From The Journal of Chinese Medicine issue 61 October 1999
An awful lot of rubbish is spoken and written about "acupuncture" as if all of its manifestations belonged to a single homogenous entity. Birch & Felt's work places the many forms of acupuncture within a wider social, ideological and historical context. This book debunks the mythology of a "Golden Age" of traditional acupuncture and argues that its theory and practice has always changed according to the needs of the culture in which it resides ' a process which continues today. This relativist view of acupuncture is used to promote the idea that acupuncture can and should be scientifically proven, in terms acceptable to the biomedical establishment. In a sense, the book is constructed around this conclusion. In order to lend weight to their argument, the authors give an arguably selective account of acupuncture practice, using descriptions and explanations which might be more acceptable to rational science. For example, in a section on the theoretical basis of acupuncture, systems theory is suggested as a way to investigate qi. "We could even think of qi as a theory". Elsewhere, Birch describes a mathematical equation to represent the interactions of the Five Elements! I was disappointed that such experienced practitioners chose to say so little about their personal "understanding" of acupuncture and instead chose to adopt a distanced, intellectual stance.
In discussing the history and concepts of Chinese acupuncture, the authors draw heavily upon the rich and authoritative work of Paul Unschuld's Medicine in China. The difficulties in retrieving and accurately translating sometimes contradictory, ancient texts are manifold and even scholarly attempts give us a version of events based on only those texts which have survived. Personally, I'm always struck by how little the oral traditions of transmitting information from father to son, master to student, are contemplated by historians. For example, the secrets of Chinese martial artists were never written down, yet their knowledge has survived via an unbroken lineage spanning thousands of years. Unwritten martial arts wisdom encompasses a highly developed understanding of acu-points and awareness of internal qi. Such ancient knowledge has close ties with the theories of Chinese medicine, but research in this area is conspicuous by its absence. The same can be said of Birch and Felt's work: an academic, historical approach scrutinises only the 'tangible' in terms of explaining acupuncture, choosing to leave aside a more experientially-based understanding. Broadly, the book is divided into two sections. The first section "What acupuncture is" covers the history, and traditional and modern explanations of acupuncture. The second section describes "How acupuncture is practised" in terms of conditions treated, and common patterns of diagnosis and treatment.
Although the authors claim that this is an acupuncture textbook, its content is not aimed at the student or practitioner so much as the researcher. Clearly, the authors have given a great deal of thought to the problems of researching the efficacy and processes of acupuncture. There is an excellent chapter on the pitfalls of trial design which is recommended reading for anyone about to embark on clinical research. I particularly enjoyed their discussion of the so-called "landmark study" by Melzack on the trigger point theory of acupuncture. By exposing the biases of this deeply flawed scientific study, they blow a huge hole in the neurological explanation of acupuncture. In the same chapter, Manaka's "X-signal" model is suggested as a possible way forward in the field of acupuncture research, as it bridges both western medical knowledge and traditional theories. This is key to the authors' central tenet that if it is to be integrated into western medicine, "acupuncture will need to be set upon some generally acceptable scientific footing". Again Professor Unschuld's authority is used to support their case: "Observing the failures to integrate TCM with the Chinese biomedical establishment, Paul Unschuld has proposed that integration should begin with the simple sharing of facilities and resources. Only later, through a series of intervening stages, can genuine conceptual integration be achieved." It is unfortunate that Unschuld proposed nothing of the kind. He merely observed that the Chinese are currently adopting a pragmatic "practical coexistence" where the two forms of medicine are practised "without any common theoretical basis". The alternative, even in China, is a "one-sided integrative trend of coexistence" says Unschuld, where acupuncture is explained in terms of biochemical and biophysical concepts.
The next section deals with a range of diagnostic and treatment methods used in acupuncture, concentrating mainly on Chinese and Japanese schools of thought. The authors give 17 short case-histories comprising 8 which use TCM, 7 Japanese (including 2 of the Manaka school and 2 Shonishin), 1 NADA and 1 using Five-Element. The range of case histories and how they are discussed is quite telling. Illnesses are identified in dry biomedical terms and discussion of the patient's emotional state is present in only two or three cases, notably the single Five-Element treatment of migraine. Changing treatment priorities within multiple diagnostic patterns is not discussed. The emphasis is on symptom-based rather than root-level treatment. This is puzzling. We've all seen apparently simple bio-mechanical symptoms that actually have a complex emotional aetiology. For example, the 'chronic shoulder-pain' belonging to the obsessive-compulsive housewife who endlessly cleans the house. A more rounded view of how different acupuncturists diagnose and treat can be found in Acupuncture in Practice : Case History Insights from the West (MacPherson, Kaptchuk 1997) describing a rich diversity of treatments ranging from restoring the spirit of someone wrecked by childhood abuse, through to releasing dragons to clear demonic possession. In stark contrast to Birch and Felt's version of acupuncture, most of MacPherson's case histories speak of the unique healing rapport between patient and practitioner. This is the "magic" of acupuncture which Birch and Felt refuse to acknowledge. In the shamanistic tradition of Chinese medicine, the healer is an instrument for greater forces - a tradition traced through many eminent practitioners of Chinese, Korean, Japanese, French, and English origins in In the Footsteps of the Yellow Emperor by Eckmann (1996). Even Unschuld points out that demonological therapy and Buddhist temple medicine still survive in China today.
By illustrating, even partially, the confusing diversity of acupuncture theory and practice, Birch & Felt argue that the truth of acupuncture can only be demonstrated in its simplest forms. If acupuncture is to become complementary to western medicine, rather than alternative, then it must co-operate with the scientific and medical establishment and prove that symptoms can be controlled with non-individualised formulaic treatments. Thus the 'traditional' holistic approach is put on the back-shelf. Birch and Felt argue that the US NIH Consensus statement, (similar to the European Commission's COST report) will ensure that acupuncture will be practised by whoever proves the economic and scientific validity of the treatment.
The authors' relativist view of acupuncture says that everything changes and nothing is sacred ' therefore why not ally ourselves with the predominant power-base to achieve wider acceptance? Thus, in the final chapter of the book, traditional healers are asked to embrace a scientific paradigm which is unable to explain how Bruce Lee's "one-inch" punch could have so much obvious force, and which has already proved that the bumble-bee is incapable of flight! The US and European medical establishments are focussing on acupuncture simply because so many people are now trusting their instincts and accepting its possibilities. The current biomedical treatment model which pervades all modern societies is in crisis. As a direct result of its very successful reductive approach, it is unable to incorporate the significance of emotional, psychosocial and spiritual factors of health. This book is an erudite appeal to the acupuncture profession to follow this approach in order to gain scientific credibility. In so doing, the concepts of 'root-level' healing are left unexplored. But it is the simple beauty of these concepts that separates oriental medicine from the crudities of reductionist western medicine. I wish I shared the authors' touching faith in the medical establishment. All my experience of the medical profession to date suggests that once evidence-based standardised treatment protocols are incorporated into biomedicine, the chances of practising more fundamental, individualised medicine would be further marginalised, if not outlawed altogether. How ironic that these renowned authors argue that we should hasten that process.
SECTION 1 What acupuncture is
2. The acculturation and re-acculturation of acupuncture
3. The theoretical basis of acupuncture: fundamental concepts and explanatory models
4. How does acupuncture work?
SECTION 2 How acupuncture is practiced
5. What does acupuncture treat?
6. Diagnosis and patient assessment: what do acupuncturists do?
8. Conclusion and strategies for the future
Appendix 1: Resources and questions
Appendix 2: Major acupuncture/moxibustion treatises