The merging ways - by Chip Chace


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The merging ways - by Chip Chace

  1. 1. feature The merging of waysAn approach to understanding the channeldivergences in meridian style therapyBy Charles Chace pathways for hyper or hypo tonicity, or per- haps through the sensation of the propaga- tion of qi along a channel when a point onThose who know heaven and know humankind are there. Those its trajectory has been needled. We also have a variety of indirect means of assessing in-who know heaven know heaven gives one life. Whoever knows fluence though changes in the pulse, tonguehumankind uses knowing to nurture what cannot be known. and abdomen; but what about the rest of theThey will run out the string of their years and not find it cut off channel system?in the middle. This is the fullest knowledge. And yet, though Our influence on those facets of the chan- nel system more closely allied to superficialthis is so, there is a problem: knowledge waits on certainty, but anatomical structures such as the channelcertainty is never quite certain. sinews (jing jin ) and the network ves- – Zhuangzi Chapter 6: The Great Ancestral Teacher sels (luo mai ) is probably best assessed in two ways, The first is through relatively local changes in the quality of tissues under- lying an effected area that has been directly treated and the second is through some very A CUPUNCTURE is commonly believed to be something of a black box. We in- troduce a stimulus and it has an effect, yet general improvements in the quality of the pulse. By and large, we know that we have had an effect on these channels because we it is often difficult to say why it has worked. literally feel it under our hands. We have a variety of tools that help us navi- The subtlety of these issues increases sig- gate this void, the theoretical structure of the nificantly when it comes to what many con- channel system being the most prominent sider the deepest facets of the channel sys- among them. Many of us have some tangi- tem, the channel divergences (jing bie ) ble experience of the primary channel sys- and the eight extraordinary vessels. Both of tem, perhaps through palpating the channel these channel systems are typically activated14 Vol 6–2
  2. 2. feature ‘’using pairs of acupuncture points that are what the text said and how it was interpret-located on the primary channels. This poses ed by virtually all the modern sources thatan immediate challenge to clearly differenti- I looked at. Subsequent writers had clearlyating the influence of a putative channel di- bridged this gap with a great deal of creativevergence or extraordinary vessel treatment interpretation of their own and this was an One passage in particular,from the more mundane primary channel aspect of the channel system that was cov- a recapitulation of theinfluence of those two points. The problem ered in virtually all basic textbooks of acu-is particularly germane to the channel diver- puncture. section on the channelgences where the source literature provides At around this time I made the acquain- divergences from Chapterno specific methodology for activating them tance of Miki Shima, a Japanese acupunc- 11 of the Divine Pivot,and there are many different modern ideas turist living in Marin County in California, would haunt me for to how they should be used.a This essay who had made an extensive study of theis an exploration of my attempts to mean- secondary vessels. He generously providedingfully apply the channel divergences in me with enough insight to turn out a pass-my own clinical practice and to develop a able translation, but how one might actu-model for verifying that I have actually ac- ally use the channel divergences remained acessed them. mystery to me. In the late 1980s I collaborated with Yang My initial exchange with Miki regardingShou-Zhong on a translation of Huangfu the channel divergences ultimately led to aMi’s , Yellow Emperor’s Systematic long and productive friendship, and by theClassic of Acupuncture and Moxibustion mid 1990s we decided to collaborate on a(Huang Di Zhen Jiu Jia Yi Jing book project. Given our mutual interest, the , 3rd century) As the name implies, century). channel divergences were an obvious topicthe book is a systematic reorganisation of for us. In this book we reviewed many ap-earlier material from the Ling Shu, Su Wen, proaches to channel divergence therapeuticsthe Tai Su and a few other now lost texts, culminating in Shima’s own considerableand it constitutes the first real textbook of experience with them.acupuncture practice. Among the most satisfying aspects of that Although I was most decidedly the junior project for me was the opportunity it pro-member of the translation team, the project vided for revisiting Chapter 11 of the Lingwas a pivotal point in my development as a Shu. This afforded me a context for oncestudent and practitioner of Chinese medi- again grappling with the issue of how onecine. At that time my work on the Jia Yi Jing makes that pivotal leap from text to prac-provided me with an in-depth exposure to tice. Many of the channel divergences arethe contents of the Su Wen and Ling Shu described as traveling along the trajectoriesand it consolidated my love of pre-modern of their associated primary channels in amedical literature even as it drove home direction but opposite to their usual challenging texts such as this can be to They therefore present some significant in-meaningfully interpret. Many of its passages terpretive problems. The more I studied thewere completely opaque to me and I had no channel system, the closer I came to a con-idea what relevance they might have to my ceptual crisis. There were so many of theseown practice of acupuncture. One passage apparent paradoxes that I began to won-in particular, a recapitulation of the section der whether the ancient Chinese actuallyon the channel divergences from Chapter thought of the channels and networks as11 of the Divine Pivot, would haunt me for tangible and “real” or were they just handyyears. ideas they used when it suited them? n Charles Chace has been a The section on the channel divergences My subsequent readings on early Chinese student of Chinese medicinewas the first place in our work on the Jia epistemology and ontology suggested that and its literature for over 25Yi Jing that truly bothered me. Although the compilers of the Nei Jing had a funda- years. He graduated fromthe grammar was clear enough, and Profes- mentally different approach to reality than the New England School ofsor Yang did his best to explain his under- we do today. Where their contemporary Acupuncture in 1984. He is thestanding of the passage to me, I remained Greek counterparts were beginning to ask author and translator of a vari-doubtful that we had any idea what it really the questions concerning the nature of real- ety of books and maintains ameant. Moreover, there was chasm between ity that would define the course of Western clinic in Boulder, Colorado. The Lantern 15
  3. 3. feature ‘’ thought for the next two millennia, these regarding the function and influence of the questions were of little interest to the Chi- channel divergences that were so fantastic I nese. During this time in Chinese history, a found them quite literally unbelievable. thing was considered real if it led to effica- Could all these really be different inter-By and large, the senior cious action. They were less concerned with pretations of the same phenomena? In moremeridian therapists I have what a thing was than how it could used. pragmatic terms, were these disparate meth- This conceptual distinction has been de- ods all simply various expressions of “howmet have little interest in scribed as a “how priority attitude” as op- priority attitude”? There was no question inthe channel divergences. posed to a “what priority attitude”b. Such a my mind that Miki, my channel divergence perspective helps to explain how the com- mentor, was satisfied that he was accessing peting and mutually contradictory theories the channel divergences, and I had seen his of yin/yang and the five phases could co- remarkably effective use of strategies that he exist. Each was efficacious in a given set of labelled as channel divergence therapies in circumstances. It also helps to explain how his clinical practice. Similarly, it was clear to qi could be conceptualised as moving in me his teachers Tadashi Irie and Seki truly opposite directions in the same channel. Qi believed they were indeed executing chan- might flow in different ways under different nel divergence treatments. I was even will- circumstances. From that point on I began ing to give some of the European theorists to sift my understanding of the classical the benefit of the doubt that they too were medical literature through the filter of what indeed accessing the channel divergences I imagined a how priority attitude might be, even though I believed that many of their but I had not focused this perspective on a fundamental premises were based on a tex- critical examination of my own practice. tual misinterpretation. Around the time our channel divergence In my own practice, some of these ap- book went to press, I had lunch with Jeffrey proaches most definitely worked better for Dann, a friend and colleague with whom I me than others and many failed my per- share an interest in palpation based styles sonal test of efficacy. Clearly, no one else’s of acupuncture, particularly those from Ja- firmly held conviction would ever be suf- pan. He quite innocently asked me if I re- ficient to dispel my own uncertainty, and ally thought that the channel divergences it was up to me to define my own criteria were an effective means of treatment. My for what constitutes a channel divergence knee-jerk response was an unqualified and treatment. When does any acupuncture effusive endorsement of the channel diver- intervention become a channel divergence gence strategies. True, I did have a vested treatment and how do I know that I have interest in that answer. I had spent the pre- been effective? vious four years researching the channel The following discussion assumes a cer- divergences and I had a book coming out tain familiarity on the part of the reader on the topic. Of course I was sure that they with both the essentials of meridian style worked! Jeffrey nodded politely the way therapy and with some of the fundamen- one does when one discovers one has unin- tal concepts associated with the channel tentionally trod on delicate ground and our divergences. Those interested in a compre- conversation turned to other things … but hensive discussion of meridian therapy will he had planted an insidious seed. find Shudo Denmei’s excellent Japanese At that point I had been exposed to a wide Classical Acupuncture, Introduction to Me- range of perspectives on channel divergence ridian Therapy (1990) informative. Those treatment from both Asia and Europe, each interested in a more thorough introduction of which was based on differing assump- to channel divergence therapeutics will find tions regarding nature and topology of the Channel Divergences, Deeper Pathways of channel divergences. Some of these strate- the Web by Miki Shima and Charles Chace gies were Byzantine in their complexity, (2001) of interest. while others were remarkably simple. Al- For the purposes of this essay, however, though the Japanese sources limited their some of the key ideas concerning channel scope of interest to relatively tangible and divergence therapy are summarised in the practical applications, others made claims following tables.16 Vol 6–2
  4. 4. feature Central characteristics of A basic channel divergence treatment model the channel divergences Channel Master point Source Network Uniting LU ST-12 LI-4 LI-6 LI-11 n The channel divergences are the primary LI ST-12 LU-9 LU-7 LU-5 and deepest internal pathways of the chan- P GB-12 P-7 P-6 P-3 nel system. SJ GB-12 SJ-4 SJ-5 SJ-10 n The channel divergences are arranged in HE BL-1 HE-7 HE-5 HE-3 yin-yang pairs referred to as confluences SI BL-1 SI-4 SI-7 SI-8 ( he). SP ST-1 SP-3 SP-4 SP-9 n The channel divergences directly link the ST ST-1 ST-42 ST-40 ST-36 core with the exterior and exterior with the LIV GB-1 LIV-3 LIV-5 LIV-8 core. GB GB-1 GB-40 GB-37 GB-34 n All channel divergences move upward and BL-11 ultimately outward in the body. KID KID-3 KID-4 KID-10 BL-1 n All channel divergences terminate in the BL-11 face/neck. BL BL-64 BL-65 BL-40 BL-1 n All confluences directly or indirectly pass through the heart/chest. The above table summarises some of n Channel divergences provide a direct con- the most common choices for channel nection between the yuan, ying and wei qi. divergence pairings. n European sources emphasise wei qi/net- This pairing of distal points on the ex- work vessel relationships. tremities with an associated master point n Japanese sources emphasise ying qi–yuan on the head is the basis for all channel di- qi/zang fu relationships. vergence strategies that I have found to be effective. As such, it is my criteria for defining chan- nel divergence activation. Fundamental treatment After six or seven years of actively ori- premises enting my acupuncture practice around n Most channel divergence treatment strate- combinations of channel divergence and gies require two points, a “master” and a extraordinary vessel treatment strategies, I “couple”, to activate them. realised that I had been consistently over- n The master points are located on the head looking the primary channels. Since my ul- and neck. timate goal was to maximise my use of the n Shima’s interpretation is that these cepha- entire channel system of which the chan- lad points must be paired with the he conflu- nel divergences are only one part, I clearly ence points. needed to expand my horizons. n Other Japanese investigators allow for a I resumed my study of Japanese style me- wider range of pairings including source and ridian therapy with its strong emphasis on network points. the primary channels with renewed enthu- siasm. This immediately brought the pri- mary channels back into play in my clinical Channel divergence treatment strategies practice but I was still left with the ques-based on point pairings combine a “master tion of how to tie everything together. Bypoint” on the head with one or more and large, the senior meridian therapistspoints on the extremities. For instance, I have met have little interest in the chan-the pairing of LI-4 and LU-9 with ST-12 nel divergences. For better of worse, I havewould be considered a sixth confluence been left to my own devices in my efforts tochannel divergence treatment exerting integrate channel divergence and meridiana deep influence on the Lung and Large therapies.Intestine viscera. The precise way in which Initially I would either do a channel diver-these points are chosen, combined and gence treatment or a meridian style treat-stimulated varies greatly from practitioner. ment. Over the course of a few years, how- The Lantern 17
  5. 5. feature ‘’ ever, the two approaches gradually blended ing in that it is difficult to substantiate in into one another to the extent that they are truly tangible terms. More importantly, be- now parts of an integrated whole. Current- cause I need information that will inform ly, although I routinely access the channel me whether I am being effective during theThe most tangible defining divergences, this is something that devel- course of a treatment, I need some morecharacteristic of a channel ops out of the overall flow of the treatment, immediate feedback mechanisms.divergence treatment is the typically as a consequence of my perception There are two immediate responses that that treating the primary channels alone has I associate with the activation of the chan-pairing of points on the been insufficient to produce the effect I am nel divergences. Neither response is entirelyextremities with associated looking for. This makes sense if we concep- unique to the channel divergences, andpoints on the head and tualise the channel divergences as digging both are considered to be indicators of anshoulder girdle. a little deeper to get the job done. As I will overall qi balancing effect. As such, they can discuss, the way in which I have integrated be achieved in a wide variety of ways. It has these two approaches to acupuncture re- been my experience, however, that they of- flects some of my fundamental assump- ten occur together when I have effectively tions regarding what a channel divergence administered what I define as a channel di- treatment really is. vergence treatment and when this happens Returning to my fundamental conun- I can be more confident of a positive out- drum: how do I know that I’m activating come from that treatment. a channel divergence? There are no indi- The first is that the pulse consolidates. By vidual points that are unique to the chan- this, I mean that the boundaries of the pulse nel divergences. The most tangible defin- become more defined and coherent. If my ing characteristic of a channel divergence needling has made the pulse stronger, fuller treatment is the pairing of points on the and more supple, its boundaries will be- extremities with associated points on the come better defined, and the qi in the pulse head and shoulder girdle. Yet if we simply more contained subsequent to needling needle such a pairing how confident can we the associated points on the head. If the be that we are actually accessing a channel pulse is hard and wiry to begin with, then divergence as opposed to a couple of points it softens even as its definition improves. on the primary channels? This is the same The tendency toward an enhanced healthy dilemma posed by using the so-called mas- definition of the pulse is consolidation and ter couple point strategies associated with it must be distinguished from hardness. It the extraordinary vessels. is not simply that the pulse becomes more Regardless of how one defines the char- tense or wiry and therefore its boundaries acteristics of channel divergences or how are easier to feel. On the contrary, consoli- they should be accessed, if they are indeed dation typically accompanies an increase different from the primary channels then it in the suppleness of the pulse. It has been is reasonable to expect that their influence my experience that the addition of the CD will be somehow distinguishable from the master points will not necessarily make the primary channels. What might this look pulse any stronger than a primary channel and feel like? If there were some phenom- intervention, but in consolidating the qi it ena that one could reliably associate with gives it some structure or container within the channel divergences, then one would which to act, thereby enhancing its efficacy. have a reasonable basis for discriminating This is analogous to the practice of includ- between them and the primary channels. ing a small astringing component into Enthusiasts of channel divergence treat- herbal prescriptions for tonifying the yin. ment strategies often claim that these chan- The improvement in the consolidation nels get to problems that are difficult to or coherence of the pulse is also accompa- access via the primary channels. This is an nied by as generalised enhancement in the eminently pragmatic response. It is consis- overall coherence of the patient’s qi that can tent with my own experience and it satis- be palpated everywhere on the body. The fies my criterion of efficacy based on early patient’s qi effectively homogenises. Chinese thinking. Clinically, something is The homogenisation that I experience of- real if it works. It is nevertheless unsatisfy- ten seems to radiate down from the head18 Vol 6–2
  6. 6. featureStandard contact needling. Needling BL-1.and initially it may or may not propagate nique was sloppy. Sometimes I have simplyalong the pathway of the channel I have jumped the gun and failed to adequatelyneedled, but the aspect of the phenomena prepare the patient for work on what is gen-I am most interested in is its generalised erally understood to be a deep facet of thenature. This change is perceptible regard- channel system. I have not yet really enteredless of where on the patient one places one’s into a conversation or resonance with thehand.c patient’s qi. Any of these factors may con- Practitioners of meridian therapy often tribute to an unremarkable response. Effec-identify pulse consolidation as a positive tive acupuncture is about doing the rightsign in the progression of treatment so thing at the right time. We have to take ourit cannot in and of itself be considered a cues from the qi and our personal agendasphenomena that is necessarily associated regarding the progression of treatment arewith the channel divergences. It is a marker often irrelevant or downright counterpro-of channel divergence activation only if it accompanied by a systemic settling andhomogenisation. Both the consolidation Contact needlingof the pulse and some significant shift to-ward increased homogenisation must oc- Many of the master points of the channelcur for me to be reasonably confident that divergences are located in the peri-orbitala channel divergence intervention has been region, an area where needling can beworthwhile. To be sure, pulse consolidation both painful and traumatic for the patient.and a general settling will often occur with- Particularly at Jing Ming (BL-1), but also atin the course of any effective acupuncture Tong Zi Liao (GB-1), and Cheng Qi (ST-1),treatment. It is their occurrence together even the most careful insertion can easilyimmediately upon needling the CD points cause a black eye. Because of this, I preferon the head that I believe is significant. The to stimulate these points using contactchannel divergences are simply a means for needling only.deepening a treatment that needs to go to a Contact needling is a highly evolveddeeper level. technique wherein the needle just barely Ante Babic’s If nothing changes then I interpret this in touches but does not penetrate the skin. Tips for runninga number of ways. It may be that a channel Arguably, it has been most fully developed a successful clinic ...divergence treatment was simply irrelevant within the Toyo Hari style of meridian Keep your insurance cur-to that patient’s needs at that moment, or therapy.d The effective use of contact nee- rent. A patient complainedthat I erred in my choice of channel diver- dling technique requires exceedingly pre- that the herbs I prescribedgences. Perhaps the focus of the problem cise point location to within a fraction of for him had given his sisterreally was in the primary channel and my a millimetre, and its efficacy is particularly a rash when she took them.point selection was poor or my needle tech- sensitive to the overall posture, level of ten- The Lantern 19
  7. 7. feature ‘’ sion and mental state of the practitioner.e to those yin channels in controlling (ke The pressure and the quality of contact of ) cycle relationship to the channels that the hand of the practitioner that is holding have been treated. For instance, if one had the needle (the oshide) and the hand that treated the Kidney and Liver channels, thenI have experimented is advancing the needle (sashide) are both one would treat either the Heart or Spleenextensively with using essential to the successful execution of the channels. My criteria for point selection isCD master points on technique. Though subtle, when adminis- based exclusively on which points I find to tered properly, contact needling exerts a po- be most available based on palpatory find-the head alone and I am tent influence on the body. ings. This may be determined by a varietyunconvinced that such an Once the point has been precisely located of techniques ranging from firm palpationapproach does much of and properly contacted by the needle, one for pressure pain to more subtle assess-anything at all. simply waits for the qi to arrive and then ments such as manual thermal diagnosis rapidly removes the needle, closing the wherein the practitioner is feeling for ther- point just prior to the point at which the mal emissions radiating from acupuncture perceived arrival of qi peaks. In the styles points 10cm off the skin.g I generally use that I am most familiar with, contact nee- contact needling alone during this phase of dling is generally administered with a #1 or treatment. #2 silver needle. I have no particular attachment to the Consistent with the principle that the channel divergences as such; they are sim- yang aspects of the body are relatively more ply a means to an end. If the stimulation of superficial and the qi more available, it gen- the primary channels has already produced erally takes only a few seconds for the qi the result I am looking for then the channel to arrive on the head. Contact needling the divergences do not even enter my mind. It is CD master points is therefore a relatively usually after I have finished working the yin rapid procedure. channels and as I’m beginning to work the In contact needling the CD master points yang channels, when I have yet to observe on the head, it is necessary to take one im- some essential shift in the patient’s internal portant liberty with the established rules environment that I engage the channel di- defining the technique. Jing Ming (BL-1) is vergences. an important point in channel divergence When I do deem the channel divergences therapy in that it is the access point of both necessary, I will typically back up a bit and confluence of the Bladder and Kidney, and needle a single point on the yin facet of the the Heart and Small Intestine confluence. main channel divergence that I think is im- As such, I use it a great deal. Because it is paired. impossible to make a proper oshide at BL-1 Depending on the situation, I may use a where both fingers are in full contact with contact needling technique here or I may the point, I form the oshide using a single insert the needle. The only criterion I have finger and the orbital surface of the eye. for the depth of this insertion is that I must have felt the qi arrive in the affected channel. The context of treatment As such, it may be an ultra superficial inser- tion that requires tape to keep it in place or My initial choice of which channels to nee- it may be an insertion of a few millimetres. dle is generally based on the rudimentary Regardless of its depth, a retained insertion rules outlined in most styles of meridian on these distal points seems to provide a therapy. Pulse, abdomen, tongue, symptoms fixed stimulus for their pairing with their and a variety of other palpation techniques associated CD master points. I have found determine the two most deficient or imbal- that simply contact needling these distal anced channels. Ideally, these two channels points again just prior to accessing the mas- are situated next to each other along the ter points is less effective. generation (sheng ) cycle of a five-phase I will occasionally couple this yin channel arrangement. For instance, one might treat point with a point on the associated yang the Pericardium and Spleen, Spleen and channel divergence on the opposite extrem- Lung, the Lung and Kidney, or the Kidney ity. Finally, I stimulate their associated CD and Liver channels.f Treatment proceeds master hole on the head using a contact20 Vol 6–2
  8. 8. feature ‘’needling technique. I almost never needle be the best one can hope for.yin and yang channels bilaterally on both It is curious to consider that after over 15extremities. With this technique I rarely years of studying, practicing and teachingfind it necessary. a wide variety of channel divergence treat- I have experimented extensively with us- ment strategies, my use of this system has If Chapter 11 of the Linging CD master points on the head alone been distilled to something as rudimentary Shu is clear on one thingand I am unconvinced that such an ap- as doing a root treatment, stimulating a few it is that the channelproach does much of anything at all. This points on the head for a few seconds, and divergences communicateleads me to conclude that the pairing of the then assessing for pulse consolidation anddistal and cephalic points is an essential qi homogenisation. with qi in the core of thecomponent of a CD effect. In any case, I am I will leave it to others to speculate further body and it is thereforequite clear I must have established some ba- on the theoretical implications of the chan- reasonable to assume thatsic groundwork, entered into some sort of nel divergences. This admittedly minimalist they might access andconversation with the qi, before those head interpretation nevertheless meets my core balance deep reserves of qi.points are of any real use to my patients. criteria for efficacy and it provides me with It would be far more satisfying for me to a relatively concrete basis for distinguish-discover palpatory or symptomatic referents ing between primary and secondary chan-that are entirely unique to the channel di- nel influences. Finally, it is an approach thatvergences or the extraordinary vessels, but allows me to move fluidly between facets ofthat does not seem to be the way human the channel system in response to moment-bodies are wired. All measures of improve- to-moment changes in a patient’s qi.ment are, by their very nature, generalised. The bimodal shift that I have described is Endnotesmerely a benchmark of a progressive deep- a. For a comprehensive discussion of theening in the balance of the qi and it often channel divergences see Miki Shima andoccurs without my ever having to access the Charles Chace (2001), Channel Divergences,CD master points. In this, the question of Deeper Pathways of the Web. Boulder, Bluehow I know what I am accessing remains Poppy On the other hand, by the measure b. Zhang Dong-Sun, cited in David L. Hallof the how priority attitude described ear- and Roger T. Ames (1998), Thinking from thelier and the immediate palpatory feedback Han: Self Truth and Transcendence in ChineseI am receiving, it seems that I have indeed and Western Culture. Albany, State Universityaccessed the channel divergences or at least of New York Press: 221.something that transcends the primary c. For a further discussion of the palpatorychannels. If Chapter 11 of the Ling Shu is indicators of balanced qi, see Charles Chace,clear on one thing it is that the channel di- “The Shape of Qi,” in The Lantern (2008). Volvergences communicate with qi in the core 5-1, pp. 4-11. d. For an overview of the Toyo Hari styleof the body and it is therefore reasonable to of meridian therapy see the website: www.assume that they might access and balance reserves of qi. e. Acupuncture points are, of course, really When I administer what I believe to be a holes or caves (xue ), but when as is thechannel divergence treatment in the proper case in many styles of meridian therapy, onecircumstances, then my palpatory indica- attends to point location with this degree oftors tend to confirm that some deeper level precision, the focus of attention shifts fromof organisation has indeed occurred. Since I the hole defining the general anatomicalhave already tried and presumably failed to region to a locus that is indeed much moreproduce this effect using primary channel like a point. For this reason, I have used thetherapies alone, it is reasonable to surmise word acupuncture point in this essay.that when I access the channel divergences f. For a comprehensive discussion of meridianand something good happens, then I am no therapy, see Denmai, Shudo (1990) Meridianlonger working on the level of the primary Therapy. Seattle, Eastland Press.channels. Given the unimaginably complex g. For a discussion of this assessment techniquenature of the system we are working with, see Jean Pierre Barral (1996), Manual Thermalthis very tentative measure of certainty may Diagnosis. Seattle, Eastland Press. The Lantern 21