A true history of acupuncture

Abstract

Traditional Chinese healing practices, including acupuncture, have been relatively recently presented as a system on par with, if not superior to, medicine in the West. However, accompanying the introduction of Chinese healing practices to the West have come some rather widespread and fundamental misunderstandings of what acupuncture is and was, and how it developed. These misunderstandings appear to have gained widespread credence. For example, the assertion may be made that Chinese medicine is more 'holistic' than Western medicine, although historical reality does not support such attributions. Another basic misconception is that acupuncture, and other aspects of Chinese medicine (currently described as traditional Chinese medicine, TCM), is a reflection of the traditional medicine that is most commonly practised in China, and, furthermore, that the medicine that is practised in China is a true reflection of ancient practice. Neither premise is correct. Indeed, acupuncture, and 'what is very much now an "alternative" Chinese medicine is only a minimal vestige of ideas and practices … extracted from a highly impressive variety of medical thought, and supplemented with modern elements of Western rationality …'1 The adaptation of Chinese medicine promoted in China as zhongyi since the mid-1970s is, in fact, not an accurate reflection of the tradition of Chinese medicine, measured from ancient times to the present. The earliest traditions of Chinese medicine (Shang dynasty, 17th–11th century BC) were linked to beliefs in ancestors. Deceased ancestors were capable of endangering or even destroying human life, and healing practices attempted to restore not only the living, but also the dead. As ancestral medicine waned, magical, demonological or supernatural beliefs became the cause of all disease. The demons of the human body could cause such things as swellings, and the insertion of needles or stone lancets, for example, could be employed in an effort to kill or expel them. The most influential formative period of Chinese medical traditions was during the Han Dynasty (roughly 2nd century BC to 2nd century AD). It was at this time that the Chinese intellectual elite first tried to categorise phenomena into a limited number of causes and effects. Here, Chinese health care took a decisive turn.2 Natural laws, conceptualised in doctrines such as 'Yin-yang' and 'Five elements,' were used to explain health and disease, and to devise preventive and therapeutic strategies. Although Han medical theorists certainly considered earlier notions of demonological and ancestral influences on human health, by comparison their theories were more rational. But from that time forward, Chinese medicine coexisted and interacted with ancient versions of health care. However, Han Chinese theories were not ubiquitous, generally accepted or consistent. For example, one school of Chinese thought subdivided the two categories of yin and yang into four yin and yang subcategories whereas a second school proposed three subcategories for both. Both of these schools of thought, although contradictory, appear to have agreed in their rejection of the 'Five Phases' doctrine that is important to other Chinese theories.3 The Chinese apparently never made any attempt to resolve such contradictions. This has resulted in many factions within the domain of 'traditional' Chinese medicine and even more within the realm of what later became acupuncture. Over time, two separate traditions of medical literature appeared in post-Han China. Pharmaceutical and prescription literature was developed and applied without reference to what has been described as theories of 'systematic correspondence.'a In contrast, the needling and moxacautery literature that developed elaborated those theories. In this literature, as theories of systematic correspondence became dominant, anatomy and physiology tended to become less significant and more symbolic. As a result, 'in the history of Chinese medicine, rather than progressing from a reasonable, although incomplete, knowledge of the body to a more detailed one by systematic dissection, the medical writers go in the opposite direction, under the sway of the cosmologists, to a less accurate picture.'4 Although efforts to unite the pharmaceutical and needling traditions were made, particularly in the 12th–15th centuries, those efforts were never successful. Another important factor for the success of acupuncture and TCM has been the notion of 'qi.' However, the concept of invisible, vapour-like agents that are responsible for maintaining life and health is not uniquely Chinese, indeed, it is one of the main concepts of ancient medicine of virtually every culture. For example, the Greek physicians Praxagoras and Erasistratus hypothesised that arteries conducted the vital force pneuma, and not blood.5 This and other similarities has led to speculation that much of Chinese medicine may simply be an adaptation of Greek medicine, and, in light of the interactions that occurred between China and the West in Han times, such speculation is not unreasonable. What can be said is that the flow of qi within channels is a very old, but not universally accepted, concept. Nevertheless, acupuncture and Chinese medicine, as interpreted by Western writers, at least promises to solve the 'energy' problem within the individual's own body. In fact, the historical meaning of the concept of qi bears no relationship to Western concepts of energy. However, by rendering qi as 'energy', and by explaining disease in terms of 'energetic disturbances', the newly invented Chinese medicine has gained plausibility. This plausibility, however, arises out of conceptual adaptation to Western fears, not out of the historical reality of Chinese thinking. The chronology of acupuncture is fairly well established, albeit along a somewhat uneven timeline. Claims that acupuncture is many thousands of years old are suspect; neither archaeological nor historical evidence suggests acupuncture was practised in China prior to the mid-2nd century BC at the earliest, and those claims are subject for debate. Indeed, exactly when acupuncture can be said to have begun in China depends on two things: (i) the willingness to accept early dating of historical texts and (ii) the definition of 'needling.' If the use of any kind of penetrating instrument ('needling') is considered acupuncture, then acupuncture began early in China but also in contemporaneous cultures, who also used bleeding and cautery at points on the human body. The earliest archaeological findings, from the 1970s, are four gold and five silver needles, discovered in the tomb of Han Dynasty Prince Liu Sheng (?–113 BC) in Hebei Province. Since these artefacts were found in association with other therapeutic instruments, they may have been employed in therapeutic 'needling' of some sort.6 However, the exact nature of this 'needling' is unclear and it may not have been used for purposes that we think of today as acupuncture (for example, according to the Chinese classic medical text Huang Di neijing, 'needles' were also used to remove 'water' from joints or to lance abscesses). The earliest Chinese medical texts known today were discovered at the Mawangdui graves, sealed in 168 BC and the Zhangjiashan burial site, closed between 186 and 156 BC.7 These documents provide the first descriptions of mai, imaginary 'channels' that were associated with diagnosis and treatment. However, in these texts, therapeutic interventions, or needling, are never mentioned. The earliest literary reference to any kind of therapeutic 'needling' (zhen) is found in a historical, rather than a medical, text, the Shiji, (Records of the Historian), of Sima Qian, written c. 90 BC. The Shiji mentions one instance of 'needling' in the texts but that needling was not associated with a system of insertion points or with the fundamental system of conduits (described in later centuries) whose qi flow might be influenced by such needling. Indeed, the story of resuscitating a dead prince with a needle placed in the back of his head may, in fact, merely reflect lancing of a boil or abscess. The classic text Huang Di neijingb introduced the practice and theoretical underpinnings of what clearly became human acupuncture in the historical sense (i.e. the manipulation of qi flowing in vessels or conduits by means of needling). The book, which now comprises three distinct redactions, is made up from textual pieces by various authors writing in various times. Although it is not clear when individual pieces were written or included in the larger textual tradition,8 the main content of the book dates from later centuries and the earliest recoverable versions date to between the 5th and 8th centuries AD9 (although Han Dynasty origins are claimed for the Huang Di neijing, they are based on dubious bibliographical references that may or may not have anything to do with existing versions of the texts). Most of the texts available today went through final revision as late as the 11th century AD and such revisions may not reflect earlier work. The Huang Di neijing introduced the idea that the body contained functional centres ('depots' and 'palaces') connected by a series of primary and secondary conduits that allowed for influences (qi) to pass within the body and to enter from without. Older parts of the book are influenced by instructions to treat illness by bloodletting. (It has been theorised that bloodletting eventually developed into acupuncture and the focus shifted from removing visible blood to regulating invisible qi.) Interestingly, the text largely ignores specific skin points at which needles can be inserted. In fact, needling is a minor tradition in the book and much of the therapy described in the text is minor surgery, bloodletting and massage. Subsequently, perhaps in Song times, (AD 960–1279), acupuncture, or at least a prototype thereof, became increasingly systematised, as typified by the work of Wang Weiyi in connection with his acupuncture bronze man.10 Later still, theories of systematic correspondence were integrated with acupuncture. The final step, taking place no earlier than late Qing times (AD 1644–1911) was the development of fine steel needles. Still, throughout Chinese history, acupuncture was a minor tradition, and only in the last few decades has it become a dominant tradition, even to the near exclusion of Chinese herbal medicine which was, historically, much more important. Doubts about the efficacy of needling therapy appear early. Repeated quotes that, if one does not believe in needling, one should not use it, appear in Han dynasty writings.11 Subsequently, for unknown reasons, needling lost much of its appeal by the middle of the second millennium. By at least 1757, the 'loss of acupuncture tradition' was lamented and it was noted that the acupuncture points, channels and practices in use at the time were very different from those described in the ancient texts.12 Eventually the Chinese and other Eastern societies took steps to try to eliminate the practice altogether. In an effort to modernise medicine, the Chinese government attempted to ban acupuncture for the first of several times in 1822, when the Qing government forbade the teaching of acupuncture and moxacautery in the taiyiyuan. The Japanese officially prohibited the practice in 1876.13 By the 1911 revolution, acupuncture was no longer a subject for examination in the Chinese Imperial Medical Academy.14 During the Great Leap Forward of the 1950s and the Cultural Revolution of the 1960s, Chairman Mao Zedong promoted acupuncture and traditional medical techniques as pragmatic solutions to providing health care to a vast population that was terribly undersupplied with doctors15 and as a superior alternative to decadent 'imperialist' practices (even though Mao apparently eschewed such therapies for his own personal health16). Here they lay until rediscovered in the most recent wave of interest in Chinese medical practices, dating from US President Richard Nixon's 1972 visit to the People's Republic of China, which ended nearly a quarter century of China's isolation from the USA. Chinese medicine was first mentioned in Western literature as early as the 13th century AD in the travelogue of William of Rubruck,17 but the Western world became aware of needling a few centuries later. By the late 16th century, a few stray manuals, now held by the Escorial in Madrid, Spain, had reached Europe. Accounts of actual practice soon followed, some quite detailed. It reached the USA somewhat later. It has since been rejected, forgotten and rediscovered again in at least four major waves, including the current one. For a time, acupuncture became fairly well established in parts of Europe, particularly in France and Germany (concurrent with Chinese attempts to ban the practice). Several prominent French physicians advocated acupuncture in the 18th and 19th centuries, but other equally prominent doctors were not impressed, accusing proponents of resurrecting an absurd doctrine from well-deserved oblivion.18 Nineteenth century England also saw a brief period of popularity for acupuncture; an 1821 journal noted that acupuncture consisted of 'inserting a needle into the muscular parts of the body, to the depth, sometimes, of an inch.'19 However, by 1829 the editor of the Medico-Chirurgical Review was able to write: 'A little while ago the town rang with "acupuncture", everybody talked of it, everyone was curing incurable diseases with it; but now not a syllable is said upon the subject.'20 Georges Souli de Morant, a French diplomat resident in China who became fascinated by acupuncture as a cure for cholera and subsequently published his influential book L'Acupuncture Chinoise in 1939, kindled the first of the 20th century waves of interest in acupuncture. Souli de Morant was important in creating the myth of acupuncture, for example inventing the term 'meridian,' now widely used in Western acupuncture literature to designate channels along which qi moves, although there is, unfortunately, no direct equivalent in Chinese literature. In the USA, acupuncture enjoyed a brief period of popularity during the first half of the 19th century, particularly among physicians in the Philadelphia area.21 In 1826, three local physicians conducted experiments with acupuncture as a possible means of resuscitating drowned people, based on claims by European experimenters that they had successfully revived drowned kittens by inserting acupuncture needles into their hearts. Those same physicians were unable to duplicate their successes and subsequently 'gave up in disgust.'22 The 1829 edition of Tavernier's Elements of Operative Surgery includes three pages on how and when one might perform not only acupuncture but also 'electro-acupuncturation.'23 Publications extolling the practice appeared on occasion for the next 20 years. Although none of the early American accounts of acupuncture make any mention of acupuncture points, channels or meridians, they all claim substantial success as a result of inserting needles directly into, or in the immediate vicinity of, painful or otherwise afflicted areas. However, by the second half of the 19th century, Western practitioners had largely abandoned acupuncture. In 1859 it was concluded that 'its advantages have been much overrated, and the practice … has fallen into disrepute.'24 The Index Catalogue of the Surgeon-General's library includes barely half-a-dozen titles on the subject for the entire half-century of 1850–1900. The 1913 edition of Webster's unabridged dictionary describes acupuncture only as, 'The insertion of needles into the living tissues for remedial purposes,' and acupressure, another modern transmogrification, as 'a mode of arresting haemorrhage resulting from wounds or surgical operations, by passing under the divided vessel a needle, the ends of which are left exposed externally on the cutaneous surface.' Twentieth century scholars have imagined a trial and error system of development whereby knowledge was collectively accumulated into a medical 'system.' One view has been that, over time, crude stone lancets were replaced with fine metal needles, and acupuncture points and channels were codified, leading to a new age of medical sophistication. However, there is now considerable doubt about the existence of a trial and error system,25 as well as the assumption that 'needling,' as described in historical Chinese medical texts, is today's acupuncture. Indeed, despite antecedent ideas and practices, modern acupuncture, which includes novel variants such as electroacupuncture, may never have existed in traditional China in anything like the form in which it is practised today. a'Systematic correspondences' followed a system of 'magic correspondences' in history. In magic correspondences the Chinese attempted to order the world in terms of an elaborate sympathetic magic. For example, the ancient Chinese saw a walnut and envisioned an open brain; they do look alike. Hence people in antiquity assumed that they must be related. To extend the correspondence, it could also be postulated that if one were to eat walnuts, the brain would be strengthened. Magic correspondence has many facets; however, the main point is that the world was seen as a conglomerate of countless separate, i.e. mutually unrelated pairs of correspondences. In early Han times came the great conceptual jump: all world phenomena, tangible or not, were related through a system of correspondences. In this view, all phenomena could be influenced by changes elsewhere in the system. The body and its functions were, of course, also part of the systematic correspondences. The medicine of systematic correspondences was, as a consequence, built on this type of ordering of the world. All emotions, all functions, all morphological entities are considered part of the more encompassing universe of systematic correspondences; the organism in all its functions and morphological units is tied to the seasons, to the surrounding physical environment, etc. To neglect this system may result in disease, for example if in winter one behaves as one should in summer, bad things might happen. bThe title Huang Di neijing has been the subject of numerous English translations. The text, which is actually three separate books, can be translated in several ways. Some confusion about the title appears to stem from a mistranslation by Dr Ilza Veith, who, in her translation of the book, suggested that the title be translated as The Yellow Emperor's Classic of Internal Medicine. However, the title simply means the 'Inner Classic of Huang Di'. Huang Di is the name of the mythological 'Yellow Emperor', originally a god of the Yellow Springs of underworld, thus his colour. He is also sometimes referred to as the 'Yellow Thearch' (Thearch = god-ruler). The 'inner' (Chinese nei) means an inner or esoteric tradition transmitted from master to student (as opposed to wai, an 'outer' tradition for public consumption). The Chinese word jing means 'canon' or 'classic'. Accordingly, any translation referring to this text as being related to 'internal medicine' is entirely wrong.

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