The Gout

One of the challenges of being an American acupuncturist is that some conditions have uniquely modern characteristics -- for instance, exposure to exotic environmental toxins. However, toxins are toxins, and Chinese medicine has many approaches available for dealing with different sorts of toxic conditions. You may have to adjust techniques as new toxins show up, but the underlying principles are spelled out in the Chinese classics of medicine.

A greater challenge may lie in dealing with conditions that especially affect individuals from certain geographic or ethnic populations. Sickle cell anemia and thalassemia spring to mind as conditions that are known to disproportionately affect certain populations, but other conditions also seem to affect specific populations. Multiple sclerosis, for instance, seems to be strongly associated with people of western European descent, especially those who live in northern latitudes.

And then there's The Gout. In central Pennsylvania there's lots of gout -- it is usually capitalized and is always preceded by the honorific, The. The Gout traditionally had an almost comic association, because it was typically overweight, red-faced, self-indulgent people who got it, and when they were suffering an attack, their suffering was operatic. Nowadays there seems to be a new class of gout sufferer, though -- although uric acid levels may be high, they aren't necessarily high enough to meet the threshold for classic gout. Maybe we are more sensitive, or maybe some genetic change has occurred, but none of the gout sufferers I have known are particularly red-faced or overweight, although indulgence in gout-triggering food and drink must be confessed.

As far as I can tell, though, gout doesn't really exist in Asia. This may be because the foods which are said to be the irritating factor in gout -- beer, wine, chocolate, coffee, smoked meats and organ meats, as well as foods rich in purines (beans, oily fish, nightshades) -- aren't as widely consumed in the East as they are in the West. Or it may have something to do with differences in genetic make-up. The Gout is said to have a pretty strong hereditary component, and if there is limited intermarriage between geographically separated groups, it's easy to see how different groups might inherit different conditions. As we move around and intermarry more these "ethnic" conditions will become more universal, but for now, gout hardly seems to exist in the East and there is practically nothing in the Chinese medical literature about how to treat it. Since it is a very painful and somewhat mysterious condition, it is something that an American acupuncturist can expect to see in his or her patients.

I certainly saw quite a few gout sufferers in my early years of practice, and it was pretty clear that I wasn't able to do a damn thing for them and their gout. Believe me, all healthcare practitioners keep internal score of what they are pretty effective at dealing with and what they are not very effective at dealing with. They don't usually advertise their score, but they know what it is. And I knew that I was getting my butt kicked by The Gout.

Then I got it. Both my brothers had it, and being native Texans, beans, beer and barbeque were like mother's milk to us. Although, by the luck of the draw, it was a coffee binge that put me over the top and brought on my first bout of The Gout. There was no mistaking it -- it was like the comic book version of The Gout, or The Gout for Dummies. I awoke out of a dead sleep at 1:30 in the morning in a feverish sweat, my right big toe joint (bunion) consumed with a throbbing, hammering and unbearable pain. I don't remember how I got through that first night, but by daylight I had begun to try to think of a way to treat myself with acupuncture. And really, feeling such an intense, specific pain, it was pretty clear what had to be done.

Throbbing, fixed and intense pain is, in Chinese terms, blood stagnation. The easiest, most direct way to move stagnant blood is by bleeding. So I had to get a thick needle and stab myself right in one of the most exquisite pains I had ever felt until I drew a few drops of blood. From a remove it sounds pretty bad, but as any sufferer of The Gout will tell you, at the height of an attack you are ready to use coyote medicine -- that is, if we were more flexible and had sharper teeth, a fair number of us would just chew the toe off and be done with it. I had the flexibility but not the teeth, and I also wanted to come up with a modality that I could use on my patients. So I got a short, stiff needle, screwed up my nerve and went: stab,stab,stab,stab,stab,stab,stab!!!

Boy, did it hurt. But also, almost immediately after a few drops of very dark blood (confirming the stagnant blood diagnosis) appeared, I felt the fever break and the throbbing begin to ebb away. It took several days for the attack to resolve -- my toe remained tender for weeks after that first attack, and I remain vulnerable to subsequent attacks (I've had three or four in four years). I have become skittish about the offending food and liquor groups, but see it more as a difficult balancing act than as a lifelong responsibility to deny myself some of the things that, for me, define pleasure. Those TV commercials for The Gout medicine that show a shlub carrying a beaker of green fluid are very evocative for me, but more as a metaphor for keeping your balance (and grace) while carrying around a fragile and unsightly burden than as a metaphor for the need to adjust your chemistry.

Which brings us to a big difference between the way that western and eastern medicine understand, and treat, The Gout. Western allopathic medicine describes gout as a build up of uric acid in the blood which precipitates into the joints, especially the proximal big toe joint, via an incompletely understood pathway. Uric acid is typically excreted in the urine, and so gout is associated with the kidneys and bladder. However, in Chinese terms the meridian which is almost always affected, at the medial side of the big toe, is the spleen meridian. How can one reconcile the western, scientific explanation of a uric acid condition with the Chinese concept of the spleen meridian?

Although there is not perfect translation of even basic physiological functions between western and eastern understandings of the internal organs, it is widely assumed that the Chinese concept of the spleen primarily encompasses the functions of the western pancreas. The Chinese spleen, like the western pancreas, is the primary organ of digestion, but unlike the pancreas, the spleen also has a primary role to play in the formation of blood. Furthermore, as one of the organs associated with the earth element, the spleen is said to be involved with boundaries. The spleen is also said to dislike dampness.

Working backwards: relief being provided by bleeding at the spleen meridian (spleen 1 - 4 area) indicates blood stagnation associated with the spleen; the spleen is responsible for beginning the process of making blood, dislikes dampness and is associated with boundaries; over-indulgence in damp or yin-intensive foods (beer, wine, beans, shellfish, organ meat) contribute to gout. So what western medicine describes as uric acid crystals which are formed through some dysfunction of the kidneys and/or bladder, Chinese medicine would describe as a damp blood accumulation associated with a weak or over-taxed spleen. Among other things, this provides some possible explanation for a long-known but little-understood fact about The Gout -- cherries and cherry juice seem to be helpful for preventing gout flare-ups. In Chinese medicine, pit fruits (especially cherries), growing in the Summer, the fire element season, and being red, the fire element color, are especially good for the function of the heart, the internal organ associated with the fire element. I previously said that the spleen initiates the process of creating blood, but the second stage, which finalizes the process, occurs in the heart. Furthermore, under certain circumstances the heart has the ability to vaporize phlegm, a particularly sticky and dense form of dampness. Perhaps cherry juice increases the heart's ability to vaporize phlegm before it stagnates in the blood. By the way, the heart meridian flows from the armpit to the little finger. Sometimes if gout is not resolved at the big toe, it next affects the little finger, lateral wrist and sometimes the elbow.

So both western and eastern medicine see The Gout as an accumulation. Western medicine looks at the internal, chemical processes, comes up with an explanation for gout's mechanism and creates chemicals to counteract that mechanism. Even though it is my western eyes looking through an eastern lens, Chinese concepts lead to an observation of the typical external sites and character of the pain, ties those observations to phenomena observed to be associated with the condition (purines bad; cherries good) and comes up with a different explanation and a different approach to treatment. Both treatment approaches (allopurinal and colchicine in the West; bleeding the site of the pain in the East) are effective.

How to make sense of both?