The practice of Chinese medicine: the treatment of diseases with acupuncture and chinese herbs [2nd ed] 9780443074905, 2152393805, 0443074909

The 2nd edition ofThe Practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbsdescribe

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Table of contents :
Front Cover......Page 1
The Practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs......Page 3
Copyright Page......Page 4
Foreword......Page 5
ACKNOWLEDGEMENTS......Page 7
PREFACE TO THE SECOND EDITION......Page 9
NOTE ON THE TRANSLATION OF CHINESE MEDICAL TERMS......Page 15
CHAPTER 1. HEADACHES......Page 21
AETIOLOGY......Page 22
CHANNELS......Page 26
PATHOLOGY......Page 30
DIAGNOSIS......Page 32
TREATMENT STRATEGIES AND PRINCIPLES OF POINT SELECTION......Page 37
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 39
MODERN CHINESE LITERATURE......Page 72
CLINICAL TRIALS......Page 75
WESTERN DIFFERENTIAL DIAGNOSIS OF HEADACHES......Page 79
PROGNOSIS AND PREVENTION......Page 83
END NOTES......Page 84
CHAPTER 2. DIZZINESS......Page 85
PATHOLOGY......Page 86
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 87
MODERN CHINESE LITERATURE......Page 93
WESTERN DIFFERENTIATION......Page 94
END NOTES......Page 95
CHAPTER 3. BREATHLESSNESS (CHUAN)......Page 97
AETIOLOGY......Page 98
PATHOLOGY......Page 99
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 101
PROGNOSIS AND PREVENTION......Page 116
WESTERN DIFFERENTIAL DIAGNOSIS......Page 117
END NOTES......Page 119
CHAPTER 4. WHEEZING (XIAO)......Page 121
PATHOLOGY......Page 122
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 123
MODERN CHINESE LITERATURE......Page 129
PROGNOSIS AND PREVENTION......Page 130
WESTERN DIFFERENTIATION......Page 131
END NOTES......Page 132
CHAPTER 5. ALLERGIC ASTHMA (ATOPIC ECZEMA)......Page 133
ALLERGIC ASTHMA IN WESTERN MEDICINE......Page 135
CONNECTIONS AND DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN......Page 145
A NEW THEORY OF ASTHMA......Page 150
IN BETWEEN ATTACKS......Page 161
THE LIVER AND ASTHMA......Page 165
ATOPIC ECZEMA......Page 167
MODERN CHINESE LITERATURE......Page 173
CLINICAL TRIALS......Page 181
CASE HISTORIES......Page 184
PROGNOSIS AND PREVENTION......Page 191
WESTERN DRUG THERAPY......Page 192
END NOTES......Page 194
ALLERGIC RHINITIS IN WESTERN MEDICINE......Page 197
THE CHINESE THEORY OF BI YUAN......Page 199
DIFFERENCES BETWEEN ALLERGIC RHINITIS AND BI YUAN......Page 201
A NEW THEORY OF ALLERGIC RHINITIS......Page 202
TREATMENT OF ALLERGIC RHINITIS......Page 204
CLINICAL TRIALS......Page 212
CASE HISTORIES......Page 217
END NOTES......Page 219
CHAPTER 7. SINUSITIS (NASAL POLYPS)......Page 221
AETIOLOGY AND PATHOLOGY......Page 222
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 223
CLINICAL TRIALS......Page 230
CHINESE MEDICINE TREATMENT......Page 231
END NOTES......Page 233
CHAPTER 8. COUGH......Page 235
AETIOLOGY......Page 236
PATHOLOGY......Page 237
ACUPUNCTURE IN COUGH......Page 239
DIAGNOSIS......Page 240
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 241
ACUTE......Page 242
ACUTE EXTERIOR......Page 243
ACUTE INTERIOR......Page 246
CHRONIC FULL......Page 249
CHRONIC EMPTY......Page 253
MODERN CHINESE LITERATURE......Page 256
CLINICAL TRIALS......Page 259
WESTERN DIFFERENTIATION......Page 260
END NOTES......Page 262
NATURE OF THE MIND (SHEN) IN CHINESE MEDICINE......Page 263
THE FIVE MENTAL-SPIRITUAL ASPECTS......Page 267
END NOTES......Page 295
CHAPTER 10. THE EMOTIONS......Page 297
THE EMOTIONS......Page 302
THE PATHOLOGY OF QI AND MINISTER FIRE IN EMOTIONAL PROBLEMS......Page 318
END NOTES......Page 330
CHAPTER 11. AETIOLOGY OF MENTALEMOTIONAL PROBLEMS......Page 331
CONSTITUTION......Page 332
DIET......Page 336
DRUGS......Page 337
PREVENTION OF MENTALEMOTIONAL PROBLEMS......Page 339
END NOTES......Page 340
COMPLEXION......Page 341
EYES......Page 343
PULSE......Page 344
TONGUE......Page 346
END NOTES......Page 351
CHAPTER 13. DEPRESSION......Page 353
DEFINITION AND WESTERN MEDICINE’S VIEW......Page 354
PATHOLOGY OF DEPRESSION IN CHINESE MEDICINE......Page 355
AETIOLOGY......Page 360
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 362
ACUPUNCTURE POINTS FOR DEPRESSION......Page 378
HERBS FOR DEPRESSION......Page 384
MODERN CHINESE LITERATURE......Page 386
CLINICAL TRIALS......Page 390
CASE HISTORIES......Page 395
PATIENTS’ STATISTICS......Page 402
END NOTES......Page 403
ANXIETY IN WESTERN MEDICINE......Page 405
ANXIETY IN CHINESE MEDICINE......Page 407
AETIOLOGY......Page 410
PATHOLOGY AND TREATMENT PRINCIPLES......Page 411
ACUPUNCTURE TREATMENT OF ANXIETY......Page 415
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 417
CASE HISTORIES......Page 424
END NOTES......Page 426
CHAPTER 15. INSOMNIA (SOMNOLENCE, POOR MEMORY)......Page 427
AETIOLOGY......Page 429
PATHOLOGY......Page 431
DIAGNOSIS......Page 433
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 434
MODERN CHINESE LITERATURE......Page 448
CLINICAL TRIALS......Page 451
PATIENTS’ STATISTICS......Page 453
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 454
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 458
END NOTES......Page 460
CHAPTER 16. PATTERNS IN MENTALEMOTIONAL PROBLEMS AND THEIR TREATMENT WITH HERBAL MEDICINE AND ACUPUNCTURE......Page 461
THE EFFECT OF MENTAL-EMOTIONAL PROBLEMS ON QI, BLOOD, YIN AND PATHOGENIC FACTORS......Page 462
MIND OBSTRUCTED, UNSETTLED, WEAKENED......Page 467
MIND OBSTRUCTED......Page 470
MIND UNSETTLED......Page 482
MIND WEAKENED......Page 498
END NOTES......Page 511
AETIOLOGY......Page 513
PATHOLOGY......Page 514
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 516
MODERN CHINESE LITERATURE......Page 524
END NOTES......Page 525
CHAPTER 18. GOITRE (HYPOTHYROIDISM, HYPERTHYROIDISM)......Page 527
AETIOLOGY......Page 529
PATHOLOGY......Page 530
DIAGNOSIS......Page 531
GENERAL TREATMENT INDICATIONS......Page 532
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 534
GOITRE IN WESTERN MEDICINE......Page 539
PATHOLOGY......Page 541
CLINICAL MANIFESTATIONS......Page 542
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 543
PATHOLOGY......Page 546
CLINICAL MANIFESTATIONS......Page 547
HYPERTHYROIDISM IN CHINESE MEDICINE: A REVIEW OF CHINESE LITERATURE......Page 548
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 553
CASE HISTORIES......Page 557
MODERN CHINESE LITERATURE......Page 559
END NOTES......Page 560
CHAPTER 19. HYPERTENSION......Page 561
HYPERTENSION IN WESTERN MEDICINE......Page 562
HYPERTENSION IN CHINESE MEDICINE......Page 567
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 577
MODERN CHINESE LITERATURE......Page 589
CASE HISTORIES......Page 590
PATIENTS’ STATISTICS......Page 592
CLINICAL TRIALS......Page 593
END NOTES......Page 597
CHAPTER 20. TIREDNESS......Page 599
AETIOLOGY......Page 601
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 606
PATHOLOGY......Page 604
EMPTY......Page 607
FULL......Page 623
PATIENTS’ STATISTICS......Page 637
WESTERN DIFFERENTIAL DIAGNOSIS......Page 638
END NOTES......Page 639
CHAPTER 21. CHEST PAINFUL OBSTRUCTION SYNDROME......Page 641
AETIOLOGY......Page 642
PATHOLOGY......Page 643
DIFFERENTIAL DIAGNOSIS......Page 646
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 647
PROGNOSIS AND PREVENTION......Page 661
MODERN CHINESE LITERATURE......Page 662
CLINICAL TRIALS......Page 674
WESTERN DIFFERENTIAL DIAGNOSIS......Page 679
END NOTES......Page 681
CHAPTER 22. EPIGASTRIC PAIN......Page 683
AETIOLOGY......Page 684
PATHOLOGY......Page 688
DIAGNOSIS......Page 689
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 691
MODERN CHINESE LITERATURE......Page 712
CLINICAL TRIALS......Page 716
WESTERN DIFFERENTIAL DIAGNOSIS......Page 720
END NOTES......Page 721
CHAPTER 23. NAUSEA AND VOMITING......Page 723
AETIOLOGY......Page 724
PATHOLOGY......Page 725
DIAGNOSIS......Page 726
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 727
CLINICAL TRIALS......Page 735
END NOTES......Page 736
CHAPTER 24. GASTRO-OESOPHAGEAL REFLUX DISEASE......Page 737
GASTRO-OESOPHAGEAL REFLUX DISEASE IN CHINESE MEDICINE......Page 739
AETIOLOGY OF GASTROOESOPHAGEAL REFLUX DISEASE......Page 740
PATHOLOGY OF GASTROOESOPHAGEAL REFLUX DISEASE......Page 741
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 743
END NOTES......Page 747
CHAPTER 25. MOUTH ULCERS......Page 749
MOUTH ULCERS IN CHINESE MEDICINE......Page 750
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 755
MODERN CHINESE LITERATURE......Page 761
END NOTES......Page 763
CHAPTER 26. HYPOCHONDRIAL PAIN (GALL BLADDER STONES)......Page 765
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 766
WESTERN DIFFERENTIATION......Page 770
IDENTIFICATION OF PATTERNS......Page 771
TREATMENT......Page 772
MODERN CHINESE LITERATURE......Page 773
END NOTES......Page 776
CHAPTER 27. ABDOMINAL PAIN......Page 777
AETIOLOGY AND PATHOLOGY......Page 778
DIAGNOSIS......Page 779
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 782
PATIENTS’ STATISTICS......Page 796
PROGNOSIS AND PREVENTION......Page 797
WESTERN DIFFERENTIATION......Page 798
END NOTES......Page 799
CHAPTER 28. ABDOMINAL MASSES......Page 801
PATHOLOGY......Page 802
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 803
MODERN CHINESE LITERATURE......Page 812
PROGNOSIS AND PREVENTION......Page 817
END NOTES......Page 818
AETIOLOGY AND PATHOLOGY......Page 819
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 821
MODERN CHINESE LITERATURE......Page 830
WESTERN DIFFERENTIATION......Page 835
END NOTES......Page 836
CHAPTER 30. CONSTIPATION......Page 837
AETIOLOGY......Page 838
PATHOLOGY......Page 839
DIAGNOSIS......Page 841
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 842
MODERN CHINESE LITERATURE......Page 853
WESTERN DIFFERENTIATION......Page 854
END NOTES......Page 855
CHAPTER 31. URINARY SYNDROME (URINARY CALCULI)......Page 857
PATHOLOGY......Page 859
OVERVIEW OF PATTERNS......Page 861
AETIOLOGY......Page 864
DIAGNOSIS......Page 865
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 867
MODERN CHINESE LITERATURE......Page 883
PATIENTS’ STATISTICS......Page 887
WESTERN DIFFERENTIATION......Page 888
CLINICAL TRIALS......Page 889
AETIOLOGY......Page 891
TREATMENT......Page 892
END NOTES......Page 894
CHAPTER 32. ENURESIS AND INCONTINENCE (BLOOD IN THE URINE)......Page 895
PATHOLOGY......Page 896
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 897
PROGNOSIS......Page 904
MODERN CHINESE LITERATURE......Page 905
END NOTES......Page 908
CHAPTER 33. URINARY RETENTION......Page 909
PATHOLOGY......Page 910
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 911
END NOTES......Page 915
CHAPTER 34. INTERSTITIAL CYSTITIS......Page 917
INTERSTITIAL CYSTITIS IN CHINESE MEDICINE......Page 918
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 919
PROGNOSIS AND PREVENTION......Page 923
THE PROSTATE AND BENIGN PROSTATIC HYPERPLASIA IN WESTERN MEDICINE......Page 925
THE PROSTATE IN CHINESE MEDICINE......Page 927
PATHOLOGY OF BENIGN PROSTATIC HYPERPLASIA IN CHINESE MEDICINE......Page 930
TREATMENT STRATEGIES......Page 932
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 934
MODERN CHINESE LITERATURE......Page 938
END NOTES......Page 943
CHRONIC PROSTATITIS IN WESTERN MEDICINE......Page 945
CHRONIC PROSTATITIS IN CHINESE MEDICINE......Page 947
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 949
MODERN CHINESE LITERATURE......Page 957
CLINICAL TRIALS......Page 961
END NOTES......Page 963
CHAPTER 37. OEDEMA (NEPHRITIS)......Page 965
AETIOLOGY......Page 966
PATHOLOGY......Page 967
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 970
MODERN CHINESE LITERATURE......Page 981
AETIOLOGY AND PATHOLOGY......Page 982
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 983
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 987
END NOTES......Page 992
CHAPTER 38. PAINFUL OBSTRUCTION SYNDROME (RHEUMATOID ARTHRITIS)......Page 993
AETIOLOGY......Page 997
PATHOLOGY......Page 999
IDENTIFICATION OF PATTERNS......Page 1000
TREATMENT PRINCIPLES......Page 1003
ACUPUNCTURE TREATMENT......Page 1004
HERBAL THERAPY......Page 1013
TREATMENT OF SPECIFIC PARTS OF THE BODY......Page 1025
PROGNOSIS AND PREVENTION......Page 1041
MODERN CHINESE LITERATURE......Page 1043
CLINICAL TRIALS......Page 1050
WESTERN DIFFERENTIATION......Page 1053
AETIOLOGY......Page 1059
PATHOLOGY AND TREATMENT PRINCIPLES......Page 1060
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1062
CLINICAL TRIALS......Page 1070
END NOTES......Page 1072
CHAPTER 39. LOWER BACKACHE AND SCIATICA......Page 1075
AETIOLOGY......Page 1078
PATHOLOGY......Page 1079
DIAGNOSIS......Page 1081
IDENTIFICATION OF PATTERNS AND HERBAL TREATMENT......Page 1084
ACUPUNCTURE TREATMENT OF LOWER BACKACHE......Page 1087
TREATMENT OF SCIATICA......Page 1094
PATIENTS’ STATISTICS......Page 1098
PROGNOSIS AND PREVENTION......Page 1099
CLINICAL TRIALS......Page 1100
WESTERN DIFFERENTIATION......Page 1107
END NOTES......Page 1110
CHAPTER 40. FIBROMYALGIA......Page 1111
FIBROMYALGIA IN WESTERN MEDICINE......Page 1112
FIBROMYALGIA IN CHINESE MEDICINE......Page 1117
AETIOLOGY OF FIBROMYALGIA IN CHINESE MEDICINE......Page 1125
PATHOLOGY OF FIBROMYALGIA IN CHINESE MEDICINE......Page 1126
TREATMENT PRINCIPLES AND STRATEGY......Page 1128
ACUPUNCTURE IN THE TREATMENT OF FIBROMYALGIA......Page 1131
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1135
COMPARISON OF MYOFASCIAL PAIN SYNDROME, FIBROMYALGIA AND POSTVIRAL FATIGUE SYNDROME......Page 1143
END NOTES......Page 1145
CHAPTER 41. CHRONIC FATIGUE SYNDROME......Page 1147
CHRONIC FATIGUE SYNDROME IN WESTERN MEDICINE......Page 1148
CHRONIC FATIGUE SYNDROME IN CHINESE MEDICINE......Page 1153
AETIOLOGY......Page 1165
PATHOLOGY AND TREATMENT PRINCIPLES......Page 1166
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1168
PATIENTS’ STATISTICS......Page 1188
END NOTES......Page 1189
CHAPTER 42. PARKINSON’S DISEASE......Page 1191
PATHOLOGY......Page 1192
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1194
PROGNOSIS AND PREVENTION......Page 1202
MODERN CHINESE LITERATURE......Page 1203
CLINICAL TRIALS......Page 1207
END NOTES......Page 1209
CHAPTER 43. WIND-STROKE......Page 1211
AETIOLOGY......Page 1212
PATHOLOGY......Page 1213
IDENTIFICATION OF PATTERNS......Page 1214
TREATMENT......Page 1217
ATTACK OF THE CHANNELS ALONE......Page 1219
PATTERNS IN THE SEQUELAE STAGE......Page 1227
OTHER METHODS OF TREATMENT......Page 1230
MODERN CHINESE LITERATURE......Page 1231
END NOTES......Page 1238
AETIOLOGY......Page 1239
PATHOLOGY......Page 1241
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1242
MODERN CHINESE LITERATURE......Page 1251
PROGNOSIS AND WESTERN DIFFERENTIATION......Page 1254
END NOTES......Page 1255
CHAPTER 45. MULTIPLE SCLEROSIS......Page 1257
AETIOLOGY......Page 1259
PATHOLOGY......Page 1260
ACUPUNCTURE TREATMENT......Page 1261
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1263
PROGNOSIS......Page 1270
END NOTES......Page 1272
CHAPTER 46. BLEEDING......Page 1275
AETIOLOGY......Page 1276
PATHOLOGY......Page 1277
TREATMENT PRINCIPLES......Page 1279
COUGHING BLOOD......Page 1284
BLOOD IN THE STOOLS......Page 1288
BLOOD IN THE URINE......Page 1291
BLEEDING UNDER THE SKIN......Page 1296
BLEEDING GUMS......Page 1298
MODERN CHINESE LITERATURE......Page 1300
END NOTES......Page 1302
CHAPTER 47. ERECTILE DYSFUNCTION......Page 1303
ERECTILE DYSFUNCTION IN CHINESE MEDICINE......Page 1305
AETIOLOGY OF ERECTILE DYSFUNCTION IN CHINESE MEDICINE......Page 1313
PATHOLOGY OF ERECTILE DYSFUNCTION IN CHINESE MEDICINE......Page 1314
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1316
MODERN CHINESE LITERATURE......Page 1326
CLINICAL TRIALS......Page 1330
INTRODUCTION......Page 1333
AETIOLOGY AND PATHOLOGY......Page 1336
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1341
PROGNOSIS AND PREVENTION......Page 1356
END NOTES......Page 1357
GREATER YANG STAGE......Page 1359
LESSER YIN STAGE......Page 1360
TERMINAL YIN STAGE......Page 1361
DEFENSIVE-QI LEVEL......Page 1363
QI LEVEL......Page 1364
BLOOD LEVEL......Page 1365
MIDDLE BURNER......Page 1367
LOWER BURNER......Page 1368
Appendix 4: PRESCRIPTIONS......Page 1369
EMPIRICAL PRESCRIPTIONS......Page 1444
Appendix 5: ACUPUNCTURE POINTS FOR MENTAL-EMOTIONAL PROBLEMS......Page 1455
ENGLISH–PINYIN GLOSSARY OF CHINESE TERMS......Page 1467
BIBLIOGRAPHY......Page 1483
CHRONOLOGY OF CHINESE DYNASTIES......Page 1487
INDEX......Page 1489
Color Plate Section......Page 1522
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To Sammi

Commissioning Editors: Karen Morley, Claire Wilson Development Editor: Kerry McGechie Project Manager: Emma Riley Designer: Charles Gray

The Practice of Chinese

Medicine

The Treatment of Diseases with Acupuncture and Chinese Herbs SECOND

EDITION

Giovanni Maciocia CAc (Nanjing) Acupuncturist and Medical Herbalist, UK Visiting Associated Professor, Nanjing University of Traditional Chinese Medicine Foreword by Steve Clavey, Ph.D., B.Ac., M.B.Ac.C. Illustrators: Michael Courtney and Richard Morris

Edinburgh • London • New York • Oxford • Philadelphia • St Louis • Sydney • Toronto • 2008

Am imprint of Elsevier Limited © Giovanni Maciocia 1994 © Giovanni Maciocia 2008 The right of Giovanni Maciocia to be identified as author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899, USA: phone (+1) 215 239 3804, fax (+1) 215 239 3805, or e-mail [email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com) by selecting ‘Support and Contact’ and then ‘Copyright and Permission’. First edition 1994 Second edition 2008 ISBN: 978-0-443-07490-5 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress

Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Author assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher

Printed in Europe

Foreword

I feel particularly honoured to be asked to pen the Foreword to the second edition of Giovanni Maciocia’s groundbreaking work, The Practice of Chinese Medicine, because – over 30 years ago – it was Giovanni himself who encouraged me to take up the study of Chinese medicine. Six years later, after leaving Taiwan, again it was Giovanni who enabled me to study in mainland China. He recalls neither of these, to me, life-changing impacts; they were simply part of what he does: surveying, cultivating, propagating. What makes his works so popular? Their clarity and system. They are easy to read, using clear everyday English, and are set out in such a way that a busy student, or an even busier clinician, can find the answers needed quickly and efficiently. Another factor in their popularity is the reflection of the cultural context we all of us outside of China share, i.e. working in societies shaped by the dominant paradigm of Western medicine, so that often the presenting complaint is not what the patients themselves feel, but rather a label applied through that paradigm. This is where The Practice of Chinese Medicine excels, providing a clear interface between the Western medicine understanding of a disease entity and the Chinese medicine view and handling of the same patient. In this, the second edition, there are over 14 new chapters, including a much expanded and in-depth discussion of the psyche in Chinese medicine, with new full chapters on anxiety, depression, chronic fatigue, nausea/vomiting, acid reflux, mouth ulcers, hypertension, prostatic enlargement, interstitial cystitis, thyroid conditions, erectile dysfunction, and more. There is also notable expansion of existing chapters, such as the differentiation and treatment of nasal polyps within the chapter on sinusitis. The chapters on gynaecology, now covered in a specialized text of their own, have not been carried over from the first edition.

This book is about Nei Ke – internal medicine – which is the guts of any general practice. From Zhang Zhong-Jing to Xu Shu-Wei, Li Gao to Cheng Guo-Peng – to name some of the taller trees in our forest – there have been many different ways of organizing the description of what happens after a patient sits down in front of you and says: “I don’t feel good.” Giovanni has gone to great lengths to develop as useful a way as possible for Westerners to access the current Chinese medicine understanding of what works best in each condition. Where that understanding is insufficient, he has brought his extensive clinical experience to bear in filling in the gaps and presenting us with his conclusions. Chinese medicine as a clinical discipline welcomes innovation, creativity; demands it, in fact. As a student, you may need to memorize for exams. When beginning clinic you may need to begin by memorizing a list of patterns for each condition, and their treatments. But though you may start with a list, you should not end up that way, but rather learn to be able to enter into a living understanding of the pathological mechanisms operating in your patients, and in the environment and society around you both. New theory, therefore, should not be a big surprise – we should all be producing it. Giovanni has invested his clinical heart and soul in the pages of this book, and the reader who really wishes to bring this book to life will meet him half way. Work to understand the mechanisms that create the various conditions in your patients, in your context, and try out the tools that are provided here, in the second edition of The Practice of Chinese Medicine. Steven Clavey Winter Solstice 2007 Melbourne

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ACKNOWLEDGEMENTS

My first trip to China, where I attended my first acupuncture course at the Nanjing University of Traditional Chinese Medicine in 1980, was an important milestone in my professional development. My first teacher there was Dr Su Xin Ming, who played an important role in the development of my acupuncture skills. I am indebted to him for the patient way in which he communicated his skills to me. I am grateful to Dr Zhou Zhong Ying of the Nanjing University of Chinese Medicine for teaching me his knowledge and skills in diagnosis and herbal medicine. I am indebted to Fi Lyburn for her exceptional attention to detail in checking the manuscript for consistency and generally helping with editing. Sylvie Perera gave me valuable help with checking the manuscript throughout, and for that I am grateful.

Becky Clarke helped me with compiling the statistics of patients from my practice with great skill. I am grateful to Suzanne Turner for her help with research and editing. Dr J.D. Van Buren was my very first teacher 35 years ago; from him, I learned the importance of diagnosis and especially of pulse diagnosis. I owe him a debt of gratitude for being my first source of inspiration in Chinese medicine. Finally, I would like to thank Karen Morley, Kerry McGechie and Claire Wilson of Elsevier for their professionalism and support. Giovanni Maciocia Amersham, 2006

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PREFACE TO THE SECOND EDITION

It is now 12 years since the first edition of The Practice of Chinese Medicine was published. That first edition was intended to be the companion volume to The Foundations of Chinese Medicine, setting out the application of the theory of Chinese medicine to the treatment of specific diseases with both acupuncture and Chinese herbs. The theory of allergic asthma and allergic rhinitis presented in this book is entirely new. Of course, this is far from perfect and will need constant revision according to our clinical experience and research, and I have added new references compared with those in the first edition. The theory of chronic fatigue syndrome, similarly new, is based on my clinical experience, although the concepts of residual pathogenic factor and Latent Heat on which it is based are very old. New too is the theory of multiple sclerosis, but this is mostly based on the pathology and symptomatology of Atrophy Syndrome. The chapter on tiredness is based on the old symptom of Xu-Lao, which means “exhaustion”, but I have departed from the traditional approach in so far as I include the Full causes of tiredness, something that is not done in the Chinese discussion of Xu-Lao. With this second edition, the following are the major changes or additions. • The text has been revised throughout, expanding the Chinese sources. • Many new patterns have been added to each disease. • New formulae have been added to many patterns. • I have added a section on modern Chinese literature to many chapters whenever applicable. • I have added new case histories. • I have added clinical trials. • I have added patients’ statistics from my own practice whenever possible.

• The discussion of mental-emotional problems has been greatly expanded (from one to eight chapters). • I have added the discussion of diseases not previously discussed. The new diseases added to this second edition are: • depression (Chapter 13) • anxiety (Chapter 14) • goitre (Chapter 18) • hypertension (Chapter 19) • nausea and vomiting (Chapter 23) • acid reflux (Chapter 24) • mouth ulcers (Chapter 25) • urinary retention (Chapter 33) • interstitial cystitis (Chapter 34) • benign prostatic hyperplasia (Chapter 35) • prostatitis (Chapter 36) • fibromyalgia (Chapter 40) • erectile dysfunction (Chapter 47). As in the first edition of this book, most of the “diseases” discussed are diseases only in the context of Chinese medicine. For example, epigastric pain is not a “disease” but a symptom in Western medicine; in Chinese medicine, it is a disease (bing) of internal medicine. However, in some cases, I discuss the treatment of Western-defined diseases (e.g. Parkinson’s disease or multiple sclerosis). Although Chinese medicine treats each individual as a whole rather than treating the “diseases” from which that patient is suffering, and explores the patterns of disharmony, lifestyle, environment, family situation, emotional life, diet, sexual habits, work routine and exercise, it is still important to discuss the treatment of individual diseases because treatment techniques vary enormously; for example, the treatment of Wind-stroke calls for specific techniques and approaches that are quite different from those used for, say, insomnia. The use of these techniques is not in

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contradiction with whatever other approach or philosophy a particular practitioner may follow, and I therefore hope that this textbook can be of use to practitioners of many different orientations. Another important reason for discussing individual diseases is their particular and specific pathology and aetiology: it is only by understanding the distinctive pathology and aetiology that we can advise the patient on lifestyle, work, emotional life, sexual habits, diet and exercise. Educating the patient in these areas is as important as the treatment imparted, as it gives the patient responsibility for his or her own health and so can prevent recurrence of the problem. An addition in this second edition compared with the first are extracts from articles in modern Chinese medicine journals. Some of these are purely theoretical, discussing interesting aspects of the theory of Chinese medicine; some are reports of clinical trials. Many of these are without a control and many do not reach the standards of proper randomized controlled clinical trials. However, I do not report such articles so much for the value of their clinical trials but to gain from the experience of doctors in the treatment of various conditions. In other words, although some of the trials may be flawed, it is in many cases interesting to learn about the treatment principle and formulae adopted. Many articles report the experience of famous modern doctors of Chinese medicine (lao zhong yi). I have removed all references to modern Chinese patent remedies because of concerns about the quality controls applied, the presence of banned or toxic substances and, sometimes, the inclusion of Western drugs within a herbal remedy. The reader should note that some herbal prescriptions may contain substances that are illegal in certain countries. This could be either because they are toxic (such as Zhu Sha Cinnabaris) or because they are of animal origin from protected species; in some countries, all substances of animal or mineral origin are banned. The mention of such herbal formulae in this book does not signify an endorsement of the use of banned substances, and readers are strongly advised to enquire about the laws governing the use of certain herbs or substances in their country. Each practitioner should therefore satisfy himself or herself as to the suitability of a particular prescription. At the time of writing, all animal and mineral

products are illegal in the European Union, although each country applies the law differently. I have decided to leave the traditional formulae as they are to give the reader an idea of the action of the formula. It is only when we know the original ingredients of a formula that we can make proper substitutions based on the action of the herb or substance we intend to replace. For example, if we want to replace Gui Ban Plastrium Testudinis within a formula, we know that we can approximate its action by using the combination of Huang Jing Rhizoma Polygonati and Gou Qi Zi Fructus Lycii chinensis. I have listed some suggested herbal substitutions in Appendix 6. As for the name of the herbs, I have changed these and followed the names used in Bensky, Clavey and Stöger’s Materia Medica (third edition). The acupuncture points indicated for each pattern are not formulae but only the possible points from which the practitioner can choose when determining an acupuncture treatment. There are a few exceptions, and these are indicated as “general prescription” or “ancient prescription”. The herbal treatment of each disease is based on several modern Chinese textbooks and integrated with the treatment found in ancient classics (see Bibliography). The main modern textbook followed was that used in all colleges of Chinese Medicine in China, i.e. Internal Medicine in Chinese Medicine (Zhong Yi Nei Ke Xue) by Zhang Bo Yu (1986). I should make some comments on the dosages of the herbal prescriptions. The dosages shown are mostly those from modern and old Chinese books. In my practice, I use much lower dosages and these are reflected in the case histories, the average for each herb being about 4 g for dried herbs. I find that these reduced dosages work very well. As for the mode of administration of the herbs, I use both decoctions and concentrated powders; I tend to use decoctions for some gynaecological problems, such as endometriosis, and for skin diseases. In my practice in England, the patients’ compliance with decoctions is very high indeed (about 95%), and even most children manage to take decoctions (albeit disguised in a variety of ways). In children under 3, the decoction can be substantially diluted and given throughout the day. In children over 3, honey can be added to the decoction. Strictly speaking, the addition of honey alters the taste of the decoction and brings in honey’s own properties, but in practice I think it is

Preface to the Second Edition

better for a child to take the herbs with honey than not to take them at all. Other ways of coaxing children to take decoctions include offering them a biscuit (cookie) or a favourite drink immediately after they have swallowed the mixture. However, I find that one of the best ways of getting children over 3 to take a decoction is by involving them in the dispensing of the herbs: the child is fascinated by the different shapes, textures and smells of the herbs and loves helping to dispense the herbs and putting them in the bags. Involving a young patient in this way ensures that when the child drinks the decoction, it is not an alien preparation but something the child relates to – the actual herbs he or she helped to dispense. This method is of course timeconsuming for the practitioner, but it is also great fun. All the case histories are drawn from my own practice, and the reader is invited to study them, as they show how prescriptions are adapted to the individual’s particular disharmony and also how acupuncture points are chosen and combined. Each chapter includes the Western differentiation of the symptom discussed (e.g. the possible causes of headaches in Western medicine). Of course, this is not intended to be a replacement of a good book on Western clinical medicine (some are mentioned in the bibliography); it is simply meant to provide the practitioner in a clinical setting with a quick checklist of the possible Western causes of that particular symptom. This is important because we should know when to refer a patient to a Western medical doctor or specialist for a further diagnosis. For example, a patient

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may come to us complaining of urinary difficulty, and we should know when to suspect a prostate carcinoma. The second reason for familiarizing ourselves with the Western differentiation of symptoms is prognosis. Although Chinese medicine is excellent at providing not only a diagnosis but also a reasonable prognosis by carefully examining symptoms, signs, tongue and pulse, in many cases the prognosis depends also on the Western diagnosis. For example, it makes a big difference to prognosis whether tingling in a limb is caused by a “simple” Liver-Blood deficiency or by the beginning of multiple sclerosis. I have removed the three gynaecological diseases of painful periods, menorrhagia and premenstrual syndrome, because these are now discussed in my gynaecology book. Finally, I have eliminated the appendix on the principles of combination of acupuncture points, as this is now in my book The Channels of Acupuncture (2006). I have added an appendix (Appendix 5) listing the points commonly used for mental-emotional problems according to my experience. As for terminology and names of diseases, I have changed two names compared with the first edition. I now call Lin disease “Urinary Syndrome” rather than “Painful Urinary Disease”, as this condition does not always involve pain. I have changed the name myalgic encephalomyelitis to chronic fatigue syndrome. Giovanni Maciocia Amersham, 2006

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NOTE ON THE TRANSLATION OF CHINESE MEDICAL TERMS

The terminology used in this book generally follows that used in the second edition of Foundations of Chinese Medicine, Obstetrics and Gynaecology in Chinese Medicine and Diagnosis in Chinese Medicine. As in those books, I have opted for translating all Chinese medical terms with the exception of Yin, Yang, Qi and cun (a unit of measurement). I have also continued using initial capitals for the terms that are specific to Chinese medicine. For example, “Blood” indicates one of the vital substances of Chinese medicine, whereas “blood” denotes the liquid flowing in the blood vessels (e.g. “In Blood deficiency, the menstrual blood may be pale.”). I use initial capitals also for all pulse qualities and for pathological colours and shapes of the tongue body. This system has served readers of my previous books well. As most teachers (including myself) use Chinese terms when lecturing (e.g. Yuan Qi rather than Original Qi), I have given each term in Pinyin whenever it is introduced for the first time. One change I have introduced in this book (as in the second edition of Foundations of Chinese Medicine) is to use the Pinyin terms more often throughout the text and at least once in each chapter when the Chinese term is first introduced. I have done this to reduce the frequency with which the reader may need to consult the glossary. I made the choice of translating all Chinese terms (with the exceptions indicated above) mostly for reasons of style: I believe that a well-written English text reads better than one peppered with Chinese terms in Pinyin. Leaving Chinese terms in Pinyin is probably the easiest option, but this is not ideal also because a single Pinyin word can often have more than one meaning; for example, jing can mean “channels”, “periods”, “Essence” or “shock”, while shen can mean “Kidneys”, “Mind” or “Spirit”. I am conscious of the fact that there is no such thing as a “right” translation of a Chinese medicine term,

and my terminology is not proposed in this spirit; in fact, Chinese medicine terms are essentially impossible to translate. The greatest difficulty in translating Chinese terms is probably that a term has many facets and different meanings in different contexts, thus it would be impossible for one translation to be “right” in every situation and every context. For example, the term Jue ( ) has many different meanings; a translation can illustrate only one aspect of a multifaceted term. In fact, Jue can mean a state of collapse with unconsciousness, coldness of hands and feet, or a critical situation of retention of urine. In other contexts, it has other meanings, for example Jue qi ( ), a condition of chaotic Qi; Jue Xin Tong ( ), a condition of violent chest pain with cold hands; and Jue Yin Zheng ( ), the Terminal Yin pattern within the Six Stage identification of patterns characterized by Heat above and Cold below. Many sinologists concur that Chinese philosophical terms are essentially impossible to translate and that, the moment we translate them, we distort them with a worldview that is not Chinese. Ames is particularly clear about the intrinsic distortion of Chinese concepts when they are translated. He gives examples of Chinese terms that are distorted when translated, such as Tian (“Heaven”), You-Wu (“Being” and “Nonbeing”), Dao (“Way”), Xing (“human nature”), Ren (“benevolence”), Li (“Principle”), and Qi (“primal substance”).1 Ames is particularly forceful in rejecting a single, one to one translation of a Chinese term into a Western one in the introduction of his book Focusing the Familiar (a translation of the Confucian text Zhong Yong).2 Ames says:3 Our Western languages are substance-oriented and are therefore most relevant to the descriptions of a world defined by discreteness, objectivity and permanence. Such

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languages are ill disposed to describe and interpret a world, such as that of the Chinese, that is primarily characterized by continuity, process and becoming. Ames then gives some examples of what he considers to be serious mistranslations of Chinese philosophical terms. The important thing is that these are not “mistranslations” because the terms are “wrong” but because of the intrinsic difference between Chinese and Western thinking and therefore the inherent inability of Western terms to convey Chinese philosophical ideas. Ames says:4 For example, You and Wu have often been uncritically rendered as “Being” and “Non-being”. Influential translators, until quite recently, have rendered wu xing as “Five Elements”. Xing is still most often translated as “nature”. All these translations promote the fixed and univocal characterizations of objects or essences emergent from a language rooted in a substantialist perspective [our Western languages]. Ames continues by saying that the use of a “substances language” (i.e. a Western language) to translate Chinese insights into a world of process and change has led to seriously inappropriate interpretations of the Chinese sensibility. Ames asserts that it is the very difference between Chinese and Western philosophy that makes translation of Chinese terms virtually impossible. He says:5 In the classical traditions of the West, being takes precedence over becoming and thus becoming is ultimately unreal. Whatever becomes is realized by achieving its end – that is, coming into being. In the Chinese world, becoming takes precedence over being. ‘Being’ is interpreted as a transitory state marked by further transition. Ames then says:6 The Chinese world is a phenomenal world of continuity, becoming and change. In such a world there is no final discreteness. Things cannot be understood as objects. Without this notion of objectivity, there can only be the flux of passing circumstances in which things dissolve into the flux and flow. A processive language precludes the assumption that objects serve as references of linguistic expressions. The precise referential language of denotation and description is to be replaced by a language of “deference” in which meanings both allude to and defer to one another in a shifting field of significance. A referential language [Western language] characterizes an event, object, or

state of affairs through an act of naming meant to indicate a particular thing. On the other hand, the language of deference [Chinese] does not employ proper names simply as indicators of particular individuals or things, but invokes hints, suggestions, or allusions to indicate foci in a field of meanings. As an example of this intrinsic impossibility of translating a Chinese philosophical term into a Western language, Ames then cites Steve Owen’s reluctance in translating shi as “poem”. Owen says:7 If we translate “shi” as “poem”, it is merely for the sake of convenience. “Shi” is not a “poem”: “shi” is not a thing made in the same way one makes a bed, a painting or a shoe. A “shi” can be worked on, polished and crafted; but that has nothing to do with what a “shi” fundamentally ‘is’ ... “Shi” is not the “object” of its writer: it is the writer, the outside of an inside. Ames says that in classical Chinese philosophical texts, allusive and connotatively rich language is more highly prized than clarity, precision and argumentative rigor. This rather dramatic contrast between Chinese and Western languages with respect to the issue of clarity presents the translator of Chinese philosophical texts with a peculiar burden. For the Chinese, the opposite of clarity is not confusion but something like vagueness. Vague ideas are really determinable in the sense that a variety of meanings are associated with them. Each Chinese term constitutes a field of meanings that may be focused by any of a number of its meanings. Ames says that in the translation of Chinese texts we must avoid what Whitehead called “the Fallacy of the Perfect Dictionary”. By this, he means the assumption that there exists a complete semantic repository of terms of which we may adequately characterize the variety and depth of our experience and that, ideally, one may seek a one to one correspondence between word and meaning. These ideas could not be more apt to illustrate the problems in translating Chinese medicine terms. Of course we must strive for precision and consistency, but to think that there is a one to one, “right” correspondence between a Chinese medicine idea and a Western term is a misunderstanding of the very essence of Chinese medicine. For example, to say that the only “right” translation of Chong Mai is “Thoroughfare Vessel” makes us fall into the trap of what Whitehead calls the “Fallacy of

Note on the Translation of Chinese Medical Terms

the Perfect Dictionary”. Of course, Chong Mai can be translated as “Thoroughfare Vessel”, but that is only one of its meanings and it is absolutely impossible for a single Western term to convey the richness of ideas behind the word Chong Mai (which I translate as “Penetrating Vessel”); to think that we can reduce a rich Chinese medicine idea to a single, one to one term in a Western language reveals, in my opinion, a misunderstanding of the very essence of Chinese medicine. Ames makes this point very forcefully. He says:8 The Fallacy of the Perfect Dictionary is largely a consequence of our analytical bias towards univocity. We would suggest that this bias does not serve us well when approaching Chinese texts. Not only is there the continued possibility of novel experiences requiring appeal to novel terminologies, but also there is seldom, if ever, a simple, one-to-one translation of Chinese terms into Western languages. The allusiveness of the classical Chinese language is hardly conducive to univocal translations. We would contend that, in translating Chinese texts into Western languages, it is most unproductive to seek a single equivalent for a Chinese character. In fact, rather than trying to avoid ambiguity by a dogged use of formally stipulated terms, the translator might have to concede that characters often require a cluster of words to do justice to their range of meanings – all of which are suggested in any given rendering of the character. In fact, any attempt to employ univocal translations of Chinese terms justified by appeal to the criteria of clarity or univocity often reduces philosophical insight to nonsense and poetry to doggerel. Such an approach to translation serves only to numb Western readers to the provocative significance harboured within the richly vague and allusive language of the Chinese texts. As an example of the multiplicity of meanings of a Chinese term and therefore of the fact that it is perfectly legitimate to translate a single Chinese idea into more than one term according to different contexts, Ames says that he translates the term zhong (“centre” or “central”) in the title of the Confucian text sometimes as “focus”, sometimes as “focusing” and other times as “equilibrium”. Other times, he even translates it as “centre” or “impartiality”. He says strongly:9 The Chinese language is not logocentric. Words do not name essences. Rather, they indicate always-transitory processes and events. It is important therefore to stress the gerundative character of the language. The language of process is vague, allusive and suggestive.

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According to Ames, in the field of philosophy, two terms particularly stand out as being influenced by a Western thinking when translated, i.e. Tian (“Heaven”) and Ren (“benevolence”). Ames says:10 When we translate Tian as “Heaven”, like it or not, we invoke in the Western reader a notion of transcendent creator Deity, along with the language of soul, sin and afterlife ... When we translate Ren as “benevolence”, we psychologize and make altruistic a term which originally had a radically different range of sociological connotations. Being altruistic for example, implies being selfless in the service of others. But this “self-sacrifice” implicitly entails a notion of “self” which exists independently of others and that can be surrendered – a notion of self which we believe is alien to the world of the Analects [of Confucius]: indeed, such a reading [of the term ren] transforms what is fundamentally a strategy for self-realization into one of selfabnegation.10 With regard to Chinese medicine, the term Xue (“Blood”) is a good example of the above-mentioned problem reported by Ames. When we translate the word Xue as “Blood”, we immediately alter its essential character and give it a Western medical connotation; in fact, in Chinese medicine, Xue is itself actually a form of Qi and one that is closely bound with Nutritive Qi (Ying Qi). Indeed, the term mai appearing in the Yellow Emperor’s Classic of Internal Medicine is often ambiguous, as it sometimes clearly refers to the acupuncture channels and other times to the blood vessels. After highlighting the problems in translating Chinese terms, Ames confirms that a single Chinese term may have different meaning in different contexts. For example, the term shen in some cases means “human spirituality”, in others it means “divinity”.11 As he considers only the philosophical meanings of the word shen, we could actually add many others in the context of Chinese medicine, for example “mind”, “spirit” and “lustre” (in the context of diagnosis). Ames then surveys the options that are presented to a translator and seems to favour simply transliterating the Chinese terms and leaves them untranslated. He says:12 To some, this approach may appear to be simply the laziest way out of a difficult problem. But “ritual” has a narrowly circumscribed set of meanings in English, and Li an importantly different and less circumscribed set. Just as no

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Indological scholar would look for an English equivalent for “karma”, “dharma” and so on, perhaps it is time to do the same for classical Chinese, the homonymity of the language notwithstanding. Hall confirms that a single Chinese term may have a plurality of meanings. He says:13 The Chinese have traditionally affirmed as the ground of their intellectual and institutional harmony the recognition of the co-presence of a plurality of significances with which any given term might easily resonate. Finally, another sinologist, Yung Sik Kim, discusses the difficulty presented by the plurality of meanings of a single Chinese term. He says:14 I have adopted the policy of sticking to one English translation for a particular Chinese word whenever possible ... Of course, exceptions cannot be avoided altogether. I have had to resort to different translations for such characters as “xin” which means both “heart” and “mind”; “tian” , both “heaven” and “sky”. In another passage, Yung Sik Kim affirms that transliteration of a Chinese term with a plurality of meanings is the only alternative:15 The term “li” is difficult to define. It is difficult even to translate because there is no single word in Western languages that covers all facets of what “li” meant to the traditional Chinese mind. The existence of many translations for the term, which often leaves transliteration as the only viable option, bespeaks the difficulty. Although a diversity of translation of Chinese terms may present its problems, these are easily overcome if an author explains the translation in a glossary and, most importantly, explains the meaning of a given Chinese term in its context (in our case, Chinese medicine). In my books, I have chosen to translate all Chinese medicine terms rather than using Pinyin purely for reasons of style as a sentence written half in English and half in Pinyin is often awkward. Moreover, if we use Pinyin terms in writing, it could be argued that we should be consistent and use Pinyin terms for all Chinese medicine terms, and this would not make for very clear reading. Consider the following sentence: “To treat Pi-Yang Xu, we adopt the zhi fa of bu pi and wen Yang” (“To treat Spleen-Yang deficiency, we adopt the treatment principle of tonifying the Spleen and warming Yang”).

Moreover, the problem arises only in the written form as, in my experience, most lecturers in colleges throughout the Western world normally prefer using Pinyin terms rather than their counterparts in English (or any other Western languages). Thus a lecturer will refer to Kidney-Jing rather than Kidney-Essence. Indeed, when I myself lecture, I generally use the Pinyin terms rather than their English translation. Again, most lecturers use a pragmatic approach, translating some terms into English (such as “treatment principle” instead of zhi fa) and leaving others in Pinyin such as Yuan Qi or Chong Mai. When I lecture, I always try to give the participants an idea of the meaning of a particular Chinese character and its significance and application in Chinese medicine. Indeed, the use of Pinyin when lecturing renders Chinese medicine truly international, as I can lecture in the Czech Republic and mention Jing, Yang Qiao Mai, Wei Qi, etc. knowing that I will be understood by everyone. A diversity of translation of Chinese terms may even have a positive aspect, as each author may highlight a particular facet of a Chinese term so that diversity actually enriches our understanding of Chinese medicine. If someone translates Zong Qi as “Initial Qi”, for example, we learn something about that author’s view and understanding of Zong Qi; the translation cannot be branded as “wrong” (I translate this term as “Gathering Qi”). Another example: if someone translates yang qiao mai as “Yang Motility Vessel”, the translation captures one aspect of this vessel’s nature; again, this could not be defined as wrong (I translate the name of this vessel as “Yang Stepping Vessel”). Trying to impose a standard, “right” translation of Chinese medicine terms may lead to suppression of healthy debate; I therefore hope that readers will continue to benefit from the diversity of translation of Chinese medical terms and draw inspiration from the rich heritage of Chinese medicine that it represents. I firmly believe that the future lies not in trying to establish a rigid, embalmed, fossilized, “right” terminology based on single, one to one translations of Chinese ideas. Indeed, I believe that this is a potentially dangerous trend, as it would, in my opinion, lead students and practitioners away from the richness of Chinese language and richness of meanings of Chinese medicine ideas. The adoption of a standardized, “approved” terminology of Chinese medical terms may indeed, in time, divorce students and practitioners

Note on the Translation of Chinese Medical Terms

from the essence of Chinese medicine. If an “official”, standardized translation of Chinese terms took hold, then students would be less inclined to study the Chinese terms to explore their meaning. Moreover, imposing an “approved” terminology in English betrays an Anglocentric worldview; to be consistent, we should then have an “approved” terminology in every major language of the world. It seems to me much better to try to understand the spirit and the essence of Chinese medicine by studying its characters and their clinical significance and using Pinyin transliteration whenever appropriate. Trying to fossilize Chinese medicine terms into an imposed terminology goes against the very essence of the Chinese language which, as Ames says, is not logocentric and in which words do not name essences; rather, they indicate always-transitory processes and events. The language of process is vague, allusive and suggestive. Because Chinese language is a language of process, the question arises also whether practising Chinese medicine actually helps the understanding of Chinese medical terminology; in my opinion, in many cases it does. For example, I feel that clinical experience helps us to understand the nature of the Chong Mai (Penetrating Vessel) and therefore helps us to understand the term Chong in a “knowing practice” way (as Farquhar defines it)16 rather than a theoretical way. Of course, a translator of Chinese books should strive for precision and consistency, but we must accept that there is a rich multiplicity of meanings for any given idea of Chinese medicine. The Chong Mai is a good example of this multiplicity, as the term chong could be translated as “throroughfare”, “strategic crossroads”, “to penetrate”, “to rush”, “to rush upwards”, “to charge”, “activity”, “movement” and “free passage”. Which of these translations is “correct”? They are all correct, as they all convey an idea of the nature and function of the Chong Mai. I therefore think that the future of teaching Chinese medicine lies not in trying to impose the straightjacket of a rigid terminology of the rich ideas of Chinese medicine, but in teaching students more and more Chinese characters, explaining the richness of meanings associated with them in the context of Chinese medicine. I myself would not like my own terminology to be “adopted” as the “correct” or “official” one; I would rather see colleges teaching more and more Chinese to their students by illustrating the rich meanings of

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Chinese medicine terms. As mentioned above, my main motive for translating all terms is purely for reasons of style in an English language textbook; when I lecture, I generally use Pinyin terms but, most of all, I show the students the Chinese characters and try to convey their meaning in the context of Chinese medicine. Finally, I would like to explain my continued translation of Wu Xing as “Five Elements”. The term “Five Elements” has been used by most Western practitioners of Chinese medicine for a long time (also in French and other European languages). Some authors consider this to be a misunderstanding of the meaning of the Chinese term Wu Xing perpetuated over the years. Wu means “five” and Xing means “movement”, “process”, “to go”, “conduct” or “behaviour”. Most authors therefore think that the word Xing cannot indicate “element” as a basic constituent of Nature, as was supposedly intended in ancient Greek philosophy. This is, in my opinion, only partly true, because the elements, as they were conceived by various Greek philosophers over the centuries, were not always considered “basic constituents” of Nature or “passive motionless fundamental substances”.17 Some Greek philosophers conceived the elements as dynamic qualities of Nature in a way similar to Chinese philosophy. For example, Aristotle gave a definite dynamic interpretation to the four elements and called them “primary form” (prota somata). He said:18 Earth and Fire are opposites also due to the opposition of the respective qualities with which they are revealed to our senses: Fire is hot, Earth is cold. Besides the fundamental opposition of hot and cold, there is another one, i.e. that of dry and wet: hence the four possible combinations of hot-dry [Fire], hot-wet [Air], cold-dry [Earth] and coldwet [Water] ... the elements can mix with each other and can even transform into one another ... thus Earth, which is cold and dry, can generate Water if wetness replaces dryness. To Aristotle, therefore, the four elements became the four basic qualities of natural phenomena, classified as combinations of four qualities: hot, cold, dry and wet. As is apparent from the above statement, the Aristotelian elements could even transform into one another and generate each other. This interpretation is very similar to the Chinese one, in which the elements are qualities of Nature. Furthermore, it is interesting to note the similarity

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with the Chinese theory of Yin-Yang: the four Aristotelian elements derive from the interaction of the basic Yin-Yang qualities of cold-hot and dry-wet. Thus it is not entirely true to say that the Greek elements were conceived only as the basic constituents of matter, the “building blocks” of Nature, which would make the use of the word “element” wrong to indicate xing. Furthermore, the word “elements” does not necessarily imply that; it does so only in its modern chemical interpretation. In conclusion, for the above reasons I have kept the word “element” as a translation of the Chinese word xing. According to Wang, the term “Five Elements” could be translated in a number of ways, for example “agents”, “entities”, “goings”, “conduct”, “doings”, “forces”, “activities” and “stages of change”.19 Recently, the term “Five Phases” is gaining acceptance, but some sinologists disagree with this translation and propose returning to ‘Five Elements”, Friedrich and Lackner, for example, suggest restoring the term “elements”.20 Graham uses the term “Five Processes”.21 I would probably agree that “processes” is the best translation of Wu Xing. In fact, the book Shang Shu, written during the Western Zhou dynasty (1000–771 BC) said:22 The Five Elements are Water, Fire, Wood, Metal and Earth. Water moistens downwards; Fire flares upwards; Wood can be bent and straightened; Metal can be moulded and can harden; Earth allows sowing, growing and reaping. Some sinologists (e.g. Needham and Fung Yu Lan) still use the term “element”. Fung Yu Lan suggests that a possible translation of wu xing could be “Five Activities” or “Five Agents”.23 Although the term “five phases” has gained some acceptance as a translation of “wu xing”, I find this term restrictive, because it clearly refers to only one aspect of the Five Elements, i.e. phases of a (seasonal) cycle.

A glossary with Pinyin terms, Chinese characters and English translation appears at the end of the book. I have included both a Pinyin–English and an English–Pinyin glossary.

END NOTES 1. Ames RT, Rosemont H 1998 The Analects of Confucius – a Philosophical Translation. Ballantine Publishing Group, New York, p. 311. 2. Ames RT, Hall DL 2001 Focusing the Familiar – a Translation and Philosophical Interpretation of the Zhong Yong. University of Hawai’i Press, Honolulu, pp. 6–16. 3. Ibid., p. 6. 4. Ibid., p. 6. 5. Ibid., p. 10. 6. Ibid., p. 10. 7. Ibid., p. 13. 8. Ibid., p. 16. 9. Ibid., p. 16. 10. Ames RT. The Analects of Confucius, p. 312. 11. Ibid., p. 313. 12. Ibid., p. 314. 13. Hall DL, Ames RT 1998 Thinking from the Han. State University of New York Press, New York, p. 4. 14. Yung Sik Kim 2000 The Natural Philosophy of Chu Hsi. American Philosophical Society, Philadelphia, p. 11. 15. Ibid., p. 19. 16. Farquhar J 1994 Knowing Practice – the Clinical Encounter of Chinese Medicine. Westview Press, Boulder, USA. 17. Needham J 1977 Science and Civilization in China, vol. 2. Cambridge University Press, Cambridge, p. 244. 18. Lamanna EP 1967 Storia della Filosofia [History of Philosophy], vol. 1. Le Monnier, Florence, pp. 220–221. 19. Wang Ai He 1999 Cosmology and Political Culture in Early China. Cambridge University Press, Cambridge, p. 3. 20. Friedrich M, Lackner M 1983–1985. Once again: the concept of Wu Xing. Early China 9–10: 218–219. 21. Graham AC 1986 Yin-Yang and the Nature of Correlative Thinking. Institute of East Asian Philosophies, Singapore, pp. 42–66 and 70–92. 22. Shang Shu (c.659 BC) cited in 1975 Shi Yong Zhong Yi Xue [Practical Chinese Medicine]. Beijing Publishing House, Beijing, p. 32. The book Shang Shu is placed by some in the early Zhou dynasty (hence c.1000 BC), but the prevalent opinion is that is was written sometime between 659 BC and 627 BC. 23. Fung Yu Lan 1966 A Short History of Chinese Philosophy. Free Press, New York, p. 131.

CHAPTER 1

HEADACHES

Wind-Dampness 22 Liver-Yang rising 23 Liver-Fire 32 Liver-Wind 34 Liver-Qi stagnation 35 Stagnation of Cold in the Liver channel 36 Dampness 37 Turbid Phlegm 40 Turbid Phlegm-Wind 42 Liver-Yang rising with Phlegm in the head 42 Retention of food 43 Stasis of Blood 44 Stomach-Heat 47 Qi deficiency 47 Blood deficiency 48 Kidney deficiency 49

AETIOLOGY 2 Constitutional deficiency 2 Emotional stress 3 Overwork 4 Excessive sexual activity 4 Irregular diet 5 Trauma 5 Childbirth 6 External pathogenic factors 6 CHANNELS

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PATHOLOGY 10 Excess of Yang 10 Deficiency of Yang 11 Excess of Yin 11 Deficiency of Yin 11

MODERN CHINESE LITERATURE DIAGNOSIS 12 Diagnosis according to channels 12 Diagnosis according to type of pain 15 Diagnosis according to amelioration and aggravation 16

CLINICAL TRIALS 55 Acupuncture 55 Herbal medicine 58 PATIENTS’ STATISTICS

TREATMENT STRATEGIES AND PRINCIPLES OF POINT SELECTION 17 Treating the Root or the Manifestation 18 Point selection 18 IDENTIFICATION OF PATTERNS AND TREATMENT Wind-Cold 20 Wind-Heat 21

52

59

WESTERN DIFFERENTIAL DIAGNOSIS OF HEADACHES Intracranial 60 Cranial 62 Extracranial 62

19 PROGNOSIS AND PREVENTION

63

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EXTERIOR • Wind-Cold • Wind-Heat • Wind-Dampness INTERIOR Full • Liver-Yang rising • Liver-Fire • Liver-Wind • Liver-Qi stagnation • Stagnation of Cold in the Liver channel • Dampness • Turbid Phlegm • Turbid Phlegm-Wind • Liver-Yang rising with Phlegm in the head • Retention of Food • Stasis of Blood • Stomach-Heat Empty • Qi deficiency • Blood deficiency • Kidney deficiency

AETIOLOGY Any of the causes of disease normally considered in Chinese medicine can play a part in the aetiology of headaches. The main aetiological factors discussed are as follows. • Constitutional deficiency • Emotional stress — Anger — Worry — Sadness and grief — Fear — Shock — Pensiveness — Guilt — Shame • Overwork • Excessive sexual activity • Irregular diet • Trauma • Childbirth • External pathogenic factors

Constitutional deficiency The constitutional body condition inherited from our parents depends on three factors:

HEADACHES Headache is one of the most common symptoms encountered in clinical practice. There are few people who have never experienced a headache at some time or other of their life. The discussion of the treatment of headaches will include that of migraine and will be based on the following headings. • • • • • • • • • • •

Aetiology Channels Pathology Diagnosis Treatment strategies and principles of point selection Identification of patterns and treatment Modern Chinese literature Clinical trials Patients’ statistics Western differential diagnosis of headaches Prognosis and prevention

1. the parents’ health in general 2. the parents’ health at the time of conception 3. the conditions of the mother’s pregnancy. Any of these factors can affect the body condition and become a cause of headaches later in life. Persistent and recurrent headaches that start in childhood (usually between about 7 and 10) strongly indicate the presence of a constitutional factor of disease. If the parents’ Qi and Essence are weak, the resulting PreHeaven Essence of the child will also be weak; similarly, if the child is conceived when one or both parents are in later life. This can result in headaches deriving from a Kidney or Liver deficiency starting during childhood. A hereditary Kidney or Liver weakness manifests with enuresis or frequent urination, lack of vitality, dull headaches, and frequently myopia. Even though the parents’ general health may be good, if it is poor at the time of the child’s conception (perhaps through overwork, excessive sexual activity, excessive consumption of alcohol, or use of certain medications or drugs such as cannabis or cocaine), this

Headaches

will result in the child’s having a weak constitution and in the possibility of suffering from headaches. In this case, the weakness will affect not the Kidneys or Liver but any of the other organs, i.e. Spleen, Lungs or Heart, depending on the particular condition that is negatively affecting the parents’ health. For example, if the parents’ health is poor from overwork at the time of the child’s conception, this may be a cause of hereditary Spleen weakness in the child. The excessive consumption of alcohol or the use of drugs or certain medicines may cause a hereditary weakness of the child’s Heart or Lungs. A hereditary Spleen weakness in a child may manifest with poor muscle tone, physical weakness, digestive problems, and in severe cases Child Nutritional Impairment (Gan). In this case, the headaches will be on the forehead and be related to food intake. A hereditary Lung weakness in a child may manifest with a tendency to catching colds and respiratory infections, whooping cough, asthma, eczema, pale complexion, a thin chest, and a pulse in both Front positions that when felt is more medial and running upwards towards the thumb (Fig. 1.1). A hereditary Heart weakness in a child may manifest with dream-disturbed sleep, nervousness, and a relatively deep midline crack on the tongue. Young children (under 3) may wake up crying at night. In such cases, the headaches are usually on the forehead or in the whole head. The condition of the mother during the pregnancy can affect the fetus. For example, an accident to the mother can cause headaches for the child. A shock during pregnancy can also cause a child to suffer head-

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aches deriving from Heart deficiency. This will also manifest with a bluish tinge on the child’s forehead and chin.

Emotional stress Emotional causes of disease are, of course, extremely frequent causes of headaches.

Anger Many different emotions fall under the broad term of “anger” in Chinese medicine. Among them are frustration, resentment and pent-up grudges. All these emotions may cause the rising of Liver-Yang or LiverFire. Among the emotional causes of headaches, anger, in the broad sense intended above, is the most common one. It will give rise to headaches from LiverYang rising or Liver-Fire blazing. These headaches are typically situated on the Gall Bladder channel on the temple or side of the head. Please note, however, that the rising of Liver-Yang is not always due to anger (see below); it may also be caused by worry.

Worry Worrying excessively knots Qi, in particular Lung- and Heart-Qi. This is often an indirect cause of headaches, as the deficiency of Lung-Qi (Metal in the Five-Element model) may allow Liver-Yang to rise (Wood in the FiveElement model) and cause headaches. Worry may also be a direct cause of headaches, which are usually situated on the forehead or the top of the head and are dull in character. Please note that, like anger, worry may also lead to Liver-Yang rising and it may therefore be a direct cause of headaches.

Sadness and grief Sadness and grief deplete Qi; in time, this may lead to the depletion of Blood and to Blood deficiency. This may cause headaches of a deficient nature from Blood deficiency. In turn, Blood deficiency may, in the long run, lead to the rising of Liver-Yang, which may cause headaches. This situation is more likely to occur in women.

Fear Figure 1.1 Pulse picture in hereditary Lung weakness.

A chronic state of anxiety and fear depletes the Kidneys and causes headaches either directly from Kidney

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The Practice of Chinese Medicine

deficiency (in this case affecting the whole head) or indirectly when the Kidney deficiency leads to the rising of Liver-Yang.

Shock Shock “suspends” Qi and it affects Heart-, Lung- and Spleen-Qi. It will usually cause headaches affecting the whole head.

Pensiveness “Pensiveness” encompasses several different emotions including brooding, thinking too much, nostalgic thinking of the past and also excessive mental work. Excessive mental activity is a frequent cause of chronic headaches in children. Although this may seem strange at first, it does occur frequently when a bright child attends an academically demanding school with high parental expectations. This sets a pattern early in life of long hours of mental work and concentration combined with the worry over the need to do well, which leads to severe headaches or migraine. The long hours of reading by himself or herself (and nowadays working at a computer monitor) strain the child’s eyes and lead to headaches.

Guilt Guilt is a pervasive emotion in Western patients that is missing from Chinese medicine books. A feeling of guilt may be due to the transgression of social or religious taboos or from having done something “wrong” that is later regretted. However, a feeling of guilt may also be innate and not related to any specific action. This latter feeling is indeed the most destructive one. It is important to distinguish the subjective sense of guilt from its objective counterparts. For example, a person may be found guilty in a court of law, without feeling guilty; in a religious context, a person may deem himself or herself to be guilty in front of God but still not feel guilty; someone may be guilty of doing something reprehensible but still not feel guilty. It is therefore the feeling of guilt that is all important. Guilt is a “dark” emotion with no redemption; it is a much “darker” emotion than shame. Guilt can have different effects in different people. First of all, it may lead to Qi stagnation: it affects any organ, especially the Lungs, Heart, Liver and Kidneys. Due to its “dark”, “stagnating” character, it causes Blood stasis easily and quickly. This Blood stasis may be

in any part of the body and any organ but occurs particularly in the Lungs, Heart, Spleen and Liver. When Blood stasis deriving from guilt affects the Upper Burner (through the Lung and/or Heart channels), it may cause headaches.

Shame Shame is a common emotion in Western patients. It may be caused by feeling ashamed of one’s behaviour but, more commonly, shame is an inborn feeling due to one’s upbringing: a feeling of worthlessness, the absence of a feeling of self-worth. Shame is directed inwards; it is self-accusation. The feeling that one has to hide is an important aspect of shame. One feels judged all the time. Shame is directed inwards and it therefore makes Qi stagnate but also possibly sink. Indeed, sinking of Qi is a very common result of shame; Dampness also frequently accompanies shame. When one feels shame, one feels “dirty”, and “dirty” is characteristic of Dampness. When Dampness deriving from shame settles in the head, it may give rise to chronic headaches.

Overwork Working too long hours without adequate rest weakens Spleen-Qi and, in the long run, Kidney-Yin. This is the most common cause of Yin deficiency in Western industrial societies. The deficiency of Kidney-Yin will give rise to headaches in the whole head, or it will lead to Liver-Yang rising and causing migraine-type headaches on one side of the head on the Gall Bladder channel.

Excessive sexual activity This is a common cause of headaches, particularly in men. Under normal circumstances, the temporary loss of Kidney-Essence resulting from sexual activity is quickly restored and so sexual activity will not lead to disease. When sexual activity is too frequent, however, there is no time for the Kidney-Essence to be restored, and this results in deficiency of Kidney energy (either Yin or Yang, depending on the constitution of the person). An old Daoist saying declares: “Sleeping alone is better than taking 100 tonics”! Men are more affected by excessive sexual activity than are women. Too many childbirths in too short a

Headaches

time weaken the uterus and the Kidneys in women. This is an important cause of depletion of KidneyEssence in women, somewhat equivalent to excessive sexual activity in men (see below). Equally, excessive loss of blood due to chronic menorrhagia over many years in women also depletes the Kidneys. By depleting the Kidneys, excessive sexual activity is a frequent cause of headaches either on the occiput or the whole head. Indeed, if someone experiences a headache and dizziness following sexual intercourse, it is a certain sign that the particular level of sexual activity is excessive and it should be moderated. It is of course impossible to define what is “excessive” sexual activity, as this is entirely relative and depends on the person’s constitution and strength of Essence.1

Irregular diet Diet has a direct and profound influence on the aetiology of headaches. Dietary irregularities may cause headaches by affecting different organs. First of all, not eating enough in itself will obviously cause headaches from general deficiency of Qi and Blood usually occurring on the top of the head. This situation occurs when people follow too strict a diet, adhering to rigid “rules” and consequently lacking essential nourishment. On the other extreme, overeating obstructs StomachQi and weakens the Spleen, leading to headaches on the forehead, which are usually sharp in character. Excessive consumption of hot-energy foods such as curries, spices, pepper (black, white or red), red meat and alcohol causes Liver-Fire and/or Stomach-Heat. Liver-Fire will result in lateral headaches and StomachHeat in frontal headaches, both of which are sharp in character. The excessive consumption of Damp-producing foods affects the Spleen and leads to Dampness, which may cause dull headaches on the forehead and a typical feeling of heaviness in the head. Damp-producing foods include all greasy foods, fried foods, milk, cheese, butter, cream, ice cream, bananas, peanuts, sweets and white sugar. Too much salt in the diet will cause a Kidney deficiency and may result in dull headaches in the whole head or on the occiput. A diet based on tinned or processed foods is often heavy in salt, because this is added to many such foods: bacon, sausages, cereals, tinned soups, smoked fish and many others.

5

An excessive consumption of sour foods affects the Liver and is also a frequent cause of headaches. Sour foods include yoghurt, grapefruit and its juice, cooking apples, pickles, vinegar, spinach, rhubarb, gooseberries and redcurrants. The way in which food is eaten also influences the energy of the internal organs. Eating too quickly or while discussing work leads to retention of food in the Stomach and to sharp headaches on the forehead. Eating irregularly or too late at night induces a deficiency of Stomach-Yin and may cause dull headaches on the forehead (see also Chapter 22, Epigastric pain). It should be remembered that the principles of Chinese diet were developed over 2000 years ago. They do not take into account modern discoveries about food and, most of all, do not consider the role of chemicals in food. Food has never been subjected to so much chemical manipulation as in the past 30 years or so. As far as headaches are concerned, they can be very much affected by chemicals in food. For example, it is well known that monosodium glutamate (found in Chinese restaurant food) can cause headaches. The possibility of a sensitivity to certain chemicals should therefore always be kept in mind when investigating the aetiology of headaches. Finally, certain foods we consume are not found in a Chinese diet at all, and for this reason are not even mentioned in books on diet. Cocoa (and chocolate) and coffee are a case in point. Both of these can aggravate headaches or precipitate a migraine attack. In particular, an excessive consumption of coffee is a frequent cause of chronic headaches in our society and, in my experience, any chronic headache sufferer always benefits greatly from not drinking coffee at all.2

Trauma Severe accidents and falls that affect the head can cause stasis of Blood in a particular area of the head. This is a frequent cause of chronic headache. If the headaches a patient suffers always occur in the same part of the head and particularly in a small area, then the possibility of an old trauma to the head should be considered. The patient may not be aware of or remember an old fall or accident and not relate it to the headaches. A single large purple spot near the tip of the tongue may indicate an old trauma in the head region.

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The Practice of Chinese Medicine

In particular, a trauma to the head may not cause headaches immediately after it, but these can start years later when a new cause of disease intervenes. For example, a child may fall on the head and be mildly concussed. Many years later, he or she may experience emotional problems related to anger or frustration, which cause Liver-Yang to rise. In such a case, the headache from Liver-Yang rising will settle in the area of the head where the old trauma occurred and will always affect such an area.

Childbirth Too many childbirths too close together weaken the Liver, Kidneys and Directing Vessel (Ren Mai) in a woman. A deficiency of the Liver and Kidneys can give rise to Empty-type headaches from Kidney-Essence not reaching the head; the deficiency of Liver and Kidneys may also induce Liver-Yang to rise and therefore cause headaches of this type. It is important to remember that miscarriages also count as “childbirth” as far as causes of disease are concerned. A miscarriage is as depleting as childbirth; in fact, some Chinese doctors even say that miscarriages are more depleting than childbirth. This is because, first of all, there may be more blood loss in a miscarriage than in childbirth; second, after a miscarriage there is an abrupt alteration of the hormone levels; third, a miscarriage (especially a late one) is emotionally very distressing and the mother often has deep feelings of loss and even failure.

External pathogenic factors The main external pathogenic factors that cause headaches are Wind and Dampness. Wind affects the top part of the body and is a very frequent cause of acute headaches, which may arise independently without other symptoms or may occur together with the symptoms of invasion of Wind-Cold. External Wind also affects the neck muscles, causing a pronounced stiffness. Wind is normally a cause of acute headaches, but repeated invasions of Wind may give rise to chronic headaches and stiffness of the neck and shoulders (called Head-Wind). External Dampness can also affect the head even though this particular pathogenic factor normally invades the lower part of the body. However, acute invasions of Dampness easily affect the Middle Burner; from here, Dampness may rise to the head and prevent

SUMMARY AETIOLOGY  Constitutional deficiency  Emotional stress — Anger — Worry — Sadness and grief — Fear — Shock — Pensiveness — Guilt — Shame  Overwork  Excessive sexual activity  Irregular diet — Not eating enough — Overeating — Excessive consumption of hot-energy foods (curries, spices, pepper, red meat and alcohol) — Excessive consumption of Damp-producing foods (greasy foods, fried foods, milk, cheese, butter, cream, ice cream, bananas, peanuts, sweets and white sugar) — Too much salt — Excessive consumption of sour foods (yoghurt, grapefruit and its juice, cooking apples, pickles, vinegar, spinach, rhubarb, gooseberries, redcurrants) — Irregular eating habits — Chemicals in food — Cocoa (and chocolate) and coffee  Trauma  Childbirth  External pathogenic factors

the clear Yang from reaching the head and clearing the head’s orifices.

CHANNELS A thorough knowledge of the channels flowing through the head is essential for the acupuncture treatment of headaches. When treating headaches, we must always look at their pathology from two different perspectives, i.e. from the perspective of Internal

Headaches

Organs’ disharmony and from that of the channels involved. Superficially, the head contains only Yang channels, as the Yang channels of the arm end in the head and those of the feet start there. This means that the head is an area of concentration of Yang Qi; for this reason, in ancient times it was compared with Heaven and it was also sometimes called the “Palace of Yang”. The Correct Seal of Medical Circles says:3

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Large Intestine Stomach

The head is like Heaven [being at the top]: the clear Qi of the three Yang channels [Greater Yang, Lesser Yang and Bright Yang] and the six Yang organs as well as the Blood and Essence of the three Yin channels [Greater Yin, Lesser Yin and Terminal Yin] and the five Yin organs, all reach it. It is affected by the six external pathogenic climates as well as by internal pathogenic factors. As the Arm Yang channels end on the face and flow into the Leg Yang channels that start on the face, the Yang channels (of Arm and Leg) could really be looked on as one channel in which there is no interruption between the arm and leg section (i.e. Large IntestineStomach, Small Intestine-Bladder and Triple BurnerGall Bladder). Indeed, this is one way in which the channels are paired, i.e. Bright Yang (Large Intestine and Stomach), Greater Yang (Small Intestine and Bladder) and Lesser Yang (Triple Burner and Gall Bladder). This means that often distal points of the arm and leg channels have very similar actions and are almost interchangeable, for example L.I.-4 Hegu and ST-44 Neiting, and T.B.-2 Yemen and G.B.-43 Xiaxi. Figure 1.2 shows the Large Intestine and Stomach channels to illustrate this principle. Thus, the connection between Yang channels on the face is more direct than that between Yin channels in the chest (the Yin channels of the arm start in the chest and those of the leg end there).

! The Yang channels communicate directly and superficially on the face (e.g. L.I.-20 Yingxiang and ST-1 Chengqi, S.I.-19 Tinggong and BL-1 Jingming, and T.B.-23 Sizhukong and G.B.-1 Tongziliao). Therefore, often distal points of the arm and leg channels have very similar actions and are almost interchangeable (e.g. L.I.-4 Hegu and ST-44 Neiting, S.I.-3 Houxi and BL-65 Shugu, T.B.-2 Yemen and G.B.-43 Xiaxi).

Figure 1.2 Large Intestine and Stomach channels as one continuous channel.

The head is the highest part of the body not only anatomically but also energetically according to the flow of Qi in the 12 channels. It is, in fact, the area of maximum potential of energy in the circulation of Qi in the channels. Qi circulates in the channels because

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The Practice of Chinese Medicine

there is a difference of energy potential between the chest and the head. If we consider the first four channels, for example, we see that Qi starts at the chest area in the Lung channel; this is the area of minimum potential of energy. In order to understand this, we can visualize a certain amount of water at the bottom of a hill, where its potential of producing energy is minimal. If we slowly carry this water up the hill, gradually its potential of producing energy will increase, as we know. When the water reaches the top of the hill, its potential of producing (hydroelectric) energy will be maximum (Fig. 1.3). The bottom of the hill corresponds to the chest, halfway up the hill corresponds to the hands (or feet), and the top of the hill corresponds to the head. Thus, from the Lung channel in the chest, Qi starts to move upwards towards the head. At the fingertips, Qi changes polarity, i.e. it flows from the Yin Lung channel to the Yang Large Intestine channel, but it is still flowing towards the head and its potential is increasing. When it reaches the head, the potential is at its maximum, and it then starts decreasing as it flows towards the

feet. At the feet, Qi changes polarity, i.e. it flows from the Yang Stomach channel to the Yin Spleen channel, but its potential is still decreasing as it flows towards the chest area, the area of minimum potential energy. Figures 1.4 and 1.5 illustrate the concept of potential energy in the flow of Qi from the chest (area of minimum potential energy) to the hands (area of average potential energy), to the head (area of maximum potential energy), to the feet (area of average potential energy) and back to the chest (area of minimum potential energy). When it reaches the chest, the potential is minimum (the water has reached the bottom of the hill again). The Qi from the Spleen channel then connects internally with the Heart channel and a new four-channel cycle starts in exactly the same way. The cycle of Qi in the first four channels can be seen in Figure 1.6, and Figure 1.7 shows the circulation of Qi in the 12 channels. The implication of all this is that the head is the area of maximum potential of Qi and therefore intrinsically prone to rising of energy (or pathogenic factors) to the top; for example, the rising of Liver-Yang, Liver-Fire,

Maximum potential energy

Minimum potential energy

Figure 1.3 Potential energy in Qi circulation. (From Maciocia G 2006 The Channels of Acupuncture. Churchill Livingstone, Edinburgh.)

Headaches

How a hydroelectric plant works

Maximum potential energy (Head)

HEAD Arm Yang

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Dam built across steep-sided river valley

LI HAND

Turbine passages

Leg Yang ST LU Arm Yin

Generators CHEST

Reservoir Turbines

Minimum potential energy (Chest)

SP Leg Yin FEET

River

Figure 1.4 Potential energy and the circulation of Qi.

Leg Yang

LI

ST FEET

LU

Face

Toes

Chest

Average potential energy

SP

Arm Yin

Fingers

YIN

HAND

Chest

YANG

HEAD Arm Yang

Maximum potential energy

Leg Yin CHEST

Minimum potential energy

Lungs

Large Intestine

Stomach

Spleen

Figure 1.5 Potential energy and the circulation of Qi. Bright Yang Greater Yin

Liver-Wind or Heart-Fire. Conversely, clear Yang Qi failing to rise to the top may lead to the obstruction of the head by Phlegm or Dampness. The head is also the area of concentration of Yang energy, as all the Yang channels directly meet and join up in the head. In fact, as far as the superficial pathways are concerned, only Yang channels reach the head. For this reason, the head is variously called “the confluence of Yang”, “the Palace of Yang” or “the Palace of clear Yang”.4 However, Yin Qi obviously also reaches the head but only internally. Of the Yin channels, only the Heart and Liver reach the head internally (deep pathway). All the other Yin channels reach the head indirectly

Figure 1.6 The circulation of Qi in the first four channels.

via their divergent channels, as each Yin divergent channel merges with its related Yang divergent channel at the neck area (Fig. 1.8). Therefore, the divergent channels are an important way in which Yin Qi reaches the head (as all Yin divergent channels eventually merge with the corresponding Yang divergent channel in the neck area). Figure 1.9 summarizes the channels reaching the head. Thus both the clear Yang from the Yang organs and the pure essences from the Yin organs reach the head.

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The Practice of Chinese Medicine Fingers

Face

Toes

Chest

Fingers

Face

Toes

Chest

Fingers

Face

Toes

Chest

YIN

YANG

Chest

LU

L.I.

ST

SP

HE

Bright Yang Greater Yin Figure 1.7 The circulation of Qi in the 12 channels.

Neck area

Yang main channel

Neck

S.I.

Yin main channel Limb

Limb Yang main channel

KL

P

T.B.

G.B.

Greater Yang

Lesser Yang

Lesser Yin

Terminal Yin

Yang main channel Yang divergent channel

Yang divergent channel

BL

Yin divergent channel

Arm Yang channels

Yin main (Heart and Liver)

HEAD Palace of Yang

Yang divergent

LIV

Leg Yang channels

Yin divergent

Figure 1.9 Channels reaching the head. Yin main channel

Figure 1.8 Connection between Yin and Yang divergent channels.

As far as headaches are concerned, the two Yang channels that are most frequently involved are the Gall Bladder and Bladder. Of the Yin channels, the two most frequently involved are the Liver and Kidneys.

PATHOLOGY As the head is an area of concentration of Yang Qi, the pathology of headaches can be reduced to four very simple and basic conditions of Excess Yang, Deficiency of Yang, Excess of Yin and Deficiency of Yin. Examples of Excess of Yang are Liver-Yang rising and Liver-Fire; examples of Deficiency of Yang are

Stomach-Qi deficiency, Kidney-Yang deficiency and Spleen-Qi deficiency; examples of Excess of Yin are Dampness and Phlegm; and examples of Deficiency of Yin are Liver-Blood deficiency and Kidney-Yin deficiency.

Excess of Yang “Excess of Yang” has two different meanings: it may indicate an actual Excess of Yang Qi in the head (such as in Liver-Fire) or an excessive rising of Yang to the head (as in Liver-Yang rising). It is important not to confuse these two separate conditions. In fact, the difference between Liver-Fire and LiverYang rising is a good illustration of this difference. With Liver-Fire, there is an actual Excess of Yang, i.e. Fire (Full Heat). This manifests with a red face, a feeling of heat in the face, intense thirst, a bitter taste in the

Headaches

mouth and irritability. This is a condition of Full Heat that must be drained with bitter-cold herbs. Liver-Fire is a type of Full Heat, and it has the tendency to dry the body fluids, it may cause bleeding and it strongly affects the Mind. Liver-Yang rising, by contrast, is not a condition of Full Heat but simply an imbalance of Qi with Qi and Yang rising excessively towards the head. Although there are a few symptoms of Heat due to the rise of Yang to the head (red face), it is neither a Full condition nor a condition of Full Heat. There is a very important difference between the herbal treatment of Liver-Fire and that of Liver-Yang rising: while the former is treated by draining Fire with bitter-cold herbs (e.g. Huang Qin Radix Scutellariae and Long Dan Cao Radix Gentianae), the latter is treated by subduing Yang using herbs that sink Qi (e.g. Shi Jue Ming Concha Haliotidis and Mu Li Concha Ostreae).

11

Excess of Yin As we have seen, although Yin Qi does reach the head indirectly through the divergent channels, superficially there are only Yang channels on the head. This is not coincidental, as clear Yang Qi needs to rise to the head to brighten the orifices. Accumulation of Excess Yin in the head will have the effect of preventing the rising of clear Yang and will therefore lead to clouding of the orifices. “Clouding of the orifices” will result in blurred vision, dizziness, a blocked nose, a sticky taste, tinnitus and a feeling of muzziness (fuzziness) and heaviness of the head. The two most common pathogenic factors that lead to an Excess of Yin in the head are Dampness and Phlegm. The headache from Excess of Yin is dull but intense.

Deficiency of Yin CLINICAL NOTE Liver-Fire is a condition of Full Heat (thirst, bitter taste, feeling of heat, red face, red eyes, dark urine, dry stools); Liver-Yang rising is purely an imbalance between Yin and Yang with excessive rising of Yang Qi to the head. The headaches from Excess of Yang are therefore due to a stagnation of Yang Qi in the head: Qi cannot circulate and this causes head pain. The headache from Excess of Yang is by definition intense and usually throbbing.

As the head is an area of confluence of Yang channels, the rise of clear Yang to the head necessarily occurs, so deficiency of Yin is not a common cause of headaches. However, as Blood is part of Yin, a deficiency of Blood, which is a relatively common cause of headaches, is also a type of deficiency of Yin. A deficiency of Liver- or Heart-Blood is a common cause of headaches. Other examples of deficiency of Yin leading to headaches are deficiency of Kidney-Yin or of Kidney-Essence. The headache from Yin deficiency is dull and mild.

Deficiency of Yang

SUMMARY

With deficiency of Yang, there is the opposite situation, i.e. not enough clear Yang reaches the head. Under normal circumstances, clear Yang Qi flows up to the head, brightening the orifices of the head (ears, nose, mouth, eyes and the Mind). The rising of clear Yang to the head is also very important to the constant clearing of potential Yin pathogenic factors from the head. The physiological rise of clear Yang to the head is facilitated by the fact that, superficially, the head contains only Yang channels. The most common examples of deficient Yang not rising to the head are Stomach-Qi or Kidney-Yang not reaching the head. Stomach-Qi deficiency will cause a frontal headache, while KidneyYang will cause an occipital headache. The headache from Deficiency is by definition dull and mild.

PATHOLOGY  Excess of Yang — Liver-Yang rising, Liver-Fire — Intense and usually throbbing  Deficiency of Yang — Deficiency of Stomach-Qi (frontal) or Kidney-Yang (occipital) — Dull and mild  Excess of Yin — Dampness and Phlegm — Dull but intense  Deficiency of Yin — Deficiency of Liver- or Heart-Blood, deficiency of Yin or Kidney-Essence — Dull and mild

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The Practice of Chinese Medicine

DIAGNOSIS Headaches can be diagnosed from two perspectives: either from the point of view of channels or from that of Internal Organs. Both of these are equally relevant in clinical practice, particularly from the acupuncturist’s perspective. I will discuss the main diagnostic pointers from three viewpoints: 1. diagnosis according to channels 2. diagnosis according to type of pain 3. diagnosis according to amelioration and aggravation. The diagnosis according to the Internal Organs will be discussed under the heading, Identification of patterns and treatment.

Diagnosis according to channels Medical Talk from the Deserted Cottage says:5 The Greater Yang type of headache affects the occiput, the Bright Yang type affects the forehead, the Lesser Yang type affects the sides of the head ... the Terminal Yin type affects the top of the head ... the Greater and Lesser Yin do not ascend to the head, but Phlegm can prevent Qi from descending and the pure Yang from ascending freely to the head. This classification provides useful guidelines in clinical practice for a quick identification of the channel involved in a given type of headache (Fig. 1.10). However, this is only a broad guideline that first of all needs to be further refined, and second needs to be integrated with the identification of patterns of the

Internal Organs. For example, a headache on the top of the head often involves the Terminal Yin channel, i.e. the Liver channel; it can be due to either Liver-Yang rising or Liver-Blood deficiency. Furthermore, a headache on the top of the head may also be due to deficient Qi’s and/or Blood’s being unable to reach the head and may not necessarily reflect a Liver channel involvement at all. A further analysis of the channels affecting various head areas in headaches is as follows.

Top of the head The Liver channel reaches the top of the head internally and is the most frequent cause of headache there (Fig. 1.11). A headache on top of the head is most often due to deficient Liver-Blood’s being unable to reach the area. This headache, which will be dull in character, will improve if the patient lies down. In a few cases, a headache in this area may be due to Liver-Yang rising, in which case it will be sharp in character. There are also other causes of headache in this area not related to the Liver channel, such as deficient Qi’s and/or Blood’s being unable to reach the top of the head, or Heart-Blood deficiency. A headache on the top of the head only should not be confused with one that affects this area but that starts at the base of the occiput and works its way up. This type of headache is due to the Bladder channel.

Sides of the head This area corresponds to the Gall Bladder channel, and a headache here is most frequently due to Liver-Yang

Terminal Yin

Bright Yang Lesser Yang

Greater Yang

Figure 1.10 Headache areas.

Headaches

Figure 1.11 Liver-channel headache area.

Figure 1.12 Sides of the head area.

rising, Liver-Fire or Liver-Wind (Fig. 1.12). Such a headache is sharp and throbbing in character.

One side only This area also corresponds to the Gall Bladder channel, and a headache here is also due either to Liver-Yang rising or to Liver-Fire. It is said in Chinese medicine that a headache on the left side is more likely to result from a Deficiency and one on the right side to result from an Excess, but this rule is by no means completely reliable.

Temples This area also corresponds to the Gall Bladder channel, and such a headache most frequently affects one side only. This headache is usually due to Liver-Fire, LiverYang or Liver-Wind rising and is throbbing in character (Fig. 1.13).

Behind the eyes This is a very frequent location for migraine. The headache is due to Liver-Blood deficiency if the pain is dull, or to Liver-Yang rising if the pain is sharp and severe.

Figure 1.13 Temple area.

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The Practice of Chinese Medicine

Forehead Headaches in this area are usually related to the Stomach. If the pain is dull, they indicate Stomach deficiency; if it is sharp, Stomach-Heat. A very frequent cause of frontal headaches is the retention in the head of either Dampness or Phlegm, preventing the clear Yang from ascending to the head to brighten the sense orifices. For this reason, this type of headache is associated with a heavy sensation of the head, a muzzy (fuzzy) feeling of the head, and a lack of concentration. If Phlegm is causing the headache, the person will also experience dizziness and blurred vision. In a few cases, frontal headaches can be due to a residual pathogenic factor, such as external Wind that has not been expelled after an invasion of exterior Wind-Cold or Wind-Heat.

Back of the head (occiput) Chronic headaches in this area are usually due to a Kidney deficiency manifesting on the Bladder channel. Acute headaches here are due to invasion of external Wind (usually Wind-Cold) and form a typical feature of the Greater Yang pattern within the SixStage pattern identification (see Appendix 1). This type of headache is accompanied by great stiffness at the back of the neck. In a few cases, occipital headache can be associated with a Bladder pattern, such as Damp Heat in the Bladder, in which case the pain will be sharp.

Whole head Chronic headaches in this area are due to Kidney-Yin or Kidney-Essence deficiency. The Kidney-Essence nourishes the brain, and when it is deficient the brain lacks nourishment. This can give rise to dull headaches in the whole head accompanied by a feeling of emptiness of the head. Acute headaches affecting the whole head are due to invasion of external Wind (which can be either Wind-Cold or Wind-Heat). These are severe and sharp in character, sometimes accompanied by a pulling sensation. Thus there is generally a correlation between the pattern related to a specific type of headache and the channel involved. For example, the pattern of LiverYang rising will give rise to headaches on the Gall Bladder channel, while the pattern of Kidney deficiency will cause headaches on the Bladder channel. However,

there can be exceptions. This happens in situations when more than one pattern is involved. For example, a person may suffer from a chronic Kidney deficiency leading to the rising of Liver-Yang. If the Kidney deficiency is very long-standing and the Bladder channel on the head is affected, it is possible for headaches of the Liver-Yang type (i.e. very sharp and throbbing in character) to manifest on the Bladder channel on the occiput. It should also be remembered that headaches frequently occur in different parts of the head at different times. This is not unusual and is simply due to the coexistence of two different patterns causing headaches. For example, Liver-Blood deficiency can give rise to Liver-Yang rising. In this case, a person may suffer from dull headaches on top of the head reflecting the Liver-Blood deficiency, occasionally changing into sharp and throbbing headaches on one or other temple, reflecting the Liver-Yang rising. If the area of the headache changes all the time and the headache is experienced in different parts of the head at different times, it either indicates the presence of Liver-Wind, in which case the pain will be accompanied by a pulling sensation, or the presence of Phlegm, in which case the pain will be accompanied by a heavy sensation of the head.

SUMMARY DIAGNOSIS ACCORDING TO CHANNELS  Top of the head — Deficiency of Liver-Blood — Deficiency of Qi and Blood — Heart-Blood deficiency  Sides of the head — Liver-Yang rising — Liver-Fire — Liver-Wind  One side only — Liver-Yang rising — Liver-Fire  Temples — Liver-Yang rising — Liver-Fire — Liver-Wind  Behind the eyes — Liver-Blood deficiency (dull) — Liver-Yang rising (sharp)

Headaches

 Forehead — Stomach deficiency (dull) — Stomach-Heat (sharp) — Dampness or Phlegm — Residual pathogenic factor, such as external Wind  Back of the head (occiput) — Kidney deficiency (chronic) — Invasion of external Wind (acute) — Bladder pattern (e.g. Damp Heat in the Bladder)  Whole head — Kidney-Yin or Kidney-Essence deficiency (chronic) — Invasion of external Wind (acute)

Diagnosis according to type of pain

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Distending pain This is a typical Chinese expression that will be seldom used by Western patients (or at least in Anglo-Saxon languages). The most frequently recurrent expressions regarding this type of pain are “throbbing”, “bursting” and “pulsating”, all of which correspond to “distending”. This sensation is typical of a Liver-related headache, which could be from Liver-Yang or Liver-Fire. However, a distending pain can also be due to exterior Wind-Heat, in which case it will affect the whole head, whereas in the case of Liver-Yang or LiverFire it will most probably affect one or both sides of the head.

Stiff A pronounced stiffness of the occiput usually indicates an invasion of exterior Wind-Cold. A chronic headache with stiffness of the top of the shoulders and neck usually indicates Liver-Yang rising.

From the Eight-Principle perspective, a dull ache generally indicates an Empty condition, while a sharp pain indicates a Full condition. A sudden onset tends to indicate an exterior invasion, while a gradual onset tends to indicate an interior one. Empty conditions causing dull headaches include deficiency of Qi and/or Blood, Liver-Blood deficiency and Kidney deficiency. Full conditions include Liver-Yang rising, Liver-Fire blazing, Liver-Wind, Phlegm, stasis of Blood and Stomach-Heat.

Pulling

Dull

A sensation of emptiness of the brain indicates deficiency of Kidney (Yin or Yang).

A dull headache is due to one of the deficiencies outlined above.

A pulling type of sensation indicates internal LiverWind.

Stabbing, boring This sensation is very intense and fixed in one place, and it indicates Blood stasis. It occurs only in chronic headaches. A description also used in this context is “splitting headache”.

Feeling of emptiness

Feeling of heaviness

We can summarize the different types of headache according to patterns.

This is characteristic when Dampness or Phlegm obstructs the head and prevents the clear Yang Qi from ascending to the head and the turbid Yin Qi from descending. The head typically feels heavy, muzzy and as if it were wrapped in a cloth. The person would also find it difficult to concentrate and think, especially in the morning. Both Dampness and Phlegm may cause the above sensations, but Phlegm is more obstructive and it clouds the “orifices” and sense organs, causing dizziness and blurred vision. These last two symptoms distinguish between headaches caused by Phlegm and those caused by Dampness in the head.

• Wind-Cold: severe occipital with pronounced stiffness. • Wind-Heat: severe, distending, in the whole head. • Wind-Dampness: feeling of heaviness, as if the head were wrapped in a cloth. • Liver-Yang, Liver-Fire: distending. • Liver-Wind: pulling. • Stasis of Blood: stabbing, splitting, boring. • Phlegm: heavy sensation, as if the head were wrapped in a cloth; dizziness. • Dampness: heavy sensation, as if the head were wrapped in a cloth. • Qi-Blood deficiency: dull. • Kidney deficiency: feeling of emptiness.

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The Practice of Chinese Medicine

SUMMARY DIAGNOSIS ACCORDING TO TYPE OF PAIN  Dull: Deficiency.  Feeling of heaviness: Dampness or Phlegm.  Distending pain: Liver-Yang or Liver-Fire, also exterior Wind-Heat.  Stiff: exterior Wind-Cold; if chronic, Liver-Yang rising.  Pulling: internal Liver-Wind.  Stabbing, boring: Blood stasis.  Feeling of emptiness: deficiency of Kidneys (Yin or Yang). — Wind-Cold: severe occipital with pronounced stiffness. — Wind-Heat: severe, distending, in the whole head. — Wind-Dampness: feeling of heaviness, as if the head were wrapped in a cloth. — Liver-Yang, Liver-Fire: distending. — Liver-Wind: pulling. — Stasis of Blood: stabbing, splitting, boring. — Phlegm: heavy sensation, as if the head were wrapped in a cloth; dizziness. — Dampness: heavy sensation, as if the head were wrapped in a cloth. — Qi-Blood deficiency: dull. — Kidney deficiency: feeling of emptiness.

Headaches that improve with rest and lying down are due to deficiency of Qi or Blood, while headaches that worsen lying down are due to Dampness or Phlegm.

Weather Headaches that get worse with heat may be due to Liver-Yang or Liver-Fire rising, while headaches that get worse with cold may be due to deficiency of Yang. If they worsen with damp weather, it is a clear indication that they are due to Dampness or Phlegm. A headache that improves temporarily with the application of cold (e.g. cold water) may be due to Liver-Yang or Liver-Fire.

Emotions Headaches that worsen with anger are due to LiverYang or Liver-Fire. Headaches that get worse when the person suddenly relaxes (the typical weekend headache) are due to Liver-Yang rising. Headaches that worsen with a sudden excitement may be due to LiverYang rising.

Sexual activity Chronic headaches that are aggravated after sexual activity (culminating in ejaculation for men or orgasm for women) clearly indicate a deficiency of the Kidneys. In rare cases, headaches may be ameliorated by sexual activity, which indicates Liver-Fire.

Food

Diagnosis according to amelioration and aggravation The factors that make a headache better or worse may give an indication of the condition causing the headache.

Time of day Chronic headaches that are worse in daytime indicate either deficiency of Qi/Yang or Dampness. Chronic headaches that are worse in the evening or at night indicate deficiency of Blood or Yin (which may be causing Yang rising).

Activity/rest Headaches that get worse with activity are due to deficiency of Qi or Blood, while headaches that improve with light exercise may be due to Liver-Yang rising or Phlegm.

Barring the vast subject of intolerance of certain foods, headaches that get worse after eating indicate Dampness, Phlegm, Retention of Food or Stomach-Heat. Headaches that get better with eating indicate deficiency of Qi or Blood. Headaches that are aggravated by the consumption of sour foods (such as oranges, grapefruit and vinegar) are due to Liver-Yang rising.

Posture If a headache improves when the patient is lying down, it is due to a Deficiency; if it worsens when lying down (and improves when sitting), it is due to an Excess. For example, severe headaches from Liver-Yang rising are usually eased if the patient sits up; such a patient dislikes lying down.

Menstruation Many types of headache are closely affected by the menstrual function. Headaches that precede the onset

Headaches

of the period are usually due to Liver-Yang rising or Liver-Qi stagnation. If they worsen during the period, they may be due to Liver-Fire or stasis of Blood. If they occur towards the end of the period, they indicate Blood deficiency.

Pressure If the person dislikes pressure on the part of the head where the headache occurs, it indicates an Excess condition. Conversely, if the headache improves with pressure, it indicates a Deficiency condition.

SUMMARY DIAGNOSIS ACCORDING TO AMELIORATION AND AGGRAVATION  Time of day — Worse in daytime: deficiency of Qi/Yang or Dampness. — Worse in the evening or at night: deficiency of Blood or Yin.  Activity or rest — Worse with activity: deficiency of Qi or Blood. — Better with light exercise: Liver-Yang rising or Phlegm. — Better with rest and lying down: deficiency of Qi or Blood. — Worse lying down: Dampness or Phlegm.  Weather — Worse with heat: Liver-Yang or Liver-Fire rising. — Worse with cold: deficiency of Yang. — Worse with damp weather: Dampness or Phlegm. — Better with the application of cold: LiverYang or Liver-Fire.  Emotions — Worse with anger: Liver-Yang or Liver-Fire. — Worse on relaxation: Liver-Yang rising. — Worse with a sudden excitement: Liver-Yang rising.  Sexual activity — Worse after sexual activity: deficiency of the Kidneys. — Better after sexual activity: Liver-Fire.  Food — Worse after eating: Dampness, Phlegm, Retention of Food or Stomach-Heat.

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— Better from eating: deficiency of Qi or Blood. — Worse with the consumption of sour foods: Liver-Yang rising.  Posture — Better on lying down: Deficiency. — Worse when lying down: Excess.  Menstruation — Worse before the period: Liver-Yang rising or Liver-Qi stagnation. — Worse during the period: Liver-Fire or stasis of Blood. — Worse after the period: Blood deficiency.  Pressure — Worse on pressure: Excess condition. — Better with pressure: Deficiency condition.

TREATMENT STRATEGIES AND PRINCIPLES OF POINT SELECTION When identifying patterns for the treatment of headaches, the first differentiation to make is between exterior and interior headaches. From an EightPrinciple perspective, exterior headaches are of Excesstype by definition. Within the interior headaches, it is important to differentiate between Deficiency type and Excess type. Zhang Jie Bin in his Classic of Categories says that all headaches are simply due to either too much or too little Qi in the head: the former is an Excess-type headache, the latter a Deficiency-type. He says: “When the head is painful, it indicates a deficiency below and an excess above ... When Qi cannot ascend, the head aches ... when Qi does not ascend, the brain is empty.”6 In many cases of chronic headache, there is a condition of simultaneous Deficiency and Excess. For example, Liver-Yang rising (a Full condition in itself) may derive from Liver-Blood deficiency (an Empty condition); Phlegm (a Full condition) may derive from Spleen-Qi deficiency (an Empty condition). The Full or Empty character of a condition is also related to the question of Root (Ben) and Manifestation (Biao). For example, Liver-Blood deficiency may be the Root that leads to Liver-Yang rising (the Manifestation), or Spleen-Qi deficiency may be the Root that gives rise to Phlegm (the Manifestation). In such cases, the question arises whether we should treat the Root only, the Manifestation only or both.

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The Practice of Chinese Medicine

Treating the Root or the Manifestation The question of treating the Root or the Manifestation is particularly important in the case of headaches. There are three possible courses of action.

Treating both the Root and the Manifestation This is the most common approach. In most cases, it is possible and necessary to deal with both the Root and the Manifestation simultaneously. For example, if a headache is due to a rising of Liver-Yang that derives from Kidney-Yin deficiency, the most obvious course of action is to tonify the Kidneys and subdue Liver-Yang simultaneously. However, even if both Root and Manifestation are treated at the same time, it is often necessary to place the emphasis on one rather than the other. If the headaches are very severe and recur very frequently, it may be necessary to concentrate one’s attention on treating the Manifestation rather than the Root. In the example given above, if the headaches caused by LiverYang rising are very severe and frequent, it would be important to direct one’s attention to treating the Manifestation first, i.e. subduing Liver-Yang. On the other hand, if the Manifestation is not causing very severe headaches, then it might be sufficient to give primary importance to treatment of the Root. For example, if a person suffers from mild headaches from Qi deficiency, one would concentrate on treating the Root, i.e. tonifying Qi.

Treating the Manifestation first, the Root second This approach is necessary when the headaches caused by the Manifestation are extremely severe and so frequent as to impede any form of normal life. For example, if the headaches from Liver-Yang are of such intensity and frequency, one would concentrate one’s attention first on treating the Manifestation only, i.e. subduing Liver-Yang. Once the severity and the frequency of the headaches have been reduced, then one can start treating the Root too.

Treating the Root only This is possible when the headaches are mild and infrequent. These headaches are usually deficient in nature, for example mild headaches from Qi or Blood

deficiency. In these cases, it might be enough to concentrate simply on tonifying Qi or Blood so that the headaches will gradually disappear.

Point selection In the treatment of headaches, it is essential to combine local with distal points. The more chronic or intense the headache, the more local points are required. Local points are also especially required when a chronic headache appears always in the same spot. This indicates a local stasis of Blood, which always calls for the use of local points to disperse it. Generally speaking, both distal and local points are chosen according to the pattern and the channel involved. However, the primary aim of distal points is to treat the pattern, while that of local points is to treat the channel involved. For example, a Liver-Yang headache nearly always manifests on the Gall Bladder channel. We might therefore choose as distal points LIV-3 Taichong according to the pattern and G.B.-43 Xiaxi according to the channel. A model of the principles governing the selection of points is illustrated in Figure 1.14. Local points are mostly chosen according to the channel involved. For example, for headaches on the Gall Bladder channel, one might choose G.B.-6 Xuanli as a local point. Some local points may be chosen according to the location of the headache irrespective of the pattern. Examples are as follows. • Frontal headache: Du-23 Shangxing and G.B.-14 Yangbai. • Headache on vertex: Du-20 Baihui and Du-21 Qianding. • Occipital headache: BL-10 Tianzhu, Du-19 Houding. • Temporal headache: G.B.-8 Shuaihu and Taiyang.

DISTAL POINTS

Pattern

Channel

LOCAL POINTS

Pattern

Channel

Figure 1.14 Principles governing selection of points in headaches.

Headaches

However, local points may also be chosen according to the pattern. In the example above, if the headache on the Gall Bladder channel is caused by Liver-Yang rising, in addition to points on the Gall Bladder channel we might also use Du-20 Baihui, as the internal pathway of the Liver channel reaches up to that point. Figure 1.15 illustrates the principles governing the selection of points for headaches using the Gall Bladder channel in headaches from Liver-Yang rising as an example. The following are the main distal and local points according to channel involved:

Gall Bladder channel This may cause headaches in many different parts of the head: the sides of the head, temples, unilateral forehead (on G.B.-14 Yangbai) or lateral occiput (on G.B.-20 Fengchi).

Distal points G.B.-43 Xiaxi, T.B.-5 Waiguan.

Local points G.B.-4 Hanyan, G.B.-5 Xuanlu, G.B.-6 Xuanli, G.B.-8 Shuaigu, G.B.-9 Tianchong, G.B.-14 Yangbai and G.B.-20 Fengchi, according to the location of the headache.

Bladder channel This may cause headaches on the occiput.

Distal points BL-60 Kunlun.

DISTAL POINTS

Pattern

Channel

LOCAL POINTS

Pattern

Channel

Local points BL-10 Tianzhu.

Stomach channel This causes headaches on the forehead.

Distal points ST-44 Neiting, L.I.-4 Hegu.

Local points ST-8 Touwei. The same principles apply to herbal therapy. The “local” herbs, i.e. those that specifically affect the head, are chosen according to the channel involved (but to a certain extent also according to the pattern), and the “distal” herbs, i.e. those that treat the condition causing the headaches, are chosen according to the pattern. For example, in frontal headaches from LiverQi stagnation and Spleen deficiency, Bai Zhi Radix Angelicae dahuricae can be selected as a “local” herb to affect the forehead, while the Xiao Yao San Free and Easy Wanderer Powder could be selected as the main prescription to deal with the pattern causing the headaches, i.e. stagnation of Liver-Qi. “Local” herbs for different parts of the head are as follows. • Greater Yang area (occiput): Qiang Huo Rhizoma seu Radix Notopterygii. • Lesser Yang area (sides of the head, Gall Bladder channel): Chuan Xiong Rhizoma Chuanxiong and Chai Hu Radix Bupleuri. • Bright Yang area (forehead): Bai Zhi Radix Angelicae dahuricae. • Terminal Yin area (vertex): Tian Ma Rhizoma Gastrodiae and Wu Zhu Yu Fructus Evodiae. • Lesser Yin channels (inside head): Xi Xin Herba Asari.

IDENTIFICATION OF PATTERNS AND TREATMENT The patterns discussed are the following.

LIV–3, LIV–8

G.B.–43

G.B.–20

G.B.–6, Taiyang

Figure 1.15 Selection of points for headache on Gall Bladder channel in the temple from Liver-Yang rising and Liver-Blood deficiency.

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EXTERIOR • Wind-Cold • Wind-Heat • Wind-Dampness

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The Practice of Chinese Medicine

INTERIOR Full • Liver-Yang rising • Liver-Fire • Liver-Wind • Liver-Qi stagnation • Stagnation of Cold in the Liver channel • Dampness • Turbid Phlegm • Turbid Phlegm-Wind • Liver-Yang rising with Phlegm in the head • Retention of Food • Stasis of Blood • Stomach-Heat Empty • Qi deficiency • Blood deficiency • Kidney deficiency

Wind-Cold External Wind-Cold invades the Greater Yang channels first and manifests with a headache and stiffness on the occiput, where these channels flow. Cold contracts and tightens the sinews and slows down the circulation of Defensive Qi, hence the typical feeling of stiffness at the back of the neck. This headache is obviously of acute onset and can be very severe but it will last only a short time, i.e. for as long as the Wind-Cold is on the Exterior. Once the pathogenic factor penetrates the Interior, this type of headache goes. There are exceptions, however, as in a few cases when the external Wind-Cold is not expelled it can settle in the muscles and give rise to chronic headaches. In acute cases, apart from the headache, there would also be generalized aches of the whole body, as the exterior Wind-Cold obstructs the free circulation of Defensive Qi in the muscles. Other symptoms and signs include aversion to cold, shivers, possibly a fever, stiff and achy shoulders, absence of thirst, some breathlessness, cough, sneezing, a runny nose with a white discharge or a blocked nose, pale urine and a Floating-Tight pulse.

Treatment principle Release the Exterior, expel Wind, scatter Cold, remove obstruction from the channels.

Acupuncture General prescription: LU-7 Lieque, G.B.-20 Fengchi, Du16 Fengfu, BL-10 Tianzhu. All with reducing method.

Explanation The above points have been selected for their action in expelling Wind-Cold, with particular reference to the headache deriving from Wind-Cold. Several other points might have been chosen to release the Exterior without a specific action on headaches, such as, for example, BL-12 Fengmen and BL-13 Feishu (see also Chapter 48, Common cold and influenza). • LU-7 is the main point to release the Exterior and expel Wind-Cold by stimulating the diffusing and descending of Lung-Qi. In addition, it especially affects the head and relieves headaches. For this reason, it can be used for headaches from WindCold, Wind-Heat and also Turbid Phlegm. • G.B.-20 expels Wind from the head. • Du-16 expels Wind from the head and treats the Greater Yang channel area. • BL-10 is used as a local point pertaining to the Greater Yang channel area, which is usually affected in invasion of Wind-Cold.

Other points • Du-20 Baihui can be used if the headache is not specifically on the occiput but affects the whole head. • S.I.-3 Houxi eliminates Wind and affects the Greater Yang area. • S.I.-3 and BL-62 Shenmai in combination open the Governing Vessel, eliminate Wind and affect the Greater Yang area. • BL-67 Zhiyin and BL-66 Tonggu can be selected to affect the Greater Yang area if the headache is on the occiput. They are the Well point and Spring point, respectively, and as such are good in Full patterns to eliminate pathogenic factors. Also, being at the tip of the foot, they will affect the head, according to the principle that points at one end of the body affect the opposite end. • BL-60 Kunlun is used if the headache also affects the lower part of the neck and the top of the shoulders. • Du-8 Jinsuo eliminates both interior and exterior Wind and relaxes the muscles and tendons of the top of the shoulders, as its name implies (“Sinew spasm”).

Headaches

Herbal therapy CHUAN XIONG CHA TIAO SAN Chuanxiong-Green Tea Regulating Powder

Herbal therapy Prescription CHUAN XIONG CHA TIAO SAN Chuanxiong-Green Tea Regulating Powder

Explanation

Three Treasures remedy Expel Wind-Cold

Prescription

This prescription is aimed at treating specifically the headache deriving from Wind-Cold, rather than releasing the Exterior, although it also has that effect. Green tea is an integral part of the prescription, which clears upwards towards the eyes and through the head, thus relieving the headache. Moreover, it is cool and thus will balance out the majority of the other herbs, which are quite warm.

Modifications • If there are pronounced symptoms and signs of invasion of the Defensive-Qi portion by Wind-Cold (such as sneezing, cough and breathlessness), then Ma Huang Tang Ephedra Decoction can be used with suitable additions to affect the headache.

Herbs Several herbs can be considered. We can classify them according to the area affected, i.e. Greater Yang, Lesser Yang or Bright Yang. These herbs are as follows. • Greater Yang: Du Huo Radix Angelicae pubescentis, Qiang Huo Rhizoma seu Radix Notopterygii and Gao Ben Rhizoma Ligustici. • Lesser Yang: Chai Hu Radix Bupleuri, Huang Qin Radix Scutellariae and Qing Hao Herba Artemisiae annuae. • Bright Yang: Sheng Ma Rhizoma Cimicifugae, Ge Gen Radix Puerariae and Bai Zhi Radix Angelicae dahuricae.

Three Treasures remedy Expel Wind-Cold Expel Wind-Cold releases the Exterior and expels Wind-Cold.

SUMMARY WIND-COLD General prescription: LU-7 Lieque, G.B.-20 Fengchi, Du-16 Fengfu, BL-10 Tianzhu. All with reducing method.

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Wind-Heat External Wind-Heat obstructs the clear orifices in the head and leads to a headache that is felt inside the head and is distending in character. It can be very severe and cause the head to feel as if it were “cracking” open. This headache, like that from Wind-Cold, also has an acute onset and can last only while the pathogenic factor is in the Exterior. Other symptoms and signs include aversion to cold, shivers, fever, slight thirst, runny nose with a yellow discharge, a sore throat, possibly swollen tonsils, red eyes, slightly dark urine, slightly red sides or tip of the tongue and Floating-Rapid pulse. The aversion to cold and shivers would be less pronounced than in WindCold and the fever would be higher.

Treatment principle Release the Exterior, clear Heat, expel Wind and remove obstruction from the channels.

Acupuncture General prescription: L.I.-4 Hegu, G.B.-20 Fengchi, Du-16 Fengfu, Du-14 Dazhui, T.B.-5 Waiguan. All with reducing method.

Explanation • L.I.-4 releases the Exterior, expels Wind-Heat, and is a special point to affect the head and face. • G.B.-20 and Du-16 expel Wind from the head. • Du-14 expels Wind, clears Heat and relieves headache. • T.B.-5 expels Wind-Heat and relieves headache.

Other points • Du-20 Baihui expels Wind and relieves headache. It is particularly used if the headache affects the whole head.

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The Practice of Chinese Medicine

• L.I.-11 Quchi expels Wind-Heat and is used if the symptoms and signs of Heat are pronounced. • T.B.-16 Tianyou expels Wind-Heat and, in particular, relieves headache.

Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction

Explanation This is the main prescription to expel Wind-Heat in mild cases. If headache is the predominant symptom, the prescription would have to be adapted by adding some herbs specific for headaches out of those listed below under Herbs.

SUMMARY WIND-HEAT General prescription: L.I.-4 Hegu, G.B.-20 Fengchi, Du-16 Fengfu, Du-14 Dazhui, T.B.-5 Waiguan. All with reducing method. Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Prescription JU HUA CHA TIAO SAN Chrysanthemum-Green Tea Regulating Powder Three Treasures remedy Expel Wind-Heat

Prescription JU HUA CHA TIAO SAN Chrysanthemum-Green Tea Regulating Powder

Explanation This prescription combines the Chuan Xiong Cha Tiao San Chuanxiong-Green Tea Regulating Powder as a whole, which expels Wind-Cold, with two herbs, Ju Hua Flos Chrysanthemi and Jiang Can Bombyx batryticatus, that expel Wind-Heat and are specific for headache.

Herbs • Man Jing Zi Fructus Viticis expels Wind-Heat and is specific for headaches. • Ge Gen Radix Puerariae, which expels Wind-Heat and releases the muscles and sinews, is specific to relieve the ache and stiffness of the neck and shoulders from invasion of exterior Wind. • Bo He Herba Menthae haplocalycis and Ju Hua Flos Chrysanthemi expel Wind-Heat. They are light and aromatic and affect the head specifically. They also relieve headaches from Liver-Yang rising. Ju Hua, in addition, specifically affects the eyes and would therefore be indicated when the headache is situated around the eyes or if the eyes are red.

Wind-Dampness This is a type of Wind-Cold but is combined with Dampness. External Dampness obstructs the clear orifices of the head and gives rise to a headache with a typical feeling of heaviness. The head feels muzzy (fuzzy), as if it were wrapped in a cloth, a sensation that is aggravated by damp weather. Because Dampness prevents the clear Yang from reaching the head and brightening the orifices, and the turbid Yin from descending, the patient feels muzzy with a heavy head, poor concentration and heavy eyes. Other symptoms and signs include aversion to cold, shivers, possibly a fever, a sensation of oppression in the chest and epigastrium, a feeling of heaviness of the whole body, a runny nose with a white discharge, a sticky tongue coating and a Floating-Slippery pulse. This is an acute pattern that gives rise to acute headaches; however, they may become chronic if the Dampness settles in the head and is not expelled. It is relatively frequent in children.

Treatment principle Release the Exterior, expel Wind, resolve Dampness and remove obstruction from the channels.

Acupuncture Three Treasures remedy Expel Wind-Heat Expel Wind-Heat releases the Exterior and expels Wind-Heat.

General prescription: LU-7 Lieque, L.I.-6 Pianli, SP-6 Sanyinjiao, ST-8 Touwei, Du-23 Shangxing. Reducing method on all points.

Headaches

Explanation • LU-7 releases the Exterior and stimulates the Lungs’ diffusing and descending of fluids. It will therefore simultaneously expel Wind and resolve exterior Dampness. It is also a specific point for headaches. • L.I.-6 releases the Exterior and also stimulates the Lungs’ descending of fluids from the Upper Burner. It is the Connecting point of the Large Intestine Connecting channel that flows up to the jaw and ear and thus relieves any headache in this region. • SP-6 resolves Dampness. • ST-8 is the main local point on the head to resolve Dampness affecting the head, and is specific for dull headaches with a feeling of the head being wrapped in a cloth. • Du-23 relieves headaches on the forehead and the eyes.

Herbal therapy Prescription QIANG HUO SHENG SHI TANG Notopterygium Dispelling Dampness Decoction

Explanation This formula is specific to expel external WindDampness causing a headache.

Herbs • Bai Zhi Radix Angelicae dahuricae expels Wind from the head and face and is specific for headaches of this type. • Huo Xiang Herba Pogostemonis is a fragrant herb that resolves exterior Dampness. It is aromatic and light and therefore affects the head. • Cang Zhu Rhizoma Atractylodis is also a fragrant herb that resolves Dampness and is particularly indicated for headaches.

SUMMARY WIND-DAMPNESS General prescription: LU-7 Lieque, L.I.-6 Pianli, SP-6 Sanyinjiao, ST-8 Touwei, Du-23 Shangxing. Reducing method on all points.

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Herbal therapy Prescription QIANG HUO SHENG SHI TANG Notopterygium Dispelling Dampness Decoction

The four organs that are most directly involved in the pathogenesis of headaches are the Spleen, Stomach, Liver and Kidneys. The aetiology and pathology of interior headaches are represented in Figure 1.16.

Liver-Yang rising This is probably the most common of all interior headaches. It arises when the Yang of the Liver “rebels” upwards, creating an excess of Yang in the head. Although it is in the nature of Liver-Qi and Liver-Yang to flow freely upwards, in pathological circumstances this movement can be excessive and give rise to headaches. As we have seen, the Liver main channel is one of only two (together with the Heart channel) to flow internally to the head; all other Yin channels reach the head via their respective divergent channels. The most frequent cause of this type of headache is emotional. Anger (whether it is manifested or repressed), frustration or resentment over a long period of time can cause the excessive rising of LiverYang. However, in my opinion, worry may also cause Liver-Yang to rise. Liver-Yang rising is usually due to one of four situations: 1. 2. 3. 4.

Liver-Blood deficiency Liver-Yin deficiency Liver- and Kidney-Yin deficiency Liver/Kidney-Yin and Kidney-Yang deficiency (Fig. 1.17).

Liver-Blood deficiency is a common cause of the rising of Liver-Yang. Blood is part of Yin and is stored in the Liver. The Blood of the Liver roots and anchors the Yang of the Liver. Hence if Liver-Blood is deficient, Liver-Yang may “escape” upwards to disturb the head. Liver-Yin deficiency is practically the same as LiverBlood deficiency. One of the main signs that distinguishes between the two conditions is the dryness of the eyes in Liver-Yin deficiency. The Liver and Kidneys share a common root, and a deficiency of one often affects the other. Liver-Blood

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The Practice of Chinese Medicine

Heart Lungs Liver

Emotions

Qi STAGNATION

BLOOD STASIS

Blood-deficiency headache

Trauma

YIN DEFICIENCY

Blood deficiency

Spleen

DEFICIENCY

LIVER-FIRE rising

Liver-Fire headache

Damages Yin, Yang rises

PHLEGM clouds orrifices

Phlegm headache

Blood fails to nourish head

FIRE

Liver-Fire rising headache

Kidney-Yin fails to nourish Liver-Yin

Diet

Blood-stasis headache

Heredity

Qi deficiency Clear Yang cannot ascend

Qi-deficiency headache

Kidneys

DEFICIENCY

Kidney-deficiency headache

Figure 1.16 Aetiology and pathology of interior headaches.

deficiency may in the long run fail to nourish the Kidney-Essence, which may become deficient. Conversely, a deficient Kidney-Essence may fail to produce Blood and lead to Liver-Blood deficiency. Both Blood and Essence pertain to Yin, and Liver- and Kidney-Yin deficiency thus lead to the excessive rising of LiverYang. In a few cases, Liver-Yang rising may also derive from Kidney-Yang deficiency. Although this appears to be a paradox, the Kidneys are the source of all the Yin and Yang energies in the human body. There is a close interaction between the Yin and the Yang of the Kidneys, and the two cannot be separated. Thus, it is not uncommon for deficiency of both Kidney-Yin and Kidney-Yang to occur simultaneously. Of course, the deficiency of Yin and Yang within the Kidneys is never in a 50/50 proportion, and one or the

Liver-Yang rising

Liver Blood Xu

Liver-Yin Xu

Liver-and Kidney-Yin Xu

Figure 1.17 Causes of Liver-Yang rising.

Liver-Yin and KidneyYin-Yang Xu

Headaches

other is predominant. The tongue-body colour always shows the predominant deficiency: if it is Pale, it indicates a predominance of Kidney-Yang deficiency, and if it is without coating, it indicates a predominance of Kidney-Yin deficiency. When Kidney-Yang is deficient over a long period of time, it can induce a lesser deficiency of Kidney-Yin that, in turn, may lead to Liver-Yang rising. This explains how a person may have several symptoms and signs of Kidney-Yang deficiency (such as frequent-pale urination, chilliness, a Pale-Swollen tongue and a Deep and Slow pulse), only one symptom of Kidney-Yin deficiency (such as night sweating), and some symptoms of Liver-Yang rising (such as headaches, irritability and dizziness). The headache from Liver-Yang rising is intense, severe, throbbing or distending in character. Some patients also describe it as “pulsating”, “pounding” or “bursting”. It usually affects either or both sides of the head along the Gall Bladder channel, or the temple or eyebrow. Frequently, it is felt behind one or both eyes (Fig. 1.18). It may also occur on a small area around the point G.B.-14 Yangbai.

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The headache from Liver-Yang rising is frequently accompanied by nausea or vomiting. These are due to Liver-Qi invading the Stomach and preventing Stomach-Qi from descending. In a few cases, it is also accompanied by diarrhoea due to Liver-Qi invading the Spleen and impairing its transformation and transportation activity. The Liver-Yang headache is usually eased by sitting up, and a patient will often prefer to be propped up by several pillows when lying in bed. Other common symptoms with headaches from Liver-Yang are visual disturbances. The person may see flashing lights or auras, or the vision may be blurred. This type of headache is often called the “weekend headache”. When someone works excessively long hours and is under considerable tension during the week, the condition of Liver-Yang may be masked, but once he or she abruptly stops work at weekends, the inactivity makes Liver-Yang flare upwards to cause the headache. Other manifestations of Liver-Yang rising include dizziness, tinnitus, deafness, a dry throat, insomnia, irritability and a Wiry pulse. The pulse may be Wiry only on the left side or even only on the left Middle position. It is important to realize that the tongue appearance varies depending on whether the headache stems from Liver-Blood or Kidney/Liver-Yin deficiency. If it stems from Liver-Blood deficiency, the tongue body may be Pale and Thin, whereas if it stems from Kidney/LiverYin deficiency the tongue body will be without coating. Finally, in the few cases in which Liver-Yang rising derives from Kidney-Yang deficiency, the tongue body will be Pale and Swollen and the pulse Deep and Slow.

Treatment principle Pacify the Liver, subdue rebellious Yang, nourish LiverBlood or Liver-Yin and/or Kidney-Yin as appropriate.

Acupuncture General prescription: LIV-3 Taichong, LIV-8 Ququan, SP-6 Sanyinjiao, T.B.-5 Waiguan, G.B.-20 Fengchi, Taiyang extra point. • In case of Liver and Kidney Yin deficiency, add KI-3 Taixi.

Figure 1.18 Areas of Liver-Yang headache.

Reducing method on LIV-3, T.B.-5 and G.B.-20, reinforcing method on LIV-8, SP-6 and KI-3. Even method on Taiyang. If the condition is very chronic,

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The Practice of Chinese Medicine

even method can be applied to the points that are normally reduced.

Explanation • LIV-3 is the main distal point to pacify the Liver and subdue Yang rising. It is also the main distal point for this type of headache. It should be needled at an appropriate depth (at least 0.5 cun) and usually reduced. In acute cases, it should be rather vigorously reduced or at least manipulated repeatedly at intervals during the treatment; for example, four or five times during 20 minutes. For very severe acute headaches when the pulse is extremely Wiry, the needles should be left in a fairly long time, i.e. longer than 20 minutes, up to 1 hour. Many of the patients with this type of headache dislike lying down during an acute attack and should therefore be treated propped up in a comfortable position. The more chronic the condition, the less one needs to reduce this point, and in very chronic cases it is enough to apply manipulation with even method. • LIV-3 will affect a Liver-Yang headache no matter where the headache is situated. • LIV-8 is reinforced to nourish Liver-Blood and/or Liver-Yin. Liver-Yang rising always derives from a deficiency of Liver-Blood (or Liver-Yin) and/or Kidney-Yin. It is therefore necessary to use points to nourish Liver-Blood and/or tonify Kidney-Yin. • SP-6 is reinforced to nourish Liver-Blood. Being the meeting point of Liver, Spleen and Kidney channels, it will also help to pacify the Liver. It also calms the Mind and helps to promote sleep. This is important in chronic headaches because if the person does not sleep well, it will be much more difficult to cure the headaches. • T.B.-5 is reduced to subdue Liver-Yang and affect the side of the head. The use of this point is based on the relationship existing between the Triple Burner and Gall Bladder channels, both pertaining to the Lesser Yang channel system. The relationship between Yang hand and foot channels is very close indeed, because they meet superficially on the head region and merge into one another. For this reason, in practice they are almost interchangeable. In this case, T.B.-5 is chosen to affect the Lesser Yang area (which includes the Gall Bladder channel area) on

the head where the Liver-Yang headache usually occurs. But why do we choose the Triple Burner instead of the Gall Bladder channel, and why T.B.-5 in preference to other points on that channel? If a choice exists between Yang hand or foot channels (as it normally does) to affect their commoninfluence area, the hand-channel points have a more moderate effect than those of the foot channels. Thus T.B.-5 has a milder effect than, say, G.B.-43. The choice between Yang hand- or footchannel points can therefore be guided by the severity of the symptoms; in severe cases, Yang foot-channel points will be used. Of course, both hand- and foot-channel points can be used simultaneously for an even stronger effect. T.B.-5 is used in preference to other points on this channel because it is the Connecting (Luo) point and, as such, it is especially suited to treat channel problems. This point is therefore used not so much to subdue Liver-Yang at internal organ level, but to pacify rebellious Yang within the Lesser Yang channels area. Specifically, T.B.-5 will affect headaches in the temple area. • G.B.-20 is used as an adjacent point to subdue Liver-Yang. It subdues Liver-Yang and Liver-Wind and is specific for headaches from these two causes. It will also relax the muscles of the upper neck and brighten the eyes, both of which actions will help chronic headaches. This point is needled at least 0.5 cun deep with the needles pointed towards the opposite eye. This direction can, however, be changed and the needle directed towards the eye on the same side in order to treat a unilateral headache on that side. This point, contrary to points situated further up the neck and skull, can be manipulated with reducing method. It can be needled with the patient lying down and reached without the patient having to sit up. • Taiyang is an extra point on the temple. It is specific to subdue Liver-Yang when it causes temporal headaches. It is used only if the headache is situated on the temple, otherwise different local points are selected. It is manipulated with even method.

Other points Many other points can be used according to the location of the headache.

Headaches

Distal points • P-6 Neiguan is used as a distal point for various reasons. First of all, the Pericardium channel is connected to the Liver channel within the Terminal Yin. P-6 will therefore indirectly help to subdue Liver-Yang and calm the Mind (Shen) and Ethereal Soul (Hun) at the same time. P-6 is also the Connecting point of the Pericardium channel, and it therefore connects with the Triple Burner channel. For this reason, it affects the Triple Burner channel on the head and can contribute to subduing Liver-Yang rising, affecting the Lesser Yang channels. For this effect, P-6 can be combined with Yangchi T.B.-4. This combination is very effective for headaches on the Lesser Yang channel area (i.e. temples, sides of the head and lateral side of the neck), especially in women. Finally, a condition of Liver-Yang rising is frequently associated with stress and a highly strung disposition. P-6 will help to harmonize the Liver and calm the Mind and Ethereal Soul, especially in women. • LU-7 Lieque is a special point for headaches. It is not specific for Liver-Yang headaches, but it can be used here for three reasons. First of all, it will affect any type of headache, and second, it can tonify the Lungs when the deficiency of Lung-Qi is contributing to the rebellious rising of Liver-Yang. In Five-Element terms, this corresponds to “Metal failing to control Wood”. This situation is quite common and is reflected in the pulse, the right Front position being very weak and the left Middle position very Wiry. Often, there may be no other symptoms or signs of Lung deficiency apart from the pulse. Third, LU-7 stimulates the descending of Qi from the head, and it will therefore indirectly help to subdue Liver-Yang. • G.B.-43 Xiaxi is the Spring point of the Gall Bladder channel. As such, it is used in Full patterns to eliminate pathogenic factors. In this case, it can be used to subdue Liver-Yang and remove obstructions from the Gall Bladder channel in the head. Being on the foot, it can treat the opposite end, i.e. the head. Specifically, it will affect the temple and eye area. Local points • G.B.-4 Hanyan, G.B.-5 Xuanlu and G.B.-6 Xuanli are all very important local points for headaches on

27

the Gall Bladder channel on the side of the head deriving from Liver-Yang rising. They are needled horizontally (i.e. just under the skin with the needle at an angle of about 15 degrees), usually pointing backwards. These local points should always be used at some time during the course of treatment, especially if the headache is very chronic and always appearing in that particular area (Fig. 1.19). • G.B.-8 Shuaigu is an effective local point for headaches around the ear area and the upper part of the lateral side of the neck. It is needled horizontally backwards. • G.B.-9 Tianchong is a very important local point for headaches on the sides of the head. In addition, it also has a general effect in calming the Mind and Ethereal Soul and subduing Liver-Yang. This point would be chosen when the person is very tense and is troubled by long-standing emotional problems. • G.B.-13 Benshen is used when the headache is on one side of the forehead, usually around G.B.-14. Besides subduing Liver-Yang, G.B.-13 has a powerful effect in calming the Mind and Ethereal Soul and helping sleep. The difference between G.B.-9 and G.B.-13 is that the former is used for emotional problems deriving from feelings of

G.B.-4 G.B.-5 G.B.-9

G.B.-8

G.B.-6

Figure 1.19 Local Gall Bladder points on the head.

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The Practice of Chinese Medicine

resentment and frustration, while the latter is better for calming the Mind when the person is extremely tense and cannot sleep. G.B.-14 Yangbai is simply used when the headache is situated around this point. Some headaches from Liver-Yang rising are situated on the forehead on one side around this point, and it feels like a nail being driven in. G.B.-21 Jianjing is used as an adjacent point when the top of the shoulders are very tense and stiff, as so often happens in those who suffer from chronic headaches. The repeated use of this point is very good for relaxing the neck muscles. BL-2 Zanzhu is used when the headache occurs around the eyes, or on the forehead extending down to the eyes. Yuyao, an extra point in the middle of the eyebrow, can be used when the headache occurs around or behind the eyes, especially when Liver-Yang rising stems from Liver-Blood deficiency. G.B.-1 Tongziliao is used when the headache occurs around the temples and outer corners of the eyes.

Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction

Explanation The main difference between this prescription and the previous one is that the latter nourishes the Yin more and is therefore suitable when there is a pronounced deficiency of Liver- and Kidney-Yin. Note that Dai Zhe Shi is not suitable for long-term use and is contraindicated in pregnancy. It could be eliminated from this prescription or replaced with Zhen Zhu Mu Concha Margatiriferae usta, which is a sinking substance that also subdues Liver-Yang.

Prescription LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction

Explanation This formula subdues Liver-Yang, nourishes Yin and resolves Phlegm. Its Yin-nourishing effect is mild.

Ancient formulae

Modifications

• General formula for headaches: Du-20 Baihui, Du-23 Shanxing, Du-16 Fengfu, G.B.-20 Fengchi, BL-2 Sizhukong, S.I.-8 Xiaohai, L.I.-5 Yangxi, S.I.-3 Houxi, L.I.-4 Hegu, S.I.-4 Wangu, P-9 Zhongchong, T.B.-3 Zhongzhu, BL-60 Kunlun, G.B.-34 Yanglingquan (Great Compendium of Acupuncture).7 • For headache from Liver-Yang rising: Du-20 Baihui, Du-21 Qianting, Du-24 Shenting, Du-23 Shangxing, T.B.-23 Sizhukong, G.B.-20 Fengchi, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei (Great Compendium of Acupuncture).8 • For headache on vertex: Du-23 Shangxing, Du-20 Baihui, L.I.-4 Hegu.9

• If Liver-Yang rising stems from Liver-Blood deficiency, Si Wu Tang Four Substances Decoction could be added to any of the above prescriptions. • If it stems from Liver-Yin deficiency, Yi Guan Jian One Linking Decoction could be added. • If it stems from Kidney-Yin deficiency, Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill or Zuo Gui Wan Restoring the Left [Kidney] Pill could be added.

Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction

Explanation This prescription is very widely used for headaches from Liver-Yang rising. It subdues Liver-Yang and tonifies the Liver and Kidneys.

Herbs • Tian Ma Rhizoma Gastrodiae is the herb for LiverYang headache. It subdues Liver-Yang and LiverWind and specifically treats headaches. • Gou Teng Ramulus cum Uncis Uncariae also subdues Liver-Yang and Liver-Wind and treats headaches. In addition, and in contrast to Tian Ma, it is cool and clears Liver-Heat. • Bai Ji Li Fructus Tribuli subdues Liver-Yang and Liver-Wind and is specific for headaches, especially if situated around the eyes. It is warm, bitter and pungent and therefore to be used with caution in Yin deficiency. • Ju Hua Flos Chrysanthemi subdues Liver-Yang and is one of the most frequently used herbs for this

Headaches















type of headache, especially if located around the eyes. It is frequently added to other prescriptions for headaches from other causes simply to direct the prescription to the head. Shi Jue Ming Concha Haliotidis subdues Liver-Yang and Liver-Wind and is specific for headaches. It is also cold and it therefore clears Liver-Fire. Ling Yang Jiao Cornu Saigae tataricae subdues LiverWind and Liver-Yang and can be used for chronic headaches. Bai Shao Radix Paeoniae alba harmonizes the Liver and is a very important herb for pain from many different Liver disharmonies. It not only promotes the smooth flow of Liver-Qi, but also subdues LiverYang and hence it can be used for headaches. It generally soothes and harmonizes (as it also nourishes Blood and Yin) and therefore stops pain, especially in combination with Gan Cao. Gan Cao Radix Glycyrrhizae uralensis, besides its other functions, can be used for chronic headaches from Liver-Yang because it is sweet in nature. The sweet flavour harmonizes and pacifies the Liver and therefore contributes to stopping pain, especially in combination with Bai Shao. The Simple Questions in Chapter 22 says: “For pain of Liver origin, [herbs with] sweet taste should be used to pacify the Liver.”10 Long Gu Mastodi Ossis fossilia sinks Liver-Yang, calms the Mind and settles the Ethereal Soul. It also nourishes Yin. Mu Li Concha Ostreae sinks Liver-Yang, calms the Mind, settles the Ethereal Soul and is suitable to treat Liver-Yang headaches. Like Long Gu, it also nourishes Yin. Suan Zao Ren Semen Ziziphi spinosae is an important addition to prescriptions for headaches from Liver-Yang. It subdues Liver-Yang and is particularly indicated for Liver-Yang headaches, as it enters the Liver and Gall Bladder channel. It also allays the irritability typical of Liver-Yang rising and is excellent for calming the Mind and settling the Ethereal Soul. Furthermore, if a person suffering from chronic headaches does not sleep well, this will definitely hinder the treatment. This herb is therefore important as it promotes sleep.

Three Treasures remedy Bend Bamboo Bend Bamboo subdues Liver-Yang and nourishes Liver-Blood. It was formulated specifically

29

to treat this type of chronic headache, especially in women.

SUMMARY LIVER-YANG RISING General prescription: LIV-3 Taichong, LIV-8 Ququan, SP-6 Sanyinjiao, T.B.-5 Waiguan, G.B.-20 Fengchi, Taiyang extra point.  In case of Liver and Kidney Yin deficiency, add KI-3 Taixi. Reducing method on LIV-3, T.B.-5 and G.B.-20, reinforcing method on LIV-8, SP-6 and KI-3. Even method on Taiyang. If the condition is very chronic, even method can be applied to the points that are normally reduced. Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction Prescription LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction Three Treasures remedy Bend Bamboo

Case history A 32-year-old woman had been suffering from migraine for the past 8 years. The headaches occurred on the top of the head and behind the eyes. They started with a dull pain and increased in intensity to a severe character, accompanied by nausea, vomiting and diarrhoea. They were better lying down. By the time she sought treatment, they occurred almost every day. Her tongue was Pale and Thin, and her pulse was Weak on the right side and slightly Wiry on the left. Diagnosis Liver-Yang rising stemming from LiverBlood deficiency. The Liver-Blood deficiency is apparent

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The Practice of Chinese Medicine

from the Pale and Thin tongue and Weak pulse. The dullness of some of the headaches and the fact that they are improved by lying down indicates that they are due to a deficiency, in this case of LiverBlood. The location of the headaches on top of the head also indicates Liver-Blood deficiency. Liver-Yang rising accounts for the more severe headaches and the vomiting and diarrhoea, due to Liver-Qi invading Stomach and Spleen, preventing Stomach-Qi from descending (vomiting) and Spleen-Qi from ascending (diarrhoea). Treatment principle Nourish Liver-Blood and subdue Liver-Yang. In this case, although the severe headaches are due to Liver-Yang rising, the pattern is still primarily one of deficiency, as evidenced by the tongue. For this reason, the treatment was aimed primarily at nourishing Liver-Blood. Acupuncture Points The main points used were P-6 Neiguan, T.B.-4 Yangchi, ST-36 Zusanli, LIV-8 Ququan, SP-6 Sanyinjiao and LIV-3 Taichong. The first two points were used with even method, LIV-3 was reduced and all the others were reinforced. Warming needle was applied to ST-36. Explanation • P-6 was used to regulate Liver-Blood, calm the Mind and settle the Ethereal Soul. • T.B.-4 was used in conjunction with Neiguan P-6 as a combination of Connecting and Source point. This combination strengthens the effect of P-6, while it also regulates the Lesser Yang channels. In addition, Yangchi T.B.-4 has a general tonifying effect. • ST-36 and SP-6 were used to nourish Blood. • LIV-8 was used to nourish Liver-Blood. • LIV-3 was used to subdue Liver-Yang. Herbal therapy Prescription The prescription used was a variation of Si Wu Tang Four Substances Decoction to nourish Liver-Blood. This prescription was chosen in preference to one of those to subdue Liver-Yang, because the condition was deemed to be primarily one of deficiency (of Liver-Blood). Herbs were added to subdue Liver-Yang. The prescription used was:

• • • • • • • •

Dang Gui Radix Angelicae sinensis 9 g Bai Shao Radix Paeoniae alba 6 g Chuan Xiong Rhizoma Chuanxiong 6 g Shu Di Huang Radix Rehmanniae preparata 6 g Shi Jue Ming Concha Haliotidis 9 g Gou Teng Ramulus cum Uncis Uncariae 6 g Man Jing Zi Fructus Viticis 4 g Ju Hua Flos Chrysanthemi 3 g

Explanation • The first four herbs are the Si Wu Tang Four Substances Decoction to nourish Liver-Blood. • Shi Jue Ming, Ju Hua and Gou Teng were added to subdue Liver-Yang. • Man Jing Zi was added to treat the headaches. This patient had a remarkable improvement after only one treatment, and her headache more or less went after three acupuncture treatments and three courses of 10 decoctions each.

Case history A 35-year-old woman had been suffering from migraine since the age of 14. The headaches got much worse when she reached 16, then got slightly better. They had been worse for the previous 6 years (i.e. since the age of about 28). The headaches occurred once a week and were therefore not related to her menstrual cycle. They were throbbing in character and were accompanied by dizziness, vision disturbance and floaters. The headaches on the right side of the head were of a different character from the ones on the left. Those on the right side were more intense, sharper, shorter and made her vomit. The ache on the left side was duller, longer, lingering and caused only nausea. In addition to these two types of headache, her head also felt heavy and muzzy as if filled with cotton wool. Her periods were normal, and she did not complain of anything else apart from insomnia. Her tongue was Red on the sides, Swollen and had a sticky coating. Her pulse was Wiry-Slippery. Diagnosis This case history is an interesting illustration of several principles of Chinese medicine. First, it is a good illustration of the life cycles (7 years for women and 8 for men). In fact, her headaches started

Headaches

when she was 14, got better when she was 21 and worse when she was 28. Interestingly, she sought treatment when she reached 35. The headache occurring on her right side is clearly from Liver-Yang rising: it is throbbing in character, involves visual disturbance and vomiting, and is intense. Although she had no symptoms of it apart from insomnia, I deduced that Liver-Yang rising stemmed from Blood deficiency. The headache on the left side was typical of Phlegm: dull, lingering, with nausea. This was confirmed also by the general heavy and muzzy feeling of the head and the Slippery pulse. This contrast between the headache on the right and the left is also a good illustration of the general principle of Chinese medicine that headaches on the right reflect a more Full condition. Indeed, this case history is a very good example of chronic headaches from the combination of LiverYang rising with Phlegm, which is very common in practice. Finally, when a condition varies clearly with the life cycles, I often attribute that to a Kidney deficiency, as I think it was the case in this patient. Treatment principle I adopted the treatment principle of subduing Liver-Yang and resolving Phlegm primarily. I did not concentrate on nourishing Blood or tonifying the Kidneys. However, this patient had been referred to me by a colleague, and I asked her to nourish Blood and tonify the Kidneys with acupuncture. I prescribed a variation of Ban Xia Bai Zhu Tian Ma Tang Pinellia-Atractylodes-Gastrodia Decoction (replacing Tian Ma with Gou Teng). Herbal therapy Prescription • Ban Xia Rhizoma Pinelliae preparatum 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6g • Gou Teng Ramulus cum Uncis Uncariae 9 g • Fu Ling Poria 6 g • Ju Hua Flos Chrysanthemi 6 g • Bai Ji Li Fructus Tribuli 6 g • Qiang Huo Rhizoma seu Radix Notopterygii 3 g • Man Jing Zi Fructus Viticis 4.5 g • Tu Si Zi Semen Cuscutae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Yuan Zhi Radix Polygalae 6 g

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• Shi Chang Pu Rhizoma Acori tatarinowii 6 g • Suan Zao Ren Semen Ziziphi spinosae 6 g Explanation • Ban Xia, Bai Zhu and Fu Ling resolve Phlegm. • Gou Teng, Ju Hua, Bai Ji Li, Qiang Huo and Man Jing Zi subdue Liver-Yang. • Tu Si Zi tonifies the Kidneys. • Dang Gui nourishes Blood. • Yuan Zhi and Suan Zao Ren calm the Mind and promote sleep. • Shi Chang Pu opens the Mind’s orifices which helps to eliminate Phlegm from the head. This patient has been treated for about 6 months at the time of writing with variations of the above formula. She is improving both in the frequency and the intensity of the headaches.

Case history A 31-year-old woman had been suffering from headaches from the age of 14. The headaches were better during a pregnancy and worse after childbirth. The headaches occurred more often on the left side and were generally dull but occasionally sharp. She said that she felt like “a pressure in the head”, “like the head wanted to explode” and a “muzzy pressure”. Her tongue was Swollen and had a sticky coating. Her pulse was Slippery and slightly Wiry on the left. Diagnosis This case history is a very good illustration of the fact that, in my opinion, pregnancy is not automatically a cause of disease (as many Chinese books say); far from it; frequently a woman’s condition improves during pregnancy. In this case, her headaches disappeared during pregnancy and returned after childbirth. When this happens, I attribute that to a Kidney deficiency (which improves during pregnancy and is aggravated after childbirth). Her headaches are clearly due to Phlegm (muzziness, dullness, Slippery pulse, Swollen tongue) and Liver-Yang rising (sharp, pressure in head, Wiry pulse). Herbal therapy Prescription I used a variation of Ban Xia Bai Zhu Tian Ma Tang Pinellia-Atractylodes-Gastrodia Decoction:

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• • • • • • • • • • • •

The Practice of Chinese Medicine

Ban Xia Rhizoma Pinelliae preparatum 6 g Bai Zhu Rhizoma Atractylodis macrocephalae 6 g Gou Teng Ramulus cum Uncis Uncariae 6 g Gua Lou Fructus Trichosanthis 6 g Fu Ling Poria 9 g Chen Pi Pericarpium Citri reticulatae 3 g Shi Chang Pu Rhizoma Acori tatarinowii 6 g Bai Zhi Radix Angelicae dahuricae 3 g Tu Si Zi Semen Cuscutae 6 g Gou Qi Zi Fructus Lycii chinensis 6 g Ju Hua Flos Chrysanthemi 6 g Man Jing Zi Fructus Viticis 4.5 g

Explanation • Ban Xia, Bai Zhu, Gua Lou, Fu Ling and Chen Pi resolve Phlegm. • Shi Chang Pu and Bai Zhu open the Mind’s orifices, which helps to resolve Phlegm from the head. • Tu Si Zi and Gou Qi Zi tonify the Kidneys. • Gou Teng, Ju Hua and Man Jing Zi subdue LiverYang.

Liver-Fire

Acupuncture General prescription: LIV-2 Xingjian, SP-6 Sanyinjiao, T.B.-5 Waiguan, G.B.-38 Yangfu, G.B.-20 Fengchi, Taiyang extra point. Distal points with reducing method, local points with even method.

Explanation • LIV-2 is the main distal point to clear Liver-Fire. Being the Spring point, it clears Heat. • SP-6 is used to nourish Yin, to prevent injury of Yin from Liver-Fire. • T.B.-5 is used as a distal point affecting the Lesser Yang channels. See the explanation given for this point under Liver-Yang rising. • G.B.-38 clears Liver- and Gall Bladder-Fire and treats unilateral headaches, especially if situated around an eye. It is especially good for very chronic migraine. • G.B.-20 expels Wind from the head and subdues Liver-Fire. See the explanation given under LiverYang rising. • Taiyang: see the explanation given under Liver-Yang rising.

Liver-Fire differs from Liver-Yang in so far as it is characterized by the presence of an actual pathogenic factor, i.e. Fire. Liver-Yang is characterized by an imbalance between Yin and Yang, without any actual pathogenic factor. Many of the symptoms and signs of Liver-Yang rising are seen in Liver-Fire too. These are dizziness, tinnitus, deafness, irritability, headache, a dry throat, insomnia and a Wiry pulse. In addition to these, Liver-Fire is characterized by thirst, a bitter taste, scanty-dark urine, constipation with dry stools, red eyes and a Red tongue with yellow coating. Liver-Fire is a purely Excess pattern, while Liver-Yang rising is a combined Excess-Deficiency pattern. The headache from Liver-Fire is similar in nature to that from Liver-Yang, being throbbing, distending, pulsating or bursting. It is, however, even more intense, tends to be more fixed in one place, and is more frequently accompanied by nausea or vomiting. This pattern is not a frequent cause of chronic headaches, and it is more common either in the elderly or in children.

Other points

Treatment principle

This formula is specific to drain Liver-Fire. Please note that it contains Mu Tong, which should be omitted because its use is illegal.

Pacify the Liver, drain Fire, subdue rebellious Liver-Qi, calm the Mind.

• G.B.-43 Xiaxi: being the Spring point, it clears Gall Bladder-Heat and is suitable if the headache is located around or behind one eye. • G.B.-44 Qiaoyin clears Gall Bladder-Heat and is suitable if the headache is located on the side of the head. • L.I.-11 Quchi is used if there are pronounced signs of Heat, such as thirst, a bitter taste, a feeling of heat, a Deep-Red tongue body with yellow coating and a Rapid pulse. • All the local points mentioned under Liver-Yang rising are equally applicable in the treatment of Liver-Fire headaches.

Herbal therapy Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction

Explanation

Headaches

Herbs • Long Dan Cao Radix Gentianae is the main herb to clear Liver-Fire. It is especially suited to the treatment of headaches, as it acts on the area around the ears and eyes. • Xia Ku Cao Spica Prunellae clears Liver-Fire and affects the head. • Jue Ming Zi Semen Cassiae clears Liver-Fire and affects the eyes. It is therefore suitable for Liver-Fire headaches around one eye.

Three Treasures remedy Drain Fire Drain Fire is a variation of Long Dan Xie Gan Tang and it drains Liver-Fire.

SUMMARY LIVER-FIRE General prescription: LIV-2 Xingjian, SP-6 Sanyinjiao, T.B.-5 Waiguan, G.B.-38 Yangfu, G.B.20 Fengchi, Taiyang extra point. Distal points with reducing method, local points with even method. Herbal therapy Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction Three Treasures remedy Drain Fire

Case history A 33-year-old woman had been suffering from chronic migraine for several years. The headaches were frequent and intense and occurred over the right eye. They were throbbing in character and aggravated by lying down. They were accompanied by nausea, a feeling of heat, thirst and a bitter taste. The headaches improved during pregnancy and worsened after childbirth. The periods were regular and normal, but she experienced premenstrual tension manifesting with irritability, mood swings and weeping. She had also been suffering from alopecia at 7, 14 and 21 years of age when the hair suddenly fell out in clumps and then regrew each time. In the past, she had suffered from severe depression.

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Her pulse was Wiry and her tongue was slightly Red, dry, rather peeled in the centre, with cracks in the central area. Diagnosis The present condition is one of Liver-Fire rising causing the migraine. This is evidenced by the Red and dry tongue, Wiry pulse, and the feeling of heat, thirst and bitter taste. Had the tongue not been dry and Red and had there been no thirst and bitter taste, the diagnosis would have been Liver-Yang rising. In this case, the Liver-Fire was beginning to injure the Yin of the Stomach, as evidenced by the centre of the tongue being slightly peeled and cracked. She must have been suffering from Liver-Qi stagnation as well preceding the development of LiverFire, as shown by the previous period of depression and premenstrual tension. The alopecia was due to Liver-Wind (which develops from Liver-Fire). When the hair falls out suddenly and in clumps, it indicates Liver-Wind. It is interesting that the alopecia occurred regularly at 7-year intervals (7, 14 and 21), coinciding exactly with a girl’s development cycles described in the first chapter of the Simple Questions. The fact that the migraine improved during pregnancy and worsened after childbirth indicates a Kidney deficiency, but this is the only sign of it in this case. Treatment principle Clear Liver-Fire, subdue LiverWind, nourish Stomach- and Kidney-Yin, calm the Mind and settle the Ethereal Soul. Treatment This patient was treated with acupuncture only and the main points used were T.B.-5 Waiguan, P-6 Neiguan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, LIV-2 Xingjian. Other points used at other times included Ren-12 Zhongwan, LU-7 Lieque and KI-6 Zhaohai in combination, G.B.-43 Xiaxi, KI-9 Zhubin, G.B.-20 Fengchi, Yuyao and G.B.-1 Tongziliao. Explanation • T.B.-5 was used on the right side as a distal point to affect the Lesser Yang channels where the headaches manifested. • P-6 was used on the left side (to balance T.B.-5) to regulate the Liver (by virtue of the connection between Pericardium and Liver within the Terminal Yin) and to calm the Mind and settle the Ethereal

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• • •

• • • • •

The Practice of Chinese Medicine

Soul. The combination of these two points for chronic headaches on the Lesser Yang channels from either Liver-Yang or Liver-Fire rising is very effective in treating the headache area, regulating the Liver and calming the Mind. In addition, T.B.-5 will regulate the Gall Bladder and P-6 will regulate the Liver. Because the Triple Burner pertains to the Lesser Yang, which is the “hinge” of the Yang channels, and the Pericardium pertains to the Terminal Yin, which is the “hinge” of the Yin channels, these two points will also regulate Yin and Yang, Defensive and Nutritive Qi, the Exterior and Interior, and Yin- and Yang-Linking Vessels. ST-36 and SP-6 were used to tonify Stomach-Yin. SP-6, in addition, will also regulate the Liver and calm the Mind. KI-3 was used to nourish the Kidneys and LiverYin. Although in this case it is Liver-Fire that is injuring Yin (and not the other way round), it is still important to nourish the Kidneys because Liver and Kidneys have a “common source”, and tonifying the Kidney points will help to regulate the Liver. LIV-2 was used with reducing method to clear Liver-Fire. Ren-12 was used to nourish Stomach-Yin. LU-7 and KI-6 in combination open the Directing Vessel. This was done to nourish the Kidneys and regulate the Uterus. G.B.-43 was used with reducing method to clear the Gall Bladder channel, where the headaches occurred. KI-9 was used to nourish the Kidneys and calm the Mind. This point has a powerful calming action. G.B.-20 was used as an adjacent point to subdue Liver-Fire and Liver-Wind. Yuyao is the extra point in the middle of the eyebrow and was used as a local point. G.B.-1 was also used as a local point to clear the Gall Bladder channel.

Liver-Wind The headache from Liver-Wind is pulling in character and affects the whole head rather than the sides. It is accompanied by severe giddiness. Other possible manifestations include a slight shaking of the head, numbness, or tremor of a limb. The pulse and tongue will vary according to whether the Liver-Wind derives from Liver-Fire, from LiverBlood deficiency or from Liver-Yin deficiency.

This is not a common pattern in chronic headaches, and it occurs only in the elderly.

Treatment principle Pacify the Liver, extinguish Wind.

Acupuncture General prescription: LIV-3 Taichong, SP-6 Sanyinjiao, G.B.-20 Fengchi, Du-16 Fengfu, Du-20 Baihui. Reducing method, except on SP-6, which should be reinforced.

Explanation • LIV-3 subdues Liver-Wind. • SP-6 is tonified to nourish Yin and Blood, which is always necessary in order to subdue internal Wind. • G.B.-20 subdues Wind (both internal and external). • Du-16 and Du-20 subdue internal Wind and relieve headache.

Other points • S.I.-3 Houxi and BL-62 Shenmai in combination open the Governing Vessel and subdue internal Wind agitating within it and causing headaches. In men, these two points can be used on their own, while in women they are best combined with the points to open the Directing Vessel, i.e. LU-7 Lieque and KI-6 Zhaohai. Any of the local points mentioned for the Liver-Yang type of headache can be used for the Liver-Wind type too.

Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction

Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction Both these prescriptions have been discussed under Liver-Yang rising.

Herbs • Bai Ji Li Fructus Tribuli extinguishes internal Wind and treats headaches, especially around the eyes. • Di Long Pheretima subdues internal Wind and is used for chronic headaches of this type, especially in old people.

Headaches

• Quan Xie Scorpio is used for severe and chronic headaches from internal Wind.

SUMMARY LIVER-WIND General prescription: LIV-3 Taichong, SP-6 Sanyinjiao, G.B.-20 Fengchi, Du-16 Fengfu, Du-20 Baihui. Reducing method, except on SP-6, which should be reinforced. Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction

Liver-Qi stagnation This type of headache usually occurs on the forehead or temples. It is frequently associated with a Stomach disharmony, such as retention of food in the Stomach. The type of ache resembles that from Stomach deficiency, but it is more intense. It is not, however, throbbing like that from Liver-Yang rising. Another characteristic of it is that it moves from one side to the other. The headache from Liver-Qi stagnation is typically caused by anxiety and stress and is a common type of headache in young and middle-aged patients. Other manifestations include hypochondrial pain or distension, nervous tension, poor digestion, belching, flatulence, abdominal distension, small-bitty stools, sighing and a Wiry pulse.

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Explanation • LIV-3 pacifies the Liver and eliminates stagnation. It is chosen out of all other Liver-channel points because it is the best point to affect the head. • G.B.-34 relieves stagnation of Liver-Qi. In combination with Du-24, it eliminates stagnation of Liver-Qi in the head. • L.I.-4 is chosen because it will combine with LIV-3 to eliminate stagnation of Liver-Qi in the head. It also calms the Mind, which is important because stagnation of Liver-Qi is normally caused by emotional problems. • ST-36 is used because the headache is caused by the influence of Liver-Qi stagnation on the Stomach channel in the head. • Du-24 and Taiyang in combination with G.B.-34 relieve stagnation of Liver-Qi in the head. Additionally Du-24 also calms the Mind.

Other points • LIV-14 Qimen can be added to help in eliminating stagnation of Liver-Qi. • Yintang is an extra point that can be used as a local point for headaches on the forehead. It also calms the Mind and promotes sleep.

Herbal therapy Prescription XIAO YAO SAN Free and Easy Wanderer Powder

Explanation This formula pacifies the Liver, moves Qi and eliminates stagnation. In order to treat headaches from Liver-Qi stagnation, it should be modified with the addition of herbs to subdue Liver-Yang, such as Gou Teng Ramulus cum cis Uncariae and Ju Hua Flos Chrysanthemi.

Treatment principle

Herbs

Pacify the Liver, eliminate stagnation, calm the Mind and settle the Ethereal Soul.

• Mu Xiang Radix Aucklandiae moves Qi in the Stomach, Spleen, Intestines and Gall Bladder. Because it enters the Gall Bladder, it can relieve headaches from Liver-Qi stagnation. • Ju Hua Flos Chrysanthemi subdues Liver-Yang and can be added as a symptomatic herb to relieve the headache. • Sang Ye Folium Mori has the same function as Ju Hua.

Acupuncture General prescription: LIV-3 Taichong, G.B.-34 Yanglingquan, L.I.-4 Hegu, ST-36 Zusanli, Du-24 Shenting, Taiyang. LIV-3, G.B.-34 and L.I.-4 with reducing method. ST-36 with reinforcing method and the local points with even method.

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The Practice of Chinese Medicine

• Zhi Shi Fructus Aurantii immaturus moves Qi and makes Qi descend. For this reason, it is a suitable addition to treat headaches from Liver-Qi stagnation. • Yan Hu Suo Rhizoma Corydalis moves Qi and Blood of Stomach and Liver and is particularly good for stopping pain. • Chen Xiang Lignum Aquilariae resinatum moves Qi and has a strong effect in subduing rebellious Qi. For this reason, it is suitable to treat headaches.

Women’s Treasure remedy Freeing the Moon Freeing the Moon pacifies the Liver, moves Qi, eliminates stagnation, calms the Mind and nourishes Liver-Blood. It is a variation of Xiao Yao San. Although it is in the Women’s Treasure range, it can be prescribed for men.

Acupuncture General prescription: LIV-3 Taichong, Du-20 Baihui. Reducing method on LIV-3 followed by application of moxa on the needle. Even method on Du-20.

Explanation • LIV-3 pacifies the Liver and subdues rebellious Liver-Qi, and is an important distal point for headaches from Liver disharmonies. • Du-20 is needled as a local point to disperse the stagnation of Liver-Qi in the vertex.

Herbal therapy Prescription WU ZHU YU TANG Evodia Decoction

Explanation

SUMMARY LIVER-QI STAGNATION

This formula is specific to expel Cold from the Liver channel.

General prescription: LIV-3 Taichong, G.B.-34 Yanglingquan, L.I.-4 Hegu, ST-36 Zusanli, Du-24 Shenting, Taiyang. LIV-3, G.B.-34 and L.I.-4 with reducing method. ST-36 with reinforcing method and the local points with even method.

Prescription

Herbal therapy Prescription XIAO YAO SAN Free and Easy Wanderer Powder

This formula subdues Yang, expels Cold and enters the Liver channel.

Women’s Treasure remedy Freeing the Moon

Stagnation of Cold in the Liver channel This is quite a rare type of headache. Caused by Cold in the Liver channel rebelling upwards to reach the head, it is called “Terminal-Yin headache”. The ache is intense and is experienced at the top of the head. It is associated with a feeling of cold, vomiting, cold limbs and a Wiry pulse. This pattern is a rare cause of headaches.

Treatment principle Pacify and warm the Liver, expel Cold, subdue rebellious Qi.

CHEN XIANG JIANG QI SAN Aquilaria Subduing Qi Powder

Explanation

Herbs • Chuan Xiong Rhizoma Chuanxiong enters the Liver and treats headaches. • Dang Gui Radix Angelicae sinensis enters the Liver channel. • Rou Gui Cortex Cinnamomi is very warm and expels Cold. • Gui Zhi Ramulus Cinnamomi cassiae is warming and enters the channels and blood vessels.

SUMMARY STAGNATION OF COLD IN THE LIVER CHANNEL General prescription: LIV-3 Taichong, Du-20 Baihui. Reducing method on LIV-3 followed by application of moxa on the needle. Even method on Du-20.

Headaches

Herbal therapy Prescription WU ZHU YU TANG Evodia Decoction Prescription CHEN XIANG JIANG QI SAN Aquilaria Subduing Qi Powder

Case history A 38-year-old man had been suffering from migraine headaches for the past 5 years. The headaches occurred over the whole head and were dull but intense in character. They were better lying down, worse from stress and worse from exposure to light. They were accompanied by nausea, vomiting without bringing up much food, and a feeling of cold. He also experienced some hypochondrial pain extending to the back, elicited by intake of fatty foods. He was also prone to belching and constipation. His tongue was of a normal colour and was Swollen with a dirty coating. His pulse was Wiry and Slow. Diagnosis The headaches were clearly due to stagnation of Cold in the Liver channel, as evidenced by the feeling of cold, the location of the headache, the dry vomiting and the Wiry-Slow pulse. The hypochondrial pain, belching and constipation were due to stagnation of Liver-Qi. In addition, there was also Spleen-Qi deficiency with accumulation of Phlegm, as indicated by the Swollen tongue and dirty coating. Treatment principle In this case, it is necessary to move Liver-Qi and eliminate Cold. Acupuncture Points The main points used were LU-7 Lieque, ST-40 Fenglong, G.B.-34 Yanglingquan and LIV-3 Taichong. The first two points were used with even method, and the latter two with reducing method. Moxa was used on LIV-3. In order to reduce the number of needles and create a balanced and dynamic combi-

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nation of points, LU-7 was used on the right side, ST-40 on the left side, G.B.-34 on the right side and LIV-3 on the left. The sides could have been inverted too, but the above was worked out so that by using G.B.-34 on the right side one treated the hypochondrial pain that was on the right side. Explanation • LU-7 was used to facilitate the flow of clear Qi up to the head. • ST-40 was used to tonify the Spleen and eliminate Phlegm. • G.B.-34 was used to move Liver-Qi and eliminate stagnation. • LIV-3 was used to move Liver-Qi and moxa was used on it to expel Cold from the Liver channel. Herbal therapy Prescription The prescription used was a variation of Wu Zhu Yu Tang Evodia Decoction: • • • • • • • •

Wu Zhu Yu Fructus Evodiae 3 g Dang Shen Radix Codonopsis 6 g Sheng Jiang Rhizoma Zingiberis recens 3 slices Gan Cao Radix Glycyrrhizae uralensis 3 g Gui Zhi Ramulus Cinnamomi cassiae 3 g Chen Pi Pericarpium Citri reticulatae 3 g Yin Chen Hao Herba Artemisiae scopariae 3 g Da Zao Fructus Jujubae 3 dates

Explanation • Wu Zhu Yu, Dang Shen, Sheng Jiang and Da Zao are all part of the Wu Zhu Yu Tang. • Gui Zhi was added to help to expel Cold. It also enters the blood vessels and channels and would therefore help the headaches. • Chen Pi was added to help to eliminate Phlegm. • Yin Chen Hao was added as a messenger herb to direct the prescription to the Liver channel. • Gan Cao was added to harmonize the prescription. This man’s headache stopped completely after 3 months.

Dampness Internal Dampness is a very frequent cause of headaches, particularly in damp countries such as the British Isles. Dampness is heavy in nature, so it has a natural tendency to settle in the Lower Burner, but

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The Practice of Chinese Medicine

it can affect the head too. In chronic cases, when Dampness obstructs the Middle Burner, prevents Stomach-Qi from descending and interferes with the normal movement of Qi in the Middle, this long-term stagnation of Dampness in the Middle leads to the obstruction gradually spreading upwards as well and filling the head. Once in the head, Dampness prevents the clear Yang from ascending to brighten the sense orifices and the turbid Yin from descending away from the head. The result is that the sense orifices are clouded by Dampness. This causes a dull headache: the head feels as if it were wrapped in a cloth or stuffed with cotton wool; there is also a sensation of heaviness there, and thinking is difficult. These symptoms are worse in the mornings. The headache may affect the whole head, or it may be on the forehead only. In a few cases, the Dampness may be affecting the Gall Bladder channel, in which case the headaches would occur on the temples or sides of the head. Other symptoms include persistent catarrh, sometimes sinusitis, nausea, lack of appetite, a feeling of fullness of the chest and epigastrium, a thick-sticky tongue coating and a Slippery pulse. If the Dampness is very chronic and the Spleen very deficient, the pulse may be Soggy, i.e. it feels Slippery but weak and soft and it is slightly Floating, especially on the right Middle position. Internal Dampness arises from a deficiency of Spleen-Qi failing to transform and transport fluids, which accumulate into Dampness. It can also derive from retention of external Dampness over a long period of time.

• L.I.-4 can eliminate pathogenic factors from the face and forehead area, and it also regulates the ascending and descending of Qi. • LU-7 is specific for headaches and is used to stimulate the ascending of clear Yang to the head. • Ren-12 and BL-20 are used to tonify the Spleen to eliminate Dampness. • ST-8 is the main local point to eliminate Dampness from the head and is specific for this type of headache.

Treatment principle

Explanation

Resolve Dampness, stimulate the ascending of clear Yang, tonify Stomach and Spleen.

This formula eliminates Dampness from the head and the top part of the body.

Acupuncture

Prescription

General prescription: SP-3 Taibai, L.I.-4 Hegu, LU-7 Lieque, Ren-12 Zhongwan, BL-20 Pishu, ST-8 Touwei. Reducing method on SP-3 and L.I.-4; reinforcing method on LU-7, Ren-12 and BL-20; even method on ST-8.

YIN CHEN WU LING SAN Artemisia scoparia Five “Ling” Powder

Explanation • SP-3 is a general point to eliminate Dampness in any part of the body. Being towards the extremity of the channel, it specifically affects the head.

Other points • Du-20 Baihui is used if the headache is accompanied by a marked cloudiness of the head. It stimulates the ascending of clear Yang to the head. • Du-24 Shenting can be used as a local point to eliminate Dampness from the forehead. • Du-23 Shangxing can be used if the headache is located around the eyes. • Yintang can be used as a local point if the headache is located on the forehead. • SP-6 Sanyinjiao and SP-9 Yinlingquan can be used as distal points to eliminate Dampness. • BL-21 Weishu can be added to strengthen the Stomach and Spleen to eliminate Dampness. It is especially good if the person suffers from chronic tiredness.

Herbal therapy Prescription QIANG HUO SHENG SHI TANG Notopterygium Dispelling Dampness Decoction

Explanation A variation of Wu Ling San Five Ling Powder, this formula is suitable for headaches from Dampness affecting the Gall Bladder rather than the Stomach and Spleen. It is used for more intense headaches on the temples or at the sides of the head rather than the forehead, which the previous formula addresses.

Headaches

It should be noted that there is nothing in these two prescriptions to strengthen the Spleen. For chronic headaches from Dampness, these prescriptions should be integrated with another to tonify the Spleen (e.g. Si Jun Zi Tang Four Gentlemen Decoction). In severe cases, the prescriptions could be used on their own first to eliminate Dampness, and then adapted with the addition of some herbs to tonify the Spleen (such as Bai Zhu Rhizoma Atractylodis macrocephalae).

SUMMARY DAMPNESS General prescription: SP-3 Taibai, L.I.-4 Hegu, LU-7 Lieque, Ren-12 Zhongwan, BL-20 Pishu, ST-8 Touwei. Reducing method on SP-3 and L.I.-4, even method on ST-8, reinforcing method on LU-7, BL-20 and Ren-12. Herbal therapy Prescription QIANG HUO SHENG SHI TANG Notopterygium Dispelling Dampness Decoction Prescription YIN CHEN WU LING SAN Artemisia scoparia Five “Ling” Powder

Case history A 52-year-old woman had been suffering from headaches for the past 3 years. The headaches occurred mostly on the forehead and in the face but also on the top of the head. They started after a fast and were worse in daytime. They were accompanied by a feeling of muzziness of the head. There was no dizziness. She had also been suffering from chronic catarrh and rhinitis for the past 25 years. She had a chronic ache in the lower back and her urination was too frequent. She felt tired. The bowels were constipated, not having a movement every day. When she did have a movement, it was sometimes loose. She felt generally cold. The Pulse was Deep and Weak on the whole, and slightly Slippery on the right side. Her tongue was Pale and Swollen with a sticky-yellow coating. The diagnosis was Spleen- and Kidney-Yang deficiency leading to Dampness obstructing the head. The headaches had all the typical features

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of Dampness: they were dull in character, with a feeling of muzziness of the head, and occurred mostly on the forehead. The absence of dizziness indicates Dampness as opposed to Phlegm. The presence of Dampness is confirmed by the chronic catarrh and rhinitis, the slippery quality of the pulse and the sticky tongue coating. The Kidney-Yang deficiency is indicated by the ache in the lower back, frequent urination, cold feeling and the Deep pulse, while the SpleenYang deficiency is indicated by the tiredness, the cold feeling, the Weak pulse and the Pale tongue. The constipation is due to deficient Kidney-Yang’s being unable to move the stools; this is confirmed by the fact that the stools were not dry and indeed were sometimes loose. It is interesting that the headaches should start after a fast. She had obviously suffered from Dampness for a long time, as evidenced by the chronic catarrh and rhinitis. Being on a fast weakened the Spleen, which became even more unable to transform and transport and therefore led to more Dampness. A person with Spleen deficiency should only fast under very controlled conditions and lead up to the fast by very gradually reducing the quantity of food eaten. Similarly, one should break the fast very gradually. Only if done under these conditions can a fast be beneficial. The treatment was based on both acupuncture and herbal therapy. Treatment principle Tonify Spleen- and KidneyYang and resolve Dampness. Acupuncture Points The main points used were LU-7 Lieque, L.I.-4 Hegu, Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai and KI-7 Fuliu. LU-7, L.I.-4 and SP-3 were needled with even method, while the others were needled with reinforcing method. Moxa was used on ST-36 and KI-7. Other points used included Ren-9 Shuifen, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu, ST-8 Touwei. Explanation • LU-7 and L.I.-4 were used to open the channels of the head and face and remove obstructions. They also stimulate the rising of clear Yang to the head.

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• Ren-12, ST-36 and BL-20 were used to tonify the Spleen. • BL-23 and KI-7 were used to tonify the Kidneys. • SP-3, SP-6 and Ren-9 were used to resolve Dampness. • ST-8 was used as a local point. It is the best local point to resolve Dampness in the head.

Phlegm is a common cause of chronic headaches in young and middle-aged patients.

Herbal therapy Prescription The prescription was based on a variation of Qiang Huo Sheng Shi Tang with the addition of:

General prescription: ST-40 Fenglong, L.I.-4 Hegu, LU-7 Lieque, ST-8 Touwei, Du-20 Baihui. Reducing method on ST-40 and L.I.-4, reinforcing method on LU-7, even method on ST-8 and Du-20.

• • • • • •

Explanation

Huo Xiang Herba Pogostemonis 3 g Pei Lan Herba Eupatorii 3 g Chen Pi Pericarpium Citri reticulatae 3 g Bai Zhu Rhizoma Atractylodis macrocephalae 6 g Du Zhong Cortex Eucommiae ulmoidis 6 g Cang Zhu Rhizoma Atractylodis 3 g

Explanation • Huo Xiang and Pei Lan were added as fragrant herbs to resolve Dampness. Being fragrant and light, these herbs also affect the head and face and relieve headache. • Cang Zhu is another fragrant herb to resolve Dampness and it is frequently used for headaches. • Chen Pi was added to help to resolve Dampness and move Qi. Moving Qi is nearly always necessary to help to resolve Dampness. • Bai Zhu was added to tonify the Spleen. • Du Zhong was used to tonify Kidney-Yang. Being slightly pungent, it would also help to relieve the backache. This patient’s headaches were cured after 6 months’ treatment.

Turbid Phlegm Phlegm is similar to Dampness in nature, and it also derives from deficiency of Spleen-Qi. The headache from Phlegm is similar to that from Dampness, i.e. it is dull and is accompanied by a feeling of heaviness and muzziness (fuzziness). However, Phlegm is more obstructive than Dampness and it clouds the sense orifices more. This results in blurred vision and dizziness, which are not present with Dampness. Other manifestations include sputum on the chest, a feeling of oppression of the chest, a Swollen tongue with a sticky coating and a Slippery pulse.

Treatment principle Resolve Phlegm, harmonize the Middle.

Acupuncture

• ST-40 is the main point to resolve Phlegm. • L.I.-4 is used as a distal point to eliminate pathogenic factors from the face and head. It also regulates the ascending and descending of Qi. • LU-7 is used as a distal point to stimulate the ascending of clear Yang to the head. • ST-8 is a local point for headaches from Phlegm (or Dampness). • Du-20 is used to stimulate the ascending of clear Yang to the head.

Other points • ST-36 Zusanli can be added as a distal point to tonify the Spleen and resolve Phlegm. It is important to use it if the person feels very tired. • SP-6 Sanyinjiao eliminates Dampness and helps to resolve Phlegm. • SP-3 Taibai eliminates Dampness and helps to resolve Phlegm. Being at the extremity of the channel, it affects the head. • L.I.-11 Quchi can be used if the Phlegm is associated with Heat. • Du-23 Shangxing can be used as a local point, especially if the eyes are affected. • Yintang can be used as a local point if the headache is on the forehead.

Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction

Explanation Ban Xia resolves Phlegm, makes Qi descend and stops vomiting. Tian Ma extinguishes internal Wind and

Headaches

stops headaches. These two herbs are the emperor herbs, one to resolve Phlegm, the other to subdue Wind. Thus, they treat Wind-Phlegm causing headache and dizziness. Li Dong Yuan in the Discussion on Stomach and Spleen says: “Headaches due to Phlegm cannot be treated without Ban Xia and headaches with dizziness due to Wind cannot be treated without Tian Ma.”11 Even though this prescription is actually for WindPhlegm, it is the prescription of choice because it includes Tian Ma, which is an important herb for headaches.

Herbs • Dan Nan Xing Rhizoma Arisaematis preparatum is a warm herb to resolve Phlegm and subdue internal Wind and is therefore suitable to treat headaches of this type. It is particularly suitable if the headaches move from one side to the other. • Bai Fu Zi Rhizoma Typhonii preparatum is another warm herb to resolve Phlegm and could be added particularly if Phlegm is associated with Cold and is difficult to eliminate. • Jiang Can Bombyx batryticatus subdues Wind and treats headaches. It is particularly useful in cases of very chronic headaches from Wind-Phlegm in old people.

Three Treasures remedy Clear Yang Clear Yang is a variation of Ban Xia Bai Zhu Tian Ma Tang to treat headaches from a combination of Phlegm and Liver-Yang rising.

SUMMARY TURBID PHLEGM General prescription: ST-40 Fenglong, L.I.-4 Hegu, LU-7 Lieque, ST-8 Touwei, Du-20 Baihui. Reducing method on ST-40 and L.I.-4, reinforcing method on LU-7, even method on ST-8 and Du-20. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction Three Treasures remedy Clear Yang

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Case history A man of 48 had been suffering from headaches for 10 years. The headaches occurred around the forehead and were dull in character. They were accompanied by a feeling of cloudiness, heaviness and dizziness. He also suffered from extreme tiredness and a lack of sexual drive. He felt cold easily. His pulse was Deep and Slippery and his tongue was Pale with swollen sides and a very thick-sticky yellow coating. Diagnosis The headaches were clearly caused by Turbid Phlegm obstructing the head orifices and preventing the clear Yang from rising. This caused the typical feeling of cloudiness, heaviness and dizziness. Dizziness, in particular, distinguishes it from Dampness. The Phlegm arose from a background of Spleen-Yang deficiency (Pale tongue with swollen sides, Deep pulse, feeling cold, tiredness and lack of sexual drive). Lack of sexual drive is not always due to Kidney deficiency; in this case, in fact, it was due to Spleen deficiency. Treatment principle In this case, due to the chronic nature of the condition, attention was directed at treating both the Root (Ben) and the Manifestation (Biao) simultaneously. This involved both tonifying the body’s Qi and eliminating the pathogenic factors (in this case Phlegm). This patient was treated with acupuncture only. Acupuncture Points The main points used were Ren-12 Zhongwan, ST-8 Touwei, LU-7 Lieque, L.I.-4 Hegu, ST-36 Zusanli, BL-20 Pishu, ST-40 Fenglong and SP-3 Taibai. ST-8 and ST-40 were needled with even method, while all the other points were needled with reinforcing method. Explanation • Ren-12, ST-36, BL-20 and SP-3 were reinforced to tonify the Spleen. Moxa was used on ST-36 to tonify Spleen-Yang. • LU-7 and L.I.-4 were used to stimulate the rising of clear Yang to the head and open the head orifices. • ST-8 is the main local point for headaches from Phlegm or Dampness. • ST-40 was used with even method to resolve Phlegm.

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Turbid Phlegm-Wind This pattern is similar to the previous one, and it simply corresponds to a combined condition of Phlegm and internal Wind. It is only seen in old people and may indicate the likelihood of Wind-stroke.

Treatment principle Resolve Phlegm, extinguish Wind, pacify the Liver.

Acupuncture General prescription: ST-40 Fenglong, L.I.-4 Hegu, LIV-3 Taichong, S.I.-3 Houxi, BL-62 Shenmai, ST-8 Touwei, Du-20 Baihui, G.B.-20 Fengchi. Reducing method on ST-40, L.I.-4, LIV-3 and G.B.-20, even method on S.I.-3, BL-62, ST-8 and Du-20.

one to subdue Liver-Wind such as Tian Ma Gou Teng Yin Gastrodia-Uncaria Decoction or Zhen Gan Xi Feng Tang Pacifying the Liver and Extinguishing Wind Decoction.

Herbs • Di Long Pheretima subdues Wind and removes obstructions from the channels. It is particularly useful for chronic Wind-Phlegm in old people. All the other herbs mentioned for the Turbid-Phlegm type are also indicated.

Three Treasures remedy Clear Yang Clear Yang is a variation of Ban Xia Bai Zhu Tian Ma Tang to treat headaches from a combination of Phlegm and Liver-Yang rising.

Explanation • ST-40, L.I.-4, ST-8, and Du-20: the use of these points has already been explained under the Phlegm-type headache. • LIV-3 extinguishes Wind and is an important point to relieve this type of headache. In combination with L.I.-4, it extinguishes Wind from the face and head. • S.I.-3 and BL-62 in combination open the Governing Vessel and extinguish Wind. In particular, by opening the Governing Vessel they will also relieve the headache. • G.B.-20 extinguishes Wind and relieves headaches.

SUMMARY

Other points

Three Treasures remedy Clear Yang

• G.B.-39 Xuanzhong extinguishes internal Wind and will relieve headaches of this type along the Gall Bladder channel. • Du-16 Fengfu extinguishes internal Wind and removes obstructions from the Governing Vessel. All the other points mentioned under the Turbid-Phlegm type are applicable to the Wind-Phlegm type too.

Herbal therapy Prescription The same prescription as for the Turbid-Phlegm type is applicable, i.e. Ban Xia Bai Zhu Tian Ma Tang (PinelliaAtractylodes-Gastrodia Decoction). Substances that extinguish internal Wind such as Quan Xie Scorpio and Jiang Can Bombyx batryticatus should be added. Alternatively, this prescription can be integrated with

TURBID PHLEGM-WIND General prescription: ST-40 Fenglong, L.I.-4 Hegu, LIV-3 Taichong, S.I.-3 Houxi, BL-62 Shenmai, ST-8 Touwei, Du-20 Baihui, G.B.-20 Fengchi. Reducing method on ST-40, L.I.-4, LIV-3 and G.B.-20, even method on S.I.-3, BL-62, ST-8 and Du-20. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction

Liver-Yang rising with Phlegm in the head Clinical manifestations Chronic headaches, frequent “background” dull headaches with muzziness of the head punctuated by occasional, severe attack of throbbing headaches, dizziness, vertigo, tinnitus, irritability, propensity to outbursts of anger, headache, a feeling of heaviness and muzziness (fuzziness) of the head as if it were full of cotton wool, blurred vision, difficulty in thinking and concentrating (especially in the morning), a feeling of oppression of the chest, nausea, poor appetite, a sticky taste.

Headaches

Tongue: Swollen with a sticky coating. Pulse: Slippery-Wiry. This is a common combination of patterns causing chronic headaches. As Liver-Yang rises, it carries Phlegm with it, aggravating the feeling of dizziness.

Treatment principle Subdue Liver-Yang, nourish the Kidneys, resolve Phlegm, tonify the Spleen, extinguish Wind if necessary.

Acupuncture Points LIV-3 Taichong, G.B.-20 Fengchi, Du-16 Fengfu, LIV-8 Ququan, KI-3 Taixi, L.I.-4 Hegu, ST-40 Fenglong, Ren-9 Shuifen, SP-9 Yinlingquan, ST-8 Touwei, Ren-12 Zhongwan, BL-20 Pishu. Ren-12, BL-20, LIV-8 and KI-3 with reinforcing method, the others with even method.

Explanation • LIV-3, G.B.-20 and Du-16 subdue Liver-Yang. • LIV-8 and KI-3 nourish the Liver and Kidneys. • L.I.-4 regulates the ascending and descending of Qi to and from the head. • ST-40, Ren-9 and SP-9 resolve Phlegm. • ST-8 resolves Phlegm from the head. • Ren-12 and BL-20 tonify the Spleen to resolve Phlegm.

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SUMMARY LIVER-YANG RISING WITH PHLEGM IN THE HEAD Points LIV-3 Taichong, G.B.-20 Fengchi, Du-16 Fengfu, LIV-8 Ququan, KI-3 Taixi, L.I.-4 Hegu, ST-40 Fenglong, Ren-9 Shuifen, SP-9 Yinlingquan, ST-8 Touwei, Ren-12 Zhongwan, BL-20 Pishu. Ren-12, BL-20, LIV-8 and KI-3 with reinforcing method; the others with even method. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction Three Treasures remedy Clear Yang

Retention of food

Prescription

This type of headache is experienced on the forehead and can be intense. It is obviously related to food intake and it will be aggravated by eating. It is frequently encountered as an acute headache after a dietary indiscretion. Other manifestations include a feeling of fullness of the epigastrium, sour regurgitation, belching, foul breath, a thick-sticky tongue coating and a Slippery pulse. This is not a common pattern seen in chronic headaches. It is more common in children.

BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction

Treatment principle

Explanation

Resolve retention of food, stimulate the descending of Stomach-Qi, promote digestion, harmonize the Middle.

Herbal therapy

This formula subdues Liver-Yang, extinguishes LiverWind and resolves Phlegm.

Modifications

Acupuncture

• In cases of Liver-Wind, add Di Long Pheretima, Quan Xie Scorpio or Jiang Can Bombyx batryticatus.

General prescription: Ren-10 Xiawan, ST-21 Liangmen, P-6 Neiguan, ST-34 Liangqiu, ST-45 Lidui, L.I.-4 Hegu, ST-8 Touwei. Even method on Ren-10, ST-21 and ST-8, reducing method on the others.

Three Treasures remedy

Explanation

Clear Yang Clear Yang is a variation of Ban Xia Bai Zhu Tian Ma Tang to treat headaches from a combination of Phlegm and Liver-Yang rising.

• Ren-10 stimulates the descending of Stomach-Qi and the movement of food downwards from the Stomach.

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• ST-21 resolves stagnant food and stops epigastric pain. • P-6 stimulates the descending of Stomach-Qi. • ST-34 relieves retention of food and stops pain. • ST-45 relieves retention of food. It is also chosen here as, being at the extremity of the channel, it will affect the head. • L.I.-4 is chosen to clear obstruction from the face and head. • ST-8 is chosen as a local point for Stomach-channel problems manifesting on the head.

Other points • ST-44 Neiting can be chosen as a distal point to eliminate obstructions from the Stomach, especially if the retention of food is associated with Heat. Being near the extremity of the channel, it will also affect the head. • SP-4 Gongsun relieves retention of food. • Ren-13 Shangwan is used if there are marked symptoms of ascending Stomach-Qi such as belching, sour regurgitation, nausea or vomiting. • ST-36 Zusanli is used if the retention of food is associated with a deficient condition of the Stomach. • ST-40 Fenglong is used if the retention of food is severe and long-standing and the tongue has a very thick and sticky coating.

Herbal therapy Prescription BAO HE WAN Preserving and Harmonizing Pill

Explanation This formula promotes digestion and resolves retention of food. Shan Zha resolves retention of food from meat and fatty foods. Shen Qu resolves retention of food from alcohol and fermented foods and Lai Fu Zi from cereals.

Prescription XIANG SHA ZHI ZHU WAN Aucklandia-Amomum-Citrus-Atractylodes Pill

Explanation This prescription is used in preference to the previous one if there are pronounced symptoms of rebellious Stomach-Qi such as belching, nausea, or vomiting.

Herbs • Da Huang Radix et Rhizoma Rhei is used if retention of food is accompanied by constipation. • Huo Xiang Herba Pogostemonis can be used to transform Dampness in the Middle. Being light and aromatic, it will help headaches from retention of food. • Cang Zhu Rhizoma Atractylodis is an aromatic herb to transform Dampness and it relieves headaches. • Zi Su Ye Folium Perillae harmonizes the Middle. It is a floating herb and will relieve headaches from retention of food. • Fang Feng Radix Saposhnikoviae expels Wind and Dampness. It is a floating herb and is used for headaches. • Bo He Herba Menthae haplocalycis clears the head, is light and aromatic and would therefore help to relieve this type of headache, especially if retention of food is accompanied by Heat.

SUMMARY RETENTION OF FOOD General prescription: Ren-10 Xiawan, ST-21 Liangmen, P-6 Neiguan, ST-34 Liangqiu, ST-45 Lidui, L.I.-4 Hegu, ST-8 Touwei. Even method on Ren-10, ST-21 and ST-8, reducing method on the others. Herbal therapy Prescription BAO HE WAN Preserving and Harmonizing Pill Prescription XIANG SHA ZHI ZHU WAN Aucklandia-Amomum-Citrus-Atractylodes Pill

Stasis of Blood This type of pattern is seen only in very chronic headaches. Stasis of Blood results from long-standing stagnation of Liver-Qi. Headaches may also often derive from local stasis of Blood in the head, caused by trauma. This may be due to an old fall or accident, often one that the person has forgotten about. If a headache always occurs on the same spot without fail, stasis of Blood from trauma should be suspected.

Headaches

The headache from stasis of Blood is very severe and intense. It is stabbing or boring in character and patients will often describe it as a “nail being driven into the head”. It is fixed in its location. This headache is more common in old people or in women with stasis of Blood associated with deficiency and dryness of Blood. Other manifestations include dark complexion, hypochondrial or abdominal pain and, in women, painful periods with dark-clotted blood. The pulse will be Firm, Wiry or Choppy and the tongue will be Purple. In case of a past accident to the head, the pulse may be very Weak on the Front position of both left and right sides and the tongue may have a purple spot on the tip while the rest of the tongue body is normal in colour. This is due to the fact that the tongue body reflects, apart from the internal organs, areas of the body. Thus the tip of the tongue corresponds to the head and an isolated purple spot there may indicate a past trauma to the head, while a normal colour of the rest of the tongue indicates that there is not a generalized stasis of Blood.

Treatment principle Invigorate Blood, open the orifices.

Acupuncture General prescription: L.I.-11 Quchi, L.I.-4 Hegu, SP-6 Sanyinjiao, LIV-3 Taichong, Ah Shi points. Reducing or even method on all points.

Explanation • L.I.-11, besides cooling Blood, also invigorates Blood and benefits sinews. • L.I.-4 in combination with LIV-3 expels pathogenic factors from the head and invigorates Blood. • SP-6 invigorates Blood. • LIV-3 invigorates Blood and alleviates headaches. • Ah Shi points on the head are an important and essential part of the treatment. The choice of local points is made simply according to the location of the headaches and a clear differentiation of the channel involved.

Other points • T.B.-5 Waiguan invigorates Qi and is especially indicated for headaches on the side of the head. • SP-10 Xuehai is used if there is general stasis of Blood.

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• BL-18 Ganshu is indicated if there are marked symptoms of Liver-Blood stasis. • BL-2 Zanzhu for stasis of Blood in the eye. • Taiyang for stasis of Blood in the temples. • T.B.-18 Qimai for stasis of Blood in the occiput. • Sishencong, extra point, for stasis of Blood on the vertex. It should be emphasized that stasis of Blood does not arise independently but may stem from various conditions, such as Qi stagnation, Blood deficiency, Blood-Heat, internal Cold and Qi deficiency. The treatment should obviously be aimed at treating the condition underlying the stasis of Blood.

Herbal therapy Prescription TONG QIAO HUO XUE TANG Opening the Orifices and Invigorating Blood Decoction

Explanation This formula invigorates Blood specifically in the head. This prescription is specific for headaches from stasis of Blood and is applicable for chronic headaches, especially but not exclusively in old people with a dark complexion. It is also suitable for women with Blood that is deficient, dry and stagnant and for children suffering from Child Nutritional Impairment (Gan disease).

Prescription TAO HONG SI WU TANG Persica-Carthamus Four Substances Decoction

Explanation This formula invigorates Blood in general. To treat headaches, it should be modified with the addition of herbs that reach the head.

Herbs • Chuan Xiong Rhizoma Chuanxiong invigorates Blood and, more specifically, the Qi portion of Blood, and is an important herb for headaches. • Hong Hua Flos Carthami tinctorii invigorates Blood and, being a flower and very light, it has a floating movement and affects the top part of the body. • San Qi Radix Notoginseng invigorates Blood (besides stopping bleeding) and is frequently used for

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The Practice of Chinese Medicine

chronic headaches, especially in combination with Tian Ma Rhizoma Gastrodiae. • Yan Hu Suo Rhizoma Corydalis invigorates Qi and Blood and is a major herb to stop pain.

Three Treasures remedy Red Stirring Red Stirring is a variation of Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction that invigorates Blood in the Upper Burner. It can be used to treat headaches from Blood stasis.

SUMMARY STASIS OF BLOOD General prescription: L.I.-11 Quchi, L.I.-4 Hegu, SP-6 Sanyinjiao, LIV-3 Taichong, Ah Shi points. Reducing or even method on all points. Herbal therapy Prescription TONG QIAO HUO XUE TANG Opening the Orifices and Invigorating Blood Decoction Prescription TAO HONG SI WU TANG Persica-Carthamus Four Substances Decoction Three Treasures remedy Red Stirring

Case history A 31-year-old woman had been suffering from chronic headaches since her childhood. The headaches occurred on either side of the head (along the Gall Bladder channel) and settling behind either eyeball. The pain was severe and stabbing in nature and was accompanied by vomiting and diarrhoea. Her periods were scanty. Her tongue was Pale and slightly Bluish-Purple, with darkswollen veins underneath it. Her pulse was Deep and Minute. Diagnosis This pattern presents a combination of Liver-Yang rising and stasis of Blood in the head. The headaches occurring along the Gall Bladder channel are a manifestation of Liver-Yang rising. The vomiting and diarrhoea are due to Liver-Qi stagnation invading

Stomach and Spleen, preventing the former from descending (hence vomiting) and the latter from ascending (hence diarrhoea). In this case, Liver-Yang rising derives from deficiency of Blood, as evidenced by the scanty periods, Pale tongue and Minute pulse. In addition, the long-standing headaches led to stasis of Blood in the head, hence the stabbing nature of the pain and the Bluish-Purple tongue with darkdistended veins underneath. Treatment principle In this case, it is possible to treat both the Root (deficiency of Liver-Blood) and the Manifestation (stasis of Blood in the head and rising of Liver-Yang). It is therefore necessary to nourish LiverBlood, invigorate Blood and subdue Liver-Yang. Acupuncture Points The main points used were T.B.-5 Waiguan, P-6 Neiguan, Ren-4 Guanyuan, LIV-8 Ququan, LIV-3 Taichong, SP-6 Sanyinjiao, G.B.-1 Tongziliao and SP10 Xuehai. Ren-4, LIV-8 and SP-6 were needled with reinforcing method to nourish Liver-Blood. The other points were needled with even method to invigorate Blood and subdue Liver-Yang. Explanation • Ren-4, LIV-8 and SP-6 were reinforced to nourish Liver-Blood. • T.B.-5 was chosen as a distal point to affect the Gall Bladder channel on the head and subdue LiverYang. • P-6 was chosen to invigorate Blood in the head. • G.B.-1 was chosen as a local point to invigorate Blood in the head. • LIV-3 subdues Liver-Yang. • SP-10 invigorates Blood. Herbal therapy Prescription The prescription chosen was a variation of Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction mentioned above. The only variations made to this prescription were increasing the dosage of Chuan Xiong Rhizoma Chuanxiong and the addition of Tian Ma Rhizoma Gastrodiae to subdue Liver-Yang.

Headaches

This patient was completely cured of her headaches in 1 year. Acupuncture was administered once a month, and she took the herbal decoction for 6 months, although with occasional breaks during that time.

Stomach-Heat This type of headache occurs on the forehead and can be acute or chronic. If it appears in the course of a febrile disease, it corresponds to the Bright-Yang stage within the Six-Stage patterns of diseases caused by exterior Cold. The Bright-Yang stage is characterized by Heat in the Stomach, which may cause intense headache on the forehead. Other symptoms include profuse sweating, intense thirst, fever and an OverflowingRapid pulse. In chronic cases, this type of headache is due to a long-standing condition of Stomach-Heat. The usual cause is the excessive consumption of hot-energy foods such as meat, spices, fried foods and alcohol. It is intense and is felt across the forehead. The headache may be brought about by eating foods that are too hot or simply by overeating. Other manifestations include thirst with desire to drink cold water, dry stools, possibly epigastric pain, a thick-yellow tongue coating and a Slippery and Overflowing pulse on the right Middle position. This is not a common type of headache.

Treatment principle Clear Heat, clear the Stomach, subdue rebellious Qi.

Acupuncture General prescription: ST-44 Neiting, L.I.-4 Hegu, Yintang extra point. Reducing method on ST-44 and L.I.-4 and even method on Yintang.

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• Du-23 Shangxing can be used as a local point to affect the forehead and eyes. • ST-8 Touwei can be used as a local point for headaches on the forehead.

Herbal therapy Prescription QING WEI SAN Clearing the Stomach Powder

Explanation This formula clears Stomach-Heat.

Herbs • Shi Gao Gypsum fibrosum clears Stomach-Heat at the Qi level. • Zhi Mu Radix Anemarrhenae clears Stomach-Heat and nourishes Yin. • Zhu Ye Folium Phyllostachys nigrae clears StomachHeat, especially when manifesting in the face region. • Lu Gen Rhizoma Phragmitis clears Stomach-Heat and promotes fluids. It is especially indicated if thirst is pronounced. It is light and floating and will therefore affect the head.

SUMMARY STOMACH-HEAT General prescription: ST-44 Neiting, L.I.-4 Hegu, Yintang extra point. Reducing method on ST-44 and L.I.-4 and even method on Yintang. Herbal therapy Prescription QING WEI SAN Clearing the Stomach Powder

Explanation • ST-44 is the main point to clear Stomach-Heat. Also, being towards the lower extremity of the channel, it will affect the other end, i.e. the head. • L.I.-4 clears Heat and affects the head and forehead. • Yintang is used as a local point for headaches on the forehead.

Other points • ST-34 Liangqiu is the Accumulation (Xi) point of the Stomach channel and, as such, it stops pain.

Qi deficiency This headache is due to deficient Qi failing to ascend to the head to brighten the orifices. It can be due to deficiency of Qi of the Stomach, Spleen, Lungs or Heart. It may manifest in the whole head or frequently on the forehead only, especially when it is due to Stomach-Qi deficiency. This headache comes in bouts. Dull in nature, it is alleviated by rest and aggravated by excessive work.

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The Practice of Chinese Medicine

It is also eased by lying down and is worse in the mornings. Other manifestations include poor appetite, tiredness, loose stools, slight breathlessness and an Empty pulse. In case of Heart-Qi deficiency, there would also be some slight palpitations and breathlessness on exertion. The Simple Questions in Chapter 18 says that in headaches from deficiency of Qi of the Heart or Lungs, the Front position pulse (of both right and left) can feel Short, i.e. not quite reaching the top of the pulse position.12 This is not a common type of chronic headache; usually the one from Blood or Yin deficiency is more common.

Treatment principle Tonify and raise Qi.

Acupuncture General prescription: ST-36 Zusanli, Ren-6 Qihai, SP-6 Sanyinjiao, Du-20 Baihui. All with reinforcing method. Du-20 with direct moxibustion.

Explanation • ST-36 and SP-6 in combination strongly tonify Qi. • Ren-6 tonifies and raises Qi. • Du-20 raises Yang.

Other points • L.I.-4 Hegu, when reinforced in combination with ST-36, can tonify and raise Qi. For this reason, it would be particularly indicated if the headache is on the forehead, because this is the area affected by this point. • BL-7 Tongtian can be used as a local point to raise Qi, especially if there is some deficiency of the Kidneys. • BL-20 Pishu can be used to tonify and raise Qi, because this is a function of Spleen-Qi.

Three Treasures remedy Tonify Qi and Ease the Muscles Tonify Qi and Ease the Muscles tonifies and lifts Qi and it promotes the ascending of clear Yang to the Head. It is therefore suitable to treat headaches from Qi deficiency. It is a variation of Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction.

SUMMARY QI DEFICIENCY General prescription: ST-36 Zusanli, Ren-6 Qihai, SP-6 Sanyinjiao, Du-20 Baihui. All with reinforcing method. Du-20 with direct moxibustion. Herbal therapy Prescription BU ZHONG YI QI TANG Tonifying the Centre and Benefiting Qi Decoction

Blood deficiency This headache is due to deficient Blood failing to reach the head and nourish the brain. It is slightly more severe in nature than the Qi-deficiency headache. It typically affects the top of the head, but it may also affect the forehead and is related to Blood deficiency of the Liver or Heart. It is often worse in the afternoon or evening and is accompanied by poor memory and lack of concentration. In women, it often occurs at the end of the period, as the temporary blood loss aggravates the Blood deficiency. This headache is also better lying down. This type of headache is more common in women.

Treatment principle Nourish Blood, tonify and raise Qi.

Herbal therapy

Acupuncture

Prescription BU ZHONG YI QI TANG Tonifying the Centre and Benefiting Qi Decoction

General prescription: ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, LIV-8 Ququan, Ren-4 Guanyuan, Du-20 Baihui, HE-5 Tongli. Tonifying method on all points.

Explanation

Explanation

This formula tonifies and lifts Qi; as it lifts Qi, it promotes the ascending of clear Yang to the head to brighten the orifices.

• ST-36, SP-6 and BL-20 nourish Blood and tonify Qi. • LIV-8 nourishes Liver-Blood. • Ren-4 nourishes Blood.

Headaches

• Du-20 raises Qi. • HE-5 nourishes Heart-Blood. It is necessary to tonify Heart-Blood, as deficient Heart-Blood not reaching the head is often a feature of this type of headache.

Other points • BL-20 Pishu and BL-18 Ganshu in combination nourish Liver-Blood. • Yuyao is indicated as a local point if the headaches occur behind the eyes.

Herbal therapy Prescription BA ZHEN TANG Eight Precious Decoction

Explanation This formula tonifies Qi and nourishes Blood.

Prescription

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Women’s Treasure remedy Precious Sea Precious Sea tonifies Qi and nourishes Blood; it is a variation of Ba Zhen Tang Eight Precious Decoction.

SUMMARY BLOOD DEFICIENCY General prescription: ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, LIV-8 Ququan, Ren-4 Guanyuan, Du-20 Baihui, HE-5 Tongli. Tonifying method on all points. Herbal therapy Prescription BA ZHEN TANG Eight Precious Decoction Prescription SHI QUAN DA BU TANG Ten Complete Great Tonification Decoction Three Treasures remedy Precious Sea

SHI QUAN DA BU TANG Ten Complete Great Tonification Decoction

Explanation

Kidney deficiency

This formula tonifies Qi and nourishes Blood. It also lifts Qi and therefore promotes the ascending of clear Yang to the head to brighten the orifices and relieve headaches.

This headache is due to deficient Kidney-Essence failing to reach the head and nourish the brain. It may manifest with deficiency of Kidney-Yin or KidneyYang, as the Essence has both a Yin and a Yang aspect. The headache is experienced inside the brain. It does not occur in any specific place and is accompanied by dizziness and a feeling of emptiness of the brain. When the Kidney deficiency affects the Bladder channel, the headache may also occur on the occiput. The headache from Kidney-Yang deficiency is somewhat milder and more similar to that from Qi deficiency, while that from Kidney-Yin deficiency is more severe and feels deeper in the head. In both cases, the headache may occur after sexual activity. Other manifestations depend on whether there is a deficiency of Kidney-Yin or Kidney-Yang. In case of Kidney-Yin deficiency, there will be night sweating, scanty urination, dizziness, tinnitus, soreness of the lower back, slight constipation, a tongue without coating and a Floating-Empty pulse. In case of Kidney-Yang deficiency, there will be a feeling of cold, soreness of the lower back and knees,

Herbs • Sang Ji Sheng Herba Taxilli nourishes Liver-Blood. • Shou Wu Radix Polygoni multiflori preparata nourishes Blood and is particularly indicated in chronic cases of Blood deficiency with manifestations of dryness (e.g. dry skin, dry hair and dry eyes). • Gou Qi Zi Fructus Lycii chinensis nourishes Blood and benefits the eyes. It is therefore particularly indicated if the headaches occur behind the eyes. • Long Yan Rou Arillus Longan nourishes Blood and promotes sleep. It is therefore indicated if the Blood deficiency causes insomnia. • Chuan Xiong Rhizoma Chuanxiong is already included in the above two prescriptions, but its dosage could be increased because it is an important and specific herb for headaches.

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abundant-pale urination, a Pale tongue and a Deep and Weak pulse.

Kidney-Yang Deficiency

Treatment principle Tonify the Kidneys, nourish Marrow.

YOU GUI WAN Restoring the Right [Kidney] Pill

Acupuncture

Explanation

General prescription: KI-3 Taixi, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui, G.B.-19 Naokong. For Kidney-Yin deficiency: Ren-4 Guanyuan. For Kidney-Yang deficiency: BL-23 Shenshu. All points should be reinforced. Moxa can be used on KI-3 unless there are pronounced symptoms of Empty Heat. In case of Kidney-Yang deficiency, moxa must be used on BL-23. Direct moxa can also be used on Du-20.

This formula tonifies and warms Kidney-Yang.

Explanation • KI-3 tonifies both Kidney-Yin and Kidney-Yang and the Original Qi. • ST-36 and SP-6 tonify Qi and Blood, which will help to tonify Yin. SP-6 also tonifies Yin. • Du-20 attracts Qi up towards the head and nourishes Marrow. • G.B.-19 attracts Kidney-Essence up to the brain, fills Marrow, and is a specific local point for headache from Kidney deficiency. Its name means “brain emptiness”. • Ren-4 nourishes Kidney-Yin. • BL-23 tonifies Kidney-Yang.

Other points • BL-60 Kunlun can be used as a distal point to affect the Bladder channel, especially if the headaches are along this channel on the occiput. • BL-10 Tianzhu can be used as an adjacent point if the headaches occur on the Bladder channel on the occiput. • BL-7 Tongtian can be used as a local point. • Du-17 Naohu can be used as an adjacent point to nourish Marrow.

Ancient formula Du-23 Shangxing, G.B.-20 Fengchi, G.B.-19 Naokong, BL-10 Tianzhu, HE-3 Shaohai (Great Compendium of Acupuncture).13

Prescription

Prescription JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill

Explanation This prescription consists of the Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill, which nourishes KidneyYin, with the addition of Fu Zi and Gui Zhi, which strongly tonify and warm Kidney-Yang and tonify the Fire of the Gate of Life.

Three Treasures remedy Strengthen the Root Strengthen the Root tonifies Kidney-Yang. It is a variation of You Gui Wan and it is less warming than the original prescription.

Kidney-Yin Deficiency Prescription ZUO GUI WAN Restoring the Left [Kidney] Pill

Explanation This formula nourishes Kidney-Yin.

Prescription LIU WEI DI HUANG WAN Six-Ingredient Rehmannia Pill

Explanation This formula nourishes Kidney-Yin.

Prescription QI JU DI HUANG WAN Lycium-Chrysanthemum-Rehmannia Pill

Herbal therapy The difference in treatment between Kidney-Yin and Kidney-Yang deficiency is more marked in herbal medicine than it is in acupuncture.

Explanation This formula is a variation of Liu Wei Di Huang Wan specifically to treat headaches.

Headaches

Herbs • Hei Zhi Ma Semen Sesami negrum nourishes Liverand Kidney-Yin and it extinguishes Wind. It is specific for headaches from Liver- and Kidney-Yin deficiency. • Du Huo Radix Angelicae pubescentis expels WindDampness and enters the Bladder channel of the back. It is indicated for headaches from deficiency of Kidney-Yang. • Qiang Huo Rhizoma seu Radix Notopterygii expels Wind-Dampness and enters the Bladder channel of the shoulders and neck. It is indicated for headaches from deficiency of Kidney-Yang. • Du Zhong Radix Eucommiae ulmoidis tonifies the Kidneys and expels Wind-Dampness from the Bladder channel. It is indicated for headaches from deficiency of Kidney-Yang. • Yu Zhu Rhizoma Polygonati odorati nourishes Stomach-Yin. In addition, it extinguishes Wind and softens and relaxes the sinews. It would therefore help headaches from deficiency of Kidney-Yin. • Sang Ji Sheng Herba Taxilli nourishes Liver and Kidneys and expels Wind-Dampness. It is indicated for headaches from Kidney and Liver Yin deficiency.

Three Treasures remedy Nourish the Root Nourish the Root nourishes KidneyYin. It is a variation of Zuo Gui Wan.

SUMMARY KIDNEY DEFICIENCY General prescription: KI-3 Taixi, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui, G.B.-19 Naokong. For Kidney-Yin deficiency: Ren-4 Guanyuan. For Kidney-Yang deficiency: BL-23 Shenshu. All points should be reinforced. Moxa can be used on KI-3, unless there are pronounced symptoms of Empty Heat. In case of Kidney-Yang deficiency, moxa must be used on BL-23. Direct moxa can also be used on Du-20. Herbal therapy The difference in treatment between Kidney-Yin and Kidney-Yang deficiency is more marked in herbal medicine than it is in acupuncture.

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KIDNEY-YANG DEFICIENCY Prescription YOU GUI WAN Restoring the Right [Kidney] Pill Prescription JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill Three Treasures remedy Strengthen the Root KIDNEY-YIN DEFICIENCY Prescription ZUO GUI WAN Restoring the Left [Kidney] Pill Prescription LIU WEI DI HUANG WAN Six-Ingredient Rehmannia Pill Prescription QI JU DI HUANG WAN Lycium-Chrysanthemum-Rehmannia Pill Three Treasures remedy Nourish the Root

Case history A woman of 45 complained of persistent headaches on the back of the neck and head, extending over the top of the head to the eyes. She also suffered from lower backache. She had been experiencing these symptoms for 2 years since she had had a kidney infection. She had been diagnosed as having pyelonephritis and was put on antibiotics. She also had a tendency to constipation, and the urine was scanty and dark at times. She sweated at night on most nights. Her tongue was slightly Red with a yellow coating that was thick on the root and rather rootless in the centre. Her pulse was Fine and very slightly Wiry in both Rear positions. Diagnosis The headaches were of a Deficiency nature and were caused by Kidney-Yin deficiency. They clearly occurred along the Bladder channel. Her main condition was one of Kidney-Yin deficiency (lower backache, night sweating, dark-scanty urine, constipation, Fine pulse and Red tongue) with Damp Heat in the Bladder (thick-yellow coating on the

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root of the tongue, slightly Wiry pulse on both Rear positions). In addition, there was also some StomachYin deficiency (slightly rootless tongue coating). Treatment principle First resolve Damp Heat from the Bladder, then nourish Kidney-Yin. Acupuncture Points The main points used initially were LU-7 Lieque and KI-6 Zhaohai (Directing Vessel), SP-6 Sanyinjiao and SP-9 Yinlingquan. Later on (after a few weeks), other points were added such as Ren-12 Zhongwan, ST-36 Zusanli, BL-10 Tianzhu, BL-60 Kunlun and KI-3 Taixi. Explanation • LU-7 Lieque and KI-6 Zhaohai open the Directing Vessel and nourish Kidney-Yin. • SP-6 Sanyinjiao and SP-9 Yinlingquan resolve Damp Heat in the Lower Burner. • Ren-12 Zhongwan and ST-36 Zusanli were used to nourish Stomach-Yin. • BL-10 Tianzhu was used as a local point to relieve the headaches along the Bladder channel. • BL-60 Kunlun was used as a distal point to open the Bladder channel and relieve the headaches. • KI-3 Taixi was used to nourish Kidney-Yin. Herbal therapy Prescription Two prescriptions were used. Applying the principle of treating the Manifestation before the Root in this case, a variation of Ba Zheng San Eight Upright Powder was used first for a few weeks to resolve Damp Heat in the Bladder. This was followed by a variation of the Zhi Bo Ba Wei Wan AnemarrhenaPhellodendron Eight-Ingredient Pill to nourish KidneyYin and resolve Damp Heat simultaneously. The variation of the Eight Upright Powder used was: • • • • • • •

Che Qian Zi Semen Plantaginis 6 g Shan Zhi Zi Fructus Gardeniae 4 g Da Huang Radix et Rhizoma Rhei 3 g Bian Xu Herba Polygoni avicularis 4 g Fu Ling Poria 6 g Zhu Ling Polyporus 6 g Gui Zhi Ramulus Cinnamomi cassiae 2 g

• Yi Yi Ren Semen Coicis 6 g • Bai Zhu Radix Atractylodis macrocephalae 4 g The variation of the Anemarrhena-Phellodendron Eight-Ingredient Pill was: • • • • • • • • • • •

Zhi Mu Radix Anemarrhenae 3 g Huang Bo Cortex Phellodendri 6 g Shu Di Huang Radix Rehmanniae preparata 9 g Ze Xie Rhizoma Alismatis 3 g Shan Yao Rhizoma Dioscoreae 6 g Fu Ling Poria 6 g Shan Zhu Yu Fructus Corni 4 g Mu Dan Pi Cortex Moutan 3 g Bai Zhu Radix Atractylodis macrocephalae 6 g Dang Shen Radix Codonopsis 6 g Sang Ji Sheng Herba Taxilli 6 g

Explanation The first prescription was used to resolve Damp Heat from the Lower Burner. Qu Mai Herba Dianthi, Hua Shi Talcum, Deng Xin Cao Medulla Junci and Gan Cao Radix Glycyrrhizae uralensis were omitted, as there was no burning on urination. Fu Ling Poria, Zhu Ling Polyporus and Yi Yi Ren Semen Coicis were added to help to eliminate Dampness. Bai Zhu Rhizoma Atractylodis macrocephalae was added to tonify the Spleen and help drain Dampness. The second prescription was used to nourish KidneyYin and simultaneously eliminate Damp Heat from the Lower Burner. To this was added Bai Zhu Rhizoma Atractylodis macrocephalae and Dang Shen Radix Codonopsis to tonify the Spleen, and Sang Ji Sheng Herba Taxilli to nourish Liver and Kidney and expel Wind-Dampness. This last herb would help to stop the back pains. This patient achieved a complete improvement of her condition after 6 months of treatment.

MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 23, No. 4, 1993, p. 214. Wang Da Quan, “Experience in the treatment of headaches.” In this article, Dr Wang reports his clinical experience with case histories on the treatment of headaches from

Headaches

five patterns, i.e. Dampness, Knotted Heat in the Liver and Gall Bladder, Qi and Blood stagnation, Kidney deficiency and Blood deficiency with Heat.

Dampness A 73-year-old man had been suffering from headaches accompanied by a feeling of fullness and heaviness; he felt as if “the cavities of his brain were obstructed”. His pulse was Deep, Short and Wiry; his tongue was Pale with a thick-sticky coating. Dr Wang diagnosed obstruction of the head by Dampness and adopted the treatment principle tonifying the Heart and Spleen, resolving Dampness and eliminating obstructions from the Connecting (Luo) channels. The formula used was as follows: • • • • • • • • • • • • • •

Tai Zi Shen Radix Pseudostellariae 25 g Mai Men Dong Radix Ophiopogonis 15 g Wu Wei Zi Fructus Schisandrae 10 g Dan Shen Radix Salviae milthiorrizae 15 g Tan Xiang Lignum Santali albi 10 g Sha Ren Fructus Amomi 10 g Bing Lang Semen Arecae catechu 10 g Cao Guo Fructus Tsaoko 10 g Hou Po Cortex Magnoliae officinalis 10 g Bai Shao Radix Paeoniae alba 25 g Zhi Mu Radix Anemarrhenae 10 g Tian Ma Rhizoma Gastrodiae 10 g Shi Chang Pu Rhizoma Acori tatarinowii 10 g Dan Nan Xing Rhizoma Arisaematis preparatum 10 g • Chi Shao Radix Paeoniae rubra 10 g • Chuan Xiong Rhizoma Chuanxiong 10 g • Bai Ji Li Fructus Tribuli 10 g

Liver and Gall Bladder Knotted Heat A 49-year-old woman had been suffering from throbbing, bilateral headaches. She also suffered from insomnia, dizziness, bitter taste, and propensity to outbursts of anger. Her pulse was Wiry and Rapid and her tongue was Red and without coating. Dr Wang diagnosed Blood deficiency with Heat in the Liver and Gall Bladder. He therefore adopted the treatment principle of nourishing Blood and clearing Heat in the Liver and Gall Bladder. The formula used was as follows: • Dan Shen Radix Salviae milthiorrizae 30 g • Bai Shao Radix Paeoniae alba 15 g

• • • • • • • • • • • • •

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Sheng Di Huang Radix Rehmanniae 15 g Han Lian Cao Herba Ecliptae 15 g Xia Ku Cao Spica Prunellae 25 g Ju Hua Flos Chrysanthemi 15 g Chuan Niu Xi Radix Cyathulae 15 g Gou Teng Ramulus cum Uncis Uncariae 15 g Shan Yao Rhizoma Dioscoreae 20 g Long Gu Mastodi Ossis fossilia 15 g Mu Li Concha Ostreae 15 g Bai Zi Ren Semen Biotae 12 g Ye Jiao Teng Caulis Polygoni multiflori 21 g Tian Ma Rhizoma Gastrodiae 10 g Bai Ji Li Fructus Tribuli 15 g

Qi and Blood stagnation A 36-year-old woman had been suffering from stabbing headaches on the temples. She also suffered from dizziness and her menstrual blood was dark with clots. Her pulse was Wiry but Empty and her tongue was Red. Dr Wang diagnosed Qi deficiency and Blood stasis and adopted the treatment principle of tonifying Qi and invigorating Blood. The formula used was as follows: • • • • • • • • • • • • • • • • •

Tai Zi Shen Radix Pseudostellariae 25 g Mai Men Dong Radix Ophiopogonis 15 g Wu Wei Zi Fructus Schisandrae 10 g Dang Gui Radix Angelicae sinensis 10 g Sheng Di Huang Radix Rehmanniae 15 g Tao Ren Semen Persicae 10 g Hong Hua Flos Carthami tinctorii 10 g Chi Shao Radix Paeoniae rubra 15 g Chuan Niu Xi Radix Cyathulae 15 g Chai Hu Radix Bupleuri 10 g Chuan Xiong Rhizoma Chuanxiong 10 g Jie Geng Radix Platycodi 10 g Zhi Ke Fructus Aurantii 10 g Mu Dan Pi Cortex Moutan 10 g Bai He Bulbus Lilii 10 g Ye Jiao Teng Caulis Polygoni multiflori 25 g Gan Cao Radix Glycyrrhizae uralensis 10 g

Kidney deficiency A 9-year-old boy had been suffering from dull headaches that were aggravated at night. He also complained of restlessness and a diminished capacity for study. His pulse was Short and Choppy and his tongue was dark with a thin coating.

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Dr Wang diagnosed a congenital deficiency of the Kidneys with an invasion of Wind in the Greater Yang channels. He adopted the treatment principle of tonifying the Kidneys, removing obstructions from the Governing Vessel, expelling Wind and invigorating the Connecting (Luo) channels. The formula used was as follows: • • • • • • • • • • • • • • •

Rou Gui Cortex Cinnamomi 2 g Fu Zi Radix Aconiti lateralis preparata 6 g Shou Wu Radix Polygoni multiflori preparata 25 g Shan Zhu Yu Fructus Corni 10 g Shan Yao Rhizoma Dioscoreae 25 g Fu Ling Poria 15 g Mu Dan Pi Cortex Moutan 10 g Ze Xie Rhizoma Alismatis 10 g Tian Hua Fen Radix Trichosanthis 15 g Gui Zhi Ramulus Cinnamomi cassiae 8 g Gen Gen Radix Puerariae 15 g Chen Pi Pericarpium Citri reticulatae 10 g Fang Feng Radix Saposhnikoviae 10 g Qiang Huo Rhizoma seu Radix Notopterygii 10 g Bai Zhi Radix Angelicae dahuricae 10 g

Blood deficiency with Knotted Heat A 52-year-old woman had been suffering from headaches with a feeling of heaviness and distension and dizziness. Her pulse was Wiry and Fine and her tongue was dark-Red and dry. Dr Wang diagnosed Blood deficiency of the Heart and Liver with Heat flaring upwards and clouding the head’s orifices. The formula used was a variation of Si Wu Tang Four Substances Decoction. • • • • • • • • • • • • • • • • •

Dang Gui Radix Angelicae sinensis 10 g Chuan Xiong Rhizoma Chuanxiong 12 g Bai Shao Radix Paeoniae alba 25 g Sheng Di Huang Radix Rehmanniae 15 g Tai Zi Shen Radix Pseudostellariae 15 g Wu Wei Zi Fructus Schisandrae 10 g Mai Men Dong Radix Ophiopogonis 15 g Shou Wu Radix Polygoni multiflori preparata 10 g Chai Hu Radix Bupleuri 10 g Huang Qin Radix Scutellariae 10 g Mu Dan Pi Cortex Moutan 15 g Shan Yao Rhizoma Dioscoreae 15 g Shan Zhu Yu Fructus Corni 15 g Long Gu Mastodi Ossis fossilia 15 g Mu Li Concha Ostreae 15 g Chuan Niu Xi Radix Cyathulae 15 g Gan Cao Radix Glycyrrhizae uralensis 10 g

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 37, No. 1, 1996, p. 57. Zhao Fu Guo, “The use of Chuan Xiong in the treatment of headaches.” Dr Zhao presents an interesting overview of the use of Chuan Xiong Rhizoma Chuanxiong in the treatment of headaches according to his clinical experience. Dr Zhao says that Chuan Xiong is pungent, warm and scattering, and it reaches the top part of the body. It moves Qi and invigorates Blood, it fragrantly opens the orifices, it expels Wind, it stops pain, and it reaches the head and face. Suitably combined with other herbs, it is the herb of choice to treat headaches. Combined with Jing Jie Herba Schizonepetae, Fang Feng Radix Saposhnikoviae, Qiang Huo Rhizoma seu Radix Notopterygii, Bai Zhi Radix Angelicae dahuricae, Xi Xin Herba Asari and Bo He Herba Menthae haplocalycis, it treats headaches from Wind-Cold. Combined with Ju Hua Flos Chrysanthemi, Shi Gao Gypsum fibrosum and Jiang Can Bombyx batryticatus, Chuan Xiong treats headaches from Wind-Heat. Combined with Tao Ren Semen Persicae, Hong Hua Flos Carthami tinctorii and Chi Shao Radix Paeoniae rubra, it treats headaches from Blood stasis. Dr Zhao reports that Zhu Dan Xi (1282–1358) says “In headaches must use Chuan Xiong” (this saying rhymes in Chinese as “Tou tong bi yong Chuan Xiong”). Dr Zhao adjusts the dosage of Chuan Xiong according to the condition treated. When used to expel Wind from the Great Yang channels, the dosage used is small, i.e. from 6 to 10 g per day. If using it for headaches from Blood stasis, Dr Zhao uses from 30 to 40 g per day. Interestingly, Dr Zhao advises against using Chuan Xiong in headaches from Liver-Yang rising, internal Wind and Phlegm-Heat. Also, as a general rule, Dr Zhao prefers using Chuan Xiong in Cold patterns and not in Heat patterns.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 35, No. 4, 1994, p. 222. Han Jin Cheng, “Clinical experience in the treatment of stubborn headaches with Chuan Xiong and Dan Shen.” The article describes how 68 patients suffering from chronic, stubborn headaches were treated with herbal medicine. There were 42 men and 26 women. The oldest patient was 72 and the youngest 30. The duration of the headaches ranged from 2 months to 34 years.

Headaches

The patients were treated with a decoction containing Chuan Xiong Rhizoma Chuanxiong and Dan Shen Radix Salviae miltiorrhizae in high doses (30–50 g and 40–60 g, respectively). The decoction was administered daily for 14 days. The decoction was modified according to pattern and channels involved. If there was Blood stasis, Tao Ren Semen Persicae, Hong Hua Flos Carthami tinctorii and Chi Shao Radix Paeoniae rubra were added. For headaches from Liver-Yang rising, Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus cum Uncis Uncariae and Shi Jue Ming Concha Haliotidis were added. For headaches from Kidney deficiency, Shan Zhu Yu Fructus Corni, Gou Qi Zi Fructus Lycii chinensis and Gui Ban Plastrium Testudinis were added. For headaches from Blood deficiency, Dang Gui Radix Angelicae sinensis, Bai Shao Radix Paeoniae alba and Huang Qi Radix Astragali were added. For headaches from Phlegm, Hou Po Cortex Magnoliae officinalis, Cang Zhu Rhizoma Atractylodis and Fu Ling Poria were added. Other modifications were carried out according to channel involved as follows: • Front of head, Bright Yang channels: Bai Zhi Radix Angelicae dahuricae • Sides of head, Lesser Yang channels: Chai Hu Radix Bupleuri • Vertex, Terminal Yin channels: Wu Zhu Yu Fructus Evodiae • Back of head, Greater Yang channels: Qiang Huo Rhizoma seu Radix Notopterygii • Greater Yin channels: Cang Zhu Rhizoma Atractylodis • Lesser Yin channels: Xi Xin Herba Asari. The results were as follows: • Headache attacks reduced in frequency and were much less intense: 35 (51.4%) • Headaches reduced in frequency and intensity: 28 (41.1%) • No improvement: 5 (7.5%)

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the treatment of headaches from physical trauma. The rationale of this use is based on the fact that physical trauma to the head causes local Blood stasis and this decoction treats Blood stasis in the Upper Burner.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 32, No. 1, 1991, p. 13. Wang Shao Hua, “The treatment of infrequently seen liver diseases.” Dr Wang reports case histories of infrequently seen Liver-related problems. One of these was the occurrence of headaches after sexual activity in a 45-yearold man following hepatitis. Apart from complaining of headaches following sexual activity, this man also suffered from dizziness, dry eyes, dry mouth and throat, bitter taste, insomnia, hot palms. His tongue was Red and his pulse Fine and Rapid. Dr Wang diagnosed Liver-Yang rising and followed the treatment principle of subduing Yang and nourishing Yin. He used a variation of Yi Yin Jian One Yin Decoction plus Zuo Gui Yin Restoring the Left [Kidney] Decoction as follows: • • • • • • • • • • •

Sheng Di Huang Radix Rehmanniae 15 g Shu Di Huang Radix Rehmanniae preparata 15 g Shi Jue Ming Concha Haliotidis 15 g Bai Shao Radix Paeoniae alba 12 g Gou Qi Zi Fructus Lycii chinensis 12 g Shan Zhu Yu Fructus Corni 10 g Tu Si Zi Semen Cuscutae 10 g Xia Ku Cao Spica Prunellae 10 g Gou Teng Ramulus cum Uncis Uncariae 10 g Di Gu Pi Cortex Lycii 10 g Gan Cao Radix Glycyrrhizae uralensis 3 g

CLINICAL TRIALS Acupuncture

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 27, No. 7, 1986, p. 41.

Comparison of pharmacological treatment versus acupuncture treatment for migraine without aura

Wang Yi Quan, “The treatment of headaches from trauma with Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction.”

Journal of Traditional Chinese Medicine 2000 September, Vol. 20, No. 3, pp. 231–240. Liguori A, Petti F, Bangrazi A, Camaioni D, Guccione G, Pitari GM, Bianchi A, Nicoletti WE Istituto Paracelso, Italian Center for Non Conventional Medicines, Rome, Italy

In this article, Dr Wang reports the use of Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction in

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Objective To determine the effects of acupuncture treatment for migraine versus conventional drug therapy.

Method One hundred and twenty patients affected by migraine without aura were randomly divided into acupuncture group (AG) and conventional drug therapy group (CDTG) and treated at four public health centres. For the AG group, acupuncture was applied to the following points: ST-8 Touwei, G.B.-5 Xuanlu, G.B-20 Fengchi, Du-14 Dazhui and LU-7 Lieque (all treated with the reducing method). Clinical results were evaluated 6 and 12 months after the beginning of treatment.

Results In AG, the occurrence of migraine attacks dropped from 9823 (in the 12-month period prior to treatment) to 1990 after 6 months and 1590 after 1 year. The total absence from work amounted to 1120 working days per year, with a total cost (private and social costs) of 96,410 euros. In CDTG, the occurrence of migraine attacks dropped from 8405 before treatment to 3927 after 6 months and 3084 after 1 year. The total absence from work amounted to 1404 working days per year, with a total cost of 137,694 euros.

Conclusion Acupuncture proved more effective than conventional drug therapy in the treatment of migraine without aura.

Acupuncture versus placebo versus sumatriptan for early treatment of migraine attacks: a randomized controlled trial Journal of International Medicine 2003 February, Vol. 253, No. 2, pp. 181–188. Melchart D, Thormaehlen J, Hager S, Liao J, Linde K, Weidenhammer W.

(one specialized in traditional Chinese medicine and one in the treatment of headache). A total of 179 migraine sufferers participated experiencing the first symptoms of a developing migraine attack. The interventions were traditional Chinese acupuncture, sumatriptan (6 mg subcutaneously) or placebo injection. The main outcome measure was the number of patients in whom a full migraine attack (defined as severe migraine headache) within 48 h was prevented. In patients who developed a migraine attack despite early treatment, acupuncture and sumatriptan were applied a second time, while patients initially randomized to placebo received sumatriptan.

Results A full migraine attack was prevented in 21 of 60 (35%) patients receiving acupuncture, 21 of 58 (36%) patients receiving sumatriptan and 11 of 61 (18%) patients receiving placebo. Response to the second intervention in patients who developed a full attack was better with sumatriptan (17/31 patients who received sumatriptan twice and 37/46 patients who had had placebo first) than with acupuncture (4/31). The number of patients reporting side effects was 14 in the acupuncture group, 23 in the sumatriptan group and 10 in the placebo group.

Conclusion In this trial, acupuncture and sumatriptan were more effective than a placebo injection in the early treatment of an acute migraine attack. When an attack could not be prevented, sumatriptan was more effective than acupuncture at relieving headache.

Acupuncture versus metoprolol in migraine prophylaxis: a randomized trial of trigger point inactivation Journal of Internal Medicine 1994 May, Vol. 235, Issue 5, pp. 451–456. Hesse J, Møgelvang B, Simonsen H

Objective

Objective

To investigate whether acupuncture is superior to placebo and equivalent to sumatriptan for the early treatment of an acute migraine attack.

To compare the effects of dry needling of myofascial trigger points in the neck region compared with metoprolol in migraine prophylaxis.

Method

Method

A randomized, partly double-blind (sumatriptan versus placebo) trial took place in two hospitals in Germany

This was a randomized, group comparative study. Patients, investigator and statistician were blinded as

Headaches

to treatment, and the therapist was blinded as to results. It took place at an outpatient pain clinic in the northern Copenhagen area. Patients were referred by general practitioners or responded to newspaper advertisements. Included were patients with a history of migraine with or without aura for at least 2 years. Excluded were persons with contraindications against treatment with beta blockers, chronic pain syndromes, pregnancy or previous experience with acupuncture or beta-blocking agents. A total of 85 patients were included; 77 completed the study. After a 4-week run-in period, patients were allocated to a 17-week regimen either with acupuncture and placebo tablets or with placebo stimulation and metoprolol 100 mg daily.

Results Both groups exhibited significant reduction in attack frequency. No difference was found between the groups regarding frequency or duration of attacks, but there was a significant difference in global rating of attacks in favour of metoprolol.

Conclusion Trigger point inactivation by dry needling is a valuable supplement to the list of migraine prophylactic tools, being equipotent to metoprolol in the influence on frequency and duration (but not severity) of attacks, and superior in terms of negative side effects.

Changes of cerebrovascular response to visual stimulation in migraine sufferers after repetitive sessions of somatosensory stimulation (acupuncture): a pilot study Headache 2004 January, Vol. 44, Issue 1, pp. 95–101. Backer M, Hammes M, Sander D, Funke D, Deppe M, Tolle TR, Dobos GJ Department of Internal Medicine V, Kliniken Essen Mitte, Germany

Objective To evaluate the effect of repetitive somatosensory stimulation (acupuncture) on cerebrovascular response in migraine sufferers by functional transcranial Doppler.

Method Ten migraine sufferers and 10 control subjects participated. Changes of cerebral blood flow velocity in the right posterior and left middle cerebral arteries were

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measured by functional transcranial Doppler during visual stimulation (flickering light over 57 seconds) in 10 sufferers before and after 10 acupuncture sessions. The same stimulation paradigm was performed in 10 control subjects. Cerebral blood flow velocity data were analysed with a previously validated technique based on automated stimulus-related averaging. To evaluate the clinical effect of the treatment, a headache diary monitored the frequency and intensity of the migraine attacks. A positive treatment effect was defined as a reduction of at least 50% in the attack frequency or the mean headache intensity (or both).

Results Before treatment, migraine sufferers showed overshooting cerebral blood flow velocity changes at the beginning and at the end of the stimulation and a delayed decline to baseline compared with control subjects. After treatment, this response pattern was significantly diminished in those who benefited from treatment (six). Those who did not benefit from treatment (four) showed a significantly more marked alteration of the cerebral blood flow velocity pattern.

Conclusion Data indicate that repetitive somatosensory stimulation (acupuncture) might positively influence the abnormal cerebrovascular response in sufferers. In a subgroup of migraine sufferers, however, the dysfunction of the cerebrovascular system might deteriorate under the treatment.

Acupuncture of chronic headache disorders in primary care: randomised controlled trial and economic analysis Health Technology Assessment 2004 November, Vol. 8, Issue 48, pp. 1–35. Vickers AJ, Rees RW, Zollman CE, McCarney R, Smith CM, Ellis N, Fisher P, Van Haselen R, Wonderling D, Grieve R Integrative Medicine Service, Biostatistics Service, Memorial Sloan-Kettering Cancer Center, New York, USA

Objective To determine the effects of a policy of using acupuncture, compared with a policy of avoiding acupuncture, on headache in primary care patients with chronic headache disorders. The effects of acupuncture on

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medication use, quality of life, resource use and days off sick in this population, and the cost-effectiveness of acupuncture were also examined.

Method This was a randomized, controlled trial involving 401 patients with chronic headache, predominantly migraine, at general practices in England and Wales. Patients were randomly allocated to receive up to 12 acupuncture treatments over 3 months or to a control intervention offering usual care. Headache score, 36-Item Short-Form Health Survey (SF-36) health status, and use of medication were assessed at baseline (start of the trial), 3, and 12 months. Use of resources was assessed every 3 months.

Results Headache score at 12 months, the primary end point, was lower in the acupuncture group: 34% reduction from baseline compared with that of the controls, who had a 16% reduction from baseline. Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year. SF-36 data favoured acupuncture, although differences reached significance only for physical role functioning, energy, and change in health. Compared with controls, acupuncture patients used 15% less medication, made 25% fewer visits to general practitioners and took 15% fewer days off sick.

Conclusion Acupuncture leads to persisting, clinically relevant benefits for primary care patients with chronic headache, particularly migraine. It is relatively cost-effective compared with a number of other interventions provided by the UK National Health Service.

Herbal medicine Clinical and experimental study on treatment of migraine with Shu Tian Ning granule Zhongguo Zhong Xi Yi Jie He Za Zhi Zhong Guo Zhong Xi Yi Jie He Za Zhi [Chinese Journal of Integrated Traditional and Western Medicine] 2002 August, Vol. 8, pp. 581–583. Hu ZQ, Song LG, Mei T Department of Neurology, Affiliated Hospital of Shandong University of TCM, Jinan

Objective To explore the cause and pathogenesis of migraine based on traditional Chinese medicine theory and modern research to seek for new thinking and effective drugs in treating migraine.

Methods Ninety patients with migraine were divided into three groups, the treated group treated with Shu Tian Ning Granule 9 g three times a day; the control A group treated with composite Yang Jiao capsule, five capsules each time, three times a day; and the control B group treated with flunarizine hydrochloride capsule, 5 mg, once a day. The treatment lasted for 28 days to observe the degree, lasting time and frequency of pain attack, and the headache index was calculated. Transcranial Doppler examination, serum beta-evoked potential (beta-EP) and neuropeptide Y (NPY) determination were also performed before and after treatment. In the experimental study, effect of treatment of cerebral NPY and beta-EP were tested in Sprague Dawley rats with chronic pain in the treated or the control groups.

Results In the treated group, the markedly effective rate was 56.67% and the total effective rate was 90.00%; significant difference was shown in comparison with those in the control B group (P < 0.05), but with no difference in comparison with those in the control A group. Cerebral beta-EP level was raised and plasma NPY level was lowered in all the three treated groups. Compared with the normal saline group, there was significant difference (P < 0.05 or P < 0.01).

Conclusion Shu Tian Ning Granule could improve the cerebrovascular function effectively, raise plasma beta-EP level, lower plasma NPY level and alleviate vascular tension in patients with migraine.

Effect of new Zheng Tian pill on expression of whole blood platelet membrane adhesion molecules in patients of migraine Zhong Guo Zhong Xi Yi Jie He Za Zhi [Chinese Journal of Integrated Traditional and Western Medicine] 2001 November, Vol. 21, Issue 11, pp. 822–824. Zhu CQ, Xie W, Chan BT

Headaches

Objective To investigate the effect of New Zheng Tian Pill (NZTP) on expression of whole blood platelet membrane adhesion molecules (PMAM) in patients of migraine.

Methods Sixty-eight patients were divided into two groups, the 35 patients in the treated group treated by NZTP orally and the 33 patients in the control group treated by Fuguiqin Capsule, with a therapeutic course of 30 days for both groups. Changes of PMAM glycoprotein IIb/ IIIa (CD41) and P-selectin (CD62P) were observed by flow cytometry and compared with those in healthy persons.

Results The markedly effective rate and total effective rate in the treated group were higher than those in the control group (P < 0.05 and P < 0.01, respectively). The PMAM expression was also higher in patients, both at onset stage and intermittent stage, than in healthy persons (P < 0.01). NZTP treatment could reduce their increased expression significantly (P < 0.01).

Conclusion NZTP could reduce the PMAM expression and inhibit the activation of platelet.

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This shows that the overwhelming majority of patients were between 31 and 60. As for Full and Empty, the distribution was as follows. • Purely Empty condition: 18 (10%) • Purely Full condition: 37 (22%) • Mixed Full-Empty condition: 116 (68%) This shows that the overwhelming majority of patients suffered from a mixed Full-Empty condition and also that more patients suffered from a purely Full than a purely Empty condition. The logical conclusion is that very few headaches are due to a purely Empty condition. As for patterns, a very large percentage of patients suffered from either Liver-Yang rising or Phlegm. In fact, 88 patients (51%) suffered from Liver-Yang rising and 35 (20%) from Phlegm. Therefore, Liver-Yang rising is by far the most common pattern found in patients suffering from chronic headaches. Liver-Yang rising and Phlegm together account for 71% of chronic headaches. There was also a large percentage of patients suffering from Empty conditions and especially Liver-Blood or Kidney deficiency; this makes sense, as a Liver-Blood or Kidney deficiency is very frequently the backround for the rising of Liver-Yang. In fact, 51 patients (30%) suffered from Liver-Blood deficiency and 74 patients (44%) suffered from a Kidney deficiency (which can be a Kidney-Yang, Kidney-Yin or mixed Kidney-Yin/ Kidney-Yang deficiency).

PATIENTS’ STATISTICS I have compiled some statistics on 171 patients suffering from headaches from my practice. There were 130 women (76%) and 41 (24%) men. As the overall percentage of women in my practice is 67%, this shows that more women than men suffer from headaches (in my practice). The age distribution was as follows. • • • • • • • • •

1–10: 3 (2%) 11–20: 10 (6%) 21–30: 17 (10%) 31–40: 42 (24%) 41–50: 48 (28%) 51–60: 36 (21%) 61–70: 14 (8%) 71–80: 0 (0) 81–90: 1 (1%)

WESTERN DIFFERENTIAL DIAGNOSIS OF HEADACHES The main causes of headaches in Western medicine may be summarized as follows (Fig. 1.20). Intracranial: • Inflammatory — Meningitis • Non-inflammatory — Vascular: migraine, cerebral haemorrhage — Neoplastic: cerebral tumour — Hypertensive: essential hypertension, secondary hypertension (glomerulonephritis) Cranial: • Sinusitis, otitis media

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The Practice of Chinese Medicine INFLAMMATORY: meningitis VASCULAR: migraine, cerebral haemorrhage

Intracranial NON-INFLAMMATORY: meningitis

NEOPLASTIC: cerebral tumour

HYPERTENSIVE: essential hypertension, secondary hypertension (nephritis) Cranial

Extracranial

Sinusitis, otitis

Glaucoma, cervical spondylosis, trigeminal neuralgia

Figure 1.20 Synopsis of causes of headache.

Extracranial: • Glaucoma, cervical spondylosis, trigeminal neuralgia

Figure 1.21 illustrates the areas influenced by the cranial nerves.

Intracranial The intracranial causes of headaches may be inflammatory or non-inflammatory. The latter may be vascular, neoplastic or hypertensive.

The main manifestations are a severe headache, fever, vomiting, neck rigidity and, in severe cases, mental confusion. Brudzinski’s sign is positive: with the patient supine and the chest held firmly to the bed, try to flex the neck. In meningitis, this procedure causes involuntary flexion of the hips (Fig. 1.22). The diagnosis of headache from meningitis is obvious from its acute onset, the age of the patient, the fever and the neck rigidity. The headache is generalized, radiating to the neck (Fig. 1.23).

Non-inflammatory

Inflammatory

Vascular

Meningitis This is an inflammation of the meninges occurring during a febrile disease. It strikes infants, children or young adults. Two-thirds of cases occur before the age of 5. Meningitis often starts during a viral infection such as influenza or a bacterial infection such as a respiratory or an ear infection.

Migraine This is the most frequent cause of recurrent headaches. It consists of an initial constriction of the head arteries (giving rise to prodromal symptoms) followed by vasodilatation and distension of the vessels

TR 1 C2 TR 2 TR 3 C3 C4

Figure 1.21 Cranial nerves.

Figure 1.22 Brudzinski’s sign.

Headaches

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become progressively worse in terms of frequency, duration and intensity and are accompanied by vertigo, vomiting and intellectual impairment, a cerebral tumour should be suspected. The headache eventually becomes continuous (Fig. 1.25). The grasp reflex may be observed: if an object is put on the palm of the hand between thumb and index finger, the patient will automatically grasp it. This reflex action is present only on the side opposite to the location of the tumour.

Hypertensive Figure 1.23 Location of headache in meningitis.

(which causes a throbbing pain). The main manifestations are a unilateral, severe and throbbing pain, photophobia, nausea and possibly vomiting. The attacks are precipitated by stress; by consumption of cheese, chocolate, red wine; and by the contraceptive pill. The headache is located around the eye, radiating to the side of the head; it is unilateral or bilateral (Fig. 1.24). Cerebral (subarachnoid) haemorrhage This is more frequent in men over 40. The main manifestations are an intense head pain, neck rigidity and vomiting followed by loss of consciousness.

Essential hypertension This indicates a persistent high blood pressure without an apparent cause. It occurs in persons between 40 and 70. The main manifestations are a vertical (on top of the head) or occipital headache, occipital stiffness, giddiness, tinnitus, irritability and, in a few cases, epistaxis. The main sign is, of course, a raised diastolic and/or systolic blood pressure. However, it is not at all uncommon for a patient with raised blood pressure not to show any of the above symptoms. The headache from hypertension can occur either on the top of the head or on the occiput and is accompanied by a pronounced stiffness of the neck muscles (Fig. 1.26).

Cerebral tumour This is an uncommon cause of headache, but if a person develops headaches that

Secondary hypertension This a raised blood pressure secondary to other factors, the most frequent of them being chronic glomerulonephritis (see Chapter 37, on oedema). The main manifestations, apart from raised blood pressure and a headache, are aching in the loins, tiredness, oedema and albuminuria.

Figure 1.24 Location of headache in migraine.

Figure 1.25 Location of headache in brain tumour.

Neoplastic

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Frontal sinus

Ethmoidal sinus Maxillary sinus

Figure 1.26 Location of headache in hypertension.

Cranial

Figure 1.27 Location of headache in sinusitis.

Sinusitis This is a common complaint in industrialized countries. It is characterized by inflammation of the sinuses. The headache from sinusitis is easily distinguished from that from other causes, as it is clearly located on the face in correspondence with the frontal, ethmoidal or maxillary sinuses (Fig. 1.27). Other manifestations include a runny nose, a postnasal discharge and a characteristic feeling of muzziness of the face.

Otitis media This may be a cause of headache in a small child. Very often, the child may not be able to distinguish the source of pain and may complain of a “headache” when he or she has an earache. The diagnosis is fairly obvious, as this type of headache will occur in a small child during a febrile disease and there may be a discharge from the ear (Fig. 1.28).

Figure 1.28 Location of headache in otitis media.

Extracranial Glaucoma This consists of a raised intraocular fluid pressure. It is rare before middle age. It may cause a headache around or behind the eyes, which is easily mistaken for migraine. It is usually worse in the evening and is accompanied by the patient’s seeing haloes around lights and by blurred vision (Fig. 1.29).

Figure 1.29 Location of headache in glaucoma.

Headaches

Cervical spondylosis This term includes arthritis of the cervical spine or cervical disc degeneration. This causes an occipital headache with ache extending to the top of the shoulders and neck (Fig. 1.30). There is marked tenderness on pressure on the neck and shoulder muscles. X-rays of the cervical spine usually show a narrowing of the intervertebral spaces and osteophyte formation.

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Mandibular branch Maxillary branch Ophthalmic branch

Trigeminal neuralgia This is an inflammation of one or more of the three trigeminal nerves (which are part of the cranial nerves). It is usually seen in the elderly. The pain is unilateral and it is usually very intense, lasting for a short time. The pain can occur on the forehead and eye, cheek or temple and jaw according to the nerve involved (Fig. 1.31). Finally, a word should be said about Western medication for headaches. Of all the various drugs used for migraine, ergotamine tartrate (Cafergot) is, in my opinion, the most detrimental one. Not only does it produce side effects such as nausea and tingling of the limbs, but I think its long-term use only makes the headaches more frequent. This occurs for two reasons: first of all, ergotamine tartrate (with a chemical structure somewhat similar to LSD) is a powerful vasoconstrictor (this stops the acute headache), but vasoconstriction is inevitably followed by vasodilatation, which is going to cause the next headache. Second, most preparations of ergotamine tartrate also include caffeine, which is

Figure 1.31 Location of trigeminal neuralgia.

also a vasoconstrictor, but, as for ergotamine, vasoconstriction is only followed by a worse vasodilatation. The role of caffeine in headaches has already been discussed in this chapter (see also note 2). For these reasons, I always advise patients who take this medication to come off it if at all possible. There is no danger in stopping this drug abruptly.

PROGNOSIS AND PREVENTION

Figure 1.30 Location of headache in cervical spondylosis.

Both acupuncture and Chinese herbs are extremely effective for headaches and migraine. Results, however, are not necessarily achieved always quickly. Obviously, the longer a person has been suffering from headaches, the longer it will take to treat him or her. Very often, we see patients who have been suffering from headaches for 20 years or more; in these cases, the treatment will necessarily take many months or even over a year. The three most difficult types of headache to treat are those from Phlegm, Wind-Phlegm and stasis of Blood.

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As for prevention, this follows logically from what was said about aetiology. A person who is prone to headaches or someone who has been successfully treated for headaches should refrain from excessive sexual activity and overwork. He or she should have enough rest and sleep and should avoid eating sour foods (as defined above in this chapter) and drinking coffee. If a person is suffering from a deficiency, he or she should have enough rest, and especially lie down for a short time after lunch. If a person has been successfully treated for headaches from Liver-Yang, Liver-Fire, Liver-Qi stagnation or Liver-Wind, he or she should pay attention to their emotional state and avoid getting angry.

END NOTES 1. For a more detailed discussion of this subject, see Maciocia G 2005 The Foundations of Chinese Medicine, 2nd edn. Elsevier, London. 2. Harrie JR 1970 Caffeine and headache. Journal of the American Medical Association 213: 628. An article in this journal states that caffeine is one of the more frequent causes of chronic headaches.

3. Wu Zhan Ren, Yu Zhi Gao 1987 Yi Lin Zheng Yin [The Correct Seal of Medical Circles]. Jiangsu Science Publishing House, Nanjing, p. 142. The Correct Seal of Medical Circles was written by Ma Zhao Sheng and first published in 1605. 4. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, Chapter 17, p. 98. First published c.100 BC. 5. Lu Yi Hua 1897 Leng Hu Yi Hua [Medical Talk from the Deserted Cottage] cited in 1981 Nei Ke Bian Bing Yu Bian Zheng [Differentiation of Diseases and Patterns in Internal Medicine]. Heilongjiang People’s Publishing House, p. 331. 6. 1982 Lei Jing [Classic of Categories]. People’s Health Publishing House, Beijing, p. 325. The Classic of Categories was written by Zhang Jie Bin (also called Zhang Jing Yue) and first published in 1624. 7. Heilongjiang Province National Medical Research Group 1984 Zhen Jiu Da Cheng Jiao Shi [An Explanation of the Great Compendium of Acupuncture]. People’s Health Publishing House, Beijing, p. 1091. The Great Compendium of Acupuncture was written by Yang Ji Zhou and first published in 1601. 8. Ibid., p. 1091. 9. Ibid., p. 1091. 10. Simple Questions, p. 141. 11. 1976 Pi Wei Lun [Discussion on Stomach and Spleen]. People’s Publishing House, Beijing, p. 362. The Discussion on Stomach and Spleen was written by Li Dong Yuan and first published in 1249. 12. Simple Questions, p. 111. 13. An Explanation of the Great Compendium of Acupuncture, p. 1091.

CHAPTER 2

DIZZINESS

AETIOLOGY 66 Emotional strain 66 Overwork and excessive sexual activity Irregular diet 66 PATHOLOGY

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IDENTIFICATION OF PATTERNS AND TREATMENT 67 Liver-Yang, Liver-Fire or Liver-Wind rising 67 Turbid Phlegm in the head 69 Liver-Yang rising with Phlegm in the head 70 Qi and Blood deficiency 71 Kidney-Essence deficiency 71 MODERN CHINESE LITERATURE WESTERN DIFFERENTIATION Ear 74 Eighth cranial nerve 75 Brainstem 75

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INTERIOR Full • Liver-Yang, Liver-Fire and Liver-Wind rising • Turbid Phlegm in the head • Liver-Yang rising with Phlegm in the head Empty • Qi and Blood deficiency • Kidney-Essence deficiency

DIZZINESS Dizziness in Chinese medicine is called Xuan Yun. Xuan means “blurred vision”, while Yun means “dizziness.”

This symptom may range from a very slight dizziness, sometimes only on changing posture, to very severe vertigo with loss of balance, when everything around the patient seems to be spinning. The term “dizziness” also includes the very common sensation of “muzziness” or “fuzziness”, a heavy feeling as if the head was full of cotton wool and, linked to this, an inability to think properly and to concentrate. In English, I shall call the symptom Xuan Yun “dizziness”; I shall use “vertigo” to indicate a stronger sensation of dizziness to the point of losing balance. The first reference to dizziness occurs in the Yellow Emperor’s Classic of Internal Medicine, which links it to various patterns. The Simple Questions in Chapter 74 relates it to Liver-Wind: “Wind causes dizziness and it pertains to the Liver.”1 The Spiritual Axis in Chapter 28 attributes dizziness to Qi not reaching the head: “When the Qi of the Upper Burner is deficient, the brain is not full [this causes] dizziness and blurred vision.”2 In Chapter 33, it relates it to deficiency of the Sea of Marrow: “When the Sea of Marrow is deficient there is dizziness.”3 Zhu Dan Xi in Essential Methods of Dan Xi (1347) relates dizziness to Phlegm and goes as far as saying “There is no dizziness without Phlegm.”4 He therefore advocates resolving Phlegm as the main method of treating dizziness. As we shall see, Phlegm is a very common cause of dizziness in the elderly. Zhang Jing Yue, on the other hand, in his book The Complete Book of Jing Yue (1624), relates dizziness to Deficiency and says: “Deficiency above causes dizziness” and “There is no dizziness without Deficiency.”5 He therefore recommends tonifying as the main method to treat dizziness. The differentiation and treatment of dizziness together with those of Headaches can be used as a guideline to treat hypertension.

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The discussion of Dizziness will be conducted according to the following topics. • • • • •

Aetiology Pathology Identification of patterns and treatment Modern Chinese literature Western differentiation

AETIOLOGY Emotional strain Anger, frustration, resentment, bottled-up hatred and any other emotion that affects the Liver may cause Liver-Yang to rise. This is a common cause of dizziness of the Full type. On the other hand, prolonged stagnation of Qi from emotional strain often gives rise to Fire, in this case Liver-Fire, which may also cause dizziness. Moreover, Liver-Fire may generate Wind, which causes even more intense dizziness to the point of loss of balance.

Overwork or excessive sexual activity Overwork and/or excessive sexual activity (in men) over many years without adequate rest weakens the Kidneys. These fail to generate enough Marrow to nourish the brain, and dizziness results. This is dizziness of the Empty type.

Irregular diet Excessive consumption of greasy foods or dairy products or simply irregular eating may weaken the Spleen and lead to Dampness and Phlegm. When this is associated with a deficiency of Qi in the Upper Burner, the clear Qi cannot rise to the head and Turbid Phlegm stagnates there, giving rise to dizziness, blurred vision and a sensation of muzziness (fuzziness) and heaviness of the head.

PATHOLOGY The most important pathological distinction to be made in dizziness is that between Deficiency and Excess. The sensation of dizziness quite simply arises either because not enough Qi reaches the head (Deficiency type) or because a pathogenic factor in the head prevents the clear Yang from reaching the head (Excess type). The main deficiencies that give rise to dizziness are those of Qi and Blood or Kidney-Essence. The main pathogenic factors causing dizziness are Liver-Yang, Liver-Fire, Liver-Wind and Phlegm. In the elderly, Blood stasis may also contribute to causing dizziness. This happens especially in elderly people suffering from arteriosclerosis. Therefore, if there are any signs of Blood stasis (such as a Purple tongue or dark and distended sublingual veins), it is important to modify the prescription used to invigorate Blood and “penetrate” the blood vessels (see second article from a modern Chinese journal mentioned below). Dizziness deriving from a deficiency is slight and is associated with blurred vision. It may occur only on change of posture. When caused by a Full condition, dizziness is more severe, in serious cases causing loss of balance. When Phlegm is the cause of dizziness, it is associated with blurred vision and a sensation of heaviness and muzziness (fuzziness) in the head, together with an inability to concentrate. Figure 2.1 summarizes the aetiology and pathology of Dizziness.

EMOTIONAL STRESS

Liver-Yang rising

LIV-Wind

Qi stagnation

Liver-Fire

OVERWORK

Kidney deficiency

IRREGULAR DIET

Phlegm

SUMMARY

Cannot nourish Sea of Marrow

DIZZINESS

AETIOLOGY  Emotional strain  Overwork or excessive sexual activity  Irregular diet

Obstructs the Brain and prevents SpleenYang from rising

Figure 2.1 Aetiology and pathology of Dizziness.

Dizziness

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SUMMARY

Treatment principles

PATHOLOGY

Liver-Yang rising Subdue Liver-Yang, nourish LiverYin or Liver-Blood and Kidney-Yin if necessary.

 Empty — Qi and Blood deficiency — Deficiency of Kidney-Essence  Full — Liver-Yang rising — Liver-Fire — Liver-Wind — Phlegm

IDENTIFICATION OF PATTERNS AND TREATMENT There are five main patterns causing dizziness: Full • Liver-Yang, Liver-Fire or Liver-Wind rising • Turbid Phlegm in the head • Liver-Yang rising with Phlegm in the head Empty • Qi and Blood deficiency • Kidney-Essence deficiency

Liver-Fire Drain Liver-Fire. Liver-Wind Extinguish Liver-Wind.

Acupuncture Points LIV-3 Taichong, G.B.-20 Fengchi, T.B.-5 Waiguan, Du-16 Fengfu, S.I.-3 Houxi, LIV-2 Xingjian, P-6 Neiguan, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi. Reducing method on all points, except LIV-8 and KI-3 which should be reinforced.

Explanation • LIV-3 and G.B.-20 subdue Liver-Yang and extinguish Liver-Wind. G.B.-20 is specific for dizziness. • T.B.-5 helps to subdue Liver-Yang. • Du-16 and S.I.-3 extinguish Liver-Wind. • LIV-2 drains Liver-Fire. • P-6 indirectly helps to subdue Liver-Yang, calms the Mind and settles the Ethereal Soul. • LIV-8 and SP-6 nourish Liver-Blood. • KI-3 nourishes Kidney-Yin.

Herbal therapy

Liver-Yang, Liver-Fire or Liver-Wind rising Clinical manifestations Liver-Yang Quite severe dizziness, tinnitus, red face, irritability, propensity to outbursts of anger, headache. Tongue: slightly Red sides. Pulse: Wiry. Liver-Fire Red face, thirst, bitter taste, dry stools, scanty dark urine. Tongue: Red with dry-yellow coating. Pulse: Rapid-Wiry-Full. Liver-Wind More severe dizziness, vertigo and loss of balance, tremors. Pulse: Wiry. The pattern of Liver-Yang as a cause of dizziness is the most common of the above three patterns. LiverFire is the least common and Liver-Wind occurs usually only in the elderly.

Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction

Explanation This formula, which has already been explained in the chapter on headaches (Chapter 1), subdues Liver-Yang and nourishes Liver and Kidneys. It is widely used for dizziness from Liver-Yang or Liver-Wind rising.

Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction

Explanation The main difference between this prescription and the previous one is that the latter nourishes the Yin more and is therefore suitable when there is a pronounced deficiency of Liver- and Kidney-Yin. Note that Dai Zhe Shi Haematitum is not suitable for long-term use and is contraindicated in pregnancy. It could be eliminated

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from this prescription or replaced with Zhen Zhu Mu Concha Margatiriferae usta, which is also a sinking substance that subdues Liver-Yang. This formula also extinguishes Liver-Wind.

Prescription LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction

Explanation This formula subdues Liver-Yang, nourishes Yin and resolves Phlegm. Its Yin-nourishing effect is mild.

Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction

Explanation This formula is specific to drain Liver-Fire. Please note that the original formula quoted here contains Mu Tong, which must now be omitted because its use is no longer legal.

Modifications • If there are symptoms and signs of Liver-Fire (indicated above), either add Long Dan Cao Radix Gentianae or use Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction instead, adding Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus cum Uncis Uncariae and Shi Jue Ming Concha Haliotidis. • If there is Liver-Wind, add Di Long Pheretima, Zhen Zhu Mu Concha Margatiriferae usta and Mu Li Concha Ostreae.

Three Treasures remedy Bend Bamboo Bend Bamboo subdues Liver-Yang and nourishes Liver-Blood.

SUMMARY LIVER-YANG, LIVER-FIRE OR LIVER-WIND RISING Points LIV-3 Taichong, G.B.-20 Fengchi, T.B.-5 Waiguan, Du-16 Fengfu, S.I.-3 Houxi, LIV-2 Xingjian, P-6 Neiguan, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi. Reducing method on all points, except LIV-8 and KI-3, which should be reinforced.

Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction Prescription LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction Three Treasures remedy Bend Bamboo

Case history A 70-year-old man had been suffering from vertigo for several years. He was very unsteady on his feet and often used a shopping trolley to steady himself while walking. His blood pressure was raised and he occasionally had blurred vision. His nails were very dry and withered, his complexion was dark and his skin dry. His tongue was Reddish-Purple with a thin yellow coating in the centre but no coating elsewhere. The tongue was also Stiff and dry. His pulse was very Full and Wiry. Diagnosis His condition was clearly due to Liver-Yang rising with an underlying deficiency of Liver-Yin. The vertigo was due to Liver-Yang rising, which was also reflected in the pulse quality, while Liver-Yin deficiency was evidenced by the blurred vision, the dry skin, the dry and withered nails and the Stiff tongue. Treatment principle The principle of treatment adopted was therefore to nourish Liver-Yin and subdue Liver-Yang. Acupuncture Points The main points used were G.B.-20 Fengchi, T.B.-5 Waiguan, L.I.-4 Hegu and LIV-3 Taichong with even

Dizziness

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method and LIV-8 Ququan, SP-6 Sanyinjiao and KI-3 with reinforcing method.

SP-3, BL-20 and BL-21. Reducing or even method on the others.

Explanation • G.B.-20 subdues Liver-Yang and relieves dizziness. • T.B.-5 subdues Liver-Yang. • L.I.-4, together with LIV-3, subdues Liver-Yang from the head. • LIV-3 subdues Liver-Yang and Liver-Wind. • LIV-8, SP-6 and KI-3 nourish Liver-Yin.

Explanation

Herbal therapy No herbs were prescribed but only the patent remedy Jiang Ya Wan Lowering [Blood] Pressure Pill, which subdues Liver-Yang and LiverWind and nourishes Liver- and Kidney-Yin.

• Ren-12, ST-36, SP-3, BL-20 and BL-21 tonify Stomach and Spleen to resolve Phlegm. • Ren-9, SP-9, ST-40 and ST-41 resolve Dampness and Phlegm. • L.I.-4 is used to affect the Stomach channels in the face and regulate the ascending of clear Yang and descending of turbid Qi. • ST-8 is a local point specific to resolve Phlegm from the head. • Du-20 facilitates the rising of clear Yang to the head.

After six treatments, his blood pressure became normal and his dizziness was much relieved.

Herbal therapy

Turbid Phlegm in the head

BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction

Clinical manifestations Dizziness, a feeling of heaviness and muzziness (fuzziness) of the head as if it were full of cotton wool, blurred vision, difficulty in thinking and concentrating especially in the morning, a feeling of oppression of the chest, nausea, poor appetite, a sticky taste. Tongue: Swollen with a sticky coating. Pulse: Slippery. This condition is due to Phlegm obstructing the head so that the clear Yang cannot rise to it and turbid Qi cannot descend. The above manifestations are purely those due to Phlegm. Obviously, the more chronic the condition, the more there will be manifestations of Spleen deficiency. This is probably the most common pattern causing chronic dizziness.

Treatment principle Dry Dampness, resolve Phlegm, strengthen the Spleen and harmonize the Stomach.

Acupuncture Points Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, BL-21 Weishu, Ren-9 Shuifen, SP-9 Yinlingquan, ST-40 Fenglong, ST-41 Jiexi, L.I.-4 Hegu, ST-8 Touwei, Du-20 Baihui. Reinforcing method on Ren-12, ST-36,

Prescription

Explanation This formula, which has already been explained in the chapter on headaches (Chapter 1), is specific to resolve Phlegm from the head.

Modifications • To enhance this formula’s resolving Phlegm effect, add Shi Chang Pu Rhizoma Acori tatarinowii to open the orifices and help the descending of turbid Qi. • If there is a pronounced feeling of nausea, add Zhu Ru Caulis Bambusae in Taeniam. • If there is a feeling of fullness in the epigastrium, add Bai Dou Kou Fructus Amomi rotundus and Sha Ren Fructus Amomi. • If there is Phlegm and Heat (mental restlessness, headache, bitter taste and a Rapid-Wiry pulse), add Zhu Ru Caulis Bambusae in Taeniam, Gua Lou Fructus Trichosanthis and Huang Qin Radix Scutellariae and remove Bai Zhu. Alternatively, use Wen Dan Tang Warming the Gall-Bladder Decoction, especially if the tongue has a Stomach crack in the centre with a rough-yellow coating inside it and the tongue-body is Red. If this formula is used, add Huang Qin Radix Scutellariae, Huang Lian Rhizoma Coptidis and Shi Chang Pu Rhizoma Acori tatarinowii to it.

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The Practice of Chinese Medicine

SUMMARY TURBID PHLEGM IN THE HEAD Points Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, BL-21 Weishu, Ren-9 Shuifen, SP-9 Yinlingquan, ST-40 Fenglong, ST-41 Jiexi, L.I.-4 Hegu, ST-8 Touwei, Du-20 Baihui. Reinforcing method on Ren-12, ST-36, SP-3, BL-20 and BL-21. Reducing or even method on the others. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction

Liver-Yang rising with Phlegm in the head Clinical manifestations Severe dizziness, vertigo, tinnitus, irritability, propensity to outbursts of anger, headache, a feeling of heaviness and muzziness (fuzziness) of the head as if it were full of cotton wool, blurred vision, difficulty in thinking and concentrating (especially in the morning), a feeling of oppression of the chest, nausea, poor appetite, a sticky taste. If there is Liver-Wind: tremor of a limb. Tongue: Swollen with a sticky coating. Pulse: Slippery-Wiry. This is a common combination of patterns causing severe dizziness in the elderly. As Liver-Yang rises, it carries Phlegm with it, aggravating the feeling of dizziness. This is also a common cause of chronic headaches.

Treatment principle Subdue Liver-Yang, nourish the Kidneys, resolve Phlegm, tonify the Spleen, extinguish Wind if necessary.

Acupuncture Points LIV-3 Taichong, G.B.-20 Fengchi, Du-16 Fengfu, LIV-8 Ququan, KI-3 Taixi, L.I.-4 Hegu, ST-40 Fenglong, Ren-9 Shuifen, SP-9 Yinlingquan, ST-8 Touwei, Ren-12 Zhongwan, BL-20 Pishu. Ren-12, BL-20, LIV-8 and KI-3 with reinforcing method, the others with even method.

Explanation • LIV-3, G.B.-20 and Du-16 subdue Liver-Yang and extinguish Liver-Wind. • LIV-8 and KI-3 nourish the Liver and Kidneys. • L.I.-4 regulates the ascending and descending of Qi to and from the head. • ST-40, Ren-9 and SP-9 resolve Phlegm. • ST-8 resolves Phlegm from the head. • Ren-12 and BL-20 tonify the Spleen to resolve Phlegm.

Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction

Explanation This formula subdues Liver-Yang, extinguishes LiverWind and resolves Phlegm.

Modifications • In cases of Liver-Wind, add Di Long Pheretima, Quan Xie Scorpio or Jiang Can Bombyx batryticatus.

Three Treasures remedy Clear Yang Clear Yang is a variation of Ban Xia Bai Zhu Tian Ma Tang to treat headaches from a combination of Phlegm and Liver-Yang rising.

SUMMARY LIVER-YANG RISING WITH PHLEGM IN THE HEAD Points LIV-3 Taichong, G.B.-20 Fengchi, Du-16 Fengfu, LIV-8 Ququan, KI-3 Taixi, L.I.-4 Hegu, ST-40 Fenglong, Ren-9 Shuifen, SP-9 Yinlingquan, ST-8 Touwei, Ren-12 Zhongwan, BL-20 Pishu. Ren-12, BL-20, LIV-8 and KI-3 with reinforcing method, the others with even method. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction Three Treasures remedy Clear Yang

Dizziness

Qi and Blood deficiency Clinical manifestations Slight dizziness, sometimes only on change of posture, tiredness, dull-pale face, poor memory, insomnia, palpitations, depression, poor appetite. Tongue: Pale and Thin. Pulse: Choppy or Fine. This is essentially a deficiency of Spleen- and HeartBlood. This is usually a cause of mild dizziness in younger patients and more in women.

Treatment principle Tonify Qi and nourish Blood, strengthen Stomach and Spleen.

Acupuncture Points ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, Ren-6 Qihai, BL-15 Xinshu. Reinforcing method. Moxa should be used.

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• If there are symptoms of Cold and epigastric pain, add Gui Zhi Ramulus Cinnamomi cassiae and Bai Shao Radix Paeoniae alba. • If Blood deficiency is pronounced, add Shu Di Huang Radix Rehmanniae preparata. • If Qi deficiency is more pronounced, remove Dang Gui and Long Yan Rou and increase the dosage of Huang Qi. Alternatively, use Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction instead.

SUMMARY QI AND BLOOD DEFICIENCY Points ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, Ren-6 Qihai, BL-15 Xinshu. Reinforcing method. Moxa should be used. Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction

Explanation • ST-36, SP-6, Ren-12, BL-20 and BL-21 strengthen the Stomach and Spleen and nourish Blood. • Du-20 facilitates the rising of clear Qi to the head and relieves dizziness. • Ren-6 tonifies Qi in general. • BL-15 nourishes Heart-Blood.

Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction

Explanation This formula tonifies Qi and Blood, strengthens the Spleen and Heart, and nourishes the brain.

Modifications • If a deficiency of Stomach and Spleen in making Blood is more pronounced than a deficiency of Liver-Blood, reduce the dosage of Dang Gui, increase that of Mu Xiang and add Fu Ling Poria, Yi Yi Ren Semen Coicis and Sha Ren Fructus Amomi.

Kidney-Essence deficiency Clinical manifestations Persistent dizziness with a feeling of emptiness in the brain, tinnitus, depression, exhaustion, waking up during the night, poor memory, sore back and knees. Tongue: Pale if Yang deficiency, without coating if Yin deficiency. Pulse: Deep and Weak if Yang deficiency, FloatingEmpty if Yin deficiency. This is essentially a deficiency of Kidney-Essence; the Essence is failing to nourish Marrow and the brain. This results in a deficiency of the Sea of Marrow, one of the main symptoms of which is dizziness. As the Essence has both a Yin and a Yang aspect, its deficiency may manifest with symptoms of either Kidney-Yang or Kidney-Yin deficiency. This is a common cause of mild dizziness in middleaged and elderly patients.

Treatment principle Tonify Kidney-Yang or nourish Kidney-Yin, strengthen the Essence and nourish the Sea of Marrow.

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The Practice of Chinese Medicine

Acupuncture

Explanation

Points

This formula, which has already been explained in the chapter on headaches (Chapter 1), tonifies KidneyYang. In particular, Lu Jiao Jiao nourishes Marrow.

Ren-4 Guanyuan, KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, S.I.-3 Houxi and BL-62 Shenmai, Du-16 Fengfu, Du-17 Naohu, Du-20 Baihui, G.B.-39 Xuanzhong. Reinforcing method. Use moxa in Kidney-Yang deficiency.

Three Treasures remedies Nourish the Root or Strengthen the Root Nourish the Root nourishes Kidney-Yin, while Strengthen the Root tonifies Kidney-Yang.

Explanation • Ren-4, KI-3, BL-23 and BL-52 strengthen KidneyYang or Yin (depending on whether moxa is used or not) and nourish the Essence. • S.I.-3 and BL-62 (better for Kidney-Yang deficiency) strengthen the Governing Vessel and nourish Marrow and the brain. • Du-16 and Du-20 are points of the Sea of Marrow according to Chapter 33 of the Spiritual Axis.6 They stimulate the rising of Qi to the brain and nourish Marrow. • Du-17, called “Brain Window”, nourishes Marrow and relieves giddiness. • G.B.-39 is the Gathering (Hui) point of Marrow and therefore nourishes Marrow and relieves dizziness from Kidney deficiency.

Herbal therapy Prescription

SUMMARY KIDNEY-ESSENCE DEFICIENCY Points Ren-4 Guanyuan, KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, S.I.-3 Houxi and BL-62 Shenmai, Du-16 Fengfu, Du-17 Naohu, Du-20 Baihui, G.B.-39 Xuanzhong. Reinforcing method. Use moxa in Kidney-Yang deficiency. Herbal therapy Prescription ZUO GUI WAN Restoring the Left [Kidney] Pill Prescription YOU GUI WAN Restoring the Right [Kidney] Pill Three Treasures remedies Nourish the Root or Strengthen the Root

ZUO GUI WAN Restoring the Left [Kidney] Pill

Explanation This formula, which has already been explained in the chapter on headaches (Chapter 1), tonifies Kidney-Yin and nourishes the Essence and Marrow. In particular, Lu Jiao and Lu Jiao Jiao (see below) nourish Marrow and the brain. It is especially suited to women.

Modifications • If there are symptoms of Empty Heat, add Zhi Mu Radix Anemarrhenae and Huang Bo Cortex Phellodendri.

Prescription YOU GUI WAN Restoring the Right [Kidney] Pill

Case history A 31-year-old man had been suffering from severe dizziness, slight deafness and tinnitus for 1 year. His condition had been diagnosed as Ménière’s disease. He sometimes sweated at night and felt generally exhausted. He had had a previous bout of dizziness 10 years earlier. He also suffered from headaches of a throbbing character on the temples, when his eyes would flicker. His tongue was slightly Red and the coating was too thin. His pulse was Empty on the deep level and Wiry on both Rear positions. Diagnosis This is a clear case of Kidney-Yin deficiency (night-sweating, exhaustion, tongue without enough coating, pulse Empty on the deep level) and LiverYang rising (throbbing headache, flickering eyes, Wiry

Dizziness

pulse). Thus this is a combined condition of Deficiency (of Kidney-Yin) and Excess (Liver-Yang rising). The dizziness and tinnitus can be accounted for both by Kidney-Yin deficiency and by Liver-Yang rising. Treatment principle Nourish Kidney-Yin and subdue Liver-Yang. Herbal therapy Prescription This patient, who had been referred to me by his acupuncturist, sought herbal treatment. The formula used was a variation of Liu Wei Di Huang Wan SixIngredient Rehmannia Pill. • • • • • • • • • •

Shu Di Huang Radix Rehmanniae preparata 9 g Shan Yao Rhizoma Dioscoreae 6 g Shan Zhu Yu Fructus Corni 4.5 g Ze Xie Rhizoma Alismatis 4 g Mu Dan Pi Cortex Moutan 4 g Fu Ling Poria 4.5 g Shi Jue Ming Concha Haliotidis 12 g Gou Teng Ramulus cum Uncis Uncariae 6 g Tian Ma Rhizoma Gastrodiae 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g

Explanation • The first six herbs constitute the Liu Wei Di Huang Wan, which nourishes Kidney-Yin. • Shi Jue Ming, Gou Teng and Tian Ma subdue LiverYang. • Zhi Gan Cao harmonizes.

MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 24, No. 7, 1983. Liu Zhi Ming, “Differentiation and treatment of dizziness.” Dr Liu considers that the three main patterns causing dizziness are Liver-Wind and Heat, deficient SpleenQi not rising to the head and deficiency of the Sea of Marrow.

Liver-Yang rising, Liver-Wind and Heat Dr Liu says that Liver-Yang rising or Liver-Wind may cause dizziness; in both cases, they stem from a

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deficiency of the Liver- and/or Kidney-Yin. An example of a prescription he uses is as follows. • • • • • • • • • • • •

Gou Teng Ramulus cum Uncis Uncariae 9 g Ju Hua Flos Chrysanthemi 9 g Huang Qin Radix Scutellariae 9 g Bai Shao Radix Paeoniae alba 9 g Fu Ling Poria 12 g Ze Xie Rhizoma Alismatis 12 g Xuan Shen Radix Scrophulariae 12 g Sheng Di Huang Radix Rehmanniae 15 g Shi Chang Pu Rhizoma Acori tatarinowii 6 g Yuan Zhi Radix Polygalae 4.5 g Zhen Zhu Mu Concha Margatiriferae usta 24 g Shi Jue Ming Concha Haliotidis 24 g

In cases of Liver-Fire, Dr Liu uses a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction as follows: • • • • • • • • • • • • •

Long Dan Cao Radix Gentianae 9 g Huang Qin Radix Scutellariae 9 g Shan Zhi Zi Fructus Gardeniae 9 g Chai Hu Radix Bupleuri 9 g Ju Hua Flos Chrysanthemi 9 g Bai Shao Radix Paeoniae alba 9 g Shi Chang Pu Rhizoma Acori tatarinowii 9 g Yuan Zhi Radix Polygalae 6 g Fu Ling Poria 12 g Ze Xie Rhizoma Alismatis 12 g Tai Zi Shen Radix Pseudostellariae 12 g Ge Gen Radix Puerariae 12 g Gan Cao Radix Glycyrrhizae uralensis 6 g

Deficient Qi not rising to the head Dr Liu considers that deficient Qi’s not rising to the head is an important cause of dizziness. This is mostly deficient Spleen-Qi. Dr Liu quotes Chapter 28 of the Spiritual Axis: “When the rising Qi is deficient, the brain cannot be filled, and there is tinnitus, the head feels like it is spinning and there is blurred vision.”7 An example of a prescription used by Dr Liu is as follows: • • • • • • • • •

Dang Shen Radix Codonopsis 12 g Huang Qi Radix Astragali 12 g Bai Zhu Rhizoma Atractylodis macrocephalae 6 g Ge Gen Radix Puerariae 9 g Dang Gui Radix Angelicae sinensis 9 g Chen Pi Pericarpium Citri reticulatae 9 g Suan Zao Ren Semen Ziziphi spinosae 9 g Fu Shen Sclerotium Poriae pararadicis 9 g Gan Cao Radix Glycyrrhizae uralensis 6 g

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Deficiency of the Sea of Marrow The Kidney-Essence fills the Sea of Marrow that forms the Brain. Chapter 33 of the Spiritual Axis mentions the symptoms caused by a deficiency of the Sea of Marrow: “When the Sea of Marrow is deficient, there is dizziness, tinnitus, blurred vision, weak legs and a desire to lie down.”8 For dizziness deriving from a deficiency of the Kidneys and of the Sea of Marrow, Dr Liu recommends tonifying the Kidneys (Yin or Yang). An example of a prescription used is as follows: • • • • • • • • • • • •

Shu Di Huang Radix Rehmanniae preparata 15 g Dang Gui Radix Angelicae sinensis 12 g Bai Shao Radix Paeoniae alba 9 g E Jiao Colla Corii Asini 12 g Xu Duan Radix Dipsaci 12 g Sang Ji Sheng Herba Taxilli 12 g Dang Shen Radix Codonopsis 12 g Huang Qi Radix Astragali 12 g Suan Zao Ren Semen Ziziphi spinosae 9 g Fu Ling Poria 12 g Zhen Zhu Mu Concha Margatiriferae usta 24 g Gan Cao Radix Glycyrrhizae uralensis 6 g

In cases of Kidney-Yang deficiency, Dr Liu uses the following prescription: • • • • • • • • • •

Fu Zi Radix Aconiti lateralis preparata 9 g Rou Gui Cortex Cinnamomi 4.5 g Shu Di Huang Radix Rehmanniae preparata 18 g Shan Zhu Yu Fructus Corni 15 g Ba Ji Tian Radix Morindae officinalis 12 g Fu Ling Poria 12g Yuan Zhi Radix Polygalae 6 g Shi Chang Pu Rhizoma Acori tatarinowii 9 g Huang Qi Radix Astragali 15 g Dang Gui Radix Angelicae sinensis 9 g

patients were 22 men and 10 women ranging in age from 48 to 72 with an average age of 63.5 years. Dr Chai considers that the invigorating of Blood in the elderly suffering from dizziness is an important treatment principle. The formula used was the following: • • • • • • • • • • • •

Tao Ren Semen Persicae 6 g Hong Hua Flos Carthami tinctorii 6 g Ban Xia Rhizoma Pinelliae preparatum 6 g Chen Pi Pericarpium Citri reticulatae 6 g Chuan Xiong Rhizoma Chuanxiong 9 g Shi Chang Pu Rhizoma Acori tatarinowii 9 g Dan Shen Radix Salviae miltiorrhizae 12 g Chi Shao Radix Paeoniae rubra 12 g Chuan Niu Xi Radix Cyathulae 12 g Di Long Pheretima 12 g Bai Zhu Rhizoma Atractylodis macrocephalae 12 g Ji Xue Teng Caulis Spatholobi 20 g The results of the treatment were as follows.

• Cured: 15 cases (46.88%) • Improved: 14 cases (43.75%) • No results: 3 cases (9.38%) This article highlights the importance of the invigorating of Blood to treat dizziness in the elderly.

WESTERN DIFFERENTIATION The causes of vertigo in Western medicine may be classified according to its site. The sites may be: • ear • eighth cranial nerve • brainstem.

Ear Journal of Nanjing University of Traditional Chinese Medicine, Vol. 13, No. 3, 1997. Chai Xiao Kang, “The treatment of dizziness from arteriosclerosis with Invigorating Blood and Penetrating the Blood Vessels Decoction.” Dr Chai reports on the treatment of 32 patients suffering from dizziness related to arteriosclerosis. The

Causes in the ear include wax, otitis media, acute labyrinthitis, Ménière’s disease and postural vertigo. The two most common causes of severe vertigo are acute labyrinthitis and Ménière’s disease.

Acute labyrinthitis This occurs during an acute febrile disease such as influenza. The sense of whirling that the patient develops has a sudden onset. Nausea and vomiting may occur. The patient has to lie flat, and the slightest movement brings on the vertigo. The symptoms

Dizziness

gradually subside and disappear in 3–6 weeks. There is no accompanying tinnitus or hearing loss.

Ménière’s disease This is characterized by recurring bouts of sudden vertigo, tinnitus and deafness. In the intervals between bouts, the patient has complete freedom from vertigo but the tinnitus and deafness continue.

Eighth cranial nerve This can be affected by acute meningitis, trauma and tumours. Damage to the eighth nerve produces vertigo, nystagmus (involuntary rapid movement of the eyeball) and hearing loss.

Brainstem This can be affected by infections (encephalitis, meningitis), trauma, thrombosis of the posteroinferior cerebellar artery and multiple sclerosis.

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Damage to the brainstem causes vertigo and nystagmus but no hearing loss. Transient vertigo may be caused by a vascular spasm.

END NOTES 1. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 538. First published c.100 BC. 2. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 68. First published c.100 BC. 3. Ibid., p. 72. 4. Zhu Dan Xi 1347 Dan Xi Xin Fa [Essential Methods of Dan Xi] cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue [Internal Medicine in Chinese Medicine]. Shanghai Science Publishing House, Shanghai, p. 204. 5. 1986 Jing Yue Quan Shu [Complete Book of Jing Yue]. Shanghai Science Publishing House, Shanghai, p. 320. The Complete Book of Jing Yue was written by Zhang Jing Yue and first published in 1624. 6. Spiritual Axis, p. 73. 7. Ibid., p. 68. 8. Ibid., p. 73.

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CHAPTER 3

BREATHLESSNESS (CHUAN)

AETIOLOGY 78 External pathogenic factors 78 Irregular diet 79 Emotional problems 79 Overwork, chronic illness 79 PATHOLOGY

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IDENTIFICATION OF PATTERNS AND TREATMENT 81 Wind-Cold invading the Lungs 82 Wind-Cold on the Exterior, Phlegm-Fluids in the Interior 83 Cold on the Exterior, Heat in the Interior 84 Phlegm-Heat in the Lungs 84 Turbid Phlegm in the Lungs 85 Lung-Qi Obstructed 86 Liver-Fire invading the Lungs 86 Lung-Qi deficiency 88 Lung-Yin deficiency 88 Lung and Kidney deficiency 89 Lung- and Kidney-Yin deficiency 92 Lung- and Kidney-Yang deficiency, Fluids overflowing to Heart and Lungs 94 Lung-, Heart- and Kidney-Yang deficiency, Fluids overflowing to the Heart 94 PROGNOSIS AND PREVENTION Diet 97 Life habits 97 Preventive treatment 97

Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung and Kidney deficiency • Lung- and Kidney-Yin deficiency • Lung- and Kidney-Yang deficiency, Fluids overflowing to Heart and Lungs • Lung-, Heart- and Kidney-Yang deficiency, Fluids overflowing to the Heart

BREATHLESSNESS (CHUAN)

96

WESTERN DIFFERENTIAL DIAGNOSIS Causes in Lungs 97 Causes in Heart 99 General causes 99

Full • Wind-Cold invading the Lungs • Wind-Cold on the Exterior, Phlegm-Fluids in the Interior • Cold on the Exterior, Heat in the Interior • Phlegm-Heat in the Lungs • Turbid Phlegm in the Lungs • Lung-Qi Obstructed • Liver-Fire invading the Lungs

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Breathlessness was called Chuan in Chinese Medicine. Chuan means “to pant”. The symptoms and signs of breathlessness have been described in the Yellow Emperor’s Classic of Internal Medicine. In fact, the Simple Questions says in Chapter 22: “When the Lungs are diseased there is panting, cough, breathlessness, pain in the shoulders and back and sweating.”1 In Chapter 62, it says: “When Qi is in excess [in the chest] there is panting, cough and breathlessness; when Qi is deficient there is difficulty in breathing with shallow breath.”2 The Spiritual Axis in Chapter 20 says: “When pathogenic factors are in the Lungs, the skin is painful, there are feelings of heat and cold, panting, sweating, cough and pain in the shoulders.”3

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The Essential Prescriptions of the Golden Chest (AD 220) in Chapter 7 indicates “panting” as breathlessness at rest with inability to lie down. Also included is a “sound in the throat like a moorhen”.4 Thus, the term “panting” in Chinese medicine includes difficulty in breathing, breathing with an open mouth, lifting of the shoulders when breathing and inability to lie down. This could be an acute or chronic state. The discussion of breathlessness will be conducted according to the following topics. • • • • •

Aetiology Pathology Identification of patterns and treatment Prognosis and prevention Western differential diagnosis

AETIOLOGY External pathogenic factors Invasion of Wind-Cold or Wind-Heat is an important causative factor of breathlessness in many ways. First of all, both can cause acute breathlessness. External Wind obstructs the Lungs and prevents the diffusing and descending of Qi; this results in an accumulation of Qi in the chest and brings breathlessness. Second, an invasion of Wind-Cold or Wind-Heat can trigger off an acute attack in patients suffering from chronic breathlessness. Third, external Wind in itself is a frequent initial cause for the beginning of what eventually becomes chronic breathlessness. This is especially true in children. If a child suffers from an invasion of WindCold or Wind-Heat (or from repeated invasions) and the pathogen is not expelled properly (either through lack of treatment or through repeated treatment with antibiotics), the external pathogenic factor turns into Phlegm (with or without Heat) and it lodges itself in the Interior; there, it continuously obstructs the descending of Lung-Qi, causing chronic breathlessness. This is called residual pathogenic factor and it is a very common cause of chronic breathlessness in both adults and children. A residual pathogenic factor may be formed at the exterior stage of an invasion of Wind or when the Wind has become interior, usually turning itself into Heat (Fig. 3.1). When exterior Wind invades the body,

WIND

Expelled completely

WEI LEVEL

RESIDUAL PATHOGENIC FACTOR

Complete recovery

QI LEVEL

RESIDUAL PATHOGENIC FACTOR

YING-BLOOD LEVEL Figure 3.1 Formation of residual pathogenic factor.

it frequently upsets the ascending and descending of Spleen- and Stomach-Qi. This is even more likely to happen at the interior stage. For this reason, a residual pathogenic factor very frequently manifests with Dampness or Phlegm (Fig. 3.2). A frequent consequence of an invasion of Wind is interior Lung-Heat or Phlegm-Heat. Wind-Heat has a strong tendency to create interior Heat from its early stages by its drying action. Wind-Cold too, can turn into Heat once in the Interior. If there is a pre-existing condition of Lung-Heat, Wind-Cold can “lock” the

EXTERIOR PATHOGENIC FACTOR

Not expelled

RESIDUAL PATHOGENIC FACTOR

DAMPNESS/PHLEGM Disrupts ascending of SP-Qi and descending of ST-Qi INTERIOR PATHOGENIC FACTOR

Not cleared

DAMPNESS/PHLEGM Disrupts ascending of SP-Qi and descending of ST-Qi

RESIDUAL PATHOGENIC FACTOR Figure 3.2 Formation of Dampness and Phlegm in residual pathogenic factor.

Breathlessness (Chuan)

Heat in the Lungs, giving rise to breathlessness. As Lung-Qi fails to descend, fluids cannot be transformed and they accumulate into Phlegm. Phlegm, of course, becomes a cause of breathlessness in itself, as it further obstructs the descending of Lung-Qi in the chest. Phlegm-Heat in the Interior also obstructs the ascending of Spleen-Qi and the descending of StomachQi so that fluids cannot be transformed properly. This further contributes to forming Phlegm or Dampness and to making the condition chronic. For these reasons, Dampness or Phlegm is a very common result of any acute disease that becomes protracted. The possibility of the development of breathlessness from repeated invasions of external Wind (which occurs especially but not exclusively in children) is a further reason to treat all such invasions seriously and actively expel the pathogenic factor while it is still on the Exterior.

Irregular diet The excessive consumption of fats, dairy foods, sweets, sugar and raw-cold foods impairs the transformation and transportation of food essences and fluids by the Spleen. As fluids are not transformed, this eventually leads to the formation of Phlegm, which settles in the Lungs. In the Lungs, Phlegm obstructs the descending of Qi and causes breathlessness. This is an extremely common aetiological factor of breathlessness in Western societies, especially due to the excessive consumption of dairy foods such as milk, cheese, butter and cream.

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Overwork, chronic illness Overwork over a long period of time weakens KidneyYin. A deficiency of Kidney-Yin leads to the impairment of various Kidney functions, in this case that of receiving Qi. Thus the deficient Kidneys cannot receive and grasp Qi, which rebels upwards and obstructs the descending of Lung-Qi. This leads to a situation of Excess above and Deficiency below and therefore chronic breathlessness. Physical overexertion over a long period of time, or standing for too long, weakens Kidney-Yang, which then cannot receive Qi and hold it down. This leads to chronic breathlessness in exactly the same way as outlined above. Thus a Kidney deficiency (whether of Yin or Yang) is nearly always present in chronic breathlessness. For this reason, Ye Tian Shi (1667–1746) said of breathlessness: “If the Lungs are the cause, it is of the Excess type; if the Kidneys are the cause, it is of the Deficiency type.”5 A chronic deficiency of Lung-Qi or Lung-Yin such as one following an external invasion of Wind prevents Lung-Qi from descending and therefore leads to chronic cough and breathlessness.

SUMMARY AETIOLOGY  External pathogenic factors  Irregular diet  Emotional problems  Overwork, chronic illness

Emotional problems Worry, pensiveness or brooding over a long period of time weakens the Lung and Spleen. Lung-Qi becomes obstructed and this leads to breathlessness. Spleen-Qi is weakened and fluids are not transformed properly, and this leads to Phlegm, which is a contributing factor in chronic breathlessness. Anger, frustration, irritation or resentment over a long period of time causes Liver-Yang or Liver-Fire to rise. Rising, it can invade the Lungs and obstruct the descending of Lung-Qi. In Five-Element terms, this is called “Wood insulting Metal”. It is a fairly common cause of breathlessness, particularly in tense young people or children who are in a stressful family situation.

PATHOLOGY As outlined above, the causes of breathlessness primarily centre on the Lungs, Spleen and Kidneys. The Lungs, which govern Qi, are always involved, as in breathlessness Lung-Qi fails to descend. This failure to descend occurs when Lung-Qi is obstructed by exterior Wind or by Phlegm, or when it is deficient. The Kidneys are the root of Qi; they receive Qi and hold it down. Lungs and Kidney work in coordination for proper breathing as Lung-Qi descends to the Kidneys and the Kidneys hold it down. The Lungs control exhalation and the Kidney inhalation. Thus, in chronic breathlessness a difficulty in inhalation indicates

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The Practice of Chinese Medicine

Assists the descending of LU-Qi

LUNGS Lung-Qi not descending

BREATHLESSNESS

SPLEEN Spleen-Qi Xu leading to

LIVER

LUNGS

Phlegm

KIDNEYS Assists the ascending of LIV-Qi

Kidneys not receiving Qi Figure 3.3 The roles of Lungs, Spleen and Kidneys in the pathology of breathlessness.

Kidney deficiency, while a difficulty in exhalation points to a Lung deficiency. Although the pattern of Kidneys not receiving Qi, which is typical of chronic breathlessness, is a Yang-deficiency pattern, both Kidney-Yin and Kidney-Yang deficiency can lead to chronic breathlessness. Other organs are involved in breathlessness too. A deficiency of the Spleen leads to the formation of Phlegm, which obstructs the descending of Lung-Qi. Phlegm is often present, especially in bronchitic breathlessness (Fig. 3.3). Liver-Yang or Liver-Fire rising can impair the descending of Lung-Qi and lead to chronic breathlessness. This happens also because the Qi of the Lungs and the Qi of the Liver are coordinated: Liver-Qi ascends and Lung-Qi descends and the proper ascending/ descending is ensured by both organs functioning well. It should be pointed out that the ascending of Liver-Qi to the Lungs is physiological (Fig. 3.4). In pathology, when Liver-Qi is excessive and rebels upwards, it may prevent Lung-Qi from descending, causing breathlessness (Fig. 3.5). In very chronic cases in old people, the Heart may also be involved in two ways. First of all, the Heart vessels fill the lungs and Lung-Qi moves Blood. If LungQi is deficient, Blood is not moved and it stagnates in the lungs. This leads to right-heart failure due to retention of fluids in the lungs. Second, Kidney-Yang is the basis for Heart-Yang. When Kidney-Yang is deficient, the Fire of the Gate of

Figure 3.4 The coordination of Liver-Qi and Lung-Qi.

Rebellious Liver-Qi prevents the descending of Lung-Qi LUNGS

– LIVER

+ Figure 3.5 Rebellious Liver-Qi affecting the descending of Lung-Qi.

Life (Ming Men) fails to warm the Heart; fluids are not transformed and they accumulate in the Lungs and Heart. This is manifested with a profuse expectoration of white, watery, dilute and frothy sputum. There will also be a pronounced feeling of oppression of the chest and palpitations. It is called “Kidney-Yang deficient with Water overflowing to Lungs and Heart”. In even more chronic cases, the deficient Heart-Yang fails to move Blood in the chest and the stagnant fluids in the chest further obstruct Blood. This leads to stasis of Blood in the chest with symptoms of chest pain, cyanotic lips, dark nails and a Purple tongue. Thus, we can summarize the aetiology and pathology of chronic breathlessness with a diagram (Fig. 3.6).

Breathlessness (Chuan)

Invasion of exterior Wind

Overwork – Fatigue Excess sex – Constitution

LUNG-QI DEFICIENCY

KIDNEY DEFICIENCY

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Lung-Qi not descending Qi not transforming Water Kidney not holding Qi

HEART-QI DEFICIENT

CHRONIC ASTHMA Diet

Emotional problems

SPLEEN DEFICIENCY

LIVER-YANG LIVER-FIRE

Phlegm obstructs Lungs Qi not moving Blood

HEART-BLOOD STAGNANT

Liver-Yang or Liver-Fire rebelling towards the Lungs

Figure 3.6 Aetiology and pathology of breathlessness.

SUMMARY PATHOLOGY  The causes of breathlessness centre on the Lungs, Spleen and Kidneys primarily.  In breathlessness, Lung-Qi fails to descend.  In chronic breathlessness, a difficulty in inhalation indicates Kidney deficiency.  A deficiency of the Spleen leads to the formation of Phlegm, which obstructs the descending of Lung-Qi.  Liver-Yang or Liver-Fire rising can impair the descending of Lung-Qi and lead to chronic breathlessness.  If Lung-Qi is deficient, Blood is not moved and it stagnates in the lungs. This leads to rightheart failure due to retention of fluids in the lungs.  When Kidney-Yang is deficient, Heart-Yang becomes deficient; fluids are not transformed and accumulate in the Lungs and Heart.

IDENTIFICATION OF PATTERNS AND TREATMENT For the treatment of breathlessness, it is most important to differentiate Excess from Deficiency. In Excess-type of breathlessness, breathing is shallow and long, the person exhales quickly with a loud noise, there are loud wheezing sounds, there may be a cough

and the pulse is Slippery or Tight and Full. In Deficiencytype of breathlessness, breathing is short and rapid, the person inhales quickly with a low noise and the pulse is Weak. The Complete Book of Jing Yue (1624) says:6 In Excess-breathlessness breathing is long, there is a feeling of oppression of the chest, the breathing sounds are loud, the person cannot hold the breath in and breathes out quickly. In Deficiency-breathlessness breathing is short, the person is flustered, Qi is weak, breathing sounds are weak, breathing is interrupted and is worse on exertion. For the treatment of Excess conditions, one concentrates on treating the Manifestation and on expelling pathogenic factors. For the treatment of Deficiency cases, one concentrates on treating the Root and tonifying the body’s Qi. For example, in breathlessness from Phlegm-Heat (the Manifestation), even though it is a Spleen deficiency (the Root) that leads to Phlegm, the first priority is to resolve Phlegm and clear Heat rather than tonifying the Spleen. On the other hand, in chronic breathlessness from deficiency of Lungs and Kidneys (the Root), the primary task is to tonify Lungs and Kidneys and only secondarily relieve breathlessness and possibly resolve Phlegm (the Manifestation). The patterns analysed will be: Full • Wind-Cold invading the Lungs • Wind-Cold on the Exterior, Phlegm-Fluids in the Interior

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Cold on the Exterior, Heat in the Interior Phlegm-Heat in the Lungs Turbid Phlegm in the Lungs Lung-Qi Obstructed Liver-Fire invading the Lungs

Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung and Kidney deficiency • Lung- and Kidney-Yin deficiency • Lung- and Kidney-Yang deficiency, Fluids overflowing to Heart and Lungs • Lung-, Heart- and Kidney-Yang deficiency, Fluids overflowing to the Heart

• LU-6, Accumulation point, is used for acute Lung patterns and it stops breathlessness. • BL-12 and BL-13 with cupping release the Exterior and restore the diffusing and descending of LungQi. Moxa can be applied after needling and cupping if Cold is predominant. • Dingchuan (0.5 cun lateral to Du-14 Dazhui) stops acute breathlessness.

Herbal therapy Prescription MA HUANG TANG Ephedra Decoction

Explanation

Wind-Cold invading the Lungs Clinical manifestations Aversion to cold, shivering, fever, cough, breathlessness, a feeling of oppression of the chest, thin-white mucus, headache, no sweating. Pulse: Floating-Tight. External Wind-Cold invades the Lung’s Defensive-Qi energetic layer and it impairs the diffusing and descending of Lung-Qi; this causes the breathlessness and cough. This situation corresponds either to an acute attack of breathlessness or an acute exacerbation of chronic breathlessness. At this acute stage, the treatment must always be aimed at releasing the Exterior and expelling Wind-Cold even in chronic breathlessness.

Treatment principle Release the Exterior, restore the diffusing and descending of Lung-Qi, expel Wind-Cold.

This is the decoction to release the Exterior and expel Wind-Cold. It has a strong scattering effect and it makes Lung-Qi diffuse and descend. It is particularly indicated for acute breathlessness. This prescription has a definite warm energy and, in order to use it, one should be absolutely certain that the pathogenic factor is Wind-Cold rather than WindHeat.

Modifications • In case of Cold-Phlegm in the Lungs, add Ban Xia Rhizoma Pinelliae preparatum, Chen Pi Pericarpium Citri reticulatae, Su Zi Fructus Perillae, Zi Wan Radix Asteris and Bai Qian Rhizoma Cynanchi stauntonii.

Prescription GUI ZHI JIA HOU PO XING ZI TANG Cinnamomum Decoction plus Magnolia and Prunus

Acupuncture

Explanation

Points

This prescription releases the Exterior by harmonizing Defensive and Nutritive Qi; it relieves fullness of the chest and stops breathlessness. Use this formula if the patient is sweating (which indicates the prevalence of Wind over Cold in invasions of Wind-Cold).

LU-7 Lieque, LU-6 Kongzui, BL-12 Fengmen, BL-13 Feishu, Dingchuan extra-point. All with reducing method, cupping on BL-12 and BL-13. Direct moxa with cones is applicable to BL-12 after needling and cupping.

Explanation • LU-7 releases the Exterior, expels Wind-Cold and restores the diffusing and descending of Lung-Qi.

Three Treasures remedy Expel Wind-Cold Expel Wind-Cold releases the Exterior, expels Wind-Cold and restores the descending and diffusing of Lung-Qi.

Breathlessness (Chuan)

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SUMMARY

Treatment principle

WIND-COLD INVADING THE LUNGS

Release the Exterior, expel Wind-Cold, restore the descending of Lung-Qi, resolve Phlegm.

Points LU-7 Lieque, LU-6 Kongzui, BL-12 Fengmen, BL-13 Feishu, Dingchuan extra-point. All with reducing method, cupping on BL-12 and BL-13. Direct moxa with cones is applicable to BL-12 after needling and cupping. Herbal therapy Prescription MA HUANG TANG Ephedra Decoction Prescription GUI ZHI JIA HOU PO XING ZI TANG Cinnamomum Decoction plus Magnolia and Prunus Three Treasures remedy Expel Wind-Cold

Acupuncture Points LU-7 Lieque, LU-6 Kongzui, LU-5 Chize, BL-12 Fengmen, BL-13 Feishu, Dingchuan extra-point, P-6 Neiguan, ST-40 Fenglong, Ren-22 Tiantu. All with reducing or even method.

Explanation • • • • • • • •

LU-7 releases the Exterior and expels Wind-Cold. LU-6, Accumulation point, relieves breathlessness. LU-5 resolves Phlegm from the Lungs. BL-12 and BL-13 with cupping (with or without needling) release the Exterior. Dingchuan stops acute breathlessness. P-6 opens the chest, relieves a feeling of oppression of the chest and helps breathing. ST-40 resolves Phlegm and opens the chest. Ren-22 stimulates the descending of Lung-Qi and resolves Phlegm.

Wind-Cold on the Exterior, PhlegmFluids in the Interior

Herbal therapy

Clinical manifestations

XIAO QING LONG TANG Small Green Dragon Decoction

Aversion to cold, fever, shivering, headache, no sweating, breathlessness, cough with profuse white-watery sputum, difficulty in lying down, swelling of the limbs. Tongue: sticky-white coating. Pulse: Floating. This corresponds to an invasion of exterior WindCold in a person with a pre-existing condition of Phlegm-Fluids in the Interior. It is a situation of an acute exacerbation of chronic breathlessness. PhlegmFluids usually occur only in the elderly. Besides the typical symptoms and signs of exterior invasion (aversion to cold, shivering, fever, headache, no sweating and Floating pulse), there are symptoms of retention of Phlegm-Fluids in the Interior, i.e. breathlessness, cough with expectoration of profuse white-watery sputum and sticky tongue coating. The swelling of the limbs is due to Phlegm-Fluids retained subcutaneously. The person finds it difficult to lie down because of the Phlegm-Fluids stagnating in the chest.

Prescription

Explanation This decoction simultaneously releases the Exterior and resolves Phlegm-Fluids in the Interior.

SUMMARY WIND-COLD ON THE EXTERIOR, PHLEGMFLUIDS IN THE INTERIOR Points LU-7 Lieque, LU-6 Kongzui, LU-5 Chize, BL-12 Fengmen, BL-13 Feishu, Dingchuan extra-point, P-6 Neiguan, ST-40 Fenglong, Ren-22 Tiantu. All with reducing or even method. Herbal therapy Prescription XIAO QING LONG TANG Small Green Dragon Decoction

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Cold on the Exterior, Heat in the Interior Clinical manifestations

Explanation This formula is specific to release the Exterior and expel Wind-Cold and to clear interior Heat.

Breathlessness, distension or pain in the chest, coarse breathing, runny nose, cough, vomiting of sticky phlegm, feeling of heat, cold limbs, irritability, aches, thirst. Tongue: Red, coating white or yellow. Pulse: Slippery-Rapid. This corresponds to the second stage of an invasion of Wind-Cold, when Wind-Cold is still on the Exterior but interior Heat has already formed. Alternatively, it could occur in an invasion of Wind-Cold in a person with a pre-existing condition of interior Heat. It can therefore be either an acute attack of breathlessness or an acute exacerbation of chronic breathlessness precipitated by an invasion of Wind-Cold on a background of interior Lung-Heat. There are some symptoms of Cold on the Exterior, such as cold limbs, aches and runny nose, and some of interior Heat (of the Lungs), such as irritability, feeling of heat, coarse breathing, thirst, Rapid pulse and Red tongue.

Modifications

Treatment principle

Phlegm-Heat in the Lungs

Clear Heat, restore the descending of Lung-Qi.

Clinical manifestations

Acupuncture Points LU-7 Lieque, LU-6 Kongzui, LU-10 Yuji, LU-5 Chize, LU-1 Zhongfu, L.I.-11 Quchi. Reducing or even method.

Explanation • • • •

LU-7 restores the descending of Lung-Qi. LU-6 relieves acute breathlessness. LU-10 and LU-5 clear Lung-Heat. LU-1, Front-Collecting point, clears Lung-Heat, relieves fullness of the chest and stops breathlessness. • L.I.-11 clears Heat.

Herbal therapy Prescription MA XING SHI GAN TANG Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction

• In case of profuse phlegm, add Huang Qin Radix Scutellariae, Sang Bai Pi Cortex Mori and Gua Lou Fructus Trichosanthis.

SUMMARY COLD ON THE EXTERIOR, HEAT IN THE INTERIOR Points LU-7 Lieque, LU-6 Kongzui, LU-10 Yuji, LU-5 Chize, LU-1 Zhongfu, L.I.-11 Quchi. Reducing or even method. Herbal therapy Prescription MA XING SHI GAN TANG Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction

Cough, breathlessness, pain in the chest, profuse stickyyellow or blood-tinged sputum, irritability, a feeling of oppression in the chest, feeling of heat, sweating, thirst, red face, dry throat, dark urine, constipation. Tongue: Red with sticky-yellow coating. Pulse: Slippery-Rapid. This corresponds to the stage following an invasion of Wind-Cold or Wind-Heat, when the pathogenic factor turns into Heat and it settles in the Lungs. All the symptoms point to Lung-Heat. This pattern occurs often after an invasion of Wind when the pathogenic factor changes into Heat, penetrates the Interior and combines with Phlegm. In such cases, it is the cause of acute breathlessness. Phlegm-Heat in the Lungs is also a very common residual pathogenic factor in the Lungs in chronic breathlessness. It occurs at any age from childhood to old age.

Treatment principle Clear Heat, resolve Phlegm, clear the Lungs.

Breathlessness (Chuan)

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Acupuncture

Turbid Phlegm in the Lungs

Points

Clinical manifestations

LU-5 Chize, LU-1 Zhongfu, L.I.-11 Quchi, ST-40 Fenglong, Du-14 Dazhui. Reducing method, no moxa.

Breathlessness, difficulty in breathing out, a feeling of oppression and fullness of the chest, cough with profuse sticky-white sputum, vomiting or nausea, sticky taste, no thirst. Tongue: Swollen body, thick-sticky-white coating. Pulse: Slippery-Full. This condition is characterized by retention of Damp-Phlegm in the Lungs. Damp-Phlegm severely obstructs the descending of Lung-Qi, resulting in cough and breathlessness. Phlegm also impairs the circulation of Qi in the chest, thus causing a feeling of oppression and fullness of the chest and nausea or vomiting (as it also prevents the descending of Stomach-Qi).

Explanation • LU-5 clears Lung-Heat. • LU-1 clears Lung-Heat and relieves fullness and pain in the chest. • L.I.-11 clears Heat. • ST-40 resolves Phlegm. • Du-14 clears Heat.

Herbal therapy Prescription SANG BAI PI TANG Cortex Mori Decoction

Treatment principle Resolve Phlegm, restore the descending of Lung-Qi.

Explanation This formula clears Lung-Heat, resolves Phlegm and restores the descending of Lung-Qi.

Modifications • In case of high fever, add Shi Gao Gypsum fibrosum and Zhi Mu Radix Anemarrhenae. • In case of profuse phlegm, add Hai Ge Ke Concha Meretricis seu Cyclinae. • In case of intense thirst, add Tian Hua Fen Radix Trichosanthis. • In case of severe breathlessness with inability to lie down and sticky phlegm, add Da Huang Radix et Rhizoma Rhei and Mang Xiao Natrii Sulfas. • If phlegm tastes of bile, add Yu Xing Cao Herba Houttuniae, Dong Gua Zi Semen Benincasae, Yi Yi Ren Semen Coicis and Lu Gen Rhizoma Phragmitis.

SUMMARY

Acupuncture Points LU-5 Chize, LU-7 Lieque, LU-1 Zhongfu, P-6 Neiguan, ST-40 Fenglong, SP-6 Sanyinjiao, Ren-9 Shuifen, BL13 Feishu, BL-20 Pishu. Reducing or even method, except on BL-20 which should be reinforced.

Explanation • LU-5 and LU-7 expel Damp-Phlegm from the Lungs and restore the descending of Lung-Qi. • LU-1 relieves the feeling of oppression of the chest. • P-6 relieves fullness of the chest, stops nausea or vomiting and opens the chest, facilitating the expulsion of Phlegm. • ST-40, SP-6 and Ren-9 resolve Phlegm. • BL-13 stimulates the descending of Lung-Qi. • BL-20 tonifies the Spleen to resolve Phlegm.

PHLEGM-HEAT IN THE LUNGS

Herbal therapy

Points LU-5 Chize, LU-1 Zhongfu, L.I.-11 Quchi, ST-40 Fenglong, Du-14 Dazhui. Reducing method, no moxa.

Prescription

Herbal therapy Prescription SANG BAI PI TANG Cortex Mori Decoction

ER CHEN TANG plus SAN ZI YANG QIN TANG Two Old Decoction plus Three-Seed Nourishing the Parents Decoction

Explanation Er Chen Tang Two Old Decoction resolves Damp-Phlegm. San Zi Yang Qin Tang Three-Seed Nourishing the Parents Decoction was especially formulated to treat old people

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who have chronic Damp-Phlegm in the chest (hence its name).

Acupuncture

Modifications

LIV-3 Taichong, LIV-14 Qimen, SP-4 Gongsun and P-6 Neiguan, LU-1 Zhongfu, Ren-17 Shanzhong, LU-7 Lieque, HE-7 Shenmen, ST-40 Fenglong. All with even method.

• In case of severe breathlessness, other herbs which make Lung-Qi descend, such as Xing Ren Semen Armeniacae, should be added. • In case of profuse phlegm, add Cang Zhu Rhizoma Atractylodis and Hou Po Cortex Magnoliae officinalis.

SUMMARY TURBID PHLEGM IN THE LUNGS Points LU-5 Chize, LU-7 Lieque, LU-1 Zhongfu, P-6 Neiguan, ST-40 Fenglong, SP-6 Sanyinjiao, Ren-9 Shuifen, BL-13 Feishu, BL-20 Pishu. Reducing or even method, except on BL-20 which should be reinforced. Herbal therapy Prescription ER CHEN TANG plus SAN ZI YANG QIN TANG Two Old Decoction plus Three-Seed Nourishing the Parents Decoction

Points

Explanation • LIV-3 and LIV-14 soothe the Liver and relieve stagnation. LIV-14, in particular, will relieve stagnation of Qi in the chest. • SP-4 and P-6 in combination, open the Penetrating Vessel (Chong Mai), free the chest and subdue rebellious Qi in the chest. • LU-1, Ren-17 and LU-7 restore the descending of Lung-Qi, free the chest and relieve fullness. • HE-7 calms the Mind. • ST-40 is used to resolve Qi-Phlegm.

Herbal therapy Prescription WU MO YIN ZI Five Powders Decoction

Explanation

Lung-Qi Obstructed Clinical manifestations

This formula is specific to restore the descending of Lung-Qi when this is obstructed by rebellious Liver-Qi. It also calms the Mind.

Sudden attacks of breathlessness precipitated by emotional problems, no wheezing sounds, feeling of suffocation or constriction in the throat, a feeling of oppression or pain in the chest, palpitations, restless sleep. Tongue: Red sides. Pulse: Wiry. This condition is due to stagnant Liver-Qi rebelling upwards towards the chest. Rebellious Liver-Qi impairs the descending of Lung-Qi and causes breathlessness. This is typically caused by emotional problems, and the attacks are brought on by some stressful situation. The feeling of constriction or suffocation in the throat is due to stagnation of Liver-Qi and obstruction of the throat by Qi-Phlegm, i.e. a very rarefied type of Phlegm to the point of being nearly like Qi.

Liver-Fire invading the Lungs

Treatment principle

Clinical manifestations

Soothe the Liver, move Qi, restore the descending of Lung-Qi, calm the Mind, settle the Ethereal Soul.

Attacks of breathlessness precipitated by emotional stress, a feeling of oppression of the chest, chest pain,

SUMMARY LUNG-QI OBSTRUCTED Points LIV-3 Taichong, LIV-14 Qimen, SP-4 Gongsun and P-6 Neiguan, LU-1 Zhongfu, Ren-17 Shanzhong, LU-7 Lieque, HE-7 Shenmen, ST-40 Fenglong. All with even method. Herbal therapy Prescription WU MO YIN ZI Five Powders Decoction

Breathlessness (Chuan)

dream-disturbed sleep, short temper, thirst, bitter taste, dark urine, constipation, headache, red eyes and face. Tongue: Red, redder and swollen on the sides, yellow coating. Pulse: Wiry and Rapid. This condition includes aspects of the previous one, i.e. rebellious Liver-Qi invading the chest and obstructing the descending of Lung-Qi. In this case, however, it is Liver-Fire that carries Liver-Qi upwards towards the chest. From a Five-Element perspective, it corresponds to Wood “insulting” Metal (i.e. reverse Controlling cycle). Because Fire dries up the body fluids, there is thirst, dark urine and constipation. Fire also affects the Mind causing dream-disturbed sleep. This type of breathlessness is more common and may be seen in nervous, highly-strung children.

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Three Treasures remedy Drain Fire Drain Fire drains Liver-Fire.

SUMMARY LIVER-FIRE INVADING THE LUNGS Points LIV-2 Xingjian, LIV-14 Qimen, LU-7 Lieque, Ren-17 Shanzhong, LU-1 Zhongfu, BL-18 Ganshu, BL-13 Feishu. Reducing or even method. Herbal therapy Prescription LONG DAN XIE GAN TANG Variation Gentiana Draining the Liver Decoction Variation Three Treasures remedy Drain Fire

Treatment principle Soothe the Liver, drain Fire, restore the descending of Lung-Qi, calm the Mind, settle the Ethereal Soul.

Acupuncture Points LIV-2 Xingjian, LIV-14 Qimen, LU-7 Lieque, Ren-17 Shanzhong, LU-1 Zhongfu, BL-18 Ganshu, BL-13 Feishu. Reducing or even method.

Explanation • LIV-2 drains Liver-Fire. • LIV-14 soothes the Liver and relieves stagnation of Qi in the chest and ribs. • LU-7, Ren-17 and BL-13 restore the descending of Lung-Qi. • LU-1 relieves fullness and pain in the chest. • BL-18 drains Liver-Fire.

Herbal therapy Prescription LONG DAN XIE GAN TANG Variation Gentiana Draining the Liver Decoction Variation

Explanation This is a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction that drains Liver-Fire. Sang Bai Pi Cortex Mori, Di Gu Pi Cortex Lycii and Su Zi Fructus Perillae restore the descending of Lung-Qi and clear Heat in the chest.

Case history A 33-year-old woman had been suffering from breathlessness for the previous 2 years. She found it difficult to breathe out, and her attacks were elicited by emotional stress. She also easily felt thirsty and occasionally experienced a bitter taste in her mouth. She frequently had headaches of a throbbing nature on her temples, and she generally felt wound-up and frustrated. She also easily felt hot and occasionally had palpitations. Her pulse was Wiry and her tongue was Red with redder sides and tip, with a shallow midline Heart crack. The sides also had red points. Diagnosis This was a very clear case of breathlessness due to Liver-Fire rebelling upwards towards the chest and obstructing the Lungs. It was also clearly due to emotional tensions mostly to do with her relationship with her father. Although Liver-Fire was the main problem, there was also some Heart-Fire, as shown by the shallow Heart crack, red tip of the tongue and palpitations. Treatment She was treated with herbs only with the following variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction. • Long Dan Cao Radix Gentianae 6 g • Huang Qin Radix Scutellariae 4 g • Shan Zhi Zi Fructus Gardeniae 4 g

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Ze Xie Rhizoma Alismatis 6 g Sheng Di Huang Radix Rehmanniae 6 g Chai Hu Radix Bupleuri 6 g Suan Zao Ren Semen Ziziphi spinosae 6 g He Huan Pi Cortex Albiziae 6 g Hou Po Cortex Magnoliae officinalis 3 g Su Zi Fructus Perillae 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g

This is almost like the original decoction with the addition of Suan Zao Ren Semen Ziziphi spinosae and He Huan Pi Cortex Albiziae to calm the Mind, and Hou Po Cortex Magnoliae officinalis to relieve fullness of the chest and also to calm the Mind. The treatment stopped her breathlessness and helped her to calm down and achieve a more balanced emotional life.

Lung-Qi deficiency Clinical manifestations Shortness of breath, weak lung sounds, slight rattling sound in the throat, sweating, chilliness, pale face, weak voice, expectoration of scanty phlegm. Tongue: Pale. Pulse: Weak, especially on the right Front position.

• ST-36 tonifies Stomach and Spleen and this helps the Lungs according to the principle of “strengthening Earth to tonify Metal”.

Herbal therapy Prescription BU FEI TANG Tonifying the Lungs Decoction

Explanation This formula tonifies Lung-Qi and restores the descending of Lung-Qi.

SUMMARY LUNG-QI DEFICIENCY Points LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, Ren-6 Qihai, ST-36 Zusanli. Reinforcing method. Herbal therapy Prescription BU FEI TANG Tonifying the Lungs Decoction

Treatment principle

Lung-Yin deficiency

Tonify the Lungs, strengthen Qi, restore the descending of Lung-Qi.

Clinical manifestations

Acupuncture Points LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, Ren-6 Qihai, ST-36 Zusanli. Reinforcing method.

Explanation • LU-7 and LU-9 tonify the Lungs and restore the descending of Lung-Qi. • BL-13 and Du-12 tonify Lung-Qi. Direct moxa can be used. • Ren-12 and Ren-6 tonify Qi in general and they are also concentration points along the Lung channel, which starts over Ren-12 and flows down to Ren-6 before coursing back upwards.

Shortness of breath, chronic breathlessness, sweating at night, dry throat, dry cough with scanty sputum, malar flush. Tongue: dry and without coating, Red body if there is Empty Heat. Pulse: Floating-Empty or Fine, Rapid and Weak in the right Front position. Lung-Yin deficiency can occur in combination with Lung-Qi deficiency. Yin deficiency is more common in old people. Only in very advanced cases would the tongue be completely without coating. In other cases, it could have a rootless coating or lack a coating only in the front part.

Treatment principle Nourish Lung-Yin and restore the descending of Lung-Qi.

Breathlessness (Chuan)

Acupuncture Points LU-9 Taiyuan, LU-7 Lieque and KI-6 Zhaohai in combination, BL-43 Gaohuangshu, Ren-4 Guanyuan, BL-13 Feishu, Du-12 Shenzhu. Reinforcing method.

Explanation • LU-9 tonifies Lung-Yin. • LU-7 and KI-6 open the Directing Vessel, nourish Yin, restore the descending of Lung-Qi and benefit the throat. The combination of these two points is excellent in cases of chronic breathlessness from Lung-Yin deficiency or both Lung- and Kidney-Yin deficiency. • BL-43 nourishes Lung-Yin and is particularly effective in very chronic diseases. • Ren-4 nourishes Yin in general and strengthens the Kidney’s grasping of Qi. • BL-13 and Du-12 tonify Lung-Qi.

Herbal therapy Prescription SHENG MAI SAN Generating the Pulse Powder

Explanation This is the best prescription to tonify Lung-Yin. However, in cases of chronic breathlessness, herbs that restore the descending of Lung-Qi, such as Xing Ren Semen Armeniacae or Su Zi Fructus Perillae, should be added. Alternatively, this prescription could simply be combined with the previous one. They would combine particularly well also because they have two herbs in common (Ren Shen Radix Ginseng and Wu Wei Zi Fructus Schisandrae).

SUMMARY LUNG-YIN DEFICIENCY Points LU-9 Taiyuan, LU-7 Lieque and KI-6 Zhaohai in combination, BL-43 Gaohuangshu, Ren-4 Guanyuan, BL-13 Feishu, Du-12 Shenzhu. Reinforcing method.

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Herbal therapy Prescription SHENG MAI SAN Generating the Pulse Powder

Lung and Kidney deficiency Clinical manifestations Chronic breathlessness, attacks brought on by exertion, difficulty in inhalation, loss of weight, depression, oedema of ankles, cold limbs, lower backache, dizziness, weak knees. Tongue: Pale, Swollen. Pulse: Deep, Weak, Slow. This condition corresponds to Yang deficiency of both Lungs and Kidneys, with the Kidneys unable to grasp Qi. It results in the situation that is described in Chinese medicine as “Fullness above and Emptiness below”, i.e. deficiency of the Kidneys with relative Fullness in the Lungs. This pattern is due to Kidney-Yang deficiency, hence the oedema of ankles, cold limbs, weak knees, dizziness, depression, Pale and Swollen tongue, and Deep and Weak pulse. As Kidneys control inhalation, typically the patient would find it more difficult to breathe in.

Treatment principle Tonify and warm the Kidneys, stimulate the descending of Lung-Qi.

Acupuncture Points BL-23 Shenshu, BL-13 Feishu, Du-4 Mingmen, KI-7 Fuliu, KI-25 Shencang, KI-3 Taixi, LU-7 Lieque. Reinforcing method, moxa.

Explanation • BL-23 and KI-7 tonify Kidney-Yang. • Du-4 tonifies the Fire of the Gate of Life (Ming Men). Used with moxa, it strongly tonifies Yang. • KI-25 is an important local point to relieve fullness of the chest and breathlessness caused by Kidney deficiency. • KI-3, source point, tonifies the Kidneys. • LU-7 stimulates the descending of Lung-Qi.

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Herbal therapy

Three Treasures remedy

Prescription

Clear Qi Clear Qi is a variation of Su Zi Jiang Qi Tang and it tonifies Kidney-Yang and restores the descending of Lung-Qi in chronic breathlessness.

JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill

Explanation

SUMMARY

This is the classic formula to tonify and warm KidneyYang, derived from Zhang’s Discussion of Cold-induced Diseases of the Han dynasty. Later versions of this formula replace Gui Zhi Ramulus Cinnamomi cassiae with Rou Gui Cortex Cinnamomi.

LUNG AND KIDNEY DEFICIENCY

Modifications • When used for chronic Kidney-breathlessness, some herbs which promote the descending of Lung-Qi should be added, such as Su Zi Fructus Perillae or Xing Ren Semen Armeniacae.

Prescription

Points BL-23 Shenshu, BL-13 Feishu, Du-4 Mingmen, KI-7 Fuliu, KI-25 Shencang, KI-3 Taixi, LU-7 Lieque. Reinforcing method, moxa. Herbal therapy Prescription JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill Prescription SHEN GE SAN Ginseng-Gecko Powder

SHEN GE SAN Ginseng-Gecko Powder

Prescription SU ZI JIANG QI TANG Perilla Seed Lowering Qi Decoction

Explanation

Three Treasures remedy Clear Qi

This formula is specific to tonify the Kidney’s receiving of Qi in chronic breathlessness from Kidney-Yang deficiency. It can be used when the symptoms of Yang deficiency are not very pronounced.

Prescription SU ZI JIANG QI TANG Perilla Seed Lowering Qi Decoction

Explanation This prescription differs from the previous two in that it deals with both the “Emptiness below” and the “Fullness above”. It is therefore better indicated when there is pronounced fullness of the chest with expectoration of white phlegm and cough. It deals with both the Manifestation (accumulation of Qi in the Lungs) and the Root (deficiency of the Kidneys).

Modifications • If Qi rebels upwards and there is a feeling of movement under the umbilicus, add Chen Xiang Lignum Aquilariae resinatum.

Case history A 48-year-old woman had been suffering from breathlessness for the previous 10 years. She found it difficult to breathe in and the condition was worse at night. The breathlessness seemed to have started after her being caught in a dust storm in the Middle East, following which she contracted bronchopneumonia. She had had pneumonia previously as a child. She had also experienced fluid retention in the abdomen and ankles for the previous 10 years. She was often constipated and felt cold, especially in the legs. Her pulse was Fine and Deep and particularly Weak in both Rear positions. Her tongue was Pale and Swollen and had a sticky-white coating (Plate 3.1). Diagnosis This is a clear condition of breathlessness from Lung- and Kidney-Yang deficiency. She obviously had had a weakness in the Lungs since childhood

Breathlessness (Chuan)

deriving from the pneumonia, later aggravated by the bronchopneumonia 10 years before. Because of her age, the Kidney energy started to decline and, combining with the Lung deficiency, triggered off the onset of her breathlessness. The Kidney-Yang deficiency is confirmed by the fluid retention, the constipation, the cold feeling of the legs and the very Weak pulse on both Rear positions. Treatment This lady was treated with both acupuncture and herbs. The acupuncture treatment was very simple, basically aimed at tonifying the Lungs and Kidneys with ST-36 Zusanli, SP-6 Sanyinjiao, BL-13 Feishu, Du-12 Shenzhu and BL-23 Shenshu. In addition to these points, the Directing Vessel opening points were used every time, i.e. LU-7 Lieque on the right and KI-6 Zhaohai on the left to tonify Lungs and Kidneys. The herbal prescription used was a variation of Su Zi Jiang Qi Tang Perilla Seed Lowering Qi Decoction. • • • • • • • •

Su Zi Semen Perillae 6 g Fa Ban Xia Rhizoma Pinelliae preparatum 6 g Qian Hu Radix Peucedani 4 g Hou Po Cortex Magnoliae officinalis 4 g Rou Gui Cortex Cinnamomi 1.5 g Dang Gui Radix Angelicae sinensis 6 g Rou Cong Rong Herba Cistanches 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g

The combination of acupuncture and Chinese herbs produced an immediate improvement, which then continued steadily until most of her symptoms were relieved after a few months.

Case history A 42-year-old lady had suffered from breathlessness since the age of 7. It had got worse since moving to an old and dusty house 13 years previously. She found it difficult to breathe in, and the condition was worse at night and worse from exposure to cold or dust. She also suffered from lower backache and dizziness. She had borne two children and her breathlessness had been better during both pregnancies. She felt cold easily and her ankles often swelled up. As a 6-month-old baby, she had contracted whooping cough that lasted for a long time.

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Her pulse was Deep and Weak, especially on both Rear positions (Kidneys). Her tongue was Red, Stiff and had a shallow Stomach crack with a yellow coating (Plate 3.2). Diagnosis The breathlessness was due to a deficiency of the Yang of both Lungs and Kidneys. Originally, it may have been due to a Lung deficiency only, following the weakening of the Lungs from whooping cough. Later on, the onset of Kidney deficiency contributed to the breathlessness. Difficulty in breathing in, feeling cold, backache, swollen ankles, dizziness and Weak pulse on Rear positions all indicated Kidney (Yang) deficiency. The fact that she got better during the pregnancies also pointed to a Kidney deficiency. However, the tongue pointed to another coexisting condition of Heat and Phlegm. The deficient Lung and Kidneys failing to transform fluids led to the formation of Phlegm, which further aggravated the breathlessness. After a long time, Phlegm easily leads to the formation of Heat. Thus, this case shows a clear combination of Deficiency (of Lungs and Kidneys) and Excess (Phlegm-Heat in the Lungs) and of Cold (from Kidney-Yang deficiency) and Heat (in the Lungs). The Root is the deficiency of Lung- and Kidney-Yang, while the Phlegm-Heat in the Lungs is the Manifestation. Treatment Because this is an internal condition, we can treat both the Root and the Manifestation simultaneously, i.e. tonifying Lung- and Kidney-Yang, restoring the descending of Lung-Qi and resolving Phlegm and clearing Heat. As the pathogenic factor is internal, we can simultaneously tonify the body’s Qi (i.e. Lung- and Kidney-Yang) and expel the pathogenic factor (i.e. Phlegm-Heat). She was treated with acupuncture only using the following points at various times during 12 months of treatment: • Ren-12 Zhongwan, Ren-9 Shuifen and ST-40 Fenglong were used to resolve Phlegm. In addition, ST-40, in combination with P-6 Neiguan, opens the chest and helps breathing. • P-6 Neiguan was used to open the chest and alleviate breathlessness. • Directing Vessel (i.e. LU-7 Lieque on the right and KI-6 Zhaohai on the left) was used several times to restore the descending of Lung-Qi and stimulate the Kidney’s grasping of Qi. This

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extraordinary vessel is very important for the treatment of chronic breathlessness from Lung and Kidney deficiency. • BL-13 Feishu, BL-20 Pishu and BL-23 Shenshu were used to tonify and warm Lungs, Spleen and Kidneys with needles and moxa. • LU-5 Chize was used to clear Heat and resolve Phlegm from the Lungs. • KI-7 Fuliu and SP-6 Sanyinjiao were used to tonify Spleen- and Kidney-Yang and resolve oedema. Needles and moxa were used. This patient’s attacks of breathlessness drastically decreased in intensity and frequency over a 12-month period of treatment.

Case history A 39-year-old woman had suffered from breathlessness since the age of 4. She found it difficult to breathe in, sweated easily in the daytime and usually felt cold. She tired easily and also suffered from what was diagnosed as allergic rhinitis. Her nose was almost always running (white mucus), and she frequently sneezed when exposed to dust and to dogs or cats. She also had myomas in the uterus, which occasionally caused bleeding in between periods. The blood was not dark and there were no clots. Her pulse was generally Weak and her tongue was Pale, with swollen edges (of the Spleen-type), a dirty coating all over and two deep transversal cracks in the Lung area. Diagnosis This breathlessness is also due to Lungand Kidney-Yang deficiency. It started in childhood with a Lung deficiency most probably due to repeated invasions of Wind not treated properly (see two transversal Lung cracks). It later affected the Kidneys, as well as becoming unable to grasp Qi. The Spleen is also deficient as evidenced by the tiredness, the swelling on the edges of the tongue and the Weak pulse. Symptoms of Lung deficiency are the breathlessness and the daytime sweating. The difficulty in breathing in is due to Kidney deficiency. Besides this, there is also Phlegm deriving from the deficiency of Spleen, Lungs and Kidneys. The Phlegm can be observed in the swelling of the tongue, the dirty tongue coating and the myomas in the uterus (these could also be

due to stasis of Blood, but this was not the case in this instance as the blood was not dark with clots). Treatment In this case, as in the previous one, the condition is internal and we can treat both the Root (deficiency of Yang of the Spleen, Lungs and Kidneys) and the Manifestation (Phlegm). On the one hand, one can tonify the body’s Qi, and on the other one can resolve Phlegm. This woman was treated with acupuncture only with the following selection of points over a period of 8 months. • Directing Vessel (i.e. LU-7 Lieque on the right and KI-6 Zhaohai on the left). This combination of points opens the Directing Vessel, restores the descending of Lung-Qi and stimulates the grasping of Qi by the Kidneys. • Ren-12 Zhongwan, Ren-9 Shuifen and ST-40 Fenglong to resolve Phlegm. • ST-36 Zusanli and BL-20 Pishu with needles and moxa to warm and tonify the Spleen. • BL-13 Feishu and Du-12 Shenzhu to tonify and warm the Lungs. • BL-23 Shenshu and KI-7 Fuliu to tonify and warm the Kidneys. • L.I.-20 Yingxiang to expel Wind and stop sneezing.

Lung- and Kidney-Yin deficiency Clinical manifestations Chronic breathlessness, difficulty in breathing in, dry throat, dry cough, night sweating, malar flush. Tongue: without coating, cracks in Lung area, dry, Red body if there is Empty Heat. Pulse: Floating-Empty. Generally speaking, the Kidney’s grasping Qi is a Yang function. However, when Kidney-Yin is deficient, it also fails to grasp Qi, leading to breathlessness.

Treatment principle Nourish Yin, strengthen Lung and Kidneys, restore the descending of Lung-Qi.

Acupuncture Points LU-9 Taiyuan, Ren-17 Shanzhong, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, Ren-4 Guanyuan, KI-3

Breathlessness (Chuan)

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SUMMARY

Taixi, LU-7 Lieque and KI-6 Zhaohai in combination, KI-25 Shencang. All with reinforcing method except KI-25, which should be needled with even method.

LUNG- AND KIDNEY-YIN DEFICIENCY Points LU-9 Taiyuan, Ren-17 Shanzhong, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, Ren-4 Guanyuan, KI-3 Taixi, LU-7 Lieque and KI-6 Zhaohai in combination, KI-25 Shencang. All with reinforcing method except KI-25 which should be needled with even method.

Explanation • LU-9 and Ren-17 tonify the Lungs and promote the descending of Lung-Qi. • ST-36 and Ren-12 strengthen Earth to reinforce Metal. • SP-6 and Ren-4 nourish Yin. • KI-3 nourishes the Kidneys. • LU-7 and KI-6 nourish Kidney-Yin, restore the descending of Lung-Qi, and benefit the throat. They open the Directing Vessel and are ideal for this type of breathlessness. • KI-25 is a local point to stimulate the Kidney’s grasping of Qi in chronic breathlessness from Kidney deficiency.

Herbal therapy Prescription BA XIAN CHANG SHOU WAN Eight Immortals Longevity Pill Prescription EMPIRICAL PRESCRIPTION BY DR DONG JIAN HUA8

Herbal therapy Prescription BA XIAN CHANG SHOU WAN Eight Immortals Longevity Pill

Explanation This is the main formula for deficiency of both Lungand Kidney-Yin. It is a variation of Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill (which nourishes Liver- and Kidney-Yin), with the addition of Mai Men Dong Radix Ophiopogonis and Wu Wei Zi Fructus Schisandrae to nourish Lung-Yin and absorb leakages (such as night sweating).

Modifications • To treat chronic breathlessness, one or two herbs to stimulate the descending of Lung-Qi should be added, as indicated for the previous prescriptions. • In the case of symptoms of rising Yang (such as dizziness and headaches), add Long Gu Mastodi Ossis fossilia and Mu Li Concha Ostreae.

Prescription EMPIRICAL PRESCRIPTION BY Dr Dong Jian Hua7

Explanation This formula tonifies both Kidney-Yin and KidneyYang as well as Lung-Yin; it promotes the descending of Lung-Qi and stops breathlessness.

Case history A 43-year-old man had complained of hay fever and breathlessness for the past 18 years. He found it difficult to breathe in and often sweated at night. His lower back was sore and he suffered from slight tinnitus in one ear. His throat was dry. His pulse was slightly Floating-Empty in general and Weak in the right Front position. His tongue was slightly Red, with rootless coating, and dry. Diagnosis This man’s breathlessness was due to Lungand Kidney-Yin deficiency. The Lung-Yin deficiency is evident from the dry throat and the rootless coating on the tongue. The Kidney-Yin deficiency caused the backache, tinnitus, difficulty in breathing in, night sweating and Floating-Empty pulse. Treatment A variation of Ba Xian Chang Shou Wan Eight Immortals Longevity Pill was used. • • • • • • • •

Shu Di Huang Radix Rehmanniae preparata 12 g Shan Zhu Yu Fructus Corni 4 g Shan Yao Rhizoma Dioscoreae 6 g Ze Xie Rhizoma Alismatis 4 g Mu Dan Pi Cortex Moutan 4 g Fu Ling Poria 6 g Mai Men Dong Radix Ophiopogonis 6 g Wu Wei Zi Fructus Schisandrae 4 g

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• Xing Ren Semen Armeniacae 4 g • Su Zi Semen Perillae 6 g • Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g

Herbal therapy

Lung- and Kidney-Yang deficiency, Fluids overflowing to Heart and Lungs

Explanation

Clinical manifestations Chronic breathlessness, cough with expectoration of white-watery sputum, a feeling of oppression of the chest, palpitations, oedema, scanty urination, chilliness. Tongue: Pale, Swollen, wet. Pulse: Deep-Weak-Slow. This condition is due to deficiency of Yang of Lung and Kidneys, leading to the accumulation of PhlegmFluids in the Lungs and Heart. The expectoration of white-watery sputum is typical of Phlegm-Fluids.

Prescription ZHEN WU TANG Variation True Warrior Decoction Variation

This formula tonifies and warms Spleen- and KidneyYang, restores the descending of Lung-Qi and resolves Phlegm-Fluids.

Modifications • In cases of Heart-Yang deficiency as well, with Phlegm-Fluids in the Heart leading to stasis of Blood (purple face, cyanotic lips, dark nails, Purple tongue), add Dan Shen Radix Salviae miltiorrhizae, Hong Hua Flos Carthami tinctorii, Tao Ren Semen Persicae and Chuan Xiong Rhizoma Chuanxiong.

Treatment principle

SUMMARY

Tonify and warm Lung and Kidneys, resolve PhlegmFluids, stimulate the descending of Lung-Qi.

LUNG- AND KIDNEY-YANG DEFICIENCY, FLUIDS OVERFLOWING TO HEART AND LUNGS

Acupuncture Points LU-7 Lieque, L.I.-6 Pianli, Ren-17 Shanzhong, Ren-12 Zhongwan, Ren-9 Shuifen, KI-7 Fuliu, Ren-6 Qihai, SP-6 Sanyinjiao, ST-40 Fenglong, P-6 Neiguan, BL-20 Pishu, BL-23 Shenshu, BL-22 Sanjiaoshu, BL-13 Feishu, BL-15 Xinshu. All with reinforcing method except for LU-7, L.I.-6 and Ren-9, which should be needled with even method. Moxa.

Explanation • LU-7, L.I.-6 and Ren-17 stimulate the descending of Lung-Qi and open the Lung Water passages to resolve oedema. • Ren-12, Ren-9 and Ren-6 tonify Qi and resolve oedema. • KI-7 and SP-6 tonify the Kidneys and resolve oedema. • ST-40 resolves Phlegm. • P-6 opens the chest, thus relieving the feeling of oppression of the chest, and tonifies Heart-Yang. • BL-20, BL-23 and BL-22 tonify Spleen- and KidneyYang and stimulate the transformation of fluids in the Lower Burner to resolve oedema. • BL-13 and BL-15 tonify Lung- and Heart-Yang.

Points LU-7 Lieque, L.I.-6 Pianli, Ren-17 Shanzhong, Ren-12 Zhongwan, Ren-9 Shuifen, KI-7 Fuliu, Ren-6 Qihai, SP-6 Sanyinjiao, ST-40 Fenglong, P-6 Neiguan, BL-20 Pishu, BL-23 Shenshu, BL-22 Sanjiaoshu, BL-13 Feishu, BL-15 Xinshu. All with reinforcing method except for LU-7, L.I.-6 and Ren-9 which should be needled with even method. Moxa. Herbal therapy Prescription ZHEN WU TANG Variation True Warrior Decoction Variation

Lung-, Heart- and Kidney-Yang deficiency, Fluids overflowing to the Heart Clinical manifestations Chronic breathlessness, a feeling of oppression and pain of the chest, nausea, cyanotic lips, purple face and nails, expectoration of white-watery sputum, difficulty in lying down, oedema, chilliness, lower backache, weak knees, scanty but pale urine.

Breathlessness (Chuan)

Tongue: Bluish-Purple and Swollen. Pulse: Deep-Slow-Knotted. This condition only occurs in old people suffering from chronic breathlessness. It is characterized by deficiency of Yang of Lungs, Kidneys and Heart leading to the formation of Phlegm-Fluids (manifesting with white-watery expectoration). These overflow to the Lungs and Heart. In the Lungs, they further impair the descending of Lung-Qi and aggravate the breathlessness. In the Heart, they obstruct the circulation of Blood in the chest, leading to pain in the chest and cyanotic colour of face, nails, lips and tongue. The deficiency of Kidney-Yang causes backache, weak knees and scanty urination.

Treatment principle Tonify and warm Lungs, Heart and Kidneys, resolve Phlegm, restore the descending of Lung-Qi, invigorate Blood and eliminate stasis.

Acupuncture Points LU-7 Lieque, L.I.-6 Pianli, Ren-17 Shanzhong, Ren-12 Zhongwan, Ren-9 Shuifen, KI-7 Fuliu, Ren-6 Qihai, SP-6 Sanyinjiao, ST-40 Fenglong, P-6 Neiguan, BL-20 Pishu, BL-23 Shenshu, BL-22 Sanjiaoshu, BL-13 Feishu, BL-15 Xinshu, BL-17 Geshu, SP-10 Xuehai. Reinforcing method except on LU-7, L.I.-6, Ren-9, SP-6 and ST-40, which should be needled with even method. Moxa.

Explanation • LU-7, L.I.-6 and Ren-17 stimulate the descending of Lung-Qi and open the Lung’s Water passages to resolve oedema. • Ren-12, Ren-9 and Ren-6 tonify Qi and resolve oedema. • KI-7 and SP-6 tonify the Kidneys and resolve oedema. • ST-40 resolves Phlegm. • P-6 opens the chest thus relieving the feeling of oppression and tonifies Heart-Yang. • BL-20, BL-23 and BL-22 tonify Spleen- and KidneyYang and stimulate the transformation of fluids in the Lower Burner to resolve oedema. • BL-13 and BL-15 tonify Lung- and Heart-Yang. • BL-17 and SP-10 move Blood and eliminate stasis.

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Herbal therapy Prescription LING GUI ZHU GAN TANG, LING GAN WU WEI JIANG XIN TANG and ZHEN WU TANG Variation Poria-Cinnamomum-Atractylodes-Glycyrrhiza Decoction, Poria-Glycyrrhiza-Schisandra-Zingiber-Asarum Decoction and True Warrior Decoction Variation

Explanation Although this is a variation of three prescriptions, there is quite an overlap of ingredients among the three prescriptions so that the total ingredients are not too many. The first prescription, Ling Gui Zhu Gan Tang (Poria-Cinnamomum-Atractylodes-Glycyrrhiza Decoction), tonifies Spleen-Yang and resolves PhlegmFluids in the chest. It alleviates nausea, a feeling of oppression of the chest and breathlessness. The second prescription, Ling Gan Wu Wei Jiang Xin Tang (Poria-Glycyrrhiza-Schisandra-Zingiber-Asarum Decoction), warms the Lungs, resolves Phlegm-Fluids and relieves breathlessness and a feeling of oppression of the chest. The third prescription, used for the previous pattern, tonifies Spleen- and Kidney-Yang and resolves oedema. To these three prescriptions were added Chuan Xiong Rhizoma Chuanxiong and Dan Shen Radix Salviae miltiorrhizae to move Blood in the chest and eliminate stasis, and Sang Bai Pi Cortex Mori and Su Zi Fructus Perillae to restore the descending of Lung-Qi.

SUMMARY LUNG-, HEART- AND KIDNEY-YANG DEFICIENCY, FLUIDS OVERFLOWING TO THE HEART Points LU-7 Lieque, L.I.-6 Pianli, Ren-17 Shanzhong, Ren-12 Zhongwan, Ren-9 Shuifen, KI-7 Fuliu, Ren-6 Qihai, SP-6 Sanyinjiao, ST-40 Fenglong, P-6 Neiguan, BL-20 Pishu, BL-23 Shenshu, BL-22 Sanjiaoshu, BL-13 Feishu, BL-15 Xinshu, BL-17 Geshu, SP-10 Xuehai. Reinforcing method except on LU-7, L.I.-6, Ren-9, SP-6 and ST-40, which should be needled with even method. Moxa.

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Herbal therapy Prescription LING GUI ZHU GAN TANG, LING GAN WU WEI JIANG XIN TANG and ZHEN WU TANG Variation Poria-Cinnamomum-Atractylodes-Glycyrrhiza Decoction, Poria-Glycyrrhiza-Schisandra-ZingiberAsarum Decoction and True Warrior Decoction Variation

• • • • • • • •

Gan Jiang Rhizoma Zingiberis 1.5 g Fu Zi Radix Aconiti lateralis preparata 3 g Bai Shao Radix Paeoniae alba 6 g Dan Shen Radix Salviae miltiorrhizae 4 g Chuan Xiong Rhizoma Chuanxiong 4 g Sang Bai Pi Cortex Mori 6 g Su Zi Fructus Perillae 6 g Xing Ren Semen Armeniacae 4 g

PROGNOSIS AND PREVENTION Case history A 75-year-old woman suffered from breathlessness for 40 years. The breathlessness started after double pneumonia and collapse of a lung. She was treated with prednisolone for many years. She found it difficult to breathe in or out, had a sensation of oppression of the chest and slight nausea. Her lips were slightly cyanotic and she expectorated white-watery sputum. She easily felt cold and her back and knees ached. Occasionally she felt palpitations. Her tongue was very Pale but also Bluish on the sides (chest area) and very Swollen. Her pulse was Deep, Weak and Slow. It was particularly Weak on both Rear positions. Diagnosis This condition is due to extreme deficiency of Yang of the Lungs, Heart, Spleen and Kidneys, leading to Phlegm-Fluids in the Lungs and Heart. Treatment Because of her age and the prolonged use of prednisolone, her condition could be only improved, not cured. She was treated with herbal medicine using a variation of Ling Gui Zhu Gan Tang, Ling Gan Wu Wei Jiang Xin Tang and Zhen Wu Tang (Poria-Ramulus Cinnamomum-Atractylodes-Glycyrrhiza Decoction, Poria-Glycyrrhiza-Schisandra-ZingiberAsarum Decoction and True Warrior Decoction). • • • •

Fu Ling Poria 10 g Gui Zhi Ramulus Cinnamomi cassiae 3 g Bai Zhu Rhizoma Atractylodis macrocephalae 9 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g • Wu Wei Zi Fructus Schisandrae 4 g

Both acupuncture and herbal medicine are effective in treating breathlessness. The kind of results obtained depends on the duration of the disease and the condition of the patient. Generally speaking, acute patterns respond very quickly while chronic conditions obviously respond slowly. For example, the first three patterns described, i.e. Wind-Cold invading the Lungs, Wind-Cold on the Exterior, Phlegm-Fluids in the Interior and Cold on the Exterior, Heat in the Interior are acute conditions and should therefore respond to treatment in a few sessions with a combination of acupuncture and herbs. The other Excess patterns of Phlegm-Heat in the Lungs, Turbid Phlegm in the Lungs, Lung-Qi Obstructed and Liver-Fire invading the Lungs will take longer to treat – between a few weeks and a few months, depending on the severity of the condition. The one of these four patterns that is most difficult to treat is that of Turbid Phlegm in the Lungs. Of the Deficiency patterns, the most difficult to treat is that of Lung-, Heart- and Kidney-Yang Deficiency. This is a very chronic condition that occurs only in old people and is characterized by the presence of PhlegmFluids affecting both Heart and Lungs. Phlegm-Fluids are a type of Phlegm that is always very difficult to treat. As for the relative importance of acupuncture and herbs, in general herbs are necessary whenever there is Phlegm, as they are better than acupuncture at resolving Phlegm. Acupuncture on its own gives particularly good results in the two Liver-related patterns, i.e. Lung-Qi Obstructed and Liver-Fire insulting the Lungs. As for prevention, after a successful treatment it is important to take certain preventive measures so that the breathlessness will not recur.

Breathlessness (Chuan)

Diet A person who has been successfully treated for breathlessness should abstain from eating dairy foods (milk, cheese, butter, cream, yoghurt, ice cream) because these tend to form Phlegm, which easily settles in the Lungs and obstructs breathing. For the same reason, greasy and fried foods should be kept to a minimum. It is also best to advise the patient not to eat too much fresh fruit and raw vegetables. Although in moderation these foods are beneficial, in excess they also tend to form Phlegm and injure Yang. This advice is particularly important for those patients whose breathlessness was caused by deficiency of Yang.

Life habits Persons who suffer from breathlessness should take great care in protecting themselves adequately from wind and cold. All too often, the dictates of fashion are not conducive to sensible dressing. Patients who have been suffering from breathlessness should especially take care to protect the upper back and chest.

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• Gan Sui Radix Euphorbiae Kansui • She Xiang Moschus • Yan Hu Suo Rhizoma Corydalis Grind these herbs (She Xiang can be omitted, as it is very expensive) into a powder in a coffee grinder, add ginger juice and honey, shape into tiny pieces (about the size of an “O”), place on a plaster and stick this on the acupuncture points. Keep the plasters on not longer than 2 hours, as the herbs are blistering. Patients who are prone to Lung-Qi deficiency could take a course of Yu Ping Feng San Jade Wind Screen Powder towards the end of August of each year. Patients who are prone to Kidney deficiency can take the patent remedy Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill (or Herbal Sentinel-Yang in the Three Treasures range) during the winter months. In case of Kidney-Yin deficiency, they should take Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill instead (or Herbal Sentinel-Yin in the Three Treasures range).

WESTERN DIFFERENTIAL DIAGNOSIS Preventive treatment Both moxa and herbs can be used to prevent a recurrence of breathlessness. Indirect moxibustion with garlic can be applied in the summertime at 10-day intervals on the following three groups of points. • First group: — extra-point Bai Lao (on the occiput 1 cun below the hairline and 1 cun from the midline) — BL-13 Feishu — BL-43 Gaohuangshu • Second group: — Du-14 Dazhui — BL-12 Fengmen — BL-20 Pishu • Third group: — BL-11 Dashu — BL-13 Feishu — BL-23 Shenshu A herbal plaster can also be applied on the same three groups of points at the same interval in summertime. The herbs used for the plaster are: • Bai Jie Zi Semen Sinapis albae • Xi Xin Herba Asari

Dyspnoea (breathlessness) can have many different causes in Western medicine. However, apart from general causes such as anaemia, they all relate either to the lungs or the heart. In fact, breathlessness can arise either from a disease of the lungs themselves (such as asthma, bronchitis or emphysema) or from a heart disease affecting the lungs (such as left ventricular heart failure). The most common causes of chronic breathlessness have been summarized with a diagram (Fig. 3.7).

Causes in Lungs Asthma This consists of the constriction of the bronchi on exhalation. It may arise during childhood in atopic individuals, i.e. those who easily form antibodies to commonly encountered allergens such as house dust, pollen or house dust mites. Such patients often suffer from other allergic diseases such as allergic rhinitis or atopic eczema. This is called early-onset or extrinsic asthma and will be discussed in a separate chapter (Chapter 5). In other cases, it starts in later life in nonatopic individuals and is called late-onset or intrinsic

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The Practice of Chinese Medicine Asthma Chronic bronchitis LUNGS Emphysema Bronchial carcinoma

DYSPNOEA HEART

Left heart failure

GENERAL

Anaemia

Figure 3.7 Causes of breathlessness in Western medicine.

asthma. This type of asthma is not due to an allergic reaction. In both types, the main manifestations are breathlessness on exertion and wheezing and coughing, which may be worse at night.

Chronic bronchitis This is due to narrowing of the bronchioles by mucus and oedema of mucous membranes within the lungs. It is this narrowing that causes the breathlessness. This condition occurs in middle-aged or elderly people, and the main distinguishing sign to differentiate it from asthma is a chronic productive cough with abundant expectoration. It also differs from asthma in so far as the breathlessness is often worse in the morning (rather than at night, as in asthma). Another feature of this condition is the propensity to frequent chest infections.

With time, chronic bronchitis may lead to emphysema, i.e. over-distension of the alveoli.

Emphysema This condition is due to a permanent and irreversible over-distension of the alveoli. It frequently develops from chronic bronchitis, as explained above. After years of over-distension, an increasing proportion of the alveolar wall disintegrates with progressive obliteration of the vascular bed of the lungs. This is the most common cause of right ventricular heart failure, which, in itself, also causes breathlessness. The main clinical features are breathlessness first on exertion and, with time, also at rest. In severe cases, the breathlessness is constant, the chest movements are limited, the breath sounds inaudible and there may be cyanosis. Emphysema can be clearly differentiated from asthma, as the breathlessness is constant, whereas in asthma it comes in bouts. It can be differentiated from chronic bronchitis, as there is no cough or abundant sputum. The differentiation between asthma, chronic bronchitis and emphysema is important for prognosis, as the first two react well to acupuncture and herbal treatment, while emphysema reacts less so (Table 3.1).

Bronchial carcinoma This is statistically the most common of all carcinomas, and it accounts for 40% of all male deaths from malignant disease. The main clinical manifestations are a cough, with scanty sputum that may be blood-tinged, chest pain and breathlessness, although this may appear only in quite late stages.

Table 3.1 Comparison of asthma, chronic bronchitis and emphysema Asthma

Chronic bronchitis

Emphysema

Frequency

Bouts of dyspnoea

Bouts of dyspnoea with chest infections

Constant dyspnoea

Time

Worse at night

Worse in the morning

All the time

Allergies

Yes

No

No

Sputum

No

Yes

Yes

Breathlessness (Chuan)

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Table 3.2 Synopsis of causes of breathlessness Disease

Pathology

Symptoms

Signs

Asthma

Bronchospasm

Bouts of dyspnoea

Wheezing sound

Chronic bronchitis

Narrowing of bronchi by mucus

Dyspnoea, stuffiness of chest

Cough with abundant sputum

Emphysema

Distension of alveoli

Constant dyspnoea

Thin chest

Carcinoma of bronchi

Tumour obstructing bronchi

Chest pain, cough, dyspnoea, tiredness, poor appetite

Blood-tinged sputum, weight loss

Left heart failure

Blood accumulating in lungs and pulmonary veins

Dyspnoea on exertion, gasping for breath, palpitations, giddiness, nausea, vomiting

Watery-frothy sputum, intervals of apnoea lasting 20–30 seconds, pulsus alternans

Anaemia

Reduced red blood cells

Dyspnoea, tiredness

Pallor

Causes in Heart

General causes

Left heart failure

Anaemia

When the left ventricle of the heart loses strength of contraction, blood accumulates behind the left ventricle in the pulmonary veins and lungs. The resulting pulmonary congestion reduces the supply of oxygen to the alveoli and causes breathlessness. Left ventricular failure may be caused by:

Breathlessness on exertion is a feature of anaemia. The causes of breathlessness are summarized in Table 3.2.

• • • •

cardiac infarction aortic disease mitral incompetence essential hypertension.

The patient is severely breathless on exertion and has to sit up in bed to breathe, gasping for breath. He or she may wake up suddenly and feel hot. The breathlessness gets progressively worse until it is constant. There may also be a cough at night with watery-frothy sputum, palpitations, giddiness, nausea, vomiting, diarrhoea and abdominal pain. The phenomenon of pulsus alternans may be heard on the sphygmomanometer: at the upper limit, only half the heartbeats come through, but when the pressure is lowered by 10 mmHg or more all the beats become audible. For example, at 180 mmHg the pulse rate may appear to be 50, while at 160 mmHg it is 100.

END NOTES 1. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 147. First published c.100 BC. 2. Ibid., p. 336. 3. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 55. First published c.100 BC. 4. He Ren 1979 Jin Gui Yao Lue Tong Su Jiang Hua [A Popular Guide to the Essential Prescriptions of the Golden Chest]. Shanghai Science Publishing House, Shanghai, p. 46. The Essential Prescriptions of the Golden Chest was written by Zhang Zhong Jing and first published c.AD 220. 5. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue [Internal Medicine]. Shanghai Science Publishing House, Shanghai, p. 66. 6. 1986 Jing Yue Quan Shu [Complete Book of Jing Yue]. Shanghai Science Publishing House, Shanghai, p. 345. The Complete Book of Jing Yue was written by Zhang Jing Yue and first published in 1624. 7. Tian Hai He 1990 [Dr Dong Jian Hua’s Experience in Treating Asthma]. Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi ) 31(6): 18. 8. Ibid., p. 18.

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CHAPTER 4

WHEEZING (XIAO)

AETIOLOGY 102 External pathogenic factors Irregular diet 102 Weak body condition 102 PATHOLOGY

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102

IDENTIFICATION OF PATTERNS AND TREATMENT Cold Phlegm 103 Hot Phlegm 104 Lung deficiency 105 Spleen deficiency 106 Kidney deficiency 108 MODERN CHINESE LITERATURE

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PROGNOSIS AND PREVENTION

110

WESTERN DIFFERENTIATION Acute bronchitis 111 Chronic bronchitis 111 Asthma 111

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ACUTE PHASE • Cold Phlegm • Hot Phlegm CHRONIC PHASE • Lung deficiency • Spleen deficiency • Kidney deficiency

WHEEZING (XIAO) Xiao indicates a wheezing sound that may resemble that of whistling, snoring or sawing. It is usually accompanied by breathlessness and an inability to breathe when lying down.

The Essential Prescriptions of the Golden Chest by Dr Zhang Zhong Jing was the first book to refer to wheezing: “For cough with a moor-hen sound in the throat, use Belamcanda-Ephedra Decoction.”1 The “moorhen sound in the throat” is wheezing. In later times, wheezing was also variously described as “hidden Yin”, “sip cough”, “howling wheezing” and “snoring wheezing”. In subsequent dynasties, the symptoms of wheezing (Xiao) and breathlessness (Chuan) were not clearly differentiated. Dr Zhu Dan Xi (1281–1358) was the first to use the term Xiao-Chuan and considered it due to Phlegm. He therefore indicated that the main principle of treatment was to tonify the body’s Qi and, in acute cases, expel pathogenic factors. The book Orthodox Medical Record (1515) by Dr Yu Tuan distinguishes between Wheezing (Xiao) and Breathlessness (Chuan) for the first time:2 Wheezing is named after its sound, Breathlessness after the breath. If breathing is rapid and there is a sound in the throat like a moor-hen, it is Wheezing [Xiao]; if breathing is rapid continuously and there is breathlessness, it is called Breathlessness [Chuan]. The Case Reports for Clinical Practice (1766) by Dr Ye Gui differentiates the two conditions by saying:3 If the pathogenic factor is expelled, breathlessness [Chuan] stops and will never return. In wheezing [Xiao], the pathogenic factor is hidden in the Interior and in the Lungs, it is sometimes active and sometimes quiescent, and there are frequent episodes over many years. Doctors of subsequent dynasties reverted to considering Wheezing and Breathlessness as one condition. In modern China they are also considered together, and modern books usually say that they may correspond to the two separate conditions of “bronchial asthma”

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or “asthmatic bronchitis” (chronic bronchitis leading to breathlessness). There are different types of asthma, and they may be summarized in three groups. 1. Allergic (or atopic) asthma, which starts in early childhood and is often associated with eczema; this will be discussed in a separate chapter (Chapter 5). 2. Asthma that starts early during childhood after repeated invasions of external Wind leading to chest infections. This is customarily due to chronic retention of a residual pathogenic factor (usually Phlegm). 3. Asthma that starts later in life as a consequence of repeated invasions of exterior Wind, irregular diet, emotional strain, overwork and excessive sexual activity. This is may be due to a combination of factors, such as chronic retention of a residual pathogenic factor (usually Phlegm) together with lifestyle factors that lead to Phlegm. The symptom of “Wheezing” discussed in this chapter corresponds to numbers 2 and 3 above. The discussion of Wheezing will be conducted according to the following topics. • • • • • •

Aetiology Pathology Identification of patterns and treatment Modern Chinese literature Prognosis and prevention Western differentiation

AETIOLOGY External pathogenic factors External Wind-Cold or Wind-Heat may invade the body, penetrate deeper and settle in the Lungs. Here the pathogenic factor obstructs Lung-Qi, which then cannot transform fluids, and the fluids accumulate into Phlegm.

Irregular diet The excessive consumption of cold, sour, or sweetgreasy foods injures the Spleen so that it cannot transform and transport food essences properly. When this happens, Phlegm forms; it accumulates in the

Lungs, obstructs Lung-Qi and causes wheezing. Old books distinguished between “food-wheezing”, “sugarwheezing” and “sour-wheezing” according to the particular type of food responsible.

Weak body condition A weakened body condition after a long illness (which in children may happen after measles or whooping cough) may deplete Lung-Qi and Spleen-Qi. When this happens, fluids are not transformed properly and Phlegm forms. If the Yin of the body is depleted, Empty Heat arises; this evaporates and condenses fluids into Phlegm.

PATHOLOGY The main pathological factor in Wheezing is “hidden Phlegm” stored in the Lungs. The upwards movement of Phlegm propelled by rebellious Qi narrows the airways and causes wheezing. The Supplement to Diagnosis and Treatment (1687) by Li Yong Cui says:4 Chronic wheezing and breathlessness are due to: 1) obstruction of Qi in the Interior; 2) an attack of an exterior pathogenic factor; 3) sticky Phlegm in the diaphragm. These three factors combine to obstruct the Qi passages and when breath is forced out there is a wheezing sound. Factors that may trigger the upwards movement of rebellious Qi and Phlegm are weather changes, diet, emotional stress and overwork. Phlegm may be cold or hot. Cold Phlegm may derive from frequent exposure to cold, which injures the Lungs, or from excessive consumption of cold foods, which injure Spleen-Yang. Cold Phlegm is more likely to be stirred by external pathogenic factors. It both derives from and causes Yang deficiency. Hot Phlegm may derive from excessive consumption of sour, sweet or greasy foods. Yin deficiency may contribute to forming Phlegm-Heat. In chronic cases, Cold Phlegm injures Spleen-Yang while Hot Phlegm injures Lung-Yin. The disease becomes therefore characterized by a combination of Fullness (Phlegm) and Emptiness (of the Lungs, Spleen or Kidneys). Deficient Lungs, Spleen and Kidney may in turn all lead to Phlegm. In particular, if KidneyYang is deficient there will be Cold Phlegm; if KidneyYin is deficient there will be Phlegm-Heat.

Wheezing (Xiao)

In severe and prolonged cases, when the deficient Lungs fail to control the blood vessels and harmonize the channels, Heart-Blood cannot circulate properly, the Fire of the Gate of Life (Ming Men) cannot rise to the Heart and this causes a deficiency of Heart-Yang.

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Treatment principle Warm the Lungs, scatter Cold, resolve Phlegm, relieve breathlessness.

Acupuncture Points

IDENTIFICATION OF PATTERNS AND TREATMENT In order to apply the correct principle of treatment, a clear distinction must be made between the acute and chronic phases. In general, one follows the principle of treating the Manifestation during the acute phase and the Root during the chronic phase. This means that in the acute phase one must expel pathogenic factors, resolve Phlegm and restore the descending of Lung-Qi. During the chronic phase, attention should be turned to tonifying the body’s Qi, particularly of the Lungs, Spleen or Kidneys. In some chronic cases, it may be necessary to treat both Manifestation and Root simultaneously. The patterns discussed are as follows. Acute phase • Cold Phlegm • Hot Phlegm Chronic phase • Lung deficiency • Spleen deficiency • Kidney deficiency Treatment of the acute phase includes not only treatment during the actual acute attack but also treatment during a period of time when attacks are frequent. The main differentiation to be made is that between Cold Phlegm and Hot Phlegm and the main principle of treatment is to resolve Phlegm and restore the descending of Lung-Qi.

Cold Phlegm Clinical manifestations Rapid breathing, wheezing, a feeling of fullness and oppression of the chest, cough, scanty phlegm, a bluishwhite complexion, no thirst, or a desire for warm drinks, feeling cold, worse in cold weather. Tongue: Swollen with a sticky-white coating. Pulse: Tight and Slippery.

LU-7 Lieque, BL-13 Feishu, LU-1 Zhongfu, LU-6 Kongzui, Ren-22 Tiantu, Ren-17 Shanzhong, ST-40 Fenglong, P-6 Neiguan. All with reducing or even method. Moxa is applicable.

Explanation • LU-7, BL-13 and LU-1 restore the descending of Lung-Qi and stop wheezing. • LU-6, Accumulation point, stops wheezing and breathlessness in acute cases. • Ren-22 restores the descending of Lung-Qi and resolves Phlegm. • Ren-17 moves Qi in the chest and affects the Lung channel. With direct moxa, it can dispel Cold from the Lungs. • ST-40 and P-6 open the chest, relieve breathlessness and resolve Phlegm.

Herbal therapy Prescription SHE GAN MA HUANG TANG Belamcanda-Ephedra Decoction

Explanation This formula is specific to stop wheezing and breathlessness from Cold Phlegm.

Modifications • If there are symptoms of exterior Cold and internal Phlegm-Fluids, use Xiao Qing Long Tang Small Green Dragon Decoction instead. • In a chronic case with Yang deficiency and frequent attacks of wheezing that sounds like low snoring, breathing not rapid, watery sputum, a dull-pale complexion, cold sweating, a Deep pulse and a Pale tongue, one must treat both the Manifestation and the Root simultaneously. One must resolve Phlegm and restore the descending of Lung-Qi on one hand, and tonify Kidney-Yang on the other hand. This therapeutic aim may be achieved by using Su Zi Jiang Qi Tang Perilla Seed Lowering Qi Decoction. Add to this formula Dang Shen Radix Codonopsis

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and Hu Tao Rou Semen Juglandis to tonify Spleen and Kidneys, and Chen Xiang Lignum Aquilariae to restore the descending of Lung-Qi. • In cases of very severe symptoms of Yang deficiency (such as severe chilliness and a very Pale and wet tongue), add Fu Zi Radix Aconiti carmichaeli preparata.

SUMMARY COLD PHLEGM Points LU-7 Lieque, BL-13 Feishu, LU-1 Zhongfu, LU-6 Kongzui, Ren-22 Tiantu, Ren-17 Shanzhong, ST-40 Fenglong, P-6 Neiguan. All with reducing or even method. Moxa is applicable. Herbal therapy Prescription SHE GAN MA HUANG TANG Belamcanda-Ephedra Decoction

Hot Phlegm Clinical manifestations Wheezing with a loud noise, breathlessness, distended chest, cough, yellow-sticky sputum, irritability, sweating, a red face, a bitter taste, thirst, a feeling of heat. Tongue: Red with a yellow-sticky coating. Pulse: Slippery-Rapid.

Treatment principle Clear Heat, restore the descending of Lung-Qi, resolve Phlegm, stop wheezing.

• LU-1 and BL-13, Front-Collecting and BackTransporting point respectively, clear Lung-Heat and restore the descending of Lung-Qi, especially in acute cases. • L.I.-11 clears Heat. • P-5 and ST-40 resolve Phlegm and open the chest. • Ren-22 resolves Phlegm, restores the descending of Lung-Qi and benefits the throat.

Herbal therapy Prescription DING CHUAN TANG Stopping Breathlessness Decoction

Explanation This formula is specific for wheezing from Hot Phlegm.

Modifications • If there are simultaneous symptoms of exterior Cold and Hot Phlegm, add Gui Zhi Ramulus Cinnamomi cassiae and Sheng Jiang Rhizoma Zingiberis officinalis recens. • If there are symptoms of Fire (as opposed to Heat), such as constipation, dark urine, dry stools, dry mouth and a dry-yellow tongue coating, add Da Huang Rhizoma Rhei and Mang Xiao Mirabilitum. • If there is vomiting of sticky-yellow phlegm, add Zhi Mu Radix Anemarrhenae, Hai Ge Ke Concha Cyclinae sinensis and She Gan Rhizoma Belamcandae. • If Heat has injured the Yin, add Mai Men Dong Tang Ophiopogon Decoction. • If Phlegm is the main problem without any clearcut hot or cold symptom, use San Zi Yang Qin Tang Three-Seed Nourishing the Parents Decoction.

Acupuncture

SUMMARY

Points

HOT PHLEGM

LU-5 Chize, LU-10 Yuji, LU-6 Kongzui, LU-1 Zhongfu, BL-13 Feishu, L.I.-11 Quchi, P-5 Jianshi, ST-40 Fenglong, Ren-22 Tiantu. All with even or reducing method.

Points LU-5 Chize, LU-10 Yuji, LU-6 Kongzui, LU-1 Zhongfu, BL-13 Feishu, L.I.-11 Quchi, P-5 Jianshi, ST-40 Fenglong, Ren-22 Tiantu. All with even or reducing method.

Explanation • LU-5 resolves Phlegm-Heat from the Lungs. • LU-10 clears Lung-Heat. • LU-6, Accumulation point, stops wheezing and breathlessness in acute cases.

Herbal therapy Prescription DING CHUAN TANG Stopping Breathlessness Decoction

Wheezing (Xiao)

Case history A 58-year-old man had been suffering from asthma for 6 years. At the time of consultation, the asthma was very severe, with frequent attacks every day. He was using a Ventolin inhaler, Becloforte (corticosteroid) spray and corticosteroids orally. His chest felt extremely tight and he could not lie down. He was prone to chest infections, developing expectoration of yellow sputum. He also experienced epigastric fullness and distension. His tongue was slightly Red, with swollen edges (of the Spleen-type) and a sticky coating (Plate 4.1). His pulse was Rapid, Full and Slippery. Diagnosis This is non-allergic late-onset asthma from Hot Phlegm against a background of Spleen deficiency. Treatment principle Because the attacks are severe and frequent, this is treated as an acute case, and attention must be turned to treating the Manifestation, i.e. resolve Phlegm, clear Heat and restore the descending of Lung-Qi.

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gradually reduced and discontinued after 3 months. As he started to improve, after 3 months the treatment included some tonification of the Spleen (with Ren-12 Zhongwan, BL-20 Pishu and ST-36 Zusanli) and the use of the patent remedy Ping Chuan Wan Calming Breathlessness Pill, which tonifies Spleen and Kidneys and restores the descending of Lung-Qi. During the chronic phase, the main priority is to tonify Lungs, Spleen, or Kidneys.

Lung deficiency Clinical manifestations Sweating, chilliness, propensity to catching colds, sneezing, a runny nose, shortness of breath, slight wheezing with a low sound, a slight cough. Tongue: Pale. Pulse: Weak.

Treatment principle Tonify the Lungs and consolidate the Exterior.

Acupuncture

Treatment This patient was treated with acupuncture only. He had to be treated every other day initially, followed by a gradual spacing-out of treatments. The main points used were as follows.

Points

• SP-4 Gongsun and P-6 Neiguan open the Penetrating Vessel, relax the chest and subdue rebellious Stomach-Qi. The Lung and Stomach channels are closely connected and rebellious Stomach-Qi will adversely affect Lung-Qi. • LU-5 Chize, LU-7 Lieque and LU-6 Kongzui restore the descending of Lung-Qi. LU-6, Accumulation point, is specific for acute cases. LU-5 also clears Phlegm from the Lungs. • LU-1 Zhongfu and BL-13 Feishu, Front-Collecting and Back-Transporting points, respectively, clear Lung-Heat and restore the descending of Lung-Qi. • ST-40 Fenglong and SP-6 Sanyinjiao resolve Phlegm. ST-40 also opens the chest and eases breathing. • Dingchuan, extra point 0.5 cun lateral to Du-14 Dazhui, is an empirical point for acute asthma.

Explanation

With treatment on alternate days, he started to improve gradually. The treatment was slowed down by his use of oral corticosteroids. However, these were

Modifications

LU-9 Taiyuan, ST-36 Zusanli, Ren-6 Qihai, BL-13 Feishu, Du-12 Shenzhu, LU-7 Lieque. All with reinforcing method.

• LU-9, BL-13 and Du-12 tonify Lung-Qi and consolidate the Exterior. • ST-36 and Ren-6 tonify Qi in general. • LU-7 restores the descending of Lung-Qi and stops wheezing and cough.

Herbal therapy Prescription YU PING FENG SAN Jade Wind Screen Powder

Explanation This formula tonifies Lung-Qi and consolidates the Exterior.

• If there are Cold symptoms, add Gui Zhi Ramulus Cinnamomi cassiae, Bai Shao Radix Paeoniae alba,

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Sheng Jiang Rhizoma Zingiberis officinalis recens and Da Zao Fructus Jujubae. • If there is both Qi and Yin deficiency, add Sheng Mai San Generating the Pulse Decoction.

Three Treasures remedy Herbal Sentinel Herbal Sentinel tonifies Lung-Qi and Kidney-Qi and consolidates the Exterior. There are two versions: Herbal Sentinel-Yang for patients with a tendency to Yang deficiency and Herbal Sentinel-Yin for those with a tendency to Yin deficiency.

SUMMARY LUNG DEFICIENCY Points LU-9 Taiyuan, ST-36 Zusanli, Ren-6 Qihai, BL-13 Feishu, Du-12 Shenzhu, LU-7 Lieque. All with reinforcing method. Herbal therapy Prescription YU PING FENG SAN Jade Wind Screen Powder Three Treasures remedy Herbal Sentinel

Spleen deficiency Clinical manifestations Slight wheezing that has a low sound, poor appetite, slight abdominal distension, intolerance to certain foods, tiredness, shortness of breath, dislike of speaking, desire to lie down, weariness. Tongue: Pale. Pulse: Weak.

Treatment principle Tonify the Spleen and resolve Phlegm.

Acupuncture

Explanation • ST-36, SP-3, BL-20, BL-21 and Ren-12 tonify Stomach and Spleen. • ST-40 resolves Phlegm. • LU-7 restores the descending of Lung-Qi. • LU-9 and BL-13 tonify Lung-Qi. • Ren-6 tonifies Qi in general.

Herbal therapy Prescription LIU JUN ZI TANG Six Gentlemen Decoction

Explanation This formula tonifies Spleen-Qi and mildly resolves Dampness.

Modifications • If there are pronounced symptoms of Cold, add Gui Zhi Ramulus Cinnamomi cassiae and Gan Jiang Rhizoma Zingiberis officinalis.

Three Treasures remedy Prosperous Earth Prosperous Earth tonifies the Spleen and mildly resolves Dampness; it is a variation of Liu Jun Zi Tang Six Gentlemen Decoction.

SUMMARY SPLEEN DEFICIENCY Points ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, BL-21 Weishu, Ren-12 Zhongwan, ST-40 Fenglong, LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Ren-6 Qihai. All with reinforcing method. Moxa is applicable. Herbal therapy Prescription LIU JUN ZI TANG Six Gentlemen Decoction Three Treasures remedy Prosperous Earth

Points ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, BL-21 Weishu, Ren-12 Zhongwan, ST-40 Fenglong, LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Ren-6 Qihai. All with reinforcing method. Moxa is applicable.

Case history A 45-year-old woman had been suffering from asthma for 8 years since she stopped smoking.

Wheezing (Xiao)

She found it difficult to breathe in and had a constant nasal discharge. She constantly felt catarrh in her throat and chest and sometimes coughed up some sticky-yellow phlegm. She often experienced a feeling of oppression of the chest and slight nausea. She was slightly deaf in one ear and her urine was rather pale. She often complained of bad digestion, slight thirst and acid regurgitation. She frequently had hiccups for long periods of time. She was overweight, particularly around her stomach and abdomen. Her tongue body was of a normal colour although slightly Purple on the sides (chest area), was very Swollen, and had a Stomach crack in the middle with a rough, dirty-yellow coating in it (Plate 4.2). Her pulse was definitely Slippery on the whole and slightly Weak on the right side. Diagnosis This is a clear case of retention of Phlegm-Heat with a background of Spleen deficiency. The symptoms of Phlegm-Heat are expectoration of sticky-yellow phlegm, nasal discharge, feeling of oppression of the chest, nausea, overweight body, Swollen tongue and Slippery pulse. Although this is Phlegm-Heat because the mucus is yellow, the Heat is only slight and the predominant aspect is the Phlegm rather than Heat. There is also a slight, secondary Kidney-Yang deficiency as shown by the slight deafness and pale urine. A third pathological condition is the retention of Phlegm-Heat in the Stomach, as shown by the acid regurgitation, bad digestion and Stomach crack with rough, yellow coating inside it. The presence of Phlegm-Heat induced Stomach-Qi to rebel upwards, causing frequent hiccups. The rebelling upwards of Stomach-Qi contributed to the asthma. The fact that her asthma started after stopping smoking is puzzling but interesting. One possible explanation could be that the conditions to cause asthma were already present but tobacco, which has a hot and drying energy, constantly dried up Phlegm, thus delaying the onset of the disease. A sudden cessation of smoking means that the drying action of tobacco is abruptly withdrawn and Phlegm therefore overflows profusely. Treatment principle Because this is a chronic condition, the treatment principle is to treat Root and Manifestation simultaneously, i.e. tonify the body’s

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Qi and expel pathogenic factors. Treating the Root involves primarily tonifying Spleen-Qi and secondarily tonifying Kidney-Yang. Treating the Manifestation involves resolving Phlegm from the Lungs, restoring the descending of Lung-Qi, resolving Phlegm-Heat from the Stomach and subduing rebellious Stomach-Qi. Acupuncture This patient was treated with both acupuncture and herbs. The acupuncture treatment was focused on tonifying the Spleen, restoring the descending of Lung-Qi and subduing Stomach-Qi. Points The main points used at various times were: • SP-4 Gongsun on the left and P-6 Neiguan on the right, to open the Penetrating Vessel and subdue rebellious Stomach-Qi. The Lung and Stomach channels are closely connected, and Qi rebelling upwards in one channel easily affects the other. It was therefore important in this case to subdue Stomach-Qi as well as stimulate the descending of Lung-Qi. The Penetrating Vessel is excellent to subdue rebellious Stomach-Qi, especially in overweight people. • ST-40 Fenglong to resolve Phlegm and open the chest. • Ren-12 Zhongwan, BL-20 Pishu and Ren-9 Shuifen to tonify the Spleen and resolve Phlegm. • LU-7 Lieque, Ren-22 Tiantu and LU-5 Chize to restore the descending of Lung-Qi. • BL-23 Shenshu and KI-7 Fuliu to tonify Kidney-Yang. Herbal therapy Prescription Because acupuncture was aimed at treating the Root by tonifying the Spleen and Kidneys, the herbs were used mainly to treat the Manifestation, i.e. to resolve Phlegm, as they are better than acupuncture at doing this. The main formula used was a variation of Wen Dan Tang Warming the Gall-Bladder Decoction, which resolves Phlegm-Heat from both Lungs and Stomach. • • • • • •

Zhu Ru Caulis Bambusae in Taeniam 6 g Zhi Shi Fructus Aurantii immaturus 6 g Ban Xia Rhizoma Pinelliae preparatum 6 g Fu Ling Poria 6 g Chen Pi Pericarpium Citri reticulatae 4 g Sheng Jiang Rhizoma Zingiberis officinalis recens 3 slices

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• • • •

The Practice of Chinese Medicine

Da Zao Fructus Jujubae 3 dates Xing Ren Semen Armeniacae 4 g Su Zi Fructus Perillae 6 g Hou Po Cortex Magnoliae officinalis 4 g

Explanation • The first seven herbs constitute the Wen Dan Tang, which resolves Phlegm-Heat. • Xing Ren and Su Zi restore the descending of Lung-Qi. • Hou Po moves Qi and relieves fullness and oppression of the chest. As the treatment progressed and she improved, a few herbs to strengthen the Spleen were added, such as Bai Zhu Rhizoma Atractylodis macrocephalae, and the dosage of Fu Ling Poria was increased. This patient achieved great improvement in 9 months of treatment.

Kidney deficiency Clinical manifestations Shortness of breath, slight wheezing that has a low sound, greater difficulty in breathing in, absentmindedness, poor memory, tinnitus, weakness and soreness of the lower back, breathlessness on exertion. Kidney-Yang deficiency: chilliness, Pale tongue, DeepWeak pulse. Kidney-Yin deficiency: feeling of heat, Red tongue without coating, Floating-Empty pulse.

Treatment principle Tonify the Kidneys, strengthen the Kidney’s grasping of Qi.

Acupuncture

Herbal therapy Prescription Kidney-Yang deficiency JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill

Explanation This formula tonifies and warms Kidney-Yang.

Modifications • For severe Yang deficiency, add Bu Gu Zhi Fructus Psoraleae and Lu Jiao Cornu Cervi. • To strengthen the Kidney’s grasping of Qi, add Hu Tao Rou Semen Juglandis.

Three Treasures remedy Herbal Sentinel-Yang Herbal Sentinel-Yang tonifies Lung- and Kidney-Yang.

Prescription Kidney-Yin deficiency MAI WEI DI HUANG WAN (BA XIAN CHANG SHOU WAN) Ophiopogon-Schisandra-Rehmannia Pill (Eight Immortals Longevity Pill)

Explanation This formula nourishes Kidney- and Lung-Yin.

Modifications • To strengthen the Kidney’s grasping of Qi, add Hu Tao Rou Semen Juglandis.

Three Treasures remedy Herbal Sentinel-Yin Herbal Sentinel-Yin tonifies the Lungs and Kidneys in people with a tendency to Yin deficiency.

Points KI-3 Taixi, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-23 Shenshu, BL-13 Feishu, Du-12 Shenzhu, KI-25 Shencang. All with reinforcing method. Use moxa for Kidney-Yang deficiency.

Explanation • KI-3, SP-6, Ren-4 and BL-23 tonify the Kidneys. • BL-13 and Du-12 strengthen the Lungs. • KI-25 is an important local point to relieve wheezing due to a Kidney deficiency.

SUMMARY KIDNEY Points KI-3 Taixi, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-23 Shenshu, BL-13 Feishu, Du-12 Shenzhu, KI-25 Shencang. All with reinforcing method. Use moxa for Kidney-Yang deficiency.

Wheezing (Xiao)

Herbal therapy Prescription Kidney-Yang deficiency JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill Three Treasures remedy Herbal Sentinel-Yang Prescription Kidney-Yin deficiency MAI WEI DI HUANG WAN (BA XIAN CHANG SHOU WAN) Ophiopogon-Schisandra-Rehmannia Pill (Eight Immortals Longevity Pill) Three Treasures remedy Herbal Sentinel-Yin

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Points The main points used were: • BL-23 Shenshu, Ren-4 Guanyuan and KI-3 Taixi, with moxa, to tonify Kidney-Yang. • LU-7 Lieque on the right and KI-6 Zhaohai on the left, to open the Directing Vessel, tonify the Kidneys and restore the descending of Lung-Qi. • LU-5 Chize and Ren-22 Tiantu to restore the descending of Lung-Qi. • BL-20 Pishu and Ren-12 Zhongwan to tonify the Spleen. • ST-40 Fenglong and SP-6 Sanyinjiao to resolve Phlegm. • P-6 Neiguan to open the chest and relieve breathlessness. This patient was treated every 2 weeks (as she lived quite far away) for 18 months, after which time there was an improvement of about 80% in her condition and she experienced only occasional breathlessness.

Case history

MODERN CHINESE LITERATURE

A 42-year-old woman had been suffering from asthma for 10 years. It started after the birth of her second child. She experienced a feeling of oppression of the chest and sometimes coughed up some yellow phlegm. She also suffered from lower backache and often felt dizzy. Occasionally, she experienced tinnitus and her urine was pale and frequent. She felt very tired. Her tongue was slightly Pale but with a yellow coating and her pulse was Deep and Weak, especially on both Kidney positions.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 25, No. 8, 1984, p. 8.

Diagnosis This is a clear case of asthma from deficiency of Kidney-Yang, with the Kidneys not grasping Qi. There is also some Phlegm-Heat (yellow sputum and yellow tongue coating) but it is not significant. Treatment principle The treatment principle must therefore be aimed primarily at strengthening KidneyYang and secondarily at tonifying the Spleen and resolving Phlegm. Acupuncture This patient was treated only with acupuncture.

Dong Shu Liu, “Experience in the differentiation and treatment of wheezing (Xiao).” Dr Dong considers Wheezing always due to “hidden Phlegm” in the bronchi, which accounts for the wheezing sound on exhalation. He considers the disease due to repeated invasions of external pathogenic factors that become interior. Phlegm obstructs the airways and causes cough, wheezing and breathlessness. In treatment, one must resolve Phlegm and restore the diffusing and descending of Lung-Qi. For Cold Wheezing (from Cold Phlegm), Dr Dong uses a variation of Xiao Qing Long Tang Small Green Dragon Decoction as follows. • • • • • • • •

Ma Huang Herba Ephedrae 4.5 g Gui Zhi Ramulus Cinnamomi cassiae 3 g Bai Shao Radix Paeoniae alba 9 g Gan Jiang Rhizoma Zingiberis 2.4 g Wu Wei Zi Fructus Schisandrae 3 g Xi Xin Herba Asari 2.4 g Ban Xia Rhizoma Pinelliae preparatum 9 g Chen Pi Pericarpium Citri reticulatae 4.5 g

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• Xing Ren Semen Armeniacae 9 g • Hou Po Cortex Magnoliae officinalis 3 g • E Guan Shi Balanophyllia 9 g For Hot Wheezing (from Hot Phlegm) Dr Dong uses a variation of Ma Xing Shi Gan Tang Ephedra-PrunusGypsum-Glycyrrhiza Decoction. • • • • • • • • • • • •

Ma Huang Herba Ephedrae 4.5 g Xing Ren Semen Armeniacae 9 g Shi Gao Gypsum fibrosum 30 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6g Gua Lou Fructus Trichosanthis 12 g Huang Qin Radix Scutellariae 9 g Sang Bai Pi Cortex Mori 9 g Di Gu Pi Cortex Lycii 12 g Zhi Shi Fructus Aurantii immaturus 6 g Dan Nan Xing Rhizoma Arisaematis preparatum 9 g Chuan Bei Mu Bulbus Fritillariae cirrhosae 9 g Lu Gen Rhizoma Phragmitis 30 g

Dr Dong considers Ma Huang Herba Ephedrae to be the most important herb in the treatment of Wheezing. He combines it with Gui Zhi Ramulus Cinnamomi cassiae for Cold Wheezing and with Shi Gao Gypsum fibrosum for Hot Wheezing. In addition to this basic combination, he uses herbs to restore the descending of Lung-Qi and herbs that resolve Phlegm (as in the two formulae above).

PROGNOSIS AND PREVENTION Apart from obvious reference to tongue and pulse, the prognosis in the symptom of Wheezing must be based on a Western differentiation. The main conditions that give rise to wheezing are acute and chronic bronchitis and asthma (see below) and the prognosis varies considerably in each of these diseases. Acute bronchitis is the easiest to treat and it normally manifests with symptoms of Hot Phlegm, as described above. It corresponds to the Qi level (affecting the Lungs) within the Four-Level identification of patterns. The treatment of this condition is discussed in further detail in the chapter on common cold and influenza (Chapter 48). Generally speaking, this condition responds extremely well to acupuncture and Chinese herbs, which should bring about an improvement within days, and it is not usually necessary to resort to

antibiotics. These damage Stomach-Yin and often lead to a residual Heat in the Lungs, which predisposes the patient to further invasions of Wind. When such a vicious circle of exterior invasions of Wind, chest infections, antibiotics, residual Heat in the Lungs and further invasions of Wind takes hold, wheezing may become chronic. Chronic bronchitis also responds extremely well to acupuncture and Chinese herbs but it will obviously take much longer to treat. The length of treatment will depend on the age of the patient and the duration and severity of the disease, but it will certainly take months rather than weeks. Chronic bronchitis should be treated by attending to the Root and Manifestation simultaneously, i.e. tonify the body’s Qi and expel pathogenic factors. Tonifying the body’s Qi will involve tonifying the Lungs, Spleen or Kidneys, or a combination of these, and expelling pathogenic factors will involve resolving Phlegm and either scattering Cold or clearing Heat, depending on whether there is Hot Phlegm or Cold Phlegm. The differentiation and treatment of this condition are discussed in further detail in the chapters on cough (Chapter 8) and common cold and influenza (Chapter 48). The prognosis of asthma depends on the age of the patient and the type of asthma. Early-onset, allergic asthma that is associated with eczema is the most difficult to treat, because it stems from an inborn deficiency of the Lung and Kidney’s Defensive-Qi systems (see Chapter 5). From a Western point of view, it is due to an inborn excessive level of immunoglobulin E antibodies. The treatment of this condition will certainly take several months and, depending on the severity, even years. Non-allergic, early-onset asthma is easier to treat, especially in children. In most cases, treatment should not take more than a few weeks. This condition is due to repeated invasions of Wind leading to retention of Phlegm in the Lungs, which obstructs the dispersing and descending of Lung-Qi. The foremost principle of treatment in children is to resolve Phlegm, restore the descending of Lung-Qi and relieve stagnation of food. Retention of food is very common in children, and the stagnation in the Middle Burner predisposes the child to retention of Phlegm in the Upper Burner. It is thus beneficial to relieve stagnation of food with digestive herbs such as Mai Ya Fructus Hordei vulgaris germinatus, Gu Ya Fructus Oryzae sativae germinatus, Lai Fu Zi Semen Raphani sativi, Shan Zha Fructus Crataegi, Shen Qu

Wheezing (Xiao)

Massa Fermentata Medicinalis and Ji Nei Jin Endothelium Corneum gigeraiae galli. Late-onset asthma in adults stands somewhat in between the previous two types in terms of prognosis: it is easier to treat than allergic asthma but more difficult than non-allergic early-onset asthma in children. Late-onset asthma in adults is usually characterized by a deficiency of Lungs, Spleen or Kidneys, or a combination of these, and retention of Phlegm. The treatment principle is therefore based on treating the Root (i.e. tonifying the body’s Qi) and the Manifestation simultaneously (i.e. resolving Phlegm and restoring the descending of Lung-Qi). The treatment will take several months at least. In some cases, asthma is caused by Liver-Qi stagnation or Liver-Fire (from emotional strain) obstructing the descending of LungQi. This type of asthma is usually easier to treat and is discussed in Chapter 5. As for prevention, this also differs according to the condition causing wheezing. Acute bronchitis cannot really be prevented as it is due to an invasion of exterior Wind. The main way of preventing chronic bronchitis is to avoid the set of circumstances leading to the vicious circle outlined above. This means that any acute invasion of Wind should never be underestimated and should be treated promptly, preferably avoiding antibiotics. The patient should also avoid dairy products and greasy foods, which facilitate the formation of Phlegm. He or she should also regulate his or her eating habits so that meals are taken at regular times. As for asthma, preventive measures for allergic asthma will be described in the chapter on asthma (Chapter 5), and these apply to other types of asthma as well.

WESTERN DIFFERENTIATION A wheezing sound is a sign of bronchiolar narrowing by spasm, oedema of the epithelium, retained mucus, or all three acting together. Wheezes are therefore like musical sounds produced by the rapid passage of air through a narrowed bronchus. Wheezes appear in obstructive lung diseases. They usually occur on exhalation but may also appear on inhalation. The state of bronchiolar narrowing on

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expiration can be diagnosed by measuring the maximum volume of air that can be blown out in a second. This is called forced expiratory volume and is a way of assessing the respiratory disability in diseases such as asthma, emphysema or chronic bronchitis. If a peak flow meter is not available, a simpler test can be carried out by asking the patient to blow out a lighted match without pursing the lips. A patient who is unable to do so and wheezes audibly in the attempt is suffering from obstructive airway disease. Another way of eliciting a wheeze is to press on the sternum while the patient breathes out. A wheeze is called polyphonic when it is composed of different sounds with different pitches all starting and stopping at the same time, and monophonic when it is composed of single sounds each with its own pitch.

Acute bronchitis This is an inflammation of the trachea and bronchi caused by various pyogenic organisms, such as Streptococcus pneumoniae, Haemophilus influenzae or Staphylococcus pyogenes. The main clinical manifestations include a cough that is productive of mucoid, viscid sputum in the beginning then becoming more copious and purulent, breathlessness, wheezing, a feeling of tightness of the chest, fever and leucocytosis. A persistent, single, monophonic wheeze may indicate obstruction of a bronchus by tumour. The main conditions that may cause wheezing are acute and chronic bronchitis and asthma.

Chronic bronchitis This condition is characterized by repeated attacks of cough during winter, gradually increasing in frequency until the cough becomes almost constant. Other manifestations include wheezing, tightness of the chest, tenacious, mucoid, purulent sputum and breathlessness.

Asthma The pathology and clinical manifestations of this disease will be described in detail in the chapter on allergic asthma (Chapter 5).

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END NOTES 1. Duan Guang Zhou et al. 1986 Jin Gui Yao Lue Shou Ce [A Manual of the Essential Prescriptions of the Golden Chest]. Science Publishing House, p. 21. The Essential Prescriptions of the Golden Chest was written by Zhang Zhong Jing and first published c.AD 220.

2. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue [Internal Medicine in Chinese Medicine]. Shanghai Science Publishing House, Shanghai, p. 59. 3. Ibid., p. 59. 4. Ibid., p. 59.

CHAPTER 5

ALLERGIC ASTHMA (ATOPIC ECZEMA) ALLERGIC ASTHMA IN WESTERN MEDICINE Pathology 115 Aetiology 118 Clinical features 123 Differential diagnosis 123

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CONNECTIONS AND DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN 125 Aetiology 125 Pathology 126 Identification of patterns and treatment 129 Late-onset, non-allergic asthma 130 A NEW THEORY OF ASTHMA 130 Aetiology and pathology 130 Identification of patterns and treatment THE LIVER AND ASTHMA 145 Liver-Qi stagnant, insulting the Lungs Liver-Fire insulting the Lungs 146 Liver-Yin deficiency 147

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145

ATOPIC ECZEMA 147 Acute eczema 150 Chronic eczema 152 External treatment 153 MODERN CHINESE LITERATURE

ATOPIC ECZEMA Acute eczema • Wind-Heat • Damp Heat

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PATIENTS’ STATISTICS

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PROGNOSIS AND PREVENTION

In between attacks • Lung-Qi deficiency • Lung-Qi and Lung-Yin deficiency • Lung-Qi and Kidney-Yang deficiency (with predominance of the latter) • Lung-Qi and Kidney-Yang deficiency (with predominance of the former) • Lung-Qi and Kidney-Yang deficiency with pronounced Cold • Lung-Yin and Stomach-Yin deficiency with Dryness and some Empty Heat • Lung-Yin deficiency, no Dryness and no Empty Heat • Lung- and Kidney-Yin deficiency • Lung-Qi and Kidney-Yang deficiency with internal Cold THE LIVER AND ASTHMA • Liver-Qi stagnant, insulting the Lungs • Liver-Fire insulting the Lungs • Liver-Yin deficiency

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CLINICAL TRIALS 161 Acupuncture 161 Herbal medicine 162 CASE HISTORIES

ALLERGIC ASTHMA During attacks • Wind-Cold (without sweating) • Wind-Cold (with sweating) • Wind-Heat

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WESTERN DRUG THERAPY 172 Antiallergic drugs (mast cell stabilizers) Bronchodilators 173 Corticosteroids 173 Leukotriene antagonists 173

172

Chronic eczema • Wind-Heat (with Blood deficiency) • Damp Heat

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ALLERGIC ASTHMA (ATOPIC ECZEMA) This chapter is dedicated to the discussion of allergic asthma and especially that in children and young people. Asthma is a general term that may refer to quite different diseases and, in my practice, I make a distinction between allergic and non-allergic asthma. I make this distinction because I believe that the Chinese theory of Xiao (Wheezing, Chapter 4) and Chuan (Breathlessness, Chapter 3) can be used to treat non-allergic asthma but not allergic asthma. I believe the aetiology and pathology of allergic asthma to be different from those of Xiao and Chuan. Also, I find that the theory of Xiao and Chuan does not explain the pathology of atopy and the association between allergic asthma and atopic eczema. In this, I differ from all modern Chinese books, which translate Xiao-Chuan as “asthma” (without specifying whether they are describing allergic or non-allergic asthma). A reader who disagrees with my views on allergic asthma may refer to Chapters 3 and 4 on Breathlessness and Wheezing instead for the treatment of asthma. The discussion of allergic asthma will be conducted according to the following topics. • Allergic asthma in Western medicine • Connections and differences between early-onset, allergic asthma and Xiao-Chuan • A new theory of asthma • The Liver and asthma • Atopic eczema • Modern Chinese literature • Clinical trials • Case histories • Patients’ statistics • Prognosis and prevention • Western drug therapy In this chapter, I will concentrate on the treatment of allergic asthma (also called early-onset or extrinsic asthma) in atopic individuals. The incidence of allergic asthma (and of eczema, which is associated with it) has steadily increased in industrialized countries in the past decades, and both morbidity and mortality are increasing. In the UK, 12% of children are diagnosed with asthma. There is no doubt that the incidence of asthma is increasing. For example, in the UK, it affected from 2% to 4% of children in 1979, and 12% in 1996; in South Wales, asthma in children doubled in 15 years; in Aberdeen between 1964 and 1989 the diagnosis of asthma increased 21⁄2 times.1

In the USA, 20 million people (of whom 5 million are children) are estimated to suffer from asthma.2 There are 20 million outpatient visits per year and 500 000 hospitalizations per year.3 In a study conducted in Scotland, it was found that in 1972–6 the incidence of asthma and allergic rhinitis in adults was 3% and 5.8%, respectively; in 1996, they were 8.2% and 19.9%, respectively. Therefore in 20 years the incidence of asthma nearly trebled and that of allergic rhinitis more than trebled.4

!  In the UK, 12% of children are diagnosed with asthma.  In the UK, the incidence of asthma went from between 2% and 4% of children in 1979 to 12% in 1996.  In South Wales, asthma in children doubled in 15 years.  In Aberdeen between 1964 and 1989, diagnosed asthma increased 21⁄2 times.  In the USA, 20 million people (of whom 5 million are children) are estimated to suffer from asthma.  In the USA, there are 20 million outpatient visits per year and 500 000 hospitalizations per year.  In Scotland, in 20 years the incidence of asthma nearly trebled and that of allergic rhinitis more than trebled.

Despite the introduction of several new drugs for the treatment of asthma, severe asthma is still by far the most common chronic debilitating disease in childhood and its mortality rate has not declined. Indeed, some think that the long-term use of some antiasthma drugs, such as bronchodilators, may be detrimental and may even have increased the mortality rate from this disease, which, in the USA, has increased by 45% in the past 10 years. All b2 agonists cause cardiac dysrhythmia. In the UK, there was an upsurge in deaths from asthma in the 1960s following the introduction of pressurized aerosols for the relief of asthma over the counter. As the sales went up, so did the deaths.5 New Zealand experienced a fourfold increase in asthma deaths in the 1980s over a period of 5 years.6 This was also attributed to the introduction of b2 agonists. In the

Allergic asthma (atopic eczema)

USA also, the mortality rate from asthma has been in constant increase from 1979. From 1978 through 1989, asthma mortality increased, with a near doubling in the mortality rates in both non-white and white people.7

BIAN BING

Gastric ulcer

!  In New Zealand, there was a fourfold increase in asthma deaths in the 1980s over a period of 5 years.  In the USA from 1978 through 1989, asthma mortality increased, with a near doubling in the mortality rates in both non-white and white people.

Because allergic asthma is a modern disease, when formulating a pathology and treatment of allergic asthma the question arises: to which Chinese disease category does allergic asthma correspond? The theoretical framework of Chinese medicine and its approach to treatment focus on symptoms rather than diseases. For example, textbooks of Chinese internal medicine discuss the treatment of “Epigastric Pain”, “Chest Pain”, “Constipation”, etc.; these are “diseases” in Chinese medicine, although they are only symptoms in Western medicine. Western internal medicine, on the contrary, discusses only the treatment of recognized “diseases” such as “stomach ulcer”, “coronary heart disease,” “diverticulitis”, etc. We generally treat specific Western diseases by referring to a corresponding Chinese symptom. For example, in order to treat a person with a stomach ulcer, we can clearly use the differentiation and treatment of “Epigastric Pain” in Chinese medicine; this is called “identifying the disease” (Bian Bing) in Chinese medicine. In some cases, the correspondence is less obvious. For example, in order to differentiate and treat hypertension, we generally need to refer to the differentiation and treatment of “Headache” and “Dizziness” in Chinese medicine (Fig. 5.1). Allergic asthma is a well-defined disease with very specific and characteristic aetiology and pathology. In order to diagnose and treat it properly with Chinese medicine, we must identify the symptom to which it most closely corresponds in the Chinese framework. All textbooks of Chinese medicine, whether Chinese or Western, say that asthma corresponds to the symptom of Xiao-Chuan as defined in Chinese medicine. The

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‘‘Epigastric pain’’

‘‘Headaches’’ Hypertension ‘‘Dizziness’’

Allergic asthma

‘?’

In other words, is it legitimate to make a Chinese Bian Bing on the basis of Western diagnosis? Figure 5.1 Identification of the disease in Chinese medicine.

reason for this is probably also semantic, as the Chinese word for “asthma” is xiao-chuan and, in terminology, there is no way of distinguishing between allergic asthma and chronic breathlessness from other causes. I propose that: • Xiao (Wheezing) and Chuan (Breathlessness) are two separate symptoms • allergic asthma does not correspond to either of them (although it is somewhat closer to Xiao than to Chuan), and the identification of patterns and treatment of Xiao or Chuan cannot be applied to allergic asthma. In order to ascertain the correspondence and differences between Xiao-Chuan and asthma, we have to discuss the three following aspects: 1. the pathology and aetiology of allergic asthma in Western medicine 2. the connections and differences between XiaoChuan and allergic asthma 3. a new theory of allergic asthma in Chinese medicine.

ALLERGIC ASTHMA IN WESTERN MEDICINE Pathology The symptoms and signs of allergic asthma evolve from three basic characteristics that underlie the disease

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and its exacerbations: airway obstruction, airway hyper-responsiveness and airway inflammation. The pathology of asthma is characterized by a partial and temporary obstruction of airflow in the airways (Fig. 5.2). Bronchial narrowing in asthma can be caused by three main factors: mucus in the bronchi, swelling of the internal layers of the bronchi and contraction of the muscles lying in the walls of the bronchi, which leads to constriction of the air passages (“bronchospasm”).8 The bronchial narrowing interferes with ventilation and raises the resistance to airflow in the bronchi. This is more marked on exhalation, and it causes air to be trapped in the lungs. The narrowed bronchi can no longer be effectively cleared of mucus by coughing. Contraction of the bronchial muscles may be the sole factor causing airway narrowing in allergic asthma. As we shall see later, from the Chinese point of view the contraction of bronchial muscles is due to Wind. However, the narrowing of the airways is more often due also to the other two factors cited above, i.e. mucus production and swelling of the inner layers.9 In allergic asthma, the bronchospasm is caused by an allergic reaction due to immune hypersensitivity. This is also called anaphylactic or type 1 reaction. Only immunoglobulin (Ig) E (reaginic) antibodies produce type 1 reactions. As these antibodies adhere strongly to tissues (and particularly to mast cells in the tissues), they are often called tissue-sensitizing antibodies. Anaphylactic crises in asthma are caused by an antigen– antibody reaction on the surface of the mast cells in the bronchi. This activates a series of enzymes, which leads to the release of certain chemical substances from the mast cells, such as histamine, serotonin, bradykinin AIRWAY IN ASTHMA

NORMAL AIRWAY

and prostaglandins. The IgE-dependent release of mastcell products not only provokes acute bronchospasm but also contributes to the development of the latephase asthmatic reaction (Fig. 5.3). Immunoglobulin G antibodies account for 73% of immunoglobulin antibodies in serum, and they can prevent IgE-mediated allergic reactions; on the other hand, the level of IgE antibodies in serum is under genetic control. IgG antibodies are the only antibodies that are transported across the placenta to reach the fetal circulation. This factor is quite significant in explaining the aetiology of allergic asthma from a Chinese medical perspective, as will be discussed later. Bronchospasm from an allergic reaction, however, is only one aspect of the pathology of asthma, chronic inflammation of the bronchial mucosa being another (Fig. 5.4). The allergic reaction in the mast cells of the bronchi causes inflammation of the airways. Inflammation causes a swelling of the inner layers of the airways, reducing their lumen. The inflamed lining then

Antigen

Antibody:

Tissue-fixed IgE Mast cells

Muscle

Tight muscles Lining

Swollen lining

Histamine, serotonin, bradykinin

Prostaglandins

Contraction of plain muscles Accumulation of eosinophils Bronchospasm Epithelial damage (late phase) Mucus Figure 5.2 Airway obstruction in asthma.

Asthma Figure 5.3 Pathology of allergic asthma.

Allergic asthma (atopic eczema)

Histamine

MAST CELLS

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• Smooth muscle contraction • Acute symptoms • Episodic wheeze

Prostaglandins IgE production Beta lymphocytes

ALLERGEN

T lymphocytes

• Inflammation • Chronic wheeze • Bronchial hyper-responsiveness

Eosinophils

Figure 5.4 Allergic and inflammatory processes in allergic asthma.

produces a mucus that further narrows the airways (Fig. 5.5). We can see therefore (as will be emphasized below) that the mucus in allergic asthma is the result rather than the cause of the pathology. The chemical mediators responsible for allergic inflammation in asthma are histamine, prostaglandins and leukotrienes manufactured by the mast cells. Eosinophils are scavenger cells that are attracted to the airways in allergic inflammation; they break up and they themselves release complex proteins and chemicals that aggravate the inflammation.

We can distinguish an early and a late inflammatory reaction, and in the interval between these two phases eosinophils crowd the airways; it is at this time that the airways become increasingly irritable and increasingly reactive to histamine.10 Lymphocytes also become activated in an allergic inflammatory reaction. They encourage more eosinophils to move into the inflamed airways and they themselves release chemicals that aggravate the inflammation; such chemicals are collectively known as cytokines.11

EARLY ALLERGIC REACTION

NORMAL AIRWAY

LATE ALLERGIC REACTION

Cytokines Histamine

Prostaglandins Leukotrienes

Allergen

Mast cell Figure 5.5 Narrowing of lumen of airways from inflammation in asthma.

Eosinophils

Lymphocytes

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The mucosa is inflamed and oedematous, and there are infiltrating inflammatory cells. There is an excess of eosinophils that lead to destruction of epithelial cells with consequent exposure of irritant receptors on the basement membrane. This, in turn, leads to an increase in bronchial responsiveness from allergic stimulation.12 Inflammatory molecules called leukotrienes are one of several substances that are released by mast cells during an asthma attack, and it is leukotrienes that are primarily responsible for the bronchoconstriction. In chronic, more severe cases of asthma, general bronchial hyper-reactivity is largely caused by eosinophils, which are attracted into the bronchioles by leukotrienes; the eosinophils themselves then also produce leukotrienes. Thus, leukotrienes seem to be critical both in triggering acute asthma attacks and in causing longer term hypersensitivity of the airways in chronic asthma. Cysteinyl-leukotrienes are concerned primarily with eosinophil- and mast cell-induced bronchoconstriction in asthma. They bind to highly selective receptors on bronchial smooth muscle and other airway tissue.

SUMMARY PATHOLOGY OF ALLERGIC ASTHMA IN WESTERN MEDICINE  Airway obstruction, airway hyperresponsiveness and airway inflammation.  Partial and temporary obstruction of airflow in the airways.  Bronchial narrowing caused by three main factors: mucus in the bronchi, swelling of the internal layers of the bronchi and contraction of the muscles lying in the walls of the bronchi, which leads to constriction of the air passages (“bronchospasm”).  In allergic asthma, the bronchospasm is caused by an allergic reaction due to immune hypersensitivity. This is also called anaphylactic or type 1 reaction from IgE (reaginic) antibodies.  Anaphylactic crises in asthma are caused by an antigen–antibody reaction on the surface of the mast cells in the bronchi.  This activates a series of enzymes, which leads to the release of certain chemical substances

from the mast cells, such as histamine, serotonin, bradykinin and prostaglandins.  The IgE-dependent release of mast cell products not only provokes acute bronchospasm but also contributes to the development of the late-phase asthmatic reaction.  The allergic reaction in the mast cells of the bronchi causes inflammation of the airways. Inflammation causes a swelling of the inner layers of the airways, reducing their lumen. The inflamed lining then produces a mucus that further narrows the airways.  The chemical mediators responsible for allergic inflammation in asthma are histamine, prostaglandins and leukotrienes manufactured by the mast cells.  We can distinguish an early and a late inflammatory reaction, and in the interval between these two phases eosinophils crowd the airways; it is at this time that the airways become increasingly irritable and increasingly reactive to histamine.  The mucosa is inflamed and oedematous, and there are infiltrating inflammatory cells. There is an excess of eosinophils that lead to destruction of epithelial cells with consequent exposure of irritant receptors on the basement membrane. This, in turn, leads to an increase in bronchial responsiveness from allergic stimulation.  Inflammatory molecules called leukotrienes are released by mast cells during an asthma attack, and it is leukotrienes that are primarily responsible for the bronchoconstriction.

Aetiology There are two types of asthma: the early-onset type, which is also called extrinsic or allergic asthma, and the late-onset type, which is also called intrinsic asthma. Our discussion will concentrate mostly on the allergic, early-onset type of asthma.

Early-onset asthma As the names imply, the early-onset asthma usually starts during childhood, while the late-onset asthma

Allergic asthma (atopic eczema)

starts later on in life. However, it is important to note that not all cases of early-onset asthma are due to atopy. On the other hand, not all cases of late-onset asthma are intrinsic, i.e. non-allergic; although it is not a common occurrence, allergic asthma may occasionally start late in life. Indeed, in children, many cases of non-allergic asthma are caused by retention of a residual pathogenic factor (usually Phlegm) following repeated invasions of external Wind. Moreover, many children are often wrongly diagnosed with asthma when they have bronchiolitis (see below). Early-onset asthma has the following characteristics: • it starts during early childhood • it appears to run in families • it is often associated with eczema from birth; individuals who suffer from this type of asthma have wealing skin reactions to common allergens • they also have antibodies in their serum that could be transferred to the skin of non-sensitized people to cause the same wealing skin reactions (Fig. 5.6).

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In patients with allergic asthma, inhalation challenge with an antigen produces an immediate bronchoconstriction, reaching a maximum in 20 minutes. This early asthmatic response is almost identical in time course to the weal reaction. This would show that the primary aetiological factor of allergic asthma is indeed the allergic reaction rather than the inflammation process that follows the allergic reaction. The main thrust of the therapeutic medical intervention is based on the use of anti-inflammatory drugs (cortisone), and one cannot help wondering how much of this approach is research-driven and how much drug-driven. Indeed, there are authors who place the stress on bronchoconstriction as opposed to inflammation as the main cause of asthma. In fact, chemical mediators of inflammatory response are present in the normal lung and do not cause bronchoconstriction; this seems to prove that inflammation is not the primary cause of asthma, while allergy is.13 The same authors also observe that normal subjects demonstrate a plateau of bronchoconstriction following histamine provocation no matter how high the dose. By contrast, asthmatics do not have such a plateau, and they obviously lack the

Family history usually positive “Allergic shiner” may be present

History of eczema in childhood

Attacks related to specific antigens Favourable response to hypersensitization

Pollen

Foods

Drugs Dust Dander

IgE-associated Skin tests usually positive

Figure 5.6 Characteristics of allergic, early-onset asthma.

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protective mechanism of healthy subjects that prevents excessive bronchoconstriction.14 Macklem thinks that the loss of plateau with resulting unrestricted bronchoconstriction cannot be explained by excessive smooth muscle excitation by neural or humoral mediators.15 He thinks therefore that the objective of asthma therapy must be to restore the plateau; as we shall see below, from the Chinese perspective, I believe this means to tonify the Lungs and Kidneys. Macklem also thinks that airway smooth muscle hypertrophy is the main culprit in producing unlimited bronchoconstriction.16 As a result, the author expresses his doubts about steroid therapy, as this has no effect on airway smooth muscles. As we shall see below, I relate the smooth muscle spasm to “Wind” from the point of view of Chinese medicine. CLINICAL NOTE  Some authors place the stress on bronchoconstriction as opposed to inflammation as the main cause of asthma.  Chemical mediators of inflammatory response are present in the normal lung and do not cause bronchoconstriction; this seems to prove that inflammation is not the primary cause of asthma, while allergy is.  Asthmatics do not have a plateau to bronchoconstriction following histamine challenge.  The loss of plateau with resulting unrestricted bronchoconstriction cannot be explained by excessive smooth muscle excitation by neural or humoral mediators.  Macklem thinks that airway smooth muscle hypertrophy is the main culprit in producing unlimited bronchoconstriction.  As a result, Macklem expresses his doubts about steroid therapy, as this has no effect on airway smooth muscles.  Individuals who suffer from allergic asthma with the above characteristics are called “atopic”, and they have levels of IgE immunoglobulins up to six times higher than those found in patients suffering from non-atopic asthma. Atopic individuals have a hereditary predisposition to anaphylactic (or type 1) reactions.

Many different allergens are implicated, but the main ones are faecal particles of house dust mites, pollen, fungal spores, feathers, animal dander and cats’ saliva. Once the mast cells have been primed by exposure to

these allergens and high levels of IgE immunoglobulins adhere to them, they also become hypersensitive to other non-specific allergens, such as smoke, tobacco smoke, petrol fumes, dust, atmospheric pollutants and perfumes. Occasionally, an allergic reaction in the bronchi can be elicited by ingested allergens from food such as shellfish, fish, eggs, milk, yeast or wheat, which reach the bronchi via the bloodstream. Viruses may also act as allergens, and that is why an attack of allergic asthma may be triggered in a child by a viral infection, the most common ones being respiratory syncytial virus and the influenza virus.17 As for the increased incidence of atopy, it is difficult to pinpoint one or two of its causes. However, several hypotheses have been advanced. One is the hygiene hypothesis, i.e. that the increased incidence of atopy may be due to the lack of infections in childhood (itself due to immunizations).18 At birth, infants destined to become allergic have impaired production of interferon-g by their circulating T lymphocytes. A possible explanation of the protective effects of exposure to bacteria in early life, when sensitization occurs, is their action in increasing production of interferon-g. This concept has given rise to the hygiene hypothesis, in which changes to infant diets, early use of antibiotics and reduced exposure to bacterial products predispose to the persistence of TH2 responses in childhood.19 This hypothesis seems to be confirmed by a study conducted on children attending anthroposophic schools. Parents following an anthroposophic lifestyle generally do not vaccinate their children, they tend to minimize use of antibiotics and consume fermented dairy products with lactobacilli. In Sweden, 295 children attending anthroposophic schools were compared with 380 children of the same age attending normal schools. At the Steiner (Waldorf) schools, 52% of the children had had antibiotics in the past, compared with 90% in normal schools, respectively; 18% and 93% of children had had combined immmunizations against measles, mumps and rubella (61% of children in Steiner schools had had measles). Foods containing lactobacilli were consumed by 63% of children at Steiner schools, compared with 4.5% of children from the control schools. Prevalence of atopy was lower in children from anthroposophic families than in children from other families.20 In a study conducted in Guinea-Bissau, it was found that exposure to measles infection protected against the development of atopy in African children.21 The

Allergic asthma (atopic eczema)

study also found that those who had been breastfed for more than 1 year were less likely to have a positive skin test to house dust mites. The clean living conditions of Western societies, by reducing the incidence of infection, may weigh the balance toward the TH2 phenotype and predispose to asthma.22 Another study also showed a possible correlation between the use of antibiotics during infancy and the development of asthma in the first year of life. This study concluded that exposure to at least one course of antibiotics in the first year of life appears to be a risk factor for the development of childhood asthma. It also formed the hypothesis that growing up in a more hygienic environment with less microbial exposure may increase atopic immune responses and, thus, the development of asthma.23 Although this study makes a correlation between the use of antibiotics in infancy and atopic asthma and therefore the so-called hygiene theory, I personally suspect that some of the cases of “asthma” in children referred to in the study are probably not “asthma” but cases of cough from retained Phlegm in the Lungs and therefore not atopic. It should be noted here that asthma that starts during early childhood is not necessarily atopic asthma. In other words, an early onset is not the only criterion for defining asthma as “allergic” or “atopic”. The familial incidence, its connection with eczema and the typical wealing skin reactions on inhalation of allergens are other important features necessary to diagnose atopic asthma. There are cases of asthma starting in early childhood without an allergic basis. This happens especially when a small child suffers from an upper respiratory infection (invasion of Wind-Cold or Wind-Heat), which is either not treated properly or treated with antibiotics. If Wind is not expelled properly, it lodges itself in the Lungs and impairs the diffusing and descending of Lung-Qi, resulting in breathlessness and Phlegm. On the other hand, the presence of Wind and Phlegm in the Lungs predisposes the child to further invasions of external Wind, which make the situation worse. Thus, a vicious cycle sets in: the child is progressively weakened and more prone to invasions of external Wind, and the breathlessness gets gradually worse. Therefore, many cases of what is essentially retention of residual pathogenic factor (as Phlegm) following repeated invasions of Wind in small children are diag-

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nosed as “asthma” and they are treated with cortisone inhalers. In my opinion, “asthma” is also often wrongly diagnosed in small children who are actually suffering from bronchiolitis (see below). The symptoms of bronchiolitis, a viral infection, closely mimic those of asthma.

Case history A 2-year-old boy had developed a fever, wheezing and breathlessness a few days after suffering an acute upper respiratory infection. He also suffered from a cough with expectoration of yellow sputum. From the Chinese perspective, this is a clear case of Phlegm-Heat at the Qi Level following an invasion of Wind at the Defensive-Qi (Wei) Level. The fever and aversion to heat indicate the presence of interior Heat at the Qi Level. From the Western perspective too, the fever indicates an infection (bacterial or viral). Surprisingly, the child was diagnosed with “asthma” and given cortisone inhalers. Most probably, the child had bronchiolitis or a viral infection from syncytial virus. This chapter, however, will concentrate primarily on discussing the typical allergic asthma, as non-allergic asthma can be diagnosed and treated mostly according to the guidelines given for Wheezing (Chapter 4).

Late-onset asthma Late-onset asthma, also called intrinsic asthma, normally starts later in life and is due to bronchial hyper-reactivity. In this case, there is no familial history of asthma and no eczema. Late-onset asthma occurs in non-atopic individuals and, although in some cases it may be triggered by certain allergens, it does not present all the typical traits of atopic asthma. In other cases, it would appear that external allergens play no part in the aetiology of this disease (Fig. 5.7). Some authors give a general guideline to differentiate extrinsic from intrinsic asthma based on the age of onset: when asthma begins before 30, the cause is allergy unless proven otherwise; when it begins after 40, the cause is not allergy unless proven otherwise.24 The diagnosis of asthma is done on the basis of lung function tests (forced expiratory volume, FEV), peak flow charts (peak expiratory flow rate, PEFR), exercise

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Family history usually negative

No history of eczema in childhood

Attacks related to infections, exercise and other stimuli Unfavourable response to hypersensitization

Skin tests usually negative

Not IgE-associated

Figure 5.7 Characteristics of non-allergic, late-onset asthma.

tests, histamine provocation tests and skin tests (inhalation of an allergen that produces large weals on the skin also triggers off asthma). Sputum and blood tests are done to exclude bronchitis, as large numbers of eosinophils in the sputum point to bronchitis. X-rays have no diagnostic value in asthma, as they show no particular feature in this disease.

SUMMARY AETIOLOGY OF ALLERGIC ASTHMA  Two types of asthma: the early-onset type, which is also called extrinsic or allergic asthma, and the late-onset type, which is also called intrinsic asthma.  Early-onset asthma has the following characteristics: — it starts during early childhood — it appears to run in families — it is often associated with eczema from birth

— individuals who suffer from this type of asthma have wealing skin reactions to common allergens.  In patients with allergic asthma, inhalation challenge with an antigen produces an immediate bronchoconstriction, reaching a maximum in 20 minutes.  There are some who place the stress on bronchoconstriction rather than inflammation as the main cause of asthma.  Individuals who suffer from allergic asthma with the above characteristics are called “atopic”, and they have levels of IgE immunoglobulins up to six times higher than those found in patients suffering from nonatopic asthma.  Many different allergens are implicated, but the main ones are faecal particles of house dust mites, pollen, fungal spores, feathers, animal dander and cats’ saliva.

Allergic asthma (atopic eczema)

 Viruses may also act as allergens, and that is why an attack of allergic asthma may be triggered in a child by a viral infection, the most common ones being respiratory syncytial virus and the influenza virus.  A study showed a possible correlation between the use of antibiotics during infancy and the development of asthma in the first year of life. This study concluded that exposure to at least one course of antibiotics in the first year of life appears to be a risk factor for the development of childhood asthma.  Late-onset asthma, also called intrinsic asthma, normally starts later in life and is due to bronchial hyper-reactivity. In this case, there is no familial history of asthma and no eczema. Late-onset asthma occurs in non-atopic individuals.

Clinical features Asthma is characterized by wheezing attacks with shortness of breath, which are usually worse at night. Sometimes there is a dry cough, which is also worse at night. The onset is sudden and is preceded by tightness of the chest. The dyspnoea and wheezing occur mainly

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on exhalation with fixing of the shoulder girdle. The patient likes to sit up. It is in the very nature of asthma that it occurs in paroxysms, i.e. it comes and goes. Indeed, some chest specialists say it is not so much the symptoms themselves (tightness of the chest and wheezing) that enable us to diagnose asthma (these symptoms are present in other chest diseases) as the circumstances under which they occur.25

Differential diagnosis Patients with asthma can have similar symptoms to those suffering from airflow limitation deriving from chronic bronchitis and emphysema. Table 5.1 illustrates the features of asthma, chronic bronchitis and emphysema.

Chronic bronchitis This disease is characterized by hypertrophy of mucussecreting glands in the bronchial tree. In advanced cases, the bronchi themselves are inflamed and there is pus with infection. The clinical features include breathlessness and a cough on most days. There is also wheezing, and the cough is productive of abundant sputum. This may become purulent from time to time, indicating a bacterial infection that often supervenes in chronic bronchitis.

Table 5.1 Differentiation of asthma, chronic bronchitis and emphysema Asthma

Chronic bronchitis

Emphysema

Pathology

Bronchospasm

Narrowing of bronchi by mucus

Distension of alveoli and/or bronchioles

Signs

Wheezing

Productive cough with profuse sputum

Thin chest

Symptoms

Bouts of dyspnoea

Dyspnoea, stuffiness of the chest

Constant dyspnoea

Frequency

Bouts of dyspnoea

Bouts of dyspnoea with chest infections

Constant dyspnoea

Time

Worse at night

Worse in the morning

All the time

Allergies

Yes

No

No

Sputum

No

Yes, abundant

Yes

Eczema

Yes

No

No

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Some specialists refer to “wheezy bronchitis” in young children, i.e. a bronchitis from a viral infection with concurrent wheezing. From the perspective of Chinese medicine, bronchitis is due to an invasion of external Wind that then penetrates into the Interior, giving rise to Phlegm-Heat in the Lungs. There is the tendency among doctors and chest specialists to treat such wheezy bronchitis as asthma. For example, one text states: “Good reasons were put forward why these children should be called asthmatics rather than be labelled as wheezy bronchitics.”26 From the point of view of Chinese medicine, this is regrettable, as it condemns young children to long-term use of cortisone inhalers when their bronchitis could be cleared by the use of acupuncture and Chinese herbs. There is also the increasing tendency by doctors and consultants to consider all cases of nocturnal cough as asthma. For example:27 There is the quite common presentation of asthma especially in pre-school children as coughing alone without any wheezing. A careful analysis of the circumstances under which the coughing occurs will reveal that it follows the same pattern as that described for wheezing. Thus the coughing will be most obvious during the night, on awakening in the morning and after exercise. There is an unfortunate tendency for these children to be regarded as “bronchitic” and to be treated with antibiotics. This is a wrong approach: they are asthmatic and they should be treated as such. There are only a few voices against this approach, and some doctors consider asthma in young children to be over-diagnosed. For example, Dr M. Rudolph says: “There are clearly groups of infants and young children who develop wheezing in association with viral infections yet who subsequently have normal lung function and do not develop asthma.”28 The over-diagnosis of asthma is an important potential disadvantage of aggressive early use of inhaled corticosteroids in young children. It may well be that some children with nocturnal cough are asthmatic but, in my experience, very many of them simply suffer from a residual pathogenic factor in the Lungs (which is usually Heat or Phlegm-Heat) following repeated invasions of external Wind.

Emphysema This disease is characterized by distension and damage of bronchioles and/or alveoli. There is breathlessness on exertion and wheezing that is almost constant.

Bronchiectasis This disease is characterized by dilatation of the bronchi with production of large amounts of sputum. There are recurrent episodes of fever or pneumonia. It may develop from pneumonia or whooping cough.

Bronchiolitis The respiratory syncytial virus is probably the most successful of all viruses, causing annual epidemics of respiratory illness throughout the world.29 In temperate climates, these epidemics last from 3 to 5 months, peaking in midwinter. The annual epidemics are remarkably consistent in timing across continents and from year to year. The virus was first isolated nearly 50 years ago from chimpanzees, but it quickly became apparent that this was the virus largely responsible for the annual epidemics of respiratory illness observed in young infants. Between 0.5% and 2% of all infants are admitted to hospital with airways obstruction due to respiratory syncytial virus infection, and it remains the commonest reason for hospitalization in infancy.30 The majority of those admitted to hospital are diagnosed as having “acute bronchiolitis”, and it has been known for many decades that such infants experience increased levels of recurrent respiratory symptoms in subsequent years.31 The most common form of lower respiratory tract illness noted in infants is “acute bronchiolitis”.32 The majority of paediatricians in the UK, Australia and parts of Europe will use this term to refer to patients showing signs of viral upper respiratory tract viral infection together with lower respiratory tract inflammation characterized by widespread crepitations. These infants may wheeze at some point during the acute illness. The term “acute bronchiolitis” in North America and other parts of Europe is frequently used to describe infants with their first wheezing episode associated with a viral upper respiratory tract infection. The main symptoms of bronchiolitis are wheezing, lung hyperexpansion and hypoxia. During a 17-year study period in the USA, there were 1.65 million hospitalizations for bronchiolitis.33 It is virtually impossible to distinguish between the symptoms of bronchiolitis and asthma in children under 1.34

Allergic asthma (atopic eczema)

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CONNECTIONS AND DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN

eaten in China. Intolerance to milk is an important aetiological factor in allergic asthma.

Let us start by analysing the gaps in the Chinese view of Xiao-Chuan in relation to early-onset, allergic asthma. We will look at the three areas of aetiology, pathology and differentiation/treatment.

Overwork and excessive sexual activity as mentioned in the theory of Xiao-Chuan are clearly not an aetiological factor in children with asthma, although they may play a part in adults with late-onset asthma.

Aetiology It will be remembered that the main aetiological factors mentioned in the theory of Wheezing (Xiao) and Breathlessness (Chuan) are: • • • •

external pathogenic factors diet emotional problems fatigue, chronic illness and excessive sexual activity.

Let us now examine each of these aetiological factors in relation to allergic asthma and also any gaps in the traditional aetiology of Xiao-Chuan.

Atopy A fundamental gap in the traditional theory of XiaoChuan is that it has no concept of allergy and atopy as an aetiological factor in asthma, although early-onset asthma is so clearly related to an allergic immune hypersensitivity. A few modern Chinese books briefly refer to the allergic nature of asthma, but they still apply the theory of Xiao-Chuan for its treatment.

External pathogenic factors Most books say that asthma attacks are elicited by invasion of external pathogenic factors such as WindCold or Wind-Heat. While this is true in some cases, it is certainly not true in all.

Diet The theory of Xiao-Chuan mentions the excessive consumption of sour, greasy or cold foods as an aetiological factor. While this is certainly true in late-onset asthma, it cannot be true when asthma starts in early childhood. Very few children, if any, are likely to eat such foods in excess. Dairy foods, which certainly are a possible aetiological factor in asthma, are not mentioned in the aetiology of Xiao-Chuan simply because they are not

Overwork and excessive sexual activity

Emotional stress Emotional stress such as worry, brooding and pensiveness mentioned in the theory of Xiao-Chuan is certainly not an aetiological factor in very young children with early-onset asthma. Of course, children may be subject to emotional stress from early age but not in the same sense as adults.

Weak body condition One of the aetiological factors of Xiao-Chuan which does apply to early-onset, allergic asthma is a weak body condition. In young children, this may be caused by a severe attack of measles, whooping cough, or pneumonia.

SUMMARY DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN AETIOLOGY  The theory of Xiao-Chuan has no concept of allergy and atopy as an aetiological factor in asthma.  Most books say that asthma attacks are elicited by invasion of external pathogenic factors such as Wind-Cold or Wind-Heat. While this is true in some cases, it is certainly not true in all.  The theory of Xiao-Chuan mentions the excessive consumption of sour, greasy or cold foods as an aetiological factor. This cannot be true when asthma starts in early childhood, as very few children, if any, are likely to eat such foods in excess.  Dairy foods, which certainly are a possible aetiological factor in asthma, are not mentioned in the aetiology of Xiao-Chuan simply because they are not eaten in China. Intolerance to milk is an important aetiological factor in allergic asthma.

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 Overwork and excessive sexual activity as mentioned in the theory of Xiao-Chuan are clearly not an aetiological factor in children with asthma.  Emotional stress such as worry, brooding and pensiveness mentioned in the theory of XiaoChuan is certainly not an aetiological factor in very young children with early-onset asthma.

Pathology The following are what I perceive to be the gaps in the traditional pathology of Xiao-Chuan in relation to allergic asthma.

Phlegm not the main pathogenic factor in allergic asthma Phlegm is central to the pathology of both Xiao and Chuan. In both conditions, wheezing and breathlessness are caused by Phlegm obstructing the airways. The wheezing sound is due to rebellious Qi ascending along the airways obstructed by Phlegm. In my opinion and according to my experience, however, Phlegm is not the main pathogenic factor in allergic asthma. In this disease, wheezing and breathlessness are due to narrowing of the airways from bronchospasm following an allergic reaction. The narrowed bronchi cannot be properly cleared of mucus by coughing. Seen from this point of view, Phlegm is therefore the result rather than the cause of the condition (see also below).

! Phlegm is not the main pathogenic factor in allergic asthma; wheezing and breathlessness are due to bronchospasm following a type 1 allergic reaction.

The old Chinese doctors had to attribute narrowing of the airways to Phlegm, as they could not know the mechanism of bronchoconstriction from parasympathetic stimulation. Interestingly, old Western medicine also attributed asthma to obstruction of the airways by mucus. John Miller wrote in 1769: “The superfluous serum, which ought to be thrown out by

expiration, is accumulated and the organs of respiration are weakened.”35 Robert Bree (1807) saw asthma as “an extraordinary effort to get rid of some peccant and irritating matter existing in the air tubes”.36 Other doctors, however, understood as early as 1868 that wheezing and breathlessness in asthma were due to bronchospasm rather than obstruction from phlegm and that this was the result rather than the cause of asthma. Dr Henry Hyde Salter in fact said: “The fact is, Dr Bree mistook the effect [i.e. phlegm] for the cause.”37 As far back as 1786, some doctors perceived the allergic nature of asthma even though they could not explain it fully. Dr William Withering (who pioneered the use of foxglove extract to treat congestive cardiac failure) wrote in 1786 that asthma might be cured by the patient’s living in large rooms from which curtains and feather beds had been removed.38 Two other elements that are not consistent with Phlegm being the main factor in asthma are the tongue and the pulse. If Phlegm were the main pathological factor in asthma, then the tongue should be Swollen with a sticky coating and the pulse Slippery. This is very often not the case. In early-onset asthma, the tongue is not usually Swollen (it is often Thin) and the pulse not Slippery (it is often Tight). Interestingly, a study in China in atopic children found a correlation between a geographic tongue (indicating Yin deficiency) with an atopic constitution and raised levels of IgE.39 Moreover, the author related the atopic constitution to a Kidney deficiency. Beaven also reports a correlation between a geographic tongue and a history of allergic rhinitis, allergic asthma and atopic eczema.40 Another factor that rules out Phlegm as a pathogenic factor in asthma is the fact that, in between attacks, an asthmatic person is often quite normal. Indeed, there are some athletes who are asthmatic. If Phlegm obstructs the Lungs, however, wheezing and breathlessness are constant and they persist until Phlegm is completely eliminated. Thus Dr Ye Gui in Case Reports for Clinical Practice (1766) correctly says:41 If the pathogenic factor is expelled, breathlessness [Chuan] stops and will never return. In wheezing [Xiao], the pathogenic factor is hidden in the Interior and in the Lungs, it is sometimes active and sometimes quiescent, and there are frequent episodes over many years. This confirms that Phlegm is the main causative factor in Breathlessness (Chuan): once Phlegm is eliminated,

Allergic asthma (atopic eczema)

the breathlessness goes completely. In Wheezing (Xiao), which is closer to asthma, the pathogenic factor is hidden in the Lungs and it becomes active in bouts causing asthma attacks. CLINICAL NOTE Although I do not consider Phlegm to be the main pathogenic factor in allergic asthma, I do use ST-40 Fenglong frequently to treat this disease not because of its action in resolving Phlegm but its other actions. In fact, ST-40:

 subdues rebellious Qi  opens and relaxes the chest  in combination with LU-7 Lieque and P-6 Neiguan, it stimulates the descending of Lung-Qi.

“Wind” as the main pathogenic factor in allergic asthma It is interesting that Dr Gui states that the pathogenic factor in Wheezing (Xiao) is “sometimes active and sometimes quiescent”. In my view, the intermittent nature of the pathogenic factor confirms that Wind rather than Phlegm is the main pathogenic factor in allergic asthma, as it is in the nature of Wind to come and go and change rapidly (see below) whereas Phlegm would not have this intermittent nature. The contraction of the bronchial muscles by itself may be the sole cause of airway narrowing; such a contraction may be attributed to “Wind” in Chinese medicine, as it manifests with the symptoms of Wind, i.e. Wind contracts, it may come and go and changes rapidly. This explains why an asthmatic breathes well in between attacks. It is in the very nature of asthma that it occurs in paroxysms, i.e. it comes and goes. Indeed, some chest specialists say it is not so much the symptoms themselves (tightness of the chest and wheezing) that enable us to diagnose asthma (these symptoms occur in other chest diseases) as the circumstances under which they occur.42 In asthma, it is characteristic that they occur in paroxysms; this is due to the nature of Wind that comes and goes. Another characteristic of allergic asthma that points to Wind as a cause of disease is the fact that, although the asthmatic does become breathless during exercise, much more importantly, he or she becomes even more breathless after exercise has ended. The progressive

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paroxysm of tightness, coughing and wheezing following exercise reaches a peak within a few minutes and may last for half an hour. Virtually no other type of chest disease is associated with symptoms that get worse immediately after exercise.43 Of course, in chronic asthma, other factors account for the narrowing of the airways, i.e. a swelling of the lining of the airways and the presence of mucus; the more chronic the asthma, the more these two factors play a role in the narrowing of the airways. The mucus that forms in the airways in allergic asthma, however, is a consequence of the inflammatory reaction, which itself is a consequence of the allergic reaction. Therefore, we can say that mucus is more the result than the cause of allergic asthma. It is also interesting to note that there is a difference between the type of mucus in chronic bronchitis and that in asthma. In chronic bronchitis, there is a reduction of serous acini; in asthma, the normal serous– mucous acinar ration is intact. The plugs in asthma have a non-mucous component. What is the pathogenic factor in allergic asthma then? Basically, it is Wind: not exterior Wind invading the Lung’s Defensive-Qi portion, nor interior Wind (which pertains to the Liver), but a kind of chronic (exterior) Wind lodged in the bronchi and periodically leading to bronchospasm. The attacks are elicited by exposure to allergens, viruses or cold weather or by emotional stress. The nature of this “Wind” as a pathogenic factor in asthma will be expanded on shortly.

! “Wind” in the bronchi is the main pathogenic factor in asthma, as it:  contracts (causing bronchospasm)  comes and goes (accounting for the paroxysmal nature of asthma)  is non-substantial (does not show up on X-rays)  changes rapidly (accounting for normality in between attacks). It is also interesting that X-rays have no diagnostic value in asthma. This seems to confirm that Wind, and not Phlegm, is the main pathogenic factor in asthma. Wind is a non-substantial pathogenic factor and, as such, it naturally would not show on an X-ray whereas Phlegm, a substantial pathogenic factor, would.

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Although there is excessive mucus production in the airways in allergic asthma as a result of the inflammatory process, this is more the result rather than the cause of the pathology. Of course, in a person with early-onset asthma, after many years, in adulthood, the pathology becomes more complicated and other factors, including Phlegm, may play a role. This happens under the influence of several aetiological factors, such as overwork, emotional stress, excessive sexual activity and irregular diet, all factors which are not present in childhood. The more chronic the asthma, the more Phlegm there is.

Case history A 42-year-old woman had been suffering from allergic asthma since childhood. The asthma had got better during adolescence, but after she was about 32 it worsened. At that time, the asthma started after an episode of influenza that then turned into bronchitis. She had three courses of antibiotics but was left with a cough productive of profuse sputum, wheezing, and breathlessness. She was prescribed inhalers of steroids (Pulmicort) and b2 agonists (Bricanyl). All these symptoms seem to point clearly to a late-onset, intrinsic, non-allergic type of asthma. However, there were other factors that pointed also to an early-onset, extrinsic, allergic type of asthma, i.e. the period of allergic asthma during childhood, the onset of asthma attacks on exposure to dust, high levels of IgE and the fact that she also suffered from allergic rhinitis. This case history is given here as a clear example of a case of asthma that is a mixture of allergic and non-allergic: in her case, although the asthma was originally of the allergic type she did also have Phlegm. This case is reported here to illustrate this combination; the treatment administered is described under Case histories.

Atopic eczema not discussed with allergic asthma in the theory of Xiao-Chuan The pathology of Xiao-Chuan does not contemplate infantile eczema, which so often accompanies or precedes early-onset asthma. And yet the connection between eczema and early-onset, allergic asthma is very close and clinically extremely frequent. Chinese

medical theory can easily explain this connection via the Lungs, which are involved in breathing and control the skin. Strangely, this connection between Lungs and skin does not seem to be used in the diagnosis and treatment of infantile eczema. The connection between asthma and eczema is also easily observed in the wealing reaction occurring on the skin of atopic individuals from inhalation of allergens.

SUMMARY DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN PATHOLOGY  Phlegm is central to the pathology of both Xiao and Chuan.  Phlegm is not the main pathogenic factor in allergic asthma.  In allergic asthma, wheezing and breathlessness are due to narrowing of the airways from bronchospasm following an allergic reaction. The narrowed bronchi cannot be properly cleared of mucus by coughing. Phlegm is therefore the result rather than the cause of the condition.  In early-onset asthma, the tongue is not usually Swollen (it is often Thin) and the pulse not Slippery (it is often Tight), therefore pulse and tongue do not show Phlegm.  Another factor that rules out Phlegm as a pathogenic factor in asthma is the fact that, in between attacks, an asthmatic person is often quite normal. Indeed, there are some athletes who are asthmatic. If Phlegm obstructs the Lungs, however, wheezing and breathlessness are constant and they persist until Phlegm is completely eliminated.  The intermittent nature of the pathogenic factor confirms that this is Wind rather than Phlegm, as it is in the nature of Wind to come and go and change rapidly (see below) whereas Phlegm would not have this intermittent nature.  In chronic asthma, other factors account for the narrowing of the airways, i.e. a swelling of the lining of the airways and the presence of mucus; the more chronic the asthma, the more

Allergic asthma (atopic eczema)

these two factors play a role in the narrowing of the airways.  The mucus that forms in the airways in allergic asthma is a consequence of the inflammatory reaction, which itself is a consequence of the allergic reaction. Therefore, we can say that mucus is more the result than the cause of allergic asthma.  The pathogenic factor in allergic asthma is Wind: not exterior Wind as such invading the Lungs, nor interior Wind, but a kind of chronic (exterior) Wind lodged in the bronchi and periodically leading to bronchospasm. The attacks are elicited by exposure to allergens or cold weather or by emotional stress.  The pathology of Xiao-Chuan does not contemplate infantile eczema, which so often accompanies or precedes early-onset asthma. And yet the connection between eczema and early-onset, allergic asthma is very close and clinically extremely frequent.

Identification of patterns and treatment In order to discuss the differences and connections between asthma and Xiao-Chuan, it is better to deal with Xiao and Chuan separately.

Xiao It will be remembered that the main patterns in Xiao are as follows. • During attacks: — Cold Phlegm — Hot Phlegm • In between attacks — Lung deficiency — Spleen deficiency — Kidney deficiency Points to note are as follows. • The differentiation of treatment during or in between attacks is important and is used in the treatment of asthma. • The distinction between Cold Phlegm and Hot Phlegm is useful in the treatment of allergic

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asthma to differentiate between two basic types with Cold or Heat even though there is no Phlegm.

Chuan It will be remembered that the main patterns in Chuan are as follows. • Full: — Invasion of Wind-Cold — Wind-Cold on Exterior, Phlegm-Fluids in Interior — Cold on Exterior, Heat in Interior — Phlegm-Heat in Lungs — Turbid Phlegm in Lungs — Lung-Qi obstructed • Empty: — Lung deficiency — Kidney deficiency Points to note are as follows. • External Wind-Cold can trigger off an acute attack of asthma. From a Western point of view too, it is well known that viral infections can trigger off allergic asthma in sensitized individuals.44 Furthermore, activation of mast cells causing bronchoconstriction may be elicited not only by allergens but also by exercise, cold air and hyperventilation.45 An invasion of external Wind that is not expelled properly or that is suppressed with antibiotics may also cause the beginning of asthma in non-atopic children. • Exterior Wind-Cold with interior Phlegm-Fluids usually occurs only in adults, as Phlegm-Fluid is a chronic condition that develops only over many years. It therefore cannot explain allergic asthma in children. • The pattern of Cold on the Exterior and Heat in the Interior corresponds not to asthma but to an acute chest infection. • The pattern of Phlegm-Heat in the Lungs corresponds not to asthma but to acute bronchitis, pneumonia or febrile episodes of bronchiectasis. • The pattern of Turbid Phlegm corresponds not to asthma but to a severe chest infection with sepsis. • The pattern of Lung-Qi Obstructed corresponds to an acute attack of asthma in adults from emotional stress affecting the Liver. It does not correspond to early-onset asthma.

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• Chuan from Lung deficiency corresponds to chronic asthma. • Chuan from Kidney deficiency corresponds to asthma or emphysema in old people, not to earlyonset asthma.

Late-onset, non-allergic asthma Late-onset asthma is not allergic and occurs without eczema. As its name implies, it starts later in life, usually during the thirties or forties. For the treatment of this disease, the theory of XiaoChuan can be applied. Late-onset asthma is characterized more often by Spleen deficiency manifesting with a Swollen tongue.

A NEW THEORY OF ASTHMA Because, as we have seen, the theory of Xiao-Chuan is not adequate to diagnose and treat allergic asthma (and eczema), we must attempt to develop a new theory of allergic asthma in Chinese medicine. It should be stressed here that the following is by no means a definitive new theory of asthma and that it will need much refining and revising according to clinical experience. This discussion will concentrate on the diagnosis and treatment of early-onset asthma, also called extrinsic or allergic asthma; the discussion will also centre primarily on the clinical manifestations of allergic asthma in children as opposed to adults. One of the reasons why the theory of Xiao-Chuan does not precisely apply to asthma is simply that allergic asthma probably did not exist in ancient China. Even in modern times, it is relatively rare in China and the Far East, and its incidence is far higher in Western countries. The development of allergic asthma must obviously be related to Western lifestyle, as the incidence of allergic asthma in Chinese people who live in the West and adopt a Western lifestyle is the same as for Westerners.46

Lung and Kidney’s Defensive-Qi systems deficiency The Kidneys and the Defensive Qi The Lungs spread Defensive Qi (Wei Qi) to skin and muscles, and the Kidneys are the root of the Defensive Qi. Defensive Qi is Yang in nature and it warms skin and muscles. Kidney-Yang is the source of all Yang energies of the body; it is in this sense that it is the root of Defensive Qi. Chapter 18 of the Spiritual Axis says: “Nutritive Qi emerges from the Middle Burner and Defensive Qi from the Lower Burner.”47 The Kidneys are paired with the Bladder, and KidneyYang provides Qi to the Bladder for its transformation of fluids. In the process of this transformation, some clear part of the fluids flows upwards along the Bladder channel in the back to the skin and muscles, where they mingle with Defensive Qi. This is another indirect way in which Kidney-Yang is the root of Defensive Qi (Fig. 5.8). Besides this, both the Bladder channel and the Governing Vessel (Du Mai), which spread Defensive Qi all over the back in the Greater Yang area, are connected to the Kidneys. It will be remembered that the Governing Vessel starts from the Kidneys themselves. Furthermore, the Spiritual Axis in Chapter 71 says:48 The Defensive Qi flows in the Yang in daytime and in the Yin at night-time, starting from the muscles portion of the Kidney channel, flowing to the five Yin and six Yang organs.

GREATER YANG AREA

Clear fluids from Kidneys

Spread Defensive Qi

Du Mai

Aetiology and pathology Two main factors play a role in the pathogenesis of asthma: the first is a deficiency of both Lung and Kidney’s Defensive-Qi systems, and the other is Wind. The former accounts for the Root of the disease, the latter for its Manifestation.

Bladder channel

KIDNEYS Figure 5.8 The Kidneys, Bladder channel, Governing Vessel and Defensive Qi.

Allergic asthma (atopic eczema) Defensive-Qi vessels

Kidney

Figure 5.9 Defensive-Qi vessels arising out of the kidneys according to Wang Qing Ren.

Interestingly, the Correction of Errors in Medicine (1831) by Wang Qing Ren has diagrams showing “DefensiveQi-gathering vessels” emerging from the Kidneys.49 Thus, resistance to pathogenic factors (which include allergens) is dependent not only on the Lungs but to a great extent also on the Kidneys (Fig. 5.9).

Kidney deficiency and allergic asthma The type of Kidney deficiency involved in allergic asthma is a deficiency of only one aspect of the Kidney functions, i.e. in connection with Defensive Qi. It could be called deficiency of the Kidney’s Defensive-Qi system, which is similar to the Lung’s Defensive-Qi system. This Kidney deficiency involves only this aspect of its functions, and therefore not many other symptoms and signs are present. For example, a child or teenager with allergic asthma would not have dizziness, deafness, tinnitus, backache, weak knees or night sweating.

! The type of Kidney deficiency involved in allergic asthma is a deficiency of only one aspect of the Kidney functions, i.e. in connection with Defensive Qi. It could be called deficiency of the Kidney’s Defensive-Qi system, which is similar to the Lung’s Defensive-Qi system. The traditional theories of Wheezing (Xiao) and Breathlessness (Chuan) both contemplate a Kidney deficiency as a factor in asthma, but only for its late

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stages in chronic cases. In allergic asthma, on the contrary, there is a deficiency of the Kidney DefensiveQi system from the beginning. In children also, prolonged wheezing and cough may induce a Kidney deficiency, which is therefore the consequence of a Lung pathology; in atopic asthma, however, a Kidney deficiency is the cause of the condition and it is present from the onset of the disease – it also the cause for chronic Wind to be lodged in the chest. It is interesting to note that atopic asthma often improves during pregnancy.50 During pregnancy, allergic asthma improves in a third of women, is aggravated in another third, and is unaffected in the rest.51 I personally relate both an improvement and an aggravation of a symptom during pregnancy to a Kidney deficiency: in the first instance, the Kidney deficiency is actually improved by the pregnancy, and in the latter instance it is aggravated. The fact that pregnancy improves or aggravates allergic asthma in two-thirds of women seems to show that a Kidney deficiency is at the root of allergic asthma. This confirms the involvement of the Kidneys in atopic asthma as a Kidney deficiency sometimes improves during pregnancy. A longitudinal cohort study of 1861 children born to women recruited during pregnancy and followed up at 5 years study in the USA showed that low maternal intake of vitamin E during pregnancy is associated with an increased risk of developing allergic asthma.52 This would confirm that the aetiology of allergic asthma is an inborn deficiency of the Kidneys.

The Kidneys and the immune system Thus, the immune hyper-reactivity that is the basis of allergic asthma is due to a deficiency of both Lung and Kidney’s Defensive-Qi systems. The Kidneys influence the immune system not only through the connection between Kidney-Yang and Defensive Qi but also because the Kidney-Essence, through the Governing (Du), Penetrating (Chong) and Directing (Ren) Vessels, is partly responsible for protection from external pathogenic factors. Interestingly, Li Shi Zhen says in his Study of the Eight Extraordinary Vessels:53 when the Qi of the channels overflows, it flows into the extraordinary vessels, where it is turned into irrigation, warming the organs internally and irrigating the space between skin and muscles externally.

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The fact that the Qi of the channels overflowing into the Extraordinary Vessels goes to irrigate the space between skin and muscles confirms that the Kidneys (through the Extraordinary Vessels) play a role in the protection from pathogenic factors and in the circulation of Defensive Qi in this space. Western physiology confirms this role of the Kidneys in the immune defences, because all cells involved in the immune response are derived from a common stem cell in the marrow (which is a product of the KidneyEssence). This is illustrated in Figure 5.10. Also, low levels of cortisol (secreted by the adrenal cortex) alter the immune function to allow an exaggerated allergic response. A Chinese study comparing the effect of Xiao Qing Long Tang Small Green Dragon Decoction versus Kidney tonics for atopic asthma showed that the Kidney tonics had a better effect and that they reduced the levels of IgE.54 There are a few modern Chinese doctors who place the stress on tonifying the Kidneys in asthma. For example, Dr Zhang Jing Lei believes that in order to treat the inflammation process, the atopy and the bronchoconstriction, it is necessary to nourish Kidney-Yin.55 Dr Shen Zi Yin thinks that tonifying the Kidneys is necessary not only from the perspective of Chinese medicine but also from that of Western medicine. Interestingly, he says that using herbs with a sweet and

Marrow stem cell

Lymphoid progenitor cells

B lymphocytes

Myeloid progenitor cells

Thymus

T lymphocytes

• Macrophages • Monocytes • Eosinophils • Neutrophils • Mast cells

Figure 5.10 Marrow stem cells and immune system cells.

sour taste stabilizes the cell membranes and therefore has a stabilizing effect on the mast cells in the bronchi.56 Dr Shen also says that tonifying the Kidneys (and especially Kidney-Yang) in asthma has the effect of regulating immunity by regulating the T-cells and reducing the levels of IgE.

Aetiology of the deficiency of the Lung and Kidney’s Defensive-Qi systems in allergic asthma How does a deficiency of the Kidney’s Defensive-Qi system arise? It may derive from: • hereditary constitutional weakness • problems to the mother during pregnancy, such as a shock, smoking, drinking alcohol or using drugs • problems at childbirth, such as fetal distress, induction and premature cutting of the umbilical cord • immunizations. Points to note are as follows. • Bronchial hyper-reactivity is hereditary, as studies on twins have shown: hyper-reactivity is higher in monozygote than in dizygote twins.57 Some authors think that heredity is the most important factor in the bronchial hyper-reactivity displayed by asthmatics.58 • It has been shown that maternal smoking during pregnancy may result in increased levels of IgE antibodies in the cord blood of the newborn baby.59 Some drugs taken during pregnancy have also been shown to predispose infants to atopic disease. For example, a double-blind placebo control study showed that children exposed in utero to betaadrenergic receptor-blocking drugs taken for toxicosis of pregnancy had elevated IgE levels in the cord blood and developed clinical allergy during the first 4 years of life – significantly more often than the children of placebo-treated control mothers.60 • Apart from a constitutional Kidney Defensive-Qi system weakness, which may be hereditary or developed in utero as in the above two points, the period of time during the actual birth has a bearing on the development of the Lung and Kidney’s Defensive-Qi systems. Studies have shown that stress during the neonatal period may increase the risk of development of allergy later in life.61

Allergic asthma (atopic eczema)

• In particular, premature severing of the umbilical cord may interrupt the vital flow of hormones and immune cells from the placenta to the offspring and the excretion of waste products from the baby to the placenta. As mentioned earlier, IgG immunoglobulins, which prevent IgE-mediated allergic reactions, are the only immunoglobulins that are transported across the placenta to reach the fetal circulation. It is therefore possible that a premature severance of the umbilical cord may lead to a deficiency of IgG immunoglobulins in the baby and therefore a predisposition to IgE-mediated allergic reactions later in life. In fact, levels of IgE antibodies are already higher at birth in infants who later develop atopic disease.62 As IgE antibodies do not cross the placental barrier, they must be of fetal origin. Their elevated levels therefore suggest a spontaneous antibody formation that is not efficiently suppressed by the IgG immunoglobulins (Fig. 5.11). Umbilical cord blood is rich in some kind of stem cells found in bone marrow, and it has been used instead of bone marrow transplant.63 There is an interesting connection here with the traditional Chinese use of placenta and umbilical cord for the treatment of asthma in children.

Placenta

IgG

IgE (do not cross the placental barrier)

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In modern China, some doctors inject placenta extract in the points LU-6 Kongzui, ST-40 Fenglong and BL-23 Shenshu to treat allergic asthma. This seems to confirm that an interruption in the twoway flow of hormones, immune cells and wastes between the placenta and the baby during childbirth is one of the causes of a deficiency of the Kidney’s Defensive-Qi system. Dr Kiiko Matsumoto also attributes allergies and asthma to the premature severing of the umbilical cord.64 Finally, the very last development of lungs and kidneys takes place in the birth canal and babies delivered by caesarean section show a higher incidence of allergic asthma. It is not surprising that the time in the womb plays such an important role in our constitution. Indeed, in ancient China, an individual’s life was divided either into “Nine Stars” or into “12 Branches”. In the first instance, the time in the womb accounted for Three Stars and, in the second, for Four Branches. In both cases, therefore, the time in the womb accounts for one-third of our life; this shows the importance of the formative time in the womb for our constitution (Fig. 5.12). • Immunizations may sometimes trigger off atopic asthma and/or eczema in susceptible individuals. Animal studies have demonstrated that pertussis bacteria induce IgE antibody formation. It is therefore possible that pertussis immunization may induce excessive levels of IgE antibodies; this effect would be enhanced if immunization is given during the pollen season.65 Some have suggested that the increasing incidence of asthma may be due to vaccinations, primarily to whole cell pertussis vaccine. Some

LIFESPAN

9 Stars 3 Placenta IgG

6

9

IgE++ 12 Branches 4

8

12

Time in the womb Figure 5.11 The effect of premature cutting of the umbilical cord.

Figure 5.12 The importance of the time in the womb in an individual’s life.

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have hypothesized that vaccines might change the balance of immunity towards allergic responses either directly (that is, caused by the immune responses to the vaccine) or indirectly (by altering the balance of immune responses to infections in infancy). The first study suggesting a possible association between vaccination and asthma was conducted in children born in 1977 in Christchurch, New Zealand.66 In this study, there was no evidence of asthma during 5–10 years of follow-up among 23 children who received neither pertussis vaccine nor oral polio vaccine, whereas asthma developed in more than 20% of 1184 children who had been vaccinated. A study of 1934 patients observed from birth to age 12 in a general medical practice in the UK found that children given an older form of pertussis vaccine (whole cell vaccine) were 40% more likely to develop asthma than unvaccinated children.67 An indirect mechanism by which vaccines might affect the tendency to develop allergies, perhaps including asthma, would be by preventing infections in childhood, causing an imbalance in immune responses later in life. More recent data, however, do not support the theory that specific vaccines or the number of vaccines administered lead to an increased risk of childhood asthma. For example, one large study involving 167 240 children from four large health maintenance organizations in Washington, Oregon and California found no increased risk of developing childhood asthma associated with vaccines against diphtheria, tetanus, whole cell pertussis, measles, mumps or rubella and with oral polio vaccine.68 It has also been reported that general anaesthesia in infants may be associated with later development of respiratory tract allergy.69 Breastfed infants may also be sensitized by minute amounts of foreign proteins (such as from cow’s milk, eggs and fish) present in the maternal milk. Studies have shown that atopic dermatitis was significantly lower in the babies of mothers avoiding the above foods during the first 6 months of breastfeeding.70 Other studies have also shown that the incidence of asthma in children under 6 is higher in children who were introduced to milk other than breast milk before 4 months of age.71

Deficiency of the Lung and Kidney’s Defensive-Qi systems and atopic eczema The deficiency of the Lung and Kidney’s Defensive-Qi systems may also play a role in the pathogenesis of eczema in babies and very young children. The relationship between the Lungs and skin is well known in Chinese medicine and yet, as mentioned above, it is seldom used to explain the linkage between asthma and atopic eczema in children. The Kidneys also influence the skin. The Lungs influence the skin, as they spread Defensive Qi and fluids to the skin and control the pores. The Kidneys control the condition and lustre of the skin. The same deficiency of the Kidney’s Defensive-Qi system that leads to IgE-mediated allergic asthma causes eczema lesions on the skin. From a Chinese perspective, the Kidneys fail to nourish the skin, leading to either Wind-Heat or Damp Heat. Furthermore, there is a close relationship between the Kidney-Essence and the Lung’s Corporeal Soul (Po). The Corporeal Soul is closely linked to the Essence and is described in Chapter 8 of the Spiritual Axis as the “exiting and entering of the Essence”.72 The Corporeal Soul derives from the mother and arises soon after the Prenatal Essence of a newly conceived being is formed. It could be described as the manifestation of the Essence in the sphere of sensations and feelings. The Corporeal Soul provides movement to the Essence, i.e. it brings the Essence into play in all physiological processes of the body. The Corporeal Soul is the closest to the Essence and, as such, is responsible for the first physiological processes after birth (Fig. 5.13). Zhang Jie Bin says: “In the beginning of life ears, eyes and Heart perceive, hands and feet move and breathing starts: all this is due to the sharpness of the Corporeal Soul.”73 He also says: “The Corporeal Soul can move and do things and [when it is active] pain and itching can be felt.” This shows that the Corporeal Soul is responsible for sensations and itching and is therefore closely related to the skin through which such sensations are experienced. This explains the somatic expression on the skin of emotional tensions that affect the Corporeal Soul via the Mind and the connection between Corporeal Soul, Lungs and skin. The relationship between Corporeal Soul and Essence may therefore explain the eruption of atopic eczema and asthma in babies. From the Chinese point of view, eczema in babies is due to the surfacing of Toxic Heat from the uterus; it is therefore closely linked with the

Allergic asthma (atopic eczema) HEREDITY ATOPIC CONSTITUTION (Excess IgE)

KIDNEYS

ESSENCE ‘‘Po is entering/exiting of Jing’’

Nourish, moisten

Allergy

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Eczema SKIN

CORPOREAL SOUL

LUNGS

Moisten skin Spread Defensive Qi EXTRAORDINARY VESSEL

Asthma

(Originate from Kidneys) Figure 5.13 Relationship between Kidneys and skin.

Prenatal Essence of the baby. Because the Essence is related to the Corporeal Soul, which manifests on the skin (itching and pain), the Toxic Heat from the uterus erupts on the baby’s skin in the form of eczema. Asthma can be explained in the same way, as the deficient Essence of the baby fails to root its Corporeal Soul and therefore its Lungs.

SUMMARY LUNG AND KIDNEY’S DEFENSIVE-QI SYSTEMS DEFICIENCY  The Lungs spread Defensive Qi (Wei Qi) to skin and muscles, and the Kidneys are the root of the Defensive Qi.  The Kidneys are paired with the Bladder, and Kidney-Yang provides Qi to the Bladder for its transformation of fluids. In the process of this transformation, some clear part of the fluids flows upwards along the Bladder channel in the back to the skin and muscles, where they mingle with Defensive Qi.  Both the Bladder channel and the Governing Vessel (Du Mai), which spread Defensive Qi all over the back in the Greater Yang area, are connected to the Kidneys.  The type of deficiency involved in allergic asthma is a deficiency of only one aspect of the Kidney functions, i.e. in connection with Defensive Qi. It could be called deficiency of

the Kidney’s Defensive-Qi system, similar to the Lung’s Defensive-Qi system. This Kidney deficiency involves only this aspect of its functions, and therefore not many other symptoms and signs are present.  The immune hyper-reactivity that is the basis of allergic asthma is due to a deficiency of both Lung and Kidney’s Defensive-Qi systems. The Kidneys influence the immune system not only through the connection between Kidney-Yang and Defensive Qi but also because the KidneyEssence, through the Governing (Du), Penetrating (Chong) and Directing (Ren) Vessels, is partly responsible for protection from external pathogenic factors.  A deficiency of the Kidney’s Defensive-Qi system arises from: — hereditary constitutional weakness — problems to the mother during pregnancy, such as a shock, smoking, drinking alcohol or using drugs — problems at childbirth, such as fetal distress, induction and premature cutting of the umbilical cord — immunizations.  The deficiency of the Lung and Kidney’s Defensive-Qi systems may also play a role in the pathogenesis of eczema in babies and very young children.

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Wind as the main pathogenic factor in asthma Having discussed the role of the Lung and Kidney’s Defensive-Qi systems as the Root in asthma, we can now turn our attention to Wind as the main Manifestation of this disease. Some of the characteristics of Wind explain its effect on the bronchi and asthma. In fact, Wind contracts, it comes and goes in bouts, and it causes spasm. A modern doctor, Dr Hu Lie of the Pharmacology Department of the Nanjing University of Chinese Medicine, calls allergic asthma “Chest Wind” (Xiong Feng). Wind is the main pathogenic factor in asthma, not in the sense of an invasion of external Wind but as a kind of chronic external Wind locked in the bronchi. The Lungs are the most exterior of the Yin organs, as they control the skin. The bronchial mucosa could be seen as an extension of the skin. Thus, just as Wind invades the skin, it may invade the bronchi, lodge itself there and cause bronchospasm (Fig. 5.14). Even from a Western point of view, animal studies suggest that the pathological features of skin and pulmonary actions are very similar.74 According to some authors, the wheezing, breathlessness, cough, expectoration and tightness of the chest are not typical diagnostic signs of asthma. They believe that the most important symptom is a history of recurrent bouts of asthma, often triggered by exogenous factors such as allergens, irritants, physical effort or viral infections. As the symptoms of asthma are typically episodic, the physical examination is often normal not only when the patient is asymptomatic but sometimes even during a period of frequent attacks.75 This would seem to show that the main pathogenic factor

“WIND” Contracts Comes and goes

Bronchospasm

in asthma is something non-substantial like Wind; if it were Phlegm, the physical examination would not be normal. This can happen only against a background of deficiency of the Lung and Kidney’s Defensive-Qi systems, which allows Wind to lodge in the bronchi for a long time. Thus, asthma is characterized by Wind, a nonsubstantial pathogenic factor. This may explain how X-rays have no diagnostic value in asthma, as they may show phlegm but not “Wind”, and also how in asthmatic children or young people the tongue is nearly always not Swollen and the pulse not Slippery as one would expect were Phlegm the main pathogenic factor; instead, the tongue is often Thin and the pulse Tight. The Chinese idea of Wind may be compared with the Western concept of allergens. The inhalation of dust, faecal matter from house dust mites, pollen and animal dander could be compared with invasion of “Wind” as conceived in Chinese medicine (Fig. 5.15). In fact, the Chinese character for Wind includes the radical for “insect” or “worm”, i.e. comparable with allergens and germs carried by the wind. Thus, the main problem in asthma is a deficiency of the Lung and Kidney’s Defensive-Qi systems, which allows Wind to penetrate and lodge itself in the bronchi, causing bouts of bronchospasm. When Dr Ye Gui (1766) said, as mentioned above, that in breathlessness [Chuan] if the pathogenic factor [Phlegm] is expelled it will never return. In wheezing [Xiao] the pathogenic factor is hidden in the Interior and in the Lungs and there are frequent episodes over the years he correctly highlighted the difference between wheezing (Xiao) and breathlessness (Chuan). Breathlessness is due to Phlegm, and once this is resolved the condition is cured permanently. Allergic asthma is due to Wind in the bronchi causing periodic

Bouts of wheezing

Insect, (chong) worm

Figure 5.14 Effect of Wind on bronchi.

Figure 5.15 Chinese character for “Wind”.

Allergic asthma (atopic eczema)

bouts of wheezing. The reason this is difficult to expel is not that it is particularly deep in the Interior but that it is linked to a deficiency of the Lung and Kidney’s Defensive-Qi systems. Until this deficiency is addressed, the Wind cannot be expelled. Another phenomenon that points to Wind rather than Phlegm as the main pathogenic factor in asthma is the remarkable effectiveness of acupuncture in stopping an acute asthma attack. This is because Wind is a non-substantial pathogenic factor and, as such, more responsive to acupuncture treatment. When Phlegm is the main pathogenic factor as in chronic bronchitis, acupuncture has only a limited efficacy in relieving breathlessness in the short term, as it obviously takes a long time to resolve Phlegm. Another interesting detail that points to Wind as the main pathogenic factor in allergic asthma is that asthma attacks are often preceded by itching on the neck and/or upper back: itching is often due to Wind, even more so when it is confined to the upper part of the body.76 Interestingly, there are some modern Chinese doctors who have similar ideas about allergic asthma, i.e. that its Root is a deficiency of the Kidneys and its Manifestation is due to Wind. For example, Dr Chen Jin treated 106 asthmatic children with a decoction of Chinese herbs that tonified the Lungs, expelled Wind and restored the descending of Lung-Qi (Ma Huang Herba Ephedrae, Xing Ren Semen Armeniacae, Ban Xia Rhizoma Pinelliae preparatum, Chen Pi Pericarpium Citri reticulatae, Fu Ling Poria, Bai Zhu Rhizoma Atractylodis macrocephalae, Fang Feng Radix Saposhnikoviae, Wu Wei Zi Fructus Schisandrae, Tai Zi Shen Radix Pseudostellariae, Dang Gui Radix Angelicae sinensis, Shu Di Huang Radix Rehmanniae preparata, Zi He Che Placenta hominis, Dong Chong Xia Cao Cordyceps).77 In the discussion of the treatment, Dr Chen explains that a deficiency of the Kidneys is the Root of asthma in children; he also notes that this is contrary to traditional theory, according to which a deficiency of the Kidneys plays a role only in chronic asthma in adults. In Dr Chen’s opinion, in children a deficiency of the Kidneys plays a role in asthma from the beginning. He also says that asthma in children is triggered by Wind (hence the presence of Fang Feng Radix Saposhnikoviae in his formula). Another modern Chinese doctor, Dr He Shu Huai, maintains (as I do) that the main pathogenic factor in asthma is not Phlegm but “Wind”. Dr He says that

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allergic asthma is due to the invasion of allergens, and he compares these with the Chinese concept of “Wind”. Interestingly, in contrast to most other modern Chinese doctors, Dr He understands the correlation between allergic rhinitis and allergic asthma as being two manifestations of the same disease. He says that when allergens settle in the nose they cause allergic rhinitis (with sneezing and itchy nose), and when they settle in the bronchi they cause allergic asthma. Dr He also says that the episodic nature of allergic asthma reflects the characteristic of Wind coming and going quickly and having rapid onset. Moreover, Dr He also thinks (as I do) that the bronchospasm that causes narrowing of the airways in asthma is also a manifestation of Wind as this contracts.78 Dr Wu Ying He recommends the use of insect substances for the treatment of acute asthma. This is based on the principle that insects extinguish Wind. The insects he adds to a formula according to pattern identification are Jiang Can Bombyx batryticatus, Chan Tui Periostracum Cicadae, Di Long Pheretima and Quan Xie Scorpio.79

SUMMARY WIND AS THE MAIN PATHOGENIC FACTOR IN ASTHMA  Wind contracts, it comes and goes in bouts, and it causes spasm.  Wind is the main pathogenic factor in asthma, not in the sense of an invasion of external Wind but as a kind of chronic external Wind locked in the bronchi.  The Chinese idea of Wind may be compared with the Western concept of allergens. The inhalation of dust, faecal matter from house dust mites, pollen and animal dander could be compared with invasion of “Wind” as conceived in Chinese medicine.  Allergic asthma is due to Wind in the bronchi causing periodic bouts of wheezing.  Asthma attacks are often preceded by itching of the neck and/or upper back: itching is often due to Wind, even more so when it is confined to the upper part of the body.

As for late-onset asthma, although this is usually not allergic, its pathology is similar, with the Root being the

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deficiency of Lungs and Kidneys but the Manifestation being Phlegm in the Lungs. The aetiology is different because the Kidney deficiency is induced by overwork, excessive sexual activity and a natural decline of Kidney-Qi in middle age, rather than being congenital. Thus the Kidneys are affected not from birth but by lifestyle. Many patients with late-onset asthma, especially men, often find the condition worse after sexual activity. In late-onset asthma, a Spleen deficiency, caused by irregular diet, is often present, and this accounts for the presence of Phlegm, which manifests with a Swollen tongue. Late-onset asthma is also characterized by a more frequent involvement of the Liver, caused by emotional stress, in the pathogenesis of the condition. Table 5.2 summarizes the differences between earlyonset and late-onset asthma.

Identification of patterns and treatment The differentiation made in Wheezing (Chapter 4) between treatment during attacks and treatment in between attacks is applicable to asthma. The differentiation made in Breathlessness (Chapter 3) between Deficiency and Excess conditions is not applicable to asthma, because this is always characterized by both a Deficiency (of the Lung and Kidney’s Defensive-Qi systems) and an Excess (Wind). The main patterns seen in allergic asthma are as follows. • During attacks: — Wind-Cold — Wind-Heat

• In between attacks: — Deficiency of Lung and Kidney’s Defensive-Qi systems and Wind in the Lungs There are three approaches to the treatment principle of asthma, as follows. 1. During an actual attack: treat the Manifestation (Biao) only, i.e. expel Wind and restore the descending of Lung-Qi. 2. In a period of time when attacks are frequent: treat primarily the Manifestation, i.e. expel Wind and restore the descending of Lung-Qi but treat also the Root (Ben), i.e. tonify the Lung and Kidney’s Defensive-Qi systems. 3. In a period of time when attacks are infrequent: treat primarily the Root, i.e. tonify the Lung and Kidney’s Defensive-Qi systems but, as a secondary aim, also expel Wind and restore the descending of Lung-Qi. In the treatment of asthma, especially acute cases, it is important also to calm the Mind. This is a useful principle of treatment, as acute asthma is due to bronchospasm from overstimulation of the parasympathetic nervous system. The herbs and acupuncture points which “calm the Mind” also have a regulating effect on the nervous system. For example, the point Du-24 Shenting, which calms the Mind, is widely used to calm asthma.

DURING ATTACKS The treatments discussed below apply not only to the actual acute attack but also to a period of time when attacks are frequent.

Table 5.2 Comparison between early-onset and late-onset asthma Early-onset, allergic, extrinsic asthma

Late-onset, non-allergic, intrinsic asthma

Root

Deficiency of Lung and Kidney’s Defensive-Qi systems

Deficiency of Lungs, Spleen and Kidneys

Manifestation

Wind

Phlegm

Aetiology

Congenital

Overwork, excessive sexual activity, irregular diet, old age

Patterns



Liver patterns often involved

Allergic asthma (atopic eczema)

The two patterns of Wind-Cold and Wind-Heat may correspond to an asthma attack elicited by an actual invasion of Wind with all its relevant symptoms, or to a picture of symptoms and signs due to a pre-existing Wind in the bronchi that is mimicking an invasion of Wind. If there were an actual invasion of Wind, there would be aversion to cold, shivering and possibly fever. The pulse would be Floating. The patterns described below, however, presume an acute attack of asthma manifesting with certain symptoms of Wind but without an actual invasion of external Wind. Even if there is not an actual invasion of external Wind, the treatment principle is to “release the Exterior”, as herbs that release the Exterior also expel Wind from the Lungs in allergic asthma. The patterns occurring during attacks discussed will be: • Wind-Cold (without sweating) • Wind-Cold (with sweating) • Wind-Heat.

Wind-Cold (without sweating) Clinical manifestations Sudden wheezing and breathlessness with difficulty in breathing out, no sweating, tightness of the chest, pale face, feeling cold, sneezing, cough, no thirst, attack elicited by cold weather, stiffness of shoulders and neck. Pulse: Tight. Treatment principle Release the Exterior, expel Wind-Cold, restore the descending of Lung-Qi, calm the Mind.

Acupuncture Points Extra point Dingchuan, BL-12 Fengmen, BL-13 Feishu, Ren-22 Tiantu, LU-7 Lieque, LU-6 Kongzui, HE-7 Shenmen, Ren-15 Jiuwei, G.B.-20 Fengchi, G.B.21 Jianjing. Reducing method. Cupping is applicable to BL-12 and BL-13. Explanation • Dingchuan stops acute asthma. • BL-12 expels Wind. • BL-13, Ren-22 and LU-7 restore the descending of Lung-Qi. • LU-6, Accumulation point, stops acute asthma. • HE-7 and Ren-15 calm the Mind. HE-7 also makes Qi descend and Ren-15 relieves fullness in the chest.

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• G.B.-20 and G.B.-21 relax the neck and shoulders, which is important to drop the shoulder girdle and help breathing. G.B.-21 also makes Qi descend.

Herbal therapy Prescription MA HUANG TANG Ephedra Decoction Explanation This is the standard formula for WindCold and the Greater Yang stage of the Six Stages from the Discussion of Cold-induced Diseases. Prescription HUA GAI SAN Glorious Lid Decoction Explanation This formula is better for asthma, as it has a stronger Qi-descending effect. Modifications • For acute asthma, increase the dosage of Su Zi Fructus Perillae and add Xuan Fu Hua Flos Inulae to restore the descending of Lung-Qi. • If there is an actual invasion of exterior Wind-Cold, add Fang Feng Radix Saposhnikoviae and Jing Jie Herba Schizonepetae.

SUMMARY WIND-COLD (WITHOUT SWEATING) Points Extra point Dingchuan, BL-12 Fengmen, BL-13 Feishu, Ren-22 Tiantu, LU-7 Lieque, LU-6 Kongzui, HE-7 Shenmen, Ren-15 Jiuwei, G.B.-20 Fengchi, G.B.-21 Jianjing. Reducing method. Cupping is applicable to BL-12 and BL-13. Herbal therapy Prescription MA HUANG TANG Ephedra Decoction Prescription HUA GAI SAN Glorious Lid Decoction

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Wind-Cold (with sweating) Clinical manifestations Slight sweating, asthma attack with breathlessness and wheezing, less noisy than previous case, not so much chilliness, a feeling of tightness of the chest, pale face. Pulse: Tight-Slow. Treatment principle Release the Exterior, harmonize Nutritive and Defensive Qi, restore the descending of Lung-Qi, calm the Mind.

Acupuncture Points Extra point Dingchuan, BL-12 Fengmen, BL-13 Feishu, Ren-22 Tiantu, LU-6 Konzui, ST-36 Zusanli, SP-6 Sanyinjiao, HE-7 Shenmen, Ren-15 Jiuwei. Reducing method except for ST-36 and SP-6, which should be needled with even method to harmonize Nutritive and Defensive Qi. Cupping is applicable on BL-12. Explanation • Dingchuan stops acute asthma. • BL-12 and BL-13 expel Wind and restore the diffusing and descending of Lung-Qi. • Ren-22 restores the descending of Lung-Qi and stops asthma. • LU-6, Accumulation point, stops acute asthma. • ST-36 and SP-6 harmonize Nutritive and Defensive Qi. • HE-7 and Ren-15 calm the Mind. HE-7 also restores the descending of Qi as Heart-Qi, similarly to Lung-Qi, also has a descending movement. The descending of Heart-Qi will also help breathing. Ren-15 also relieves fullness in the chest.

Herbal therapy Prescription GUI ZHI JIA HOU PO XING ZI TANG Cinnamomum Decoction plus Magnolia and Prunus Explanation The first five herbs constitute the Gui Zhi Tang Ramulus Cinnamomi Decoction, which is the standard decoction for expelling Wind-Cold by harmonizing Nutritive and Defensive Qi. It is used instead of Ma Huang Tang Ephedra Decoction when the patient is sweating slightly, which indicates a deficiency of Nutritive-Qi.

Modifications • If there is an acute invasion of external Wind-Cold, add Fang Feng Radix Saposhnikoviae and Jing Jie Herba Schizonepetae. • To strengthen the descending of Lung-Qi, add Su Zi Fructus Perillae and Xuan Fu Hua Flos Inulae. • If some symptoms of interior Heat are just beginning, add Shi Gao Gypsum fibrosum.

SUMMARY WIND-COLD (WITH SWEATING) Points Extra point Dingchuan, BL-12 Fengmen, BL-13 Feishu, Ren-22 Tiantu, LU-6 Konzui, ST-36 Zusanli, SP-6 Sanyinjiao, HE-7 Shenmen, Ren-15 Jiuwei. Reducing method except for ST-36 and SP-6, which should be needled with even method to harmonize Nutritive and Defensive Qi. Cupping is applicable on BL-12. Herbal therapy Prescription GUI ZHI JIA HOU PO XING ZI TANG Cinnamomum Decoction plus Magnolia and Prunus

Wind-Heat Clinical manifestations Fever and aversion to cold (if true exterior invasion, otherwise feeling of heat), headache, tightness of the chest, loud wheezing, barking cough, asthma, slight thirst. Tongue: Red sides towards the front. Pulse: Rapid. Treatment principle Release the Exterior, restore the descending of Lung-Qi, expel Wind-Heat, calm asthma, calm the Mind.

Acupuncture Points LU-5 Chize, LU-7 Lieque, LU-1 Zhongfu, BL-13 Feishu, LU-6 Kongzui, LU-11 Shaoshang, Dingchuan, HE-7 Shenmen, Ren-15 Jiuwei. Reducing method, no moxa. Explanation • LU-5 clears Lung-Heat. • LU-7, LU-1 and BL-13 restore the descending of Lung-Qi.

Allergic asthma (atopic eczema)

• • • •

LU-6, Accumulation point, stops acute asthma. LU-11 expels Wind-Heat and eases the throat. Dingchuan stops acute asthma. HE-7 and Ren-15 calm the Mind and open the chest.

Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Explanation This formula expels Wind-Heat and restores the descending of Lung-Qi. Prescription DING CHUAN TANG Stopping Breathlessness Decoction Explanation This formula is stronger than the previous one and it is used if Heat is more prevalent. It also has a stronger effect in calming asthma. Modifications • A small dose of Ma Huang may be added, even if it is hot, in order to calm asthma. • If there is pronounced irritability, increase the dosage of Huang Qin Radix Scutellariae and add Dan Dou Chi Semen Sojae preparatum. • If symptoms of interior Heat are beginning, add Shi Gao Gypsum fibrosum.

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CLINICAL NOTE Acupuncture is important in acute attacks of asthma, as it is usually very effective. As for herbal medicine, some doctors use a small dose of Ma Huang Herba Ephedrae for its adrenergic properties even if there are some Heat signs. Ma Huang yields many different alkaloids, among which are ephedrine and psi ephedrine. Ephedrine is alpha-adrenergic and psi ephedrine is betaadrenergic. An alpha-adrenergic effect produces vasoconstriction and a rise in the blood pressure, while a beta-adrenergic effect induces dilatation of the bronchi and increases the respiration rate and cardiac output and rate. The balance of alkaloids in the natural plant is such that none of the undesirable effects of the isolated alkaloids has been observed from administration of Ephedra itself. For this reason, many doctors use a small dose of Ma Huang in any acute asthma attack. Ma Huang may be combined with many different herbs for different situations. Some of the herbs with which it is combined are listed below.

 Cold: Gui Zhi Ramulus Cinnamomi cassiae  Heat: Shi Gao Gypsum fibrosum  Lung-Heat: Sang Bai Pi Cortex Mori  Rebellious Qi: Xing Ren Semen Armeniacae  Phlegm: She Gan Rhizoma Belamcandae  Stagnation of Qi in the chest: Hou Po Cortex Magnoliae officinalis

 Qi deficiency: Dang Shen Radix Codonopsis  Kidney deficiency: Shu Di Huang Radix Rehmanniae preparata

 Lung-Yin deficiency: Bei Sha Shen Radix Glehniae

SUMMARY WIND-HEAT Points LU-5 Chize, LU-7 Lieque, LU-1 Zhongfu, BL-13 Feishu, LU-6 Kongzui, LU-11 Shaoshang, Dingchuan, HE-7 Shenmen, Ren-15 Jiuwei. Reducing method, no moxa. Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Prescription DING CHUAN TANG Stopping Breathlessness Decoction

or Wu Wei Zi Fructus Schisandrae

 Kidney-Yang deficiency: Fu Zi Radix Aconiti lateralis preparata

IN BETWEEN ATTACKS This refers to periods of time when asthma attacks are very infrequent or when the asthma is controlled by the occasional use of inhalers. At this stage, some asthma attacks are typically elicited by exposure to cats, dogs, pollen or dust, causing wheezing, breathlessness and tightness of the chest. If the patient is using inhalers, there is no conflict with Chinese herbs or acupuncture and these can be used concurrently. Indeed, the frequency with which the patient needs to use the inhalers can be a very useful benchmark to gauge the efficacy of the treatment.

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The priority of treatment in between attacks is to treat the Root, i.e. tonify the Lung and Kidney’s Defensive-Qi systems. At the same time, the Manifestation (i.e. Wind in the bronchi obstructing the descending of Lung-Qi) should not be overlooked, so that each formula should always include some herbs to expel Wind and make Lung-Qi descend. Within the scope of Lung and Kidney deficiency, there may be many variations, with different degrees of deficiency between Lung and Kidneys and, within the Kidneys, between deficiency of Yang or of Yin. Some Chinese doctors treat chronic asthma in between attacks simply by tonifying Lung, Spleen or Kidneys or a combination of these with the addition of small doses of Ma Huang Herba Ephedrae and Xing Ren Semen Armeniacae.80 This runs contrary to traditional theory, according to which Ma Huang should be used strictly for Full conditions because it has a scattering effect. However, in small doses (3 g) and combined with tonics, it can be used in chronic Deficiency-asthma for its strong adrenergic properties. Furthermore, in order to decrease its scattering effect, one could use honeytoasted Ma Huang. Some doctors also use Dan Shen Radix Salviae miltiorrhizae in chronic cases of asthma to invigorate Blood in the chest. Interestingly, modern research shows that Dan Shen reduces levels of the IgE immunoglobulins that are responsible for the antigen–antibody reaction that triggers an asthma attack.81 The following formulae are all aimed at tonifying the Lung and Kidney’s Defensive-Qi systems, with several variations to account for varying involvement of Lungs or Kidneys and deficiency of Yin or Yang. All the formulae without exception should be modified with the following aims in mind. 1. Tonify the Kidney’s Defensive-Qi system with such herbs as Tu Si Zi Semen Cuscutae, Xu Duan Radix Dipsaci, Du Zhong Cortex Eucommiae ulmoidis, Bu Gu Zhi Fructus Psoraleae, Hu Tao Rou Semen Juglandis or Shu Di Huang Radix Rehmanniae preparata. A small dose of a KidneyYang-tonic herb may be added, even in Yin deficiency, in order to bolster the Kidney’s Defensive-Qi system. 2. Stimulate the descending of Lung-Qi and expel Wind with such herbs as Xing Ren Semen Armeniacae, Su Zi Fructus Perillae, Xuan Fu Hua Flos Inulae and Fang Feng Radix Saposhnikoviae.

3. Use herbs that have an antiallergy effect, such as Dan Shen Radix Salviae miltiorrhizae, Wu Wei Zi Fructus Schisandrae and Wu Mei Fructus Mume. The above modifications apply to all the following formulae and will therefore not be repeated in each case. For each formula, the pattern and clinical manifestations will be given. These are in addition to the pattern and clinical manifestations of deficiency of Lung and Kidney’s Defensive-Qi systems present in all cases and that are essentially asthma, wheezing, tightness of the chest and, in some cases, eczema.

Acupuncture The four aims of treatment with acupuncture are: 1. to tonify the Lung and Kidney’s Defensive-Qi systems 2. to restore the descending of Lung-Qi 3. to calm the Mind 4. in late-onset asthma, there is also the necessity to tonify the Spleen. The points to use for the above aims are: 1. BL-23 Shenshu, Ren-4 Guanyuan, KI-13 Qixue, BL-52 Zhishi, Ren-8 Shenque with moxa cones on salt, KI-16 Huangshu, LU-9 Taiyuan, Du-12 Shenzhu and BL-13 Feishu to tonify Lung and Kidney’s Defensive-Qi systems. 2. LU-7 Lieque, LU-5 Chize, Ren-17 Shanzhong and BL-13 Feishu to restore the descending of Lung-Qi. 3. Du-24 Shenting, HE-7 Shenmen, DU-19 Houding and Ren-15 Jiuwei to calm the Mind. 4. ST-36 Zusanli, ST-40 Fenglong, Ren-12 Zhongwan, BL-20 Pishu and BL-21 Weishu to tonify the Spleen. The patterns discussed under the various formulae in this section are: • Lung-Qi deficiency • Lung-Qi and Lung-Yin deficiency • Lung-Qi and Kidney-Yang deficiency with predominance of the latter • Lung-Qi and Kidney-Yang deficiency with predominance of the former • Lung-Qi and Kidney-Yang deficiency with pronounced Cold

Allergic asthma (atopic eczema)

• Lung-Yin and Stomach-Yin deficiency with Dryness and some Empty Heat • Lung-Yin deficiency, no Dryness and no Empty Heat • Lung- and Kidney-Yin deficiency • Lung-Qi and Kidney-Yang deficiency with internal Cold

Lung-Qi deficiency Clinical manifestations Sweating, pale face, weak voice, prone to catching colds, sneezing, runny nose, shortness of breath, attacks of asthma elicited by pollen or dust, allergic rhinitis. Pulse: Empty.

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Lung-Qi and Kidney-Yang deficiency (with predominance of the former) Clinical manifestations Daytime sweating, infrequent attacks of asthma, chilliness, backache, frequent-pale urination, pale face, tiredness. Tongue: Pale. Pulse: Deep-Weak.

Prescription REN SHEN HU TAO TANG Ginseng-Juglans Decoction

Lung-Qi and Kidney-Yang deficiency with pronounced Cold

Prescription

Clinical manifestations

YU PING FENG SAN Jade Wind Screen Powder

Infrequent attacks of asthma elicited by exposure to cold, wheezing, chilliness, frequent-pale urination, tiredness, depression. Tongue: Pale, wet. Pulse: Deep-Weak-Slow.

Lung-Qi and Lung-Yin deficiency Clinical manifestations Attacks of asthma at night, tightness of the chest, wheezing, dry cough, dry throat, weak voice, night sweating, tiredness, prone to catching colds, pale face, palpitations. Tongue: dry, slightly Red in the Lung area. Pulse: Floating-Empty.

Prescription DING CHUAN SAN Stopping Breathlessness Powder

Lung-Yin and Stomach-Yin deficiency with dryness and some Empty Heat Clinical manifestations

Prescription SHENG MAI SAN Generating the Pulse Powder

Mild attacks of asthma at night, dry cough, dry throat, breathlessness on exertion, slight night sweating. Tongue: Red, without coating in the front part. Pulse: Floating-Empty on the right Front position.

Lung-Qi and Kidney-Yang deficiency (with predominance of the latter)

Prescription

Clinical manifestations Asthma attacks worse at night, tightness of the chest, chilliness, oedema of the face, tiredness, backache, depression, husky voice. Tongue: Pale. Pulse: Weak-Deep-Slow.

Prescription REN SHEN GE JIE SAN Ginseng-Gecko Powder

SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction This formula is also suitable to treat either late-onset asthma with Lung-Yin deficiency or asthma attacks from injury of Lung-Yin in children after a febrile Warm disease.

Lung-Yin deficiency, no dryness and no Empty Heat Clinical manifestations Same as above but with fewer symptoms of Dryness.

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Prescription MAI MEN DONG TANG Ophiopogon Decoction

Modifications • If the asthma attacks are relatively frequent, add Xuan Fu Hua Flos Inulae and Sang Bai Pi Cortex Mori to restore the descending of Lung-Qi.

Lung- and Kidney-Yin deficiency Clinical manifestations Chronic asthma with infrequent attacks that usually occur at night, wheezing, breathlessness on exertion, dry throat, night sweating, backache, tinnitus, dry cough, five-palm heat. Tongue: Red and without coating in the front part. Pulse: Floating-Empty.

Prescription BAI HE GU JIN TANG Lilium Consolidating Metal Decoction

Lung-Qi and Kidney-Yang deficiency with internal Cold Clinical manifestations Chronic asthma with infrequent attacks occurring mostly in daytime, chilliness, wheezing, backache, frequent-pale urination, oedema of ankles. Tongue: Pale, wet. Pulse: Deep-Weak-Slow.

Prescription SU ZI JIANG QI TANG Perilla Seed Lowering Qi Decoction

 LU-7 Lieque, LU-5 Chize, Ren-17 Shanzhong and BL-13 Feishu to restore the descending of Lung-Qi.  Du-24 Shenting, HE-7 Shenmen, DU-19 Houding and Ren-15 Jiuwei to calm the Mind.  ST-36 Zusanli, ST-40 Fenglong, Ren-12 Zhongwan, BL-20 Pishu and BL-21 Weishu to tonify the Spleen. Herbal therapy LUNG-QI DEFICIENCY Prescription YU PING FENG SAN Jade Wind Screen Powder LUNG-QI AND LUNG-YIN DEFICIENCY Prescription SHENG MAI SAN Generating the Pulse Powder LUNG-QI AND KIDNEY-YANG DEFICIENCY (WITH PREDOMINANCE OF THE LATTER) Prescription REN SHEN GE JIE SAN Ginseng-Gecko Powder LUNG-QI AND KIDNEY-YANG DEFICIENCY (WITH PREDOMINANCE OF THE FORMER) Prescription REN SHEN HU TAO TANG Ginseng-Juglans Decoction LUNG-QI AND KIDNEY-YANG DEFICIENCY WITH PRONOUNCED COLD Prescription DING CHUAN SAN Stopping Breathlessness Powder

TONIFY THE LUNG AND KIDNEY’S DEFENSIVE-QI SYSTEMS

LUNG-YIN AND STOMACH-YIN DEFICIENCY WITH DRYNESS AND SOME EMPTY HEAT Prescription SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction

Acupuncture  BL-23 Shenshu, Ren-4 Guanyuan, KI-13 Qixue, BL-52 Zhishi, Ren-8 Shenque with moxa cones on salt, KI-16 Huangshu, LU-9 Taiyuan, Du-12 Shenzhu and BL-13 Feishu to tonify Lung and Kidney’s Defensive-Qi systems.

LUNG-YIN DEFICIENCY, NO DRYNESS AND NO EMPTY HEAT Prescription MAI MEN DONG TANG Ophiopogon Decoction

SUMMARY

Allergic asthma (atopic eczema)

LUNG- AND KIDNEY-YIN DEFICIENCY Prescription BAI HE GU JIN TANG Lilium Consolidating Metal Decoction LUNG-QI AND KIDNEY-YANG DEFICIENCY WITH INTERNAL COLD Prescription SU ZI JIANG QI TANG Perilla Seed Lowering Qi Decoction

145

HE

LIV

SP Stagnant Liver-Qi

Deficient KidneyYin ‘‘draws’’ from Kidneys (Mother)

Liver-Fire

KI

LU Deficient KidneyYin ‘‘draws’’ from Lungs (Mother)

THE LIVER AND ASTHMA The Liver is also involved in the pathogenesis of asthma, especially in the late-onset type. In early-onset asthma, emotional stress affecting the Liver can often be a triggering factor for an attack. The Liver can play a role in the pathology of asthma in three possible ways. 1. Stagnant Liver-Qi may rebel upwards in the chest and obstruct the descending of Lung-Qi. From a Five-Element perspective, this is called “Wood insulting Metal”. 2. Liver-Fire may also rebel upwards in the chest and similarly obstruct the descending of Lung-Qi. This is also called “Wood insulting Metal”. In addition, Liver-Fire may dry up the Lung fluids. 3. Deficient Liver-Yin may fail to nourish the Kidneys, and this may lead to the Kidneys’ not grasping it. Furthermore, a deficiency of Kidney-Yin may lead to dryness in the Lungs (Fig. 5.16). Stagnant Liver-Qi derives from emotional problems such as repressed anger, frustration and resentment over a long period of time. After some years, stagnant Liver-Qi may easily turn to Liver-Fire. Liver-Yin deficiency may also derive from emotional problems such as sadness. In addition, in women it may be induced by childbirth and overwork. The three main Liver patterns affecting asthma are therefore: 1. Liver-Qi stagnant, insulting the Lungs 2. Liver-Fire insulting the Lungs 3. Liver-Yin deficiency.

Figure 5.16 The Liver in asthma.

Liver-Qi stagnant, insulting the Lungs Clinical manifestations Asthma attacks elicited by emotional stress, a feeling of oppression and distension of the chest and hypochondrium. Tongue: the tongue body may not change in colour except in long-standing cases, when the sides might be Red. Pulse: Wiry.

Treatment principle Soothe the Liver, regulate Qi, restore the descending of Lung-Qi, calm the mind.

Acupuncture Points SP-4 Gongsun, P-6 Neiguan, LIV-14 Qimen, G.B.-34 Yanglingquan, Ren-17 Shanzhong, BL-18 Ganshu with reducing or even method. These points are in addition to those mentioned above for the various types of deficiency of Lung and Kidney’s Defensive-Qi systems.

Explanation • SP-4 and P-6, in combination, open the Penetrating Vessel (Chong Mai), relieve fullness in the chest and subdue rebellious Qi in the chest. In addition, P-6 calms the Mind and indirectly moves Liver-Qi, as the Pericardium and Liver channels are connected within the Terminal Yin channels.

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• LIV-14 and BL-18, as Front-Collecting and BackTransporting points of the Liver respectively, move Liver-Qi. • G.B.-34 moves Liver-Qi. • Ren-17 moves Qi in the chest and restores the descending of Lung-Qi.

Herbal therapy Prescription CHEN XIANG JIANG QI SAN Aquilaria Subduing Qi Powder

hypochondrial and chest fullness and distension, bitter taste, thirst. Tongue: Red with redder sides and yellow coating. Pulse: Wiry-Rapid.

Treatment principle Clear the Liver, drain Fire, subdue rebellious Qi, restore the descending of Lung-Qi and calm the Mind.

Acupuncture Points

This formula soothes the Liver, moves Qi and restores the descending of Lung-Qi.

LIV-2 Xingjian, LIV-14 Qimen, BL-18 Ganshu, P-6 Neiguan, LU-7 Lieque. Reducing or even method. These points are to be used in addition to those mentioned previously for the various patterns of asthma.

Modifications

Explanation

• In cases in which Liver-Qi stagnation plays a role in asthma, any of the formulae mentioned above for deficiency of the Lung and Kidney’s Defensive-Qi systems can be modified with the addition of herbs such as Qing Pi Pericarpium Citri reticulatae viride, Mu Xiang Radix Aucklandiae, Yu Jin Radix Curcumae, Zhi Ke Fructus Aurantii and He Huan Pi Cortex Albiziae.

• LIV-2 is the main point to drain Liver-Fire. • LIV-14 and BL-18 clear Liver-Heat and move Liver-Qi. • P-6 regulates the Liver, opens the chest, eases breathing and calms the Mind. • LU-7 restores the descending of Lung-Qi.

Explanation

Herbal therapy Prescription

SUMMARY LIVER-QI STAGNANT, INSULTING THE LUNGS Points SP-4 Gongsun, P-6 Neiguan, LIV-14 Qimen, G.B.-34 Yanglingquan, Ren-17 Shanzhong, BL-18 Ganshu with reducing or even method. These points are in addition to those mentioned above for the various types of deficiency of Lung and Kidney’s Defensive-Qi systems. Herbal therapy Prescription CHEN XIANG JIANG QI SAN Aquilaria Subduing Qi Powder

LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction

Explanation This is the most important formula to drain Liver-Fire.

Modifications • When this formula is used for Liver-Fire insulting the Lungs in asthma, one needs to add some herbs to restore the descending of Lung-Qi, such as Xuan Fu Hua Flos Inulae, Xing Ren Semen Armeniacae and Su Zi Fructus Perillae.

Prescription EMPIRICAL PRESCRIPTION82

Modifications

Liver-Fire insulting the Lungs Clinical manifestations Loud wheezing, attacks of asthma elicited by emotional strain, irritability, propensity to outbursts of anger,

• If one were to use one of the formulae for deficiency of the Lung and Kidney’s Defensive-Qi systems mentioned above, then herbs to clear LiverFire should be added (e.g. Long Dan Cao Radix Gentianae).

Allergic asthma (atopic eczema)

SUMMARY

Herbal therapy

LIVER-FIRE INSULTING THE LUNGS

Prescription

Points LIV-2 Xingjian, LIV-14 Qimen, BL-18 Ganshu, P-6 Neiguan, LU-7 Lieque. Reducing or even method. These points are to be used in addition to those mentioned previously for the various patterns of asthma.

YI GUAN JIAN One Linking Decoction

Herbal therapy Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction Prescription EMPIRICAL PRESCRIPTION

Liver-Yin deficiency Clinical manifestations Infrequent asthma attacks at night, dry throat, dry cough, blurred vision, dry eyes, hypochondrial and chest distension. Floating-Empty pulse and Red tongue without coating.

Treatment principle Nourish Liver-Yin, move Liver-Qi, restore the descending of Lung-Qi and calm the Mind.

Acupuncture Points LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, P-6 Neiguan and SP-4 Gongsun. Reinforcing method. These points are used in addition to the ones previously mentioned for deficiency of the Lung and Kidney’s Defensive-Qi systems.

Explanation • LIV-8 and Ren-4 nourish Liver-Yin. • SP-6 and KI-3 nourish Kidney-Yin, which helps to nourish Liver-Yin. • P-6 and SP-4 open the Yin Linking vessel (Yin Wei Mai), nourish Liver-Blood, open the chest and calm the Mind.

147

Explanation This formula nourishes Liver-Yin.

Modifications • When used for chronic asthma, herbs to restore the descending of Lung-Qi should be added, such as Xuan Fu Hua Flos Inulae, Xing Ren Semen Armeniacae and Su Zi Fructus Perillae. • If one were to use one of the formulae for deficiency of the Lung and Kidney’s Defensive-Qi systems, then some herbs to nourish Liver-Yin should be added, such as Sheng Di Huang Radix Rehmanniae, Gou Qi Zi Fructus Lycii chinensis, Nu Zhen Zi Fructus Ligustri lucidi and Sang Ji Sheng Herba Taxilli.

SUMMARY LIVER-YIN DEFICIENCY Points LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, P-6 Neiguan and SP-4 Gongsun. Reinforcing method. These points are used in addition to the ones previously mentioned for deficiency of the Lung and Kidney’s Defensive-Qi systems. Herbal therapy Prescription YI GUAN JIAN One Linking Decoction

ATOPIC ECZEMA Eczema from a very early age or even from birth often accompanies or precedes the development of allergic asthma. The two conditions of eczema and asthma have the same allergic root, as is easily demonstrated by the wealing skin reactions occurring on inhalation of allergens in individuals suffering from extrinsic asthma.

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From the point of view of Chinese pathology, eczema is also due to an inborn deficiency of the Lung and Kidney’s Defensive-Qi systems. The relationship between the Lungs and skin is well known and yet, when discussing the pathology of skin diseases, Chinese books always seem to stress more the role of Blood (and Liver) in connection with the skin. In the case of atopic eczema and asthma, the connection between the Lungs and the skin could not be clearer. These two symptoms are very clearly related, and often one will appear as the other improves. For example, often eczema appears first at a very early age or even from birth, to be followed later by asthma when the child is about 4 or 5 years old. This pattern is more likely to occur if the eczema is suppressed with the application of cortisone creams. The reverse may also occur when asthma appears first and then apparently improves only to be followed by eczema. The relationship between skin diseases and the Lungs can also be observed in the action of many of the herbs that are used to expel Wind in skin diseases. The same herbs that expel Wind from the skin in eczema or rashes also stimulate the diffusing and descending of Lung-Qi in exterior conditions. The following are some examples, with their action on the skin given in brackets. • Fang Feng Radix Saposhnikoviae (expels WindDampness) • Jing Jie Herba Schizonepetae (expels Wind) • Chan Tui Periostracum Cicadae (expels Wind-Heat) • Ge Gen Radix Puerariae (expresses rashes) • Ma Huang Herba Ephedrae (expels Wind-Cold) • Bai Zhi Radix Angelicae dahuricae (expresses pus from skin) • Cang Er Zi Fructus Xanthii (expels Wind) • Bo He Herba Menthae haplocalycis (expresses rashes) • Niu Bang Zi Fructus Arctii (expresses rashes, reduces erythema) • Fu Ping Herba Spirodelae (expresses rashes) • Sheng Ma Rhizoma Cimicifugae (expresses rashes) There are also other herbs that act on the Lungs and affect the skin. • Bei Sha Shen Radix Glehniae, which tonifies LungYin, is used frequently for chronic skin diseases, especially if there is dryness.

• Wu Wei Zi Fructus Schisandrae, which tonifies LungYin and promotes the Lung’s fluids, is also used frequently for chronic skin diseases with dryness. • Sang Bai Pi Cortex Mori, which restores the descending of Lung-Qi and resolves Phlegm-Heat from the Lungs, is used in chronic skin diseases with Damp Heat. Thus, there is a very close relationship between the Lungs, and in particular the Lung’s Defensive-Qi system, and the skin. The Kidneys also play a role in the pathogenesis of eczema. First of all, while the Lungs control the skin in the sense of being linked to its pores, the Kidneys nourish and moisten the skin. Second, as mentioned before, the Kidney-Essence is closely bound with the Corporeal Soul (Po) of the Lungs, which manifests on the skin and which is responsible for sensations of itching and pain on the skin. An inborn defect of the Kidney-Essence, such as occurs in atopic asthma and eczema, can therefore affect the Corporeal Soul and the skin. Third, the Extraordinary Vessels, especially the Penetrating (Chong) and Directing (Ren) Vessels, nourish the skin through a network of secondary vessels all over the body. Because these two vessels arise from the Kidneys and spread the Kidney-Essence to the skin, they provide a further link between the Kidneys and the skin. Li Shi Zhen, in his work A Study of the Eight Extraordinary Vessels (1578), says: “when the Qi of the channels overflows, it flows into the extraordinary vessels, where it is turned into irrigation, warming the organs internally and irrigating the space between skin and muscles externally.”83 The Penetrating Vessel also moistens the skin. The Spiritual Axis in Chapter 65 says: “if the Blood [of the Penetrating Vessel] is abundant, the skin is moist.”84 Skin pigmentation also depends on the Extraordinary Vessels. That is why darker pigmentation is concentrated along the pathway of the Extraordinary Vessels (Directing and Penetrating Vessels) such as the genitals and the midline between pubis and umbilicus and nipples. In fact, the pigmentation on the midline between pubis and umbilicus (Directing Vessel) often becomes darker during pregnancy.85 Another example of the relationship between Kidneys and skin is the development of nephritis from a blood infection deriving from a skin disease.

Allergic asthma (atopic eczema)

CLINICAL NOTE The Kidneys and the skin  The Kidneys nourish and moisten the skin.  The Kidney-Essence is closely bound with the Corporeal Soul (Po) of the Lungs, which manifests on the skin and which is responsible for sensations of itching and pain on the skin.  An inborn defect of the Kidney-Essence, such as occurs in atopic asthma and eczema, can affect the Corporeal Soul and the skin.  The Extraordinary Vessels (arising from the Kidneys and spreading the Kidney-Essence to the skin), especially the Penetrating (Chong) and Directing (Ren) Vessels, nourish the skin through a network of secondary vessels all over the body.  Li Shi Zhen: “when the Qi of the channels overflows, it flows into the extraordinary vessels, where it is turned into irrigation, warming the organs internally and irrigating the space between skin and muscles externally.”  The Penetrating Vessel moistens the skin.  Skin pigmentation depends on the Extraordinary Vessels.  Nephritis from a blood infection may derive from a skin disease.

There are two basic types of eczema in babies, one characterized by Wind-Heat (called “dry fetus”) and the other characterized by Damp Heat (called “damp fetus”). They are both due to a deficiency of Lung and Kidney’s Defensive-Qi systems but with varying degrees of involvement of the Lungs or Kidneys. The Wind-Heat type is more due to the Lungs, while the Damp Heat type is more related to the Kidneys. As for the treatment, the aim depends on whether the asthma or the eczema is the predominant problem. If asthma is the predominant problem, one would simply use one of the formulae indicated above and add some herbs to treat the eczema according to type. • Wind-Heat: — Jing Jie Herba Schizonepetae — Chan Tui Periostracum Cicadae — Bo He Herba Menthae haplocalycis — Bai Xian Pi Cortex Dictamni • Damp Heat: — Fang Feng Radix Saposhnikoviae — Bai Xian Pi Cortex Dictamni — Ge Gen Radix Puerariae — Bai Zhi Radix Angelicae dahuricae

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— Niu Bang Zi Fructus Arctii — Sheng Ma Rhizoma Cimicifugae All these herbs are suitable for babies or young children. Eczema from Wind-Heat is characterized by skin lesions that are very dry, red and itchy, with the itchiness being spread all over the body and moving from place to place. Eczema from Damp Heat is characterized by skin lesions that are moist, oozing fluid, red and itchy, with the itchiness being more confined to specific parts of the body, often the forearm and lower leg. However, please remember that in eczema there is always Dampness, even in the “dry” type; in fact, the typical skin puffiness seen in eczema is a manifestation of Dampness. CLINICAL NOTE Wind-Heat eczema Dry, red and itchy skin lesions, with the itchiness being spread all over the body and moving from place to place. Damp Heat eczema Moist, oozing fluid, red and itchy skin lesions, with the itchiness being more confined to specific parts of the body, often the forearm and lower leg.

! Remember that in eczema there is always Dampness, even in the “dry” type; in fact, the typical skin puffiness seen in eczema is a manifestation of Dampness. Table 5.3 summarizes the differences between Wind-Heat and Damp Heat in eczema. If eczema is the main problem but the patient suffers also from asthma, then one must use one of the following formulae and modify it with the addition of herbs to restore the descending of Lung-Qi, such as Su Zi Fructus Perillae, Xing Ren Semen Armeniacae, Sang Bai Pi Cortex Mori, Pi Pa Ye Folium Eriobotryae, or Xuan Fu Hua Flos Inulae. In particular, Pi Pa Ye and Sang Bai Pi are suitable to restore the descending of Lung-Qi and they also clear Damp Heat from the skin. In babies and young children, I often use a variation of Chu Shi Wei Ling Tang Eliminating Dampness Stomach “Ling” Decoction, which is aimed primarily at

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Table 5.3 Comparison between Wind-Heat and Damp Heat types of eczema Wind-Heat (Dry fetus)

Damp Heat (Damp fetus)

Organ

Lungs

Kidneys

Clinical manifestations

Dry skin lesions, red, itchy, itchiness all over and moving from place to place

Moist skin lesions, oozing fluid, itchy, itchiness confined to specific parts (usually limbs)

Herbs

Jing Jie, Chan Tui, Bo He, Bai Xian Pi

Fang Feng, Bai Xian Pi, Ge Gen, Bai Zhi, Niu Bang Zi, Sheng Ma

eliminating Dampness. I modify it with the addition of herbs with the following aims: • To expel Wind: Jing Jie Herba Schizonepetae or Chan Tui Periostracum Cicadae. • To tonify the Lung’s Defensive-Qi system: Bei Sha Shen Radix Glehniae and Mai Men Dong Radix Ophiopogonis. • To tonify the Kidney’s Defensive-Qi system: Tu Si Zi Semen Cuscutae. • Antiallergy herbs: Dan Shen Radix Salviae miltiorrhizae, Wu Wei Zi Fructus Schisandrae.

Acute eczema Wind-Heat

• HE-8 and HE-7 stop itching, and one of these points is used if this symptom is pronounced. • Zhiyangxue, extra point, stops itching. It is situated 2 cun directly above L.I.-11 Quchi on the Large Intestine channel. • LU-7 and KI-6, in combination, open the Directing Vessel (Ren Mai), tonify the Lung and Kidney’s Defensive-Qi systems, nourish the Essence and benefit the skin. These points are used in women. In men, use LU-9 and KI-3 to tonify the Lung and Kidney’s Defensive-Qi systems and benefit the skin. • Sifeng, extra point, can be pricked in infants for acute Wind-Heat. It is located in the cracks of the fingers.

Acupuncture

Herbal therapy

Points T.B.-6 Zhigou, G.B.-31 Fengshi, BL-12 Fengmen, L.I.-11 Quchi, L.I.-4 Hegu, Du-14 Dazhui, SP-10 Xuehai, SP-6 Sanyinjiao, LIV-2 Xingjian, HE-8 Shaofu, HE-7 Shenmen, Zhiyangxue extra point, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, Sifeng. Reducing method on all points except SP-6, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa.

Prescription XIAO FENG SAN Clearing Wind Powder

Explanation • T.B.-6 and G.B.-31 are the main points to expel Wind-Heat from the skin. • BL-12 helps to expel Wind. • L.I.-11 and L.I.-4 expel Wind-Heat and cool Blood. • Du-14 is used if Heat is pronounced. • SP-10 and SP-6 cool and nourish Blood. This is necessary according to the principle of “harmonizing Blood in order to expel Wind”. • LIV-2 is used if there are signs of Liver-Heat. It also helps to expel Wind.

Explanation This formula expels Wind-Heat, clears Heat, cools Blood and nourishes Blood. It is specific for acute skin diseases from Wind-Heat. Modifications • In very chronic conditions, there may be a pronounced deficiency and dryness of the Blood. In these cases, the herbs that resolve Dampness (Ku Shen, Cang Zhu) can be eliminated or reduced in dosage, and the herbs that nourish Blood (Sheng Di Huang Radix Rehmanniae and Dang Gui Radix Angelicae sinensis) should be increased in dosage. Furthermore, Shou Wu Radix Polygoni multiflori preparata should be added.

Allergic asthma (atopic eczema)

SUMMARY ACUTE ECZEMA – WIND-HEAT Points T.B.-6 Zhigou, G.B.-31 Fengshi, BL-12 Fengmen, L.I.-11 Quchi, L.I.-4 Hegu, Du-14 Dazhui, SP-10 Xuehai, SP-6 Sanyinjiao, LIV-2 Xingjian, HE-8 Shaofu, HE-7 Shenmen, Zhiyangxue extra point, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, Sifeng. Reducing method on all points except SP-6, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa.

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tonify the Lung and Kidney’s Defensive-Qi systems and benefit the skin. • Sifeng, in infants, expels Damp Heat.

Herbal therapy Prescription BI XIE SHEN SHI TANG Dioscorea Draining Dampness Decoction Explanation This formula drains Damp Heat from the Lower Burner and the skin. Prescription CHU SHI WEI LING TANG Eliminating Dampness Stomach “Ling” Decoction

Herbal therapy Prescription XIAO FENG SAN Clearing Wind Powder

Explanation This formula drains Damp Heat and clears Heat. Compared with the previous formula, the emphasis is slightly more on Heat and on Dampness.

Damp Heat Acupuncture Points L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Du-14 Dazhui, SP-10 Xuehai, Ren-12 Zhongwan, BL-20 Pishu, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, Sifeng. Reducing method except on Ren-12, BL-20, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa. Explanation • L.I.-11, SP-9 and SP-6 resolve Damp Heat. • Du-14 and SP-10 clear Heat and cool Blood. • Ren-12 and BL-20 tonify the Spleen to resolve Dampness. • LU-7 and KI-6, in combination, are used in women to open the Directing Vessel, tonify the Lung and Kidney’s Defensive-Qi systems, nourish the Essence and benefit the skin. In men, use LU-9 and KI-3 to

Prescription QING RE SHEN SHI TANG Clearing Heat and Draining Dampness Decoction Explanation This formula drains Damp Heat, clears Heat, cools Blood and expels Toxic Heat. These three formulae for acute eczema may be differentiated in Table 5.4.

SUMMARY ACUTE ECZEMA – DAMP HEAT Points L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Du-14 Dazhui, SP-10 Xuehai, Ren-12 Zhongwan, BL-20 Pishu, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, Sifeng. Reducing method

Table 5.4 Differentiation of acute eczema formulae Bi Xie Shen Shi Tang

Chu Shi Wei Ling Tang

Qing Re Shen Shi Tang

Action

Drain Damp Heat via urine

Drain Damp Heat via urine and relieve epigastric fullness

Drain Damp Heat and resolve Toxic Heat

Skin

Moist-red skin lesions

Moist-red skin lesions, eczema more on legs

Pustular-red skin lesions

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except on Ren-12, BL-20, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa. Herbal therapy Prescription BI XIE SHEN SHI TANG Dioscorea Draining Dampness Decoction Prescription CHU SHI WEI LING TANG Eliminating Dampness Stomach “Ling” Decoction Prescription QING RE SHEN SHI TANG Clearing Heat and Draining Dampness Decoction

Chronic eczema Wind-Heat (with Blood deficiency) Acupuncture Points T.B.-6 Zhigou, G.B.-31 Fengshi, BL-12 Fengmen, L.I.-11 Quchi, L.I.-4 Hegu, Du-14 Dazhui, SP-10 Xuehai, SP-6 Sanyinjiao, LIV-2 Xingjian, HE-8 Shaofu, Zhiyangxue extra point, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, ST-36 Zusanli, BL-17 Geshu, LIV-8 Ququan, Ren-4 Guanyuan. Even method on all points except SP-6, LU-7, KI-6, LU-9, KI-3, ST-36, BL-17, LIV-8 and Ren-4, which should be reinforced. No moxa.

Kidney’s Defensive-Qi systems, nourish the Essence and benefit the skin. In men, use LU-9 and KI-3 to tonify the Lung and Kidney’s Defensive-Qi systems and benefit the skin. • ST-36 and BL-17 nourish Blood. • LIV-8 and Ren-4 are reinforced if there are symptoms of Liver-Blood deficiency.

Herbal therapy Prescription YANG XUE DING FENG TANG Nourishing Blood and Clearing Wind Decoction Explanation This formula is for chronic eczema from Wind-Heat in the Blood affecting the skin against a background of Blood deficiency. The skin lesions are not very red and the skin is very dry and itchy. Prescription XIAO FENG CHONG JI Clearing Wind Decoction Explanation This formula is for a more complex condition than the previous one. It is for chronic eczema from both Wind-Heat and some Damp Heat against a background of Blood deficiency with some Blood-Heat. The skin lesions are quite red, not too itchy, dry but frequently turning moist.

SUMMARY Explanation • T.B.-6 and G.B.-31 are the main points to expel Wind-Heat from the skin. • BL-12 helps to expel Wind. • L.I.-11 and L.I.-4 expel Wind-Heat and cool Blood. • Du-14 is used if Heat is pronounced. • SP-10 and SP-6 cool and nourish Blood. This is necessary according to the principle of “harmonizing Blood in order to expel Wind”. • LIV-2 is used if there are signs of Liver-Heat. It also helps to expel Wind. • HE-8 stops itching and is used if itching is pronounced. • Zhiyangxue, extra point, stops itching. It is situated 2 cun directly above L.I.-11 on the Large Intestine channel. • LU-7 and KI-6, in combination, are used in women to open the Directing Vessel, tonify the Lung and

CHRONIC ECZEMA – WIND-HEAT (WITH BLOOD DEFICIENCY) Points T.B.-6 Zhigou, G.B.-31 Fengshi, BL-12 Fengmen, L.I.-11 Quchi, L.I.-4 Hegu, Du-14 Dazhui, SP-10 Xuehai, SP-6 Sanyinjiao, LIV-2 Xingjian, HE-8 Shaofu, Zhiyangxue extra point, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, ST-36 Zusanli, BL-17 Geshu, LIV-8 Ququan, Ren-4 Guanyuan. Even method on all points except SP-6, LU-7, KI-6, LU-9, KI-3, ST-36, BL-17, LIV-8 and Ren-4, which should be reinforced. No moxa. Herbal therapy Prescription YANG XUE DING FENG TANG Nourishing Blood and Clearing Wind Decoction

Allergic asthma (atopic eczema)

Prescription XIAO FENG CHONG JI Clearing Wind Decoction

LU-9 and KI-3, which should be reinforced. No moxa. Herbal therapy Prescription SAN FENG CHU SHI TANG Scattering Wind and Eliminating Dampness Decoction

Damp Heat Acupuncture Points L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Du-14 Dazhui, SP-10 Xuehai, Zhiyangxue, Ren-12 Zhongwan, BL-20 Pishu, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi. Reducing method except on Ren-12, BL-20, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa. Explanation • L.I.-11, SP-9 and SP-6 resolve Damp Heat. • Du-14 and SP-10 clear Heat and cool Blood. • Zhiyangxue, extra point located 2 cun above L.I.-11, stops itching. • Ren-12 and BL-20 tonify the Spleen to resolve Dampness. • LU-7 and KI-6, in combination, are used in women to open the Directing Vessel, tonify the Lung and Kidney’s Defensive-Qi systems, nourish the Essence and benefit the skin. In men, use LU-9 and KI-3 to tonify the Lung and Kidney’s Defensive-Qi systems and benefit the skin.

Herbal therapy

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External treatment The application of herbs externally is very beneficial for chronic eczema. The herbs may be boiled in the usual way but with a much larger quantity of water and then strained. The resulting liquid may then be poured in a shallow bath. Let the patient bathe in this water. A common formula for external use is as follows. • • • • • •

Da Huang Radix et Rhizoma Rhei Huang Qin Radix Scutellariae Huang Bo Cortex Phellodendri Ku Shen Radix Sophorae flavescentis Ju Hua Flos Chrysanthemi Zi Hua Di Ding Herba Violae

MODERN CHINESE LITERATURE

Prescription SAN FENG CHU SHI TANG Scattering Wind and Eliminating Dampness Decoction

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 36, No. 11, 1995, p. 666.

Explanation This formula is for chronic eczema from Damp Heat with dark lesions usually in a limited area oozing fluid and with a thick-rough skin.

Chen Jin and Luo Guan Liang, “The treatment of paediatric asthma by simultaneously tonifying and expelling.”

SUMMARY CHRONIC ECZEMA – DAMP HEAT Points L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Du-14 Dazhui, SP-10 Xuehai, Zhiyangxue, Ren-12 Zhongwan, BL-20 Pishu, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi. Reducing method except on Ren-12, BL-20, LU-7, KI-6,

The authors treated 156 children with asthma, of whom 106 received treatment with Chinese herbs and 50 were in a control group treated with Western medication. Of the 106 children in the treatment group, 81% were under 3. The asthma was elicited by invasion of external Wind in 86% of cases, by diet in 26%, by exercise in 19%, and by distress in 7.4%. In 71.7% of cases, there was a deficiency of Prenatal Qi. One hundred per cent of the children displayed wheezing, breathlessness and cough; 96% had Phlegm;

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64% had a Kidney deficiency; 70% had Lung-Yin deficiency; 63% a Spleen deficiency; 9% Blood stasis; and 7% Lung-Yang deficiency. The formula used was as follows. • • • • • • • • • • • • •

Ma Huang Herba Ephedrae Xing Ren Semen Armeniacae Ban Xia Rhizoma Pinelliae preparatum Chen Pi Pericarpium Citri reticulatae Fu Ling Poria Bai Zhu Rhizoma Atractylodis macrocephalae Fang Feng Radix Saposhnikoviae Wu Wei Zi Fructus Schisandrae Tai Zi Shen Radix Pseudostellariae Dang Gui Radix Angelicae sinensis Shu Di Huang Radix Rehmanniae preparata Zi He Che Placenta hominis Dong Chong Xia Cao Cordyceps

The children in the control group were treated with Tranilast, an antiallergy medication. The total of positive results in the treatment group was 90.6% and that in the control group 66.7%. In the discussion, the authors say that external Wind can trigger asthma attacks only when there is Phlegm in the Lungs and a deficiency of the Kidneys. Contrary to traditional theory, according to which a deficiency of the Kidneys is a factor in chronic asthma in adults in the late stages of the disease, they say that in children a deficiency of the Kidneys is present from the beginning and is at the root of the disease. They make a correlation between the Kidney deficiency and an insufficiency of the adrenal cortex.

Dr He says that allergic asthma is due to the invasion of allergens, and he compares these to the Chinese concept of “Wind”. Interestingly, in contrast to most other modern Chinese doctors, Dr He understands the correlation between allergic rhinitis and allergic asthma as being two manifestations of the same disease. He says that when allergens settle in the nose they cause allergic rhinitis (with sneezing and itchiness), and when they settle in the bronchi they cause allergic asthma. Dr He says, in addition, that the episodic nature of allergic asthma reflects the characteristic of Wind in coming and going quickly and having rapid onset. Moreover, Dr He also thinks (as I do) that the bronchospasm that causes narrowing of the airways in asthma is also a manifestation of Wind as this contracts. Dr He recommends using two main points to expel Wind in asthma: G.B.-20 Fengchi and LU-7 Lieque. In the same article, Dr Shao Jing Ming says that the three most important points to treat asthma are BL-12 Fengmen, BL-13 Feishu and Du-14 Dazhui. The other points he uses according to clinical manifestations are as follows. • Cough with sputum: LU-5 Chize, LU-9 Taiyuan. • Profuse phlegm: Ren-12 Zhongwan, ST-36 Zusanli. • Phlegm in the throat: Ren-22 Tiantu, Ren-17 Shanzhong. • Better with rest and worse with exercise: Ren-4 Guanyuan, BL-23 Shenshu and KI-3 Taixi. • Palpitations: BL-14 Jueyinshu and BL-15 Xinshu.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 26, No. 5, 1985, p. 47.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 29, No. 1, 1988, pp. 5–11.

Shao Jing Ming, “Clinical observation on the treatment of 111 cases of asthma with acupuncture.”

He Shu Huai, “Patterns and treatment of asthma.”

Dr Shao Jing Ming treated 111 cases of asthma with acupuncture. The three main points were BL-12 Fengmen, BL-13 Feishu and Du-14 Dazhui. Other points according to clinical manifestations were as follows.

This article is a collection of clinical experiences of modern Chinese doctors. Dr He Shu Huai stands out as having a theory of asthma that is different from the traditional theory. In fact, Dr He maintains (as I do) that the main pathogenic factor in asthma is not Phlegm but “Wind”. Dr He uses the quotation marks for “Wind” because he says (as I do) that in type it differs slightly from Wind as usually considered in Chinese medicine.

• Cough with sputum: LU-5 Chize, LU-9 Taiyuan. • Profuse phlegm: Ren-12 Zhongwan, ST-36 Zusanli. • Phlegm in the throat: Ren-22 Tiantu, Ren-17 Shanzhong. Of 111 patients, 48 (43.2%) reported a large improvement in symptoms, 61 (54.9%) a noticeable improvement, and 2 (1.8%) no improvement.

Allergic asthma (atopic eczema)

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 39, No. 2, 1998, pp. 99–100. Zhang Jing Lei, “The treatment of bronchial asthma with Chinese medicine.” Dr Zhang Jing Lei treated 764 patients with bronchial asthma, of whom 600 were in the treatment group (with Chinese herbs) and 164 in the control group treated with Western medication (bronchodilators, cortisone and histamine). There were 410 men and 354 women. The youngest patient was 18 and the oldest 65, with the average age being 42 years. The prescription used is not fully disclosed in the article but is based on tonification of the Kidneys with the main ingredients given as follows. • • • • • •

Sheng Di Huang Radix Rehmanniae Shu Di Huang Radix Rehmanniae preparata Mai Men Dong Radix Ophiopogonis Ren Shen Radix Ginseng Wu Wei Zi Fructus Schisandrae Ci Shi Magnetitum

Dr Zhang believes that in order to treat the inflammation process, the atopy and the bronchoconstriction, it is necessary to nourish Kidney-Yin.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 40, No. 3, 1999, pp. 139–40. Wang Xing Juan, “The experience of Dr Shen Zi Yin in the treatment of asthma.” Dr Wang Xing Juan reports the experience of Dr Shen Zi Yin in the treatment of asthma. Dr Wang considers that the two main treatment methods for asthma are to restore the descending and diffusing of Lung-Qi and to tonify the Kidneys. To restore the descending and diffusing of Lung-Qi, Dr Shen uses formulae such as Ma Huang Tang Ephedra Decoction, San Ao Tang Three Break Decoction, Xiao Qing Long Tang Small Green Dragon Decoction or Ma Xing Shi Gan Tang Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction. Dr Shen thinks that tonifying the Kidneys is necessary not only from the perspective of Chinese medicine but also from that of Western medicine. Interestingly,

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he says that using herbs with a sweet and sour taste stabilizes the cell membranes and therefore has a stabilizing effect on the mast cells in the bronchi. Dr Shen also says that tonifying the Kidneys (and especially Kidney-Yang) in asthma has the effect of regulating immunity by regulating the T-cells and reducing the levels of IgE.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 31, No. 1, 1990, p. 57. Hu Jin Sheng, “Needle manipulation for asthma.” Dr Hu Jin Sheng discusses the needle manipulation for points to stop asthma. For the extra point Dingquan, he recommends inserting the needle obliquely towards Du-14 Dazhui to the depth of 1.5 cun. The needling sensation should radiate to the chest and it should be retained for 30 minutes. It should be reduced with rotation technique. The point LU-10 Yuji should be needled perpendicularly to the depth of 0.7 cun, and it should be retained for 30 minutes. It should be reduced with rotation technique. The point Du-14 Dazhui should be needled to a depth of 1.3 cun, and the patient should experience a distending and heaviness sensation.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 42, No. 3, 2001, p. 185. Cui Hong Sheng, “Differences between cough and asthma.” Dr Cui Hong Sheng discusses the differences between the Chinese disease entities of “Cough” and “Asthma”. Dr Cui has a theory of allergic asthma that differs from the traditional one and that is close to my theory of asthma. He says that in allergic asthma there is a deficiency of Liver-Blood and a dryness of Blood leading to Wind. The Wind travels upwards and causes wheezing. Dr Cui says that the treatment principle for allergic asthma is to soothe the Liver and restore the descending of Lung-Qi, together with the administration of herbs that have an antiallergy effect. The formula he uses is as follows.

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• Wu Mei Fructus Mume 15 g (antiallergy effect) • Wu Wei Zi Fructus Schisandrae 6 g (antiallergy effect) • Chai Hu Radix Bupleuri 10 g • Fang Feng Radix Saposhnikoviae 6 g • Bai Shao Radix Paeoniae alba 10 g • Bei Sha Shen Radix Glehniae 10 g • Sang Ye Folium Mori 10 g • Sang Bai Pi Cortex Mori 10 g • Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6 g

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 36, No. 4, 1995, p. 242. Wang Zhi Ying, “Research on the treatment of asthma by invigorating blood and eliminating stasis.” Dr Wang Zhi Ying’s ideas on the treatment of asthma differ from the traditional ones. To treat asthma, in fact, he uses the method of invigorating Blood. He bases his view on two factors. First, he says that in asthma, the failure of Lung-Qi to descend also causes some Qi stagnation. As Qi is the mother of Blood, this Qi stagnation frequently leads to Blood stasis. Second, as in Phlegm there is asthma, Phlegm often harbours stasis of Blood because of the interaction between Fluids and Blood; in fact, Phlegm and Blood stasis are two pathogenic factors that aggravate each other. The formulae Dr Wang uses are Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction, Fu Yuan Huo Xue Tang Restoring the Source and Invigorating Blood Decoction and Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 39, No. 7, 1998, p. 398. Zhang Cheng, “A case of asthma treated with large doses of Shu Di Huang Radix Rehmanniae preparata.” Dr Zhang Cheng reports the treatment of asthma by using large doses of Shu Di Huang Radix Rehmanniae preparata (30–60 g) within a prescription. He says that Shu Di Huang nourishes Kidney-Yin, tonifies the Original Qi and strengthens the Kidney’s receiving of Qi. The formula he uses is as follows.

• • • • • • • • • • • •

Shu Di Huang Radix Rehmanniae preparata Dang Gui Radix Angelicae sinensis Yin Yang Huo Herba Epimidii Bu Gu Zhi Fructus Psoraleae Wu Wei Zi Fructus Schisandrae Bai Zhu Rhizoma Atractylodis macrocephalae Qian Shi Semen Euryales Xing Ren Semen Armeniacae Zi Wan Radix Asteris Sang Bai Pi Cortex Mori Dan Shen Radix Salviae miltiorrhizae Tao Ren Semen Persicae

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 39, No. 7, 1998, p. 396. Wu Ying He, “The treatment of acute bronchial asthma according to pattern identification and with the addition of insect substances to extinguish Wind.” Dr Wu Ying He recommends the use of insect substances for the treatment of acute asthma. This is based on the principle that insects extinguish Wind. The insects he adds to a formula according to pattern identification are Jiang Can Bombyx batryticatus, Chan Tui Periostracum Cicadae, Di Long Pheretima and Quan Xie Scorpio.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 28, No. 12, 1987, p. 37. Shi Guang Yu, “Dr Shao Jing Ming’s experience on the acupuncture treatment of asthma.” Dr Shao Jing Ming is an expert in the treatment of asthma with acupuncture. The three main points he uses are BL-12 Fengmen, BL-13 Feishu and Du-14 Dazhui. The combination of these three points for asthma is described as the “Three Points, Five Needles, One Cupping” (because cupping is applied to Du-14 Dazhui). He inserts Du-14 to the depth of 1 cun and rotates it to obtain deqi; he inserts BL-12 and BL-13 to the depth of 5-8 fen. He uses rotation for an even manipulation. He retains the needles for 20 minutes in adults but only 2–3 minutes in children. Other points he uses according to clinical manifestations are as follows.

Allergic asthma (atopic eczema)

• External invasion of Wind: L.I.-4 Hegu and LU-7 Lieque. • Cough with sputum: LU-5 Chize, LU-9 Taiyuan. • Profuse phlegm: Ren-12 Zhongwan, ST-36 Zusanli. • Phlegm in the throat: Ren-22 Tiantu, Ren-17 Shanzhong. • Better with rest and worse with exercise: Ren-4 Guanyuan, BL-23 Shenshu and KI-3 Taixi.

Journal of the Nanjing University of Traditional Chinese Medicine (Nan Jing Zhong Yi Yao Da Xue Xue Bao), Vol. 12, No. 2, 1996, p. 53. Qiu Li Sheng, “The treatment of children’s allergic asthma with the method of expelling Wind and penetrating the Connecting channels.” Dr Qiu Li Sheng reports the treatment of 38 children suffering from allergic asthma. In one of a few Chinese articles that discusses allergic asthma specifically, Dr Qiu adopted the method of expelling Wind and removing obstructions from the Connecting channels with herbs such as Fang Feng Radix Saposhnikoviae, Chan Tui Periostracum Cicadae, Gou Teng Ramulus cum Uncis Uncariae, Wu Shao She Zaocys and Si Gua Luo Fructus Retinervus Luffae. The other treatment methods used in addition to the above include restoring the descending of Lung-Qi, resolving Phlegm and nourishing Lung-Yin.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 38, No. 6, 1997, p. 340. Hu Jin Sheng, “The treatment of allergic asthma with acupuncture.” Dr Hu Jin Sheng discusses the treatment of allergic asthma with acupuncture. He distinguishes two main patterns in allergic asthma: Qi deficiency with Blood stasis and Lung and Kidney deficiency. The main points he uses fall into two groups. They are divided as follows. 1. Du-20 Baihui, Du-23 Shangxing, Yintang, BL-7 Tongtian, L.I.-20 Yingxiang, LU-1 Zhongfu, L.I.-4 Hegu, Ren-17 Shanzhong, P-6 Neiguan, ST-36 Zusanli, SP-6 Sanyinjiao. 2. Du-14 Dazhui, Dingchuan, Chuanxi, G.B.-20 Fengchi, BL-13 Feishu, BL-17 Geshu, BL-20 Pishu, BL-23 Shenshu, BL-25 Dachangshu.

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The points used by Dr Hu are interesting, as they are quite different from the ones used by other modern doctors. The first group includes many points from the Governing Vessel (Du Mai) and, surprisingly, BL-7 Tongtian (on the head). The inclusion of Du-20 Baihui is also surprising, as this point lifts Qi (something that one would not want to do in asthma when Qi needs to descend). The second group includes points that expel Wind and points that tonify the Lungs and Kidneys. This is interesting from my perspective, as it would confirm my theory of Wind being the main pathogenic factor and a deficiency of Lungs and Kidneys the underlying condition in allergic asthma. Dr Hu’s explanation of the points is as follows. • Du-20 lifts the deficient Qi. • Du-23, Yintang and L.I.-20 open the Lung’s orifices to make Qi descend. • BL-7, as the name Tongtian implies (according to Dr Hu), “makes Lung-Qi penetrate (Tong) to Heaven (Tian)” and promotes the exchange and communication between Lung-Qi and air. • LU-1, Front-Collecting point of the Lungs, regulates the Lungs and promotes the descending of Lung-Qi. • L.I.-4, Source (Yuan) point of the Large Intestine, helps Lung-Qi to descend thanks to the exterior–interior relationship between Large Intestine and Lung channels. • Ren-17 and P-6 regulate the Qi Mechanism (Qi Ji). • ST-36 and SP-6 tonify Stomach and Spleen which will help to tonify the Lungs (Earth being the mother of Metal). • Du-14 is a meeting point of all Yang channels (Dr Hu does not say how exactly this helps asthma). • Dingchuan (0.5 cun lateral to Du-14) and Chuanxi (1 cun lateral to Du-14) are empirical points for asthma. • G.B.-20 expels Wind. • BL-13, BL-20 and BL-23 tonify Lungs, Spleen and Kidneys. • BL-17 regulates Blood: invigorating Blood will help to move Qi. Dr Hu adds other points according to clinical manifestations as follows. • Qi deficiency: Ren-6 Qihai and SP-10 Xuehai to tonify Qi and Blood. • Lung and Kidney deficiency: KI-3 Taixi, LU-9 Taiyuan.

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• Cough, chest pain: KI-26 Yuzhong and KI-27 Shufu. • Profuse phlegm, itchy throat: ST-40 Fenglong, Ren-22 Tiantu, Zengyin (literally “increase voice”, 1 cun lateral to the tip of the laryngeal prominence). • Digestive symptoms: Ren-12 Zhongwan, ST-25 Tianshu. • Oedema of upper limbs: L.I.-6 Pianli and LU-7 Lieque. • Oedema of lower limbs: SP-9 Yinlingquan, SP-6 Sanyinjiao, SP-5 Shangqiu. Dr Hu recommends using the above two groups of points four times a week initially, twice for each group. After 3 weeks, reduce the treatment to three times a week using the first group twice and the second group once. After 4 weeks, reduce the frequency to twice a week, once for each group. Use even method after obtaining the needling sensation and needle Dingquan to a depth of 1–1.2 cun.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 29, No. 2, 1988, pp. 38–39. Hu Wen Hao, “Clinical observation of 39 cases of allergic asthma treated with acupuncture and Chinese herbs.” Dr Hu Wen Hao discusses the treatment of 39 cases of allergic asthma with acupuncture and Chinese herbs. The formula used was Er Ma Si Ren Tang Two Hemp Four Seeds Decoction. The main acupuncture points used were Dingchuan, ST-40 Fenglong, BL-23 Shenshu, LU-6 Kongzui, ST-36 Zusanli. Dr Hu explains that if Phlegm predominates, Dingchuan and LU-6 should be the main points; if there is Phlegm and Kidney deficiency, ST-40, ST-36 and BL-23 should be the main points.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 33, No. 8, 1992, p. 55. Shen Zhuang Fa, “The treatment of Wheezing (Xiao) by restoring the diffusing and descending of Qi, by rectifying Qi and by benefiting Qi.” Dr Shen Zhuang Fa discusses the treatment principles for asthma (Xiao). He says that in asthma there is stagnation of Qi in the Interior, invasion of external Wind (eliciting acute attacks) and accumulation of

Phlegm in the diaphragm. The organs involved are Lungs, Spleen and Kidneys. Dr Shen explains that in asthma there is a failure of the diffusing and descending of Lung-Qi, leading to the formation of Phlegm; the Spleen is deficient and cannot transform and transport, so fluids accumulate into Dampness and Phlegm; the deficient Kidneys fail to hold and receive Qi, so this rebels upwards towards the Lungs. Therefore the treatment methods must be based on stimulating the diffusing of Lung-Qi and the descending of Lung-Qi (which will help to resolve Phlegm) and on rectifying Qi (i.e. promote its flow in the right direction). In between attacks, one must tonify Qi of the Lungs, Spleen and Kidneys. The formulae used by Dr Shen are as follows. • To stimulate the diffusing of Lung-Qi (for Phlegm in the Lungs): She Gan Ma Huang Tang BelamcandaEphedra Decoction. • To stimulate the descending of Lung-Qi (for PhlegmHeat in the Lungs): Ding Chuan Tang Stopping Breathlessness Decoction. • To rectify Qi (for Phlegm and Qi deficiency): Su Zi Jiang Qi Tang Perilla Seed Lowering Qi Decoction. • To benefit Qi (for chronic stage with deficiency of Lungs and Spleen): Yu Ping Feng San Jade Screen Powder. • To stimulate the reception of Qi (for deficient Kidneys not holding Qi): You Gui Wan Restoring the Right [Kidney] Pill plus Shen Ge San Ginseng-Gecko Powder.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 24, No. 5, 1983, p. 33. Huo Guo Shang, “The effect of tonifying the Kidneys in asthma on serum levels of IgE and T cells.” Dr Hu Guo Shang conducted a study to test the effect of tonifying the Kidneys on serum levels of IgE and T-cells in patients suffering from allergic asthma. Interestingly, rather than testing Chinese medicine against Western medicine or a placebo, the study tested the effect of herbs that tonify the Kidneys against the formula Xiao Qing Long Tang Small Green Dragon Decoction, which eliminates Cold Phlegm from the Lungs. In the treatment group (taking Kidney tonics), there were 60 patients, 38 men and 22 women, with the median age of 32 and the average duration of the

Allergic asthma (atopic eczema)

disease was 22 years. In the control group (taking Xiao Qing Long Tang), there were 36 patients, 21 men and 15 women, with the median age of 29 and the average duration of the disease was 26 years. The Kidney-tonic prescription tonified Kidney-Yang and included the following herbs. • • • • • • •

Fu Zi Radix Aconiti lateralis preparata Sheng Di Huang Radix Rehmanniae Shu Di Huang Radix Rehmanniae preparata Shan Yao Rhizoma Dioscoreae Xian Ling Pi Herba Epimidii Bu Gu Zhi Fructus Psoraleae Tu Si Zi Semen Cuscutae

The control group took Xiao Qing Long Tang. After 1 year of therapy, the effective rate in the group taking Kidney tonics was 75%, while that in the control group was 19.5%. The levels of IgE in serum in the treatment group decreased from 97.74 to 94.99, while those in the control group increased from 115.15 to 147.43. The study also found that tonifying the Kidneys will not treat the Manifestation (Biao) in asthma, but the treatment works best if administered in the summer to prevent attacks in winter. This article is particularly interesting in light of my theory of allergic asthma, as it confirms that the high levels of IgE in atopic individuals are connected to a Kidney deficiency and that tonifying the Kidneys will induce a decrease in the levels of IgE (and therefore treat the underlying cause of atopy). In view of my theory, it is also significant that tonification of the Kidneys was compared with resolving Phlegm (with Xiao Qing Long Tang) and that this treatment method produced worse results.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 3, No. 5, 1983, p. 7. Ding Yi Dan, “Preliminary research on effect of relieving asthma by needling BL-13, BL-12 and Du-14.” Dr Ding Yi Dan treated 124 patients suffering from asthma with acupuncture on the points BL-13 Feishu, BL-12 Fengmen and Du-14 Dazhui. The results were compared with those of a control group who had no treatment. The FEV, forced vital capacity and PEFR were monitored before and after treatment, and the results

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in the control group showed that the lung function is improved by acupuncture (P < 0.001). Interestingly, the study also compared the effect of acupuncture with moxibustion to that of acupuncture with cupping, and the results showed that the former method gives better results. The points used were BL-13 Feishu, BL-12 Fengmen and Du-14 Dazhui, the first two needled at a depth of 0.8 fen and the third at a depth of 1.3 cun; the needles were retained for 20 minutes.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 2, No. 5, 1982, p. 13. Li Zhi Ming, “Observations on the treatment of 182 cases of asthma with scarring moxibustion.” Dr Li Zhi Ming treated 182 asthmatic patients with scarring moxibustion. This article is reported here even though it is unlikely that we could use such a method on Western patients. However, ordinary moxibustion would also have an effect. The points used were selected according to the organ involved as follows. • Lungs: Du-14 Dazhui 5–7 cones, BL-13 Feishu 5–7 cones, Ren-17 Shanzhong 3–5 cones. • Spleen: Du-14 Dazhui 5–7 cones, BL-13 Feishu 5–7 cones, BL-43 Gaohuangshu 5–7 cones, Ren12 Zhongwan 7–9 cones. • Kidneys: Du-14 Dazhui 5–7 cones, BL-13 Feishu 5–7 cones, BL-43 Gaohuangshu 5–7 cones, Ren-6 Qihai 5–9 cones, BL-23 Shenshu 5–9 cones. Dr Li reports that 12.1% of patients were cured, 8.2% reported a clear improvement, 56.6% an improvement, and 23.1% no improvement.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 20, No. 3, 2000, p. 155. Chen Ming, “Preliminary study on the relationship between acupuncture in different solar terms and changes in pulmonary function in asthma.” Dr Chen Ming treated 43 patients with asthma by giving them acupuncture during specific solar terms

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and compared the results to those in 24 patients who were not treated according to solar terms. The solar terms are 24 periods of 2 weeks each in a year, beginning from the first day of the Chinese New Year (which would fall on a different date of the Western calendar each year). The solar terms during which the treatment was administered were as follows. • • • •

Spring equinox (4th solar term) Summer solstice (10th solar term) Autumn equinox (16th solar term) Winter solstice (22nd solar term)

The points used were Du-14 Dazhui and BL-13 Feishu with moxibustion on ginger juice. A small plaster with Chinese herbs was also applied on the points during the solar term. The herbs were Bai Jie Zi Semen Sinapis albae, Gan Sui Radix Euphorbiae Kansui, Xi Xin Herba Asari and Yan Hu Suo Rhizoma Corydalis. The FEV was measured in each patient in each group, and the patients treated according to the solar terms registered a greater improvement than those who did not.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 30, No. 5, 1989, pp. 35–36. Zhu Sheng Chao, “Clinical observation on the prevention of cough and breathlessness in children with massage in the summer.” Dr Zhu recommends a massage treatment for children suffering from asthma to be given in summertime. This treatment consists of three massage techniqes: 1. massaging the ring finger from the base towards the tip 100 times 2. kneading LU-5 Chize 50 times 3. kneading LU-10 Yuji 100 times.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 20, No. 2, 2000, p. 75. Wu Jian Ming, “Research on the treatment of 260 cases of allergic asthma with moxibustion.” Dr Wu treated 260 patients with allergic asthma, 148 men and 112 women, with ages ranging from 6 to 75. The shortest duration of the disease was 6 months and the longest 60 years. The patients were divided into two groups of two patterns, one with manifestations of Cold, the other with manifestations of Heat. The treatment consisted of the application of indirect moxibustion to the points Du-14 Dazhui, BL-13 Feishu, BL-17 Geshu, BL-23 Shenshu, Ren-22 Tiantu, Ren-17 Shanzhong, and KI-1 Yongquan. Treatment was given in the summer with one application of moxibustion every 10 days, three times constituting a course. Moxibustion was applied with moxa cones after placing a herbal poultice on the acupuncture points. The herbal prescription for external application with moxibustion included Yan Hu Suo Rhizoma Corydalis, Xi Xin Herba Asari, Gan Sui Radix Euphorbiae Kansui, Bai Jie Zi Semen Sinapis albae and Fang Feng Radix Saposhnikoviae. The results were differentiated according to the Cold and Heat group as shown in the table. Predictably, the results were better in the Cold group.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 20, No. 2, 2000, p. 109. Zhang Zhi Guo et al., “Experience on the treatment of asthma with plum-blossom tapping and cupping in Algeria.” Dr Zhang and others treated 125 cases of asthma with an interesting combination of treatment. They used

Pattern

No. of patients

Cure

Good

Results Satisfactory

None

Cure rate (%)

Cold

144

28 (19.5%)

56 (38.9%)

46 (31.9%)

14 (9.7%)

90.3%

Heat

60

5 (8.3%)

12 (20%)

30 (50%)

13 (21.7%)

78.3%

Not determined

56

11 (19.7%)

18 (32.1%)

18 (32.1%)

9 (16.1%)

83.9%

Allergic asthma (atopic eczema)

plum-blossom tapping on points on the chest and cupping on points of the upper back. The area that was tapped with the plum-blossom hammer was from Ren-22 Tiantu to Ren-15 Jiuwei, along the Directing Vessel (Ren Mai). The area of the back that was cupped was along the Governing Vessel (Du Mai) from Du-14 Dazhui to Du-8 Jinsuo.

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IL-8 rose significantly. Additionally the in vitro lymphocyte proliferation rate increased significantly and the eosinophils decreased from 4.4% to 3.3% after acupuncture. In the control group, these variables showed no significant changes apart from an increase in CD4+ cells.

Conclusion

Acupuncture

The results imply that asthma patients benefit from acupuncture treatment given in addition to conventional therapy. Furthermore, acupuncture performed in accordance with the principles of TCM showed significant immunomodulatory effects.

Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study

Effect of acupuncture or acupressure on quality of life of patients with chronic obstructive asthma: a pilot study

Journal of Alternative and Complementary Medicine 2000 December, Vol. 6, Issue 6, pp. 519–525. Joos S, Schott C, Zou H, Daniel V, Martin E, Brinkhaus B Department of Anaesthetics, University of Heidelberg, Germany

Journal of Alternative and Complementary Medicine 2003 October, Vol. 9, Issue 5, pp. 659–670. Maa SH, Sun MF, Hsu KH, Hung TJ, Chen HC, Yu CT, Wang CH, Lin HC School of Nursing, Chang Gung University, Tao-Yuan, Taiwan

CLINICAL TRIALS

Objective To investigate the immunological effects of Chinese acupuncture in a randomized controlled study of patients with allergic asthma.

Method The effects of acupuncture treatment given according to the rules of traditional Chinese medicine (TCM group, n = 20) were compared with those of acupuncture treatment using points not specific for asthma (control group, n = 18). All patients were treated 12 times for 30 minutes over 4 weeks. Besides the documentation of the patients’ general well-being, several immunological parameters (eosinophils, lymphocyte subpopulations, cytokines, in vitro lymphocyte proliferation) were determined in the peripheral blood before and after acupuncture treatment.

Results In the TCM group, significantly more patients indicated an improvement in general well-being (79% in the TCM group versus 47% in the control group) after acupuncture treatment. Moreover, in the TCM group the CD3+ and CD4+ cells increased significantly after acupuncture. There were also significant changes in cytokine concentrations: IL-6 and IL-10 fell, whereas

Objective To determine the contribution of acupuncture or acupressure to the improvement of quality of life of adults with chronic obstructive asthma.

Method This randomized study involved 8 weeks of treatment at Chang Gung Memorial Hospital (Tao-Yuan, Taiwan) and was conducted between March 1997 and September 1998. Forty-one patients with chronic obstructive asthma were enrolled. Patients were randomly assigned to receive acupuncture in addition to standard care (n = 11), acupressure and standard care (n = 17) or standard care alone (n = 13). Twenty acupuncture treatments were administered, and self-administered acupressure was performed daily for 8 weeks. Sixminute walking, the Dyspnea Visual Analogue Scale, the modified Borg scale, St George’s Respiratory Questionnaire (SGRQ) and the Bronchitis Emphysema Symptom Checklist (BESC) were used at the beginning and end of the 8 weeks of treatment.

Results The total SGRQ score of acupuncture subjects showed an average 18.5-fold improvement; the improvement for

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the acupressure subjects was 6.57-fold. Additionally, for patients who received acupressure, the irritability domain score determined by the BESC exhibited an 11.8-fold improvement after adjustment for covariables. The other variables did not differ from those of the controls.

Conclusion Patients with clinically stable, chronic obstructive asthma experienced clinically significant improvements in quality of life when their standard care was supplemented with acupuncture or acupressure.

Herbal medicine Effect of Yi Qi Bu Shen Huo Xue (benefiting Qi, tonifying the Kidneys and invigorating Blood) herbs in treating childhood asthma and on levels of nitric oxide, endothelin-1 and serum endothelial cells Chinese Journal of Integrated Traditional and Western Medicine 2001 September, Vol. 21, Issue 9, pp. 667–669. Kong LF, Guo LH, Zheng XY

Objective To observe the therapeutic effect of Yi Qi Bu Shen Huo Xue herbs (YQBSHX, the Chinese herbs for supplementing Qi, tonifying Kidney and activating blood circulation) on childhood asthma, looking particularly at its effect on the serum levels of nitric oxide (NO), endothelin-1 (ET-1) and circulating endothelial cells (CEC).

Method Two hundred children with asthma were divided into two groups, the YQBSHX and the control group, and their serum levels of NO, ET-1 and CEC were detected in acute and remission stage, respectively. Twenty patients in each group were followed up for 1 year to observe the frequency of asthma attack and the changes in ET-1, NO and CEC levels.

Results Serum levels of ET-1, NO and CEC in patients of acute stage were obviously raised. After treatment, the above-mentioned criteria in the YQBSHX group were significantly lower than those in the control group. The

frequency of attack in the YQBSHX group was markedly reduced.

Conclusion The YQBSHX herbs could reduce ET-1, NO and CEC levels in children with asthma, lessen the frequency of attack, and therefore elevate the cure rate of childhood asthma.

Evaluation of efficacy of traditional Chinese medicines in the treatment of childhood bronchial asthma: clinical trial, immunological tests and animal study Paediatric Allergy and Immunology 1996, Vol. 7, Issue 3, pp. 130–140. Hsieh KH, Chuang CY, Cheng CH, Hsiao WC, Chou CC, Su KC, Wang JY, Yang CH, Liu WJ, Wang JS, Chou CT, Kao ST, Lue KH, Shen JJ, Tsay JJ, Huang MT, Tang RB, Chang BT, Lan JL, Chang CK, Lin JG, Shih TY

Objective To evaluate the efficacy of traditional Chinese medicines in the treatment of childhood bronchial asthma.

Method A multicentre, double-blind and placebo-controlled study was conducted to evaluate the clinical efficacy in terms of symptom score, medication score, morning and evening PEFRs, and changes of immunoregulatory function, such as distribution of lymphocyte subsets and in vivo and in vitro production of lymphokines (interferon-g and interleukin-4) and inflammatory mediators (histamine, prostaglandin E2 [PGE2] and leukotriene C4 [LTC4]). Furthermore, the protective effect of traditional Chinese medicine on the late asthmatic reaction was evaluated by using asthmatic guinea pigs. Three hundred and three asthmatic children were classified by Chinese doctors, according to a standardized questionnaire designed on the basis of basic logic of Chinese medicine, into three groups of specific constitution (groups A, B and C). Group A consisted of 32 herb A-treated patients and 34 placebotreated; group B, 74 herb B-treated and 64 placebotreated; and group C, 55 herb C-treated and 44 placebo-treated. The study period was 6 months.

Results • Both the treatment group and the placebo group showed an improvement in all clinical parameters,

Allergic asthma (atopic eczema)

• • •



thus demonstrating a placebo effect. However, the improvement was usually greater in the former than the latter, although only the difference in PEFR was significant. Herb A could increase total T-cells and decrease B cells. Herbs A and B enhanced production of PGE2 but not LTC4, interferon-g and interleukin-4. There was a general tendency for in vivo and in vitro production of histamine to decrease at the end of the study in both the treatment group and the placebo group; however, the decrease was significantly greater in the former than in the latter. In asthmatic guinea pigs, 10 days’ pretreatment with Chinese herbs could reverse the decrease of sGaw, suppress eosinophilia in bronchoalveolar lavage fluid, prevent the eosinophil infiltration of airways, increase PGE2 production and decrease LTC4 production in serum and bronchoalveolar lavage fluid. The decreased production of histamine and LTC4 and the increased production of PGE2 that were found in both asthmatic children and asthmatic guinea pigs, as well as the prevention of occurrence of late asthmatic reaction by suppressing eosinophil infiltration of airways and preserving airway conductance that was observed in asthmatic guinea pigs after allergen challenge, might be used to account partly for the effectiveness.

Conclusion Thus, traditional Chinese medicines did show a certain degree of clinical efficacy.

The potential use of Chinese herbal medicines in treating allergic asthma Annals of Allergy, Asthma and Immunology 2004 August, Vol. 93, Issue 2, Suppl. 1, pp. 35–44. Li XM, Zhang TF, Sampson H, Zou ZM, Beyer K, Wen MC, Schofield B Department of Paediatrics, Mount Sinai School of Medicine, New York, USA

Objective To discuss the potential use of the Chinese herbal formula MSSM-002 in treating asthma based on its effects on a murine model of allergic asthma, immunoregulatory actions on TH2 cells in vitro and the means of standardization for herbal formula quality control.

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Data sources Information presented at the 2002 American College of Allergy, Asthma and Immunology (ACAAI) Annual Scientific Meeting International Symposium on Complementary Alternative Medicine in San Antonio, Texas.

Study selection All presentations from the ACAAI meeting that discussed MSSM-002 were considered for this review.

Results The Chinese herbal formula MSSM-002 suppressed airway hyper-reactivity and eosinophilic inflammation in a murine model of allergic asthma. These effects were comparable with dexamethasone but were not accompanied by the suppression of TH1 responses seen with dexamethasone. In vitro studies demonstrated that MSSM-002 significantly decreased antigen-induced TH2 cytokine secretion by murine TH2-polarized splenocytes and human mucosal TH2 cell lines, which in contrast to dexamethasone did not cause apoptosis and was not cytotoxic but was associated with decreased GATA-3 expression. Chromatographic fingerprints of MSSM-002 and evaluation of in vivo actions showed that the quality of several batches of MSSM-002 was consistent.

Conclusion MSSM-002 has a therapeutic effect on allergic asthma and immunoregulatory actions on established TH2 cells and may prove to be of potential clinical benefit to asthma patients.

Experimental study on prevention and treatment of bronchial asthma by compound Chinese herbal monomer recipe Zhong Guo Zhong Xi Yi Jie He Za Zhi [Chinese Journal of Integrated Traditional and Western Medicine] 2004 August, Vol. 24, Issue 8, pp. 717–721. Dong JC, Ni J, Gong ZH Institute of Pulmonary and Atopic Diseases by Integrative Chinese and Western Medicine, Huashan Hospital, Fudan University, Shanghai

Objective To observe the effect of compound Chinese herbal monomer (CHM) recipe, consisting of ligustrazin

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(3.75 mg/kg μ d), baicalin (7.5 mg/kg μ d) and ginkgolide (2 mg/kg μ d), on airway atopic inflammation and hyper-responsiveness in asthma.

Method Model guinea pigs with asthma were randomly divided into three groups: the model group, the CHM group and the cromolyn sodium (CS) group. They were treated by atomizing inhalation with normal saline, CHM and CS, respectively. The eosinophil count and eosinophil cation protein in blood and bronchial alveolar lavage fluid (BALF) and the total cell count in BALF were measured and compared. The effect of treatment on the airway hyper-responsiveness and pathology among groups was also compared.

Results The CHM showed significant inhibition of blood eosinophil count and BALF and total cell count in BALF, showing significant differences compared with those in the model group. The level of eosinophil cation protein was not different in the various groups. Airway responsiveness determination showed that CHM has significant inhibitory action on it. And the pathology of airway inflammation in the CHM group was significantly milder than that in the model group.

Conclusion The compound inhalation liquid consisting of ligustrazin, baicalin and ginkgolide affects the antiasthmatic airway atopic inflammation and decreases the airway hyper-responsiveness, suggesting that components of compound CHM recipe could inhibit the multiple pathogenetic asthmatic inflammation from different angles and on multiple targets so as to cure asthma effectively.

CASE HISTORIES Case history A 35-year-old woman had been suffering from eczema since she was 3 months old. Over the years, she used all sorts of steroid creams. She had three children and, during each of her gestations, her eczema was always worse in the

first 3 months of pregnancy, better in the last 6 months and worse after childbirth. It was mostly on the limbs and face (around her mouth). It consisted of papules (red spots) that were very itchy. They then turned into pustules and oozed a liquid. She had also been suffering from asthma since the age of 3 after pneumonia. Her wheezing attacks were triggered by dust, house dust mites, animals’ fur, dairy products and shellfish. She also suffered from hay fever (seasonal allergic rhinitis). She occasionally had mild tinnitus. Her pulse was unremarkable, only slightly Weak on the right Front and the left Rear positions. Her tongue was also unremarkable, with slightly Swollen sides (Plate 5.1). This is a good example of how the tongue is often unremarkable in patients with atopic asthma, seemingly confirming that Wind and not Phlegm is the main pathological feature of asthma. Diagnosis Asthma, seasonal allergic rhinitis and eczema from Lung and Kidney’s Defensive-Qi systems deficiency from birth. Kidney-Essence affecting the Lung-Corporeal Soul that, in turn, affected the skin. The Kidney deficiency is also clearly shown by the aggravation during the first 3 months of pregnancy, amelioration in the last 6 months and again aggravation after childbirth. The relatively normal pulse and tongue show that the Kidney deficiency involves only the Kidney Defensive-Qi system and not other aspects of the Kidney functions. The eczema is of the chronic Damp Heat type. The eliciting of asthma attacks from certain foods points to Large Intestine-Heat. Treatment principle Her main problem at the time of consultation was the eczema rather than the asthma, the attacks of which were quite infrequent. The principle of treatment adopted was therefore to clear Wind in the skin, resolve Damp Heat, cool Blood, tonify the Lung and Kidney’s Defensive-Qi systems and stimulate the descending of Lung-Qi. Herbal therapy Prescription The prescriptions chosen were those for chronic Damp Heat, with some variations to tonify the Kidney’s Defensive-Qi system. The formula was a variation of

Allergic asthma (atopic eczema)

San Feng Chu Shi Tang Scattering Wind and Eliminating Dampness Decoction and Chu Shi Wei Ling Tang Eliminating Dampness Stomach “Ling” Decoction, with the addition of herbs to tonify the Lung and Kidney’s Defensive-Qi systems and to stimulate the descending of Lung-Qi. • • • • • • • • • • • • • • • • • •

Huang Bo Cortex Phellodendri 4 g Cang Zhu Rhizoma Atractylodis 4 g Fang Feng Radix Saposhnikoviae 4 g Bai Xian Pi Cortex Dictamni 6 g She Chuang Zi Semen Cnidii 4 g Zhu Ling Polyporus 4 g Fu Ling Poria 6 g Yi Yi Ren Semen Coicis 9 g Chen Pi Pericarpium Citri reticulatae 3 g Ze Xie Rhizoma Alismatis 4 g Shou Wu Radix Polygoni multiflori preparata 9 g Sheng Di Huang Radix Rehmanniae 9 g Tu Si Zi Semen Cuscutae 6 g Bu Gu Zhi Fructus Psoraleae 4 g Mai Men Dong Radix Ophiopogonis 6 g Bai He Bulbus Lilii 6 g Sang Bai Pi Cortex Mori 4 g Gan Cao Radix Glycyrrhizae uralensis 3 g

Explanation • Huang Bo and Cang Zhu resolve Damp Heat. • Fang Feng resolves Dampness and expels Wind. • Bai Xian Pi and She Chuang Zi expel Wind and resolve Dampness and Toxic Heat. They are both very important herbs for skin diseases. • Zhu Ling, Fu Ling, Yi Yi Ren, Chen Pi and Ze Xie drain Dampness via urination. • Shou Wu and Sheng Di nourish and cool Blood. • Tu Si Zi and Bu Gu Zhi tonify the Kidney’s DefensiveQi system. • Mai Dong and Bai He tonify the Lung’s DefensiveQi system and will also help to regenerate new skin. • Sang Bai Pi restores the descending of Lung-Qi and also helps the skin. • Gan Cao harmonizes. Acupuncture Points LU-7 Lieque and KI-6 Zhaohai, KI-16 Huangshu, KI-3 Taixi, BL-23 Shenshu, L.I.-11 Quchi, SP-10 Xuehai, SP-9 Yinlingquan, BL-13 Feishu, DU-12 Shenzhu.

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Explanation • LU-7 and KI-6 tonify Lung and Kidneys, benefit the Essence and the Corporeal Soul, nourish the skin and stimulate the descending of Lung-Qi. • KI-16, KI-3 and BL-23 tonify the Kidney’s DefensiveQi system. In particular, KI-16 also benefits the Essence and therefore acts at a deep level to correct the inborn deficiency of the Kidney’s Defensive-Qi system. In a way, it is the acupuncture equivalent of the herbal use of placenta and umbilical cord for asthma. • L.I.-11 and SP-10 cool Blood and clear Heat from the skin. • SP-9 resolves Damp Heat. • BL-13 and Du-12 tonify the Lung’s Defensive-Qi system. After 9 months’ treatment, mostly with herbal medicine and infrequent sessions of acupuncture treatment, this woman’s eczema cleared up almost completely.

Case history A 19-year-old woman had been suffering from eczema and asthma since the age of 2. At the time of consultation, both the eczema and asthma were still very bad. She had to use Ventolin and Becotide every day for her asthma and had used steroid creams in the past for her eczema. Her asthma attacks were elicited by exposure to cats and house dust mites. She also sweated at night, and her bowels opened only every other day. Apart from this, she had no other symptoms. She was very thin and shy. Her skin was very dry, red and itchy. The pulse and tongue were unremarkable, as they often are in atopic asthma. Diagnosis This is a very typical case of atopic asthma and eczema from deficiency of the Lung and Kidney’s Defensive-Qi systems in a highly allergic individual. There is some Lung-Yin deficiency as shown by the night sweating and constipation. Treatment principle Tonify the Lung and Kidney’s Defensive-Qi systems, nourish Lung-Yin, nourish Blood, moisten the skin, clear Wind from the skin and expel Wind from the chest. She had only herbal therapy and the formula used initially was as follows.

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The Practice of Chinese Medicine

Mai Men Dong Radix Ophiopogonis 6 g Bai He Bulbus Lilii 6 g Su Zi Fructus Perillae 4 g Xing Ren Semen Armeniacae 4 g Fang Feng Radix Saposhnikoviae 4 g Tu Si Zi Semen Cuscutae 6 g Du Zhong Cortex Eucommiae ulmoidis 4 g Nu Zhen Zi Fructus Ligustri lucidi 4 g Shou Wu Radix Polygoni multiflori preparata 9g Dang Gui Radix Angelicae sinensis 6 g Bai Xian Pi Cortex Dictamni 6 g Chan Tui Periostracum Cicadae 4 g Nan Sha Shen Radix Adenophorae 4 g Huo Ma Ren Semen Cannabis 4 g Hei Zhi Ma Semen Sesami negrum 6 g Hong Hua Flos Carthami tinctorii 3 g Gan Cao Radix Glycyrrhizae uralensis 3 g

Explanation • Mai Dong and Bai He nourish Lung-Yin and tonify the Lung’s Defensive-Qi system. • Su Zi and Xing Ren restore the descending of LungYin. • Fang Feng expels Wind from the chest. • Tu Si Zi and Du Zhong tonify the Kidney’s DefensiveQi system. • Nu Zhen Zi, Shou Wu and Dang Gui nourish Blood and the skin. • Bai Xian Pi and Chan Tui clear Wind-Heat from the skin. • Nan Sha Shen, Huo Ma Ren and Hei Zhi Ma moisten the skin and promote the bowel movements. • Hong Hua moves Blood and, being a light petal, has a floating movement and therefore carries the other herbs towards the surface, i.e. the skin. • Gan Cao harmonizes and detoxifies. This patient is still being treated and the eczema and asthma are gradually improving.

Case history A 23-year old woman had been suffering from asthma since she was 4 years old. She used Ventolin and Becotide. Her asthma attacks were elicited by exposure to dogs, cats and house dust mites. She also suffered mildly from eczema only when exposed to inhaled or ingested allergens. She usually felt tired, her lower back ached and her

bowels opened only every 2 or 3 days. Her sleep was not good, with her waking up frequently during the night. Her periods lasted 7–8 days and she suffered from premenstrual tension. Her pulse was slightly Weak in the left Rear position and slightly Wiry in the left Middle position. Her tongue was Red on the sides and tip. Diagnosis This is again a clear case of Lung and Kidney’s Defensive-Qi systems being deficient from birth. There are, however, other factors, notably some Liver-Yang rising (red sides of the tongue and premenstrual tension) and some Kidney-Yin deficiency (constipation, backache and insomnia). Treatment principle The principle of treatment was to tonify the Lung and Kidney’s Defensive-Qi systems, nourish Kidney-Yin, restore the descending of LungQi, expel Wind and subdue Liver-Yang. Herbal therapy Prescription The formula used was a variation of Bai He Gu Jin Tang Lilium Consolidating Metal Decoction. • • • • • • • • • • • • • •

Bai He Bulbus Lilii 15 g Mai Men Dong Radix Ophiopogonis 9 g Shu Di Huang Radix Rehmanniae preparata 9 g Dang Gui Radix Angelicae sinensis 6 g Bai Shao Radix Paeoniae alba 9 g Jie Geng Radix Platycodi 6 g Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g Fang Feng Radix Saposhnikoviae 4 g Tu Si Zi Semen Cuscutae 6 g Bu Gu Zhi Fructus Psoraleae 4 g Xing Ren Semen Armeniacae 3 g Su Zi Fructus Perillae 4 g Suan Zao Ren Semen Ziziphi spinosae 4 g Gan Cao Radix Glycyrrhizae uralensis 3 g

Explanation • Bai He and Mai Dong nourish Lung-Yin and tonify the Lung’s Defensive-Qi system. • Shu Di tonifies the Kidney’s function of grasping Qi. • Dang Gui, Bai Shao and Suan Zao Ren harmonize the Liver, subdue Liver-Yang and calm the Mind. • Jie Geng, Chuan Bei Mu, Xing Ren and Su Zi restore the descending of Lung-Qi and calm asthma. • Fang Feng expels Wind.

Allergic asthma (atopic eczema)

• Tu Si Zi and Bu Gu Zhi tonify the Kidney’s DefensiveQi system. • Gan Cao harmonizes.

Case history A 30-year-old woman had been suffering from eczema and asthma since birth. She used Ventolin and Becloforte inhalers every day and also took Phyllocontin tablets. As a baby, she was given steroids for the asthma, but these made the eczema worse. She used cortisone creams for her eczema from the age of 7. The eczema seemed to clear during her school years but returned with a vengeance at around 20. When she came for treatment, it was extremely bad. It covered practically the whole body and was worse on her face, chest and limbs. The skin was very red, very dry, thick, coarse and itchy. Although the skin was dry, the eczema lesions would also weep occasionally. She also suffered from seasonal allergic rhinitis (hay fever) and her mouth often felt dry. There were no other obvious symptoms and signs, and her urine and stools were normal. Her tongue was slightly Pale, Thin and dry. Her pulse was Weak, Choppy and both Rear positions (Kidneys) were particularly Weak. Diagnosis This is also a clear case of inborn deficiency of Lung and Kidney’s Defensive-Qi systems. The pulse confirms the Kidney weakness. Because of the long duration of the illness, there is also some Blood deficiency (as the Kidneys also contribute to making Blood) that, leading to the development of Wind-Heat in the skin, aggravates the eczema. The Blood deficiency is clearly shown by the tongue being Pale, Thin and dry. The eczema is primarily of the Wind-Heat type, although there is some Damp Heat as well because it is sometimes weepy. Treatment principle Because the eczema was by far the most distressing problem at the time, attention was turned to treating it first. The aim of treatment was to tonify the Lung and Kidney’s Defensive-Qi systems, expel Wind from the chest, nourish Blood, clear Wind-Heat from the skin and restore the descending of Lung-Qi. The formula used was a variation of Yang Xue Ding Feng Tang Nourishing Blood and Clearing Wind Decoction.

• • • • • • • • • • • • • • • •

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Sheng Di Huang Radix Rehmanniae 12 g Dang Gui Radix Angelicae sinensis 9 g Shou Wu Radix Polygoni multiflori preparata 9 g Tian Men Dong Radix Asparagi 9 g Mai Men Dong Radix Ophiopogonis 6 g Chi Shao Radix Paeoniae rubra 6 g Mu Dan Pi Cortex Moutan 4 g Shan Zhi Zi Fructus Gardeniae 4 g Chan Tui Periostracum Cicadae 6 g Jing Jie Herba Schizonepetae 4 g Fang Feng Radix Saposhnikoviae 4 g Tu Si Zi Semen Cuscutae 6 g Bu Gu Zhi Fructus Psoraleae 4 g Xing Ren Semen Armeniacae 4 g Su Zi Fructus Perillae 4 g Gan Cao Radix Glycyrrhizae uralensis 4 g

Explanation • Sheng Di Huang, Dang Gui and Shou Wu nourish Blood. Sheng Di also cools Blood. • Tian Dong and Mai Dong nourish Yin to help to nourish Blood and they moisten; Mai Dong also tonifies the Lungs. They also tonify the Lung’s Defensive-Qi system. • Chi Shao, Dan Pi and Zhi Zi clear Heat and cool Blood to help to clear Heat from the skin. • Chan Tui and Jing Jie clear Wind-Heat from the skin. • Fang Feng expels Wind from the chest. • Tu Si Zi and Bu Gu Zhi tonify the Kidney’s DefensiveQi system. • Xing Ren and Su Zi restore the descending of Lung-Qi. • Gan Cao harmonizes and detoxifies. This patient is slowly improving and the treatment is still in progress.

Case history A 28-year-old woman had been suffering from asthma since she was 7 years old. The attacks were worse at night and were elicited by exposure to cold, dogs, cats or horses. She had to resort to using a Ventolin inhaler every day. She also suffered from seasonal allergic rhinitis (hay fever). She generally felt cold and her hands and feet were cold. Her tongue was slightly Pale and her pulse was Slow and Weak, especially on the right Rear position.

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Diagnosis This is yet another case of deficiency of the Lung and Kidney’s Defensive-Qi system on a background of Kidney-Yang deficiency, as is very clear from the general cold feeling, the Pale tongue and the Weak pulse on the right Rear position. Treatment principle The principle of treatment was to tonify the Lung and Kidney’s Defensive-Qi systems, strengthen Kidney-Yang, expel Wind and restore the descending of Lung-Qi. The formula used was a variation of Su Zi Jiang Qi Tang Perilla Seed Lowering Qi Decoction. • • • • • • • • • • •

Su Zi Fructus Perillae 9 g Zi Su Ye Folium Perillae 5 leaves Ban Xia Rhizoma Pinelliae preparatum 9 g Hou Po Cortex Magnoliae officinalis 6 g Fang Feng Radix Saposhnikoviae 4 g Rou Gui Cortex Cinnamomi 3 g Dang Gui Radix Angelicae sinensis 6 g Tu Si Zi Semen Cuscutae 6 g Xu Duan Radix Dipsaci 4 g Sheng Jiang Rhizoma Zingiberis recens 2 slices Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6 g • Da Zao Fructus Jujubae 1 date Explanation • Su Zi and Su Ye restore the descending of Lung-Qi. • Ban Xia and Hou Po subdue rebellious Qi and relieve fullness in the chest. • Fang Feng expels Wind from the chest. • Rou Gui and Dang Gui tonify Kidney-Yang and the Liver to strengthen the Lower Burner. • Tu Si Zi and Xu Duan tonify the Kidney’s DefensiveQi system and strengthen Kidney-Yang. • Sheng Jiang, Gan Cao and Da Zao harmonize.

Case history A 40-year-old woman had been suffering from asthma since her early twenties. The attacks started following a deep emotional trauma. She used Ventolin and Becotide inhalers four times a day. At the time of consultation, she was also on corticorsteroids orally (prednisolone). She was not seemingly allergic to any substance, nor did she suffer from allergic rhinitis.

In addition to asthma, she also had a lot of catarrh with a profuse, sticky-yellow nasal discharge. She said that when under stress she became very tense and weak, her hands became cold and she felt unable to cope. She also complained of premenstrual tension and hypochondrial and abdominal distension. Her tongue was Red, redder on the sides and tip with a yellow coating. Her pulse was Wiry on the left side. Diagnosis This asthma is not allergic but of the lateonset type, and it is very clearly related to a Liver disharmony. Stagnation of Liver-Qi, over a long period of time, has turned into Liver-Fire, and this has obstructed the descending of Lung-Qi in the chest, giving rise to asthma. The presence of Liver-Fire is obvious from the Red tongue body with redder sides. The thick-yellow nasal discharge is a case of rhinorrhoea (Bi Yuan) from Liver- and Gall Bladder-Fire rising to the nose. Treatment principle Move Liver-Qi, clear Liver-Fire, restore the descending of Lung-Qi, calm the Mind and settle the Ethereal Soul. Herbal therapy Prescription This patient was treated only with herbs. The formula chosen was a variation of Si Ni San Four Rebellious Powder, which moves Liver-Qi, and Xie Bai San Draining Whiteness Powder, which clears Lung-Heat and restores the descending of Lung-Qi. Si Ni San was chosen because it was Liver-Qi stagnation that led to Liver-Fire. The method to be adopted therefore is not to drain Liver-Fire with bitter and cold herbs, but to clear Liver-Fire with pungent herbs that open Qi and bitter herbs that drain. A further reason for choosing Si Ni San was that the patient had cold hands when under emotional strain, one of the symptoms of this formula. The formula used was as follows. • • • • •

Chai Hu Radix Bupleuri 6 g Bai Shao Radix Paeoniae alba 9 g Gan Cao Radix Glycyrrhizae uralensis 4.5 g Zhi Shi Fructus Aurantii immaturus 6 g Hou Po Cortex Magnoliae officinalis 4.5 g

Allergic asthma (atopic eczema)

• • • • • • •

Shan Zhi Zi Fructus Gardeniae 4 g Sang Bai Pi Cortex Mori 6 g Di Gu Pi Cortex Lycii 4 g Su Zi Fructus Perillae 6 g Xing Ren Semen Armeniacae 6 g Suan Zao Ren Semen Ziziphi spinosae 4 g Yuan Zhi Radix Polygalae 4 g

Explanation • Chai Hu, Bai Shao, Gan Cao and Zhi Shi constitute the Si Ni San, which moves Liver-Qi and calms the Mind. • Hou Po, a pungent herb, was added to help to move Qi and open the chest. It will therefore help breathing and has also a good calming effect on the Mind. • Shan Zhi Zi, a bitter herb to clear, was added to clear Liver-Fire. • Sang Bai Pi and Di Gu Pi constitute the Xie Bai San, which clears Lung-Heat and restores the descending of Lung-Qi. • Su Zi and Xing Ren restore the descending of LungQi and relieve asthma. • Suan Zao Ren and Yuan Zhi calm the Mind and settle the Ethereal Soul. This patient was treated with this basic formula, with some variations along the way, and she reacted very well, reaching almost a complete cure after 9 months.

Case history A 33-year-old man had been suffering from asthma since he was 1. He got better during his teenage years but then worse again from 20 onwards. His asthma attacks were brought on by exposure to dust, house dust mites and cats. He had to resort to using a Ventolin inhaler every day. Apart from his asthma, he had hardly any other symptoms. He had to urinate at night. His tongue-body colour was nearly normal and only very slightly Pale, its body was Swollen, and there was a Stomach crack (Plate 5.2). His pulse was slightly Weak on the right side. Diagnosis This is another case of deficiency of the Lung and Kidney’s Defensive-Qi systems, especially of the Lung’s. In addition, there was a deficiency of the Stomach and Spleen, as evidenced by the Weak pulse

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on the right, the Stomach crack on the tongue and the Swollen tongue body. Treatment principle Tonify the Lung and Kidney’s Defensive-Qi systems and strengthen the Spleen. Herbal therapy Prescription This patient was treated only with herbs, and the formula used was a variation of Ren Shen Ge Jie San Ginseng-Gecko Powder. • Ge Jie Gecko 4 g (as a powder) • Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 4 g • Ren Shen Radix Ginseng 6 g • Fu Ling Poria 6 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g • Sang Bai Pi Cortex Mori 6 g • Xing Ren Semen Armeniacae 9 g • Huang Qi Radix Astragali 6 g • Mai Men Dong Radix Ophiopogonis 3 g Explanation This formula tonifies the Lung and Kidney’s DefensiveQi systems, strengthens the Spleen and restores the descending of Lung-Qi. • The first seven herbs constitute the original prescription. • Zhi Mu was eliminated from the original formula, as there are no signs of Heat. • Huang Qi and Mai Dong were added to tonify the Lung’s Defensive-Qi system further. This patient is still being treated, and he is gradually reducing the use of his inhaler.

Case history A 42-year-old woman had been suffering from allergic asthma since childhood. The asthma had got better during adolescence, but it had then got worse when she was about 32. At that time, the asthma started after an episode of influenza that then turned into bronchitis. She had three courses of antibiotics but was left with a cough productive of profuse sputum, wheezing, and breathlessness. She was prescribed inhalers of steroids (Pulmicort) and b2 agonists (Bricanyl).

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All these symptoms seem to point clearly to a late-onset, intrinsic, non-allergic type of asthma. However, there were other factors that pointed also to an early-onset, extrinsic, allergic type of asthma, i.e. the period of allergic asthma during childhood, the onset of asthma attacks on exposure to dust, high levels of IgE and the fact that she also suffered from allergic rhinitis. This case history is a clear example of a case of asthma that is a mixture of allergic and nonallergic; in her case, although the asthma was originally of the allergic type, she did also have Phlegm. Her pulse was Tight in general and Weak on the left Rear position; her tongue was slightly Pale and Bluish-Purple. Diagnosis This is a clear example of asthma that started as an early-onset, allergic one and became combined with a late-onset one. The main pathology was Phlegm in the Lungs (Swollen tongue, Slippery pulse and expectoration of mucus), a deficiency of the Lung and Kidneys’ Defensive-Qi systems with Wind and Phlegm in the Lungs. There was also a Spleen deficiency, which contributed to the formation of Phlegm. Treatment principle Treat the Root by tonifying the Lung and Kidneys’ Defensive-Qi systems and the Spleen, expel Wind from the bronchi, resolve Phlegm. She was treated only with acupuncture. Although she would have benefited from herbal treatment, she specifically declined it. Acupuncture Points The treatment was carried out over several years and is still ongoing. The acupuncture points were selected from the following: LU-7 Lieque and KI-6 Zhaohai (Directing Vessel’s opening points), Ren-4 Guanyuan, KI-13 Qixue, SP-6 Sanyinjiao, KI-7 Fuliu, BL-23 Shenshu, Ren-12 Zhongwan, BL-20 Pishu, BL-13 Feishu, LU-5 Chize and ST-40 Fenglong. Explanation • LU-7 and KI-6 open the Directing Vessel (Ren Mai), which tonifies Lungs and Kidneys. • Ren-4, KI-13, SP-6, KI-7 and BL-23 tonify the Kidneys. • Ren-12 and BL-20 tonify the Spleen.

• BL-13 tonifies the Lungs. • LU-5 and ST-40 restore the descending of Lung-Qi, open the chest and resolve Phlegm from the Lungs.

Case history A 65-year-old man had been suffering from asthma since early childhood after a bout of bronchitis. The asthma improved when he became 17. There was no allergy, no familial incidence, no eczema and no allergic rhinitis. Three years before his consultation with me, he had a cold that went to the chest and caused bronchitis. He was treated with antibiotics. After that, his asthma worsened considerably and he was put on a steroid inhaler and a bronchodilator inhaler. He suffered from wheezing, breathlessness and cough with expectoration of mucus. His blood pressure was raised, for which he took a diuretic. His pulse was Full, Slippery and Wiry. His tongue was Red, Swollen and without a coating. Diagnosis This is a clear example of asthma that had an early onset but was not allergic. The main pathology was Phlegm in the Lungs (Swollen tongue, Slippery pulse, expectoration of mucus) and deficiency of Lung- and Kidney-Yin (tongue without coating) with Empty Heat (Red tongue). Treatment principle Resolve Phlegm, nourish Lungand Kidney-Yin, restore the descending of Lung-Qi. Herbal therapy Prescription This patient was treated only with herbs, and the formula used was a variation of Wen Dan Tang Warming the Gall Bladder Decoction. • • • • • • • • • •

Zhu Ru Caulis Bambusae in Taeniam Ban Xia Rhizoma Pinelliae preparatum Chen Pi Pericarpium Citri reticulatae Fu Ling Poria Zhi Shi Fructus Aurantii immaturus Su Zi Fructus Perillae Sang Bai Pi Cortex Mori Xing Ren Semen Armeniacae Kuan Dong Hua Flos Farfarae Mai Men Dong Radix Ophiopogonis

Allergic asthma (atopic eczema)

• Xi Yang Shen Radix Panacis quinquefolii • Huang Qin Radix Scutellariae This patient’s symptoms improved remarkably after only 3 weeks of therapy. His breathing was much easier and he was able to reduce the use of his medication. He is still under treatment at the time of writing and improving steadily.

PATIENTS’ STATISTICS These statistics are based on a population of 93 patients from my practice. The age distribution was as follows. • • • • • • • • •

0–10: 10 (11%) 11–20: 11 (12%) 21–30: 17 (18%) 31–40: 23 (25%) 41–50: 18 (19%) 51–60: 7 (8%) 61–70: 3 (3%) 71–80: 3 (3%) 81–90: 1 (1%)

There were 41 male and 52 female patients. Please note that, although at first sight this would seem to show that more women than men suffer from asthma, this is not so. In fact, the total percentage of women in my practice is 67% against 34% of men. As in the above statistics 55% are women, this is below the average of 67%. This would therefore indicate that more men than women suffer from asthma. Of course, this is a statistic from my practice reflecting conditions in the UK and the situation might well be different in other countries. Of the 93 patients with asthma, a third (31) also had eczema, which shows the strong association between allergic asthma and eczema. As readers will know from reading this chapter, I relate allergic asthma to a deficiency of the Lung and Kidney’s Defensive-Qi systems. In this statistic, 62% of patients had such a deficiency, which indicates that 62% of asthma patients suffer from early-onset, allergic asthma. I relate the pathology of late-onset, non-allergic asthma to Phlegm, as the traditional theory of asthma (Xiao-Chuan) does. Thirty-nine per cent of patients had Phlegm, which means that about that percentage of patients suffered from late-onset, non-allergic asthma. I say “about”. because some middle-aged or elderly patients with allergic asthma may also develop Phlegm.

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The percentage of patients with Phlegm (39%) correlated almost exactly with that of patients with a Slippery pulse (30%). The pulse qualities by quality were as follows. • • • • • • • •

Wiry: 14 (16%) Slippery: 26 (30%) Tight: 8 (9%) Empty: 12 (14%) Weak: 46 (52%) Deep: 14 (16%) Slow: 4 (5%) Rapid: 4 (5%)

If we consider the Empty and Weak pulses together, the percentage of patients with a weak-type of pulse (66%) correlates almost exactly with the percentage of patients suffering from a deficiency of the Lung and Kidney’s Defensive-Qi systems (62%).

PROGNOSIS AND PREVENTION The treatment of allergic asthma will necessarily take a long time, because the disease is always based, as we have seen, on an inborn deficiency of Lung and Kidney’s Defensive-Qi systems. In most cases, the treatment may need many months if not years to produce lasting results. Both acupuncture and Chinese herbs are equally effective in combination or independently. If children can be treated fairly early after the development of the disease, the course of treatment will be much shorter. If the patient is on bronchodilator inhalers (such as Ventolin), it is not necessary to make a conscious effort to stop them, as the need to use them will automatically decrease as the treatment progresses. As for oral steroids, it is much better if the patient can reduce them very gradually as soon as possible, as they have many side effects, the main one being that of inducing a deficiency of the Kidneys in the long run. As allergic asthma is based on a deficiency of the Kidney’s Defensive-Qi system, oral steroids, although affording relief in the short run, can only make it worse in the long run. If asthma is accompanied by eczema and the patient is using steroid creams, these should be stopped. This means, and the patient should be warned, that the eczema may temporarily become worse. This aggravation can and should be counteracted, however, by the use of herbs externally as described above. To do

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this is important to gain the patient’s confidence in the treatment. After successfully treating a patient with asthma, it is important to take preventive measures to avoid its recurrence. Adults should be advised to have enough rest and avoid excessive sexual activity. Children (or rather their parents) should be advised to avoid eating excessive amounts of dairy foods, sweets and greasy-fried foods. They should also take great care to avoid exposure to cold and wind without proper clothing. Both adults and children should be treated immediately at the first signs of invasion of external Wind, because this may easily precipitate an attack of asthma in susceptible individuals. If there is eczema, they should never eat shellfish such as shrimps, prawns, crab and lobster. They should also avoid eating spinach and mushrooms, dairy products, fried-greasy foods, spicy foods and alcohol.

Herbal therapy Certain herbal formulae may also be given, especially during the early autumn. “Autumn” is meant here as autumn according to the Chinese calendar in which equinoxes and solstices mark not the beginning but roughly the middle of each season. Thus early autumn would be towards the end of August. The following are some of the formulae used.

Prescription • • • • • • •

Ren Shen Radix Ginseng 60 g Ge Jie Gecko 2 geckos Ma Huang Herba Ephedrae 30 g Xing Ren Semen Armeniacae 100 g Gan Cao Radix Glycyrrhizae uralensis 50 g Sheng Jiang Rhizoma Zingiberis recens 60 g Hong Zao Fructus Jujubae 120 g

These are the proportions to make roughly 500 g of powder. Grind the above ingredients very finely in a coffee grinder and give one teaspoonful a day to be swallowed with hot water after a meal. Alternatively, and even better, one can buy the concentrated powders of the above herbs (in equal parts), mix them together, and take one teaspoonful a day dissolved in hot water.

Prescription (for external use) • Bai Jie Zi Semen Sinapsis albae 12 g

• • • •

Yan Hu Suo Rhizoma Corydalis 12 g Xi Xin Herba Asari 21 g Gan Sui Radix Euphorbiae Kansui 12 g She Xiang Moschus 0.15 g

Grind the above herbs into a fine powder, mix with fresh ginger juice, shape into small cones and apply with plaster on the following points: BL-13 Feishu, BL-43 Gaohuangshu and DU-14 Dazhui. Remove after 2 hours. Apply two or three times in August for the reason explained above. She Xiang can be omitted from the above formula, as it is both illegal and expensive.

Acupuncture Points Reinforce the following points with moxa (unless there is Yin deficiency): • BL-13 Feishu, DU-12 Shenzhu and BL-43 Gaohuangshu to strengthen the Lung’s DefensiveQi system. Use these points in late August. • BL-23 Shenshu, Ren-4 Guanyuan and KI-16 Huangshu to strengthen the Kidney’s Defensive-Qi system. Use these points in late October.

WESTERN DRUG THERAPY Because most asthmatic patients whom we treat are bound to be on some kind of medication, it is important to understand the medications’ mode of action and how they affect our treatment. The four main approaches to drug treatment of asthma in Western medicine are: 1. 2. 3. 4.

antiallergic drugs bronchodilators corticosteroids leukotriene antagonists.

Each of these drugs acts on a certain stage of the pathological process that leads to asthma.

Antiallergic drugs (mast cell stabilizers) These act by stabilizing the mast cells in the bronchi and reducing their sensitivity to allergen stimulation. They are used only as a prophylactic in the prevention and not the treatment of asthma. They seem to be more effective in children than in adults.

Allergic asthma (atopic eczema)

They do not affect the treatment with acupuncture or herbs and do not produce any appreciable change in the pulse or tongue. The most common brand names of this class of drug in the USA and UK are cromolyn inhaler (Intal inhaler) and nedocromil oral inhalation (Tilade).

Bronchodilators These act by stimulating the adrenergic receptors in the sympathethic nerves to the bronchi and thus causing bronchodilation. The most widely used ones are the b2-adrenoceptor stimulants, as they are more selective and produce fewer side effects than adrenaline (epinephrine) or theophylline (which stimulate both alpha- and beta-adrenoceptors). Even these, however, have side effects and, in particular, they may stimulate the heart, producing tachycardia. Some authors point out that bronchial hyperreactivity is not decreased with the use of b2 agonists, and that their effect runs out rapidly within 3–4 weeks of ceasing to use them. According to these authors, when side effects are taken into account, mast cell stabilizers are therapeutically superior to b2 agonists or anti-inflammatory agents.86 From the point of view of Chinese diagnosis, selective bronchodilators such as salbutamol (Ventolin) do not affect the tongue, although they may make the Heart pulse slightly Overflowing. Other brochodilators, such as isoprenaline (Iso-Autohaler) and orciprenaline (Alupent) have more side effects on the heart and, besides making the Heart pulse Overflowing, they may also make the tip of the tongue red. The use of bronchodilator inhalers may be integrated with acupuncture and herbal therapy. Indeed, they may provide a useful benchmark of the efficacy of our treatment as the patient gradually reduces the frequency of use of inhalers. The most common brands of this type of drug (USA and UK) are: • salmeterol (Serevent) • albuterol (Ventolin, Proventil) • salbutamol (Ventolin).

beclometasone. When given orally, they produce many more side effects. From a Chinese perspective, they produce Heat and weaken the Kidneys. They definitely affect the tongue, making it Red and Swollen. They also affect the pulse, as the Kidney position becomes Weak and the pulse is generally more Rapid than normal. Although they can be combined with acupuncture and herbal therapy, corticosteroids slow down the effects of our treatment somewhat. In the course of our treatment, it is necessary to tonify the Kidneys even more by using points such as BL-23 Shenshu and herbs such as Shu Di Huang Radix Rehmanniae preparata and Sheng Di Huang Radix Rehmanniae. The mode and site of action of the above three drugs may be summarized in two diagrams (Figs 5.17 and 5.18).

Leukotriene antagonists Inflammatory molecules called leukotrienes are one of several substances that are released by mast cells during an asthma attack, and it is leukotrienes that are primarily responsible for the bronchoconstriction. A new class of antiasthma drugs has been designed to interfere with the activity of leukotrienes. Both leukotriene synthesis inhibitors and cysteinylAllergen

Mast cells

These act by reducing bronchial mucosal inflammation and hypersecretion of mucus. They are given either orally, such as prednisolone, or by inhalation, such as

Cromoglicate (Intal)

Histamine Bronchospasm

Corticosteroids

173

Incomplete clearing of mucus inflammation

Salbutamol (Ventolin)

Corticosteroids

Figure 5.17 Mode and site of action of antiallergy agents, bronchodilators and corticosteroids.

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Avoidance

ALLERGENS 3. 4.

DSCG (Intal)

MAST CELLS

5. 6. 7. 8. 9. 10. 11. 12.

EOSINOPHILS

13.

MEDIATOR AND CYTOKINASE RELEASE

Blockers

Steroids

14. 15. 16. 17.

INFLAMMATION

18. 19. 20. 21.

Bronchodilators

BRONCHOSPASM

TISSUE SWELLING

AIRWAY MUCUS

Figure 5.18 Mode and site of action of antiallergy agents, bronchodilators and corticosteroids.

leukotriene receptor antagonists have recently been shown to protect asthmatic patients against asthma attacks, but they are not useful as “rescue” remedies once an attack has already started. These drugs act by preventing leukotriene release from mast cells or by blocking the specific leukotriene receptors on bronchial tissues, thus preventing bronchoconstriction, mucus secretion and oedema. These drugs also reduce the influx of eosinophils, thus limiting inflammatory damage in the airways. These oral, nonsteroidal, anti-inflammatory drugs reduce the incidence of acute asthma attacks when taken regularly. The most common brand names of this class of drug in both the UK and USA are montelukast (Singulair) and zafirlukast (Accolate).

END NOTES 1. Lane DJ 1996 Asthma: the Facts, 3rd edn. Oxford University Press, Oxford, p. 123. 2. National Institutes of Health. Who is at risk for asthma? Online.

22. 23.

24. 25. 26. 27. 28. 29.

30.

31.

32. 33. 34. 35. 36. 37. 38.

39.

40. 41.

Available: http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/ Asthma_WhoIsAtRisk.html Centers for Disease Control and Prevention. Online. Available: http://www.cdc.gov Upton MN et al. 2000 Intergenerational 20-year trends in the prevalence of asthma and hay fever in adults. British Medical Journal 321: 88–92. Ibid., p. 131. Ibid., pp. 131–132. Arrighi HM 1995 US asthma mortality: 1941 to 1989. Annals of Allergy, Asthma and Immunology 74(4): 321–326. Asthma: the Facts, p. 26. Ibid., p. 27. Ibid., p. 68. Ibid., p. 68. Kay AB 1989 Allergy and Asthma. Blackwell Scientific Publications, Oxford, p. 153. Macklem PT 1992 The importance of excessive bronchoconstriction in asthma. Giornale Italiano di Allergologia e Immunologia Clinica 2(5): 276. Ibid., p. 276. Ibid., p. 279. Ibid., p. 280. Middleton E et al. 1991 Treatise of Allergology, Italian edition. Momento Medico, Salerno, p. 205. Voelker R 2000 The hygiene hypothesis. JAMA 283(10):1282. Holgate ST 2000 Allergic disorders. British Medical Journal 320: 231–234. Alm JS et al. 1999 Atopy in children of families with an anthroposophic lifestyle. The Lancet 353(9163): 1485–1488. Shaheen SO et al. 1996 Measles and atopy in Guinea-Bissau. The Lancet 347(9018): 1792–1796. William OCM, Moffatt M 1997 Asthma – an epidemic in the absence of infection? Science 275(5296): 41. Marra F et al. 2006 Does antibiotic exposure during infancy lead to development of asthma? A systematic review and metaanalysis. Chest 129: 610–618. Asthma: the Facts, p. 94. Ibid., p. 32. Ibid., p. 77. Ibid., p. 96. Strube G, Rudolph M 2000 Should steroids be the first line treatment for asthma? British Medical Journal 320: 47–49. Gilchrist S, Torok TJ, Gary HE Jr et al. 1994 National surveillance for respiratory syncytial virus, United States, 1985–1990. Journal of Infectious Diseases 170: 986–990. Everard ML 1998 Respiratory syncytial virus bronchiolitis and pneumonia. In: Taussig L, Landau L (eds) Textbook of Paediatric Respiratory Medicine. Mosby, St Louis, pp. 580–595. Wittig HJ, Glaser J 1959 The relationship between bronchiolitis and childhood asthma: a follow-up study of 100 cases of bronchiolitis. Journal of Allergy 30: 19–23. Johnston SL 1998 Viruses and asthma. Allergy 53: 922–932. Shay DK et al. 1999 Bronchiolitis-associated hospitalizations among US children, 1980–1996. JAMA 282(15):1440–1446. Treatise of Allergology, p. 207. Mygind N et al. 1990 Rhinitis and Asthma. Munksgaard, Lund, p. 10. Ibid., p. 10. Ibid., p. 10. Ibid., p. 14. Dr. Withering also advocated “coffee made very strong” as the prime reliever of asthma. This is in accordance with the modern use of sympathomimetic agents to promote bronchodilation. Caffeine is a xanthine with sympathomimetic effects. Bao Jing 1992 [Patterns and treatment of children with geographic tongue]. Journal of Chinese Medicine (Zhong Yi Za Zhi ) 33(4): 40–41. Beaven DW, Brooks SE 1988 Colour Atlas of the Tongue in Clinical Diagnosis. Wolfe, London, p. 117. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue

Allergic asthma (atopic eczema)

42. 43. 44. 45. 46. 47. 48. 49. 50. 51.

52.

53.

54.

55.

56. 57. 58. 59. 60. 61. 62. 63.

64. 65.

[Internal Medicine in Internal Medicine]. Shanghai Science Publishing House, Shanghai, p. 59. Asthma: the Facts, p. 32. Ibid., p. 33. Allergy and Asthma, p. 104. Ibid., p. 159. Kumar PJ, Clark ML 1987 Clinical Medicine. Baillière Tindall, London, p. 586. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 52. First published c.100 BC. Ibid., p. 126. Andrews BJ 1991 Wang Qingren and the history of Chinese anatomy. Journal of Chinese Medicine 36: 31. Rhinitis and Asthma, p. 252. National Heart, Lung, and Blood Institute, National Institutes of Health 1992 International report on the diagnosis and treatment of asthma. Giornale Italiano di Allergologia erectile dysfunction Immunologia Clinica 2: 260. Devereux G, Turner SW, Craig LCA et al. 2006 Low maternal vitamin E intake during pregnancy is associated with asthma in 5-year-old children. American Journal of Respiratory and Critical Care Medicine 174: 499–507. Wang Luo Zhen 1985 Qi Jing Ba Mai Kao Jiao Zhu [A Compilation of the Study of the Eight Extraordinary Vessels]. Shanghai Science Publishing House, Shanghai, p. 1. The Study of the Eight Extraordinary Vessels was written by Li Shi Zhen and first published in 1578. Hu Guo Rang et al. 1983 [The influence of the method of tonifying the kidneys on serum IgE and T-cell levels in patients with asthma]. Journal of Chinese Medicine 5: 33. Zhang Jing Lei 1985 Clinical observation on the treatment of 111 cases of asthma with acupuncture. Journal of Chinese Medicine 26(5): 47. Wang Xing Juan 1999 The experience of Dr Shen Zi Yin in the treatment of asthma. Journal of Chinese Medicine 40(3): 139–140. Treatise of Allergology, p. 205. Ibid., p. 205. Ibid., p. 113. Allergy and Asthma, p. 107. Ibid., p. 114. Rhinitis and Asthma, p. 102. Kline RM, Bertolone S 1998 Umbilical cord blood transplantation: providing a donor for everyone needing a bone marrow transplant? Southern Medical Journal 91(9): 821–828. Kiiko Matsumoto 1990 Presentation at Pacific Symposium of Oriental Medicine. Rhinitis and Asthma, p. 112.

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66. Kemp T, Pearce N, Fitzharris P et al. 1997 Is infant immunization a risk factor for childhood asthma or allergy? Epidemiology 8: 678–680. 67. Farooqi IS, Hopkin JM 1998 Early childhood infection and atopic disorder. Thorax 53: 927–932. 68. DeStefano F, Gu D, Kramarz P et al. 2002 Childhood vaccinations and risk of asthma. Pediatric Infectious Disease Journal 21(6): 498–504. 69. Allergy and Asthma, p. 107. 70. Ibid., p. 108. 71. Oddy W et al. 1999 Association between breast feeding and asthma in 6-year-old children: findings of a prospective birth cohort study. British Medical Journal 319: 815–819. 72. Spiritual Axis, p. 23. 73. 1982 Lei Jing [Classic of Categories]. People’s Health Publishing House, Beijing, p. 63. The Classic of Categories was written by Zhang Jie Bin and first published in 1624. 74. Allergy and Asthma, p. 162. 75. National Heart, Lung, and Blood Institute, National Institutes of Health 1992 International report on the diagnosis and treatment of asthma. Giornale Italiano di Allergologia erectile dysfunction Immunologia Clinica 2: 215–216. 76. Treatise of Allergology, p. 208. 77. Chen Jin 1995 [The treatment of paediatric asthma with combined tonifying and eliminating method]. Journal of Chinese Medicine 36(11): 666–667. 78. He Shu Huai 1988 [Patterns and treatment of asthma]. Journal of Chinese Medicine 29(1): 5–11. 79. Wu Ying He 1998 [The treatment of acute bronchial asthma according to pattern identification and with the addition of insect substances to extinguish wind]. Journal of Chinese Medicine 39(7): 396. 80. Shi Zi Guang 1988 Dang Dai Ming Yi Lin Zheng Jing Hua [Essential Clinical Experience of Famous Modern Doctors – Asthma]. Ancient Chinese Medical Texts Publishing House, p. 96. 81. Journal of Chinese Medicine 32(12): 4. 82. Essential Clinical Experience of Famous Modern Doctors, p. 180. 83. A Compilation of the Study of the Eight Extraordinary Vessels, p. 1. 84. Spiritual Axis, p. 120. 85. De Giacomo E 1991 Rivista Italiana di Medicina Tradizionale Cinese (Italian Journal of Chinese Medicine) 3: 10. 86. Novembre E et al. 1994 Terapia Antinfiammatoria dell’Asma: quale Farmaco prima? In: Proceedings of the International Meeting of Allergology and Clinical Immunology Paediatric Perspectives, February 1994, pp. 207–208.

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CHAPTER 6

ALLERGIC RHINITIS

ALLERGIC RHINITIS IN WESTERN MEDICINE Aetiology 178 Pathology 178 THE CHINESE THEORY OF BI YUAN Aetiology 179 Pathology 180

179

DIFFERENCES BETWEEN ALLERGIC RHINITIS AND BI YUAN 181 Differences between allergic rhinitis and Bi Yuan 181 The Chinese theory of Bi Qiu (“stuffy nose”) 181 A NEW THEORY OF ALLERGIC RHINITIS Aetiology 182 Pathology 182 TREATMENT OF ALLERGIC RHINITIS Seasonal allergic rhinitis 184 Perennial allergic rhinitis 188 MODERN CHINESE LITERATURE

182

184

The approach to the diagnosis and treatment of allergic rhinitis presents similar problems to that of asthma. Because “allergic rhinitis” is a disease defined according to Western medicine, we need to establish which symptom it might correspond to in the Chinese medical literature. Most books, both Chinese and English language ones, correlate allergic rhinitis to the Chinese symptom of Bi Yuan , which literally means “nose pool”. We need first to ascertain whether there is such a correspondence and whether the theory of Bi Yuan may be used to differentiate and diagnose allergic rhinitis. As for asthma, we shall therefore discuss the following topics. • • • •

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CLINICAL TRIALS 192 Acupuncture 192 Acupuncture and herbal medicine Herbal medicine 195

ALLERGIC RHINITIS

177

194

Allergic rhinitis in Western medicine The theory of Bi Yuan in Chinese medicine Differences between allergic rhinitis and Bi Yuan A new theory of allergic rhinitis in Chinese medicine

Allergic rhinitis will be discussed according to the following topics.

SEASONAL ALLERGIC RHINITIS Treatment of the Manifestation • Wind-Cold • Wind-Heat

• • • • • • • •

Treatment of the Root • Deficiency of Lung and Kidney’s Defensive-Qi systems and the Governing Vessel

ALLERGIC RHINITIS IN WESTERN MEDICINE

PERENNIAL ALLERGIC RHINITIS Simultaneous treatment of the Manifestation and Root

The main clinical manifestations of allergic rhinitis are nasal congestion, a watery nasal discharge and sneezing. In a few cases, it affects the eyes and the

CASE HISTORIES

197

Allergic rhinitis in Western medicine The Chinese theory of Bi Yuan Differences between allergic rhinitis and Bi Yuan A new theory of allergic rhinitis Treatment of allergic rhinitis Modern Chinese literature Clinical trials Case histories

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conjunctiva may become red and itchy. In 20% of cases, there is also asthma in conjunction with the rhinitis.

Aetiology Allergic rhinitis is due to an antigen–antibody reaction in the nasal mucosa. If the antigens responsible are only pollen particles, then it is called seasonal allergic rhinitis (hay fever). If the antigens are dust, house dust mites’ faecal matter, fungal spores and animal dander, it is called perennial allergic rhinitis. As for furry animals such as dogs and cats, the most allergenic substances are protein from their skin, urine and saliva. In perennial rhinitis, the nose becomes more reactive to non-specific stimuli such as cigarette smoke, petrol fumes, perfumes and, in the case of acupuncturists, moxa smoke.

Pathology Allergic rhinitis develops as a result of the interaction between the inhaled allergen and adjacent molecules

IgE

High levels of IgE in atopic individuals attached to mast cells in respiratory tract

of immunoglobulin (Ig) E antibodies. These adhere to the surface of the mast cells that line the nasal epithelium with the first exposure to the offending allergen (Fig. 6.1). After the first exposure, the mast cells are “primed”, i.e. high levels of IgE antibodies adhere to their surface. With subsequent exposure to allergens, the IgE antibodies provoke an “explosion” in the mast cells, with the massive release of histamine. Histamine itself causes an increase in permeability of the epithelium, allowing allergens to reach IgE-primed mast cells. Sneezing results from overstimulation of the afferent nerve endings and starts within minutes of the allergens entering the nose. This is followed by a greatly increased nasal secretion and eventually nasal blockage about 15–20 minutes after contact with the allergen. This pathological process is similar to that of asthma, the main difference being that histamine plays a more important role in the development of allergic rhinitis than of asthma. In fact, antihistamines are effective for allergic rhinitis but are of little value for asthma.

Pollen grains

Protein leaches out of pollen grains and binds IgE antibodies on to mast cells

Figure 6.1 Allergic reaction in allergic rhinitis.

Histamine, prostaglandins

Linkage of IgE on to mast cells sparks off ‘’explosion‘’ in them. Histamine and prostaglandins (among others) leak from the cells. These cause sneezing, congestion and itching.

Allergic Rhinitis

A higher number of mast cells are present in the nasal mucosa of individuals with rhinitis, and they probably increase as allergen stimulation continues. This accounts for the increasing responsiveness of the nose to lower amounts of allergens. The grossly swollen mucosa in allergic rhinitis may obstruct drainage from the sinuses, causing sinusitis in half the patients. Thus, infection of the paranasal sinuses is a frequent complication and consequence of allergic rhinitis (Fig. 6.2). This is an important point to remember when discussing the differences between allergic rhinitis and Bi Yuan. Some individuals may also lose the sense of taste and smell. The antigen–antibody reaction is illustrated in Figure 6.1, in which the allergen in question is pollen granules. The Western treatment of allergic rhinitis relies mostly on the use of antihistamine agents. These work by preventing histamine from reaching its site of action, i.e. the H1-receptors, and hence they are called H1-receptor blockers. Side effects include sedation, dizziness, fatigue, insomnia, nervousness and gastrointestinal disturbances. Failure to respond to antihistamines is due to the fact that active substances other than histamine are released in allergic states. Steroids by nasal inhalation are also used for allergic rhinitis; these do not seem to have the same general, systemic effect of oral steroids.

Infection in paranasal sinuses Nasal cavity Swollen mucosa prevents drainage from sinuses

179

SUMMARY ALLERGIC RHINITIS IN WESTERN MEDICINE Aetiology  Allergic rhinitis is due to an antigen–antibody reaction in the nasal mucosa.  If the antigens responsible are only pollen particles, then it is called seasonal allergic rhinitis (hay fever).  If the antigens are dust, house dust mites’ faecal matter, fungal spores and animal dander, it is called perennial allergic rhinitis. Pathology  Allergic rhinitis develops as a result of the interaction between the inhaled allergen and adjacent molecules of IgE antibodies.  After the first exposure, the mast cells are “primed”, i.e. high levels of IgE antibodies adhere to their surface.  With subsequent exposure to allergens, the IgE antibodies provoke an “explosion” in the mast cells, with the massive release of histamine.  Sneezing results from overstimulation of the afferent nerve endings and starts within minutes of the allergens entering the nose.  The grossly swollen mucosa in allergic rhinitis may obstruct drainage from the sinuses, causing sinusitis in half the patients.  The Western treatment of allergic rhinitis relies mostly on the use of antihistamine agents.

THE CHINESE THEORY OF BI YUAN The main clinical manifestations usually mentioned in connection with Bi Yuan are a purulent nasal discharge with a foul smell, a stuffed nose, a runny nose, headache and sneezing.

Aetiology

Figure 6.2 Sinusitis secondary to allergic rhinitis.

Bi Yuan is due to repeated invasions of Wind-Cold in the Lung channel that are not treated properly. After some time, Cold turns into Heat, the Lung cannot diffuse and descend Qi and local stagnation of Qi and Blood develops in the nose. All these factors lead to nasal discharge. The Gall Bladder channel carries Heat upwards to the brain, and as the Governing Vessel also

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flows into the brain and the nose, this therefore causes a purulent yellow nasal discharge. In Chinese medicine, this condition was in fact also called “brain flooding” or “brain discharge”.

Stomach- and Spleen-Heat

Pathology

Qi and Blood stagnation

Thus two channels and organs are involved: Lungs and Gall Bladder. After several years, the Spleen will usually also become involved, and a Spleen deficiency leading to Dampness further aggravates the condition. The Manifestation of this condition consists of symptoms of Wind-Cold or Wind-Heat. The Root of the condition is a deficiency of the Lung in diffusing and descending Qi and, in some cases, Gall Bladder-Heat. The treatment is variously aimed at expelling WindCold, clearing Gall Bladder-Heat or clearing SpleenHeat, according to the pattern involved. The main patterns encountered in Bi Yuan are:

White or yellow, purulent, sticky nasal discharge, headaches, nasal mucosa swollen and red, hypertrophy of nasal mucosa, Purple tongue, Wiry or Choppy pulse.

• • • • •

Lung invaded by Wind-Cold Lung invaded by Wind-Heat Liver- and Gall Bladder-Heat Lung-Heat Stomach- and Spleen-Heat.

In chronic conditions, there may be any of the above patterns of Heat plus one of the following patterns: • Qi and Blood stagnation • Liver- and Kidney-Yin deficiency • Lung- and Spleen-Qi deficiency.

Lung invaded by Wind-Cold Stuffed nose, runny nose with clear mucus, slight headache, sneezing.

Lung invaded by Wind-Heat Sneezing, stuffed nose, runny nose with thick-yellow discharge, itchy nose and throat, redness and swelling around the nose, itchy eyes.

Liver- and Gall Bladder-Heat Dry nose, runny nose with yellow-sticky-purulent and foul-smelling discharge, diminished sense of smell, bitter taste, dry throat, headache.

Lung-Heat Stuffed nose, runny nose with yellow foul-smelling discharge that may contain blood, dry mouth, feeling of heat.

Stuffed nose, runny nose with yellow foul-smelling discharge, diminished sense of smell, feeling of heaviness of the head, headache, bitter and sticky taste.

Liver- and Kidney-Yin deficiency Runny but scanty nasal discharge, diminished sense of smell, headache experienced inside the skull, dizziness, tinnitus, night sweating, poor memory, lower backache, atrophy of nasal mucosa, tongue without coating, Floating-Empty pulse.

Lung- and Spleen-Qi deficiency White-watery nasal discharge without smell, varying in amount, nasal obstruction, diminished sense of smell, feeling of heaviness of the head, headache, inflamed nasal mucosa, hypertrophy of nasal mucosa, tiredness, poor appetite, loose stools, spontaneous sweating, weak voice, Pale tongue, Weak pulse.

SUMMARY THE CHINESE THEORY OF BI YUAN  Clinical manifestations: a purulent nasal discharge with a foul smell, a stuffed nose, a runny nose, headache and sneezing. Aetiology and pathology  Bi Yuan due to repeated invasions of WindCold in the Lung channel.  Cold turns into Heat, the Lung cannot diffuse and descend Qi and local stagnation of Qi and Blood develops in the nose.  The Gall Bladder channel carries Heat upwards to the brain, and this causes a purulent yellow nasal discharge.  The Manifestation consists of symptoms of Wind-Cold or Wind-Heat.  The Root of the condition is a deficiency of the Lung in diffusing and descending Qi and, in some cases, Gall Bladder-Heat.  The main patterns encountered in Bi Yuan are: — Lung invaded by Wind-Cold

Allergic Rhinitis

— Lung invaded by Wind-Heat — Liver- and Gall Bladder-Heat — Lung-Heat — Stomach- and Spleen-Heat.

BI YUAN

181

Sinusitis

BI QIU Allergic rhinitis

DIFFERENCES BETWEEN ALLERGIC RHINITIS AND BI YUAN I shall explore first the differences between allergic rhinitis and Bi Yuan and then the Chinese theory of Bi Qiu (“stuffy nose”).

Differences between allergic rhinitis and Bi Yuan The use of the theory of Bi Yuan to treat allergic rhinitis presents several problems. The theory of Bi Yuan presents no clear explanation of the allergic nature of rhinitis and no explanation of its aetiology. Some of the patterns described in Bi Yuan are not allergic rhinitis but sinusitis. In fact, all of them, except for Lung invaded by Wind-Cold, include runny nose with a yellow, sticky, purulent and foul-smelling discharge. This is very clearly a symptom of sinusitis, not rhinitis, as it is the infection of the sinuses, not rhinitis, that produces the yellow and purulent discharge.

The Chinese theory of Bi Qiu (“stuffy nose”) All modern Chinese books equate allergic rhinitis to Bi Yuan, but this disease corresponds more to sinusitis rather than to allergic rhinitis. There is, in fact, an ancient Chinese disease entity called Bi Qiu that actually corresponds more closely to allergic rhinitis. Bi Qiu means “stuffy nose”, and it is characterized by a profuse, thin, clear nasal discharge, stuffed nose and sneezing. Another Chinese disease category that may correspond to allergic rhinitis is called Qiu Ti , which may be translated as “stuffy nose and sneezing” (Fig. 6.3). The only exception is the modern book A New General Outline of Chinese Medicine by the Guangzhou Army Health Department, which attributes the pathology of

QIU TI Figure 6.3 Sinusitis and allergic rhinitis in Chinese medicine.

allergic rhinitis to a Kidney deficiency and a deficiency of the Governing Vessel (as I do). The book also says specifically:1 The Kidneys control sneezing. The Governing Vessel flows to the upper lip. Sneezing, stuffed nose, runny nose with a watery, clear nasal discharge is due to a deficiency of the Kidneys and of the Governing Vessel. Itchy nose is due to Wind. This book mentions four patterns for allergic rhinitis, two clearly “borrowed” from the theory of Bi Yuan and two different ones that are a deficiency of the Kidneys and of the Governing Vessel and a deficiency of the Spleen with Dampness. Bi Qiu (“stuffy nose”) is characterized by itchy nose, sneezing, profuse, white-watery nasal discharge and stuffy nose. On examination, the nasal mucosa is swollen but not inflamed. The patterns of Bi Qiu are: • Lung-Qi deficiency and weakness of the Defensive Qi • Spleen-Qi deficiency • Kidney-Yang deficiency and weakness of the Governing Vessel • Qi deficiency and Blood stasis.

Lung-Qi deficiency and weakness of the Defensive Qi Itchy nose, sneezing, white-watery nasal discharge, swollen nasal mucosa, itchy throat, cough, elicited by Wind, propensity to catching colds, spontaneous sweating, Pale tongue, Empty pulse.

Prescription WEN FEI ZHI LIU DAN plus GUI ZHI TANG Warming the Lungs and Stopping Discharge Pill plus Ramulus Cinnamomi Decoction

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Spleen-Qi deficiency Chronic attacks, sneezing, white-watery nasal discharge, stuffy nose, white nasal mucosa, feeling of heaviness of the head, tiredness, poor appetite, loose stools, Pale tongue, Weak pulse.

Prescription BU ZHONG YI QI TANG plus QIANG HUO SHENG SHI TANG Tonifying the Centre and Benefiting Qi Decoction plus Notopterygium Dispelling Dampness Decoction

Kidney-Yang deficiency and weakness of the Governing Vessel Chronic condition, sneezing, white-watery nasal discharge, worse in winter, stuffy nose, diminished sense of smell, white nasal mucosa, dizziness, tinnitus, lower backache, chilliness, cold feet, Pale tongue, Weak and Deep pulse.

Prescription JIN GUI SHEN QUI WAN plus MA HUANG FU ZI XI XIN TANG Golden Chest Kidney-Qi Pill plus Ephedra-AconitumAsarum Decoction

Qi deficiency and Blood stasis Chronic condition, sneezing, white-watery nasal discharge, white nasal mucosa, swollen nose, polyps, headache, Purple tongue, Wiry or Choppy pulse.

Prescription WEN FEI HUA YU TANG Warming the Lungs and Eliminating Stasis Decoction

SUMMARY DIFFERENCES BETWEEN ALLERGIC RHINITIS AND BI YUAN  The theory of Bi Yuan presents no clear explanation of the allergic nature of rhinitis and no explanation of its aetiology.  All the patterns described in Bi Yuan (with the exception of Lung invaded by Wind-Cold) are not allergic rhinitis but sinusitis.  The ancient Chinese disease entity called Bi Qiu corresponds more closely to allergic rhinitis.

A NEW THEORY OF ALLERGIC RHINITIS Allergic rhinitis is due to an over-reactivity of the immune system to certain allergens. Like asthma, this is due, from the Chinese point of view, to a deficiency of the Lung and Kidney’s Defensive-Qi systems, a deficiency of the Governing Vessel combined with retention of chronic Wind in the nose.

Aetiology The deficiency of Lung and Kidney’s Defensive-Qi systems is either hereditary or due to problems during the pregnancy or childbirth. The aetiological factors are exactly the same as for asthma (see Chapter 5). Repeated invasions of Wind that are not treated properly, combined with a pre-existing deficiency of Lung and Kidney’s Defensive-Qi systems, lead to the retention of what could be described as chronic Wind in the nose, similar to what happens in asthma when Wind is retained in the chest.

Pathology Allergic rhinitis is therefore characterized by two factors: a deficiency of Lung and Kidney’s Defensive-Qi systems and retention of Wind in the nose. As mentioned for asthma, a deficiency of the Kidney’s Defensive-Qi system involves only this particular aspect of its function and not others. One would not expect therefore to see symptoms such as tinnitus, dizziness, night sweating, and weak back and legs. Even more than asthma, a Kidney deficiency is involved in the pathology of allergic rhinitis. This is so because, in allergic rhinitis, the Kidneys are involved not only in the Root of the disease but also in the Manifestation through the Governing Vessel (Fig. 6.4). The Governing Vessel emerges from between the Kidneys and flows up the spine to the top of the head and then down to the nose and lips. It is therefore the channel connection between the Kidneys and the nose. For this reason, the Kidneys are responsible not only for breathing, due to their function of grasping Qi, but also sneezing. Sneezing itself is also directly linked to the Kidneys and not necessarily due only to Wind. Chapter 23 of the Simple Questions says: “The Kidneys control sneezing.”2 Chapter 64 of the Simple Questions discusses the consequences of inserting a needle into

Allergic Rhinitis Governing Vessel Deficiency of Governing Vessel Deficiency of Lung and Kidney’s DefensiveQi systems Wind

Frontal sinus Olfactory bulb Sphenoidal sinus Pharyngeal tonsil

Nasopharynx

Cartilage Nasal bone Nasal cavity Lip muscle Tongue Figure 6.4 The influence of the Governing Vessel on the nose in allergic rhinitis.

an organ and, for the kidneys, it says: “If we pierce the kidneys, this will cause sneezing and death will ensue within 6 days.”3 Thus the hyper-reactivity of the immune response of allergic rhinitis is due to a deficiency of the Kidney’s Defensive-Qi system and the Governing Vessel. With regard to the role of the Governing Vessel in allergic rhinitis, it is interesting that many of the herbs that Li Shi Zhen connected with this vessel are expelling-Wind herbs that act on the nose. These herbs are Fang Feng Radix Saposhnikoviae, Cang Er Zi Fructus Xanthii, Jing Jie Herba Schizonepetae, Qiang Huo Rhizoma seu Radix Notopterygii, Xi Xin Herba Asari and Gao Ben Rhizoma Ligustici.4 The symptoms and signs of allergic rhinitis are those of Wind-Cold, as the nasal discharge is always white and watery. This indicates a deficiency of Defensive Qi, which is spread by the Lungs but has its root in the Kidneys.5 Thus, although some books do refer to a Kidney deficiency as the Root of allergic rhinitis, the Kidneys are responsible not only for the Root of this disease (because of the deficiency of the Kidney’s Defensive-Qi system), but also for the Manifestation through their direct connection with the Defensive Qi and sneezing and with the Governing Vessel (which flows through the nose). Allergic rhinitis often starts in early childhood, but it may also start later in life, with a progressive decline of Kidney-Qi or perhaps with a decline of Kidney-Qi connected to the beginning of sexual activity. In fact, in men over 40 suffering from allergic rhinitis there is often a direct connection between sexual activity

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and an attack of rhinitis. Thus, although rhinitis is obviously a much less severe disease than asthma, when compared with it, it indicates a more severe deficiency of the Kidneys. As for the difference between seasonal and perennial allergic rhinitis (hay fever), the latter simply occurs when there is a more severe Kidney deficiency. Obviously, in patients aged 50 or over the pathology will be complicated by other factors, the most common of which is a Spleen deficiency, which produces more mucus and therefore a runny nose. Also, allergic rhinitis causes a congestion of the nasal mucosa, which may prevent proper drainage from the sinuses; this may lead to a secondary sinus infection complicating the clinical manifestations, as the patient will display the symptoms of both allergic rhinitis and of sinusitis. As for the Manifestation, the main pathogenic factor is Wind invading the Lung channel in the nose. However, this is due not only to repeated invasions of Wind, as in the theory of Bi Yuan, but primarily to the inherent deficiency of the Kidney’s Defensive-Qi system and Governing Vessel in the nose, which mimics symptoms of invasion of Wind-Cold. As mentioned above, sneezing itself is also directly due to the Kidneys and not necessarily only to Wind.

SUMMARY A NEW THEORY OF ALLERGIC RHINITIS Aetiology  Deficiency of Lung and Kidney’s Defensive-Qi systems.  Chronic “Wind” in the nose. Pathology  Deficiency of Lung and Kidney’s Defensive-Qi systems (Ben) and retention of Wind in the nose (Biao).  The Kidneys are involved not only in the Root of the disease but also in the Manifestation through the Governing Vessel.  Sneezing is linked to the Kidneys.  The symptoms and signs of allergic rhinitis are those of Wind-Cold, as the nasal discharge is always white and watery.  Deficiency of Defensive Qi.  The Kidneys are responsible not only for the Root of this disease but also for the Manifestation through their direct connection

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with the Defensive Qi and sneezing and with the Governing Vessel.  Allergic rhinitis causes a congestion of the nasal mucosa, which may lead to a secondary sinus infection.  The Manifestation of Wind invading the Lung channel in the nose is due not only to repeated invasions of Wind, but primarily to the inherent deficiency of the Kidney’s Defensive-Qi system and Governing Vessel in the nose.

TREATMENT OF ALLERGIC RHINITIS As for treatment, it is important to distinguish seasonal from perennial rhinitis. In seasonal rhinitis, we should apply different principles of treatment according to the season. In perennial rhinitis, the principle of treatment is irrespective of the season. The discussion of the treatment will therefore be structured in the following way. Seasonal allergic rhinitis: • Treatment of the Manifestation — Wind-Cold — Wind-Heat • Treatment of the Root — Deficiency of Lung and Kidney’s Defensive-Qi systems and the Governing Vessel Perennial allergic rhinitis: • Simultaneous treatment of the Manifestation and Root

Seasonal allergic rhinitis In seasonal rhinitis, one must adapt the treatment according to the season. During the pollen season, attention is directed at treating the Manifestation, i.e. expelling Wind-Cold or Wind-Heat. Outside the summer season, attention is directed at treating the Root, i.e. tonifying the Lung and Kidney’s Defensive-Qi systems and strengthening the Governing Vessel.

TREATMENT OF THE MANIFESTATION Wind-Cold Clinical manifestations Sneezing, profuse runny nose with white-watery discharge, pale complexion, stuffed nose, slight headache, no thirst.

Treatment principle Expel Wind-Cold and restore the diffusing and descending of Lung-Qi.

Acupuncture Points BL-12 Fengmen, BL-13 Feishu, LU-7 Lieque, L.I.-20 Yingxiang, Bitong, Du-23 Shangxing, G.B.-20 Fengchi, Yintang. Reducing or even method. Cupping is applicable on BL-12 and BL-13. Explanation • BL-12, BL-13 and LU-7 restore the diffusing and descending of Lung-Qi and expel Wind. BL-12 is particularly effective with cupping. • L.I.-20, Bitong and Yintang are local points to expel Wind from the nose and to stop itching and sneezing. • Du-23 and G.B.-20 are adjacent points to expel Wind from the head. Du-23, in particular, expels Wind from the nose and stops nasal discharge.

Herbal therapy Prescription XIAO QING LONG TANG Small Green Dragon Decoction Modifications • In case of very itchy and runny nose, add Xin Yi Hua Flos Magnoliae, Cang Er Zi Fructus Xanthii and Bai Zhi Radix Angelicae dahuricae. Prescription CANG ER ZI SAN Xanthium Powder Explanation This formula is applicable if sneezing rather than runny nose is the main problem. As it is composed of only four herbs, it may also be added as a unit to other formulae when sneezing is a predominant problem. Prescription MA HUANG TANG Ephedra Decoction Explanation This formula is used if there are pronounced symptoms of Wind-Cold, such as chilliness, absence of sweating and a Floating-Tight pulse.

Allergic Rhinitis

Prescription GUI ZHI TANG Ramulus Cinnamomi Decoction Explanation This formula is used if there are symptoms of WindCold with slight sweating. Prescription TONG XUAN LI FEI TANG Penetrating, Diffusing and Regulating the Lungs Decoction

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Prescription TONG XUAN LI FEI TANG Penetrating, Diffusing and Regulating the Lungs Decoction Prescription JIA WEI XIANG SU SAN New Cyperus-Perilla Powder

Wind-Heat

Explanation This formula is used if there is a profuse discharge from the nose, sneezing, a cough and possibly a headache.

Clinical manifestation Sneezing, runny nose with white and watery discharge, itchy throat, itchy-red eyes, slight thirst.

Prescription JIA WEI XIANG SU SAN New Cyperus-Perilla Powder

Treatment principle Expel Wind, clear Heat, restore the dispersing and descending of Lung-Qi.

Explanation This prescription is used if there is stiffness of the shoulders, a headache and sneezing. It is suitable for a more chronic condition that has led to stagnation of Qi and Blood in the head and shoulders.

Points BL-12 Fengmen, BL-13 Feishu, L.I.-4 Hegu, L.I.-11 Quchi, L.I.-20 Yingxiang, Bitong, Yintang, G.B.-20 Fengchi. Reducing or even method. Cupping is applicable on BL-12 and BL-13.

SUMMARY WIND-COLD Points BL-12 Fengmen, BL-13 Feishu, LU-7 Lieque, L.I.-20 Yingxiang, Bitong, Du-23 Shangxing, G.B.-20 Fengchi, Yintang. Reducing or even method. Cupping is applicable on BL-12 and BL-13. Herbal therapy Prescription XIAO QING LONG TANG Small Green Dragon Decoction Prescription CANG ER ZI SAN Xanthium Powder Prescription MA HUANG TANG Ephedra Decoction Prescription GUI ZHI TANG Ramulus Cinnamomi Decoction

Acupuncture

Explanation • BL-12 and BL-13 restore the dispersing and descending of Lung-Qi. • L.I.-4 and L.I.-11 expel Wind and clear Heat. • L.I.-20, Bitong and Yintang are local points to expel Wind from the nose. • G.B.-20 expels Wind.

Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Explanation This is a general formula for WindHeat, especially affecting the throat and causing itchy throat and a cough. Modifications • If there is pronounced sneezing, add Cang Er Zi Fructus Xanthii, Xin Yi Hua Flos Magnoliae and Bai Zhi Radix Angelicae dahuricae. Prescription CHAI GE JIE JI TANG Bupleurum-Pueraria Relaxing the Tendons Decoction

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Explanation This formula is used for sneezing with symptoms of Wind-Heat and some interior Heat. Three Treasures remedy To treat the Manifestation of allergic rhinitis, I use the remedy Jade Screen. In case of seasonal allergic rhinitis, I use Jade Screen during the hay fever season in a relatively high dose, i.e. 9 tablets a day or more (for adults). Jade Screen can be taken both for the manifestations of Wind-Cold and Wind-Heat.

SUMMARY WIND-HEAT Points BL-12 Fengmen, BL-13 Feishu, L.I.-4 Hegu, L.I.-11 Quchi, L.I.-20 Yingxiang, Bitong, Yintang. Reducing or even method. Cupping is applicable on BL-12 and BL-13. Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Prescription CHAI GE JIE JI TANG Bupleurum-Pueraria Relaxing the Tendons Decoction Three Treasures remedy Jade Screen

Treatment of the Root In seasonal rhinitis, attention should be directed at treating the Root of the disease at any time outside the pollen season. The best time to do it is actually towards the end of the summer and beginning of Autumn, i.e. August, September and October. In treating the Root, the aim is to tonify the Lung and Kidney’s Defensive-Qi systems and strengthen the Governing Vessel. As the rhinitis is seasonal, there is no need to treat the Manifestation. Herbs that strengthen the Governing Vessel include Lu Rong Cornu Cervi pantotrichum, Lu Jiao Cornu Cervi, Lu Jiao Jiao Gelatinum Cornu Cervi and Gui Ban Plastrium Testudinis. Lu Rong, Lu Jiao and Lu Jiao Jiao are particularly important to treat allergic rhinitis, as they tonify Kidney-Yang without creating too much

Heat, strengthen the Governing Vessel and bolster the Lung and Kidney’s Defensive-Qi systems. By entering the Governing Vessel and tonifying the Kidneys, they treat both the Root and the Manifestation of the disease. Lu Jiao Jiao is particularly applicable to women, as it additionally nourishes Blood. Lu Rong, in particular, strengthens the Governing Vessel, tonifies Yang without drying, nourishes the Essence and Marrow and strengthens tendons and bones. In other words, it strengthens both the Yin and Yang aspects of the Governing Vessel and of the Essence. Gui Ban nourishes the Directing Vessel and is particularly used in women, in combination with Lu Jiao or Lu Jiao Jiao, to strengthen both Governing and Directing Vessels. With acupuncture in women, this is achieved by using the opening and coupled points of both the Governing and Directing Vessels. Thus, in a woman, one would needle S.I.-3 Houxi on the right, BL-62 Shenmai on the left, LU-7 Lieque on the left and KI-6 Zhaohai on the right in this order. Li Shi Zhen indicates the following herbs for the Governing Vessel.6 • • • • • • • • • •

Rou Gui Cortex Cinnamomi Gui Zhi Ramulus Cinnamomi cassiae Fu Zi Radix Aconiti lateralis preparata Du Huo Radix Angelicae pubescentis Qiang Huo Rhizoma seu Radix Notopterygii Fang Feng Radix Saposhnikoviae Jing Jie Herba Schizonepetae Xi Xin Herba Asari Gao Ben Rhizoma Ligustici Cang Er Zi Fructus Xanthii

The first three herbs tonify the Original Qi (Yuan Qi), from which the Governing Vessel originates, and strengthen the Fire of the Gate of Life. Du Huo strengthens the back and expels Wind-Dampness from the lower back. All the other herbs affect the Governing Vessel in its upper part along the nose. In fact, all these herbs expel Wind from the nose and restore the dispersing of Lung-Qi.

Deficiency of Lung and Kidney’s Defensive-Qi systems and the Governing Vessel Clinical manifestations Pale complexion, weak back, propensity to catching colds, Pale tongue, WeakDeep pulse.

Allergic Rhinitis

Treatment principle Tonify the Lung and Kidney’s Defensive-Qi systems and strengthen the Governing Vessel.

Acupuncture Points Du-4 Mingmen, Ren-4 Guanyuan with moxa, BL-23 Shenshu, KI-3 Taixi, BL-13 Feishu, Du-12 Shenzhu, Du-24 Shenting, Du-23 Shangxing, G.B.-20 Fengchi, Du-14 Dazhui with moxa, S.I.-3 Houxi and BL-62 Shenmai (in women combined with LU-7 Lieque and KI-6 Zhaohai). Reinforcing method, except on the head points which should be needled with even method. Explanation • Du-4 and Ren-4, in combination with moxa, strengthen the Governing Vessel. Ren-4 is used because the internal pathway of the Governing Vessel actually runs along the front midline of the body under the Directing Vessel. The use of Du-4 and Ren-4, therefore, tonifies both the Yang and the Yin aspects of the Governing Vessel. • BL-23, KI-3, BL-13 and Du-12 tonify the Lung and Kidney’s Defensive-Qi systems. • Du-24 and Du-23 expel Wind from the nose, strengthen the Governing Vessel locally and stop nasal discharge. • G.B.-20 is an adjacent point to expel Wind. In order to affect the nose, it should be needled with the tip of the needle pointing towards the nostril of the same side. • Du-14 with moxa strengthens the Governing Vessel in its upper part. • S.I.-3 and BL-62 open the Governing Vessel. The points are crossed over with S.I.-3 on the left side for men and right for women and BL-62 on the right side for men and left for women. In women, it is preferable to combine the Governing Vessel with the Directing Vessel; one would therefore needle S.I.-3 on the right, BL-62 on the left, LU-7 on the left and KI-6 on the right.

Herbal therapy Prescription YI DU YANG YUAN TANG Benefiting the Governing Vessel and Nourishing the Original Qi Decoction

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Modifications • If there are pronounced symptoms of Cold and deficiency of Kidney-Yang, add Rou Gui Cortex Cinnamomi. • If there is a propensity to catching colds, add Huang Qi Radix Astragali, Bai Zhu Rhizoma Atractylodis macrocephalae and Fang Feng Radix Saposhnikoviae. • If there is a nasal discharge and a sticky tongue coating, add Bai Zhu Rhizoma Atractylodis macrocephalae, Ban Xia Rhizoma Pinelliae preparatum and Fu Ling Poria. The above formula is particularly suited to allergic rhinitis, as it tonifies the Lung and Kidney’s DefensiveQi systems, strengthens the Governing Vessel and nourishes the Essence. However, any Kidney-Yangtonifying formula may be used modified with the addition of the following ingredients. • Herbs that strengthen the Governing Vessel: Lu Rong Cornu Cervi pantotrichum, Lu Jiao Cornu Cervi or Lu Jiao Jiao Gelatinum Cornu Cervi in women. • Herbs that nourish the Essence and Marrow: Gui Ban Plastrium Testudinis, Tu Si Zi Semen Cuscutae, Gou Qi Zi Fructus Lycii chinensis or Wu Wei Zi Fructus Schisandrae. • Herbs to tonify the Lung’s Defensive-Qi system: Huang Qi Radix Astragali, Mai Men Dong Radix Ophiopogonis and Bei Sha Shen Radix Glehniae. If necessary, add small doses of one or two cold herbs to prevent overheating from the hot herbs that tonify Kidney-Yang, for example Zhi Mu Radix Anemarrhenae and Huang Bo Cortex Phellodendri. In women, it is necessary to strengthen the Directing as well as the Governing Vessel with such herbs as Sheng Di Huang Radix Rehmanniae, Gui Ban Plastrium Testudinis, Bie Jia Carapax Trionycis or E Jiao Colla Corii Asini. Although allergic rhinitis in itself indicates a deficiency of Lung and Kidney’s Defensive-Qi systems, especially in people over 40, this may be combined with a Kidney-Yin deficiency. In such cases, it is better to start from a prescription to nourish Kidney-Yin such as Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill and modify it with the addition of herbs to tonify Lung and Kidney’s Defensive-Qi systems and strengthen the Governing Vessel, as indicated above.

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Finally, if there are symptoms and signs of Spleen deficiency, simply add Bai Zhu Rhizoma Atractylodis macrocephalae, Huang Qi Radix Astragali and Fu Ling Poria. Many other formulae can be used according to the patient’s body condition, and these are illustrated below when discussing the treatment of perennial rhinitis.

Treatment principle Tonify the Lung and Kidney’s Defensive-Qi systems, strengthen the Governing Vessel, consolidate the Exterior and expel Wind.

Acupuncture Points

Three Treasures remedies To treat the Root in seasonal allergic rhinitis, I use the remedy Herbal Sentinel, of which there are two variants: Herbal Sentinel-Yang for patients with a tendency to Yang deficiency and Herbal Sentinel-Yin for patients with a tendency to Yin deficiency. I generally prescribe Herbal Sentinel during autumn and winter, with the dosage of 4–6 tablets a day (for adults).

• BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, ST-36 Zusanli, LU-7 Lieque, LU-9 Taiyuan, with reinforcing method, to tonify the Lung’s Defensive-Qi system. • L.I.-4 Hegu, L.I.-20 Yingxiang, Bitong, Du-23 Shangxing, with even method, to expel Wind from the nose. • All other Kidney and Governing Vessel as indicated above for treatment of the Root of seasonal rhinitis.

SUMMARY DEFICIENCY OF LUNG AND KIDNEY’S DEFENSIVE-QI SYSTEMS AND THE GOVERNING VESSEL Points Du-4 Mingmen, Ren-4 Guanyuan with moxa, BL-23 Shenshu, KI-3 Taixi, BL-13 Feishu, Du-12 Shenzhu, Du-24 Shenting, Du-23 Shangxing, G.B.-20 Fengchi, Du-14 Dazhui with moxa, S.I.-3 Houxi and BL-62 Shenmai (in women combined with LU-7 Lieque and KI-6 Zhaohai). Reinforcing method, except on the head points, which should be needled with even method. Herbal therapy Prescription YI DU YANG YUAN TANG Benefiting the Governing Vessel and Nourishing the Original Qi Decoction. Three Treasures remedy Herbal Sentinel

Perennial allergic rhinitis SIMULTANEOUS TREATMENT OF THE MANIFESTATION AND ROOT To treat perennial rhinitis, one must treat both the Root and the Manifestation simultaneously because the symptoms are evident the whole year round.

Herbal therapy There are many suitable formulae, and they should all be modified with the addition of the following types of herb. • Herbs to tonify the Lung and Kidney’s Defensive-Qi systems: Du Zhong Cortex Eucommiae ulmoidis, Xu Duan Radix Dipsaci or Bu Gu Zhi Fructus Psoralelae. • Herbs that strengthen the Governing Vessel: Lu Rong Cornu Cervi pantotrichum, Lu Jiao Cornu Cervi or Lu Jiao Jiao Gelatinum Cornu Cervi in women. • Herbs to tonify the Lung’s Defensive-Qi system: Huang Qi Radix Astragali, Mai Men Dong Radix Ophiopogonis and Bei Sha Shen Radix Glehniae. • Herbs that expel Wind from the nose and stop nasal discharge: Fang Feng Radix Saposhnikoviae, Jing Jie Herba Schizonepetae, Cang Er Zi Fructus Xanthii, Xin Yi Hua Flos Magnoliae and Xi Xin Herba Asari. • Herbs that nourish the Essence and Marrow: Gui Ban Plastrium Testudinis, Tu Si Zi Semen Cuscutae, Gou Qi Zi Fructus Lycii chinensis or Wu Wei Zi Fructus Schisandrae. If necessary, add small doses of one or two cold herbs to prevent overheating from the hot herbs that tonify Kidney-Yang, for example Zhi Mu Radix Anemarrhenae and Huang Bo Cortex Phellodendri. The comments made above on the treatment of the Root of seasonal allergic rhinitis apply also to the treatment of perennial rhinitis.

Allergic Rhinitis

• In women, it is necessary to strengthen the Directing as well as the Governing Vessel with such herbs as Sheng Di Huang Radix Rehmanniae, Gui Ban Plastrium Testudinis, Bie Jia Carapax Trionycis or E Jiao Colla Corii Asini. • If there is a background of Kidney-Yin deficiency or a deficiency of both Kidney-Yang and KidneyYin, it is better to start from a prescription to nourish Kidney-Yin such as Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill or Zuo Gui Wan Restoring the Left [Kidney] Pill and modify it with the addition of herbs to tonify Lung and Kidney’s Defensive-Qi systems and strengthen the Governing Vessel, as indicated above. • If there are symptoms and signs of Spleen deficiency, simply add Bai Zhu Rhizoma Atractylodis macrocephalae, Huang Qi Radix Astragali and Fu Ling Poria.

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Prescription JIA JIAN YU ZHU TANG Variation of Polygonatum Decoction

Explanation This formula is used if there is a background of Stomach-Yin deficiency.

Prescription WU JI SAN Five Accumulations Powder

Explanation This formula is suitable for very chronic allergic rhinitis with Spleen- and Stomach-Yang deficiency and some stasis of Blood. It is particularly suitable for women.

Prescription Prescription YU PING FENG SAN Jade Wind Screen Powder

Explanation This is a very simple and effective formula to tonify Lung-Qi and consolidate the Exterior.

GUI ZHI REN SHEN TANG Ramulus Cinnamomi-Ginseng Decoction

Explanation This prescription is for deficiency of Lung- and SpleenYang with Phlegm and profuse runny nose with very watery and white discharge.

Prescription Prescription SHEN SU YIN Ginseng-Perilla Decoction

Explanation This formula is suitable if there is some Spleen deficiency as well and Phlegm with a profuse nasal discharge.

Prescription REN SHEN BAI DU SAN Ginseng Expelling Poison Powder

MA HUANG FU ZI XI XIN TANG Ephedra-Aconitum-Asarum Decoction

Explanation This formula is suitable if there is severe Kidney-Yang deficiency and internal Cold with profuse white-watery discharge from the nose. It may be used as a unit added to other prescriptions for Yang deficiency. In this case, much smaller doses should be used; for example, reduced by two-thirds.

Prescription ZAI ZAO SAN Renewal Powder

Explanation

Explanation

This prescription is suitable if there is some Spleen deficiency with Phlegm and pronounced stiffness of the muscles of the top of the shoulders and neck.

This formula is for deficiency of Yang of the Spleen, Lungs and Kidneys with a profuse nasal discharge and sweating.

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Prescription

SUMMARY

YI DU YANG YUAN TANG Benefiting the Governing Vessel and Nourishing the Original Qi Decoction

SIMULTANEOUS TREATMENT OF THE MANIFESTATION AND ROOT

Explanation This formula strengthens the Governing Vessel and tonifies the Kidney’s Defensive-Qi system. It has already been discussed above in connection with treatment of the Root of seasonal rhinitis.

Modifications These modifications apply to all the above formulae. • If there is profuse sneezing and nasal discharge, add Fang Feng Radix Saposhnikoviae, Cang Er Zi Fructus Xanthii and Xi Xin Herba Asari. This last herb is used in a small dose such as 1.5 g. • If there is profuse nasal discharge, add Bai Zhi Radix Angelicae dahuricae, Xi Xin Herba Asari and Gan Jiang Rhizoma Zingiberis. • If there are symptoms of Wind-Heat, use Ju Hua Flos Chrysanthemi and Chan Tui Periostracum Cicadae. • If there are headaches, add Ju Hua Flos Chrysanthemi, Ge Gen Radix Puerariae and Man Jing Zi Fructus Viticis. • If there is sweating, use Gui Zhi Tang Ramulus Cinnamomi Decoction. • If there is Spleen deficiency and Phlegm, add Bai Zhu Rhizoma Atractylodis macrocephalae, Fu Ling Poria and Ban Xia Rhizoma Pinelliae preparatum.

Three Treasures remedies In perennial allergic rhinitis, I treat both the Root and the Manifestation simultaneously. To treat the Root, I prescribe Herbal Sentinel (Herbal Sentinel-Yang for those with a tendency to Yang deficiency and Herbal Sentinel-Yin for those with a tendency to Yin deficiency). To treat the Manifestation, I prescribe Jade Screen. Generally speaking, when I use two remedies I ask the patient to take them at different times of the day. Thus, if I was using Herbal Sentinel-Yang I would prescribe that to be taken in the morning and Jade Screen in the afternoon. If I was using Herbal Sentinel-Yin I would prescribe that to be taken in the afternoon and Jade Screen in the morning.

Points BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, ST-36 Zusanli, LU-7 Lieque, LU-9 Taiyuan, with reinforcing method, to tonify the Lung’s Defensive-Qi system. L.I.-4 Hegu, L.I.-20 Yingxiang, Bitong, Du-23 Shangxing, with even method, to expel Wind from the nose. All other Kidney and Governing Vessel as indicated above for treatment of the Root of seasonal rhinitis. Herbal therapy Prescription YU PING FENG SAN Jade Wind Screen Powder Prescription SHEN SU YIN Ginseng-Perilla Decoction Prescription REN SHEN BAI DU SAN Ginseng Expelling Poison Powder Prescription JIA JIAN YU ZHU TANG Variation of Polygonatum Decoction Prescription WU JI SAN Five Accumulations Powder Prescription GUI ZHI REN SHEN TANG Ramulus Cinnamomi-Ginseng Decoction Prescription MA HUANG FU ZI XI XIN TANG Ephedra-Aconitum-Asarum Decoction Prescription ZAI ZAO SAN Renewal Powder Prescription YI DU YANG YUAN TANG Benefiting the Governing Vessel and Nourishing the Original Qi Decoction Three Treasures remedies Herbal Sentinel and Jade Screen

Allergic Rhinitis

During the season

Treat Biao with Jade Screen

Outside the season

Treat Ben with Herbal Sentinel

SEASONAL

Treat Biao with Jade Screen and Ben with Herbal Sentinel

PERENNIAL

Figure 6.5 Protocol for treatment of allergic rhinitis with the Three Treasures remedies.

Figure 6.5 summarizes the protocol for the use of the Three Treasures remedies for allergic rhinitis.

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control group were treated with the formula Xiao Qing Long Tang Small Green Dragon Decoction. The results were as shown in the table.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 18, No. 8, 1998, p. 453 Chen Yong Hong, “Clinical study on bleeding therapy for 31 cases of allergic rhinitis.” This study compared the effect of bleeding therapy on serum IgE in patients with allergic rhinitis compared with a control group taking Chinese herbal medicine, a placebo control group and a healthy control group. The bleeding therapy was applied to L.I.-20 Yinxiang, Bitong, Yintang, L.I.-4 Hegu and L.I.-11 Quchi. Results showed that bleeding of the acupuncture points reduced serum IgE levels.

MODERN CHINESE LITERATURE Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 18, No. 8, 1998, p. 477.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 18, No. 9, 1998, p. 533.

Wang Jia Tai, “Clinical observation on the treatment of 152 cases of allergic rhinitis with the application of herbal paste on acupuncture points.”

Wei Xia Ri, “Treatment of 36 cases of perennial allergic rhinitis with scarring moxibustion.” Dr Wei treated 51 cases of perennial allergic rhinitis, of which the treatment group of 36 was treated with scarring moxibustion and the control group of 15 was treated with herbal medicine. For the treatment group, he used four groups of points: 1. 2. 3. 4.

Du-14 Dazhui, Du-23 Shangxing, Naohu BL-13 Feishu, BL-20 Pishu Ren-4 Guanyuan, Du-4 Mingmen BL-58 Feiyang, BL-67 Zhiyin.

The points from each group were treated in succession at intervals of 4 days. The patients in the

This study treated 188 patients suffering from allergic rhinitis, 152 in the treatment group and 36 in the control group. The treatment group received acupuncture (with the application of a herbal paste on acupuncture points) and the control group received antihistamine. In the treatment group, there were 66 men and 86 women; the youngest patient was 3 and the oldest 72. The shortest duration of the disease was 1 week and the longest 26 years. Two herbal pastes were used, one for Cold patterns and the other for Heat patterns. The one for Cold

Group

No.

Cure

Marked results

Some results

No results

Moxibustion

36

19 (52.8%)

6 (16.7%)

8 (22.2%)

3 (8.3%)

Control

15

3 (20%)

4 (26.7%)

3 (20%)

5 (33.3%)

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patterns consisted of Bai Jie Zi Semen Sinapis albae, Xi Xin Herba Asari, Yan Hu Suo Rhizoma Corydalis and Rou Gui Cortex Cinnamomi. The paste for the Heat group consisted of Xu Chang Qing, Xin Yi Hua Flos Magnoliae, Cang Er Zi Fructus Xanthii, Chen Xiang Lignum Aquilariae resinatum and Huang Qin Radix Scutellariae. The points to which the paste was applied are in the abdomen, and they are found by drawing an imaginary circle with its centre in the umbilicus and a radius of 5 cm. There are four points at North, South, East and West and four more at North-West, NorthEast, South-East and South-West. The paste was left in place for 24 hours if the skin of the patient showed no allergic reaction; if it showed an allergic reaction, it was left in place for 8 hours. This procedure was carried out once every 10 days for three times in total. Before the application of the paste, the points BL-13 Feishu, BL-15 Xinshu and BL-17 Geshu were needled. The results were as shown in the table.

The authors report that 41 (78.8%) patients showed marked improvement, 9 (17.3%) some improvement and 2 (3.9%) no improvement.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 18, No. 12, 1998, p. 739.

Objective

Acupuncture A double-blind, randomized, placebocontrolled trial of acupuncture for the treatment of childhood persistent allergic rhinitis Paediatrics 2004 November, Vol. 5, Issue 114, pp. 1242–1247. Ng DK, Chow PY, Ming SP, Hong SH, Lau S, Tse D, Kwong WK, Wong MF, Wong WH, Fu YM, Kwok KL, Li H, Ho JC Department of Paediatrics, Kwong Wah Hospital, Kowloon, Hong Kong

To compare active acupuncture with sham acupuncture for the treatment of persistent allergic rhinitis among children.

Acupuncture Department of Zhejiang Province Hospital, “Clinical observation on the treatment of 52 cases of allergic rhinitis with acupuncture.”

Method

Fifty-two patients suffering from allergic rhinitis were treated with acupuncture. There were 29 men and 23 women; the youngest patient was 11 and the oldest 59. The main points used were L.I.-20 Yingxiang, Yintang, L.I.-4 Hegu and ST-36 Zusanli. Other points were selected according to patterns. • Wind-Cold: BL-12 Fengmen, G.B.-20 Fengchi • Spleen deficiency: BL-13 Feishu and BL-20 Pishu • Kidney deficiency: BL-23 Shenshu, Du-23 Shangxing

CLINICAL TRIALS

Subjects with persistent allergic rhinitis were recruited from the paediatric outpatient clinic. They were randomized to receive either active acupuncture or sham acupuncture. Main outcome measures included daily rhinitis scores, symptom-free days, visual analogue scale scores for immediate effects of acupuncture, daily relief medication scores, blood eosinophil counts, serum IgE levels, nasal eosinophil counts, patients’ and parents’ preferences for treatment modalities, and adverse effects. Eighty-five patients were recruited from the paediatric outpatient clinic at Kwong Wah Hospital, in Hong Kong. Thirteen patients withdrew before randomization, 35 patients (mean age 11.7 ± 3.2 years)

Group

No.

Marked results

Some results

No results

Percentage

Treatment

152

121 (79.6%)

21 (13.8)

10 (6.6)

93.4%

36

8 (22.2%)

Control

24 (66.7%)

4 (11.1)

88.9%

Allergic Rhinitis

were randomized to receive active acupuncture for 8 weeks, and 37 patients (mean age 11 ± 3.8 years) were randomized to receive sham acupuncture for 8 weeks. Acupuncture was performed twice per week for both groups. Both the assessing paediatricians and the patients were blinded.

Results There were significantly lower daily rhinitis scores and more symptom-free days for the group receiving active acupuncture, during both the treatment and the follow-up periods. The visual analogue scale scores for immediate improvement after acupuncture were also significantly better for the active acupuncture group. There was no significant difference in the following outcome measures between the active and sham acupuncture groups: daily relief medication scores, blood eosinophil counts, serum IgE levels and nasal eosinophil counts, except for the IgE levels before and 2 months after acupuncture in the sham acupuncture group. No severe adverse effects were encountered. Numbness, headache and dizziness were found in both the active and sham acupuncture groups, with no difference in incidence, and the effects were self-limiting.

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Method Cytokine levels were determined before and after treatment in 30 healthy volunteers (group A) and 90 chronic allergic rhinitis patients (group B) with an increased plasma IL-10 level. Group B was then divided into three subgroups: 30 patients treated with real acupuncture (group B1), 30 patients treated with sham acupuncture (group B2) and 30 non-treated patients (group B3).

Results The allergic subjects of group B1, compared with controls, showed a significant reduction of IL-10 after a specific treatment with acupuncture. On the other hand, in those patients treated with sham acupuncture (group B2) as well as in non-treated patients (group B3), the IL-10 values remained high and unchanged. There was a statistically significant change in IL-2 values at 24 hours after real acupuncture (groups A and B1); however, the values remained within normal ranges. The IL-6 did not change after therapy.

Conclusion Acupuncture treatment can reduce plasmatic level of IL-10 in chronic allergic rhinitis.

Conclusion This study showed that active acupuncture was more effective than sham acupuncture in decreasing the symptom scores for persistent allergic rhinitis and increasing the symptom-free days. No serious adverse effect was identified. A large-scale study is required to confirm the safety of acupuncture for children.

Study on cytokines IL-2, IL-6, IL-10 in patients of chronic allergic rhinitis treated with acupuncture Journal of Traditional Chinese Medicine 2002 June, Vol. 22, Issue 2, pp. 104–111. Petti FB, Liguori A, Ippoliti F Paracelso Institute, Body Corporate of Italian Ministry of Health, Chair of Social Medicine, School of Medicine La Sapienza University, Rome, Italy

Objective To observe the plasmatic concentration of interleukin (IL)-6, IL-10 and IL-2 in patients suffering from chronic allergic rhinitis before and after acupuncture therapy.

The effect of acupuncture on allergic rhinitis: a randomized controlled clinical trial American Journal of Chinese Medicine 2004, Vol. 32, Issue 1, pp. 105–115. Magnusson AL, Svensson RE, Leirvik C, Gunnarsson RK Bollebygd’s Primary Health Care Centre, Bollebygd, Sweden

Objective To evaluate the effect of acupuncture on allergic rhinitis.

Method This study compared active versus sham acupuncture in 40 consecutive patients with a history of allergic rhinitis and a positive skin test. Patients were randomized and assessed prior to treatment and then reassessed after 12 months. Improvements in symptoms using visual analogue scales, reduction in skin test reactions and levels of specific IgE were used to compare the effect of treatment.

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Results For one allergen, mugwort, a greater reduction in levels of specific IgE (P = 0.019, 0.039) and skin test reaction (P = 0.004) was seen in the group receiving active acupuncture compared with the group receiving sham acupuncture. However, this finding might be an artefact. No differences in clinical symptoms were seen between active versus sham acupuncture.

acupuncture treatment group. No side effects were observed for both groups.

Conclusion The results indicate that acupuncture is an effective and safe alternative treatment for the management of seasonal allergic rhinitis.

Conclusion

Acupuncture and herbal medicine

The effect of acupuncture on allergic rhinitis should be further evaluated in larger randomized studies.

Acupuncture and Chinese herbal medicine in the treatment of patients with seasonal allergic rhinitis: a randomized-controlled clinical trial

Effect of acupuncture in the treatment of seasonal allergic rhinitis: a randomized controlled clinical trial American Journal of Chinese Medicine 2002, Vol. 30, Issue 1, pp. 1–11. Xue CC, English R, Zhang JJ, Da Costa C, Li CG The Chinese Medicine Unit, RMIT University, Victoria, Australia

Objective

Allergy 2004 September, Vol. 59, Issue 9, pp. 953–960. Brinkhaus B, Hummelsberger J, Kohnen R, Seufert J, Hempen CH, Leonhardy H, Nogel R, Joos S, Hahn E, Schuppan D Department of Medicine I, Friedrich-AlexanderUniversity of Erlangen-Nuremberg, Erlangen, Germany

Objective

To evaluate the efficacy and safety of acupuncture in the treatment of seasonal allergic rhinitis.

The aim of this study was to determine whether traditional Chinese therapy is efficacious in patients suffering from seasonal allergic rhinitis.

Method

Method

A two-phase crossover single-blind clinical trial was adopted. Thirty subjects were randomly assigned to two groups with 17 and 13 subjects, respectively. They were treated with real or sham acupuncture three times per week for 4 consecutive weeks and then a crossover of treatments for a further 4 weeks without a wash-out period. The administration of real acupuncture treatment was guided by a syndrome differentiation according to Chinese medicine theory. Subjects were assessed by various criteria before, during and after the treatments. Outcome measures included subjective symptom scores using a five-point scale, relief medication scores and adverse effect records. Twenty-six subjects completed the study.

Fifty-two patients between the ages of 20 and 58 who had typical symptoms of seasonal allergic rhinitis were assigned randomly and in a blinded fashion to:

Results There was a significant improvement in five-point scale (nasal and non-nasal symptoms) in the real group compared with the sham group. No significant differences were shown in relief medication scores between the real acupuncture treatment group and the sham

• an active treatment group that received a semistandardized treatment of acupuncture and Chinese herbal medicine • a control group that received acupuncture applied to non-acupuncture points in addition to a nonspecific Chinese herbal formula. All patients received acupuncture treatment once per week and the respective Chinese herbal formula as a decoction three times daily for a total of 6 weeks. Assessments were performed before, during, and 1 week after treatment. The change in severity of hay fever symptoms was the primary outcome measured on a visual analogue scale. Each patient received a total of six acupuncture sessions once a week. Chinese herbal medicine was taken three times a day over a period of 6 weeks. The protocol used is shown in the table.

Allergic Rhinitis

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Protocol for study on allergic rhinitis Points

Herbal formula

Every patient

L.I.-4 Hegu, L.I.-20 Yingxiang. G.B.-20 Fengchi, LU-7 Lieque, LIV-3 Taichong

Jing Jie Herba Schizonepetae, Ju Hua Flos Chrysanthemi, Jue Ming Zi Semen Cassiae, Che Qian Zi Semen Plantaginis, Bai Ji Li Fructus Tribuli

Wind-Heat in Lungs

L.I.-11 Quchi

Bo He Herba Menthae haplocalycis, Sang Ye Folium Mori, Fu Ping Herba Spirodelae, Bai Shao Radix Paeoniae alba

Liver-Heat and Liver-Fire

L.I.-11 Quchi, G.B.-37 Guangming, G.B.-42 Diwuhui, T.B.-5 Waiguan

Lian Qiao Fructus Forsythiae, Shan Zhi Zi Fructus Gardeniae, Chi Shao Radix Paeoniae rubra, Sheng Di Huang Radix Rehmanniae

Lung-Yin deficiency

LU-5 Chize

Mai Men Dong Radix Ophiopogonis, Bei Sha Shen Radix Glehniae

Cold in Lungs

BL-12 Fengmen, BL-13 Feishu

Xi Xin Herba Asari, Bai Zhi Radix Angelicae dahuricae

Spleen-Qi deficiency

ST-36 Zusanli, T.B.-6 Zhigou, LU-9 Taiyuan, Yintang

Huang Qi Radix Astragali, Fu Ling Poria, Dang Shen Radix Codonopsis, Bai Zhu Rhizoma Atractylodis macrocephalae, Gan Cao Radix Glycyrrhizae uralensis

Results Compared with patients in the control group, patients in the active treatment group showed a significant after treatment improvement on the visual analogue scale and Rhinitis Quality of Life Questionnaire. Improvement on the Global Assessment of Change Scale was noted in 85% of active treatment group participants versus 40% in the control group. No differences between the two groups could be detected with the Allergic Rhinitis Symptom Questionnaire. Both treatments were well tolerated.

Conclusion The results of this study suggest that traditional Chinese therapy may be an efficacious and safe treatment option for patients with seasonal allergic rhinitis.

Herbal medicine The Chinese herbal formulation Bi Min in management of perennial allergic rhinitis: a randomized, double-blind, placebo-controlled, 12-week clinical trial Annals of Allergy, Asthma and Immunology 2002 May, Vol. 88, Issue 5, pp. 478–487.

Hu G, Walls RS, Bass D, Ramon B, Grayson D, Jones M, Gebski V Department of Medicine, University of Sydney, Australia

Objective The aim of this study was to test the effects of the Chinese herbal formulation Bi Min in patients with moderate to severe perennial allergic rhinitis.

Method In a randomized, double-blind, placebo-controlled clinical trial, 58 patients were randomized to receive either Bi Min capsules (n = 26) or placebo (n = 32) in doses of five capsules twice a day for 12 weeks. Main outcomes were measured by changes in symptom diaries, quality of life scores, patients’ evaluations of improvement on visual analogue scores, and physicians’ overall evaluation. Total serum IgE was measured in all patients without knowledge of which group they were in. After 1 year, a randomized, double-blind, dose– response study was performed with 22 patients who had previously received placebo.

Results The trial outcomes evaluated by four instruments showed a statistically significant improvement in some

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of the symptoms of allergic rhinitis, whereas others exhibited a positive trend that did not reach statistical significance. A follow-up 1 year after completion of the trial suggested that the benefit of the treatment persisted. A pilot dose–response study showed both half and full strengths were effective. Total serum IgE was reduced after the herbal treatment.

Conclusion The results suggest that the Bi Min formulation is effective in the treatment of perennial allergic rhinitis. Its mode of action is unknown.

Decreased serum IgE level, decreased IFN-gamma and IL-5 but increased IL-10 production, and suppressed cyclooxygenase 2 mRNA expression in patients with perennial allergic rhinitis after treatment with a new mixed formula of Chinese herbs International Immunopharmacology 2001 June, Vol. 1, Issue 6, pp. 1173–1182. Yang SH, Hong CY, Yu CL Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan

Objective

Clinical and experimental study for allergic rhinitis with treatment of Bi Min Kang mixture Chinese Journal of Integrated Traditional and Western Medicine 1997 February, Vol. 17, Issue 2, pp. 70–72. Bao L, Sun QW, Hu L

Objective To observe the efficacy of Bi Min Kang in treating allergic rhinitis.

Method One hundred and sixty-four cases of allergic rhinitis were treated with the Chinese medicine Bi Min Kang mixture, mainly consisting of the Kazak folk herb Artemisia rupestris L. Fifty-two cases of allergic rhinitis were treated as the control with the patent medicine Bi Yan Kang.

Results The total effective rates in both groups were 93.9% and 69.2%, respectively. After stopping the medications, the recurrence rates were 46.8% and 87.1%. Bi Min Kang was better than Bi Yan Kang in short or long term of effectiveness. Pharmacological study demonstrated that Bi Min Kang played a significant role in resisting histamine, inhibiting allergic reaction type 1 and stabilizing the cell membrane of mastocytes.

Conclusion Bi Min Kang mixture is an effective drug in treating allergic rhinitis.

To evaluate the effects of Chinese herbs on patients with perennial allergic rhinitis.

Method A new mixed formula of Chinese herbs containing Xin Yi San (Magnolia Powder) plus Xiao Qing Long Tang (Small Green Dragon Decoction) plus Xiang Sha Liu Jun Zi Tang (Aucklandia-Amomum Six Gentlemen Decoction) by the weight of 9 plus 3 plus 3 g/day was prescribed for the treatment of patients with perennial allergic rhinitis for 3 months. The patients were classified into high and low IgE groups according to the titre of serum total IgE (> 200 KIU/L in high IgE versus < 200 KIU/L in low IgE) and the presence of house dust mite-specific IgE.

Results The nasal symptomatic score in the high IgE group was significantly improved from 7.19 ± 0.18 before treatment to 2.67 ± 0.37 after treatment. In addition, the serum total and house dust mite-specific IgE levels were also decreased after treatment. For elucidating the working mechanism of the mixed formula, the TH1 (interferon-g) and TH2 (IL-4, IL-5, IL-10 and IL-13) cytokine production by phytohemagglutinin-stimulated mononuclear cells (2 μ 106 cells/mL) and cyclooxygenase type 2 (COX-2) mRNA expression in LPS or IL-13-stimulated PMN were compared before and after 3 months of treatment. It was found that the mixed formula treatment significantly enhanced IL-10 but decreased interferon-g and IL-5 production by phytohemagglutinin-stimulated mononuclear cells. The IL-5 production was also decreased by phytohemagglutinin-stimulated lymphocyte. In addition,

Allergic Rhinitis

the COX-2 mRNA expression in stimulated PMN was significantly suppressed after treatment.

Conclusion These results suggest that the new mixed formula treatment is beneficial to the patients with perennial allergic rhinitis via modulating the function of lymphocytes and neutrophils.

Treatment for seasonal allergic rhinitis by Chinese herbal medicine: a randomized placebo controlled trial Alternative Therapies Health Medicine 2003 September– October, Vol. 9, Issue 5, pp. 80–87. Xue CC, Thien FC, Zhang JJ, Da Costa C, Li CG RMIT Chinese Medicine Research Group, RMIT University, Bundoora West Campus, Bundoora, Australia

Objective To evaluate the efficacy of a Chinese herbal formulation for the treatment of seasonal allergic rhinitis.

Method A randomized, double-blind, placebo-controlled trial was adopted at RMIT Chinese Medicine Clinic. Fiftyfive patients with seasonal allergic rhinitis took part (active 28, placebo 27). A Chinese herbal medicine extract capsule containing 18 herbs or a placebo was given daily for 8 weeks. The primary measure of efficacy was a change in the severity of nasal and nonnasal symptoms using a five-point scale measured by both patients and the practitioner. The secondary measure was the change in score for the domains measured in the Rhinoconjunctivitis and Rhinitis Quality of Life Questionnaire (RRQLQ) assessed by patients.

Results Forty-nine patients completed the study (active 24, placebo 25). After 8 weeks, the severity of nasal symptoms and non-nasal symptoms was significantly less in the active treatment group than in the control group, for both measurements made by patients and those by the practitioner. Comparison of active and placebo treatment groups RRQLQ scores also indicated significant beneficial effects of treatment. Intention to treat analyses of categorical items showed that moderate to marked improvement rates were 60.7%

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and 29.6% for active and placebo groups, respectively. Eleven patients reported mild adverse events, including one withdrawal from the trial.

Conclusion This Chinese herbal medicine formulation appears to offer symptomatic relief and improvement of quality of life for some patients with seasonal allergic rhinitis.

CASE HISTORIES Case history A 33-year-old woman had been suffering from allergic rhinitis since the age of 18. She sneezed and her nose ran (white-watery discharge) when exposed to dust, cats and dogs. She also sneezed and “came out in blotches” on drinking tea, coffee, wine, spirits or eating certain foods (such as cheese, butter, chocolate, fats and spices). She suffered from frequent urination, and her need to urinate sometimes became urgent. She described it as “cystitis”, but there was no burning and the urine was pale. This symptom had started only a few months previously. She had also been suffering from backache for the previous 6 years. Her pulse was Weak and Deep, and both Rear positions were Weak. Her tongue was Pale and slightly bluish, with teeth marks and a yellow coating on the root. Diagnosis Perennial rhinitis from deficiency of Lung and Kidney’s Defensive-Qi systems, particularly Kidneys and specifically Kidney-Yang (hence the backache, frequent-urgent urination and Pale-Bluish tongue). The fact that she also sneezed on eating certain foods indicates that there was some Heat in the Large Intestine (hence the yellow tongue coating on the root). She obviously had a Lung and Kidney’s DefensiveQi systems deficiency from birth; the backache and frequent urination appeared later with the physiological decline of Kidney-Qi. Treatment Because this is perennial rhinitis, one must treat both Root and Manifestation simultaneously with a formula that tonifies Kidney-Yang. However,

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The Practice of Chinese Medicine

this patient was treated primarily with acupuncture using: • LU-7 Lieque and KI-6 Zhaohai to open the Directing Vessel and tonify Lungs and Kidneys • ST-36 Zusanli and SP-6 Sanyinjiao to tonify Qi in general • BL-23 Shenshu, KI-7 Fuliu, Ren-4 Guanyuan and KI-16 Huangshu to tonify Kidney-Yang and the Kidney-Essence • BL-13 Feishu and Du-12 Shenzhu to tonify the Lung’s Defensive-Qi system • SP-9 Yinlingquan and BL-25 Dachangshu to clear Large Intestine-Heat • Du-23 Shangxing and L.I.-20 Yingxiang to expel Wind from the nose. Additionally, she was given the patent remedy Quan Lu Wan Whole-Deer Pill. The combination of acupuncture and this patent remedy produced a complete cure of her condition.

• • • • • • •

Bu Gu Zhi Fructus Psoralelae 6 g Lu Jiao Jiao Gelatinum Cornu Cervi 4 g Wu Wei Zi Fructus Schisandrae 3 g Zhi Mu Radix Anemarrhenae 3 g Fang Feng Radix Saposhnikoviae 4 g Chan Tui Periostracum Cicadae 4 g Bai Xian Pi Cortex Dictamni 6 g

Explanation • Gui Ban and Shu Di Huang nourish the KidneyEssence and strengthen the Directing Vessel. • Bu Gu Zhi and Lu Jiao Jiao tonify the Kidney’s Defensive-Qi system and strengthen the Governing Vessel. • Wu Wei Zi tonifies the Lung’s Defensive-Qi system. • Zhi Mu clears Heat. • Fang Feng, Chan Tui and Bai Xian Pi clear WindHeat from the skin. This formula and subsequent variations produced a considerable improvement over 6 months.

Case history

Case history

A 25-year-old woman had been suffering from hay fever (seasonal allergic rhinitis) for as long as she could remember. During the summer season, she sneezed and had itchy eyes and throat. She also suffered from eczema at the sides of her nose and on her chin. The eruptions were papulelike (red spots) at first, and they then turned dry and flaky some weeks later. The spots were red and itchy and worse with exposure to the sun. Her pulse was only slightly Weak, and the left Rear position was weaker. Her tongue had a normal colour with a slightly sticky coating.

A 44-year-old man had suffered from seasonal rhinitis since the age of 22. The main manifestations were sneezing, sensitive eyes and a runny nose with a white-watery discharge (except in the morning, when it was thick-yellow). His pulse was only slightly Weak, and the left Rear position was weaker. His tongue was Pale and Swollen.

Diagnosis Seasonal rhinitis from deficiency of Lung and Kidney’s Defensive-Qi systems. Eczema from same cause. Treatment The aim of the treatment is to tonify Lung and Kidney’s Defensive-Qi systems and clear WindHeat from the Lung’s Defensive-Qi system (skin). The formula chosen was a variation of Yi Du Yang Yuan Tang Benefiting the Governing Vessel and Nourishing the Original Qi Decoction. • Gui Ban Plastrium Testudinis 15 g • Shu Di Huang Radix Rehmanniae preparata 9 g

Diagnosis Seasonal rhinitis from Lung and Kidney’s Defensive-Qi systems deficiency. The Pale and Swollen tongue also indicates a deficiency of Spleen-Yang, which often occurs in such cases after 40. The stickyyellow mucus in the mornings indicates that the sinuses have been affected due to swelling of the nasal mucosa preventing proper drainage. Treatment The main aim (outside the season) is to tonify Lung and Kidney’s Defensive-Qi systems and Spleen-Yang. The formula used was a variation of Yi Du Yang Yuan Tang Benefiting the Governing Vessel and Nourishing the Original Qi Decoction. • Gui Ban Plastrium Testudinis 15 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Bu Gu Zhi Fructus Psoralelae 6 g

Allergic Rhinitis

• • • • • • •

Lu Jiao Cornu Cervi 9 g Wu Wei Zi Fructus Schisandrae 3 g Zhi Mu Radix Anemarrhenae 3 g Huang Qi Radix Astragali 9 g Fang Feng Radix Saposhnikoviae 4 g Bai Zhu Rhizoma Atractylodis macrocephalae 6 g Fu Ling Poria 6 g

Explanation • Gui Ban and Shu Di Huang nourish the KidneyEssence. • Bu Gu Zhi and Lu Jiao tonify the Kidney’s DefensiveQi system and strengthen the Governing Vessel. • Wu Wei Zi and Huang Qi tonify the Lung’s DefensiveQi system. • Zhi Mu clears Heat. • Fang Feng expels Wind from the nose. • Bai Zhu and Fu Ling tonify the Spleen and drain Dampness. This formula produced an improvement after a short time. The patient is still under treatment.

Case history A 37-year-old woman had been suffering from seasonal allergic rhinitis (hay fever) for 11 years. The problem started after the birth of her first child. She was Chinese and came to England from Singapore 3 years before the birth of her fist child. She had a second child 2 years after the first, and the allergic rhinitis was better during the pregnancy. Her symptoms were the usual ones: sneezing, runny nose with watery nasal discharge, itchy eyes. She was also occasionally slightly wheezy. She also suffered from lower backache and tinnitus. Her tongue was Pale, Swollen and with a sticky coating. Her pulse was Soggy, i.e. Weak but slightly Slippery. It was particularly Weak on the Kidney positions. Diagnosis As explained above, I relate the Root of allergic rhinitis to a deficiency of the Lung and Kidney’s

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Defensive-Qi systems. Her symptoms of Kidney-Yang deficiency were the lower backache, the tinnitus, the Pale tongue and the Weak pulse. The onset of the allergic rhinitis after childbirth is also related to a Kidney deficiency; the fact that the rhinitis got better during the second pregnancy also confirms this. I think that the Kidneys can become not only weaker during a pregnancy but also stronger, therefore I relate both an aggravation or an amelioration of a symptom during pregnancy to a Kidney deficiency. In her case, however, the allergic rhinitis has a slightly different and more complex pathology than the one outlined in this chapter. Her tongue and pulse also show a Spleen deficiency and Phlegm; the Phlegm plays a role in the pathology of allergic rhinitis in her case. I think that the change in diet from a Chinese to a Western diet when she moved from Singapore to England contributed to the formation of Phlegm. I report this case history mostly for its interesting aspect of the onset of allergic rhinitis after childbirth and amelioration during pregnancy. It is far too early to report any reaction, as the treatment was only just started at the time of writing.

END NOTES 1. Guangzhou Army Health Department 1974 Xin Bian Zhong Yi Xue Gai Yao [A New General Outline of Chinese Medicine]. People’s Health Publishing House, Beijing, p. 676. 2. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 150. First published c.100 BC. 3. Ibid., p. 355. 4. Wang Luo Zhen 1985 Qi Jing Ba Mai Kao Jiao Zhu [A Compilation of the Study of the Eight Extraordinary Vessels]. Shanghai Science Publishing House, Shanghai, p. 89. The Study of the Eight Extraordinary Vessels was written by Li Shi Zhen and first published in 1578. 5. Another interesting connection between the Kidneys and rhinitis could be observed in the use by some Chinese doctors of injection of cortisone in the point BL-12 Fengmen with far fewer side effects than in a systemic administration of cortisone. If we view cortisone as a kind of “Kidney tonic”, it would make sense to inject it in the point BL-12, which expels Wind and spreads Defensive Qi in the Exterior. 6. A Compilation of the Study of the Eight Extraordinary Vessels, p. 89.

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CHAPTER 7

SINUSITIS (NASAL POLYPS)

SINUSITIS 202 AETIOLOGY AND PATHOLOGY Repeated invasions of Wind Diet 203

202 202

IDENTIFICATION OF PATTERNS AND TREATMENT Wind-Heat 205 Lung-Heat 205 Liver- and Gall Bladder-Fire 206 Stomach and Spleen Damp Heat 207 Qi and Blood stagnation 207 Lung- and Spleen-Qi deficiency 208 Liver- and Kidney-Yin deficiency 209 MODERN CHINESE LITERATURE

203

210

CLINICAL TRIALS 210 Acupuncture 210 PROGNOSIS

211

NASAL POLYPS 211 CHINESE MEDICINE TREATMENT 211 Lung-Heat with stagnation 212 Damp Phlegm with stasis 212 Lung- and Spleen-Qi deficiency with Damp Phlegm 213

NASAL POLYPS • Lung-Heat with stagnation • Damp Phlegm with stasis • Lung- and Spleen-Qi deficiency with Damp Phlegm

SINUSITIS (NASAL POLYPS) The sinuses are mucosa-lined cavities in the skull communicating with the nasal cavities. There are four pairs of sinuses, i.e. the ethmoidal, frontal, maxillary and sphenoidal sinuses. The frontal and maxillary sinuses, especially the latter ones, are more prone to infection and inflammation. Figures 7.1 and 7.2 show the location of frontal and maxillary sinuses in relation to nasal cavities, while Figure 7.3 shows for clinical examination the areas overlying such sinuses. The condition of sinusitis broadly corresponds to the old Chinese medical category of Bi Yuan, which literally means “nose pool”. As we have seen in the chapter on allergic rhinitis, the differentiation and treatment of Bi Yuan are often used to diagnose and

SINUSITIS Full • Wind-Heat • Lung-Heat • Liver- and Gall Bladder-Fire • Stomach and Spleen Damp Heat • Qi and Blood stagnation

Frontal sinus Sphenoidal sinus Bony position of nasal septum

Empty • Lung- and Spleen-Qi deficiency • Liver- and Kidney-Yin deficiency

Hard palate Figure 7.1 Frontal and sphenoidal sinuses.

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Orbit Nasal cavity Maxillary sinus

Figure 7.2 Maxillary sinuses (cross-section, anterior view).

Frontal sinus

Maxillary sinus

and into the palate by the pituitary gland; but I shall prove that the structure of these parts is such that neither is possible. It is interesting to note that, when seen from the viewpoint of Chinese medicine, the assumption that nasal discharges originate from the brain is obviously anatomically wrong but physiologically possible, because the Gall Bladder channel flows through the brain. In Chinese medicine, Heat in the brain affects the Governing Vessel and flows down to the nose and sinuses. The main symptoms of sinusitis are a purulent, yellow nasal discharge from the front and the back of the nose (into the throat), a stuffy nose, a frontal headache, facial pain and a feeling of muzziness (fuzziness) and heaviness of the head. There may be local tenderness over the maxillary or frontal sinuses. The discussion of sinusitis will be done according to the following topics. Sinusitis • Aetiology and pathology • Identification of patterns and treatment • Modern Chinese literature • Clinical trials • Prognosis Nasal polyps • Chinese medicine treatment

Figure 7.3 Location of frontal and maxillary sinuses.

SINUSITIS treat allergic rhinitis, which is a mistake, because Bi Yuan corresponds more closely to sinusitis. Bi Yuan is sometimes also called Nao Lou, which means “brain discharge”, because the profuse and purulent discharge from the nose was considered to come from the brain. Interestingly, Hippocrates and his disciples also thought that the evil humour (of sinusitis) arose in the brain and from there descended into the nasal cavities.1 It was not until 1672 that Richard Lower demonstrated in his book De Catarrhis that it was anatomically impossible for respiratory catarrh to originate in the brain:2 Since the opinion has generally persisted amongst learned doctors everywhere that catarrh ... comes from the cerebrum I shall ... attempt to prove the contrary. People claim that the fluid collected in the ventricles of the brain oozes down into the nostrils solely by the cribriform plate,

AETIOLOGY AND PATHOLOGY Repeated invasions of Wind Repeated invasions of external Wind, whether WindHeat or Wind-Cold (but more frequently Wind-Heat), impair the diffusing and descending of Lung-Qi in the nasal passages so that fluids stagnate in the nose and sinuses. The long-term stagnation of fluids leads to Phlegm and Heat, which manifest with a yellow, purulent nasal discharge. Repeated invasions of external Wind are the main cause of sinusitis, especially when the person does not take care or have extra rest during such invasions. From a Western medical perspective, infections from the common cold or influenza viruses frequently cause secondary infections in the sinuses, especially the

Sinusitis (Nasal Polyps)

maxillary sinuses. For anatomical reasons, sinus infection is liable to become chronic. In fact, the openings through which the maxillary sinuses communicate with the nasal cavities are narrow, and inflammatory oedema of the mucosa lining them often prevents adequate drainage of the infected sinuses. As a result, resolution of sinus infection is often slow and incomplete so that, when the next viral infection from the common cold or influenza occurs, the already infected and inflamed sinuses will be affected again. Thus, repeated infections by the common cold or influenza viruses will lead to chronic sinusitis.

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nasal passages so that fluids stagnate in the nose and sinuses.  Infections from the common cold or influenza viruses frequently cause secondary infections in the sinuses, especially the maxillary sinuses.  Repeated infections by the common cold or influenza viruses will lead to chronic sinusitis. Diet  Excessive consumption of greasy-hot foods leading to Phlegm and Heat.

Diet Excessive consumption of greasy-hot foods leading to Phlegm and Heat may predispose one to sinusitis. This type of food may lead to the formation of Damp Heat in the Stomach and Spleen, which may be carried upwards to the sinuses via the Stomach channel. However, this can be only a predisposing factor in the development of sinusitis, the repeated invasions of Wind being the necessary condition. It is important to understand clearly the difference between the clinical manifestations of allergic rhinitis and of sinusitis. In allergic rhinitis, the nasal discharge is clear, runny and profuse. In sinusitis, the nasal discharge is thick, sticky and yellow. CLINICAL NOTE In allergic rhinitis, the nasal discharge is clear, runny and profuse. In sinusitis, the nasal discharge is thick, sticky and yellow. In some cases, the congestion of the nasal mucosa that occurs in allergic rhinitis may prevent proper drainage from the sinuses and lead to a secondary sinusitis. If the patient has a clear history of reaction to allergens (sneezing and runny nose) and the nasal discharge is sometimes clear and runny and sometimes thick and yellow, we know that the sinusitis is secondary to allergic rhinitis.

SUMMARY AETIOLOGY AND PATHOLOGY Repeated invasions of Wind  Repeated invasions of external Wind impair the diffusing and descending of Lung-Qi in the

IDENTIFICATION OF PATTERNS AND TREATMENT The patterns discussed will be: • • • • • • •

Wind-Heat Lung-Heat Liver- and Gall Bladder-Fire Stomach and Spleen Damp Heat Qi and Blood stagnation Lung- and Spleen-Qi deficiency Liver- and Kidney-Yin deficiency

It should be remembered that all the above patterns are of the Excess type, and the formulae used are aimed at expelling pathogenic factors. However, in chronic cases, there is always an underlying deficiency, especially of the Spleen, which needs to be addressed. In such cases, all the formulae indicated below need to be modified with the addition of Spleen-Qi tonic herbs such as Bai Zhu Rhizoma Atractylodis macrocephalae, Dang Shen Radix Codonopsis or Huang Qi Radix Astragali. With acupuncture, the points indicated below will have to be integrated by the addition of points to tonify the Spleen such as ST-36 Zusanli and BL-20 Pishu. The above patterns should be clearly classified according to Full-Empty and Acute-Chronic conditions. The Empty patterns appear only in chronic conditions, while some of the Full patterns may appear in acute or chronic conditions. The classification of the above patterns according to Full and Empty is as follows. Full • Wind-Heat • Lung-Heat • Liver- and Gall Bladder-Fire

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• Stomach and Spleen Damp Heat • Qi and Blood stagnation

Table 7.1 Full-Empty and Acute-Chronic classification of sinusitis patterns

Empty • Lung- and Spleen-Qi deficiency • Liver- and Kidney-Yin deficiency The classification of the above patterns according to Acute and Chronic is as follows (Fig. 7.4 and Table 7.1). Acute • Wind-Heat • Lung-Heat • Liver- and Gall Bladder-Fire • Stomach and Spleen Damp Heat

Full

Empty

Acute

Wind-Heat Lung-Heat Liver- and Gall BladderFire Stomach and Spleen Damp Heat



Chronic

Lung-Heat Liver- and Gall BladderFire Stomach and Spleen Damp Heat Qi and Blood stagnation

Lung- and Spleen-Qi deficiency Liver- and Kidney-Yin deficiency

Chronic • Lung- and Spleen-Qi deficiency • Liver- and Kidney-Yin deficiency • Qi and Blood stagnation

the same name. The main herb to use from this category is Shi Chang Pu Rhizoma Acori tatarinowii. However, there are herbs from other categories that also open the nose and sinus orifices and these are:

Both acute and chronic • Lung-Heat • Liver- and Gall Bladder-Fire • Stomach and Spleen Damp Heat As for treatment, although not “officially” one of the four orifices of the face, the sinuses should be considered like an “orifice” (assimilated to those of the nose). In sinusitis, there is always an obstruction of the orifices of the nose and sinuses. The implication of this in treatment is that we should use the method of “opening the orifices” by using some herbs from the category with

• • • • •

Bai Zhi Radix Angelicae dahuricae Xin Yi Hua Flos Magnoliae Cang Er Zi Fructus Xanthii Xi Xin Herba Asari Cong Bai Bulbus Allii fistulosi.

As for acupuncture points, the main points that act on the sinuses are as follows (Fig. 7.5).

ST-8 FULL Acute

EMPTY

Du-23

WIND-HEAT BL-2 LUNG-HEAT

Acute or chronic

LIVER- AND GALL BLADDER-FIRE STOMACH AND SPLEEN DAMP HEAT

Chronic

QI AND BLOOD STAGNATION

Yintang

Ethmoid sinus

Bitong L.I.-20

Maxillary sinus

LUNG- AND SPLEENQI DEFICIENCY LIVER- AND KIDNEYYIN DEFICIENCY

Figure 7.4 Full-Empty and Acute-Chronic classification of sinusitis patterns.

Frontal sinus

Distal points: LU-7, L.I.-4, ST-44 Figure 7.5 Points for sinusitis.

Sinusitis (Nasal Polyps)

Local • ST-8 Touwei • Du-23 Shangxing • BL-2 Zanzhu • Yintang • Bitong • L.I.-20 Yingxiang Distal • LU-7 Lieque • L.I.-4 Hegu • ST-44 Neiting

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Explanation This formula expels Wind-Heat, opens the nasal orifice, separates turbid from clear and restores the descending of Lung-Qi.

Prescription EMPIRICAL PRESCRIPTION (No. 2)

Explanation This formula has a stronger effect than the previous one in clearing Damp Heat and Toxic Heat and is therefore used when there is a profuse sticky-yellow or purulent nasal discharge.

Wind-Heat Clinical manifestations

SUMMARY

Stuffed nose, yellow-sticky or purulent nasal discharge, headache, diminished sense of smell, aversion to cold and fever. Tongue: Red sides and/or front. Pulse: Floating-Rapid. This corresponds to an acute attack of sinusitis following an invasion of Wind-Heat.

WIND-HEAT Points L.I.-11 Quchi, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Bitong, Du-23 Shangxing, BL-12 Fengmen. Reducing method.

Treatment principle

Herbal therapy Prescription EMPIRICAL PRESCRIPTION (No. 1)

Release the Exterior, expel Wind-Heat and restore the dispersing and descending of Lung-Qi.

Prescription EMPIRICAL PRESCRIPTION (No. 2)

Acupuncture Points L.I.-11 Quchi, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Bitong, Du-23 Shangxing, BL-12 Fengmen. Reducing method.

Explanation • L.I.-11 expels Wind-Heat and clears Heat. • L.I.-4 expels Wind-Heat and clears the nose. • L.I.-20, BL-2 and Bitong (extra point) expel Wind and clear the nose and sinuses. • Du-23 opens the nose and expels Wind. It should be needled horizontally forwards. • BL-12, with cupping, expels Wind.

Herbal therapy Prescription EMPIRICAL PRESCRIPTION (No. 1)

Lung-Heat Clinical manifestations Sticky-yellow or purulent nasal discharge, tenderness over maxillary sinuses, flushed face, feeling of heat, thirst, headache. Tongue: Red with sticky-yellow coating. Pulse: Slippery and Full, although possibly only on the right Front position. This is a condition of chronic sinusitis when repeated invasions of Wind-Heat have impaired the diffusing and descending function of the Lungs so that fluids stagnate in the sinuses and give rise to PhlegmHeat.

Treatment principle Restore the diffusing and descending of Lung-Qi, clear Lung-Heat.

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Acupuncture Points L.I.-11 Quchi, L.I.-4 Hegu, LU-10 Yuji, LU-7 Lieque, L.I.-20 Yingxiang, BL-2 Zanzhu, Bitong, Du-14 Dazhui. Reducing method.

Explanation • • • •

L.I.-11 clears Heat. L.I.-4 opens the nose. LU-10 clears Lung-Heat and opens the nose. LU-7 restores the dispersing and descending of Lung-Qi. • L.I.-20, BL-2 and Bitong open the nose and expel Wind. • Du-14 is added if the symptoms of Heat are pronounced.

Herbal therapy Prescription XIN YI QING FEI YIN Magnolia Clearing the Lungs Decoction

Explanation This formula clears Lung-Heat and resolves Toxic Heat.

SUMMARY LUNG-HEAT Points L.I.-11 Quchi, L.I.-4 Hegu, LU-10 Yuji, LU-7 Lieque, L.I.-20 Yingxiang, BL-2 Zanzhu, Bitong, Du-14 Dazhui. Reducing method. Herbal therapy Prescription XIN YI QING FEI YIN Magnolia Clearing the Lungs Decoction

This condition is due to Liver- and Gall Bladder-Fire rising to the nose and the brain. Fire condenses the fluids in the nose and leads to Phlegm-Heat. The Gall Bladder channel flows through the brain, and Gall Bladder-Fire causes what is considered to be a discharge of purulent fluid from the brain. Although this pattern is always mentioned in Chinese books, in my experience, it is not a common cause of sinusitis.

Treatment principle Drain Liver- and Gall Bladder-Fire, restore the descending of Lung-Qi.

Acupuncture Points LIV-2 Xingjian, G.B.-43 Xiaxi, LU-7 Lieque, L.I.-4 Hegu, Bitong, BL-2 Zanzhu, G.B.-15 Toulinqi. Reducing method.

Explanation • • • • • •

LIV-2 drains Liver-Fire. G.B.-43 drains Gall Bladder-Fire. LU-7 restores the descending of Lung-Qi. L.I.-4 and Bitong open the nose and the sinuses. BL-2 opens the frontal sinuses. G.B.-15 is a local point to clear the Gall Bladder channel. It affects the eyes and the sinuses.

Herbal therapy Prescription QING GAN TOU DING TANG Clearing the Liver and Penetrating the Crown (of the head) Decoction

Explanation This formula subdues Liver-Yang, drains Liver-Fire and cools Blood.

Liver- and Gall Bladder-Fire

Prescription

Clinical manifestations

LONG DAN BI YUAN FANG Gentiana “Nose Pool” Formula

Yellow-purulent nasal discharge, bloodshot eyes, red face, headache on temples and cheeks, dizziness, a bitter taste, dry stools, irritability. Tongue: Red with redder sides, sticky-yellow coating. Pulse: Wiry, Slippery and Rapid.

Explanation This formula drains Liver-Fire, resolves Toxic Heat and opens the sinuses.

Sinusitis (Nasal Polyps)

SUMMARY LIVER- AND GALL BLADDER-FIRE Points LIV-2 Xingjian, G.B.-43 Xiaxi, LU-7 Lieque, L.I.-4 Hegu, Bitong, BL-2 Zanzhu, G.B.-15 Toulinqi. Reducing method. Herbal therapy Prescription QING GAN TOU DING TANG Clearing the Liver and Penetrating the Crown (of the head) Decoction Prescription LONG DAN BI YUAN FANG Gentiana “Nose Pool” Formula

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• Ren-13 harmonizes the Stomach and regulates the Upper Burner. • Bitong and BL-2 open the nose and the sinuses.

Herbal therapy Prescription CANG ER BI DOU YAN FANG Xanthium Sinusitis Formula

Explanation This formula resolves Dampness, clears Heat, harmonizes the Stomach and opens the sinuses. It is specific to treat sinusitis.

Modifications • If there is Stomach-Fire with constipation or dry stools, add Da Huang Rhizoma Rhei.

Stomach and Spleen Damp Heat Clinical manifestations Sticky-yellow nasal discharge, red cheeks, thirst, dry lips, impaired sense of smell, a feeling of heaviness and muzziness of the head, a frontal headache, a sticky taste, a feeling of oppression of the chest and epigastrium. Tongue: sticky-yellow coating in the centre. Pulse: Slippery. This pattern is a common cause of chronic sinusitis. It is common also in children.

Treatment principle Clear Heat, resolve Dampness, harmonize the Stomach, tonify the Spleen.

Acupuncture Points Ren-12 Zhongwan, BL-20 Pishu, Ren-9 Shuifen, SP-9 Yinlingquan, BL-22 Sanjiaoshu, L.I.-11 Quchi, L.I.-4 Hegu, Ren-13 Shangwan, Bitong, BL-2 Zanzhu. Even method, except on the first two points, which should be reinforced.

Explanation • Ren-12 and BL-20 tonify the Spleen to resolve Dampness. • Ren-9, SP-9 and BL-22 resolve Dampness. • L.I.-11 resolves Damp Heat. • L.I.-4 opens the nose and harmonizes the Stomach.

Three Treasures remedy Welcome Fragrance Welcome Fragrance is a variation of the above formula, and it resolves Dampness and clears Heat from the sinuses. It is specific for acute or chronic sinusitis.

SUMMARY STOMACH AND SPLEEN DAMP HEAT Points Ren-12 Zhongwan, BL-20 Pishu, Ren-9 Shuifen, SP-9 Yinlingquan, BL-22 Sanjiaoshu, L.I.-11 Quchi, L.I.-4 Hegu, Ren-13 Shangwan, Bitong, BL-2 Zanzhu. Even method, except on the first two points, which should be reinforced. Herbal therapy Prescription CANG ER BI DOU YAN FANG Xanthium Sinusitis Formula Three Treasures remedy Welcome Fragrance

Qi and Blood stagnation Clinical manifestations Sticky, white or yellow nasal discharge, headache, facial pain that may be worse at night, nasal mucosa inflamed and hypertrophied, polyps.

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Tongue: Purple. Pulse: Wiry or Firm. This pattern is seen in sinusitis only in very chronic conditions in middle-aged people.

Treatment principle Invigorate Blood, eliminate stasis, move Qi.

Acupuncture

LIV-3 Taichong, SP-10 Xuehai. All with even method. Herbal therapy Prescription TONG QIAO HUO XUE TANG plus CANG ER ZI SAN Opening the Orifices and Invigorating Blood Decoction plus Xanthium Powder

Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, P-6 Neiguan, LIV-3 Taichong, SP-10 Xuehai. All with even method.

Explanation • LU-7 and L.I.-4 regulate the ascending and descending of Qi in the head and therefore help to open the orifices. • L.I.-20, BL-2 and Yintang are local points to open the sinuses and relieve inflammation. • ST-8 is a local point to open the orifices of the head. • P-6 invigorates Blood and eliminates stasis in the Upper Burner. • LIV-3 and SP-10 invigorate Blood and eliminate stasis.

Herbal therapy

Lung- and Spleen-Qi deficiency Clinical manifestations White-sticky nasal discharge without smell, stuffy nose, diminished sense of smell, feeling of heaviness of the head, facial pain, inflamed and hypertrophied nasal mucosa, polyps, tiredness, poor appetite, loose stools, weak voice, propensity to catching colds. Tongue: Pale. Pulse: Weak.

Treatment principle Tonify Lung- and Spleen-Qi, resolve Dampness, open the sinuses.

Prescription TONG QIAO HUO XUE TANG plus CANG ER ZI SAN Opening the Orifices and Invigorating Blood Decoction plus Xanthium Powder

Explanation These two formulae together invigorate Blood, eliminate stasis and open the orifices specifically from the head and therefore also the sinuses. Please note that the first formula contains She Xiang Moschus, which should be omitted (as its use is illegal) and replaced with Shi Chang Pu Rhizoma Acori tatarinowii.

SUMMARY QI AND BLOOD STAGNATION Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, P-6 Neiguan,

Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-13 Feishu. The first six points with even method, the rest with reinforcing method.

Explanation • LU-7 and L.I.-4 regulate the ascending and descending of Qi in the head and therefore help to open the orifices. • L.I.-20, BL-2 and Yintang are local points to open the sinuses and relieve inflammation. • ST-8 is a local point to open the orifices of the head. • ST-36, SP-6, Ren-12 and BL-20 tonify Spleen-Qi. Ren-12 also tonifies Lung-Qi. • BL-13 tonifies Lung-Qi.

Sinusitis (Nasal Polyps)

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Herbal therapy

Liver- and Kidney-Yin deficiency

Prescription

Clinical manifestations

SHEN LING BAI ZHU SAN Ginseng-Poria-Atractylodes Powder

Runny but scanty nasal discharge, diminished sense of smell, headaches felt inside the skull, dizziness, tinnitus, lower backache, night-sweating, inflamed nasal mucosa but not hypertrophied. Tongue: without coating. Pulse: Floating-Empty.

Explanation This formula tonifies Lung- and Spleen-Qi and resolves Dampness. To treat chronic sinusitis, it should be adapted according to the modifications listed below.

Modifications • Stuffy nose: Bai Zhi Radix Angelicae dahuricae and Xin Yi Hua Flos Magnoliae. • Feeling of heaviness of the head, facial pain: Ge Gen Radix Puerariae and Xi Xin Herba Asari. • Inflamed mucosa: Dang Gui Radix Angelicae sinensis and Chuan Xiong Rhizoma Chuanxiong. • Propensity to catching cold, sinusitis elicited by exposure to wind: Huang Qi Radix Astragali and Fang Feng Radix Saposhnikoviae. • Damp Heat, sticky-yellow nasal discharge: Che Qian Zi Semen Plantaginis and Huang Lian Rhizoma Coptidis.

Three Treasures remedies Central Mansion plus Welcome Fragrance Central Mansion tonifies Lung- and Spleen-Qi and resolves Dampness; it is a variation of Shen Ling Bai Zhu San Ginseng-Poria-Atractylodes Powder. Welcome Fragrance resolves Damp Heat from the sinuses.

SUMMARY LUNG- AND SPLEEN-QI DEFICIENCY Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-13 Feishu. The first six points with even method, the rest with reinforcing method. Herbal therapy Prescription SHEN LING BAI ZHU SAN Ginseng-Poria-Atractylodes Powder Three Treasures remedies Central Mansion plus Welcome Fragrance

Treatment principle Nourish Liver- and Kidney-Yin, open the sinuses.

Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, Ren-4 Guanyuan, SP-6 Sanyinjiao, LIV-8 Ququan, KI-3 Taixi. All with even method, except the last four points, which should be reinforced.

Explanation • LU-7 and L.I.-4 regulate the ascending and descending of Qi in the head and therefore help to open the orifices. • L.I.-20, BL-2 and Yintang are local points to open the sinuses and relieve inflammation. • ST-8 is a local point to open the orifices of the head. • Ren-4, SP-6, LIV-8 and KI-3 nourish Liver- and Kidney-Yin.

Herbal therapy Prescription QI JU DI HUANG WAN Variation Lycium-Chrysanthemum-Rehmannia Pill Variation

Explanation This formula nourishes Liver- and Kidney-Yin and opens the sinuses.

SUMMARY LIVER- AND KIDNEY-YIN DEFICIENCY Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, Ren-4 Guanyuan,

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SP-6 Sanyinjiao, LIV-8 Ququan, KI-3 Taixi. All with even method, except the last four points, which should be reinforced. Herbal therapy Prescription QI JU DI HUANG WAN Variation Lycium-Chrysanthemum-Rehmannia Pill Variation

CLINICAL TRIALS Acupuncture Comparison of traditional Chinese acupuncture, minimal acupuncture at non-acupoints and conventional treatment for chronic sinusitis Complementary Therapies in Medicine 2005 March, Vol. 13, Issue 1, pp. 4–10. Rossberg E, Larsson PG, Birkeflet O, Soholt LE, Stavem K Balder-Klinikken, Oslo, Norway

MODERN CHINESE LITERATURE

Objective

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 27, No. 6, 1986, pp. 34–35.

To compare traditional Chinese acupuncture, minimal acupuncture at non-acupoints and conventional treatment for chronic sinusitis.

Tan Hui Zhen, “Clinical analysis of 100 cases of chronic sinusitis treated with Chinese herbs.”

Method

Dr Tan Hui Zhen treated 100 patients suffering from chronic sinusitis; there were 57 men and 43 women. The youngest patient was 12 and the oldest 56. The formula used was as follows. • • • • • • • • • • • • • • •

Pu Gong Ying Herba Taraxaci 12 g Ju Hua Flos Chrysanthemi 12 g Huang Qin Radix Scutellariae 15 g Yu Xing Cao Herba Houttuniae 15 g Bai Jiang Cao Herba Patriniae 15 g Ban Lan Gen Radix Isatis seu Baphicacanthis 10 g Bai Zhi Radix Angelicae dahuricae 15 g Xin Yi Hua Flos Magnoliae 15 g Cang Er Zi Fructus Xanthii 10 g Man Jing Zi Fructus Viticis 10 g Chi Shao Radix Paeoniae rubra 10 g Chuan Xiong Rhizoma Chuanxiong 6 g Jie Geng Radix Platycodi 10 g Gao Ben Rhizoma Ligustici 6 g Gan Cao Radix Glycyrrhizae uralensis 3 g

The treatment principle behind this formula is to resolve Toxic Heat, invigorate Blood and open the nasal and sinosal orifices. The results were as follows. • Good results: 71 cases (71%) • Some results: 23 cases (23%) • No results: 6 cases (6%)

A three-armed, single-blind, randomized controlled study was adopted at an outpatient specialist clinic. Sixty-five patients with symptoms of sinusitis for more than 3 months and signs of sinusitis on computed tomography were recruited. Patients were randomized to one of three trial groups: 1. 2–4 weeks of medication with antibiotics, corticosteroids, 0.9% sodium chloride solution and local decongestants (n = 21) 2. 10 treatments with traditional Chinese acupuncture (n = 25) 3. 10 treatments with minimal acupuncture at nonacupoints (n = 19). Change in sinus soft tissue swelling on computed tomography, symptoms of sinusitis, and health-related quality of life, using the two component summary scales of the Short Form-36 and a rating scale, were observed.

Results In the conventional treatment group, sinus soft tissue swelling was reduced over 4 weeks and health-related quality of life improved over 12 weeks. Pairwise comparisons of changes in total symptom score between the groups showed signs of a difference between conventional medication and sham over 4 weeks.

Conclusion Sinus soft tissue swelling was reduced in the conventional treatment group over 4 weeks and health-related

Sinusitis (Nasal Polyps)

quality of life improved over 12 weeks. Only a nonsignificant difference in symptom score change over 4 and 12 weeks was shown between conventional medication and traditional Chinese acupuncture.

The effects of acupuncture on thermal sensitivity and the clinical perception of pain in patients with sinusitis Ear, Nose, and Throat Journal 1988, Vol. 67, Issue 8, pp. 565–566, 571–572. Lundeberg T, Laurell G, Thomas M

Objective This study was carried out to determine the effects of acupuncture on thermal sensitivity and the clinical perception of pain in patients with sinusitis.

Method Thirty-five patients with sinusitis and 12 healthy subjects took part. Patients received acupuncture with manual stimulation, 2-Hz electroacupuncture, 80-Hz electroacupuncture or two different modes of placebo.

Results The intensity of pain was reduced in 13 out of the 21 patients receiving active stimulations, but in only 4 out of 14 patients receiving placebo treatments. Thresholds for the perceptions of cold, warm and heat sensations did not differ significantly between painful and non-painful skin areas in patients or between patients and healthy controls. Despite the finding that 17 of the 35 patients had a definite reduction in the intensity of sinus pain, no significant changes in thermal sensitivity were noted in any of these test groups.

Heat. The most likely deficiencies are those of Lung-Qi and Stomach- and Spleen-Qi. If both acupuncture and herbal medicine are used, it is possible to use acupuncture to tonify any underlying deficiency and herbal medicine to clear pathogenic factors (Heat, Damp Heat or Toxic Heat).

NASAL POLYPS Small nasal polyps usually cause few problems, but larger ones can affect breathing and diminish the sense of smell. Sometimes they may cause dull headaches or snoring (Fig. 7.6). Nasal polyps result from inflammation of the nasal mucosa. Signs and symptoms include: • • • • • •

runny nose persistent stuffiness chronic sinus infections diminished sense of smell dull headaches snoring.

Polyps are treated either with nasal corticosteroid sprays or with surgery; however, when excised they frequently return.

CHINESE MEDICINE TREATMENT Polyps are usually associated with the condition of Bi Yuan in Chinese medicine. The patterns appearing in polyps are: • Lung-Heat with stagnation • Damp Phlegm with stasis

Conclusion These results indicate that acupuncture may be effective for reducing the pain felt by patients suffering from sinusitis, but further trials are needed. Nasal polyps

PROGNOSIS Sinusitis is a stubborn, chronic disease that requires long-term treatment. The more obvious the signs of Toxic Heat, the longer it will take to treat. It is important to attend to any underlying deficiency as well as clearing Heat, resolving Damp Heat or Toxic

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Figure 7.6 Nasal polyps.

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• Lung- and Spleen-Qi deficiency with Damp Phlegm.

Lung-Heat with stagnation Clinical manifestations

Herbal therapy Prescription HUANG QIN QING FEI YIN plus CANG ER ZI SAN Scutellaria Clearing the Lungs Decoction plus Xanthium Powder

Red, shiny, soft and slippery polyps, diminished sense of smell, yellow-sticky nasal discharge, headache. Tongue: Red with yellow coating. Pulse: Overflowing-Rapid.

Treatment principle Clear Lung-Heat, invigorate Blood, open the nose and sinuses.

Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, LU-5 Chize, L.I.-11 Quchi, BL-2 Zanzhu, ST-8 Touwei, Bitong, P-6 Neiguan. All with even method.

Explanation • • • •

LU-7 and L.I.-4 open the nose and sinuses. LU-5 clears Lung-Heat. L.I.-11 clears Heat. BL-2, ST-8 and Bitong are local points to open the nose and sinuses. • P-6 invigorates Blood in the Upper Burner.

Herbal therapy

Damp Phlegm with stasis Clinical manifestations White-sticky, shiny, soft polyps, diminished sense of smell, white, sticky or runny nasal discharge, headache, feeling of heaviness of the head, a feeling of oppression of the chest, expectoration of sputum. Tongue: Swollen, sticky coating. Pulse: Slippery.

Treatment principle Resolve Phlegm, soften hardness, dissolve nodules.

Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei, Bitong, Ren-12 Zhongwan, Ren-9 Shuifen, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-40 Fenglong. All with even method.

Prescription

Explanation

HUANG QIN QING FEI YIN plus CANG ER ZI SAN Scutellaria Clearing the Lungs Decoction plus Xanthium Powder

• LU-7 and L.I.-4 open the nose and sinuses. • BL-2, ST-8 and Bitong are local points to open the nose and sinuses. • Ren-12, Ren-9, SP-6, SP-9 and ST-40 resolve Phlegm.

Explanation These two formulae together clear Lung-Heat, open the nose and sinuses and invigorate Blood.

Herbal therapy

SUMMARY

Prescription

LUNG-HEAT WITH STAGNATION

DAO TAN TANG plus CANG ER ZI SAN Conducting Phlegm Decoction plus Xanthium Powder

Points LU-7 Lieque, L.I.-4 Hegu, LU-5 Chize, L.I.-11 Quchi, BL-2 Zanzhu, ST-8 Touwei, Bitong, P-6 Neiguan. All with even method.

Explanation These two formulae together resolve Phlegm and dissolve nodules from the nose and sinuses.

Sinusitis (Nasal Polyps)

SUMMARY DAMP-PHLEGM WITH STASIS Points LU-7 Lieque, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei, Bitong, Ren-12 Zhongwan, Ren-9 Shuifen, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-40 Fenglong. All with even method. Herbal therapy Prescription DAO TAN TANG plus CANG ER ZI SAN Conducting Phlegm Decoction plus Xanthium Powder

Lung- and Spleen-Qi deficiency with Damp Phlegm Clinical manifestations White, shiny polyps which return after surgery, diminished sense of smell, runny or sticky nasal discharge, a feeling of oppression of the chest, expectoration of sputum, tiredness, loose stools, poor appetite, weak voice, propensity to catching colds. Tongue: Pale, Swollen, sticky coating. Pulse: Weak and slightly Slippery or Soggy.

Treatment principle Tonify Lung- and Spleen-Qi, resolve Phlegm, dissolve nodules.

Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei, Bitong, Ren-9 Shuifen, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-40 Fenglong, Ren-12 Zhongwan, ST36 Zusanli, BL-20 Pishu, LU-9 Taiyuan, BL-13 Feishu. All with even method, except the last five points, which should be needled with reinforcing method.

Explanation • LU-7 and L.I.-4 open the nose and sinuses. • BL-2, ST-8 and Bitong are local points to open the nose and sinuses.

213

• Ren-9, SP-6, SP-9 and ST-40 resolve Phlegm. • Ren-12, ST-36 and BL-20 tonify Spleen-Qi. • LU-9 Taiyuan and BL-13 Feishu tonify Lung-Qi.

Herbal therapy Prescription BU ZHONG YI QI TANG plus ER CHEN TANG Tonifying the Centre and Benefiting Qi Decoction plus Two Old Decoction

Modifications • Stuffy nose, diminished sense of smell: Bai Zhi Radix Angelicae dahuricae, Xin Yi Hua Flos Magnoliae, Shi Chang Pu Rhizoma Acori tatarinowii. • Stubborn polyps resistant to treatment: Jiang Can Bombyx batryticatus.

SUMMARY LUNG- AND SPLEEN-QI DEFICIENCY WITH DAMP PHLEGM Points LU-7 Lieque, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei, Bitong, Ren-9 Shuifen, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-40 Fenglong, Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, LU-9 Taiyuan, BL-13 Feishu. All with even method, except the last five points, which should be needled with reinforcing method. Herbal therapy Prescription BU ZHONG YI QI TANG plus ER CHEN TANG Tonifying the Centre and Benefiting Qi Decoction plus Two Old Decoction

END NOTES 1. Mygind N et al. 1990 Rhinitis and Asthma: Similarities and Differences. Munksgaard, Lund, p. 10. 2. Ibid., p. 10.

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CHAPTER 8

COUGH

AETIOLOGY 216 External pathogenic factors Emotional stress 217 Diet 217 Chronic illness 217 PATHOLOGY

Phlegm-Heat in the Lungs 230 Phlegm-Fluids in the Lungs 231 Liver-Fire insulting the Lungs 232 CHRONIC EMPTY 233 Lung-Qi Deficiency 233 Lung-Yin Deficiency 234 Lung-Dryness 234

216

217

ACUPUNCTURE IN COUGH

219

MODERN CHINESE LITERATURE

DIAGNOSIS 220 Sound 220 Time of day 220 Sputum 221 IDENTIFICATION OF PATTERNS AND TREATMENT ACUTE 222 ACUTE EXTERIOR 223 Invasion of Wind-Cold 223 Invasion of Wind-Heat 224 Invasion of Wind-Dryness 225 ACUTE INTERIOR 226 Lung-Heat 226 Lung Phlegm-Heat 227 CHRONIC 229 CHRONIC FULL 229 Damp Phlegm in the Lungs 229

ACUTE Exterior • Invasion of Wind-Cold • Invasion of Wind-Heat • Invasion of Wind-Dryness Interior • Lung-Heat • Lung Phlegm-Heat

236

CLINICAL TRIALS 239 Herbal medicine 239 PROGNOSIS 221

240

WESTERN DIFFERENTIATION 240 Tracheitis 240 Acute bronchitis 240 Chronic bronchitis 241 Whooping cough 241 Pleurisy 241 Pneumonia 241 Carcinoma of the bronchi 241 Tuberculosis of the lungs 241 Bronchiectasis 241 Heart disease 241

CHRONIC Full • Damp Phlegm in the Lungs • Phlegm-Heat in the Lungs • Phlegm-Fluids in the Lungs • Liver-Fire insulting the Lungs Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung-Dryness

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COUGH Cough is mentioned in the Yellow Emperor’s Classic, in which a whole chapter is dedicated to it. The two characters of its Chinese name, Ke Sou, originally referred to two different types of cough. Ke denotes a cough that makes a noise but is without phlegm; this indicates injury of the Lungs. Sou denotes a cough with phlegm but that does not make a noise; this indicates that the Spleen is obstructed by Phlegm. Ke-Sou therefore denotes a cough that is both noisy and phlegmridden due to injury of the Lungs and Spleen from Phlegm. CLINICAL NOTE  Ke: cough that makes a noise but is without phlegm.  Sou: cough with phlegm but without making a noise.

Chapter 23 of the Simple Questions relates different sounds to different organs, and it says: “Diseases of Qi manifest ... in the Lungs with cough.”1 Chapter 38 of the Simple Questions, which is entirely dedicated to cough, says that coughing does not depend only on the Lungs but may be caused by each of the five Yin organs:2 Lung-cough [is accompanied by] breathlessness and spitting of blood; Heart-cough by pain in the heart region and a feeling of an obstruction in the throat; Livercough by hypochondrial fullness and pain ... Kidneycough by backache ... Spleen-cough by right hypochondrial pain ... It then goes on to say that when cough is prolonged it may transmit from the Yin organs to their related Yang organs:3 When the cough of the five Yin organs persists for a long time, it will be transmitted to the six Yang organs. If a Spleen-cough persists for a long time, it will transmit to the Stomach ... [causing] vomiting on coughing ... If a Livercough persists for a long time, it will transmit to the Gall Bladder ... [causing] coughing of bile. If a Lung-cough persists for a long time, it will transmit to the Large Intestine ... [causing] bowel incontinence on coughing. If a Heart-cough persists for a long time, it will transmit to the Small Intestine ... [causing] flatulence on coughing. If a Kidney-cough persists for a long time, it will transmit to

the Bladder ... [causing] incontinence of urine on coughing. Any chronic cough will affect the Triple Burner ... [causing] cough with abdominal fullness and no desire to eat or drink. The same chapter clearly attributes cough to a combination of invasion of an external pathogenic factor and improper diet:4 The skin is in relation with the Lungs; when an external pathogenic factor [Wind-Cold] invades the skin, it progresses to the Lungs. When cold food and drinks enter the Stomach, they go upwards to the Lungs via the Lung channel [which starts in the Middle Burner] and give rise to Cold in the Lungs. The combination of exterior and interior Cold causes cough in the Lungs. The chapter on cough ends by giving indications for treatment:5 For cough of the Yin organs, needle the [Back] Transporting (Shu) points; for cough of the Yang organs, needle the Sea (He) points; for cough with oedema, needle the River (Jing) points. The Complete Book of Jing Yue (1624) distinguishes between cough caused by invasion of an external pathogenic factor and cough due to an internal disharmony.6 The discussion of cough will be conducted according to the following topics. • • • • • • • •

Aetiology Pathology Diagnosis Identification of patterns and treatment Modern Chinese literature Clinical trials Prognosis Western differentiation

AETIOLOGY External pathogenic factors External Wind is the main cause of exterior coughs. Wind penetrates the skin and the Defensive-Qi portion, which is controlled by the Lungs. It therefore impairs the descending of Lung-Qi and causes a cough. This is an exterior type of cough that, with proper treatment, disappears rather quickly without any consequences.

Cough

Wind combines with other pathogenic factors, and the most likely to cause a cough are Wind-Cold, WindHeat and Wind-Dryness. Wind-Cold invades the skin and the Defensive-Qi portion, impairing the descending of Lung-Qi and thus causing a cough, usually with a white nasal discharge. Wind-Heat enters via the nose and mouth and affects the throat. It causes a cough by invading the Lung channel in the throat and preventing the descending of Lung-Qi. The cough caused by Wind-Heat is of a drier type than that caused by Wind-Cold. Wind-Dryness, rare in the British Isles but rather prevalent in the American South-West, also invades the Lung channel in the throat and causes a very dry and ticklish cough. Besides impairing the descending of Lung-Qi, Wind-Dryness also dries up the Lung’s fluids and the resulting cough is more persistent than that caused by Wind-Cold or Wind-Heat.

Emotional stress Worry is a frequent emotional cause of cough. It affects the Lungs directly and it knots Qi, preventing the descending of Lung-Qi. The resulting type of cough is dry and irritating. Sadness and grief deplete Lung-Qi, and they may cause a Deficiency-type cough as the deficient Lung-Qi fails to descend. Prolonged anger, frustration or resentment lead to stagnation of Liver-Qi and, over a long period of time, to Liver-Fire. This may invade the Lungs and prevent the descending of Lung-Qi, causing a cough.

Diet Excessive consumption of sweets, greasy foods and dairy foods may lead to the formation of Phlegm, which settles in the Lungs and prevents Lung-Qi from descending. This causes a cough with profuse expectoration. Excessive consumption of hot foods, alcohol and fried-greasy foods leads to the formation of Heat and Phlegm. Phlegm settles in the Lungs and impairs the descending of Lung-Qi, while Heat dries up the Lung fluids. Both these processes cause coughing. Excessive consumption of cold and raw foods such as salads and fruit impairs the transformation of fluids and may lead to Phlegm, which settles in the Lungs.

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Chronic illness A chronic illness affecting the Lungs weakens Lung-Qi and/or Lung-Yin. The deficient Lung-Qi fails to descend and causes a chronic cough of the Empty type.

SUMMARY AETIOLOGY  External pathogenic factors  Emotional stress — Worry — Sadness and grief — Anger, frustration or resentment  Diet — Excessive consumption of sweets, greasy foods and dairy foods, leading to Phlegm — Excessive consumption of hot foods, alcohol and fried-greasy foods, leading to Heat and Phlegm — Excessive consumption of cold and raw foods, leading to Phlegm  Chronic illness

PATHOLOGY As indicated above, the Chinese term for “cough”, Ke Sou, is composed of two parts, each being a distinct symptom. The Su Wen Bing Ji Qi Zu Bao Ming Ji says:7 Ke refers to a cough without sputum, in which case one uses pungent-sweet herbs to moisten the Lungs; Sou refers to cough with sputum, in which case one must resolve Phlegm and restore the descending of Lung-Qi. The Jin Gui Gou Xuan gives the treatment principles for various types of cough as follows:8 For Wind-Cold, open the space between skin and muscles and use Er Chen Tang plus Ma Huang, Xing Ren and Jie Geng; for Fire, drain Fire, clear the Lungs and resolve Phlegm; for Deficiency, use Si Wu Tang plus Zhu Li and Jiang Ye [ginger juice]. Cough that is worse in daytime is due to StomachFire: use Zhe Bei Mu and Shi Gao to drain Stomach-Fire. Cough that is worse in the evening is due to Yin deficiency: use Si Wu Tang plus Zhi Mu and Huang Bo. The pathology of cough is always characterized by Lung-Qi failing to descend. This may happen either because the Lungs are obstructed by an exterior or

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interior pathogenic factor (Full type), or because LungQi (or Lung-Yin) is deficient and fails to descend properly (Empty type). Pathogenic factors in the Lungs that impair the descending of Qi include external Wind, Heat, Phlegm, stagnation of Qi and Liver-Fire. In such cases when Qi fails to descend because of a pathogenic factor, it is said to be “rebelling upwards”. All the old classics convey this idea of cough being caused by rebellious Qi. The Simple Questions in Chapter 10 says: “Cough consists of Qi rebelling upwards.”9 The Essential Prescriptions of the Golden Chest by Zhang Zhong Jing says: “Cough is due to Qi rebelling upwards.”10 The implication is that, in order to treat cough, one must restore the descending of Lung-Qi and subdue rebellious Qi. In Chinese, subduing rebellious Qi and making Qi flow in the correct direction is called shun, a term that is used in opposition to ni, which means “rebellious”. The Yi Xue Zheng Chuan says: “To treat cough, one must first resolve Phlegm; to resolve Phlegm, one must rectify [shun] Qi.”11 The Yi Tong Zheng Mai Quan Shu confirms this when it says: “To treat cough one must resolve Phlegm; to resolve Phlegm, one must make Qi descend.”12 External coughs are by definition of the Full type. Interior coughs may be of the Deficiency or Excess type, and the main pathology in the Excess type is Phlegm or Fire. Phlegm combines with Heat or Cold, and Fire may be of the Excess or Deficiency type.

Thus coughs may be classified in various ways. Using Fullness and Emptiness as parameters, we may classify them as follows (Fig. 8.1). FULL Exterior • Wind-Cold • Wind-Heat • Wind-Dryness Interior • Damp Phlegm • Phlegm-Heat • Fire • Phlegm-Fluids EMPTY • Lung-Qi deficiency • Lung-Yin deficiency Using Exterior and Interior as parameters, we may classify coughs as follows (Fig. 8.2). EXTERIOR • Wind-Cold • Wind-Heat • Wind-Dryness INTERIOR Full • Damp Phlegm • Phlegm-Heat Wind-Cold EXTERIOR

Wind-Heat Wind-Dryness

FULL Damp Phlegm INTERIOR

Phlegm-Heat Fire

COUGH

Phlegm-Fluids Lung-Qi deficiency EMPTY Lung-Yin deficiency Figure 8.1 Classification of cough according to Full and Empty.

Cough

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Wind-Cold EXTERIOR

Wind-Heat Wind-Dryness Damp Phlegm

COUGH Phlegm-Heat FULL

Fire Phlegm-Fluids

INTERIOR Lung-Qi deficiency EMPTY Lung-Yin deficiency Figure 8.2 Classification of cough according to Exterior and Interior.

• Fire • Phlegm-Fluids Empty • Lung-Qi deficiency • Lung-Yin deficiency However, I prefer to classify coughs as acute or chronic, because this factor is clinically more significant. In fact, when presented with a patient with a cough the first thing to ascertain is whether the cough is acute or chronic. Once this has been ascertained, one needs to establish whether the cough is external or internal. Acute coughs may be external or internal but are always of the Full type, while chronic coughs are always internal and they may be either of the Full or the Empty type. Many of the old classics also stress the classification of cough according to acute and chronic. For example, the Yi Xue Ru Men classifies cough according to acute and chronic, each of them with or without Phlegm:13 If an acute cough manifests with Phlegm, it is due to exterior invasion and the treatment principle is to release the Exterior and eliminate the pathogenic factor. If an acute cough manifests without Phlegm, it is due to Fire and the treatment principle is to drain Fire. The Ming Yi Za Zhu also recommends distinguishing between acute and chronic cough. It says:14

Acute cough may be due to invasion of Wind-Cold, in which case one must scatter the pathogenic factor; to Fire, in which case one must drain Fire; or to Damp Heat, in which case one must resolve Dampness. Chronic cough may be due to Deficiency or to stagnation: in Deficiency one must tonify Qi or nourish Blood; in stagnation, one must eliminate stagnation. The Za Bing Yuan Liu says:15 Cough should be classified according to acute/chronic and Full/Empty. In acute cough, the Lungs are obstructed by a pathogenic factor. This may be Wind, in which case one must release the Exterior; Cold, in which case one must scatter; Heat, in which case one must clear; Fire, in which case one must drain; Dampness, in which case one must resolve Dampness; Phlegm, in which case one must resolve Phlegm. The train of thought and the guideline for interrogation of the patient may be represented with a diagram (Fig. 8.3).

ACUPUNCTURE IN COUGH As we have seen, most Chinese books place the emphasis on resolving Phlegm as a treatment method for cough. It is important to understand that all these books give this recommendation primarily from the

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The Practice of Chinese Medicine Hot (Wind-Heat) EXTERNAL Cold (Wind-Cold) ACUTE With Phlegm INTERNAL

Hot Without Phlegm

COUGH Hot FULL Cold CHRONIC Qi EMPTY

With Empty Heat Yin Without Empty Heat

Figure 8.3 Classification of cough and guideline for interrogation.

perspective of herbal medicine. If we use only acupuncture, our thinking must be somewhat different. Of course we can resolve Phlegm with acupuncture, but it is important to understand that acupuncture’s way of achieving this differs from that of herbal medicine. Herbal medicine resolves Phlegm with herbal drugs that actually dry up Phlegm; herbs that resolve Phlegm are generally pungent and drying (e.g. Ban Xia Rhizoma Pinelliae preparatum, Dan Nan Xing Rhizoma Arisaematis preparatum). How can acupuncture resolve Phlegm? It can do so only by regulating Qi, i.e. restoring the correct ascending/descending and entering/exiting of Qi in the Qi Mechanism. It follows therefore, that, when giving acupuncture, we must pay attention to regulating the flow of Qi rather than attributing a “Phlegm-resolving action” to specific points (e.g. ST-40 Fenglong). In other words, as acupuncturists, we must think more of Qi flow than “actions” of a particular point (e.g. “ST-40 resolves Phlegm”). Indeed, how does ST-40 “resolve Phlegm”? It does so specifically because it subdues rebellious Qi in the chest and makes Qi descend. Moreover, by regulating the ascending/descending of Stomach-Qi, it also affects Spleen-Qi: the regulating of the flow of Qi in these two

organs results in their transporting and transforming fluids in the correct way and therefore indirectly “resolves Phlegm”.

DIAGNOSIS Cough can be diagnosed according to its sound, the time of occurrence and the character of any sputum.

Sound As a general rule, a weak-sounding cough indicates Deficiency while a loud cough indicates Excess. A barking cough denotes Heat while a loose, rattling cough indicates the presence of Phlegm.

Time of day A cough that occurs only in the late afternoon or evening indicates Yin deficiency. A cough that is worse in the morning is usually due to Phlegm.

Cough

Sputum A cough without sputum indicates either Deficiency or Heat. If there is abundant sputum, it is due to Phlegm. A yellow sputum denotes Heat, while white sputum denotes Cold. White sputum may be sticky or dilute; if it is sticky, it indicates the prevalence of Dampness and Phlegm over Cold, while if it is dilute it indicates the prevalence of Cold over Dampness or Phlegm (Fig. 8.4). Blood-tinged sputum indicates either Full or Empty Heat. Greenish sputum indicates Heat, while white, very watery and frothy sputum indicates Phlegm-Fluids.

IDENTIFICATION OF PATTERNS AND TREATMENT As mentioned above, I shall classify coughs into acute or chronic. Acute cases are usually characterized by Fullness, while chronic cases may be of the Full or Empty type. Fullness and Emptiness, however, often combine. Zhang Jing Yue says in the Complete Book of Jing Yue (1624):16 Coughs of external origin are very frequent [and are characterized by] some Deficiency within the Fullness,

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hence one must tonify somewhat as well as expelling [pathogenic factors]. In coughs of internal origin, there is some Fullness within Emptiness, hence one must clear and moisten simultaneously. The patterns discussed are the following. ACUTE Exterior • Invasion of Wind-Cold • Invasion of Wind-Heat • Invasion of Wind-Dryness Interior • Lung-Heat • Lung Phlegm-Heat CHRONIC Full • Damp Phlegm in the Lungs • Phlegm-Heat in the Lungs • Phlegm-Fluids in the Lungs • Liver-Fire insulting the Lungs Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung-Dryness

Deficiency WITHOUT SPUTUM

STICKY

+Dampness –Cold

DILUTE

+Cold –Dampness

Heat COUGH WHITE ABUNDANT SPUTUM

Cold WATERYFROTHY

PHLEGM

YELLOW

Heat Full Heat

BLOODTINGED Empty Heat GREENISH Figure 8.4 Diagnosis of cough.

Heat

PhlegmFluids

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ACUTE By acute is meant a cough of a few days’ or, at most, a few weeks’ duration. The most important fact to establish when seeing a patient suffering from acute cough is whether the cough is external or internal. All acute coughs are originally due to invasion of external Wind, but the external pathogenic factor may become internal in only a few days while the cough is still at the acute stage. The identification of patterns according to the Four Levels provides the clinical framework for the symptomatology of invasions of external Wind turning into interior Heat. For example, within the Four Levels patterns, invasion of exterior Wind-Heat may cause a cough (together with shivering, fever, aversion to cold, body aches and a Floating-Rapid pulse). If the exterior Wind penetrates into the Interior, it gives rise to the pattern of Lung-Heat with a barking cough (together with high fever, thirst, sweating and a Big pulse). Although the patterns of the Four Levels initially start with an invasion of Wind-Heat, Wind-Cold may also turn into interior Heat in the Lungs so that, at that stage, the identification of patterns according to the Four Levels may be used also for invasions of WindCold. Acute Lung-Heat with cough in the course of a febrile disease may therefore derive either from WindHeat or Wind-Cold, although the former is more likely (Fig. 8.5). Thus, when presented with a patient with acute cough, the crucial distinction must be made between exterior or interior cough. Apart from many other

symptoms, this differentiation may be made very simply on the basis of the patient’s feelings of cold or heat. If the patient shivers and feels aversion to cold, and this feeling is not alleviated by wrapping up, it indicates an exterior pattern, i.e. the pathogenic factor is still on the Exterior. If the patient feels aversion to heat and is generally hot, very thirsty and restless, it indicates an interior pattern of Heat, i.e. the pathogenic factor is in the Interior and it has turned into Heat. In such a case, the presence of cough, breathlessness, some chest pain and possibly flaring of the alae nasi indicate the location of Heat in the Lungs. After establishing from its character whether a cough is exterior or interior, we must differentiate the pattern further in each case. If it is exterior, we must ascertain whether it is Wind-Cold or Wind-Heat. If it is interior, it is due to Lung-Heat and we must ascertain whether there is just Lung-Heat or Lung Phlegm-Heat (see Fig. 8.6). For a description of the Six-Stage and Four-Level patterns, see Appendices 1 and 2. The acute patterns to be discussed are as follows. Exterior • Invasion of Wind-Cold • Invasion of Wind-Heat • Invasion of Wind-Dryness Interior • Lung-Heat • Lung Phlegm-Heat WEI – Acute, exterior cough from Wind-Heat QI – Acute, interior cough from Lung-Heat YING

WIND-HEAT

4 Levels

BLOOD

COLD-HEAT

6 Stages

TAI YANG – Acute, exterior cough from Wind-Cold

EXTERIOR WIND

YANG MING SHAO YANG TAI YIN SHAO YIN JUE YIN Figure 8.5 Invasions of Wind in the Four Levels patterns.

Cough

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Hot (Wind-Heat) EXTERNAL Cold (Wind-Cold)

ACUTE COUGH

With Phlegm INTERNAL

Hot Without Phlegm

Figure 8.6 Patterns in acute cough.

ACUTE EXTERIOR Invasion of Wind-Cold Clinical manifestations Cough, slight breathlessness, sneezing, runny nose with white discharge, aversion to cold, shivers, no temperature or one that is only slightly raised, no sweating, body aches, stiff neck, headache and pale urine. Tongue: there may be no evident change. Pulse: Floating-Tight. This is the typical pattern of invasion of Wind-Cold with prevalence of Cold. It corresponds to the Greater Yang pattern with prevalence of Cold within the Six Stages (see Appendix 1). It is a common pattern in acute cough.

Treatment principle Release the Exterior, restore the diffusing and descending of Lung-Qi, expel Wind, scatter Cold by promoting sweating and stop cough.

• L.I.-4 (reduced) and KI-7 (reinforced), in combination, promote sweating to release the Exterior. • LU-6, Accumulation point, stops acute cough.

Herbal therapy Prescription MA HUANG TANG Ephedra Decoction

Explanation This formula expels Wind, scatters Cold, promotes sweating, releases the Exterior, restores the diffusing and descending of Lung-Qi and stops cough and breathlessness.

Modifications • To enhance the antitussive effect, add Kuan Dong Hua Flos Farfarae, especially treated with honey, and increase the dosage of Xing Ren.

Prescription

Acupuncture Points LU-7 Lieque, BL-12 Fengmen, BL-13 Feishu, L.I.-4 Hegu, KI-7 Fuliu, LU-6 Kongzui. Reducing method; cupping is applicable on BL-12 and BL-13.

Explanation • LU-7 releases the Exterior, restores the descending of Lung-Qi and stops cough. • BL-12 expels exterior Wind and releases the Exterior. It is very effective with cupping. • BL-13 releases the Exterior, restores the descending of Lung-Qi and stops cough. Cupping is also applicable on this point.

SAN AO TANG and ZHI SOU SAN Three Break Decoction and Stopping Cough Powder

Explanation These two formulae together release the Exterior, expel Wind, scatter Cold, restore the descending of Lung-Qi and stop cough.

Modifications • If there is a lot of sputum, stuffiness of the chest and a sticky tongue coating (signs of Phlegm), add Ban Xia Rhizoma Pinelliae preparatum, Hou Po Cortex Magnoliae officinalis and Fu Ling Poria. • If there are Heat signs such as thirst and red sides of the tongue, add Shi Gao Gypsum fibrosum, San

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Bai Pi Cortex Mori and Huang Qin Radix Scutellariae.

Prescription XING SU SAN Variation Armeniaca-Perilla Powder Variation

Explanation This formula releases the Exterior, expels Wind-Cold, restores the descending of Lung-Qi and stops cough.

SUMMARY INVASION OF WIND-COLD Points LU-7 Lieque, BL-12 Fengmen, BL-13 Feishu, L.I.-4 Hegu, KI-7 Fuliu, LU-6 Kongzui. Reducing method; cupping is applicable on BL-12 and BL-13. Herbal therapy Prescription MA HUANG TANG Ephedra Decoction Prescription SAN AO TANG and ZHI SOU SAN Three Break Decoction and Stopping Cough Powder Prescription XING SU SAN Variation Armeniaca-Perilla Powder Variation

Invasion of Wind-Heat Clinical manifestations Dry cough with a tickling sensation in the throat, aversion to cold, shivers, fever, sore throat, slight sweating, body aches, headache, runny nose with yellow discharge, sneezing, slight thirst and slightly dark urine. Tongue: slightly Red sides and/or front part. Pulse: Floating-Rapid. This is a common pattern in acute cough, especially in children.

Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, BL-12 Fengmen, BL-13 Feishu, L.I.-11 Quchi, LU-11 Shaoshang, Du-14 Dazhui, LU-6 Kongzui. All with reducing method; cupping is applicable to BL-12 and BL-13.

Explanation • LU-7 and BL-13 release the Exterior, expel Wind, restore the descending of Lung-Qi and stop cough. • L.I.-4 expels Wind-Heat. • BL-12 releases the Exterior. • L.I.-11 expels Wind-Heat. • LU-11 expels Wind-Heat and is used if the throat is sore and the tonsils are swollen. • Du-14 is used if symptoms of Heat are pronounced. • LU-6, Accumulation point, stops acute cough.

Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction

Explanation This formula releases the Exterior and expels WindHeat. Sang Ye and Xing Ren, in particular, restore the descending of Lung-Qi and stop cough.

Modifications • In case of pronounced Heat signs, add Huang Qin Radix Scutellariae and Zhi Mu Radix Anemarrhenae. • In case of very sore throat and hoarse voice, add She Gan Rhizoma Belamcandae and Chi Shao Radix Paeoniae rubra. • If Heat has begun to injure the Lung fluids, causing dry mouth and throat, add Nan Sha Shen Radix Adenophorae and Tian Hua Fen Radix Trichosanthis.

Prescription SANG JU YIN Variation Morus-Chrysanthemum Decoction Variation

Treatment principle

Explanation

Release the Exterior, expel Wind, clear Heat, restore the descending of Lung-Qi and stop cough.

This formula releases the Exterior, expels Wind-Heat, restores the descending of Lung-Qi, stops cough and

Cough

resolves Phlegm. Compared with the previous formula, it has a more marked Phlegm-resolving effect.

SUMMARY INVASION OF WIND-HEAT Points LU-7 Lieque, L.I.-4 Hegu, BL-12 Fengmen, BL-13 Feishu, L.I.-11 Quchi, LU-11 Shaoshang, Du-14 Dazhui, LU-6 Kongzui. All with reducing method; cupping is applicable to BL-12 and BL-13. Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction. Prescription SANG JU YIN Variation Morus-Chrysanthemum Decoction Variation

Invasion of Wind-Dryness Clinical manifestations Dry and ticklish cough, dry-itchy-sore throat, sore sensation in the upper chest (trachea), dry lips, dry mouth, stuffy nose, headache, slight aversion to cold, mild shivers. Tongue: slightly Red sides and/or front part. Pulse: Floating.

Treatment principle Release the Exterior, restore the descending of LungQi, promote fluids and stop cough.

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• KI-6 promotes fluids and benefits and moistens the throat. • SP-6 promotes fluids.

Herbal therapy Prescription SANG XING TANG Morus-Prunus Decoction

Explanation This formula restores the descending of Lung-Qi, stops cough and promotes fluids.

Modifications • If the fluids have been severely injured, add Mai Men Dong Radix Ophiopogonis and Yu Zhu Rhizoma Polygonati odorati. • If symptoms of Heat are pronounced, add Shi Gao Gypsum fibrosum and Zhi Mu Radix Anemarrhenae. • If there is coughing of scanty, blood-flecked sputum, add Bai Mao Gen Rhizoma Imperatae.

Prescription XING SU SAN Prunus-Perilla Leaf Powder

Explanation This formula is used if Dryness is accompanied by symptoms of Wind-Cold (normally it is accompanied by Wind-Heat). It restores the descending of Lung-Qi, stops cough, expels Wind-Cold and promotes fluids.

SUMMARY INVASION OF WIND-DRYNESS

Acupuncture Points LU-7 Lieque, LU-9 Taiyuan, Ren-12 Zhongwan, KI-6 Zhaohai, SP-6 Sanyinjiao. All with reinforcing method except for LU-7 which should be needled with reducing method.

Explanation • LU-7 releases the Exterior and restores the descending of Lung-Qi to stop cough. • LU-9 nourishes the Lung’s fluids. • Ren-12, the point marking the beginning of the Lung channel’s internal pathway, promotes fluids.

Points LU-7 Lieque, LU-9 Taiyuan, Ren-12 Zhongwan, KI-6 Zhaohai, SP-6 Sanyinjiao. All with reinforcing method except for LU-7, which should be needled with reducing method. Herbal therapy Prescription SANG XING TANG Morus-Prunus Decoction Prescription XING SU SAN Prunus-Perilla Leaf Powder

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Case history A 41-year-old man had contracted an upper respiratory infection while holidaying in the Rocky Mountains in summertime. At the time, this manifested with symptoms of Wind-Heat and Dryness, i.e. aversion to cold, a slight temperature, a dry cough, a dry and itchy sensation of the throat and a headache. He came for treatment on his return from his holiday when he still had a dry, persistent and ticklish cough that was keeping him awake at night. Diagnosis This was originally an attack of WindHeat-Dryness that had then dried up the Lung’s fluids and left him with some Dryness. Treatment The principle of treatment adopted was to moisten the Lungs, promote fluids and restore the descending of Lung-Qi. Although this was not an Exterior pattern any longer, I used a variation of Sang Xing Tang Morus-Prunus Decoction, as this prescription does not contain many herbs that release the Exterior. The variation used was as follows. • • • • • • • • • •

Sang Ye Folium Mori 6 g Xing Ren Semen Armeniacae 6 g Dan Dou Chi Semen Sojae preparatum 4 g Shan Zhi Zi Fructus Gardeniae 3 g Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g Nan Sha Shen Radix Adenophorae 6 g Li Pi Pericarpium Fructi Pyri 6 g Tian Hua Fen Radix Trichosanthis 6 g Yu Zhu Rhizoma Polygonati odorati 6 g Kuan Dong Hua (honey-treated) Flos Farfarae 9 g

Explanation • Sang Ye and Xing Ren are the two main herbs to restore the descending of Lung-Qi. • Dan Dou Chi and Zhi Zi clear any residual Heat. Their dosage was reduced, as there was no sign of much Heat left; they were left in, however, to prevent any residual Heat forming. • Zhe Bei Mu helps to restore the descending of Lung-Qi and stop cough. • Sha Shen, Li Pi, Tian Hua Fen and Yu Zhu promote fluids and moisten the Lungs and throat. • Kuan Dong Hua restores the descending of Lung-Qi and stops cough. Its antitussive effect is enhanced by toasting with honey.

Only three doses of this decoction were enough to stop the cough completely.

ACUTE INTERIOR Lung-Heat Clinical manifestations Barking cough, chest pain, breathlessness, fever, thirst, sweating, flaring of alae nasi, restlessness and a feeling of heat. Tongue: Red with yellow coating. Pulse: Rapid and Overflowing. This corresponds to the pattern “Heat in the diaphragm” within the Qi Level of the Four-Level identification of patterns. This pattern is seen only in acute coughs following an invasion of Wind when the pathogenic factor has turned into Heat and penetrated the Interior.

Treatment principle Clear Lung-Heat, restore the descending of Lung-Qi and stop cough.

Acupuncture Points LU-5 Chize, LU-1 Zhongfu, Du-14 Dazhui, LU-6 Kongzui and L.I.-11 Quchi. Reducing method.

Explanation • LU-5 clears Lung-Heat and restores the descending of Lung-Qi. • LU-1 clears Lung-Heat and treats acute patterns of the Lungs. • Du-14 clears Heat. • LU-6, Accumulation point, treats acute patterns of the Lungs and stops cough. • L.I.-11 clears Heat.

Herbal therapy Prescription MA XING SHI GAN TANG Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction

Explanation This formula restores the descending of Lung-Qi, stops cough, clears Heat and stops breathlessness.

Cough

Modifications • To enhance the antitussive effect of the formula, add Sang Bai Pi Cortex Mori, Pi Pa Ye Folium Eriobotryae and Kuan Dong Hua Flos Farfarae. • To enhance the Lung-clearing effect, add Huang Qin Radix Scutellariae.

SUMMARY LUNG-HEAT Points LU-5 Chize, LU-1 Zhongfu, Du-14 Dazhui, LU-6 Kongzui and L.I.-11 Quchi. Reducing method. Herbal therapy Prescription MA XING SHI GAN TANG Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction

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SP-15 Daheng. All with reducing method except Ren-12, which should be reinforced.

Explanation • LU-5 expels Phlegm and clears Heat from the Lungs. • LU-1 and LU-6, Front-Collecting point and Accumulation point, respectively, are used for acute cases; they clear Lung-Heat and stop cough. • Ren-12, Ren-9, ST-40 and SP-6 resolve Phlegm. • Du-14 and L.I.-11 clear Heat. • T.B.-6 and SP-15 clear Heat and move downwards.

Herbal therapy Prescription QING QI HUA TAN TANG Clearing Qi and Resolving Phlegm Decoction

Explanation

Lung Phlegm-Heat Clinical manifestations Barking cough with expectoration of profuse-stickyyellow sputum, fever, restlessness, thirst, feeling of heat and a sensation of oppression in the chest. Tongue: Red with a sticky-yellow coating. Pulse: Rapid and Slippery. This corresponds to Lung-Heat at the Qi Level within the Four-Level identification of patterns, but with the presence of Phlegm in addition to Heat. Wind-Heat easily leads to Phlegm, because it quickly dries up the body fluids, which condense, forming Phlegm. This is a very common pattern in acute cough. It occurs when an external pathogenic factor turns into Heat, penetrates the Interior and combines with Phlegm.

This formula resolves Phlegm, clears Lung-Heat, restores the descending of Lung-Qi, stops cough.

Prescription XIAO XIAN XIONG TANG Small Sinking [Qi of the] Chest Decoction

Explanation This formula clears Heat, makes Qi descend and stops cough. The main difference between these two formulae is that the former is better at resolving Phlegm (and therefore used for profuse expectoration), while the latter is better to make Qi descend in the chest (and therefore used for a feeling of oppression in the chest).

Prescription

Treatment principle

GUN TAN WAN Chasing-away Phlegm Pill

Clear Lung-Heat, resolve Phlegm, restore the descending of Lung-Qi and stop cough.

Explanation

Acupuncture Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, LU-6 Kongzui, Du-14 Dazhui, L.I.-11 Quchi, T.B.-6 Sanyangluo and

This formula drains Fire by moving downwards, resolves Phlegm and stops cough. This is a strong formula for Lung-Fire as opposed to Lung-Heat. Although Heat and Fire are the same in nature, there are differences between them, the main one being that Heat is more superficial and less intense than Fire. This distinction is not very significant or important in

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acupuncture, but it is crucial when herbal medicine is used. For Heat, one uses pungent-cold herbs (such as Shi Gao Gypsum fibrosum) to clear it by pushing it outwards. Fire is more intense and is knotted deep inside in the Interior of the body; one therefore drains it with bitter-cold herbs (such as Huang Qin Radix Scutellariae or Long Dan Cao Radix Gentianae) and, if the stools are dry, with moving-downward herbs such as Da Huang Radix et Rhizoma Rhei. Some of the clinical manifestations of Heat and Fire overlap, such as a feeling of heat, thirst, sweating, a red face, a Red tongue and a Rapid pulse. Fire, however, is more drying, affects the Mind more and may cause bleeding. Thus, in addition to the above manifestations, Fire also causes mental restlessness, dark urine, dry stools, very dry tongue coating, a bitter taste, dry mouth and a deeper pulse. In this case, there is Lung-Fire as opposed to LungHeat, and the manifestations would be a barking cough with profuse yellow-purulent or blood-flecked expectoration, fever, constipation or dry stools, dark urine, a red face, dry mouth, mental restlessness, a Red tongue with a thick-dry-yellow or dark brown or even black coating and a Deep-Full and Rapid pulse. In such a case, clearing Heat is not enough; we need to drain Fire by moving downwards, which is what this formula does.

Modifications • To enhance the antitussive effect, add Kuan Dong Hua Flos Farfarae, Sang Bai Pi Cortex Mori and Xing Ren Semen Armeniacae.

SUMMARY LUNG PHLEGM-HEAT Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, LU-6 Kongzui, Du-14 Dazhui, L.I.-11 Quchi, T.B.-6 Sanyangluo and SP-15 Daheng. All with reducing method except Ren-12, which should be reinforced. Herbal therapy Prescription QING QI HUA TAN TANG Clearing Qi and Resolving Phlegm Decoction

Prescription XIAO XIAN XIONG TANG Small Sinking [Qi of the] Chest Decoction Prescription GUN TAN WAN Chasing-away Phlegm Pill

Case history A 2-year-old girl had contracted an upper respiratory infection, which had been treated with antibiotics. Her mother took her to me for treatment about 1 week into the antibiotic treatment, as she was not getting better. Although the initial temperature had gone, she now had a barking cough productive of yellow sputum; she also wheezed slightly, was restless and slept badly. Her tongue had a sticky-yellow coating and was Red in the front part. Diagnosis This is a typical example of progression of an external pathogenic factor into the Interior due to treatment with antibiotics (see also Chapter 48). The pathogenic factor is now interior Phlegm-Heat obstructing the Lungs. Treatment The treatment’s aim was to resolve Phlegm, clear Lung-Heat, restore the descending of Lung-Qi and stop cough and wheezing. She was treated only with herbal decoctions, and the one used was a variation of Qing Qi Hua Tan Tang Clearing Qi and Resolving Phlegm Decoction. • Dan Nan Xing Rhizoma Arisaematis preparatum 3g • Gua Lou Fructus Trichosanthis 6 g • Huang Qin Radix Scutellariae 4 g • Shan Zhi Shi Fructus Aurantii immaturus 3 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g • Xing Ren Semen Armeniacae 4 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Su Zi Fructus Perillae 4 g • Sang Bai Pi Cortex Radicis Mori albae 4 g • Kuan Dong Hua (honey-treated) Flos Farfarae 6g

Cough

Explanation • The first eight herbs constitute the Qing Qi Hua Tan Tang, which resolves Phlegm and clears Lung-Heat. • Su Zi and Sang Bai Pi were added to restore the descending of Lung-Qi. • Kuan Dong Hua, especially good when honeytreated, restores the descending of Lung-Qi and stops cough. The decoction was given to the little girl well diluted with water and mixed with some honey in small amounts throughout the day. She improved completely after 1 week. Her treatment was followed up with a decoction to tonify the Spleen and resolve Phlegm (the Liu Jun Zi Tang Six Gentlemen Decoction) in order to prevent any recurrence.

CHRONIC Chronic cough may be of the Full or Empty type. The main patterns are as follows. Full • Damp Phlegm • Phlegm-Heat • Phlegm-Fluids • Liver-Fire Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung-Dryness The pathology of chronic coughs is characterized by involvement of other organs besides the Lungs. The organs involved for each pattern are as follows. • Damp Phlegm: Spleen-Qi or Spleen-Yang deficiency, Kidney-Yang deficiency • Phlegm-Heat: Spleen-Qi deficiency • Phlegm-Fluids: Spleen- and Kidney-Yang deficiency • Liver-Fire insulting the Lungs: Liver-Fire • Lung-Qi deficiency: Spleen-Qi deficiency • Lung-Yin deficiency: Kidney-Yin deficiency • Lung-Dryness: Stomach-Yin deficiency Thus, the pattern of Lung-Qi deficiency will be nearly always accompanied by Spleen-Qi deficiency, while that of Lung-Yin deficiency will be nearly always accompanied by Stomach- and/or Kidney-Yin deficiency.

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CHRONIC FULL Damp Phlegm in the Lungs Clinical manifestations Repeated attacks of cough, profuse expectoration of white-sticky sputum, breathlessness, worse in the mornings and after eating, a feeling of oppression in the chest, a feeling of fullness of the epigastrium, nausea, poor appetite, tiredness, a feeling of heaviness, loose stools. Tongue: Pale or normal, Swollen, sticky-thick-white coating. Pulse: Slippery. This is a common pattern seen in chronic cough, especially in middle-aged and elderly patients.

Treatment principle Dry Dampness, resolve Phlegm, tonify the Spleen, restore the descending of Lung-Qi and stop cough.

Acupuncture Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu. Reinforcing method on ST-36, Ren-12 and BL-20, reducing or even method on the others. Moxa is applicable.

Explanation • LU-5 resolves Phlegm from the Lungs and restores the descending of Lung-Qi. • LU-1 restores the descending of Lung-Qi. • Ren-12, BL-20 and ST-36 tonify the Spleen to resolve Phlegm. • Ren-9, ST-40 and SP-6 resolve Dampness and Phlegm. • BL-13, Back-Transporting point, is used for chronic patterns to restore the descending of Lung-Qi.

Herbal therapy Prescription ER CHEN TANG and SAN ZI YANG QIN TANG Two Old Decoction and Three-Seed Nourishing the Parents Decoction

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Explanation

Phlegm-Heat in the Lungs

These two formulae together resolve Damp Phlegm or Cold Phlegm, restore the descending of Lung-Qi and stop cough. This pattern nearly always occurs against a background of Spleen-Qi or Spleen-Yang deficiency. In such cases, it is necessary to add some Spleen tonics such as Bai Zhu Rhizoma Atractylodis macrocephalae and, if there is Spleen-Yang deficiency, Gan Jiang Rhizoma Zingiberis.

Clinical manifestations

Modifications • To enhance the antitussive effect, add Kuan Dong Hua Flos Farfarae and Xing Ren Semen Armeniacae. • In cases of pronounced Dampness, add Cang Zhu Rhizoma Atractylodis and Hou Po Cortex Magnoliae officinalis. • If there are symptoms of Cold Phlegm (see above), add Gan Jiang Rhizoma Zingiberis and Xi Xin Herba Asari. • If there is a pronounced deficiency of the Spleen, add Bai Zhu Rhizoma Atractylodis macrocephalae and Dang Shen Radix Codonopsis. • After the Phlegm has been successfully resolved, use the Liu Jun Zi Tang Six Gentlemen Decoction to consolidate the results by strengthening the Spleen. • If the attacks of cough are elicited by frequent colds, add Huang Qi Radix Astragali and Fang Feng Radix Saposhnikoviae.

SUMMARY DAMP PHLEGM IN THE LUNGS Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu. Reinforcing method on ST-36, Ren-12 and BL-20, reducing or even method on the others. Moxa is applicable. Herbal therapy Prescription ER CHEN TANG and SAN ZI YANG QIN TANG Two Old Decoction and Three-Seed Nourishing the Parents Decoction

Repeated attacks of a barking cough with profuse expectoration of yellow or blood-flecked purulent sputum, breathlessness, rattling sound in the throat, a feeling of oppression in the chest, red face, feeling of heat, dry mouth, thirst, tiredness, loose stools. Tongue: Red, Swollen, with a sticky-yellow coating. Pulse: Slippery and Rapid. This condition is similar to Phlegm-Heat cough at the acute stage. It differs from it insofar as it is a chronic condition occurring against a background of Spleen deficiency (hence the tiredness and loose stools). In chronic cases, it occurs when there is a residual Phlegm-Heat in the Lungs; this is a very common cause of chronic cough at all ages from childhood to old age.

Treatment principle Clear Heat, resolve Phlegm, restore the descending of Lung-Qi, stop cough, tonify the Spleen.

Acupuncture Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu, Du-14 Dazhui and L.I.-11 Quchi. Reinforce Ren-12, BL-20, and ST-36; reduce all the others. No moxa.

Explanation • Du-14 and L.I.-11 clear Heat. • All the other points are the same as for Damp Phlegm and have already been explained.

Herbal therapy Prescription QING JIN HUA TAN TANG Clearing Metal and Resolving Phlegm Decoction

Explanation This formula clears Lung-Heat, resolves Phlegm-Heat in the Lungs and restores the descending of Lung-Qi.

Modifications • As there is nearly always a Spleen deficiency that produces Phlegm, add Bai Zhu Rhizoma Atractylodis macrocephalae and Dang Shen Radix Codonopsis.

Cough

• If there is purulent sputum, add Dan Nan Xing Rhizoma Arisaematis preparatum, Yi Yi Ren Semen Coicis and Dong Gua Ren Semen Benincasae. • If there is a pronounced feeling of oppression of the chest and constipation, add Da Huang Radix et Rhizoma Rhei. • If the Heat part of Phlegm-Heat has begun to injure fluids, add Nan Sha Shen Radix Adenophorae, Tian Men Dong Radix Asparagi and Tian Hua Fen Radix Trichosanthis.

SUMMARY PHLEGM-HEAT IN THE LUNGS Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu, Du-14 Dazhui and L.I.-11 Quchi. Reinforce Ren-12, BL-20, and ST-36; reduce all the others. No moxa. Herbal therapy Prescription QING JIN HUA TAN TANG Clearing Metal and Resolving Phlegm Decoction

Case history An 80-year-old woman had been suffering from a persistent cough for 5 years. The cough was productive of scanty-sticky yellow sputum, and she experienced a feeling of oppression of the chest. Her health was otherwise very good; she was a keen practitioner and teacher of yoga. Her body was thin and her skin was dry. Her pulse was slightly Floating-Empty in general and slightly Slippery on the Lung position. Her tongue was Red, dry, and without coating in the front part (Plate 8.1). Diagnosis This is a case of retention of Phlegm-Heat in the Lungs occurring against a background of LungYin deficiency. The Phlegm-Heat is indicated by the sticky-yellow sputum and Slippery pulse quality on the Lung position, while the Lung-Yin deficiency is apparent from the thin body, the dry skin, the FloatingEmpty pulse and the Red tongue without coating in the front part (Lung area).

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Treatment The treatment principle adopted was to resolve Phlegm, clear Heat, nourish Lung-Yin and clear Lung Empty Heat. She was treated with herbs only, and the decoction used was a variation of Qing Jin Hua Tan Tang Clearing Metal and Resolving Phlegm Decoction. • • • • • • • • • • • • • •

Huang Qin Radix Scutellariae 6 g Shan Zhi Zi Fructus Gardeniae 4 g Zhi Mu Radix Anemarrhenae 6 g Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g Gua Lou Fructus Trichosanthis 9 g Sang Bai Pi Cortex Mori 4 g Chen Pi Pericarpium Citri reticulatae 4.5 g Fu Ling Poria 6 g Jie Geng Radix Platycodi 5 g Mai Men Dong Radix Ophiopogonis 6 g Gan Cao Radix Glycyrrhizae uralensis 3 g Tian Men Dong Radix Asparagi 6 g Kuan Dong Hua (honey-treated) Flos Farfarae 9 g Di Gu Pi Cortex Lycii 4 g

Explanation The original formula was used in its entirety, because it corresponds well to the treatment aim of resolving Phlegm, clearing Heat and restoring the descending of Lung-Qi. • Tian Men Dong was added to nourish Lung-Yin. • Kuan Dong Hua was added to restore the descending of Lung-Qi and stop cough. • Di Gu Pi was added to clear Lung Empty Heat. This patient made a complete recovery after 3 months of taking herbal decoctions along lines similar to the one above.

Phlegm-Fluids in the Lungs Clinical manifestations Cough with a low sound and expectoration of whitewatery-dilute sputum, a feeling of cold, a feeling of oppression in the chest, tiredness, poor appetite and low spirits. Tongue: Pale, Swollen, with a sticky-white coating. Pulse: Soggy. This is not a common pattern seen in chronic cough; it usually occurs only in the elderly.

Treatment principle Drain Dampness, resolve Phlegm, scatter Cold, tonify the Spleen and Kidneys and stop cough.

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Acupuncture

SUMMARY

Points

PHLEGM-FLUIDS IN THE LUNGS

LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, SP-9 Yinlingquan, KI-7 Fuliu, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu, Du-4 Mingmen, BL-23 Shenshu, BL-22 Sanjiaoshu. Reinforcing method on ST-36, Ren-12, BL-20, Du-4 and BL-23, reducing or even method on the others. Moxa is applicable.

Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, SP-9 Yinlingquan, KI-7 Fuliu, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu, Du-4 Mingmen, BL-23 Shenshu, BL-22 Sanjiaoshu. Reinforcing method on ST-36, Ren-12, BL-20, Du-4 and BL-23, reducing or even method on the others. Moxa is applicable.

Explanation With acupuncture, the treatment of Phlegm-Fluids is not very different from that of Damp Phlegm outlined above. • Du-4 and BL-23 are reinforced with moxa if there is a Kidney-Yang deficiency. • BL-22 is reduced to promote the transformation of fluids and therefore resolve Phlegm. • All the other points have been explained under Damp Phlegm.

Herbal therapy Prescription LING GAN WU WEI JIANG XIN TANG Poria-Glycyrrhiza-Schisandra-Zingiber-Asarum Decoction

Liver-Fire insulting the Lungs Clinical manifestations

Herbal therapy Prescription LING GAN WU WEI JIANG XIN TANG Poria-Glycyrrhiza-Schisandra-Zingiber-Asarum Decoction

Explanation This formula resolves Cold Phlegm and Phlegm-Fluids.

Modifications • This condition is very chronic and occurs against a background of Spleen-Yang deficiency and often Kidney-Yang deficiency. In such cases one should add herbs to tonify Spleen- and Kidney-Yang, such as Bai Zhu Rhizoma Atractylodis macrocephalae, Huang Qi Radix Astragali, Yin Yang Huo Herba Epimidii and Du Zhong Cortex Eucommiae ulmoidis. • If there are very pronounced symptoms of Cold, add Fu Zi Radix Aconiti lateralis preparata. However, in such a case, one must be absolutely sure that there is no Heat anywhere in the body, as the three herbs Gan Jiang, Xi Xin and Fu Zi are very hot, pungent and scattering. Please note that the use of Fu Zi is illegal in Europe. • To enhance the antitussive effect, add Su Zi Fructus Perillae, Xuan Fu Hua Flos Inulae and Xing Ren Semen Armeniacae.

Sudden bouts of cough, a red face often elicited by emotional stress, dry throat, a feeling of phlegm in the throat, expectoration of scanty phlegm, hypochondrial distension and pain, pain on coughing, bitter taste, dark urine, dry stools, irritability and a dry mouth. Tongue: Red with redder sides, dry-yellow coating. Pulse: Wiry and Rapid. This is not a common pattern seen in chronic cough.

Treatment principle Clear the Lungs, drain Liver-Fire, restore the descending of Lung-Qi and stop cough.

Acupuncture Points LIV-2 Xingjian, G.B.-34 Yanglingquan, L.I.-11 Quchi, LU-5 Chize, LU-1 Zhongfu, Ren-17 Shanzhong, G.B.-21 Jianjing. All with reducing or even method.

Explanation • LIV-2 drains Liver-Fire. • G.B.-34 pacifies the Liver and eliminates stagnation from the hypochondrial region and chest. • L.I.-11 clears Heat. • LU-5 and LU-1 clear Lung-Heat and restore the descending of Lung-Qi.

Cough

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• Ren-17 subdues rebellious Qi in the chest and restores the descending of Lung-Qi. • G.B.-21 subdues rebellious Qi and makes Qi descend.

CHRONIC EMPTY

Herbal therapy

Slight cough with low sound, no phlegm, spontaneous sweating, propensity to catching cold, weak voice, tiredness and pale face. Tongue: Pale. Pulse: Empty.

Prescription XIE BAI SAN and DAI GE SAN Draining Whiteness Powder and Indigo-Concha Cyclinae Powder

Explanation

Lung-Qi Deficiency Clinical manifestations

Treatment principle Tonify Lung-Qi and restore the descending of Lung-Qi.

These two formulae together clear Lung-Heat, drain Liver-Fire, restore the descending of Lung-Qi and stop cough.

Acupuncture

Modifications

Points

• If symptoms of Heat are pronounced, add Shan Zhi Zi Fructus Gardeniae and Mu Dan Pi Cortex Moutan. • If there is a lot of Phlegm and severe cough, add Zhu Ru Caulis Bambusae in Taeniam, Su Zi Fructus Perillae and Pi Pa Ye Folium Eriobotryae. • If there is severe cough and other symptoms of rebellious Qi (such as fullness of the chest), add Shan Zhi Shi Fructus Aurantii immaturus and Xuan Fu Hua Flos Inulae. • If there is chest pain, add Yu Jin Radix Curcumae. • If Fire has begun to injure fluids, add Nan Sha Shen Radix Adenophorae, Mai Men Dong Radix Ophiopogonis and Tian Hua Fen Radix Trichosanthis.

LU-9 Taiyuan, BL-13 Feishu, LU-7 Lieque, BL-43 Gaohuangshu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao. Reinforcing method; moxa is applicable.

SUMMARY LIVER-FIRE INSULTING THE LUNGS Points LIV-2 Xingjian, G.B.-34 Yanglingquan, L.I.-11 Quchi, LU-5 Chize, LU-1 Zhongfu, Ren-17 Shanzhong, G.B.-21 Jianjing. All with reducing or even method. Herbal therapy Prescription XIE BAI SAN and DAI GE SAN Draining Whiteness Powder and Indigo-Concha Cyclinae Powder

Explanation • LU-9 and BL-13 tonify Lung-Qi and stop cough. • LU-7 restores the descending of Lung-Qi. • BL-43 nourishes Lung-Yin and is specific for chronic Lung problems. • Ren-12, ST-36 and SP-6 tonify both Spleen and Lungs (since the Lung channel starts in the Middle Burner).

Herbal therapy Prescription BU FEI TANG Tonifying the Lungs Decoction

Explanation This formula tonifies Lung-Qi, restores the descending of Lung-Qi and stops cough.

Modifications • If there is Spleen-Qi deficiency, add Bai Zhu Rhizoma Atractylodis macrocephalae. • If there is Kidney-Yang deficiency, add Xu Duan Radix Dipsaci and Hu Tao Rou Semen Juglandis.

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SUMMARY

Herbal therapy

LUNG-QI DEFICIENCY

Prescription

Points LU-9 Taiyuan, BL-13 Feishu, LU-7 Lieque, BL-43 Gaohuangshu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao. Reinforcing method; moxa is applicable.

SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction

Herbal therapy Prescription BU FEI TANG Tonifying the Lungs Decoction

Lung-Yin Deficiency Clinical manifestations Dry cough in short bursts and with a low sound, scanty phlegm or none, blood-flecked sputum, dry throat, feeling of heat in the evening, night sweating, thin body, extreme tiredness. Tongue: without coating, dry, Lung cracks. If there is Empty Heat, the body is Red. Pulse: Floating-Empty.

Treatment principle Nourish Lung-Yin, moisten the Lungs, clear Empty Heat if necessary, restore the descending of Lung-Qi and stop cough.

Acupuncture Points LU-9 Taiyuan, LU-10 Yuji, Ren-12 Zhongwan, LU-1 Zhongfu, ST-36 Zusanli, SP-6 Sanyinjiao, LU-7 Lieque and KI-6 Zhaohai. All with reinforcing method except for LU-10, which should be reduced. No moxa.

Explanation • LU-9 and LU-1 nourish Lung-Yin. • LU-10 clears Lung Empty Heat. • Ren-12, ST-36 and SP-6 tonify the Spleen to nourish the Lungs. • LU-7 and KI-6 in combination open the Directing Vessel (Ren Mai), benefit the throat, nourish LungYin, restore the descending of Lung-Qi and stop cough from Lung-Yin deficiency.

Explanation This formula nourishes Lung-Yin, clears Empty Heat, restores the descending of Lung-Qi and stops cough.

Modifications • To enhance the antitussive effect, add Zhe Bei Mu Bulbus Fritillariae thunbergii and Xing Ren Semen Armeniacae. • If there are pronounced symptoms of Empty Heat in the Lungs, add Di Gu Pi Cortex Lycii and Qing Hao Herba Artemisiae annuae. • If there is sweating at night, add Wu Mei Fructus Mume and Fu Xiao Mai Fructus Tritici levis. • If there is some scanty yellow sputum, add Hai Ge Ke Concha Meretricis seu Cyclinae and Huang Qin Radix Scutellariae. • If there is blood in the sputum, add charred Shan Zhi Zi Fructus Gardeniae, Mu Dan Pi Cortex Moutan and Bai Mao Gen Rhizoma Imperatae.

SUMMARY LUNG-YIN DEFICIENCY Points LU-9 Taiyuan, LU-10 Yuji, Ren-12 Zhongwan, LU-1 Zhongfu, ST-36 Zusanli, SP-6 Sanyinjiao, LU-7 Lieque and KI-6 Zhaohai. All with reinforcing method except for LU-10, which should be reduced. No moxa. Herbal therapy Prescription SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction

Lung-Dryness Clinical manifestations Dry cough with a low sound, dry throat and mouth. Tongue: Dry. Pulse: Floating-Empty.

Cough

This is a condition of Dryness of the Lungs and, although it does not show all the symptoms of Yin deficiency, it is a state that often precedes Yin deficiency. It frequently occurs in people with a predisposition to Lung deficiency who, through their work, need to use their voice a lot (such as teachers). In such cases, it is usually associated with a deficiency of Stomach-Yin because the Stomach is the origin of fluids. This pattern may also arise following an invasion of Wind-Heat that dries the Lung’s fluids and leads to Dryness with some residual Heat or Phlegm-Heat in the Lungs. It is manifested with a very dry and ticklish cough immediately following an invasion of WindHeat. The cough is very persistent and is worse at night.

Treatment principle Moisten the Lungs, restore the descending of Lung-Qi and stop cough.

Acupuncture

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Modifications • To enhance the antitussive effect, add Sang Bai Pi Cortex Mori and Zi Wan Radix Asteris.

Prescription QING ZAO JIU FEI TANG Clearing Dryness and Rescuing the Lungs Decoction

Explanation This formula, which is for Dryness and residual Heat in the Lungs following an invasion of Wind-Heat, restores the descending of Lung-Qi, stops cough, clears Lung-Heat and nourishes and moistens Lung-Yin. The cough is usually dry without phlegm, although it may be dry with the occasional, difficult expectoration of scanty phlegm.

Prescription BEI MU GUA LOU SAN Fritillaria-Trichosanthes Powder

Points

Explanation

LU-9 Taiyuan, LU-10 Yuji, Ren-12 Zhongwan, LU-1 Zhongfu, ST-36 Zusanli, SP-6 Sanyinjiao, LU-7 Lieque and KI-6 Zhaohai. All with reinforcing method except for LU-10, which should be reduced. No moxa.

This formula restores the descending of Lung-Qi, stops cough and resolves Phlegm-Heat. It is also for Dryness and residual Heat in the Lungs following an invasion of Wind-Heat, but with the addition of some Phlegm. The cough is therefore dry but with some scanty and sticky phlegm that is difficult to expectorate. This situation arises because of WindHeat, which, on the one hand, may dry up fluids leading to Dryness or, on the other hand, condenses fluids into Phlegm.

Explanation These points are the same as for Lung-Yin deficiency and have already been explained above.

Herbal therapy Prescription SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction

Explanation This formula has already been explained above.

Prescription SHENG MAI SAN Generating the Pulse Powder

Explanation This formula tonifies Lung-Qi, generates fluids and nourishes Lung-Yin.

SUMMARY LUNG-DRYNESS Points LU-9 Taiyuan, LU-10 Yuji, Ren-12 Zhongwan, LU-1 Zhongfu, ST-36 Zusanli, SP-6 Sanyinjiao, LU-7 Lieque and KI-6 Zhaohai. All with reinforcing method except for LU-10, which should be reduced. No moxa. Herbal therapy Prescription SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction

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The Practice of Chinese Medicine LU

Prescription SHENG MAI SAN Generating the Pulse Powder

KI SP

Prescription QING ZAO JIU FEI TANG Clearing Dryness and Rescuing the Lungs Decoction Prescription BEI MU GUA LOU SAN Fritillaria-Trichosanthes Powder

MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 30, No. 5, 1999, pp. 35–36. Zhu Sheng Chao, “Clinical observation on the prevention of cough and breathlessness in children with massage in the summer.” This article explores the clinical effect of giving children preventive treatment in the summer to prevent cough and breathlessness in the winter. Dr Zhu treated 112 children (73 boys and 39 girls), of whom 35 were aged between 1 and 3, 59 between 3 and 7, and 18 between 7 and 12. To prevent their developing a cough of external origin in winter, treatment was given in the summer based on the “Three Tonifications”, “Two Kneadings” and “One Pressure”. The “Three Tonifications” are tonification of the Spleen, Lungs and Kidneys. These three organs are tonified by massaging the thumb, fourth finger and fifth finger. To tonify the Spleen, the thumb is massaged with a stroking movement on the radial side from the tip towards the wrist. To tonify the Lungs, the ring finger is massaged with a stroking movement on the radial side from the tip towards the palm. To tonify the Kidneys, the little finger is massaged with a stroking movement on the radial side from the tip towards the palm (Fig. 8.7). Each of the fingers is stroked 100 times.

Figure 8.7 Paediatric massage to prevent cough in winter.

The “Two Kneadings” are kneading of Ren-17 Shanzhong (50 times) and BL-13 Feishu (100 times). The “One Pressure” consists of pinching-pulling over the spine from the coccyx to Du-14 Dazhui and in kneading BL-13 Feishu, BL-20 Pishu and BL-21 Weishu 10 times each. For chronic cough in children, Dr Zhu recommends three techniques: 1. massaging the areas of the “Eight Trigrams” in the palm of the hand 50 times (Fig. 8.8) 2. massaging the radial side of the thumb from LU10 Yuji to LU-11 Shaoshang 100 times (Fig. 8.9). The latter technique is called the “Three Gates”. 3. massaging BL-23 Shenshu.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 41, No. 10, 2000, p. 637. Hong Hai Zhou, “Treat stasis for night cough.” Dr Hong says that coughing at night is due to deficient Yang and Excess of Yin. More specifically, it is due to Lung-Qi not descending, Qi and Blood not being regulated, Cold stagnating in the Interior and Blood stasis.

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LU-10 5

6

4

7 8

3

2

1

Figure 8.9 “Three Gates” massage for children.

Figure 8.8 “Eight Trigrams” massage for children.

Dr Hong therefore advocates invigorating Blood and eliminating stasis for night cough. He considers Dang Gui Radix Angelicae sinensis to be the main herb for this aim, together with Hong Hua Flos Carthami tinctorii and Tao Ren Semen Persicae.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 36, No. 7, 1995, p. 409. Shi Xin De and An Bao Hua, “284 cases of cough from Lung-Heat treated with Qing Jin Zhi Ke Tang.” Dr Shi and Dr An report on the treatment of 284 patients with acute cough from Lung-Heat. There were 161 men and 123 women; the youngest patient was 2.5 and the oldest 42. The formula used was Qing Jin Zhi Ke Tang Clearing Metal and Stopping Cough Decoction. • • • • • • •

Jin Yin Hua Flos Lonicerae japonicae 10 g Chai Hu Radix Bupleuri 10 g Huang Qin Radix Scutellariae 12 g Shi Gao Gypsum fibrosum 20 g Da Huang Radix et Rhizoma Rhei 6 g Sang Bai Pi Cortex Mori 12 g Xing Ren Semen Armeniacae 10 g

• • • • • • • •

Jie Geng Radix Platycodi 10 g Ma Huang (fried with honey) Herba Ephedrae 3 g Lu Gen Rhizoma Phragmitis 12 g Mai Men Dong Radix Ophiopogonis 10 g Sheng Di Huang Radix Rehmanniae 10 g Ju Hua Flos Chrysanthemi 10 g Bo He Herba Menthae haplocalycis 6 g Gan Cao Radix Glycyrrhizae uralensis 6 g

This formula should be modified according to clinical manifestations. • Headache, stuffy nose, sore throat: add Ban Lan Gen Radix Isatis seu Baphicacanthis, Ma Bo Lasiosphaera/ Calvatia, Shan Dou Gen Radix Sophorae tonkinensis. • Aversion to cold, wheezing: add Xuan Shen Radix Scrophulariae, Ma Bo Lasiosphaera/Calvatia, Zhe Bei Mu Bulbus Fritillariae thunbergii. • Dry throat, no phlegm or scanty phlegm: add Bei Sha Shen Radix Glehniae, Li Pi (pear skin), Shan Zhi Zi Fructus Gardeniae, Zhe Bei Mu Bulbus Fritillariae thunbergii. • Thirst, profuse yellow phlegm: add Chi Shao Radix Paeoniae rubra, Gua Lou Fructus Trichosanthis, Yu Jin Radix Curcumae, Xuan Shen Radix Scrophulariae. • Mental restlessness, thirst: add Bei Sha Shen Radix Glehniae, Xuan Shen Radix Scrophulariae, Tian Hua Fen Radix Trichosanthis. • Lesser Yang pattern: add Shi Gao Gypsum fibrosum, Ban Xia Rhizoma Pinelliae preparatum, Bai Bu Radix Stemonae.

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Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 42, No. 9, 2001, p. 568. Bo Li Ye et al, “The treatment of cough of external origin in children with the method of restoring the diffusing of Lung-Qi and penetrating the Yang Organs.” This is an interesting article reporting a clinical trial that did not involve the comparison of Chinese medicine with a placebo or a Western drug but that of two different Chinese methods of treatment. The authors explain that, in the treatment of cough from external origin, one normally uses the method of restoring the diffusing of Lung-Qi with pungent and clearing herbs that make Qi diffuse and descend. They think that, in children, it is necessary also to “penetrate the Yang Organs”, which means moving Qi downwards by stimulating the bowel movement with Da Huang Radix et Rhizoma Rhei. The rationale behind the use of Da Huang to stimulate the bowel movement and “penetrate the Yang Organs” is based on the exterior–interior relationship between the Large Intestine and Lungs. The unblocking of the Large Intestine means that Lung-Qi can descend and therefore alleviate cough. The authors treated 130 children suffering from cough of external origin and a control group of 70 children. In the treatment group, there were 62 boys and 68 girls; 99 were aged between 2 and 10, and 31 between 11 and 15. The formula used for the treatment and control groups was the same, i.e. Ma Xing Shi Gan Tang EphedraArmeniaca-Gypsum-Glycyrrhiza Decoction, except that the decoction in the treatment group contained Da Huang Radix et Rhizoma Rhei and that in the control group it did not. If the children suffered from constipation, Da Huang was added towards the end of boiling the decoction (this increases its downwards movement and stimulates the bowel movement more); if they did not suffer from constipation, Da Huang was boiled together with the other herbs. The results in the treatment group were as follows. • Cured within 1–3 days: 118 (90.8%) • Cured within 4–6 days: 10 (7.7%) • Cured in over 7 days: 2 (1.5%)

In the control group, the results were as follows. • Cured within 1–3 days: 48 (69.1%) • Cured within 4–6 days: 19 (27.1%) • Cured in over 7 days: 3 (3.8%) Statistically, P < 0.01.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 42, No. 9, 1994, p. 524. Su Yun Fang, “The experience of Dr Jiang Shi Ying in the treatment of cough from autumn Dryness with the method of moistening.” In an account of the experience of a famous contemporary doctor in the treatment of dry cough caused by autumn dryness, Dr Su reports three different formulae: one for dryness affecting the Lungs and the Upper Burner, one for Dryness affecting the Lungs and one for Dryness affecting the Lungs with Lung-Qi deficiency. The formula for Dryness affecting the Lungs and the Upper Burner (dry eyes and mouth) is as follows. • • • • • • • •

Sang Ye Folium Mori 10 g Ju Hua Flos Chrysanthemi 12 g Lian Qiao Fructus Forsythiae 10 g Chan Tui Periostracum Cicadae 6 g Jie Geng Radix Platycodi 12 g Zhu Ye Folium Phyllostachys nigrae 10 g Ku Ding Cha Folium Ilecis cornutae 10 g Lai Fu Zi Semen Raphani 10 g The formula for Dryness in the Lungs is as follows.

• • • • • • • • • •

Sang Ye Folium Mori 12 g Bei Sha Shen Radix Glehniae 12 g Mai Men Dong Radix Ophiopogonis 10 g Xing Ren Semen Armeniacae 10 g Zi Wan Radix Asteris 10 g Kuan Dong Hua Flos Farfarae 10 g Pi Pa Ye Folium Eriobotryae 10 g Bai Bu Radix Stemonae 12 g Chen Pi Pericarpium Citri reticulatae 6 g Jie Geng Radix Platycodi 6 g

The formula for Dryness in the Lungs with Lung-Qi deficiency is as follows. • Xi Yang Shen Radix Panacis quinquefolii 12 g • Bei Sha Shen Radix Glehniae 10 g

Cough

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asthma and in 82% with non-bronchial asthma conditions. Bakumondo-to was more effective in reducing cough sensitivity to capsaicin in bronchial asthma than in non-bronchial asthma conditions. While Bakumondo-to did not significantly reduce the sputum eosinophil count, its effectiveness in suppressing cough was greatest in patients whose sputum eosinophil count was less than or equal to 2%. It remains to be established whether Bakumondo-to inhibits eosinophil activation.

Herbal medicine

Conclusion

• • • • • • •

Mai Men Dong Radix Ophiopogonis 12 g Lu Gen Rhizoma Phragmitis 10 g Xing Ren Semen Armeniacae 6 g Zi Wan Radix Asteris 10 g Kuan Dong Hua Flos Farfarae 10 g Bai Bu Radix Stemonae 10 g Sang Ye Folium Mori 10 g

The effects of Bakumondo-to (Mai Men Dong Tang Ophiopogon Decoction) on asthmatic and non-asthmatic patients with increased cough sensitivity

The results suggest that Bakumondo-to is an effective therapeutic preparation for cough hypersensitivity accompanying chronic cough disease, especially in cases of severe allergic inflammation.

Nihon Kokyuki Gakkai Zasshi [Japanese Respiratory Journal] 2004 January, Vol. 42, Issue 1, pp. 49–55. Watanabe N, Gang C, Fukuda T Department of Pulmonary Medicine and Clinical Immunology, Dokkyo University School of Medicine, Tochigi, Japan

Treatment of acute bronchiolitis with Chinese herbs

Objective

Objective

This study was conducted to investigate the effect of Bakumondo-to (Mai Men Dong Tang) on cough sensitivity in patients with bronchial asthma and nonasthmatic (non-bronchial asthma) conditions. The effect on respiratory tract inflammation was also examined.

To evaluate the effect of the Chinese herb Huang Lian (Rhizoma Coptidis) on acute bronchiolitis.

Method Twenty-one bronchial asthma and 22 non-bronchial asthma subjects whose cough threshold for capsaicin was less than 3.9 mM were examined. Solutions of 1000, 500, 250, 125, 62.5, 31.2, 15.6, 7.80, 3.90, 1.95, 0.98, and 0.49 mM were prepared. Cough thresholds to a concentration of inhaled capsaicin solution causing five or more coughs was measured before treatment and after 2 months or more of treatment with Bakumondo-to (9 g/day, TJ-29). The number of eosinophils in the peripheral blood, the sputum eosinophil ratio, and the eosinophil cationic protein level in the serum were also measured before and after treatment.

Results Bakumondo-to significantly improved the cough threshold value in 76% of patients with bronchial

Archives of Disease in Childhood 1993 April, Vol. 68, Issue 4, pp. 468–471. Kong XT, Fang HT, Jiang GQ, Zhai SZ, O’Connell DL, Brewster DR

Method In a randomized single-blind trial, children with acute bronchiolitis and serological evidence of recent respiratory syncytial virus infection were studied in a tertiary hospital in Harbin, China. The 96 children were randomized into three treatment groups: herbs, herbs with antibiotics and antibiotics alone. The herbs were prepared by the medical school pharmacy and administered daily by intravenous infusion for 7 days.

Results The main outcomes, assessed blindly, were symptomatic improvement in cough, fever, wheezing, chest signs and duration of stay in hospital. The mean duration of symptoms from the start of treatment was 6.2 (ranging from 5.6 to 6.9) days in the two groups treated with herbs, compared with 8.6 (ranging from 7.5 to 9.8) days in the group treated with antibiotics alone. The mean reductions in duration of clinical manifestations for treatment with antibiotics alone compared with herbs were from 3.1 to 1.5 days for fever, 9.1 to

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6.1 days for cough, 6.5 to 4.1 days for wheezing and 7.2 to 4.9 days for chest crackles. No adverse effect of Huang Lian herbal treatment was detected.

Conclusion In conclusion, this study confirms that Huang Lian is safe and effective and warrants further study.

Cochrane Database Systemic Review 2005 Wu T, Chen X, Duan X, Juan N, Liu G, Qiao J, Wang Q, Wei J, Zhen J, Zhou L Chinese Cochrane Centre, Chinese Evidence-Based Medicine Centre and Regional Clinical Epidemiology Resource and Training Centre, China

Objective This review aimed to summarize the existing evidence on the comparative effectiveness and safety of Chinese medicinal herbs for treating uncomplicated acute bronchitis.

Search strategy The search included the Cochrane Central Register of Controlled Trials (the Cochrane Library Issue 1, 2005), which includes the Cochrane Acute Respiratory Infections Group’s specialized register; the Chinese Cochrane Centre’s Controlled Trials Register (up to December 2004); Medline (1966 to March week 1, 2005); Embase (1988 to December 2004); and the Chinese Biomedical Database (1980 to December 2004).

were beneficial in terms of relief of signs and symptoms. Thirteen trials analysed the data on physician global assessment of improvement at follow-up. Nine of 13 trials showed that Chinese herbs were superior to routine treatment, and the other four trials showed a similar effect to routine treatment. In general, Chinese herbs appeared beneficial. Only one trial reported on adverse effects during treatment.

PROGNOSIS Both acupuncture and Chinese herbs give excellent results in the treatment of cough. Obviously acute cough, whether it is external or internal, is easier and quicker to treat. Coughs from acute respiratory infections can be cleared in a few days at the Defensive-Qi or Qi level, and it is not necessary to take antibiotics, which often only lead to residual Heat or Phlegm-Heat. Chronic coughs are also relatively easy to treat; the most difficult one is that from Lung-Yin deficiency, which may take some months to clear. Of all the patterns appearing with a chronic cough, Chinese herbs give better results in the patterns of Damp Phlegm, Phlegm-Heat, Phlegm-Fluids and Lung-Yin deficiency.

WESTERN DIFFERENTIATION

Selection criteria

The following are the main causes of cough from the perspective of Western medicine.

Randomized controlled trials comparing Chinese medicinal herbs with placebo, antibiotics or other Western medicines for the treatment of uncomplicated acute bronchitis.

Tracheitis

Data collection and analysis At least two authors extracted data and assessed trial quality.

Main results Four trials reported the time to improvement of cough, fever and rales associated with bronchitis and showed that patients treated with Chinese herbs had a shorter duration of signs and symptoms. Two trials reported the proportion of patients with improved signs and symptoms at follow-up and showed that Chinese herbs

This usually occurs following an invasion of WindHeat (upper respiratory infection). The cough is harsh and painful, and the throat and trachea feel very raw and sore. It is usually worse at night. From a Chinese perspective, this broadly corresponds to Lung-Dryness following an invasion of Wind-Heat.

Acute bronchitis This usually follows an upper respiratory infection, and the cough is loose with expectoration of yellow, green or purulent sputum. The temperature and pulse are raised.

Cough

From the point of view of Chinese medicine, this broadly corresponds to the Qi level with Phlegm-Heat in the Lungs.

Chronic bronchitis This is usually the consequence of repeated bouts of acute bronchitis. It is more frequent in smokers over 40. The cough is productive of white, yellow or bloodflecked sputum. From a Chinese perspective, this corresponds to either Damp Phlegm or Phlegm-Heat in the Lungs on a background of Spleen deficiency.

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is high, the patient is flushed, the pulse and the breathing are rapid. There may also be movement in the alae nasi. From the Chinese point of view, it corresponds to Lung-Heat at the Qi level.

Carcinoma of the bronchi The most common cancer of all, this occurs most often in men between 40 and 55. It is characterized by a dry cough, breathlessness and a deep-seated thoracic pain. There may be some scanty, blood-flecked sputum. The patient is weak and debilitated and lacks appetite. From the Chinese point of view, it corresponds, in its late stage, to Lung-Yin deficiency.

Whooping cough This occurs in children, mostly under 5. It starts like an ordinary cold with a cough. After a week, the characteristic “whoop” appears. The cough comes in bouts that are worse at night and are very distressing. The coughing bouts often end in vomiting. The child is flushed or cyanosed and looks frightened. Chinese medicine can alleviate the symptoms and shorten the course of this disease, but it requires very many treatments given every day. In the beginning stage, it corresponds to invasion of Wind-Heat; in the middle stage to Lung-Heat; and in the recovery stage to Stomach- and Lung-Yin deficiency, possibly with some residual Heat.

Pleurisy This consists of inflammation of the pleura, usually occurring after an upper respiratory infection. The cough is unproductive and distressingly painful. There is also chest pain and the temperature is raised. From the point of view of Chinese medicine, it corresponds to Lung Phlegm-Heat at the Qi level.

Pneumonia This consists of inflammation of the lung alveoli. It may begin abruptly with shivering, a headache, a high temperature and breathlessness. The cough is short and unproductive at first. It then develops scanty sputum, which is viscid, rust-coloured and bloodflecked. Pneumonia is nearly always accompanied by pleurisy, which causes chest pain. The temperature

Tuberculosis of the lungs This is an uncommon disease, but it is on the increase in both the UK and the USA. It is more frequent between the ages of 15 and 45. The cough is dry or with a scanty, blood-flecked sputum. There is also a chest pain, breathlessness and night sweating. The patient is very tired and debilitated and may have a low-grade fever in the afternoons. From the Chinese point of view, this condition is typical of Lung-Yin deficiency with Empty Heat.

Bronchiectasis This consists of permanent dilatation of bronchi and/or bronchioles. The alveoli become distended and filled with mucus. The cough occurs more in the mornings and is productive of large amounts of sputum, which is purulent and has a fruity odour. The breath is offensive after a bout of coughing. During acute episodes, there is a temperature. From the point of view of Chinese medicine, it may broadly correspond to the pattern of Turbid Phlegm in the Lungs in Breathlessness (Chuan).

Heart disease In the elderly, cough may also occur with heart disease. A cough at night that is productive of a very watery, white and frothy sputum may indicate impending left ventricular failure. On the other hand, left ventricular failure may also cause pulmonary

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embolism manifesting with a sudden, severe chest pain with dyspnoea and followed by a cough with bloodstained sputum.

END NOTES 1. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 150. First published c.100 BC. 2. Ibid., p. 215. 3. Ibid., pp. 215–216. 4. Ibid., p. 214. 5. Ibid., p. 216. 6. 1986 Jing Yue Quan Shu [Complete Book of Jing Yue]. Shanghai Science Publishing House, Shanghai, p. 336. The Complete Book of Jing Yue was written by Zhang Jing Yue and first published in 1624.

7. Zhou Chao Fan 2000 Li Dai Zhong Yi Zhi Ze Jing Hua [Essential Chinese Medicine Treatment Principles in Successive Dynasties]. Chinese Herbal Medicine Publishing House, Beijing, p. 285. 8. Ibid., p. 285. 9. Simple Questions, p. 74. 10. 1981 Jin Gui Yao Lue Fang Xin Jie [A New Explanation of the Essential Prescriptions of the Golden Chest]. Zhejiang Scientific Publishing House, Zhejiang, p. 56. The Essential Prescriptions of the Golden Chest was written by Zhang Zhong Jing and first published c.AD 220. 11. Ibid., p. 285. 12. Ibid., p. 287. 13. Essential Chinese Medicine Treatment Principles in Successive Dynasties, p. 286. 14. Ibid., p. 286. 15. Ibid., p. 291. 16. Complete Book of Jing Yue, p. 336.

CHAPTER 9

THE PSYCHE IN CHINESE MEDICINE NATURE OF THE MIND (SHEN) IN CHINESE MEDICINE THE FIVE MENTAL-SPIRITUAL ASPECTS The Ethereal Soul (Hun) 248 The Corporeal Soul (Po) 264 The Intellect (Yi) 272 The Will-Power (Zhi) 274

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THE PSYCHE IN CHINESE MEDICINE A discussion of the treatment of mental and emotional problems is not possible without first exploring the concept of the mind and spirit in Chinese medicine. It is only by understanding the concept of mind and spirit in Chinese culture that we can truly grasp how to treat psychological and emotional problems with acupuncture and Chinese herbs. We must be careful not to interpret the Chinese concepts of “mind” and “spirit” in terms of Western (and often Christian) concepts of “mind” and “spirit”. The discussion of the treatment of mental-emotional problems will be centred on the following subjects. • The nature of the psyche in Chinese medicine (Chapter 9) • The five mental-spiritual aspects of a human being (Chapter 9) • The effect of the emotions on the Mind and Spirit (Chapter 10) • Aetiology of mental-emotional problems (Chapter 11) • Diagnostic signs in mental-emotional problems (Chapter 12) • Acupuncture in the treatment of mental-emotional problems (Appendix 5) • Pathology and treatment of depression (Chapter 13)

• Pathology and treatment of anxiety (Chapter 14) • Pathology and treatment of insomnia (Chapter 15) • Patterns in mental-emotional problems and their treatment with herbal medicine and acupuncture (Chapter 16) The discussion of the psyche in Chinese medicine in the present chapter will be conducted according to the following topics. • Nature of the Mind (Shen) in Chinese medicine • The five mental-spiritual aspects

NATURE OF THE MIND (SHEN) IN CHINESE MEDICINE The Mind (Shen) is one of the vital substances of the body. It is the most subtle and non-material type of Qi. Most authors translate the word Shen as “spirit”; for reasons that will be clearer as the discussion progresses, I prefer to translate Shen of the Heart as “Mind” rather than as “Spirit”. I translate as “Spirit” the complex of all five mental-spiritual aspects of a human being, i.e. the Ethereal Soul (Hun), the Corporeal Soul (Po), the Intellect (Yi), the Will-Power (Zhi) and the Mind (Shen) itself. All sinologists who write about the Confucian and neo-Confucian philosophers of the Song and Ming dynasty translate “School of Xin” as “School of Mind”, i.e. they translate the word “Xin” (meaning Heart) as “Mind”. The word Shen is used in the Yellow Emperor’s Classic of Internal Medicine with many different meanings. The two main meanings that concern us are the following. 1. Shen indicates the activity of thinking, consciousness, self-identity, insight and memory, all of which depend on the Heart. I translate this as “Mind”.

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2. Shen indicates the complex of all five mentalspiritual aspects of a human being, i.e. the Mind itself of the Heart, the Ethereal Soul (Hun) of the Liver, the Corporeal Soul (Po) of the Lungs, the Intellect (Yi) of the Spleen and the Will-Power (Zhi) of the Kidneys. I translate this as “Spirit”. There is another meaning to the word Shen that is frequently mentioned in relation to diagnosis. In this context, the word shen indicates an undefinable and subtle quality of “life”, “flourishing” or “lustre”, which can be observed in health. This quality can be observed in the complexion, the eyes, the tongue and the pulse, as will be explained in Chapter 12.

The Mind (Shen) The Chinese character for Shen is composed of two parts. The one on the left, called shi , indicates “influx from heaven; auspicious or inauspicious signs by which the will of Heaven is known to mankind”; this character is itself composed of two horizontal lines at the top, indicating what is above, high and therefore Heaven, and three vertical lines representing what is hanging from Heaven, i.e. the sun, the moon and the stars, the mutations of which reveal to people transcendent things. The right part of the character is the word shen , meaning “to state, to express, to explain, to stretch, to extend”. As we shall see later, the quality of “extending” has an important psychological implication in the life of the Mind (Shen). This part of the character, called shen, is also phonetic, i.e. it gives the word its sound (“shen”). The seal writing shows two hands stretching a rope and hence the idea of stretching, expansion (Fig. 9.1). The combination is probably phonetic, but the idea of spirit may have some connection with an increased or extended spiritual revelation.

! The Chinese character for Shen (Mind) conveys two ideas: “spiritual manifestation” and “to extend”, “to stretch”. It is therefore a pure and subtle Vital Substance that “extends” outwards towards the environment and mediates the relationship between the individual and the environment.

What then is the Chinese view of the Mind? As explained above, the Mind, like other vital substances, is a form of Qi; in fact, it is the most subtle and nonmaterial type of Qi. One of the most important characteristics of Chinese medicine is the close integration of body and Mind, which is highlighted by the integration of the three Vital Substances of Essence (Jing), Qi and Mind (Shen), called the “Three Treasures”. The Essence is the origin and biological basis of the Mind. The Spiritual Axis in Chapter 8 says: “Life comes about through the Essence; when the two Essences [of mother and father] unite, they form the Mind.”1 Zhang Jie Bin says: “The two Essences, one Yin, one Yang, unite ... to form life; the Essences of mother and father unite to form the Mind.”2 See Figure 9.2. Therefore the Mind of a newly conceived being comes from the Prenatal Essences of its mother and father. After birth, its Prenatal Essence is stored in the Kidneys and provides the biological foundation for the Mind. The life and Mind of a newly born baby, however, also

Essence of mother

Essence of father

MIND (Shen) Figure 9.1 Ancient Chinese script for shi.

Figure 9.2 Union of Essences to form Mind.

The Psyche in Chinese Medicine

depend on the nourishment from its own Postnatal Essence. The Spiritual Axis in Chapter 30 says:3 When the Stomach and Intestines are coordinated, the five Yin organs are peaceful, Blood is harmonized and mental activity is stable. The Mind derives from the refined essence of water and food.

will tend to weaken the Essence either when it is combined with overwork and/or excessive sexual activity or when the Fire generated by long-term emotional tensions injures Yin and Essence. CLINICAL NOTE The Three Treasures The Essence (Jing), Qi and Mind (Shen) interact with and influence each other in both directions, i.e. from the Essence to Qi and the Mind, and from the Mind to Qi and to Essence.

Thus the Mind draws its biological basis and nourishment from the Prenatal Essence stored in the Kidneys and the Postnatal Essence produced by Lungs, Stomach and Spleen. Hence the Three Treasures (Fig. 9.3): Mind (Shen) = Heart Qi = Lungs-Stomach-Spleen Essence (Jing) = Kidneys. These Three Treasures represent three different states of condensation or aggregation of Qi, the Essence being the densest, Qi more rarefied, and the Mind the most subtle and non-material. The activity of the Mind relies on the Essence and Qi as its fundamental basis. Hence the Essence is said to be the “foundation of the body and the root of the Mind”. Thus if Essence and Qi are strong and flourishing, the Mind will be happy, balanced and alert. If Essence and Qi are depleted, the Mind will suffer and may become unhappy, depressed, anxious or clouded. Zhang Jie Bin says: “If the Essence is strong, Qi flourishes; if Qi flourishes, the Mind is whole.”4 However, the state of the Mind also affects Qi and Essence. If the Mind is disturbed by emotional stress, becoming unhappy, depressed, anxious, or unstable, it will definitely affect Qi and/or the Essence. In most cases, it will affect Qi first, because all emotional stress upsets the normal functioning of Qi. Emotional stress

MIND

QI

ESSENCE

Heart

Lungs-Stomach-Spleen

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Of all the organs, the Mind is most closely related to the Heart, which is said to be the “residence” of the Mind. The Simple Questions in Chapter 8 says: “The Heart is the Monarch and it governs the Mind ...”5 The Spiritual Axis in Chapter 71 says: “The Heart is the Monarch of the five Yin organs and six Yang organs, and it is the residence of the Mind.”6 The “Mind” residing in the Heart or Heart-Mind is responsible for many different mental activities, including: • • • • • • • • • •

thinking memory consciousness insight emotional life cognition sleep intelligence wisdom ideas.

In addition to these, the Mind of the Heart is also responsible for hearing, sight, touch, taste and smell. Of course, many of the above activities are also carried out by other organs, and there often is an overlap between the functions of various organs. For example, although the Mind is mainly responsible for memory, the Spleen and Kidneys (and therefore Intellect and Will-Power) also play a role. CLINICAL NOTE In order to stimulate the thinking function that is associated with the Heart, I use the points HE-5 Tongli and BL-15 Xinshu.

Kidneys

Figure 9.3 The Three Treasures (Essence, Qi, Mind).

Let us now briefly look at the above functions in more detail.

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Thinking depends on the Mind. If the Mind is strong, thinking will be clear. If the Mind is weak or disturbed, thinking will be slow and dull. The Chinese characters for “thought” (yi), “to think” (xiang) and “pensiveness” (si) all have the character for “heart” as their radical. Memory has two different meanings. On the one hand, it indicates the capacity of memorizing data when one is studying or working. On the other hand, it refers to the ability to remember past events. Both of these depend on the Mind and therefore the Heart, although also on the Spleen and Kidneys. Consciousness indicates the totality of thoughts and perceptions as well as the state of being conscious. In the first sense, the Mind is responsible for the recognition of thoughts, perceptions and feelings. In the latter sense, when the Mind is clear, we are conscious; if the Mind is obfuscated or suddenly depleted, we lose consciousness. Insight indicates our capacity of self-knowledge, self-recognition and identity of self. The Mind of the Heart is responsible for our identity of self as individuals. This is lost in serious mental illness such as schizophrenia. Emotional life refers to the perception and feeling of emotional stimuli. With regard to emotions, only the Mind (and therefore the Heart) can “feel” them. Of course, emotions definitely affect all the other organs too, but it is only the Mind that actually recognizes, feels and assesses them. For example, anger affects the Liver, but the Liver cannot feel it because it does not house the Mind. Only the Heart can feel it, because it houses the Mind, which is responsible for insight. When one feels sad, angry or worried, it is the Mind of the Heart that feels these emotions. It is for this reason that all emotions eventually affect the Heart (in addition to other specific organs), and it is in this sense that the Heart is the “emperor” of all the other organs.

CLINICAL NOTE Only the Mind (and therefore the Heart) can “feel” the emotions. Each emotion affects one or more organs, but it is only the Mind that actually recognizes, feels and assesses them. It is for this reason that all emotions eventually affect the Heart (in addition to other specific organs), and it is in this sense that the Heart is the “emperor” of all the other organs.

As emotions usually tend to cause some Heat, it is for this reason that a red tip of the tongue is such a common sign as all emotions affect the Heart. The best point to use when the Heart is affected by emotional stress is HE-7 Shenmen.

Cognition indicates the activity of the Mind in perceiving and conceiving, in reaction to stimuli. Sleep is dependent on the state of the Mind. If the Mind is calm and balanced, a person sleeps well. If the Mind is restless, the person sleeps badly. However, the Ethereal Soul is also responsible for sleep. Intelligence also depends on the Heart and the Mind. A strong Heart and Mind will make a person intelligent and bright. A weak Heart and Mind will render a person slow and dull. It should be remembered, however, that the Essence, and therefore heredity, plays a role in determining a person’s intelligence. Wisdom derives from a strong Heart and a healthy Mind. As the Mind is responsible for knowing and perceiving, it also gives us the sagacity to apply this knowledge critically and wisely. Ideas are another function of the Mind. The Heart and Mind are responsible for our ideas, our projects and the dreams that give our lives purpose. Thus, if the Heart is strong and the Mind healthy, a person can think clearly, memory is good, the state of consciousness and insight are sharp, the cognition is clear, sleep is sound, intelligence is bright, the emotional life is balanced, ideas flow easily and he or she acts wisely. If the Heart is affected and the Mind weak or disturbed, a person is unable to think clearly, memory is poor, the consciousness is clouded, insight is poor, sleep is restless, the emotional life is unbalanced, intelligence is lacking, ideas are muddled and he or she acts unwisely. Finally, the Mind of the Heart performs the very important function of coordinating and integrating the various parts of our mental-emotional life into an individual whole; this is probably its most important characteristic and function. It is really in this sense that the Heart is the “emperor” or “monarch” of the other organs. Most of the above functions of the Mind are attributed to the brain in Western medicine. During the course of development of Chinese medicine too, there have been doctors who attributed mental func-

The Psyche in Chinese Medicine

tions to the brain rather than the Heart; in particular, Sun Si Miao of the Tang dynasty, Zhao You Qin of the Yuan dynasty, Li Shi Zhen of the Ming dynasty and especially Wang Qing Ren of the Qing dynasty. As the Heart controls all mental activities of the Mind and is responsible for insight and cognition, which other organs do not have, this is another reason that it is the “emperor” of all the other organs. For this reason, the Heart is also called the “root of life”, as in Chapter 9 of the Simple Questions: “The Heart is the root of life and the origin of mental life ...”7 Apart from the above mental functions, the Mind also plays a role in the senses of sight, hearing, smell, taste and touch. The eyes and sight are obviously related to the Liver, especially Liver-Blood, and the Ethereal Soul. The book The Essence of Medical Classics on the Convergence of Chinese and Western Medicine (1892) says: “When the Ethereal Soul swims to the eyes, they can see.”8 However, although the eyes rely on the nourishment from LiverBlood, blood flows to the eyes through blood vessels that are under the control of the Heart. On the other hand, the Mind “gathers” the Ethereal Soul and, in this way, it has an influence on sight. The Simple Questions says in Chapter 10: “Blood vessels influence the eyes.”9 In fact, the Simple Questions also lists excessive use of the eyes as harmful to the blood vessels and Heart. It says in Chapter 23: “Excessive use of the eyes injures Blood [i.e. the Heart].”10 Ren Ying Qiu in Theories of Chinese Medicine Doctors says: “The Heart governs the Mind ... sight is a manifestation of the activity of the Mind.”11 Wang Ken Tang in Standards of Diagnosis and Treatment (1602) says: “The eye is an orifice of the Liver ... but a function of the Heart.”12 From the point of view of channels, both the Heart Main and Connecting (Luo) channels flow to the eye. Hearing depends on the Kidneys, but the Heart also has an influence on it in so far as it brings Qi and Blood to the ears. The Simple Questions in Chapter 4 says: “The colour of the Southern direction is red; it is related to the Heart, which opens into the ears ...”13 Some types of tinnitus are due to Heart-Qi being deficient and not reaching the ears. The sense of smell is also dependent on the Heart and Mind besides the Lungs. The Simple Questions in Chapter 11 says: “The five odours enter the nose and are stored by Lungs and Heart; if Lungs and Heart are diseased, the nose cannot smell.”14 The sense of taste naturally depends on the Heart and Mind, as the tongue is an offshoot of the Heart.

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The sense of touch is also dependent on the Heart and Mind, as this is responsible for the cognition and organization of external stimuli sensations. To sum up, all sensations of sight, hearing, smell, taste and touch depend on the Mind in much the same way as they depend on the brain in Western medicine. Therefore, the Mind (Shen) of the Heart is the Qi that allows the following: • forms life from the union of the Essence of the parents (but life needs also the Corporeal and Ethereal Souls) • allows the individual to be conscious of his or her self • permits the cohesion of various parts of our psyche and emotions • defines us as individuals • feels and assesses the emotions • is responsible for perceptions and senses • is responsible for thinking, memory, intelligence, wisdom, ideas • determines consciousness • allows insight and identity of self • is responsible for perception and cognition • determines sleep • governs the five senses (sight, hearing, smelling, taste, touch).

SUMMARY THE MIND (SHEN)  The Mind is the most subtle and refined Vital Substance of the Three Treasures, i.e. Essence (Jing), Qi and Mind (Shen).  The Essence, Qi and Mind interact with and influence each other.  The Mind is responsible for thinking, memory, consciousness, insight, emotional life, cognition, sleep, intelligence, wisdom and ideation.  The Mind is responsible for self-consciousness and the integration of various parts of our psyche.

THE FIVE MENTAL-SPIRITUAL ASPECTS As we have just seen, the Mind, and therefore the Heart, plays a pivotal and leading role in all mental

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activities. Yu Chang in Principles of Medical Practice (1658) says clearly: “The Mind [Shen] of the Heart gathers and unites the Ethereal Soul [Hun] and the Corporeal Soul [Po] and it combines the Intellect [Yi] and the Will-Power [Zhi].”15 However, all other organs also play roles in mental, emotional and spiritual activities, very often overlapping with that of the Heart. In particular, the Yin organs are more directly responsible for mental activities. Each Yin organ “houses” a particular mental-spiritual aspect of a human being. These are: • • • • •

Mind (Shen) – Heart Ethereal Soul (Hun) – Liver Corporeal Soul (Po) – Lungs Intellect (Yi) – Spleen Will-Power (Zhi) – Kidneys.

The Simple Questions in Chapter 23 says: “The Heart houses the Mind, the Lungs house the Corporeal Soul, the Liver houses the Ethereal Soul, the Spleen houses the Intellect and the Kidneys house the Will-Power.”16 In Chapter 9 it says:17 The Heart is the root of life and the origin of the Mind ... the Lungs are the root of Qi and the dwelling of the Corporeal Soul ... the Kidneys are the root of sealed storage [Essence] and the dwelling of Will-Power ... the Liver is the root of harmonization and the residence of the Ethereal Soul. The commentary to Chapter 23 of the Simple Questions, also based on passages from the Spiritual Axis, says:18 The Mind is a transformation of Essence and Qi; both Essences [i.e. the Prenatal and Postnatal Essences] contribute to forming the Mind. The Corporeal Soul is the assistant of the Essence and Qi; it is close to Essence but it moves in and out. The Ethereal Soul complements the Mind and Qi; it is close to the Mind but it comes and goes. The Intellect corresponds to memory; it is the memory that depends on the Heart. The Will-Power is like a purposeful and focused mind; the Kidneys store Essence ... and through the Will-Power they can fulfil our destiny. These five aspects together form the “Spirit”, which is also called Shen or sometimes the “Five Shen” in the old classics. The five Yin organs are the residences of Shen, i.e. the Spirit, and they are sometimes also called the “Five-Shen residences”, as in Chapter 9 of the Simple Questions.19 As indicated above, I use the term “Mind” to indicate the Shen that resides in the Heart and is responsible

for thinking, consciousness, self-identity, insight and memory, and the term “Spirit” to denote the Shen as the complex of all five mental-spiritual aspects of a human being, i.e. the Mind itself of the Heart, the Ethereal Soul (Hun) of the Liver, the Corporeal Soul (Po) of the Lungs, the Intellect (Yi) of the Spleen and the Will-Power (Zhi) of the Kidneys (Fig. 9.4). The five Yin organs are the physiological basis of the Spirit. The indissoluble relationship between them is well known to any practitioner of Chinese medicine. The state of Qi and Blood of each organ can influence the Mind or Spirit and, conversely, alterations of the Mind or Spirit will affect one or more of the internal organs. We can now discuss the five mental-spiritual aspects one by one.

The Ethereal Soul (Hun) The Ethereal Soul broadly corresponds to our Western concept of “soul”. According to ancient Chinese beliefs, it enters the body shortly after birth. Ethereal in nature, after death it survives the body and flows back to “Heaven” (Tian); this is the ancient Chinese concept of “Heaven”, i.e. a state of subtle and non-material energies and beings, and has therefore nothing to do with the Western and Christian concept of “Heaven”. The Ethereal Soul can be described as “that part of the Soul [as opposed to Corporeal Soul] that at death leaves the body, carrying with it an appearance of physical form.”20

Shen of Heart

= MIND

SHEN HUN

YI = SPIRIT ZHI

PO

Figure 9.4 The two meanings of Shen.

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The Chinese character for Ethereal Soul is:

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a dead person, but it is Yang and ethereal in nature and essentially harmless, i.e. it is not one of the evil spirits (hence the presence of the “cloud” radical).

This is composed of the following parts: = clouds = spirit, ghost. The ancient form of this last radical is shown in Figure 9.5; it means a head without a body. This form is itself composed of two parts (Fig. 9.6), meaning a swirling movement. This ancient radical therefore depicts the bodiless head of a dead person flowing to Heaven in a swirling movement or swimming in the realm of spirits and ghosts. The combination of the two characters for “cloud” and “spirit” in the character for Ethereal Soul conveys the idea of its nature; it is like a “ghost” or the spirit of

Old character for gui

Figure 9.5 Old Chinese character for gui.

Head of dead person without a body

Swirling movement of the spirit of dead person in the realm of spirits

Figure 9.6 Parts of old Chinese character for gui.

! The Chinese character for Ethereal Soul (Hun) contains the radical for gui, i.e “ghost, spirit, demon”. This immediately conveys the idea that the Ethereal Soul is a “dark”, subterranean part of our psyche with its own independent existence. There are three types of Ethereal Soul: a vegetative one (called Shuang Ling or “Clear Spirit”) common to plants, animals and human beings; an animal one (called Tai Guang or “Brilliant Light”) common to animals and human beings; and a human one (called You Jing or “Dark Essence”), which is present only in human beings (Fig. 9.7). Zhang Jie Bin in the Classic of Categories says: “The Mind and Ethereal Soul are Yang ... the Ethereal Soul follows the Mind; if the Mind is unconscious, the Ethereal Soul is swept away.”21 It also says: “The Mind corresponds to Yang within Yang, the Ethereal Soul corresponds to Yin within Yang.”22 The Spiritual Axis in Chapter 8 says: “The Ethereal Soul is the coming and going of the Mind.”23 See Figure 9.8. The concept of Ethereal Soul is closely linked to ancient Chinese beliefs in spirits, ghosts and demons. According to these beliefs, spirits, ghosts and demons are spirit-like creatures who preserve a physical appearance after death and wander in the world of spirit. Some are good and some are evil. In the times prior to the Warring States period (476–221 BC), such spirits were considered to be the main cause of disease. Since the Warring States period, a belief in naturalistic causes of disease (such as weather) gradually came to the fore; however, the belief in spirits has never really disappeared, even to the present day. What is the Ethereal Soul then and what does it do? An analysis of the Chinese character depicting the Ethereal Soul is essential to gain an understanding and a feeling for what it is. The presence of the radical for gui within its character immediately tells us that the Ethereal Soul has a somewhat “dark” nature; in ancient Greek philosophy, we would say it has a “Dionysian” nature. It pertains to a “subterranean” world that is different from the world of the Mind.

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Vegetative Ethereal Soul Shuang Ling (‘‘Clear Spirit’’)

Animal Ethereal Soul Tai Guang (‘‘Brilliant Light’’)

Human Ethereal Soul You Jing (‘‘Dark Essence’’)

Figure 9.7 The three Ethereal Souls.

ETHEREAL SOUL (Hun)

MIND (Shen)

‘‘Coming and going’’ of Ethereal Soul Figure 9.8 Relationship between Ethereal Soul and Mind.

The Ethereal Soul is the gui, i.e. the “dark”, intuitive, non-rational side of human nature; Yang in character, it enters and exits through the nose and communicates with Heaven. The gui in the character hun for the “Ethereal Soul” has also another important meaning. The fact that the Ethereal Soul has the nature of gui means that it has an independent existence from the Mind (Shen). The Ethereal Soul has its own life and

“agenda” over which the Mind has no say; the interaction and integration of the Mind with the Ethereal Soul is the basis for our rich psychic life. Unlike the Ethereal Soul, the other two mentalspiritual aspects of Intellect (Yi of the Spleen) and WillPower (Zhi of the Kidneys) do not have an independent existence but could be said to be part of the Mind (Shen) of the Heart. As we shall see below, the character for “Corporeal Soul” (Po) also contains the character for gui; like the Ethereal Soul, the Corporeal Soul also has its own independent existence, although on a physical level. Thus, the Ethereal Soul has its own separate existence from the Mind on a psychic level and the Corporeal Soul on a physical level. The Chinese character for Ethereal Soul should be compared and contrasted with that for the Mind (Shen). The radical gui in the character for “Ethereal Soul” is a ghost or spirit; it is “dark” and leads its own independent existence from that of the Mind. The character shen, by contrast, indicates the influx from Heaven – something pure, spiritual. The Ethereal Soul can be described as that part of the soul (as opposed to Corporeal Soul) that at death leaves the body, carrying with it an appearance of physical form. From this point of view, therefore, the soul has an independent existence just like in the ancient Greek–Roman civilization and during the Middle Ages. At death, the Ethereal Soul survives the body and returns to “Heaven”; the Corporeal Soul dies with the body and returns to Earth and the Mind is simply extinguished. It is interesting to note that, when describing the changes occurring at death, Chinese books say that the Ethereal Soul and not the Mind (Shen) returns to “Heaven”; this would seem to confirm that the Shen has indeed the nature of Mind rather than “Spirit”. Figure 9.9 uses the image of a cigarette to convey the different destinies of the Ethereal Soul, Corporeal Soul and Mind at death: the cigarette itself is the Mind (Shen), the smoke is the Ethereal Soul, the ashes the Corporeal Soul and the tobacco the Essence (Jing). As the cigarette is extinguished, the Ethereal Soul survives and goes to “Heaven” in the form of smoke, the Corporeal Soul dies with the body and returns to Earth in the form of ashes, the Mind is extinguished (the cigarette itself) and the Essence is used up (in the form of tobacco).

The Psyche in Chinese Medicine

Smoke going up to ‘‘Heaven’’ is Hun

Cigarette is Shen Tobacco is the Essence that is used up

Ashes going down to Earth are Po

Figure 9.9 Comparison between Ethereal Soul, Mind, Corporeal Soul and Essence represented by a cigarette.

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that, through this ceremony, the baby was assigned his or her place in the family and society. The Ethereal Soul corresponds to our individuality, but an individuality within the family and society. When describing the Ethereal Soul, the theme of “movement”, “swirling”, “wandering” is ever present. As we have seen above, the old form of the Chinese radical within the word Hun depicts the swirling movement of the soul of a dead person in the realm of spirit. The Ethereal Soul provides movement to the psyche in many ways: movement of the soul out of the body as in dreaming, movement out of one’s everyday life as in life dreams and ideas, movement towards the others in human relationships, movement in terms of plans and projects. CLINICAL NOTE The Ethereal Soul provides movement to the psyche in many ways: movement of the soul out of the body as in dreaming, movement out of one’s everyday life as in life dreams and ideas, movement towards the others in human relationships, movement in terms of plans, projects, ideas, life dreams, inspiration, creativity. The best point to stimulate the coming and going of the Ethereal Soul is G.B.-40 Qiuxu together with BL-47 Hunmen.

! At death, the Ethereal Soul survives the body and returns to “Heaven”, the Corporeal Soul dies with the body and returns to Earth and the Mind is simply extinguished.

According to ancient Chinese beliefs, the Ethereal Soul was imparted by the father 3 days after birth during a naming ceremony, i.e. the baby was given a name and the father “imparted” the Ethereal Soul to him or her. The fact that the Ethereal Soul is imparted by the father after birth is significant, as it is symbolic of the social, relational nature of the Ethereal Soul (as opposed to the Corporeal Soul). The Ethereal Soul is responsible for relationships and our relating to other people in the family and society. The ceremony during which the father imparted the Ethereal Soul and the name to the baby 3 days after birth is therefore symbolic of the fact

To sum up, the Ethereal Soul is basically another level of consciousness, different from the Mind but closely related to it. It is a part of the psyche that is not rational like the Mind (Shen) but is responsible for intuition, inspiration, ideas, life dreams, artistic inspiration; it is also responsible for the “movement” of our psyche towards the environment and other people in relationships.

CLINICAL NOTE The Ethereal Soul is another level of consciousness, different from the Mind but closely related to it. It is a part of the psyche that is not rational like the Mind (Shen) but is responsible for intuition, inspiration, ideas, life dreams, artistic inspiration; it is also responsible for the “movement” of our psyche towards the environment and other people in relationships. The point BL-47 Hunmen regulates the movement of the Ethereal Soul.

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The Ethereal Soul is rooted in the Liver and in particular Liver-Yin (which includes Liver-Blood). If Liver-Yin or Liver-Blood is depleted, the Ethereal Soul is deprived of its residence and becomes rootless. This can result in insomnia. The Ethereal Soul, deprived of its residence, wanders without aim. At death, the Ethereal Soul survives and goes to “Heaven” while the Corporeal Soul dies and returns to Earth. The nature and functions of the Ethereal Soul can be summarized under seven headings as follows. 1. 2. 3. 4. 5. 6. 7.

Sleep and dreaming Mental activities Balance of emotions Eyes and sight Courage Planning Relationship with the Mind

Dreams constitute the wandering of the Ethereal Soul in the Nine Heavens and Nine Earths. When one wakes up, one feels obscure and confused [because] one is constrained by the Corporeal Soul.

The Ethereal Soul influences sleep and dreaming. The length and quality of sleep are related to the state of the Ethereal Soul. If this is well rooted in the Liver (Liver-Blood or Liver-Yin), sleep is normal and sound and without too many dreams. If Liver-Yin or LiverBlood is deficient, the Ethereal Soul is deprived of its residence and wanders off at night, causing a restless sleep with many tiring dreams (Fig. 9.10). Sleep disturbances related to excessive dreaming are particularly related to the Ethereal Soul. As it is in the nature of the Ethereal Soul to “wander”, at night it wanders, giving rise to dreams. Tang Zong Hai says: “At night during sleep, the Ethereal Soul returns to the

Liver-Blood Liver-Yin

ETHEREAL SOUL

Liver-Blood Liver-Yin deficient

Ethereal Soul Ethereal Soul rooted in Liver unrooted in Liver Figure 9.10 Ethereal Soul and sleep.

In the daytime, the Ethereal Soul is in the eyes and at night in the Liver. When it is in the eyes, we can see; when it is in the Liver, we dream. It also says:26

Sleep and dreaming

ETHEREAL SOUL

Liver; if the Ethereal Soul is not peaceful, there are a lot of dreams.”24 The length and quality of sleep are also related to the state of the Ethereal Soul. If this is well rooted in the Liver (Liver-Blood or Liver-Yin), sleep is normal and sound, without too many dreams. If Liver-Yin or LiverBlood is deficient, the Ethereal Soul is deprived of its residence and wanders off at night, causing a restless sleep with many tiring dreams. The Secret of the Golden Flower in Chapter 2 says:25

Insomnia

Chinese books do not define “excessive dreaming”. In my experience, dreaming can be defined as excessive either when they are nightmares or when one has unpleasant or anxiety-causing dreams the whole night, waking up exhausted. In such cases, it is necessary to nourish Liver-Yin with sour and absorbing herbs such as Mu Li Concha Ostreae, Long Chi Fossilia Dentis Mastodi, Suan Zao Ren Semen Ziziphi spinosae or Bai Shao Radix Paeoniae alba. There is an interesting correlation between the astringent and absorbing quality of such herbs on a physical level and their use in calming the Mind and “absorbing” the Ethereal Soul to draw it back into the Liver. CLINICAL NOTE In order to nourish Liver-Blood and anchor the Ethereal Soul into the Liver, I use (with reinforcing method) LIV-8 Ququan, Ren-4 Guanyuan and SP-6 Sanyinjiao.

If Liver-Yin is very depleted, at times the Ethereal Soul may even leave the body temporarily at night during or just before sleep. Those who suffer from severe deficiency of Yin may experience a floating sensation in the few moments just before falling asleep; this is said to be due to the “floating” of the Ethereal Soul not rooted in Yin.

The Psyche in Chinese Medicine

Of course, the length and quality of sleep also depend on the state of Heart-Blood, and there is an overlap between the influence of Heart-Blood and Liver-Blood on sleep. Besides dreaming at night, the Ethereal Soul influences dreaming in a broad sense, i.e. the dreams, aims and projects of our life. When one has a life “dream”, this is dependent on the activity of the Ethereal Soul. The Ethereal Soul is therefore also responsible for “dreaming” in a positive sense, i.e. having a sense of purpose in life and “dreams” in the sense of goals. As we shall see later, the lack of a sense of direction and purpose and the absence of dreams and goals in one’s life is an important feature of depression, and it is due to a lack of “movement” of the Ethereal Soul. Thus, the Ethereal Soul influences dreaming at night and “life dreams” in our awake state. When the Ethereal Soul is in the eyes, we have external visualization; when it is in the Liver, we have internal visualization as in dreams or life dreams. Finally, the Ethereal Soul is also responsible for daydreaming. Zhang Jie Bin says in the Classic of Categories: “Absent-mindedness as if in a trance is due to the Ethereal Soul wandering outside its residence.”27 Thus if Liver-Blood or Liver-Yin is deficient, the Ethereal Soul wanders off in a daydream and the person has no clear sense of direction in life. The Ethereal Soul may even leave the body temporarily; some Chinese idiomatic expressions confirm this. For example, fan hun (literally “Hun returning”) means “to come back to life”, as after being in a trance during which the soul leaves the body. Hun fei po san (literally “hun flying, po scattered”) means “to be scared out of one’s wits” or also “to be struck dumb”, for example by love.

SUMMARY THE ETHEREAL SOUL, SLEEP AND DREAMING  The Ethereal Soul is responsible for sound sleep and a normal amount of dreaming.  When the Ethereal Soul flows to the eyes in daytime, we can see; when it flows to the eyes at night, we dream.  If the Ethereal Soul is not rooted in Liver-Blood and Liver-Yin, it may wander too much and we have too many dreams or unpleasant dreams.

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Mental activities The Ethereal Soul assists the Mind in its mental activities. The Five-Channel Righteousness, a text from the Tang dynasty, says: “Knowledge is dependent on the sharpness of the Ethereal Soul.”28 The Ethereal Soul provides the Mind, which is responsible for rational thinking, with intuition and inspiration. It also gives the Mind “movement” in the sense that it allows the Mind the capacity of self-insight and introspection as well as the ability to project outwards and relate to other people. This capacity for movement and outward projection is closely related to the Liver-Qi quality of quick and free movement. It will be remembered that the words “movement,” “coming and going,” “swimming” are often used in connection with the Ethereal Soul. For example, as mentioned above, the Ethereal Soul is the “coming and going of the Mind” or “when the Ethereal Soul swims to the eyes, they can see”. It is interesting to compare this quality of the Ethereal Soul, on an ethereal level, with the swirling movement of a spirit depicted in its old character and, on a physical level, with the smooth flow of Liver-Qi. The Ethereal Soul is always described as the “coming and going of the Mind (Shen)” (sui Shen wang lai wei zhi Hun) or, to put it differently, “what follows the Mind in its coming and going is the Ethereal Soul”. On a psychic level, this means that the Ethereal Soul provides the Mind with “movement” in the sense of intuition, inspiration, movement towards others in relationships, creativity, dreaming (in the sense of life dreams), planning, imagination, projects, symbols, and archetypes. The Ethereal Soul gives the Mind the necessary psychic tension of Wood. The Mind without the Ethereal Soul would be like a powerful computer without software. CLINICAL NOTE On a psychic level, the Ethereal Soul provides the Mind with “movement” in the sense of intuition, inspiration, movement towards others in relationships, creativity, dreaming (in the sense of life dreams), planning, imagination, projects, symbols, and archetypes. The Ethereal Soul gives the Mind the necessary psychic tension of Wood. In order to stimulate the movement of the Ethereal Soul, I use BL-47 Hunmen and G.B.-40 Qiuxu.

The relationship between the Mind, responsible for rational thinking (but also our emotional life), and the

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Ethereal Soul, responsible for intuition and inspiration, is somewhat similar to the relationship between Athena and Dionysus in Greek mythology. In fact, Athena is the Goddess of reason and wisdom while Dionysus is the God of mystery religions, ecstasy, personal delivery from the daily world through spiritual intoxication, and initiation into secret rites. A delightful illustration on an ancient Greek vase depicts Dionysus pushing Athena, who is sitting on a swing (Fig. 9.11). This illustrates the necessary coordination and integration of the rational side of the psyche (symbolized by Athena) with the “dark”, inspirational and non-rational side (symbolized by Dionysus). This Greek painting is a good illustration of the “movement” that the Ethereal Soul imparts to the Mind, symbolized by the pushing movement of the swing by Dionysus.

SUMMARY MENTAL ACTIVITIES OF ETHEREAL SOUL  The Ethereal Soul contributes to the mental activities of the Mind (Shen) by providing it with ideas, intuition, images and creativity.  This activity of the Ethereal Soul depends on its “coming and going”.

Balance of emotions The Ethereal Soul is responsible for maintaining a normal balance between excitation and restraint of the emotional life, under the leadership of the Heart and

the Mind. Emotions are a normal part of our mental life: we all experience anger, sadness, worry, or fear on occasions in the course of our life, and these do not normally lead to disease. The Ethereal Soul, being responsible for the more intuitive and subconscious part of the Mind, plays a role in keeping an emotional balance and, most of all, prevents the emotions from becoming excessive and therefore turning into causes of disease. This regulatory function of the Ethereal Soul is closely related to the balance between Liver-Blood (the Yin part of the Liver) and Liver-Qi (the Yang part of the Liver). Liver-Blood and Liver-Qi need to be harmonized, and Liver-Blood must root Liver-Qi to prevent it from becoming stagnant or rebelling upwards. On a mentalemotional level, Liver-Blood needs to root the Ethereal Soul, thus allowing a balanced and happy emotional life. This is one of the meanings, on a mental level, of the Liver being a “regulating and harmonizing” organ (Fig. 9.12). Chapter 9 of the Simple Questions says: “The Liver has a regulating function [literally. the root of stopping extremes], it houses the Ethereal Soul ...”29 If Liver-Blood is deficient, there will be fear and anxiety; if Liver-Yang is in excess, there will be anger. The Spiritual Axis in Chapter 8 says: “If the Liver is deficient, there will be fear; if it is in excess, there will be anger.”30 Tang Zong Hai in the Discussion on Blood Patterns says: “If Liver-Blood is deficient, Fire agitates the Ethereal Soul, resulting in nocturnal emissions with dreams.”31 The free flow of Liver-Qi is the physical counterpart of the “coming and going” of the Ethereal Soul; this “coming and going” should be regulated and balanced. If it is deficient (as in Liver-Qi stagnation), the person is depressed and not in touch with his or her emotions; if it is excessive (as in Liver-Yang rising or Liver-Fire),

Movement of Ethereal Soul

LIVER-QI LIVERBLOOD Figure 9.11 Comparison between the relationship between Ethereal Soul and Mind with that between Dionysus and Athena.

Roots the Ethereal Soul Figure 9.12 Relationship between Liver-Qi and Liver-Blood and the Ethereal Soul.

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Deficient: depression Excessive: ‘‘mania’’, agitation, anger, emotional LIVER-QI LIVERBLOOD Deficient: insomnia, anxiety, fear Figure 9.13 Pathological states of the relationship between Liver-Qi and Liver-Blood.

the person may be agitated, angry, too emotional or slightly manic (Fig. 9.13). CLINICAL NOTE The free flow of Liver-Qi is the physical counterpart of the “coming and going” of the Ethereal Soul; this “coming and going” should be regulated and balanced. If it is deficient (as in Liver-Qi stagnation), the person is depressed and not in touch with his or her emotions; if it is excessive (as in Liver-Yang rising or Liver-Fire), the person may be agitated, angry, too emotional or slightly manic. The best points to regulate and balance the coming and going of the Ethereal Soul are LIV-3 Taichong and BL-47 Hunmen.

These two opposing emotional states characterized by a hyperactive Liver-Qi (with excessive “coming and going” of the Ethereal Soul) or a stagnant Liver-Qi (with insufficient “coming and going” of the Ethereal Soul) are described in the Simple Questions as “Fullness” and “Emptiness” of the Mind (Shen). Chapter 62 of the Simple Questions says:32 What are the symptoms of Fullness and Emptiness of the Mind [Shen]? When the Mind is in Excess, the person laughs uncontrollably; when the Mind is Deficient, the person is sad.

SUMMARY THE ETHEREAL SOUL’S BALANCE OF EMOTIONS  The Ethereal Soul is responsible for maintaining a normal balance between

excitation and restraint of the emotional life, under the leadership of the Heart and the Mind.  On an emotional level, Liver-Blood needs to root the Ethereal Soul, thus allowing a balanced and happy emotional life.  The free flow of Liver-Qi is the physical counterpart of the “coming and going” of the Ethereal Soul; this “coming and going” should be regulated and balanced. If it is deficient (as in Liver-Qi stagnation), the person is depressed and not in touch with his or her emotions; if it is excessive (as in Liver-Yang rising or Liver-Fire), the person may be agitated, angry, too emotional or slightly manic.

Eyes and sight The Ethereal Soul relates to the eyes and sight. Tang Zong Hai says: “When the Ethereal Soul wanders to the eyes, they can see.”33 The Secret of the Golden Flower in Chapter 2 says:34 In the daytime, the Ethereal Soul is in the eyes and at night in the Liver. When it is in the eyes, we can see; when it is in the Liver, we dream. Apart from physical sight, the Ethereal Soul also gives us “vision” in life, i.e. the capacity to have life dreams, projects and creativity. CLINICAL NOTE The best points to influence the Ethereal Soul and sight are G.B.-37 Guangming, LIV-2 Xingjian and BL-18 Ganshu.

This connection with the eyes can easily be related to the rooting of the Ethereal Soul in Liver-Blood, as this nourishes the eyes. On a psychic level, the Ethereal Soul gives us “vision” and insight. At night, the Ethereal Soul makes us “see” when we dream. Thus, the Ethereal Soul is responsible for vision in three ways: physical sight, “seeing” at night in the form of dreams and “vision” in life (Fig. 9.14).

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On a physical level

SIGHT

At night

DREAMS

On a psychic level

VISION, INSIGHT

Figure 9.14 The three influences of the Ethereal Soul on “seeing”.

SUMMARY THE ETHEREAL SOUL, EYES AND SIGHT  The Ethereal Soul relates to the eyes and sight.  In the daytime, the Ethereal Soul is in the eyes and at night in the Liver. When it is in the eyes, we can see; when it is in the Liver, we dream.  On a psychic level, the Ethereal Soul gives us “vision” and insight.

CLINICAL NOTE In order to stimulate the “courage” of the Ethereal Soul, I use the point G.B.-40 Qiuxu.

The quality of courage and resoluteness is also dependent on the strength of Gall Bladder-Qi.

SUMMARY THE ETHEREAL SOUL AND COURAGE

Courage The Ethereal Soul is related to courage or cowardice, and for this reason the Liver is sometimes called the “resolute organ”. Tang Zong Hai says: “When the Ethereal Soul is not strong, the person is timid.”35 The “strength” of the Ethereal Soul in this connection derives mainly from Liver-Blood. If Liver-Blood is abundant, the person is fearless and is able to face up to life’s difficulties without being easily discouraged. Just as in disease Liver-Yang easily flares upwards causing anger, in health the same type of mental energy deriving from Liver-Blood can give a person courage and resoluteness. If Liver-Blood is deficient and the Ethereal Soul is dithering, the person lacks courage and resolve, cannot face up to difficulties or make decisions and is easily discouraged. A vague feeling of fear at night before falling asleep is also due to a lack of rooting of the Ethereal Soul.

 The Ethereal Soul is related to courage or cowardice, and for this reason the Liver is sometimes called the “resolute organ”.  If Liver-Blood is abundant, the person is fearless and is able to face up to life’s difficulties with an indomitable spirit; if Liver-Blood is deficient and the Ethereal Soul is dithering, the person lacks courage and resolve, cannot face up to difficulties or making decisions and is easily discouraged.

Planning The Ethereal Soul influences our capacity for planning our life and giving it a sense of direction. A lack of direction in life and a sense of spiritual confusion may be compared with the aimless wandering of the Ethereal Soul; such a sense of lack of direction and plans is due to the insufficient “coming and going” of the Ethereal Soul.

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If the Liver is flourishing, the Ethereal Soul is firmly rooted and can help us to plan our life with vision, wisdom and creativity. If Liver-Blood and Liver-Qi are deficient, the Ethereal Soul does not “come and go” enough and we lack a sense of direction and vision in life.

SUMMARY THE ETHEREAL SOUL AND PLANNING  The Ethereal Soul influences our capacity for planning our life and giving it a sense of direction.  If the Liver is flourishing, the Ethereal Soul is firmly rooted and can help us to plan our life with vision, wisdom and creativity; if LiverBlood and Liver-Qi are deficient, the Ethereal Soul does not “come and go” enough and we lack a sense of direction and vision in life.

Relationship with the Mind It is important to consider the relationship between the Mind (Shen) and the Ethereal Soul (Hun). Both Yang in nature, they are closely connected to each other and both partake in all the mental activities of a human being. We have already seen that the Ethereal Soul is described as the “coming and going” of the Mind. This means that, through the Ethereal Soul, the Mind can project outwards to the external world and to other people and can also turn inwards to receive the intuition, inspiration, dreams and images deriving from the unconscious. Thus if Liver-Blood is abundant and the Ethereal Soul firm, there will be a healthy flow from it to the Mind, providing it with inspiration, creativity and plans. The perfect relationship between the Mind and the Ethereal Soul is one in which the latter provides the former with “movement”, manifesting with aims, intuition, creativity, ideas, life dreams, plans, etc.; on the other hand, the Mind provides control and integration to the Ethereal Soul. This means that the Mind must exercise some form of “control” over the material coming from the Ethereal Soul. Figure 9.15 illustrates the ideal relationship between the Mind and the Ethereal Soul, in which the movement of the Ethereal Soul is normal and the control and integration of the Mind is also normal.

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Gives movement ideas, inspiration, intuition, creativity

Controls, integrates

HUN Figure 9.15 Normal relationship between Ethereal Soul and Mind.

Being the source of ideas and life dreams for the Mind, the Ethereal Soul may be compared with a sea; the Ethereal Soul’s world is a subterranean world, an undifferentiated sea, and it is also the world of gui. The Ethereal Soul is the gui of the Mind’s emotionalspiritual life. The Mind can only cope with one idea at a time originating from the Ethereal Soul, and it must therefore exercise some form of control over the material coming from the Ethereal Soul. It must also integrate the material deriving from the Ethereal Soul in the general psyche life. If the Mind is strong and the Ethereal Soul properly “gathered”, there will be harmony between the two and the person has calm vision, insight and wisdom. If the Ethereal Soul does not “come and go” enough, it may lack movement and inspiration and the person may be depressed, without aim or life dreams. The Ethereal Soul may be restrained in its movement either by itself or because the Mind is over-controlling it. This happens, for example, in people who are rigid in their views and repressed. Figure 9.16 illustrates the

SHEN

SHEN

HUN

HUN

Hun coming and going not enough (control by Shen normal) = depression Figure 9.16 Deficient movement of the Ethereal Soul.

Shen over-controls = depression

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two situations when the “coming and going” of the Ethereal Soul is restrained either by itself (on the right side) or because the Mind is over-controlling it (on the left side). If the Mind is weak and fails to restrain and control the Ethereal Soul, it may be too restless and its “movement” excessive, only bringing confusion and chaos to the Mind, making the person scattered, unsettled and slightly manic. This can be observed in some people who are always full of ideas, dreams and projects, none of which ever comes to fruition because of the chaotic state of the Mind, which is therefore unable to restrain the Ethereal Soul. Figure 9.17 illustrates the two situations when the “coming and going” of the Ethereal Soul is excessive either by itself (on the left side) or because the Mind does not control it enough (on the right side). If the Mind is weak or if the Ethereal Soul “comes and goes” too much, contents breaking through from the Ethereal Soul cannot be integrated by the Mind. The Mind should integrate the Ethereal Soul so that images, symbols and dreams coming from it can be assimilated. For the conscious Mind, this means bringing together two disparate ways of seeing the world: the conscious and rational one (of the Mind) and the entirely different one in which the Ethereal Soul holds sway. If not, the Mind may be flooded by the contents of the Ethereal Soul with risk of obstruction of the Mind and, in serious cases, psychosis.

! The key words that describe the function of the Mind in relation to the Ethereal Soul are control and integration. As I have mentioned the terms “manic” and “mania” a few times in connection with the situation when the Ethereal Soul is not restrained by the Mind and its “coming and going” is excessive, I should define what I mean by this term. In psychiatric terms, signs and symptoms of mania (or a manic episode) include:36 • • • •

increased energy, activity and restlessness excessively “high”, overly good, euphoric mood extreme irritability racing thoughts and talking very fast, jumping from one idea to another

SHEN

SHEN

HUN

HUN

Hun coming and going too much = ‘‘mania’’

Hun coming and going too much (Shen not controlling Hun) = ‘‘mania’’ Figure 9.17 Excessive movement of the Ethereal Soul.

• • • • • • • • • •

distractibility, inability to concentrate well little sleep needed unrealistic beliefs in one’s abilities and powers poor judgement spending sprees a lasting period of behaviour that is different from usual increased sexual drive abuse of drugs, particularly cocaine, alcohol and sleeping medications provocative, intrusive or aggressive behaviour denial that anything is wrong.

The important thing to realize is that mania and manic behaviour can occur in many degrees of severity, i.e. the border between “mental illness” and “normality” is not a clear-cut separation between the two but there is a broad area of behaviours that, while not normal, do not constitute “mental illness”. In other words, in its milder forms, “mania” and “manic behaviour” are relatively common. Whenever the “coming and going” of the Ethereal Soul is excessive, there is the possibility of “manic” behaviour. CLINICAL NOTE Mania and manic behaviour can occur in many degrees of severity, i.e. the border between “mental illness” and “normality” is not a clear-cut separation between the two but there is a broad area of behaviours that, while not normal, do not constitute “mental illness”. In other words, in its milder forms, “mania” and “manic behaviour” are relatively common. Whenever the “coming and going” of the Ethereal Soul is excessive, there is the possibility of “manic” behaviour.

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My own criteria for diagnosing mild “mania” (i.e. in normal people who are not mentally ill) are as follows: • • • • • • • • • • •

mental restlessness, agitation hyperactivity working and being active at night spending a lot having many projects simultaneously, none of which comes to fruition mental confusion obsessive thoughts laughing a lot talking a lot propensity to taking risks often artistic.

In order to give the reader a feel for the actions of the Ethereal Soul, I have listed six things (Fig. 9.18): 1. 2. 3. 4. 5. 6.

children artistic inspiration dreams sleepwalking guided daydreams coma.

Children are a good example of the activity of the Ethereal Soul. In small children, the Mind (Shen) is

Figure 9.18 Six illustrations of the activity of the Ethereal Soul.

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“immature” and therefore does not control and restrain the Ethereal Soul, a situation that, while pathological in adults, is perfectly normal in children. The result is that, from the age of about 2 to about 7, children live in the world of the Ethereal Soul, a world of wild imagination and fantasy where inanimate objects come to life. Behaviours that are normal in children would be considered mental illness in adults. After the age of about 7, the Mind (Shen) is more mature and starts to control and restrain the Ethereal Soul. Artistic inspiration is another good example of the activity of the Ethereal Soul. Artistic inspiration (at least in Western art) derives from the Ethereal Soul, not the Mind. The Ethereal Soul is the source from which springs forth creativity and inspiration. The same psychic energy that, in pathological conditions, leads to manic behaviour is also responsible for artistic inspiration. In fact, this is the result of the “coming and going” of the Ethereal Soul; it is the Ethereal Soul that is the source of artistic images coming forth in an artist. It is interesting to note that, among the artistic community, there is a disproportionate incidence of bipolar disorder compared with in the general population.37 Dreams derive from the wandering of the Ethereal Soul at night: when the Ethereal Soul goes to the eyes

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in daytime, we see; when it goes to the eyes at night, we dream. It is interesting that most dreaming takes place during the rapid eye movement (REM) periods of sleep. It could be argued that the REM is due to the Ethereal Soul going to the eyes at night! It is also interesting to note that we suffer more from dream- than from sleepdeprivation. In sleepwalking, the Mind is inactive but the Ethereal Soul is active: the Ethereal Soul wanders at night and leads to sleepwalking. In fact, the point BL-47 Hunmen (the Door of the Hun) was used for sleepwalking. Guided daydreams are a technique used in psychotherapy whereby the therapist sets a certain scene for the client who is asked to imagine himself or herself in that scene and to proceed as if in a dream. The aim of this exercise is to bypass the critical analysis of the Mind and bring forth psychological material from the Ethereal Soul as happens in dreams. Jung described this technique:38 We learn to sit and simply observe a fragment of a dream without any attempt to guide, control or interfere with it. The aim is to allow the image to come to life of its own autonomous psychic energy [= Ethereal Soul], our ego [= Mind] letting go of all expectations, presuppositions, or interpretations. After a certain period of practice and initial coaching by the therapist, this inner image will start to move in some way and our observing ego [Mind] learns to participate in the story very much like a dream. In coma, the Mind is completely devoid of residence and it therefore cannot function at all, and yet the person is not dead. This means that there are other mental aspects at play, and these are the Ethereal Soul and the Corporeal Soul. In fact, for death to occur, not only must the Mind die, but the Ethereal Soul must leave the body and the Corporeal Soul return to Earth. Finally, drawing from Buddhist and Jungian ideas, the Mind could be said to be the individual Mind, and the Ethereal Soul the link between the individual and Universal Mind. This can be represented with a diagram (Fig. 9.19). The Universal Mind is the repository of images, archetypes, symbols and ideas belonging to the collective unconscious in Jungian psychology. These often manifest to our Mind as myths, symbols and dreams. They come into our consciousness (individual Mind) via the Ethereal Soul, because this belongs to the world of image and ideas. Thus the Ethereal Soul is the vehicle

UNIVERSAL MIND (collective unconscious)

HUN

MIND

HUN

Archetypes, images, symbols, ideas

MIND

Figure 9.19 The relationship between Ethereal Soul and Mind from Buddhist and Jungian viewpoint.

through which images, ideas and symbols from the Universal Mind (or collective unconscious) emerge into our individual Mind (conscious). This shows the vital importance of the Ethereal Soul for our mental and spiritual life. Without the Ethereal Soul, our mental and spiritual life would be quite sterile and deprived of images, ideas and dreams. If the Liver is strong and the Ethereal Soul firm and flowing harmoniously, ideas and images from the Universal Mind will flow freely and the mental and spiritual state will be happy, creative and fruitful. If the “coming and going” of the Ethereal Soul is insufficient, the individual Mind will be cut off from the Universal Mind and will be unhappy, confused, isolated, aimless, sterile and without dreams (Fig. 9.20). On the other hand, if the Mind is clouded and cannot exercise its proper control over the Ethereal Soul,

UNIVERSAL MIND (collective unconscious)

HUN

MIND

Hun lacks ‘‘movement’’, Mind cut off from Universal Mind (unconscious) Archetypes, images, symbols, ideas

HUN

MIND

Figure 9.20 Deficient movement of the Ethereal Soul and its relation with Universal Unconscious.

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Conscious UNIVERSAL MIND (collective unconscious)

HUN

261

SHEN

MIND

Hun ‘‘going’’ too much, Mind cannot cope with material from Universal Mind (unconscious) Archetypes, images, symbols, ideas

Unconscious HUN

HUN

MIND

Figure 9.21 Excessive movement of the Ethereal Soul and its relation with Universal Unconscious.

contents breaking through from the Ethereal Soul cannot be integrated by it (Fig. 9.21). It is important for the Mind to assume an integrating position towards the Ethereal Soul so that images, symbols and dreams coming from it can be assimilated. If not, the Mind may be flooded by the contents of the Ethereal Soul with risk of obstruction of the Mind and, in serious cases, psychosis. According to Jung, the unconscious is compensatory to consciousness. He said: “The psyche is a self-regulating system that maintains itself in equilibrium ... Every process that goes too far immediately and inevitably calls forth a compensatory activity.”39 This compensatory relationship between the unconscious and consciousness resembles the balancing relationship between the Ethereal Soul and the Mind. The Mind discriminates and differentiates, whereas the Ethereal Soul is like an undifferentiated sea that flows around, under and above the Mind, eroding certain parts and depositing fresh ones. The psyche as a whole, i.e. the sum total of Mind, Ethereal Soul, Corporeal Soul, Intellect and Will-Power, contains all possibilities, whereas the Mind can only work with one possibility at a time (Fig. 9.22). Figure 9.22 shows many arrows from the Ethereal Soul to the Mind (indicating the material in the form of ideas coming from the Ethereal Soul) but only one arrow coming out of the Mind. It is no wonder that in myths and fairy tales the unconscious is often symbolized by the sea. The Ethereal Soul is an underwater world, and a total immersion of the Mind in it means insanity (Fig. 9.23). In Figure 9.23, the Mind is totally enclosed by the

Figure 9.22 Comparison of the relationship between the Ethereal Soul and Mind with that between the unconscious and the conscious.

SHEN

Mental illness

HUN Figure 9.23 Total absorption of the Mind within the Ethereal Soul in mental illness.

Ethereal Soul; this image is used to depict mental illness. In myths and fairy tales, the unconscious is often symbolized by the sea; in Christian mythology too, baptism and the parting of the waters by God use water and the sea as a spiritual symbol. The Ethereal Soul is an underwater world, and a total immersion of the Mind in it means insanity. The Ethereal Soul is like an ocean that is the source of archetypes, symbols, ideas, images; the Mind draws from this sea through the intermediary of the Ethereal Soul. The material coming forth is controlled and integrated by the Mind, one at a time (hence the key words “control” and “integration” expressing the Mind’s function in relation to the Ethereal Soul). The relationship between the Mind and the Ethereal Soul is all about expansion (stimulation of “coming and going” of the Hun) and contraction (restraint of coming and going of Ethereal Soul) in our psychic life. Shen and gui can be interpreted as the two opposing states of expansion (shen) and contraction (gui) in our psychic life (Figs 9.24 and 9.25).

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MIND

Ethereal Soul

Expansion (‘‘shen’’)

MIND

Ethereal Soul

Contraction (‘‘gui’’) Figure 9.24 Expansion and contraction of the Ethereal Soul.

Shen

Expansion

Gui

Figure 9.25 Shen and gui as expansion and contraction.

Expansion and contraction in our psychic life are two normal, physiological states that alternate naturally. When we feel “up”, we are in an extrovert mood, we feel like going out and we are active; then we are in a state of expansion and the Ethereal Soul is “coming and going” normally. When we feel “down”, we are in an introvert mood, we do not feel like going out and we feel passive; then we are in a state of contraction and the Ethereal Soul’s “coming and going” is restrained.40 The proper alternation of expansion (stimulation of the coming and going of the Ethereal Soul) and contraction (restraint of the coming and going of the Ethereal Soul) in our psychic life allows for a healthy and normal psychic life. Chinese herbal medicine reflects this polarity of expansion and contraction in our psychic life as, within the category of herbs that calm the Mind, some are pungent and stimulate expansion (and therefore the coming and going of the Ethereal Soul), while others are sour and astringent and stimulate contraction (and therefore restrain the coming and going of the Ethereal Soul).

Contraction

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The two important herbs Yuan Zhi Radix Polygalae and Suan Zao Ren Semen Ziziphi spinosae are representative of this polarity of expansion and contraction. The actions of these two herbs are described below. • Yuan Zhi Radix Polygalae: pungent, bitter, warm, dispersing and draining, resolves Phlegm, opens the Heart orifices = stimulates expansion, i.e. coming and going of Ethereal Soul. • Suan Zao Ren Semen Ziziphi spinosae: sour, sweet, astringent, promotes sleep, anchors Ethereal Soul = stimulates contraction, i.e. restraint of coming and going of Ethereal Soul. In terms of patterns, what are the patterns that arise from the Ethereal Soul “coming and going” too much or too little? The coming and going of the Ethereal Soul may become excessive either from Full conditions of Heat or Fire or from Empty conditions with a deficiency of Liver-Blood and/or Liver-Yin. In case of Full conditions with Heat or Fire, these agitate the Ethereal Soul and stimulate its coming and going excessively; in the case of deficiency of Liver-Blood and/or LiverYin, these fail to anchor the Ethereal Soul so that this becomes agitated and its coming and going becomes excessive. Although the end result is the same, the symptoms and signs of the Ethereal Soul coming and going too much from Full or Empty conditions will be different. Excessive coming and going of the Ethereal Soul results in “manic behaviour” as described above. The coming and going of the Ethereal Soul may become deficient under three conditions. Liver-Qi stagnation, Liver-Blood and Liver-Qi deficiency, and deficiency of Yang of the Spleen and Kidneys may all impair the coming and going of the Ethereal Soul and result in depression. I should explain the pattern of Liver-Qi deficiency in more detail. Although we are often told that “Liver-Qi cannot be deficient”, this is not quite true. Deficiency of Liver-Qi does exist and it manifests primarily in the psychic sphere with depression. As we know, every organ’s Qi should flow in a proper, correct direction, for example Stomach-Qi descends and Spleen-Qi ascends. Liver-Qi should flow in all directions; this is the manifestation of the free flow of Liver-Qi. However, the normal, correct flow of Liver-Qi is also ascending; its ascending movement is coordinated with the descending of Lung-Qi. Where does Liver-Qi ascend to? One important aspect of its ascending movement is the ascension of Liver-Qi towards the Heart and the Mind (Shen). The

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Ascends Provides ‘‘movement’’ of Ethereal Soul LIVER-QI Figure 9.26 Ascending movement of Liver-Qi in relation to the movement of the Ethereal Soul.

ascending of Liver-Qi towards the Mind is an important way in which the Ethereal Soul stimulates the “coming and going” of the Mind (Fig. 9.26). A deficiency of Liver-Qi always implies a failure of Liver-Qi to ascend to the Mind and therefore results in depression. What are the symptoms of Liver-Qi deficiency? First, they include all the symptoms of Liver-Blood deficiency (blurred vision, tingling of limbs, dry hair and skin); second, they include symptoms such as sighing, tiredness and depression. The patterns manifesting in excessive or insufficient movement of the Ethereal Soul are listed below. Ethereal Soul coming and going too much (“manic” behaviour): • Heat or Fire • Phlegm-Fire • Liver-Blood and/or Liver-Yin deficiency Ethereal Soul coming and going too little (depression): • Liver-Qi stagnation • Liver-Blood and Liver-Qi deficiency • Spleen- and Kidney-Yang deficiency

SUMMARY RELATIONSHIP BETWEEN MIND AND ETHEREAL SOUL  The Ethereal Soul is the “coming and going” of the Mind.  Through the Ethereal Soul, the Mind can project outwards to the external world and to other people and can also turn inwards to receive the intuition, inspiration, dreams and images deriving from the unconscious.

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 The Ethereal Soul provides the Mind with “movement”, manifesting with aims, intuition, creativity, ideas, life dreams, plans, etc.; on the other hand, the Mind provides control and integration to the Ethereal Soul.  If the Ethereal Soul does not “come and go” enough, it may lack movement and inspiration and the person may be depressed, without aim or life dreams.  If the Mind is weak and fails to restrain and control the Ethereal Soul, this may be too restless and its “movement” excessive and only bring confusion and chaos to the Mind, making the person scattered, unsettled and slightly manic.  The nature and activity of the Ethereal Soul may be observed in six areas, i.e. children’s fantasy, artistic inspiration, dreams, sleepwalking, guided daydreams and coma.  The patterns that arise from the Ethereal Soul “coming and going” too much are Full conditions of Heat or Fire or Empty conditions with a deficiency of Liver-Blood and/or LiverYin; the patterns that arise from the Ethereal Soul coming and going too little are Liver-Qi stagnation, Liver-Blood and Liver-Qi deficiency and deficiency of Yang of the Spleen and Kidneys.

SUMMARY THE ETHEREAL SOUL  The Ethereal Soul enters the body 3 days after birth; at death, it survives the body and returns to “Heaven”.  It resides in the Liver and is anchored in LiverBlood and Liver-Yin.  It is responsible for: — sleep and dreaming — mental activities in association with the Mind (Shen) — emotional balance — sight — courage — planning — giving the Mind “movement” in the sense of ideas, vision, plans, life dreams, intuition, creativity.

The Corporeal Soul (Po) The Corporeal Soul (Po) resides in the Lungs and is the physical counterpart of the Ethereal Soul. Its Chinese character is composed of two parts: one (on the right) is the radical gui, which means “spirit” or “ghost”. the other (on the left) is the radical for bai (or bo), meaning “white”. The character for Corporeal Soul is Po:

This is composed of the radical gui for “spirit” or “ghost”:

and the character for “white”:

The radical for “white” in the character for Po can have several interpretations. The bai (or bo) meaning “white” within the character is related to the light of the waxing moon, but it is also phonetic, i.e. it gives the character the sound po. The association with the waxing moon (Yin) is in keeping with the association of the Corporeal Soul with Yin (as opposed to the Ethereal Soul that is Yang) and the dark forces of gui. The connection between the Corporeal Soul and the moon is also related to the fact that this physical soul comes into being on the third day after conception, analogous to the thin crescent on the third day of the rising moon. Finally, the association with the colour white somewhat tempers the radical for the dark gui and it conveys the idea that the Corporeal Soul, although related to gui, is a human, physical soul. See Figure 9.27. Hence there is a connection between the Corporeal Soul and the embryonic lunar light (Yin) as opposed to

Corporeal Soul

Entering and exiting Essence

Movement

GUI Figure 9.27 Gui within the Corporeal Soul.

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the hot (Yang) sun light of the Ethereal Soul. In fact, in ancient times the Corporeal Soul was also called “Moon-Po”. As the waxing moon is in the West, one can therefore build the following correspondence:

As we shall see below, the Corporeal Soul is in relation with gui. Confucius said: “Qi is the fullness of the Shen; the Corporeal Soul is the fullness of gui.”43 He Shang Gong said:44

WEST – WHITE – METAL – CORPOREAL SOUL – LUNGS.

The turbid and humid five flavours from bones, flesh, blood, vessels and the six passions ... these gui are called Corporeal Soul. This is Yin in character and enters and exits through the mouth and communicates with Earth.

The Corporeal Soul can be defined as “that part of the Soul [as opposed to the Ethereal Soul] which is indissolubly attached to the body and goes down to Earth with it at death.”41 It is closely linked to the body and could be described as the somatic expression of the Soul, or conversely, the organizational principle of the body. The Corporeal Soul is active from conception and it shapes the body. It could be also described as the organization of the organism and the coordinating force of all physiological processes. Zhang Jie Bin says:42 In the beginning of an individual’s life, the body is formed; the spirit of the body is the Corporeal Soul. When the Corporeal Soul is in the Interior, there is [enough] Yang Qi. At death, unlike the Ethereal Soul, the Corporeal Soul dies with the body, but it is thought to adhere to the corpse for some time, especially the bones, before returning to Earth. This explains the importance of looking after the bones of the dead in ancient Chinese culture. Some years after death, relatives of the dead used to clean the bones of the skeleton carefully and place them in neat bundles. There are seven types of Corporeal Soul: the five senses, the limbs and the Corporeal Soul as a whole. The link between the five senses and the Corporeal Soul will be explained shortly. As we have seen for the Ethereal Soul, the ancient character for gui conveys the idea of movement, an expression of the swirling movement of the bodiless head of a dead person in the realm of spirits. The Ethereal Soul is responsible for movement in a psychic sense. The movement related to the Corporeal Soul is a physical movement of this soul in all physiological processes of the body. Also, the Corporeal Soul gives the body the capacity of movement, agility, balance and coordination of movements. The Ethereal Soul is described as “coming and going” of the Mind while the Corporeal Soul is described as the “entering and exiting” of the Essence (see below).

The discussion of the Corporeal Soul will be done according to the following topics. • • • • • • • • • •

The Corporeal Soul and the Essence (Jing) Infancy Senses Emotions Physiological activity Breathing Corporeal Soul and individual life Corporeal Soul and gui The Corporeal Soul and the anus Relationship between Corporeal Soul and Ethereal Soul

The Corporeal Soul and the Essence (Jing) The Corporeal Soul is closely linked to the Essence (Jing) and is described in Chapter 8 of the Spiritual Axis as the “exiting and entering of Essence”.45 The Corporeal Soul derives from the mother and arises at conception (in theory 3 days after conception) soon after the Prenatal Essence of a newly conceived being is formed. Thus the Corporeal Soul, closely linked to Essence, is the first to come into being after conception. Both Essence and Corporeal Soul represent the organizational principles of life that shape the body from conception (the Extraordinary Vessels are the channels through which this happens). “Entering and exiting” implies an Interior and Exterior, i.e. a separation of the individual from the environment. It also implies a vertical movement, as ru (to enter) evokes “roots” and chu (to exit) evokes “branches”. Thus the centripetal, separating, materializing of the Corporeal Soul (see below) also depends on the vertical exiting and entering of the Essence (Fig. 9.28). The Corporeal Soul could be described as the manifestation of the Essence in the sphere of sensations and feelings. Just as the Ethereal Soul provides psychic movement to the Mind (“coming and going of the Mind”),

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Whole body

Essence

Corporeal Soul

Deficiency of Kidney’s Defensive-Qi system

Deficiency of Lung’s Defensive-Qi system

Skin (atopic eczema)

Figure 9.29 The Corporeal Soul and atopic eczema. Entering

Corporeal Soul

Exiting

Essence (Jing) Figure 9.28 The entering and exiting of the Essence.

the Corporeal Soul provides physical movement to the Essence, i.e. it brings the Essence into play in all physiological processes of the body. Without the Corporeal Soul, the Essence would be an inert, albeit precious, vital substance. The Corporeal Soul is the closest to the Essence and is the intermediary between it and the other vital substances of the body. In fact, Zhang Jie Bin in the Classic of Categories says: “If the Essence is exhausted, the Corporeal Soul declines, Qi is scattered and the Ethereal Soul swims without a residence.”46 CLINICAL NOTE Through the Corporeal Soul, the Essence (Jing) of the Kidneys plays a role in all physiological processes. This is further confirmation that the Essence, although a precious, partly inherited and constitutional Essence, does not simply “reside” in the Lower Dan Tian. Through the Corporeal Soul, it “enters and exits” in all parts of the body, playing a role in all physiological activities. The implication of this is that, when nourishing the Essence (through tonification of the Kidneys), it is better to also strengthen the Corporeal Soul (through tonification of the Lungs). This may be an explanation why the opening points of the Directing Vessel (Ren Mai), the best vessel to nourish the Essence, are one on the Lung and the other on the Kidney channel (LU-7 Lieque and KI-6 Zhaohai).

The relationship between Corporeal Soul and Essence also explains the eruption of atopic eczema and asthma in babies. From the Chinese point of view, eczema in

babies is due to the surfacing of Toxic Heat from the uterus; it is therefore closely linked with the Prenatal Essence of the baby (Fig. 9.29). Because the Essence is related to the Corporeal Soul that manifests on the skin (with itching and pain), the Toxic Heat from the Uterus erupts on the baby’s skin in the form of eczema.

CLINICAL NOTE As I interpret the pathology of atopic eczema as being due to a deficiency of the Lung and Kidney’s Defensive-Qi systems, when using herbal medicine in children I modify the classic formulae with the addition of Tu Si Zi Semen Cuscutae and Mai Men Dong Radix Ophiopogonis to tonify the Kidneys and the Lungs, respectively (and therefore the Essence and the Corporeal Soul).

Asthma can be explained in the same way, as the deficient Essence of the baby fails to root its Corporeal Soul and therefore its Lungs. During gestation, the fetus is “all Corporeal Soul and Essence” and is nourished by the Corporeal Soul of the mother (Fig. 9.30). This is of clinical importance, as we are inclined to think that it is the Kidneys of the mother that nourish the fetus; this is certainly so, but the Lungs and Corporeal Soul of the mother also play an important role in nourishing the fetus. The connection between Corporeal Soul and fetal life is very ancient: Granet calls the Corporeal Soul the “soul of blood”. The fetus depends on the mother’s Corporeal Soul, Blood and Essence for its nourishment. By giving rise to the human form during gestation, the Corporeal Soul has a centripetal, separating, materializing, aggregating movement. As it separates, it aggregates and it materializes into a separate existence in the fetus. As this separation is expressed by the skin (which separates the being from the world), there is a further connection between the Corporeal Soul, the skin and the Lungs.

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sensations and it is nourished by the mother’s Corporeal Soul through breast feeding and touching.

Mother’s Corporeal Soul

Nourishes

Essence/Corporeal Soul

Figure 9.30 The Corporeal Soul during pregnancy.

This separating power of the Corporeal Soul allies itself with the centripetal forces of gui, which are constantly fragmenting and which, eventually, become the germ of death. With regard to the fragmenting of the Corporeal Soul and of gui, there is a resonance between the word gui and kuai (formed by the radical for gui with “earth” in front), which means “pieces”. The Corporeal Soul is therefore linked to a “thirst for existence”, centripetal, materializing life force, aggregating into a separate existence.

Infancy Being the closest to the Essence, the Corporeal Soul is responsible for the first physiological processes after birth. Zhang Jie Bin says: “In the beginning of life, ears, eyes and Heart perceive, hands and feet move and breathing starts; all this is due to the sharpness of the Corporeal Soul.”47 It is said that, in the first month of life especially, the baby is “all Corporeal Soul”. As it resides in the Lungs, the Corporeal Soul is responsible for touch and skin

CLINICAL NOTE In the first month of life, the baby is “all Corporeal Soul”, i.e. its life revolves around its Corporeal Soul (breast feeding, touch from the mother) and its Corporeal Soul is nourished by the mother’s Corporeal Soul.

Senses Later in life, the Corporeal Soul gives us the capacity of sensation, feeling, hearing and sight. When the Corporeal Soul is flourishing, ears and eyes are keen and can register. The decline of hearing and sight in old people is due to a weakening of the Corporeal Soul. We often attribute the decline of sensory acuity in the elderly to the decline of the Kidneys and of the Essence; this may certainly be so, but the influence of the Corporeal Soul in this decline should not be underestimated. Zhang Jie Bin says: “The Corporeal Soul can move and do things and [when it is active] pain and itching can be felt.”48 This shows that the Corporeal Soul is responsible for sensations and itching and is therefore closely related to the skin through which such sensations are experienced. This explains the somatic expression on the skin of emotional tension that affects the Corporeal Soul and the connection between the Corporeal Soul, Lungs and skin (Fig. 9.31). The Corporeal Soul, being closely related to the body, is the first to be affected when needles are inserted; the almost immediate feeling of relaxation following the insertion of needles is due to the unwinding of the Corporeal Soul. Through it, the Mind, Ethereal Soul, Intellect and Will-Power are all affected.

Emotions The Corporeal Soul is also related to weeping and crying. Just as the Corporeal Soul makes us feel pain on

Emotions

Corporeal Soul

Skin

Figure 9.31 The Corporeal Soul, emotions and the skin.

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a physical level, it also makes us cry and weep when subject to grief and sadness. Especially unexpressed grief constricts the Corporeal Soul and gives rise to accumulations. Emotional stress (especially worry, pensiveness, grief and sadness) “constricts” the Corporeal Soul and causes Lung-Qi stagnation in the chest. Lung-Qi stagnation affects the breasts and may give rise to the formation of lumps.

Physiological activity Some modern doctors consider the Corporeal Soul the “basic regulatory activity of all physiological functions of the body”.49 In this sense, it is the manifestation of the Lung’s function of regulating all physiological activities. Chapter 8 of the Simple Questions says: “The Lungs are like a Prime Minister in charge of regulation.”50 This description of the Lungs’ function in the Simple Questions should be seen in context. In fact, the sentence preceding the above concerning the function of the Heart says: “The Heart is like the Emperor, in charge of the Spirit (Shen Ming).”51 Thus, the Heart is compared to an Emperor and the Lungs to a Prime Minister assisting the Emperor.52 This relationship is an expression of the close relationship between Qi and Blood. The Lungs govern Qi and the Heart governs Blood; Qi is the “commander of Blood” (it moves Blood) and Blood is the “mother of Qi”. Qi and Blood assist and depend on each other, hence the comparison of the relationship between the Heart and Lungs to that between an Emperor and his Prime Minister. After saying that the Lungs are like a Prime Minister, the Simple Questions says that the Lungs are in charge of “regulation”. This means that, just as the Prime Minister regulates all administrative functions, the Lungs help to regulate all physiological activities in every organ and every part of the body, just as the Prime Minister’s office controls and directs the administrative functions of all government departments. The Lungs regulate all physiological activities in various ways: • by governing Qi • by controlling all channels and blood vessels • by governing breathing. As Qi is the basis for all physiological activities, the Lungs, by governing Qi, are naturally in charge of all physiological activities. This regulation function is

dependent also on the Lungs’ action in moving Qi around the body. Thus, the Corporeal Soul is the expression of the Lungs’ regulatory function in all physiological processes; the Corporeal Soul is the physical soul that makes this regulation possible.

Breathing Residing in the Lungs, the Corporeal Soul is closely linked to breathing. Breathing can be seen as the pulsating of the Corporeal Soul. Meditation makes use of the link between breathing and the Corporeal Soul. By concentrating on the breathing, someone who is meditating quietens the Corporeal Soul, the Mind becomes still and empty, and through this the Ethereal Soul becomes open and gets in touch with the Universal Mind.

Corporeal Soul and individual life The Corporeal Soul is related to our life as individuals, while the Ethereal Soul is responsible for our relations with other people and the world. From this point of view, there is an important difference between the Ethereal Soul and the Corporeal Soul. As we have seen, the Ethereal Soul is imparted by the father 3 days after birth; this shows that it is a soul that is socially constructed, a soul that lets us take and identify our place in the family and society. As we know, the Ethereal Soul is responsible for the “movement” of our psyche towards other people and the world in general. By contrast, the Corporeal Soul is a physical, individual soul that is formed soon after conception; it is the “blind” force of a soul whose only function is the regulation of physical activity and of the life force itself. However, that is not to say of course, that the Corporeal Soul is not affected by our emotional life. Emotional stress certainly always affects the Corporeal Soul, but the Corporeal Soul does not control our emotional life in the same way that the Mind and Ethereal Soul do.

The Corporeal Soul and the gui Beyond its nature of “spirit” or “ghost”, gui can have a very interesting psychological interpretation. Gui is like a “dark” force of the psyche, which gives the Ethereal and Corporeal Souls its imprint; in fact, as we have seen, the Chinese characters for these two souls contain the radical gui. Apart from other implications,

The Psyche in Chinese Medicine

this tells us that these two souls have their own existence independent from that of the Mind; they are “dark” forces of the psyche, one on a psychic level, the other on a physical level (Fig. 9.32). The gui within the Ethereal Soul gives it movement on a psychic level (coming and going of the Mind), which, as we have seen, generates ideas, intuition, creativity; the gui within the Corporeal Soul gives it movement on a physical level (entering and exiting of the Essence) in all the body’s physiological processes. Thus, the gui within the Corporeal Soul is the “dark” force that animates it in carrying out its function of promoting all physiological processes and of bringing the Essence into play in all parts of the body. There is a close connection between Corporeal Soul and gui intended in the sense of a contracting, centripetal, fragmenting, materializing force (Fig. 9.33). As mentioned above, He Shang Gong says: “The five turbid and humid flavours form bones, muscles,

Ethereal Soul

Coming and going MIND

Entering and exiting

Essence

Figure 9.32 The gui, the Ethereal Soul and the Corporeal Soul.

Qi

Corporeal Soul

is fullness of

blood, vessels and the six passions ... these gui are called Corporeal Soul.”53 In other words, one can say that the Corporeal Soul represents the forces of gui in the human sphere.

The Corporeal Soul and the anus Because of the relationship between the Corporeal Soul and the Lungs and of that between these and the Large Intestine, the anus is sometimes called po men, the “door of the Po”, as in Chapter 11 of the Simple Questions: “The door of the Po [anus] is the messenger for the five viscera and it drains off water and food without storing them for too long.”54 In fact, the point BL-42 Pohu (the “Window of the Po”) was indicated for incontinence of both urine and faeces from fright.

Relationship between Corporeal Soul and Ethereal Soul Because the Ethereal Soul and Corporeal Soul are two aspects of the soul, it is interesting to compare and contrast their various characteristics and functions (Table 9.1). Most of these are derived from Zhang Jie Bin’s Classic of Categories.55 As can be seen from Table 9.1, the Ethereal Soul is involved in problems occurring at night (although not exclusively), and the Corporeal Soul in problems occurring in daytime. The Discussion on Blood Patterns (1884) by Tang Zong Hai says:56

Gui

Corporeal Soul

269

MIND (Shen)

is fullness of

Figure 9.33 Qi, Mind, Corporeal Soul and gui.

GUI

Restlessness at night with excessive dreaming is due to an unsettled Ethereal Soul; this is Yang, and if at night it has no resting place the person is restless and dreams a lot. Restlessness in the daytime and a clouded Mind are due to an unsettled Corporeal Soul; this is Yin, and if Yin is deficient in daytime restlessness and mental confusion result. The Ethereal Soul pertains to the realm of Image and the Corporeal Soul to that of Form. This can be represented with a diagram (Fig. 9.34). The Ethereal Soul is ethereal, and is last to arrive (after birth) and first to go (after death); the Corporeal Soul is physical, and is the first to arrive (at conception) and the last to go after death (it lingers in the bones). According to Granet, the Ethereal Soul corresponds to the higher aspect of personality, to the personal name through which each person takes his or her social and family place; the Ethereal Soul conferred one one’s individuality.

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Corporeal Soul

Is the “coming and going” of the Mind

Is the “entering and exiting” of the Essence

Pertains to the Mind

Pertains to the body

Is the Qi of the Mind

Is the spirit of the body

Follows the changes of Qi

Follows the changes of the body

Is Yang and moves

Is Yin and quiescent

Creates action with movement

Creates action without movement

Related to the Mind: when Qi gathers, the Ethereal Soul gathers

Related to the Essence: when this gathers, the Corporeal Soul gathers

At birth, the Ethereal Soul joins with the Corporeal Soul

At birth, the Corporeal Soul restrains the Ethereal Soul

At death, it swims away and returns to Heaven

At death, it dissolves and returns to Earth

Is bright and lights the Corporeal Soul

Is dark and roots the Ethereal Soul

Is like a fire: the more things you add, the more it burns

Is like a mirror: it shines but holds only a reflection (of the Ethereal Soul)

Represents the movement of the Mind outwardly

Represents the movement of the Essence inwardly

Is rooted in Blood and Yin

Is connected to Qi and Yang

Disharmony causes problems with sleep at night

Disharmony causes problems in daytime

Disharmony causes lack of direction and inspiration, confusion

Disharmony causes lack of vigour and vitality

It is the link with the Universal Mind

It is purely individual

Corresponds to full moon

Corresponds to new moon

MIND (Heart)

ETHEREAL SOUL (Liver)

CORPOREAL SOUL (Lungs)

ESSENCE (Kidneys)

en er gy

Ethereal Soul

Image

bo dy ,v igo ur,

Table 9.1 Comparison of Ethereal Soul and Corporeal Soul

mi nd ,s ou l, s pir it

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Form

Figure 9.34 The realms of Image and Form and the Ethereal and Corporeal Souls.

The Huai Nan Zi says: “The Ethereal Soul derives from Heavenly Qi, the Corporeal Soul from Earthly Qi.”57 The Wu Xing Da Yi says: “The Corporeal Soul is like the envelope, the Ethereal Soul is the source of Life’s Qi.”58 These statements highlight the nature of the Corporeal Soul as the centripetal, materializing, separating force that produces Form and the body, hence it is like an “envelope” separating the body from the world. Hence the Corporeal Soul is constraining, contracting, centripetal; this constraining, separating and fragmenting movement eventually ends in death. By contrast, the Ethereal Soul is expansive, it is constantly moving towards the world; hence it is expansive, centrifugal. The Ethereal Soul is the source of Life’s Qi, it is centrifugal, and it has an outward movement and goes towards life. The Ethereal Soul is called the “Essence of Life’s Qi” and the Corporeal Soul the “Abode of Death’s Qi”. The connection of the Corporeal Soul with death is due to the fact that it is separating, constraining, fragmenting and contracting and it dies with the body (Fig. 9.35). The Secret of the Golden Flower says: “The Corporeal Soul partakes of the nature of darkness. It is the energy of the heavy and turbid. The Ethereal Soul loves life; the Corporeal Soul seeks death.”59 The Wu Xing Da Yi says:60 The Qi of the Ethereal Soul is the fullness [perfection] of Shen, the Qi of the Corporeal Soul is the fullness [perfection] of Gui. Human life includes death. At death, one returns to Earth; that is called Gui.

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Ethereal Soul

271

Warm Qi of Hun rising Expansive centrifugal ‘‘Essence of Life’s Qi’’

Corporeal Soul

Contracting, centripetal ‘‘Abode of Death’s Qi’’ Cold Po returning to Earth

Figure 9.37 Ethereal Soul rising and Corporeal Soul falling at death.

Figure 9.35 Expansive and contracting movements of Ethereal Soul and Corporeal Soul.

Zhu Xi said: Qi belongs to the Ethereal Soul, and the body is governed by the Corporeal Soul. The Ethereal Soul is the spirit of Yang, and the Corporeal Soul is the spirit of Yin. When a person is about to die, the warm Qi leaves him or her and rises. This is called the Ethereal Soul rising. The lower part of the body gradually becomes cold. This is called the Corporeal Soul falling.

Po falling

Warm Qi of Hun rising

See Figures 9.36–9.40. In ancient China, the dead were temporarily buried in the corner of the house where seeds were kept. This allowed the substance of the dead to penetrate the Earth in the house. The body of the dead decomposed in the corner where seeds were kept to symbolize the sprouting of new life from the seeds. In the same place

YANG ‘‘Essence of Life’s Qi’’

HUN

SHEN

Figure 9.38 Rising of Ethereal Soul and falling of Corporeal Soul.

HUN YIN ‘‘Abode of Death’s Qi’’

PO

GUI

PO

GUI

Figure 9.36 Ethereal Soul, Corporeal Soul, Mind and Gui.

Figure 9.39 Gui in Ethereal Soul and Corporeal Soul.

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The Practice of Chinese Medicine HUN YI

ZHI

SHEN

ETHEREAL SOUL – YANG – MIND (SHEN) – CENTRIFUGAL – “ESSENCE OF LIFE’S QI”

PO 6 passions

5 natures Ethereal Soul

Corporeal Soul

GUI

Figure 9.40 Ethereal Soul and Corporeal Soul as the gui of the five natures and six passions.

was the marital bed, where new lives are conceived. As the Corporeal Soul returned to Earth after death, this allowed people to imagine that a new life sprouted from the Earth in the house and from the dead ancestors as if the baby had taken the substance of the ancestors. The bodiless gui were hovering around the marital bed waiting for a new incarnation. This continuity between dead and living allowed people to believe in an unbroken family lineage, in an eternal family substance like the Earth. A death did not diminish this family substance and a birth did not increase it. The family was formed of two parallel communities: the living (with their individualities in the Corporeal Soul) and the dead. The Ethereal Soul’s “coming and going” gives “horizontality” to life; the Corporeal Soul’s “entering and exiting” gives “verticality” to life (Fig. 9.41). “Horizontality” means that the Ethereal Soul is constantly exploring the bounds of consciousness into the world of ideas, creativity, art, exploration, dreams, etc. “Verticality” means that the Corporeal Soul is constantly materializing into the body in the spheres of senses, feelings, etc. From what we have said about the Ethereal Soul and the Corporeal Soul, we can build the following sets of correspondences:

Going

CORPOREAL SOUL – YIN – GUI – CENTRIPETAL – “ABODE OF DEATH’S QI” CLINICAL NOTE Given the connection between the Corporeal Soul and death, it is interesting to note the association with death among the indications of three points related to the Lungs (and therefore Corporeal Soul).

 BL-13 Feishu: “suicidal”  Du-12 Shenzhu: “desire to kill people”  BL-42 Pohu: “three corpses flowing”.

SUMMARY THE CORPOREAL SOUL  It is a physical soul that resides in the Lungs.  It is formed 3 days after conception.  It is closely related to the Essence (Jing).  It is the “entering and exiting” of Essence, bringing this into play in all physiological processes.  During infancy, the baby’s life revolves entirely around the Corporeal Soul.  The Corporeal Soul is responsible for acuity of the sense organs.  The Corporeal Soul is affected by all emotions, especially pensiveness, worry, grief and sadness.  The Corporeal Soul is responsible for all physiological processes; it is the “soul” that animates all physiological activities.  The Corporeal Soul is responsible for breathing.  The Corporeal Soul is closely linked to gui as a centripetal, materializing, fragmenting force.  The anus is related to the Corporeal Soul.

PO HUN

Shen

Entering

Exiting Jing

Coming Horizontal movement

Vertical movement

Figure 9.41 Verticality of Corporeal Soul and horizontality of Ethereal Soul.

The Intellect (Yi) The Chinese character for Intellect is Yi , which can mean “idea”. I have chosen to translate this as “Intellect”, as it is very close to the Mind (Shen) of the Heart. The Intellect (Yi) resides in the Spleen and is responsible for applied thinking, studying, memorizing, focusing, concentrating and generating ideas.

The Psyche in Chinese Medicine

The Postnatal Qi and Blood are the physiological basis for the Intellect. Thus if the Spleen is strong, thinking will be clear, memory good and the capacity for concentrating, studying and generating ideas will also be good. If the Spleen is weak, the Intellect will be dull, thinking will be slow, memory poor and the capacity for studying, concentrating and focusing will all be weak. In the sphere of thinking, remembering and memorizing, there is considerable overlap between the Intellect (Yi of Spleen), the Mind (Shen of Heart) and the Will-Power (Zhi of Kidneys). The main differentiating factor is that the Spleen is specifically responsible for memorizing data in the course of one’s work or study (Fig. 9.42). For example, it is not uncommon for someone to have a brilliant memory in his or her field of study or research (a function of the Spleen) and yet be quite forgetful in daily life (a function of the Heart and Kidneys). The Heart and Kidneys also naturally contribute to this function, but they are also responsible for the memory of past events, whether recent or long past. In particular, the overlap between the Intellect and the Mind in thinking activity is very close, so much so that the Spiritual Axis says in Chapter 8: “The Heart function of recollecting is called Intellect.”61 In turn, the memorizing function of the Intellect is so closely related to the Will-Power (Zhi of the Kidneys) that the same chapter continues: “The storing [of data] of the Intellect is called Will-Power [Zhi].”62 It should be noted here that I translate the mental aspect of the Kidneys

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Zhi as Will-Power, although it also has the meaning of “memory” or “mind”. Another aspect of the Intellect of the Spleen is the generation of ideas (Fig. 9.43). We have seen above, that the Ethereal Soul also generates ideas, plans, projects, etc. The “ideas” generated by the Spleen differ from those deriving from the Ethereal Soul. The Ethereal Soul is responsible for “ideas” more in the sense of intuition, inspiration and creativity; these are broad ideas also in the sense of vision. The Intellect is responsible for “ideas” more in the sense of specific ideas in a given field. For example, the “idea” that allows us to carry out a repair job successfully derives from the Intellect of the Spleen; by contrast, the “idea” that gives us vision and creativity derives from the Ethereal Soul of the Liver. Ideas

INTELLECT (Spleen)

Memorizing, concentration, focusing

Figure 9.43 The Intellect as source of memorization and ideas.

SUMMARY THE INTELLECT (YI)

MIND (Heart)

Memory

Memory of events

INTELLECT (Spleen) Memorizing, concentrating, studying

Memory of events

ZHI (Kidneys)

Figure 9.42 Relationship of Mind, Intellect and Will-Power with memory.

 The Intellect (Yi) resides in the Spleen and is responsible for applied thinking, studying, memorizing, focusing, concentrating and generating ideas.  The Postnatal Qi and Blood are the physiological basis for the Intellect.  In the sphere of thinking, remembering and memorizing, there is considerable overlap between the Intellect (Yi of Spleen), the Mind (Shen of Heart) and the Will-Power (Zhi of Kidneys). The main differentiating factor is that the Spleen is specifically responsible for memorizing data in the course of one’s work or study.  The Intellect of the Spleen is also responsible for the generation of ideas.

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The Will-Power (Zhi) The word Zhi

has at least three meanings:

1. it indicates “memory” 2. it means “will-power “ (Fig. 9.44) 3. it is sometimes used to indicate the “five Zhi”, i.e. the five mental aspects Mind, Ethereal Soul, Corporeal Soul, Intellect and Will-Power itself. So as to avoid confusion between “Mind” (of the Heart), “Intellect” (of the Spleen) and “Memory” (of the Kidneys), I translate “Zhi” as Will-Power, bearing in mind that it also includes the meaning of “memory” and capacity of memorizing and recollecting. In this sense, the Kidneys influence our capacity for memorizing and storing data. Some of the ancient doctors even said that the Intellect (of the Spleen) and the memory (of the Kidneys) are almost the same thing, except that the Intellect is responsible for memorizing in the course of studying and the memory of the Kidneys is responsible for the storing of data over the long term. Tang Zong Hai says: “Memory [Zhi] indicates Intellect with a capacity for storing [data].”63 In the second and clinically more important sense, the Kidneys house Will-Power, which indicates drive, determination, single-mindedness in the pursuit of goals, enthusiasm and motivation. Zhang Jie Bin says in the Classic of Categories: “When one thinks of something, decides on it and then acts on it, this is called WillPower [Zhi].”64 The implication of this passage is that thinking of something (an “idea”) derives from the Ethereal Soul or the Intellect depending on the kind of idea, making a decision depends on the Liver and Gall Bladder (and the Ethereal Soul), and acting on it depends on the drive provided by the Will-Power (Zhi) of the Kidneys. Thus, if the Kidneys are strong, the Will-Power is strong and the person will have drive, enthusiasm, motivation and determination in the pursuit of goals. If the Kidneys are depleted and the Will-Power weakened, the person will lack drive and initiative,

Memory

ZHI (Kidneys)

Figure 9.44 Zhi as “memory” and “will-power”.

Will-Power

will be easily discouraged and swayed from his or her aims. A deficiency of the Kidneys and Will-Power is an important aspect of chronic depression. CLINICAL NOTE I always tonify the Kidneys in order to strengthen the Will-Power in depression, even in the absence of a specific Kidney pattern. To do so, I reinforce BL-23 Shenshu and BL-52 Zhishi.

The Will-Power (Zhi) must be coordinated with the Mind (Shen), just as on a physiological level the Kidneys and Heart must communicate (Fig. 9.45). The Will-Power gives Mind drive and determination in the pursuit of its goals, and the Mind directs and harnesses the Will-Power. If the Mind is clear in its aims and plans and the Will-Power is strong, then the person will have the drive to pursue goals. Thus it is necessary for both Will-Power and Mind to be strong. The Mind may be clear in its objectives, but if the Will-Power is weak the person will have no drive to realize such objectives. Conversely, the Will-Power may be strong, but if the Mind is confused the force of WillPower will only become destructive. Although not a pathology, a good example of this second situation may be seen in toddlers who have a strong Will-Power (the age at which they always say “No!”) but an immature Mind (Shen). A similar situation in adults transforms the normal drive and determination of Will-Power (Zhi) into recklessness and excessive risk taking.

MIND (Heart)

Directs and harnesses Will-Power

Gives the Mind drive and determination

WILL-POWER (Kidneys)

Figure 9.45 Relationship between Will-Power (Zhi) and Mind.

The Psyche in Chinese Medicine

SUMMARY THE WILL-POWER (ZHI)  The word Zhi has at least three meanings: 1. it indicates “memory” 2. it means “will-power” 3. it is sometimes used to indicate the “five Zhi”, i.e. the five mental aspects Mind, Ethereal Soul, Corporeal Soul, Intellect and Will-Power itself.  In the sense of Zhi as memory, the Kidneys influence our capacity for memorizing and storing data.  In the second sense of Zhi as will-power, the Kidneys house Will-Power, which indicates drive, determination, enthusiasm, motivation and single-mindedness in the pursuit of goals.  A deficiency of the Kidneys and Will-Power is an important aspect of chronic depression.  The Will-Power (Zhi) must be coordinated with the Mind (Shen). The Will-Power is the basis for the Mind, and the Mind directs the Will-Power. If the Mind is clear in its aims and plans and the Will-Power is strong, then the person will have the drive to pursue goals. Thus it is necessary for both Will-Power and Mind to be strong.

END NOTES 1. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 23. First published c.100 BC. 2. 1982 Lei Jing [Classic of Categories]. People’s Health Publishing House, Beijing, p. 49. The Classic of Categories was written by Zhang Jie Bin and first published in 1624. 3. Spiritual Axis, p. 71. 4. Classic of Categories, p. 63. 5. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 58. First published c.100 BC. 6. Spiritual Axis, p. 128. 7. Simple Questions, p. 67. 8. Tang Zong Hai 1892 Zhong Xi Hui Tong Yi Jing Jing Yi [The Essence of Medical Classics on the Convergence of Chinese and Western Medicine], cited in Wang Ke Qin 1988 Zhong Yi Shen Zhu Xue Shuo [Theory of the Mind in Chinese Medicine]. Ancient Chinese Medical Texts Publishing House, p. 22. 9. Simple Questions, p. 72. 10. Ibid., p. 154. 11. Ren Ying Qiu 1985 Zhong Yi Ge Jia Xue Shuo [Theories of Chinese Medicine Doctors], cited in Theory of the Mind in Chinese Medicine, p. 22. 12. Wang Ken Tang 1602 Zheng Zhi Zhun Sheng [Standards of Diagnosis and Treatment], cited in Theory of the Mind in Chinese Medicine, p. 22. 13. Simple Questions, p. 26.

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14. Ibid., p. 78. 15. Yu Chang 1658 Yi Men Fa Lu [Principles of Medical Practice], cited in Theory of the Mind in Chinese Medicine, p. 39. 16. Simple Questions, p. 153. 17. Ibid., pp. 67–68. 18. Ibid., p. 153. 19. Ibid., p. 63. 20. Giles H 1912 Chinese–English Dictionary. Kelly & Walsh, Shanghai, p. 650. 21. Classic of Categories, p. 50. 22. Ibid, p. 50. 23. Spiritual Axis, p. 23. 24. 1979 Xue Zheng Lun [Discussion on Blood Patterns]. People’s Health Publishing House, Beijing, p. 29. The Discussion on Blood Patterns was written by Tang Zong Hai and first published in 1884. 25. Wilhelm R (translator) 1962 The Secret of the Golden Flower. Harcourt, Brace & World, New York, p. 26. 26. Ibid., p. 26. 27. Classic of Categories, p. 50. 28. Kong Ying Da Wu Jing Zheng Yi [Five-Channel Righteousness], cited in Theory of the Mind in Chinese Medicine, p. 37. 29. Simple Questions, p. 68. 30. Spiritual Axis, p. 24. 31. Discussion on Blood Patterns, p. 29. 32. Simple Questions, p. 335. 33. The Essence of the Convergence between Chinese and Western Medicine, cited in Theory of the Mind in Chinese Medicine, p. 36. 34. The Secret of the Golden Flower, p. 26. 35. Ibid., p. 36. 36. National Institute of Mental Health. Online. Available: http://www.nimh.nih.gov 37. Redfield Jamison K 1993 Touched with Fire – Manic-Depressive Illness and the Artistic Temperament. Free Press, New York. 38. Jung CG 1961 Modern Man in Search of a Soul. Routledge & Kegan Paul, London. 39. Modern Man in Search of a Soul. 40. Many pieces of classical music display such alternation of expansion and contraction, none more than Beethoven’s. Very many of Beethoven’s works are characterized by musical phrases of intense, deep, romantic feeling (“expansion”) to be followed quickly by phrases of turbulent and dark passion (“contraction”). The best example of such an alternation of feelings is Beethoven’s Violin Sonata no. 5 (the “Spring” Sonata). 41. Giles H 1912 Chinese–English Dictionary, p. 1144. 42. Classic of Categories, p. 63. 43. Eyssalet J-M 1990 Le Secret de la Maison des Ancêtres. Guy Trédaniel Editeur, Paris, p. 30. 44. Ibid., p. 31. 45. Spiritual Axis, p. 23. 46. Classic of Categories, p. 63. 47. Ibid., p. 63. 48. Ibid., p. 63. 49. Zhao You Chen 1979 Liao Ning Zhong Yi [Chinese Medicine of Liao Ning], no. 5, p. 24. 50. Simple Questions, p. 58. 51. Ibid., p. 58. 52. In order to understand the clinical significance of the Lungs being like a Prime Minister, we should see this statement in the context of the social and political situation of ancient China. In modern, Western societies, the Prime Minister has primarily political responsibility, and the administration of government is delegated to government departments (or the Civil Service in Britain). In ancient China, society was administered very tightly by a central, pyramidal bureaucracy with the Prime Minister at its apex; the Prime Minister, therefore, was the head of all government departments administering the country. It is in this context that the functions of the Lungs should be seen. 53. Le Secret de la Maison des Ancêtres, p. 31.

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54. 55. 56. 57. 58. 59. 60.

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Simple Questions, p. 77. Classic of Categories, pp. 63–64. Discussion on Blood Patterns, p. 236. Le Secret de la Maison des Ancêtres, p. 441. Ibid., p. 441. The Secret of the Golden Flower, p. 28. Ibid., p. 453.

61. Spiritual Axis, p. 23. 62. Ibid, p. 23. 63. The Essence of Medical Classics on the Convergence of Chinese and Western Medicine, cited in the Theory of the Mind in Chinese Medicine, p. 38. 64. Classic of Categories, p. 50.

CHAPTER 10

THE EMOTIONS

THE EMOTIONS 282 Anger 282 Joy 285 Worry 287 Pensiveness 288 Sadness and grief 290 Fear 291 Shock 292 Love 293 Craving 294 Guilt 295 Shame 297 THE PATHOLOGY OF QI AND MINISTER FIRE IN EMOTIONAL PROBLEMS 298 The effect of emotions on the body’s Qi 298 The pathology of the Minister Fire in emotional problems 303

THE EMOTIONS Le coeur a ses raisons que la Raison ne connait point. (“The heart has its reasons that Reason does not know”.) Pascal, Pensées The Chinese term for what we translate as “emotion” is qing ; this is composed of the radical for “heart” on the left and another component on the right (qing) that is partly phonetic and partly conveying the idea of “green” of growing plants.

! The Chinese word for “emotion” (qing) contains the radical for “heart” on the left and that for “green” on the right.

The word “emotion” itself is not, in my opinion, a good term to indicate the Chinese view of the “emotional” causes of disease. The word “emotion” derives from Latin, and it refers to “e-movere”, i.e. to “move out”; it is used to indicate any feeling of the mind “moving outwards” or “being moved”, as distinct from the cognitive or volitional states of consciousness. In this sense, the term “emotion” may refer to any feeling, such as fear, joy, hope, surprise, desire, aversion, pleasure and pain; it is therefore not entirely suitable as a term denoting the emotions as intended in Chinese medicine. In fact, emotions are considered in Chinese medicine as causes of disease, and some of the emotions just mentioned (e.g. surprise) are not causes of disease. It is interesting to note that the word used to indicate a suffering of the mind (as they are in Chinese medicine) originally was “passion” rather than “emotion”. The word “passion” derives from the Latin verb “patire”, which means “to suffer”, and it would therefore be a better translation of the Chinese word “qing” in the context of emotions as causes of disease. The word “emotion” replaced “passion” in the time between Descartes and Rousseau, i.e. between 1650 and 1750 (as the former used the word “passion” and the latter the word “emotion”). Thus, the word “passion” would convey the idea of mental suffering better than “emotion” also because it implies the idea of something that is “suffered”, something that we are subject to. Indeed, feelings such as sadness, fear, anger become causes of disease when they take over our mind – when we no longer possess them but they “possess” us. Indeed, the Chinese expression most Chinese books use to describe the “stimulation” or “excitation” produced by the emotions is ci ji , in which “ji” contains the radical for “water” and means to “swash, surge” as a wave does, i.e. it denotes the surge of emotions like a wave that carries us away.

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Emotions are mental stimuli that influence our affective life. Under normal circumstances, they are not a cause of disease. Hardly any human being can avoid being angry, sad, aggrieved, worried or afraid at some time in his or her life. For example, the death of a relative provokes a very natural feeling of grief. Emotions become causes of disease only when they are either long-lasting or very intense. It is only when we are in a particular emotional state for a long time (months or years) that they become a cause of disease; for example, if a particular family or work situation makes us angry and frustrated in an ongoing way, this will affect the Liver and cause an internal disharmony. In a few cases, emotions can become a cause of disease in a very short time if they are intense enough: shock is the best example of such a situation. CLINICAL NOTE Emotions become causes of disease only when they are either long-lasting or very intense.

Each emotion stems from a psychic field that pertains to the relevant Yin organ. This, in fact, explains why a certain emotion affects a specific organ: that particular organ already produces a certain psychic energy with specific characteristics that, when subject to emotional stimuli, responds to or “resonates” with a particular emotion; for example, an external stimulus resonates with the Liver’s psychic energy, giving rise to anger (Fig. 10.1). Thus emotions are not something that comes from outside the internal organs to attack them; the internal organs already have a Emotion

LIVER Mental energy

psychic energy that turns into a negative emotion only when triggered by certain external circumstances. For example, why does anger affect the Liver? If one considers the Liver’s characteristics of free-going, easy and quick movement, with a tendency for its Qi to rise, its correspondence to Spring when the powerful Yang energy bursts outwards and upwards and its correspondence to Wood with its expansive movement, it is easy to understand that the Liver would be affected by anger. This emotion, with its quick outbursts, the rising of blood to the head that one feels when very angry, the destructive, expansive quality of rage, mimics, on an affective level, the characteristics of the Liver and Wood outlined above. The same psychic and affective qualities of the Liver that may give rise to anger and resentment over many years under normal circumstances are also harnessed and used for creative activities. The healthy counterpart of emotions will be considered further when each emotion is discussed in detail. In Chinese medicine, emotions (intended as causes of disease) are mental stimuli that disturb the Mind (Shen), Ethereal Soul (Hun) and Corporeal Soul (Po) and, through these, they alter the balance of the Internal Organs and the harmony of Qi and Blood. For this reason, emotional stress is an internal cause of disease that injures the Internal Organs directly. On the other hand, and this is a very important feature of Chinese medicine, the state of the Internal Organs affects our emotional state. For example, if Liver-Blood is deficient (perhaps from dietary factors) and causes Liver-Yang to rise, this may cause a person to become irritable all the time. Conversely, if a person is constantly angry about a certain situation or with a particular person, this may cause Liver-Yang to rise. The Spiritual Axis in Chapter 8 clearly illustrates the reciprocal relationship between the emotions and the Internal Organs. It says:1 The Heart’s fear, anxiety and pensiveness injure the Mind (Shen) ... the Spleen’s worry injures the Intellect (Yi) ... the Liver’s sadness and shock injure the Ethereal Soul (Hun) ... the Lung’s excessive joy injures the Corporeal Soul (Po) ... the Kidney’s anger injures the Will-Power (Zhi). On the other hand, further on it says:2

External stimuli Figure 10.1 Conversion of organ’s mental energy into “emotion”.

If Liver-Blood is deficient, there is fear; if it is in excess, there is anger ... if Heart-Qi is deficient, there is sadness; if it is in excess, there is manic behaviour.

The Emotions

These two passages clearly show that, on the one hand, emotional stress injures the Internal Organs and, on the other hand, disharmony of the Internal Organs causes emotional imbalance. The emotions taken into consideration in Chinese medicine have varied over the years. From a Five-Element perspective, the Yellow Emperor’s Classic considered five emotions, each one affecting a specific Yin organ: • • • • •

anger affects the Liver joy affects the Heart pensiveness affects the Spleen worry affects the Lungs fear affects the Kidneys.

SUMMARY THE EMOTIONS AND THE FIVE ELEMENTS WOOD – ANGER – LIVER FIRE – JOY – HEART EARTH – PENSIVENESS – SPLEEN METAL – WORRY – LUNGS FEAR – WATER – KIDNEYS

Although each emotion affects a particular Yin organ selectively, the relationship between a given emotion and a particular organ should not be interpreted too rigidly. Each emotion can and does affect more than one organ, and often in a pattern that does not follow that of the Five Elements. This will be explained more in detail below. Passages of the Spiritual Axis and Simple Questions confirm Dr Zhang’s ideas. For example, with regard to excess joy, Chapter 8 of the Spiritual Axis says: “Excess joy of the Lungs injures the Corporeal Soul, and this may cause manic behaviour.”3 With regard to anger, Chapter 23 of the Simple Questions says: “When the Gall Bladder is diseased, there is anger.”4 Chapter 62 of the Simple Questions says: “When Blood rushes upwards and Qi downwards, the Heart is harassed and may cause anger.”5 Chapter 8 of the Spiritual Axis says: “Anger affecting the Kidneys injures the Will-Power [Zhi].”6 With regard to pensiveness, Chapter 39 of the Simple Questions says: “Pensiveness makes the Heart [Qi] accumulate, causing the Mind to stagnate; the Upright Qi settles and does not move, and therefore Qi stagnates.”7 With regard to worry, Chapter 23 of the Simple Questions says: “When Qi rushes upwards, it affects the

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Liver, causing worry.”8 Chapter 8 of the Spiritual Axis says: “Worry of the Spleen injures the Intellect.”9 With regard to fear, Chapter 4 of the Spiritual Axis says: “Worry and fear injure the Heart.”10 Chapter 62 of the Simple Questions says: “When Blood [of the Liver] is deficient, there is fear.”11 Chapter 19 of the Simple Questions says: “Fear makes Spleen-Qi stagnate.”12 Chapter 23 of the Simple Questions says: “When Stomach-Qi rebels upwards, there is vomiting and fear.”13 Chapter 8 of the Spiritual Axis deals with the mental effect of the emotions in quite some detail. It says:14 The method of needling should first of all be rooted in the Mind (Shen). Blood, blood vessels, Nutritive Qi (Ying Qi), Qi and the spirit (Jingshen) are stored in the five Yin Organs. When they are out of harmony due to the emotions, the Essence (Jing) is lost, the Ethereal Soul [Hun] and Corporeal Soul [Po] are scattered, the Will-Power (Zhi) and Intellect (Yi) are chaotic and the person lacks wisdom and reflection: why is that? Heaven bestows us Virtue (De), Earth bestows us Qi. When Virtue flows and Qi pulsates, there is life. When the two Essences [of mother and father] unite, the Mind comes into being. What follows the Mind in its coming and going is the Ethereal Soul, what follows the Essence in its entering and exiting is the Corporeal Soul. The Heart directs mental activities; it houses memory that is called Intellect (Yi); the storing [of data] of the Intellect is called Will-Power [or Memory, Zhi]; WillPower generates pensiveness; pensiveness (si ) generates reflection (lu ). Thus the wise nourish life (yang sheng) by following the four seasons, adapting to cold and heat, moderating joy and anger, regulating Yin and Yang and thus will enjoy long life. Fear, pensiveness and worry injure the Mind and Spirit. When the Spirit is injured, fear may run wild. When sadness agitates inside, it injures life. Joy scatters the Spirit out of its residence. Worry obstructs Qi so that it stagnates. Anger causes loss of self-control. Fear sweeps the Spirit away. Fright and pensiveness of the Heart injure the Spirit. Worry of the Spleen injures the Intellect. Sadness of the Liver injures the Ethereal Soul, which may cause manic behaviour and mental confusion; there is contraction of the sinews, the hypochondrium cannot be raised, the hair withers. The joy of the Lungs injures the Corporeal Soul; when the Corporeal Soul is injured, there is manic behaviour and the Yin cannot reside, the skin becomes like heated leather, the hair withers. Anger of the Kidneys injures the Will-Power; when the Will-Power is injured, it affects the memory and one does not remember what they said, there is lower backache and inability to bend or extend the back,

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the hair withers. Fear injures the Essence; this injures the bones. Thus, the five Yin Organs that store the Essence should not be injured; if they are, Yin deficiency results and from this, Qi deficiency. Therefore when needling one should observe the patient in order to know the condition of the Essence, Mind, Ethereal Soul, Corporeal Soul, and whether they have been preserved or not. The Liver stores Blood and Blood houses the Ethereal Soul: when Liver-Qi is deficient, there is fear; when full, anger. The Spleen stores nourishment, and this houses the Intellect: when Spleen-Qi is deficient, the four limbs are weak and there is an imbalance in the five Yin Organs; when full, there is abdominal distension and menstrual and urinary problems. The Heart stores the blood vessels, and these house the Mind: when Heart-Qi is deficient, there is sadness; when full, incessant laughter. The Lungs store Qi, and this houses the Corporeal Soul: when Lung-Qi is deficient, there is nasal obstruction; when full, breathlessness and a feeling of tightness of the chest. The Kidneys store the Essence, and this houses Will-Power: when Kidney-Qi is deficient, there is collapse; when full, distension and the five Yin Organs are not at peace. See Figure 10.2. An interesting aspect of the above passage from the Spiritual Axis is the sentence: “Heaven bestows us Virtue

(De), Earth bestows us Qi. When Virtue flows and Qi pulsates, there is life.” These two sentences show very clearly the Confucian influence on Chinese medicine, i.e. the idea that “Heaven bestows Virtue”; the term used for “Virtue” [de ] is a typical Confucian term indicating the qualities of the Confucian sage, and the translation as “virtue” is inevitably inadequate. This is discussed more fully below. Chapter 5 of the Simple Questions says:15 Anger injures the Liver, sadness counteracts anger ... joy injures the Heart, fear counteracts joy ... pensiveness injures the Spleen, anger counteracts pensiveness ... worry injures the Lungs, joy counteracts worry ... fear injures the Kidneys, pensiveness counteracts fear. An interesting feature of this passage is that each emotion is said to counteract another along the Controlling Sequence of the Five Elements (Fig. 10.3). For example, fear pertains to the Kidneys and Water, Water controls Fire (Heart), the emotion related to the Heart is joy, hence fear counteracts joy. This thinking presents some interesting ideas that are certainly true in practice, for example that “anger counteracts pensiveness”. Thus, according to this scheme, emotions counteract each other as follows (Fig. 10.3):

Empty = fear LIVER

Blood

HUN Full = anger Empty = sadness

HEART

Blood Vessels

SHEN Full = laughter Empty = weak limbs, Five-Zang disorder

SPLEEN

Nourishment

YI Full = distension, menstrual-urinary disorders Empty = nasal obstruction

LUNGS

Qi

PO Full = breathlessness Empty = collapse

KIDNEYS

Essence

ZHI Full = distension, Five-Zang disorder

Figure 10.2 Effect of Internal Organs disharmony on emotional state according to Chapter 8 of the Spiritual Axis.

The Emotions Joy fire

Anger wood

6. shock 7. sadness 8. fear (wei Pensiveness earth

Fear Sadness water metal Figure 10.3 Emotions counteracting each other along the Controlling Sequence of the Five Elements.

• • • • •

anger counteracts pensiveness joy counteracts sadness pensiveness counteracts fear sadness counteracts anger fear counteracts joy.

However, the above five emotions are not by any means the only emotions discussed in the Yellow Emperor’s Classic. In other passages, sadness and shock are added, giving seven emotions as follows: 1. 2. 3. 4. 5. 6. 7.

anger affects the Liver joy affects the Heart worry affects the Lungs and Spleen pensiveness affects the Spleen sadness affects the Lungs and Heart fear affects the Kidneys shock affects the Kidneys and Heart.

Zhang Jie Bin actually mentions eight emotions in his Classic of Categories.16 These are: 1. 2. 3. 4. 5.

excess joy anger pensiveness worry fright (kong

)

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)

Besides the above emotions, I shall also discuss some emotions that are not usually mentioned in modern Chinese books but were mentioned in the ancient ones. Moreover, I am also going to discuss some emotions that are never mentioned in Chinese books, modern or ancient. Indeed, the list of emotions that are not discussed in Chinese books is very long, and the following are some examples: • • • • • • • • • • • • • • • • • • • • •

pride shame guilt envy contempt resentment angst despair hopelessness frustration hatred rejection (being rejected) indignation humiliation regret remorse self-contempt self-hatred self-love (narcissism) spite vanity.

Besides the usual seven emotions, some Chinese doctors considered other emotions, such as grief, love, hatred and desire. Grief would naturally be akin to sadness. “Love” here means not normal love, such as that of a mother towards her child or that between two lovers, but rather the condition when love becomes an obsession or when it is misdirected, as when a person loves someone who persistently hurts them. Hatred is a common negative emotion that would be akin to anger. “Desire” means excessive craving. The inclusion of this as a cause of disease reflects the Daoist, Confucianist and Buddhist influence on Chinese medicine, as all three major Chinese religions/philosophies considered excessive desire as the root of many emotional problems.

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Indeed, according to Buddhist thought, desire is the ultimate cause of disease, i.e. clinging to external objects or other people and to life itself. Indeed, from a Buddhist perspective, it is the very “craving” for the warmth of a womb by a soul in the Bardo state (the state in between death and life) that brings our existence into being. This excessive craving, which is one aspect of the emotion of “joy” in Chinese medicine, causes the Minister Fire to blaze upwards and harass the Mind. Finally, two emotions that are common in Western patients but not mentioned in Chinese books are guilt and shame. Thus, the list of emotions could be expanded as follows, and these are the emotions I will discuss: • anger (including frustration and resentment) affects the Liver • joy affects the Heart • worry affects the Lungs and Spleen • pensiveness affects the Spleen • sadness and grief affect the Lungs and Heart • fear affects the Kidneys • shock affects the Kidneys and Heart • love affects the Heart • craving affects the Heart • guilt affects the Kidneys and Heart • shame affects the Heart and Spleen.

• craving • guilt • shame.

Anger The term “anger”, perhaps more than any other emotion, should be interpreted broadly to include several other allied emotional states, such as resentment, repressed anger, feeling aggrieved, frustration, irritation, rage, indignation, animosity or bitterness. If they persist for a long time, any of these emotional states can affect the Liver, causing stagnation of LiverQi, stasis of Liver-Blood, rising of Liver-Yang or blazing of Liver-Fire. Anger (intended in the broad sense outlined above) usually makes Qi rise, and many of the symptoms and signs will manifest in the head and neck, such as headaches, tinnitus, dizziness, red blotches on the front part of the neck, a red face, thirst, a bitter taste and a Red tongue with red sides (Fig. 10.4). Chapter 8 of the Spiritual Axis says: “Anger causes loss of self-control.”17 The Simple Questions in Chapter 39 says: “Anger makes Qi rise and causes vomiting of blood and diarrhoea.”18 It causes vomiting of blood because it

Dizziness, tinnitus, dry throat, shouting, blurred vision

I shall first discuss the effects of emotions on Qi in general and then discuss each emotion individually. The discussion of the emotions will be carried out according to the following topics. • The Emotions • The pathology of Qi and Minister Fire in emotional problems

Tense shoulders

THE EMOTIONS As mentioned above, the emotions discussed are: • • • • • • • •

anger joy worry pensiveness sadness and grief fear shock love

Wiry pulse

Figure 10.4 Clinical picture of anger.

The Emotions

makes Liver-Qi and Liver-Fire rise, and diarrhoea because it induces Liver-Qi to invade the Spleen. Chapter 3 of the Simple Questions says: “Severe anger severs the body and Qi, Blood stagnates in the upper part and the person may suffer from syncope.”19 The effect of anger on the Liver depends, on the one hand, on the person’s reaction to the emotional stimulus and, on the other hand, on other concurrent factors. If the anger is bottled up, it will cause stagnation of Liver-Qi, whereas if it is expressed it will cause Liver-Yang rising or Liver-Fire blazing (Fig. 10.5). In a woman, stagnation of Liver-Qi may easily lead to stasis of Liver-Blood. If the person also suffers from some Kidney-Yin deficiency (perhaps from overwork), then he or she will develop Liver-Yang rising. If, on the other hand, the person has a tendency to Heat (perhaps from excessive consumption of hot foods), then he or she will tend to develop Liver-Fire blazing. Anger does not always manifest outwardly with outbursts of anger, irritability, shouting, red face, etc. Some individuals may carry anger inside them for years without ever manifesting it. In particular, longstanding depression may be due to repressed anger or resentment. Because the person is very depressed, he or she may look very subdued and pale, walk slowly and speak with a low voice, all signs which one would associate with a depletion of Qi and Blood deriving from sadness or grief. However, when anger rather than sadness is the cause of disease, the pulse and tongue will clearly show it: the pulse will be Full and Wiry, and

Liver-Yang rising

Liver

Liver-Qi stagnation

Heart

ANGER

Intestines Figure 10.5 Effects of anger.

Stomach

283

the tongue will be Red with redder sides and with a dry yellow coating. This type of depression is most probably due to long-standing resentment often harboured towards a member of that person’s family. In some cases, anger disguises other emotions, such as guilt. Some people may harbour guilt inside for many years and may be unable or unwilling to recognize it; they may then use anger as a mask for their guilt. Moreover, there are some families in which every member is perpetually angry; this happens more in Mediterranean countries such as Italy, Spain or Greece. In these families, anger is used as a mask to hide other emotions such as guilt, fear, dislike of being controlled, weakness or inferiority complex. When this is the case, it is important to be aware of this situation, as one needs to treat not the anger but the underlying psychological and emotional condition. In some cases, anger can affect organs other than the Liver, especially the Stomach. This can be due to stagnant Liver-Qi invading the Stomach. Such a condition is more likely to occur if one gets angry at mealtimes, which may happen if family meals become occasions for regular rows. It also happens when there is a pre-existing weakness of the Stomach, in which case the anger may affect only the Stomach without even affecting the Liver. If one regularly gets angry an hour or two after meals, then the anger will affect the Intestines rather than the Stomach. This happens, for example, when one goes straight back to a stressful and frustrating job after lunch. In this case, stagnant Liver-Qi invades the Intestines and causes abdominal pain, distension and alternation of constipation with diarrhoea. Finally, anger, like all other emotions, also affects the Heart. This is particularly prone to be affected by anger also because, from a Five-Element perspective, the Liver is the mother of the Heart and often Liver-Fire is transmitted to the Heart, giving rise to Heart-Fire. Anger makes the Heart full with blood rushing to it. With time, this leads to Blood-Heat affecting the Heart and therefore the Mind. Anger tends to affect the Heart, particularly when the person does a lot of jogging, hurrying or exercising. Thus, anger may cause either stagnation of Liver-Qi or Liver-Yang rising. When advising patients on how to deal with their anger, we should note that if anger has caused stagnation of Liver-Qi – expressing the anger may be helpful. However, if anger has given rise to Liver-Yang rising, expressing it will not usually help; it

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is too late, and expressing the anger forcefully may only make Liver-Yang rise even more. In my opinion, anger is overemphasized as an emotional cause of disease in Chinese books. I feel that this is very much due to the Confucian influence on Chinese medicine. A very important aspect of Confucianism is the emphasis laid on social harmony, which, according to them, begins with family harmony, which, in turn, is based on the rigid respect of family hierarchy. For example, the younger brother obeys the older brother, the sister obeys the brother, all the children obey the parents and the wife obeys the husband. When every member of the family and society takes his or her proper place and role in the family and social hierarchy, then familial, social and political harmony reigns. Figure 10.6 summarizes the effects of anger and the organs affected by it.

! In my opinion, anger is overemphasized as an emotional cause of disease in Chinese books.

It is easy to see that the emotion that most threatens the established order is anger, because this emotion may lead people to rebel. Given the Confucian influence on Chinese medicine, I believe it is for this reason that anger plays such a predominant role among the emotional causes of disease. Anger makes Qi “rebel”, i.e. go in the wrong direction, and it is interesting to note that the Chinese character for “rebellious” Qi is ni , which means “rebellious”,

Liver-Yang rising

Qi rising

Liver-Qi stagnation Heart-Qi stagnation

ANGER Qi stagnation

Stomach-Qi stagnation Intestine-Qi stagnation

Figure 10.6 Summary of effects of anger.

“contrary”, “to counter”, “to disobey”, “to defy”, “to go against”; it is easy to see the “social” nature of this pathological movement of Qi. Indeed, the opposite of ni is shun , which, in Chinese medicine, denotes Qi going the right, proper way; again, it is easy to see the social implication of this term, which means “to conform”, “in the same direction as”, “to obey”, “to yield to”, “to act in submission to”. With regard to Liver-Qi stagnation and anger, there are two issues to consider. First, anger is, in my opinion, over-diagnosed as an emotional cause of disease (see case history below). Second, Qi stagnation does not derive always necessarily from anger, and it therefore may affect organs other than the Liver; in emotional problems, Qi stagnation may affect especially the Lungs, Heart and Spleen. It follows that when we diagnose Qi stagnation in a patient we should not assume that it is necessarily due to Liver-Qi stagnation and to anger: worry, sadness, grief and guilt may all cause Qi stagnation in the Lungs and/or Heart. The patterns of Qi stagnation in the Lungs and Heart are mentioned below. How can we diagnose whether Qi stagnation is due to the Liver or to another organ? Apart from the difference in symptoms, the pulse is an important diagnostic factor. Generally, in Liver-Qi stagnation the pulse is Wiry in all positions. In Qi stagnation due to other organs, the pulse is Wiry only in that organ’s position; moreover, it may be Tight rather than Wiry. The Lungs are a good case in point: in Lung-Qi stagnation, the Lung pulse is often very slightly Tight (bearing in mind that the Lung pulse should naturally feel relatively soft and therefore it takes only a very small change to make it “Tight”).

Case history This case history is presented here to show how, in my opinion, Western therapists too sometimes overemphasize anger as an emotional cause of disease. A 33-year-old woman complained of a variety of physical symptoms, such as some skin eruptions on the arms, a slight breathlessness, some abdominal distension and premenstrual tension. On an emotional level, she was depressed and her immediate problem was a feeling of sadness deriving from the break-up of a relationship. She found it difficult to keep to a long-term

The Emotions

relationship and seemed to go from one unsuitable relationship to another, ending up feeling used by men. This patient had a history of sexual abuse from her stepfather when she was a teenager. She was under therapy, and her therapist suggested that she had repressed anger about the sexual abuse and that she should acknowledge it and manifest it. In my opinion, her pulse and other signs completely contradicted this analysis. Her pulse was Weak and soft in general, and the weakest pulse of all was that of the Lungs; the Heart pulse was very slightly Overflowing. Her complexion was very pale, and her voice was very weak. On the basis of the pulse, complexion and voice, I diagnosed primarily Lung-Qi deficiency and Qi stagnation of the Lungs and Heart. Therefore, in my opinion, in her case the prevailing emotion deriving from her history of sexual abuse was not anger but sadness and grief. The counterpart of anger in terms of mental energies is power, dynamism, creativity and generosity. The same energy that is dissipated in outbursts of anger can be harnessed to achieve one’s goals in life. It is probably for this reason that the Gall Bladder (closely related to the Liver) is said to be the source of courage. A strong Gall Bladder gives one the courage to make decisions and changes in one’s life. This aspect of the Gall Bladder’s functions is obviously closely linked to the Liver and the Ethereal Soul. If Liver-Blood is deficient, there is fear; therefore if Liver-Blood is abundant, the person will be fearless and decisive.

SUMMARY ANGER  The term “anger” should be interpreted broadly to include resentment, repressed anger, feeling aggrieved, frustration, irritation, rage, indignation, animosity or bitterness.  Anger makes Qi rise, and many of the symptoms and signs will manifest in the head and neck, such as headaches, tinnitus, dizziness, red blotches on the front part of the

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neck, a red face, thirst, a bitter taste and a Red tongue with red sides.  If the anger is bottled up, it will cause stagnation of Liver-Qi, whereas if it is expressed it will cause Liver-Yang rising or Liver-Fire blazing.  Anger may sometimes disguise itself as depression.  Anger may mask guilt.  Anger can affect organs other than the Liver, for example Stomach and Intestines.  Anger, like all other emotions, also affects the Heart.  Anger is probably overemphasized as an emotional cause of disease in Chinese books due to the Confucian influence on Chinese medicine.  Qi stagnation does not derive always necessarily from anger, and it may affect organs other than the Liver; in emotional problems, especially the Lungs, Heart and Spleen.

Joy A normal state of joy is obviously not in itself a cause of disease; on the contrary, it is a beneficial mental state that favours a smooth functioning of the Internal Organs and their mental faculties. The Simple Questions in Chapter 39 says: “Joy makes the Mind peaceful and relaxed, it benefits the Nutritive and Defensive Qi and it makes Qi relax and slow down.”20 On the other hand, in Chapter 2 the Simple Questions says: “The Heart ... controls joy, joy injures the Heart, fear counteracts joy.”21 See Figure 10.7. What is meant by “joy” as a cause of disease is obviously not a state of healthy contentment but one of excessive excitement and craving that can injure the Heart. This happens to people who live in a state of continuous mental stimulation (however pleasurable) or excessive excitement: in other words, a life of “hard playing”. As indicated above, inordinate craving is an aspect of the emotion “joy”, and it stirs up the Minister Fire, which overstimulates the Mind. Joy, in the broad sense indicated above, makes the Heart larger. This leads to excessive stimulation of

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Over-excitement, insomnia, restlessness, talking a lot Red tip of tongue

Palpitations

Makes heart larger

Pulse Overflowing-Empty on left Front position

Figure 10.7 Clinical picture of joy.

the Heart, which in time may lead to Heart-related symptoms and signs (Fig. 10.8). These may deviate somewhat from the classic Heart patterns. The main manifestations would be palpitations, over-excitability, insomnia, restlessness, talking a lot and a red tip of the tongue. The pulse would typically be slow, slightly Overflowing but Empty on the left Front position. Joy may also be marked out as a cause of disease when it is sudden; this happens, for example, on hearing good news unexpectedly. In this situation, “joy” is akin to shock (although the former makes the heart larger and the latter smaller). Fei Bo Xiong (1800–1879) in Medical Collection from Four Families from Meng He says: “Joy injures the Heart ... [it causes] Excessive stimulation Excessive craving Sudden joy Over-excitement

JOY

JOY

Slows down Qi

Figure 10.8 Effect of joy.

Heart-Qi deficiency

Yang Qi to float and the blood vessels to become too open and dilated …”22 In these cases of sudden joy and excitement, the Heart dilates and slows down and the pulse becomes Slow and slightly Overflowing but Empty. One can understand the effect of sudden joy further if one thinks of situations when a migraine attack is precipitated by the excitement of suddenly hearing good news. Another example of joy as a cause of disease is that of sudden laughter triggering a heart attack; this example also confirms the relationship existing between the Heart and laughter. One can also understand joy as a cause of disease by observing children; in fact, in children, joy and overexcitement often end in tears. The best way to understand why “joy” features in Chinese medicine is in relation to the three major Chinese religions, i.e. Confucianism, Buddhism and Daoism. All these three religions (or rather philosophies), for different reasons, considered “desire” and craving” as the chief root of emotional problems. For example, the Daoists shunned social relations and advocated “following the Dao”, “absence of desire” (wu yu) and “non-action” (wu wei). They felt that “desire” would stop one from following the Dao. The Buddhists considered “desire” as the root of human suffering. According to them, our very existence begins out of desire and craving when the mind in the Bardo state (the period after death and before the next reincarnation) is attracted by the warmth of a womb and it reincarnates. Later on in life, desire causes our mind to try to grasp objects like a monkey sways from tree to tree. Finally, Confucianists believed that the true “gentleman” (a mistranslation of the term jun zi that actually applies to both men and women) is not stirred by emotions, because these cloud his or her true nature.

SUMMARY JOY  A normal state of joy is obviously not in itself a cause of disease.  What is meant by “joy” as a cause of disease is obviously not a state of healthy contentment but one of excessive excitement and craving that can injure the Heart.  Joy makes the Heart larger.

The Emotions  All three major Chinese religions, i.e. Confucianism, Buddhism and Daoism, for different reasons, considered “desire” and craving” (included under “joy”) as the chief root of emotional problems.

Pale complexion Dry cough Uncomfortable feeling in the chest, slight shortness of breath, tensing of shoulders (Lungs)

Worry Worry is one of the most common emotional causes of disease in our society. The extremely rapid and radical social changes that have occurred in Western societies in the past decades have created a climate of such insecurity in all spheres of life that only a handful of Daoist sages are immune to worry! See Figure 10.9. Of course, there are also people who, because of a pre-existing disharmony of the internal organs, are very prone to worry, even about very minor incidents in life. For example, many people appear to be very tense and worry a lot. On close interrogation about their work and family life, often nothing of note emerges. They simply worry excessively about trivial everyday activities, and they tend to do everything in a hurry and be pressed for time. This may be due to a constitutional weakness of the Spleen, Heart or Lungs or a combination of these. Worry knots Qi, which means that it causes stagnation of Qi, and it affects both Lungs and Spleen: the Lungs because when one is worried breathing is shallow, and the Spleen because this organ is respon-

Abdominal distension (Spleen) Tight Lung pulse

Figure 10.9 Clinical picture of worry.

sible for thinking and ideas (Fig. 10.10). Thus, from this point of view, worry is the pathological counterpart of the Spleen’s capacity for concentration and focus. Chapter 8 of the Spiritual Axis confirms that worry knots Qi: “Worry causes obstruction of Qi so that Qi stagnates.”23

Lung-Qi Xu Lungs Lung-Qi stagnation

Heart-Qi Xu WORRY

Knots Qi

Heart Heart-Qi stagnation

Spleen-Qi Xu Spleen Spleen-Qi stagnation Figure 10.10 Effect of worry.

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Worry may affect the Spleen as well, and Chapter 8 of the Spiritual Axis confirms that: “In the case of the Spleen, excessive worry injures the Intellect [Yi].”24 CLINICAL NOTE Worry knots Lung-Qi and causes Lung-Qi stagnation. LU-7 Lieque is the best point to treat Lung-Qi stagnation deriving from worry.

Worry is the emotional counterpart of the Spleen’s mental energy, which is responsible for concentration and memorization. When the Spleen is healthy, we can concentrate and focus on the object of our study or work; the same type of mental energy, when disturbed by worry, leads to constantly thinking, brooding and worrying about certain events of life.

SUMMARY In a few cases, worry may also affect the Liver directly, in my experience causing either Liver-Qi stagnation or Liver-Yang rising. In both cases, when worry affects the Liver it affects the shoulder muscles, causing a pronounced stiffness and ache of the trapezius muscles.

! Worry may affect the Liver directly, causing either Liver-Qi stagnation or Liver-Yang rising, in both cases resulting in ache and stiffness of the trapezius muscles. The symptoms and signs caused by worry will vary according to whether it affects the Lungs or the Spleen. If worry affects the Lungs, it will cause an uncomfortable feeling of the chest, slight breathlessness, tensing of the shoulders, sometimes a dry cough and a pale complexion. The right-Front pulse position (of the Lungs) may feel slightly Tight or Wiry, indicating the knotting action of worry on Qi. When judging the quality of the Lung pulse, one should bear in mind that, in normal circumstances, this should naturally feel relatively soft (in relation to the other pulse positions). Thus a Lung pulse that feels as hard as a (normal) Liver pulse may well be Tight or Wiry. If worry affects the Spleen, it may cause poor appetite, a slight epigastric discomfort, some abdominal pain and distension, tiredness and a pale complexion. The right Middle pulse position (Spleen) will feel slightly Tight but Weak. If worry affects the Stomach as well (which happens if one worries at meal times), the right Middle pulse may be Weak-Floating. Finally, like all emotions, worry affects the Heart, causing stagnation of Heart-Qi. This will cause palpitations, a slight feeling of tightness of the chest and insomnia.

WORRY  Worry is one of the most common emotional causes of disease in our society.  Worry knots Qi, which means that it causes stagnation of Qi, and it affects both Lungs and Spleen.  In some cases, worry may affect the Liver.  Like all emotions, worry affects the Heart, causing stagnation of Heart-Qi.

Pensiveness Pensiveness is very similar to worry in its character and effect. It consists of brooding, constantly thinking about certain events or people (even though not worrying), nostalgic hankering after the past and generally thinking intensely about life rather than living it. In extreme cases, pensiveness leads to obsessive thoughts. In a different sense, pensiveness also includes excessive mental work in the process of one’s work or study. See Figure 10.11. Pensiveness affects the Spleen and, like worry, it knots Qi. Chapter 39 of the Simple Questions says: “Pensiveness makes the Heart [Qi] accumulate, causing the Mind to stagnate; the Upright Qi settles and does not move, and therefore Qi stagnates.”25 Pensiveness will therefore cause similar symptoms as outlined above for worry, i.e. poor appetite, a slight epigastric discomfort, some abdominal pain and distension, tiredness and a pale complexion (Fig. 10.12). The right Middle pulse position (Spleen) will feel slightly Tight but Weak. The only difference will be that the pulse of the right side will not only feel slightly Tight but will also have no wave. One can feel the normal pulse as a wave under the fingers moving from the Rear towards the Front position. The pulse without wave lacks this flowing movement from Rear to Front position, and it is instead

The Emotions

Pale complexion

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Inch Gate Foot

Poor appetite Front (Cun)

Rear (Chi)

Middle (Guan)

Front (Cun)

Middle (Guan)

Rear (Chi)

Epigastric discomfort

Tiredness

Pulse with wave Figure 10.13 Pulse without wave.

Pulse Tight without a wave in Middle position

Abdominal distension and pain

Pulse without wave

contemplation will, if excessive and misguided, lead to pensiveness, brooding or even obsessive thinking.

SUMMARY PENSIVENESS Figure 10.11 Clinical picture of pensiveness.

felt as if each individual position were separate from the others (Fig. 10.13). In the case of pensiveness, the pulse will lack a wave only on the right Middle position. A pulse without wave in the Front and Middle positions indicates Sadness. The positive mental energy corresponding to pensiveness is quiet contemplation and meditation. The same mental energy that makes us capable of meditation and

 Pensiveness consists of brooding, constantly thinking about certain events or people (even though not worrying), nostalgic hankering after the past and generally thinking intensely about life rather than living it.  In extreme cases, pensiveness leads to obsessive thoughts.  Pensiveness also includes excessive mental work in the process of one’s work or study.  Pensiveness affects the Spleen and, like worry, it knots Qi.

Spleen-Qi Xu Spleen Spleen-Qi stagnation

Lung-Qi Xu PENSIVENESS

Knots Qi

Lungs Lung-Qi stagnation

Heart-Qi Xu Heart Heart-Qi stagnation Figure 10.12 Effect of pensiveness.

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Sadness and grief

Heart-Qi Xu

Sadness includes the emotion of regret, as when someone regrets a certain action or decision in the past and the Mind is constantly turned towards that time. Sadness and grief affect the Lungs and Heart. See Figure 10.14. In fact, according to the Simple Questions, sadness affects the Lungs via the Heart. It says in Chapter 39:26 Sadness makes the Heart cramped and agitated; this pushes towards the lungs’ lobes, the Upper Burner becomes obstructed, Nutritive and Defensive Qi cannot circulate freely, Heat accumulates and dissolves Qi. According to this passage then, sadness primarily affects the Heart and the Lungs suffer in consequence because they are both situated in the Upper Burner. The Lungs govern Qi, and sadness and grief deplete Qi (Fig. 10.15). This is often manifested on the pulse as a Weak quality on both left and right Front positions (Heart and Lungs). In particular, the pulse on both Front positions is Short and has no wave, i.e. it does not flow smoothly towards the thumb. As indicated above, one can feel the normal pulse as a wave under the fingers moving from the Rear towards the Front position. The pulse without wave

Pale complexion Tiredness

Weak voice

Slight shortness of breath, slight feeling of oppression in chest

Weak pulse without a wave

Figure 10.14 Clinical picture of sadness and grief.

SADNESS

Dissolves Qi

Lung-Qi Xu

Qi stagnation

Liver-Blood Xu Figure 10.15 Effect of sadness and grief.

lacks this flowing movement from Rear to Front position, and it is instead felt as if each individual position were separate from the others. In the case of sadness, the pulse lacks a wave in the Front and Middle positions. CLINICAL NOTE Sadness causes the pulse to lack a wave; instead of feeling like a wave flowing from the Rear to the Front position, it feels as if each pulse position were separate. Such a pulse is a very reliable sign of sadness.

Other manifestations deriving from sadness and grief include a weak voice, tiredness, pale complexion, slight breathlessness, weeping and a slight feeling of oppression in the chest. In women, deficiency of LungQi from sadness or grief often leads to Blood deficiency and amenorrhoea. Although sadness and grief deplete Qi and therefore lead to deficiency of Qi, they may also, after some time, lead to stagnation of Qi, because the deficient Lungand Heart-Qi fail to circulate properly in the chest. As mentioned before, each emotion can affect other organs apart from its “specific” one. For example, the Spiritual Axis in Chapter 8 mentions injury of the Liver from sadness rather than anger: “When sadness affects the Liver, it injures the Ethereal Soul; this causes mental confusion ... the Yin is damaged, the tendons contract and there is hypochondrial discomfort.”27 This shows how organs can be affected by emotions other than their “specific” one. In this case, sadness can naturally affect the Ethereal Soul and therefore Liver-Yin. Sadness has a depleting effect on Qi and it therefore, in some cases, depletes Liver-Yin, leading to mental confusion, depression, lack of a sense of direction in life and inability to plan one’s life.

The Emotions

Case history A 40-year-old woman was under a great deal of stress due to her divorce, which caused her great sadness. She often felt weepy. She felt aimless and questioned her role in her relationships with men; she was at a turning point in her life and did not know what direction to take. She slept badly and her pulse was Choppy. This is a clear example of sadness affecting the Liver and therefore the Ethereal Soul. She was treated, improving tremendously, with the Yin Linking Vessel (Yin Wei Mai) points (P-6 Neiguan on the right and SP-4 Gongsun on the left) and BL-23 Shenshu, BL-52 Zhishi and BL-47 Hunmen. Dr John Shen considers that grief that is unexpressed and borne without tears affects the Kidneys. According to him, when grief is held in without weeping, the fluids cannot come out (in the form of tears) and they upset the fluid metabolism within the Kidneys. This would happen only in situations when grief had been felt for many years.28 I personally find that sadness and grief are very common and important causes of disease in Western patients, much more than “anger”. As I indicated above, I personally feel that anger as an emotional cause of disease is overemphasized in Chinese books. What are sadness and grief caused by in Western patients? Apart from the obvious causes due to bereavement, very many Western patients of all ages suffer from sadness and grief deriving from the breakup of relationships or marriage. In other words, sadness and grief are primarily about loss, whether it be the loss of a dear one from death or the loss of a partner through separation. It is very important to remember that Qi stagnation affects not only the Liver but, especially in emotional problems, also the Heart and Lungs. Sadness, grief and worry are common causes of Qi stagnation affecting the Lungs and Heart. For example, in women, Lung-Qi stagnation affects the chest and breasts and, in the long run, it can give rise to breast lumps (benign or malignant). In my experience, in Western women, this is a more common cause of breast lumps than Liver-Qi stagnation. Dr Xia Shao Nong thinks that breast lumps and breast cancer are due to sadness and grief deriving from widowhood, breaking of relationships, divorce, death of one’s children and bereavement at a young age from the death of one’s spouse. These events,

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especially if they occur suddenly, upset the Mind and lead to Qi stagnation and Qi depletion. It is interesting to note that all the events mentioned by Dr Xia involve separation and loss.

SUMMARY SADNESS AND GRIEF  Sadness and grief affect the Lungs and Heart.  Sadness and grief deplete Qi.  Sadness often causes a pulse without wave, i.e. the pulse lacks a flowing movement from Rear to Front position, and it is instead felt as if each individual position were separate from the others. In the case of sadness, the pulse lacks a wave in the Front and Middle positions.  Sadness and grief deplete Qi but, after some time, they also lead to stagnation of Qi.  In some cases, sadness injures the Liver.  According to Dr John Shen, grief that is unexpressed and borne without tears affects the Kidneys.  Sadness and grief often derive from the breakup of relationships or marriage.

Fear Fear includes a chronic state of fear, anxiety and a sudden fright. Fear depletes Kidney-Qi and it makes Qi descend. The Simple Questions in Chapter 39 says: “Fear depletes the Essence; it blocks the Upper Burner, which makes Qi descend to the Lower Burner.”29 Examples of Qi descending are nocturnal enuresis in children and incontinence of urine or diarrhoea in adults following a sudden fright. See Figure 10.16. This statement from the Simple Questions is interesting in that it says that fear blocks the Upper Burner (resulting in Qi of the Lower Burner to descend); this would imply that fear does not simply “make Qi descend” (as we usually say), but that it also causes some Qi stagnation in the Upper Burner (Fig. 10.17). CLINICAL NOTE Fear makes Qi descend by blocking the Upper Burner. Treatment of fear, therefore, should not consist simply of lifting Qi, for example with Du-20 Baihui, but also in unblocking Qi in the Upper Burner with HE-5 Tongli and LU-7 Lieque.

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SUMMARY FEAR  Fear includes a chronic state of fear, anxiety and a sudden fright.  Fear depletes Kidney-Qi and it makes Qi descend.  Situations of chronic anxiety and fear will have different effects on Qi depending on the state of the Heart: if the Heart is strong, fear will cause Qi to descend, but if the Heart is weak it will cause Qi to rise in the form of Empty Heat.  Liver-Blood deficiency and a Gall Bladder deficiency can also make the person fearful.

If Qi rises: palpitations, insomnia, dry mouth

Incontinence of urine, diarrhoea

Figure 10.16 Clinical picture of fear.

Qi rising

Heart

Shock

HeartQi stagnation

FEAR Qi descending

Kidneys

Figure 10.17 Effect of fear.

Situations of chronic anxiety and fear will have different effects on Qi depending on the state of the Heart. If the Heart is strong, fear will cause Qi to descend, but if the Heart is weak it will cause Qi to rise in the form of Empty Heat. This is more common in old people and in women, as fear and anxiety weaken Kidney-Yin and give rise to Empty Heat of the Heart with such symptoms as palpitations, insomnia, night sweating, a dry mouth, a malar flush and a FloatingEmpty and Rapid pulse. There are other causes of fear, not related to the Kidneys. Liver-Blood deficiency and a Gall Bladder deficiency can also make the person fearful. Chapter 8 of the Spiritual Axis says: “If Liver-Blood is deficient, there is fear.”30 The positive counterpart of fear within the mental energies of the Kidneys is flexibility, yielding in the face of adversity and quiet endurance of hardship.

Mental shock scatters Qi and affects the Heart and Kidneys. It causes a sudden depletion of Heart-Qi, makes the Heart smaller and may lead to palpitations, breathlessness and insomnia. See Figure 10.18. It is often reflected in the pulse with a so-called “moving” quality, i.e. a pulse that is short, slippery, shaped like a bean, rapid and giving the impression of vibrating as it pulsates.

Palpitations, shortness of breath, insomnia

Moving pulse

Figure 10.18 Clinical picture of shock.

The Emotions

The Simple Questions in Chapter 39 says: “Shock affects the Heart, depriving it of residence; the Mind has no shelter and cannot rest, so that Qi becomes chaotic.”31 Shock also “closes” the Heart or makes the Heart smaller. This can be observed in a bluish tinge on the forehead and a Heart pulse which is Tight and Fine (Fig. 10.19). Shock also affects the Kidneys, because the body draws on the Kidney-Essence to supplement the sudden depletion of Qi. For this reason, shock can cause such symptoms as night sweating, a dry mouth, dizziness or tinnitus.

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Insomnia, mental restlessness Red tip of tongue, red face Pulse Overflowing on Heart position Palpitations

SUMMARY SHOCK  Mental shock scatters Qi and affects Heart and Kidneys.  It causes a sudden depletion of Heart-Qi and makes the Heart smaller.  Shock also affects the Kidneys, because the body draws on the Kidney-Essence to supplement the sudden depletion of Qi.

Love Here, “love” does not mean the normal affection felt by human beings towards one another, such as, for example, the love of parents for their children and vice versa, or the affection of a loving couple, but rather obsessive love for a particular person. Love also becomes a cause of disease when it is misdirected, as happens, for example, when a person loves someone who persistently hurts them, whether physically or mentally. Obsessive jealousy would also fall under this broad category. See Figure 10.20.

Heart-Qi Xu Suspends Qi SHOCK

Heart-Qi stagnation Depletes Qi Kidney-Qi deficiency

Figure 10.19 Effect of shock.

Figure 10.20 Clinical picture of love.

Love in the sense outlined above affects the Heart and it quickens Qi. This will be felt on the left Front position (Heart) with an Overflowing quality, and the pulse will also be rapid. It may cause Heart-Fire, with such symptoms and signs as palpitations, a red tip of the tongue, a red face, insomnia and mental restlessness (Fig. 10.21).

SUMMARY LOVE  Here, “love” does not mean the normal affection felt by human beings towards one another but rather obsessive love for a particular person.  Love also becomes a cause of disease when it is misdirected, as happens, for example, when a person loves someone who persistently hurts them, whether physically or mentally.  Obsessive jealousy would also fall under this broad category.  Love affects the Heart and it quickens Qi.

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Heart-Fire LOVE

Quickens Qi

Heart-Fire

CRAVING

Makes Minister Fire rise to Heart and Pericardium Heart Empty Heat

Figure 10.21 Effect of love. Figure 10.23 Effect of craving.

Craving As explained above, “craving” should be seen in the context of the three major philosophies of China, i.e. Confucianism, Buddhism and Daoism. All these three philosophies considered “craving” and “desire” as the root of mental-emotional suffering. See Figure 10.22. In the context of Chinese medicine, “craving” indicates a state of constant craving that is never satisfied. This can include craving for material objects or social recognition. Although rooted in the ancient philosophies of China, it is interesting to note that “craving” as an emotional cause of disease is common in our Western consumer societies where not only is there “craving” but where this is also artificially stimulated by advertising.

Insomnia, mental restlessness Red face Slight “manic” behaviour

Palpitations

Craving affects the Heart and it scatters Qi. Craving also affects the Pericardium by stirring the Minister Fire. In disease, Minister Fire refers to a pathological, excessive Empty Fire arising from the Kidneys (Fig. 10.23). It arises from the Kidneys and it affects the Pericardium and therefore the Mind. For this reason, “Minister Fire” refers to the physiological or pathological Fire of the Kidneys and to the Pericardium. This accounts for the assignment of the Right-Rear position on the pulse either to the Kidney-Yang by some doctors, or to the Pericardium by others. If the Mind is calm, settled and content, the Pericardium follows its direction and there is a happy and balanced life. If the Mind is weak and dissatisfied, the Pericardium follows the demands of the craving and the person constantly desires new objects or new recognition, which, even when attained, is never satisfying and leaves the person more frustrated. It is for these reasons that Confucianism, Daoism and Buddhism put the emphasis on reducing craving to prevent the arousal of Minister Fire, which stirs the Mind. Craving will cause Heart-Fire or Heart Empty Heat depending on the underlying condition of the person. If it causes Heart-Fire, there will be palpitations, a red face, thirst, insomnia, agitation, a slight “manic” behaviour. If there is a tendency to Yin deficiency, which is common in people who tend to overwork, it will lead to Heart Empty Heat. This will cause palpitations, a malar flush, a dry throat, insomnia and mental restlessness.

SUMMARY CRAVING  “Craving” should be seen in the context of the three major philosophies of China, i.e. Confucianism, Buddhism and Daoism.  All these three philosophies considered “craving” and “desire” as the root of mentalemotional suffering. Figure 10.22 Clinical picture of craving.

The Emotions  In the context of Chinese medicine, “craving” indicates a state of constant craving that is never satisfied. This can include craving for material objects or social recognition.  Craving affects the Heart and it scatters Qi. Craving also affects the Pericardium by stirring the Minister Fire.  Craving will cause Heart-Fire or Heart Empty Heat depending on the underlying condition of the person.

Guilt For all have sinned and fall short of the glory of God.32 Romans 3.23 In Him we have redemption through His blood, the forgiveness of sins, in accordance with the riches of God’s grace that He lavished on us with all wisdom and understanding.33 Ephesians 1.7 Let us draw near to God with a sincere heart in full assurance of faith, having our hearts sprinkled to cleanse us from a guilty conscience and having our bodies washed with pure water.34 Hebrews 10.22 For whoever keeps the whole law and yet stumbles at just one point is guilty of breaking all of it.35 James 2.10 Guilt is a pervasive emotion in Western patients. It is completely missing from Chinese medicine books, and one could say that it simply does not exist in the Chinese psyche and soul. It could be argued that guilt is intrinsically related to the Judaeo-Christian religions and especially the Christian religion, with its concept of “original sin”. There are few expressions in Chinese to indicate guilt, and all of them refer to “guilt” in a legal sense rather than a feeling of guilt. An everyday expression to indicate a feeling of guilt would be you zui e gan, which means “having a guilt feeling”, in which zui means “guilt” or “crime” in a legal sense. I have never seen expressions referring to “feeling of guilt” in modern Chinese books. It could be argued that this is due to the fact that in Judaeo-Christian societies the feeling of guilt is pervasive, while in Eastern societies such feeling is more or less absent. In

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fact, the concept of guilt is totally absent in all three major Chinese religions of Confucianism, Daoism and Buddhism. Indeed, Confucius did not even believe in the value of punishment for crimes. It should be stressed that what concerns us here in dealing with emotions is not guilt but the feeling of guilt, which is totally unrelated to an actual crime or transgression. For example, a person may have committed a crime but feel no guilt at all; conversely, a person may have committed no crime or transgression but feel guilty. Guilt can manifest in many different ways, and I list some below. • Feeling of responsibility for negative circumstances that have befallen oneself or others. • Feeling of regret for real or imagined misdeeds, both past and present. • Feeling responsible (and guilty) for any negative thing that occurs to members of one’s family or one’s partner. • Taking responsibility for someone else’s misfortune or problem. Apart from the above examples of the consequences of a guilt feeling, this may make a person take very important, life-changing steps such as marriage or job. In other words, a subconscious guilty feeling may play a role in the choice of job or life partner. The above are only a few examples of the sort of behaviour induced by feelings of guilt. A feeling of guilt may be due to the transgression of social or religious taboos or from having done something “wrong” that is later regretted. However, a feeling of guilt may also be innate and not related to any specific action. This latter feeling is indeed the most destructive one. Guilt forms the core of Judaeo-Christian psychology and theology. Guilt formed also an important cornerstone of Freud’s theories. It is important to distinguish the subjective sense of guilt from its objective counterparts. For example, a person may be found guilty in a court of law without feeling guilty; in a religious context, a person may deem himself to be guilty in front of God but still not feel guilty; someone may be guilty of doing something reprehensible but still not feel guilty. It is therefore the feeling of guilt that is all important. People who are prone to blame themselves for everything that goes wrong may also suffer an unjustified and subjective sense of guilt.

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Guilt is self-reproach for some actual misdeeds or an inborn feeling of guilt totally disconnected from any misdeeds. Guilt includes a sense of inadequacy and despair not found in shame (see below). Guilt does not require any particular offence, and the doctrine of original sin is an example of this. When assailed by a feeling of guilt, a person is one’s own judge and a more ruthless and less reasonable judge than any real judge. Guilt is inwardly directed, and its object is the self; in this sense, it is almost the “opposite” emotion to that of anger, as this latter emotion is usually directed at another person. Guilt is based on moral criteria of having broken a law of morality. The “mythology” of guilt is the doctrine of the original sin. The “authority” providing the criteria is absolute and unquestionable. Guilt is a “dark” emotion with no redemption; it is a much “darker” emotion than shame. Guilt can have different effects in different people. First of all, it may lead to Qi stagnation; it affects any organ and especially the Lungs, Heart, Liver and Kidneys (Fig. 10.24). Because of its “dark”, “stagnating” character, the Qi stagnation may cause Blood stasis easily and quickly. This Blood stasis may be in any part of the body and any organ but particularly in the Lungs, Heart, Spleen and Liver.

Purple tongue, red tip

Under certain conditions, guilt may also cause sinking of Qi and affects the Kidneys, causing some urinary problems or menstrual problems from sinking of Qi (Fig. 10.25). The tongue has a red tip and possibly purple body. The pulse is Deep, Weak on the Kidney positions, possibly slightly Overflowing on the Heart position and Choppy, without wave. It may also be Firm; when guilt results from repressed anger, the pulse will be Wiry.

SUMMARY GUILT  Guilt is a pervasive emotion in Western patients, and it is completely missing from Chinese medicine books.  What concerns us in dealing with emotions is not guilt but the feeling of guilt, which is totally unrelated to an actual crime or transgression.  Guilt forms the core of Judaeo-Christian psychology and theology. Guilt also formed an important cornerstone of Freud’s theories.  Guilt is self-reproach for some actual misdeeds or an inborn feeling of guilt totally disconnected from any misdeeds.  Guilt may lead to Qi stagnation; it affects any organ, especially the Lungs, Heart, Liver and Kidneys.  Because of its “dark”, “stagnating” character, the Qi stagnation may cause Blood stasis (particularly in the Lungs, Heart, Spleen and Liver) easily and quickly.  Guilt may also cause sinking of Qi and affect the Kidneys causing some urinary problems or menstrual problems from sinking of Qi.

Blood stasis

Lungs

Sinking of Qi (urinary or gynaecological problems)

Heart Blood stasis

Deep-Weak pulse, Firm pulse

Qi stagnation

GUILT

Kidneys Qi sinking

Figure 10.24 Clinical picture of guilt.

Liver

Figure 10.25 Effect of guilt.

Kidneys

The Emotions

Shame Shame is a common emotion in Western patients. It may be caused by a feeling of shame about one’s behaviour but, more commonly, it is an inborn feeling of shame due to one’s upbringing. It is a feeling of worthlessness, an absence of a feeling of self-worth. It is, in a way, the opposite emotion to anger and pride. Anger is outwardly-directed (“I am angry at someone”), while shame is inwardly directed. It is self-accusation; a feeling that one has to hide is an important aspect of shame. When affected by shame, one feels judged all the time. According to Solomon, in “small doses” shame may be an affirmation of one’s autonomy, a confirmation that one will live by one’s standards and accept responsibility. According to him, although opposite to pride, shame is similarly conducive to self-esteem. It is easy to feel good about oneself when one has no values, when one refuses to accept responsibility for one’s actions, or when one happens not to have done anything wrong. The ability to admit and atone for one’s mistakes is as essential to wisdom and personal dignity as the ability to love other people. However, in severe cases (which are the ones that concern us when shame becomes a cause of disease), shame is overwhelming and it is self-demeaning, extremely defensive and impotent. As a cause of disease, we consider shame that is overwhelming, that is due to one’s upbringing and is not related to one’s actions or to having done anything wrong. A person suffering from this shame will always feel as if they had done something wrong and will want to hide. It is often said that Western societies are “guiltbased” and Eastern ones “shame-based”, so it is useful to explore the differences between shame and guilt. Shame is related more to one’s place in society, what people think of us, the feeling that one has to hide because one has done something wrong, something that society frowns on, something “dirty”. In other words, as long as we do not do anything that society disapproves of or, most importantly, as long as we are not seen, not found out to be doing something “wrong”, we do not feel shame. By contrast, in such situations we would feel guilty even if nobody sees us doing something “wrong”. One could say that with guilt, we hear a voice condemning us; with shame, we see people condemning us. Therefore shame can be avoided if we are not seen doing

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something wrong. Guilt is unremitting; we cannot avoid it even if nobody sees us, because we hear the voice of the inner judge condemning us. What is paramount in shame is how one appears to the other members of the community, not how one feels inside. Guilt is a “darker” emotion, more inwardly directed, an emotion from which there is no escape; the judgement is there, whether anyone sees us or not. The big difference between guilt and shame is that guilt has no redemption and it “eats” one inside forever; shame has redemption and repair. It is certainly true that Eastern societies are shamebased, probably due to the strong Confucian influence; however, that does not mean that shame is not a prevalent emotion in the West too. As the Confucian ethics is all about social relationships, and about one’s place in society and conforming to strict rules of conduct and social hierarchy, it is natural that shame ensues from contravening the established rules of society. Thus, people are worried about not being seen to be doing anything that society would frown on. That is why shame can sometimes produce extreme consequences, as when Japanese businessmen commit suicide when they are disgraced socially. It is probably also for this reason that anger plays such a prominent role in the emotional causes of disease for the Chinese. Anger is probably the most disruptive of the emotions from the social point of view and an emotion that can potentially challenge and disrupt the social order and hierarchy. The Confucian gentleman never gets angry, and it is shameful to be seen to be angry. However, shame is common also in the West and, I would say, more in Protestant countries with a strong Puritan tradition. Shame is inwardly directed. The objects of shame are one’s own actions; it is dictated by moral criteria and has a negative evaluation. One is responsible and blameworthy. As in anger, shame involves a courtroom mythology of law and judgement, accusation and punishment. In shame, unlike anger, one casts oneself in the uncomfortable position of defendant rather than judge, but a defendant who has openly admitted to his crime and is willing to accept punishment for it. Shame is inwardly directed, and it therefore makes Qi stagnate but also possibly sink (Fig. 10.26). Indeed, sinking of Qi is a frequent result of shame; Dampness also frequently accompanies shame. When one feels shame, one feels “dirty”, and “dirtiness” is characteristic

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SUMMARY SHAME

Prolapse, chronic excessive vaginal discharge, chronic menorrhagia, chronic slight urinary incontinence

Dampness Sinking of Qi

Figure 10.26 Clinical picture of shame.

of Dampness. In my experience, shame often manifests with sinking of Qi and Dampness, for example prolapse of organs, chronic and stubborn vaginal discharge, chronic excessive menstrual bleeding from sinking of Spleen- and Kidney-Qi and chronic slight urinary incontinence (Fig. 10.27).

Spleen

Kidneys

SHAME

Qi sinking

Spleen

Kidneys Figure 10.27 Effect of shame.

THE PATHOLOGY OF QI AND MINISTER FIRE IN EMOTIONAL PROBLEMS I shall first discuss the effect of emotional stress on the body’s Qi and then explore the pathology of the Minister Fire in emotional problems.

Heart Qi stagnation

 Shame is a common emotion in Western patients.  It may be caused by a feeling of shame about one’s behaviour but, more commonly, it is an inborn feeling of shame due to one’s upbringing.  Shame is overwhelming and is self-demeaning, extremely defensive and impotent.  Shame is related more to one’s place in society, what people think of us, the feeling that one has to hide because one has done something wrong, something that society frowns on, something “dirty”. By contrast, in such situations we would feel guilty even if nobody sees us doing something “wrong”.  With guilt, we hear a voice condemning us; with shame, we see people condemning us.  Shame is inwardly directed, and it therefore makes Qi stagnate but also possibly sink. Indeed, sinking of Qi is a frequent result of shame; Dampness also frequently accompanies shame.  When one feels shame, one feels “dirty”, and “dirtiness” is characteristic of Dampness.

Dampness

The effect of emotions on the body’s Qi Derangement of Qi in emotional problems The first effect of emotional stress is to affect the circulation of Qi. Qi circulates in the Qi Mechanism in the correct direction in each given pathway. In each part of the body, Qi ascends or descends and enters or exits in the correct direction as appropriate. The correct

The Emotions

ascending/descending and entering/exiting of Qi in the Qi Mechanism ensures the smooth flow of Qi. Emotional stress upsets the ascending/descending and entering/exiting of Qi, and each emotion affects the circulation of Qi in a different way as follows (Fig. 10.28). • • • • • • •

Anger makes Qi rise. Joy slows Qi down. Sadness dissolves Qi. Worry knots Qi. Pensiveness knots Qi. Fear makes Qi descend. Shock scatters Qi.

In Figure 10.28, the solid arrows indicate the physiological movement of Qi, while the dotted lines indicate the pathological movement of Qi induced by emotional stress. The Simple Questions in Chapter 39 says: “Anger makes Qi rise, joy slows down Qi, sadness dissolves Qi, fear makes Qi descend ... shock scatters Qi ... pensiveness knots Qi.”36 However, the above are not the only terms used in the Yellow Emperor’s Classic to describe the effect of the emotions. Dr Chen Yan in A Treatise on the Three Categories of Causes of Diseases (1174) says: “Joy scatters, anger arouses, worry makes Qi unsmooth, pensiveness knots, sadness makes Qi tight, fear sinks, shock moves.”37 The effect of each emotion on Qi should not be interpreted too restrictively as, in certain cases, emotional pressure may have a different effect on Qi from the one outlined above. For example, fear is said to make Qi descend and it may cause enuresis, incontinence of EMOTIONS Ascending of Qi

Exiting of Qi

QI MECHANISM

EMOTIONS

Entering of Qi EMOTIONS

Descending of Qi EMOTIONS Figure 10.28 Effect of emotions on Qi Mechanism.

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urine or diarrhoea, because the Kidneys control the two lower orifices (urethra and anus). This is certainly true in cases of extreme and sudden fear, which may cause incontinence of urine or diarrhoea, or in the case of children when anxiety about a certain family situation may cause enuresis. However, the effect of fear on Qi depends also on the state of the Heart. If the Heart is strong, it will cause Qi to descend, but if the Heart is weak it will cause Qi to rise in the form of Empty Heat. This is more common in old people and in women. In such cases, fear and anxiety may weaken Kidney-Yin and give rise to Empty Heat of the Heart with such symptoms as palpitations, insomnia, night sweating, a dry mouth, red face and a Rapid pulse. CLINICAL NOTE The effect of each emotion on the direction of flow of Qi should not be interpreted too rigidly, as occasionally an emotion may have an effect on Qi that is different than the “normal” one. For example, fear may make Qi rise.

Effects of emotions on Internal Organs As indicated above, each emotion affects one or more organs as follows. • Anger (including frustration and resentment) affects the Liver. • Joy affects the Heart. • Worry affects the Lungs and Spleen. • Pensiveness affects the Spleen. • Sadness and grief affect the Lungs and Heart. • Fear affects the Kidneys. • Shock affects the Kidneys and Heart. • Love affects the Heart. • Craving affects the Heart. • Guilt affects the Kidneys and Heart. • Shame affects the Heart and Spleen. However, the effect of each emotion on a relevant organ should not be interpreted too restrictively. There are passages from the Yellow Emperor’s Classic that attribute the effect of emotions to organs other than the ones just mentioned. For example, the Spiritual Axis in Chapter 28 says: “Worry and pensiveness agitate the Heart.”38 The Simple Questions in Chapter 39 says: “Sadness agitates the Heart.”39

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CLINICAL NOTE The effect of each emotion on a relevant organ should not be interpreted too restrictively. For example, sadness (usually affecting the Lungs) may affect Liver-Blood and worry (usually affecting the Lungs) may cause Liver-Yang rising, etc.

Indeed, the whole Chapter 216 of the Classic of Categories (Lei Jing, 1624) is dedicated to the discussion of the influence of each emotion on groups of organs. The Classic of Categories says:40 The five emotions interact with each other in causing disease; for example, excess joy affects the Heart but it may also affect the Lungs and injure the Corporeal Soul [Po]. Excess joy derives from the Heart but moves to the Lungs. Anger affects the Liver but also the Gall Bladder; Liver and Gall Bladder are interiorly–exteriorly related, and when Liver-Qi is excessive it affects the Gall Bladder. [When there is anger] Blood rushes upwards and Qi downwards, and this harasses the Heart. Sometimes anger affects the Kidneys and it injures the Will-Power. Hence anger can affect the Liver, Gall Bladder, Heart and Kidneys. Pensiveness pertains to the Spleen but it also affects the Heart. The Heart is the Mother of the Spleen; when the Qi of the Mother does not move freely, it affects the Child and therefore both Spleen and Heart are affected by pensiveness. Worry pertains to the Lungs but it also affects the Heart. Worry makes Qi rise and can affect the Liver; the Liver becomes overactive and it invades the Spleen. The Spleen is then affected by worry, and this injures the Intellect [Yi]. Hence worry affects the Lungs, Heart, Liver and Spleen. Thus, excess joy, anger, pensiveness and worry affect the following organs. • • • • •

Excess joy: Heart and Lungs. Anger: Liver, Gall Bladder, Heart and Kidneys. Pensiveness: Spleen and Heart. Worry: Lungs, Heart, Liver and Spleen. Fear: Kidneys, Heart, Liver, Spleen and Stomach. CLINICAL NOTE Multiple organs affected by emotions  Excess joy: Heart and Lungs.  Anger: Liver, Gall Bladder, Heart and Kidneys.  Pensiveness: Spleen and Heart.  Worry: Lungs, Heart, Liver and Spleen.  Fear: Kidneys, Heart, Liver, Spleen and Stomach.

The effect of an emotion on an organ depends also on other circumstances and on whether the emotion is manifested or repressed. For example, anger that is expressed affects the Liver (causing Liver-Yang rising), but anger that is repressed also affects the Heart. If one gets angry at mealtimes (as sadly often happens in certain families), the anger will affect the Stomach and this will be manifested with a Wiry quality on the right Middle position of the pulse. The effect of an emotion will also depend on the constitutional trait of a person. For example, if a person has a tendency to a constitutional weakness of the Heart (manifested with a midline crack on the tongue extending all the way to the tip), fear will affect the Heart rather than the Kidneys. Furthermore, all emotions, besides affecting the relevant organ directly, affect the Heart indirectly because the Heart houses the Mind. It alone, being responsible for consciousness and cognition, can recognize and feel the effect of emotional tension. Fei Bo Xiong (1800–79) put it very clearly when he said:41 The seven emotions injure the five Yin organs selectively, but they all affect the Heart. Joy injures the Heart ... Anger injures the Liver; the Liver cannot recognize anger, but the Heart can, hence it affects both Liver and Heart. Worry injures the Lungs; the Lungs cannot recognize it, but the Heart can, hence it affects both Lungs and Heart. Pensiveness injures the Spleen; the Spleen cannot recognize, it but the Heart can, hence it affects both Spleen and Heart. Yu Chang in Principles of Medical Practice (1658) says:42 Worry agitates the Heart and has repercussions on the Lungs; pensiveness agitates the Heart and has repercussions on the Spleen; anger agitates the Heart and has repercussions on the Liver; fear agitates the Heart and has repercussions on the Kidneys. Therefore all the five emotions [including joy] affect the Heart. Chapter 28 of the Spiritual Axis also says that all emotions affect the Heart:43 The Heart is the Master of the five Yin and six Yang organs ... sadness, shock and worry agitate the Heart; when the Heart is agitated, the five Yin and six Yang organs are shaken. Chinese writing clearly bears out the idea that all emotions affect the Heart, because the characters for all seven emotions are based on the “heart” radical.

The Emotions

This is probably the most important aspect of the Heart functions and the main reason for it being compared to the “monarch”. The way that all emotions afflict the Heart also explains why a red tip of the tongue, indicating HeartHeat, is so commonly seen even in emotional problems related to other organs. The main effects of emotional stress are Qi stagnation, Blood stasis, Heat or Fire and Dampness or Phlegm; these are discussed below.

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Tongue: slightly Pale-Purple on the sides in the chest area. Pulse: Empty but very slightly Overflowing on the left Front position.

Acupuncture Points HE-5 Tongli, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong, L.I.-4 Hegu.

Herbal therapy

QI STAGNATION The first effect of emotional stress on the body is to affect the proper circulation and direction of Qi. Qi is non-substantial, and the Mind, with its mental and emotional energies, is the most non-material type of Qi. It is therefore natural that emotional stress affecting the Mind impairs the circulation of Qi and disrupts the Qi Mechanism first of all. Although each emotion has a particular effect on Qi (e.g. anger makes it rise, sadness depletes it), all emotions have a tendency to cause some stagnation of Qi after some time (Fig. 10.29). Even the emotions that deplete Qi, such as sadness, may cause some Qi stagnation, because if Qi is deficient it cannot circulate properly and it therefore may tend to stagnate. For example, sadness depletes Lung-Qi in the chest; the deficient Qi in the chest fails to circulate properly and it causes some stagnation of Qi in the chest. The patterns of Heart-Qi and Lung-Qi stagnation are not often mentioned, but they are very common in mental-emotional problems and, for this reason, they are reported below.

Heart-Qi stagnation Clinical manifestations Palpitations, a feeling of distension or oppression of the chest, depression, a slight feeling of lump in the throat, slight shortness of breath, sighing, poor appetite, chest and upper epigastric distension, dislike of lying down, weak and cold limbs, slightly purple lips, pale complexion.

Prescriptions MU XIANG LIU QI YIN Aucklandia Flowing Qi Decoction BAN XIA HOU PO TANG Pinellia-Magnolia Decoction Three Treasures remedy Open the Heart

Lung-Qi stagnation Clinical manifestations A feeling of a lump in the throat, difficulty swallowing, a feeling of oppression or distension of the chest, slight breathlessness, sighing, sadness, slight anxiety, depression. Tongue: slightly Red on the sides in the chest areas. Pulse: very slightly Tight on the right Front position.

Acupuncture Points LU-7 Lieque, ST-40 Fenglong, Ren-15 Jiuwei, P-6 Neiguan.

Herbal therapy Prescription BAN XIA HOU PO TANG Pinella-Magnolia Decoction Three Treasures remedy Open the Heart

Rising Emotion

Qi

Descending Knotting Dissolving

Figure 10.29 Qi stagnation from emotional stress.

Qi stagnation

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The Practice of Chinese Medicine When compressed, Qi generates heat

Heat

Qi stagnation EMOTION

Fire Heat condenses fluids

Yin deficiency

Phlegm Qi deficiency

Fire dries up Yin

Phlegm and Blood stasis aggravate each other Blood stasis

Yin Xu leads to Empty Heat Empty Heat

Figure 10.30 Summary of effect of emotions on Qi and Blood.

Blood stasis

Dampness or Phlegm

When Qi stagnates, it may, in time, lead to Blood stasis, especially in women. Blood stasis particularly affects the Heart, Liver and Uterus. Anger and guilt are particularly prone to lead to Blood stasis after Qi stagnation. However, other emotions, such as sadness, grief and worry, may also lead to Blood stasis in the chest after a period of Qi stagnation. In women in particular, Qi stagnation in the breasts from sadness and grief may lead to Blood stasis and to breast lumps.

Finally, the disruption of Qi in the Qi Mechanism caused by the emotions may, in time, also lead to the formation of Phlegm. As the proper movement of Qi in the Qi Mechanism is essential to transform, transport and excrete fluids, disruption in the movement of Qi may result in the formation of Dampness or Phlegm. Phlegm, in turn, obstructs the Mind’s orifices and

Heat or Fire Qi stagnation may also lead to Heat, and most of the emotions can, over a long period of time, give rise to Heat or Fire. There is a saying in Chinese Medicine: “The five emotions can turn into Fire”. This is because most of the emotions can cause stagnation of Qi, and when Qi is compressed in this way over a period of time it creates Heat, just as the temperature of a gas increases when its pressure is increased. For this reason, when someone has suffered from emotional problems for a long time there are often signs of Heat, which may be in the Liver, Heart, Lungs or Kidneys (in the case of this last organ, Empty Heat). This often shows on the tongue, which becomes red or dark red and dry and usually has a red tip. A red tip of the tongue is a very common sign in practice, which is always a reliable indicator that the patient is subject to some emotional stress. With time, Heat may turn into Fire, which is more intense, more drying and affects the Mind more. Therefore, emotional stress may, in time, cause Fire, and this, in turn, harasses the Mind, causing agitation and anxiety.

CLINICAL NOTE Five points to remember  Do not interpret the relationship between an organ and an emotion too rigidly (e.g. sadness may affect the Liver).  Do not interpret the relationship between an emotion and its effect on Qi too rigidly (e.g. fear may make Qi ascend).  All emotions affect the Heart.  Other organs besides the Liver suffer from Qi stagnation from emotional stress (e.g. Heart and Lungs).  Qi stagnation does not derive only from anger but may also derive from sadness, grief, worry, pensiveness, guilt and shame – in fact, from any emotion.

SUMMARY THE EFFECT OF EMOTIONS ON THE BODY’S QI  Emotions disrupt the proper direction of movement of Qi (e.g. anger makes Qi rise, fear makes Qi descend).

The Emotions

 Each emotion affects a given organ (e.g. anger affects the Liver, fear affects the Kidneys).  All emotions affect the Heart.  After disrupting the proper direction of flow of Qi, all emotions lead to some Qi stagnation.  In emotional problems, Qi stagnation affects not only the Liver but other organs too (especially Lungs and Heart).  Other consequences of the disruption of the Qi Mechanism from emotional stress are Blood stasis, Heat, Dampness and Phlegm.

becomes a further cause of emotional and mental disturbance. Figure 10.30 summarizes the effect of emotions on Qi and Blood.

The pathology of the Minister Fire in emotional problems The Minister Fire refers to the physiological Fire of the Kidneys. The Minister Fire is the motive force of all functional activities of the body, being the physiological Fire that is essential to life. The Minister Fire should be “concealed” in its resting place in the Lower Burner. In other words, it carries on its function of heating the body but without the creation of visible Heat signs and symptoms. The importance of the Fire nature of the Minister Fire is that it provides heat for all our bodily functions and for the Kidney-Essence itself. The Kidneys are unlike any other organ in that they are the origin of Water and Fire of the body, the Primary Yin and Primary Yang (Fig. 10.31). The Minister Fire is the embodiment of the Fire within the Kidneys, and it is

LEFT KIDNEY

RIGHT KIDNEY

Fire of Ming Men Minister Fire Water Figure 10.31 The Minister Fire and the Kidneys.

Water

303

KIDNEY ESSENCE

Ming Men True Fire Minister Men

KIDNEY ESSENCE

YUAN YIN original Yin

YUAN YANG original Yang

YUAN YIN original Yin

Figure 10.32 The Minister Fire and the Kidney-Essence.

a special type of Fire in that not only does it not extinguish Water but it can actually produce Water. The Minister Fire of the Kidneys complements the Yin quality of the Kidney-Essence (Fig. 10.32). This “Minister Fire” is quite different from the “Minister Fire” of the Pericardium, and these differences will be explored below. In this respect, the theory of the Minister Fire is at variance with the Five-Element theory, according to which the “Minister Fire” is the Triple Burner and Pericardium. CLINICAL NOTE The Minister Fire is the physiological Fire of the Kidneys that provides the heat necessary to all physiological processes of the body. It should be “concealed” in the Lower Burner, carrying on its heating function without manifesting itself. Although the point Du-4 Mingmen is specific to tonify the Fire of the Gate of Life and the Minister Fire (as its name implies), I personally prefer to use the point Ren-4 Guanyuan.

The main functions of the Minister Fire are as follows. • It is the Root of the Original Qi (Yuan Qi). • It is the Source of (physiological) Fire for all the Internal Organs. • It warms the Lower Burner and Bladder. • It warms the Stomach and Spleen to aid digestion. • It harmonizes the sexual function and warms the Essence and Uterus. • It assists the Kidney function of reception of Qi. • It assists the Heart function of housing the Mind. In the context of mental-emotional problems, the importance of the Minister Fire is that this is frequently and easily “stirred” by emotional stress, with the creation of Heat and an upward movement of Qi that goes up to disturb the Heart and Pericardium. As we

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have seen in emotional stress, Heat is frequently the result of Qi stagnation; however, in my experience it may also arise independently without a preceding Qi stagnation. CLINICAL NOTE In mental-emotional problems, the Minister Fire is frequently and easily “stirred” by emotional stress, with the creation of Heat and an upward movement of Qi, which goes up to disturb the Heart and Pericardium. To subdue the rising Minister Fire in emotional problems, one must use Heart and Pericardium points such as HE-5 Tongli and P-7 Daling. In addition, tonifying the physiological Minister Fire with points such as Ren-4 Guanyuan will also help to bring the Minister Fire back into its place of “concealment” and therefore to calm the Mind.

When Heat is formed under the influence of emotional stress, the Minister Fire becomes pathological; it is “stirred” out of its residence in the Lower Burner and it flows upwards to the Heart and Pericardium (Fig. 10.33). Some Chinese books actually say that the physiological Minister Fire should be “hidden” in the Lower Dan Tian and it should not be seen. When there is Heat, the Minister Fire is seen.

HEAT HEART

When the Minister Fire is stirred into a pathological state under the influence of emotional stress, three patterns of Heat may appear: 1. Full Heat 2. Empty Heat (from Yin deficiency) 3. Yin Fire.

Full Heat Full Heat as a result of emotional stress derives usually from long-term Qi stagnation; when Qi stagnates for some time, it may give rise to Heat. However, in emotional stress, Heat may also be formed independently; this may happen, for example, with anger, joy, love or craving. The main manifestation of Full Heat is the tongue; this is Red and with a yellow coating. If the tongue body is Red and there is a coating with root, there is Full Heat (even if the coating is not yellow). The other important manifestation is the pulse: in Full Heat, the pulse is Full in general (which may include Wiry, Overflowing, Big or Firm). It should also be Rapid, but it frequently is not. Other clinical manifestations include feeling of heat, thirst, dry mouth, insomnia, agitation, mental restlessness and red face. Full Heat of any organ may overstimulate the coming and going of the Ethereal Soul, and it may therefore lead to “manic” behaviour, agitation, mental restlessness, insomnia, hyperactivity, and anxiety.

SUMMARY FULL HEAT FROM EMOTIONAL PROBLEMS

PERICARDIUM

Feeling of heat, thirst, dry mouth, insomnia, agitation, mental restlessness, red face, “manic” behaviour, hyperactivity, anxiety, Red tongue with red tip and a yellow coating, Overflowing-Rapid pulse.

Pathological Minister Fire rises

Empty Heat EMOTIONS

LEFT KIDNEY

RIGHT KIDNEY MINISTER FIRE

Figure 10.33 Pathological Minister Fire.

Empty Heat derives from Yin deficiency. It is important to note that, although Empty Heat derives from Yin deficiency eventually, Yin deficiency may occur for many years without Empty Heat. Empty Heat is seen in emotional stress when this is combined with overwork that leads to Yin deficiency. It is a relatively common situation in Western patients. The combination of overwork with emotional stress

The Emotions

leads to Yin deficiency and Empty Heat. Thus, in such cases, the Empty Heat does derive from Yin deficiency, but it is aggravated by the emotional stress, which in itself leads to Heat. Most of all, the emotional stress causes the Empty Heat to rise more, causing agitation, red face and thirst. In Empty Heat, the tongue is Red but either without a coating (totally or partially) or with a rootless coating. Thus, in Full Heat the tongue is Red with a coating; in Empty Heat, it is Red without a coating. In Empty Heat, the pulse is Floating-Empty and Rapid. Other clinical manifestations include feeling of heat in the evening, dry mouth with desire to drink in small sips, malar flush, mental restlessness and insomnia. As Full Heat does, Empty Heat of any organ may also overstimulate the coming and going of the Ethereal Soul, and it may therefore lead to “manic” behaviour, a vague mental restlessness, insomnia, fidgetiness and anxiety. The mental restlessness from Empty Heat manifests differently to that from Full Heat. In Empty Heat, the patient has a vague feeling of anxiety and restlessness that also manifests more in the evening.

SUMMARY EMPTY HEAT FROM EMOTIONAL PROBLEMS Feeling of heat in the evening, dry mouth with desire to drink in small sips, malar flush, insomnia, “manic” behaviour, a vague mental restlessness, fidgetiness, anxiety, Red tongue without coating (or partially without coating), red tip, Floating-Empty and Rapid pulse.

Yin Fire The concept of Yin Fire was introduced by Li Dong Yuan in his book Discussion of Stomach and Spleen (Pi Wei Lun, 1246). Dr Li says that, as a result of improper diet and overwork, the Original Qi (Yuan Qi) becomes weak in the Lower Burner. This causes the patient to feel tired and often cold. When the patient is also subject to emotional stress, the Minister Fire is stirred, it becomes pathological and it leaves its place of “concealment” in the Lower Dan Tian. Moreover, as the Minister Fire and the Original Qi reside in the same place in the Lower Dan Tian, the pathological Minister Fire displaces and weakens the Original Qi even more (Fig. 10.34). Dr Li said that the pathological Minister Fire becomes a “thief ” of the

Pathological Minister Fire harasses Heart and Pericardium

305

Anxiety, depression, feeling of heat on face, red cheeks

Yuan Qi

displaces

MINISTER FIRE

Deficiency of Stomach and Spleen: exhaustion, feeling cold, cold feet. Figure 10.34 Pathology of Yin Fire.

Original Qi. The arousal of the pathological Minister Fire upwards causes some Heat symptoms in the upper part of the body, such as a red face and mouth ulcers. This he called “Yin Fire”; Yin Fire is neither Full Heat nor Empty Heat but simply a different kind of Heat that derives from a deficiency of the Original Qi. It follows that Yin Fire is not treated by clearing Heat or draining Fire but by tonifying the Original Qi and gently clearing Heat upwards. The pathology of Yin Fire is further complicated by Dampness and by a pathology of the Middle Burner as well (Fig. 10.35). When the Spleen is deficient, Dampness is formed and this infuses down to the Lower Burner. Here it “swamps” the Original Qi and the Minister Fire, displacing the latter from the place (the Lower Burner) where it should be “concealed”. The Middle Burner has Dampness too; Spleen-Qi (or even Spleen-Yang) is deficient and fails to rise. For this reason, Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction is used to raise Spleen-Qi and warm Spleen-Yang so that Dampness no longer infuses downwards to the Lower Burner. When the Lower Burner is opened and unblocked from Dampness, the Minister Fire will return to its place of concealment in the Lower Burner, thus eliminating the symptoms of Yin Fire. Bu Zhong Yi Qi Tang eliminates Yin Fire by tonifying the Original Qi with Ren Shen Radix Ginseng and by lightly clearing Heat upwards with Chai Hu Radix Bupleuri and Sheng Ma Rhizoma Cimicifugae.

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Upper Burner

YIN Fire

Feeling of heat, thirst, red face, red tip of tongue

Fails to ascend Emotional stress

Middle Burner

SP-QI Dampness infuses down

Lower Burner

Dampness Displaces Minister Fire from place of concealment

Minister Fire

Spontaneous sweating, tiredness, shortness of breath, pale tongue, weak pulse

Figure 10.35 Pathology of Yin Fire and Dampness.

Any emotion can lead to Yin Fire, as all emotions may stir the Minister Fire out of its residing place in the Lower Dan Tian. All emotions lead to Qi stagnation, which, in turn, eventually leads to some Heat. The situation can be aggravated by the presence of Dampness in the Lower Burner (as happens in shame). This accounts for symptoms of Heat in mentalemotional problems that may defy a classification into Full- or Empty Heat; this happens when there are symptoms of Heat above (red face, thirst, feeling of heat in the face) and Cold below (cold feet, general cold feeling); such situation is due to Yin Fire. Emotional stress is more likely to lead to Yin Fire when it is combined with overwork and dietary irregularity. The acupuncture treatment of emotional stress manifesting with Yin Fire should be based on the following steps. • Tonify the Original Qi: Ren-4 Guanyuan. • Lift Qi: Du-20 Baihui, Ren-6 Qihai. • Clear Heat in the upper part of the body: P-8 Laogong, P-7 Daling, L.I.-4 Hegu, LU-7 Lieque, Ren-15 Jiuwei. • Calm the Mind: Du-24 Shenting, Du-19 Houding, HE-5 Tongli.

SUMMARY YIN FIRE FROM EMOTIONAL PROBLEMS Red face, thirst, feeling of heat in the face, depression, anxiety, general tiredness, cold feet, general cold feeling, red tip of the tongue but Pale tongue, Weak pulse.

• Regulate the Triple Burner: T.B.-6 Zhigou, T.B.-5 Waiguan.

The Pericardium in mental-emotional problems In the context of mental-emotional problems, it is important to explore the nature of the Pericardium, how it relates to “Minister Fire”, and what connection (if any) there is between this “Minister Fire”, in a FiveElement context and the Minister Fire of the Kidneys. The Simple Questions in Chapter 8 says: “The Pericardium is the ambassador, and from it joy and happiness derive.”44 Like the Heart, the Pericardium houses the Mind, and it therefore influences our mental-emotional state deeply. For example, a deficiency of Blood will affect the Pericardium as well as the Heart, making the person depressed and slightly anxious. Heat in the Blood will agitate the Pericardium and make the person agitated and restless. Phlegm obstructing the Pericardium will also obstruct the Mind, causing mental confusion. The Pericardium’s function on the mental-emotional plane could be seen as the psychic equivalent of its physical function of moving Qi and Blood in the chest; just as it does that on a physical level, on a mental-emotional level the Pericardium is responsible for “movement” towards others, i.e. in relationships (Fig. 10.36). Given that the Pericardium is related to the Liver within the Terminal Yin channels, this “movement” is also related to the “movement” of the Ethereal Soul from the ego towards others in social relationships and familial interactions. For this reason, on a mentalemotional level the Pericardium is particularly

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Minister Fire (with Triple Burner)

Pericardium moves Qi of Heart and Lungs in chest

Physical level

PERICARDIUM

Mental-emotional level Ren-17 Shanzhong (relationships)

Ren-15 Jiuwei Ren-14 Juque

Figure 10.36 The moving action of the Pericardium.

responsible for a healthy interaction with other people in social, love and family relationships. The unique place that the Pericardium occupies in the pathology and treatment of mental-emotional problems is partly due to its partaking of Fire (as it is the “Minister” Fire that assists the Emperor Fire of the Heart) and of Wood (with the Liver within the Terminal Yin). Partaking of Wood and the Ethereal Soul, it gives the Mind “movement” towards others, i.e. it plays an important role in relationships. On a physical level, the Pericardium moves Qi and Blood in the chest. See Figure 10.37. Moreover, the “moving” nature of the Pericardium is also enhanced by its relationship with the Triple Burner as a channel (within the “Minister Fire” channels). As the Triple Burner is responsible for the free flow of Qi

HEART (Emperor Fire)

PERICARDIUM (Minister Fire)

Terminal Yin

LIVER (Wood) Ethereal Soul Figure 10.37 The Fire and Wood nature of the Pericardium.

Minister Fire (Kidneys)

Figure 10.38 Relationship of Pericardium with Heart and Triple Burner.

(together with the Liver), the Pericardium’s relationship with the Triple Burner accounts for its action in moving Qi and Blood and its mental-emotional function of “movement” towards others. See Figure 10.38. The Pericardium houses the Mind (with the Heart), and its pathology includes the following. • Blood deficiency of the Pericardium will cause depression and slight anxiety. • Blood-Heat of the Pericardium will cause anxiety, insomnia and agitation. • Phlegm in the Pericardium will cause mental confusion and, in severe cases, mental illness. • The Pericardium affects emotional problems from relationship problems. The “Minister Fire” is the Fire of the Gate of Life (Ming Men). As we have seen above, this Fire is essential to the healthy functioning of the body. Although many doctors, such as Zhu Zhen Heng (1281–1358) identified “Minister Fire” with the Fire of the Gate of Life (Ming Men) (and therefore the Kidneys), others, such as Zhang Jie Bin (1563–1640), identified the “Minister Fire” with such internal organs as the Kidney, Liver, Triple Burner, Gall Bladder and Pericardium. Thus, purely from a Five-Element perspective, the Pericardium pertains to the Minister Fire (with the Triple Burner) compared to the Emperor Fire of the Heart, while from the perspective of the Internal Organs the Minister Fire is the Fire of the Gate of Life (Ming Men) pertaining to the Kidneys.

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However, there is a connection between the two views, as the Minister Fire of the Kidneys does flow up to the Liver, Gall Bladder and Pericardium. In pathology, this has an even greater relevance, as the pathological Minister Fire of the Kidneys (driven by emotional stress) flares upwards to harass the Pericardium, causing mental restlessness, agitation, anxiety and insomnia. Indeed, the Minister Fire and the Original Qi are said to emerge from between the Kidneys through the “intermediary” of the Triple Burner (Fig. 10.39). It is not by chance that the Back-Transporting point of the Triple Burner is on the back at BL-22 Sanjiaoshu, one vertebral space above the Back-Transporting point of the Kidneys BL-23 Shenshu and the point Du-4 Mingmen; indeed, it reflects the fact that the Minister Fire emerges from the space between the Kidneys through the Triple Burner. In fact, the Minister Fire of the Kidneys is said to go upwards to the Liver, Gall Bladder and Pericardium (Fig. 10.40). The Minister Fire going up is compared to the “Fire Dragon flying to the top of a high mountain”, and that going down to the Kidneys is compared to the “Fire Dragon immersing in the deep sea” (Fig. 10.41). The fact that the Minister Fire of the Kidneys flows up to the Pericardium could explain the assignment of this organ to “Minister Fire” in the Five-Element relationships.

Internal Organs

Triple Burner

Du-4 Mingmen

BL-22 Sanjiaoshu BL-23 Shenshu

Original Qi Minister Fire Figure 10.39 Minister Fire and Original Qi emerging through the Triple Burner.

LIVER

GALL BLADDER

PERICARDIUM

Flares up

SUMMARY PERICARDIUM AND KIDNEY MINISTER FIRE  The Pericardium pertains to the Minister Fire together with the Triple Burner (in terms of channels).  The Pericardium pertains to the Minister Fire together with the Kidneys, as Minister Fire originates there.  The Minister Fire flares upwards to Liver, Gall Bladder and Pericardium and flows downwards to the Kidneys.  From a Five-Element perspective, the Pericardium pertains to the Minister Fire channels with the Triple Burner.  From an organ perspective, the Minister Fire originates from the Kidneys.  In emotional problems, the pathological Minister Fire flares upwards to harass the Pericardium.

MINISTER FIRE Flows down

KIDNEYS Figure 10.40 Relationship between Minister Fire of the Kidneys and the Pericardium.

Many Pericardium channel points have a deep influence on the mental state and are frequently used in mental-emotional problems. In particular, the Pericardium influences a person’s relations with other people, and the points on its channel are often used to treat emotional problems caused by relationship difficulties (e.g. P-7 Daling).

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Liver, Gall Bladder, Pericardium

Minister Fire

Fire Dragon flying to the top of a high mountain

Kidneys

Fire Dragon immersing in the deep sea

Figure 10.41 Minister Fire flowing up to Liver, Gall Bladder and Pericardium and down to Kidneys.

CLINICAL NOTE Action of Pericardium points  P-6 Neiguan stimulates the coming and going of the Ethereal Soul, lifts mood and treats depression.  P-7 Daling restrains the coming and going of the Ethereal Soul, settles the Ethereal Soul, calms the Mind and settles anxiety.  P-5 Jianshi resolves Phlegm from the Pericardium to treat mental confusion.

It could be said that the protective function of the Pericardium in relation to the Heart so often mentioned is reflected primarily in the mental-emotional sphere, where the “Minister Fire” of the Pericardium protects the “Emperor Fire” of the Heart. The clinical use of the point P-6 Neiguan should be explored further. P-6 Neiguan has a synergistic effect on acupuncture point prescriptions. The addition of P-6 to any prescription increases the therapeutic effect. Just as P-6 has this effect on a physical level, it has one on a mental-emotional level, i.e. it can bolster the effect of a point combination for mental-emotional problems. This effect of P-6 is due to various factors. First, it affects the Mind, but how does its effect on the Mind differ from that of the Heart? The Heart is more Yin; it governs Blood, which houses the Mind. The Pericardium is more Yang; it is the external covering of the Heart and it therefore controls movement of Qi on a mental-emotional level. This effect on Qi is due also to its relationship with the Liver within the Terminal Yin (Jue Yin).

Second, the Pericardium channel, being paired with the Liver channel within the Terminal Yin channels, affects the coming and going of the Ethereal Soul; in particular, P-6 can stimulate the coming and going of the Ethereal Soul and therefore treat depression. Third, the mental-emotional “moving” effect of P-6 is due also to its being the Connecting (Luo) point of the Pericardium channel. As Connecting point, it affects the Triple Burner; it can therefore move Qi of the Triple Burner in all three Burners, and this also has a mentalemotional effect. Fourth, the Pericardium pertains to the Terminal Yin, which is the “hinge” of the Yin channels (between the Greater Yin and Lesser Yin). Being the Connecting point and therefore the hinge between Yin and Yang, P-6 is the “hinge” of the Hinge; in its capacity as a “hinge”, it connects things. On a mental-emotional level, that means that it regulates our capacity for relationships. Its function of a “hinge” is also related to its being the opening point of the Yin Linking Vessel (Yin Wei Mai), which links all the Yin channels. CLINICAL NOTE P-6 Neiguan  It has a synergistic effect on acupuncture point prescriptions. The addition of P-6 to any prescription increases the therapeutic effect.  On a mental-emotional level, P-6 it can bolster the effect of a point combination for mentalemotional problems.  It moves Qi on an emotional level.  It stimulates the coming and going of the Ethereal Soul and therefore treats depression.  It regulates our capacity for relationships.

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END NOTES 1. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 24. First published c.100 BC. 2. Ibid., p. 24. 3. Ibid., p. 24. 4. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, pp. 150–151. First published c.100 BC. 5. Ibid., p. 339. 6. Spiritual Axis, p. 24. 7. Simple Questions, p. 222. 8. Ibid., p. 151. 9. Spiritual Axis, p. 24. 10. Ibid., p. 11. 11. Simple Questions, p. 337. 12. Ibid., pp. 124–125. 13. Ibid., p. 150. 14. Spiritual Axis, p. 23. 15. Simple Questions, p. 37. 16. 1982 Lei Jing [Classic of Categories]. People’s Health Publishing House, Beijing, p. 424. The Classic of Categories was written by Zhang Jie Bin (also called Zhang Jing Yue) and first published in 1624. 17. Spiritual Axis, p. 23. 18. Simple Questions, p. 221. 19. Ibid., p. 17. 20. Ibid., p. 221. 21. Ibid., p. 38. 22. Zhang Yuan Kai 1985 Meng He Si Jia Yi Ti [Meng He Medical Collection of Four Doctors]. Jiangsu Province Scientific Publishing House, Nanjing, p. 40.

23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37.

38. 39. 40. 41. 42. 43. 44.

Spiritual Axis, p. 24. Ibid., p. 24. Simple Questions, p. 222. Ibid., p. 221. Spiritual Axis, p. 24. Personal communication from Dr John Shen, London, 1982. Simple Questions, p. 222. Spiritual Axis, p. 24. Simple Questions, p. 222. International Bible Society 1984 Holy Bible, New International Version. Online. Available: http://www.biblegateway.com Ibid. Ibid. Ibid. Simple Questions, p. 221. Chen Yan 1174 San Yin Ji Yi Bing Zheng Fang Lun [A Treatise on the Three Categories of Causes of Diseases], cited in Wang Ke Qin 1988 Zhong Yi Shen Zhu Xue Shuo [Theory of the Mind in Chinese Medicine]. Ancient Chinese Medical Texts Publishing House, Beijing, p. 55. Spiritual Axis, p. 67. Simple Questions, p. 221. Classic of Categories, p. 424. Medical Collection of Four Doctors, p. 40. Principles of Medical Practice, cited in Theory of the Mind in Chinese Medicine, p. 34. Spiritual Axis, p. 67. Simple Questions, p. 58.

CHAPTER 11

AETIOLOGY OF MENTALEMOTIONAL PROBLEMS CONSTITUTION 312 Wood type 312 Fire type 312 Earth type 314 Metal type 314 Water type 315 DIET 316 Excessive consumption of hot-energy foods 316 Excessive consumption of Damp-producing foods 317 Excessive consumption of cold-energy foods 317 Irregular eating habits 317 Insufficient eating 317 OVERWORK

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317

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319

AETIOLOGY OF MENTAL-EMOTIONAL PROBLEMS In this chapter, I shall discuss the aetiology of mentalemotional problems according to the following topics. • • • • • •

and the other aetiological factors (e.g. diet) are usually only contributory factors. Although I am discussing aetiological factors separately, in practice they are often combined. In order to formulate an idea of the aetiological factors involved, it is useful to divide a person’s life in stages. It is usually the overlap of different causative factors, each originating from different times in one’s life, that leads to the development of mental-emotional problems. It is useful to form an idea of the origin of mentalemotional problems in terms of time. To do this, one can divide a person’s life into three broad periods, each of which is characterized by its own specific aetiological factors.

Constitution Diet Overwork Excessive sexual activity Drugs Prevention of mental-emotional problems

Under aetiology, I shall discuss the aetiological factors of mental-emotional problems other than emotional stress, which was discussed in Chapter 10. Emotional stress is the main cause of mental-emotional problems,

1. The period in the womb: constitution. 2. Childhood, up until about 18: childhood patterns. 3. Adulthood: emotions, diet, overwork, sex, drugs. Broadly speaking, inherited traits obviously affect our life in the womb, juvenile development affects our childhood, and emotional problems, diet, sex and overwork affect our adulthood. Many of the emotional patterns adults fall into are often set during childhood. This may be due to very many different factors, such as relations with parents, lack of demonstrative affection from parents, relations with siblings, fighting between parents, emotional strain put on a child by a parent who pours out all his or her troubles to the child, a too strict and rigid upbringing, too many academic demands at school, a parental preference for one child over his or her siblings, pressure on a child to fulfil a parent’s failed dreams, or a child assuming almost the role of husband or wife after the death of the father or mother, respectively. Thus the three stages of life and their causative factors of mental-emotional problems can be summarized as shown in Table 11.1. There is of course an

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Table 11.1 The three periods of life Inherited or in womb

Childhood

Adult age

Weak nervous system

Childhood patterns

Emotions, diet, sex, overwork

interaction among these three periods of life and their respective causes of disease. For example, emotional problems during childhood may also interact with constitutional traits to cause disease later in life. For instance, if a girl has a constitutional imbalance in the Penetrating and Directing Vessels (Chong and Ren Mai) and she is subject to emotional strain at the time of puberty, this will often cause mental-emotional problems later in life. It is important to form an idea of the origin of the problem so that we can give the right advice to the patient. The aetiological factors discussed are: • • • • •

constitution diet overwork excessive sexual activity drugs.

the eyes slightly during sleep and sometimes develop fevers of unexplained origin. In such cases, the baby often has a bluish colour on the forehead. If not treated, this will have repercussions later in life and affects the Mind and Ethereal Soul. An inherited weak nervous system is often manifested with a Heart crack on the tongue (see Fig. 12.4). Such a crack indicates that the person has an inherited weakness of the Heart, which predisposes that person to the development of mental-emotional problems. However, this may never manifest unless other causative factors intervene later in life. Traditionally, five different constitutional body shapes are described, one for each Element. The FiveElement constitutional types are described below.

Wood type People of the Wood type have a subtle shade of green in their complexion, a relatively small head and longshaped face, broad shoulders, straight back, tall, sinewy body and elegant hands and feet. In terms of personality, they have developed intelligence but their physical strength is poor. They are hard workers, think things over and tend to worry. See Figure 11.1. From an emotional point of view, people of the Wood type are prone to worry, frustration and repressed anger. These are often the cause of Liver patterns such as Liver-Qi stagnation or Liver-Yang rising.

CONSTITUTION The constitutional make-up of an individual is an extremely important aetiological factor in mentalemotional problems. For example, I frequently see patients who are extremely anxious about the smallest things in life, and an investigation of their present emotional life and past history does not reveal any cause for this. When this happens, it is generally due to the constitutional make-up of the individual. “Constitutional” refers to an aetiological factor that is either inborn and inherited from the parents or developed in utero during pregnancy. In either case, the inherited state of the nervous system plays an important role in mental-emotional problems in later life. For example, a shock to the mother during pregnancy may affect the fetus and cause the newborn baby to sleep fitfully, cry during sleep, open and close

SUMMARY WOOD TYPE  Greenish complexion  Small head  Long face  Broad shoulders  Straight back  Sinewy body  Tall  Elegant hands and feet  Tendency to worry, frustration and anger

Fire type People of the Fire type have a red, florid complexion; wide teeth; a pointed, small head, possibly with a

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Figure 11.1 Wood type.

Figure 11.2 Fire type.

pointed chin; hair that is either curly or scanty; welldeveloped muscles of the shoulders, back, hips and head; and relatively small hands and feet. In terms of personality, they are keen thinkers. The Fire type is quick, energetic and active. They are shorttempered. They walk firmly and shake their body while

walking. They tend to think too much and often worry. They have a good spirit of observation, and they analyse things deeply. See Figure 11.2. From an emotional point of view, people of the Fire type are very energetic, they laugh a lot and they have a tendency to “manic” behaviour. However, at the

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opposite pole, people of the Fire type may be prone to depression and anxiety.

SUMMARY FIRE TYPE  Red complexion  Wide teeth  Pointed, small head  Well-developed shoulder muscles  Curly hair or not much hair  Small hands and feet  Walking briskly  Tendency to “manic” behaviour

Earth type People of the Earth type have a yellowish complexion, round-shaped face, relatively big head, wide jaws, well-developed and nice-looking shoulders and back, large abdomen, strong thigh and calf muscles, relatively small hands and feet, and well-built muscles of the whole body. They walk with firm steps without lifting their feet very high. The Earth type is calm and generous, has a steady character, likes to help people and is not overambitious. They are easy to get on with. See Figure 11.3. From an emotional point of view, people of the Earth type are generous and they like to help others. They give of themselves emotionally; at the opposite pole, they may be the complete contrary and be selfish. They may have a tendency to guilt and shame.

SUMMARY EARTH TYPE  Yellowish complexion  Round face  Wide jaws  Large head  Well-developed shoulders and back  Large abdomen  Large thighs and calf muscles  Well-built muscles  Emotionally giving

Figure 11.3 Earth type.

Metal type People of the Metal type have a relatively pale complexion, a square-shaped face, a relatively small head, small shoulders and upper back, a relatively flat

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SUMMARY METAL TYPE  Pale complexion  Square face  Small head  Small shoulders and upper back  Flat abdomen  Strong voice  Prone to worry, sadness and grief

Water type People of the Water type have a relatively dark complexion, wrinkles, a relatively large head, a round face and body, broad cheeks, narrow and small shoulders and a large abdomen. They keep their body in motion while walking and find it difficult to keep still. They have a long spine. The Water type is sympathetic and slightly laid back. They are good negotiators and loyal to their work colleagues. They are aware and sensitive. See Figure 11.5. From the emotional point of view, people of the Water type are very sensitive, have a high sex drive and a tendency to guilt.

SUMMARY WATER TYPE

Figure 11.4 Metal type.

abdomen, and small hands and feet. They have a strong voice, move swiftly and have keen powers of thought. They are honest and upright. They are generally quiet and calm in a solid way but also capable of decisive action when necessary. They have a natural aptitude for leadership and management. See Figure 11.4. From the emotional point of view, people of the Metal type are prone to worry, sadness and grief.

 Dark complexion  Wrinkly skin  Large head  Broad cheeks  Narrow shoulders  Large abdomen  Long spine  Tendency to guilt This typology can be used in diagnosis and prognosis. These portraits describe an archetype, but in reality, due to the way people live their lives and other factors, there can be considerable variations from the types. For example, although a Wood type typically has a tall and slender body, if there is a tendency to overeat he or she may obviously become fat and deviate from their type. The Five-Element constitutional body types are useful in practice because they explain inherent

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differences between people that might otherwise be taken as pathological. For example, the Fire type is active and energetic and he or she walks fast; if we did not know about the Fire type, we might interpret these characteristics as pathological (i.e. Excess of Yang). Deviations from the Element type are also significant. For example, to stay with the Fire Element type, if all the characteristics of the body shape point to someone being a Fire type but he or she walks slowly, it indicates a problem. This is useful as this discrepancy may herald a future problem. It should be borne in mind that a person may be a mixture of two or more types; one can have a mixed Earth-Wood type, for example. Treatment of the constitutional Element type is particularly useful in the case of mental-emotional problems. For example, a Wood type might display some typical emotional traits such as indecision and inability to plan one’s life; treatment of the Wood Element would help the person on a mental-emotional level, whatever other disharmony that person might suffer from.

DIET Diet plays a secondary role in contributing to mentalemotional problems. There are several aspects to “irregular eating” as described in Chinese books. The main ones that apply to Western patients are: • • • • •

excessive consumption of hot-energy foods excessive consumption of Damp-producing foods excessive consumption of cold-energy foods irregular eating habits insufficient eating.

Excessive consumption of hot-energy foods

Figure 11.5 Water type.

An excessive consumption of hot-energy foods (red meat, spices) and drinks (including and especially alcohol) leads to Heat and Fire, which may easily harass the Mind. It should be noted that tobacco also has a hot energy and, especially combined with alcohol, it contributes to forming Heat in the body. Heat or Fire harass the Mind and may therefore cause anxiety, agitation and insomnia. They also overstimulate the Ethereal Soul, leading to a slight “manic” behaviour.

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Moreover, Fire easily damages Yin and may therefore cause Yin deficiency, which in itself would aggravate anxiety, agitation and insomnia.

against a background of Yin deficiency, the feeling of anxiety would be aggravated by the Stomach-Yin deficiency.

Excessive consumption of Dampproducing foods

Insufficient eating

An excessive consumption of Damp-producing foods (dairy foods, greasy foods, animal fats, sugar) leads to the formation of Dampness or Phlegm. Both Dampness and Phlegm may obstruct the Mind but Phlegm more so. Both Dampness and Phlegm are “heavy” pathogenic factors. While on a physical level they cause a feeling of heaviness of the body, on a mental-emotional level, they also “weigh a person down” and aggravate feelings of depression. In my experience, shame often leads to Dampness. Dampness is a “dirty” pathogenic factor and just as on a physical level it causes turbid discharges, on a mental-emotional level shame makes the person feel “dirty” and unworthy. Phlegm has a more obstructive effect on the Mind, which, in extreme cases, is the cause of serious mental illness. However, it occurs in many degrees of severity and, in mild cases, Phlegm obstructing the Mind causes a certain mental confusion that may aggravate both feelings of depression or feelings of excessive elation. When Phlegm that obstructs the Mind combines with Heat, it leads to agitation, manic behaviour and insomnia. In such cases, the tongue would be Swollen with a Stomach-Heart crack with a sticky-yellow coating inside it (see Fig. 12.8).

Excessive consumption of coldenergy foods Excessive consumption of cold-energy foods (fruit, most vegetables, cold drinks) injures Yang and may lead to Yang deficiency of the Spleen and Kidneys. This would aggravate feelings of depression in patients suffering from depression occurring against a background of Kidney-Yang deficiency.

It may seem strange to include “insufficient eating” as a cause of disease in affluent Western societies. However, from a Chinese medical perspective insufficient nourishment may be caused by an injudicious vegetarian diet (especially in women) or by strict slimming diets. Insufficient eating causes Blood deficiency, and this would aggravate feelings of anxiety and insomnia occurring against a background of Blood deficiency.

OVERWORK By “overwork” I mean working long hours without adequate rest (often combined with irregular eating); intended in this sense, overwork depletes the Kidneys and especially Kidney-Yin. Overwork would therefore aggravate feelings of depression and/or anxiety occurring against a background of Kidney-Yin deficiency.

EXCESSIVE SEXUAL ACTIVITY Excessive sexual activity is a cause of disease more in men than in women. This is because sperm is a direct manifestation of Kidney-Essence, and in women there is no corresponding loss of Kidney-Essence during orgasm. It is difficult to define what is an “excessive” level of sexual activity, as that depends on the age and the physical condition of the man; however, sexual activity could be defined as “excessive” if the man feels very tired after it. Excessive sexual activity in men is a cause of Kidney deficiency, which may manifest with Yang or Yin deficiency depending on the constitution of the man. Such Kidney deficiency would aggravate feelings of depression, and Kidney-Yin deficiency would also aggravate feelings of anxiety.

Irregular eating habits “Irregular eating habits” includes eating late at night, skipping meals and eating on the run. All these habits tend to cause Stomach-Qi and/or Stomach-Yin deficiency. In persons suffering from anxiety occurring

DRUGS Drugs such as cannabis, cocaine, heroine, LSD and others deeply affect the Mind. Prolonged use of such

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drugs leads to mental confusion and lack of memory and concentration. In combination with other causes of disease, they definitely contribute to mentalemotional problems and cloud the Mind. Indeed, there is considerable and mounting evidence of the link between heavy cannabis use and the development of schizophrenia.1 Several studies have shown a correlation between cannabis use and a higher risk of developing schizophrenia. On an individual level, cannabis use confers an overall twofold increase in the relative risk for later schizophrenia. At the population level, elimination of cannabis use would reduce the incidence of schizophrenia by approximately 8%, assuming a causal relationship.2 The first evidence that cannabis use might predispose to later psychosis came from a study of Swedish conscripts who were observed using record linkage techniques based on in-patient admissions for psychiatric care. A dose–response relationship was observed between cannabis use at conscription (age 18 years) and schizophrenia diagnosis 15 years later. Self-reported “heavy cannabis users” (i.e. who had used cannabis more than 50 times) were six times more likely than non-users to have been diagnosed with schizophrenia 15 years later. The authors concluded that the findings are consistent with a causal relationship between cannabis use and schizophrenia.3 The Netherlands Mental Health Survey and Incidence Study examined the effect of cannabis use on self-reported psychotic symptoms among the general population. A total of 4045 psychosis-free individuals and 59 who had a psychotic disorder were assessed at baseline and were administered follow-up assessments 1 year later and again 3 years after the baseline assessment. Compared with non-users, individuals using cannabis at baseline were nearly three times more likely to manifest psychotic symptoms at follow-up. The highest risk (odds ratio 6.8) correlated with the highest level of cannabis use. Lifetime history of cannabis use at baseline, as opposed to use of cannabis at follow-up, was a stronger predictor of psychosis 3 years later. This suggests that the association between cannabis use and psychosis is not merely the result of short-term effects of cannabis use leading to an acute psychotic episode. The authors concluded that their study confirmed that cannabis use is an independent risk factor for the

emergence of psychosis in psychosis-free persons, and that those with an established vulnerability to psychotic disorders are particularly sensitive to its effects, resulting in a poor outcome.4 The Christchurch Health and Development Study (New Zealand) examined a general population birth cohort for more than 20 years. The association between cannabis dependence disorder and the presence of psychotic symptoms at ages 18 and 21 years was examined. Findings indicated concurrent associations between cannabis dependence disorder and risk of psychotic symptoms both at ages 18 and 21 years. Individuals who met the diagnostic criteria for cannabis dependence disorder at age 18 years had a 3.7-fold increased risk of psychotic symptoms compared with those without cannabis dependence problems. The risk of psychotic symptoms was 2.3 times higher for those with cannabis dependence disorder at age 21 years. The authors concluded that the findings are clearly consistent with the view that heavy cannabis use may make a causal contribution to the development of psychotic symptoms, because they show that, independently of pre-existing psychotic symptoms and a wide range of social and contextual factors, young people who develop cannabis dependence show an elevated rate of psychotic symptoms.5 An appreciable proportion of cannabis users report short-lived adverse effects, including psychotic states following heavy consumption, and regular users are at risk of dependence. People with major mental illnesses such as schizophrenia are especially vulnerable in that cannabis generally provokes relapse and aggravates existing symptoms. The untoward mental effects of cannabis include psychological responses such as panic, anxiety, depression or psychosis. There is good evidence that taking cannabis leads to acute adverse mental effects in a high proportion of regular users. Many of these effects are dose-related, but adverse symptoms may be aggravated by constitutional factors including youthfulness, personality attributes and vulnerability to serious mental illness.6 Studies on cocaine abusers in clinical settings report that more than half of such individuals experience paranoia and hallucinations.7 Among patients who attend psychiatric emergency services, non-schizophrenic cocaine abusers are reported to have as severe hallucinations as schizophrenic patients who do not abuse cocaine. Believing that their drug-using behaviour

Aetiology of Mental-Emotional Problems

is being watched and they are being followed, hallucinations, in keeping with these delusions, are typical of cocaine-induced psychosis. This is so typical that it may be used as an important tool to differentiate it from schizophrenia.8 Cocaine-induced psychosis shows sensitization, i.e. psychosis becomes more severe and occurs more rapidly with continued cocaine use.9 Interestingly, sensitization occurs only with psychosis and not with other effects of cocaine.10 Ecstasy (an amfetamine derivative) has become popular with participants in “raves” because it enhances energy, endurance, sociability and sexual arousal. Ecstasy has serious acute and chronic toxic effects that resemble those seen with other amfetamines and are caused by an excess of the same sympathomimetic actions for which the drugs are valued by the users. Neurotoxicity to the serotonergic system in the brain can also cause permanent physical and psychiatric problems. A review of the literature has revealed over 87 ecstasy-related fatalities caused by hyperpyrexia, rhabdomyolysis, intravascular coagulopathy, hepatic necrosis, cardiac arrhythmias, cerebrovascular accidents and drug-related accidents or suicide. Undesired psychological acute effects include: • hyperactivity, flight of ideas (with a resulting inability to focus one’s thoughts in a sustained and useful manner) and insomnia • hallucinations, depersonalization (a feeling of separation of the self from the body), anxiety, agitation and bizarre or reckless behaviour • panic attacks • psychotic episodes. The long-term adverse effects arise from a neurotoxic action of the methylenedioxy derivatives of the amfetamines. The massive release of serotonin not only gives rise to acute psychotic symptoms but also causes chemical damage to the cells that released it. Long-term psychiatric problems include: • impairment of memory, both verbal and visual, with the degree of impairment being roughly proportional to the intensity of the preceding ecstasy use • impairment of decision making, information processing, logical reasoning and simple problem solving • greater impulsivity and lack of self-control

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• panic attacks occurring repeatedly when the person is not under the influence of the drug, even after many months of abstinence • recurrent paranoia, hallucinations, depersonalization, flashbacks and even psychotic episodes occurring some time after the individual has stopped using ecstasy • severe depression, which is sometimes resistant to any treatment other than selective serotonin reuptake inhibitors, occasionally accompanied by suicidal thoughts.11

PREVENTION OF MENTALEMOTIONAL PROBLEMS Mental activity is the most important aspect of the Mind, and this is affected by either excessive thinking or excessive emotional strain. It follows then that the most important measures one can take to prevent mental-emotional problems are to restrain one’s mental activity and avoid emotional stress, which, of course, in our modern stressful times, is much easier said than done. “To restrain one’s mental activity” means not only avoiding excessive mental work but also avoiding thinking too much altogether. These concepts are heavily influenced by Daoist ideas of “nourishing life” by calming the Mind and preventing distracting thoughts. The very first chapter of the Simple Questions says:12 One should live a quiet life with few desires, so that one can preserve one’s Qi and guard one’s Mind in order to avoid disease. Thus if emotions are absent and craving is curbed, the Heart is peaceful and there is no fear. Thus, in order to attain a tranquil Mind the ancient Daoist sages advocated three basic attitudes: 1. avoid excessive thinking 2. avoid excessive craving 3. avoid distracting thoughts. Restraining craving is particularly applicable to Western industrialized societies, in which consumerism is rampant and the pressures of advertising contribute to creating ever new “needs”. Restraining craving and desire is very important to achieve mental tranquillity, as excessive craving stirs up the Minister Fire, which harasses the Heart and Pericardium.

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This Daoist ideal is of course terribly difficult to attain, but even just barely striving towards parts of it is a step in the right direction. In the past, some Daoist doctors even formulated “prescriptions”, mimicking herbal prescriptions, to calm the Mind, restrain thinking and curb emotions. Two of them will be presented here as examples. XIANG SUI WAN “Pill” to the Likeness of Marrow • Not thinking too much: nourishes the Heart (emperor ingredient) • Restraining anger: nourishes the Liver • Restraining sexual desire: nourishes the Kidneys • Careful talking: nourishes the Lungs • Regulating diet: nourishes the Spleen ZHEN REN YANG ZANG GAO The Sage’s “Paste” to Nourish the Internal Organs • Remain indifferent whether granted favours or subjected to humiliation: makes the Liver balanced • Be indifferent whether moving or still: calms Heart-Fire • Regulate diet: does not overburden the Spleen • Regulate breathing and moderate talking: makes Lungs healthy • Calm the Mind and prevent distracting thoughts: replenishes the Kidneys

END NOTES 1. Byrne P, Jones S, Williams R 2004 The association between cannabis and alcohol use and the development of mental disorder. Current Opinion in Psychiatry 17(4): 255–261. 2. Arseneault L, Cannon M, Witton J et al. 2004 Causal association between cannabis and psychosis: examination of the evidence. British Journal of Psychiatry 184: 110–117. Online. Available: http://bjp.rcpsych.org/cgi/content/full/184/2/110 3. Zammit S, Allebeck P, Andreasson S et al. 2002 Self reported cannabis use as a risk factor for schizophrenia in Swedish conscripts of 1969: historical cohort study. British Medical Journal 325: 1199. 4. Os J, Bak M, Hanssen M et al. 2002 Cannabis use and psychosis: a longitudinal population-based study. American Journal of Epidemiology 156: 319–327. 5. Arseneault L, Cannon M, Witton J et al. 2004 Causal association between cannabis and psychosis: examination of the evidence. British Journal of Psychiatry 184: 110–117. 6. Johns A 2001 Psychiatric effects of cannabis. British Journal of Psychiatry 178: 116–122. Online. Available: http://bjp.rcpsych.org/cgi/content/full/178/2/116 30 Aug 2006. 7. Brady KT, Lydiard RB, Malcolm R et al. 1991 Cocaine-induced psychosis. Journal of Clinical Psychiatry 52: 509–512. 8. Serper MR, Chou JC, Allen MH et al. 1999 Symptomatic overlap of cocaine intoxication and acute schizophrenia at emergency presentation. Schizophrenia Bulletin 25: 387–394. 9. Brady KT, Lydiard RB, Malcolm R et al. 1991 Cocaine-induced psychosis. Journal of Clinical Psychiatry 52: 509–512. 10. Bartlett E, Hallin A, Chapman B et al. 1997 Selective sensitization to the psychosis inducing effects of cocaine: a possible marker for addiction relapse vulnerability? Neuropsychopharmacology 16: 77–82. 11. Lieb R, Schuetz CG, Pfister H et al. 2002 Mental disorders in ecstasy users: a prospective-longitudinal investigation. Drug and Alcohol Dependence 68: 195–207. Online. Available: http://www.maps.org/research/mdma/litupdates/human/comparis ons/09.02/lieb2002-1.html 12. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 3. First published c.100 BC.

CHAPTER 12

DIAGNOSIS OF MENTALEMOTIONAL PROBLEMS COMPLEXION EYES

state of the Mind and Spirit. Yu Chang in Principles of Medical Practice (1658) calls the complexion the “banner of the Mind and Spirit”, and he says:1

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PULSE 324 The pulse and the emotions 324 The Heart pulse 325 General pulse qualities and the emotions TONGUE 326 Red tip 326 Heart crack 328 Sides of the tongue 328 Body shape 329 Combined Stomach and Heart crack

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DIAGNOSIS OF MENTAL-EMOTIONAL PROBLEMS The diagnosis of mental-emotional problems follows the same lines as diagnosis of other problems, for the body and Mind are an inseparable unit that, when it is disturbed, gives rise to symptoms and signs in both the physical and mental-emotional spheres. However, some special diagnostic signs in mentalemotional problems will be discussed. The diagnosis of mental-emotional problems will be discussed according to the following topics. • • • •

Complexion Eyes Pulse Tongue

COMPLEXION All organs can obviously influence the complexion, but, whatever the organ, the complexion shows the

When the Mind and Spirit are flourishing, the complexion is glowing; when the Mind and Spirit are declining, the complexion withers. When the Mind is stable the complexion is florid ... A healthy Mind and Spirit show most of all in a complexion with shen. This indicates an indefinable quality of lustre, glow, glitter and florid state of the complexion that indicates a good prognosis even if the colour itself is pathological. Shi Pa Nan in Origin of Medicine (1861) says:2 The shen of the complexion consists of lustre and body. “Lustre” means that the complexion appears clear and bright from the outside; “body” means that it is moist and with lustre in the inside. If a complexion has such attributes, even if the colour is pathological, it indicates that the Mind and Spirit are stable and unaffected and therefore the prognosis is good. The Simple Questions in Chapter 17 describes the look of pathological colours with or without shen:3 A red complexion should look like vermilion covered with white, not like ochre. A white complexion should look like feathers of a goose, not like salt. A blue complexion should look like moistened greyish jade, not like indigo. A yellow complexion should look like realgar covered with gauze, not like loess (the soil in North China along the Yellow River basin). A black complexion should look like dark varnish, not like greyish charcoal. These are summarized in Table 12.1. Therefore, each pathological colour may be with shen (indicating a good prognosis) or without shen (denoting a poor prognosis).

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Table 12.1 Good and poor prognosis in pathological complexion colours Colour

Good prognosis

Poor prognosis

Red

Like vermilion covered with white

Like ochre

White

Like goose feathers

Like salt

Blue

Like grey jade

Like indigo

Yellow

Like realgar covered with gauze

Like loess (soil in North China)

Black

Like dark varnish

Like greyish charcoal

Dr Chen Shi Duo in Secret Records of the Stone Room (1687) goes so far as saying:4 If the complexion is dark but with shen, the person will live even if the disease is serious. If the complexion is bright but without shen, the person will die even if there is no disease. Observation of the complexion must be closely linked to the feeling of the pulse. The pulse shows the state of Qi, while the complexion the state of the Mind and Spirit. If the pulse shows changes but the complexion is normal, it indicates that the problem is recent. If both the pulse and the complexion show pathological changes, it indicates that the problem is long-standing. The shen of the complexion should also be checked against the lustre of the eyes (see below). A change in the complexion always indicates a deeper or more long-standing problem. For example, a sustained period of overwork and inadequate sleep may cause the eyes to lack lustre; if the complexion is not changed, this is not too serious and the person can recover easily by resting. If, however, the eyes lack lustre and the complexion is dull, without lustre or dark, it indicates that the problem is not transient but deeper-rooted. Various emotions may show on the complexion with specific signs. Anger usually manifests with a greenish tinge on the cheeks. A greenish tinge on the forehead means that Liver-Qi has invaded the Stomach; a greenish tinge on the tip of the nose that Liver-Qi has invaded the Spleen. A character prone to anger may also manifest with eyebrows that meet in the centre. In some cases, if the

anger is bottled up inside as resentment leading to long-standing depression, the complexion may be pale. This is due to the depressing effect of stagnant Liver-Qi on Spleen- or Lung-Qi. In such cases, the Wiry quality of the pulse will betray the existence of anger rather than sadness or grief (indicated by the pale complexion) as a cause of disease. Excess joy may manifest with a red colour on the cheekbones. Worry causes a greyish complexion and a skin without lustre. Worry knots Lung-Qi and affects the Corporeal Soul, which manifests on the skin. For this reason, the skin becomes greyish and lustreless. Pensiveness may manifest with a sallow complexion because it depletes Spleen-Qi. Fear shows with a bright-white complexion on the cheeks and forehead. If chronic fear causes deficiency of Kidney-Yin and the rising of Empty Heat of the Heart, there will be a malar flush, with the underlying colour being bright-white. Shock also causes a bright-white complexion. Shock early in childhood may manifest with a bluish tinge on the forehead. If there is a bluish tinge on the forehead or around the mouth, it indicates a prenatal shock (while in the uterus). Hatred often shows with a greenish complexion on the cheeks. Craving shows with a reddish colour on the cheeks. Guilt shows with a dark-ruddy complexion. Shame manifests with a dull, sallow complexion without lustre.

SUMMARY EMOTIONS AND COMPLEXION COLOURS  Anger: greenish tinge on the cheeks.  Excess joy: a red colour on the cheekbones.  Worry: a greyish complexion and a skin without lustre.  Pensiveness: a sallow complexion.  Fear: a bright-white complexion on the cheeks and forehead.  Shock: a bright-white complexion.  Shock early in childhood: a bluish tinge on the forehead.  Prenatal shock: a bluish tinge on the forehead and around the mouth  Hatred: a greenish complexion on the cheeks.  Craving: a reddish colour on the cheeks.  Guilt: a dark-ruddy complexion.  Shame: a dull, sallow complexion without lustre.

Diagnosis of Mental-Emotional Problems

EYES Observation of the eyes plays an extremely important role in the diagnosis of emotional and mental problems. As soon as the patient sits down, the first thing I observe carefully is the lustre of the eyes. In my experience, the lustre (or lack of it) of the eyes reflects very closely and accurately the state of the Mind and Spirit; I have never experienced this sign giving a false information. The eyes reflect the state of the Mind, Spirit and Essence. The Spiritual Axis in Chapter 80 says:5 The Essence of the five Yin and the six Yang organs ascends to the eyes ... the essence of bones goes to the pupil, the essence of tendons goes to the iris, the essence of Blood goes to the blood vessels in the eyes, the essence of the Lungs goes to the sclera ... This shows that the essence of all the Yin organs and therefore the Mind, Ethereal Soul, Corporeal Soul, Intellect and Will-Power manifests in the eyes. The same chapter of the Spiritual Axis says further on:6 The eyes manifest the essence of the five Yin and six Yang organs, the Nutritive and Defensive Qi, and they are the place where the Qi of the Mind is generated ... the eyes are the messengers of the Heart, which houses the Mind. If the Mind and Essence are not coordinated and not transmitted, one has visual hallucinations. The Mind, Ethereal Soul and Corporeal Soul are scattered so that one has bewildering perceptions. Shi Pa Nan in Origin of Medicine (1861) says: “The Qi of the Mind and Spirit dwells in the eyes.”7 Zhou Xue Hai in A Simple Guide to Diagnosis from Body and Colour (1894) says: “Even if the illness is serious, if the eyes have good shen, the prognosis is good.”8 When looking at the eyes, we need to consider two aspects: 1. whether they have lustre or not 2. whether they are “controlled” or not. If the eyes are clear, have lustre, sparkle or gleam and are brilliant, it shows that the Mind and Spirit are in a good state of vitality. If they are dull as if they were clouded by a mist, it shows that the Mind or Spirit is disturbed by emotional problems. I find that in practice this sign is never wrong and is therefore completely reliable. The duller the eyes, the more severe or longstanding the emotional problems. “Controlled” look means a fixed, sustained and penetrating look; this indicates a stable and integrated

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personality. “Uncontrolled” means that the look is shifty or too fixed. If the eyes look uncontrolled, it may indicate that the person is affected by anger. In terms of personality, an uncontrolled look points to a mercurial character, an unreliable person, a person ridden by guilt, fanatical or possibly destructive. Sadness, grief and shock make the eyes dull and without lustre. Excess joy and guilt make the eyes uncontrolled and slightly too watery. Fear makes the eyes bulge out slightly and shift frequently. Guilt makes the eyes shifty and the eyelids flap shut in rapid movements while talking. Shame makes the eyes dull and “uncontrolled” in the sense that the person is unable to look at the others in the eyes. The lack of lustre of the eyes reflects very accurately the presence of emotional stress, which, however, could also be in the past rather than the present. The intensity of dullness is also directly related to the intensity and duration of the emotional stress: the duller the eyes, the more intense and long-lasting the emotional stress.

SUMMARY THE EYES AND THE EMOTIONS  The eyes reflect the state of the Mind, Spirit and Essence.  When looking at the eyes, we need to consider two aspects: whether they have lustre or not and whether they are “controlled” or not.  Eyes with shen are clear, have lustre, sparkle or gleam and are brilliant: Mind and Spirit are in a good state of vitality.  Eyes without shen are dull, as if they were clouded by a mist: Mind or Spirit are disturbed by emotional problems.  “Controlled” look refers to a fixed, sustained and penetrating look: stable and integrated personality.  “Uncontrolled” look refers to a look that is shifty or too fixed: the person is affected by anger, mercurial character, guilt, fanatical.  Sadness, grief and shock: eyes dull and without lustre.  Excess joy and guilt: eyes uncontrolled and slightly too watery.  Fear: eyes bulging out slightly and shifting frequently.

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 Guilt: eyes shifty and eyelids flapping shut in rapid movements while talking.  Shame: eyes dull and “uncontrolled” in the sense that the person is unable to look at the others in the eyes.

PULSE The pulse reflects the state of Qi, while the eyes directly reflect the state of the Mind and Spirit. Of course, by reflecting Qi the pulse also reflects the state of the Mind and Spirit but, when confronted with a pulse sign, it is often very difficult to determine (from the pulse alone) whether that is due to emotional problems or to other causative factors. For example, sadness and grief can render the eyes dull and without lustre, which definitely indicates a disturbance of the Spirit. The same emotions can make the Lung pulse Weak, but this can be caused by very many other factors too. Thus the pulse, tongue and complexion should always be closely integrated in order to diagnose mental-emotional problems correctly. It is only after some years of clinical experience that one can draw conclusions about the relation between certain pulse qualities and mental-emotional problems.

necessarily draw the conclusion that they are suffering from anger or repressed anger. Sadness and grief make the pulse Choppy or Short, and it characteristically flows without a wave. The pulse without wave seems to flow distally towards each pulse position separately, rather than flowing smoothly from the rear towards the Front position (see Fig. 10.13). The sad pulse quality occurs only in the Front and Middle position, never on the Rear position. If only one position is affected (e.g. only the Lung position), the sadness has not lasted for over a year. If both the Front and Middle positions of left and right have the sad quality, the sadness is long-standing. Sometimes sadness and grief manifest with a very Weak quality on both Lung and Heart positions. Again, this finding should be checked against others, because such a pulse configuration can also be caused by an accident to the chest. Excessive joy makes the pulse slow and slightly Hollow or Overflowing-Empty on the Heart position. Fear and shock render the pulse rapid. In severe cases, they can give the pulse a Moving quality; that is, a pulse that is short and shaped like a bean and that gives the impression of vibrating rather than pulsating. Shock also makes the Heart pulse Tight and Fine. Guilt makes the pulse rapid; the pulse also gives the impression of shaking as it pulsates. Shame makes the pulse Slippery and without a wave.

The pulse and the emotions

SUMMARY

Anger makes the pulse Wiry, sometimes only on the left side. A Wiry quality of the pulse is always a reliable pointer to problems from anger when other signs (such as a pale face and weak voice) seem to point to sadness and grief. If anger occurs at mealtimes, it manifests with a Wiry quality on the Stomach position. Repressed anger and resentment make the pulse “stagnant”, a quality that is not one of the traditional 28 pulse qualities. A stagnant pulse is somewhat tight but not so hard as the Tight pulse, and it seems to flow reluctantly. I find that a Wiry pulse is a reliable indication of emotions such as anger, repressed anger, frustration, hatred or resentment. A Wiry pulse may also sometimes reflect guilt. There is, however, an important consideration: in the elderly, the pulse often becomes Wiry because the arteries harden, so we cannot

THE PULSE AND THE EMOTIONS  Anger: Wiry, sometimes only on the left side.  Repressed anger and resentment: “stagnant”, i.e. somewhat tight but not so hard as the Tight pulse, flowing reluctantly.  Sadness and grief: Choppy or Short, without wave; also very Weak on both Lung and Heart positions.  Excessive joy: Slow and slightly Hollow or Overflowing-Empty on the Heart position.  Fear: Rapid.  Shock: Moving; also makes the Heart pulse Tight and Fine.  Guilt: Rapid; also gives the impression of shaking as it pulsates.  Shame: Slippery and without a wave.

Diagnosis of Mental-Emotional Problems

The Heart pulse The Heart pulse is of course very important in the diagnosis of mental-emotional problems, because the Heart houses the Mind; its pulse qualities and significance often differ from the traditional ones. The following are some Heart-pulse qualities and their emotional significance according to my experience. An Overflowing quality on the Heart pulse often indicates emotional problems of most kinds (sadness, grief, anger, guilt, etc.). Please note that I use the word “Overflowing” in a different sense than the true Overflowing quality. “Overflowing” here means that the Heart pulse is slightly more superficial (and relatively Full) in relation to other positions; thus, it is not really Overflowing as the true Overflowing pulse, but it is bigger and more superficial than the other pulses. In some cases, it may be that the pulse is all Weak and Choppy and the only position that stands out is the Heart one; one might be inclined to think that, in such a picture, only the Heart position is normal while it is, in fact, the opposite. When all positions are Weak and Choppy and only the Heart pulse can be felt clearly, I consider that Heart-pulse quality as relatively “Overflowing”, and such a picture usually indicates deep emotional problems. A Rounded quality of the Heart pulse indicates that the pulse feels rounder than normal, somewhat like a small ball, but at the same time rather short. This quality indicates stagnation of Qi in the Heart together with a deficiency of Heart-Qi. Therefore it is associated

with emotions such as sadness and grief, especially when unexpressed. A Choppy Heart-pulse quality indicates HeartBlood deficiency from sadness, grief or worry. It is very common in women, and it may also indicate unexpressed emotions. An Empty Heart-pulse quality pulse indicates HeartQi deficiency from sadness and grief. The Pericardium pulse is also felt on the Heart position, especially in emotional problems. A Pericardium pathology is reflected especially in Full-types of Heart pulse and particularly when there are chest symptoms (oppression, stuffiness, tightness, discomfort, pain). When we feel a pathological quality on the Heart pulse, how do we know that that particular quality reflects emotional problems rather than an actual heart problem of Western medicine? Generally, an actual heart problem is often indicated by an abnormal pulse quality in the peripheral pulse positions felt by rolling the finger proximally, distally, laterally and medially from the Heart position itself. These qualities are usually Slippery and/or Wiry. These peripheral pulse positions are related to the heart valves, aorta and pulmonary vein. A Slippery or Wiry quality of such peripheral pulse positions may indicate aortic aneurysm, hypertension, arteriosclerosis or valve problems (Fig. 12.1). However, in some cases a congenital valve problem may be indicated by a Deep, Weak and Choppy Heart

MEDIAL SIDE

LATERAL SIDE Superior vena cava

Tricuspid valve

Mitral valve Aorta Pulmonary artery Pulmonary veins

Left atrium/ventricle/ aorta/pulmonary artery

HEART

Diaphragm Figure 12.1 Heart pulse in actual heart problems.

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Right atrium/ ventricle/ aorta

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pulse combined with a pulse that is Weak and Choppy in general.

indicates that the sadness the patient is suffering from is severe and of long duration.

SUMMARY

Wiry

HEART-PULSE QUALITIES

A pulse that is Wiry all over is a clear indication of stagnation (of Qi or Blood), and it is usually related to anger and other allied emotional states (frustration, resentment, hatred, fury) and also to guilt. The Wiry pulse may also reflect Liver-Yang rising or Liver-Fire, also deriving from such emotions. However, Qi stagnation may affect other organs besides the Liver (e.g. Lungs, Heart, Stomach, Spleen, Intestines). When it does, the pulse may be Wiry in a specific position, for example on the right-Front, left-Front, right-Middle and both Rear positions, respectively. Please bear in mind that a “Wiry” Lung pulse will never be as Wiry as a Wiry Liver pulse. As the normal Lung pulse is soft, it takes only a small change in quality to make it “Wiry”. In emotional problems, a Wiry quality on the Lung pulse usually indicates worry, while on the Heart pulse it may indicate various emotions such as worry, fear, guilt, shame or anger.

 Overflowing: emotional problems of most kinds (sadness, grief, anger, guilt, etc.).  Rounded: stagnation of Qi in the Heart together with a deficiency of Heart-Qi; sadness and grief, especially when unexpressed.  Choppy: Heart-Blood deficiency from sadness, grief, worry.  Empty: Heart-Qi deficiency from sadness and grief.

General pulse qualities and the emotions The following is a discussion of general pulse qualities in emotional problems.

Choppy The Choppy pulse feels, weak, “jagged”, soft, empty, and without wave. In the context of mental-emotional problems, the Choppy pulse indicates sadness primarily (usually against a background of Blood deficiency). Indeed, one of the characteristics of the Choppy pulse is that it lacks a “wave”, as what Dr Shen calls the Sad pulse does (see below).

Sad The “Sad” pulse was described by Dr Shen. It is similar to the Choppy pulse in that it has no wave; however, it is not necessarily Choppy. The Sad pulse would appear before the pulse becomes Choppy. The normal pulse should flow smoothly like a wave from the Rear to the Front position. The Sad pulse has no such wave, and it flows reluctantly and “sadly” (Fig. 10.13). The Sad pulse is also similar to the Short pulse, as it does not fill the pulse position. The Sad pulse indicates sadness. According to Dr Shen, one can judge the severity and duration of the sadness according to how many pulse positions have the Sad quality. Generally, only the first or first and second positions show the Sad quality; if all three positions have this quality, it

SUMMARY GENERAL PULSE QUALITIES AND THE EMOTIONS  Choppy: sadness (usually against a background of Blood deficiency).  Sad: sadness.  Wiry: stagnation (of Qi or Blood), and it is usually related to anger and other allied emotional states (frustration, resentment, hatred, fury).  Wiry on Lung position: worry.  Wiry on Heart position: worry, fear, guilt, shame, anger.

TONGUE Red tip One of the tongue’s most reliable indications of emotional problems is a red tip (Plate 12.1). However, although this is a sure sign of emotional or mental

Diagnosis of Mental-Emotional Problems

problems, it is not very specific, because it can arise from almost any emotion. Why is the tip of the tongue affected, and why is it red? First of all, the tip of the tongue is affected because it corresponds to the Heart, and this organ, as mentioned above, is affected by all emotions. This is because the Heart is the seat of insight and feelings, and although each emotion affects its relevant organ, it also affects the Heart, which alone feels it. Second, the tip becomes red because every emotion, after some time, causes some stagnation of Qi and this, in turn, often produces Heat. Hence the Chinese medicine saying: “All emotions lead to Heat.” It is important to remember that “tip” here means the very tip of the tongue. If a larger area in the front part of the tongue is red, it usually indicates LungHeat (Fig. 12.2). If the tip of the tongue is Red, how do we know that this is due to Heart-Heat deriving from emotional problems and not from an actual heart disease in a Western medical sense? In my experience, the tip of the tongue reflects the condition of the Heart, specifically in the sense of the Mind (Shen) and not really the heart itself. I find that pathologies of the actual heart in a Western sense are reflected on the chest/breast areas of the tongue (Fig. 12.3). For example, when there is Blood stasis in the Heart and a Western heart pathology (such as coronary heart disease), I find that the chest areas on the tongue become Purple, never the tip. Thus, we can say that the

Heart area Figure 12.2 Comparison of Heart and Lung areas on the tongue.

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Figure 12.3 Chest/breast areas.

tip of the tongue reflects the condition of the Mind (Shen), while the chest areas on the tongue reflect the condition of the actual heart.

! The tip of the tongue reflects the condition of the Mind (Shen), while the chest areas on the tongue reflect the condition of the actual heart. It is interesting to note that this situation does not apply to other areas of the tongue; for example, the

Lung area

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sides of the tongue reflect the condition of the Liver both in a Chinese and in a Western sense. If the sides of the tongue are Red, it may indicate both an emotional problem deriving from anger and a condition of Heat in the liver organ itself.

Heart crack A Heart crack is in the midline; it is relatively narrow and it extends from the border of the root of the tongue to edge of the tip (Fig. 12.4 shows a Heart crack on the left and compares it with a Stomach crack). See Plate 12.2. If the Heart crack is shallow and the body colour normal, it simply indicates a constitutional tendency to Heart patterns and to emotional problems, but it does not have a specific clinical significance. However, if a person has such a crack, any emotional stress from which he or she might suffer will have deeper repercussions than in someone without a Heart crack. According to Dr J.H.F. Shen, a shallow Heart crack on a normal body colour may also indicate heart disease in the parents or even grandparents. The clinical significance of the Heart crack depends on its depth and on the colour of the tongue body. If the Heart crack is accompanied by a change in the tongue body colour and a red tip, it then indicates actual mental-emotional problems. If the Heart crack is deep, it indicates that the person may suffer from a Heart pattern due to emotional stress, all the more so

Heart crack Figure 12.4 Comparison of Heart crack and Stomach crack.

if the tip is also Red: the deeper the crack, the more severe the emotional problem. One could describe different situations of emotional stress in order of increasing severity as manifested on the tongue as follows: • • • • • • •

shallow Heart crack, normal body colour no Heart crack, Red tip deep Heart crack, normal body colour shallow Heart crack, Red tip deep Heart crack, Red tip deep Heart crack, Red tip with red points deep Heart crack, Red tongue with redder tip and red points • deep Heart crack, Red tongue with redder and swollen tip and red points. I personally find that a Heart crack on the tongue is a very reliable sign of either a tendency to emotional stress (as indicated above) or of an actual severe emotional stress.

Sides of the tongue The sides of the tongue reflect the state of the Liver. With regard to the sides of the tongue, we should differentiate clearly between the areas that reflect the condition of the Liver and those that reflect that of the Spleen (Fig. 12.5). The areas on the edge of the tongue extending from the edge of the root to the edge of the tip reflect the condition of the Liver; the areas on the

Stomach crack

Diagnosis of Mental-Emotional Problems

Liver areas

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Stomach/Spleen areas

Figure 12.5 Comparison of Liver and Stomach/Spleen areas.

tongue in the middle section of it and extending more towards the centre of the tongue reflect the condition of the Spleen and Stomach. Anger very often manifests with red sides of the tongue, indicating severe Liver-Qi stagnation, LiverYang rising or Liver-Fire (Plate 12.3). If both sides and tip are red, it usually indicates severe emotional problems from anger and frustration affecting both the Liver and Heart (Plate 12.4).

Body shape There are a few other body shape signs on the tongue that show emotional or mental problems. For example, severe mental problems such as manic depression or psychosis can manifest with a grossly abnormal shape of the tongue, as is shown in Figure 12.6 and Plate 12.5. This consists of a large swelling of the front third of the tongue. If such a shape is seen in people who do not apparently have any mental problems, it indicates that they have a tendency to develop such problems if the inner balance is suddenly upset, such as by a shock or by a traumatic childbirth. These people are nearly always sad; even if they do experience happiness, it only lasts a few minutes. If such a tongue is combined with very dull eyes; this is a very bad sign indicating the possibility of severe mental illness. Another sign in the tongue body shape indicating the tendency to severe mental problems is a tongue

Figure 12.6 Tongue swelling indicating tendency to mental illness.

that is grossly Swollen almost to the point of being round (Fig. 12.7).

Combined Stomach and Heart crack Yet another tongue sign in mental-emotional problems is a combined Stomach and Heart crack; as indicated in Figure 12.8, the Heart crack is narrow and extends almost the whole length of the tongue, while the Stomach crack is wide and is concentrated in the middle section of the tongue (Plate 12.6). A combined Stomach and Heart crack extends the whole length of the tongue and is wide in the middle

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SUMMARY THE TONGUE AND THE EMOTIONS Red tip  Red tip of the tongue: emotional stress giving rise to Heat.

Figure 12.7 Gross swelling of the tongue, indicating tendency to mental illness.

Heart crack  A Heart crack is in the midline; it is relatively narrow, and it extends from the border of the root of the tongue to edge of the tip.  Heart crack shallow and body colour normal: constitutional tendency to Heart patterns and to emotional problems.  Heart crack with a change in tongue body colour and a red tip: actual mental-emotional problems.  The deeper the crack, the more severe the emotional problem. Sides of the tongue  The sides of the tongue reflect the state of the Liver.  Anger often manifests with red sides of the tongue, indicating severe Liver-Qi stagnation, Liver-Yang rising or Liver-Fire.  Both sides and tip red: severe emotional problems from anger and frustration affecting both the Liver and Heart.

Figure 12.8 Combined Stomach–Heart crack.

section (Fig. 12.8). Such a crack usually indicates severe emotional stress, which may derive from sadness, grief, worry, guilt or shame. If there is a sticky, rough, brush-like yellow coating inside the crack, it indicates the presence of Phlegm clouding the Mind. If, in addition, the tongue body is Red, it denotes the presence of Phlegm and Fire obstructing the Stomach and the Heart and misting the Mind. It is often seen in manic depression (Plate 12.7).

Body shape  Grossly abnormal shape of the tongue with a large swelling of the front third of the tongue: tendency to mental problems.  Grossly Swollen tongue almost to the point of being round: tendency to mental problems, obstruction of the Mind. Combined Stomach and Heart crack  Combined Stomach and Heart crack: severe emotional stress that may derive from sadness, grief, worry, guilt or shame.  Combined Stomach and Heart crack with a sticky, rough, brush-like yellow coating inside the crack: Phlegm clouding the Mind.  Combined Stomach and Heart crack with a sticky, rough, brush-like yellow coating inside the crack, red tongue body: Phlegm and Fire obstructing the Stomach and the Heart and misting the Mind; manic depression.

Diagnosis of Mental-Emotional Problems

END NOTES 1.

2. 3.

Yi Men Fa Yu [Principles of Medical Practice], cited in Wang Ke Qin 1988 Zhong Yi Shen Zhu Xue Shuo [Theory of the Mind in Chinese Medicine]. Ancient Chinese Medical Texts Publishing House, p. 56. Shi Pa Nan 1861 Yi Yuan [Origin of Medicine], cited in Theory of the Mind in Chinese Medicine, p. 55. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 99. First published c.100 BC.

4. 5. 6. 7.

8.

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Chen Shi Duo 1687 Shi Shi Mi Lu [Secret Records of the Stone Room], cited in Theory of the Mind in Chinese Medicine, p. 56. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, pp. 151–152. First published c.100 BC. Ibid., pp. 151–152. Shi Pa Nan 1861 Yi Yuan [Origin of Medicine], cited in Guo Zhen Qiu 1985 Zhong Yi Zhen Duan Xue [Diagnosis in Chinese Medicine]. Hunan Science Publications, p. 33. Zhou Xue Hai 1894 Xing Se Wai Zhen Jian Mo [A Simple Guide to Diagnosis from Body and Colour], cited in Diagnosis in Chinese Medicine, p. 33.

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CHAPTER 13

DEPRESSION

DEFINITION AND WESTERN MEDICINE’S VIEW Major depressive syndrome 335

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PATHOLOGY OF DEPRESSION IN CHINESE MEDICINE 335 Yu as stagnation 335 Yu as mental depression 336 Depression and the relationship between the Mind (Shen) and the Ethereal Soul (Hun) 337 The Will-Power (Zhi) of the Kidneys in Depression 337 Distinction between Depression in Yu Syndrome and in Dian Syndrome 338 Lilium Syndrome (Bai He Bing) 338 Agitation (Zang Zao) 339 Plum-Stone Syndrome (Mei He Qi) 339

• • • • • • •

Liver-Qi stagnation Heart- and Lung-Qi stagnation Stagnant Liver-Qi turning into Heat Phlegm-Heat harassing the Mind Blood stasis obstructing the Mind Qi stagnation with Phlegm Diaphragm Heat

ACUPUNCTURE POINTS FOR DEPRESSION HERBS FOR DEPRESSION

358

364

MODERN CHINESE LITERATURE

AETIOLOGY 340 Emotional stress 340 Constitutional traits 341 Irregular diet 341 Overwork 341 IDENTIFICATION OF PATTERNS AND TREATMENT Liver-Qi stagnation 342 Heart- and Lung-Qi stagnation 345 Stagnant Liver-Qi turning into Heat 346

Phlegm-Heat harassing the Mind 347 Blood stasis obstructing the Mind 348 Qi stagnation with Phlegm 350 Diaphragm Heat 352 Worry injuring the Mind 353 Heart and Spleen deficiency 354 Heart-Yang deficiency 355 Kidney- and Heart-Yin deficiency, Empty Heat blazing 356 Kidney-Yang deficiency 357

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CLINICAL TRIALS 370 Acupuncture 370 Herbal medicine 374 342

CASE HISTORIES

375

PATIENTS’ STATISTICS

• • • •

382

Worry injuring the Mind Heart and Spleen deficiency Heart-Yang deficiency Kidney- and Heart-Yin deficiency, Empty Heat blazing • Kidney-Yang deficiency

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DEPRESSION The main categories of mental illness mentioned in the classics are as follows. • Bai He Bing : Lilium Syndrome; this is mentioned in Essential Prescriptions of the Golden Chest (Jin Gui Yao Lue Fang Lun), Chapter 3-1.1 • Yu Zheng : Depression. • Mei He Qi : Plum-Stone Syndrome. • Zang Zao : Agitation. • Xin Ji Zheng Chong : Palpitations and Anxiety. • Dian Kuang : Manic depression. • Yi : Hysteria. • Chi Dai : Cretinism. • Dian Xian : Epilepsy. Depression as defined in Western medicine has aspects of the first five ancient disease categories mentioned above, i.e. Lilium Syndrome (Bai He Bing), Depression (Yu Zheng), Plum-Stone Syndrome (Mei He Qi), Agitation (Zang Zao) and Palpitations and Anxiety (Xin Ji Zheng Chong). See Figure 13.1. The categorization of epilepsy with mental illnesses by ancient Chinese doctors is, of course, wrong. The discussion of Depression will be conducted according to the following topics. • Definition and Western medicine’s view • Pathology of Depression in Chinese medicine • Aetiology Chinese medicine

Western medicine

BAI HE BING (Lilium Syndrome) YU ZHENG (Depression) MEI HE QI (Plum-Stone Syndrome)

DEPRESSION

ZANG ZAO (Agitation) XIN JI ZHENG CHONG (Palpitations and Anxiety) Figure 13.1 Correspondence between Chinese mentalemotional conditions and depression in Western medicine.

• • • • • • •

Identification of patterns and treatment Acupuncture points for Depression Herbs for Depression Modern Chinese literature Clinical trials Case histories Patients’ statistics

DEFINITION AND WESTERN MEDICINE’S VIEW A depressive illness is primarily characterized by a change in mood consisting of a feeling of sadness that may vary from mild despondency to the most abject despair. The change in mood is relatively fixed and persists over a period of days, weeks, months or years. Associated with the change in mood are characteristic changes in behaviour, attitude, thinking, efficiency and physiological functioning. In distinguishing the normal reaction from pathological depression, a quantitative judgement has to be made. If the precipitant seems inadequate, the depression too severe and too long lasting, the condition is regarded as abnormal. In addition, the severity and incapacity in depressive illness differs qualitatively as well as quantitatively from depressed feelings that are part of normal experience. Depression accounts for 35–40% of all psychiatric illnesses. It is twice as common in women as in men. The onset of depression increases towards middle age, with a maximum onset in the 55–60 age group. Depressive illness that is predominantly determined by genetic–constitutional factors is referred to as endogenous depression. This is characterized by being worse in the morning. Depressive illness that is predominantly a reaction to external influences is referred to as reactive depression. The main symptoms and signs of depression are: • • • • • • • • • •

painful thoughts anxiety and agitation loss of interest loss of self-esteem derealization and depersonalization hypochondriasis disorders of perception insomnia loss of appetite diurnal variation (worse in the morning).

Depression

According to Bowlby, depression as a mood that most people experience on occasion is an inevitable accompaniment of any state in which behaviour becomes disorganized, as it is likely to do after a loss.2 So long as there is active interchange between ourselves and the external world, either in thought or in action, our subjective experience is not one of depression: hope, fear, anger, satisfaction, frustration or any combination of these may be experienced. It is when interchange has ceased that depression occurs until such time as new patterns of interchange have become organized towards a new object or goal. It is characteristic of the mentally healthy person that he or she can bear this phase of depression and disorganization and emerge from it after not too long a time, with behaviour, thought and feeling beginning to be reorganized for interactions of a new sort. A person prone to depression will not be able to reorganize new patterns of interaction between himself or herself and the external world. According to Seligman, depression is characterized by a feeling of helplessness; principally, the issue about which a person feels helpless is his or her ability to make and to maintain affectional relationships. The feeling of helplessness can be attributed to experiences in the family of origin from childhood to adolescence. • He or she is likely to have had the bitter experience of never having attained a stable and secure relationship with his or her parents, despite having made repeated efforts to do so. These childhood experiences result in developing a strong bias to interpret any loss he or she may later suffer as yet another of his or her failures to make or maintain a stable affectional relationship. • He or she may have been told repeatedly how unlovable, inadequate and/or incompetent he or she is. These experiences would result in developing a model of himself or herself as unlovable and unwanted, and attachment figures as likely to be unavailable, rejecting or punitive. Whenever such a person suffers adversity, far from expecting others to be helpful he or she expects them to be hostile and rejecting. • He or she is more likely than others to have experienced actual loss of a parent during childhood. Therefore the particular pattern of depressive illness that a person develops will turn on the particular pattern of childhood experiences he or she has had.

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Exposure to such experiences in childhood also explains why in individuals prone to depression there is a strong tendency for the sadness, yearning and perhaps anger aroused by a loss to become disconnected from the situation that aroused them.

Major depressive syndrome Major depressive syndrome has four main aspects. 1. A particular set of symptoms. 2. It has no organic factor and is not the normal reaction to the death of a family member. 3. There are no delusions or hallucinations in the absence of mood symptoms. 4. It is not superimposed on schizophrenia, delusional disorders or psychotic disorders. The main symptoms of major depressive syndrome are: • depressed mood most of the day nearly every day • markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day • significant weight loss (or gain), decrease or increase in appetite • insomnia or sleepiness • psychomotor agitation or retardation every day • fatigue nearly every day • feelings of worthlessness or guilt (which may be delusional) nearly every day (not merely selfreproach or guilt about being ill) • diminished ability to think or concentrate, indecisiveness nearly every day • recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

PATHOLOGY OF DEPRESSION IN CHINESE MEDICINE The Chinese term for depression is yu . Yu has the double meaning of “depression” and “stagnation”.

Yu as stagnation The Simple Questions in Chapter 71 discusses the five stagnations of Wood, Fire, Earth, Metal and Water. It says: “When Wood stagnates, it extends; when Fire

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stagnates, it rises; when Earth stagnates, it seizes; when Metal stagnates, it discharges; when Water stagnates, it pours.”3 The Essential Method of Dan Xi (Dan Xi Xin Fa, 1347) talks about six stagnations, i.e. stagnation of Qi, Blood, Dampness, Phlegm, Heat and Food. It says:4 When Qi and Blood are harmonized, no disease arises. If they stagnate, diseases arise. Many diseases are due to stagnation. ... stagnation makes things accumulate so that they would like to descend but cannot, they would like to transform but cannot ... thus the six stagnations come into being. Zhu Dan Xi formulated a prescription for these six stagnations called Yue Ju Wan Gardenia Chuanxiong Pill, which is an important formula for mental depression deriving from Qi stagnation. Of the six stagnations mentioned above, Qi stagnation is the primary factor. The Complete Book of Jing Yue (Jing Yue Quan Shu, 1624) gives an emotional interpretation to stagnation and talks about the six stagnations in a different way from Zhu Dan Xi, i.e. stagnation of anger, pensiveness, worry, sadness, shock and fear. This statement confirms that all emotions can lead to stagnation of Qi, even those (such as sadness) that initially lead to depletion of Qi. Zhang Jing Yue said: “In the six stagnations, stagnation is the cause of the disease. In emotional stagnation, the disease [i.e. the emotion] is the cause of the stagnation.”5

SUMMARY THE SIX STAGNATIONS ACCORDING TO ZHU DAN XI (1347) 1. 2. 3. 4. 5. 6.

Qi Blood Dampness Phlegm Heat Food

3. 4. 5. 6.

Worry Sadness Shock Fear

Yu as mental depression Besides meaning “stagnation”, Yu also means “mental depression”. Some Chinese doctors say that, in a broad sense, Yu indicates stagnation and is the pathological basis for very many diseases; in a narrow sense, Yu refers to the disease category of “mental depression”. Chinese books ascribe Depression always to Full causes, at least in its beginning stages, with Liver-Qi stagnation being the main, fundamental pathology underlying this disease. Other Full pathologies include Qi stagnation turning into Heat, Phlegm and Blood stasis. A heavy emphasis is put on Liver-Qi stagnation, at least in the beginning stages. In the later stages, the Fullness can change into a deficiency, leading to Empty types of mental depression. In fact, Heat can injure Yin and lead to KidneyYin deficiency. On the other hand, Phlegm can impair the function of the Spleen and lead to Spleen deficiency. The main Empty conditions underlying depression are deficiency of Blood of the Spleen and Heart, deficiency of Qi and Yin of the Heart and Lungs and Liver- and Kidney-Yin deficiency. Thus in Chinese medicine, stagnation and mental depression are almost synonymous, implying that all depression is due to stagnation. This is obviously not true in practice, as there are many Deficiency conditions leading to Depression. However, it is true that all emotions, even those that initially deplete Qi, lead to some Qi stagnation, thus the first effect of emotional stress is some Qi stagnation. When discussing Qi stagnation, it is important to stress that this affects not only the Liver but also, especially in emotional stress, the Heart, Lungs and Spleen.

SUMMARY

!

THE SIX STAGNATIONS ACCORDING TO ZHANG JING YUE (1624)

In Chinese medicine, stagnation (Yu) and mental depression (Yu) are almost synonymous, implying that all depression is (at least initially) due to stagnation.

1. Anger 2. Pensiveness

Depression

Depression and the relationship between the Mind (Shen) and the Ethereal Soul (Hun) The relationship between Mind (Shen) of the Heart and Ethereal Soul (Hun) of the Liver has already been discussed in Chapter 9. As we have seen, the Ethereal Soul gives the Mind inspiration, creativity, ideas, plans, life dreams and aspirations; this psychic energy is the result of the “coming and going” of the Ethereal Soul, and it is the psychic manifestation of the free flow of Liver-Qi (and, in particular, of the physiological ascending of Liver-Qi). On the other hand, the Mind needs to control the Ethereal Soul somewhat and to integrate the psychic material deriving from it. It is in the nature of the Ethereal Soul to “come and go”, i.e. it is always searching and has ideas, inspiration, aims, etc. It will be remembered that the Ethereal Soul is the gui of our human nature and it has its own independent existence. The Mind needs to integrate the material deriving from the Ethereal Soul in the general psyche. The Ethereal Soul is the source of many ideas simultaneously; the Mind can deal with only one at a time. Therefore “control” and “integration” are the key words describing the function of the Mind in relation to the Ethereal Soul (see Fig. 9.15). When the “coming and going” of the Ethereal Soul is deficient, there is a lack of inspiration, creativity, ideas, plans, life dreams and aspirations; this is an important feature of mental depression. It is important to note that the psychic “coming and going” of the Ethereal Soul may be deficient either because itself is deficient or because the Mind is over-controlling it. The latter is common in individuals with strong, rigid beliefs (“religious” in a broad sense), which lead the Mind to suppress the psychic ideas coming from the Ethereal Soul. This situation may also arise as a consequence of guilt. In severe depression, there is a disconnection between the Mind (Shen of the Heart) and Ethereal Soul (Hun): the Ethereal Soul lacks its normal “movement”, and the person lacks creativity, ideas, imagination and, most of all, plans, projects, life aims and inspiration, so that depression results.

! In severe depression, there is a disconnection between the Mind (Shen of the Heart) and

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Ethereal Soul (Hun): the Ethereal Soul lacks its normal “movement”, and the person lacks creativity, ideas, imagination and, most of all, plans, projects, life aims and inspiration, so that depression results.

The Will-Power (Zhi) of the Kidneys in Depression The Zhi of the Kidneys has several different meanings; for example, it can mean “memory”, reflecting the influence of the Kidneys on the Sea of Marrow and the Brain and therefore memory. Zhi can also mean “Will-Power”, and it is in this context that it plays an important role in depression. “Will-Power” as a translation of Zhi includes will-power itself, drive, determination, steadfastness, enthusiasm and physical and mental power. CLINICAL NOTE Will-Power (Zhi) of the Kidneys “Will-Power” as a translation of Zhi includes willpower, drive, determination, steadfastness, enthusiasm and physical and mental power.

In my experience, depression always involves a weakening of “Will-Power” intended in the broad sense described above, i.e. including drive, determination, steadfastness, enthusiasm and physical and mental power. These are all qualities that are missing in a depressed person and, for this reason, I therefore always tonify the Kidneys in depression, even if there are no specific symptoms and signs of Kidney deficiency. I do so because the mental-emotional lack of drive and will-power seen in depression is indeed a Kidneydeficiency symptom by itself. To tonify the will-power and drive deriving from the Kidneys, I generally use BL-23 Shenshu and BL-52 Zhishi. CLINICAL NOTE Will-Power (Zhi) of the Kidneys A deficiency of the Kidneys’ “Will-Power” (Zhi) is nearly always a feature of depression and, for this reason, in depression I tonify the Will-Power with BL-23 Shenshu and BL-52 Zhishi.

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Distinction between Depression in Yu Syndrome and in Dian Syndrome Many modern Chinese books often discuss Depression Syndrome (Yu Zheng) as if it were identical to the depressive phase of manic depression (Dian of Dian Kuang). Many Chinese books, therefore, when giving the symptoms of “depression” give the symptoms of Dian. I personally feel that this is unhelpful and not corresponding to clinical practice. The “depression” in clinical depression is quite different from the “depression” in bipolar disorder (manic depression) from both a Western and a Chinese perspective. From a Chinese perspective, the depressive and manic phases of bipolar disorder (Dian Kuang) are two poles of a pathological spectrum with the same pathology. Central to the pathology of Dian Kuang is Phlegm obstructing the Mind (Shen); this accounts for both the depressive and the manic phases of the disease. Phlegm obstructs the Mind (Shen) but also the Ethereal Soul (Hun) so that it interferes with its “coming and going”, resulting in depression when it does not “come and go” enough and mania when it “comes and goes” too much. By contrast, in Depression (Yu Zheng) Phlegm is not always present and the “coming and going” of the Ethereal Soul is always impaired (without a manic phase), resulting in a depressed mood, a lack of inspiration, lack of a sense of direction in life, lack of life dreams and plans, etc.

Lilium Syndrome (Bai He Bing) The Lilium Syndrome (Bai He Bing) is described in the Essential Prescriptions of the Golden Chest (Jin Gui Yao Lue, c.AD 220), Chapter 3-1. This syndrome sounds remarkably like the description of a depressed patient. It says:6 The patient wants to eat but is reluctant to swallow food and unwilling to speak. He or she wants to lie in bed but cannot lie quietly, as he or she is restless. He or she wants to walk but is soon tired. Now and then, he or she may enjoy eating but cannot tolerate the smell of food. He or she feels cold or hot but without fever or chills, bitter taste or dark urine [i.e. it is not external Wind or internal Heat]. No drugs are able to cure this syndrome. After taking the medicine, the patient may vomit or have diarrhoea. The disease haunts the patient (hu huo) [hu means “fox” and huo means “bewildered”] and, although he or she looks normal, he or she is suffering. The pulse is rapid.

Modern books describe the syndrome with the following symptoms: “as if in a trance” or “absent-minded” (huang hu ), mental restlessness, bitter taste, dark urine, anxiety, depression, red tongue (which may be without coating) and rapid pulse. The treatment principle recommended by modern doctors is to moisten and nourish the Heart and Lungs, tonify Qi, nourish Yin, clear Heat (or Empty Heat), calm the Mind and strengthen the Will-Power (Zhi). The points suggested by the book Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Liao Xue) are as follows.7 • HE-7 Shenmen, KI-3 Taixi, LU-9 Taiyuan • HE-5 Tongli, LU-7 Lieque, KI-4 Dazhong, SP-6 Sanyinjiao • HE-9 Shaochong, P-9 Zhongchong, KI-7 Fuliu • BL-15 Xinshu, BL-13 Feishu, BL-23 Shenshu • LU-7 Lieque, KI-6 Zhaohai, LIV-3 Taichong With herbal medicine, to treat this syndrome I use the formula Bai He Zhi Mu Tang Lilium-Anemarrhena Decoction, which is composed only of the two herbs Bai He Bulbus Lilii and Zhi Mu Radix Anemarrhenae. In fact, I use these two herbs in any situation when a patient is depressed against a background of a Lung and Heart syndrome, but especially Qi and Yin deficiency of these two organs or Heart-Heat. The combination of these two herbs is particularly good to treat sadness and grief. In such cases, I frequently add these two herbs to whatever formula I am using.

SUMMARY LILIUM SYNDROME (BAI HE BING)  The patient wants to eat but is reluctant to swallow food.  Unwilling to speak.  He or she wants to lie in bed but cannot lie quietly, as he or she is restless.  He or she wants to walk but is soon tired.  Cannot tolerate the smell of food.  He or she feels cold or hot.  Rapid pulse.

CLINICAL NOTE Bai He (Bulbus Lilii) and Zhi Mu (Radix Anemarrhenae) I use the combination of Bai He Bulbus Lilii and Zhi Mu Radix Anemarrhenae to treat Lilium Syndrome

Depression

(Bai He Bing). In fact, I use these two herbs in any situation when a patient is depressed against a background of a Lung and Heart syndrome, but especially Qi and Yin deficiency of these two organs or Heart-Heat. The combination of these two herbs is particularly good to treat sadness and grief. In such cases, I frequently add these two herbs to whatever formula I am using.

Agitation (Zang Zao) Zang Zao, literally meaning “visceral restlessness”, was first mentioned in the chapter Pulse, Syndromes and Treatment of Miscellaneous Gynaecological Diseases of the Essential Prescriptions of the Golden Chest (Jin Gui Yao Lue, c.AD 220). This text says:8 The patient suffers from Agitation [Zang Zao], feels sad and tends to weep constantly as if she were haunted. She stretches frequently and yawns repeatedly. The decoction of Fu Xiao Mai, Zhi Gan Cao and Da Zao can calm the patient. The formula for Agitation (Zang Zao) is therefore Gan Mai Da Zao Tang Glycyrrhiza-Triticum-Jujuba Decoction. I personally use this formula not only for Agitation but also for Depression arising against a background of Qi and Blood deficiency.

Plum-Stone Syndrome (Mei He Qi) Plum-Stone Syndrome was first described in the chapter Pulse, Syndromes and Treatment of Miscellaneous Gynaecological Diseases of the Essential Prescriptions of the Golden Chest (Jin Gui Yao Lue, c.AD 220). This text says: “The patient has a suffocating feeling as if there was a piece of roast meat stuck in the throat. Use Ban Xia Hou Po Tang.”9 Therefore, as can be seen from the above statement, originally the symptom of Plum-Stone Syndrome was compared to the feeling of having a piece of meat (rather than a plum stone) in the throat. The aetiology of this syndrome is emotional and is due to depression. Subsequent Chinese books attributed this syndrome to the combination of Qi stagnation and Phlegm obstructing the throat. This type of Phlegm is actually called Qi-Phlegm, and it is the most non-substantial type of Phlegm. Although all modern Chinese books attribute the Plum-Stone Syndrome to stagnation of Liver-Qi, the for-

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mula Ban Xia Hou Po Tang Pinellia-Magnolia Decoction actually acts on Lung- and Stomach-Qi. I therefore use it primarily for stagnation of Qi of the Heart and Lungs in the chest area deriving from sadness, grief and worry. CLINICAL NOTE Plum-Stone Syndrome Although all modern Chinese books attribute the Plum-Stone Syndrome to stagnation of Liver-Qi, the formula Ban Xia Hou Po Tang actually acts on Lungand Stomach-Qi. I therefore use it primarily for stagnation of Qi of the Heart and Lungs in the chest area deriving from sadness, grief and worry.

In conclusion, the pathology of depression could be summarized as follows, with the acupuncture points suggested for each aspect and the main mentalemotional aspect or organ involved. • The Will-Power (Zhi) is impaired; there is lack of will-power, drive, initiative and momentum to break out of depression: BL-23 Shenshu, Du-4 Mingmen, BL-52 Zhishi, KI-3 Taixi. WILL-POWER (ZHI). • The Ethereal Soul does not come and go enough; there is a lack of plans, ideas, dreams, hope, inspiration and sense of direction: G.B.-40 Xiuxu, LIV-3 Taichong, G.B.-13 Benshen, BL-18 Ganshu, BL-47 Hunmen. ETHEREAL SOUL (HUN). • Deficiency of the Gall Bladder’s “courage” leads to indecisiveness: G.B.-40 Qiuxu, G.B.-13 Benshen, Du-20 Baihui. GALL BLADDER. • Angst, anxiety, despair leads to sadness: Du-24 Shenting, Ren-15 Jiuwei, HE-7 Shenmen. MIND (SHEN). • Morbid thoughts of death: Du-24 Shenting, BL-13 Feishu (“suicidal”), Du-12 Shenzhu (“desire to kill people”), BL-42 Pohu (“three corpses flowing”). CORPOREAL SOUL (PO). • Obsessive thinking, pensiveness, brooding: Du-24 Shenting, G.B.-13 Benshen, G.B.-15 Toulinqi, BL-20 Pishu, BL-49 Yishe. INTELLECT (YI). • Problem in forming relationships: T.B.-5 Waiguan, P-7 Daling, P-6 Neiguan, Ren-17 Shanzhong. PERICARDIUM and TRIPLE BURNER. The above are not alternative pathologies of depression but aspects of its pathology; although not all of them need to be present, most of them usually are.

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SUMMARY PATHOLOGY OF DEPRESSION IN CHINESE MEDICINE  Yu as stagnation  Yu as mental depression  Depression and the relationship between the Mind and the Ethereal Soul  The Will-Power (Zhi) of the Kidneys in depression  Distinction between Depression in Yu Syndrome and in Dian Syndrome  Lilium Syndrome (Bai He Bing)  Agitation (Zang Zao)  Plum-Stone Syndrome (Mei He Qi)

generally Wiry in all positions, it is always a definite sign that the mental depression is due to Liver-Qi stagnation. Often, the pulse picture contradicts the first appearance of the patient. In fact, the patient may appear depressed, slow in movement and pale with a weak voice – all signs pointing to a deficiency as the cause of the problem, but the pulse is Full and Wiry in every position; this is a sure sign that the depression is due to Qi stagnation. Indeed, in some cases (and in my experience, especially in men) the person may seek treatment for tiredness as his or her main complaint, but if the pulse is Full and Wiry in every position it almost certainly indicates that the person is depressed, with Liver-Qi stagnation as the main cause of it.

Sadness and grief

AETIOLOGY Emotional stress Emotional stress is the main aetiological factor in depression. The main emotions that may give rise to depression are anger, sadness, grief, worry and guilt.

Anger Anger (intended in a broad sense to include frustration, resentment and hatred) causes either Liver-Qi stagnation or Liver-Yang rising (Fig. 13.2). When it is suppressed, it is more likely to cause Liver-Qi stagnation and depression. Liver-Qi stagnation is a frequent cause of mental depression, especially in its beginning stages. Liver-Qi stagnation causes depression by restraining the “coming and going” of the Ethereal Soul, therefore resulting in a lack of ideas, projects, aims, inspiration and a general lack of sense of direction in life. One of the most significant and important signs of Liver-Qi stagnation is a Wiry pulse; if the pulse is

LIVER-QI STAGNATION (anger repressed)

Sadness and grief initially deplete Qi and therefore lead to Qi deficiency of the Spleen, Heart and Lungs (Fig. 13.3). However, after some time the very deficiency of Qi impairs its circulation and leads also to some Qi stagnation; this is a Qi stagnation that affects not the Liver but the Heart and Lungs. The Heart- and/or Lung-Qi stagnation also affect the Ethereal Soul and restrain its “coming and going”, resulting in a lack of ideas, projects, aims and inspiration and a general lack of sense of direction in life. Sadness and grief are frequent causes of depression from loss of a family member or partner through death or separation; this is called reactive depression in Western psychiatry.

Worry Worry “knots” Qi, which means that it causes Qi stagnation. Worry causes stagnation of Qi of the Spleen, Lungs and Heart (Fig. 13.4); in my experience, worry also affects the Liver and may cause either Liver-Qi stagnation or Liver-Yang rising.

SADNESS GRIEF

QI DEFICIENCY

ANGER QI STAGNATION (Lungs and Heart)

LIVER-YANG RISING (anger manifested) Figure 13.2 Effect of anger.

Figure 13.3 Effect of sadness and grief.

Depression

WORRY

QI STAGNATION (Spleen, Lungs and Heart)

GUILT

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QI STAGNATION (Heart and Kidneys)

Figure 13.4 Effect of worry. Figure 13.5 Effect of guilt.

The Heart- and/or Lung-Qi stagnation also affect the Ethereal Soul and restrain its “coming and going”, resulting in a lack of ideas, projects, aims and inspiration and a general lack of sense of direction in life.

Guilt Guilt is, in my experience, a common cause of Qi stagnation; it affects primarily the Heart and Kidneys (Fig. 13.5). The Heart-Qi stagnation also affects the Ethereal Soul and restrains its “coming and going”, resulting in a lack of ideas, projects, aims and inspiration and a general lack of sense of direction in life. As guilt also affects the Kidneys, it weakens the WillPower (Zhi), the weakness of which is an important feature of depression. CLINICAL NOTE Emotions and Qi stagnation  All emotions lead to some Qi stagnation initially (also those that deplete Qi, such as sadness and grief).  Not all Qi stagnation is related to the Liver.  In emotional problems, other organs suffer from Qi stagnation, notably the Lungs and Heart.  Note that Liver-Qi stagnation may also derive from emotions other than “anger” (e.g. worry and guilt).

Irregular diet Diet plays a secondary role in the aetiology of depression; in my experience, it contributes to the development of depression in the presence of emotional stress. Excessive consumption of dairy foods, sweets, sugar and bread may lead to the formation of Phlegm. Phlegm may become a contributory pathological element of depression because, first of all, it impairs Qi and would therefore aggravate any deficiency and stagnation of Qi. It is also obstructive and heavy and therefore would cloud the Mind, leading to mental confusion; this condition would aggravate a condition of restraint of the Ethereal Soul. In my experience, a dietary contributory factor in the development of depression is a diet lacking in nourishment. This occurs when patients follow strict slimming diets or when they apply a vegetarian diet inappropriately. This leads to deficiency of Qi and Blood, which are the conditions underlying Deficiency types of depression.

Overwork Overwork, in the sense of working long hours without adequate rest for several years, leads to Kidney-Yin deficiency, and this often forms the background for depression in older people.

Constitutional traits In my experience, constitutional traits play an important role in the aetiology of depression. For example, a constitutional deficiency of the Kidneys, with its resulting weakness of the Will-Power (Zhi), is a frequent underlying background for the development of depression. A constitutional tendency to Heart patterns is also an important contributory factor to the development of depression. The most important and reliable sign of a tendency to emotional problems is a midline Heart crack on the tongue (see Fig. 12.4).

SUMMARY AETIOLOGY AND PATHOLOGY  Emotional stress — Anger — Sadness and grief — Worry — Guilt  Constitutional traits  Irregular diet  Overwork

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IDENTIFICATION OF PATTERNS AND TREATMENT The patterns discussed will be: • • • • • • • • • • • •

Liver-Qi stagnation Heart- and Lung-Qi stagnation Stagnant Liver-Qi turning into Heat Phlegm-Heat harassing the Mind Blood stasis obstructing the Mind Qi stagnation with Phlegm Diaphragm Heat Worry injuring the Mind Heart and Spleen deficiency Heart-Yang deficiency Kidney- and Heart-Yin deficiency, Empty Heat blazing Kidney-Yang deficiency.

Patient’s profile Liver-Qi stagnation is a common cause of depression in young people, roughly from teenage years to about 35. It is usually due to repressed anger, frustration or resentment.

Treatment principle Soothe the Liver, move Qi, eliminate stagnation.

Acupuncture Points P-6 Neiguan, LIV-3 Taichong, G.B.-34 Yanglingquan, T.B.-3 Zhongzhu, G.B.-13 Benshen, BL-47 Hunmen, Du-20 Baihui. Reducing or even method on all points except Du-20, which should be reinforced.

Explanation

Liver-Qi stagnation Clinical manifestations Depression, moodiness, worry, frustration, feeling uptight and tense, hypochondrial pain and distension, tension and ache of the muscles of the neck and top of the shoulders, abdominal distension, irregular bowel movement, irregular periods, premenstrual tension. Tongue: the tongue-body colour may be normal or slightly red on the sides. Pulse: Wiry.

Pathology and mental-emotional pattern Depression is characterized by the insufficient “coming and going” of the Ethereal Soul, resulting in a lack of dreams, aspirations, plans, ideas and inspiration. LiverQi stagnation is one of the most common causes of constraint of the movement of the Ethereal Soul. Liver-Qi stagnation may derive from anger intended in a broad sense (including frustration and resentment); anger is even more prone to cause Liver-Qi stagnation when it is repressed. However, in my experience, Liver-Qi stagnation may also derive from worry and guilt. The patient who is depressed against a background of Liver-Qi stagnation will not only be depressed but also moody and prone to outbursts of anger. He or she will also suffer from irritability and an intense feeling of frustration. An important sign of Liver-Qi stagnation as the cause of depression is a Wiry pulse.

• P-6 is an important point for depression from LiverQi stagnation. It moves Liver-Qi by virtue of the association between the Pericardium and Liver channels within the Terminal Yin (Jue Yin). This point acts on the Liver and has a “centrifugal” movement; it therefore stimulates the “coming and going” of the Ethereal Soul in depression from Liver-Qi stagnation. As it lies on the Pericardium channel, P-6 also acts on the Heart lifting mood. It is frequently used for this purpose in modern China. • LIV-3 and G.B.-34 move Liver-Qi and therefore stimulate the “coming and going” of the Ethereal Soul to relieve depression. LIV-3 also has a calming effect and is good when the patient also suffers from anxiety. • T.B.-3 lifts mood and stimulates the “coming and going” of the Ethereal Soul to relieve depression. • G.B.-13 lifts mood, calms the Mind and stimulates the “coming and going” of the Ethereal Soul. • BL-47 regulates the “coming and going” of the Ethereal Soul; it can either stimulate it when it is deficient or calm it when it is excessive. • Du-20 lifts mood and depression.

CLINICAL NOTE P-6 Neiguan P-6 is an important point for depression from LiverQi stagnation. It combines the function of moving Liver-Qi by virtue of the association between the

Depression

Pericardium and Liver channels within the Terminal Yin (Jue Yin) with that of nourishing the Heart and moving Heart-Qi, because of the close connection between the Heart and Pericardium. This point acts on the Liver and has a “centrifugal” movement; it therefore stimulates the “coming and going” of the Ethereal Soul in depression from Liver-Qi stagnation. As it lies on the Pericardium channel, P-6 also acts on the Heart lifting mood. It is frequently used for this purpose in modern China.

Herbal therapy Prescription YUE JU WAN Gardenia-Chuanxiong Pill

Explanation Yue Ju Wan is the formula for mental depression deriving from Liver-Qi stagnation. It was formulated by Zhu Dan Xi for the six stagnations of Qi, Blood, Dampness, Phlegm, Heat and Food. It contains five herbs for six stagnations, because Cang Zhu treats stagnation both from Dampness and from Phlegm. Although this formula is for the six stagnations, it is primarily for Qi stagnation, and therefore Xiang Fu is its emperor herb. This is an intriguing formula as, when considered individually, none of its ingredients has a particularly strong mental effect (indeed, one of them, Shen Qu, is a digestive herb), but together they form a prescription that has an undoubted mental effect in relieving depression. When this formula is used as an individualized prescription (as opposed to a remedy), the ingredients’ dosage can be modified to take into account the presenting pattern. For example, if Phlegm is predominant, then the dosage of Cang Zhu is increased; if Blood stasis is present, then Chuan Xiong is increased, etc. An important sign for the use of this formula is a Wiry pulse. CLINICAL NOTE Yue Ju Wan I find the formula Yue Ju Wan excellent to treat depression from Liver-Qi stagnation. If the pulse is Full and Wiry in every position in a depressed person, this is the first formula I consider.

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Prescription CHAI HU SHU GAN TANG Variation Bupleurum Soothing the Liver Decoction Variation

Explanation This formula is a well-known and much-used formula for Liver-Qi stagnation; it acts primarily on the Lower Burner, and it would therefore be suitable if the patient somatizes his or her feelings in the lower abdomen with digestive problems such as abdominal distension and pain and bowel irregularity. Qing Pi strengthens the moving-Qi effect, and it directs it to the upper part of the body and the head; Yu Jin moves Qi and invigorates Blood and opens the Mind’s orifices. It has a specific effect on mental depression from Qi stagnation.

Prescription XIAO YAO SAN Free and Easy Wanderer Powder This formula is selected when the stagnation of Liver-Qi occurs against a background of Liver-Blood deficiency, which is more likely to occur in women. The tongue could therefore be Pale, and the pulse is not Wiry on all positions (as for Yue Ju Wan) but only slightly Wiry on the left and Fine in general (indicating Blood deficiency). This situation is more common in women, and this formula is therefore particularly suited to women.

Explanation This formula is selected when Liver-Qi stagnation derives from or occurs against a background of LiverBlood deficiency and Spleen-Qi deficiency. In my experience, this formula is probably overused to treat mental depression from Liver-Qi stagnation; it is specifically for Liver-Qi stagnation deriving from or occurring against a background of Liver-Blood deficiency. In “pure” Liver-Qi stagnation with a Full and Wiry pulse on all positions, one should use Yue Ju Wan rather than Xiao Yao San. Table 13.1 illustrates the differences between Xiao Yao San and Yue Ju Wan.

Prescription WU GE KUAN ZHONG SAN Five Diaphragms Relaxing the Centre Powder

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Table 13.1 Differences between Xiao Yao San and Yue Ju Wan Xiao Yao San

Yue Ju Wan

Patterns

Liver-Qi stagnation, Liver-Blood deficiency, Spleen-Qi deficiency

Liver-Qi stagnation

Aetiology

Emotional stress combined with overwork and irregular diet

Emotional stress

Pulse

Fine and slightly Wiry; Weak in general and slightly Wiry on the left

Full and Wiry on all positions

Tongue

Body colour may be normal or Pale

Slightly red sides

Emotional symptoms

Depression, sadness, crying

Depression, repressed anger

• • • • •

Worry diaphragm Anger diaphragm Qi diaphragm Cold diaphragm Heat diaphragm.

The symptoms of each of these five conditions are as follows. Worry diaphragm Stagnation of Qi in the chest, fluids not being transformed, food does not go down, shortness of breath. Anger diaphragm Fullness under the heart, food not digested, difficulty in urination and defecation. Qi diaphragm Fullness in chest and hypochondrium, choking sensation.

Explanation

Cold diaphragm Distension and fullness of abdomen and heart region, cough, wheezing, feeling of cold in the abdomen, flatulence, umbilical pain, inability to digest fats.

This formula is specific for mental depression from Qi stagnation. It has a wider range of effect than the previous formulae, and it is particularly indicated when the Qi stagnation manifests in the Middle Burner. It is called Five Diaphragms Relaxing the Centre Powder because it treats five different pathological conditions of the diaphragm, all of them with an underlying Qi stagnation. The five conditions are:

Heat diaphragm Five-palm heat, mouth ulcers, burning and heaviness of the limbs, dry lips and mouth, feeling of heat of the body, lower backache, chest pain radiating to the upper back, cannot eat much. Table 13.2 compares Yue Ju Wan, Chai Hu Shu Gan Tang, Xiao Yao San and Wu Ge Kuan Zhong San.

Table 13.2 Comparison of Yue Ju Wan, Chai Hu Shu Gan Tang, Xiao Yao San and Wu Ge Kuan Zhong San Patterns

Pulse

Tongue

Emotional symptoms

Yue Ju Wan

Liver-Qi stagnation

Full and Wiry on all positions

Slightly red sides

Depression, repressed anger

Chai Hu Shu Gan Tang

Liver-Qi stagnation in Lower Burner

Wiry, may be Wiry only on left

Slightly red sides

Depression, anger

Xiao Yao San

Liver-Qi stagnation, Liver-Blood deficiency, Spleen-Qi deficiency

Fine and slightly Wiry; Weak in general and slightly Wiry on the left

Body colour may be normal or Pale

Depression, sadness, crying

Wu Ge Kuan Zhong San

Liver-Qi stagnation in Middle and Upper Burner

Wiry on Stomach and Lung positions

Slightly red sides

Depression, worry

Depression

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Three Treasures remedies

!

Release Constraint This remedy is a variation of Yue Ju Wan Gardenia-Chuanxiong Pill with all the same actions and indications.

Remember: Qi stagnation occurs not only in the Liver but, especially in emotional problems, also in the Lungs and Heart.

Freeing the Moon (Women’s Treasure) This remedy is a variation of Xiao Yao San with its same functions, i.e. move Liver-Qi, nourish Liver-Blood and tonify Spleen-Qi.

SUMMARY LIVER-QI STAGNATION Points P-6 Neiguan, LIV-3 Taichong, G.B.-34 Yanglingquan, T.B.-3 Zhongzhu, G.B.-13 Benshen, BL-47 Hunmen, Du-20 Baihui. Reducing or even method on all points except on Du-20, which should be reinforced. Herbal therapy Prescriptions YUE JU WAN Gardenia-Chuanxiong Pill CHAI HU SHU GAN TANG Variation Bupleurum Soothing the Liver Decoction Variation XIAO YAO SAN Free and Easy Wanderer Powder WU GE KUAN ZHONG SAN Five Diaphragms Relaxing the Centre Powder Three Treasures remedies Release Constraint Freeing the Moon

Pathology and mental-emotional pattern Sadness, grief and worry affect the Heart and Lungs; while sadness and grief initially deplete Qi while worry knots Qi, all three emotions, after some time, lead to Qi stagnation in the chest area. The Lungs are particularly affected by the sadness and grief deriving from separation and loss; this is a frequent cause of depression. The Qi stagnation deriving from the above emotions affects the circulation of Heart-Qi and Lung-Qi in the chest and constricts the Corporeal Soul; on a physical level, this causes a feeling of distension or tightness of the chest and sighing. On a mental-emotional level, the person is sad, depressed and tends to weep a lot.

Patient’s profile Heart- and Lung-Qi stagnation are common in young people (up to about 35). They nearly always derive from sadness and grief due to loss.

Treatment principle Move Heart- and Lung-Qi, calm the Mind, lift mood, settle the Corporeal Soul.

Acupuncture Points HE-5 Tongli, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong, L.I.-4 Hegu. All with even method.

Heart- and Lung-Qi stagnation Clinical manifestations Depression, sadness, slight anxiety, palpitations, a feeling of distension or oppression of the chest, a slight feeling of lump in the throat, slight shortness of breath, sighing, poor appetite, chest and upper epigastric distension, dislike of lying down, weak and cold limbs, pale complexion. Tongue: slightly Red on the sides in the chest areas. Pulse: Empty but very slightly Overflowing on the left-Front position and very slightly Tight on the rightFront position.

Explanation • HE-5, HE-7 and P-6 move Heart-Qi, lift the mood and calm the Mind. • Ren-15 calms the Mind and nourishes the Heart. • Ren-17 and LU-7 move Lung-Qi. • ST-40 and L.I.-4 stimulate the descending of Qi.

Herbal therapy Prescription MU XIANG LIU QI YIN Aucklandia Flowing Qi Decoction

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Explanation This formula moves Qi in the Heart and Lungs, subdues rebellious Qi in the chest and tonifies Qi and Yin.

Prescription BAN XIA HOU PO TANG Pinellia-Magnolia Decoction

Explanation This formula moves Qi in the Heart and Lungs and relieves depression. It is used when the physical symptoms are centred in the chest area, with a feeling of oppression and distension of the chest and sighing.

Three Treasures remedy Open the Heart This remedy is a variation of Ban Xia Hou Po Tang with its same actions.

SUMMARY HEART- AND LUNG-QI STAGNATION

Tongue: Red body colour with redder sides or normal body colour with red sides. Pulse: Wiry-Rapid.

Pathology and mental-emotional pattern In Liver-Qi stagnation, the clinical manifestations are centred primarily in the hypochondrium and abdomen, while in Stagnant Liver-Qi turning into Heat there are also manifestations in the head, such as headache, dry mouth, red eyes and face and bitter taste. Liver-Qi stagnation impairs the “coming and going” of the Ethereal Soul, leading to depression in the same way as described above under the pattern of “Liver-Qi stagnation”. The Heat deriving from the long-term Qi stagnation, on the other hand, agitates the Mind and leads to anxiety.

Patient’s profile Stagnant Liver-Qi turning into Heat tends to be more common in people over 35. The aetiology of this pattern is usually repressed anger combined with overwork and excessive consumption of alcohol.

Points HE-5 Tongli, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong, L.I.-4 Hegu. All with even method.

Treatment principle

Herbal therapy Prescriptions MU XIANG LIU QI YIN Aucklandia Flowing Qi Decoction BAN XIA HOU PO TANG Pinellia-Magnolia Decoction

Points

Three Treasures remedy Open the Heart

Explanation

Stagnant Liver-Qi turning into Heat Clinical manifestations Depression, moodiness, worry, frustration, feeling uptight and tense, anxiety, agitation, short temper, dry mouth, bitter taste, constipation, headache, red face and eyes, hypochondrial pain and distension, tension and ache of the muscles of the neck and top of the shoulders, abdominal distension, irregular bowel movement, irregular periods, premenstrual tension.

Soothe the Liver, move Qi, eliminate stagnation, clear Liver-Heat.

Acupuncture P-6 Neiguan, LIV-3 Taichong, LIV-2 Xingjian, G.B.-34 Yanglingquan, T.B.-3 Zhongzhu, G.B.-43 Xiaxi, G.B.-13 Benshen, Taiyang, BL-47 Hunmen, Du-20 Baihui. Reducing or even method on all points except on Du-20, which should be reinforced.

• P-6, LIV-3, G.B.-34, T.B.-3, G.B.-13, BL-47 and Du-20 have all been explained above under the pattern of Liver-Qi stagnation. As the Heat here derives from Qi stagnation, it must be cleared primarily by moving Qi and eliminating stagnation. • LIV-2 clears Liver-Heat. • G.B.-43 clears Liver-Heat and treats headaches. It clears Heat from the head region. It is added to the point combination because the Heat in the Liver (as opposed to purely Liver-Qi stagnation) causes some symptoms to appear in the head (headache, dry mouth, bitter taste, red face and eyes). • Taiyang calms the Mind.

Depression

Herbal therapy Prescription DAN ZHI XIAO YAO SAN Moutan-Gardenia Free and Easy Wanderer Powder

Explanation This is the representative formula to clear Liver-Heat deriving from Liver-Qi stagnation. It is based on Xiao Yao San to move Liver-Qi and eliminate stagnation, with the addition of Mu Dan Pi and Shan Zhi Zi to clear Liver-Heat.

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Herbal therapy Prescriptions DAN ZHI XIAO YAO SAN Moutan-Gardenia Free and Easy Wanderer Powder XIAO YAO SAN plus ZUO JIN WAN Free and Easy Wanderer Powder plus Left Metal Pill Three Treasures remedy Freeing the Sun

Prescription XIAO YAO SAN with ZUO JIN WAN Free and Easy Wanderer Powder plus Left Metal Pill

Phlegm-Heat harassing the Mind

Explanation

Depression, mental restlessness, anxiety, agitation, restless sleep, excessive dreaming, insomnia, palpitations, a feeling of heaviness of the head, dizziness, a feeling of oppression of the chest, expectoration of phlegm, nausea, bitter taste, sticky taste. Tongue: Red, Swollen, sticky tongue coating, possibly Heart crack. Pulse: Slippery-Rapid.

When Heat derives from Qi stagnation, the primary treatment principle is to move Qi and eliminate stagnation; when this is eliminated, Heat is also automatically cleared. However, some herbs to clear Heat are also added, hence the addition of Zuo Jin Wan (that clears Liver-Heat) to Xiao Yao San (that moves Liver-Qi). CLINICAL NOTE When Heat derives from Qi stagnation, the primary herbal treatment principle must be to move Qi and eliminate stagnation.

Three Treasures remedy Freeing the Sun This remedy is a variation of Dan Zhi Xiao Yao San, and it is specific for Liver-Heat deriving from Liver-Qi stagnation. Compared with the original formula, it has a stronger calming the Mind action.

SUMMARY STAGNANT LIVER-QI TURNING INTO HEAT Points P-6 Neiguan, LIV-3 Taichong, LIV-2 Xingjian, G.B.-34 Yanglingquan, T.B.-3 Zhongzhu, G.B.-43 Xiaxi, G.B.-13 Benshen, Taiyang, BL-47 Hunmen, Du-20 Baihui. Reducing or even method on all points except on Du-20, which should be reinforced.

Clinical manifestations

Pathology and mental-emotional pattern Phlegm obstructs the Mind, while Heat agitates it. Phlegm obstructing the Mind causes mental confusion and, in severe cases, a certain loss of insight; Heat makes the person agitated, restless and anxious. In some cases, the person may alternate between periods of depression and confusion (due to Phlegm obstructing the Mind and also impairing the “coming and going” of the Ethereal Soul) and periods of abnormal elation, agitation and manic behaviour (due to Fire). In severe cases, this leads to manic depression. CLINICAL NOTE Phlegm obstructs the Mind (causing a certain loss of insight) and Heat agitates it (causing anxiety and mental restlessness).

Patient’s profile The pattern of Phlegm-Heat harassing the Mind is more common in people over 35 and with a tendency to obesity. The aetiology is usually long-standing emotional stress (particularly worry, guilt and anger)

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together with irregular diet and the excessive consumption of greasy foods and alcohol.

Treatment principle Resolve Phlegm, clear Heat, open the Mind’s orifices.

Acupuncture Points Ren-12 Zhongwan, BL-20 Pishu, ST-40 Fenglong, SP-9 Yinlingquan, SP-6 Sanyinjiao, P-5 Jianshi, P-7 Daling, ST-8 Touwei, Du-24 Shenting, G.B.-13 Benshen, G.B.-17 Zhengying, G.B.-18 Chengling, Du-20 Baihui. All points with reducing or even method except for Ren-12 and BL-20, which should be reinforced.

Explanation • Ren-12, BL-20, ST-40, SP-9 and SP-6 resolve Phlegm. In particular, ST-40 resolves Phlegm and calms the Mind and SP-6 calms the Mind. • P-5 and P-7 calm the Mind and open the Mind’s orifices. • ST-8 resolves Phlegm from the head. • Du-24 and G.B.-13 calm the Mind and lift mood. • G.B.-17 and G.B.-18 open the Mind’s orifices. • Du-20 lifts mood.

Herbal therapy Prescriptions WEN DAN TANG Warming the Gall Bladder Decoction

Explanation This interesting formula has two main interpretations. Originally, it was used for a Gall Bladder deficiency following a severe acute disease, the Gall Bladder deficiency manifesting with timidity, jumpiness, insomnia (waking up early in the morning) and mental restlessness. In more recent times, it is more frequently used for Phlegm-Fire affecting Stomach, Heart or Lungs. The main manifestations for which it is used in this context are mental restlessness, jumpiness, insomnia, a bitter and sticky taste, a flustered feeling in the heart region, nausea, vomiting, palpitations, dizziness, a Swollen tongue with a sticky-yellow coating and a Wiry or Slippery pulse. A characteristic tongue configuration strongly indicates the use of this formula. It is a tongue that is

Swollen and has a combination of Heart and Stomach crack with a rough, brush-like yellow coating inside the Stomach crack. A combined Heart and Stomach crack extends all the way to the tip, as a Heart crack would do, but it is wide and shallow in the centre, as a Stomach crack would be (see Fig. 12.8). Wen Dan Tang is an excellent formula for the pattern of Phlegm-Heat agitating and obstructing the Mind and causing depression; I generally modify it with the addition of Yuan Zhi Radix Polygalae and Suan Zao Ren Semen Ziziphi spinosae.

Three Treasures remedies Clear the Soul This remedy is a variation of Wen Dan Tang but with a stronger action in calming the Mind. Settling the Soul This remedy drains Fire and resolves Phlegm, with a strong action in calming the Mind and opening the Mind’s orifices.

SUMMARY PHLEGM-HEAT HARASSING THE MIND Points Ren-12 Zhongwan, BL-20 Pishu, ST-40 Fenglong, SP-9 Yinlingquan, SP-6 Sanyinjiao, P-5 Jianshi, P-7 Daling, ST-8 Touwei, Du-24 Shenting, G.B.-13 Benshen, G.B.-17 Zhengying, G.B.-18 Chengling, Du-20 Baihui. All points with reducing or even method except for Ren-12 and BL-20, which should be reinforced. Herbal therapy Prescriptions WEN DAN TANG Warming the Gall Bladder Decoction Three Treasures remedies Clear the Soul Settling the Soul

Blood stasis obstructing the Mind Clinical manifestations Depression, mental restlessness, agitation at night, short temper, restless sleep, dreaming a lot, pain in the chest. Tongue: Purple. Pulse: Wiry.

Depression

Pathology and mental-emotional pattern Blood is the “residence” of the Mind (Shen) and Ethereal Soul, and a deficiency of Blood frequently affects both the Mind and the Ethereal Soul, depriving them of their “residence”. However, it is important to note that Blood stasis also affects the Mind and the Ethereal Soul. In particular, Blood stasis tends to obstruct the Mind in a similar way that Phlegm does and, in serious cases, it can lead to a certain loss of insight. The patient is depressed but also anxious and agitated and may dream a lot, as Blood stasis frequently causes an aggravation of symptoms at night.

! Remember: not only Blood deficiency but also Blood stasis affects the Mind (Shen).

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• Ren-14 and HE-5 invigorate Blood in the Heart and therefore calm the Mind when this is agitated by Blood stasis. HE-5 invigorates Blood by virtue of its being the Connecting point. • SP-6 and LIV-3 calm the Mind and invigorate Blood. • G.B.-15 has a deep effect on the emotional life and is particularly indicated to balance the moods when the person oscillates between periods of low spirits and periods of elation.10 In my experience, this point is effective to stop obsessive thoughts and pensiveness. • Du-20 lifts mood.

Herbal therapy Prescription XUE FU ZHU YU TANG Blood Mansion Eliminating Stasis Decoction

Patient’s profile The pattern of Blood stasis obstructing the Mind is more common in people over 40 and in women. It is usually due to long-standing repressed anger, worry or guilt.

Treatment principle Invigorate Blood, calm the Mind, eliminate stasis.

Acupuncture Points P-6 Neiguan, BL-17 Geshu, SP-10 Xuehai, Ren-14 Juque, HE-5 Tongli, SP-6 Sanyinjiao, LIV-3 Taichong, G.B.-15 Toulinqi, Du-20 Baihui. All with reducing or even method except for Du-20, which should be reinforced.

Explanation • P-6 invigorates Blood and affects the Upper Burner and therefore the head. It also calms the Mind and regulates the “coming and going” of the Ethereal Soul. • BL-17 and SP-10 invigorate Blood. Both these points invigorate Blood, and they are often used together, as the former invigorates Blood in the Upper Burner and the latter in the Lower Burner.

Explanation This formula is very widely used for stasis of Blood in the Upper Burner causing chest pain. Because Blood is the residence of the Mind, any Blood pathology can affect the Mind. Blood stasis agitates and obstructs the Mind. It agitates the Mind because Qi and Blood cannot flow smoothly, and this is reflected on the mentalemotional level. It obstructs the Mind because the impeded flow of Blood retards the circulation of Blood to the Mind and thus obfuscates its orifices. Anger, frustration, resentment, shock and guilt can all lead to Heart-Blood stasis. This usually occurs only after a long period of time, going through the stage of Qi stagnation first. When stagnant Blood in the Heart affects the Mind, it may cause depression, palpitations, insomnia, a suffocating sensation in the chest, irritability, mood swings and, in severe cases, psychosis. Sleep is very disturbed, the patient waking up frequently at night, tossing and turning and with nightmares. Shi Chang Pu Rhizoma Acori graminei and Yu Jin Tuber Curcumae should be added to open the Mind’s orifices and invigorate Blood.

Three Treasures remedy Red Stirring This remedy is a variation of Xue Fu Zhu Yu Tang with the same functions, except that it has a stronger action in calming the Mind.

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SUMMARY BLOOD STASIS OBSTRUCTING THE MIND Points P-6 Neiguan, BL-17 Geshu, SP-10 Xuehai, Ren-14 Juque, HE-5 Tongli, SP-6 Sanyinjiao, LIV-3 Taichong, G.B.-15 Toulinqi, Du-20 Baihui. All with reducing or even method except for Du-20, which should be reinforced. Herbal therapy Prescriptions XUE FU ZHU YU TANG Blood Mansion Eliminating Stasis Decoction Three Treasures remedy Red Stirring

The “coming and going” of the Ethereal Soul may be restrained both by Qi stagnation and by Phlegm, hence the patient is depressed and lacks a sense of direction in life. When, in addition to Qi stagnation, there is Phlegm, this clouds the Mind’s orifices and it leads to a certain loss of insight. The person feels confused and bewildered, without being able to pinpoint what the trouble is. On a physical level, the clinical manifestations are centred on the throat and chest, with a feeling of obstruction of the throat (that comes and goes) and a feeling of tightness of the chest.

Patient’s profile The pattern of Qi stagnation with Phlegm is more common in patients between 35 and 45. It is usually due to sadness, grief, worry or shame.

Treatment principle

Qi stagnation with Phlegm

Resolve Phlegm, move Qi, eliminate stagnation.

Clinical manifestations

Acupuncture

Depression, moodiness, uncomfortable feeling in the throat like a foreign body that cannot be coughed up or swallowed, difficulty in swallowing, sighing, a feeling of oppression in the chest, hypochondrial pain, premenstrual tension. Tongue: Swollen body, possibly red sides, sticky coating. Pulse: Wiry or Slippery.

Points

Pathology and mental-emotional pattern The Ethereal Soul, residing in the Liver, is responsible for ideas, projects, life dreams, aims, creativity, etc. The Ethereal Soul provides this “movement” on a mental and psychic level to the Mind (Shen) and, for this reason, the Ethereal Soul is said to be the “coming and going” of the Mind. When the Ethereal Soul does not “come and go” enough, the person lacks dreams, aims, projects, inspiration and creativity; he or she lacks a sense of direction and feels frustrated. These people are often at crossroads (which may have to do with relationships or work) in life and lack a sense of direction; in short, the person is depressed. When Qi stagnates over a long period of time, the free flow of Qi in the Triple Burner is impaired, and this leads to impairment of the metabolism of fluids; after time, this may result in the formation of Phlegm.

ST-40 Fenglong, Ren-12 Zhongwan, BL-20 Pishu, SP-9 Yinlingquan, SP-6 Sanyinjiao, P-5 Jianshi, T.B.-6 Zhigou, P-6 Neiguan, LIV-3 Taichong, Ren-17 Shanzhong, Ren-15 Jiuwei, Du-21 Qianding, Du-20 Baihui. All with reducing or even method except for Ren-12 and BL-20, which should be reinforced to tonify the Spleen.

Explanation • ST-40, Ren-12, BL-20, SP-9 and SP-6 resolve Phlegm. In particular, ST-40 resolves Phlegm and calms the Mind and SP-6 calms the Mind. • P-5 resolves Phlegm from the Mind and opens the Mind’s orifices. • T.B.-6, P-6, LIV-3 and Ren-17 move Qi and calm the Mind. T.B.-6 is particularly indicated if there is hypochondrial pain. • Ren-15 and Du-21 open the Mind’s orifices and calm the Mind. • Du-20 lifts mood.

Herbal therapy Prescription BAN XIA HOU PO TANG Pinellia-Magnolia Decoction

Depression

Explanation This formula, from the Discussion of Cold-Induced Diseases, is normally used for the plum-stone pattern characterized by a feeling of obstruction in the throat, mental depression and irritability. In modern times, this pattern is related to stagnation of Liver-Qi, for which this formula is used. An analysis of the formula, however, reveals that it contains no herbs that move Liver-Qi or even enter the Liver. The main emphasis of the formula is to move stagnant Heart- and Lung-Qi. Stagnation of Heart- and Lung-Qi derives from sadness and grief over a long period of time. These emotions first deplete Heart-Qi and Lung-Qi and depress the Mind and Corporeal Soul. The depletion of Lung-Qi from sadness and grief leads to shallow breathing and poor circulation of Qi in the chest and, eventually, to stagnation of Lung-Qi in the chest. The simultaneous weakness and stagnation of Lung-Qi may also lead to Phlegm. The Lung channel influences the throat, and its stagnation can cause a feeling of obstruction in the throat. The person becomes depressed, anxious as well as sad, sighs frequently and has the typical feeling of obstruction in the throat and chest. This is caused by the constriction of the Corporeal Soul in the throat and chest. The chronic stagnation of Heart-Qi obstructs the Mind and causes severe confusion.

Modifications • Similarly as for stagnation of Liver-Qi, Shi Chang Pu Rhizoma Acori tatarinowii should be added to open the Mind’s orifices. • If there is a pronounced feeling of oppression of the chest from Qi stagnation (slightly Wiry pulse), add Qing Pi Pericarpium Citri reticulatae viridae and Mu Xiang Radix Aucklandiae. • If there is a feeling of heaviness under the heart, add Zhi Shi Fructus Aurantii immaturus. • If mental restlessness and irritability are pronounced, add He Huan Pi Cortex Albiziae.

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it preserves the element of resolving Phlegm but, contrary to it, it does not clear Heat. It moves Qi, eliminates stagnation, opens the Mind’s orifices, calms the Mind and relieves depression.

Prescription SHUN QI DAO TAN TANG Variation Rectifying Qi and Eliminating Phlegm Decoction Variation

Explanation This formula resolves Phlegm, moves Qi and subdues rebellious Qi; it resolves Phlegm not only by using herbs that dry up Phlegm but also by using herbs that make Qi flow in the right direction. Shi Chang Pu Rhizoma Acori tatarinowii and Yuan Zhi Radix Polygalae are added to open the Mind’s orifices.

Three Treasures remedies Open the Heart Open the Heart treats Qi stagnation of the Lungs and Heart and is used when the patient is affected by sadness, grief or worry causing these two patterns. The patient is depressed and the symptoms are somatized in the chest area, resulting in a feeling of oppression or distension of the chest and sighing. Bright Spirit Bright Spirit specifically treats Qi stagnation and Phlegm affecting the Mind. Like Open the Heart, it acts on the chest area and treats depression manifesting with chest symptoms such as a feeling of oppression and distension of the chest and sighing; it differs from Open the Heart in that it resolves Phlegm, which Open the Heart does not do. Clear the Soul Clear the Soul resolves Phlegm and clears Heat and can treat depression deriving from Phlegm-Heat affecting the Heart and Lungs. In this case too, the symptoms manifest in the chest area with a feeling of oppression of the chest, sighing and possibly slight expectoration of yellow mucus.

SUMMARY

Prescription

QI STAGNATION WITH PHLEGM

SHI WEI WEN DAN TANG Variation Ten-Ingredient Warming the Gall Bladder Decoction Variation

Points ST-40 Fenglong, Ren-12 Zhongwan, BL-20 Pishu, SP-9 Yinlingquan, SP-6 Sanyinjiao, P-5 Jianshi, T.B.-6 Zhigou, P-6 Neiguan, LIV-3 Taichong, Ren-17 Shanzhong, Ren-15 Jiuwei, Du-21 Qianding, Du-20 Baihui. All with reducing or even

Explanation This formula is a variation of Wen Dan Tang Warming the Gall Bladder Decoction. Of the original prescription,

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method except for Du-20, which should be reinforced. Herbal therapy Prescriptions BAN XIA HOU PO TANG Pinellia-Magnolia Decoction SHI WEI WEN DAN TANG Variation Ten-Ingredient Warming the Gall Bladder Decoction Variation SHUN QI DAO TAN TANG Variation Rectifying Qi and Eliminating Phlegm Decoction Variation Three Treasures remedies Open the Heart Bright Spirit Clear the Soul

Patient’s profile The pattern of Diaphragm Heat as a cause of depression is more common in teenagers and young people. It is due to residual Heat after a febrile disease but occurring against a pre-existing background of emotional stress and particularly repressed anger or guilt.

Treatment principle Clear the diaphragm, clear Lung-Heat, calm the Mind.

Acupuncture Points T.B.-5 Waiguan, L.I.-11 Quchi, Ren-15 Jiuwei, BL-17 Geshu, Du-9 Zhiyang, P-6 Neiguan, LU-5 Chize. All points with reducing method except P-6 and LU-5, which should be needled with even method.

Explanation

Diaphragm Heat Clinical manifestations Depression, mental restlessness, anxiety feeling below the heart, insomnia, feeling of oppression of the chest, vomiting. Tongue: yellow coating. Pulse: Rapid and slightly Wiry.

Pathology and mental-emotional pattern This pattern occurs in the aftermath of an invasion of exterior Wind-Heat; the exterior Wind-Heat moves into the Interior and changes into Heat. If the patient does not take care, it may give rise to residual Heat in the diaphragm, resulting in depression and the other physical symptoms listed above. Heat agitates the Mind, and the person suffers also from anxiety and insomnia. This pattern occurs only after an invasion of external Wind, and it is usually a short-lasting condition. However, if the residual Heat is not cleared, it may also lead to long-term consequences and the patient may suffer from depression for years. CLINICAL NOTE Depression deriving from Diaphragm Heat has a fairly acute onset and is more common in young people and teenagers. It is relatively easy to treat by clearing residual Heat, calming the Mind and lifting mood.

• T.B.-5 and L.I.-11 clear residual Heat. • Ren-15, BL-17 and Du-9 clear Heat from the diaphragm. • P-6 lifts mood and clears the diaphragm. • LU-5 clears Lung-Heat.

Prescription ZHI ZI CHI TANG Gardenia-Semen Sojae Decoction

Explanation This is the standard formula to eliminate residual Heat after an invasion of Wind-Heat. It is often modified with the addition of Zhi Shi Fructus Immaturus Citri aurantii.

SUMMARY DIAPHRAGM HEAT Points T.B.-5 Waiguan, L.I.-11 Quchi, Ren-15 Jiuwei, BL-17 Geshu, Du-9 Zhiyang, P-6 Neiguan, LU-5 Chize. All points with reducing method except P-6 and LU-5, which should be needled with even method. Herbal therapy Prescription ZHI ZI CHI TANG Gardenia-Semen Sojae Decoction

Depression

Worry injuring the Mind Clinical manifestations Depression, mental confusion, feeling absent, anxiety, no desire to do anything, insomnia, sadness, worry, crying, stretching and yawning. Tongue: Pale, sticky-white coating. Pulse: Fine and very slightly Wiry.

• ST-36 and BL-20 tonify Spleen Qi. • BL-49 tonifies the Intellect (Yi) that resides in the Spleen. It is used to brighten the Mind. • BL-47 stimulates the “coming and going” of the Ethereal Soul. • Du-20 lifts mood.

Herbal therapy

Pathology and mental-emotional pattern

Prescription

The pattern of “Worry injuring the Mind” is an Empty pattern giving rise to depression. It is caused primarily by worry, which knots Qi, but also, in the long run, leads to depletion of Qi and Blood. Heart-Blood is the residence of the Mind, and when it is deficient the Mind is deprived of its residence, resulting in depression, anxiety and insomnia. The patient presents with characteristic manifestations of Deficiency, i.e. pallor, slow walking, slow speech, sad expression and Weak pulse. The Deficiency makes the patient lacking in drive so that he or she feels unwilling or incapable of doing things.

GAN MAl DA ZAO TANG Glycyrrhiza-Triticum-Jujuba Decoction

Patient’s profile The pattern of Worry injuring the Mind is more common in young women.

Treatment principle Nourish the Heart, calm the Mind.

Acupuncture Points LU-9 Taiyuan, LU-3 Tianfu, BL-13 Feishu, Du-12 Shenzhu, Ren-6 Qihai, HE-5 Tongli, ST-36 Zusanli, BL-20 Pishu, BL-49 Yishe, BL-47 Hunmen, Du-20 Baihui. • Crying: Du-20 and Du-26 (ancient formula). • Mental dullness due to worry, thinking, shock, fear: Ren-12 Zhongwan, 50 moxa cones (ancient formula).

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Explanation This ancient formula from the Essential Prescriptions of the Golden Chest is specific for mental depression and confusion occurring against a background of Qi deficiency. It is an intriguing formula, as it has a profound mental effect and yet is composed of only three apparently mild herbs, two of which are items of food as well as herbs, i.e. wheat husks (Fu Xiao Mai) and black dates (Da Zao). Modern Chinese books, which always tend to emphasize Liver-Qi stagnation in mental-emotional problems, say that this formula tonifies Spleen-Qi, nourishes the Heart, calms the Mind and pacifies the Liver through its sweet taste. The explanation is that the sweet taste (taste of the Earth Element) pacifies the Liver (Wood Element); I find this explanation unconvincing and think that this formula is not for Qi stagnation but primarily for Qi and Blood deficiency. I find this formula excellent when the patient is not only depressed but also mentally confused and kind of “absent”. Often, this can be the result of heavy cannabis use in the past. I use this formula when these mental-emotional symptoms occur against a background of deficiency of Qi of the Spleen, Heart and Lungs and of Heart-Blood deficiency. This formula may also be effective in the treatment of attention deficit disorder and hyperactivity in children.

All points with reinforcing method.

SUMMARY

Explanation

WORRY INJURING THE MIND

• LU-9, LU-3, BL-13 and Du-12 tonify Lung-Qi and lift mood. LU-3 is a Window of Heaven point. • Ren-6 tonifies Qi in general. • HE-5 tonifies Heart-Qi.

Points LU-9 Taiyuan, LU-3 Tianfu, BL-13 Feishu, Du-12 Shenzhu, Ren-6 Qihai, HE-5 Tongli, ST-36 Zusanli,

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BL-20 Pishu, BL-49 Yishe, BL-47 Hunmen, Du-20 Baihui. All points with reinforcing method. Herbal therapy Prescription GAN MAI DA ZAO TANG Glycyrrhiza-Triticum-Jujuba Decoction

• Ren-15, P-6, BL-15 and HE-7 nourish Heart-Blood, calm the Mind and lift mood. • Du-14 tonifies Heart-Yang (with direct moxa cones). • Du-20 lifts mood.

Herbal therapy Prescription

Heart and Spleen deficiency Clinical manifestations Depression, brooding, always thinking, palpitations, timidity, difficulty in falling asleep, pale face, dizziness, poor appetite. Tongue: Pale. Pulse: Weak or Choppy.

GUI PI TANG Tonifying the Spleen Decoction

Explanation This is a widely used formula that tonifies Spleen-Qi, nourishes Heart-Blood and calms the Mind. As it is a tonic, it also lifts mood and can be used when the patient is depressed and anxious. The tongue is Pale and the pulse is Choppy or Fine.

Pathology and mental-emotional pattern Heart-Blood is the residence of the Mind, and when it is deficient the Mind is deprived of its residence, resulting in depression, anxiety and insomnia. This pattern is characterized by Qi and Blood deficiency, the latter affecting three organs, i.e. the Heart, Spleen and Liver. Heart-Blood houses the Mind, and its deficiency causes depression, anxiety and insomnia; Liver-Blood houses the Ethereal Soul, and its deficiency causes insomnia and dream-disturbed sleep.

Prescription

Patient’s profile

BU XIN DAN Variation Tonifying the Heart Pill Variation

The pattern of Heart and Spleen deficiency is more common in young women. It is usually caused by sadness and grief.

Treatment principle Tonify Spleen-Qi, nourish Heart-Blood, calm the Mind.

Acupuncture Points ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu, Ren-15 Jiuwei, P-6 Neiguan, BL-15 Xinshu, HE-7 Shenmen, Du-14 Dazhui with moxa cones, Du-20 Baihui. All points with reinforcing method.

Explanation • ST-36, SP-6, BL-20 and BL-21 tonify the Stomach and Spleen and Qi and Blood in general.

YANG XIN TANG Nourishing the Heart Decoction

Explanation This formula is similar to Gui Pi Tang, but it differs from it in that it also tonifies Yang (as it contains Rou Gui).

Prescription

Explanation The original formula tonifies Qi, nourishes Blood and Yin and calms the Mind. It differs from the previous two in that it also nourishes Yin. Shi Chang Pu Rhizoma Acori tatarinowii and He Huan Pi Cortex Albiziae open the Mind’s orifices and lift mood. The tongue lacks a coating (totally or partially), indicating Yin deficiency. Table 13.3 compares Gui Pi Tang, Yang Xin Tang and Bu Xin Dan.

Three Treasures remedy Calm the Shen Calm the Shen is a variation of Gui Pi Tang. It differs from the original formula in that it has a stronger calming the Mind action.

Depression

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Table 13.3 Comparison of Gui Pi Tang, Yang Xin Tang and Bu Xin Dan Gui Pi Tang

Yang Xin Tang

Bu Xin Dan

Patterns

Qi and Blood deficiency of Spleen, Liver and Heart

Qi, Blood and Yang deficiency of Spleen and Heart

Blood and Yin deficiency of Liver and Heart

Emotional symptoms

Depression, insomnia

Depression

Depression, anxiety, insomnia, mental restlessness

Tongue

Pale, teeth marks

Pale

Pale or normal-coloured without coating

Pulse

Choppy or Fine

Choppy, Fine, Deep, Slow

Fine

SUMMARY HEART AND SPLEEN DEFICIENCY Points ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu, Ren-15 Jiuwei, P-6 Neiguan, BL-15 Xinshu, HE-7 Shenmen, Du-14 Dazhui with moxa cones, Du-20 Baihui. All points with reinforcing method. Herbal therapy Prescriptions GUI PI TANG Tonifying the Spleen Decoction YANG XIN TANG Nourishing the Heart Decoction BU XIN DAN Variation Tonifying the Heart Pill Variation Three Treasures remedy Calm the Shen

Heart-Yang deficiency Clinical manifestations Depression, feeling cold with desire to curl up, not wanting to do anything, palpitations, tiredness, easily startled. Tongue: Pale. Pulse: Weak or Knotted.

there is Yang deficiency, there is in particular a lack of activity and of drive, so that the patient does not wish to do anything and finds everything a struggle. Note that, as there is Yang rather than Blood deficiency of the Heart, there is no anxiety or insomnia but a propensity to be startled.

Patient’s profile The pattern of Heart-Yang deficiency is more common in middle-aged or elderly patients.

Treatment principle Warm and tonify the Heart, calm the Mind, lift mood.

Acupuncture Points HE-5 Tongli, Du-14 Dazhui with moxa cones, BL-15 Xinshu, Ren-6 Qihai, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui. All points with reinforcing method; moxa should be used.

Explanation • HE-5, Du-14 and BL-15 tonify Heart-Qi and HeartYang. • Ren-6 tonifies Qi and Yang in general. • ST-36 and SP-6 tonify Spleen-Qi. • Du-20 lifts mood.

Herbal therapy

Pathology and mental-emotional pattern

Prescription

The Heart houses the Mind, and a deficiency of Yang of the Heart affects the Mind, causing depression. As

GUI ZHI GAN CAO LONG GU MU LI TANG Cinnamomum-Glycyrrhiza-Os Draconis-Ostrea Decoction

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Explanation This formula tonifies Heart-Yang and strongly calms the Mind.

Prescription ROU FU BAO YUAN TANG Cinnamomum-Aconitum Preserving the Source Decoction

This combination of patterns is more common in the middle-aged or elderly. The deficiency of Yin itself causes the patient to become depressed, while the Empty Heat harasses the Mind and the Ethereal Soul, causing the person to become anxious and restless. An important sign for this combination of patterns is a Red tongue without coating.

Explanation

!

This formula strongly tonifies and warms Heart-Yang; compared with the previous formula, it has a stronger action in tonifying and warming Heart-Yang and a weaker action in calming the Mind. The tongue is very Pale and wet, and the pulse is Weak, Deep and Slow.

Remember: it is the lack of coating (and not its redness) on the tongue that indicates Yin deficiency. A tongue without coating indicates Yin deficiency; a Red tongue without coating indicates Yin deficiency with Empty Heat.

SUMMARY HEART-YANG DEFICIENCY

Patient’s profile

Points HE-5 Tongli, Du-14 Dazhui with moxa cones, BL-15 Xinshu, Ren-6 Qihai, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui. All points with reinforcing method; moxa should be used.

The pattern of Heart- and Kidney-Yin deficiency with Heart Empty Heat is more common in middle-aged or elderly patients. It is usually due to worry, fear, sadness, guilt or grief.

Herbal therapy Prescriptions GUI ZHI GAN CAO LONG GU MU LI TANG Cinnamomum-Glycyrrhiza-Os Draconis-Ostrea Decoction ROU FU BAO YUAN TANG Cinnamomum-Aconitum Preserving the Source Decoction

Treatment principle Nourish Kidney- and Heart-Yin, clear Heart Empty Heart, calm the Mind, lift mood.

Acupuncture Points

Kidney- and Heart-Yin deficiency, Empty Heat blazing

KI-3 Taixi, KI-6 Zhaohai, SP-6 Sanyinjiao, KI-2 Rangu, KI-9 Zhubin, BL-52 Zhishi, HE-6 Yinxi, P-7 Daling, Du-24 Shenting, Du-19 Houding, Ren-15 Jiuwei. Reinforcing method on all points except KI-2, HE-6 and P-7, which should be needled with even method.

Clinical manifestations

Explanation

Depression, anxiety in the evening, feeling hot, malar flush, dizziness, palpitations, waking up at night, five-palm heat, night sweating, mental restlessness, nocturnal emissions with dreams, sore back. Tongue: Red without coating. Pulse: Floating-Empty or Fine and very slightly Wiry.

• • • • • •

Pathology and mental-emotional pattern This pattern is characterized by deficiency of Yin of the Kidneys and Heart and by Empty Heat of the Heart. The deficiency of Yin of the Kidneys leads to Empty Heat, which blazes upwards to affect the Heart.

KI-3, KI-6 and SP-6 nourish Kidney-Yin. KI-2 clears Empty Heat. KI-9 nourishes Kidney-Yin and calms the Mind. BL-52 strenghthens the Will-Power. HE-6 and P-7 clear Heart Empty Heat. Du-24, Du-19 and Ren-15 calm the Mind.

Herbal therapy Prescription ZI SHUI QING GAN YIN Nourishing Water and Clearing the Liver Decoction

Depression

Explanation This formula nourishes Kidney-Yin and clears LiverHeat. It is indicated for patients suffering from depression and irritability.

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Calming Mental Restlessness and Benefiting the Heart Decoction Three Treasures remedy Heavenly Empress (Women’s Treasure)

Prescription TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill

Explanation This remedy nourishes Kidney- and Heart-Yin, clears Heart Empty Heat and calms the Mind. The tongue is Red without coating.

Prescription JIE FAN YI XIN TANG Calming Mental Restlessness and Benefiting the Heart Decoction

Explanation This remedy nourishes Yin and calms the Mind, but it also tonifies Qi.

Three Treasures remedy Heavenly Empress (Women’s Treasure) Heavenly Empress is a variation of Tian Wang Bu Xin Dan with the same actions as the formula above.

SUMMARY KIDNEY- AND HEART-YIN DEFICIENCY, EMPTY HEAT BLAZING Points KI-3 Taixi, KI-6 Zhaohai, SP-6 Sanyinjiao, KI-2 Rangu, KI-9 Zhubin, BL-52 Zhishi, HE-6 Yinxi, P-7 Daling, Du-24 Shenting, Du-19 Houding, Ren-15 Jiuwei. Reinforcing method on all points except KI-2, HE-6 and P-7, which should be needled with even method. Herbal therapy Prescriptions ZI SHUI QING GAN YIN Nourishing Water and Clearing the Liver Decoction TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill JIE FAN YI XIN TANG

Kidney-Yang deficiency Clinical manifestations Depression, exhaustion, does not want to do anything or go out, weariness, chilliness with desire to curl up, sore back, frequent urination, pale urine, no will-power, no initiative, lack of drive and determination. Tongue: very Pale, wet. Pulse: Weak-Deep-Slow.

Pathology and mental-emotional pattern The Kidneys house the Will-Power (Zhi). “Will-Power” as a translation of Zhi includes will-power itself, drive, determination, steadfastness and physical and mental power. As Yang implies activity and movements towards the outside, in this pattern of Kidney-Yang deficiency there is a definite lack of drive, determination and initiative. The person is deeply depressed, lacks enthusiasm and is unable to find the drive to do anything. CLINICAL NOTE Depression occurring against a background of Kidney-Yang deficiency is particularly characterized by a weakness of the Kidneys’ Will-Power (Zhi) and therefore lack of drive and initiative.

Patient’s profile The pattern of Kidney-Yang deficiency is more common in middle-aged patients. It is due to worry, sadness, grief or fear.

Treatment principle Tonify and warm the Kidneys.

Acupuncture Points KI-7 Fuliu, KI-3 Taixi, Ren-4 Guanyuan with moxa cones, Du-4 Mingmen, BL-23 Shenshu, BL-52 Zhishi,

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BL-47 Hunmen, Du-20 Baihui. All points with reinforcing method. Moxa should be used.

Explanation • KI-7 tonifies Kidney-Yang. • KI-3, Source point, tonifies the Kidneys. • Ren-4, with moxa cones, tonifies Kidney-Yang and the Original Qi. • Du-4 tonifies Kidney-Yang and warms the Fire of the Gate of Life. • BL-23 tonifies Kidney-Yang. • BL-52 and BL-47 in combination, strengthen drive, determination and will-power and stimulate the “coming and going” of the Ethereal Soul. • Du-20 lifts mood.

Herbal therapy Prescription YOU GUI WAN Restoring the Right [Kidney] Pill

Explanation This formula from Zhang Jing Yue (1624) tonifies Kidney-Yang. This is my preferred formula to tonify Kidney-Yang, because it is balanced by the presence of Kidney-Yin tonics (Gou Qi Zi and Shan Zhu Yu).

Prescription JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill

Explanation This well-known formula from Zhang Zhong Jing (c.AD 200) tonifies Kidney-Yang.

Three Treasures remedy Strengthen the Root This formula is a variation of You Gui Wan, of which it has all the same actions.

SUMMARY KIDNEY-YANG DEFICIENCY Points KI-7 Fuliu, KI-3 Taixi, Ren-4 Guanyuan with moxa cones, Du-4 Mingmen, BL-23 Shenshu, BL-52 Zhishi, BL-47 Hunmen, Du-20 Baihui. All points with reinforcing method. Moxa should be used.

Herbal therapy Prescriptions YOU GUI WAN Restoring the Right [Kidney] Pill JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill Three Treasures remedy Strengthen the Root

ACUPUNCTURE POINTS FOR DEPRESSION I am going to discuss various acupuncture points that I may use for depression without categorizing them according to a pattern as we do for herbs or formulae. There are important differences between the mode of action of acupuncture and that of herbal medicine. For example, to treat depression deriving from LiverQi stagnation, one naturally uses a formula from the category of formulae for Qi stagnation; to treat depression from Spleen- and Heart-Blood deficiency, one naturally uses a formula from the category of formulae for Blood deficiency. Although this approach may be followed also for acupuncture points and point prescriptions, acupuncture works in a different way from herbal medicine. Acupuncture points are not so closely related to patterns as herbs are. For example, a herb from the moving-Qi category (e.g. Xiang Fu Rhizoma Cyperi) cannot nourish Blood. By contrast, an acupuncture point such as LIV-3 Taichong can be used to move Liver-Qi, but it can also be used to nourish Liver-Blood (as it is the Source point). As for Qi stagnation, it is indeed my opinion that every acupuncture point moves Qi; by the very nature of Qi and of the channels, one cannot insert a needle in a channel without moving Qi (and Blood). This is a very useful characteristic of acupuncture compared with herbal medicine. In fact, with herbal medicine, if we use a formula to nourish Blood, this contains herbs that are “sticky” in nature and that may have the tendency to give rise to some Qi stagnation; for this reason, it may be a good idea to add one or two herbs to move Qi (that is why Gui Pi Tang has Mu Xiang). By contrast, when we use acupuncture to nourish Blood

Depression

with points such as ST-36 Zusanli, SP-6 Sanyinjiao and LIV-8 Ququan, there is no danger of these points giving rise to Qi stagnation, because they automatically move Qi.

LU-7 Lieque LU-7 brings clear Qi up to the head and promotes the descending of turbid Qi from the head (Fig. 13.6). On a physical level, this means that LU-7 can treat problems of the nose and sinuses. On a psychic level, it clears the Mind and lifts mood. I use it for most types of depression, whatever the pattern involved.

LU-3 Tianfu The actions and indications of this point are closely related to its being a Window of Heaven point. One of the characteristics of these points is that they regulate the ascending and descending of Qi from the body to

Promote the ascending of clear Qi to the Brain

LU-3

Promote the descending of turbid Qi from the Brain

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and from the head; they do so in the crucial neck area (the gateway between the body and the head). Therefore, they can both subdue rebellious Qi and promote the ascending of clear Qi to the head (Fig. 13.6). On a psychic level, this point’s action in regulating the ascending and descending of Qi to and from the head has a mental-emotional effect. For example, insomnia is due to Qi ascending too much to the head (or not descending from it), while somnolence and forgetfulness are due to clear Qi not ascending to the head. The Explanation of the Acupuncture Points says that LU-3 can make Qi rise to treat forgetfulness, sadness and weeping due to Qi not rising to head.11 Forgetfulness is an important indication for this point; this is forgetfulness due to clear Qi not rising to the head. According to the Explanation of the Acupuncture Points, this point treats forgetfulness by stimulating the ascending of Qi of both the Lungs and Heart.12 Finally, “talking to ghosts” features heavily in this point’s indications. Generally speaking, when ancient books mention such symptoms as talking or seeing ghosts among the indications of a point, it means that the point is indicated for relatively serious mentalemotional problems and, in particular, when the Mind is obstructed. Obstruction of the Mind can potentially cause serious mental problems such as manic depression or psychosis. Again, this point can open the Mind’s orifices, i.e. deobstruct the Mind by regulating the ascending and descending of Qi to and from the head; it opens the Mind’s orifices by promoting the descending of turbid Qi from the head and the ascending of clear Qi to the head. This is a general function of the Window of Heaven points.

L.I.-4 Hegu

LU-7

In my experience, L.I.-4 has a strong influence on the Mind and can be used to soothe the Mind and allay anxiety, particularly if combined with LIV-3 Taichong and with Du-24 Shenting and G.B.-13 Benshen. I use this combination in depression accompanied by anxiety.

ST-36 Zusanli

Figure 13.6 Effect of LU-7 Lieque and LU-3 Tianfu.

ST-36 has a powerful tonic action and, on the psychic level, it lifts mood in patients who are depressed against a background of Qi and Blood deficiency.

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ST-40 Fenglong ST-40 has a long history of use for mental-emotional conditions; it is especially indicated to open the Mind’s orifices in persons tending to manic behaviour. This point has a profound “calming the Mind” action, and I use it frequently in patients who are depressed and anxious. The Phlegm-resolving of this point should not be overemphasized, overlooking its other functions. Apart from its use to resolve Phlegm, ST-40 can also be used to subdue rebellious Qi of the Stomach and Lungs when the person is very anxious and the anxiety reflects on the Stomach function, with such symptoms as tightness of the epigastrium, a feeling of a knot in the Stomach or, as some people say, a feeling of “butterflies in the stomach” (Fig. 13.7). Apart from the epigastrium, ST-40 also has an action on the chest: it relaxes and “opens” the chest both from

a physical point of view when it is obstructed by Phlegm, and from a psychic point of view when Qi stagnates in the chest from emotional problems. CLINICAL NOTE ST-40 Fenglong The Phlegm-resolving effect of ST-40 should not be overemphasized. This point has many other actions:

 it calms the Mind  it opens the Mind’s orifices  it treats all Full conditions of the Stomach  it subdues rebellious Stomach-Qi  it treats the epigastrium  it opens the chest and makes Lung-Qi descend when the chest is obstructed by Phlegm

 it relaxes and opens the chest when Qi stagnates here from emotional problems.

SP-6 Sanyinjiao From the emotional point of view, it helps to smooth Liver-Qi to calm the Mind and allay irritability. It can therefore be used in depression occurring against a background of Liver-Qi stagnation. However, from the mental-emotional point of view SP-6 has a wide range of actions. It can calm the Mind and is often used for insomnia, particularly if from Blood or Yin deficiency. In particular, it is used for Spleen- and Heart-Blood deficiency, when the Spleen is not making enough Blood, the Heart is not supplied with enough Blood and the Mind lacks residence and floats at night so that insomnia ensues. SP-6 is the point to use in this case, as it will simultaneously tonify the Spleen, nourish Blood and calm the Mind. If such a comparison could be made, this action is comparable to that of the formula Gui Pi Tang Tonifying the Spleen Decoction.

HE-5 Tongli

ST-40

Figure 13.7 Effect of ST-40 Fenglong.

I use HE-5 as the main point to tonify Heart-Qi and Heart-Blood, and it is therefore my point of choice for depression occurring against a background of Qi and Blood deficiency. Its indications include sadness, mental restlessness, anger, fright, depression, agitation, palpitations and weak Heart-Qi. My use of HE-5 in depression is also connected to this point’s nature of Connecting (Luo) point. As a Connecting point, it moves Qi and removes in the

Depression

channel; on a psychic level, this means that it can lift mood and stimulate the “coming and going” of the Ethereal Soul.

HE-7 Shenmen I use HE-7 as a point to both lift mood in depression and to calm the Mind in anxiety. Its indications include insomnia, poor memory, manic depression, inappropriate laughter, shouting at people, sadness, fear, mental restlessness, agitation and palpitations. HE-7 primarily nourishes Heart-Blood and is the point of choice for Heart-Blood deficiency causing the Mind to be deprived of its “residence”, resulting in anxiety, insomnia, poor memory, palpitations and a Pale tongue. Again, this action could be compared to that of Gui Pi Tang Tonifying the Spleen Decoction. Indeed, the combination of the two points SP-6 mentioned above and HE-7 closely resembles the action of Gui Pi Tang.

BL-15 Xinshu Indications for this point include anxiety, weeping, fright, insomnia, excessive dreaming, manic depression, disorientation, delayed speech development, poor memory, poor concentration and mental confusion. I use BL-15 to tonify Heart-Qi and Heart-Blood in depression occurring against a background of Qi and Blood deficiency.

BL-42 Pohu The indications for this point include sadness, grief, feeling of oppression of the chest, depression, suicidal thoughts, and “three corpses flowing”. On a psychological level, BL-42 is related to the Corporeal Soul (Po), which is the mental-spiritual aspect residing in the Lungs. It strengthens and roots the Corporeal Soul in the Lungs. It frees breathing when the Corporeal Soul is constricted by worry, sadness or grief. It is therefore used for emotional problems related to the Lungs, particularly sadness, grief and worry. It has a very soothing effect on the spirit, and it nourishes Qi when this is dispersed by a prolonged period of depression, sadness or grief. The Explanation of the Acupuncture Points reports the interesting indication “three corpses flowing” for this point.13 The association with corpses and death should be interpreted in the way that this point is indicated for suicidal thought.

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Because of the connection between the Corporeal Soul and death, points associated with the Corporeal Soul (such as BL-13 Feishu and BL-42 Pohu) are indicated for suicidal thoughts.

BL-44 Shentang Indications for this point include depression, insomnia, anxiety, mental restlessness, sadness, grief and worry. BL-44 is mostly used for emotional and psychological problems related to the Heart. It is best used in conjunction with BL-15 Xinshu for anxiety, insomnia and depression. BL-44 strengthens and calms the Mind. It stimulates the Mind’s clarity and intelligence.

BL-47 Hunmen Indications for this point include fear, depression, insomnia, excessive dreaming, lack of sense of direction in life and “possession by corpse”.14 BL-47 is used for emotional problems related to the Liver, such as depression, frustration and resentment over a long period of time. This point settles and roots the Ethereal Soul in the Liver. It strengthens the Ethereal Soul’s capacity of planning, sense of aim in life, life dreams and projects. It is a “door”, so this point regulates the “coming and going” of the Ethereal Soul and Mind, i.e. relationships with other people and the world in general. It has an outward movement that could be compared and contrasted with the inward movement of BL-42 Pohu. The Explanation of Acupuncture Points (1654) confirms that, due to this point’s nature of “window”, “gate” or “door”, the Ethereal Soul goes in and out through it. This confirms the dynamic nature of this point in stimulating the movement of the Ethereal Soul and Mind; however, it can also work the other way, i.e. to calm down the excessive movement of the Ethereal Soul. In my experience, when used in conjunction with BL-18 Ganshu, it has a profound influence on a person’s capacity of planning his or her life by rooting and steadying the Ethereal Soul. It can help a person find a sense of direction and purpose in life. This point will also help to lift mental depression associated with such difficulties.

BL-52 Zhishi Indications for this point include depression, lack of motivation, lack of drive and lack of will-power.

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This point strengthens will-power and determination, which are the mental-spiritual phenomena pertaining to the Kidneys. It is a very useful point in the treatment of certain types of depression, when the person lacks motivation and drive and lacks the willpower and mental strength to make an effort to get out of the spiral of depression. Needling this point with reinforcing method, especially if combined with BL-23, will stimulate the will-power and lift the spirit. BL-52 strengthens will-power, drive, determination, the capacity of pursuing one’s goals with singlemindedness, spirit of initiative and steadfastness. I often use this point, if there is a Kidney deficiency, in combination with one of the other four points affecting the Spiritual Aspects of the Yin organs, i.e. BL-42 Pohu, BL-44 Shentang, BL-47 Hunmen and BL-49 Yishe, as a solid mental-emotional foundation for the other aspects of the psyche. In particular, for depression I use the following combination: • BL-23 Shenshu, BL-52 Zhishi and BL-47 Hunmen to strengthen will-power and drive and to instil a sense of direction and aim in one’s life. This combination is excellent to treat the mental exhaustion, lack of drive and aimlessness and confusion that are typical of chronic depression. If we analyse the names of the above five points, we get the following pattern. • BL-42 Pohu (hu means “window”): “Window of Po” • BL-44 Shentang (tang means “hall”): “Hall of Shen” • BL-47 Hunmen (men means “door”): “Door of Hun” • BL-49 Yishe (she means “abode”): “Abode of Yi” • BL-52 Zhishi (shi means “room”): “Room of Zhi” (see Fig. A5.8) We can detect a pattern, as the points correspond to a house – an image for the psyche – with the Mind (Shen), Will-Power (Zhi) and Intellect (Yi) corresponding to “hall”, “room” and “abode”, respectively, and the Ethereal Soul (Hun) and Corporeal Soul (Po) corresponding to a “door” and “window”, respectively. The images of door and window fit well the nature of the Ethereal Soul and Corporeal Soul, which provide movement to the psyche, the former providing the “coming and going” of the Mind and the latter the “entering and exiting” of the Essence. For this reason,

BL-47 Hunmen is particularly important in the treatment of depression.

KI-3 Taixi KI-3 is the Source (Yuan) point of the Kidney channel, and it is the best point to tonify the Kidneys. I use this point in depression from a Kidney deficiency to strengthen the will-power, drive and initiative.

KI-9 Zhubin Indications for this point include anxiety, insomnia, palpitations and manic behaviour. KI-9 is an excellent point to calm the Mind in cases of deep anxiety and mental restlessness deriving from Kidney-Yin deficiency. It also relaxes any tension or feeling of oppression felt in the chest, often with palpitations. Because it tonifies Kidney-Yin, calms the Mind and treats palpitations, this point is particularly indicated in the pattern of “Heart and Kidneys not harmonized”. It is the starting point of the Yin Linking Vessel (Yin Wei Mai), and its mental-emotional effect is largely due to this. The Yin Linking Vessel nourishes Heart-Blood and calms the Mind.

P-6 Neiguan P-6 is an extremely important point for depression. It is always used in modern China for mental depression. It treats especially depression deriving from Liver-Qi stagnation in two ways. First, it moves Liver-Qi due to its connection with the Liver channel within the Terminal Yin (Jue Yin) channels. Second, it treats the Mind (Shen) due to its close connection with the Heart. Indications for this point include insomnia, manic behaviour, poor memory, anxiety, fright, sadness and depression.

T.B.-3 Zhongzhu In my experience, T.B.-3 moves Qi and eliminates stagnation. Because of its relationship with the Gall Bladder (within the Lesser Yang) and between this latter organ and the Liver, T.B.-3 indirectly affects the Liver, so that it can be used to eliminate stagnation of Liver-Qi manifesting with hypochondrial pain, depression and mood swings. On a psychological level, it moves Qi and lifts depression deriving from stagnation of Liver-Qi, particularly in combination with Du-20 Baihui. It is

Depression

extremely effective in lifting the Mind when a person is depressed.

G.B.-13 Benshen G.B.-13 is a very important point for mental and emotional problems. It is very much used in psychiatric practice for schizophrenia and split personality combined with HE-5 Tongli and G.B.-38 Yangfu.15 It is also indicated when the person has persistent and unreasonable feelings of jealousy and suspicion. Apart from these mental traits, it has a powerful effect in calming the Mind and relieving anxiety deriving from constant worry and fixed thoughts. Its effect is enhanced if it is combined with Du-24 Shenting. However, apart from anxiety, G.B.-13 can also be used for depression. In fact, its deep mental and emotional effect is also due to its action of “gathering” Essence to the head. The Kidney-Essence is the root of our Pre-Heaven Qi and is the foundation for our mental and emotional life. A strong Essence is the fundamental prerequisite for a clear Mind (Shen) and a balanced emotional life. This is the meaning of this point’s name, “Root of the Mind”, i.e. this point gathers the Essence that is the root of the Mind (Shen). The Kidney-Essence is the source of Marrow that fills up the Brain (called Sea of Marrow): G.B.-13 is a point where Essence and Marrow “gather”. The Great Dictionary of Acupuncture says that this point “makes the Mind [Shen] return to its root”;16 the “root” of the Mind is the Essence, hence this point “gathers” the Essence to the Brain and affects the Mind. As it connects the Mind and the Essence, it also treats both the Heart and the Kidneys and therefore the Mind (Shen) and Will-Power (Zhi); for this reason, it is an important point in the treatment of depression. When combined with other points to nourish Essence (such as Ren-4 Guangyuan), G.B.-13 attracts Essence towards the head, with the effect of calming the Mind and strengthening clarity of mind, memory and will-power. The connection between G.B.-13 and the Essence is confirmed by the text An Enquiry into Chinese Acupuncture, which has among the indications of this point: “excessive menstrual bleeding, impotence and seminal emissions.”17

LIV-3 Taichong LIV-3 is a major point for depression deriving from stagnation of Liver-Qi. It moves Liver-Qi, stimulates the

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“coming and going” of the Ethereal Soul in depression and also calms the Mind. It has a particularly calming effect when it is combined with L.I.-4 Hegu.

Du-4 Mingmen Du-4 tonifies the Fire of the Gate of Life and KidneyYang. As this is the sea of Will-Power (Zhi), this point strongly tonifies the will-power, drive and determination in patients who suffer from depression. However, please note that this point should be used only in the presence of Kidney-Yang deficiency.

Du-11 Shendao Indications for this point include sadness, anxiety, poor memory, palpitations, disorientation and timidity. Du-11 is on the same level as BL-15 Xinshu, the Back-Transporting point of the Heart, and its action mostly extends to the Heart. It nourishes the Heart and calms the Mind and therefore treats depression, sadness and anxiety.

Du-12 Shenzhu Indications for this point include agitation, mad walking, delirious raving, seeing ghosts and rage with desire to kill people. This point is indicated for manic behaviour and morbid thoughts of death, for conditions in which the Ethereal Soul comes and goes too much. It settles the Corporeal Soul. This point should be seen in conjunction with BL-13 Feishu and BL-42 Pohu. Please note that the shen in this point’s name means “body” and not the shen that means “Mind” as in the previous point Shendao.

Du-14 Dazhui This point strengthens the Heart, tonifies Yang, strengthens the Will-Power (Zhi), tonifies Heart- and Kidney-Yang; it is very effective for depression and lack of will-power and drive, with the Ethereal Soul not coming and going enough.

Du-16 Fengfu Indications for this point include manic behaviour, incessant talking, mad walking, desire to commit suicide, sadness and fear. I use this point for depression and anxiety with morbid thoughts of death.

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Du-19 Houding Indications for this point include mad walking and insomnia. This point calms the Mind and nourishes the Heart, and it is good for sadness and depression. Good combined with Ren-15 Jiuwei.

Du-20 Baihui I use Du-20 in practically every case of depression, whatever the pattern, to lift Qi; on a psychic level, lifting Qi has the effect of lifting mood. This point’s lifting action on Yang has a mental effect in that it promotes the rise of clear Yang to the Brain and the Mind. In my experience, Du-20 has a powerful effect in lifting depression and clearing of the mind.

Du-24 Shenting An important feature of this point that makes it particularly useful in mental-emotional problems is that it can both calm and lift the Mind, therefore it is used not only for anxiety and insomnia but also for depression and sadness. It is also used in psychiatric practice for schizophrenia and split thoughts.18 The name of this point refers to its strong influence on the Mind and Spirit. The courtyard was traditionally considered to be a very important part of the house, as it was the one that gave the first impression to visitors; it is the entrance. Thus, this point could be said to be the “entrance” to the Mind and Spirit, and its being a courtyard highlights its importance. Indications for this point include manic depression, depression, anxiety, poor memory and insomnia.

Ren-4 Guanyuan I use Ren-4 frequently to tonify the Kidneys and the Will-Power in patients suffering from depression. In Kidney deficiency, I tend to use Ren-4 more than Du-4, as the former has a more balanced effect. In fact, it can tonify Kidney-Yang with direct moxa cones but, with needling, it also nourishes Blood and tonifies the Original (Yuan) Qi. Ren-4 can calm the Mind (Shen) and settle the Ethereal Soul (Hun) by nourishing Blood and Yin. It can strengthen the Lower Burner in persons who are very anxious, especially if such anxiety derives from Yin deficiency. This point tonifies the Qi of the Lower Burner, thus rooting Qi downwards and subduing the rising of Qi to the head, which happens in severe anxiety. In this way, it has a powerful calming effect.

Ren-4 can root the Ethereal Soul and can be used for a vague feeling of fear at night, which is said to be due to the floating of the Ethereal Soul.

Ren-15 Jiuwei I use Ren-15 very frequently to nourish the Heart, calm the Mind and lift mood. I prefer this point to Ren-14 Juque. This point nourishes all Yin organs and it calms the Mind, particularly in Deficiency of Yin and/or Blood. It has a very powerful calming action in severe anxiety, worry, emotional upsets, fears or obsessions. Although its indications show that it can be used to open the Mind’s orifices in serious mental conditions from a Full condition, I personally use this point in mental-emotional states occurring against a background of deficiency of Blood or Yin. Indications for this point include manic depression, palpitations, anxiety and insomnia.

HERBS FOR DEPRESSION XIANG YUAN Fructus Citri medicae Category: moving Qi. Channels entered: Liver, Spleen, Lungs. Taste and energy: pungent, slightly bitter, sour, warm. Xiang Yuan moves Qi, eliminates stagnation, relieves depression, resolves Phlegm and benefits the diaphragm. It is a very important herb for mental depression deriving from Liver-Qi stagnation, as it eliminates stagnation and specifically relieves depression. It is especially useful, as it also resolves Phlegm that frequently accompanies Qi stagnation. It combines well with Fo Shou Fructus Citri sarcodactylis.

FO SHOU Fructus Citri sarcodactylis Category: moving Qi. Channels entered: Liver, Lungs, Stomach, Spleen. Taste and energy: pungent, bitter, warm. Fo Shou is a very important herb for depression from Liver-Qi stagnation. In fact, I frequently use one or two herbs to move Qi in a prescription even in conditions not involving Liver-Qi stagnation. I do so because the Qi-moving action of these herbs stimulates the “coming and going” of the Ethereal Soul, which is always deficient in depression.

Depression

Fo Shou moves Qi, harmonizes the Stomach and Spleen and resolves Phlegm. As for Xiang Yuan, the latter action is useful as Phlegm often accompanies Qi stagnation (because stagnant Qi fails to move correctly in the Triple Burner’s Water passages, resulting in the formation of Phlegm). Finally, within the Qi-moving herbs, Fo Shou has a particularly strong mental effect in relieving depression, and I frequently add it to a formula to stimulate the “coming and going” of the Ethereal Soul.

QING PI Pericarpium Citri reticulatae viride Category: moving Qi. Channels entered: Gall Bladder, Liver, Stomach. Taste and energy: pungent, bitter, warm. Qing Pi has a strong Qi-moving action, and it primarily enters the Upper Burner. For this reason, it goes to the chest and head, and this makes it particularly suitable to treat depression. Qing Pi has a stronger action than other Qi-moving herbs, and this is another reason why I often use it in formulae to treat mental depression, as it strongly stimulates the “coming and going” of the Ethereal Soul.

MEI GUI HUA Flos Rosae rugosae Category: moving Qi. Channels entered: Liver, Spleen. Taste and energy: sweet, slightly bitter, warm. Mei Gui Hua is frequently used for mental depression occurring against a background of Liver-Qi stagnation. I personally use this herb frequently in depression from Qi stagnation. Compared with the Qi-moving herbs, especially Qing Pi (mentioned above), it has a gentle Qi-moving effect due to its sweet rather than pungent taste. Another characteristic that makes it suitable to treat mental depression is that it is a flower; as such, it is light and it therefore affects the upper part of the body and the head. Although it is not pungent, it is highly aromatic, and that is another feature that makes it suitable to treat mental depression.

HE HUAN HUA Flos Albiziae Category: calming the Mind. Channels entered: Liver, Stomach. Taste and energy: sweet, neutral.

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Although He Huan Hua is placed in the category of herbs that calm the Mind, it also moves Qi and eliminates stagnation. These two actions make it very useful to treat mental depression accompanied by anxiety and insomnia. As for Mei Gui Hua, another characteristic that makes He Huan Hua suitable to treat mental depression is that it is a flower; as such, it is light and it therefore affects the upper part of the body and the head. Although it is not pungent, it is highly aromatic, and that is another feature that makes it suitable to treat mental depression.

HE HUAN PI Cortex Albiziae Category: calming the Mind. Channels entered: Heart, Liver. Taste and energy: sweet, neutral. He Huan Pi is an important herb for the treatment of mental depression. It combines the two actions of moving Qi and eliminating stagnation with that of calming the Mind (in fact, it enters the Liver and Heart). It has an ancient history of use for mental depression, and its indications include depression, bad temper, insomnia and irritability. The Treasury of Words on the Materia Medica says: “He Huan Pi allows the five spirits [Shen, Hun, Po, Yi and Zhi] to open and reach outwards, eliminating extremes of the five emotions.”19

YUAN ZHI Radix Polygalae Category: calming the Mind. Channels entered: Heart, Lungs. Taste and energy: bitter, pungent, slightly warm. Yuan Zhi calms the Mind, opens the Mind’s orifices and resolves Phlegm. “Calming the Mind”, in the category of herbs that calm the Mind, should not be interpreted literally. The category of herbs that “calm the Mind” include herbs that are pungent in taste and “stimulate” the Mind and open the Mind’s orifices. The category of herbs that “calm the Mind” comprises two subcategories of herbs: one subcategory of herbs that are “heavy” and therefore anchor, settle and calm the Mind (many of these are minerals), and another subcategory of herbs that nourish the Heart and calm the Mind. Within this subcategory, there are two quite distinct group of herbs: some sweet and sour that specifically

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calm the Mind (such as Suan Zao Ren Semen Ziziphi spinosae and Bai Zi Ren Semen Platycladi), and others pungent that open the Mind’s orifices, such as Yuan Zhi, or move Qi, such as He Huan Pi. Yuan Zhi pertains to the latter group, and it is a very important herb to open the Mind’s orifices and to stimulate the “coming and going” of the Ethereal Soul with its pungent and bitter taste. It is an extremely important herb for depression. Yuan Zhi is often combined with Suan Zao Ren, as these two herbs complement each other very well: one pungent, the other sour, they regulate the coming and going of the Ethereal Soul (as the pungent taste stimulates its coming and going and the sour taste restrains it).

YU JIN Tuber Curcumae Category: invigorating Blood. Channels entered: Heart, Lungs, Liver. Taste and energy: pungent, bitter, cold. Yu Jin moves Qi, invigorates Blood, cools Blood, opens the Mind’s orifices and resolves Phlegm. It combines several functions that affect the Mind and the Ethereal Soul. By moving Qi and invigorating Blood, it stimulates the “coming and going” of the Ethereal Soul when this is restrained by stagnation of Qi and/or Blood. By cooling Blood, it calms the Mind when this is affected by Heat. By resolving Phlegm and opening the Mind’s orifices, it clears the Mind when this is clouded by Phlegm, and it also stimulates the “coming and going” of the Ethereal Soul when this is restrained by Phlegm. I use this herb very frequently in depression in combination with Yuan Zhi Radix Polygalae.

SHI CHANG PU Rhizoma Acori tatarinowii Category: opening the orifices. Channels entered: Heart, Stomach. Taste and energy: pungent, bitter, warm, aromatic. Shi Chang Pu opens the orifices and the Mind’s orifices; it resolves Phlegm and calms the Mind. I use this herb very frequently in combination with Yuan Zhi Radix Polygalae to open the Mind’s orifices and stimulate the “coming and going” of the Ethereal Soul when this is restrained by Phlegm. Shi Chang Pu enters the Heart and is pungent, bitter and aromatic;

it is these properties that make it so valuable to open the Mind’s orifices and move Qi when the person is depressed.

MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 32, No. 5, 1991, p. 36. Liu Guang Zhi et al., “Clinical observations on the treatment of depression in the elderly with electroacupuncture.” Thirty elderly patients suffering from depression were treated with electroacupuncture. The patients ranged in age from 50 to 74 and comprised 16 men and 14 women (average age 57.4). The average duration of the disease was 5.5 years. The points used were Du-20 Baihui and extra point Yintang. Electroacupuncture was applied to the points with dense-sparse wave ranging from 6 V to 1.5 V, 8–9 mA, Hz 8 μ 100. The treatment was given once a day for 6 days a week for a total of 30 sessions. There were no therapeutic results in five patients. Thirteen patients were completely cured, and the rest experienced various degrees of improvement.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 24, No. 12, 1983, p. 55. Jiang Ke Ming, “A brief discussion of herbal prescriptions for depression (Yu Zheng).” Dr Jiang emphasizes the dual nature of Yu Zheng as “mental depression” and “stagnation”. In fact, following the statement from Zhang Jing Yue quoted at the beginning of this chapter, Dr Jiang says that “stagnation may cause depression; conversely, depression may cause stagnation”. Like most Chinese doctors, Dr Jiang says that most cases of mental depression start with Liver-Qi stagnation, and the prescriptions he favours is as follows. • Xiao Yao San Free and Easy Wanderer Powder • Chai Hu Shu Gan Tang Bupleurum Soothing the Liver Decoction • Xuan Fu Dai Zhe Tang Inula-Haematitum Decoction • Ban Xia Hou Po Tang Pinellia-Magnolia Decoction

Depression

• Su He Xiang Wan Styrax Pill • Yue Ju Wan Gardenia-Chuanxiong Pill As for pathology, Dr Jiang states that, in the beginning, the pathology starts with Liver-Qi stagnation, which may later lead to Liver-Blood stasis. The Liver may invade the Stomach and cause Stomach-Qi to rebel upwards. The dysfunction of the Stomach may give rise to Dampness or Phlegm. In late stages, the Spleen becomes deficient and there may be Blood stasis, which affects menstruation in women.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 24, No. 4, 1983, p. 58. Tan Jia Ming, “A brief account on the treatment of depression.” Dr Tan states that depression starts with Qi stagnation, which may lead to Blood stasis, Phlegm accumulation, Food accumulation, Heat accumulation and, in late stages, Heart and Spleen deficiency and Liver- and Kidney-Yin deficiency. Dr Tan therefore summarizes the pathology of depression as follows. • • • • • •

Qi stagnation Blood (stasis) Dampness Phlegm Heat Food

As for the aetiology of depression, Dr Tan thinks that three emotions are the most important ones, i.e. pensiveness, worry and anger. Dr Tan’s contribution is interesting as, unlike most other Chinese doctors, he does not place anger at the top of the list as an emotional cause of depression, but he places pensiveness and worry as main causes. Given my experience with Western patients, I would thoroughly agree with him and would add sadness, grief and guilt to the list. As for the pathology, Dr Tan says that this starts with Liver-Qi stagnation; stagnant Qi may turn into Heat, or long-term Qi stagnation may give rise to Blood stasis. Then, either Liver-Qi invades the Spleen or this is directly affected by pensiveness and worry so that Spleen-Qi deficiency develops. The Spleen-Qi deficiency may give rise to Dampness and Phlegm and Food accumulation. Dampness and

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Phlegm may combine with Heat. The long-term depression injures Heart-Qi and Heart-Blood, which fails to properly house the Mind; this leads to insomnia and anxiety. Therefore in chronic cases of depression there is a deficiency of Spleen and Heart; if there is Heat, this may injure Yin and lead to Yin deficiency. Dr Tan suggests some herbal prescriptions for Full and Empty conditions as follows. FULL Qi stagnation • Chai Hu Shu Gan Tang Bupleurum Soothing the Liver Decoction • Yue Ju Wan Gardenia-Chuanxiong Pill Heat • Dan Zhi Xiao Yao San Moutan-Gardenia Free and Easy Wanderer Powder Phlegm • Ban Xia Hou Po Tang Pinellia-Magnolia Decoction • Tan Yu Tang Phlegm Stagnation Decoction Dampness • Shi Yu Tang Dampness Stagnation Decoction Blood (stasis) • Xue Yu Tang Blood Stagnation Decoction Food (accumulation) • Shi Yu Tang Food Stagnation Decoction EMPTY Worry injuring the Mind • Gan Mai Da Zao Tang Glycyrrhiza-Triticum-Jujuba Decoction Heart and Spleen deficiency • Gui Pi Tang Tonifying the Spleen Decoction Yin deficiency with Empty Heat • Zi Shui Qing Gan Yin Nourishing Water and Clearing the Liver Decoction

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 41, No. 11, 2000, p. 654. Zhang Peng, “The experience of Zhang Tai Kang in the treatment of depression.” Dr Zhang says that in the beginning stages depression is characterized by Qi stagnation and Phlegm and usually occurs against a background of Full conditions; in

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the late stages, it is characterized by Blood and Yin deficiency and usually occurs against a background of Empty conditions. Dr Zhang distinguishes only two major types of pathology: the first is characterized by Liver-Qi stagnation, disharmony of Liver and Spleen, Phlegm and “obstruction of the Brain”; the second by Qi and Blood deficiency, deficiency of Marrow and deficiency of the Brain.

Liver-Qi stagnation, disharmony of Liver and Spleen, Phlegm and obstruction of the Brain Pensiveness, sadness, depressed mood, hypochondrial distension, Wiry pulse. Dr Zhang used the prescription Kai Yu Yue Shen Tang Opening Stagnation and Cheering the Mind Decoction.

Qi and Blood deficiency, deficiency of Marrow, deficiency of the Brain Depression, sadness, decreased mental power, poor memory, decreased capacity in working and studying. This condition is more frequent in the elderly. Dr Zhang distinguishes two conditions: the first characterized by Heart and Spleen deficiency, for which he uses Yang Xin Jian Pi Tang Nourishing the Heart and Strengthening the Spleen Decoction; the other characterized by Liver and Kidney deficiency, for which he uses Bu Sui Rong Nao Tang Tonifying Marrow and Nourishing the Brain Decoction.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 30, No. 2, 1989, pp. 10–12. Xu Jing Fan, “Academic thoughts on Ye Tian Shi’s diagnosis and treatment of depression.” Dr Xu Jing Fang confirms the two views of the syndrome Yu mentioned at the beginning of this chapter. Dr Xu says that, in a broad sense, Yu indicates “stagnation” and it includes many different conditions; in a narrow sense, Yu denotes “mental depression”. When discussing the pathology of Depression, Dr Xu concords with many other Chinese doctors in that, in the beginning, the disease affects the Liver first and is at the Qi level, i.e. Liver-Qi stagnation. He says that the stagnation of Liver-Qi also affects the Gall Bladder, giving rise to physical symptoms related to

this organ and also to the timidity and lack of initiative that is related to a disharmony of the Gall Bladder. According to Dr Xu, Ye Tian Shi says “Long-term stagnation causes stagnation of the Heart and Spleen.” This statement is interesting, as it confirms that, especially in emotional problems, Qi stagnation does affect the Heart (and also other organs such as the Spleen). The Spleen is also affected directly by the Qi stagnation in the Liver. Dr Xu therefore says that in Depression Qi stagnation affects the Liver and Heart and that the Qi stagnation in this latter organ affects the Mind (Shen), as this is deprived of its normal “residence”. This is another interesting concept, according to which the Mind is deprived of its residence not only when HeartBlood is deficient but also when Heart-Qi is stagnant. Two pathological consequences derive from Qi stagnation: first, the stagnant Qi may give rise to Heat; second, the Qi stagnation in the passages of the Triple Burner impairs the transformation, transportation and excretion of the Body Fluids, which therefore accumulate into Phlegm. Ye Tian Shi says that when pathological Heat is formed, the “Lesser Fire changes into Exuberant Fire”. “Lesser Fire” (Shao Huo) is another name for the physiological Heat of the Minister Fire, and “Exuberant Fire” (Zhuang Huo) is a pathological Heat that is formed under the influence of emotional stress. Ye Tian Shi says that in the elderly, Depression frequently occurs against a background of Yin deficiency, while in young people it occurs against a background of Qi stagnation and Heat. The pathology of Depression deriving from Qi stagnation becomes complicated due to the several pathological consequences of Qi stagnation. First, Phlegm may be formed, as indicated above; second, the Qi stagnation may give rise to Blood stasis, and this interacts with Phlegm, the two aggravating each other. So the pathology of Depression in later stages may be summarized in the three terms of Qi, Phlegm and Stasis (of Blood). In chronic cases, these three pathogenic factors usually give rise to a deficiency that may be of Qi, Yang, Blood or Yin. As Qi stagnation, Phlegm and Blood stasis may all obstruct the orifices, in treatment Ye Tian Shi placed the emphasis on brightening the orifices (which include the orifices of the Mind). He also placed the emphasis of treatment methods that move, clear obstructions and drain.

Depression

The key words Ye Tian Shi used to indicate the treatment methods in Depression are as follows. • • • •

Da : “to extend”, “to relax”. Xuan : “to diffuse”, “to drain”. Chang : “to free”. Tong : “to remove obstructions”.

In particular, in Qi stagnation one should move, free and relax; in Blood stasis, one should remove obstructions from the Blood Connecting (Luo) channels; in Heat (that derives from Qi stagnation), one should cool with bitter and cool herbs and remove obstructions with Qi-moving herbs. When the above pathogenic factors are combined with a deficiency, one should combine tonification with moving and removing obstructions.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 42, No. 9, 2001, p. 566. Li Bao Ling, “Development of herbal medicine research in Depression.” The pathology and treatment discussed by Dr Li are a little different from those discussed by other Chinese doctors. Dr Li discusses five main pathological conditions in Depression. 1. Liver-Qi stagnation giving rise to Heat: this is characterized by depression and irritability; Dr Li suggests using Xiao Chai Hu Tang Small Bupleurum Decoction or Xiao Yao San Free and Easy Wanderer Powder. 2. Heart not housing the Mind: this is characterized by depression, insomnia, excessive dreaming and mental restlessness; Dr Li suggests using Gan Mai Da Zao Tang Glycyrrhiza-Triticum-Jujuba Decoction. 3. Gall Bladder deficiency: this is characterized by depression, timidity, lack of initiative, difficulty in taking decisions, and waking up early in the morning; Dr Li suggests using Yi Lu Kang Jiao Nang Relieving Depression and Worry Capsule. 4. Heart- and Lung-Yin deficiency: this is characterized by depression, mental confusion and dislike to speak. Dr Li suggests using Bai He Di Huang Tang Lilium-Rehmannia Decoction. 5. Stomach and Spleen deficiency: this is characterized by depression, tiredness, desire to lie

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down, reluctance in going out and digestive problems. Dr Li suggests using a variation of Er Chen Tang Two Old Decoction (see below). Dr Li suggests various formulae for depression classified according to the organ involved, which may be the Liver, Heart, Heart and Lungs, and Spleen as follows. Liver • Xiao Chai Hu Tang Small Bupleurum Decoction • Xiao Yao San Free and Easy Wanderer Powder • Gan Mai Da Zao Tang Glycyrrhiza-Triticum-Jujuba Decoction • Yi Lu Kang Jiao Nang Relieving Depression and Worry Capsule • Ping Xin Wang You Tang Settling the Heart and Forgetting Worry Decoction Heart • Bao Nao Ning Jiao Nang Preserving the Brain’s Tranquillity Capsule • Huang Lian Wen Dan Tang Coptis Warming the Gall Bladder Decoction Heart and Lungs • Bai He Di Huang Tang Lilium-Rehmannia Decoction Spleen • Er Chen Tang Two Old Decoction Variation Dr Li also suggests the following acupuncture points for depression: HE-7 Shenmen, P-7 Daling, LIV-3 Taichong, ST-40 Fenglong, ST-36 Zusanli, SP-6 Sanyinjiao, P-5 Jianshi, BL-15 Xinshu and BL-18 Ganshu.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 46, No. 1, 2005, p. 47. Chen Ze Qi et al., “Research into the criteria for commonly seen patterns in Depression.” This article confirms what is, in my opinion, an excessive stress by Chinese doctors on Liver-Qi stagnation as the main pattern in Depression. The authors carried out a multicentre investigation and classification of the main patterns diagnosed in depression. Out of 1731 cases, the following were the five main patterns diagnosed.

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Table 13.4 Correlation between symptoms and patterns in depression

• • • • •

Symptom

Liver-Qi stagnation (%)

Liver-Qi stagnation and Spleen-Qi deficiency (%)

Liver-Qi stagnation with Phlegm (%)

Heart and Spleen deficiency (%)

Liver- and Kidney-Yin deficiency (%)

Depressed mood

99.7

99.6

99.6

99.6

96.4

Sadness and pessimistic mood

89.1

88.5

91.7

88.6

92.0

Affective disorder

95.6

97.1

96.6

98.8

91.3

Tiredness

90.6

95.7

97.7

94.6

98.6

Anxiety

92.3

88.9

87.5

92.5

93.5

Mental restlessness

90.6

83.9

84.5

85.8

91.3

Worry

81.5

91.8

84.8

85.8

86.2

Dejection

81.6

86.5

92.8

90.2

88.4

Listlessness

81.3

94.0

89.8

91.7

88.4

Insomnia

84.3

93.2

89.0

96.9

94.2

Excessive dreaming

81.0

85.2

86.0

88.6

97.1

Liver-Qi stagnation: 588 (34%). Liver-Qi stagnation with Spleen deficiency: 487 (28%). Liver-Qi stagnation with Phlegm: 264 (15%). Heart and Spleen deficiency: 254 (15%). Liver- and Kidney-Yin deficiency: 138 (8%).

Therefore, out of a total of 1731 cases, Liver-Qi stagnation in all its variations constituted 77% of cases. The article reports an interesting correlation between the most common symptoms and patterns (Table 13.4).

CLINICAL TRIALS Acupuncture Does acupuncture influence the cardiac autonomic nervous system in patients with minor depression or anxiety disorders? Fortschritte der Neurologie-Psychiatrie 2003 March, Vol. 71, Issue 3, pp. 141–149.

Agelink MW, Sanner D, Eich H, Pach J, Bertling R, Lemmer W, Klieser E, Lehmann E

Objective To evaluate the effects of acupuncture on the cardiac autonomic nervous system function in patients with minor depression or anxiety disorder.

Method Patients (n = 36) were randomly distributed into a true acupuncture group (needles were applied at classic acupuncture points HE-7 Shenmen, P-6 Neiguan, Du-20 Baihui, BL-62 Shenmai and Ex-6 Yuyao extra point) or a placebo group (needles were applied only epidermally at non-acupuncture points). Both groups underwent standardized measurements of the 5-minute resting heart rate variability, which were performed before the first and after the ninth acupuncture session of the acupuncture series, and also three times (before the start, then 5 and 15 minutes after needle application) during the third acupuncture session. Demographic data between the true acupuncture and placebo group did not differ.

Depression

Results

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treatment but with insignificant difference between the groups. For patients with somatic syndrome, the HAMD score decrease rate was higher in the maprotiline group than that in the electroacupuncture group. However, for the patients with anxiety somatization syndrome, the Self-Rating Scale for Anxiety and Asberg Rating Scale for side effects scores in the electroacupuncture group were significantly lower than those in the maprotiline group. Moreover, the efficacy index was higher in the electroacupuncture group.

Before the start of the acupuncture, there were also no significant differences in heart rate variability data between these groups. Compared with the placebo group, the true acupuncture group showed a significant decrease of the mean resting heart rate both 5 and 15 minutes after needle application, combined with a trend towards an increase of the high frequency (0.15–0.4 Hz) and a decrease of the low frequency (0.04–0.15 Hz) spectral power. The latter effects resulted in an overall significant decrease of the mean low frequency:high frequency ratio in true acupuncture compared with in placebo-treated patients.

Conclusion

Conclusion

Both electroacupuncture and maprotiline are effective in treating depression.

This pattern of findings suggests that in patients with minor depression or anxiety only true acupuncture leads to a relative increase of cardiovagal modulation of heart rate and facilitates the physiological regulatory autonomic nervous system function in response to alterations of the external or internal environment.

The use of acupuncture in the treatment of depression Zhong Guo Zhong Xi Yi Jie He Za Zhi [Chinese Journal of Integrated Traditional and Western Medicine] 2002 July, Vol. 22, Issue 7, pp. 512–514, 521. Han C, Li XW, Luo HC

Objective To compare the effect of electroacupuncture and maprotiline in treating depression.

Method Thirty patients suffering from depression were treated with electroacupuncture, and 31 patients were given maprotiline orally. The therapeutic effects and side effects were evaluated by measurement of Hamilton Depression Rating Scale (HAMD), Self-Rating Scale for Depression, Self-Rating Scale for Anxiety, Clinical Global Impression Scale and Asberg Rating Scale for side effects before treatment and on days 14, 28 and 42 of the therapeutic course.

Results After treatment, the scores of HAMD and Self-Rating Scale for Depression were significantly lower than before

Acupuncture in patients with minor depressive episodes and generalized anxiety. Results of an experimental study Fortschritte der Neurologie Psychiatrie 2000 March, Vol. 68, Issue 3, pp. 137–144. Eich H, Agelink MW, Lehmann E, Lemmer W, Klieser E

Objective To ascertain the effects of acupuncture in patients with minor depression and generalized anxiety.

Method In a placebo-controlled, randomized, modified doubleblind study, the effects of acupuncture were investigated in 43 patients with minor depression and 13 patients with generalized anxiety disorders. The severity of the disease was assessed by the Clinical Global Impression Scale. Treatment response was defined as a significant improvement in Clinical Global Impression Scale score. An intent to treat analysis was performed to compare treatment responses between true and placebo acupuncture. Points needled were HE-7 Shenmen, P-6 Neiguan, Du-20 Baihui, BL-62 Shenmai and Ex-6 Yuyao extra point.

Results After completing a total of 10 acupuncture sessions, the true acupuncture group (n = 28) showed a significantly larger clinical improvement compared with the placebo group (Mann–Whitney test, P < 0.05). There were significantly more responders in the true group

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compared with the placebo group. In contrast, no differences in the response rates were evident just after five acupuncture sessions.

no differences between acupressure and TEAS groups in outcome measures.

Conclusion

This study provides an alternative method for healthcare providers in treating dialysis patients with symptoms of fatigue, poor sleep or depression.

Acupuncture on the points HE-7 Shenmen, P-6 Neiguan, Du-20 Baihui, BL-62 Shenmai and Ex-6 (Yuyao extra point) leads to a significant clinical improvement as well as to a remarkable reduction in anxiety symptoms in patients with minor depression or with generalized anxiety disorders. The total sum of acupuncture sessions and the specific location of acupuncture needle insertions might be important factors for bringing about therapeutic success.

Conclusion

Clinical study on electroacupuncture treatment for 30 cases of mental depression Journal of Traditional Chinese Medicine 2004 September, Vol. 24, Issue 3, pp. 172–176. Han C, Li X, Luo H, Zhao X, Li X

Acupressure and transcutaneous electrical acupoint stimulation in improving fatigue, sleep quality and depression in hemodialysis patients

Objective

American Journal of Chinese Medicine 2004, Vol. 32, Issue 3, pp. 407–416. Tsay SL, Cho YC, Chen ML

Method

Objective The purpose of this study was to test the effectiveness of acupressure and transcutaneous electrical acupoint stimulation (TEAS) on fatigue, sleep quality and depression in patients who were receiving routine haemodialysis treatment.

Method The study was a randomized controlled trial; qualified patients were randomly assigned to acupressure, TEAS or control groups. Patients in the acupressure and TEAS groups received 15 minutes of treatment three times a week for 1 month, whereas patients in the control group received only routine unit care. A total of 106 patients participated in the study. Methods of measurement included the revised Piper Fatigue Scale, the Pittsburgh Sleep Quality Index and the Beck Depression Inventory. Data were collected at baseline, during the intervention and after treatment.

Results The results indicated that patients in the acupressure and TEAS groups had significantly lower levels of fatigue, a better sleep quality and less depressed moods compared with patients in the control group based on the adjusted baseline differences. However, there were

To compare the effect of electroacupuncture and maprotiline in treating mental depression.

Thirty patients were treated by electroacupuncture on Du-20 Baihui and Ex-3 (Yintang extra point) as the main points and other points according to the pattern. The other points were: • G.B.-34 Yanglingquan and SP-6 Sanyinjiao in cases of disharmony between Liver and Spleen • P-6 Neiguan and SP-6 Sanyinjiao in cases of Heart and Spleen deficiency • KI-3 Taixi and SP-6 Sanyinjiao in cases of Liverand Kidney-Yin deficiency. Maprotiline, which is a medication that strongly inhibits the uptake of noradrenaline (norepinephrine) in the brain and peripheral tissues, was used in the control group of 31 cases. The therapeutic effect and side effects were evaluated by measurement of the Hamilton Depression Rating Scale (HAMD) and the Asberg Rating Scale.

Results After the treatment, the scores in HAMD for both groups had decreased, but without significant differences between each group. The total effective rate in the treatment group was 96.7% and that of the control group was 90.3%, showing no significant differences between the groups. Both groups showed a decrease in traditional Chinese medicine symptoms, but the treatment group showed a far greater decrease. The Asberg score decreases were far superior in the

Depression

treatment group. After the treatment, the cortisol content and the endothelin-1 content of the two groups were decreased and registered near normal, without significant differences between the groups.

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Conclusion Acupuncture holds promise for the treatment of depression during pregnancy.

Conclusion

The benefits of whole body acupuncture in major depression

Electroacupuncture therapy can produce the same clinical therapeutic effect as that produced by the tetracyclic drug maprotiline, giving fewer side effects and better symptomatic improvement.

Journal of Affective Disorders 2000 January–March, Vol. 57, Issue 1–3, pp. 73–81. Roschke J, Wolf C, Muller MJ, Wagner P, Mann K, Grozinger M, Bech S

Acupuncture: a promising treatment for depression during pregnancy Journal of Affective Disorders 2004 November, Vol. 83, Issue 1, pp. 89–95. Manber R, Schnyer RN, Allen JJ, Rush AJ, Blasey CM

Objective To investigate the efficacy of acupuncture applied in addition to mianserin drug treatment for major depression using a single-blind placebo-controlled study.

Method Objective The aim of this randomized controlled pilot study was to determine whether acupuncture holds promise as a treatment for depression during pregnancy, as there are few medically acceptable treatments in existence.

Method Sixty-one pregnant women with major depressive disorder and a 17-item Hamilton Rating Scale for Depression were randomly assigned to one of three treatments delivered over 8 weeks: active acupuncture (20), active control acupuncture (21) and massage (20). Acupuncture treatments were standardized but individually tailored, and were provided in a doubleblind fashion. Responders to acute phase treatment continued the treatment until 10 weeks postpartum.

Results Response rates at the end of the acute phase were statistically significantly higher for the active acupuncture group (69%) than for the massage group (32%), with an intermediate response rate in the active control acupuncture group (47%). The active acupuncture group also exhibited a significantly higher average rate of reduction in Beck Depression Inventory scores from baseline to the end of the first month of treatment than the massage group. Responders to the acute phase of all treatments combined had significantly lower depression scores at 10 weeks postpartum than non-responders.

Seventy in-patients with a major depressive episode were randomly included in three different treatment groups: true acupuncture, placebo acupuncture and a control group. All three groups were pharmacologically treated with the antidepressant mianserin. The true group received acupuncture at specific points considered effective in the treatment of depression. The placebo group was treated with acupuncture at nonspecific locations, and the control group received pharmacological treatment plus clinical management. Acupuncture was applied three times a week over a period of 4 weeks. Psychopathology was rated by judges blind to true and placebo conditions twice a week over 8 weeks.

Results Patients who experienced acupuncture improved slightly more than patients treated with mianserin alone.

Conclusion Additionally applied acupuncture improved the course of depression more than pharmacological treatment with mianserin alone. However, no differences were detected between placebo and true acupuncture.

152nd Annual Meeting of the American Psychiatric Association, Washington, 15–20 May 1999 Allen JJ, Manber R, Schnyer RN, Hitt SK

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Objective

Method

To ascertain the efficacy of acupuncture in the treatment of major depression in women.

Thirty-eight women were randomized to one of three treatment conditions in a double-blind randomized controlled trial of acupuncture in depression. All participants eventually received 8 weeks of acupuncture treatment specifically for depression.

Method Thirty-three women with major depression were randomly assigned to one of three treatment groups. Those in the specific treatment group received acupuncture treatments individually tailored to their symptoms of depression. Those in the non-specific group first received acupuncture treatments tailored to address symptoms that were not clearly part of the depressive episode (e.g. back pain) and later received the acupuncture treatments specifically tailored to their symptoms of depression. Those in the wait list group waited without treatment for 8 weeks before receiving the acupuncture treatments tailored for their symptoms of depression.

Results Following treatments specifically designed to address symptoms of depression, 64% of women experienced remission. Comparing the immediate effect of these three 8-week treatment conditions, subjects receiving specific acupuncture treatments demonstrated greater improvement than those receiving non-specific acupuncture treatments and showed marginally more improvement than wait list controls.

Conclusion Based on this outpatient sample of women with major depression, it appears that acupuncture can provide significant symptom relief at rates comparable with standard treatments such as psychotherapy or pharmacotherapy. Acupuncture may hold sufficient promise to warrant a larger scale clinical trial.

6-month depression relapse rates among women treated with acupuncture Complementary Therapies in Medicine 2001 December, Vol. 9, Issue 4, pp. 216–218. Gallagher SM, Allen JJ, Hitt SK, Schnyer RN, Manber R

Objective To ascertain the efficacy of acupuncture in treating major depression in women.

Results From among the 33 women who completed treatment, 26 (79%) were interviewed after 6 months. Relapse rates were comparable with those of established treatments, with four of the 17 women (24%) who achieved full remission at the conclusion of treatment experiencing a relapse 6 months later.

Conclusion Compared with other empirically validated treatments, acupuncture designed specifically to treat major depression produces results that are comparable in terms of rates of response and of relapse or recurrence.

Herbal medicine Changes in serum tumor necrosis factor (TNF-alpha) with kami shoyo san (Jia Wei Xiao Yao San Augmented Free and Easy Wanderer Powder) administration in depressed climacteric patients American Journal of Chinese Medicine 2004, Vol. 32, Issue 4, pp. 621–629. Ushiroyama T, Ikeda A, Sakuma K, Ueki M

Objective To investigate the changes in serum tumour necrosis factor (TNF)-a in depressed climacteric patients after administration of kami shoyo san (Jia Wei Xiao Yao San TJ-24).

Method This study included 113 depressed menopausal patients who visited the gynaecological and psychosomatic medicine outpatient clinic of the Osaka Medical College Hospital in Japan. Serum TNF-a levels were compared in two treated groups, with and without concurrent use of herbal medicine: 58 patients were administered kami shoyo san and 55 patients who were administered antidepressants. Hamilton Rating

Depression

Scale for Depression scores were determined at baseline and 12 weeks after starting treatment. TNF-a concentrations were analysed before and after 12 weeks of treatment.

Results Kami shoyo san significantly increased plasma concentrations of TNF-a after 12 weeks of treatment, to 17.22 ± 6.13 pg/mL from a baseline level of 14.16 ± 6.27 pg/mL. The percentage change in plasma concentration of TNF-a differed significantly between the kami shoyo san therapy group and the antidepressant therapy group at 4, 8 and 12 weeks.

Conclusion

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induced HPA disruption. However, the behavioral and neurochemical bases of this drug remain unclear. In this study, the effects of saiko ka ryukotsu borei to on the depressive behavioural state and the reduction of transmission resulting from chronic stress were examined.

Method The chronic stress was induced by water immersion and restraint (2 h/day) for 4 weeks followed by recovery for 10 days. The treatment with saiko ka ryukotsu borei to (100, 300 or 1000 mg/kg p.o.) improved the stress-induced depressive state in a dose-dependent manner, evaluated by a Rotarod test.

This study found that kami shoyo san increased plasma TNF-a levels in depressed menopausal patients. Cytokines may play various roles in mood and emotional status via the central nervous system and may be regulated by herbal medicines, although the interactions are very complex.

Results

Saiko ka ryukotsu borei to (Chai Hu Jia Long Gu Mu Li Tang Bupleurum-mastodi Ossis-ostrea Decoction), a herbal medicine, ameliorates chronic stress-induced depressive state in Rotarod performance

These results suggest that saiko ka ryukotsu borei to improves the chronic stress-induced depressive state, based on the prevention of PFC dysfunction.

Pharmacological Biochemical Behaviour 2003 May, Vol. 75, Issue 2, pp. 419–425. Mizoguchi K, Yuzurihara M, Ishige A, Aburada M, Tabira T

CASE HISTORIES

Objective To ascertain if the herbal medicine saiko ka ryukotsu borei to (Chai Hu Jia Long Gu Mu Li Tang Bupleurummastodi Ossis-ostrea Decoction) improves chronic stressinduced depression in rats.

Background Exposure to chronic stress is thought to play an important role in the aetiology of depression. This disorder has been shown to involve disruption of the hypothalamo–pituitary–adrenal (HPA) system and dysfunction of the prefrontal cortex (PFC). It has been demonstrated that chronic stress in rats induces similar HPA disruption or a depressive state caused by a reduction of dopaminergic and serotonergic transmission in the PFC. It has also been shown that saiko ka ryukotsu borei to prevents such chronic stress-

A microdialysis study indicated that the drug treatment significantly prevented the chronic stressinduced decreases in extracellular concentrations of dopamine and serotonin in the PFC.

Conclusion

Case history A 43-year-old woman had been suffering from depression for several years. This was very apparent as soon as she started talking. She looked very distressed and in mental anguish and frequently burst into tears. She had suffered from the break-up of a relationship, and she felt very depressed. She also felt confused about her life aims both in her work and in relationships. It was very obvious that she had very low selfesteem and harboured suicidal thoughts. During the first interview, she mentioned only her depression and the shock following the break-up of her relationship. A week after the first interview, I got an e-mail from her. In it, she described how she was sexually abused when she was 10 years old for 9 months by her teacher. To keep her quiet, he told her that she was evil, that she had made him do that to her and that she

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would never amount to anything except a prostitute or similar. He also told her that she was stupid. He coerced her not to say anything, threatening that, if she did, people would know what she was, i.e. an “evil, twisted, stupid slut who deserved to be abused”. On her 16th birthday, she was still a virgin and wanted to remain so. She was raped by her boyfriend. She had been struggling with this for the past 32 years. She went to university to prove to herself that she was not stupid, but she said that she was still now struggling with feeling worthy. She put herself down all the time and blamed herself constantly. Her boyfriend of 11 years left her for a younger woman, telling her there was no one else and that it was all her fault. Four and half years later, she was still trying to come to terms with this. Her boyfriend’s words took her right back to the abuse; it was as if he triggered the same feelings of shame as she had felt when she was abused. She said that it also made her feel like a child, totally unable to cope. Then being made redundant 18 months previous to the consultation made her feel really useless and unwanted. Her letter was very eloquent and bared the roots of her emotional problems very clearly. Her eyes had an anguished look about them, looking like a cry for help. Her periods were regular but she bled for 9 days and suffered from premenstrual tension right from soon after her ovulation. Her tongue was Red, redder on the sides and with a sticky-yellow coating. Her pulse was Wiry all over in every position. Diagnosis Obviously, the sexual abuse suffered when she was 10 wounded her emotionally in a very deep way. It caused her to have deep feelings of worthlessness and shame. The cruel behaviour of her boyfriend resonated with those feelings from the time when she was 10 and triggered her depression. The emotional stress had caused Qi stagnation; this is evidenced by the tongue and pulse, both of which play a very important role in the diagnosis. Judging from the tongue and pulse, this patient’s was definitely a Full condition. The redder colour of the sides of the tongue, the Wiry pulse and the premenstrual tension indicate Liver-Qi stagnation as the main pathology.

However, the redness of the tongue clearly indicates that the stagnant Qi has given rise to Heat. As for the emotional aetiology, I feel that it would be wrong to attribute it to “anger” simply because there is Liver-Qi stagnation. I personally feel that the Liver is affected by other emotions too, in her case shame, frustration and feeling of worthlessness. The stagnation of Liver-Qi restrains the “coming and going” of the Ethereal Soul, and this results in her depression and confusion about her life’s aims. Treatment I started off by prescribing a variation of Yue Ju Wan Gardenia-Chuanxiong Pill, primarily on the basis of the pulse. In patients who are depressed from Liver-Qi stagnation and have a Wiry pulse, I nearly always use Yue Ju Wan, Zhu Dan Xi’s formula for the “six stagnations”. After that, my treatment oscillated between using this formula and Dan Zhi Xiao Yao San Moutan-Gardenia Free and Easy Wanderer Powder. My variation of Yue Ju Wan (in the form of concentrated powder) was as follows. • • • • • • • • • • •

Xiang Fu Rhizoma Cyperi 15 g Shen Qu Massa medicata fermentata 10 g Chuan Xiong Rhizoma Chuanxiong 8 g Cang Zhu Rhizoma Atractylodis 10 g Shan Zhi Zi Fructus Gardeniae 10 g Mu Dan Pi Cortex Moutan 10 g Suan Zao Ren Semen Ziziphi spinosae 10 g Yuan Zhi Radix Polygalae 15 g Zhi Gan Cao Radix Glycyrrhizae preparata 10 g Fu Xiao Mai Fructus Tritici levis 10 g Da Zao Fructus Jujubae 10 g

Explanation The above dosages are for a concentrated powder mixture to be taken one teaspoonful three times a day. The first five herbs constitute the root formula Yue Ju Wan Gardenia-Chuanxiong Powder. • Mu Dan Pi was added to clear Heat, as the tongue is Red and the sides redder. • Suan Zao Ren and Yuan Zhi work in combination to regulate the “coming and going” of the Ethereal Soul and treat depression. The former is sour and astringent and therefore “absorbs” the Ethereal Soul into the Liver, while the latter is pungent and stimulates the movement of the Ethereal Soul.

Depression

• Zhi Gan Cao, Fu Xiao Mai and Da Zao constitute the formula Gan Mai Da Zao Tang GlycyrrhizaTriticum-Jujuba Decoction. Although I normally use this formula for Empty conditions of depression, I do sometimes add to other formula when the patient is very distressed and anguished simply to nourish the Heart, the Mind and the Ethereal Soul. After two courses of this formula, the patient felt somewhat better and her tongue was considerably less Red, but her premenstrual tension was quite bad, with pronounced distension and pain of the breasts. I therefore decided to use Dan Zhi Xiao Yao San Moutan-Gardenia Free and Easy Wanderer Powder. I gave her the following variation of it. • • • • • • • • • • • • •

Bo He Herba Menthae 5 g Chai Hu Radix Bupleuri 6 g Dang Gui Radix Angelicae sinensis 10 g Bai Shao Radix Paeoniae alba 10 g Bai Zhu Rhizoma Atractylodis macrocephalae 10 g Fu Ling Poria 10 g Gan Cao Radix Glycyrrhizae 5 g Mu Dan Pi Cortex Moutan 10 g Shan Zhi Zi Fructus Gardeniae 10 g Yuan Zhi Radix Polygalae 10 g Suan Zao Ren Semen Ziziphi spinosae 10 g Mei Gui Hua Flos Rosae rugosae 10 g He Huan Pi Cortex Albiziae 10 g

Explanation The first nine herbs constitute the root formula. • The rationale of Yuan Zhi and Suan Zao Ren has already been explained above. • Mei Gui Hua was added to move Liver-Qi and lift mood. • He Huan Pi nourishes the Heart and lifts mood. I gave her two courses of this formula and then reverted again to the variation of Yue Ju Wan because her pulse was beginning to feel more Wiry. She took five courses of this formula and, after that, she felt very much better, she found a job, she was much more confident and she was not crying so much and was much more optimistic about the future. Her tongue was now of a normal colour and the pulse much less Wiry. Her eyes lost the anguished look.

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Case history A 38-year-old woman had been suffering from depression for several years. According to her, this did not seem to have any obvious cause as she was, in her words, happily married and had no financial or work problems. She initially did not come to me complaining of depression, but she sought treatment for chilblains, very cold hand, blue lips and tiredness. She felt very cold all the time. On interrogation, it transpired that she also suffered from dizziness, lower backache, frequent urination and nocturia. Her tongue was Pale and Swollen in the front part (Lung area); her pulse was Weak in general and especially on both Rear positions but very slightly Wiry on the left. Diagnosis Judging by her pulse, her condition is clearly primarily Empty. There is a clear deficiency of Kidney-Yang, as evidenced by the feeling of cold, cold limbs, tiredness, dizziness, backache, frequent urination, nocturia, Pale tongue and pulse Weak on both Rear positions. However, there are two Full conditions of which she had no symptoms. First, there is some Phlegm; this is shown by the swelling on the front of the tongue; second, there is some Qi stagnation, and this is shown by the slight Wiry quality of the pulse on the left side. Therefore the feeling of depression in her case has two causes, one Empty, the other Full, with a predominance of the first. The deficiency of KidneyYang fails to stimulate the “coming and going” of the Ethereal Soul, resulting in depression. On the other hand, this deficiency also implies a weakness of the Kidney’s Will-Power and therefore of drive, determination and initiative; this contributed to her feeling of depression. Treatment In my treatment, I concentrated on treating the Deficiency with a formula to tonify KidneyYang, i.e. You Gui Wan Restoring the Right [Kidney] Pill. This is the variation I used (modified to treat Qi stagnation and Phlegm). • • • •

Rou Gui Cortex Cinnamomi 5 g Du Zhong Cortex Eucommiae ulmoidis 10 g Shan Zhu Yu Fructus Corni 10 g Tu Si Zi Semen Cuscutae 10 g

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Lu Jiao Jiao Gelatinum Cornu Cervi 10 g Shu Di Huang Radix Rehmanniae preparata 10 g Shan Yao Rhizoma Dioscoreae 10 g Gou Qi Zi Fructus Lycii chinensis 10 g Dang Gui Radix Angelicae sinensis 5 g Xu Duan Radix Dipsaci 10 g Gui Zhi Ramulus Cinnamomi cassiae 10 g Yuan Zhi Radix Polygalae 10 g Xiang Fu Rhizoma Cyperi 10 g Ban Xia Rhizoma Pinelliae preparatum 10 g

Explanation • The first nine herbs constitute the root formula minus Fu Zi, which I do not use. • Xu Duan was added to tonify Kidney-Yang. • Gui Zhi was added to tonify Yang and stimulate the circulation of Yang in the limbs. • Yuan Zhi was added to stimulate the “coming and going” of the Ethereal Soul and lift mood. • Xiang Fu was added to move Liver-Qi. • Ban Xia was added to resolve Phlegm. I gave the patient one course of the above formula as a concentrated powder, one teaspoonful twice a day. For the second course, I made some changes to strengthen the Phlegm-resolving action, as follows. • • • • • • • • • • • • • • •

Rou Gui Cortex Cinnamomi 5 g Du Zhong Cortex Eucommiae ulmoidis 10 g Shan Zhu Yu Fructus Corni 10 g Tu Si Zi Semen Cuscutae 10 g Lu Jiao Jiao Gelatinum Cornu Cervi 10 g Shu Di Huang Radix Rehmanniae preparata 10 g Shan Yao Rhizoma Dioscoreae 10 g Gou Qi Zi Fructus Lycii chinensis 10 g Dang Gui Radix Angelicae sinensis 5 g Gui Zhi Ramulus Cinnamomi cassiae 10 g Yuan Zhi Radix Polygalae 10 g Xiang Fu Rhizoma Cyperi 10 g Ban Xia Rhizoma Pinelliae preparatum 10 g Chen Pi Pericarpium Citri reticulatae 10 g Fu Ling Poria 10 g

After this second course, she said that not only were her limbs much less cold and without chilblains (she was being treated in wintertime), but that her depression had completely and totally lifted. She went out to buy herself new clothes and she said she felt as if she “were on antidepressants”.

Case history A 48-year-old man had been suffering from depression for over 10 years. He was successful in his profession but, in the last 10 years, he felt increasingly dissatisfied and questioned the meaning of life. He was happily married and had no financial problems. His depression manifested with a low mood, a sense of frustration and irritability, a lack of drive and a feeling of pessimism. From the physical point of view, he had few problems, but he did suffer from lower backache and low libido. His pulse was Wiry but Empty at the deep level. His tongue was Reddish-Purple on the sides and had a deep Heart crack. After seeing the deep Heart crack on his tongue, I asked him some more questions about his depression and personal history. A deep Heart crack on the tongue always indicates that the person has either been subject to severe emotional stress for many years or that he or she has a family history of mental-emotional problems. When I asked this patient about his family and personal history, he said that his father had suffered from depression for many years when he was a child and a teenager. His memories of his father were of a man who was in the grip of major depressive disorder and hardly ever left his bedroom. This had affected him deeply (although he himself did not realize this). Therefore the deep Heart crack reflected this situation. The clinical significance of a deep Heart crack also concerns prognosis; in fact, such a crack always indicates that results will be slower to come. Diagnosis The Wiry pulse and the sense of frustration and irritability indicate Liver-Qi stagnation. As the sides of the tongue were Purple, this indicates that the Qi stagnation has given rise to Blood stasis. The stagnation of Liver-Qi and Liver-Blood contributes to the depression, as they restrain the “coming and going” of the Ethereal Soul. The emptiness of the pulse at the deep level, lower backache and low libido indicate a Kidney deficiency. The Kidney deficiency induces a weakness of WillPower (Zhi) and therefore a lack of drive and enthusiasm that contributes to the feeling of depression.

Depression

Treatment The treatment adopted was to move Qi, soothe the Liver, invigorate Blood and tonify the Kidneys. I used primarily acupuncture and some Three Treasures remedies. With acupuncture, I chose the points primarily from the following. • BL-23 Shenshu, Ren-4 Guanyuan and BL-52 Zhizhi to tonify the Kidneys and strengthen the WillPower. • LIV-3 Taichong and BL-47 Hunmen to move LiverQi and invigorate Liver-Blood and stimulate the “coming and going” of the Ethereal Soul. • HE-7 Shenmen, HE-5 Tongli and Ren-15 Jiuwei to nourish the Heart. • Du-20 Baihui and Du-24 Shenting to lift mood. The Three Treasures remedy used was Release Constraint, which is based on Zhu Dan Xi’s Yue Ju Wan Gardenia-Chuanxiong Pill for the six stagnations. This remedy was very well indicated, as the patient suffered from Liver-Qi and Liver-Blood stagnation. I treated this patient with acupuncture only once a month because he lived a long way away. He started to improve after 3 months of treatment with acupuncture and the herbal remedy. After 18 months, he felt a lot better in himself, he was not feeling so frustrated and dejected and he felt much more enthusiastic about life, so much so that he found the mental drive to make a radical change in his career. A deep Heart crack such as the one he had cannot completely disappear but it did get less deep.

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Her pulse was Wiry and Slippery and Weak on both Rear positions. Her tongue was Pale, Swollen, with teeth marks, and had a sticky coating. Diagnosis The Wiry pulse indicates that there was Liver-Qi stagnation, and this restrains the “coming and going” of the Ethereal Soul, leading to depression. The Weak pulse on both Rear positions, backache and frequent urination indicate a Kidney deficiency, which accounts for the lack of drive and enthusiasm. There is also some Phlegm, as evidenced by the Slippery quality of the pulse, the swelling of the tongue and the occasional expectoration of Phlegm. The Phlegm also restrains the “coming and going” of the Ethereal Soul, contributing to the feeling of depression. Treatment As she lived far away, I treated her with herbal medicine only and prescribed the Three Treasures remedy Release Constraint for the stagnation of Liver-Qi and depression. Besides moving Qi, this remedy also resolves Phlegm, from which this patient also suffered. I combined this remedy with the formula Gan Mai Da Zao Tang Glycyrrhiza-Triticum-Jujuba Decoction in a powdered form. I prescribed this formula to nourish the Heart and lift mood. I was drawn to using this formula by her emotional symptoms, characterized by vulnerability, sadness and crying. In such cases, I feel the Mind (Shen) needs to be nourished, and I find the formula Gan Mai Da Zao Tang ideal for this. After 2 years of treatment, she felt completely different and her depression was completely relieved.

Case history A 51-year-old woman had been suffering from depression for 3 years. This had coincided with the onset of the menopause. She felt very low, dissatisfied with life and sad and was prone to crying. She also felt vulnerable and burst into tears at the slightest negative comment that a member of her family might make. She also lacked drive and enthusiasm. On interrogation, it transpired that she suffered from lower backache and frequent urination; she always felt cold. Occasionally, she experienced some phlegm in the throat that she needed to expectorate.

Case history A 48-year-old woman had been suffering from depression for 12 years. Besides feeling depressed, low and sad, she also felt anxious and slept badly. As she described it, her mind was in constant “turmoil”. She also experienced a feeling of oppression of the chest and palpitations. Her tongue was slightly Red on the sides and Swollen, with a StomachHeart crack and a sticky coating. Her pulse was Slippery, Weak on both Rear positions and slightly Overflowing on both Front positions.

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Diagnosis The tongue and pulse are absolutely crucial to diagnose this case. The redness of the tongue indicates Heat, while the swelling and sticky coating indicate Phlegm; this was confirmed by the feeling of oppression of the chest. The Stomach–Heart crack is a midline crack that is long and narrow like a Heart crack but also broader in the centre, in the Stomach area. The swelling, redness and the crack all indicate the presence of Phlegm-Heat in the Heart and Lungs. This is confirmed by the slightly Overflowing quality on both Front positions (Heart and Lungs) of the pulse. Such an overflowing quality is often related to emotional stress affecting those two organs. Finally, the weakness of the pulse on both Rear positions indicates that there is also a Kidney deficiency. Treatment I treated this patient with herbal medicine only, as she lived a long way away. I actually used three prescriptions in a powdered form. • Wen Dan Tang Warming the Gall Bladder Decoction to resolve Phlegm and clear Heat from the Heart and Lungs and calm the Mind. • Bai He Zhi Mu Tang Lilium-Anemarrhena Decoction to nourish Heart- and Lung-Yin and nourish the Mind. • Gan Mai Da Zao Tang Glycyrrhiza-Triticum-Jujuba Decoction to nourish the Heart and lift mood. I added the following herbs to the above prescriptions. • Yuan Zhi Radix Polygalae and Shi Chang Pu Rhizoma Acori tatarinowii to stimulate the “coming and going” of the Ethereal Soul and open the Mind’s orifices. • Tu Si Zi Semen Cuscutae and Gou Qi Zi Fructus Lycii chinensis to tonify the Kidneys. She took this prescription for over a year, and her tongue became gradually less Red and less Swollen; her pulse became stronger on the Rear positions. After 18 months, she felt much better in herself, much less depressed and sad but still rather anxious.

Case history A 73-year-old man had been suffering from depression for many years. He complained of feeling depressed, irritable and frustrated. He conceded that a certain family situation was

causing him great frustration and resentment, but he did not show any willingness to elaborate on that or to want to discuss it. Physically, he was in remarkably good health, complaining only of some constipation and abdominal pain. He was not on any medication. His tongue was quite normal except for being Red on the sides. His pulse was Wiry in all positions. Diagnosis This is a very clear example of depression occurring against a background of Liver-Qi stagnation and deriving from repressed anger, frustration and resentment. The redness on the sides of the tongue reflects Heat deriving from Liver-Qi stagnation, while the Wiry quality of the pulse in all positions is a clear indication of Liver-Qi stagnation. The stagnation of Liver-Qi restrains the “coming and going” of the Ethereal Soul and caused him to feel depressed. Treatment I treated him only with a Three Treasures remedy called Release Constraint, because his condition corresponded very well to that treated by Yue Ju Wan Gardenia-Chuanxiong Pill, of which Release Constraint is a variation. He felt no change for the first 2 months (taking two tablets twice a day) but started feeling an improvement into the third month. He got gradually better and less depressed and, most importantly, he recognized the repressed anger as a cause of his depression and started undergoing psychotherapy. After 18 months, he felt very much better in himself and his depression lifted completely.

Case history A 35-year-old woman had been suffering from depression for 7 years. She felt very depressed all the time, was sad and cried frequently. The problem started after the break-up of a relationship 8 years previously. She had found this breakup very painful, and she had an intense feeling of rejection and loss. She had never recovered from this break-up and had not been in another relationship since then. She was pale and had a sad expression; she spoke with a very low voice. She sometimes experienced a dry mouth, palpitations and a slight breathlessness.

Depression

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Her tongue was Pale, and the coating was missing in patches. Her pulse was very Weak on the right Front position and Floating-Empty on the left side.

deficiency. The redness on the sides of the tongue indicates Liver-Qi stagnation. There is also a Spleen deficiency, as evidenced by the tiredness and desire to lie down.

Diagnosis Her symptoms, pulse and tongue all clearly point to a deficiency of Lung-Qi and Lung-Yin. The symptoms indicating deficiency of the Lungs are crying, pale face, sadness, weak voice and a slight breathlessness. The lack of coating in patches on the tongue indicates Yin deficiency. There is also a deficiency of the Heart, as evidenced by the palpitations. In summary, there is therefore a deficiency of Qi and Yin of both Heart and Lungs.

Treatment I treated this patient only with two Three Treasures remedies. I gave her Freeing the Moon to be taken only for 10 days prior to the period and Breaking Clouds to be taken every day. The former remedy is a variation of Xiao Yao San Free and Easy Wanderer Powder that nourishes Liver-Blood and moves Liver-Qi; the latter is a variation of Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction, which tonifies and lifts Spleen-Qi. This latter formula has been modified to lift mood and treat depression. After taking these two remedies for 2 months, she felt a lot more energetic and positive; after 12 months, she felt completely better and her pulse was much stronger.

Treatment I treated this patient with herbal medicine. I used the formula Gui Pi Tang Tonifying the Spleen Decoction to nourish Heart-Blood and Heart-Yin and lift mood, together with the formula Bai He Zhi Mu Tang Lilium-Anemarrhena Decoction (which contains only two herbs) to nourish Heart-Yin and Lung-Yin. I used these two formulae in concentrated powder form, one teaspoonful twice a day. The patient started improving after taking the prescription for only 1 week. After 6 months, she felt very much better and, significantly, she embarked on a new relationship.

Case history A 37-year-old woman had been suffering from depression for 2 years after the birth of her fourth child. She had had four children close together. She felt depressed and lacked any drive; she felt confused about her life aims and was torn between the desire to go back to work or to spend all the time at home to look after her children. She felt exhausted all the time, with a desire to lie down. Her periods were regular and not painful, but she suffered from premenstrual tension manifesting with a pronounced irritability and an aggravation of her depression. Her tongue was slightly Red on the sides but Pale in general. Her pulse was Weak and Choppy. Diagnosis Again, the tongue and pulse are crucial to the diagnosis. The Choppy quality of the pulse and the Pale colour of the tongue indicate Blood

Case history A 48-year-old woman had been suffering from depression for over 10 years. Her life had been very difficult in this time, going through the loss of a child and a divorce. She felt depressed, extremely tired and sad and was prone to crying. She was pale and spoke with a weak voice. She also suffered from backache; on interrogation, it transpired that she felt easily hot and experienced a dry mouth at night. She felt a feeling of constriction of the chest. Her tongue was Pale but had a red tip; the coating was rootless. Her pulse was Weak on the right Front position and generally empty at the deep level. Diagnosis There are symptoms of Lung-Qi deficiency: pale face, weak voice, tendency to crying and Weak pulse on the right Front position. The feeling of constriction of the chest indicates some stagnation of Lung-Qi; in emotional problems, this frequently accompanies a Lung-Qi deficiency. Other symptoms indicate a Kidney-Yin deficiency: lower backache, dry mouth at night, pulse empty at the deep level and rootless tongue coating. The sadness and grief deriving from her loss and separation injured Lung-Qi and Kidney-Yin, resulting

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in depression and a restraint of the “coming and going” of the Ethereal Soul. The Kidney deficiency involved a deficiency of the Will-Power (Zhi), and this caused her to lack drive and enthusiasm. Treatment I treated this patient with both acupuncture and herbs. I gave her the Three Treasures remedy Nourish the Root, which is a variation of Zuo Gui Wan Restoring the Left [Kidney] Pill, to nourish Kidney-Yin (in the evening) and Breaking Clouds, which is a variation of Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction, to tonify Lung-Qi and lift mood (in the morning). With acupuncture, I used points from the following groups. • LU-9 Taiyuan, LU-3 Tianfu, BL-13 Feishu and BL42 Pohu to tonify the Lungs, soothe the Corporeal Soul and lift mood. • Ren-4 Guanyuan, SP-6 Sanyinjiao and KI-3 Taixi to nourish Kidney-Yin. • BL-23 Shenshu and BL-52 Zhishi to strengthen the Will-Power. • Du-20 Baihui to lift mood. The combination of acupuncture and herbal medicine produced excellent results in a relatively short time. After 15 months of treatment, the patient felt very much more positive, did not cry and looked forward to the future.

PATIENTS’ STATISTICS I have compiled statistics from 68 patients with depression from my practice. There were 47 women (69%) and 21 men (31%); this is almost exactly in line with the overall percentage of women in my practice (67%). The age distribution was as follows. • • • • • • • •

21–30: 1 (1%) 31–40: 4 (6%) 41–50: 28 (41%) 51–60: 13 (19%) 61–70: 10 (15%) 71–80: 8 (12%) 81–90: 3 (5%) 91–100: 1 (1%)

Therefore, the highest incidence of depression is in the 41–50 age bracket and the second highest in

the 51–60 age bracket. If we take these two bands together, they account for 60% of cases of depression. This finding is in line with the aetiology of depression and its incidence in mid-life. During the mid-life years, the ego-building of the earlier years does not satisfy the individual any longer, and the demands of the Soul are being felt. From a Jungian perspective, depression in mid-life is a way for the Soul to make its demands on the individual felt. In terms of patterns, 33% of patients displayed a purely Full condition, 40% a purely Empty condition and 27% a mixed Full-Empty one. The figure of 33% for a purely Full condition is interesting, as it shows that a substantial proportion of patients with depression suffer from a purely Full condition; from the manifestations of depression (slow movement, weak voice, sadness, etc.), it would be easy to conclude wrongly that it is always caused by an Empty condition. Quite a high percentage of patients (30%) suffered from either Liver-Qi stagnation or Liver-Blood stasis, showing that stagnation is an important feature of the pathology of depression. In terms of Internal Organs involved, these were as follows. • • • • •

Liver: 29 (42.6%) Kidneys: 26 (38.2%) Spleen: 17 (25%) Heart: 13 (19.1%) Lungs: 9 (13.2%)

Please note that the total of the above numbers do not add to 68 (the total number of patients), and the percentages do not add to 100 because many patients suffer from patterns from more than one organ (e.g. Liver-Qi stagnation with Kidney deficiency). The Liver patterns were overwhelmingly of the Full type, and the breakdown is as follows. • • • • • • • •

Liver total: 29% Liver-Blood Xu: 6 (21%) Liver-Blood stasis: 8 (27%) Liver-Fire: 5 (17%) Liver-Wind: 2 (7%) Liver-Qi stagnation: 12 (41%) Liver-Yang rising: 1 (3%) Liver-Yin Xu: 1 (3%)

Please note that the numbers on the left do not add up to 29 nor the percentages to 100, because one patient may have more than one pattern (e.g. Liver-Qi

Depression

stagnation with Liver-Blood deficiency); in other words, some patients may appear in more than one box. In terms of pathogenic factors, the main ones were those related to the Liver and especially Liver-Qi stagnation, Liver-Blood stasis and Liver-Fire. The other important pathogenic factor was Phlegm, accounting for 26 patients (39%); this correlates with the incidence of Swollen tongue, i.e. 24 cases (36%). As for the tongue, many more tongues were Red than Pale, i.e. 42 (63%) against 14 (21%), respectively. This shows how common Heat is in depression; this is obviously due to the Qi stagnation from emotional stress giving rise to Heat. Quite a high percentage of tongues were Purple (17 or 25%), showing that Blood stasis is a common pathogenic factor in depression. An interesting finding is the percentage of patients with a Heart crack. These were 9 or 13%; this percentage is above the norm, which, for all patients, is 7%.

END NOTES 1. 1981 Jin Gui Yao Lue Fang Xin Jie [A New Explanation of the Essential Prescriptions of the Golden Chest]. Zhejiang Scientific Publishing House, Zhejiang, pp. 24–26. The Essential Prescriptions of the Golden Chest was written by Zhang Zhong Jing and first published c.AD 220.

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2. Bowlby J 1980 Loss, Sadness and Depression. Hogarth Press, London, p. 246. 3. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, pp. 501–502. First published c.100 BC. 4. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue [Internal Medicine in Chinese Medicine]. Shanghai Science Publishing House, Shanghai, pp. 121. 5. Ibid., p. 121. 6. A New Explanation of the Essential Prescriptions of the Golden Chest, p. 26. 7. Chen You Bang 1990 Zhong Guo Zhen Jiu Zhi Liao Xue [Chinese Acupuncture Therapy]. China Science Publishing House, Shanghai, pp. 511–512. 8. A New Explanation of the Essential Prescriptions of the Golden Chest, p. 185. 9. Ibid., p. 185. 10. Dr Zhang Ming Jiu, personal communication, Nanjing, 1982. 11. Shan Chang Hua 1990 Jing Xue Jie [An Explanation of the Acupuncture Points]. People’s Health Publishing House, Beijing, pp. 26–27. An Explanation of the Acupuncture Points was written by Yue Han Zhen and first published in 1654. 12. Ibid., p. 27. 13. Ibid., p. 207. 14. Ibid., p. 211. 15. Dr Zhang Ming Jiu, personal communication, Nanjing, 1982. 16. Cheng Bao Shu 1988 Zhen Jiu Da Ci Dian [Great Dictionary of Acupuncture]. Beijing Science Publishing House, Beijing, p. 11. 17. Jiao Shun Fa 1987 Zhong Guo Zhen Jiu Xue Qiu Zhen [An Enquiry into Chinese Acupuncture]. Shanxi Science Publishing House, p. 52. 18. Dr Zhang Ming Jiu, personal communication, Nanjing, 1982. 19. Cited in Bensky D, Clavey S, Stöger E 2004 Materia Medica, 3rd edn. Eastland Press, Seattle, p. 936.

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CHAPTER 14

ANXIETY

ANXIETY IN WESTERN MEDICINE

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ANXIETY IN CHINESE MEDICINE 387 Chinese disease entities corresponding to anxiety Rebellious Qi of the Penetrating Vessel (Chong Mai) 387 Palpitations in Chinese diagnosis 390 Difference between Mind Unsettled and Mind Obstructed in anxiety 390

• Heart and Gall Bladder deficiency • Heart-Blood deficiency • Kidney- and Heart-Yin deficiency with Empty Heat • Heart-Yang deficiency • Lung- and Heart-Qi deficiency • Lung- and Heart-Qi stagnation • Lung- and Heart-Yin deficiency • Heart-Blood stasis • Phlegm-Heat harassing the Heart

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AETIOLOGY 390 Emotional stress 390 Constitution 391 Irregular diet 391 Loss of blood 391 Overwork 391

ANXIETY

PATHOLOGY AND TREATMENT PRINCIPLES Heart 392 Lungs 393 Kidneys 393 Spleen 394 Liver 394

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ACUPUNCTURE TREATMENT OF ANXIETY 395 Distal points according to channel 395 Head points 396 IDENTIFICATION OF PATTERNS AND TREATMENT 397 Heart and Gall Bladder deficiency 397 Heart-Blood deficiency 398 Kidney- and Heart-Yin deficiency with Empty Heat 399 Heart-Yang deficiency 399 Lung- and Heart-Qi deficiency 400 Lung- and Heart-Qi stagnation 401 Lung- and Heart-Yin deficiency 401 Heart-Blood stasis 402 Phlegm-Heat harassing the Heart 403 MODERN CHINESE LITERATURE CASE HISTORIES

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Anxiety is a normal reaction to stress. In general, it helps one to cope. But when anxiety becomes an excessive, irrational dread of everyday situations, it has become a disabling disorder. The discussion of anxiety will follow the following topics. • • • • • • • •

Anxiety in Western medicine Anxiety in Chinese medicine Aetiology Pathology and treatment principles Acupuncture treatment of anxiety Identification of patterns and treatment Modern Chinese literature Case histories

ANXIETY IN WESTERN MEDICINE The anxiety disorders discussed in Western medicine are: • generalized anxiety disorder • panic disorder

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obsessive-compulsive disorder post-traumatic stress disorder social phobia (or social anxiety disorder) specific phobias.

Each anxiety disorder has its own distinct features, but they are all bound together by the common theme of excessive, irrational fear, worry and dread. A chronic state of anxiety is usually called generalized anxiety disorder. The essential characteristic of generalized anxiety disorder is an excessive, uncontrollable worry about everyday things. This constant worry affects daily functioning and can cause physical symptoms. Generalized anxiety disorder can occur with other anxiety disorders, depressive disorders or substance abuse. Generalized anxiety disorder is often difficult to diagnose, because it lacks some of the dramatic symptoms, such as unprovoked panic attacks, that are seen with other anxiety disorders; for a diagnosis to be made, worry must be present more days than not for at least 6 months. Physical symptoms may include: • • • • • • • • • •

muscle tension sweating nausea cold, clammy hands difficulty in swallowing jumpiness gastrointestinal discomfort or diarrhea irritability, feeling on edge tiredness insomnia.

A panic attack is defined as the abrupt onset of an episode of intense fear or discomfort, which peaks in approximately 10 minutes and includes at least four of the following symptoms: • • • • • • • • • • •

a feeling of imminent danger or doom the need to escape palpitations sweating trembling shortness of breath or a smothering feeling a feeling of choking chest pain or discomfort nausea or abdominal discomfort dizziness or lightheadedness a sense of things being unreal, depersonalization

• • • •

a fear of losing control or “going crazy” a fear of dying tingling sensations chills or hot flushes.

Panic disorder is diagnosed when an individual suffers at least two unexpected panic attacks followed by at least 1 month of concern over having another attack. Sufferers are also prone to situationally predisposed attacks. The frequency and severity of the attacks varies from person to person: an individual might suffer from repeated attacks for weeks, while another will have short bursts of very severe attacks. Panic disorder affects about 2.4 million adult Americans1 and is twice as common in women as in men.2

SUMMARY ANXIETY IN WESTERN MEDICINE The anxiety disorders discussed in Western medicine are:  generalized anxiety disorder  panic disorder  obsessive-compulsive disorder  post-traumatic stress disorder  social phobia (or social anxiety disorder)  specific phobias. All anxiety disorders involve excessive, irrational fear, worry and dread. Generalized anxiety disorder is an excessive, uncontrollable worry about everyday things. This constant worry affects daily functioning and can cause physical symptoms. A panic attack is defined as the abrupt onset of an episode of intense fear or discomfort, which peaks in approximately 10 minutes and includes at least four of the following symptoms:  a feeling of imminent danger or doom  the need to escape  palpitations  sweating  trembling  shortness of breath or a smothering feeling  a feeling of choking  chest pain or discomfort  nausea or abdominal discomfort

Anxiety

 dizziness or lightheadedness  a sense of things being unreal, depersonalization  a fear of losing control or “going crazy”  a fear of dying  tingling sensations  chills or hot flushes.

ANXIETY IN CHINESE MEDICINE “Anxiety” is a modern term that does not have an exact equivalent in Chinese medicine. I shall discuss the view of anxiety in Chinese medicine according to the following topics. • • • •

Chinese disease entities corresponding to anxiety Rebellious Qi of the Penetrating Vessel (Chong Mai) “Palpitations” in Chinese diagnosis Difference between Mind Unsettled and Mind Obstructed in anxiety

Chinese disease entities corresponding to anxiety There is no Chinese medicine term that corresponds exactly to what we call “anxiety”, but several ancient Chinese disease entities closely resemble anxiety. The two main disease entities that correspond to anxiety are: • “Fear and Palpitations” (Jing Ji) • “Panic Throbbing” (Zheng Chong). Both these conditions involve a state of fear, worry and anxiety, the first with palpitations and the second with a throbbing sensation in the chest and below the umbilicus. “Fear and Palpitations” is usually caused by external events such as a fright or shock, and it comes and goes; it is more frequently of a Full nature. “Panic Throbbing” is not caused by external events and it is continuous; this condition is usually of an Empty nature and is more serious than the first. In chronic cases, “Fear and Palpitations” may turn into “Panic Throbbing”. In severe cases, “Panic Throbbing” may correspond to panic attacks. Despite the name “Fear and Palpitations”, such states of fear and anxiety may occur without palpitations.

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Zhu Dan Xi (1281–1358) says:3 In both Fear and Palpitations and Panic Throbbing, there is Blood deficiency. Fear and Palpitations come in bouts; Panic Throbbing is constant. Panic Throbbing is due to worry and pensiveness agitating within, causing a deficiency and Phlegm-Heat. Zhang Jing Yue says of “Panic Throbbing” in his Complete Book of Jing Yue (Jing Yue Quan Shu, 1624):4 In Panic Throbbing, the heart is shaking in the chest, the patient feels fear and anxiety. There is Yin deficiency and exhaustion; there is Yin deficiency below so that the Gathering Qi [Zong Qi] has no root and Qi cannot return to its origin. For this reason, there is shaking [or throbbing] of the chest above and also throbbing on the sides of the umbilicus.

SUMMARY CHINESE DISEASE ENTITIES CORRESPONDING TO “ANXIETY”  “Fear and Palpitations” (Jing Ji)  “Panic Throbbing” (Zheng Chong)  Rebellious Qi of the Penetrating Vessel (Li Ji)

Rebellious Qi of the Penetrating Vessel (Chong Mai) There is a third Chinese condition that may correspond to anxiety and especially to panic attacks, and that is the condition of Rebellious Qi of the Penetrating Vessel (Chong Mai) causing the symptom of “internal urgency” (Li Ji). One of the most common pathologies of the Penetrating Vessel is rebellious Qi and “internal urgency” (Li Ji); this has been recognized since the times of the Classic of Difficulties (Nan Jing). Chapter 29 of the Classic of Difficulties says: “The pathology of the Penetrating Vessel is rebellious Qi with internal urgency [Li Ji].”5 “Internal urgency” indicates a feeling of anxiety and restlessness; in severe cases, there may be panic attacks with palpitations. On a physical level, it may also be interpreted as an uncomfortable, tight sensation from the lower abdomen radiating upwards towards the heart. Palpitations are frequently associated with the anxiety or panic attacks deriving from rebellious Qi

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of the Penetrating Vessel, because this vessel flows through the heart. This type of anxiety or panic attack may also be accompanied by a throbbing abdominal sensation, which is also due to rebellious Qi of the Penetrating Vessel in the abdomen. From this point of view, Rebellious Qi of the Penetrating Vessel could be considered as a form of “Panic Throbbing” (Zheng Chong). Li Shi Zhen said: “When Qi rebels upwards, there is internal urgency [Li Ji] and a feeling of heat; this is rebellious Qi of the Penetrating Vessel.”6 Rebellious Qi of the Penetrating Vessel causes various symptoms at different levels of the abdomen and chest. It causes primarily fullness, distension or pain in these areas. By plotting the pathway of the Penetrating Vessel, we can list the possible symptoms of rebellious Qi of the Penetrating Vessel starting from the bottom (Fig. 14.1): • • • • • • • •

cold feet fullness, distension or pain of the lower abdomen hypogastric fullness, distension or pain painful periods, irregular periods fullness, distension or pain of the umbilical area fullness, distension or pain of the epigastrium feeling of tightness below the xiphoid process feeling of tightness of the chest Pathology of Rebellious Qi Hot face

Penetrating Vessel pathway

Face

Kidney channel

Qi rebellious

Abdominal symptoms

Qi deficient in leg branch

Cold feet

Uterus Blood

REN-1

Legs

Figure 14.1 Rebellious Qi of the Penetrating Vessel.

• • • • • • • •

palpitations feeling of distension of the breasts in women slight breathlessness sighing feeling of lump in the throat feeling of heat of the face headache anxiety, mental restlessness, “internal urgency” (Li Ji). See Figure 14.2.

Obviously, not all these symptoms need occur simultaneously to diagnose rebellious Qi of the Penetrating Vessel, but it is necessary to have at least three or four symptoms at different levels (e.g. lower abdomen, epigastrium, chest or throat). For example, if someone had fullness, distension or pain of the lower abdomen, that would not be enough to diagnose the condition of rebellious Qi of the Penetrating Vessel. A feeling of energy rising from the lower abdomen up towards the throat would be a strong indication of rebellious Qi of the Penetrating Vessel. What makes the Qi of the Penetrating Vessel rebel upwards? In my experience, this may happen for two reasons manifesting with two conditions, one Full, the other mixed Full–Empty. First, the Qi of the Penetrating Vessel can rebel upwards by itself from emotional stress that makes Qi rise or stagnate (e.g. anger, repressed anger, worry, frustration or resentment). In this case, Qi rebels upwards by itself and the condition is Full; I call this “primary” rebellious Qi of the Penetrating Vessel. Qi of the Penetrating Vessel may rebel upwards also as a consequence of a Deficiency in this vessel in the lower abdomen. In such cases, Qi of the lower Dan Tian is weak and the Qi of the Penetrating Vessel “escapes” upwards; this is therefore a mixed Full–Empty condition, and I call this “secondary” rebellious Qi of the Penetrating Vessel. The Empty condition is deficiency of Blood and/or deficiency of the Kidneys (which may be Yin or Yang). This second condition is more common in women. Li Shi Zhen mentions the possibility of this pattern when he says: “When there is Blood deficiency leading to internal urgency, use Dang Gui.”7 The Classic of Categories also hints to Blood deficiency as a background for rebellious Qi of the Penetrating Vessel:8 The Qi of the Penetrating Vessel rises up to the chest, Qi is not regulated and therefore it rebels in the diaphragm, Blood is deficient and therefore there is internal urgency in the abdomen and chest.

Anxiety Anxiety, mental restlessness, ‘‘internal urgency’’ (Li Ji) Headache Feeling of heat of the face Sighing Feeling of lump in the throat Slight breathlessness Feeling of tightness of the chest Palpitations Feeling of distension of the breasts in women Feeling of tightness below the xiphoid process Hypogastric fullness, distension or pain Fullness, distension or pain of the umbilical area Fullness, distension or pain of the lower abdomen Painful periods, irregular periods

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CLINICAL NOTE  “Primary” rebellious Qi of the Penetrating Vessel: the Qi of the Penetrating Vessel rebels upwards by itself from emotional stress that makes Qi rise or stagnate; Full condition.  “Secondary” rebellious Qi of the Penetrating Vessel: Qi of the Penetrating Vessel rebels upwards as a consequence of a Deficiency (of Blood and Kidneys) in this vessel in the lower abdomen; Full–Empty condition.

A particular feature of the syndrome of rebellious Qi of the Penetrating Vessel is that it is characterized by a feeling of heat in the face and cold feet simultaneously. This is due to Qi rebelling upwards towards the face, causing a feeling of heat there; on the other hand, as it rebels upwards there is proportionately less Qi in the descending branch of the Penetrating Vessel, which causes cold feet. In fact, as have seen above, the old text specifically says that the descending branch of the Penetrating Vessel warms the feet. This feeling of heat in the face, therefore, is neither Full nor Empty Heat but just the result of a disharmony of Qi in the Penetrating Vessel, i.e. Qi rebelling upwards in its abdominal and head branches and being deficient in the descending branch in the legs. CLINICAL NOTE The feeling of heat in the face caused by Rebellious Qi of the Penetrating Vessel is neither Full Heat nor Empty Heat: it is simply an imbalance within the Penetrating Vessel. It is accompanied by cold feet, because the Qi of the Penetrating Vessel escapes upwards and not enough flows into its descending branch. This apparent contradictory picture of hot feeling of the face and cold feet is particularly common in women.

Cold feet

SUMMARY REBELLIOUS QI OF THE PENETRATING VESSEL (CHONG MAI)

Figure 14.2 Symptoms of Rebellious Qi of the Penetrating Vessel.

 Cold feet  Fullness, distension or pain of the lower abdomen  Hypogastric fullness, distension or pain  Painful periods, irregular periods

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 Fullness, distension or pain of the umbilical area  Fullness, distension or pain of the epigastrium  Feeling of tightness below the xiphoid process  Feeling of tightness of the chest  Palpitations  Feeling of distension of the breasts in women  Slight breathlessness  Sighing  Feeling of lump in the throat  Feeling of heat of the face  Headache  Anxiety, mental restlessness, “internal urgency” (Li Ji)

Palpitations in Chinese diagnosis On the subject of “palpitations”, it is worth explaining what this term indicates. If we ask most Western patients whether they have “palpitations”, most of them will reply in the negative because they think that by “palpitations” we mean “tachycardia”, i.e. a rapid beat of the heart. In reality, “palpitations” denotes simply an uncomfortable, subjective sensation of the heart beating in the chest; it has nothing to do with the speed or rate of the heart. Therefore, when I want to ask a Western patient about this symptom, I do not ask “Do you get palpitations?” but ask instead “Are you sometimes aware of your heart beating in an uncomfortable way?” If we ask in this manner, we will see that palpitations are a more common symptom than we think. CLINICAL NOTE “Palpitations” denotes simply an uncomfortable, subjective sensation of the heart beating in the chest; it has nothing to do with the speed or rate of the heart. Therefore, when I want to ask a Western patient about this symptom, I do not ask “Do you get palpitations?” but ask instead “Are you sometimes aware of your heart beating in an uncomfortable way?”

Difference between Mind Unsettled and Mind Obstructed in anxiety The difference between anxiety and panic attacks is a good illustration of the difference between Mind

Unsettled and Mind Obstructed. In anxiety, the person’s Mind is unsettled either by a Full condition (such as Heart-Heat) or by an Empty condition (such as Heart-Blood deficiency). The person is anxious and restless, but the Mind is unobstructed and insight is not affected. In obsessive-compulsive disorder, the Mind is also obstructed. When the Mind is obstructed, there is a certain loss of insight and rationality, as may happen in severe panic attacks when the person may have an irrational fear of death. The main pathogenic factors that obstruct the Mind are Phlegm and Blood stasis; severe Qi stagnation may also lead to mild obstruction of the Mind. We can therefore say that in “Fear and Palpitations” (Jing Ji) the Mind is unsettled, while in severe panic attacks, which are more likely to correspond to “Panic Throbbing” (Zheng Chong), the Mind is unsettled but also mildly obstructed.

AETIOLOGY The main aetiological factor in anxiety is obviously emotional stress. However, other factors play a role too, and constitution and diet are important aetiological factors.

Emotional stress “Anxiety” is a general term that indicates a chronic state of fear and uneasiness. However, that does not mean that, among the emotions, only fear leads to anxiety. A chronic state of anxiety may derive from many emotions, and particularly worry, fear, excess joy, shock, guilt, shame or pensiveness. Any of the above emotions may lead to some Qi stagnation initially. After some time, stagnant Qi generates Heat and, with time, this injures Blood and Yin leading to Blood and/or Yin deficiency. Therefore Heat may agitate the Mind, causing anxiety; on the other hand, Blood and Yin deficiency deprive the Mind of its residence and also lead to anxiety (Fig. 14.3). The Qi stagnation and Qi deficiency deriving from emotional stress may also lead to the formation of Phlegm, which may obstruct the Mind and lead to more serious anxiety or panic attacks. Chapter 39 of the Simple Questions says: “When shock affects the Heart, it deprives it of its residence, the Mind

Anxiety

Heat

Fire

Phlegm

Yin deficiency

Blood stasis

Empty Heat

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QI STAGNATION

EMOTION

QI DEFICIENCY

Figure 14.3 Consequences of emotional stress.

has no place to return to, thoughts come ceaselessly [i.e. anxiety] and Qi becomes chaotic.”9

Constitution In my experience, a constitutional tendency is an important and frequent aetiological factor in chronic anxiety. There are many people who simply have a constitutional tendency to worry and anxiety for no apparent external reasons; I have also noticed that there is often a familial incidence when I have treated various members and even generations of one family. An important sign indicating a constitutional tendency to emotional stress and anxiety is a Heart crack on the tongue (see Fig. 12.4). According to the National Institute of Mental Health, the risk of developing panic disorder appears to be inherited.10 This confirms the importance of constitution in the aetiology of chronic anxiety and panic disorders.

Irregular diet Irregular eating causes deficiency of Qi and Yin of the Stomach; in the long run, this may affect the Heart and lead to Heart-Yin deficiency and anxiety. Irregular eating and the excessive consumption of Damp-producing foods lead to the formation of Phlegm. This may obstruct the Mind and aggravate anxiety and panic disorders.

Loss of blood A heavy loss of blood, such as that which may happen during childbirth, leads to Blood deficiency. The Heart governs Blood, and this may therefore lead to HeartBlood deficiency and anxiety.

Overwork Overwork in the sense of working long hours without adequate rest for many years seriously depletes KidneyYin. A deficiency of Kidney-Yin eventually affects the Heart and may cause chronic anxiety. A deficiency of Kidney-Yin may also cause chronic anxiety by itself, without affecting the Heart.

SUMMARY AETIOLOGY  Emotional stress  Constitution  Irregular diet  Loss of blood  Overwork

PATHOLOGY AND TREATMENT PRINCIPLES In Chinese books, the pathology of “Fear and Palpitations” (Jing Ji) and of “Panic Throbbing” (Zheng

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Chong) is always related primarily to the Heart and secondarily to the Liver and Kidneys. These two conditions are related primarily to the Heart, because they are closely linked to the symptom of “palpitations”. Indeed, all modern Chinese books include the disease entities of “Fear and Palpitations” and “Panic Throbbing” under the disease entity of “Palpitations” (Xin Ji). Strangely, although the essential feature of anxiety is worry, Chinese books do not report Lung patterns in relation to the above two diseases. I have therefore added Lung patterns according to my clinical experience. Chinese books attribute the pathology of anxiety primarily to Heart patterns, which may include any of the Deficiency patterns (Qi, Yang, Blood and Yin), as well as Full patterns such as Heart-Heat or HeartBlood stasis. In my experience, apart from the Heart, the Lungs and Kidneys are also very much involved in the pathology of anxiety, the Lungs because they are affected by worry and the Kidneys because they are affected by fear. Zhu Dan Xi recommends resolving Phlegm in “Fear and Palpitations” and transforming Water in “Panic Throbbing”. Zhang Jing Yue says in the Complete Book of Jing Yue (Jing Yue Quan Shu, 1624):11 In Fear and Palpitations, the Heart, Spleen, Liver and Kidneys are involved. Yang is connected to Yin and the Heart to the Kidneys. [In this disease,] the upper part of the body is restless because it cannot link with the lower part; Heart-Qi is deficient and cannot connect with the Essence [of the Kidneys]. In Fear and Palpitations, the main treatment principles are to nourish the Heart and the Mind [Shen], supplement the Liver and Gall Bladder and tonify the Original Qi. The above statement from Zhang Jing Yue is interesting because it confirms my clinical experience, according to which fear often makes Qi rise (rather than descend). In fact, in the statement above, Zhang Jing Yue says that in “Fear and Palpitations” there is restlessness above and a disconnection between the Heart and Kidneys with Qi rising. Fright makes Qi rise, and it is necessary to make Qi sink with sinking substances such as Long Gu Mastodi Ossis fossilia or Zhen Zhu Mu Concha Margatiriferae usta. As Fire dries up Blood, it is also necessary to nourish Yin, clear Heart-Heat and nourish Blood.

Fright also deprives the Mind of its residence in the Heart; fluids change into Phlegm, and they enter the space left vacant so that the Mind cannot return to it. Therefore one must resolve Phlegm with formulae such as Shi Wei Wen Dan Tang Ten-Ingredient Warming the Gall Bladder Decoction.12 Wang Qing Ren (late Qing dynasty) thought that the main cause of anxiety is Blood stasis. He thought that nourishing Blood and calming the Mind does not yield good results in anxiety, and he advocated using his own Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction to invigorate Blood and eliminate stasis.13 Lin Pei Qin (late Qing dynasty) thought that in Fear and Palpitations caused by fright, the Mind is chaotic and one should tonify and nourish with a formula like Da Bu Yin Jian Great Tonifying Yin Qi Decoction. If there is Yin deficiency, he advocated using Zuo Gui Yin Restoring the Left [Kidney] Decoction; if Yang deficiency, use You Gui Yin Restoring the Right [Kidney] Decoction.14 Apart from the patterns with which anxiety may present, it is useful to differentiate the pathology and symptoms of anxiety from the point of view of Internal Organs; this approach is also more relevant to the acupuncture treatment of anxiety. In my experience, the main organs involved in anxiety are the Heart, Lungs, Liver and Kidneys. The symptoms and characteristics of anxiety for each organ are indicated below.

Heart The cardinal symptom of a Heart pattern is palpitations (see above); if there are palpitations, there is a Heart pattern. The patient suffering from anxiety from a Heart disharmony will suffer from palpitations, and the anxiety will be experienced in the chest. This may be a feeling of tightness, discomfort or oppression of the chest. In Full conditions, there may be a tight feeling of the chest, while in Empty conditions a feeling of the heart being “suspended”. The person suffering from anxiety with a Heart disharmony will appear flustered and somewhat “haunted”. They will be restless and fidgety, and they will tend to move in rapid movements (Fig. 14.4). There will be insomnia, and other symptoms will depend on whether it is a Full or an Empty condition of

Anxiety

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Figure 14.4 Heart-type anxiety.

Figure 14.5 Lung-type anxiety.

the Heart. Deficiency of Heart-Blood is more common in women who, besides being anxious, will tend to feel sad and cry.

a mild anxiety may ensue after the initial sadness (Fig. 14.6). The anxiety of the Lungs is often about spiritual matters, the meaning of life and existential suffering.

Lungs The Lungs are affected by sadness and grief usually deriving from loss. The patient will therefore be sad and prone to crying. Sighing is also a characteristic symptom of mental-emotional patterns of the Lungs. The person will also tend to be pale and speak with a weak voice (Fig. 14.5). Sadness and grief deplete Qi and therefore lead to Qi deficiency, especially of the Lungs and Heart. This makes the pulse Weak or Empty. However, after some time the Qi deficiency in the chest may also give rise to some Qi stagnation in the chest, affecting the Heart and Lungs. This may make the Lung pulse very slightly Tight. When the Lungs are affected by Qi stagnation,

Kidneys The emotion of the Kidneys is fear; this emotion, together with worry, is the one that is most closely linked to anxiety. The patient will appear gaunt and scared with almost a look of panic in the eyes. He or she may have a dark complexion. The person will always fear the worst in any situation (Fig. 14.7).

SADNESS GRIEF Deplete Qi

LUNG-QI DEFICIENCY

Qi stagnates in the chest

QI STAGNATION

Figure 14.6 Lung-Qi deficiency and Lung-Qi stagnation.

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Figure 14.7 Kidney-type anxiety.

Figure 14.8 Spleen-type anxiety.

The fear of the Kidneys has a “dark” quality about it and is different from the anxiety related to other organs. The anxiety of the Kidneys is usually about life situations; the person is deeply pessimistic, and the anxiety derives from such pessimism. The Kidneyrelated anxiety is often due to guilt. Although it is said that fear make Qi descend, in my experience chronic fear and anxiety of the Kidney makes Qi rise to the head, so that the person feels hot in the face, slightly dizzy and anxious. In my experience, the Kidneys are also affected by guilt, which may cause sinking or stagnation of KidneyQi. In both cases, the person may become anxious, being constantly haunted by the feeling of guilt.

obsessive. In chronic cases, pensiveness may cause anxiety, as the person is constantly anxious about his or her own mental arguments (Fig. 14.8). The Spleen anxiety may also be related to nurturing Earth issues, such as being overprotective towards one’s children, ignoring one’s own needs and putting the needs of others first or suffering from a lack of mothering.

Spleen The emotion related to the Spleen is pensiveness; this is akin to worry. Pensiveness is encountered in people whose thoughts go “round in circles” or have “mental arguments”; in severe cases, pensiveness may become

Liver The anxiety related to the Liver is akin to worry. People of the Wood type tend to worry easily; they are often tense and sometimes perfectionists. Their anxiety derives from the high standards they set themselves, and it is therefore related to a feeling of not achieving what one has set out to achieve (Fig. 14.9). The Liver houses the Ethereal Soul, which is responsible for our ideas, plans, projects, life dreams and vision. The Liver anxiety is therefore also related to a dissatisfaction with one’s achievements.

Anxiety

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Heart HE-7 Shenmen HE-7 is the main point on the Heart channel to calm the Mind and relieve anxiety. It is effective in both Full and Empty conditions, but I personally use it more for Empty conditions when anxiety derives from HeartBlood or Heart-Yin deficiency. HE-7 combines well with Ren-15 Jiuwei.

HE-8 Shaofu I use HE-8 to calm the Mind and relieve anxiety primarily in Full conditions such as Heart-Fire.

Liver LIV-3 Taichong LIV-3 is the main point on the Liver channel to calm the Mind and settle the Ethereal Soul. It combines well with L.I.-4 Hegu to calm the Mind. It also combines well with G.B.-13 Benshen to calm the Mind and settle the Ethereal Soul.

Spleen SP-6 Sanyinjiao

Figure 14.9 Liver-type anxiety.

SP-6 is the main point on the Spleen channel to calm the Mind. It is particularly indicated when the person is affected by worry and pensiveness. It also promotes sleep and it combines well with HE-7 Shenmen.

Lungs

SUMMARY

LU-7 Lieque

PATHOLOGY AND TREATMENT PRINCIPLES

I use LU-7 to calm the Mind, especially when the person is affected by worry, sadness or grief. LU-7 has a “centrifugal” movement, so it promotes the surfacing of emotions that may have been repressed or not acknowledged.

The pathology of “Fear and Palpitations” (Jing Ji) and of “Panic Throbbing” (Zheng Chong) is related primarily to the Heart and secondarily to the Liver, Lungs and Kidneys.

Kidneys KI-4 Dazhong

ACUPUNCTURE TREATMENT OF ANXIETY Distal points according to channel I shall discuss the distal points according to channels, starting with the Yin Organs.

I use KI-4 to nourish the Kidneys and relieve anxiety deriving from a Kidney disharmony.

KI-9 Zhubin I use KI-9 to calm the Mind relieve anxiety, especially in women suffering from a deficiency of the Kidneys and of Blood. I often combine this point with the open-

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Large Intestine

To calm the Mind and nourish the Heart in mental-emotional problems occurring against a background of Deficiency, I frequently combine Du-24 with Ren-15. An important feature of this point that makes it particularly useful is that it can both calm and lift the Mind, therefore it is used not only for anxiety and insomnia but also for depression and sadness. It is also used in psychiatric practice for schizophrenia and split personality.15 The name of this point refers to its strong influence on the Mind and Spirit. The courtyard was traditionally considered to be very important, as it was the part that gave visitors their first impression of the house; it is the entrance. Thus, this point could be said to be the “entrance” to the Mind and Spirit, and it being called a courtyard highlights its importance.

L.I.-4 Hegu

G.B.-13 Benshen

L.I.-4 has a strong calming action with or without LIV-3 Taichong. It regulates the ascending and descending of Qi to and from the head, and it therefore subdues Qi in the head when the person is anxious.

G.B.-13 calms the Mind (Shen) and subdues LiverYang. It also extinguishes Wind, resolves Phlegm, gathers Essence (Jing) to the head and clears the brain. Its classic indications include manic behaviour and fright. G.B.-13 is a very important point for mental and emotional problems and for anxiety. It is very much used in psychiatric practice for schizophrenia and split personality combined with HE-5 Tongli and G.B.-38 Yangfu.16 It is also indicated when the person has persistent and unreasonable feelings of jealousy and suspicion. Apart from these mental traits, it has a powerful effect in calming the Mind and relieving anxiety deriving from constant worry and fixed thoughts. Its effect is enhanced if it is combined with Du-24 Shenting. Its deep mental and emotional effect is also due to its action of “gathering” Essence to the head. The KidneyEssence is the root of our Pre-Heaven Qi and is the foundation for our mental and emotional life. A strong Essence is the fundamental prerequisite for a clear Mind (Shen) and a balanced emotional life. This is the meaning of this point’s name “Root of the Mind”, i.e. this point gathers the Essence that is the root of the Mind (Shen). The Kidney-Essence is the source of Marrow, which fills up the Brain (called Sea of Marrow); G.B.-13 is a point where Essence and Marrow “gather”. The Great Dictionary of Acupuncture says that this point “makes

ing points of the Yin Linking Vessel, i.e. P-6 Neiguan and SP-4 Gongsun.

Pericardium P-6 Neiguan P-6 calms the Mind and relieves anxiety. I use it particularly when there is anxiety against a background of Qi stagnation (which may be of the Liver, Heart or Lungs) or Heart-Blood deficiency.

P-7 Daling I use P-7 to calm the Mind, settle the Ethereal Soul and relieve anxiety more in Full conditions such as HeartFire or Liver-Fire.

Stomach ST-40 Fenglong ST-40 has a strong action in calming the Mind and relieving anxiety. It has a particular action on the chest, and it is therefore particularly indicated for anxiety that is related to the Heart and/or Lungs with a feeling of tightness or oppression in the chest.

Head points In order to calm the Mind and relieve anxiety, it is important to combine distal points with points on the head. The following are the main head points I use for anxiety.

Du-24 Shenting Du-24 traditional indications include manic depression, depression, anxiety, poor memory and insomnia. The most important aspect of Du-24’s energetic action is its downward movement: it makes Qi descend and subdues rebellious Yang. This is a very important and powerful point to calm the Mind. It is frequently combined with G.B.-13 Benshen for severe anxiety and fears.

Anxiety

the Mind [Shen] return to its root”17; the “root” of the Mind is the Essence, hence this point “gathers” the Essence to the Brain and calms the Mind and relieves anxiety. When combined with other points to nourish Essence (such as Ren-4 Guangyuan), G.B.-13 attracts Essence towards the head, with the effect of calming the Mind and strengthening clarity of mind, memory and will-power. The connection between G.B.-13 and the Essence is confirmed by the text An Enquiry into Chinese Acupuncture, which has among the indications of this point “excessive menstrual bleeding, impotence and seminal emissions”.18 Finally, G.B.-13 resolves Phlegm in the context of mental-emotional disorders or epilepsy, i.e. it opens the Mind’s orifices when these are clouded by Phlegm. The Explanation of the Acupuncture Points says: “The indications of G.B.-13 show that it eliminates the three pathogenic factors of Wind, Fire and Phlegm from the Lesser Yang, in which cases this point should be reduced.”19

Du-19 Houding Du-19 calms the Mind and opens the Mind’s orifices. Its classic indications include manic behaviour, anxiety, mental restlessness and insomnia. Du-19 has a powerful calming effect on the Mind and is very often used in severe anxiety, especially in combination with Ren-15 Jiuwei.

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Pericardium  P-6 Neiguan  P-7 Daling Large Intestine  L.I.-4 Hegu Stomach  ST-40 Fenglong Head points  Du-24 Shenting  G.B.-13 Benshen  Du-19 Houding

IDENTIFICATION OF PATTERNS AND TREATMENT Heart and Gall Bladder deficiency Clinical manifestations Palpitations, anxiety, timidity, easily frightened, lack of self-assertion, easily discouraged, cannot sit or lie down, insomnia, waking up early in the morning. Tongue: Pale. Pulse: Weak.

Mental-emotional profile

SUMMARY

This person is timid, shy and lacking in drive. He or she is easily discouraged and finds it difficult to make decisions. The anxiety is mild.

ACUPUNCTURE TREATMENT OF ANXIETY

Treatment principle

Distal points according to channel Heart  HE-7 Shenmen  HE-8 Shaofu

Tonify the Heart and Gall Bladder, calm the Mind.

Liver  LIV-3 Taichong

HE-7 Shenmen, HE-5 Tongli, BL-15 Xinshu, Ren-14 Juque, G.B.-40 Qiuxu, ST-36 Zusanli. All with reinforcing method. Moxa is applicable if the tongue is Pale.

Spleen  SP-6 Sanyinjiao Lungs  LU-7 Lieque Kidneys  KI-4 Dazhong  KI-9 Zhubin

Acupuncture Points

Explanation • HE-7, HE-5, BL-15 and Ren-14 tonify the Heart and calm the Mind. • G.B.-40 tonifies the Gall Bladder. I use this point in particular to stimulate the psychic aspect of the Gall Bladder, i.e. courage and assertiveness. • ST-36 is used to tonify the Heart.

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Herbal therapy Prescription AN SHEN DING ZHI WAN Variation Calming the Mind and settling the Spirit Pill Variation

Explanation The original formula tonifies the Heart and calms the Mind. It has been modified with the addition of sinking substances that calm the Spirit. Please note that the use of minerals in herbal prescriptions is not allowed in the UK.

Prescription PING BU ZHEN XIN DAN Variation Calming and Tonifying the Heart Pill Variation

Explanation This formula differs from the previous one in that it provides a more general tonification of the Heart, as it tonifies Qi and nourishes Blood.

Prescription WU WEI ZI TANG Variation Schisandra Decoction Variation

Heart-Blood deficiency Clinical manifestations Palpitations, anxiety, dizziness, pale face, insomnia, poor memory, tiredness. Tongue: Pale and Thin. Pulse: Choppy or Fine.

Mental-emotional profile This person is most likely to be a woman, pale, depressed and anxious. The anxiety is mild and she hides it well.

Treatment principle Nourish Heart-Blood, calm the Mind.

Acupuncture

Prescription

Points

WU WEI ZI TANG Variation Schisandra Decoction Variation

HE-7 Shenmen, Ren-14 Juque, ST-36 Zusanli, SP-6 Sanyinjiao. All with reinforcing method. Moxa may be used.

Explanation This formula tonifies the Heart and calms the Mind, emphasizing nourishing the Yin.

Explanation

SUMMARY

• HE-7 and Ren-14 nourish Heart-Blood and calm the Mind. • ST-36 and SP-6 are used to nourish Blood in general.

HEART AND GALL BLADDER DEFICIENCY

Herbal therapy

Points HE-7 Shenmen, HE-5 Tongli, BL-15 Xinshu, Ren-14 Juque, G.B.-40 Qiuxu, ST-36 Zusanli. All with reinforcing method. Moxa is applicable if the tongue is Pale. Herbal therapy Prescription AN SHEN DING ZHI WAN Variation Calming the Mind and settling the Spirit Pill Variation Prescription PING BU ZHEN XIN DAN Variation Calming and Tonifying the Heart Pill Variation

Prescription GUI PI TANG Variation Tonifying the Spleen Decoction Variation

Explanation The original formula nourishes Qi and Blood of Heart, Spleen and Liver and calms the Mind. It has been modified only slightly by removing Mu Xiang Radix Aucklandiae and adding Bai Zi Ren Semen Platycladi.

Three Treasures remedy Calm the Shen Calm the Shen is a variation of Gui Pi Tang, and it nourishes Heart-Blood and calms the Mind.

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SUMMARY

Herbal therapy

HEART-BLOOD DEFICIENCY

Prescription

Points HE-7 Shenmen, Ren-14 Juque, ST-36 Zusanli, SP-6 Sanyinjiao. All with reinforcing method. Moxa may be used.

TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill

Herbal therapy Prescription GUI PI TANG Variation Tonifying the Spleen Decoction Variation

This formula nourishes Heart- and Kidney-Yin, clears Empty Heat and calms the Mind.

Three Treasures remedy Calm the Shen

Heavenly Empress (Women’s Treasure) Heavenly Empress nourishes Heart- and Kidney-Yin, clears Empty Heat and calms the Mind. Please note that, although this remedy is part of the Women’s Treasure range, it is equally suitable for men, as it is a variation of Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill.

Kidney- and Heart-Yin deficiency with Empty Heat

Explanation

Three Treasures remedy

Clinical manifestations Palpitations, anxiety that is worse in the evening, mental restlessness, insomnia, night sweating, feeling of heat in the evening, five-palm heat, dizziness, tinnitus. Tongue: Red without coating. Pulse: Floating-Empty and Rapid.

Mental-emotional profile This person is more likely to be middle-aged. The anxiety is marked and is experienced more in the evenings. In women, this type of anxiety is markedly aggravated with the onset of the menopause. There is a characteristic restlessness and fidgetiness.

Treatment principle Nourish Heart- and Kidney-Yin, clear Empty Heat, calm the Mind.

Acupuncture Points HE-7 Shenmen, Ren-14 Juque, KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, HE-6 Yinxi, KI-7 Fuliu. Reinforcing method.

Explanation • HE-7 and Ren-14 nourish Heart-Yin. • KI-3, Ren-4 and SP-6 nourish Kidney-Yin. • HE-6 clears Heart Empty Heat; together with KI-7, it treats night sweating.

SUMMARY KIDNEY- AND HEART-YIN DEFICIENCY WITH EMPTY HEAT Points HE-7 Shenmen, Ren-14 Juque, KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, HE-6 Yinxi, KI-7 Fuliu. Reinforcing method. Herbal therapy Prescription TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill Three Treasures remedy Heavenly Empress (Women’s Treasure)

Heart-Yang deficiency Clinical manifestations Palpitations, anxiety, pale face, feeling cold, cold hands, slight breathlessness, discomfort in the chest. Tongue: Pale, wet. Pulse: Deep-Weak.

Mental-emotional profile This person is anxious but also depressed and listless. Everything is an effort, and they speak with difficulty.

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Treatment principle Tonify Heart-Yang, calm the Mind.

Acupuncture

Prescription YANG XIN TANG Nourishing the Heart Decoction

Points HE-5 Tongli, BL-15 Xinshu, Du-14 Dazhui, Ren-6 Qihai, ST-36 Zusanli. Reinforcing method; moxa is applicable.

Explanation • HE-5, BL-15 and Du-14 tonify Heart-Yang and calm the Mind. • Ren-6 and ST-36 with moxa tonify Yang in general.

Herbal therapy Prescription GUI ZHI GAN CAO LONG MU MU LI TANG Variation Cinnamomum-Glycyrrhiza-Mastodi Ossis fossilia-Concha Ostreae Decoction Variation

Lung- and Heart-Qi deficiency Clinical manifestations Palpitations, anxiety, timidity, easily frightened, sadness, tendency to crying, weak voice, slight breathlessness, propensity to catching colds. Tongue: Pale. Pulse: Weak on both Front positions.

Mental-emotional profile This person is anxious but also sad. They are often affected by grief following a loss. They will tend to be pale and speak with a weak voice. The anxiety is experienced in the chest.

Treatment principle

Explanation

Tonify Heart- and Lung-Qi, calm the Mind.

This formula tonifies Heart-Yang and calms the Mind. It also stops sweating from Heart-Yang deficiency.

Acupuncture Points

Prescription YANG XIN TANG Nourishing the Heart Decoction

Explanation This formula tonifies Heart-Qi and calms the Mind. Its calming the Mind effect is stronger than that of the previous formula.

SUMMARY

HE-5 Tongli, HE-7 Shenmen, BL-15 Xinshu, Ren-14 Juque, LU-9 Taiyuan, LU-7 Lieque, BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, Ren-6 Qihai, ST-36 Zusanli. Reinforcing method.

Explanation • HE-5, HE-7, BL-15 and Ren-14 tonify the Heart and calm the Mind. • LU-9, LU-7, BL-13 and Du-12 tonify Lung-Qi. • Ren-12, Ren-6 and ST-36 tonify Qi in general.

HEART-YANG DEFICIENCY

Herbal therapy

Points HE-5 Tongli, BL-15 Xinshu, Du-14 Dazhui, Ren-6 Qihai, ST-36 Zusanli. Reinforcing method; moxa is applicable.

Prescription

Herbal therapy Prescription GUI ZHI GAN CAO LONG MU MU LI TANG Variation Cinnamomum-Glycyrrhiza-Mastodi Ossis fossiliaConcha Ostreae Decoction Variation

YANG XIN TANG (I) Nourishing the Heart Decoction

Explanation This formula tonifies Heart- and Lung-Qi and calms the Mind.

Prescription BU FEI TANG Variation Tonifying the Lungs Decoction Variation

Anxiety

SUMMARY LUNG- AND HEART-QI DEFICIENCY Points HE-5 Tongli, HE-7 Shenmen, BL-15 Xinshu, Ren-14 Juque, LU-9 Taiyuan, LU-7 Lieque, BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, Ren-6 Qihai, ST-36 Zusanli. Reinforcing method. Herbal therapy Prescription YANG XIN TANG (I) Nourishing the Heart Decoction Prescription BU FEI TANG Variation Tonifying the Lungs Decoction Variation

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• Ren-15 and Ren-17 relax the chest and calm the Mind. • LU-7 moves Lung-Qi. • ST-40, in combination with LU-7 and P-6 relaxes the chest and calms the Mind.

Herbal therapy Prescription BAN XIA HOU PO TANG Pinellia-Magnolia Decoction

Three Treasures remedy Open the Heart Open the Heart moves Qi of the Heart and Lungs and calms the Mind. It has a special action on the chest and it is therefore particularly indicated when there are chest symptoms such as a feeling of tightness or oppression of the chest.

Lung- and Heart-Qi stagnation Clinical manifestations Palpitations, anxiety, a feeling of distension or oppression of the chest, depression, a slight feeling of a lump in the throat, slight shortness of breath, sighing, sadness, chest and upper epigastric distension, slightly purple lips, pale complexion. Tongue: slightly Pale-Purple on the sides in the chest area. Pulse: Empty but very slightly Overflowing on both Front positions.

Mental-emotional profile This person is anxious but also worried and sad. They will tend to be pale and speak with a weak voice. The anxiety is experienced in the chest.

Treatment principle Move Qi in the Heart and Lung, relax the chest, calm the Mind.

Acupuncture Points HE-5 Tongli, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong. Even method.

Explanation • HE-5, HE-7 and P-6 move Heart-Qi and calm the Mind.

SUMMARY LUNG- AND HEART-QI STAGNATION Points HE-5 Tongli, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong. Even method. Herbal therapy Prescription BAN XIA HOU PO TANG Pinellia-Magnolia Decoction Three Treasures remedy Open the Heart

Lung- and Heart-Yin deficiency Clinical manifestations Anxiety, cough that is dry or with scanty-sticky sputum, weak and hoarse voice, dry mouth and throat, tickly throat, palpitations, insomnia, dream-disturbed sleep, poor memory, propensity to be startled, mental restlessness, uneasiness, dry mouth and throat in the afternoon or evening, tiredness, dislike speaking, thin body or thin chest, night sweating. Tongue: normal-coloured, dry without coating (or with rootless coating) in the front part. Pulse: Floating-Empty.

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Treatment principle Nourish Lung- and Heart-Yin and calm the Mind.

Acupuncture Points LU-9 Taiyuan, Ren-17 Shanzhong, BL-43 Gaohuangshu, BL-13 Feishu, Ren-4 Guanyuan, Ren-12 Zhongwan, SP-6 Sanyinjiao, HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei. Reinforcing method.

Explanation • LU-9, Ren-17, BL-43, and BL-13 nourish Lung-Yin. • Ren-4, Ren-12 and SP-6 nourish Yin in general. • HE-7, Ren-14 and Ren-15 nourish Heart-Yin and calm the Mind.

Tongue: Purple on the sides (chest area). Pulse: Wiry, Choppy or Firm.

Mental-emotional profile This person will tend to be middle-aged. The anxiety is experienced more in the evening and often also in the middle of the night, when they might wake up with a panicky feeling.

Treatment principle Invigorate Heart-Blood, eliminate stasis, calm the Mind.

Acupuncture Points

Herbal therapy

HE-5 Tongli, P-6 Neiguan, Ren-14 Juque, Ren-15 Jiuwei, LIV-3 Taichong, SP-6 Sanyinjiao. Even method.

Prescription

Explanation

BAI HE GU JIN TANG Variation Lilium Consolidating Metal Decoction Variation

Explanation

• HE-5, P-6, Ren-14 and Ren-15 invigorate HeartBlood and calm the Mind. • LIV-3 invigorates Blood in general. • SP-6 invigorates Blood and calms the Mind.

This formula variation nourishes Lung- and Heart-Yin and calms the Mind.

Herbal therapy Prescription

SUMMARY LUNG- AND HEART-YIN DEFICIENCY Points LU-9 Taiyuan, Ren-17 Shanzhong, BL-43 Gaohuangshu, BL-13 Feishu, Ren-4 Guanyuan, Ren-12 Zhongwan, SP-6 Sanyinjiao, HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei. Reinforcing method. Herbal therapy Prescription BAI HE GU JIN TANG Variation Lilium Consolidating Metal Decoction Variation

TAO REN HONG HUA JIAN Persica-Carthamus Decoction

Explanation This formula invigorates Heart-Blood and calms the Mind.

Three Treasures remedy Red Stirring Red Stirring invigorates Heart-Blood. It can be used to invigorate Blood in the Heart, but it does not have a pronounced calming the Mind effect. This should therefore be integrated with acupuncture.

SUMMARY HEART-BLOOD STASIS

Heart-Blood stasis Clinical manifestations Palpitations, anxiety, insomnia, agitation, poor memory, chest pain.

Points HE-5 Tongli, P-6 Neiguan, Ren-14 Juque, Ren-15 Jiuwei, LIV-3 Taichong, SP-6 Sanyinjiao. Even method.

Anxiety

Herbal therapy Prescription TAO REN HONG HUA JIAN Persica-Carthamus Decoction Three Treasures remedy Red Stirring

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Explanation This formula clears Heart-Heat, resolves Phlegm and calms the Mind.

Prescription GUI SHEN TANG Restoring the Mind Decoction

Explanation

Phlegm-Heat harassing the Heart Clinical manifestations Palpitations, anxiety, insomnia, dreaming a lot, feeling of oppression of the chest, sputum in the throat, slightly “manic” behaviour. Tongue: Red, Swollen with sticky-yellow coating. Pulse: Slippery-Rapid.

Mental-emotional profile In this case, the anxiety is marked, to the point of agitation. The person may be hyperactive and slightly chaotic.

Treatment principle Resolve Phlegm, clear Heart-Heat, calm the Mind, open the Mind’s orifices.

This formula opens the Mind’s orifices, tonifies the Heart, resolves Phlegm and calms the Mind. Its clearing-Heat effect is not strong. Please note that the original formula contains Zi He Che Placenta hominis and Zhu Sha Cinnabaris, which should be omitted, as the use of these two substances is not allowed.

Three Treasures remedies Clear the Soul Clear the Soul clears Heat and resolves Phlegm from the Heart and Lungs and calms the Mind. Settling the Soul Settling the Soul clears Heat and resolves Phlegm from the Heart and Liver, calms the Mind and settles the Ethereal Soul.

Acupuncture

SUMMARY

Points

PHLEGM-HEAT HARASSING THE HEART

P-5 Jianshi, HE-8 Shaofu, Ren-12 Zhongwan, ST-40 Fenglong, ST-8 Touwei, G.B.-13 Benshen, Ren-15 Jiuwei, Du-24 Shenting. Even method on all points except Ren-12, which should be needled with reinforcing method.

Points P-5 Jianshi, HE-8 Shaofu, Ren-12 Zhongwan, ST40 Fenglong, ST-8 Touwei, G.B.-13 Benshen, Ren15 Jiuwei, Du-24 Shenting. Even method on all points except Ren-12, which should be needled with reinforcing method.

Explanation • P-5 and HE-8 clear Heart-Heat and resolve Phlegm from the Heart. • Ren-12 and ST-40 resolve Phlegm. • G.B.-13, Ren-15 and Du-24 calm the Mind and resolve Phlegm from the head.

Herbal therapy Prescription WEN DAN TANG Warming the Gall Bladder Decoction

Herbal therapy Prescription WEN DAN TANG Warming the Gall Bladder Decoction Prescription GUI SHEN TANG Restoring the Mind Decoction Three Treasures remedies Clear the Soul Settling the Soul

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MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 41, No. 2, 2000, p. 95. Sun Song, “The treatment of generalized anxiety disorder with a variation of Chai Hu Long Gu Mu Li Tang BupleurumMastodi Ossis fossilia-Concha Ostreae decoction.” Seventy-two cases of generalized anxiety disorder were treated with a variation of the formula Chai Hu Long Gu Mu Li Tang Bupleurum-Mastodi Ossis fossilia-Concha Ostreae decoction. The age distribution of the patients was as follows. • • • •

16–20: 2 cases 21–40: 38 cases 41–60: 24 cases over 60: 8

There were 29 men and 43 women. The formula used was as follows. • • • • • • • • • • •

Chai Hu Radix Bupleuri 10 g Huang Qin Radix Scutellariae 10 g Ban Xia Rhizoma Pinelliae preparatum 10 g Gui Zhi Ramulus Cinnamomi cassiae 10 g Da Huang Radix et Rhizoma Rhei 10 g Long Gu Mastodi Ossis fossilia 30 g Mu Li Concha Ostreae 30 g Zhen Zhu Mu Concha Margatiriferae usta 30 g Fu Xiao Mai Fructus Tritici levis 30 g Da Zao Fructus Jujubae 5 pieces Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 10 g • Shu Di Huang Radix Rehmanniae preparata 10 g

Modifications • In case of Phlegm, add Dan Nan Xing Rhizoma Arisaematis preparatum and Zhu Ru Caulis Bambusae in Taeniam. • In case of Liver-Fire, add Long Dan Cao Radix Gentianae and Shan Zhi Zi Fructus Gardeniae. • In case of Empty Heat from Yin deficiency, remove Gui Zhi Ramulus Cinnamomi cassiae and add Zhi Mu Radix Anemarrhenae and Huang Bo Cortex Phellodendri.

• In case of Stomach- and Liver-Yin deficiency, remove Gui Zhi Ramulus Cinnamomi cassiae and add Bei Sha Shen Radix Glehniae and Mai Men Dong Radix Ophiopogonis. The results were as follows. • • • •

Complete cure: 48 cases (68.6%) Significant improvement: 13 cases (18.05%) Moderate improvement: 7 cases (9.72%) No results: 3 cases (4.17%)

CASE HISTORIES Case history A 40-year-old woman had been suffering from severe anxiety for many years. She was constantly anxious with a panicky feeling that she experienced in the chest. She had a frightened and restless look in her eyes. Her severe anxiety caused her great distress. Although she did have some problems with her work and finances, these were not serious enough to warrant that level of anxiety. On interrogation, it transpired that she had always been a “worrier” ever since she was a teenager. She also suffered from dizziness, occasional tinnitus and night sweating. When she was anxious, she also suffered from palpitations and sweating. Her face was red and her tongue was Red, with a deep Heart crack and almost totally without coating. Her pulse was Fine and Rapid. Diagnosis Her tongue and pulse indicate a clear condition of Yin deficiency (tongue without coating) with Empty Heat (tongue Red). The Heart crack, palpitations and anxiety indicate that the Yin deficiency is affecting the Heart; the dizziness, tinnitus and night sweating indicate that the Kidneys are also affected. In her case, therefore, the anxiety is due not only to the Heart but also the Kidneys (fear). My feeling was that her anxiety was largely of constitutional origin; the deep Heart crack led me to this conclusion. Such patients are very difficult to treat as the anxiety is ingrained in their mental-emotional constitution. The look in her eyes also led me to believe that her anxiety might also be due to a feeling of guilt, but she did not show any willingness to discuss this.

Anxiety

Treatment I chose the formula Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill, as it was perfectly suited to her configuration of patterns, i.e. Heart- and Kidney-Yin deficiency with Heart Empty Heat. I used the following variation of this formula. • • • • • • • • • • • • •

Sheng Di Huang Radix Rehmanniae 6 g Mai Men Dong Radix Ophiopogonis 6 g Tian Men Dong Radix Asparagi 6 g Ren Shen Radix Ginseng 6 g Fu Ling Poria 9 g Wu Wei Zi Fructus Schisandrae 4 g Dang Gui Radix Angelicae sinensis 6 g Dan Shen Radix Salviae miltiorrhizae 6 g Suan Zao Ren Semen Ziziphi spinosae 6 g Bai Zi Ren Semen Platycladi 6 g Yuan Zhi Radix Polygalae 6 g Lian Zi Xin Plumula Nelumbinis 6 g Jie Geng Radix Platycodi 3 g

I also treated this patient with acupuncture and selected points from the following pool of points: HE-7 Shenmen, P-7 Daling, Du-24 Shenting, Ren-15 Jiuwei, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan and KI-3 Taixi. I treated this patient for over a year with both acupuncture and herbal medicine. She made a remarkable improvement, with a marked reduction in her levels of anxiety. However, she could never be free of it completely. This is probably due to the fact that it was constitutional. I therefore stopped the treatment but advised her to come back for a few treatments every 3–4 months, which she did.

Case history A 42-year-old woman had been suffering from anxiety ever since the birth of her second child 5 years previously. Her anxiety was mild but constant and disabling. She had a vague feeling of anxiety without being able to pinpoint the cause or the object of it. She also slept badly. Her health was otherwise good apart from complaining of palpitations, blurred vision and tingling of the limbs. Her tongue was Pale and her pulse Choppy. Diagnosis This is a very clear example of anxiety deriving from Heart-Blood deficiency, as evidenced

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by the anxiety, insomnia and palpitations. There was some Liver-Blood deficiency, as evidenced by the blurred vision and tingling. Her tongue and pulse confirm the Blood deficiency. In her case, the Blood deficiency arose after the birth of her second child; this is a common cause of Blood deficiency in women and one that may also give rise to postnatal depression. Treatment I treated this patient primarily with acupuncture and with a herbal remedy. The points I used were selected from the following. • Ren-4 Guanyuan, ST-36 Zusanli, LIV-8 Ququan and SP-6 Sanyinjiao to nourish Liver-Blood. • HE-7 Shenmen to nourish Heart-Blood. • Du-24 Shenting and Ren-15 Jiuwei to calm the Mind. In addition to acupuncture, I used the Three Treasures remedy Calm the Shen, which nourishes Liver- and Heart-Blood and calms the Mind. I treated her for 9 months, after which her anxiety was completely relieved.

Case history A 50-year-old woman had been suffering with anxiety for a long time. She experienced her anxiety more in the daytime, and her sleep was good. She worried very easily about the smallest things. She was rather overweight and felt cold easily. She suffered from lower backache and dizziness, and her urination was frequent and her urine pale. I enquired about her working life, and she had been overworking for many years, leaving home early in the morning and returning in the evening. Her tongue was Pale and her pulse was Weak and Deep, particularly on both Rear positions. Diagnosis In this case, the anxiety derives clearly from a deficiency of the Kidneys and specifically Kidney-Yang. Fear is the emotion pertaining to the Kidneys. Treatment I treated this patient with a combination of acupuncture and a herbal remedy. The acupuncture points I used were selected from the following.

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• Ren-4 Guanyuan with moxa, BL-23 Shenshu, KI-7 Fuliu, KI-3 Taixi to tonify Kidney-Yang. • Du-24 Shenting and Ren-15 Jiuwei to calm the Mind. I also used the Three Treasures remedy Strengthen the Root, which is a variation of You Gui Wan Restoring the Right [Kidney] Pill to tonify Kidney-Yang.

END NOTES 1. National Institute of Mental Health 2005 Online. Available: http://www.nimh.nih.gov 2. Robins LN, Regier DA (eds) 1991 Psychiatric Disorders in America: the Epidemiologic Catchment Area Study. Free Press, New York. 3. Cited in Wang Yong Yan 2004 Zhong Yi Nei Ke Xue [Chinese Internal Medicine]. People’s Health Publishing House, Beijing, p. 265. 4. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue [Internal Medicine in Chinese Medicine]. Shanghai Science Publishing House, Shanghai, p. 107. 5. Nanjing College of Traditional Chinese Medicine 1979 Nan Jing Jiao Shi [A Revised Explanation of the Classic of Difficulties]. People’s Health Publishing House, Beijing, pp. 73–74. First published c.AD 100.

6. Wang Luo Zhen 1985 Qi Jing Ba Mai Kao Jiao Zhu [A Compilation of the Study of the Eight Extraordinary Vessels]. Shanghai Science Publishing House, Shanghai, p. 60. The Study of the Eight Extraordinary Vessels was written by Li Shi Zhen and first published in 1578. 7. Ibid., p. 61. 8. 1982 Lei Jing [Classic of Categories]. People’s Health Publishing House, Beijing, p. 281. The Classic of Categories was written by Zhang Jie Bin and first published in 1624. 9. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 222. First published c.100 BC. 10. National Institute of Mental Health Genetics Workgroup 1998 Genetics and mental disorders. National Institutes of Health publication no. 98-4268. NIMH, Rockville. 11. Cited in Chinese Internal Medicine, p. 270. 12. Ibid., p. 270. 13. Ibid., p. 270. 14. Ibid., p. 270. 15. Dr Zhang Ming Jiu, personal communication, Nanjing, 1982. 16. Dr Zhang Ming Jiu, personal communication, Nanjing, 1982. 17. Cheng Bao Shu 1988 Zhen Jiu Da Ci Dian [Great Dictionary of Acupuncture]. Beijing Science Publishing House, Beijing, p. 11. 18. Jiao Shun Fa 1987 Zhong Guo Zhen Jiu Qiu Zhen [An Enquiry into Chinese Acupuncture]. Shanxi Science Publishing House, p. 52. 19. Yue Han Zhen 1990 Jing Xue Jie [An Explanation of the Acupuncture Points]. People’s Health Publishing House, Beijing, p. 334. Originally published in 1654.

CHAPTER 15

INSOMNIA (SOMNOLENCE, POOR MEMORY) AETIOLOGY 409 Worry 409 Anger 410 Overwork 410 “Gall Bladder timid” 410 Irregular diet 410 Childbirth 410 Residual Heat 410 Excessive sexual activity 411 PATHOLOGY

MODERN CHINESE LITERATURE CLINICAL TRIALS 431 Acupuncture 431 Herbal medicine 433 PATIENTS’ STATISTICS

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CHAPTER APPENDIX 1/SOMNOLENCE 434 IDENTIFICATION OF PATTERNS AND TREATMENT 434 Dampness obstructing the Brain 434 Phlegm misting the Brain 435 Spleen deficiency 436 Kidney-Yang deficiency (Deficiency of Sea of Marrow) 436

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DIAGNOSIS 413 Sleep 413 Dreams 413 Sleeping positions Snoring 414

428

414

IDENTIFICATION OF PATTERNS AND TREATMENT Liver-Fire blazing 415 Heart-Fire blazing 416 Phlegm-Heat harassing the Mind 417 Heart-Qi stagnation 418 Heart-Blood stasis 419 Residual Heat in the diaphragm 420 Retention of Food 420 Heart- and Spleen-Blood deficiency 421 Heart-Yin deficiency 423 Heart and Kidneys not harmonized 424 Heart and Gall Bladder deficiency 425 Liver-Yin deficiency 425

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CHAPTER APPENDIX 2/POOR MEMORY 437 AETIOLOGY 438 Worry and pensiveness 438 Overwork and excessive sexual activity 438 Childbirth 438 Sadness 438 “Recreational” drugs 438 IDENTIFICATION OF PATTERNS AND TREATMENT Spleen deficiency 438 Kidney-Essence deficiency 439 Heart deficiency 439

438

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INSOMNIA Full • Liver-Fire blazing • Heart-Fire blazing • Phlegm-Heat harassing the Mind • Heart-Qi stagnation • Heart- Blood stasis • Residual Heat in the diaphragm • Retention of Food Empty • Heart- and Spleen-Blood deficiency • Heart-Yin deficiency • Heart and Kidneys not harmonized • Heart and Gall Bladder deficiency • Liver-Yin deficiency SOMNOLENCE • Dampness obstructing the Brain • Phlegm misting the Brain • Spleen deficiency • Kidney-Yang deficiency (Deficiency of Sea of Marrow) POOR MEMORY • Spleen deficiency • Kidney-Essence deficiency • Heart deficiency

INSOMNIA (SOMNOLENCE, POOR MEMORY) The term “insomnia” covers a number of different problems, such as inability to fall asleep easily, waking up during the night, sleeping restlessly, waking up early in the morning and dream-disturbed sleep. The amount and quality of sleep depend of course on the state of the Mind (Shen). The Mind is rooted in the Heart, and specifically in Heart-Blood and HeartYin. If the Heart is healthy and the Blood abundant, the Mind is properly rooted and sleep will be sound. If the Heart is deficient or if it is agitated by pathogenic factors such as Fire, the Mind is not properly rooted and sleep will be affected (Fig. 15.1). As always in Chinese medicine, there is an interrelationship between body and Mind. On the one hand, a deficiency of Blood or a pathogenic factor such as

PATHOGENIC FACTORS

MIND SHEN

Agitate the Mind Deprives Mind of its root HEART-BLOOD AND HEART-YIN DEFICIENCY Figure 15.1 Pathology of insomnia.

Fire may affect the Mind; on the other hand, emotional stress affecting the Mind may cause a disharmony of the Internal Organs. If the disharmony of the Internal Organs, whether it is due to a Deficiency or an Excess, affects Blood and Essence, this affects the Mind. Because the Essence and Qi are the root of the Mind (the “Three Treasures”), the Mind has then no residence and insomnia may result. The Simple Questions in Chapter 46 says:1 When a person lies down and cannot sleep, [it means] the Yin organs are injured [so that] the Essence has no residence and is not quiet and the person cannot sleep. See Figure 15.2. As far as sleep is concerned, the Mind is not the only mental-spiritual faculty involved. The Ethereal Soul (Hun) also plays an important role in the physiology and pathology of sleep, and the length and quality of sleep are related to its state (see Chapter 9). In particular, the Ethereal Soul controls dreaming, and therefore

MIND

Insomnia

Qi-Blood-Yin deficiency of Internal Organs or pathogenic factors cause insomnia QI Essence deficiency affects Qi and Blood of all Organs ESSENCE Figure 15.2 The Three Treasures (Jing–Qi–Shen) and sleep.

Insomnia (Somnolence, Poor Memory)

dream-disturbed sleep is often due to a disharmony of the Ethereal Soul. If the Ethereal Soul is well rooted in the Liver (Liver-Blood or Liver-Yin), sleep is normal, sound and without too many dreams. If Liver-Yin or Liver-Blood is deficient, the Ethereal Soul is deprived of its residence and wanders off at night, causing a restless sleep with many tiring dreams. Tang Zong Hai says: “At night during sleep, the Ethereal Soul returns to the Liver; if the Ethereal Soul is not peaceful, there are a lot of dreams.”2 The Ethereal Soul is affected not only by a deficiency of the Liver but also by any pathogenic factor (such as Fire or Wind) agitating the Liver. The Complete Book of Jing Yue (1624) by Zhang Jing Yue says: “Overexertion, worrying and excessive thinking injure Blood and fluids so that the Mind and Ethereal Soul are deprived of residence and insomnia results.”3 It also says: “Worrying and excessive thinking injure the Spleen so that it cannot make Blood and insomnia results.”4 Another organ and mental-spiritual aspect influencing sleep are the Kidneys and the Will-Power (Zhi). I translate Zhi as “Will-Power”, but Zhi encompasses also other aspects of the psyche. The Zhi is the root of the Mind (Shen), and it controls memory and sleep. Thus, when the Kidneys and the Zhi are deficient, the person may sleep badly; in particular, he or she may wake up frequently during the night. CLINICAL NOTE Sleep depends on the following.

 Heart and Mind (Shen): BL-44 Shentang  Liver and Ethereal Soul (Ethereal Soul): BL-47

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ing from a skin disease; in such cases, sleep is restored once the relevant disease is treated successfully. It should be remembered that because in old people there is a physiological decline of Qi and Blood, they normally need less sleep than younger people. Chapter 18 of the Spiritual Axis says:5 Young people have abundant Qi and Blood ... [so that] they are energetic in the daytime and sleep well at night. Old people have declining Qi and Blood ... [so that] they are less active in daytime and cannot sleep at night. Finally, according to traditional Chinese views, the best sleeping position is lying on the right side, with the legs slightly bent, the right arm bent and resting in front of the pillow, and the left arm resting on the left thigh. According to these views, with this position the heart is in a high position so that Blood can circulate freely; the liver is in a low position so that Blood can collect there and root the Ethereal Soul to promote sleep; and the stomach and duodenum are in such a position that facilitates the downward movement of food. Insomnia will be discussed according to the following topics. • • • • • • •

Aetiology Pathology Diagnosis Identification of patterns and treatment Modern Chinese literature Clinical trials Patients’ statistics

Hunmen

 Kidneys and Will-Power (Zhi): BL-52 Zhishi

When a patient complains of poor sleep, we must ascertain that the condition is true insomnia and not an inability to sleep well due to other external or temporary causes. For example, a sudden change in weather, jet lag, a bedroom that is too hot or too cold, drinking a lot of tea or coffee, an emotional upset or worrying about something specific may all cause a person to sleep badly but cannot be defined as “insomnia”. In fact, once the above causes are removed, the person sleeps well. Also, one cannot diagnose insomnia when sleep is disturbed by other medical conditions, such as asthma, a pain (e.g. shoulder, hip or back pain) or itch-

AETIOLOGY Worry Worrying a lot injures the Spleen, Lungs and Heart. When the Spleen is deficient, it cannot produce enough Blood, and this deficiency affects the Heart and the Mind is deprived of its residence. Worry may also injure Heart-Blood directly, and this also leads to the Mind’s being deprived of its residence and therefore to insomnia. In some cases, worry may lead to Heart-Heat (through Heart-Qi stagnation); this harasses the Mind and may lead to insomnia. Worry leads to Heart-Qi stagnation and, with time, this may lead to Heart-Blood stasis. Stagnant

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Kidneys are not harmonized. This is a common cause of insomnia in the elderly.

Lung-Qi Xu Lungs Lung-Qi stagnation

WORRY

Knots Qi

“Gall Bladder timid”

Heart-Qi Xu Heart

Insomnia Heart-Qi stagnation

Spleen-Qi Xu Spleen Spleen-Qi stagnation Figure 15.3 Worry and insomnia.

Heart-Blood harasses the Mind and may lead to insomnia (Fig. 15.3).

A constitutional weakness of both Heart and Gall Bladder may give rise to a timid character. The Gall Bladder is the mother of the Heart, and a person whose Gall Bladder is weak will be timid, fearful and indecisive and lack self-assertiveness. Chinese language bears out this connection between the Gall Bladder and timidity: “big gall bladder” means “courageous”, while “small gall bladder” means “timid” or “cowardly”. This constitutional deficiency of Heart and Gall Bladder causes insomnia, especially waking up early.

Irregular diet Irregular diet, overeating or eating too much greasy and hot food may lead to the formation of PhlegmHeat in the Stomach, which harasses the Mind, leading to insomnia.

Childbirth Anger Anger, intended in a broad sense including frustration, resentment and irritation, leads to either Liver-Yang rising or Liver-Fire. Liver-Yang or Liver-Fire agitates the Ethereal Soul, so that this is not rooted in the Liver at night. This causes insomnia and dream-disturbed sleep.

Overwork Working long hours without adequate rest, working under conditions of severe stress combined with irregular diet, all weaken Kidney-Yin. When KidneyYin is deficient over a long period of time, it fails to nourish Heart-Yin so that Heart Empty Heat develops. This especially happens when the person worries a lot. The same pattern may be the result of the reverse process. Severe emotional strain over a long period of time may lead to the formation of Heart-Fire, which flares upwards and fails to communicate downwards with the Kidneys. On the other hand, excessive Fire injures the Yin and may lead to Kidney-Yin deficiency. The end result is a similar condition: Heart and

A large loss of blood during childbirth may induce a deficiency of Blood of the Liver. This may also happen not because the loss of blood is substantial but because of a pre-existing condition of deficiency of Blood. In either case, it causes a fairly sudden and severe deficiency of Liver-Blood. Deprived of its residence, the Ethereal Soul floats at night, causing insomnia and excessive dreaming. On the other hand, as the Liver is the mother of the Heart, a deficiency of Liver-Blood may induce a deficiency of Heart-Blood; the Mind is deprived of its residence and it floats at night, causing insomnia.

Residual Heat During an invasion of Wind-Heat, the pathogenic factor may progress into the Interior and give rise to interior Heat. If this is not cleared properly, the person may make an apparent recovery but residual Heat is left in the body. This is said to lodge in the diaphragm, where it harasses the Heart and may lead to insomnia. This residual Heat in the diaphragm is often the cause of insomnia and mental restlessness in patients suffering from chronic fatigue syndrome.

Insomnia (Somnolence, Poor Memory)

Excessive sexual activity

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PATHOLOGY

Excessive sexual activity applies more to men than to women. Sperm (called Tian Gui) is a direct manifestation of the Kidney-Essence. If sexual activity is so frequent that it does not allow the Kidney-Essence to replenish sperm fast enough, this is defined as “excessive” sexual activity. This leads to a deficiency of the Kidneys (which may be Yang or Yin) and to a deficiency of the WillPower (Zhi); Zhi fails to root the Mind and insomnia may result. Excessive sexual activity is seldom a cause of disease in women as, in women, Tian Gui (a manifestation of Essence) is menstrual blood and ova, and these are not lost during sexual activity in the same way as sperm is lost in men.

SUMMARY AETIOLOGY  Worry  Anger  Overwork  “Gall Bladder timid”  Irregular diet  Childbirth  Residual Heat  Excessive sexual activity

The pathology of insomnia (as that of many other diseases) revolves around Fullness and Emptiness. Empty conditions usually involve a deficiency of either Blood or Yin, which deprives the Mind and/or Ethereal Soul of its residence; Full conditions involve a pathogenic factor (usually Heat/Fire or Blood stasis) agitating the Mind and/or the Ethereal Soul. In other words, the Mind and the Ethereal Soul may be restless either because they are not rooted in Heart- and Liver-Blood, respectively, or because a pathogenic factor is agitating them. The various aetiological factors and pathologies may be summarized in a diagram (Fig. 15.4). As can be seen from the diagram, the Deficiency conditions causing insomnia occur mostly in Heart, Spleen, Liver and Kidneys, while the Excess conditions occur in the Liver and Stomach. Worry and pensiveness may weaken Heart-Blood so that the Mind is deprived of its residence and the person cannot sleep. In some people, worry, anxiety and pensiveness lead not to Heart-Blood deficiency but to Heart-Fire. This is also due to a constitutional tendency to Yang Excess. Heart-Fire flares upwards to agitate the Mind, and insomnia results. Worry, pensiveness, sadness, grief and guilt may lead to Heart-Qi stagnation; Qi stagnation obstructs the Heart so that this cannot house the Mind, and insomnia

DEFICIENCY

EXCESS

Worry

HE-SP

Blood deficiency

Overwork

HE-KI

Yin deficiency

HE-Fire

HE

Worry

HE-LIV

Anger

Phlegm-Heat

ST-HE

Diet

Residual Heat

DIAPH

Wind-Heat

LIV-Fire INSOMNIA

Timid Gall Bladder

HE-G.B.

Qi deficiency

Childbirth

HE-LIV

Blood deficiency

Figure 15.4 Aetiology and pathology of insomnia.

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results. The same emotions in the long term may lead to Heart-Blood stasis; the stagnant Blood in the Heart prevents it from housing the Mind, and insomnia results. When Kidney-Yin is deficient over a long period of time, it fails to nourish Heart-Yin so that Heart Empty Heat develops. This especially happens when the person worries a lot. This pattern is also called “Heart and Kidneys not harmonized”. The same pattern may be the result of the reverse process. Severe emotional strain over a long period of time may lead to the formation of Heart-Fire, which flares upwards and fails to communicate downwards with the Kidneys. On the other hand, excessive Fire injures the Yin and may lead to Kidney-Yin deficiency. The end result is a similar condition: Heart and Kidneys are not harmonized. This is a common cause of insomnia in the elderly. Liver-Yang rising or Liver-Fire may both cause insomnia, especially in young or middle-aged people. A constitutional deficiency of Heart and Gall Bladder causes insomnia, especially waking up early. Phlegm-Heat in the Stomach harasses the Mind, leading to insomnia. Loss of Blood causes a fairly sudden and severe deficiency of Liver-Blood. Deprived of its residence, the Ethereal Soul floats at night, causing insomnia and excessive dreaming. A deficiency of LiverBlood often induces a deficiency of Heart-Blood, which also deprives the Mind of its residence and leads to insomnia. Residual Heat lodges itself in the diaphragm, where it harasses the Heart and may lead to insomnia. Retention of Food in the Stomach may affect the Heart due to the close relationship between these two organs, and insomnia results. This is a common cause of insomnia, especially in children.

Acupuncture From the perspective of the channel system, insomnia is due to a breakdown of the interconnection of Yin and Yang. Yang-Qi and Yin-Qi have to be harmonized and flow into one another in a daily cycle. Defensive Qi flows in the Yang during the day and in the Yin during the night. If it remains in the Yang by night as well as by day, the person cannot sleep. The Spiritual Axis in Chapter 80 says:6 If Defensive Qi does not enter into the Yin at night and remains in the Yang, Yang-Qi becomes Full and the Yang

Stepping Vessel (Yang Qiao Mai) in Excess, Yin becomes deficient and the eyes cannot close. For this reason, the beginning points of the Yang and Yin Stepping Vessels (Yang and Yin Qiao Mai), i.e. BL-62 Shenmai and KI-6 Zhaohai, respectively, can be used, together with BL-1 Jingming, for insomnia (see below).

SUMMARY PATHOLOGY  The pathology of insomnia (as that of many other diseases) revolves around Fullness and Emptiness.  Empty conditions involve a deficiency of either Blood or Yin.  Full conditions involve a pathogenic factor (usually Heat/Fire or Blood stasis).  Deficiency conditions occur mostly in Heart, Spleen, Liver and Kidneys.  Excess conditions occur in the Liver and Stomach.  Heart-Blood deficiency deprives the Mind of its residence and the person cannot sleep.  Stagnation of Qi or stasis of Blood of the Heart may cause insomnia.  Heart-Fire agitates the Mind and leads to insomnia.  Deficient Kidney-Yin fails to nourish Heart-Yin so that Heart Empty Heat develops.  Liver-Yang rising or Liver-Fire may both cause insomnia, especially in young or middle-aged people.  A constitutional deficiency of Heart and Gall Bladder causes insomnia, especially waking up early.  Phlegm-Heat in the Stomach harasses the Mind, leading to insomnia.  Loss of blood causes a fairly sudden and severe deficiency of Liver-Blood and insomnia.  Residual Heat lodges itself in the diaphragm, where it harasses the Heart and may lead to insomnia.  Retention of Food obstructs the Stomach and affects the Heart and Mind, causing insomnia.

Insomnia (Somnolence, Poor Memory)

DIAGNOSIS

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and Heart. The following is a list of dreams from the Simple Questions and Spiritual Axis.

Sleep When questioning a patient about insomnia, it is important to establish clearly what the main problem is. Difficulty in falling asleep usually indicates deficiency of Blood, while falling asleep easily but waking up frequently during the night denotes Yin deficiency. This is not, however, an absolute rule. Of course the two conditions may coexist, in which case the person has both difficulty in falling asleep and wakes up during the night. Waking up early in the morning indicates Heart and Gall Bladder deficiency.

Dreams As for dreams, they are due to the wandering of the Mind and/or Ethereal Soul at night. A certain amount of dreaming is therefore normal. Ancient Chinese books do not define what “normal” dreaming is. I personally would say that “excessive dreaming” certainly includes nightmares; I think it also involves anxious dreams or dreams of being angry. Finally, dreaming is excessive also when a person dreams so much all night that he or she wakes up exhausted from it. Dreaming that does not make the sleep restless, is not frightening, does not disturb the Mind the morning after and does not leave the person very tired in the morning can be described as normal and is not a pathological condition. The old classics described various types of unpleasant dreams, such as nightmares, waking up screaming, sleepwalking and talking in one’s sleep. They related dreaming to the wandering of the Ethereal Soul at night. When a person’s physical body receives something, it is real; when the Mind receives something, it produces dreams. When the Mind is slave to objects [i.e. pursues objects], the Ethereal Soul and the Corporeal Soul become restless, they fly around and, gathering at the eyes, they produce dreams. Grasping [i.e. excessive craving] in daytime produces dreaming at night. Excessive dreaming may be due to deficiency of Blood or Yin. Frightening dreams that wake one up denote a deficiency of Gall Bladder and Heart. Restless dreams are often due to Phlegm-Heat affecting Stomach

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Flying: Emptiness in the Lower Burner7 Falling: Fullness in the Lower Burner8 Floods and fear: Excess of Yin9 Fire: Excess of Yang10 Killing and destruction: Yin and Yang both in Excess11 Giving away things: Excess condition12 Receiving things: Deficiency condition13 Being angry: Liver in Excess14 Crying, weeping: Lungs in Excess15 Crowds: round worms in the intestines16 Attack and destruction: tapeworms in the intestines17 Fires: Heart deficiency18 Volcanic eruptions (if the dream takes place in summertime): Heart deficiency19 Laughing: Heart in Excess20 Mountains, fire and smoke: Heart deficiency21 Very fragrant mushrooms: Liver deficiency22 Lying under a tree being unable to get up (if the dream takes place in springtime): Liver deficiency23 Forests on mountains: Liver deficiency24 White objects or bloody killings: Lung deficiency25 Battles and war (dream taking place in the autumn): Lung deficiency26 Worry, fear, crying, flying: Lungs in Excess27 Flying and seeing strange objects made of gold or iron: Lung deficiency28 Being hungry: Spleen deficiency29 Building a house (dream taking place in late summer): Spleen deficiency30 Singing and feeling very heavy: Spleen in Excess31 Abysses in mountains and marshes: Spleen deficiency32 Swimming after a shipwreck: Kidney deficiency33 Plunging into water and being scared (dream taking place in wintertime): Kidney deficiency34 Spine being detached from the body: Kidneys in Excess (i.e. Dampness in Kidneys)35 Being immersed in water: Kidney deficiency36 Having a large meal: Stomach deficiency37 Large cities: Small Intestine deficiency38 Open fields: Large Intestine deficiency39 Fights, trials, suicide: Gall Bladder deficiency40 Voyages: Bladder deficiency41 Crossing the sea and being scared: Excess of Yin42

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Sleeping positions If a person is unable to sleep supine (lying on the back), it indicates an Excess condition, often of the Lungs or Heart. The Simple Questions in Chapter 46 says:43 The Lung is the “lid” of the other organs; when Lung-Qi is in Excess [i.e. obstructed by a pathogenic factor], the channels and blood vessels are full and the person cannot lie on the back. This often occurs in asthma, for example when the Lungs are obstructed by Phlegm. If a person can only sleep on the back with the arms outstretched, it indicates a Heat condition. If a person always sleeps in a prone position, it indicates a Deficiency condition, often of the Stomach. If a person can only sleep on one side, it indicates that there is either a deficiency of Qi and Blood on that side of the body or an Excess on the opposite side. This especially applies to Heart or Lungs and can be checked on the pulse. By rolling the finger medially and laterally on the Lung pulse, one can feel the state of Qi in right (laterally) and left (medially) lung. If an imbalance is felt, the patient is only able to sleep on the deficient side.

Dreams  Dreams are due to the wandering of the Mind and/or Ethereal Soul at night.  Excessive dreaming may be due to Liver-Blood/ Yin deficiency or to Liver-Fire or Heart-Fire.  Frightening dreams that wake one up denote a deficiency of Gall Bladder and Heart.  Restless dreams are often due to Phlegm-Heat affecting Stomach and Heart. Sleeping positions  Inability to sleep supine (lying on the back): Excess condition.  Sleeping on the back with the arms outstretched: Heat condition.  Sleeping in a prone position: Deficiency condition, often of the Stomach.  Can sleep only on one side: either a deficiency of Qi and Blood on that side of the body or an Excess on the opposite side. Snoring  Snoring is usually due to Phlegm affecting the Stomach channel and to rebellious Qi in the three Yang channels of the leg.

Snoring Snoring is usually due to Phlegm affecting the Stomach channel and to rebellious Qi in the three Yang channels of the leg. Chapter 34 of the Simple Questions says:44

IDENTIFICATION OF PATTERNS AND TREATMENT

Those who suffer from rebellious Qi cannot sleep well and have noisy breathing [snoring]; this is due to rebellious Qi in the Bright Yang channels. When the Qi of the three Yang channels of the leg cannot flow down and rebels upwards, it causes insomnia and snoring.

The most important distinction is that between Full and Empty types of insomnia. The main patterns are as follows.

SUMMARY DIAGNOSIS Sleep  Difficulty in falling asleep usually indicates deficiency of Blood.  Waking up frequently during the night denotes Yin deficiency.  Waking up early in the morning indicates Heart and Gall Bladder deficiency.

Full • Liver-Fire blazing • Heart-Fire blazing • Phlegm-Heat harassing the Mind • Heart-Qi stagnation • Heart-Blood stasis • Residual Heat in the diaphragm • Retention of Food Empty • Heart- and Spleen-Blood deficiency • Heart-Yin deficiency • Heart and Kidneys not harmonized • Heart and Gall Bladder deficiency • Liver-Yin deficiency

Insomnia (Somnolence, Poor Memory)

Liver-Fire blazing Clinical manifestations Restless sleep, unpleasant dreams, nightmares, dreaming of fires, irritability, propensity to outbursts of anger, bitter taste, headache, red face, thirst, dark urine, dry stools and dizziness. Tongue: Red, redder on the sides with a dry-yellow coating. Pulse: Wiry and Rapid.

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cannot flow back into the Yin at night, the eyes stay open at night and insomnia results. The opposite would cause somnolence. The Spiritual Axis in Chapter 21 says:45 The Yin and Yang of the Yin and Yang Stepping Vessels interconnect: Yang enters Yin and Yin exits towards Yang and the two meet at the corner of the eyes. When Yang-Qi is in Excess, the eyes stay open; when Yin-Qi is in Excess, they stay closed.

Treatment principle

These points may be used for any of the other Full types of insomnia.

Drain Liver-Fire, calm the Mind and settle the Ethereal Soul.

Herbal therapy Prescription

Acupuncture Points LIV-2 Xingjian, LIV-3 Taichong, G.B.-44 Qiaoyin, G.B.12 Wangu, G.B.-20 Fengchi, SP-6 Sanyinjiao, BL-18 Ganshu, Du-24 Shenting, G.B.-13 Benshen, G.B.-15 Toulinqi, BL-47 Hunmen, BL-62 Shenmai (reduced), BL-1 Jingming (even) and KI-6 Zhaohai (reinforced). Reducing method, no moxa.

Explanation • LIV-2 is the main point to drain Liver-Fire. • LIV-3 is added because it has a better Mind-calming effect than LIV-2. • G.B.-44 clears Liver- and Gall Bladder-Heat and is specific for dream-disturbed sleep. • G.B.-12 and G.B.-20 subdue rebellious Liver-Qi and promote sleep. • SP-6 cools Blood and calms the Mind. • BL-18 regulates the Liver and drains Liver-Fire. • Du-24 and G.B.-13 in combination have a strong effect in calming the Mind and settling the Ethereal Soul in Liver patterns. • G.B.-15 is used istead of G.B.-13 if the Mind is very overactive and the person cannot stop thinking obsessively. • BL-47 roots the Ethereal Soul into Liver-Yin at night, thus promoting sleep. • BL-62 (reduced), BL-1 (even) and KI-6 (in combination) harmonize the flow of the Yin and Yang Stepping Vessels (Yin and Yang Qiao Mai) to the eyes and promote sleep. The Yin Stepping Vessel carries Yin-Qi, and the Yang Stepping Vessel Yang-Qi, to the eyes. If Yang is in Excess, Yang-Qi

LONG DAN XIE GAN TANG Variation Gentiana Draining the Liver Decoction Variation

Modifications • If the symptoms and signs of Fire are not too evident (no thirst, no bitter taste, urine not dark, stools not dry), omit Huang Qin and Shan Zhi Zi. • If there are symptoms of Liver-Yang rising (frequent headaches, dizziness, tinnitus), add Tian Ma Rhizoma Gastrodiae.

Three Treasures remedies Drain Fire Drain Fire is a variation of Long Dan Xie Gan Tang; it drains Liver-Fire and calms the Mind. The original formula has been modified to drain Heart-Fire as well. Settling the Soul Settling the Soul is also a variation of Long Dan Xie Gan Tang; it drains Liver-Fire and it also resolves Phlegm.

SUMMARY LIVER-FIRE BLAZING Points LIV-2 Xingjian, LIV-3 Taichong, G.B.-44 Qiaoyin, G.B.-12 Wangu, G.B.-20 Fengchi, SP-6 Sanyinjiao, BL-18 Ganshu, Du-24 Shenting, G.B.-13 Benshen, G.B.-15 Toulinqi, BL-47 Hunmen, BL-62 Shenmai (reduced), BL-1 Jingming (even) and KI-6 Zhaohai (reinforced). Reducing method, no moxa.

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Herbal therapy Prescription LONG DAN XIE GAN TANG Variation Gentiana Draining the Liver Decoction Variation Three Treasures remedies Drain Fire Settling the Soul

Explanation This formula drains Heart-Fire by moving downwards. It is applicable only if there is Full Fire without any signs of Yin deficiency. An important condition for the use of this formula is that the tongue should have a thick, dry and yellow coating.

Prescription DAO CHI SAN Eliminating Redness Powder

Heart-Fire blazing Clinical manifestations

Explanation

Waking up during the night, nightmares, dreams of flying, mental restlessness, bitter taste, thirst, tongue ulcers and palpitations. Tongue: Red, redder tip with red points, yellow coating. Pulse: Rapid and Overflowing on the left Front position.

This formula differs from the previous one in so far as, in addition to draining Heart-Fire, it also cools Blood and nourishes Yin (because of the inclusion of Sheng Di Huang). It is therefore suitable for cases when Fire has begun to injure the Yin. The tongue would therefore be Red with a yellow coating, although this coating might be rootless or missing in places.

Treatment principle Drain Heart-Fire, calm the Mind.

Acupuncture Points HE-8 Shaofu, HE-7 Shenmen, SP-6 Sanyinjiao, L.I.-11 Quchi, Ren-15 Jiuwei, Du-19 Houding, BL-15 Xinshu, BL-44 Shentang. Reducing method. No moxa.

Modifications • Other versions of this formula include Deng Xin Cao Medulla Junci to clear Heart-Heat and calm the Mind. • To enhance the sleep-promoting effect of both this formula and the previous one, add Ye Jiao Teng Caulis Polygoni multiflori, Fu Shen Sclerotium Poriae pararadicis and Yuan Zhi Radix Polygalae.

Explanation • • • • • • • •

HE-8 drains Heart-Fire. HE-7 calms the Mind and promotes sleep. SP-6 cools Blood and calms the Mind. L.I.-11 is used if there are pronounced general signs of Fire. Ren-15 clears the Heart, calms the Mind and promotes sleep. Du-19 in combination with Ren-15 calms the Mind and promotes sleep. BL-15 drains Heart-Fire. BL-44 calms the Mind and promotes sleep.

Herbal therapy Prescription XIE XIN TANG Draining the Heart Decoction

SUMMARY HEART-FIRE BLAZING Points HE-8 Shaofu, HE-7 Shenmen, SP-6 Sanyinjiao, L.I.-11 Quchi, Ren-15 Jiuwei, Du-19 Houding, BL-15 Xinshu, BL-44 Shentang. Reducing method. No moxa. Herbal therapy Prescription XIE XIN TANG Draining the Heart Decoction Prescription DAO CHI SAN Eliminating Redness Powder

Insomnia (Somnolence, Poor Memory)

Phlegm-Heat harassing the Mind Clinical manifestations Restless sleep, tossing and turning, unpleasant dreams, nightmares, a feeling of heaviness, dizziness, a feeling of oppression the chest, nausea, no appetite, palpitations, feeling of heat, sputum in the throat, mental restlessness and a sticky taste. Tongue: Red with a sticky-yellow coating. Heart crack (or Stomach–Heart crack) with sticky-rough yellow coating inside it. Pulse: Slippery and Rapid. This pattern is due to Phlegm-Heat in the Stomach and Heart with Stomach-Qi rebelling upwards. When Phlegm is present, Stomach-Qi rebelling upwards will carry Phlegm and Heat to the Upper Burner to harass the Heart and Mind, thus causing insomnia. In severe cases, this causes mental illness. The Simple Questions in Chapter 34 says: “The Stomach is the Sea of the five Yin and six Yang organs; its Qi must go downwards; when Stomach-Qi rebels upwards ... one cannot sleep.”46

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This is one of the few cases when moxa is used to counteract Heat. • SP-1, often combined with ST-44, clears Heat in the Stomach and Spleen, calms the Mind and promotes sleep. The points ST-44 and SP-1 are also specific for excessive and unpleasant dreaming.

Herbal therapy Prescription SHI WEI WEN DAN TANG Ten-Ingredient Warming the Gall Bladder Decoction

Explanation This prescription is used if there is Phlegm-Heat in the Stomach and Heart together with some deficiency of Qi and Blood, which is a very common situation.

Prescription HUANG LIAN WEN DAN TANG Coptis Warming the Gall Bladder Decoction

Treatment principle

Explanation

Clear Heat, resolve Phlegm and calm the Mind.

This formula is used in preference to the previous one if symptoms and signs of Heat are more pronounced and the tongue is definitely Red with a thick-yellow coating.

Acupuncture Points ST-40 Fenglong, Ren-12 Zhongwan, Ren-9 Shuifen, SP-9 Yinlingquan, BL-20 Pishu, L.I.-11 Quchi, ST-8 Touwei, G.B.-12 Wangu, SP-6 Sanyinjiao, ST-45 Lidui, SP-1 Yinbai. Reducing method except for Ren-12 and BL-20, which should be reinforced. No moxa, except for ST-45 (see below).

Explanation • ST-40 resolves Phlegm and calms the Mind. • Ren-12, Ren-9 and BL-20 tonify the Spleen to resolve Phlegm. • SP-9 and SP-6 resolve Dampness, which helps to resolve Phlegm. SP-6 also calms the Mind. • L.I.-11 resolves Phlegm and clears Heat. • ST-8 is the main local point to resolve Phlegm from the head and it promotes sleep. • G.B.-12 promotes sleep. • ST-45 relieves retention of food, calms the Mind and promotes sleep. Very small moxa cones can be used after needling to conduct Fire downwards.

Modifications These formulae have a powerful effect in calming the Mind and promoting sleep and may need little variation or addition. • To enhance the sleep-promoting effect, add Ye Jiao Teng Caulis Polygoni multiflori and Yuan Zhi Radix Polygalae. • If there are symptoms of retention of food, add Shen Qu Massa medicata fermentata and Lai Fu Zi Semen Raphani. • If there are more symptoms of retention of food rather than those of Phlegm-Heat, use Bao He Wan Preserving and Harmonizing Pill instead. • If there is constipation, add Da Huang Radix et Rhizoma Rhei.

Three Treasures remedies Clear the Soul Clear the Soul resolves Phlegm-Heat from the Lungs and Heart, opens the Mind’s orifices and calms the Mind.

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Settling the Soul Settling the Soul drains Liver-Fire and Heart-Fire and resolves Phlegm-Heat from the Liver and Heart.

SUMMARY PHLEGM-HEAT HARASSING THE MIND Points ST-40 Fenglong, Ren-12 Zhongwan, Ren-9 Shuifen, SP-9 Yinlingquan, BL-20 Pishu, L.I.-11 Quchi, ST-8 Touwei, G.B.-12 Wangu, SP-6 Sanyinjiao, ST-45 Lidui, SP-1 Yinbai. Reducing method except for Ren-12 and BL-20, which should be reinforced. No moxa, except for ST-45. Herbal therapy Prescription SHI WEI WEN DAN TANG Ten-Ingredient Warming the Gall Bladder Decoction Prescription HUANG LIAN WEN DAN TANG Coptis Warming the Gall Bladder Decoction Three Treasures remedies Clear the Soul Settling the Soul

Explanation • P-6 opens the chest, moves Qi and calms the Mind. • HE-5 and HE-7 move Heart-Qi and calm the Mind. • Ren-15 opens the chest and calms the Mind. • Ren-17 moves Qi in the chest. • LU-7 moves Qi in the chest. • ST-40 is used here not to resolve Phlegm but to open the chest and move Qi in the chest. • L.I.-4 regulates the ascending and descending of Qi and therefore moves Qi.

Herbal therapy Prescription MU XIANG LIU QI YIN Aucklandia Flowing Qi Decoction

Explanation This formula moves Heart-Qi.

Prescription BAN XIA HOU PO TANG Pinellia-Magnolia Decoction

Explanation This formula moves Qi of the Heart and Lungs and frees the throat and chest.

Heart-Qi stagnation Clinical manifestations Palpitations, a feeling of distension or oppression of the chest, depression, a slight feeling of lump in the throat, slight shortness of breath, sighing, poor appetite, weak and cold limbs, slightly purple lips, pale complexion. Tongue: slightly Pale-Purple on the sides in the chest area. Pulse: Empty but very slightly Overflowing on the left Front position.

Treatment principle Move Heart-Qi, open the chest, calm the Mind.

Acupuncture

Prescription YUE JU WAN plus SI NI SAN Gardenia-Ligusticum Pill plus Four Rebellious Powder

Explanation These two formulae move Liver- and Heart-Qi, relieve depression, calm the Mind and settle the Ethereal Soul. These two formulae should be selected when stagnation of Heart-Qi is accompanied by that of Liver-Qi.

Modifications These formulae should be modified with the addition of herbs to promote sleep, such as Ye Jiao Teng Caulis Polygoni multiflori and Suan Zao Ren Semen Ziziphi spinosae.

Points P-6 Neiguan, HE-5 Tongli, HE-7 Shenmen, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong, L.I.-4 Hegu. Reducing or even method on all points.

Three Treasures remedies Open the Heart Open the Heart moves Qi, eliminates stagnation of Heart-Qi and calms the Mind.

Insomnia (Somnolence, Poor Memory)

Release Constraint Release Constraint moves Liver-Qi, settles the Ethereal Soul and calms the Mind. It should be selected when there is stagnation of Qi of both Heart and Liver and the person is depressed.

SUMMARY HEART-QI STAGNATION Points P-6 Neiguan, HE-5 Tongli, HE-7 Shenmen, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong, L.I.-4 Hegu. Reducing or even method on all points. Herbal therapy Prescription MU XIANG LIU QI YIN Aucklandia Flowing Qi Decoction Prescription BAN XIA HOU PO TANG Pinellia-Magnolia Decoction Prescription YUE JU WAN plus SI NI SAN Gardenia-Ligusticum Pill plus Four Rebellious Powder Three Treasures remedies Open the Heart Release Constraint

Heart-Blood stasis Clinical manifestations Insomnia, dream-disturbed sleep, tossing and turning in bed during the night, palpitations, chest ache, mental restlessness, anxiety. Tongue: Purple (it may be Purple only in the chest area; see Fig. 21.4). Pulse: Choppy or Firm.

Treatment principle Invigorate Blood, calm the Mind.

Acupuncture Points HE-7 Shenmen, HE-5 Tongli, P-6 Neiguan, Ren-17 Shanzhong, BL-17 Geshu, BL-44 Shentang. Even method on all points.

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Explanation • HE-7, HE-5 and P-6 invigorate Heart-Blood and calm the Mind. • Ren-17 invigorates Heart-Blood and opens the chest. • BL-17 invigorates Blood in the Upper Burner. • BL-44 calms the Mind.

Herbal therapy Prescription XUE FU ZHU YU TANG Variation Blood Mansion Eliminating Stasis Decoction Variation

Explanation The original formula Xue Fu Zhu Yu Tang invigorates Blood in the Upper Burner. It has been modified with the addition of herbs that calm the Mind (Ye Jiao Teng Caulis Polygoni multiflori and Suan Zao Ren Semen Ziziphi spinosae).

Prescription TONG QIAO HUO XUE TANG Opening the Orifices and Invigorating Blood Decoction

Explanation This formula is specific to eliminate Blood stasis from the head. Replace She Xiang Moschus with Shi Chang Pu Rhizoma Acori tatarinowii.

Three Treasures remedy Red Stirring Red Stirring invigorates Heart-Blood and calms the Mind.

SUMMARY HEART-BLOOD STASIS Points HE-7 Shenmen, HE-5 Tongli, P-6 Neiguan, Ren-17 Shanzhong, BL-17 Geshu, BL-44 Shentang. Even method on all points. Herbal therapy Prescription XUE FU ZHU YU TANG Variation Blood Mansion Eliminating Stasis Decoction Variation

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Prescription TONG QIAO HUO XUE TANG Opening the Orifices and Invigorating Blood Decoction Three Treasures remedy Red Stirring

• SP-6 calms the Mind and protects Yin from injury from Heat. • Ren-15 relaxes the diaphragm, clears the Heart and calms the Mind.

Herbal therapy Prescription ZHU YE SHI GAO TANG Phyllostachys Gipsum Decoction

Residual Heat in the diaphragm

Explanation

Clinical manifestations

This is one of the formulae for clearing residual Heat, especially from the diaphragm area.

Restless sleep, waking up during the night, mental restlessness, cannot lie down or sit, a feeling of stuffiness of the chest, epigastric discomfort and sour regurgitation. Tongue: Red in the front part or red points around the centre. Pulse: Deep and slightly Rapid. This condition arises after an invasion of Wind-Heat that has turned into Interior Heat and has not been cleared properly, often through wrong use of antibiotics; some residual Heat remains in the body and settles in the diaphragm area. From here, it rebels upwards to disturb the Heart and Mind.

Prescription ZHI ZI CHI TANG Gardenia-Soja Decoction

Explanation This formula lightly clears Heat and is often used to clear residual Heat. • To enhance the sleep-promoting effect, add Fu Shen Sclerotium Poriae pararadicis, Deng Xin Cao Medulla Junci and Ye Jiao Teng Caulis Polygoni multiflori.

SUMMARY Treatment principle Clear residual Heat, calm irritability and calm the Mind.

Acupuncture Points LU-10 Yuji, HE-8 Shaofu, BL-17 Geshu, ST-40 Fenglong, L.I.-11 Quchi, SP-6 Sanyinjiao, Ren-15 Jiuwei. Reducing method, no moxa.

Explanation • LU-10 and HE-8 clear Lung-Heat and Heart-Heat, respectively. They are chosen because, from the point of view of channels, residual Heat in the diaphragm is located in Lungs and Heart. Besides this, HE-8 also calms the Mind. • BL-17 relaxes the diaphragm. • ST-40 relaxes the diaphragm, subdues rebellious Qi and calms the Mind. • L.I.-11 clears Heat.

RESIDUAL HEAT IN THE DIAPHRAGM Points LU-10 Yuji, HE-8 Shaofu, BL-17 Geshu, ST-40 Fenglong, L.I.-11 Quchi, SP-6 Sanyinjiao, Ren-15 Jiuwei. Reducing method, no moxa. Herbal therapy Prescription ZHU YE SHI GAO TANG Phyllostachys Gipsum Decoction Prescription ZHI ZI CHI TANG Gardenia-Soja Decoction

Retention of Food Clinical manifestations Fullness, pain and distension of the epigastrium (which are relieved by vomiting), nausea, vomiting of

Insomnia (Somnolence, Poor Memory)

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sour fluids, foul breath, sour regurgitation, belching, insomnia, loose stools or constipation, poor appetite. Tongue: thick coating (which could be white or yellow). Pulse: Full-Slippery.

Explanation

Treatment principle

Modifications

Resolve Retention of Food, stimulate the descending of Stomach-Qi, calm the Mind.

Both these formulae should be modified with the addition of herbs that promote sleep, such as Ye Jiao Teng Caulis Polygoni multiflori and Suan Zao Re Semen Ziziphi spinosae.

Acupuncture Points Ren-13 Shangwan, Ren-10 Xiawan, ST-21 Liangmen, ST-44 Neiting, ST-45 Lidui, SP-4 Gongsun, P-6 Neiguan, ST-40 Fenglong, ST-19 Burong, KI-21 Youmen, Ren-12 Zhongwan. Reducing or even method.

Explanation • Ren-13 subdues rebellious Stomach-Qi. • Ren-10 stimulates the descending of Stomach-Qi. • ST-21 stimulates the descending of Stomach-Qi and resolves stagnant food. • ST-44 resolves stagnant food and clears Heat. • ST-45 resolves stagnant food and calms the Mind (if there is insomnia). • SP-4 resolves stagnant food. • P-6 stimulates the descending of Stomach-Qi. • ST-40 restores the descending of Stomach-Qi. • ST-19 and KI-21 restore the descending of Stomach-Qi. ST-19 is specific to resolve Retention of Food. • Ren-12 resolves Retention of Food.

This formula relieves Retention of Food and promotes the descending of Stomach-Qi. It is indicated when Retention of Food is accompanied by Heat or DampHeat.

SUMMARY RETENTION OF FOOD Points Ren-13 Shangwan, Ren-10 Xiawan, ST-21 Liangmen, ST-44 Neiting, ST-45 Lidui, SP-4 Gongsun, P-6 Neiguan, ST-40 Fenglong, ST-19 Burong, KI-21 Youmen, Ren-12 Zhongwan. Reducing or even method. Herbal therapy Prescription BAN XIA SHU MI TANG Pinellia-Sorghum Decoction Prescription ZHI SHI DAO ZHI WAN Aurantium Eliminating Stagnation Pill

Heart- and Spleen-Blood deficiency Clinical manifestations

Herbal therapy

This formula resolves Retention of Food. It should be modified with the addition of Ye Jiao Teng Caulis Polygoni multiflori to promote sleep.

Difficulty in falling asleep, palpitations, tiredness, poor appetite, slight anxiety, blurred vision, dizziness, poor memory, pale face. Tongue: Pale. Pulse: Choppy. This is a very common type of insomnia due to deficiency of Blood of the Heart and Spleen. Because Blood is deficient, the person cannot fall asleep easily, but once asleep, because Yin is sufficient, he or she stays asleep.

Prescription

Treatment principle

ZHI SHI DAO ZHI WAN Aurantium Eliminating Stagnation Pill

Tonify the Spleen, nourish Blood, tonify the Heart and calm the Mind.

Prescription BAN XIA SHU MI TANG Pinellia-Sorghum Decoction

Explanation

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Acupuncture Points ST-36 Zusanli, SP-6 Sanyinjiao, HE-7 Shenmen, Ren14 Juque, Ren-15 Jiuwei, BL-20 Pishu, BL-15 Xinshu, Yintang, P-6 Neiguan and SP-4 Gongsun in combination together with KI-9 Zhubin. Reinforcing method; moxa may be used.

Explanation • ST-36, SP-6 and BL-20 tonify the Spleen to produce Blood. SP-6 also calms the Mind. • HE-7, Ren-14 and Ren-15 nourish Heart-Blood and calm the Mind. • BL-15 nourishes Heart-Blood and calms the Mind. • Yintang calms the Mind and promotes sleep, especially in Empty conditions. The patient may also be advised to apply gentle moxibustion to this point with a moxa stick every night. • P-6 and SP-4 in combination open the Yin Linking Vessel (Yin Wei Mai); KI-9 is the starting point of this vessel. I use these three points to nourish Blood and calm the Mind, especially in women.

Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction

Explanation This formula tonifies Spleen-Qi and Heart-Qi, nourishes Heart-Blood and calms the Mind. This formula is specific for this pattern and it promotes sleep, therefore no modifications are needed.

Three Treasures remedy Calm the Shen Calm the Shen is a variation of Gui Pi Tang; it tonifies Qi and Blood of the Heart and Spleen and calms the Mind.

SUMMARY HEART- AND SPLEEN-BLOOD DEFICIENCY Points ST-36 Zusanli, SP-6 Sanyinjiao, HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei, BL-20 Pishu, BL-15 Xinshu, Yintang, P-6 Neiguan and SP-4 Gongsun

in combination together with KI-9 Zhubin. Reinforcing method; moxa may be used. Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction Three Treasures remedy Calm the Shen

Case history A 42-year-old woman had been suffering from insomnia for some years. The problem became much worse after the birth of twins 8 years previously. She was also very anxious and revealed that she had suffered tremendous emotional strain throughout her life due to her mother’s bipolar disorder. She said during the first consultation of her mother’s disease: “It destroyed me.” She used zopiclone for the insomnia. She also suffered from recurrent headaches, which also had become worse after the childbirth. The headaches occurred in the forehead and were dull in nature. She also said that she felt “foggy” in her head. She had been prescribed Prozac, and she was on it at the time of the consultation. Her periods were regular but were very heavy, lasting 7–8 days. She also complained of dizziness, palpitations and blurred vision. Her tongue was Pale and Swollen; her pulse was Weak and Deep and especially weak on both Rear positions (Kidneys). Diagnosis The insomnia was due to Blood deficiency of the Spleen, Liver and Heart (palpitations, blurred vision, dizziness, Pale tongue). However, there were other factors at play. First, there was a pronounced deficiency of Kidney-Yang (pulse very Weak on both Rear positions); this was evidenced by the aggravation of both insomnia and headaches after childbirth. The headaches were due partly to Blood deficiency and partly to Phlegm in the head (“foggy” feeling, Swollen tongue). Treatment This patient was treated only with herbal medicine. To concentrate on treating the insomnia

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and headaches, I nourished Heart-Blood and calmed the Mind with a variation of Gui Pi Tang.

Heart-Yin deficiency

• • • • • • • • • • • •

Waking up frequently during the night, dry throat, mental restlessness, palpitations, night sweating, poor memory. Tongue: without coating, Heart crack, red tip. If there is Empty Heat, Red body. Pulse: Floating-Empty.

Bai Zhu Rhizoma Atractylodis macrocephalae Huang Qi Radix Astragali Dang Gui Radix Angelicae sinensis Bai Shao Radix Paeoniae alba Gou Teng Ramulus cum Uncis Uncariae Yuan Zhi Radix Polygalae Suan Zao Ren Semen Ziziphi spinosae Bai Zi Ren Semen Platycladi Long Yan Rou Arillus Longan Ye Jiao Teng Caulis Polygoni multiflori Dan Shen Radix Salviae milthiorrizae Tu Si Zi Semen Cuscutae

After the first course of herbs (in concentrated powder form), she reported feeling very much better in herself. She also reported a breakthrough in her psychotherapy and she said that she felt like she had “discarded a lot of luggage”. I continued treating her with similar prescriptions for about 8 months, during which all her problems underwent a remarkable improvement (insomnia, headaches, heavy periods). She was also able to stop taking zopiclone and Prozac. After about 8 months, I turned my attention to tonifying the Kidneys and changed the formula, using a variation of You Gui Wan Restoring the Right [Kidney] Pill modified with the addition of herbs to calm the Mind, as the sleep was still a problem. • • • • • • • • • • • • • •

Shu Di Huang Radix Rehmanniae preparata Shan Yao Rhizoma Dioscoreae Shan Zhu Yu Fructus Corni Tu Si Zi Semen Cuscutae Gou Qi Zi Fructus Lycii chinensis Dang Gui Radix Angelicae sinensis Dan Shen Radix Salviae milthiorrizae Suan Zao Ren Semen Ziziphi spinosae Bai Zi Ren Semen Platycladi Ye Jiao Teng Caulis Polygoni multiflori Bai Zhu Rhizoma Atractylodis macrocephalae Du Zhong Cortex Eucommiae ulmoidis Sheng Di Huang Radix Rehmanniae Xu Duan Radix Dipsaci

After a further 3 months of treatment with this formula, she reported a total improvement in all her main symptoms, i.e. the insomnia, headaches and heavy periods.

Clinical manifestations

Treatment principle Nourish Heart-Yin and calm the Mind.

Acupuncture Points HE-7 Shenmen, BL-15 Xinshu, Ren-14 Juque, SP-6 Sanyinjiao, ST-36 Zusanli, Ren-4 Guanyuan. Reinforcing method.

Explanation • HE-7 nourishes the Heart, calms the Mind and promotes sleep. • BL-15 and Ren-14, Back-Transporting points and Front-Collecting point of the Heart, nourish the Heart and calm the Mind. • SP-6 and ST-36 nourish Qi and Yin in general. • Ren-4 nourishes Yin in general and calms the Mind.

Herbal therapy Prescription YANG XIN TANG (II) Nourishing the Heart Decoction

Explanation This formula tonifies Heart-Qi, Heart-Blood and HeartYin. It shares the same name as another formula (Yang Xin Tang I) that tonifies Heart-Qi and Heart-Blood. When used for Heart-Yin, it can be modified by reducing the dosage of the Qi tonics and increasing that of the Yin tonics.

Modifications • If the symptoms of Yin deficiency are pronounced, add Tian Men Dong Radix Asparagi and Sheng Di Huang Radix Rehmanniae. • If there are pronounced symptoms of Empty Heat, add Qing Hao Herba Artemisiae annuae and Mu Li Concha Ostreae.

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SUMMARY

Herbal therapy

HEART-YIN DEFICIENCY

Prescription

Points HE-7 Shenmen, BL-15 Xinshu, Ren-14 Juque, SP-6 Sanyinjiao, ST-36 Zusanli, Ren-4 Guanyuan. Reinforcing method.

TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill

Herbal therapy Prescription YANG XIN TANG (II) Nourishing the Heart Decoction

Heart and Kidneys not harmonized Clinical manifestations Waking up frequently during the night, difficulty in falling asleep, dry throat, night sweating, five-palm heat, poor memory, palpitations, dizziness, mental restlessness, tinnitus, backache. Tongue: Red without coating, tip redder, Heart crack, dry. Pulse: Floating-Empty and slightly Rapid. This pattern consists of deficiency of Kidney-Yin, deficiency of Heart-Yin and Heart Empty Heat.

Treatment principle Nourish Yin, tonify Kidneys and Heart, clear Empty Heat and calm the Mind.

Acupuncture Points

Explanation This prescription nourishes Kidney- and Heart-Yin, clears Empty Heat and calms the Mind.

Modifications • To enhance the sleep-promoting effect, add Ye Jiao Teng Caulis Polygoni multiflori. • If there are pronounced symptoms of Empty Heat, add Mu Li Concha Ostreae and Qing Hao Herba Artemisiae annuae.

Three Treasures remedy Heavenly Empress Heavenly Empress is a variation of Tian Wang Bu Xin Dan; it nourishes Yin of Heart and Kidneys, clears Heart Empty Heat and calms the Mind.

SUMMARY HEART AND KIDNEYS NOT HARMONIZED Points HE-7 Shenmen, HE-6 Yinxi, P-7 Daling, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, KI-6 Zhaohai, Ren-15 Jiuwei, BL-15 Xinshu, BL-23 Shenshu, BL-44 Shentang, BL-52 Zhishi. Reinforcing method on all points except HE-6, which should be reduced.

HE-7 Shenmen, HE-6 Yinxi, P-7 Daling, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, KI-6 Zhaohai, Ren-15 Jiuwei, BL-15 Xinshu, BL-23 Shenshu, BL-44 Shentang, BL-52 Zhishi. Reinforcing method on all points except HE-6, which should be reduced.

Herbal therapy Prescription TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill

Explanation

Three Treasures remedy Heavenly Empress

• • • • • • • •

HE-7 calms the Mind and promotes sleep. HE-6 clears Heart Empty Heat. P-7 calms the Mind. Ren-4 nourishes Kidney-Yin and calms the Mind. SP-6, KI-3 and KI-6 nourish Kidney-Yin. Ren-15 nourishes the Heart and calms the Mind. BL-15 and BL-23 harmonize Heart and Kidneys. BL-44 and BL-52 harmonize the Mind and WillPower.

Case history A 58-year-old man had been suffering from insomnia for 2 years. He fell asleep easily but woke up several times during the night with a feeling of dryness of the throat. He had also been suffering from impotence for 3 years.

Insomnia (Somnolence, Poor Memory)

His tongue was Red, the coating was too thin and it had a Heart crack. His pulse was Empty at the deep level and extremely Weak and Fine on the left Rear and Middle positions. He was born with one kidney. Diagnosis The insomnia in this case was due to Kidney-Yin deficiency and Kidney and Heart not harmonized. Although he had comparatively few symptoms, judging from the pulse the Kidney deficiency was very severe, and this obviously also had something to do with his congenital anatomical abnormality.

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More than a pattern, this describes a certain character type of a person. Such character may be constitutional or may arise as a consequence of a protracted illness, for example glandular fever (mononucleosis). Originally, the formula Wen Dan Tang Warming the Gall Bladder Decoction was used for this condition, but nowadays this formula is more often used for PhlegmHeat.

Treatment principle Tonify Heart and Gall Bladder, calm the Mind.

Treatment principle Nourish Kidney-Yin and HeartYin and calm the Mind.

Acupuncture

Acupuncture The main points used were as follows.

HE-7 Shenmen, G.B.-40 Qiuxu. Reinforcing method.

• S.I.-3 Houxi and BL-62 Shenmai to open the Governing Vessel and strengthen the Kidneys. Although this combination strengthens KidneyYang more than Kidney-Yin, it was used to help his impotence, which was worrying him more than the insomnia. • Ren-4 Guanyuan, SP-6 Sanyinjiao and KI-3 Taixi nourish Kidney-Yin. • BL-23 Shenshu to strengthen the Kidneys. • HE-7 Shenmen, Ren-15 Jiuwei and Du-19 Houding to calm the Mind. • G.B.-12 Wangu and Yintang to promote sleep.

Explanation

Herbal therapy No herbs were prescribed but only the patent remedy Tian Wang Bu Xin Dan Heavenly Emperor’s Tonifying the Heart Pill to nourish Kidneyand Heart-Yin and calm the Mind. The patient’s sleep became normal after 6 months of treatment, while his impotence improved by about 50%.

Heart and Gall Bladder deficiency

Points

HE-7 and G.B.-40, both Source points, tonify Heart and Gall Bladder, calm the Mind and stimulate the person’s drive and assertiveness.

Herbal therapy Prescription AN SHEN DING ZHI WAN Calming the Mind and Settling the Spirit Pill

SUMMARY HEART AND GALL BLADDER DEFICIENCY Points HE-7 Shenmen, G.B.-40 Qiuxu. Reinforcing method. Herbal therapy Prescription AN SHEN DING ZHI WAN Calming the Mind and Settling the Spirit Pill

Clinical manifestations Waking up very early in the morning and being unable to fall asleep again, light sleep, dreaming a lot, propensity to being easily startled, timidity, lack of initiative and assertiveness, palpitations, breathlessness, tiredness, depression. Tongue: Pale, Heart crack. Pulse: Empty.

Liver-Yin deficiency Clinical manifestations Waking up during the night, dreaming a lot, talking in one’s sleep, in severe cases sleepwalking, dry throat, irritability, blurred vision, feeling of heat, sore and dry eyes, dry skin and hair, dizziness.

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Tongue: without coating. Pulse: Floating-Empty, especially on the left side. The deficiency of Liver-Yin causes the Ethereal Soul to be deprived of its root and to “wander” at night during sleep. This causes insomnia and excessive dreaming.

Treatment principle Nourish Liver-Yin, root the Ethereal Soul and calm the Mind.

Acupuncture Points LIV-8 Ququan, Ren-4 Guanyuan, Hunshe extra point, SP-6 Sanyinjiao, P-7 Daling, Du-24 Shenting and G.B.-15 Toulinqi, BL-47 Hunmen, Anmien. Reinforcing method. No moxa.

Explanation • LIV-8 nourishes Liver-Blood and Liver-Yin. • Ren-4 nourishes Liver- and Kidney-Yin and calms the Mind. • Hunshe (situated level with Ren-8 Shenque and 1 cun lateral to it) roots the Ethereal Soul into the Liver. • SP-6 nourishes Liver-Yin, calms the Mind and settles the Ethereal Soul. • P-7 harmonizes the Liver (due to the relationship between Pericardium and Liver within the Terminal Yin), calms the Mind and settles the Ethereal Soul. • Du-24 and G.B.-15 calm the Mind, especially in Liver patterns. • BL-47, called the “Door of the Ethereal Soul”, settles the Ethereal Soul into the Liver at night. Some old books give sleepwalking as an indication for this point. • Anmien calms the Ethereal Soul and the Mind and promotes sleep in Liver patterns.

Herbal therapy Prescription SUAN ZAO REN TANG Ziziphus Decoction

Explanation This is an excellent formula for this condition, and it is very reliable in its sleep-promoting effect.

Modifications • If there is Empty Heat arising from Liver-Yin deficiency, add Han Lian Cao Herba Ecliptae and Mu Li Concha Ostreae. • If there are symptoms of Liver-Yang rising, add Tian Ma Rhizoma Gastrodiae and Gou Teng Ramulus cum Uncis Uncariae.

Prescription YIN MEI TANG Attracting Sleep Decoction

Explanation This formula is specific to nourish Liver-Yin and promote sleep by rooting the Ethereal Soul in the Liver. Compared with the previous formula, it is used when the person has many unpleasant dreams.

Three Treasures remedies Nourish the Soul Nourish the Soul is a variation of Suan Zao Ren Tang; it nourishes Liver-Yin, settles the Ethereal Soul and calms the Mind. Root the Spirit Root the Spirit is a variation of the formula Yin Mei Tang mentioned above. It nourishes Liver-Yin, settles the Ethereal Soul and sinks Qi to promote sleep.

SUMMARY LIVER-YIN DEFICIENCY Points LIV-8 Ququan, Ren-4 Guanyuan, Hunshe extra point, SP-6 Sanyinjiao, P-7 Daling, Du-24 Shenting and G.B.-15 Toulinqi, BL-47 Hunmen, Anmien. Reinforcing method. No moxa. Herbal therapy Prescription SUAN ZAO REN TANG Ziziphus Decoction Prescription YIN MEI TANG Attracting Sleep Decoction

Insomnia (Somnolence, Poor Memory)

Three Treasures remedies Nourish the Soul Root the Spirit

Case history A 61-year-old man had been suffering from insomnia ever since his wife died 2 years previously. He found it difficult to fall asleep and also woke up frequently during the night. He was extremely sad about his wife’s death and found it very difficult to come to terms with it. His vision was sometimes blurred and his memory was affected. His tongue was Red, dry and Flabby, and its coating was too thin (Plate 15.1). His pulse was Floating-Empty and very slightly Wiry on the left side. Diagnosis In this case, sadness affected the Liver and Heart rather than the Lungs and Heart. In particular, sadness weakened Liver-Yin so that the Ethereal Soul was deprived of its root. When this happens it wanders at night, causing insomnia. The Spiritual Axis in Chapter 8 clearly states that sadness can affect the Liver: “The Liver’s sadness and shock injure the Ethereal Soul ...” and:47 When sadness affects the Liver, it injures the Ethereal Soul; this causes mental confusion ... the Yin is damaged, the tendons contract and there is hypochondrial discomfort. This quotation clearly indicates that Liver-Yin may be damaged by sadness. The blurred vision confirms the deficiency of LiverYin. Treatment principle Nourish Liver-Yin, root the Ethereal Soul and calm the Mind. Acupuncture The points used were: • LIV-8 Ququan, SP-6 Sanyinjiao and Ren-4 Guanyuan to nourish Liver-Yin. • HE-7 Shenmen and Ren-15 Jiuwei to calm the Mind. • Du-24 Shenting and G.B.-13 Benshen to calm the Mind and root the Ethereal Soul.

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Herbal therapy No herbs were prescribed but only the patent remedy Suan Zao Ren Tang Pian Tablet of the Ziziphus Decoction, which specifically treats insomnia from Liver-Yin deficiency. This patient’s sleep pattern first improved by being able to fall asleep easily, although he still woke up during the night. Presumably, this is because LiverBlood (responsible for not falling asleep) was helped before Liver-Yin. After about 6 months of fortnightly treatments, he started sleeping through the night.

Case history A 53-year-old woman had been suffering from insomnia for over 10 years. This started after suffering two shocks in the 2 years preceding its onset. Her problem was not so much falling asleep as waking up during the night. Occasionally, she sweated at night. She has a red rash on the face and neck, and her eyes were often dry. Her tongue was slightly Red and without coating with a shallow Heart crack. Her pulse was Empty at the deep level and very slightly Overflowing on the Liver position. Diagnosis This is a clear case of Liver-Yin deficiency with some Empty Heat. The Yin deficiency is evidenced by the lack of coating on the tongue, the pulse being Empty at the deep level and night sweating, and the Liver involvement by the insomnia, dry eyes and red rash. Treatment I treated this patient only with two Three Treasures remedies. The first was Nourish the Soul, which is a variation of Suan Zao Ren Tang Ziziphus Decoction; this formula nourishes Liver-Yin, clears Empty Heat, calms the Mind and settles the Ethereal Soul. I prescribed three tablets twice a day for this remedy. The second remedy was Female Treasure, which subdues Liver-Yang, clears Empty Heat and nourishes Liver-Yin. I prescribed only two tablets a day to be taken in the evening. The combination of these two remedies had a very good effect on her sleep, and she gradually slept better. The patient is still being treated at the time of writing.

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MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 35, No. 3, 1994, p. 180. Anwei Province Hospital of Chinese Medicine, “What to do when Suan Zao Ren and Ye Jiao Teng fail in the treatment of insomnia.” The authors of this article say that, in insomnia, it is essential to distinguish between a condition with a pathogenic factor (Full) from one without a pathogenic factor (Empty). Empty conditions without a pathogenic factor are due to worry, pensiveness and overwork injuring the Spleen and Heart, resulting in insomnia, anxiety and palpitations. The formula to use in this case is Shou Pi Jian Spleen Longevity Decoction. • • • • • • • •

Dang Shen Radix Codonopsis Bai Zhu Rhizoma Atractylodis macrocephalae Shan Yao Rhizoma Dioscoreae Zhi Gan Cao Radix Glycyrrhizae uralensis preparata Suan Zao Ren Semen Ziziphi spinosae Yuan Zhi Radix Polygalae Gan Jiang Rhizoma Zingiberis Lian Rou Fructus Nelumbinis

If fear injures the Kidneys and the Gall Bladder, the Mind and Ethereal Soul are deprived of their residence, the Yin and Essence are deficient and insomnia ensues. The formula to use is Da Bu Yuan Jian Great Tonifying the Original [Qi] Decoction. • • • • • • • •

Shu Di Huang Radix Rehmanniae preparata 15 g Shan Yao Rhizoma Dioscoreae 12 g Shan Zhu Yu Fructus Corni 9 g Gou Qi Zi Fructus Lycii chinensis 12 g Dang Gui Radix Angelicae sinensis 9 g Ren Shen Radix Ginseng 12 g Du Zhong Cortex Eucommiae ulmoidis 9 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6 g

If overwork injures the Heart, Heart-Yin becomes deficient and Empty Heat harasses the Mind. The tongue lacks a coating and is cracked. In this case, use Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill. If Liver-Qi stagnation agitates the Ethereal Soul, Heart and Gall Bladder become deficient; in such a case, use Wen Dan Tang Warming the Gall Bladder

Decoction. Please note that the authors are using this formula for the purpose for which it was originally designed, i.e. to “warm the Gall Bladder” and strengthen resolve and decisiveness and to treat insomnia and anxiety. As for the Full conditions of insomnia, if the Stomach suffers from Retention of Food the authors recommend using Da He Zhong Yin Great Harmonizing the Centre Decoction. • Xing Ren Semen Armeniacae • Bai Jie Zi Semen Sinapis albae • Sheng Jiang Rhizoma Zingiberis recens If Phlegm is causing insomnia, the authors recommend using Dao Tan Tang Conducting Phlegm Decoction. If there is Phlegm with Heat, they recommend using Di Tan Tang Washing Away Phlegm Decoction. The authors conclude stressing the importance of pattern identification in the treatment of insomnia and not relying simply on the use of Suan Zao Ren and Ye Jiao Teng. The authors say that these herbs are used for insomnia only if deriving from the specific patterns they address, i.e. Liver-Blood deficiency for Suan Zao Ren and Liver-Yin deficiency for Ye Jiao Teng.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 39, No. 11, 1998, p. 658. Qian Yan Fang, “The treatment of stubborn insomnia based on identification of patterns.” Dr Qian discusses what he considers to be the main patterns causing stubborn insomnia.

Disharmony of the Nutritive and Defensive Qi The first pattern is disharmony of the Nutritive (Ying) and Defensive (Wei) Qi. Defensive Qi should enter into the Yin at night; if it does not, it stays in the Yang, it remains on the Exterior of the body and in the eyes, the Yang Stepping Vessel (Yang Qiao Mai) is full, the eyes cannot close and insomnia ensues. The symptoms of this type of insomnia are difficulty in falling asleep or difficulty in staying asleep, inability to close the eyes, excessive dreaming, headache, a sensation rising from the chest to the head, aversion to wind and Wiry pulse. The formula Dr Qian suggests is Gui Zhi Jia Long Gu Mu Li Tang Cinnamomum-Mastodi Ossis fossilia-Concha

Insomnia (Somnolence, Poor Memory)

Ostreae Decoction. Gui Zhi Tang harmonizes Nutritive and Defensive Qi, while Long Gu and Mu Li calm the Mind and settle the Ethereal Soul.

Deficiency of Qi and Yin, disharmony of Heart and Kidneys The second pattern discussed is deficiency of Qi and Yin and disharmony of Heart and Kidneys. Overwork and pensiveness injure the Spleen and Heart, leading to Blood deficiency, or Heat may injure Yin and lead to Kidney-Yin deficiency. This leads to deficiency of Heart-Yin and Heart Empty Heat. The formula to use is Sheng Mai San Generating the Pulse Power together with Huang Lian E Jiao Tang Coptis Colla Corii Asini Decoction.

Phlegm-Heat The third pattern is Phlegm-Heat. Dr Qian considers the main symptoms of Phlegm-Heat causing insomnia to be chronic insomnia, palpitations, excessive dreaming, a feeling of heaviness of the head, anxiety, expectoration of sputum, bitter taste, tinnitus, belching, nausea, loose stools, sticky coating and Slippery-Wiry pulse. The recommended formula is Huang Lian Wen Dan Tang Coptis Warming the Gall Bladder Decoction.

Heart-Blood stasis The fourth pattern is Blood stasis of the Heart. The main manifestations are inability to close the eyes at night, startled as soon as the eyes close, headache, blurred vision, poor memory, numbness of limbs, chest pain, Purple tongue and Wiry or Choppy pulse. The formula recommended is Tong Qiao Huo Xue Tang Opening the Orifices and Invigorating Blood Decoction.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 34, No. 2, 1993, p. 117. Zhou Jing Ming, “Clinical significance of Zhang Jing Yue’s treatment principle of insomnia according to the differentiation between that with and that without pathogenic factors.” The article discusses Zhang Jing Yue (1624) treatment of insomnia. Dr Zhang differentiates clearly insomnia with a pathogenic factor and insomnia without. The author mentions two main patterns with a pathogenic factor: Liver- and Heart-Fire and Phlegm-Heat.

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Patterns with pathogenic factors Liver- and Heart-Fire For Liver- and Heart-Fire, Dr Zhang uses Qing Huo An Shen Tang Clearing Fire and Calming the Mind Decoction. • • • • • • • • •

Sheng Di Huang Radix Rehmanniae 12 g Huang Lian Rhizoma Coptidis 3 g Huang Qin Radix Scutellariae 6 g Shan Zhi Zi Fructus Gardeniae 9 g Long Gu Mastodi Ossis fossilia 15 g Mu Li Concha Ostreae 15 g Long Dan Cao Radix Gentianae 3 g Lian Qiao Fructus Forsythiae suspensae 6 g Gan Cao Radix Glycyrrhizae uralensis 3 g

Phlegm-Heat For insomnia from Phlegm-Heat, Dr Zhang uses He Zhong An Shen Tang Harmonizing the Centre and Calming the Mind Decoction. • • • • • • • •

Ban Xai Rhizoma Pinelliae preparatum 6 g Fu Ling Poria 9 g Chen Pi Pericarpium Citri reticulatae 6 g Zhi Shi Fructus Aurantii immaturus 9 g Huang Lian Rhizoma Coptidis 3 g Zhu Ru Caulis Bambusae in Taeniam 6 g Bei Shu Mi Sorghum 9 g Gan Cao Radix Glycyrrhizae uralensis 3 g

Patterns without pathogenic factors The three main patterns without pathogenic factors causing insomnia are Heart and Spleen deficiency, deficiency of Heart and Gall Bladder and deficiency of Liver- and Kidney-Yin. Deficiency of Heart and Spleen For deficiency of Heart and Spleen, Dr Zhang uses Yang Xin An Shen Tang Nourishing the Heart and Calming the Mind Decoction. • • • • • • • • • • • •

Dang Shen Radix Codonopsis 9 g Bai Zhu Rhizoma Atractylodis macrocephalae 9 g Huang Qi Radix Astragali 12 g Dang Gui Radix Angelicae sinensis 12 g Fu Shen Sclerotium Poriae pararadicis 9 g Yuan Zhi Radix Polygalae 3 g Long Yan Rou Arillus Longan 12 g Suan Zao Ren Semen Ziziphi spinosae 9 g Bai Zi Ren Semen Platycladi 10 g Bai Shao Radix Paeoniae alba 12 g Mu Xiang Radix Aucklandiae 3 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 4.5 g

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Deficiency of Heart and Gall Bladder The second Empty pattern is deficiency of the Heart and Gall Bladder with the following manifestations: anxiety, Mind (Shen) and Ethereal Soul unsettled, easily sad, excessive dreaming, waking up at night, palpitations, shortness of breath and tiredness. The formula recommended for this pattern is Ding Zhi An Shen Tang Settling the Spirit and Calming the Mind Decoction. • • • • • • • • •

Dang Shen Radix Codonopsis 6 g Fu Ling Poria 9 g Yuan Zhi Radix Polygalae 3 g Suan Zao Ren Semen Ziziphi spinosae 9 g Shi Chang Pu Rhizoma Acori tatarinowii 3 g Long Chi Fossilia Dentis Mastodi 15 g Zhen Zhu Mu Concha Margatiriferae usta 15 g Fu Xiao Mai Fructus Tritici levis 15 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g

Liver- and Kidney-Yin deficiency The third Empty pattern in insomnia is deficiency of Liver- and KidneyYin, for which Dr Zhang uses Zi Yin An Shen Tang Nourishing Yin and Calming the Mind Decoction. • • • • • • • • •

Sheng Di Huang Radix Rehmanniae 9 g Shan Zhu Yu Fructus Corni 9 g Shan Yao Rhizoma Dioscoreae 9 g Fu Ling Poria 10 g Huang Lian Rhizoma Coptidis 3 g Mu Dan Pi Cortex Moutan 6 g Bai Shao Radix Paeoniae alba 9 g E Jiao Colla Corii Asini 9 g Ze Xie Rhizoma Alismatis 9 g

Of particular interest in this article is also the small dosage of the herbs, which is contrary to modern use.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 45, No. 11, 2004, p. 843. Hong Yong Bo et al., “Clinical observation on the treatment of 31 cases of insomnia with Jie Yu Wan.” Fifty-three patients suffering from insomnia were randomly divided into a treatment group (31) treated with Jie Yu Wan and a control group (22) treated with trazodone. The patients were assessed before treatment

and at the 14th and 28th days of therapy with the Sleeping Questionnaire (SQ), Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS). Adverse effects and efficacy index were evaluated by the method of Clinical Global Impression. The marked improvement rate was 54.9% in the treatment group and 59.1% in the control group, with no significant difference between the groups (P > 0.05). After treatment, the scores for SQ, SDS and SAS decreased significantly in both groups with no significant difference between them, although patients reported fewer side effects in the treatment group. The formula Jie Yu Wan Eliminating Stagnation Pill contained the following (dosages for a batch of pills). • • • • • • • • •

Bai Shao Radix Paeoniae alba 270 g Chai Hu Radix Bupleuri 190 g Yu Jin Radix Curcumae 140 g Fu Ling Poria 170 g Bai He Bulbus Lilii 170 g He Huan Pi Cortex Albiziae 170 g Gan Cao Radix Glycyrrhizae uralensis 85 g Fu Xiao Mai Fructus Tritici levis 210 g Da Zao Fructus Jujubae 140 g

This trial is reported here as a typical example of a poorly designed study from the point of view of Chinese medicine. First, it treats all patients suffering from insomnia with the same formula, something that we would never do in practice. As the formula’s main aim is to move Qi and eliminate stagnation, it assumes that all patients with insomnia suffer from Qi stagnation, something that is clearly not true. Second, the formula seems aimed more at treating depression than insomnia (see use of Yu Jin and He Huan Pi), and therefore there is a basic misunderstanding underlying this trial, as there is a difference between the insomnia that is secondary to depression and insomnia that occurs by itself.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 20, No. 2, 2000, p. 90 Ren Jian Jun, “38 cases of insomnia treated with moxibustion on KI-1 Yongquan.” Dr Ren reports on the use of moxibusion on KI-1 Yongquan for the treatment of insomnia. The point

Insomnia (Somnolence, Poor Memory)

was heated with a moxa stick once a day for 15–20 minutes each time. Treatment was given in 7-day courses. Dr Ren reports 100% success in the treatment of 38 cases of insomnia with this method.

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Conclusion In conclusion, it is suggested that intradermal acupuncture on HE-7 Shenmen and P-6 Neiguan is a useful treatment for post stroke onset insomnia.

Acupuncture and insomnia

CLINICAL TRIALS

Forschende Komplementarmedizin 1999 February, Vol. 6 (Suppl. 1), pp. 29–31. Montakab H

Acupuncture

Objective

Intradermal acupuncture on HE-7 Shenmen and P-6 Neiguan acupoints in patients with insomnia after stroke

To ascertain the effect of acupuncture on insomnia.

American Journal of Chinese Medicine 2004, Vol. 32, Issue 5, pp. 771–778. Kim YS, Lee SH, Jung WS, Park SU, Moon SK, Ko CN, Cho KH, Bae HS Department of Cardiovascular and Neurological Diseases (Stroke Centre), College of Oriental Medicine, Kyung-Hee University, Seoul, Korea

Objective To analyse the effects of intradermal acupuncture on insomnia after stroke.

Method Hospitalized stroke patients with insomnia were enrolled and assigned to a real intradermal acupuncture group or a sham acupuncture group by randomization. The real acupuncture group received intradermal acupuncture on HE-7 Shenmen and P-6 Neiguan for 2 days, and the sham acupuncture group received sham acupuncture on the same points. The effectiveness was measured by the Morning Questionnaire (MQ), Insomnia Severity Index (ISI) and Athens Insomnia Scale (AIS). These scales were examined by an independent, blinded neurologist before and 1 and 2 days after treatment, repeatedly. Thirty subjects (15 in the real acupuncture group and 15 in the sham acupuncture group) were included in the final analysis.

Method Forty patients with primary difficulties in either falling asleep or remaining asleep were diagnosed according to traditional Chinese medicine, allocated to specific diagnostic subgroups and treated individually by a practitioner in his private practice. The patients were randomized into two groups, one group receiving true acupuncture and the other needled at non-acupuncture points for three to five sessions at weekly intervals. The outcome of the therapy was assessed in several ways, first and foremost by an objective measurement of the sleep quality by polysomnography in a specialized sleep laboratory, performed once before and once after termination of the series of treatments. Additional qualitative results were obtained from several questionnaires.

Results The objective measurement showed a statistically significant effect only in the patients who received the true acupuncture. The subjective, qualitative assessment was better in the proper treatment group than in the control group but was not calculated statistically for methodological reasons.

Conclusion Based on the results of this study, it can be concluded that true and individualized acupuncture indeed shows efficacy in primary sleep disorders. However, a direct influence by the therapist cannot be excluded.

Results The real acupuncture group showed more improvement on insomnia than the sham acupuncuture group. Repeated measures analysis detected that there were significant between-subjects effects in the MQ, the ISI and the AIS.

Effects of individualized acupuncture on sleep quality in HIV disease Journal of Associated Nurses AIDS Care 2001 January–February, Vol. 12, Issue 1, pp. 27–39. Phillips KD, Skelton WD

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Department of Administrative and Clinical Nursing, College of Nursing, University of South Carolina, USA

Objective Although it may begin at any point, sleep disturbance often appears early in HIV disease and contributes to decreased quality of life during the course of the illness. The purpose of this study was threefold: to explore the nature of sleep quality in HIV disease, to test the relationship between pain and sleep quality, and to test the effectiveness of acupuncture delivered in a group setting for improving sleep quality in those who are HIV-infected.

Method A pretest, post-test, pre-experimental design was used to test the effects of acupuncture on sleep quality. Participating in the study were 21 HIV-infected men and women between the ages of 29 and 50 years who reported sleep disturbance three or more times per week and who scored greater than 5 on the Pittsburgh Sleep Quality Index. The Wrist Actigraph was used to measure sleep activity, and the Current Sleep Quality Index was used to measure sleep quality for two nights before and after a 5-week acupuncture intervention (10 treatments). Acupuncture was individualized to address insomnia and other symptoms reported by the participants.

Results Sleep activity and sleep quality significantly improved following 5 weeks of individualized acupuncture delivered in a group setting.

Conclusion The results suggest that acupuncture may be an effective therapy to address problems of insomnia for HIV sufferers.

Acupuncture for insomnia in pregnancy – a prospective, quasi-randomised, controlled study Acupuncture in Medicine 2005 June, Vol. 23, Issue 2, pp. 47–51 Da Silva JB, Nakamura MU, Cordeiro JA, Kulay LJ Medical School of Sao Jose do Rio Preto, Brazil

Objective This study was undertaken to test the effects of acupuncture on insomnia in a group of pregnant women

under real life conditions and to compare the results with those of a group of patients undergoing conventional treatment alone (sleep hygiene).

Method A total of 30 conventionally treated pregnant women were allocated at random into groups with or without acupuncture. Seventeen patients formed the study group and 13 the control group. The pregnant women scored the severity of insomnia using a numerical rating scale from 0 to 10. Women were followed up for 8 weeks and interviewed five times at 2-week intervals.

Results Eight women dropped out, five in the study group and three in the control group. The study group reported a larger reduction on insomnia rating (5.1) than the control group (0.0), a difference that was statistically significant. Average insomnia scores decreased by at least 50% over time in nine (75%) patients in the study group and in three (30%) in the control group.

Conclusion The results of this study suggest that acupuncture alleviates insomnia during pregnancy and further research is justified.

Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: a preliminary report Journal of Neuropsychiatry and Clinical Neurosciences 2004 winter, Vol. 16, Issue 1, pp. 19–28. Spence DW, Kayumov L, Chen A, Lowe A, Jain U, Katzman MA, Shen J, Perelman B, Shapiro CM Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Extract The response to acupuncture by 18 anxious adult subjects who complained of insomnia was assessed in an open prepost clinical trial study. Five weeks of acupuncture treatment was associated with a significant nocturnal increase in endogenous melatonin secretion (as measured in urine) and significant improvements in polysomnographic measures of sleep onset latency, arousal index, total sleep time and sleep efficiency.

Insomnia (Somnolence, Poor Memory)

Significant reductions in state and trait anxiety scores were also found. These objective findings are consistent with clinical reports of acupuncture’s relaxant effects. Acupuncture treatment may be of value for some categories of anxious patients with insomnia.

Herbal medicine TCM treatment for 63 cases of senile dyssomnia Journal of Traditional Chinese Medicine 2005 March, Vol. 25, Issue 1, pp. 45–49. Yang Y, Li H, Zhang S, Li Q, Yang X, Chen X, Zhao D, Wang Y Beijing University of Chinese Medicine, Beijing, China

Objective To ascertain the therapeutic effects of Chinese herbal medicine on senile dyssomnia.

Method A total of 121 such patients were randomly divided into a treatment group of 63 cases (given the traditional Chinese medicine drugs) and a control group of 58 cases (given estazolam). The changes shown in the SDRS and HAMA scores and the other indices were observed in both of the two groups to evaluate the therapeutic effects.

Results The results showed that the effective rate was 76.3% in the treatment group and 69.1% in the control group, and that the traditional Chinese medicine drugs had better effects in improving such symptoms as lethargy, dry mouth and rebound of insomnia.

Conclusion It can be concluded that the effect of the traditional Chinese medicine drugs is better for senile dyssomnia than that of the Western drug estazolam.

The effects of Yoku Kan San on undifferentiated somatoform disorder with tinnitus European Psychiatry 2005 January, Vol. 20, Issue 1, pp. 74–75. Okamoto H, Okami T, Ikeda M, Takeuchi T Department of Psychiatry, Teikyo University Ichihara Hospital, Ichihara City, Chiba, Japan

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Extract Up to the present, there have been few strategies that are completely effective in treating undifferentiated somatoform disorder with tinnitus. Yoku kan san (TJ-54), one of Japan’s traditional herbal medicines, is an effective treatment for tinnitus in undifferentiated somatoform disorder complicated with headache and insomnia. TJ-54 has been also used as an effective treatment for insomnia and irritability in recent centuries and is considered to have some effects on the excitability of nerves. Further studies are needed to confirm the efficacies of Japanese herbal medicines.

PATIENTS’ STATISTICS I have compiled a statistics of 73 patients suffering from insomnia in my practice. There were 45 women (62%) and 28 men (38%). The age distribution was as follows. • • • • • • •

0–10: 3 (4%) 11–20: 0 (0%) 21–30: 6 (8%) 31–40: 20 (27%) 41–50: 14 (19%) 51–60: 23 (32%) 61–70: 7 (10%)

As can be observed, the highest incidence of insomnia is in the 51–60 age group, and the overwhelming majority falls in the 31–60 age group. As for patterns, these were as follows. • Purely Empty patterns: 20 (27%) • Purely Full patterns: 18 (25%) • Combined Full–Empty patterns: 35 (48%). The breakdown of the main Empty patterns is as follows. • Blood deficiency (of Liver and/or Heart): 22 (30%) • Kidney deficiency: 33 (45%) • Heart deficiency (of Blood, Qi or Yin): 9 (12%). Interestingly, a deficiency of the Kidneys is a more common Empty pattern in insomnia than Blood deficiency. • • • •

Phlegm: 28 (38%) Blood stasis: 8 (11%) Fire (of Liver and/or Heart): 8 (11%) Qi stagnation: 6 (8%).

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Again, it is interesting that Phlegm (rather than Fire) is the most common pathogenic factor in insomnia. Phlegm is a pathogenic factor in insomnia, especially in the elderly. The most common pulse qualities were: • • • • • •

Wiry: 18 (25%) Slippery: 24 (34%) Weak: 25 (35%) Choppy: 9 (13%) Deep: 12 (17%) Fine: 12 (17%)

The main types of tongue seen in insomnia were as follows. • • • • • •

Pale: 21 (29%) Red: 29 (40%) Purple: 10 (14%) Swollen: 37 (51%) Peeled: 13 (18%) Red tip: 9 (12%)

An interesting feature of the tongues seen in insomnia is the high percentage of tongues with a red tip (12%); in my database of 2786 patients, 1.8% have a red tip.

CHAPTER APPENDIX 1/ SOMNOLENCE Somnolence indicates the tendency to be always rather sleepy and lethargic. Like insomnia, this is also due either to a pathogenic factor obstructing the Mind or to deficient Qi and Blood not reaching and nourishing the Mind (Shen).

IDENTIFICATION OF PATTERNS AND TREATMENT Dampness obstructing the Brain Clinical manifestations Sleepiness after lunch, a feeling of heaviness of the head, a feeling of muzziness of the head as if it were full of cotton wool, a feeling of fullness of the epigastrium and chest. Tongue: Thick-sticky coating. Pulse: Slippery or Soggy.

This pattern is due to Dampness obstructing the head and Brain and preventing the clear Qi from rising upwards to brighten the upper orifices. Another explanation of somnolence deriving from Dampness is that this pathogenic factor obstructs the space between the skin and muscles where the Defensive Qi flows. Because this space is obstructed, the Defensive Qi, Yang in nature, cannot flow there, so it stays in the Yin and the patient feels always sleepy. Chapter 80 of the Spiritual Axis says:48 Defensive Qi flows in the Yang during the day and in the Yin at night: when Yang slows down, one is sleepy; when Yin slows down, one is awake. When Stomach and Intestines are big, Defensive Qi stays there for a long time, the skin is obstructed by Dampness ... Defensive Qi slows down, it stays in the Yin for a long time, Qi is not clear and somnolence results.

Treatment principle Resolve Dampness and tonify the Spleen.

Acupuncture Points Ren-12 Zhongwan, BL-20 Pishu, ST-36 Zusanli, Ren-9 Shuifen, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, LU-7 Lieque, ST-8 Touwei, Du-20 Baihui, Du-24 Shenting. Renforcing method on Ren-12, BL-20 and ST-36. Reducing method on Ren-9, SP-6 and BL-22. Even method on LU-7, ST-8, Du-20 and Du-24.

Explanation • Ren-12, BL-20 and ST-36 tonify the Spleen to resolve Dampness. • Ren-9, SP-6 and BL-22 drain Dampness. • LU-7 removes obstruction from the channels in the head and favours the ascending of clear Qi to the head. • ST-8 and Du-20 are local points to expel Dampness from the head and facilitate the rising of clear Yang to the head. • Du-24 clears the brain and improves memory.

Herbal therapy Prescription PING WEI SAN Variation Balancing the Stomach Powder Variation

Insomnia (Somnolence, Poor Memory)

Explanation The first six herbs constitute the Ping Wei San, which drains Dampness from the Middle Burner. Huo Xiang Herba Pogostemonis and Pei Lan Herba Eupatorii resolve Dampness in the head (as they are fragrant and their fragrance reaches upwards). Yi Yi Ren Semen Coicis drains Dampness through the Lower Burner.

SUMMARY DAMPNESS OBSTRUCTING THE BRAIN Points Ren-12 Zhongwan, BL-20 Pishu, ST-36 Zusanli, Ren-9 Shuifen, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, LU-7 Lieque, ST-8 Touwei, Du-20 Baihui, Du-24 Shenting. Renforcing method on Ren-12, BL-20 and ST-36. Reducing method on Ren-9, ST-40, SP-6 and BL-22. Even method on LU-7, ST-8, Du-20 and Du-24. Herbal therapy Prescription PING WEI SAN Variation Balancing the Stomach Powder Variation

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Fenglong, LU-7 Lieque, ST-8 Touwei, Du-20 Baihui, Du-24 Shenting. Reinforcing method on Ren-12, BL-20 and ST-36. Reducing method on Ren-9, SP-6, BL-22 and ST-40. Even method on LU-7, ST-8, Du-20 and Du-24.

Explanation • Ren-12, BL-20 and ST-36 tonify the Spleen to resolve Phlegm. • Ren-9, SP-6 and BL-22 resolve Dampness. • ST-40 resolves Phlegm. • LU-7 removes obstruction from the channels in the head and favours the ascending of clear Qi to the head. • ST-8 and Du-20 are local points to expel Phlegm from the head and facilitate the rising of clear Yang to the head. • Du-24 clears the brain and promotes memory.

Herbal therapy Prescription WEN DAN TANG plus BAN XIA SHU MI TANG Warming the Gall Bladder Decoction plus PinelliaSorghum Decoction

Explanation

Phlegm misting the Brain Clinical manifestations Sleepiness after lunch, a feeling of heaviness, a feeling of muzziness of the head as if it were full of cotton wool, a feeling of oppression of the chest, dizziness, blurred vision, sputum in the throat. Tongue: Swollen and with a sticky coating. Pulse: Slippery. This pattern is due to Phlegm obstructing the head and preventing the clear Qi from rising upwards to brighten the upper orifices. Phlegm is more obstructive than Dampness, and this causes the dizziness and blurred vision (as Phlegm obstructs the orifices of the head).

Treatment principle Resolve Phlegm and tonify the Spleen.

Acupuncture Points Ren-12 Zhongwan, BL-20 Pishu, ST-36 Zusanli, Ren-9 Shuifen, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, ST-40

These two formulae together resolve Phlegm from the head. To strengthen their effect, add Shi Chang Pu Rhizoma Acori tatarinowii to open the head’s orifices.

Modifications • To relieve the muzzy feeling of the head, add Shi Chang Pu Rhizoma Acori tatarinowii. • If there are signs of Spleen deficiency, add Bai Zhu Rhizoma Atractylodis macrocephalae and Huang Qi Radix Astragali.

Three Treasures remedy Limpid Sea Limpid Sea is a general remedy to resolve Phlegm. It is a variation of Er Chen Tang.

SUMMARY PHLEGM MISTING THE BRAIN Points Ren-12 Zhongwan, BL-20 Pishu, ST-36 Zusanli, Ren-9 Shuifen, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, ST-40 Fenglong, LU-7 Lieque, ST-8 Touwei, Du-20

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Baihui, Du-24 Shenting. Reinforcing method on Ren-12, BL-20 and ST-36. Reducing method on Ren-9, SP-6, BL-22 and ST-40. Even method on LU-7, ST-8, Du-20 and Du-24. Herbal therapy Prescription WEN DAN TANG plus BAN XIA SHU MI TANG Warming the Gall Bladder Decoction plus PinelliaSorghum Decoction Three Treasures remedy Limpid Sea

Explanation This formula tonifies the Spleen, resolves Dampness and opens the head’s orifices.

Prescription BU ZHONG YI QI TANG Variation Tonifying the Centre and Benefiting Qi Decoction Variation

Explanation This formula is used if there is Spleen-Yang deficiency. The original formula tonifies the Spleen and raises Qi.

Three Treasures remedy

Spleen deficiency

Soothe the Centre Soothe the Centre tonifies Spleen-Qi and resolves Dampness.

Clinical manifestations Somnolence, lethargy, tiredness, feeling of heaviness, slight abdominal distension and fullness, poor appetite, loose stools. Tongue: Pale, sticky coating. Pulse: Weak or Soggy. Although this pattern is primarily one of deficiency, there is also some Dampness.

Treatment principle Tonify the Spleen and resolve Dampness.

Acupuncture Points ST-36 Zusanli, SP-3 Taibai, Ren-12 Zhongwan, BL-20 Pishu, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, ST-8 Touwei, Du-20 Baihui. Reinforcing method on the first four points and even method on the others. Moxa can be used.

Explanation • ST-36, SP-3, Ren-12 and BL-20 tonify the Spleen. • SP-6 and BL-22 resolve Dampness. • ST-8 and Du-20 drain Dampness from the head and facilitate the rising of clear Yang to the head.

Herbal therapy Prescription LIU JUN ZI TANG Variation Six Gentlemen Decoction Variation

SUMMARY SPLEEN DEFICIENCY Points ST-36 Zusanli, SP-3 Taibai, Ren-12 Zhongwan, BL-20 Pishu, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, ST-8 Touwei, Du-20 Baihui. Reinforcing method on the first four points and even method on the others. Moxa can be used. Herbal therapy Prescription LIU JUN ZI TANG Variation Six Gentlemen Decoction Variation Prescription BU ZHONG YI QI TANG Variation Tonifying the Centre and Benefiting Qi Decoction Variation Three Treasures remedy Soothe the Centre

Kidney-Yang deficiency (Deficiency of Sea of Marrow) Clinical manifestations Lethargy, tiredness, apathy, lack of will-power, poor memory, lack of initiative, depression, chilliness, lower backache, dizziness, tinnitus, frequent-pale urination.

Insomnia (Somnolence, Poor Memory)

Tongue: Pale. Pulse: Deep and Weak.

Treatment principle Tonify Kidney-Yang, nourish the Sea of Marrow and stimulate the rising of Qi.

Acupuncture Points KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, Du-20 Baihui, Du-24 Shenting, Ren-6 Qihai, Du-16 Fengfu. Reinforcing method.

Explanation • KI-3, BL-23 and BL-52 tonify the Kidneys, strengthen Will-Power, promote memory and nourish Marrow. • Du-20 and Du-24 facilitate the rising of clear Yang to the head. • Ren-6 with direct moxa tonifies Yang. • Du-16, point of the Sea of Marrow, nourishes Marrow.

Herbal therapy Prescription SHI BU WAN Ten Tonifications Pill

Explanation This formula tonifies the Kidneys and nourishes Marrow.

SUMMARY KIDNEY-YANG DEFICIENCY (DEFICIENCY OF SEA OF MARROW) Points KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, Du-20 Baihui, Du-24 Shenting, Ren-6 Qihai, Du-16 Fengfu. Reinforcing method. Herbal therapy Prescription SHI BU WAN Ten Tonifications Pill

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CHAPTER APPENDIX 2/ POOR MEMORY In Chinese medicine, memory depends on the state of the Spleen, Kidneys and Heart, and there is a considerable overlap among these three organs’ functions. The Spleen houses Intellect and influences memory in the sense of memorization, studying and concentrating. Its corresponding pathological aspect is excessive thinking and pensiveness. The Kidneys house Will-Power (Zhi) and influence the brain, because the Kidney-Essence produces Marrow, which nourishes the brain. As mentioned above, besides meaning “will-power”, Zhi also means “memory”. The Kidneys are responsible for memory in the sense of memorization of everyday events, names, faces, etc. The Heart controls memory because it houses the Mind (Shen). There is a considerable overlap between the Kidneys and Heart with regard to memory, but the Heart is responsible more for the memory of long-past events rather than of everyday things like the Kidneys. Indeed, memory depends primarily on the communication between the Heart and Kidneys. The Heart is above and houses the Mind (Shen), and the Kidneys are below and house the Essence (Jing) and memory (Zhi). One of the functions of the Mind of the Heart is memory and consciousness, and this faculty needs to descend towards the Kidneys. On the other hand, the KidneyEssence and Zhi need to ascend towards the Heart and Brain. When this communication takes place, Essence can generate Qi and Qi, in turn, can generate the Mind and memory is good. Thus, the Kidneys control memory in two ways: by its Zhi reaching the Heart and the Mind, and by its Essence reaching the Brain. Besides the Heart and Kidneys, memory also relies on the Spleen and its Intellect (Yi). The Heart controls the memory or past events, the Kidneys that of everyday events and the Spleen the capacity of memorizing in the course of study. Chapter 8 of the Spiritual Axis clearly refers to the relationship between Heart, Spleen and Kidneys in memory: “The recollection of the Heart is called Intellect (Yi-Spleen); the storage of memory by the Intellect is called Zhi (of the Kidneys).”49 The Yi Xue Ji Cheng says:50 With regard to poor memory, in the elderly the Essence dries up; in the young, worry, pensiveness and overwork

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weaken the Heart. [To strengthen memory] One must promote the communication between Heart and Kidneys, reinforce the Spleen and harmonize Qi and Blood.

AETIOLOGY

SUMMARY AETIOLOGY OF POOR MEMORY  Worry and pensiveness  Overwork and excessive sexual activity  Childbirth  Sadness  “Recreational” drugs

Worry and pensiveness Worry and pensiveness affect Lungs, Spleen and Heart, and they influence memory simply because the Spleen and Heart’s mental capacity is employed in worrying and obsessive thinking and cannot therefore be used for memorization.

IDENTIFICATION OF PATTERNS AND TREATMENT Spleen deficiency Clinical manifestations

Overwork and excessive sexual activity Overwork and excessive sexual activity (primarily in men) weaken Kidney-Yin and Kidney-Essence, which decreases mental power and memory.

Inability to concentrate and study, poor memory, tiredness, poor appetite. Tongue: Pale. Pulse: Weak.

Treatment principle Tonify the Spleen and strengthen the Intellect (Yi).

Childbirth Excessive bleeding at childbirth weakens Blood and affects the Heart. Deficient Heart-Blood is unable to nourish the brain and the Mind and poor memory results.

Sadness Sadness depletes Heart-Qi so that this cannot brighten the Mind and poor memory results.

“Recreational” drugs Prolonged and continued use of cannabis and other drugs is an important cause of poor memory and concentration. It would appear that the conversion of short-term to long-term memory is impaired by prolonged use of cannabis due to interference by a flow of sensory impressions.51 Moreover, there have also been reports of loss of brain substance in heavy users of cannabis.52 I have certainly verified the relationship between heavy, long-term use of cannabis and poor memory in my clinical practice.

Acupuncture Points ST-36 Zusanli, SP-3 Taibai, Du-20 Baihui, BL-15 Xinshu, Du-14 Dazhui with moxa, BL-20 Pishu, BL-49 Yishe. Reinforcing method.

Explanation • ST-36 and SP-3 tonify the Spleen and strengthen the Intellect. • Du-20 raises clear Yang to the head to brighten the Mind and Intellect. • BL-15, Back-Transporting point of the Heart, strengthens the Mind and the Intellect. • Du-14 with moxa also facilitates the rising of clear Yang to the brain. • BL-20 and BL-49 tonify the Spleen and strengthen the Intellect and memory.

Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction

Insomnia (Somnolence, Poor Memory)

Explanation This formula tonifies Heart-Qi and Heart-Blood and therefore strengthens the Mind and memory.

Three Treasures remedy Calm the Shen Calm the Shen is a variation of Gui Pi Tang; it tonifies Qi and Blood of Heart and Spleen.

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• Du-20 facilitates the rising of clear Yang to the head.

Herbal therapy Prescription LIU WEI DI HUANG WAN Variation Six-Ingredient Rehmannia Pill Variation

SUMMARY

Explanation

SPLEEN DEFICIENCY

The variation of this formula tonifies the Kidneys, strengthens Marrow and promotes memory.

Points ST-36 Zusanli, SP-3 Taibai, Du-20 Baihui, BL-15 Xinshu, Du-14 Dazhui with moxa, BL-20 Pishu, BL-49 Yishe. Reinforcing method. Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction Three Treasures remedy Calm the Shen

Modifications • If there is both Yin and Yang deficiency, add Lu Jiao Jiao Gelatinum Cornu Cervi, Ba Ji Tian Radix Morindae officinalis and Zi He Che Placenta hominis.

Three Treasures remedies Strengthen the Root or Nourish the Root Strengthen the Root can be used if there is Kidney-Yang deficiency and Nourish the Root if there is Kidney-Yin deficiency.

SUMMARY Kidney-Essence deficiency Clinical manifestations Poor memory of everyday events, dizziness, tinnitus, weak knees and back. Tongue: Pale in case of Kidney-Yang deficiency; without coating in case of Kidney-Yin deficiency. Pulse: Deep and Weak.

KIDNEY-ESSENCE DEfiCIENCY Points KI-3 Taixi, Ren-4 Guanyuan, BL-23 Shenshu, BL52 Zhishi, BL-15 Xinshu, Du-20 Baihui. Reinforcing method.

Treatment principle

Herbal therapy Prescription LIU WEI DI HUANG WAN Variation Six-Ingredient Rehmannia Pill Variation

Tonify the Kidneys, nourish Essence and Marrow and strengthen memory.

Three Treasures remedies Strengthen the Root or Nourish the Root

Acupuncture Points

Heart deficiency

KI-3 Taixi, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, BL-15 Xinshu, Du-20 Baihui. Reinforcing method.

Clinical manifestations

Explanation • KI-3, Ren-4 and BL-23 tonify the Kidneys. • BL-52 strengthens the Will-Power and memory. • BL-15 strengthens the Mind and memory.

Poor memory of past events, forgetting names, absent mindedness, palpitations, slight breathlessness on exertion, tiredness. Tongue: Pale or Red, depending on whether there is Yang or Yin deficiency. Pulse: Weak.

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Treatment principle Tonify the Heart, strengthen the Mind and memory.

Acupuncture Points HE-5 Tongli, BL-15 Xinshu, BL-44 Shentang, Ren-6 Qihai and Du-14 Dazhui with reinforcing method. If Phlegm obstructs the Heart, use ST-40 Fenglong and Ren-14 Juque with reducing method.

Explanation • HE-5 and BL-15 tonify Heart-Qi and strengthen the Mind. • BL-44 strengthens the Mind and memory. • Ren-6 with moxa tonifies Qi in general. • Du-14 with moxa tonifies the Heart and brightens the Mind. It is coordinated with Ren-6: one is on the Directing Vessel (Ren Mai), the other on the Governing Vessel (Du Mai), both of which flow through the Heart. • ST- 40 and Ren-14 resolve Phlegm from the Heart.

Herbal therapy Prescription ZHEN ZHONG DAN Bedside Pill

Explanation This formula could also be used for poor memory from other Heart patterns, such as Heart Empty Heat.

SUMMARY HEART DEFICIENCY Points HE-5 Tongli, BL-15 Xinshu, BL-44 Shentang, Ren6 Qihai and Du-14 Dazhui with reinforcing method. If Phlegm obstructs the Heart, use ST-40 Fenglong and Ren-14 Juque with reducing method. Herbal therapy Prescription ZHEN ZHONG DAN Bedside Pill

END NOTES 1. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 256. First published c.100 BC. 2. Tang Zong Hai 1892 Zhong Xi Hui Tong Yi Jing Jing Yi [The Essence of the Convergence between Chinese and Western Medicine], cited in Wang Ke Qin 1988 Zhong Yi Shen Zhu Xue Shuo [Theory of the Mind in Chinese Medicine]. Ancient Chinese Medical Texts Publishing House, p. 36. 3. 1986 Jing Yue Quan Shu [The Complete Book of Jing Yue], Shanghai Scientific Publishing House, Shanghai, p. 329. The Complete Book of Jing Yue was written by Zhang Jing Yue and first published in 1624. 4. Ibid., p. 329. 5. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 51. First published c.100 BC. 6. Ibid., p. 152. 7. Simple Questions, p. 102. 8. Ibid., p. 102. 9. Ibid., p. 102. 10. Ibid., p. 102. 11. Ibid., p. 102. 12. Ibid., p. 102. 13. Ibid., p. 102. 14. Ibid., p. 102. 15. Ibid., p. 102. 16. Ibid., p. 102. 17. Ibid., p. 103. 18. Ibid., p. 569. 19. Ibid., p. 569. 20. Spiritual Axis, p. 84. 21. Ibid., p. 84. 22. Simple Questions, p. 569. 23. Ibid., p. 569. 24. Spiritual Axis, p. 85. 25. Simple Questions, p. 569. 26. Ibid., p. 569. 27. Spiritual Axis, p. 85. 28. Ibid., p. 85. 29. Simple Questions, p. 569. 30. Ibid., p. 569. 31. Spiritual Axis, p. 85. 32. Ibid., p. 85. 33. Simple Questions, p. 569. 34. Ibid., p. 569. 35. Spiritual Axis, p. 85. 36. Ibid., p. 85. 37. Ibid., p. 85. 38. Ibid., p. 85. 39. Ibid., p. 85. 40. Ibid., p. 85. 41. Ibid., p. 85. 42. Ibid., p. 85. 43. Simple Questions, p. 256. 44. Ibid., p. 199. 45. Spiritual Axis, p. 56. 46. Simple Questions, p. 199. 47. Spiritual Axis, p. 24. 48. Ibid., p. 152. 49. Ibid., p. 23. 50. Zhou Chao Fan 2000 Li Dai Zhong Yi Zhi Ze Jing Hua [Essential Chinese Medicine Treatment Principles in Successive Dynasties]. Chinese Herbal Medicine Publishing House, Beijing, p. 456. 51. Laurence DR 1973 Clinical Pharmacology. Churchill Livingstone, Edinburgh, p. 14.29. 52. Ibid., p. 14.30.

CHAPTER 16

PATTERNS IN MENTALEMOTIONAL PROBLEMS AND THEIR TREATMENT WITH HERBAL MEDICINE AND ACUPUNCTURE THE EFFECT OF MENTAL-EMOTIONAL PROBLEMS ON QI, BLOOD, YIN AND PATHOGENIC FACTORS 442 Effects on Qi 442 Effects on Blood 443 Effects on Yin 444 Pathogenic factors in mental-emotional problems 445 MIND OBSTRUCTED, UNSETTLED, WEAKENED 447 Mind Obstructed 447 Mind Unsettled 448 Mind Weakened 448 Herbal treatment methods for Mind Obstructed, Unsettled or Weakened 449 Treatment principles 449 MIND OBSTRUCTED 450 Qi stagnation 451 Blood stasis 455 Phlegm misting the Mind

Blood stasis • Heart-Blood stasis • Liver-Blood stasis • Stasis of Blood in the Lower Burner Phlegm misting the Mind • Phlegm-Heat harassing the Mind MIND UNSETTLED Blood deficiency • Heart-Blood deficiency

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MIND UNSETTLED 462 Blood deficiency 462 Yin deficiency 463 Yin deficiency with Empty Heat 467 Liver-Yin deficiency with Empty Heat 469 Qi stagnation 471 Blood stasis 472 Fire 472 Phlegm-Fire 476 MIND WEAKENED 478 Qi and Blood deficiency Yang deficiency 482 Blood deficiency 484 Yin deficiency 484

MIND OBSTRUCTED Qi stagnation • Stagnation of Liver-Qi • Stagnation of Heart- and Lung-Qi

Yin deficiency • Heart-Yin deficiency • Liver-Yin deficiency • Kidney-Yin deficiency Yin deficiency with Empty Heat • Heart- and Kidney-Yin deficiency with Heart Empty Heat • Liver-Yin deficiency with Empty Heat Qi stagnation

478

Blood stasis

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Fire • Heart-Fire • Liver-Fire

THE EFFECT OF MENTAL-EMOTIONAL PROBLEMS ON QI, BLOOD, YIN AND PATHOGENIC FACTORS

Phlegm-Fire • Stomach and Heart Phlegm-Fire

The effects of the various aetiological factors in mentalemotional problems can be classified into four broad categories:

MIND WEAKENED Qi and Blood deficiency • Qi deficiency • Qi and Blood deficiency Yang deficiency • Kidney-Yang deficiency Blood deficiency Yin deficiency • Kidney-Yin deficiency • Lung- and Kidney-Yin deficiency • Kidney- and Liver-Yin deficiency • Kidney-Essence deficiency

1. 2. 3. 4.

effects on Qi effects on Blood effects on Yin generation of pathogenic factors.

Given the indissoluble link between body and mind in Chinese medicine, it should be remembered that, just as emotional problems have an effect on Qi, Blood or Yin, a disharmony of Qi, Blood or Yin (from causes other than emotional) will affect the Mind. The following discussion of conditions arising from emotional stress applies equally to mental-emotional problems deriving from a disharmony of Qi, Blood and Yin of the internal organs.

Effects on Qi PATTERNS IN MENTAL-EMOTIONAL PROBLEMS AND THEIR TREATMENT WITH HERBAL MEDICINE AND ACUPUNCTURE After discussing the treatment of specific conditions such as depression (Chapter 13) and anxiety (Chapter 14), we can now turn our attention to differentiating mentalemotional problems and their treatment according to patterns. I will discuss first the pathology of mentalemotional problems in terms of their effects on Qi, Blood, Yin and pathogenic factors. I will then classify mental-emotional patterns in the three broad categories of Mind Obstructed, Mind Unsettled and Mind Weakened. The discussion will be conducted according to the following topics. • The effect of mental-emotional problems on Qi, Blood, Yin and pathogenic factors • Mind Obstructed, Unsettled, Weakened — Mind Obstructed — Mind Unsettled — Mind Weakened

The Mind and Spirit are a form of Qi in its subtlest state. Therefore the very first effect of emotional causative factors is to upset the movement and transformation of Qi. As we have seen, each emotion has a certain effect on Qi by raising it, depleting it, knotting it, scattering it or making it descend. Hence, injury to the Mind or Spirit by emotions causes either Qi-deficiency or rebellious Qi. Rebellious Qi, it will be remembered, indicates a counterflow movement of Qi, i.e. Qi rising when it should descend (as in the case of Stomach-Qi) or Qi descending when it should rise (as in the case of Spleen-Qi). Ultimately, however, both deficient and rebellious Qi may lead to stagnation of Qi. This happens because, especially in emotional problems, deficient or rebellious Qi impairs the proper circulation and movement of Qi, leading to stagnation. Stagnation of Qi from emotional problems affects various organs but the Liver, Heart and Lungs most of all.

Liver-Qi stagnation This is the most common effect of emotional stress on the Liver. It derives from anger, resentment, frustration, worry and guilt. Anger causes Liver-Qi stagnation, especially if it is held in and not manifested.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

The main manifestations of Liver-Qi stagnation are distension of the hypochondrium, epigastrium or abdomen, belching, sighing, nausea, depression, moodiness, feeling wound up, a feeling of a lump in the throat, premenstrual tension, irritability with distension of the breasts and a Wiry pulse. From an emotional perspective, the most characteristic and common signs are mental depression, alternation of moods, irritability, “snapping” easily and an intense feeling of frustration. Liver-Qi stagnation affects the movement of the Ethereal Soul (Hun), restraining its “coming and going”; this causes a lack of movement of the Ethereal Soul towards the Mind (Shen), with the resulting lack of ideas, plans, inspiration, creativity, life dreams, etc. In short, this leads to some mental depression.

Heart- and Lung-Qi stagnation Heart- and Lung-Qi stagnation derives either from worry, which knots Qi, or from sadness and grief, which deplete Qi and lead to Qi-stagnation in the chest after some time. Heart- and Lung-Qi stagnation is characterized by a feeling of distension and tightness in the chest, palpitations, sighing, slight breathlessness, a feeling of a lump in the throat with difficulty in swallowing, a weak voice, a pale complexion and a pulse that may be slightly Overflowing or Tight in both Heart and Lung positions and is without wave. From an emotional point of view, a person will feel very sad and depressed and will tend to weep. This state is due to the constriction of the Corporeal Soul by the stagnation of Qi. The person will also be very sensitive to outside psychic influences. The effects of emotional causative factors are confined to Qi only in the early stages. After some time, disruption in the movement and transformation of Qi necessarily leads to the formation of pathogenic factors such as Dampness, Phlegm, stasis of Blood, Fire or Wind, all of which further affect and disturb the Mind and Spirit (see Fig. 14.3).

Effects on Blood The effects of emotional problems on Blood are more important than those on Qi, for Blood provides the material foundation for the Mind and Spirit. Blood, which is Yin, houses and anchors the Mind and Spirit, which are Yang in nature. It embraces the Mind and

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Spirit providing the harbour within which they can flourish. In particular, Heart-Blood houses the Mind (Shen) and Liver-Blood the Ethereal Soul (Hun). The Simple Questions in Chapter 26 says: “Blood is the Mind of a person.”1 The Spiritual Axis says in Chapter 32: “When Blood is harmonized, the Mind has a residence.”2 Blood is also closely related to Mind and Spirit because of its relation with the Heart and Liver. The Heart, which houses the Mind, also governs Blood, and the Liver, which houses the Ethereal Soul, also stores Blood. Any emotional stress that affects the Heart or Liver would influence Heart-Blood or Liver-Blood and therefore the Mind or Ethereal Soul. The Blood can be affected by emotional problems in three ways: it can become deficient, stagnant or hot.

Blood deficiency Blood deficiency is one of the most common consequences of emotional problems. Its manifestations will vary according to whether the Heart or Liver is more affected.

Heart-Blood deficiency If the Heart is affected (as it is by sadness and grief), there will be palpitations, mild anxiety, insomnia (inability to fall asleep), poor memory, mild dizziness, a propensity to be startled, a dull-pale complexion, a Pale-Thin tongue and a Choppy pulse. From a mental-emotional point of view, such a person may feel depressed, anxious and tired, and the Mind may be confused and lack concentration. This is due to a weakness of the Mind, it being deprived of its residence and therefore failing to direct all the mental activities.

Liver-Blood deficiency If Liver-Blood is affected, there will be mild dizziness, numbness of the limbs, insomnia (inability to fall asleep), blurred vision, floaters in eyes, scanty menstruation or amenorrhoea, a dull-pale complexion, muscle cramps, brittle nails, a Pale-Thin tongue and a Choppy pulse. From a mental-emotional viewpoint, the person may feel anxious and tired and not sleep well. This is due to the Ethereal Soul not being rooted in Liver-Blood and therefore leading to anxiety and insomnia. Both the above conditions of Blood deficiency are very much more frequent in women, who are more prone to Blood disorders.

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Blood stasis Blood stasis also affects the Mind, albeit in a different way. Blood stasis may agitate the Mind and Spirit, causing anxiety and insomnia; Blood stasis also obstructs the Mind, and it may lead to some loss of insight causing mental confusion.

Heart-Blood stasis If Blood stasis affects the Heart, it will cause chest pain, a feeling of tightness in the chest, anxiety, insomnia, cold hands, cyanosis of lips and nails, a Purple tongue and a Knotted or Choppy pulse. From a mental-emotional point of view, this person will feel very anxious with an acute sense of anxiety in the chest, and even up to the throat. The person will be restless and prone to be easily startled. This condition is due to stagnant Blood agitating and confusing the Mind. In severe cases, if the Mind is obstructed the person may lose insight and become psychotic. The postnatal psychosis occurring when there is Blood stasis after childbirth is an example of such a condition.

This person will be extremely anxious and agitated and in some cases may be very impulsive and restless. All these symptoms and signs are due to Blood-Heat agitating the Mind.

Liver-Blood Heat If Blood-Heat affects the Liver, there will be irritability, propensity to outbursts of anger, thirst, a bitter taste, dizziness, tinnitus, insomnia, dream-disturbed sleep, headache, red face and eyes, dark urine, dry stools, a Red tongue that is redder on the sides and a RapidWiry pulse. The person will be very angry and tend to shout at other people. He or she may also be violent and hit people, and may also feel angry and frustrated about his or her life and may tend to be impulsive. All this is due to Blood-Heat disturbing the Ethereal Soul and over-accentuating its essential character of movement towards the outer world and relations with other people.

Liver-Blood stasis

Effects on Yin

If Liver-Blood is stagnant, there may be vomiting of blood or epistaxis, painful periods with dark and clotted blood, irregular periods, abdominal pain, a feeling of a mass in the abdomen, insomnia, a tongue that is Purple on the sides and a Wiry pulse. From a mental-emotional point of view, the person will be very anxious, restless and confused about his or her aims in life. He or she will also be very irritable and prone to outbursts of anger. This condition is due to the Ethereal Soul being agitated and confused by the stasis of Blood. In severe cases, this may also lead to psychosis.

Blood is part of Yin, and the effects of emotional stress on Yin are similar to those on Blood. Affection of Yin may, however, be considered as a deeper level of problem than affliction of Blood. Yin, like Blood, is the residence and anchor of the Mind and Spirit. Emotional problems can affect the Yin of different organs, especially the Heart, Liver, Kidneys, Lungs and Spleen. The effect depends on whether Yin deficiency gives rise to Empty Heat or not. If there is Yin deficiency only, without Empty Heat, the Mind and Spirit become weakened and the person feels depressed, tired and dispirited, the Mind is confused and the memory and concentration poor. If Yin deficiency gives rise to Empty Heat, this unsettles the Mind and Spirit, causing anxiety, insomnia and mental restlessness.

Blood-Heat Blood-Heat is the third possible effect of emotional problems affecting Blood; Blood-Heat affects the Mind and Spirit by agitating and harassing them. BloodHeat also mostly affects the Heart or Liver.

Heart-Blood Heat If Blood-Heat affects the Heart, there will be palpitations, insomnia (inability to stay asleep), anxiety, mental restlessness, thirst, tongue ulcers, a feeling of heat, a red face, dark urine, possibly blood in the urine, a bitter taste, a Red tongue and a Rapid and Overflowing pulse.

Heart-Yin deficiency with Empty Heat Heart-Yin is readily affected by emotional stress, because it is the residence of the Mind. Heart-Yin deficiency deprives the Mind of residence, and there will be palpitations, insomnia (inability to stay asleep), propensity to be startled, poor memory, anxiety, mental restlessness, a malar flush, night sweating, a dry mouth, five-palm heat, a Red tongue (with redder tip) without coating and a Rapid-Thin or Floating-Empty pulse.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

The person will feel very anxious, particularly in the evening, with a vague and fidgety sense of anxiety, uneasy without knowing why. “Mental restlessness” is a loose translation of a typical Chinese expression (xin fan), which always refers to this pattern and literally means “heart feels vexed”. The person will also feel dispirited, depressed and tired. Memory and concentration will be poor. The sleep will be disturbed and, typically, the person wakes up frequently during the night. All this is due to the Mind being deprived of its residence. If the Empty Heat is pronounced, the effects on the Mind will be more pronounced; the patient will feel extremely restless and anxious. On a mental level, the patient may become aggressive and very impatient.

Liver-Yin deficiency with Empty Heat Liver-Yin is the residence of the Ethereal Soul, and when emotional stress depletes Liver-Yin it may cause anxiety, insomnia and mental restlessness. On a physical level, this may cause poor memory, dizziness, dry eyes, skin and hair, scanty periods, insomnia, fivepalm heat, night sweating, a red tongue without coating and a Floating-Empty pulse. On a mental-emotional level, the patient may suffer from anxiety, insomnia with many dreams and mental restlessness. He or she may also have a floating sensation immediately before falling asleep. Both a deficiency of Liver-Yin and the resulting Empty Heat affect the Ethereal Soul. A deficiency of Liver-Yin will render the Ethereal Soul rootless, resulting in anxiety and insomnia. The Empty Heat, on the other hand, will agitate the Ethereal Soul and, if the Heat is pronounced, this may even cause slight manic behaviour.

Lung-Yin deficiency with Empty Heat Lung-Yin is the residence of the Corporeal Soul (Po). Emotional problems that affect Lung-Yin will cause tiredness, a dry cough, slight breathlessness, night sweating, five-palm heat, a dry throat, a Red tongue without coating and a Floating-Empty pulse. On a mental-emotional level, the patient may be anxious and worried. He or she will tend to weep a lot and will feel very dispirited and lonely.

Spleen-Yin deficiency with Empty Heat Spleen-Yin is the residence of the Intellect (Yi), and Spleen-Yin deficiency may cause a dry mouth with no desire to drink, dry lips, dry stools, poor appetite, a slight abdominal pain, a tongue without coating in the centre and a Floating-Empty pulse in the Right-Middle position. From a mental-emotional point of view, these people will suffer from poor memory and concentration and will find it very difficult to apply themselves to study. The imbalance may also work in the opposite way and may lead to anxiety, over-thinking and obsessive ideas.

Pathogenic factors in mentalemotional problems The effects of emotional stress on the body’s vital substances are summarized in Table 16.1, which shows the effects of emotional stress on the vital substances under the column headed “Effect”. These conditions themselves with time become a cause of further

Table 16.1 The effect of emotional stress on vital substances

Kidney-Yin deficiency with Empty Heat Kidney-Yin is the residence of Will-Power and memory. Emotional stress that affects Kidney-Yin will cause great exhaustion, a lack of will-power and drive, depression, anxiety and a decrease in mental capacities and memory. On a physical level, it will cause dizziness, tinnitus, night sweating, five-palm heat, backache, a Red tongue without coating and a Floating-Empty pulse. The Empty Heat from Kidney-Yin deficiency will affect the Mind, causing insomnia and pronounced anxiety.

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Vital substance

Effect

Consequence

Qi

Deficiency Stagnation

Phlegm Blood stasis

Blood

Deficiency Heat Stasis

– Phlegm-Heat –

Yin

Deficiency

Empty Heat Internal Wind

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disharmony, and the effects are in the column headed “Consequence”. For example, Blood-Heat may easily lead to the formation of Phlegm-Heat because Heat condenses the body fluids into Phlegm. Qi deficiency of the Spleen, Lungs or Kidneys easily leads to the formation of Phlegm as Qi fails to transform, move and excrete fluids, which therefore accumulate into Phlegm. Qi stagnation easily leads to Blood stasis, and Yin deficiency may lead to Empty Heat or internal Wind. All these pathogenic factors, Phlegm, Phlegm-Heat, Empty Heat and internal Wind, further disturb the Mind. We shall now discuss their effects and symptomatology. Blood stasis has already been discussed above.

Phlegm Phlegm obstructs the Mind (the Heart’s orifices) and may cause dullness of thought, a fuzzy head, a confused mind and dizziness. In the mental-emotional field, Phlegm obstructing the Mind causes a certain loss of insight that, in extreme degrees, gives rise to serious mental illnesses such as psychosis, schizophrenia or bipolar disorder. However, it is important to note that there are many different degrees of obstruction of the Mind by Phlegm. In mild degrees, obstruction of the Mind by Phlegm will manifest with mental confusion, a slight “manic” behaviour if there is also Heat, and irrational behaviour. Phlegm obstructs the Mind and thinking, but it does not agitate the Mind (unless it is combined with Heat). Thus the person will not be restless but, on the contrary, tired, subdued, depressed and quiet. Phlegm shows with a Swollen tongue body, a sticky coating and a Slippery pulse. In particular, I relate the swelling of the tongue body more to Phlegm than Dampness.

Fire or Heat Fire or Heat agitates the Mind and Spirit. Fire and Heat are the same in nature, but there are some differences between the two. Fire is a more “solid” pathogenic factor and more intense than Heat. It differs from Heat in the following respects. • It is more intense (pronounced feeling of heat, Deep-Red tongue, Rapid pulse).

• It dries up fluids more (thirst, scanty urine, dry stools). • It affects the Mind more (pronounced anxiety, insomnia). • It easily causes bleeding. • It is located in deeper energetic layers. Therefore, Fire affects and agitates the Mind more than Heat. In treatment, Heat is cleared with pungent-cold herbs; Fire is drained with bitter-cold herbs. In terms of mental-emotional symptoms, Fire or Heat will cause anxiety, insomnia and agitation.

Phlegm-Fire In Phlegm-Fire, Phlegm obstructs the Mind and Fire agitates it. Phlegm-Fire therefore makes the person agitated, restless and anxious. In some cases, the person may alternate between periods of depression and confusion (due to Phlegm) and periods of abnormal elation, agitation and manic behaviour (due to Fire). In severe cases, this leads to bipolar disorder. Chinese books always describe this condition as alternation of periods of severe depression (the depressive phase called Dian) and periods of manic behaviour (the manic phase called Kuang). The manic phase is usually described as shouting, scolding or hitting people, climbing mountains, taking off clothes, crying or laughing uncontrollably. It is important to realize that, in practice, much milder versions of this condition appear fairly frequently, and one should not always expect such violent symptomatology in order to diagnose this condition. Phlegm-Fire manifests with a Slippery and Rapid pulse and a Red-Swollen tongue with a sticky yellow coating and a Heart crack in the midline.

Empty Heat Empty Heat agitates the Mind and causes severe anxiety, insomnia, agitation, mental restlessness and fidgetiness. This is sometimes called the rising of Minister Fire, i.e. Empty Fire arising from the Kidneys and disturbing the Pericardium and the Mind. It is frequently caused by excess joy, craving, anger, worry, guilt, jealousy and excessive love (in the sense outlined before). Empty Heat may agitate the Heart (and therefore the Mind), the Liver (and therefore the Ethereal Soul) and the Kidneys (which also affects the Mind). We should not make the mistake of thinking that Empty Heat is

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

not “real” Heat: it is “real” Heat that heats the body and affects the Mind as much as Full Heat does. Indeed, in the mental-emotional sphere, the effect of Empty Heat may be even more pronounced than that of Heat, because the Yin deficiency (from which Empty Heat derives) deprives the Mind and the Ethereal Soul of their residence. This agitates the Mind and the Ethereal Soul even more. Empty Heat manifests with a Floating-Empty or FineRapid pulse and a Red tongue without coating, possibly with a Heart crack in the midline and a redder tip.

Internal Wind Internal Wind agitates the Mind in a similar way as Liver-Yang rising does and causes nervous tics and tremors.

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MIND OBSTRUCTED, UNSETTLED, WEAKENED The mental-emotional effects of emotions and other pathogenic factors may be summarized in three broad types. 1. Mind Obstructed: characterized by confused thinking, irrational behaviour, clouding of the Mind and, in severe cases, complete loss of insight resulting in mental illness. 2. Mind Unsettled: characterized by insomnia, agitation, mental restlessness and anxiety. 3. Mind Weakened: characterized by depression, melancholy, mental exhaustion and physical tiredness.

Mind Obstructed SUMMARY EFFECTS OF MENTAL-EMOTIONAL PROBLEMS Effects on Qi  Liver-Qi stagnation  Heart- and Lung-Qi stagnation Effects on Blood  Blood deficiency — Heart-Blood deficiency — Liver-Blood deficiency  Blood stasis — Heart-Blood stasis — Liver-Blood stasis  Blood-Heat — Heart-Blood Heat — Liver-Blood Heat Effects on Yin  Heart-Yin deficiency with Empty Heat  Liver-Yin deficiency with Empty Heat  Kidney-Yin deficiency with Empty Heat  Lung-Yin deficiency with Empty Heat  Spleen-Yin deficiency with Empty Heat Pathogenic factors in mental-emotional problems  Phlegm  Fire or Heat  Phlegm-Fire  Empty Heat  Internal Wind

When the Mind is obstructed, there is a certain loss of insight, resulting in confused thinking, irrational thinking and behaviour and, if there is also Heat, manic behaviour. In extreme cases, obstruction of the Mind leads to the psychosis seen in bipolar disorder or schizophrenia. However, it is important to realize that obstruction of the Mind occurs in a wide variety of degrees and having the Mind obstructed does not by any means mean mental illness in every case (Fig. 16.1).

MIND TOTALLY OBSTRUCTED (Mental illness)

MIND TOTALLY CLEAR (Normality) Figure 16.1 Degrees of obstruction of the Mind.

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Severe Qi stagnation

XU

MIND OBSTRUCTED

Blood stasis

Phlegm

XU/SHI

SHI

Figure 16.2 Patterns in Mind Obstructed.

Blood and/or Yin deficiency

Yin deficiency with Empty Heat

Pathogenic factors (Qi stagnation, Blood stasis, Heat, Fire)

Fail to house Shen and Hun

Yin Xu fails to house Shen/Hun Empty Heat agitates Shen/Hun

MIND UNSETTLED

Pathogenic factors agitate Shen/Hun

Figure 16.4 Patterns in Mind Unsettled.

The Mind is obstructed by Phlegm or by Blood stasis. In mild cases, it may be obstructed by severe stagnation of Qi (Fig. 16.2). The aetiology of Mind Obstructed is illustrated in Figure 16.3.

Mind Unsettled If the Mind is unsettled, there is no loss of insight as there is when the Mind is obstructed, but the person suffers from insomnia, anxiety and worry. A good example of the difference between Mind Obstructed and Mind Unsettled can be seen in anxiety and panic attacks. Anxiety and panic attacks are a clear sign of Mind Unsettled; however, if the person has very severe panic attacks to the point of having an irrational fear of dying, then we can say that the Mind is slightly obstructed. The Mind is unsettled by deficiency of Blood or Yin (mild cases), Qi stagnation, Blood stasis, Fire, Empty Heat, Phlegm-Fire and internal Wind (Fig. 16.4).

Mind Weakened The Mind is weakened by a deficiency of Qi (intended here in a general sense and to include deficiency of Qi, Yang, Blood or Yin); the patient becomes physically

and mentally tired, depressed, dispirited and lacking initiative and motivation. Of course, there can be combinations of these three conditions. For example, a deficiency of Yin may lead to Mind Weakened, causing tiredness and depression, and Empty Heat may lead to Mind Unsettled (insomnia and anxiety). A combination of Mind Obstructed and Unsettled is also common as when, for example, Blood stasis affects the Mind, causing some loss of insight (obstruction) and anxiety. The Mind may also be Obstructed and Weakened at the same time, and anorexia is an example of this. In fact, in anorexia the Mind is obviously Weakened, resulting in physical tiredness and depression; however, the Spleen deficiency may lead to Phlegm, which may obstruct the Mind so that the person’s mind is obfuscated. Indeed, persons suffering from severe anorexia may look at themselves in the mirror and genuinely see themselves as fat. This is a good example of mental hallucination that indicates obstruction of the Mind.

Case history A 51-year-old man sought treatment for atopic asthma and eczema. For 10 years from the age of

Confuse spirit Emotional stress

Obfuscate Mind’s orifices

Disharmony of Yin-Yang Phlegm

Brain Qi and Zang Fu Qi not connected Figure 16.3 Aetiology of Mind Obstructed.

MIND OBSTRUCTED

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

32, he drank a lot of alcohol and used amfetamines regularly and heavily. His eyes were dull and lacked lustre, and he complained of poor memory and concentration. When spoken to, he always looked like he was slightly absent and he found it difficult to find words. His tongue was Swollen and had a Stomach-Heart crack with a sticky-yellow coating (Plate 16.1), and his pulse was slightly Slippery. This is given here as an example of a mild case of obstruction of the Mind, in his case by Phlegm.

Herbal treatment methods for Mind Obstructed, Unsettled or Weakened The principle of treatment for mental-emotional problems follows the above classification closely and must be based, as usual, on a clear distinction between Deficiency and Excess and between the Root and the Manifestation. Such distinction is very important to choose the correct herbal formula. When selecting a herbal formula in mental-emotional problems, I always keep in mind the distinction between Mind Obstructed, Mind Unsettled and Mind Weakened. I do this because I attach great importance to the taste of the herbs (and therefore the predominant taste of the prescription). Although a formula contains several herbs with different tastes, I still expect the resulting decoction to have a predominant taste according to the desired effect. The taste I aim for depends on my classification of mental-emotional problems in the three broad categories of Mind Obstructed, Mind Unsettled and Mind Weakened. In Mind Obstructed, I aim for the decoction (or powdered formula) to have a predominantly pungent and also fragrant taste. The pungent and fragrant taste moves Qi and opens the Mind’s orifices. It is therefore absolutely essential for the prescription to have that taste predominantly. In Mind Unsettled, one needs to make Qi descend with herbs that have a sinking movement (as many minerals do). If there is Heat, the bitter taste also has a descending movement. Of course, Mind Unsettled may also derive from a deficiency of Blood and/or Yin, and therefore one needs herbs that are sweet. In Mind Weakened, one needs to tonify Qi, Blood or Yin, and one must rely primarily on the sweet taste

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(sweet and warm in case of Qi and Yang deficiency, and sweet and cold in case of Yin deficiency).

Treatment principles In more detail, the main principles of treatment in mental-emotional problems are five. 1. Nourish the Heart and calm the Mind: this is applicable to Deficiency conditions, i.e. Qi, Blood or Yin deficiency causing Mind Weakened or Mind Unsettled. 2. Clear pathogenic factors and calm the Mind: this is applicable to Excess conditions such as stagnation of Qi or Blood, Phlegm-Fire and Fire, causing Mind Obstructed or Mind Unsettled. 3. Clear pathogenic factors, nourish the Heart and calm the Mind: this is applicable to deficiency of Yin leading to Empty Heat, causing Mind Unsettled and/or Mind Weakened. 4. Resolve Phlegm, open the orifices and calm the Mind: this is applicable to Phlegm or Phlegm-Fire causing Mind Obstructed. 5. Sink and calm the Mind: this consists of the use of heavy minerals to sink rising Qi and is used as an addition to other methods of treatment to treat the Manifestation when the Mind is very unsettled; please note that the use of minerals in herbal prescriptions is not allowed in Europe. It should be noted that “calm the Mind” in the context of herbal treatment methods is an expression that recurs, as a method of treatment, in all cases of mental-emotional problems. It should be interpreted broadly to include not only the strict sense of calming the Mind (as in anxiety) but also the broader sense of lifting mood (as in depression). The various pathologies and relevant methods of treatment may be summarized in tabular form (Table 16.2). The action of some of the most frequently used points in mental-emotional problems are shown in Appendix 5. We can now discuss the acupuncture and herbal treatment for each of the patterns discussed above. The mental-emotional pattern for each of the syndromes will be mentioned after the relevant herbal prescription; those who use only acupuncture are invited to read them, as they obviously apply whether one uses acupuncture or herbs. Figure 16.5 clarifies

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Table 16.2 Mind pathologies and methods of treatment Affliction of Mind

Pathology

Method of treatment

Obstructed

Stagnation of Qi Stasis of Blood Phlegm

Move Qi, calm the Mind Invigorate Blood, calm the Mind Resolve Phlegm, open the orifices, calm the Mind

Unsettled

Blood-Yin Deficiency Yin deficiency with Empty-Heat Qi stagnation Blood stasis Fire Phlegm-Fire

Nourish Blood or Yin, nourish the Heart and calm the Mind Nourish Yin, clear Empty-Heat and calm the Mind Move Qi and calm the Mind Invigorate Blood and calm the Mind Drain Fire and calm the Mind Drain Fire, resolve Phlegm, open the orifices and calm the Mind

Weakened

Qi deficiency Yang deficiency Blood deficiency Yin deficiency

Tonify Qi, calm and clear the Mind Tonify Yang, calm and clear the Mind Nourish Blood and calm the Mind Nourish Yin and calm the Mind

PATTERN (e.g. Liver-Qi stagnation)

Treatment principle

Acupuncture

Herbal treatment

Prescription 1

Prescription 2

Mental-emotional pattern

Mental-emotional pattern

Figure 16.5 Structure of patterns’ treatment discussion.

how the discussion of the treatment for each pattern is structured.

MIND OBSTRUCTED The Mind may be obstructed or “misted” by stagnation of Qi, stasis of Blood or Phlegm. It may also be obstructed by Heat during an acute febrile disease,

such as in the pattern “Heat in Pericardium” at the Nutritive Qi level, but this is a special case that does not concern us here. Obstruction of the Mind causes mental confusion, because the obstructing factor impairs the Mind’s activity of thinking, memory, insight, conceptualization, application and understanding. Thus the person will suffer from mental confusion, poor memory, dizziness, poor concentration, inability to find the right words and slow thinking. In severe cases, there may be a complete loss of insight, causing mental illness. On an emotional level, when the Mind is obstructed there is a certain loss of insight and the person will feel mentally confused and behave somewhat irrationally. Obstruction of the Mind can occur in many different degrees, ranging from very mild and manifesting with a slight mental confusion to very severe, in which case there may be complete loss of insight in conditions such as manic depression, psychosis or schizophrenia. Of course, there is a difference of degree in obstruction of the Mind by stagnation of Qi, stasis of Blood, or Phlegm, stagnation of Qi being the mildest and Phlegm the most severe. The treatment principle in obstruction of the Mind is to eliminate the pathogenic factors, open the Mind’s orifices and calm the Mind. As indicated above, a herbal formula should have a predominantly pungent and fragrant taste. Herbs to open the orifices in mental-emotional problems include:

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

• • • • • •

Shi Chang Pu Rhizoma Acori tatarinowii Yu Jin Tuber Curcumae Yuan Zhi Radix Polygalae He Huan Pi Cortex Albiziae Su He Xiang Styrax Hu Po Succinum.

Acupuncture points that open the Mind’s orifices include P-5 Jianshi, Du-20 Baihui, Du-26 Renzhong, ST-40 Fenglong, ST-25 Tianshu, all the Well points, G.B.-18 Chengling, Du-19 Houding and G.B.-13 Benshen.

Qi stagnation Stagnation of Liver-Qi Treatment principle Move Qi, pacify the Liver, settle the Ethereal Soul and calm the Mind.

Acupuncture Points LIV-3 Taichong, L.I.-4 Hegu, LIV-14 Qimen, P-6 Neiguan, T.B.-6 Zhigou, Du-24 Shenting, G.B.-13 Benshen. Reducing or even method. Explanation • LIV-3 is the main point to simultaneously move Liver-Qi and calm the Mind. In combination with L.I.-4 (the “Four Gates”), it has a very powerful calming effect on the Mind. • LIV-14, Front-Collecting point of the Liver, moves Liver-Qi. • P-6, indirectly connected to the Liver via the Terminal Yin channels, moves Liver-Qi and calms the Mind. • T.B.-6 moves Liver-Qi. • Du-24 and G.B.-13 powerfully calm the Mind in Liver patterns. Special formula ST-30 Qichong, KI-14 Siman, KI13 Qixue, LIV-3 Taichong, P-6 Neiguan, BL-15 Xinshu, BL-18 Ganshu, SP-6 Sanyinjiao. Explanation This formula is used for Liver-Qi stagnating in the lower abdomen and Qi of the Penetrating Vessel (Chong Mai) rebelling upwards to disturb the Heart. This condition arises from shock or prolonged worry and pensiveness, which cause stagnation of Qi. Combined with other causes of disease (such as, for

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example, excessive lifting, loss of blood in childbirth or declining Blood and Yin during the menopause), this may cause stagnation of Liver-Qi and rebellious Qi in the Penetrating Vessel. The Liver channel courses through the lower abdomen, the stomach, diaphragm, lungs and throat; the Kidney channel goes through the liver, diaphragm, lungs and throat. Thus they both go up to the throat, where they may cause a feeling of constriction of the throat. They both also go to the chest where, with stagnation of Qi, they may cause a feeling of oppression and tightness of the chest. In the chest, they affect the Heart and Lungs and therefore Mind and Corporeal Soul, giving rise to anxiety, palpitations and unhappiness. The Spiritual Axis in Chapter 65 says: “The Penetrating and Directing Vessels originate from the uterus, go up through the spine and form the Sea of channels ... from the abdomen, they go up to the throat.”3 The Simple Questions in Chapter 60 says: “The Penetrating Vessel rises through ST-30 Qichong, follows the Kidney channel to the umbilicus and chest, where it scatters.”4 Thus, rebellious Qi in the Penetrating Vessel affects the Heart, causing anxiety, palpitations and mental confusion. • ST-30 is an important point of the Penetrating Vessel, which emerges at this point, coming from the perineum. The point name means “rushing Qi” or “penetrating Qi”, and the chong in its name refers to the Chong Mai, i.e. the Penetrating Vessel. This vessel is also related to the Bright Yang, and the connection takes place through this point. ST-30 is therefore used to subdue rebellious Qi in the Penetrating Vessel affecting not only the lower abdomen but also the whole length of this vessel. • KI-14 also subdues rebellious Qi in the Penetrating Vessel when this affects the lower abdomen. The name of this point means “four fullnesses”, which may refer to a feeling of fullness of the lower abdomen radiating in all four directions; this feeling of fullness derives from stagnation of Qi in the Penetrating Vessel. Another meaning of its name is that the point treats four fullnesses deriving from stagnation of Qi, Blood, food and Dampness. • KI-13 is another point along the Penetrating Vessel, and it also regulates its Qi by strengthening its root in the lower abdomen. • LIV-3 subdues rebellious Qi in the Liver channel and settles the Ethereal Soul.

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• P-6 also subdues rebellious Qi in the Liver channel, relaxes the chest, calms the Mind, settles the Ethereal Soul and relieves unhappiness. • BL-15 and BL-18 regulate Qi of the Heart and Liver channel, move Qi, calm the Mind and settle the Ethereal Soul. • SP-6 helps to subdue rebellious Qi by strengthening the root, i.e. Liver and Kidneys.

Herbal therapy Prescription YUE JU WAN Gardenia-Chuanxiong Pill Explanation This formula is primarily for Liver-Qi stagnation, although it also treats stasis of Blood, Retention of Food, stagnation of Phlegm and Dampness and Knotted Heat. For this reason, it is called the “formula for the six stagnations”. It is, however, extremely effective in moving Qi, pacifying the Liver and calming the Mind. It is especially effective in opening the Mind’s orifices and lifting mental depression deriving from stagnation of Liver-Qi. Mental-emotional pattern This formula addresses the emotional and mental manifestations of stagnation of Liver-Qi when it causes the Mind to be obstructed: moodiness, mental depression, severe premenstrual tension, irritability, frustration, irrational behaviour, annoyance and impatience. On a physical level, there would be a feeling of distension, sighing, belching, tiredness, hypochondrial pain, a feeling of tightness in the chest, irregular periods, clumsiness, breast distension and a Wiry pulse (which may be Wiry only on the left side). In most cases, the tongue may not change, while in severe cases it may be slightly red on the sides. The three most important signs for the use of this formula are tiredness, depression and a Wiry pulse. Modifications • For the Mind obstruction of this condition, add Shi Chang Pu Rhizoma Acori tatarinowii to open the Mind’s orifices and Yu Jin Tuber Curcumae to open orifices and move Qi. Yu Jin, in particular, is extremely effective for mental depression, because its strongly moving nature provides the necessary “push” to unblock the set patterns established by chronic depression.

• If there is pronounced stagnation of Qi, increase the dosage of Xiang Fu and, if necessary, add Mu Xiang Radix Aucklandiae and Fo Shou Fructus Citri sarcodactylis. • If there is pronounced depression, add He Huan Pi Cortex Albiziae. • If Dampness is pronounced, increase the dosage of Cang Zhu and, if necessary, add Fu Ling Poria, Ze Xie Rhizoma Alismatis and Hou Po Cortex Magnoliae officinalis. • If stasis of Blood is pronounced, increase the dosage of Chuan Xiong and, if necessary, add Hong Hua Flos Carthami tinctorii and Tao Ren Semen Armeniacae. • If Fire is pronounced, increase the dosage of Zhi Zi and, if necessary, add Huang Lian Rhizoma Coptidis. • If Phlegm is pronounced, add Ban Xia Rhizoma Pinelliae preparatum. • If Retention of Food is pronounced, increase the dosage of Shen Qu and, if necessary, add Mai Ya Fructus Hordei germinatus, Shan Zha Fructus Crataegi and Sha Ren Fructus Amomi. • If there is emotional confusion, add Shi Chang Pu Rhizoma Acori tatarinowii. Three Treasures remedy Release Constraint Release Constraint moves LiverQi and stimulates the coming and going of the Ethereal Soul when the person is depressed.

SUMMARY MIND OBSTRUCTED – QI STAGNATION, STAGNATION OF LIVER-QI Treatment principle Move Qi, pacify the Liver, settle the Ethereal Soul and calm the Mind. Points LIV-3 Taichong, L.I.-4 Hegu, LIV-14 Qimen, P-6 Neiguan, T.B.-6 Zhigou, Du-24 Shenting, G.B.-13 Benshen. Reducing or even method. Herbal therapy Prescription YUE JU WAN Gardenia-Chuanxiong Pill Three Treasures remedy Release Constraint

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

Case history A 38-year-old woman sought treatment for primary infertility. She had been trying to conceive for 2 years. The gynaecologist had diagnosed endometriosis and adhesions in the fallopian tubes, for which she had had laser treatment. Her periods were quite normal and regular, except for being rather scanty (lasting 3 days). She suffered from very pronounced abdominal distension and fullness. She had panic attacks and experienced a feeling of oppression of the chest and palpitations. During such attacks, she also had a suffocating feeling in the throat. Her eyes had an unstable look, as if she were scared. Her tongue had a Red tip and sides, but apart from that it was quite normal. Her pulse was Slippery, Short and Moving (the Moving pulse is short, shaped like a bean and vibrating). During the consultation, on asking her about any shocks she might have had, she said she had been raped when she was 22. Diagnosis This is a condition of stagnation of Qi in the Liver channel and the Penetrating Vessel, affecting the Heart. Shock affects the Heart but also the Kidneys; in women, this often causes stagnation of Qi in the Penetrating Vessel and the Liver channel. Rebellious Qi in the lower abdomen rises upwards to harass the Heart and the Mind, causing, in her case, palpitations, a feeling of oppression in the chest and anxiety. The stagnation of Qi in the Penetrating Vessel in the lower abdomen caused the feeling of fullness and distension there. Her eyes and her pulse clearly showed the strong possibility of shock in the past, and this was the reason for me asking her about this. The tongue also showed stagnation in the Liver and Heart. In this case, therefore, infertility was not due to a deficiency but to stagnation of Qi in the Penetrating and Directing Vessels preventing conception. Treatment She was treated with both acupuncture and herbs. The acupuncture treatment was quite infrequent, as she lived over 100 miles away. Whenever I saw her, I used the special formula indicated above, more or less unchanged, i.e. ST-30 Qichong, KI-14 Siman, KI-13 Qixue, LIV-3 Taichong, P-6 Neiguan, BL-15 Xinshu, BL-18 Ganshu and SP-6 Sanyinjiao. This formula was explained above under Stagnation of Liver-Qi.

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The herbal decoction used was a variation of two formulae together: Yue Ju Wan Gardenia-Chuanxiong Pill and An Shen Ding Zhi Wan Calming the Mind and Settling the Spirit Pill. • • • • • • • • • • • • • •

Xiang Fu Rhizoma Cyperi 9 g Shan Zhi Zi Fructus Gardeniae 4 g Chuan Xiong Radix Chuanxiong 4 g Shen Qu Massa Fermentata Medicinalis 4 g Cang Zhu Rhizoma Atractylodis 4 g Dang Shen Radix Codonopsis 6 g Fu Shen Sclerotium Poriae cocos pararadicis 6 g Yuan Zhi Radix Polygalae 6 g Shi Chang Pu Rhizoma Acori tatarinowii 4 g Dang Gui Radix Angelicae sinensis 6 g Chen Xiang Lignum Aquilariae 4 g Suan Zao Ren Semen Ziziphi spinosae 4 g Bai Zi Ren Semen Platycladi 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g

Explanation • The first five herbs constitute the Yue Ju Wan Gardenia-Chuanxiong Pill, which pacifies the Liver and eliminates stagnation. The emphasis is on Xiang Fu (hence with a higher dose) to eliminate stagnation and subdue rebellious Qi in the Penetrating Vessel. • The next four herbs make the An Shen Ding Zhi Wan Calming the Mind and Settling the Spirit Pill (without Long Chi Fossilia Dentis Mastodi), which tonifies the Heart and calms the Mind, especially after shock. • Dang Gui was added to nourish and root the Penetrating Vessel in the lower abdomen; this will help to root it and subdue rebellious Qi. • Chen Xiang was added to subdue rebellious Qi in the Penetrating Vessel, a function also attributed to it by Li Shi Zhen in his book on the Extraordinary Vessels.5 • Suan Zao Ren and Bai Zi Ren were added to settle the Ethereal Soul and calm the Mind. After 6 months of this treatment she conceived, but unfortunately she miscarried in the second month. She restarted the treatment and again she became pregnant after 6 months. This time, I prescribed a decoction to take as soon as she became pregnant to prevent miscarriage. • Tu Si Zi Semen Cuscutae 6 g • Du Zhong Cortex Eucommiae ulmoidis 6 g

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• Sha Ren Fructus Amomi 4 g • Zi Su Ye Folium Perillae 4 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g All these herbs prevent miscarriage, and this time she was able to continue her pregnancy to full term and give birth to a baby.

Stagnation of Heart- and Lung-Qi Treatment principle Move Qi, stimulate the descending of Heart- and Lung-Qi and calm the Mind, settle the Corporeal Soul.

Acupuncture Points LU-7 Lieque, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, ST-40 Fenglong, L.I.-4 Hegu, S.I.-5 Yanggu. Reducing or even method if the condition is chronic. Explanation • LU-7 stimulates the descending of Lung-Qi and calms the Corporeal Soul. It has a strong mental effect, and it relieves stagnation of Qi in the chest. According to An Explanation of Acupuncture Points (1654), this point is used when the person is sad and cries a lot.6 • HE-7 nourishes the Heart and calms the Mind. • P-6 stimulates the descending of Heart-Qi, opens the chest, relieves fullness and stagnation and calms the Mind. • Ren-15 has a powerful calming effect on the Mind. It also relieves fullness in the chest. • Ren-17 stimulates the descending of Lung-Qi and relieves fullness and stagnation in the chest. • ST-40 harmonizes the Stomach, opens the chest and calms the Mind. • L.I.-4 harmonizes the ascending and descending of Qi in the Middle Burner, relieves fullness and calms the Mind. • S.I.-5 opens the Mind’s orifices and relieves confusion. It helps the patient to see issues clearly.

Herbal therapy Prescription BAN XIA HOU PO TANG Pinellia-Magnolia Decoction Explanation This formula, from the Discussion of Cold-Induced Diseases, is normally used for the plum-

stone pattern characterized by a feeling of obstruction in the throat, mental depression and irritability. In modern times, this pattern is related to stagnation of Liver-Qi, for which this formula is used. An analysis of the formula, however, reveals that it contains no herbs that move Liver-Qi or even enter the Liver. The main emphasis of the formula is to move stagnant Heartand Lung-Qi. Stagnation of Heart- and Lung-Qi derives from sadness and grief over a long period of time. These emotions first deplete Heart-Qi and Lung-Qi and depress the Mind and Corporeal Soul. The depletion of Lung-Qi from sadness and grief leads to shallow breathing and poor circulation of Qi in the chest and, eventually, to stagnation of Lung-Qi in the chest. The simultaneous weakness and stagnation of Lung-Qi may also lead to Phlegm. The Lung channel influences the throat, and its stagnation can cause a feeling of obstruction in the throat. Other manifestations include sighing, difficulty in swallowing, slight breathlessness, tightness of the chest, nausea and vomiting. The pulse will be Weak on both Front positions on the left and right and without wave. The tongue will be Swollen if there is some Phlegm. Mental-emotional pattern Stagnation of Heartand Lung-Qi derives from long-term sadness and grief, with the resulting depletion of the Mind and Corporeal Soul. This resides in the Lungs, and it therefore affects breathing. The person becomes anxious as well as sad, sighs frequently and has the typical feeling of obstruction in the throat and chest. This is caused by the constriction of the Corporeal Soul in the throat and chest. The chronic stagnation of Heart-Qi obstructs the Mind and causes severe confusion. When this pattern causes obstruction of the Mind, the patient will feel confused and experience mental cloudiness. He or she may also suffer from severe panic attacks with fear of death. Modifications • Similarly as for stagnation of Liver-Qi, Shi Chang Pu Rhizoma Acori tatarinowii should be added to open the Mind’s orifices. • If there is a pronounced feeling of oppression of the chest from Qi stagnation (slightly Wiry pulse), add Qing Pi Pericarpium Citri reticulatae viride and Mu Xiang Radix Aucklandiae.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

• If there is vomiting, increase Ban Xia Rhizoma Pinelliae preparatum and Sheng Jiang Rhizoma Zingiberis recens. • If there is a feeling of heaviness under the heart, add Zhi Shi Fructus Aurantii immaturus. • If there is epigastric pain, add Sha Ren Fructus Amomi. • If there is sour regurgitation with a yellow tongue coating, add Huang Lian Rhizoma Coptidis. • If there is sour regurgitation with a Pale tongue, add Wu Zei Gu Os Sepiae. • If there is a bitter taste, add Huang Qin Radix Scutellariae. • If mental restlessness and irritability are pronounced, add He Huan Pi Cortex Albiziae. Associated prescription SI QI TANG Four Seasons Decoction for the Seven Emotions This consists of Ban Xia Hou Po Tang plus Da Zao Fructus Ziziphi jujubae. This formula has the same use and indications as Ban Xia Hou Po Tang, except that its effect on the Mind is even stronger. “Seven” in the name of the formula stands for the seven emotions and “Four” stands for the four seasons, indicating a condition that spans at least four seasons, i.e. a chronic condition. Three Treasures remedy Open the Heart Open the Heart moves Qi in the Lungs and Heart when their Qi stagnates in the chest and throat from emotional problems such as worry, sadness or grief.

SUMMARY MIND OBSTRUCTED – QI STAGNATION, STAGNATION OF HEART- AND LUNG-QI Treatment principle Move Qi, stimulate the descending of Heart- and Lung-Qi and calm the Mind, settle the Corporeal Soul. Points LU-7 Lieque, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, ST-40 Fenglong, L.I.-4 Hegu, S.I.-5 Yanggu. Reducing or even method if the condition is chronic.

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Herbal therapy Prescription BAN XIA HOU PO TANG Pinellia-Magnolia Decoction Associated prescription SI QI TANG Four Seasons Decoction for the Seven Emotions Three Treasures remedy Open the Heart

Blood stasis Heart-Blood stasis Treatment principle Invigorate Blood, eliminate stasis, clear the Heart, calm the Mind.

Acupuncture Points P-6 Neiguan, P-5 Jianshi, Ren-14 Juque, BL-14 Jueyinshu, BL-15 Xinshu, Ren-17 Shanzhong, HE-7 Shenmen, SP-6 Sanyinjiao, BL-17 Geshu, BL-44 Shentang, G.B.-18 Chenling. Reducing or even method if the condition is chronic. Explanation • P-6 invigorates Heart-Blood, opens the chest and calms the Mind. • P-5 opens the Mind’s orifices. • Ren-14, Front-Collecting point of the Heart, invigorates Heart-Blood and calms the Mind. • BL-14 and BL-15, Back-Transporting points of the Pericardium and Heart, respectively, invigorate Blood and calm the Mind. • Ren-17 moves Qi in the chest: moving Qi will help to invigorate Blood. • HE-7 calms the Mind. • SP-6 invigorates Blood and calms the Mind. • BL-17, Gathering point for Blood, invigorates Blood (if needled with reducing or even method). • BL-44 clears the Heart and calms the Mind. • G.B.-18 opens the Mind’s orifices.

Herbal therapy Prescription XUE FU ZHU YU TANG Blood Mansion Eliminating Stasis Decoction

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Explanation This formula is very widely used for stasis of Blood in the Upper Burner causing chest pain. The tongue is Purple and the pulse is Wiry or Choppy. Mental-emotional pattern Because Blood is the residence of the Mind, any Blood pathology can affect the Mind. Blood stasis agitates and obstructs the Mind. It agitates the Mind because Qi and Blood cannot flow smoothly, and this is reflected on the mental-emotional level with anxiety, mental restlessness and insomnia. It obstructs the Mind because the impeded flow of Blood retards the circulation of Blood to the Mind and thus obfuscates its orifices. Anger, frustration, resentment, excess joy, shock, craving and guilt can all lead to Heart-Blood stasis. This usually occurs only after a long period of time, going through the stage of Qi stagnation first. When stagnant Blood in the Heart affects the Mind, it may cause depression, anxiety, palpitations, insomnia, a suffocating sensation in the chest, irritability, mood swings and, in severe cases, manic behaviour. Sleep is very disturbed, the patient waking up frequently at night, tossing and turning and with nightmares. Modifications • Shi Chang Pu Rhizoma Acori tatrinowii and Yu Jin Tuber Curcumae should be added to open the Mind’s orifices and invigorate Blood. Three Treasures remedy Red Stirring Red Stirring invigorates Heart-Blood in the chest and calms the Mind.

SUMMARY MIND OBSTRUCTED – BLOOD STASIS, HEARTBLOOD STASIS Treatment principle Invigorate Blood, eliminate stasis, clear the Heart, calm the Mind. Points P-6 Neiguan, P-5 Jianshi, Ren-14 Juque, BL-14 Jueyinshu, BL-15 Xinshu, Ren-17 Shanzhong, HE-7 Shenmen, SP-6 Sanyinjiao, BL-17 Geshu, BL-44 Shentang, G.B.-18 Chenling. Reducing or even method if the condition is chronic.

Herbal therapy Prescription XUE FU ZHU YU TANG Blood Mansion Eliminating Stasis Decoction Three Treasures remedy Red Stirring

Liver-Blood stasis Treatment principle Invigorate Blood, pacify the Liver, calm the Mind and settle the Ethereal Soul.

Acupuncture Points LIV-3 Taichong, LIV-14 Qimen, BL-18 Ganshu, BL-17 Geshu, BL-47 Hunmen, P-6 Neiguan, P-7 Daling, SP-6 Sanyinjiao, Du-24 Shenting and G.B.-13 Benshen, G.B.-18 Chengling. Reducing or even method if the condition is chronic, except for BL-47, which should be reinforced. Explanation • LIV-3 invigorates Liver-Blood and calms the Mind and Ethereal Soul. • LIV-14 and BL-18, Front-Collecting and BackTransporting point, respectively, invigorate Liver-Blood. • BL-17 invigorates Blood. • BL-47 settles the Ethereal Soul and regulates its coming and going. • P-6 invigorates Blood, pacifies the Liver and calms the Mind. • P-7 invigorates Blood, opens the Mind orifices and calms the Mind. • SP-6 invigorates Blood and calms the Mind. • Du-24 and G.B.-13 calm the Mind in Liver patterns. • G.B.-18 opens the Mind’s orifices.

Herbal therapy Prescription YUE JU WAN Gardenia-Chuanxiong Pill Explanation This formula has already been discussed under Liver-Qi stagnation. It can be adapted to treat Liver-Blood stasis by increasing the dosage of Chuan Xiong.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

Mental-emotional pattern Anger, resentment, frustration, jealousy and hatred may all lead to LiverBlood stasis. This will cause extreme depression, severe mood swings, intense irritability, propensity to violent outbursts of anger, obsessive jealousy and, in severe cases, manic behaviour. Modifications • Yu Jin Tuber Curcumae should be added to invigorate Liver-Blood, open the Mind’s orifices and relieve depression. • In cases of severe depression, add He Huan Pi Cortex Albiziae. • In cases of violent outbursts of anger, add Suan Zao Ren Semen Ziziphi spinosae. Three Treasures remedy Stir Field of Elixir Stir Field of Elixir is a variation of Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction. It invigorates Liver-Blood.

Acupuncture Points SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, Ren-6 Qihai, ST-29 Guilai, BL-18 Ganshu, BL-17 Geshu, SP-1 Yinbai, Du-18 Qiangjian. Reducing method. Explanation • SP-10 invigorates Blood in the uterus. • SP-6 invigorates Blood and calms the Mind. • SP-4 and P-6 in combination regulate the Penetrating Vessel and invigorate Blood. • Ren-6 moves Qi in order to invigorate Blood. • ST-29 invigorates Blood in the uterus. • BL-18 and BL-17 in combination invigorate Blood. • SP-1 invigorates Blood in the uterus and calms the Mind. • Du-18 opens the Mind orifices, calms the Mind and regulates Liver-Blood. It is a strong head point for mental restlessness, manic behaviour and agitation.

SUMMARY

Herbal therapy

MIND OBSTRUCTED – BLOOD STASIS, LIVERBLOOD STASIS

Prescription TAO HE CHENG QI TANG Persica Conducting Qi Decoction

Treatment principle Invigorate Blood, pacify the Liver, calm the Mind and settle the Ethereal Soul. Points LIV-3 Taichong, LIV-14 Qimen, BL-18 Ganshu, BL-17 Geshu, BL-47 Hunmen, P-6 Neiguan, P-7 Daling, SP-6 Sanyinjiao, Du-24 Shenting and G.B.-13 Benshen, G.B.-18 Chengling. Reducing or even method if the condition is chronic, except for BL-47, which should be reinforced. Herbal therapy Prescription YUE JU WAN Gardenia-Chuanxiong Pill Three Treasures remedy Stir Field of Elixir

Stasis of Blood in the Lower Burner Treatment principle Invigorate Blood, harmonize the Penetrating and Directing vessels, eliminate stasis and calm the Mind.

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Explanation This formula is for Blood stasis in the Lower Burner. It is from the Discussion of Cold-Induced Diseases, and it invigorates Blood in the Lower Burner by moving downwards with Da Huang Radix et Rhizomz Rhei and Mang Xiao Natrii Sulfas. Mental-emotional pattern This prescription is from the Discussion of Cold-Induced Diseases, and it refers to the Greater Yang-organ pattern from accumulation of Blood. This consists of accumulation of Blood in the hypogastrium following an invasion of Cold. It manifests with fever at night, delirium, severe lower abdominal pain, mental restlessness and manic behaviour. This is the original use of the formula. It can be used for mental-emotional problems deriving from (or causing) stasis of Blood in the Lower Burner. Anger, frustration, hatred, resentment and guilt may all lead to this condition over a long period of time. Guilt frequently leads to stasis of Blood in the Lower Burner, especially in women. Why do these emotions in this case lead to stasis of Blood in the Lower Burner and not somewhere else? First of all, it is obviously

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more common in women who are prone to stasis of Blood in the uterus. However, it may also be due to other concurrent causes of disease, such as excessive lifting, which leads to stagnation in the Lower Burner. A special use of this formula is for psychosis from stasis of Blood in the uterus following childbirth. Three Treasures remedy Stir Field of Elixir Stir Field of Elixir invigorates Blood in the Lower Burner.

SUMMARY MIND OBSTRUCTED – BLOOD STASIS, STASIS OF BLOOD IN THE LOWER BURNER Treatment principle Invigorate Blood, harmonize the Penetrating and Directing vessels, eliminate stasis and calm the Mind. Points SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, Ren-6 Qihai, ST-29 Guilai, BL-18 Ganshu, BL-17 Geshu, SP-1 Yinbai, Du-18 Qiangjian. Reducing method. Herbal therapy Prescription TAO HE CHENG QI TANG Persica Conducting Qi Decoction Three Treasures remedy Stir Field of Elixir

Phlegm misting the Mind Phlegm-Heat harassing the Mind Treatment principle Resolve Phlegm, open the orifices and calm the Mind.

Acupuncture Points ST-40 Fenglong, P-7 Daling, P-6 Neiguan, P-5 Jianshi, Du-14 Dazhui, BL-15 Xinshu, BL-44 Shentang, Du-20 Baihui, L.I.-4 Hegu, LU-7 Lieque, Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, L.I.-7 Wenliu, ST-25 Tianshu. Reducing or even method except for Du-14, Du-20, Ren-12, ST-36, BL-20, BL-15 and BL-44, which should be reinforced.

Explanation • ST-40 resolves Phlegm. • P-7 resolves Phlegm from the Heart and calms the Mind. • P-6 opens the Mind’s orifices. • P-5 resolves Phlegm from the Heart. • Du-14, with reducing method clears Heart-Heat. • BL-15 and BL-44 tonify the Heart and clear the Mind. • Du-20 clears the Mind. • L.I.-4 and LU-7 regulate the ascending of clear Qi and descending of turbid Qi in the head, thus clearing the Mind. • Ren-12, ST-36 and BL-20 tonify the Spleen to resolve Phlegm. • L.I.-7 opens the Mind’s orifices. The book An Explanation of Acupuncture Points (1654) says that this point is for “madness and seeing ghosts”.7 • ST-25 is an important point for mental-emotional problems from Phlegm misting the Mind. It regulates the Stomach and opens the Mind’s orifices. The book An Explanation of Acupuncture Points says that this point is used when “Ethereal Soul and Corporeal Soul have no residence.”8

Herbal therapy Prescription WEN DAN TANG Warming the Gall Bladder Decoction Explanation This interesting formula (dating from 1174) has two main interpretations. Originally, it was used for a Gall Bladder deficiency following a severe acute disease, the Gall Bladder deficiency manifesting with timidity, jumpiness, insomnia (waking up early in the morning) and mental restlessness. From this point of view, its action was exactly that described by its name, i.e. “Warming the Gall Bladder”: it tonifies the Gall Bladder and stimulates the physiological rise of Liver-Qi. In more recent times, it is more frequently used for Phlegm-Heat affecting Stomach, Heart or Lungs. The main manifestations for which it is used in this context are mental restlessness, jumpiness, insomnia, a bitter and sticky taste, a flustered feeling in the heart region, mental confusion, irritability, manic behaviour, nausea, vomiting, palpitations, dizziness, a Swollen tongue with a sticky-yellow coating and a Wiry or Slippery pulse.

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Two characteristic pulse and tongue configurations strongly indicate the use of this formula. One is a tongue that is Swollen and has a combination of Heart and Stomach crack with a rough, brush-like yellow coating inside the Stomach crack. A combined Heart and Stomach crack extends all the way to the tip, as a Heart crack would do, but it is wide and shallow in the centre, as a Stomach crack would be (see Fig. 16.6). The other sign is a pulse that is Big, Slippery and Wiry on both Middle positions of left and right.

previous two cases. He or she will feel very confused mentally, exhausted and depressed. The obstruction of the Mind by Phlegm, combined with the deficient Heart and Kidneys not nourishing the Mind, will make this person very forgetful and disorientated.

Mental-emotional pattern Phlegm-Heat disturbs the Mind in two ways: Phlegm obstructs the Mind’s orifices and Heat agitates the Mind. The combination of these two factors will cause mental restlessness, slightly “manic” behaviour, mental confusion, irrational behaviour, talking a lot, laughing a lot, staying up late at night to work and insomnia. In severe cases, this corresponds to bipolar disorder or schizophrenia.

Settling the Soul Settling the Soul resolves PhlegmHeat from the Liver, calms and Mind and settles the Ethereal Soul. It restrains the coming and going of the Ethereal Soul. It is suitable for emotional problems deriving from repressed anger, worry and guilt.

Prescription GUI SHEN TANG Restoring the Mind Decoction Explanation This formula combines opening the Mind’s orifices and resolving Phlegm with tonifying the Spleen, Heart and Kidneys. It is therefore suitable in chronic conditions when Phlegm mists the Mind on a background of Qi and Yang deficiency. Mental-emotional pattern From a mental-emotional viewpoint, the patient will be calmer than in the

Three Treasures remedies Clear the Soul Clear the Soul resolves Phlegm-Heat from the Lungs and Heart. It is suitable for emotional problems deriving from worry, sadness and grief.

SUMMARY MIND OBSTRUCTED – PHLEGM MISTING THE MIND, PHLEGM-HEAT HARASSING THE MIND Treatment principle Resolve Phlegm, open the orifices and calm the Mind. Points ST-40 Fenglong, P-7 Daling, P-6 Neiguan, P-5 Jianshi, Du-14 Dazhui, BL-15 Xinshu, BL-44 Shentang, Du-20 Baihui, L.I.-4 Hegu, LU-7 Lieque, Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, L.I.-7 Wenliu, ST-25 Tianshu. Reducing or even method except for Du-14, Du-20, Ren-12, ST-36, BL-20, BL-15 and BL-44, which should be reinforced. Herbal therapy Prescription WEN DAN TANG Warming the Gall Bladder Decoction Prescription GUI SHEN TANG Restoring the Mind Decoction Three Treasures remedies Clear the Soul Settling the Soul

Figure 16.6 Combined Stomach and Heart crack.

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Case history A 39-year-old man had been suffering from what was labelled as “phobic anxiety” for 8 years. His history was quite complex, and many factors contributed to his problem, so rather than starting from his presenting symptoms it might be better to describe his history from the beginning. His childhood had been very troubled, most of all because his mother was very unloving towards him and she constantly reproached him. At the age of 28, he worked in Belfast at the time of a very tense political and military situation that caused a great deal of anxiety to him. He suffered a shock when he found a bomb under his car. When he was 30, he had a car accident and had concussion. Nine months after that, he contracted an extremely severe case of influenza that was nearly fatal. He was in bed for a month with a constant temperature. A few months after that, he collapsed crying hysterically, was unable to speak, could not move and could not bear to look at a light. His GP thought he had a brain haemorrhage, but this was not the case. After that collapse, he continued to be extremely anxious, lost all confidence in himself, lacked self-esteem, felt extremely insecure and was prone to bouts of crying. At this time, he started seeing a psychotherapist and then a psychiatrist who prescribed tranquillizers (diazepam and temazepam) and antidepressants of the monoamine oxidase inhibitor kind. He started having acupuncture with a colleague, who referred him to me for herbal treatment. His main symptoms when he came to me were epigastric pain, alternation of constipation and diarrhoea, ache in the joints, burning eyes and a hot feeling at the back of the head. On a mental level, his main manifestations were severe anxiety, insomnia, bouts of crying, poor memory and concentration, depression and a lack of confidence and self-esteem. His eyes lacked glitter and looked scared, his body was overweight and his complexion was very dull and sallow. His tongue was dark-Red, Swollen, with a Heart crack, without coating and dry. The tip of the tongue was redder and the root had no spirit (Plate 16.2). His pulse, however, was slightly Rapid, quite Full and Slippery.

Diagnosis This is an extremely complex condition. As far as patterns are concerned, there are basically two main patterns: severe Yin deficiency of the Heart and Kidneys (Red-peeled tongue with red tip and root without spirit, mental restlessness, anxiety, insomnia, burning eyes, a hot feeling on the occiput, lack of confidence and self-esteem) and Phlegm-Heat misting the Mind (crying without reason, poor memory and concentration). There are a few other patterns, but these can be considered secondary. For example, there is Stomach-Yin deficiency causing the epigastric pain, Damp Heat causing the joint pain, some stagnation of Liver-Qi causing the alternation of constipation and diarrhoea, and some Spleen deficiency causing him to be overweight and generally tired. It is this underlying Spleen deficiency that, over the years, led to the formation of Phlegm, later transformed into Phlegm-Heat. If there is Phlegm, why does the tongue not have a thick-sticky coating? This is because there is an underlying severe deficiency of Yin, which caused the coating to fall off. Thus, although not shown on the tongue body colour, Phlegm does manifest in the swelling of tongue body (which in such a severe case of Yin deficiency should have been Thin) and in the symptoms and the pulse, which is Full and Slippery. The Yin deficiency obviously derived from the time of his severe influenza. A constant temperature for a month burned the body fluids and injured Yin. The deficiency of Yin over the years led to the formation of Empty Heat, which harasses the Mind. On the other hand, the deficiency of Yin itself deprives the Mind and Ethereal Soul of their root and causes lack of confidence and self-esteem. Phlegm-Heat, conversely, obstructs the Mind and causes the bouts of crying. Obviously, all this is affected by his childhood experiences, which formed the basis for the development of his condition later on in life especially, causing his lack of confidence and self-esteem, having never received love from his mother. Other aetiological factors also played a role. The concussion suffered following the car accident could have affected his brain and therefore contributed to his illness. Thus we can summarize his causes of disease in three stages (Fig. 16.7). Treatment principle Treatment was focused on the two main patterns of Yin deficiency and PhlegmHeat; the treatment principles were to nourish Heart-

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

0

Age (years) 18

Troubled childhood (lack of love)

3031

Car accident (concussion) Influenza (Yin deficiency)

Figure 16.7 Causes of disease in a patient diagnosed with “phobic anxiety”.

and Kidney-Yin, clear Empty Heat, open the Mind’s orifices, calm the Mind, root the Ethereal Soul and Corporeal Soul and strengthen Will-Power. Herbal therapy This patient was treated for 4 years and is still under treatment, therefore the formula used was obviously modified very many times. The formula used most frequently was a variation of three prescriptions. 1. Wen Dan Tang Warming the Gall Bladder Decoction 2. Tian Wang Bu Xin Dan Heavenly Emperor’s Tonifying the Heart Pill 3. Gan Mai Da Zao Tang Glycyrrhiza-TriticumZiziphus Decoction An example of a formula used is as follows. • • • • • • • • • • • • • • • • • •

Zhu Ru Caulis Bambusae in Taeniam 6 g Zhi Shi Fructus Aurantii immaturus 4 g Ban Xia Rhizoma Pinelliae preparatum 6 g Fu Ling Poria 6 g Chen Pi Pericarpium Citri reticulatae 3 g Sheng Di Huang Radix Rehmanniae glutinosae 9g Mai Men Dong Radix Ophiopogonis 6 g Xuan Shen Radix Scrophulariae 4 g Ren Shen Radix Ginseng 6 g Bai Zi Ren Semen Platycladi 6 g Suan Zao Ren Semen Ziziphi spinosae 6 g Wu Wei Zi Fructus Schisandrae 4 g Yuan Zhi Radix Polygalae 9 g Shi Chang Pu Rhizoma Acori tatarinowii 4 g Yu Jin Tuber Curcumae 4 g Fu Xiao Mai Fructus Tritici levis 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 9 g Da Zao Fructus Jujubae 10 dates

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Explanation This is a variation of the three formulae listed above. • Shi Chang Pu and Yu Jin to open the Mind’s orifices are the main additions. These two herbs were not used every time, as they are pungent and therefore injure Yin. Modifications Modifications used at different times according to the patient’s condition were as follows. • Du Zhong Cortex Eucommiae ulmoidis to strengthen the Kidneys, the Will-Power and the patient’s sense of self-confidence and self-esteem. Although this herb tonifies Kidney-Yang, it can be added to the prescription in combination with the many herbs that nourish Yin. • He Huan Pi Cortex Albizziae to open the Mind’s orifices and lift depression. • Bai He Bulbus Lilii to nourish Lung-Yin and relieve sadness and crying. • Ju Hua Flos Chrysanthemi to relieve burning eyes. • Ye Jiao Teng Caulis Polygoni multiflori to promote sleep. • Mu Xiang Radix Aucklandiae to move Qi to help resolve Phlegm. • Tai Zi Shen Radix Pseudostellariae and Shan Yao Rhizoma Dioscoreae to nourish Stomach-Yin. Recently, this patient had a consultation with Professor Zhou Zhong Ying, one of my teachers from Nanjing, and he confirmed the diagnosis of PhlegmHeat misting the Mind and Yin deficiency. He suggested a prescription that incorporates the formula Bai He Zhi Mu Tang Lilium-Anemarrhena Decoction from the Essential Prescriptions from the Golden Chest.9 A mental condition similar to this patient’s was described in this old classic and was called “Lilium syndrome”. The book says:10 Symptoms and signs [of the Lilium syndrome] include the patient wants to eat but he cannot swallow and cannot speak. He wants to lie in bed yet he cannot lie quietly, as he is restless. He wants to walk but soon becomes tired. Sometimes he likes eating; at other times he cannot tolerate the smell of food. He feels sometimes hot and sometimes cold but without fever or chill. He has a bitter taste and the urine is dark. The patient looks as if he was possessed and his pulse is rapid.

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The treatment suggested for this condition is a decoction of Bai He Bulbus Lilii and Zhi Mu Radix Anemarrhenae asphodeloidis. Thus the formula suggested by Professor Zhou was as follows. • Huang Lian Rhizoma Coptidis 4 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Dan Nan Xing Rhizoma Arisaematis preparatum 4g • Fu Ling Poria 9 g • Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g • Chen Pi Pericarpium Citri reticulatae 4 g • Zhu Ru Caulis Bambusae in Taeniam 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Mai Men Dong Radix Ophiopogonis 9 g • Zhi Mu Radix Anemarrhenae 9 g • Bai He Bulbus Lilii 9 g • Mu Li Concha Ostreae 15 g Explanation • The first seven herbs are a variation of Wen Dan Tang Warming the Gall Bladder Decoction, eliminating Zhi Shi Fructus Aurantii immaturus and adding Huang Lian and Nan Xing to resolve PhlegmHeat. • Dan Shen enters the Heart and calms the Mind. • Mai Dong nourishes Heart-Yin. • Zhi Mu nourishes Yin and clears Empty Heat. • Bai He nourishes Yin and relieves sadness and crying. • Mu Li nourishes Yin. After 4 years of treatment, this patient has improved considerably, although there is still a way to go. On a physical level, he has lost all his symptoms and his tongue is considerably less Red and now has a thin coating. On a mental level, his memory and concentration have improved and his self-confidence and self-esteem are much better. He is less anxious and is off all medication.

MIND UNSETTLED The Mind (Shen), Ethereal Soul (Hun) and Corporeal Soul (Po) may be unsettled either because of a deficiency of Blood-Yin or because of the presence of a pathogenic factor that disturbs the Mind. Such patho-

genic factors may be stagnation of Qi, stasis of Blood, Fire, Phlegm-Fire or Empty Heat. The manifestations will be similar in both cases, except that they will be milder if they are due purely to a deficiency without a pathogenic factor. The main manifestations of unsettled Mind are anxiety, mental restlessness, insomnia and agitation. In case of unsettled Ethereal Soul, there will be in addition, nightmares, irritability and absent-mindedness. In cases of unsettled Corporeal Soul, there will be anxiety with breathlessness and a feeling of tightness of the chest, worrying a lot and some somatization of the emotions on the skin (such as itchy rashes). The treatment principle for an unsettled Mind is to nourish Blood or Yin, eliminate pathogenic factors and calm the Mind.

Blood deficiency Heart-Blood deficiency Treatment principle Tonify the Heart, nourish Blood and calm the Mind.

Acupuncture Points BL-15 Xinshu, BL-44 Shentang, Ren-14 Juque, HE-7 Shenmen, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, P-6 Neiguan and SP-4 Gongsun. Reinforcing method; moxa may be applied. Explanation • BL-15, Back-Transporting point of the Heart, tonifies the Heart. It can be used with direct moxa cones only. • BL-44 tonifies the Heart and calms the Mind. • Ren-14, Front-Collecting point of the Heart, and HE-7 calm the Mind. • Ren-4 nourishes Blood and calms the Mind. • ST-36 nourishes Blood. • SP-6 nourishes Blood and calms the Mind. It is effective for insomnia from Blood deficiency. • P-6 and SP-4 open the Yin Linking Vessel (Yin Wei Mai), which nourishes Blood and calms the Mind.

Herbal therapy Prescription YANG XIN TANG Nourishing the Heart Decoction

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

Explanation This formula is specific to treat any mental and emotional effect of Heart-Blood deficiency, such as insomnia (difficulty in falling asleep), palpitations, mild anxiety and poor memory. Other manifestations would include a dull-pale complexion, a Pale-Thin tongue and a Choppy pulse. Mental-emotional pattern Fear, sadness, grief and worry may weaken Heart-Blood and cause this condition. This person would be pale with a dull complexion, the eyes would look anxious and rather dull, and he or she would be fearful, mildly anxious and vaguely depressed. In this case, the manifestations of an unsettled Mind (anxiety and agitation) would be rather mild, as there is only deficiency of Blood with no Empty Heat. He or she would also be very eager to please other people and members of his or her family. Because of women’s propensity for Blood deficiency, this condition is much more common in women. In fact, it may also arise from loss of Blood in childbirth. The loss of Blood from the Directing and Penetrating vessels during childbirth may affect the Heart, also due to its connection with the uterus via the Uterus-Vessel (Bao-Mai). When Heart-Blood is weakened, the Mind is deprived of its residence and becomes fearful and anxious. Modifications • If there is severe insomnia, add Long Yan Rou Arillus Euphoriae longanae, which nourishes HeartBlood and calms the Mind. Three Treasures remedy Calm the Shen Calm the Shen nourishes Heart-Blood and calms the Mind. It is suitable for depression, anxiety and insomnia. It is a variation of Gui Pi Tang.

SUMMARY MIND UNSETTLED – BLOOD DEFICIENCY, HEART-BLOOD DEFICIENCY Treatment principle Tonify the Heart, nourish Blood and calm the Mind. Points BL-15 Xinshu, BL-44 Shentang, Ren-14 Juque, HE-7 Shenmen, Ren-4 Guanyuan, ST-36 Zusanli,

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SP-6 Sanyinjiao, P-6 Neiguan and SP-4 Gongsun. Reinforcing method; moxa may be applied. Herbal therapy Prescription YANG XIN TANG Nourishing the Heart Decoction Three Treasures remedy Calm the Shen

Yin deficiency Heart-Yin deficiency Treatment principle Tonify the Heart, nourish Yin and calm the Mind.

Acupuncture Points BL-15 Xinshu, BL-44 Shentang, Ren-14 Juque, HE-7 Shenmen, HE-6 Yinxi, Ren-15 Jiuwei, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao. Reinforcing method, no moxa. Explanation • BL-15, Back-Transporting point of the Heart, tonifies the Heart. • BL-44 tonifies the Heart and calms the Mind. • Ren-14, Front-Collecting point of the Heart, and HE-7 calm the Mind. • HE-6 nourishes Heart-Yin. • Ren-15 calms the Mind and relieves anxiety. • Ren-4 nourishes Yin and calms the Mind. It nourishes Kidney-Yin, which is often at the basis of Heart-Yin deficiency. • ST-36 nourishes Stomach-Yin. • SP-6 nourishes Yin and calms the Mind.

Herbal therapy Prescription BAI ZI YANG XIN WAN Platycladum Nourishing the Heart Pill Explanation This formula is similar to the previous one, as it also nourishes Heart-Blood; it differs from it in so far as it nourishes Heart-Yin. The configuration of symptoms and signs would therefore be different, as

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there would be more Yin-deficiency manifestations: insomnia (waking up at night frequently), a feeling of heat in the evening, a dry mouth and throat, night sweating, more pronounced anxiety and mental restlessness, a malar flush, palpitations, a Red tongue without coating with a redder tip and a FloatingEmpty pulse. Mental-emotional pattern Fear, sadness, grief and worry, combined with overwork over many years, may lead to Heart-Yin deficiency. Yin deficiency is a deeper level of deficiency than Blood deficiency; when it affects the Heart, the Mind is deprived of its residence. This makes the person fearful, very anxious and restless. These symptoms would be more severe than in HeartBlood deficiency. Another difference is that they would be more pronounced in the evening. Please note that Yin deficiency makes the Mind unsettled even without Empty Heat. A person suffering from this condition would tend to be depressed and dispirited, lacking will-power and drive, and the body would probably be thin.

SUMMARY MIND UNSETTLED – YIN DEFICIENCY, HEARTYIN DEFICIENCY Treatment principle Tonify the Heart, nourish Yin and calm the Mind. Points BL-15 Xinshu, BL-44 Shentang, Ren-14 Juque, HE-7 Shenmen, HE-6 Yinxi, Ren-15 Jiuwei, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao. Reinforcing method, no moxa. Herbal therapy Prescription BAI ZI YANG XIN WAN Platycladum Nourishing the Heart Pill

Case history A 28-year-old man complained of nervousness with shaking of the hands. He said he felt nearly always very nervous, especially at work, and found the shaking of his hands very distressing. He also complained of dryness of the mouth, sweating, short-

ness of breath and insomnia (waking up during the night). He also lacked confidence and felt insecure, worried and anxious most of the time. His tongue was unremarkable, being only slightly Swollen. His pulse was Moving; this is a pulse that is Rapid, Short, shaped like a bean and giving the impression of vibrating rather than pulsating. Diagnosis This man’s symptoms fall somewhat outside the scope of regular patterns. Some of the symptoms seem to point to Yin deficiency (waking up at night and feeling hot), but they are not severe enough to warrant such a diagnosis and the tongue does not show any Yin deficiency. There are, on the other hand, some signs of Qi deficiency (sweating, shortness of breath). This is a problem caused by fear and worry over many years; fear affected the Heart, and the Mind and worry affected the Lungs and Corporeal Soul. Affliction of the Mind caused the insomnia, and affliction of the Corporeal Soul caused the breathlessness, sweating and shaking of the hands. When asked about his childhood, he said that it was quite troubled and insecure due to his father’s open preference for his sister. His father constantly praised his sister for being quite brilliant at school and blamed him for not being up to his sister’s standards. The unyielding censure by his father over several years of childhood development instilled a deep feeling of insecurity in him that led to fear and worry. Treatment principle Tonify Qi and Yin of Lungs and Heart, nourish and calm the Mind and settle the Corporeal Soul. Acupuncture The following points were reinforced. • HE-7 Shenmen, SP-6 Sanyinjiao, BL-15 Xinshu, BL-44 Shentang and Ren-15 Jiuwei nourish the Heart and calm the Mind. • LU-9 Taiyuan, BL-13 Feishu and BL-42 Pohu tonify the Lungs and settle the Corporeal Soul. After 6 months of weekly treatments, all his symptoms disappeared and his hands stopped shaking. In conjunction with counselling, which I recommended, he explored the behavioural patterns developed in his childhood and gained much self-confidence and selfassurance.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

Liver-Yin deficiency Treatment principle Tonify the Liver, nourish Yin, calm the Mind and settle the Ethereal Soul.

Acupuncture Points LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, Du-24 Shenting, G.B.-13 Benshen, BL-18 Ganshu, BL-47 Hunmen. Reinforcing method, no moxa. Explanation • LIV-8 nourishes Liver-Yin. • SP-6 nourishes Yin and strengthens Liver, Spleen and Kidneys. • KI-3 and Ren-4 nourish Kidney-Yin. As this is the mother of Liver-Yin, it will indirectly nourish Liver-Yin. Ren-4 has also a strong grounding effect, and it calms the Mind and settles the Ethereal Soul. • Du-24 and G.B.-13 calm the Mind, especially in Liver disharmonies. • BL-18 and BL-47 root the Ethereal Soul.

Herbal therapy Prescription HUANG LIAN E JIAO TANG Coptis-Colla Corii Asini Decoction Explanation This prescription therefore nourishes Liver-Yin, clears any Empty Heat that there might be, calms the Mind and settles the Ethereal Soul. The main manifestations would be a feeling of heat in the evening, poor memory, insomnia (waking up at night), a dry throat, dry hair, a Red tongue without coating and a Floating-Empty pulse. Please note that this formula contains E Jiao, which is illegal in Europe. It can be replaced in this formula by Dang Gui Radix Angelicae sinensis. Mental-emotional pattern Anger, frustration and resentment combined with overwork and/or excessive sexual activity over many years may lead to this condition. In women, a contributory factor is excessive loss of blood at childbirth or a prolonged, excessive loss of blood if the periods are heavy. Liver-Yin deficiency deprives the Ethereal Soul of its residence, and it necessarily affects the Mind as well because Liver-Yin is the mother of Heart-Yin. Those

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suffering from this condition will feel depressed, lack a sense of direction in life and be mentally restless. Their sleep will be broken, and they may wake up frequently during the night. They may also have restless dreams due to the wandering of the unrooted Ethereal Soul at night. The formula Suan Zao Ren Tang Ziziphus Decoction may also be used for this pattern (see below under Liver-Yin Deficiency with Empty Heat). Prescription ZHEN ZHU MU WAN Concha margaritiferae Pill Explanation This formula sinks Liver-Yang, calms the Mind and settles the Ethereal Soul. Please note that Zhu Sha is a toxic substance and should therefore be removed from the formula. The use of Zhen Zhu Mu and Long Chi is not allowed in Europe. This formula, originally for the pattern of LiverWind at the Blood level of the Four Levels, nourishes Liver-Yin, subdues Liver-Yang, calms the Mind and settles the Ethereal Soul. It has a similar action to the previous one, but it differs in so far as the emphasis is on subduing Liver-Yang and calming the Mind, whereas in the previous one the emphasis was more on nourishing Yin and clearing Heat. The main manifestations leading to the use of this prescription are dizziness, tinnitus, headache, insomnia, propensity to outbursts of anger, poor memory, dry hair and eyes, numbness of the limbs, a tongue with red sides and a Wiry-Fine pulse. Mental-emotional pattern Anger, frustration, resentment and hatred can cause this condition. In particular, anger will cause Liver-Yang or Liver-Wind to rise, for which condition this prescription is indicated. This person would therefore be very angry and be prone to outbursts of anger. His or her sleep would be very restless and filled with unpleasant dreams. Prescription YIN MEI TANG Attracting Sleep Decoction Explanation This formula restores Liver-Blood and Liver-Yin to allow the Ethereal Soul to settle and the person to sleep peacefully. When Liver-Yin is deficient, the Ethereal Soul has no residence and there is

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insomnia. This formula makes the Ethereal Soul peaceful so that it does not wander. It tonifies Liverand Heart-Yin, calms the Mind and settles the Ethereal Soul. The tongue presentation appropriate to this formula is a Red body without coating. The original text says that this formula makes the Ethereal Soul peaceful so that it cannot “jump over”. Mental-emotional pattern Frustration, resentment, old grudges and sometimes sadness can cause LiverYin to become deficient. This person’s Liver-Yin would have been consumed by repressed anger over many years; he or she would feel very tense, anxious and sleep very badly with the sleep being disturbed by unpleasant dreams. The pulse would be Fine but also slightly Wiry on the left side. In some cases, sadness depletes Liver-Yin; in this case, the person would feel very depressed and sad and sleep badly but without too many dreams. The pulse would be Choppy or Fine. Three Treasures remedy Searching Soul Searching Soul nourishes Liver-Blood and Liver-Qi, calms the Mind and settles the Ethereal Soul.

Prescription YIN MEI TANG Attracting Sleep Decoction Three Treasures remedy Searching Soul

Kidney-Yin deficiency Treatment principle Tonify the Kidneys, nourish Yin, calm the Mind and strengthen the Will-Power.

Acupuncture Points KI-3 Taixi, KI-6 Zhaohai, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, HE-6 Yinxi, Ren-15 Jiuwei. Reinforcing method except for HE-6, which is either reduced or needled with even method according to how chronic the condition is. Explanation • KI-3 and KI-6 nourish Kidney-Yin. • Ren-4 nourishes Kidney-Yin and calms the Mind. • BL-23 strengthens the Kidneys. • BL-52 strengthens the Will-Power. • HE-6 clears Heart Empty Heat. • Ren-15 calms the Mind.

SUMMARY

Herbal therapy

MIND UNSETTLED – YIN DEFICIENCY, LIVERYIN DEFICIENCY

Prescription GUI ZHI GAN CAO LONG GU MU LI TANG Cinnamomum-Glycyrrhiza-Os Draconis-Ostrea Decoction

Treatment principle Tonify the Liver, nourish Yin, calm the Mind and settle the Ethereal Soul. Points LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, Du-24 Shenting, G.B.-13 Benshen, BL-18 Ganshu, BL-47 Hunmen. Reinforcing method, no moxa. Herbal therapy Prescription HUANG LIAN E JIAO TANG Coptis-Colla Corii Asini Decoction Prescription ZHEN ZHU MU WAN Concha margaritiferae Pill

Explanation This formula warms and tonifies the Heart, calms the Mind, nourishes Kidney-Yin and strengthens Will-Power. Long Gu and Mu Li also help timidity. Being astringent, on a physical level they stop sweating, while on a mental level they “absorb” the Mind and the Ethereal Soul into the Yin. The main manifestations are palpitations, mental restlessness, propensity to be startled, sweating, cold limbs and a Pale tongue. Although it contains Mu Li, which primarily strengthens Kidney-Yin, this formula can be adapted to treat both Kidney-Yin and Kidney-Yang deficiency. In fact, its primary aim is to strengthen Heart-Yang with Gui Zhi and Zhi Gan Cao (hence the Pale tongue) and calm the Mind with the sinking substances Long Gu and Mu Li.

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Please note that the use of minerals in herbal prescriptions is not allowed in the European Union countries at the time of writing (2006). It is not possible to give substitutes for Long Gu and Mu Li in this particular formula because they are such an integral part of it.

SUMMARY

Mental-emotional pattern This formula is suitable, with adaptations, to treat the mental restlessness deriving from Kidney-Yin deficiency and Heart deficiency. Fear, guilt and shock, perhaps combined with overwork and/or excessive sexual activity, may lead to this condition, which guilt is especially liable to cause. This emotion, when suffered for a long time, weakens the Kidneys and the Will-Power, and it gnaws away at the Mind, thus depleting the Heart. Such patients are very anxious and mentally restless, and they sleep fitfully. They tend to be thin (indicating Yin deficiency), are tired, depressed and lack willpower.

Points KI-3 Taixi, KI-6 Zhaohai, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, HE-6 Yinxi, Ren-15 Jiuwei. Reinforcing method except for HE-6, which is either reduced or needled with even method according to how chronic the condition is.

Prescription ZHEN ZHONG DAN Bedside Pill Explanation This formula nourishes Kidney-Yin, clears Empty Heat, calms the Mind, opens the Mind’s orifices and harmonizes the Heart and Kidneys. This formula differs from the previous one in so far as it is slightly more directed at opening the Mind’s orifices and clearing the Heart, while the previous one tonifies the Heart. On a physical level, the manifestations corresponding to this prescription would include insomnia, anxiety, backache, night sweating, dizziness, tinnitus, poor memory, a Red tongue without coating and a FloatingEmpty pulse.

MIND UNSETTLED – YIN DEFICIENCY, KIDNEY-YIN DEFICIENCY Treatment principle Tonify the Kidneys, nourish Yin, calm the Mind and strengthen the Will-Power.

Herbal therapy Prescription GUI ZHI GAN CAO LONG GU MU LI TANG Cinnamomum-Glycyrrhiza-Os Draconis-Ostrea Decoction Prescription ZHEN ZHONG DAN Bedside Pill Three Treasures remedy Nourish the Root

Yin deficiency with Empty Heat Heart- and Kidney-Yin deficiency with Heart Empty Heat Treatment principle Nourish Heart- and KidneyYin, strengthen the Will-Power and calm the Mind.

Acupuncture

Mental-emotional pattern A person with this condition would suffer from a confused Mind and would be unable to see clearly what needs to be done. He or she would also be anxious, depressed and lack will-power, and would sleep badly and sweat at night. This condition would also be caused by fear or guilt.

Points HE-7 Shenmen, HE-6 Yinxi, P-7 Daling, Yintang, Ren-15 Jiuwei, Du-19 Houding, KI-3 Taixi, KI-6 Zhaohai, KI-10 Yingu, KI-9 Zhubin, Ren-4 Guanyuan, SP-6 Sanyinjiao. The first three with reducing or even method; Yintang, Ren-15 and Du-19 with even method, all the others with reinforcing method. No moxa.

Three Treasures remedy Nourish the Root Nourish the Root nourishes Kidney- and Liver-Yin and strengthens Will-Power (Zhi).

Explanation • HE-7, HE-6 and P-7 can all calm the Mind. In combination with KI-7 Fuliu, HE-6 also stops night sweating.

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• Yintang, Ren-15 and Du-19 calm the Mind. • KI-3, Source point, nourishes the Kidneys. • KI-6 nourishes Kidney-Yin, benefits the throat, promotes fluids and helps sleep. • KI-10 nourishes Kidney-Yin. • KI-9 tonifies the Kidneys, calms the Mind and opens the chest. • Ren-4 nourishes Kidney-Yin and roots the Mind. • SP-6 nourishes Yin, calms the Mind and promotes sleep.

Herbal therapy Prescription TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill Explanation This is the most widely-used formula to nourish Heart- and Kidney-Yin (also called “harmonizing Heart and Kidneys”), clear Empty Heat and calm the Mind. The main manifestations are night sweating, backache, dizziness, tinnitus, a malar flush, feeling of heat in the evening, palpitations, insomnia, restless sleep, dry mouth and throat, poor memory, dry stools, a Red tongue without coating with a redder tip and a Rapid-Fine pulse. Such a condition is common in menopause, so it can be used with modifications; also, if there is some Kidney-Yang deficiency in addition to Kidney-Yin deficiency, modify with the addition of a small dose (1.5 g) of Rou Gui Cortex Cinnamomi. Mental-emotional pattern Fear, guilt and shock can all cause this condition. Because there is a deficiency of Kidney-Yin, there usually are concurrent causes of disease, such as overwork, irregular diet and excessive sexual activity. It is also a common pattern appearing in menopausal problems. This person would be very anxious, especially in the evening, and he or she would sleep very badly, waking up several times. There might be dreams of fires or flying. He or she would be unable to relax and there would be palpitations. Prescription LIU WEI DI HUANG WAN Variation Six-Ingredient Rehmannia Pill Variation Explanation This formula is used for mental restlessness and insomnia from Yin deficiency and Empty Heat, especially in the elderly. It is specific to restore the

connection between Heart-Fire and Kidney-Water: the Heart-fluids rely on the nourishment of the KidneyEssence. Thus one needs to nourish Kidney-Water in order to subdue Heart Empty Heat. Mental-emotional pattern This is almost the same as for the previous formula, except that the emphasis is on Yin deficiency with the consequent depression and lack of will-power, in addition to anxiety and insomnia. Also, because of its emphasis on the Liver, it is suitable for mental-emotional problems deriving from resentment and bitterness harboured for many years. Three Treasures remedy Heavenly Empress Heavenly Empress nourishes Kidney- and Heart-Yin, clears Heart Empty Heat and calms the Mind. It is a variation of Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill.

SUMMARY MIND UNSETTLED – YIN DEFICIENCY WITH EMPTY HEAT, HEART- AND KIDNEY-YIN DEFICIENCY WITH HEART EMPTY HEAT Treatment principle Nourish Heart- and Kidney-Yin, strengthen the Will-Power and calm the Mind. Points HE-7 Shenmen, HE-6 Yinxi, P-7 Daling, Yintang, Ren-15 Jiuwei, Du-19 Houding, KI-3 Taixi, KI-6 Zhaohai, KI-10 Yingu, KI-9 Zhubin, Ren-4 Guanyuan, SP-6 Sanyinjiao. The first three with reducing or even method; Yintang, Ren-15 and Du-19 with even method; all the others with reinforcing method. No moxa. Herbal therapy Prescription TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill Prescription LIU WEI DI HUANG WAN Variation Six-Ingredient Rehmannia Pill Variation Three Treasures remedy Heavenly Empress

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

Case history A 52-year-old woman sought treatment for persistent night sweating and hot flushes. She also complained of abdominal distension and water retention. Her periods had stopped the year before, and she had been worse since then. Apart from the above symptoms, she often felt anxious in the evening and experienced palpitations. Her sleep was disturbed by the hot flushes, and she felt mentally restless. She was overweight, her cheekbones were slightly red and her eyes had no glitter and looked scared. Her tongue was slightly Red, Swollen on the sides (Spleen-type of swelling), cracked and with a rootless coating; it also had a Heart crack in the middle (Plate 16.3). Her pulse was Weak on both Rear positions, the Heart position was Weak and Short and the whole pulse had no wave. She had been treated with acupuncture elsewhere (tonifying Spleen and resolving Dampness) without much result. Her acupuncturist referred her to me. Diagnosis This patient obviously has a Spleen deficiency, manifesting with being overweight, water retention and a swelling on the sides of the tongue. However, there are other factors involved. The hot flushes, red cheekbones, insomnia, mental restlessness, Red tongue with rootless coating and Weak pulse on both Kidney positions clearly indicate Kidney-Yin deficiency. Besides this, there is also a Heart deficiency, as evidenced by the palpitations and the eyes without glitter, indicating that the Mind is disturbed. When asked about it, she confirmed that she had been under tremendous strain when she lived in East Africa, having to manage a large farm for 2 years after being widowed suddenly. Thus the main causes of disease were sadness and shock (from bereavement) and fear. The sadness showed in her eyes’ lack of glitter and the fear in their scared look. Treatment principle Nourish Kidney-Yin and HeartYin, subdue Empty Heat, calm the Mind and strengthen Will-Power. Herbal therapy She was treated with herbs only. The main formula used was a variation of Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill.

• • • • • • • • • • • • • • • •

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Sheng Di Hhuang Radix Rehmanniae 12 g Mai Men Dong Radix Ophiopogonis 6 g Tian Men Dong Radix Asparagi 6 g Ren Shen Radix Ginseng 6 g Fu Ling Poria 6 g Wu Wei Zi Fructus Schisandrae 6 g Dang Gui Radix Angelicae sinensis 6 g Dan Shen Radix Salviae miltiorrhizae 6 g Bai Zi Ren Semen Platycladi 6 g Suan Zao Ren Semen Ziziphi spinosae 6 g Yuan Zhi Radix Polygalae 6 g Jie Geng Radix Platycodi 3 g Ze Xie Rhizoma Alismatis 4 g Qing Hao Herba Artemisiae annuae 3 g Qin Jiao Radix Gentianae macrophyllae 3 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g

Explanation The first 12 herbs constitute the original formula, which nourishes Kidney-Yin and Heart-Yin, clears Empty Heat and calms the Mind. Xuan Shen was eliminated from the formula, as Yin deficiency is not too pronounced yet. • Ze Xie, Qing Hao and Qin Jiao were added to clear Empty Heat and treat the hot flushes. • Gan Cao harmonizes. This formula, repeated several times, produced a dramatic improvement in her mental state from the beginning, with her feeling much more relaxed, calmer and happier. Her eyes gradually changed too, acquiring more lustre.

Liver-Yin deficiency with Empty Heat Treatment principle Nourish Liver-Yin, clear Empty Heat, calm the Mind and settle the Ethereal Soul.

Acupuncture Points LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, Du-24 Shenting, G.B.-13 Benshen, Du-18 Qiangjian, BL-18 Ganshu, BL-47 Hunmen, KI-2 Rangu and LIV-3 Taichong. Reinforcing method except for the last two points, which should be reduced. Explanation • LIV-8 nourishes Liver-Yin. • SP-6 nourishes Yin and strengthens Liver, Spleen and Kidneys.

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• KI-3 and Ren-4 nourish Kidney-Yin. As this is the mother of Liver-Yin, it will indirectly nourish LiverYin. Ren-4 also has a strong grounding effect and it calms the Mind. • Du-24 and G.B.-13 calm the Mind, especially in Liver disharmonies. • Du-18 calms the Mind and settles the Ethereal Soul. It is indicated for mental restlessness, agitation and manic behaviour. • BL-18 and BL-47 root the Ethereal Soul. • KI-2 and LIV-3 would be used only if there is Empty Heat.

Herbal therapy Prescription SUAN ZAO REN TANG Ziziphus Decoction Explanation This formula nourishes Liver-Yin, calms the Mind, settles the Ethereal Soul and clears Empty Heat. Mental-emotional pattern This formula is specific for Liver-Yin deficiency with its associated symptoms and signs, such as insomnia, waking up frequently at night, dry throat, blurred vision, dry eyes, mental restlessness, night sweating, a Red tongue without coating and a Floating-Empty pulse. This situation can arise in two ways. Emotional stress, such as anger, resentment or frustration, may lead to the rising of Minister Fire, which agitates the Heart and the Liver. Fire injures Yin so that the Ethereal Soul is deprived of its residence. Alternatively, it may start with a reverse process; overwork combined with irregular diet and excessive sexual activity (and in women, too many childbirths or chronic menorrhagia) may deplete Liver-Yin and therefore deprive the Ethereal Soul of its residence. No matter how this situation arises, the end result is a condition characterized most of all by insomnia. The person may also be depressed and lack any sense of vision in life. The mental restlessness in this condition derives from Yin deficiency and typically manifests with a vague feeling of anxiety, restlessness and fidgetiness, which is worse in the evening. The Liver is a harmonizing organ, and its harmony derives from a proper balance between its Yang (the free flow of Liver-Qi) and its Yin aspect (Blood and Yin). Mental irritation from emotional stress stirs up LiverYang and injures Liver-Yin and thus alters the balance of Yin and Yang within the Liver.

This formula is also applicable to some women’s problems such as premenstrual tension with breast distension or breast lumps from stagnation of Liver-Qi on a background of Liver-Yin deficiency. In women, Liver-Yin deficiency is even more likely to happen due to the monthly loss of menstrual blood, which depletes Liver-Blood. In these cases, stagnation of Liver-Qi, with its associated emotional consequences, is very often secondary to a deficiency of Liver-Yin. The Yin and Yang aspects of the Liver need to be harmonized and coordinated. If Liver-Yin is deficient, the Yang aspect of the Liver gets out of control, and this may lead to both stagnation of Liver-Qi and Liver-Yang rising. Thus, this formula can be used for premenstrual tension if it presents with the above configuration. Finally, although this formula is specific for Liver-Yin deficiency with Empty Heat, it can also be used for Liver-Yin deficiency without Empty Heat. It is therefore applicable also to Mind Unsettled or Mind Weakened from Yin deficiency. Modifications • If Empty Heat manifestations are severe (malar flush and feeling of heat), decrease the amount of Chuan Xiong and add Sheng Di Huang Radix Rehmanniae, Nu Zhen Zi Fructus Ligustri lucidi and Han Lian Cao Herba Ecliptae. • If night sweating is profuse, add Di Gu Pi Cortex Lycii and Wu Wei Zi Fructus Schisandrae. • If insomnia is difficult to treat, add Ye Jiao Teng Caulis Polygoni multiflori. • If the person is very depressed, add He Huan Pi Cortex Albiziae. Three Treasures remedy Nourish the Soul Nourish the Soul nourishes LiverYin, calms the Mind and settles the Ethereal Soul. It is a variation of Suan Zao Ren Tang.

SUMMARY MIND UNSETTLED – YIN DEFICIENCY WITH EMPTY HEAT, LIVER-YIN DEFICIENCY WITH EMPTY HEAT Treatment principle Nourish Liver-Yin, clear Empty Heat, calm the Mind and settle the Ethereal Soul.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

Points LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, Du-24 Shenting, G.B.-13 Benshen, Du-18 Qiangjian, BL-18 Ganshu, BL-47 Hunmen, KI-2 Rangu and LIV-3 Taichong. Reinforcing method except for the last two points, which should be reduced. Herbal therapy Prescription SUAN ZAO REN TANG Ziziphus Decoction Three Treasures remedy Nourish the Soul

Case history A 63-year-old woman sought treatment for hypertension. The systolic blood pressure, which oscillated between 200 and 150, was more of a problem than the diastolic one, which was always 95. Her main physical symptoms included a stiff neck, a feeling of pressure in the head, throbbing headaches on the vertex, dizziness, tinnitus, blurred vision, dry eyes, insomnia (waking up frequently during the night) and a feeling of heat in the evening. Her complexion was dull with red patches on both cheekbones, and her eyes were rather dull and without glitter. Her tongue was Red, redder on the sides and slightly Stiff, and the coating was too thin. Her pulse was Wiry but Fine. Diagnosis The blurred vision, dry eyes, insomnia, Fine pulse and Stiff tongue with insufficient tongue coating indicate Liver-Yin deficiency, while the feeling of heat in the evening, red cheekbones and Red tongue with insufficient coating denote Empty Heat. Because of the deficiency of Liver-Yin, there was also Liver-Yang rising, as manifested by the stiff neck, throbbing vertical headaches, dizziness, tinnitus, a feeling of pressure in the head and a Wiry pulse. Her hypertension, which was the reason for seeking treatment, was due to the rising of LiverYang. When the systolic pressure is high while the diastolic one is near to normal, it usually indicates the rising of Liver-Yang. Furthermore, when the systolic

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reading oscillates considerably from day to day; it indicates that nervous stress, rather than a hardening of the arteries, is the cause of the problem. This is usually due to emotional strain affecting the Liver. In this patient’s case, this was very obvious from the dullness of her complexion (lack of shen) and eyes, which indicate long-standing affliction of the Mind and/or Ethereal Soul by emotional strain. When asked about emotional strain, she confirmed that she had been under great stress about her daughter’s marital problems. Because of financial problems, her daughter was trapped in a marriage to a very cruel husband and suffered a great deal; this made her mother very angry towards her son-in-law and over the years caused the rising of Liver-Yang and deficiency of Liver-Yin. Treatment principle Nourish Liver-Yin, clear Empty Heat, subdue Liver-Yang, calm the Mind and root the Ethereal Soul. Acupuncture Reinforce LIV-8 Ququan, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi. Even method: LIV-3 Taichong, KI-2 Rangu, Du-24 Shenting, G.B.-13 Benshen, P-7 Daling. Explanation • LIV-8, Ren-4, SP-6 and KI-3 nourish Liver-Yin. • LIV-3 subdues Liver-Yang. • KI-2, in combination with LIV-3, clears Empty Heat from Liver-Yin deficiency. • Du-24 and G.B.-13 calm the Mind and root the Ethereal Soul. • P-7 calms the Mind and indirectly subdues Liver-Yang. Herbal therapy No herbs were prescribed but only the patent remedy Suan Zao Ren Tang Pian Tablet of Ziziphus Decoction, which fitted her symptoms quite well. After 20 weekly treatments, most of her symptoms had cleared up or decreased in intensity and she was able to react more calmly to her daughter’s plight and not to allow her anger to dominate her life.

Qi stagnation This has already been discussed under Mind Obstructed above. The manifestations of Qi stagnation when it causes the Mind to be unsettled are similar. The main

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difference is that, instead of mental confusion, the predominant manifestations will be anxiety, irritability and mental restlessness.

Herbal therapy Prescription DAO CHI SAN Eliminating Redness Powder

Treatment principle Move Qi, eliminate stagnation and calm the Mind. The same prescriptions and acupuncture points indicated for Stagnation of Qi under Mind Obstructed are applicable.

Blood stasis Again, the manifestations of this condition are similar to those discussed under Mind Obstructed from Blood stasis. The main difference is that, when stasis of Blood causes the Mind to become unsettled, there will be severe anxiety and mental restlessness.

Treatment principle Invigorate Blood, eliminate stasis and calm the Mind. The same prescriptions and acupuncture points indicated under Mind Obstructed from Blood stasis are applicable.

Fire Heart-Fire Treatment principle Clear the Heart, drain Fire and calm the Mind.

Acupuncture Points HE-8 Shaofu, HE-7 Shenmen, P-7 Daling, Ren-15 Jiuwei, SP-6 Sanyinjiao, G.B.-15 Toulinqi. Reducing method on all points. Explanation • HE-8 clears Heart-Fire and calms the Mind. • HE-7 calms the Mind. • P-7 clears Heart-Heat and calms the Mind. • Ren-15 calms the Mind. • SP-6 nourishes Yin, which helps to cool Fire, and it calms the Mind. • G.B.-15 clears Heat and calms the Mind. It balances moods when they oscillate violently. It is particularly indicated if the eyes are red.

Explanation This formula drains Heart-Fire causing such symptoms as a sensation of heat in the chest, thirst, red face, tongue ulcers, mental restlessness, red eyes, scanty-dark urine, burning on urination, a Red tongue with a redder tip and yellow coating and an Overflowing pulse. Please note that this formula contains Mu Tong Caulis Akebiae trifoliatae, the use of which is not allowed. It can be replaced by Tong Cao Medulla Tetrapanacis. Mental-emotional pattern Excess joy, worry, anger, guilt and craving may lead to this pattern. These emotions agitate the Mind and create an implosion of Qi, which leads to Fire. Fire agitates the Mind, and the person will be very agitated, restless, impatient and unable to sleep well. The sleep will be very restless and disturbed by violent dreams, which may involve flying, fires and killings. The mental restlessness deriving from Fire is quite different from that deriving from Empty Heat. A person with Empty Heat will feel restless and anxious, especially in the evening, but will, by and large, endure it in silence. A person with Fire will feel restless all the time and will project it outwards towards other people or always doing something in a compulsive way. These people may be quite creative and artistic. Modifications • In case of severe anxiety, add Bai Zi Ren Semen Biotae orientalis, Suan Zao Ren Semen Ziziphi spinosae and Yuan Zhi Radix Polygalae tenuifoliae.

SUMMARY MIND UNSETTLED – FIRE, HEART-FIRE Treatment principle Clear the Heart, drain Fire and calm the Mind. Points HE-8 Shaofu, HE-7 Shenmen, P-7 Daling, Ren-15 Jiuwei, SP-6 Sanyinjiao, G.B.-15 Toulinqi. Reducing method on all points.

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Herbal therapy Prescription DAO CHI SAN Eliminating Redness Powder

Case history A 33-year-old woman sought treatment for infertility. She had been trying to become pregnant for 8 years, and there was no abnormality in her hormone levels or fallopian tubes. Her periods were always late (from a 32- to a 44-day cycle), the menstrual blood was bright red but with dark clots and the periods were painful. She also felt cold during the period and liked to have a hot water bottle on her abdomen. She suffered from lower backache, loose stools and general exhaustion. The backache started after a fall 10 years before. Her memory was poor, and she dreamt a lot every night. Her dreams were always unpleasant, and she regularly dreamed of burning buildings, often waking up crying or laughing. She occasionally experienced palpitations. In her teenage years, from 13 to 18, she had been very nervous, frequently had palpitations and often fainted. Facial diagnosis revealed an uneven, blemished surface on the forehead in the area corresponding to the teenage years between 16 and 19 (Fig. 16.8) and rather dull eyes. Her tongue was Pale but with a Red tip. Her pulse was Weak on the right side and on both Rear positions, and the Heart pulse was relatively Overflowing and very slightly Moving, i.e. it was Overflowing in relation to all the other pulse positions, which were Weak. Diagnosis At first observation, all her symptoms would seem to point to Spleen- and Kidney-Yang deficiency. While there certainly was a Spleen-Yang deficiency (tiredness, loose stools, Pale tongue and pulse Weak on the right side), there was not much Kidney-Yang deficiency. The symptoms that would seem to point to Kidney-Yang deficiency are a late

Figure 16.8 Area corresponding to parents’ influence and years from 16 to 19.

menstrual cycle, feeling cold during the period, infertility, backache and poor memory. However, on closer analysis, although there was some KidneyYang deficiency, some of these symptoms could be explained differently. First of all, the backache started only after the fall and was therefore due to a structural rather than an energetic Kidney problem. As for the other symptoms, they are also partially due to the Heart’s influence on the Kidneys. The Fire of the Heart (in a Five-Element sense) needs to communicate with Kidney-Water: Kidney-Water needs to flow upwards to nourish Heart-Yin, while the Fire of the Heart needs to flow downwards to the Kidneys and the Lower Burner. In this case, this patient had been affected by deep emotional problems during her teenage years. This was probably a mixture of shock and sadness, which caused HeartFire (in a pathological sense). This was deduced from the Heart-pulse’s Overflowing and Moving quality, from the blemished area on her forehead, dull eyes and her dreams. The shock and sadness had obviously affected the Heart (causing dreams of fire and waking up laughing) and Lungs (causing dreams of buildings and waking up crying). When asked about it, she confirmed this was true, but she did not wish to discuss it further. Thus, Heart-Fire was blocked upwards, unable to communicate downwards with the Kidneys and Lower Burner, which became cold.

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This was the cause of the infertility, delayed menstrual cycle, blood clots and cold feeling. Treatment principle The main treatment principle adopted was to calm the Mind and conduct HeartFire downwards to communicate with the Kidneys. In this case, it was not a matter of “clearing” HeartFire so as to establish a communication between the Fire of the Heart and the Kidneys. Shock “closes” the Heart and makes it smaller, while sadness depletes Heart- and Lung-Qi. The formula therefore needs some herbs with a pungent taste to open the Heart’s orifices, some with a sour taste to nourish the Heart and calm the Mind and some sinking substances to calm the Mind and make Heart-Qi descend to the Lower Burner. Herbal therapy She was already receiving acupuncture from another practitioner who referred her to me for herbal treatment. The prescription used was not a classic one but one I formulated for this particular case. This was as follows. • • • • • • • • • •

Dang Shen Radix Codonopsis 9 g Fu Shen Sclerotium Poriae cocos pararadicis 6 g Yuan Zhi Radix Polygalae 9 g Bai Zi Ren Semen Biotae orientalis 6 g Suan Zao Ren Semen Ziziphi spinosae 3 g Bai He Bulbus Lilii 6 g Shi Chang Pu Rhizoma Acori tatarinowii 4 g Huang Qin Radix Scutellariae 3 g Rou Gui Cortex Cinnamomi cassiae 1.5 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 2 g • Hong Zao Fructus Ziziphi jujubae 3 dates Explanation • Dang Shen and Fu Shen tonify the Spleen. Fu Shen also calms the Mind. • Yuan Zhi, Bai Zi Ren and Suan Zao Ren calm the Mind and nourish the Heart. Yuan Zhi is pungent and opens the Heart’s orifices, while Bai Zi Ren and Suan Zao Ren are sweet and sour, respectively, and therefore nourish the Heart and calm the Mind. • Bai He nourishes the Lungs, especially when they are affected by sadness. • Chang Pu opens the Mind’s orifices and counteracts the effects of shock.

• Huang Qin clears Heart-Heat and calms the Mind. It is used in a very small dose more to enter the Heart than to clear it. • Rou Gui was used to warm the Fire of the Gate of Vitality, attract the Fire of the Heart downwards and re-establish the communication between the Kidneys and Heart. • Zhi Gan Cao and Hong Zao harmonize. This formula was repeated with minor modifications over a period of 4 months, producing a marked improvement in the mental state of this patient. Her dreams of fire stopped and the menstrual blood became normal.

Liver-Fire Treatment principle Drain Liver-Fire, calm the Mind and settle the Ethereal Soul.

Acupuncture Points LIV-2 Xingjian, LIV-3 Taichong, L.I.-4 Hegu, BL-18 Ganshu, SP-6 Sanyinjiao, Du-18 Qiangjian, Du-24 Shenting, G.B.-13 Benshen, G.B.-15 Toulinqi, HE-7 Shenmen, P-7 Daling, LU-3 Tianfu. All with reducing or even method. Explanation • LIV-2 clears Liver-Fire. • LIV-3 pacifies the Liver and calms the Mind. In combination with L.I.-4, it strongly calms the Mind and settles the Ethereal Soul. • BL-18, Back-Transporting point of the Liver, clears Liver-Fire. • SP-6 nourishes Yin and calms the Mind. • Du-18 calms the Mind, regulates the Liver and settles the Ethereal Soul. • Du-24 and G.B.-13 calm the Mind and settle the Ethereal Soul in Liver disharmonies. G.B.-13 also treats jealousy and suspicion. • G.B.-15 clears Heat, brightens the eyes and settles the Ethereal Soul. • HE-7 and P-7 calm the Mind. P-7 is related to the Liver via the Terminal Yin channels. • LU-3 harmonizes Liver and Lungs and, according to An Explanation of Acupuncture Points (1654), is particularly indicated when Liver-Fire obstructs the Lungs, causing forgetfulness. The book also says this point is indicated when the person “talks to ghosts”.11

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

Herbal therapy

SUMMARY

Prescription XIE GAN AN SHEN WAN Draining the Liver and Calming the Mind Pill

MIND UNSETTLED – FIRE, LIVER-FIRE

Explanation This formula (a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction) specifically drains Liver-Fire and calms the Mind. It addresses the mental restlessness and irritability deriving from Liver-Fire. The main manifestations are dizziness, tinnitus, red face and eyes, thirst, scantydark urine, dry stools, insomnia, dream-disturbed sleep, propensity to outbursts of anger, headache, a Red tongue with redder sides and yellow coating and a Wiry and Rapid pulse. Please note that this formula contains three minerals, the use of which is not allowed in European Union countries. Mental-emotional pattern Anger, frustration, resentment and hatred can all cause rising of LiverYang and, over a long period of time, Liver-Fire. This especially happens if the person eats very greasy food and drinks alcohol. These people would be very angry, prone to outbursts of anger, impatient, mentally restless and irritable, and their sleep would be very disturbed by violent dreams of fights. In this condition, Fire harasses the Ethereal Soul and makes the person destructive and restless. At times, this situation may lead to depression, especially if the anger (usually towards a member of the family) is harboured inside for many years. In these cases, the appearance of the person, depressed, subdued and speaking in a low voice, may disguise the true origin of the problem and look as if sadness and grief were the cause of the disease. However, the Red tongue with redder sides and the Wiry and Rapid pulse clearly point to the true origin of the problem, i.e. anger. Three Treasures remedies Drain Fire Drain Fire drains Liver- and Heart-Fire, calms the Mind and settles the Ethereal Soul. It is a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction. Settling the Soul Settling the Soul drains Liver- and Heart-Fire, resolves Phlegm, calms the Mind and settles the Ethereal Soul. It is used instead of Drain Fire if there is Phlegm.

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Treatment principle Drain Liver-Fire, calm the Mind and settle the Ethereal Soul. Points LIV-2 Xingjian, LIV-3 Taichong, L.I.-4 Hegu, BL-18 Ganshu, SP-6 Sanyinjiao, Du-18 Qiangjian, Du-24 Shenting, G.B.-13 Benshen, G.B.-15 Toulinqi, HE7 Shenmen, P-7 Daling, LU-3 Tianfu. All with reducing or even method. Herbal therapy Prescription XIE GAN AN SHEN WAN Draining the Liver and Calming the Mind Pill Three Treasures remedies Drain Fire Settling the Soul

Case history A 40-year-old woman complained of asthma, which had started in her early twenties from “emotional trauma” as she herself described it. She used Ventolin and Becotide inhalers every day as well as tablets of prednisolone. Her attacks were clearly elicited by emotional strain, and the asthma did not have an allergic basis. She felt very tense and irritable and often had a pain under the right rib cage. She also suffered from premenstrual tension. Her tongue was Red, redder on the sides, with a yellow coating (Plate 16.4). Her pulse was Weak on the right and Wiry on the left. Diagnosis The main problem in this case is Liver-Qi stagnation leading to Liver-Fire. Prolonged stagnation of Qi over many years often leads to Fire. Liver-Fire can overflow into the chest and obstruct the descending of Lung-Qi, causing asthma. This type of asthma starts later in life (i.e. not during childhood) and is clearly related to emotional strain, as it is in this case. Liver-Fire is evident from the Red sides of the tongue but not many other symptoms; this is because it did not arise independently but from stagnation of

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Liver-Qi. Hence the symptoms of stagnation of LiverQi such as the hypochondrial pain, the irritability, the premenstrual tension and the Wiry pulse on the left.

• Xing Ren and Su Zi restore the descending of LungQi and ease asthma. • Suan Zao Ren and He Huan Pi calm the Mind and settle the Ethereal Soul.

Treatment principle When Liver-Fire develops from Liver-Qi stagnation, it does not require draining with bitter-cold herbs or purging, but only clearing with a combination of pungent herbs to open and move Qi and some light-bitter herbs to clear. Hence the treatment principle is to move Qi, clear Liver-Fire, restore the descending of Lung-Qi, calm the Mind and settle the Ethereal Soul.

This patient was off all medication after 6 months of treatment and felt much less irritable and depressed.

Acupuncture LU-7 Lieque, LU-1 Zhongfu, G.B.-34 Yanglingquan, LIV-3 Taichong, LIV-14 Qimen, P-7 Daling, P-6 Neiguan, ST-40 Fenglong. All with even method. Explanation • LU-7 and LU-1 restore the descending of Lung-Qi. • G.B.-34, LIV-3 and LIV-14 move Liver-Qi. LIV-14, in particular, will move Liver-Qi in the chest. • P-7 and P-6 calm the Mind, settle the Ethereal Soul, indirectly move Liver-Qi, restore the descending of Lung-Qi and open the chest. • ST-40, especially in combination with P-6, opens the chest and eases breathing. Herbal therapy The formula used was a variation of Si Ni San Four Rebellious Powder. • • • • • • • • • •

Chai Hu Radix Bupleuri 6 g Bai Shao Radix Paeoniae alba 9 g Zhi Shi Fructus Aurantii immaturus 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6 g Huang Qin Radix Scutellariae 3 g Shan Zhi Zi Fructus Gardeniae 3 g Xing Ren Semen Armeniacae 6 g Su Zi Fructus Perillae 6 g Suan Zao Ren Semen Ziziphi spinosae 4 g He Huan Pi Cortex Albiziae 6 g

Explanation The first four herbs constitute Si Ni San. • Huang Qin and Zhi Zi lightly clear Heat. In combination with the pungent herbs to move Qi, they clear Liver-Fire from stagnation of Liver-Qi.

Phlegm-Fire Stomach and Heart Phlegm-Fire Treatment principle Resolve Phlegm, harmonize the Stomach, open the Mind’s orifices, clear the Heart and calm the Mind.

Acupuncture Points ST-40 Fenglong, Ren-12 Zhongwan, Ren-9 Shuifen, ST-25 Tianshu, G.B.-13 Benshen, ST-8 Touwei, G.B.-18 Chengling, G.B.-15 Toulinqi, G.B.-17 Zhengying, BL-20 Pishu, BL-49 Yishe, P-7 Daling, Du-20 Baihui. ST-40 and P-7 with reducing method, Ren-12, BL-20 and BL-49 with reinforcing method and all the others with even method. Explanation • ST-40 resolves Phlegm, harmonizes the Stomach and calms the Mind. • Ren-12 and Ren-9 tonify the Spleen to resolve Phlegm. • ST-25 calms the Mind, opens the Mind’s orifices and settles the Ethereal Soul and Corporeal Soul. It is an important point for mental-emotional problems occurring against a background of Stomach-Fire or Stomach Phlegm-Fire. • G.B.-13 clears the Mind’s orifices and calms mental restlessness. • ST-8 is a local point to resolve Phlegm affecting the head. • G.B.-18 calms the Mind, stops obsessive ideas and relieves dizziness. • G.B.-15 calms the Mind, settles the Ethereal Soul and clears Heat. • G.B.-17 calms the Mind and stimulates concentration. It combines with ST-40 to clear Phlegm from the head and clear the Mind. • BL-20 tonifies the Spleen to resolve Phlegm. • BL-49 strengthens the Intellect and clears the Mind.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

• P-7 calms the Mind and resolves Phlegm-Fire from the Heart. • Du-20 clears the Mind.

Herbal therapy Prescription WEN DAN TANG Warming the Gall Bladder Decoction Explanation This formula, already discussed above under “Mind Obstructed”, resolves Phlegm-Heat from the Stomach and Heart. Mental-emotional pattern Worry and pensiveness knot Qi and, after a long time, the impaired Qi movement leads to the formation of Phlegm. On the other hand, knotted Qi easily turns into Fire after a long time. Fire, in turn, may lead to the formation of more Phlegm as it burns and condenses fluids. Phlegm-Fire both mists and agitates the Mind. The Phlegm aspect of it causes mental confusion, poor memory, dizziness and, in severe cases, total mental confusion with loss of insight. The Fire aspect of it causes agitation, mental restlessness, insomnia, a flustered feeling in the chest, anxiety and, in severe cases, manic behaviour. Nowadays, this formula is widely used for manic depression. Phlegm-Fire in this case affects Stomach, Heart and Gall Bladder. In the Heart, it mists the Mind and causes mental confusion. In the Gall Bladder, it prevents the Ethereal Soul from returning to the Liver at night, hence the insomnia. Disturbance of the Ethereal Soul also causes depression and a lack of direction in life. Obviously, irregular eating plays an important role in the development of this pattern. These people are often busy executives who eat at irregular times or in a hurry while working or late at night. Modifications • If Heart-Fire is evident, add Huang Lian Rhizoma Coptidis. • If obstruction of the Mind by Phlegm is pronounced, add Shi Chang Pu Rhizoma Acori tatarinowii and Yuan Zhi Radix Polygalae. • If there is pronounced mental restlessness and anxiety, add Suan Zao Ren Semen Ziziphi spinosae. • If insomnia is pronounced, add Ye Jiao Teng Caulis Polygoni multiflori.

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Three Treasures remedy Clear the Soul Clear the Soul resolves Phlegm-Heat from the Lungs, Stomach and Heart and calms the Mind. It is suitable for emotional problems deriving from worry, sadness and grief.

SUMMARY MIND UNSETTLED – PHLEGM-FIRE, STOMACH AND HEART PHLEGM-FIRE Treatment principle Resolve Phlegm, harmonize the Stomach, open the Mind’s orifices, clear the Heart and calm the Mind. Points ST-40 Fenglong, Ren-12 Zhongwan, Ren-9 Shuifen, ST-25 Tianshu, G.B.-13 Benshen, ST-8 Touwei, G.B.-18 Chengling, G.B.-15 Toulinqi, G.B.-17 Zhengying, BL-20 Pishu, BL-49 Yishe, P-7 Daling, Du-20 Baihui. ST-40 and P-7 with reducing method, Ren-12, BL-20 and BL-49 with reinforcing method and all the others with even method. Herbal therapy Prescription WEN DAN TANG Warming the Gall Bladder Decoction Three Treasures remedy Clear the Soul

Case history A 54-year-old woman complained of longstanding depression and anxiety since she was 10. She had had a very unhappy childhood and harboured deep feelings of resentment towards her father. She had been on antidepressants (tricyclics) for several years and she had just recently come off tranquillizers (Valium). Despite the antidepressants, she still felt very depressed and she described her condition as a “black cloud hanging over her”. She felt also extremely anxious and her sleep was very restless. She also suffered from severe, stabbing headaches on the forehead and

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was prone to a lot of catarrh. Her tongue was Reddish-Purple, Stiff, Swollen, with a Stomach crack in the centre, and a thick-sticky-yellow coating (Plate 16.5). Her pulse was Wiry, Slippery and Full. Diagnosis This patient suffered from two main conditions: Phlegm-Fire affecting Stomach and Heart and stasis of Blood. Both Phlegm-Fire and stasis of Blood agitate the Mind and the Ethereal Soul, leading to depression and anxiety. Treatment The principle of treatment adopted was to resolve Phlegm, drain Fire, invigorate Blood, calm the Mind and settle the Ethereal Soul. She was treated with herbs only, and the formula used was a variation of Wen Dan Tang Warming the Gall Bladder Decoction. • • • • • • • • • • • •

Ban Xia Rhizoma Pinelliae preparatum 6 g Fu Ling Poria 5 g Chen Pi Pericarpium Citri reticulatae 9 g Zhu Ru Caulis Bambusae in Taeniam 6 g Zhi Shi Fructus Aurantii immaturus 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g Sheng Jiang Rhizoma Zingiberis officinalis recens 5 slices Da Zao Fructus Jujubae 1 date Yuan Zhi Radix Polygalae 6 g Suan Zao Ren Semen Ziziphi spinosae 4 g He Huan Pi Cortex Albiziae 6 g Yu Jin Tuber Curcumae 6 g

Explanation • The first eight herbs constitute the root formula, which resolves Phlegm-Heat from the Stomach and Heart. • Yuan Zhi and Suan Zao Ren calm the Mind and open the Mind’s orifices. These two herbs blend particularly well together, as one is pungent and the other sour. • He Huan Pi and Yu Jin invigorate Blood, open the Mind’s orifices and lift depression. The patient was treated with variations of the above prescription for 9 months, after which she felt a lot better and was able to come off the antidepressants completely.

MIND WEAKENED This is characterized by physical and mental exhaustion, depression, lack of will-power and initiative, insomnia (waking up early), mild anxiety, poor memory, dislike to speak and pessimism. More than the conditions associated with Unsettled Mind and Obstructed Mind, the conditions of Weakened Mind are often the result rather than the cause of a disharmony of the internal organs, Qi and Blood. For example, the Mind can easily become weakened after a long chronic disease, after many childbirths too close together or after a lifetime of overwork that has severely depleted Qi and Essence. The conditions causing a weakened Mind are Qi deficiency, Blood deficiency or Yin deficiency. The treatment principle for weakened Mind is to nourish Qi, Blood or Yin, calm the Mind and strengthen Will-Power.

Qi and Blood deficiency Qi deficiency Treatment principle Tonify Qi, strengthen the Mind.

Acupuncture Points ST-36 Zusanli, SP-3 Taibai, Ren-6 Qihai, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, HE-7 Shenmen, LU-3 Tianfu, BL-15 Xinshu, BL-13 Feishu, BL-44 Shentang and BL-42 Pohu. All with reinforcing method. Moxa is applicable. Explanation • ST-36, SP-3, BL-20 and BL-21 tonify Stomach- and Spleen-Qi. As the Stomach and Spleen are the source of the Postnatal Qi, they should always be tonified in Qi deficiency. • Ren-6 tonifies Original Qi. • Du-20 clears the Mind and lifts mood. • HE-7 calms the Mind. • LU-3 tonifies Lung-Qi and stimulates the ascending of clear Qi to the brain. • BL-15 with direct moxa, tonifies Heart-Qi, clears the Mind and lifts mood. • BL-13 tonifies Lung-Qi and is selected if there is Lung deficiency, as there would be when sadness is the cause of this pattern. • BL-44 tonifies the Heart and calms and clears the Mind.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

• BL-42 tonifies the Lungs and settles the Corporeal Soul that suffers from sadness and grief.

Herbal therapy Prescription AN SHEN DING ZHI WAN Calming the Mind and Settling the Spirit Pill Explanation This formula tonifies Qi, strengthens the Original Qi, calms and clears the Mind and lifts mood. It is used for chronic Qi deficiency affecting the Mind, making it on the one hand restless and, on the other hand, confused and depressed. The main manifestations would be extreme tiredness, dislike to speak, slight breathlessness, no appetite, restless sleep with unpleasant dreams, palpitations, a weak voice, a Pale tongue and an Empty or Weak pulse. Please note that this formula contains a mineral substance (Long Chi Fossilia Dentis Mastodi), the use of which is not allowed in European Union countries. Mental-emotional pattern This pattern either arises from a depletion of Qi due to a chronic disease or from emotional problems affecting Qi. Sadness, grief and regret are the most likely causes of this condition; they deplete Qi of the Lungs and Heart. This person would feel very tired, be depressed and not sleep well. He or she would also lack motivation.

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Qi. Sadness, grief and regret are the most likely causes of this condition, as they deplete Qi of the Lungs and Heart. This person would feel very tired, depressed and would also lack motivation.

SUMMARY MIND WEAKENED – QI AND BLOOD DEFICIENCY, QI DEFICIENCY Treatment principle Tonify Qi, strengthen the Mind. Points ST-36 Zusanli, SP-3 Taibai, Ren-6 Qihai, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, HE-7 Shenmen, LU-3 Tianfu, BL-15 Xinshu, BL-13 Feishu, BL-44 Shentang and BL-42 Pohu. All with reinforcing method. Moxa is applicable. Herbal therapy Prescription AN SHEN DING ZHI WAN Calming the Mind and Settling the Spirit Pill Prescription DING ZHI WAN Settling the Will-Power Pill

Case history

Explanation This formula is very similar to the previous one. It differs from it in so far as it does not have as strong a calming effect on the Mind, due to the omission of Long Chi Dens Draconis. This formula tonifies Qi, strengthens the Original Qi, calms and clears the Mind and lifts mood. It is used for chronic Qi deficiency affecting the Mind, making it confused and depressed. The main manifestations would be extreme tiredness, dislike to speak, slight breathlessness, no appetite, palpitations, a weak voice, a Pale tongue and an Empty or Weak pulse.

A 41-year-old woman suffered from abdominal distension, belching, constipation and hypochondrial pain. Her periods started hesitantly and were painful. The menstrual blood was dark with some clots. She also complained of premenstrual tension and irritability. She had a feeling of vague anxiety at night, with a sensation of tightness of the chest. Some years before, she had gone through a difficult period emotionally and experienced great sadness. Her complexion was pale and her eyes were slightly dull. Her tongue body colour was normal with teeth marks. Her pulse was very Weak and Fine on the Lung position and slightly Wiry on the left side.

Mental-emotional pattern As in the previous case, this pattern arises either from a depletion of Qi due to a chronic disease or from emotional problems affecting

Diagnosis Most of the symptoms and signs point to stagnation of Liver-Qi and Liver-Blood: abdominal distension, belching, hypochondrial pain, painful

Prescription DING ZHI WAN Settling the Will-Power Pill

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periods with dark blood and premenstrual tension. However, the very Fine Lung pulse, the feeling of anxiety at night, the pale complexion and the teeth marks on the tongue point to Lung-Qi deficiency. This, combined with the absence of a Red colour on the sides of the tongue, indicated that the main problem lay in deficient Lung-Qi not controlling the Liver (Metal insulting Wood from a Five-Element perspective) and leading to stagnation of Liver-Qi. The feeling of vague anxiety at night was due to agitation of the Corporeal Soul from Lung-Qi deficiency. The deficiency of LungQi was obviously due to the period of great sadness years before. Treatment principle Tonify Lung-Qi, settle the Corporeal Soul and Ethereal Soul and move Liver-Qi. Herbal therapy The prescription used was not a classic one but one I formulated for this patient. • • • • • • • • • • •

Bai He Bulbus Lilii 9 g Mai Men Dong Radix Ophiopogonis 6 g Bei Sha Shen Radix Glehniae 6 g Huang Qi Radix Astragali 6 g Dang Shen Radix Codonopsis 9 g Wu Wei Zi Fructus Schisandrae 4 g Shu Di Huang Radix Rehmanniae preparata 9 g Bai Shao Radix Paeoniae alba 9 g Yi Mu Cao Herba Leonuri 4 g Yu Jin Tuber Curcumae 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6 g

Explanation • Bai He, Mai Men Dong and Bei Sha Shen nourish Lung-Yin. Although she does not suffer from LungYin deficiency, these herbs are used to nourish and settle the Corporeal Soul and relieve sadness. • Huang Qi and Dang Shen tonify Lung- and SpleenQi. It is necessary to tonify Spleen-Qi according to the principle of reinforcing Earth to strengthen Metal. • Wu Wei Zi tonifies Lung-Qi and Lung-Yin and settles the Corporeal Soul. • Shu Di, Bai Shao and Yi Mu Cao harmonize LiverBlood. Bai Shao is sour and absorbing and, in combination with Gan Cao, it stops pain, calms the Mind and moderates urgency. • Yu Jin invigorates Liver-Blood, opens the Mind’s orifices and lifts depression.

• Zhi Gan Cao, in a larger dose than normal, is combined with Bai Shao as indicated above. After taking this prescription for 2 weeks, the patient experienced less abdominal distension, less belching and no constipation. She felt calmer in the evening and brighter in herself but also more moody and more up and down emotionally. I attributed this to Yu Jin Tuber Curcumae within the prescription; this herb is pungent and hot and powerfully moves Liver-Qi and Liver-Blood. The second prescription was as follows. • • • • • • • • • • •

Bai He Bulbus Lilii 9 g Bei Sha Shen Radix Glehniae 6 g Mai Men Dong Radix Ophiopogonis 6 g Dang Shen Radix Codonopsis 6 g Hou Po Cortex Magnoliae officinalis 6 g Ban Xia Rhizoma Pinelliae preparatum 6 g Su Ye Folium Perillae 6 g Fu Ling Poria 4 g Xiang Fu Rhizoma Cyperi 4 g Suan Zao Ren Semen Ziziphi spinosae 3 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6 g • Bai Shao Radix Paeoniae alba 6 g • Da Zao Fructus Jujubae 5 dates

Explanation • The first four herbs have already been discussed above. • Hou Po, Ban Xia, Su Ye, and Fu Ling constitute Ban Xia Hou Po Tang Pinellia-Magnolia Decoction, which moves Liver-Qi in the chest and makes LungQi and Stomach-Qi descend. It particularly relieves depression, moodiness and sadness associated with the Lungs. • Xiang Fu and Suan Zao Ren move Liver-Qi and settle the Ethereal Soul. They are coordinated, as one is pungent and moves whereas the other is sour and absorbs. • Zhi Gan Cao and Bai Shao stop pain, harmonize the Liver and moderate urgency. • Da Zao harmonizes. After repeating this prescription three times, she was much better and her periods became painless.

Qi and Blood deficiency Treatment principle Tonify Qi, nourish Blood and calm the Mind.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

Acupuncture Points ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, HE-7 Shenmen, Ren-15 Jiuwei, BL-15 Xinshu, and BL-44 Shentang. All with reinforcing method. Moxa is applicable. Explanation • ST-36, SP-6, BL-20 and BL-21 tonify Stomach- and Spleen-Qi. As the Stomach and Spleen are the source of the Postnatal Qi, they should always be tonified in Qi deficiency. SP-6 also nourishes Blood, calms the Mind and promotes sleep. • Ren-4 tonifies Original Qi and nourishes Blood. • Du-20 clears the Mind and lifts mood. • HE-7 calms the Mind. • Ren-15 calms the Mind and nourishes Heart-Blood. • BL-15 with direct moxa, tonifies Heart-Qi, clears the Mind and lifts mood. • BL-44 tonifies the Heart and calms and clears the Mind.

Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction Explanation This well-tested prescription is excellent to tonify Spleen-Qi and Heart-Blood and calm the Mind. Besides calming the Mind, it also clears and stimulates it, helping memory, thinking and concentration. The main manifestations are palpitations, tiredness, a pale complexion, insomnia (difficulty in falling asleep), poor memory, poor appetite, menorrhagia in women (from Spleen-Qi not holding Blood), a Pale tongue and a Weak or Choppy pulse. Mental-emotional pattern Worry, pensiveness or shame over a long period of time injures the Spleen and Heart and leads to Spleen-Qi deficiency and HeartBlood deficiency. This weakens the Mind, which is deprived of its residence. Thus the patient becomes tired and depressed and finds sleep difficult. The Mind controls memory and thinking, and therefore there is a poor memory, poor concentration and slow thinking. Another feature of this pattern is obsessive thinking or phobias, which are due to Spleen and Blood deficiency. The Spleen controls thinking, intelligence and concen-

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tration and, when in disharmony, these same qualities may generate obsessive thinking or phobias. Modifications • If Blood deficiency is pronounced, add Shu Di Huang Radix Rehmanniae preparata. With the addition of this herb, this formula is called Hei Gui Pi Tang Black Tonifying the Spleen Decoction. Prescription SHI WEI WEN DAN TANG Ten-Ingredient Warming the Gall Bladder Decoction Explanation This formula is a variation of Wen Dan Tang Warming the Gall Bladder Decoction; like the original prescription, it resolves Phlegm but does not clear Heat. In addition, this formula tonifies Qi and Blood. The main manifestations are tiredness, poor appetite, poor memory, timidity, insomnia, palpitations, mild anxiety, propensity to be startled, a Pale tongue and a Weak or Choppy pulse. This formula, contrary to the previous one, also addresses any sweating that may derive from Empty Heat developing from Blood deficiency. This is quite possible, and it happens more frequently in women. In the prescription, Wu Wei Zi and Suan Zao Ren have this function. Another important difference from the previous formula is that this one resolves Phlegm as well. It is therefore suited to treat mental confusion as well as anxiety and restlessness. Mental-emotional pattern Worry, pensiveness or shame depletes the Spleen and the Heart, and this leads to deficiency of Qi and Blood. The Mind is deprived of its residence, and the person feels exhausted, depressed and anxious. The Spleen-Qi deficiency leads to the formation of Phlegm, which mists the Mind, causing confused thinking and obsessive thoughts. The Blood deficiency causes insomnia, poor memory, timidity and the propensity to be startled. Prescription GAN MAI DA ZAO TANG Glycyrrhiza-Triticum-Ziziphus Decoction Explanation This interesting formula has been the subject of much speculation and different interpretations. Essentially, it tonifies Heart-Qi and calms

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the Mind. It can also be used for deficiency of HeartYin with Empty Heat, only when the Empty Heat is not such that it requires the use of bitter-cold herbs, because these would further injure Qi. On the other hand, the deficiency of Qi is not such that it requires strong tonifying herbs, hence the gentle tonification of these three herbs. The hallmark of this prescription then is that it provides enough tonification but not so much that it would make any Empty Heat worse. All the herbs in it are sweet, and this taste soothes the Liver. For this reason, this formula is also said to treat Liver-Qi stagnation, which may be associated with Heart-Qi deficiency. I personally use this formula very frequently to nourish the Heart and tonify Qi not only in cases of Mind Weakened but also of Mind Unsettled and Mind Obstructed. As it contains only three herbs, I may often combine this formula with other ones to nourish the Heart and calm the Mind. However, it can be used in both anxiety and depression. Mental-emotional pattern All the manifestations normally relevant to this formula are of mental or emotional character. Worry, excess joy, craving, love, guilt and pensiveness may all injure Heart-Qi and lead to this condition. The main manifestations are worrying, anxiety, sadness, weeping, insomnia, depression, inability to control oneself, yawning, moaning, speaking to oneself, disorientation, a Weak pulse and a Pale tongue. The tongue may be Red without coating if there is Heart-Yin deficiency. In severe cases, this corresponds to the depressive phase of manic depression. This formula is often added as a whole to other prescriptions to treat the above manifestations. Three Treasures remedy Calm the Shen Calm the Shen nourishes Heart-Blood and calms the Mind. It is suitable for depression, anxiety and insomnia. It is a variation of Gui Pi Tang.

SUMMARY MIND WEAKENED – QI AND BLOOD DEFICIENCY, QI AND BLOOD DEFICIENCY Treatment principle Tonify Qi, nourish Blood and calm the Mind.

Points ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, HE-7 Shenmen, Ren-15 Jiuwei, BL-15 Xinshu, and BL-44 Shentang. All with reinforcing method. Moxa is applicable. Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction Prescription SHI WEI WEN DAN TANG Ten-Ingredient Warming the Gall Bladder Decoction Prescription GAN MAI DA ZAO TANG Glycyrrhiza-Triticum-Ziziphus Decoction Three Treasures remedy Calm the Shen

Yang deficiency Kidney-Yang deficiency Treatment principle Tonify and warm Yang, strengthen the Kidneys, calm the Mind and lift mood.

Acupuncture Points BL-23 Shenshu, BL-52 Zhishi, Du-4 Mingmen, Du-14 Dazhui, Ren-4 Guanyuan, KI-3 Taixi, KI-7 Fuliu, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui, BL-8 Luoque, BL-10 Tianzhu. All with reinforcing method except for the points in the head, which are usually needled with even method. Moxa should be used. Explanation • BL-23 tonifies Kidney-Yang. • BL-52 tonifies the Kidneys and strengthens the Will-Power. • Du-4, with direct moxa, strongly tonifies the Fire of the Gate of Vitality and it lifts mood. • Du-14, with direct moxa, tonifies Yang and lifts mood. • Ren-4 nourishes the Kidneys and calms the Mind.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

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• KI-3 and KI-7 tonify Kidney-Yang. KI-7 in particular would resolve oedema, a possible consequence of Kidney-Yang deficiency. • ST-36 and SP-6 tonify the Stomach and Spleen to raise vitality in general. In particular, SP-6 also nourishes Yin and is therefore indicated in complicated cases of deficiency of both Yang and Yin of the Kidneys. • Du-20 raises Yang, improves memory and concentration and lifts mood. • BL-8 calms the Mind, lifts mood and strengthens memory. • BL-10 clears the Mind.

This person will feel mentally and physically exhausted, be depressed and lack will-power and spirit of initiative. He or she will have almost given up any hope of getting better or of starting or changing anything in life. Everything is too much effort. This condition is characterized not only by KidneyYang deficiency but also by Essence depletion. The Kidney-Essence is the material basis for all the Kidney’s physiological activities. The Essence has a Yin and a Yang aspect and, in this case, its Yang aspect is deficient. Because the Essence is the foundation for the Three Treasures, the Essence, Qi and Mind, a deficiency of its Yang aspect causes extreme exhaustion and low spirits.

Herbal therapy

Modifications • In cases of mixed Yin and Yang deficiency symptoms of the Kidneys (a very frequent occurrence), halve the dosage of Fu Zi and Rou Gui to 1.5 g each and replace Shu Di Huang with Sheng Di Huang Radix Rehmanniae.

Prescription YOU GUI WAN Restoring the Right [Kidney] Pill Explanation This formula is excellent to tonify Kidney-Yang and the Fire of the Gate of Life with its associated mental manifestations. The main physical manifestations are lower backache, weak knees, poor memory, exhaustion, cold legs and back, frequent-pale urination, a Pale and Swollen tongue and a Weak-Deep pulse. I personally prefer this formula to Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill for two reasons: first of all, it also nourishes Blood, which makes it more suitable for women (due to the inclusion of Gou Qi Zi Fructus Lycii chinensis and Dang Gui Radix Angelicae sinensis), and second, because it is better for the mental aspects of Kidney-Yang deficiency (due to the inclusion of Du Zhong Cortex Eucommiae and Lu Jiao Jiao Colla Cornu Cervi). Please note that this formula contains Fu Zi Radix Aconiti lateralis preparata and Lu Jiao Jiao Colla Cornu Cervi, the use of which is not allowed in European Union countries. Fu Zi can be simply eliminated from the prescription by increasing the dosage of Rou Gui Cortex Cinnamomi. Lu Jiao Jiao can be eliminated from the formula without altering it substantially. Mental-emotional pattern Fear, shock and guilt may injure the Kidneys and cause this condition. However, it is often the result rather than the cause of Kidney-Yang deficiency. Kidney-Yang may be depleted by chronic disease, overwork, excessive physical work and lifting, and excessive sexual activity.

Three Treasures remedy Strengthen the Root Strengthen the Root tonifies Kidney-Yang and strengthens the Will-Power (Zhi).

SUMMARY MIND WEAKENED – YANG DEFICIENCY, KIDNEY-YANG DEFICIENCY Treatment principle Tonify and warm Yang, strengthen the Kidneys, calm the Mind and lift mood. Points BL-23 Shenshu, BL-52 Zhishi, Du-4 Mingmen, Du-14 Dazhui, Ren-4 Guanyuan, KI-3 Taixi, KI-7 Fuliu, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui, BL-8 Luoque, BL-10 Tianzhu. All with reinforcing method except for the points in the head, which are usually needled with even method. Moxa should be used. Herbal therapy Prescription YOU GUI WAN Restoring the Right [Kidney] Pill Three Treasures remedy Strengthen the Root

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Case history A 46-year-old woman complained of nocturia; she woke to urinate up to seven times a night. Her urine was generally pale and she experienced a dry mouth at night. She had a lower backache and felt generally cold, although she occasionally also felt hot in the face. Her tongue was slightly Pale with a Red tip with red points (Plate 16.6). Her pulse was Weak on both Kidney positions of left and right.

This remedy is mostly astringent rather than tonifying. It treats the Manifestation by astringing the urine but not the Root, i.e. Kidney-Yang deficiency. It is therefore suitable to be used in conjunction with the acupuncture treatment, which is aimed at treating the Root.

Blood deficiency Treatment principle Nourish Blood and calm the Mind.

Diagnosis This is a clear pattern of Kidney-Yang deficiency. Although this is the predominant condition, there is also the very beginning of some Kidney-Yin deficiency manifesting with a dry mouth at night and the occasional hot flush. When asked about her earlier life and how the condition might have developed, she said that as a child she was evacuated during the war to stay with a family who did not treat her well. She was with them from the ages of 4 to 8. She was intimidated by her foster parents and was often scared. At that time, she developed nocturnal enuresis, which did not disappear until she was 13. This is a very clear example of the effect of fear on the Kidneys in children, producing a deficiency of Kidney-Yang that persisted throughout her life. Treatment principle Tonify Kidney-Yang, astringe the Essence, strengthen Will-Power and calm the Mind. Acupuncture The following points were reinforced. • BL-23 Shenshu, Du-4 Mingmen (with moxa), Ren-4 Guanyuan (moxa) and KI-3 Taixi to tonify Kidney-Yang and strengthen Will-Power. • P-7 Daling and Ren-15 Jiuwei to calm the Mind. Herbal therapy No herbs were used but only the patent remedy Jin Suo Gu Jing Wan Golden Lock Consolidating the Essence Pill. • • • • • •

Qian Shi Semen Euryales Lian Xu Stamen Nelumbinis Long Gu Mastodi Ossis fossilia (calcined) Mu Li Concha Ostreae (calcined) Lian Zi Semen Nelumbinis Sha Yuan Ji Li Semen Astragali membranacei

Herbal therapy The same prescriptions used for Blood deficiency under Mind Unsettled are applicable here.

Yin deficiency Kidney-Yin deficiency Treatment principle Nourish Yin, calm the Mind and lift mood.

Acupuncture Points KI-3 Taixi, KI-6 Zhaohai, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, Du-20 Baihui. Reinforcing method. Explanation • KI-3, KI-6, SP-6 and Ren-4 nourish Kidney-Yin and calm the Mind. • BL-23 and BL-52 tonify the Kidneys and strengthen Will-Power. Although BL-23 is better to tonify Kidney-Yang, it is added here for its mental effect in lifting mood. • Du-20 lifts mood and relieves depression.

Herbal therapy All the prescriptions mentioned for Yin deficiency causing unsettled Mind are applicable here. However, the emphasis of those prescriptions was on calming the Mind, while in the case of weakened Mind the emphasis should be on clearing the Mind and lifting mood. They should therefore be suitably adapted by the addition of more Yin-nourishing herbs, such as Sheng Di Huang Radix Rehmanniae, Mai Men Dong Radix Ophiopogonis or Tian Men Dong Tuber Asparagi.

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

The following are formulae that nourish Yin, with the emphasis on lifting mood rather than calming the Mind. Prescription LIU WEI DI HUANG WAN Six-Ingredient Rehmannia Pill Explanation This is the most famous Yin-nourishing formula. Fear, guilt and shock can deplete the Kidneys. A feeling of guilt, especially when harboured for many years, is very destructive and may lead to Kidney deficiency. The main manifestations that apply to this formula are dizziness, tinnitus, backache, night sweating, a dry mouth, five-palm heat, exhaustion, a dark complexion, a thin body, dry hair, a Red tongue without coating and a Floating-Empty pulse. Mental-emotional pattern Again, this condition can arise either as a consequence of emotional problems due to shock, fear or guilt, or vice versa, as a result of depletion of Kidney-Yin and Kidney Essence. This person will feel very exhausted and depressed, lacking in will-power and spirit of initiative. Unlike those who suffer from Kidney-Yang deficiency with similar mental characteristics, those who suffer from Kidney-Yin deficiency are slightly more restless, uneasy and fidgety. They may also tend to complain more. The Essence is the foundation of the Three Treasures, Essence, Qi and Mind, and when it is depleted the Mind and the Will-Power suffer, causing exhaustion, depression and despair. Three Treasures remedy Nourish the Root Nourish the Root nourishes Kidneyand Liver-Yin and strengthens Will-Power (Zhi).

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Herbal therapy Prescription LIU WEI DI HUANG WAN Six-Ingredient Rehmannia Pill Three Treasures remedy Nourish the Root

Lung- and Kidney-Yin deficiency Treatment principle Nourish Lung- and KidneyYin, strengthen Will-Power and settle the Corporeal Soul.

Acupuncture Points LU-9 Taiyuan, LU-5 Chize, KI-3 Taixi, Ren-4 Guanyuan, LU-7 Lieque and KI-6 Zhaohai, BL-23 Shenshu, BL-52 Zhishi, BL-42 Pohu. Reinforcing method. Explanation • LU-9 tonifies Lung-Yin. • LU-5 nourishes the Water of the Lungs, according to the book An Explanation of Acupuncture Points (1654), when sadness has affected the Lungs, causing dryness of this organ, and the person cries a lot.12 • KI-3 and Ren-4 nourish Kidney-Yin and calm the Mind. • LU-7 and KI-6 open the Directing Vessel, nourish Lung- and Kidney-Yin and benefit the throat. • BL-23 and BL-52 tonify the Kidneys and strengthen Will-Power. • BL-42 tonifies the Lungs and settles the Corporeal Soul.

Herbal therapy

SUMMARY MIND WEAKENED – YIN DEFICIENCY, KIDNEYYIN DEFICIENCY Treatment principle Nourish Yin, calm the Mind and lift mood. Points KI-3 Taixi, KI-6 Zhaohai, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, Du-20 Baihui. Reinforcing method.

Prescription MAI WEI DI HUANG WAN Ophiopogon-Schisandra-Rehmannia Pill Explanation This is a variation of the previous formula, with the addition of Mai Men Dong Radix Ophiopogonis and Wu Wei Zi Fructus Schisandrae, which nourish Lung-Yin. The main physical manifestations, in addition to those of Liu Wei Di Huang Wan, are therefore a dry cough, a dry throat, slight breathlessness and possibly blood-flecked sputum.

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Mental-emotional pattern All the mental-emotional characteristics of the previous case apply here. The main difference is that, in this case, the Corporeal Soul is affected, and this condition may be caused by emotions that injure the Lungs, such as sadness, worry and grief. In terms of mental-emotional manifestations, this person will probably somatize the emotions on the skin, which will be dry with skin rashes. This person will also tend to be more melancholic, sad and apt to hanker nostalgically after the past. Prescription DI PO TANG Earth Corporeal Soul Decoction Explanation This formula nourishes Lung-Yin, roots the Corporeal Soul into the Lungs and subdues rebellious Lung-Qi. Mental-emotional pattern This formula is from the Discussion on Blood Diseases (1884) and is for mental confusion and restlessness resulting from an unsettled Corporeal Soul. The patient is mildly restless, depressed and slightly confused, and has palpitations, symptoms occurring against a background of deficient Lung-Yin not rooting the Corporeal Soul. Please note that Mu Li Concha Ostreae can be replaced by Suan Zao Ren Semen Ziziphi spinosae.

SUMMARY MIND WEAKENED – YIN DEFICIENCY, LUNGAND KIDNEY-YIN DEFICIENCY Treatment principle Nourish Lung- and Kidney-Yin, strengthen WillPower and settle the Corporeal Soul. Points LU-9 Taiyuan, LU-5 Chize, KI-3 Taixi, Ren-4 Guanyuan, LU-7 Lieque and KI-6 Zhaohai, BL-23 Shenshu, BL-52 Zhishi, BL-42 Pohu. Reinforcing method. Herbal therapy Prescription MAI WEI DI HUANG WAN Ophiopogon-Schisandra-Rehmannia Pill

Prescription DI PO TANG Earth Corporeal Soul Decoction

Case history A 35-year-old man presented with insomnia (waking up during the night), slight anxiety, depression, lack of concentration, numbness of the hands at night, a dry mouth, a feeling of heat in the evening and palpitations. His eyes lacked glitter and were unstable, his tongue was Red, with a Heart crack and without enough coating (Plate 16.7), and his pulse was Rapid and Moving. Diagnosis The pattern is Heart-Yin deficiency, and the patient’s eyes and pulse (Moving quality) clearly point to shock as the cause of the disease. When asked about it, he confirmed that he had suffered a tremendous shock when his brother was murdered a few years before. Treatment principle Nourish the Heart, tonify Yin, open the Heart’s orifices and calm the Mind. It is necessary to open the Heart’s orifices, as shock “closes” the Heart. Acupuncture The main points used (with reinforcing method) were as follows. • HE-7 Shenmen, SP-6 Sanyinjiao and Ren-14 Juque to nourish the Heart and calm the Mind. • Ren-15 Jiuwei and BL-15 Xinshu to open the Heart’s orifices. • Ren-4 Guanyuan to nourish Yin and root the Mind. Herbal therapy The formula used was a variation of Mai Wei Di Huang Wan Ophiopogon-SchisandraRehmannia Pill. • • • • • •

Shu Di Huang Radix Rehmanniae preparata 12 g Ren Shen Radix Ginseng 6 g Ze Xie Rhizoma Alismatis 6 g Fu Shen Sclerotium Poriae cocos pararadicis 6 g Mai Men Dong Radix Ophiopogonis 9 g Wu Wei Zi Fructus Schisandrae 6 g

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

• Yuan Zhi Radix Polygalae 6 g • Shi Chang Pu Rhizoma Acori tatarinowii 6 g • Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g Explanation The original formula nourishes Lung- and Kidney-Yin but, modified as above, it can nourish Heart-Yin and calm the Mind. • Shu Di, besides tonifying the Kidneys, also enters the Heart and therefore settles the Mind. • Shan Zhu Yu and Mu Dan Pi were eliminated; they are in the original formula to nourish the Liver, which is not deficient in this case. • Shan Yao was replaced by Ren Shen, as this enters the Heart. Also, in combination with Wu Wei Zi and Mai Men Dong (see below), it makes the Sheng Mai Tang, which nourishes Qi and Yin of the Heart. • Ze Xie combines with Shu Di Huang to clear any Empty Heat. • Fu Ling was replaced with Fu Shen to calm the Mind. • Mai Dong and Wu Wei Zi are part of the original prescription and they both enter the Heart. • Yuan Zhi and Chang Pu open the Heart’s orifices. They are both pungent and therefore scattering and are coordinated with Wu Wei Zi, which is sour and absorbing. • Zhi Gan Cao harmonizes. This patient was treated for 9 months, producing an all-round improvement in his physical and mental symptoms.

Kidney- and Liver-Yin deficiency Treatment principle Nourish Kidney- and Liver-Yin, strengthen the Will-Power and settle the Ethereal Soul.

Acupuncture Points KI-3 Taixi, KI-6 Zhaohai, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-8 Ququan, BL-23 Shenshu, BL-52 Zhishi, BL-47 Hunmen. Reinforcing method. Explanation • KI-3, KI-6, SP-6, Ren-4 and LIV-8 nourish Kidneyand Liver-Yin. • BL-23 and BL-52 strengthen the Kidneys and WillPower.

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• BL-47 settles the Ethereal Soul. The combination of BL-47, BL-23 and BL-52 is excellent to relieve mental depression deriving from a deficiency of Liver and Kidneys.

Herbal therapy Prescription DA BU YIN JIAN Great Tonifying Yin Decoction Explanation This formula is for deficiency of Kidneyand Liver-Yin. The main manifestations are dizziness, tinnitus, backache, weak knees, blurred vision, dry eyes, night sweating, five-palm heat, headache, a Red tongue without coating and a Floating-Empty pulse. Mental-emotional pattern Fear, shock and guilt may cause a deficiency of Kidney and Liver-Yin in the same way as mentioned above. In this case, the Mind, Ethereal Soul and Will-Power are all affected. This person may feel exhausted and depressed and lack will-power. As the Ethereal Soul is deprived of its residence, he or she will also feel aimless and sleep badly. Prescription ZUO GUI WAN Restoring the Left [Kidney] Pill Explanation This formula nourishes Liver- and Kidney-Yin. Its emphasis is on strengthening the tendons and bones, tissues related to Liver and Kidneys, respectively. Niu Xi and Lu Jiao have this function in the prescription. There is a correlation between the physical aspect of strengthening tendons and bones with herbs that act on the Liver and Kidneys and the strengthening of the Ethereal Soul and Will-Power related to these organs. The main physical manifestations for this formula are, apart from other Yin-deficiency symptoms as above, weakness, stiffness and ache of the lower back and knees, a cold sensation of legs, knees and lower back, dizziness and a headache with a feeling of emptiness of the head. Please note that this formula contains Lu Jiao Cornu Cervi, the use of which is not allowed in European Union countries; it can be removed from the formula without altering it substantially.

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Mental-emotional pattern The same emotions mentioned for the previous two formulae may lead to this condition. Alternatively, a weakness of the Liver and Kidneys from overwork and excessive sexual activity, or simply from old age, may cause this condition. This person will feel exhausted and depressed and will lack will-power. In the same way that there is physical stiffness in the back, this person may tend to be rather rigid in his or her mental attitude. Three Treasures remedy Nourish the Root Nourish the Root nourishes Kidneyand Liver-Yin and strengthens Will-Power (Zhi).

SUMMARY MIND WEAKENED – YIN DEFICIENCY, KIDNEYAND LIVER-YIN DEFICIENCY Treatment principle Nourish Kidney- and Liver-Yin, strengthen the Will-Power and settle the Ethereal Soul. Points KI-3 Taixi, KI-6 Zhaohai, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-8 Ququan, BL-23 Shenshu, BL-52 Zhishi, BL-47 Hunmen. Reinforcing method. Herbal therapy Prescription DA BU YIN JIAN Great Tonifying Yin Decoction Prescription ZUO GUI WAN Restoring the Left [Kidney] Pill Three Treasures remedy Nourish the Root

Case history A 39-year-old woman complained of an irregular menstrual cycle (always late) with some premenstrual tension, a lack of will-power and insomnia (waking up during the night). Her eyes often felt very dry. She also felt generally very tired, both physically and mentally. She had had a lot of stress in the past due to a difficult divorce and

she now felt aimless, was undecided about her current relationship and did not know what direction to take in her life. Her tongue was Red, with a Heart crack, almost entirely without coating (Plate 16.8), and her pulse was Empty on the deep level on the left side and Choppy on the right. The pulse also completely lacked any wave. Diagnosis This is a clear pattern of Liver-Yin deficiency, even though there are not many symptoms. However, the pulse and tongue clearly indicate Yin deficiency, and the insomnia, late menstrual cycle and dry eyes allow us to locate the Yin deficiency in the Liver. Most of all, the feeling of being aimless, the indecision and lack of direction in life clearly point to the Ethereal Soul being deprived of its root in Liver-Yin. Secondary to Liver-Yin deficiency, there was some Liver-Qi stagnation manifested in the premenstrual tension. The lack of wave in the pulse points to sadness as the emotion at the root of the problem. Different individuals react in different ways to the stresses of life. When going through a painful and stressful divorce, some may feel angry, some worried, some discouraged, etc. This woman reacted by feeling very sad about the breaking up of her marriage, and sadness weakened Liver-Blood and Liver-Yin. Treatment principle Nourish Yin, strengthen the Liver and root the Ethereal Soul. Acupuncture This patient was treated only four times, with very good results. The first treatment consisted only in the opening points of the Yin Linking Vessel, i.e. P-6 Neiguan on the right and SP-4 Gongsun on the left. This extraordinary vessel nourishes Yin and roots the Ethereal Soul. In the second treatment, the opening points of the Yin Linking Vessel were repeated, with the addition of SP-6 Sanyinjiao and Ren-15 Jiuwei (both reinforced) to help to nourish Yin and root the Ethereal Soul. In the third and fourth treatments, the above points were needled again with the addition of the following points. • ST-36 Zusanli and LIV-8 Ququan to nourish the Liver. • BL-23 Shenshu, BL-52 Zhishi and BL-47 Hunmen to nourish the Kidneys and Liver and to root the

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

Ethereal Soul. The Kidneys were treated not because there was any Kidney deficiency but because Liver and Kidneys share a common root, and the points BL-52 and BL-42, combined with BL-23, strengthen the Will-Power, root the Ethereal Soul and help a person find a sense of direction. After these four treatments, the patient felt much better, more positive and decisive, so much so that she decided to break off her current troubled relationship, which she felt very good about.

Case history A 32-year-old woman complained of fatigue, hypochondrial pain, a feeling of oppression of the chest and an ache behind the eyes. Her periods were always late and painful, and the menstrual blood was dark with clots. Her sleep was restless and disturbed by many dreams, she felt hot in the evenings and her vision was sometimes blurred. She felt aimless and lacked a sense of direction in her life. She was at a crossroads in both her work and a personal relationship, and she often felt that she “did not see the point of it all”. Her tongue was Red and without coating. Her pulse was Floating-Empty and Fine but also slightly Wiry on the left side. Diagnosis This is another clear example of Liver-Yin deficiency, as in the previous patient. In this case, however, there is a much more pronounced stagnation of Liver-Qi and Liver-Blood (hypochondrial pain, feeling of oppression of the chest, painful period with dark blood). In this case too, stagnation of Liver-Qi is secondary to Liver-Yin deficiency. The deficient Liver-Yin fails to root the Ethereal Soul, and this causes the feeling of aimlessness in her life and dream-disturbed sleep.

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• Ren-15 Jiuwei and BL-47 Hunmen to root the Ethereal Soul. Herbal therapy The formula used was a variation of Da Bu Yin Jian Great Tonifying Yin Decoction. • • • • • • • • • • • •

Shu Di Huang Radix Rehmanniae preparata 12 g Shan Yao Radix Dioscoreae 9 g Shan Zhu Yu Fructus Corni 4 g Gou Qi Zi Fructus Lycii chinensis 9 g Dang Gui Radix Angelicae sinensis 6 g Dang Shen Radix Codonopsis 6 g Du Zhong Cortex Eucommiae 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g Chuan Lian Zi Fructus Toosendan 4 g Mei Gui Hua Flos Rosae rugosae 3 g Yi Mu Cao Herba Leonuri 4 g Suan Zao Ren Semen Ziziphi spinosae 4 g

Explanation The formula was left unchanged apart from the dosages, which were reduced. Du Zhong could have been eliminated, as there is no Kidney deficiency, but it was left in for its mental effect of strengthening the Will-Power and providing a strong basis for the Ethereal Soul. • Chuan Lian Zi and Mei Gui Hua move Liver-Qi without injuring Yin. • Yi Mu Cao invigorates Liver-Blood. • Suan Zao Ren, sour and astringent, roots the Ethereal Soul and calms the Mind. Apart from an improvement in her menstrual cycle, this patient felt a lot stronger, more focused and determined after 3 months’ treatment.

Kidney-Essence deficiency Treatment principle Nourish the Kidneys, tonify the Essence and strengthen Will-Power.

Treatment principle Nourish Liver-Yin, move LiverQi and Liver-Blood and root the Ethereal Soul.

Acupuncture

Acupuncture The main points used were as follows. • LIV-8 Ququan, ST-36 Zusanli, Ren-4 Guanyuan and SP-6 Sanyinjiao, reinforced, to nourish Liver-Yin. • LIV-3 Taichong and G.B.-34 Yanglingquan, with even method, to move Liver-Qi and Liver-Blood.

Points Ren-4 Guanyuan, Ren-7 Yinjiao, BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, SP-6 Sanyinjiao, G.B.-13 Benshen, Du-20 Baihui. Reinforcing method. These points are suitable to treat both Kidney-Yang and Kidney-Yin deficiency, depending on whether one uses moxa or not.

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Explanation • Ren-4 and Ren-7 nourish the Essence. • BL-23 and BL-52 tonify the Kidneys and strengthen Will-Power. • KI-3 and SP-6 nourish Kidney-Yin. • G.B.-13 gathers Essence to the brain. • Du-20 raises clear Qi and lifts depression.

Herbal therapy Prescription HE CHE DA ZAO WAN Placenta Great Fortifying Pill Explanation This formula’s emphasis is on tonification of the Essence. Zi He Che, Wu Wei Zi, Gou Qi Zi and Suo Yang all benefit the Essence. Its secondary therapeutic aim is also to tonify Kidney-Yang. This formula is therefore well adapted to treat complicated cases of deficiency of all aspects of the Kidneys: Yin, Essence and Yang. It should be noted that the above doses are to make a quantity of pills, not for individual daily decoctions. The daily dosages of a decoction can be adapted according to proportions. The main manifestations for this prescription would be exhaustion, depression, weak back and knees, weak sexual function (lack of desire or impotence), nocturnal emissions, weak teeth, prematurely grey or falling hair, dizziness, tinnitus, night sweating, a thin body, a Red tongue without coating and a Floating-Empty pulse. Please note that the use of placenta is not allowed in European Union countries; it can be removed from the formula. Mental-emotional pattern Fear, shock and guilt may cause a deficiency of Kidney-Yin and KidneyEssence, or vice versa; this may be the result of overwork and excessive sexual activity. In women, it may result from too many childbirths or prolonged loss of blood with the periods over many years. This person will feel mentally and physically exhausted and depressed, and he or she will lack will-power and initiative. He or she may also suffer from some deficiency in sexual function, such as lack of desire or impotence. Modifications The following are modifications that apply to all four formulae above. It should, first of all,

be noted that, when nourishing Kidney-Yin in mentalemotional problems, it is advisable to add one or two Kidney-Yang tonics in a small dosage. This is necessary to make the formula more moving and dynamic and thus affect the Mind and Will-Power more readily. In chronic depression especially, one of the clear features of the condition is the way the patient is “stuck” in a mental-emotional pattern from which it is very difficult to break out. A certain resistance to treatment, hopelessness and despair are typical of chronic depression. In such cases, assuming they present with a configuration of Yin deficiency, it is important to add some Kidney-Yang tonics to invigorate Yang and provide movement to the prescription. In particular, one would choose those Kidney-Yang tonics that are pungent in taste, as this taste moves and invigorates. Two examples are Du Zhong Cortex Eucommiae ulmoidis and Ba Ji Tian Radix Morindae officinalis. Of course, some of the above four prescriptions already contain some Kidney-Yang tonics. Another frequent addition to the above Yinnourishing prescriptions is Shi Chang Pu Rhizoma Acori tatarinowii to open the Mind’s orifices, clear the Mind and lift mood. This would be an essential addition to all four previous prescriptions. It is also pungent in taste and would therefore also have a beneficial moving effect as the Yang tonics mentioned above.

SUMMARY MIND WEAKENED – YIN DEFICIENCY, KIDNEYESSENCE DEFICIENCY Treatment principle Nourish the Kidneys, tonify the Essence and strengthen Will-Power. Points Ren-4 Guanyuan, Ren-7 Yinjiao, BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, SP-6 Sanyinjiao, G.B.-13 Benshen, Du-20 Baihui. Reinforcing method. These points are suitable to treat both KidneyYang and Kidney-Yin deficiency, depending on whether one uses moxa or not. Herbal therapy Prescription HE CHE DA ZAO WAN Placenta Great Fortifying Pill

Patterns in Mental-Emotional Problems and their Treatment with Herbal Medicine and Acupuncture

NOTE As will be remembered, the main treatment methods used in mental-emotional problems were five: 1. nourish the Heart and calm the Mind 2. clear pathogenic factors and calm the Mind 3. clear pathogenic factors, nourish the Heart and calm the Mind 4. resolve Phlegm, open the orifices and calm the Mind 5. sink and calm the Mind. The first four have all been discussed when dealing with the various patterns of mental-emotional problems. We should now discuss the fifth method of treatment, and that is to sink and calm the Mind. This consists of the use of minerals and shells, which have a high density and are heavy. The traditional idea is that they weigh on the Heart to sink the Mind, thus relieving anxiety, agitation and insomnia when these are caused by rebellious Qi. This is usually either Liver-Yang or Liver-Wind rising or Heart Empty Heat. These substances may be added to any of the formulae we discussed to treat the Manifestation whenever the symptoms are severe, i.e. very severe agitation, intractable insomnia, intense anxiety and, in serious cases, violent behaviour. All these substances have side effects, because they are indigestible and therefore their prolonged use may injure the Stomach and Spleen. For this reason, they are usually combined with digestive herbs. Please note that the use of minerals is not allowed in European Union countries. The main sinking substances that calm the Mind are: • • • • • •

Long Gu Mastodi Ossis fossilia Long Chi Fossilia Dentis Mastodi Mu Li Concha Ostreae Ci Shi Magnetitum Zhen Zhu Mu Concha margaritiferae Hu Po Succinum.

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Long Chi, Long Gu and Mu Li are all astringent and therefore also nourish Yin. Mu Li is especially good at nourishing Yin, while Long Chi is the best of the three to sink and calm the Mind. Ci Shi and Zhen Zhu Mu both sink Liver-Yang and Liver-Wind. Hu Po, besides sinking and calming the Mind, also invigorates Blood and enters the Liver; this makes it useful to treat depression and anxiety from Liver-Qi or Liver-Blood stagnation. As for sinking and calming the Mind prescriptions, these have not been mentioned because many of them contain many indigestible and often toxic minerals. Their use is not often necessary. Most mental-emotional problems can be treated by the prescriptions discussed above, with the addition of one or two sinking substances if the manifestations call for it.

END NOTES 1. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 168. First published c.100 BC. 2. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 72. First published c.100 BC. 3. Ibid., p. 120. 4. Simple Questions, p. 319. 5. Wang Luo Zhen 1985 Qi Jing Ba Mai Kao Jiao Zhu [A Compilation of the Study of the Eight Extraordinary Vessels]. Shanghai Science Publishing House, Shanghai, p. 129. The Study of the Eight Extraordinary Vessels was written by Li Shi Zhen and first published in 1578. 6. Shan Chang Hua 1990 Jing Xue Jie [An Explanation of the Acupuncture Points]. People’s Health Publishing House, Beijing, p. 31. An Explanation of the Acupuncture Points was written by Yue Han Zhen and first published in 1654. 7. Ibid., p. 45. 8. Ibid., p. 88. 9. 1981 Jin Gui Yao Lue Fang Xin Jie [A New Explanation of the Essential Prescriptions of the Golden Chest]. Zhejiang Scientific Publishing House, p. 24. The Essential Prescriptions of the Golden Chest was written by Zhang Zhong Jing and first published c.AD 220. 10. Ibid., p. 24. 11. An Explanation of Acupuncture Points, pp. 26–27. 12. Ibid., p. 28.

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CHAPTER 17

TINNITUS

TINNITUS

AETIOLOGY 493 Emotional strain 493 Overwork 494 Old age 494 Diet 494 Excessive sexual activity 494 Exposure to loud sounds 494 PATHOLOGY

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IDENTIFICATION OF PATTERNS AND TREATMENT FULL 496 Liver-Yang rising 496 Rising of Liver- and Gall Bladder-Fire 497 Liver-Wind 499 Phlegm-Fire flaring upwards 499 EMPTY 501 Kidney-Essence deficiency 501 Upper Burner Qi weak 503 Heart-Blood deficiency 504 MODERN CHINESE LITERATURE PROGNOSIS

504

505

Full • Liver-Yang rising • Rising of Liver- and Gall Bladder-Fire • Liver-Wind • Phlegm-Fire flaring upwards Empty • Kidney-Essence deficiency • Upper Burner Qi weak • Heart-Blood deficiency

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Tinnitus indicates the subjective sensation experienced on hearing a noise in one or both ears. The noise may be constant or come in bouts and may vary in intensity and character. It may sound like a high-pitched whistle, like bells, like an engine running or like rushing water. Although the Kidneys open into the ears, many other organs influence the ears and may be involved in causing tinnitus. The Gall Bladder channel, for example, flows through the ear and is very much involved in ear problems, especially those of an Excess nature. The ears are also influenced by the Heart, as it is one of the functions of the Mind (Shen) to control the sense orifices and senses, and by the Lungs, as they house the Corporeal Soul, which influences all senses. Please note that the identification of patterns and treatment of tinnitus largely applies also to deafness. The discussion of tinnitus will be conducted according to the following topics. • • • • •

Aetiology Pathology Identification of patterns and treatment Modern Chinese literature Prognosis

AETIOLOGY Emotional strain Emotional problems such as anger, frustration, resentment, hatred or guilt cause Liver-Qi stagnation and, in the long run, Liver-Fire, which may rise upwards to disturb the ears. This may cause tinnitus with a sudden onset and a loud noise.

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Emotions such as sadness, grief and worry, which weaken Lungs and Heart, may also lead to tinnitus. This occurs when deficient Heart- and Lung-Qi fail to rise to the head to brighten the ear orifices.

Overwork Overwork, in the sense of working long hours without adequate rest for years, weakens the Kidneys so that they cannot nourish the ear, and tinnitus may result. This type of tinnitus is of gradual onset, and the noise is of low pitch. This is the most common cause of tinnitus.

Old age Kidney-Essence declines naturally as we grow older, and in old people it may fail to nourish the ears and brain, leading to tinnitus. This does not mean, of course, that every old person will inevitably suffer from tinnitus. This type of tinnitus would also have a very gradual onset and a low pitch.

Diet Excessive consumption of dairy products and greasy foods, together with irregular eating habits, may lead to the formation of Phlegm, which may rise to the head. Here, it prevents the rising of clear Qi to the head to brighten its orifices (which include the ears) and the descending of turbid Qi from the head, resulting in tinnitus and dizziness.

Excessive sexual activity Excessive sexual activity in men weakens the Kidneys, as sperm is Tian Gui, i.e. a direct manifestation of Kidney-Essence. The deficient Kidney-Essence fails to nourish the ears and tinnitus results (low pitch).

Exposure to loud sounds Long-term exposure to very loud sounds, such as occur in certain factories or in discotheques where loud rock music is played, may also cause tinnitus. From the Chinese perspective, this usually manifests with Full condition.

SUMMARY AETIOLOGY  Emotional strain  Overwork  Old age  Diet  Excessive sexual activity  Exposure to loud sounds

PATHOLOGY Each of the Five Yin Internal Organs controls a sense and a sense orifice, for example Kidneys and ears, Liver and eyes. The Kidneys nourish the ears and promote hearing, and a Kidney pathology is the first one we would think of in tinnitus and deafness. As we shall see below, however, other Internal Organs are also involved. The ears rely on the nourishment of the Essence for their proper functioning, and they are therefore physiologically related to the Kidneys. The Spiritual Axis in Chapter 17 says: “The Kidneys open into the ears; if the Kidneys are healthy, the ears can hear the five sounds.”1 If the Kidneys are weak, hearing may be impaired and there may be tinnitus. Thus if Kidney-Essence declines (as it does in old age), it may fail to reach and nourish the ears and tinnitus and/or deafness may result. Other Internal Organs beside the Kidneys influence the ears and hearing. The Heart controls hearing and the ears simply because the Mind (Shen) controls and coordinates all senses and sense organs. The Mind is responsible for all sensory perceptions. Each sense is related to a certain organ, i.e. smell to the Lungs, taste to the Spleen and Heart, hearing to the Kidneys and sight to the Liver. However, all senses rely also on the Heart, because it is the Mind that ultimately receives the sensory perceptions. Hearing depends on the Kidneys, but the Heart also has an influence on it in so far as it brings Qi and Blood to the ears. The Simple Questions in Chapter 4 says: “The colour of the Southern direction is red; it is related to the Heart, which opens into the ears ...”2 Some types of tinnitus are due to Heart-Qi and/or Heart-Blood being deficient and not reaching the ears.

Tinnitus

The Lungs also influence the ears because they house the Corporeal Soul, which is a physical soul that, apart from other functions, activates all senses and sense orifices. This is the reason why some people may still hear people around them after fainting; in such a situation, the Mind (Shen) is temporarily disabled but the Corporeal Soul is unaffected so that the person can hear. The Corporeal Soul affects hearing and ears also, because it brings the Essence into play in all physiological processes. The Corporeal Soul is called the “entering and exiting of Essence (Jing)”. Essence is the foundation for a healthy body, and the Corporeal Soul makes for sharp and clear sensations and movements. Through the Corporeal Soul, the Essence “enters and exits”, which allows it to play a role in all physiological processes and all senses. Thus, the Kidneys, Heart and Lungs are the three Internal Organs that most affect the ears and hearing (Fig. 17.1). A factor in the health of the senses and sense orifices is the balance of Yin and Yang in the head. The clear Yang rises to the head, where it “brightens” the sense orifices and allows us to have normal sight, hearing, smell and taste. On the other hand, the turbid Yin descends away from the head. The Divergent channels play an important role in maintaining the balance of Yin and Yang in the head, i.e. ensuring the rise of clear Yang and the descent of turbid Yin from the head (Fig. 17.2). Four of the Upper Meeting points of the Divergent channels are also Window of Heaven points (T.B.-16 Tianyou, BL-10 Tianzhu, ST-9 Renying and L.I.-18 Futu); the Window of Heaven points also have the function of regulating the ascent of clear Yang and descent of turbid Yin to and from the head.

BL-1 ST-1

G.B.-1

T.B.-16

Clear Yang rising

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ST-9

L.I.-18

BL-10 Turbid Yin descending

Figure 17.2 Balance of Yin and Yang in the head.

Therefore, some types of tinnitus are due to the failure of the clear Yang to rise to the head (e.g. Heartand Lung-Qi not reaching the head); others are due to the failure of turbid Yin to descend (Phlegm in the head); yet others are due to lack of nourishment of the ears (Kidney-Essence not reaching the ears and Brain). Apart from the Internal Organs, many channels influence the ears: the Gall Bladder, Triple Burner, Small Intestine, Bladder, Stomach and Large Intestine Muscle channel (Fig. 17.3).

Gall Bladder Main Channel EARS Brings clear Yang to the head

LUNG-QI

Bladder Main Channel Brings Blood to the head

Nourishes the ears KIDNEYESSENCE

Figure 17.1 Internal Organs affecting the ears.

HEARTBLOOD

Small Intestine Main Channel Triple Burner Main Channel Large Intestine Connecting Channel Stomach Main Channel Figure 17.3 Channels affecting the ears.

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CLINICAL NOTE Channels influencing the ear  Gall Bladder  Triple Burner  Small Intestine  Bladder  Stomach  Large Intestine Connecting channel

Apart from being affected by the lack of nourishment brought to them by the Internal Organs, ears and hearing are also negatively affected when they are obstructed by a pathogenic factor. Phlegm is the main pathogenic factor that affects the ears, because this pathogenic factor is particularly “obstructive” (compared with Dampness, for example) and, when in the head, it obstructs the sense orifices. In the ears, it may cause tinnitus and/or deafness. This tinnitus is not caused by a lack of nourishment, as in Empty causes, but by the obstruction of Phlegm, which prevents the clear Yang from rising and brightening the orifices and the turbid Qi from descending. Incidentally, when it obstructs the eyes, Phlegm is also a frequent cause of blurred vision. Thus, as always, the most important differentiation is that between Full and Empty types of tinnitus. Full types of tinnitus are caused by the flaring up of some pathogenic factors disturbing the ear. These are usually Fire, Wind, Yang, Phlegm or Phlegm-Fire. The tinnitus deriving from exposure to loud sounds is also considered to be of the Full type and is treated as such. Empty types of tinnitus are due to not enough Qi (intended in a broad sense to include Blood and Essence) reaching the head and ears. This may be Kidney-Qi, Kidney-Essence, Lung-Qi or Heart-Blood. From a diagnostic point of view, tinnitus with a sudden onset and a loud sound is of the Full type. It is also aggravated by cupping one’s hands over the ears. Tinnitus with a gradual onset and a low sound is of the Empty type. It is improved by cupping one’s hands over the ears.

SUMMARY PATHOLOGY  The Kidneys nourish the ears and promote hearing.

 The Heart controls hearing and the ears because the Mind (Shen) controls and coordinates all senses and sense organs.  The Lungs also influence the ears because they house the Corporeal Soul, which is a physical soul that activates all senses and sense orifices.  Thus, the Kidneys, Heart and Lungs are the three Internal Organs that most affect the ears and hearing.  Phlegm is the main pathogenic factor that affects the ears, because this pathogenic factor is particularly “obstructive” and, when in the head, it obstructs the sense orifices.  Some types of tinnitus are due to the failure of the clear Yang to rise to the head, others to the failure of turbid Yin to descend.

IDENTIFICATION OF PATTERNS AND TREATMENT The patterns discussed will be as follows. Full • Liver-Yang rising • Rising of Liver- and Gall Bladder-Fire • Liver-Wind • Phlegm-Fire flaring upwards Empty • Kidney-Essence deficiency • Upper Burner Qi weak • Heart-Blood deficiency

FULL Liver-Yang rising Clinical manifestations Tinnitus with high pitch and acute onset, dizziness, deafness, throbbing headaches, a dry throat, insomnia, irritability. Tongue: normal or slightly Red sides. Pulse: Wiry.

Treatment principle Subdue Liver-Yang, nourish Liver and Kidneys.

Tinnitus

Acupuncture

Prescription

Points

LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction

T.B.-5 Waiguan, G.B.-43 Xiaxi, T.B.-3 Zhongzhu, LIV-3 Taichong, G.B.-2 Tinghui, T.B.-21 Ermen, T.B.-17 Yifeng. All with reducing or even method. Other points should be added to treat the Root, i.e. the cause of Liver-Yang rising, which may be LiverBlood, Liver-Yin and Liver- and Kidney-Yin deficiency. Please see Chapter 1 (Headaches) under the pattern of Liver-Yang rising.

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Explanation This formula subdues Liver-Yang, nourishes Yin and resolves Phlegm. Its Yin-nourishing effect is mild.

Three Treasures remedy Bend Bamboo Bend Bamboo subdues Liver-Yang and nourishes Liver-Blood.

Explanation • T.B.-5 and G.B.-43 are the main distal points to subdue Liver-Yang in the ear region. • T.B.-3 subdues Liver-Yang and eases the ears. • LIV-3 subdues Liver-Yang in general. • G.B.-2, T.B.-21 and T.B.-17 are local points for tinnitus, especially that related to the Gall Bladder channel. Chinese doctors stress that, when selecting local points for the ear, it is good to combine points in the front (e.g. G.B.-2 Tinghui) with some behind the ear (e.g. T.B.-17 Yifeng).

Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction

Explanation This prescription is very widely used for headaches from Liver-Yang rising. It subdues Liver-Yang and tonifies the Liver and Kidneys.

SUMMARY LIVER-YANG RISING Points T.B.-5 Waiguan, G.B.-43 Xiaxi, T.B.-3 Zhongzhu, LIV-3 Taichong, G.B.-2 Tinghui, T.B.-21 Ermen, T.B.-17 Yifeng. All with reducing or even method. Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Subduing Wind Decoction Prescription LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction Three Treasures remedy Bend Bamboo

Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Subduing Wind Decoction

Rising of Liver- and Gall Bladder-Fire

Explanation

Clinical manifestations

The main difference between this prescription and the previous one is that the latter nourishes the Yin more and is therefore suitable when there is a pronounced deficiency of Liver- and Kidney-Yin. Please note that Dai Zhe Shi is not suitable for long-term use and is contraindicated in pregnancy. It could be eliminated from this prescription or replaced with Zhen Zhu Mu Concha Margatiriferae usta, which a sinking substance that subdues Liver-Yang.

Tinnitus with a sudden onset and high pitch and clearly related to emotional strain, headache, irritability, a bitter taste, thirst, red face, dizziness, constipation. Tongue: Red with redder sides, yellow coating. Pulse: Wiry and Rapid.

Treatment principle Drain Liver-Fire, ease the ears, calm the Mind and settle the Ethereal Soul.

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Acupuncture

SUMMARY

Points

RISING OF LIVER- AND GALL BLADDER-FIRE

LIV-2 Xingjian, T.B.-17 Yifeng, G.B.-2 Tinghui, T.B.-5 Waiguan, T.B.-3 Zhongzhu, G.B.-43 Xiaxi, G.B.-20 Fengchi, G.B.-8 Shuaigu. Reducing or even method.

Points LIV-2 Xingjian, T.B.-17 Yifeng, G.B.-2 Tinghui, T.B.-5 Waiguan, T.B.-3 Zhongzhu, G.B.-43 Xiaxi, G.B.-20 Fengchi, G.B.-8 Shuaigu. Reducing or even method.

Explanation • LIV-2 drains Liver-Fire. • T.B.-17 and G.B.-2 are the main local points for this type of tinnitus. The needle should be inserted to a depth of 1 cun and the needling sensation should be very strong. • T.B.-5 subdues Liver-Yang. • T.B.-3 subdues Liver-Yang and eases the ears. • G.B.-43 drains Gall Bladder-Fire and affects the ears. • G.B.-20 subdues Liver-Yang and eases the ear if needled with the tip of the needle pointing towards the area between eye and ear on the same side. In other words, the needle is oblique towards the front of the face. • G.B.-8 is an adjacent point that eases the ear and subdues Liver-Yang.

Herbal therapy Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction

Explanation This formula, which has already been explained in Chapters 1 and 10, is suitable to treat tinnitus without modifications.

Modifications • To direct the prescription to the ears, add Ci Shi Magnetitum. Especially in combination with Chai Hu, this substance directs other herbs to the ear. • If there are symptoms of Liver-Yang or Liver-Wind rising, add Tian Ma Rhizoma Gastrodiae elatae, Gou Teng Ramulus Uncariae and Shi Jue Ming Concha Haliotidis. • If there is constipation and a very thick and dry tongue coating, add Da Huang Rhizoma Rhei.

Three Treasures remedy Drain Fire Drain Fire is a variation of Long Dan Xie Gan Tang; it drains Liver-Fire and Heart-Fire.

Herbal therapy Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction Three Treasures remedy Drain Fire

Case history A 39-year-old man had been suffering from tinnitus for 1 year. It had started fairly suddenly and was of a high pitch. It was better with rest and worse when under stress. He did not have any other symptom. His tongue was Red, redder on the sides, with a yellow coating. His pulse was very Full and Wiry, and slightly Rapid and slightly Weak on both Rear positions. Diagnosis His tinnitus was due primarily to Liverand Gall Bladder-Fire blazing upwards. Although he did not have many symptoms, the high pitch of the tinnitus, its aggravation under stress and, most of all, the tongue indicated Liver-Fire. However, there was also an underlying slight deficiency of Kidney-Yin, as shown by the pulse being Weak on both Rear positions and also by the fact that the tinnitus improved with rest. This is probably the reason why the tinnitus started at an age when Kidney-Qi is just beginning to decline. Treatment principle Clear the Liver and Gall Bladder, drain Fire, benefit the ears and nourish Kidney-Yin. Acupuncture T.B.-2 Yemen, L.I.-4 Hegu, LIV-2 Xingjian, G.B.-43 Xiaxi, T.B.-17 Yifeng, G.B.-2 Tinghui, SP-6 Sanyinjiao and KI-3 Taixi. The first six points were reduced, while the last two were reinforced.

Tinnitus

Explanation • T.B.-2 indirectly subdues Liver-Fire and benefits the ear. It is an important distal point for tinnitus of the Excess type. • L.I.-4 was used as a distal point to affect the ear and also to calm the Mind. • LIV-2 and G.B.-43 clear Liver-Fire and Gall BladderFire, respectively. G.B.-43 also affects the ear. • T.B.-17 and G.B.-2 are the main local points for tinnitus of the Excess type. • SP-6 and KI-3 nourish Kidney-Yin. Herbal therapy No herbs were prescribed, but two patent remedies were used: Long Dan Xie Gan Wan Gentiana Draining the Liver Pill (eight pills twice a day) to drain Liver- and Gall Bladder-Fire and Er Ming Zuo Ci Wan Tinnitus Pill that is Kind to the Left [Kidney] (a small dose of six pills a day in the evening) to nourish Kidney-Yin.

Liver-Wind Clinical manifestations Tinnitus in the elderly, high pitch, dizziness, vertigo, numbness of limbs, tremors, tics. Tongue: the colour of the tongue body depends on the underlying cause of Wind. Pulse: Wiry.

Treatment principle

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• G.B.-2 and T.B.-17 are local points to ease the ears in Liver and Gall Bladder channels’ pathology.

Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction

Prescription ZHEN GAN XI FENG TANG Calming the Liver and Subduing Wind Decoction Both these prescriptions have been discussed under Liver-Yang rising.

SUMMARY LIVER-WIND Points LIV-3 Taichong, SP-6 Sanyinjiao, G.B.-20 Fengchi, Du-16 Fengfu, G.B.-2 Tinghui, T.B.-17 Yifeng. Reducing method except on SP-6, which should be reinforced. Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction Prescription ZHEN GAN XI FENG TANG Calming the Liver and Subduing Wind Decoction

Extinguish Wind, pacify the Liver, ease the ears.

Acupuncture Points LIV-3 Taichong, SP-6 Sanyinjiao, G.B.-20 Fengchi, Du-16 Fengfu, G.B.-2 Tinghui, T.B.-17 Yifeng. Reducing method except on SP-6, which should be reinforced.

Explanation • LIV-3 extinguish Liver-Wind. • SP-6 is tonified to nourish Yin and Blood, which is always necessary in order to subdue internal Wind. • G.B.-20 subdues Wind (both internal and external). • Du-16 extinguishes internal Wind and relieves headache.

Phlegm-Fire flaring upwards Clinical manifestations Tinnitus sound like cicadas or crickets, impaired hearing, a feeling of oppression of the chest, expectoration of sputum, thirst, a feeling of muzziness and heaviness of the head, blurred vision, dizziness, feeling of heat, thirst but no desire to drink, mental restlessness. Tongue: Red, Swollen, sticky-yellow coating. Pulse: Slippery and Rapid.

Treatment principle Resolve Phlegm, drain Fire, subdue Liver-Yang, regulate the ascending of clear Qi and descending of turbid Qi, tonify the Spleen.

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Acupuncture

Three Treasures remedies

Points

Clear the Soul Clear the Soul resolves Phlegm-Heat mostly from the Heart and Lungs; it is a variation of Wen Dan Tang.

T.B.-21 Ermen, S.I.-19 Tinggong, G.B.-2 Tinghui, T.B.-5 Waiguan, T.B.-3 Zhongzhu, L.I.-4 Hegu, Ren-9 Shuifen, ST-40 Fenglong, SP-9 Yinlingquan, G.B.-20 Fengchi, Ren-12 Zhongwan, BL-20 Pishu. Reducing method on all points except the last two, which should be reinforced.

Settling the Soul Settling the Soul resolves PhlegmHeat from the Liver; it is a variation of Long Dan Xie Gan Tang. It also strongly calms the Mind, settles the Ethereal Soul and opens the Mind’s orifices.

Explanation • T.B.-21 is the main local point for this type of tinnitus. • T.B.-21, S.I.-19 and G.B.-2 can regulate the ascending of clear Qi to the ear and descending of turbid Qi away from the ear. Some doctors recommend needling these three points for five consecutive treatments, simultaneously horizontally from top to bottom, i.e. from T.B.-21 to G.B.-2; this makes the turbid Qi descend from the ear. Then needle the same three points for another five consecutive treatments, horizontally upwards, i.e. from G.B.-2 to T.B.-21; this makes the clear Qi ascend to the ear. • T.B.-5 and T.B.-3 subdue Liver-Yang and ease the ear. • L.I.-4 regulates the ascending of clear Qi and descending of turbid Qi in the head. • Ren-9, ST-40 and SP-9 resolve Phlegm. • G.B.-20 subdues Liver-Yang and eases the ear if needled, as explained for the previous pattern. • Ren-12 and BL-20 tonify the Spleen to resolve Phlegm.

Herbal therapy Prescription WEN DAN TANG Warming the Gall Bladder Decoction

Explanation This formula resolves Phlegm-Heat mostly from the chest.

Modifications • To direct the prescription to the ears, add Chai Hu Radix Bupleuri and Ci Shi Magnetitum. • If Phlegm is abundant, add Dan Nan Xing Rhizoma Arisaemae and Hai Fu Shi Pumice.

SUMMARY PHLEGM-FIRE FLARING UPWARDS Points T.B.-21 Ermen, S.I.-19 Tinggong, G.B.-2 Tinghui, T.B.-5 Waiguan, T.B.-3 Zhongzhu, L.I.-4 Hegu, Ren-9 Shuifen, ST-40 Fenglong, SP-9 Yinlingquan, G.B.-20 Fengchi, Ren-12 Zhongwan, BL-20 Pishu. Reducing method on all points except the last two, which should be reinforced. Herbal therapy Prescription WEN DAN TANG Warming the Gall Bladder Decoction Three Treasures remedies Clear the Soul Settling the Soul

Case history A 39-year-old man had been suffering from tinnitus for the previous 11 years. The tinnitus had started gradually, and he said it sounded like a jet engine. He also suffered from lower backache, dizziness, a slight loss of hearing and slight impotence with an occasional discharge of mucuslike substance from the penis. He also complained of diarrhoea or loose stools, a problem he had had since his teenage years. His stools were often mixed with some mucus. He slept badly, waking up frequently with a dry throat. He had some soft swellings under the skin on the limbs, which had been diagnosed as ganglioneuromas. Finally, he also complained of constant mucus on his chest and dryness of the mouth.

Tinnitus

His tongue and pulse were rather complex. His tongue was slightly Red, Swollen with swollen sides (of the Spleen type). The coating was rootless and missing in places. There was a deep Heart crack. His pulse was Fine on the right, slightly Slippery and Full on the left, with the left Front position (Heart) very slightly Overflowing but Empty and somewhat pointed in shape. Diagnosis There are three main problems, the longest-standing being Spleen deficiency leading to Phlegm. The Spleen deficiency causes diarrhoea and loose stools and a Fine pulse on the right side. Phlegm is reflected by the Slippery pulse, the presence of mucus in the stools, the discharge from the penis, the ganglioneuromas and the swelling of the tongue. The second problem is a Kidney-Yin deficiency reflected in the dizziness, loss of hearing, insomnia with dry throat at night and impotence. Finally, there is also some Stomach-Yin deficiency, which most probably preceded the Kidney-Yin deficiency. The Stomach-Yin deficiency is mirrored in the coating being rootless and missing in places and in the dryness of the mouth. Underlying all of this, there was also a certain deficiency of Heart-Qi from emotional problems obviously dating back to childhood or teenage years. One can tell this from the Heart crack on the tongue and the Heart pulse being slightly Overflowing but Empty. These two findings often indicate that the Heart is affected by emotional problems. That these date back to the patient’s early years is indicated by the depth of the crack; the deeper it is, the older the emotional problems that caused it. As for the tinnitus, this is caused by both an Excess and a Deficiency: Excess in the form of Phlegm obstructing the head’s orifices (in this case the ears) and Deficiency in the form of Kidney-Yin deficiency. Treatment principle Tonify the Spleen, resolve Phlegm, nourish Kidney-Yin and calm the Mind. Acupuncture Many different points were used at different times, but the main ones were as follows. • ST-36 Zusanli, Ren-12 Zhongwan and ST-40 Fenglong to tonify the Spleen and resolve Phlegm. • ST-25 Tianshu to stop diarrhoea. • KI-3 Taixi and Ren-4 Guanyuan to nourish KidneyYin.

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• HE-5 Tongli and HE-7 Shenmen to calm the Mind. • S.I.-19 Tinggong and T.B.-17 Yifeng as local points for the tinnitus. Herbal therapy No decoctions were used but herbal powders. The formulae used were Shen Ling Bai Zhu San Ginseng-Poria-Atractylodes Powder to tonify Spleen-Qi and Stomach-Yin and Ban Xia Bai Zhu Tian Ma Tang Pinellia-Atractylodes-Gastrodia Decoction to resolve Phlegm from the head. This patient is gradually improving and is still being treated at the time of writing.

EMPTY Kidney-Essence deficiency Clinical manifestations Tinnitus with gradual onset and low pitch, sometimes like rushing water and coming in bouts, slight dizziness, a feeling of emptiness of the head, poor memory, blurred vision, sore back and knees, diminished sexual desire or performance. Tongue: Pale or without coating depending on whether there is a deficiency of Kidney-Yang or Kidney-Yin. Pulse: Deep and Weak if there is Kidney-Yang deficiency and Floating-Empty in case of Kidney-Yin deficiency. • If the Kidneys and Heart are not harmonized, there will also be palpitations, insomnia, mental restlessness and a dry throat. • If there is Liver-Yang rising from Kidney-Yin deficiency, there will also be dizziness, irritability and headaches. This corresponds to deficiency of the Sea of Marrow and Brain. The deficient Kidney-Essence fails to nourish the Sea of Marrow and Brain and ears, resulting in tinnitus, dizziness and poor memory. The Kidney-Essence has a Yang and a Yin aspect, and its deficiency can therefore manifest with symptoms of deficiency of either. The Kidneys and Heart communicate with each other, Kidney-Water flowing upwards to the Heart and Heart-Fire flowing downwards to the Kidneys. If HeartFire fails to reach down to the Kidneys, the tinnitus will be worse and there will be the additional symptoms outlined above.

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The Practice of Chinese Medicine

If Kidney-Yin is deficient, it may cause Liver-Yang to rise; in this case, the tinnitus may present with contradictory signs, as it is caused both by the deficiency of Kidney-Yin and the rising of Liver-Yang. For example, tinnitus with a loud sound and a high pitch (which indicates an Excess condition, in this case Liver-Yang rising) may have a gradual onset (which indicates a Deficiency condition, in this case KidneyYin deficiency).

Prescription

Treatment principle

Modifications

Nourish the Essence, benefit the Sea of Marrow, tonify Kidney-Yang or nourish Kidney-Yin. If necessary, harmonize Heart and Kidneys and subdue Liver-Yang.

• To direct the formula to the ears and treat tinnitus, add Chai Hu Radix Bupleuri and Ci Shi Magnetitum.

YOU GUI WAN Restoring the Right [Kidney] Pill

Explanation This formula tonifies Kidney-Yang. It is suitable for tinnitus from Kidney-Essence deficiency, because it also contains Lu Jiao Jiao and Gou Qi Zi, which nourish the Essence.

Prescription

Acupuncture

TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill

Points

Explanation

G.B.-2 Tinghui, S.I.-19 Tinggong, T.B.-17 Yifeng, KI-3 Taixi, Ren-4 Guanyuan, BL-23 Shenshu, KI-3 Taixi, SP-6 Sanyinjiao, HE-6 Yinxi, LIV-3 Taichong. Reinforcing method on all points except for the last two, which should be needled with even method. Use moxa in Kidney-Yang deficiency.

This formula is selected if there is deficiency of both Kidney- and Heart-Yin. It nourishes Kidney- and Heart-Yin, clears Heart Empty Heat and calms the Mind.

Explanation • G.B.-2, S.I.-19 and T.B.-17 are local points for this type of tinnitus. • KI-3, Ren-4 and BL-23 tonify the Kidneys and the Essence. • SP-6 helps to nourish the Kidneys. • HE-6, in combination with KI-3, harmonizes Heart and Kidneys. • LIV-3 subdues Liver-Yang.

Herbal therapy

Three Treasures remedies Nourish the Root Nourish the Root nourishes KidneyYin. It is a variation of Zuo Gui Wan Restoring the Left [Kidney] Pill. Strengthen the Root Strengthen the Root tonifies Kidney-Yang. It is a variation of You Gui Wan Restoring the Right [Kidney] Pill. Heavenly Empress Heavenly Empress nourishes Kidney- and Heart-Yin and clears Heart Empty Heat. It is a variation of Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill.

Prescription

SUMMARY

ER LONG ZUO CI WAN Pill for Deafness that is Kind to the Left [Kidney]

KIDNEY-ESSENCE DEFICIENCY

Explanation This formula is selected if the deficiency of KidneyEssence presents with symptoms and signs of KidneyYin deficiency. It nourishes Kidney-Yin, subdues Liver-Yang and opens the orifices and therefore opens the ears.

Points G.B.-2 Tinghui, S.I.-19 Tinggong, T.B.-17 Yifeng, KI-3 Taixi, Ren-4 Guanyuan, BL-23 Shenshu, SP-6 Sanyinjiao, HE-6 Yinxi, LIV-3 Taichong. Reinforcing method on all points except for the last two, which should be needled with even method. Use moxa in Kidney-Yang deficiency.

Tinnitus

Herbal therapy Prescription ER LONG ZUO CI WAN Pill for Deafness that is Kind to the Left [Kidney] Prescription YOU GUI WAN Restoring the Right [Kidney] Pill

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Herbal therapy No herbs were prescribed but only the patent remedy Er Ming Zuo Ci Wan Tinnitus Pill that is Kind to the Left [Kidney]. This man is still under treatment and is gradually improving. Although tinnitus is difficult to treat, the prognosis in this case is relatively good due to his young age.

Prescription TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill

Upper Burner Qi weak

Three Treasures remedies Nourish the Root Strengthen the Root Heavenly Empress

Intermittent tinnitus that is quite mild with a low pitch and gradual onset, tiredness, slight breathlessness, pale complexion, slight spontaneous sweating. Tongue: Pale, teeth marks. Pulse: Empty, especially in the right Front position. This corresponds to deficiency of Lung-Qi, with the deficient Lung-Qi unable to rise towards the head, thus causing tinnitus.

Clinical manifestations

Case history A 36-year-old man had complained of tinnitus for the past 10 years. The tinnitus started gradually over several years, and other symptoms included lower backache, dizziness, sweating at night and general tiredness. He also slept badly, waking up frequently with a dry mouth. His tongue was Red with a coating that was too thin although not entirely missing. His pulse was weak on both Rear positions. Diagnosis This is a very clear case of Kidney-Yin deficiency, as indicated by the symptoms and the tongue. The tongue still has a coating, albeit too thin, as he is still young. If the condition were allowed to deteriorate without treatment, the tongue would gradually lose its coating completely over the next few years. Treatment principle Nourish benefit the ears.

Kidney-Yin

and

Treatment principle Tonify Lung-Qi, promote the rising of clear Qi to the head.

Acupuncture Points Ren-17 Shanzhong, BL-13 Feishu, LU-9 Taiyuan, Ren-6 Qihai, Du-20 Baihui, T.B.-16 Tianyou, S.I.-19 Tinggong. Reinforcing method. Moxa may be used.

Explanation • Ren-17, BL-13 and LU-9 tonify Lung-Qi. • Ren-6 tonifies Qi in general. • Du-20 and T.B.-16 raise clear Qi to the head. T.B.-16 is a Window of Heaven point; as such, it regulates the ascending of clear Yang and descending of turbid Yin to and from the head. • S.I.-19 is the main local point for this type of tinnitus.

Herbal therapy

Acupuncture The main points used were as follows.

Prescription

• KI-3 Taixi and Ren-4 Guanyuan to strengthen the Kidneys. • ST-36 Zusanli and SP-6 Sanyinjiao to tonify Qi and Blood, which will help to nourish the KidneyEssence. • T.B.-17 Yifeng and S.I.-19 Tinggong as local points.

BU QI CONG MING TANG Tonifying Qi and Clearing Hearing Decoction

Explanation This formula tonifies and raises Qi, brightens the orifices and makes turbid Qi descend. Huang Bo makes

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turbid Qi descend via urination, and Bai Shao directs Huang Bo to the Yin (turbid Qi) portion.

Modifications • If there are signs of Phlegm in the head, add Bai Zhu Rhizoma Atractylodis macrocephalae, Tian Ma Rhizoma Gastrodiae and Ban Xia Rhizoma Pinelliae preparata.

SUMMARY UPPER BURNER QI WEAK Points Ren-17 Shanzhong, BL-13 Feishu, LU-9 Taiyuan, Ren-6 Qihai, Du-20 Baihui, T.B.-16 Tianyou, S.I.-19 Tinggong. Reinforcing method. Moxa may be used. Herbal therapy Prescription BU QI CONG MING TANG Tonifying Qi and Clearing Hearing Decoction

• BL-15 and Ren-14, Back-Transporting and FrontCollecting point of the Heart, respectively, tonify the Heart. • Ren-17 tonifies Heart-Qi. • P-6 tonifies Heart-Blood. • SP-6 nourishes Blood. • S.I.-19 is the main local point for this type of tinnitus.

Herbal therapy Prescription BU QI CONG MING TANG Variation Tonifying Qi Clear Hearing Decoction Variation

Explanation This formula tonifies and raises Qi, brightens the orifices and makes turbid Qi descend. Huang Bo makes turbid Qi descend via urination, and Bai Shao directs Huang Bo to the Yin (turbid Qi) portion. Dang Gui, Shu Di and Long Yan Rou have been added to the original prescription to nourish Heart-Blood.

SUMMARY HEART-BLOOD DEFICIENCY

Heart-Blood deficiency Clinical manifestations Intermittent tinnitus with low pitch and gradual onset, dull-pale complexion, palpitations, insomnia, poor memory, slight anxiety. Tongue: Pale and Thin. Pulse: Weak or Choppy, especially on the left Front position. This tinnitus is due to deficient Heart-Blood not reaching the head.

Treatment principle Tonify the Heart, nourish Blood.

Acupuncture Points HE-5 Tongli, BL-15 Xinshu, Ren-14 Juque, Ren-17 Shanzhong, P-6 Neiguan, SP-6 Sanyinjiao, S.I.-19 Tinggong. All with reinforcing method.

Explanation • HE-5 tonifies the Heart.

Points HE-5 Tongli, BL-15 Xinshu, Ren-14 Juque, Ren-17 Shanzhong, P-6 Neiguan, SP-6 Sanyinjiao, S.I.-19 Tinggong. All with reinforcing method. Herbal therapy Prescription BU QI CONG MING TANG Variation Tonifying Qi Clear Hearing Decoction Variation

MODERN CHINESE LITERATURE Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 20, No. 4, 2000, p. 205. Wang Cun Ying et al., “Clinical study on the treatment of tinnitus with acupuncture.” Dr Wang treated 60 patients suffering from tinnitus with acupuncture. There was a control group treated with injections of a solution of Dan Shen Radix Salviae miltiorrhizae.

Tinnitus

The points used were Du-20 Baihui, S.I.-4 Wangu, S.I.-19 Tinggong and T.B.-5 Waiguan. The needles were retained for 30 minutes, and the patients were treated once a day for 20 days.

PROGNOSIS Tinnitus is an extremely difficult condition to treat, and results with acupuncture and/or herbal medicine are not the best. However, it is always worth trying, as Western medicine has absolutely nothing to offer for this condition. Obviously, the older the patient and the longer-lasting the condition, the more difficult it will be to treat. Results are better for the Full than the Empty types. Of the Full types, the one from Liver-Fire is easier (or rather less difficult) to treat than the one from PhlegmFire.

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In any case, at least 10 treatments should be given before deciding whether it is working or not. In tinnitus from Kidney deficiency, it is essential that the patient takes adequate rest and restrains sexual activity. In tinnitus from Phlegm-Fire, it is important for the patient to avoid eating dairy products and greasy-hot foods. In tinnitus from Liver-Fire, the patient should be encouraged to relax and engage in moderate exercise. If Liver-Fire is caused by deep emotional problems, it may be necessary to recommend counselling.

END NOTES 1. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 50. First published c.100 BC. 2. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 26. First published c.100 BC.

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CHAPTER 18

GOITRE (HYPOTHYROIDISM, HYPERTHYROIDISM) CLINICAL MANIFESTATIONS

AETIOLOGY 509 Emotional stress 509 Diet 509 Environment 509 Constitution 509 PATHOLOGY DIAGNOSIS

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IDENTIFICATION OF PATTERNS AND TREATMENT Spleen- and Kidney-Yang deficiency 524 Qi and Blood deficiency 524 Liver- and Kidney-Yin deficiency 526

523

510 HYPERTHYROIDISM PATHOLOGY 526

511

GENERAL TREATMENT INDICATIONS 512 Acupuncture 512 Herbal treatment of masses 513 IDENTIFICATION OF PATTERNS AND TREATMENT 514 Qi stagnation and Phlegm (also called Qi Goitre) 514 Liver-Qi stagnation, Spleen-Qi deficiency and Phlegm 515 Phlegm and Blood stasis 516 Liver-Fire blazing with Phlegm-Heat 517 Heart- and Liver-Yin deficiency with Phlegm 518

CLINICAL MANIFESTATIONS

527

HYPERTHYROIDISM IN CHINESE MEDICINE: A REVIEW OF CHINESE LITERATURE 528 IDENTIFICATION OF PATTERNS AND TREATMENT 533 Liver-Qi stagnation 533 Heat in Liver, Heart and Stomach 534 Liver- and Kidney-Yin deficiency with Empty Heat 535 Phlegm-Heat in the Liver 536 CASE HISTORIES

PROGNOSIS AND PREVENTION

526

537

519 MODERN CHINESE LITERATURE

GOITRE IN WESTERN MEDICINE HYPOTHYROIDISM PATHOLOGY 521

539

519

521

THYROID • Qi stagnation and Phlegm • Liver-Qi stagnation, Spleen-Qi deficiency and Phlegm • Phlegm and Blood stasis • Liver-Fire blazing with Phlegm-Heat • Heart- and Liver-Yin deficiency with Phlegm

HYPOTHYROIDISM • Spleen- and Kidney-Yang deficiency • Qi and Blood deficiency • Liver- and Kidney-Yin deficiency HYPERTHYROIDISM • Liver-Qi stagnation • Heat in Liver, Heart and Stomach • Liver- and Kidney-Yin deficiency with Empty Heat • Phlegm-Heat in the Liver

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GOITRE (HYPOTHYROIDISM, HYPERTHYROIDISM) In this chapter, I shall discuss the clinical symptom of goitre, first as it is done in ancient Chinese books and then the pathology and treatment of thyroid problems. As explained in the preface, ancient Chinese disease symptoms are not “diseases” in a Western sense but clinical signs or symptoms. For example, “goitre” is not a “disease” in a Western sense but simply a clinical sign; hypo- and hyperthyroidism, by contrast, are “diseases” in a Western sense. Nevertheless, “Goitre” is a “disease” in the context of Chinese medicine. In Chinese, goitre is called Ying ( ). Ancient books mentioned Shi Ying (Stone Goitre), Lao Ying (Exhaustion Goitre), Tu Ying (Earth Goitre), You Ying (Worry Goitre) and Qi Ying (Qi Goitre). There are records of goitre in Chinese medicine as early as the third century BC. The name Ying appears in a book from the Warring States period. The book says: “There are more people with bald head and with goitre in places of light water.”1 This statement shows that the ancient Chinese were aware of environmental goitre. Another book tells the following story:2 A man called Jia Gui developed goitre due to anger. The goitre grew large, and he wanted a doctor to remove it. The minister Cao Cao persuaded him not to have the operation by saying that nine out of ten people who have had the operation died. The Discussion of the Origin of Symptoms in Diseases (Zhu Bing Yuan Hou Zhong Lun, AD 610) illustrates the cause of goitre as emotional stress and environment by saying:3 Goitre results from worry leading to Qi stagnation. It may also be caused by drinking sandy water; the sand follows Qi into the channels and vessels and accumulates in the neck. It also said: “Do not live long in mountainous regions with black earth and spring water. Drinking such water for a long time may cause goitre.”4 The book Thousand Golden Ducat Prescriptions (Qian Jin Yao Fang) by Sun Si Miao records dozens of formulae for goitre, recommending the use of Hai Zao, Kun Bu and thyroid of sheep and deer. This shows that ancient doctors had an understanding of the role of iodine in thyroid disease even though they obviously did not know about iodine.

Other books classified goitre into “Stone Ying”, “Sand Ying”, “Exhaustion Ying”, “Worry Ying” and “Qi Ying”. The book Treatise on the Three Categories of Aetiology of Diseases (San Yin Ji Yi Bing Zheng Fang Lun) has a different classification of goitre:5 Goitre that feels hard and tough and does not move is called Stone Ying. A goitre that does not change the colour of the skin is called Muscle Ying. That with exposed sinews is called Sinews Ying. That with exposed vessels is called Blood Ying. That which changes size according to emotions is called Qi Ying. It also says: “In all five types of goitre do not break [Blood], as this may cause a massive discharge of pus and blood and untimely death.” Another book says: “All three herbs, Hai Zao, Kun Bu and Hai Dai, are from the sea. Eat at least two of them often and goitre will be prevented.”6 Another book mentions the use of Huang Yao Zi to cool Blood, drain Fire, dissolve goitre and dispel Toxin. The book also asks people to look in the mirror and stop taking Huang Yao Zi when the goitre disappears or measure the size of the goitre with a thread every day to know exactly the results of the tincture.

! Ancient Chinese doctors were aware that seaweeds can help goitre even though they did not know about the role of iodine in the physiology of the thyroid. Another book considers Qi stagnation, Phlegm and Blood stasis as the main pathogenic factors in simple goitre. So the treatment method should be to move Qi, invigorate Blood, resolve Phlegm and soften masses. The book mentions the formula Hai Zao Yu Hu Tang, which is still widely used today. Another book says:7 Simple goitre results from Qi and Blood stagnation. It is a disease that develops slowly for years; it is called Ying because the skin is enlarged like a cherry stone [Ying Tao]. The discussion of goitre will be conducted according to the following topics. • Aetiology • Pathology • Diagnosis

Goitre (Hypothyroidism, Hyperthyroidism)

• • • •

General treatment indications Identification of patterns and treatment Prognosis and prevention Goitre in western medicine

HYPOTHYROIDISM • Pathology • Clinical manifestations • Identification of patterns and treatment HYPERTHYROIDISM • Pathology • Clinical manifestations • Hyperthyroidism in Chinese Medicine: a review of Chinese literature • Identification of patterns and treatment • Case histories • Modern Chinese literature

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CLINICAL NOTE Please note that Qi stagnation deriving from emotional stress does not affect only the Liver but also the Lungs, Heart, Stomach and Spleen. Qi stagnation of all these organs plays a role in the pathology of goitre.

Diet Irregular eating and excessive consumption of greasy foods or dairy foods weaken the Spleen and Stomach, which cannot transform and transport food essences; Dampness is formed, later leading to Phlegm. Irregular diet also disrupts the Qi Mechanism and leads to Qi stagnation and eventually Blood stasis, which contribute to the formation of goitre.

Environment AETIOLOGY Emotional stress Anger, worry and pensiveness may all lead to Qi stagnation after a period of time. This may affect not only the Liver, which loses its free flow of Qi, but also the Lungs (whose Qi fails to descend and stagnates in the chest and throat), the Stomach (whose Qi fails to descend), the Heart (whose Qi fails to descend affecting the throat) and the Spleen (whose Qi fails to ascend giving rise to Phlegm). Qi stagnation in various organs affects the proper functioning of the Qi Mechanism, and this disrupts the proper movement of Qi in the right direction. That therefore also affects the movement and transformation of fluids, which eventually leads to Phlegm. Qi stagnation and Phlegm interact, and both focus on the front of the throat where the Liver, Lung and Heart channels flow. This type of Phlegm is called “QiPhlegm” and is the most non-substantial type of Phlegm. This type of goitre lump, especially in the beginning stages when there is only Qi stagnation, would go up and down in size. After a prolonged time, Qi stagnation may lead to Blood stasis, which, in itself, interacts with Phlegm; in such cases, the goitre lump would be hard, not going up and down in size and probably painful.

People who live in high mountainous regions lack iodine in the water, and this may contribute to goitre. Although they did not know about the role of iodine in thyroid disorders, the ancient Chinese doctors did observe the higher incidence of goitre in people living in high mountains but attributed that to factors other than iodine. Some ancient books talked about a “cold poison” in the water in high mountains in the North-West of China. As indicated above, other doctors mentioned the presence of “sand” in the water; yet others mentioned “black earth” and “spring water” as environmental causes of goitre. Interestingly, although the ancient Chinese doctors did not know about the role of iodine (or the lack of it) in the pathology of goitre, they did observe the beneficial effect of seaweeds on goitre.

Constitution Women are more prone to goitre. This is because of the relationship between the Liver channel on both goitre and menstruation. Because of menstruation, pregnancy and lactation, the Liver channel is much more prone to Qi and/or Blood stagnation in women, and this causes a higher incidence of goitre in them. Excessive blood loss after childbirth or too many children too close together may also lead to depletion of Liver and Kidneys in women and predispose them to goitre.

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Another reason why women are more prone to goitre lies in the relationship between the Uterus and the Directing and Penetrating Vessels (Ren Mai and Chong Mai). The Directing Vessel flows through the uterus, deeply influencing menstruation, conception and pregnancy, and up to the throat, where goitre forms. Many cases of goitre in women are a reflection of a pathology of these two vessels in the Uterus, which is transmitted upwards to the throat via the Directing Vessel. That is why women with goitre outnumber men by 8:1.

SUMMARY

The Root is usually a deficiency of Qi, Yang or Yin. In hypothyroidism, the Root is usually Yang deficiency, and in hyperthyroidism, Fire. There is no direct correspondence between the Chinese disease-symptom of “Goitre” and thyroid problems in Western medicine. Hence, Chinese medicine discusses only goitre, while Western medicine discusses many thyroid dysfunctions, such as hypothyroidism, hyperthyroidism, Graves’ disease and Hashimoto’s thyroiditis. The discussion of hypo- and hyperthyroidism in this chapter is based on modern Chinese books and articles, and the reader is particularly invited to read the articles from modern Chinese literature at the end of this chapter.

AETIOLOGY OF GOITRE Emotional stress Anger, worry and pensiveness may all lead to Qi stagnation. The Liver loses its free flow of Qi, Lung-Qi fails to descend (and stagnates in the throat), Stomach-Qi fails to descend, Heart-Qi fails to descend (affecting the throat) and SpleenQi fails to ascend (giving rise to Phlegm). Diet Irregular eating and excessive consumption of greasy foods or dairy foods weaken the Spleen and Stomach, which cannot transform and transport food essences; Dampness is formed later, leading to Phlegm. Environment People who live in high mountainous regions lack iodine in the water, and this may contribute to goitre. Constitution Women are more prone to goitre. This is because of the relationship between the Liver channel on both goitre and menstruation and also between the throat and uterus via the Directing and Penetrating Vessels (Ren Mai and Chong Mai).

PATHOLOGY In “Goitre”, Chinese pathology is essentially concerned only with the Manifestation (rather than the Root) of goitre, i.e. Qi stagnation, Blood stasis and Phlegm.

CLINICAL NOTE Chinese medicine disease categories include only “Goitre”. Therefore ancient Chinese medicine did not provide a theory on the pathology of thyroid dysfunctions.

Each of these biomedical diseases can manifest with or without goitre; therefore, Chinese medicine does not really have a theory of thyroid problems without goitre, and these must simply be treated according to the normal identification of patterns. For example, if without goitre, hypothyroidism may correspond to Exhaustion (Xu Lao) or Oedema in Chinese medicine, while hyperthyroidism may correspond to “Palpitations and Anxiety” or “Tremors”. CLINICAL NOTE Thyroid dysfunctions without goitre may correspond to unrelated Chinese disease categories. For example, hypothyroidism may correspond to Exhaustion (Xu Lao) or Oedema in Chinese medicine, while hyperthyroidism may correspond to “Palpitations and Anxiety” or “Tremors”.

As Chinese medicine focuses only and entirely on goitre, its pathology and treatment are focused on the treatment of masses, i.e. it stresses the treatment methods of “dissolving masses”, “dissolving nodules” and “softening hardness”. The treatment principles must therefore be adapted when there are thyroid problems without goitre; i.e. in such cases, it is not necessary to

Goitre (Hypothyroidism, Hyperthyroidism)

resolve Phlegm (unless there are Phlegm symptoms), soften masses or dissolve masses. Ancient doctors differentiated between “internal” and “external” treatment. Internal treatment consisted of the administration of seaweeds to provide iodine and of thyroid glands of sheep, deer, pig or lamb. External treatment consisted of herbal treatment and acupuncture (and of course surgery). The use of seaweeds is interesting, because they were given without knowing about iodine but ancient doctors perceived that there was something missing in the water of mountainous regions that could be supplemented by seaweeds. They were also given for their action of “softening” masses; in this respect, they are given for any type of mass, not just goitre. The pathology of goitre boils down to three main factors in order of appearance and severity: 1. Qi stagnation (lump goes up and down according to emotional problems) 2. Phlegm (lump is relatively soft and large and does not go up and down) 3. Blood stasis (lump is relatively hard, fixed and probably painful). Other pathologies may be involved. First of all, LiverFire may develop from Liver-Qi stagnation; Liver-Fire, in turn, contributes to Phlegm, as Fire dries up and condenses body fluids into Phlegm. Second, Liver-Fire may, in time, injure Yin and lead to Liver-Yin deficiency, which may appear in very long-standing cases in older women (Fig. 18.1). In its very beginning stage, goitre is not dissimilar to the Plum-Stone Syndrome, which is due not only to Liver-Qi stagnation but also Lung-Qi stagnation in

Emotional stress

the throat from emotional problems (for which the formula Ban Xia Hou Po Tang Pinellia-Magnolia Decoction is used).

SUMMARY PATHOLOGY OF GOITRE  Qi stagnation (lump goes up and down according to emotional problems)  Phlegm (lump is relatively soft and does not go up and down)  Blood stasis (lump is relatively hard, fixed and probably painful)  Liver-Fire (goitre relatively soft, nodules)  Phlegm-Fire (goitre large)  Liver-Yin deficiency (goitre small)

DIAGNOSIS The goitre swelling in itself always indicates Phlegm; however, this may be combined with Qi stagnation or Blood stasis. The following are indications regarding the feel of the goitre lump in relation to patterns. • Soft goitre with indistinct edges, varying in size with emotional state: Qi stagnation and Phlegm. • Large, soft and smooth mass: Phlegm. • Hard, nodular mass that is immovable and grows rapidly, dark skin over mass: Phlegm with Blood stasis. • Small or medium-size goitre, relatively soft, slippery under the finger: Liver-Fire (with Phlegm).

Fire

QI STAGNATION

Irregular diet Figure 18.1 Pathology of goitre.

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Phlegm

Blood stasis

Yin deficiency

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SUMMARY

Main acupuncture points for goitre

DIAGNOSIS

Before discussing the treatment according to patterns, it is useful to discuss the main acupuncture points and ancient point prescriptions that are applicable in the treatment of goitre. As mentioned before, acupuncture and herbal medicine work in different ways and, while the herbal treatment must be firmly based on pattern identification, acupuncture points are chosen primarily according to the channel involved. There are three principal groups of points.

 The goitre swelling in itself always indicates Phlegm, which may be combined with Qi stagnation or Blood stasis.  Soft goitre with indistinct edges, varying in size with emotional state: Qi stagnation and Phlegm.  Large, soft and smooth mass: Phlegm.  Hard, nodular mass that is immovable and grows rapidly, dark skin over mass: Phlegm with Blood stasis.  Small or medium-size goitre, relatively soft, slippery under the finger: Liver-Fire (with Phlegm).

GENERAL TREATMENT INDICATIONS Acupuncture

1. Ah Shi points for goitre: four points inserted on the top, bottom, left and right of the thyroid, inserted obliquely towards the centre. 2. Local points: ST-11 Qishe, Ren-22 Tiantu, Ren-23 Lianquan, L.I.-17 Tianding, ST-9 Renying, L.I.-18 Futu, S.I.-17 Tianrong, ST-10 Shuitu, extra point Ping Ying (0.7 cun lateral to the space between the fourth and fifth cervical vertebrae), extra point Shangtianzhu (0.5 cun above BL-10 Tianzhu); see Figure 18.3. 3. Hua Tuo Jia Ji points of the dorsal vertebrae T-1 and T-2.

Channels involved in goitre Apart from the predominant patterns, one must pay attention also to diagnosis of the channel involved. In terms of channels, the main channels involved are Heart, Liver, Lungs, Stomach and Directing Vessel, all of which go through the front of the throat. Although other channels also go through the front of the throat (e.g. Spleen and Kidneys), these five channels are the main ones involved in the pathology of goitre (Fig. 18.2). In women, the Directing and Penetrating Vessels’ pathology influences the development of goitre through menstrual irregularities.

Stomach channel

Shangtianzhu BL-10 Pingying

Ren-23 ST-9 ST-10 ST-11

Ren-22 L.I.-18 L.I.-17

S.I.-17 Heart channel

Lung channel

Directing Vessel

Liver channel

Figure 18.2 Channels flowing over the thyroid.

Figure 18.3 Local points for goitre.

Goitre (Hypothyroidism, Hyperthyroidism)

Ancient acupuncture prescriptions • The ABC of Acupuncture (Zhen Jiu Jia Yi Jing, AD 259): S.I.-17 Tianrong. • The Great Treatise of Acupuncture (Zhen Jiu Da Quan, 1439): LU-7 Lieque, L.I.-18 Futu, Ren-22 Tiantu, L.I.-17 Tianrong, ST-12 Quepen, KI-27 Shufu, Ren-17 Shanzhong, L.I.-4 Hegu, Shixuan (bleeding). • Thousand Golden Ducat Prescriptions (Qian Jin Yao Fang, AD 682): T.B.-13 Naohui, LU-3 Tianfu, ST-11 Qishe. • The Classic of Acupuncture Endowment (Zhen Jiu Zi Sheng Jing, 1220): G.B.-10 Fubai and ST-11 Qishe.

Moxibustion Ren-22 Tiantu, BL-7 Tongtian, LU-2 Yunmen, L.I.-11 Quchi, Ren-17 Shanzhong, LIV-4 Zhongfeng, G.B.-20 Fengchi, Du-14 Dazhui, ST-11 Qishe, LU-3 Tianfu, ST-42 Chongyang. Practical Acupuncture (Shi Yong Zhen Jiu Xue) has two groups of points for moxibustion:8 1. G.B.-20 Fengchi, Du-14 Dazhui, L.I.-14 Binao, extra point lateral to Du-14 and 1.5 cun below it. 2. Ren-22 Tiantu, BL-7 Tongtian, LU-2 Yunmen, L.I.-14 Binao, LIV-4 Zhongfeng, Ren-17 Shanzhong, G.B.-20 Fengchi, Du-14 Dazhui, ST-11 Qishe, T.B.-13 Naohui, LU-3 Tianfu, ST-42 Chongyang.

Ear acupuncture Endocrine, thyroid, Shenmen, neck.

Herbal treatment of masses Before discussing the herbal treatment according to patterns, it is opportune to discuss briefly the herbal treatment of masses. In Chinese medicine, masses may form from Phlegm or from Blood stasis. Masses from Phlegm are usually soft and painless, and goitre is a typical mass from Phlegm (but if it is hard it is due to a combination of Phlegm and Blood stasis). In order to dissolve masses from Phlegm, three treatment methods are applied: 1. resolve Phlegm 2. soften hardness 3. dissolve masses.

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It is necessary to “soften” the masses in order to dissolve them, and some Chinese herbs have this function. The herbs that soften masses are found in various categories so that each of these herbs has its own particular action besides that of softening masses. I shall list below the main herbs that soften masses, with their category in brackets. Obviously, although one can use any of these herbs to soften masses, it is better to target the herb more precisely so that it softens a particular type of mass. For example, Mu Li Concha Ostreae would be better to soften a mass in the presence of Yin deficiency, while Chuan Shan Jia Squama Manitis Pentadactylae would be better to soften a mass from Blood stasis. In the particular case of goitre, two of the substances that soften masses are seaweeds, and therefore they also provide a source of iodine. The main herbs that soften masses are as follows. • • • • • • • • • •

Gui Ban Plastrium Testudinis (nourish Yin) Mu Li Concha Ostreae (nourish Yin) Kun Bu Thallus Eckloniae (resolve Phlegm) Hai Zao Herba Sargassi (resolve Phlegm) Zhe Bei Mu Bulbus Fritillariae thunbergii (resolve Phlegm) Jiang Can Bombyx batryticatus (extinguish internal Wind) Xia Ku Cao Spica Prunellae (resolve Toxic Heat) Chuan Shan Jia Squama Manitis Pentadactylae (invigorate Blood) Wa Leng Zi Concha Arcae (invigorate Blood) Yi Yi Ren Semen Coicis (resolve Dampness)

Of the above herbs that soften hardness, Xia Ku Cao Spica Prunellae has a particular affinity for masses in the region of the neck. The herbs that “dissolve” masses or nodules are also found scattered in various categories. Herbs that “break Blood” are used to dissolve masses from Blood stasis, for example E Zhu Rhizoma Curcumae and San Leng Rhizoma Sparganii stoloniferi. Examples of herbs that dissolve masses or nodules are as follows. • • • • • •

Mu Li Concha Ostreae (nourish Yin) Bie Jia Carapax Trionycis (nourish Yin) Lou Lu Radix Rhapontici (clear Heat) Xuan Shen Radix Scrophulariae (clear Heat) Yu Jin Radix Curcumae (invigorate Blood) Tu Bie Chong Eupolyphaga/Steleophaga (invigorate Blood)

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• E Zhu Rhizoma Curcumae (invigorate Blood) • San Leng Rhizoma Sparganii stoloniferi (invigorate Blood) • Zhe Bei Mu Bulbus Fritillariae thunbergii (resolve Phlegm) • Fu Shi Pumex (resolve Phlegm) • Huang Yao Zi Radix Dioscoreae bulbiferae (resolve Phlegm) Of the above herbs that dissolve masses, Xuan Shen Radix Scrophulariae and Huang Yao Zi Radix Dioscoreae bulbiferae have a particular affinity for masses in the region of the neck.

Note Please note that Huang Yao Zi Semen Dioscoreae bulbiferae (present in some of the formulae mentioned below) may be toxic if taken for too long. I would advise not prescribing it for longer than about 2 months at a time, and at a dosage no higher than 6 g per day. Do not use it if the patient has an abnormal liver function. Liver function should be checked regularly in all patients taking this herb. Practitioners should also check the legality of this herb in their particular country.

IDENTIFICATION OF PATTERNS AND TREATMENT The main patterns discussed are: • Qi stagnation and Phlegm • Liver-Qi stagnation, Spleen-Qi deficiency and Phlegm • Phlegm and Blood stasis • Liver-Fire blazing with Phlegm-Heat • Heart- and Liver-Yin deficiency with Phlegm. These patterns are interlinked; for example, Qi stagnation and Phlegm often lead to Phlegm and Blood stasis, while Liver-Fire often leads to Heart- and LiverYin deficiency. Also, the order in which the patterns are presented broadly reflects the pathological progression in goitre, i.e. in the beginning stages it is likely to manifest with Qi stagnation and Phlegm and in the later stages with Yin deficiency and Phlegm.

Qi stagnation and Phlegm (also called Qi Goitre) Clinical manifestations Goitre that is relatively soft and not painful, often neck ache, a feeling of oppression of the chest, sighing, hypochondrial distension and pain, the size of the goitre may fluctuate according to emotional state. Tongue: Swollen with a sticky coating. Pulse: Wiry. Heart: palpitations, anxiety, chest discomfort, feeling of constriction in the throat. Lungs: sighing, dry cough, feeling of constriction and/or lump in the throat, slight breathlessness, sadness. Liver: irritability, a feeling of a lump in the throat, depression.

Treatment principle Regulate Qi, eliminate stagnation, soothe the Liver, make Lung-Qi descend, make Heart-Qi descend, resolve Phlegm, dissolve goitre.

Acupuncture Points • Distal points: T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, ST-40 Fenglong, SP-6 Sanyinjiao, Ren-12 Zhongwan, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel), SP-4 Gongsun and P-6 Neiguan (Penetrating Vessel), Hua Tuo Jia Ji points. Reducing method. • Local points: points surrounding the goitre, Ren-22 Tiantu, L.I.-17 Tianding. Even method. • Heart-Qi stagnation: HE-5 Tongli, HE-7 Shenmen, Ren-15 Jiuwei. • Lung-Qi stagnation: LU-7 Lieque, L.I.-4 Hegu, Ren-17 Shanzhong, LU-3 Tianfu. • Liver-Qi stagnation: LIV-3 Taichong, BL-18 Ganshu.

Explanation • T.B.-6, G.B.-34, LIV-3 and P-6 move Liver-Qi. In particular, T.B.-6 affects the neck. • ST-40, SP-6 and Ren-12 resolve Phlegm. • HE-5, HE-7 and Ren-15 calm the Mind. • LU-7 and KI-6 open the Directing Vessel, which regulates the Uterus and flows over the throat. • SP-4 and P-6 open the Penetrating Vessel, which regulates the Uterus, moves Qi and Blood and flows over the throat.

Goitre (Hypothyroidism, Hyperthyroidism)

• LU-7, L.I.-4, Ren-17 and LU-3 are used if there is a Lung pathology and excessive sweating. • BL-18 is added if the stagnation of Liver-Qi is pronounced.

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Three Treasures remedies Open the Heart with Clear the Soul Bright Spirit

Herbal therapy Prescription SI HAI SHU YU WAN Four Seas Soothe Stagnation Pill

Explanation This formula moves Qi, resolves Phlegm, soften hardness and dissolves masses. From a Western perspective, the seaweeds within the formula will also provide iodine.

Three Treasures remedies

Liver-Qi stagnation, Spleen-Qi deficiency and Phlegm Clinical manifestations Large, soft goitre, depression, irritability, feeling of oppression of the chest and hypochondrium, difficulty in swallowing, feeling of a lump in the throat, loose stools, tiredness, desire to lie down, poor digestion, irregular periods, premenstrual tension. Tongue: Pale, possibly slightly Red sides, Swollen. Pulse: Wiry, Weak on the right, Slippery.

Open the Heart with Clear the Soul Open the Heart moves Qi in the Heart and Lungs and treats the chest and throat; Clear the Soul resolves Phlegm.

Treatment principle

Bright Spirit Bright Spirit moves Qi of the Heart and Liver and resolves Phlegm.

Acupuncture

SUMMARY QI STAGNATION AND PHLEGM Points  Distal points: T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, ST-40 Fenglong, SP-6 Sanyinjiao, Ren-12 Zhongwan, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel), SP-4 Gongsun and P-6 Neiguan (Penetrating Vessel), Hua Tuo Jia Ji points. Reducing method.  Local points: points surrounding the goitre, Ren-22 Tiantu, L.I.-17 Tianding. Even method.  Heart: HE-5 Tongli, HE-7 Shenmen, Ren-15 Jiuwei.  Lungs: LU-7 Lieque, L.I.-4 Hegu, Ren-17 Shanzhong, LU-3 Tianfu.  Liver: LIV-3 Taichong, BL-18 Ganshu. Herbal therapy Prescription SI HAI SHU YU WAN Four Seas Soothe Stagnation Pill

Soothe the Liver, move Qi, tonify Spleen-Qi, resolve Phlegm, soften masses.

Points • Distal points: T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, Ren-12 Zhongwan, BL-20 Pishu, ST-36 Zusanli. Even method on all points except Ren-12 and BL-20, which should be needled with reinforcing method. • Local points: Ren-22 Tiantu, ST-9 Renying, ST-10 Shuitu. Even method.

Explanation • T.B.-6, G.B.-34, LIV-3 and P-6 move Liver-Qi. • Ren-12, BL-20 and ST-36 tonify the Spleen and resolve Phlegm.

Herbal therapy Prescription XIAO YAO SAN plus LIU JUN ZI TANG Variation Free and Easy Wanderer Powder plus Six Gentlemen Decoction Variation

Explanation These two formulae together move Liver-Qi, tonify the Spleen and resolve Phlegm. It has been modified with the addition of herbs to resolve Phlegm (Bai Jie Zi Semen Sinapis albae and Huang Qin Radix Scutellariae)

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and to invigorate Blood (Dan Shen Radix Salviae milthiorrizae).

Three Treasures remedies Freeing the Moon with Soothe the Centre and Limpid Sea These three remedies move Liver-Qi, tonify Spleen-Qi and resolve Dampness and Phlegm.

SUMMARY LIVER-QI STAGNATION, SPLEEN-QI DEFICIENCY AND PHLEGM Points  Distal points: T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, Ren-12 Zhongwan, BL-20 Pishu, ST-36 Zusanli. Even method on all points except Ren-12 and BL-20, which should be needled with reinforcing method.  Local points: Ren-22 Tiantu, ST-9 Renying, ST-10 Shuitu. Even method. Herbal therapy Prescription XIAO YAO SAN plus LIU JUN ZI TANG Variation Free and Easy Wanderer Powder plus Six Gentlemen Decoction Variation Three Treasures remedies Freeing the Moon with Soothe the Centre and Limpid Sea

SP-10 Xuehai, BL-17 Geshu, SP-4 Gongsun and P-6 Neiguan (Penetrating Vessel, Chong Mai), ST-40 Fenglong, Ren-12 Zhongwan, SP-6 Sanyinjiao. Even method except Ren-12, which should be needled with reinforcing method. • Local points: Ren-22 Tiantu, ST-9 Renying, L.I.-18 Futu, ST-10 Shuitu, L.I.-17 Tianding. Even method.

Explanation • T.B.-6, G.B.-34, LIV-3, P-6 and BL-18 move LiverQi; moving Qi is necessary to invigorate Blood (P-6 and LIV-3 also invigorate Blood). • SP-10 and BL-17 invigorate Blood. • SP-4 and P-6 open the Penetrating Vessel which invigorates Blood. • ST-40, Ren-12 and SP-6 resolve Phlegm.

Herbal therapy Prescription HAI ZAO YU HU TANG Sargassum Jade Pot Decoction

Explanation This formula moves Qi, resolves Phlegm, soften hardness, dissolves masses and mildly invigorates Blood.

Prescription JIA SHI JIA KANG FANG Master Shi’s Formula for Hyperthyroidism

Explanation

Phlegm and Blood stasis Clinical manifestations Goitre that is hard, possibly with nodules, painful, dark skin over the goitre, a feeling of oppression of the chest, insomnia, anxiety. Tongue: Purple, Swollen, sticky coating. Pulse: Wiry.

This formula moves Qi, resolves Phlegm, softens hardness, dissolves masses and strongly invigorates Blood. Compared with the previous formula, it also has a stronger resolving Phlegm effect.

Modifications (for both prescriptions)

Regulate Qi, invigorate Blood, eliminate stasis, resolve Phlegm, soften hardness, dissolve goitre.

• For nodules on thyroid, add E Zhu Rhizoma Curcumae, Sang Leng Rhizoma Sparganii stoloniferii and Huang Yao Zi Semen Dioscoreae bulbiferae. • If Qi stagnation has given rise to Fire, add Xia Ku Cao Spica Prunellae, Mu Dan Pi Cortex Moutan radicis and Xuan Shen Radix Scrophulariae ningpoensis.

Acupuncture

Three Treasures remedies

Points

Limpid Sea plus Red Stirring Limpid Sea is a general remedy for Phlegm, and Red Stirring invigorates Blood and eliminates stasis in the Upper Burner.

Treatment principle

• Distal points: T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, BL-18 Ganshu,

Goitre (Hypothyroidism, Hyperthyroidism)

SUMMARY PHLEGM AND BLOOD STASIS Points  Distal points: T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, BL-18 Ganshu, SP-10 Xuehai, BL-17 Geshu, SP-4 Gongsun and P-6 Neiguan (Penetrating Vessel, Chong Mai), ST-40 Fenglong, Ren-12 Zhongwan, SP-6 Sanyinjiao. Even method except Ren-12, which should be needled with reinforcing method.  Local points: Ren-22 Tiantu, ST-9 Renying, L.I.-18 Futu, ST-10 Shuitu, L.I.-17 Tianding. Even method. Herbal therapy Prescriptions HAI ZAO YU HU TANG Sargassum Jade Pot Decoction JIA SHI JIA KANG FANG Master Shi’s Formula for Hyperthyroidism Three Treasures remedies Limpid Sea plus Red Stirring

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• Prescription by Dr Wang Xue Tai (Great Treatise of Chinese Acupuncture [Zhong Guo Zhen Jiu Da Quan]): SP-6 Sanyinjiao, KI-6 Zhaohai, KI-7 Fuliu (which according to him nourishes Yin and clears Heat), P-5 Jianshi, LIV-3 Taichong.9 • If ST-Heat: ST-44 Neiting. • Tremor of hands: G.B.-34 Yanglingquan. • Goitre big: ST-10 Shuitu and extra point Ping Ying. • Exophthalmos: extra point Shangtianzhu and G.B.-20 Fengchi.

Explanation • LIV-2 and HE-8 drain Liver- and Heart-Fire. • L.I.-11 and L.I.-4 clear Heat and influence the throat area. • ST-40 and SP-6 resolve Phlegm. • HE-7 and P-7 calm the Mind.

Herbal therapy Prescription ZHI ZI QING GAN TANG plus HAI YAO SAN Variation Gardenia Clearing the Liver Decoction plus SargassumDioscorea bulbifera Powder Variation

Explanation

Liver-Fire blazing with Phlegm-Heat Clinical manifestations Small or medium-size goitre, relatively soft, slippery under the finger, mental restlessness, insomnia, thirst, feeling of heat, irritability, red eyes, tremor of hands, red face, bitter taste. Tongue: Red, redder sides and tip, dry-yellow coating. Pulse: Rapid and Wiry.

Treatment principle Drain Fire, clear the Liver, resolve Phlegm, soften hardness, dissolve goitre, calm the Mind.

These two formulae together clear Heat, resolve Phlegm, soften hardness and dissolve masses. Niu Bang Zi was added to the original prescription to direct the formula to the throat.

Three Treasures remedies Drain Fire plus Clear the Soul Drain Fire drains Liver- and Heart-Fire, while Clear the Soul resolves Phlegm-Heat and acts on the chest and throat. Settling the Soul Settling the Soul drains Liver- and Heart-Fire and resolves Phlegm-Heat. Compared with Drain Fire, it has a stronger Mind-calming action.

Acupuncture

SUMMARY

Points

LIVER-FIRE BLAZING WITH PHLEGM-HEAT

• Distal points: LIV-2 Xingjian, HE-8 Shaofu, L.I.-11 Quchi, L.I.-4 Hegu, ST-40 Fenglong, SP-6 Sanyinjiao, HE-7 Shenmen, P-7 Daling. Reducing method. • Local points: Ren-22 Tiantu, L.I.-17 Tianding, ST-9 Renying, L.I.-18 Futu, ST-10 Shuitu. Even method.

Points  Distal points: LIV-2 Xingjian, HE-8 Shaofu, L.I.-11 Quchi, L.I.-4 Hegu, ST-40 Fenglong, SP-6 Sanyinjiao, HE-7 Shenmen, P-7 Daling. Reducing method.

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 Local points: Ren-22 Tiantu, L.I.-17 Tianding, ST-9 Renying, L.I.-18 Futu, ST-10 Shuitu. Even method. Herbal therapy Prescriptions ZHI ZI QING GAN TANG plus HAI YAO SAN Variation Gardenia Clearing the Liver Decoction plus Sargassum-Dioscorea bulbifera Powder Variation Three Treasures remedies Drain Fire and Clear the Soul Settling the Soul

Heart- and Liver-Yin deficiency with Phlegm Clinical manifestations Goitre that may be large or small, relatively soft, slow onset, chronic course, palpitations, insomnia, feeling of heat in the afternoon, night sweating, tremor of hands, dry eyes, blurred vision, tiredness. Tongue: without coating, Swollen; Red if there is Empty Heat. Pulse: Floating-Empty, relatively Overflowing on leftFront position.

• SP-6, Ren-4, LIV-8 and KI-6 nourish Liver-Yin. • LU-7 and KI-6 open the Directing Vessel and nourish Yin. This vessel also influences the throat.

Herbal therapy Prescription TIAN WANG BU XIN DAN Variation Heavenly Emperor Tonifying the Heart Pill Variation

Explanation This formula nourishes Kidney- and Heart-Yin, clears Heart Empty Heat and calms the Mind. • Gou Qi Zi Fructus Lycii chinensis and Chuan Lian Zi Fructus Meliae toosendan are added to nourish Liver-Yin. • Gua Lou Fructus Trichosanthis is added to resolve Phlegm.

Prescription PING YING FU FANG Formula to Dissolve Goitre

Explanation This formula nourishes Liver- and Kidney-Yin, softens hardness, dissolves masses and invigorates Blood.

Treatment principle Nourish Yin, nourish Heart and Liver, nourish LiverBlood, calm the Mind, resolve Phlegm, soften hardness, dissolve goitre.

Acupuncture Points • Distal points: HE-7 Shenmen, P-6 Neiguan, L.I.-4 Hegu, LIV-3 Taichong, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-8 Ququan, KI-6 Zhaohai, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel, Ren Mai). Reinforcing method. • Ah Shi points surrounding the goitre, L.I.-17 Tianding. Even method.

Prescription FU FANG JIA KANG GAO Formula for Hyperthyroidism

Explanation This formula nourishes Liver- and Kidney-Yin, tonifies Qi, resolves Phlegm and softens hardness.

Prescription ZHI BO YANG WEI TANG Anemarrhena-Phellodendron Nourishing the Stomach Decoction

Explanation

Explanation

• HE-7 and P-6 nourish Heart-Yin and calm the Mind. • L.I.-4 and LIV-3 calm the Mind. L.I.-4 influences the throat.

This formula nourishes Liver- and Kidney-Yin, clears Empty Heat, softens hardness, dissolves masses and resolves Phlegm.

Goitre (Hypothyroidism, Hyperthyroidism)

Prescription

Explanation

ZHI BO YANG WEI TANG Anemarrhena-Phellodendron Nourishing the Stomach Decoction YU YIN SAN JIE TANG Nourish Yin and Scatter Nodules Decoction

This formula nourishes Liver- and Kidney-Yin, resolves Phlegm, softens hardness and dissolves masses.

Three Treasures remedies Nourish the Root plus Limpid Sea

YU YIN SAN JIE TANG Nourish Yin and Scatter Nodules Decoction

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Modifications (for all the formulae) • If there is internal Wind, add Gou Teng Ramulus Uncariae, Bai Ji Li Fructus Tribuli terrestris and Bai Shao Radix Paeoniae alba. • If there is Spleen deficiency with loose stools, add Bai Zhu Rhizoma Atractylodis macrocephalae, Yi Yi Ren Semen Coicis, Shan Yao Radix Dioscoreae and Mai Ya Fructus Hordei vulgaris germinatus. • If there is Kidney-Yin deficiency, add Gui Ban Plastrum Testudinis and Tu Si Zi Semen Cuscutae.

Three Treasures remedies Nourish the Root plus Limpid Sea Nourish the Root nourishes Liver- and Kidney-Yin, and Limpid Sea resolves Phlegm.

SUMMARY HEART- AND LIVER-YIN DEFICIENCY WITH PHLEGM Points  Distal points: HE-7 Shenmen, P-6 Neiguan, L.I.-4 Hegu, LIV-3 Taichong, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-8 Ququan, KI-6 Zhaohai, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel, Ren Mai). Reinforcing method.  Ah Shi points surrounding the goitre, L.I.-17 Tianding. Even method. Herbal therapy Prescriptions TIAN WANG BU XIN DAN Variation Heavenly Emperor Tonifying the Heart Pill Variation PING YING FU FANG Formula to Dissolve Goitre FU FANG JIA KANG GAO Formula for Hyperthyroidism

Empirical prescriptions • Xuan Shen Radix Scrophulariae, Mu Li Concha Ostreae, Kun Bu Thallus Eckloniae, Hai Zao Herba Sargassi, Fu Hai Shi Pumice, Hai Ge Ke Concha Cyclinae sinensis, Zhe Bei Mu Bulbus Fritillariae thunbergii, E Zhu Rhizoma Curcumae, Ze Lan Herba Lycopi lucidi, Xia Ku Cao Spica Prunellae, Tian Hua Fen Radix Trichosanthis. • Huang Yao Zi Radix Dioscoreae bulbiferae, 300 g, crushed into small pieces, soaked in 1500 ml of water and put in a sealed jar, heated over a slow fire for 4 hours and stored in the fridge for 1 week. Drink 10 ml of the liquor six times a day but not before bed.

PROGNOSIS AND PREVENTION The prognosis depends on the duration of the disease and the size of the goitre. If the goitre is small, soft and the duration not too long, the prognosis is very good. Vice versa, if the goitre is large, hard and the duration long, the prognosis is less good. If the goitre is very hard, immovable and grows rapidly, the prognosis is the worst. The Qi Goitre reacts best to acupuncture and herbs, and the Muscle Goitre second best. For prevention, one must pay attention to dealing with emotional stress and to avoiding dairy foods and other Phlegm-inducing foods.

GOITRE IN WESTERN MEDICINE The thyroid gland is situated at the front of the throat, below the hyoid bone (Adam’s apple) of the larynx. It comprises two lobes that lie on either side of the trachea and are joined in the front by an isthmus (Fig. 18.4).

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Hypothalamus

– Thyroid cartilage

Right thyroid gland

Left thyroid gland Pituitary

+

TRH



TSH Trachea

+

Figure 18.4 The thyroid gland.

Thyroid

The thyroid gland is under the control of the pituitary gland (Fig. 18.5). When the level of thyroid hormones (triiodothyronine, T3, and thyroxine, T4) drops too low, the pituitary gland produces thyroidstimulating hormone (TSH), which stimulates the thyroid gland to produce more hormones. Under the influence of TSH, the thyroid will manufacture and secrete T3 and T4, thereby raising their blood levels. The pituitary senses this and responds by decreasing its TSH production. One can imagine the thyroid gland as a boiler (furnace) and the pituitary gland as the thermostat. Just as a thermostat cuts off the boiler when the temperature reaches the desired level, the pituitary gland secretes less TSH, thus reducing the levels of T3 and T4 when an optimal level is reached. The thyroid cannot manufacture its hormones without sufficient dietary iodine. If a person’s diet is low in iodine, the pituitary keeps sending chemical messages to the thyroid, but in vain. The thyroid gland enlarges as it attempts to comply with the pituitary’s demands. A goitre is a swelling of the thyroid gland. The symptoms of a goitre include: • enlargement of the throat, ranging from a small lump to a huge mass • swallowing problems if the goitre is large enough to press on the oesophagus • breathing problems if the goitre is large enough to press on the trachea. Goitres are broadly classified into the two groups of endemic and sporadic.

Peripheral conversion T3 Triiodothyronine T4 Thyroxine

Negative feedback loop

Peripheral tissues

Tissue actions Figure 18.5 Hypothalamus–pituitary–thyroid axis. TRH, thyrotrophin-releasing hormone; TSH, thyroid-stimulating hormone.

+

In endemic goitre, a whole community is affected by insufficient dietary iodine. One common reason is that the soil in which foods are grown is iodine depleted. Certain areas of Australia, including Tasmania and areas along the Great Dividing Range (e.g. the Australian Capital Territory), have low iodine levels in the soil. There is also evidence of a re-emergence of iodine deficiency in cities such as Melbourne and Sydney. Mountainous areas and areas far from the sea are the ones most likely to be iodine-deficient. However, endemic goitres tend to be more prevalent in developing countries. They are rare in developed countries because of widespread iodine supplementation. In sporadic goitre, only the individual is affected. Risk factors for sporadic goitre include family history, diet, age (over 40 years) and sex (women are much more susceptible than men).

Goitre (Hypothyroidism, Hyperthyroidism)

Goitre can be caused by a range of factors, including: • insufficient iodine in the diet • high consumption of certain foods that neutralize iodine, such as cabbage, broccoli and cauliflower; other foods, such as soy, may also induce goitre • certain drugs, such as lithium and phenylbutazone • thyroid cancer • nodules growing on the thyroid gland • hyperthyroidism (overactive thyroid gland) • hypothyroidism (underactive thyroid gland).

Diagnosis methods A goitre, and its underlying causes, is diagnosed using a number of tests, including: • physical examination • blood tests to check for thyroid hormone levels and particular antibodies • ultrasound scan • fine-needle biopsy • radioactive iodine scan.

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Thyroid nodules Thyroid nodules are lumps that grow on the gland. Nodules are classified into two groups. 1. Hot or warm: these nodules account for around 15% of cases and can cause hyperthyroidism; the cancer risk is low. 2. Cold: these nodules account for around 85% of cases; around 20% of these are cancerous.

Thyroid cancer Sometimes, the thyroid gland is enlarged because of cancer. Anyone can develop thyroid cancer, regardless of age or sex. The incidence rates are very low, and the cure rate is very good. Some of the risk factors include: • • • •

chronic goitre family history female gender radiation exposure (high doses of radiation were used during the 1950s to treat disorders of the throat and skin).

Types of goitre Goitres can be either diffuse or multinodular. A multinodular goitre is usually a simple goitre that has progressed to nodularity.

Treatment options Treatment depends on the underlying cause. • Goitre caused by iodine deficiency can be helped with the introduction of iodine-rich foods into the diet, such as seafood and iodized salt. • Hyperthyroidism is managed with drugs that slow the activity of the thyroid. If these fail to work, part or all of the thyroid gland is surgically removed. Alternatively, some or all of the thyroid’s hormoneproducing cells can be destroyed with radioactive iodine treatment. • Hypothyroidism is treated by lifelong thyroid hormone replacement therapy. • Benign thyroid nodules are shrunk with medications, destroyed with radioactive iodine treatment or surgically removed, depending on the type. • Cancer of the thyroid is treated by surgical removal of the gland followed by radioactive iodine treatment.

HYPOTHYROIDISM The thyroid is a small, butterfly-shaped gland located in the front of the neck that produces thyroid hormones; these signal cells throughout the body to increase oxygen use. The two key thyroid hormones are T3 and T4. The secretion of T3 and T4 is controlled by the pituitary gland and the hypothalamus. Thyroid disorders may result not only from defects in the thyroid gland itself but also from abnormalities of the pituitary or hypothalamus (Fig. 18.5).

PATHOLOGY Hypothyroidism occurs when there is an inadequate secretion of thyroid hormones, resulting in a slowing down of the body’s metabolism. While low production of these hormones results in hypothyroidism (an underactive thyroid), high production of these hormones results in hyperthyroidism (an overactive thyroid). There are various causes of hypothyroidism. The first is a result of previous (or currently ongoing)

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inflammation of the thyroid gland, which leaves a large percentage of the cells of the thyroid damaged (or dead) and incapable of producing sufficient hormone. The most common type of inflammation of the thyroid gland failure is autoimmune thyroiditis, a form of thyroid inflammation caused by the patient’s own immune system. Atrophic (autoimmune) hypothyroidism is the most common cause of hypothyroidism and is associated with antithyroid autoantibodies leading to lymphoid infiltration of the gland and eventual atrophy and fibrosis. It is six times more common in females, and the incidence increases with age. The condition is associated with other autoimmune diseases such as pernicious anaemia, vitiligo and other endocrine deficiencies. Hashimoto’s thyroiditis is also an autoimmune thyroiditis, again more common in women and most common in late middle age; it produces atrophic changes with regeneration, leading to goitre formation. The gland is usually firm and rubbery but may range from soft to hard. Patients may be hypothyroid or euthyroid, although they may go through an initial toxic phase, “Hashi toxicity”. T4 therapy may shrink the goitre even when the patient is not hypothyroid, although this may take a long time. Another major cause of hypothyroidism is surgical removal of a portion or all of the thyroid gland. If the total mass of thyroid-producing cells left within the body is not enough to meet the needs of the body, the patient will develop hypothyroidism. Removal of all or part of the thyroid gland is carried out to remove tumours or nodules of this gland. Sometimes the remaining thyroid lobe and isthmus will produce enough hormone to meet the demands of the body. Hypothyroidism may also derive from radioactive iodine treatment for goitre. The aim of the radioactive iodine therapy (for benign conditions) is to kill a portion of the thyroid to prevent goitre from growing larger. Occasionally, the result of radioactive iodine treatment will be that too many cells are damaged so the patient develops hypothyroidism a year or two later. Postpartum thyroiditis is usually a transient phenomenon observed following pregnancy and may involve hyperthyroidism, hypothyroidism or the two sequentially. It is believed to result from the modifications to the immune system necessary in pregnancy and histologically is a lymphocytic thyroiditis. The

process is normally self-limiting, but when conventional antibodies are found there is a high chance of this proceeding to permanent hypothyroidism. Iodine deficiency is a common cause of hypothyroidism in mountainous areas (the Alps, Himalayas, South America and Central Africa). In these regions, dietary iodine deficiency still exists, and in some areas endemic goitre, in which goitre is occasionally massive, is common. The patients may be euthyroid or hypothyroid depending on the severity of iodine deficiency. The mechanism is thought to be borderline hypothyroidism leading to TSH stimulation and thyroid enlargement in the face of continuing iodine deficiency.

SUMMARY CAUSES OF HYPOTHYROIDISM  Atrophic (autoimmune) hypothyroidism  Hashimoto’s thyroiditis  Surgical removal of a portion or all of the thyroid gland  Radioactive iodine treatment for goitre  Postpartum thyroiditis  Iodine deficiency

CLINICAL MANIFESTATIONS Hypothyroidism may cause a variety of symptoms and may affect all body functions. The body’s normal metabolic rate slows down, causing mental and physical sluggishness. The symptoms may vary from mild to severe, with the most severe form called myxoedema, which is a medical emergency. Risk factors include being aged over 50 years, female sex, obesity, thyroid surgery and exposure of the neck to X-ray or radiation treatments. The early symptoms and signs of hypothyroidism are (Fig. 18.6): • • • • • • •

weakness fatigue cold intolerance constipation weight gain depression joint or muscle pain

Goitre (Hypothyroidism, Hyperthyroidism)

Symptoms

Signs

Tiredness/malaise Weight gain Cold intolerance Poor memory Poor libido Goitre Puffy eyes Dry, brittle unmanageable hair Dry, coarse skin Muscle weakness Constipation Oligomenorrhoea in women

Mental slowness Dry thin hair Loss of eyebrows Hypertension Hypothermia Bradycardia Cold peripheries Carpal tunnel syndrome Oedema

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Periorbital oedema Deep voice Goitre Dry skin Overweight/obesity Slow-relaxing reflexes Anaemia

Figure 18.6 Clinical manifestations of hypothyroidism. (After Kumar PJ, Clark ML 2002 Kumar and Clark Clinical Medicine, 5th edn. Saunders, Edinburgh, with permission.)

• • • •

thin, brittle fingernails thin and brittle hair paleness low libido. Late symptoms and signs include:

• • • • • • • • •

slow speech poor memory dry, flaky skin thickening of the skin puffy face, hands and feet decreased taste and smell thinning of eyebrows hoarseness abnormal menstrual periods, usually amenorrhoea.

The patient is usually pale with a sallow complexion; there is loss of the outer edge of the eyebrows, thin and brittle hair, coarse facial features, brittle nails, firm swelling of the arms and legs (non-pitting oedema) and mental slowing. Vital signs may reveal slow heart rate, low blood pressure and low temperature. A chest X-ray may reveal an enlarged heart. Laboratory tests to determine thyroid function include: • T4 test (low) • serum TSH (high in primary hypothyroidism, low or low-normal in secondary hypothyroidism). The purpose of treatment in Western medicine is to replace the deficient thyroid hormone. Levothyroxine is the most commonly used medication. The lowest dose effective in relieving symptoms and normalizing

the TSH is used. According to treatment guidelines, lifelong therapy is needed and medication must be continued even when symptoms subside. Thyroid hormone levels should be monitored yearly after a stable dose of medication is determined. As discussed above, there is no direct correspondence between the Chinese disease symptom of “Goitre” and thyroid problems in Western medicine. Hence, Chinese medicine discusses only goitre, while Western medicine discusses many thyroid dysfunctions, such as hypothyroidism, hyperthyroidism, Graves’ disease and Hashimoto’s thyroiditis. Chinese medicine does not really have a theory of thyroid problems without goitre, and these must simply be treated according to the normal identification of patterns. For example, if without goitre, hypothyroidism may correspond to “Exhaustion” (Xu Lao) or “Oedema” in Chinese medicine. As Chinese medicine focuses only and entirely on goitre, its pathology and treatment are focused on the treatment of masses. The treatment principles must therefore be adapted when there are thyroid problems without goitre; i.e. in such cases, it is not necessary to resolve Phlegm (unless there are symptoms of QiPhlegm), soften masses or dissolve masses.

IDENTIFICATION OF PATTERNS AND TREATMENT The main patterns with which hypothyroidism may present are:

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• Spleen- and Kidney-Yang deficiency • Qi and Blood deficiency • Liver- and Kidney-Yin deficiency.

Spleen- and Kidney-Yang deficiency Clinical manifestations Tiredness, feeling cold, slowness, cold limbs, oedema, pale complexion, puffy face, puffy under eyes, tiredness, shortness of breath, desire to lie down, backache, dizziness, poor digestion. Tongue: Pale, Swollen. Pulse: Weak-Deep-Slow.

Treatment principle Warm Yang, strengthen Spleen and Kidneys.

Explanation This formula strongly warms and tonifies Spleen- and Kidney-Yang.

Prescription JI SHENG SHEN QI TANG plus SI JUN ZI TANG Kidney-Qi Pill from “Formulae that Aid the Living”

Explanation This formula strongly warms and tonifies Spleen- and Kidney-Yang. Compared with the previous formula, it also resolves Dampness.

Three Treasures remedy Strengthen the Root Strengthen the Root tonifies Kidney-Yang.

Acupuncture

SUMMARY

Points

SPLEEN- AND KIDNEY-YANG DEFICIENCY

BL-20 Pishu, Ren-12 Zhongwan, ST-36 Zusanli, Du-14 Dazhui, BL-23 Shenshu, KI-7 Fuliu, Ren-4 Guanyuan, Du-4 Mingmen, ST-40 Fenglong, SP-6 Sanyinjiao, Ren-22 Tiantu, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel, Ren Mai). Reinforcing method. Moxa must be used.

Points BL-20 Pishu, Ren-12 Zhongwan, ST-36 Zusanli, Du-14 Dazhui, BL-23 Shenshu, KI-7 Fuliu, Ren-4 Guanyuan, Du-4 Mingmen, ST-40 Fenglong, SP-6 Sanyinjiao, Ren-22 Tiantu, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel, Ren Mai). Reinforcing method. Moxa must be used.

• Oedema: BL-13 Feishu, BL-20 Pishu, BL-22 Sanjiaoshu, LU-7 Lieque, L.I.-6 Pianli. Even method.

Explanation • • • •

BL-20, Ren-12 and ST-36 tonify Spleen-Yang. Du-14 strengthens Heart- and Kidney-Yang. BL-23, KI-7, Ren-4 and Du-4 tonify Kidney-Yang. ST-40 and SP-6 resolve Phlegm and are used if there is a goitre. • Ren-22 is a local point that affects the thyroid. • LU-7 and KI-6 open the Directing Vessel and can be used in combination with Ren-4 (with moxa cones) to tonify Kidney-Yang. The Directing Vessel also regulates the Uterus and should be used if there are menstrual irregularities.

 Oedema: BL-13 Feishu, BL-20 Pishu, BL-22 Sanjiaoshu, LU-7 Lieque, L.I.-6 Pianli. Even method. Herbal therapy Prescriptions ZHANG SHI JIA JIAN FANG Master Zhang’s Hypothyroidism Formula JI SHENG SHEN QI TANG plus SI JUN ZI TANG Kidney-Qi Pill from “Formulae that Aid the Living” Three Treasures remedy Strengthen the Root

Qi and Blood deficiency Herbal therapy Prescription ZHANG SHI JIA JIAN FANG Master Zhang’s Hypothyroidism Formula

Clinical manifestations Tiredness, weakness, dislike to speak, slowness, palpitations, sallow complexion, loose stools, dry skin, amenorrhoea, cold limbs.

Goitre (Hypothyroidism, Hyperthyroidism)

Tongue: Pale. Pulse: Choppy.

Treatment principle Tonify Qi and nourish Blood.

Acupuncture

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Explanation This is a simple variation of the formula Shi Quan Da Bu Tang Ten Complete Great Tonification Decoction, which tonifies Qi and nourishes Blood.

Three Treasures remedy Precious Sea Precious Sea tonifies Qi and nourishes Blood.

Points BL-20 Pishu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-23 Shenshu, Ren-4 Guanyuan, Du-20 Baihui, Ren-22 Tiantu. Reinforcing method. Moxa can be used.

Explanation • BL-20, Ren-12, ST-36 and SP-6 tonify Spleen-Qi and nourish Blood. • BL-23 and Ren-4 tonify the Kidneys and nourish Blood. • Du-20 lifts Qi. • Ren-22 is a local point to affect the thyroid.

Herbal therapy Prescription DENG SHI JIA YI FANG Master Deng’s Thyroid Formula

Explanation This formula primarily tonifies Spleen-Qi and secondarily Kidney-Yang. It also lifts Qi and can be considered a variation of Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction.

Prescription XU SHI ZHI JIAN FANG Master Xu’s Formula for Hypothyroidism

Explanation Compared with the previous formula, this formula is more focused on nourishing Blood than tonifying Qi (although it does tonify Qi). It is also aimed at treating goitre.

Prescription SHI QUAN DA BU TANG Variation Ten Complete Great Tonification Decoction Variation

SUMMARY QI AND BLOOD DEFICIENCY Points BL-20 Pishu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-23 Shenshu, Ren-4 Guanyuan, Du-20 Baihui, Ren-22 Tiantu. Reinforcing method. Moxa can be used. Herbal therapy Prescriptions DENG SHI JIA YI FANG Master Deng’s Thyroid Formula XU SHI ZHI JIAN FANG Master Xu’s Formula for Hypothyroidism SHI QUAN DA BU TANG Variation Ten Complete Great Tonification Decoction Variation Three Treasures remedy Precious Sea

Case history A 47-year-old woman had been suffering from an underactive condition of the thyroid, which had been diagnosed a year before the consultation. This was still a mild state of underactivity and she was not on T4. She had no swelling of the thyroid. Her main complaints were tiredness, palpitations, cold feeling, loose stools, backache and dizziness. Her tongue was Pale with a Heart crack and her pulse was Weak and Choppy. The tongue and the pulse show a very clear condition of Qi and Blood deficiency. The deficiency of Qi affects primarily the Spleen and Stomach, and it tends to Yang deficiency due to the cold feeling and Pale tongue; the Blood deficiency affects primarily the Heart (palpitations).

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I treated her with a variation of Deng Shi Jia Yi Fang Master Deng’s Thyroid Formula. • • • • • • • • • • •

Huang Qi Radix Astragali 30 g Dang Shen Radix Codonopsis 18 g Bai Zhu Rhizoma Atractylodis macrocephalae 24 g Dang Gui Radix Angelicae sinensis 12 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g Chai Hu Radix Bupleuri 6 g Sheng Ma Rhizoma Cimicifugae 6 g Ba Ji Tian Radix Morindae officinalis 9 g Chen Pi Pericarpium Citri reticulatae 3 g Gou Qi Zi Fructus Lycii chinensis 6 g Tu Si Zi Semen Cuscutae 6 g

I added Tu Si Zi to the formula to tonify Kidney-Yang. I did not use any herbs to resolve Phlegm or dissolve masses. She took this formula with some variations for a period of 1 year, and her thyroid function returned to normal. Her symptoms also subsided and she felt much more energy. However, she would need “top-up” treatments regularly in order to maintain the thyroid function to a normal level.

Liver- and Kidney-Yin deficiency Clinical manifestations

• LU-7 and KI-6 open the Directing Vessel and nourish Yin. • Ren-22 is a local point acting on the thyroid.

Herbal therapy Prescription YOU GUI YIN Variation Restoring the Right [Kidney] Decoction Variation

Explanation This formula nourishes Liver- and Kidney-Yin.

Three Treasures remedy Nourish the Root Nourish the Root nourishes Liverand Kidney-Yin.

SUMMARY LIVER- AND KIDNEY-YIN DEFICIENCY Points ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, Ren-4 Guanyuan, KI-3 Taixi, KI-6 Zhaohai, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel, Ren Mai), Ren-22 Tiantu. Reinforcing method. Herbal therapy Prescription YOU GUI YIN Variation Restoring the Right [Kidney] Decoction Variation

Tiredness, feeling of heat in the afternoon and evening, night sweating, backache, dizziness, tinnitus, tremor of hands, blurred vision, dry throat. Tongue: Red without coating. Pulse: Floating-Empty.

Three Treasures remedy Nourish the Root

Treatment principle

HYPERTHYROIDISM

Nourish Yin, strengthen Liver and Kidneys.

Acupuncture

Hyperthyroidism is an imbalance of metabolism caused by overproduction of thyroid hormone.

Points ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, Ren-4 Guanyuan, KI-3 Taixi, KI-6 Zhaohai, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel, Ren Mai), Ren-22 Tiantu. Reinforcing method.

Explanation • ST-36, SP-6, LIV-8 and Ren-4 nourish Liver-Yin. • Ren-4, KI-3 and KI-6 nourish Kidney-Yin.

PATHOLOGY The main causes of hyperthyroidism are: • Graves’ disease • non-cancerous growths of the thyroid gland or pituitary gland • tumours of the testes or ovaries

Goitre (Hypothyroidism, Hyperthyroidism)

• inflammation (irritation and swelling) of the thyroid due to viral infections or other causes • ingestion of excessive amounts of thyroid hormone • ingestion of excessive iodine. Graves’ disease accounts for 85% of all cases of hyperthyroidism. This is the most common cause of hyperthyroidism and is due to an autoimmune process. Serum IgG antibodies bind to the thyroid TSH receptor, stimulating thyroid hormone production and behaving like TSH. These TSH receptor antibodies can be measured in serum. Yersinia enterocolitica as well as Escherichia coli and other Gram-negative organisms contain TSH-binding sites. This raises the possibility that the initiating event in the pathogenesis may be an infection with possible “molecular mimicry” in a genetically susceptible individual, but the precise initiating mechanisms remain unproven in most cases. Thyroid eye disease accompanies the hyperthyroidism in many cases (see below), but other components of Graves’ disease, for example Graves’ dermopathy, are very rare. Rarely lymphadenopathy and splenomegaly may occur. Graves’ disease is also associated with other autoimmune disorders, such as pernicious anaemia, vitiligo and myasthenia gravis. The natural history is one of fluctuation, many patients showing a pattern of alternating relapse and remission; only about 40% of

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subjects have a single episode. Many patients eventually become hypothyroid.

CLINICAL MANIFESTATIONS The symptoms and signs of Graves’ disease are (Fig. 18.7): • • • • • • • • • •

weight loss increased appetite nervousness restlessness heat intolerance increased sweating fatigue frequent bowel movements menstrual irregularities in women goitre may be present.

Additional symptoms that may be associated with this disease are: • • • • • •

weakness sleeping difficulty clammy skin skin blushing or flushing bounding pulse nausea and vomiting

Symptoms

Signs

Weight loss Increased appetite Irritability/behaviour change Restlessness Malaise Muscle weakness Tremor Breathlessness Palpitations Heat intolerance Itching Thirst Vomiting Diarrhoea Eye complaints Goitre Gynaecomastia Sweating

Tremor Hyperkinesis Irritability Palmar erythema Tachycardia or atrial fibrillation Full pulse Warm vasodilated peripheries Systolic hypertension Pretibial myxoedema Exophthalmos Goitre Weight loss

Figure 18.7 Clinical manifestations of hyperthyroidism. (After Kumar PJ, Clark ML 2002 Kumar and Clark Clinical Medicine, 5th edn. Saunders, Edinburgh, with permission.)

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• • • • • • • • •

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amenorrhoea itching all over the body palpitations hand tremor hair loss diarrhoea breast development in men high blood pressure protruding eyes (exophthalmos).

In the elderly, a frequent presentation is with atrial fibrillation, other tachycardias and/or heart failure, often with few other signs. Thyroid function tests are mandatory in any patient with atrial fibrillation. Children frequently present with excessive height or excessive growth rate, or with behavioural problems such as hyperactivity. They may also show weight gain rather than loss. The clinical signs show an increased heart rate, and the systolic blood pressure may be elevated. Physical examination may reveal thyroid enlargement or goitre. Laboratory tests that evaluate thyroid function: • serum TSH is usually decreased • T3 and free T4 are usually elevated. The treatment of Graves’ disease in modern medicine depends on the cause of the condition and the severity of symptoms. Hyperthyroidism is usually treated with antithyroid medications, radioactive iodine (which destroys the thyroid and thus stops the excess production of hormones) or surgery to remove the thyroid. If the thyroid must be removed with radiation or surgery, replacement thyroid hormones are prescribed. Hyperthyroidism caused by Graves’ disease is usually progressive and has many associated complications, some of which are severe and affect quality of life.

HYPERTHYROIDISM IN CHINESE MEDICINE: A REVIEW OF CHINESE LITERATURE From the point of view of Chinese medicine, when confronted with a patient suffering from hyperthyroidism, the first question we should ask ourselves is how we should consider this disease from a Chinese perspective. In other words, we should establish to which Chinese “disease” hyperthyroidism might cor-

respond. For example, when treating hypertension we can quite safely say that this disease corresponds to the three Chinese “diseases” of “Headaches”, “Dizziness” and “Tinnitus.” The overwhelming majority of Chinese doctors say that hyperthyroidism corresponds to the Chinese disease of “Goitre” (Ying Bing). I personally disagree with this view, because hyperthyroidism does not always present with a goitre; as goitre always indicates Phlegm, it would be wrong to resolve Phlegm in a patient without goitre. Certainly, if a patient suffering from hyperthyroidism does have a goitre, it is legitimate to assume that the pathology and treatment methods of “Goitre” are largely applicable to the treatment of hyperthyroidism. Of the Chinese doctors mentioned below, only two (Zhu Ceng Bo and Wei Zi Xiao) are of the opinion that hyperthyroidism cannot be equated to “Goitre”. This raises the question of the importance of the integration of a Chinese with a Western medical diagnosis. For example, it would be wrong to treat a patient for “Palpitations” and “Tremors” (Chinese disease entities) without investigating whether those two symptoms are due to a dysfunction of the thyroid.

Dr Wei Zi Xiao Dr Wei Zi Xiao says that hyperthyroidism may correspond to many different Chinese “diseases”, such as “Palpitations” (Xin Ji), “Insomnia”, “Depression”, “Sweating”, “Tremors”, “Diabetes” (Xiao Ke), “Fever” (of internal origin), “Exhaustion” (Xu Lao) and “Phlegm” (Fig. 18.8).10 According to Dr Wei Zi Xiao, in the treatment of hyperthyroidism it is important to distinguish Fullness from Emptiness and the Root (Ben) from the Manifestation (Biao). He says that the Root is most often a Deficiency of Yin and that the Manifestation is Full and may consist of Qi stagnation, Blood stasis, Fire or Phlegm. The presence of a goitre indicates Phlegm. Dr Wei Zi Xiao says that the three main organs involved in the pathology of hyperthyroidism are the Heart, Liver and Kidneys. As mentioned above, Dr Wei Zi Xiao says that hyperthyroidism cannot be equated with “Goitre” in Chinese medicine; he says that hyperthyroidism may correspond to many different Chinese “diseases”, such as “Palpitations”, “Insomnia”, “Depression”, “Sweating” and “Tremors”. In this opinion, Dr Wei differs from most other Chinese doctors who equate hyperthyroidism

Goitre (Hypothyroidism, Hyperthyroidism)

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— Liver (dizziness, blurred vision, irritability, tremor): Huang Qin Radix Scutellariae, Long Dan Cao Radix Gentianae, Xia Ku Cao Spica Prunellae, Ci Shi Magnetitum, Mu Li Concha Ostreae. • Eliminate stagnation (Chai Hu Radix Bupleuri, Xiang Fu Rhizoma Cyperi, Yu Jin Radix Curcumae, Fu Ling Poria, Bai Zhu Rhizoma Atractylodis macrocephalae).

Exhaustion (Xu-Lao)

Palpitations

Insomnia

Depression HYPERTHYROIDISM Sweating

Tremors

Diabetes (Xiao Ke)

Fever Figure 18.8 Chinese diseases corresponding to hyperthyroidism.

with “Goitre” (Ying Bing) of Chinese medicine; I personally tend to agree with Dr Wei in thinking that hyperthyroidism corresponds to “Goitre” only when there is a goitre, and very many patients suffering from hyperthyroidism do not have a goitre. According to Dr Wei Zi Xiao, the treatment principles for hyperthyroidism are as follows. • Nourish Yin (Sheng Di Huang Radix Rehmanniae, Dang Gui Radix Angelicae sinensis, Gou Qi Zi Fructus Lycii chinensis, Nu Zhen Zi Fructus Ligustri lucidi, Han Lian Cao Herba Ecliptae, Tian Men Dong Radix Asparagi, Mai Men Dong Radix Ophiopogonis, Bie Jia Carapax Trionycis, Bai Shao Radix Paeoniae alba, Ji Xue Teng Caulis Spatholobi). • Clear Heat — Heart (palpitations, insomnia, anxiety): Huang Lian Rhizoma Coptidis, Shan Zhi Zi Fructus Gardeniae, Lian Xin Plumula Nelumbinis nuciferae, Bai Zi Ren Semen Platycladi. — Stomach (thirst and hunger): Shi Gao Gypsum Fibrosum, Zhi Mu Radix Anemarrhenae, Gan Cao Radix Glycyrrhizae uralensis, Huang Lian Rhizoma Coptidis, Huang Qin Radix Scutellariae.

For goitre, Dr Wei Zi Xiao uses Si Qi Tang Four Seasons Decoction for the Seven Emotions plus Gui Zhi Ramulus Cinnamomi cassiae, E Zhu Rhizoma Curcumae, Chuan Shan Jia Squama Manitis Pentadactylae, Bai Jie Zi Semen Sinapis albae, Mu Li Concha Ostreae. For exophthalmos, he drains Dampness, resolves Phlegm, eliminates stasis and expels Wind using Mu Tong Caulis Akebiae trifoliatae, Ze Xie Rhizoma Alismatis, Bai Jie Zi Semen Sinapis albae, Ban Xia Rhizoma Pinelliae preparatum, Zhe Bei Mu Bulbus Fritillariae thunbergii, E Zhu Rhizoma Curcumae, Chi Shao Radix Paeoniae rubra, Yi Mu Cao Herba Leonuri, Ju Hua Flos Chrysanthemi, Mu Zei Cao Herba Equiseti hiemalis, Bai Ji Li Fructus Tribuli. Finally, he uses Hai Zao Herba Sargassi 20–30 g per day.11

Shanghai Municipal Acupuncture and Channels Research Group According to the Shanghai Municipal Acupuncture and Channels Research Group, the main pathology of hyperthyroidism is Yin deficiency of the Liver and Kidneys with Empty Heat in the Liver and Heart. These doctors’ thinking very much follows the Five Elements, and they say that the deficiency of the Water Element affects the Child, i.e. Wood, and this in turn affects Fire. For this reason, the treatment principle is to nourish Water and drain Wood and Fire.12 The main points used are KI-10 Yingu, KI-7 Fuliu, SP-6 Sanyinjiao and KI-3 Taixi reinforced to nourish Water, and HE-7 Shenmen, P-7 Daling, P-8 Laogong and P-5 Jianshi reduced to drain Fire. Other distal points are L.I.-4 Hegu and ST-40 Fenglong. Local points for goitre are ST-10 Shuitu (most important according to them) and extra points Ping Ying and Shangtianzhu.

Dr Zhao Fen According to Dr Zhao Fen (Fujian College of Traditional Chinese Medicine), the pathology of hyperthyroidism

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often starts with Liver-Qi stagnation; this usually leads to Liver-Fire. Liver-Fire injures the fluids and leads to deficiency of Yin of the Liver and Kidneys.13 Dr Zhao Fen therefore differentiates three stages in the development of hyperthyroidism: in the initial stage, the treatment principle is to move Liver-Qi, remove stagnation, resolve Phlegm, dissolve goitre, and drain Fire; in the middle stage, the treatment principle is to subdue Liver Yang, clear Heat, cool Blood and nourish Yin; in the late stage, the treatment principle is to nourish the Liver, tonify Qi and Yin, and clear Empty Heat. The prescription for Liver-Qi stagnation used by Dr Zhao is a variation of Xiao Chai Hu Tang Small Bupleurum Decoction.14 The prescription used by Dr Zhao for the middle stage of hyperthyroidism is a variation of Zhen Zhu Mu Tang Concha Margatiriferae Decoction.15 The prescription used for the late stage of hyperthyroidism is a variation of Sheng Mai Tang Nourishing the Pulse Decoction.16

vessels, this herb treats channels and blood vessels, thereby removing obstructions that cause goitre. Dr Peng says that, although quite different conditions, there are similarities between hyperthyroidism and the Lilium Syndrome (Bai He Bing) mentioned in the Essential Prescriptions of the Golden Chest (Jin Gui Yao Fang). The prescription for the Lilium Syndrome is Bai He Zhi Mu Tang Lilium-Anemarrhena Decoction. Dr Peng recommends the following additions according to symptoms. • For thirst and dry mouth, add Tian Hua Fen Radix Trichosanthis. • For dark urine, add Hua Shi Talcum. • For Qi stagnation and Blood stasis, add Yu Jin Radix Curcumae and Tao Ren Semen Persicae. • For insomnia, add Ye Jiao Teng Caulis Polygoni multiflori and Suan Zao Ren Semen Ziziphi spinosae. • For profuse sweating, add Huang Qi Radix Astragali and Gui Zhi Ramulus Cinnamomi cassiae.

Dr Peng Lu Xiang

Dr Ren Duan Xue

According to Dr Peng Lu Xiang (Chengdu College of Traditional Chinese Medicine), the main treatment principles for hyperthyroidism are to move Liver-Qi, nourish Yin, clear Heat, soften hardness, dissolve nodules, resolve Phlegm and eliminate stasis. The main organs involved are the Heart, Liver, Spleen and Stomach. However, Dr Peng is unique among Chinese doctors in that he considers that the Lungs are also involved in the pathology of hyperthyroidism. He says that LiverFire can rebel horizontally to invade the Heart, Lungs, Spleen and Stomach, injuring the Yin of these organs. For this reason, he uses a variation of Bai He Di Huang Tang Lilium-Rehmannia Decoction. Dr Peng gives two main reasons for using this decoction and in particular the herb Bai He Bulbus Lilii. He says that by entering the Lungs, Bai He clears Metal so that Wood is regulated, Liver-Qi moves, Fire is subdued and the Yin fluids nourished. On the other hand, Sheng Di Huang Radix Rehmanniae nourishes Yin; Zhi Mu Radix Anemarrhenae clears Lung- and Stomach-Heat. The combination of these three herbs clears the Lungs, drains and subdues Liver-Fire, nourishes Yin and clears Heat. The second reason for using Bai He is that, as it enters the Lungs, which control channels and blood

According to Dr Ren Duan Xue (Changchun College of Traditional Chinese Medicine), Qi stagnation is at the root of the pathology of hyperthyroidism. He says that the emotional root of this disease is anger leading to Qi stagnation. Stagnant Liver-Qi turns into Fire, which flares upwards to disturb the Heart, causing mental restlessness, palpitations and anxiety. Liver-Fire flares up to harass the Lungs as well, causing excessive sweating. Moreover, Liver-Fire moves horizontally to invade the Stomach and Spleen, injuring their fluids and causing thirst, hunger and loss of weight. The Liver opens into the eyes, and the upward rise of Liver-Fire causes exophthalmos (bulging of the eyeballs). Dr Ren therefore says that the main treatment principle for hyperthyroidism is to move Liver-Qi, subdue Liver-Fire, clear Heat and extinguish Wind. The prescription he recommends is his own empirical prescription based on these treatment principles.17

Dr Chen Yuan Sheng According to Dr Chen Yuan Sheng (Chongqing Chinese Medicine Research Group), the main treatment principle in hyperthyroidism is to nourish Liver- and Kidney-Yin, clear Empty Heat, resolve Phlegm and dissolve goitre. Dr Chen uses a variation of Chai Shao

Goitre (Hypothyroidism, Hyperthyroidism)

Long Mu Tang Bupleurum-Paeonia-Mastodi Ossis fossilia-Concha Ostreae Decoction.18 Dr Chen recommends the following additions according to symptoms. • For Qi deficiency, add Huang Qi Radix Astragali. • For goitre, add Bie Jia Carapax Trionycis, Zhe Bei Mu Bulbus Fritillariae thunbergii and Xia Ku Cao Spica Prunellae. • For insomnia, add Suan Zao Ren Semen Ziziphi spinosae. • For Heat, add Huang Qin Radix Scutellariae and Shan Zhi Zi Fructus Gardeniae. • For excessive sweating, add Fu Xiao Mai Fructus Tritici levis. • For tremors, add Dang Gui Radix Angelicae sinensis and Mu Gua Fructus Chaenomelis.

Dr Chen Duan Ming According to Dr Chen Duan Ming (Nantong Hospital of Chinese Medicine), the main treatment principle for hyperthyroidism is to nourish Yin, drain and subdue Fire, dissolve goitre and dissolve nodules. Dr Chen uses a variation of Dang Gui Liu Huang Tang Angelica Six Yellow Decoction.19

Dr Chen Ze Lin According to Dr Chen Ze Lin (Shanghai Zhongshan Hospital of the University of Medical Science), there are two main patterns involved in hyperthyroidism: the first is Liver-Fire and Stomach-Heat with internal Wind; the second is Liver-Qi stagnation with Phlegm. The prescription he uses to drain Liver-Fire, clear Stomach-Heat and extinguish internal Wind is a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction.20 Dr Chen suggests the following modifications according to symptoms. • For Heart-Fire, add Huang Lian Rhizoma Coptidis 3 g. • For palpitations, add Zhen Zhu Mu Concha Margatiriferae usta 30 g and Long Chi Mastodi Dens fossilia 15 g. • For dry mouth, add Tian Hua Fen Radix Trichosanthis 30 g and Lu Gen Rhizoma Phragmitis 30 g. • For exophthalmos, add Zhe Bei Mu Bulbus Fritillariae thunbergii 9 g, Dan Nan Xing Rhizoma

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Arisaematis preparatum 6 g, Che Qian Zi Semen Plantaginis 15 g and Ze Xie Rhizoma Alismatis 10 g. The prescription that Dr Chen uses to move Liver-Qi and resolve Phlegm is a variation of Si Hai Jie Yu Tang Four Seas Eliminating Stagnation Decoction. Dr Chen recommends the following modifications according to symptoms. • For the feeling of a lump in the throat, add Hou Po Cortex Magnoliae officinalis 9 g and Ban Xia Rhizoma Pinelliae preparatum 9 g. • For a large goitre, add San Leng Rhizoma Sparganii stoloniferi 12 g and Chuan Shan Jia Squama Manitis Pentadactylae 9 g. • For insomnia, add Suan Zao Ren Semen Ziziphi spinosae 9 g and Ye Jiao Teng Caulis Polygoni multiflori 9 g. • For Heat, add Shan Zhi Zi Fructus Gardeniae 9 g and Zhi Mu Radix Anemarrhenae 9 g. As an empirical remedy, Dr Chen also recommends the use of seaweeds such as Kun Bu Thallus Eckloniae and Hai Zao Herba Sargassi in large doses (at least 50 g of each).

Dr Lu Cheng Ren Dr Lu Cheng Ren (Beijing Medical College) says that hyperthyroidism corresponds to the Chinese disease of “Goitre”. He attributes the aetiology of hyperthyroidism to emotional stress and in particular anger leading to Liver-Qi stagnation; stagnant Liver-Qi turns into Fire, and this dries up the body fluids. Stagnant Liver-Qi upsets the movement of Qi in the Qi Mechanism, and this leads to the formation of Phlegm. The Liver opens into the eyes, and Liver-Qi stagnation causes exophthalmos. The Liver influences the sinews, and deficiency of Liver-Blood causes tremor of the hands. Liver-Fire injures the fluids and leads to Heart-Yin deficiency, resulting in insomnia, palpitations and sweating. Liver-Fire invades the Stomach and causes thirst, excessive hunger and weight loss. Liver and Kidneys have a common root, and the deficiency of Yin of the Liver induces Kidney-Yin deficiency. Dr Lu recommends the treatment principle of nourishing Yin and clearing Heat to treat hyperthyroidism. He uses a variation of the formula Zi Shui Qing Gan Yin Nourishing Water and Clearing the Liver Decoction.21

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Dr Lu recommends the following modifications according to symptoms. • For large goitre, add Hai Fu Shi Pumice, Chi Shao Radix Paeoniae rubra and Hai Zao Herba Sargassi. • For bitter taste, dry eyes and dry stools from LiverFire, add Long Dan Cao Radix Gentianae, Huang Qin Radix Scutellariae and Da Huang Radix et Rhizoma Rhei. • For tremors from Liver-Wind, add Gou Teng Ramulus cum Uncis Uncariae, Ling Yang Jiao Cornu Saigae tataricae and Zhen Zhu Mu Concha Margatiriferae usta.

Dr Zhu Ceng Bo Dr Zhu Ceng Bo (Hubei College of Traditional Chinese Medicine) thinks that hyperthyroidism cannot be equated to the Chinese disease of “Goitre”. Dr Zhu distinguishes three main conditions in hyperthyroidism. The first is characterized by Fire of the Liver, Stomach and Heart with manifestations such as propensity to outbursts of anger, feeling of heat, sweating, excessive hunger, weight loss, thirst and insomnia. For this condition, he recommends an empirical prescription according to his experience.22 The second condition is characterized by LiverFire invading the Stomach, causing manifestations such as thirst, dry mouth, excessive hunger, weight loss, insomnia and palpitations. He recommends an empirical prescription according to his clinical experience (see Appendix 4 [Prescriptions], Empirical prescription by Dr Zhu Ceng Bo for Liver-Qi stagnation turning into Liver-Fire). The third condition is characterized by deficiency of Yin, with such clinical manifestations as exhaustion, weight loss, dizziness, palpitations, anxiety, dry mouth, insomnia, a feeling of heat in the evening and fivepalm heat. Dr Zhu recommends an empirical prescription according to his experience.

Dr Zhou Guo Xiong Dr Zhou Guo Xiong distinguishes three main conditions in the pathology of hyperthyroidism: the first is characterized by Liver-Qi stagnation, Liver-Fire and Phlegm; the second by Yin deficiency with Empty Heat; the third by Qi and Yin deficiency. For the first condition with Liver-Qi stagnation, Liver-Fire and Phlegm, he uses a variation of Hai Zao Yu Hu Tang Sargassum Jade Pot Decoction.23

For the second condition with Yin deficiency and Empty Heat, Dr Zhou uses a variation of Qing Gan Lu Hui Wan Clearing the Liver Aloe Pill together with Yu Nu Jian Jade Woman Decoction. For the third condition with Qi and Yin deficiency, Dr Zhou uses a variation of Huang Qi Tang Astragalus Decoction.

Dr Zhang Zhen Ru Dr Zhang Zhen Ru (Wuhan City College of Traditional Chinese Medicine) indicates two main treatment principles for hyperthyroidism: the first is to nourish Liver-Yin; the second is to soften hardness and eliminate Blood stasis. He formulated his own prescription, called Xiao Ying Zhi Kang Tang Dissolving Goitre and Reducing Hyperthyroidism Decoction24 (see Appendix 4 [Prescriptions], empirical prescription by Dr Zhang Zhen Ru for hyperthyroidism).

Dr Wang Zhu Bie Dr Wang Zhu Bie (Zhejiang Province Public Health Department) considers that in hyperthyroidism the main patterns are Liver-Qi stagnation, Yin deficiency and Phlegm. He thinks that the two main organs involved are the Liver and Kidneys. The main treatment principle is to nourish Yin, subdue the Liver, move Liver-Qi, resolve Phlegm and soften hardness. Dr Wang uses an empirical prescription according to his experience.25

Dr Xu Feng Gong According to Dr Xu Feng Gong, hyperthyroidism corresponds to the Chinese disease of “Goitre”. and he thinks that the main treatment principle is to resolve Phlegm, move Liver-Qi, drain Liver-Fire, clear StomachHeat, calm the Mind and extinguish Liver-Wind.26 Dr Xu uses an empirical prescription according to his experience (see Appendix 4 [Prescriptions], empirical prescription by Dr Xu Feng Gong for hyperthyroidism).

Dr Xu Qing Cheng Dr Xu Qing Cheng (Wuhan Medical College) thinks that the main conditions appearing in hyperthyroidism are Heart- and Liver-Yin deficiency, Heat and Phlegm. He therefore advocates the treatment principle of supporting Heart-Qi, nourishing Liver-Yin, softening hardness and dissolving nodules.27

Goitre (Hypothyroidism, Hyperthyroidism)

Dr Xu uses an empirical prescription according to his experience (see Appendix 4 [Prescriptions], empirical prescription by Dr Xu Qing Cheng for hyperthyroidism).

Dr Xia Shao Nong Dr Xia Shao Nong (Shanghai College of Traditional Chinese Medicine) thinks that hyperthyroidism corresponds to the Chinese disease “Goitre”. He states that the main treatment principles are three: to nourish Yin and clear Heat, to move Qi and resolve Phlegm, and to tonify Qi and Yin. Dr Xia recommends his own empirical prescription to treat hyperthyroidism28 (see Appendix 4 [Prescriptions], empirical prescription by Dr Xia Shao Nong for hyperthyroidism). He recommends the following modifications according to symptoms. • For Spleen-Qi deficiency, remove Sheng Di Huang Radix Rehmanniae and add Shan Yao Rhizoma Dioscoreae and Bai Zhu Rhizoma Atractylodis macrocephalae. • For Heart-Fire, add Huang Lian Rhizoma Coptidis. • For Liver-Fire, add Long Dan Cao Radix Gentianae. Based on the above, we can build a table showing the frequency with which a particular treatment method for hyperthyroidism is mentioned by modern Chinese doctors (Table 18.1).

IDENTIFICATION OF PATTERNS AND TREATMENT Based on the experience of the above doctors and partly my own, the following patterns are the most common ones in hyperthyroidism. • • • •

Liver-Qi stagnation Heat in the Liver, Heart and Stomach Liver- and Kidney-Yin deficiency with Empty Heat Phlegm-Heat in the Liver

Most of the patterns discussed below assume the absence of goitre. If there is goitre with hyperthyroidism, one must resolve Phlegm, soften hardness and dissolve masses with some of the following herbs. • Zhe Bei Mu Bulbus Fritillariae thunbergii and Ban Xia Rhizoma Pinelliae preparatum to resolve Phlegm.

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Table 18.1 Frequency of treatment methods for hyperthyroidism mentioned by modern Chinese doctors Treatment method

Frequency of mention

Nourish Yin

14

Clear Heat

13

Eliminate Qi stagnation

10

Resolve Phlegm

9

Soften hardness

3

Dissolve nodules

3

Extinguish Wind

3

Eliminate Blood stasis

2

Clear Empty Heat

2

Tonify Qi and Yin

1

• Kun Bu Thallus Eckloniae, Hai Zao Herba Sargassi or Zhe Bei Mu Bulbus Fritillariae thunbergii to soften masses. • Xia Ku Cao Spica Prunella, E Zhu Rhizoma Curcumae or Huang Yao Zi Radix Dioscoreae bulbiferae to dissolve masses. From the point of view of acupuncture treatment, if there is a goitre the distal points are selected according to the patterns discussed below, but the local points indicated above under Goitre should be added.

Liver-Qi stagnation Clinical manifestations Hyperthyroidism, beginning stage, nervousness, restlessness, heat intolerance, fatigue, palpitations, irritability, mental restlessness, depression, moodiness, abdominal distension, menstrual irregularities in women, premenstrual tension. Tongue: slightly Red sides. Pulse: Wiry.

Treatment principle Soothe the Liver, move Liver-Qi, calm the Mind, settle the Ethereal Soul.

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Acupuncture Points T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, L.I.-4 Hegu, Ren-22 Tiantu. Even method.

Explanation • T.B.-6, G.B.-34, LIV-3 and P-6 move Liver-Qi, calm the Mind and settle the Ethereal Soul. • L.I.-4 treats the neck area and together with LIV-3, calms the Mind and settles the Ethereal Soul. • Ren-22 is a local point to affect the thyroid function.

Herbal therapy Prescription EMPIRICAL PRESCRIPTION by Dr Zhao Fen Three Treasures remedies Open the Heart Bright Spirit Release Constraint Freeing the Moon

Heat in Liver, Heart and Stomach Herbal therapy

Clinical manifestations

Prescription

Hyperthyroidism, thirst, excessive hunger, irritability, feeling of heat, weight loss, nervousness, restlessness, fatigue, insomnia, skin flushing, amenorrhoea or heavy periods, itching all over the body, palpitations, exophthalmos, propensity to outbursts of anger, mental restlessness, insomnia, palpitations, bloodshot eyes. Tongue: Red, with redder sides, yellow coating. Pulse: Wiry-Rapid.

EMPIRICAL PRESCRIPTION by Dr Zhao Fen Explanation This formula is a variation of Xiao Chai Hu Tang Small Bupleurum Decoction.

Three Treasures remedies Open the Heart Open the Heart moves Lung- and Heart-Qi and is used to move Qi stagnation in these two organs.

Treatment principle

Bright Spirit Bright Spirit moves Liver-Qi and resolves Phlegm from the chest and throat.

Move Liver-Qi, drain Liver-Fire, Heart-Fire and StomachHeat, calm the Mind, settle the Ethereal Soul.

Release Constraint Release Constraint soothes the Liver, moves Qi, calms the Mind and settles the Ethereal Soul.

Acupuncture

Freeing the Moon Freeing the Moon (a Women’s Treasure remedy) moves Liver-Qi, nourishes LiverBlood, calms the Mind and settles the Ethereal Soul. It is indicated when Liver-Qi stagnation occurs against a background of Liver-Blood deficiency.

SUMMARY LIVER-QI STAGNATION Points T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, L.I.-4 Hegu, Ren-22 Tiantu. Even method.

Points LIV-2 Xingjian, LIV-3 Taichong, HE-8 Shaofu, HE-7 Shenmen, ST-44 Neiting, L.I.-11 Quchi, G.B.-13 Benshen, Du-24 Shenting, Du-19 Houding, Ren-15 Jiuwei, SP-6 Sanyinjiao, Ren-22 Tiantu. Even method.

Explanation • LIV-2 drains Liver-Fire. • LIV-3 moves Liver-Qi. • HE-8 and HE-7 drain Heart-Fire and calm the Mind. • ST-44 and L.I.-11 clear Stomach-Heat. • G.B.-13, Du-24, Du-19 and Ren-15 calm the Mind and settle the Ethereal Soul. • SP-6 helps to clear Heat and also calms the Mind. • Ren-22 is a local point affecting the thyroid function.

Goitre (Hypothyroidism, Hyperthyroidism)

Herbal therapy Prescription

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Pulse: Floating-Empty. If there is internal Wind: tremor of the hands.

EMPIRICAL PRESCRIPTION by Dr Zhao Fen

Treatment principle

Explanation

Nourish Liver- and Kidney-Yin, clear Empty Heat, calm the Mind.

This formula clears Heat in the Liver, Heart and Stomach and resolves Phlegm-Heat. If there is no goitre, Zhu Ru and Xia Ku Cao can be omitted.

Acupuncture

Prescription EMPIRICAL PRESCRIPTION by Dr Zhu Ceng Bo

Explanation This formula is for Heat in the Liver, Heart and Stomach.

Three Treasures remedy Drain Fire Drain Fire drains Liver- and Heart-Fire.

SUMMARY HEAT IN LIVER, HEART AND STOMACH Points LIV-2 Xingjian, LIV-3 Taichong, HE-8 Shaofu, HE-7 Shenmen, ST-44 Neiting, L.I.-11 Quchi, G.B.-13 Benshen, Du-24 Shenting, Du-19 Houding, Ren15 Jiuwei, SP-6 Sanyinjiao, Ren-22 Tiantu. Even method. Herbal therapy Prescriptions EMPIRICAL PRESCRIPTION by Dr Zhao Fen EMPIRICAL PRESCRIPTION by Dr Zhu Ceng Bo Three Treasures remedy Drain Fire

Points Ren-4 Guanyuan, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel, Ren Mai), HE-7 Shenmen, Ren-15 Jiuwei, L.I.-4 Hegu with LIV-3 Taichong, Ren-22 Tiantu. Reinforcing method except on LIV-3, L.I.-4 and Ren-22, which should be needled with even method.

Explanation • Ren-4, LIV-8, SP-6 and KI-3 nourish Liver- and Kidney-Yin. • LU-7 and KI-6 open the Directing Vessel and nourish Yin. • HE-7 and Ren-15 nourish and calm the Mind. • L.I.-4 and LIV-3 are used if there are hand tremors to extinguish internal Wind. • Ren-22 to affect the thyroid function.

Herbal therapy Prescription EMPIRICAL PRESCRIPTION by Dr Zhao Fen

Explanation This formula nourishes the Yin of the Liver, Kidneys and Heart.

Prescription EMPIRICAL PRESCRIPTION by Dr Zhu Ceng Bo

Liver- and Kidney-Yin deficiency with Empty Heat Clinical manifestations Hyperthyroidism, mental restlessness, feeling of heat in the evening, weight loss, nervousness, fatigue, insomnia, skin flushing, itching all over the body, palpitations, hair loss, exophthalmos, backache, dizziness, blurred vision, dry eyes, tinnitus, night sweating. Tongue: Red without coating or partially without coating.

Explanation This formula nourishes Liver- and Kidney-Yin and calms the Mind.

Prescription EMPIRICAL PRESCRIPTION by Dr Wang Zhu Bie

Explanation This formula nourishes Liver- and Kidney-Yin, resolves Phlegm and extinguishes internal Wind; it can therefore

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be used if there is a goitre and the patient has a hand tremor.

Three Treasures remedy Nourish the Root Nourish the Root nourishes Liverand Kidney-Yin.

SUMMARY LIVER- AND KIDNEY-YIN DEFICIENCY WITH EMPTY HEAT Points Ren-4 Guanyuan, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel, Ren Mai), HE-7 Shenmen, Ren-15 Jiuwei, L.I.-4 Hegu with LIV-3 Taichong, Ren-22 Tiantu. Reinforcing method except on LIV-3, L.I.-4 and Ren-22, which should be needled with even method.

Sanyinjiao, Du-24 Shenting, G.B.-13 Benshen, Ren-22 Tiantu. Even method except on Ren-12, which should be needled with reinforcing method.

Explanation • LIV-3 and LIV-2 drain Liver-Fire, soothe the Liver, calm the Mind and settle the Ethereal Soul. • L.I.-11 clears Heat. • Ren-12, Ren-9, ST-40 and SP-6 resolve Phlegm. • Du-24 and G.B.-13 calm the Mind and settle the Ethereal Soul. • Ren-22 to affect the thyroid function.

Herbal therapy Prescription EMPIRICAL PRESCRIPTION by Dr Ren Duan Xue

Explanation

Herbal therapy Prescriptions EMPIRICAL PRESCRIPTION by Dr Zhao Fen EMPIRICAL PRESCRIPTION by Dr Zhu Ceng Bo EMPIRICAL PRESCRIPTION by Dr Wang Zhu Bie

This formula clears Heat, resolves Phlegm, moves Qi (necessary to resolve Phlegm), nourishes Yin, calms the Mind and settles the Ethereal Soul.

Three Treasures remedy Nourish the Root

Settling the Soul Settling the Soul drains Liver- and Heart-Fire and resolves Phlegm-Heat.

Three Treasures remedy

Phlegm-Heat in the Liver Clinical manifestations Mental restlessness, feeling of heat, weight loss, nervousness, fatigue, insomnia, skin flushing, itching all over the body, palpitations, exophthalmos, blurred vision, goitre, expectoration of phlegm, thirst, a sticky taste, a feeling of oppression of the chest. Tongue: Red with a sticky-yellow coating. Pulse: Wiry-Slippery-Rapid.

Treatment principle Drain Liver-Fire, resolve Phlegm, soften hardness, dissolve masses, calm the Mind, settle the Ethereal Soul.

Acupuncture Points LIV-3 Taichong, LIV-2 Xingjian, L.I.-11 Quchi, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6

SUMMARY PHLEGM-HEAT IN THE LIVER Points LIV-3 Taichong, LIV-2 Xingjian, L.I.-11 Quchi, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, Du-24 Shenting, G.B.-13 Benshen, Ren-22 Tiantu. Even method except on Ren-12, which should be needled with reinforcing method. Herbal therapy Prescription EMPIRICAL PRESCRIPTION by Dr Ren Duan Xue Three Treasures remedy Settling the Soul

Goitre (Hypothyroidism, Hyperthyroidism)

CASE HISTORIES Case history A 30-year-old woman had been suffering from hyperthyroidism for over 1 year; she did not have a goitre and she was not on medication. She did not have many symptoms apart from palpitations, a feeling of heat and thirst. She did not have any menstrual irregularity. Her tongue was Red, with redder sides and tip and a yellow coating. Her pulse was Wiry and Rapid. Although she did not have many symptoms, her tongue and pulse showed the presence of Liver- and Heart-Fire clearly, the tongue being Red in general and particularly redder on the sides and tip (Liver and Heart area). I therefore treated her with a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction as follows. • • • • • • • • •

Long Dan Cao Radix Gentianae Huang Qin Radix Scutellariae Shan Zhi Zi Fructus Gardeniae Ze Xie Rhizoma Alismatis Che Qian Zi Semen Plantaginis Sheng Di Huang Radix Rehmanniae Dang Gui Radix Angelicae sinensis Chai Hu Radix Bupleuri Gan Cao Radix Glycyrrhizae

I used the straight formula, removing only Mu Tong Caulis Akebiae trifoliatae. She started improving a few weeks after taking the medication. After some months, her tongue was much less Red. As this formula is bitter and cold in nature and can therefore injure the Spleen, I decided to suspend it for a month after 6 months of continuous use. I treated her again with another course of 4 months after that, and her tongue and symptoms all became normal.

Case history A 55-year-old woman had been suffering from hyperthyroidism for 2 years; there was no goitre. She complained of irritability, severe anxiety, a feeling of heat, sweating, weight loss, fatigue, insomnia, palpitations, hand tremor and slightly

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protruding eyes. Her pulse was Wiry and Rapid and slightly Overflowing on the Heart position; her tongue was Red with a dry-yellow coating. I diagnosed Liver- and Heart-Fire and used a variation of Long Dan Xie Gan Tang as follows. • • • • • • • • • • •

Long Dan Cao Radix Gentianae 6 g Huang Qin Radix Scutellariae 9 g Shan Zhi Zi Fructus Gardeniae 9 g Ze Xie Rhizoma Alismatis 9 g Che Qian Zi Semen Plantaginis 9 g Sheng Di Huang Radix Rehmanniae 12 g Dang Gui Radix Angelicae sinensis 9 g Chai Hu Radix Bupleuri 9 g Suan Zao Ren Semen Ziziphi spinosae 6 g Lian Zi Xin Plumula Nelumbinis nuciferae 6 g Gan Cao Radix Glycyrrhizae uralensis 3 g

I treated her with variations of the above formula for 6 months, and her T3 and T4 levels went back to normal. All her symptoms subsided.

Case history A 44-year-old woman had been suffering from hyperthyroidism for some months. It had been diagnosed only a few days before her consultation. Her main symptoms were palpitations, tachycardia, weight loss, a slight tremor of the hands, night sweating, a feeling of a lump in the throat, itchy eyes and loose stools. She had a small, hard goitre. She was on carbimazole. She had been referred to me by her acupuncturist and was receiving acupuncture regularly from her. Her tongue was without coating and with Stomach cracks in the centre. It was slightly Red in the centre, and it had red points on the tip. Her pulse was Fine and Wiry. Diagnosis This was a clear example of hyperthyroidism occurring against a background of Yin deficiency of the Stomach, Liver and Heart with some Empty Heat. Treatment I prescribed a variation of Sha Shen Mai Dong Tang Glehnia-Ophiopogon Decoction as follows.

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• • • • • • • • • • • • •

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Bei Sha Shen Radix Glehniae 9 g Mai Men Dong Radix Ophiopogonis 9 g Yu Zhu Rhizoma Polygonati odorati 6 g Tian Hua Fen Radix Trichosanthis 4.5 g Tian Men Dong Radix Asparagi 6 g Sheng Di Huang Radix Rehmanniae 6 g Kun Bu Thallus Eckloniae 4.5 g Hai Zao Herba Sargassi 4.5 g Suan Zao Ren Semen Ziziphi spinosae 4.5 g Yuan Zhi Radix Polygalae 6 g Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g Gou Qi Zi Fructus Lycii chinensis 6 g Gan Cao Radix Glycyrrhizae uralensis 3 g

Explanation • The first four herbs form the nucleus of Sha Shen Mai Dong Tang, which nourishes Stomach-Yin. • Tian Men Dong and Sheng Di Huang nourish Kidney-Yin. • Kun Bu and Hai Zao regulate the thyroid and soften masses. • Suan Zao Ren and Yuan Zhi calm the Mind. • Zhe Bei Mu softens masses. • Gou Qi Zi nourishes Liver-Yin. • Gan Cao harmonizes. This patient continued to be treated with acupuncture as well, and after 14 months her thyroid function went back to normal and she was able to stop taking carbimazole. Her goitre remained, but it became smaller and softer.

Case history A 50-year-old man had been suffering from hyperthyroidism for 9 months. His main symptoms were palpitations, a fine tremor of the hands, sweating, thirst, anxiety, insomnia, lack of appetite, nausea. He had been diagnosed as having Graves’ disease and had been prescribed carbimazole. He also described how he felt “out of touch” and found it difficult to work. He said he felt “disconnected from his work”, which he previously enjoyed. He occasionally experienced some sputum in the throat, a bitter taste, sore eyes and constipation.

His tongue was Red, with redder sides and tip; and a sticky-yellow coating. His pulse was Wiry and Rapid (100). Diagnosis The patient shows clear signs of LiverFire: thirst, bitter taste, constipation, sore eyes, Red tongue and Wiry pulse. There is also Heart-Fire, as evidenced by the palpitations, anxiety and insomnia. As a secondary condition, he has also Phlegm, as evidenced by the sputum in the throat. Treatment principle Drain Liver- and Heart-Fire, resolve Phlegm, calm the Mind. Herbal therapy I treated this patient only with herbal medicine. I started off with a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction. • • • • • • • • •

Long Dan Cao Radix Gentianae Huang Qin Radix Scutellariae Shan Zhi Zi Fructus Gardeniae Jie Geng Radix Platycodi Zhu Ru Caulis Bambusae in Taeniam Ban Xia Rhizoma Pinelliae preparatum Zhe Bei Mu Bulbus Fritillariae thunbergii Lian Zi Xin Plumula Nelumbinis Suan Zao Ren Semen Ziziphi spinosae

Explanation • The core formula drains Liver-Fire. • I added Zhu Ru, Ban Xia and Zhe Bei Mu to resolve Phlegm. • Lian Zi Xin was added to clear Heart-Fire and calm the Mind. • Suan Zao Ren was added to calm the Mind and settle the Ethereal Soul. In subsequent treatments, I added Da Huang Radix et Rhizoma Rhei to drain Fire by promoting the downward movement of Yang organs. The addition of Da Huang seemed to improve the efficacy of the formula, and he felt much better in himself, with no palpitations, good sleep and less tremor. I continued treating him for some months with variations of the above formula, with a constant, gradual improvement in his symptoms and his mental state. He was also able to stop taking his medication.

Goitre (Hypothyroidism, Hyperthyroidism)

MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), No. 11, 1992, p. 28. Hua Ling Zhen et al., “Clinical observation on the treatment of 115 cases of goitre with Xiao Yin Chong Ji.” One hundred and fifteen cases of nodules on the thyroid with hyperthyroidism, raised T4 and T3 levels. Formula used (dosages for a batch of pills): Chai Hu Radix Bupleuri 240 g, Xia Ku Cao Spica Prunellae 300 g, Shan Ci Gu Pseudobulbus Cremastrae/Pleiones 200 g, Chen Pi Pericarpium Citri reticulatae 200 g, Gui Jian Yu Herba Euonymi alati 200 g, Ban Xia Rhizoma Pinelliae preparatum 200 g, Zhe Bei Mu Bulbus Fritillariae thunbergii 200 g, Hai Zao Herba Sargassi 200 g, Kun Bu Thallus Eckloniae 200 g.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 25, No. 9, 1984, p. 47. Xia Shao Nong et al., “The treatment of hyperthyroidism by benefiting Qi and nourishing Yin.” Ninety-eight cases of hyperthyroidism, with raised levels of T4 and T3. The treatment principle adopted was to tonify Qi and nourish Yin. Formula: Huang Qi Radix Astragali 30–45 g, Bai Shao Radix Paeoniae alba 12 g, Sheng Di Huang Radix Rehmanniae 15 g, Xiang Fu Rhizoma Cyperi 12 g, Xia Ku Cao Spica Prunellae 30 g and Shou Wu Radix Polygoni multiflori preparata 20 g. If Spleen-Qi deficiency present: Shan Yao Rhizoma Dioscoreae and Bai Zhu Rhizoma Atractylodis macrocephalae. If Heart-Fire present: Huang Lian Rhizoma Coptidis. If Liver-Fire present: Long Dan Cao Radix Gentianae.

Journal of Chinese Medicine (Zhong Yi Za Zhi), No. 9, 1993, p. 542. Li Qiu Gui et al., “The treatment of hyperthyroidism in Chinese medicine.” Formula used for hypothyroidism: Fu Zi Radix Aconiti lateralis preparata, Yin Yang Huo Herba Epimidii, Rou

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Gui Cortex Cinnamomi, Fu Ling Poria, Bai Zhu Rhizoma Atractylodis macrocephalae, Gan Jiang Rhizoma Zingiberis, Huang Qi Radix Astragali, Dang Gui Radix Angelicae sinensis, Sheng Di Huang Radix Rehmanniae, Shu Di Huang Radix Rehmanniae preparata, Shan Zhu Yu Fructus Corni and Bai Shao Radix Paeoniae alba.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), No. 5, 1986, p. 15. He Quan Sen et al., “Analysis of clinical effect of treatment of hyperthyroidism with different acupuncture methods.” This study involved 129 cases of hyperthyroidism. The study compared three groups of points: 1. Ah Shi points around goitre and ST-10 Shuitu 2. P-6 Neiguan, P-5 Jianshi, ST-36 Zusanli, SP-6 Sanyinjiao 3. Ah Shi points around goitre, P-6 Neiguan, P-5 Jianshi, ST-36 Zusanli, SP-6 Sanyinjiao. The best results were obtained with the third group, i.e. with combination of distal and local points.

Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 46, No. 8, 2005, pp. 593–594. Chen Jie, “Clinical observation of 22 cases of severe hyperthyroidism treated by combination of Western and Chinese medicine.” Forty patients with serious hypothyroidism were randomly divided into two groups, 22 being treated with a combination of T4 and Chinese herbs and 18 being treated with T4 only. The treatment group was significantly superior to the control group in improvement of T3 (P < 0.01). The formula used tonifies and warms Spleen- and Kidney-Yang: Fu Zi Radix Aconiti lateralis preparata, Rou Gui Cortex Cinnamomi, Yin Yang Huo Herba Epimidii, Shan Zhu Yu Fructus Corni, Tu Si Zi Semen Cuscutae, Gan Jiang Rhizoma Zingiberis, Fu Ling Poria and Zhi Gan Cao Radix Glycyrrhizae uralensis preparata.

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END NOTES 1. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue [Internal Medicine in Chinese Medicine]. Shanghai Science Publishing House, Shanghai, p. 218. 2. Ibid., p. 218. 3. Ding Guang Di 1991 Zhu Bing Yuan Hou Lun [Discussion of the Origin of Symptoms in Diseases]. People’s Health Publishing House, Beijing, p. 856. The Discussion of the Origin of Symptoms was written by Chao Yuan Fang in AD 610. 4. Ibid., p. 856. 5. Cited in Internal Medicine in Chinese Medicine, p. 218. 6. Ibid., p. 218. 7. Ibid., p. 218. 8. Li Wen Chuan, He Bao Yi 1987 Shi Yong Zhen Jiu Xue [Practical Acupuncture]. People’s Health Publishing House, Beijing, p. 361. 9. Wang Xue Tai 1988 Zhong Guo Zhen Jiu Da Quan [Great Treatise of Chinese Acupuncture]. Henan Science Publishing House, Zhengzou. 10. Wei Zi Xiao 1995 [Experience of diagnosis and treatment of hyperthyroidism]. Journal of Chinese Medicine (Zhong Yi Za Zhi ) 6: 334.

11. Ibid., p. 334. 12. Shanghai Municipal Acupuncture and Channels Research Group 1984 [Experience on acupuncture treatment of hyperthyroidism]. Journal of Chinese Medicine (Zhong Yi Za Zhi) 25(9): 58. 13. Zhao Fen et al. 1987 Diagnosis and treatment of hyperthyroidism. Journal of Chinese Medicine (Zhong Yi Za Zhi) 28(1): 16. 14. Ibid., p. 16. 15. Ibid., p. 16. 16. Ibid., p. 16. 17. Ibid., p. 16–17. 18. Ibid., p. 17. 19. Ibid., p. 17. 20. Ibid., p. 18. 21. Ibid., p. 18. 22. Ibid., p. 19. 23. Ibid., p. 20. 24. Ibid., p. 20. 25. Ibid., p. 20. 26. Ibid., p. 20. 27. Ibid., p. 20. 28. Xia Shao Nong et al. 1994 Hyperthyroidism treated by the method of nourishing Yin and tonifying Qi. Journal of Chinese Medicine (Zhong Yi Za Zhi) 25(9): 47–49.

CHAPTER 19

HYPERTENSION

HYPERTENSION IN WESTERN MEDICINE 542 Causes of hypertension 543 Pathology of essential hypertension 544 Complications 544 Assessment 545 Treatment 545

• • • • • •

HYPERTENSION IN CHINESE MEDICINE 547 Pathology of hypertension in Chinese medicine 547 Aetiology of hypertension in Chinese medicine 552 Thoughts on hypertension in Chinese medicine 552 Effects of hypertension medication on the pulse 556 IDENTIFICATION OF PATTERNS AND TREATMENT 557 Liver-Yang rising 557 Liver-Wind 559 Liver-Fire 560 Liver-Qi stagnation, Blood rebelling upwards 562 Liver invading the Spleen 562 Phlegm obstructing the orifices and the blood vessels 563 Blood stasis in the Connecting (Luo) channels 564 Liver- and Kidney-Yin deficiency 565 Qi and Yin deficiency 566 Spleen- and Kidney-Yang deficiency 567 Disharmony of Penetrating and Directing Vessels (Chong and Ren Mai) 568 MODERN CHINESE LITERATURE CASE HISTORIES

570

PATIENTS’ STATISTICS

572

CLINICAL TRIALS 573 Acupuncture 573 Herbal medicine 575

569

• • • • •

Liver-Yang rising Liver-Wind Liver-Fire Liver-Qi stagnation, Blood rebelling upwards Liver invading the Spleen Phlegm obstructing the orifices and the blood vessels Blood stasis in the Connecting (Luo) channels Liver- and Kidney-Yin deficiency Qi and Yin deficiency Spleen- and Kidney-Yang deficiency Disharmony of Penetrating and Directing Vessels (Chong and Ren Mai)

HYPERTENSION “Hypertension” is not one of the traditional Chinese disease entities, as ancient Chinese doctors obviously did not have the instruments to measure blood pressure. The textbook Davidson’s Principles and Practice of Medicine describes hypertension as follows: “Hypertension is a trait as opposed to a specific disease, and represents a quantitative rather than qualitative deviation from the norm. Any definition of hypertension is therefore arbitrary.”1 It then says: “A useful and practical definition of hypertension is the level of blood pressure at which the benefit of treatment outweighs its costs and hazards.”2 The discussion of hypertension will be conducted according to the following topics. • • • •

Hypertension in Western medicine Hypertension in Chinese medicine Identification of patterns and treatment Modern Chinese literature

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• Case histories • Patients’ statistics • Clinical trials

HYPERTENSION IN WESTERN MEDICINE Blood pressure is maintained at a physiological level by a complex interaction of neurosympathetic control with the renin–angiotensin–aldosterone system. The Textbook of Medicine says: “Activation of preganglionic sympathetic neurones to the heart produces an increased heart rate and increased strength of contraction. Vasomotor sympathetic outflow constricts vascular smooth muscle, producing arterial vasoconstriction.”3 Reflex control of the blood circulation is via the arterial baroreceptors in the wall of the aorta and in the carotid arteries. The speed of this pressure-controlling mechanism is illustrated by its important role in maintaining systemic pressure during abrupt changes in posture. Neurosympathetic influences on blood pressure are rapid but transient. The renin–angiotensin–aldosterone system (Fig. 19.1) plays a major role in the control of blood pressure, regional blood flow and blood volume via its control of

Blood pressure rises

4 Angiotensin II 3 Angiotensinconverting enzyme Angiotensin I 2

Renin

Salt retention

5 Aldosterone

1

Angiotensinogen Blood pressure falls Figure 19.1 Renin–angiotensin–aldosterone system to control blood pressure.

sodium balance. Renin secretion from granules in the juxtaglomerular apparatus is stimulated by a fall in plasma volume, a drop in blood pressure and sodium depletion. The consequent rise in angiotensin II production and aldosterone secretion leads to sodium and water retention and hence restoration of sodium balance and plasma volume. Under conditions of plasma volume reduction and sodium depletion (