Paolo Evangelista MD
General Practitioner and Acupuncturist Italy
[Translated and edited by Phil Rogers MRCVS, March 1998]
Summary and Conclusions
The article has three parts: (a) a summary of some Chinese work on the effects of AP on the immune system; (b) a discussion of the influence of TianGui on immune function, in line with the Traditional Chinese Medical (TCM) theory of acupuncture (AP); and (c) the results of AP treatment of four cases of SLE.
As proposed in the theory of TCM, TianGui seemed to activate the immune response. On applying TCM theory to four clinical cases of Systemic Lupus Erythematosus (SLE), AP was seemed to be an effective therapy for this difficult condition.
This is a clinical study of a small number of cases. Because of its limited nature, it is not scientific proof of the efficacy of AP in SLE. However, it suggests that controlled studies of AP in SLE are desirable.
Traditional Chinese Medicine (TCM) has held for over two millennia that the body has an innate system to defend against external and internal attack, and that the system can be activated by a many TCM procedures (balanced life-style, herbal medicine, AP, Taiqi, Qigong, Tuina etc).
Modern research has shown for decades that AP positively influences the immune system (see bibliographies and reviews on the Medical Acupuncture Web Page [http://users.med.auth.gr/~karanik/english/main.htm and http://users.med.auth.gr/~karanik/english/hels/helsfram.html]. A few examples of older Chinese research on this area are summarised below.
Acupuncture (AP) and Immunity
Most Chinese research on AP and immunity involved the study of changes in blood biochemistry from before to after AP. Control (untreated) groups were usually studied contemporaneously. More emphasis was placed on monitoring the biochemical and clinical responses than on the precise mechanisms by which AP induced the changes. Responses in lymphocyte subpopulations, interleukins, endorphins etc. were monitored in many studies. Moreover, most of the data were obtained from experiments on laboratory animals. Therefore the results are unlikely to be explainable by "placebo effect", or by the influence of "suggestion", which may play a more significant part in clinical trials in humans
Jilin Medical College: "The effects of the AP especially on immunity and adaptive functions of the body", also: Guangxi Medical School: "Research on the effects of the AP on the functions of the reticuloendothelial system and on the mechanisms correlated to it". These papers were discussed by the Dalian Medical School, in the "Discussion of the effect of acupuncture on the activities of the inner organs and the mechanism of its function", at the National Conference to exchange experiences related to combined TCM and Western Medicine, 1961. Experimental inflammatory granulatomatous conditions, mainly skeletal osteoarthritis, were induced in three groups of white rats: Group 1 had moxibustion on Zusanli-ST36; Group 2 had AP at ZuSanLi-ST36; Group 3 was the untreated Control. After eight days, they measured the amount of fluid that had effused from the sacs. Groups 1, 2 and 3 respectively, averaged 3.59, 3.45 and 7.03 ml. The data are cited in: "AP, a comprehensive text", p524.
Shanghai College of TCM: "Effects of AP and moxibustion on the phagocytic activity of the reticuloendothelial system in rabbits". [Shanghai Journal of Traditional Medicine, 4, 1965]. They studied the necrosis to the inside of granulomata, provoked by experimental trauma in white rats. AP reduced or prevented the inflammatory reaction in three ways: (a) by resolution of spasm in the lymphatic vessels; (b) by the reduction of capillary permeability; and (c) by activation of phagocytic cells in the reticuloendothelial system.
Zhongjing Medical School: "Evidence on the effects of AP in the immune responses of the organism". (In the Dalian Medical School.Discussion, cited above). They studied tissue regeneration in caecal ulcers, induced experimentally in cats by a caustic substance. AP at Zusanli-ST36 and JieXi-ST41 accelerated the formation collagen and fibrous tissue granulation, and enhanced the self-regeneration of damaged cells. The treated cats had faster and better repair of the damaged tissues.
Xi'an School of Hygiene, Shenxi Province: "The effect of electro-AP on the phagocytic function of leukocytes". [Research on Electro-AP, Vol 1, 1959]. They used a chemical agent to induce fever in two groups of animals. One group was pretreated with electro-AP or moxibustion at DaZhui-GV14 and ShiQiZhuiXia-M-BW-25. The latter is an Extra-Channel point, located under the spinal process of vertebra L5. Relative to the control group, the treated group developed a much lower fever of short duration, or no fever. Similarly, in animals with chronic suppurative infections, electro-AP clearly reduced body temperature relative to that in the control animals, but the effectiveness of AP fell with usage until it became negligible after repeated use.
Research Institute of TCM, Shenxi Province: "Effects of AP on the bactericidal ability of blood in rabbits". (From a Collection of Research Studies on TCM, 1964) Studies there, and at the Beijing Medical School showed that AP at Zusanli-ST36 and ZhongFeng-LV04 in healthy people, showed a 1 to 2-fold increase in the phagocytic index of the leukocytic cells to Staphylococcus aureus. A single moxibustion increased the mean index 150%. The maximum effect occurred at 24 h after treatment. The same authors studied the effects of AP on bacillary dysentery. They found that the phagocytic leukocytes began to increase from the third hour after AP and reached a maximum at the twelfth hour. Investigators at the Research Institute of Shenxi Province studied bactericidal activity of phagocytes in peripheral blood of animals before and after electro-AP. Activity was highest after 3-6 hours, but returned to normal levels by 48 hours. Simple AP gave a similar increase in bactericidal activity, but of short duration. A single session of moxibustion had a similar but less intense effect, and the effect was of short duration. In other experiments on laboratory animals, the same investigators showed that AP at Zusanli-ST36 and DaZhui-GV14 in rabbits raised the level of circulating opsonin and gave a clear increase in leukocytic phagocytosis.
"Effects of AP and electro-AP on immune responses". [Chinese Medical Journal, 12, 1958]. This 40-year-old article was important, because it stimulated active research in the Jilin Medical College and the Research Institute for TCM, Shenxi Province. The College researched the effect of AP combined with 2 shots (0.1 ml/shot) of cholera / typhoid / paratyphoid AB vaccine. The combined vaccine, given at one-seventh of the normal dose, was injected twice at Zusanli-ST36. Afterwards they needled the point three times/week. They examined the blood three times at fixed intervals. The rate at which the bacteria were lysed in the AP-vaccinated group was considerably higher than that of the control group, and the duration of the effect was longer. Relative to vaccinatedcontrols, the blood of the AP-treated animals had much higher antibacterial titres. AP prolonged the persistence after vaccination of blood antibodies. The work also showed that, relative to titres in rabbits exposed to antidiphtheritic vaccination (but which were not given AP), AP treatment markedly increased the titres and persistence of antibodies.
Zusanli-ST36, DaZhui-GV14 (if needled deeply), ShiQiZhuiXia-M-BW-25, ShenShu-BL23, GanShu-BL18, Danshu-BL19 are the more important acupoints that have shown positive immunostimulant effects, especially to activate phagocytosis in the blood and the reticuloendothelial system.
B. Immunity and TianGui
TCM has no concept of "immunity", as understood, or defined, in terms of western physiology. Instead, TCM has the concept of "defence" of the organism from external attack. This attack is seen as aggression by external forces which western medicine largely ignores. The "External Evils" of TCM include trauma, pestilence, and the classical "Six Devils" (Heat, Summer-Heat, Damp, Dryness, Cold and Wind). The latter six are said to invade the surface of the body via the acupoints, especially in the head, neck and shoulder area.
These Perverse Climates [the "Six Devils", the TCM Pathogenic Factors] gain access to the superficial Channels. If not repelled, they can gain the interior of the body, to attack the inner organs.
In TCM, the energy (vital force) that repels the invaders is called the WeiQi. The SuWen (Chapter 43) says: "WeiQi is formed from Nutritive (food) Qi. It is too mobile and elusive in nature to be constrained in the vessels, therefore it circulates in the skin and between the muscle fibres. It spreads to protect the membranes of the diaphragm and the thoracic and abdominal cavities". Chapter 33 says: "the Xie (pathogenic energy) can (only) flow where there is a deficiency (emptiness) of Qi". WeiQi is a part of YangQi, and for this also WeiYang is called the "protecting Yang".
The relationship with the Lung is obvious. SuWen (Chapter 10): "Every type of Qi reaches the Lung". Again, to specify the role of protection (Chapter 38): "the skin it is associated with the Lung, before the Xie can reach the Lung, it must first invade (and overcome) the skin".
WeiQi is formed at the level of Earth [Spleen/Stomach] and is transmuted (transformed) in the Lower Burner (the lower part of the Triple Heater, in the lower abdomen). Thus, WeiQi is under the control of Kidney Qi. Also, in order to carry out its protective role, WeiQi circulates partially in the piliferous system (skin, sweat glands and body hair follicles). To bring its protective force to all parts of the surface of the body, WeiQi also circulates in the YinQiao (Yin Motility-Heel Vessel) and YangQiao (Yang Motility-Heel Vessel). These Extraordinary Vessels, respectively, begin near the heel at acupoints of the Kidney (ZhaoHai-KI06) and Bladder (ShenMai-BL62), and pass to the eye (JingMing-BL01 and ChengQi-ST01). The TCM connection between WeiQi, the Yin and Yang Qiao (Motility Vessels) and the eyes explains the fact that, for best protection against external attack, practitioners of the martial arts must keep the eyes open during their exercises. This concept is confirmed also by the fact that the WeiQi influences sleep. The relationship between WeiQi, YinQiao and YangQiao confirms its link with Kidney Qi.
Classical TCM also teaches that YuanQi (Source Qi), which is housed in the Hara, Lower Burner and Kidney, is important in defending the body. Thus Kidney Qi, which relates to WeiQi, YuanQi and the Qiao vessels, is of prime importance in the defence of the body.
TianGui (Leung Kwokpo - Vito Marino)
The term TianGui was in use before the time of the first chapter of SuWen. A search of the 1989 text by Ellis, Wiseman & Boss ("Grasping the Wind") shows that Tian means heavenly, celestial, or divine; Gui means a Spectre, Ghost, Spirit or Apparition. However, the precise meaning of "TianGui" in the SuWen is unclear; no acupoint of that name is listed in the comprehensive work of Ellis et al 1989. There are several interpretations.
Three common western translations are "Koei Celeste" [Spirit of Heaven], by Nguyen Van Nghi; "the sexual life" by Albert Husson, and "the genital glands" by Ung Kang-sam.
Oriental interpretations include:
the Quintessence of human life: the female Blood Cycle (fertility and menstruation), and male potency and ejaculation (Xie Guan, 1921);
the original cells of life, i.e. the ova and spermatozoa (Chen Wu-jiu, 1931);
the Essential Substance to activate procreation, and to maintain menstruation and pregnancy; it originates from Kidney Essence (Ying), and is nourished from the Food Essence (Academy of TCM of Beijing, 1979);
the Ying (Yin Essence) that it is activated from Kidney Qi, that gives power and fluid for procreation (Zhao Li-hua, 1980); the innate Essence of Water (Kidney / Bladder), an essential substance to active procreation (Shi Guan-Qin, 1982);
the term, also called YuanYin, designates the start of puberty, the state of maturity of sexual power, which depends on the state of Kidney Qi (Xu Yuan-zhen, 1983).
In summary, most citations agree that TianGui is necessary for procreation, the development and maturation of the individual, and therefore depends highly on Kidney Qi.The Qi (energy, vital force) to assure procreation must contain the YuanQi (the Source, Original, Primordial Energy). This has two aspects, the YuanYin and the YuanYang. Between them, they have all the potentialities of the individual as regards the ability to defend against external aggressive forces. The body's immune defences manifest through the functions of the WeiQi. However, WeiQi originates in, and is transformed by, the YuanQi (Primordial energy), which is in the Kidney, and is involved with hereditary transmission. Thus TianGui is an inherent part of Kidney Qi and function, and, for this reason, is streectly connetted with immune defences
C. AP in Clinical Cases of SLE
The American Rheumatism Association [ J.W. Hurst, Clinical Medicine; 1991.] has classified SLE on the basis of up to 11, or more, criteria. SLE is a serious autoimmune disease, in which noxious pathogens, or toxic factors, related to common viral diseases, trigger an inappropriate response. Usually the body recognises foreign antigens, or proteins, and responds by mounting an antibody response against them. In SLE, and other autoimmune diseases, however, the external antigenic stimuli can trigger antibody formation against host-tissues and antigens, such as native DNA. This anomalous response probably has a genetic basis. In that case, it is closely related to the concept of YuanQi in TCM. Other types of autoantibodies, especially against erythrocytes and circulating platelets, and immune-complexes of DNA (-anti DNA), are produced also. The mechanism most widely accepted today as the basis for autoimmune diseases is thought to be a loss of balance of the activity of the "T-helper" and "T-suppresser" lymphocytes. Adult females are more susceptible than males to these diseases.
Most of the organs, can be damaged in SLE. Lesions are found more often in the joints (91.6%), skin (71.5%), lymphatics (58.6%), blood (56.5%), gastrointestinal tract (53.2%), muscles (48.2%), kidneys (46.1%), heart (30%) and Central Nervous System (25.5%).
Corticosteroid therapy is the most common approach to management of patients with autoimmune diseases.
TCM regards SLE as a Syndrome caused by Inner Heat, due to Xu (deficiency) of Kidney-Yin. Kidney-YinXu allows a flare-up of Perverse Fire to attack the Viscera, the skin and muscles. In the pathogenesis of SLE, an attack by External Heat can exaggerate the condition. On this basis, SLE can evolve towards a deficit of Yin, or of Yang, in several Organs and Viscera.
SLE is a rare condition. It is seldom seen in routine medical outpatient practice, especially in a primary care service.
This was a clinical SLE study, without a control group. The number of cases treated was small (4 only). All were women, aged 22-55 (mean 41) years. Subjective and laboratory signs of SLE had been present for a mean of 3 (range 1-10) years. The clinical signs included : weakness, pain in the joints, sexual problems, menstrual problems, mental depression, rush, lynphoadenopathy, oedema, fever, electocardiographic modifications.
All cases were treated with AP, auricular AP and moxibustion over a period of about 3 months. The mean number of sessions was 16, and the range was 12-22. Treatments were given 1-2 times/week.
Of the 4 cases, #1 and 2 had subjective, and laboratory confirmed, signs suggestive of Kidney involvement from a western and TCM viewpoint. The other 2 cases (#3 and 4) had no clear signs of Kidney involvement. Thus, the cases were treated as two separate groups, Group 1 as "Kidney imbalance" cases, and Group 2, "non-Kidney cases" by a different approach. From a TCM viewpoint, the main acupoints used in Group 1 cases were on the Channels of the Bladder, Kidney, Spleen and Liver with supplementary points on the Channels of the Stomach and Triple Heater. The main acupoints used in Group 2, were on the Channels of the Triple Heater, Stomach and Liver, with supplementary points on the Heart, Kidney and Bladder. The acupoints used differed from patient to patient, and from session to session, depending on the TCM-assessment at each session.
The laboratory data for blood and urine refer to paired samples taken once before AP-treatment and once after clinical AP-treatment was attained. The following parameters were chosen to monitor the response to AP treatment of SLE: blood levels of RBC (red- cells), PLT (platelets), Hb, VES (red-cell sedimentation rate, the most important sign of inflammation), PCR (C-reactive protein), complement C3, anti-DNA antibodies, gamma-globulins, urine protein, and haematuria. RBC and PLT are important autoimmune targets in SLE. Thus, they are useful parameters of the course of the therapy.
Groups 1 and 2 differed in the responses of their indices, reflecting the fact that Group 1 (renal involvement) and Group 2 (non-renal involvement) were treated differently. AP clearly helped to raise RBC in Group 1, but had less effect on RBC in Group 2
A non-significant fall in RBC in Group 2 was reflected in little change in Hb in that group
VES fell in 3 cases
and PLT (Platelets. In italian: Piastrine) increased in all cases
PCR (C-reactive protein an index of inflammation) had a clear trend to fall, except in Case 3
An increased level of complement was one of the more meaningful findings. Many works accept that a fall in complement levels, especially fraction C3, corresponds with a flare-up of SLE, and especially with renal damage. In spite of the renal disorder in Group 1, complement C3 increased from subnormal (<60 units) to normal levels (>60 units). By the time of clinical cure, complement C3 had also increased in Group 2, but to a lesser extent. This suggests that the reduced formation of immune-complexes "makes available" a part of the complement that therefore is increased
Globulin levels were high, and increased slightly in all cases. This confirms the findings of others, that AP can increase globulin levels in clinical cases
clearly show the repair of renal damage; proteinuria clearly diminished; microhaematuria, present only in Cases 1 and 2, completely disappeared. A slight loss of protein in urine remained but was much less than before the treatment, when it was about 500 mg/dl (considerably high) The most meaningful improvements in the laboratory data were the increase in complement ( see Figure 6 ), and the fall in the level of antibodies anti-DNA towards the end of the course of the treatment in all cases
It' very difficult to value the entity of subjective improvements. In the following table, the world improvement means a disappearing of the symptom, or his reduction upper 80% or q subjective opinion of patient like "very improved".
| Symptom || |
( Concerned patients % )
( Improved patients % )
| 100 || 100 |
Pain in the joints
| 100 || |
| 100 || |
|Menstrual problems || 75 || |
| 50 || |
| 25 || |
| Lymphoadenopathy || 25 || |
| Oedema || 25 || |
| Fever || 25 || |
| Electrocardiografic modifications || 25 || |
AP and SLE
In summary, AP, given according to the TCM diagnosis, was effective in SLE as regards the subjective symptomatology, and the laboratory data (> RCC, Hb and PLT). AP had a "harmonising effect" to "re-balance" the alterations of the immune system: >C3, >gammaglobulins; < ac anti DNA, < VES, < PCR.
The data suggest a mechanism whereby AP activates lymphocytic CD8 suppresser. Improvement of the symptoms suggests that AP induced an increased secretion of endogenous cortisol, to evoke a clinical effects similar to those evoked by with exogenous corticosteroid therapy.
Before the results were known, one might have expected better results of AP in the less severe, and more recent cases (Group 2). This was not so; the AP-effect, especially on the laboratory data, was better in Group 1 (the cases with Kidney disorder). Where there was renal involvement, it can be assumed that the AP-treatment polarised the renal energy more effectively than the other AP-protocol did in Group 2 (the less severe cases) This allows us to reaffirm the TCM claim as to the importance of the Kidney and the YuanQi in the genesis and the maintenance of the SLE. The resolution of the menstrual/sexual problems confirms the participation of TianGui in the physiopathology of this immune-mediated disease.
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