Tuesday, March 15, 2011

An Analogy for the Mechanism of Acupuncture

In the Spring of 2009 a patient asked me how I thought acupuncture worked in scientific terms. I’ve heard this question many times in ten years of practice and don’t have an answer, but told her I thought it had something to do with the undifferentiated nerve fibers that occur throughout the sub-dermal level of our bodies. These fibers were found in the 1990’s by scientists looking for something else, and are remarkable because they don't have a connection to the central nervous system. Those researchers thought that perhaps the fibers were involved in the pain response, but didn’t really know their purpose. I have always wondered if these undifferentiated nerve fibers might be associated with proprioception, but in any event I have reasoned that whatever else an acupuncture needle does, it penetrates this layer of nerve fibers when it is inserted into the body.

In casting about for a way to describe this that might make sense to my patient, a computer network specialist, I suddenly had an idea and said, “Maybe these undifferentiated nerve fibers work like a wireless computer network. Maybe what has been previously described as a mystical ‘aura’ or ‘subtle energy’ is actually like an internal wireless communication system between these fibers and the central nervous system.”

And I was pretty pleased with my metaphor.

However, my patient took it a step further the next day. She told me that in thinking about what I had said, it occurred to her that many wireless networks she had worked with periodically needed to be hard-wired to the server. After adding new hardware or software, you had to re-sync the wireless and the wired systems by briefly connecting them with a wire and re-booting. Maybe, she suggested, the acupuncture needle fulfills the role of the wire acting to re-sync the wireless system with the server.

Well, I have to give it to her. Exchanging physical, mental and spiritual trauma for the computer system’s hard and software trauma, I think this makes more sense than any other scientific explanation I have heard for describing the mechanism of acupuncture. The more I've tested it the more I have liked the analogy, but I have no idea how to turn it into a hypothesis capable of being tested. Still, it comes closer than other scientific ideas I have heard for describing at least part of the range of mechanisms I have witnessed in ten years of practicing and 20 years of receiving acupuncture.

Tuesday, March 8, 2011

The Pulse

Feeling the pulse is the strangest part of what I do. Utterly subjective impressions of 27 possible qualities at 12 more or less specific points on the radial artery are one of the primary sources of diagnostic information. As a student, of course, you're terrified you won't ever be able to feel it, and I could only feel thump-thump-thump for about a year. Finally one night I could feel qualities in the pulse. My wife and I had gotten into bed and turned out the lights before I remembered that I needed to feel a 12th pulse for the next day's homework assignment. I reached out under the covers and held her wrist. I was relaxed and she was at a point in her menstrual cycle when her pulse was more active than usual. Clear as day there in the dark, her heart pulse was thin! Liver was soft, Kidney was..soft, too!

That was a cool moment, but come on. Really. How can you justify making diagnoses of mental, physical or spiritual illness by feeling the pulse on each wrist at three points on the radial artery?

I can't. And so once I could feel it I kind of ignored it. I'd feel the pulse and write a note, but I gave it very little attention in diagnosing the people I was treating. But after a couple of years I noticed that people with healthy heart pulses did okay. That is, I worked with a number of people who had real physical issues and very weak pulses at all of the other pulse positions, but were robust at the heart position. All such people tended to have fairly positive outcomes. On the other hand, I noticed some people had all decent pulses except for a weak heart pulse and they tended to not do as well as expected. The shen is called the Emperor or Empress, and is the spirit associated with the heart. The shen has to do with your fate, destiny or karma. Knowing you are on the right track, whatever it looks like on the outside and however it affects others, is a sign of heart health. Knowing you are on the right track, even if you have significant health issues, seems to give you better health. And being unsure of your path, even in the absence of physical or mental issues, seems to have a depressing impact on your health.

After proving to my satisfaction that there was this correlation between the heart pulse and the status of my patient's spirit, I started to pay more attention to all the pulses and to see how the qualities I felt did or did not help with accurately diagnosing conditions. By this point, ten years along, I feel pretty confident that what I feel at my patients' radial arteries is real and really does indicate something pretty much like what the Chinese tell us it does.

However, I still have no idea why.

Friday, March 4, 2011

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?

Wednesday, March 2, 2011


One of the things that I appreciate more and more about Chinese medicine is the wisdom of its observations of the seasons. Especially the season we are currently in, Spring. On the Chinese lunar calendar, Spring began this year on February 3rd, even though the vernal equinox isn't until March 20. The beginning of Spring varies each year on the Chinese calendar, but it is always earlier than solar Spring, some time in early February or even late January.

Why do I think this is wise? Well, Spring is associated with the wood element, and a tree can either be an inspiring and graceful example of life's resilience, beauty and tenacity or it can be a big damn nuisance if it's growing through your sidewalk. The emotion associated with Spring is anger/impatience/frustration, but it has a positive aspect too -- drive/focus/determination. All seasons on the Chinese calendar and their associated elements have this duality, but it is particularly easy to see in the Spring. Almost every year, there is a spell of "unseasonably mild" weather sometime in late January or early February. When it is over and cold weather returns, people are suddenly fed up with Winter. They get crabby and bent out of shape, and call it cabin fever. The organ associated with Spring is the liver, whose nickname is "the free and easy wanderer." The liver tends to get clogged up with the over-eating (and drinking) and reduced physical activity of the Winter season. The combination of this physical clogging with cabin fever psychology leads inexorably, year after year, to people feeling angry, impatient and frustrated sometime around now. If you're lucky, or know what to expect, you'll bend this potentially destructive energy to a project of some kind which requires a little drive, focus and determination. This time of year is especially well-suited to cleaning up your act and getting a fresh start, whether that involves going on a fast or cleaning and re-organizing your home, office or shop.

The other thing I appreciate about Spring starting in early February is that usually in this part of the world (central Pennsylvania), the first day of spring is the first day that the tips of the daffodils and other early Spring flowers first poke through the earth. It will be weeks or months before they bloom, but even if snow covers the ground, underneath the snow there are these stirrings of new life. And trees, even though they will be without leaves for a couple more months, have begun sending sap from their roots up toward the canopy. Making syrup is a great springtime activity -- it gets you out of the house, gets your sap flowing, and requires a little drive, focus and determination to see it though, from dozens of gallons of watery sap to a gallon or two of sweet syrup.

Sprouts and things that grow upward, like asparagus, are especially good to eat in this season, and springtime eating rituals (dandelions, maple syrup and shad around here) persist long after we have access to almost any food at any time from the local supermarket. The ancestral memory persists of creeping out when there's still snow on the ground to find something, ANYTHING, green to eat, or fresh meat after a long weary winter of eating dried, salted, preserved or buried food. Or starving.

Even in our modern, sealed-off world we still are connected to the earth, which starts awakening right around the time ancient Chinese observations say it does.

The color associated with the wood element is green, of course, and I chose the bamboo photograph in the background of this blog to indicate the season. The photo will change at each season. The next season, Summer, is due to start on May 5th this year.



I have just seen that "the official quarterly professional publication of the American Association of Acupuncture and Oriental Medicine (AAAOM)" is called The American Acupuncturist.

The AAAOM is a fine organization that I have belonged to and support, but I want to make clear that my blog has absolutely no connection to the AAAOM or any of its publications.

Thank you.

Welcome to An American Acupuncturist


Trey Casimir L.Ac. here. I was born in Texas, raised in Pennsylvania and received my acupuncture training in New York City. I have been licensed for 10 years and have been in private practice for that entire time. I have spoken and written about acupuncture and Chinese medicine many times in the last ten years, but have been seeking a broader audience and an expanded format. Therefore this blog.

I intend to write posts on basic concepts of Chinese medicine, to describe interesting case histories and to respond to questions you may have, about either general or specific topics. Most of all, I hope to begin a dialogue with patients, other acupuncturists and other healthcare practitioners about what it means to be a modern, science-loving practitioner of an ancient, decidedly non-scientific form of healing. How are Chinese medical principles universal, and how are they rooted in a particular time and place that may not always be easy to translate to other times and other places?

I have had many excellent teachers over the past 30 years and would like to acknowledge them, both to pay my respects and to give you some idea of my background and training. I have to start with my friend Elisa King. Although she is a dancer, dance teacher and choreographer rather than a healer, her influence started me trusting non-literal, non-linear reality. She also browbeat me into going to White Cloud Studio, which is where my training as a healer began in earnest. Juliu Horvath and Hilary Cartwright were the co-owners of the studio, and each of them taught me priceless lessons about yoga, healing and life. I was extremely lucky to get into the Swedish Institute's short-lived Acupuncture program as a member of their second class. The academic dean at the time was Sheila George, M.D., L.Ac., but the program's main teacher and driving force was Jeffrey Yuen. Jeffrey is known in the Chinese medical community as a once in a lifetime teacher with an encyclopedic knowledge of classical Chinese medical schools of thought, and I was extremely fortunate to be able to study with him. My other teachers were no slouches, either, and I would especially like to mention Francesca Biryukov, Edith Lee, Urayoana Trinidad, Sheila Mason and John Katomski as people whose words still ring in my ears. Finally, although she wasn't one of my formal teachers, Frania Zins, P.T. and Feldenkrais practitioner, taught me a tremendous amount during the 7 years I worked for and with her. I am humbled and grateful to say that several of these amazing people continue to advise, inform and enlighten me to this day.

My next two posts will be out in the next few days. The first will deal with a basic concept of Chinese medicine -- the seasons, specifically the current season, Spring. The second post will deal with a case history (my own) that illustrates an example of translating universal Chinese principles in order to treat a condition of a different culture (and possibly a different gene pool).

Thank you for your interest!

Please send me some questions!

Take good care!