If the pathogen cold is responsible for a particular disease process, then heat must be used to treat it. Moxa is the Chinese version of the heat lamp and, as shall be discussed in a late chapter, the Chinese burn the dried leaves of Artemisia vulgaris over the areas that require heat. Heat, or more specifically smoldering moxa, provides local heat for a variety of chronic muscular aches. It is interesting to note that the types of disease due to cold are commonly the muscular and rheumatic ache which are temporarily alleviated by heat lamps.

More than one pathogen can invade at the same time; if a patient is suffering from 'flu, then there will be a fever and all muscular aches that wander all over the body. This is defined as invasion by the pathogens wind and heat and, as one doctor said when I described this to him, 'the patient will be suffering from a great deal of hot air.'

Other factors may also cause disease, such as worry, or eating contaminated food. The Nei Ching Su Wen states that excessive grief, anxiety and overthinking will cause cancer. This idea has been supported by some recent comments in the medical press which suggest that if a woman has a breast removed for cancer she will survive longer if she is of a 'happy' disposition.

Pulse Diagnosis
For the acupuncturist, one of the most difficult aspects of traditional Chinese medicine is the diagnosis of the specific organ affected by any particular disease. In ancient China this was achieved by using a refined form of pulse diagnosis.

The palpation of the pulse enables the acupuncturist to assess which organ is diseased, whether the organ is over- or underactive, and the pathogen causing the damage. This is achieved by feeling the pulse at three positions at each wrist, and by feeling the pulse at the superficial and deep positions at each end of three positions on the wrist. There are six pulses at each wrist, three superficial and three deep. There are twelve main organs in the Chinese medical system2 and each of these is represented by one of the pulses at one of the wrist positions. It is unclear how this system of pulse diagnosis came into existence but it was a refined and very important system by the time the Nei Ching Su Wen was written. This method of diagnosis allows the whole body to be assessed, and it also defines the relative balance between each of the organs. In addition, pulse diagnosis is said to give a clear idea of the type of disease process, whether it is acute or chronic, and to give a prognosis for that disease in that individual patient. This allowed the Chinese physician to give an indication of how the disease would affect the individual.

The observation that each of these pulses represents a different organ is a difficult fact to accept and understand. It is astonishing to think that different organs are represented by the pulse in the left and right hands, and that these pulses are separated only by a centimeter or so. There are also severe different types of pulse that can be felt in any given position, for instance the pulse in the spleen position can be described as a 'Fu' pulse in one disease, or a 'Ch'en' pulse in another disease. These pulses were given rather poetic descriptions. A 'Fu' pulse is described as a superficial pulse, it is light and flowing like a piece of wood floating on water, whilst a 'Ch'en' purse is a deep pulse, like a stone thrown into water.

Surprisingly enough, these pulses can be recorded accurately with the aid of modern technology. They can be printed out from a six channel oscilloscope with three pulse sensors at each wrist. In terms of modern electronics this is not a particularly complex device and allows clear graphic verification of the idea of the ancient Chinese. The poetic description of the pulse characteristics also seems to be verified by the recording; a superficial pulse

is indeed superficial in that there is an upward deflection of the pulse wave on the recording, and very little downward motion of the pulse in that position.

In Western medicine examination of the pulse only gives information about the rate, rhythm and volume of the pulse wave, and this information is correlated with the state of the heart and blood vessels. From the pulse recordings it is obvious that the pulse shows a great deal of variation over a small area at the wrist. It is also obvious that the shape of the pulse wave changes radically when a little pressure is placed on the artery. A superficial pulse is felt superficially and a deep pulse is felt when a little pressure is put on the artery by a finger or, in the case of the pulse-recording machine, an inflatable cuff. Although not easily explicable these facts are certainly of interest.

The Ancient Diagnostic System
Pulse diagnosis is not used in isolation, but as part of a system that involves taking the history of the disease and examining the patient. The facial complexion, smell and posture of the patient are also used diagnostically. Assessing the history of the complaint is the basis of all good medical practice, whether Western or Eastern, and can be summed up by an old Chines quotation called the ten askings: 'One, ask chill and fever; two perspiration; three, ask head and trunk; four, stool and urine; five, food intake and six, chest. Deafness and thirst are seven and eight; nine, past history and ten, causes. Besides this, you should ask about the drugs taken and for women you should ask the menstrual and obstetric history. Finally, for infants ask about normal childhood diseases'. This ancient Chinese system of history-taking is almost exactly the same as that employed in the West today. Pulse diagnosis was therefore included as an important part of a sophisticated system for diagnosing disease.

Modern Chinese Diagnosis
Modern Chinese acupuncture differs from the old tradition system. The old traditional system of diagnosis by the 'twelve pulses' takes many years to learn to a standard of competence which allows the acupuncturist to make a clear diagnosis Although there are some people in both China and the West

who are able to diagnose by the twelve pulses, they are few in number, and a modified system of pulse diagnosis has therefore been developed by the Chinese. This allows a simple but relatively accurate system of traditional diagnosis to be taught and practiced, quite quickly and proficiently, the mainstays of this 'shorter method' being the use of a pulse generalization and the tongue.

The pulse is not felt in any particular position, but for its general character, hence the term 'pulse generalization'. The pulse can be felt at either wrist and classed as generally excessive or deficient. The tongue is also used to give quite specific information about the disease process and, in combination with the history, this system gives much the same answer as the 'twelve pulses'. Proficiency at this method will usually give the same traditional diagnosis as the pulse-recording machine, so the simplification of this system has not caused a significant loss of diagnostic accuracy.

The Selection of Acupuncture Points
The diagnosis of a particular problem does not tell the acupuncturist where to place the acupuncture needle. A set of therapeutic rules must be applied to solve that problem. To a large degree all medical systems are based on clinical experience and acupuncture is no exception to this; the rules that govern point selection are therefore based on a combination of philosophic concepts and empirical clinical experience.

There are special points that can be used to disperse the invasion of specific pathogens, such as cold or heat, and judging by some recent Chinese research work it would seem that the points used to disperse heat do lower fever. These pathogen-dispersing points are based largely on practical experience, and they form part of the basic grammar of acupuncture.

The other rules of point selection are many and varied; for example, points can be selected on the basis of the law of the five elements. This law assumes that each of the organs represents one of the five elements in traditional Chinese thought (earth, fire, water, metal and wood). They have a creating and destroying cycle.

On each of the channels there are points representing one of these elements and by applying a complex set of rules the diseased organ

can be sedated, (if it is overactive) or tonified, (if it is underactive). There are also points on the back and front of the body that represent specific organs, and these too can be used to treat the represented organs when they are diseased. There is a plethora of such rules, each of which is applied in specific conditions and at specific times. The problem for the acupuncturist is to define the few points that will be best in any particular condition. The skill of point selection is based largely on clinical experience; the rules of point selection give guidelines, although they are not the complete answer.

The Use of Specific Points
Why does acupuncture need such specific diagnostic and treatment methods7 Why not use all the acupuncture points at the same time? It would seem logical that if one acupuncture point helps, then two will help even more, and if all the points are used then the patient is bound to get better!

The Western doctor sometimes assumes that 'more is better'. If a drug does not give therapeutic benefit, or side effects at a given dose, then he may double the dose and the patient will probably improve. Traditional Chinese medicine implies that a small stimulus is probably more effective than a large one. Biological systems do seem to respond to small stimuli; for instance, a small change in the ecology of a 'food chain' can be amplified to cause major damage to another animal species in that environment. The emphasis in acupuncture therapy is to select a minimal number of acupuncture points in order to give the body a small but specific stimulus, as this seems to result in a better therapeutic response.

Clinical Skill
It is quite simple to practice acupuncture because it is quite simple to needle patients, but it is difficult to learn and practice the traditional Chinese acupuncture properly. It also takes some time to gain the clinical skill required to insert and manipulate the acupuncture needle. The Chinese teach that each needle inserted should be manipulated so that the patient receives a numbing or burning sensation in the acupuncture point. Many Western schools of acupuncture do not believe this and state that this sensation, which the Chinese call needling sensation, is not required. The available evidence suggests that if a needling sensation is obtained then the acupuncture is more effective, although many patients obtain adequate symptom relief without experiencing needling sensation.

Acupuncture is not a static subject. The Chinese have achieved a great deal by adapting and redefining the ideas of traditional Chinese medicine so that they are more understandable and acceptable to Western doctors. Technologically based acupuncture techniques have also been developed by Western doctors and these will be discussed in the next chapter.

1 The Nei Ching Su Wen is the first known acupuncture text (see The Physiology of Traditional Chinese Medicine, a section of this chapter).

2 The main organs are the heart, kidney, liver, spleen, lung, pericardium, triple warmer, large intestine, small intestine, stomach, gall bladder and urinary bladder.