The term medicine generally evokes the concept of a modern discipline that uses advanced technology and that is integrated with large research efforts and high-technology hospitals and medical schools. Worldwide, however, many healing enterprises exist, at several levels of sophistication. Even in the most advanced cultures, for example, some form of \Tfolk medicine\t may be detected--suggested curative procedures that do not involve formal training and are passed on from person to person. In certain cultures another form of medicine exists, known as traditional medicine, that is distinct from both folk medicine and modern medical practice. Traditional medicine constitutes various institutionalized and regularized procedures. Practitioners profess a common standard for which normal methods of training exist, and they often accept a common text as the source of knowledge. Whereas the oldest forms of traditional medicine, such as shamanism, are chiefly magical and religious in nature, some of the highly developed forms, such as those found in India and China, are comparable to Western medicine prior to the Scientific Revolution. These higher forms of traditional medicine characteristically went through a period of rapid development, established a set of texts, customs, and manners, and then ceased to develop. In some instances, due to the pressure of the availability of modern medicine, practitioners of traditional medicine have initiated new research. Ancient texts have remained the guideposts, however, and such current efforts are directed mainly toward reinterpreting and justifying reliance on those texts. Shamanism The phenomenon of shamanism centers on the figure of the \Tshaman\t, a person believed supernaturally endowed to deal with the spirit world. In terms of medicine, shamanistic powers include the power to cure the ill. The word is derived from Ural-Altaic languages, which are spoken throughout central and northern Asia. Shamanism also crossed the Bering Straits in prehistoric times and is found among the Eskimos, Aleuts, and American Indian tribes throughout North and South America. Closely allied systems occur in the Malay Peninsula, in Indonesia, and among the Australian Aborigines; until recent times, remote tribal groups in India and Korea maintained shamanistic systems as well. Among American Indians, shamans are known as medicine men; somewhat shamanistic figures in African cultures are called witch doctors. Even when the position passes from generation to generation, a person is not accepted as a shaman until first instructed by shaman masters and then subjected to a series of trials. The person may wander, or remain for a long period in a tent or hut, and behave in a manner that in modern terms might well be called "psychotic," finally ending the ordeal in a crisis that results in a self-cure. The entire rite of initiation is a symbolic form of death and resurrection. After being tortured by evil spirits and wandering in a netherworld, the shaman returns to earth as the rightful intermediary between members of the tribe and supernatural forces. Sickness in such groups is conceived of as spiritual; in serious illnesses, the soul may have been taken to the netherworld by spirits and must therefore be rescued by the shaman and restored to its rightful body. In terms of modern medicine, the shaman practices primitive physical techniques but may be an expert herbalist and can also have strong psychological effects that can in turn influence the physical health of a patient. Traditional Medicine in India The subcontinent of India has a large and well-trained force of practitioners of modern medicine. In addition, it has several types of traditional medicine, the largest of which is called Ayurvedic medicine. The ancestry of this type can be traced back 3,000 years or so, but it evolved into its current form from about 500 BC to AD 500. Based on Sanskrit texts, it has a wide following at every level of society. It is governmentally supported, has a defined curriculum, and has schools that grant degrees. Some of these schools are part of universities that may also have a modern medical school. Like other major types of Asian traditional medicine, Ayurvedic medicine is based on humoral theories. That is, the human body is considered a microcosm of the universe. The seven body substances--bone, flesh, fat, blood, semen, marrow, and chyle-- are the product of three humors: kapha, or phlegm, pitta, or bile; and vayu, or wind. Health depends on the equilibrium of these humors, and sickness is a disequilibrium. The point of equilibrium depends on age, sex, temperament, climate, nutrition, and the nature of daily activities. The basic texts of Ayurvedic medicine are the works of the physician Charaka, the Charakasamhita, which reached its present form around the 1st century AD, and those of Susruta, the Susrutasamhita, which also went through many rewritings but reached its present form in the 7th century AD. Later texts are essentially reworkings of these classics and the writings of Madhava and Vagbhata. In the texts, medicine is considered to be the science of living to a great age, and emphasis is placed on diet and the conduct of life. The works of Charaka express quite clearly that diseases are normally of natural origin. The Ayurvedic physician, or vaidya, requires great skill, knowledge, and experience in order to make a diagnosis. Treatment makes use of herbs, animal parts, manipulation of the patient, and modification of the diet. The list of medicines found in the texts exceeds 700 plants. Ayurvedic medicine arose with and is related to the development of the Hindu religion, substantially ceasing further growth when Hinduism reached its full flower. Because the Hindu religion forbade cutting a dead body, Ayurvedic knowledge of anatomy was fragmentary. Nonetheless, by Susruta's era, more than 120 surgical instruments made of steel were being used for specific tasks, and physicians were performing operations on the urinary bladder for the removal of stones. Indeed, plastic surgery in India was unrivaled anywhere in the world until the mid-18th century. In modern India, with the advances made in standard medicine, vaidyas have been relegated to a more or less paraprofessional status despite their increasing professionalism. A smaller branch of traditional medicine on the subcontinent, and one common to Muslim areas, is known as Yunani or Unani. This is in fact the medicine of ancient Greece, translated into Arabic and Persian and then slowly modified by its practitioners, the hakim. The works of Galen are accepted literally and in detail. True to this Mediterranean tradition, the medicine has four humors: yellow bile, black bile, phlegm, and blood. These humors combine with the four primary qualities of heat, cold, moisture, and dryness. If the humors and qualities are in equilibrium, a person is healthy; if not, illness results. Yunani, like Ayurvedic medicine, prohibits dissection and autopsy, but innovations continue to be made in pharmacology. Emphasis is placed on what is now referred to as internal medicine and, to a lesser extent, on psychiatry. No attention is paid to surgical problems, and little more is paid to the problems of women (all hakim are men). In sharp contrast to Ayurvedic texts, Yunani texts are full of case histories. Therapy is by contrary medications; a "hot" disease, for example, is treated by administering a "cold" remedy. Yunani schools with set curricula exist, but the professionalism of the hakim has not progressed as rapidly as that of the vaidya. The smallest group of traditional practitioners in India is the Siddha school. Also based on humoral theories, it originated in the Tamil culture of southern India. Finally, it should be noted that whereas \Thomeopathy\t has only a marginal existence today in Western countries, it has gained the status of a traditional form of medicine in India. Both Ayurvedic and Yunani practitioners add it to their therapeutic offerings, since the emphasis it places on decoctions of herbs has made it attractive to them. In contrast, an uneasy relationship is maintained with contemporary medicine. The therapeutic power of such medicine is apparent, but its vocabulary and methods do not strike a responsive chord in the average Indian patient. Modern medicine seems a mystery, whereas traditional medicine seems more logical and related to life. For serious illnesses, however, patients do frequently turn to modern practitioners. Traditional Medicine in China Chinese traditional medicine is deeply rooted in the Chinese view of the universe. The fundamental concept, of the duality of all processes, extends at least as far back as the 8th century BC. It is expressed as yin and yang; for example, yang is the heavens and yin the earth, yang is hot and yin cold, yang is male and yin is female. The universe is composed of five elements--metal, wood, water, fire, and earth--in varying proportions, but their interactions are in turn controlled by yang and yin. The two forces or essences are equal but in constant ebb and flow, causing continual changes. In medicine the primary role of the physician is to restore the balance between them. This requires the ability to control the levels of yang and yin. Twelve invisible channels, called chin, are assumed to carry the forces. These channels are deep in the muscle but not in communication with the blood vessels, and they communicate with three "burning spaces" that are analogous to reservoirs of yang and yin. Such theories are contained in several major texts of traditional Chinese medicine. They include the Nei Ching, The Book of Medicine of the Yellow Emperor, which is presumed to have been written in the last two centuries BC and which encompasses anatomy, physiology, hygiene, \Tacupuncture\t, and moxibustion (explained below); Mei Ching, a 10-volume study of the pulse; Shang-hang Lun, a treatise on fevers; and Pen-t'sao Kang Mu, a compendium on the use of drugs in therapy. The first step in treatment of the ill is diagnosis. The methods involve interrogation and the use of the senses, each modality being described in exquisite detail. Inspection of the pulses alone can take three hours, since this is thought to be the single most valuable source of information about a patient. The pulse is said to vary with many factors, and 51 chief types of pulse are said to exist. Where the pulse is abnormal is where one of the 12 yang-yin channels is likely to be blocked. Diseases are diagnosed in this way, down to the specific organ involved and the future course of the disease. The next step, therapy, involves methods affecting the unsatisfactory yang-yin balance. Acupuncture, or the insertion of long needles into the body channels, is thought to restore equilibrium. A great deal of interest has been shown in the practice of acupuncture throughout the world in recent years, because it has been claimed effective as an anesthetic agent for the relief of chronic pain, for overcoming addictions, and for treating a host of other disabilities. Acupuncture today may be performed using the traditional needles, whether heated or unheated, or by using mild electrical voltages. Proponents of acupuncture relate its supposed effectiveness to the blocking of pain-conducting nerves or to the local release of neurotransmitters called endorphins. Moxibustion, another characteristic therapy of traditional Chinese medicine, is analogous to the blistering procedures found in many other traditional and folk medicines. Powdered leaves of a plant, Artemesia, are compressed into a pellet, placed at the desired site of the patient's skin, and ignited, forming a blister. Just as acupuncture charts point out where a needle is to be inserted, moxibustion charts identify where blistering is to take place for a desired effect. The traditional Chinese physician also makes use of a large collection of therapeutic materials. The Pen-t'sao Kang Mu, The Great Herbal, was published at the end of the 16th century and contains some 1,900 prescriptions; it remains the standard in the field. Many of the medications are potent, and some have been acquired by modern medicine. Of these the best known is ephedrine, an effective medication for asthma. The dangerous procedure of using an inoculation of pus from patients recovering from smallpox to give immunity to other persons was used by the Chinese since ancient times but only came to Europe in 1720, where it was later replaced by the use of cowpox virus. Surgery, on the other hand, was not much practiced in traditional Chinese medicine, although fractures were treated by bonesetters (a social role below that of physicians). The lack of interest in surgery was based on the yang-yin philosophy of harmony and on the Chinese consideration of the body as a sacred inheritance from ancestors, so that body injuries indicated a lack of filial piety. Traditional Medicine in Japan By the 7th century AD the influence of Chinese medicine had spread to Japan. At first the texts of this imported product were meticulously followed, and drugs important in Chinese medicine but not grown in Japan were imported as well. The oldest known Japanese text on the subject, a 30-volume compendium, Ishinpo, written in the late 10th century, consists to a large extent of quotations from Chinese texts. In the 17th century, however, a "reformist" interpretation of Chinese medicine arose claiming that the only basis for medicine should be the Shang-hang Lun as interpreted by Japanese authorities. This marked the beginning of Japan's own school of traditional medicine. One of the great exponents of this school, Goto Konzan (1659-1733), stated that all disease was due simply to stagnation of ki (Chinese ch'i, literally meaning "air" but representing the vital force); therapy must therefore consist of removing this stagnation. When the Portuguese landed in Japan in the 16th century, they introduced the European medicine of that period. Even during the period when Japan was virtually closed to the outside world, European anatomical texts, admired for their accuracy, had considerable influence, and the introduction (1824) of vaccination for smallpox convinced the Japanese government to undertake the encouragement of European medicine. Such training was required of a physician after the Meiji Restoration of 1868, and after 1883 a person could practice traditional medicine only after being qualified in this way. In spite of this, traditional medicine in its Chinese-Japanese amalgam continues to be a significant element in Japanese health care. Traditional Medicine in Modern Society Much has been written to explain the enduring presence of traditional medicine in societies exposed to modern medicine. One primary reason is that traditional medicine is part of the culture of some peoples, reflecting their vocabulary and philosophy, whereas modern medicine may exhibit no such qualities. Another reason is that although modern medicine has many obvious strengths, it also has equally obvious shortcomings in a number of chronic degenerative diseases; traditional medicine offers the possibility of another route to recovery. Finally, modern medicine has become increasingly subdivided into specialties and subspecialties. Whereas in the United States this has led to the development of a specialty called family practice, designed to restore a closer relationship between patient and physician, in other parts of the world the response has been the reawakening of traditional medicine. Aaron D. Freedman, M.D. Bibliography: Bowers, J. Z., When the Twain Meet: The Rise of Western Medicine in Japan (1981); Dow, James, The Shaman's Touch: Otomi Indian Symbolic Healing (1986); Edsman, C. M., ed., Studies in Shamanism (1967); Eisenberg, David, and Wright, T. L., Encounters with Qi: Exploring Chinese Medicine (1985); Kakar, Sudhir, Shamans, Mystics and Doctors: A Psychological Inquiry into India and Its Healing Traditions (1983); Kleinman, Arthur, ed., Culture and Healing in Asian Societies (1978); Sharma, Shiv, The System of Ayurvedic Medicine, 2d ed. (1983); Unshuld, Paul U., ed., Medicine in China (1985).