A History of Chinese Bone-Setting
Editors' note:
This is an article written forty-six years ago. The narrator, Xia Xiwu, was at the time a well-known senior TCM orthopedist; he gives a vivid account of the recent development of TCM bone-setting and an even-handed analysis of the merits and weaknesses of TCM and Western orthopedics. We have made some abridgements in presenting it.
A History of Chinese Bone-Setting
Outline
This booklet concisely narrates the source and stream of TCM orthopedics. To make for an engaging read, it is told in the form of a story. It introduces the therapeutic value of bone-setting and how, on the basis of TCM's existing clinical experience, we should earnestly and humbly learn from Western medicine to raise both technique and theory and the better serve the people's health.
I. Foreword
To talk of TCM history is no easy thing, and to talk of the history of TCM bone-setting is harder still. Chinese medicine has documentary records stretching back several thousand years; the field is broad and the strands many. TCM internal medicine has many records, scattered though they are; if all of medicine were mobilized to research them, the picture could be cleared. But TCM bone-setting is otherwise. Bone-setting was never highly valued like internal medicine; its scope of contact with patients was narrow; it leaned heavily on manipulation, with little independent improvement and study; for ages it held to the inherited rules and lived by experience. To this day, in literature it has not built a theoretical base; the rare mentions are in passing and never given an important place.
Whether internal or external, Chinese or Western, the purpose of medicine is to reduce illness, ease pain, save life, and restore the patient's normal life and function. Internal medicine can lift up the gravely ill; can bone-setting not also lift the suffering of humankind?
TCM bone-setting, in particular, accumulated rich clinical experience over the long fight against disease but failed to systematically summarize and organize that experience; its pace fell behind the development of science. This is not to say the ancestral medicine never developed — only that its progress was slow, and notably so in bone-setting. To put it simply, bone-setting long stayed at a fixed level; its technique and herbs did not greatly improve; even the most basic theoretical foundation was not built — a great loss.
Since Liberation I have seen with my own eyes that the Communist Party has done many things former people did not do, did not wish to, did not dare. These living, great deeds taught me much and moved me. Especially after the Party put forward the great call to bring forth the ancestral medicine, unite Chinese and Western medicine in mutual help, I was so happy I almost forgot my near-eighty years. I want to join this surge, and step forward with my medical colleagues.
How to remove the long-standing distance between Chinese and Western medicine, let each have its place and contribute its strength, and unite for mutual help — and bring forth the ancestral medicine's splendor — is a question of organizing strength. The task of meeting the health of 600 million, of strengthening safety in production, of avoiding the loss of labor, is hard. It cannot be done by the limited number of Western physicians alone, nor by the scientifically less-equipped Chinese physicians alone. So mutual help and unity carry great meaning.
TCM does not deny it lacks modern scientific analysis in theory; but many of its treatments quietly agree with modern scientific principle, and the individual Western physician's mechanical formula treatment also deserves criticism. If Western physicians will learn TCM's unique strengths and help TCM gain modern scientific theory — its experience analyzed and organized by modern science — and the two move forward together, public health will reach greater heights.
Bone-setting is even more lacking in scientific theory than the other TCM specialties, and the help of Western medicine is the more urgent. As Director Fu Lianzhang has written: "We should, on the base of our own, absorb what comes from outside; in absorbing outside culture, enrich and lift our own. The aim in studying Chinese medicine is to learn and organize the ancestral medicine and to lift it by today's scientific knowledge. This task needs close cooperation between Chinese and Western physicians, and especially the active participation of Western physicians with modern scientific knowledge — only thus can our medical knowledge develop and rise to a modern scientific level." This judgment is just and timely; it does more than show us the road — it speaks our wish, our need for help, our hope for cooperation.
My aim in writing this booklet is to introduce TCM bone-setting in outline, in story form, to call the attention and understanding of every quarter. I also aim to set out its clinical manipulation and therapeutic value. In writing, no exaggeration, no factional bias — and a sincere hope to win the support and help of the medical community.
II. The source of bone-setting
TCM bone-setting is a precious part of the ancestral medicine, with a long history — over 2,300 years on the documentary record. Already in Zhou and Qin times the feudal court set up a special bone-setting physician. As Chen Bangxian's medical history says: "The king and nobles' diseases were treated by dedicated physicians; among them the ulcer-physician treated all ulcers and trauma." The ulcer-physician of the old times is the bone-setter of today. The treatment relied chiefly on manipulation; medicine played a secondary role. The technique was sound, safe, simple — restoring limb function in short order and leaving little aftereffect.
Bone-setting in TCM external medicine treats hard trauma and deformed bones — common-tongue falls, strikes, sprains, bruises. The most common are fractures and joint dislocations. To one suffering bone injury the pain is past imagining; so since ancient times the people have honored those who relieve such suffering. In Tang, a temple was built for the famed physician Bian Que; by the 13th century a Guangyi Temple was established to honor named physicians. To this day, temples and inscriptions honoring physicians remain across the country.
The physician's sacred task is to save the dying and bind the wounded and help man fight disease. With selfless humanism and outstanding skill they saved many lives and prevented many disabilities — and were sung and honored by the people. Yet the worldly looked down on them: the saying yi-bu-xing-xiang (physicians, diviners, astrologers, physiognomists) placed the physician with the diviner — proof of the disdain. In the Ming this disdain grew more general and severe.
Hua Tuo, a scholar-physician, regretted his career in his late years; the Six Dynasties' Yin Hao, learned in medicine, would not let it be known and secretly burned his own formulas. The reason was that the educated of the time disdained medical study, considering physicians of the bottom nine trades.
The Ming had the official-physician system. Officials were divided into thirteen subjects, of which gold-needle and bone-setting combined into one — nominally an independent subject, but socially unprestigious. So it stayed for a long stretch. By the Qing, the wind eased a little, and bone-setting found a clear place in the imperial system.
III. The bone-setting office in the Qing court
What most know today as bone-setting is the Chuoban-chu of the Imperial Stud Office. Chuoban is Manchu for bone-setting. The office had three rotating head physicians as a collective leadership, and ten-to-twenty chuoban to set bones for the imperial household. Some were still learning, others had won their titles. The head physicians were graded — usually shiwei (guards) — names suggesting attendance close at hand to guard the health. The guard titles were graded by experience and skill, but the key to promotion was connection; without someone to put in a word with the powerful, advancement was hard. The guards were in four ranks — by the feudal system, from rank six down to rank three.
Apart from the bone-setting office there was the Taiyiyuan (Imperial Medical Academy) — formed of famed internal-medicine physicians — who treated the imperial family's internal complaints. Taiyiyuan doctors were many; their physicians were the imperial internal-medicine physicians, as the chuoban were the imperial external-medicine physicians.
Entry to study at the chuoban-chu was not simple. If one were not the son of a guard or imperial physician, qualification was hard, since this office served the imperial family and recruited not by open exam but by recommendation — with the recommender as guarantor. This narrow path of cultivation stifled the proper development of bone-setting. The feudal system's strangling of learning brought decline and stagnation to bone-setting.
Once recommended, the student began to receive monthly help — qianliang (money-grain): four taels of silver a month. Study lasted six years; on completion, the skilled were promoted to head physician or made guards.
The chuoban-chu's textbook was the single Yizong Jinjian — Zhenggu Xinfa (Heart-Method of Bone-Setting). In theory it has merit; besides stressing manipulation, it discusses splinting and internal medication. In modern scientific eyes it has a certain scientific quality. But teaching bone-setting then was master-and-apprentice, with oral instruction and heart-knowing; the essential was to absorb the master's clinical experience.
In late Qing the venerated teacher was Elder De Shoutian, surnamed Chuoban De; his learning and skill outshone all. He was widely respected. His direct disciple was Gui Zhufeng, and I in turn entered the door of Master Gui. While I studied under Master Gui, Elder De was still alive; beyond my master's teaching I also received the grandmaster's guidance. To this day I have only one disciple, Wu Dinghuan.
At seventy-six I do not feel old, and in fifty-plus years of medical life I have not felt weary. I keep the learn-to-the-end-of-life attitude — every day finding my bone-setting knowledge still wanting, in need of deeper study and refinement. With the help of Western medicine I hope to summarize, analyze, and organize my experience, and bring TCM bone-setting onto the broad scientific road as soon as may be.
IV. The unique manipulation methods
Manipulation is paramount in bone-setting — its unique therapy. Medicines are auxiliary. To learn bone-setting one must first study manipulation. Without deep manipulation, no special-effect drug will bring high effect. To some, manipulation may seem unimportant or even doubtful. But to take real responsibility for the patient, one must grasp the inner meaning of manipulation and reach precise mastery — not a one-morning feat. The body's bones, muscles, nerves, and joints — their shapes and connections, the actions of joints — must all be at the practitioner's fingertips.
By long case experience, four common categories appear: ① fracture; ② old fractures and post-surgical aftereffects; ③ joint dislocation; ④ traumatic soft-tissue injury.
Fractures — any break or fissure in any bone — divide into traumatic and pathological; the traumatic is most common. Adults, given their work, fracture more often; children too fall and fracture; some enthusiastic builders of the nation lack safety awareness and fracture as well. Fractures arise from the bone's elasticity meeting outer force — direct or indirect. With skin intact, subcutaneous or simple fracture; with skin involved, open or complex fracture. By severity, complete, incomplete, or fissure fracture. By form, longitudinal, transverse, oblique, spiral, compressed, and so on. Common sites: forearm (ulna/radius), lower leg (tibia/fibula), ribs, clavicle, then humerus, femur, patella, vertebrae, phalanges. Simple-fracture signs: local swelling and pain, deformity, function loss, faint friction-sound on motion, slow discoloration of skin. Complex-fracture signs: blood flowing out, often with free bone-end through skin or with surrounding-tissue damage.
Joint dislocations — loss of normal articulation, three types: ① traumatic; ② pathological; ③ congenital. Traumatic is common; the others rare. Sites: jaw, shoulder, elbow, wrist, hip. By degree: full and partial; by associated injury: simple and complex; by history: fresh, old, habitual; by direction: anterior, posterior, lateral, dispersed. Symptoms: local pain, function loss, deformity, swelling, lengthening or shortening of the limb, with slight elastic resistance.
The eight bone-setting techniques:
1. Touch (mō): use the touch to make a preliminary diagnosis — touch the injured part to judge fracture, fissure, dislocation, or complications, and then treat accordingly. With X-ray now in use the diagnosis is more certain; cross-checking X-ray and touch is a great help.
2. Join (jiē): bring the broken bone back together. Fractures vary in shape — separated, sunken, comminuted, protruding. The unique technique gradually rejoins the freshly broken bone, lifts the sunken, flattens the protruding, and gathers the comminuted.
3. Press-up (duān): hold the dislocated part and judge the force — push from outside in, or apply zhi-duān and xie-duān, returning the joint to place.
4. Lift (tí): lift the sunken bone back to position — used for sprained waist or sunken rib.
5. Massage (àn-mó): for soft-tissue injury, local numbness, sluggish blood, stagnant qi-blood, function loss — press downward and massage to open the blockage, dissolve swelling, aid circulation.
6. Tuiná (push-grasp): push with the hand to restore the limb, grasp with the fingers to ease it home — used when an injury has healed but qi-blood is still blocked or joints displaced.
(The original lists eight techniques; the above six representative ones cover the chief uses.) Many today have come to this through Zhenggu Xinfa of the Yizong Jinjian. Let me quote part of it:
"Manipulation is the use of both hands to place the injured sinew-and-bone back where it was. But injuries vary in severity, and the technique must fit. Whether recovery is quick or slow, whether deformity remains — all depend on the technique's fitness. The body, the bones, the twelve sinew-channels, all have their own arrangement; one must know the body, know the part. In the moment of treating, contact comes from outside, skill arises within; the hand turns with the heart, the technique follows the hand. Pull what is broken to meet again; push what is misplaced to return. The bone broken, fractured, oblique; the sinew slack, knotted, twisted — even in the flesh the touch can know. Apply the technique so the patient does not know its pain — that is what is called manipulation. And many sites are vital: the seven orifices link to the brain marrow; the diaphragm is near the heart-sovereign; the four extremities, when injured, send pain to the heart. Even those of strong original qi, whose stale blood scatters easily, may recover after the time — and the manipulation must not be applied carelessly. If the original qi is already weak, and the trauma exhausts it, then a single mistaken manipulation leaves no return. So special care is required. The bone-setter must have a clear heart and skilled hand; both knowing the disease and skilled in technique, he treats — and so most are cured. The hand is of flesh and blood; its delicate use can adjust high or low, swift or slow, light or heavy, open or close — to reach the patient's congealed qi-and-blood, swollen flesh, contracted sinew, twisted bone — and the suffering and longing of his feeling. Compared with rigid instrument-bound methods, it stands far ahead. So manipulation is the foremost task of bone-setting."
This passage on manipulation is thorough. Today's bone-setters, who lean heavily on manipulation — sometimes treating it as a killer move — are deeply influenced by it.
Specialists in manipulation place high value on it — to be discussed further. Whether enhanced medicines can replace it is a question worth study. In over fifty years of practice, I have seen many cases; manipulation, in my experience, is the most important link.
V. Physical therapy — hot xun-medicine
Beyond manipulation, bone-setting uses medicines. The medicines are internal, poultice, and xun (steam/wash). They work to ease pain, dissolve swelling, nourish sinews and quicken blood, break stasis and open channels, knit bones.
Among these, the hot xun is close to a physical therapy. It is a mixture of some twenty-odd mineral and plant herbs. After repeated study, the effect is striking. Preparation and use: grind to a salty coarse powder, add liquor and salt, place in two coarse cloth bags, steam in a tray five minutes; xun alternately on the affected area, switching bags every five minutes, for one hour. Useful for traumatic and old fractures, joint injuries, dislocations.
The xun is highly effective. For fractures, dislocations, soft-tissue inflammation — where tissue is damaged, muscles contract or circulation is blocked, blood pools, vessels and nerves are compressed, local nutrition is lost — without prompt treatment, function loss or deformity arises. Apply manipulation and the xun together, and in a short time function is restored, circulation returns, obstruction is cleared.
In all my years of bone-setting I have not given up the xun's help, and shall continue. Furthermore, I intend to spread it. After the government called to develop the ancestral medicine, I have not held back, but made the formula public; the outpatient department of the Chinese Medical Association now uses it.
Before Liberation, like most TCM physicians I held the secret formula as a priceless family treasure not to be shared, my rice bowl. I would not let others spoon from it. This narrow self-interest has been washed clean by the Communist Party's greatness; the closed-door habit smashed by the spirit of revolutionary humanism. In the old days I would lock the door to compound the medicine, as if doing something shameful, lest others see. Pitiable and comic in retrospect. With a new outlook, I am no longer in that state of toil and decline. To make a secret public and cure more is the joy I had never known. As a physician, life should be lived for relieving others' pain, and treat the relief of others' pain as one's own joy.
VI. Comparison with the Western plaster method
Chinese and Western medicine, in spirit, do not differ — both are to give skill to human health. In recent centuries Western-medicine theory has developed fast with great results, while TCM has stalled in theoretical scholarship and lagged in the scientific race. So absorbing what comes from outside, on its own rich base, is TCM's common goal. But Western medicine has its strengths and also its weaknesses; TCM, though not greatly advanced, has its strengths too. We must summarize strengths and weaknesses on both sides, cast off the dregs and keep the essence, and push medical scholarship forward.
Their greatest divergence lies in treatment and medicine. Western clinic and medicine follow scientific principle, as is widely admitted; but is the result without any weakness? There is room for discussion. Let us examine the plaster problem.
For example: the chief aim in fracture treatment is to restore the bone's integrity. The general Western use of plaster bandages has helped fracture healing, but long plaster fixation cannot necessarily restore full limb function, and after healing may leave aftereffects: muscle atrophy, joint stiffness, even loss of voluntary use.
Yang Keqin, head of orthopedics at Peking University Hospital, and his attending Tian Wuchang, have actively reached out to me. I have often turned to them on Western methods. Since the Chinese Medical Association outpatient department was established, our two sides keep introducing patients to each other. Those needing Western treatment go to the hospital; those suited to bone-setting come to the Association. This matches treat-according-to-disease and shows that the mutual unity of Chinese and Western medicine has gained a shared view.
Drs. Yang Keqin and Tian Wuchang are seasoned in Western orthopedics with brilliant results — authority-figures of Western orthopedics — and yet not proud, often coming to the Association to consult and look after us with warmth. We are moved. With their help, I have learned the use of X-ray and want to absorb other Western methods to lift our theoretical and technical level.
Drs. Yang Keqin and Tian Wuchang frankly admit that plaster is not suited to every fracture and that aftereffects are real; they further state that they will avoid plaster as much as possible and avoid surgery where it can be avoided. Such humility and honesty are the marks of a scholar; I fully agree and support this clear, just view.
For limb fixation, the TCM tying method, after improvement, has continuing value, with these strengths:
1. Less prone to aftereffects.
2. Lets qi and blood pass; local stasis dissolves easily.
3. Lighter psychological burden for the patient.
4. Easy to undo, helpful for checking changes.
Some may not agree, may even oppose. Some may suspect I am blowing for TCM. I do not mind — I judge this therapy from objective standpoint.
VII. Recollections of the eating-grain, swindling-treasury, jumping-the-table underworld
Social customs reflect human activity. Each society has its own. In late Qing, the dissolute drifters, idling in ease, hating work, lived on rich indulgence; they could not raise pigeons or carry caged birds without also envying the parasitic life. They styled themselves heroes, and produced for-pay-being-beaten hoodlums — adding to the rot of feudal society.
Their best-known shake-downs: eating-grain, swindling-treasury, jumping-the-table. The three differ in form; all use buying a beating as means and indulgent life as goal.
Eating-grain: Beijing had nine grain warehouses under the feudal court — Lumi, East Gate, South Gate, West Gate, North Gate, Haiyun, Beixin, Taiping, Chuji. Inside, corruption was rife: officials and runners colluded to swap good rice for moldy; this was an open secret. When grain was moved out, the hoodlum would block the road and threaten: "Take these few carts to my house." The smuggler would bare teeth: "Eat rice? Easy. Let me see you first." The hoodlum would lie before the cart wheels; if he held firm and was not afraid, he had passed; if he did not flinch, the wheels rolled over and his shin and fibula were crushed. Pass the test, and the hoodlum drew monthly hero stock or arm money.
Swindling-treasury: the feudal court hoarded the wealth of the empire in the Silver Vault. As with the grain warehouses, abuses were many — officials freely took, guards too. When guards smuggled silver, the hoodlum would appear and demand a share by force; the guard would throw him down and beat him with a stick — the hoodlum bearing it without a sound.
Jumping-the-table: more notable still. Many princes and high officials in late Qing kept retainers and enforcers. Some hoodlums attached to influence opened bao-ju (gambling dens) — the den ruined many. While the den was running, a stranger would suddenly jump on the table — and gambling would stop. The den-master signaled the enforcers to drag him down and beat him with sticks, some sticks snapping — the hero with broken bones. Pitifully battered, but the price was paid: as long as the den ran, the hero drew a daily share, becoming one of the den's shareholders.
The activities reflected the society. Outwardly the hoodlums seemed unafraid of power; inwardly the trade was shameful, only adding parasites to society and worsening the customs.
You may ask: Why move from bone-setting to such ugliness? I answer firmly: it is not. Bone-setting and those three trades share a source.
Whether eating-grain, swindling-treasury, or jumping-the-table — beatings were involved, and the beaten man's lower limbs were a mess of broken bones and torn flesh. On the spot a tent was set up, and a famed chuoban called to treat. I have treated such cases too. Of all bone disease this is the most tangled — fracture, comminuted bone, dislocation, even infection and tetanus, all at once. Without good treatment, aftereffects are devastating. I have treated a few; my elders treated more, and the patients all recovered well after about a hundred days, with no other change, function restored. The fearlessness of these dregs is, paradoxically, evidence of TCM bone-setting's excellence.
VIII. Smashing the high wall between TCM and Western medicine
Through a long period, especially the past century, feudal forces, imperialism, and bureaucratic capital have not only strangled China's medical and health development but also brought severe disease and death to the Chinese people. Before Liberation, the laboring people lived in misery; in addition to natural disaster and human misfortune, illness meant near-death for the working man — illness in the home was a death sentence. After Liberation, in only a few years, the whole face of the country changed. Rot was replaced by new growth; the masses freed from heavy oppression rose in politics and gained economically. The government's value of public health gave the medical world a tonic, transforming the old picture.
As early as 1934 Chairman Mao wrote Concern for the Masses' Life and Methods of Work, saying: "A revolutionary worker should solve the masses' disease and health problems." And: "Many have sores and illness; what can be done? These problems should be on our agenda, discussed, decided, executed, checked." In On Coalition Government (1945) he wrote: "We should actively prevent and cure the people's disease and broaden the people's medical and health work." He valued the people's life and cared with detail for the disease and health within it.
Today, as the First Five-Year Plan nears completion, the country's medical-and-health enterprise leaps forward. Under correct leadership and emphasis from the Party and government, new achievements have come. After the all-national health conference set out the three principles — face the workers, peasants, and soldiers; prevention first; unite Chinese and Western medicine — and called to bring forth the ancestral medicine and march toward science, fresh airs swept the medical field. TCM hospitals were set up across the land, broad academic exchange went on, study classes and refresher classes were widely founded. Plain proof that the old factional walls between Chinese and Western medicine have fallen, and both have taken in a new outlook.
In the past Western physicians looked down on TCM, said it was unscientific, treated it with disdain — facts. But TCM physicians' own failure to go deep into theory, leaning entirely on familiar prescriptions, and not absorbing modern science — also undeniable. From the long mutual ignorance, deep emotional barriers grew. Under the Party's vigorous leadership and the criticism of Western disdain for TCM and the education of TCM physicians and the call to march toward science, the feelings of both sides are converging. The high wall between Chinese and Western medicine is broken.
IX. Secret formulas shall no longer be carried into the coffin
Many things in China go by customary law. Take master and apprentice: whatever the trade, once you enter the master's door, your manner, technique, learning must follow him; no innovation or independence is allowed. If through labor experience you find a clever way or break a new line, the master may bristle his beard, glare his eye, scold you for unfilial — for failing his teaching. So in martial arts, in handicraft, in scholarship — in medicine all the more so. The narrow lineage thought ran deep and wide.
If the master's habit is so narrow and selfish, then the apprentice should at least get the master's full learning. But not quite — under the historic conditions of the time, most masters kept one trick back and would not let the apprentice surpass them. The trick was no small thing. In medicine especially, many high-value, effective secret formulas were carried into the coffin generation after generation — one reason secret formulas were lost.
I am fortunate to have lived to see — myself included — the people's complete liberation, and the never-valued TCM learning given the chance to be brought forth. An unprecedented thing. Under so many great works, I have shed the shackles long borne on my body. I have voluntarily, with joy, made public my secret formulas — internal medicines, poultice, hot xun. Apart from Beijing TCM Outpatient No. 2 (already in use), other medical units will try them. I hope they spread further — that workers, peasants, and the broad working people from generation to generation live ever fuller, happier, healthier!
Narrated by Xia Xiwu; organized by Wu Dinghuan