895

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 physi-
cians 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 thor-
oughly. 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 acupunc-
ture in Western medicine. The reasons are several.
A knowledge of superficial anatomy enables the practicing acu-
puncturist 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.

Vol. 51, No. 8, September 1975

 8 96
896W. W. H. L. DORNETTE
H. L.

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 bal-
ance within the body.1 2 No Western scientist and few modern Ori-
entals still espouse this belief. A second theory relates to conditioning;
evidence emanating from China suggests that candidates for acupunc-
ture 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, how-
ever. 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 pro-
posal 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 forma-
tion is involved in the acupuncture effect. Considering the numerous
ramifications and interconnections of the reticular formation through-
out 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 in-
volved in acupuncture, it is probably not the principal structure im-
plicated. 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 acu-
puncture 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 ori-
gin. Many of the meridians follow peripheral nerves. M~any of the
acupuncture points overlie concentration of somatic receptors, both
Bull. N. Y. Acad. Med.
 THE ANATOMY OF ACUPUNCTURE 8 97

END ORGANS OF SENSATION

Nerve fiber
Location Type Modality innervation

Dermal Free endings Pain, heat, cold C

Dermal Ruffini's endings Temperature, touch B
Dermal Merkel's endings Touich, temperature B
Deriual Hair-follicle endings 'Iouch, pain B
Dermal Meissner's corpuscle Touch, pain B
Dermal Pacinian corpuscle Pressure A
Subdermnal Muscle spindle Tension, contraction A
Subdermal Organ of Golgi Tension A

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 numbness-
are also neurogenic, both the somatic and autonomic nervous systems
being involved. Finally, local anesthesia of an acupuncture point pre-
vents 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. Under-
lying many of the acupuncture points are concentrations of conven-
tional 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 trans-
mitted over the A and B fibers to the substantia gelatinosa located
within the dorsal horn of the spinal cord. When the cells of the sub-
Vol. 51, No. 8, September 1975
 8 98
89
W. H. L. DORNETTE

stantia gelatinosa are stimulated they produce an inhibitory postsynap-

tic 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 acu-
puncture impulses are strong enough, the inhibitory postsynaptic po-
tential 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 inhibi-
tory postsynaptic potential in the thalamocortical tract, preventing
transmission of pain impulses from the spinothalamic tract to the cere-
bral 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

Bull. N. Y. Acad. Med.

 THE ANATOMY OF ACUPUNCTURE 89 9
dorsal spinal nerve root and the spinothalamic tract) as well as at the
synapses in the posterolateral ventral nucleus of the thalamus. Cortico-
thalamic (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 anal-
gesia for operative procedures. But what of the other acupuncture
effects? The Teh Ch'i effect-swelling, soreness, warmth, and numb-
ness-undoubtedly relates to more than an interruption in the percep-
tion of pain. At least some of these effects clearly are mediated pri-
marily 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 re-
ceives fibers from the autonomic centers in the hypothalamus and other
structures in the midbrain. Tracts descending in this column have sy-
napses with the preganglionic sympathetic fibers which leave the spinal
cord in the ventral spinal nerve roots and enter the paraverteberal sym-
pathetic 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 auto-
nomic 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 sym-
pathetic efferent fibers are stimulated or inhibited, producing the au-
tonomic aspects of the acupuncture effect. That is, these sympathetic
fibers and, ultimately, glands and blood vessels, may be either stimu-
lated (excitatory postsynaptic potential) or inhibited (inhibitory post-
synaptic potential).

Vol. 51, No. 8, September 1975

 9 00 W. H. L. DORNETTE

POSTULATED CONNECTIONS FOR ACUPUNCTURE

MESSAGES
PAIN PATHWAY ACUPUNCTURE MESSAGE
bare Ruffini, Merkel Pacinian
nerve hair follicle corpuscle, muscle
endings endings, Meissner spindle, Organ of
corpuscle Golgi
C 6ibe&AL B 6beta A 6ibeas
synapse in
dorsal horn of
spinal horn
N's
intermedio teral
/ \substantia
\
gelatinosa cell column of
thoracic spinal
6accicutua gaacZit's cord
and cuneatuz
Apinothatamic /
ttacta 7 autonomic
nucleus gracilis e66ekent
and cuneatus dibe&ta
reticular /
formation
medtat temntscuz autonomic
\/ effector
structures
posterolateral nucleus of thalamus

t hatamoco'ttcat t'Lacwts cortico-

\ /I thalamic
vt 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 acupunc-
ture effects.
One of the acupuncture effects which is beconiing better appre-
ciated is the relief of post-traumatic muscle spasm, e.g., following acute
cervical strain, the so-called whiplash injury. Relief probably is effect-
ed 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 cra-
nial nerves or by stimulating loci innervated by these nerves. The sen-
sory innervation of the face is mainly by the fifth cranial (trigeminal)

Bull. N. Y. Acad. Med.

 THE ANATOMY OF ACUPUNCTURE go I

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 loca-
tion 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 dif-
ficult. 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 com-
ponents 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 resear-
ches 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.
Vol. 51, No. 8, September 1975
 902 W. H. L. DORNETTE

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