accupuncture trigger points and musculoskeletal pain

8/10/2019 Accupuncture Trigger Points and Musculoskeletal Pain

1/742

Accupuncture Trigger Points and Musculoskeletal Pain

To Oina, my wife, for her patience and forbearanceduring the writing of this book.The phenomena of pain belong to that borderland between the body and

soul about which it is so delightful to speculate from the comfort of anarmchair, but which offers such formidable obstacles to scientific inquiry.J. H. Kellgren (!"#$%&tracts from re'iews of the first edition)*+ warmly recommend this book to anyone who wants to learn more about thisoften neglected area of common musculoskeletal pain conditions*Journal of the -oyal ollege of /hysicians of 0ondon)This is a book that should belong to physicians, neurologists, rheumatologists andteachers of medical students*/ain%ndorsements of the new edition

)/eter 1aldry is one of the most respected practitioners of 2edical 3cupuncture inthe 4K. This new edition is yet another first5class book, which adeptly combinesthe theory and practice of treatment of trigger points for musculoskeletal pain.3n eminently readable and informati'e te&t6 this is a tour du force and an essentialacquisition for those practitioners who want a clear practical guide for thetreatment of musculoskeletal pain using trigger point treatment and the scientificunderstanding that underpins the treatment.Jacqueline 7ilshie, onsultant in 3naesthesia and /ain 2anagement, -oyal2arsden Hospital, 0ondon and 8urrey6 8ecretary of the 1ritish 2edical3cupuncture 8ociety)+n this fine comprehensi'e book, 9r 1aldry remo'es much of the mystique

from acupuncture as a technique for musculoskeletal pain relief. 4sing a fullyscientific integration of %astern and :estern knowledge, coupled with therele'ant literature on clinical effecti'eness of acupuncture, he pro'ides an ideal,e'idence5based te&t for the practitioner.7rom the beginner to the e&pert, anyone with an interest in the nature ofmuscle pain, its pathophysiology and treatment will be informed by this book theentry5le'el therapist will gain a better understanding based on sound scientifice'idence, while the e&perienced clinician will be rewarded with a well5writtenguide to what is significant in e'eryday clinical practice. linicians of se'eralmedical specialties (neurologists, orthopaedic surgeons, general practitioners, painspecialists, physiatrists$ and other practitioners (acupuncturists, physiotherapists,

nurses, occupational therapists$ will find this book an indispensable reference intheir daily work. 7or those who wish to implement acupuncture in the clinic, thiste&tbook is an in'aluable resource for responsible practice.+n total, this book offers an inno'ati'e approach to the diagnosis,understanding and treatment of myofascial trigger point pain using acupuncturethat integrates all current concepts of neurophysiology and neuroanatomyprinciples. 9r /eter 1aldry is to be congratulated for conceptuali;ing, editing andwriting such a truly 'aluable asset for e'ery clinical practice.9r


2/742

0ecturer, Technological %ducational +nstitute of 3thens, 9epartment of/hysiotherapy,


3/742

@uod est ante pedes nemo spectat coeli 8crutanturplagas. (:hat is before ones feet no one looks at6they ga;e at the regions of hea'en.$%nnius, quoted by icero, 9e 9i'inat., A, B.This is an important and 'aluable book that

needed to be written. 2usculoskeletal or myofascialpain is an all too common and e&traordinarilyneglected sub?ect of medicine6 it is barely mentionedin many te&tbooks of medicine. +n reality itis a ubiquitous condition that causes a great dealof pain and suffering and one which, unfortunately,either slips by unrecogni;ed or is passedoff as tri'ial or untreatable. +n this book 9r /eter1aldry has shown how musculoskeletal pain canbe simply and effecti'ely treated by acupuncture.1ut this book is much more than that because it isreally three books in one.The first part presents an interesting historicalbackground to hinese acupuncture and its spreadto the outside world, particularly to the :est. Thesecond part deals with the principles of triggerpoint acupuncture wherein, o'er the course of si&chapters, the reader is presented with a detailedand critical account of the e'idence for and thenature of trigger points and the way in which acupuncturecan be used to deacti'ate them. 9r 1aldryspares no effort to pro'ide the reader with an up5todateand accurate account of the neurophysiologyof pain and the possible ways in which acupuncturecan be used to control it. He also grasps the difficultand important nettle concerning the scientifice'aluation of acupuncture. The results of properlycontrolled e&periments and trials demonstratingthe efficacy of acupuncture are slowly but surelyaccumulating and 9r 1aldry discusses these criticallyand points the way to the further rigorousstudies that are urgently needed. The third part ofthe book gi'es a detailed and splendidly practicalaccount of the many different forms of musculoskeletalpain and the way that these can be treatedwith acupuncture.%'en for the reader who does not intend to useacupuncture, this book still ser'es a most 'aluablepurpose by drawing attention to the 'ery largenumber of common musculoskeletal pain conditionsthat are all too commonly o'erlooked. 3particularlyhelpful feature of 9r 1aldrys book is therich admi&ture of case histories of his own


4/742

patients, from which the medical reader can learnthe correct way to diagnose and subsequently totreat these painful conditions.There seems little doubt that, through unfamiliaritywith this condition, much time and effort areoften e&pended unnecessarily both by the medical

profession and by patients seeking the cause andtreatment of pain problems that are, in fact, musculoskeletalin origin. 9r 1aldry has performed amost 'aluable ser'ice in writing this eminentlyreadable book and + wish it the 'ery considerablesuccess that it richly deser'es.John :. Thompson'ii7oreword


5/742

The aims of this book+t is because traditional hinese acupuncture is perforceine&tricably bound up with archaic conceptsconcerning the structure and function of the bodythat most members of the medical profession in the

:estern world 'iew it with suspicion and scepticismand assign it, together with 'arious otherseemingly esoteric forms of therapy, to what iscalled alternati'e or complementary medicine.2oreo'er, it is e'ident that attempts during the past"C years to place hinese acupuncture on a morerational and scientific basis ha'e done little to dispelthis attitude.2y reason for writing this book is to bring to theattention of doctors and physiotherapists a ACthcentury5e'ol'ed scientific approach to acupuncturefor the relief of pain emanating from triggerpoints in the myofascial pain syndrome and fromtender and trigger points in the fibromyalgia syndrome,and to take acupuncture (so far as the alle'iationof nocicepti'e pain of this type is concerned$out of the category of alternati'e or complementrymedicine by describing a method of employing itthat has been de'eloped as a result of obser'ationsmade by physicians during recent years and isnow fast becoming incorporated within the frameworkof present5day orthodo& medical practice.+t is because there ha'e been so many ad'ancesin our knowledge concerning the pathophysiology,diagnosis and treatment of the myofascial triggerpoint and fibromyalgia syndromes since the Andedition of this book was published, that in this editionfour chapters in /art A (/rinciples of Trigger/oint 3cupuncture$ ha'e had to be replaced byentirely new ones. +n addition to these changesmost of the other chapters in /art A and /artB (The /ractical 3pplication of Trigger /oint3cupuncture$ ha'e had to be e&tensi'ely re'ised.+t is hoped that as a result of reading this bookmany more anaesthetists, rheumatologists, orthopaedicspecialists, general physicians, general practitionersand physiotherapists than at present maynot only be led to search for trigger points in theirroutine clinical in'estigation of pain, but may alsobe persuaded to include dry needling at thesepoints in their therapeutic armamentarium.ase histories+ offer no apology for ha'ing included case histories


6/742

in this book. They are, of course, by their 'erynature essentially anecdotal and certainly no inferenceis meant to be drawn from them concerningthe effecti'eness of trigger point acupuncture, forany conclusions about that can only come fromclinical trials. The sole purpose of including these

'ignettes is to pro'ide illustrations from e'erydayclinical practice that ser'e to highlight certainimportant principles underlying the diagnosis andmanagement of 'arious painful musculoskeletaldisorders.i&/reface


7/742

2y 'ery sincere thanks are due to /rofessor JohnThompson for the meticulous manner in which heread the manuscript of this book and then ga'e memuch 'aluable ad'ice and constructi'e criticismbesides kindly writing a foreword.

+ wish to e&press my gratitude to 9r 3le&ander2acdonald for it was he who, some years ago, firstdrew my attention to the aetiological importanceof trigger points in the pathogenesis of musculoskeletalpain and introduced me to triggerpoint acupuncture as a method of alle'iating it.+ thank 9r 7eli& 2ann for ha'ing initially broughtto my notice the close relationship between triggerpoints and traditional hinese acupuncture points.+ wish to say how indebted + am to the late9rs Janet Tra'ell and 9r 9a'id 8imons for the'ery considerable contribution they made tomy knowledge of specific patterns of myofascialtrigger point pain referral. +t has largely been fromstudying their descriptions and illustrationsof these patterns in 'arious publications referredto later in this book that + am now able to recogni;ethem in my own patients.+ also wish to say how 'ery grateful + am to9r 9a'id 1owsher, for it has been from him in particularthat + ha'e learnt so much about what iscurrently known concerning the mechanisms responsiblefor the pain5relie'ing effect of acupuncture.+ ha'e to thank /rofessors /eter :illiams and-oger :arwick, the editors of


8/742

and Haworth /ress for permission to reproduce7igure F.A6 9r 3le&ander 2acdonald and


9/742

7or reasons to be e&plained later in this book, theearly !FCs saw the dawn of an era when people inthe :estern world began taking an increasing interestin the ancient oriental mode of therapy knownas acupuncture, with lay practitioners of it leading

the public to belie'e that it has such wide ranginghealing properties as to be an effecti'e alternati'eto orthodo& medicine in the treatment of a largenumber of diseases.There is clearly no ?ustification for such e&tra'agantclaims and it has to be said that, at the onsetof this era, the medical profession in %urope and3merica 'iewed this form of therapy with considerablesuspicion and continued to do so for so longas e&planations as to how it might work remainedine&tricably bound up with abstruse concepts formulatedby the hinese BCCC years pre'iously.This reluctance to belie'e in these long5establishedbut somewhat esoteric hypotheses was, of course,because they had been concei'ed at a time whenideas concerning the structure and function of thebody together with those concerning the nature ofdisease belonged more to the realms of fantasy thanfact, and for this reason it was difficult to reconcilethem with the principles upon which the presentday:estern system of medical practice is based.9uring the latter part of the ACth century, howe'er,there has been a considerable increase inknowledge concerning the neurophysiology ofpain and because of this there is now a scientifice&planation for acupunctures ability to alle'iatepain. +t has become apparent that this technique,which in'ol'es the use of dry needles (acus (0atin$,needle$ for the purpose of stimulating peripheralner'e endings, achie'es its pain5relie'ing effectby 'irtue of its ability to e'oke acti'ity in painmodulatingmechanisms present in the peripheraland central ner'ous systems.+n the light of this disco'ery and a number ofothers the public in general and the medical professionin particular ha'e had to re'ise their attitudestowards acupuncture.7urthermore, when the House of 0ords selectcommittee in science and technology (ACCC$ took aclose look at 'arious types of treatment at presentincluded within the ambit of complementaryNalternati'e medicine, it di'ided them into threegroups and placed acupuncture in the one containing


10/742

therapeutic procedures deemed to be themost organi;ed and regulated.The committee, in addition, considered that theresearch bases of these procedures are of sufficientlyhigh standards to allow them to be usedwithin the 4Ks ational Health 8er'ice.

/rior to the publication of this report the 1ritish2edical 3cupuncture 8ociety (!!F$ had publisheda discussion paper entitled )3cupunctures /lace:ithin 2ainstream 2edicine. +n this it was stated)*2edical acupuncture practice depends onthree important principles an orthodo& :esterndiagnosis needs to be made for e'ery patient6acupuncture should be integrated with con'entionalmedicine6 and it must be appreciated thatthe traditional hinese 'iew of acupuncture is beingreplaced in many areas by an approach based onmodern physiology and neuroanatomy. *&iii+ntroduction to the third edition


11/742

+n accordance with the abo'e, in ACCC The -oyalollege of /hysicians of 0ondon set up a subcommitteeto assist with the present task of bringingacupuncture and a strictly selected number of otherhitherto somewhat pe?orati'ely called complementary

or alternati'e therapeutic procedures withinthe framework of orthodo& medical practice.0ewith et al (ACCB$, moreo'er, during the courseof discussing the current status of certain therapeuticprocedures in the Journal of the -oyal ollegeof /hysicians of 0ondon, including acupuncture, madethe following two apposite comments concerningthe latter ($ )needling trigger points is particularlyeffecti'e in the treatment of pain6 (A$)acupuncture is currently used in at least #" ofpain clinics in the 4K*3 paucity of suitably funded research has beenthe principle hindrance to getting certain therapeuticprocedures including acupuncture integratedwithin the fabric of con'entional medical practice.This has prompted 0esley -ees, 9irector of %ducationat the -oyal ollege of /hysicians of 0ondonand 3ndrew :eil, /rofessor of 2edicine at the 4ni'ersityof 3ri;ona (-ees :eil ACC$, to emphasi;ethe need for the H8 research and de'elopmentdirectorate and the 2edical -esearch ouncil tonow help correct this unfortunate state of affairs.The purpose of this book is to discuss the scientificaspects of acupuncture in general and triggerpoint acupuncture in particular and to show howthis latter type of therapy can readily be used bydoctors and physiotherapists in the treatment ofthe myofascial pain and fibromyalgia syndromes.7or those trained in the :estern system of medicinethere are ob'ious ad'antages in using thisparticular method rather than the traditionalhinese one, but clearly these ad'antages cannotbe fully appreciated without knowing somethingabout the latter. This book is, therefore, di'ided intothree parts with /art containing a brief accountof traditional hinese acupuncture. +t also gi'esreasons as to why doctors in %urope on first learningabout this type of treatment in the Fth centuryre?ected it, and describes how certain !th5century%uropean and 3merican doctors, ha'ing put onone side what they considered to be unacceptablehinese concepts concerning this mode of therapy,de'ised a method of practising it principally for


12/742

the relief of musculoskeletal pain that may be consideredto be a forerunner of the somewhat moresophisticated one de'eloped in recent years anddescribed in this book. +t is also pointed out that,although physicians who ad'ocated the use ofacupuncture in the :estern world during the last

century wrote enthusiastically about it, it was ne'erwidely practised by their contemporaries, mainlyit would seem because at that time there was nosatisfactory e&planation as to the manner in whichit might work.+n /art A attention is drawn to fundamental laboratoryin'estigations into the phenomenon ofreferred pain from musculoskeletal structures carriedout by J. H. Kellgren at 4ni'ersity ollegeHospital, 0ondon, in the late !BCs. +n addition itis e&plained how these in'estigations promptedmany physicians during the !"Cs, in particularthe late Janet Tra'ell in 3merica, to study the clinicalmanifestations of this particular type of pain,and how, as a result of this, she came to recogni;ethe importance of what she termed trigger pointsas being the source of pain in many commonlyoccurring musculoskeletal disorders.+t is also shown how once it had been disco'eredthat it is possible to alle'iate such pain byin?ecting trigger points with a local anaesthetic orwith one or other of a 'ariety of different irritantsubstances, it was found that this could be accomplishede'en more simply, as well as more safelyand equally effecti'ely, by means of the carryingout of needle5e'oked ner'e stimulation at triggerpoint sites./art A also contains a brief account of ad'ancesin knowledge concerning the neurophysiology ofpain during the !DCs and !FCs and describes the'arious pain5modulating mechanisms now consideredto be brought into action when acupuncture iscarried out. +n addition, it includes a discussion ofsome of the difficulties so far encountered in scientificallye'aluating the pain5relie'ing efficacy of thisparticular type of therapy and in determining itsplace relati'e to other forms of treatment in the alle'iationof musculoskeletal pain./art B is de'oted to the practical applications oftrigger point acupuncture.&i' +T-O94T+O TO TH% TH+-9 %9+T+O


13/742

1ritish 2edical 3cupuncture 8ociety !!F 3cupuncturesplace within mainstream medicine. 3cupuncture in2edicine E(A$ C"CFHouse of 0ords 8elect ommittee on 8cience andTechnology ACCC Dth report, 8ession !!!ACCC.

omplementary and alternati'e medicine. 8tationaryOffice, 0ondon0ewith < T, 1reen 3, 7ilshie J, 7isher / et al ACCBomplementary medicine e'idence base, competence topractice and regulation. linical 2edicine (Journal of the-oyal ollege of /hysicians of 0ondon$ B(B$ ABEA"C-ees 0, :eil 3 ACC +ntegrated medicine. 1ritish 2edicalJournal BAA !AC+ntroduction to the third edition &'-eferences


14/742

The hinese first carried out acupuncture, thatseemingly strange practice whereby needles areinserted into people for therapeutic purposes, atleast BCCC years ago. ews of this, howe'er, did notreach the :estern world until about BCC years ago

when %uropean medical officers employed by the9utch %ast +ndies Trading ompany in and aroundJa'a saw it being used there by the Japanese, andwhen at about the same time Jesuit missionariescame across it whilst endea'ouring to con'ert thehinese to hristianity.7rom their writings it is clear that both thesegroups found the concepts upon which the hinesebased their curious practice difficult to comprehend,due to the fact that these appeared to be completelyat 'ariance with what %uropeans by that time hadcome to know about the anatomy and physiologyof the human body. 3nd it has been this inabilityto reconcile the theoretical concepts put forward bythe hinese in support of acupuncture with thoseupon which modern scientific medicine is basedthat has for so long been the cause of such littleinterest being taken in it in the :estern world.9uring the past BC years, howe'er, attitudes towardsacupuncture in the :est ha'e been changing sinceresearch into the mechanisms of pain has pro'ideda certain amount of insight as to how possibly itachie'es its effect on pain. These, as might bee&pected, are entirely different from those originallyput forward by the hinese.The prime purpose of this book is to describe arecently de'eloped method of practising acupuncturein which dry needles are inserted into the tissueso'erlying what ha'e come to be known asBhapter Traditional hinese acupunctureH3/T%- OT%T83ncient hinese concepts concerning thepractice of acupuncture and mo&ibustion


15/742

" 34/4T4-%, T-+


16/742

pain. 1efore turning to this, howe'er, itis necessary to gi'e a brief account of the disco'eryand de'elopment of the traditional practiceof hinese acupuncture as it is only by ha'ing aproper understanding of this that the merits ofthe trigger point approach to acupuncture can be

fully appreciated. 7or an e&planation as to how thehinese came to disco'er the therapeutic propertiesof acupuncture in the first place it is helpfulto turn to an early hinese medical book entitledHuang Ti ei hing and known in the %nglishspeakingworld as The Iellow %mperors 2anual oforporeal 2edicine. This is a most unusual te&tbookof medicine as it is written in the form of a dialoguebetween the %mperor Huang Ti and his ministerhhi5/o. +t is a work which incorporates much concerningthe philosophical thoughts of the ancienthinese, their religious beliefs with particular referenceto Taoism, their obser'ations concerning theworkings of the uni'erse in general, and the applicationof all this to their practice of medicine.The :estern world is much indebted to the3merican scholar, +l;a Leith, who, in 7ebruary !"Eat the +nstitute of the History of 2edicine at JohnsHopkins 4ni'ersity, undertook the e&tremely difficulttask of translating this important treatise into%nglish. This translation together with her ownin'aluable introductory analysis of the work wasfirst published in !"!. 3lso, for those who wish toread a detailed account of how the hinese practiceof acupuncture has gradually e'ol'ed o'er thecenturies, there is much of considerable interestin elestial 0ancets, an erudite study of the sub?ectwritten by the two distinguished ambridge historians,0u


17/742

acupuncture. 8ometimes it is used as a counter irritantby being allowed to blister and scar the skin.3t other times it is used as a milder form of heattreatment, by applying it to the skin with a layer of'egetable material interposed between this and the

cone in order to protect the former from damage.Iet another method is to combine mo&ibustion withacupuncture by placing a piece of mo&a on top of aneedle inserted into the body, and igniting it, whenthe heat from the mo&a is conducted down theneedle to the surrounding tissues.34/4T4-%The concepts which prompted the ancient hineseto use acupuncture for therapeutic purposes werecomple& and to the modern :estern mind difficultto comprehend. They were intricately bound upwith their 'iews concerning all aspects of theli'ing world, including in particular their beliefin the e&istence of two cosmic regulators known asIin and Iang.The supremacy of power and influence accordedto these two forces in the creation of the world iswell illustrated by the following quotations fromthe ei hing.The principle of Iin and Iang is the basis of theentire uni'erse. +t is the principle of e'erythingin creation. +t brings about the transformation toparenthood6 it is the root and source of life anddeath *Hea'en was created by an accumulation ofIang6 the %arth was created by an accumulationof Iin.The ways of Iin and Iang are to the left and tothe right. :ater and fire are the symbols of Iinand Iang. Iin and Iang are the source of powerand the beginning of e'erything in creation.Iang ascends to Hea'en6 Iin descends to %arth.Hence the uni'erse (Hea'en and %arth$ representsmotion and rest, controlled by the wisdomof nature. ature grants the power to beget andto grow, to har'est and to store, to finish and tobegin anew.7urther, the hinese considered that, followingthe creation of the world, Iin and Iang continued toe&ert a considerable influence, and that indeed thepreser'ation of order in all natural phenomena,both celestial and terrestial, was dependent on themaintenance of a correct balance between them.


18/742

+t should be noted in this connection that neitherof these two opposing forces were e'er en'isagedas e&isting in pure form but rather that each containeda modicum of the other. 3nd moreo'er,there was the belief that all e'ents, both in natureand in the human body, were influenced by a constantly

changing relationship between them.Iin and Iang were thus said to be ubiquitousessential components of all things, with in somecases Iang being predominant and in others Iin.+n the uni'erse for e&ample, phenomena such as thesun, hea'en, day, fire, heat and light were all consideredto be predominantly Iang in nature, whereastheir opposites, the moon, earth, night, water, coldand darkness were considered to be predominantlyIin. The indi'idual structures of the body werealso thought to ha'e either Iang or Iin qualities.7or e&ample, fi'e hollow 'iscera the stomach,small intestine, large intestine, bladder and gallbladder were said to be Iang organs because lyingnear to the surface on opening the body they gete&posed to light. +n contrast, fi'e solid 'iscera theheart, lungs, kidneys, spleen and li'er were saidto be Iin organs due to their being in the darkrecesses of the body.The conclusion reached by the hinese that fi'eorgans had Iang and fi'e had Iin characteristicswas apparently not a fortuitous one but seeminglybecause fi'e was considered to be a dominantnumber in their conception of the uni'erse. Thisstemmed from their fundamental belief in the theoryof the fi'e elements, which stated that Iin andIang consist of fi'e elements, namely water, fire,metal, wood and earth, and that man and, indeed,all natural phenomena are products of an interactionbetween these two opposing forces.The theory of the fi'e elements was e&tremelycomplicated and there is little to be gained bygoing into it in detail e&cept to say, in 'iew of itsrele'ance to the traditional practice of hineseacupuncture, that in its application to the organs ofthe body the ei hing teaches thatThe heart is connected with the pulse and ruleso'er the kidneys. The lungs are connected withthe skin and rule o'er the heart. The li'er is connectedwith the muscles and rules o'er the lungs.Traditional hinese acupuncture E


19/742

The spleen is connected with the flesh and ruleso'er the lungs. The kidneys are connected withthe bones and rule o'er the spleen.:ith this background it is now possible to seehow these 'arious considerations concerning Iin

and Iang came to be applied to matters concerningthe maintenance of health and the de'elopmentof disease. +t was considered that in order tobe healthy these two opposing forces ha'e to be ina correct state of balance (crasis$ and that it iswhen this is not so that disease occurs (dyscrasia$.7urther, it was considered that this health5gi'ingbalance between Iin and Iang only e&ists when aspecial form of energy, known as chhi, flows freelythrough a system of tracts. 3nd, as a corollary tothis, that disease de'elops when a collection of )e'ilair in one or other of the tracts obstructs the flowof chhi through it as this leads to an imbalancebetween Iin and Iang. +t was in attempting to dispelthis )e'il air or wind that the hinese were firstled to insert needles into these tracts, and then fromthis, o'er the course of centuries, to de'elop a somewhatcomple& system of therapy now known to the:estern world as acupuncture (from the 0atin acus,a needle6 and punctura, a prick$.3s it is only possible to understand how thehinese de'eloped their system of acupuncture byha'ing some knowledge of their original, somewhatprimiti'e ideas concerning the anatomy and physiologyof the body, these will now be discussed.The knowledge of anatomy and physiologypossessed by the hinese when they first started topractise acupuncture was ob'iously both scantyand inaccurate. +t is, therefore, surprising to findthat from an early date and certainly by the time the8u :%Qn was compiled in the And century 1 theyhad with considerable perspicacity come to reali;ethat blood circulates continuously around the body.7or in this manuscript hhi5/o saysThe flow (of blood$ * runs on and on, and ne'erstops6 a ceaseless mo'ement in an annular circuit.hhi5/o is here showing remarkable intuitionespecially when it is remembered that it wasanother FCC years before the :estern world cameround to this 'iew. This tardy reali;ation of thetrue state of affairs in the :est was of coursebecause


20/742

mo'ement of blood in the 'essels of the body is bymeans of a tidal ebb and flow. This remained theofficial 'iew for centuries and anyone who dared toquestion it was considered a blasphemous heretic.+ndeed, it was not until DA# that :illiam Har'eywith considerable courage published his proof that

blood mo'es around the body in a continuouscircle in his %&ercitatio 3natomica de 2otu ordiset 8anguinis in 3nimalibus.The ancient hinese admittedly had no scientifice'idence to support their belief in the circulationof the blood but because of their inherentcon'iction that the workings of the body are amicrocosmic representation of those to be found inthe macrocosm or uni'erse itself, they may ha'ecome to this conclusion from obser'ing the meteorologicalwater5cycle that occurs in nature.+t should be noted that the hinese at an earlydate not only correctly concluded that blood circulatesaround the body but also that this is effectedby a pumping action of the heart, for in the 8u :%Qnit says )the heart presides o'er the circulation ofthe blood and ?uices and the paths in which theytra'el. 2oreo'er, they were quick to appreciatethat the action of the heart is reflected in mo'ementsof the pulse felt at the wrist, and were ableto measure the pulse rate by using an instrumentcapable of measuring time by a regulated flow ofwater, an apparatus similar to that used by theancient


21/742

D 34/4T4-%, T-+


22/742

The


23/742

we do not adopt the term.The hinese described A main acu5tracts correspondingin number with the months of the yearwith each one being considered to ha'e a connectionwith and taking its name from an organ ofthe body. Howe'er, as already stated, the hinese

were of the opinion that there were only ten principalorgans, fi'e with Iin characteristics and fi'ewith Iang characteristics. Therefore, in order thatthe A tracts could be linked with A organs theyfound it necessary to include the pericardiumamongst the Iin organs, and to in'ent a structurewith no known equi'alent in modern anatomy,which they called the san chiao (triple warmer$and included this amongst the Iang organs.+t is of interest to note that because the brain wasconsidered to be nothing more than some form ofstorage organ it was not included amongst theprincipal organs. The ei hing in fact states that itis the li'er that )is the dwelling place of the soul orspiritual part of man that ascends to hea'en.Those who pioneered the de'elopment ofacupuncture in ancient hina belie'ed that acutractsfor most of their course are situated in thedepths of the bodys tissues, but that at certainpoints, now known in the :est as acu5points, theycome to lie immediately under the skin surfacewhere needles can readily be inserted into them.+t will be remembered that, according to traditionalhinese teaching, the purpose of insertingneedles into acu5points in disease is to release no&iousair or )wind (malignant chhi$ that impedesthe free flow of chhi in acu5tracts and thereby disturbsthe balance between Iin and Iang.+t is possible to gain some idea as to how thehinese ha'e always thought about acu5points bystudying the 'arious names they use to describethem in their writings. One of the commonest ofthese being chhi hsSeh hsSeh being a word meaninga hole or minute ca'ity or cre'ice6 in the 8u:n, chhi hsSeh are described as pores or intersticesin the flesh that are connected to the naturallyoccurring Iin and Iang forms of chhi in the acutractand blood 'essel systems. +t is also said thatthese )holes in the flesh are open to in'asion bymalignant chhi from outside the body but that ifand when this onslaught occurs it is readily repelledby acupunctureRThe ei hing in se'eral places says that there


24/742

are BDE acu5points. 3 figure no doubt arri'ed atTraditional hinese acupuncture F


25/742

because of its symbolic association with the numberof degrees in the celestial circle, the number ofdays in the year and the number of bones in thehuman body. This, howe'er, was only the numberof points supposed to be present in theory, as e'en

in the ei hing itself only DC points actuallyrecei'e names, and with the passage of time e'enfewer ha'e remained in regular use.The hinese ha'e gi'en each of their acupointsa specific name and ?ust as they ha'e named acutractsafter 'arious ri'ers so they ha'e incorporatedinto the names of acu5points references tosuch parts of natures waterway system as tanks,pools and reser'oirs. 3lso, during the course of time,acu5points along the length of each tract ha'e beenindi'idually numbered, and, as e'ery tract bearsthe name of the organ to which it is supposed to belinked, it necessarily follows that each point maybe identified by reference to the name of the tractalong which it is situated and its number on thistract. 7or e&ample, the point on the gall bladdertract situated half5way between the neck and thetip of the shoulder at the highest point of the shouldergirdle has been named by the hinese Jian?ingbut is more commonly referred to as


26/742

insert needles to combat it.The reason why the hinese ha'e placed suchimportance on e&amining the pulse is becausethey ha'e always considered that it is at that sitethat the Iin chhi in the blood 'essels and the Iangchhi in the tracts con'erge, and the pulse in some

of their writings is referred to as The


27/742

# 34/4T4-%, T-+


28/742

of agreement as to the significance of the 'ariousnuances that they considered they could detect atthe wrist. e'ertheless, their diagnostic interpretationof these was of necessity e&pressed in nosologicalterms quite irreconcilable with those based

on our present5day knowledge of pathology, and,therefore, it is surprising to find that certain :esterntraineddoctors e'en to this day still try to base theirpractice of acupuncture on this archaic approachto diagnosis, and are quite unwilling to accept thatsuch an anachronistic procedure should long agoha'e been relegated to the realms of history.3s the practice of acupuncture has of necessityalways depended on the insertion of needles intothe body it is of considerable interest to disco'erhow primiti'e 3siatic man found ob?ects of sufficienttensile strength and sharpness for thispurpose.Thorns of 'arious plants, sli'ers of bamboo, andneedles fashioned from bone ha'e always beena'ailable. 1one needles ha'e in fact been found inrecent years in tombs from the neolithic age, andby the Dth century, which is about the date of theoldest e&isting reference to acupuncture, it wouldha'e been technically possible to make needlesfrom bron;e, copper, tin, sil'er and e'en gold.3nd certainly gold needles ha'e recently been disco'eredin the tomb of the Han /rince, 0iu58hVng(B 1$. +t is therefore somewhat surprising tofind that seemingly needles in the early days ofacupuncture were commonly made of stone, for inHuang Ti ei hing (And century 1$, hhi5/o says+n the present age it is necessary to bring forwardpowerful drugs to combat internal illnesses, andto use acupuncture with sharp stone needles andmo&a to control the e&ternal ones.3lso, in manuscripts written on silk before thisand found in the tomb of the son of the 0ord of Tai,there are two separate specific references to theuse of stone needles.+t seems difficult to concei'e how needles madeof stone could ha'e been sharpened sufficiently topenetrate the tissues of the body, but, of the 'ariousmineral substances a'ailable in those far off days,it has been suggested that the following mightha'e been employed flint, mica, asbestos and ?ade.Howe'er, there is no confirmatory e'idence thatany of these were utili;ed and the e&act nature of


29/742

the type of stone originally used still remains amatter for con?ecture. The only certainty is that asiron and steel did not become a'ailable to thehinese until the Eth century 1 and as the practiceof acupuncture was started long before this, itnecessarily follows that materials other than iron

must ha'e initially been employed.+t is impossible in this brief re'iew to mention allthe 'arious stages in the de'elopment of this techniqueo'er the centuries. -eference will howe'erbe made to the hen hiu hia + hing as this is theoldest e&isting book entirely de'oted to acupunctureand mo&ibustion. +t was written soon after thehinese %mpire became re5unified in 39 ADE byone Huang 7u5mi who apparently became interestedin medicine partly because his mother wasparalysed and partly because he himself sufferedfrom rheumatismR +n this book Huang 7u5mi forthe first time groups the 'arious acu5points underthe names of the 'arious tracts to which they belongand, after numbering them, gi'es a detailed descriptionof their positions and how to locate them.7urther, he names specific acu5points recommendedin the treatment of 'arious illnesses and gi'es muchad'ice as to how he considers acupuncture shouldbest be practised. This is, therefore, an outstandingbook in the history of acupuncture and one whichwas to e&ert a great influence on the practice of thistechnique throughout the %ast.2ention must be made of the eminent physician8un 8su5mo (39 E#DFB$ as it was he whointroduced the so5called module system for determiningthe e&act position of acu5points on peoplesbodies irrespecti'e of their 'arious si;es by takingmeasurements using relati'e or modular inches.He defined a modular inch as being the distancebetween the upper ends of the distal and middleinterphalangeal folds when a person fle&es themiddle finger6 and recommended that measurementsshould be made by using strips of bamboo,paper, or straw, cut to the length of a personsindi'idual modular inch.8un 8su5mo was also the author of two outstandingbooks on acupuncture and mo&ibustionand was the first to draw attention to the importanceof inserting needles into e&quisitely tenderpoints, particularly, he said, in treating low backpain. He called these ah5shih (oh5yesR$ points, fromthe e&pleti'e often uttered by the patient when


30/742


31/742

pressure is applied o'er themR This is of particularinterest as he was clearly practising what is knownnow as trigger point acupuncture, and which ha'ingbeen redisco'ered in recent years is describedin /arts A and B of this book.

The +mperial 2edical ollege, with a departmentalprofessor of acupuncture, lecturers, anddemonstrators, had been founded by 39 D#, andby 39 DA! a similar college of medicine had beenestablished in each pro'ince.7rom 39 CAF the teaching of acupuncture atthese institutions was carried out with the help oflife5si;e bron;e figures of the human body. Thewalls of these figures had holes punched in themat the sites of all the known acu5points. The figureswith their holes filled with water and co'ered bywa& were then used for e&amining medical studentsin acupuncture. This was done by makingthe students insert needles into sites on these figureswhere they considered acupoints points might e&ist,and if, on attempting this, no water poured outthey failed their e&aminationRThe hinese ha'e always had a deep con'ictionthat the workings of the body are intimately linkedwith those of nature in general, and that 'ariouscyclical e'ents e&ternal to the body ha'e an importantinfluence o'er matters of health and disease.7urther, that for the successful eradication of diseaseby acupuncture it is necessary to perform thelatter at a propitious time and one that can only bedetermined by taking into consideration the interrelationshipof these 'arious e&ternal factors. +t is,therefore, not surprising to find that the ei hingclearly states that in order to disco'er the righttime for both the application of acupuncture andmo&ibustion the physician must first establish theposition of the sun, the moon, other planets, and thestars in addition to taking into account the seasonof the year and the pre'ailing weather conditionsRThe following is a quotation from hapter AD ofthat bookTherefore one should act in accordance with theweather and the seasons in order to ha'e bloodand breath thoroughly ad?usted and harmoni;ed and consequently when the weather is cold, oneshould not apply acupuncture. 1ut when the daysare warm there should not be any hesitation. *+n an earlier part of the same book there is a


32/742

statement that when acupuncture is applied for ane&cess of Iang it has a draining effect, and whenfor a deficit of Iin it supplements 'igour. 0ater onin the same chapter it states3t the time of the new moon one should notdrain, and when the moon is full one should not

supplement. :hen the moon is empty to the rimone cannot heal diseases, hence one should consultthe weather and the seasons and ad?ust thetreatment to them.This concept that cyclical e'ents ha'e an importantcontrolling influence o'er matters of healthand disease was still further de'eloped with theintroduction of the wu5ySn liu5chhi system (thecyclical motions of the fi'e elements and the si&chhi$ in 39 C!!, and of the t;u5wu liu5chu system(noon and midnight differences in the following ofthe chhi$ in about the middle of the Ath century.These are comple& systems the details of whichwill not be entered into. 8uffice it to say that thefirst was based on the con'iction that e&ternalcyclical, astronomical, meteorological, and climaticfactors influence the workings of the body and thatfrom a study of these the occurrence of disease andparticularly epidemics of it may be predicted. 3ndthat the second was based on the idea that there areinternal cyclical changes occurring inside the bodyand that these ha'e to be taken into account whendeciding upon ideal times for performing acupunctureand mo&ibustion. +t is of great interest that suchideas concerning circadian rhythms in the bodywere put forward so long ago considering that itis only in 'ery recent years that proof has beenobtained of the e&istence of internal biological clocks.7rom this brief re'iew it may be seen that thehinese did not disco'er the therapeutic effectsof acupuncture as a result of some astute clinicalobser'ation nor alternati'ely were they inspiredto use it by the logical de'elopment of some wellfoundedhypothesis. On the contrary, it wouldseem that it was 'ery much by luck that they stumbledupon this 'aluable form of therapy becausetheir original reasons for using it ha'e subsequentlybeen shown to be entirely fallacious. 3nd further,to a 'ery large e&tent they succeeded in obscuringthe merits of this therapy by grafting upon it asomewhat esoteric set of rules for its application.The manner in which all this pre'ented acupuncturefrom becoming readily accepted in the :estern


33/742

world during the past BCC years will be discussedC 34/4T4-%, T-+


34/742

in detail in the ne&t two chapters but before this itis necessary to say something about its changingfortunes in hina itself.7rom the time that acupuncture was first usedin hina it remained in the ascendance in that part

of the world until reaching its ;enith at about theend of the Dth century. 7rom then onwards duringthe hing dynasty (D""!$, when hinawas under 2anchu rule, the practice of it wentinto a gradual decline. This initially was mainlybecause the onfucian religion practised by the2anchu people was associated with much prudishnessso that the baring of the body, as clearly isso often necessary with treatment by acupuncture,was considered to be immoral. 3nd also becausethe religion discouraged the inserting of needlesinto a persons body for fear that this might damagethat which was considered to be sacred by'irtue of it ha'ing been bestowed on that indi'idualby lo'ing parents. 3nother important reasonwas that from the Fth century onwards missionariesfrom %urope, with initially these mainly being/ortuguese Jesuits, in bringing the hristian religionto hina, also brought with them the :estern formof medical practice, and this o'er the ne&t BCC yearsprofoundly influenced the type of medicine practisedin the 7ar %ast with the practice of acupuncturegradually being displaced.%'ents mo'ed so quickly that when HsS 0ingThai, an eminent hinese physician and medicalhistorian, wrote about the history of hinese medicinein FEF, he had to report that by that timeacupuncture had become somewhat of a lost artwith few e&perts left to teach it to medical students.9uring the !th century its status declined stillfurther, with the hing emperors in #AA orderingthat it should no longer be taught at the +mperial2edical ollege. 7rom then on an increasing numberof colleges were opened by medical missionariesfor the e&press purpose of teaching hinesestudents :estern medicine, until finally this ancientform of treatment reached its nadir in !A! whenthe hinese authorities officially outlawed thepractice of it in that country.+t has to be remembered, howe'er, that whathas been said only really applied to a minority ofthe population because hina has always beena land of the rich and poor, of the rulers and the


35/742

oppressed, and whilst :estern medicine increasinglydisplaced traditional hinese medicine in thewealthy coastal cities the rural peasants that inhabitedmost of the country continued to depend ontraditional forms of treatment including acupuncture,and increasingly, what health care system was

a'ailable to them became more and more chaoticdue to years of Japanese occupation, ci'il war, andlack of doctors trained in this type of medicine.The hinese communist 'ictory in the so5called:ar of 0iberation in !"!, howe'er, changed all thiswith 2ao Tse Tung being determined to impro'ethe health ser'ice for the poor by ensuring thatmore doctors became trained in traditional hinesemedicine6 and by ensuring that the practice of thisform of medicine and :estern medicine becameclosely integrated with both being taught in themedical colleges.7ollowing the


36/742

Kaptchuk T J !#B hinese medicine the :eb that has nowea'er. Hutchinson, 0ondon2acdonald 3 !#A 3cupuncture from ancient art to modernmedicine.


37/742

The hinese had practised acupuncture and mo&ibustionfor se'eral centuries before news of itreached the outside world. The first people to hearabout it were the Koreans and then not until aboutthe beginning of the Dth century 39. +t was not

long after that, howe'er, that both hinese andKorean missionaries introduced it to Japan duringthe course of con'erting the people of that countryto 1uddhism.The :estern world, on the other hand, did notlearn about these oriental practices until the Fthcentury when Jesuit missionaries, whilst attemptingto con'ert the hinese to hristianity, saw thembeing used in anton, and when %uropean doctorsemployed by the 9utch %ast +ndian ompanyin and around Ja'a saw them being used by theJapanese in that part of the world. :illem ten-hi?ne (D"FFCC$, a physician born in the 9utchtown of 9e'enter, and who recei'ed his medicaleducation at 0eyden 4ni'ersity, must be gi'en thecredit for being the first person to gi'e the :esternworld a relati'ely detailed, if unfortunately a somewhatmisleading, account of the hinese practiceof acupuncture and mo&ibustion.His opportunity to see orientals practising thesetechniques came when, soon after qualifying as adoctor, he ?oined the 9utch %ast +ndia ompany inDFB and was sent to Ja'a. 9uring the latter part ofhis life there he was to become the director of the0eprosarium but as a young man he had no soonerarri'ed than he was ordered to go to the island of9eshima in agasaki 1ay. +t was during the A yearshe was stationed there that he first saw the techniquesof hinese acupuncture and mo&ibustionBhapter AHow news of acupuncture andmo&ibustion spread from hinato the outside worldH3/T%- OT%T8How the :estern world learned about thehinese practice of acupuncture in the Fthcentury when physicians working for the 9utch%ast +ndia Trading ompany saw it beingpractised by the Japanese in and around Ja'a atthat time


38/742

" 34/4T4-%, T-+


39/742

were made of gold, or occasionally of sil'er,being practised by the Japanese, and managed toacquire four illustrations depicting acupuncturepoints lying along channels. He not unnaturallyassumed that the latter must be blood 'essels, butfound the matter confusing as the directions in

which they appeared to run in no way conformedwith those taken by any anatomical structures withwhich he was familiar. He was ne'ertheless 'erymuch impressed with the therapeutic effects ofthese two techniques and was therefore determinedto learn more about them and in particular to getsomeone to e&plain the drawings to him. This howe'erwas not to pro'e easy because as he later saidin his book on the sub?ectThe ;ealous Japanese are quite reluctant to share,especially with foreigners, the mysteries of theirart which they conceal like most sacred treasuresin their book cases.+t would seem, howe'er, that the Japanese on theother hand had no such inhibitions when it came tothem wanting to know all about :estern medicinefor, on the orders of the


40/742


41/742

which is somewhat surprising considering thatsteel must ha'e been readily a'ailable to them.The main indication for their use according to himwas for the release of )winds for as he saysThe Japanese employ acupuncture especially for

pain of the belly, stomach and head caused bywinds * They perforate those parts in order topermit the confined wind to e&it.+n an attempt to e&plain this further, he adds thefollowing somewhat homely simile )in the sameway, sausages, when they threaten to e&plode in aheated pan, are pierced to allow the e&pandingwind to go out.+t would seem therefore that although thehinese originally employed acupuncture for thepurpose of clearing collections of )wind in acutracts(p. F$ in due course both they and the Japanesecame to use it for the relief of abdominal painbrought about by the entrapment of a quite differenttype of )wind in the intestinal tract.+t is of particular interest in this respect that theonly case history ten -hi?ne includes in his book isof a Japanese soldier with some abdominal pain.The soldier belie'ing this to be due to )wind producedas a result of drinking an e&cessi'e amountof water, is reported to ha'e carried out his owntreatment by inserting an acupuncture needle intohis abdomen. Ten -hi?ne was ob'iously presentwhen he did this for he says* lying on his back, he dro'e the needle into theleft side of his abdomen abo'e the pylorus at fourdifferent locations * while he tapped the needlewith a hammer (since his skin was rather tough$he held his breath. :hen the needle had beendri'en in about the width of a finger, he rotatedits twisting5handle * -elie'ed of the pain andcured by this procedure, he regained his health.Ten -hi?ne whilst watching this demonstrationof auto5acupuncture must ha'e cast his mind backto his youth for by a strange coincidence the title ofhis dissertation for his doctorate in medicine was9e dolore intestinorum e flatu * R +n his essay he alsogi'es a long list of other disorders that the Japanesein those days were treating with acupunctureincluding conditions such as headaches, rheumaticpains, and arthritis that people all o'er the worldare still using it for. The one notably bi;arre andcertainly 'ery ha;ardous use for it at that time was


42/742

in the field of obstetrics with the acupuncturistbeing ad'ised to )puncture the womb of a pregnantwoman when the foetus mo'es e&cessi'ely beforethe appropriate time for birth and causes themother such se'ere pains that she frequently is indanger of death6 puncture the foetus itself with a

long and sharp needle, so as to terrify it and makeit cease its abnormal mo'ement fraught with dangerfor the motherR+t is 'ery unfortunate considering that ten -hi?newas sufficiently impressed with the practical 'alueof acupuncture to feel that he wanted to pass on hisknowledge of the sub?ect to the :estern world bywriting an essay on it, that this should ha'e pro'edto be a totally inaccurate account, due to his failureto understand that the hinese belie'ed in thee&istence of a system of channels (now referred to inthe :est as acutracts or meridians$ completely separatefrom and yet closely associated with blood'essels. His knowledge of anatomy was e&tensi'efor at one stage in his life he taught the sub?ect andtherefore in all fairness there was no reason why itshould ha'e e'er crossed his mind that the acutractsdepicted in the illustrations he acquired couldbe anything but structures already well known tohim from dissecting the human body. 3s a result herepeatedly refers to them as arteries, and to confusethe matter e'en more insists that the hineseand Japanese use the terms artery, 'ein, and ner'einterchangeably and so in some places he e'enrefers to them as 'eins and in others as ner'es.His belief that these tracts were arteries is alsoreadily understandable when it is remembered howmuch importance the hinese placed on their longheldbeliefs concerning the circulation of the bloodin de'eloping their practice of acupuncture. This isclearly e&pressed by ten -hi?ne when he said3lthough hinese physicians (who are the forerunnersfrom whom Japanese physicians borrowedthese systems of healing$ are ignorant inanatomy, nonetheless they ha'e perhaps de'otedmore effort o'er many centuries to learning andteaching with 'ery great care the circulation of theblood, than ha'e %uropean physicians, indi'iduallyor as a group. They base the foundation oftheir entire medicine upon the rules of the circulation,as if the rules were oracles of 3pollo at 9elphi.How news of acupuncture and mo&ibustion spread from hina E


43/742

He then goes on to point out how, )among thehinese the masters employ hydraulic machinesto demonstrate the circulation of the blood to theirdisciples who ha'e earned the title of physician6 inthe absence of such machines the masters assist

understanding with clear figures. +t is ob'ious thatten -hi?ne was under the impression that the drawingshe possessed were e&amples of such figures.3nother reason for his confusing acu5tractswith arteries was that he knew that the hineseplace considerable emphasis on the e&aminationof the pulse in making a diagnosis before undertakingacupuncture or mo&ibustion. +n referring tothe latter for instance he says* where'er pain has set in, burn6 burn howe'erin the location in which the arteries beat moststrongly. 7or in that place the seat of the pain islodged, where harmful winds inordinately mo'ethe blood. 3fter prior e&amination of the pulse ofthe arteries, place the burning tow on the locationmarked with its own sign.3nd in another place he says* where'er pain has lodged, burn. To which +add, when it is necessary puncture, punctureand burn where the arteries beat strongest. :hatthe patient can detect by the sensation of pain thephysician can detect by feeling the pulses in theaffected part.3t the same time he is clearly aware that if thechannels depicted in his illustrations and which hedescribes in the te&t of his book are arteries thenthey are a 'ery inaccurate anatomical representationof the course known to be taken by such 'essels.3nd it would seem that, fearing that for thisreason alone authorities in the :estern worldmight re?ect out of hand the whole system ofacupuncture and mo&ibustion, he finds it necessaryto apologi;e for the apparent ineptness ofthose who drew the illustrations by saying+n many instances, a person especially skillfulat the art of anatomy will belittle the lines andthe precise points of insertion, and will censurethe awkward presentation of the short notes on thediagrams, when these should be more closelyidentified with walls of the blood 'essels. 1ut wemust not on this account casually abandon ourconfidence in e&periments undertaken by the'ery great number of superb and polished intellects


44/742

of antiquity. hinese physicians prefer tocast the blame for a mistake upon their own ignorance,rather than diminish in the slightest theauthority of and trust in antiquity *3lthough the account of acupuncture in ten-hi?nes book was the first detailed one to appear

in the :estern world, a passing reference to thesub?ect had already been made in a book writtenby Jacob de 1ondt (E!#DB$ who as surgeongeneralto the 9utch %ast +ndia ompany in Ja'ahad also seen the technique being used in that partof the world. This book, Historia aturalis et 2edica+ndiae Orientalis, published in DE#, is in the mainan account of the natural history of animals andplants found in the %ast, but it contains a paragraphabout acupuncture.:hen ten -hi?ne quotes this paragraph in his ownbook he cannot refrain from putting in parentheseshis own critical comments thus causing de 1ondtsdescription of acupuncture to read as followsThe results with acupuncture in Japan which + willrelate e'en surpass miracles Wwithout underminingbelief in their authenticityX. 7or chronic painsof the head Wand moreo'er for recent ones, especiallythose arising from windsX, for obstruction ofthe li'er and spleen, and also for pleurisy Wand forother ailments, as is here made clearX they borethrough Wand they perforateX with a stylus Wheshould ha'e said, with a needleX made of sil'er orbron;e Wmore correctly, from goldX and not muchthicker than ordinary lyre strings. The stylus Wherethe good author is quite in errorX should be dri'enslowly and gently through the abo'e mentioned'itals so as to emerge from another part.One book that presumably ten -hi?ne did notread, but which could ha'e been a help to him inunderstanding something about acu5tracts, waswritten anonymously but almost certainly by a7rench Jesuit missionary working in anton. Thiswork was based on a translation of a st5centurymanual, the 2o chSeh (8phygmological +nstructions$.This book printed at


45/742

8ecrets de la 2Ydecine des hinois, consistant en laparfaite onnoissance du /ouls, en'oye; de la hinepar un 7rancois, Homme de grand mYrite.+t is more surprising that ten -hi?ne did notlearn about the belief of hinese physicians in a

system of channels or acu5tracts separate from theanatomically demonstrable circulatory system fromthe


46/742

pulse rate including food, drink, tobacco, an&ietyand fe'ers. He implored all young physicians touse the instrument )to discern all those dangerouse&orbitances which are caused by an irregular diet,'iolent passions, and a slothful life.His reference to leyers obser'ations on

hinese medicine comes in the first part of thesecond 'olume under the title of 3n %ssay to makea new 8phygmologia, by accommodating the hineseand %uropean obser'ations about the /ulse into one8ystem. 3s may be gathered from the title this onlydiscusses the hinese method of pulse diagnosisand there is no mention of acupuncture in it. +twould seem in fact that 7loyer had no interest inthe latter belie'ing that the hinese in the maintreated most diseases pharmaceutically after ha'ingdiagnosed them in the first place by meansof obser'ations on the pulse. uriously enough hewas not all that wrong because unbeknown tohim, at the time his book was being written, acupuncturein hina was going through one of itsperiodic phases of being out of fashion.+n spite of 7loyers enthusiasm for hinesesphygmology his contemporaries failed to showany real interest in it, or for that matter in the practiceof acupuncture itself. This perhaps is surprisingconsidering that in the early part of the Fthcentury :illiam Har'ey dramatically changedlong5held ideas in the :estern world concerningthe physiology of the circulatory system when inDA# he published his famous book %&ercitatio3natomica de 2otu ordis et 8anguinis in 3nimalibus.+n this he was at last able to refute the hithertoseemingly in'iolable but erroneous teaching of


47/742

principle that blood circulates around the body oneHow news of acupuncture and mo&ibustion spread from hina F


48/742

might therefore ha'e thought that in the climate ofopinion pre'ailing in the :est towards the end ofthe Fth century that more interest might ha'ebeen shown in them. Iet when the book la'is2edica ad hinarum 9octrinam de /ulsibus, which

basically was yet another translation of the 2ochSeh, written by 2ichael 1oym (DADE!$ a/olish Jesuit missionary in hina, was published inD#D, it prompted /ierre 1ayle in re'iewing it thatyear in ou'elles de la -Ypublique des 0ettres to sayThe -e'erend 7ather e&pounds to us the hinesesystem of medicine 'ery clearly, and it is easy tosee from what he says that the physicians of hinaare rather cle'er men. True, their theories andprinciples are not the clearest in the world, but ifwe had got hold of them under the reign of thephilosophy of 3ristotle, we should ha'e admiredthem 'ery much, and we should ha'e found themat least as plausible and well based as our own.4nfortunately, they ha'e reached us in %urope ?ustat a time when the mechanick /rinciples in'ented,or re'i'ed, by our 2odern Lirtuosi ha'e gi'en usa great distaste for the )faculties of


49/742

2ost %uropean physicians also showed little orno enthusiasm for the hinese practice of applyingheat to the skin by burning mo&a on it, when theyfirst heard of this in the Fth century, in spite of thefact that at that time they were still firm belie'ers inblistering their patients with strong irritants, and

burning them with boiling oil and red hot ironsROne person, howe'er, who did ad'ocate its use wasHermann 1uschof, a 9utch -eformed 2inister anda friend of ten -hi?ne when they worked together inJa'a. He wrote a laudatory account of its use ingout and other arthritic conditions in a book publishedin DF" entitled Het /odagra * 3nother protagonistwas 8ir :illiam Temple the eminentFth5century diplomat who wrote appreciati'elyabout it in an essay )The cure of


50/742

# 34/4T4-%, T-+


51/742

and known to the Japanese as senki. There is adetailed account of how needles should be insertedin this condition but all reference to acu5tracts isa'oided, and it does not really add anything tothat which had by that time already been written

on the sub?ect.The essay on mo&ibustion, howe'er, is far morewide ranging. His description of the sites at whichhe saw a mo&a cautery applied, and the reasonsfor doing this make fascinating reading, as may beseen from the following quotationonsidering the places cauterised, you wouldthink the une&pected successes illusory. 7ore&ample to facilitate birth, the tip of the small toeon the left foot6 to pre'ent conception or to promotesterility, the na'el6 to relie'e toothache, theadducting muscle of the thumb on the same sideas the aching tooth.The latter is a clear reference to the classicalhinese acupuncture and mo&a point Ho5Ku,stimulation of which to this day is widely recogni;edas ha'ing a powerful analgesic effect.7rom what has been said it will be clear thatmuch information concerning acupuncture andmo&ibustion reached %urope during the Fth centurybut only limited use was made of these techniqueseither during that century or the followingone because physicians in the :estern world werecompletely mystified as to how these particularforms of therapy achie'e their effects. One of thefew men to think deeply about this matter was


52/742

practical e&perience identified such points.+t was of course another ACC years before researchinto the neurophysiology of pain pro'ided ob?ecti'ee'idence in support of 'an 8wietens hypothesis.+t is now necessary to consider the attitudes ofdoctors, both in %urope and 3merica, to acupuncture

during the !th century as this was a periodwhen a few of the more courageous of them, inspite of not being able to accept the traditional theoriesupon which the hinese based their practiceof it, decided to e&plore empirically its clinicalapplications. 3nd ha'ing con'inced themsel'es ofits merits in alle'iating musculoskeletal pain, theyattempted to populari;e its use for this purpose.They were, howe'er, to find their efforts thwartedby entrenched conser'atism. 2embers of the medicalprofession at that time showed a strangelyinconsistent attitude whereby they were morethan willing to prescribe potentially to&ic substancesof uncertain efficacy whilst being quiteunwilling to try out the relati'ely harmless procedureof inserting needles into people, presumablybecause they could not bring themsel'es to belie'ethat anything so simple could ha'e the effectsclaimed for it an attitude of mind, regretfully, stilladopted by some in the late ACth centuryRHow news of acupuncture and mo&ibustion spread from hina !-eferences1owers J U !DD %nglebert Kaempfer6 /hysician, e&plorer,scholar and author. Journal of the History of 2edicineand 3llied 8ciences A ABFAE!1owers J U, arrubba - : !FC The doctoral thesis of%nglebert Kaempfer on tropical diseases, orientalmedicine and e&otic natural phenomena. Journalof the History of 2edicine and 3llied 8ciences AEAFCBCarrubba - :, 1owers J U !F" The :estern worlds firstdetailed treatise on acupuncture :illem ten -hi?nes 9e3cupunctura. Journal of the History of 2edicine and3llied 8ciences A! B!B!F


53/742

AC 34/4T4-%, T-+


54/742

There is good e'idence to show that acupuncturecame to be widely practised by the medical professionin %urope during the first half of the !thcentury.+ts protagonists, howe'er, turned their backs

on the comple&ities of the traditional hineseapproach to the sub?ect and, in a determined effortto shed it of all its mysticism, ignored the acu5tractsystem and refused to attempt to use the orientalsystem of pulse5diagnosis. They confined themsel'esfor the most part to the treatment of painfulconditions and the method adopted was simply astraightforward insertion of needles into painfulareas, similar to the ah shih hsSeh type of acupuncturepractised by 8un 8su5mo in hina in the Fthcentury (see h. $. 1oth of these forms of acupuncture)in loco dolenti, as 0u


55/742

AA 34/4T4-%, T-+


56/742

before the clinical application of the techniquebecame widely adopted but in #A# some importantpapers appeared, including one by 1ernsteinand another by 0ohmayer, reporting good resultswith this form of treatment in the alle'iation ofrheumatic pain.

+n 7rance, interest in acupuncture wasreawakened in a far more direct manner. :hen +saacTitsingh, a surgeon attached to the 9utch %ast +ndiaompany at 9eshima, e'entually returned to%urope, he brought with him among the memorabiliaof his tra'els, an ebony case containing needlesand mo&a tinder6 and also a teaching5aid in theform of a cardboard doll with acu5points and tractspainted on it that had been presented to him by aJapanese +mperial /hysician. His friends in %uropeshowed considerable interest in these items, butwhat was to pro'e to be of e'en greater importancewas his translation of an #th5century Japanesetreatise on acupuncture, for when this came to theattention of the /arisian physician 8arlandiZre hewas so intrigued with it that he began to practiseacupuncture himself and persuaded se'eral otherphysicians in /aris to do likewise. +ncluded amongthese were 1erlio;, the father of the composer, whoin #D wrote the first book on the sub?ect in 7rance,and loquet 9antu who reported their results oftreating patients with this technique in an articleObser'ations sur less %ffets ThYrapeutiques de + 3cupuncturein 1ayles 1ibliothZque de ThYrapeutiquepublished in #A#.8arlandiZre himself was the first to apply electriccurrents to implanted needles, and his book gi'ingan account of this was published in #AE. This willno doubt surprise anyone who might ha'e thoughtthat electroacupuncture is a recent in'ention.7rom their reports it is clear that these /arisianphysicians were using acupuncture in the treatmentof many different disorders but that their bestresults, as might be e&pected, were in the relief ofmusculoskeletal pain and migraine.+n +taly the first book to be published on the practiceof acupuncture was that of 1o;etti in #AC, butthe one that was to become best known was that of3ntonio arraro published in #AE. 3lso of particularinterest were two books, the first appearing in#B" and the second in #BF, in which da amindescribes how following the e&ample of 8arlandiZre


57/742

by some and 'isionary by others + prefer to preser'ea profound silence.8uch honesty has to be admired particularly ashe clearly recogni;es that his self5confessed ignoranceconcerning its action could seriously undermine

his efforts to populari;e the technique for hesays )* if on the other hand, a rational theory, builton sound logical reasons, be the only e'idenceto which any 'alue can be attached, then willmy efforts ha'e been una'ailing and fruitless. 8uchfears, howe'er, pro'ed groundless because hisbook undoubtedly aroused much interest with it,not only being translated into


58/742

farfetched to anyone who has not practised acupuncturebut on occasions it is surprising howrapidly pain is relie'ed in response to needlestimulation6 and his third is in line with the currentlyheld 'iew that for acupuncture to be successfulin the relief of chronic pain the needling

itself has to be such as to produce a brief intenselypainful stimulus (see h. #$.3nother person whose interest in acupuncturewas aroused by hurchill was John %lliotson, aphysician who was originally on the staff at 8tThomass Hospital, 0ondon but who later became/rofessor of 2edicine at 4ni'ersity ollege Hospital.%lliotson writing in the 2edico5hirurgicalTransactions in #AF stated that the use of acupunctureboth in his pri'ate practice and at 8t ThomassHospital o'er se'eral years had led him to agreewith 2r hurchill that it was mainly of 'alue in the)rheumatism of the fleshy parts, which he also inplaces referred to as )rheumatalgia.+n 'iew of %lliotsons high standing as a teacherin a leading medical school it was unfortunate thathis enthusiastic support for animal magnetism, aform of hypnosis introduced by 2esmer, causedhim to suffer professional opprobrium, as this inturn ser'ed to undermine any influence he mightotherwise ha'e had in furthering the cause ofacupuncture.+t is clear that in !th5century 1ritain any interestthat may ha'e been shown in acupuncture bothby the medical profession and the general publicwas intermittent, as may be seen from the followingcontribution to the sub?ect by 9r T Ogier :ardof Kensington, in the 1ritish 2edical Journal on A#th3ugust #E#* acupuncture is a remedy that seems to ha'e itsfloods and ebbs in public estimation6 for we see itmuch belauded in medical meetings e'ery tenyears or so, e'en to its recommendation in neuralgiaof the heart, and then it again sinks intoneglect or obli'ion. 3nd it is not unlikely thatits disuse may be occasioned partly by fear ofthe pain, and partly by the difficulty the patientfinds to belie'e so trifling an operation canproduce such powerful effects. +ts use is not asfrequent as it deser'es and now that we know3cupuncture in the :estern world during the !th century AB


59/742

the rationale of its operation + 'enture to bringforward a few cases in illustration of its remedialpowers in order that others may be induced togi'e it a more e&tensi'e trial, and thus ascertainits true 'alue in the treatment of neuralgia or

rheumatic pains.There then follows si& case reports describinghow muscle pain in 'arious parts of the bodyincluding the shoulder, lower back and thigh wasalle'iated by inserting needles into the areas wherethe pain was most intensely felt. 3cupuncture maynot ha'e been widely adopted by the 1ritish medicalprofession during the !th century but there ise'idence to show that at least one large pro'incialgeneral hospital in this country fa'oured its use inthe alle'iation of musculoskeletal pain. T. /ridginTeale, 8urgeon to the


60/742

3nother surgeon to write about the use of acupuncturein hospital practice at 0eeds was 8imeon8nell. 8nell writing in the 2edical Times and


61/742

later (1ache #AD$, )may be arranged into the fourgeneral heads of muscular rheumatism, chronicpains, neuralgia, and ophthalmia. +n his reportin which he re'iewed the results of the effects ofacupuncture on A! people, most of whom were

con'icts, he concluded that the treatment hadmuch to offer in remo'ing and mitigating pain,and that it was )a proper remedy in almost all diseases,whose prominent symptom is pain.One cannot help but feel that if only more noticehad been taken of this wise dictum that interest inacupuncture in !th5century 3merica might ha'ebecome more widespread, but, unfortunately, certainother /hiladelphian physicians decided todirect their energies to e&ploring its use in conditionsof a far more dubious nature.These included %. J. o&e, 9. T. o&e, and 8amuelJackson, who ha'ing heard reports from %uropeabout it being possible to re'i'e drowned kittensby inserting needles into their hearts, decided toin'estigate whether the same procedure had anythingto offer in resuscitating drowned peopleR3nd finding, as might be e&pected, that it had not,they clearly became disillusioned with the therapeuticproperties of acupuncture in general, for as%dward o&e (#AD$ in reporting the results of theire&periment remarked:hate'er others may think of the possibility ofresuscitating drowned persons by acupuncture,+ can only say that + should think myself highlyculpable, if, called to a case of asphy&ia, + were towaste time, e'ery moment of which is precious,in endea'ouring to resuscitate by a means which+ sincerely belie'e to be good for nothing.This in my opinion is a 'ery good e&ample asto how acupuncture can so readily be brought intodisrepute when it is not employed in a selecti'e anddiscerning manner, and should ser'e as an ob?ectlesson to all those currently engaged in in'estigatingthe clinical applications of acupuncture. 9espitethis ad'erse report the cause of acupuncture in3merica recei'ed a boost when in #BB the editorsof the 2edical 2aga;ine reprinted a paper thatJohn %lliotson, the physician at 8t Thomass Hospital,0ondon, had originally contributed to theyclopaedia of /ractical 2edicine. 3lso, in #BD theeditors of the prestigious and widely read 1oston2edical and 8urgical Journal reprinted an article that


62/742

had appeared shortly before in the 8outhern 2edicaland 8urgical Journal. +n this paper, :illiam 2. 0ee of8outh arolina reported how he had used acupuncturefor D years in the treatment of rheumatismand concluded that this method of treatment was)entitled to far more attention than it has yet

recei'ed in the 4nited 8tates.8uch a 'iew, howe'er, does not seem to ha'ebeen widely shared, for there continued to be apaucity of literature on acupuncture in 3merica atthat time with the only further outstanding contributionbeing that of -obley 9unglison, another/hiladelphian physician. This took the form of aneight5page account of the sub?ect in a compendiumof his entitled ew -emedies, and published in #B!.The same article was reproduced in subsequenteditions of the book up to the last one whichappeared in #ED, but in spite of this any interestthat there may ha'e been in this type of treatmentwas gradually fading lea'ing 8amuel


63/742

+t would seem that early in Oslers career atthat hospital a certain /eter -edpath, a wealthy2ontreal sugar refiner and member of the hospitalsboard, ha'ing suffered from intractable lumbagofor some time, had high hopes that the newly

appointed physician might be able to cure him.3rrangements were therefore made for him toconsult Osler in his office at the hospital and it isrecounted that -edpath, ha'ing arri'ed e&haustedfrom the effort of mounting the stairs, did not takekindly to being treated with acupuncture, forushing reports that* at each ?ab the old gentleman is said to ha'erapped out a string of oaths, and in the end gotup and hobbled out, no better of his pain, this toOslers great distress, for he had e&pected to gi'ehim immediate relief which as he said )meant amillion for 2c


64/742

hinese acupuncture points but so far as musculoskeletaldisorders were concerned, which 'erysensibly is what in the main they used it for, theysimply inserted them into the painful areas. Howe'er,it is now reali;ed that musculoskeletal paindoes not necessarily originate at the site where it is

felt, but is referred there 'ia the central ner'ous systemfrom some focus of neural hyperacti'ity nowknown as a trigger point that is often situatedsome distance away. Therefore, rather than insertinga needle into the area where pain is felt, the painis more likely to be relie'ed if the needle is insertedinto the tissues o'erlying the trigger point for thepurpose of stimulating 3delta ner'e fibres in its'icinity.This is the fundamental principle upon whichthe recently de'eloped :estern approach to triggerpoint acupuncture is based, and the manner inwhich it was disco'ered will now be e&plained.AD 34/4T4-%, T-+


65/742


66/742

loquet J, 9antu T 2 #A# Obser'ations sur les effectsthYrapeutiques de acupuncture. +n 1ayle 3 0 J (ed$1ibliotheque de ThYrapeutique, 'ol , p. "BDo&e % J #AD Obser'ations on asphy&ia from drowning.orth 3merican 2edical and 8urgical Journal A A!AA!B

ushing H !AE The life of 8ir :illiam Osler. larendon/ress, O&fordda amin 7 8 #B" 8ulla agopuntura, con alcuni cenni sullapuntura elettrica. 3ntonelli, Leniceda amin 7 8 #BF 9ellagopuntura e della gal'ano5puntura.Osser'a;ioni, Lenice9unglison - #B! 3cupuncture. +n ew remedies. :aldie,/hiladelphia, pp. ABBC%lliotson J #AF The use of the sulphate of copper in chronicdiarrhoea together with an essay on acupuncture.2edicochirurgical transactions B, part A "E"DF%lliotson J #BB 3cupuncture. 2edical 2aga;ine BC!B"


67/742

+T-O94T+OThe traditional practice of hinese acupunctureha'ing become officially recogni;ed once again inhina during the !ECs, and it ha'ing since thenbeen increasingly used by some doctors, and to

an e'en greater e&tent by non5medically qualifiedpractitioners in the :est, there are at present manyacupuncturists throughout the world who claimit is beneficial in the treatment of a wide 'ariety ofdisorders. +t is, howe'er, only in the alle'iation ofpain, and in particular musculoskeletal pain, thatthere is any scientific basis to its use. 3nd, e'enwhen used within these strictly defined limits, thetraditional hinese approach to this form of therapyhas serious drawbacks.The principal disad'antage is that, for mostpractitioners of traditional hinese acupuncture,needles ha'e to be inserted somewhat arbitrarily inaccordance with the numerous lists of points thatare recommended for use in the treatment of 'ariousrather ill5defined clinical conditions in e'erystandard te&tbook on the sub?ect. 2oreo'er, beforea person is able to use these lists, recipes, or prescriptions,as they are sometimes called, it is firstnecessary to memori;e the course taken by the 'arioushinese acu5tracts, and the e&act anatomicalposition on them of the 'arious acu5points. +tcan only be assumed that these traditional guidesto point selection owe their origin to the timehonoured,but highly contentious, hinese methodof pulse5diagnosis, and for this reason alone they areunlikely to be acceptable to most doctors trained inACth5century scientific :estern medicine.Bhapter "8ome basic obser'ations leadingto its de'elopmentH3/T%- OT%T8+ntroduction B3 re'iew of John Kellgrens laboratory andclinical obser'ations during the !BCs whichestablished that pain which arises from pointsof ma&imum tenderness in muscle and certainother structures is referred to distant sites.3lso, his in?ection method of treating thispain BABEThe rele'ance of his disco'eries to thesubsequent de'elopment of trigger point


68/742

acupuncture BD


69/742

BA 34/4T4-%, T-+


70/742

research department at 4ni'ersity ollege Hospitalwho, because of his particular interest in the sub?ectof pain in general, prompted Kellgren to carry outclinical obser'ations on the referral of musculoskeletalpain.0ewis in his paper 8uggestions -elating to the

8tudy of 8omatic /ain published in 7ebruary !B#states3s an e&perimental method of producing musclepain the in?ection of a minute quantity of a saltsolution is the most satisfactory * +n these obser'ations+ ha'e noted that muscle pain is referred toa distance. Thus pain arising from the lower partof the triceps is often referred down the inner sideof the forearm to the little finger, from the trape;iusit is usually referred to the occiput. + ha'e beenfortunate in interesting 9r Kellgren in this matter.+n a long series of 'ery careful researches carriedout in my laboratory he has formulated some 'erystriking principles underlying the reference ofpain from muscle principles which appear toha'e an important practical bearing.Kellgren, in his paper Obser'ations on -eferred/ain 3rising from 2uscle, published later the sameyear, states that in taking on the task set him by8ir Thomas 0ewis he was aware that the latters/oints ofin?ection2usclepain7igure ". The distribution of diffuse referred pain(hatched area$ produced by in?ecting D saline into threepoints in the gluteus medius muscle. (-eproduced withpermission of J. H. Kellgren from linical 8cience, 'ol. B.pp FE!C [ !B# The 1iochemical 8ociety, 0ondon.$


71/742

Kellgren also points out in this paper that anin?ection of saline into muscle produces pain atsome distance from the point stimulated and that,in certain cases, the ma&imal pain is not e&periencedin muscle itself but in other structures. 7rom

his e&perimental work he was able to show, fore&ample, that when an in?ection is gi'en into theoccipital muscle, pain is felt diffusely as a headache6when into the masseter muscle, it is felt in themouth as toothache6 when into the infraspinatusmuscle, it is felt at the tip of the shoulder6 when intothe 'astus intermedius, it is felt around the knee?oint6 when into the peroneus longus, it is felt at theankle ?oint6 and when into the multifidus muscleopposite the first and second lumbar 'ertebrae, it isfelt in the scrotum.His finding that referred pain from a focusof irritation in a muscle may be felt in such structuresas ?oints, teeth, or the testicles is, of course,of considerable importance, and one which hasconstantly to be borne in mind in e'eryday clinicalpractice.7rom these obser'ations he decided that thedistribution of referred pain, induced artificially innormal people, by in?ecting hypertonic saline intomuscle broadly follows a spinal segmental patternbut that it does not correspond with the sensorysegmental patterns of the skin.Kellgren did not confine himself to laboratorye&periments but applied knowledge gained fromthese to clinical medicine. 3nd his paper, 3 /reliminary3ccount of -eferred /ains 3rising from 2uscle,published in !B#, is of the greatest possible interestbecause, unbeknown to him, from his study of anumber of cases of what he calls )fibrositis or)myalgia he laid down certain principles uponwhich the practice of modern :estern acupunctureis now based. 3s his obser'ations are therefore ofsuch fundamental impo

accupuncture trigger points and musculoskeletal pain

Documents