AN INTEGRATED APPROACH TO
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I would like to present a survey of acupuncture in American Medicine, briefly reviewing acupuncture's distant past,
a look at western medical acupuncture research with special focus on the aspect of pain transmission and
modification of pain by acupuncture, and an introduction to what many term "Energetic Medicine", where the old and
the new can work side by side in our contemporary practice of medicine.
Our initial introduction to acupuncture is often filled with language,
charts and symbols which appropriately lead us to ask, "What is acupuncture?"
Acupuncture has evolved over two millennia and continues to evolve
today. Acupuncture is bringing new insight to a healthcare
system borne of careful and untiring observation of patient, environment, and physician.
The heritage of acupuncture brings a wealth of information which, if
ignored, would deprive the important models of health, disease, and treatment.
These models of healthcare may critically enhance our patient care through
integration into our contemporary practices.
While the ancient classic texts were written in poetic and metaphoric
language, they still present models of health, dysfunction, and treatment that are compatible with contemporary
psychology, physiology, physics, and neuropharmacology.
Early acupuncture history tells of the legendary emperor and doctor Fu Xi Shi from
approximately 4000 B.C. who is credited with inventing nine types of stone acupuncture needles.
Bone etchings circa 1600 B.C. represent the earliest "written"
The I Ching, compiled from 2500-1000 B.C., presented the foundation of
energy dynamics which serve as a basis for the operating laws in acupuncture as well as a reference and guide for
The Huang Ti Nei Ching, known as the "Yellow Emperor's Classic of Internal
Diseases", is a compilation of a series of authors from the 5th to the 2nd centuries BC and represent the Chinese
Following came the Nan Ching or "Classic of Difficulties" in the 1st
century A.D., perhaps the cleanest source of ancient thoughts. In the 2nd century A.D., the Shang Han Lun presented an organized approach to the "Cold
Ancient China is certainly not the only source of references to energetic
or acupuncture-like therapies.
The papyrus Ebers from 1550 BC are the most important ancient Egyptian
medical writings and discuss peripheral "vessels" or meridians.
Indian Ayurvedic medicine presents many similar concepts as those in
acupuncture. South African Bantu tribes have known to
scratch various body parts to treat disease.
Treatment of sciatica with ear cauterizations has been known through much
of Arabic history.
Eskimo people have used simple stone stimulation of the skin for
Even an isolated Brazilian tribe has used tiny blowpipe arrows to the body
for healing. Interestingly, these tribal members present
with distinct Mongoloid features.
European colonization of Indochina led to an abundance of training and
textual sources since the 16th century. Many of these were
later translated into Latin and French by Jesuit priests.
Since that time, the French have been intimately involved in the further
development of acupuncture as it continues to evolve to this day.
WESTERN MEDICAL LITERATURE
Medical literature, even that of the United States, is more significant than
most recognize. In 1792,
Galvani observed small tissue generated electric currents.
Dr. Franklin Bache, Benjamin Franklin's great grandson, wrote the first US medical
acupuncture article in 1825, entitled Memoirs on Acupuncture, and also translated Mourand's French treatise into
Dr. Edward Warren's 1863 medical and surgical text discussed the use of acupuncture
and acupressure. Others also wrote of acupuncture's use
during the US Civil War.
Sir William Osler's 1892 The Principles and Practice of Medicine
"for lumbago, acupuncture is, in acute cases, the most efficient treatment" and that
for sciatica "acupuncture may be used".
In the 1960s, Dr. Felix Mann was a pioneer translator of acupuncture
texts and explained acupuncture physiologic activity as a complex of cutaneovisceral, visceromotor, and
viscerocutaneous reflexes with dermatomal radiation.
Dr. Ron Lawrence of Los Angeles showed a 300% increase in plethysmographic flow in
the digits with electroacupuncture, endorsing a sympathetic hypothesis.
Dr. Omura of New York showed an increase in the WBC if low, and a decrease if
He further showed an increase titre of immune substances, bacteriolysins, opsonins,
and complement. An increase ACTH effect of the CBC with
increased segmented neutrophils, decreased lymphocytes and eosinophils were demonstrated in response to
acupuncture. He showed an increase in seratonin, and
decrease in cholesterol and triglycerides, as well as modulation of blood sugar
A survey of the Western Medical literature demonstrates acupuncture's
effects on nearly every biophysiologic system.
For the pulmonary system, acupuncture was shown
to attenuate exercise induced asthma (Lancet) and diminish
bronchoconstriction in clinical asthma attacks (Annals of Allergy).
In obstetrics, acupuncture has relieved pain of labor and delivery (Anesthesiology),
aided in induction of labor (Obstetrics and Gynaecology), and controlled morning sickness. (Obstetrics &
For the genitourinary system, acupuncture has been presented as treatment for
infertility (Gynecology and Endocrinology 9/92 and a German Publication).
For the treatment of renal colic, acupuncture demonstrated more rapid response than
contemporary medical treatment (avaforton) and with no side effects (Journal of Urology
With the gastrointestinal system, acupuncture has arrested cholestatic
crisis (personal communication with Dr. Chan Gunn), relieved GI tract spasm which failed medication (Lancet),
and demonstrated support for regulation of GI motor and secretory function via opioid and neural pathways
(American Journal of Gastroenterology 10/92).
A significant decrease in perioperative nausea and vomiting has been demonstrated
through perioperative acupuncture (British Medical Journal, Anesthesiology News), and a Neiguan (PC-6) injection of
glucose in water prevented nausea and vomiting in laparoscopy patients (Acta Anaesthesia Scandinavia
For the cardiovascular system, acupuncture led to reversal of CV arrest
in experimental animals (Journal of Surgical Research). An acceleration of wound healing through electroacupuncture has been demonstrated (Archives of
Physical Medicine & Rehabilitation), as well as accelerated skin ulcer healing (Southern Medical Journal)
and augmentation of bone repair (Science).
Additionally, acupuncture in sports medicine has shown increased maximum
performance capacity over controls (International Journal of Sports Medicine 8/92), and Substance P and
Prostaglandin E have been shown to be increased in patients with successful acupuncture anesthesia (analgesia),
yet are normal or decreased in patients with unsuccessful acupuncture anesthesia
Important in a society infected with widespread drug abuse, acupuncture
has provided dramatic enhancement of drug detoxification programs for over twenty years, with the Lincoln
Hospital programs of Dr. Michael Smith serving as a template for success in this challenging area of
Clearly there is a need for further prospective, randomized medical
outcome studies in acupuncture and those of us in the
acupuncture community are confident that the responses seen daily in our practices will withstand properly
designed, critical investigation.
It is important to remember that a substantial portion of contemporary
western medical and surgical practices, however, have never met the standards by which acupuncture is now
Indeed, to challenge contemporary medical and surgical practices to the
same level of scrutiny as is demanded of acupuncture would likely have a multi-billion dollar effect on American
medicine, not to mention the dramatic change in morbidity and mortality patterns for our
After several thousand years of critical clinical challenges and
development by the most respected medical minds of their times, acupuncture is recognized by the World Health
Organization as a valid medical approach not only for pain problems, but also to treat medical problems ranging
from chronic sinusitis to functional bowel problems.
The contemporary physician who integrates acupuncture into a medical practice of any
specialty discipline incorporates new diagnostic and treatment tools which often allow the patient to recover and
move toward wellness with far less risk and morbidity associated with many drugs and
NEUROHUMORAL EFFECTS OF
Dr. Bruce Pomeranz has presented the most comprehensive data regarding
the measured neurohumoral effects of electroacupuncture.
The following discussion is a brief look at the neurohumoral effects of
typical pain and the interruption of that pain impulse with either high or low frequency electroacupuncture
Various afferent nerve fibers are involved in transmitting pain impulses
from the skin to the cortex. These include large
myelinated fibers, the majority of large muscle afferents, with A-beta fibers in the skin to perceive touch and
Type I fibers in the muscle for proprioception sense. Small myelinated fibers include A-delta fibers in the skin to transmit pain as well as Type II
and III fibers in the muscles also sensing pain. Very
small unmyelinated C-fibers in the skin and Type IV fibers in the muscles also sense
pain. Types II, III, IV and C fibers also send
To first review transmission of a painful stimulus from the skin to the
cortex, we see that an injury to the skin activates the sensory receptors (squares) of small afferent A-delta
and C-fibers (#1), which synapse onto the Spinothalamic Tract in the spinal cord
(#2). The Spinothalamic Tract cell projects its axon to
the Thalamus (#3), where it synapses with a cell that sends impulses to activate the primary sensory cortex
(#4). (Dark triangles on Pomeranz slide are excitatory
synapses, white triangles are inhibitory.)
Second, we can now look at the effect of low frequency/high intensity
electroacupuncture stimulation. The acupuncture needle
activates a Type II or III small myelinated afferent nerve (#5) from a sensory receptor in the muscle
(square). This cell synapses in the spinal cord onto an
anterolateral tract cell (#6) which projects to one of three centers: the spinal cord, the midbrain, and the
In the spinal cord, cell 6 sends a short segmental branch to cell 7, an
endorphinergic cell, which releases either enkephalin or dynorphin (but not B-endorphin), which in turn causes
presynaptic inhibition of cell 1, thereby preventing transmission of the painful message from 1 to
Cell 6 also ascends along the anterolateral tract of the spinal cord to
the midbrain, where it excites cells in the Periaqueductal Grey (#8 and 9), which releases enkephalin to
disinhibit cell 10, thus activating the raphe nucleus in the medulla (#11), causing it to send impulses down the
dorsolateral tract to release monoamines (labeled M), such as seratonin and norepineprhine onto spinal cord
cells. Cell 2 is thereby inhibited by postsynaptic
inhibition, while cell 1 is presynaptically inhibited through cell 7.
The action of cell 6 onto cells 12 and 13 in the pituitary-hypothalamus
complex is less well understood. Probably cell 12 in the
arcuate nucleus activates the raphe through B-endorphin, and cell 13 in the hypothalamus releases
B-endorphin from the
pituitary. In the Pituitary, B-endorphin and ACTH are
co-released on an equimolar basis into the circulation. ACTH travels to the adrenal cortex, where cortisol is released into the blood, perhaps
explaining the anti-inflammatory effects of acupuncture in the treatment of arthritis and
This slide shows the three centers activated by low frequency/high
intensity electroacupuncture, using the endorphin mechanisms in them. Low frequency stimulation is thus inhibited by naloxone.
Next, we look at the effects of high frequency/low intensity
electroacupuncture stimulation. High frequency/low
intensity electroacupuncture stimulates only the spinal cord and the midbrain, but bypasses endorphin synapses
there. It is therefore not blocked by naloxone, but is
sensitive to the manipulations of monoamines. Also, high
frequency electroacupuncture has a strong spinal segmental effect, not antagonized by naloxone, suggesting that
cell 7 uses non-endorphinergic transmitters such as GABA.
Anatomic areas not included in this discussion because of insufficient
data include the Nucleus Accumbus, Amygdala, Habenula, and the Anterior
Caudate. Also not shown are numerous peptides present in
the terminals of Cell 1, including CCK, Somatostatin, Neurotensin, Bombesin, Calcitonon Gene-Related Peptide,
Angiotensin, Substance P, and Vasoactive Intestinal Peptide.
In summary, we see that electro-acupuncture activates nerve fibers in
the muscle, which send impulses to the spinal cord to activate three centers to cause
The spinal site uses enkephalin and dynorphin to block incoming messages
with low frequency stimulation, and other transmitters such as GABA at high
The midbrain uses enkephalin to activate the raphe descending system,
which inhibits spinal cord pain transmission by a synergistic effect of the monoamines seratonin and
norepinephrine. The midbrain also has a circuit which
bypasses the endorphinergic links at high frequency stimulation.
Finally, the pituitary releases B-endorphin into the blood and CSF to
cause analgesia at a distance, and the hypothalamus sends long axons to the midbrain which along with
B-endorphin activate the descending analgesia system, activated only at low frequency
The significance of this three-level system is fascinating: When needles
are placed close to the site of pain (Ah Shi points), they are maximizing the segmental circuits operating at
cell 7 within the spinal cord, while also bringing in cells 11 and 14 of the other two
When needles are placed in distal points away from the painful region,
they activate the midbrain and hypothalamic-pituitary complex without benefit of the segmental
effects. Clinically, the two kinds of needling are often
to enhance one another.
The analgesia produced by these two approaches is quite
The low frequency stimulation produces analgesia of slower onset and long
duration, with a 20 minute stimulation effecting 30-120 minutes of analgesia.
The effects are also cumulative in their response to repeat
This may be due to an observed increase in the presence of m-RNA for
endorphins seen more than 48 hours after stimulation.
The high frequency stimulation is rapid but of very short duration and
has no cumulative effects.
It is apparent that these above "explanations" do not give an adequate
understanding of acupuncture, even to the strictly orthodox or western scientifically-oriented
It is likely that these explanations are only a part of the mechanism,
even only a part of the central mechanisms involved.
As a basic model in physiology, all human life may be reduced to a sac
of electrolytes containing the organ to be studied.
Each organ has an electric field resulting from the sum of the metabolic
activity within the organ. This electric activity is
measured as positive on the surface of
the organ with respect to a more negative interior. The
electric field of the organ
is projected to the surface of the container, through the medium of the interstitial electronic
With a sac of electrolytes containing a dozen organs, each one produces
an electric field, and each is producing its field to the surface of the container following the path of least
resistance through the interstitial electro-ionic medium.
Applying this model to the thoracic, abdominal, or pelvic cavities is
not difficult to conceptualize. In the extremities,
however, the paths of least resistance are the cleavage plains between the major muscle groups, and the lamellar
flow of the interstitial fluid is least obstructed outside the fascial sheaths of the muscle groups.
The percolation through the muscle planes projects onto the surface of the body as
acupuncture meridians, familiar to you from the many classic acupuncture charts.
Now let us consider the surgical instrument, the acupuncture needle,
usually composed of a stainless steel shaft and a spiraled handle of copper, bronze, or other
alloy. Inherent in this construction are two physical
properties which make this an ideal instrument.
The thermocouple effect of Kelvin-Thomson is the
first. It describes an electrical gradient along the
length of a homogenous conductor with a temperature gradient produced by the ends of the conductor at different
Secondly, the Benedick's effect states that the current along a uniform
conductor is reinforced by the electromagnetic effect between the second (spiraled) metal of the handle in
contact with the first metal of the shaft.
Thus the typical needle is 1 to 8 cm long, 0.3-0.4 mm in diameter or 28 to 26 gauge, has and electric potential of 3 microvolts with the tip at body T∞ and the handle at room T∞
. This gradient reaches equilibrium in 10-15
This represents a needle "in dispersion".
Dispersion is used in a condition defined as a problem of excess, such
as acute strain or sprain, and the needle may be inserted and simply allow the reaction to take
place. This local treatment provokes a local reaction,
often producing a local erythema of the skin around the needle insertion, and reaching equilibrium as the
If we heat the needle or manipulate the needle manually, the potential
changes to 10-15 microvolts and reaches equilibrium in 60-90 minutes. This represents a needle "in tonification".
Tonification is the technique used for a condition defined as
deficiency, such as chronic illness or dysfunction states, and requires heating, manual manipulation or
electrical stimulation of the needles in an anatomically logical circuit.
This tonification provokes a wave of depolarization/repolarization that propagates itself from one needle to the
next along the course of least resistance, that is, the lamellar flow around the muscles, the deep aspect of the
Acupuncture points are access sites generally in depressions between the
muscle groups allowing direct access to the lamellar flow, the surface projections of which are presented by the
points on the charts of ancient China.
French Acupuncture Professor Claude Dewars explored the diffusion
patterns of Technetium 99 when injected into acupoints compared with non-acupoints.
The linear pattern of diffusion following injection gives evidence that
the interstitial lamellar flow pattern is at least one aspect of acupuncture circulation.
This flow traveled at
Consistent with classical Chinese energetic acupuncture and French
energetic theories, the placement of needles in circuit leads to the
The placement of a single needle in the chosen acupuncture meridian
gives us a local agitation. When a second needle is
placed in circuit, we have an agitated equilibrium. Then
a third needle leads to a dynamic disequilibrium, creating a flow within the
meridian. This energetic equation works with any
Principal Meridian circuit.
The Principal Meridians are demonstrated on the classic acupuncture
They represent an organization of the main circuits used in acupuncture, and develop
early in the embryonic stages of life. Each Principal
Meridian is associated with one of the 12 Organ/Functions recognized in classic
acupuncture. These meridians are paired in a somewhat
longitudinal fashion and each pair is coupled with another pair to complete a circuit.
These meridian circuits form the basis for a large percentage of the treatment plans
used in acupuncture and are represented in a bilateral manner. In addition, there are numerous other circuits or groupings of energetic flow for addressing
problems of a different nature or at different levels.
These include the Tendino-Muscular Meridians, often very useful in acute injuries,
the Distinct Meridians for problems in the organs themselves, the Shu-Mu system which is often used to enhance the
patient's energetic level, the Curious Meridians, and others.
In our scientific conceptualization of acupuncture, the needle is
working through multiple vectors in the body's physiology. These inputs including functioning electrically on the surface of the body, electroionically
in the interstitial milieu, with nerve and neurohumoral functions as discussed by the Pomeranz studies,
perineural conduction along myelin sheaths, perivascular sympathetic input, blood input via effects of
neurohumoral, cellular and blood chemistry changes, and immunologically via humoral and cellular
IN TO AMERICAN MEDICAL
The United States’ Food and Drug Administration (FDA) reclassified the
primary instrument used, the acupuncture needle, as a Class 2B medical device in 1996.
This was a significant turn toward mainstream from its previous classification as an
“experimental” device. Further, the National Institutes of
Health and its Office of Alternative Medicine convened a consensus conference in November, 1997 on the subject of
The conference determined there is “clear evidence” demonstrating the efficacy of
acupuncture for the treatment of nausea and vomiting associated with chemotherapy and pregnancy and in the
treatment of dental pain.
Acupuncture was deemed appropriate as “part of comprehensive care” in the treatment
of addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, low back pain, carpal
tunnel syndrome and asthma. The NIH expressed a need for
further high quality research in acupuncture.
Chairperson Dr. David J. Ramsay noted, “There are a number of situations where it
really does, in fact, work- the evidence is very clear-cut. It has few side effects and is less invasive than many other things we
do. It’s time to take it