The Elephant in the Room
Every now and then, a patient asks me if I treat myself.
As I write this, I’m sitting on a kitchen chair with needles in my gluteus medius muscles, which, according to Travell & Simons’s The Trigger Point Manual, are the adductors of the thighs related to “pain when walking, when lying on the back or on the affected side, and when sitting slouched in a chair.” As noted in my previous post, I almost always treat these muscles when someone complains of lower back pain. I don’t have lower back pain or pain when walking but I do slouch in my chair more than I want to, and I’ve been waking in the morning feeling a little stiff, finding it hard to get out in the winter for exercise as often as I’d like. Occasional needling here keeps these potentially tetchy muscles healthier and happier.
I do slouch on the couch. Couches seem to be designed for slouching, unless you’re at a formal tea, sitting forward on your sit bones while you balance a teacup in a saucer as you eat finger sandwiches. To err is human. As part of my lifetime balancing act, in all spheres, due to slouching or for other reasons, I make time to treat myself while the family and I watch movies, four or five of us seated on the couch together.
Perhaps because I’m left-handed (I use my left hand to write, wield chopsticks and insert acupuncture needles) I sit on the left side of the couch, next to a table with my needles. When my knee needs attention, I place needles in the muscles that support the knee, including the quads, gastrocnemius, and the various knee-related tendons and ligaments. The hamstrings are possible, if I sit forward. If my shoulder feels tweaky, I treat my shoulder muscles. The muscles of my posterior neck get attention from time to time. The son or daughter sitting immediately to my right gives me enough space so I don’t get jostled.
It’s a useful exercise. I get immediate feedback about each twist, twirl and pistoning of the needle, time-honored needling techniques. I feel my muscles twitch. I provide my own feedback, and get to experience myself the business end of a needle that I’m manipulating. Sometimes I get the childhood sense memory of the painful, pleasurable, nervy children feel when a baby tooth is about to fall out of its comfy nest. The sensation of the needle does feel like that sometimes, and I wonder if it feels like that for my patients. I think about whether I should contextualize it that way when I’m treating. (Helping people who are new to acupuncture frame their very strange experience is integral to what acupuncturists do.) Sometimes the needle feels sharp, and I have to remove it and try again with another. It’s instructive. (I don’t advocate non-acupuncturists doing this. Only acupuncturists should use acupuncture needles.)
When I was in acupuncture school, I remember the academic dean saying that she put needles in her hip “all the time.” This mystified me because I was receiving a (mostly traditional) acupuncture education. Our first task as students was to learn the names and locations of the 361 “classical acupuncture points” of the 12 “regular” or “primary” meridians plus two of the Eight Extraordinary Meridians. As a beginning student, I was under the impression I would be moving energy, or qi, along these meridians. It seemed hard enough to do this to someone else (we hadn’t gotten to that stage, yet), so how was one to do it to oneself?
The starting place for “doing it” was to learn the locations of the 361 standard meridian acupuncture points (plus a set of “extra points” that had special functions but were not on the meridians). The names and locations of these mysterious entities were codified in 1993 by the World Health Organization (WHO). Because 12 of the meridians flow bilaterally – the Heart and Liver meridians, to give two examples, are found on both the right and the left sides of the body – when you learned the basic 361 point names and locations, you were actually learning 670 locations. (Folded into this total are the points along the Du and Ren meridians, which move along the posterior and anterior center lines, respectively, so these meridians are singletons.) The points have precise locations along the pathways, often as multiples of an anatomical unit of measurement called the cun, pronounced “tsun” (the “u” has the same vowel sound as “good”). The width of a thumb equals one cun, as does the difference between the first two joints of the middle finger. The distance between the midpoint of the eyebrows and the hairline is three cun, to give another example. The length of the forearm between the wrist and the crease of the elbow is nine cun. Cun measurements, and anatomical landmarks like the collarbone, the cheekbone or openings for the passage of nerves in and out of other structures, have enabled acupuncturists through the ages to find the precise locations of points on tall, short, thin, and fat people, since anatomical measurements are proportional relative to the size of an individual’s anatomy.
Acupuncture points, written only in Han Chinese characters for almost all their recorded history, have metaphorical, poetic names that require translation for non-Asian cultures. The WHO document titled “Standard Acupuncture Nomenclature, Second Edition” < http://www.wpro.who.int/publications/pub_9290611057/en/> explains that the Han Chinese character is used not only in China but also in Japan, the Republic of Korea, Singapore and Hong Kong, and that “it gives the meridian and the acupuncture point name a meaning of therapeutic value which often defies translation.” This is pretty interesting when you think of it: the name of the point has therapeutic value. If you could not read Chinese, you not only had no way of knowing which point was where – because you had no naming map – but, equally important, you had no access to the presumed power of the name itself. The achievement of the WHO working groups was that they standardized the names of meridians and acupuncture points, as well as their respective paths and approximated locations, through the creation of an alphanumeric coding system. They provided a graphic model of the elephant in the acupuncture room that various cultures, nationalities and probably even national and cultural subgroups had probably called their own.
The Blind Men and the Elephant
What did the blind men who groped the elephant say about the beast? The indefatigable Wikipedia reports the story has had many tellings. I’ll take this one as representative, just by way of example:
"A Jain version of the story says that six blind men were asked to determine what an elephant looked like by feeling different parts of the elephant's body. The blind man who feels a leg says the elephant is like a pillar; the one who feels the tail says the elephant is like a rope; the one who feels the trunk says the elephant is like a tree branch; the one who feels the ear says the elephant is like a hand fan; the one who feels the belly says the elephant is like a wall; and the one who feels the tusk says the elephant is like a solid pipe.
"A king explains to them:
"All of you are right. The reason every one of you is telling it differently is because each one of you touched the different part of the elephant. So, actually the elephant has all the features you mentioned." ["Elephant and the blind men". Jain Stories. JainWorld.com. Retrieved 2006-08-29.] https://en.wikipedia.org/wiki/Blind_men_and_an_elephant
Meaning disrespect neither to Jainism nor to the importance of tolerance, it seems to me that each blind man was wrong. An elephant is neither a pillar, a tail, a rope, a tree, an ear, a hand fan, a wall, or a solid pipe. It is an animal that lives, breathes and thinks, an entity worthy of our respect as a totality, not as a sum of parts. Real respect means seeing its animal wholeness. Taking this story as a departure point, we must agree that the WHO working groups did achieve something quite important, the creation of a crosscultural nomenclature that permitted acupuncture’s blind men, diverse perspectives rooted in nationality and ideology, to begin speaking to each other about the entity they all groped to understand. But, though venerable, is the model valid? Before we considering whether the WHO model has any validity, it’s worth taking a brief look at how its nomenclature works.
Let’s look at some examples. The Large Intestine Meridian is postulated as having 20 points, numbered 1 through 20, running roughly from a corner of the fingernail of the index finger to the border of the nostril on the other side of the body. One commonly used point, between the thumb and forefinger, is named Hegu 合 谷 in Chinese, listed as the fourth point on the meridian in the WHO document, and thus labeled Large Intestine 4, or LI 4. There is “a brief explanation of the point, i.e., the meaning of the characters . . . , and a brief explanation of the point in [a] second paragraph These meanings have been recommended by the All-China Acupuncture and Moxibustion Society.” For this LI 4, these read as follows: “He : junction. Gu : valley. This point lies between the 1st and 2nd metacarpal bones. The location of the point is depressed as a valley.”
In fact, the WHO reports gives the English name of LI 4 as “Connecting Valleys”, with an additional note in smaller print that it’s “Fond du vallée“ in French. The French version is not an exact equivalent of the English. Google Translate gives the French as “Bottom of the Valley,” offering 15 additional meanings of fond, none of which have anything to do with the concept of connecting or connection. In other words, there is some degree of inexactitude here even in the official translation, which doesn’t surprise, since translation is always inexact. In addition, the names encourage metaphor.
Picking several books off my bookshelf (I’ve since removed the acupuncture needles!), I see that the Chinese name is variously translated as “Joining Valley”, Adjoining Valleys, and Joining of the Valleys. Other books have other, similar names. The inexactitude thickens.
Let’s choose another acupuncture point. What do we make of Shang Yang 商 陽 / Large Intestine 1, or LI 1? The WHO description of this point is “Shang : one of the Five Sounds, pertaining to metal; Yang “ Yang in Yin -Yang.” The three other sources I consulted for LI 4 translate the name as Shang Yang, Metal’s Note Yang and Merchant Yang, respectively?
As a final point of comparison, let’s consider Touwei 頭 維 / Stomach 8, or ST 8). The WHO description reads, “Tou ; head; wei : corner. The point is at the corner between the two hairlines at the forehead.” The three other sources translate the Chinese as Head’s Binding, Skull’s Safeguard, and Head Tied. Metaphor is powerful. The images inherent in Chinese characters resonate in the various Asian languages that are tied to them, and probably with different flavors in the differing cultures of each nation, and surely give rise to different sets of associations. Translated into English, we see reflections of still different poetic sensibilities or of competing acupuncture ideologies. These differences beg several questions: What is it we’re doing, actually, when we insert an acupuncture needle? What are our intentions, and not merely intentions but rather expectations? How do these intentions and expectations tally with the rest of our intentions, expectations and knowledge of the world?
The feeling that I was engaged in an extraordinary endeavor as a student of acupuncture was reinforced when I learned that the World Health Organization, through the publication of its report, had weighed in on the validity of acupuncture meridians and points. To say that it gave my newly chosen profession the bright polish of respectability is too left-handed a compliment. More to the point, one of the world’s major health and medicine organizations was saying that acupuncture was worth its time and focus. In other words, acupuncture was real. But reviewing the official document for the purpose of writing this article, I draw two other conclusions. The first is that, yes, the final WHO report was indeed an achievement: it provided a simple, non-poetic, non-metaphorical lingua franca for speaking about acupuncture across languages, cultures and nations. One of the project’s stated aims was to facilitate information exchange across cultures, which it succeeded in doing. The final alphanumeric code used English abbreviations as their departure point because much “international exchange on acupuncture, at least in the Western Pacific region [of WHO, where the final meetings were held] is mainly conducted in English;” but it also retained the Chinese character “because it gives the meridian and acupuncture point name a meaning of therapeutic value which often defies translation,” which is why I include these characters in the preceding paragraph, although I cannot read them. The formal name also includes the Pinyin, or Chinese phonetic alphabet, name because non-Asians are unlikely to able to read the character. The document also lists the names of the characters in French, Japanese, Korean and Vietnamese, as well as American English and two variants of British English.
Seeing the beast and naming it
Naming shapes understanding and in shaping our understanding molds our reality. Acupuncture came to the West reflecting the mix of Asian cultures that gave birth to it and nurtured it over at least two millennia. The WHO document gave primacy to a specific Chinese version with roots in ancient thinking, though perhaps muddied with Mao-era politics, with an additional nod to English in each point's alphanumeric abbreviation, location and description. Each of the subsidiary languages were in smaller print. The world was given a ready-made. Whether it’s a valid description of the body on the acupuncturist’s table, or a Potemkin village of a description, is, in my opinion, open to debate.
If you’ve been to my office and we’ve spoken face to face about my acupuncture point of view, you know I don’t accept the existence of acupuncture meridians. There are interesting congruencies between the ancient lens of energy flow – and even this phrase needs a little more explication, because it came to the West in the early Twentieth Century freighted with associations that may or may not have been implicit in the age-old Chinese teachings – and the network of nerves and fasciae in the body, which we understand because of modern anatomical and physiological insights. You also know I don’t believe the named locations of acupuncture points have any validity. Rather, the action of acupuncture lies in the microlesion the needle creates in the soft tissues of the body. Any place on the surface of the body or just below the surface can be an acupuncture “point”, although certain locations are prohibited, including the nipples, genitals and navel. Acupuncture is a bodywork, a soft-tissue therapy, which is a logical approach to resolving health issues, since 50% body mass is soft tissue: the skin, fascia, muscles, tendons and ligaments. This is key to understanding why I can treat myself so handily. I don’t believe I am getting in touch with flows of energy along mysterious pathways. Rather, I’m engaging in a sort of creative injury to my muscles and fascia, at once alerting the central nervous system to my intervention and creating cascades of central and local events.
I like the metaphor of a splinter in explaining this. If you get a splinter in your finger and don’t remove it, you get a hot, painful, pus-filled swelling. That little splinter is upholstered in a velvety cloak of pathogens: bacteria, viruses, fungi and parasites, as well as environmental toxins. Unless we are debilitated through illness, malnutrition, or the adverse effects of medical treatment (i.e., chemotherapy, bone-marrow replacement therapy, and the like), the body’s robust immune system has the means to mount a vigorous defense of its home. In the best case, the pathogens are killed, dismantled and ported away. While the body is subduing the infection, it’s also regenerating damaged tissue and restoring itself to health.
The acupuncture needle is sterile. It lacks the velvety cloak, it doesn’t dose the body with bacteria and fungi; nonetheless, the body identifies the needle as an invader. In Dr. Ma’s Neurogenic Dry Needling, Yun-tao Ma writes that the application of needles (whether an acupuncture needle or a “dry needling needle”) to the body will “inoculate minute lesions in the tissue without scar formation. This process creates acute inflammation and activates self-healing potential in the biological system. Dry needling [in other words, acupuncture] accelerates natural healing without suppressing protective physiological mechanisms like inflammation, pain and fever.”
Dr. Ma goes on to stay that a “well-controlled acute inflammatory response” provoked by needling has “several protective roles: (1) It prevents the spread of infectious agents and damage to nearby tissues. (2) It helps to remove damages tissue and pathogens. (3) It assists the body’s repair processes.”
I’m content to place needles in myself because I don’t think the action of the needle is confined to the world of metaphor or a world of mysterious forces. It seems clear that the placement of an acupuncture needle sets of a cascade of physiological responses that make my muscles, tendons, ligament and fasciae healthier in the end, a set of responses we’re still trying to shed light on. Metaphor is important. We make sense of the world through metaphor. But if you believe there is an underlying biological reality we all share as human beings, and further share with the living things the co-populate our planet, a model for understanding that’s consistent with our 21st Century understanding of anatomy, biology, chemistry and physics, it’s to those disciplines we must look for answers. Let’s look at the whole beast and not a misidentified part.
As for myself, I will suggest a family movie night in the very near future. “Dr. Strange”, anyone?
Gesner Elephant. http://riowang.blogspot.com/2009/02/more-elephants.html
What the blind men saw. http://www.curezone.org/upload/Members/WhistlingBooger/elephant.jpg
Wise elephant. Courtesy, Bigstock Images.
 Chinese is a written language. All the main dialects of China, variously listed as between seven and fourteen in number, use the same characters, although they pronounce the characters differently.
 A Manual of Acupuncture. Peter Deadman, Mazin Al-Khafaji with Kevin Baker. Journal of Chinese Medicine Publications: 1998.
 Acupuncture Points: Images and Functions. Arnie Lade. Seattle: Eastland Press, 1991.
 Traditional Chinese Acupuncture: Meridians and Points. J. R. Worsley. Boston: Element, 1993.
 An essential of Chinese philosophy is the conceptualizing of the universe as consisting of five elements: Wood, Fire, Earth, Metal and Water. The sound of Metal in the pentatonic scale is Shang, corresponding to a D Natural in the Western scale. For a quick description, consult the subheading “Music” in the following: https://en.wikipedia.org/wiki/Wu_Xing#Music.
 Biomedical Acupuncture for Sports and Trauma Rehabilitation: Dry Needling Techniques. Yun-tao Ma. St. Louis: Churchill Livingstone Elsevier, 2011. P.51.
 Yun-tao Ma states that he is not writing about acupuncture but about dry needling. Whether acupuncture and dry needling are one and the same is a subject of intense debate in the acupuncture and dry needling communities and will merit comment in a future post. For the time being, I’m willing to say that his first book was about “biomedical acupuncture,” his second about “biomedical acupuncture and dry needling, and his current about “dry needling” only. In my opinion, they make up the best three books about acupuncture that I’m aware of.
 Dr. Ma’s Neurologic Dry Needling. Yun-tao Ma. 2017: Lanterna Medica Press. p.2.
 Ma. p.5.
© 2017 William Weinstein