JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Acupuncture: Practical Considerations CARL S. JENKINS, M.D., FA.A.F P, Adjunct Protessor of Biology and Psychology, Wittenberg University, Springfield, Ohio.
In a practical consideration of acupuncture, we must briefly review its history, its principles as originally considered by the Chinese and the circulatory system. Along with these, Western acupuncture theories, techniques, type of cases commonly seen and treated and a consideration of complications are presented. The history of acupuncture extends back to approximately 8000 B.C. when the acupuncture effect was first noticed in warriors who had painful wounds and who found their old wounds were less painful when wounded again in, what later became known as acupuncture points.' In 4700 B.C., there is some evidence that acupunctrue had been practiced in Egypt.2 Between 2700 and 2400 B.C., the Huang Ti Nei Ching was written, which is commonly called the Yellow Emperor's Classic of Internal Medicine. This is an account of a conversation between the Yellow Emperor and his physician, Chi Po, about medicine as it was practiced in China. This book, which is comprised of 81 chapters,3 is the earliest recorded detailed discussion of acupuncture which is still being practiced in China today. In 1,644 B.C., acupuncture was used widely in China. It declined and in 600 B.C. there was a resurgence, however, it declined again. From 1644 to 1850 A.D., the Dutch brought acupuncture to Europe.4 The concept of acupuncture points dates to about 2,000 years ago. The linking of the acupuncture points by connections, commonly called meridians, was introduced during the same era.5 The intermediate history of acupuncture dates from the 17th century, when acupuncture was used for gout and arthritis in Europe. In Paris, France, about 181 1, acupuncture was used for the treatment of gonorrhea and syphilis, but failed. Afterwards, it was not used or was discounted for other diseases.6
In 1821, 1822, and 1823, the first English publications on acupuncture were written by Churchill and in 1879, Van Kemper first talked about using acupuncture in Germany.6 In 1900, with the upsurge of Western medicine in China, acupuncture declined, but was revived in 1936 when a French consul, who had been stationed in China returned to France and published the first Western book on acupuncture. This book was not in depth, but several years later, books were published by physicians and this marked the beginning of acupuncture in France. In 1936, acupuncture was used by the Chinese Army for malaria and diabetes when supplies of quinine and insulin6 were depleted. In 1958, acupuncture was first used for anesthesia. We are currently modifying our concept about acupuncture anesthesia, more in terms of it being an analgesic. The use for anesthesia first arose after it was noted that if acupuncture could be used to quiet pain after operative intervention, why could it not be used to quiet pain during surgery? In 1958, in Shanghai, an acupuncturist treated a tonsillectomy patient for post tonsillectomy pain. This administration of acupuncture to the HoKu point, in the area between the first and second fingers of one hand, raised questions that still have not been answered by any of the theories on acupuncture that have been proposed to the present time. The first question was-how could an acupuncture needle in one hand, supplied by a branch of the radial nerve or a deep interosseus branch of the ulnar nerve, stop the pain in the tonsilar area which is supplied by the glossopharyngeal nerve, which comes from the 9th cranial? The second question was-how could an acupuncture needle in one side of the HoKu point affect and produce anesthesia on the opposite side in the other tonsil area? The third question was-how could an acupuncture
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needle, inserted for 10 or 15 minutes, and then extracted, give anesthesia which persisted for hours afterwards? The whole concept of classic questions was written by Tien.8 He called it the question of persistence. The Chinese have thought that all matter is composed of opposing energy which is called Yang and Ying. In nature, their concept of Yang energy is sky, sun and heat, and Ying energy is earth, cold and water. In man, the Chinese consider Yang as being outside and above, and Ying as being inside and below.9 Chinese classify organs into solid organs, called Tsang organs, or hollow organs, called Fu organs. The Chinese envision an extension of these organs into lines called meridians, which extend through and just under the surface of the body. The Chinese concept of organs, taken into account not only the anatomical consideration, but also the physiological consideration. When the Chinese speak of an organ, they talk not only about the organ anatomically, but how the organ works in a physiological sense and the principle of its meaning and importance in man. '0 The Chinese also envision an energy flow in man, just as there is an energy flow in nature, a flow from Yang to Ying and from Ying to Yang. The solid organs are the heart, liver, spleen, lung, kidney and pericardium; and they consider that these organs all emit and energy flow, which goes to the hollow organs (small intestines, gall bladder, large intestines, bladder, stomach and triple burner). This exchange again is like nature-like the overall consideration of Yang to Ying and Ying to Yang.9 This concept is used in the classification of points. The circulation of energy is by meridian and the extension of the organ energy flow. The lung and the large intestine are two organs which comprise part of the energy circulation in the upper extremities and here you have the interchanqe between them traveling along the surface of the arm in the energy interchange. Likewise, the stomach and spleen are two organs which interchange along the Yang and Ying meridians of the lower extremities, and here you have the energy interchange flow. In disease, the flow is altered and needles are used to adjust the flow to normal by inserting them in acupuncture points.
One of the common techniques of training is to use a mannequin with acupuncture points or loci already marked and also the acupuncture meridians are marked. Choh-loh Li, " mentioned Western acupuncture theories and discussed them. The specific theory stated that small nerves convey only pain sensation to the higher centers without interaction from large fibers. The reverberation theory explains the persistence of pain following the stimulation of nerve, for instance, in the tooth pulp. The idea is that pain impulses reverberate along the internucleus cell conducting paths. The sensory and intertheory infers that the small fibers incite and the large fibers inhibit the cells which are responsible for pain interpretation. If we hit our elbow against a hard object, pain impulses are generated in small nerve fibers, and if we rub or pinch the skin on our elbow, other impulses are generated in the large fibers and pain is reduced. The gate control theory is based on a similar concept except that in this theory, inhibition states take place at the pre-ganglionic terminals. In the double gate and multiple gate control theories, emphasis is made of the importance of control from higher nervous centers. Choh-loh Li concluded his article by stating that there are a number of theories which can be used for the explanation of certain pain syndromes, and the mechanism by which pain sensation is perceived is not fully understood. He also stated that the final answer to the question of how acupuncture analgesia works depends upon further,understanding of our central nervous system.'" Warren spoke in April at the Hahnemann Medical College Symposium on Pain and Acupuncture where he named the theories. He felt that only a few of them had prospects, at this time, of being useful.'2 One of the difficulties in talking to groups about the type of cases commonly treated with acupuncture, is that the classification of its usefulness does not fall in normal Western terminology. In general this classification seems to work well, and is a type of approach used by most persons practicing acupuncture at this time.'3
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Usually, patients who come for acupuncture are those who have had considerable treatment before. These patients have had neuro-surgical or orthopedic evaluation along with surgical intervention, sometimes two or three times with no relief or some relief with later acupuncture and are able to dispense with pain medication, or at least limit its use. Use of acupuncture in headaches, specifically migraine, has been reported. Again, the physician gets this type of patient only after all other treatment approachs have been used, however acupuncture seems to be a valid approach and gets good results, usually
75-85%1/o. There is some controversy about the treatment of nerve deafness in this country, but papers initially reported by Pein and by Kao and associates, indicate good results in the treatment of deafness. A follow-up report in March 1974 at the Second World Symposium on Acupuncture and Chinese Medicine in San Francisco, seemed to indicate that results were poorer for patients over 50, decreasing as the patients grew older. With these patients we have seen seemingly good results. One begins to wonder if we are treating the patients or treating the tests, or that we may not just have the right test for evaluation. In the treatment of subdeltoid bursitis, four needles are inserted in the bursa and the area stimulated. This type of an approach some-
times relieves pain before the patient leaves the office, and certainly reduces the use of analgesic drugs. Usually one or two treatments suffice. Treatment of obesity has received considerable publicity recently. The same points are used for obesity and excessive smoking. These are usually points in the ear, sometimes stimulated by acupuncture needles and at other times stimulated by stainless needle clips or staples, which remain from two days to six months. This procedure is relatively new and the results seem to vary from 90% to poor, depending upon the reporter. Shearer reports 90% of his patient group of 300, lost from 20 to 35 pounds. With acupuncture, there is no chance of overdose, and with acupuncture there is no chance for gastric irritation or hormonal inter-
ference. As far as blood changes are concerned, some authorities have indicated minimal blood changes after acupuncture. There have been reports of white blood cells increased or decreased depending on the loci used. A decrease in the serum albumin, in patients who have inflammation and temporary small increases in blood sugar and serum lactate have been reported. Some electrolytes seem not to change, such as sodium, postassium, and calcium, but there have been reports of slight decreases in the excretion of potassium.'4 In any event, the blood changes are minimal compared to blood changes with some of the more harmful, but commonly used drugs. Since there is no material injected during acupuncture, the chances for allergic response or other common complication are practically nil. Complications of acupuncture are few indeed, and represent possibly the risk of masking a disease or condition. This, however, is no more risk than there would be in any other treatment not particularly suited to the patient's problem. Penetrating an organ may pose a problem but this should be no more a risk than from any other type of injection. In conclusion, it is my belief that acupuncture, as a treatment modality, should be used as a clinical tool in Western medicine and that all physicians should have a working knowledge of acupuncture technique and its application. LITERATURE CITED
1. TAN, L. and M. TAN, and 1. VEITH, Acupuncture Therapy. Temple Univ. Press. Phila., 1973, p. 5. 2. VEITH, 1. Second World Symposium, Acupuncture and Chinese Medicine, Mar. 74, San Francisco. 3. KAO, F China, Chinese Medicine, and the Chinese Medical System, Amer. Jour. Chin. Med., 1:8, 1973. 4. Wilkison, W Chairman Oriental Studies, Wittenberg University, Springfield, Ohio. Personal Communication, 1974. 5. Section of East Asian Studies, Wittenberg Univ. Springfield, Ohio. 1974. 6. VEITH, 1. Historical Review of Acupuncture, Pain and Acupuncture Seminar, Hahnemann Med. Coll., Phila., Pa., April, 1974. 7. Acupuncture Anesthesia, Foreign Languages Press., Peking, 1972. 8. TIEN, H.C., Neurogenic Interference Theory of Acupuncture Anesthesia, Amer. Jour. Chin. Med., 1:106-108, 1973.
(Conchlded on page 161)
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for all blacks and this effectively blocks better qualified black students from entering the university. He is their latter day "house nigger" who can be petted and brushed aside. Thus one lowly black student becomes the embodiment of all their fears, prejudices and assumptions and with slight effort is contained and made impotent. We are faced with the dilemma as psychiatric professionals that if raising questions like this is considered detrimental to the student and construed as "keeping our own down." Should we continue to sit by while the university and its agents delude this individual into believing he had greater capacity, strength and more basic knowledge. Institutional racism is difficult to counteract. It is also undercover. There has to be a special relationship with the institution and the individual, so that he or she is not swept along in the tide of their misdirected beneficence. Black students themselves play a part in this reverse racism and institutional evasion by participating in self-demeaning and self-deprecatory actions which give them short term gain. Like a particular concession from a professor or delay in a grade, but in these gains they deny their own inherent capabilities and self-esteem. The benevolent stance of the university contributes to poor self-esteem. Professors too often expect and accept poor work from intellectually competent and academically prepared black students. This reinforces the black students poor sense of self and perpetuates denial of real competency by both parties. There must be an interplay between the two worlds, black and White, and negotiating the system without self debasement. The universities too, should re-examine their recruitment policies. Many well-qualified black students who could function at a high level at the university should be sought after.
Blacks at predominantly white universities must learn to negotiate and develop a strategy which positions him in the two worlds. There is a great deal of strain on this tenuous membership with its interplay and different value concepts. To negotiate this system successfully the individual must at first be able to negotiate the interplay of the black and white world. The intervention process and strategy has to begin early so that the predicted success can occur. A whole system must be set up, not only to help the student with the intervention process but also with group coping mechanisms, strategies, tutoring and financial assistance and, most importantly, help with their own self-esteem. Those persons who head the agency which helps these students must be certified professionals who cannot only be role models but also serve as a reality base for the students trying to get through the system. It has been said that academic success is not only dependent on one's performance and examinations but on how well the individual is able to cope with the multifaceted strategies of the university setting. With the proper intervention process there is no reason why predominantly white universities cannot accommodate and graduate successfully minority students. So John did graduate and is now in graduate school. Some may say he did negotiate that system. Well, he did indeed, but for what price glory? He will not be able to hold down a job unless he is carried and his delusional system is so tenuous that he has to be heavily tranquilized, and he was in dssence robbed of a chance that he may have had to function at a level which would be -rnore comfortable for him. Instead he was pushed to a higher level at which he is doomed to fail. The university has a psychiatric tragedy and it should accept the full brunt of this unfortunate occurrence.
(Jenkins, from page 114) 9. NGHI, N., and G. FISCH and J. KAO. An Introduc12. WARREN, F Acupuncture Anesthesia, Indications, tion to Classical Acupuncture. Amer. Jour. Chin. Effectiveness, Failure and Side Effects. Seminar Pain Med., 1:75-83, 1973. and Acupuncture, Hahnemann Med. Coll. Phila., Pa., 10. KAO, F Opening Remarks. First World Symposium Apr., 1974. on Acupuncture and Chinese Medicine, San Fran13. CHOI, Y.W, The Topography of Meridians, 1973, cisco, Sept. 1973. Cunningham Press. Alahambra, Calif. 11. CHO-LUH LI, Neurological Basis of Pain and its 14. KAO, F., Seminar Pain and Acupuncture, Possible Relationship to Acupuncture-Analgesia. Hahnemann Med. Coll., Phila., Pa., Apr., 1974 (and Amer. Jour., Chin. Med., 1:61-72, 1973. personal communication).