Acupuncture, trigger points & musculoskeletal pain 3rd edition


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Acupuncture, trigger points & musculoskeletal pain 3rd edition

  1. 1. 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 andsoul 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 (1948)Extracts from reviews of the first edition:‘…I warmly recommend this book to anyone who wants to learn more about thisoften neglected area of common musculoskeletal pain conditions…’Journal of the Royal College of Physicians of London‘This is a book that should belong to physicians, neurologists, rheumatologists andteachers of medical students…’PainEndorsements of the new edition:‘Peter Baldry is one of the most respected practitioners of Medical Acupuncture inthe UK. This new edition is yet another first-class book, which adeptly combinesthe theory and practice of treatment of trigger points for musculoskeletal pain.An eminently readable and informative text; 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 Filshie, Consultant in Anaesthesia and Pain Management, RoyalMarsden Hospital, London and Surrey; Secretary of the British MedicalAcupuncture Society‘In this fine comprehensive book, Dr Baldry removes much of the mystiquefrom acupuncture as a technique for musculoskeletal pain relief. Using a fullyscientific integration of Eastern and Western knowledge, coupled with therelevant literature on clinical effectiveness of acupuncture, he provides an ideal,evidence-based text for the practitioner. From the beginner to the expert, anyone with an interest in the nature ofmuscle pain, its pathophysiology and treatment will be informed by this book: theentry-level therapist will gain a better understanding based on sound scientificevidence, while the experienced clinician will be rewarded with a well-writtenguide to what is significant in everyday clinical practice. Clinicians of severalmedical 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. For those who wish to implement acupuncture in the clinic, thistextbook is an invaluable resource for responsible practice. In total, this book offers an innovative approach to the diagnosis,understanding and treatment of myofascial trigger point pain using acupuncturethat integrates all current concepts of neurophysiology and neuroanatomyprinciples. Dr Peter Baldry is to be congratulated for conceptualizing, editing andwriting such a truly valuable asset for every clinical practice.’Dr George Georgoudis, Research Physiotherapist, University of Manchester, UK;Lecturer, Technological Educational Institute of Athens, Department ofPhysiotherapy, Greece; “Tzanio” General Hospital of Pireaus, GreeceFor Elsevier LtdCommissionning Editor: Karen MorleyProject Development Manager: Kerry McGechieProject Manager: Derek Robertson
  2. 2. Distributed in the United States of America by RedwingBook Company, 44 Linden Street, Brookline, MA 02146.© Longman Group UK Limited 1993© Harcourt Brace and Company Limited 1998© Harcourt Publishers Limited 2000© Elsevier Ltd 2005No part of this publication may be reproduced, stored in a retrieval system, ortransmitted in any form or by any means, electronic, mechanical, photocopying,recording or otherwise, without either the prior permission of the publishers or alicence permitting restricted copying in the United Kingdom issued by theCopyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP.Permissions may be sought directly from Elsevier’s Health Sciences RightsDepartment in Philadelphia, USA: phone: (ϩ1) 215 238 7869, fax: (ϩ1) 215 2382239, e-mail: You may also complete yourrequest on-line via the Elsevier homepage (, byselecting ‘Customer Support’ and then ‘Obtaining Permissions’.First edition 1989Second edition 1993Third edition 2005Translated into Japanese 1995Translated into German 1996ISBN 0 443 06644 2British Library Cataloguing in Publication DataA catalogue record for this book is available from the British Library.Library of Congress Cataloging-in-Publication DataA catalog record for this book is available from the Library of CongressNoteKnowledge and best practice in this field are constantly changing. As new researchand experience broaden our knowledge, changes in practice, treatment and drugtherapy may become necessary or appropriate. Readers are advised to check themost current information provided (i) on procedures featured or (ii) by themanufacturer of each product to be administered, to verify the recommended doseor formula, the method and duration of administration, and contraindications.It is the responsibility of the practitioner, relying on their own experience andknowledge of the patient, to make diagnoses, to determine dosages and the besttreatment for each individual patient, and to take all appropriate safetyprecautions. To the fullest extent of the law, neither the Publisher nor the authorassumes any liability for any injury and/or damage. The Publisher The Publisher’s policy is to use paper manufactured from sustainable forestsPrinted in China
  3. 3. Prelims.qxd 13*10*04 14:30 Page vii vii Foreword Quod est ante pedes nemo spectat: coeli Scrutantur evaluation of acupuncture. The results of properly plagas. (What is before one’s feet no one looks at; controlled experiments and trials demonstrating they gaze at the regions of heaven.) the efficacy of acupuncture are slowly but surely Ennius, quoted by Cicero, De Divinat., 2, 13. accumulating and Dr Baldry discusses these criti- cally and points the way to the further rigorous This is an important and valuable book that studies that are urgently needed. The third part of needed to be written. Musculoskeletal or myofas- the book gives a detailed and splendidly practical cial pain is an all too common and extraordinarily account of the many different forms of muscu- neglected subject of medicine; it is barely men- loskeletal pain and the way that these can be treated tioned in many textbooks of medicine. In reality it with acupuncture. is a ubiquitous condition that causes a great deal Even for the reader who does not intend to use of pain and suffering and one which, unfortu- acupuncture, this book still serves a most valuable nately, either slips by unrecognized or is passed purpose by drawing attention to the very large off as trivial or untreatable. In this book Dr Peter number of common musculoskeletal pain condi- Baldry has shown how musculoskeletal pain can tions that are all too commonly overlooked. A par- be simply and effectively treated by acupuncture. ticularly helpful feature of Dr Baldry’s book is the But this book is much more than that because it is rich admixture of case histories of his own really three books in one. patients, from which the medical reader can learn The first part presents an interesting historical the correct way to diagnose and subsequently to background to Chinese acupuncture and its spread treat these painful conditions. to the outside world, particularly to the West. The There seems little doubt that, through unfamil- second part deals with the principles of trigger iarity with this condition, much time and effort are point acupuncture wherein, over the course of six often expended unnecessarily both by the medical chapters, the reader is presented with a detailed profession and by patients seeking the cause and and critical account of the evidence for and the treatment of pain problems that are, in fact, mus- nature of trigger points and the way in which acu- culoskeletal in origin. Dr Baldry has performed a puncture can be used to deactivate them. Dr Baldry most valuable service in writing this eminently spares no effort to provide the reader with an up-to- readable book and I wish it the very considerable date and accurate account of the neurophysiology success that it richly deserves. of pain and the possible ways in which acupunc- ture can be used to control it. He also grasps the dif- John W. Thompson ficult and important nettle concerning the scientific
  4. 4. Prelims.qxd 13*10*04 14:30 Page ix ix Preface The aims of this book point and fibromyalgia syndromes since the 2nd edition of this book was published, that in this edi- It is because traditional Chinese acupuncture is per- tion four chapters in Part 2 (Principles of Trigger force inextricably bound up with archaic concepts Point Acupuncture) have had to be replaced by concerning the structure and function of the body entirely new ones. In addition to these changes that most members of the medical profession in the most of the other chapters in Part 2 and Part Western world view it with suspicion and scepti- 3 (The Practical Application of Trigger Point cism and assign it, together with various other Acupuncture) have had to be extensively revised. seemingly esoteric forms of therapy, to what is It is hoped that as a result of reading this book called alternative or complementary medicine. many more anaesthetists, rheumatologists, ortho- Moreover, it is evident that attempts during the past paedic specialists, general physicians, general prac- 40 years to place Chinese acupuncture on a more titioners and physiotherapists than at present may rational and scientific basis have done little to dispel not only be led to search for trigger points in their this attitude. routine clinical investigation of pain, but may also My reason for writing this book is to bring to the be persuaded to include dry needling at these attention of doctors and physiotherapists a 20th- points in their therapeutic armamentarium. century-evolved scientific approach to acupunc- ture for the relief of pain emanating from trigger Case histories points in the myofascial pain syndrome and from tender and trigger points in the fibromyalgia syn- I offer no apology for having included case histor- drome, and to take acupuncture (so far as the alle- ies in this book. They are, of course, by their very viation of nociceptive pain of this type is concerned) nature essentially anecdotal and certainly no infer- out of the category of alternative or complementry ence is meant to be drawn from them concerning medicine by describing a method of employing it the effectiveness of trigger point acupuncture, for that has been developed as a result of observations any conclusions about that can only come from made by physicians during recent years and is clinical trials. The sole purpose of including these now fast becoming incorporated within the frame- vignettes is to provide illustrations from everyday work of present-day orthodox medical practice. clinical practice that serve to highlight certain It is because there have been so many advances important principles underlying the diagnosis and in our knowledge concerning the pathophysiology, management of various painful musculoskeletal diagnosis and treatment of the myofascial trigger disorders.
  5. 5. Prelims.qxd 13*10*04 14:30 Page xi xi Acknowledgements My very sincere thanks are due to Professor John 15.17, 15.23*, 16.8, 16.9, 16.10, 18.1*, 18.6, 18.7*, Thompson for the meticulous manner in which he 18.9*, 18.11*, 20.1, 20.2, 20.5*, 20.6. The illustrations read the manuscript of this book and then gave me from Gray’s Anatomy marked with an asterisk orig- much valuable advice and constructive criticism inally appeared in Quain’s Anatomy 11th edition. besides kindly writing a foreword. Finally, I have to thank the following: I wish to express my gratitude to Dr Alexander Dr J. H. Kellgren and the editor of Clinical Science Macdonald for it was he who, some years ago, first for permission to publish Figures 4.1 and 4.2; drew my attention to the aetiological importance Dr Kellgren and the editor of the British Medical of trigger points in the pathogenesis of mus- Journal for permission to publish Figure 4.3; culoskeletal pain and introduced me to trigger Dr Howard Fields and McGraw Hill, New York for point acupuncture as a method of alleviating it. permission to reproduce Figures 6.1, 6.2, 6.3 and I thank Dr Felix Mann for having initially brought 7.3 from Pain 1987; Dr David Bowsher and the edi- to my notice the close relationship between trigger tor of Acupuncture in Medicine – The Journal of the points and traditional Chinese acupuncture points. British Medical Acupuncture Society for permission I wish to say how indebted I am to the late to reproduce Figures 6.5 and 9.1; Dr David Simons Drs Janet Travell and Dr David Simons for the and Haworth Press for permission to reproduce very considerable contribution they made to Figure 7.2; Dr Alexander Macdonald and George my knowledge of specific patterns of myofascial Allen & Unwin, London for permission to repro- trigger point pain referral. It has largely been from duce Figures 7.4 and 7.5 from Acupuncture – from studying their descriptions and illustrations Ancient Art to Modern Medicine 1982; Mr R. J. of these patterns in various publications referred D’Souza for providing me with Figure 7.6; to later in this book that I am now able to recog- Professor Yunus and Lea & Febiger, Philadelphia nize them in my own patients. for permission to reproduce Figure 7.7; Dr J. Park I also wish to say how very grateful I am to and the editor of Acupuncture in Medicine for per- Dr David Bowsher, for it has been from him in parti- mission to reproduce Figure 11.1; Dr David Simons cular that I have learnt so much about what is and Churchill Livingstone, Edinburgh for permis- currently known concerning the mechanisms respon- sion to reproduce Figure 16.6 from Textbook of sible for the pain-relieving effect of acupuncture. Pain (Wall P., Melzack R., eds) 2nd edition 1989; I have to thank Professors Peter Williams and Professor R. W. Porter and Churchill Livingstone, Roger Warwick, the editors of Gray’s Anatomy Edinburgh for permission to reproduce Figures (36th edition 1980) and its publishers Churchill 17.2 and 17.3 from The Lumbar Spine and Back Pain Livingstone for giving me permission to repro- (Jason M. I. V., ed) 3rd edition 1987. duce Figures 12.1, 12.5, 12.9, 12.14, 13.12, 15.1, 15.2, P.E.B. (
  6. 6. Prelims.qxd 13*10*04 14:30 Page xiii xiii Introduction to the third edition For reasons to be explained later in this book, the needle) for the purpose of stimulating peripheral early 1970s saw the dawn of an era when people in nerve endings, achieves its pain-relieving effect the Western world began taking an increasing inter- by virtue of its ability to evoke activity in pain- est in the ancient oriental mode of therapy known modulating mechanisms present in the peripheral as acupuncture, with lay practitioners of it leading and central nervous systems. the public to believe that it has such wide ranging In the light of this discovery and a number of healing properties as to be an effective alternative others the public in general and the medical pro- to orthodox medicine in the treatment of a large fession in particular have had to revise their atti- number of diseases. tudes towards acupuncture. There is clearly no justification for such extra- Furthermore, when the House of Lords select vagant claims and it has to be said that, at the onset committee in science and technology (2000) took a of this era, the medical profession in Europe and close look at various types of treatment at present America viewed this form of therapy with consid- included within the ambit of complementary/ erable suspicion and continued to do so for so long alternative medicine, it divided them into three as explanations as to how it might work remained groups and placed acupuncture in the one con- inextricably bound up with abstruse concepts for- taining therapeutic procedures deemed to be the mulated by the Chinese 3000 years previously. most organized and regulated. This reluctance to believe in these long-established The committee, in addition, considered that the but somewhat esoteric hypotheses was, of course, research bases of these procedures are of suffi- because they had been conceived at a time when ciently high standards to allow them to be used ideas concerning the structure and function of the within the UK’s National Health Service. body together with those concerning the nature of Prior to the publication of this report the British disease belonged more to the realms of fantasy than Medical Acupuncture Society (1997) had published fact, and for this reason it was difficult to reconcile a discussion paper entitled ‘Acupuncture’s Place them with the principles upon which the present- Within Mainstream Medicine’. In this it was stated: day Western system of medical practice is based. ‘… Medical acupuncture practice depends on During the latter part of the 20th century, how- three important principles: an orthodox Western ever, there has been a considerable increase in diagnosis needs to be made for every patient; knowledge concerning the neurophysiology of acupuncture should be integrated with conven- pain and because of this there is now a scientific tional medicine; and it must be appreciated that explanation for acupuncture’s ability to alleviate the traditional Chinese view of acupuncture is being pain. It has become apparent that this technique, replaced in many areas by an approach based on which involves the use of dry needles (acus (Latin), modern physiology and neuroanatomy. …’
  7. 7. Prelims.qxd 13*10*04 14:30 Page xiv xiv INTRODUCTION TO THE THIRD EDITION In accordance with the above, in 2000 The Royal devised a method of practising it principally for College of Physicians of London set up a subcom- the relief of musculoskeletal pain that may be con- mittee to assist with the present task of bringing sidered to be a forerunner of the somewhat more acupuncture and a strictly selected number of other sophisticated one developed in recent years and hitherto somewhat pejoratively called complemen- described in this book. It is also pointed out that, tary or alternative therapeutic procedures within although physicians who advocated the use of the framework of orthodox medical practice. acupuncture in the Western world during the last Lewith et al (2003), moreover, during the course century wrote enthusiastically about it, it was never of discussing the current status of certain thera- widely practised by their contemporaries, mainly peutic procedures in the Journal of the Royal College it would seem because at that time there was no of Physicians of London, including acupuncture, made satisfactory explanation as to the manner in which the following two apposite comments concerning it might work. the latter: (1) ‘needling trigger points is particu- In Part 2 attention is drawn to fundamental lab- larly effective in the treatment of pain’; (2) oratory investigations into the phenomenon of ‘acupuncture is currently used in at least 84% of referred pain from musculoskeletal structures car- pain clinics in the UK …’ ried out by J. H. Kellgren at University College A paucity of suitably funded research has been Hospital, London, in the late 1930s. In addition it the principle hindrance to getting certain therapeut- is explained how these investigations prompted ic procedures including acupuncture integrated many physicians during the 1940s, in particular within the fabric of conventional medical practice. the late Janet Travell in America, to study the clin- This has prompted Lesley Rees, Director of Edu- ical manifestations of this particular type of pain, cation at the Royal College of Physicians of London and how, as a result of this, she came to recognize and Andrew Weil, Professor of Medicine at the Uni- the importance of what she termed trigger points versity of Arizona (Rees & Weil 2001), to emphasize as being the source of pain in many commonly the need for the NHS research and development occurring musculoskeletal disorders. directorate and the Medical Research Council to It is also shown how once it had been discover- now help correct this unfortunate state of affairs. ed that it is possible to alleviate such pain by The purpose of this book is to discuss the scien- injecting trigger points with a local anaesthetic or tific aspects of acupuncture in general and trigger with one or other of a variety of different irritant point acupuncture in particular and to show how substances, it was found that this could be accom- this latter type of therapy can readily be used by plished even more simply, as well as more safely doctors and physiotherapists in the treatment of and equally effectively, by means of the carrying the myofascial pain and fibromyalgia syndromes. out of needle-evoked nerve stimulation at trigger For those trained in the Western system of medi- point sites. cine there are obvious advantages in using this Part 2 also contains a brief account of advances particular method rather than the traditional in knowledge concerning the neurophysiology of Chinese one, but clearly these advantages cannot pain during the 1960s and 1970s and describes the be fully appreciated without knowing something various pain-modulating mechanisms now consid- about the latter. This book is, therefore, divided into ered to be brought into action when acupuncture is three parts with Part 1 containing a brief account carried out. In addition, it includes a discussion of of traditional Chinese acupuncture. It also gives some of the difficulties so far encountered in scien- reasons as to why doctors in Europe on first learn- tifically evaluating the pain-relieving efficacy of this ing about this type of treatment in the 17th century particular type of therapy and in determining its rejected it, and describes how certain 19th-century place relative to other forms of treatment in the alle- European and American doctors, having put on viation of musculoskeletal pain. one side what they considered to be unacceptable Part 3 is devoted to the practical applications of Chinese concepts concerning this mode of therapy, trigger point acupuncture.
  8. 8. Prelims.qxd 13*10*04 14:30 Page xv Introduction to the third edition xv References British Medical Acupuncture Society 1997 Acupuncture’s Lewith G T, Breen A, Filshie J, Fisher P et al 2003 place within mainstream medicine. Acupuncture in Complementary medicine: evidence base, competence to Medicine 15(2): 104–107 practice and regulation. Clinical Medicine (Journal of the House of Lords Select Committee on Science and Royal College of Physicians of London) 3(3): 235–240 Technology 2000 6th report, Session 1999–2000. Rees L, Weil A 2001 Integrated medicine. British Medical Complementary and alternative medicine. Stationary Journal 322: 119–120 Office, London
  9. 9. Chap-01.qxd 11*10*04 10:11 Page 3 3 Chapter 1 Traditional Chinese acupuncture The Chinese first carried out acupuncture, that CHAPTER CONTENTS seemingly strange practice whereby needles are inserted into people for therapeutic purposes, at Ancient Chinese concepts concerning the least 3000 years ago. News of this, however, did not practice of acupuncture and moxibustion reach the Western world until about 300 years ago when European medical officers employed by the Dutch East Indies Trading Company in and around Java saw it being used there by the Japanese, and when at about the same time Jesuit missionaries came across it whilst endeavouring to convert the Chinese to Christianity. From their writings it is clear that both these groups found the concepts upon which the Chinese based their curious practice difficult to comprehend, due to the fact that these appeared to be completely at variance with what Europeans by that time had come to know about the anatomy and physiology of the human body. And it has been this inability to reconcile the theoretical concepts put forward by the Chinese in support of acupuncture with those upon which modern scientific medicine is based that has for so long been the cause of such little interest being taken in it in the Western world. During the past 30 years, however, attitudes towards acupuncture in the West have been changing since research into the mechanisms of pain has provided a certain amount of insight as to how possibly it achieves its effect on pain. These, as might be expected, are entirely different from those origi- nally put forward by the Chinese. The prime purpose of this book is to describe a recently developed method of practising acupunc- ture in which dry needles are inserted into the tis- sues overlying what have come to be known as
  10. 10. Chap-01.qxd 11*10*04 10:11 Page 4 4 ACUPUNCTURE, TRIGGER POINTS AND MUSCULOSKELETAL PAIN trigger points as a means of alleviating muscu- each time of extensive commentaries by a variety of loskeletal pain. Before turning to this, however, it different people. This prompted Ilza Veith to say: is necessary to give a brief account of the discov- It is obvious that any work that has undergone ery and development of the traditional practice the fate of the Yellow Emperor’s Canon of Internal of Chinese acupuncture as it is only by having a Medicine contains but little of its authentic original proper understanding of this that the merits of text; it is also clear that its various commentators the trigger point approach to acupuncture can be have frequently obscured rather than elucidated fully appreciated. For an explanation as to how the its meaning. It seems impossible to determine now Chinese came to discover the therapeutic proper- how much of the original text remains; especially ties of acupuncture in the first place it is helpful since in former times it was difficult to distinguish to turn to an early Chinese medical book entitled text from commentary. Huang Ti Nei Ching and known in the English- speaking world as The Yellow Emperor’s Manual of Nevertheless, in spite of all these difficulties it is Corporeal Medicine. This is a most unusual textbook generally agreed that from a study of this work it of medicine as it is written in the form of a dialogue is possible to gain a clear idea as to how the prac- between the Emperor Huang Ti and his minister tice of acupuncture had developed in China by the Chhi-Po. It is a work which incorporates much con- 2nd century BC. cerning the philosophical thoughts of the ancient Acupuncture and a related form of heat ther- Chinese, their religious beliefs with particular ref- apy and counter irritation known as moxibustion erence to Taoism, their observations concerning the almost certainly had their origins long before this, workings of the universe in general, and the appli- as may be seen from recently discovered medical cation of all this to their practice of medicine. manuscripts written on sheets of silk in the tomb of The Western world is much indebted to the the son of the Lord of Tai, a young man who died in American scholar, Ilza Veith, who, in February 1945 168 BC. As Lu Gwei-Djen & Joseph Needham point at the Institute of the History of Medicine at Johns out ‘the style and contents of the texts is similar to Hopkins University, undertook the extremely dif- that of the Nei Ching but more archaic, so that they ficult task of translating this important treatise into present a picture of Chinese medical thought dur- English. This translation together with her own ing the two or three centuries preceding the compil- invaluable introductory analysis of the work was ation of that great classic’. first published in 1949. Also, for those who wish to It is interesting to observe that these manu- read a detailed account of how the Chinese prac- scripts, whilst certainly referring to the practice of tice of acupuncture has gradually evolved over the acupuncture with needles made of stone, discuss centuries, there is much of considerable interest moxibustion in even greater detail and there are in Celestial Lancets, an erudite study of the subject reasons for believing that that technique may have written by the two distinguished Cambridge his- been introduced even longer ago than acupuncture torians, Lu Gwei-Djen and Joseph Needham (1980). itself. It is by no means certain that Huang Ti ever lived, with the general consensus of opinion being MOXIBUSTION that he is a legendary figure, but nevertheless he is to this day worshipped as the father of Chinese This is a process by which heat is applied to the medicine. It is very difficult to determine with any body by the burning of Artemisia leaves that have degree of accuracy the date the Nei Ching first been dried to a tinder. This Artemisia tinder has appeared, but it seems likely that Part I, the Su WEnˆ come to be known in the West as moxa – a word of (Questions and Answers), originated in the 2nd Japanese derivation (mogusa, herb for burning) century BC and that Part II Chen Ching (Needle because it was from Japan that the Western world Manual) first appeared in the 1st century BC. first heard about this technique in the 17th century. However, not only was the latter re-named the The classical method of performing moxibus- Ling Shu (Vital Axis) in about AD 762, but both parts tion is to make the tinder into a cone and apply it have been repeatedly revised with the addition to the skin at points identical to those used for
  11. 11. Chap-01.qxd 11*10*04 10:11 Page 5 Traditional Chinese acupuncture 5 acupuncture. Sometimes it is used as a counter irri- both celestial and terrestial, was dependent on the tant by being allowed to blister and scar the skin. maintenance of a correct balance between them. At other times it is used as a milder form of heat It should be noted in this connection that neither treatment, by applying it to the skin with a layer of of these two opposing forces were ever envisaged vegetable material interposed between this and the as existing in pure form but rather that each con- cone in order to protect the former from damage. tained a modicum of the other. And moreover, Yet another method is to combine moxibustion with there was the belief that all events, both in nature acupuncture by placing a piece of moxa on top of a and in the human body, were influenced by a con- needle inserted into the body, and igniting it, when stantly changing relationship between them. the heat from the moxa is conducted down the Yin and Yang were thus said to be ubiquitous needle to the surrounding tissues. essential components of all things, with in some cases Yang being predominant and in others Yin. In the universe for example, phenomena such as the ACUPUNCTURE sun, heaven, day, fire, heat and light were all con- The concepts which prompted the ancient Chinese sidered to be predominantly Yang in nature, whereas to use acupuncture for therapeutic purposes were their opposites, the moon, earth, night, water, cold complex and to the modern Western mind difficult and darkness were considered to be predominantly to comprehend. They were intricately bound up Yin. The individual structures of the body were with their views concerning all aspects of the also thought to have either Yang or Yin qualities. living world, including in particular their belief For example, five hollow viscera – the stomach, in the existence of two cosmic regulators known as small intestine, large intestine, bladder and gall Yin and Yang. bladder – were said to be Yang organs because lying The supremacy of power and influence accorded near to the surface on opening the body they get to these two forces in the creation of the world is exposed to light. In contrast, five solid viscera – the well illustrated by the following quotations from heart, lungs, kidneys, spleen and liver – were said the Nei Ching. to be Yin organs due to their being in the dark recesses of the body. The principle of Yin and Yang is the basis of the The conclusion reached by the Chinese that five entire universe. It is the principle of everything organs had Yang and five had Yin characteristics in creation. It brings about the transformation to was apparently not a fortuitous one but seemingly parenthood; it is the root and source of life and because five was considered to be a dominant death … number in their conception of the universe. This Heaven was created by an accumulation of stemmed from their fundamental belief in the the- Yang; the Earth was created by an accumulation ory of the five elements, which stated that Yin and of Yin. Yang consist of five elements, namely water, fire, The ways of Yin and Yang are to the left and to metal, wood and earth, and that man and, indeed, the right. Water and fire are the symbols of Yin all natural phenomena are products of an inter- and Yang. Yin and Yang are the source of power action between these two opposing forces. and the beginning of everything in creation. The theory of the five elements was extremely Yang ascends to Heaven; Yin descends to Earth. complicated and there is little to be gained by Hence the universe (Heaven and Earth) repre- going into it in detail except to say, in view of its sents motion and rest, controlled by the wisdom relevance to the traditional practice of Chinese of nature. Nature grants the power to beget and acupuncture, that in its application to the organs of to grow, to harvest and to store, to finish and to the body the Nei Ching teaches that: begin anew. Further, the Chinese considered that, following The heart is connected with the pulse and rules the creation of the world, Yin and Yang continued to over the kidneys. The lungs are connected with exert a considerable influence, and that indeed the the skin and rule over the heart. The liver is con- preservation of order in all natural phenomena, nected with the muscles and rules over the lungs.
  12. 12. Chap-01.qxd 11*10*04 10:11 Page 6 6 ACUPUNCTURE, TRIGGER POINTS AND MUSCULOSKELETAL PAIN The spleen is connected with the flesh and rules movement of blood in the vessels of the body is by over the lungs. The kidneys are connected with means of a tidal ebb and flow. This remained the the bones and rule over the spleen. official view for centuries and anyone who dared to With this background it is now possible to see question it was considered a blasphemous heretic. how these various considerations concerning Yin Indeed, it was not until 1628 that William Harvey and Yang came to be applied to matters concern- with considerable courage published his proof that ing the maintenance of health and the develop- blood moves around the body in a continuous ment of disease. It was considered that in order to circle in his Exercitatio Anatomica de Motu Cordis be healthy these two opposing forces have to be in et Sanguinis in Animalibus. a correct state of balance (crasis) and that it is The ancient Chinese admittedly had no scien- when this is not so that disease occurs (dyscrasia). tific evidence to support their belief in the circu- Further, it was considered that this health-giving lation of the blood but because of their inherent balance between Yin and Yang only exists when a conviction that the workings of the body are a special form of energy, known as chhi, flows freely microcosmic representation of those to be found in through a system of tracts. And, as a corollary to the macrocosm or universe itself, they may have this, that disease develops when a collection of ‘evil come to this conclusion from observing the meteoro- air’ in one or other of the tracts obstructs the flow logical water-cycle that occurs in nature. of chhi through it as this leads to an imbalance It should be noted that the Chinese at an early between Yin and Yang. It was in attempting to dis- date not only correctly concluded that blood circu- pel this ‘evil air’ or wind that the Chinese were first lates around the body but also that this is effected by a pumping action of the heart, for in the Su WEn ˆ led to insert needles into these tracts, and then from this, over the course of centuries, to develop a some- it says ‘the heart presides over the circulation of what complex system of therapy now known to the the blood and juices and the paths in which they Western world as acupuncture (from the Latin acus, travel’. Moreover, they were quick to appreciate a needle; and punctura, a prick). that the action of the heart is reflected in move- As it is only possible to understand how the ments of the pulse felt at the wrist, and were able Chinese developed their system of acupuncture by to measure the pulse rate by using an instrument having some knowledge of their original, somewhat capable of measuring time by a regulated flow of primitive ideas concerning the anatomy and physi- water, an apparatus similar to that used by the ology of the body, these will now be discussed. ancient Greeks for timing speeches in their law The knowledge of anatomy and physiology courts and called by them a clepsydra. possessed by the Chinese when they first started to The ancient Chinese also with much ingenuity practise acupuncture was obviously both scanty attempted to estimate the time it takes for blood to and inaccurate. It is, therefore, surprising to find circulate around the body and to assist with this that from an early date and certainly by the time the calculation measured the approximate total length ˆ Su WEn was compiled in the 2nd century BC they of the great blood vessels. Although their conclusion had with considerable perspicacity come to realize that the circulation time is 28.8 minutes was about that blood circulates continuously around the body. 60 times too slow, modern methods having now For in this manuscript Chhi-Po says: shown it to be only 30 seconds, it was nevertheless a praiseworthy effort, especially when it is remem- The flow (of blood) … runs on and on, and never bered that even William Harvey several hundred stops; a ceaseless movement in an annular circuit. years later got the calculation wrong! Chhi-Po is here showing remarkable intuition The Chinese whilst realizing that blood circu- especially when it is remembered that it was lates around the body in specially designed ves- another 1700 years before the Western world came sels also believed, as did the ancient Greeks, that round to this view. This tardy realization of the there is a separate substance very difficult to define true state of affairs in the West was of course in modern terms but which could perhaps best be because Galen, that remarkably influential early described as a vital force or special form of energy, Greek physician, had categorically stated that the that also circulates around the body.
  13. 13. Chap-01.qxd 11*10*04 10:11 Page 7 Traditional Chinese acupuncture 7 The Greeks referred to it as pneuma and con- The Chinese described 12 main acu-tracts corres- sidered it to be present with the blood in arteries. ponding in number with the months of the year The Chinese called a substance of similar nature with each one being considered to have a connec- chhi, with part of it having Yang properties and the tion with and taking its name from an organ of other part Yin properties. Following the appear- the body. However, as already stated, the Chinese ance of the Ling Shu in about 762 AD it has always were of the opinion that there were only ten prin- been said that the Yin chhi circulates around the cipal organs, five with Yin characteristics and five body in the blood vessels, whilst the Yang chhi with Yang characteristics. Therefore, in order that travels outside them in a completely separate sys- the 12 tracts could be linked with 12 organs they tem of channels or tracts. found it necessary to include the pericardium This system of tracts, which anatomically is amongst the Yin organs, and to invent a structure not demonstrable, has nevertheless always been with no known equivalent in modern anatomy, very real to the Chinese who from the beginning which they called the san chiao (triple warmer) believed it to consist of an intricate network of and included this amongst the Yang organs. main channels, connecting channels and tributaries It is of interest to note that because the brain was similar to the rivers, tributaries and canals which considered to be nothing more than some form of together make up the waterways of the earth. storage organ it was not included amongst the The idea is to be found clearly expressed in a book principal organs. The Nei Ching in fact states that it entitled the Kuan Tzu written about the late 4th is the liver that ‘is the dwelling place of the soul or century BC where it says ‘one can say water is the spiritual part of man that ascends to heaven’. blood and the chhi of the earth, because it flows Those who pioneered the development of and penetrates everywhere in the same manner as acupuncture in ancient China believed that acu- the circulation … in the tract and blood vessel tracts for most of their course are situated in the systems’. depths of the body’s tissues, but that at certain A belief in the existence of such tracts was vital points, now known in the West as acu-points, they to the Chinese in developing their practice of come to lie immediately under the skin surface acupuncture and it is because of the essential part where needles can readily be inserted into them. these channels play in this that they are specific- It will be remembered that, according to trad- ally known as acu-tracts. Nonetheless, it must be itional Chinese teaching, the purpose of inserting emphasized that it is the lack of any tangible proof needles into acu-points in disease is to release nox- of their existence that has been one of the main ious air or ‘wind’ (malignant chhi) that impedes reasons why the Western world has viewed the the free flow of chhi in acu-tracts and thereby dis- traditional Chinese method of practising acupunc- turbs the balance between Yin and Yang. ture with such considerable suspicion since first It is possible to gain some idea as to how the hearing about it 300 years ago. Chinese have always thought about acu-points by The Chinese have always visualized and studying the various names they use to describe described these tracts in a three-dimensional form them in their writings. One of the commonest of and considered them to be at variable depths along these being chhi hsüeh – hsüeh being a word mean- their individual courses. Clear descriptions of this ing a hole or minute cavity or crevice; in the Su are given in their writings, although their illustra- Wên, chhi hsüeh are described as pores or inter- tions merely give the impression that the tracts stices in the flesh that are connected to the naturally run in a relatively straight line along the surface of occurring Yin and Yang forms of chhi in the acu- the body. It should be noted that modern Western tract and blood vessel systems. It is also said that writers often refer to the Chinese acutracts as these ‘holes’ in the flesh are open to invasion by meridians but this is better avoided because as Lu malignant chhi from outside the body but that if Gwei-Djen & Joseph Needham in the Celestial Lancets and when this onslaught occurs it is readily repelled point out ‘the analogy with astronomical hour- by acupuncture! circles or terrestrial longitude is so far-fetched that The Nei Ching in several places says that there we do not adopt the term’. are 365 acu-points. A figure no doubt arrived at
  14. 14. Chap-01.qxd 11*10*04 10:11 Page 8 8 ACUPUNCTURE, TRIGGER POINTS AND MUSCULOSKELETAL PAIN because of its symbolic association with the num- The reason why the Chinese have placed such ber of degrees in the celestial circle, the number of importance on examining the pulse is because days in the year and the number of bones in the they have always considered that it is at that site human body. This, however, was only the number that the Yin chhi in the blood vessels and the Yang of points supposed to be present in theory, as even chhi in the tracts converge, and the pulse in some in the Nei Ching itself only 160 points actually of their writings is referred to as The Great Meeting receive names, and with the passage of time even Place. fewer have remained in regular use. In the Nan Ching – The Manual of Explanations The Chinese have given each of their acupoints of Eighty-one Difficult Points in the Nei Ching – a specific name and just as they have named acu- a work that first appeared some time around the tracts after various rivers so they have incorp- 1st century AD it says: orated into the names of acu-points references to The Yin chhi runs within the blood vessels, such parts of nature’s waterway system as tanks, while the Yang chhi travels outside them (in the pools and reservoirs. Also, during the course of time, tracts). The Yin chhi circulates endlessly, never acu-points along the length of each tract have been coming to a stop (save at death). After fifty revolu- individually numbered, and, as every tract bears tions the two chhi meet again and this is called a the name of the organ to which it is supposed to be ‘great meeting’. The Yin and Yang chhi go along linked, it necessarily follows that each point may with each other in close relation, travelling in cir- be identified by reference to the name of the tract cular paths which have no end. So one can see how along which it is situated and its number on this the Yin and Yang mutually follow one another. tract. For example, the point on the gall bladder tract situated half-way between the neck and the The Chinese method of examining the pulse tip of the shoulder at the highest point of the shoul- consists of placing three fingers along the length of der girdle has been named by the Chinese Jianjing the radial artery at both wrists and by first apply- but is more commonly referred to as Gall Bladder ing superficial pressure to these points and then 21 (GB 21); the point situated between the head deep pressure 12 separate observations can be of the fibula and the upper end of the tibia called made. From this it is said to be possible to ascertain by the Chinese Zusanli is more usually known as the state of chhi in the 12 main tracts, and when Stomach 36 (St 36); and the point just above the disease is present, to tell which organ is affected web between the first and second toes known as and into which tract needles have to be inserted. Taichong is more often referred to as Liver 3 Chinese sphygmology is therefore basically (Liv 3). complicated and has been made even more com- In the recently developed Western type of plex over the centuries by the laying down of rules approach to acupuncture to be described in this as to when the examination might most profitably book, acu-tracts and their alleged links with inter- be carried out, including the taking into account of nal organs are not of themselves of any practical certain astrological considerations in determining importance. However, because most of the trigger the best day for it. Next, the right time of day has points employed in this Western form of acupunc- to be selected for according to the Nei Ching the ture have been found to have a close spatial cor- examination must be done very early in the morn- relation with many of the traditional Chinese ing ‘when the breath of Yin has not yet begun to acu-points, some of the latter will be referred to in stir and when the breath of Yang has not yet begun the text as a matter of interest. to diffuse, when food and drink have not yet been In traditional Chinese acupuncture it is from an taken, when the twelve main vessels are not yet examination of the pulse that disease is mainly abundant, … when vigour and energy are not yet diagnosed. The Nei Ching contains a clear account exerted’. of how, from a detailed study of the pulse at the It is clear that the technique of pulse diagnosis wrist, it is possible to establish the nature of a dis- must always have been extremely difficult to mas- ease, its location in the body and where best to ter and yet it would seem that those who devised insert needles to combat it. the procedure must have achieved some measure
  15. 15. Chap-01.qxd 11*10*04 10:11 Page 9 Traditional Chinese acupuncture 9 of agreement as to the significance of the various the type of stone originally used still remains a nuances that they considered they could detect at matter for conjecture. The only certainty is that as the wrist. Nevertheless, their diagnostic interpret- iron and steel did not become available to the ation of these was of necessity expressed in noso- Chinese until the 5th century BC and as the prac- logical terms quite irreconcilable with those based tice of acupuncture was started long before this, it on our present-day knowledge of pathology, and, necessarily follows that materials other than iron therefore, it is surprising to find that certain Western- must have initially been employed. trained doctors even to this day still try to base their It is impossible in this brief review to mention all practice of acupuncture on this archaic approach the various stages in the development of this tech- to diagnosis, and are quite unwilling to accept that nique over the centuries. Reference will however such an anachronistic procedure should long ago be made to the Chen Chiu Chia I Ching as this is the have been relegated to the realms of history. oldest existing book entirely devoted to acupunc- As the practice of acupuncture has of necessity ture and moxibustion. It was written soon after the always depended on the insertion of needles into Chinese Empire became re-unified in AD 265 by the body it is of considerable interest to discover one Huang Fu-mi who apparently became inter- how primitive Asiatic man found objects of suf- ested in medicine partly because his mother was ficient tensile strength and sharpness for this paralysed and partly because he himself suffered purpose. from rheumatism! In this book Huang Fu-mi for Thorns of various plants, slivers of bamboo, and the first time groups the various acu-points under needles fashioned from bone have always been the names of the various tracts to which they belong available. Bone needles have in fact been found in and, after numbering them, gives a detailed descrip- recent years in tombs from the neolithic age, and tion of their positions and how to locate them. by the 6th century, which is about the date of the Further, he names specific acu-points recommended oldest existing reference to acupuncture, it would in the treatment of various illnesses and gives much have been technically possible to make needles advice as to how he considers acupuncture should from bronze, copper, tin, silver and even gold. best be practised. This is, therefore, an outstanding And certainly gold needles have recently been dis- book in the history of acupuncture and one which covered in the tomb of the Han Prince, Liu-ShÊng was to exert a great influence on the practice of this (113 BC). It is therefore somewhat surprising to technique throughout the East. find that seemingly needles in the early days of Mention must be made of the eminent phys- acupuncture were commonly made of stone, for in ician Sun Ssu-mo (AD 581–673) as it was he who Huang Ti Nei Ching (2nd century BC), Chhi-Po says: introduced the so-called module system for deter- mining the exact position of acu-points on people’s In the present age it is necessary to bring forward bodies irrespective of their various sizes by taking powerful drugs to combat internal illnesses, and measurements using relative or modular inches. to use acupuncture with sharp stone needles and He defined a modular inch as being the distance moxa to control the external ones. between the upper ends of the distal and middle Also, in manuscripts written on silk before this interphalangeal folds when a person flexes the and found in the tomb of the son of the Lord of Tai, middle finger; and recommended that measure- there are two separate specific references to the ments should be made by using strips of bamboo, use of stone needles. paper, or straw, cut to the length of a person’s It seems difficult to conceive how needles made individual modular inch. of stone could have been sharpened sufficiently to Sun Ssu-mo was also the author of two out- penetrate the tissues of the body, but, of the various standing books on acupuncture and moxibustion mineral substances available in those far off days, and was the first to draw attention to the import- it has been suggested that the following might ance of inserting needles into exquisitely tender have been employed: flint, mica, asbestos and jade. points, particularly, he said, in treating low back However, there is no confirmatory evidence that pain. He called these ah-shih (oh-yes!) points, from any of these were utilized and the exact nature of the expletive often uttered by the patient when
  16. 16. Chap-01.qxd 11*10*04 10:11 Page 10 10 ACUPUNCTURE, TRIGGER POINTS AND MUSCULOSKELETAL PAIN pressure is applied over them! This is of particular excess of Yang it has a draining effect, and when interest as he was clearly practising what is known for a deficit of Yin it supplements vigour. Later on now as trigger point acupuncture, and which hav- in the same chapter it states: ing been rediscovered in recent years is described At the time of the new moon one should not in Parts 2 and 3 of this book. drain, and when the moon is full one should not The Imperial Medical College, with a depart- supplement. When the moon is empty to the rim mental professor of acupuncture, lecturers, and one cannot heal diseases, hence one should con- demonstrators, had been founded by AD 618, and sult the weather and the seasons and adjust the by AD 629 a similar college of medicine had been treatment to them. established in each province. From AD 1027 the teaching of acupuncture at This concept that cyclical events have an import- these institutions was carried out with the help of ant controlling influence over matters of health life-size bronze figures of the human body. The and disease was still further developed with the walls of these figures had holes punched in them introduction of the wu-yün liu-chhi system (the at the sites of all the known acu-points. The figures cyclical motions of the five elements and the six with their holes filled with water and covered by chhi) in AD 1099, and of the tzu-wu liu-chu system wax were then used for examining medical stu- (noon and midnight differences in the following of dents in acupuncture. This was done by making the chhi) in about the middle of the 12th century. the students insert needles into sites on these figures These are complex systems the details of which where they considered acupoints points might exist, will not be entered into. Suffice it to say that the and if, on attempting this, no water poured out first was based on the conviction that external they failed their examination! cyclical, astronomical, meteorological, and climatic The Chinese have always had a deep conviction factors influence the workings of the body and that that the workings of the body are intimately linked from a study of these the occurrence of disease and with those of nature in general, and that various particularly epidemics of it may be predicted. And cyclical events external to the body have an import- that the second was based on the idea that there are ant influence over matters of health and disease. internal cyclical changes occurring inside the body Further, that for the successful eradication of dis- and that these have to be taken into account when ease by acupuncture it is necessary to perform the deciding upon ideal times for performing acupunc- latter at a propitious time and one that can only be ture and moxibustion. It is of great interest that such determined by taking into consideration the inter- ideas concerning circadian rhythms in the body relationship of these various external factors. It is, were put forward so long ago considering that it therefore, not surprising to find that the Nei Ching is only in very recent years that proof has been clearly states that in order to discover the right obtained of the existence of internal biological clocks. time for both the application of acupuncture and From this brief review it may be seen that the moxibustion the physician must first establish the Chinese did not discover the therapeutic effects position of the sun, the moon, other planets, and the of acupuncture as a result of some astute clinical stars in addition to taking into account the season observation nor alternatively were they inspired of the year and the prevailing weather conditions! to use it by the logical development of some well- The following is a quotation from Chapter 26 of founded hypothesis. On the contrary, it would that book: seem that it was very much by luck that they stum- bled upon this valuable form of therapy because Therefore one should act in accordance with the their original reasons for using it have subsequently weather and the seasons in order to have blood been shown to be entirely fallacious. And further, and breath thoroughly adjusted and harmonized – to a very large extent they succeeded in obscuring and consequently – when the weather is cold, one the merits of this therapy by grafting upon it a should not apply acupuncture. But when the days somewhat esoteric set of rules for its application. are warm there should not be any hesitation. … The manner in which all this prevented acupunc- In an earlier part of the same book there is a ture from becoming readily accepted in the Western statement that when acupuncture is applied for an world during the past 300 years will be discussed
  17. 17. Chap-01.qxd 11*10*04 10:11 Page 11 Traditional Chinese acupuncture 11 in detail in the next two chapters but before this it the Chinese authorities officially outlawed the is necessary to say something about its changing practice of it in that country. fortunes in China itself. It has to be remembered, however, that what From the time that acupuncture was first used has been said only really applied to a minority of in China it remained in the ascendance in that part the population because China has always been of the world until reaching its zenith at about the a land of the rich and poor, of the rulers and the end of the 16th century. From then onwards dur- oppressed, and whilst Western medicine increas- ing the Ch’ing dynasty (1644–1911), when China ingly displaced traditional Chinese medicine in the was under Manchu rule, the practice of it went wealthy coastal cities the rural peasants that inhab- into a gradual decline. This initially was mainly ited most of the country continued to depend on because the Confucian religion practised by the traditional forms of treatment including acupunc- Manchu people was associated with much prud- ture, and increasingly, what health care system was ishness so that the baring of the body, as clearly is available to them became more and more chaotic so often necessary with treatment by acupuncture, due to years of Japanese occupation, civil war, and was considered to be immoral. And also because lack of doctors trained in this type of medicine. the religion discouraged the inserting of needles The Chinese communist victory in the so-called into a person’s body for fear that this might dam- War of Liberation in 1949, however, changed all this age that which was considered to be sacred by with Mao Tse Tung being determined to improve virtue of it having been bestowed on that individ- the health service for the poor by ensuring that ual by loving parents. Another important reason more doctors became trained in traditional Chinese was that from the 17th century onwards mission- medicine; and by ensuring that the practice of this aries from Europe, with initially these mainly being form of medicine and Western medicine became Portuguese Jesuits, in bringing the Christian religion closely integrated with both being taught in the to China, also brought with them the Western form medical colleges. of medical practice, and this over the next 300 years Following the Great Proletariat Cultural Revolu- profoundly influenced the type of medicine prac- tion during the years 1966–69 there was even further tised in the Far East with the practice of acupunc- emphasis placed on the importance of traditional ture gradually being displaced. Chinese medicine including acupuncture with Events moved so quickly that when Hsü Ling the result that most hospitals offered both forms Thai, an eminent Chinese physician and medical of treatment to their patients. It is therefore not historian, wrote about the history of Chinese medi- surprising that when President Nixon and his cine in 1757, he had to report that by that time entourage visited China in 1972, with acupuncture acupuncture had become somewhat of a lost art by then having been fully restored to its former with few experts left to teach it to medical students. prestigious position, its use in the treatment of dis- During the 19th century its status declined still ease and in particular as an anaesthetic was demon- further, with the Ch’ing emperors in 1822 ordering strated to them with considerable pride. And it was that it should no longer be taught at the Imperial because his personal physician was so impressed Medical College. From then on an increasing num- with what he saw that, on returning to America, ber of colleges were opened by medical missionar- he generated a wave of enthusiasm for it in the ies for the express purpose of teaching Chinese Western world that advances in knowledge con- students Western medicine, until finally this ancient cerning the neurophysiology of pain since that form of treatment reached its nadir in 1929 when time have helped to sustain. References Lu Gwei-Djen, Needham J 1980 Celestial lancets. A history Veith I 1949 Huang Ti Nei Ching Su Wen The Yellow and rationale of acupuncture and moxa. Cambridge Emperor’s classic of internal medicine. University of University Press, Cambridge California Press, Berkeley
  18. 18. Chap-01.qxd 11*10*04 10:11 Page 12 12 ACUPUNCTURE, TRIGGER POINTS AND MUSCULOSKELETAL PAIN Recommended further reading Kaptchuk T J 1983 Chinese medicine: the Web that has no Ma Ran-Wen 2000 Acupuncture: its place in the history of weaver. Hutchinson, London Chinese medicine. Acupuncture in Medicine 18(2): 88–98 Macdonald A 1982 Acupuncture from ancient art to modern Porkert M 1974 The theoretical foundations of Chinese medicine. George Allen & Unwin, London medicine. MIT Press, Cambridge, Massachusetts
  19. 19. Chap-02.qxd 11*10*04 10:12 Page 13 13 Chapter 2 How news of acupuncture and moxibustion spread from China to the outside world The Chinese had practised acupuncture and moxi- CHAPTER CONTENTS bustion for several centuries before news of it reached the outside world. The first people to hear How the Western world learned about the about it were the Koreans and then not until about Chinese practice of acupuncture in the 17th the beginning of the 6th century AD. It was not century when physicians working for the Dutch long after that, however, that both Chinese and East India Trading Company saw it being Korean missionaries introduced it to Japan during practised by the Japanese in and around Java at the course of converting the people of that country that time to Buddhism. The Western world, on the other hand, did not learn about these oriental practices until the 17th century when Jesuit missionaries, whilst attempt- ing to convert the Chinese to Christianity, saw them being used in Canton, and when European doctors employed by the Dutch East Indian Company in and around Java saw them being used by the Japanese in that part of the world. Willem ten Rhijne (1647–1700), a physician born in the Dutch town of Deventer, and who received his medical education at Leyden University, must be given the credit for being the first person to give the Western world a relatively detailed, if unfortunately a some- what misleading, account of the Chinese practice of acupuncture and moxibustion. His opportunity to see orientals practising these techniques came when, soon after qualifying as a doctor, he joined the Dutch East India Company in 1673 and was sent to Java. During the latter part of his life there he was to become the director of the Leprosarium but as a young man he had no sooner arrived than he was ordered to go to the island of Deshima in Nagasaki Bay. It was during the 2 years he was stationed there that he first saw the tech- niques of Chinese acupuncture and moxibustion
  20. 20. Chap-02.qxd 11*10*04 10:12 Page 14 14 ACUPUNCTURE, TRIGGER POINTS AND MUSCULOSKELETAL PAIN being practised by the Japanese, and managed to which he included with essays on other subjects in acquire four illustrations depicting acupuncture his book Dissertatio de Arthritide; Mantissa Schematica; points lying along channels. He not unnaturally de Acupunctura …, written some time after he had assumed that the latter must be blood vessels, but left Nagasaki on 27 October 1676 and returned to found the matter confusing as the directions in Java, and which was published simultaneously in which they appeared to run in no way conformed London, The Hague, and in Leipzig in 1683. with those taken by any anatomical structures with In the introduction to this essay on acupunc- which he was familiar. He was nevertheless very ture, in which he also included comments on moxi- much impressed with the therapeutic effects of bustion, he gave reasons why the Chinese and these two techniques and was therefore determined Japanese preferred these two particular forms of to learn more about them and in particular to get therapy to the therapeutic form of bleeding (phle- someone to explain the drawings to him. This how- botomy; venesection) that was so widely practised ever was not to prove easy because as he later said in Europe in his time, by saying: in his book on the subject: Burning and acupuncture are the two primary The zealous Japanese are quite reluctant to share, operations among the Chinese and Japanese especially with foreigners, the mysteries of their who employ them to be free from every pain. If art which they conceal like most sacred treasures these two people (especially the Japanese) were in their book cases. deprived of the two techniques, their sick would be in a pitiful state without hope of cure or alle- It would seem, however, that the Japanese on the viation. Both nations detest phlebotomy because, other hand had no such inhibitions when it came to in their judgement, venesection emits both healthy them wanting to know all about Western medicine and diseased blood, and thereby shortens life. for, on the orders of the Governor of Nagasaki, a They have, accordingly, attempted to rid unhealthy Chinese-speaking Japanese physician, Zoko Iwanga, blood of impurities by moxibustion; and to rid it was sent to see ten Rhijne in order to question him of winds, the cause of all pain, with moxibustion closely about the way in which medicine was prac- and acupuncture. tised in Europe. Ten Rhijne however seemed to take all this in good part for when writing about It is interesting to learn from him that in Japan at it later he refers to the various questions put to him that time therapy was mainly carried out by tech- as nothing but ‘bothersome trifles, to be sure’, nicians working under the direction of medical and moreover in return for the information he practitioners, but as ten Rhijne said, ‘For difficult gave Iwanga he managed to persuade the latter to illnesses the physicians themselves administer the attempt to explain to him the drawings in his pos- needle.’ session. Unfortunately as ten Rhijne later pointed These technicians called by the Chinese Xinkieu, out in his book, in order for him to understand and by the Japanese Farritatte, must have had a Iwanga’s explanations of the notes attached to the fair degree of independence and clinical freedom drawings it necessitated one interpreter having for they had their own establishments with each to translate the Chinese into Japanese and then of the latter having a distinctive sign outside it in another interpreter, whose command of the Dutch the form of a wooden statue with acupuncture language was limited, having to translate the and moxibustion points marked in different col- Japanese into Dutch. It therefore follows that the ours, an eye-catching device, similar to the multi- information ten Rhijne received was of necessity coloured striped pole often seen outside a barber’s inaccurate and yet he himself then had to do his best shop in the Western world representing the splint to translate this into Latin, which was the universal for which the barber-surgeon in former times language in the Western world at that time. bound the arms of his patients during the process In spite of these difficulties there is no doubt of blood-letting. that ten Rhijne convinced himself that he had suf- From ten Rhijne’s account it would seem that ficient understanding as to how the Japanese prac- the needles used by the Japanese in the 17th cen- tised acupuncture for him to write an essay on it tury were made of gold, or occasionally of silver,
  21. 21. Chap-02.qxd 11*10*04 10:12 Page 15 How news of acupuncture and moxibustion spread from China 15 which is somewhat surprising considering that certainly very hazardous use for it at that time was steel must have been readily available to them. in the field of obstetrics with the acupuncturist The main indication for their use according to him being advised to ‘puncture the womb of a pregnant was for the release of ‘winds’ for as he says: woman when the foetus moves excessively before the appropriate time for birth and causes the The Japanese employ acupuncture especially for mother such severe pains that she frequently is in pain of the belly, stomach and head caused by danger of death; puncture the foetus itself with a winds … They perforate those parts in order to long and sharp needle, so as to terrify it and make permit the confined wind to exit. it cease its abnormal movement fraught with dan- In an attempt to explain this further, he adds the ger for the mother’! following somewhat homely simile: ‘in the same It is very unfortunate considering that ten Rhijne way, sausages, when they threaten to explode in a was sufficiently impressed with the practical value heated pan, are pierced to allow the expanding of acupuncture to feel that he wanted to pass on his wind to go out’. knowledge of the subject to the Western world by It would seem therefore that although the writing an essay on it, that this should have proved Chinese originally employed acupuncture for the to be a totally inaccurate account, due to his failure purpose of clearing collections of ‘wind’ in acu- to understand that the Chinese believed in the tracts (p. 7) in due course both they and the Japanese existence of a system of channels (now referred to in came to use it for the relief of abdominal pain the West as acutracts or meridians) completely sep- brought about by the entrapment of a quite differ- arate from and yet closely associated with blood ent type of ‘wind’ in the intestinal tract. vessels. His knowledge of anatomy was extensive It is of particular interest in this respect that the for at one stage in his life he taught the subject and only case history ten Rhijne includes in his book is therefore in all fairness there was no reason why it of a Japanese soldier with some abdominal pain. should have ever crossed his mind that the acu- The soldier believing this to be due to ‘wind’ pro- tracts depicted in the illustrations he acquired could duced as a result of drinking an excessive amount be anything but structures already well known to of water, is reported to have carried out his own him from dissecting the human body. As a result he treatment by inserting an acupuncture needle into repeatedly refers to them as arteries, and to con- his abdomen. Ten Rhijne was obviously present fuse the matter even more insists that the Chinese when he did this for he says: and Japanese use the terms artery, vein, and nerve interchangeably and so in some places he even … lying on his back, he drove the needle into the refers to them as veins and in others as nerves. left side of his abdomen above the pylorus at four His belief that these tracts were arteries is also different locations … while he tapped the needle readily understandable when it is remembered how with a hammer (since his skin was rather tough) much importance the Chinese placed on their long- he held his breath. When the needle had been held beliefs concerning the circulation of the blood driven in about the width of a finger, he rotated in developing their practice of acupuncture. This is its twisting-handle … Relieved of the pain and clearly expressed by ten Rhijne when he said: cured by this procedure, he regained his health. Ten Rhijne whilst watching this demonstration Although Chinese physicians (who are the fore- of auto-acupuncture must have cast his mind back runners from whom Japanese physicians bor- to his youth for by a strange coincidence the title of rowed these systems of healing) are ignorant in his dissertation for his doctorate in medicine was anatomy, nonetheless they have perhaps devoted De dolore intestinorum e flatu … ! In his essay he also more effort over many centuries to learning and gives a long list of other disorders that the Japanese teaching with very great care the circulation of the in those days were treating with acupuncture blood, than have European physicians, individu- including conditions such as headaches, rheumatic ally or as a group. They base the foundation of pains, and arthritis that people all over the world their entire medicine upon the rules of the circula- are still using it for. The one notably bizarre and tion, as if the rules were oracles of Apollo at Delphi.