana. 2009. The Essentials of Buddhist Meditation. Translated by Bhikshu Dharmamitra. Seattle: Kalavinka Press.

Salguero, C. Pierce, ed. 2017. Buddhism and Medicine: An Anthology of Premodern Sources. New York City: Columbia University Press.

See more

Pierce Salguero

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The Seminal Suwen Chapters: A Blueprint for Human and Ecological Health


Given the fact that I am really busy right now finishing up my forthcoming book Humming with Elephants: The Great Treatise on the Resonant Manifestations of Yīn and Yáng (a discussion of the Yellow Emperor’s Inner Classic, Plain Questions 5 黃帝內經素問:陰陽應象大論) and getting ready for a busy spring lecturing season, my esteemed colleague Z’ev Rosenberg, professor emeritus and former chair of the Department of Herbal Medicine at the Pacific College of Oriental Medicine in San Diego, has kindly offered to help out. Incidentally, Z’ev and I will be teaching a “medical classics study and herb expedition summer retreat” in Taos, New Mexico, in August of this year, which will incorporate material from both of our books. For more information on that, see here. To read more about Z’ev and his ongoing projects, visit his website here. In the guest blog below, he is providing a brief excerpt from his long awaited brand-new book Returning to the Source: Han Dynasty Medical Classics in Modern Clinical Practice, which has just been released by Singing Dragon and promises to be a real gem. Here is a little taste:

The essential first three chapters of the Huang di nei jing Su wen set the stage for the core principles of Chinese medicine. These opening chapters contain the compass of life and medicine; the text reveals the equations that allow us to see how far we’ve deviated from the principles of life. As Wang Bing explains in his commentary of Chapter 3 in the Su wen:

“If one’s desires cannot fatigue one’s eyes, if the evil of lewdness cannot confuse one’s heart, if no recklessness causes fatigue, this is ‘clarity and purity.’ Because of one’s clarity and purity, the flesh and interstice [structures] are closed and the skin is sealed tightly. The true and proper qi guards the interior and no depletion evil intrudes… Those that are ‘clear and pure’ follow the order/sequence of the four seasons, …they do not cause fatigue through reckless behavior, and rising and resting follow certain rules. As a result, their generative qi is never exhausted and they are able to preserve their strength forever.”

Many modern practitioners of Chinese medicine criticize the seminal first three chapters of the Su wen as ‘fantasy’, about a world that no longer exists, of sages living in perfect harmony with the way (dào 道). The Su wen describes it as an ideal, as a way of living that even at the time of the Huang Di nei jing was long past. In Chapter 1 of the Su wen Huang Di asked Qi Bo:

“The people of high antiquity, in [the sequence of] spring and autumn, all exceeded one hundred years. But it their movements and activities there was no weakening. As for the people of today, after one half of a hundred years, the movements and activities of all of them weaken. Is this because the times are different? Or that the people have lost this [ability]?”

Qi Bo responded:

“The people of high antiquity, those who knew the Way, they modeled [their behavior] on yin and yang…. [Their] eating and drinking was moderate. [Their] risings and resting had regularity. They did not tax [themselves]) with meaningless work. Hence, they were able to keep physical appearance and spirit together, and to exhaust the years [allotted by] heaven. Their life span exceeded one hundred years before they departed.”

What many people don’t glean from the passage is that the Su wen presents the principles for the practice of ecological medicine, based on living in harmony with natural law and its influences on the intricacies of human health. This has been known since ancient times, first mentioned in the Mawangdui manuscripts, as nourishing life (yǎng shēng 養生). The ideal way of life attributed to the sages is based on the intrinsic harmony of heaven (sky) and earth, and the human being as an intermediary between these poles of existence. So right at the beginning of Chinese history, we are seeing that the human being has a profound influence on the world around us.

In modern times, the predominating dogma(s) in modern science, on the one hand, are that nature is unconscious, working according to Darwinian mechanisms that push survival and adaption forward. On the other hand, are the religious fundamentalists who believe that such phenomena as climate change are a hoax, and free-market evangelists who believe that energy companies should be deregulated and be allowed to despoil the environment in the name of economic need and job growth? Nowhere is this problem more acute than in mainland China, as we discussed above. The closest modern theory I could find from a scientist is James Lovelock and Lynn Margulis’ “Gaia Principle,” which states that the Earth is a living being that responds to our activities. One of the great sea changes of the scientific revolution in the West was the complete repudiation of what is called the vitalist principle, the concept of a life force in creation that animates all living and sentient beings, replaced by a more mechanistic view of life. In my opinion, this is the biggest rift between Western and Chinese medicine. And to the degree that Chinese medicine abandons so-called vitalism, it moves far from its Han dynasty sources.

According to the evidence, of course doctors should recommend acupuncture for pain

Last week, the BMJ published an invited head to head debate as to whether doctors should recommend acupuncture for the treatment of pain. Below is my rapid response:

What’s most interesting about this discussion of whether or not doctors should recommend acupuncture for pain is a total lack of discussion of the other available treatment options that doctors and patients decide amongst and how acupuncture compares in terms of efficacy, effectiveness, safety and cost-effectiveness. Surely this is the only reasonable starting point for any intelligent discussion about how healthcare resources should be utilized to best help this patient population.

If we continue for a moment to look at acupuncture in an artificial vacuum, as Ernst and Hrobjartsson have done here, there are a few things to note. First, the small effect size that they note of acupuncture over sham needling for pain, which given that the review in question discarded the most positive studies constitutes an underestimation,1 both demonstrates specific effects of acupuncture and at the same time, is a completely irrelevant comparison to determine ‘clinical effects.’2 Doctors and patients are not choosing between acupuncture and sham acupuncture needling control; they are choosing between acupuncture, paracetomol, NSAIDs, opioids, surgery, off-label, poorly tolerated, experimental medication in the case of migraines and fibromyalgia, and physiotherapy, all of which are limited in their ability to effectively treat pain whilst introducing considerable and measurable harm. Sham controlled acupuncture trials merely assess two different types of acupuncture needling. Both are often superior to conventional care in terms of pain reduction and improved quality of life, with the highest-quality evidence demonstrating a statistically significant benefit of acupuncture over sham needling, with an effect size greater than that of paracetomol compared to placebo for many types of pain.3

If we look at sham controlled studies of orthopedic surgery, we find not a small difference between surgery and the sham procedure but no difference at all.4 Clearly surgery and acupuncture have similar methodological challenges to being studied using the double-blind RCT study design held as the gold-standard for pharmaceuticals. If lack of practitioner blinding is such a powerful force as the authors suggest, surely this should have a much stronger effect in the case of surgery, which is more invasive and more expensive (factors that we’re told influence acupuncture outcomes), and yet there’s no difference between fake surgery and the real thing when it comes to reducing patients’ pain. It seems odd to argue against something with at least small specific effects and large non-specific effects (in other words, large proven clinical effects in helping patients reduce their pain) rather than something that’s ineffective, invasive and expensive to boot.

It’s also helpful to note that studies of placebo, including Hrobjartsson’s own research, repeatedly and consistently demonstrate that placebos are ineffective and while they can bring short-term benefits for subjective outcome measures such as pain, they don’t work in the long-term at all.56 This is diametrically opposed to what we see in acupuncture research. Acupuncture brings meaningful reduction in pain symptoms that persists at 12 months,7 as Dr Cummings has pointed out. No placebo has been demonstrated to do this so I’m curious if the authors are arguing that acupuncture is a particularly special placebo unlike any other that has ever been studied before. Of course, this would be special pleading, which is an argument firmly rooted in the authors’ own bias rather than faithfully interpreting the evidence in a consistent and objective way in order to best help patients.

If the authors’ reading of the acupuncture mechanism literature stops at the gate control theory as they have stated, I’m confused as to why they feel qualified to comment as subject experts. Specific mechanisms for acupuncture in pain control are numerous and well-documented, involving but not limited to peripheral effects mediated by purinergic signalling and nitric oxide release, spinal reflexes, modulation of endogenous analgesic biochemicals (including endorphins i.e. endogenous morphine, very effective for pain relief!), improved functional connectivity in the brain, modulation of parasympathetic activity and modulation of inflammatory signaling.8

Of course, the ability to articulate how a treatment works has zero relevance for clinical effectiveness, which is what we’re actually discussing. On the other hand, a recent review in this journal that found that paracetamol is even more harmful than generally appreciated, notes that the ‘mechanism of paracetamol’s analgesic action remains largely unknown.’9

This comes after another recent review of paracetamol for spinal pain and osteoarthritis, also published in this journal, that finds that “paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis” 10. In short, paracetamol is widely used and prescribed, increases the risk heart attack, stroke, kidney damage, GI bleeding and death, and we don’t know how it works which is moot because it doesn’t work anyways. In that light, doesn’t it seem a bit silly to debate whether or not to recommend a treatment that is repeatedly demonstrated to be efficacious, effective, cost-effective, and safe, where the only question is exactly how much of its sizable clinical effect is down to the specific effects through analgesia induced through mechano-transduction and how much is due to the ambiance of the acupuncture clinic or the caring disposition of the clinician?

Another mainstay of pain treatment in the NHS are NSAIDs. This class of drugs suffers from a paucity of long-term clinical data but are frequently prescribed indefinitely, despite serious risks. A recent review looking at over 400,000 patients, also published in this journal, found that “All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction” (which is fancy medical speak for ‘heart attack’) when taken for any time period, including as little as one week.11 A now out-dated and absurdly conservative estimate shows that the adverse effects of NSAIDs costs the NHS a median estimate of £251 million pounds a year.12 This figure is only based on the cost of treating GI perforation and doesn’t take into account any of the heart attacks and strokes caused by NSAIDs when taken as directed.

Of course, the harms caused by NSAID and paracetamol consumption pale in comparison to those of opioids, which are extremely addictive, frequently debilitating and often lethal (in the UK, deaths related to prescription opioids doubled between 2005 and 200913), which is why until a successful albeit illegal marketing campaign by their manufacturer in the 1990’s, oral opioids were only available as part of end-of life pain management for terminal cancer patients. In this light, it’s interesting to note that the first and only study ever performed on long-term effectiveness of opioids for pain-relief found that those taking opioids were actually in more pain than their non-opioid popping counter-parts.14 Talk about a poor benefit to harm ratio! While NICE guidelines for various pain conditions urge doctors to use these drugs sparingly and as a last resort, recommending against using acupuncture as a treatment for pain directly increases the usage of these drugs, which is clearly in no one’s best interest and makes the recommendations seem disingenuous.

As acupuncture has been repeatedly demonstrated to reduce the consumption of pain medication, including opioids and NSAIDs, surely a discussion of the cost of acupuncture should take this into account, given how much treating the harms of these drugs costs the NHS each year. Indeed, if we look at the cost-benefit ratio of what’s typically offered for pain, it would be more germane to discuss the cost to the NHS and harms to patients of not recommending acupuncture.

Compared to physiotherapy, acupuncture has a much stronger evidence base. As one point of reference, there are over 10,000 trials on Cochrane’s Central Register for acupuncture compared to under 7,000 for physio (ironically, this latter number includes studies of physios doing acupuncture). With this in mind, it’s interesting to note that physios frequently add acupuncture to their practice (the UK’s Acupuncture Association of Chartered Physios boasts over 6,000 members), often after very minimal training, contrary to World Health Organisation safety recommendations. It’s difficult to reconcile why physios would increasingly start using acupuncture if it didn’t work and their own tools that they learned in their training yielded satisfactory results in practice. Are you suggesting that physiotherapy techniques are so ineffective at treating pain that thousands of physios are offering a placebo to their patients instead?

Any discussion about which treatments should be recommended for pain that center on patients’ wellbeing and the allocation of precious healthcare resources should be based on a comparison of the benefits versus the harms of available treatments. This is self-evident. Such an approach, no matter how you slice the evidence-base, leaves acupuncture amongst first-line treatment options for pain, if not a clear winner. If Hrobjartsson and Ernst insist on banging the disproven placebo drum despite repeated demonstration of specific effects, clinical superiority over treatments that themselves are shown to be superior to placebo and despite the scientific community’s clear understanding of specific mechanisms of how acupuncture is able to achieve these results, then the discussion we should be having is not about the ethics of recommending placebos. Rather the discussion would need to be about the ethics of recommending treatments that fail to outperform or in some cases are inferior to a treatment that you claim is s placebo, all while exposing patients to considerable and avoidable harm. That’s the only logically consistent reading of your suggested interpretation. So let’s have a discussion about the ethics of that.

In the interest of patients and the responsible provision of healthcare resources, I sincerely invite the authors to explain: if not acupuncture for pain, then what do they recommend instead and based on what evidence? If they are unable to provide evidence of a more effective treatment, one with stronger evidence of positive effect, one that does not unacceptably harm patients, then perhaps a reconsideration of providing such a respectable platform for such outdated and un-evidenced opinions is appropriate, as it directly puts patients at risk while impeding access to a proven and effective treatment for a poorly treated affliction.

The post According to the evidence, of course doctors should recommend acupuncture for pain appeared first on A Better Way To Health.

Healing Experiences of Vipassanā Practitioners in Contemporary China, Case study 5

This is a case study that is part of a series of linked posts:
Introduction, case 1 | 2 | 3 | 4 | 5

Case 5: Candasaro

Before ordaining as a monk in Thailand, Candasaro had worked at a private factory as a production manager in Sichuan for over 30 years. In 2008 he started exploring Theravāda meditation by learning observing the breath[i] with Pa-Auk Sayadaw’s method at Jiju Mountain for about two months in Yunnan. He later gave up this practice as he could not see any sign[ii] emerged in his sitting. “My personality is quite fast-paced. It’s difficult to cultivate calmness.”[iii] In May 2011, he firstly learnt about the practice of dynamic movement at a ten-day retreat led by Luangpor Khamkhian Suvanno, from Thailand, in Hongzhou.[iv] During the retreat, he tasted a sense of joy[v], a positive outcome of meditation.

Candasaro found that dynamic movement suited him perfectly. He explained about the practice: “In the beginning [you] observe the movement of the body. Later [you can] observe the mind. All practices are similar. They firstly cultivate calmness by bringing awareness to one point. That is developing an ability of concentrating the mind. Without calmness, it is impossible to practice vipassanā. When you open the six sense doors, you hold one of them, like a monkey holding the main pillar. In dynamic movement, the main practice is moving the arms. In Mahāsi’s method, it is about the rising and falling of the abdomen. … I like observing the movement.”

He also practiced the dynamic movement at workplace. “While I was working at the control room, I managed the office work and communicated with my colleagues [when it was necessary]. The workload was not so heavy. There was only about one working our every day. It was relaxing.” Then in October 2011 Candasaro joined an organized trip to stay at WatPa Sukato[vi] for two months in South Thailand. This was the first time he travelled to Thailand. Located at Chaiyaphum Province, the temple covering an area of 185 acres, including a river and Phu Kong Mountain that was 470 meters above sea level. Sukato means ‘good’. Luang Phor Kham Khian Suwanno, the first abbot, shared his intention of building the temple, “Sukato is a place where people come and go for wellness, also for the beneficial impact of the environment, human being, river, forest and air. This is the wellness in coming, going and being. This wellness is born from earth, water, air and fire, not from one person alone. …There are shelter, food and friends who will teach, demonstrate, and give advice. Should one wish to stay here, his or her intention to practice dharma shall be fulfilled.”[vii]

In this huge forest temple, there were around 30 monks and 30 lay people only. As there were plenty established huts, every resident could stay in one hut.[viii] Every morning, all residents woke up at 3 o’clock in the early morning to prepare for the chanting and dhamma talk at 4 o’clock. Around 6 am, Candasaro and other monks, dressed in yellow monastic robe, formally visited villages nearby carrying their alms bowls for their daily alms round. (See Fig. 3 and Fig. 4) In Chinese Buddhist communities in China, alms round practices have been faded out for many centuries. With bare feet, the monks lined up tidily first and started walking towards one of the target villages. After entering the village, they stopped in front of a household where donors were waiting with cooked rice and food. Whenever people from households offered food to monks one by one, they would line up before the householders and chant blessing words in Pāli. All the monks went back to the monastery with the received alms. At around 7.30 am, volunteers in the monastery kitchen finished preparing the foods so that the monks and all residents could have their first meal. For monks, this was also the only meal according to their precepts.

In August 2012, he stayed there again for a month. In 2013, he decided to quit his job and receive early retired pension. He decided to ordain as a bhikkhu and settled at WatPa Sukato. He enjoyed his monastic life very much, “I don’t need to spend any money by living at a monastery. I have been working in government and business sectors for many years. I am very tired of them. And my wife agreed to that [the separation] ….  After you practice diligently, awareness lead you to have a strong sense of renunciation from the mundane world. Firstly, [it’s] renunciation; secondly, you do not attach or crave something.” (See Fig. 5)

Although Candasaro could not speak English, he had learnt some basic Thai words to communicate with Thai people for his daily basic needs. Over the past four years, he went back to China a few times to attend retreats and also invited some friends to travel to WatPa Sukato. In 2017, he returned to China and settled in Fujian Province. He started teaching dynamic meditation and led alms round in the village.

[i] Ch. guanhuxi; P. ānāpānasati.

[ii] Ch. chanxiang; P. nimitta.

[iii] Ch. ding; P. samādhi.

[iv] Luangpor Khamkhian Suvanno was a disciple of Luangpor Teean.

[v] Ch. xi; P. piti.

[vi] See “Wa-Pa-Sukato,” Tourism Authority of Thailand, https://www.tourismthailand.org/Attraction/Wat-Pa-Sukato–3354

[vii] Ibid.

[viii] Ch. gudi; P. kuṭi

Healing Experiences of Vipassanā Practitioners in Contemporary China, Case study 4

This is a case study that is part of a series of linked posts:
Introduction, case 1 | 2 | 3 | 4 | 5

Case 4: Jiang Hailong

Since May in 2006, Jiang Hailong, a forty-six-year-old civil servant from Fujian Province, had started practicing vipassanā with Goenka’s method for ten years. He attended four ten-day retreats and five eight-day satipaṭṭhāna retreats. Jiang said: “Learning vipassanā can purify the mind and cultivate wisdom. After a car accident in October 2005, I started suffering from headaches all the time. They could not be cured, although I had tried various kinds of treatment in clinics by spending a lot of money.”

Finally, he started practicing vipassanā to help relieve his physical pain in his daily life. He shared with me in a grateful tone: “I practice mindfulness every moment. From my experience, I feel pain in my head if I don’t practice. Yet with moment-to-moment awareness, the headache can be released. I can see clearly the change in the mind and the body. The whole body is composed of waves and particles. They emerge and disappear. I can see the phenomenon clearly during sitting and in my daily life. There is no concept of my arms, legs and head. They are waves only, with the vibration of particles. They arise and fall like bubbles… many bubbles …arise and fall… very quickly.”

Jiang highly recommend the teaching of Goenka. He believes that the teaching can lead to liberation of life and death. “Without awareness, I feel so painful. It is suffering. With awareness, the pain is relieved. Previously I had hatred towards the pain. Progressively the pain and hatred have faded away. A pleasant feeling even sometimes arises. Yet [I remind myself] not to attach to it.”

Jiang highlighted meditators should report to meditation teachers, who would give instructions during interview. Jiang thought that he did not practice well. He said shyly and humbly, “I have never dared to share with anyone about my practice–the experience of impermanence and not-self. But when I report to teacher, he confirmed that he could see it [in a similar way].”

Healing Experiences of Vipassanā Practitioners in Contemporary China, Case study 3

This is a case study that is part of a series of linked posts:
Introduction, case 1 | 2 | 3 | 4 | 5

Case 3: Xie Mingda

Xie Mingda, in his 40s, was born in Shamen of Fujian Province. With the influence of his parents and relatives, he has had chances of learning Buddhism since he was a child. “I attended some classes of Buddhism, and learned some Chinese Buddhist scriptures, such as The Diamond Sutra. I have a few good friends who have ordained as monks in Chinese Buddhist tradition, and also some in Theravāda tradition. I have been interested in learning scriptures in Theravāda tradition and Pāli language.”

Since 2008 he has attended ten-day vipassanā retreats of Goenka’s method for ten times, twenty-day for once and thirty-day for twice.[i] He has also served ten-day vipassanā retreats ten times as a volunteer helper.[ii] Nowadays he practices meditation for two hours every day. He found that his physical health has improved. His mind has become more balanced and more compassionate.

“I had suffered from Ankylosing Spondylitis, a disease related to immune system. It took me a few minutes to get up from sitting meditation posture. After I insisted to practice regular meditation, my body has been improved a lot. I feel that the body is full of energy after meditation.” However, he emphasized that a right attitude of meditation practice is important. In the beginning of his practice, he hurt his leg as he tried to strive for good results.

Overall, Xie Mingda showed a great sense of gratitude to meditation practice. “[Through practicing meditation, I have experience the sense of impermanence[iii] and not-self.[iv] Comparing with a few years ago, I feel that the sense of self has been reduced.” The benefits of meditation have influenced his mental state. “I work in Futures trading [which renders me a lot of stress.] After practicing vipassanā, the anxiety emotion has been reduced. The mind has become more balanced. I think that my frequent donation also helps.”

[i] See Vipassana Meditation website for details https://www.dhamma.org/

[ii] It is usually called as Dhamma worker (Ch. fagong).

[iii] Ch. wuchang; P. anicca.

[iv] Ch. wuwo; P. anattā.