3. 2. 1.1 Needling with filiform needles
3.2. 1.1.1 Insertion
The needle usually should be held with the right hand known as the puncturing hand. The left hand, known as the pressing hand, pushes firmly against the area close to the acupoint or presses the needle body from both sides to assist the right hand. The needle should be inserted coor-dinately with the help of both hands. The following are some of the commonly used methods of insertion in clinical treatment:
Nailing insertion of the needle (Inserting the needle aided by the pressure of the finger of the pressing hand) : Press beside the acupoint with the nail of the thumb or the index finger of the left hand, hold the needle with the right hand and keep the needle tip closely against the nail, and then insert the needle into the acupoint (Fig. 108). This method is suitable for puncturing with short needles.
Holding insertion of the needle (Inserting the needle with the help of the puncturing and pressing hands)£ºHold the needle tip with sterilized dry cotton balls held by the thumb and the index finger of the left hand, keep the nee-dle tip on the skin surface of the acupoint. Then insert the needle into the skin with both hands (Fig. 109). This method is suitable for puncturing with long needles.
Relaxed insertion of the needle (Inserting the needle with the fingers stretching the skin): Stretch the skin where the acupoint is located with the thumb and the in-dex finger of the left hand, hold the needle with the right hand and then insert it into the area between the two fin-gers (Fig. 110). This method is suitable for puncturing the acupoints located on the regions with loose skin.
Lifting and pinching insertion of the needle (Inser-ting the needle by pinching the skin) : Pinch the skin up a-round the acupoint with the thumb and index finger of the left hand, insert the needle into the acupoint with the right hand (Fig. 111). This method is suitable for punctu-ring the acupoints where the muscles are thin.
The above methods can make the insertion smooth and alleviate pain. These methods are selected according to the anatomical features of the needled area and the depth of needle insertion in clinical treatment.
3.2. 1.1.2 Angle and depth of insertion
Different angles and depth in needling the same acu-point may puncture different tissues, produce varied nee-dling sensation and therapeutic effects. To different acu-points, appropriate angle and depth are selected according to the location of the acupoints. Therefore, angle and depth are especially important in the process of needle in-sertion. Correct angle and depth are helpful in producing desired therapeutic effects and preventing needling acci-dents.
Angle of insertion: The angle formed by the needle and the skin surface is usually classified into three kinds (see Fig. 112) :
Perpendicular insertion: Perpendicular insertion, in which the needle is inserted perpendicularly, means that there is an angle of 90¡ã formed between the needle and the skin surface. This method is applicable to most acupoints on the body.
Oblique insertion: The needle is inserted obliquely to form an angle of approximately 45¡ã between the needle and the skin surface. This method is used for needling the acupoints close to the important viscera or tissues, or the acupoints which are not suitable for perpendicular and deep insertion.
Horizontal insertion: The needle is inserted trans-versely to form an angle of about 15¡ãbetween the needle and the skin surface, also known as transverse insertion. This method is applicable to the areas where the muscle is thin.
Depth of needle insertion£ºIn clinical treatment, the depth of insertion mostly depends upon the location of the acupoints, the constitution of the patient and the path-ological conditions. For example, shallow insertion is ap-plicable to the needling of such areas as the head, face, chest and abdominal region as well as such patients as in-fants, people with delicate constitution, or the aged. Deep insertion is applicable to the needling of the acu-points located on the limbs, buttocks and abdominal region as well as the young and the middle-aged with strong con-stitution and heavy body.
3.2. 1.1.3 Manipulations and arrival of qi
Manipulations: Needle manipulation may induce needling effect, for which several methods can be used. The arrival of qi refers to the sensation of aching, numb-ness, heaviness or distension around the acupoint after the needle is inserted. At the same time the acupuncturist may feel heaviness and tension beneath the needle.
The arrival of qi is directly related to the therapeutic effect. Generally speaking, obvious and quick arrival of qi suggests good therapeutic effects, while unclear and slow arrival of qi shows poor therapeutic effects. Many factors may influence the arrival of qi, such as the constitution of the patient, pathological conditions, the acupoints select-ed, and the needling method used. Clinically the patient with abundant yang-qi may experience quick needling sen-sation, while the patient with abundant yin-qi may feel slow arrival of qi. Accurate location of acupoints on thick muscles is easy to induce needling sensation while inaccu-rate location of acupoints on these areas is difficult to in-duce the arrival of qi. Proper and skillful manipulation promotes the arrival of qi. Therefore, correct manipula-tions are prerequisite to better therapeutic effects.
Manipulations can be divided into basic manipulation techniques and supplementary ones:
Basic manipulation techniques:
Twirling-rotating: Mter the needle is inserted to the desired depth, the needle is twirled and rotated backward and forward with the thumb, index and middle fingers of the right hand.
Lifting-thrusting: Mter the needle is inserted to a certain depth, the needle is lifted and thrusted perpendi-cularly and continuously.
Twirling-rotating and lifting-thrusting are the two basic manipulations and can be used individually or in com-bination. The amplitude of twirling and the scope of lift-ing-thrusting as well as the frequency and duration of ma-nipulation depend upon the patient's constitution, patho-logical conditions and the acupeints to be needled.
The supplementary manipulation techniques: Un-der certain conditions, the supplementary manipulations are employed after insertion. The following are the com-monly used techniques:
Pressing. Slightly rub, knead and press the skin a-long the route of the meridian or around the acupoint to promote the flow of qi and blood. This method is used to promote the arrival of qi.
Scraping. Scrap the needle handle with the nail of the thumb, or the index or middle finger downward and upward, or vice versa. This method can be used to strengthen the needling sensation.
Plucking.. Pluck the needle handle lightly to make the needle body shake slightly. It is often used to strengthen the stimulation in order to obtain qi.
Shaking: Shaking the needle handle slightly with the hand can strengthen the needling sensation. If the needle is inserted obliquely or horizontally, shaking the needle handle can make the needling sensation transmit toward a certain direction.
3.2. 1.1.4 Retention and withdrawal of the needle
Retention: Retention means to hold the needle in the acupoint after the use of needling manipulations. For patients with a slow and weak needling sensation, reten-tion of the needle may strengthen needling effect and induce needling sensation. Whether the needles should be retained or not and the duration of retention depend on the patients' conditions. For common diseases, the needles can be withdrawn or be retained for 10 - 20 minutes after the application of needling manipulations. But for some special diseases, the time for retaining the needle may be appropriately prolonged. At the same time, manipulations may be performed at intervals in order to improve the therapeutic effects.
Withdrawal: For the withdrawal of the needle, press the skin around the acupoint slightly with sterilized dry cotton balls held by the left hand, rotate the needle handle gently and lift it slowly to the subcutaneous level with the right hand, then withdraw it quickly and press the punctured acupoint with sterilized dry cotton balls to prevent bleeding. After the treatment, the acupuncturist should count the number of the needles to make sure that all the needles are withdrawn.
3. 2. 1.1.5 Reinforcing and reducing methods
Reinforcing and reducing methods refer to specific needling manipulations used to treat asthenia and sthenia syndromes. They can be used to regulate the asthenia and sthenia states of the body. In terms of manipulations, the reinforcing and reducing manipulations in each kind of reinforcing-reducing method are in relation to each other. The following are some of the commonly used methods in clinical treatment:
Reinforcing and reducing manipulation by twir-ling and rotating the needle£º When qi is obtained after insertion of the needle, rotating the needle gently and slowly with small amplitude is known as the reinforcing manipulation, while rotating the needle rapidly with large amplitude is known as the reducing manipulation. Rotating the needle forward with the thumb and backward with the index finger means reinforcing, while rotate the needle backward with the thumb and forward with the index fin-ger means reducing.
Reinforcing and reducing manipulation by lifting and thrusting the needle: After the needling sensation has been achieved, the reinforcing effect is obtained by repeatedly thrusting the needle heavily and rapidly and then lifting the needle gently and slowly. The reducing effect is achieved by repeatedly lifting the needle forcefully and rapidly and then thrusting the needle gently and slowly.
Reinforcing and reducing manipulation by rapid and slow insertion and withdrawal of the needle: Af-ter the needle is inserted into the subcutaneous level, in-serting the needle slowly and withdrawing it rapidly means reinforcing, while inserting the needle rapidly and with-drawing it slowly means reducing.
Reinforcing and reducing manipulation by keeping the needled acupoint open or close: Pressing the acupoint quickly to close it after the withdrawal of the needle means reinforcing, while shaking it to enlarge the needled hole means reducing.
Reinforcing and reducing manipulation by the di-rection of the needle tip toward which the tip of the needle points: The needle tip pointing to the direction following the flowing route of the meridian means reinfor-cing while the needle tip pointing to the direction against the flowing route of the meridian means reducing.
Reinforcing and reducing manipulation by means of respiration: The reinforcing is achieved by inserting the needle when the patient breathes out and withdrawing the needle when the patient breathes in. The opposite way of practice means reducing.
The above reinforcing and reducing methods can be used individually or in combination.
In addition, for treatment of diseases without typical sthenia or asthenia syndrome, mild reinforcing and reduc-ing method can be used. Mild reinforcing and reducing method means to lift and thrust as well as twirl and rotate the needle evenly and gently at moderate speed when the needle is inserted into the acupoint.
3. 2. 1.1.6 Cautions
It is advisable to delay giving acupuncture treatment to the patients who are very nervous, or over-fatigued.
It is inadvisable to give acupuncture treatment to women during pregnancy, or women with menstruation. Acupeints on the vertex of infants should not be needled when the fontanel is not closed. Acupoints on the areas with infection, ulcer, scar or tumor should not be needled. Patients with disturbance of blood coagulation and hemorrhagic tendency should not be punctured.
Acupoints on the ocular area, neck, or close to the vital organs or large blood vessels should be carefully needled (see Section 3.5).
The selection of needling methods should be made ac-cording to the tolerance of patients. For the patients who are very nervous or weak, mild manipulation can be used.
3.2. 1.1.7 Management of possible accidents
Fainting: This is caused by nervousness, delicate constitution, over-fatigue, improper position or forceful manipulation. During acupuncture treatment, there may display such manifestations as dizziness, vertigo, pallor, palpitation, chest distress, nausea, vomiting and cold limbs. In severe cases, sudden syncope may be caused. When fainting has occurred, the needle should be with-drawn immediately. The acupuncturist should soothe the patient, help the patient lie down and offer him or her some warm boiled water. The patient's condition will be improved after a short rest. In severe cases, acupoints like Shuigou (GV26), Suliao (GV25) and Neiguan (PC6) can be needled and Baihui (GV20), Guanyuan (CV4) can be moxibusted to resuscitate the patient. If the patient does not respond to the treatment, other emergency measures should be taken.
Stuck needle: When stuck needle happens, the acu-puncturist may feel tense and unsmooth beneath the nee-dle and difficult to twirl, rotate, lift or thrust the needle; the patient feels unbearably painful. Then the needle should not be twirled and rotated again. The methods used to cope with such accidents vary according to the condi-tions of the patient. If stuck needle is caused by nervous-ness and excessive contraction of the local muscles, the acupuncturist should soothe the patient first, appropriate-ly prolong the retention of the needle, or press the local region gently, or insert another needle near the stuck needle. If it is caused by excessive rotation to one direc-tion, then rotation of the needle to the opposite direction with slight lifting and thrusting will solve the problem.
Bent needle: When the needle is bent, twirling and rotating manipulation should in no case be applied. The needle may be removed and withdrawn slowly by following the direction of bending. The following methods can be taken to avoid bending the needle. During needling, the patient should not change his or her position; the acupunc-turist should manipulate the needle gently, avoiding force-ful manipulation. And during the retention period, the needle handle shall in no case be impacted or pressed by external force.
Broken needle: When the needle is broken, the acu-puncturist should keep calm, ask the patient not to change his or her position to prevent the broken needle from getting deeper into the body. If the broken part protrudes over the skin, it should be removed with forceps. If the broken part is kept at the same level of the skin or a little depressed, the skin around the needle is pressed perpen-dicularly with the thumb and the index finger of the left hand in order to expose the broken end which is then re-moved with forceps. If it is completely sunken into the skin, surgical treatment should be resorted to. The fol-lowing methods can be taken to prevent breaking of the needle: The quality of the needle is inspected carefully prior to the treatment; the patient is advised not to change the position; manipulation should be performed gently and slightly, avoiding forceful manipulation lest the needle be broken.
Hematoma: Hematoma refers to swelling pain caused by subcutaneous hemorrhage around the area nee-dled. If the local region is cyanotic or painful after the withdrawal of the needle, the needled region should be immediately sterilized with dry cotton balls for a while to stop bleeding. If hematoma is mild, it will disappear auto-matically. If the local swelling and pain is serious and the area with cyanosis is large, cold compress can be used to stop immediate bleeding. After bleeding is stopped, hot compress or pressure is performed slightly and gently to help disperse the hematoma.
Pneumatothorax: On puncturing the acupoints loca-ted on the supraclavicular fossa, chest, back, axilla, and hypochondriac region, deep insertion may lead to pneumo-thorax due to the injury of the pleura and lung. The mani-festations are sudden chest distress, pectoralgia, and short breath. In severe cases, there may exhibit dyspnea, cyanosis of the lips and nails, sweating and drop of blood pressure. Physical examination may find hyperresonance in percussing the chest, attenuation or disappearance of vesicular respiration, or shift of the trachea to the healthy side. X-ray can diagnose the degree of pneumothorax. If it is mild, the patient may rest in half-lying position and take some antitussive and antiseptic. The patient should be treated under careful inspection. In severe cases, emergency measures should be employed at once.

3. 2. 1.2 Needling methods of the three-edg-ed needles
The three-edged needle is the needle shaped with a triangular head and a sharp tip, known as "Lance needle" in the ancient times. It is used to prick superficial vein for bloodletting.
3. 2, 1.2. 1 Scope of application
Pricking superficial vein for bloodletting with three-edged needle can dredge the meridians and collaterals, promote blood circulation to remove blood stasis, resusci-tate the patient and expel heat. It is often used to treat sthenia syndrome and heat syndrome as well as acute and chronic diseases due to qi and blood stagnation in the me-ridians and collaterals, blood stasis and exuberance of pathogenic factors, such as high fever, loss of conscious-ness, convulsion and syncope, blood stasis in local region and pain syndrome.
3.2. 1.2, 2 Manipulations
Spot pricking: Hold the three-edged needle with the right hand, prick swiftly about 2 - 3 mm in depth for bloodletting. The needle is withdrawn immediately fol-lowing bleeding. Or squeeze the punctured hole slightly to let out several drops of blood, then press the hole with a sterilized dry cotton ball until the bleeding stops.
Clumpy pricking: Prick around an affected small ar-ea, squeeze slightly with the hand or use cupping to drive the decayed blood out. This method can remove pathogenic factors and stop pain. It is usually used for treating car-buncles and obstructive syndrome, etc.
Pricking: Find the reaction point of disease first for pricking, pinch up the local skin with the left hand, prick about 2 mm in depth into the reaction point with a three-edged needle and push the needle up swiftly for bloodletting.
3.2. 1.2. 3 Cautions
It is advisable to make necessary explanations for the patient.
Sterilization of the area for operation must be done strictly.
The pricking should be slight, shallow and swift; it is inadvisable to induce excessive bleeding; cares should be taken to avoid pricking the large blood vessels.
It is inadvisable to apply this method to the treatment of the patients with poor constitution or pregnant women or the patients with susceptibility to bleeding.

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