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Correspondence to
Morry Silberstein, Faculty of
Science and Engineering, Curtin
University, GPO Box U1987,
Perth, WA 6845, Australia;
m.silberstein@curtin.edu.au
Accepted 12 January 2012
Acupunct Med 2012;30:17–20. doi:10.1136/acupmed-2011-010091
Do acupuncture meridians exist? Correlation with
referred itch (mitempfindung) stimulus and referral
points
Morry Silberstein
ABSTRACT
Objective To describe the relationship between
referred itch (mitempfindung) stimulus and referral
points and acupuncture meridians, noting that the
neuroanatomical mechanism of mitempfindung has
never previously been satisfactorily explained.
Methods Analysis of clinical findings in the author
as well as subjects in four previously described
studies, comparing proportions in each of five groups.
Results Ninety-two per cent (range 85–94%) of
mitempfindung point pairs (stimulus and referral)
aligned to a recognised acupuncture meridian with
no statistical difference (p<0.05) between the five
data sources.
Conclusion While previous authors have
speculated on an association between
mitempfindung and acupuncture, this is the first
description of a relationship between stimulus and
referral points and acupuncture meridians. The
author suggests that the transmission of
mitempfindung along acupuncture meridians may
involve a series of C-fibre–Merkel cell relays, with
the final referred itch sensation caused by substance
P release triggering mast cell degranulation.
While there is mounting evidence that acu-
puncture is a beneficial therapeutic modality
for pain relief,1 the traditional Chinese medi-
cine concept of specific acupuncture points
and meridians2 has defied explanation.3
Similarly, referred itch, or mitempfindung, a
curious phenomenon first described over 120
years ago, in which a stimulus applied to one
cutaneous location is perceived as a pricking
or tingling sensation in a different cutane-
ous location, has also yet to be satisfactorily
explained.4 Proposed mechanisms have sug-
gested either abnormal branching of afferent
axons during development4 or spinocervical
tract anomalies,5 the latter tract being a column
of axons ascending from spinal cord segments,
conveying pain information to neurons in the
upper cervical cord.6 This tract, while promi-
nent in cats, is of minimal size and importance
in humans,6 and is unlikely to be involved in
mitempfindung perception.5
Having experienced this phenomenon since
childhood, the author had taken little interest
Original paper
in it until he accidentally happened upon a
Wikipedia article in which it was described.7
The author had previously speculated on the
nature of acupuncture meridians,8 and the
subsequent perusal of mitempfindung point
locations in published diagrams9 10 made him
wonder whether there was a relationship
between these and meridians. The author has
given informed consent for his clinical data to
be used and published.
MATERIALS AND METHODS
Subjects
Initially, the author mapped mitempfindung
points on himself over a 3-month period, and
then perused previously published diagrams
and tables of points. Studies containing the
words ‘mitempfindung’, ‘mitempfindungen’
or ‘referred itch’ in the title, abstract or key-
words were identified in a Pubmed search.
In addition, all available references cited in
these published studies were examined for
potential inclusion. Studies were included if
mitempfindung point pairs were described—
either on a labelled diagram, or in tabulated
format—in sufficient detail to enable unbiased
localisation.
Data collection
Each mitempfindung pair (stimulus and refer-
ral points) was designated as either located
(positive) or not located (negative) on one of
eight meridian groups, as defined below.
There are 14 main meridians (those that
contain acupuncture points). Twelve are bilat-
eral and may be grouped into six pairs, as
described below, partly by linking upper-limb
and lower-limb channels, and two (GV and
CV) are midline, resulting in eight groups (GV
and CV are each treated as a separate group).11
The six pairs described above (three Yin and
three Yang) are the same as Zhonjing Zhang’s
six meridians, originally described almost
2000 years ago as forming the basis for the
physical response to illness caused by exog-
enous agents.12 While Zhang’s description
encompasses the vast majority of acupuncture
points, it omits those located on the CV and
17
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Original paper
Table 1 Alignment of mitempfindung point pairs with acupuncture meridians
Subjects Data source Point pairs HT/KI LU/SP
The author (1) Clinical mapping 38 3 1
Bean10 (1) Diagrams 51 1 3
Evans14 (8) Tabulated points 153 21 14
Richter9 (1) Diagrams 13
Sinclair15 (4) Tabulated points 18 1 4
GV meridians, which, for the purpose of this study, were
added to Zhang’s six, resulting in the eight meridian sets
used. Therefore, all traditional acupuncture points can be
mapped to one of the following eight groups:11 Shao Yin
axis (HT/KI), Tai Yin axis (LU/SP), Jue Yin axis (PC/LR),
Tai Yang axis (BL/SI), Shao Yang axis (TE/GB), Yang Ming
axis (LI/ST), CV and GV.
If only one half of the mitempfindung pair was on one
of these eight meridian groups, or each of stimulus and
referral points was on a separate meridian group, the
pair was designated negative. Points were excluded from
assignment if the location was unclear on a diagram or
published table.
Statistical analysis
The proportions of mitempfindung point pairs aligned
with a single meridian group were calculated, and differ-
ences between each were compared pairwise using the
Marascuillo procedure13 at a 0.05 significance level.
RESULTS
Four peer-reviewed articles were identified with either
diagrammatic9 10 or tabulated14 15 mitempfindung point
locations. The locations of these as well as the author’s
own points, mapped to acupuncture meridian groups, are
recorded in table 1. Alignment of mitempfindung point
pairs with meridians ranged from 85% to 94% and, of a
total of 273 point pairs, 252 (92%) aligned with an individ-
ual meridian group. Each proportion was then individu-
ally compared pairwise, yielding eight comparisons, with
no significant difference demonstrated among any of the
pairs at the 0.05 level. None of the mitempfindung points
corresponded to recognised acupuncture points.
DISCUSSION
In his recent review of the history of mitempfindung, the
neurologist John Pearce,4 noted the absence of any cor-
relation between acupuncture points and mitempfind-
ung points. As noted by Bean,10 Richter9 speculated that
mitempfindung points may, in prehistoric times, have led
to the development of acupuncture, but neither author
was able to identify any relationship between these
two entities. Yet, both mitempfindung and acupuncture
involve cutaneous transmission of sensory information
over long distances without definite anatomical correlates
and, for each, only a proportion of the human population
demonstrates susceptibility to responding.16 While Pearce4
18
Meridian
PC/LR BL/SI TE/GB LI/ST CV GV Proportion
13 9 5 3 1 0.921
1 24 8 11 0.941
6 36 38 9 12 6 0.928
3 5 3 0.846
1 1 6 3 0.889
is probably correct that there is no relationship between
mitempfindung points and acupuncture points, no previ-
ous study has sought to determine whether mitempfind-
ung points lie along acupuncture meridians, the lines that
connect the points.
In demonstrating the alignment of over 92% mitemp-
findung point pairs with acupuncture meridians, this
study offers a potential connection between two previ-
ously unexplained neurological phenomena. The author
previously proposed that acupuncture might disrupt the
bifurcation of C-fibre tactile afferent axons at acupuncture
points, preventing communication between Merkel cells
along acupuncture meridians.8 Subsequently, preliminary
evidence was found of axonal branching at human acu-
puncture points.17 Merkel cells, also referred to as ‘touch
cells’, are specialised sensory and neuroendocrine cells
located in the basal epidermis in distinct disc-like struc-
tures called ‘touch domes’.18 At these sites, Merkel cells
are found in close proximity to sensory nerve fibres, and
touch domes are believed to have both mechanical and
pain sensing roles.19 Both Richter9 and Sinclair15 have noted
that mitempfindung stimulus points were located at touch
domes. Given that Merkel cells in touch domes receive
input from unmyelinated C-fibre afferents,19 the transmis-
sion of mitempfindung along acupuncture meridians may
involve one or more C-fibre–Merkel cell relays, with the
final referred itch sensation caused by substance P release20
triggering mast cell degranulation (see figure 1).
This model raises two key questions: first, noting that
Merkel cells are responsible for light touch perception,21
why is mitempfindung referral perceived at a considerable
distance to the stimulus, as opposed to the next Merkel
cell along the relay? At least part of the answer may relate
to the heterogeneity of the granule composition of Merkel
cells,22 such that the perception of mitempfindung would,
according to this model, require both the presence of sub-
stance P and localisation near one or more mast cell. In
addition, antidromic C-fibre stimulation, as would occur
in this model, has been shown to inhibit Merkel cell mech-
anoreceptor activation23 so that intervening Merkel cell
activation along the relay would not be perceived. Second,
why is there no weal or flare response at the mitempfind-
ung referral point, at the site of mast cell degranulation?
The release of histamine by mast cells is known to be in
direct proportion to the concentration of substance P24,
while the weal and flare response is proportional to the
concentration of histamine released.25 In contrast, there
is a poor correlation between the subjective sensation of
Acupunct Med 2012;30:17–20. doi:10.1136/acupmed-2011-010091
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Figure 1 Proposed model for mitempfindung transmission. Stimulus at the touch dome on right of figure activates Merkel cell with
sensory transmission, both orthodromic and antidromic, along C-fibre branches. At referral point (left of figure), Merkel cell (MC)
releases substance P (SP), triggering mast cell degranulation and release of histamine (HA).
histamine-induced itch and the objective measurement of
weal and flare.26 In the proposed model, only very small
quantities of substance P are likely to be released at the
referral point, triggering the release of a small quantity of
histamine, sufficient for the perception of transient itch,
but insufficient for a visible weal and flare response.
The model may also assist in explaining the inconsis-
tent results for acupuncture encountered in the literature.
Mitempfindung is only experienced by a proportion of
people, with estimates ranging from 20%14 to 25%.15
Similarly, the response to acupuncture, especially for pain
relief, is non-uniform.16 Perhaps this variability relates to
the degree of connectivity of C-fibre–Merkel cell relays,
with responders (to both mitempfindung stimulation
and acupuncture) demonstrating better developed or
more widespread connections (equating to acupuncture
meridians).
This study is limited in three ways: first, the five groups
examined comprise quite diverse data sources, including
the author, two sets of diagrammed data and two sets of
tabulated data; second, overall subject numbers are small,
noting that few subjects have previously been described,
despite a significant prevalence of mitempfindung in the
general population; and third, the method used for merid-
ian classification might appear to be somewhat arbitrary.
In response, the classification used in this study is based
on one specific traditional description. Some traditional
Chinese medicine practitioners pair meridians in a differ-
ent manner (eg, LU with LI) based on their location on
the outer or inner surface of a limb, noting that the latter
descriptions do not connect upper and lower-limb merid-
ians as in Zhang’s classification, as used in this study.11
Mindful of these limitations, has this study finally elu-
cidated the mechanism of mitempfindung? The existence
of the referred itch phenomenon is an indication that the
central nervous system has important pathways about
which we are still ignorant, and this is certainly relevant to
acupuncture. Evans14 previously speculated that this phe-
nomenon related to the arrangement of fibres in the thala-
mus or thalamocortical tracts, but no subsequent work
has been published to support or refute this suggestion.
Acupunct Med 2012;30:17–20. doi:10.1136/acupmed-2011-010091
Original paper
Finally, it is tempting to speculate on the implications of
this study on acupuncture in general. Despite wide clini-
cal use, acupuncture remains a controversial therapeutic
technique, partly because its mode of action is not well
understood, and there has previously been little, if any,
strong scientific evidence for the existence of either merid-
ians or acupuncture points.27 As noted by Ramey,28 if such
structures could be shown to exist and be reliably demon-
strated, this would revolutionise anatomy and physiology.
If, indeed, there is a definite link between acupuncture and
a recognised neurophysiological phenomenon, as sug-
gested by the current study, this would open a new and
exciting direction for acupuncture research.
In conclusion, this study, having found over 92%
mitempfindung point pairs from five diverse data sources
aligning with acupuncture meridians, offers a new model
for mitempfindung in which stimulation at a touch
dome is referred to a distant point along one or more
C-fibre–Merkel cell relay along an acupuncture meridian.
Additional studies, with larger numbers of subjects, will
be required to confirm these conclusions.
Summary points
▶ Mitempfindung means that touch refers a sensation of itch
elsewhere
▶ Stimulus and referral sites were mapped and compared
with published descriptions
▶ Locations of mitempfindung overlap acupuncture meridians
Competing interests None.
Ethics approval This study was approved by the institution’s research ethics commit-
tee (Curtin University human ethics approval no SMEC-60-09).
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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Acupunct Med 2012;30:17–20. doi:10.1136/acupmed-2011-010091
 Downloaded from http://aim.bmj.com/ on June 20, 2017 - Published by group.bmj.com

Do acupuncture meridians exist? Correlation

with referred itch (mitempfindung) stimulus
and referral points
Morry Silberstein

Acupunct Med 2012 30: 17-20

doi: 10.1136/acupmed-2011-010091

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