Acupuncture

• 1. Introduction

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  Acupuncture has been called a theatrical placebo. Thin metal needles slide into the skin, and for centuries practitioners have insisted those needles redirect an invisible life force. The global market for this treatment was worth 24.55 billion US dollars in 2017, and one 2021 estimate projected it would reach 55 billion by 2023. Yet trials and systematic reviews generally find no good evidence that it works for almost anything. How did a practice with no proven mechanism become the most popular alternative medicine in the United States? Why do scientists describe it as quackery while academic discussions still invoke its ancient concepts? And what happens inside a body when a needle goes in, if not the flow of qi? The answers run from a tomb sealed around 100 BC to a heart surgery staged for a visiting American president.

• 2. The Needle In The Skin

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  Five to twenty needles, left in place for ten to twenty minutes, while the patient lies still. That is how the Mayo Clinic describes a typical session. The needles are usually stainless steel, flexible enough to bend, treated so they will not rust or break. They range in length from 13 to 130 millimeters, with shorter ones near the face and eyes and longer ones in areas of thicker tissue. A quick insertion is recommended, since most pain is felt in the superficial layers of skin. The acupuncturist then often twists or flicks the needle to produce a dull, aching feeling the tradition calls de qi, the arrival of qi. There is also a tugging the practitioner feels, known as needle grasp, generated by a mechanical interaction between needle and skin. A 2014 paper in Nature Reviews Cancer reported something awkward for the tradition. Researchers usually find it does not matter where the needles go, how often, or even whether they are inserted at all.

• 3. Qi And Meridians

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  Qi was believed to flow from the body's primary organs to the skin, muscles, tendons, bones, and joints, through channels called meridians. In traditional Chinese medicine, disease is read as a disharmony among energies like yin, yang, and qi, and the body's interaction with its environment. To find the pattern of disharmony, practitioners examine the color and shape of the tongue, the strength of pulse points, the smell of the breath, the sound of the voice. Acupuncture points sit mainly along the meridians, though points off any meridian are called extraordinary points, and those with no fixed site are A-shi points. Scientific investigation has found no histological or physiological evidence for qi, meridians, or acupuncture points. Human tests for electrical continuity near meridians have been inconclusive. A Nature editorial described the wider tradition as fraught with pseudoscience. Many modern practitioners no longer support the existence of qi or meridians at all, even as the term has grown more prominent in American discussions of the practice.

• 4. The Placebo Problem

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  Sham acupuncture is the heart of the difficulty. Because the treatment is invasive, building a convincing placebo control is one of the hardest tasks in the field. Researchers use non-penetrating needles, or needle points unrelated to the condition, or spots not on any meridian. The trouble is what the trials show. Sham acupuncture generally produces the same effects as real acupuncture, and in some cases does better. A 2013 meta-analysis found little evidence that needle location, needle count, or the practitioner's experience changed the effect on pain compared to sham. Steven Novella, writing for Science-Based Medicine, compared the overall pattern to homeopathy, consistent with benefits coming entirely from the placebo effect. David Gorski has argued that when proponents talk about harnessing placebo effects, they essentially concede the point. As of the review period, the only conditions with any evidence of benefit were shoulder pain and fibromyalgia, and even there the evidence was low quality or not clinically significant.

• 5. When Things Go Wrong

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  Ninety-five cases of serious adverse events, including five deaths, were reported between 2000 and 2009, according to a 2011 review of systematic reviews. The most frequent serious events were pneumothorax, a collapsed lung, and infections of the chest cavity and organs. A separate 2013 review counted 295 cases of infection, with mycobacterium the pathogen in at least 96 percent of them. Likely sources included towels, hot packs, boiling tank water, and reused needles. A 2011 review of cardiac tamponade after acupuncture found 26 cases and 14 deaths, calling it a serious, usually fatal, though theoretically avoidable complication. Most events are not inherent to the practice but trace to malpractice, which may be why they rarely appear in surveys of well-trained acupuncturists. One prospective survey of 34,000 treatments found no serious events and 43 minor ones, a rate of 1.3 per 1,000. Within the UK's National Health Service, 468 safety incidents were recorded from January 2009 to December 2011, including retained needles, dizziness, and loss of consciousness. People with hemophilia, advanced liver disease, or those taking warfarin are warned away, and electroacupuncture is to be kept clear of pacemakers.

• 6. Older Than Steel

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  Gold and silver needles found in the tomb of Liu Sheng, dated to around 100 BC, are believed to be the earliest archaeological evidence of acupuncture, though it is unclear if that was their purpose. The first documented organized system of diagnosis and treatment appears in the Inner Classic of Huang Di, the Huangdi Neijing, from about the same time. Before metal, there were Bian shi, sharpened stones from the Neolithic era, though it is more likely these were used to drain abscesses than to needle points. The mummified body of Otzi the Iceman, around 5,000 years old, carried 15 groups of tattoos near points used today for abdominal and lower back problems. The Oxford Handbook of the History of Medicine calls the acupuncture interpretation of that finding speculative. The autobiography of Bian Que, from around 400 to 500 BC, references inserting needles at designated areas, including a point at the top of the skull he called the point of the hundred meetings. By the 4th century AD, most acupuncture sites still in use had been named and identified.

• 7. Charts Of The Heavens

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  In the first half of the 1st century AD, acupuncturists began teaching that the treatment's power depended on the time of day, the lunar cycle, and the season. The science of the yin-yang cycles held that curing disease required aligning heavenly and earthly forces tuned to the sun and moon. Needham and Lu described these arbitrary predictions as elaborate charts with their own special terminology. Needles then were far thicker than modern ones and often caused infection, which was blamed not on a lack of sterilization but on the wrong needle, place, or time. The Great Compendium of Acupuncture and Moxibustion, from 1601, recommended nine needles, perhaps reflecting an old belief that nine was a magic number. The Zhen Jiu Jia Yi Jing, from the mid-3rd century, is the oldest acupuncture book still in existence. By the end of the Song dynasty in 1279, the practice had lost much of its standing, drifting toward less prestigious trades. A 1757 history of Chinese medicine called acupuncture a lost art, and in 1822 the Chinese Emperor barred it from the Imperial Medical Institute as unfit for gentlemen-scholars.

• 8. Crossing The World

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  Willem ten Rhijne, a physician for the Dutch East India Company, met Japanese practitioners and coined the term acupuncture in his 1683 work De Acupunctura, the first in-depth description for European readers. France adopted it early, helped by Jesuit missionaries, and Louis Berlioz, father of the composer Hector Berlioz, is usually credited as the first European to experiment with the procedure in 1810. Korea is thought to be the first country acupuncture reached beyond China, likely arriving around 514 AD. Medical missionaries carried traditional Chinese medicine to Japan starting around 219 AD. The modern revival came when Mao Zedong took power in 1949 and consolidated many practices under the name traditional Chinese medicine. In 1971, New York Times reporter James Reston wrote about his own acupuncture experience in China, and the following year Richard Nixon's delegation watched a patient apparently undergoing major surgery while awake on acupuncture alone. It later emerged those patients had high pain tolerance, heavy indoctrination, and morphine slipped in through an intravenous drip. In 2010, UNESCO inscribed acupuncture and moxibustion of traditional Chinese medicine on its Intangible Cultural Heritage List, the same tradition that more than 14 million Americans had tried by the early 2010s.