This is an immense book. It is immense in size (750 action packed pages), immense in scope (a detailed discussion on managing autoimmune conditions in general and then an in-depth account of 16 common conditions), and immense in learning - which the author shares with great clarity and generosity. If your life is busy and you are in a hurry you can stop reading this review now and just buy this book.
For those of you with more time or tighter purses here is a more considered review. The author of the book, Professor Shen, a fifth generation Chinese medicine practitioner, graduated in 1962 from the Shanghai College of TCM. Four years later China descended into the turmoil of the Cultural Revolution, which removed the senior echelon of experienced doctors and left junior interns treating hundreds of inpatients and outpatients every day. This crisis forced Professor Shen back to the classical texts of Chinese medicine to identify treatment strategies, which he then applied and revised in order to achieve effective results. Once the Cultural Revolution ended Professor Shen became Director of the Rheumatology and Immunology department and combined a busy clinical practice with basic scientific research into immune, autoimmune and rheumatic disease. Since then he has lectured internationally, written prolifically, and seen a number of his empirical formulae granted patent medicine licenses in China.
The Management of Autoimmune Diseases with Chinese Medicine reflects the key elements of its author's biography. It is rooted in a deep and detailed understanding and appreciation of traditional Chinese medicine. This theory informs and is in turn tested by extensive clinical experience that makes this book a highly practical treatment manual that uses the full panoply of Chinese medicinal arts to address autoimmune disease. Traditional theory is also supplemented by more recent pharmacological insights into the actions of Chinese herbs that will satisfy the reader with more modern medical tastes.
The basic tenet of the book is that although autoimmune diseases are essentially a modern categorisation, Chinese medicine has encountered these diseases throughout its history and has developed a sophisticated understanding and an array of tools to help manage them. Indeed, the correspondences and associations that emerge from Chinese medicine pattern diagnosis can introduce a greater coherence into the understanding and treatment of autoimmune diseases compared to Western medicine, which tends to identify basic mechanisms brilliantly but often fails to apply a whole systems approach to these conditions. One of the major contributions that Chinese medicine can make in this area is an appreciation of the underlying 'root' pathologies that need to be addressed once the 'branch' symptoms have been brought under control. Whilst the use of steroids, non-steroidal anti-inflammatory drug (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs) and immunosuppressive drugs may be effective in managing acute presentations, they are sadly lacking when it comes to effecting a deeper and more lasting change.
The first five chapters of this book present an overview of immune function from the perspective of both Western and Chinese medicine. They introduce the main elements of aetiology, pathology and treatment that are then developed in the subsequent discussion of 16 common autoimmune conditions (which include rheumatoid arthritis, Sjögrens syndrome, ulcerative colitis, Crohn's disease, thyroid disease and multiple sclerosis). These introductory chapters are detailed and well-written and considerable credit is due to the publisher, Donica, for the excellent English language editing and the careful attention given to biomedical information throughout this book. Professor Shen explores autoimmunity as a complex process that frequently combines an underlying Kidney deficiency (usually Kidney yin with empty heat) with invasion of external pathogens. These pathogens disturb the harmony of the ying and wei systems and damage the jingluo, before penetrating more deeply into the body to affect the zangfu. Secondary complications of blood and phlegm stasis may then develop, which contribute to the complexity of these diseases and their resistance to treatment.
The discussion of the main treatment methods for autoimmune diseases in Chapter 4 is another detailed and informative section that will appeal to both novice and experienced practitioners. Professor Shen introduces the importance of adapting treatment according to the phase of the disease (acute or chronic, root or branch) and the individual nature of each patient. He discusses 'straight treatment' (countering heat with cold herbs) and 'paradoxical treatment' (treating cold with cold and heat with heat) for instances where 'false' signs can lead to confusing presentations. There is a wonderful section on when to keep to a formula and when to modify treatment that captures the practical orientation of the text and will be greatly appreciated by those beginning their herbal careers. He then proceeds to identify the main treatment principles (nourishing yin, clearing heat, invigorating blood etc.) and discusses the key herbs from the point of view of their traditional use and then from a biomedical 74 Reviews Journal of Chinese Medicine • Number 100 • October 2012 perspective. Professor Shen maintains a respectful balance between these two approaches. The treatment principle of clearing heat, for example, is differentiated into six categories that include nourishing yin, thrusting pathogenic factors outward, cooling ying, cooling blood, relieving toxicity and transforming blood stasis. This exemplifies the Chinese approach of compiling relatively simple building blocks into complex, targeted formulae, which optimises clinical effectiveness. Biomedical details - such as the ability of Sheng Di Huang (Radix Rehmanniae Glutinosa) to inhibit humoral immunity, enhance the production of adrenal corticosteroids and increase the secretion of saliva - can then rest on a solid foundation of traditional practice.
This manual takes a broad view of possible Chinese medical interventions. In addition to herbal medicines there is extensive information on the use of acupuncture, moxibustion, cupping, external treatments (many different herbal compresses and medicinal plasters are described), tuina, remedial exercise and diet. These are given both a generic introduction in Chapter 4 and then considered more specifically within the subsequent chapters on particular diseases. The dietary information in particular looks interesting, and the acupuncture adopts a fairly standard TCM approach with some added extras including, for example, various bleeding techniques.
Chapter 5 discusses the integration of Chinese and Western medicine in the treatment of autoimmune diseases. There is a clear and practical appreciation of the value of drug intervention in controlling acute, disabling and life-threatening symptoms of autoimmune conditions. This is balanced by a recognition of their side effects, the potential for rebound reactions on withdrawal, and the limited ability of these interventions to address underlying causes to restore normal physiological function and prevent reoccurrence of disease. Once again, Professor Shen's approach is practical and clinically based. Most of the patients he sees with active disease will already be taking some form of pharmaceutical drug. For those taking long-term steroids Chinese medicine can be used to enhance their therapeutic effect (thereby allowing a lower dose to be used), reduce side effects of these powerful but frequently damaging drugs, and in the long term (in many cases requiring over three years of treatment) replacing steroids with Chinese medical treatments. This account is thorough and pragmatic. The main adverse effects of steroids are considered and the role of Chinese medicine in alleviating them discussed. There are formulae to help heal gastrointestinal inflammation and ulceration arising from steroid and NSAID use, and to address drug-induced problems of osteoporosis, diabetes mellitus, reduced immunity to infection, adrenal insufficiency, mood changes and insomnia. This valuable information extends beyond the field of autoimmunity and is applicable to other common presentations in our clinics.
The sections on individual diseases show the same care and attention to detail in the introduction to the Western medical approach and in the account of the aetiology, pathophysiology and pattern differentiation according to Chinese medicine. The treatment that is recommended to address these various patterns includes a guiding formula, modifications and acupuncture treatment. Other treatment methods such as the use of patent remedies, external treatments, dietary advice and rehabilitation exercises are then discussed. One of my few criticisms of this book is the lack of diagrams to clarify the application of these remedial exercises; perhaps this can be added in subsequent editions.
There is an additional and very useful section on 'clinical notes', which provides a helpful commentary on the management of each disease according to Professor Shen's clinical experience. In the chapter on rheumatoid arthritis, for example, there is an important discussion on differentiating between cold and heat and excess and deficiency. The account of cold-heat complex, where hot swollen joints are aggravated by exposure to cold requires a complex formula that combines warming herbs such as Gui Zhi (Ramulus Cinnamomi Cassia), with cooling herbs such as Zhi Mu (Rhizoma Anemrrhenae) and Shi Gao (Gypsum Fibrosum Crudum). This is an established treatment principle within Chinese medicine, but it is good to see it explained so clearly with reference to clinical practice. The known biomedical characteristics of the herbs are also described. Ren Dong Teng (Caulis Lonicera Japonicae), for example, is described as a herb that 'regulates immunity, controls vasculitis and inhibits fibrositis; it reduces the level of immunoglobulins, is analgesic and anti-inflammatory…' (p.224). This is a controversial area that I will return to briefly in this review but my personal view is that this information can make an important contribution to how we use herbal medicines and to the effectiveness of our treatment.
The final sections of each chapter describe in-depth case studies and summaries of modern clinical research. The case studies are detailed, with good accounts of the rationale for the formula and how it was modified over time. Several less common herbs are used that will help to extend practitioners' therapeutic repertoire. Dosages are substantial and, to my eyes, ring true as potent forms of clinical intervention. Interestingly, despite the chapter on integrated medicine, most of the cases presented in the rheumatoid arthritis chapter use Chinese rather than Western medicine as the primary form of treatment. I wonder how much the prevailing zeitgeist of integrated medicine has influenced the theoretical sections of this book, and whether this is indeed an accurate reflection of most clinical practice? In China this integration may be easier than in the West and it is good to see Chinese medicine on its own exerting a powerful and sustained effect on this disease. In my own limited experience of the treatment of autoimmune disease this is a therapeutic outcome that is indeed possible to achieve.
Some practitioners will question the dominance of biomedical thinking in the organisation of this book. Personally I have little time for this argument and believe we have to accept that biomedicine is the dominant paradigm that currently defines disease categories. Chinese medicine practitioners have to learn how to apply Chinese medical principles to these Journal of Chinese Medicine • Number 100 • October 2012 Reviews 75 conditions or we will become even more marginalised and anachronistic. Of course problems can arise when we apply current biomedical understanding to herbal medicines. Biomedical understanding in this regard is frequently incomplete and unreliable. Whilst I appreciate its value, I am wary of using it as a primary determinant for when or when not to use a particular herb. In Professor Shen's text for example there is an injunction to use Huang Qi (Radix Astragali seu Hedysari) or Ling Zhi (Ganoderma) with great care and in low dosages in autoimmune disease (p.53). This is because these herbs can enhance humoral immunity and may thereby exacerbate an autoimmune condition. However, in another section of the text it is acknowledged that Huang Qi has the potential to have a two-way immunoregulatory function - inhibiting an overactive humoral immune response or enhancing it when it is weak. A similar regulatory effect has been noted for Ganoderma, which is commonly used in allergic asthma and for autoimmune related infertility (see Li & Brown's article 'Efficacy and mechanisms of action of traditional Chinese medicines for treating asthma and allergy' in the February 2009 Journal of Allergy and Clinical Immunology). This leaves us on rather unstable ground. Professor Shen has noted from his own clinical experience that use of these herbs in the acute phase of an inflammatory autoimmune illness can exacerbate the problem. Maybe in such cases we should rely more on traditional Chinese medicine theory that would generally prohibit the use of qi and blood tonics during acute phases of inflammatory illness, but retain their role in the longer term treatment of underlying deficiencies, or within formulae that are strongly clearing and draining. In reality this is the line generally recommended by Professor Shen but, in this instance, the biomedical explanation is more tenuous, rigid and less helpful than the traditional understanding of the application of these herbs.
Another potential shortcoming of this work arises from the geographical, cultural and genetic differences that may exist between Chinese and Western populations. This may lead to variations in the aetiology and presentation of disease, and in the response to Chinese medicine treatment. This may mean we need to adapt approaches recommended by Professor Shen according to our own experience (although this is true for any transfer of knowledge and practice between cultures and should not deter us from using this text).
Professor Shen has written an excellent book that combines a deep theoretical understanding with hard-earned clinical experience. He has generously shared this knowledge in a detailed and comprehensive text that will enrich the practice of Chinese medicine for many years to come. I am confident that this text will be a classic of our time and the author, editors and publisher deserve our support and gratitude for this venture. So, for those of you who made it thus far, you are led back to my initial recommendation many paragraphs ago … buy this book!