The different levels of Acupuncture

Am I talking of quality or of quantity? Am I mentioning the number of hours of study or the years of practice?

Am I pointing at how many minutes or hours a practitioner spends with a patient? Am I making a difference between the virtuosity of a needle manipulator – if such a person stills exists and performs in the privacy of his practice -, or the straightforward insertion of a needle in a located point, or region?

Am I thinking of a progressive historical evolution throughout the centuries leading to a unanimously accepted technical system?

By asking the question I suggest the answer, which depends on the perspective, the approach, the understanding, the appreciation of what we are doing and, maybe, why we are doing it.

But first of all, why am I asking all these questions? And why do I feel the necessity, the urge, of such interrogations?

I apologise for talking here of myself, and mentioning my first contact with the world of acupuncture, but we can use it as a starting point of a thinking process which I have never ceased to stimulate, and which I hope will trigger eventually in you a similar kind of dynamics.

For that we must go back to 1955. The action takes place in a beautiful abbey in the outskirts of Paris. It belonged to an uncle and aunt of mine, and they used to entertain a lot: dinner parties, cocktail parties, concerts and exhibitions, seminars and plays. In this cultural and worldly environment I met a cousin of mine, thirty years older than my young fourteen. She was elegant, beautiful, and charming, but most of all she had known very well Soulié de Morant, had learned the theory of acupuncture, not TCM, and she practised what I call dinner party acupuncture. During these events, whenever a guest, or a member of the family complained of a headache, or a pain, or a discomfort somewhere in the body, she would take that person in a corner and, with her long, pointed, red nails, she would quietly massage one or two points for five minutes, often relieving the person of his or her complaint, which of course was not very serious. And everybody found it normal, and she explained to me, in a few words, the theory of acupuncture. Was it because she was fascinating, or was it my destiny, but there and then I decided to learn acupuncture.

Years later I found books giving recipes of one point to treat a symptom or a condition: ST36 for tiredness, Liv3 for tension, BL12 for an attack of cold, CV22 for an asthma crisis, Yin Tang for nose problems, CV4 for gonorrhoea – yes – GB20 for headache, etc…

In the Compendium of Acupuncture, the Zhenjiu Dacheng, Yang Jizhou writes about the 14 points of Ma Danyang, about the four Master points. The Japanese built the system of Shiatsu, and in recent times books have been written on Daoyin, a self massage of points or small areas.

All this was the expression of a dream. To use as few points as possible and, if possible, only one point, which would target, not only a symptom, but maybe a configuration of symptoms, a pathological pattern.

What is the origin of this tendency? In many ancient books, and in most modern manuals, we find lists of points and, for each point, a list of indications, sometimes two or three, but it could amount to dozens of indications.

What are the origins of these indications? Of course there are many.

  1. Observation, practice, experience, repeated and collected, verified with various degrees of rigorous thinking. This is the stronghold of acupuncture, the basic nucleus common to all levels.
  1. The interference of clinical reasoning, using the different systems of reference, like the relations between meridians and points on the one hand, channel pathway pathology, organ or function pathology on the other hand, as well as the large functional responsibilities of each organ towards tissues, sense organs, fundamental substances, or large synthetic functions involving the whole body’s mechanisms. Here we have a mixture of understandable reflex therapy, of broad clinically related observations, and of sometimes abusively extended and farfetched conclusions.
  2. The interference and application of abstract reasoning, using the Laws of the Five Elements, the cosmic relations between Yin and Yang, the mysteries of the Book of Changes and its fascinating hexagrams, the modifications through time, as exemplified in the determination of one point depending on the hour the day, the month and the yearn using the Chinese calendar cycles, or the attraction of numerology and the symbolic power of numbers.

Where are limits between 1 and 2, or between 2 and 3? Up to what point can our modern thinking and knowledge stretch its logical acceptation, and when does it feel that things have gone too far? It is not my purpose to answer those questions, because I am incapable of it, leaving later generations of clinicians and thinkers try to shed some light on the intricacies of these confusing groups.

But let us go back to the mass of indications for each point. When many treatises or manuals agree, and therefore many observations or reasoning arrived at the same conclusion, then a point found itself with one or a few principal indications, rising to the condition of best point for this or that symptom or condition. And it is probably here that appeared the dream of using one point and only one point.

However this system cannot be generalised, because of the complexity of each individual pathological condition.

First because a symptom is seldom unique, it is nearly always accompanied by others, creating a pathological pattern, for which the use of one point would lead to failure.

Second because a symptom can be the expression of several patterns: a headache can be a sign of a hangover, of a brain tumour, or Arnold’s neuralgia, of high blood pressure. Here again, the use of one point would lead to failure.

Still sometimes, but not often, in some simple and not serious cases, the needling of one point may have positive results.

But what appeared in the course of many centuries was the notion of principal point, or principal points, or most effective and important points, accompanied by secondary points depending on the variety of symptoms and their respective hierarchy in significance, or urgency.

This is what we call combination of points, and represents the fundamental thinking of all practitioners.

This does not mean that all practitioners think alike:

  1. Some use rigid formulas for similar patterns, whether defined according to modern medicine or to TCM.
  1. Some use semi-rigid formulas, which they adapt to each condition, adding here and there a few points to account for the discrepancies between the configuration of symptoms.
  1. And some use individual combinations of points for each individual patient at each moment of the illness’ evolution.

Once again, the limits between these groups are not clear, and many practitioners pass from one group to the other depending on the complexity of the patient’s condition.

To add to the confusion, when deciding on the points to be used, one draws from many sources: without going into too many details, we can discern different kinds of sources:

  1. Those who are obviously, or indirectly, related to segmental enervation: the Back Shu Points, some of the Mu points, some of the most important extremity points like LI4, PC6, ST36 or BL40.
  2. Of course all of the local points, A Shi points or trigger points, also relying on neurological reflex stimulation.
  3. The extra-meridian points, some supported by neurological logic, some rather suspicious from a modern point of view.
  4. The so-called New Points, some of which have been used for local indications without knowing that they had a name, some highly suspicious and fanciful.
  5. A whole group of points with specific names: Yuan – Source, Luo – Collateral, Xi – Cleft, Master, Influential, Key, Secret, Tonification, Dispersion, 5 Elements points, Windows of the Sky, Barrier, Ghost, empirical – yes – empirical. Here the dilemma of choice is critical, as in each of these groups some points are often used, because they are efficient, and some are never used.
  6. A group of points used because their ideograms allude to a therapeutical action, like Dispersing the Wind, Boosting the Qi, Supporting the Blood or Harmonising Fluids circulation.
  7. Finally a group of points which find their justification in the integration of Acupuncture into TCM, and the application of TCM reasoning to eventually effective points for pathological patterns.

What rules to follow? What level do we belong to? Are we not facing an intellectual torture, an impossible task? Many practitioners stick to the basic rule: “chose the point according to the area and the meridian”, with local, regional and eventually distant points. They usually treat mostly locomotor pathologies. Is this acupuncture? Of course, even in its simplest form, like using the three needles of the shoulder, or the main points for sciatic neuralgia.

Other practitioners will try to influence functional pathologies by using a mixture of points coming from the different groups just described, whether as rigid recipes, what some comptemptuously call “cookbook” acupuncture, or as more adaptable formulas depending on the individual cases. Is this acupuncture? Of course. Is it better acupuncture? Can we say it is of a higher level.? For the tenants of so-called traditional acupuncture, yes. For the tenants of the so-called scientific acupuncture, there are some doubts, and with reason, because of the mixture of points, and the variety of justifications and sometimes the inherent contradictions of the choices.

However these practitioners do achieve results, whether because of the choice of points, because of the special relation developed with the patient, the indispensable minimal psychotherapy, and of course the placebo effect, although this last argument does not impress me because it seems to be everywhere in medicine, not only in acupuncture.

So from dinner party acupuncture, maybe to be compared with a nice glass of cool and refreshing water offered by a kind hand when you were very thirsty, we have arrived at cocktail acupuncture: whisky soda, dry martini, Singapore Sling or Tequila Sunrise, obviously a very good cure for relieving the tension of being in a crowd, the anxiety of having to talk to so many people, remember their names, be polite to everybody, not kissing a man’s hand or patting a lady in the back, not asking a man his brand of lipstick or not asking a lady her real age. Discreet or effusive, silent or talkative, smiling or laughing, there are so many rules to obey.

How did we learn this sophisticated behaviour? Through learning, through education, through practice, through experience. And the same goes for acupuncture. But is one level better than the other? And are there really several levels. Does it not depend finally on the inclination of each practitioner, and his ability to be efficient in treating his patients?

My dear colleagues, I hope that these few thoughts have disturbed you if you are new to them, and have put some disorder in the mind of those who are familiar with them, triggering at the same time a positive and critical thinking process, for the benefit of future generations of medical acupuncturists.

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