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AcuXpert: An intelligent computer aided learning and diagnosing system for acupuncture
Expert Systems With Applications, Vol. 10, No. 1, pp. 1-15, 1996 Copyright © 1996 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0957-4174/96 $15.00 + 0.00
Pergamon 0957-4174(95)00029-1
AcuXpert: An Intelligent Computer Aided Learning and Diagnosing System for Acupuncture K.ESHENG WANG Department of Production and Quality Engineering, NTH, N-7034 Trondheim, Norway
JUNXIA LIU Chinese Acupuncture Institute, N-7013 Trondheim, Norway
Abstract--The Acupuncture Expert (AcuXpert) is the first Intelligent Computer-Aided Learning (ICAL) system in the science of acupuncture and moxibustion in the worM. There are two purposes for the development of such a system: the first is to teach students the principles and concepts of the science of acupuncture and moxibustion; the second is to instruct acupuncturists to make correct diagnoses, employ right treatment methods, select effective acupuncture points and find precise positions during the clinical practice. AcuXpert is an 1CAL system in which two emerging technologies, expert systems and multimedia, are being incorporated into organisations. The system consists of five modules: (1) Introduction; (2) The channels and points; (3) The techniques of acupuncture and moxibustion; (4) Acupuncture treatment; and (5) Diagnosis expert. The intelligent system was developed using an intelligent system development tool, KnowledgePro Windows, and runs on a PC. It demonstrates the usefulness and advantages of the integration of expert systems and multimedia. Multimedia is supported by hypertext and hyperregion based searches and by imaging technology to assist students and acupuncture doctors in analysing symptoms and providing recommended prescriptions. Results achieved indicate that the system offers advantages in quick learning and correct diagnosis. In addition, training is faster and the user satisfaction is higher.
1. I N T R O D U C T I O N TRADITIONALCHINESE MEDICINE (TCM) is a representative of eastern medicine and it is a famous national traditional medicine in the world. As it is known to all, several hundred million of the Chinese population used to be under the care by the TCM before the western medicine was introduced to China. Even now, a large number of Chinese people prefer to see a Chinese traditional doctor when they get ill. The science of acupuncture and moxibustion is an important component of Traditional Chinese Medicine (TCM) with a long history. For thousands of years it has been accepted by the general population for its good curative effect, wide range of indications, simple application, low cost, safety and no side effects, etc. Since the 1970s, the spread of the science of acupuncture and moxibustion has become widened in Norway. The science of acupuncture and moxibustion as an alternative medicine treatment generally accepted by the western medicine doctors and it has become a very popular
alternative medicine treatment in Scandinavian countries. In Norway, about 1500 individuals had learned and practised acupuncture and moxibustion until 1994. At present, most of them obtain very shallow knowledge of the science of acupuncture and moxibustion through some short, intensive and weekend courses from not very experienced and qualified teachers. In such a way, it is very difficult for them to understand clearly the principle of the science and learn correctly the method to cure the different diseases. The main reason for the situation is that they lack substantial training and practice. All of this will lead to misunderstanding and misuse of acupuncture. The most serious result is to cause the death of patients. To train and produce the qualified acupuncturists under such conditions, as lack of teaching time, school facilities and experienced acupuncture teachers, is an urgent problem in Scandinavia. Intelligent ComputerAided Learning (ICAL) will explore the possibility of employing Artificial Intelligence (AI) techniques to support learning and diagnosing with the help of
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computers. The advantages of using ICAL in education are clear. Such a kind of education is individual; it is independent of time, place and teachers. The students can always use computers to study the principles and conceptions again and again and to repeat exercises and demonstrations by themselves. The philosophy in ICAL is very suitable for coping with the present situation of acupuncture in Norway. In 1993, The Chinese Acupuncture Institute (CAI) working together with the Department of Production and Quality Engineering launched the project: to develop the Intelligent Computer Aided Learning system, AcuXpert, for aiding in the learning of the science of acupuncture and moxibustion and in diagnosis of different diseases. Two emerging technologies that are being incorporated into organizations at an ever-increasing rate are expert systems (ES) and multimedia (MM). While these technologies have developed independently, they possess capabilities that make them highly suitable for integration with each other. AcuXpert, is examined to demonstrate the usefulness and advantages of ES and MM integration in ICAL systems. Expert systems provide an effective approach for diagnosing of diseases, analysing of symptoms and recombining of prescriptions similar to experienced acupuncture doctors. Multimedia is supported by hypertext and hyperregion-based searches and by imaging technology to assist acupuncturists in studying subjects, and understanding the fundamental principles of the science. The system could be used by either medical students or trained qualified medical personnel, such as doctors or acupuncturists. The knowledge used in AcuXpert is extracted from the Chinese Acupuncture Institute at Trondheim and a number of famous Chinese acupuncture experts (Han, 1994; Guo, 1991; Liu, 1988; Liu, 1991; Yang, 1987). Dr Liu at CAI has her acupuncture and moxibustion practice for several years in Trondheim and combined the Traditional Chinese Medicine (TCM) and the western school medicine to treat effectively patients. Dr Liu cured a lot of Norwegian patients of difficult illness which could not be treated by the school medicine. CAI has a high reputation in Norway due to the high skills, the qualified treatment and the good service. To serve the people wholeheartedly and release the sufferings of the patient is the sole aim of CAI. This provided a handy, concise, and compact collection of high quality acupuncture knowledge. KnowledgePro Windows, an intelligent system development tool, is chosen as the programming language because it combines both expert systems and multimedia in a single development and runs on the PC. The program is easy to use and relatively inexpensive, and has good interface capabilities to external programs. This paper is concerned with one particular facet of ICAL, namely the integration of expert system technology and multimedia techniques as a resource to facilitate the implementation of computer-based teaching and
K. Wang and J. Liu
Receptive Response Contructive Response FIGURE 1. A conventional education system.
learning processes within the science of acupuncture and moxibustion. The first gives an overview of ComputerAided Learning (CAL), expert systems and multimedia techniques. The second offers the model of the integration of theses two techniques. The third describes the development of the Acupuncture Expert (AcuXpert). And finally, the last part of the paper will draw the conclusions. 2. LEARNING PROCESS OF ACUPUNCTURE AND MOXIBUSTION Generally, the learning process of acupuncture and moxibustion is the same as the conventional learning process. Figure 1 shows a conventional learning system. A teacher sends out the education information to a student using language, blackboards, and other media, and the student receives the information. This is called Receptive Response. The student has to understand the information sent by the teacher and can answer all the questions from the teacher. That is called Constructive Response. To become a qualified acupuncturist, at least, it is necessary for him/her to learn and understand the following contents: (1) The fundamental principle of the Traditional Chinese Medicine (TCM); (2) Body-surface distribution of the Fourteen Channels; (3) The locations of acupoints; (4) Classification and therapeutic properties of acupoints; (5) The techniques of acupuncture and moxibustion; (6) Principles of acupuncture treatment; (7) Acupuncture therapy of common diseases; and he/she must have a good clinic practice under the instruction of qualified acupuncture doctors to learn, check and modify the knowledge they have learned in a classroom. The expert knowledge of acupuncture is often obtained through a long period of practice and some special knowledge cannot be learned from books and beneath teachers. 3. THE PROBLEM SOLVING STRATEGY In order to find out the approach to solve the mentioned problem above, that is, to reduce the learning time and improve the education quality, several techniques are examined in the following sections. The best approach will be selected for developing the system from these alternatives. 3.1. The Computer-Aided Learning (CAL) The application of computers for implementation of learning and instruction processes is referred to as
AcuXpert Computer-Aided Learning (CAL) (Kong, 1994; Steenhvisen, 1991; Barker, 1985; Watson, 1987). Computers play a different role from a blackboard, books and other media in education processes. CAL systems involve the development of a special type of instructional software or providing a student with appropriate program tools that can be used in problem-solving situations within the domain of study. By the use of a computer, course materials can be directly sent out to and received from students. In other words, in the learning process, a computer can be employed to replace a teacher partly or wholly. The new education system is illustrated in Figure 2. Over the last decade there has been a growing development of using Artificial Intelligence (AI) as a tool to aid the fabrication of a wide range of learning resources in computer-aided learning system. The application of AI techniques to improve conventional CAL methods are described by the term Intelligent ComputerAided Learning (ICAL). Compared with CAL systems, ICAL covers a broad and diverse range of topics such as the construction of intelligent authoring, student modelling, the creation of intelligent tutor systems, and fabrication of sophisticated systems to support knowledge-based CAL (Barker, 1988). The use of expert systems technology can considerably improve the computer-aided learning processes. A typical ICAL system, which consists of an expertise module, a tutoring module, a student module, and an intelligent user interface is presented in Figure 3 (Burn, 1991).
3.2. Multimedia Techniques Basically, multimedia is an information management tool that links text, graphics, sounds, or other types of media in an associative way (Suhayya, 1993; Nielsen, 1990). In doing so, it allows users of a system to navigate through information in a nonlinear fashion. Moreover multimedia has the potential to simulate the human ability to organise and retrieve information by referential links, the technology is also capable of providing a form of a relational object-oriented network that can extend knowledge representation within an intelligent system application. With this kind of capability, multimedia can play a major role in intelligent systems development through its ability to access information or control program navigation in a nonlinear way. Unlike a book, where pages are ordered sequentially and routinely read in a linear fashion, multimedia information can represent a collection of interconnected files that contain text and graphics linked into a network. Users are free to progress, or navigate, through a system using any
I~eacher~--~ Computer~H~ Student1 FIGURE 2. A Computer Aided Leamlng system.
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..... almmatlon 1~ d Instruefionall, ~q-~ Expert ~ . ~ I Intelligent Interface q _ _ ~
FIGURE 3. Architecture of a general ICAL system.
number of nonlinear pathways for which links have been established by the designer. Through multimedia is an extremely powerful tool for interconnecting information in intuitive way, thereby augmenting human intelligence, it is not by itself, capable of rendering intelligent applications. As an organizational and information retrieval tool, multimedia does provide a highly flexible context for representing knowledge, it lacks the reasoning or inference ability to generate to truly 'intelligent system' found in expert systems. Multimedia is a technology that is highly complementary to expert systems in building effective intelligent system applications. Multimedia is well suited to applications that include training or education, primarily because of the flexibility that the technology offers over conventional ComputerAided Learning. This flexibility is reflected in a nonlinear access to information and a transfer of program control for the developer to the user. Unlike a traditional CAL program, multimedia can be more adaptive overall, offering a more effective program navigation that is geared to the needs and interest of the user. A second benefit of using multimedia in a training/education environment is its ability to foster greater exploration of relevant, but perhaps tangential, information. The Dynamic Medical Handbook project, the drug information data base and Explore-l, etc. are good examples of this use of multimedia in the medical profession (Schneiderman, 1989). These multimediabased systems and many others in the specialized education offer instruction at all levels the ability to link creatively diverse sources of information to single problem or issue.
3.3. The Integration Models Generally, knowledge representation, inference, and nonlinear association of information are critical to intelligent systems. Unfortunately no single information technology or application program can integrate these functions well. However, when integrated within a single application or used with existing programs, multimedia and expert systems offer a rich environment for creating software applications that can indeed behave intelligently (Bielawski, 1991; Clarke, 1994). They do by combining the problem-solving, associative, or expressive powers of humans at work.
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The integration models of ICAL system can be classified as the three following models: Model 1: Expert system-based ICAL system with multimedia support. Model 2: Multimedia-based ICAL system with expert system support. Model 3: Integrating ICAL system with existing information and data-based applications. These basic design models suggest that, although ICAL systems can effectively combine multimedia and expert systems, one technology will often dominate the over-all program structure. Model 2 is selected to construct AcuXpert system (see Figure 4). The system is an information access system primarily based on multimedia, but containing an integrated or embedded expert system component, How the development tool facilitated technology integration will be described in Section 5. 4. T H E D E V E L O P M E N T OF ACUXPERT Because AcuXpert uses existing information sources and employs the experience of CAI, the intelligent system exhibits both relational knowledge in the form of multimedia and procedure knowledge within its expert system component.
4.1. The Use of Hypertext The use of hypertext within AcuXpert is fundamental to the implementation of the multimedia paradigm. The text about the description of points and channels etc. is stored in the external text files. The text references are embedded directly within knowledge base. When a hypertext reference is selected for display, the system searches the current knowledge base for a topic corresponding to the selected item. An integral part of AcuXpert is hypertext linking. Hypertext works in much the same way as a system of index cards. Information is entered on an initial hypertext card, which pops up like a window. On the information cards are buttons, which are highlighted word(s) that can be clicked on to bring up additional, overlaid cards. Thus, further investigation of highlighted topics is possible. The information on cards covers topics about the description of channels and points, equipment used, diagnosis procedures, and any other relevant information
about the science of acupuncture and moxibustion. In this way, hypertext allows the users to breeze through large amounts of information to find whatever is needed for quick learning and diagnosing. The hypertext is used mainly by less experienced user. It helps them quickly find useful information and learn the science. More experienced users use the hypertext as a time-saving device. Using the hypertext, they do not have to check books and notes and they do not have to remember minute details.
4.2. The Use of Still Images AcuXpert makes extensive use of images to aid in science learning and diseases diagnosing, including images of 14 channels, all acupoints and devices of acupuncture. These images play a very important role in AcuXpert for two reasons. First, they increase effectiveness through-visual picture. Second, they show the directions of the channels and the positions of acupoints. Still images are incorporated as follows: • Images are obtained by scanner. • Images are edited using a PC-based graphics development tool, for example, Paintbrush. • Digitised images are then translated into bitmap files. • KnowledgePro retrieves and display the bitmaps in Windows environment.
4.3. The Use of the Expert System Based on the principle of the theory of Traditional Chinese Medicine, the process of the acupuncture treatment may be represented by the following steps: (1) Symptom; (2) Identification; (3) Differentiation; (4) Treatment; (5) Prescription; (6) Supplementary points; and (7) Methods. Generally, the identification of the diseases from the symptom for acupuncture treatment is not so difficult. The major problem is how to use the symptom to make differentiation and the differentiation does play an important part in the acupuncture therapy of the diseases. In the expert module of the system, the step of identification is omitted, that is, users have to identify the diseases and the symptoms are just used for differentiation of diseases. The remaining can be automatically executed in the system. 5. T H E S T R U C T U R E O F A C U X P E R T AcuXpert has five modules, which are described below and shown in the opening of the program (see Figure A1. in Appendix):
FIGURE 4. The structure diagram of integration model 2.
Module 1: An introduction to the AcuXpert program. Module 2: The channels and points, which describe the 14 channels and the related points. Module 3: The techniques of acupuncture and moxibustion.
AcuXpert
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Module 4: Treatment, which tells about the general principle of acupuncture treatment. Module 5: Therapy of common diseases, which is an expert system component for diagnosing common diseases. The details of all these modules are described as follows:
5.1. Module 1 Module 1 consists of the information about the concept of the science of acupuncture and moxibustion; history; situation in China; developments in the world; problems at present; advantages of AcuXpert; how to use AcuXpert and References.
5.2. Module 2 14 channels and ca 300 acupoints are displayed using still images which are located on 95 bitmap files, respectively. After the pictures representing 14 channels and all points has been scanned by the hand-scanner, any annotation and modification that was needed was done using PC Paintbrush.
5.3. Module 3 The techniques of acupuncture and moxibustion consists of: (1) Acupuncture techniques which contain: Preparations prior to acupuncture treatment, Needling methods, and Management of possible accidents; (2) Moxibustion and cupping therapy which contains: Moxibustions commonly used and Precautions; (3) The three-edged needle; (4) Point injection; (5) Eletrotherapy; (6) Scalp acupuncture; (7) Ear acupuncture therapy.
5.4. Module 4 A general introduction to acupuncture treatment consists of: (1) General Principle of acupuncture treatment; (2) Point prescription; (3) Application of specific points.
5.5. Expert Module Based on the theory of Traditional Chinese Medicine (TCM), the reasoning process can be represented as the following figure 5. In AcuXpert, identification of diseases is not carried out by the computer. The type of a disease can be easily identified by the acupuncturists or diagnosed by doctors in a hospital. The main task of AcuXpert is to recognise the differentiation and to make the decision of a
prescription (to determine the points). Forty-three different diseases are included in the system. According to the symptoms of a patient, an acupuncturist can determine the type of a disease and click the item of a given menu. The computer will give the suggestion of main points needed for treating the disease. Following the symptoms of the disease, the acupuncture makes differentiation of the disease. It is done just by selecting the item of the menu in the window. The computer will indicate the supplementary points. In order to illustrate the implementation of the system, a common disease, headache, is taken as an example.
(1) Knowledge Acquisition For the therapy of headaches, Dr Liu at CAI has designed a treatment according to her experience. Based on her experience, acupuncture prescription includes main points and supplementary points. The prescription plays a very important role in the therapy of diseases. The key problem is to make correct differentiation of diseases. The prescription put into AcuXpert has been proven to be very effective and high satisfactory through several years of practice in both China and Norway.
(2) Knowledge Representation (a) Decision Trees. The knowledge of the trophy of headaches can be represented by the use of the decision tree shown in Figure 6. The three types of differentiation are represented in level 1 in the decision tree. DI: Headache due to invasion of pathogenic wind into the channels and collaterals; D2: Headache due to upsurge of live-yang; D3: Headache due to deficiency of both qi and blood. In level 2, the symptoms can be divided into three groups: headache symptom, tongue colour and pulse. Headache symptom can be represented as S l: Headache occurs often, especially on exposure to wind. $2: Headache, distension of the head, irritability, hot temper, dizziness. $3: Lingering headache, dizziness, lustreless face. Tongue colour as $4: Thin and white tongue coating. $5: Red tongue with thin and yellow coating. $6: Pale tongue Headache Level 0
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Level 2 S1 FIGURE 5. The reasoning process of TCM.
$4
$7
$2
$5
$8
$3 $6
$9
FIGURE 6. The decision tree of the differentiation of headache.
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suggestion of the prescription of acupuncture and moxibustion for a specified disease and then to look closely at the location of the points on the body. All these possibilities can easily be realised within the system.
Level 0
Level 1 6. CHOICE OF SYSTEM PLATFORM Level 2 Level 3
LIILi Extra 2 SJ 5 SI 3 G 20 G 20 D u 2 3 G 4 1 L i v 3 B 60 G 4 3 S 44 B 67 Liv 2
ten 6 ; 36 20 B 23
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Du 20 Extra 1 L4
Main points
Supplementarypoints FIGURE 7. The decision tree of treatment of headache.
with thin and white coating. Pulse as $7: Floating pulse. $8: Taut and rapid pulse. $9: Thin and weak pulse.
(b) Recommendation of Treatment. The recommendation of prescription consists of prescription (main acupoints) and supplementary points. All acupoint are represented in the form of hypertext and they are linked to the images which show the right position of the corresponding points on the human body. The decision tree of recommendation is shown in Figure 7. (c) Production System. The production system used to represent the knowledge, for example: IF 'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND 'Tongue color' is 'Thin and white tongue coating.' AND 'Pulse' is 'Floating pulse' AND 'Location' is 'Frontal headache' THEN 'The supplementary points' are: Yintan (Extra 2), Shangxing (DU 23), and Neiting (S 44). (d) Reasoning Strategies. AcuXpert's five modules demonstrate the usefulness, power, and flexibility of combining multimedia and expert systems technologies within a single application. Using relational knowledge in the form of multimedia, AcuXpert retrieves information along different, nonlinear pathways determined by the user. The expert system module uses procedural knowledge reflected in a rule-based system that imparts the expertise of CAI through an interactive, menu-driven session. Once the images had been stored (as bitmap files) they could easily be retrieved and display in KnowledgePro. One user might first want to look simply at a description of the 14 channel and then run the diagnosis module to find the suggestion of the prescription of acupuncture and moxibustion for a specified disease. Another user might first want to obtain the
It was recognised that ICAL systems would be either PC based or the mainframe based (Kershberg, 1988). There have been reported many applications in medical consultation such as MYCIN, CASNET, INTERNIST, and PIP (Akiba, 1983). But the most of these systems are mainframe based. As we know, these systems have not yet been popular with clinicians as effective practical tools of diagnosis or treatment. The important condition at present is that most users of AcuXpert have the possibility of using PCs in their offices. PC based ICAL has the following advantages: • The PC is the standard personal workstation. • Ability to communicate with other PC applications. • Powerful PC/PS/2 graphics capabilities got graphics and imaging. • Portable even when there are no host terminals. • Low price. • Ease of maintenance. The disadvantages of using PC are: • For stand-alone systems, difficulties in updating new version of the systems to the end-user community. • Expert system software, data files, and graphic images utilise large amount of disc space. Considering all of these factors, it was decided to go with a PC based ICAL system. AcuXpert desired that this system be used by individuals and most of them are using PCs in their environments. 7. DEVELOPMENT T O O L The following are some of the factors considered prior to the selection of the development software (Wang, 1994): • Ease of development. • Ease of maintenance. • Ease of transportability. • Ability to fulfil current requirements. • Ability to fulfil further requirements. Based on the mentioned criteria and a review of several potential products, it was determined that KnowledgePro Windows would be used. This product was chosen for its relative low price, its relative ease of use, its robust external routine-calling ability, and its native hypertext development feature. The runtime version of this system can be run on any PC. Working on AcuXpert system under the Microsoft Windows environment on a PC, the developers built a prototype version of AcuXpert using KnowledgePro Windows, which is an application development tool from knowledge Garden Inc., that incorporates both expert systems and multimedia techologies (Thompson, 1991;
AcuXpert Barker, 1989). This tool fits the AcuXpert project very well because of its many features, such as full multimedia handling (including text, bit-map images and hyper-regions), good string manipulation, on-screen page scrolling, use of inheritance, extensive use of the windows library of screen design tools (such as buttons, check lists, and dialogue boxes), and inclusion of a powerful programming environment for rule-based expert system development. However, it was the high level of integration between multimedia, expert systems, and Windows components that made KnowledgePro Windows fit perfectly for the project. For example, any topic within the KnowledgePro environment can contain text, graphics, hyper-regions, procedural rule-based statements, or specific Windows commands. Thus, from a development point of view, the tool was well suited to the AcuXpert project and provided a vehicle for quickly prototyping a system that was largely based on existing information. An additional advantage for using KnowledgePro Windows for AcuXpert was that the tool runs under Microsoft Windows. Because most students and doctors currently bundle Windows with most of its desktop computer systems, the developers sought to develop an application for this software platform. Our major reasons for wanting to use the KnowledgePro Windows as an shell for producing AcuXpert are as follows: • Ease of use. • Consistent and friendly end-user interface. • Its built-in multimedia facility. • Its powerful range of primitive commands and functions. • Its comprehensive list processing facilities. • The facilities it offers for dynamic programming. • Its powerful input/output facilities. • The ease with which it can be 'tailored' to user's requirements. • Its ability to interface to other software items and packages. • Its range of add-on toolkits. • The easy way in which it can be used to produce other courseware-development shells. • The fact that it can act as an expert system shell. The last reason of using KnowledgePro is that Kpwin + + lets the developers write the entire application (runtime version) in a high-level, ease-to-learn language (KnowledgePro), and then generate native C + + code. The finished application is a fast, industry standard .EXE file with all performance advantage, but without the step learning curve of developing in C programming language. When you work in the high-level Kpwin environment, you can see your program run instantly using the Kpwin interpreter and then, when it's completed, use Kpwin to generate efficient, readable, error-free and object-oriented C + + code.
7 The learning and diagnosing processes used in AcuXpert are illustrated by Figures from A1 to A l l shown in the first part of the Appendix. The code of the knowledge base of headache in KnowledgePro Windows is listed in the second part of the Appendix. 8. EVALUATION During the development of AcuXpert, CAI and PQE has organised numerous discussion and evaluation meetings for the project in both Norway and China. Many important suggestions and much advice have helped the developers improve AcuXpert. After AcuXpert has been developed and evaluated in CAI the system has been presented and demonstrated in several medical institutes and conferences for evaluations and modifications. The discussions between medical doctors and AI development scientists play a very important role in the process of the development and evaluation of the system. Based on the demonstrations and feedback information, satisfaction of the system from acupuncturists and doctors is very high and they felt that such integration of ES and MM is a good approach to computer aided learning and diagnosing for acupuncture and moxibustion. The system will be put into international market soon. The new version of AcuXpert, in which moving images will be employed to show the needling method, the treatment processes, etc. is under development. 9. CONCLUSIONS This paper describes the structure and development of AcuXpert, which is an intelligent computer aided learning and diagnosing system. The integration of multimedia and expert systems techniques has been successfully implemented in the development of AcuXpert. Expert systems and multimedia can be combined in several different modes. This paper demonstrated only one mode of combining ES and multimedia technologies. The application of such a system to support the acupuncturists to learn the science of acupuncture and moxibustion and diagnosing of diseases is strongly recommended. AcuXpert is the first Intelligent Computer-Aided Learning system developed for the science of acupuncture and moxibustion. This system paves the way for the new research direction for further computer aided learning in Traditional Chinese Medicine and other alternative medicines. It also opens the door to smoothly introduce the Traditional Chinese Medicine into the western countries. This project has been developed for learning and diagnosing of real acupuncture practices. All the data and knowledge were extracted from CIA and a number of experienced Chinese acupuncture experts. It was so designed that it could be learned fast and reliably, and be
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directly used by inexperienced computer users. Evaluation at CAI was very satisfactory. Such a system aims at narrowing the gap between Chinese medicine and computer technology.
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lishing Company. Kong, H. P. (1994). An intelligent, multimedia-supported instructional system, Expert System with Applications, 7, 451-465. Guo, X. Z. (1991). The geometric solutions of the effective acupoints, Science and TechnologyLiterature Publisher (in Chinese). Hart, M. (1994). The Collection of Practice of Acupuncture and Moxibustion. Chinese Medicine and Medicament publisher (in Chinese). Liu, H. Y. (1988). Practice Acupuncture, Beijing Publisher (in Chinese). Liu, S. Y. and Jian, X. Z. (1991). Therapy of Acupuncture, Xuiewan Publisher (in Chinese). Nielsen, J. (1990). Hypertext & Hypermedia, Academic Press Inc. Shneiderman, B. and Kearsley, G. (1989). Hypertext Hand-On~ Reading, MA: Addison-Wesley. Steenhvisen, D. M. (1991). FisioDisc: Using Knowledge Technology for Education Purposes. OperationalExpert SystemApplications in Europe, 207-221. Suhayya, A., Halasz, M. and Phan, S. (1993). An approach to hypermedia in diagnostic systems. In Maybury, M. T. (Ed.), Intelligent Multimedia Interfaces pp. 225-256. AAAI Press/The MIT Press. Thompson, B. (1991). KnowledgePro Windows User Manual, Knowledge Garden Inc. Yang, Z. S. (1987). The Science of Acupuncture and Moxibustion, Science and Technology. Publisher of Shanghai, Shanghai. (in Chinese). Wang, K. (1994). Development of expert diagnosis system using knowledge, Proceedings of the International Symposium on Manufacturing Science and Technologyfor 21st Century, Beijing. Watson, D. (1987). Developing CAL: Computers in the Curriculum. London: Harper & Row.
APPENDIX 1 AcuXpert [ACUPUNCTURE EXPER'I'J Exit
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INTRODUCTION THE CHANNELS AND POINTS THE TECHNIQUES TREATMENT THERAPY OF COMMON DISEASES
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FIGURE A1. Opening menu screen In AcuXpert.
AcuXpert
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The The The The The
Lung Channel of Hand-Taiyin Large Intestine Channel of Hand-Yangming Stomach Channel of Foot-Yangming Spleen Channel of Foot-Taiyin Heart Channel of Hand-Shaovin
ThE The The The The The
Bladder Channel of Foot-Talyang Kidney Channel of Foot-Shaoyin Pericardium Channel of Hand-Jueyin Sanjiao Channel of Hand-Shaoyang Gallbaldder Channel of Foot-Shaoyan9 Liver Channel of Foot-Jucyin
FIGURE A2. Selection of the channel 'The Small Intestine Channel of Hand-Talyang'.
The Small Intestine Channel of Hend-Teiyen~l Close 1. The Course of the Channel: The Small intestine Channel of Hand-Talyang starts from the ulnar side of the tip of the I finger. Following the ulnar side of the dorsum of the hand it reaches the wrist where it el from the styloid process of the ulna. From there it ascends along the posterior border of lateral aspect of the forearm, passes between the olecranon of the ulna and the medial epicondyle of the humerus end runs along the posterior border of the lateral aspect of ill arm to the shoulder joint. Circling around the scapular region, it meets Dezhui |Du 14) eJ superior espectof the shoulder. Then. turning downwards to the supraclavicular fosse, i! connects with heart. From there, it descends along the esophagus passes through the d reaches the stomach, and finally enters the small Intestine. its pertaining organ. The branch from the supralavicular fosse ascends along the neck to the cheek Vie the ol canthus, it enters the ear. The branch from the cheek runs upwards to the infraorbital region end furhter to the late, of the nose. Then it reaches the inner centhus to link with the Bladder Channel of Foot-T; !. Principal Indications )iseases of the head. nape ear eye and throat febrile and mental diseases, and the dis1 he regions along the course of this channel. 3. Points Commonly used See: The Small Intestine Channel of Hand-TeiyanolGraohicsl FIGURE A3. The description of the selected channel.
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K. Wang andJ. Liu
The Small Intestine Channel Close
J~ I~ SI ]O ( - / ~ _ ~ ~J~ SI9
PB-~-SI5
Sill
SI 16
iTS- sI~ sI t ~
FIGURE A4. The detail view of the selected channel.
Exit
AcuXpert (ACUPUNCTURE EXPERT] --Back Help
DISEASES OF THE RESPIRATORY SYSTEM DISEASES OF THE DIGESTIVE SYSTEM DISEASES OF THE CIRCULATIORY SYSTEM DISEASES OF THE UROGENTIAL SYSTEM DISEASES OF THE MOTOR SYSTEM NEUROTIC AND MENTAL DISEASES OTHER DISEASES
FIGURE AS. The general classification of common diseases.
II
AcuXpert
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Acuxped [ACUPUNCTURE EXPERT) Exit
Back
ii
Help
HEADACHE INTERCOSTAL NEURALGIA SCIATICA FACIAL PARALYSIS HYSTERIA SCHIZOPHRENIA CEREBROVASCULAR ACCIDENTAL SEQUELA NEUROSISM
FIGURE A6. The sub-menu of 'Neurotic end Mental Diseases'.
HEADACHE_TEXT _Close escription: eadache is a subjective symptom. It can be Induced by various acute or chronic Iseases. ifferentiation: I. Headache due to invaUon of pathogenic wind into the channels and collaterals. _~.Headache due to upsurge of Iiver-yang. ]. Headache due to diflciency of both ql and blood. E3aihuJ (DU 20),Talyan (F.2d;r_J~_]_),and Hegu (LJA). lethod: LJsethe flliform needles to puncture the points with the reinforcing method and ~oxibustiorL, for differenUaUon 3, and the reducing method or even movement or the other two types of headache.
HEADACHE_DIFFERENTIATION Back Restart Headache symptom. Headache occurs often, especially on exposure to wind. Headache. distension of the head, Irritability, hot temper, dizziness. Lingering headache, dizziness, lustTeless face
FIGURE A7. The window of Headache.
m
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K. Wang and J. Liu
Heau Point
~
~ ~]'[e~Lz
(T_,I4)
Erjian (LI 2)
$hangyang (LI
FIGUREA8. The location of point 'Hegu (L14)'.
HEADACHE DIFFERENTIATION Back __Restart Iue colour.
IPale t ~ h
thin and white coating.
HEADACHE DIFFERENTIATION Back
_.Restart
~. HEADACHE_DIFFERENTIATION Back Restart upplementary points should be selected according to the channel and collateral which the points located.
IOccipital headache
FIGURE A9. The consultation windows of Headache dlfferentiatlon.
AcuXpert
13
HEADACHE_DIFFERENTIATION Back
Restart )lementary points are: Yintan $hangxing (DU 23). and Neiting (S 44)
FIGURE A10. The supplementary points recommended for Headache.
NeiIJng Point
Jiexi(S 4 ] ) - - " ~
~.1.(s43)~ ,..."
Ii I
Nei/h~ (S 44) ~ ~,7 ~
L;a,,;(s 45)
FIGURE All. The location of supplementary point 'Neiting(S14)'.
(Appendix 2 overleaf)
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K. Wang and J. Liu
APPENDIX 2 The knowledge base of Headache written in KnowledgePro Windows (********** headache Rule ********************** topic headacheRules. !main:therapynumber is 1. IF ?'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND ?'Tongue colour' is 'Thin and white tongue coating.' AND ?'Pulse' is 'Floating pulse' AND ?'Location' is 'Frontal headache' THEN therapy_text in ask w ('The supplementary points are: Yintan (#mExtra 2#m), Shangxing (#mDU 23#m), and Neiting (#mS 44#m)',6). IF ?'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND ?'Tongue colour' is 'Thin and white tongue coating.' AND ?'Pulse' is 'Floating pulse' AND ?'Location' is 'Temporal headache' THEN therapy_text_in_ask_w ('The supplementary points are: Waiguan (#mSJ 5#m), and Zulinqi (#rnG 41#m)',6). IF ?'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND ?'Tongue colour' is 'Thin and white tongue coating.' AND ?'Pulse' is 'Floating pulse' AND ?'Location' is 'Parietal headache' THEN therapy_text_in ask_w ('The supplementary points are: Houxi (#mSI 3#rn), Taichong (#mLIV 3#m), and ZHIyin (#roB 67#m)',6). IF ?'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND ?'Tongue colour' is 'Thin and white tongue coating.' AND ?'Pulse' is 'Floating pulse' AND ?'Location' is 'Occipital headache' THEN therapy_text_in_ask_w ('The supplementary points are: Fengchi (#mG 20#m), and Kunlun (#mB 60#m)',6). IF ?'Headache symptom' is 'Headache, distention of the head, irritability, hot temper, dizziness.' AND ?'Tongue colour' is 'Red tongue with thin and yellow coating.' AND ?'Pulse' is 'Taut and rapid pulse' THEN therapy_text_in_ask_w ('The supplementary points are: Fengchi (#raG 20#m), Xiaxi (#mG 43#m), and Xingjian (#mLIV 2#rn)',5). IF ?'Headache symptom' is 'Lingering headache, dizziness, lustreless face' AND ?'Tongue colour' is 'Pale tongue with thin and white coating.' AND ?'Pulse' is 'Thin and weak pulse' THEN therapy_text_in_ask_w ('The supplementary points are: Qihai (#mRen 6#m), Zuanli (#mS 36#m), Pishu (#mB 20#m), and Shenshu (#mS 44#m)',5).
AcuXpert
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topic 'Headache symptom'. !main:threapynumber is 2. ask ('Headache symptom.',, ['Headache occurs often, especially on exposure to wind.', 'Headache, distention of the head, irritability, hot temper, dizziness.', 'Lingering headache, dizziness, lustreless face' ]). end. topic 'Tongue colour'. !main:therapynumber is 3. ask ('Tongue co lour.',, ['Thin and white tongue coating.', 'Red tongue with thin and yellow coating.', 'Pale tongue with thin and white coating.' ]). end. topic 'Pulse'. !main:therapynumber is 4. ask ('Pulse.',, ['Floating pulse', 'Taut and rapid pulse', 'Thin and weak pulse' ]). end. topic 'Location'. !main:therapynumber is 5. ask ('Supplementary points should be selected according to the channel and collateral #nin which the points located.',, ['Frontal headache', 'Temporal headache', 'Parietal headache', 'Occipital headache' ]). end. end.
Appendix 2 continued
Pergamon 0957-4174(95)00029-1
AcuXpert: An Intelligent Computer Aided Learning and Diagnosing System for Acupuncture K.ESHENG WANG Department of Production and Quality Engineering, NTH, N-7034 Trondheim, Norway
JUNXIA LIU Chinese Acupuncture Institute, N-7013 Trondheim, Norway
Abstract--The Acupuncture Expert (AcuXpert) is the first Intelligent Computer-Aided Learning (ICAL) system in the science of acupuncture and moxibustion in the worM. There are two purposes for the development of such a system: the first is to teach students the principles and concepts of the science of acupuncture and moxibustion; the second is to instruct acupuncturists to make correct diagnoses, employ right treatment methods, select effective acupuncture points and find precise positions during the clinical practice. AcuXpert is an 1CAL system in which two emerging technologies, expert systems and multimedia, are being incorporated into organisations. The system consists of five modules: (1) Introduction; (2) The channels and points; (3) The techniques of acupuncture and moxibustion; (4) Acupuncture treatment; and (5) Diagnosis expert. The intelligent system was developed using an intelligent system development tool, KnowledgePro Windows, and runs on a PC. It demonstrates the usefulness and advantages of the integration of expert systems and multimedia. Multimedia is supported by hypertext and hyperregion based searches and by imaging technology to assist students and acupuncture doctors in analysing symptoms and providing recommended prescriptions. Results achieved indicate that the system offers advantages in quick learning and correct diagnosis. In addition, training is faster and the user satisfaction is higher.
1. I N T R O D U C T I O N TRADITIONALCHINESE MEDICINE (TCM) is a representative of eastern medicine and it is a famous national traditional medicine in the world. As it is known to all, several hundred million of the Chinese population used to be under the care by the TCM before the western medicine was introduced to China. Even now, a large number of Chinese people prefer to see a Chinese traditional doctor when they get ill. The science of acupuncture and moxibustion is an important component of Traditional Chinese Medicine (TCM) with a long history. For thousands of years it has been accepted by the general population for its good curative effect, wide range of indications, simple application, low cost, safety and no side effects, etc. Since the 1970s, the spread of the science of acupuncture and moxibustion has become widened in Norway. The science of acupuncture and moxibustion as an alternative medicine treatment generally accepted by the western medicine doctors and it has become a very popular
alternative medicine treatment in Scandinavian countries. In Norway, about 1500 individuals had learned and practised acupuncture and moxibustion until 1994. At present, most of them obtain very shallow knowledge of the science of acupuncture and moxibustion through some short, intensive and weekend courses from not very experienced and qualified teachers. In such a way, it is very difficult for them to understand clearly the principle of the science and learn correctly the method to cure the different diseases. The main reason for the situation is that they lack substantial training and practice. All of this will lead to misunderstanding and misuse of acupuncture. The most serious result is to cause the death of patients. To train and produce the qualified acupuncturists under such conditions, as lack of teaching time, school facilities and experienced acupuncture teachers, is an urgent problem in Scandinavia. Intelligent ComputerAided Learning (ICAL) will explore the possibility of employing Artificial Intelligence (AI) techniques to support learning and diagnosing with the help of
2
computers. The advantages of using ICAL in education are clear. Such a kind of education is individual; it is independent of time, place and teachers. The students can always use computers to study the principles and conceptions again and again and to repeat exercises and demonstrations by themselves. The philosophy in ICAL is very suitable for coping with the present situation of acupuncture in Norway. In 1993, The Chinese Acupuncture Institute (CAI) working together with the Department of Production and Quality Engineering launched the project: to develop the Intelligent Computer Aided Learning system, AcuXpert, for aiding in the learning of the science of acupuncture and moxibustion and in diagnosis of different diseases. Two emerging technologies that are being incorporated into organizations at an ever-increasing rate are expert systems (ES) and multimedia (MM). While these technologies have developed independently, they possess capabilities that make them highly suitable for integration with each other. AcuXpert, is examined to demonstrate the usefulness and advantages of ES and MM integration in ICAL systems. Expert systems provide an effective approach for diagnosing of diseases, analysing of symptoms and recombining of prescriptions similar to experienced acupuncture doctors. Multimedia is supported by hypertext and hyperregion-based searches and by imaging technology to assist acupuncturists in studying subjects, and understanding the fundamental principles of the science. The system could be used by either medical students or trained qualified medical personnel, such as doctors or acupuncturists. The knowledge used in AcuXpert is extracted from the Chinese Acupuncture Institute at Trondheim and a number of famous Chinese acupuncture experts (Han, 1994; Guo, 1991; Liu, 1988; Liu, 1991; Yang, 1987). Dr Liu at CAI has her acupuncture and moxibustion practice for several years in Trondheim and combined the Traditional Chinese Medicine (TCM) and the western school medicine to treat effectively patients. Dr Liu cured a lot of Norwegian patients of difficult illness which could not be treated by the school medicine. CAI has a high reputation in Norway due to the high skills, the qualified treatment and the good service. To serve the people wholeheartedly and release the sufferings of the patient is the sole aim of CAI. This provided a handy, concise, and compact collection of high quality acupuncture knowledge. KnowledgePro Windows, an intelligent system development tool, is chosen as the programming language because it combines both expert systems and multimedia in a single development and runs on the PC. The program is easy to use and relatively inexpensive, and has good interface capabilities to external programs. This paper is concerned with one particular facet of ICAL, namely the integration of expert system technology and multimedia techniques as a resource to facilitate the implementation of computer-based teaching and
K. Wang and J. Liu
Receptive Response Contructive Response FIGURE 1. A conventional education system.
learning processes within the science of acupuncture and moxibustion. The first gives an overview of ComputerAided Learning (CAL), expert systems and multimedia techniques. The second offers the model of the integration of theses two techniques. The third describes the development of the Acupuncture Expert (AcuXpert). And finally, the last part of the paper will draw the conclusions. 2. LEARNING PROCESS OF ACUPUNCTURE AND MOXIBUSTION Generally, the learning process of acupuncture and moxibustion is the same as the conventional learning process. Figure 1 shows a conventional learning system. A teacher sends out the education information to a student using language, blackboards, and other media, and the student receives the information. This is called Receptive Response. The student has to understand the information sent by the teacher and can answer all the questions from the teacher. That is called Constructive Response. To become a qualified acupuncturist, at least, it is necessary for him/her to learn and understand the following contents: (1) The fundamental principle of the Traditional Chinese Medicine (TCM); (2) Body-surface distribution of the Fourteen Channels; (3) The locations of acupoints; (4) Classification and therapeutic properties of acupoints; (5) The techniques of acupuncture and moxibustion; (6) Principles of acupuncture treatment; (7) Acupuncture therapy of common diseases; and he/she must have a good clinic practice under the instruction of qualified acupuncture doctors to learn, check and modify the knowledge they have learned in a classroom. The expert knowledge of acupuncture is often obtained through a long period of practice and some special knowledge cannot be learned from books and beneath teachers. 3. THE PROBLEM SOLVING STRATEGY In order to find out the approach to solve the mentioned problem above, that is, to reduce the learning time and improve the education quality, several techniques are examined in the following sections. The best approach will be selected for developing the system from these alternatives. 3.1. The Computer-Aided Learning (CAL) The application of computers for implementation of learning and instruction processes is referred to as
AcuXpert Computer-Aided Learning (CAL) (Kong, 1994; Steenhvisen, 1991; Barker, 1985; Watson, 1987). Computers play a different role from a blackboard, books and other media in education processes. CAL systems involve the development of a special type of instructional software or providing a student with appropriate program tools that can be used in problem-solving situations within the domain of study. By the use of a computer, course materials can be directly sent out to and received from students. In other words, in the learning process, a computer can be employed to replace a teacher partly or wholly. The new education system is illustrated in Figure 2. Over the last decade there has been a growing development of using Artificial Intelligence (AI) as a tool to aid the fabrication of a wide range of learning resources in computer-aided learning system. The application of AI techniques to improve conventional CAL methods are described by the term Intelligent ComputerAided Learning (ICAL). Compared with CAL systems, ICAL covers a broad and diverse range of topics such as the construction of intelligent authoring, student modelling, the creation of intelligent tutor systems, and fabrication of sophisticated systems to support knowledge-based CAL (Barker, 1988). The use of expert systems technology can considerably improve the computer-aided learning processes. A typical ICAL system, which consists of an expertise module, a tutoring module, a student module, and an intelligent user interface is presented in Figure 3 (Burn, 1991).
3.2. Multimedia Techniques Basically, multimedia is an information management tool that links text, graphics, sounds, or other types of media in an associative way (Suhayya, 1993; Nielsen, 1990). In doing so, it allows users of a system to navigate through information in a nonlinear fashion. Moreover multimedia has the potential to simulate the human ability to organise and retrieve information by referential links, the technology is also capable of providing a form of a relational object-oriented network that can extend knowledge representation within an intelligent system application. With this kind of capability, multimedia can play a major role in intelligent systems development through its ability to access information or control program navigation in a nonlinear way. Unlike a book, where pages are ordered sequentially and routinely read in a linear fashion, multimedia information can represent a collection of interconnected files that contain text and graphics linked into a network. Users are free to progress, or navigate, through a system using any
I~eacher~--~ Computer~H~ Student1 FIGURE 2. A Computer Aided Leamlng system.
3
..... almmatlon 1~ d Instruefionall, ~q-~ Expert ~ . ~ I Intelligent Interface q _ _ ~
FIGURE 3. Architecture of a general ICAL system.
number of nonlinear pathways for which links have been established by the designer. Through multimedia is an extremely powerful tool for interconnecting information in intuitive way, thereby augmenting human intelligence, it is not by itself, capable of rendering intelligent applications. As an organizational and information retrieval tool, multimedia does provide a highly flexible context for representing knowledge, it lacks the reasoning or inference ability to generate to truly 'intelligent system' found in expert systems. Multimedia is a technology that is highly complementary to expert systems in building effective intelligent system applications. Multimedia is well suited to applications that include training or education, primarily because of the flexibility that the technology offers over conventional ComputerAided Learning. This flexibility is reflected in a nonlinear access to information and a transfer of program control for the developer to the user. Unlike a traditional CAL program, multimedia can be more adaptive overall, offering a more effective program navigation that is geared to the needs and interest of the user. A second benefit of using multimedia in a training/education environment is its ability to foster greater exploration of relevant, but perhaps tangential, information. The Dynamic Medical Handbook project, the drug information data base and Explore-l, etc. are good examples of this use of multimedia in the medical profession (Schneiderman, 1989). These multimediabased systems and many others in the specialized education offer instruction at all levels the ability to link creatively diverse sources of information to single problem or issue.
3.3. The Integration Models Generally, knowledge representation, inference, and nonlinear association of information are critical to intelligent systems. Unfortunately no single information technology or application program can integrate these functions well. However, when integrated within a single application or used with existing programs, multimedia and expert systems offer a rich environment for creating software applications that can indeed behave intelligently (Bielawski, 1991; Clarke, 1994). They do by combining the problem-solving, associative, or expressive powers of humans at work.
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K. Wang and J. Liu
The integration models of ICAL system can be classified as the three following models: Model 1: Expert system-based ICAL system with multimedia support. Model 2: Multimedia-based ICAL system with expert system support. Model 3: Integrating ICAL system with existing information and data-based applications. These basic design models suggest that, although ICAL systems can effectively combine multimedia and expert systems, one technology will often dominate the over-all program structure. Model 2 is selected to construct AcuXpert system (see Figure 4). The system is an information access system primarily based on multimedia, but containing an integrated or embedded expert system component, How the development tool facilitated technology integration will be described in Section 5. 4. T H E D E V E L O P M E N T OF ACUXPERT Because AcuXpert uses existing information sources and employs the experience of CAI, the intelligent system exhibits both relational knowledge in the form of multimedia and procedure knowledge within its expert system component.
4.1. The Use of Hypertext The use of hypertext within AcuXpert is fundamental to the implementation of the multimedia paradigm. The text about the description of points and channels etc. is stored in the external text files. The text references are embedded directly within knowledge base. When a hypertext reference is selected for display, the system searches the current knowledge base for a topic corresponding to the selected item. An integral part of AcuXpert is hypertext linking. Hypertext works in much the same way as a system of index cards. Information is entered on an initial hypertext card, which pops up like a window. On the information cards are buttons, which are highlighted word(s) that can be clicked on to bring up additional, overlaid cards. Thus, further investigation of highlighted topics is possible. The information on cards covers topics about the description of channels and points, equipment used, diagnosis procedures, and any other relevant information
about the science of acupuncture and moxibustion. In this way, hypertext allows the users to breeze through large amounts of information to find whatever is needed for quick learning and diagnosing. The hypertext is used mainly by less experienced user. It helps them quickly find useful information and learn the science. More experienced users use the hypertext as a time-saving device. Using the hypertext, they do not have to check books and notes and they do not have to remember minute details.
4.2. The Use of Still Images AcuXpert makes extensive use of images to aid in science learning and diseases diagnosing, including images of 14 channels, all acupoints and devices of acupuncture. These images play a very important role in AcuXpert for two reasons. First, they increase effectiveness through-visual picture. Second, they show the directions of the channels and the positions of acupoints. Still images are incorporated as follows: • Images are obtained by scanner. • Images are edited using a PC-based graphics development tool, for example, Paintbrush. • Digitised images are then translated into bitmap files. • KnowledgePro retrieves and display the bitmaps in Windows environment.
4.3. The Use of the Expert System Based on the principle of the theory of Traditional Chinese Medicine, the process of the acupuncture treatment may be represented by the following steps: (1) Symptom; (2) Identification; (3) Differentiation; (4) Treatment; (5) Prescription; (6) Supplementary points; and (7) Methods. Generally, the identification of the diseases from the symptom for acupuncture treatment is not so difficult. The major problem is how to use the symptom to make differentiation and the differentiation does play an important part in the acupuncture therapy of the diseases. In the expert module of the system, the step of identification is omitted, that is, users have to identify the diseases and the symptoms are just used for differentiation of diseases. The remaining can be automatically executed in the system. 5. T H E S T R U C T U R E O F A C U X P E R T AcuXpert has five modules, which are described below and shown in the opening of the program (see Figure A1. in Appendix):
FIGURE 4. The structure diagram of integration model 2.
Module 1: An introduction to the AcuXpert program. Module 2: The channels and points, which describe the 14 channels and the related points. Module 3: The techniques of acupuncture and moxibustion.
AcuXpert
5
Module 4: Treatment, which tells about the general principle of acupuncture treatment. Module 5: Therapy of common diseases, which is an expert system component for diagnosing common diseases. The details of all these modules are described as follows:
5.1. Module 1 Module 1 consists of the information about the concept of the science of acupuncture and moxibustion; history; situation in China; developments in the world; problems at present; advantages of AcuXpert; how to use AcuXpert and References.
5.2. Module 2 14 channels and ca 300 acupoints are displayed using still images which are located on 95 bitmap files, respectively. After the pictures representing 14 channels and all points has been scanned by the hand-scanner, any annotation and modification that was needed was done using PC Paintbrush.
5.3. Module 3 The techniques of acupuncture and moxibustion consists of: (1) Acupuncture techniques which contain: Preparations prior to acupuncture treatment, Needling methods, and Management of possible accidents; (2) Moxibustion and cupping therapy which contains: Moxibustions commonly used and Precautions; (3) The three-edged needle; (4) Point injection; (5) Eletrotherapy; (6) Scalp acupuncture; (7) Ear acupuncture therapy.
5.4. Module 4 A general introduction to acupuncture treatment consists of: (1) General Principle of acupuncture treatment; (2) Point prescription; (3) Application of specific points.
5.5. Expert Module Based on the theory of Traditional Chinese Medicine (TCM), the reasoning process can be represented as the following figure 5. In AcuXpert, identification of diseases is not carried out by the computer. The type of a disease can be easily identified by the acupuncturists or diagnosed by doctors in a hospital. The main task of AcuXpert is to recognise the differentiation and to make the decision of a
prescription (to determine the points). Forty-three different diseases are included in the system. According to the symptoms of a patient, an acupuncturist can determine the type of a disease and click the item of a given menu. The computer will give the suggestion of main points needed for treating the disease. Following the symptoms of the disease, the acupuncture makes differentiation of the disease. It is done just by selecting the item of the menu in the window. The computer will indicate the supplementary points. In order to illustrate the implementation of the system, a common disease, headache, is taken as an example.
(1) Knowledge Acquisition For the therapy of headaches, Dr Liu at CAI has designed a treatment according to her experience. Based on her experience, acupuncture prescription includes main points and supplementary points. The prescription plays a very important role in the therapy of diseases. The key problem is to make correct differentiation of diseases. The prescription put into AcuXpert has been proven to be very effective and high satisfactory through several years of practice in both China and Norway.
(2) Knowledge Representation (a) Decision Trees. The knowledge of the trophy of headaches can be represented by the use of the decision tree shown in Figure 6. The three types of differentiation are represented in level 1 in the decision tree. DI: Headache due to invasion of pathogenic wind into the channels and collaterals; D2: Headache due to upsurge of live-yang; D3: Headache due to deficiency of both qi and blood. In level 2, the symptoms can be divided into three groups: headache symptom, tongue colour and pulse. Headache symptom can be represented as S l: Headache occurs often, especially on exposure to wind. $2: Headache, distension of the head, irritability, hot temper, dizziness. $3: Lingering headache, dizziness, lustreless face. Tongue colour as $4: Thin and white tongue coating. $5: Red tongue with thin and yellow coating. $6: Pale tongue Headache Level 0
?
Level 2 S1 FIGURE 5. The reasoning process of TCM.
$4
$7
$2
$5
$8
$3 $6
$9
FIGURE 6. The decision tree of the differentiation of headache.
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K. Wang and J. Liu Headache
suggestion of the prescription of acupuncture and moxibustion for a specified disease and then to look closely at the location of the points on the body. All these possibilities can easily be realised within the system.
Level 0
Level 1 6. CHOICE OF SYSTEM PLATFORM Level 2 Level 3
LIILi Extra 2 SJ 5 SI 3 G 20 G 20 D u 2 3 G 4 1 L i v 3 B 60 G 4 3 S 44 B 67 Liv 2
ten 6 ; 36 20 B 23
J
Du 20 Extra 1 L4
Main points
Supplementarypoints FIGURE 7. The decision tree of treatment of headache.
with thin and white coating. Pulse as $7: Floating pulse. $8: Taut and rapid pulse. $9: Thin and weak pulse.
(b) Recommendation of Treatment. The recommendation of prescription consists of prescription (main acupoints) and supplementary points. All acupoint are represented in the form of hypertext and they are linked to the images which show the right position of the corresponding points on the human body. The decision tree of recommendation is shown in Figure 7. (c) Production System. The production system used to represent the knowledge, for example: IF 'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND 'Tongue color' is 'Thin and white tongue coating.' AND 'Pulse' is 'Floating pulse' AND 'Location' is 'Frontal headache' THEN 'The supplementary points' are: Yintan (Extra 2), Shangxing (DU 23), and Neiting (S 44). (d) Reasoning Strategies. AcuXpert's five modules demonstrate the usefulness, power, and flexibility of combining multimedia and expert systems technologies within a single application. Using relational knowledge in the form of multimedia, AcuXpert retrieves information along different, nonlinear pathways determined by the user. The expert system module uses procedural knowledge reflected in a rule-based system that imparts the expertise of CAI through an interactive, menu-driven session. Once the images had been stored (as bitmap files) they could easily be retrieved and display in KnowledgePro. One user might first want to look simply at a description of the 14 channel and then run the diagnosis module to find the suggestion of the prescription of acupuncture and moxibustion for a specified disease. Another user might first want to obtain the
It was recognised that ICAL systems would be either PC based or the mainframe based (Kershberg, 1988). There have been reported many applications in medical consultation such as MYCIN, CASNET, INTERNIST, and PIP (Akiba, 1983). But the most of these systems are mainframe based. As we know, these systems have not yet been popular with clinicians as effective practical tools of diagnosis or treatment. The important condition at present is that most users of AcuXpert have the possibility of using PCs in their offices. PC based ICAL has the following advantages: • The PC is the standard personal workstation. • Ability to communicate with other PC applications. • Powerful PC/PS/2 graphics capabilities got graphics and imaging. • Portable even when there are no host terminals. • Low price. • Ease of maintenance. The disadvantages of using PC are: • For stand-alone systems, difficulties in updating new version of the systems to the end-user community. • Expert system software, data files, and graphic images utilise large amount of disc space. Considering all of these factors, it was decided to go with a PC based ICAL system. AcuXpert desired that this system be used by individuals and most of them are using PCs in their environments. 7. DEVELOPMENT T O O L The following are some of the factors considered prior to the selection of the development software (Wang, 1994): • Ease of development. • Ease of maintenance. • Ease of transportability. • Ability to fulfil current requirements. • Ability to fulfil further requirements. Based on the mentioned criteria and a review of several potential products, it was determined that KnowledgePro Windows would be used. This product was chosen for its relative low price, its relative ease of use, its robust external routine-calling ability, and its native hypertext development feature. The runtime version of this system can be run on any PC. Working on AcuXpert system under the Microsoft Windows environment on a PC, the developers built a prototype version of AcuXpert using KnowledgePro Windows, which is an application development tool from knowledge Garden Inc., that incorporates both expert systems and multimedia techologies (Thompson, 1991;
AcuXpert Barker, 1989). This tool fits the AcuXpert project very well because of its many features, such as full multimedia handling (including text, bit-map images and hyper-regions), good string manipulation, on-screen page scrolling, use of inheritance, extensive use of the windows library of screen design tools (such as buttons, check lists, and dialogue boxes), and inclusion of a powerful programming environment for rule-based expert system development. However, it was the high level of integration between multimedia, expert systems, and Windows components that made KnowledgePro Windows fit perfectly for the project. For example, any topic within the KnowledgePro environment can contain text, graphics, hyper-regions, procedural rule-based statements, or specific Windows commands. Thus, from a development point of view, the tool was well suited to the AcuXpert project and provided a vehicle for quickly prototyping a system that was largely based on existing information. An additional advantage for using KnowledgePro Windows for AcuXpert was that the tool runs under Microsoft Windows. Because most students and doctors currently bundle Windows with most of its desktop computer systems, the developers sought to develop an application for this software platform. Our major reasons for wanting to use the KnowledgePro Windows as an shell for producing AcuXpert are as follows: • Ease of use. • Consistent and friendly end-user interface. • Its built-in multimedia facility. • Its powerful range of primitive commands and functions. • Its comprehensive list processing facilities. • The facilities it offers for dynamic programming. • Its powerful input/output facilities. • The ease with which it can be 'tailored' to user's requirements. • Its ability to interface to other software items and packages. • Its range of add-on toolkits. • The easy way in which it can be used to produce other courseware-development shells. • The fact that it can act as an expert system shell. The last reason of using KnowledgePro is that Kpwin + + lets the developers write the entire application (runtime version) in a high-level, ease-to-learn language (KnowledgePro), and then generate native C + + code. The finished application is a fast, industry standard .EXE file with all performance advantage, but without the step learning curve of developing in C programming language. When you work in the high-level Kpwin environment, you can see your program run instantly using the Kpwin interpreter and then, when it's completed, use Kpwin to generate efficient, readable, error-free and object-oriented C + + code.
7 The learning and diagnosing processes used in AcuXpert are illustrated by Figures from A1 to A l l shown in the first part of the Appendix. The code of the knowledge base of headache in KnowledgePro Windows is listed in the second part of the Appendix. 8. EVALUATION During the development of AcuXpert, CAI and PQE has organised numerous discussion and evaluation meetings for the project in both Norway and China. Many important suggestions and much advice have helped the developers improve AcuXpert. After AcuXpert has been developed and evaluated in CAI the system has been presented and demonstrated in several medical institutes and conferences for evaluations and modifications. The discussions between medical doctors and AI development scientists play a very important role in the process of the development and evaluation of the system. Based on the demonstrations and feedback information, satisfaction of the system from acupuncturists and doctors is very high and they felt that such integration of ES and MM is a good approach to computer aided learning and diagnosing for acupuncture and moxibustion. The system will be put into international market soon. The new version of AcuXpert, in which moving images will be employed to show the needling method, the treatment processes, etc. is under development. 9. CONCLUSIONS This paper describes the structure and development of AcuXpert, which is an intelligent computer aided learning and diagnosing system. The integration of multimedia and expert systems techniques has been successfully implemented in the development of AcuXpert. Expert systems and multimedia can be combined in several different modes. This paper demonstrated only one mode of combining ES and multimedia technologies. The application of such a system to support the acupuncturists to learn the science of acupuncture and moxibustion and diagnosing of diseases is strongly recommended. AcuXpert is the first Intelligent Computer-Aided Learning system developed for the science of acupuncture and moxibustion. This system paves the way for the new research direction for further computer aided learning in Traditional Chinese Medicine and other alternative medicines. It also opens the door to smoothly introduce the Traditional Chinese Medicine into the western countries. This project has been developed for learning and diagnosing of real acupuncture practices. All the data and knowledge were extracted from CIA and a number of experienced Chinese acupuncture experts. It was so designed that it could be learned fast and reliably, and be
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directly used by inexperienced computer users. Evaluation at CAI was very satisfactory. Such a system aims at narrowing the gap between Chinese medicine and computer technology.
REFERENCES Akiba, Y., Tanaka, H., Hara, S., Nakazawa, S., & Furukawa, T. (1983). A microcomputer-aided fluid therapy consultation system. In Bemmel Ball & Wigertz (Eds) MEDINFO-83, North-Holland: IFIP-IMIA. Barker, P. G., & Yeats, H. (1985). Introducing Computer Assisted Learning Prentice Hall, London. Barker, P. (1988). Expert systems in engineering education. English Application of A1, 1, 47-58. Barker, P. (1989). Knowledgepro--A review and assessment. English Application orAl, 2, 325-338. Bielawski, L., & Lewand, R. (1991). Intelligent Systems Design - Integrating Expert Systems, Multimedia, and Data Base Technologies, New York: Wiley. Bums, H., & Parlett, J. W. (1991). The evolution of intelligent tutoring systems. In Bums, H. (Ed.), Dimensions of Design, Intelligent Tutoring Systems: Evolution in Design pp, 1-12. Hillsdale, NJ: Erlbaum. Clarke, D. E., Turban, E & Wang, P. (1994). Integrating expert systems and multimedia for improved troubleshooting of the city of Los Angele's computer hardware. Expert System with Application, 7, 441--449. Kershberg, L., & Dickinson, J. (1988). FINEX: A PC-based expert support system for financial analysis. In Ernst, E. J. (Ed.) Management Expert Systems pp. 111-133 Addison-Wesley Pub-
lishing Company. Kong, H. P. (1994). An intelligent, multimedia-supported instructional system, Expert System with Applications, 7, 451-465. Guo, X. Z. (1991). The geometric solutions of the effective acupoints, Science and TechnologyLiterature Publisher (in Chinese). Hart, M. (1994). The Collection of Practice of Acupuncture and Moxibustion. Chinese Medicine and Medicament publisher (in Chinese). Liu, H. Y. (1988). Practice Acupuncture, Beijing Publisher (in Chinese). Liu, S. Y. and Jian, X. Z. (1991). Therapy of Acupuncture, Xuiewan Publisher (in Chinese). Nielsen, J. (1990). Hypertext & Hypermedia, Academic Press Inc. Shneiderman, B. and Kearsley, G. (1989). Hypertext Hand-On~ Reading, MA: Addison-Wesley. Steenhvisen, D. M. (1991). FisioDisc: Using Knowledge Technology for Education Purposes. OperationalExpert SystemApplications in Europe, 207-221. Suhayya, A., Halasz, M. and Phan, S. (1993). An approach to hypermedia in diagnostic systems. In Maybury, M. T. (Ed.), Intelligent Multimedia Interfaces pp. 225-256. AAAI Press/The MIT Press. Thompson, B. (1991). KnowledgePro Windows User Manual, Knowledge Garden Inc. Yang, Z. S. (1987). The Science of Acupuncture and Moxibustion, Science and Technology. Publisher of Shanghai, Shanghai. (in Chinese). Wang, K. (1994). Development of expert diagnosis system using knowledge, Proceedings of the International Symposium on Manufacturing Science and Technologyfor 21st Century, Beijing. Watson, D. (1987). Developing CAL: Computers in the Curriculum. London: Harper & Row.
APPENDIX 1 AcuXpert [ACUPUNCTURE EXPER'I'J Exit
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INTRODUCTION THE CHANNELS AND POINTS THE TECHNIQUES TREATMENT THERAPY OF COMMON DISEASES
=
FIGURE A1. Opening menu screen In AcuXpert.
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The The The The The
Lung Channel of Hand-Taiyin Large Intestine Channel of Hand-Yangming Stomach Channel of Foot-Yangming Spleen Channel of Foot-Taiyin Heart Channel of Hand-Shaovin
ThE The The The The The
Bladder Channel of Foot-Talyang Kidney Channel of Foot-Shaoyin Pericardium Channel of Hand-Jueyin Sanjiao Channel of Hand-Shaoyang Gallbaldder Channel of Foot-Shaoyan9 Liver Channel of Foot-Jucyin
FIGURE A2. Selection of the channel 'The Small Intestine Channel of Hand-Talyang'.
The Small Intestine Channel of Hend-Teiyen~l Close 1. The Course of the Channel: The Small intestine Channel of Hand-Talyang starts from the ulnar side of the tip of the I finger. Following the ulnar side of the dorsum of the hand it reaches the wrist where it el from the styloid process of the ulna. From there it ascends along the posterior border of lateral aspect of the forearm, passes between the olecranon of the ulna and the medial epicondyle of the humerus end runs along the posterior border of the lateral aspect of ill arm to the shoulder joint. Circling around the scapular region, it meets Dezhui |Du 14) eJ superior espectof the shoulder. Then. turning downwards to the supraclavicular fosse, i! connects with heart. From there, it descends along the esophagus passes through the d reaches the stomach, and finally enters the small Intestine. its pertaining organ. The branch from the supralavicular fosse ascends along the neck to the cheek Vie the ol canthus, it enters the ear. The branch from the cheek runs upwards to the infraorbital region end furhter to the late, of the nose. Then it reaches the inner centhus to link with the Bladder Channel of Foot-T; !. Principal Indications )iseases of the head. nape ear eye and throat febrile and mental diseases, and the dis1 he regions along the course of this channel. 3. Points Commonly used See: The Small Intestine Channel of Hand-TeiyanolGraohicsl FIGURE A3. The description of the selected channel.
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The Small Intestine Channel Close
J~ I~ SI ]O ( - / ~ _ ~ ~J~ SI9
PB-~-SI5
Sill
SI 16
iTS- sI~ sI t ~
FIGURE A4. The detail view of the selected channel.
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DISEASES OF THE RESPIRATORY SYSTEM DISEASES OF THE DIGESTIVE SYSTEM DISEASES OF THE CIRCULATIORY SYSTEM DISEASES OF THE UROGENTIAL SYSTEM DISEASES OF THE MOTOR SYSTEM NEUROTIC AND MENTAL DISEASES OTHER DISEASES
FIGURE AS. The general classification of common diseases.
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HEADACHE INTERCOSTAL NEURALGIA SCIATICA FACIAL PARALYSIS HYSTERIA SCHIZOPHRENIA CEREBROVASCULAR ACCIDENTAL SEQUELA NEUROSISM
FIGURE A6. The sub-menu of 'Neurotic end Mental Diseases'.
HEADACHE_TEXT _Close escription: eadache is a subjective symptom. It can be Induced by various acute or chronic Iseases. ifferentiation: I. Headache due to invaUon of pathogenic wind into the channels and collaterals. _~.Headache due to upsurge of Iiver-yang. ]. Headache due to diflciency of both ql and blood. E3aihuJ (DU 20),Talyan (F.2d;r_J~_]_),and Hegu (LJA). lethod: LJsethe flliform needles to puncture the points with the reinforcing method and ~oxibustiorL, for differenUaUon 3, and the reducing method or even movement or the other two types of headache.
HEADACHE_DIFFERENTIATION Back Restart Headache symptom. Headache occurs often, especially on exposure to wind. Headache. distension of the head, Irritability, hot temper, dizziness. Lingering headache, dizziness, lustTeless face
FIGURE A7. The window of Headache.
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Heau Point
~
~ ~]'[e~Lz
(T_,I4)
Erjian (LI 2)
$hangyang (LI
FIGUREA8. The location of point 'Hegu (L14)'.
HEADACHE DIFFERENTIATION Back __Restart Iue colour.
IPale t ~ h
thin and white coating.
HEADACHE DIFFERENTIATION Back
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~. HEADACHE_DIFFERENTIATION Back Restart upplementary points should be selected according to the channel and collateral which the points located.
IOccipital headache
FIGURE A9. The consultation windows of Headache dlfferentiatlon.
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Restart )lementary points are: Yintan $hangxing (DU 23). and Neiting (S 44)
FIGURE A10. The supplementary points recommended for Headache.
NeiIJng Point
Jiexi(S 4 ] ) - - " ~
~.1.(s43)~ ,..."
Ii I
Nei/h~ (S 44) ~ ~,7 ~
L;a,,;(s 45)
FIGURE All. The location of supplementary point 'Neiting(S14)'.
(Appendix 2 overleaf)
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APPENDIX 2 The knowledge base of Headache written in KnowledgePro Windows (********** headache Rule ********************** topic headacheRules. !main:therapynumber is 1. IF ?'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND ?'Tongue colour' is 'Thin and white tongue coating.' AND ?'Pulse' is 'Floating pulse' AND ?'Location' is 'Frontal headache' THEN therapy_text in ask w ('The supplementary points are: Yintan (#mExtra 2#m), Shangxing (#mDU 23#m), and Neiting (#mS 44#m)',6). IF ?'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND ?'Tongue colour' is 'Thin and white tongue coating.' AND ?'Pulse' is 'Floating pulse' AND ?'Location' is 'Temporal headache' THEN therapy_text_in_ask_w ('The supplementary points are: Waiguan (#mSJ 5#m), and Zulinqi (#rnG 41#m)',6). IF ?'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND ?'Tongue colour' is 'Thin and white tongue coating.' AND ?'Pulse' is 'Floating pulse' AND ?'Location' is 'Parietal headache' THEN therapy_text_in ask_w ('The supplementary points are: Houxi (#mSI 3#rn), Taichong (#mLIV 3#m), and ZHIyin (#roB 67#m)',6). IF ?'Headache symptom' is 'Headache occurs often, especially on exposure to wind.' AND ?'Tongue colour' is 'Thin and white tongue coating.' AND ?'Pulse' is 'Floating pulse' AND ?'Location' is 'Occipital headache' THEN therapy_text_in_ask_w ('The supplementary points are: Fengchi (#mG 20#m), and Kunlun (#mB 60#m)',6). IF ?'Headache symptom' is 'Headache, distention of the head, irritability, hot temper, dizziness.' AND ?'Tongue colour' is 'Red tongue with thin and yellow coating.' AND ?'Pulse' is 'Taut and rapid pulse' THEN therapy_text_in_ask_w ('The supplementary points are: Fengchi (#raG 20#m), Xiaxi (#mG 43#m), and Xingjian (#mLIV 2#rn)',5). IF ?'Headache symptom' is 'Lingering headache, dizziness, lustreless face' AND ?'Tongue colour' is 'Pale tongue with thin and white coating.' AND ?'Pulse' is 'Thin and weak pulse' THEN therapy_text_in_ask_w ('The supplementary points are: Qihai (#mRen 6#m), Zuanli (#mS 36#m), Pishu (#mB 20#m), and Shenshu (#mS 44#m)',5).
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topic 'Headache symptom'. !main:threapynumber is 2. ask ('Headache symptom.',, ['Headache occurs often, especially on exposure to wind.', 'Headache, distention of the head, irritability, hot temper, dizziness.', 'Lingering headache, dizziness, lustreless face' ]). end. topic 'Tongue colour'. !main:therapynumber is 3. ask ('Tongue co lour.',, ['Thin and white tongue coating.', 'Red tongue with thin and yellow coating.', 'Pale tongue with thin and white coating.' ]). end. topic 'Pulse'. !main:therapynumber is 4. ask ('Pulse.',, ['Floating pulse', 'Taut and rapid pulse', 'Thin and weak pulse' ]). end. topic 'Location'. !main:therapynumber is 5. ask ('Supplementary points should be selected according to the channel and collateral #nin which the points located.',, ['Frontal headache', 'Temporal headache', 'Parietal headache', 'Occipital headache' ]). end. end.
Appendix 2 continued