The Search for International Consensus on Auricular Acupuncture Nomenclature

Introduction

A series of conferences sponsored by the World Health Organization (WHO) established a standardized nomenclature for body acupuncture in 1989. ¹ Such an international consensus for auricular acupuncture nomenclature has remained more elusive. Organizers for an international symposium on auriculotherapy that will meet in Singapore in 2017 have undertaken the task of finalizing a standardized auricular nomenclature that can be used internationally. ^* The need for a common language to facilitate the exchange of acupuncture information at a global level was long recognized in China because of its vast expanse and many dialects. The WHO Regional Office for the Western Pacific held a series of meetings from 1981 to 1987^2,3 that included representatives from multiple Asian nations and Australia. All of these countries have a large number of acupuncturists, and the practice of acupuncture has long been established.

The WHO Working Group proposed a standard nomenclature for body acupuncture points; this nomenclature consisted of an alphanumeric code, the Pinyin Chinese phonetic name, and the Han character for each acupuncture point. Given that international exchanges in medical science are mainly conducted in the English language, the Working Group recommended that the alphanumeric code should be derived from the English translation of the Chinese names for acupuncture meridians. Subsequently, 361 classical acupuncture points were adopted that included the 14 main meridians. ⁴ A two-letter—rather than a one letter—abbreviation was adopted for each meridian, which included common abbreviations such as ST for the Stomach meridian, LI for the Large Intestine meridian, and LU for the Lung meridian. In order to not be confused with other abbreviations, LR was chosen for the Liver meridian. Some acupuncturists use a single letter to abbreviate certain Zang Fu organs; the WHO Working Group decided to use PC for Pericardium, SP for Spleen, KI for Kidney, and HT for Heart in order to establish consistency with the two-letter abbreviation system. ⁵

The WHO sponsored a 1990 meeting in Lyon, France, ⁶ that included representatives from Asia, Australia, Europe, and North America charged with the task of developing an international standardization for auricular acupuncture. Unfortunately, the representatives at this international conference were not able to arrive at a collective consensus regarding differences in the ear acupuncture maps used by acupuncturists from China, Japan, and Korea, in contrast to the somatotopic system developed by European doctors from France, Germany, Italy, and Norway. While there was agreement for the names and locations of 43 ear acupuncture points, another 43 ear points were labeled non–agreed upon points.

The auricular zone chart developed in the 1980s at the University of California–Los Angeles ⁷ was used as a framework to identify each anatomical region of the auricle, such as the helix, antihelix, and triangular fossa. To conform to the nomenclature for body acupuncture points, a two-letter alphanumeric code—rather than a single letter—was used for distinguishing different auricular structures, such as HX for the helix, AH for the antihelix, and TF for triangular fossa. Each subdivision of an auricular part was designated by a letter and a number, such as A1, in contrast to using AH8. However, auricular locations of certain anatomical organs, such as the knee, lumbosacral spine, and kidney, remained a divisive issue.

The basic contention revolved around the view of Asian doctors that the large number of acupuncture patients treated in China and other Asian countries provided a strong basis for adopting the Chinese ear acupuncture maps, whereas the European doctors cited the importance of the pioneering discoveries of Paul Nogier, MD, the French physician acknowledged as the “Father of Auriculotherapy.” Subsequent conferences were held in Beijing, China, in 1995 and 2010, and additional, international symposiums were held in Lyon, France, in 1994 and 2012. The disparity between the Chinese and European schools of auriculotherapy still reflected the differences in opinion that had been noted in 1990.

It was agreed at the 1990 WHO meeting to call the locations of ear acupuncture points by their auricular anatomical names, rather than using the names for the body organs represented by particular anatomical areas of the ear. The auricular zone system that was originally suggested by Dr. Nogier ⁸ divided the auricle into a rectangular, grid pattern of rows and columns. Capitol letters from “A” to “O” identified the horizontal axis, whereas the lower-case letters “a” to “z” indicated the vertical axis. While such a grid pattern is simple to use on a flat two-dimensional piece of paper, it is not as easily adaptable to the three-dimensional depths of the auricle. The curving contours of the external ear do not readily conform to the configuration of rectangular rows and columns and the Nogier auricular system did not provide a method for indicating hidden or posterior regions of the auricle.

A linear grid system that used only numbers rather than letters was subsequently proposed by Winfried Wojak, MD ⁹ of Germany to designate different areas of the auricle. The first number of this German system identified different auricular territories on the anterior side of the external ear with the numbers 1 to 7, while the numbers 8, 9, and 0 were used for specific regions of the back of the auricle. Wojak noted that external ears may differ in the physical dimensions of the described zones but stated that these 10 zones could be found on everyone's external ears. For the remaining numbers in the auricular zones, Wojak utilizes the “X” and “Y” coordinates known from classical mathematics. The second of three numbers represented the “X-axis,” whereas the third of three numbers represented the “Y-axis.” The proposed advantage of using only numbers was that they could be read all over the world just like postal codes. Each auricular zone had nine vertical lines and nine or six horizontal lines, achieved by dividing the maximal extension distance of that anatomical area.

Discussion

Matching the curving spirals of auricular anatomy, a different format for distinguishing specific regions of the external ear was suggested by Marco Romoli, MD, of Italy.^10,11 His auricular classification system was based upon the circular radiation of specific lines that were like the spokes of a bicycle wheel. Each radiation line began at Dr. Nogier's Point 0 at the center of the ear. The 40 radiation lines that spread from this central source were referred to by Dr. Romoli as Auricular Sectograms. A different array of circular radiations from a central region of the ear was proposed by the French physician David Alimi, MD. ¹² The most widely accepted auricular nomenclature system that incorporated the recommendations of the 1990 WHO conference was developed by Liqun Zhou, MD, PhD.^13,14 Now widely accepted in China, this system created by Zhou incorporated earlier Chinese ear acupuncture charts with an alpha-numeric code of two letters and a number for different anatomical regions.

I described these different auricular zone systems previously in Medical Acupuncture. ¹⁵ Specific auricular landmarks were identified for distinguishing the division between one auricular zone and another. The proportional representation of the location of these auricular landmarks can be used to compare the auricle in someone with large ears as opposed to someone with small ears. The locations of auricular points within these auricular zones were denoted by the letter “C” for Chinese ear charts and by the letter “E” for charts developed by European practitioners of auricular medicine.

Part of the problem that led to international differences regarding the somatotopic localization of certain body organs is related to the history of auriculotherapy. The most commonly used text for establishing the foundation for all of acupuncture is the Huang Di Nei Jing (The Yellow Emperor's Classic of Internal Medicine). ¹⁶ Multiple articles that have described the history of auricular acupuncture^17–20 refer to the Huang Di Nei Jing to document the meridian connections between the auricle and the meridian channels. The posterior side of the external ear was said to connect to the five Zang-Fu organs for the Kidney, Spleen, Liver, Lung, and Heart and the anterior surface of the auricle to all six Yang meridians. It was not until 1958, after Chinese doctors learned of the “inverted fetus” map first developed by Dr. Nogier, that the Nanking Army Ear Acupuncture Team conducted a study of >2000 patients. Using little models of the ear, these practitioners actually conducted a replication study of the Nogier proposal by determining which areas of the auricle were tender when there was pathology in the corresponding organ and determining that the treatment of that point led to alleviation of the disorder. ¹⁸

Although an auricular diagnosis study conducted by Andersson et al. ²¹ did not support the specificity of auricular musculoskeletal points previously documented by me and my colleagues, ²² Andersson et al.'s double-blinded evaluation of auricular maps for musculoskeletal pain ²¹ only examined the tenderness of corresponding auricular points but did not include any measurements of electrodermal skin resistance at active ear points. In contrast, Volf and Ferdman ²³ and Usichenko et al. ²⁴ reported lower electrical skin resistance in specific auricular points that did correspond to diseased organs or body areas undergoing surgery.

Conclusions

The standard nomenclature system that has been adopted in China has the most widespread agreement. “Chinese Standard Ear-Acupoints” have served as the basis for the location of ear points in recent systematic reviews of auriculotherapy research.^25,26 It is intended that concurrence between practitioners of Asia and Europe regarding a standard auricular nomenclature can be established further at the 2017 Singapore Symposium. ^*