INTRODUCTION
Traditional Chinese Medicine (TCM) is several millennia old. Its main therapeutic procedures are Ben-cao (Herbology) and Zhen-jiu (Zhen = needle; Jiu = Fire) but other methods (massage, diet, exercise, meditation etc.) are used also.
Zhen (needle) = acupuncture (AP); it literally means needle puncture (acus = needle) but the term has a more general meaning: stimulation of specific AP points in the superficial areas of the body by many different methods. Jiu (Fire) = moxibustion (combustion of mokusa (Japanese term for burning herbs) is the direct or indirect application of heat to the AP points. These will be dealt with in detail.
Other methods of stimulating the AP points will be discussed briefly. These include point injection; "dermojet" injection; implantation; incision of the points; application of heat or cold; massage, pressure or vibration of the points; cupping or application of a vacuum to the points; electro-AP (EAP); transcutaneous electrostimulation, faradism; application of magnetic, static, electromagnetic or electrostatic fields to the points; ultrasonic stimulation and laser stimulation. Rare methods of stimulation include concentration of "psychic energy" and "hand energy" to the points without actually touching the animal.
The most important aspect of AP is not the precise method of stimulation but to apply an adequate stimulus to the correct points. Methods of choosing correct points are discussed elsewhere.
NEEDLING (ZHEN)
In traditional AP, 9 types of needles were used. Some of these were like scalpel blades or lances and must have inflicted severe pain on the animal. These are seldom if ever used in western AP today. To avoid unnecessary suffering, the finest needles possible should be used. In practice, this means using 25-32 gauge needles in small animals and 19-25 gauge needles in large animals.
The length of the needles depends on the species of animal and on the location of the points to be needled. Points over bony areas, such as the scalp, face, ears and distal limbs require the shortest needles. Those over the thorax, abdomen and lightly muscled areas require medium length needles and those over heavily muscled areas, such as the lumbar area, the hindquarter (buttock and thigh) area and the heavy muscles of the shoulder area require the longest needles.
In general, needle lengths ranging from 10-50 mm should suit all purposes in small animals and needles 10-100 mm should suit all purposes in large animals. In human surgery under AP analgesia, occasionally very long (up to 250 mm) needles are placed parallel to the incision site, one on each side of the wound. This method is seldom used in veterinary surgery.
The needles can be of two types (a) special solid, stainless steel AP needles, made of very high quality steel wire and (b) standard hypodermic needles.
a. AP needles: The cheapest needles are made in China and Taiwan but many other eastern and western countries make AP needles. They are available through AP supply houses. The cheapest source is via Hong Kong mail-order houses, such as Mayfair Medical Supplies, which accepts international credit cards and orders can be placed by Fax (852-721-2851).
Human-type needles are suitable for small animals but they are too fine for use in large animals. The problem is that muscular twitching and spasm, which frequently occurs during the needling session (especially when the needles are electrically stimulated), can twist the fine needles into bizarre shapes (L-shapes, Z-shapes and U-shapes etc), making them difficult to extract and destroying them for future use. AP needles are expensive and between 1 and 20 may be required during a session. If 6-12 needles are bent or destroyed each time, the cost in one year can be high. Therefore, the thicker needles (19-25g) are used in large animals. Even then, some of them will be bent during therapy. Chinese (Yuan Li) needles, 30 mm long and 21 gauge wide are ideal for use in large animals. Similar vet needles made by the Richter Company, Wels, Austria, are also available.
b. Standard hypodermic needles have the advantage of being very cheap and disposable but they have the disadvantage of causing more pain and they may introduce dirt or skin into the tissues because they have a lumen. They also cause more tissue damage and bleeding.
Before use, each needle should have been properly sterilised. It should be checked to ensure that it has no physical defects such as a blunted or hooked tip, bent or rusted body or loose handle. The points are clipped and cleaned with alcohol or other antiseptic solution. In my opinion, unless the skin is visibly dirty, attempts to clean it by alcohol swabbing or by aerosol spray are a public-relations exercise more than a useful hygienic procedure. Clipping makes the points easier to find on subsequent visits. Occasionally clipping is omitted, as some owners may object to their animal being clipped in up to twenty places.
Insertion of needles: The animal should be restrained adequately. Hypodermic needles can be inserted to the required depth in one swift, firm movement. In nervous or dangerous horses, it may help to have a twitch placed on the horse's upper lip, or ear, and to apply counter-pressure to the point (using, for instance, the plastic needle cover) with one hand as the needle is thrust home with the other hand.
AP needles need a different technique. They are inserted by a push-twirl technique in two stages: the first movement to penetrate the skin and the second to place the needle to the required depth in the tissues. With longer needles, it is useful to hold the needle shaft with one hand about 25 mm from the tip (using a cotton-wool bud or piece of sterile tissue) and to push-twirl the handle of the needle with the other hand. Alternatively, a stainless steel or plastic needle guide can be used. Needle guides are hollow tubes, about 10-13 mm shorter than the needle. The guide is placed firmly on the point and held with one hand. The needle is inserted into the tube and the needle-handle, protruding from the guide, is tapped firmly with the finger of the free hand to drive the needle 10-13 mm deep. The guide is then removed and the needle is advanced to the correct depth.
It is not possible to give an exact depth or direction for needle insertion: these vary between points (within species) and between points (between species). The direction of insertion depends on the body region being needled. Over muscular areas, the needle is usually inserted at 90o to the skin, deep into the muscle. Over bony areas and on Earpoints, the needle is inserted perpendicularly until- the skin is penetrated and then is advanced subcutaneously. One should not normally needle the periosteum (except in cases where this is specifically indicated) or the ear cartilage. Accidental striking of bone can bend the tip of the needle, making it difficult to extract and destroying the tip.
Penetration of the human ear cartilage can cause a chronic auricular chondritis which can be very difficult to cure. In animals (because ear AP is less commonly used than in humans) this problem is uncommon but, it is safer to avoid penetrating the cartilage. Penetration of the thoracic or abdominal cavities is normally forbidden, except in specific cases, such as aspiration of fluid or releasing gas from the viscera etc. Therefore, when needling points over the thorax and abdomen, the needles are usually inserted at 45o, to reduce the risk of accidental penetration into the cavity. Penetration of major arteries (such as the carotid) or of sensitive organs such as the eye is forbidden.
The depth of insertion also varies within and between species. In large animals the needles can be inserted up to 100 mm deep in certain points, such as those over heavy muscles, or when the needle is obliquely inserted in certain points on the head. However depths of 25-50 mm would be more usual. Certain points are merely pricked to a depth of 3 mm or so. The exact depth and direction of needle insertion is described for each point in the vet AP textbooks, such as those of Westermayer, Brunner, Klide and Kung etc.
In small animals heavy muscle groups would be needled to depths 10-50 mm, depending on the amount of muscle. Pricking of certain points and shallow needling (up to 10 mm deep) of other points is applied as in the human textbooks. (The Chinese have no texts on small animals and Western vets have to approach these species by reference to similar human conditions).
In humans and in animals, the most active points are over peripheral nerves especially main nerves, such as the trigeminal, facial, radial, median, ulnar, sciatic, spinal nerves etc. Nerves running on and in the muscles are also very important. The acupuncturist deliberately inserts the (very fine) needles directly through these nerves. Nerve stimulation (by twirling the needle clockwise and anticlockwise and pecking it up and down) causes very specific sensations (De Qi) in humans. Shooting sensations (paraesthesia), numbness and heaviness must be elicited, otherwise the needle is not exactly in the correct position. Once the needle is correctly in the nerve point and De Qi has been attained, care is taken to avoid further pecking motion with the needle to avoid physical damage to the nerve. This is more important when hypodermic needles (with sharp cutting edges) are used.
When the needle is correctly placed and stimulated, a local reflex muscle spasm grips the needle tightly, "like a fish taking the bait". The response is felt both by the patient and the acupuncturist. Animals, however cannot tell the acupuncturist what they feel. Thus, vets have to seek the objective signs of strong nerve stimulation. Animal reaction to this may differ, but shivering, local muscle twitch, vocalisation, lifting of a limb, attempts to escape, bending of the back, swishing the tail, lowering of the head and defensive reaction may occur during strong stimulation. The needle should be tightly gripped by the tissue, as in humans.
Tonification and sedation techniques: Classic methods of manipulating the needle are different if the diagnosis indicates a definite excess of Qi in a meridian (SHI diseases = excess Qi) or definite deficiency of Qi in a meridian (XU diseases = deficient Qi). These topics are discussed further in the paper on "Holistic concepts of health and disease". In SHI diseases use XI (Sedation) technique. In XU diseases use BU (Tonification) technique. In both methods, the needle is manipulated until De Qi arrives (i.e.) until sensation of tingling, numbness, heaviness and gripping sensation needle occurs.
In BU (tonification) technique the needle is thrust in heavily and rapidly. It is rotated (twirled) with small amplitude and low frequency and is lifted gently and slowly before the next rapid and heavy thrust.
In XIE (sedation) technique the needle is thrust in gently and slowly. It is then twirled strongly (large amplitude) at high frequency and is lifted forcibly and rapidly before the next gentle and slow thrust. The techniques are summarised below.
| Needle Manipulation | Tonification (BU technique) (in XU (deficiency) diseases) |
Sedation (XIE technique) (in SHI (excess) diseases) |
| Thrusting in | Heavily, rapidly | Gently, slowly |
| Twirling | Small amplitude, slowly | Large amplitude, quickly |
| Lifting up | Gently and slowly | Forcibly and quickly |
Duration of needling: Needles are usually left in position for 10-30 minutes in conditions such as rheumatism, muscle pain, arthritic lameness etc. Occasionally the vet may be too busy to wait for up to 30 minutes until the needles are withdrawn. In these cases the farmer or owner may be instructed to twirl the needles for 10 seconds every 2-4 minutes, until 10-30 minutes have elapsed and to remove the needles then. (In this case, disposable needles are used). In some cases, for instance rhinitis, conjunctivitis, shock etc, duration of needling can be very short, 10-60 seconds.
Textbooks seldom indicate whether quick needling or longer duration of needling is required. In general, for paralysis and painful conditions (especially of the muscles) long duration of needling (up to 30 minutes) is indicated, whereas for most other conditions a quick needling is sufficient. Some Chinese sources claim that if De Qi is obtained, there is no advantage to be gained from leaving the needles in situ for 10-30 minutes, except in certain chronic conditions, such as peripheral nerve damage. Thus, a short, quick, strong needling may replace the longer, more gentle method in many diseases.
Needles falling out: If (having been properly planted at the beginning) a needle falls out during treatment, it is usually left out. Relaxation of the muscles around the needle is taken to indicate sufficient stimulation for that point.
Other types of needling: The textbooks describe other types of needle - the blood needle and the fire needle.
The blood needle is a thick needle or lance used to puncture points over superficial blood vessels to allow a small amount of blood to escape. A mild haematoma around the puncture would may cause longer stimulation of the point than if a fine needle were used. However this method has few adherents at best.
The fire needle is a thick needle which is heated before use by burning a swab soaked in alcohol on the needle. It is then plunged in the tissues, taking special precautions. This method is seldom used in the West.
Moxa-needle: This method is used widely, especially in muscle rheumatism and "Cold Diseases", such as chronic infertility in cattle. ln this method, standard AP needles are inserted into the points as usual. A piece of moxa about 20 mm long and 20 mm diameter is pushed aver the handle of the needle and is ignited. The moxa burns slowly for 5-10 minutes and the heat is transferred to the needle and the tissues. This method is not painful and does not usually cause noticeable tissue damage. At the end of the session the animal may be sweating profusely near the needle site and occasionally in other areas if multiple needles are used. (It is well known that heat applied to the trunk will cause reflex sweating of the face in humans).
POINT INJECTION
This method is popular in human and vet AP. It has two advantages (a) it is much quicker to use than classic needling and electro-needling and (b) it produces stimulation which lasts for up to 1 hour or more after injection.
The points are chosen in the usual manner. Standard precautions of needle sterility and skin cleanliness are taken, and sterile solutions are used. Disposable hypodermic needles, 19-25 gauge (depending on species) are inserted to the correct depth. The needles are manipulated to elicit the needle reaction (De Qi) as described above. Then a syringe is attached and 1-10 ml of solution is injected. Small volumes are used in small animals and on Earpoints. Larger volumes are used in large animals and in muscular areas.
The choice of solution is largely a matter of personal preference: aqua pro injectione; sterile saline; weak glucose saline; very dilute Lugol's iodine; 0.25-0.5% procaine or lignocaine or xylocaine solution; "Impletol" (a procaine solution manufactured by a German pharmaceutical firm, Bayer); Sarapin; P Block; dilute Vitamin B12, B1, or C solution; very dilute sodium salicylate solution; DMSO/B12 saline; placental fluid etc.
If orthodox drugs, suitable for intramuscular injection (such as antibiotics, hormone solutions, electrolyte solutions etc) or plant extracts (as in Chinese herbal medicine) are indicated, they can be diluted, as needed, before injection into the points. Alternatively, they can be given subcutaneously over the points if they are suitable for s/c injection. Some vets claim that drugs injected at the correct AP points have clinical effects at much smaller dose rates than if they were injected in random (usual) sites. This claim, however, is not proved.
In Austria, Germany and France, homeopathic remedies are widely used in human and animal medicine. Special injectable preparations are available from the homeopathic supply houses. Vets who use the system claim that the clinical results are markedly improved if the correct homeopathic drugs are injected into the correct points for the pathological condition. Walter Greiff (Memmingen) uses this method to great effect. I have witnessed two almost incredible responses to his treatment. (1) A cow with total rumen stasis, anorexia, depression and drop in milk yield was found to be very sensitive on a point in the intercostal space between ribs 9-10, left side. This point corresponds with one of Kothbauer's "Rumen Points". One needle was used to inject the point with Spasmovetsan (homeopathic: Chelidonium, Colocynth, Nux Vomica; potency 1-2; Willmar Schwabe, Karlsruhe, Laupheim, West Germany). Within three minutes the cow began to eat and I confirmed that the rumen was now active. (2) A calf in extremis with scouring, dehydration, hypothermia, limb spasticity and opisthotonos (probably E. coli enterotoxaemia) had needles placed at Jen Chung (GV26), Ya Men (GV15), Ta Chui (GV14); Feng Chih (GB20); Hsin Shu (BL15); Chi Hai (CV06). The points (except GV26) were injected with a mixture of Dysenteral (homoeopathic: Arsen alb., Rheum., Podophyllum; c. 30 preparations Waldemar- Weimer, Baden, West Germany), Laseptal (homoeopathic: Lachesis, Echinacea ang., Pyrogenium, Chlorophyll; potency 1-14; Willmar-Schwabe, Karlsruhe, Laupheim, West Germany) and 5 ml Borgal (sulphadoxin/ Trimethoprim). An electrolyte powder was left with the farmer for administration as fluid replacement therapy. Within 20 hours the calf was remarkably improved and standing. In my opinion, the Borgal and electrolyte alone by conventional routes, would not have saved that calf. These two cases were treated by Walter Greiff, Memmingen.
Injection of scar tissue: The importance of treating tender areas along scars, (especially those which cause marked twisting or distortion of tissue on a major meridian) has been discussed elsewhere. Such scars can be quickly treated, using a dental or tuberculin syringe, set to deliver 0.1-0.2 ml/point. The solution (Impletol or procaine solution) is injected intradermally at a depth of 2-5 mm, using a very fine (c. 25 gauge), short (2.5-10 mm) needle. The scar is injected at intervals of c. 4 mm along its length, (i.e.) about 11 shots along the length of a 40 mm scar. Some experts inject straight into the centre of the scar. Others inject from the periphery of the scar, towards its centre. Still others inject only the tender (sensitive) parts of the scar.
The use of Dermojet instrument (see next section) is ideal for treating scar tissue. Scars should be injected c. 3 times at intervals of 2-7 days, as part of the general AP therapy. If scars are in accessible areas, the owner is encouraged to massage the area as strongly as the animal will allow for c. 5 minutes each day during the course of AP therapy.
If one does not wish to inject scar tissue, one may still reestablish the flow of Qi through the area by a technique known as "Bridging the Scar". In his Manual on Small animal AP, Gilchrist lists a number of different methods of using needles to do this. They are summarised in the diagrams below.
The needles are left in position for up to 20 minutes and are then removed. The scar is treated 3-6 times at intervals of 2-7 days.
Intradermal point injection: Some experts use dental, tuberculin or Dermojet syringes to inject intradermally in the location of the Ear or body AP points. This method uses dilute procaine, vitamin B12 or other solutions (as in the injection method). The small blebs which are created give physical (pressure) stimulation for a short period after injection. The number of sessions and the interval between sessions is similar to "standard" AP methods.
DERMOJET INJECTION
This is a very fast and simple method of point stimulation. It uses a high-pressure (jet) spray injection technique, without the need for needles. It is very suitable for stimulating points on the limbs of horses and cats which would not accept needling of the same points. It is also ideal for the treatment of zoo animals.
The nozzle of the instrument is held 1-2 cm from the skin and the lever is depressed. The jet of spray is shot into the point, leaving a blister on the skin. Solutions which are suitable for point injection are also suitable for the dermojet technique. This technique is especially valuable in nervous or highly-strung animals. French vets claimed highly successful results in treating colic in horses by using Dermojet treatment of points such as Tsu San Li (ST36), Pi Shu (BL20), Ta Chang Shu (BL25), Kuan Yuan Shu (BL26) and Tien Shu (ST25). Dermojet is also very valuable in the treatment of cats.
Cats tolerate needling of the face and trunk very well but they resent needling of the distal parts of the limbs. Dermojet is ideal for these parts.
IMPLANTS, INCISION, NERVE MASSAGE
In human AP sterile foreign bodies are often implanted in the tissues at AP points to elicit long-term stimulation in chronic diseases, such as chronic bronchitis and asthma.
Stainless steel AP needles and other special steel implants may be used. They are anchored externally or internally so that they can be removed easily, if required.
Absorbable material such as catgut and foetal or placental tissue is also used. In this method a curved suture needle is used to introduce the material in through the active point and out through another (such as Fei Shu (BL13) and Chueh Yin Shu (BL14) in asthma). The ends are cut off at the skin and the skin is massaged to bury the material in the tissues, where it is left until it is resorbed by the body. This method is listed as a valid method in vet AP textbooks but it does not appear to be popular. It could be used in chronic conditions of the lumbo-sacral and sacroiliac region and chronic gastric and pulmonary conditions.
Other types of implant include press needles, AP staples and gold beads. Press needles and intradermal needles are made of stainless steel, usually 30-32 gauge. Press needles may be 1 or 2 mm long. Intradermal needles may be up to 10 mm long. They are inserted into the dermis and are taped in position for 1-6 weeks, depending on the condition being treated. Press needles are used especially on Ear AP points. Intradermal needles (5-10 mm long) may be used on Ear or body points (but usually on the body points). They are used especially in human chronic diseases and chronic pain. For instance to counteract withdrawal symptoms when cigarette smokers let go of the habit, press needles may be put in Ear points Lung and Shenmen and left in for 2-4 weeks. In asthma, intradermal needles may be put in points PC06; NX04; CV17; BL13 and press needles in Earpoints Lung or Asthma. Intradermal needles are left in position for 1-2 days in summer and for longer periods in winter. Care must be taken to prevent local infection at the needle sites.
Gold beads 1 mm diameter, are useful implants in certain chronic conditions in animals. For instance in treating hip dysplasia in dogs, the late Grady Young of Thomasville, Georgia, inserted these beads under general anaesthesia. The hip area is shaved and prepared for surgery. Then, 5-8 hypodermic needles, c. 50 mm long and 12-14 gauge are inserted through the skin and tissue until the tip of each needle touches the rim of the acetabulum. A stilette is then used to deposit one gold bead near the rim of the acetabulum.
The technique is fast, safe and very effective. Only one session is needed. Alternatively, small double knots of orthopoedic suture wire, with the loose ends clipped off, can be used instead of gold beads. They are inserted in the same way as the beads. To prevent postoperative infection/ inflammation, penicillin is injected i/m and oral antibiotic is given for 5 days afterwards. Young used gold bead implants in >200 dogs, with no serious complications. Marked improvement in the clinical signs can be expected in >80% of cases in 1-3 days after the operation.
Stainless steel staples, shot into the skin by special surgical staple-guns, are used by American and Canadian vets. The technique is fast and easy to use, especially in large animals. The staples are left in position until they fall out. The method has been used on body points with claims of success in many conditions responsive to AP. They have also been used on Ear points. However, chondritis (which may be difficult to treat) may follow puncture of ear cartilage. (The use of such staples in the human ear has caused this problem already).
The advantage of the method is its speed and the claim that many conditions (such as muscular lameness, pain and other chronic conditions) respond to one treatment session because the AP stimulus continues for a long time after insertion. Some authorities would advise against the use of staples near the eyes; over bony areas; over major blood vessels and nerves and in the ears. Their use over well muscled areas would seem to be safe enough.
Incision of certain AP points, leaving a 10-25 mm wound in the skin down to the subcutaneous layer, is used in certain chronic human conditions also. An example is Yu Chi (LU10) in chronic asthma. This method does not appear to be used in vet AP in the West, although in vet AP texts it is mentioned in relation to certain points, especially in the horse and ox. The use of the wide (spear-shaped) lance needle would have identical effects.
In the West of Ireland, traditional healers (not vets !) used a method similar to incision and implantation to treat shoulder lameness and dislocation of the shoulder joint in cattle. Two twigs about 250 mm long and 10 mm diameter were cut from the willow tree. The external bark was removed to leave the moist, white inner wood. One end of each twig was sharpened with a knife. Then 4 stab-incisions were made with the knife about 70 mm above, below, cranial and caudal to the shoulder joint. One twig was inserted above and advanced downwards to emerge at the lower incision. The other twig was inserted at the cranial incision and advanced to emerge at the caudal. A piece of string was used to secure the implants in position. It was said that the lameness disappeared quickly and that dislocated joints spontaneously reset themselves. The implants were removed when the problem was corrected or within one week, whichever occurred first. I cannot vouch for the efficiency of this method but it was still used in the countryside in the 1960s.
Incision, with exposure of the nerve and blunt massage of the nerve using artery forceps is used in poliomyelitis paralysis in China. For instance incision of Chien Cheng (SI09) over the junction of the radial, median and ulnar nerves above the posterior axillary crease is used in paralysis of the upper limb or difficulty in raising the shoulder. Other points which may be treated in this way in very serious cases are Ho Ku (LI04) and Chu Chih (LI11) near branches of the radial nerve; Huan Tiao (GB30) near the superior gluteal nerve; Yang Ling Chuan (GB34) near the tibial and common peroneal nerves and ST36 near the deep peroneal nerve. This method does not appear to be used in vet AP.