Necessity is the mother of learning acupuncture points
One of the things I have noticed in my scant 20 or so weeks of hands-on clinical practice is the great difficulty of accurately locating acupuncture points. At times the body seems an intolerably huge landscape - full of unfamiliar landmarks and confounding convolutions. Yes, at other times the complications diminish and it seems as easy as anything. I find the latter times become more frequent as I go along.
Along with a general increase in my confidence and ability comes a deep interest in REALLY learning the points and channels. Before clinic, acupuncture very obviously played second fiddle in my hierarchy of my interests in Chinese medicine. I have always recognized its power, but simply didn’t feel drawn to study or understand it that much. Now, with my struggles in clinic, I find myself fascinated by each point and driven to learn more on multiple levels. I am also developing my non-intellectual skills, my ability to feel Qi, to palpate channels and to connect with the patient. I note this because most often when I relate my problems I have people telling me that I need to get out of my head and just “connect” with the energy of the patient. While I recognize the importance of that, it certainly isn’t the whole answer.
My methods
Before I talk about how I’ve been working with the points, I’d like to make one small note. I’ve divulged various study methods and tips before on Deepest Health. With the exception of a few suggestions, these have all been methods I’ve used. However, they were methods that I learned directly from others or developed after reading ideas in a book or on a blog. This is a great way to pick up new strategies, and I certainly will continue to use it. On the other hand, the methods I list below are different. They emerged organically to solve particular problems. What I mean is that in response to a particular experience, I desired some particular skill or understanding and worked out the best way to obtain it on my own.
This may seem to be a minor point, and I don’t want to hammer away at it. However, it definitely feels different. I feel more committed to consistently using these methods, and they seem to be more effective. Each new thing I learn inflames my desire to learn even more. A similar thing is happening to me regarding formulas, but the effect isn’t so dramatic since I’ve always been interested in understanding them. I expect clinical practice will create some new developments in that arena, however.
In essence, what I’ve been doing is simply making a list of all the points I use in a given week and then reviewing them in great detail. This is the bulk of my “method.” It has several parts, which I will describe in detail below. However, there are more subtle things that I’ve been doing in the treatment room. I don’t know if I’m quite ready to describe those pieces of the puzzle. One recent development was the return of very focused attention on sensing the layers of the body that the needle is passing through. This is something we learned in our first needling class, as one of our points Professors places a high importance on needling and manipulation in the various layers. I think being in clinic and having to manage so many things at once found me being a little neglectful in this realm - I’m glad I’ve remembered it now.
Anatomy : Descriptions, 2D, 3D, palpation and multiple sources
I’ve never been particularly interested in gross anatomy. In fact, this new revolution in my thinking has helped me to understand that I have an odd detachment from the physical nature of the body in general. Working with the anatomy has helped unravel that personal issue, yet another example of the many benefits of dedication to study. Anyway, we did take anatomy during our first year, but given my general reluctance described already and the fact that I was so enthralled with learning the cosmology and symbolism of Chinese medicine, I frankly didn’t pay much attention. I’ve used various sources to help deepen my understanding of anatomy.
Descriptions: Sometimes a word is worth a thousand pictures. While seeing what things look like on the body is very important, often it has been a stray description of a particular bony landmark in relation to a point that has really solidified its location for me. I use Deadman
as a primary source here.
2-D: Again, Deadman’s Manual of Acupuncture
3-D: I have an old version of Qpuncture that has 3D renditions of a needle in various commonly used acupuncture points. While some of the anatomical accuracy has been sacrificed, it is very helpful to see how the needle penetrates with reference to the anatomical markers we cannot see with the eye. I also subject my partner and daughter to infrequent channel palpation and point location (”Is this sensitive? What about this? This?”) which is often very helpful. Of course, while I’m studying the above sources, I palpate my own channels and feel the points on myself.
“Actions”, prescriptions and theory
The point location has been most bothersome for me, mostly because I’m obsessed with being sure that every needle has a real effect. That may seem to be a stupid statement. However, I’ve been needled by many interns and practitioners who don’t seem too interested in actually working with the POINTS - content just to needle anywhere on the body. I gather this from my perception of their lack of intention when needling, the obvious lack of accuracy based on where the needles end up as well as my conversations with them. I do believe that the “points” as they were laid out in ancient times are very special places on the human body that have powerful effects on the human being - I don’t think that “just anywhere” will do.
Despite my obsession with fully knowing where the points are, I haven’t lost sight of the importance of understanding “what they do.” I put “what they do” and “actions” in quotations for a reason. Acupuncture points are not like buttons on a machine. It’s not as if you press the red one and you get a cherry candy, blue one and you get a razzleberry one. It’s not as if some little ghost in the machine stands behind the point ready to report your instructions via the CNS with exactness and machine-like one-to-one correspondence. If a person asks me for “a point for asthma,” I’m reluctant to report the points we all know to be commonly used in prescriptions for that Western defined condition. It isn’t that points don’t “do something” and it isn’t that I’m afraid to talk about certain points as unequivocally treating some particular pathological state, it’s just that the way we try to simplify things for easy consumption result in overly simplistic ideas about how Chinese medicine works.
I think about acupuncture points like areas where one can access a river. They come in big and large sizes, they have varying ranges of ease of access, some put you in at a furious current, others at gentle pools. The direction you’re heading when you put in at any given point makes a difference, as does your intention when you do so - will you paddle upstream or let the current carry you down? Are you fighting the flow or not? Are you dredging the channel a bit to allow greater flow in a given area? Are you moving boulders that have obstructed your path?
The river metaphor breaks down a bit when we drill down a little more. Each point has its particular characteristics based on its location on the channel, its symbolic power given the part of the body and its physical features as well as a whole range of correspondences that fit the channels and points and the human being in with the consistent patterning of the universe. Thus five elements, yin-yang, six divisions and all their permutations and combinations are peppered throughout the system in remarkably predictable and usable ways. When we needle a patient, we are not pushing buttons, but mixing colors and flavors, textures and spirits in alchemically beautiful ways with the purpose of influencing the body in particular ways for the creation of health.
You know, no big deal. :D
All that being said, I’m not just going to abandon myself to studying nature and meditating as a way to understand what KINDS of mixtures are effective in what kinds of situations. I’m not comfortable with that, frankly. Instead, I look to the classics and the theories passed down by the ancients. I use Deadman and some sources given to me by my teachers to understand the Classical point prescriptions. I study closely the theory of the five elements and six conformations as well as point categories to fully comprehend the effect of a given point within a particular clinical context.
All of this is really helping my clinical confidence a great deal and I find that more often than not I am able to recall most of this information when I next encounter a particular point. Sweet! I’ve talked enough about this for now, but I would like to pose a couple of questions. Have you encountered the kinds of troubles I started out this article by describing? If so, how did you get past it? Do any of the methods or ideas above resonate with you? If so, how? If not, why not? I’d really like to hear about others’ experiences. Reply in the comments!
Thanks!
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Tags: Acupuncture, channels, clinic, confidence, focus, Learning, student, study-methods, studyingRelated posts
Deepest Health Chinese Medicine Podcast : Episode 10 : End of term clinical reflections
Welcome to another Episode of the Deepest Health Podcast! In this episode, I discuss my reflections as I come to the end of my first term/quarter in clinic at NCNM. I reiterate the importance of memorization and excellent patient care, but then go in a philosophical direction on a couple of topics. First, I discuss my experience of being able to separate the disease from the person experiencing the disease. Second, I talk about the paradoxical reactions of some patients to treatment. I wrap up the podcast by a discussion of utilizing our many human gifts, referring often to the quintissential “Renaissance Man,” Leonardo da Vinci.
In the podcast, I reference a blog - but cannot remember the name of the blog, so cannot link to the post that inspired my da Vinci explorations. If you, for some strange reason, know what I’m talking about - let me know and I’ll link it. I also reference a book I’m currently reading about da Vinci and the practices one might take from his life. You can click on the link below to check it out.
Tags: clinic, memorization, ncnm, patient care, Podcast
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The Art of Palpating the Abdomen for the Purpose of Prescribing Chinese herbal formulas
This is a guest post from recent National College of Natural Medicine (NCNM) graduate, Kumiko Shirai. She is a fine herbalist already and obviously has an expertise in the (almost) lost art of abdominal diagnosis. I have seen this work in action and can attest to its amazing effectiveness! Please enjoy the article. There are more guest articles to come! -Eric
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Japanese abdominal diagnosis, known as fukushin 腹診 is an art form of medical practice that is virtually lost in modern practice of Chinese medicine. There are two major schools and types of abdominal diagnosis, Nanjing and Shanghan Lun schools, which separates into the Japanese schools of acupuncture and the schools of herbalism respectively. There are many modern books written on acupuncture style of abdominal diagnosis, which is also referred to as hara diagnosis, however books written on herbal prescription style of fukushin are difficult to find.
In the studies of Japanese style of herbal prescriptions, kampo, 漢方 which is mostly based on Han Dynasty formulas from the classical texts of the Shanghan Lun and the Jingui Yaolue, one can find many abdominal patterns and findings for almost every formula. It appears, though it is not certain, that Zhang Zhongjing used abdominal palpation as part of his diagnostic tools. And there are many Japanese scholars who have elaborated and perfected their practices of fukushin for the purpose of herbal prescriptions based on Zhang Zhongjing’s classical texts.
The concept and significance of the abdomen are different in Japan from what exists in Western cultures. It was not too long ago that Japanese people commonly said, “I am going to go see a doctor to get my abdomen examined.” In Japanese culture, the abdomen or hara is central. Alternatively, the nervous system and mind seem to be central in Western cultures. But, when we think about it, the Japanese idea makes a lot of sense. The abdomen is physically a central part of the body, containing many of the vital organs. Japanese people also believe that hara is the seat of the soul, where self-consciousness is anchored. On the other hand, from pathological sense, the abdomen is where people hold emotional stress, affecting their digestive problems as well as other physical discomforts. For this reason, in Japanese medicine, the hara becomes a pivotal part of the body during the examination, diagnosis, and treatment.
In fukushin, abdominal patterns are named after herbal formulas such as “Xiao Chaihu Tang pattern” or “sho” in Japanese, which already gives a diagnosis and a treatment plan. On the other hand, in the Nanjing school of abdominal diagnosis, abdominal patterns are named after theoretical diagnostic concepts such as “Liver qi overacting on Spleen”. The difference between Nanjing style of theoretical approach versus Shanghang Lun style of clinical approach is interesting in that it shifted the clinical practice of kampo in Japanese medical history. One of the most influential Japanese scholars, Todo Yoshimasu (1702-1773), emphasized mastering clinical skills rather than understanding theories. He claimed that “proof is always more convincing than logic,” accentuating the importance of the practice of palpation, and to treat what is obvious by carefully examining the abdomen. For this reason, Todo inspired many practitioners to practice palpation during the examination. However, Japanese scholars did not ignore fundamental theories of Chinese medicine completely, and fukushin is still very much based on theory as well.
In order to give an herbal formula based on abdominal diagnosis, one must understand the architecture of the formulas first. There are eight therapeutic methods in the study of herbal prescriptions, however, it is important to break up each method into further smaller groups, understanding the function of the pivotal herb or herbs in each formula. The key herb in a formula may not always be the emperor of the formula, though often times it is. For example, in the purging method, there can be different causes for accumulation in the middle burner hence requiring different approaches and treatment plans. While Dahuang (in Da Chengqi Tang) treats fullness caused by middle burner accumulation due to qi stagnation causing heat, Mangxiao (in Tiaowei Chengqi Tang) treats accumulation of the middle burner due to dryness of the intestines, and Taoren and Mudanpi (in Dahuang Mudanpi Tang) treat fullness by breaking up blood stasis, hence moving both qi and blood. As a consequence, these three formulas, which share a common category of method, will have different abdominal patterns and imply different treatment plans.
In closing, I want to emphasize that examining a person’s center is not only theoretically appropriate but also clinically helpful in the process of assessment, diagnosis and finally planning a treatment. Hence, Chinese medicine practitioners, are encouraged to cherish the art form of practicing this medicine by observing and touching each patient and interpreting such information as holographic representation of the body.
Tags: abdominal diagnosis, asian medicine, clinic, Diagnosis, formulas, japanese medicine, patterns, schools, shang-han-lun, study, TheoryRelated posts
Deepest Health Chinese Medicine Podcast : Episode 7 : Clinical confidence and memorization
In this episode of the Deepest Health Chinese Medicine podcast, I discuss what it means to have confidence in clinic and why I believe memorization is so important for Chinese medicine practitioners. I do go into a little detail regarding best practices around memorization, and I hope this information will be helpful for everyone.
Look for an interview with Heiner Fruehauf as next week’s podcast, assuming all things go according to plan!
Thank you as always - please do leave comments on this post if you would like to start a discussion about the podcast.
Eric
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Tags: clinic, Learning, memorization, Podcast, studentRelated posts
How the Chinese organ clock yields a more nuanced view of the Heart
Here I will present a basic overview of TCM information concerning the Heart and then add a layer of information gleaned from the Organ clock (a more CCM way of looking at things). I want to do this to demonstrate how the Classical approach yields a more nuanced view than the straight organ-based TCM approach does, including a small aspect of the clinical relevance of this approach. Disclaimer : I’m still a student. :)
The Heart is a central organ system. From the perspective of governmental metaphor, the Heart is most easily compared to the Ruler of feudal society. What does the ruler do? It’s tempting to simply say that he rules and leave it at that. However, most rulers through history have acted less as hands-on managers of their empires and acted more as figureheads - acting as moral compasses, inspiring and motivating the people when needed, acting as interpreters of Divine law and generally providing a center point around which the wheel of government turned. The Heart is said to provide a similar function for the human body. To look at this and say that the Heart is “most important” would be erroneous. The Emperor without his ministers, without the workers, without the land - is nothing. It is an interdependent system. But, still, the Emperor is crucial and a lot of attention should be paid to those things that are crucial. We’ll do so now.
In TCM, the Heart is said to have many functions/associations:
- The Heart contains the Shen, which rules the other “spirits” of the Zang organs
- Shen, as I have explained briefly elsewhere, can be translated as “Spirit” but it contains more meaning than the normal English concept of Spirit. Many contemporary commentators talk about Shen simply as consciousness, but I feel it is more than that.
- The Heart governs the Blood Vessels
- The Heart acts as Ruler of the other organ systems
- The Heart, as related to the brain and consciousness, is in charge of many mental processes (one can see this as similar to the Heart’s function via its relationship to Shen - the fire of consciousness)
- The Heart propels the Blood
- The Heart governs speech
- There are other attributes, but these are the main ones mentioned in a variety of texts.
In truth, despite all of these things, most Heart related pathologies diagnosed in TCM have to do with mental function or, sometimes, heart organ abnormalities (such as blood stasis in the Heart yielding angina). In clinic, I mostly see Heart Qi/Blood deficiency (with palpitations and poor memory) and some version of the confusingly named “Heart Fire” resulting in insomnia, anxiety and some type of vexation. Rarely do I see doctors diagnosing a problem with the heart when there are circulation problems (blood vessels) or speech problems. Further, I think that there should be more attention paid to the fact that, as EMPEROR of the other organ systems, the Heart may be a great place to look when a seemingly unrelated pathology is difficult to cure with the methods we would normally utilize. While I will not focus much on blood vessel or speech problems in this article - I would like to do so in the future.
For now, to help us understand the Heart a little more deeply, I offer a brief exposition of some of the basic symbols associated with the Heart on the Chinese medicine organ clock. I will then describe some ways we can use this understanding to expand on the basic information we learn from TCM literature.
What do we learn about the Heart organ system from the organ clock?
Temporal nature : 11-1pm (High Noon) and the Summer Solstice
At first glance, the pairing of the Heart with high noon makes intuitive sense. This is the time we associate with the zenith of the sun, the burning off of morning fogs, the time when all things are apparent, illuminated, complete. But look again at the symbol for the taiji and superimpose this over the organ clock. Remember these symbol fields are multi-layered and 
while some aren’t meant to be compared one-to-one, the flow of Yin and Yang through the organ clock (and through the days on Earth) is a crucial piece of information in our understanding of organ systems.
This is the time of the birth of the Yin. Which brings us to another temporal aspect of the Heart - it is situated at the time of the Summer solstice. The solstice is the time of the greatest day length - so again, it is all flourishing and awake and alive. However, the hidden principle is the one of the birth of the dark - for the zenith of a thing always brings about its immediate descent into expiration. What goes up must come down.
What does this tell us about the Heart? That while it is a very Yang organ, as the Emperor should be, but it also contains a deep Yin principle within it. Our professor, Heiner Fruehauf, often relates the Heart to the feminine principle - which makes sense given this information. In that way, it may be more accurate for us to think of the Heart as the Empress - or some amalgam of the Emperor and Empress. Here is perfect control, high intelligence, beauty, grace, compassion, mercy and power. It is an intensely active principle - Yang - but with this huge strength of the Yin.
Why do I say that the strength of Yin is large when it is, in reality, just the beginning of the growth of Yin? Because the entire momentum of Yin’s growth starts at this point - it somehow contains the whole force of the future splendor of Yin’s fullness. It is strong in the sense that is young, vital, and on the ascent.
I think this Yin principle is very important. At the height of summer, at the height of noon, this is when we may have the tendency to go all upward and outward - but it is crucially important that we go within, nourish our deep spiritual nature. Some cultural customs bear this out - such as the tradition of the midday siesta and the many spiritual activities that go on around the summer solstice. I think that, in some ways, the failure to do this can be seen in American capitalist culture. The principle of constant up, out, grow, flourish is often not balanced with careful reflection, willingness to “stand down,” controlled descent and respect for the more passive aspects of the universe. This failure has penetrated the consciousness of many American people and others affected by this philosophy and may have something to do with much of the pathology we see today. More about this later.
Earthly Branch Wu : combined with the symbolism of the Horse in the Chinese zodiac
The Earthly branch Wu 午, reinforces what we’ve already discussed about the Summer Solstice - given that it is the Earthly branch associated with that part of the year. It is a picture of either a battering ram or a mortar and pestle, and thus we see again the idea of death or destruction in this life affirming and light giving symbol of the Heart. Wu 午 is also associated with the number five insofar that it is pronounced the same as 五, Wu - “five.”
This brings us to consideration of the association of the number five and the Heart. We should note that we’re talking about the fifth month when we talk about the Heart. The number five is extremely important in Chinese cosmology - witness the deep symbolism of the five elements and a whole variety of other symbolism assocaited with five. There’s just so much that I could say in this realm (and actually did, but then deleted to save your poor eyes) but I will have to stop here for the sake of article length.
The Earthly Branch Wu 午 is related to the Horse in the Chinese Zodiac. Remember, the Earthly Branches were associated with an animal to help them be easier to understand by the common people. The Horse is a particularly fascinating symbol for the Heart, which I could talk for a long time about. But consider just a few simple items. The horse is tireless, constantly galloping away, carrying great loads, even fighting in battle - just as our physical Heart must
persist throughout our lifetimes. The horse seems to share a Shen level connection with the human being - a really close rider and horse seem to read one another’s minds, few verbal commands are needed when the relationship is strong. The horse is one of the most beloved animals in all cultures, people sometimes take better care of their horses than they do their children!
I am certain there is more to understand about the horse - I would love to hear what people come up with in the comments to this post - please post below!
As always, there are many more symbols that we can pull from the organ clock to help us understand the Heart more deeply - but let’s work with what we have so far.
How does this help us understand the Heart more completely?
There’s a lot one could say about these symbols. The most important take-home message I have received is the crucial nature of respecting the Yin nature of the Heart. However, I don’t think you should start dousing your anxiety ridden patients with cooling herbs! On the contrary, they probably need Fu Zi. Which actually brings me to an important relationship and my overall point. You’ll excuse me if I diverge a bit into conjecture and philosophical exploration? Thanks.
We often talk about the relationship of the Heart and Kidney - fire and water. They are obviously related via their Liuqi designation of Shaoyin, or lesser Yin. We learn that the Shaoyin fire of the Heart must descend through the Earth to reach the Shaoyin water of the Kidney. In doing so, the cold Kidney water, the depth of our wisdom and lineage, is animated by the pure fire of Spirit and consciousness. Wisdom without use of that wisdom is nothing but a lifeless puddle. Likewise, the pure Kidney water must be steamed up to cool and contain the sometimes over-exuberant Heart Shen. Consciousness without wisdom quickly becomes tyranny and zealotry.
This is one way that I understand the importance of using Fu Zi even in the case of patients who appear to have lots of flaring Heat - such as patients with intense insomnia and anxiety. So many TCM physicians would balk at serving Fu Zi to such a patient. To provide one example of a powerful use of this principle, let’s go to that little book known as the Shang Han Lun.
下之後．復發汗．晝日煩躁不得眠．夜而安靜．不
嘔不渴．無表證．脈沈微者．乾薑附子湯主之
Xià zhīhòu．fù fāhàn．zhòurì fánzào bùdé mián．yè ér ānjìng．bù
ǒu bù kě. wú biǎozhèng．mài chén wēi, shēn wú dà rè zhě,gān jiāng fùzǐ tāng zhǔ zhī.
When precipitation has been used, yet sweating is then promoted so that the person in the daytime is vexed, agitated and sleepless, but by night time becomes peaceful and retching, thirst, exterios signs and great generalized heat are all absent, and the pulse is sunken adn faint, then Gan Jiang Fu Zi Tang governs (Mitchell/Ye/Wiseman version).
While I would like to think that most doctors would see patient with this picture - particularly the faint pulse - and realize that an intensely warming formula can be indicated, I think that most would still shun such strength and instead use something milder, more cooling, and most likely less effective.
One more point and then I’ll close this article. I believe that this fire-water relationship and the general Yin nature of the Heart leads us to realize the wisdom of having a well-developed spirituality. Only by combining the deep wisdom of contemplation (dwelling in the water) with the animating ecstacy of consciousness (dwelling in the fire) can we have balance. Advising our patients to nourish themselves in this way - of course without necessarily promoting a particular practice or tradition - may go a long way to helping them achieve greater health.
Tags: balance, clinic, earthly branches, fire, heiner fruehauf, horse, insomnia, law, organ system, Organ systems, organ-clock, shang-han-lun, spirituality, symbolism, taiji, traditional-chinese-medicine, water
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