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15年出版的《五行针灸指南》，现已成为五行针灸学员和爱好者的一本自学手册。但在最新版出版的几年后，据诺娜老师自己表述：“我的学生开始向我指出，我在课堂上教的内容与我在书中所写存在差异，这时我才意识到，不知不觉中，我已经在临床实践中对别人教给我的东西做出了多么大的改动......”
作为更有经验的五行针灸师，我的实际临床操作和我在教授学生时给予他们的建议之间总是存在某种差异。我想，多年来许多五行针灸同行也必然发展出了属于他们自己的临床实践方式。
我在写《五行针灸指南》（译者注：以下简称《指南》）时便曾考虑过这一点，这本书是为五行针灸初学者所著，在其最新版本中，现已为那些无法参加学校课程或接受五行针灸师培训的学员增加了一本自学手册。在15年前的首版书中，我一味照搬了最初在华思礼教授的莱明顿学院接受培训时所学到的知识。直到几年后我的学生开始向我指出，我在课堂上教的内容与我所写的在某些方面存在差异时，我才意识到，不知不觉中，我已经在临床实践中对别人教给我的东西做出了多么大的改动。
最近，一些针灸师就五行针灸操作的两个重要方面向我提出了一些问题，这些问题都与临床操作的步骤有关。第一个是关于清除内障的步骤，第二个是关于祛除邪气（AE）的步骤。
这两个问题都让我仔细思考为什么我要对老师曾经教的方法做出改变，以及在以后的教学中加入这些变化是否合适。
另外，我也会问自己，有经验的治疗师的做法与我们给予新手的建议之间是否总会存在这种差异。
-01-
清除内障的步骤
我们先来谈谈清除内障的步骤。在我跟随华思礼教授治疗的这些年里，他虽诊断过许多例内障，却从未让我们做过外七龙（EDs），在他唯一一次认为内七龙（IDs）没有成功时，也并没有立即建议我做外七龙，这件事曾在一段时间内让我相当困扰。而在他的《经络腧穴（Points Book）》一书中，不仅列出了外七龙的穴位，内七的穴位甚至还列了两组，使得可能的穴位一共有三组。
这一直让我困惑不已，但遗憾的是，在跟随华思礼教授的那么多个小时里，我竟没有抓住机会去问他，我们应该在什么时候考虑使用外七龙，或者在两组内七龙的穴位之间应该如何选择。他告诉我们使用其中一组内七龙穴位，说这是针对“抑郁”患者的。如今我还有好多问题想一问究竟，机会却一去不复返了，现在我永远无法知道他为何会列出这三组穴位。
那么为什么老师会在课堂上说，如果内七龙不能清除内障，我们就应该直接转向外七龙，而我在实践中从未见过这种情况?
事实上，在治疗被华思礼教授诊断为内障的患者的过程中，我学到的是内七龙治疗能很快清除内障。且根本不像老师告诉我们的那样需要等上20分钟。但我尽职地把这20分钟的等待作为步骤的一部分抄进了自己的《指南》中。
多年来我观察到，如果正确取穴和进针，内障可以被很快清除，现在我建议学生们的留针时间要短得多，只留大约5分钟，如果无效，则行强补后出针。
我发现强补通常能达到最初的泻法所不能达到的效果，而且很少需要重复这一过程。即使我觉得泻法已经清除了内障，我还是会在出针前施以补法，以防内障仍然存在。以防万一嘛，我心想。
因此，当最近一位治疗师指出我在视频课上所说的内障治疗与我在《指南》中所写的不同时，这让我停下来思考并意识到，既然我在学生时代所学的步骤已随着我的临床经验发生了改变，那么我最好在《指南》以后的版本中反映这种变化，我现在正在这样做。
-02-
祛除邪气的步骤
学生所指出的关于临床步骤发生改变的第二个例子与祛除邪气的步骤、尤其是进针顺序有关。我在《指南》中所写的是基于我学生时代所学的知识。老师告诉我们心俞不可针，除非位于其上方的两个穴，即心包俞的针周围出现红斑。
作为一个听话的学生，我一直都是这样操作的，但临床了很长一段时间之后，有一天我想或许可以把包括心俞在内的六对针一起扎进去，这样可以加快操作速度，但操作的时候我非常小心。
由于没有发现任何不良影响，我便理所当然地继续这样做着，但我会确保针心俞时不刺入太深。
令我惊讶的是，有一天我发现一位病人的心俞周围出现了红斑，但心包俞周围却没有，这似乎与之前老师说的不太一致，即邪气只有通过心包俞才能到达心俞。这让我更加坚定了一起针这六对穴位的决心。我还遇到过心俞上出现邪气后，心包俞两颗针的周围才逐渐出现红斑的情况，仿佛这些邪气是因为刺激了心俞才被引发出来。
在心而非心包上发现邪气这件事仍让我感到不解，但在我多年的临床中，这种情况也只发现过寥寥数例。因此，我认为这些都是无法解释的罕见案例，也或许是我心包俞的定位不准，没有检测出心包俞的邪气。
我仍然认为，给予心包俞时间让其显示是否有邪气后再针心俞，是更加安全的操作步骤。
对新手而言尤其如此，因为他们的针刺技术可能不够好，无法避免将针刺入太深。稍等片刻后，便可以很安全地将针浅刺入心俞中，这样可以确保将可能存在的邪气清除。
-03-
小结
受益于众多医者许多年甚至数个世纪以来传递下来的经验，所有的医学传统都将随着时间的推移而变化和发展。理应如此，否则实践将不进则退。跟随华思礼教授的这些年里，我曾目睹他对临床方案所做的改变。因此对医者而言，如果他们希望向经验更丰富的人学习，应准备好在他们的实践中融入变化。重要的是，他人向我们建议的任何新方案，我们需要确信它们是基于那些有明确临床专业知识的人的经验，只有在这样的前提下，我们才可做出相应改变。
我确信，五行针灸将继续受益于未来的针灸师对当今之临床实践所做的调整。
原文
Updating The Procedures For Clearing Internal Barrier And Aggressive Energy
When teaching students I have always had to draw an imagery line between what I have learnt to do in my practice as an experienced five element practitioner and what it is advisable to tell students to do. I am sure that many of my fellow five element acupuncturists have over the years also developed their own approaches to their practice.
I had to consider this when writing my Handbook of Five Element Practice, which is intended for budding five element acupuncturists, and now, in its latest edition, has the addition of a Teach Yourself Manual for all those who are not able to join a college course or train with a five element acupuncturist. In the original edition, published first more than 15 years ago, I rather blindly copied what I had been taught in my original training at JR Worsley’s Leamington College. It was only when my own students started pointing out to me some years later that what I was teaching them in class differed in some respects from what I had written that I realised how far in my own practice I must have adapted what I had been taught without realising it.
This has been brought home to me very strongly recently by questions from practitioners on two different and important aspects of five element practice, both relating to clinical procedures. The first is about the procedure for clearing Internal Barrier and the second about that for an AE drain. Both questions have made me think carefully about why I have adapted what I was taught in the way I have, and whether it is appropriate to incorporate these changes into any future teaching that I do. Alternatively I ask myself whether there will always be some discrepancy of this kind between what an experienced practitioner does compared with what it is advisable for novice practitioners to do.
First, to the procedure for clearing Internal Barrier. I have been troubled for some time by the fact that in all the years during which I saw JR Worsley with patients, and he diagnosed many cases of Internal Barrier, not once did he suggest that we should start treatment with EDs (External Dragons), nor, on the only occasion when he thought IDs (Internal Dragons) had not been successful, did he immediately suggest that I should move on to EDs. And yet in his Points Book not only are the points for EDs listed, but also two sets of points for IDs, making a total of three sets of possible points. This has always puzzled me, but I sadly never took the opportunity of my many hours following JR to ask him when we should be thinking of using EDs, nor how we should choose between the two sets of ID points. We were told to use one set of the ID points listed, those for patients “with depression”. Like so many things I now wish I had asked him, I wasted that opportunity, and will now never know why all three sets of points were listed.
So why did we learn in class that if IDs did not clear Internal Barrier, we should straightaway move on to EDs, when I never saw this happening in practice?
In fact, what I did learn from treating my patients with IDs diagnosed by JR was how quickly Internal Barrier cleared with ID treatment. Certainly it never took the 20 minutes’ wait that we had all been told might be necessary, and which I dutifully copied into my Handbook as part of the procedure.
Having over the years therefore observed how quickly Internal Barrier clears if the needles are inserted correctly, I now tell students to leave them in for a much shorter time, about 5 minutes, if there is no effect, before tonifying the points strongly and removing them. I find the strong tonification usually does the trick which the initial sedation may not have done, and there is rarely need to repeat the procedure. Even if I feel that sedation has cleared the block I still tonify the needles before removing them, as a fall-back procedure just in case Internal Barrier is still there. Better safe than sorry, I think to myself.
So when a practitioner recently pointed out that what I said about Internal Barrier treatment in a video lesson I gave was different from what I had written in my Handbook, this gave me pause for thought, and made me realise that since my clinical experience had modified the procedure I had been taught as a student, it was sensible to reflect this change to my thinking in future editions of my Handbook, which I am now doing.
The second example of a change in clinical procedure which has been pointed out to me by a student concerns the procedure for an Aggressive Energy drain, and specifically the order in which the needles are inserted. What I have written in my Handbook is based on what I learnt as a student. We were told not to insert the needles in the AEPs (back shu points) of the Heart unless there is first erythema around the needles of the two points immediately above them, those of the AEPs of the Heart Protector. Like the good student I was, I continued to do this until one day, after I had been in practice for quite a while, I thought I would speed the procedure up a little by inserting all six sets of needles including those in the Heart AEPs, which I did very carefully. Since I noticed no ill-effects from this, I have continued to do this as a matter of course, making sure that I am particularly careful not to insert the needles too deeply into III (Bl) 15.
To my surprise one day I found that erythema appeared around the Heart AEPs in one patient but not around those of the Heart Protector AEPs, something which seemed at odds with what we had been told. This was that Aggressive Energy could only reach the Heart AEPs if it was passed through from the Heart Protector. This made me all the more determined to needle all six sets of points. I also found that it was only after the AE appeared on the Heart AEPs that erythema gradually emerged around the two Heart Protector needles, almost as though I had summoned Aggressive Energy to emerge by stimulating the Heart AEPs.
The discovery of Aggressive Energy on the Heart but not on the Heart Protector still puzzles me, but I have only found this to happen in very few cases in my many years of practice. I therefore assume that these were very rare examples of something slightly inexplicable, or perhaps I did not position the needles correctly on the Heart Protector AEPs, and missed detecting the AE that was there.
I still feel it is a safer procedure to putting needles into the Heart AEPs until the Heart Protector is given time to reveal whether it has Aggressive Energy or not. This is particularly the case for novice practitioners whose needling skills may not be sufficiently good to avoid inserting the needles too deeply. After waiting a little while, it would then be perfectly safe to insert needles very shallowly in the Heart AEPs just to make sure you drain any Aggressive Energy which might happen to be there.
All medical traditions change and develop with time, as they benefit from the experiences of all the many practitioners who have passed through over the years and the centuries. This is right and proper, otherwise practices would atrophy. I myself observed the changes JR Worsley made to clinical protocols he developed during my years observing him. It is therefore always good for practitioners to be prepared to incorporate changes in their practice if they wish to learn from those with greater experience. The important thing here is that we should make such changes only if we are sure that any new protocols suggested to us are based on the experiences of those with clear clinical expertise.
I am sure that five element acupuncture will continue to benefit from the adaptations future generations of acupuncturists may feel they should make to today’s practice.
五行针灸线上课：《跟诺娜学五行》
34讲视频课
作者：诺娜·弗兰格林
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