Network Vessel Pricking: The Forgotten Key to Chronic Problems

In A Practical Dicitionary of Chinese Medicine, Wiseman and Feng define network vessel pricking (ci luo, a.k.a. luo ci) as one of the nine traditional needling methods. It is described as bloodletting by pricking small visible subcutaneous vessels with either a three-edged or skin needle (i.e., a plum blossom or seven star needle).[1] This treatment method is often combined with cupping. In that case, the cupping strengthens or increases the effects of this therapy. In Chinese, this is referred to as ci luo ba guan liao fa (network vessel pricking and cupping treatment method). According to the authors of the Jian Ming Zhong Yi Ci Dian (A Simple, Clear Dictionary of Chinese Medicine), this combined method is commonly used for acute and chronic obstructive and accumulation conditions, injuries, neurodermatitis, neurasthenia, and stomach and intestinal nervous disorders.[2] When I was an intern with Miriam Lee of Palo Alto, CA, I saw Ms. Lee use this technique on many patients with often startling effect in chronic, protracted cases. Because of fear of blood-borne pathogens, such as the AIDS virus and hepatitis, many Western acupuncturists are reluctant to use this technique in contemporary clinical practice. However, if one understands Chinese medical theory, it is an extremely important technique when faced with chronic, enduring conditions. Also, when done with appropriate safety procedures, bleeding or pricking therapy is not dangerous to the health of either the practitioner or other patients. It is, therefore, both my belief and experience that eliminating this technique from modern practice severely handicaps us as health care providers and limits our therapeutic outcomes.

It is a statement of fact in Chinese medicine that, “New diseases are in the channels; enduring diseases enter the network vessels.” This means that all chronic, enduring diseases eventually result in the blood stasis which then obstructs and hinders the free flow of the network vessels. For instance, based on Zhu Dan-xi’s theory of the six depressions (of which blood stasis is one), any evil qi lodged in the body will eventually result in blood stasis. This is because any evil qi, whether it is an externally invading evil, internally engendered phlegm, food, or stagnant qi, hinders and obstructs the free flow of the qi and the blood. It is also axiomatic in Chinese medicine that:

The qi moves the blood. If the qi moves, the blood moves. If the qi stops the blood stops.

That means that anything leading to qi stagnation will, over time, also lead to blood stasis. Likewise, since the blood and fluids flow together, enduring water dampness may also lead to blood stasis.

However, it is not just such evil repletions that may lead to blood stasis. Qi, blood, yin, or yang vacuities may all result in blood stasis. If qi becomes vacuous and weak, it has no strength to stir or propel the blood. If blood becomes vacuous and insufficient, it will fail to nourish the vessels which will, in turn, fail to promote the movement of the blood. Furthermore, blood and yin vacuities are nothing other than a continuum. If blood vacuity becomes yin insufficiency, the tissues and vessels will not be moistened and nourished. If yin vacuity leads to vacuity heat, the heat may dry the blood, impeding its movement through the vessels. In addition, if yin blood fails to nourish and moisten the liver, the liver will fail in its duty of coursing and discharging the qi. And finally, if yang becomes vacuous, there is insufficient warmth to warm the channels and vessels. Instead, the contents of the channels and vessels will contract and constrict and their contents (i.e., blood) congeal and become stagnant. Since, yang is nothing other than a certain quantity of qi, yang vacuity will also fail to supply sufficient qi to move and transform blood and fluids.

This is why the famous Chinese geriatric specialist, Yan De-xin, says that, “...through both literary research and clinical experience, I have come to the conclusion that static blood is the chief mechanism of senility.”[3] Yan explains this further by saying:

With advancing years, the human body has long been subject to the influences of the seven emotions, six environmental excesses, external injuries, falls and contusions, and various other diseases. Thus there necessarily occurs loss of harmony of qi and blood. Coursing and free flow suffer obstruction, and static blood stops internally. The production and existence of static blood then further inhibits the flow and movement of qi and blood, even and balance lose their regulation, and thus the viscera and bowels are not able to obtain their nourishment. Phlegm turbidity and various other evils are then engendered internally, and various diseases come in their wake. Then there will appear viscera and bowel vacuity and debility with deficiency and consumption of the essence, qi, and spirit. Because the functions of engenderment and transformation of the qi is decreased, the viscera and bowels cannot perform their physiological functions normally. This then aggravates the loss of balance of the qi and blood and the static blood hidden internally, thus forming a vicious circle and finally leading to senility and death.[4]

This is the meaning when the ancients said, “If the blood vessels are open and freely flowing, diseases cannot obtain engenderment.”

The network vessels in network vessel pricking refer to visible superficial veins, sometimes called spider nevi, and especially if these veins are unusually distended, darkened, tortuous, and/or engorged. Such engorged, distended superficial veins are themselves a sign of blood stasis. Within Chinese medicine, visible veins are also called blue-green “sinews”, and Yan De-xin lists prominent greenish-blue sinews as a sign of blood stasis.[5] This is supported by the saying in the Gu Jin Yi Jian (The Mirror of Ancient & Modern Medicine), “As regards the pattern of exposure of greenish-blue sinews, its source is qi counterflow and blood not moving.” Likewise, Wang Qing-ren, the famous Qing dynasty blood stasis theoretician, in his Yi Lin Gai Cuo (Correction of Errors in the Forest of Medicine) says:

Prominent greenish blue sinews are not sinews. What appears on [i.e., from under] the skin is the blood vessels. Greenish blue vessels show that there is stasis internally.

Prominent blood vessels or spider nevi are due to local blood stasis resulting in engorgement and varicosity. However, they may also indicate systemic or distant stasis and obstruction. When one pricks such prominent blue-green vessels in order to bleed, the first blood discharged is usually darker than normal, sometimes even appearing as if almost black. As the Yi Xue Zheng Zhuan (The Correct Transmission of the Study of Medicine) says, “When blood is quickened, it is red; when it congeals, it is black.” Thus, the discharge of darker than normal blood from pricked superficial vessels is yet a further indication that there is pathological blood stasis. In that case, the bleeding is encouraged to continue until the blood turns fresh red in color, thus showing that the static blood has been removed. To encourage continued bleeding and discharge of as much static blood as possible, it is common practice to follow network vessel pricking with cupping, since the effect produced by the cupping pulls the blood outward.

Therefore, in the treatment of chronic, enduring diseases, it is important to identify the presence of blood stasis and to assess its role in the patient’s overall disease mechanisms. If there are signs and symptoms of blood stasis and if acupuncture is one’s main treatment modality, then network vessel pricking can be a useful modality and should always be seriously considered. If the disease is localized, it is important to search for engorged superficial veins in the affected area. Examples of this are visible perianal varicosities in the case of external hemorrhoids, varicose veins in the leg associated with chronic leg pain, or visibly engorged veins in the region of the temple in the case of chronic headaches.

However, in many chronic diseases, no such locally engorged veins can be found in the affected area. In that case, one should search for prominent, distended, or engorged veins in other parts of the body. For instance, in chronic urogenital diseases, there will often be engorged veins around and below the medial malleolus, while in chronic low back pain, the engorged veins may appear in and around the popliteal fossa near Wei Zhong (Bl 40). When abnormally prominent or engorged veins can be found in patients with chronic disease, and especially if there are other signs and symptoms of blood stasis, it is my experience that network vessel pricking can mean the difference between success and failure.

For example, in my own clinical practice, I always actively search for abnormal veins or spider nevi both in cases of enduring disease and, because of Yan De-xin’s theories, in patients over 40 years of age. In either case, it is not unusual that I find them. And, when such veins are present, network vessel pricking is an axiomatic part of the treatment for me in the majority of such cases.

When using network vessel pricking, one important treatment consideration has to do with the strength of the patient’s righteous qi. Similarly to any type of draining therapy, the stronger the righteous qi, the more bleeding the patient can handle and vice versa. For example, in a person whose righteous qi is vacuous and weak, I advise starting with two or three “pricks” on each leg (if both sides need to be treated) and mild warming moxa or pole moxa over each prick to ensure that the treatment does not aggravate the root vacuity and therefore exhaust the patient.

Recently, a number of articles have been published on network vessel pricking in the treatment of chronic disease. In the April 2000 issue of Si Chuan Zhong Yi (Sichuan Chinese Medicine), Lian Qiu-hua and Li Shu-jun describe the treatment of 56 cases of cervical dizziness with network vessel pricking and cupping.[6] Of these 56 patients, 24 were male and 32 were female. The youngest was 22 and the oldest was 68, with an average age of 42 years. The shortest course of disease was two months, and the longest was two years. All the patients had varying degrees of cervical hyperplasia with narrowing of the cervical foramena negatively affecting cervical arterial flow. This then produced insufficient blood flow to basal ganglia which, in turn, resulted in the symptoms of headache, dizziness, blurred vision, hearing disturbances, heart palpitations, nausea, and/or vomiting, the symptoms of Meniere’s disease.

The treatment method consisted of bleeding Bai Hui (GV 20), Feng Fu (GV 16), Ya Men (GV 15), and Da Zhui (GV 14) as the ruling points. These were bleed with either a three-edged or plum blossom needle. Hand pressure was applied to press out 2ml of blood. Afterwards, cups may have been applied for 10-20 minutes. Supplemental points consisted of Feng Chi (GB 20), An Mian (M-HN- ), Yi Ming ( ), and Tai Yang (M-HN-9) if there was accompanying headache, head distention, insomnia, and profuse dreams. It is assumed that these points were needled with fine needles except for Tai Yang which may have been bled. If there was upper back and shoulder soreness and encumbrance, aching and pain, Feng Chi (GB 20), Jian Jing ( ), and a shi points on the upper back and neck were needled. If there were heart palpitations, nausea, and vomiting, Nei Guan (Per 6), Wei Shu (Bl 21), and Zu San Li (St 36) were needled. One treatment was given every other or every third day. Five treatments equaled one course of treatment, and 3-5 days were skipped between courses.

Using this protocol, 40 cases (71.4%) were judged cured. This meant that their clinical symptoms disappeared or basically disappeared, their cervical x-rays returned to normal, the diameters of their cervical foramena markedly improved, and there was no recurrence in one year or more. Fourteen cases (25%) markedly improved. This meant their clinical symptoms markedly improved and their cervical vertebrae were basically normal, but the diameter of their cervical foramena had not markedly improved or there was recurrence within one year. Two cases (3.6%) got no effect. Thus the total amelioration rate was 96.4%.

In their discussion of this protocol, Liang and Li state that their patient’s patterns included liver-kidney debility and vacuity, taxation detriment or external injury of the neck region, of contraction of wind, cold, damp evils, all of which had resulted in the channels and vessels of the neck region losing their free flow. The vessels and network vessels had become static and obstructed. Thus the brain marrow was not able to obtain sufficient blood and fluids to nourish it. Bleeding the main points on the governing vessel discharged the locally static blood. This diffused and freed the flow of the channels and vessels. Because yang qi flowing through the area was full and sufficient and the channels and vessels were smoothly and freely flowing, the brain and its network vessels was enriched and nourished by blood and fluids, the brain marrow was full and sufficient, and thus the dizziness was automatically leveled or cured.

In the same issue of Si Chuan Zhong Yi, Dong Hong-kui and Fan Ye describe the treatment of 46 cases of chronic coughing and panting with network vessel pricking and cupping.[7] Of these 46 patients, 2 were male and 24 were female. The youngest was three years and the oldest was 75 years of age. The shortest course of disease was three months, and the longest was 38 years. X-rays showed that all the patients had chronic bronchitis and/or bronchial asthma. Five case had accompanying lung qi swelling, while another three cases had bronchiole dilation.

The main points were Dan Zhong (CV 17), Da Zhui (GV 14), Ding Chuan ( ), Fei Shu (Bl 13), Ge Shu (Bl 17), Xin Shu (Bl 15), Pi Shu (Bl 20), and Shen Shu (Bl 23). Dan Zhong, Ding Chuan, and Da Zhui were bled and then cupped. Bleeding was accomplished by a three-edged needle in patients with replete patterns and/or robust conditions. A plum blossom needle was used in children, those with vacuity patterns, and/or bodily weakness. Cupping after bleeding was applied for 5-10 minutes to withdraw 3-5ml of blood from those who were adolescents or older, replete, or strong. It is assumed that the other points were selected on the basis of each patient’s pattern discrimination and treated with fine needles. Five treatments equaled one course, and seven days were skipped between courses. If a second course of treatment was necessary, it was not deemed necessary to withdraw 3-5ml of blood each time.

Using this protocol, 26 patients (56.5%) were judged cured based on the criteria promulgated at the 1997 National Asthma Symposium. This meant that the clinical symptoms had all disappeared and no treatment was required if there were recurrent attacks. Nine cases (19.6%) experienced a marked effect. This meant that, in comparision from before to after treatment, the severity of attacks was less, their number was less, their duration was shorter, and the number of colds and flus was markedly decreased. Eight cases (17.4%) got some effect, which meant that, after treatment, the severity of attacks were less, their number was less, and that their duration was shorter. No effect meant there was no change from before to after treatment. Three cases (6.5%) were judged to had experienced no effect.

According to the Chinese authors of this study, chronic coughing and panting are characterized by a combination of hot and cold, vacuity and repletion, in which case, the root is vacuity and the branch is repletion. In addition, there is always qi depression and blood stasis due to the function of the lungs vis à vis the movement of the qi and the interrelationships between the qi and blood and lungs and heart. Network vessel pricking and cupping not only discharge heat and eliminate evils, they also regulate the blood and rectify the qi, quicken the blood and transform stasis. Thus, within this protocol, network vessel pricking followed by cupping primarily addresses the branch repletions, while fine needling the other points regulates visceral function and treats the underlying vacuity. When both network vessel pricking and fine needling are combined, root and branch, repletion and vacuity are treated simultaneously.

In the March 2000 issue of Si Chuan Zhong Yi, Gao Hong et al. describe the treatment of rheumatoid arthritis with a combination of grain sized moxibustion, network vessel pricking, and cupping.[8] All these patients were treated as out-patients. Twelve were male and 18 were female. The youngest was 19 and the oldest was 58, with an average age of 43 years. The shortest disease duration was two years, the longest was 21 years, and the average was seven years. All these patients had been previously treated with Western and Chinese medicines but without marked effect. In addition, all the patients met the diagnostic criteria promulgated by the 1987 American Rheumatology Symposium for rheumatoid arthritis.

Systemic treatment consisted of using three grain-sized cones of direct moxibustion at Da Zhui (Gv 14), Ming Men (Gv 4), Gan Shu (Bl 18), Shen Shu (Bl 23), and Zu San Li (St 36). In the case of damp heat obstructing the network vessels, local treatment consisted of using a skin needle to prick the network vessels surrounding any swollen, painful joints in order to cause slight bleeding. If pain and swelling were severe, this was followed by cupping, ostensibly to increase the amount of bleeding. In the case of cold damp obstructing the network vessels, a skin needle was used to create localized erythema over any affected joints. If swelling and pain were severe, three cones of grain-sized moxa were burnt over the site of pain. If there was mixed cold and heat pattern, the same treatment for damp heat was used. Each patient received one treatment every other day, with 10 treatments equaling one course of treatment. Two days were skipped between such courses, and patients were assessed after three courses.

Clinical control was defined as disappearance of joint swelling and pain, basic return to normal in function, return to normal of sedimentation rate and rheumatoid factor, and cessation of any internally administered medicines. Marked effect meant that joint swelling and pain basically disappeared, function markedly improved, sedimentation rates and rheumatoid factors improved, but, after stopping the above treatment, the patient did have to continue using their original medications. Some effect meant that joint swelling and pain decreased and function improved. No effect meant that there was no improvement in joint swelling and pain, function, sedimentation rate, or rheumatoid factor. Based on these criteria, six cases (20%) were judged cured, 12 cases (40%) got a marked effect, seven cases (23.33%) got some effect, and five cases (16.67%) got no effect. Thus the total amelioration rate was 83.33%.

According to the authors of this study, rheumatoid arthritis is categorized as an impediment condition in Chinese medicine. Its disease mechanisms are a righteous insufficiency of the liver, spleen, and kidneys with wind, cold, damp, and/or heat evils taking advantage of this vacuity to enter and assail the muscles and skin, channels and network vessels, joints, and sinews and bones. This results in loss of free flow of the channels and network vessels with the blood vessels becoming impeded and obstructed. Therefore, network vessel pricking courses and frees the flow of the channels and network vessels, regulates and harmonizes the qi and blood, and quickens the blood and transforms stasis. Grain-sized direct moxibustion supports the righteous and secures the root, dispels wind and eliminates dampness, scatters cold and frees the flow of the network vessels, quickens the blood and transforms stasis.[9]

Because we now know about blood-borne pathogens, such as AIDS and hepatitis, in a way the ancient founders of our art did not, there are certain precautions we must take today when doing network vessel pricking in modern clinical practice. These best practices have to do with reducing the risk of contagion from such blood-borne pathogens and essentially revolve around providing a barrier between the practitioner’s skin (and any of their employees) and the patient’s blood. This is done with latex or rubber gloves that fit the practitioner’s hands as snugly as possible. For full details on the proper use of gloves and other best practices relating to blood-borne pathogens, readers are referred to David Kailin’s book, Acupuncture Risk Management, published by CMS Press and carried by Redwing Book Company or to David’s class offered by Blue Poppy Seminars, Making It In the Mainstream: Achieving Success with Acupuncture in Mainstream Medical Settings.

While some practitioners may be squeamish about bleeding and others may fear contagion from blood-borne pathogens, I believe it is important for modern acupuncturists to understand that the art of zhen jiu, acupuncture and moxibustion, does not just mean fine-needling. The fine needle is only one of nine needles, and fine-needling is only one of a number of traditional needling techniques. Likewise, moxibustion is half the traditional practice of this art, or at least that is what its Chinese name seems to imply. If the ancients had thought that all diseases could be adequately treated by fine needles alone, why did they repeatedly discuss the use of the other eight needles and moxibustion in every basic primer?

Therefore, I believe that it is extremely important for contemporary clinicians to learn and routinely use these other acupuncture-moxibustion techniques when the situation requires. In my experience, they are what often make the difference between success and failure, especially in difficult-to-treat, chronic, and enduring diseases. If we forget or choose not to use these other modalities within our art when the situation demands, we may not get the results we and, more importantly, our patients are expecting.

[1] Wiseman, Nigel & Feng Ye, A Practical Dictionary of Chinese Medicine, Paradigm Publications, Brookline, MA, 1998, p. 409

[2] Chinese National Chinese Medicine Research Institute & Guangzhou College of Chinese Medicine, Jian Ming Zhong Yi Ci Dian (A Simple, Clear Dictionary of Chinese Medicine), People’s Healthy & Hygiene Press, Beijing, 1986, p. 509

[3] Yan De-xin, Aging & Blood Stasis, trans. by Tang Guo-shun & Bob Flaws, Blue Poppy Press, Boulder, CO, 1995, p. xi

[6] Lian Qiu-hua & Li Shu-jun, “The Treatment of 56 Cases of Cervical Dizziness with Network Vessel Princking & Cupping,” Si Chuan Zhong Yi (Sichuan Chinese Medicine), #4, 2000, p. 53

[7] Dong Hong-kui & Fan Ye, “The Treatment of 46 Cases of Chronic Coughing & Panting with Network Vessel Pricking & Cupping,” Si Chuan Zhong Yi (Sichuan Chinese Medicine), #4, 2000, p. 55

[8] Gao Hong et al., “The Treatment of Rheumatoid Arthritis with Grain[-sized] Moxibustion Plus Network Vessel Pricking & Cupping,” Si Chuan Zhong Yi (Sichuan Chinese Medicine), #3, 2000, p. 53-54

[9] Grain-sized direct moxibustion is another traditional modality of acupuncture-moxibustion that is much underused in modern clinical practice. Like network vessel pricking, it is especially useful in the treatment of chronic, enduring diseases, in which case, it often makes the difference between clinical success or failure.