First published in: OREZ - the Israeli magazine for Chinese Medicine. Spring 2011
How Long Should the Needles Stay In
Writing articles and teaching workshops has been a wonderful mean which helped me progress in my studies, while further investigating and deepening my understanding of certain issues that raised questions in my mind, yet were not answered by my teachers. And so I arrived to the subject of “acupuncture techniques”, which was hardly dealt with during my studies of acupuncture. While investigating ancient Chinese texts, I realized how much there is to elaborate on that subject. While investigating the subject of “acupuncture techniques”, two surprising topics came up. Surprising, since what I thought to be safe and clear, turned out to be a subject of debate among scholars of Chinese Medicine along history.
The first subject of debate has been the Turning direction of the needle: clockwise or anti clockwise? Clearly, I thought clockwise direction will provide a tonification affect, whereas anti clockwise will provide a dispersing affect. As it turned out, this subject is not so clear cut. There are serious claims on both sides, on which I may elaborate in a different article.
The second issue, which this article addresses, regards the duration of time that the needles should stay inserted in the body.
As part of my basic training as well as my continued education studies, I have been taught that the needles should be kept in for twenty one minutes. At this point, I accepted things as told, no questions asked. Throughout the years of practicing acupuncture, often I felt not at ease regarding the setting of a strict time frame for treatment. While listening to the pulse and observing the patient, I often felt that I have missed by taking the needle out “on time”, after twenty one minutes. Sometimes, I felt that I had to take them out much earlier, and other times it seems I should have kept them in longer. I asked one of my teachers and was reprimanded: "Don't invent new theories” ….
The contraction movement caused by being reprimanded enabled me the break through, and the growth movement which followed. Charged with QI of action, I went ahead to investigate the subject, and realized that I cannot find a source that provides instructions such as leaving the needles inserted for the duration of twenty one minutes.
The main sources of information, on which I based my “Needling techniques” workshop, and which includes the issue of duration of needling time, was mainly the writings of the Nei Jing. Additional texts that were used were Nan Jing and Zhen Jiu Jia Yi Jing.
Before writing this article, I sent a question to at least ten of the leading teachers and practitioners of Acupuncture in Israel, and around the world. Their answers reinforced my conclusion, which is stated at the end of this article. To my surprise, there were no two answers alike. The answers ranged between statements that this issue indeed is not so cut clear, to interesting theories, yet completely different from one another.
DESCRIPTIONS FROM ANCIENT CHINESE MEDICINE WRITINGS
Let's start with Su Wen Chapter 27, which is one of the main chapters dealing with acupuncture techniques. This chapter provides a description of dispersing and then tonification techniques:
Dispersing: “Inserting the needle while the patient inhales…吸則內針…
The needle stays in for a “long time”, quietly, in order to prevent distribution of the Pathogen, 靜以久留, 無令邪布…”
tonification: “Inserting the needle while the patient exhale… 呼 盡 內 針…
Leave the needle in quietly, for a “long time” until the Qi arrives,
One should wait for the arrival of Qi quietly and patiently, like waiting patiently for a guest, not noticing that it became dark already, 如 待 所 貴 ， 不 知 日 暮…”
The written description of both tonifying and dispersing techniques, states that the needles are kept in for a period of what was translated as “long time”. Long-time, is one of the meanings of the radical 久, Jiu. Yet, another meaning could be: "a defined period of time”. The choice of translation for Chinese Radical in ancient texts is a fairly complicated task. The final result in choosing a translation depends, after all, on the translator’s understanding and his choice. Therefore, when reading different translations of the same chapter, we may find sometimes significant differences between them. There are many articles that deal with the difficulty to translate ancient Chinese texts.
The above mentioned quote states that in the case of dispersing, the goal is to expel the pathogen without causing its distribution in the body, while in the case of tonifying, the goal is to wait for the pure Qi to arrive. Waiting patiently, letting the time pass by unnoticed. but for how long? It is not stated, since there is no defined time. Timing is what counts - taking the needle out at the right time. So, this quote shed some light on solving the mystery regarding the duration of needle insertion.
Ling Shu Chapter 40 teaches us that the Qi in the Yang Meridians is “murky” whereas the Qi in the Yin meridians is “pure”. Therefore: “the Yin meridians should be needled deep and for a “longer” period of time, 故刺陰者，深而留之,
And the Yang meridians should be needled superficially and for a shorter period of time, 刺陽者， 淺而疾之.
We can see now a reference regarding the duration of needle insertion. Since there is an energetic difference between the Yin and Yang meridians, the duration of time for needling them is different. However, we are not told what is that duration of time.
The first chapter of the Ling Shu emphasizes the importance of achieving the Qi: “If the treatment failed to achieve the Qi, treatment should continue as long as needed, 刺之而氣不至， 無問其數.
Once Qi arrives, needles should be pulled out and acupuncture should be ceased,
刺之而氣至， 乃去之， 勿復針”.
Now it becomes clearer. The duration of the needle insertion is not defined. What defines the duration of acupuncture is the “arrival of Qi”, 氣 至.
What is the meaning of “the arrival of Qi”?
Well, it depends whether we used a dispersing technique or a tonification technique.
If we choose dispersing, we wait for the pathogen Qi (邪 氣) to arrive,
Whereas if we choose tonification, we wait for the true Qi (真 氣) to arrive.
How would we know that the Qi arrived?
This subject too is open for debate. Most of the time, we talk about a sensation that the patient sense around the needled area, as well as a sense of “resistance” of the needle against the skin, that the practitioner senses. Some claim that it is about sensing the difference in the pulse.
A similar idea is expressed in Ling Shu Chapter 3: “(The idea that when) the Qi arrives (then the needle) is taken out means, 氣至而去之者,
That the dispersing or tonification technique should be continued until the Qi is well regulated, 言補瀉氣調而去之也.
In my investigation, I found one classical source which provides a defined time for acupuncture. I refer to the important book called: Zhen Jiu Jia Yi Jing, which was written by Huang Fu-mi around 260 A.D.
Zhen Jiu Jia Yi Jing contains many paragraphs which gives us important information regarding acupuncture points. The source for these paragraphs is a book which was lost, named: Zhen Jiu Ming Tang Zhi Yao.
The third tome of the book Zhen Jiu Jia Yi Jing provides the basic information for all acupuncture points: their names, their location, which meridian they belong to, what other meridians are crossing through it, what depth it should be punctured, how many Moxa cones should be burn on it, and how long to leave the needle in it. The time defined to leaving the needle in is given to almost all acupuncture points, and it varies. The “time” is measured by exhalations. For most points the time range is between three to seven exhalations! This of course is a much shorter time than twenty-one minutes.
Following are a number of examples:
“Upper Star” (Shang Xing) GV-23
“There is one acupuncture point called “Upper Star”, 上星一穴, (GV23),
Located on the skull, just above the nose, on the median line,
One Cun posterior to the hair-line, in the pea -size depression,
(This point) belongs to the Qi of the Du-Mai, 督脈氣所發,
(it is ) punctured three Fen depth, 刺入三分,
for the duration of six exhalations, 留六呼.
Should be treated with five Moxa cones, 灸五壯”.
Joining of the Valleys (He Gu) L.I. -4 called also “Tiger’s Mouth”
“joining of the Valleys (L.I.-4) is also called “Tiger’s Mouth”, 合谷， 一名虎口…
(this is a point) of “streaming out” on the “Large Intestine” meridians, and therefore, a Yuan (point), 手陽明脈之所過也,為原.
Punctured three Fen depth and stays in for the duration of six inhalations,
Moxa: three cones, 刺入三分, 留六呼, 灸 三 壯”.
Three Yin Crossing ( San Yin Jiao) SP-6
“Three Yin Crossing (SP-6), 三陰交,
A crossing point of Spleen, Liver and Kidney meridians, 足太陰厥陰少陰之會.
Punctured three Fen depths, needle stays in for seven exhalations, Moxa: three cones,
刺入三分, 留七呼, 灸三壯”.
Summary from the citations:
No mentioning, not even a hint on leaving the needles in for a duration of twenty-one minutes. We saw only two possibilities that points to the right moment of taking the needles out:
- Arrival of Qi - 氣至
- A defined number of exhalations for most acupuncture points.
THE MAIN CAUSES WHICH INFLUENCE THE TIME OF QI ARIVAL
Quality of the patient’s Qi
This quality has to do with the patient’s age, his or her constitution and Life Style:
Age: in the case of children, their Qi is more dynamic, and therefore will arrive sooner.
In the case of the Elderly, the base of Yin is tending to be weaker. Leaving the needles in for a long period of time may weaken them.
Constitution: Stem, Branch and Division that were present at the time of their birth (year, month, day, hour) influence the energetic structure of a person. The energetic structure of a person has an influence on the speed of Qi arrival.
Life Style: Especially living environment and nutrition. Both factors have an influence on the quality of Qi of a person, as well as on the speed of its arrival.
“Quality of time during the treatment”:
Time is the Qi quality as an expression of the Five Elements, Yin and Yang. The most precise expression of time as a quality of Qi, is given by the Stems and Branches Cycles which are built from sixty stages that exists on the level of the year, the month, the day and the hour. In order to understand the idea that Time is a quality of Qi, we need not be scholars of the “Stems and Branches” school. It is sufficient to learn the second Chapter of the Su Wen, where we learn that each season (period of time) represents a basic quality of Qi.
As I have been practicing in my Clinic, I have noticed that there are years in which the Qi (as it is expressed by the pulse) is changing quickly (during the years where the Stem is Yang). Same goes for the days. Some days everything happens so quickly, while others all happens slowly. This too can be explained by the quality of Qi, as it is expressed in the “Stems and Branches” “language”.
“Quality of the pathogen”:
Yin pathogens such as: damp and cold (Internal and External), Internal Pathogen such as Emotions, and pathogens which are present in the body for a long period of time, all are “heavier”, therefore demands leaving the needles in for a longer period of time.
A discussion regarding the duration of time of leaving the needles in can be found in the modern book: "Acupuncture and Moxibustion” as well. It is mentioned in this book that the question weather to leave the needles in or take them out immediately after being manipulated, has always been debatable. The writers of this book state their opinion saying that the needles should be taken out immediately after achieving the Qi and performing the correct manipulation (disperse or tonify) on the needle. Furthermore, it has been stated that the longer the needles remain inserted, the greater the dispersing affect. Finally, it has been suggested in the book that the decision whether to leave the needles in for a while or take them out immediately depends on the patient and on the illness. For example: in the treatment of children, or in the treatment of acute cases, the needles should not be left in after the manipulation.
There is no definition which determines that the time period of leaving the needles in should be twenty one minutes. The duration of time the needles should stay in, is dynamic and changing, and depends on various causes. These causes will influence the time of Qi arrival. The signs that confirm the Qi arrival and the affect these signs create, can be observed both by the patient’s sensation, by the "friction" sensation of the needle against the skin, by the sensation of the pulse, as well as the look of the tongue, the look of the eyes and face, even the change in the tone of voice. Preceding this research, based on its conclusions, I personally stopped working with a watch in my clinic, I don't use a defined time period for leaving the needles in. Time could be a few second, a few moments, and sometimes half an hour, all according to the signs mentioned above. The results are satisfying and I am most content with my treatments. A number of my students as well as colleagues have changed their way of needling accordingly, and report feeling more content with their treatments as well.
I will be happy to receive your comments, based on your experience.
- B. Auteroche, G. Gervais, M. Auteroche, P. Navailh and E. Toui-Kan (1989) Acupuncture and Moxibustion – A Guide to Clinical Practice, Translated into English by Oran Kivity, Churchill Livingstone.
- Jing-Nuan, Wu (1993) Ling Shu or The Spiritual Pivot (translation), Asian Spirituality, Taoist Studies Series.
- Liansheng Wu, Nelson and Qi Wu, Andrew (1997) Yellow Emperor’s Canon Internal Medicine with Original Notes of Wang Bing (translation), China Science & Technology press.
- Lu, Henry C. (2004), Huang Di Nei Jing + Nan Jing: A Complete Translation of
the yellow Emperor's Classics of Internal Medicine and the Difficult Classic, International College of Traditional Chinese Medicine of Vancouver.
- Mathews, R.H. (1931) Mathews’ Chinese- English Dictionary, Revised American Edition, Harvard University press.
- Paul U. Unschuld (1989) Terminological problems encountered and experiences gained in the process of editing a commented Nan-ching Edition. Approaches to Traditional Chinese Medical Literature, Paul U. Unschuld (ed.).
- Rochat de la Vallee, Elizabeth (1989) Obstacles to translating Classical Chinese Medical Texts into Western Languages. Approaches to Traditional Chinese Medical Literature, Paul U. Unschuld (ed.), 67-76.
- Schuessler, Axel (2007) ABC Etymological Dictionary of Old Chinese, University of Hawai’i Press.
- U. Unschuld, Paul (1986) Nan-Ching, Classic of Difficult Issues (translation), University of California Press.
- Zhaoguo, Li (2005) Yellow Emperor’s Canon of Medicine Plain Conversation Vol. 1- 3 (translation), Library of Chinese Classsics.
- Van Nghi, Nguyen, Tran Viet Dzung, Recours-Nguyen, Christine (2005-2010) Huangdi neijing Ling Shu with commentary Vol. 1-3 (translation), Jung Tao Productions.
- Veith ,Ilza (1984) The Yellow Emperor’s Classic of Internal Medicine-(translatin), University Of California press.
- Williams Cart, Dutton Diane (2003) The Subtlety of the Image – The importance of Metaphor in Translating and Understanding Chinese Medicine Concepts. The European Journal of Oriental Medicine, 4:46-52.
- Yang Shou-zhong and Charles Chace (1994) Zhen Jiu Jia Yi Jing (The Systematic Classic of Acupuncture and Moxibustion, 262 AD) by Huang Fu Mi (translation), Blue Poppy press.
- A Chinese Internet Edition of the Su Wen:
Su Wen (http://www.chinapage.com/medicine/hw2.htm)
- A Chinese Internet Edition of the Ling Shu:
Ling Shu (http://www.chinapage.com/medicine/hw1.htm)
- A Chinese Internet Edition of the Nan Jing:
Nan Jing (http://www.chinapage.com/big5/science/njin.htm)
- A Chinese Internet Edition of the Zhen Jiu Jia Yi Jing:
Zhen Jiu Jia Yi Jing (http://www.theqi.com/cmed/oldbook/book45/index.html)
-  My basic studies took place in "Medicine"- The College for Chinese Medicine. 1995-2000. My continued education studies included: "Ten Celestial Stems and Twelve Earthly Branches” method with Adi Goldberg and Peter Van Kervel, and continued with CCTM studies with Peter Van Kervel and Chris Bankel.
-  The Nei Jing includes the Su Wen and the Ling Shu. Several translations were used simultaneously, see Bibliography.
-  See Bibliography
-  Partial list includes Adi Goldberg, Dr. Yair Maimon, Dr. Leon Hammer, Elizabeth Rochat de la Vallee, Peter Deadman, Heiner Fruehauf, Joan Duveen, and more.
-  Examples of articles that deal with difficulties in translations:
- Terminological problems encountered, and experiences gained in the process of editing a commented Nan-Ching Edition.
- Obstacles to translating Classical Chinese Medical Texts into Western Language.
- The Subtlety of the Image – The importance of Metaphor in Translating and Understanding Chinese Concepts.
-  See Bibliography
-  The knowledge of the "Ten Celestial Stems and Twelve Earthly Branches" method is an inseparable part of the Chinese Philosophy and Chinese Medicine, from the dawn of its conception. Almost all of ancient Chinese texts, weather medical or non-medical, refer to "Stems and Branches" in the same breath with terms such as "five Elements", "Yin & Yang". An example from the Literature: A book from the time of the Han dynasty called: Hai Nan Zi, or in the Medical Literature such as the Nei Jing, especially chapters 22 and 66-73 of the Su Wen, in Pi Wei Lun, and many others.
-  According to "Stems and Branches" theory.
-  When studying chapters 22, 66-73 of the Su Wen, that deal with the concept of "Stems and Branches", one can learn that the quality of Qi of the year and of the day, is tied to the Celestial stems, whereas the quality of Qi of the month as well as of the two hours' time periods, is tied to the Earthly Branches.
-  See Bibliography.
-  I would like to emphasize that this conclusion is based on what I have learned from my research so far, and request to be most careful with this conclusion, as I honor and respect all practitioners and teachers who choose to leave the needles in for the duration of twenty-one minutes. In spite of the comprehensive research I have conducted, I am aware that the possibility that I will be exposed to further information not known to me, exists, which may lead me to draw a different conclusion in the future.
Avihai Wolczak is a practitioner and teacher of Ancient Chinese Medicine, researcher, student and teacher of the ancient Chinese texts. He teaches the course "Golden Gate" in Tel Aviv, Israel.
Translated from Hebrew by: Michal Gilo, M.Ac.
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