JOURNAL OF CHINESE MEDICINE NUMBER 50 JANUARY 1996

GUA SHA AS COUNTERACTION

The Crisis is the Cure

Arya Nielsen
I wish I could make a petechial fever; that is, I wish I could produce upon the skin that state of counteraction existing when petechial spots are formed. (Boerhave, Dutch physician 1668-1738) What is Gua Sha? Gua means to scrape or scratch. Sha is a reddish, elevated, millet-like skin rash14. Gua Sha is a technique that intentionally raises sha rash or petechiae. Sha is the term used to describe stuck surface blood before or after it is raised as petechiae. See figures 1 and 2. When is Gua Sha used? Gua Sha is applied for pain when external factors such as wind or cold have obstructed the blood in the surface tissues. When normal finger pressure on a patients skin causes blanching that is slow to fade,
Fig. 2: Gua Sha at neck and shoulder for pain subsequent to whiplash injury.

Fig. 2 Fig. 2

Fig. 1 Fig. 1

sha is present. See figures 3 and 4. Gua Sha is applied as treatment and prevention for common cold, 'flu, bronchitis and asthma, as well as chronic disorders involving congestion of qi and blood. Where is Gua Sha applied? Sha is raised primarily at the yang surface of the body: the back, neck, shoulders, buttocks, and limbs. On occasion, Gua Sha is applied at the chest and abdomen. How is Gua Sha applied? The area where Gua Sha is to be applied is lubricated with oil. I use Vicks Vapo-rub because my patients are familiar with its smell and are comforted by it, although a thick oil such as peanut oil was traditionally used. The skin is pressured in downward strokes by a round-edged instrument such as a coin, spoon, metal jar lid etc. (see figure 5). Strokes are continued along one area until the petechiae that surface are completely raised. If there is no sha, petechiae will not form and the skin will only turn pink.

Fig. 1: Gua Sha at left shoulder and upper back for pain due to trauma.

What does the type of sha indicate? The colour of the sha is both diagnostic and prognostic. Very light coloured sha can indicate deficiency of blood.

JOURNAL OF CHINESE MEDICINE NUMBER 50 JANUARY 1996

Fig. 3 Fig. 3

congesting surface tissues and muscles and promotes normal circulation and metabolic processes. It is a valuable treatment for both external and internal pain, and facilitates the resolution of both acute and chronic disorders. I have practised Chinese medicine for nearly twenty years. Next to needles, Gua Sha has been the most valuable technique that I know. The results of Gua Sha are visible and the relief it provides for patients immediate. For some disorders it is all that is needed; for others, it opens the way to a deeper process of healing. Why then has Gua Sha been slighted by practitioners in the West? Why do our schools venerate acupuncture and herbal therapy while de-emphasising techniques integral to the tradition of Chinese medicine like Gua Sha, cupping, bloodletting, moxibustion, plum blossom needling and so on? I believe the answer lies in our own history, and modern Western cultural values that cast shadow status on some therapeutic methods and light on others. The truth is that techniques like Gua Sha, and the humoural theory that drives them, are not new to the West. When the Western humoural perception of the body gave way to micro-analysis advanced by technology, therapies like Gua Sha were rejected. It is my hope that they can be revived, to be used when clinically appropriate. In this article I will examine the counteractive techniques of early Western medicine, the humoural theory that informed them, and their decline in the West. Lastly, I will consider in more detail the clinical relevance of Gua Sha to modern practice.

Fig. 3: Palpating painful areas for sha; the practitioner presses her fingers onto the flesh.

Fig. 4 Fig. 4

Fig. 4: Sha is indicated when finger pressure causes blanching that is distinct and disappears slowly.

Fig. 5 Fig. 5

PART ONE: CHINESE MEDICINE AND EARLY WESTERN MEDICINE

As I was doing research for my book on Gua Sha , I was surprised to find many of the techniques used in Chinese medicine were a part of early Western medicine. Known as Hippocratic or counteractive, early Western medicine has a language and intent strikingly similar to the theories of Chinese medicine. Hippocratic medicine held that sickness resulted when a body humour became impure, out of place or out of balance. Dietary or behavioural indiscretions as well as exposure to the elements led to illness 1. Restorative treatment aimed at removing or diminishing the excess offending humour by manipulation, purging, bleeding or blistering, or by inducing vomiting, urination, salivation, or sweating. A deficient humour was restored by manipulation, diet, and herbs or drugs2. Drugs, herbs, food and behaviour were classified according to their warm, cold, moist, or dry qualities. For example, pepper was a heating herb that countered cold. Cucumber was a cooling herb that countered heat. Speaking in terms of excess and deficiency, and applying principles of hot and cold, counteractive medicine

Fig. 5: Gua Sha is applied with a round-edged tool. In China this may be a soup spoon, or slice of water buffalo horn specifically made for this purpose. The slice in the foreground has an indentation for finger joints. A simple metal lid with a rounded lip is the most comfortable tool I have found.

If the sha is fresh red, it is of recent penetration. If the sha is purple or black, the blood stasis is long-standing. If brown, the blood may be dry. Dark red sha can indicate heat. The sha petechiae should fade in 2-3 days. If it is slower to fade, the patient has poor blood circulation. What are the benefits of Gua Sha? Gua Sha moves stuck qi and blood, releases the exterior mimicking sweating, moves fluids and metabolic waste

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used discutient3 touch to scatter and disperse pathologic accumulation and revive a balanced circulation of humours.

Theory of Counteraction
It was a maxim of early Western medicine dating to the Hippocratic corpus that "no two diseased actions, affecting the general constitution, can go on at the same time, for any considerable period in the same system4". A patients asthma subsided with an attack of gout or was relieved by a discharge of blood from piles. A childs seizures stopped when an accidental poker burn caused a small infection on his lower leg. It was thought the new disease action created a crisis that counteracted the original disease5. Hippocratic method recorded these crises, surmising that artificial crises could be created as intervention, hastening resolution. In fact, the definition of allopathy springs from this approach: "Allopathy is a therapeutic system in which a disease is treated by producing a second condition that is incompatible with or antagonistic to the first6". For example, observing that fever resolves in sweating, inducing sweat might cure a fever7. Natural critical haemorrhages preceding the crisis stage in acute disease were thought to have fostered bloodletting as counteraction. Bloodletting was practised by every ancient culture to prevent or reduce pathologic accumulation described as heat, residue, malevolent spirit or just bad blood. In the West, bloodletting became venesection; patients were bled until they fainted8. In the East, blood was let by drops until its colour changed from dark to light. Sites were bled according to channel theory, time of day, month, and year. Tracing the chronology and language of the Su Wen, Epler argues convincingly that acupuncture descends from bloodletting9. Hippocratic medicine never developed a procedure like acupuncture but utilised cupping, cautery, setons and issues10, poultices, and so on. The Western counteractive analogue to Gua Sha was called frictioning. The indications for frictioning share a similar history to Gua Sha.

A seton is the early Western medicine counteractive technique closest to acupuncture. Here the skin was pinched at the back of the head and a fibre or hair was threaded into the flesh. The subsequent surface infection, though mild, counteracted a deeper infection, in this case of the eye.

cases of cholera. In the West cholera was described as congestion of blood and internal heat at the pit of the stomach with excessive coldness at the surface: " ... excite counteraction at the surface. We relieve the internal congestion. Warmth is the counteragent13". Classical Chinese medicine describes cholera as disease from evil water with exterior cold and interior damp. The character for sha is sometimes translated as cholera14, or loosely sickness from discharge of water15.

Gua Sha and Frictioning

Frictioning applies rough pressure to chafe, stress or irritate the surface, counterirritating and counteracting a deeper condition. Kaim describes The part vexed by friction begins to be red, to swell, to be warm11 Broussais (1772-1838), surgeon to the French army explains: The theory of disease took irritation to be at the bottom of every morbid condition, and held that this irritation always resulted in an increased flow of blood to the part. This was inflammation, and the seemingly reasonable way to act in such a case was, if possible, prevent that flow of blood and that Inflammation. An External irritant would serve this purpose. It would determine the flow of blood outwards and away from the diseased direction in which it might be going. It would stop the inflammation. This is called counterirritant12. Frictioning in the West and Gua Sha in Asia were applied in
Sha or cholera

+
Chi to lie on a bed Sick/Sickness Sha Sediment, gravel or sand deposed by water, or sandlike rash from severe dehydration

Cholera is characterised by diarrhoea, vomiting, cramps, suppression of urine, and collapse. It quickly dehydrates its victims. An end stage of choleric dehydration is rashlike petechiae and ecchymosis from ruptured blood vessels at the surface (italics mine)16. As seen in figures 1 and 2, application of Gua Sha results in the surfacing of sha petechiae that can range in colour from red to dark purple. The petechial or ecchymotic stage of cholera is naturally occurring sha. By raising the petechiae, Gua Sha counteracts the action of cholera; it artificially induces the crisis that is the cure.

JOURNAL OF CHINESE MEDICINE NUMBER 50 JANUARY 1996

Into the Shadows

Counteractive therapies of early Western medicine were abandoned over time. As the West industrialised, it developed a micro-analysis of disease. Humoural theory was replaced with the view that inflammation was caused by micro-organisms that could not be rubbed away or flushed by letting blood17. With some exception, the West focused on smaller and smaller body units, refining an attack the pathogen approach to cure, and a win lose military model of immunity. The East continued to view health and disease as a play of natural forces; yin and yang, hot and cold, excess and deficiency, operating within and without. Chinese medicine included the attack the pathogen approach, but emphasised supporting the bodys natural resistance. The Eastern disease model included metaphors of war, but also of peace in abiding observable laws of nature. On the positive side, modern science dashed the religious and superstitious bias that saw illness as a cause for reproach. On the downside, technology separated mind from body, patient from context and distanced the physician from the patient. The patient became a passive recipient and rarely an agent to his or her own condition. The humoural approach, which tends to view the patient as a whole in a larger context, came to be viewed as unsophisticated and unscientific. The therapeutic techniques, even when useful, were discouraged as archaic. It is no coincidence that many physical therapy departments are housed in hospital basements. There is a modern expectation, held even by acupuncturists that science, medicine, even acupuncture or herbs can intervene and cure. And when a cure is obtainable, who would not want it? However, "In many cases, medical science prevents the patient from dying, without restoring him to health. It is thus a primary cause of chronic illness18." Chinese medicine practised with its traditional perceptions, techniques and recommendations, can restore many patients to health. It is up to acupuncturists to utilise all of Chinese medicine even in a cultural setting that has abandoned much of its own hands-on interventions and humoural outlook.

There are three significant points to this definition. The first is the notion, shared by early Western medicine, that disease can be caused by exposure to the elements or climatic factors.

1. Climatic elements act in the body like they act outside

If a climatic element is able to penetrate the bodys resistance, it is the character or nature of the element that invades the body. The inner qi is disturbed in a manner characteristic of that factor. Cold Penetration by cold causes the body to contract, slowing things down just like a stream freezing over. Just as cold causes the water in rivers to freeze so it is said to cause the blood in the vessels to congeal20. Cold inhibits circulation causing stagnation and hence pain characterised by chilliness, contraction, cramps and spasms. Damp Penetration by dampness gives rise to wetness and sluggishness, which may collect as oedema or pour down as diarrhoea or discharge. Pain due to dampness is characterised by a steady heavy aching that is fixed in location. Dryness Dryness deprives the body of moisture, injuring all functions dependent upon fluid. Fluids conduct body nourishment and elimination, and even facilitate movement itself. Fever, fluid loss or inability to drink create internal dryness that can be life threatening. External dryness injures the skin and the Lungs first, causing dry skin, dry cough, and thirst. As dryness persists, its effects deepen in the body causing dry stool, dark infrequent urine, fatigue, and stiffness. Dryness as yin deficiency can also lead to internal wind that appears as dizziness or spasms. Heat Heat causes things to stir and agitate. Heat raises body temperature systemically or locally, and dries fluids. Pain due to heat is characterised by a subjective sensation of heat and irritability. Hippocrates understood fever to arise from excessive internal motion. He believed frictioning could augment the vital force and excite a warm fever in even the most frigid dropsical person21 . Wind Wind moves. It can blow through openings carrying other factors into the body. External wind affects the skin, head, throat, and Lungs first. Wind can advance itself as well as other factors inward, to the body interior. Wind acts internally in the same way it acts externally. Pain due to wind can be of sudden onset and tends to move around or shoot. Wind pain can cause rigidity like a tree strained against a steady gale. The common effect of the penetrating nature of cold, damp, wind, and sometimes heat is blockage to the meridians or channels. This is the second significant point of the sha syndrome definition. External factors obstruct the surface qi.

PART TWO: OUT OF THE SHADOWS

The Clinical Use of Gua Sha in the Context of Chinese Medicine
Gua Sha is effective for any condition that involves pain. It is practised throughout Asia as popular medicine, not limited to the professional sector. Acupuncturists generally use Gua Sha after acupuncture needling, but it can be used outside of acupuncture practice. Modern TCM describes Gua Sha as treatment for sha syndrome: A disease caused by the exposure of wind, cold, summerheat or wetness evil in summer or autumn leading to blockage to meridians; manifested as chilliness, fever, distension and pain of the body, or vomiting and diarrhoea, or rigidity and numbness of extremities19 .

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2. Pain means obstruction: consider Gua Sha

The ceaseless flow of qi is a body concept analogous to the ceaseless flow of water in nature. Obstruction causes problems reflected by the maxim: Bu tong ze tong, tong ze bu tong which means no free flow, pain; free flow, no pain. Pain means obstruction; intervention is aimed at freeing the flow. When the pain is at the surface, in the muscles, it can indicate obstruction by external factors or climates, as described above. If only the qi is obstructed, massage will disperse the pain. If the blood becomes obstructed, massage will not resolve it. Obstructed surface blood, sha, can be verified by palpation. When finger pressure causes blanching that is distinct and disappears slowly, there is sha (see Figures 3 and 4). Intervention is aimed at freeing the flow by releasing the exterior, and by removing stagnant blood. I palpate every patient I see for the presence of sha.

may be deficient. If the sha itself clears slowly, the circulation is poor, reflecting a deficiency in qi or yang. Hence Gua Sha is relevant to almost any presenting disorder. Decongesting blood at the surface moves blood internally, promotes blood production and improves dissemination of fluids throughout the body. The following cases illustrate that Gua Sha is able to counteract long standing problems deep to the surface and hasten resolution.

Cases
1. Male, 55 Presenting Complaint This patient complained of a lifetime chronic infection in the right ear subsequent to a punctured ear drum as a child. He has earaches and drainage, some headaches at the back of the head, sinus drainage and a peculiar taste in the mouth. Tongue: red with thick white coating, dry and sticky. Pulse: 64, clear*, even but for a moving Lung pulse. Other signs and symptoms His appetite and stools are normal. Urination is normal with some night-time urination. His sleep is good. He has a history of back problems and occasional haemorrhoids. He has 2 martinis each evening. He works outside most of the day. Treatment Back: Dazhui DU-14, Tianyou SJ-16, Fengchi GB-20, Jianjing GB-21, Gua Sha right neck, shoulder and upper back. Front: Zhongzhu SJ-3, Tianyou SJ-16, Yifeng SJ-17, Ermen SJ-21, Tinghui GB-2, Tinggong SI-19 all right side. Indirect moxa around ear, (at the third session left Quchi L.I.-11 and Hegu L.I.-4 were added), Gua Sha in front of ear, along right sternocleidomastoid and scalenes. Course of treatment: 9 sessions, 8 of them one week apart, with the ninth 5 weeks later. Recommendations: Avoid cold and sour foods and drinks, keep the ear covered and warm, even to the point of wearing a light hat indoors. Results: The day after the first treatment he had a rush of brown and red fluid from the right ear which abated. The ear was less sensitive and hearing improved. By the third session he had some pain in the ear with clear fluid draining. By the fourth the fluid was once again brown, bad smelling and his ear really hurt. By the fifth treatment the ear stopped draining completely for the first time, but remained sensitive to cold and noise. By the sixth session he had no pain or draining, and his hearing was much improved. His neck was now feeling warm. The last three sessions treated his back, haemorrhoids and his ears secondarily. During this time he had one more episode of clear fluid from the ear. He presented five years later for a hand injury. His ear remained completely healed.
*This is a pulse quality taught by Dr. James So meaning a pulse that has clear edges and is firm but not wiry.

3. Gua Sha releases the Exterior

Gua Sha not only treats pain but treats and prevents acute illness by releasing the exterior. Gua Sha extravasates stagnant fluid and blood, mimicking sweat. This stabilises the pores and halts further penetration of wind, cold, and damp. The pathogenic factor is said to be weakened, allowing the bodys wei, or anti-pathogenic qi, to resolve the acute illness. If already sick the patient may get sicker for a day and then recover rather quickly. Release of the exterior promotes a speedy resolution and rebound to health. Gua Sha prevents protraction of illness to chronic unresolved syndromes like chronic fatigue, cough, sinusitis, diarrhoea, and so on. When you come in the house, close the door. Aside from acute pain, acupuncturists are most often asked to treat chronic disorders. The Jinkui yaolue fanglun warns that treatment directed toward the interior can drive external factors deeper into the body, making a patient sicker22. This is reflected in the maxim Xian biao hou li: first treat the exterior, then the interior. Treatment of a chronic condition is postponed until any acute illness is resolved. Palpating for sha can help elucidate whether there are in fact external pathogens present and help the practitioner avoid deepening them when they have not yet expressed as an acute illness. The surface becomes stabilised, the door to the outside is closed, the patients interior chronic condition can be safely treated.

Gua Sha resolves stagnation of blood at the surface

Sha petechiae verify stagnation of blood at the surface. If there were no stagnation of blood, Gua Sha or any other surface frictioning would only be rubifacient, causing a pink blush. Practitioners can diagnose and prognose by the colour and nature of sha, and by how fast it disappears. The darker the sha, the older the blood stasis. If the sha surfaces quickly, it is a more recent penetration. If the sha is pale, the blood

JOURNAL OF CHINESE MEDICINE NUMBER 50 JANUARY 1996

2. Male, 36 Presenting Complaint: Patient complained of sharp epigastric pain, more pronounced after eating, with a dislike of touch or pressure. He had been medically diagnosed as suffering from a stomach ulcer, and had refused medication. Tongue: red with a crack in the stomach region; yellow greasy coating thicker in the central stomach region. Pulse: wiry and full, especially at both middle jiao positions. Other signs and symptoms The patient works as a contractor; his job involves physical and mental stress. Treatment Back: Feishu BL-13, Ganshu BL-18, Weishu BL-21; Gua Sha middle back. Front: Zusanli ST-36, Neiguan P-6, Zhongwan REN-12, Liangmen ST-21, ahshi on the left side, lateral to Jianli REN-11. Recommendations: Avoid overheating foods: spicy, greasy and roasted. Avoid alcohol and coffee. Course of treatment: 6 sessions. Results: This patient experienced steady improvement over the 6 sessions and his symptoms resolved completely. There has been no recurrence in the ten years since. 3. Female, 33 Presenting Complaint Patient feels very cold, has knee pain and swelling, and mild low back pain. Tongue: flat, pale pink, slightly pinker at the tip; coating at the rear of the tongue is slightly yellow. Pulse: slow, overall weak with middle jiao showing more strength. Treatment Back: Kunlun BL-60, Weizhong BL-40, Dachangshu BL-25, Shenshu BL-23, ahshi (lateral gluteus medius trigger point for knee). Gua Sha whole back and lateral gluteus medius. Front: Zusanli ST-36, Xuehai SP-10, ST-34, Xiyan (Extra), medial Wing of Knee (Extra)*. Course of treatment: 2 sessions 8 days apart. Results: After the first session she felt warm all over. Her knees were no longer swollen or painful, but weak. 4 months later she asked to be treated again for knee weakness. She reported that the sensation of warmth had remained. It is satisfying for practitioners to be able to deepen their reach into the body and quicken the process of healing. The Hippocratic physician Boerhave had a vision, a sense of what petechial counteraction could do. The answer to his prayer is Gua Sha and next to needles, it is the most valuable technique I know. Practitioners or patients interested in learning exactly how and when to use Gua Sha can refer to the book below.

References
The Apothecary in Eighteenth-Century Williamsburg, Williamsburg Craft Series, pub. Colonial Williamsburg MCMLXX. 1987 Jinkui yaolue fanglun, Synopsis of the Golden Chamber, New World Press, Beijing, first published c.AD 220. 1988 Chinese-English Dictionary of Traditional Chinese Medicine, Ou Ming (ed), Guandong Science and Technology Publishing House, Hong Kong. 1988 Chinese-English Dictionary of Traditional Chinese Medicine, Joint Publishing, Hong Kong. Brockbank, W. 1954 Ancient Therapeutic Arts, In: Fitzpatrick Lectures, Royal College of Physicians, William Heineman Medical Books, London. Castiglione, A. 1941 A History of Medicine, Krumbhaar E B (trans. and ed.) Knopf, New York. Epler, D.C .1980 Bloodletting in Early Chinese Medicine and its Relation to the Origin of Acupuncture, Bulletin of the History of Medicine 54:337-367. Epps, J. Counteraction, Viewed as a Means of Cure with Remarks of the Use of the Issue, Renshaw and Rush, London 1832. Gilles, C .1895 The Theory and Practice of Counter Irritation, Macmillan and Company, London . Jackson, H. 1806 On Efficacy of Certain External Applications, Inaugural Dissertation printed in Medical Theses, University of Pennsylvania, TW Bradford, Philadelphia. Kaim, S. 1756 Dissertatio Inauguralis Medica de Frictionibus, Kaliwodian Press, University of Vienna. translated for Arya Nielsen by Chipok R 1994. Kluger, M. 1978 The History of Bloodletting, Natural History Vol 87 No11 p78-83. Mathews, R.H. 1931 Mathews Chinese-English Dictionary, A Chinese-English dictionary compiled for the China inland mission and Presbyterian Mission Press, Harvard University Press, Cambridge MA. McNeill, W. 1989 Plagues and Peoples, Anchor Press New York. Nielsen, A. 1995 Gua Sha, A Traditional Technique for Modern Practice, Churchill Livingstone Edinburgh. OConnor, J., Bensky, D. 1981 Acupuncture, a Comprehensive Text, Eastland Press Seattle. Porket, M., Ullman, C. 1982 Chinese Medicine as a Scientific System: its History, Philosophy, and Practice, and How it Fits with the Medicine of the West. Henry Holt, NY. Stedmans Medical Dictionary, 1987 Williams and Wilkins, Baltimore MD. Weiger, L. 1965 Chinese Characters: Their Origin, Etymology, History, Classification and Signification. A Thorough Study from Chinese Documents, Dover, New York first published 1915.

Notes
1. Castiglione, 1941, "Hippocrates ...On Airs, Waters and Places ... constitutes the first example known to us of a rational attempt by a man of genius to put the phenomena of the macrocosm and the microcosm in direct causal relations ... The first part of the book is a true work on climatology. It considers the diseases that occur in a given locality in relation to its climatic position and to the seasons. The second part treats of the difference between Europe and Asia and without doubt constitutes one of the most interesting books that classical antiquity has transmitted to us. It is the first attempt to put external causes in direct connection with the origin of diseases, but also with the constitution of man and with the ethnic characteristics of nations". Quoted in: 2. The Apothecary in Eighteenth-Century Williamsburg, Williamsburg Craft Series, publ: Colonial Williamsburg MCMLXX.

*An extra point used by Dr. James So.

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JOURNAL OF CHINESE MEDICINE NUMBER 50 JANUARY 1996

3. Stedmans 1987 Discutient: Scattering or Dispersing a Pathologic Accumulation, refers to early medicine's humoural view. 4. Epps 1832. 5. Ibid. 6. Stedmans 1987. 7. This approach has survived its humoural context. For example, until the mid 1970s malaria was used to treat syphilis, and is currently being researched as a treatment for AIDS. The body can also create its own antagonistic condition to a disease as seen in sickle cell trait as defense against malaria. 8. Kluger 1978. 9. Epler 1980. 10. Cautery is like direct moxibustion. Setons and Issues introduce a thread or piece of metal posterior to an infection. The thread or metal is left in place, causing a small surface infection which counters the deeper one. See Nielsen 1995, Brockbank 1954, and OConnor & Bensky 1981 (threading). 11. Kaim 1756. 12. Gilles 1985. 13. Jackson 1806. 14. Mathews 1931, The character for sha has several translations: reddish elevated millet-like skin rash, (Ou Ming 1988); Dr.So translated sha as sand or sharkskin. (So, lecture notes 1976). 15. Weiger 1965. 16. McNeil 1989. 17. Kluger, 1978. Bloodletting may be therapeutic in cases of infection from bacteria. Bacteria are dependent upon trace amounts of iron for growth. "At elevated temperatures, bacteria appear to be even more sensitive to reduced levels of iron". 18. Porkert 1982 quoting Dr. Arthur Jores. 19. Ou Ming 1988. 20. Epler 1980. 21. Kaim 1756. 22. Jinkue yaolue fanglun, 220 Clause 1-15. All illustrations and cases are taken from Gua Sha, A Traditional Technique for Modern Practice. The book gives details on how to use Gua Shain clinical practice, includes over 40 cases and gives classical point prescriptions used with Gua Shafor treatment of common disorders. The book can be purchased from Customer Services, Churchill Livingstone, Robert Stevenson House, 1-3 Baxter Place, Leith Walk, Edinburgh EH1 3AF, United Kingdom. Tel: within UK toll free: 0500 556 242, outside UK: 0131535-1022, Fax: 031-535-1022. The book can be ordered in the US through: Redwing Book Company, 44 Linden Street, Brookline MA 02146, Tel: 1-800-873-3946; or Churchill Livingstone, 650 Avenue of the Americas, New York, NY 10114, Tel: 1-800-5535426.

seasons. The second part treats of the difference between Europe and Asia and without doubt constitutes one of the most interesting books that classical antiquity has transmitted to us. It is the first attempt to put external causes in direct connection with the origin of diseases, but also with the constitution of man and with the ethnic characteristics of nations. quoted in
2 The Apothecary in Eighteenth-Century Williamsburg,

Williamsburg Craft Series, publ: Colonial Williamsburg MCMLXX 3 Stedmans 1987 Discutient: Scattering or dispersing a pathologic accumulation. refers to early medicines humoural view. 4 Epps 1832 5 Ibid 6 Stedmans 1987 7 This approach has survived its humoural context. For example, until the mid 1970s malaria was used to treat syphilis, and is currently being researched as a treatment for Aids. The body can also create its own antagonistic condition to a disease as seen in sickle cell trait as defense against malaria.
8 Kluger 1978 9 Epler 1980 10 Cautery is like direct moxibustion. Setons and Issues

Biography
Arya Nielsen is National Board Certified in Acupuncture and Chinese Herbal Medicine, a Fellow of the National Academy of Acupuncture and Oriental Medicine, and Chair of the New York State Board for Acupuncture. She has been in private practice for nearly 20 years and is a Senior Faculty member at the Tri-State Institute of Traditional Chinese Acupuncture in New York City.
1 irs, Waters and Places. ..constitutes the first example known

to us of a rational attempt by a man of genius to put the phenomena of the marcrocosm and the microcosm in direct

causal relations...The first part of the book is a true work on climatology. It considers the diseases that occur in a given locality in relation to its climatic position and to the

introduce a thread or piece of metal posterior to an infection. The thread or metal is left in place, causing a small surface infection which counters the deeper one. See Nielsen 1995, Brockbank 1954, and OConnor & Bensky 1981 (threading) 11 Kaim 1756 12 Gilles 1985 13 Jackson 1806 14 Mathews 1931, The character for sha has several translations. reddish elevated millet-like skin rash, (Ou Ming 1988). Dr.So translated sha as sand or sharkskin. (So, lecture notes 1976) 15 Weiger 1965 16 McNeil 1989 17 Kluger 1978 Bloodletting may be therapeutic in cases of infection from bacteria. Bacteria are dependent upon trace amounts of iron for growth. At elevated temperatures, bacteria appear to be even more sensitive to reduced levels of iron. 18 Porket 1982 quoting Dr. Arthur Jores 19 Ou Ming 1988 20 Epler 1980 21 Kaim 1756 22 Jinkue yaolue fanglun. 220 Clause 1-15

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