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A Short History of Acupuncture

The history of acupuncture is rich and varied and in writting this I hope to outline some current thinking intraditional chinese medicine and how that might differ from a western medical approach.

Before the discussion of the origins of acupuncture begins it must be stated that acupuncture is just one part of an ancient medical system. Typically there are four main disciplines that form part of Traditional Chinese Medicine (TCM).


1. Acupuncture


2. Herbal Medicine


3. Chinese massage/bodywork/physical therapy known as tui na (which means push and grasp)


4. Chinese exercise such as martial arts, tai chi, chi gong and esoteric practices


These disciplines are still in use in China and other parts of the orient today and when combined provide a powerful tool for healing. Treatments draw from all aspects of Oriental medicine; acupuncture, bodywork, exercise, meditation and herbal medicine.

For example in China, Tuina is one of the most commonly used modalities in the practice of TCM. It includes techniques such as pushing (Tui) and grasping (Na) of soft tissue. Tuina is a manual therapy based on the principles of TCM aimed at restoring health and treating various clinical conditions, primarily MSK conditions. Tuina has developed and such is now incorporated into other clinical disciplines, such as acupuncture, gynaecology and paediatrics. Tuina uses a variety of manual techniques guided by the theory of TCM. The philosophy of TCM strongly influences the attitude and approach of Tuina practitioners towards health care World Health Organisation (2010).

The practice of herbal medicine is one that can be traced back to the third century AD where the classification of herbs had already begun. The classification of herbs continued and were documented in works such as The Compendium of Materia Medica an impressive 52 volumes which described 1,892 herbs. In clinical practice, traditional diagnosis may be followed by the prescription of a complex and often individualized remedies. Although animal and mineral materials have been used, the primary source of remedies is botanical. Herbs are taken individually or as part of prescription where a combination of herbs is used where a typical practitioner may routinely use between 200 and 600 substances.. (John et al 2012)

The use of herbal remedies is widespread in China. Ergil et al (2002) describe the extent of herbal medicie such that "It was once customary for families to have a household repertoire of herbal formulae to treat medical problems and to address life changes (pregnancy, menopause, old age) and the seasons. Some families retain, and especially older patients may continue to follow, these practices." Large pharmaceuticals companies are currently investing and researching the active ingredients in many of the herbs used in TCM.


Lewith (2014) describes the first attempt at recording disease dating back to around 1500 BC during the Shang Dynasty. Tortoise shells with inscriptions were found, and it is thought that these were used for divination in the art of healing. As with much as TCMs history the philosophical basis of much of these findings indicate that practitioners sought to seek harmony between the living and their dead ancestors, and the good and evil spirits that inhabited the earth.

Another huge milestone in the development of acupuncture is the Yellow Emperors Classic. This is the first Chinese medical text to describe acupuncture and is in a question-and-answer format between the Yellow Emperor and one of his ministers. The academic divergence of thoughts in this book sufficiently indicates that it is neither a work of a single individual, nor medical achievement of a certain period or a local region, but rather the summarization of experiences of many medical practitioners over a long time. This text dates possibly (as sources vary ) to as early as the second century BC. Later texts evolved and included a description of the meridians (acupuncture channels), functions of the acupuncture points, needling techniques, types of Qi, description of diseases and location of acupuncture points.

Collectively these early but comprehensive texts are known as the Chinese medical classics and are the philosophical foundation for the practice of Chinese medicine. TCM Practitioners continually refer back to these sources to inform current practice. These documents contain a comprehensive source of theoretical and clinical information. (Neal 2012)

The roots of acupuncture and Chinese Medicine developed over a long period of time drawing upon a variety of sources. Wang and Roberston (2008) and Denmei (2003) describes 5 main sources of knowledge and development of acupuncture.


1. Early Massage


Every early civilisation has some form of touch therapy and China is no exception. Massage therapy predates acupuncture and is still in use today. Massage therapy is called tui na in China. It was previously called anmo, an (pressing) mo (rubbing) whilst tui na is translated as tui (push) and na (grasp) giving an insight of how it works. Acupuncturist will often use tui na alongside acupuncture for more effective treatments and when studying in China students have to learn both tui na and acupuncture giving an indication of the two separate disciplines close relationship.

Through time this tui na grew into a cohesive body of knowledge and was used to treat a variety of conditions. The practice of Tui na can focus on painful areas, acupuncture points and acupuncture channels. Today the range of conditions treated by tui na includes musculoskeletal conditions, gynaecology, paediatrics and rehabilitation and is widely used in hospitals throughout China.

One proposition is that pressing on certain points away from painful areas relived pain/discomfort. For example, rubbing a point near the wrist relived stomach ache. This led to practitioners searching for more points away for the area of pain that would relieve the main compliant. Over time more areas and points were found and used on a frequent basis to help a wide variety of conditions. Particular points were more effective for certain conditions and that knowledge was passed on to other practitioners and eventually was written down. This discovery was probably a major contributor to the development of acupuncture and was invaluable in the treatment of pain and disease.

As more practitioners used touch to search and identify points other noticeable changes were found on the body they were working on. It was discovered that certain points and areas showed signs of disease before disease presented itself. This discovery aided the early practitioners to diagnosis disease before it had manifested and would use this information as a diagnostic aid.

When the introduction of inserting needles on points on the body first started is unclear. Early stone needles were in use for blood letting and perhaps these were used initially as primitive acupuncture needles. Eventually metal needles were used made from bronze, gold or silver. Today the modern needles are made from surgical stainless steel.

Perhaps the early practitioners had too many points to try and massage at one time (they simply didn't have enough hands!) so tried inserting needles. Perhaps the points needed longer stimulation for better effects, or the better the practitioner got he had more patients and less time? Some of the acupuncture points are extremely small and are often found in between joint spaces so maybe this required something finer than a thumb or finger. Also using acupuncture needles is less labour intensive than using thumbs or fingers. So maybe the early practitioners, well they just got lazy.

Denmei (2003) suggests that acupuncture needles developed from the needles used in sewing and were adapted for use for acupuncture. Seamstresses would sew for long hours and develop shoulder and neck pain. Perhaps the pain got so bad one day that a needle was inserted into the tight neck and shoulders and relieved the pain. Once needles were used, practitioners discovered just how effective needling was and the practice grew from there which echoes the situation today.


2. Historical Autopsy


There are many early accounts of physicians examining the location, size and weight of organs. These examinations formed the basis of anatomical drawings and locations of major organs. They listed the average weight, volume and measurements for all of the internal organs. They named the organs and described their functions. In fact, they knew that the heart is the organ that pumps blood through the body more than 2,000 years ago. This wasn’t discovered in Western medicine until the early 16th century.

Anatomical location of the major organs were known early on and played an important part in the development of medical knowledge. Historically though China was isolated from the medical development in Europe so much of the scientific ideas remained unchallenged. The Chinese therefore formulated ideas that stated that health consisted of the interaction of qi, blood and body fluids. Some of these ideas will be expanded on later.


3. Surgery and Punishment


Early surgery was performed when no other option was available which again informed the medical profession. Physicians would attend these punishments and observe what took place. China has a long history of brutal wars and the physicians who treated the wounded and dying would draw upon their experience to formulate medical ideas.

Chinese surgeons, given the unavailability of anaesthesia, wisely restricted their procedures to the surface of the body where operations could be performed quickly with a minimum of discomfort without the necessity for muscular relaxation Zaroff (1999). Neal (2013) from his studies of the Neijing suggest that acupuncture was the primary intervention for emergency conditions similar to surgery used today.

Kan-Wen Ma (2000) gives one such example when in 1034, the Emperor was sick and imperial doctors were having no success in treating him so an acupuncturist Xu Xi was recommended and summoned. After examining the Emperor he announced that he could cure him if he were allowed to insert needles between the external membranes below the Emperor’s heart. The court physicians deemed the procedure extremely dangerous therefore tested the method first on their own bodies. The procedure was declared safe and Xu Xi was allowed to treat the Emperor with success which resulted him being appointed medical officer of the Imperial Medical Institute.


4. Qi Gong, Tai Chi and Martial Arts


Qi gong, literally energy (Qi) skill (Gong), is an ancient Chinese healing art involving meditation, controlled breathing and movement exercises designed to improve physical and mental well-being and prevent disease. The aims of such exercises are to nourish, cultivate, balance and increase awareness of Qi (pronounced chee) our life force. Qi gong therapy is an important branch of traditional Chinese medicine which has a history of thousands of years and is still used today to prevent diseases and treat illness around the world.

For example Qi gong exercises are often prescribed to patients as part of their treatment plan to help them recover just as a physiotherapist would give patients stretches and exercises so too a Qi gong doctor would prescribe Qi gong exercises. Mediation also might be prescribed to patients. Qi gong and other forms of Chinese exercises are performed daily in the parks in China and are a common site.

Qi gong is often translated as energy work and can be considered to be both body and mind medicine. Undoubtedly practitioners of this art helped discover the acupuncture channels and points by regular practice of Qi gong. Practitioners of Qi gong through regular practice are able to feel Qi in their body. The more experience one has with Qi gong the more one feels the flow of energy in the body the different acupuncture channels. These sensations felt by practitioners over thousands of years were documented and formed part of the knowledge that led to the development of acupuncture and TCM theory.

Throughout Chinese history numerous acupuncturist have been Qi gong experts and the practice of Qi gong has helped their skill level. Qi gong shares many of the same theoretical foundations as acupuncture.

Qigong popularity in China can not be underestimated. As Deadman (2014) declares "At the height of its popularity in China in the 1980s, it is estimated that one hundred million people were practising qigong in parks and public spaces. Crowds flocked to hear great masters speak and to be healed simply by being in their presence or hearing their words. Prime-time television showed miraculous acts being performed by the power of qi while China’s top scientists and politicians were caught up in an extraordinary vision of qigong releasing the supernormal powers latent in human beings."

As a healing modality, the position of Qi gong in TCM matches that of acupuncture and Tuina. Acupuncture and Tuina – especially acupuncture – cannot be separated from an understanding of the meridians (channels and Qi), and ancient people considered the discovery of the meridians directly related to Qi gong.

Acupuncture points have also been used in martial arts. A style of martial arts known as dim mak makes extensive use of striking certain acupuncture points with devastating effects. The acupuncture points are over major nerves and blood vessels and the most vulnerable parts of the neck and skull so by striking them can cause considerable pain. Different results are possible depending on which point or combination of points are hit and how they are hit, much like acupuncture but with entirely different intent. There is an entire branch of Chinese medicine devoted to repairing beaten up martial artists called dit dar which is by itself another great story of Chinese medicine. Briefly dit dar could be considered a combination of skills including bone setting, manipulation similar to Chiropractic and Osteopathy but also uses massage, chi gung and external herbs to facilitate healing.


5.Clinical Experience and empirical experience


If a treatment worked then usually is was written down, repeated and further refined. If a treatment did not work then it was abandoned and fell out of use. Acupuncture points are undoubtedly the end-product of millions of detailed observations. As they were developed, so each of them was given a name and Chinese character, depending on its therapeutic properties. Particular acupuncture points were noted relating to which conditions they were useful at treating and this recording of knowledge continues to this day. In clinical practice, a set of acupuncture points are selected for treatment in order to produce a specific effect in the body.


6. Philosophy


As with any system of medicine, acupuncture was influenced by the ideas of the time. Influential philosophical ideas stemmed from Buddhism, Doaism and Confucianism along with the observation of the seasons and nature. All these aspects had their part to play in informing ideas about the developments of disease from birth to death.

The Chinese considered the human body a microcosm of the universe and world. Part of this idea is the concept of yin and yang. Yin and yang are thought to be essential components of all living things. For example dualities such as light and dark, fire and water, and male and female are thought of as physical manifestations of the duality of yin and yang. The taijitu symbol is an example of this concept. The Chinese symbol represents yin and yang existing in harmony and shows how they give rise to each other as they interrelate to one another.


Some Basic Principles of TCM


In TCM The individual structures of the body are also assigned to either be yin or yang in nature. The organs in TCM are known as the Zang fu. The Zang Organs are the "solid" organs and are Yin in nature and the The Fu Organs are the "hollow" organs and are Yang in nature.

The stomach, small intestine, large intestine, bladder and gall bladder and are yang. The yin organs are considered to be heart, lungs, kidneys, spleen and liver. The Yin and Yang aspects of the body counterbalance each other. A deficit of one naturally leads to a surfeit of the other, while a surfeit of one will weaken the other. In both cases, Yin and Yang no longer counterbalance each other, and disease arises as a result. Nothing is ever completely yin or yang, but a combination of the two. These two principles are always interacting, opposing, and influencing each other. The goal of Chinese medicine is not to eliminate either yin or yang, but to allow the two to balance each other and for the energies influence to exist harmoniously together. Ultimately, every modality within TCM is aimed at regulating yin and yang, to balance yin and yang.

In addition to the zang-fu there are the extraordinary fu-organs which re characterized by hollowness, similar to the six fu-organs in morphology, and storage of essence, similar to the five zang-organs in function. This group of tissues and organs are the brain, the marrow, the bones, the vessels, the gallbladder and the uterus.

Acupuncture points were subsequently grouped into a system of channels which run over the body, conducting the flow of vital energy through the body. The acupuncture points on a channel are said to influence the flow of vital energy through the channel, thereby influencing disease processes within the body. As a further representation of the human body of the natural world. The current of energy and fluids of the body are sometimes referred to as channels, seas, rivers, and reservoirs. There are 12 main acupuncture channels and each channel is considered to connected to an organ, for example there is the large intestine channel and so on.

In addition to the main 12 channels there are also eight extra meridians. This is because they have independent points- points that are not also on any of the twelve regular meridians. There are also so called extra points that are not located on the 12 main channels.

For further clarification the Chinese named each acupuncture point and also numbered each acupuncture point along the course of the channel assigned to each organ. For example the Heart channel has nine acupuncture points running from the armpit down the inner surface of the arm to the tip of the little finger where as the bladder channel has a total of 67 points.


QI


Qi is the word which encompasses the meaning of all vital activities and substances in the human body. It is a the "Life Force" of all living things as well as representative of all energy within the universe. It is beyond a simple definition but is the key to understanding eastern philosophy and the unique holistic approach when assessing health in humans.

According to TCM, our health and well-being is dependent on the body’s vital energy our Qi, moving in a smooth and balanced way through a series of channels beneath the skin. The energy of a person’s body is distributed along 12 main acupuncture channels which run up and down the body connecting and linking the different organs and parts of the body with one another creating a living interconnecting network that can be easily accessed. The acupuncturist taps into the network of meridians and guides the body to begin its own healing process.

During a treatment a fine, single use, sterile, stainless steel needle is inserted just below the surface of the skin to stimulate acupuncture points lying along the acupuncture channels which run throughout the body to activate or unblock the flow of energy, restoring balance and triggering the body's natural healing response. Health is seen as a state of physical, mental and social well-being accompanied by freedom from illness or pain.

In TCM theory every organ has its own Qi. For example when the heart becomes weak, known as weak heart Qi, a person can experience palpations. When someone has weak lung Qi they have problems breathing or may be asthmatic. Each organ will have signs and symptoms when malfunctioning which the practitioner will search for whilst looking for disharmony. Thus, one of traditional Chinese models of health and restoration are concerned with the function of the organs. By assessing each organ function through questioning and diagnosis this leads the practitioner to a "Pattern of disharmony" that affects one or more organs. Treatment is then aimed at restoring the disharmony by selecting a point on the appropriate acupuncture channel and stimulating that point. An over simplistic example for example would be needling an acupuncture point like heart 7 ,shen men, which is on the heart channel for example is said to regulate the heart.

Western observers often thought that the acupuncture channels were in fact blood vessels and qi was blood. Western practitioners have dismissed much of TCM theory because of lack of evidence of these channels and no definable way of measuring this so called energy. In addition the diagnostic methods used often seemed chaotic to the western mind and based on unfamiliar concepts which were extremely subjective making them unreliable tools.


Pulse Diagnosis


A common tool amongst TCM practitioners is the examination of the radial pulse on both wrists. Three fingers are placed on the radial pulse and superficial and deep pressure applied to all three positions. Different positions and depths correspond to different organs.

Common Pulse Locations and Related Meridians


Left Wrist


Right Wrist

Cun (inch) - 1st position


HT / SI


LU / LI

Guan (barr) - 2nd position


LV / GB


SP / ST

Chi (foot) - 3rd position


KD / UB


PC / TH



The practitioner detects the rate, width, amplitude and length of each pulse position which then gives them information about the state of balance of the body as a whole and the state of individual organs. There are generally speaking 29 different pulse qualities that can be assigned to each pulse position. Pulse diagnosis takes time to master but practitioners would not of spent considerable time unless they found it to be a useful diagnostic tool.


Tongue Diagnosis


Another key diagnostic tool in TCM is tongue diagnosis. The tongue has many relationships and connections in the body, and is considered to be a reflection of the internal organs with different areas of the tongue representing different organs. Tongue diagnosis gives visual indicators of a person's overall health. When examining the tongue, the practitioner looks at the colour of the tongue body, its size and shape, the colour and thickness of its coating, movement such as quivering, moistness or dryness of the tongue body. By itself tongue diagnosis is not a stand alone diagnostic tool but the information from it is taken as part of an overall pattern.


In TCM, health implies that the body system is in a state of dynamic equilibrium, not only between the various parts of the body but also between the body and environmental conditions. The final diagnosis is based on the information gathered from all the above-mentioned diagnostic methods. These methods are not used in isolation, but as parts of a system. From patient questioning and examination the information gathered is matched into a corresponding TCM pattern. Pattern identification is the process used in TCM that enables a practitioner to determine the significance of symptoms and to create a coherent picture of a client’s state of ill/well being. TCM differentiates biomedical diseases into patterns. Each pattern comprises symptom/signs that have their own unique treatment protocol. This is the TCM clinical reasoning model and further breaks down patterns into organs dysfunctions, channels disorders or local injury. This system gives TCM a holistic approach towards the sick individual, and disturbances are treated at the physical, emotional, mental, spiritual and environmental levels simultaneously.



MOXIBUSTION


Acupuncture is defined as puncturing with a sharp instrument but the original term (sometimes referred to as acumoxa) includes both needling and moxibustion,. Moxibustion is the method of burning the herb mugwort on, around, or above acupuncture points for therapeutic purposes. The leaves of the mugwort are dried and ground until the right consistency so that it can bind well together. Moxa is typically rolled into balls for use for burning on acupuncture points, shaped into cones to put on top of acupuncture needles, or can be bought in pre packaged tiny or long rolls known as moxa sticks to warm large areas of the body. The advantage of moxa over other types of herbs or plant is that Moxa holds together well, burns evenly, is inexpensive and was widely available throughout China. Interestingly the practice of moxibustion was widespread in ancient China due to its relative safety and ease of practice compared to acupuncture which would of carried a certain amount of risk (Wang Xue Tai 1984).

One possible explanation for moxa to be chosen is that certain religious rites, and divination for healing purposes, led to the direct use of burning by incense or tree branches on the body itself for healing. In fact, mugwort was also used for divination, and it is perhaps as a result of this that mugwort was chosen as the best plant for moxibustion (Maciocia 1982).

Development of Acupuncture Needles

The majority of people prefer not to be punctured with needles, and associate needling with pain and injury. Many plants and animals have evolved thorns or quills as powerful weapons for protection or attack so this represents a barrier to many people even considering having acupuncture and begs the question as to how acupuncture came and stayed in use throughout history. (Xinghua and Baron 2008).

A good case highlighting fear of needles is in 1945, when Japan was occupied by the Allied Forces, the Japanese Government was ordered to ban acupuncture and moxibustion as a barbarous and unscientific therapy. This was due to the fact that some Japanese soldiers used acupuncture or moxibustion on Allied Forces prisoners of war (POWs), with good intentions because of the medical supply shortage, but the POWs took it as a form of torture, and some of those Japanese soldiers were subsequently indicted as war criminals.

Other stories surrounding the birth of acupuncture include tales of soldiers who were cured of an Illness/disease after being shot with an arrow. Other accounts suggest the practice of bloodletting had a part to play. Bloodletting is the practice of withdrawal of blood to cure disease and illness. The tools used for blood letting may have been available to practitioners to experiment with.

The first needles are widely considered to have be made of stone and examples of which have been found in ancient tombs excavated in Inner Mongolia and Hunan Province. Maciocia (1982) describes three kinds of stone needles with varying degrees of sharpness. The sharpest probably used to make incisions to let out pus, while the blunt ones were probably used for some kind of skin-scraping.

After stone, needles were made principally of bone and bamboo. During the bronze age the introduction of metals needles began and later other metals were used including silver and gold from around 500BC. Other evidence indicates that Jade was also used and by 200 B.C. steel was available Maciocia (1982). The manufacture and production of acupuncture needles today are thankfully very sophisticated and have evolved with patient comfort in mind. The needles are often made of high grade steel and the tips are highly polished to provide a very smooth needle insertion.



Brief Overview of Acupuncture Development in Modern China


This next section is a brief summary of acupuncture as its history is vast so the material here is just a very brief overview of a very small period in history. It must be remembered however that acupuncture has not always enjoyed the popularity it does today. Throughout Chinas history it has suffered periods of decline. Often it symbolised old backward ways of thinking in direct opposition to those people who wanted to modernise China. One such example is in 1929 when the Ministry of Health limited the advertising of TCM and prohibited the establishment of any teaching TCM.

In 1928 the Communist party of China was formed, under the leadership of Chairman Mao. A long guerrilla war ensued and the Communist party finally took power in 1949. The Communists had little or no medical services in the 'liberated areas' and actively encouraged the use of traditional Chinese remedies to keep their troops on the move. These remedies were cheap, acceptable to the Chinese peasants, and utilised the skills already available in the countryside. There was around 12,000 western trained doctors a staggering one doctor for every 26,000 people in China. Traditional doctors such as acupuncturists, herbalist and tui na practitioners were estimated to be around 400,000 in number.

China needed to establish a low cost effective care system that could be duplicated and provide health for all of its citizens. Essentially China could not afford to train a large number of doctors in western medicine however it could easily afford to train large numbers of people in traditional medicine and thereby promote traditional methods of Chinese medicine and integrate them into mainstream medicine.. There were many contradictory theories and practices techniques in China at that time and schools which made up traditional medicine in China were standardised and systematised similar to a western style University. During this period an attempt was made to unify the various family, regional, and theoretical schools of acupuncture throughout China an seemingly impossible task.. The new teaching model was in direct contrast to the previous student master apprenticeship. In order to teach large numbers of people the medicine of the time had to be standardised.

During the early 1950's many hospitals opened clinics to provide, teach and investigate the traditional methods. This renaissance of acupuncture, combined with a sophisticated scientific approach, has allowed the development of many new methods of acupuncture. This is reflected in some hospitals in China where a variety of disciplines are all under one roof working in unison together including western doctors, acupuncturists, herbalists, radiology and so on.

The Great Cultural Revolution was a ten-year political campaign - a social experiment aimed at rekindling revolutionary fervour and purifying the party led by Chairman Mao from 1966 - 1976. He shut down the nation’s schools, calling for a massive youth mobilization to take current party leaders to task for their embrace of bourgeois values and lack of revolutionary spirit. One of Maos beliefs was that the progress China had made since 1949 had lead to a privileged class developing including engineers, scientists, managers and teachers.

As part of this great purge many surgeons and Western Medicine doctors were thought to be too elitist and therefore were persecuted. TCM was also hailed as a national treasure and a great symbol for China. It must be remembered that in 1942, Mao had ordered the government to banish all superstitious and shamanic beliefs so his new appraisal and approval of TCM was a popular political move. TCM practitioners were not exempt from persecution and may senior key figures were executed or expelled. A further part of healthcare reform as emphasised in Moas speech given in Beijing on 26 June 1965 was to abolish all entrance exams and the training provided to TCM entrants was minimal. This led to the so called barefoot doctors who were sent out with very little training to address the medical needs of the vast majority of the Chinese who lived in the countryside.

The persecution of the medical establishment and the new medical reforms meant that medical learning was now open to the under-privileged classes such as peasants and general workers. This resulted in acupuncture having to replace Western Medicine in many areas, and acupuncturists had the opportunity of gaining experience in many new areas. As part of this experimentation many new therapies emerged propelled by the fear of failure they would face the same fate as their predecessors. Estimates vary but roughly 1.5 million people were killed during the Cultural Revolution, and millions of others suffered imprisonment, seizure of property, torture or general humiliation which the aftermath of still effects Chinas politics today.

Maciocia (1982) reports that during the Cultural Revolution these new methods of acupuncture developed included:

(i) Ear acupuncture.

(ii) Scalp acupuncture.

(iii) Cat-gut surgery.

(iv) Needle-embedding therapy.

(v) Point-injection therapy.

(vi) Long needle therapy.

(vii) Acupuncture analgesia.

(viii) Electrical acupuncture.


Many of these new methods were influenced by western medicine. For example scalp acupuncture is a technique that has developed from the neuro-anatomy of the central nervous system. When the brain is damaged, in diseases such as a stroke, the scalp is stimulated superficially over the area of damaged brain Lewith (1982).

To present TCM as a cohesive whole would be misleading because as a result of standardisation many lineages and styles of acupuncture were excluded when TCM schools and institutions were founded. What TCM does represent is a starting block for the practitioner to start somewhere and explore other styles of acupuncture later on. It is important to note that there is more than one style of acupuncture in existence and more than one way of practising acupuncture within TCM. Entirely different acupuncture modalities have developed and evolved without being incorporated into so TCM. The acupuncture that has been exported/imported to the west may represent just a small sample of acupuncture theory and practice. However what was taught was clinically verified and much of the superstitious theories were excluded from modern textbooks.

Part of this unification of methodology included applying the methodology that was used in the practice of herbal medicine to acupuncture. Many of the practitioners involved in the unification of ideas were herbalist therefore they simply applied the diagnostic principles that were in use for the prescription of herbs to acupuncture. Therefore a diagnosis would involve first a pattern discrimination, based upon looking, listening, asking and pulse/palpation. This would lead to treatment principles and to a to treatment plan, with the treatment plan including the use of basic points. Acupuncture points were also given theoretical functions again so to fit the formulaic approach as described. This approach is often criticized for using a repertoire of only the most basic points. Another criticism of the standardization of acupuncture is that it resulted in the loss of palpatory techniques central to the diagnosis of acupuncture. For example the technique of channel palpation involves palpating the pathways of the twelve main channels to look for diagnostic tissue changes. Vital tools like this can help refine and focus both the diagnosis and treatment which is often not taught in modern acupuncture schools and absent in many acupuncture clinics leading to acupunctures ineffectiveness.

As China develops it has been keen to train more western doctors; the number of physicians trained in Western medicine has soared. Current estimates is that China has 2,3 million Doctors 90% who are trained in Western Medicine (Sussmutt-Dyckorhoff and Wang 2010). China is attempting to train more physician and according to the 1991 Chinese Health Statistical Digest, the number of Western-trained doctors soared from 3,800 in 1949 to 1.1 million in 1991; and over the same period, the number of doctors practicing TCM rose from 27,600 to 362,600.

The Chinese Government still to this day promotes the development of a modern TCM industry, as well as the integration of TCM into the national health care system and integrated training of health care practitioners. This is reflected in both training and the building and infrastructure of modern hospitals. TCM is often integrated within the major hospitals engaged with both specialization and integration of western medicine. TCM within hospitals may range (depending on size) from having busy in patient outpatient wards for musculoskeletal problems, to herbal dispensaries and qi gong wards where exercises are prescribed. TCM is also included within the syllabus of most medical Universities.



Acupuncture in Japan


Throughout history there has been an exchange of knowledge between China and Japan and Chinese ideas and medicines were a vital part of this knowledge exchange. Traditional Japanese medicine has been used for 1500 years and includes herbal medicine, acupuncture, moxibustion and acupressure. One of the earliest known introductions was in 552 when the Chinese Emperor presented to the Japanese Emperor an acupuncture book. Later in 562, a Chinese man, Zhi Cong, brought a acupuncture book of Illustrations of Channels and Points and other medical works to Japan (Kan-Wen Ma 2000). Many schools of acupuncture were set up in Japan and students were sent to China or Korea to bring back knowledge of acupuncture.

In 1935 the Edo government closed its borders with neighbouring countries and during this isolated period that lasted for around 200 years and as a result acupuncture developed within Japan from outside influences. Over time the Japanese transformed these ideas, skills and medicines into modalities that are uniquely Japanese. There are a few key developments and stories that must be taken into account to appreciate how Japanese acupuncture has developed (Kobayashi et al 2008).

Japanese acupuncture significantly differs from other styles in its delicacy preferring shallower needling and less stimulation that TCM in China.. One of the most interesting facts about the development of Japanese acupuncture is that for the last three hundred and fifty years some of the leading figures in its development have been blind. Estimates vary but around 30% of acupuncturists in Japan are blind. The concept of blind practitioners using needles may initially seem somewhat strange to us in the West. However, it is well known that people who lose one sense have a greater sensitivity within another area. The blind develop an extra capacity in the fields of sound and touch.

In 1680 the first school was established to teach acupuncture and massage to the blind. This was the world’s first organised vocational school for the physically handicapped, an innovation in itself. From that time, many acupuncture schools for the blind were built all over the country. In Japan, the practice of acupuncture utilises the enhanced tactile skill of the blind and provides a profession where they may naturally excel (it must be stressed that not all blind people in Japan want to be acupuncturists and some feel frustrated and limited by their limited job options). A large group of blind practitioners continue to influence both the practice and theory of acupuncture and massage in modern day Japan moreover it is still believed that acupuncture and massage are occupations for the blind.

For example Kodo Fukushima founded the Toyohari association in 1959 after loosing his sight during the war and later qualified as an acupuncturist. The Toyohari association was developed primarily for blind acupuncturists. It emphasises practical hands on skills as opposed to large amounts of theory again placing emphasis on abdominal palpation. Members meet regularly in small groups, to practise, exchange ideas and present papers to each other as part of their ongoing training (Fixler And Kivity 1988).

A blind acupuncturist, Waichi Sugiyama, created a method for inserting a needle using a tube. In this technique a needle is put into a thin tube before inserting it in the body. This technique is now common place within acupuncture. As a result from this innovative technique practitioners could now insert the needle with less pain and consequently the use of thinner needles became common place in Japan. This may not seem such an innovation until you consider that until that time, the main needle insertion methods was a method were the needle is inserted directly into the body and tapped with a hammer. Evolving from thinner needles the Japanese did not emphasis obtaining strong deqi during treatment. Instead they believed that the meridian system responds to more gentle light stimuli.

Acupuncture and massage schools were set up for the blind in Japan where traditional skills were taught. A refined sense of palpation is one of the defining features of Japanese acupuncture. Palpation is an important diagnostic tool. Palpation dictates which points are chosen for treatment, rather than choosing according to disease or theory. This again developed because a blind practitioner has to rely on his sense of touch as opposed to any grand theory about which points may or may not work. Also, point location is not always at the exact location prescribed in traditional anatomical charts. Points are found again by palpation. The idea that a point would be treated without palpation first is alien to many Japanese practitioners.

Another diagnostic significance between the to styles is the use of abdominal palpation. In China the palpation of the pulses is used which may be in part to being culturally more acceptable and less intimate or invasive than abdominal or body palpation. In contrast Japanese acupuncturists use the abdomen, known as the Hara, as part of diagnosis to determine the health or otherwise of the patient, particularly, but not exclusively, the state of the abdominal organs or tissues and the related energy fields. (Birch and Massutaton 1993). This is partly due to the practical influence blind acupuncturists have exerted on Japanese acupuncture having a more hands on approach.

Practitioners of Japanese acupuncture also confirm that the needle technique causes an immediate and noticeable change usually by noticing changes in the pulse to which they pay a great deal of attention or by confirmation of changes in abdominal reflex areas. Feedback from the patient is critical to guiding the treatment and confirms that an energetic change has taken place.

During the 19th century in Japan the introduction of western medicine led to the political leaders of the time believing it to be superior to acupuncture sought to seek acupunctures demise. Despite this acupuncture continued to be practised in Japan as western medicine was often expensive and only available in the major cities where as acupuncture and traditional medicine was accessible and easily accessed. Acupuncture was also exported to Korea and Vietnam through trade routes, scholars and practitioners.



The Spread of Acupuncture to the West


It was through contact and trade with Japan that Dutch medical practitioners observed the use of acupuncture and moxibustion.. One such Dutch physician was William Ten Rhijne who observed the use of acupuncture at Nagasaki bay where he was stationed for 2 years. William Ten Rhijne was part of the travelling doctors of the Dutch East-India Company and had witnessed how acupuncture was practised and were impressed by its therapeutic effects and techniques. Ten Rhijne’s 1683 essay ‘De acupuntura’ introduced the first substantial work on acupuncture to a wider western audience. It focused on practical acupuncture and moxibustion techniques rather than the theory behind them.

Also during the 17th Century Jesuit missionaries had travelled to China and had observed the practice of acupuncture. The Jesuit missionaries understood the language and as a result their documentation of acupuncture included more than just the practice of acupuncture and included pulse diagnosis, they understood that acupuncture was based on the circulation of QI and were even able to translate Chinese medical books. Assimilation of the practice of acupuncture took place within two separate professional groups in Europe from the Jesuits to travelling doctors. Sadly the Jesuits’ efforts had little impact on the practice of acupuncture. (Hsu 1989). The term “acupuncture” has its origins from Jesuit missionaries from a combination of two Latin words: acus (needle) and punctura (puncture).

It is worth noting that English translations of Chinese texts can be misleading. Chinese texts are rich in imagery and whilst in translating texts certain compromises may have to be made. The word ‘point’ in English is not a translation of xué, Acupuncture points are usually found in depressions or crevices between bones or sinews, and as such, have length, width and depth. Their location is not fixed and are found by palpation , only then are they effective. The term ‘point’, therefore, does not truly reflect the complex, three dimensional image of xué. (Wilcox 2006)

It was in France that the practice of “acupuncture” was in vogue at the beginning of the 19th century, and from there it spread to other European countries. With a delay of about ten years it spread also to England, Germany and Italy. However, this fashion of needling had a short life. Most doctors of the early 19th century applied only the so-called “locus dolendi” mode of treatment where localised pain was treated by the local insertion of needles. Also they felt little or need to consult Chinese sources. (Hsu1989)

In England J.M. Churchill rote two books on acupuncture in 1821 and followed on with a series of case histories. The English Acupuncture Association was formed in 1960. In the UK The British Medical Acupuncture Society was formed in 1980 as an association of medical practitioners interested in acupuncture.

Acupuncture was returned to the public eye until 1971 when Henry A. Kissinger, Secretary of State for President Richard M. Nixon's administration, went to Communist China in to prepare for a trip the following year as part of the efforts to re-establish relationships with China. Whilst on the trip one of the accompanying journalists had an acute appendicitis attack which required an emergency operation.

The journalist, one James Reston of the New York Times, suffered from post operation pain and nausea. To help him ease the pain Chinese doctors used acupuncture into his forearm which was effective. On his return James Reston wrote an article for the New York times where he detailed his own recovery by the use of acupuncture and his other observations of the effectiveness of acupuncture. Acupuncture was further propelled into the minds of the west when Kissinger mentioned the incident during a press conference after the visit to China.

These events sparked the public's curiosity concerning acupuncture and TCM. There was enormous excitement and interest among American doctors and non-physicians alike, with groups of each going to China to seek training and investigate the claims independently.



Prehistoric Acupuncture


Acupuncture may have actually already been a practice familiar to ancient Europeans. The mummified remains of the so-called Austrian Iceman, who has come to be known as Otzi, because he was found in a glacier of the Otztal Alps, near the border between Austria and Italy has led to this speculation. What is remarkable about this discovery is that he was perfectly preserved shortly after his death providing an insight into prehistoric man dating back to 3200BC.

Initial investigations found that Otzi had 15 groups of simple tattoos marking points on the skin. The tattoos did not appear ornamental and an acupuncturist was consulted and asked about the possible relationship between the markings and acupuncture points. It was found that 80 percent of these points corresponded to the acupuncture points used today. Further analysis has confirmed the presence of 61 tattoos divided into 19 groups in various parts of the body.

The tattoos were therefore primarily intended as therapeutic measures rather than as symbols. The points found on Otzi would have been used to treat symptoms of diseases that he seems to have suffered from, such as digestive parasites and osteoarthritis. The purpose of the tattoos is that wherever Otzi went he could go undergo treatment because the points were mapped out for a layperson to use. Further speculation is that a form of bone needle could of been used to stimulate the points similar to the objects found on Otzi.

This discovery indicates that ancient Europeans might have been aware of the practice of acupuncture earlier than had previously been thought. Lars Krutak a tattoo anthropologist has uncovered further evidence for medicinal tattooing in Sarawak, Papua New Guinea again suggesting that practices similar to acupuncture may of already been in existence (Samadelli et al 2015).



Conclusion


Over thousands of years TCM has developed a theoretical and practical approach to the treatment and prevention of many different diseases. TCM obviously had to deal with a huge range of health conditions from pandemics to accident and emergency cases. As a result TCM has a vast array of texts and practices describing the diagnosis and treatment of a huge range of disorders. TCM and oriental medicine is clearly an enormous tradition which has evolved over centuries. It has adapted to different cultures and continues to thrive. The adaptation and the integration of acupuncture into Western mainstream healthcare could be considered to be another cultural adaptation.

Eckman (2014) sums up the arguments from both sides by calling for tolerance "Biomedicine gives us one very useful lens to look at health and illness. Oriental medicine provides us with a different, but equally valid and useful lens. Like so many other challenges that face humanity, the solution to this quandary is peaceful coexistence."



References


Birch, S. and Massutato,K. (1993) Hara Diagnosis: Reflections on the Sea. Paradigm Press.

Deadman, P. (2014) 'Brief History of Qigong.' Journal of Chinese Medicine .Number 105.

Denmei, S.(2003) Finding Effective Acupuncture Points. Eastland Press.

Eckman, P. (2014) 'Traditional Chinese Medicine - Science or Pseudoscience? A Response to Paul Unschuld.' Journal of Chinese Medicine .Number 104.

Ergil, K. V., Kramer, E. J., & Ng, A. T. (2002). Chinese herbal medicines. Western Journal of Medicine, 176(4), 275–279.

Fixler,M. And Kivity,O (1988) 'Four Styles.' European Journal of Oriental Medicine

Hsu, E (1989) 'Outline of the History of Acupuncture.' Journal of Chinese Medicine Number 28.

John, W.M. Yuen, Sonny H.M. Tse and Jolene Y.K. Yung (2012) Traditional Chinese Herbal Medicine –East Meets West in Validation and Therapeutic Application School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China

Kan-Wen Ma (2000) 'Acupuncture: Its Place in the History of Chinese Medicine'.

Acupuncture in Medicine Volume 18

Kobayashi, A., Uefuji, M., & Yasumo, W. (2010). 'History and Progress of Japanese Acupuncture.' Evidence-Based Complementary and Alternative Medicine.

Lewith, G. (1982) Acupuncture-Its Place in Western Medical Science, Thorsons Publishing Group.

Maciocia, G. (1982) 'History of Acupuncture'. Journal of Chinese Medicine. Number 9.

Neal, E (2013) 'Introduction to Neijing Classical Acupuncture Part II: Clinical Theory' Journal of Chinese Medicine. Number 102.

Samadelli,M. Melis,M Miccoli,M. Vigl,E. R. Zink,A. (2015) 'Complete mapping of the tattoos of the 5300-year-old Tyrolean Iceman.' Journal of Cultural Heritage

Sussmutt-Dyckorhoff, C. Wang,J. (2010) 'Chinas Health Care Reforms.' Health International, Issue 10.

Wang, Ju-Yi. Robertson, J. (2008) Applied Channel Therapy in Chinese Medicine: Wang Ju-Yi's Lectures on Channel Therapeutics. Eastland Press; 1 edition.

World Health Organisation (2010) Benchmarks for Training in Tuina Published by WHO Library Cataloguing-in-Publication Data

Wilcox, L. (2006) 'What is an Acu-moxa Point?.' Journal of Chinese Medicine. Number 80.

Xinghua, B. (2008) 'How Old is Acupuncture? Challenging the Neolithic Origins.' Journal of Chinese Medicine.Number 86.

Zaroff, L. (1999) 'The Case of Surgery in Pre-Modern China.' Journal of Chinese Medicine. Number 59.



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