By Jeffrey Dann
(This article is a slightly modi ed version of my presentation at Dr. Wang Ju-Yi’s Channel Theory Symposium, Beijing 2013.)
I would like to discuss several topics stimulated by the signi cant publication into English of Dr. Wang Ju-Yi’s book with Jason Robertson, Applied Channel Theory in Chinese Medicine. I believe it is the most important book in English on TCM in the past 25 years. This book may have a profound impact on how standardized TCM is taught in the United States and Europe.
The work of Dr. Wang returns acupuncture to the domain of manual medicine where the presence and aware precise of touch of the doctor engages the living tissue of the patient rather than merely nding a switch, like a motor point or xed ana- tomical acupoint and turning it on or off.
His brilliance is theory rooted in the classics yet backed by a current understanding of modern anatomy and physiology. He sees the channels in the context of the most modern understanding of fascial planes and the dynamics of capillary and extra-cellular matrix uids.
His scholarship illuminates, for Western students, the rst clear theoretical and clinical uses of six- level pathophysiology. Acupuncture students of course learn the names of the six levels that relate to each same named zang-fu channel such as hand tai yin lung and foot tai yin spleen.
I would like here to take a small piece of Dr. Wang’s work, that of understanding the signi cance of the tai yin level. This functional energetic pair of spleen and lung opens new vistas to the exte- rior and super cial physiological meaning to the shared interaction of the lung – wei qi and the spleen - ying qi in the cutaneous (dermis) and subcutaneous levels.
Where the qi dynamic is disordered, where ying and wei are not in harmony, we see alterations
in the interstices (couli) and extracellular uid quality. The super cial fascia begins to demon- strate palpable aberrations such as swelling, depressions, nodules, or bands. It is there, in the interstitial uids and connective tissue structures that the tai yin dynamic regulates the ying and wei surface layers. It is at the tai yin level that we see the signs of health, the luster of the skin, the sparkle of the eyes, the tone of the tissues, the quality of movement.
There are numerous references in the Ling Shu and Su Wen to a well-differentiated sense of tissue textures and levels. Su Wen 5 says, “The most skilled healer treats the surface ...and those doctors are those who disperse (the pathogens) before they sweep inward. The healer next in skill treats the subcutaneous tissue (jifu). The healer next in skill after that treats the sinews and ves- sels. The healer next in skill treats the six hollow fu viscera. The healer next in skill after that treats the ve solid zang viscera.”
Blockage of qi occurs where transformation of blood and uids lack free ow (通 tong). Im- balances in the tai yin super cial layers of the body represent a pathophysiology involving the lung’s ability to move qi or the spleen’s inability to transform and move blood. Without free ow, the connective tissue bers and the extracellular uid movement through the fascial planes begin to demonstrate structural change. Skin tonus, tex- ture, and temperature begin to alter at the exterior. Qi dynamic (qihua) pathology affects the spaces between the couli; they become sore, aching, and can exhibit varying degrees of brotic change.
I saw my Japanese teachers carefully assessing by touch two super cial layers of the body – the skin and the underlying super cial fascia. Their touch was light, quick, and highly sensitive. Their clini- cal practice of identifying changes in super cial and muscular tissue textures was highly re ned but there was no clear theoretical premise that was usually offered. There was mention of wei and ying levels but again without their classical physiology and pathophysiology. Dr. Wang’s book suddenly explained the theoretical basis of what I had observed in the Japanese precision and detailed attention to surface conformations and their varied treatments.
Many Japanese styles have paid attention to the super cial tai yin level for a long time, in part because of the profound in uence of blind prac- titioners. Today the guide tube, developed by the blind acupuncturist Sugiyama Waichi in the mid 17th century, is the standard tool for needle insertions throughout the Western countries. There are many advantages to having a guide tube compared to freehand insertion.
However many people do not realize that the guide tube was invented in part as a device to carefully measure the depths of super cial insertions. Be- cause the needle-handle projects 4 mm above the guide tube, the acupuncturist can become very precise at more minute levels of stimulation from 0-1mm to 2-3 mm, to 4-5mm. With very ne thin gauge needles, 0.12-.20 mm, emphasis is placed on the acupuncturists sense of “arrival of qi” (气 至 qi zhi), rather than the patient’s felt sense of deqi (得气)“obtaining of qi.”
Japanese teachers feel that there have been growing de ciencies in people now living in urban mega-city environments with cyber stimulation, highly processed food, stationary jobs, family alienation, mass transit and more, which all create a variety of de cient conditions.
Furthermore, needle techniques that are not insertive, that are minimally insertive, or that are only just under the skin and do not reach the muscle level are highly developed in the Japanese styles known as Meridian therapy and Toyohari. The foundational classic references for them is Nan Jing 71, Nan Jing 78, Nan Jing 80, and Ling Shu 9.
Here are some of classical highlights that inform the Japanese practitioners sensitivity to reading and treating the super cial layers of the body.
The text here clearly differentiates between the wei and the ying levels and states that to treat the
super cial wei the needle should be shallow or “lying down” and that to treat the slightly deeper nutritive ying layer, the point or area must be pre- pared by manual techniques to move the wei qi so as not to damage it while accessing the ying layer.
Nan Jing 78 states the importance of using the left hand: “knowledgeable practitioners put faith in the left hand. Practitioners who do not know put faith in their right hand.” But in any case, before insertion, it is necessary to prepare the point by pressing and kneading.
Nan Jing 80 opens the discussion of sensing the “arrival of qi” and the critical sensations of the assisting left hand. The cultivation of awareness of the arrival of qi represents a highly developed sensibility to feeling the qi dynamic. “When it is seen” refers to when the qi is felt to be at its full- est the needle should be extracted. This is what is meant by “when it is seen, enter, and when it is seen leave.”
Ling Shu 9 is also a foundational text both for 9
Japanese and Dr. Wang who place emphasis on cultivating awareness of the qi dynamic when an area is needled correctly.
深居静处。占神往来。闭户塞牖。魂魄不散。 专意一 神。 精气不分。 毋闻人声。以守其精。 必一其神。 令志在针。神志之专一也
浅而留之。微而浮之。以移其神。气至而休。 This critical text describes the deep “open atten- tion” that the acupuncturist must hold, without distracting thoughts, to grasp the moment, to grasp the dynamic (the moment of qi transforma- tion) to appropriately tonify or disperse without overstimulating.
Furthermore, it says “[In this way, the practitioner may skillfully practice] shallow insertion while re- taining the needle, or gentle, super cial insertion so as to successfully transform the patient’s spirit to (以移其神) and as the qi arrives then one stops”.2
Acupuncture and Cultural Change
Japanese teachers I have studied with, such as Shudo Denmei, repeatedly emphasize that in the modern lifestyle people are becoming more and more de cient, and as such they require more delicate and supportive strategies to bolster their fundamental de ciencies. To this end con- temporary Japanese practitioners have developed consistently gentler means of toni cation with shallow insertions and a varied repertoire of non- insertive contact or touch needling.
We also nd de ciencies in our American patients, much of this rooted in our modern lifestyle. The excesses of modern urban life can create deep de ciencies. Many live in a state of adrenal exhaus- tion (kidney de ciency) with insomnia and sleep disturbances, lack of exercise (liver de ciency) and obesity and poor diets (spleen de ciency), and also deal with respiratory problems due to smoking and air pollution (lung xue). People live longer but without great vitality surviving on a com- plex polypharmacy of drugs. In our acupuncture schools many nd Chinese styles of acupuncture too stimulating, too painful, and do not continue treatments. Even acupuncture school clinics are nding that Japanese-style treatments are much better tolerated with satisfactory results for de - cient patients, hypersensitive patients, and very old and young patients.3
The Beijing that I studied in in 1981 was very dif- ferent from the China I see today. The transforma- tion in lifestyle and abundance is dramatic. Most people back then rode bicycles and walked a lot to get around. Houses did not have air conditioning or heat in each room; unlike today they had to internally adjust to environmental changes. Most people ate simple locally grown foods without all
the sugar and highly re ned foods with arti cial preservatives and high-fructose corn syrup. Obesity was rare. Most were laborers or farmers, hard-working people; even city life was spartan and simple. And when Mao integrated acupuncture into the national health care system, and for free, the clinics were swamped with waiting patients. Doctors did not have time to carefully palpate; they needed a quick assessment from the pulse and history, and a quick strong treatment plan to move the qi and stagnation from these hard labor- ing bodies. Acupuncture since the founding of the PRC was developed as a mass system for hard- working hard-body patients. The nationalization of free medicine forced TCM doctors to develop a streamlined strong treatment style to meet the great demand for care.
Today, even in China we see the rise of obesity, the development of metabolic syndrome and the growing problems of the excesses of modern post- industrial urban life styles such as hypertension, diabetes, and high cholesterol.
I see the rise of super cial and gentle needle technique as being more appropriate to the qi deficiencies of modern post-industrial cyber urban life. The growth and interest in Japanese- style acupuncture in America and Europe is in part a reaction to the harsher TCM styles that have dominated the foreign acupuncture school curriculum and licensing for the past 30-40 years. Numerous people who love and appreciate acu- puncture dislike the TCM experience but take it as “bitter medicine.” Soft bodies with entrenched yin de cient conditions do not tolerate strong deqi needle techniques. They do not have enough essential qi and blood to handle strong qi moving techniques, deep insertions with vigorous lifting and thrusting to obtain deqi.
In closing I would like to ask the question of my esteemed teacher, Dr. Wang Ju-Yi and his stu- dents and colleagues here in China. How do you see changes in treatment for your modern urban Chinese compared to those patients of 30 or 40 years ago? How are the bodies, by palpation, different for those now raised in post-industrial urban desk work compared to the past? How does acupuncture therapy vary and change with changes in environment and lifestyle and what are the historical precedents for the changes in acupuncture by era and by country?
1. Translation from Paul Unschuld, Nan-Ching: The Classic of Dif cult Issues, 1986, Univer- sity of California, Berkeley.
2. This translation is from the Charles Chace article “On Greeting a Friend, an approach to
NAJOM vOlume 21 number 61 NeedleTechnique”publishedinTheLantern,
vol 3. No.3.
3. Elizabeth Talcott, “Enhancement Of Trad- itional Chinese Medical Education With Japanese Meridian Therapy”, 2013, Doctoral Capstone thesis, Paci c College of Oriental Medicine, San Diego, CA.
1. Langevin HM, “Mechanical signaling through connective tissue: a mechanism for the thera- peutic effect of acupuncture.” FASEB J. 2001 Oct;15(12):2275-82.
needle manipulation transmits a mechanical signal to connective tissue cells via mecha- notransduction
2. Langevin HM, “Relationship of acupuncture points and meridians to connective tissue planes.” Anat Rec. 2002 Dec 15;269(6):257- 65.
acupuncture points and meridians can be viewed as a representation of the network formed by interstitial connective tissue. ...80% correspondence between the sites of acupuncture points and the location of intermuscular or intramuscular connective tissue planes in postmortem tissue sections
3. Langevin HM, “Tissue displacements during acupuncture using ultrasound elastography techniques”. Ultrasound Med Biol. 2004 Sep;30(9):1173-83.
4. Langevin HM. “Dynamic broblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo.” Am J Physiol Cell Physiol. 2005 Mar;288(3):C747-56
5. Langevin HM. “Connective tissue broblast response to acupuncture: dose-dependent effect of bidirectional needle rotation.” J Altern Complement Med. 2007 Apr;13(3):355-60.
6. Staying Super cial in Order to Go Deep: Japanese Acupuncture, Classical Energetics, and Staying Super cial in Order to Go Deep: Japanese Acupuncture, Classical Energetics, and the Super cial Fascia
Jeffrey Dann, Ph. D., L. Ac.
7. This article originally appeared in the March 2007 issue (Vol. 14, No. 39) of the North American Journal of Oriental Medicine. the Super cial Fascia
Jeffrey Dann, Ph. D., L. Ac.
8. This article originally appeared in the March 2007 issue (Vol. 14, No. 39) of the North American Journal of Oriental Medicine.
9. Liquid crystalline meridians. M.W. Ho and D.M. Knight. The American Journal of Chinese
July 2014 NAJOM Medicine 26, 251-263, 1998.
10. The acupuncture system and the liquid crystalline collagen bers of the connective tissues. Ho MW, Knight DP. Am J Chin Med. 1998 26:251-63. Review.
Jeffrey Dann began studying seitaiho and shiatsu in Japan in 1972 while training at the Mito Tobu- kan. He has been an acupuncturist since 1981 and has a practice in Hawaii and Boulder Colorado. His interests are in movement therapy and os- teopathic palpation. He teaches internationally and around the US and is on the faculty for the Japanese Acupuncture doctoral program at the Tri-State College of Acupuncture in New York City.
Staying superficial in Order to Go Deep: Japanese Acupuncture, Classical Channel Energetics, and the Superficial Fascia
Jeffrey Dann, Ph. D., L. Ac.
Over the years I have struggled to understand the differences between Chinese TCM acupuncture and Japanese styles (TJM) represented by Meridian therapy and Toyohari schools. Each impacts the body in very different ways and in at different levels.
TCM acupuncture uses thick heavy gauge needles (28 -32 gauge) with relatively deep insertions (more than 30 mm) into the muscle layer, with vigorous techniques to elicit a deep aching sensation in the patient (known as “deqi” or “obtaining qi.”) The pulse is generally taken only once at the beginning of the session, and rarely are abdomen or distal points palpated for assessment. Needle insertion is traditionally done freehand, without a guide tube.
TJM , on the other hand, is characterized by the use of thin needles (38 -42 gauge), with superficial insertion (0-7mm) and with gentle stimulation that seeks to have the practitioner sense a sensation known as “the arrival of qi”. TJM is also differentiated from TCM by its careful use of the left hand (oshide) to palpate and prepare the point, as well as to sense the “arrival of qi.” Point selection for root treatments is derived from the classical five phase points. In addition TJM frequently palpates for re-confirmation in the pulse, abdomen, and treated channels to determine if the point selection and techniques of stimulation were appropriate.
The contemporary teachers of Meridian Therapy and Toyohari Japanese acupuncture emerged from the mid 20th century “Return to Classics” movement. They emphasize: 1) clinical reference to the classics (Suwen, Lingshu and the Nanjing),
2) refined palpatory diagnostics of pulse, abdomen, and meridians, 3) varieties of superficial needle stimulation, and 4) feeling the “arrival of qi.” These acupuncture styles focus on listening through touch - by “staying on the surface” with very little deep palpation or needle insertion.
Shudo Denmei’s most recent text, “Locating Effective Acupuncture Points,” distinguishes various needle depths as follows: 1) contact and super-superficial insertion, 0 - 1 mm
2) superficial insertion, 1-5 mm 3) shallow insertion 5 – 30 mm
4) deep needling, more than 30mm
I want to look at the anatomical structures that comprise the zones of contact from 0 to10mm. Shudo Sensei’s first three levels describe the terrain of the skin and superficial fascia Think of the skin as the outside of the brain. It is like a wet suit layer given shape by bundles and compartments of connective tissue (fascia). It is filled with a liquid crystal fluid, the extra-cellular matrix, which brings blood and nutrients to the surface and takes away waste products. It is our protective barrier. The skin has many specialized cells and receptors that communicate to the brain our interaction with the outside world. It is here that the Ying qi and Wei qi interact around the channels.
The brilliant medical historian, Shigehisa Kuriyama, notes that the ancients had a concept of structured depths of the body’s anatomy and pathophysiology. Their way of plumbing these depths, Kuriyama says, was to “gaze” upon the surface and palpate its terrain. The inner essence is hidden and mysterious but it can be apprehended in the flowering manifestations on the surface, just as a master gardener can tell the health of a plant by looking at its luster and feeling the texture of the leaves. The Suwen says, “It is through the external manifestation (Biao) that we know the intimate reality (Li)”
The “arrival of qi” is not a metaphysical concept. The ancients carefully palpated the superficial structures on the skin, the interstices (cou li) through which the Ying qi and Wei qi course. They described a highly differentiated system of network channels, cutaneous channels, large and small vessels (sun, miao) and finally the meridian pathways themselves.
The body-mind is a vibrating pulsating field that, like the breath, reflects state of being and reactivity to internal and external conditions This can actually be palpated anywhere on the body, not just at the radial pulse. And the energetic physiologic shift induced by acupuncture can also actually be felt. Shudo Sensei describes this as the arrival of qi and both the classics and modern physiology can describe this phenomenon.
In classical texts, traditional surface energetics starts with the Wei qi. SUWEN: 43 “The Wei qi is the defensive qi that is formed from the same foodstuff (Ying); this qi is different; it is fast and smooth. It cannot travel in the blood vessels but flows between the skin and the muscles. It circulates through the chest and remains outside of the channels and vessels.”
Healthy surface conformations are presented when Ying qi and Wei qi are in harmony. The Wei qi, to some extent, is governed by the Lungs and has a rapid circulatory cycle of 50 circuits being most active on the surface during day and deeper and more quiescent at night in the lower Jiao. The Wei qi moves between the skin and the superficial fascia, the cou li or interstices. The Wei qi acts as first layer of defense against external pathogens. It regulates skin functions of peripheral body temperature and fluid balance by regulating the pores and sweat glands. When in harmony with the deeper nutritive Ying qi, vascular and lymphatic circulation is free flowing and the skin is lustrous and its texture is resilient and healthy. Luster or vitality can be seen and felt in the skin and superficial tissues: this reflects the ability of the Lungs to infuse and move the blood.
Recent studies of the skin show a vibrant active immune function, the result of specialized lymphoid cells known as Langerhan cells and other structures. They may stick to the external pathogen, alerting T-cells to it, and thereby activate other immune protective reactions. The superficial fascia is the zone in which Wei qi and Ying qi interact.
Donald Kendall describes the classic Wei-Ying relationship in terms of modern immune physiology: “Defensive substances can leave the blood circulation through the walls of the capillaries to fight off an external assault, or respond to tissue trauma the defensive interaction takes place s place due to an interplay of nutrients (Ying), which include blood coagulation system proteins, and defensive substances (Wei), which include immune cells and complement proteins.
Suwen 5 is particularly descriptive of this precise anatomical awareness. “The most skillful healer treats the surface hairs (pimao)…and those doctors are best who disperse them before they sweep inward. The healer next in skill treats in the subcutaneous tissues (jifu); The healer next in skill after that treats the sinews and the vessels; the healer next in skill treats the Six Fu (hollow viscera); the healer next in skill after that treats the Five Zang (solid viscera).
Lingshu 75 says: “First, attentively observe and differentiate…By pressing with the fingers, using sliding techniques, also rubbing and flicking the points. Then, attentively, watch the response and reactiveness “
What does it mean to “watch” the response? The classics suggest one can actually feel and sense the balancing of qi. In describing how to apprehend the “arrival of qi”, Shudo Sensei often refers to Lingshu 9: “Reside deeply in a place of stillness, divine the comings and goings of the spirit with one’s (sensory) doors and windows shut…”Successfully transform the patient’s spirit; when the qi arrives then one stops”. This is very different from causing a deqi sensation or doing qi propagation through the needle as done in TCM.
Shudo Sensei interprets this listening as being in a centered place, not talking, not thinking extraneous thoughts, but carefully listening and sensing to the shift. He resonates with this shift and has said he sometimes even salivates when the qi arrives. This indicates a clear parasympathetic response of increased saliva secretion. This is a complete oneness with the patient, needle, and oneself. It’s like the kendo (art of swordsmanship) expression “ki – ken – tai itchi,” the mind-sword-body are one.
This arrival of qi is an actual sensation that can be sensed in the change in fascial tissue texture, or a subtle sensation that is the result of the stimulus-response to the acupuncture needle skillfully and sensitively wielded.
The work of neurophysiologist-acupuncturist Helen Langevin, studying the relationship of acupuncture stimulation upon the fascial structures confirms that a bioelectric discharge occurs when the acupuncture needle interacts with the stressed collagen fibers. This piezoelectric discharge moves through the liquid crystalline structure of the extra-cellular matrix. This activates lymphatic, vascular, hormonal, and autonomic shifts.
Langevin proposes a new theory of acupuncture mechanisms that goes beyond the more common Western gate control theory describing stimulation of neurological pathways. She proposes that acupuncture meridians follow connective tissue planes. Acupoints, in fact, occur at the convergence of connective tissue planes. Qi is defined as the sum of all body energetic phenomena (e.g. metabolism, movement, signaling, information exchange). Meridian qi is the connective tissue biochemical–bioelectric signaling system. This theory is supported by the research of Mae-Ho Wan’s research on the liquid crystalline communication signaling system of the extra-cellular matrix fascial net.
I propose that the” Return to Classics” superficial acupuncture approach of TJM creates a different response and regulation of qi and Blood than the deep needling of TCM. Superficial needling activates what is known as a Diffuse Non-Specific Regulatory Response (DNSRR). Because the surface of the skin has so many more specialized receptors, its activation with acupuncture sends a different array of signals to the brain. Superficial needling activates those signals that cross over to the other hemisphere rather than going straight up to the pain interpretation center, the thalamus. These cross over sensations and messages often have to do with making finer discriminations and exploratory sensations. I’m not a neurologist but I think there is a lot of interesting research for them to do. I like to open this discussion and I look forward to hearing from those that know much more about this subject than I do.
The real purpose at the heart of this article is to encourage us to develop our sensitivities, to listen ever more closely, and help our patients by being better acupuncturists.
Jeffrey Dann, Ph. D., L. Ac. currently teaches and practices in Boulder, Colorado. He practiced for many years on the Big Island of Hawaii. His previous training was in cultural and medical anthropology. He conducted fieldwork in Japan where he also studied Kendo, Shiatsu, and Seitai-ho at the Mito Tobukan Dojo in Ibaraki Prefecture. He attained the rank of yondan in Kendo. He is currently president of the Traditional Japanese Acupuncture Foundation, and has played a key role in networking and promoting Japanese acupuncture and bodywork.
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