Understandings and misunderstandings of gua sha : A discussion from the perspective of scientific multiculturalism

Abstract

As a traditional therapeutic practice, gua sha (刮痧) has been controversial because of its differences from the theoretical understandings of modern Western medicine. This paper presents an analysis of the historical evolution of the concept, treatments and theoretical origins of gua sha based on previous studies and examines the practice of gua sha from the perspective of scientific multiculturalism. It stresses that the body concept and the medical theory represented by this therapy are also parts of science in a diversified and broader sense. The resolution of disputes about gua sha requires a change in people's conservative mindset to adopt a position of scientific multiculturalism.

1. Introduction

Gua sha (刮痧) ¹ is a traditional medical therapy that is popular in China. Recently, a female star's photos on the internet of her bloody back from gua sha treatment started an online debate: some people thought that excessive ‘dampness evil’ in the body had caused such a heavy concentration of scar-like markings on her back; some believed it was dangerous to scrape the skin to such a degree, as it might lead to rhabdomyolysis and acute renal failure. In 2001, the film The Gua Sha Treatment, directed by Zheng Xiaolong, presented a plot in which misunderstandings relating to gua sha therapy were the main theme. The film tells a story in which a grandfather treats his grandson using gua sha while they are in the United States, and this raises suspicion of child abuse by the authorities. Because gua sha involves the creation of areas of purple–red ‘blood stasis’ marks on the skin, it can be viewed as torture in the eyes of Westerners. This kind of traditional Chinese medicine (TCM) practice is difficult to explain and is not recognized by modern Western medical theorists. The film shows the many kinds of difficulties that Chinese immigrants in the United States have encountered because of cultural conflicts, and it highlights the great differences between Chinese and Western medical cultures.

Since the 1990s, gua sha has become popular and widely recognized in China as people pay more attention to health care. However, not only it is difficult for Westerners to accept this mysterious oriental therapy but gua sha is also controversial among Chinese people. On the one hand, some people like it and believe in its therapeutic effects; on the other hand, some people question its validity and suspect that it is a pseudoscience. Coverage of gua sha by the media has also focused on publicizing its modes of treatment and purported curative effects. Its particularities are also manifested in the fact that, as an external therapy with strong local cultural characteristics, it has been widely applied in rural areas until the present day. Nonetheless, the history of its development is one of ups and downs. It flourished in the Qing Dynasty, attracting the attention of doctors and leading to the publication of dozens of medical monographs. However, in contemporary vocabulary and professional books, there are still different opinions on the definition of ‘sha’ (痧) (Ji, 2008). This phenomenon has not been paid enough attention in the history of science, medicine, science communication, health communication and other related fields. It is difficult to explain the kinds of disputes and problems that have arisen around gua sha without an in-depth analysis of the above-mentioned state of gua sha. Therefore, by summarizing the historical evolution of the concepts and theoretical origins of gua sha in China's medical history, and from the perspective of the theory of scientific multiculturalism combined with social-background factors, this paper presents an in-depth analysis of the body concepts reflected in this therapy and the medical culture it represents so as to seek out an understanding of gua sha and find solutions to its problems.

2. Historical evolution of gua sha therapy

2.1 Concept and historical connotations

There is no uniform definition of the concept of the gua sha therapy in the major contemporary dictionaries and medical reference books, as there was no authoritative and prevalent definition of the therapy in ancient medical books. Therefore, referring to Ji's (2008) systematic study of the therapy in his doctoral thesis, this paper briefly describes and interprets the history and development of its concept in combination with general analyses by several other researchers in the history of TCM. In the related TCM literature, we find that the therapy has had different meanings in different historical periods.

First, sha was understood to come from water worms as stated in one study (Yang et al., 2007), sha had its origin in the Chinese word for ‘sand’ (沙), and scholars from the Ming and Qing dynasties and in modern times declared that the sha syndrome originates from diseases associated with water (stream poison, worm poison and sand-lice poison). Among these, the worms and poison are reflected in the early Chinese idiom ‘han sha she ying’ (含沙射影, meaning that a water worm called Yu can attack people and cause similar symptoms to typhoid fever by shooting at people's shadow with water mixed with sand). Sand-lice diseases, as mentioned in the Jin Dynasty, were said to need to be picked and scraped out, as exemplified in the Handbook of Prescriptions for Emergencies in the Eastern Jin Dynasty, the Excerpts of Prescriptions in the Southern and Northern dynasties, and the Supplement to Materia Medica in the Tang Dynasty, all of which make mention of the symptoms and treatments for diseases caused by worms. However, the names of diseases with the same concept as the syndrome of sha were not found before the Song Dynasty; nor was there any description of any therapy similar to that referred to in later generations (Ji, 2008).

Second, the concept of sha disease was established the Song, Yuan and Ming dynasties were important periods for the development of medicine concerning the sha syndrome. The concept of ‘sand disease’ was recorded for the first time in the Southern Song Dynasty (Wang and Yang, 2010), after which mentions of sha increased, and its name, etiology, pathogenesis, symptoms and treatment were described. For example, in the Complement to the Secret Prescriptions of Sun Rencun's Living Therapy in the early Yuan Dynasty, sha was called ‘sand disease’, the cause of which was considered to be mountainous evil air rather than poison spurted from worms. It was noted that ‘the place where blood stasis marks are caused by the skin being rubbed on a rope today is the place through which the Yang meridians pass. Then the pathogenic factors are purged, and the disease is cured’ (Sun, 2008: 319). The described therapeutic mechanism is closer to the therapy for the sha syndrome mentioned in later generations, and especially to the method of rubbing out purple spots on the skin with a rope, which is referred to as ‘outing of sha’ in later generations. In the Yuan Dynasty, ‘twisted intestinal disease’ was regarded as a subcategory of sha for the first time. Later, ‘typhoid fever’, ‘the watery sand disease’ and other names appeared. On the basis of understanding the sha syndrome in the Song and Yuan dynasties, its etiology was further discussed in the Ming Dynasty, the sha syndrome was differentiated into cold and heat variations, and the scope of sha was further expanded.

Third, various epidemics were included in sha the epidemic in the Qing Dynasty gave birth to a group of experts and medical books on sha. The first monograph—Guo Zhisui's Sha Zhang Yu Heng— appeared, which, together with Wang Kai's Encyclopaedia of Sha Disease (Sha Zheng Quan Shu) and the monk Pujing's Profound and Subtle Works of Sha Disease (Sha Zheng Zhi Wei), established a system of theories different from those of earlier generations. This drew more attention to sha from the public and medical circles, and the content concerning ‘swelling sha’ evolved into treatment against epidemic diseases, especially those with characteristic symptoms of ‘swelling and inner pressurizing’. The causes of these diseases were considered to be plague, as with other epidemic diseases; they were also understood to be caused by foul gases, summer heat and unhealthy vapors, which were related to ‘sand disease’ described before the Qing Dynasty. In its heyday, it was considered that ‘no one is free of sha, and there are no symptoms without sha’. Therefore, different names, such as ‘swelling sha’, ‘smelly drugs’, ‘foreigners’ sha’, ‘yin–yang toxins’, ‘plague sha’, ‘epidemic sha’, ‘spotted sha’ and ‘inner evils’ were coined: there are more than 100 kinds of diseases and syndromes named after sha (Wang et al., 2012).

2.2 Evolution and development of the skin-scraping therapy

Most scholars believe that gua sha therapy is closely related to stone needle, acupuncture, hot ironing, massage, cupping and blood-letting in their sources and evolution. In this sense, the history of gua sha therapy can be traced back to the pre-Qin era more than 2000 years ago (Yang et al., 2007). For example, the Prescriptions for Fifty-Two Ailments recorded: ‘roast the cloth for ironing’ and ‘caress the skin with the cloth’; although this was still in the primary stage of gua sha therapy, more specific technical requirements were imposed (Ming, 2004). In medical books such as the Handbook of Prescriptions for Emergencies, the methods of brushing, scraping, picking and moxibustion were adopted to expel sand lice invading the skin. Although the exact date when scraping therapy was invented is unknown, it had been widely developed and popularized among the public for a long time. Later still, during the Song and Yuan dynasties, the methods of scraping the back with a spoon and using copper coins dipped in water or oil to treat abdominal pain were widespread and attracted the attention of medical scholars. The ‘rope rubbing’ and ‘hemp scraping’ methods that appeared in the Yuan Dynasty further laid the foundations for the scraping method and made it clear that these external treatments can cause dots or spots on the skin in an approach aimed at ‘opening up the muscular interstices, relieving stagnation, promoting the circulation of qi and blood, and expelling pathogenic factors’ (Ji, 2008: 64).

By the Qing Dynasty, the therapy of gua sha was very popular, and some new progress was made in the treatment. The sources, prevalence, manifestations, classification, methods, tools and comprehensive treatments for more than 80 kinds of disease were discussed in detail in Guo Zhisui's Sha Zhang Yu Heng. In addition to traditional methods of detecting sha points, checking sha tendons and testing sha prescriptions for diagnosis, the theory that ‘strange diseases are called sha’ was also put forward, which meant that there were no definite pulse signs or symptoms for sha syndrome. As for the specific treatment, Guo (1675: 5) put forward three methods: scraping, blood-letting and drugs. ‘If sha is on the skin, scrape the skin; in the flesh and blood, release the blood; in the stomach, intestines, meridians, spleen, liver or kidney, use medicine. If it is widespread and rampant, existing both outside and inside, the three methods shall be used at the same time.’

The treatment proposed by Pujing in his Profound and Subtle Works of Sha Disease includes scraping, pricking, moxibustion, ironing and medication, with a combination of scraping and pricking the acupoints as the main external treatment, and there are great changes in the parts for scraping and pricking, which cover the acupuncture points over the whole body (Ji, 2008). Wang Kai's Encyclopaedia of Sha Disease declares that ‘for sha treatment, the most important factor lies in the use of the hand’, and it provides the method of touching the spot with the end of a burning lamp wick as external treatment for ‘patients with sha on the muscle surface’. It also proposes that scraping is for ‘patients with sha within the skin which cannot let out’, while pricking is used to let out blood (Wang, 1876: 62–63). Later, a method of ‘pricking with the tip of one finger’ appeared in association with a massage school. Literature covering acupuncture and relieving sha treatments was thus greatly enriched in the Qing Dynasty. Due to the over-expanded scope of sha therapy, epidemic diseases and many unknown diseases were classified as sha. However, with the introduction of epidemiology from Western medicine in the late Qing Dynasty, sha disease began to fall sharply in scope (Ji, 2008).

After the founding of the People's Republic of China, until 1960, a book by Jiang Jingbo titled Therapies for Gua Sha was published, in which the term ‘gua sha’ as sha therapy was used to encompass scraping, blood-letting and patting. This initiated modern research into the scraping therapy for sha and made it possible for the therapy—which had previously been confined to the sha disease and to bringing about blood stasis marks—to become established in academic circles and gave the therapy its due (Yang et al., 2007). Gua sha therapy appeared as an approach to achieving good health under the advocacy of Professor Lv Jiru in the 1990s, and the instruments, tools and media for scraping were updated accordingly. As the works of Lv's followers came out one after another, the therapy was not only brought onto the stage of medical care, but was also promoted to be included in textbooks, and it finally became a more accepted aspect of health care (Ji, 2014).

Gua sha therapy has experienced ups and downs, but, on the whole, it has evolved ‘from superficial, intuitive, singular and experiential therapy to one of natural therapies with systematic theoretical guidance, complete techniques and improved tools, which are suitable for a wide range of diseases’ (Yang et al., 2007). Gua sha, in parallel with acupuncture, massage and cupping, has become to be one of the four basic skills of TCM practitioners.

3. The theory of gua sha and its body concept from the perspectives of TCM and Western medicine

As described above, sha disease had different characteristics in different historical times. With people's constant struggles against disease, experience in gua sha therapy has been continuously improved, and theoretical research examining the therapy is constantly changing and developing.

3.1 The traditional theoretical basis of TCM

Before the Yuan and Ming dynasties, gua sha was widely conducted as an external therapy among people, yet there are only sporadic records of it in medical classics, and it is not valued by orthodox Chinese medicine. Although ancient physicians held different views on the names, symptoms and pathogenesis of sha, they had basically the same understanding of the mechanism of its treatment; that is, by scraping. By the Yuan Dynasty, Sun Rencun and Wei Yilin began to elaborate on the principles of gua sha, which were further improved by various physicians in the Ming Dynasty. In summary, it was described as mainly serving to ‘open up the muscular interstices, promote the circulation of qi and blood, dredge collaterals and expel pathogenic factors’ (Wang and Yang, 2010). Ancient physicians’ scattered research on sha finally made a breakthrough in the Qing Dynasty. The theoretical system of ‘swelling from sha’ represented by Guo Zhisui's classification of the nature of sha swelling as a heat-excess disease was developed, for which an educing method was mainly adopted, and that was quite different from the methods used in the Song and Ming dynasties. Although it also caused controversy, this laid the foundation for the differentiation of sha in the Qing Dynasty (Ji, 2008).

In terms of therapeutic mechanisms, the theory of meridians in TCM was introduced to treat sha. Guo described a corresponding relationship between the diseased location and symptoms from the perspective of the six meridians and viscera, but he failed to explain the internal relationship and transmission between each meridian and the viscera (Ji, 2008). In the early Qing Dynasty, syndrome differentiation and the theories of experts regarding sha appeared to be in a state of disorder, and that laid the groundwork for the disorderly expansion and final decline of gua sha therapy (Ji, 2008).

Researchers considering gua sha in recent years also recognized the theoretical basis of the meridian theory (Chen et al., 2014). For example, Cao et al. (2019) revealed the reasons that gua sha works through the theory of skin and collaterals: ‘The skin is the direct part where gua sha works as well as the external part through which reaction with qi and blood of viscera and meridians is achieved; collaterals are scattered all over the body, communicating the exterior and interior, connecting the viscera and infiltrating qi and blood, which are closely related to the skin.’ Huang (2018) further pointed out that scraping the body parts along the meridians not only follows the theory of acupoints in the meridians but also conforms to the theory of viscera state, holography, blood stasis and the bodily-axis theory.

The method for achieving good health by scraping is represented by the ideas of Professor Lv Jiru, who put forward the possibility of reinforcing or reducing the intensity of scraping by using different postures of the fingers. He holds that ‘scraping brings qi to the body’, thus restoring the circulation of qi by meridians and bringing recovery (Lv and Lv, 1997). It is considered that ‘according to the direction of meridians, forward scraping is for reinforcement, and reverse scraping is for reduction’ (Lv, 1995: 19–22). Lu et al. (2016) also emphasized that ‘in scraping therapy, as in acupuncture, an appropriate method (i.e., reinforcement of good qi or reduction of bad qi) can be used according to the patients’ physical constitutions and specific diseases for the purpose of strengthening the body's immune system, eliminating pathogenic factors and adjusting yin and yang’. Traditional physicians hold the view that gua sha ‘is purely for reducing bad qi rather than reinforcing good qi’, whereas contemporary physicians, represented by Professor Lv, believe that, similarly to acupuncture, acupoints have a two-way benign regulatory effect on the body; scraping serves not only to eliminate evil factors but also to strengthen the body, and its reinforcing and reducing effects are closely related to the selection of acupoints and the skill of the practitioner in using the scraping tools (Gan et al., 2021).

The meridian theory of TCM is thus the main theoretical core governing scraping. TCM states that external stimulation (including acupuncture, massage, etc.) of the meridians and collateral systems can accelerate the movement of qi and blood in the corresponding parts of the body, thereby contacting the viscera, liver and other organs and changing the state of the whole body to adapt to different environments in the diseased state. In addition, TCM also holds that various diseases appear as different symptoms under different conditions, including the directions of various meridians. The distribution of qi in collaterals enables its connection with the qi and blood in meridians and viscera in the body. As an external therapy, scraping for sha serves to dredge meridians and collaterals, regulating qi and promoting blood circulation, thereby playing a role in both diagnosis and treatment. Gua sha thus embodies the body concept in TCM, which is a philosophical and comprehensive way of thinking with integrity and harmony, advocating a balance to be struck by moving qi and blood to follow meridians, strengthening the body's immunity and eliminating evil energy, and connecting qi, meridians and viscera (Zhang, 2016).

3.2 Modern theoretical medical explanation

Under the influence of modern Western medicine, there is a tendency within research in contemporary Chinese medical circles involving gua sha to attempt to further explore the modern scientific (medical) theories underlying scraping based on traditional medical theories and clinical practice. Professor Lv Jiru carried out experiments on the effect of scraping on haemorheology in rabbits and concluded that the mechanism of gua sha could strengthen metabolism (Ji, 2014). Wang and Yang (2010) continued that work, and they believed that the mechanism of gua sha—opening up the muscular interstices, promoting the circulation of qi and blood, and dredging collaterals and expelling pathogenic factors—was basically consistent with the functions of improving microcirculation, regulating immunity and strengthening metabolism formulated in modern research. Huang (2018) summarized the traditional medical theories concerning gua sha, pointing out that the mechanism of gua sha in the treatment of some related diseases is difficult to explain based on modern medical theories; he suggested that the theoretical mechanisms of modern medicine should be explored from the perspectives of morphology (observing the morphological changes of local tissues after gua sha), immunological research (causing the release of immune factors by conducting the stimulation produced by scraping into the immune system), microcirculation (the blood perfusion of local skin microcirculation after gua sha is higher than that in patients treated by other methods), antioxidation (gua sha serves to improve certain peroxide indicators) and nerves–immunity–internal secretion. Xu (2015) put forward the hypothesis that gua sha stimulates the skin to release neurotransmitters, which are then transmitted to the central nervous system to release corticotropin-releasing hormones to regulate human metabolism, strengthen immunity and maintain the homeostasis of the internal environment.

In recent years, with the wide application of gua sha in clinics and in health care, the theory of ‘scraping following the direction of the meridians’ was put forward when Wang et al. (2021) pointed out that mature science and technology should be the perfect combination of theories, methodologies and techniques. It is thus necessary to theoretically sublimate and clinically improve traditional scraping therapy within the theoretical system of TCM. They also suggested that quantitative research should be carried out on the force used in gua sha, alongside objective research evaluating the degree of blood stasis marks and other signs manifested. This helps to strengthen scientific support for gua sha and promote the perfection of theories and the construction of disciplines regarding ‘scraping following meridians’, and thus to standardize the clinical application of the therapy and improve its therapeutic effects.

4. The philosophical position behind the pluralistic understandings of gua sha

Gua sha, as an experiential therapy, has been rooted in folk medicine in rural areas since ancient times, and it was incorporated into orthodox theoretical medicine by doctors in the Ming and Qing dynasties. Since the 1990s, it has taken on a new perspective through its combination with health care. It could therefore be said that gua sha is not a surprise for anyone who has been immersed in Chinese culture (Ji, 2008). However, there are still a large number of people with scientistic views who question or deny the value of the therapy. Even among Chinese medicine researchers, there seems to be a lack of sufficient confidence in TCM theories concerning gua sha. Either by advocating to improve the existing theory of ‘scraping following the meridians’ using quantitative research and objective evaluation or by directly borrowing theories and concepts from Western medicine to explain the clinical effects of gua sha, they are trying to build a ‘coincidence’ between Chinese and Western medicine in many theories to show the ‘modernity’ contained in TCM (Liu, 2011). However, the curative effects of gua sha can be only partially proved with the help of various explanations from Western medicine, and it is still difficult to explain its mechanism; it is thus necessary to resort to the theory of Chinese medicine (Ji, 2014). Judging from the tortuous development of the therapy, although doctors’ opinions have been controversial in different periods, they have continued to borrow statements from TCM until their discoveries were fully incorporated into the theoretical framework of TCM, thus avoiding the blindness and limitations of folk scraping to move towards obtaining stable support and development. This indicates that the therapeutic principles and the effects of gua sha remain essentially the same despite all of its apparent changes, and this reflects the body concept in TCM and the inclusiveness and stability of TCM theories and culture.

The phenomenon of TCM being judged from the perspectives and methodologies of Western medicine leads one to a realization that reveals a very typical philosophical standpoint about science and culture. In reality, some people are sceptical about gua sha therapy because they are not only unfamiliar with the theories of TCM and its underlying body concept, but they are also under the inevitable influence of the monistic science (medicine) culture that currently occupies the mainstream position in China. This holds that only Western medicine, which is quantifiable and verifiable with double-blind experiments, has an objective, correct and effective cognitive system. Therefore, if we maintain the position of Western science (medicine) monism and think that there is only one ‘truth’, then TCM therapies that cannot be verified using Western science are not true and not convincing. The theory and standard of Western medicine should not be used to measure the treatment of TCM. Gua sha conforms to TCM theories—treatment following the meridians and strengthening the body's immunity and eliminating evil energies. It would inevitably seem to be far-fetched when verified and explained with modern scientific (medical) theories. In addition, as the health-care boom of recent decades continues, some pseudo Chinese medicine practitioners falsely using the name of TCM have also caused some adverse effects with their abuse and misuse of gua sha. Therefore, dirt has inevitably been thrown at the theories and therapies associated with TCM, and the public might easily regard these incidents as evidence of inherent problems in TCM.

In terms of the philosophy of science, TCM and Western medicine belong to different theoretical systems under different paradigms, so they have a degree of incommensurability. Elements of the body in TCM include the mind, qi, meridians, collaterals and viscera; conversely, in Western medicine, the human body is dealt with from the aspects of cells, molecules and genes. The dualism of body and mind in Western medicine removed obstacles to the development of modern medicine and anatomy, but at the same time it led to the neglect of psychological factors and to the separation of ‘diseases’ and ‘the person’, and this dualism of body and mind has gradually come to be criticized due to its deficiencies and negative effects. TCM adheres to the philosophy of the unity of the body and mind; the ancient body theories found in TCM constitute a simple and unified understanding of the body and mind, form and spirit, and this provides theoretical resources for modern people to better understand life, health and diseases using a holistic and interactive view of the body (Zhang, 2016).

Looking at the formation and development of gua sha, it can be seen that it evolved as a product of long-term practical experience accumulated by ancient folk doctors. It moved towards the orthodox theories of TCM occasioned by the great epidemic in the Qing Dynasty, before finally entering the academic sphere, when it expanded along a professional road to medical treatment and health-care provision with the help of commercial promotion. We thus find that it is not only closely related to the traditional social culture of China but is also inseparable from the diversity, inclusiveness and openness of the Chinese medicine system itself. If we mistakenly pursue all the paradigms and theories of Western medicine to understand and evaluate gua sha therapy, that is tantamount to cutting one's feet to fit one's shoes. In short, from the standpoint of monism in science, ‘traditional medicine such as TCM can never be properly treated, nor can it be developed ideally’ (Bao and Liu, 2017). Therefore, what urgently needs to be changed is first and foremost a matter of our standpoint.

5. Discussion and conclusion

To summarize: it is of great practical significance to analyse and explain the phenomena of gua sha from the perspective of scientific multiculturalism and to promote the role of reflective science communication.

First, the controversy around gua sha reveals the standpoint of ubiquitous monism regarding Western science on the part of not only Western people but also the public in China, and this is inevitably permeated with the influences of social science and culture. What contemporary society is therefore facing is the lack of an educational environment that can promote scientific multiculturalism. Since Western medicine has gradually become the mainstream discipline worldwide, including in China, near-universal trust in and admiration of Western medicine exists widely in education and mass-media communication; inevitably, it has even infiltrated vocational education, training and development in TCM.

Second, the concept of scientific multiculturalism has so far been the outcome of interdisciplinary research that has absorbed the achievements from many disciplines, including the philosophy of science, the history of science and technology, and the study of science, technology and society; there have been many research achievements that have seriously criticized the concept that science is universal, de-contextualized and de-localized. From this philosophical standpoint, science is not only diachronic, but also contextual, and in essence belongs under the umbrella of local knowledge. A concept of diverse sciences that does not pursue uniformity and standardization should be advocated, and a broad cognitive and receptive attitude towards local ethnic medicine should be adopted. Traditional therapies such as gua sha are also kinds of local medicine (science) that have arisen from traditional Chinese culture and history, so they should be included, and in fact they are already in a diverse and multicultural system of sciences.

Finally, the above analysis reminds us of the importance of instilling the concept and importance of scientific multiculturalism in the public. This is also the essence of replacing traditional ‘science literacy’ with ‘science culture literacy’, as currently advocated by science culture researchers. To promote the public's understanding of science (medicine), what we need to disseminate should not be just scientific (medical) knowledge, or rather, the first priority is not knowledge, but a diversified concept of science in a broader sense. People's overall understanding of science should be promoted so that their recognition of science as a human cultural and social activity that also has cultural and social attributes can be enhanced (Yue and Liu, 2019). This places greater requirements on researchers and practitioners of science communication, especially practitioners in the medical and health fields, in which a change towards the concept and position of scientific multiculturalism is required.