Journal of Chinese Medicine Number 84 June 2007

Modern Auricular Therapy: A Brief History

Modern Auricular Therapy: A Brief History and the Discovery of the Vascular Autonomic Signal
Abstract
This article looks at the recent history of ear acupuncture, the discovery of the somatic representation of the homunculus in the ear and an acupuncture microsystem. It discusses the differences between the Chinese and European systems of auriculotherapy and encourages the integration of significant European discoveries, particularly the pulse quality known as the vascular autonomic signal (VAS) into traditional Chinese medicine (TCM) practice. By: Jim Chalmers Keywords: Auricular, ear acupuncture, auriculotherapy, vascular autonomic signal, VAS, pulse, master points, Nogier.

uriculotherapy describes an acupuncture micro-system that includes the detection and reexive treatment of physical, emotional and neurological dysfunction via specic zones on the ear at which these dysfunctions are reected. Modern auricular therapy is not, by its very denition, either traditional or Chinese. The use of the ear as a micro-system for the treatment of bodily disharmony became a primary treatment methodology only in the 1950s after the discoveries of Paul Nogier, a French physician. The anatomical representations and acupuncture points identied in the ear are therefore, for the most part, recent discoveries and cannot be considered traditional, but because of the inclusive nature of Chinese medicine and its ability to absorb ideas from outside, auricular therapy (or auriculotherapy) has been embraced by traditional Chinese medicine (TCM). Most TCM courses worldwide now include an auricular therapy module. Historical references to the use of auricular treatments date from 450 BCE, when Hippocrates, who studied medicine in Egypt, wrote about the Egyptian method of treating impotence by bleeding points on the posterior (mastoid) surface of the ear. The Huang Di Nei Jing (The Yellow Emperors Classic of Internal Medicine), dating from 250 BCE to 200 CE, refers to the meeting of all the yang channels at the ear and to non-channel ear points for the treatment of specic conditions. Throughout early Chinese medical literature, specic points on the ear are identied for bleeding, needling or cauterising. However, no systematised anatomical correspondence between the ear and the body was recognised. Ashi points in the ear were treated similarly to those on the rest of the body. European writers, including Zactus Lusitanus (1637), Valsalva (1717) and Colla (1810) all describe the use of the ear to treat painful conditions such as lumbago and leg pain (sciatica) as well as

functional disorders such as impotence, weak vision and infertility. The most signicant development in the history of auricular therapy was the discovery of anatomical correspondences associated with the image of the inverted foetus in the ear made by Dr Paul Nogier in the early mid-twentieth century. In 1951 he observed a scar located precisely on the upper portion of the ear on several of his patients; they all reported the scar was from a cauterisation performed by Madame Barrin, a lay healer from Marseilles, to successfully treat their sciatic pain. Nogier claims that for the subsequent two or three years he searched in vain for other associated locations that might work in the same fashion as this sciatic point. The turning point came with the realisation that a sciatic problem was related to the fourth and fth lumbar vertebrae. By 1956 he had mapped the spine and the somatic representation of the inverted foetus in the ear. In 1957, the discovery of the anatomical correspondences of the inverted foetus in the ear and Nogiers anatomical charts were published in Deutsche Zeitschrift fr Akupunctur, a German acupuncture journal. This publication, which also appeared in Japan, eventually reached China and was received with great interest. At that time Mao Zedong, having apparently adopted a new attitude towards traditional medicine, was publicly encouraging its development. At his prompting new colleges of Chinese medicine had been established with the aim of revising and modernising TCM; reviving that which was functional and scientic and removing aspects that were considered feudal and superstitious. By 1958, intense research and large clinical trials of ear acupuncture, involving thousands of patients, had been initiated by the Chinese medicine community, particularly the Nanjing Army Ear Acupuncture Research Team.

Fig 1: The inverted foetus

Modern Auricular Therapy: A Brief History

Journal of Chinese Medicine Number 84 June 2007

Fig 2: Nogiers phases

These trials validated Nogiers discoveries and led to the eventual widespread acceptance of his approach. Auricular therapy charts were published in China shortly thereafter. With some exceptions, the Chinese charts were very similar to Nogiers originals but they additionally attributed functional names and/or locations to some of the points e.g. Shenmen, Dental Anaesthesia, Stop Wheezing (Dingchuan). Charts and small plastic ear models were produced and used by doctors, students and the barefoot doctors to guide them in simple treatments to improve the health of the rural population. Paul Nogiers research brought to light the profound relationship between the auricle and the rest of the body. In recognition of that discovery, the Chinese published an article (Popular Medicine, TaChung I hsueh, 1959) acknowledging Paul Nogiers discoveries and called him the Father of Auricular Acupuncture. By 1966 Nogier had clearly systematised the musculoskeletal system, identifying the anatomy of the spine in ne detail and the projections of the viscera to the concha and the brain to the lobe of the ear. He was investigating the possibility of masterpoints which exert an inuence on zones of the ear and the predominant organs reected within those zones e.g Point Zero on the organs of the digestive system reected in the concha. At this time in the history of the development of auricular therapy, Nogier and the Chinese were using palpation of tender points on the ear to locate sites for treatment although there was some investigation into the use of electrical detection of these points. The year 1968 saw a signicant development in the functional use of auriculotherapy. Nogier became aware that a perceptible change in the arterial pulse - a few slightly larger pulsations - occurred when the skin on the ear was lightly touched with a probe or stimulated with a particular light source. Initially Nogier called this pulse the Rexe Auriculocardiaque (RAC), assuming that it involved the

ear and the heart, but later realised that this was a generalised autonomic nervous system response and subsequently changed the name to the vascular autonomic signal (VAS). This is a vasculo-cutaneous reex that can be felt on the arterial wall. The sine wave-like radial arterial pulse is a consequence of cardiac output and its rebound as the blood surges against the arterioles and capillaries. This creates the stationary waves of the pulse in a similar manner to those that occur when a stone is dropped into a pond. As the ripples expand to the perimeter and then rebound, stationary waves are formed at the point at which the outgoing and incoming ripples meet. The VAS results from a vasomotor change in the tone of the vascular wall, a reex mediated by the sympathetic nervous system. It is the bodys initial response to changes in its immediate environment; a response that happens at a very elementary biophysical level. In general, stimulus of the skin, be it by light or laser, by heat, touch or even by proximity of a substance, will provoke a VAS (a few slightly enlarged pulsations) as the nervous system responds and adjusts. It is a sympathetic autonomic vasculo-cutaneous reex, a cellular awareness of, and response to, its immediate environment. The VAS response can now be documented by bidirectional Doppler ultrasonography. Gentle contact of painful points on the auricle evokes several VAS pulses. This observation was the point at which the Chinese and European systems of auriculotherapy started to diverge. The Europeans began to use the VAS to determine the precise location of a point and whether or not this point was pathologic, something determined by an increased number of pulsations. Palpation was no longer necessary. The Chinese system retained the evoked pain (palpation for tender points) technique, observation of dermal changes in the ear and reliance on clinically researched maps of the ear, later including the evolving techniques of electrical detection of auricular points. Auricular therapists using the Chinese system look to grid charts and diagrams to identify point locations or simply palpate for tender points to needle. The former allows inaccuracy in location whilst the latter changes the dynamic of the point by applying pressure. Other auricular therapists use sensitive differential skin resistance point detectors to identify active points. This latter approach appears to be the most objective of the alternative techniques but runs the risk of turning the treatment into a research process, eliminating the dynamic interrelation between the practitioner and patient that occurs while the practitioner listens to the pulse. By observing the VAS, practitioners are able to identify whether a point should be treated and its precise location.

Journal of Chinese Medicine Number 84 June 2007

Modern Auricular Therapy: A Brief History

The vascular autonomic signal can be felt at any arterial pulse on the body but it is often easier for the practitioner to use the pulse on the left radial artery. Unlike the TCM method of pulse-taking in which three ngers are placed at right angles to the patients wrist, the VAS is detected using the sensitive pulp of the thumb placed over the radial artery, at the descending portion of the apophysis of the styloid process of the radius. The axis of the thumb and radius should be aligned. With the patient lying supine and the practitioner at the head of the treatment table, the practitioner uses the left hand to palpate the pulse of the patients left hand. This frees the practitioners right hand to probe and needle the right ear, the dominant ear in right-handed persons. For TCM practitioners with already highly-developed tactile and pulse-taking skills, this pulse is easily learned. The evoked pain process (palpating points or regions of the ear and needling the painful ones) identies reex points. This remains a very effective basic protocol for symptomatic relief of painful conditions. To treat a painful knee, Fig 3: Correct VAS position palpate the region of the ear that is representative of the knee and needle the tender point. This is a form of ahshi point where there is pain, needle. Nogier, however, identied other types of point, which he called neurohumoural points. These represent organs and functions and are not tender to palpation, but when dysfunctional they exhibit a change in electrical skin resistance, usually lower, and have an inuence on various functions in the body. It is worth noting that not every dysfunctional body system reects in the ear as a painful point. These non-painful, yet highly diagnostic, points can be readily identied with the VAS. Electrical detection, used both by the Europeans and the Chinese, is an alternative to using the VAS to locate points. To do this effectively requires relatively expensive and sophisticated equipment to investigate skin resistance differentials within a very narrowly dened area. Areas of low relative resistance, as well as high relative resistance, may be identied as active points. This equipment may impart a sense of independent assessment of a points pathological state but it runs the risk of changing the dynamic of the point by introducing further (electrical) energy to the ear. It invites the question of whether acupuncture is an art or science. Inevitably it is both, but it is the practitioners tactile skill in identifying and interpreting the vascular autonomic signal that enables the art.

By using the anatomical charts in conjunction with the VAS, practitioners can search in the described zone for the auricular wrist point for wrist pain, shoulder point for shoulder pain and so on; the exact location is identied by several positive VAS pulses. Needling these points will, in most cases, promptly alleviate pain. However, the location of a point is by no means xed; it may be determined by the pathology of the condition. In 1981 Nogier published De lauriculothrapie lauriculomdecine which included further observations regarding the VAS and locations of points. He stressed that active points may be found in different locations on the ear depending on the degree of chronicity of the complaint. Acute vertebral symptoms manifest on the rim of the antihelix while chronic conditions may present in the pretragal region and degenerative conditions on the root of the helix. This concept could account for the different localisations of points on the Chinese charts. In some instances it is easy to recognise that the Chinese location of organs represents the reection of the same organ in a different phase, either chronic or degenerative. For example, the Chinese charts locate the heart in the inferior concha between the lungs while the European location is on the antihelix in the anatomically appropriate region of the thorax and mesodermal tissues. When it is realised that the Chinese location of the heart is identied as Nogiers Phase 2 (degenerative) heart, the functional localisation can be understood, given that this is commonly the site for treatment of degenerative cardiac conditions. Although the Chinese and European systems use a different cartography of the auricle and a different approach to therapy, both can be effective if appropriate points are chosen and correctly located. The European system looks to anatomy and pathophysiology whilst the Chinese system pragmatically addresses function. Nogiers phase theory was criticised by many of his medical associates from (mostly) France and Germany who felt that this, along with his attention to energetic medicine and his interest in chakras and esoteric approaches, was unscientic. Schisms occurred. The German school, the Academy of Auricular Medicine, was founded by Nogiers colleague Frank Bahr, while Nogiers close associate Ren Bourdiol, whose texts and illustrations represent the most anatomically correct description of the enervation and anatomy of the man in the ear, went his own way in 1981. By 1987 Nogier had identied master points that have inuence over individual zones of the ear and the organs reected within those zones. These included Point Zero, Point R, Master Sensorial, Point E, Thalamus, Master Oscillation, and Summit (Apex) Point; these supplemented earlier functional points identied by Chinese researchers such as Shenmen, Endocrine, Master Cerebral. In 1990, the World Health Organization held a meeting in Lyon, France to attempt standardisation of Auricular Therapy nomenclature.

Modern Auricular Therapy: A Brief History

Journal of Chinese Medicine Number 84 June 2007

determination, not only of the points location on the ear but whether or not it should be needled. A point that does not respond with a positive VAS is benign; needling may even be counter-productive. This cannot be reproduced as effectively if the practitioner does not refer to the VAS and simply uses visual scaling references from charts to identify points.

Conclusion and summary

History records the utilisation of auricular treatments in ancient Egypt, China and in early European medicine. It was only after recent European discoveries that it was developed into a sophisticated diagnostic and therapeutic methodology. Although auricular therapy is already included in most TCM acupuncture courses, little attention has been paid to signicant developments that have occurred in the European approach since the rst charts were published by Nogier. Modern auricular therapy and its methodology, particularly the utilisation of the VAS and the recognition of the location of points according to the phases, can be harmoniously absorbed into the TCM practitioners routine. Easily learnt, the additional skills can make the difference between an effective or an ineffective outcome. While not limiting oneself to a particular dogma, incorporating both Eastern and Western developments in auriculotherapy is worthwhile and constructive - beneting both practitioner and patient.
Jim Chalmers, a former Director of the Australian Acupuncture and Chinese Medicine Association and Chair of their Standing Committee for Continuing Professional Education, graduated from Acupuncture College in Australia in 1988, and in 1991 undertook postgraduate internship training in Nanning, China. He introduced CPE training courses on Nogiers auriculotherapy approach to Australian practitioners in 1996 and currently conducts auricular therapy training workshops in Australia with his colleague and cotrainer Stephen Janz. Contact: Jim@auriculotherapy.info

Fig 4: Zones rather than points

More recently, in Europe, the concept of an auricular point being in a precise location as identied on a chart has been abandoned in favour of a zone. This change resulted from consideration of the variations in the anatomical structure of individual ears and the realisation that a point may present in a slightly different location due to its pathology. The need then to identify the precise location within a zone by a veriable technique - electrical, palpation or the VAS - becomes paramount. Treament of the ear, whether considered from the Chinese or European points of view, may be performed without recourse to the ve phases, qi and blood, hot and cold, excess and deciency, yin and yang, internal and external. However, there are points on the ear that can calm the spirit, that by removing pain can re-establish the harmonious ow of qi and blood and that can unblock stagnation and facilitate tonication. The organ points can be used to treat both the physical function of the organ and/or its psycho-spiritual-emotional aspects. All these functions can be facilitated within the terrain of the auricle. Being able to recognise a response (the VAS) from the patients own autonomic nervous system to a diagnostic stimulus allows for precise

References
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Systems of Ear Acupuncture Churchill Livingstone 2003 Strittmatter, B. Identifying and Treating Blockages to Healing. Thieme 2004 Fruehauf Heiner. Science Politics and the making of TCM, Chinese Medicine in Crisis The Journal of Chinese Medicine. October 1999 No.61 George T. Lewith, Acupuncture: Its Place in Western Medical Science. Thorsons Publishing Group