When President Xi Jinping visited WHO headquarters for the first time in Geneva in 2017 he brought along a bronze statue showing acupuncture marks on the body.

China has been promoting TCM on the world stage, both as away to burnish its global image and influence, and for a slice of a growing market internationally. In China, TCM is worth $130 billion. The country's 2016 "strategic plan" on the Development of Traditional Chinese Medicine supports the expansion of Chinese medicine overseas and advocates the use of Beijing's Belt and Road global economic initiative to promote TCM.

But WHO's move has left some scientists perplexed. The effectiveness of Chinese medicine is in most cases unproven, and only a few herbs have been tested systematically for toxicity or carcinogenicity in the same way Western medicines are in the United States and Europe, said Grollman.

In his research, Grollman looked at Aristolochia plants that have long been used for medical purposes and found they can cause cancer and kidney failure. "Empirical knowledge based on tradition should not be permitted to "trump" the scientific method in matters of public health," he wrote in 2016 in the journal EMBO.

David Colquhoun, a professor of pharmacology at University College London, said that the evidence that any form of traditional medicine works is "negligible."-"We've looked at acupuncture as its gained the most traction in the West," he said. Some studies have found a small effect but it's not clinically significant," he said. "There's endless evidence it makes no difference where you put needles. These imaginary meridians are baseless, he added.

Plus while most people assume that acupuncture is a system of medicine that has its origins in China, in 1991 evidence surfaced indicating it might even have a European or Eurasian origin (or has been spread more widely early on that previously accepted). In 1991 two German tourists, Helmut and Erika Simon, were hiking across an alpine glacier in the Otz valley near the border between Italy and Austria when they encountered a frozen corpse. At first, they assumed it was the body of a modem hiker, many of whom have lost their lives due to treacherous weather conditions. In fact, they had stumbled upon the remains of a 5,000-year-old man.

Otzi the Iceman, named after the valley in which he was found, became world famous because his body had been remarkably well pre­served by the intense cold, making him the oldest European mummified human by far. Scientists began examining Otzi, and soon a startling series of discoveries emerged. One of the more unexpected avenues of research was a series of tattoos that covered parts of his body. These tattoos consisted of lines and dots, as opposed to being pictorial, and seemed to form fifteen distinct groups with 80 per cent of the points corres­ponding to those used in acupuncture today.

Various acupuncture experts agreed that the majority of tattoos seemed to lie within 6mm of known acupuncture points, and that the remainder all lay close to other areas of special significance to acupuncture. Allowing for the distortion of Otzi's skin in the past 5,000 years, it was even possible that every single tattoo corresponded with an acupuncture point. Bahr came to the conclusion that the markings were made by an ancient healer in order to allow Otzi to treat himself by using the tattoos as a guide for apply­ing needles to the correct sites.

The majority of tattoo sites are exactly those that would be used by a modern acupuncturist to treat back pain, and the remainder can be linked to abdominal disorders. In a paper published in 1999 in the highly respected journal Lancet, F. Bahr, L. Dorfer, and S. Suwanda, presidents of the German, Austrian, and Swiss academies of acupuncture, wrote: 'From an acupuncturist's viewpoint, the combination of points selected represents a meaningful therapeutic regimen.' Not only do we have an apparent treatment regime, but we also have a diagnosis that fits the speculation, because radiological studies have shown that Otzi suffered from arthritis in the lumbar. region of his spine and we also know that there were numerous whip­worm eggs in his colon that would have caused him serious abdominal problems.

Why acupuncture is a placebo based on pre-scientific mysticism

Earliest Chinese evidence for the origins of acupuncture has been found in prehistoric burial tombs, where archaeologists have discovered fine stone tools apparently intended for needling. One line of speculation is that such tools were fashioned because of the ancient Chinese belief that all disease was caused by demons within the human body. It may have been thought that the insertion of needles into the body could kill or release such demons.

The first detailed, description of acupuncture then appeared in the Huangdi Seijing (known as The Yellow Emperor's Classic of Internal Medicine), a collection of writings dating from the second century BC. It presents the complex philosophy and practice of acupuncture in terms that would be largely familiar to any modem practitioner. Most importantly of all, Huangdi Neijing describes how Ch 'i, a vital energy or life force, flows through our body via channels known as meridians. Illnesses are due to imbalances or blockages in the flow of Ch'i, and the goal of acupuncture is to tap into the meridians at key points to rebalance or unblock the Ch'i.

Chinese medicine, however, emerged from a society that rejected human dissection. Unable to look inside the body, the Chinese developed a largely imaginary model of human anatomy that was based on the world around them. For example, the human body was supposed to have 365 distinct components, but only because there are 365 days in the year. Similarly, it seems likely that the belief in twelve meridians emerged as a parallel to the twelve great rivers of China. In short, the human body was interpreted as a microcosm of the universe, as opposed to understanding it in terms of its own reality.

The Ancient Greeks also had reservations about using corpses for medical research, but many notable physicians were prepared to break, with tradition in order to study the human body. For instance, in the third century Be, Herophilus of Alexandria explored the brain and its connection to the nervous system. He also identified the ovaries and the fallopian tubes, and was credited with disproving the bizarre and widely held view that the womb wandered around the female body.

In the case of Ch'i, a core principle in Chinese acupuncture, different schools have evolved over the centuries and developed their own interpretations of how Ch'i flows through the body. For instance, some acupuncturists work on the basis of fourteen main meridians carrying Ch'i, while the majority support the notion that the body contains only twelve main meridians. Similarly, different schools of acupuncture have included additional concepts, such as yin and yang, and interpreted them in different ways. While some schools divided yin and yang into three subcategories, others divided them into four.

The emergence of new models of the body (and disease) also stimulated interest in acupuncture. These new hypotheses were based on increasingly materialistic interpretations of humourism; they retained the assumption that the body was a system in a state of dynamic equilibrium, but anticipated and sought the physical substrates of that fluid system. Acupuncture's mysterious effects and mode of operation-taken in conjunction with its clear empirical success-raised questions to which experimentalists hoped their new models would provide answers. For example, could the Chinese and Japanese practice of treating certain conditions by performing acupuncture at sites far from the location of the pain be explained by the new imponderable fluid 'electricity'? If so, the ancient practice of therapeutic needling might point the way for a revolution in medicine. Such speculation placed acupuncture among the first therapies to be examined in terms of its electrical potential. Similarly, clinicians and experimentalists hoped that the strange power of the metal needles might finally, provide a diagnostic test of whether a patient's ailment sprang from 'a disorder of the nervous system' or from the somatic disease. This distinction had, of course, been made by earlier medical generations, but rose to prominence as a focus of medical interest in part because of increasing skepticism of patient self-reporting ('he [the patient] will seldom tell the truth, and perhaps never the whole truth', grumbled William Buchan in 1796.1). Berlioz himself pursued both of these interrogative strands, speculating that acupuncture 'acts by stimulating the nerves, or by restoring to them a principle of which they [were] deprived through the effects of the pain .... Very likely, the communication of galvanic shock produced by Volta's apparatus would increase the medical effects of acupuncture.2

As a vector for experimentation, and a site for testing broader medical hypotheses, acupuncture proved far more captivating to medical audiences than it had been as merely another exotic medical import. However, its origins were still too interesting to medical consumers (and too problematic for medical professionals) to be entirely erased. Berlioz responded to this dilemma by introducing acupuncture in terms of its exciting past, but simultaneously denying Chinese and Japanese physicians any intellectual credit for discovering or refining the technique:

The savage peoples living in the torrid and temperate zones were ... in the habit of marching almost nude when they went into combat. They [therefore] experienced the necessity of imprinting on their bodies some particular signs, which ... enabled them to identify "themselves. The operation which they practised to that end has been by chance done on injured parts, the resultant relief ensured its repetition in analogous circumstances. The need for signs graven on the skin having ceased with the progress of civilization, and the pricks seemingly procuring the cure only of a tiny number of maladies, the usage was lost in most nations. This remedy has been conserved only by the Chinese and the Japanese, their neighbors, where all the first institutions are sacred .... It is from these people that we take the method of acupuncture.3

As has often been the case when Europeans have borrowed medical or scientific expertise from non-western cultures, the Chinese were painted merely as chance discoverers and rote preservers of ancient knowledge, not its skillful creators. Berlioz and his cohort did not refer to or reproduce the Chinese body map; nor did they acknowledge or (publicly) experiment with its system of specific points.

In the absence of the perplexing body maps and explanatory notes so painfully translated by Ten Rhyne and Kaempfer, acupuncture was reintroduced to the western world by its Parisian exponents as a stand-alone technique. In other words, 'acupuncture' in this western incarnation ostensibly entailed no more and no less than puncturing the living body with a needle. While both lay and professional audiences continued to associate acupuncture with its Asian roots, these ties were ornamental. Acupuncture, as practiced in Paris, made no appeals to yin, yang, qi, or a system of channels and vessels linking the body's organs with its surface; nor did its supporters claim that acupuncture was a 'specific' for any particular diseases. Rather they pointed to its empirical success in individual cases, and in certain categories of complaint (particularly nervous and chronic pain). Framed in this way, acupuncture neither conflicted with nor challenged established understandings of the body and disease, even though it could not be fully integrated with them. Thus, although acupuncture's mechanism remained mysterious to western medicine-and indeed is unexplained in biomedical terms today-it was not dismissed as quackery. Even tentative analogies drawn between acupuncture and animal magnetism (another, more controversial 'imponderable fluid' of the day) did not drive the practice out of 'regular' hands (though proponents of the technique were active in disputing such explanations of its mode of action).

Although keen to explain the mechanism of acupuncture along with the most 'modem' and 'scientific' lines, and thus to protect it from the tarnish of quackery, exponents of acupuncture were even more eager to spread the practice. They took to the rapidly expanding medical press, producing both case studies of its therapeutic successes and (even more copiously) experimental reports. Both types of account circulated widely, aided by the then-common practice in European and American medical journals of reprinting 'digests' of each other's more prominent articles. Perhaps even more effective in spreading information about the 'new' technique were the enthusiastic accounts of foreign medical students in Paris. Such first-hand descriptions of near-miraculous cures engaged personally as well as social networks and helped to transmit the hands-on practice of acupuncture.

Investigations of the technique, particularly those driven by an interest in electricity and its biological effects, spread across Europe. Trials took place in England, Scotland, Germany, France, Italy, the Low Countries, and the United States, as well as in more remote locations. Monographs, too, played an important role in propagating acupuncture. For example, the practice of acupuncture by the English-speaking profession was profoundly influenced by a single book: A Treatise on Acupuncturation, published by James Morss Churchill in 1822. Churchill's book, like Berlioz's text before it, introduced the healing needle through a disquisition on its 'Oriental' origins. Again like Berlioz, Churchill took pains to distinguish the practice of acupuncture in Europe from its practice in China, and to emphasize his own initial skepticism of Chinese claims for the technique:

I should not have taken the tales which are told of the wonderful cures effected by this operation amongst the original founders of it, as sufficient authority for recommending it, nor would I admit the fables which are promulgated by these people, as evidence of its efficacy, had not this efficacy been witnessed by European spectators on its native soil, and at length experienced in our own hemisphere; and even latterly, in our own country.4

Although he later gently chided his medical predecessors for their reluctance to adopt or even thoroughly test acupuncture, Churchill initially blamed that too on the Chinese themselves: 'It is probable, that the hyperbole in which it has been related, has induced the sober minds of our Northern soil, to treat these relations as the fictions of the Eastern imagination, and to reject them without examination, as fables.'5 So that 'gay luxurious imagination' crops up again, but this time clearly marked as a liability, rather than a lesser virtue.

Fictional or not, by the second decade of the nineteenth century, the British, French, and American medical presses had succumbed to the forces of curiosity and rising interest, and began to report on acupuncture. For twenty years, studies of acupuncture, and cases of its success (and later of its failure) peppered medical periodicals. Physicians and surgeons in private and hospital practice alike experimented with the technique, and speculated on the cause of its curious effects. As the US-based commentator Dunglison noted in a compendium of 'new remedies' of the 1840s, '[a]lthough acupuncturation is really an ancient therapeutical agent, attention to it has been so much revived of late years, and its use has been so largely extended, that it may be looked upon as constituting one of the novelties of therapeutics':

M. Jules Cloquet had much to do with reviving its employment in his own country and elsewhere, by his treatise on the subject published at Paris, in 1826, where it was for a long period a fashionable article in the hospitals; so much so, it is affirmed, that attempts were even made to heal a fractured bone by it without the application of any appropriate apparatus! and at one time, it is said, the patients in one of the hospitals actually revolted against the piqueurs medecins.6

Laymen and -women too played a crucial role in increasing awareness of the technique and promoting its use by medical professionals. Patients were amazed by acupuncture's efficiency in relieving pain that had, in many cases, plagued them for years. Mr A. W., 'a corpulent man' afflicted with lumbago lower back pain and stiffness, such as that caused muscle strain or a slipped disc), was reported by his Fulham surgeon as 'expressing the greatest astonishment at what he termed the "magical effect of the needles"!!!' The same surgeon reported of another patient, a poor woman with 'six infant children' (and thus', unsurprisingly, a bad back):

Although perfectly freed from pain, it was enough to excite a smile to witness the woman's skepticism on the success of the operation; she could scarcely credit her senses, for when desired to turn on her back she obeyed with hesitation, and doubt, dreading lest she should encounter the 'pain' .... It was very gratifying to see the poor creature sit up; her countenance beamed with delight, equaled only by her astonishment and grateful thanks for the 'wonderful cure' I wrought her.7

Another patient, this time Churchill's own, wrote an account of his illness and cure, at his doctor's request. Sick with pain and weakness in his left hip, unable to walk any distance, and generally debilitated by 'a residence in a tropical climate, together with indulging too freely in excesses, which destroyed the digestive powers', C. Lindo of Margate sought Churchill's opinion on his case. Churchill regarded it as unsuitable for acupuncture, and Lindo instead 'visited the whole round of celebrated regulars, and irregulars', without success. 'As a forlorn hope, and at his earnest desire', Churchill agreed to try out the needles. Lindo concluded his account: '1 derived temporary relief from acupuncture, there is not the least doubt, and had I at the time, the advantage of country air, it is probable that a more beneficial result might have accrued ... ' .8 No miracle cure here, then, but after Lindo's unavailing round of treatments-including apparently, a caustic chemical rub that blistered him badly-his willingness to publicize a nearly painless, and at least temporarily beneficial, the remedy is hardly surprising. Indeed one of the features most marked and discussed acupuncture was that 'It would seem, that the operation is, as a general rule, most successful when it occasions the least pain.'9 The consumer appeal of this unusual attribute can be readily imagined ...

As had been the case for moxibustion (and as would be the case for homeopathy), socially prominent individuals played a crucial role in raising the visibility of acupuncture. In Britain, for example, one noble gout-sufferer-George O'Brien, Third Earl of Egremont, a noted patron of the racing world and member of the Prince-Regent's high-flying Brighton set-was cured of an excruciating, five-week bout of sciatica by acupuncture. In his relief, he paid the innovative surgeon a small fortune renamed his favorite racehorse 'Acupuncture', and promoted the technique enthusiastically amongst his high-flying circle. As his well-rewarded surgeon recalled, 'There are no bounds to his Lordship's gratitude and delight: he went. .. to Brighton, a distance of thirty miles, to make it known amongst the nobility and faculty there.'10 As with moxa in the eighteenth century, it was the existence of and interactions between lay and professional networks--local, national, and international-that facilitated the spread of acupuncture in the early and middle nineteenth century.

Another version of the Earl of Egremont's miraculous cure, told post-prandially in the clubrooms of a London medical society some five years later, offers additional evidence of acupuncture's specific attractions for both patients and medical professionals. A surgeon named Dendy recounted the tale with some considerable gusto. Rich in detail, his version differed from earlier accounts in several ways: first, he told his medical audience much more about the Earl's case-and especially about its intractability to orthodox cures. George O'Brien was clearly nothing if not determined; by the time he heard of acupuncture, he had endured every orthodox measure and several well-known quackish ones at the hands of 'every medical man of note in London'. They had availed him nothing: 'he retired to his seat at Petworth, in despair'. It was upon his arrival at Petworth that the central importance of both lay and professional networks in propagating acupuncture becomes evident.

A friend of mine [Martin], who resided in Sussex at that time, happened to get an early copy of Mr. Churchill's little work on acupuncture and tried the remedy therein advocated with perfect success on an old woman who was a protege of Lady Burrell, the daughter-in-law of the Earl. Her ladyship heard of the cure, and told the Earl what had been done; the result was, that the surgeon was sent for forthwith to try the new process on the peer.11

Martin, a surgeon, got his advanced copy because he and Churchill were acquainted in their student days at Guys and St Thomas's Hospitals. Sometimes, who you knew determined what you knew, and when. The Earl called Martin because of his daughter-in-Iaw's network of charitable patronage. And O'Brien, in turn, deployed his own elite social network in acupuncture's cause.

But Dendy's enthusiasm waned as he came to the close of his tale. He admitted that he had himself no very good news to tell of the technique: 'When first it was proposed, it certainly affected some singular cures, but, of late, success does not seem to have attended it ... As regards my own experience ... I have lately had three cases in which I have tried this remedy without advantage.12Neither Dendy nor his auditors offered any explanation of acupuncture's declining efficacy. Other contemporaries argued that the needle's early success had encouraged too many practitioners to use it as a panacea in unsuitable or indeed incurable cases. Certainly, by the 1840s, acupuncture was typically tried by doctors on precisely those patients whose ailments had proven particularly intransigent. No longer novel, nor sufficiently 'miraculous', acupuncture disappeared from the medical press almost as quickly as it had appeared.

The practice of acupuncture, however, continued. Dendy's story and the social setting within which it was told offer substantial clues to the mechanism of acupuncture's survival after its media heyday. Rarely in the spotlight of the medical periodicals, local groups like the London Medical Society offered a convivial space in which medical gentlemen could quietly exchange news and trade tips on the practice of medicine (as opposed to the often more contentious issues of theory). These societies were shaped both by traditions of gentlemanly amateurism and by the newer demands of competition and professionalization. In the nineteenth century, science and experiment remained largely the province of the amateur, and doctors were prominent participants in scientific and technical innovation and debate. Medical men pursued both as matters of interest and in pursuit of gains tangible and intangible. With increased training in the 'allied sciences' of medicine, doctors considered themselves uniquely well able to evaluate mesmerism, galvanism, new drugs, the use of the stethoscope, and myriad other medical innovations of indeterminate worth-including acupuncture-and gathered together to do so in precisely these settings. Thus, although periodicals were a crucial mechanism by which to propagate a new technique, they were far from the only one.

Churchill himself had initially learned of acupuncture not from reading the published French reports of it, but from another surgeon, Mr Scott of Westminster. Churchill's interest was aroused by privately communicated and subsequently directly witnessed successes with needling. Even before he published his Treatise on Acupuncturation, Churchill was part of a growing nexus of British practitioners interested in or using acupuncture. And he tapped into the power of such personal networks himself as he struggled both to popularize and to standardize acupuncture practice. Churchill actively sought out acupuncture success stories and collected cases in which his adopted technique had procured long-sought health. He was not alone in this Endeavour; at least one prominent patient insisted that his doctors not only learn the technique (as propounded by Churchill), but that they report their successes back to him for further distribution. Another valuable tool for fostering acupuncture's credibility and inculcating its practice was eye-witnessing. Just as Churchill had been converted to acupuncture by seeing it in action, so others were brought into the fold. The act of witnessing was a frequent point of contact and potential transmission, and one that also illuminates (changing) contemporary structures of authority and its propagation. At the beginning of the century and for some considerable period, Churchill and his successors regularly listed the names of socially prominent observers who were in attendance upon successfully cured acupuncture patients, implying that their presence added weight to the reported results.13 But this model of authority was in decline within medicine. By the mid-century, it was slowly being replaced by statistics and by large-scale clinical observation.

This proved a stumbling block for acupuncture's proponents. Most of the men who publicly supported acupuncture depended on their practices for both livelihood and 'clinical material' (patients). In a second volume, presenting case studies proving the efficacy of acupuncture, Churchill complained that he could not perform the experiments necessary to establish acupuncture's active principle because his small practice threw up insufficient numbers of appropriate cases.14 This dilemma only worsened as the century progressed and the single case study lost its primacy in the periodical literature. Acupuncture supporters found themselves reporting on individual cases even after the multiple case study had become the norm for testing the efficacy of a medical practice or innovation. But what could they do? They often saw little chance of another suitable case appearing in their practices. Reporting late in the  century on a solitary case in which acupuncture had relieved the pain of a man dying from cancer, one such practitioner prefaced his datum with the apologetic acknowledgment:

[O]ne case goes only a short way in establishing any method of alleviating or curing the pain of this formidable disease, but a long interval may pass before another presents itself in a small provincial town with a sparse surrounding population. Hence my reason for publishing a single case.15

As the balance in medicine tilted away from 'art' and toward 'science', the power of individual practitioners in private practice to significantly influence medical practice diminished. Often silent in the face of 'scientific medicine', such practitioners still had to satisfy their patients at the bedside, where doctors still struggled to establish themselves as the exclusive interpreters of the body. Day-to-day medicine remained a social art, and the laity, heterodox practitioners, midwives, and others still claimed the right to observe the body and pronounce upon it authoritatively. Patients demanded particular cures based on what they saw and acupuncture's near invisibility in the medical press limited lay awareness of the technique as well. Acupuncture's proponents may have regarded a blandly empirical westernization as more readily assimilable, but it was hardly attention-grabbing. Certainly, it lacked in drama, particularly as adversarial new systems like homeopathy emerged to offer formidable competition to merely orthodox alternatives, and controversy swept the medical and popular presses.

As an explicitly and vocally alternative medical system originating in a European context, homeopathy offers an excellent foil to acupuncture's non-European origins, and to its status as an apparently unthreatening stand-alone innovation. Moreover, where the history of acupuncture in Europe is cyclic and discontinuous, the history of homeopathy is continuous, illuminating the impact of changes in the institutions of biomedicine on medical systems which opposed it. So what can the history of homeopathy in the nineteenth century tell us about nineteenth-century responses to acupuncture?

First, it may be worthwhile to spell out the similarities between homeopathy and acupuncture as each emerged from the marketplace pluralism of the eighteenth century into the medical monopoly building of the nineteenth. Both homeopathy and acupuncture depended heavily-at least in theory-on subjective accounts of sensation and experience. Homeopathic doctors used their own experiences and sensations to 'prove' drugs. Homeopathic diagnosis relied heavily on patient self-reporting, and on the equally subjective accounts of the patient's friends and family. And certainly the mechanism by which homeopathic medicines produced their effects was mysterious: how could medicines compose almost entirely of water produce any effect on the sick body, much less a curative one? Neither was initially conceived as an 'alternative' in the sense in which we use the term today-as an either/or proposition. Acupuncture's proponents (like the advocates of mesmerism) wished to add new weapons to orthodoxy's armory in the battle against the disease, while homeopaths expected their system to gradually displace by expansion the inferior techniques of allopathy while absorbing its useful accumulated knowledge.

However, like orthodox medicine-or, as homeopathists rather polemically described it, 'allopathy'-homeopathy was and was understood to be, a fully elaborated system of medical thought. In other words, both lay and professional responses to homeopathy took into account its theory and its practices as well as its material culture (the drugs themselves). Moreover, as we saw, over the course of the nineteenth century, homeopathists developed their own professional journals, medical societies, research institutes, hospitals, medical schools, and even corporate pharmaceutical offshoots. Reactions to homeopathy from within the orthodox profession, although initially moderate and assimilative, rapidly became violently hostile (if still, surreptitiously, assimilative). And this hostility had a profound effect: rules like those of the AMA and BMA forbidding any consultation or cooperation between their members and 'homeopathists' and mandating the expulsion of any member caught 'dabbling' with homeopathy forced a unitary identity upon the wide range of healers who took up the system. Whatever their training, whatever the degree of their belief in Hahnemann's principles, all were equally 'homeopathists' in the eyes of their professional organizations. No such judgments or demands were made of regulars who chose to use acupuncture; one could easily take up the needle without taking up the title 'acupuncturist'-and indeed few if any even of acupuncture's most eloquent proponents would have defined themselves in terms of their use of the technique. Each of these differences played a crucial role in acupuncture's failure to thrive, or to challenge established medical models in the way that homeopathy did so successfully.

To render acupuncture assimilable by the 'regular' medical profession at the beginning of the nineteenth century, its proponents had relied on the pragmatism of the average practitioner and patient, and presented it as simply, empirically, effective treatment for particular ailments. And at the beginning of the nineteenth century, good empirical evidence of success in particular cases was enough; a culturally challenging theory for which no material evidence could be found was considerably worse than no theory at all, at least in terms of rendering acupuncture acceptable. After the mid-century, however, this was no longer the case; pure empiricism (particularly when disconnected from even the possibility of a material explanation) was becoming a threat to the profession's aspirations to scientificity and the social authority that came with it. Empiricism was slipping back into the hands of the 'quacks'. But by then, western practitioners of acupuncture had become so habituated to trial-by-error needling in locus dolenti that it's lost theoretical basis would, in any case, have been almost irrelevant.

By the same token, acupuncture users, lacking a unitary identity they were consultant surgeons and physicians, general practitioners, and very occasionally late in the century also followers of the new 'specialties’ such as neurology-and not excluded from the orthodox medical communion, felt no impulse to create their own institutions. In particular, they created no centers of training; individuals like Elliotson might mention acupuncture in lectures, or demonstrate it on teaching rounds should a suitable case be present. As long as acupuncture remained novel (and as long as it's prominent practitioners remained orthodox!) such mentions could gain wide audiences: both lectures and notes on ward rounds were often serialized by the medical periodicals. But as acupuncture became familiar, its use-limited as it was to relatively minor and unexciting ailments-was no longer worthy of mention. Such essentially opportunistic efforts could not substitute for inclusion in a formal education program, once the medical press turned its spotlight elsewhere. the other hand, local cultures of acupuncture use persisted; for instance, it was 'for years a favorite traditional practice at the Leeds Infirmary' where three generations of Pridgin Teales used it as Surgeons to the Infirmary.16 But informal networks and family traditions were increasingly peripheral to the process by which innovations in medicine were diffused and entered the mainstream. Periodicals, textbooks, and formal medical education had, by the end of the nineteenth century, become the essential media for the transmission of medical knowledge. Homeopaths, precisely because of their formal exclusion from these venues were well prepared for this shift, with journals, schools, and textbooks of their own, through which to propagate succeeding generations of homeopathic practitioners.

In fact, the case of homeopathy usefully illustrates both the benefits and the disadvantages of the 'alternative' position/posture. Clearly, homeopathists and supporters of homeopathy used the rhetoric of opposition to-and oppression by medical orthodoxy to draw attention to the flaws of allopathic practice and the distinctiveness of their own. This, in turn, allowed them to build a strong and visible identity, which could be shared by professionals, amateurs, and consumers alike. However, by choosing to position homeopathy as an alternative to orthodox medicine, and by defining their therapy in part by what it was not, homeopathy's proponents left homeopathy open to being grouped with all the other self proclaimed 'alternatives', ranging from the medically respectable (such as osteopathy) to the downright disreputable (clairvoyance, for example). Similarly, by promoting homeopathy as an exclusive choice, they brought upon themselves the same set of disadvantages that faced allopaths in their battles to exclude homeopathy. The adversarial approach also encouraged dogmatism among homeopathic 'purists', which in turn reduced the flexibility of modernizers to incorporate popular new techniques or respond to challenging new doctrines, like germ theory. If acupuncture was rendered amorphous in the absence of a theory, homeopathy was rendered brittle by an overly rigid theoretical structure.

And that brings us again to the question of culture and the cross-cultural specificity (or not) of medicine. Were the different responses to and trajectories of acupuncture and homeopathy influenced by the fact that the former originated in China and the latter in Europe, and if so in what ways? Certainly, the separation of practice from theory in the case of acupuncture was intimately related to European perceptions of Chinese natural and medical knowledge as devoid of merit (beyond its antiquarian interest as an earlier stage of civilization). Those perceptions, as Floyer's diligent efforts of translation suggests, related not just to the factual content of that body of knowledge (on what side of the body the heart was lodged; the length of the intestines; the rate of circulation in the body) but to the cosmologies and epistemologies embedded therein (a non-dichotomous universe, a body internally legible through physical sensations, rather than auditory clues or direct inspection) and the manner in which the substance of each of these categories was expressed ('flowery', 'poetical' language). But perceptions of cross-cultural medical expertise was also influenced by far less arcane matters: for instance, the politics of international trade. Simply put, when Britain's political and economic relationship with China was or was expected to be profitable, British attitudes towards China and all things Chinese tended to be buoyant. When that relationship soured, as it did after the failure of successive missions to China seeking more favorable trading terms, and in the period preceding and during the Opium Wars so did attitudes towards other aspects of Chinese culture.

In the 1820s, when Churchill was first promoting the use of acupuncture in Britain, Lord Amherst had recently returned from a British ambassadorial mission to China in the years 1816 and 1817. The end of the Napoleonic Wars had allowed the re-expansion of British diplomatic and economic horizons, and the rigidity of the Canton Cohong system was again a focus for anti-Chinese sentiments. Moreover, the Country (private) traders were simultaneously pressing for the ending of the East India Company's monopoly of the China trade, and illicitly expanding their own ventures in East Asia. The embassy was ignominiously expelled from China without even a formal audience with the Emperor, much less any new agreement on trade terms. The embarrassing future of Amherst's mission contributed to growing (elite) British disgust with China in general and the Chinese government in particular. In the popular press, the British public read tales of Chinese medicine and technology, set in the context of an obstinate and autocratic government. Perhaps even worse, at least for perceptions of Chinese medicine, they were told that Britain's generous attempt to negotiate had been blocked by a Chinese doctor.

China during this period gallingly persisted in regarding itself as self-sufficient, and culturally superior. Consequently, it did not seek to ally itself with or learn from European nations and regarded its many foreign visitors and inhabitants as mere pilgrims to the shrine of a higher culture. Embassies from European powers were routinely referred to as 'tribute envoys' and required to follow long established schedules, routes, and rituals. The Amherst mission evaded these rules (arguing that it was not a tribute mission) and attempted to establish its own pace and precedents-or as the Chinese officials perceived it, stalled and prevaricated. On the Embassy's arrival in Beijing, Amherst was immediately summoned to the Emperor's presence. He declined, on the grounds of illness, and begged for time to recover. The Emperor immediately offered the assistance of his own physician:

The Ambassador was immediately visited by the promised physician. This gentleman, who appeared to be something beyond the middle age, was dressed as a Mandarin. He felt His Lordship's pulse in both wrists, and having observed that his stomach was probably disordered from the use of a Chinese diet, recommended repose and an emetic, and retired. The report of this person to the Emperor, materially influenced, as it afterward appeared, our subsequent treatment.

In other words, the imperial physician appears to have reported that Amherst was faking illness; as this was apparently the only reason given to the Emperor for the Ambassador's refusal to attend him, the Embassy was disgraced.17 Unsurprisingly, a considerable number of pages and column inches reporting and discussing the failed mission were expended on critiques of Chinese medical knowledge and theory, and the 'absurdities' of its practices. In particular, Chinese practitioners were criticized as 'entirely destitute of anatomical knowledge'.18 As the Lancet scoffed,

The knowledge of Anatomy among these primitive people is extremely slight and superficial .... The existence of the great viscera of the chest and abdomen is certainly ascertained, but the Chinese are profoundly ignorant of their relative position. The heart is thus supposed by them to be on the right side and the liver on the left.- There is scarcely an allusion made to the nervous, fibrous, and muscular structures .... In Physiology the Chinese are seen to scarcely less disadvantage.19

At first glance, this hostility seems to have had little effect on perceptions of acupuncture--after all, it was in the first flush of its British glory in the 1820s and 1830s-but of course, it does explain the urgency with which Churchill and other acupuncture supporters worked to cut acupuncture's ties with China, and to define their practice of acupuncture as anatomically based. Moreover, particularly in medical forums, they presented France, rather than China, as the immediate origin of European acupuncture, both in terms of its intellectual and its empirical antecedents. Obviously, Churchill and his counterparts knew that acupuncture was developed in China, but few traces of China persisted in the description and practice of acupuncture in Britain in the face of that nation's growing unpopularity. Even the needles themselves were domesticated and, westernized-this not only stripped them of undesirably 'Chinese' attributes, but powerfully illustrated the ease with which practitioners could construct their own apparatus to test the new treatment.

Contemporary observers were certainly aware of a close relationship between popular attitudes towards different cultures and public medical enthusiasms. Britain's victory over China in the Opium Wars enabled Britain to negotiate her own trade terms, punitive damages, and perhaps most importantly, healed British amour-propre, wounded by Chinese indifference to British trade and British culture. In its wake, orthodox medical practitioners contemplated the likely effects of increased exchange with the Chinese.20 Some even saw stirrings of a medical equivalent to the eighteenth-century chinoiserie craze, which had itself occurred during a period of greater openness in the China trade and correspondingly positive perceptions of China. In 1844, a scandalized but anonymous 'Medical Practitioner' scolded the government for its lax attitudes towards quacks in general, from mesmerists to dentists (for specialism-the notion that one could understand and treat one part of the human organism in isolation from its systemic context was itself seen as a sort of quackery until the late nineteenth century). In the midst of his tirade, the author singled out 'for its bare-faced impudence' the 'Chinese pills', as exemplifying all the frauds from which the Government should be protecting its citizens:

No sooner had the news of peace having been made in China reached us, then a 'most important discovery' was announced, and 'Chinese Pills' were placarded throughout the kingdom, recommended as a 'Universal remedy,' their virtues transcendently soaring above those of all other universal remedies hitherto known ... What, I ask, is the humble, unlettered, laboring man to think of these lies about the Chinese Physician's effectual means for contending with disease? He knows not but that all there stated may be true; he knows not that the Chinese theory and practice of Medicine is about as correct, in most of its principles, as the vain conceit of their own celestial relationship; that it is, in fact, the deepest in the dark, of all the intellectual pursuits of that singular people.21

Other authors were less perturbed, but nonetheless recognized that the forced opening of China was likely to bring new competitors to the medical scene. John Wilson, Medical Inspector of Naval Hospitals and Fleets, and recently returned from duty in China, mused in 1844: 'There is no saying whether, among the curiosities which will find their way hence to London, a celestial doctor may not be one.' Perhaps Wilson's complacency stemmed from his quite accurate view that Chinese medicine would compete far more directly with homeopathy than with orthodoxy:

He [the hypothetical Chinese practitioner] would possess pre-eminently the charm of novelty; and if to that he added the irresistible recommendation of boasting loudly, and boldly professing his power to cure all manner of disease, he might prove a formidable rival to the homeopathist. At any rate, he would be his fit antagonist, and a pretty race might be run between them for the popular favor. It is suspected, however, that the expounder of the pun-tsaow would be beaten, principally though the burthen of his big boluses, by the light weight of the disciple of Hahneman,; for the imaginative invalid who delights to toy with the immeasurable minute doses of the latter, would be frightened or disgusted by the drenches and balls of the former.22

In the end, if a 'celestial doctor' came to Britain in the decades after the Opium Wars, he or she left no traces on British medical culture. 'Chinese pills' and similar Orientalized patent medicines came and went. Acupuncture remained, albeit in its highly westernized form, embedded in local cultures and private practices. Its proponents occasionally grabbed the spotlight of the medical periodicals with unusual case studies, and more rarely, clinical studies in hospitals. One 'quack' practice associated itself with acupuncture: Baunscheidtism, used most famously to treat male sexual dysfunction and involving the use of a spring-loaded array of blades or needles and an irritating ointment applied to the site of puncture to create an eruptive rash. But in general, the practice of therapeutic needling stayed free from such taints, and firmly within (although peripheral to) orthodox practice across Europe and North America until the closing years of the nineteenth century.

As I and other historians have argued, the rise of homeopathy ended the reign of 'heroic medicine' and promoted the growth of a unified (and monopolistic) orthodox medical profession. Acupuncture certainly had no such profound effects, although arguably its advent and popularity did help to familiarize and domesticate the needle itself as a medical instrument. By the end of the nineteenth century, needles were commonly used to treat aneurism, to relieve various forms of edema, to introduce vaccine matter, and the hypodermic needle and syringe was being introduced; proponents of each of these innovations all harked back to acupuncture's relative safety and painlessness as evidence that they too were safe. In the first decades of the twentieth century, changes in medical education and in the structures of medical practice, and the rise of new therapies for the treatment of ailments like tetanus, rheumatism, neuralgia, gout, and sciatica-and perhaps most importantly, a rising sense amongst the orthodox medical profession of the power of the new scientific medicine-saw acupuncture drop out of western practice altogether. It would not return to its early nineteenth-century heights of popularity until the 1960s and 1970s.

In conclusion one should ad that physicians of Chinese medicine currently employ more than one hundred different diagnostic systems. At least seven methods of pattern differentiation are taught in today's universities and colleges. To these might be added a large number of other widely used methods, including biomedical diagnostics and methods derived from biomedicine but assimilated into Chinese medicine. There is no agreement between physicians about which method should be applied to a particular case, nor are there any established mechanisms to bring about convergence.

Today methods of diagnosis are often divided in classical/gudaide, traditional/chuantonde, modern/xiandaide, and new/xin. No unanimity exists, however, regarding the details of specific diagnostic techniques, the interpretation of diagnostic data thus obtained, or the relative value of various types. One can find, for instance, several different systems of pulse diagnosis on various sites of the body.

Treatment practices are equally varied, and the history of Chinese medicine is characterized by polemics between advocates of different schools of thought. Such polemics might concern theoretical issues or the correct interpretation of textual sources as much as the diagnostic and treatment techniques appropriate to a given case. The same acupuncture point is located differently by different physicians, and points are also selected on the basis of personal experience and stimulated by means of highly individualized needle techniques. That is, practitioners may use the same stylized terms taken from the canonical literature to describe a therapeutic intervention, but in practice they apply to it their own interpretations.

But if meridians and Ch'i are fictional, then what is the mechanism behind the apparent healing power of acupuncture?

Singh and Ernst in their book conclude:

 

1 The traditional principles of acupuncture are deeply flawed, as there is no evidence at all to demonstrate the existence of Ch'i or meridians.

2 Over the last three decades, a huge number of clinical trials have tested whether or not acupuncture is effective for treating a variety of disorders. Some of these trials have implied that acupuncture is effective. Unfortunately, most of them have been without adequate placebo control groups and of poor quality ­the majority of positive trials are therefore unreliable.

3 By focusing on the increasing number of high-quality research papers, reliable conclusions from systematic reviews make it clear that acupuncture does not work for a whole range of con­ditions, except as a placebo. Hence, if you see acupuncture being advertised by a clinic, then you can assume that it does not really work, except possibly in the treatment of some types of pain and nausea.

4 There are some high-quality trials that support the use of acupuncture for some types of pain and nausea, but there are also high-quality trials that contradict this conclusion. In short, the evidence is neither consistent nor convincing - it is border­line.

One could ad that when medical researchers argue that the evidence seems largely to disprove the benefits of acupuncture, the response from acupuncturists often includes five main criticisms. We shall address them one by one:

1 Acupuncturists point out that we cannot simply ignore those randomized placebo-controlled clinical trials that indicate that acupuncture works. Of course, such evidence should not be ignored, but it has to be weighed against the evidence that counters it, and we need to decide which side of the argument is more convincing, much as a jury would do in a legal case. So let us weigh up the evidence. Is acupuncture effective for a wide range of disorders beyond all reasonable doubt? No. Is acupuncture effective for pain and nausea beyond all reasonable doubt? No. Is acupuncture effective for pain and nausea on the balance of probabilities? The jury it still out, but as time has passed and scientific rigour has increased, then the balance of evidence has moved increasingly against acupuncture. For example, as this book goes to print, the results have emerged of a clinical trial involving 640 patients with chronic back pain. According to this piece of research, which was sponsored by the Nationallnstitute of Health in America and conducted by Daniel Cherkin, sham acupuncture is just as effective as real acupuncture. This supports the view that acupuncture treatment acts as nothing more than a powerful placebo.

2 Practitioners argue that acupuncture, like many alternative therapies, is an individualized, complex treatment and therefore is not suitable for the sort of large-scale testing that is involved in a trial. This argument is based on the misunderstanding that clinical trials necessarily disregard individualization or com­plexity. The truth is that such features can be (and often are) incorporated into the design of clinical trials. Furthermore, most conventional medicine is equally complex and individualized, and yet it has progressed thanks to clinical trials. For instance, a doctor will ask a patient about his or her medical history, age, their general health, any recent changes in diet or routine and so on. Having considered all these factors, the doctor will offer a treatment appropriate to that individual patient - that treatment is likely to have been tested in a randomized clinical trial.

3 Many acupuncturists claim that the underlying philosophy of their therapy is so at odds with conventional science that the clinical trial is inappropriate for testing its efficacy. But this afcusation is irrelevant, because clinical trials have nothing to do with philosophy. Instead, clinical trials are solely concerned with establishing whether or not a treatment works.

4 Acupuncturists complain that the clinical trial is inappropriate for alternative therapies because the impact of the treatment is very subtle. But if the effect of acupuncture is so subtle that it cannot be detected, then is it really a worthwhile therapy? The modern clinical trial is a highly sophisticated, flexible and sensitive approach to assessing the efficacy of any treatment and it is the best way of detecting even the most subtle effect. It can measure effects in all sorts of ways, ranging from analysing a patient's blood to asking a patient to assess their own health. Some trials use well-established questionnaires that require patients to report several aspects of their quality of life, such as physical pain, emotional problems and vitality.

5 Finally, some acupuncturists point out that real acupuncture may perform only as well as sham acupuncture, but what if sham acupuncture offers a genuine medical benefit to patients? We have assumed so far that sham acupuncture is inert, except as a placebo, but is it conceivable that superficial and misplaced needling also somehow tap into the body's meridians? If this turns out to be true, then the entire philosophy of acupuncture falls apart - inserting a needle anywhere to any depth would have a therapeutic benefit, which seems highly unlikely. Also, the development of the telescopic needle sidesteps this question because it does not puncture the skin, so it cannot possibly tap into any meridians. Acupuncturists might counter by arguing that telescopic needles also offer therapeutic benefit because they apply pressure to the skin, but if this were the case then we would also receive benefits from a handshake, a tap on the back or scratching an ear. Alternatively, such pressure on the skin might sometimes detrimentally influence the flow of Ch'i, so such bodily contact might make us ill.23

Conclusion: Acupuncture is based on pre-scientific mysticism. It is supposed to work via the manipulation of acupoints, but scientists have been unable to find evidence that acupoints actually exist (i.e., they are not physiologically distinguishable from other points on the body). Additionally, there is no known mechanism through which acupuncture could work. Nevertheless, thousands of tests have been conducted. Meta-analyses and systematic reviews of these tests are extremely inconsistent, with little agreement among them. Many analyses failed to find evidence that it is better than a placebo, while others found a significant difference. However, the positive results usually had very small effect sizes, suggesting that the results were not clinically significant and were likely statistical flukes. Further, these studies also documented a large placebo component to the treatments. Additionally, several studies have documented a positive bias in the literature, with higher quality studies tending to produce more negative results. This lack of mechanism, a large number of negative results (especially from high-quality studies), inconsistency among studies, and small effect sizes all indicate that acupuncture is nothing more than a placebo.

 

1. William Buchan, Observations Concerning the Prevention and Cure of Venereal Disease (London: Chapman, 1796), p. iv.

2. Berlioz, The Memoirs of Hector Berlioz, 2002, 310-11.

3. Ibid. 296-7.

4. James Morss Churchill, A Treatise on Acupunauration (London: Simpkin and Marshall, 1822), 5.

5. Ibid. 10.

6. Robley Dunglison, New Remedies, 2014, 45-6.

7. T. W. Wansbrough, as quoted inJames Morss Churchill, Cases fllustrative of the Effects of Acupuncturation, in Rheumatism, Lumbago, Sciatica, Anomalous Muscular Diseases, and in Dropsy of the Cellular Tissue, etc. (London: Callow and Wilson, 1828),73-5.

8. C. Lindo, quoted ibid. 39-43.

9. Dunglison, New Remedies, 48.

10. Churchill, Cases, 46.

11. 'London Medical Society. March 18th, 1833. Mr. Kingdon, President. Rheumatism.-Elaterium. Acupuncture', Lancet (23 March 1833), 817-18, at 817.

12. Ibid.

13. See Steven Shapin and Simon Schaffer, Leviathan and the Air-Pump (see Chapter 3, n. I) for more on the emergence of the culture of the witness, the audience, and the performance in science.

14. Churchill, Treatise, 23-4.

15. William Craig, 'Art. VII. Acupuncture in a Case of Cancer', Edinburgh Medical journal, Combining the Monthly journal of Medicine and the Edinburgh Medical and Surgical journal, 14 (1869), 617-20, at 619.

16. T. Pridgin Teale, 'Clinical Essays, No. III. On the Relief of Pain and Muscular Disability by Acupuncture', Lancet (29 April 1871), 567-8, at 567.

17. Clarke Abel, Narrative of a journey in the Interior of China ... in the Years 1816 and 1817; Containing an Account of the Most Interesting Transactions of Lord Amherst's Embassy to the Court of Pekin (London: Longman, Hurst, Rees, Orme, and Brown, 1818), 107.

18. Ibid. 216.

19. 'Medicine in China' Lancet, 1(1838--9),481-5.

20. The Opium Wars, also know as the Anglo-Chinese wars, were fought between 1839 and 1842, and 1856 and 1860, and as the name suggests, were sparked by China's decision to eradicate the highly profitable trade in opium dominated by the British. Opium, though known to be addictive and poisonous, was Britain's only successful export to China, and an effective ban would certainly have threatened Britain's balance in trade; however, Britain was anxious also to defend the right to free trade, and to eliminate the corrupt system under which Europeans were licensed to trade with China.

21. A Medical Practitioner, Quacks and Quackery: A Remonstrance against the Sanction given by the Government, the Press, and the Public, to the System of Imposture and Fraud Practised on the Ignorant and Credulous in the Quackeries of the Day (London: Simpkin, Marshall and Co., 1844), 30-1.

22. John Wilson, Medical Notes on China (London: John Churchill, 1846) 248.

23. Trick or Treatment: The Undeniable Facts about Alternative Medicineby Simon Singh and Ernst M.D., Edzard.

 

 

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