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THE ANATOMY OF ACUPUNCTURE*

WILLIAM H. L. DORNETTE, M.D., J.D.
Director of Education and Research Division of Anesthesiology The Cleveland Clinic Cleveland, Ohio

UTNQUESTIONABLY, acupuncture is a real therapeutic modality. It is being employed by competent, conscientious American physicians on increasing numbers of patients. In certain applications the results border on the miraculous. Beyond using anatomic landmarks to assist in the location of acupuncture points, the reader may question the need for concerning himself with any other anatomic aspect. I believe that the anatomy of acupuncture should be understood thoroughly. This belief appplies to those who use acupuncture regularly, to physicians who are interested but have not yet begun to use the technique, and to anyone who plans to promote the role of acupuncture in Western medicine. The reasons are several. A knowledge of superficial anatomy enables the practicing acupuncturist to locate the points more carefully and quickly. By being aware of the anatomy of underlying structures, an acupuncturist can avoid injuring nerves and major blood vessels or introducing the needle into a body cavity. Finally, a knowledge of the anatomic pathways involved in the transmission of acupuncture messages will help the practitioner promote acupuncture as a scientific discipline. Whether he is addressing himself to students, members of organized medicine, legislators, licensing boards, or the general public, the acupuncturist who possesses and espouses a knowledge of applied anatomy places the technique on a truly scientific basis in terms of Western medicine. We should realize that one of the great disadvantages of acupuncture -an impediment to its acceptance among scientists in the United States -is that it is often associated with the philosophy, mysticism, and magic of the East. Clearly, too, the study of anatomy as applied to acupuncture will reveal that neural and vascular structures are truly involved.
*Presented as part of a Symposium on Acupuncture held by the Section on Medicine of the New York Academy of Medicine October 22, 1974.

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THEORIES OF ACUPUNCTURE Closely related to the anatomy of acupuncture are the modalities by which the effect is produced. According to traditional Chinese concepts, acupuncture works by a balancing of the Yin and the Yang, with a consequent restoration to normal of the energy flows and balance within the body.1 2 No Western scientist and few modern Orientals still espouse this belief. A second theory relates to conditioning; evidence emanating from China suggests that candidates for acupuncture analgesia are conditioned for the procedure.3 This explanation is closely akin to the hypnotic theory.4 Advocates of this thesis believe that since the phenomenon of the acupuncture effect can be produced by deep hypnosis, acupuncture is really a form of hypnosis. Neither conditioning nor hypnosis explain all the effects of acupuncture, however. Nor do they explain the failure to produce these effects if the acupuncture loci are first numbed with a regional anesthetic and the success of acupuncture in young children and animals. Another proposal relates to a postulated "third vascular system." It is suggested that a heretofore undiscovered or undescribed vascular system exists in the body, and that stimulation of acupuncture loci induces changes in this system. Other investigators suggest the possibility that the reticular formation is involved in the acupuncture effect. Considering the numerous ramifications and interconnections of the reticular formation throughout the entire nervous system, one certainly can conclude that the reticular formation may well play a role in acupuncture. Evidence suggests that it is involved in the production of both anesthesia' and hypnosis.6 Nevertheless, although the reticular formation may be involved in acupuncture, it is probably not the principal structure implicated. This formation is distributed throughout the central nervous system, but it has not been identified as extending into the peripheral nervous system. Thus, it cannot be suggested that it is involved in the transmission of impulses over the spinal nerves for the receipt of acupuncture impulses or the production of the acupuncture effect. Finally, we come to the gate theory of XVall and Melzack.7 First propounded in I965, this theory makes a great deal of sense in light of a number of factors. Unquestionably, acupuncture is of neural origin. Many of the meridians follow peripheral nerves. M~any of the acupuncture points overlie concentration of somatic receptors, both
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Location

Type
Free endings Ruffini's endings Merkel's endings Hair-follicle endings Meissner's corpuscle Pacinian corpuscle Muscle spindle Organ of Golgi

Modality
Pain, heat, cold Temperature, touch Touich, temperature 'Iouch, pain Touch, pain Pressure Tension, contraction Tension

Nerve fiber
C B B B B A A A

innervation

Dermal Dermal Dermal

Deriual Dermal Dermal Subdermnal Subdermal

dermal and musculoskeletal. The spinal-cord pathways over which the impulses travel both centrally and peripherally are identified readily. The acupuncture effects-soreness, swelling, warmth, and numbnessare also neurogenic, both the somatic and autonomic nervous systems being involved. Finally, local anesthesia of an acupuncture point prevents the acupuncture effects.
ACUPUNCTURE RECEPTORS Traditional Chinese sources have identified 365 acupuncture points on the body. Some of these points correspond to most of the original trigger points of Travell and Rinzler.8 The acupuncture point per se, however, does not appear to be a special anatomic structure. Underlying many of the acupuncture points are concentrations of conventional sensory receptors. The accompanying table lists those located in both the dermis and the deeper structures. These structures run the entire gamut of sensory receptors, and include Ruffini's, Merkel's, and hair-follicle-endings, Meissner's and Pacinian corpuscles, muscle spindles, and organs of Golgi. The table also lists the function of these receptors and the type of innvervation.

ACuPUNc-rURE PATHWAYS According to the Wall-Melzack theory, if one or more of these endings is stimulated by an acupuncture needle the impulses are transmitted over the A and B fibers to the substantia gelatinosa located within the dorsal horn of the spinal cord. When the cells of the subVol. 51, No. 8, September 1975

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stantia gelatinosa are stimulated they produce an inhibitory postsynaptic potential at the synapse between the pain-carrying C fibers of the dorsal nerve roots of the spinal nerves and the spinothalamic tracts which transmit these impulses cephalad to the thalamus. If the acupuncture impulses are strong enough, the inhibitory postsynaptic potential will prevent an excitatory postsynaptic potential from being created in the neurons of the spinothalamic tract. The perception of pain thus will be reduced or obliterated. Unquestionably, the substantia gelatinosa also sends impulses to the immediately adjacent intermediolateral cell column of the thoracic spinal cord. This column supplies sympathetic efferent impulses to the spinal nerves which supply autonomic fibers to organs and tissues innervated by those nerves. This single gate theory explains the mediation of the acupuncture effects over single or adjacent spinal nerve-reflex arcs. It does not explain, however, the remote acupuncture effects that are known to occur. Melzac has postulated the existence of a second gate located centrally in the thalamus.9' 10 Melzack proposes that the acupuncture messages reach this gate over the pathways by which impulses from the majority of the somatic sensory receptors listed in the table ascend to the higher levels of the central nervous system. The main pathway is believed to be the fasciculus gracilis and fasciculus cuneatus. These tracts send impulses rostrally to their nuclei in the medulla. Within these nuclei synapses occur with the medial lemniscus, a fiber tract which carries the ascending impulses across to the opposite side of the brain stem and into the posterolateral ventral nucleus of the thalamus.
CENTRAL CONNECTIONS The posterolateral ventral nucleus of the thalamus is also the site of the synapse between the spinothalamic and thalamocortical tracts; it is the second gate of the Wall-Melzack theory. Here, it is postulated, the impulses picked up at the acupuncture receptors create an inhibitory postsynaptic potential in the thalamocortical tract, preventing transmission of pain impulses from the spinothalamic tract to the cerebral cortex. It is also postulated that the reticular formation, perhaps under the influence of the cerebral cortex, also blocks transmission at the synapse in the dorsal horn of the spinal cord (between the C fibers of the
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dorsal spinal nerve root and the spinothalamic tract) as well as at the synapses in the posterolateral ventral nucleus of the thalamus. Corticothalamic (descending) tracts also may be involved in the inhibition of transmission.
MEDIATION OF OTHER ACUPUNCTURE EFFECTS The discussion up to this point has delineated a mechanism for the inhibition of transmission of pain. Many applications of acupuncture are concerned with the treatment of pain or the production of analgesia for operative procedures. But what of the other acupuncture effects? The Teh Ch'i effect-swelling, soreness, warmth, and numbness-undoubtedly relates to more than an interruption in the perception of pain. At least some of these effects clearly are mediated primarily by sympathetic efferent pathways. The intermediolateral cell column, located midway between the dorsal and ventral horns of the gray matter in the thoracic and upper lumbar regions of the spinal cord, transmits impulses to these efferent pathways. The column receives fibers from the autonomic centers in the hypothalamus and other structures in the midbrain. Tracts descending in this column have synapses with the preganglionic sympathetic fibers which leave the spinal cord in the ventral spinal nerve roots and enter the paraverteberal sympathetic ganglia via myelinated fibers (white rami communicates). There a second synapse occurs and postganglionic nonmyelinated fibers (grey rami) reenter the spinal nerves to traverse the tissues of the body and reach the effector cells and organs. It is well known that somatic sensory impulses can produce autonomic effects reflexly. The proximity of the substantia gelatinosa to the intermediolateral cell column is an anatomical fact. Thus, one can postulate that the A and B somatic sensory nerves, as they carry the acupuncture messages, send fibers not only to the substantia gelatinosa and fasciculi gracilis and cuneatus but also to the intermediolateral cell column. There the impulses impinge upon sympathetic nerve fibers. The latter connection would explain the mechanism whereby the sympathetic efferent fibers are stimulated or inhibited, producing the autonomic aspects of the acupuncture effect. That is, these sympathetic fibers and, ultimately, glands and blood vessels, may be either stimulated (excitatory postsynaptic potential) or inhibited (inhibitory post-

synaptic potential).
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POSTULATED CONNECTIONS FOR ACUPUNCTURE MESSAGES

PAIN PATHWAY
bare nerve endings
C

ACUPUNCTURE MESSAGE
Ruffini, Merkel
hair follicle endings, Meissner

corpuscle

Pacinian corpuscle, muscle spindle, Organ of Golgi

6ibe&AL

6beta

6ibeas

synapse in

dorsal horn of spinal horn

N's

/ \substantia gelatinosa
and cuneatuz / 7 nucleus gracilis and cuneatus /

6accicutua gaacZit's

intermedio teral cell column of thoracic spinal cord

Apinothatamic ttacta
reticular formation

autonomic

e66ekent
dibe&ta
autonomic effector
structures

medtat temntscuz
\/

posterolateral nucleus of thalamus

t hatamoco'ttcat t'Lacwts \ /I vt corticothalamic tracts

cerebral cortex

| inhibition -_- excitation

The accompanying figure shows diagrammatically the various structures involved in the reception of acupuncture impulses over the spinal nerves and the production of sensory and autonomic acupuncture effects. One of the acupuncture effects which is beconiing better appreciated is the relief of post-traumatic muscle spasm, e.g., following acute cervical strain, the so-called whiplash injury. Relief probably is effected by the inhibition of transmission in the substantia gelatinosa of afferent sensory impulses from the injured area. It is doubtful that the muscles are relaxed directly by the inhibition of ventral horn cells. Muscular weakness does not accompany the acupuncture effect, merely relief of muscular spasm. Finally, one must consider the anatomic pathways involved in the production of the acupuncture effect in areas innervated by cranial nerves or by stimulating loci innervated by these nerves. The sensory innervation of the face is mainly by the fifth cranial (trigeminal)
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nerve. The sensory nucleus of this nerve is large and extends from a point high in the pons caudally to the cervical region of the spinal cord, where it is contiguous with the substantia gelatinosa of the dorsal horn of the cord at about the level of the second cervical vertebra. Thus, one can postulate a connection between fibers of this nucleus and the first gate of the Wall-Melzack theory. A detailed discussion of the anatomy of the neuronal connections of auriculotherapy is beyond the scope of this paper. It is germane, however, to mention the principal nerves involved. Arnold's nerve, a branch of the tenth cranial (vagus) nerve, supplies the skin of the external auditory canal and immediately adjacent portions of the pinna. The cell bodies of the sensory fibers of Arnold's nerve are located in the jugular ganglion. From there the nerve fibers pass to the brain stem and enter the nucleus of the tractus solatarius in the medulla. From this nucleus ascending sensory impulses traverse the medial lemniscus to synapses in the posterolateral ventral nucleus of the thalamus, the location of Melzack's second gate.

CONCLUSION The involvement in acupuncture of the anatomic structures described herein is based on the validity of the XWall-M\lelzac theory or on some similar theory. Detecting and tracing neuronal activity in vivo is difficult. Therefore, it would be difficult to prove or disprove this theory and state with certainty the exact anatomic pathways that carry the acupuncture messages. The evidence seems irrefutable that some components of the nervous system do produce the acupuncture effect and available evidence strongly supports the role suggested for the various structures mentioned in this paper. It is to be hoped that current researches directed toward the neurophysiology of acupuncture wvii provide better understanding. The researchers may even prove Melzack's thesis, or postulate a better one. Acupuncture deserves better understanding among the scientific community. Perhaps studies now underwvay wvill help to develop that understanding.
ACKNOWLEDGMIENT The author acknowledges with appreciation the invaluable help given by Marta C. Steinberg, M.D., neuropathologist of the Cleveland Clinic, in the preparation of this paper.
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1. 2.
3.

4.

5.

REFERENCES 69:519-29, 1953. McGarey, W. A.: A cupuncture and Body 6. West, L. J.: Psychophysiology of hypEnergies. Phoenix, Gabriel, 1974, pp. 6 nosis. J.A.M.A. 172:672-75, 1960. et seq. 7. Melzack, R. and Wall, P. D.: Pain Perlow, B. W.: Acupuncture: Its theory mechanisms: A new theory. Science 150: and use in general practice. Proc. Roy. 971-79, 1965. Soc. Med. 66:426-28, 1973. 8. Travell, J. and Rinzler, S. H.: The myChaves, J. F. and Barber, T. X.: Unofascial genesis of pain. Postgrad. Med. published data. J. 11:425-34, 1952. Kroger, W. S.: Acupuncture analgesia: 9. Melzack, R.: The Puzzle of Pain. New Its explanation by conditioning theory, York, Basic Books, 1973, pp. 153-72. autogenic training and hypnosis. Amer. 10. Man, P. L. and Chen, G. H.: AcupuncJ. Psychiat. 130:855-60, 1973. ture "anesthesia"-A new theory and French, J. D., Verzeano, M., and clinical study. Curr. Ther. Res. 14:390Magoun, H. W.: A neural basis for the 94, 1972 anesthetic state. Arch. Neurol. Psychol.,

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