Preface

This is an acupuncture textbook. That may seem an odd claim for a book that offers history, research, and science but no needling instructions. Yet, acupuncture, like many familiar Western arts and sciences, is intellectually hierarchal. Learning acupuncture has never been solely a matter of learning technical details. History shows that some acupuncturists have always been technicians trained only to follow the established procedures of a family tradition, teacher, or school. Others have been medical artists whose refined sensory and physical skills were honed by a social, moral, or religious philosophy. Some have been eminent teachers and innovators, who extended acupuncture through scholarship and experimentation. Fewer have been of such rare brilliance that their inspirations and realizations are the landmarks of acupuncture's history and substance of its practice.

In Asian societies the practice of traditional acupuncture is not unlike many modern Western careers. For example, some electricians are trained to follow instructions known as 'codes'. They know how to install electrical equipment that will pass commercial and governmental inspections. But those code books contain no history, no science, no references; none of the information by which to judge the intellectual or scientific foundations of the devices they install. On the other hand, the electrical engineers who design those devices learn not only the historical development of the principles, but also the science necessary to create new systems. They are guided not by codes but by qualitative and quantitative standards, some of which derive from allied fields. They are taught not to follow rules but to understand and apply measures and standards. Those standards are developed by physicists who refine their ideas by subjecting them to experimental trials. Following this extended analogy, this is a textbook for those who must judge for themselves the utility of information provided by academic, clinical, commercial, and scientific sources.

When traders arrive on a foreign shore they bargain for what most brightly shines of their own values. It is thus reasonable that the idea of acupuncture that has reached the broadest Western audiences reflects the values of those who first discovered it. Some information, particularly that carried by scholarly and scientific vehicles, has received little attention, not only because it is not always applicable to the acquisition of clinical skill, but also because commercial sources are more quickly and easily available. This too is expected, because acupuncture's economic application is the most powerful stimulus for its survival and transmission. However, there is more.

Whether it is for students evaluating a career in acupuncture, acupuncturists who must judge the services and products they are offered, teachers who hope to develop better courses, or the rapidly expanding corps of physicians whose patients need to know if acupuncture can help, technical knowledge alone is not enough. Acupuncture must be understood as a human intellectual pursuit in order to best choose a course of study, to make referrals, to judge efficacy, or to advise a complex health care system.

This is not a theoretical need. Because more and more people associated with the practice or delivery of medicine feel, along with a majority of their patients, that there is a useful role for acupuncture in modern medical systems, acupuncture must now adapt not only to the needs of new patient populations but also to the demands of Western culture. This is nothing new. Acupuncture's 2000 year history is a story not only of gradual dissemination to virtually every country on Earth, but also of adaptation to the needs of many different cultures in many different eras. Thus we have concentrated on the presentation of principles. By examining ideas common to most views and systems, we are best prepared to understand and apply the technical details. However, if only because there is no consensus among systems and cultures, we have considered many views while preparing this book. We have taken a survey approach, reporting facts, thoughts, and opinions gathered from experts and practitioners.

Among the things that are clear from this survey is that, without understanding the broad outlines of Chinese medical history, it is easy, and perhaps even inevitable to misunderstand acupuncture. The themes and techniques of acupuncture begin in history and can only be clearly understood in relation to the needs of those who created them. A tradition can only be understood through its history. Indeed, even the most basic technical features of acupuncture needle selection, insertion technique, and stimulation vary with time, culture, and school of thought. It is also true that acupuncture has been widely practiced in many countries besides China, in some for more than a millennium. Without recognizing the contribution of these societies, acupuncture's story is incomplete. It is also necessary to understand something about other traditional medicines, for example, traditional pharmaceutics and massage, to understand acupuncture's place among China's traditional medical arts.

Acupuncture's breadth must also be understood. Acupuncture is as broad as it is ancient. It includes techniques beyond the use of needles. Historically, not only was there a selection of needles, nine to be exact, but several of those needles were never used to puncture. Acupuncture also was, and is, routinely used with moxibustion, a heat therapy. Its therapeutic repertoire has also included a bloodletting very different from that of medieval Europe, a suction stimulation now called 'cupping', massage and physical manipulation in several forms, as well as disciplines like qi gong that apply movement arts to medicine.

Practitioners in different times and different cultures have thought many different things when they used the Chinese term that today we call 'acupuncture'. It is still a word that is difficult to define, precisely because it is sometimes used in a very narrow sense, and sometimes more broadly, with meanings that include many commonly (but not universally) associated techniques. In this book we use the term 'acupuncture' in its narrow sense; that is, as the therapeutic use of needles by those specifically trained to do so. We describe moxibustion as a separate tradition.

Today, acupuncturists use a range of tools and techniques, from disposable needles to electric stimulators and lasers. Each defines what they do as acupuncture. Speaking precisely, however, zhen in Chinese refers to the use of needles. Although individual practitioners have combined needling with other techniques, there has never been any absolute link between one treatment method and another. Although the time required to master the skills has tended to keep clinician's practices fairly narrow, the choice to combine different therapies has always been a mix of personal preference, the training available, social needs, and economic advantages.

In sum, there is no quick and easy description of acupuncture; there is no one and only answer we can ask you to believe at the expense of all others. There is no one and only explanatory analogy that diminishes all others. There is no unique access to clinical success. There is only a fascinating story of human genius applied to the universal human quest for a long, happy, and healthy life.

It is hard to tell that story without superlative, even mythic terms. Words such as 'ancient' and 'cosmological' are so often mixed with a space-age vocabulary of 'energetics', that acupuncture has acquired the reputation of something fantastic. It often sounds as if writers were claiming to have found a fully functional electrical stimulator among the wood ash and flint tools of an ancient cave. However, acupuncture's roots are not fantastic but indistinct. It begins in mythology and archeology, reaches the domains of philology, anthropology, and history as early as the 3rd century, and arrives in modern times entwined with sufficient complexity to challenge linguistics, biology, psychology, political science, economics, and sociology. In fact, making any statement about any of Asia's indigenous medicines requires the knowledge of experts in several arts and sciences.

Yet, even for experts the facts are elusive. China has not only burned books but has re-written them almost routinely. Thus scholars must search for unknown authors' meanings in texts that have been re-edited, re-written, re-attributed, re-interpreted, and censored. As the wisdom of one age lost favor, tradition and history, logic and philosophy, and science and medicine were rewritten. Neither were Asian cultures pure or isolated. Over caravan trails and through oft-told tales, shared myths, Asian religions and cultural institutions have migrated among populations for nearly three millennia. Thus their cultures reflect one another, often as imperfect mirrors distorted by longevous memories of invasions, wars, and ethnic hatreds.

Neither is reporting on acupuncture in the modern era free of problems. In China nothing escaped the turmoil of the 20th century. Even the so-called objective sciences suffered in China's political upheavals. For example, China's once considerable progress in genetics was surrendered to a politically correct but fallacious Soviet theory. Then, during a devastating cultural revolution, peasants became laboratory directors and senior scientists were sent to distant villages for 'rural re-education', a euphemism for social isolation and psychological, and even physical, torture. Purges, plagues, and the starvation brought about by vastly mismanaged resources may have killed as many as 20 million Chinese in the post-liberation (1949) period. During this time, elements of acupuncture changed dramatically, as it was conscripted to serve not only China's vast health-care needs but also its political imperatives.

Within the lives of China's current political leaders acupuncture has been described as a vile feudal superstition that should be entirely purged from communist society. It has been seen as a primitive, pre-Marxist dialectic and as a treasury of techniques that might be useful if integrated with modern medicine. Then, as acupuncture and Chinese traditional pharmacotherapies were enfused with modern medicine to produce the synthesis known as Traditional Chinese Medicine (TCM), acupuncture became a secondary component of the now-proposed 'World Medicine', a policy-derived goal where traditional and modern practices are to be integrated and imparted to other nations. However, the theoretical co-equality of integrated medicine has been comfortable for neither biomedical nor traditional practitioners, and preserving the integrity of traditional medicine against the encroachment of its Western rival continues to be a strong impetus for its adaptation and development.

Today, TCM is officially one of three theoretically co-equal branches of medicine in the People's Republic of China. In this policy, known as 'The Three Roads', traditional practices such as acupuncture, herbal medicine, qi gong, and the martial arts are permitted to seek their own ground in a competitive coalition with biomedicine and the TCM supported by the state. In fact, China's struggle to bring its native medicine into harmony with modern biomedicine has been a consistent theme throughout the 20th century. In the face of truly vast public-health problems, innovations such as the barefoot doctors, and massive people's campaigns against epidemic disease, have made the integration of traditional techniques with Western science a matter of acute attention in the West. While once highly visible techniques such as so-called 'acupuncture anesthesia' are now known as less worthwhile than when first brought to Western attention, and the budgets for their development have become accordingly less generous, the integration of traditional techniques into the Western medical infrastructure continues to fascinate writers.

In fact, this is so much the case that some of acupuncture's outstanding accomplishments in China and the rest of East Asia have received almost no attention. In an era when managed care is the central focus of Western medical economics, China's experience using traditional medicine in a vast, cost-driven public health-care system is of considerable potential value to the West. Although Japan, Korea, and Taiwan are less often investigated than is China, acupuncture nonetheless plays a role in the modern managed medical institutions in these countries. Although acupuncture has earned a stable and not insignificant role, often in regard to conditions for which Western patients seek acupuncture treatment, this has gone nearly unnoticed in the West. Today, for example, the courses and tests used to qualify acupuncturists in the USA are mostly drawn from TCM sources.

Although Western views of acupuncture have been less politically driven than in China, they are nonetheless just as strongly colored by cultural needs and desires. Some Western writers see in China's medicine an antidote to what they believe to be a dangerously technological and impersonal medicine. Others see acupuncture as the product of a golden age, believing not only that it was fully formed in antiquity, but also that it suffers no deficit except a loss of purity. Quoting Chinese texts that long ago discussed lost, ancient wisdom, these writers proffer images of pure sages who lived long lives uncorrupted by pain or disease. While righteousness and wellness are so inextricably linked in Chinese thought that even bubonic plagues in the 20th century were attributed to the misbehavior of the victims, such views better mirror our own culture's religious images of 'before the fall' than they reflect the evidence of archaeology or history.

In Western thought a long-lived idea is no more or less true than one just now conceived; if anything, we are biased in favor of the new, of progress. However, perhaps stimulated by our dimming infatuation with technology, age does give ideas a patina of truth. Because acupuncture's patina is amazing by any culture's standards, its longevity often lures Western authors into projecting modern ideas backward into antiquity. This happens even to the most cautious and well intentioned. When George Soulie de Morant, the father of acupuncture in the West, arrived in China in 1901, Chinese archaeology and history were still tightly bound by tradition. Thus he returned to the West with a story that began in the -3rd millennium. Although he accurately represented his sources, he delivered unlikely dates that have been quoted and re-quoted. Even today, dates of -2800 or earlier are commonly ascribed to Chinese books written in the first century.

Today, Chinese medical history is often treated like a rich but unpleasant uncle whom we call when in need but otherwise ignore. Although tradition, which can only be understood through history, is often offered as proof of acupuncture's clinical validity, history plays almost no role in the education of Western acupuncturists. Authors who link modern acupuncture technically to the ancient past are so rarely challenged that there is a popular impression that peasants in ancient China were treated exactly like patients in modern London or Beijing. This image obliterates not only the actual social order of feudal China, but also the adaptive genius of acupuncture. It also burdens modern acupuncture with a reputation for religiosity. Because acupuncture is by any measure ancient, and by anyone's standard one of the most longevous products of human genius, its history cannot be so profoundly abbreviated. It did not rise fully grown like a Mediterranean Venus but rather earned its keep in thousands of dusty marketplaces by continual change and adaptation,  an accomplishment that needs no fantastic antiquity to earn our conscientious attention.

In China, age is still honored to a greater degree than the West. Furthermore, Western ideas of scholarship have never been universal. Even today Chinese writers are rarely edited or conform to the scholarly conventions of the West. It has been common for Chinese authors to ascribe their writings to some ancient writer, borrowing credibility for their ideas. The Huang Di Nei Jing of -100 to -200 was ascribed to Huang Di, the Yellow Emperor of -2800. The Nan Jing, written near the first century, was ascribed to the famous clinician Bian Que of the -5th century. This practice continues throughout the history of acupuncture in China, indeed, into the 20th century. Thus historical accounts need to be screened carefully in order to do justice to the story.

How to proceed

In avoiding the presentation of an entirely personal or fanciful version of acupuncture, it is not only important to follow the journalist's regimen of "who, what, when, and where", but also to describe what parts of the story we have chosen not to tell. The subject is so large that its is easy to misrepresent. Therefore, we have followed a set of principles we have taken from the consensus of experts.

In studying any subject as vast as acupuncture, there is considerable room for disagreement. Sinologists have already filled that room with competing ideas of Chinese intellectual history. However, there are principles about which there is no significant disagreement, and it is these that we have tried to honor. For example, sinologists agree that acupuncture, like all Chinese traditional medicines, must be understood in its cultural context. In addition, experts agree that Chinese traditional medicine is not a smooth and invariant monolith, but an aged sculpture of great complexity. Some features have been worn smooth and indistinct by time, while others are being constantly re-sculpted. Thus, sinologists understand that we must examine the specifics of acupuncture's practice in each particular era. And, for example, although scholars may disagree about the precise extent of Confucian influence, there is no disagreement that the major Asian religions must be studied. We have thus reported the major cultural influences.

Sinologists also agree that the history of acupuncture cannot be divorced from the history of Chinese culture. If we are to understand acupuncture, we must also understand the social, economic, and political activities of each era. Thus, in the historical summary that begins this book we have reported the major intellectual, social, political, and economic events that affected Chinese culture. Because Chinese history is usually reported in eras named for a hereditary ruling family, what are called 'dynasties', our report is ordered chronologically by the generally accepted modern dates for each. However, this is only a useful way to write a chapter, not a truth. Acupuncture probably developed in a far less orderly way, but too much of acupuncture's development remains unknown for even experts to make definitive statements.

Another area of broad agreement among experts regards the heterogeneity of Chinese traditional medicine. Chinese traditional medicine is roughly equivalent to Western medicine in the extent of its written history. Its library includes more than ten-thousand texts, by thousands of writers. It is a history with hundreds of critical events and thousands of schools of thought and practice, many of which have never been explored by Western clinicians or scholars. It is simplistic, but not unfair, to summarize this complexity as if there were three general categories of Chinese traditional medicine. The first is the uncapitalized 'Chinese traditional medicine' - the heterogeneous medicine of China's long recorded history. The second is the 'traditional East Asian medicines' (TEAM) that evolved as other Asian societies imported medical practices and ideas from China. The third is the capitalized Traditional Chinese Medicine (TCM). This is the synthesis of internal medicine and biomedicine currently taught in Chinese medical schools to which modern Chinese acupuncture has conformed. TCM is what is best known in the West. As such, we afford it a greater emphasis than its relatively few years of existence would allow in an academic history.

The newer TCM is, of course, a subset of the others. All three categories are complexes of related ideas, some of which have been dominant at times, dormant at others. Furthermore, these ideas are linked, intertwined and inseparable to the point that undue concentration on any aspect can de-emphasize much of what is important. In fact, the subject is so vast that any concentration can be misleading. Fortunately, the work of Professor Paul Unschuld has provided us with a central theme with which to guide your tour of acupuncture past and present.

Through his study of the surviving artifacts and primary documents - the foundation texts of Chinese medicine and acupuncture - Professor Unschuld has described the logical process by which information was gathered, processed, and used to arrive at medical conclusions. This he termed the 'medicine of systematic correspondence'. This is what we have taken as an organizing theme. Its principal feature, the recognition of observable patterns in nature as the basis for medical categorization and decision-making, is not only the development we will follow from the beginning of Chinese history into the future, but also the essence of each aspect of acupuncture we explore.

The medicine of systematic correspondence

Although we will later describe the medicine of systematic correspondence in greater detail, for now, begin by thinking of it as the discovery that humans interact with their environment in patterns that can be realized through observation using the trained but naked human senses. Although China never developed the science of statistics, the observation of pattern plays a role parallel to that of statistics in the West. Both disciplines assume that repeatability substantiates ideas. Pattern in Chinese traditional medicines describes the most probable outcome of a particular set of clinical observations, just as statistics are used to predict trends. Pattern is not absolute, just as statistics are not absolute, both represent what is probable.

Although Chinese clinical researchers still do not use statistical analysis to any great extent, the patterns used in acupuncture were observed over very long times. Although the mathematical safeguards of statistics allow many misperceived relationships to be discovered, they also tend to limit research to problems that can be assessed by statisticians. The so-called 'test of time' has allowed Chinese traditional medicine to accrete scientifically untested assumptions, but it has also provided the ability to recognize patterns that were unseen or untestable in the West. For example, among the patterns of acupuncture are conditions that, with the appropriate training can be seen, felt, and even intuited.

This reliance on the naked senses and human perceptions has had a profound influence on all of Chinese traditional medicine but is critical to acupuncture, which is essentially a hands-on skill. To understand this more intuitively, imagine that you have a time machine fitted with language translators of the utmost sophistication. Imagine that you are able to return to China in antiquity, find the finest physicians, the greatest physician-scholars, chosen by whatever standards you wish. Follow them through their days and you will certainly find that theirs was a bedside medicine. Unlike the clinical orientation of today's acupuncturists, these ancients and their apprentices worked at their patients' bedsides, providing acute care, and following the progression of disease through patient observation. Although there were social reasons for the development of a beside medicine, the critical point is that practitioners' senses were their most important tools.

No matter how sophisticated your time machine, whether you looked in the imperial palace or a peasant hut, you would not find a thermometer or a blood-pressure cuff. Acupuncture would be already ancient before these, the most basic measurement tools of biomedicine, would arrive. Clinicians thought about the heat perceived at the body's surface ('heat effusion') rather than the measure of the temperature within ('fever'). Thus, there is very little in acupuncture that was quantified in the way of the West. In the medicine of systematic correspondence the microcosm is not the world of measurable bacteria, viruses, genes or the energies of subatomic process; it is the sensorial world of humanity, our thoughts, our feelings, our bodily experiences, the sensations of our lives. The universe was not the infinity our modern instruments describe - vast galaxies separated by measured expanses of invisible, cold, dark matter - but the subtle seasons of human life revealed by steady observation. Not only were heaven, human, and earth closer than our modern view proposes, they were intimately linked. Thus patterns in the medicine of systematic correspondence are at times related to calendric cycles (natural phenomena), but are always reported according to their sensory qualities. The same is true of disease identifications. For example, what modern TCM physicians routinely label 'acute conjuctivitis', their traditional Chinese counterparts called 'wind fire eye', for its cause, sensation, and color. What we call 'organs',
Chinese doctors thought of as 'depots and palaces', images that reflected their view of order in life and society.

These naked sense observations and trained perceptions can be seen forming into a coherent system in three landmark documents: the Ma Wang-dui scripts of the late -3rd or early -2nd second century, the Huang Di Nei Jing texts of the 1st century, and the Nan Jing of the 1st century. These documents trace over approximately 400 years the development of the major conceptual features of the medicine of systematic correspondence. These features include the development of the qi concept, the functional description of bodily process, and the theory of qi circulation on which modern acupuncture depends - what we call the 'qi paradigm'.

'Qi' and 'paradigm' are both powerful words. Because qi is so often translated as 'energy' and paradigm is usually thought of in its Khunian but not its linguistic sense, both words have come to note a thinker's place in a presumed East-versus-West, tradition-versus-science conflict. This is sometimes explained as a shift of 'paradigms'. Thus, for example, questioning the equation of qi to energy, or proposing that acupuncture shares means and methods with biomedicine, is sometimes considered a challenge to acupuncture itself. Some writers have even proposed that modern medical thinkers and traditional theorists inhabit such different paradigms that they cannot share methods of research, or even participate in a productive medical pluralism.

This is a pessimism we do not share. Traditional and conventional medicines share many ideas and observations. Although qi is not a shared concept, the observations upon which it is based are often familiar. When considered individually there are some traditional ideas of qi that can be fairly described and researched as energy. There are also traditional ideas of qi that are entirely lost when submerged in this connotively powerful Western idea. Thus, to understand acupuncture we must stand aside from positions in today's debates and examine it on its own terms.

Acupuncture is paradigmatic, not because it conflicts with Western ideas, but because it is a set of concepts linked, stored, and transmitted through the linguistic relations that reflect the experience of Asian peoples. It is true that when traditional acupuncturists labeled an individual's state as a 'lung yin vacuity' they were not referencing laboratory tests. However, they were logically using features of their language to access the treatment knowledge it stored, in this case by following the top-down logic of vacuity-yin-lung to determine acupoints known to positively affect the signs they observed. Thus, although there are instances where Western ideas of what can be true, and how truth must be tested, do affect how proponents and skeptics think about acupuncture, particularly in East Asia where the faith in Western science has had considerable cultural impact, the paradigmatic characteristic with which this text is most concerned, is acupuncture's coherence with the cultural constructs from which it was derived.

Thus using the term 'qi paradigm' is a way to emphasize that acupuncture is more than any one of its aspects. It is a reminder that the whole must be explored. This text is meant as a beginning to that exploration.