1. Introduction

 From the moment of birth on human beings are subjected to constant physical and mental stresses [1]. Various regions of ancient China used different methods to accommodate: moxa in the cold North; needles of flint or Bian-stone in the East; medicines and herbals in the West; nine classical needles in the South; with remedial massage and breathing exercises or Qi-gong in Central China [2,23,24]. Acupuncture formed a basic part of treating the whole organism, can stimulate various biological activities; maintain natural homeostasis functions of the living body [2, 3, 4, 12, 14, 36]. Today acupuncture has been used and tested in a wide range of health problems not only in China but also in the world [5, 6, 7, 8]. In 1996, the U.S. Food and Drug Administration reclassified acupuncture needles and substantially equivalent devices from class III (premarket approval, investigational use) to class II (special controls), which includes medical devices for general use such as scapels and syringes [9].  


Clinical research provides a systematic approach for understanding of disease and dysfunction that can be effectively treated by acupuncture; physiological research examines how acupuncture works. Undoubtedly, understanding the mechanisms by which needling promotes healings enhances the acceptance of acupuncture in the west, particularly when changes are detected in cells or molecules related to neural [10,11,12,36,37,38], hormonal [13,33], immune[4,14,30,31,32], cardiovascular[15], gastrointestinal[16], and other biomedically defined systems[17,18]. In consequence, acupuncture is rapidly moving out of the arena of "alternative" medicine. However, the question guiding most mechanism-directed research "What biochemical or physiological changes correlate with acupuncture" is useful and indispensable but limiting. Equally needed are studies that ask the broader question "What can acupuncture tell us about how the body functions that Western medicine have not yet discovered?"  Although enthusiastic regarding the growth of acupuncture, it should be noted that many research papers have been published without mention of the philosophical traditions inherent in its practice.

 In China Acupuncture has a clearly recorded history of about 2,400 years [19,22]. It has always formed part of treating the whole organism through an individualized treatment system. The present paper reviews the progression of acupuncture in China with the potential to revealing additional biomedical correlates of acupuncture and for shedding light on new ways to understand TCM and human health.

Rong Yu, Ph.D, Yu Health Care TCM Clinic, Tokyo, Japan


2. Acupuncture: when and how it was developed?

 The oldest records of ancient Chinese medicine are found on bone etchings with inscriptions were from at least 2000 BC. Many Bian-Stones for medical treatments were found from ruins in China dating back to the New Stone Age [20,22]. Some of these stone slivers were used to make skin incisions and to stimulate specific points on the body. According to the record in 'A Dictionary of Characters' compiled by Wang Bin during the Han Dynasty (206 BC - 220 AD), 'bian' means 'the use of a sharp edged stone to treat disease'. This was the beginning of acupuncture. Bone needles and bamboo needles were also used. With the development of metal casting techniques, copper, bronze, or gold and silver needles were developed. In 1968 a set of nine needles, four being of gold and five of silver were discovered in the tomb of one of the Han-Prince Chungshan, dating from 112 BC [22]. Today some acupuncturists use gold and silver needles, but the majority use only stainless steel filliform needles.

 Moxibustion was gradually created after discovery and using of fire. It developed separate from acupuncture, although it is now very much a part of current acupuncture practice. The first recorded attempt at conceptualizing and treating disease by moxibustion dates back to 1324 BC during the Shang dynasty, was confirmed by the discovery of the tortoise shells with Chinese character’s inscriptions [20,22]. The main material of moxibustion is made from the dried leaves of Artemisia vulgaris. Today, the moxibustion is generally applied over the group of the acu-points as acupuncture needles. Moxa can be used in a variety of ways. Loose moxa is made into a cone and burnt on the skin, the cone then being removed when it is half burnt, to avoid blistering. Moxa can also be used as a needle moxa, a moxa stick burnt a centimeter or two away from the skin, or over the herb-platform like ginger, garlic or aconite tuber etc. so that the practitioners can not only control the heat value of combustion, but also induce various immune system responses percutaneously based on the different chemical compositions of moxibustion materials [20]. Both animal and human studies suggest that stimulation of moxibustion can lead to a wide range of immune responses, including cell-mediated and humoral immunity [14, 30,31,32] and improve the depression state and myodynamia [33].

 Chinese medicine developed and prospered greatly during the Zhou Dynasty 1066-221 BC. State public health doctors were employed and kept very accrate clinical records [22]. One of them was the famous Dr. Bian Que. He developed and refined the radial pulse diagnostic microsystem, which can evaluate the patient's overall condition from minute to minute. The pulses also serve as a subjective measurement from visit to visit, revealing the stability of the changes made through the acupuncture treatments. Dr. Bian Que’s acupuncture treatment based on the visual and pulse diagnositc procedures, to cure a comatose prince of Kuo-State in 384 BC with the Bian-stones and metal needles, was described 100BC in details and marks the earliest known record of an effective cure by acupuncture [19,22]. This was also the first record of acupuncture being used with emergency medical situations. Not limited to the high society peoples, many discovered sculptures in northern China indicated that Dr. Bian Que and his followers practiced medicine including acupuncture for the common peoples [22].

 Two silk scrolls recording meridians and collaterals dating from 200 BC., "Moxabustion Classic with Eleven Foot-Hand meridians" and "Moxabustion Classic with Eleven Yin-Yang meridians" , which were discovered at Mawangdui, Changsha City in 1973, provided the earliest material proof for the description of the meridians, collaterals and acupoints [22].

 The first significant milestone in the history of TCM and Acupuncture is the Yellow Emperor's Nei Jing, or the Yellow Emperor's Classic of Internal Medicine [23, 24]. The Nei Jing, multiple authors contributed to this work, served as the earliest major source of classic medicine dating from the Han dynasty in the 2nd century BC, during the Warring States period. The Warring States period is a particularly prosperous time in Chinese history [19]. Two main philosophical ideologies surfaced: Taoism and Confucianism. Confucianism defined the social status. It was opposed to the development of anatomy and surgery, the whole body should remain complete throughout life and as well as in death. Compared to the closed system of Confucianism, Taoism was an open, natural and balanced holistic system. Chinese medicine is based on this open system. At that time, many people still believed in divination and superstitious Myth and Magic. The Yellow Emperor's Classic of Classic Medicine clearly stated that pathogenesis is connected with the internal and external environment. Therefore, Nei Jing represented the classical scientific view of medicine so as to defeat divination and superstition.

Rong Yu, Ph.D, Yu Health Care TCM Clinic, Tokyo, Japan


3. The spirit of TCM, What the Yellow Emperor's Nei Jing tells us?

 The Nei Jing consists of two parts: the first part is Su Wen, means plain questions. It begins with a discussion between the Yellow Emperor Huang Ti and his Minister Chi Bo to introduce the philosophy of Chinese Medicine, such as the concepts of the five agents doctrine and the opposing effects of the Yin and Yang that states opposite ends of a spectrum are vital for change as well as internal balance. The Su Wen presented a unified and comprehensive system of Chinese medicine. These concepts are believed to illuminate the visionary aspects of the work that focused upon the climate, the environment, and behavior as precipitants of disease and the primary natural laws that govern illness. Furthermore, the objective to preserve and protect an individual's well being began to surface with descriptions that outline methods to normalize emotions, employ balanced diets, maintain personal hygiene, consume clean water and fresh food, and to incorporate regular exercise into one's daily regimen.

 The second part of Nei Jing is the Ling Shu. It’s focus was Acupuncture. It descripts types of Qi, the meridians, locations and functions of 160 points, functions of the zang-fu organs, nine types of classical needles which most of them are still being used today, and their respective needling techniques.

 The Nei Jing indicates six parenchymal, energy-producing organs relating to yin, six visceral, hollow,substance-transporting organs relating to yang. It is important to note that in TCM, the liver, heart, spleen, lung, and kidneys are not only the anatomical names, but also refers to the functional units to which each of them belongs, and entail a wide range of concepts. The Nei Jing authors regarded the human body as a microuniverse reflection of the macrouniverse, and considered the physician's role was that of maintaining the body's harmonious balance, both in relation to the internal and external environment. Organ pathology is identified either in conventional biomedical terms or as a disturbance in the organ's physiological activities according to acupuncture terms (eg, nephrolithiasis is a disturbance in both Kidney and Bladder organs and spheres of influence). Based on the unified philosophy, classical anatomy, physiology, pathology, etiology, diagnosis procedures, and most important, strategies of preventive medicine, it is unequivocally that the Nei Jing is a leading classical science treatise.

Rong Yu, Ph.D, Yu Health Care TCM Clinic, Tokyo, Japan


4.The long prosperity and the sharp decline of TCM and acupuncture

 The cornerstone of TCM is logic-based individualized therapy. Zhang Zhong Jing, in the 2nd century did the pioneering work of the systematization of TCM logic-based individualized therapy [22,25]. He approached the process through the use of four diagnositc procedures: visual examination, examination by ausculation and smell, inquiring, palpation, and more importantly, the analysis, to find the disease’s nature and root causes. These techniques allow the doctors to apply qualitative and quantitative research to gather and analyze information systematically, and to do so with attention to minimazing bias. For instance, the same disease with the same surface symptoms may constitute two or more differentiations based on TCM diagnositc procedures and the analysis. This was TCM’s greatest contribution to medicine. Combining acupuncture with medical herbs according to the traditional logic, identification of pattern according to six meridians (which means classification of diseases into six stages of progression), both were also his contributions. Although this article focuses on Acupuncture, it must be realized that acupuncture and moxibustion represent only one facet of Chinese medical system.

 In 282 AD acupuncture was comprehensively summed up in "Rudiments of Acupuncture and Moxibustion "(the Zhen Jiu Jia Yi Jing ) by Huangfu Mi. It listed 349 points and their clinical indications for the first time, it was the first book devoted solely to acupuncture and moxibustion theory and treatment; Huangfu Mi also established the standards for safe practice. Some acupoints, mainly based on anatomical foundations, were forbidden to be used with acupuncture or moxa. The principle of a superior physician is to prevent; common physician is to treat the present disease; ignorant physician is to past help, was presented by him. Today, the basic concepts of TCM acupuncture is to first, improve the overall state, second, prevent the disease before the diease-oirented state, third, the treatment of disease [20]. Acupuncture therapy is not miraculous. It has its appropriate range of applications, and, like any other medical intervention, yields good results in well-selected early problems and less successful results when chronicity and complexity of the presenting problems increase. Usually the best moment to initiate acupuncture therapy is early in the evolution of a problem. However, the flexibility and adaptability of acupuncture allow it to be practiced at almost any stage of treatment.

    From the Han dynasty (206 BC-200 AD) to the Ming Dynasty (1368-1644 AD), acupuncture practice was refined and its literature underwent continual exegesis. Research, education, clinical refinement, and collation and commentary on previous classics flourished in the Ming dynasty. Acupuncture has evolved over 2 millennia, both through refinements based on treatment responses and through adaptations to changing social situations.

 During Tang period (AD 618-907), China was undergoing the process of economical and cultural prosperity of the feudal society. The Imperial Medical College set up a special acupuncture department. The institutions of acupuncture doctor, acupuncture instructor, acupuncturist, acupuncture student, besides the institutions of medical doctor, doctor and medical
student were organized, and acupuncture was administered under the authorization of the national government [22]. Not only the knowledge and skills of TCM but also these medicine policies had a profound influence on medical practice in Japan [43]. The Tang dynasty witnessed a great flowering of the art of acupuncture and moxibustion. The Thousand Golden Remedies by Sun Si-Miao was one of the products of this period. This text was the first to contain clear color charts of the channels with front, side and back views of the body, first to introduce the location and application of Ashi acu-points; obviously a great boon to students and teachers of acupuncture.

 During Sung dynasty (AD 960-1280), the improvement and extensive application of type case printing techniques greatly promoted the development of  acupuncture as far more books became available. In 1027 'The Illustrated Manual on the Points for Acupuncture and Moxibustion as Found on the Bronze Figure', was written by Wang Weiyi. Wang made bronze figures holed with acu-points, linked into meridians, for use in teaching and examinations. The statues were used in the Imperial acupuncture exams in ancient China. The statues were coated in thick wax and then filled with water. Students taking the exam would locate the acupoint and needle into the wax covered statue. When the needle was withdrawn a small drop of water would be evident if the student had needled the correct point.  Visual teaching methods of acupuncture were greatly developed.

 During Yuan Dynasties (1279-1367), the famous TCM doctors, He Ruoyu and Dou Hanqing suggested that the acu-points should be selected according to the chronobiology (midnight-noon ebb-flow cycles) in the book of 'The Indication of Acupuncture', which the original thoughts could be traced back to the Nei Jing [23,24]. They discussed the rhythms of meridians, and explained the close relationship between selection, compatible application of acu-points and the time. There is by now indisputable evidence that physiological variables cycle on a daily basis, such as circadian rhythms [44] and immune responses [45].     
Research, education, and clinical refinement flourished during the Ming Dynasty (AD 1368-1644). In 1601, Yang Chi-chou edited the Great Compendium of Acupuncture and Moxibustion(The Zhen Jiu Da Cheng), where pediatric acupuncture was introduced. The Zhen Jiu Da Cheng was the most influential medical text for later generations in Asia and Europe. It was the source of acupuncture information transmitted to Europe in the 17th through the 19th centuries via Latin translations by Portuguese, French, Dutch, and Danish missionaries, and physicians traveling and working in China and Japan. Li Shi-chen completed the classical Chinese Materia Medica and included a volume on the Eight Extra Channels.

 During the Qing Dynasty (A.D.1644-1911) acupuncture faced its most testing period and fared quite. The Qing dynasty was a time of chaos for the Chinese Empire. Western influences pervaded a war-torn China, especially during the nineteenth century when various Western nations were given 'spheres of influence' on the Chinese mainland. A government decree was issued in 1822 by the Grand Medical College Board banning its practice on ethical grounds; the Federal Court considered exposure of the naked form indecent [22]. In spite of its decline, and even at the low level, acupuncture remained the medicine of the masses.

Rong Yu, Ph.D, Yu Health Care TCM Clinic, Tokyo, Japan

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