Dermatopathology: Practical and Conceptual
http://www.derm101.com/
© 2002–2004 Ardor Scribendi, Ltd. All rights reserved.
[Press Ctrl-P (PC) or Command-P (Mac) to print]
Acupuncture: Different Perspectives in the East and the West
Yong Ming Li, M.D.
Introduction
The word "acupuncture" is divisable in two parts, acu- and
puncture. Acu- in Latin means needle and -puncture comes from Latin to pierce
with a pointed instrument. The definition of acupuncture in Dorland's
Illustrated Medical Dictionary (29th ed.,
Fig. 1: There are several dozens of acupuncture schools in the
Fig. 2: A case of headache treated with acupuncture, published in General Ophthalmology by Fu Renyu (1664, Ming Dynasty). The figure on this centuries-old scroll, seemingly suffering from a headache, was incorrectly interpreted as having a cataract or a migraine in modern English and Chinese literature. In fact, it is one of the first case reports on temporal arteritis (unpublished data - Y. Li).
Fig. 3: The longer needle is commonly used in China, while the shorter one is popular in the U.S.
The history of acupuncture in China
The origin of acupuncture
In historical records of Chinese medicine it is evident that the healing
art of acupuncture has existed at least for 2000 years. Some indirect evidence
suggests that acupuncture may have been practiced in
A description of acupuncture and herbal medicine was found in records written between 100 B.C. and 200 A.D. Well-known classics written during this period include the Ma Wang Dui (Ma Wang Tomb) scripts, the Nan Jing (Na Classic), and the Huang Di Nei Jing (The Yellow Emperor's Classic). That various diseases could be treated by acupuncture, the points of which had been established, were discussed in detail in those classics.
The very first book that prepared the foundation for acupuncture, as well as of traditional Chinese medicine, was Huang Di Nei Jing, known as " the bible of Chinese medicine." It was completed somewhere around the 2nd century B.C. and probably was written by numerous authors. At the least it summarized the thoughts and experience of leading physicians of that day. The book is comprised of hundreds of articles that are divided into two volumes. Volume one, Su Wen, (Fundamental Questions), addressed many issues that pertained to the theory of medicine in a didactic way. Volume two, titled Ling Shu (Spiritual Axis), is devoted almost entirely to applications of acupuncture. These two volumes, together, not only teach rudiments of anatomic, physiologic, and pathologic aspects of the human body, but they also engage the philosophical basis of the theory of acupuncture and provide technical details about how to perform it, with particular attention paid to management of individual symptoms.
In Huang Di Nei Jing, the distribution of 12 regular meridians, both on the surface and inside of the body, and anatomic locations of 295 acupuncture points were set forth in detail. Later, in Nan Jing, two extra meridians were added to make up the so-called 14-meridians system for acupuncture. The description of meridians and of points written 2000 years ago remain the gold standard for the practice of acupuncture to this day.
The theory, traditionally, that animates treatment by acupuncture
The most important concept in traditional Chinese medicine is that of natural balance. The idea of balance comes from ancient Chinese philosophy, namely, the theory of yin and yang. That theory states that for every functional unit of human body there is dynamic change in the form of two attributes, to wit, yin and yang. They are an inseparable couple. Their proper relationship always is in balance and when that state is maintained good health is experienced. When, however, there is a disturbance in this balance, the result is disease.
The ancient Chinese philosophers and physicians both assumed and thought they observed that an essential substance in the body gives support to the life of a human. The amount and activity of this substance determines the health of a person. This substance, which probably corresponds to countless different molecules that now have been idenitifed, as well as ones yet to be identified, was named "qi," which is air in Chinese. Qi is classified further into various types according to location and function.
In Chinese medicine it is theorized that in the human body, as well as in every other living organism, qi flows naturally throughout it. Qi is said to travel the body along meridians, moving constantly up and down or circulating in these pathways, traveling among various organs. When the flow of qi is insufficient, unbalanced, or interrupted, yin and yang become unbalanced, and illness may occur. An understanding of the relationship among the body, yin and yang, and qi is necessary to understand the utility of acupuncture.
Acupuncture can be described as the insertion of fine needles, sometimes in combination with an electrical stimulus or with heat produced by burning specific herbs, called moxibustion, into the skin at specific points for the purpose of influencing the function of the body. There are 365 classic acupuncture points on the body, most of which have a specific function in regard to energy. Some are at the meeting of meridian pathways, whereas others are at the junction of an internal pathway of the meridian. There also are over 500 points located outside the meridians. The particular acupuncture points chosen varies from patient to patient and from treatment to treatment, and depends on the diagnosis, which really is a pattern of analysis of symptoms and signs. Diagnosis entails the observation of the body by looking, touching, smelling, and listening. Taking the pulse and scrutinizing the tongue are given special emphasis in Chinese medicine. Once a specific pattern has been determined, different methods, which include acupuncture, herbs, diet, massage, and physical exercises performed while meditating, may be employed to improve the flow of qi, to balance yin and yang, and, eventually, to achieve a cure.
The scientific basis of acupuncture
The search for an anatomic basis of meridians and of acupuncture points and for the biochemical basis for qi turned out to be much more difficult than had been imagined. Chinese scientists found that meridians do not correspond directly to parts of the nervous system or to pathways of circulation of the blood. Some researchers believe that the meridians are a unique system which pervades connective tissue, muscle, and soft tissue of the human body. Others do not believe that meridians and qi exist at all. These controversies remain the most vexing issues in the study of traditional Chinese medicine.
Animal studies, case reports, and controlled clinical trials all have documented the efficacy of acupuncture for many diseases and for many symptoms. Controlled studies have shown that after insertion of a needle into an acupuncture point, a blind human subject reports that the needle induces a sensation of traveling along meridians. Various instruments have been able to record the "sensation." Interestingly, the speed of conduction of the sensation along the meridians is slower than the conduction along nerves, but faster than circulation of the blood.
Several mechanisms have been proposed to explain the effects of acupuncture on pain. Acupuncture points are believed to stimulate the central nervous system to release chemicals, such as endorphins, into muscles, the spinal cord, and the brain. These chemicals either change the experience of how pain is perceived or they release second messengers that influence the systems whereby pain and sensation are regulated. The biochemical changes may stimulate the ability of the body to heal naturally and to promote physical and emotional well-being. Three main mechanisms have been proposed for this as follows:
(1) Conduction of electromagnetic signals: Scientists have found evidence that acupuncture points are strategic conductors of electromagnetic signals. Stimulating points along these pathways (meridians) by acupuncture enables electromagnetic signals to be relayed at a greater rate than under normal conditions. These signals may direct the flow of chemicals, such as pain-killers, cytokines, hormones, and of specific cells of the immune system, to the sites that are injured or are particularly vulnerable to disease.
(2) Activation of opioid systems: Research has revealed that several types of opioids may be released into the central nervous system during treatment by acupuncture, thereby reducing pain. Studies on animals showed that stimulation by acupuncture increases the expression of opioid mRNA in the central nervous system, which could explain the effects of acupuncture long term.
(3) Changes in chemistry of the brain in regard to sensation and involuntary body functions: The results of studies indicate that acupuncture may alter the chemistry of the brain by altering the release in various ways of neurotransmitters and hormones. Acupuncture has been shown to affect parts of the central nervous system that are related to sensation and involuntary body functions, such as immune reactions, blood pressure, blood flow, and body temperature.
Ample evidence exists to affirm that therapy by acupuncture has some biological basis, and it is more than enough to explain the theory and practice of this age-old treatment. Some authorities believe that meridians and acupuncture points are mere surface phenomena of the body that reflect activities of internal organs and tissues, but no one specific anatomic structure can explain all of the phenomena. Moreover, the traditional theory of acupuncture has seemed to work clinically for the last 2,000 years and it is unlikely that another better theory will soon replace it.
The History of acupuncture in the United States
Acupuncture fever in 1970s
Although Chinese medicine as a part of Chinese culture came to
One of the most popular versions goes this way: While visiting
Among more than a dozen different versions of this story about the birth
of acupuncture fever, some say that Chinese physicians secretly used acupuncture
as anesthesia during the appendectomy and only told the truth to the reporter
after the operation was over. Another version claims that it was the famous
Henry Kissinger, the negotiator of Nixon's trip to
In fact, it is easy to learn the true story because it was printed
straightforwardly in The New York Times. The reporter who published the essay
about acupuncture was James Reston, known also as Scotty Reston, a famous
reporter then for The Times. While visiting
What actually happened was that not long after the
In 1971, rather than being a young man, Reston already was a senior
reporter more than 60-years-old. Because of his extraordinary experience and
credibility, as well as the prestige of The New York Times itself, most
Americans trusted deeply what he wrote. In addition, just before publishing his
essay, the White House announced that President Nixon planed to visit
Here is what
"PEKING, July 25 – There is something a little absurd about a man publishing an obituary notice on his own appendix, but for the last 10 days this correspondent has had a chance to learn a little about the professional and political direction of a major Chinese hospital from the inside, and this is a report on how I got there and what I found.
In brief summary, the facts are that with assistance of 11 of the leading medical specialists in Peking, who were asked by Premier Chou Enlai to cooperate on the case, Prof. Wu Wei-jan of the Anti-Imperialist Hospital's surgical staff removed my appendix on July 17 after a normal injection of Xylocain and Benzocain, which anesthetized the middle of my body.
There were no complications, nausea or vomiting. I was conscious throughout, followed the instructions of Professor Wu as translated to me by Ma Yu-chen of the Chinese foreign Ministry during the operation, and was back in my bedroom in the hospital in two and a half hours.
However, I was in considerable discomfort if not pain during the second night after the operation, and Li Chang-yuan, doctor of acupuncture at the hospital, with my approval, inserted three long, thin needles into the outer part of my right elbow and below my knees and manipulated them in order to stimulate the intestine and relieve the pressure and distension of the stomach.
This sent ripples of pain racing through my limbs and, at least, had the effect of diverting my attention from the distress in my stomach. Meanwhile, Doctor Li lit two pieces of an herb called ai, which looked like the burning stumps of a broken cheap cigar, and held them close to my abdomen while occasionally twirling the needles into action.
All this took about 20 minutes, during which I remember thinking that it was rather a complicated way to get rid of gas in the stomach, but there was a noticeable relaxation of the pressure and distension within an hour and no recurrence of the problem thereafter.
I will return to the theory and controversy over this needle and herbal medicine later. Meanwhile, a couple of disclaimers.
Judging from the cables reaching me here, recent reports and claims of
remarkable cures of blindness, paralysis and mental disorders by acupuncture
have apparently led to considerable speculation in
Hardly a Journalistic Trick
On the other side, it has been suggested that maybe this whole accidental experience of mine, or at least the acupuncture part of it, was a journalistic trick to learn something about needle anesthesia. This is not only untrue but greatly overrates my gifts of imagination, courage and self-sacrifice. There are many things I will do for a good story, but getting slit open in the night or offering myself as an experimental porcupine is not among them." (The New York Time, June 26, 1971, page 1 and 6)
At the beginning of acupuncture fever in the early 1970s, because of the
lack of formal diplomatic ties between the
Recommendations of the World Health Organization and a consensus conference on acupuncture at the National Institute of Health
In the early 1980s, the World Health Organization (WHO) recommended over
40 conditions that it thought responded well to treatment by acupuncture, among
those being allergies, colds and flu, back pain, asthma, neuromuscular
disorders, gastrointestinal conditions, and vascular maladies. This list was
based primarily on trials and on case reports that originated in
Nevertheless, the use of acupuncture in the
In 1996, the United States Food and Drug Administration (FDA) announced
that an acupuncture needle should be regulated as any other medical instrument.
For the first time in history, an agency of the government of the
In 1997, a quarter of century after the introduction of acupuncture to
the
Dr. Bruce Pomeranz, a physician/scientist at the
"After review of 15 lines of evidence from over 100 papers published in refereed journals," he was compelled to conclude that, "Beyond any doubt that acupuncture stimulates peripheral nerves to release endorphin in brain and spinal cord, which blocks pain messages.
We have more evidence on this mechanism than exists for most conventional therapies."
Interestingly, the first condition for which treatment by acupuncture
was recommended by the panel of the NIH happened to be gastrointestinal
disorder that follows a surgical procedure, the very kind of condition for
which
The NIH has estimated that more than 1 million Americans receive therapy
with acupuncture each year. Private and public insurance coverage for
acupuncture is available in many states. One study shows that 57.2 percent of
physicians in northern
Different Practices of acupuncture in the East and the West
Since the formal introduction of acupuncture into the United States 30
years ago, acupuncture has become a popular alternative therapy, and throughout
the Western world as well. In most states, it is legal to practice acupuncture
as a profession as long as the practitioner holds a proper permit or
certificate. Conventional medical communities and government agencies, such as
NIH and FDA, began to recognize acupuncture as an effective therapy for certain
painful conditions and now regard acupuncture as part of complementary and
alternative medicine (
To the surprise of many, however, the technique of acupuncture being
practiced in the
Comparison
of the practice of acupuncture in the
Practitioners of acupuncture
U.S. Mainly professional acupuncturists who are not physicians and a small percentage of physicians.
China Mainly physicians devoted to practice exclusively of traditional Chinese medicine and a small percentage of physicians who practice Western medicine.
Education required for acupuncturists
China 5 years of medical school in which courses in acupuncture are taught as part of the curriculum both in colleges of traditional Chinese medicine and of Western medicine.
Students of acupuncture
U.S. Mostly part time, but a small percentage full-time; many middle aged-adults, healthcare workers, and students who seek a second career; a very different population than comprises medical schools.
China Young high school graduates, all full-time students, a similar
population to that of students of medical school in the
Licensure for acupuncture
Requirements for acupuncturists to be licensed
China In addition to education for 5 years at medical school or an equivalent education, extensive clinical training or an apprenticeship is necessary to be qualified as an acupuncturist.
Legal regulations for acupuncture
China No special law exists in regard to acupuncture. Acupuncture, which is a form of medical therapy, is regulated just as any other medical therapy under common law.
Medical responsibilities of acupuncturists
U.S. Study by analysis of patterns the possible points for acupuncture, select particular points, and perform acupuncture. Many states require referral from a physician or a pre-operative diagnosis before treatment by an acupuncturist can begin. Acupuncturists have no right to diagnosis or prescribe.
China Acupuncturists, being the physicians that they are, are allowed to order laboratory tests, make diagnoses, and prescribe drugs or herbs in addition to performing acupuncture treatment.
Requirements in regard to an acupuncture needle
China Sterile, non-disposable or disposable, stainless steel, long and short, thin and thick (length: 1-5 inch; gauge: 26-28) needles without guiding tubes are permissable. Many different types of needles are used. Needles are designed to induce different levels and various strengths of stimuli.
Health professionals who actually practice acupuncture
U.S. Chiropractors, nurse practitioners, podiatrists, veterinarians and dentists.
China Professionals other than physicians rarely practice acupuncture.
Use of moxibustion and electrical stimuli in combination with acupuncture
U.S. Electrical stimuli often is used during treatment by acupuncture, but not moxibustion.
Herbal treatment combined with acupuncture
China Most physician-acupuncturists have extensive training in both acupuncture and herbal medicine, and a combination of those therapies is used often.
Diseases treated most often by acupuncture
U.S. Depression, post-operation pain, nausea and vomiting, chronic pain, and detoxification are the major indications for acupuncture.
China Neuromuscular disorders, stroke, Bell's palsy, arthritis, acute and chronic pain, detoxification, and chronic conditions in general all lend themselves to treatment by acupuncture.
NIH and WHO recommendations regarding indications for acupuncture
U.S. Conditions approved by the panel of the NIH consensus conference
for acupuncture therapy are based on controlled clinical trials in the
China Over 40 conditions are recommended for
acupuncture by the WHO and they were identified on the basis of clinical
experience and limited trials accumulated in
Techniques of needle manipulation during acupuncture
U.S. Standard insertion and stimulating techniques. Electrical stimuli are used often.
China Highly individualized methods of manual stimulation, mostly of those techniques being based on experience.
Sensations induced during acupuncture
U.S. Seek to induce weak sensation only, and no pain. The aim is avoidance of complaint by a patient.
China Seek to induce weak or strong sensation as it is necessary. In some patients, inducing pain by acupuncture is part of the therapy.
Frequency of treatment by acupuncture
China Treatment daily, there being no limit to the number of treatments.
Kinds of patients who seek acupuncture
U.S. Mostly white-collar persons with an above average education.
Geographic distribution of practitioners of acupuncture
Fee per each treatment by acupuncture
U.S. $30-100 per visit.
Annual income of acupuncturists
U.S. $30,000 – 120,000.
Number of private clinics for acupuncture
China Very few.
Number of acupuncturists based in hospitals
U.S. Very few.
Number of research institutes devoted to acupuncture
U.S. Very few.
China Most medical research institutes include research about acupuncture.
Number of professional journals devoted to acupuncture
U.S. Less than 10 journals.
China Nearly 1,000 medical journals publish articles about acupuncture.
Professional associations devoted to acupuncture
China They are a part of medical associations or of associations given to traditional Chinese medicine.
Insurance coverage for patients treated by acupuncture
U.S. Few insurance companies cover acupuncture therapy. As of today, Medicare/Medicaid does not cover acupuncture.
China Most insurances and government medical benefit cover acupuncture.
Availability of liability insurance for acupuncturists
Acupuncture as business
China Not a business but a profession given to health care sometimes as part of hospital based service.
In the
By contrast, acupuncture in
In summary, acupuncture originated from
Yong Ming Li, M.D., Ph.D. is an Attending Physician at
Warren Hospital,
Dermatopathology: Practical and Conceptual
http://www.derm101.com/
© 2002–2004 Ardor Scribendi, Ltd. All rights reserved.
[Press Ctrl-P (PC) or Command-P (Mac) to print]