The purpose of this book is to give an introduction to the philosophy of acupuncture and to review the current developments in this system of medicine. The initial chapters deal with acupuncture treatment generally—indicating its successes in a variety of common diseases—and there then follows an account of its evolution and history both in China and the West.

Throughout, the book is addressed to the lay reader. It neither pretends to be an acupuncture textbook nor to describe how to carry out acupuncture, but it does summarize the available information on acupuncture and what can be achieved by this form of therapy.

Within the field of acupuncture there are those who believe that their own ideas are the only correct approach to this type of treatment, so I have attempted to describe, in a balanced and systematic manner, the use and abuse of all the currently available theories concerned with the practice of acupuncture.

I do not hold to any one particular approach, but feel that all the ideas within the field should be understood, evaluated and used to benefit those who seek help. Acupuncture is growing in popularity and importance, and as it becomes more acceptable it is gradually being integrated into the fabric of Western medicine.

Before going to an acupuncturist it is wise to discuss your problem with your own general practitioner. It may be that acupuncture is not the best treatment for your complaint and a diagnosis should be made before any treatment is given. Your general practitioner can then refer you to an acupuncturist if this type of treatment is indicated. However, the patient is the final arbiter of the type of health care he wishes to receive and ultimately the decision is his, whatever professional advice he may receive.

There are two groups of people practicing acupuncture in the United Kingdom; non-medically qualified acupuncturists, and those who also have a medical degree.

There are several organizations that cater for non-medical qualified acupuncturists. Two of the main ones are the British Acupuncture Association and the Traditional Acupuncture Society. A request from any member of the general public, to these organizations, will usually secure a list of the acupuncturists affiliated to them. Most non-medically qualified acupuncturists have completed an acupuncture course; however it is quite legal (in the United Kingdom) to practice acupuncture without any form of training, in either acupuncture or Western medicine. It is therefore wise to assure yourself that the acupuncturist you wish to visit does have some sort of formal training or qualification in acupuncture.

The British Medical Acupuncture Society is the only organization in the United Kingdom that caters for medically qualified acupuncturists. The general public is not able to obtain lists of medically qualified acupuncturists, but this list is available to doctors, via the British Medical Association, if they wish to refer a patient for acupuncture.

In spite of this, many acupuncturists, including the Chinese, treat a wide range of ‘mental disorders’ with acupuncture. Many people have stated that acupuncture is clearly effective in helping symptoms such as insomnia and bed-wetting, and can also create a feeling of general well-being. Patients who receive acupuncture for specific problems, such as ankle pain, will often note how well they feel after the treatment. It would be very misleading to give figures of ‘cure rates’ for these problems because such disorders naturally relapse and remit, often improving when a sympathetic listener becomes involved. I think it is fair to say, however, that acupuncture can sometimes effect mood changes that help these problems significantly.
The Chinese have completed trials on some of the more clearly defined and serious mental diseases, such as schizophrenia. In a trial involving over 400 patients they claim a 54 per cent cure rate for this disease, with a further 30 per cent showing ‘significant improvement’. These figures are exceptionally high and, if correct, are most interesting. Their criteria for evaluating a ‘cure’ or a ‘significant improvement’ are not clearly stated and so it is difficult to be sure whether these results are valid. Many claims have been made for the effects of acupuncture in the treatment of a variety of ‘nervous disorders’ but, sadly, there is no good hard evidence to substantiate or refute such claims; however, from a variety of excellent research papers it is clear that acupuncture can influence quite radically many areas of the central nervous system. This work is of a purely scientific nature and at present it is not directly applicable to the clinical effects of acupuncture therapy.

1. The Conceptual Basis of Traditional Chinese Medicine



One of the major assumptions inherent in traditional Chinese medicine is that disease is due to an internal imbalance of Yin and Yang; therefore disease can be treated by correcting the Yin Yang imbalance, thereby returning the body to a healthy state. Western medicine tends to approach disease by assuming that it is due to an external force, such as a virus or bacteria, or a slow degeneration of the functional ability of the body. Both Chinese and Western concepts are valid alternatives. Although this chapter is devoted to the philosophy of traditional Chinese medicine it is useful to start by examining briefly some of the assumptions and philosophies of Western medicine. This will provide a useful comparative basis which will elucidate the understanding of both systems.
Western medicine is based on the Cartesian philosophy that the body represents one functioning system and the mind another It accepts that each system may affect the other, but essentially it sees disease as either physical or mental. The Chinese assume that the body is whole, and each part of it is intimately connected. Each organ has a mental as well as a physical function, as will be discussed later.

Until fairly recently most Western doctors and pharmaceutical companies have worked on the basis that there is ‘a pill for every ill’. The philosophical approach behind this idea is that an external force, or chemical, can cure disease, but although some pills are of great value, both the general public and the medical profession have become considerably more skeptical about the widespread use of such chemicals. Traditional Chinese medicine states that the body has the potential to cure its own diseases if pushed (or needled) in the correct way.

Some authors, such as Ivan Illich, have been hypercritical of Western medicine and thus some people have looked upon acupuncture as not just an alternative but a superior system of medicine. Acupuncture is just another medical system, with ideas that may be of benefit to the individual patient and Western medicine as a whole, but it cannot be promulgated as either superior or a cure all. The major disadvantage of Western medicine is that it has the potential to cause a great deal of harm. Acupuncture, on the other hand, is most unlikely to cause any serious damage as it is a particularly safe form of therapy; this is undoubtedly one of its main advantages.

Even though the traditional Chinese explanations for acupuncture are somewhat enigmatic to the Western doctor, acupuncture does seem to have a clearly validated scientific basis. In spite of their radically different philosophical assumptions it is wiser to look at these two medical systems as mutually beneficial, rather than mutually exclusive. Each system has ideas and therapeutic methods that can be explained both scientifically and philosophically, each can benefit the individual, and together they can broaden the philosophical and ideological basis of medicine.

The Balance of Nature

The Chinese believe that health is achieved, and disease prevented, by maintaining the body in a ‘balanced state’. This concept was applied to both individuals and society at large. In individual terms the ancient Chinese physicians preached moderation in all things, such as alcoholic intake and gastronomic excess. They also stated that daily activities should include mental as well as physical tasks. The wealthier Chinese visited their doctor when they were well, paying a retainer to the doctor to keep them healthy. If they became ill the doctor lost his fee.

Such a highly sophisticated and personal system of health care is impracticable within the current limitations of Western society, but the concept behind such ideas represents a radically different approach to health and disease. The Chinese culture was also one of the first to grasp the potential within the broader field of preventative medicine. Many of these ideas were effected in the public health measures, which first began to be introduced during the Warring States period.

The body is a delicate balance of Yin and Yang. Yin represents water, quiet, substance and night, whilst Yang represents fire, noise, function and day. The two are polar opposites and because of this one must be present to allow the other to exist; for instance, how can you experience joy if you do not understand misery? The state of the body is determined by the balance of Yin and Yang within it. Each of the organs of the body has an element of Yin and Yang, although one organ may be more Yang in its nature, whilst the other is more Yin. One organ may be more important in its substantive form (Yin) whilst another is more important because of its functional abilities (Yang). When the healthy body is examined as a complete functioning system the Yin and Yang properties within it are in a fluctuating balance.

The balance of Yin and Yang is not always exact. Sometimes a person’s mood may be more fiery, or Yang, whilst at other times he may be quieter and therefore more Yin. Normally the balance changes from hour to hour and day to day, but if the balance is permanently disordered, for instance if Yin consistently outweighs Yang, then the body is unhealthy and disease results.

The Therapeutic Application of Yin and Yang

When there is imbalance external agents can invade the body and cause disease, these external agents being called pathogens. The essential principle of Chinese traditional medicine is to decide on the exact nature of the imbalance between Yin and Yang, and the pathogen causing the trouble, and then to correct these pathological processes. As the natural forces of the body return to a normal balance the disease is then cured.

The art of traditional Chinese medicine is to particularize the imbalance accurately so that it can be corrected quite specifically The patient is then treated by using specific acupuncture points on the body, or the ear, in order to re-balance the body. This broad system of traditional medicine applies to all aspects of

therapy used by the ancient Chinese, particularly acupuncture and herbal medicine.

The diagnostic and therapeutic principles of Yin and Yang and the pathogens are based on a system of anatomy and physiology peculiar to traditional medicine. The anatomy of traditional medicine is represented by the acupuncture points and the channels that connect them. The physiology is represented by the organ functions that are outlined in the Nei Ching Su Wen,1 and will be discussed later in this chapter.

The Anatomy of Traditional Chinese Medicine

The channels are a system of conduits that carry and distribute Qi, or vital energy, throughout the body. Each of the organs of the body is represented by a channel, and diseases of a particular organ can be treated by using acupuncture points on the channel representing that organ.

Disease is present when the flow of vital energy through the channels is disrupted. This may occur when the integrity of the channels themselves is damaged by a sprain or strain. The Chinese describe this as a disease of ‘Bi’, or pain, caused by a localized disruption to the flow of Qi. The flow of Qi through the channels may also reflect the result of internal disease; for instance, if there is a disease of the liver then the flow of Qi through the liver channel will be abnormal.

The concept of channels exists exclusively in traditional Chinese medicine. Many of the facts handed down to us by the ancient Chinese do seem to have scientifically explicable reasons, but their ideas about the channels have eluded any explanation, so far. A variety of research workers have tried to correlate the channels with nerve pathways or muscle groups in the body, but all these explanations are inadequate. In spite of their elusiveness the channels represent a practical working system for acupuncture and are therefore still useful.

Acupuncture points are quite specific areas on the channels. They represent points of maximum influence on the flow of vital energy, or Qi, through the channels. This can be demonstrated clinically by thinking about the disease process that occurs when someone tears a muscle. The traditional Chinese explanation for

this disorder is that the channel running through the damaged muscle has been physically disrupted, resulting in local pain, a disease of Bi. In order to treat the pain, the integrity of the channel and the flow of vital energy through the channel, must be restored. This can be achieved by the selective use of acupuncture points on the damaged channel, which restores the flow of Qi and relieves the pain.

If the internal balance of Yin and Yang is seriously disrupted (so that disease results), then there will be an abnormal flow of Qi, or vital energy, through the channel representing the diseased organ. The diseased organ must be diagnosed and then acupuncture points can be selected from the relevant channel. The use of these specific acupuncture points corrects the flow of Qi in the channel and this, in turn, has an effect on the diseased internal organ. The overall result of this therapy is to correct the imbalance within the body, and thus heal the disease; an internal disease can therefore be treated by external means.

The Chinese Biological Clock

Vital energy flows through the channels in a well defined circadian rhythm.
As the diagram overleaf shows, vital energy, or Qi, flows through the stomach channel in the early part of the day. A recent French survey showed that an accident driving to work is much more likely if breakfast has been missed. The ancient Chinese would explain this by saying that the energy required by the stomach, during the morning, has not been absorbed and therefore the body is not in a healthy state because it has ‘missed breakfast’. Perhaps the idea of a large English breakfasts is more healthy than previously supposed.

The lung channel is dominant between 3.00 a.m. and 5.00 a.m. If there is a disease of the lung it should manifest itself at these times, as indeed it does; the worst time for a sufferer from bronchial asthma is usually in the early hours of the morning.

The circulation of Qi represents the traditional Chinese view of the biological clock within all of us, and, in the light of current medical knowledge, it is interesting to note how accurate are some of their observations.

The Physiology of Traditional Chinese Medicine

The physiology of traditional Chinese medicine has many similarities to that of Western medicine. Most of the specific organ functions defined in the Nei Ching Su Wen are astonishingly accurate in the light of modern scientific discoveries.

The heart is said to dominate the circulation of the blood. The Nei Ching Su Wen says, ‘The heart fills the pulse with blood . . . and the force of the pulse flows into the arteries and the force of the arteries ascends into the lungs’. This seems to be a clear description of the circulation of the blood through the body, via the lungs. The idea that blood circulated in this way was peculiar to Chinese medicine until it was ‘rediscovered’ by William Harvey in the early seventeenth century. The publication of Harvey’s work Du Mote Cordis has subsequently been hailed as one of the great landmarks of Western medicine, although at the time Harvey was thought to be mad, ‘inflaming the medical profession by the suggestion of such a preposterous idea’.

The Nei Ching Su Wen also makes some surprising observations about the kidneys. It states that the kidneys dominate bone, that they play an integral part in the process of growth and reproduction (in fact the Chinese character for kidney and testicle is sometimes indistinguishable) and that the kidneys control body fluid in concert with the lungs.

During the last forty years it has become obvious that vitamin D is a very important factor in bone growth, and if it is not present then rickets results. The exact mechanism of this disease process was unclear as it was not really understood how vitamin D actually worked, but recently it has been shown that the kidney provides the missing link in the control of bone growth and development, by changing the chemistry of vitamin D. The idea that the ‘kidney dominates bone’ is therefore an accurate, detailed, complex and surprising observation to have been made some 2,500 years ago.

Embryology is the study of the growth and development of the foetus in the mother’s womb. With the advent of good microscopic technique, in the early part of this century, embryology developed apace. It has been shown, quite conclusively, that both the ovaries and the testicles develop from the same original cells as the kidney. This process begins when the foetus is about five weeks old, (when a baby is born it is said to be in its fortieth week of development). The kidneys therefore, do seem to play an important part in the process of growth and reproduction.

The detailed and specific control of body fluid is a very complex chemical system, and one that we are only just beginning to understand properly, but it is quite obvious that the kidney and the lung do work together to control the fluid in our bodies. Most of this information has become available since the Second World War, with the development of complex and expensive machines to look at small changes in the chemicals and fluid within the body.

Communication Problems

The Nei Ching Su Wen contains a vast array of medical knowledge, much of which has been hidden from the West by the Chinese language, and it was not until this text was translated that the information became freely available. Many of the observations and rules within the Nei Ching Su Wen are based on the intricate and detailed observations made by the Chinese physicians. It does not seem to be part of the cultural make-up of Western societies to use this time-consuming method of gaining knowledge. Often we tend to be too impatient to ‘waste time’ observing petty detail, seeming to pursue instead the idea of scientific ‘break-throughs’, although, in the end, both approaches yield the same answer. One of the major precepts of Taoism is that if the individual waits and watches the ‘Way’ will become clear. In the West we are motivated to search actively for the answer and therefore the ‘Way’ sometimes takes far longer to become clear. This is well illustrated by medical concepts contained in the Nei Ching Su Wen, and their subsequent rediscovery.

The Five Zang Organs

Although many organs have the same functions as in Western medicine there are also radical differences between the Western and Chinese systems. In traditional Chinese medicine the major functions of the body are built around the five main organs which are the heart, the lungs, the kidneys, the liver and the spleen. In Western medicine these organs are important, but not to the same extent as in traditional Chinese medicine. The Chinese call them the five Zang or five solid organs, and the system of the five Zang organs controls the main Yin Yang balance of the body.

Each of the Zang, or solid, organs is linked to a hollow or Fu organ. For instance, the kidney is linked both structurally and functionally to the urinary bladder. In Eastern and Western medicine both organs control the production and passage of urine. The channels representing the kidney and urinary bladder are also ‘paired’ as Qi is said to flow from one channel to the other. The liver and gall bladder are linked in a similar manner; they both control the formation and secretion of bile and they are also ‘paired’ charnels.

For these specific ‘paired’ organs the linked functions are exactly the same as in Western medicine. The ‘pairing’ of the channels is particularly important when deciding on which acupuncture points should be used. Diseases of any organ can be treated by using the ‘paired’ channels; for example, diseases of the liver can be treated by using acupuncture points on the gall bladder channel. Traditional Chinese medicine considers migraine headaches to be a disease of the liver and they can be effectively treated (with acupuncture) by using points on the gall bladder channel.

The Emotions and Mental Disease

Traditional Chinese medicine considers that the emotions are governed by individual organs. They do not consider the brain, or subconscious, as discrete entities, therefore the body and the mind are a real part of the same functional system. Each organ is given a particular emotion; for instance, the liver is said to be the organ affected by anger. The concept that emotional functions are completely tied in with physical ones is deeply rooted in Chinese culture. In China there is less ‘mental disease’ as we know it in the West, because the neurotic is considered to have a disease of the liver or spleen, rather than anxiety or depression. Perhaps this explains the fallacious claim that ‘no mental disease exists in China’. In my experience, having worked in a Chinese hospital, the Chinese are just as prone to neurosis as we are in the West.

There are great advantages in seeing mental functions in this way because, instead of being labeled a depressive, the patient feels that the liver is playing up and therefore perceives the disease in a different context. In the West a depressive may still be stigmatized and considered weak because he, or she, is unable to cope. In China this is not so because the cultural history and social context of mental disease is different, the depressed patient being made to feel that the disease is real and organic, rather than imagined. In spite of the constructive efforts of those who work in the field of mental health in Western nations, the body and the mind are generally still considered to be separate, and those who are unable to keep the mind under control are thought, by some, to have failed.

In acupuncture, the Chinese have a method of effectively treating a proportion of mental disease, which therefore has not been considered incurable, and there has been no necessity to shut all sufferers away in institutions. In the West most of those who are working within the area of mental disease are dealing with diseases that are poorly understood. As a general rule the level of understanding in any area of human knowledge can be judged by the number of theories that are used to explain a single phenomenon. If there is one theory that seems to explain all the facts, for a given observation, then it is probably correct. If many ideas are used to explain the same set of facts then it is likely that most of them are, at best half truths. At present the field of mental health embraces a large number of theories which are used to give opposing explanations for the same basic facts.

Without a defined idea of the origin of disease, treatment is difficult, therefore a wide variety of poorly understood treatment methods are used in mental disease, such as electroconvulsive therapy. Perhaps the lack of social stigma attached to mental disease in China is because there has been some form of consistent explanation, and treatment, for this type of problem for the last 2,000 years. The area of mental disease is particularly interesting as I am sure that there is as much mental disease in China, if not more, than in the United Kingdom, but it would seem that the cultural and medical heritage of the Chinese people has allowed them to deal with it in a different manner from that in the West, and possibly more effectively.

Vital Energy (Qi) and Blood

The force behind the biological functions occurring in any living tissue is Qi. Qi represents the vital energy of the body but it also has a material form. It is both substance and function; the substantive or material form of Qi is oxygen (clean Qi) or food, the non-substantive form of Qi is the real but evasive concept of ‘vital force’. The idea of a ‘vital force’ is common to many early, medical systems, but it has been highly developed within the concept of traditional Chinese medicine.

If a substance has no Qi then it is dead. The Qi of the liver is the functional ability of the liver, and the Qi of the body is the total vital force of a human being. Qi is disseminated through out the body by the channels. It is also divided into various sub groups such as original Qi, or the Qi with which you are born and nourishing Qi, or the Qi that you gain from the food you eat. Defensive Qi is the Qi that protects the body from invasion by disease, circulating just below the skin and fending off invasion by viruses and bacteria (pathogens).

Qi is a very wide concept, difficult to understand in detail, but it is an essential part of the traditional Chinese picture of the body. Blood also exists in the system of traditional Chines medicine, and blood production is said to be dependent on the liver, the kidney and the bone marrow. The modern medical theories on blood production also tie up these three organs as being the functional system for blood production.

Pathogens

Disease results when the Qi of the body is weakened and unable to resist the onslaught of pathogens (disease-causing factors). In Chinese medicine the agents that cause disease are given the name of meteorological conditions; an infection (often associated with a fever) is called a disease of heat, and a chronically painful joint is usually a disease of cold. These pathogens allow diseases to be grouped according to their broad symptoms. The pathogen wind is an interesting idea. Wind means a changeable symptom, so the type of muscular ache often occurring with ‘flu, would be classed as invasion by wind. The idea that disease is due to physical conditions is an intuitive explanation for many common aches and pains. People often complain that ‘the caught a chill when they got wet’, or that their ‘neck is stiff after

having slept in a draught’. The Chinese pathogens represent formalization of this approach.

A particular pathogen usually presents itself with a defined symptom complex. By using the information gained from the history of the disease, and the physical examination of the patient, it is often possible to make a clear diagnosis of the pathogen causing the disease. If the patient has a fever then heat is one of the pathogens involved in the disease process. Once the diagnosis has been made, then specific acupuncture points can be used to disperse the pathogen; when heat is the invading pathogen, then specific points are used to reduce the fever. Acupuncture points are therefore used to correct the Yin Yang balance of the body and to disperse pathogens.

If the pathogen cold is responsible for a particular disease process, then heat must be used to treat it. Moxa is the Chinese version of the heat lamp and, as shall be discussed in a late chapter, the Chinese burn the dried leaves of Artemisia vulgaris over the areas that require heat. Heat, or more specifically smoldering moxa, provides local heat for a variety of chronic muscular aches. It is interesting to note that the types of disease due to cold are commonly the muscular and rheumatic ache which are temporarily alleviated by heat lamps.

More than one pathogen can invade at the same time; if a patient is suffering from ‘flu, then there will be a fever and all muscular aches that wander all over the body. This is defined as invasion by the pathogens wind and heat and, as one doctor said when I described this to him, ‘the patient will be suffering from a great deal of hot air.’

Other factors may also cause disease, such as worry, or eating contaminated food. The Nei Ching Su Wen states that excessive grief, anxiety and overthinking will cause cancer. This idea has been supported by some recent comments in the medical press which suggest that if a woman has a breast removed for cancer she will survive longer if she is of a ‘happy’ disposition.

Pulse Diagnosis

For the acupuncturist, one of the most difficult aspects of traditional Chinese medicine is the diagnosis of the specific organ affected by any particular disease. In ancient China this was achieved by using a refined form of pulse diagnosis.

The palpation of the pulse enables the acupuncturist to assess which organ is diseased, whether the organ is over- or underactive, and the pathogen causing the damage. This is achieved by feeling the pulse at three positions at each wrist, and by feeling the pulse at the superficial and deep positions at each end of three positions on the wrist. There are six pulses at each wrist, three superficial and three deep. There are twelve main organs in the Chinese medical system2 and each of these is represented by one of the pulses at one of the wrist positions. It is unclear how this system of pulse diagnosis came into existence but it was a refined and very important system by the time the Nei Ching Su Wen was written. This method of diagnosis allows the whole body to be assessed, and it also defines the relative balance between each of the organs. In addition, pulse diagnosis is said to give a clear idea of the type of disease process, whether it is acute or chronic, and to give a prognosis for that disease in that individual patient. This allowed the Chinese physician to give an indication of how the disease would affect the individual.

The observation that each of these pulses represents a different organ is a difficult fact to accept and understand. It is astonishing to think that different organs are represented by the pulse in the left and right hands, and that these pulses are separated only by a centimeter or so. There are also severe different types of pulse that can be felt in any given position, for instance the pulse in the spleen position can be described as a ‘Fu’ pulse in one disease, or a ‘Ch’en’ pulse in another disease. These pulses were given rather poetic descriptions. A ‘Fu’ pulse is described as a superficial pulse, it is light and flowing like a piece of wood floating on water, whilst a ‘Ch’en’ purse is a deep pulse, like a stone thrown into water.

Surprisingly enough, these pulses can be recorded accurately with the aid of modern technology. They can be printed out from a six channel oscilloscope with three pulse sensors at each wrist. In terms of modern electronics this is not a particularly complex device and allows clear graphic verification of the idea of the ancient Chinese. The poetic description of the pulse characteristics also seems to be verified by the recording; a superficial pulse

is indeed superficial in that there is an upward deflection of the pulse wave on the recording, and very little downward motion of the pulse in that position.

In Western medicine examination of the pulse only gives information about the rate, rhythm and volume of the pulse wave, and this information is correlated with the state of the heart and blood vessels. From the pulse recordings it is obvious that the pulse shows a great deal of variation over a small area at the wrist. It is also obvious that the shape of the pulse wave changes radically when a little pressure is placed on the artery. A superficial pulse is felt superficially and a deep pulse is felt when a little pressure is put on the artery by a finger or, in the case of the pulse-recording machine, an inflatable cuff. Although not easily explicable these facts are certainly of interest.

The Ancient Diagnostic System

Pulse diagnosis is not used in isolation, but as part of a system that involves taking the history of the disease and examining the patient. The facial complexion, smell and posture of the patient are also used diagnostically. Assessing the history of the complaint is the basis of all good medical practice, whether Western or Eastern, and can be summed up by an old Chines quotation called the ten askings: ‘One, ask chill and fever; two perspiration; three, ask head and trunk; four, stool and urine; five, food intake and six, chest. Deafness and thirst are seven and eight; nine, past history and ten, causes. Besides this, you should ask about the drugs taken and for women you should ask the menstrual and obstetric history. Finally, for infants ask about normal childhood diseases’. This ancient Chinese system of history-taking is almost exactly the same as that employed in the West today. Pulse diagnosis was therefore included as an important part of a sophisticated system for diagnosing disease.

Modern Chinese Diagnosis

Modern Chinese acupuncture differs from the old tradition system. The old traditional system of diagnosis by the ‘twelve pulses’ takes many years to learn to a standard of competence which allows the acupuncturist to make a clear diagnosis Although there are some people in both China and the West

who are able to diagnose by the twelve pulses, they are few in number, and a modified system of pulse diagnosis has therefore been developed by the Chinese. This allows a simple but relatively accurate system of traditional diagnosis to be taught and practiced, quite quickly and proficiently, the mainstays of this ‘shorter method’ being the use of a pulse generalization and the tongue.

The pulse is not felt in any particular position, but for its general character, hence the term ‘pulse generalization’. The pulse can be felt at either wrist and classed as generally excessive or deficient. The tongue is also used to give quite specific information about the disease process and, in combination with the history, this system gives much the same answer as the ‘twelve pulses’. Proficiency at this method will usually give the same traditional diagnosis as the pulse-recording machine, so the simplification of this system has not caused a significant loss of diagnostic accuracy.

The Selection of Acupuncture Points

The diagnosis of a particular problem does not tell the acupuncturist where to place the acupuncture needle. A set of therapeutic rules must be applied to solve that problem. To a large degree all medical systems are based on clinical experience and acupuncture is no exception to this; the rules that govern point selection are therefore based on a combination of philosophic concepts and empirical clinical experience.

There are special points that can be used to disperse the invasion of specific pathogens, such as cold or heat, and judging by some recent Chinese research work it would seem that the points used to disperse heat do lower fever. These pathogen-dispersing points are based largely on practical experience, and they form part of the basic grammar of acupuncture.

The other rules of point selection are many and varied; for example, points can be selected on the basis of the law of the five elements. This law assumes that each of the organs represents one of the five elements in traditional Chinese thought (earth, fire, water, metal and wood). They have a creating and destroying cycle.

On each of the channels there are points representing one of these elements and by applying a complex set of rules the diseased organ

can be sedated, (if it is overactive) or tonified, (if it is underactive). There are also points on the back and front of the body that represent specific organs, and these too can be used to treat the represented organs when they are diseased. There is a plethora of such rules, each of which is applied in specific conditions and at specific times. The problem for the acupuncturist is to define the few points that will be best in any particular condition. The skill of point selection is based largely on clinical experience; the rules of point selection give guidelines, although they are not the complete answer.

The Use of Specific Points

Why does acupuncture need such specific diagnostic and treatment methods7 Why not use all the acupuncture points at the same time? It would seem logical that if one acupuncture point helps, then two will help even more, and if all the points are used then the patient is bound to get better!

The Western doctor sometimes assumes that ‘more is better’. If a drug does not give therapeutic benefit, or side effects at a given dose, then he may double the dose and the patient will probably improve. Traditional Chinese medicine implies that a small stimulus is probably more effective than a large one. Biological systems do seem to respond to small stimuli; for instance, a small change in the ecology of a ‘food chain’ can be amplified to cause major damage to another animal species in that environment. The emphasis in acupuncture therapy is to select a minimal number of acupuncture points in order to give the body a small but specific stimulus, as this seems to result in a better therapeutic response.

Clinical Skill

It is quite simple to practice acupuncture because it is quite simple to needle patients, but it is difficult to learn and practice the traditional Chinese acupuncture properly. It also takes some time to gain the clinical skill required to insert and manipulate the acupuncture needle. The Chinese teach that each needle inserted should be manipulated so that the patient receives a numbing or burning sensation in the acupuncture point. Many Western schools of acupuncture do not believe this and state that this sensation, which the Chinese call needling sensation, is not required. The available evidence suggests that if a needling sensation is obtained then the acupuncture is more effective, although many patients obtain adequate symptom relief without experiencing needling sensation.

Acupuncture is not a static subject. The Chinese have achieved a great deal by adapting and redefining the ideas of traditional Chinese medicine so that they are more understandable and acceptable to Western doctors. Technologically based acupuncture techniques have also been developed by Western doctors and these will be discussed in the next chapter.

1 The Nei Ching Su Wen is the first known acupuncture text (see The Physiology of Traditional Chinese Medicine, a section of this chapter).

2 The main organs are the heart, kidney, liver, spleen, lung, pericardium, triple warmer, large intestine, small intestine, stomach, gall bladder and urinary bladder.

The theory of yin and yang is a kind of world outlook. It holds that all things have two opposite aspects, yin and yang, which are both opposite and at the same time interdependent. This is a universal law of the material world. These two aspects are in opposition to each other but because one end of the spectrum cannot exist without the other they are interdependent.

The ancient Chinese used water and fire to symbolize yin and yang; anything moving, hot, bright and hyperactive is yang, and anything quiescent, cold, dim and hypoactive is yin.

The yin and yang properties of things are not absolute but relative. As an object or person changes so the yin and yang components change at a gradual rate. Each of the yin and yang properties of the object is a condition for the existence of the other; neither can exist in isolation.

These two opposites are not stationary but in constant motion. If we imagine the circadian rhythm, night is yin and day is yang; as night (yin) fades it becomes day (yang), and as yang fades it becomes yin. Yin and yang are therefore changing into each other as well as balancing each other.

The Application of Yin and Yang to Chinese Medicine

Each organ has an element of yin and yang within it. The histological structures and nutrients are yin, and the functional activities are yang. Some organs are predominantly yang in their functions, such as the gan-liver, while others are predominantly yin, such as the shen-kidney. Even though one organ may be predominantly yin (or yang) in nature, the balance of yin and yang is maintained in the whole healthy body because the sum total of the yin and yang will be in a fluctuating balance.

If a condition of prolonged excess or deficiency of either yin or yang occurs then disease results. In an excess of yin the yang qi would be damaged, and a disease of cold of shi nature would develop. Excess of yang will consume yin and a disease of heat of shi nature would develop. In a deficiency of yin, diseases of heat of xu nature develop, while a deficiency of yang causes diseases of cold of xu nature.

II. The Channels and Collaterals
The channels and collaterals are the representation of the organs of the body. They are also a functional system in their own right and they are responsible for conducting the flow of qi and blood through the body. The flow of qi can be disrupted by direct damage to the channels, such as trauma, or by an internal imbalance of yin and yang within the body.

The central principle of traditional Chinese medicine is to diagnose the cause of the internal disease, or yin yang imbalance within the body, and, by using the relevant acupuncture points, to correct the flow of qi in the channels and thus correct the internal disease. The acupuncture points that are on the channels have a direct influence on the flow of qi through the channels, and also on the internal organs. The zang channels are yin in nature and the fu channels are yang in nature.

Qi circulates through the channels of the body in a well defined circadian rhythm.

III. Zang and Fu Organs

The zang and fu organs are the internal visible organs of the body. The xin-heart, gan-liver, pi-spleen, fei-lung, shen-kidney and pericardium are the zang organs. The small intestine, large intestine, stomach, gall-bladder, urinary bladder and sanjiao are the fu organs.

The zang organs have a Chinese prefix because a direct translation from the Chinese might be misleading. The Chinese xin has functions rather different from the concept of the heart in Western medicine, so if we call the heart ‘xin-heart’, or the liver ‘gan-liver’, we are able to understand that we are referring to the organ of the heart or the liver, but it is really rather different from our concept of those organs.

The zang organs are of paramount importance in the body. They co-ordinate with the fu organs and connect with the five tissues (channels, jin¹ muscles, skin-hair, bones), and the nine openings (eyes, nose, ears, mouth, tongue, anus and external genitalia), to form the system of the Five Zang. The pericardium is not considered to be an important zang organ.

The Functions of the Zang Organs

The xin-heart

The xin-heart dominates the circulation of blood. When it functions properly the tissues and organs are well perfused and nourished, but when it malfunctions there is precordial pain, cyanosis and ischaemia. This disease is due to ‘stagnation of the blood of xin-heart’.

The xin-heart ‘keeps’ the mind. Normally there is a clear mind, normal mentality, normal sleep and a good memory. When this fails there is coma, insomnia or somnolence, amnesia and mental derangement, because the xin-heart is failing to ‘keep’ the mind.

The xin-heart takes the tongue as its orifice and opens through it. Normally the tongue is reddish, moist, and moves freely. When the tongue has ulcers, is swollen or becomes purplish-red, there is ‘upward blazing of the fire in xin-heart’. When the tongue is rigid and curled up (this may be accompanied by mental symptoms) ‘phlegm and heat are covering the orifice of the xin-heart’.

The gan-liver

The gan-liver is the main yang organ of the body.

The gan-liver stores blood. Normally there is sufficient blood supply to all tissues. When this fails there is ischaemia, dizziness, malaise, abnormal menstruation and hemorrhage.

The gan-liver takes charge of freeing. Freeing really means the free flow of blood and qi through the body, especially digestion and the discharge of bile. When this is impaired there is irritability, mental depression, anorexia, abdominal distension and jaundice.

The gan-liver controls the jin which governs the muscle tone. When this function is disturbed there is muscle spasm, twitching, opisthotonos and convulsions. This is due to an ‘insufficiency of yin and blood of the gan-liver, resulting in the malnutrition of the jin’.

The gan-liver takes the eye as its orifice and opens through it. Usually there is normal vision and normal eye movement. When this function is disturbed there is poor vision, night blindness, nystagmus and abnormal eye movements. This is due to an ‘insufficiency of yin and blood in the gan-liver causing malnutrition of the eyes and stirring of the inner wind of the gan-liver.’

The pi-spleen

The pi-spleen governs the transportation and transformation of food, i.e. digestion. When digestion is abnormal there is anorexia, distension of the abdomen, diarrhea, emaciation, lassitude and oedema. This is due to ‘a deficiency of the qi of pi-spleen’.

The pi-spleen commands the blood. Normally the blood circulates within the blood vessels but when this function fails there is extravasation of blood, chronic recurrent hemorrhage and bruising.

The pi-spleen dominates the muscles. This really means controlling the muscle bulk. Normally there is no muscle wasting, but when there is malnutrition of the muscles they are weak and wasted.

The pi-spleen takes the mouth as its orifice and opens through it. Normal people have a good appetite, a sense of smell and taste and red and moist lips. Abnormally there is anorexia, tastelessness or a sweetish, greasy taste, and pale sore lips. This is due to ‘heat and damp in the pi-spleen’.

In addition the qi of pi-spleen lifts and fixes the internal organs in their normal position.

The fei-lung

The fei-lung takes charge of respiration. Normally respiration is even and the tissues are well oxygenated. When this function fails breathing is uneven, there is a cough, dyspnoea, shallow respiration and anoxia. This is due to ‘a deficiency of qi of fei-lung which causes an impairment of dissipation and descent of clean qi (oxygen).

The fei-lung frees and regulates the water passage. This function covers the transportation and distribution of nutrients and water, the secretion of sweat and the excretion of urine. Abnormally there will be hyperhydrosis or hypohydrosis, oedema and difficulty in urination due to ‘obstruction of the water passage’.

The fei-lung dominates the hair and skin. Normally the skin is lubricious, the hair lustrous, and sweating is normal. Abnormally the skin is rough, the hair dry and withered and the skin is ‘loose’. This looseness opens the pores and increases the susceptibility to invasion by pathogenic factors.

The fei-lung takes the nose as its orifice and opens through it. Normally the nose is open and there is an acute sense of smell. Abnormally it may be obstructed, there may be anosmia, epistaxis and flaring of the alae nasi (usually accompanied by fever). This is due to ‘invasion of the fei-lung by wind and cold or wind and heat’.

The shen-kidney

The shen-kidney is the main yin organ of the body. The shen-kidney dominates growth, reproduction and development. When this function fails there is a loss of reproductive function, retardation of growth, failure to thrive, and premature senility due to ‘an insufficiency of the qi of shen-kidney’.

The shen-kidney produces marrow, filling the brain with marrow, dominating the bones and producing blood. Normally the spinal cord and the brain are fully developed, the bones are strong and the blood sufficient. Abnormally there will be dizziness, tinnitus, insomnia, poor memory and lassitude. The bones will be weak and brittle and the blood will be insufficient. This is due to ‘an insufficiency of the essence of shen-kidney’.

The shen-kidney controls body water. This entails normal urine production and micturition. Abnormally there will be oliguria or anuria, oedema, difficult or dribbling micturition, polyuria, enuresis and incontinence. This is due to ‘an insufficiency of yang of the shen-kidney failing to control body water’.

The shen-kidney controls the intake of clean qi (air). Abnormally there will be wheezing due to ‘the failure of the shen-kidney to control the intake of clean air’.

The shen-kidney takes the ear as its orifice, opening through it. Normally there is sharp hearing, abnormally there is tinnitus, hearing loss, and even total deafness.

The pericardium

This may be called the organ of circulation in some texts. It is the least important of the zang organs.

It encloses and protects the xin-heart and the diseases of the pericardium result in dysfunction of the xin-heart.

The Functions of the Fu Organs

In general the traditional functions of the fu organs are very similar to their functions in Western medicine. Each fu organ channel connects internally and externally with a zang organ channel. This can have therapeutic importance in that a point on the fu channel may be used to treat a problem on its connected zang channel, and vice versa.

The small intestine

The small intestine connects with the xin-heart. The small intestine receives and digests food from the stomach. It absorbs the pure part and distributes it to the whole body, the impure part going on to the large intestine. This function of the small intestine belongs to the transforming and transporting function of the pi-spleen.

The gall-bladder

The gall-bladder connects with the gan-liver. It stores and discharges bile. The expulsion of bile from the gall-bladder is closely related to the freeing function of the gan-liver. The gan-liver and the gall-bladder take charge of freeing together, and jaundice results when this function is deranged.

The stomach

The stomach connects with the pi-spleen. The stomach stores and digests food, passing it on to the small intestine. A deficiency of qi of the stomach causes indigestion, epigastric pain and sour regurgitation When the qi of the stomach ascends then nausea, heartburn, vomiting, hiccoughs and flatulence occur.

The large intestine

The large intestine connects with the fei-lung. The large intestine absorbs the residue of water and turns the rest of the food into feces. Disturbance of this function results in diarrhea or constipation due to the ‘descent of qi’.

The urinary bladder

The urinary bladder connects with the shen-kidney. The bladder stores and then discharges urine from the body.

The sanjiao

In Chinese the sanjiao means the three cavities. The xin-heart and the fei-lung are in the upper jiao (the chest), and they transport qi and blood to all parts of the body in order to nourish the body. The pi-spleen and stomach are in the middle jiao (the epiastrium) and they digest and absorb food. The shen-kidney and bladder are in the lower jiao (the hypogastrium) and they control water metabolism and the storage and excretion of water. The sanjiao is also sometimes called the triple warmer organ. This is because the three body cavities are intended to control the body temperature.

Extra Organs

The brain

The brain is a sea of marrow, i.e. it is an enlarged part of the spinal cord. The shen-kidney produces the marrow that fills the brain. If the essence of shen-kidney is absent then there is inadequate marrow for the brain. In traditional Chinese medicine the function of the mind is included in that of the xin-heart.

The uterus

The function of the uterus is to control the menstrual cycle, develop the embryo and nourish the foetus. The qi and blood of the channels pass into the uterus through the chong and the ren channels, so that the qi of the body is able to influence the flow and regularity of the menstrual cycle.

IV. Qi, Blood And Body Fluid

Qi, blood and body fluid are important substances and structures in the body. They sustain the vital activities and they nourish the body, thereby keeping the functions of the tissues, organs and channels in good order. The production and circulation of qi and blood also depends on the health of the tissues and organs that are nourished by these substances.

Qi

Qi is a complex concept; it relates to both substance and function. Clean qi (oxygen), waste qi (carbon dioxide) and qi (nutrients) are generally known as material qi, and the existence of material qi is shown by the functional activity of various organs. The function of an organ depends on the functional qi of that organ; for instance, qi of xin-heart or qi of pi-spleen is the vital energy and functional activity of the xin-heart or pi-spleen. The function of an organ, or its functional qi, cannot exist without material qi, and vice versa.

Zhong qi

Zhong qi is found mainly in the chest. It nourishes the structures and functions of the xin-heart and fei-lung.

Nourishing qi

Nourishing qi circulates in the channels and collaterals, mainly in the viscera

Defensive qi

Defensive qi is in the muscles and skin. It circulates outside the channels, in the subcutaneous tissues, and it defends the body against invasion by pathogens.

The original qi is nourished and maintained by qi derived after birth. These combine to form genuine qi, i.e. the total sum of qi in the healthy body. This contrasts with pathogenic factors that are known as pathogenic qi.

Blood

The nutrients from food are digested by the pi-spleen and stomach and they are then transported to the xin-heart and fei-lung and turned into red (oxygenated) blood by qi. The essence of shen-kidney produces bone marrow, and bone marrow uses the digested food to produce blood.

Qi of shen-kidney promotes digestion by pi-spleen, which in turn strengthens the xin-heart and fei-lung. This interaction therefore promotes haemopoesis.

There is a close relationship between qi and blood. The formation and circulation of blood depends on qi, whereas the formation and distribution of qi, as well as the health of the various organs of the body, is dependent on adequate nourishment from the blood. If the flow of blood ‘stagnates’ the circulation of qi is ‘retarded’ and, conversely, if the circulation of qi is ‘retarded’ then the blood flow ‘stagnates’.

Body Fluid

Body fluid is formed from food and drink. It exists in the blood, the tissues, and all the body openings and cavities.

V. The Pathogenesis of Disease

In traditional Chinese Medicine various elements and other factors cause disease. These are known as pathogenic factors or pathogens. Normally the human body is able to resist pathogens and maintain a healthy balance between the body and the environment. This ability is a function of normal qi, especially the defensive qi.

Disease develops because normal qi is unable to resist the onslaught of the pathogenic qi; if pathogenic qi overwhelms normal qi then a functional disturbance of the body results. The major principle of treating a disease in Chinese medicine is to strengthen and protect normal qi and maintain a healthy body. In ancient China a physician was only paid while his patient was healthy, not while his patient was ill!

Pathogenic Factors

These are divided into three main groups, exogenous pathogens, mental pathogens and various miscellaneous pathogens. ‘Phlegm and humour’ and ‘stagnant blood’ are pathological products; once they are formed new pathological changes will ensue so they are considered to be secondary pathogens.

Pathological factors serve as a generalization of clinical symptoms and signs, reflecting the struggle of normal qi and pathogenic qi. By differentiating the clinical symptoms and signs the cause of the disease can be traced, and then treatment can be determined. In order to do this the diseased organs must be defined and the pathogen causing that disease must also be diagnosed. This is called the ‘determination of treatment on the basis of the differentiation of a syndrome’, and it is the basis of diagnosis and treatment in Chinese medicine.

The Exogenous Pathogens

These refer to six relatively abnormal meteorological conditions; wind, cold, summer heat, damp, dryness and heat (fire, warmth). The diseases caused by these pathogens include most viral, bacterial and protozoal diseases and some ‘allergic’ conditions such as urticaria.

	cold and damp				normal qi of

	invade pi spleen			pi-spleen is

	impairing its function		        overpowered

	symptoms of disease—			impairment of the

	anorexia. abdominal distention,		function of pi-spleen

	pain, diarrhoca, cold extremities,

	greasy white tongue, deep thready  pulse

Wind

This pathogen is characterized by movability (of symptoms) and changeability. The clinical manifestations are abnormal limb motion, such as spasm or twitching, and a wandering symptomatic site as in urticaria or arthralgia. The symptoms may vary in intensity and they usually include a dislike of wind, fever, sweating, headache and an itchy throat.

Cold

Invasion of cold will consume the yang causing a contraction of the channels and the blood vessels, and therefore a poor circulation of qi and blood. The symptoms are those of a slight fever, a dislike of cold, hypohydrosis, headache, muscular pain and spasm, and occasionally a dark blue and painful area in the local muscles and skin; a frozen shoulder is a good example of the pathogen cold.

Summer heat

This only occurs in the summer; it damages the yin and may progress to affect the level of consciousness. The symptoms are excessive body heat, profuse sweating, thirst, a dry mouth, dry red skin and, in severe cases, delirium (this is known as heat exhaustion in Chinese medicine). Summer heat may combine with wind and cause convulsions. Summer heat often combines with damp to produce dizziness, nausea, a stuffy sensation in the chest and general malaise.

Damp

Diseases caused by damp are sticky, muddy, greasy and stagnant. Damp causes a generalized heavy feeling associated with distension, dizziness and a heavy head, general malaise and a stuffy sensation in the chest. The patient may also complain of abdominal swelling and an exudative and prolonged skin disease.

Dryness

Dryness consumes yin fluid. There may be a dry sore feeling in the nose, mouth and throat, a coarseness of the skin, or a cough with scanty sputum and possibly haemoptysis. Tuberculosis is an example of the pathogen dryness.

Heat (fire, warmth)

All these represent the same pathogen, but at different intensities. Fire is the most severe and warmth the mildest. As with summer heat the yin may be damaged and this will affect the level of consciousness. The main difference is that summer heat only occurs in the summer and is generally less severe than fire. Diseases that are caused by heat are generally of abrupt onset and rapid change, they are nearly always acute infections. Initially the patient may complain of a high fever, chill, thirst, restlessness, irritability and profuse sweating. In severe cases the patient may be in coma with convulsions.

Mental Pathogens

These are overjoy, anger, anxiety, overthinking, grief, fear and fright.

Excessive fear and fright, or overjoy, injures the xin-heart. This causes palpitations, insomnia, irritability, anxiety and mental abnormality.

Excessive anger causes dysfunction of the gan-liver. This impairs the function of freeing, and causes pain and distention in the costal and hypochondriac region, abnormal menstruation, depression and irritability. If the function of storing blood is disturbed then menorrhagia and hemorrhage can result.

Excessive grief, anxiety and overthinking cause dysfunction of the pi-spleen and stomach. This causes anorexia and a feeling of fullness or distension after meals.

Excessive grief, anxiety and anger cause poor circulation of qi and blood. If there is retardation of qi and stagnation of blood then this can cause a tumor.

Miscellaneous Pathogens

Irregular feeding

Overeating, or eating too much uncooked or cold food, impairs the function of pi-spleen and stomach and causes nausea, vomiting, heartburn, sour regurgitation and diarrhea, for example dyspepsia, gastritis and enteritis.

Over-indulgence in alcohol and an excess of fatty or hot, pungent food produces damp and heat, or phlegm and heat, in the pi-spleen and stomach. Initially dyspepsia results but in more severe cases hypertension, enteritis, gastritis, cirrhosis, cancer or ischaemic heart disease can result. All these are related to nutritional habits.

Too little food intake, or lack of some essential material in food may cause malnutrition. This results in a deficiency of qi and blood which causes emaciation, lassitude, palpitations and sometimes coma.

The intake of contaminated food may impair the function of pi-spleen and stomach, and cause intestinal infections and various parasitic diseases.

Too little or excessive physical labor

Excessive physical labor results in feebleness, emaciation, palpitations and dizziness.

Too little physical exercise causes a poor circulation, limp muscles, soft bones and obesity. This lowers the resistance of the body to disease.

Traumatic injuries

These are the same as in Western medicine.

Appendix

Stagnant blood and phlegm and humour are pathogenic products that may cause further pathological change if they are not eliminated. They have substantive and non-substantive meanings. Substantively they could be described as a blood clot or sputum, the non-substantive meaning is a generalization of a clinical syndrome, for instance, the stertorous breathing that may occur after a severe stroke is described as ‘phlegm covering the orifice of the xin-heart’.

Stagnant blood

Stagnant blood can cause pain. The painful area is fixed and has a stabbing, boring or colicky nature.

Stagnant blood causes hemorrhage. This produces deep purple blood, often with clots.

Stagnant blood causes ecchymosis or petechia.

Stagnant blood can cause a mass. This can be any sort of mass, tumor, splenomegaly or hepatomegaly.

Phlegm and humour

Phlegm and humour are formed when water metabolism is disordered; an accumulation of excess water then turns into phlegm or humour. Phlegm and humour in the lung causes cough, dyspnoca and excessive sputum.

Phlegm and humour in the stomach causes abdominal distension and a succussion sound.

Phlegm covering the heart orifice causes coma and a rattling sound from the sputum in the throat, such as in a stroke.

Phlegm blocking the channels and collaterals causes hemiplegia, numbness of the extremities and difficulty in speech, such as in a stroke.

Phlegm accumulating subcutaneously occurs when there is a subcutaneous lymph node.

VI. Differentiation of Disease According to the Eight Principles

This is the diagnostic system of Chinese traditional medicine. The notes in the ensuing section explain the broad principles of diagnosis, using the history and examination of the patient as a basis.

Diseases are either exterior or interior. If a pathogen such as cold invades the body then it may be superficial or exterior in its damaging effect, such as the common cold, or it may be deep or interior, such as septicaemia. Usually diseases of the exterior show mild fever, headache, generalized aches and pains, and a superficial pulse. Diseases of the interior are characterized by a high fever, thirst, restlessness, delirium, vomiting, diarrhea, a purplish-red tongue proper, with a white or yellow coating and a deep pulse.

Disease may be hot or cold. This means they may be due to the pathogen factors cold or heat. Diseases of heat show the signs of an acute infection or intestinal obstruction, whereas diseases of cold are more chronic in nature. Diseases of cold are characterized by a dislike of cold, pallor, loose stool, polyuria, a large flabby white tongue with a white coating, and a slow or deep and thready pulse. Diseases of heat show fever, dislike of heat, thirst, a red face, constipation, red scanty urine, and a red tongue proper with a yellow coating, associated with a rapid pulse.

Diseases may be xu or shi: Diseases of xu are usually more chronic in nature and are due to a deficiency of either the yin or the yang within the body. The patient is in low spirits, pale, emaciated, has palpitations and the tongue proper is light or red with a white or yellow coating, and there is a xu pulse. A shi disease is often more acute and is due to an excess of the yin or the yang within the body. This presents with irritability, distension and fullness of the chest and abdomen, scanty urine and dysuria, a red or white tongue proper with a yellow or white coating, and a shi or forceful pulse. There is a great deal of reference to xu and shi and it is important to realize that xu really means a deficiency, and shi really means an excess.

The last two principles are yin and yang. They are the generalization of the above ideas, which have already been discussed in Part I of this section.

VII. Methods Of Diagnosis

Inspection

Mental condition

See mental pathogens.

Facial complexion

A red face occurs with febrile diseases, a pale wizened face is due to anaemia or xu diseases, a yellow face occurs in jaundice and a purple face occurs in anoxia, severe pain or stagnation of blood.

Body build, posture and motion

In an obese person there is a chronic deficiency of qi with invasion of phlegm and damp, while in an emaciated person there is hyperactivity of fire due to a deficiency of yin. Paralysis of the limbs indicates insufficiency of qi and blood with blocked channels and collaterals. Convulsions and muscle spasm are often due to an invasion of the channels by wind, due to an insufficiency of yin.

Examination of the tongue

This is a most important diagnostic tool; the tongue is divided into the tongue proper and the tongue coating. A normal tongue has a pink tongue proper with a white clear coating over the tongue.

The tongue proper

A light coloured tongue proper: A light tongue proper indicates insufficiency of qi and blood, invasion of cold, and xu of yang.

A red tongue proper: A red tongue proper indicates diseases due to heat, or internal diseases of heat due to xu of yin.

A purplish-red tongue proper: This occurs in acute diseases of heat when heat has been transmitted from the exterior of the body to the interior, for instance septicaemia. It can also be seen in diseases that exhaust the body fluid, causing hyperactivity of yang due to an insufficiency of yin, for instance terminal carcinoma.

A purplish tongue proper: A purple or bluish-purple tongue proper indicates retardation of qi and stagnation of blood, causing internal cold due to xu of yang, for instance ischaemic heart disease or heart failure.

A large flabby tongue proper: A large and flabby tongue proper with teeth marks indicates xu of qi and xu of yang, for instance chronic enteritis. If there are purplish-red spots on the tongue then this means that there is an invasion of heat.

A streaked tongue proper: Some people have a congenital streaked tongue (this is called a geographical tongue in Western medicine) and it must be ignored. Streaks or red prickles on the tongue normally indicate hyperactivity of fire causing consumption of the body fluid and this is often found after infectious diseases.

Stiff and tremulous tongue proper: The tongue shows fasciculation and it may curl up. This is often accompanied by indistinct speech and mental disorders and indicates disturbance of the mind by phlegm and heat, or deficiency of yin of the gan-liver.

The tongue coating

A white coating: A thick white coating indicates stagnation of food, for instance dyspepsia.

A white greasy coating indicates invasion by the pathogen cold and damp, or phlegm, for instance chronic bronchitis.

A white powder-like coating indicates invasion by plague, for instance typhoid.

A yellow coating: A thick yellow coating indicates chronic indigestion.

A thin yellow coating indicates invasion of fei-lung by wind and heat, for instance a cold.

A greasy yellow coating indicates internal damp and heat, or phlegm and heat, for instance bacillary dysentry or a lung abscess.

A charring yellow coating indicates the accumulation of heat in the intestines which damages the yin, for instance infectious diseases of the intestine.

A yellow tongue coating may also be caused by smoking.

A greyish- black coating: A grayish-black slippery coating indicates excessive cold due to xu of yang, and this occurs in certain types of dyspepsia.

A grayish-black dry coating indicates exhaustion of the body fluids due to excessive heat, for instance dehydration.

A peeling coating: When the tongue coating is partially or completely peeled off the tongue proper can be seen. This indicates severe damage of the normal qi and an extreme deficiency of yin, for instance the late stages of terminal cancer.

Auscultation

Listening to the speech

Speaking in a low feeble voice indicates diseases of xu nature and sonorous speech indicates shi diseases. A partial loss of consciousness means that heat and phlegm are covering the heart orifice. Talking to oneself means that there is a derangement of the mind, and indistinct speech often means that the channels are blocked by wind and phlegm.

Listening to the respiration

Feeble respiration with dyspnoea and excessive sweating indicates xu of qi of the xin-heart and fei-lung. Heavy respiration, with a productive cough, indicates a shi disease of fei-lung due to an accumulation of phlegm and heat, or phlegm and humour, in fei-lung.

Listening to the cough

A heavy unclear cough is caused by invasion of fei-lung with wind and cold, or accumulation of cold and humour in fei-lung. A loud clear cough often indicates wind and heat, or phlegm and heat, in fei-lung. A dry cough with minimal sputum is often caused by a chronic xu of yin of fei-lung, for instance tuberculosis.

Smell

A rank foul smell of any discharge or secretion indicates a disease of shi nature (infection). A light smell indicates a disease of xu nature, for instance scanty red urine with a foul smell indicates a hot shi-disease, like cystitis, while clear profuse urine indicates a cold xu disease, like diabetes insipidus.

Interrogation

This is best summed up by the translation of an old Chinese text called the ten askings:

One ask chill and fever, two perspiration, three ask head and trunk, four stool and urine, five food intake and six chest. Deafness and thirst are seven and eight, nine past history and ten causes. Besides this you should ask about the drugs taken, and for women patients you should ask their menstrual and obstetric history. Finally, for infants, ask about the normal childhood diseases.

This section is included purely for interest as the method of taking a history so clearly corresponds with that used in Western medicine.

Palpation

Palpation of the pulse

The pulse provides a great deal of the information gained from palpation, although a mass or trauma will obviously have to be examined on a more Westernized basis. In classical Chinese medicine there are six pulses at each wrist. These pulses occupy three positions at each wrist over the radial artery, and each position has a deep and superficial pulse. Each of these pulses represents a different organ and in this way all twelve of the zang fu organs are represented by a wrist pulse. The character of the pulse indicates the state of health of each organ and also the balance between each organ. Although traditional pulse diagnosis is still used in China we were taught a much simpler form of pulse ‘generalization’ rather than the traditional pulse diagnosis, and it is this purse ‘generalization’ that will be discussed in the following section.

A superficial pulse: This pulse responds to the finger when pressed lightly and becomes weak on heavy pressure. It is often seen in the early stages of diseases caused by exogenous pathogens, such as infections.

A deep pulse: This pulse is not clear on superficial palpation but it is felt on deep pressure. It is often seen in interior diseases such as glomerulonephritis.

A slow pulse: This pulse is less than sixty beats per minute; it may be normal or it may be seen in atrio-venticular block, i. e. diseases of cold.

A rapid pulse: This pulse is greater than sixty beats per minute; it is often seen in diseases of heat.

A xu pulse: The pulse is weak and forceless and goes on heavy pressure. This is seen in diseases of xu nature, such as malnutrition or diseases of pi-spleen.

A shi pulse. The pulse is forceful and will not go on deep palpation; it is seen in shi diseases.

A large pulse: This is an abundant pulse; it is like a surging wave and is seen in diseases of shi nature and heat.

A thready pulse: This is like a thready flow of water and it is often seen in xu diseases

A bowstring pulse. The pulse is hard and forceful and gives the sensation of pressing on the string of a bent bow. It may be normal or it may be seen in diseases where there is hyperactivity of the yang of the gan-liver.

A gliding pulse: This is round and forceful, like beads rolling on a plate. It is often seen in cases of indigestion or obstruction of phlegm. Sometimes a gliding pulse may be seen in a healthy person, especially in pregnancy.

An intermittent pulse. The pulse is irregular. This occurs in retardation of qi and stagnation of blood, causing a deficiency of qi in the xin-heart, such as atrial fibrillation.

Palpation for all other pathology, such as mass or trauma, follows the same rules as in Western medicine.

VIII. The Differentiation Of Syndromes

The Chinese described symptom pictures which allow the differentiation of specific Zang Fu syndromes. The major syndromes are described below and provide further useful information which will enable the acupuncturist to reach a clear Zang Fu diagnosis.

Syndromes of the Xin-heart

1. Weakness of the qi of the xin-heart

Clinical Manifestations: Palpitations, dyspnoea aggravated by exertion, a pale tongue and a thready xu or irregular pulse. If there is evidence of a deficiency of the yang of the xin-heart then cold limbs, pallor, and purplish lips can be found. Exhaustion of the yang of the xin-heart may manifest itself as profuse sweating, mental confusion and a fading, thready pulse.

Aetiology and pathology: This syndrome is usually caused by general malaise after anxiety or a long illness, which injures the qi of the xin-heart. When the qi of the xin-heart is weak it fails to pump blood normally resulting in palpitations, dyspnoea and a thready irregular or xu pulse. Alternatively, a prolonged weakness of the qi of the xin-heart may lead to weakness of the yang of the xin-heart. When the body lacks yang it lacks energy and heat, therefore symptoms such as chills, cold limbs and pallor occur. If the yang of the xin-heart is exhausted, the defensive qi of the body surface can no longer protect the essential qi and lets it dissipate, this results in profuse sweating and a fading, thready pulse.

2. Insufficiency of the yin of the xin-heart

Clinical Manifestations: Palpitations, insomnia, dream disturbed sleep, anxiety and possible malar flush with a low grade fever. A red tongue proper and a thready and rapid pulse will also be found.

Aetiology and pathology: This syndrome is usually due to damage of the yin by a febrile disease or anxiety, which consumes the yin of the xin-heart. Insufficiency of the yin of the xin-heart often leads to hyperactivity of the fibber of the xin-heart, resulting in the above symptoms. Insufficiency of the yin of the xin-heart may also cause insufficiency of the blood of the xin-heart. If this happens then there is not enough yin and blood to nourish the xin-heart, and the xin-heart fails in its function of keeping the mind. The symptoms of insomnia, poor memory and dream-disturbed sleep will therefore appear.

3. Stagnation of the blood of the heart

Clinical Manifestations: Palpitations, cardiac retardation and pain (paroxysms of pricking pain, or in more severe cases colicky pain often referred to the shoulders and the back), peripheral and central cyanosis and a thready or irregular pulse.

Aetiology and pathology: This syndrome is due to anxiety leading to stagnation of qi and stagnation of blood. It may also be due to insufficiency of the qi of the xin-heart after a chronic illness; if the qi of the xin-heart is too weak to sustain the cardiac circulation then stagnation of blood of the xin-heart and obstruction of the blood vessels results. Stagnation of the blood often impedes the distribution of yang qi in the chest causing discomfort in the chest (angina) and peripheral cyanosis. A dark purplish tongue proper, or purple spots on the tongue, and a thready or irregular pulse are manifestations of stagnation of blood and confinement of the yang qi.

4. Hyperactivity of the fire of the xin-heart

Clinical Manifestations: Ulceration, swelling and pain in the mouth and tongue, insomnia accompanied by fever, a flushed face, a bitter taste in the mouth, hot, dark and yellow urine, a red tongue proper and a rapid pulse.

Aetiology and pathology: This syndrome is often due to mental irritation which causes depression of qi. The depressed qi may turn into endogenous fire and disturb the mind, causing the symptoms of insomnia and fever to appear. As the xin-heart has the tongue as its orifice, and its function is reflected in the face, a disorder of the fire of the xin-heart may cause many of the above symptoms.

5. Derangement of the mind

Clinical Manifestations: Depression, dullness, muttering to oneself, anxiety, incoherent speech, mania and in severe cases coma.

Aetiology and pathology: This syndrome is often due to mental irritation which causes depression of qi. The body fluid stagnates to form damp and/or phlegm which causes blurring of the xin-heart and mind, resulting in dullness and depression. If the depressed qi turns into fire and the phlegm and fire disturb the xin-heart, anxiety, incoherent speech and mania result. Blurring of the mind by phlegm and/or damp, or phlegm and/or fire causes coma. A high fever, coma and delirium resulting from invasion of the pericardium by heat, are due to pathogenic heat invading deep into the interior of the body and disturbing the mind.

Syndromes of the Gan-liver

1. Depression of the qi of the gan-liver

Clinical manifestations: Hypochondrial and lower-abdominal pain and distension, a distended sensation in the breasts, discomfort in the chest and belching, sighing, or a sensation of a foreign body in the throat. Women may experience irregular periods.

Aetiology and pathology: This syndrome is usually due to mental irritation causing depression of the qi of the gan-liver and stagnation of the qi in the liver channel. This leads to hypochondrial and lower abdominal pain and distension, a distended sensation in the breasts and discomfort in the chest. Stagnation of the qi of the gan-liver may affect the stomach, causing failure of the qi of the stomach to descend and resulting in belching. The sensation of a foreign body in the throat is due to stagnation of the qi of the liver channel, which with the phlegm forms a lump in the throat. Depression of the qi of the gan-liver and the subsequent lack of freeing may further impair the gan-liver’s function of blood storage. Stagnation of qi leads to stagnation of blood, the cause of irregular periods.

2. Flare-up of the fire of the gan-liver

Clinical manifestations: Dizziness, a distended sensation in the head, headache, red eyes, a bitter taste in the mouth, a flushed face, irritability and sometimes haematemesis and epistaxis can occur. The tongue proper is red with a yellow coating and the pulse is wiry and rapid.

Aetiology and pathology: This syndrome is often due to a longstanding depression of the qi of the gan-liver which can turn into fire. It may also be due to over-indulgence in alcohol and tobacco causing an accumulation of heat which turns into fire. The upward disturbance of the fire of the gan-liver causes dizziness, a distended sensation in the head, headache, red eyes, a bitter taste in the mouth and a flushed face. Fire injures the gan-liver, causing impairment of its function in promoting the free flow of qi and this causes irritability. When the fire of the gan-liver injures the blood vessels it causes extravasation of blood and haematemesis and epistaxis can occur.

3. Stagnation of cold in the liver channel

Clinical manifestations: Lower-abdominal pain, swelling and distension in the testis with tenesmus. The scrotum may be cold and contracted and these symptoms can be alleviated by warmth. The tongue proper is pale with a white coating and the pulse deep and wiry or slow.

Aetiology and pathology: The liver channel curves around the external genitalia and passes through the lower abdomen. When cold, which is characterized by contraction and stagnation, stays in the liver channel, stagnation of the qi and blood may occur and cause lower-abdominal pain, swelling and distension of the testis with tenemus. Cold and contraction of the scrotum are also due to the pathogen cold.

4. Insufficiency of the blood of the gan-liver

Clinical manifestations: Dizziness, blurred vision, dry eyes, pallor, spasm of the tendons and muscles, numb limbs and a scanty light coloured menstrual flow with a prolonged cycle.

Aetiology and pathology: This syndrome often occurs after a hemorrhage or another chronic disease in which blood is destroyed, and the reserves of the gan-liver are depleted, thereby resulting in a failure of the gan-liver to nourish the channels. A xu (deficiency) of blood may cause endogenous wind so that the symptoms of muscle spasticity and numb limbs appear. An upward disturbance of endogenous wind (xu type) can cause dizziness and blurred vision. Insufficiency of the blood of the gan-liver and disruption of its blood storage function results in emptiness of the chong channel which will cause menstrual abnormalities.

5. Stirring of the wind of the gan-liver by heat

Clinical manifestations: High fever, convulsions, neck rigidity (Opisthotonos) and coma. A deep-red tongue proper and a wiry, rapid pulse are also found.

Aetiology and pathology: This syndrome is due to transmission of the pathogen heat from the exterior to the interior, which burns the yin of the gan-liver and deprives the tendons and blood vessels of nourishment. Furthermore, pathogenic heat in the interior stirs up endogenous wind causing fever, convulsions and neck rigidity. Coma is due to pathogenic heat affecting the pericardium and disturbing the mind.

Syndromes of the Pi-spleen

1. Weakness of the qi of the pi-spleen

Clinical manifestations: Sallow complexion, anorexia, loose stools, oedema, and lassitude. There may be distension and a bearing-down sensation in the abdomen, a prolapse of the rectum and/or uterus, or a chronic blood disorder such as purpura, bloody stools or uterine bleeding. A pale tongue proper and a thready xu pulse will be found on examination. If there is evidence of xu (deficiency) of the yang of the pi-spleen, symptoms of cold such as cold limbs will occur.

Aetiology and pathology: This syndrome is often caused by irregular food intake, excessive mental strain or chronic disease. These problems result in weakness of the qi of the pi-spleen and impair its function of transportation and transformation, which consequently results in a poor appetite and loose stools. Accumulation of fluid in the interior is the cause of the oedema. The general malaise is due to a lack of food failing to provide a nourishing basis for blood formation. When the qi of the pi-spleen is weak, it loses its ability to uplift tissues so that there is distension, a bearing-down sensation in the abdomen and a prolapse of the rectum and/or uterus. Weakness of the qi of the pi-spleen also causes the blood disorders. Xu (deficiency) of the yen of the pi-spleen causes cold limbs.

2. Invasion of the pi-spleen by cold and damp

Clinical manifestations: Fullness and distension in the chest and epigastrium, a poor appetite, a heavy feeling in the head, malaise, borborygmii, abdominal pain and loose stools. A white sticky tongue coating and a thready pulse will be found.

Aetiology and pathology: This syndrome usually occurs after rain, or it may be due to over-indulgence of raw or cold food. In both cases the pathogen cold and damp injure the pi-spleen impairing its function of transportation and transformation and resulting in a poor appetite, borborygmii, abdominal pain and loose stools. As pathogenic damp is sticky and stagnant, it is liable to block the flow of qi causing a sensation of epigastric fullness and distension.

Syndromes of the fei-lung

1. Invasion of the fei-lung by the pathogen wind

Clinical manifestations: An itchy throat and cough associated with fever and chills. If the wind is accompanied by cold then the patient usually feels cold and presents with nasal obstruction, a watery nasal discharge and mucoid sputum. The tongue coating is thin and white. If the wind is associated with heat, fever will be the most prominent symptom and will be associated with a red, swollen throat, a purulent nasal discharge and purulent sputum. The tongue coating will be yellow.

Aetiology and pathology: Invasion of the fei-lung by the pathogen wind disturbs its function of dispersal and descent. Normal respiration is affected producing the symptoms of cough and nasal obstruction. Cold is a yin pathogen and therefore liable to damage the yang qi. Consequently when wind is associated with cold, the sensation of cold will be more severe than that of fever and will be accompanied by a watery nasal discharge and white mucoid sputum. Heat is a yang pathogen, and if wind is accompanied by heat, fever will become the most prominent symptom and will be associated with a purulent nasal discharge and purulent sputum.

2. Retention of damp and/or phlegm in the fei-lung

Clinical manifestations: Cough, dyspnoea and white frothy Sputum The onset is generally precipitated by cold, and the tongue coating is white and sometimes sticky.

Aetiology and pathology: This syndrome is due to the disturbance of the normal circulation of body fluid, the body fluid accumulates and precipitates the formation of damp/or phlegm. When damp and phlegm remain in the fei-lung the passage of qi is blocked and the functions of the fei-lung are impaired, this results in the above symptoms.

3. Retention of phlegm and/or heat in the fei-lung

Clinical manifestations: Cough, dyspnoea, wheezing and thick yellow and/or green sputum (occasionally pus). This can be associated with rigors and a fever; the tongue proper is red with a yellow coating and there is a rapid pulse.

Aetiology and pathology: This syndrome is caused by invasion of exogenous wind and/or heat, or wind and/or cold, which later develops into heat. The heat mixes with phlegm, which remains in the fei-lung and blocks the circulation of qi; this impairs the functions of the fei-lung and causes cough, dyspnoea and wheeze. Heat exhausts body fluid causing purulent sputum. When phlegm and heat are found in the fei-lung, stagnation of blood results which in turn leads to purulent, bloody sputum.

4. Insufficiency of the yin of the fei-lung

Clinical manifestations: A dry, unproductive cough associated with sticky, scant, blood-stained sputum, fever, a malar flush, a feverish sensation in the palms and soles, a dry mouth and night sweats. A red tongue proper and a thready and rapid pulse will be found.

Aetiology and pathology: Such symptoms are usually caused by chronic disease of the fei-lung, which consumes the yin and results in insufficiency of body fluid. The fei-lung is deprived of nourishment, its functions are impaired and this produces a dry mouth. Xu (deficiency) of yin causes endogenous heat which drives out body fluid and injures blood vessels, this results in a fever, a malar flush, a feverish sensation in the palms and soles, night sweats and bloody sputum.

Syndromes of the Shen-kidney

1. Weakness of the qi of the shen-kidney

Clinical manifestations: A sore and weak sensation in the lumbar region and knee joints, urinary frequency, polyuria, dribbling, enuresis, urinary incontinence, dyspnoea, wheezing, and occasionally infertility. The pulse will be thready.

Aetiology and pathology: This syndrome is often caused by malaise after a prolonged chronic illness, or may be the result of senility or congenital deficiency. Weakness of the qi of the shen-kidney results in an inability of the urinary bladder to control urination; this causes enuresis, incontinence, frequency and urgency. Shen-kidney stores essence (shen), but when the qi of the shen-kidney is deficient, infertility can result. When the qi of the shen-kidney is weak, it fails to help the fei-lung perform its function of descent, qi therefore attacks the fei-lung resulting in dyspnoca and wheezing.

2. Insufficiency of the yang of the shen-kidney

Clinical manifestations: These are broadly similar to the syndrome described as ‘Weakness of qi of the shen-kidney’. The major symptoms are a dull ache in the lumbar region and knee joints, cold, pallor, impotence, oliguria and oedema of the lower limbs. A pale, tooth-marked tongue and a deep thready pulse will be found.

Aetiology and pathology: This syndrome usually occurs after a prolonged chronic illness in which the yang of the shen-kidney is injured, it may occasionally be due to an excess of sexual activity which also injures the yang of the shen-kidney. In either instance, the yang of the shen-kidney fails to warm the body which results in cold aching sensations in the low back and knee joints, and impotence. Then shen-kidney controls water metabolism, and an insufficiency of the yang of the shen-kidney results in oliguria; the subsequent fluid excess presents with the symptom of oedema.

3. Insufficiency of the yin of the shen-kidney

Clinical manifestations: Blurred vision, tinnitus, amnesia, feverish sensation in the palms and soles, a malar flush, night sweats, hot yellow urine and constipation. The tongue proper will be red and the pulse thready and rapid.

Aetiology and pathology: This usually occurs after a prolonged chronic illness in which the yin of the shen-kidney is impaired, it may also be due to an over-indulgence in sexual activity, which consumes the shen-kidney. Either of these factors can result in the shen-kidney failing to produce marrow and maintaining normal cerebral function. The symptoms that result are dizziness, blurred of nourishment. Furthermore, pathogenic heat in the interior stirs up endogenous wind causing fever, convulsions and neck rigidity. Coma is due to pathogenic heat affecting the pericardium and disturbing the mind.

Syndromes of the Pericardium

The syndromes of the pericardium are seen clinically as the invasion of the pericardium by heat. The symptoms are a high fever, coma and delirium, these result from heat invading the interior of the belly, which in turn disturbs the mind.

Syndromes of the Small Intestine

Disturbance of the function of the small intestine is included in the syndromes of the pi-spleen, particularly with respect to its main function (transformation and transportation).

Syndromes of the Gall Bladder

Damp and heat in the gall bladder
Clinical manifestations: Yellow sclera and skin, pain in the costal and hypochondrial region, pain in the right upper abdominal quadrant and a bitter taste in the mouth. Some patients may vomit sour and/or bitter fluid. The tongue coating is yellow and sticky.

Aetiology and pathology: The function of the gall bladder is to store and excrete bile, and this depends on the normal function of the gan-liver. Exogenous damp and/or heat (heat caused by depression of the gan-liver, damp and heat caused by overindulgence in alcohol and rich food) may accumulate in the gan-liver and gall bladder, thereby impairing the free flow of qi. Bile cannot therefore be secreted and freely excreted, and the subsequent biliary overflow causes jaundice, a bitter taste in the mouth and vomiting. Stagnation of the qi of the gan-liver and gall bladder also leads to stagnation of blood, causing right hypochondria! pain. This syndrome is closely related to the gan-liver, and is also known as ‘damp and heat in the gan-liver and gall bladder’.

Syndromes of the Stomach

1. Retention of food in the stomach

Clinical manifestations: Distension and pain in the epigastric region, anorexia, belching, heartburn and vomiting. The tongue has a thick sticky coating.

Aetiology and pathology: This syndrome is usually caused by over-eating, which leads to the retention of undigested food in the stomach; the qi of the stomach ascends rather than descending.

2. Retention of fluid in the stomach due to cold

Clinical manifestations: The sensation of fullness associated with a dull epigastric pain, aggravated by cold and alleviated by warmth. The tongue coating will be white and sticky and the pulse thready or slow.

Aetiology and pathology: This syndrome usually follows a cold after rain, or may be precipitated by the excessive ingestion of raw or cold food. Either of these factors result in cold in the stomach which causes stagnation of qi and pain. Prolonged damage injures the yang qi of the pi-spleen and stomach so that body fluid is retained in the stomach instead of being transported and transformed, this results in vomiting.

3. Hyperactivity of the fire of the stomach

Clinical manifestations: A burning in the epigastrium, thirst, a preference for cold drinks, vomiting of undigested food or sour fluid, gingival swelling pain and ulceration, halitosis. The tongue proper will be red with a dry yellow coating.

Aetiology and pathology: This syndrome is usually due to overeating rich food, which causes heat to accumulate in the stomach. The heat consumes body fluid and causes the qi of the stomach to ascend. This results in a burning epigastric pain, thirst, a preference for cold drinks and vomiting. Halitosis and gingival ulceration are due to the fire element in the stomach.

Acupuncture anaesthesia is a recent and purely Chinese invention. The Thoughts of Chairman Mao state that ‘Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level.’ This was a very important impetus to the development of this application of acupuncture.

The Chinese look upon acupuncture anaesthesia as a useful working method for local or regional anaesthesia. They do not consider their methods of acupuncture anaesthesia to be perfect, but they look upon it as a subject that is being evaluated and developed all the time. The majority of operative procedures in Chinese hospitals are done with local or regional anaesthetics, and acupuncture anaesthesia is probably the commonest form of regional anaesthetic in use. Most hospitals that we visited seemed to be using acupuncture anaesthesia for between 40 % and 60 % of their surgical procedures.

The use of acupuncture anaesthesia is not confined to minor operations but includes major abdominal and cardio-thoracic surgery. During our visit to China we saw more than forty operations with acupuncture as the anaesthetic. There is no doubt that it was effective in a wide variety of operations. The Chinese often give figures of about 90% success rate, but our impression was that it was an acceptable form of anaesthesia for nearly all the operations we saw.

The clinical advantages of acupuncture anaesthesia are obvious. It is a safe and considerably less dangerous procedure than general anaesthesia, it is safer for the old and disabled, postoperative recovery is far swifter, it is a very cheap and simple form of anaesthesia, and the physiological functions of the body, such as the pulse rate and blood pressure, remain consistently stable during anaesthesia. The main disadvantage is that very occasionally the anaesthetic does not work and an alternative form of anaesthesia may be required fairly swiftly.

The possibility that a small number of patients might experience some pain is probably unacceptable in the context of a Western medical system. Furthermore, there is no muscle relaxation in acupuncture anaesthesia so it can be quite hard work to retract the abdominal muscles. Also, the Chinese have not found a solution to the discomfort that is occasionally caused by traction on the visceral contents.

Before acupuncture anaesthesia the Chinese explain to the patients what is going to happen. Most people, including the Chinese, are very frightened before going into an operating theatre, especially if they are going to be awake. It is therefore important to have the confidence of the patient before embarking on any type of surgery involving local anaesthesia. A premedication of barbiturates is usually given and the patient is wheeled to theatre. Body and ear points are selected on the same basis as for therapy and these are then stimulated electrically. In general low frequencies are used on the ear points and on distal body points (5-300Hz), and high frequencies are used on local points (3,000-l0,000Hz). When using the body points deqi is obtained first. When using ear points the Chinese insert the needle obliquely to be sure of hitting the point, and tape the needle in. Ear points will not be painful because there is not usually any local pain pre-operatively.

A period of induction is required whether ear or body points are used, and this is usually about twenty minutes. After inserting the needles the electrical stimulator is connected, set at the required frequency and maximum tolerable intensity, and left on throughout the operation. After the induction period anaesthesia should be adequate for the operation. For particularly painful operative procedures, such as separating the periosteum from the bone, small amounts of local anaesthetic are sometimes used. Very occasionally intravenous narcotics may be given if the operation is prolonged or the procedure is painful.

Point selection for acupuncture anaesthesia follows exactly the same rules as acupuncture therapy. When selecting body points for a thyroidectomy use Hegu (LI 4) and Neiguan (P 6) as distal points, and Neck-Futu (LI 18) as a local point. The ear points for this operation would be Throat, Neck, Shenmen and Subcortex; Throat and Neck are local points and Shenmen and Subcortex are sedative points. It is obvious, therefore, that the principles of point selection follow the principles of point selection for therapy, i.e., when using body acupuncture select local and distal points and when using ear acupuncture select local representative points and add in sedative points.

Acupuncture anaesthesia is a fascinating application of acupuncture; perhaps, in the West, it could be used for postoperative analgesia rather than anaesthesia.

Some Ideas on the Physiological Basis of Acupuncture

At present there is no unified theory that explains the complex mechanism of acupuncture, but there are many well substantiated physiological changes that do occur when this technique is applied. The Chinese are investing a large amount of research resources in the investigation of the physiology of acupuncture; they are not limited to the traditional approach but they do see that this is empirically useful and gives better results than simply needling tender areas. Contradictions can co-exist easily in the Chinese mind and so there is no real conflict between the traditional and the more scientific approach to acupuncture, and furthermore they see this combined approach as mutually beneficial.

Acupuncture points are well known to us in the West, studies by Melzack show that acupuncture points correlate very closely with trigger points¹ and that the use of these trigger points, particularly for injection therapy, is a well recognized technique within Western medicine. These tender areas (acupuncture points) are frequently to be found on or near neuromuscular junctions. Further work by Becker also strongly suggests that acupuncture points have special electrical properties, and that the skin over acupuncture points is able to pass electrical current more easily than the surrounding areas of normal skin.² As yet, however, there is no good anatomical or physiological basis for the theory of the channels; although a considerable amount of physiological investigation has been directed at attempting to prove the existence of channels.³

The fact that acupuncture works as an analgesic is quite clear; surgical analgesia in animals and in man follows the needling of specific acupuncture points, and sham needling of non-specific points does not produce analgesia.⁴ Furthermore, using the human model of dental pain, acupuncture can also be shown to be a specific and relatively powerful analgesic.⁵ However, there has been a distinct lack of good clinical trials on the effect of acupuncture as a therapy for chronic pain problems; the author has reviewed the studies that are available and suggested models that can be used for the clinical evaluation of acupuncture.⁶ Such clinical trials are essential if acupuncture is to progress as a therapeutic technique within the context of Western medicine.

When an acupuncture point is stimulated various neurological and neurohumoral changes occur in the body. In decerebrate cats, stimulation of the skin inhibits the passage of painful stimuli.⁷ Work on small animals also shows that stimulating a specific acupuncture point changes the nerve transmission in the painful area, the spinal cord and the thalamus.⁸ Furthermore, some of the detailed neurophysiological studies completed at the Shanghai Institute of Physiology suggests that there is a supraspinal centre that inhibits viscerosomatic reflexes and that this is stimulated via acupuncture points; there is considerable evidence which would support the mediation of painful stimuli at a thalamic level as being one of the important mechanisms through which acupuncture can have an effect.⁹

The gate theory of pain¹⁰ also goes some way to explain the mechanism of acupuncture in pain. All pain input enters the spinal cord via the substantia gelatinosa, pain impulses travelling along the small nerve fibres. The large myelenated nerve fibres have an inhibitory effect on pain, by closing the gate to pain at cordal level, within the substantia gelatinosa. If pain is not transmitted to the brain, no pain is perceived. Melzack has suggested that acupuncture stimulates large myelenated nerve fibres, thereby closing the gate to pain.¹¹ However, there are a large number of problems with the gate theory of pain, particularly as it is used to explain the mechanism of acupuncture. It is probable that acupuncture does work partially through the gate control theory, although this cannot be seen as a complete explanation of its mechanism.

Endorphins, or naturally occurring morphine-like substances, have recently been found in a wide variety of body tissues. In people suffering from chronic pain the endorphin level in the fluid around the brain, the cerebrospinal fluid, is low. Acupuncture increases the endorphin level in various parts of the central nervous system and beta-endorphin can be shown to attenuate chronic pain.¹² This analgesic effect can sometimes be blocked by naloxone, a morphine antagonist¹³ although other studies suggest that the analgesic effect of acupuncture cannot be reversed by naloxone. Therefore, although the endorphin theory is another very useful idea through which acupuncture can be shown to have an effect, it does not seem to explain the complete physiological mechanism of this therapeutic technique.

These two ideas, the gate control theory of pain and endorphins, are not mutually exclusive. They go some way towards explaining the possible mechanism of acupuncture in pain, but the clinical application of acupuncture is much wider than its use in pain, so these ideas leave a great deal unexplained.

During our course we had a considerable number of lectures on the physiological basis of acupuncture, and some interesting ideas were discussed. As well as having an analgesic effect acupuncture seems to have a sedative effect. Puncturing Zusanli (St 36) bilaterally causes the alpha rhythm in the brain to predominate, and its amplitude to increase. Acupuncture also has a regulatory and anti-shock effect, which has been clearly demonstrated by creating massive blood loss in dogs; the dogs receiving acupuncture show a significantly increased survival rate.¹⁴ Acupuncture also affects the immune system; needling increases the white cell count, raises the titres of all groups of immunoglobulins, increases the activity of the reticulo-endothelial system and raises the level of serum complement. The claims that acupuncture can affect the immune system have been made primarily by the Chinese, but the author has also conducted some preliminary research which would seem to confirm this hypothesis. Furthermore, acupuncture has been shown, quite clearly, to cause changes in many of the chemical messengers (neurotransmitters) within many different areas of the brain.¹⁵

This short summary of the available evidence strongly suggests that acupuncture is having a fundamental physiological effect on the human body. The reason for including this section is that the scientific investigation of acupuncture is an integral part of the modern Chinese approach to acupuncture; this brief review just summarizes some of the current ideas in this field and more detailed information, dealing with these and other concepts, is available in many Western scientific journals (particularly the journal Pain). The effect of acupuncture on the body is attracting a great deal of scientific interest, both in China and the West. The field is changing fast and progressively more of the empirical findings of the ancient Chinese are being scientifically validated.

References

1 Melzack et al, 1977, Pain, 3 (1977), page 3.

2 Becker et al, Transactions on Biomedical Engineering, (1975) page 533.

3 National Symposia of Acupuncture Moxibustion and Acupuncture Anaesthesia, Peking, 1979.

4 Teral (Doctoral thesis), Faculty of Medicine, Montpellier, (1975).

5 Chapman et al, Pain, 9 (1980), page 183.

6 Lewith et al, Pain, 16 (1983), page 111.

7 Hill et al, Experimental Brain Research, 9 (1969), page 284.

8 Niboyet et al, L’Anaesthesic par l’Acupuncture, Moulins-les Metz, France, (1973).

9 Eh Shen et al, Chinese Medical Journal, 1 (1975), page 431.

10 Melzack et al, Science, 150 (1965), page 197.

11 Melzack et al, Pain, 1 (1975), page 357.

12 Akil et al, Science, 201 (1978), page 463.

13 Pomeranz, Advances in Biomedical Psychopharmacology, 18, page 351.

14 Anon, 1974, Journal of Chinese Medicine, 2 (1974), page 261.

15 Han Jisheng, National Symposia of Acupuncture, Moxibustion and Acupuncture Anaesthesia. Peking, 1979, page 27.

How Does Acupuncture Work?

In spite of a great deal of excellent research designed to answer this question, as yet there are no good, clear, simple answers available. There are, however, a variety of theories that attempt to explain the mechanism of acupuncture. Pain is the area in which most research has been completed, and therefore most of the theories about the mechanism of acupuncture are related to the use of acupuncture in diseases of pain.

The Gate Theory of Pain

In 1965 a theory called the ‘Gate Theory of Pain’ was produced, and for this idea, and others, Drs. Melzack and Wall won scientific acclaim. This theory was the first serious attempt to unify the many ideas that existed about the mechanism that perceives and transmits pain through the nervous system. The Gate Theory states that there are some specific nerve fibers that transmit pain to the spinal cord, whilst the input of other nerve fibers inhibits the transmission of pain. Both of these groups of fibers meet at a sort of ‘micro-chip’ in the spinal cord called the substancia gelatinosa.

The substancia gelatinosa is responsible for the integration of painful and pain inhibitory stimuli. If the pain input is excessive then pain is transmitted up the spinal cord, and the brain perceives it as pain. Pain fibers are probably the bare nerve endings found in the skin and other superficial tissues; they are easily stimulated and it would be an impossible situation if pain was experienced

every time we touched something. This theory proposes a balance between stimulation of the pain fibers and inhibition of that stimulus, so that pain is perceived only if the pain input overrides the inhibition of pain.

The only problem with this theory is that it does not explain fully the available facts. Acupuncture excites the pain inhibitory nerve fibers for a short period of time, thereby blocking pain, but the effects of acupuncture can last for some months after the acupuncture needle has been removed, and nothing in the Gate Theory really explains this prolonged effect. Acupuncture is a valuable treatment in a variety of non-painful diseases and the Gate Theory makes no attempt to explain the mechanism of acupuncture in the treatment of these diseases.

Another theory frequently proposed for acupuncture is that it represents a type of counter-pain. If pain is created in one part of the body then pain experienced in another part of the body is not noticed. This is a valid experimental model for short term relief of relatively mild pain, but again it does not explain the long-lasting effects of acupuncture in some types of severe pain.

Endorphins

The growing level of drug addiction in the West has provided a great stimulus for research into the mechanism of morphine action and addiction. Morphine-like substances have recently been discovered in the central nervous system. These substances are called endorphins, or naturally-occurring morphines,1 and they have been found to be very effective in blocking pain. Endorphins are released into the nervous system by the action of acupuncture and the effects of acupuncture anaesthesia can be reversed by the use of anti-morphine drugs.

From some recent research work it would seem that not all types of acupuncture are blocked by anti-morphines. If a patient has a painful arthritic knee, and acupuncture provides relief for the knee pain, then anti-morphines do not usually block the effects of this type of acupuncture therapy. The effects of acupuncture can be very swift (in terms of seconds) and it seems that the release of chemicals might possibly be too slow a process to have such a swift action. The endorphin theory again only deals with pain and makes little attempt to explain the use and effects of acupuncture in non-painful diseases.

No Real Answer?

The fact of the matter is that acupuncture does work, and has been shown to do so, but the exact answer as to how it works is unclear. The current scientific explanations give a logical and supportable basis for stating that it does have an effect on the nervous system, but it is difficult to draw any more definite conclusions.

The mechanism of pain perception and transmission has not been clearly and completely defined, and in the light of the current state of knowledge about the basic mechanism of pain it is a little unreasonable to expect an explanation of the effects of acupuncture on pain.

The Autonomic System

It is fascinating to speculate about the mechanism of acupuncture in the non-painful diseases, such as asthma. The autonomic nervous system control’s the body’s breathing, heart beat and digestion. It continues to function without any conscious will, but it should not be confused with the unconscious mind, frequently alluded to in text-books on psychology. It is really better to think of the autonomic system as the automatic base or foundation on which the body is built. We understand very little about the way in which the autonomic system works, and even less about how acupuncture might affect this system.
Asthma is due to a contraction of the small breathing tubes that allow air to enter the lungs. As these tubes contract, and become gummed up, the air flow in the tubes becomes turbulent, causing the whistle or wheeze that is heard in asthma. The small breathing tubes are lined with muscle, and this muscle is largely controlled by the autonomic system. When acupuncture is used to treat this type of disease it is logical to suppose that it works through the autonomic system, and it seems possible that many of the effects of acupuncture, on diseases like indigestion and diarrhoea, work through the same system, but as yet there are no unified theories that explain either the autonomic system or the effects of acupuncture on this system.

It is quite likely that when we understand this system a little more fully we will be able to understand the mechanism of acupuncture a little better. It is also possible that the body is influenced far more by the autonomic system than we now believe. If the autonomic system is anaesthetized, then severe intractable pain can sometimes be alleviated; for instance, if severe arm pain is experienced then it may be possible to cure the arm pain by infiltrating local anesthetic into the autonomic nerves that supply the arm. As the local anaesthetic wears off so the arm pain returns. This observation has no real explanation at the moment, because the interplay between pain and the autonomic system is unexplained.

Suggestibility

Acupuncture has been criticized for being no more than a complex form of ‘hypnotic suggestion’. Available research work shows that those gaining benefit from acupuncture treatment are no more or less suggestible than those for whom acupuncture does not work. It would therefore seem that acupuncture does not depend on suggestibility. At the same time, acupuncture does have a certain amount of ‘magic and mystery’ surrounding it. Almost certainly this creates a small amount of benefit although it does not fully explain the dramatic and significant therapeutic effects of acupuncture.

Other Ideas

Some research workers, particularly in Russia, have suggested that fields of biological activity exist around all living objects. The concept of ‘biofields’ has little hard scientific evidence to support it, but there are people in both Russia and America who are suggesting that acupuncture may work through these ‘fields Dr. Nogier’s pulse reflex may possibly be part of the effect of such ‘biofields’. At present there are no good grounds for accepting or rejecting these theories.

The Clinical Application of These Theories

Whatever scientific theories are used to explain the mechanism of acupuncture, not one, at present, explains where to place an acupuncture needle when the acupuncturist is confronted by a patient. The choice of which acupuncture point to use is largely based on the information obtained from traditional Chinese acupuncture, and even those acupuncturists who know no traditional theories use recipes based on them2 We will remain dependent on the empirical experience and philosophical theories of the ancient Chinese until a method of point selection can be deduced from an understanding of the scientific mechanism of acupuncture. Science will, and should, provide an explanation for the observations of the ancient Chinese, but in the meantime we should not reject acupuncture just because we cannot explain it completely.

1 Morphine, heroin and opium are all related chemicals, collectively called opiates.

2 An acupuncture recipe is a selection of points used for a particular disease. No attempt is made to follow a traditional diagnosis, the points are just learnt ant used automatically.

What Happens When You Have Acupuncture?

Some people are frightened by the thought of acupuncture and may feel that it takes a great deal of courage to inflict ‘the needles’ on themselves. The first, and probably the most important fact to understand about acupuncture, is that it is not a frightening experience. It does involve the insertion of fine needles through the skin, and most acupuncturists use between six and eight acupuncture needles at each treatment session. The needles used are smaller than injection needles, in fact an acupuncture needle fits into the central hole of a normal injection needle. Acupuncture needles have a doweled end, not a cutting end like most hypodermic needles, and therefore are far less likely to cause tissue damage or bruising when inserted.

Needle Insertion

The insertion of an acupuncture needle is not a painful experience. Patients sometimes sit with eyes closed and teeth clenched asking, ‘When are you going to put the needles in?’, and are often surprised to learn that the needles are in place before they have finished asking the question. It would be wrong to suppose that the insertion of an acupuncture needle is devoid of any sensation, but those who experience acupuncture do not usually describe it as a painful sensation.

Needling Sensation

The Chinese state that if acupuncture is to achieve its maximum

effect it is necessary for the acupuncturist to obtain a ‘needling sensation’, over each acupuncture point that is used. This involves the needle being moved slightly while it is in the skin, and the sensation experienced by the patient will vary. Needling sensation is not painful but it is a dull, bursting or numb sensation around the site of the inserted needle. The sensation may also travel up or down the channel being treated; the stimulation of an acupuncture point on the right knee may precipitate the experience of a strange burning or numb sensation in the right ankle. Needling sensation is probably best defined by the statement, ‘When needling sensation is experienced the needle no longer feels like a needle!’

Some acupuncturists use an electrical stimulator to excite acupuncture points as a substitute for obtaining needling sensation. Electro-acupuncture causes a tingling sensation over the acupuncture points that are being stimulated, but the Chinese believe that this does not replace the need to obtain needling sensation. If the stimulator is mistakenly turned to a very high intensity then the patient will experience some discomfort, so it is wise to be cautious when using electrical stimulators, and to adjust the intensity slowly and carefully.

Belief

Another common misconception is that patients must ‘believe’ in acupuncture to enable it to work. This is similar to the idea that acupuncture is a complex form of suggestibility, but this is quite wrong. Like any other type of medicine acupuncture works on those who believe in it and those who do not. The mechanism of acupuncture is not clearly understood but, as has already been mentioned, it is quite clear that reproducible biological changes occur when an acupuncture needle penetrates the skin. Whilst accepting that all medical treatment is more effective if the doctor is trusted by the patient, this trust is not a prerequisite for the physiological changes that occur during and after acupuncture.

Will I Get Better?

No medical treatment works all the time, and acupuncture is no exception to this rule. There are many problems in assessing acupuncture as a form of treatment for any disease. First of all the doctor must have a clear idea of the natural history of the disease; if the disease is going to get better anyway, it is a little presumptuous to claim that the cure is due to acupuncture, just because the patient has received acupuncture. Furthermore vast number of statistics must be collected and analyzed before any treatment can be adequately assessed, and in the field of acupuncture the research has not yet been satisfactorily completed. This makes the question ‘What chance of improvement do I have?’ a very difficult one to answer exactly for specific condition.
In the West, the condition that is most commonly treated is by acupuncture is pain and, in general, acupuncture has a significant effect in about seventy per cent of painful diseases. The results and data available about ‘success rates’ will be discuss in detail in later sections.

Response to Treatment

It is very difficult to be dogmatic about how a patient will respond to acupuncture. Occasionally, one treatment is all that is required, whilst other people may need a number of treatments to gain the same result for the same disease. In general most people, and their problems, do not respond magically to one treatment, and between four and eight treatment sessions may be required in order to obtain the best results from acupuncture.

Acupuncture usually works in stages. The first two or three treatments represent a process of ‘understanding the needs of the patient’, and are therefore a sort of experiment designed to assess the specific requirements for that person in that particular condition. Some people respond to classical Chinese body at puncture, whilst others respond better to ear acupuncture. This partially reflects the skill of the acupuncturist in the use specific techniques, but it also represents the fact that the body responds in a slightly different way to slightly different stimuli. Some people seem to respond to a particular acupuncture technique for one condition, whilst requiring a completely different technique for another complaint. A patient may even respond to a particular approach for a specific condition and then stop improving half way through treatment, thus necessitating an alternative approach to that condition.

If a patient experiences some symptomatic improvement at the first consultation, then they often gain considerable relief from a course of acupuncture; equally, many people who do not obtain symptomatic improvement at the first consultation may also gain a great deal from acupuncture. It is a good prognostic sign if there is some instant improvement, although the improvement gained at the first consultation rarely lasts longer than a few hours, and may last only a few minutes. Each subsequent treatment should then give a better and more prolonged result and, as shown on the graph, the symptoms should gradually disappear as the treatment becomes effective.

Three treatments should be adequate to assess whether a patient will respond to acupuncture. If there has been no response to treatment after the first three sessions then it is doubtful whether any response will occur. This should be taken as a general guideline and not as an unbreakable rule as sometimes the symptoms of a particular condition may be very fluctuate, and it may be difficult to obtain a clear assessment of the results of treatment. Occasionally the patient may not find it easy to remember exactly what the condition was like three weeks before and this too can create difficulties, so it is wise to keep a diary and assess day by day the changes that are arising in the problem being treated. This will allow the patient and the acupuncturist to develop a clear idea of the response to treatment, and to assess whether the treatment is worthwhile.

Most acupuncturists continue to treat a patient until there is no further improvement in their condition. The response, as shown by the graph, tends to ‘level off’ towards the end of treatment (usually after five or six treatments) and this ‘leveling off’ signifies that further treatment will probably not give further benefit. Acupuncturists in the West tend to treat people on a weekly basis; in China treatment is given daily, but this seems to be more from habit rather than for any good medical reason. Weekly treatments allow both patient and acupuncturist to gain a clear assessment of the progress and response to treatment.

Reactions

Sometimes a patient may experience a temporary worsening of symptoms due to acupuncture; this is a response to treatment and is a good sign. Such ‘reactions’ to treatment only last for a short time, perhaps a day or two, and are usually followed by improvement. A ‘reaction usually means that the acupuncture needles have been overstimulated as some patients are very sensitive to acupuncture and may respond to normal stimulation by overreacting. If a ‘reaction’ occurs, the patient should be stimulated less at the next treatment session, this means giving a shorter and less aggressive treatment. Sometimes the improvement may be very delayed and the condition may not improve until the treatment has ceased. Occasionally patients who have been abandoned, with no improvement after three weeks, will suddenly find improvement some weeks after the acupuncture has ceased.

Although I have outlined general guidelines about the response to treatment it is important to take each problem as it arises. The general rules are not always obeyed, and if they are followed too dogmatically then the versatility of acupuncture may be lost.

Cure or Symptom Relief?

Acupuncture can be a cure, or it can act as a palliative treatment; this depends on the condition that is being treated. If a chronically painful arthritic knee is treated with acupuncture then, on average, the improvement will last about six months and the knee will then require re-treatment. Some acupuncturists treat their patients every three months or so to avoid any deterioration in their condition. The traditional Chinese approach is to attempt to maintain the patient in a state of health and a regular three-monthly treatment pattern is therefore justified; however, many acupuncturists just treat patients when the symptoms recur. If the condition is self-limiting, such as the pain from an attack of shingles, then no further treatment is required after the pain is relieved.

Whole Body Therapy

In the West the vast majority of people look upon acupuncture as an alternative treatment for pain; therefore pain is the most frequently presented complaint at an acupuncture clinic. If the patient is approached from the traditional Chinese viewpoint then the body is treated as an integrated system. People in pain frequently have other complaints, such as heartburn or

depression, and if the body is treated as a complete system then these complaints will also be treated, and often resolve during the course of acupuncture. The patient may be quite surprised to find that some other problem has suddenly improved, as it was not realized it was amenable to acupuncture treatment and therefore not mentioned to their acupuncturist.

Acupuncture, or needle puncture, is a European term invented by Willem Ten Rhyne, a Dutch physician who visited Nagasaki in Japan in the early part of the seventeenth century. The Chinese describe acupuncture by the character ‘Chen’, which literally means ‘to prick with a needle’, a graphic description of this therapeutic technique.

Early History

Acupuncture has a clearly recorded history of about 2,000 years, but some authorities claim that it has been practiced in China for some 4,000 years. The Chinese believe that the practice of acupuncture began during the Stone Age when stone knives or sharp edged tools, described by the character ‘Bian’, were used to puncture and drain abscesses. In fact the Chinese character ‘Bian’ means the ‘use of a sharp edged stone to treat disease’, and the modern Chinese character ‘Bi’, representing a disease of pain, is almost certainly derived from the use of ‘Bian stones’ for the treatment of painful complaints.

The origin of Chinese medicine is a fascinating story and acupuncture represents only one facet of their medical system. The first recorded attempt at conceptualizing and treating disease dates back to about 1500 BC during the Shang dynasty. Tortoise shells with inscriptions dating from that time have been found, and it is thought that these were used for divination in the art of healing. The philosophical basis of much of the very early Chinese medicine seems to have been to seek harmony between the living and their dead ancestors, and the good and evil spirits that inhabited the earth.

The Development of the Chinese Approach to Medicine and Science

The first known acupuncture text is the Nei Ching Su Wen and there is a great deal of controversy about the exact origins and authorship of this book. The Nei Ching Su Wen is divided into two main sections, the Su Wen, or simple questions and the Ling Shu, or difficult questions. The book is also known by a variety of alternative titles such as the Yellow Emperor’s Classic of Internal Medicine, or the Canon of Medicine, but all these titles refer to the same basic text.

The initial section of the Nei Ching Su Wen involves a discussion between the Yellow Emperor, Huang Ti, and his Minister, Ch’i Pai. This discussion lays down the philosophical basis of traditional Chinese medicine, and makes the Nei Ching Su Wen more of a treatise on health and disease rather than a textbook of medicine. Early Greek texts on medicine are mainly of interest to the medical historian rather than the practicing physician. For instance, Hippocrates does make many excellent philosophical and practical observations about disease and the doctor-patient relationship, but for the most part these texts are recipe books for a variety of ill-defined diseases. The Nei Ching Su Wen is timeless and deals almost exclusively with philosophical concepts, many of which seem to be as important today as they were 2,000 years ago.

Read more about Acupuncture on Healthy.net

Professor Joseph Needham, one of the greatest living experts on Chinese scientific philosophy, describes some aspects of the ancient Chinese system of science as mediaeval and retrogressive He feels that many of these concepts have distorted that development and obvious potential of Chinese medicine There is undoubtedly an element of truth in this but there is still a great deal of useful and valuable information within the traditional Chinese approach to medicine.

The Western doctor observes the facts before him and uses the current physiological theories to explain them. Chinese medicine is based on a much wider world view, which is described in the Nei Ching Su Wen, and these ideas are woven into a complete and intact system based on a philosophy different from that of modern Western medicine. The concepts of Yin and Yang, and the number five, are two of the more important ideas that permeate much of traditional Chinese scientific thought.

Yin and Yang are opposite aspects of the material world. Like night and day they are interdependent, and the existence of one end of the spectrum presupposes the existence of the other aspect; i.e. Yin is necessary for Yang to exist, and vice versa. At first the idea of Yin and Yang seems very simplistic; it is not, it describes the fundamental fluctuating balance of nature. A modern concept that pre-supposes the existence of Yin and Yang is ecology, one of the main principles of which is that the forces of the environment must be in a fluctuating balance.

The number five is also very important to Chinese thought. For example, there are five notes in the musical scale, five tastes for food and five elements in the physical world (earth, fire, water, wood and metal). The five elements are not just atomic constituents of matter, they have also been described as the five transitional stages of all physical materials. It is these philosophical ideas that form the basis of much of the discussion in the Nei Ching Su Wen.

The authorship of the Nei Ching Su Wen is attributed to Huang Ti, the Yellow Emperor, but there is some doubt as to whether Huang Ti actually existed and a great deal more doubt about the claim that he wrote the Nei Ching Su Wen. Genealogies of the Chinese dynasties list him as the third of first five rulers of China, and ascribe the dates 2697-2579 B.C to him. Ssu-Ma Ch’ien, an historian of the second century BC begins the Historical Records with an account of Huang Ti and defines him as the founder of the Chinese civilization, and the first ruler of the Empire. He is one of three legendary Emperors who founded the art of healing; the others are Shen Nung and Hsi.

It is probable that the Nei Ching Su Wen was written by a variety of people and was updated by several important Chinese physicians. Some authorities date the Nei Ching Su Wen from 1000 BC whilst others, probably more correctly, date this text to the Warring States period (475-221 BC). The Ling Shu was almost certainly added during the Warring States period, and the twenty-four chapters that comprise the Nei Ching Su Wen were probably revised and re-written at this time.

The Development of Chinese Philosophy

The Warring States period is a particularly interesting time in Chinese history and has exerted a great deal of influence on Chinese thought. Two main philosophical ideologies became part of the mainstream of Chinese thought at this time, Taoism and Confucianism.

Confucianism defined the social status of prince and pauper within Chinese society and elected the Emperor a god. It result in a basically feudal and totalitarian system of government that still exists today, in an adapted form. Confucianism impinged on medicine in that it was opposed to the development of anatomy and surgery, one of its main tenets being that the whole body was sacred and should remain complete throughout life and also in death. The Confucians believed that it was important to present oneself to ‘the ancestors’ whole, and there-fore one of the most feared methods of execution in ancient China was decapitation. Acupuncture and related methods were the logical answer to this constraint, as they were able to cure internal disease with external means.

The Tao literally means the ‘way’ and the philosophy of Taoism is a method of maintaining harmony between man and his world, and between this world and beyond. The Tao, or the ‘way’, has been linked to a separate creed called Taoism but its basic naturalistic philosophies permeate all Chinese thought and religion, including Buddhism. Yin and Yang are very much part of the Tao, as the Book of Changes states, ‘one Yin, one Yang, being called the Tao’. The religion of Taoism became formalized during the Warring States period and a book of poems entitled the Tao attributed to Lao Tsu (c. 500 BC ), describes many of the basic concepts within this philosophy.

The Taoist concept of health is to attempt to attain perfect harmony between the opposing forces of the natural world, between Yin and Yang, the belief being that the only way to be healthy is to adjust to the natural forces within the world and become part of their rhythm. It is further realized that the natural forces are completely dependent on each other; earth is dependent on rain and rain is dependent on heaven, which in turn cannot exist without the earth. In the same way Yin cannot exist without Yang, and yet the two are opposites. The concept of a unified, but at the same time polar force, governing natural events, is central to much of Chinese thought.

At first glance these concepts seem to be an irrelevant side-line to the development of a system of medicine, but acupuncture, and its development can only really be understood if the reader grasps the traditional Chinese approach to health and disease In essence, the ideal of health is perfect harmony between the forces of Yin and Yang; this represents the correct ‘way’ or Tao. Disharmony brings disease and death. Taoism is a passive philosophy, exalting the art of detailed and accurate observations. This was also an essential part of the development of Chinese medical thought and allowed detailed observations on organ structure and function to be made, as discussed in the first chapter.

Acupuncture Needles

As acupuncture developed, the Bian stones were discarded and needles of stone and pottery were used. These simple, primitive needles are still used in some of the rural areas of China. Eventually metal needles began to appear and these took the form of the classical ‘nine needles’. The ‘nine needles’ comprised the arrowhead needle for superficial pricking, the round needle for massaging, the blunt needle for knocking or pressing, the three edged needle for puncturing a vein, the sword-like needle for draining abscesses, the sharp round needle for rapid pricking, the filliform needle, the long needle for thick muscles and the large needle for puncturing painful joints.

The main needle now used for acupuncture is the filliform as most of the others have been replaced by more sophisticated surgical instruments, for instance, the sword-like needle has been replaced by the scalpel.

The ‘nine needles’ were initially made of either bronze, or gold and silver, and seem to have been first used about 2,000 years ago. The tomb of the Prince of Chungshan, dating from the second century BC, was excavated in 1968 and contained a set of nine needles, four being of gold and five of silver. Some acupuncturists use gold and silver needles but the majority only stainless steel filliform needles.

Moxibustion

A discussion of the history of acupuncture is incomplete without mentioning moxibustion. Moxibustion is the burning on the skin of the herb moxa. The Chinese character ‘Chiu’ is used to describe the art of moxibustion, and literally means ‘to scar with a burning object’. Moxibustion does not now involve scarring, but moxa is still used to provide local heat over acupuncture points. It is made from the dried leaves of Artemisia vulgaris and the Chinese believe that the older the moxa, the better its therapeutic properties.

Moxibustion developed as a medical practice completely separate from acupuncture, although it is now very much a part of current acupuncture practice in China. It is used to treat specific types of disease and is applied over the same body points (acupuncture points) as acupuncture needles. Some of the acupuncture points, such as those around the eye, are forbidden to moxa. In ancient China, moxa was also burnt on specific acupuncture points to keep the body healthy, and was said to act as a prophylactic against disease.

Moxa can be used in a variety of ways. Loose moxa is made into a cone and burnt on the skin, the cone then being removed when it is half burnt, to avoid blistering. It may also be burnt on ginger or garlic so that the skin is isolated from extreme heat, or a moxa stick may be used and burnt a centimeter or two away from the skin.

Therapeutic Success

The exceptionally productive period of the Warring States also gives us the first known and recorded therapeutic success of acupuncture The Historical Records by Ssu-ma Ch’ien tells how the physician Pien Cheuh used acupuncture to revive the Governor of the State of Kuo from a coma. In fact the name of the physician was Chin Yenh-jen, but by taking the legendary name of the famous Chinese physician, Pein Cheuh, we can assess his prestige. The Governor was treated by acupuncture and subsequently with herbal medicines. In ancient China, as today, an event like this is a powerful argument in favor of the acceptance of any form of treatment.

The Evolution of Acupuncture Points and Channels

Initially, there were no specific locations on the body for applying either moxa or acupuncture but gradually, through empirical experience, the use of specific points on the skin were shown to be of value in particular diseases. Acupuncture points are undoubtedly the end-product of millions of detailed observations and as they were developed so each of them was given a name and Chinese character, depending on its therapy properties.

Acupuncture points were subsequently grouped into a system of channels which run over the body, conducting the flow of vital energy through the body. The acupuncture points on a channel are said to influence the flow of vital energy through the channel, thereby influencing disease processes in the body. The first clear reference to the points and channels is in the Nei Ching Su Wen which defines the main channels and acupuncture points. The Nei Ching Su Wen also makes the observation ‘in pain, puncture the tender spot’, and the use of painful points probably represents the original method by which many of the acupuncture points were discovered. There is an instinctive urge to cause more pain over a painful area; the image of a person with toothache, pressing on the painful tooth, is a frequent cartoonists’ joke. Common painful diseases consistently cause painful points to emerge in well defined anatomical locations over the body. When this point is stimulated the pain can be alleviated; hence the idea of a point for treating pain. From this simple beginning it is easy to see how a system of acupuncture points evolved.

The evolution of the channels connecting these acupuncture points is more difficult to understand. These seem to have evolved from an intuitive understanding of the flow of vital energy through the body. It is unclear from where the idea of channels originated, but for the last 2,000 years they have formed an essential part of traditional Chinese medicine.

Acupuncture Texts and Teaching Methods

Another major text, the Classic of Acupuncture and Moxibustion, also made its appearance during the Warring States period. This was written by Huang Fu Mi in the third century BC Together with the Nei Ching Su Wen these two texts form the basis for the anatomical descriptions of the main channels, and some 349 acupuncture points on these channels. The Warring States period saw the coalescence of acupuncture, and indeed most of Chinese thought, in the mold in which it existed until the recent Communist revolution.

During the Sui dynasty (AD 561-618) the first medical college in China was founded. The Imperial Medical College was established to administer medical research and to train doctors. Acupuncture and moxibustion, as well as herbal medicine, formed the basis of the curriculum. According to the Old History of the Tang Dynasty the Imperial College had one professor of acupuncture, ten instructors, twenty needle craftsmen and twenty students. The main teaching texts were the Nei Ching Su Wen and the Classic of Acupuncture and Moxibustion. The bulk of the teaching and practice of traditional Chinese medicine, however, has never been based in formalized medical colleges, although these colleges have been in existence since the Sui dynasty. The medical arts have more often been handed down from father to son, or from master to apprentice. This type of medical apprenticeship has only recently died out, and in fact some of the older acupuncturists in China today have been trained in this way.

The Tang dynasty saw a great flowering of the art of acupuncture, and the Thousand Golden Remedies by Sun Szu-Miao was one of the products of this period. This text was the first to contain clear color charts of the channels with front, side and back views of the body; obviously a great boon to students and teachers of acupuncture. We are aware of the existence of these charts from the references made to them in a number of other texts, but unfortunately they have been lost.

Printing and Language

China developed the art of printing in the Sui and Tang dynasties, although it was not widely used during these periods as most books were copied by hand. Early Chinese printing is rather like a lino-cut, the characters being carved on stone and hand-made prints taken from each block. During the Sung dynasty (AD 960-1280), printing techniques were improved and used extensively. This gave a great boost to acupuncture as far more books became available. Many of the pre-Sun, books suffered from repetition and confusion, especially over the location of various points and channels. These books were copied by non-medical calligraphers and this led to a great deal of confusion over the exact meaning of some of the characters in the text.

Chinese characters can change their meaning completely with a slight change in the text, and therefore a transcription error can easily change the sense of the text. The ambiguity of Chinese characters still poses a great problem in the translation of classical Chinese; for instance the character ‘Ni’ can mean to disobey, or to be in accord with someone. Exact translations therefore require the translator to understand the sense of the text and translate in accordance with this. The advent of more efficient printing techniques led to a more exact and faithful copy of the author’s work, and therefore a clearer interpretation of the meaning of the characters. It is interesting to note that in Chinese philosophy all things have their natural opposites inherently within them (there is Yin in Yang, and Yang in Yin), and this is also displayed in the language as each of the characters may have a diametrically opposite translation.

The “New” Bronze Model for Teaching Acupuncture Points

Because of the confusion that had gone before him, Wei-yi collected and collated all the information that was available to him in the eleventh century. He redefined all the points and channels and compiled an authoritative text called Illustrated Manual on the Points for Acupuncture and Moxibustion on the New Bronze Model. This text dates from AD 1026 and details the use of 354 points on the body. A vast amount of information is given about the location of the points, the method of needle insertion into each point, and the clinical indications for the use of specific points. There are also illustrations in the text to assist teaching and to act as a method of swift reference for the acupuncturist.

The Chinese were so impressed by this book that a statue was erected with the whole text on it! Two huge stone tablets were carved, some two metros high and seven metros wide, containing all the characters in Wang Wei-yi’s book. These tablets stood in the capital of the Sung dynasty, now the city of Kaifeng in Honan province, where they could be read directly, or used like a brass-rubbing to make a permanent copy of the book.

Wang Wei-yi also directed foundry men to create two life sized bronze models for acupuncture. These hollow models had on them the exact locations and names of the acupuncture points, and were used for teaching. Chou Mi, of the southern Sung dynasty, records in the Historical Anecdotes the way in which these models were used to examine students. The model was coated with wax and then filled with water, the student being given the name of an acupuncture point and a needle. If the point was punctured correctly the student was soaked as a fountain erupted from the model; failure to achieve this result meant that the acupuncture point had been missed.

In the Yuan dynasty (AD 1280-1368) the capital of China was moved to Tatu, now better known as Peking. The stone tablets and the bronze model were moved to the Imperial Medical College in Peking, but they were very worn and overused. Reproductions were therefore made in the mid-thirteenth century. Until fairly recently, the original model and tablets were thought to have been lost, but in 1971 five fragments of the original stone tablets were found in Peking, with much of the information still legible.

The Consolidation of Acupuncture Techniques

Acupuncture grew and developed over the next three hundred years; no new concepts evolved, but the old ones were refined. During the Ming dynasty (AD 1368-1644), Chinese society underwent the beginnings of an industrial revolution as paper mills, and textile and iron workshops began to emerge; Ming means ‘bright’ and this was undoubtedly a bright period of Chinese history. Acupuncture and related medical arts were encouraged, as were all the arts and crafts in China.

Li Shih-chen, one of the most outstanding physicians of this period, wrote and compiled the classical Chinese Materia Medica describing the pharmacology and botany of many indigenous herbs. He was also an expert acupuncturist and wrote a treatise on the Eight Extra Channels, describing their course and the indications for their use. Kao Wu collected the essential principles from many of the old acupuncture texts, editing the material into A Summary of the Writings on Acupuncture and Moxibustion. He soon found a great demand for this text and in 1537 he went further, compiling a similar but more detailed and complete text entitled Essential Readings in Acupuncture and Moxibustion.

Some of the observations in Kao Wu’s book give us a amusing insight into the mores and morals of Chinese society The Chinese seem very reluctant to allow a doctor to remove their clothing, and this habit is as widespread today as it was in the Ming dynasty. Kao Wu makes a point of disapproving strongly of the method of needling a patient through the clothing, but perhaps the fact that a patient can be diagnosed without removing clothing is one of the unsung benefits of Chinese pulse diagnosis!

Yang Chi-chou edited the Compendium of Acupuncture and Moxibustion during this period. Kao Wu’s books were really short summaries for acupuncture students, but the Compendium was a complete collection of all the available material on this subject. It is copiously annotated and integrates the herbal remedies used with acupuncture and moxibustion. The Compendium was first published in 1601 and is still used as reference text. Many of the source materials for this book have subsequently disappeared and consequently the Compendium represents an invaluable reference for those interested in acupuncture.

The Arrival of the Europeans

During the Ming dynasty contact was established with Europe, the earliest date being 1504 when the Portuguese landed; Macao. At about the same period, China’s fleets began to visit India, Persia and some of the Arab states. Cheng Ho led the first recorded fleet of merchant ships to India in 1405, but it is certain that other Chinese merchantmen had traveled far afield prior to this date. The overland ‘silk route’ to China had been open for many centuries and merchants had for some time traveled into China and central Asia, following in the footsteps of Marco Polo.

With the advent of renewed interest in China, and also the wish of various European nations to ‘discover and colonize’ the non-European world, the Portuguese began to establish trading settlements in mainland China. With the traders went priests to convert the ‘heathen’. It was through these priests, and also various physicians who visited China, that the idea of acupuncture began to filter through to the west. The Jesuits were particularly active in collecting and disseminating this information in Europe, but the process was far from one-sided as the Jesuits also introduced Western science to China. Dominique Parrenin, a missionary, translated a textbook of anatomy into Mandarin but this was banned from general circulation by the Emperor K’ang Hsi as he recognized that many of the Western concepts contradicted those of traditional Chinese medicine.

The Decline of Acupuncture and the Rise of Western Medicine in China

The Ching dynasty (A.D.1644-1911) was a time of chaos for the Chinese Empire. Western influences pervaded a war-torn China, especially during the nineteenth century when various Western nations were given ‘spheres of influence’ on the Chinese mainland. The Ching Emperors regarded acupuncture as ‘a bar to progress’ and in 1822 a government decree eliminated acupuncture from the curriculum of the Imperial Medical College.

During this period a great number of medical missionaries entered China to ‘teach, heal and preach’. The medicine they practiced in the early part of the nineteenth century had little similarity to the Western medicine of today, as there were no anaesthetics, antibiotics or sepsis. The concept that bacteria caused disease was only disseminated in the 1860’s and 1870’s, and therefore the missionaries had very little real medical skill to offer. Their main advantage was their understanding of the elementary principles of surgery.

The Confucian ethic had blocked completely the progress of surgery, as the Chinese felt that the dead must present themselves to their ancestors with a whole body. They were afraid to submit themselves to surgery in case they died and went to their ancestors with part of the body missing; surgery was therefore the province of the medical missionary and the basis on which their medical skills were accepted. The first full-time missionary was Peter Parker who worked in Canton. At first, the activity of the medical missionaries was limited by hostility, money and manpower, but as Western influence expanded the missionary work grew. By the 1920’s, growth had reached a peak and there were some 550 hospitals and out-patient clinics spread over most of the provinces and cities in mainland China.

During this period the art of acupuncture was in decline. Many acupuncturists seemed to be no more than ‘pavement physicians’ with poor training. Their surgery was often the market place, their knowledge of traditional Chinese medicine was very limited, and their equipment was filthy and of poor quality. The majority of ‘respectable’ Chinese doctors were practicing herbal medicine and massage, rather than acupuncture and moxibustion. In spite of its decline, and even at this low level, acupuncture remained the medicine of the masses. The Imperial denigration of acupuncture reflected not only the poor standard of practice but also the fact that some of the educated Chinese were looking to the West for progress. After the pneumonic plague of 1910 the Viceroy of Manchuria, Hsi Liang, remarked, ‘The lessons of the epidemic are great . . . if railways, telegraphs and other modern inventions are indispensable to the material welfare of this country, we should also make use of the wonderful resources of Western medicine.’

Western medical colleges were set up by the missionaries, the first being in Canton. The missionaries translated Western medical books into Chinese and in 1886 began to print the China Medical Missionary Journal which was the first scientific journal in China. Another medical college was established shortly afterwards in Tientsin and there was a gradual increase in the number of Western-trained Chinese doctors. In 1929 the practice of acupuncture was outlawed in China; the passage of acupuncture has not always been smooth, even in China!

Communist Support for Acupuncture

In 1928 the Communist party of China was formed, under the leadership of Chairman Mao. A long guerrilla war ensued and the Communist party finally took power in 1949. The Communists realized that there were little or no medical services in the ‘liberated areas’ and actively encouraged the use of traditional Chinese remedies to keep their troops on the move. These remedies were cheap, acceptable to the Chinese peasants, and utilized the skills already available in the countryside.

Acupuncture gained new momentum; in 1940 Yang Shao proposed to ‘scientificize, “Sinocize” and popularize’ traditional Chinese medicine. During the early 1950’s many hospital opened clinics to provide, teach and investigate the traditional methods, the main research institutes being in Peking, Shanghai and Nanking. This renaissance of acupuncture, combined with a sophisticated scientific approach, has allowed the development of many new methods of acupuncture.

New Ideas Based on Traditional Chinese Medicine

Ear acupuncture is a particularly useful new acupuncture method. The Ling Shu states: ‘The ear is the place where all the channels meet’, and with this statement the Chinese justify the origin of ear acupuncture. The external ear is an homunculus, or little man, with all the organs and parts of the, body being represented on the ear. Puncturing the external ear at a specific point allows a disease to be treated in the body; for instance, if the arm is hurting then needling the arm point on the, external ear will alleviate the pain in the arm.

Ear acupuncture has been used and developed by the French and the Chinese as a form of therapy and also, specifically by the Chinese, for acupuncture anesthesia. Many people in the West think of acupuncture as being synonymous with acupuncture anesthesia. The application of acupuncture as a form of anesthetic is a relatively new development, and a direct product of the impetus given to acupuncture by the Communists. In 1958 acupuncture was first used by the Chinese to control post-operative pain and it then began to be used as an anesthetic for simple operations. This technique was found to be effective and its use expanded quickly. In China it is now used for a wide variety of major and minor operations.

Acupuncture anesthesia has many advantages including safety and swift post-operative recovery; however, it does not always provide complete pain relief, and whilst a small failure rate is acceptable to the Chinese it would not be acceptable in most Western societies. It is obviously better to use a site far away from the area of the operation when applying acupuncture anesthesia, and this makes ear acupuncture the method of choice for anaesthetics.

The concept of the homunculus is one that the Chinese have developed further. There are complete representations of the body on the hand, foot, face and nose. Each of these represents complete ‘micro-acupuncture’ system, capable of treating ailments throughout the body. Acute back pain can be relieved by stimulating the points on the hand that represent the back. Perhaps this can be equated with the fact that each cell in the body has the information potential to duplicate the whole human. The genetic material in each of our cells is exactly the same as the information in the cell from which we all originated, the fertilized egg.

New Ideas Based on Western Medicine

The Chinese have also applied a variety of Western techniques within the field of acupuncture. They have established research institutes and these, particularly in Shanghai and some other Chinese cities, measure up to any found in the West. Scalp acupuncture, a technique invented in the last decade, is a direct development from the neuro-anatomy of the central nervous system. When the brain is damaged, in diseases such as a stroke, the scalp is stimulated superficially over the area of damaged brain. Although there is no clear connection between the nerves in the skin of the scalp, and the brain, this method does seem to produce an effect on the brain and the Chinese claim that they are able to alleviate some of the symptoms of a stroke with this procedure. Modern medicine has undoubtedly provided the stimulus for the development of this type of acupuncture.

Acupuncture points can also be treated by injection with ordinary injection needles, this method having been used in the West for some time although not called acupuncture. Tender, painful areas often occur in and around arthritic joints. Recent research work has shown that most of these ‘tender points’ are acupuncture points, and that injection therapy relieves the pain. Is it perhaps the needle insertion, rather than the fluid injection, that alleviates the pain?

Electro-acupuncture is the stimulation of acupuncture needles with small electrical currents, and its growth and development has been pioneered by the Chinese over the last thirty years. Throughout long operations, under acupuncture anesthesia, electrical machines have been used to avoid prolonged, continual manual stimulation of acupuncture needles. Electroacupuncture is now widely used in many acupuncture clinics, for acupuncture therapy as well as for anesthesia.

Contradictions Resolved?

The Chinese are well aware of the current scientific explanations of acupuncture and its mode of action, and through their research institutes they are contributing to this field. The cultural heritage of the Chinese has made it possible for them to accept the contradictions inherent in the practice of acupuncture; science versus philosophy. The concepts of traditional Chinese medicine allow the acupuncturist to approach and treat a patient. Eventually science will provide a logical explanation for these empirical findings, but, until such time as that happens, science and traditional ideas will both play an equal part in helping patients by the use of acupuncture.

It is almost certain that acupuncture has been known and used in the West since the seventeenth century, but the first recorded use of acupuncture was by Dr. Berlioz at the Paris medical School in 1810. He treated a young woman suffering from abdominal pain. The Paris Medical Society described this as a somewhat reckless form of treatment, but Dr. Berlioz continued to use acupuncture, and claimed a great deal of success with it.

Acupuncture is not new to England, the first known British acupuncturist being John Churchill who, in 1821, published a series of results on the treatment of tympany and rheumatism with acupuncture. John Elliotson, a physician at St Thomas’ Hospital, also use acupuncture widely in the early part of the nineteenth century. In 1823 acupuncture was mentioned in the first edition of the Lancet and in 1824 Dr. Elliotson began to use this method of treatment. In 1827 he published a series of results on the treatment of forty-two cases of rheumatism by acupuncture, and came to the conclusion that this was an acceptable and effective method of treatment for these complaints.

Ear Acupuncture

Those who traveled to China brought back information about body acupuncture. Ear acupuncture has been developed largely outside China. It is quite clear that there are some ancient Chinese manuscripts that mention the use of the external ear for acupuncture, but classical Chinese acupuncture applies to the body rather than the ear. The detailed ear map that is now being used by most acupuncturists was developed by Dr. Paul Nogier in France in the early 1950’s.

Ear acupuncture was known to the ancient Egyptians. Ear cauteries have been found in the pyramids; these were used for burning or scarring specific ear points for conditions like sciatica. Hippocrates also mentions that the external ear could be used to treat conditions such as impotence.

In 1637 a Portuguese doctor, Zactus Lusitanus, described the use of auricular cautery for sciatica, and in 1717 Valsalva demonstrated the use of ear acupuncture for toothache. These early European and Middle Eastern experiments with ear acupuncture are a completely separate discovery; they have nothing to do with the growth and development of acupuncture in China. Sciatica seems to have been a disease that was particularly amenable to this crude form of acupuncture, and studies in the mid-nineteenth century indicate that 56 per cent of people who were treated with ear cautery for sciatica, obtained relief from their symptoms.

It was this crude form of acupuncture that interested Dr. Nogier in the early 1950’s. Some of his patients had received ear cautery and obtained relief from pain, and therefore Dr. Nogier began to develop and investigate this form of treatment. He soon produced an ear map and since the early 1950’s he has refined and developed this technique. One of his earliest findings was that if there was pain in the body then the equivalent part of the ear also became painful.

If the hand is painful then the part of the ear representing the hand also becomes painful when slight pressure is applied to the relevant part of the ear. If the painful ear point is punctured with a needle then the hand pain will be relieved. The picture of a pirate with a gold ear ring through his ear lobe is a well remembered childhood image; according to folklore the gold ring is supposed to increase the visual ability of the pirate, so that he can see ships to plunder before he is seen by them! Strangely enough, the ear ring usually seems to be placed in the eye point on the ear lobe.

Painful Points

Within the context of Western medicine, the development of acupuncture points on the body demonstrates an interesting story of re-discovery. Over the last fifty years many Western physicians have discovered independently that pressing, stimulating or injecting various superficial body points can help to relieve pain. This is particularly true of muscular or rheumatic-like pains. These points are not necessarily at the site of pain, but often over distant areas. For instance, neck pain is frequently referred to the shoulder or arm and can present to the doctor as shoulder or arm pain. On close examination of the patient it is quite easy to define the origin of the pain, and to show that the neck is the cause of the problem. Injection, or stimulation of the painful points around the shoulder or arm, will often relieve the pain and free the movement of the neck.

These points have a variety of names, such as trigger points (for pain), or motor points. In 1977 Dr. Melzack, who has been awarded the Nobel prize for his work in the field of pain, correlated these trigger points with acupuncture points, and found that most of the trigger points were already well known as acupuncture points. There are a number of explanations for the existence of trigger points but, as yet, there is no clear answer to this phenomenon. It is interesting to note that the Chinese realized this fact at least some three thousand years ago, and the Ling Shu summarises this approach when it says ‘In pain, puncture the tender point’.

The Future

Acupuncture is now quite widely used in Europe and North America, both as a method of therapy and, in a few centers, as a method of anesthesia. Operations with acupuncture as the main anesthetic have been carried out in France and Austria, and the results have been comparable with those of the Chinese. Since its intimate contact with the Chinese in the 1950’s, the USSR has also been using and researching into acupuncture, although the relationship between Russia and China could not be described as good. In 1972 a Russian researcher published work suggesting that acupuncture points were points of low electrical resistance on the body. He also found a network of low resistance points in both animals and plants.
The use of acupuncture in the USSR steadily increased during the 1970’s and in 1972 acupuncture clinics were planned for all the major medical centers in the Soviet Union. The Russians claim they are using acupuncture for a wide variety of conditions such as asthma, stomach ulcers, raised blood pressure and angina, as well as for pain. In the West, acupuncture has been used mainly for pain relief. This is primarily because acupuncture for pain is easy to learn, and does not require a knowledge of traditional Chinese concepts in order to obtain results. The concepts of traditional Chinese medicine can seem alien and unacceptable to Western doctors and they are therefore rejected in favor of a simpler and probably less efficient method of treatment, in spite of the value of many of the traditional concepts. Some doctors practicing acupuncture in the West are simply puncturing tender points as this seems a rational and logical approach.

Acupuncture has become very popular in North America since President Nixon reopened relationships with the Chinese. There are many research clinics evaluating the effectiveness of acupuncture, and also investigating the basic physiological mechanisms involved. The research output from North America is prolific and some excellent work has been done much of which re-emphasizes that acupuncture is an effective form of therapy for many conditions, especially pain, although it is not a guaranteed cure.
Over the last twenty years the West has developed a great deal of technological hardware which is now being applied in the field of acupuncture. The chapter on modern acupuncture techniques describes briefly the use of a variety of electrical machines and sources of stimulation, such as lasers and electroacupuncture. Many of these techniques are still in their infancy and some will be rejected whilst others may prove to be important.

China is a poor nation without enough resources and trained manpower to research and develop acupuncture adequately. Until fairly recently few useful statistics were available from the acupuncture clinics in China, and most of the research into the basic mechanism of acupuncture had come from Western research institutes. Within this context it is probable that many of the major advances in acupuncture will come from the West rather than from the East.