Zang Fu Tui Na Basic Principles and Core Techniques (Zang Fu Tui Na: Regulating and Harmonizing the Internal Organs) 9781695437074, 1695437071

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Zang Fu Tui Na Basic Principles and Core Techniques

Tom Bisio Photos by Valerie Ghent

Copyright © 2019 Tom Bisio & New York Internal Arts LLC. All rights reserved. ISBN: 9781695437074

DEDICATION

To all my teachers of Chinese Medicine and Internal Martial Arts .

Disclaimer The author and publisher of this book are not responsible in any manner for any injury or illness, which may result from following the instructions contained within the book. The point and treatments described in this book may be too strenuous or dangerous for a given individual and are presented here for informational and historical purposes only. Before using any of the points or treatments described in this book, the reader should consult his or her physician for advice regarding their individual suitability for performing such activity. Any health or medical benefits attributed to these techniques, physical movements, herbal remedies, and medical treatments whether mentioned or inferred, are not advocated or promised by the author or publisher. Any health benefits, whether mentioned or inferred, are those typically attributed to these techniques, and protocols in traditional Chinese culture. We neither endorse nor advocate these benefits and opinions, nor do we vouch for their veracity. They are presented for educational purposes only.

CONTENTS Acknowledgments

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Preface

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1 Introduction to Zang Fu Tui Na

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2 Regulating & Harmonizing the San Jiao

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3 Regulating & Harmonizing the Five Zang Organs

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4 Introduction to Regulating & Harmonizing the Liver

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5 Regulating & Harmonizing the Diaphragm

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6 Regulating & Harmonizing the Pericardium

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7 Regulating & Harmonizing the Thoracic Outlet and Pleural Dome 65

ACKNOWLEDGMENTS Endless thanks to my wife Valerie Ghent for being my partner in life, teaching and learning. Valerie has come with me on most of the many trips to China and her zest for life, charm and enthusiasm open doors, and keeps my spirit from faltering. Valerie’s ongoing collaboration with me on books, photos, videos and articles about Ba Gua Zhang, Xing Yi Quan, Nei Gong and Daoist practices is invaluable. Her proofreading skills are amazing, as she catches my many mistakes and my tendency to take the reader’s understanding for granted. Valerie, thank you for your love and support. A big thanks you to Thad Wong for being “the patient” in the photos and to Valerie Ghent for taking all of the photographs. Thank you MG Kriger for helping me format this book for the Amazon template. Thank you to Pascal Jauffret and Association San Qi for organizing Zang Fu Tui Na seminars in France, which in some ways were the testing ground for teaching this Tui Na method. Mr. Jauffret’s excellent translation and feedback have contributed to this presentation. And thank you to the many students in the United States, Canada and France who have taken the Zang Fu Tui Na seminars. Many of you have used the techniques in clinic and reported back with feedback and clinical case studies. My thanks to Vince Black who initially showed me how to unwind fascia and for introducing me to Cranio-Sacral Therapy and organ regulating methods, to Jean-Pierre Barral for his pioneering work in Visceral Manipulation, and to Karin Sorvik for her teachings in Chi Nei Tsang. Much of the initial research and teaching of the methods for regulating the Five Zang and working with the Qi Dynamic was done in collaboration with Frank Butler. Thank you, Frank for your friendship and all of your input.

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Preface I came to traditional Chinese medicine through the gateway of internal martial arts (Nei Jia), which included the study of Traditional Tui Na, Zheng Gu (bone setting) techniques, medical Qi Gong/Nei Gong and Gong Fu Injury (Die Da) Medicine. Later I went on to more formally study acupuncture and Chinese herbal medicine in school and through apprenticeships. During the course of my studies I was also introduced to osteopathic methods – Cranio-Sacral Therapy and Jean-Pierre Barral’s visceral manipulation techniques. I began to incorporate some of these principles into my work with Traditional Tui Na and Zheng Gu methods. Rather than being separate therapies that I added into Chinese medicine, the osteopathic concepts were easily integrated into the theory and practice of Chinese medicine, largely because to some degree, they are already contained within Chinese medicine, and its associated Nei Gong and Nei Dan practices. Another influence on the development of Zang Fu Tui Na is Mantak Chia’s work with Chi Nei Tsang. A seminal moment for me was a brief meeting with Ba Gua Zhang and Nei Gong Master Xie Pei Qi in Beijing. Xie was also a master of Chinese medical massage and an expert herbalist. As we were having tea in his sitting room, he pointed at the wall behind me where there were eight framed Chinese characters and said: “if you want to understand Chinese medicine you need to understand those eight characters.” The framed characters were the eight movements of the Qi dynamic: ascending, descending, entering, exiting, opening, closing, gathering (storing), and spreading out (dissipating). Working with this idea over a period of years, while practicing Ba Gua Zhang, Xing Yi Quan, Nei Dan and Nei Gong, Tui Na, Zheng Gu, acupuncture and herbal medicine, eventually led to the development of Zang Fu Tui Na as it is practiced today. Some elements of Zang Fu Tui Na could fall under what some experts call “Yin Tui Na.” Yin Tui Na, is described as manifesting less obvious outer physical activity than Traditional Tui Na: The practitioner works from a still, very relaxed, centered and grounded place. A smaller range of techniques are employed. Techniques are applied gently, slowly and subtlety to an area or point for a relatively long period of time. The practitioner directs their attention and Qi into points, channels, bones and organs. Space and time are given for the patient’s awareness, breath and Qi come to the

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Zang Fu Tui Na: Basic Principles and Core Techniques area being treated and for changes to take place from within.1 Although I fundamentally disagree with the idea that there are separate Yin and Yang Tui Na methods, the above quote is not a bad description of the idea of harmonization and regulation used in Zang Fu Tui Na. Zang Fu Tui Na regulates and harmonizes the internal organs (Zang Fu) and their connected physical and energetic structures through the use of relatively gentle hands-on techniques. The main mechanism through which we regulate and harmonize the organs and their connected structures is the regulation and harmonization of the Qi Dynamic. Zang Fu Tui Na (ZFTN) can be utilized effectively as a stand-alone therapy that can produce very effective clinical results. At the same time, ZFTN does not exist in a vacuum. ZFTN is easily integrated with acupuncture, Traditional Tui Na and Zheng Gu techniques, Nei Gong and Nei Dan methods, and herbal medicine. One of ZFTN’s great strengths is that it provides a direct, hands-on diagnostic of Zang Fu functioning that can compliment and confirm traditional pulse and tongue diagnosis. Another important aspect of ZFTN is that it allows the practitioner to understand the connection of anatomical structure to energetic functioning. This connection has powerful ramifications for both diagnosis and treatment. Because Nei Gong and Nei Dan methods are a vital part of the practice of ZFTN, practitioners quickly develop sensitivity to detecting and correcting structural misalignment and subtle energetic and physical changes. I see ZFTN as a work in progress, one that will develop and transform over time as students and instructors adapt the techniques and methods to meet the needs of patients. For example, currently we are researching herbal formulas based on classical formulas that can be used to harmonize and regulate the Qi Dynamic. These formulas are designed to be used in conjunction with ZFTN principles and methods. We are also working on a more fined-tuned integration of ZFTN with Traditional Tui Na and Zheng Gu methods, in order to develop more seamless integrated treatments that interact with the body on a variety of levels simultaneously. For me, Traditional Tui Na, Zheng Gu techniques, Zang Fu Tui Na, fascial unwinding, Nei Gong and Nei Dan practices, and internal martial arts are one interlocking entity. The challenge is to convey this integral connection through our teaching methods. Zang Fu Tui Na: Basic Principles and Core Techniques introduces the reader to the foundational concepts and methods of Zang Fu Tui Na. Simultaneously, this book is the first in a series of workbooks for ZFTN students. Therefore, the first focus of Zang Fu Tui Na: Basic Principles and Core Techniques is on two key treatment methods that form the foundation of Zang Fu Tui Na: 1. Regulating the San Jiao (Three Heaters) 2. Regulating the Five Organs and their Qi Dynamics The second focus is on methods of regulating the Upper Jiao (containing the heart, pericardium and 1

Tui Na: A Manual of Chinese Massage Therapy. Sarah Pritchard (Philadelphia: Singing Dragon 2015) p. 14. 2

Zang Fu Tui Na: Basic Principles and Core Techniques lungs) and the diaphragm, which separates the Upper Jiao from the Middle Jiao. Techniques for regulating the liver are also introduced because of the intimate connection of the liver and diaphragm, the Liver-Pericardium relationship (Jue Yin), and the vital importance of the Liver-Lung Qi Dynamic.

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Chapter 1 Introduction to Zang Fu Tui Na Zang Fu Tui Na is a method of harmonizing the organs (Zang Fu) through palpation and gentle manipulation. Zang Fu Tui Na (ZFTN) is based upon theories of traditional Chinese medicine pertaining to the Qi Dynamic, the functions and interactions of the Zang Fu, and their interface with the theory and practice of Dao Yin, Qi Gong, and Nei Gong methods. The concepts and techniques of ZFTN are approached from six perspectives: 1. Nei Gong and Qi Gong Theory and Practice 2. Daoist perspectives including the “True Breath” 3. Zang Fu theories according to traditional Chinese medicine 4. The Jing Luo (Meridians) and acupuncture points 5. Modern knowledge of anatomy and physiology 6. Osteopathic theories & techniques that have congruence with traditional Chinese medicine These six interwoven perspectives give balance and perspective to the practice of ZFTN, allowing for maximum flexibility and adaptation to treatment in a clinical setting. This global perspective includes dietary advice, analysis of the impact of lifestyle on health, and internal exercises (Nei Gong and Qi Gong) prescriptions, and herbal prescriptions. Zang Fu Tui Na can easily be integrated with other aspects of traditional Chinese medicine, including acupuncture, herbal medicine, Traditional Tui Na, and Zheng Gu methods. ZFTN can also be integrated with osteopathic methods like Cranial Sacral Therapy, various massage methods, and physical therapy.

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Zang Fu Tui Na: Basic Principles and Core Techniques

Zang Fu Tui Na: Basic Concepts 1. The organs & bowels (Zang Fu) each have their own unique intrinsic movement. The intrinsic movements of the internal organs can be understood from a Chinese perspective as the “breaths,” or Qi, of the organs. The intrinsic movement associated with each organ is a reflection of the vitality (Qi) of that organ, and is related to its harmonious and correct functioning. These intrinsic movements are related to the Qi Dynamic (Qi Ji). 2. The organs and bowels also interact with each other. The interactions of the five Zang organs (liver, heart, spleen, lungs and kidneys) and their related Fu organs (gallbladder, small intestine, stomach, large intestine, bladder) are a reflection of global connections that take place through the mechanism of the Qi Dynamic. These global interactions are the basis of diagnosis and treatment. 3. There is a global Qi Dynamic between the three parts of the San Jiao.2 Restoring and maintaining free-flow between the three Jiao regulates the Zang Fu. 4. The anatomic relationships of the organs, their position in the body, their ligamentous and fascial attachments and their functioning according to modern medicine are of critical importance, as these elements are directly connected to the intrinsic movements and energetic functioning of the organs. 5. ZFTN is a direct mode of diagnosis of the Zang Fu, as they are understood in traditional Chinese medicine. ZFTN provides a very useful and complimentary alternative to pulse and tongue diagnosis, and serves as another means of verifying the efficacy of various modalities of Chinese medicine including acupuncture, Traditional Tui Na and herbal therapy. 6. ZFTN could also be referred to as “Organ Regulating Tui Na.” Regulation and harmonization represent a very sophisticated approach to medicine. The goal of regulation and harmonization is to restore the normal movement and interaction (Qi Dynamic) of the organs. This allows the global system to “return to balance.” 7. Fascia is an uninterrupted viscoelastic tissue, which forms a functional three-dimensional collagen matrix. The fascial network of the human body represents one continuum, from the internal cranial reciprocal tension membranes to the plantar fascia of the feet. In this sense, fascia forms a wholebody continuous matrix that interpenetrates and surrounds all the organs, muscles, bones, blood vessels and nerve fibers. ZFTN techniques engage with the fascial system on many levels, both to release organ restrictions and to unwind more global facial binds that can affect the muscles, sinews, joints, and general body alignment.

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The San Jiao is also commonly referred to as the Triple Heater, Triple Warmer, or Triple Burner. 6

Zang Fu Tui Na: Basic Principles and Core Techniques

Implications In traditional Chinese medicine we talk about Organ Qi, the Qi Dynamic of an organ, and organ functioning, but to some degree we are diagnosing these things indirectly through the pulse and tongue, or through signs and symptoms both specific and constitutional in nature. ZFTN allows one to directly access Organ Qi and functioning by palpating the movement, or lack of movement, of the organs. Movement is reflection of Qi, and Qi is an expression of movement. Movement is life. Even in extreme quiescence there is internal movement and transformation. Without movement and transformation, there is no life and no functioning. Classic texts in Chinese medicine make oblique references to the connection of the organs with different pathologies of the bones, sinews, flesh and other tissues. Many acupuncturists have observed that to some degree acupuncture is operating through the fascial system, which forms one contiguous network from the bottoms of the feet to the top of the head. The Sinew Channels of acupuncture are an obvious representation of this idea. Understanding the fascial connections between the organs, and between the organs and surrounding structures, makes one understand that relationships often described as “energetic connections,” are actually are composed of direct tissue connections. The liver’s connection to the neck through the suspensory ligaments of the pericardium (Jue Yin), the connection of the liver to right shoulder pain and the stomach to left shoulder pain, the relationship of the kidneys and aspects of the colon to hip pain and restriction, or lower back pain – these connections instantly become becomes obvious and concrete when one directly palpates the organs and their surrounding tissues. Rather than detracting from our understanding of acupuncture, channels and points, or herbal therapy, this knowledge can actually broaden our understanding and increase our ability to more precisely intervene using the principles of traditional Chinese medicine. The notion that the ancient Chinese did not know anatomy has been questioned before. One only has to look at how the lesser omentum directly connects the liver and the stomach, to understand how Chinese medicine may have conceived of the idea of “Liver Invading Spleen.” Many modern practitioners of traditional Chinese medicine have also theorized that the concept of the San Jiao may have congruency with the fascial tissue that wraps the organs and the sinews, muscle and bones.

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Zang Fu Tui Na: Basic Principles and Core Techniques

Levels of Treatment in ZFTN There are five basic categories, or one might say, levels/stages of treatment, in ZFTN. These five levels/stages can also be understood as methods of diagnosis: 1. 2. 3. 4. 5.

Regulating and Harmonizing the San Jiao Regulating the Five Zang Regulating Digestion and the Center (Separating the Clear and Turbid) Diagnosing and Treating Individual Organ Dysfunctions Global Fascial Unwinding

The five levels of treatment listed above allow for multiple points of entry into diagnosis and treatment. In addition, the five levels offer a model of staged treatments: 1. 2. 3. 4. 5.

Begin broadly by globally harmonizing the San Jiao Progress to the interactions of the five Zang Harmonize the spleen, stomach and the intestines (Central Qi) Treat individual organs Work with restrictions in the fascia that affect large sections of the body and involve the limbs and spine.

Usually Fascial Unwinding (Level 5), is followed by a return to harmonization of the organs, provided by harmonizing the San Jiao or regulating the Five Zang (Levels 1 and 2). This five stage, or five level model, and the global treatment protocols described below, serve as templates for learning and understanding the techniques and principles of ZFTN. Of course, in a clinical interaction with a patient, levels, stages and treatment protocols interweave and transform, according to the circumstances.

Global Treatment Protocols Four global protocols provide yet another entry point into treatment and diagnosis, by combining the five levels of treatment listed above with four global treatment protocols that address four of the most common and seemingly complex disharmonies encountered in clinical practice. The Four Global Treatment Protocols are: 1. 2. 3. 4.

Harmonizing Earth: Balancing & Harmonizing Digestion Treating Fire Disease (Excess Heat): Balancing Imperial and Ministerial Fire Balancing Water and Fire (Yin and Yang): Connecting the Kidneys and Heart Transformation of Qi and Jing: Harmonizing Lungs and Kidneys 8

Zang Fu Tui Na: Basic Principles and Core Techniques These four protocols can be an entry point for diagnosis and treatment, or act as a final stage of global harmonization that could follow a clinical progression through the five levels of treatment and diagnosis. The Four Global Treatment Protocols further contribute to the flexibility of diagnosis and treatment with ZFTN.

Relationship between Zang Fu Tui Na & Traditional Tui Na For purposes of education and understanding, ZFTN and more Traditional Tui Na (based on hand techniques and direct manipulation of the flesh, muscles, sinews and bones) are often separated. In fact, ZFTN and Traditional Tui Na form a single unified mode of treatment that conforms to the principles of Chinese medicine. The organs are bound by fascial attachments that connect to the joints and muscles of the neck and the limbs. In Chinese Medicine, the Sinew Channels or Muscle-Tendon Channels (Jin Jing 筋經) are broad longitudinal bands of muscles tendons and ligaments and connective tissue that wrap, or “knot”, at the big joints of the body (hip, knee, ankle, shoulder, elbow and wrist, occiput and face). The joints divide the limbs into sections, like the nodes in bamboo. Other words commonly used to describe the action of the Sinew Channels at the joints are “inserting,” “binding,” or “fruiting.” The knotting and wrapping of the Sinew channels provides the joints with structural integrity, and allows the muscles, sinews and joints to generate physical force. The nexus of these forces lies in the Dan Tian and Ming Men, which lie inside the lower abdomen and lower back. In fact, the Three Dan Tian: head, chest and lower abdomen, are nexuses of interconnection for the sinew channels. The Sinew Channels are the conduits of Wei Qi (Defensive Qi). Wei Qi warms, protects, activates upright posture, and activates movement. Wei Qi, as it moves through the Sinew Channels, allows the individual to respond in a reflexive and spontaneous manner without volition or cognition. Wei Qi and the Sinew Channels generate an immediate ability to respond to changes in an individual’s environment. The Sinew Channels have connections with other channels and collaterals, and other parts of the Jing Luo (Meridian) network. From another perspective, the Sinew Channels are a part of the fascial system. Fascia surrounds and penetrates all structures of the body extending from head to toe. Fascia is like a series of interlocking packets or wrappers. The fascial network represents one continuum from the head to the feet, it interpenetrates and surrounds the organs, muscles, bones, sinews, blood vessels and nerves. In this sense, fascia could be considered as a single organ, a unified whole, connecting to every aspect of human physiology. Recent research has indicated that (among other things) fascia is a vast sensory network that we are only beginning to understand. Traditional Tui Na techniques interact with the fascial network on many levels. Because of the 9

Zang Fu Tui Na: Basic Principles and Core Techniques interconnectivity of the fascial network, a Zheng Gu (“Bone-Setting”) technique that mobilizes and realigns one or more ribs can release fascial restrictions in the diaphragm and liver. Similarly, balancing and harmonizing the intrinsic movements (the Qi Dynamic) of the liver produces ripples that affect shoulder alignment, rib alignment, the position of the diaphragm and the ligamentous attachments to the pericardium, which in turn is suspended between the neck and diaphragm. Therefore, these same ripples can also create changes in the muscles and sinews of the neck. Similarly, Traditional Tui Na techniques that release or re-align the neck can affect fascial tensions relating to the pericardium and liver organs.

Acupuncture & Zang Fu Tui Na Much of what was said about Traditional Tui Na and its associated Zheng Gu techniques also applies to acupuncture. The acupuncture channels (meridians) and their collateral branches have many interconnections with the organs and their related structures. Acupuncture pairs quite well with ZFTN. Acupuncture also works with the Qi Dynamic, and many distal points on the arms and legs have powerful effects on internal organ functioning. Acupuncture points can be needled or pressed to aid and enhance the effects of ZFTN techniques. Often if the facial restrictions holding an organ will not release completely, needling an appropriate point related to that organ and its functioning can instantly change the situation. Acupuncture treatments can also consolidate improvements made using ZFTN techniques. In the discussions of ZFTN techniques for treating organs and other internal structures that follow, there are lists of complimentary acupuncture points that can be used to aid and enhance treatment. These points are not just for acupuncturists – they are part of the fabric of diagnosis, treatment, and consolidation of treatment and can be pressed and held during treatment. If you are an acupuncturist, distal points on the arms and legs can be needled while one is working in the local area. Points could be needled after using ZFTN techniques, or in between a series of ZFTN techniques. Many points can be held or gently pressed while working locally with ZFTN techniques, which can greatly enhance the effectiveness of treatment. In many cases I have had an assistant push points while I perform a ZFTN technique. I have frequently found pressing points to be more effective than needling points, because the assistant can directly connect the point with the ZFTN technique, creating a constant modulation and adjustment that is very specific.

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Zang Fu Tui Na: Basic Principles and Core Techniques

The Qi Dynamic (Qi Ji) The Qi Dynamic, or “Qi Mechanism” (氣機), refers to eight movements of Qi. Some Chinese medical practitioners consider the Qi Dynamic be one of the most important principles in traditional Chinese medicine, because it guides how each therapy - herbs, acupuncture, massage, diet, Nei Gong, lifestyle change and exercise - interact with the Qi of the patient. In one sense, all life is bound by the Qi Dynamic, as our daily rhythms, seasonal change, and the movement of our minds and bodies through our lives are all expressions of the Qi Dynamic. As mentioned in the preface, in China I once visited a master of herbal medicine, Ba Gua Zhang, Nei Gong and Tui Na. While drinking tea in his sitting room and discussing Chinese medicine, he pointed up at some calligraphy that was framed on his wall. There were eight frames each containing a single character. He said: if you want to understand Chinese medicine, you need to understand those eight characters. The framed characters were the eight characters of the Qi Dynamic reproduced in the list below.

The Eight Movements of the Qi Dynamic 1. Ascending (yang)

升 Sheng

2. Descending (yin)

降 Jiang

3. Entering (yin)

⼊ Ru

4. Exiting (yang)

出 Chu

5. Opening (yang)

开 Kai

6. Closing (yin)

合 He

7. Gathering/Storing (yin)

聚 Ju / 藏 Cang

8. Spreading Out/Dissipating (yang)

散 San / 放 Fang

The Actions of these Eight Movements can be described as follows: 1. Ascending increases the power of vitality and movement. 2. Descending increases the ability to pass things on and through. 3. Entering increases the ability to fill up. 11

Zang Fu Tui Na: Basic Principles and Core Techniques 4. Exiting increases the ability to flow without obstruction 5. Opening increases the power of growth and releasing outward. 6. Closing increases the ability to maintain growth and strength. 7. Gathering or Storing Jing, Qi and Shen, builds the body’s physical wherewithal. 8. Spreading Out or Dissipating Jing and Qi increases the ability to generate and transform.3

The Lungs & the Qi Dynamic To some degree, respiration initiates and drives the Qi Dynamic, because if we cannot breathe and oxygenate our blood we cannot survive, hence the importance of the lungs in regulating and moving the Qi. In Chinese medicine, there are many statements that elucidate the importance of the lungs in relationship to the Qi: 1. The lungs are said to “govern the Qi” (Fei Zhu Qi), meaning that to some degree they govern the Qi of the entire body. 2. The lungs are also the “Root of the Qi” (Fei Zhe Qi Zhi Ben). 3. “Qi entirely homes to the lungs” (Zhu Qi Zhe Jie Shu Yu Fei). 4. “The chest center is the sea of Qi” (Dan Zhong Zhe Qi Zhi Hai). 5. “Heaven’s Qi communicates and flows freely to the lungs” (Tian Qi Tong Yu Fei). 6. “The lungs govern the downbearing of Qi” (Fei Zhu Jiang Qi). 7. The Lung Qi assists the heart to move the blood (Fei Qi Zhu Xin Xing Xue). 8. The lungs are the “Governor of Qi” and the kidneys are the “Root of Qi” (Fei Wei Qi Zhi Zhu, Shen Wei Qi Zhu Gen). 9. “The lungs are the ruler of the axis of Qi; the spleen is the source of the engenderment of Qi” (Fei Wei Zhu Qi Zhi Shu, Pi Wei Sheng Qi Zhi Yuan).4 It is easy to see that Qi and breath are connected, and to some degree inseparable. The lungs play an important role in regulating the Qi Dynamic and disseminating Qi throughout the entire body. For 3

The Eight Healing Sounds of Yin Style Ba Gua. Xie Pei Qi, Trans. Andrew Nugent-Head. (San Francisco: Traditional Studies Press 1995), p.23. 4 Statements of Fact In Traditional Chinese Medicine. Bob Flaws, Michael Johnston, and Timothy Rogers (Boulder, CO: Blue Poppy Press, 1994-2008), p. 69-71. 12

Zang Fu Tui Na: Basic Principles and Core Techniques this reason, Nei Gong routines often begin with an exercise that activates the lungs. Beginning with the lungs activates and opens the Qi Pathways (the meridians), preparing the body and the other organs for the exercises that follow. The deep abdominal “Kidney Breathing”, or “Dan Tian Breathing”, that one employs in practicing Nei Gong helps stimulate the intrinsic movements of the organs, aiding the internal movement of Qi and its free and relaxed movement throughout the body. In Nei Gong practices, inhalation should enter deeply into the Dan Tian so that as the breath is naturally held, in the moment before it turns to exhalation, the Qi of the organs is closed and the apertures of the body are sealed. Exhaling is exiting. The Qi gates open, the pathways of Qi (channels and collaterals) open, and the organs and apertures also open. Inhaling is Yin. It is entering, closing, gathering, sealing, and storing. Exhaling is Yang. It is opening, exiting, spreading out, and dispelling.5 In this context, inhaling and exhaling do not refer to normal respiration, but to the internal respiration of the organs. When working with the internal organs in Zang Fu Tui Na, we are always working with the Qi Dynamic. Regulating the Qi Dynamic regulates the organs; Regulating the organs regulates the Qi Dynamic.

Zang Fu Tui Na and the Concept of Wu Wei When practicing Zang Fu Tui Na, the practitioner attempts to engage with the concept of Wu Wei (無爲). Wu Wei is often translated as non-action; however, Wu Wei does not mean doing nothing at all. It does not signify the complete absence of activity, but rather not overdoing - doing less, and acting without artificiality or arbitrariness. Wu Wei also implies the performance of actions that are “non-coercive.” This means acting in way that does not interfere with the potential or focus of the situation, which in turn implies a knowing and acting that is without fixed rules or principles, and achieving results without seeking to possess or control. The idea of Wu Wei also conveys a sense of understanding what is appropriate to the situation. In Tui Na this could mean doing something very direct, like straightening tissue or putting bones back into their correct position, or, it could mean gently guiding something in the direction it is already moving, with imperceptible effort or force. By doing what is appropriate to a given situation, one does exactly what need to be done - no less and no more.



The Eight Healing Sounds of Yin Style Ba Gua. Xie Pei Qi, Trans. Andrew Nugent-Head. (San Francisco: Traditional Studies Press 1995), p.23. 5

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Zang Fu Tui Na: Basic Principles and Core Techniques

The Role of Nei Gong and Qi Gong Although there is much quibbling about names in the realm of internal exercise, the terms “Qi Gong,” “Dao Yin,” and “Nei Gong” interlock and overlap in so many ways that the names are more confusing than helpful. Hereafter these kinds of internal exercises will globally be referred to as “Nei Gong.” Nei Gong serves as a useful umbrella term for internal exercises in general, and Daoist Nei Dan (Inner Alchemy) practices that form part of the curriculum of Zang Fu Tui Na. Self-cultivation is an essential part of practicing Chinese medicine. Understanding how one’s own viscera move and interact through internal experience aids one in treatment of others. Selfcultivation through Nei Gong practice is essential for developing the ability to quiet the mind and body, so that one can perceive the subtle movements of the internal organs. Nei Gong practice improves one’s ability to touch someone else with sensitivity, intention and compassion. Nei Gong practices like Five Element Qi Gong (Wu Xing Qi Gong) and the Six Healing Sounds (Liu Zi Jue), as well as Nei Dan practices which involve cultivating the “True Breath”, are of vital importance to performing ZFTN correctly. These practices develop an inner sensitivity and a visceral, experiential connection to the internal organs and their interrelationships, a connection and sensitive awareness that cannot be understood by the intellect alone. The Three Nei Gong practices listed below are essential to increasing internal perception of the internal organs, both within one’s own body and within that of the patient: 1. Five Element Qi Gong (Wu Xing Qi Gong) Five Element Qi Gong consists of five basic exercises, one for each Zang organ. Each of these five exercises stimulates the intrinsic movements of one of the five Zang organs, while simultaneously activating and freeing the spinal segments related to each 0rgan. Each exercise also “opens” and “activates” the meridian associated with each organ. Three additional exercises harmonize the San Jiao (Triple Warmer). The final exercise allows Qi to gather and consolidate. 2. Six Healing Sounds (Liu Zi Jue) In Six Healing Sound Nei Gong, each mouth shape and sound connects to one of the five Zang organs (the sixth sound opens and activates the San Jiao) Each mouth shape and sound generates an internal vibration which “homes’ to the associated organ, breaking blockages in both the facial attachments of each organ, and in the meridian associated with that organ.

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Zang Fu Tui Na: Basic Principles and Core Techniques 3. Daoist Nei Dan Meditation Methods Daoist Nei Dan (literally: “Inner Elixir”) meditation practices can be of great help in learning to sense subtle movement of the Qi Dynamic. An important part of Nei Gong and meditation practices is the cultivation of inner stillness. This inner stillness is what allows us to fully sense the Qi Dynamic that is unfolding under our hands, and to engage with the subtle changes happening within the structures we are working with. The famous Nei Gong teacher Hu Yao Zhen describes this as follows: First fix the Heart-Mind. When the Heart-Mind is fixed, the Spirit (Shen) condenses. When the Shen condenses, the Heart-Mind becomes still. When the Heart-Mind is still, you are calm. When you are calm, you do not intervene (Wu Wei). When you don’t intervene, the Qi circulates. When the Qi circulates, you move.6 There are two main Daoist Nei Dan practices used in Zang Fu Tui Na: 1) Wu Ji Meditation Wu Ji Meditation helps the practitioner to harmonize with the vibrations of “Heaven and Earth,” in order to generate an internal vibration that opens the internal channels. In treatment, this inner vibration can be transmitted to the patient to release restrictions in the tissues and organs. 2) Meditation on the “True Breath” Meditation on the True Breath is a method of focusing one’s attention on the deep internal “respiration” that is slower than and independent of normal respiration. This “breath” that moves between Ming Men and Dan Tian, and enters and exits through the pores of the skin, is sometimes called “fetal breathing” or “pore breathing.” The True Breath underlies the intrinsic movements (“breaths”) of the individual organs. The Zang Fu Tui Na practitioner can use his or her own experience of the True Breath to help patients modulate their own True Breath.

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Les Jeu Des Cinq Animaux (Five Animal Play) by Jiao Guo Rui, De Ye Tao, and Hu Yao Zhen, translated by Grégory Mardaga. 15

Zang Fu Tui Na: Basic Principles and Core Techniques

The Importance the Yin Yang (Tai Ji) Diagram The inter-transformation of Yin and Yang is a very important concept in the practice of Chinese medicine, Nei Gong and the internal martial arts. In the Tai Ji diagram below, it is clear that Yin and Yang each cannot exist without the other. One comes out of (is generated by) the other, and each blends into each other.

Yin and Yang oppose each other. As one grows, the other diminishes. Yin and Yang push against each other and attract each other. Each contains the other, represented by the white dot within the black “fish”, and the black dot within the white “fish.” As the white fish grows to its maximum, we see the beginning of the black fish about to arise, symbolizing that change from one thing to another starts with small signs. If we can detect these minute shifts early, or in their minutest form, we have an opportunity to flow with the natural cycle and make adjustments with minimal effort. The Yin Yang Diagram is not merely a symbol of the interaction of these two forces, but a very clear description of how Yin Yang interactions occur. Whether one inserts a needle in order to interact with a patient’s Qi, performs Tui Na massage manipulations, or allows Qi to gather and circulate in the Meridians or in Dan Tian by regulating respiration, the spiraling movement of the Qi is exactly described by the Yin Yang Diagram. In its basic form, the Yin Yang Diagram shows a spiraling interchange along the central line. However in the versions of the diagram shown below, rather than interchanging linearly, Yin and Yang spiral and wrap around each other.

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Zang Fu Tui Na: Basic Principles and Core Techniques Tai Ji (太極) is often translated as the “Great Ultimate”, or more literally as the “Great Polarity.” A more accurate way of expressing Tai Ji in English might be “Supreme Pivot” - the pattern that produces and transforms the Qi (vital force), and is the center of the alternation and transformation of the fundamental vibrations of Yin and Yang and their manifestations as the Five Elements (fire, water, wood, metal, and earth). In looking at two-dimensional drawings it is easy to forget that this wrapping spiral occurs in three dimensions - like a Yin Yang marble where the two “fish” simultaneously wrap inward and outward, into, and away from the center of the marble. This three dimensional spiral creates a series of internal twisted figure-eights that, like a Mobius strip, have no beginning and no end. This constant unending series of circular, spiral patterns and cycles that are similar, but never exactly the same, is exactly the movement we see in the natural world around us. There are no straight lines in nature, only the multiple arcs, curves and spirals that can take on the appearance of linearity. Fractal Geometry studies these kinds of interactions, and diagrams them in fascinating patterns, like the “Lorenz Attractor” shown below. The endlessly repeating pattern resembling wings or an owl’s mask, never exactly repeats itself. It loops around in a series of ongoing, continuous, spiral-like transformations.7 The crossover point from one “wing” to the other illustrates the reversal of direction, the transformation from Yin to Yang, which permeates the entire series of finely interwoven movements.



Diagrams like the Lorenz Attractor and the Yin Yang Diagram exactly describe interactions that we feel in our joints when they are moving smoothly and effortlessly. In acupuncture and Traditional Tui Na we can learn to feel these same spirals moving in and between the meridians and the internal 7

Chaos: Making a New Science, By James Gleick. London and New York: Penguin Books, 1987 and 2008, pp.28-29. 17

Zang Fu Tui Na: Basic Principles and Core Techniques organs. Through this understanding, the practitioner can interact with the ability of the organs to attract and oppose, enfold and open up. When the kidneys “grasp Qi” from the lungs, these two organs are attracted toward each and interact in a spiral configuration. When the heart and kidneys (Fire and Water) are said to “communicate”, the opposing forces of Water and Fire reach the limit of their movement away from each other and the heart and kidneys are drawn back toward each other in a rolling, twisting, spiraling interchange, much like the Mobius Strip pictured below.

This same kind of spiral occurs in Dan Tian and Ming Men when practicing Nei Gong exercises. It occurs when releasing power in martial movements, and it is present in the internal, circular, rolling movement that spontaneously occurs in the Ren and Du Channels in Daoist meditation practices. The subtle internal movement that is a product of the inter-transformation of Yin and Yang is often described as pearl rolling and rotating, or like two dragons fighting around a pearl, so completely wrapped up in their twisting coiling movements that it is impossible to tell exactly where one dragon begins and the other ends.

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Chapter 2 Regulating the San Jiao Regulating the San Jiao is a basic yet very important step in regulating the Zang Fu. It is an invaluable method of diagnosing and treating organ dysfunctions. If the internal Qi Dynamic is healthy, there is smooth movement and interchange between the Three Jiao. Organ dysfunction, fascial restrictions, injuries, surgeries and illness can create dysfunctions that are reflected in the San Jiao system, leading to impeded movement within, or even reversal of, the normal Qi Dynamic (“Rebellious Qi” or Counter-Flow Qi”), in parts of the San Jiao system. Often, just regulating the San Jiao is enough to return the body to a self-regulating equilibrium. In general, there should be unrestricted downward movement from the Upper Jiao (above the diaphragm), to the Lower Jiao (below the navel), and also unrestricted upward movement from the Lower Jiao to the Upper Jiao. The Middle Jiao is the hub, or crossroads of this Ascending-Descending Qi Dynamic, so maintaining free flow through the Middle Jiao in both directions is very important.

Anatomical & Energetic Considerations Anatomically speaking, the Upper Jiao is usually defined as being above the diaphragm, and the Middle Jiao as being between the diaphragm and the navel. The Lower Jiao is considered to be below the navel. The internal organs are not so easily divided among these three areas. The organs of the Upper Jiao and Middle Jiao have broad attachments to the diaphragm, and the movement of the diaphragm has direct impact on the movement and functioning of the organs of the Lower Jiao. The pericardium has direct connection with the liver across the diaphragm, and the large intestine, although largely considered to be in the Lower Jiao, connects directly with the liver, spleen and diaphragm at the hepatic and splenic flexures. The duodenum is considered to be part of the small intestine, yet it has intimate connections with the functions ascribed to the spleen and stomach in traditional Chinese medicine. The pancreas butts up against one of the curves in the duodenum and deposits digestive enzymes into the duodenum, while 19

Zang Fu Tui Na: Basic Principles and Core Techniques the gallbladder feeds bile into the duodenum. The anatomical position of the duodenum is particularly interesting, as it connects to the stomach in the middle heater and then wraps around the navel before going into the jejunum-ilium. In a sense it is at the center of “the center”, and connects the Middle and Lower Jiao. Even the kidneys do not behave and reside in their assigned place in the Lower Jiao. They ride up and down the psoas muscle, driven in part by the movement of the diaphragm associated with respiration. The upper pole of each kidney can be found quite high, almost level with the xiphoid process, while the lower pole of the left kidney is often found just above the navel. The organs related to each Jiao could be flexibly divided as follows: Upper Jiao • • • •

Thoracic Outlet and the Shoulder Well Lungs & Pleura Pericardium & Heart Diaphragm

Middle Jiao • • • • • • • •

Diaphragm Liver Gallbladder Pancreas Spleen Stomach Duodenum Large Intestine: particularly the hepatic and splenic flexures of the colon and the transverse colon

Lower Jiao • • • • • •

Duodenum Small Intestine (Jejunum and Ilium) Portions of the Large Intestine: particularly the cecum, ascending colon, descending colon and sigmoid colon Kidneys Bladder Pelvic Floor

However, conceptually speaking, the San Jiao is not just describing three body cavities: thorax, 20

Zang Fu Tui Na: Basic Principles and Core Techniques abdomen and lower abdomen - it is also a description of the function of the San Jiao in relation to processing fluids and other substances: 1) The Upper Jiao is likened to a "Fog" or "Mist" that pervades and fills every area of the body. In combination with Heart Qi and Lung Qi and the diaphragm, this aspect of the San Jiao distributes Qi and fluids throughout the body. 2) The Middle Jiao dominates digestion and is therefore likened to a “Fermentation Vat,” a “Froth of Bubbles,” or a “Bubbling Cauldron.” These names refer to the actions of the Stomach in “rotting and ripening” food, and of the Spleen in “transforming and transporting” refined essence upwards to the Lungs. This aspect of the San Jiao can be said to include elements of the duodenum, gallbladder, pancreas, and the intestines. 3) The Lower Jiao is called a "Drainage Ditch" or "Canal". It dominates the separation of the "clear from the turbid" and the excretion of wastes. This aspect of the San Jiao includes some of the functions of the intestines, the kidney and bladder. The San Jiao is considered to be a passageway for the movement and transformation of Qi and fluids. In this context, the San Jiao represents the space surrounding the tissues of the internal organs and the external muscles. These “small spaces” are where interstitial fluid moves through the body, and they act like corridors for fluid metabolism. This view of the San Jiao encompasses not only the spaces or cavities, but also the tissues that wrap and connect the organs. Modern studies of the connective tissues reveal that not only does water pass through connective tissue fibers, the connective tissue network may also act as a sophisticated communication system.8 The San Jiao can also be thought of as the spaces that make up the other channels. Commentary from the Difficult Classic (Nan Jing) supports this idea: The San Jiao is called a palace [an organ] because it links and because it spreads. That makes it obvious that the San Jiao has the function of storing and draining. It is spread out all around the upper and lower [parts of the body] enclosing [all the other] depots and palaces [organs].9 The San Jiao is part of Shao Yang, which includes the San Jiao Channel and Gallbladder Channel (Hand and Foot Shao Yang). Shao Yang acts as an energetic pivot between the exterior and interior of the body, and therefore has a role in both regulating Qi and blood, and regulating the movement of fluids through the interstitial tissue. The Shao Yang pivot is associated with movement and regulation outside of the internal organs, and in the spaces between the sinews and bones. In order for movement and regulation to occur smoothly, these pathways must be free of stagnation or blockage. In Qi Gong practices, exercises that regulate and harmonize Shao Yang are generally referred to as 8

The Amazing Fascial Web, Part I, By Leon Chaitow, ND, DO. Massage Today. May 2005, Vol. 05, Issue 05. Medicine in China: Nan-Ching The Classic of Difficult Issues, translated and annotated by Paul Unschuld (Berkeley: University of California Press, 1986) p. 396.

9

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Zang Fu Tui Na: Basic Principles and Core Techniques San Jiao Exercises or “Triple Heater” Exercises. Exercises that harmonize the San Jiao are said to “dredge” Shao Yang, so that it can function properly as an axis that regulates and promotes the activities of Qi in the whole body. Ba Gua Master Xie Pei Qi felt that the San Jiao connects Lung Qi (Heavenly Qi from the air), Spleen Qi (Post-Natal Qi of nutrition), and the True Qi of Ming Men and Dan Tian. He viewed these three Qi as a kind of “unified respiratory system.” If one Jiao becomes diseased, the others are also affected. Opening and regulating the San Jiao allows Lung Qi to descend to Dan Tian. This connects Heaven and Earth, and activates (“bumps and sways”), the organs of the Middle Jiao, so that the clear Qi rises and the turbid Qi descends. Opening and regulating the San Jiao also activates the kidneys and Dan Tian, so that Qi and Essence (Jing) fill Dan Tian and rise up the Du (Governing) Vessel to engender Spirit (Shen).10

Methods of Regulating & Harmonizing the San Jiao 1. Connecting Upper & Middle Jiao Place one hand on the upper chest just below the sternal notch (Upper Jiao), and place the other hand so that the Lao Gong point in the palm center is just below the solar plexus (Middle Jiao). Let the hands gently sink into the tissue by connecting your hands to your own Dan Tian and Ming Men. Gently direct Qi from the hand on the Upper Jiao to the hand on the Middle Jiao. This is a bit like sending a slow moving wave from one hand to the other.

Connecting Upper & Middle Jiao

The Eight Healing Sounds of Yin Style Ba Gua. Xie Pei Qi, Trans. Andrew Nugent-Head. (San Francisco: Traditional Studies Press 1995) p. 121-122. 10

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Zang Fu Tui Na: Basic Principles and Core Techniques As you send this wave from the Upper Jiao to the Middle Jiao, “observe” or “listen to what is happening under your hands. Is the movement from your upper hand to your lower hand slow, smooth and steady? Does the “wave” pass smoothly through the diaphragm to reach your lower hand, or does it slow or stop somewhere along the way? Now direct Qi from the lower hand to the upper hand (Middle Jiao to Upper Jiao), noticing again whether the movement is smooth and steady, or whether it is retarded, uneven, or blocked. Sometimes the movement trickles through, or only partially passes through, from one hand to the other. Continue to direct Qi back and forth between the Upper and Middle Jiao, gently applying your intention to guide and lead Qi more smoothly and easily between the two Jiao. This is largely a question of augmenting or smoothing what is already happening, rather than interfering with, or changing the movement that exists between the two Jiao. If there are blockages, or places where the movement is retarded or uneven, notice them. What side of the body are they on? What organs might be restricting the movement?

2. Connecting Middle & Lower Jiao Move your hands so that the palm center of one hand is just below the solar plexus (Middle Jiao). The palm center of the other hand will be just below the navel (Lower Jiao), either on Qi Hai (Ren 6), 1.5 body inches (cun) below the navel, or Guan Yuan (Ren 4), which is located 3 body inches below the navel. If your hand is big, it may cover both areas.

Connecting Middle & Lower Jiao 23

Zang Fu Tui Na: Basic Principles and Core Techniques The procedure is the same as in the first technique above - connecting Upper & Middle Jiao. One can also notice, does the movement from the Middle Jiao to the Lower Jiao pass through to the legs, or does it stop in the pelvis?

3. Connecting the Upper and Lower Jiao Keep one hand below the navel on the Lower Jiao, and move your other hand back to the Upper Jiao, so that it rests lightly on the chest, just below the sternal notch. The procedure is the same in Part 1 above, gently direct Qi from the hand on the Upper Jiao to the hand on the Lower Jiao and back again. This generates a larger movement, that also passes through the Middle Jiao. The Middle Jiao is to some degree like a hub that connects the Three Jiao, so you may feel that movement spirals through the Middle Jiao. Remember, the idea of the internal movement described by Tai Ji Diagram. The larger movement generated by connecting Upper and Lower Jiao will also give you different information about the Qi Dynamic than the previous two steps, and information about the interaction of the organ system as whole.

Connecting the Upper and Lower Jiao

Note: While balancing and harmonizing movement and communication between the Three Jiao, you have also gathered information about the global movement of the ascending and descending aspects of the Qi Dynamic. This gives you diagnostic information that will aid you as you perform other levels of treatment, like regulating and harmonizing the five Zang organs. The diagnostic information in this level of treatment can also be returned to, after going on to other techniques and other levels of treatment, as a way of checking the efficacy of those other levels and techniques (ie: did further treatment make a change in any restrictions to movement between the San Jiao or not?). 24

Zang Fu Tui Na: Basic Principles and Core Techniques

Complimentary Acupuncture San Jiao Regulatory Treatments 1. Basic San Jiao Regulatory Treatment Upper Warmer Control Point:

Ren 17

Transitional Point:

Ren 13

Middle Warmer Control Point:

Ren 12

Transitional Point:

Ren 10

Lower Warmer Control Point:

Ren 7

Procedure: To move stagnant Qi from one Jiao to next, needle or stimulate the control point of the Jiao where Qi is stagnant. Then needle or stimulate the transition point between the two Jiao and the control point of the adjacent Jiao (the Jiao you are attempting to get Qi to flow into more smoothly). If all 3 Jiao are imbalanced, needle all three control and two transitional points. Add channel points or Mu points as needed. For example: For Qi stuck in the Upper Jiao, needle or stimulate Ren 17, the control point and the transition point between the Upper and Middle Jiao – Ren 13. Then stimulate Ren 12, the control point of the middle Jiao. One could add the Lung Mu Point (LU 1) and a point that opens the Lung Channel, or LIV 14 (Liver Mu Point), or points on the liver channel or stomach channel that facilitate the downward movement of Qi. A similar reasoning could be used for Qi that is stuck in the Middle Jiao that will not move smoothly upward or downward. Distal points that help to move stuck Qi, or points that draw energy upward or downward, may also be added.

2. Three Powers (San Cai) San Jiao Regulatory Treatment 1 Heaven:

Du 20 (Shen)

Humans: CV 17 (Qi) Earth:

KID 1 (Jing)

The Three Powers Regulatory Treatment is a global regulatory treatment that can balance the three Jiao and their connection to the Qi Dynamic of Heaven and Earth.

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Zang Fu Tui Na: Basic Principles and Core Techniques

3. Three Powers (San Cai) San Jiao Regulatory Treatment 2 Upper Level:

SP 21 (Da Bao: “Great Wrapper”)

Middle Level:

ST 25 (Tian Shu: “Heaven’s Pivot”)

Lower Level:

SP 8 (Di Ji: “Earth Pivot”)

According to the Ode to Elucidate Mysteries, SP 8 dominates the Lower Jiao, ST 25 dominates the Middle Jiao, and SP 21 the Upper Jiao. These three zones and regions also correspond with the San Cai: Earth, Human Beings, and Heaven This San Jiao Regulatory Treatment focuses on Yang Ming and Tai Yin, and more specifically the spleen and stomach actions of regulating digestion and the water metabolism. SP 21 is the Great Luo of the Spleen. According to Deadman and Al-Khafaji: One of the functions of the of the LuoConnecting Channels in general is to assist in the distribution of Qi, and more especially blood, to all the tissues of the body via the network of the minute Luo connecting vessels. Since the Spleen controls the blood, its great luo connecting channel dominates this function of blood distribution throughout the body.11

4. Jue Yin-Shao Yang San Jiao Regulatory Treatment Upper Jiao:

Ren 18 (Yu Tang: “Jade Hall”)

Middle Jiao:

Liv 13 (Zhang Men: “Completion Gate”)

Lower Jiao

Liv 1 (Da Dun: “Big Mound”)

Add: SJ 6 (Zhi Gou: “Branch Ditch”) and GB 34 (Yang Ling Quan: “Yang Mound Spring”) This San Jiao regulatory treatment focuses on Jue Yin and Shao Yang. Liv 1 and Ren 18 are the “root and node” of Jue Yin and are very effective for harmonizing Jue Yin (liver and pericardium). Liv 13 helps to harmonize the liver and spleen. It is the meeting point of the Five Zang and the Mu point of the spleen, as well as a meeting point for the liver and gallbladder channels. As a pair, SJ 6 and GB 34 dredge Hand and Foot Shao Yang (gallbladder and san jiao channels) Note: San Jiao regulatory treatments 3 and 4 (above) are useful when you have ascertained that restrictions or imbalances in the San Jiao have their roots in specific, interrelated channel and organ systems – in this case Spleen/Lung (Tai Yin) and Stomach/Large Intestine (Yang Ming), or Liver/Pericardium (Jue Yin) and Gallbladder/San Jiao (Shao Yang). 11

A Manual of Acupuncture. Peter Deadman and Mazin Al-Khafaji (Hove, UK: Journal of Chinese Medicine Publications, 2000), 26

Chapter 3 Regulating & Harmonizing the Five Zang Organs Regulating and Harmonizing the Five Zang Organs, along with Regulating the San Jiao (Chapter 2), are the two most important diagnostic and treatment methods in Zang Fu Tui Na. Regulating and Harmonizing the Five Zang Organs is the keystone of Zang Fu Tui Na diagnosis and treatment. Rather than working with the Zang organs individually, the advantage of the Regulating and Harmonizing the Five Zang Organs Method is that it looks at the Qi Dynamic of pairs of organs. This method of working with the organs is the most efficient way of diagnosing and treating the Five Zang Organs and their interwoven Qi Dynamic. The Qi Dynamic pairs outlined below are global in nature; they affect the entire body on many levels. A good practice in working with the Five Zang is to build a habit of always sensing and regulating the five organs in the order described below. Later this order can be varied, and even altered, according to the situation.

1. Regulating the Heart Although we refer to this technique as “regulating and harmonizing the heart”, in fact this initial step is more of a “listening” technique - one that is more passive than active. Because of the heart’s innate sensitivity, no manipulations are performed directly with the heart. We can interact with the heart through the pericardium (the protector of the heart), or via the heart’s relationships with other organs (see Chapter 6 for methods of treating the pericardium). The pericardium is a sac-like structure that surrounds the heart, making it difficult to treat the heart directly. The heart is in the center of the chest, tilted slightly to the left. The heart is actually quite close to the back. In Chinese medicine we say that the front of the heart is deep as a well, but the back of the heart is as thin as a pancake. The cardiac area on the back is between the fourth thoracic vertebra and seventh thoracic vertebra. Our goal in this first step is to merely sense and assess the heart’s natural movement without 27

Zang Fu Tui Na: Basic Principles and Core Techniques interfering with it. Remember the principle of Wu Wei. The patient’s heart and spirit should not be agitated by this technique. It should feel comfortable.

Sensing and Regulating the Heart 1. Put your hand over the heart in the center of the chest, and let your hand sink into the tissue. Feel as though you sink through the sternum and into the chest cavity. Sink internally with your Dan Tian, rather than with your muscular force, so that you are not putting pressure on the heart. The heart does not respond well to pressure, hence it is protected by the ribcage and sternum. 2. Feel the figure eight-like movement of the heart. Follow this movement without interfering with it. Is this figure-eight movement relatively even, smooth and unrestrained? Are the tissues around the heart relaxed and supple? Can you sense the movement of the blood moving through the chambers of the heart? You may already know the answer to these questions if you previously harmonized the San Jiao. However, the goal here is to get more information about the heart specifically. In Chinese medicine, the heart must be empty and open in order to properly house the Shen (Spirit). Does the heart have this space within it for blood to flow and the spirit to be properly housed?

Sensing & Regulating the Heart

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Zang Fu Tui Na: Basic Principles and Core Techniques

Qi Dynamic of the Heart and Lungs It is impossible to separate the heart’s Qi Dynamic from the general cardio-pulmonary dynamic of the heart and lungs, represented by Gathering Qi or Pectoral Qi (Zong Qi). Zong Qi is stored in the chest. It pours into the channels of the heart and lungs, and goes out of the lungs to circulate through the larynx and pharynx. Zong Qi also goes down to Dan Tian to be stored, fills ST 30 (Qi Jie) and then goes downward to the feet. Zong Qi assists the lungs in controlling Qi and respiration, and assists the heart's function of governing the blood and blood vessels. It flows through the respiratory tract to promote the respiratory movement of the lung, and is involved in the loudness or softness of voice and words. Zong Qi also fills the heart channel to promote and adjust the heartbeat, and to promote and adjust the circulation of blood and vital energy. Zong Qi exerts an influence on the warmth and activities of the limbs. Because Zong Qi gathers in the throat, it influences speech (under control of the heart), and the strength of the voice (under control of the lungs). The regulation of the heartbeat and the strength of the pulse that we feel at ST9 Ren Ying (Carotid Pulse), LU9 Tai Yuan (Radial Pulse), ST30 Qi Chong (Femoral Pulse), and ST42 Chong Yuan (Pedal Pulse) are ultimately dependent upon the Zong Qi. Zong Qi is sometimes referred to as "Ancestral" Qi, because it represents an inherited ability, a genetic template for our capacity to produce and use the other energies of the body.12 Zong Qi is also known as "Gathering" Qi, because it is formed in the chest at the time and place of the meeting of the essences of food and drink and the air from the lungs – where the heart and lungs gather the bodily energies for distribution. The point of concentration of the Zong Qi is CV17 (Dan Zhong "Chest Center"), midway between the two nipples. CV17 is the Influential (Hui) Point of the Qi. It is often used in conjunction with heart and/or lung acupuncture points to affect the Zong Qi.

12

Terrains And Pathology In Acupuncture. Yves Requena (Brookline, Mass: Paradigm Publications, 1986) p.13. 29

Zang Fu Tui Na: Basic Principles and Core Techniques

2. Regulating the Lungs The Lungs and Respiration On inhalation the diaphragm drops, so that pressure decreases inside the lungs and chest relative to pressure in the atmosphere, and air flows in. In exhalation the diaphragm lifts, increasing pressure inside the lungs, and air flows out. The lung is like an upside down tree. Much of the lung surface area is bathed in blood, which perfuses into the heart to be oxygenated. To a large degree, respiration initiates and drives the Qi Dynamic, because if we cannot breathe and oxygenate our blood, we cannot survive. The lungs “Command the Qi” because of their role in respiration, thus they play a critical role in regulating the Qi Dynamic of the whole body.

Regulating and Harmonizing the Lungs 1. Lungs: Ascending and Descending Qi Dynamic 1) Place your hands on the upper chest, with one hand on the top portion of each lung. Your hands are above the breasts, “cupping” the upper part of the lungs. Notice the cephalad (upward) and caudad (downward) movement of the lungs. This upward and downward movement is related to respiration. Observe the movement for a moment, and then discard the respiratory cycle and look for the upward and downward movement of the lungs that is independent of, and much slower than, the respiratory rhythm.

Regulating & Balancing the Lungs 30

Zang Fu Tui Na: Basic Principles and Core Techniques 2) Observe this slower rhythm and note whether the two lungs move together at the same speed, and the evenness and smoothness of their upward and downward movement. Are these movements restricted in any way? 3) Balance the two lungs by encouraging movement. If one lung lags behind, or has retarded movement, use your intention and the movement of the other lung to encourage and augment the movement. If one lung (or both) do not go to one of the end points of the upward or downward movement – for example if the left lung does not descend completely - gently encourage it to keep moving towards its endpoint, coaxing it to go a little farther each time you follow it though its cycle of movement and approach the endpoint. It may take several cycles to balance and harmonize the upward and downward movement of the lungs.

2. Lung Rotational Qi Dynamic (Opening/Closing & Entering/Exiting) 1) Keep your hands on the upper chest, with one hand on the top portion of each lung. Your hands are above the breasts. Notice the rotation of the lung in both directions along its axis (see the diagram on the following page). Note that the axis of rotation is bent, following the angle of the lungs. This rotational movement is independent of, and much slower than, the respiratory rhythm.

Lung Rotation Combined with Downward Movement 31

Zang Fu Tui Na: Basic Principles and Core Techniques 2) As with the ascending and descending (above) movements, balance the rotational movement of the two lungs. Again encourage them to move together and to move completely through their full movement in both directions. It may take several cycles to balance and harmonize the rotational movement of the lungs. Note: The lungs move upward and downward and rotate simultaneously. Once you are familiar with these two movement patterns, they can be perceived and harmonized simultaneously. The two movement patterns – rotation and ascending/descending - are a direct reflection of the function of the lungs governing the Qi, and the descending and dispersing function of the lungs, which disseminates Qi and fluids throughout the body. If lung movement is impaired, the lungs’ ability to downbear and disseminate Qi and fluids is probably also impaired. The axes of rotation, and the ascending and descending movements of the lungs, are more clearly diagrammed below.

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Zang Fu Tui Na: Basic Principles and Core Techniques

3. Regulating and Harmonizing the Lungs and Kidneys The Lung-Kidney Qi Dynamic has a global effect on the body, with ramifications relating to the circulation, dissemination, and storage of Qi, and the circulation and dissemination of fluids. 1) With one hand on the upper part of both lungs and the other hand cupping the lower pole of the kidneys, feel how the lungs and kidneys move towards and away from each other. Sense the movement of these organs in relation to the breath. Note: The lower pole of the right kidney is roughly level with the navel, while the lower pole of the left kidney is just above, and to the left of the navel. Rest your hand lightly on the surface of the abdomen and let your hand sink through the flesh until you feel as though you are cupping the lower ends of the two kidneys. 2) After several respiratory cycles, look for a deeper, much slower movement that is independent of the breathing pattern. Notice that when the lungs move downward and the kidneys move slightly upward, it feels as though something is exchanged, something is passed from the lungs to the kidneys, and the kidneys in turn grasp what is passed on by the lungs - the kidneys “Grasping the Qi.”

Regulating & Harmonizing the Lungs and Kidneys

3) If the kidneys do not feel as if they adequately grasp the Qi, or if the lungs do not carry the Qi smoothly to the kidneys, gently augment the movement of the lungs and kidneys towards each other, and guide the organs through several movement cycles.

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Zang Fu Tui Na: Basic Principles and Core Techniques

Lung-Kidney Qi Dynamic The lungs disseminate the Qi, moving it outward and downward. This outward and downward movement is intimately interconnected to the lung action of opening and closing, which in turn allows air to enter and exit the body. We know that the body also “breathes” through the skin. In Chinese medicine, the lungs control the opening and closing of the pores and sweat glands. As Qi disseminates and spreads outward and downward, it percolates fluids throughout the body. This action brings fluids to the lower body, the skin and the other organs including the kidneys. The lungs are the “Mother” of the kidneys. The lungs form a canopy or dome over the other organs. In a sense, the lungs are situated at the upper source of the heavenly stream of Qi that flows downward through head and into the body. Lung Qi harmonizes with this downward stream, which ultimately connects to the ocean of water in Dan Tian (associated with Kidney-Water) by disseminating a fluid-like dew that percolates downward, returning to, and combining with, the “True Water” of the Kidneys. The lungs are said to “spread and descend the clear, contracting Qi” so that it can enter the kidneys. The kidneys in turn “grasp” this clear, inward-moving Qi. All of the above actions must take place smoothly and easily in order for inhalation to be complete and full. The kidneys process both the fluids that percolate downward from the lungs, with the downward dissemination of Qi, and those that arrive via digestion and are absorbed by the intestines. The kidneys separate out the impure fluids for excretion via the bladder, and via the large intestine and stool. The kidneys also gather the “clear” (purer) fluids so that they can be re-circulated. 34

Zang Fu Tui Na: Basic Principles and Core Techniques

4. Regulating the Heart and Kidneys The interaction of the Heart-Fire and the Kidney-Water is to some degree a reflection of the global interaction of Yin and Yang in the body. The Kidney–Heart Qi Dynamic is often referred to as “Communication Between Heart and Kidneys.” The harmonious communication between the heart and kidney occurs through the descending and ascending Qi Dynamic of Yin and Yang in the heart and kidney - Heart Yang descends to strengthen the Kidney Yang, and warm the kidneys, while Kidney Yin ascends to help the Heart Yin control the Heart, preventing the development of excess Heart Fire. When this “communication” is blocked or disharmonious, a wide variety of symptoms can arise. Regulating the Kidney-Heart Qi Dynamic therefore balances Yin and Yang by balancing Water and Fire. From a Daoist perspective, working with the Kidney-Heart Qi Dynamic is also a means of reconnecting the everyday mind and consciousness to one’s True Self and True Nature. 1) Place one hand over the center of the chest. The other hand cups the lower pole of the kidneys. Feel how the kidneys and heart slowly move toward each other and then slowly move away from each other.

Regulating & Harmonizing Heart & Kidneys

Note: The lower pole of the right kidney is roughly level with the navel, while the lower pole of the left kidney is just above, and to the left of the navel. Rest your hand lightly on the surface of the abdomen and let your hand sink through the flesh until you feel as though you are cupping the lower ends of the two kidneys. 35

Zang Fu Tui Na: Basic Principles and Core Techniques 2) As the heart and kidneys move toward each other, they have a mutual attraction. There is a moment where the two organs seem to overlap, as though they are about to exchange their positions. The organs seem to interweave and then move apart again. The moment of interchange is the moment Heart-Fire moves downward to connect with Kidney-Water, while simultaneously KidneyWater moves upward to connect with Heart-Fire. Notice that the interchange of Heart-Fire and Kidney-Water is a rolling, spiral interchange, almost like tying a bow with two ends of a ribbon. The two ends of the ribbon interweave, but then as you pull the ends they separate again. 3) Once they interchange, the two organs move apart, separating in a rolling spiral. The kidney moves downward and the heart upward. Feel how they stay connected as they move apart, until the next cycle of attraction and interweaving starts. Remember these cycles are independent of, and much slower than, the respiratory cycle.

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The Heart-Kidney Qi Dynamic In order for Yin and Yang to be harmonious, Kidney-Water must unite with Heart-Fire. Water must upbear in order to control Fire and Heart Yang. In turn, Heart Yang must downbear in order to join with Kidney Yang and control Water. It is said that the Fire of the heart and kidneys warms Kidney Water so that Water does not freeze.13 The interactions of Water and Fire represent Yin and Yang inter-transforming in order to promote balance. The kidney is the organ of Yin-Water, but within Water there is Yang-Fire. Fire governs Water. This is why Fire must downbear in order to move and regulate Water and Yin. Inside Water there is Fire, hence Water must upbear in order to support and balance Fire and Yang. The interchange that occurs between the heart and kidneys regulates Kan-Water and Li-Fire. The Kan Trigram in the diagrams below represents Water. It is composed of a single Yang (solid) line, surrounded by two Yin (broken) lines. This Yang line represents the hidden Fire within KidneyWater. The Li Trigram represents Fire. It is composed of a single Yin (broken) line, surrounded by two Yang (solid) lines. This single Yin line represents the hidden Water within Heart-Fire.

Fire tends to flare upward and Water to flow downward. There is therefore a tendency toward separation and non-interaction. However, if these two elements are harmonious and act in relation to one another they communicate and inter-transform - Fire downbears and Water upbears.

13

“The Movements of Qi According to Chinese Medicine” Philippe Sionneau: https://sionneau.com/medecinechinoise/articles/the_movements_of_qi_according_to_chinese_medicine 37

Zang Fu Tui Na: Basic Principles and Core Techniques

Water is the source of Fire; this is why Kidney Qi must upbear to support Fire - therefore Water follows the upward movement of Yang and upbears. Water that does not rise and upbear can become pathogenic. Fire Qi follows the downward movement of Yin and therefore downbears. Fire that does not downbear can also become pathogenic. The interaction between Water and Fire can be likened to water heated on a stove, creating vapor, which rises upward only to coalesce and descend again. The two elements must act in relation to each other, and in balance with one another. If the heat (Yang) is too great, the water (Yin) will evaporate. If the water (Yin) boils over, the fire (Yang) will be extinguished. This state of balance is represented by Hexagram Sixty Three: Ji Ji (Completion), in which the trigram for Water is above, and the trigram for Fire below. Because Water flows downward and Fire flares upward, these two elements interact and inter-transform, manifesting in an internal alchemical process.

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5. Regulating & Harmonizing Liver and Spleen/Stomach The Spleen/Stomach Qi Dynamic exemplifies the body’s Ascending-Descending Qi Dynamic. However, it is important to recognize that Stomach Qi spirals and closes inward, in addition to descending, and that Spleen Qi spirals open and outward, in addition to ascending. Regulating the spleen/stomach in relation to the liver is important because the liver exerts a powerful influence on Spleen/Stomach Qi Dynamic. This influence is not merely a product of the liver’s role in maintaining the smooth movement and patency of Qi. Liver Qi aids Spleen Qi in moving upward, while the Qi of the liver’s paired organ, the gallbladder, aids Stomach Qi in descending. Additionally, anatomically speaking, the liver and gallbladder have a direct connection with the stomach and spleen through the curtain-like sheet of the lesser omentum. 1) Put your left hand on the liver, and your right hand on the spleen and stomach. In sensing the

interaction of the liver and the spleen/stomach, we view the spleen and stomach as though they form a single organ with two distinct sections.

Regulating the Liver & Spleen

Note: The liver is under the right ribs. Your left hand should cover the right ribs, from the area below the breast with the palm near the lower ribs. Your hand should overlap the ribs, and the area just in front of and below the costal cartilage. The stomach is under the left ribs. Your right hand should cover the left ribs, from the area below the breast with the palm near the lower ribs. Because the spleen is behind the stomach under the left lower ribs, it is not necessary to try to separate it or isolate it from the stomach when performing this technique. It is better to sense the spleen and stomach as single entity. 39

Zang Fu Tui Na: Basic Principles and Core Techniques 2) First pay attention to your left hand. Notice how the liver rolls forward, downward and inward and then back, up and out. This movement is independent of the respiratory rhythm. 3) Now pay attention to your right hand. Notice how the spleen and stomach together move downward and inwards, and then upward and outward. 4) Simultaneously feel the intrinsic movements of both organs. Notice the spiraling interchange occurring between these organs. It is like a three-dimensional Tai Ji diagram. Note: The amplitude and shape of the spleen/stomach movement is different from that of the liver and is not completely synchronized with the liver’s movement. As the liver’s downward and inward roll finishes, the inward and upward roll of the spleen/stomach is just beginning. Even though the two movements you are sensing seem like they are not “in sync,” the movements of the spleen/stomach and the liver are like two puzzle pieces that “fit together.”

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Qi Dynamic of the Spleen and Stomach The spleen and stomach are often referred to together, and are often treated together, because their respective functions are intertwined and inseparable. Together the spleen and stomach regulate digestion by assimilating the essence from food and drink, while simultaneously facilitating the removal of the waste that results from this transformation. What can be assimilated is the clear (Qing), while the waste is referred to as the turbid (Zhuo). The spleen upbears the clear toward the lung and heart to be absorbed and further transformed. The stomach downbears the turbid toward the large intestine, where it is eliminated. If the turbid downbears properly, the clear will upbear more easily. If the turbid, which has an obstructive and sticky nature, downbears poorly and stagnates in the middle burner, the upbearing of the clear runs the risk of being obstructed, heavy, and slow. If the clear, which has the job of tonifying the Zang Fu and therefore allowing them to perform their duties properly, does not upbear correctly, the downbearing function of the stomach, gallbladder, lung and large intestine is impaired and they cannot eliminate the turbid.14 The Qi Dynamic of the Spleen and Stomach is assisted by the Qi Dynamic of the other organs • •

The upbearing of the spleen is aided by the upbearing of the liver The downbearing of the stomach is aided by the downbearing of the gallbladder.

The Spleen is the Yin of Earth from which Yang upbears, and the stomach is the Yang earth from which Yin downbears. Earth is situated in the center, thus Fire [of the earth] upbears, and Water [of the earth] downbears. On the left there is Wood, on the right there is Metal; the left (Wood) governs upbearing, the right governs downbearing (Metal).15 This references the idea that the Liver Qi rises on the left and Lung Qi descends on the right. In essence, upbearing and downbearing movements of the four other Zang turn around a central pivot of the Spleen and Stomach. The importance of the Spleen-Stomach Qi Dynamic is further emphasized in the following quotation from the Si Sheng Xin Yuan (Secret Sources of Four Masters): Spleen is the Yin Earth, it is Tai Yin and controls rising; stomach is Yang Earth, it is Yang Ming and controls descent The initiative to rise or descend derives from the meeting of yin and yang, and this [meeting] is in the Qi of the center. The stomach controls reception, the spleen controls transformation. If the central Qi is vigorous, it can descend and is good at receiving, spleen rises and promotes churning and ripening of the water and grain; essential Qi nourishes life so there is no disease. If spleen rises then [the Qi of the] liver and kidneys also rise, therefore Water and Wood do 14

The Movements of Qi According to Chinese Medicine Philippe Sionneau. https://sionneau.com/medecine-chinoise/articles/the_movements_of_qi_according_to_chinese_medicine 15 Yi Xue Qiu Shi (Real Research on Medicine), Wu Da, 1879, Qing dynasty 41

Zang Fu Tui Na: Basic Principles and Core Techniques not become obstructed. If stomach descends, then [the Qi of] the heart and lungs can also descend, and therefore Metal and Fire have no blockage. Fire can descend so that Water does not chill the lower body. Water rises so that Fire does not over-heat the upper body. The state of a healthy person, in being warm below and cool above is a result of the proficient transportation of the central Qi, which harmonizes and benefits this mechanism of Fire and Water and forms the axis for the rising and falling of Metal and Wood.16

16

From Si Sheng Xin Yuan (Secret Sources of Four Masters) by Huang Yuan-Yu (1753) in Fluid Physiology and Pathology in Traditional Chinese Medicine 2nd Edition. Steve Clavey, p. 6. 42

Chapter 4 Introduction to Regulating & Harmonizing the Liver This chapter introduces the basic method of harmonizing the liver by working with the liver’s intrinsic movement, which is itself an expression of Liver Qi. There are a number of other techniques for working with the liver, but they all build on the ability to sense and gently influence the Liver Qi through the liver’s intrinsic movement. These other techniques will be discussed in our second volume on Zang Fu Tui Na, which covers specific techniques for the individual Zang and Fu organs. The liver has important connections with the pericardium, both energetically and anatomically. Energetically these two organs are Jue Yin, and anatomically they connect to each other through the diaphragm. Additionally, the liver is a large, solid and heavy organ that has broad attachments to the diaphragm. Therefore, dysfunctions of the diaphragm and Upper Jiao and Middle Jiao disharmonies often involve the liver.

Regulating and Harmonizing the Liver: Basic Method 1) Sit or stand on the right side of the patient. Place the right hand on the right ribs with the fingers

facing to the left, so that your fingertips make contact with the left lobe of the liver. The left hand is underneath the patient’s back, opposite the right hand. It is as though you are holding the liver between your hands. 2) As you gently hold the liver, feel its intrinsic movement. The liver moves downward and leftward (inward) as it simultaneously rolls forward. Then it reverses this movement pattern, moving upward and outward as it rolls backward. One cycle of this movement pattern takes place over several breaths. Because your hands can also to some degree sense the movement of the diaphragm with the respiratory pattern, it can be difficult to isolate the liver’s intrinsic movement, which is independent of the respiratory rhythm. If you have difficulty, first isolate the respiratory rhythm and mentally set it aside as you tune in to the movement of the liver. 43

Zang Fu Tui Na: Basic Principles and Core Techniques 3) As you follow and observe the liver’s intrinsic movement, note the amplitude of the movement. Does it move at all? Is it sluggish during some part of the movement, during the whole movement? Does the liver move upward and outward more easily than downward and inward, or vice versa?

Regulating & Harmonizing the Liver

4) Encourage the liver’s natural movement. If the liver is sluggish in one part of the movement, use your intention to coax it to move through the sluggish area. If the liver moves upward and outward more easily than inward and downward, gently emphasize the inward and downward movement, so that with each cycle that portion of the liver’s intrinsic movement incrementally increases. You can also gently prevent the liver from moving upward until it increases its movement in the downward and inward direction. This allows the liver to move a little farther each time you approach the endpoints of the liver’s range of motion. 5) When you are encouraging the liver’s natural movement, follow it through several cycles until the movement is more or less even in both directions. Notice also if there are areas of restriction that are still inhibiting completely smooth movement, as these areas may need to be addressed by more specific techniques.

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Zang Fu Tui Na: Basic Principles and Core Techniques

Liver-Lung Qi Dynamic The liver and lungs also operate in a kind of balanced opposition. Liver Qi spreads upward and outward, while Lung Qi diffuses downward and outward. The liver is rooted in the blood, and the lungs are rooted in their connection with Qi and breath. The upward and outward movement of the liver is tied in to the “Spirit” of the liver, the Hun, which seeks to return to the heavenly, cosmic sphere, while the “Spirit” of the lungs, the Po, attempts to return to the earth, in a downward diffusing action. The liver’s movement can be compared to the upward and outward spreading of a tree, and the lung’s movement to a mist spreading and sinking to the ground. Another way to view this is to see the liver as a tree and the lung as an upside down tree. This lung-liver dynamic must also be balanced. If the Liver Qi pushes upward too strongly it can block the descending, disseminating action of the lungs, leading to cough, chest tension and shortness of breath. If the lungs are forced to push downward too strongly, this can compress and irritate the liver, impeding its expansive, upward movement.

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Zang Fu Tui Na: Basic Principles and Core Techniques

Liver-Wood Qi rising represents an expansion of Yang corresponding with the rising sun (Yang) in the east, spring and birth; Lung-Metal Qi represents inward contraction of Yin corresponding with the setting sun (Yin) in the west, autumn, and death. Traditionally this dynamic is pictured as though a person is facing south, thus it is said that Liver Qi rises on the left, and Lung Qi descends on the right, as pictured in the diagram below.

The movements of the Liver–Lung Qi Dynamic respectively help Spleen Qi to upbear, and Stomach Qi to downbear. In return, the spleen and the stomach assist the movements of the liver and lung. The liver promotes upbearing, while the lung promotes downbearing. The upbearing movement of the liver sends Qi upwards to the head and the upper orifices, the downbearing movement of the lung sends Qi downward to the Zang Fu, tendons and bones. This downbearing action ensures that Qi circulates freely and that the Zang Fu are calm and harmonious.” 46

Chapter 5 Regulating & Harmonizing the Diaphragm The diaphragm is the principle muscle of respiration. It is a dome-shaped, muscular, and membranous structure that separates the thoracic (chest) and abdominal cavities. The diaphragm also separates the Upper Jiao from the Middle Jiao. Because the diaphragm effectively drives the respiratory mechanism like a piston or bellows, it plays a very important role in the Qi Dynamic of the entire body and of the lungs in particular. Diaphragmatic restrictions and imbalances can affect any or all of the organs that attach to it. This includes the stomach, spleen, liver, pericardium, and portions of the large intestine. The Lung Qi Dynamic, and the Qi Dynamics of Liver-Lung, Heart-Kidney, Lung-Kidney and SpleenStomach, are all to some degree are dependent on smooth and harmonious diaphragmatic functioning. Therefore, regulating and harmonizing the diaphragm has wide clinical application.

Anatomical Considerations 1. The diaphragm is like an upside-down bell inside the thoracic cage. 2. The diaphragm inserts on its own central tendon, which is shaped a bit like a three-leaf clover. 3. To some degree, the diaphragm is suspended from the mediastinum by the phrenopericardial ligament. 4. In the middle of the diaphragm, near the spine, there are openings for the esophagus, inferior vena cava and aorta. 5. The diaphragm is not symmetrical, hence its intrinsic motion is asymmetrical. Muscular Portion of Diaphragm has three main attachments or origins: 1. Xiphoid Process (Sternal Origin) 2. Ribs 7-10 and transverse abdominis muscle (Costal Origin) 3. Left and Right Crus at L-1 to L-3 (Vertebral Origin)

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Zang Fu Tui Na: Basic Principles and Core Techniques Diaphragmatic ligaments are structures that connect the diaphragm to the viscera: 1. Inferior Pulmonary Ligament: a pleural thickening connecting the diaphragm to the base of the lungs. 2. Phreno-Pericardial Ligament: connects the diaphragm to the heart/pericardium. This ligament is the fulcrum around which the diaphragm is supported when the diaphragm distributes its contractile tension laterally. 3. Phrenico-Esophageal Ligament: connects the esophagus and the diaphragm. 4. Hepatic Ligaments: The liver has various ligaments, which attach from the surface of the liver to the diaphragm and also to the anterior abdominal wall. These ligaments are folds of peritoneum and they anchor the liver in place. • The Coronary Ligament is a broad band of fibrous tissue on posterior side of liver, connecting it to diaphragm. Insertions into diaphragm are called “triangular ligaments.” The Right Triangular Ligament is on the right axillary line. • The Falciform Ligament divides the liver into right and left lobes. The Falciform Ligament stretches from the underside of the diaphragm to the posterior surface of the sheath of the right rectus abdominis muscle, as low down as the umbilicus. 5. Phrenicocolic Ligament: connects the diaphragm to the splenic flexure of the large intestine on the left side of the body and also supports, and to some degree, suspends the spleen. 6. Ligament of Treitz: muscular tracts that start in the main left pillar of the diaphragm and go to the duodenojejunal angle.

The Diaphragm and Respiration During inhalation, the diaphragm contracts and lowers - its dome descends and the central tendon pulls down. This action increases the volume in the thorax and lungs. Increasing the volume inside the thorax and lungs decreases pressure inside the lungs, creating a pressure gradient that allows air to enter from outside. During exhalation, the diaphragm relaxes – it moves upward. This action decreases lung volume, and increases pressure in the lungs, so that air moves outward. The diaphragm is attached to the base of the lungs. During exhalation the diaphragm is also pulled upward by the ascending movement of the lungs. There is a connection between the movement of the diaphragm and the pelvic floor. During inhalation, as the diaphragm descends, there is a corresponding lowering of the pelvic floor. This complimentary movement ensures the steadiness of the human trunk and maintaining urinary continence during respiration and coughing. Various studies have established that, before inhalation, electrical activity can be observed in the muscles of the pelvic floor. 48

Zang Fu Tui Na: Basic Principles and Core Techniques

Diaphragm: Important Energetic and Tissue Relationships The ideogram for the diaphragm is 膈 (Ge). The Ge character is composed of the flesh radical (月) and the radical f0r an iron cauldron, or earthen pot (鬲). In Daoist inner-cultivation practices the diaphragm is very important, as the diaphragm controls the rising and descending of Fire and Water. The movement of the diaphragm mixes the Yuan Qi and Post-Heaven Qi. The diaphragm is sometimes thought of as a cauldron, or an earthen pot. It defines the abdominal area, where Jing and Qi “cook” (transform).

Diaphragmatic Movement The upward and downward movements of the diaphragm affect all of the organs by creating pressure gradients that move blood, Qi and fluids through them. The connection of the diaphragm with the lungs has a large influence on the ascending, descending, and entering and exiting aspects of the Qi Dynamic. Because the major meridians pass through the diaphragm, the movement of the diaphragm helps to modulate the flow of Qi, blood and fluids in the meridians and their associated organs. The diaphragm is the divider that separates the Upper Jiao and Middle Jiao. The smooth functioning of the diaphragm aids the movement of Qi, blood and fluids between the Upper and Middle Jiao. The descent of Lung Qi, the kidney’s ability to “grasp” the Lung Qi, and the ability of the heart and kidneys to communicate, all depend on the smooth, unobstructed movement and functioning of the diaphragm.

Diaphragm Acu-Points The acu-point BL 17 (Ge Shu) is the “Diaphragm Shu” point or “Diaphragm Transporting Point”. Ge Shu is a point where blood collects; it is sometimes called the “master of blood,” because the heart (above) produces the blood and the liver (below) stores it. Ge Shu is commonly used in many blood related diseases, and it moves blood and Qi. Traditionally, this point is forbidden to needle and is treated with direct or indirect moxa. It is often moxaed in conjunction with BL 19 (Dan Shu) – this combination is called the “Four Flowers.” Moxibustion of the Four Flowers supplements the blood by promoting its movement; moxibustion of the Four Flowers also relaxes the diaphragm. BL 46 (Ge Guan - “Diaphragm Gate”) is directly lateral to Ge Shu. It also opens the diaphragm. Ge Guan harmonizes the diaphragm, and is able to resolve Qi stagnation in the Upper Jiao (characterized by sighing and fullness and oppression of the chest and diaphragm), and descend stomach Qi in the Middle Jiao. If Stomach Qi does not descend, there may be vomiting, difficult ingestion, belching, or acid reflux.

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Zang Fu Tui Na: Basic Principles and Core Techniques

Liver, Pericardium and the Diaphragm The liver and pericardium are two important organs that affect the diaphragm. The liver has broad attachments to the diaphragm. If the liver is drawn upward tightly against the diaphragm, the liver will heat up as it comes closer to Heart Fire. Liver and Gallbladder Yang can, in turn, agitate heart heat. This is called Ti Xin Diao Dan: “Lift the heart and hang the gallbladder.” When this happens, the person feels jittery. If the liver is drawn upward towards the diaphragm, the large intestine and stomach may also be drawn upward through their ligamentous attachments and press on the liver and gallbladder, causing liver tension and heat.

The Phrenic Nerve The phrenic nerve arises from the cervical plexus and goes to the diaphragm. The phrenic nerve is often chronically irritated or over-innervated if the neck and/or the diaphragm are under excess tension. When the phrenic nerve is chronically over-stimulated or irritated, the diaphragm and neck become tight. There may be diaphragmatic restriction, sore ribs and chronic neck tension. In these cases, phrenic nerve over-stimulation must be addressed as part of the treatment. The phrenic nerve lies against the scalenus anterior muscle, and can be accessed between the heads of the sternocleidomastoid muscle (SCM) by needling LI 18 or ST 11.

Lymphatic Drainage Lymphatic drainage is aided by the movement of the diaphragm. Lymphatic flow is helped by diaphragmatic contractile activity. Lymphatic absorption depends to some degree on the rhythmicity and stretching of the diaphragm. Incorrect functioning of the diaphragm therefore negatively affects the lymphatic system. The cisterna chyli, the main destination point for the lymph, is located under the diaphragmatic crural region.

Diaphragm Signs & Symptoms • Shortness of breath • Neck tension • Difficulty breathing into the belly (“Kidney Breathing” or “Dan Tian Breathing”) • Upper back pain • Intercostal pain 50

Zang Fu Tui Na: Basic Principles and Core Techniques

• Hiccups • Narrow costal angle • Difficulty breathing into the belly (Kidney Breathing/ Dan Tian Breathing)

Methods of Regulating and Harmonizing the Diaphragm Two methods 0f releasing the diaphragms are shown below. When treating diaphragmatic tension and dysfunction, one may need to look for, harmonize, and release any or all of the following: 1. Restrictions in the movement of the liver can affect the diaphragm due to the liver’s broad connections with the diaphragm. 2. Restrictions in the movement of stomach and its Qi dynamic can affect the diaphragm. There are often symptoms of Qi not descending: indigestion, nausea, and vomiting. 3. Tensions in the ligaments that suspend the pericardium, and connect the pericardium to the diaphragm, can negatively impact diaphragmatic function. 4. The movement of the lungs and the suspensory ligaments of the lungs can directly affect the diaphragm. 5. Restrictions in the thoracic outlet, which may affect free-flow between the Upper and Middle Heater, can cause tension in the diaphragm. 6. Tension in the neck, and particularly between the two heads of the SCM (reflecting overstimulation of the phrenic nerve), can cause tension in the diaphragm. 7. Lumbar and lower thoracic spine tension and misalignment that affect the crus of the diaphragm which attaches to the spine at L-1 to L-3, can interfere with diaphragmatic functioning.

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Zang Fu Tui Na: Basic Principles and Core Techniques

1. Releasing the Central Tendon and the Inside of the “Bell” Place your palm root in the center of the patient’s solar plexus. Feel the Yin-Yang spiral under your hand that releases the center of the bell-like structure of the diaphragm. The release may be felt all the way to the back, or it may move along the ribs towards the back. Be careful not to push upward too much when performing this technique.

Regulating & Releasing the Diaphragm

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Zang Fu Tui Na: Basic Principles and Core Techniques

2. Release Diaphragm With Thumb or Fingers Use the thumbs or three fingers to spiral into and release tight tissues, working under the rib cage, making sure that your fingers are working between the organs and rib cage. Go all around the costal margin. Work slowly and gently, always moving in spirals. You can also push downward on the ribs with one hand to aid the ability of your thumb to get under the ribs and connect with the diaphragm (see picture on following page).

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Zang Fu Tui Na: Basic Principles and Core Techniques

Pushing Ribs Down and Releasing Diaphragm Restrictions with Thumb

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Zang Fu Tui Na: Basic Principles and Core Techniques

Complimentary Acupuncture Points for the Diaphragm SP 4 (Gong Sun: “Grandfather Grandson”) Use if there are signs of Stomach Qi not descending (vomiting, belching, hiccuping, acid regurgitation or vomiting). Treats Chong Mai symptoms of Qi and heat flushing upward. Treats “Running Piglet Qi” – a sensation of movement that goes upward from the lower abdomen to the throat, accompanied by a tight, or choking sensation in the throat, emotional unease, and palpitations. P 6 (Nei Guan “Inner Pass”) Unbinds chest and regulates Qi, and harmonizes stomach. Often used in cases of nausea, vomiting, hiccup. Use P 6 with SP 4 for vomiting, nausea belching, hiccuping, hiccup, and acid regurgitation. BL 17 (Ge Shu: “Diaphragm Transport Point”) & BL 19 (Dan Shu “Gallbladder Transport Point”) Moxibustion on these four points (the “Four Flowers”) aids movement of Qi and blood through the diaphragm and relaxes the diaphragm. BL 46 (Ge Guan “Diaphragm Gate”) This point harmonizes the diaphragm, resolves stagnation of Qi in the Upper Jiao, and aids descent of Stomach Qi in the Middle Jiao. LIV 14 (Qi Men: “Cyclical Gate”) Qi Men is the Mu Point of the liver. It spreads Liver Qi and regulates the liver. BL 18 (Gan Shu: Liver Transport Point) Gan Shu is the Liver Back Shu Point. It regulates and harmonizes the liver, and aids the diaphragm. GB 22 (Yuan Ye: “Armpit Abyss”) GB 22 opens and unbinds the Qi of the chest, and relaxes the interior chest wall. This point is said to open the Bao Mai (“Wrapper Vessel”) in the chest. SP 21 (Da Bao: “Great Wrapper”) Da Bao opens the Qi of the chest and ribs, and relaxes the exterior chest wall. This point also opens the Great Luo Vessel of Spleen, which spreads Qi in the chest and ribs. 55

Zang Fu Tui Na: Basic Principles and Core Techniques LIV 1 (Da Dun: “Great Mound”) with Ren 18 (Yu Tang: “Jade Hall”) This three-point combination (LIV 1 bilaterally) is the “Root and Node” of Jue Yin. Together these three points regulate the liver and pericardium, both of which have broad attachments to the diaphragm. ST 11 (Qi She: “Qi’s Abode”) and/or LI 18 (Fu Tu: “Supporting Prominence”) Both points access the Phrenic Nerve – for rebellious Qi (cough, wheezing; throat pain). Ah Shi Points along border of costal cartilage to release local areas of restriction.

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Chapter 6 Regulating & Harmonizing the Pericardium The pericardium is essentially an envelope around the heart that protects and anchors the heart in the chest. In general, when we are working with the heart, we are doing so in conjunction with the pericardium. The internal branch of the pericardium channel passes through the diaphragm to connect with the liver, and then spirals downward to connect the Upper Jiao with the Middle Jiao and Lower Jiao. The internal connection of the pericardium with the liver (Jue Yin), and the direct attachment of both of these organs to the diaphragm, one from above and one from below, means that diaphragmatic tension and dysfunction can affect these two organs and vice-versa. Ligamentous attachments suspend the pericardial sac from the cervical vertebra and anchor the pericardium to the diaphragm. Therefore, it comes as no surprise that neck injuries can affect the heart, pericardium and diaphragm, and that heart, pericardium, and diaphragm issues can affect the neck.

Anatomical Considerations The pericardium is essentially a sac that surrounds and protects the heart. It is composed of serous membranes and a fibrous pouch. The pericardial sac has two layers of tissue – a visceral layer and a parietal layer. The parietal layer of the pericardium forms the fibrous pouch that covers the heart. The pouch is actually a doubling of the parietal layer. The pericardial cavity is the space between the visceral layer and parietal layer. The linings of this cavity are moistened by serous fluid, so that the linings can slide smoothly across each other. Attachments of the Pericardium 1. The Superior Sterno-Pericardial Ligament attaches the pericardial sac to the upper potion of the sternum (manubrium). 2. The Inferior Sterno-Pericardial Ligament attaches the pericardial sac to the lower portion of the sternum (xiphoid process). 57

Zang Fu Tui Na: Basic Principles and Core Techniques 3. The Vertebro-Pericardial Ligament effectively suspends the pericardial sac from the last four cervical vertebrae (C4-C7), and from the first four thoracic vertebrae (T1-T4). 4. The Phreno-Pericardial Ligament anchors the pericardial sac to the diaphragm. 5. The Falciform Ligament, which connects to the diaphragm and divides the liver into its two lobes, is anatomically very close to the diaphragmatic surface of the pericardium. Note: These attachments explain why in neck injuries like whiplash, there is often upper thoracic and lower cervical pain, and diaphragmatic involvement that may affect the phrenic nerve.

Pericardium: Important Energetic and Tissue Relationships In Chinese medicine, the pericardium is known by two different names, each indicating a different aspect of its functioning. The first is Xin Bao Luo, or Xing Bao, which means "Heart Envelope" or “Heart Wrapper,” referring to the network of channels and vessels that envelop the heart. These channels serve as a protective wrapping, or a shield, that protects the heart from invasion by pathogens. Hence, the pericardium is sometimes called the “Heart Protector.” The pericardium is also sometimes referred to as the “Heart Governor” or the “Heart Constrictor.” These names refer to the role of the pericardium as an assistant that carries out the active work of the heart, stressing its active energetic aspect. The heart is often compared to the Emperor who issues orders but does not leave the capital, while the pericardium is the loyal minister who not only protects the Emperor, but also carries out the Emperor’s mandates. Thus the pericardium is considered to be one aspect of the “Ministerial Fire,” associated with both Heart Fire and Ming Men Fire. Ming Men communicates with the heart via the pericardium, and its paired Fu organ, the San Jiao. Hence, Ming Men and the pericardium together are called “Ministerial Fire” in relation to the “Imperial Fire” of the heart. This relationship of the pericardium (and the San Jiao) to Ming Men and the kidneys is the reason why in some pulse diagnosis methods, the pericardium and San Jiao pulses are taken at the lower position (chi position) of the right wrist. This position is also associated with the right kidney.

Heart, Small Intestine, San Jiao and Pericardium The heart and small intestine are both related to Fire This relationship also explains connection of small intestine and Ming Men, which are both “Fire” in the lower body and related to Kidney Yang. The small intestine is oriented toward the right side, where it has fine connections with the right kidney. Kidney Yang and Ming Men are associated with the right kidney. The 36th Difficult Question of the Nan Jing says that: The two kidneys are not both kidneys. The one on the left is the kidney; the one on the right is the 58

Zang Fu Tui Na: Basic Principles and Core Techniques Ming Men (Gate of Life). The Ming Men is the place where the spirit-essence lodges; it is the place to which the original influences are tied. Ming Men is associated with the right kidney, but at the same time Ming Men is considered to be the “moving Qi between the kidneys.” Ming Men ascends to connect with the pericardium. This is part of the connection of Imperial and Ministerial Fire. The San Jiao relates to the functioning of Ministerial Fire. The San Jiao divides and spreads the Yuan Qi of Ming Men. The San Jiao connects with the pericardium, and therefore is the intermediary between the Ministerial Fire of the pericardium and the Imperial Fire of the heart. One interesting physical structure that provides an indirect connection between the duodenum of the small intestine and the heart and pericardium, is the Ligament of Treitz. The Ligament of Treitz is the suspensory muscle of the duodenum. It is a thin muscle that connects the duodenojejunal flexure to the diaphragm at the celiac trunk (celiac artery), and to the left crus of the diaphragm near the esophageal opening. The Ligament of Treitz is actually a group of three small muscles, one from the diaphragm and two from the small intestine. When it contracts, it widens the angle of the duodenojejunal flexure, allowing movement of the intestinal contents.

Pericardium Signs and Symptoms • Neck pain and sequelae of whiplash (pericardium attaches to neck) • Chest pain • Upper back pain • Stuffy feeling in chest • Upper rib articulation restrictions • Reduction of movement in the lungs • Esophageal problems • Pain around the sternum (pericardium attaches to sternum and xiphoid) • Diaphragmatic problems (pericardium attaches to diaphragm)

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Zang Fu Tui Na: Basic Principles and Core Techniques

Methods of Regulating and Harmonizing the Pericardium 1. Yin Yang Hand on Sternum Stand at the right side of the patient and overlap your hands so that palm root of the bottom (left) hand is just below the sternal notch (the Ren 22 acu-point). The palm root of the top (right) hand is over the xiphoid process. The hands make a Yin-Yang shape. Gently squeeze the palms toward each other with the intention of gently flexing the sternum and manubrium. This effectively slackens, releases and balances the ligaments that attach the pericardial sac to the sternum and manubrium: • •

Superior Sterno-Pericardial Ligament - attaching above, behind the manubrium The Inferior Sterno-Pericardial Ligament - attaching below, behind the xiphoid process

Gently squeeze until you feel a relaxation and slackening in these ligamentous structures. Then the lower and upper portions of the sternum and manubrium will begin to push and “stretch” outward. Follow this motion until the sternum and manubrium relax.

Releasing the Pericardium with Yin Yang Hand on Sternum

Important: Note that the inward flexing and outward stretching movements will not necessary happen along a linear trajectory. There may be a sensation of twisting, coiling, and side-bending as the tissues slacken, followed by an uncoiling, untwisting, and slipping side-to-side movement as the tissues open and stretch outward. These movements may feel a bit like a three-dimensional Yin Yang Diagram exhibiting its innate turning, twisting, hub-like action.

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2. Traction and Lift Head with Hand on Sternum The second, more global technique can release all pericardial attachments, especially those that attach to the neck (Vertebro-Pericardial Ligaments connecting to C4-C7 to T1-T4), and those that attach to the diaphragm (Phreno-Pericardial Ligaments). Sit or stand at the head of the patient. Your left hand is under the patient’s upper back, contacting T1 to T-4, and the patient’s head rests on your left forearm. Your right hand is on their sternum. Gently draw your left hand upward in an arc, so that the neck is lengthened along that arc, as your left hand creates a subtle oppositional movement downward toward the patient’s lower body. These actions will send a tensile force into the Vertebral-Pericardial and Phreno-Pericardial Ligaments, as well as the sternal attachments of the pericardial sac (mentioned on the previous page). The tissues will begin to unwind, twisting and coiling in and out at specific angles that connect to the diaphragm, and the cervical and thoracic vertebrae.

Traction and Lift the Head to Regulate and release the Pericardium

Foll0w the tissues into areas of restriction, so that the tissues slacken. Wait for a release, and then follow the tissue outward until they release again. These cycles of tension, slacken, and release can and will happen several or even many times at multiple angles and trajectories. Make sure you are connecting to pericardial attachments to the diaphragm and vertebrae, as well as the attachments to the xiphoid and manubrium. The head will change positions as you connect with different aspects of the fascial network attached to the pericardium. The hand positions described and illustrated are not fixed, and may be adjusted as you work. If necessary, lever your bottom (left) arm off of the treatment table in order to hold the head with less strain.

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3. Holding P 1 (Tian Chi) and Ren 17 (Dan Zhong) Hold the two acu-points Ren 17 and P 1. Holding these points helps open up the pericardium and allows Qi to flow out into the pericardium channel in the arm. Simply hold these two points and connect them together, waiting to feel a sense of softening and relaxation in the chest and a sense of Qi flowing into the pericardium channel in the arm. Ideally hold the points until the pericardium channel is open and clear. Ren 17 (Dan Zhong) is the Pericardium Mu Point, and the meeting point of the Ren Mai, spleen, kidney, small intestine and San Jiao channels. Ren 17 regulates chest Qi and unbinds the chest. Tian Chi (P 1) is where Qi from the chest enters the pericardium channel. The pericardium, gallbladder, liver and San Jiao Channels all meet at Tian Chi. Tian Chi opens and unbinds the chest, relaxes the diaphragm and attachments of the pericardium to the diaphragm.

4. Holding and Releasing the Pericardium Place one hand palm down on the sternum directly over the heart and pericardium. The other hand slides under the patient in a palm up position, so that it is directly behind the heart and pericardium. Let the top hand gently sink into the tissue, imagining that you are slipping through the sternum and ribs to gently hold the pericardium and heart. It should feel as though you are holding the pericardial sac between your hands. Gently let the tissues around the pericardium relax. Follow tissue restrictions, gently compressing into the restriction to create slack and then, as the tissue opens, following the opening movement. As you do this, sense the connection between your two hands. Try and sense all of the connections of the pericardial sac to the surrounding tissues – the vertebral connections in the neck and upper thorax, the sternal attachments and the diaphragmatic attachments. Pay attention to lines of tension and “pull.” See if you can release and relax these various vectors of tension, so that when you are finished the pericardium and heart are still and calm, and “floating” in the chest. Note: Remember, that the heart does not like to be compressed, so your top hand must be gentle. The heart needs empty space inside to properly house the Shen (Spirit). In Nei Gong and Nei Dan practices, the Li-Fire Trigram is used to represent the chest and the heart. Li-Fire has a broken (empty, Yin) line in the middle. This represents the open space that the heart must have in order for to feel relaxed and calm. One image for this is the expression Han Xiong Ba Bei (含胸拔背), which describes the chest as “containing” like “holding something in the mouth.”

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Zang Fu Tui Na: Basic Principles and Core Techniques

Complementary Acupuncture Points for Heart & Pericardium Ren 14 (Ju Que: “Great Gate Tower”) Jue Que is the Heart Mu Point, sometimes called the “Heart Mouth.” This point regulates the heart, unbinds the chest, and can help heart heat descend. BL 14 (Jue Yin Shu “Pericardium Transport Point”) Jue Yin Shu is the Pericardium Back Shu point. It regulates heart and pericardium, descends Qi, and relieves heart and chest pain and oppression. Ren 17 (Shan Zhong “Chest Center”) Ren 17 is the pericardium Mu point, and the meeting point of the Ren Mai, spleen, kidney, small intestine, and San Jiao channels. It regulates Qi, unbinds the chest, benefits Gathering Qi. CV 22 (Tian Tu: “Heavenly Prominence”) Tian Tu helps rebellious Qi of the lungs and stomach to descend. It also benefits the throat and voice. P 1 (Tian Chi “Heavenly Pool”) Tian Chi opens and unbinds the chest. It is where Qi from the chest enters the pericardium channel, and is the meeting point of the pericardium, gallbladder, liver and San Jiao channels. P 6 (Nei Guan “Inner Pass”) P 6 unbinds the chest and regulates Qi. This point also harmonizes the stomach and is used for nausea, vomiting, hiccup, and acid regurgitation. It is often combined with SP 4. P 7 (Da Ling “Great Mound”) Da Ling clears heat from the heart, calms the spirit, and unbinds the chest. HT 7 (Shen Men “Calm Spirit”) Shen Men regulates the heart and calms the spirit. HT 6 (Yin Xi: “Yin Cleft”) Yin Xi clears heat from the heart, calms the spirit and moderates acute conditions.

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Zang Fu Tui Na: Basic Principles and Core Techniques BL 43 (Gao Huang Shu: “Vital Region Transport Point”) Gao Huang Shu unbinds the chest and clears restrictions and pathogens from the area between diaphragm and heart/pericardium. Gao Huang Shu also calms the spirit. BL 15 (Xin Shu: “Heart Transport Point”)) Xin Shu is the Heart Back Shu Point. It regulates Heart Qi, calms the spirit, clears Heart Fire, and unbinds the chest. GB 22 (Yuan Ye: “Armpit Abyss”) Yuan Ye opens and unbinds the Qi of the chest and relaxes the interior chest wall. GB 22 opens the Bao Mai (“Wrapper Vessel”) in the chest. SP 21 (Da Bao: “Great Wrapper”) Da Bao opens the Qi of the chest and ribs and relaxes the exterior chest wall. It also opens the Great Luo Vessel of the spleen, which spreads Qi in the chest and ribs. LIV 1 (Da Dun: “Great Mound”) with Ren 18 (Yu Tang: “Jade Hall”) This three-point combination (LIV 1 bilaterally) is the “Root and Node” of Jue Yin. Together these three points regulate the liver and pericardium, both of which have broad attachments to the diaphragm. Ah Shi Points Ah Shi points can be used to treat localized restrictions, such as hard or tense areas on the back at the attachments of the ribs to the transverse process of the vertebrae from T-3 to T-7, or hard or tense areas around the attachments of the ribs to the sternum.

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Chapter 7 Regulating & Harmonizing the Thoracic Outlet and Plural Dome The Thoracic Outlet is an important passageway for blood vessels and nerves that pass between the head/neck and the torso. The suspensory ligaments of the lung, which connect the upper ribs and cervical vertebrae to the plural dome, pass through this relatively narrow passage. In Nei Gong and the internal martial arts, the Thoracic Outlet is included in the concept of the “Shoulder Well,” a larger area extending from the side of the neck, down under the scapula, between the scapula and the chest wall. The Shoulder Well must be relaxed and open in order for Qi to move freely between the head and torso, and in order for Qi to circulate freely into the arms and hands. Compression or restrictions of the Thoracic Outlet, or parts of the Shoulder Well, can affect cerebral circulation, nerve innervation and blood flow to the arms, diaphragmatic functioning, the smooth flow of Qi from the Upper to the Middle Jiao, and the ability of the lungs to disseminate Qi downward.

Anatomical Considerations The Thoracic Outlet is generally the area of your upper torso between your armpit and your throat, but more specifically it is the space between your clavicle and the first rib. The Thoracic Outlet serves as a passageway for the subclavian artery and vein, the brachial plexus and some smaller nerves. Compression or tension in this area can put pressure on the brachial plexus and/or the subclavian artery and vein. The top or apex of each lung extends into the lowest part of the neck, just above the level of the first rib. This part of the lung is called the Pleural Dome. The lungs “hang” from their suspensory ligaments, which attach to the pleural dome of each lung. This suspensory system is made up of muscular fibers of the scalenus minimus, sometimes mixed with fibers of the anterior and medial scalene muscles. Various ligaments also connect to the Pleural Dome, including: 1. The Vertebral Pleural Ligament goes from the lower cervical vertebra and first thoracic vertebrae (C6, C7 and T1) to the Pleural Dome. 65

Zang Fu Tui Na: Basic Principles and Core Techniques 2. The Transverse Pleural Ligament is composed of fibers from the transverse processes of C6 and C7 that connect directly to the Pleural Dome. 3. Fibers from the first rib - the Costopleural Ligament – also attach to the Pleural Dome. These structures do not directly insert into the pleura, but into the intrathoracic fascia, forming a connective tissue dome at the top of the lungs. This creates a partition, or canopy. The perception of the lung as a canopy is illustrated in in anatomical pictures from ancient Chinese medicine books, like the one below. Although anatomically the lung does not really look like this, the image below can be useful when working with the pleural dome.

Plural Dome & Thoracic Outlet: Important Energetic and Tissue Relationships The Shoulder Well The “Shoulder Well” is the area extending from the side of the neck, down under the scapula, between the scapula and the chest wall. The gallbladder channel passes through this area, from GB 21 to GB 22. The Shoulder Well also includes the pectoral muscles in the front anterior corner of the shoulder, and the teres muscles in the rear posterior corner of the shoulder. In Nei Gong practices, the Shoulder Well must be relaxed in order for Qi to circulate freely into the arms. The concept of the Shoulder Well includes the structures of the thoracic outlet, the suspensory ligaments of the pleural dome, the brachial plexus and brachial arteries, and the Qi, blood, and fluids flowing through these structures and areas.

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Zang Fu Tui Na: Basic Principles and Core Techniques Downward movement of Qi from the head to the trunk must pass through the neck, Thoracic Outlet, and Shoulder Well. This movement can be described as follows: In the Tai Yang zone, Qi emerges at BL 10 to pass downward into the upper back. In the Shao Yang zone, Qi passes through GB 21, goes downward between the scapula and the chest wall to reach GB 22, where Qi enters the interior of the chest. In the Yang Ming zone, Qi passes into trunk in the front of the neck, at ST 11 and ST 12.

• • •

Upward movement of Qi from the trunk to the head also passes through the neck and Shoulder Well as follows: • • •

In the Tai Yang zone, Qi ascends from Trunk to emerge at SI 14, and then passes into GV 14. In the Shao Yang zone, Qi passes through SJ 14 and SJ 15, and then up into the neck at SJ 16. In the Yang Ming zone, Qi passes through LI 18, and continues upward to the ST 2/LI 18 area of the face.

The Gallbladder Channel The gallbladder channel passes through the Shoulder Well and controls the sides of the neck. The San Jiao channel also passes through the side of the neck and arm, therefore, the San Jiao and gallbladder channels are important structures relating to smooth movement of Qi and blood through the areas of the neck and upper thorax.

The “Lungs are Like a Florid Canopy That Covers the Other Organs” This statement refers to the lungs as both the physical covering of the other organs and the close connection of the lungs to the outside world through the action of respiration. The other Zang organs are relatively more internal, and do not have a direct connection to the outside world. The image of the lungs as a canopy refers to the lungs’ ability to recoil elastically in response to the movements of the diaphragm. During inhalation, as the diaphragm drops, the chest wall expands out and away from the lungs. When air fills the lungs, elastic recoil within the tissues of the lungs exerts pressure toward the interior of the lungs. Upon exhalation, the lungs recoil again to force the air out of the lungs. The “canopy” of the lungs must be flexible and elastic in order to perform these actions optimally. The acupuncture point Hua Gai (Ren 20), “Florid Canopy”, is located at the upper extreme of the lung, on the midline of the sternum, level with the junction of the first intercostal space and the sternum. This point is used to treat dyspnea, wheezing, asthma, cough, rebellious Qi, difficulty breathing with inability to speak, and pain and fullness of the chest and lateral costal region.

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Thoracic Outlet & Shoulder Well Signs & Symptoms 1. Nerve Compression Symptoms:

• Cervico-brachial neuralgia • Paresthesias of the arms: tingling, burning, pricking, or numbness • Weakness of the hands • Cold hands 2. Venous and Arterial Compression Symptoms:

• Swelling of fingers and hands • Heaviness of the upper extremity • Tiredness, heaviness and paresthesias on elevation of arms 3. Shoulder and neck pain and tightness 4. Chest wall pain and tightness 5. Scapular pain

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Shoulder and Neck Pain Manifestations 1. Tai Yang Obstruction • • • •

Pain and stiffness in the nape and upper back Radiating pain or numbness going down into the upper back and back of the shoulder Pain may radiate up into the occiput The Tai Yang Zone (BL and SI channels) is affected

2. Shao Yang Obstruction Contracture of sides of neck with tight scalene and trapezius muscles Torticollis type symptoms (difficulty turning the head on one side) Pain may go up into the face around the ears and eyes The Shao Yang Zone (SJ and GB channels) is affected

• • • •

3. Yang Ming Obstruction • • • •

Throat tension or facial tension A pulling down sensation in the front of the neck Difficulty swallowing The Yang Ming Zone (LI and ST channels) is affected

Pleural Dome Signs & Symptoms 1. Shortness of breath or labored breathing 2. Neck and shoulder tension 3. Chest tension 4. Jaw tension 5. Lung Qi does not descend

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Methods of Regulating & Harmonizing the Thoracic Outlet, Shoulder Well and Plural Dome The following techniques overlap a bit, therefore one does not necessarily need to perform all six techniques in order to open and release the Thoracic Outlet and Shoulder Well, and free restrictions in the suspensory ligaments and muscles of the Pleural Dome. However, if you wish to be thorough, you can perform all six techniques.

1. Releasing the Suspensory Structures of the Plural Dome: Pressing Jing Bi Jing Bi is a very useful “extra point” that releases many of the structures that suspend the pleural dome, including fibers of scalenus anterior and scalenus minimus (scalenus minimus is only present in about 40% of the population). Jing Bi is located at the base of the neck, in the fossa between the sternocleidomastoid muscle and the trapezius muscle. Gently and slowly press into the two Jing Bi points with your thumbs. Your fingers may hang down over the clavicle, where they can sense the top of the lung and tissues of the upper chest. The pressure should be directed toward the center of the body, as though vectors emanating from the thumbs would cross in the upper chest. As you press, the patient may feel a warm, tingling sensation down one or both arms, or a sense of Qi rising upward to the head. Modulate the pressure so that Qi does not rise too forcefully.

Jing Bi (Extra)

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Zang Fu Tui Na: Basic Principles and Core Techniques Hold the two Jing Bi points until you feel the tissues on the sides of the neck relax, and until there is a sensation of relaxation and tissue softening that passes through the pleural dome and into the chest. If one side is very tight, or if these points are sensitive, you can release one side at a time by pressing a single Jing Bi point with one thumb, while your free hand gently manipulates the head in order to create subtle changes in the angles of pressure and release.

Pressing Jing Bi (Extra) with Both Thumbs

2. Releasing the Suspensory Structures of the Plural Dome: Medial and Posterior Scalene Muscles Pressing and holding Jing Bi will sometimes release all of the scalene muscles, but often it only releases scalenus anterior and scalenus minimus. To release scalenus medius, move your thumbs very slightly posterior and lateral from Jing Bi until you feel tight, hard fibers under the tip of your thumb. This is the medial scalene. Press gently, and hold until the tissues release. Repeat the same procedure for scalenus posterior. From the position where you released the medial scalene, move your thumbs very slightly posterior and lateral until you again feel tight, hard fibers under the tip of your thumb. This is the posterior scalene. Press gently, and hold until the tissues release.

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3. Releasing the Suspensory Structures of the Plural Dome & Thoracic Outlet: Clavicle Gently place your thumbs just below the medial end of the clavicle, as shown in the photo below. Your thumbs should be just below and roughly parallel with the clavicle, and the thumb tips should be touching the articulation of the clavicle with the sternum. Let your thumbs sink through the flesh to connect with the bones. The thumbs sink and hold until it feels like the two clavicles “float.” Once the clavicle is “floating,” gently begin to pull your thumbs apart. The thumbs will not visibly move, but it should feel as though the clavicles separate a tiny bit from the sternum and move outward. The clavicles may feel like they twist or rotate, but eventually the sternal ends of the clavicles will feel as though they “seat” themselves, and the tissues will relax. Because fibers from the first rib (the costopleural ligament) attach to the pleural dome, and because the first rib is attached to the clavicle (by the costoclavicular ligament), it is usually necessary to release the tissues around the clavicle in order completely open and regulate the structures that suspend the pleural dome. Additionally, the Thoracic Outlet is in the space bounded by the clavicle and the first rib. Therefore releasing restrictions in the tissues around the clavicle helps free-flow of blood, Qi and fluids through the Thoracic Outlet (and the Shoulder Well).

Releasing the Clavicle 72

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4. Opening & Releasing the Thoracic Outlet and Medial Shoulder Well Place your left hand on the chest and sternal end of the clavicle, so that the “Tiger’s Mouth” of your hand (the space between the thumb and forefinger) creates a half-circle around the thoracic inlet. Meanwhile, your right hand gently contacts the jaw and neck at the axis of rotation for the neck. The left hand creates a faint downward traction that is roughly in the direction of the left hip, while the right hand creates a gentle opposing traction that is upward (cephalad), and without any downward pressure. Hold this “stretch”, allowing the tissue, to twist, “unwind”, and release. There may be multiple releases at multiple angles. Sense the releases of tissues of the neck, first rib, collarbone, and chest, and sense relaxation and movement through the Thoracic Outlet. This technique should be repeated on the right side in order to balance movement and free-flow through the two Thoracic Outlets.

Opening & Releasing the Thoracic Outlet and Medial Shoulder Well

5. Opening and Releasing the Thoracic Outlet, Clavicle and Lateral Shoulder Well Place the palm of your right hand on the distal end of the collarbone (acromio-clavicular joint), so that the Tiger’s Mouth spans sections of the lateral chest, lateral clavicle, acromio-clavicular joint, and a portion of the trapezius muscle. Meanwhile, your left hand gently contacts the jaw and neck at the axis of rotation for the neck. The right hand creates a faint downward traction that follows the acromio-clavicular joint to the point of the shoulder, while the left hand creates a gentle opposing traction that is upward (cephalad), and without any downward pressure. 73

Zang Fu Tui Na: Basic Principles and Core Techniques

Opening and Releasing the Thoracic Outlet, Clavicle and Lateral Shoulder Well

The angles of “stretch” should engage sections of the thoracic inlet, the clavicle and a large portion of the Shoulder Well. There may be multiple releases at multiple angles. Sense the releases of tissues of the neck, first rib, collarbone, acromioclavicular joint, trapezius muscle and chest, and sense relaxation and movement through the entire Shoulder Well, including the section of the gallbladder channel that runs under the scapula and connects to the chest. This technique should be repeated on the left side in order to balance movement and free-flow through the two Shoulder Wells.

6. Opening and Releasing the Chest and Upper Thoracic Cavity Place the palm of your right hand below the collarbone on the chest so that the palm is over the chest muscles. Meanwhile, your right hand gently contacts the jaw and neck at the axis of rotation for the neck. The right hand creates a faint downward traction that goes toward the right hip, while the left hand creates a gentle opposing traction that is upward (cephalad), and without any downward pressure. The angles of “stretch” should engage sections of the neck and thoracic cavity as well as portions of the Thoracic Outlet and Shoulder Well. There may be multiple releases at multiple angles. This technique should be repeated on the left side in order to balance movement and free-flow 74

Zang Fu Tui Na: Basic Principles and Core Techniques through both sides of the chest and thorax.

Opening and Releasing the Chest and Upper Thoracic Cavity



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Complimentary Acupuncture Points: Pleural Dome, Thoracic Inlet, and Shoulder Well Jing Bi (Extra Point: “Neck-Upper Arm”) Jing Bi opens the Thoracic Outlet and releases the scalene muscles. It also releases suspensory ligaments of the pleural dome. Bai Lao (Extra Point: “Hundred Taxations”) Bai Lao helps Qi to descend along the back and sides of the neck. It is indicated for cough, asthma, and neck rigidity. Ren 20 (Hua Gai: “Florid Canopy”) Hua Gai releases the upper part of the lung and helps Lung Qi descend. It is indicated for dyspnea, wheezing, asthma, cough, counter-flow Qi, difficulty breathing with inability to speak, and pain and fullness of the chest and lateral costal region. ST 11 (Qi She: “Qi’s Abode”) and/or LI 18 (Fu Tu: “Supporting Prominence”) Both of these points access the Phrenic Nerve and treat counter-flow Qi (cough, wheezing; throat pain, and throat tightness). These points release the front of neck. Ren 23 (Lian Qian “Corner Spring”) Ren 23 releases front of neck and treat counter-flow Qi. Ren 22 (Tian Tu: “Heavenly Prominence”) Tian Tu helps Lung Qi descend and aids the descent of counter-flow Qi (cough and wheezing). It also benefits the throat and voice. ST 12 (Que Pen: “Empty Basin”) and ST 13 (Qi Hu: “Qi’s Door”) Both of these points can be used to release the subclavius muscle and Thoracic Outlet. These points also help Stomach Qi and Lung Qi descend (cough, hiccup, asthma, etc.).

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Zang Fu Tui Na: Basic Principles and Core Techniques Points that Aid Downward Movement of Qi from Head to Trunk - by Zone Tai Yang (Nape Zone) BL 10 (Tian Zhu “Celestial Pillar”) Ding Chuan (Extra Point: “Calm Dyspnea”) SI 14 (Jian Wai Shu: “Outer Shoulder Transport Point”) – levator scapula attachment Du 14 (Da Zhui “Big Hammer”) Shao Yang (Sides of Neck): open “Shoulder Well” and Thoracic Outlet GB 20 (Feng Chi “Wind Pool”) GB 21 (Jian Jing “Shoulder Well”) GB 22 (Yuan Ye: “Armpit Abyss”) Jing Bi (Extra Point: “Neck-Upper Arm”) Yang Ming (Front of Neck) ST 11 (Qi She: “Qi’s Abode”) ST 12 (Que Pen: “Empty Basin”) LI 18 (Fu Tu: “Supporting Prominence”)

Note: Add acu-points that release the lung, diaphragm, liver, pericardium and chest as needed.

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ABOUT THE AUTHOR Tom Bisio is known internationally as a martial artist, practitioner of Chinese medicine, educator and author. He has studied Chinese medicine and martial arts extensively in Mainland China and practiced acupuncture, Tui Na and herbal medicine since 1990. Tom has written numerous books and articles on Martial Arts, Nei Gong, Daoist Meditation and Chinese medicine. He is the founder of New York Internal Arts and Internal Arts International (NYIA/IAI) (internalartsinternational.com).



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