Round Earth Society - R.E.S.: Acupuncture, The Facts

Introduction

The practice of acupuncture is fairly widespread in Australia, and is used by both medically and non-medically trained persons. The technique is based on the belief that the human body is subject to disease when there are imbalances in the level of invisible life forces. Balance can be restored by using fine needles, or other means, to stimulate various points located over the body. The needles are usually inserted and twirled and may be left in for short periods. The points chosen for stimulation depend upon the patient’s symptoms, the season, the weather, and the result of taking the pulse at the wrist.

Acupuncture is a therapy based on ancient Chinese philosophy and was described for the first time in 90 BC in the Shih-chi text. No known Chinese source prior to this time refers to the technique.¹

Modern authors (eg, Needham²) have expressed views on acupuncture that are not consistent with the descriptions in the ancient Chinese medical texts. This is clearly inappropriate. Any assessment of acupuncture should involve accessing these texts as the historical documents they are, and not merely reinterpreting them to suit some other purpose. When this is done it is clear that there is often little connection between the modern western form and understanding of acupuncture and the past.

Only by accurate reference to source material can those who are interested in acupuncture determine whether its concepts are applicable in a meaningful way to modern times. Objectivity is an important scientific principle and provides protection from the influence of pre-existing beliefs or ideas.³

History of Acupuncture

The earliest Chinese medical texts are those discovered at the Ma-wang-tui graves in 1973, dating from 168 BC.^4-6 These provide a picture of Chinese medicine as it existed during the 3rd to 2nd century BC. Acupuncture is not mentioned in these texts, which record all modes of treatment in use at the time. ¹

The Ma-wang-tui texts do describe eleven mo or vessels, which were believed to contain in addition to blood a life force known as ch’i or pneuma.⁶ There was no distinction made between vessels on the basis of content and no information was provided on how the blood and ch’i circulated in the vessels, which did not make up a connected system. ¹ By the end of the first century BC it was believed that there were twelve vessels, and that these were connected in a network. In addition a picture had developed of the ch’i flowing through vessels separate from blood.¹,⁴,⁶

The most important text of this time - the Huang-ti nei-ching - mentions twelve connected vessels with different courses to the eleven described earlier ⁷. These were called "conduits" (ching) or "conduit vessels" (ching-mo). It also records a large number of holes which are located over the body on these vessels. Most modern writers refer to these vessels as meridians.⁸,⁹

Ch’i

Disease was closely related to the vascular system and was, in earlier times, treated by causing bleeding from a vessel with sharp stones or needles ⁶. Later the concept of a disease causing agent--the hsieh--was developed. It was believed that this could lodge in the vessels and interfere with the flow in them. The concept of ch’i came from the term hsieh-chi, or evil influences which in turn developed from an earlier time in Chinese history when the agents of illness were thought to be demons (hsieh-kuei).¹

The wind was originally regarded as a demon and therefore an agent of illness. Later it was regarded merely as a natural phenomenon, though it was still considered a warning of future events. As a spirit or demon the wind resided, it was believed, in caves or tunnels. The term for ‘caves’ is used in acupuncture literature to designate the holes in the skin through which the ch’i is able to flow into and out of the body - hsueh. It was believed that through the insertion of different kinds of needles into these holes the flow of ch’i could be increased or decreased to achieve a more normal state of health.

Ch’i was considered to float through the air, and flow with blood. The Chinese character used to represent ch’i is literally read as vapours rising from food.¹

Supporters of acupuncture like to use the word ‘energy’ in association with the term ch’i, but it is clear that:

"the core concept of ch’i bears no resemblance to the western concept of energy (regardless of whether the latter is borrowed from the physical sciences or from colloquial use)."^4(p5)

Celestial Influence

Over time the connection between needling and ch’i, which formed the basis of acupuncture, was described in the context of an emerging cosmological view of the world, not evident in the earlier descriptions of medical bleeding. Organic medicine was subsumed under this emerging system of cosmological correspondences.¹,⁶

For example, the types of needles used were grouped together as nine because of the cosmological significance of the number. When the system of openings or holes along the vessels was first described there were 365, not because this number had been anatomically identified, but because this corresponded to the days in one year. Early texts make no reference to the openings - they are just suddenly described, and there are 365 of them. The absence of any objective basis for the openings is shown by the fact that many texts describe a different total number of them.¹⁰

Contradictory Elements

The vessels, and not the openings, were the central feature of ‘ancient’ acupuncture, whereas in modern practice the points appear to be of prime importance. The vessels have, over time, lost their association with the vascular system⁶ and in the west are now viewed primarily as functional pathways linking the openings. The use of the term ‘meridian’ rather than ‘vessel’ merely serves to aid in clouding the issue.

A further problem is an apparent contradiction in that the modern practice of acupuncture seems to be based on the pre and post-circulation concepts. That is, the vessels are needled as if they constitute separate units, whilst at the same time most practitioners of Traditional Chinese Medicine also rely on wrist pulse palpation, which makes sense only if the flow through the vessels is continuous.

If the flow was not continuous (ie, the vessels not connected) then each vessel would need to be palpated for its own pulse. This is, in fact, what was originally described, and it seems that this basic contradiction has arisen from a partial acceptance and a partial rejection of history.⁴ It is unclear why this occurred and how it was decided what to retain and what to discard.

Yin, Yang and the Five Elements

Most people have heard of the terms yin and yang which describe concepts that form an important part of the history of Chinese medicine and acupuncture. An ill person was considered to be out of balance with nature and these two opposing forces. Originally the terms meant shady (yin) and sunny (yang) side of a hill.¹

The belief in these forces was based on the view that most of the natural world consisted of events that were cyclical, and therefore caused by the rise and fall of opposite, but complementary, forces. There was also an element of the ancient belief in a particular form of magic - that like corresponds to like. In other words, it was believed that hurting a picture of a person would result in real harm to the person, or eating food that looked like a particular body organ would be beneficial to that organ.

Another important natural philosophy in the history of Chinese medicine was the doctrine of the Five Phases or Elements (wu-hsing), which involved the categorising of natural phenomena, in particular water, fire, metal, wood, and soil into five separate lines of correspondence.¹¹ A sixth component, grain, is also described.

The initial application of these philosophies to medicine was characterised by a number of different schools with different theories, many of them contradicting each other (eg supporters of the Five Phases doctrine rejected the yin/yang concept).⁷ Even in the one book, virtually side by side, there could be guidelines based on mutually exclusive patterns of knowledge. With the passage of time a kind of reconciliation took place, but no formal standardisation of these conflicting views was attempted.

For example, do the terms hsin (heart), kan (liver) and p’i (spleen) refer to anatomical structures or abstract functional systems? In the Chinese medical literature there is reference to both and so neither is ‘correct’.

These problems arose because there was primarily a reliance on subjective perceptions and no system for acquiring and recording information objectively.

The Power of Anecdote

The early understanding of health and illness in China was derived almost entirely from analogical conclusions and not anatomical evidence.¹,⁴,⁶ It was not until the eighteenth century that it began to be acknowledged that a conception of function is of no use without an understanding of actual structure. Surgery was prohibited for a long time in China, since it was regarded as unacceptable to open the body in this way.¹

It is important to realise that acupuncture arose at a time when there was no understanding of modern physiology, biochemistry, or healing mechanisms. If a person was sick, and treated with acupuncture, and they improved, it was assumed that the treatment had caused the improvement. There was no formal study of diseases and their natural history and no attempt was made to determine whether the person would have improved without the treatment.

Without having a scientific basis for determining the success or failure of treatment the two events - giving a treatment and symptom improvement - were causally related, and these specific treatments have been passed on untested to this day.

The Early 1900s

By the early twentieth century Traditional Chinese Medicine (TCM) was regarded as an historical oddity and its use was mainly in rural areas.^12-14 The early Chinese Communist Party expressed considerable antipathy towards TCM, ridiculing it as superstitious, irrational and backward, and claiming that it conflicted with the Party’s dedication to science as the way of progress ¹³. Acupuncture was included in this criticism. The person who would become the first secretary-general of the Communist Party stated in 1919:

"Our men of learning do not understand science; thus they make use of yin-yang signs and beliefs in the five elements to confuse the world...Our doctors do not understand science: they not only know nothing of human anatomy, but also know nothing of the analysis of medicines; as for bacterial poisoning and infections they have not even heard of them...We will never comprehend the ch’i even if we were to search everywhere in the universe. All of these fanciful notions and irrational beliefs can be corrected at their roots by science."^15(p135)

Mao Tse-tung and the Cultural Revolution

It was left to Mao Tse-tung to save TCM, including acupuncture, by casting it into the political arena.¹²,¹⁴,¹⁶,¹⁷ The era of Mao Tse-tung saw a resurgence of interest in TCM as a result of:

(1) Mao’s personal involvement,
(2) The need to utilise all available resources to deliver health care to rural areas. When the People’s Republic of China was formed in 1949, China was an unhealthy place and the rural areas were particularly poorly serviced. One of Mao’s primary aims was to improve this situation.
(3) The Party’s desire for increased power and control. By 1968 the Ministry of Public Health had become largely irrelevant and most of the pre-Cultural Revolution leaders had been removed and replaced with army representatives. Decision-making power resided almost entirely with Party leaders.

Acupuncture and other traditional therapies such as herbal medicine were powerful political tools and were used to judge support for the Cultural Revolution.¹,¹⁴ At one stage the head of the North-East Public Health Board was publicly denounced for expressing opposition to TCM and the First Vice Minister who had been the Health Care leader since the 1930s ‘confessed’ in the People’s Daily to having also opposed it. The reason for his opposition was because he was "divorced from Party leadership".^14(p47) Doctors and patients also came under considerable political pressure to use traditional techniques, and critics were harshly treated.

In October 1966 the Chinese Medical Journal was replaced by a frankly political journal - China’s Medicine - whose banner included the words ‘official organ of the Chinese Medical Association’.¹⁷ The editorial of the first edition proclaimed:

"We will hold still higher the great red banner of Mao Tse-tung’s thought, creatively study and apply Chairman Mao’s works and continuously advance the revolutionization of our ideology and work so that we may better serve the Chinese people and the revolutionary people of the world."^17(p112)

After the Chinese Medical Journal was recommenced in 1973 this policy of publishing material of a political nature continued.¹⁸,¹⁹ It was only after the demise of the ‘Gang of Four’ in 1976 that this emphasis was discarded and there appeared for the first time revelations about the impact the political climate in China had had on medical practice.

In 1987, in a paper on the history of the Chinese Medical Journal, this period was reviewed:

"It is sad to recollect the gloomy days of the ‘Cultural Revolution’, which lasted 10 years starting in 1966. What happened to the Journal? CMJ was replaced by China’s Medicine, which appeared from 1966 to 1968, filled with political documents, but very few medical papers...Although our Journal resumed publication in 1975, many authors still started their scientific articles with superfluous political sloganeering... Low quality papers were also accepted. Fortunately, normalcy was gradually restored in the Journal after 1979"."^20(p438-39)

The Modern Era

In China today medicine has adopted a more scientific approach and whilst certain elements of traditional Chinese medicine are retained, there is a growing call for objective scientific evaluation of past claims.¹²,²¹ Western medicine and bio-medical science dominates, and it is generally agreed that if TCM is to secure a place it will only be through scientific research. This is consistent with Mao’s teaching, as he called for the modernisation of Traditional Chinese Medicine¹² and urged the Chinese to "uncover the treasurehouse and raise its standards".^1(p252)

Of the approximately 46 major medical journals published by the Chinese Medical Association not one is devoted to acupuncture or its variants. In other parts of Asia such as Japan acupuncture has been all but rejected.²²

In Japan western medicine was first presented as an alternative to TCM in the 18th century²³ and by the late 19th century had assumed the dominant position²⁴. Proclamations of 1875 and 1883 restricted the practice of Chinese style medicine and doctors were urged to discard TCM and switch to western medicine. ²⁴

Fact From Fiction

We have a more detailed knowledge of the human body than when acupuncture was first being described, and since that time many of its beliefs have been examined closely. We can now confidently state that:

(a) The concept of ch’i has no basis in human physiology.
(b) The vessels, or meridians, along which the needling points are supposedly located, have not been shown to exist and do not relate to knowledge of human anatomy.
(c) Specific acupuncture points have also not been shown to exist - as noted earlier, different acupuncture charts give different numbers and locations of points.

Evidence supporting acupuncture must support the view that it is a separate and distinct entity. That is, it must support the claim that acupuncture has an effect as a result of needling specific points on the body that correspond to the vessels as described historically.

Before this claim can be tested, though, we must know which historical description is being used as the ‘true’ one.Which description of the vessels is being used - eleven or twelve, connected or not connected - and how many points are to be used? Why is this particular model being used in preference to the alternatives? The scientific assessment of acupuncture can proceed only when this information is provided, and its source is declared. No scientific paper on acupuncture should be published which does not provide this vital information.

Assessing Acupuncture: The Crucial Questions

Many of acupuncture’s apparent benefits are anecdotal and in assessing this technique it is important to quantify the objective value conferred. That is, it is important to exclude natural history and the placebo effect so that one can confidently ascribe any benefit seen to the therapy.²⁵

There must be clear evidence of a distinction between general sensory counter-irritant techniques shown to have a mild analgesic effect - such as trans-electrical nerve stimulation (TENS) - and acupuncture. The analgesic effect of counter-irritant stimulation is regarded as a physiological phenomenon in which the transmission of pain signals from one site or area is inhibited by the application of another noxious stimulus at a separate site, which may be remotely situated.^26-30

In addition there must be evidence that insertion of needles at random points on the body does not exert the same effect as specific needling. This matter is crucial. Proponents of traditional Chinese acupuncture claim that it takes many years of specialised training to be able to identify the specific acupuncture needling sites. If an equivalent effect is seen when a needle is inserted in the same way anywhere away from the specific site that the theory requires, then this refutes the theory.

Those who continue to claim that traditional Chinese acupuncture is a specific modality must address the existing scientific studies that refute this belief and not merely quote supportive studies or anecdotes.

Acupuncture and Hearing Loss: A Lesson Learned

The importance of objective testing is very well illustrated in a published review of the use of acupuncture in sensorineural hearing loss.³¹ This paper describes well how easily an unproven remedy may be unquestioningly promoted, and how scientific assessment usually occurs pretty much as an afterthought. It describes the following process:

(a) A visit to China by a well-known, and respected, ear nose and throat specialist.
(b) Demonstrations for this person of apparent cures effected by acupuncture. No inquiry made as to whether the patients ‘cured’ had had pre- and post-treatment audiometric testing.
(c) Return to the USA, whereupon reports of cures began to reach the public via the media, particularly popular newspapers and magazines.
(d) Public demand for the treatment to be made available as a result of the media reports of these cures, and the apparently high success rates being achieved by trained local practitioners.
(e) The lack of objective scientific evidence for the reported cures is noted with concern, and research is conducted.
(f) Formal studies show that acupuncture has no effect upon hearing levels of individuals with sensorineural hearing loss.

The specialist who originally travelled to China, and wrote of the remarkable demonstrations he saw there, wrote the following just three years later:

"...it is a tragic mistake to take a child - or an adult for that matter - for acupuncture treatment for neurosensory deafness to any of the so-called acupuncture centers. There has not been one case of improvement demonstrated audiometrically, when a child or any deaf patient was tested before undergoing treatment and then afterwards by any reputable otologist. There have only been unreliable and perhaps planted testimonials."^31(p433)

From East to West

The early 1970s were a period during which visits to China were popular and these usually involved demonstrations of the almost miraculous effectiveness of acupuncture. These visits were then written up in western medical journals more as journalistic pieces than as critical scientific reviews.^32-34

The rapid increase in popularity of acupuncture in the West followed on from the reports of these visits, and it had captured the public’s imagination long before scientific studies began to question the validity of the anecdotes.

Acupuncture Research

Carefully designed and conducted scientific studies have shown that traditional Chinese acupuncture is no more effective in providing pain relief than placebo or counter-irritant stimulation such as TENS.^35-58

Many of these trials have compared ‘real’ acupuncture (needles inserted according to traditional theory) and ‘sham’ acupuncture (needles inserted at other sites which, in some cases, were sites that the traditional theory said were least likely to reduce pain) - with no difference in effectiveness found.³⁶,³⁹,^40-42,⁴⁴ Since many of the studies were conducted with the cooperation and participation of professionals trained in traditional acupuncture, it is insufficient to dismiss them as a part of some imaginary anti-alternative conspiracy.

It is accepted that there are modern theories that go part of the way to explaining the analgesic action of the counter-irritant techniques such as TENS^27-29,^59-65, though it must be noted that not all studies confirm that these have an effect over and above placebo.^66-68 There is currently no evidence to support the view that acupuncture has an action or effect that is separate to that seen with these techniques.

Some modern practitioners, in view of such evidence, have abandoned the ancient theories, including the vessels/meridians and even the acupuncture points. The British practitioner Felix Mann has been noted to observe wryly that if the modern texts are to be believed there is "no skin left which is not an acupuncture point".⁶⁹

Pain is a subjective symptom and the perception of it is affected by other factors, including psychological state.⁷⁰ There is evidence of a considerable placebo effect in trials of many pain conditions⁷¹ and any scientific evaluation of acupuncture must include an attempt to see whether it can relieve pain or other symptoms better than placebo. As noted in the 1989 National Health and Medical Research Council (NHMRC) report:

"..it might well be that the clinical effectiveness of acupuncture in the reduction of pain is due more to psychological than to physical factors".^65(p46)

There is certainly no evidence to support the view that acupuncture is of use in various systemic disorders (eg asthma⁴⁹,⁵⁸, arthritis³⁸,⁴⁰,⁵⁵) and it is bordering on the fraudulent to suggest so.

Side Effects

Acupuncture is not without its risks^72-76 and if equally effective techniques are available that do not involve puncturing the skin then it is hard to justify using this invasive procedure.

"Viewed in this way acupuncture is an elaborate but unnecessarily complicated means of achieving analgesia when a clinically safer and easier method is available."^65(p15)

Animal Acupuncture

Supporters of acupuncture sometimes refer to studies in animals claiming that these clearly demonstrate an analgesic effect and since animals are not suggestible the placebo effect is excluded.

Animals must be restrained to have acupuncture and it is well described that when animals are restrained that they can develop anaesthesia due to fear and catalepsy - the so-called ‘still reaction’.⁵,⁷⁷ In addition the studies do not compare ‘real’ and ‘sham’ acupuncture and provide no details as to the source of the acupuncture points used. Where is the description of acupuncture in animals in the historical Chinese literature?

A Desire For Dialogue?

Concern must be expressed at the views of some supporters of acupuncture regarding whether there is a need for closer cooperation with scientific medicine. For example, advice given to acupuncturists by one prominent author included a recommendation to undermine the public’s faith in modern medicine and science and educate them as to their need for alternative medicine.⁷⁸

Attempts to obtain comments from a number of acupuncture organisations on a draft of this ACSH paper were met by either silence or mocking sarcasm. None of the organisations approached chose to provide even a single specific comment on any part of the paper. This is particularly intriguing given that the 1989 NHMRC report was condemned by acupuncturists on the basis of:

"..failing to invite traditional acupuncturists into an open debate in which they had the opportunity to hear and to endeavour to meet points advanced against them."^79(p51)

Conclusion

The Australian Council on Science and Health [and the Round Earth Society] asserts that:

(1) The public must be made aware of acupuncture’s current scientific status. There is a marked difference between the claims of acupuncturists and the findings of the clinical trials research.
(2) The onus is on those who are claiming that traditional acupuncture is effective, and a distinct entity, to establish this by conducting well-controlled trials and submitting the results for peer review.
(3) There is a need for scientifically rigorous studies of the effectiveness of acupuncture in a range of conditions.
(4) Until such time as such supporting evidence is available acupuncture should not be offered without full informed consent - patients must be advised of acupuncture’s unproven status and its possible adverse effects.
(5) The public should not be made to pay for this unproven therapy via Medicare rebates.

The need for more research, and research of a higher standard, has been stressed by authors of previous reviews of acupuncture.^54-58,^80-82

References

1. Unschuld PU. Medicine in China. A history of ideas. University of California Press. Berkeley. 1985 Back

2. Lu DG, Needham J. Celestial lancets. A history and rationale of acupuncture and moxibustion. Cambridge University Press. Cambridge. 1980 Back

3. West R. Assessment of evidence versus consensus or prejudice. Journal of Epidemiology and Community Health. 1992; 46: 321-2 Back

4. Unschuld PU. Nan-ching - the Classic of Difficult Issues. University of California Press. Berkeley. 1986 Back

5. MacDonald A. Acupuncture: From ancient art to modern medicine. Allen and Unwin. London. 1982 Back

6. Epler Jr DC. Bloodletting in early Chinese Medicine and its relation to the origin of acupuncture. Bull Hist Med. 1980; 54: 357-67 Back

7. Keiji Y. The formation of the Huang-ti Nei-ching. Asia Asiatica. 1979; 36: 67-89 Back

8. Worsley JR. Traditional Chinese Acupuncture.Vol.1. Meridians and Points. Element Books. Salisbury. 1982 Back

9. Weisner D. Alternative medicine. A guide for parents and health professionals in Australia. Kangaroo Press. New South Wales. 1989 Back

10. Lun L. Acupuncture develops in the struggle between the Confucian thinking and the legalist thinking. Scientia Sinica. 1975; 18(5): 581-90 Back