TCM Case Studies: Pain Management 9787117193368

Table of contents :
Cover
Editors
Copyright(in Chines)
Copyright(in English)
Authors
Contributors
Translation Committee
English Editors
About the Authors
Editorial Board for the TCM Case Studies in the International Standard Library of Chinese Medicine
Preface
Table of Contents
Introduction
* How does pain happen?
* Notes about editorial decisions
SECTION I　Systemic Pain
1. Bi Syndrome
2. Fibromyalgia
3. Gout
4. Rheumatoid Arthritis
5. Ganglion Cysts
6. Osteoarthritis (Bone Bi)
SECTION II　Pain of the Head and Face
7. Eye Pain
8. Toothache
9. Sore Throat
10. Headache
11. Facial Pain (Trigeminal Neuralgia)
SECTION III　Pain of the Neck, Shoulders,and Upper Limb
12. Thoracic Outlet Syndrome(Neck and Shoulder Pain)
13. Cervical Spondylosis (Neck Bi)
14. Stiff Neck (Torticollis)
15. Shoulder Pain
16. Brachial Plexus Neuralgia(Arm Pain)
17. Lateral Epicondylitis(Elbow Pain)
SECTION IV　Pain of the Chest and Abdomen
18. Chest Bi and Heart Pain
19. Angina Pectoris
20. Stomachache
21. Abdominal Pain
22. Flank Pain
23. Dysmenorrhea
24. Renal Colic (Kidney Stones)
25. Gallbladder Pain
26. Lower Back Pain
SECTION V　Pain of the Lower Limb
27. Piriformis Syndrome
28. Sciatica
29. Ankle Sprain
30. Heel Pain
Appendix I:Pinyin-English Formula Cross Reference
Appendix II:　List of Cited Sources

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Copyright(in Chines) 图书在版编⽬（CIP）数据 疼痛治疗学= Pain management：英⽂ /胡幼平，（美）斯通 （Stone，A.），吴俊梅主编. —北京：⼈民卫⽣出版社，2014 （英⽂版中医病案教育系列） ISBN 978-7-117-19336-8 Ⅰ. ①疼… ①R441.1

Ⅱ. ①胡…②斯…③吴… Ⅲ. ①疼痛-诊疗-英⽂ Ⅳ.

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Website: http://www.pmph.com/en Book Title: TCM Case Studies: Pain Management 中医病案教育系列：疼痛治疗学 Copyright © 2014 by People’s Medical Publishing House. All rights reserved. No part of this publication may be reproduced, stored in a database or retrieval system, or transmitted in any form or by any electronic, mechanical, photocopy, or other recording means, without the prior written permission of the publisher. Contact address: No. 19, Pan Jia Yuan Nan Li, Chaoyang District, Beiing 100021, P.R. China, phone/fax: 8610 5978 7584, E-mail: [email protected] For text and trade sales, as well as review copy enquiries, please contact PMPH at [email protected] Disclaimer This book is for educational and reference purposes only. In view of the possibility of human error or changes in medical science, the author, editor, publisher and any other party involved in the publication of this work do not guarantee that the information contained herein is in any

respect accurate or complete. The medicinal therapies and treatment techniques presented in this book are provided for the purpose of reference only. If readers wish to attempt any of the techniques or utilize any of the medicinal therapies contained in this book, the publisher assumes no responsibility for any such actions. It is the responsibility of the readers to understand and adhere to local laws and regulations concerning the practice of these techniques and methods. The authors, editors and publishers disclaim all responsibility for any liability, loss, injury, or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this book. First published: 2014 ISBN: 978-7-117-19336-8/R·19337 Cataloguing in Publication Data: A catalogue record for this book is available from the CIP-Database China. Printed in The People’s Republic of China

TCM Case Studies:Pain Management Hu You-ping, Ph.D. TCM Professor, Chief Physician and Ph.D. Supervisor of Acupuncture and Moxibustion, Chengdu University of TCM, Chengdu, China Al Stone, L.Ac., DAOM, Founder of the Web-sites Acupuncture.com, Gancao.net and Eagleherbs.com, Instructor and Clinic Supervisor at Emperor’s College of Traditional Oriental Medicine, Santa Monica, CA, USA Wu Jun-mei, Ph.D. TCM Professor, Chief Physician and Master’s Level Supervisor of Acupuncture and Moxibustion, Director of Teaching ＆ Research Department of Acupuncture Fundamentals, Chengdu University of TCM, Chengdu, China Associate Editors Chen Hong-pei, Ph.D. TCM Associate Professor of Acupuncture and Moxibustion, Director of Teaching and Research Department of Clinical Acupuncture, Chengdu University of TCM, Chengdu, China Wu Ping, Ph.D. TCM Professor of Acupuncture and Moxibustion, Faculty of Teaching and Research Department of Basic Acupuncture, Chengdu University of TCM, Chengdu, China Wu Xi, Ph.D. TCM

Associate Professor of Acupuncture and Moxibustion, Faculty of Teaching and Research Department of Clinical Acupuncture, Chengdu University of TCM, Chengdu, China Associate Translator-in-Chief Ma Tao, MD., Ph.D. (China), L.Ac., Dipl. O.M. (NCCAOM) Assistant Professor ＆ Clinical Instructor, American College of Acupuncture and Oriental Medicine, Houston, Texas; Fellow of American Board of Oriental Reproductive Medicine, weMED Clinic, Houston, Texas, USA

Contributors Hu You-ping, Ph.D. TCM Professor, Chief Physician and Ph.D. Supervisor of Acupuncture and Moxibustion, Chengdu University of TCM, Chengdu, China Chen Hong-pei, Ph.D. TCM Associate Professor of Acupuncture and Moxibustion, Director of Teaching and Research Department of Clinical Acupuncture and Moxibustion, Chengdu University of TCM, Chengdu, China Wu Ping, Ph.D. TCM Professor of Acupuncture and Moxibustion, Faculty of Teaching and Research Department of Basic Acupuncture and Moxibustion, Chengdu University of TCM, Chengdu, China Wu Xi, Ph.D. TCM Associate Professor of Acupuncture and Moxibustion, Faculty of Teaching and Research Department of Clinical Acupuncture and Moxibustion, Chengdu University of TCM, Chengdu, China Wang Wei, M.S. TCM Atending Physician of Orthopedics and Traumatology and Rehabilitation Department, TCM Hospital Afliated to Luzhou Medical

College, Luzhou, China Liu Ying, M.S. TCM Atending Physician of the TCM Rehabilitation Department, Chengfei Hospital, Chengdu, China Zhang Xue, M.S. TCM Attending Physician of the Acupuncture, Moxibustion and Tuina Department, Changzheng Hospital, Langfang, China Hu Ji-ke, M.S. TCM Attending Physician, Teaching Hospital of Chengdu University of TCM, Chengdu, China Tan Hui, M.S. TCM Atending Physician of the Rehabilitation Department, Yueyang Second People’s Hospital, Yueyang, China

Translation Committee Translator-in-Chief Wu Jun-mei, Ph.D. TCM Professor, Chief Physician and Master’s Level Supervisor of Acupuncture and Moxibustion, Director of Teaching ＆ Research Department of Acupuncture Fundamentals, Chengdu University of TCM, Chengdu, China Associate Translator-in-Chief Ma Tao, MD., Ph.D. (China), L.Ac., Dipl. O.M. (NCCAOM) Assistant Professor ＆ Clinical Instructor, American College of Acupuncture and Oriental Medicine, Houston, Texas; Fellow of American Board of Oriental Reproductive Medicine, weMED Clinic, Houston, Texas, USA Translators Wang Yun-fei, Ph.D. TCM Resident Physician, Taian Hospital of Traditional Chinese Medicine, Taian, China You Bing, M.S., L.Ac, Dipl. O.M. (NCCAOM) Associate Professor, American College of Acupuncture and Oriental Medicine, Houston, Texas, USA

Chen Ji, Ph.D. TCM Instructor, Director of the Medical English Department, International Educational College, Chengdu University of TCM, Chengdu, China Huang Wen-jing, Ph.D. TCM. Instructor, International Educational College, Chengdu University of TCM, Chengdu, China Hou Tian-shu, Ph.D. of Acupuncture and Tui na Chengdu University of TCM, Chengdu, China Liu Zhen-yan, M.S. of Acupuncture Chengdu University of TCM Chengdu, China

English Editors Al Stone, L.Ac., DAOM Founder of the Web-sites Acupuncture.com, Gancao.net and Eagleherbs.com, Instructor and Clinic Supervisor at Emperor’s College of Traditional Oriental Medicine, Santa Monica, CA, USA Harry F. Lardner, Dipl.Ac. Editor and Project Manager of International Publication Department, People’s Medical Publishing House

About the Authors

胡幼平教授

Prof. Hu You-ping is currently serving as a doctoral supervisor at the Chengdu University of Traditional Chinese Medicine. He is the principal professor of Acupuncture and Moxibustion Technique Manipulations, the Essential Curriculum of Sichuan province and is the main professor of Science of Acupuncture and Moxibustion, the National Essential Curriculum of China. Prof. Hu has rich clinical experience in combining identification of diseases with syndrome differentiations, and channel, collateral, and channel-sinews. He is an expert at treating pain syndromes and channelsinew disorders with Chinese herbs and with ancient acupuncture manipulation using channel theory. Prof. Hu has acted as the principal investigator (PI) or co-PI in more than 20 academic research projects, including the 11th 5-year project

supported by the Ministry of Science and Technology, the National Natural Science Foundation of China as well as teaching research subjects. He has been granted awards including the first prize of Sichuan Science ＆ Technology Progress Award, the first-prize, second-prize and third-prize of Sichuan Excellent Teaching Achievement Prize and the third-prize of Chengdu Science ＆ Technology Progress Award. He is a council to the Clinical Branch of the Chinese Association for Acupuncture and Moxibustion (CAAM), the associate chairman of the Popular Science Committee of CAAM, a member of the Disease Spectrum Committee of CAAM, a standing member of the traditional nongovernmental diagnosis and treatment techniques and effective formula collection branch of the China Association of Chinese Medicine, a council to the Sichuan Association of Acupuncture and Moxibustion (SAAM), a member of the Clinical Commitee of SAAM, and a standing member of the pain management commitee of the Sichuan Association of Chinese Medicine. He has been honored as a renowned teacher of the Chengdu University of TCM. With 30 years of experience in teaching TCM and acupuncture for undergraduates and graduates from many countries, Prof. Hu has engaged in clinical treatment, teaching traditional Chinese medicine and acupuncture and academic exchanges in Europe, Asia and Africa countries including Germany, Thailand and Mozambique. Prof. Hu served as Editor-in-Chief and Associate Editor-in-Chief for 3 works, including the 10th 5-year planning textbook organized by the Ministry of Education, which included Acupuncture and Moxibustion Manipulation Techniques and TCM Rehabilitation; and as an editorial board member of 11 textbooks. Additionally, he has published more than 50 academic papers, out of which one paper is included in the Science Citation

Index (served as the second author) and 20 papers in core journals of China. He also supervised numerous doctoral and master degree candidates.

Al Loren Stone

Al Loren Stone, L.Ac, DAOM (1958-2013) was a graduate of the masters (1997) and doctoral (2007) programs at Emperor’s College of Traditional Oriental Medicine in Santa Monica, California, after which he was a popular classroom instructor and clinic supervisor at that school. In 1995, while still a student, Dr. Stone founded Acupuncture.com, a pioneering internet site that earned numerous awards and international goodwill. He recognized the Internet’s potential for spreading information about Chinese medicine in a time when many people still lacked an email account. Eventually he sold the site in order to travel and study in China. At the Yunnan Provincial Hospital of Traditional Chinese Medicine, he worked with elder doctors who were experts in internal medicine. It was from these elder masters that he witnessed the profound path of the Lao Zhong Yi (elder Chinese herbal medicine doctor) that became his professional goal. Dr. Stone later created Gancao. net which continues to serve practitioners of Chinese medicine to provide insight into Chinese medicine diagnosis. He was highly active in the American Association of Acupuncture and Oriental Medicine (AAAOM), and spearheaded major projects related to good

dispensing practices for practitioners as well as being a provider of continuing education for physicians, nurses, and acupuncturists. Dr. Stone was the co-author of two books with his teacher, colleague and friend, Dr. Qiao Yi: the Traditional Chinese Medicine Diagnosis Study Guide and the Traditional Chinese Medicine Formula Study Guide as well as serving as the editor of several PMPH books.

吴俊梅教授

Dr. Wu Jun-mei is currently a professor and supervisor of graduate students, director of teaching and research department of Acupuncture Fundamentals at Chengdu University of Traditional Chinese Medicine. She is the principal professor of Meridians and Acupoints, the Essential Curriculum of Sichuan province and is one of the main professors of Science of Acupuncture and Moxibustion, the National Essential Curriculum of China. She is the peer reviewer of National Natural Science Foundation of China, the leader reserve in Academic and Technology Development in Traditional Chinese Medicine of TCM Managing Bureau of Sichuan Province, the Secretary of Clinical Committee of Sichuan Association for Acupuncture and Moxibustion (SAAM), a member of Chinese Association for Acupuncture and Moxibustion (CAAM) and an editor of the International Journal of Clinical Acupuncture (USA). She was

a visiting scholar and research fellow at the Massachusets General Hospital Harvard Medical School in the U.S. from 2011 to 2012. Prof. Wu Jun-mei has participated in 27 natural science and teaching reform projects. Among them, she finished 9 projects as the principle investigator (PI), including items of the National Natural Science Foundation of China and teaching research subjects. She published 62 academic papers, one of which is included in the Science Citation Index (served as the first author). She received the second prize of the Sichuan Science ＆ Technology Progress Award, the third prize of the Chengdu Science ＆ Technology Progress Award and the First Prize of Doctoral and Expert Forum of Sichuan Province. She also has supervised and supported many master’s degree and doctoral candidates. Prof. Wu has accumulated more than 4200 teaching hours in Acupuncture and TCM English for graduates, undergraduates, and international students, and has been awarded the Prize of Excellent College Teachers by the Educational Ministry of China and the Favorite Undergraduate Professor by the University Student Union of Chengdu University of TCM. She was invited to teach acupuncture at Dr. Pedro Choy College of Portugal in May 2007, and was invited to give lectures for continuing acupuncture education at American College of Acupuncture ＆ Oriental Medicine in October, 2011. She was invited to give 5 presentations in the First Acupuncture Forum of Thailand in September, 2012. Prof. Wu served as the Editor-in-Chief for 2 textbooks, including Fundamentals of Acupuncture, a Chinese-English bilingual textbook for undergraduates majoring in Acupuncture and English, Basic Acupuncture, a textbook for undergraduates majoring in Acupuncture and Tui na. She worked as the associate editor-in-chief for Acupuncture and Immunology,

the main translator for Nutrition Secrets, which is one of the series of The Latest Clinical Medicine Question and Answer in the U.S. Prof. Wu also served as an editorial board member for 9 texts, such as Technique Training for Locating the Meridians and Acupoints, a nationwide textbook for Chinese medical colleges, supported by the 11th 5-year planning textbook organized by the Ministry of Education in China, Meridians and Acupoints, a nationally used textbook for Chinese medical colleges, Acupuncture Cosmetology, and Modern Red Blood Cell Immunology among others.

Editorial Board for the TCM Case Studies in the International Standard Library of Chinese Medicine Executive Directors Li Zhen-ji (李振吉) Vice Chairman and Secretary-General, World Federation of Chinese Medical Societies, Beiing, China Hu Guo-chen (胡国臣) President and Editor-in-Chief, People’s Medical Publishing House, Beiing, China Directors Liang Fan-rong (梁繁荣) Professor and Doctoral Supervisor of Acupuncture and Moxibustion, and President of Chengdu University of TCM, Chengdu, China He Qing-hu (何清湖) Professor and Doctoral Supervisor of Chinese External Medicine, and Vice President of Hunan University of CM, Changsha, China

General Coordinators Liu Shui (刘⽔) Vice-Director of International Publication Center, People’s Medical Publishing House, Beiing Wang Han-bing (王寒冰) Former Vice-Director of International Cooperation and Exchange Department, Chengdu University of TCM, Chengdu, China Harry F. Lardner, Dipl.Ac. Editor and Projector Manager of International Publication Center, People’s Medical Publishing House, Beiing Members Al Stone, L.Ac., DAOM, Founder of the Web-sites Acupuncture.com, Gancao.net and Eagleherbs.com, Instructor and Clinic Supervisor at Emperor’s College of Traditional Oriental Medicine, Santa Monica, CA, USA Cai Guang-xian (蔡光先), M.S. TCM Chief Physician, Professor, Doctoral Supervisor and Academic Leader of TCM Internal Medicine, Hunan University of CM; Director of Key Laboratory of TCM Internal Medicine Sponsored by Provincial Government and Ministry of Education, Changsha, China Cara O. Frank, L.OM. Dipl. OM. Educational Director of the Department of Chinese Herbology, Won Institute of Graduate Studies, Glenside, PA, USA Chen Yun-hui (陈云慧), Ph.D. TCM

Lecturer of Chinese Materia Medica, School of International Education, Chengdu University of TCM, Chengdu, China He Qing-hu (何清湖), Ph.D. TCM Professor and Doctoral Supervisor of Chinese External Medicine, and Vice President of Hunan University of CM, Changsha, China Hu You-ping (胡幼平) Professor and Doctoral Supervisor, Acupuncture and Tuina College/The Third Afliated Hospital, Chengdu University of TCM, Chengdu, China Huang Ying (黄莺) Chief Physician, Professor and Vice-Director of the Department of Dermatology, Teaching Hospital of Chengdu University of TCM, Chengdu, China Jake Paul Fratkin, OMD, L.Ac. Continuing Education Faculty, American College of Traditional Chinese Medicine, San Francisco; Continuing Education Faculty, Oregon College of Oriental Medicine, Portland; Continuing Education Faculty, Austin College of Oriental Medicine, Austin, Texas, USA James Flowers PhD Candidate, College of Oriental Medicine, Wonkwang University, South Korea; Secretary General, International Association for the Study of Traditional Asian Medicine Lei Lei (雷磊), Ph.D. TCM

Chief Physician, Professor ＆ Doctoral Supervisor of TCM Gynecology; Academic Leader of TCM Gynecology, National Key Discipline of the State Administration of Traditional Chinese Medicine, Hunan University of CM, Changsha, China Lei Yu-e (雷⽟娥） Associate Professor, Hunan University of CM, Changsha, China Liu Bai-yan (刘柏炎), Ph.D. Integrative Medicine Professor and Doctoral Supervisor of TCM Internal Medicine, Hunan University of CM; Director of Hunan Provincial Key University Laboratory of TCM Internal Medicine, Changsha, China Ma Xi-tao (马喜桃) Resident Physician, Teaching Hospital of Chengdu University of TCM, Chengdu, China Misha R. Cohen, OMD, L.Ac. Clinic Director, Chicken Soup Chinese Medicine; Research Specialist in Integrative Medicine, UCSF Institute for Health and Aging; Associate Member, UCSF Comprehensive Cancer Center; Director, MRCE Foundation Pär Rufus Scott, MOAM, Lic. Ac. Peng Qing-hua (彭清华), Ph.D. TCM Chief Physician, Professor and Doctoral Supervisor of TCM Ophthalmology, the First Hospital Afliated to Hunan University of Chinese Medicine; President of the School of International Education, Hunan University of CM, Changsha, China

Portia Barnblatt, DAOM, L.Ac. Dipl.Ac. Portia Chan Acupuncture Clinic, San Francisco, U.S.A.; Clinical supervisor for American College of Traditional Chinese Medicine, San Francisco, U.S.A Suzanne Robidoux, Ph.D., DOM, L.Ac. Post Doctor Laureates of Beiing University of Chinese Medicine, Specialized in Classical Medicine and Neurology, Beiing, China Wan Peng (万鹏), M.S. TCM Lecturer and Atending Physician of Chinese External Medicine, School of Clinical Medicine/ Teaching Hospital of Chengdu University of TCM, Chengdu, China Wang Jing (王静), Ph.D. TCM Lecturer of TCM Gynecology, Chengdu University of TCM, Chengdu, China Wang Meng-qing (王孟清), Ph.D. TCM Professor and Chief physician of TCM Pediatrics, the First Hospital Afliated to Hunan University of Chinese Medicine; Director of TCM Pediatrics Department and TCM Pediatrics Teaching Ofce, Hunan University of CM, Changsha, China William R. Morris, PhD, DAOM, L.Ac. President, AOMA Graduate School of Integrative Medicine, Austin, Texas, USA Wu Jun-mei (吴俊梅), Ph.D. of Acupuncture and Moxibustion

Professor and Master Supervisor, Acupuncture and Tuina College/The Third Afliated Hospital, Chengdu University of TCM, Chengdu, China Wu Qian-zhi (吴潜智), M.S. TCM Vice President of Faculty, Professor and Licensed Acupuncturist, AOMA Graduate School of Integrative Medicine, Austin, Texas, USA Ye Xiao (叶晓), M.S. TCM Lecturer, Foreign Languages College, Zhejiang Chinese Medical University, Hangzhou, China Zeng Chun (曾纯), M.S. TCM Editor and Projector Manager of International Publication Center, People’s Medical Publishing House, Beiing, China Zeng Sheng-ping (曾升平), M.S. TCM Chief Physician and Professor of TCM Rheumatology and Immunology, Chengdu University of TCM, Chengdu, China Zhang Yan-hong (张艳红) Associate Professor, English Teaching and Research Ofce, Hunan University of CM, Changsha, China Zheng Qi (郑琦) Freelance Translator/Interpreter, Beiing, China Sponsored by World Federation of Chinese Medical Societies

Preface This book details TCM ideology, etiology, pathogenesis, pattern differentiation and treatment, and herbal formula and acupuncture treatment for common pain disorders. In order to inspire the thinking process for clinical doctors, clinical case studies, discussion, medical examples and study questions are included. In this book, common pain disorders have been classified according to their disease location, including pains of the head and face, neck, shoulders, upper limbs, chest and abdomen, and pain of the lower limbs. In order to reflect TCM history and characteristics as well as to meet the demands of modern clinical practice, this book discusses common clinical pain syndromes with both TCM and modern medicine names according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) released by World Health Organization (WHO). The authors, who have published many materials and reference books of TCM, are experienced TCM and acupuncture doctors rich in clinical experience as well as having taught undergraduate students and international students majoring in TCM. In this book, the principles, methods, prescriptions of Chinese materia medica, acupoints, manipulating techniques for pains are described. In order to combine theory with clinical practice, we have presented many medical cases, extended clinical theories, and discussions of clinical issues. Classic medical examples, indispensable for TCM and acupuncture students, are selected to help impart the essence

of TCM. The edition of this book has been created for teachers and students in TCM schools and biomedical doctors around the world who interested in TCM and acupuncture. For a better understanding of this book, it is best for readers to obtain some basic knowledge of TCM, basic actions and compatibility and contra-indications of Chinese herbs, ingredients and function of general formulas, fundamental knowledge of meridianacupoints, techniques and clinical applications of acupuncture, laws of acupoint compatibility, principles of formula as well as Chinese culture. This book has been reorganized from the original manuscripts which we feel better serves its original purpose of being a practical and educational text. Due to the rapid development of TCM and acupuncture therapy for pain, as well as our own evolving knowledge, deficiencies in this book are inevitable. Thus, your forgiveness would be highly appreciated and comments or suggestions from scholars and readers are always welcomed. Hu You-ping Al Stone Wu Jun-mei January, 2013

Table of Contents

Introduction * How does pain happen? * Notes about editorial decisions SECTION I Systemic Pain 1. Bi Syndrome 2. Fibromyalgia 3. Gout 4. Rheumatoid Arthritis 5. Ganglion Cysts 6. Osteoarthritis (Bone Bi) SECTION II Pain of the Head and Face 7. Eye Pain 8. Toothache 9. Sore Throat 10. Headache 11. Facial Pain (Trigeminal Neuralgia) SECTION III Pain of the Neck, Shoulders,and Upper Limb 12. Thoracic Outlet Syndrome(Neck and Shoulder Pain) 13. Cervical Spondylosis (Neck Bi) 14. Stiff Neck (Torticollis) 15. Shoulder Pain 16. Brachial Plexus Neuralgia(Arm Pain) 17. Lateral Epicondylitis(Elbow Pain) SECTION IV Pain of the Chest and Abdomen 18. Chest Bi and Heart Pain 19. Angina Pectoris 20. Stomachache 21. Abdominal Pain 22. Flank Pain 23. Dysmenorrhea

24. Renal Colic (Kidney Stones) 25. Gallbladder Pain 26. Lower Back Pain SECTION V Pain of the Lower Limb 27. Piriformis Syndrome 28. Sciatica 29. Ankle Sprain 30. Heel Pain Appendix I:Pinyin-English Formula Cross Reference Appendix II: List of Cited Sources

Introduction * How does pain happen? “Stagnation causes pain” is a statement that appears frequently in this text. This is a restatement of the ancient adage that states: “Where there is flow, there is no pain, and where there is pain, there is no flow.” Still, this is a somewhat incomplete explanation for pain. Why exactly does stagnation cause pain? The answer is simply that downstream structures are not nourished. These structures can be adjacent to or distant from the site of the stagnation. Boldly speaking, there are two causes of stagnation: excess and deficiency. In the case of excessive stagnation, the cessation to flow is immediate and profound. This gives rise to acute pain that is intense and sudden. This excess type stagnation can be from either an internal pathogenic factor such as phlegm or blood stasis, or an external invasion of wind, damp, heat, cold, etc. In the case of stagnation due to deficiency, the cessation of flow is due to the lack of qi to push or blood to be pushed. In either case, stagnation occurs. This gives rise to chronic pain that is low-grade but chronic.

These various causes for stagnation are essentially what this book talks about. You’ll see these pain mechanisms repeated in each and every chapter.

* Notes about editorial decisions Formula ingredients may vary: it should be noted that formulas appearing in this book are modified formulas, even if not stated explicitly. For example, in the rheumatoid arthritis chapter, Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) is used for qi and blood deficiency, while in the gouty arthritis chapter, it is used for liver-kidney deficiency with many of the same herbs, but a few different ones as well. There were many cases of blood stagnation where the tongue body’s color was described as “dark”, “dusky”, or “pale”. Sometimes, these terms were left as they were, other times they were replaced with the term “dim” to approximate the lack of spirit that is found in the tongue color when the blood is stagnated. Dim, in this sense is the opposite of “vivid”. There is a term in color photography that is used to describe the amount of ink in a color image. The more ink, the greater the “saturation”. The tongue body that “has spirit” will also have vivid colors with greater saturation than a tongue body with blood stagnation that appears to have less color saturation. It is pale, compared to bright, but it is not necessarily pale in color as you might find in the qi or yang deficient tongue. This is still a colored tongue but the color intensity is dim. Hence, the word “dim” shows up in some of the descriptions of the tongue color that arises in patterns of blood stagnation. Of course, where the original text described the tongue color as “purple” that remains clear and unambiguous, and so those were not changed.

In just about every chapter, there is some mention of the pathogenic factor of “wind, cold, and damp”. The question that arose during the editing process was if the author was saying that any one of these pathogenic factors could cause the pain or if all three would have to attack together for the pattern to be called “wind-cold-damp”. It appears that in most cases, the author’s intent was that these three items exist together but in varying degrees. However, in the fibromyalgia chapter, the original text mentions that wind is the carrier, but it is the cold or damp that actually causes stagnation and the resultant pain. There are some very long treatment principles described in this book. As a practitioner, I sometimes felt that they were unnecessarily wordy and redundant. As an example, one treatment principle suggests one “Soothe the liver and resolve constraint, regulate qi and relieve pain”. This at first seemed redundant, however as the editing process unfolded, I began to sense that these long detailed treatment principles also provided some insight into particular medicinals or acupuncture points that were chosen as well. As such, the original translations of the treatment principles were for the most part left untouched so as to allow practitioners to read between the lines as I believe the author intended. For example, sometimes the location of the stagnation ended up at unique levels, such as in the collaterals, and it is interesting to see which medicinals or acupuncture points address stagnation at various levels of the channel and collateral system. Many thanks go out to Lorraine Wilcox, Eric Brand and Par Scott for their scholarly assistance with alternative translations, to Cara Frank, Douglas Eisenstark, and Will Morris for their editorial second opinions, and from the PMPH home office in Beijing, the patient and guiding hand of Mr. Harry F. Lardner, who conceived of and edited this series of case study books.

Al Stone 2012

SECTION I Systemic Pain 1. Bi Syndrome ANCIENT THEORIES AND MODERN INSIGHTS Bi syndrome is a common disease encountered in the clinical setting. Bi refers to blockage or obstruction. The meaning of “bi syndrome” is divided into a broad and a narrow sense. The narrow sense points to symptoms that are localized to one area such as the limbs, whereas the broad sense applies to zang-fu organ-type bi syndromes. Symptoms of the narrow bi syndrome discussed in this chapter refer to aches and pain or sensations of numbness and heaviness in the muscles, sinews, bones and joints; other characteristics include joint stiffness, limited range of motion, swollen or deformed joints, burning sensations, and muscle atrophy. The broad sense describes zang-fu organ disorders that result from a deficiency of upright qi after which a mixture of wind, cold, dampness or heat attack the body to affect the channels and collaterals. This leads to an inhibited flow of qi and blood on a systemic level. Traditional Chinese medicine teaches that bi syndrome is caused by pathogenic qi blocking the channels and collaterals, and thus inhibiting the

flow of qi and blood. Treatment principles include dispelling the pathogen, quickening flow within the collaterals, and alleviating pain. An ancient adage provides some insight into the best method of addressing bi syndrome, especially when associated with wind: “Regulate the blood [flow] first to expel wind; the wind may extinguish when the blood circulates smoothly.” As such, medicinals that nourish and invigorate the blood should be used when pathogenic wind is predominant or the chronic process of the disease makes the pathogen enter deeply into the collaterals. If the bi syndrome becomes a chronic condition, it can further inhibit the flow of qi and blood and lead to the accumulation of phlegm stasis. Another ancient adage teaches that “when blood is blocked and transformed into stasis, dampness congeals into phlegm”. When phlegm is created, it becomes stubborn and more difficult to cure as phlegm and blood stasis bind together to block the channels, collaterals, and joints.

ETIOLOGY AND PATHOMECHANISMS External Causes The main etiology and pathomechanism begin with an external attack by pathogenic wind, cold and dampness. However, in the clinical setting we classify bi syndrome types boldly into two groups: pathogenic wind, cold and dampness, or pathogenic wind, dampness and heat. Bi syndrome is most commonly formed when all three pathogenic factors—wind, dampness and cold (or heat) are combined to cause stagnation because of their mutually accumulative effects. Wind-cold-damp: Pathogenic wind is a yang-pathogen which easily penetrates the skin and interstices, while pathogenic cold invades the muscles, tendons and bones. When accompanied by dampness, wind and cold can more easily stick to the diseased location due to the sticky nature of pathogenic dampness. When wind is predominant there is migratory bi (wind bi), cold predominance leads to painful bi (cold bi), and predominant dampness leads to fixed bi (damp bi). Wind-damp-heat: Wind and heat are both yang-pathogens. Wind can lead to heat, and heat produces wind. Wind-heat opens the skin pores and interstices, helping dampness invade, after which a more chronic condition can arise. Heat bi can form from pathogenic heat, a yang-type constitution, or from yin deficiency generating heat.

Internal Causes

Bi syndrome results from pathogenic qi attacking the body when upright qi is deficient, thus upright qi deficiency is the internal cause and the root of this condition. When the patient’s long-term constitution is weak and qi and blood become deficient, there arises a disharmony between ying and wei where openings arise in the skin pores thus allowing for the pathogenic wind, cold, dampness and heat to invade. They then block the flow of qi and blood. The deficient upright qi is unable to dispel the pathogenic qi, which then invades deeper and is gradually retained in the muscles, joints, tendons and bones. Thus bi pain lingers and becomes chronic.

Other Causes The initial stage of bi syndrome is an excess pattern, but then it becomes a complex pattern of deficiency and excess because long-term exposure to pathogenic factors consumes the upright qi. Soon, bi appears with symptoms of qi and blood deficiency, liver and kidney depletion, or the appearance of the pathogenic qi entering deeply into the zang-fu organs.

COMMON CLINICAL PATTERNS The most commonly encountered clinical patterns include migratory bi (wind bi), painful bi (cold bi), fixed bi (damp bi), heat bi, lame bi, qi and blood deficiency, and liver-kidney depletion. Migratory bi: Wind-prevalence leads to migratory pain in various joints. Painful bi: Cold-prevalence leads to severe pain that is aggravated by cold and relieved by warmth. Fixed bi: Damp-prevalence leads to fixed pain with numbness or a sensation of heaviness. Heat bi: Heat-prevalence leads to severe burning pain and the color red appearing at affected locations. Lame bi: Long-term bi syndrome leads to distorted joints, spasms and contracted muscles. Qi and blood insufficiency: Sore joints with a sensation of heaviness, dull pain, or obvious numbness, accompanied by fatigue and weakness, pale complexion and lips; the tongue is pale with a white coating, the pulse is deep, deficient and slow. Liver and kidney depletion: Long-term bi syndrome failing to be addressed leads to swollen, distorted, stiff and dysfunctional joints, accompanied by a sore lower back, weak knees, an aversion of cold and a preference for warmth. The tongue body may appear red, pale, or dim, possibly with stasis dots, the coating may be white or yellow, and the pulse is commonly deep, thready or wiry.

THERAPEUTICS Chinese Medicinals For external conditions, it is wise to dissipate the external pathogen immediately, whereas for internal disharmonies the zang-organs should be nourished first. Migrating bi treatment principles: Dispel wind while dissipating cold and eliminating dampness; assist with blood-supplementing medicinals. Painful bi treatment principles: Dissipate cold while dispelling wind and eliminating dampness; assist with medicinals that supplement fire and assist yang. Fixed bi treatment principles: Eliminate dampness while dispelling wind and dissipating cold; assist with medicinals that fortify the spleen and boost qi. 1. Migratory Bi Formula: Xuān Bì Dá Jīng Tāng (Impediment-Diffusing ChannelUnblocking Decoction) Ingredients: fēng fáng (Nidus Vespae), wū shāo shé (Zaocys), tŭ biē chóng (Eupolyphaga seu Steleophaga), táng láng (Mantis), wēi líng xiān (Radix et Rhizoma Clematidis), qiāng huó (Rhizoma et Radix Notopterygii), fáng fēng (Radix Saposhnikoviae), qín jiāo (Radix Gentianae Macrophyllae), xī xiān căo (Herba Siegesbeckiae), qīng fēng téng (Caulis Sinomenii), dāng guī (Radix Angelicae Sinensis), chuān shān jiă (Squama Manitis)

2. Painful Bi Formula: Wū Tóu Tāng (Aconite Main Tuber Decoction) Ingredients: zhì chuān wū (Radix Aconiti Praeparata), má huáng (Herba Ephedrae), sháo yào (Radix Paeoniae), huáng qí (Radix Astragali), gān căo (Radix et Rhizoma Glycyrrhizae), fēng mì (Mel) 3. Fixed Bi Formula: Yì Yĭ Rén Tāng (Coix Decoction) Ingredients: yì yĭ rén (Semen Coicis), dāng guī (Radix Angelicae Sinensis), sháo yào, má huáng, guān guì zhī (Cinnamomi Cortex Tubiformis), gān căo, cāng zhú (Rhizoma Atractylodis) 4. Heat Bi Formula: Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) Ingredients: zhī mŭ (Rhizoma Anemarrhenae), zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle), shí gāo (Gypsum Fibrosum), jīng mĭ (Oryza Sativa L.), guì zhī (Ramulus Cinnamomi) 5. Lame Bi Formula: Bŭ Shèn Qū Hán Zhì Wāng Tāng (Kidney-Supplementing Cold-Dispelling Lameness Decoction) Ingredients: chuān xù duàn (Radix Dipsaci), bŭ gŭ zhī (Fructus Psoraleae), gŭ suìbŭ (Rhizoma Drynariae), yín yáng huò (Herba Epimedii), zhì fù zĭ (sliced Radix Aconiti Lateralis Praeparata), shú dì huáng (Radix Rehmanniae Praeparata), guì zhī, dú huó (Radix Angelicae Pubescentis), wēi líng xiān, bái sháo (Radix Paeoniae Alba)

6. Qi and Blood Deficiency Formula: Qì Xuè Bìng Bŭ Róng Jīn Tāng (Qi and BloodSupplementing Sinew-Nourishing Decoction) Ingredients: shēng yì yĭ rén (raw Semen Coicis), fú líng (Poria), shēng bái zhú (raw Rhizoma Atractylodis Macrocephalae), hé shŏu wū (Radix Polygoni Multiflori), dāng guī, shā rén (Fructus Amomi), shú dì huáng (Radix Rehmanniae Praeparata), huáng jīng (Rhizoma Polygonati), fēng fáng, wū shāo shé, xī xiān căo (HerbMedicinala Siegesbeckiae), luò shí téng (Caulis Trachelospermi), jīn máo gŏu jĭ (Rhizoma Cibotii), qín jiāo (Radix Gentianae Macrophyllae), tù sī zĭ (Semen Cuscutae) 7. Liver and Kidney Depletion Formula: Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) Ingredients: dú huó, sāng jì shēng (Herba Taxilli), dù zhòng (Cortex Eucommiae), niú xī (Radix Achyranthis Bidentatae), xì xīn (Radix et Rhizoma Asari), qín jiāo (Radix Gentianae Macrophyllae), fú líng, ròu guì (Cortex Cinnamomi), fáng fēng, chuān xiōng (Rhizoma Chuanxiong), rén shēn (Radix et Rhizoma Ginseng), gān căo, dāng guī, sháoyào, dì huáng (Radix Rehmanniae) ★ Commonly Used Key Medicinals for Different Parts of the Body

● Joints of the upper limbs (wind-predominance): qiāng huó, bái zhĭ (Radix Angelicae Dahuricae), sāng zhī (Ramulus Mori), wēi líng xiān, jiāng huáng (Rhizoma Curcumae Longae), chuān xiōng

● Joints of the lower limbs (damp-predominance): dú huó, niú xī, fáng jĭ (Radix Stephaniae Tetrandrae), bì xiè (Rhizoma Dioscoreae Hypoglaucae), sōng jié (Lignum Pini Nodi)

● Joints of the lower back and waist (related to kidney qi deficiency): dù zhòng, sāng jì shēng, yín yáng huò, bā jĭ tiān (Radix Morindae Officinalis), xù duàn (Radix Dipsaci)

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Mainly select points on the yang channels. Distal points along the affected channels are commonly selected to treat bi syndrome, such as points on the gallbladder, urinary bladder, large intestine and stomach channels. (2) Points on both hand and foot yang channels can be selected simultaneously. (3) Emphasize the use of specific points (he-sea, yuan-source, fivephase points, etc.). 2. Point Selection According to Location (1) Select points near the joints or ashi points. “Any painful point is an acupoint” is an effective guideline for bi syndrome point selection. Commonly used points include:

● Shoulders: LI 15 (jiān yú), SJ 14 (jiān liáo), SI 10 (nào shù) ● Elbows: LI 11 (qū chí), SJ 10 (tiān jĭng), LU 5 (chĭ zé), HT 3 (shào hăi), SI 8 (xiăo hăi) ● Wrists: SJ 4 (yáng chí), SJ 5 (wài guān), LI 5 (yáng xī), SI 4 (wàn gŭ)

● Back and spinal region: DU 14 (dà zhuī), DU 12 (shēn zhù), DU 3 (yāo yáng guān),

jiā jĭ (EX-B2)

● Hips: GB 30 (huán tiào), GB 29 (jū liáo), BL 54 (zhì biān) ● Thighs: ST 32 (fú tù), BL 37 (yīn mén), BL 36 (chéng fú), BL 31 (fēng shì), GB 34 (yáng líng quán)

● Knees: xī yăn (EX-LE5), ST 34 (liáng qiū), GB 34 (yáng líng quán), GB 33 (xī yáng guān)

● Ankles: BL 62 (shēn mài), KI 6 (zhào hăi), BL 60 (kūn lún), GB 40 (qiū xū) (2) Select points on the yang channels of the lower limbs: GB 31 (fēng shì), GB 38 (yáng fŭ), ST 36 (zú sān lĭ), BL 58 (fēi yáng), GB 39 (xuán zhōng) 3. Point Selection Based on Pattern Differentiation (1) Migratory bi: Points for dispelling wind and unblocking the collaterals are commonly used. For wind-pain in four limbs, commonly used points include: GB 20 (fēng chí), GB 31 (fēng shì), LI 11 (qū chí), SJ 5 (wài guān), GB 34 (yáng líng quán), SP 6 (sānyīn jiāo), and LI 10 (shŏu sān lĭ). Two additional points that regulate the blood can also be added: BL 17 (gé shù) and SP 10 (xuè hăi). The use of blood-regulating points is consistent with the ancient adage: “Regulate the blood [flow] first to expel wind; the wind may extinguish when the blood circulates smoothly”.

(2) Painful bi: When a cold-pathogen is liable to injure yang qi, treatment should focus on warming yang. Commonly used points to warm the yang qi and dispel cold include: DU 4 (mìng mén), DU 14 (dà zhuī), RN 4 (guān yuán), GB 34 (yáng líng quán), BL 23 (shèn shù), and ST 36 (zú sān lĭ). (3) Fixed bi: Caused by the spleen failing in transportation and transformation and the kidney failing in qi transformation. Select points that fortify the spleen and eliminate dampness such as SP 9 (yīn líng quán), ST 36 (zú sān lĭ) and ST 33 (yīnshì). (4) Heat bi: Select points that clear and reduce heat-toxin such as DU 14 (dà zhuī), LI 4 (hé gŭ), and LI 11 (qū chí). (5) Lame bi: Select ST 36 (zú sān lĭ), RN 4 (guān yuán), RN 6 (qì hăi), BL 23 (shèn shù) and KI 3 (tài xī). Moxibustion is commonly used. In acupuncture treatment, needling is mainly employed to stop pain. Migratory (wind) bi, painful (cold) bi and fixed (damp) bi should be treated by acupuncture and moxibustion together. Moxibustion is contraindicated in heat bi. Because the pathogenic qi can enter the collaterals and result in blood stasis in long-term cases of bi syndrome, bleeding therapy can be used at the points near the joints, ashi points, or at sites where the distended veins appear. The amount of the bleeding varies based on the location and size of the blood vessel.

CASE STUDY I Ms. He, age 79. Initial Visit: April 3rd, 2005

Chief Complaint: Migratory pain in the whole body for over four months. History: The patient suffered from a common cold at the end of December in 2004 at which time she felt pain throughout the entire body. The diagnostic work in a Beijing hospital two months ago showed: Rheumatoid Factor (RF) (+) 1200 IU/ml, Erythrocyte Sedimentation Rate (ESR): 113 mm/h. She had been treated as an inpatient with Western medicine for nearly a month but this approach resulted in no obvious beneficial effect. So she came to our clinic for further treatment. Signs and Symptoms: Bilateral swelling and pain in the joints of the fingers, wrist and knees, migratory aching pain in the whole body, joint stiffness for 1-2 hours every morning, a red tongue, and a deep and thready pulse. Past History: Had suffered from ulcerative colitis (UC) earlier in her life and was cured. No other medical history and allergic history. Laboratory Examination: RF (+) 1190 IU/ml, ESR 67 mm/h, CRP 16.5 mg/dl. Pattern Differentiation This patient was invaded by the three external pathogens of wind, cold and dampness, which resulted in bilateral joint pain in the fingers, wrists and knees, and migratory aching pain in the whole body with joint stiffness. Because the patient is elderly and weak, her liver and kidney are depleted. As such, the pathogens of wind, cold and dampness were able to easily invade because her defenses were weak. This resulted in blockage to the flow of qi and blood in the channels, and ultimately the appearance of pain. Being invaded by the wind-pathogen caused migratory pain in the

whole body, being invaded by cold-pathogen resulted in severe pain, and being invaded by a damp-pathogen caused swollen joints. This case is a pattern of liver and kidney deficiency with externallycontracted wind, cold and dampness, a deficiency-excess complex pattern. Diagnosis WM diagnosis: Rheumatoid arthritis TCM diagnosis: Bi syndrome due to liver and kidney deficiency with external contraction of wind-cold-dampness Clinical Treatment The patient was aged, weak and deficient in the liver and kidney. Wind, cold and dampness invaded the weakened body (which was further weakened by fighting off a cold at the time of the original symptoms) and blocked the qi and blood flow in the channels and collaterals, thus resulting in bi syndrome. Treatment should dispel wind, eliminate dampness, dissipate cold, supplement liver and kidney, unblock the collaterals and relieve pain. In addition to receiving acupuncture and Chinese medicinal treatment, the patient should take measures to strengthen her constitution and address her cold and damp living quarters such that they are warmer and drier. Principles: Dispel wind, eliminate dampness, dissipate cold, supplement liver and kidney, unblock the collaterals, relieve pain Formula: Modified Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) [独活寄⽣汤加减]

Decocted with water as one divided dose, taken twice daily. [Formula Analysis] In this prescription, dú huó and sāng jì shēng are used as the chief medicinals to dispel wind, eliminate dampness, dissipate cold, nourish blood, harmonize ying, invigorate the collaterals and unblock bi. Niú xī and dù zhòng are used as deputy medicinals to supplement liver and kidney, and strengthen the sinews and bone. Chuān xiōng, dāng guī, dān shēn, chuān shān lóng and dì gŭ pí supplement and quicken the blood, zhì huáng qí supplements qi and fortifies the spleen. These assistant medicinals used to invigorate qi and blood in order to dispel wind and dampness.

Gān căo regulates and harmonizes all the medicinals in the prescription. In addition, qīng fēng téng, hăi fēng téng, xī xiān căo, wēi líng xiān and shēn jīn căo assist to dispel the wind-pathogen in the limbs. This prescription is able to treat the root and branch (ben and biao), simultaneously by reinforcing upright qi and dispelling the pathogenic factors. This is a common and effective formula for bi syndrome due to pathogenic wind-cold-dampness.

Acupuncture Main points: GB 20 (fēng chí), sì shén cōng (EX-HN1), GB 34 (yáng líng quán), SP 10 (xuèhăi), bā xié (EX-UE9), SJ 5 (wài guān), nèi xī yăn (EX-LE4), xī yăn (EX-LE5), BL 40 (wĕi zhōng) Supplementary points: DU 14 (dà zhuī), DU 9 (zhì yáng), DU 4 (mìng mén) Method: Treatment took place once a day. The needles were retained for 30 min. One month constitutes one course of treatment. Techniques: Needle all points with even supplementation and drainage. Further Consultation On May 4th, all her symptoms had improved. There was still pain in the fingers, the right shoulder, and the right knee. Joint stiffness continued in the morning, lasting for about an hour. She also reported a poor appetite and inhibited urination. We maintained the previous treatment method, but added to her previous formula with jiāng huáng 12g, chē qián zĭ (Semen

Plantaginis) 12g, fú líng 12g and jī nèi jīn (Endothelium Corneum Gigeriae Galli) 10g. The acupuncture method was not changed. On August 31st, her symptoms were further relived, and her appetite was good. There remained a distending and uncomfortable sensation in the fingers of both hands. The knee on the right side was swollen. Other symptoms included spontaneous perspiration, head distention, slight morning stiffness and occasionally inhibited urination. RF 138 IU/ml, ESR 54 mm/dl. We removed the jiāng huáng and jī nèi jīn from the previous prescription and added xiāng fù (Rhizoma Cyperi) 12g, yán hú suŏ (Rhizoma Corydalis) 12g, dăng shēn (Radix Codonopsis) 15g, sāng zhī 12g, guì zhī 6g, bái zhú (dry-fried) 12g, mù guā (Fructus Chaenomelis) 12g, shā rén 8g, and shān yào 12g. The acupuncture method remained unchanged. On Dec. 7th, our evaluation showed that the symptoms had disappeared after treatment for eight months. The examinations did not show any abnormality. Huà YūJuān Bì Chōng Jì (Stasis-Dissolving ImpedimentAlleviating Soluble Granules) were used to maintain the effect of treatment. No recurrence was noted during the followup period. The patient felt a slight ache occasionally, but she was otherwise able to return to normal life.

CASE STUDY II (ACUPUNCTURE, Lu Shouyan) Mr. Wang, age 22. Initial Visit: April 30th, 1963. Chief Complaint: Migratory aching pain at the joints of the four limbs for two months. History: The patient had suffered from migratory aching pain at the joints of the four limbs, and his knees and wrists had been unable to flex or extend freely for two months. Other symptoms included vertigo, fatigue, chest distress, palpitations, and scanty dark urine. Physical Examination: Tongue was swollen with a thin coating; pulse was wiry and rapid. The pulse at GB 4 (hán yàn) felt excessive. Diagnosis Migrating bi due to deficient water-phase with excessive wood, floating wind and yang Clinical Treatment Principles: Enrich yin and subdue yang, scatter wind and drain dampness. Points: DU 20 (băi huì), GB 20 (fēng chí), DU 16 (fēng fŭ), ST 35 (dú bí), xī yăn (EX-LE5), SJ 3 (zhōng zhŭ), LI 4 (hé gŭ), GB 43 (xiá xī), KI 3 (tài xī), LV 3 (tài chōng). Manipulations: Lifting, thrusting and twirling were used for supplementation for KI 3 (tài xī) and drainage was used for all the other points. All needles were retained for 10 min.

Further Consultation After being treated four times with the above method, the vertigo was relieved and the aching pain in the limbs was gradually improving. The patient still felt palpitations and chest distress, and the pulse remained thready and wiry. The pulses at GB 4 (hán yàn) and ST 42 (chōng yáng) remained excessive due to the bi-pathogen entering the heart where it disturbed the heart-spirit. The treatment principle remained the same as the first treatment, but with the added principle of calming the heart. Points: GB 20 (fēng chí), PC 4 (xì mén), HT 7 (shén mén), SJ 3 (zhōng zhŭ), LI 4 (hé gŭ), KI 3 (tài xī), LV 3 (tài chōng). Supplementation methods were used at KI 3 (tài xī), and drainage was used at all the other points. All needles were retained for 10 min. After another three treatments, the patient’s palpitations were relieved, his vertigo disappeared, and he could sleep well. The aching pain in his limbs was greatly improved, and he only felt slight pain when bending his knees. He had a crimson tongue tip with a thin white coating, and slightly wiry pulses with the right pulse wider than the left. The original point prescription was modified. Points: GB 20 (fēng chí), HT 7 (shén mén), PC 6 (nèi guān), LI 4 (hé gŭ), KI 3 (tài xī), LV 3 (tài chōng), ST 35 (dú bí), xī yăn (EX-LE5). After another three treatments, the patient’s palpitations and aching pain in the limbs disappeared. His pulse was slightly wiry, but the right pulse and the left pulse were balanced. The tongue coating was thin. The original point prescription was modified. Points: GB 20 (fēng chí), PC 4 (xì mén), HT 5 (tōng lĭ), PC 6 (nèi guān), LI 4 (hé gŭ), KI 3 (tài xī), LV 3 (tài chōng), ST 35 (dú bí).

After a total of twelve treatments, the pulse of the patient was slightly wiry and rapid, and the left pulse was wider than the right. The pulse at GB 4 (hán yàn) felt normal, and the tongue coating was thin and white. The following point prescription was given to consolidate the effect: GB 20 (fēng chí), PC 4 (xì mén), GB 4 (hán yàn) and LV 3 (tài chōng) needled with drainage techniques. The needles were retained for 10 min. Note An exuberance of pathogenic wind causes migratory bi. The patient in this case contracted an attack of external wind-cold-dampness, while internally there was an agitation of liver wind resulting from water depletion. The internal and external wind working together led to the migratory pain of the four limbs and migratory bi syndrome. The palpitations and chest distress reflected the bi-pathogens attempting to invade the heart. Dr. Lu selected DU 20 (băi huì), GB 20 (fēng chí) and DU 16 (fēng fŭ) with drainage technique to dispel wind and subdue yang, and needled bilateral LI 4 (hé gŭ) and LV 3 (tài chōng) with drainage to open the four gates and subdue the internal agitation of wind and yang. KI 3 (tài xī) was supplemented to enrich kidney-water and contain liver-wood. Draining techniques were used at HT 7 (shén mén), PC 4 (xì mén), and PC 6 (nèiguān) to scatter the pathogen invading the heart. In addition, he selected channel points in the local region of the affected limbs to eliminate bi and relieve pain according to the theory of “selecting points on the channelpassing through the affected region”. This case achieved clear benefits after twelve treatments.

An interesting item in this case is Dr. Lu’s use of pulse diagnosis at GB 4 (hán yàn) and ST 42 (chōng yáng). In this case, both of these pulses felt “excessive”, suggesting to the doctor that the pathogenic factor had entered the heart, causing palpitations and chest distress. Because this case is from 1963, and because these pulse locations are no longer in common use, anymore, this case provides an interesting look into the nottoo-distant standard of care within China.

STUDY QUESTIONS 1. Why were DU 14 (dà zhuī), DU 9 (zhì yáng) and DU 4 (mìng mén) chosen to treat bi syndrome in the first case? 2. In addition to the use of acupuncture and Chinese medicinals, what lifestyle advice should be provided to the patient in the first case? Answers 1. This patient was aged with acute pain in all her joints. She was treated as an inpatient but did not achieve any relief. As the red tongue body and deep, thready pulse indicated liver and kidney depletion, DU 14 (dà zhuī), DU 9 (zhì yáng) and DU 4 (mìng mén) were selected to regulate and supplement the liver and kidney. 2. Pay attention to not overwork or stress the body in order to help the liver and kidney recover. The patient should avoid cold and damp environments so she won’t be further attacked by external pathogens. Once catching a cold or being exposed to rain, the patient should get treatment as soon as possible in order to prevent recurrence. While being treated for cold-damp bi with liver and kidney deficiency, it is important to keep warm and avoid exposure to cold weather or environments; also protect the affected limbs to prevent any additional trauma. Encourage occupational training for the affected limbs to benefit the recovery.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mr. Chen, age 41, had severe fixed pain at the joints of the limbs which was aggravated by cold and relieved by warmth. The joints failed to flex or extend freely, the tongue body was pale with a thin white coating, and the pulse was wiry and tight. Which of the following formulas is your first choice? A. Fáng Fēng Tāng (Ledebouriella Decoction) B. Shuāng Hé Tāng (Double Combined Decoction) C. Yì Yĭ Rén Tāng (Coix Decoction) D. Wū Tóu Tāng (Aconite Main Tuber Decoction) E. Xuān Bì Tāng (Painful Obstruction-Resolving Decoction) 2. Ms. Wang, age 38, has had aversion to wind, fever and a sore throat for three days. Now, she is noticing migratory aching pain at multiple joints in her limbs which now fail to flex and extend freely. Her tongue has a thin white coating; the pulse is floating and moderate. Which of the following treatment principles will most help Ms. Wang? A. Dispel wind and unblock collaterals, dissipate cold and eliminate dampness

B. Dissipate cold and unblock the collaterals, dispel wind and eliminate dampness C. Eliminate dampness and unblock collaterals, dispel wind and dissipate cold D. Clear heat and unblock collaterals, dispel wind and eliminate dampness E. Enrich and supplement liver and kidney, relaxing tendons to stop pain 3. Mr. He, age 48, complains of aching pain in the joints of his four limbs. His knees feel painful, stiff and burning which prevents him from flexing or extending his lower legs freely, he is also very sweaty and thirsty. The tongue coating is dry and yellow; his pulse is slippery and rapid. Which of the following bi patterns apply? A. Migratory bi B. Fixed bi C. Wind, damp and heat bi D. Painful bi E. Bi due to phlegm and stasis blocking 4. Ms. Yu, age 47 has an aching fixed pain in the joints of her limbs, sometimes accompanied by swelling and numbness. Her pain is worse on rainy days. The tongue has a white greasy coating; her pulse is slippery and moderate. Which of the following formulas is your first choice for Ms. Yu? A. Shuāng Hé Tāng (Double Combined Decoction)

B. Fáng Fēng Tāng (Ledebouriella Decoction) C. Xuān Bì Tāng (Painful Obstruction-Resolving Decoction) D. Wū Tóu Tāng (Aconite Main Tuber Decoction) E. Yì Yĭ Rén Tāng (Coix Decoction) 5. Ms. Liu, age 54, reports that her elbows and knees were aching. She also reports fatigue, vertigo, tinnitus, low back and leg pain and weakness. The doctor observed that she had a pale complexion, weak respiration, no desire to speak, spontaneous perspiration, and muscular atrophy. Which of the following formulas is your first choice? A. Shuāng Hé Tāng (Double Combined Decoction) B. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) C. Jīn Guì Shèn Qì Wán (Golden Cabinet’s Kidney Qi Pill) D. Xuān Bì Tāng (Painful Obstruction-Resolving Decoction) E. Bŭ Zhōng Yì Qì Tāng (Center-Supplementing Qi-Boosting Decoction) 6. Mr. Chen, age 49, complains of weakness in all four limbs, lingering aching pain, and heaviness in the joints with obvious numbness. He sweats easily and has an aversion to cold with occasional palpitations, poor appetite, a pale green complexion, and a weak body condition. His tongue was pale and dry with a thin off-white coating; the pulse was deep and moderate. What kind of bi pattern is this case? A. Migratory bi

B. Fixed bi C. Heat bi D. Painful bi E. Bi due to qi and blood insufficiency 7. Ms. Xu, age 61, reports an aching pain in the joints, especially at the waist, legs, knees and ankles. The aching pain is aggravated on rainy days or by working late. She has a pale complexion, fatigue and muscle weakness, she sweats easily, and has an aversion to cold. Her tongue is pale with a thin coating. Which of the following treatment principles best applies? A. Dispel wind and unblock collaterals, dissipate cold and eliminate dampness B. Dissipate cold and unblock collaterals, dispel wind and eliminate dampness C. Eliminate dampness and unblock collaterals, boost qi and nourish blood D. Clear heat and unblock collaterals, dispel wind and eliminate dampness E. Enrich and supplement liver and kidney, relax tendons to stop pain Answers 1. D 2. A 3. C

4. E 5. B 6. E 7. C

2. Fibromyalgia ANCIENT THEORIES AND MODERN INSIGHTS Fibromyalgia is a non-joint related rheumatic disease with unclear pathological causes. Its main symptoms include general body aches with areas of localized tenderness as well as fatigue, anxiety, disturbed sleep, headache and gastrointestinal discomfort, sometimes with swelling and numbness in the joints. The term “fibromyalgia” does not exist in traditional Chinese medicine, when considering the symptoms described above, the condition generally falls under the category of “bi syndromes”, including “generalized bi”, “muscle bi” or “depressed bi”. The main internal causes of fibromyalgia include: constitutional weakness, zang-fu organ deficiencies, qi deficiency, ying-wei disharmony and yin–yang imbalances. External causes include wind, cold and dampness, or heat attacking and invading the weakened body. Zang-fu organ deficiencies of the spleen, liver or kidney result in insufficient production of qi and blood followed by ying–wei disharmony and subsequent invasion of the interstitial spaces where wind, cold or dampness enter the body to cause bi syndrome. Abnormal emotions or stress cause liver qi stagnation that leads to impaired blood circulation and blocked fluid distribution; such blockages are the cause of many pain symptoms.

The chief therapeutic approaches used in the treatment of fibromyalgia are to regulate yin and yang, expel pathogens and unblock the channels. Treatment principles include the following: dispel wind and disperse cold, eliminate dampness and unblock the channels to alleviate pain, soothe the liver and remove stagnation, strengthen the spleen and regulate qi, supplement qi and nourish blood, nourish liver and kidney, harmonize heart and kidney, and promote blood circulation to dissolve blood stasis.

ETIOLOGY AND PATHOMECHANISMS Dysfunctions of the heart, liver, spleen or kidney combined with an attack of wind, cold or dampness form the fundamental pathogeneses for bi syndrome. Such combinations lead to obstructed qi movement in the five zang-organs. Such failure in ascending or descending and poor circulation of qi and blood eventually results in pain due to blockage within the channels. Fibromyalgia is ultimately an excess branch pattern of wind, cold, dampness with a zang-fu organ deficiency as the root.

External Causes Wind, cold and dampness: In Basic Questions: Bi Theory (Sù Wèn: Bì Lùn, 素问·痹论) it is written that bi syndrome is the result of a combined attack from wind, cold, or dampness. Wind is a yang-pathogen. Cold and dampness are yin-pathogens which generate constriction, and ultimately obstruction. Wind-cold and wind-dampness are more commonly seen with wind being the carrier, thus pathogenic cold and dampness are the most important factors. Trauma: Body aches and joint pain following falls or sprain and strain incidents often arise as secondary to poor nourishment of the tendons and bones due to damaged vessels or blood clots.

Internal Causes Upright qi deficiency: Refers to deficiencies of essence, qi or blood due to a weak constitution, over-exertion, chronic illness, or during the post-partum period in women, all of which result in weakened zang-fu

organ function. Upright qi deficiency can also be caused by chronic bi syndrome obstructing the collaterals which causes blood stasis, obstructs the production of fresh blood and consumes essence. Such conditions lead to a deficiency of yin, blood, or ying as well as wei qi deficiency and subsequent invasion by external pathogens. External pathogens attach to the ying and wei to obstruct the circulation of qi and blood, and bi pain results. Liver blood deficiency can fail to nourish the tendons thus giving rise to bi syndrome with pain in the muscles or joints with limited range of motion. Abnormal emotions: Stress undermines the liver’s dispersing function which leads to qi stagnation. Qi stagnation will then result in stagnant blood circulation with multiple sites of soreness and tenderness, weak limbs and lassitude. Depressed liver function often causes depression, anxiety, insomnia and fatigue. Introduction toMedicine (Yī Xué Rù Mén, 医学入门) refers to general body aches caused by poor liver qi flow as “generalized bi”. Chronic injury by overstrain: This type of pain results from long-term localized damage from long-distance walking, excessive standing, or working in a nonergonomic manner. The repetitive movements consume blood and marrow, damage tendons and bones, and cause blood stasis, thus allowing for dampness to obstruct and cold to congeal. Excessive worry and mental exertion which leads to chronic consumption of heart blood results in poor memory and insomnia in some cases.

COMMON CLINICAL PATTERNS Commonly seen clinical patterns include: wind-cold obstructing the collaterals, qi stagnation and blood stasis, qi and blood deficiency, liver qi stagnation and spleen deficiency, heart and kidney deficiency, cold-damp overwhelming the spleen, damp-heat obstruction, liver and kidney deficiency. Wind-cold obstructing the collaterals: Main symptoms are multiple wandering and moderately tender spots all over the body which get worse when cold or at night. The pain is relieved by heat and better during the daytime. Pain is accompanied by a limited range of motion, and joint or muscle stiffness in the morning which is relieved by activity. There is a thin white tongue coating; the pulse is tight and floating, or tight and deep. Qi stagnation and blood stasis: The main symptoms are multiple sites of muscular pain that are fixed in location, and feel like needle pricks (assuming of course the pain does not arise during an acupuncture session). Accompanying signs and symptoms include poor mobility, headache, dizziness, a dark gray complexion, dim purple tongue and lips, and a deep or thin and choppy pulse. Qi and blood deficiency: Main symptoms include lingering, multiple tender spots, stiffness, and difficulty in walking, any of which are fluctuating in severity. Other signs and symptoms include insomnia, a pale complexion, palpitations, spontaneous sweating, dizziness, lethargy, a depressed mood, and poor appetite. The tongue is pale with a thin white coating; the pulse is thin and weak.

Liver qi stagnation and spleen deficiency: Main symptoms include multiple tender sites or general body tenderness. The pain will tend to be fixed in location, possibly including swelling and numbness aggravated by cold or rainy weather. Accompanying signs and symptoms include poor appetite, loose or watery stools, poor sleep and memory, and anxiety and irritability. The tongue coating is greasy white; the pulse is wiry. Heart and kidney deficiency: Main symptoms include multiple tender sites, stiffness in the morning, poor mobility, aversion to cold, weak and sore lower back and knees, and insomnia and poor memory. Accompanying signs and symptoms include lassitude, dizziness, tinnitus, night sweats, and anxiety. The tongue is pale red; the pulse is thin and rapid. Cold-damp overwhelming the spleen: Main symptoms are multiple tender sites, heavy sensations in the body, and lethargy. In general, the symptoms get worse in cold and rainy weather. Accompanying signs and symptoms include fullness and distention of the stomach and abdomen, a heavy or tightly-wrapped sensation in the head, a dark yellow complexion, decreased or no appetite, a bland taste in the mouth and no thirst. Patients with cold-dampness may favor warm drink, and report a sticky or greasy sensation in the mouth. Cold-dampness also produces loose stools, scanty urine, and profuse leukorrhea in females. The tongue is pale or swollen; the pulse is slippery or moderate. Damp-heat obstruction: Main symptoms include multiple sites of muscular tenderness, distending pain, morning stiffness, heavy and numb sensations in the body, and general difficulty in movement. The accompanying signs and symptoms include a bitter taste in the mouth, dry throat, fullness in the chest and abdomen, and scanty yellow urine. The tongue coating is greasy yellow; the pulse is wiry and slippery.

Liver and kidney deficiency: Main symptoms are chronic and lingering multiple sites of tenderness, stiffness, numbness, difficulty in movement and poor endurance. The accompanying symptoms include dizziness and blurred vision, tinnitus and poor memory, rib-side pain, aching of the lower back and weak knees, dry throat and mouth, insomnia or profuse dreaming, low-grade fever or five-center heat, red cheeks, spermatorrhea in men, or scanty menses in women. The tongue is red with scanty coating; the pulse is thin and rapid. In cases where the kidney deficiency is more yang in nature, there may be aversion to cold and a preference for warmth, cold extremities, palpitations and shortness of breath; the tongue is pale with white coating; the pulse is deep and thin.

THERAPEUTICS Chinese Medicinals 1. Wind-Cold Obstructing the Collaterals Formula: Modified Juān Bì Tāng (Impediment-Alleviating Decoction) Ingredients: qiāng huó (Rhizoma et Radix Notopterygii), dú huó (Radix Angelicae Pubescentis), fáng fēng (Radix Saposhnikoviae), huáng qí (Radix Astragali), jiāng huáng (Rhizoma Curcumae Longae), sāng zhī (Ramulus Mori), hăi fēng téng (Caulis Piperis Kadsurae), má huáng (Herba Ephedrae), qín jiāo (Radix Gentianae Macrophyllae), guì zhī (Ramulus Cinnamomi), dāng guī (Radix Angelicae Sinensis), bái sháo (Radix Paeoniae Alba), zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle), shēng jiāng (Rhizoma Zingiberis Recens), dà zăo (Fructus Jujubae) 2. Qi Stagnation and Blood Stasis Formula: Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) Ingredients: chuān xiōng (Rhizoma Chuanxiong), qiāng huó, qín jiāo, táo rén (Semen Persicae), hóng huā (Flos Carthami), mò yào (Myrrha), dāng guī, wŭ líng zhī (Faeces Trogopterori), zhì xiāng fù (Rhizoma Cyperi Praeparatum), niú xī (Radix Achyranthis Bidentatae), dì lóng (Pheretima), gān căo (Radix et Rhizoma Glycyrrhizae) 3. Qi and Blood Deficiency

Formula: Bā Zhēn Tāng (Eight-Gem Decoction) or Shèng Yù Tāng (Sagacious Cure Decoction) Ingredients: dăng shēn (Radix Codonopsis), huáng qí, chuān xiōng, dāng guī, shú dìhuáng (Radix Rehmanniae Praeparata), fú líng (Poria), bái sháo, gān căo 4. Liver Qi Stagnation and Spleen Deficiency Formula: Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder) Ingredients: mŭ dān pí (Cortex Moutan), chăo zhĭ shí (dry-fried Fructus Aurantii Immaturus), chái hú (Radix Bupleuri), dāng guī, fú líng, bái zhú (Rhizoma Atractylodis Macrocephalae), bái sháo, cù xiāng fù (prepared with vinegar) (Rhizoma Cyperi), héhuān pí (Cortex Albiziae), suān zăo rén (Semen Ziziphi Spinosae), yán hú suŏ (Rhizoma Corydalis), dà zăo, shēng gān căo (Radix et Rhizoma Glycyrrhizae), bò he (Herba Menthae), shēng jiāng 5. Heart and Kidney Deficiency Formula: Modified Xīn Shèn Wán (Heart and Kidney Pill) Ingredients: niú xī (Radix Achyranthis Bidentatae), ròu cōng róng (Herba Cistanches), huáng qí, tù sī zĭ (Semen Cuscutae), rén shēn (Radix et Rhizoma Ginseng), shān yào (Rhizoma Dioscoreae), zé xiè (Rhizoma Alismatis), fù zĭ (Radix Aconiti Lateralis Praeparata), fú shén (Sclerotium Poriae Pararadicis), wŭ wèi zĭ (Fructus Schisandrae Chinensis), lóng gŭ (Os Draconis; Fossilia Ossis Mastodi), yuăn zhì (Radix Polygalae), băi zĭ rén (Semen Platycladi), shān zhū yú (Fructus Corni), dāng guī, shú dìhuáng 6. Cold-Dampness Overwhelming Spleen

Formula: Shí Pí Yĭn (Spleen-Strengthening Beverage) Ingredients: zhì fù zĭ (Radix Aconiti Lateralis Praeparata), fú líng, bái zhú, gān căo, gān jiāng (Rhizoma Zingiberis), hòu pò (Cortex Magnoliae Officinalis), bàn xià (Rhizoma Pinelliae), cāng zhú (Rhizoma Atractylodis), mù guā (Fructus Chaenomelis), mùxiāng (Radix Aucklandiae), căo guŏ (Fructus Tsaoko), dà fù zĭ (Semen Arecae), guì zhī (Ramulus Cinnamomi) 7. Damp-Heat Obstruction Formula: Modified Dāng Guī Niān Tòng Tāng (Chinese Angelica Pain-Alleviating Decoction) Ingredients: bái zhú, zé xiè, kŭ shēn (Radix Sophorae Flavescentis), fáng fēng, qiānghuó, zhū líng (Polyporus), yīn chén (Herba Artemisiae Scopariae), huáng qín, dăng shēn, shēng má (Rhizoma Cimicifugae), gān căo, zhī mŭ (Rhizoma Anemarrhenae), gé gēn (Radix Puerariae Lobatae), cāng zhú, sāng zhī (Ramulus Mori) 8. Liver and Kidney Deficiency Formula: Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) Ingredients: dú huó, dù zhòng (Cortex Eucommiae), chuān xiōng, dāng guī, fú líng, bái sháo, gān căo, qín jiāo, niú xī, sāng jì shēng (Herba Taxilli), xì xīn (Radix et Rhizoma Asari), ròu guì xīn (Cortex Cinnamomi), fáng fēng, shēng dì, rén shēn

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels Selected points include those of the inner and outer line of the urinary bladder channel and du mai. The purpose is to eliminate general body bi pain by regulating zang-fu organ qi flow and regulating ying and wei. 2. Point Selection According to Pattern Differentiation (1) Wind-cold obstructing collaterals: LI 11 (qū chí), GB 20 (fēng chí), BL 12 (fēngmén), LI 4 (hé gŭ), SJ 5 (wài guān), DU 3 (yāo yáng guān), GB 34 (yáng líng quán), jĭng băiláo (EX-HN15), SI 12 (bĭng fēng), SI 11 (tiān zōng), SI 14 (jiān wài shù), ashi points (2) Qi stagnation and blood stasis: BL 17 (gé shù), BL 40 (wĕi zhōng), SP 10 (xuè hăi), LI 4 (hé gŭ), SP 6 (sān yīn jiāo), BL 60 (kūn lún), PC 6 (nèi guān), LV 3 (tài chōng), BL 10 (tiān zhù), jĭng băi láo (EX-HN15), SI 12 (bĭng fēng), SI 11 (tiān zōng), SI 13 (qū yuán), ashi points (3) Qi and blood deficiency: BL 20 (pí shù), BL 21 (wèi shù), ST 41 (jiĕ xī), LI 11 (qūchí), LI 4 (hé gŭ), Sp 6 (sān yīn jiāo), RN 6 (qì hăi), RN 4 (guān yuán), ST 36 (zú sān lĭ), SP 10 (xuè hăi), ashi points (4) Liver qi stagnation and spleen deficiency: BL 20 (pí shù), BL 18 (gān shù), LI 4 (hé gŭ), SP 6 (sān yīn jiāo), ST 36 (zú sān lĭ), SP 9 (yīn líng quán), PC 6 (nèi guān), LV 3 (tàichōng), jĭng băi láo (EX-HN15), ashi points (5) Heart and kidney deficiency: HT 7 (shén mén), BL 23 (shèn shù), BL 15 (xīn shù), KI 3 (tài xī), RN 4 (guān yuán), KI 6 (zhào hăi), BL 62

(shēn mài), ashi points (6) Cold-dampness overwhelming spleen: SP 9 (yīn líng quán), SP 6 (sān yīn jiāo), ST 36 (zú sān lĭ), PC 6 (nèi guān), ST 40 (fēng lóng), SP 4 (gōng sūn), GB 34 (yáng língquán), ashi points (7) Damp-heat obstruction: GB 20 (fēng chí), LI 11 (qū chí), LI 4 (hé gŭ), SP 9 (yīn língquán), DU 14 (dà zhuī), GB 21 (jiān jĭng), SI 12 (bĭng fēng), SI 11 (tiān zōng), SI 14 (jiān wàishù), SI 3 (hòu xī), SJ 6 (zhī gōu), ashi points (8) Liver and kidney deficiency: BL 23 (shèn shù), BL 18 (gān shù), SP 6 (sān yīn jiāo), GB 39 (xuán zhōng), KI 3 (tài xī), RN 4 (guān yuán), DU 3 (yāo yáng guān), SP 10 (xuèhăi), KI 6 (zhào hăi), ashi points

CASE STUDY I Alice B., Female, age 48, teacher. Initial Visit: October 13th, 2003 Chief Complaint: General body aches for eight months, worsening over the past two months. History: Eight months ago, during a period of work-related stress the patient started having pain in the neck, shoulders, chest, back, lower back, hip and buttocks. Over the past two months, the pain has worsened and spread to the elbows, legs, ankles, soles, palms and plantar fascia. Other symptoms included insomnia with dream-disturbed sleep, poor memory, mental confusion and moodiness, restlessness, pain that migrated through the chest, rib-sides and epigastrium, irritability, poor appetite, and abdominal pain with diarrhea. Over the past six months, the patient had difficulty putting on clothes due to the sensation of the clothes cutting into the skin. She also experienced severe insomnia, low appetite, and weight loss from 176 to 99 lbs (80 to 45 kg). The patient had been evaluated and treated at several hospitals and admitted to a psychiatric hospital two months prior; however, she experienced poor improvement in terms of pain, or mental and nervous system symptoms. The Western medicine physician recommended Chinese medicine therapy. Signs and Symptoms: Multiple locations of fixed tenderness on the neck, shoulder, chest, back, lower back, hip and buttocks areas. This sensitivity was worse with fluctuations of her mood. She complained of migrating pains in her chest, rib-side and epigastric areas, irritability, poor appetite, abdominal pain with diarrhea, insomnia with dream disturbed

sleep, poor memory, and anxiety. The tongue body was red with teeth marks and the coating was thin and greasy. Her pulse was wiry and slippery. Past History: Healthy with no history of illness in the past. Menstrual, Marital and Childbearing History: Married at average age, one full-term pregnancy. Her daughter and husband are both healthy. Physical Examination: Normal vital signs, no abnormal findings in the head, face or internal organs. Twenty-eight tender spots were found to be sensitive to 9 lbs (4 kg) thumb pressure located on the neck, shoulder, chest, scapular areas, elbows, lower back, iliac, knees and ankles. The muscle strength of the limbs was graded as 3/5. Normal heart and lungs, soft abdomen without obvious tenderness or masses, no palpable liver or spleen, normal physiological reflex, no pathological reflex. Auxiliary Examination: CBC, urine analysis, blood sedimentation, rheumatoid factor, antinuclear antibody, abdominal ultrasound, cerebral Doppler ultrasound, and electromyography were normal. This case was diagnosed as fibromyalgia, based on comprehensive analysis of the patient’s medical history, symptoms, signs, physical examination, biochemistry, and consultation with specialists. Pattern Differentiation The main findings of this patient’s condition are: middle-aged female, 50 years old, and perimenopausal. The yin and blood deficiency results in poor nourishment of the sinews and channels. Excessive emotional distress from her work results in the liver failing to ensure free flow of qi, with subsequent qi and blood stagnation. The blockage produces general body achiness, while liver-wood overacting on the spleen undermines the spleen’s transportation and transformation functions and production of qi

and blood. Poor nourishment for the muscles in the four limbs follows, so the condition is sometimes simply referred to as “general fatigue”. Long-term stagnated liver qi often transforms into fire which caused this patient’s anxiety and insomnia due to liver fire disturbing the heart and mind. Rib-side and stomach distention and pain is caused by liver-wood overacting on the spleen and leading to poor transportation and transformation. Deficient spleen qi fails to lift the clear qi or transport and transform the food and drink, resulting in abdominal pain and diarrhea. Poor concentration arises when the deficiency qi and blood are unable to nourish the brain and heart. Her red tongue with a thin greasy coating and teeth marks suggest heat in the liver and a weakened spleen. The wiry and slippery pulses also conform to the diagnosis of a wood/earth disharmony. Diagnosis WM diagnosis: Fibromyalgia TCM diagnosis: Generalized bi to liver qi stagnation with spleen deficiency Clinical Treatment Since this female patient’s general body pain results from several factors such as menopause, emotional distress resulting in poor liver qi flow, blood stagnation, and a systemic lack of nourishment, the therapy should also regulate the emotions and mood. Principles: Soothe the liver, strengthen the spleen, regulate qi and blood, unblock the channels to alleviate pain Formula: Modified Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder)

[丹栀逍遥散加减]

[Formula Analysis] Mŭ dān pí and zhī zĭ clear liver fire. Chái hú, xiāng fù and yán hú suŏ soothe the liver and move qi. Suān zăo rén and hé huān pí calm the shen (spirit), dāng guī and bái sháo harmonize qi and blood and soften the liver. Bái zhú, fú líng and yì yĭ rén fortify the spleen and dispel dampness. Zhĭ qiào regulates qi flow. Sī guā luò unblocks the channels to stop pain.

Shēng jiāng and dà zăo regulate the spleen and stomach. Shēng gān căo acts to harmonize all formula ingredients.

Acupuncture Main points: BL 20 (pí shù), ST 36 (zú sān lĭ), BL 18 (gān shù), GB 34 (yáng língquán), PC 6 (nèi guān), LI 4 (hé gŭ), LV 3 (tài chōng), ashi points Supplementary points: HT 7 (shén mén), SP 10 (xuè hăi), ST 40 (fēng lóng), SP 9 (yīnlíng quán), SP 6 (sān yīn jiāo), jĭng băi láo (EX-HN15) Method: Needles were retained for 30-40 min, manipulating the needle every 10 min. Ten visits count as one course of treatment, with a one-week break between courses. Techniques: Select ashi points with the group of main points while adding two or three supplementary points; apply supplementation techniques after the arrival of qi at BL 20 (pí shù) and ST 36 (zú sān lĭ), and the even method for the rest of the points. The patient was treated every other day. Electro-acupuncture can be beneficial in pain syndromes such as this. Further Consultation After ten visits, the patient reported that her sleep, mood, appetite, pain and accompanying symptoms had shown moderate improvement. After a one-week break, the patient’s symptoms disappeared completely and her life returned back to normal after two more courses of treatment. After six months or follow-up, the patient showed no recurrence of the illness.

CASE STUDY II (ACUPUNCTURE, Huang Zhuzhai) Ms. Wang, age 52. Chief Complaint: Multi-site pain, associated with difficult movement for six years. History: The patient suffered from pain in the four limbs, shoulders, back and lower back, with difficulty in movement. The pain was in fixed locations and worse at night and on rainy days; the painful areas felt cold to the patient. Other symptoms included profuse clear urine, fatigue, poor appetite, and heavy sensations in the limbs. There was little improvement after extensive usage of Western medications and Chinese herbs. Physical Examination: Pale tongue with a thick white coating and teeth marks, and a wiry tight pulse. A total of fifteen tender spots were found, and the patient complained that these spots also felt cold. Diagnosis Generalized bi due to wind-cold-dampness obstructing the collaterals Clinical Treatment Principles: Dispel wind and dissipate cold, drain dampness, warm and unblock the collaterals Points: ashi points, LI 11 (qū chí), LI 4 (hé gŭ), SJ 5 (wài guān), BL 12 (fēng mén), GB 20 (fēng chí), DU 3 (yāo yáng guān), GB 34 (yáng líng quán), SP 9 (yīn líng quán), DU 14 (dà zhuī), SI 12 (bĭng fēng), SI 11 (tiān zōng), SI 14 (jiān wài shù)

Manipulations: Apply direct moxibustion on the 15 tender points, and needle the rest of the points with drainage. After the arrival of qi, retain the needles for 30 min, manipulate the needle every 10 min. The goal is to unblock the collaterals, and warm and dispel the cold-dampness. Regarding direct moxibustion, one cone on each tender spot and let it burn out completely. In this case, all fifteen spots were blistered while six of them produced pus. The patient felt significant relief after these burned spots healed. Eight tender spots were found on the return visit two weeks later. Those tender spots were less painful than before, the condition was resolved after reapplying the same treatment. Note The patient’s fluctuating fixed pain was caused by long-term windcold-dampness obstructing the channels, which resulted in further obstruction in the collaterals. The points on the regular channels chosen by her previous doctors were not effective. The location of wind-colddampness was in the channels during the early stage, but later in the blood and collaterals. Since the collaterals are distributed all over the body like a web, there were fifteen tender points located in total. In conclusion, this patient had a chronic bi syndrome which resulted in upright qi deficiency. The purpose of applying moxibustion is to strengthen the upright qi while expelling the pathogens, assisted by stimulation on the regular points to expel the pathogen in the regular channels. “Deep moxibustion”, where the moxa cone burns completely to the skin, is especially effective for such conditions deep within the collaterals. The blistering and pus should be carefully attended to, such that the pus is hygienically removed with standard medical procedures, and then covered with anti-inflammatory ointment or powder to prevent the infection from

spreading. The burned areas usually heal in a few days while the patient’s symptoms subside. (Editor’s note: practitioners in Western countries should operate within local standards of care before engaging in any treatment that could result in a burn or scarring.)

COMMENTARY AND DISCUSSION The etiologies and patterns presented in this chapter point to most of the usual bi syndromes; however, Western medicine also has many tools to address many of them such as NSAIDs, steroids, etc. One deficiency in the biomedical paradigm involves solutions to the wide variety of responses to chronic stress, while in fact TCM is well-familiar with stress-induced diseases via the liver and its qi-regulating functions. As such, paying close attention to the liver is a wise choice when treating fibromyalgia.

STUDY QUESTIONS 1. Why were LI 4 (hé gŭ) and LV 3 (tài chōng) chosen in the first case? 2. Why were supplementation techniques applied to BL 20 (pí shù) and ST 36 (zúsān lĭ) in the first case? 3. Why did this case include ashi points among the main points in the first case? Answers 1. LI 4 (hé gŭ) is the yuan-source point on the large intestine channel, which is good at regulating the qi and blood, unblocking channels and collaterals, promoting qi flow and opening orifices, dispersing wind and clearing heat, and most importantly in this case, tranquilizing the spirit. LV 3 (tài chōng) is the shu-stream and yuan-source point on the liver channel, which is used to regulate the qi and blood, unblock channels and collaterals, soothe the liver and move the qi, subdue the liver and extinguish wind, clear heat, and drain dampness. Located on both hands and feet, LI 4 (hé gŭ) and LV 3 (tài chōng) are named the “four gates”, a point combination that acts to unblock channels and collaterals to alleviate bi syndrome and pain while soothing the liver and promoting the free-flow of qi. The Song to Elucidate Mysteries (Biāo Yōu Fù, 标幽赋) states that the four gates can stop bi pain due to cold or heat. 2. Applying supplementation to BL 20 (pí shù) and ST 36 (zú sān lĭ) strengthen the spleen and promote the production of qi and blood, important

because this case was due to liver qi stagnation resulting in a spleen deficiency. 3. Ashi points are the sensitive or reactive points, whether or not they found on a channel. The Spiritual Pivot: Channel Sinews (Líng Shū: Jīng Jīn, 灵枢·经筋) recommends the use of tender points. An ashi point reflects the pathological condition because it results from blocked qi and blood in the affected area. Stimulation of an ashi point can ensure qi and blood circulation by dispersing congealed qi and blood. Relief from pain is thus achieved.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Ms. Li, age 52, retired, has suffered from general body aches for five months, worsened over the past month. Main symptoms are fluctuating, multiple tender spots around the shoulder blades, knees, elbow, lower back and pelvic area. Stiff joints cause difficult movement. Other signs and symptoms include insomnia, poor memory, pale complexion, palpitations, spontaneous sweating, dizziness, fatigue, and a poor appetite. Her tongue is pale with a thin white coating; the pulse is thin and weak. Which of the following formulas is the best choice? A. Bā Zhēn Tāng (Eight-Gem Decoction) B. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) C. Modified Juān Bì Tāng (Impediment-Alleviating Decoction) D. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) E. Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder) 2. Mr. Xue, age 35, an office worker, complains of general body aches over the past four years. Main symptoms are multiple severely tender spots

that migrate all over the body. Symptoms are aggravated by cold weather and at night. Symptoms are relieved by warmth and during the daytime. There is joint stiffness which is worse in the morning and relieved after movement. The tongue coating is thin white; he has a floating and tight pulse. Which of the following formulas is the best choice? A. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) B. Modified Juān Bì Tāng (Impediment-Alleviating Decoction) C. Shèng Yù Tāng (Sagacious Cure Decoction) D. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) E. Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder) 3. Ms. Pang, age 37, has suffered from general body aches for eight months. Main symptoms include sharp fixed tender spots on the back, lower back, hips and knees. Accompanying symptoms include stiff joints with difficulty in movement, insomnia with dream-disturbed sleep, headache and dizziness, and a dark and grayish complexion. The tongue is dim purple, and the pulse is deep, thin and choppy. Which of the following formulas is most suitable for this case? A. Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder) B. Modified Juān Bì Tāng (Impediment-Alleviating Decoction) C. Shèng Yù Tāng (Sagacious Cure Decoction)

D. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) E. Shí Pí Săn (Spleen-Strengthening Formula) 4. Ms. Sun, age 39, has suffered from multiple sites of muscular pain over the past three years. Accompanying symptoms include migrating pain in the chest, rib-sides and stomach areas, a weak stomach with poor appetite, insomnia with dream-disturbed sleep, and loose stools. Her pain gets worse when depressed and she also has a short temper. There is abdominal pain and diarrhea immediately following the ingestion of oily or greasy foods. She has a red tongue with a thin greasy coating and teeth marks, and her pulse is wiry. Which of the following formulas is most suitable for this case? A. Modified Dāng Guī Niān Tòng Tāng (Chinese Angelica PainAlleviating Decoction) B. Modified Juān Bì Tāng (Impediment-Alleviating Decoction) C. Shèng Yù Tāng (Sagacious Cure Decoction) D. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) E. Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder) 5. Ms. Yang, age 35, complains of generalized wandering body pain over the past five years, which has been worse over the past month. Main symptoms include multiple tender and sore spots on the neck, upper and lower back, sacrum and four extremities. Other symptoms include general body heaviness and fatigue; all symptoms are aggravated by rainy weather

and at night. Accompanying symptoms include abdominal distention, a heavy sensation of the head, a sticky greasy feeling in the mouth, no appetite, loose stools, scanty urination, and profuse leucorrhea. The tongue is pale and swollen with a white greasy coating, and the pulse is moderate. Which of the following formulas is the best choice? A. Modified Dāng Guī Niān Tòng Tāng (Chinese Angelica PainAlleviating Decoction) B. Modified Juān Bì Tāng (Impediment-Alleviating Decoction) C. Shí Pí Yĭn (Spleen-Strengthening Beverage) D. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) E. Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder) 6. Mr. Liu, age 36, complains of general body aches for the past six months. Main symptoms include multiple tender spots all over the body, morning stiffness, aversion to cold, sore and weak low back and knees, insomnia and poor memory. Accompanying symptoms include lassitude, dizziness, tinnitus, night sweats, and anxiety. There is a pink tongue, and a deep, thin rapid pulse. Which of the following formulas is the best choice? A. Dāng Guī Niān Tòng Tāng (Chinese Angelica Pain-Alleviating Decoction) B. Xīn Shèn Wán (Heart and Kidney Pill) C. Shèng Yù Tāng (Sagacious Cure Decoction)

D. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) E. Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder) 7. Ms. Xiang, age 72, has had general body aches over the past two years. The main symptoms are lingering and include multiple areas of muscular tenderness, stiffness, numbness, difficulty in movement and poor endurance. Accompanying symptoms include weight-loss, dry skin, dizziness and blurred vision, tinnitus and poor memory, sore and weak lower-back and knees, dry throat and mouth, insomnia and profuse dreaming, five-center heat, and red cheeks. There is a red tongue with a scanty coating, and a thin deep pulse. Which of the following formulas would be the best choice? A. Dāng Guī Niān Tòng Tāng (Chinese Angelica Pain-Alleviating Decoction) B. Xīn Shèn Wán (Heart and Kidney Pill) C. Shèng Yù Tāng (Sagacious Cure Decoction) D. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) E. Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder) 8. Ms. Zhu, age 21, has suffered with general body aches for 1 ½ years. The main symptoms are multiple tender spots that feel large and bloated which give her the sensation of five to ten pounds of pressure on the body. Her symptoms are worse in the morning. She also reports numbness

in the extremities, and difficulty in movement. The accompanying symptoms include a bitter taste in the mouth, dry throat, fullness in the chest and abdomen, and scanty yellow urine. There is a greasy yellow tongue coating, and a wiry and slippery pulse. Which of the following formulas would you select? A. Shí Pí Yĭn (Spleen-Strengthening Beverage) B. Xīn Shèn Wán ( Heart and Kidney Pill) C. Shèng Yù Tāng (Sagacious Cure Decoction) D. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) E. Dāng Guī Niān Tòng Tāng (Chinese Angelica Pain-Alleviating Decoction) Answers 1. A 2. B 3. D 4. E 5. C 6. B 7. D 8. E

3. Gout ANCIENT THEORIES AND MODERN INSIGHTS Gout is a common disease caused by a disorder of purine metabolism. Its main manifestation is recurrent gouty arthritis (or “gout”). According to traditional Chinese medicine, gout is classified as a “bi syndrome”, “painful wind”, or “pain of multiple joints” which is rooted in liver-kidney depletion with a failure of the spleen’s transportation function. The branch symptoms arise from wind, cold, dampness, heat, turbid phlegm and static blood obstructing the channels. Gout then, is a pattern of root deficiency with excess branch manifestations. Gout initially affects the limbs, joints and channels, later invading the sinews and bones and damaging the zang-fu organs. Treatment is determined according to its stage; branch manifestations should be addressed during acute episodes, while in chronic conditions the root pattern should be treated. Further Discourses on the Acquisition of Knowledge through Profound Study (Gé ZhìYú Lùn, 格致余论) states, “Congealing turbidity leads to pain. The pain is worse at night because congealing turbidity is a yin-pathogen.” This passage suggests that the cause of gout is mainly turbidity. Therefore, the appropriate treatment strategy should remove turbidity by invigorating blood, unblocking the collaterals, dispelling stasis. The acute stage of gout presents with obvious redness, swelling, hotness and pain, the manifestations of excess internal heat. The obvious

treatment approach for this stage is to eliminate the excess. Acupuncture therapies employ the drainage method or bleeding on yang channel points. “Stagnation causes pain”. The stagnation arises from pathogenic qi entering the channels from internal or external sources. External sources include pathogenic wind, cold, dampness or heat that blocks the channels in the limbs and joints. The stagnation then generates heat, and over time scorches fluids into phlegm. This results in hot swellings in the joints and muscles that become numb, heavy, and stiff with difficult bending or stretching. Internal causes of stagnation include chronic illnesses where over time the blood vessels tend to be obstructed by stasis. This leads to a coagulation of body fluids leading to blockage of turbid-phlegm and blood stasis in the channels, resulting in joint swelling, deformity, stiffness, purplish-red skin, nodules, etc. Another internal mechanism for gouty arthritis is a congenital deficiency with a poor diet. Key pathomechanisms involve the kidney failing to warm, the spleen failing to transport and transform, or deficiency of both liver and kidney. These conditions give rise to phlegm-damp, blood stasis, turbid-toxin, and cold-dampness. The early stage of gout is always characterized by excess branch manifestations, while the chronic stage includes both root deficiency and branch excess, either of which may predominate.

ETIOLOGY AND PATHOMECHANISMS Gouty arthritis is commonly divided into acute and chronic stages although the etiologies and pathomechanisms may be complex. Its branch is mainly due to blockage and obstruction in the channels due to wind, cold, dampness, heat, turbid phlegm and blood stasis. The root pattern involves the liver, spleen or kidney. Wind-damp-heat: Arises when wind-damp-heat attacks the exterior, or when a pre-existing yang exuberance or yin deficiency generates heat in the channels, or as a result of long-term stagnation and constraint that transforms into heat, causing heat bi. Wind-cold-damp: If the three qi of wind, cold and dampness attack the exterior at the same time, the wind causes movement (of pain), the cold causes constriction, and the dampness causes sensations of heaviness and internal turbidity. Constricting cold and dampness stagnation causes qi to stagnate and the blood flow to become rough, thus leading to bi syndrome accompanied by cold pain in the joints, sinews and muscles. Turbid-phlegm and stagnation: Over-consumption of spicy and fatty foods generates internal turbid-phlegm. Another scenario is that chronic invasion of pathogenic qi injures qi and blood, which then congeals into phlegm. This phlegm obstructs the channels and collaterals, stagnates in the sinews, muscle and joints, and leads to qi and blood blockage. It is also possible that the kidney fails to warm, and/ or the spleen fails to transport and transform water and grain. The outcome of this pathomechanism involves the retention of phlegm-dampness and blood stasis.

COMMON CLINICAL PATTERNS The most commonly encountered clinical pattern during the acute stage is winddamp-heat. During the chronic stage we more often find windcold-dampness, blockage of phlegm and blood stagnation, liver-kidney deficiency, and spleen deficiency leading to internal dampness. Wind-damp-heat: Severe red and swollen joints which are hot to the touch, acute onset, often with sensitivity on points along the yang channels. Wind-cold-damp: The three pathogenic qi of wind, cold and dampness attack the body at the same time, with symptoms differing according to the strength of the wind, cold or dampness. Blockage of phlegm and blood stagnation: Recurrent chronic arthralgia, swollen stiff or deformed joints, difficulty in bending and stretching, subcutaneous nodes, and a purple or dim skin tone. In severe cases, local tissues can rupture. Spleen deficiency leading to damp encumbrance: Chronic arthralgia accompanied by poor appetite and digestion, a greasy sensation in the mouth, abdominal distention, thin unformed stools, full-body sensations of heaviness, fatigue. Liver-kidney deficiency: In addition to symptoms affecting the joints, there are also manifestations of liver and kidney deficiency such as low back and knee pain, dizziness and tinnitus.

THERAPEUTICS Chinese Medicinals Gout is classified in TCM as a bi syndrome, so medicinals that unblock the channels and collaterals and diffuse bi pain play a most important role in treatment. Herbs that are vines are often used as guides to lead other medicinals into the affected channels and collaterals of the four limbs and joints. Vine-based medicinals also have applicable therapeutic benefits of their own.

Acute Stage Wind-damp-heat Formula: Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) Ingredients: shí gāo (Gypsum Fibrosum), zhī mŭ (Rhizoma Anemarrhenae), guì zhī (Ramulus Cinnamomi), jīng mĭ (Oryza Sativa L.), gān căo (Radix et Rhizoma Glycyrrhizae)

Chronic Stage 1. Wind-cold-damp Formula: Yì Yĭ Rén Tāng (Coix Decoction) Ingredients: qiāng huó (Rhizoma et Radix Notopterygii), dú huó (Radix Angelicae Pubescentis), fáng fēng (Radix Saposhnikoviae), cāng zhú (Rhizoma Atractylodis), dāngguī (Radix Angelicae Sinensis), guì zhī,

chuān xiōng (Rhizoma Chuanxiong), má huáng (Herba Ephedrae), yì yĭ rén (Semen Coicis), zhì chuān wū (Radix Aconiti Praeparata), shēng jiāng (Rhizoma Zingiberis Recens), gān căo 2. Blockage of Phlegm and Blood Stagnation Formula: Táo Hóng Yĭn (Peach Kernel and Carthamus Beverage) and Èr Chén Tāng (Two Matured Substances Decoction) Ingredients: táo rén (Semen Persicae), hóng huā (Flos Carthami), dāng guī (Radix Angelicae Sinensis), chuān xiōng (Rhizoma Chuanxiong), fú líng (Poria), chén pí (Pericarpium Citri Reticulatae), fă bàn xià (Rhizoma Pinelliae Praeparatum), wēi língxiān (Radix et Rhizoma Clematidis), gān căo 3. Spleen Deficiency Leading to Damp Encumbrance Formula: Fáng Jĭ Huáng Qí Tāng (Stephania Root and Astragalus Decoction) Ingredients: fáng jĭ (Radix Stephaniae Tetrandrae), huáng qí (Radix Astragali), báizhú (Rhizoma Atractylodis Macrocephalae), gān căo 4. Liver-kidney Deficiency Formula: Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) Ingredients: dú huó (Radix Angelicae Pubescentis), sāng jì shēng (Herba Taxilli), niú xī (Radix Achyranthis Bidentatae), dù zhòng (Cortex Eucommiae), xì xīn (Radix et Rhizoma Asari), qín jiāo (Radix Gentianae Macrophyllae), fú líng (Poria), ròu guì (Cortex Cinnamomi), fáng fēng (Radix Saposhnikoviae), dăng shēn (Radix Codonopsis), dāng guī, shú dì

huáng (Radix Rehmanniae Praeparata), bái sháo (Radix Paeoniae Alba), gān căo ★ Key Medicinals

● Wind-damp stagnation in the collaterals: luò shí téng (Caulis Trachelospermi), fáng fēng

● Dampness in the collaterals: qīng fēng téng (Caulis Sinomenii), hăi fēng téng (Caulis Piperis Kadsurae), sī guā luò (Retinervus Luffae Fructus)

● Heat in the collaterals: rĕn dōng téng (Caulis Lonicerae Japonicae) ● Blood stagnation in the collaterals: jī xuè téng (Caulis Spatholobi) Acupuncture and Moxibustion Treatment 1. Point Selection According to Stage (1) Acute stage: SP 1 (yĭn bái), LV 1 (dà dūn), LV 3 (tài chōng), SP 6 (sān yīn jiāo), KI 3 (tài xī), KI 6 (zhào hăi), ashi points (2) Chronic stage: LV 3 (tài chōng), SP 6 (sān yīn jiāo), SP 3 (tài bái), KI 3 (tài xī), KI 6 (zhào hăi), SP 36 (zú sān lĭ), BL 18 (gān shù), BL 23 (shèn shù) 2. Point Selection Based on Pattern Differentiation (1) Wind-damp-heat: GB 40 (qiū xū), SP 2 (dà dū), SP 3 (tài bái) (2) Wind-cold-damp: GB 20 (fēng chí), SJ 5 (wài guān) (3) Blockage of phlegm and blood stagnation: ST 40 (fēng lóng), BL 20 (pí shù), SP 10 (xuè hăi), BL 17 (gé shù)

(4) Spleen deficiency leading to damp encumbrance: SP 9 (yīn líng quán), BL 20 (pí shù) (5) Liver-kidney deficiency: KI 3 (tài xī), SP 6 (sān yīn jiāo) 3. Point Selection According to Location (1) Pain at the first metatarsal joint (big toe): LV 3 (tài chōng), SP 3 (tài bái), SP 6 (sān yīn jiāo) (2) Pain in the toes: SP 3 (tài bái), SP 2 (dà dū), SP 6 (sān yīn jiāo), LV 3 (tài chōng) (3) Pain in the ankle: LV 4 (zhōng fēng), BL 60 (kūn lún), ST 41 (jiĕ xī), GB 40 (qiū xū), BL 40 (wĕi zhōng), GB 39 (xuán zhōng) (4) Pain in the knees: xī yăn (EX-LE5), GB 34 (yáng líng quán), LV 8 (qū quán) (5) Pain in the wrist: SJ 4 (yáng chí), SJ 5 (wài guān), LI 4 (hé gŭ), LV 3 (tài chōng) (6) Pain in the elbow: LI 4 (hé gŭ), LI 10 (shŏu sān lĭ), LI 11 (qū chí), LU 5 (chĭ zé) (7) Pain in the shoulder: LI 15 (jiān yú), SI 9 (jiān zhēn), GB 21 (jiān jĭng), ashi points Use the drainage method during the acute stage, and the even method during the chronic stage. Moxibustion can be combined with the acupuncture for patterns of wind-damp-cold. Moxibustion is also indicated for deficiency patterns following a chronic illness. However, in patterns of wind-damp-heat, moxibustion is contraindicated.

Clinical research suggests that external treatments such as collateral bleeding, point injection and the topical application of Chinese herbal medicines can produce considerable therapeutic effects.

CASE STUDY I Mr. Lin, age 15. Initial Visit: April 26th, 1979 Chief Complaint: Redness, swelling, heat and pain of the first metatarsophalangeal joint on the left side for over two months. History: Two months prior, Mr. Lin’s first metatarsophalangeal joint on the left side ached for no reason. He noted redness, swelling and stiffness that were aggravated by walking and fatigue. He was treated with the methods for an assumed sprain or cold injuries, which proved ineffective. Signs and Symptoms: The patient reported redness and severe swelling pain of his first metatarsophalangeal joint on the left side. He found it difficult to walk due to the pain in his foot. He also reported generalized joint stiffness, making it hard to bend and stretch. Other signs and symptoms included a greasy sensation in the mouth, thirst, restlessness, low appetite, and frequent dark-colored urine. His tongue was red with a greasy yellow coating, and his pulse was thready, wiry and rapid. Past History: No history of hypertension or diabetes; no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or food. Personal History: Student, unmarried, no history of cigarette smoking, alcoholism or addictions. Physical Examination: The patient was well-developed and showed no signs of malnutrition, slightly overweight; his skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). The bilateral respiratory movements

were symmetrical, resonant percussion sound was normal. Heart rate was 96 bpm, regular, with no pathological murmur at any valve area. The abdomen was flat, and the liver and spleen were impalpable. The first metatarsophalangeal joint on the left side was red and swollen. The skin around the injured joint was warm to the touch. The injured joint was stiff with limited movement. No deformity of the spine or four limbs, and no edema in the lower limbs. Laboratory Examination: BUA was 12 mg/dL, ESR was 10 mm/h, ASO was below 250 U. All others values normal. Pattern Differentiation The key pathological indications are: Complaint: redness, swelling, heat and pain in the first metatarsophalangeal joint on the left side, worse after walking or when fatigued Qualities: redness, swelling, heat-type pain Location: the first metatarsophalangeal joint on the left side Concurrent symptoms: difficulty in walking, joint stiffness, difficulty in bending and stretching Palpation: skin was warm to the touch, and the pulse was thready, wiry, and rapid Inquiry: greasy sensation in the mouth, thirst, restlessness, poor appetite, dark and frequent urination Observation: the tongue was red with a greasy yellow coating

This patient had always been overweight and had a poor appetite. The spleen failed to transport and transform, thus water-dampness spread into the channels and generated multiple sites of damp-stagnation in the joints. After time, this constraint turned into heat and damaged the yin, blocked the qi and blood, and eventually deteriorated into blood stasis with associated pain, swelling, and redness. Based on the signs and symptoms, the channels and joints are the pathological location, and the presenting pattern is damp-heat. Diagnosis WM diagnosis: Gout TCM diagnosis: Bi syndrome due to damp-heat obstructing the channels and joints Clinical Treatment In this case, damp-heat obstructed the channels and joints, thus the treatment strategy was to clear heat, drain dampness, invigorate blood, dissolve stasis, unblock the channels and quicken the collaterals. In Western medicine, gout is related with a purine metabolism disorder and uric acid deposition; therefore, in addition to acupuncture and herbal medicine, it is necessary to regulate the diet, limit purine-rich food intake, and advise the patient to get some exercise. Principles: Clear heat and drain dampness, invigorate blood and dissolve stasis, unblock the channels and quicken the collaterals Formula: Modified Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) and Sì Miào Săn (Wonderfully Effective Four Powder)

[⽩虎加桂枝汤合四妙散加减]

Seven doses. One decocted dose per day. [Formula Analysis] Shí gāo is acrid, sweet, and cold in nature. It enters the lung channel and stomach channel, effectively clears heat, purges internal excess heat on the qi-level, and relieves cough and restlessness. Guì zhī unblocks yang qi; the two medicinals act in combination to clear heat and unblock the collaterals. Fáng jĭ and cāng zhú drain and aromatically dry dampness respectively. Huáng băi and lián qiào together help shí gāo to clear heat. Xuán shēn, chì sháo and dān pí clear heat and cool the blood, niú xī leads the blood downwards; the three together act to cool and invigorate the blood to dissolve stasis.

Acupuncture

Main points: SP 1 (yĭn bái), LV 1 (dà dūn), LV 3 (tài chōng), GB 39 (xuán zhōng), ashi points Supplementary points: LV 2 (xíng jiān), SP 2 (dà dū), SP 3 (tài bái), SP 4 (gōng sūn), ST 36 (zú sān lĭ) Method: Select three main points and 4-5 supplementary points each day. The points were changed every other day. After qi was obtained, all needles were retained for 15 to 20 min. One course of treatment lasted 10 days. Techniques: After disinfecting the skin, needle the points with the drainage method. Upon withdrawal, swing the needles to enlarge the hole. Collateral bleeding can be applied at the same time. Seek superficial collaterals in the tissues adjacent to the redness and swelling. Choose 2-3 points each treatment and manipulate a tri-edged needle at a depth of 1-2 mm, bleed 5-20 ml, then disinfect and cover the wound with a sterile bandage. Repeat this process every third day. Further Consultation After one course of treatment, the pain was greatly relieved, the red swelling reduced, and the distance that he could walk had lengthened.

CASE STUDY II (ACUPUNCTURE, Yang Yongxuan) Mr. Tang, age 52. Chief Complaint: Swelling and pain at the ankle joint and foot for over three days History: Mr. Tang’s foot has been aching for three days, worse at night. His first metatarsophalangeal joint was a hard and inflamed nodule. It and the ankle were warm to the touch. There was also redness, swelling and pain that were aggravated by pressure and walking. Accompanying signs and symptoms included fever that was not relieved by sweating, a bitter taste in the mouth, and scanty dark urine. The tongue was red with a thin greasy white coating; the pulse was soggy and slippery. Physical Examination: Swelling and pain on joints of the ankle and foot, obvious tenderness, all other joints were normal. Laboratory Examination: BUA 804 pmol/L, ESR 32 mm/h. Diagnosis WM diagnosis: Gout TCM diagnosis: Painful bi (wind-damp-heat bi) Clinical Treatment Principles: Clear heat and drain dampness, unblock the channels and relieve pain Points: SP 6 (sān yīn jiāo), SP 5 (shāng qiū), GB 40 (qiū xū), SP 3 (tài bái), bā fēng (EX-LE10)

Method: Manipulate with drainage, retain needles for 30 min, stimulating the needles every 10 min. Combine Chinese medicinals with the acupuncture therapy. Formula: Supplemented Sān Miào Wán (Wonderfully Effective Three Pill) Ingredients: pèi lán (Herba Eupatorii), huò xiāng (Herba Agastachis), chē qián zĭ (Semen Plantaginis), zé xiè (Rhizoma Alismatis), huáng băi (Cortex Phellodendri Chinensis), niú xī (Radix Achyranthis Bidentatae), fú líng (Poria), cāng zhú (Rhizoma Atractylodis), lián qiào (Fructus Forsythiae), shān zhī (Fructus Gardeniae), fáng fēng (Radix Saposhnikoviae), fáng jĭ (Radix Stephaniae Tetrandrae), chì xiăo dòu (Semen Phaseoli), rĕn dōng téng (Caulis Lonicerae Japonicae). 2 doses. [Formula Analysis] Huáng băi, cāng zhú, and niú xī, make up Sān Miào Wán (Wonderfully Effective Three Pill), a formula used for damp-heat in the feet. Modifications include the addition of pèi lán and huò xiāng, which aromatically dry dampness. Chē qián zĭ, zé xiè, and fáng jĭ drain dampness via diuresis and do so with a cooling nature, and fú líng is a diuretic with a neutral temperature. Lián qiào, chì xiăo dòu and zhī zĭ reduce swellings. Lián qiào expels wind and heat, while fáng fēng expels wind and dampness from the skin. Rĕn dōng téng opens the channels and collaterals and eliminates heat bi.

The patient was given two doses of this formula. Upon Mr. Tang’s second treatment, his symptoms were relieved although there was still tenderness at the first metatarsophalangeal joint which was then diagnosed as being qi stagnation and blood stasis. Acupuncture points were used as listed above. His herbal formula saw the addition of dāng guī wěi (Radix Angelicae Sinensis Extremitas), chì sháo, and dān shēn (Radix et Rhizoma Salviae Miltiorrhizae) to invigorate blood and dissolve stasis. The patient was given two doses. By the time he arrived for his third treatment, the symptoms had disappeared with no tenderness or difficulty in walking. The same acupuncture points were selected, but this time combined with warmingneedle technique. He was not given the herbal formula this time. However, he was advised to avoid alcohol and spicy foods, to not work so hard that he gets overly fatigued, and to avoid unnecessary exposure to cold weather. There have been no reports of relapse.

COMMENTARY AND DISCUSSION “White tiger joint-running wind” is described in the Teachings of [Zhu] Dan-xi (DānXī Xīn Fă, 丹溪⼼法). It is derived from the ancient “jointrunning wind” and “white tiger wind”. It is described as “the bones and joints all over the body ache as if they were bitten by the tiger, aggravated at night and eased during the daytime”. Li Chan said in the Introduction to Medicine (Yī Xué Rù Mén, 医学入门): “The pain stretched along joints all over the body during the daytime and was as severe as if bitten by the tiger. It was often called ‘white tiger wind’ or ‘white tiger arthralgia’”. It is suggested that to ensure effective treatment, practitioners should manipulate with an aggressive method during the acute stage to invigorate the blood in the collaterals and clear internal heat. In Case I, collateral bleeding was used. Bleeding such as applies to this case was described in Basic Questions: The Corresponding Relation Between the Yin and Yang of Manand All Things and That of the Four Seasons (Sù Wèn: Yīn Yáng Yìng Xiàng Dà Lùn, 素问·阴阳应象⼤论) indicated that disease of excess blood can be treated by bleeding. The treatment principle was based on the statement that “Excess blood should be drained, and blood stasis should be dispelled”. Basic Questions: On Adjusting the Channels by Pricking (Sù Wèn: Tiáo Jīng Lùn, 素问·调经论) said, “When the disease is located in the channels, regulate the blood; whenin the blood, adjust the collaterals”. The Spiritual Pivot: On Superficial Venules (Líng Shū:Xuè Luò Lùn, 灵枢·⾎络 论) discussed indications for the method of bleeding the collaterals: “If

there are tough and plentiful red vein-collaterals, apply the bleeding methodregardless of location and size, and there will be no disease.” In the acute stage of this disease we focused on dispelling the pathogenic factor, but during the chronic period we should address the underlying liver-kidney deficiency. To regulate and nourish the liver and kidney, use Zuŏ Guī Wán (Left-Restoring Pill) and select points such as BL 18 (gān shù), BL 23 (shèn shù), SP 10 (xuèhăi), and BL 17 (gé shù). In addition to the acupuncture and medical treatments, during the acute stage the patient needs to rest in bed with the affected extremity elevated above the rest of the body. Exercise should wait until 72 hours after the gout pain is relieved. To avoid a future attack, watch the diet and avoid purine-rich foods such as organ meats, anchovies, sardines, herring, liver and kidney meats, dried beans and peas, mushrooms, spinach, asparagus, cauliflower and baking or brewer’s yeast. Searching online for “gout diet” is a quick way to expand this list to the benefit of the patient. Meat in general should be eaten in Asian quantities, such as a side dish rather than as a main course. Maintaining a calm emotional life, and avoiding alcohol or exposure to cold is also of benefit to the patient with gouty arthritis.

STUDY QUESTIONS 1. Chronic joint pain with limited joint mobility is usually due to which pathogen? A. Phlegm B. Blood stasis C. Dampness D. Cold E. Heat 2. Which of the following symptoms are NOT characteristic of winddamp-heat bi syndrome? A. Localized red swelling and burning sensation B. Yang channel points sensitive to pressure C. Better with exposure to cold D. Acute onset E. Migrating pain of the joints 3. Which pattern of bi syndrome most benefits from Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction)? A. Blockage of phlegm and stagnation B. Wind-damp-heat bi C. Painful bi D. Fixed bi

E. Liver-kidney deficiency 4. If the bi syndrome is located in the lower limbs, which if the following medicinals can we use as an envoy? A. Rĕn dōng téng (Caulis Lonicerae Japonicae) B. Guì zhī (Ramulus Cinnamomi) C. Chuān niú xī (Radix Cyathulae) D. Jī xuè téng (Caulis Spatholobi) E. Qiāng huó (Rhizoma et Radix Notopterygii) 5. A case of gouty arthritis presents with a joint that is red and swollen, high skin temperature, sharp pain, spasms and convulsions that are worse at night, high fever, restlessness, and thirst. There is a red tongue with a greasy yellow coating, and a wiry and rapid pulse. Which decoction should be selected? A. Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) and XuānBì Tāng (Painful Obstruction Resolving Decoction) B. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) C. Fáng Jĭ Huáng Qí Tāng (Stephania Root and Astragalus Decoction) D. Táo Hóng Yĭn (Peach Kernel and Carthamus Beverage) combined with Èr ChénTāng (Two Matured Substances Decoction) E. Yì Yĭ Rén Tāng (Coix Decoction) 6. A patient presents with chronic bi syndrome in the collaterals that is aggravated by fatigue.

Which treatment principles are most appropriate for this patient? A. Invigorate blood, diffuse stagnation and relieve pain B. Supplement deficiency and relieve pain C. Dispel wind, dissipate cold and relieve pain D. Expel wind and relieve pain E. Clear heat, dispel swelling and relieve pain Answers 1. A 2. E 3. E 4. C 5. A 6. B

4. Rheumatoid Arthritis ANCIENT THEORIES AND MODERN INSIGHTS Rheumatoid arthritis is a chronic autoimmune disease which manifests as symmetrical arthritis. Rheumatoid arthritis can also cause pain, soreness, numbness, heaviness, limited range of motion, swollen joints, and even severe deformities. In TCM theory, the condition belongs to bi syndrome. The internal etiology of rheumatoid arthritis is the deficiency of yang qi and yin-essence, while the external etiology is an invasion of pathogenic wind, cold, dampness and heat. After many years of rheumatoid arthritis, the disease of the channel and collateral can enter the zang-fu organs. Turbid phlegm and stasis might obstruct the channels, collaterals and joints, making the disease difficult to cure. Deficiencies of qi and blood, or the liver and kidney can give rise to a deficiency of upright qi leading to a lingering state and deficiency-excess complex patterns, both of which can cause a recurring disease state. The general treatment approach is to dispel the pathogens while unblocking the channels, invigorating the collaterals and relieving pain. The main treatment principles are to dispel wind, dissipate cold, and eliminate dampness while clearing heat and unblocking the collaterals. Rheumatoid arthritis is a chronic disease with a deficiency-excess complex, so treatment may also involve supplementing qi and nourishing blood, supplementing

liver and kidney to strengthen upright qi; and dissolving phlegm and dispersing stasis.

ETIOLOGY AND PATHOMECHANISMS External pathogens block the channels and collaterals and inhibit the circulation of qi and blood, thus resulting in pain, numbness, heaviness and limitation of movement in the affected muscles and joints. So the basic pathomechanism involves obstruction that causes pain.

External Causes According to Basic Questions: Bi Syndrome (Sù Wèn: Bì Lùn, 痹论), bi is caused by the combined pathogens of wind, cold and dampness. Wind: Wind rapidly moves and transforms, and is the leading factor in causing various kinds of diseases because it often invades the body together with other pathogens. It can obstruct the qi and blood in the channels and collaterals which leads to pain, and moving wind results in migratory arthralgia. Cold: The nature of cold is to congeal. This leads to stagnation and inhibited circulation of qi and blood. Cold-type joint pain is aggravated by cold and relieved by warmth. Dampness: The nature of dampness is heavy, turbid, and sticky; these qualities lead to qi and blood stagnation with malnourishment of the muscles and joints. The unique characteristic of pain due to dampness is that of soreness with a heavy sensation in the muscles and joints. Heat: The nature of heat is yang, which accelerates local blood circulation even to the point of blood escaping from the vessels. Heat

causes inhibited circulation that leads to joint pain accompanied by swelling, redness and warmth in the local tissues.

Internal Causes The internal causes of rheumatoid arthritis are closely related to the liver and kidney. Overstrain: Overwork or improper rest leads to a depletion of essenceqi which is then unable to nourish and moisten the channels and collaterals. As such, the patient suffers from severe pain and a limited range of motion, often accompanied by fatigue. Weakness due to advanced age: The elderly often have liver and kidney deficiency where the body’s sinews are not adequately nourished, leading to joint pain. Additionally, external pathogens can invade the body when qi and blood is deficient due to chronic illness. In these cases, internal deficiency combines with external wind-cold or dampness to cause joint pain. Weakness due to childbirth: The post-partum period is one of deficiency in many women. As such, they also run the risk of an invasion of external pathogens due to internal deficiency. Chronic illness: In patients with chronic illness, pathogens often block the channels and collaterals and obstruct the vessels where the circulation of qi, blood, essence and fluids is impaired, and they are difficult to dispel. Blood stagnation results in stasis and fluid stagnation results in phlegm; turbid phlegm and stasis combined then give rise to bi syndrome.

COMMON CLINICAL PATTERNS The most commonly encountered clinical patterns include: wind-colddamp bi, wind-damp-heat bi, phlegm and stasis obstruction, kidney deficiency with congealing cold, liver and kidney deficiency, qi and blood deficiency. 1. Wind-cold-damp Bi (1) Migratory bi (wind bi): Migratory pain in various joints, accompanied by external patterns such as aversion to wind, and fever. The tongue coating is thin white to light yellow; the pulse is wiry. (2) Painful bi (cold bi): Pain is severe and limited to one location, aggravated by cold and relieved by warmth; preferring touch, pressure relieves the pain; the local skin feels cold. The tongue coating is thin and white; the pulse is floating and tight. (3) Fixed bi (damp bi): Soreness, pain and heaviness of the body, the joints are swollen, but not red. The pain is limited to one location, aggravated when the weather is rainy and cold. The tongue coating is greasy; the pulse is soggy. 2. Wind-damp-heat Bi Migratory pain in various joints with the local areas red, swollen and hot to the touch. The swollen areas are averse to pressure; the pain is aggravated by heat and relieved by cold. 3. Phlegm and Stasis Obstruction

Long-term disease with stabbing pain in the muscles and joints, limited to a stable location; there is purple or dark skin, swollen stiff joints possibly with joint deformities or numbness. 4. Kidney Deficiency and Cold Congealing Long-term disease with swollen joints and limited range of motion; pain is worse in the morning, aggravated by cold weather, often accompanied by low back pain. 5. Liver and Kidney Deficiency Long-term disease with limited range of motion, thin muscles, and soreness and weakness of the low back and knees, accompanied by cold limbs, aversion to cold, impotence, nocturnal emissions, steaming bone fever, or tidal fever. 6. Qi and Blood Deficiency Long-term disease with painful, swollen stiff numb joints with limited range of motion, accompanied by a pale complexion, palpitations, spontaneous sweating, mental fatigue and a lack of strength.

THERAPEUTICS Chinese Medicinals 1. Wind-cold-damp Bi Syndrome (1) Migratory bi Formula: Fáng Fēng Tāng (Ledebouriella Decoction) Ingredients: fáng fēng (Radix Saposhnikoviae), má huáng (Herba Ephedrae), guì zhī (Ramulus Cinnamomi), gé gēn (Radix Puerariae Lobatae), dāng guī (Radix Angelicae Sinensis), fú líng (Poria), shēng jiāng (Rhizoma Zingiberis Recens), dà zăo (Fructus Jujubae), gān căo (Radix et Rhizoma Glycyrrhizae) (2) Painful bi Formula: Wū Tóu Tāng (Aconite Main Tuber Decoction) Ingredients: zhì chuān wū (Radix Aconiti Praeparata), má huáng (Herba Ephedrae), sháo yào (Radix Paeoniae), gān căo, huáng qí (Radix Astragali) (3) Fixed bi Formula: Yì Yĭ Rén Tāng (Coix Decoxion) Ingredients: yì yĭ rén (Semen Coicis), cāng zhú (Rhizoma Atractylodis), gān căo, qiāng huó (Rhizoma et Radix Notopterygii), dú huó (Radix Angelicae Pubescentis), fángfēng, má huáng, guì zhī, zhì chuān wū, dāng guī, chuān xiōng (Rhizoma Chuanxiong) 2. Wind-damp-heat Bi Syndrome

Formula: Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) and Xuān Bì Tāng (Painful Obstruction-Resolving Decoction) Ingredients: shēng shí gāo (Gypsum Fibrosum), zhī mŭ (Rhizoma Anemarrhenae), huáng băi (Cortex Phellodendri Chinensis), lián qiào (Fructus Forsythiae), guì zhī, xìngrén (Semen Armeniacae Amarum), fáng fēng, yì yĭ rén, huá shí (Talcum), chì xiăo dòu (Semen Phaseoli), cán shā (Faeces Bombycis) 3. Phlegm and Stasis Obstruction Formula: Shuāng Hé Tāng (Double Combined Decoction) Ingredients: táo rén (Semen Persicae), hóng huā (Flos Carthami), dāng guī, chuānxiōng, bái sháo (Radix Paeoniae Alba), fú líng, bàn xià (Rhizoma Pinelliae), chén pí (Pericarpium Citri Reticulatae), bái jiè zĭ (Semen Sinapis) 4. Kidney Deficiency and Cold Congealing Formula: Zhēn Wŭ Tāng (True Warrior Decoction) or Guì Zhī Tāng (Cinnamon Twig Decoction) Ingredients: páo fù zĭ (Radix Aconiti Lateralis Praeparata), bái zhú (Rhizoma Atractylodis Macrocephalae), fú líng, shān yào (Rhizoma Dioscoreae), shēng jiāng (Rhizoma Zingiberis Recens), guì zhī, zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle), fáng fēng, qín jiāo (Radix Gentianae Macrophyllae) 5. Liver and Kidney Deficiency Formula: Huáng Qí Guì Zhī Wŭ Wù Tāng (Astragalus and Cinnamon Twig Five Substances Decoction)

Ingredients: huáng qí, guì zhī, shú dì huáng (Radix Rehmanniae Praeparata), ròucōng róng (Herba Cistanches), bái sháo (Radix Paeoniae Alba), niú xī (Radix Achyranthis Bidentatae), dù zhòng (Cortex Eucommiae), sāng jì shēng(Herba Taxilli), mù guā (Fructus Chaenomelis), dāng guī 6. Qi and Blood Deficiency Formula: Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) Ingredients: rén shēn (Radix et Rhizoma Ginseng), bái zhú, bái sháo, fú líng, gān căo, dāng guī, shú dì huáng, chuān xiōng, qín jiāo, sāng jì shēng, dú huó

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels Favor points on the yang channels and du mai. 2. Point Selection According to Location Points near the joints or tender areas. Frequently used points include: (1) Neck: DU 14 (dà zhuī), BL 10 (tiān zhù), GB 20 (fēng chí) (2) Shoulder: LI 15 (jiān yú), SJ 14 (jiān liáo), SI 9 (jiān zhēn), SI 10 (nào shù) (3) Elbow: LI 11 (qū chí), SJ 10 (tiān jĭng), LU 5 (chĭ zé), HT 3 (shào hăi), SI 8 (xiăo hăi)

(4) Wrist: SJ 4 (yáng chí), SJ 5 (wài guān), LI 5 (yáng xī), SI 4 (wàn gŭ) (5) Fingers: bā fēng (EX-LE10), bā xié (EX-UE9), LI 4 (hé gŭ) (6) Hip: GB 30 (huán tiào), GB 29 (jū liáo), BL 54 (zhì biān) (7) Knee: xī yăn (EX-LE5), ST 34 (liáng qiū), GB 34 (yáng líng quán), GB 33 (xī yángguān) (8) Ankle: BL 62 (shēn mài), KI 6 (zhào hăi), BL 60 (kūn lún), GB 40 (qiū xū), ST 41 (jiĕxī), GB 39 (xuán zhōng) (9) Spine: DU 14 (dà zhuī), DU 12 (shēn zhù), DU 3 (yāo yáng guān), jiā jĭ (EX-B2), BL 12 (fēng mén), DU 4 (mìng mén) 3. Point Selection Based on Pattern Differentiation (1) Migratory bi: Use GB 20 (fēng chí) and BL 12 (fēng mén) to treat patterns of external wind. An ancient adage teaches: “Regulate the blood [flow] first to expel wind; the wind may extinguish when the blood circulates smoothly”. Hence, to needle BL 17 (gé shù) and SP 10 (xuè hăi) to regulate blood. (2) Painful bi: To treat excess cold, apply moxa to BL 23 (shèn shù) and RN 4 (guānyuán) to warm and supplement the yang qi and to expel the cold. (3) Fixed bi: To treat excess dampness, use ST 36 (zú sān lĭ), SP 9 (yīn líng quán) and SP 5 (shāng qiū) to fortify the spleen and eliminate dampness. (4) Heat bi: To treat excess heat, use DU 14 (dà zhuī), DU 12 (shēn zhù) and LI 11 (qūchí) to clear heat and resolve toxins.

(5) Phlegm and stasis obstruction: Use BL 17 (gé shù), SP 10 (xuè hăi) and BL 20 (píshù). Manipulate with drainage to invigorate blood and dissolve stasis. (6) Kidney deficiency and cold congealing: Use KI 10 (yīn gŭ), BL 23 (shèn shù), KI 3 (tài xī), BL 20 (pí shù), ST 36 (zú sān lĭ), GB 34 (yáng líng quán), GB 39 (xuán zhōng). (7) Liver and kidney deficiency: Use BL 18 (gān shù), BL 23 (shèn shù) and ST 36 (zúsān lĭ). (8) Qi and blood deficiency: Use LI 11 (qū chí), LI 4 (hé gŭ), ST 36 (zú sān lĭ), DU 20 (băi huì), BL 15 (xīn shù), BL 17 (gé shù), BL 20 (pí shù), SP 6 (sān yīn jiāo), SP 9 (yīn língquán) and GB 34 (yáng líng quán).

CASE STUDY I Mr. Ren, age 48. Initial Visit: Oct 12th, 2001 Chief Complaint: Painful, swollen, stiff and deformed joints for more than one year, accompanied by a limited range of motion. History: The patient worked for years as a manual laborer working underground (literally). One year ago, he had developed a fever of more than 40℃ (104°F). Accompanying symptoms included red, painful, swollen knees and ankles which prevented him from walking upright comfortably. After his fever dropped, he began getting acupuncture treatments, but after six months, his symptoms persisted. He presented with red, painful, swollen, stiff and deformed joints of the wrists and index fingers. Both of the knees were swollen, deformed, and could not flex or extend freely, this was more severe in the left leg. Both of his ankles were extremely swollen. The examination at a local hospital showed: erythrocyte sedimentation rate (ESR ): 55 mm/h, rheumatoid factors (RF): (+). The diagnosis was rheumatoid arthritis and the patient was treated in the TCM department. The patient had 80 doses of decoction, but the symptoms were not relieved. The ESR was 118 mm/h at the initial visit to our hospital. Signs and Symptoms: Painful, swollen, deformed and limited range of motion in the joints of the knees, ankles, wrists and fingers. The joints of the hip were rigid and deformed, and limited his posture to one forward position. The angle from the thigh to the body was 120°, roughly the same position one would expect to take while digging with a shovel, as he did for much of his life. His two shoulders and elbows were also stiff and could not

move. The patient was carried by others into the clinic. He continued to have intermittent fever, aversion to cold, vexing heat, poor appetite, nausea, and dark urine. He moved his stools 1-2 times daily. His tongue was pale with a greasy white coating; the pulse was wiry and rapid. Past History: The patient was healthy in the past. No medical history. Physical Examination: Temperature 37.5℃ (99.5°F), clear mind, dark complexion, tired; the joints of his two knees, ankles, wrists and fingers were visibly swollen, deformed, painful and extremely stiff; the joints of the hip were rigid and deformed, limited to one position (leaning forward, mimicking the stance of one using a shovel); the two shoulders and elbows were also stiff and could not flex and extend. The patient was carried by others to the clinic. Normal heart and lung, flat abdomen, liver and spleen were non-palpable. The muscular strength and tension was normal, pathologic reflex (-). Auxiliary Examination: X-Ray findings: rheumatoid arthritis. Pattern Differentiation This patient spent much time underground where he worked as a manual laborer, where the ground was cold and damp. The patient was invaded by the three external pathogens of wind, cold and dampness. The cold-dampness easily impaired the kidney. When the kidney became deficient, it could not protect the body from further invasion of the external pathogen. The cold-dampness went deeper into the body and entered the bone and could not be dispersed. Then the bones could not be nourished and deformity appeared. The sinews contracted, so the limbs could not flex nor extend. The feet were severely swollen. This indicated that the invasion of the wind, cold and dampness had gone deep in the liver, kidney, sinew

and bones. After chronic exposure, the wind-cold, turbid phlegm, stasis and pathogen wind interacted with each other and stayed in the body, resulting in blockage of the channels and collaterals, inhibited qi and blood circulation and unnourished bones. The intermittent fever, vexing heat, dark urine and wiry and rapid pulse indicated that the cold pathogen had transformed into heat. Due to long-term upright qi deficiency and pathogen exuberance, the patient had an aversion to cold with a pale tongue and greasy white coating. This indicated kidney yang deficiency with an invasion of wind-cold pathogen. Taking into account the tongue and pulse manifestations, this case was a complex syndrome involving cold and heat, and excess and deficiency; the deficiency cold was the root and the heat manifestation was the branch. The pattern of this case was kidney yang deficiency with cold-dampness invasion that had transformed to internal heat. Diagnosis WM diagnosis: Rheumatoid arthritis TCM diagnosis: Bi syndrome due to kidney yang deficiency, colddampness invasion transforming to heat Clinical Treatment This case was caused by long-term exposure to a cold and damp environment (underground). When invaded by wind, cold and dampness, the result was bi syndrome. The cold-dampness easily impaired the kidney. When the kidney became deficient, it could not protect the body from invasion of other external pathogens. The cold-dampness went deeper into the body, entered the bones and could not be dispersed. The bones then could not be nourished and deformity appeared. When the sinews

contracted, the limbs could not flex or extend. The feet were severely swollen. So besides the Chinese medicinal and acupuncture treatment, the patient had to make some changes in his living environment and protected himself from further exposure to cold-dampness. Principles: Mainly supplement the kidney and disperse cold while also clearing heat, dissolving dampness, dispersing wind, nourishing blood and sinews, dissolving stasis and unblocking collaterals Formula: Modified Guì Zhī Sháo Yào Zhī Mŭ Tāng (Cinnamon Twig, Peony and Anemarrhenae Decoction) and Hŭ Gŭ Săn (Tiger Bone Powder) [桂枝芍药知母汤合虎骨散加减]

[Formula Analysis] Guì Zhī Sháo Yào Zhī Mŭ Tāng acts to warm yang and dispel cold, while the Hŭ GŭSăn supplements the liver and kidney.

The chief medicinal zhì fù piàn supplements the liver yang and dispels cold. Gŭ suì bŭ and gŏu jĭ warm and supplement liver and kidney and strengthen sinew and bone. Guì zhī and wēi líng xiān dispel the wind, cold and dampness of the sinews and bones. Bái sháo nourishes the blood and relax the sinews. These are all deputy medicinals. Fáng fēng dispels wind, má huáng dispels cold, bái zhú fortifies the spleen and drains dampness, chì sháo dissolves stasis and clears heat, zhī mŭ enriches the kidney and clears heat, and zhì shān jiă unblocks the channels and dissolves stagnation. These are all assistant medicinals. Gān căo, harmonizes all formula medicinals, also acting as an envoy.

Acupuncture Main points: BL 23 (shèn shù), DU 3 (yāo yáng guān), DU 9 (zhì yáng), ST 36 (zú sānlĭ), hua tuo jia ji points (L2), DU 4 (mìng mén) Supplementary points: LI 11 (qū chí), DU 12 (shēn zhù), DU 14 (dà zhuī), LI 4 (hégŭ), GB 31 (fēng shì), BL 12 (fēng mén), BL17 (gé shù), SP 10 (xuè hăi), local points near the diseased joints Method: Choose 2-3 main points and 6-7 supplementary points per day. The points were changed every other day. After qi was obtained, the needles were retained for 30-40 min. 10 daily treatments constitute one treatment course. Techniques: Supplementation methods were used along with box moxibustion at BL 23 (shèn shù), DU 3 (yāo yáng guān), DU 9 (zhì yáng), hua tuo jia ji points (L2), and DU 4 (mìng mén). The mountain-burning

warming method was used at ST 36 (zú sān lĭ) and warm needling was applied afterwards; drainage was used on the supplementary points. Further Consultation After one course of the combined treatment of medicinals and acupuncture, the joint pain was relieved, the symptoms of fever and vexing heat were eliminated, appetite and sleep were greatly improved, and range of motion was slightly improved. Overall, the patient was greatly pleased.

CASE STUDY II (ACUPUNCTURE, Lu Shouyan) Mr. Shen, age 12. Chief Complaint: Severe joint pain in all four extremities, accompanied by fever and delirium for half of the day. History: This patient was invaded by wind-heat. The joints of the four limbs were painful and swollen. The patient had a fever for half of the day during which he cried all the time. The skin temperature was high, and the patient was delirious. The tongue was pink with a thin white coating; the pulse was slow and choppy. Examination: Hand and feet joints swollen with aversion to pressure, skin was feverish. Diagnosis Bi syndrome (heat bi) Clinical Treatment Principles: Clear sanjiao heat, promote joint function, relieve pain Points Selection:

● Upper Limbs: SJ 13 (nào huì), SJ 11 (qīng lĕng yuān), SJ 10 (tiān jĭng), SJ 9 (sì dú), SJ 7 (huì zōng), SJ 14 (jiān liáo)

● Lower Limbs: GB 27 (wŭ shū), GB 28 (wéi dào), GB 29 (jū liáo), GB 31 (fēng shì), GB 32 (zhōng dú), GB 30 (huán tiào) Techniques:

● For the points on the upper extremities, SJ 13 (nào huì), SJ 11 (qīng lĕng yuān), SJ 10 (tiān jĭng), SJ 9 (sì dú), and SJ 7 (huì zōng) were needled to promote sanjiao functions, clear heat, and promote joint function. The pain-relieving method of “red phoenix shaking its head” was used on SJ 14 (jiān liáo).

● For the points on the lower extremities, GB 27 (wŭ shū), GB 28 (wéi dào), GB 29 (jū liáo), GB 31 (fēng shì), GB 32 (zhōng dú), GB 30 (huán tiào) were needled with drainage to free the flow of liver and gallbladder qi, promote joint function and relieve pain. Deep needling to 3 cun was used at GB 30 (huán tiào), as qi was obtained the patient felt as if something was beating between the bones; then the needle was removed and the pain was relieved. Note According to Illustrated Classic of Acupoints on the Bronze Figure (Tóng Rén Shū XuéZhēn Jiŭ Tú Jīng, 铜⼈腧穴针灸图经), GB 30 (huán tiào) governs the lower limb, and the muscle of the area is thick. Deep needling was applied at GB 30 (huán tiào) with drainage; after qi arrival, the needle was removed and the pain was relieved.

COMMENTARY AND DISCUSSION Now and then an honest-to-goodness textbook presentation patient arrives in one’s practice. However, here in the West, where most patients visit conventional allopathic providers first, we often see conditions that have had a chance to degenerate and comingle with other conditions, thus leading to complex patterns. Complex patterns such as these are not generally well-addressed in most TCM textbooks. Complex patterns in chronic conditions are so much the norm that when I see a simple textbook pattern, I secretly assume that I am missing something. American practitioner-author Bob Flaws has provided some insight into the lifecycle of common bi syndromes as follows: (1) Wind-cold-damp bi is often preceded by Wood overacting on Earth, which is then unable to generate Metal, leading to a wei qi deficiency. When the wei qi is deficient, wind-cold-dampness can more easily enter the body. (2) Wind-damp-heat bi follows a similar trajectory. It begins with a liver/spleen disharmony. When the spleen becomes deficient, the outcome is internal dampness. When the liver is congested, depressed or otherwise stagnated, the outcome is heat. When dampness and heat co-mingle, the outcome is obviously damp-heat, which then gives rise to bi syndrome.

STUDY QUESTIONS 1. Why were BL17 (gé shù), SP 10 (xuè hăi) chosen to treat arthritis in the first case? 2. Why were methods of “mountain-burning warming” and “warming needle”used on ST 36 (zú sān lĭ) in the first case? 3. Why was box moxibustion used on BL 23 (shèn shù), DU 3 (yāo yáng guān), DU 9 (zhì yáng), hua tuo jia ji points (L2), DU 4 (mìng mén) in the first case? Answers 1. In this case, the root was deficient and the branch was excess; the pathogens of wind, cold and dampness blocked the circulation of qi and blood in the channels and vessels. As such, we kept in mind the ancient adage: “Regulate the blood [flow] first to expel wind; the wind may extinguish when the blood circulates smoothly”. These points invigorate blood while dispelling wind, cold and dampness and promoting qi and blood circulation. When the blood was regulated, the pain was relieved. 2. ST 36 (zú sān lĭ) is a strengthening point that supplements and enriches qi and blood. The mountain-burning warming method warm and supplements; this effect was also reinforced by warm needling. 3. BL 23 (shèn shù), DU 3 (yāo yáng guān), DU 9 (zhì yáng), hua tuo jia ji points (L2), DU 4 (mìng mén) are common points for enriching and strengthening the kidney yang. Box moxibustion enhances the effect of strengthening yang qi.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mrs. Dong, age 42, had sore pain of the joints of the four limbs. She could not flex nor extend. The joint pain was migratory, accompanied by aversion to wind, and fever. The tongue coating was thin and white; her pulse was floating and slow. Which of the following formulas would best serve this case? A. Fáng Fēng Tāng (Ledebouriella Decoction) B. Wū Tóu Tāng (Aconite Main Tuber Decoction) C. Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) D. Shuāng Hé Tāng (Double Combined Decoction) E. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) 2. Mr. Liu, age 72, had painful and swollen joints of the four limbs, with limited range of motion. His symptoms were more severe in the morning. He also reported an aversion to cold, fatigue, sore pain in the back that prevented him from bending forward and backward. All the symptoms were worse when the weather was cold. The tongue was pale with a glossy white coating; his pulse was deep and thready.

Which of the following formulas is the best choice? A. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) B. Wū Tóu Tāng (Aconite Main Tuber Decoction) C. Shuāng Hé Tāng (Double Combined Decoction) D. Zhēn Wŭ Tāng (True Warrior Decoction) E. Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) 3. Mrs. Hu, age 50, had pain in the joints of the four limbs that was severe with fixed locations. The pain was aggravated by cold and relieved by warmth. The patient had a demonstrably limited range of motion. The skin over the joints was cold to the touch. The tongue body was pale with a thin white coating; her pulse was wiry and tight. Which of the following formulas would be the best choice? A. Wū Tóu Tāng (Aconite Main Tuber Decoction) B. Yì Yĭ Rén Tāng (Coix Decoction) C. Guì Zhī Tāng (Cinnamon Twig Decoction) D. Shuāng Hé Tāng (Double Combined Decoction) E. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) 4. Mr. Shen, age 59, was a fisherman who often waded into cold water. He reported soreness, pain, heaviness and swelling in the joints with limited range of motion and numb skin. The tongue was pale with a greasy white coating; his pulse was soggy and slow.

Which of the following formulas would most benefit this case? A. Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig） B. Shuāng Hé Tāng (Double Combined Decoction) C. Fáng Fēng Tāng (Ledebouriella Decoction) D. Yì Yĭ Rén Tāng (Coix Decoction) E. Guì Zhī Tāng (Cinnamon Twig Decoction) 5. Mrs. Yang, age 65, had painful, swollen, numb and stiff joints with limited range of motion accompanied by a pale complexion, palpitations, spontaneous sweating, fatigue and weakness. The tongue was pale with a thin white coating; her pulse was thready and weak. Which of the following formulas would you select? A. Zhēn Wŭ Tāng (True Warrior Decoction) B. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) C. Shuāng Hé Tāng (Double Combined Decoction) D. Wū Tóu Tāng (Aconite Main Tuber Decoction) E. Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) 6. Mr. Tang, age 63, had migratory joint pain, red and swollen joints with a limited range of motion. The effected joints were averse to pressure and relieved by cold. The patient also had a fever, sweating, thirst and vexation. The tongue was red with a yellow greasy coating; his pulse was slippery and rapid.

Which of the following formulas would you select? A. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) B. Shuāng Hé Tāng (Double Combined Decoction) C. Zhēn Wŭ Tāng (True Warrior Decoction) D. Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) and XuānBì Tāng (Painful Obstruction-Resolving Decoction) E. Fáng Fēng Tāng (Ledebouriella Decoction) 7. Mrs. Wen, age 78, had pain in her joints with a limited range of motion for more than 8 years. The pain was stabbing, fixed in location and worse at night. The skin over the joints was dark purple. The patient felt heaviness in her joints. The joints were deformed, could not flex nor extend. Her complexion was dark with swollen eyelids. The tongue was purple with stasis dots and a white greasy coating; her pulse was wiry and choppy. Which of the following formulas would you select? A. Shuāng Hé Tāng (Double Combined Decoction) B. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) C. Wū Tóu Tāng (Aconite Main Tuber Decoction) D. Yì Yĭ Rén Tāng (Coix Decoction) E. Fáng Fēng Tāng (Ledebouriella Decoction) 8. Mr. Xu, age 70, had pain in his joints for nearly ten years. He presented with an obviously limited range of motion. He had thin muscles, soreness and weakness in the lower back and knees, cold limbs, aversion to

cold, impotence, and nocturnal emission. The tongue body was pink with a dry thin white coating; his pulse was deep and thready. Which of the following formulas is the best choice? A. Huáng Qí Guì Zhī Wŭ Wù Tāng (Astragalus and Cinnamon Twig Five Substances Decoction) B. Yì Yĭ Rén Tāng (Coix Decoction) C. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) D. Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) E. Fáng Fēng Tāng (Ledebouriella Decoction) Answers 1. A 2. D 3. A 4. D 5. B 6. D 7. A 8. A

5. Ganglion Cysts ANCIENT THEORIES AND MODERN INSIGHTS A ganglion cyst is a kind of mass that contains thick and colorless or pale white or yellow-colored mucus. It primarily affects the tendon sheath and joints. Ganglion cysts are caused by mucoid degeneration of the joint capsule or tendon sheath, or by local colloid degeneration of the connective tissues. Young and middle-aged adults are more apt to suffer from a ganglion cyst than the elderly. This condition occurs more commonly in women than men. Main symptoms: subjective pain and soreness, or muscle paralysis caused by compression of the local nerves. In Chinese medicine ganglion cyst belongs to the categories “knotted sinew”, “sinew tumor”, “contracted sinew” and “sinew bi”. Based on the pathomechanism involved, treatments should endeavor to eliminate phlegm and stasis, relax the sinews and quicken the collaterals.

ETIOLOGY AND PATHOMECHANISMS Ganglion cyst is usually caused by external trauma, internal exhaustion, or fatigue. When the sinew membrane is damaged by external trauma, pathogenic qi can invade. This undermines the flow of qi and fluids which leads to the retention of water in the channels, which then forms into cysts. The location of disease is in the channel sinews.

External Causes Trauma: External trauma damages the channels with subsequent stagnation of qi and fluids.

Internal Causes Exhaustion or fatigue: Stagnation of qi and water in the channels can also arise from excessive athletic activities, repetitive stress, or standing for a long time. Any of these activities can damage the channel sinews and block the transportation of channel-qi. The resulting stagnation of qi and water leads to cyst formation. The deficiency-type pattern presentation generally involves deficiencies of the kidney and liver:

● The liver: governs the sinews and stores the blood. When the liver blood is deficient, it is unable to nourish the channel sinews. This deficiency causes constraint of the qi mechanism, leading to stagnation of qi and fluids and the creation of the ganglion cyst.

● The kidney: governs bones and stores the essence. Because the “liver and kidney have the same source”, they both regulate the movement of essence and qi in the channels. Kidney deficiency with failure to regulate essence and qi movement in the channels can also result in ganglion cyst formation.

COMMON CLINICAL PATTERNS The most commonly encountered clinical patterns include stagnation due to external trauma, and deficiency of liver and kidney. Stagnation due to external trauma: Mainly follows external trauma with damage to channel sinews and obvious swelling of the joints. Cysts resulting from trauma tend to grow quickly. Deficiency of liver and kidney: Exhaustion-damage of the bones and joints combined with mental and physical fatigue and soreness in the low back and knees are all expressions of liver and kidney deficiency.

THERAPEUTICS Chinese Medicinals 1. Stagnation due to External Trauma Treatment principles: Invigorate blood, dissolve stasis, harmonize ying, disperse swelling Formula: Modified Huó Xuè Sàn Yū Tāng (Blood-Quickening StasisDissipating Decoction) Ingredients: chuān xiōng (Rhizoma Chuanxiong), dāng guī wěi (Radix Angelicae Sinensis Extremitas), chì sháo (Radix Paeoniae Rubra), sū mù (Lignum Sappan), hónghuā (Flos Carthami), mŭ dān pí (Cortex Moutan), zhĭ qiào (Fructus Aurantii), táo rén (Semen Persicae), bīng láng (Semen Arecae), dà huáng (Radix et Rhizoma Rhei) 2. Deficiency of the Liver and Kidney Treatment principles: Supplement liver and kidney, nourish blood, rectify the sinews Formula: Modified Sì Wù Tāng (Four Substances Decoction) Ingredients: chuān xiōng, dāng guī wěi, bái sháo (Radix Paeoniae Alba), mùguā (Fructus Chaenomelis), shú dì (Radix Rehmanniae Praeparata), niú xī (Radix Achyranthis Bidentatae), jiāng huáng (Rhizoma Curcumae Longae), wăn cán shā (Faeces Bombycis), wй jiā pí (Cortex Acanthopanacis), hăi tóng pí (Cortex Erythrinae)

Acupuncture and Moxibustion Treatment

1. Local Points Conventional acupoints: ashi points around the local cyst The ganglion cyst is always caused by stasis of channel-qi and blood with stagnation of fluids and water. As such, local ashi points are the favored points for soothing the local channel-qi, unblocking the collaterals and dissipating masses. 2. Adjacent Points For cysts on the hand: add SJ 5 (wài guān) For cysts on the foot: add ST 41 (jiě xī) 3. Point Selection According to Channels Select points local to areas of soreness and pain along the channels where the ganglion cyst is located, including any pressure-sensitive points on the upper and lower limbs. This will invigorate blood and unblock the collaterals, relax the tendons and relieve pain. When treating, needle around the cyst, allowing the needles to pierce the cyst wall. Aggressively shake the needle to enlarge the hole through which the cyst’s fluids can escape. For this reason, the drainage method is most often applied. In addition to needling around the cyst, tri-edged needling is used to make sure that the fluid within the cyst is evacuated. Then, to provide a better clinical outcome, moxibustion can be used to warm and unblock the collaterals and harmonize qi and blood.

CASE STUDY I Ms. Liu, age 16. Student. Initial Visit: June 10th, 2003 Chief Complaint: Finding a movable, painless and palpable mass the size of a soybean on the back of her right wrist one month prior. History: One month ago, Ms. Liu found a bean-sized mass on the right wrist after it had been sprained. The patient reported no obvious symptoms of redness, swelling, heat, or aching that limited her activity, thus she didn’t take any action to address the sprain or the lump. As the days passed, she observed the mass growing bigger, which was movable. Other than the growing lump, no discomfort was reported. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or foods. Menstrual, Marital and Childbearing History: Menarche age 13, menstruation arrives every 30 days, menstrual period for 5-6 days, normal quantity and quality of menses. Physical Examination: A cyst on the back of the right wrist with a size of about 1.5 cm × 1.5 cm, movable when palpated, soft and not tender, hand and wrist moved normally. Pattern Differentiation The key indication in Ms. Liu’s pathology was the history of recent external trauma. The trauma caused constraint, the transportation of qi and

the blood became static, fluids and water gathered in the joints and channels, and the ganglion cyst arose. This case is an excess pattern, and the location of disease is the joint and sinews. Diagnosis Sinew tumor due to external trauma with local stagnation Clinical Treatment Principles: Invigorate blood, dissolve stasis, harmonize ying, disperse swelling Formula: Modified Huó Xuè Sàn Yū Tāng (Blood-Quickening StasisDissipating Decoction) [活⾎散瘀汤加减]

[Formula Analysis] Hóng huā, the chief medicinal, acts to invigorate blood, dispel constraint and relieve pain.

Chuān xiōng, dāng guī wěi, chì sháo, mŭ dān pí, and sū mù invigorate the blood, expel stasis, regulate and harmonize ying-blood. Zhĭ qiào and bīng láng break up qi and dispel accumulation to unblock the channels. Dà huáng and guā lóu rén can expel masses via purgation, and moisten the intestines to promote defecation. Bīng láng and zhĭ qiào help dà huáng expel masses. Dāng guī wěi, chuān xiōng, zhĭ qiào and chì sháo all expel stasis, especially when combined with medicinals that regulate qi.

Acupuncture Main points: ashi points around the cyst Supplementary points: SJ 5 (wài guān), SP 10 (xuè hăi), LI 11 (qū chí) Method: After qi was obtained, the needles were retained for 20-30 min. Needles were manipulated once or twice per treatment, shaken to enlarge the hole through which the cyst’s fluid can be expelled. Techniques: Use conventional methods to sterilize the skin around the cyst, use a thick needle to puncture perpendicularly into the cyst with one needle. From the four sides around the cyst, puncture with four additional needles. With the needles coming in from the sides, pierce the cyst through to its opposite wall. Further Consultation After three treatments, the patient was cured. At a two-year follow-up, no relapses were reported. Note

The treatment involved an external therapy where the skin was broke open. As such, strict with sterilization procedures are required. Following the needling, wrap gauze around the wound with enough pressure to fully expel the fluid within the cyst and to prevent infection of the wound. Be sure to keep the patient and area warm in order to prevent invasion of colddampness and subsequent relapse.

CASE STUDY II (ACUPUNCTURE, Zhang Tao) Mrs. Liu, age 23. Chief Complaint: A tumor on the back of the left wrist for over one month. History: One month ago, Mrs. Liu discovered a cyst on the back of her left wrist. It was neither painful nor red, but was gradually increasing in size. She was diagnosed with a ganglion cyst in a hospital. She refused surgery and came to our hospital for her first visit. Physical Examination: A round tumor with the size of 1.5 cm x 1.5 cm was observed on the back of the left hand. The tumor was not red, nor adherent to the epidermis. There was no pain associated with pressure to the cyst. The tongue color was red with a thin white coating; her pulse was deep and thready. Diagnosis Ganglion cyst due to phlegm stasis and qi stagnation Clinical Treatment Principles: Break stagnant qi and disperse swelling Points: SJ 5 (wài guān), PC 7 (dà líng), ashi points around the cyst Techniques: The cyst and the adjacent skin were disinfected as normal. The four sides around the cyst were punctured with #26 gauge needles with the needling sensation guided to the center of the cyst. A fifth needle was then inserted from top of the cyst. Points SJ 5 (wài guān) and PC 7 (dà líng)

were manipulated for thirty seconds with twirling and lifting-thrusting drainage. The needles were not left in the arm. After two acupuncture treatments, the cyst had reduced in size by approximately one third of its original size. This treatment was performed on Mrs. Liu six times in total, after which the cyst completely disappeared. There was no relapse during her follow-up period.

COMMENTARY AND DISCUSSION Some Western orthopedic surgeons take a slightly more aggressive approach to the treatment of ganglion cysts. They position the hand and wrist on a table, very flat, such that sudden blunt downward force will not cause any damage to the bone or tendons. A heavy book (any Chinese medicine materia medica would do) is then slapped down atop the hand to rupture the cyst. After which, the hand is wrapped up tightly in a bandage for a few days to let it heal. To prevent a recurrence of this condition, the usual pattern differentiation and treatment principles to prevent blood or phlegm stagnation are encouraged.

STUDY QUESTIONS 1. In Chinese Medicine, to which categories do ganglion cyst belong? (Choose three) A. Sinew tumor B. Elbow-consumption C. Joint-wind D. Contracted sinew E. Sinew bi 2. Which two of the following are treatment principles for ganglion cyst? (Choose two) A. Invigorate blood and dissipate masses B. Dispel wind and eliminate dampness C. Unblock the channels and relieve pain D. Clear heat and cool the blood E. Supplement liver and lung 3. Which three of the following statements are correct? (Choose three) A. External therapies are to be avoided in the treatment of ganglion cysts B. When needling cysts, it is essential that the skin be sterilized C. Ganglion cysts are contagious D. Use gauze to bind the wound with pressure after surround-needling

E. Keep the wound warm to prevent wind-cold from entering Answers 1. ADE 2. AC 3. BDE

6. Osteoarthritis (Bone Bi) ANCIENT THEORIES AND MODERN INSIGHTS Osteoarthritis, also called hyperplastic arthritis or degenerative arthritis, is often caused by a degeneration of articular cartilage and secondary bone hyperplasia. It can be divided into primary and secondary osteoarthritis. Here, we mainly discuss the primary degeneration of the articular cartilage. This condition is often seen in the middle-aged and elderly age groups. This kind of disease is also related to heredity and physical fitness. In Chinese medicine, osteoarthritis belongs to bone bi. Combined pathogens of wind, cold and dampness lead to qi and blood obstruction, and ultimately as osteoarthritis. The kidney governs the bones and produces the marrow, and osteoarthritis is closely related to deficiency of the kidney. Osteoarthritis often occurs at weight-bearing joints and that those move the most.

ETIOLOGY AND PATHOMECHANISMS External Causes Wind, cold and dampness: Old or weak persons have a deficiency of wei-yang (defensive yang), which allows for attacks of wind, cold or dampness which leads to obstruction in the channels and stasis with pain. Local trauma: Trauma can impede the circulation of local qi and blood; the resulting stasis of qi and blood accompanied by pain.

Internal Causes Kidney yang deficiency: Deficiency of yang in the elderly leads to a lack of nourishment to the bones and sinews, which leads to osteoarthritis. Essence and blood deficiency: Liver blood, kidney essence and bone marrow are all insufficient; because the channels are empty and unable to nourish the sinews, muscle, bones and joints, osteoarthritis occurs.

COMMON CLINICAL PATTERNS Kidney essence and marrow deficiency: Osteoarthritis that presents with dull pain in the joints, soreness and weakness of the lower back and knees, and difficult movement in the lower back and legs. There may be other marrow deficiency indications such as dizziness and tinnitus. The tongue is pink with a thin white coating; the pulse is thready. Yang deficiency with internal cold: Osteoarthritis that presents with aching and numbness of the extremities, bones and muscles, with difficult movement. Symptoms are aggravated when the weather changes, especially worse at night, and relieved during the day. The pain is aggravated by cold and relieved with warmth. The tongue is pale with a thick white coating; the pulse is deep and thready. Blood stasis: Arthritis with a stabbing pain in a fixed location, joint deformity with limited range of motion, or hunched shoulders, and a dark complexion. The tongue body color is dim; the pulse is deep, choppy, or thready.

THERAPEUTICS Chinese Medicinals 1. Kidney Essence and Marrow Deficiency Formula: Modified Zuŏ Guī Wán (Left-Restoring Pill) Ingredients: shú dì (Radix Rehmanniae Praeparata), sháo yào (Radix Paeoniae), shān zhū yú (Fructus Corni), gŏu qĭ zĭ (Fructus Lycii), guī băn jiāo (Colla Testudinis Plastri), tù sī zĭ (Semen Cuscutae), huái niú xī (Radix Achyranthis Bidentatae) 2. Yang Deficiency with Internal Cold Formula: Modified Yòu Guī Wán (Right-Restoring Pill) and Juān Bì Tāng (Impediment-Alleviating Decoction) Ingredients: fù zĭ (Radix Aconiti Lateralis Praeparata), ròu guì (Cortex Cinnamomi), lù jiăo jiāo (Colla Cornus Cervi), shú dì, shān yào, shān zhū yú, gŏu qĭ zĭ, tù sī zĭ, dù zhòng (Cortex Eucommiae), dāng guī (Radix Angelicae Sinensis), qiāng huó (Rhizoma et Radix Notopterygii), dú huó (Radix Angelicae Pubescentis), qín jiāo (Radix Gentianae Macrophyllae), guì zhī (Ramulus Cinnamomi), chuān xiōng (Rhizoma Chuanxiong), mùxiāng (Radix Aucklandiae), rй xiāng (Olibanum) 3. Blood Stasis Formula: Modified Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction)

Ingredients: táo rén (Semen Persicae), hóng huā (Flos Carthami), dāng guī, chuānxiōng, niú xī (Radix Achyranthis Bidentatae), dì lóng (Pheretima), shēng dì (Radix Rehmanniae), yán hú suŏ (Rhizoma Corydalis), dú huó ★ Key Medicinals Niú xī is the best medicinal for treating diseases of the lower limbs. Niú xī’s properties are bitter, sweet, sour and neutral. It can invigorate the blood and unblock the channels, supplement liver and kidney, reinforce both the sinews and bones, and conduct fire downward. Niú xī is often used to treat traumatic injury, or soreness or weakness of the lower back and knees caused by kidney deficiency. Many pharmacies stock both chuān niú xī and huái niú xī. Huái niú xī supplements the liver and kidney, and reinforces the lower back and knees; chuān niú xī (Radix Cyathulae) unblocks the channels and quickens the collaterals, dispels wind and eliminates dampness. They can be used singly or together, as indicated by the patient’s presentation.

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Most attention should be paid to the three yang channels of the foot, the foot jueyin liver channel and the foot taiyin spleen channel. Select points on these channels consistent with the location of the osteoarthritis. (2) Select secondary points on the foot shaoyin kidney channel because the kidney governs bones and produces marrow. 2. Local Point Selection

(1) For hip pain: add GB 30 (huán tiào), BL 32 (cì liáo), GB 29 (jū liáo), GB 31 (fēngshì), BL 54 (zhì biān), BL 36 (chéng fú), ashi points (2) For pain in the back of the knee: nèi xī yăn (EX-LE 4), xī yăn (EXLE 5), BL 40 (wěizhōng), GB 33 (xī yáng guān), SP 10 (xuè hăi), ST 34 (liáng qiū), hè dĭng (EX-LE 2) 3. Point Selection According to Patterns (1) Kidney essence and marrow deficiency: LV 8 (qū quán), GB 39 (xuán zhōng), BL 23 (shèn shù). LV 8 (qū quán) is the he-sea point of the foot jueyin liver channel. Not only does it supplement the liver blood, but it dredges the local channels. GB 39 (xuán zhōng) is the influential point of marrow among the eight influential points, and acts to supplement the liver and kidney. BL 23 (shèn shù) is the back-shu point of the kidney, it acts to supplement essence and boost the kidney. All of these points supplement the liver blood and boost marrow. (2) Yang deficiency with internal cold: BL 18 (gān shù), BL 23 (shèn shù), KI 3 (tài xī), GB 34 (yáng líng quán). BL 18 (gān shù) and BL 23 (shèn shù) supplement kidney and liver. KI 3(tài xī) is the yuan-source point of the foot shaoyin kidney channel, and acts to supplement the kidney and boost qi. GB 34 (yáng líng quán) is the he-sea point of the foot shaoyang gallbladder channel and also the influential point of the sinews; it can relax the sinews and suppress convulsions. (3) Blood stasis: LV 3 (tài chōng), BL 17 (gé shù).

BL 17 (gé shù) is the influential point of blood, and LV 3 (tài chōng) is the yuan-source point of the foot jueyin liver channel. Together they can invigorate blood and dissolve stasis. The treatment of arthritis of the hip or the knee always requires therapies local to the joint in question. One can also choose warm-needling, bleeding, electrostimulation etc. The treatment principles are to supplement the kidney, boost the essence, and dredge the qi and blood of the local channels by warming the channels, dispelling cold, invigorating blood and dissolving stasis. To boost the upright qi and adjust the qi of five zang- and six fuorgans, needling with supplementation is more often used than the drainage method. To improve efficacy, flash-cupping at local points can be used after treatment.

CASE STUDY I Ms. Zhang, age 55. Initial Visit: Nov 3rd, 2000 Chief Complaint: Pain and swelling in the left knee for two years, getting worse over the prior two weeks. History: Two years ago, Ms. Zhang developed pain and swelling in her knee after exposure to cold. The pain was constant no matter if she were sitting or standing. Self-applied heat to the knee was effective in relieving the pain. X-ray showed that she had osteoarthritis of the knee with a narrowing of the articular space. The outcome of taking Chinese medicine orally was not good. The pain would still get worse after activity, while it was relieved with rest. Two weeks ago, Ms. Zhang found that her pain was getting worse, and walking became difficult. Signs and Symptoms: The patient reported swelling and pain in her knee with insomnia due to the pain. The pain was aggravated by cold and relieved with warmth. The local skin was neither red nor warm to the touch. The medial aspect of the left knee was tender to palpation. The floating patella test was negative. The tongue was pale with a greasy white coating; her pulse was soggy and moderate. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis or tuberculosis. No past history of allergies to drugs or foods. Menstrual, Marital and Childbearing History: Menarche at age 14, menstrual cycle 28-30 days, menstrual period 4-5 days. Her son, daughter, husband and children were all healthy.

Physical Examination: The patient was a lean female, well-developed and moderately nourished, and a little thin. Her skin and sclera showed no indication of jaundice, there were no palpable superficial lymph nodes, no jugular vein distention, or hepatojugular reflux (-). The bilateral respiratory movements were symmetrical, with resonant percussion sounds (normal). Heart rate was 70 bpm, regular, with no pathological murmur at any valve area. Flat abdomen, liver and spleen non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Pattern Differentiation The key indications stem from the fact that this is a longstanding condition in a 55 year-old patient. Years ago she found pain and swelling in her knee after exposure to cold, which undermined her full range-ofmotion. X-ray examination showed knee osteoarthritis. The patient reported swelling and pain in her knee, with insomnia due to the pain. The pain was worsened by cold and relieved by warmth. Her tongue was pale with a greasy white coating, and her pulse was soggy and moderate. The patient is over 50 years old, and as such, yang qi is decreasing. The kneejoint is worn out by heavy use, while the pathogenic cold that had invaded her body caused the swelling. The knee-joint responded consistent with the theory: “Qi damage causes pain, and yang damage causes swelling”. The tongue and pulse both indicated yang deficiency with internal cold. The location of osteoarthritis is in the knee, presenting as a mixed pattern of both excess and deficiency. Diagnosis WM diagnosis: Osteoarthritis

TCM diagnosis: Bi syndrome due to yang deficiency with internal cold Clinical Treatment This patient’s condition was caused by an innate deficiency of yang and 55 years of strain to the knee; additionally, combined with the external cold invasion, it resulted in the pattern of yang deficiency with cold in the channels. We can supplement kidney and strengthen yang, dissipate cold and unblock bi. Therefore, when treating osteoarthritis, besides acupuncture and medicine, we should also advise the patient to move the knee without pressure as much as the patient can bear in order to promote the restoration of the normal function of the knee. Principles: Supplement the kidney and strengthen yang, dissipate cold and unblock bi Formula: Modified Yòu Guī Wán (Right-Restoring Pill) and Juān Bì Tāng (Impediment-Alleviating Decoction) [右归丸合蠲痹汤加减]

Seven doses, boiled with water, taken twice a day. [Formula Analysis] In this formula, we used fù zĭ, ròu guì, and lù jiăo jiāo to warm yang and supplement the kidney. Qiāng huó and dú huó dissipate the cold, wind and dampness evil from the body. These medicinals warm yang, supplement the kidney, and dissipate cold. As such, all of the above act as chief medicinals. Shú dì, shān yào, shān zhū yú and gŏu qĭ zĭ together enrich yin to supplement the kidney, nourish the liver and fortify the spleen.

Qín jiāo and guì zhī dispel wind, overcome dampness, and warm the collaterals to unblock the channels. They also supplement the kidney, warm yang and dispel cold. These are the deputy medicinals. Tù sī zĭ, dù zhòng and dāng guī supplement the essence and nourish blood, while chuān xiōng, rй xiāng, mò yào and mù xiāng invigorate the blood and relieve pain. Niú xī guides all formula medicinals downward to the knees. These are all assistant medicinals. Zhì gān căo harmonizes all formula medicinals, and acts as an envoy in this formula.

Acupuncture Main points: nèi xī yăn (EX-LE 4), xī yăn (EX-LE 5), BL 40 (wěi zhōng), SP 10 (xuèhăi), ST 34 (liáng qiū), hè dĭng (EX-LE 2), GB 34 (yáng líng quán) Supplementary points: BL 18 (gān shù), BL 23 (shèn shù), KI 3 (tài xī), GB 33 (xīyáng guān), ST 36 (zú sān lĭ） Method: Choose 4-5 main points and 2-3 supplementary points each day, changing the selection every other day. After qi was obtained, the needles were retained for 20-30 min. Ten daily treatments constitute one course of treatment. Techniques: The even method was used with threading between points nèi xīyăn (EX-LE 4) and xī yăn (EX-LE 5). Warm-needle moxibustion was applied to SP 10 (xuè hăi) and ST 34 (liáng qiū). The even method was used at hè dĭng (EX-LE2) and GB 33 (xī yáng guān). Warm-needle moxibustion was used at GB 34 (yáng líng quán). Supplementation with moxibustion was used at BL 18 (gān shù) and BL 23 (shèn shù).

Supplementation was used at KI 3 (tài xī) and ST 36 (zú sān lĭ). This treatment was given every other day. However, electro-stimulation could also have been applied at nèi xī yăn (EX-LE 4) and xī yăn (EX-LE 5). Further Consultation After two treatments, all knee joint symptoms were cured, and there were no other complaints. There was no relapse at a six-month follow-up.

CASE STUDY II (ACUPUNCTURE, He Pu-ren) Mrs. Hakema, age 52. Chief Complaint: Pain around both of the knees for over thirty years. History: Patient reported a history of pain in both knees which had not been relieved by treatment elsewhere. The pain was nearly constant. Sometimes her low back also ached. Physical Examination: Around the knee, there were many purple collaterals (veins) showing through the skin. Some of the area was sensitive to touch and pressure. The tongue coating was white; her pulse was thready. Diagnosis WM diagnosis: Osteoarthritis TCM diagnosis: Bi syndrome due to blood stasis blocking the collaterals Clinical Treatment Principles: Unblock the channels and quicken the collaterals Manipulations: Bleed the tender collaterals for an immediate painrelieving effect. Further Consultation After a month, the patient came for a second treatment. She said the pain around her knees had disappeared; however, her lower back still ached. Examination: Thick collaterals were still visible in the low back region, specifically surrounding the spine where the tissue was also

sensitive to pressure. Treatment: Bleeding the collaterals for 10 min, after which her pain disappeared. The patient had suffered these pains for over 30 years. After only two treatments of bleeding, she was cured.

COMMENTARY AND DISCUSSION One of the more popular ingredients for bi syndromes due to an invasion of cold is fù zĭ (Radix Aconiti Lateralis Praeparata). This medicinal of course has some toxicity issues, but the risks associated with this very potent and helpful medicinal can be mitigated by observing some basic precautions: Only prescribe the prepared varieties of fù zĭ. Of course, even the prepared varieties have some toxicity. There also seems to be a relationship between both the toxic and therapeutic effects of the chemical constituents of fù zĭ. As an example, if the dosage or toxicity of fù zĭ is too great, it can cause numbness on the tongue. Perhaps this analgesic effect on the tongue is a reflection of its effects on aches and pains in the body. For practitioners using granules, there are no versions of granules available from manufacturers available in the U.S. that are not processed. To turn raw herbs into granules requires that the herbs are cooked, and heat destroys much of the toxicity; so assuming that the manufacturing practices of the supplier include adequate testing and quality control measures, the granular versions of fù zĭ have already been well-processed. One way to know if the fù zĭ you have is adequately processed or not is by taking the completed decoction and rolling a small amount of the decoction in the mouth. There should be no tingling or numbness. The usual dosage of fù zĭ is 3-15 grams. However there are therapeutic schools of thought such as the so-called “Fire-god School” that favors higher dosages of processed fù zĭ from 30 to 150 grams, with no side-effects are reported, even when used with some heat patterns. However, herbalists

who are not well-schooled or experienced with the use of this medicinal should go slowly and operate safely within their comfort zone. Formulas that include fù zĭ often include gān căo (Radix et Rhizoma Glycyrrhizae) and/or gān jiāng (Rhizoma Zingiberis), as they both act to diminish the medicinal toxicity. The key constituent assay used in China to determine the toxicity of fù zĭ, HPLC (High-Performance Liquid Chromatography), suggests a maximum aconitine content of 20mg/kg. Aconitine content is higher than this is considered dangerous. This aconitine content concentration also applies to other aconite species which are also warm and toxic in nature and commonly used for bi syndromes. These include: chuān wū (Radix Aconiti) and căo wū (Radix Aconiti Kusnezoffii). The United States Food and Drug Administration have some concerns about the use of fù zĭ and have begun to research adverse events associated with this herb. As of the time of this writing, summer of 2012, fù zĭ is still freely available to practitioners through our usual channels. However, it only takes one adverse event in a celebrity to make it much more difficult to obtain certain Chinese medicinals, so let’s be careful with its use.

STUDY QUESTIONS 1. Why choose the even method with threading between points in the first case? 2. In addition to the acupuncture and medicinal treatment in the first case, what further action should the practitioner take? 3. Why to choose warm-needle moxibustion in the first case? Answers 1. Nèi xī yăn (EX-LE 4) and xī yăn (EX-LE 5) lubricate the joints. Threading between these points reinforces the needling sensation and unblocks the qi and blood of the local channels. 2. Practitioners should insist that the patient begin rehabilitation therapy and an exercise program. 3. Ài yè (Folium Artemisiae Argyi) is bitter and acrid; it unblocks the channels, courses qi and blood, and dissipates cold and dampness. Moxibustion acts to further dredge the collaterals and warm the channels to dispel cold and dampness.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mr. Xue, age 58, complains of a pain in the right knee for one year. He walks with heavy steps. Stretching aggravates his pain which also got worse when cold. Other symptoms include soreness and coldness in the lower back. His tongue is pale with a glossy white coating; the pulse is deep and thready. Which of the following patterns is causing the knee pain? A. Cold-dampness stasis obstruction B. Kidney yang deficiency C. Yang deficiency due to cold congealing D. Blood stasis obstruction E. Kidney deficiency and essence insufficiency 2. Mr. Zhai, age 67, presents with pain and soreness in the lower back accompanied by soreness and sensitivity to pressure to the knee. His lower back and legs move with great difficulty. He also reports dizziness and tinnitus. The tongue is slightly red with a thin white coating; his pulse is thready. Which of the following formulas best addresses the pain in this case? A. Zuŏ Guī Wán (Left-Restoring Pill)

B. Yòu Guī Wán (Right-Restoring Pill) and Juān Bì Tāng (Impediment-Alleviating Decoction) C. Shèn Qì Wán (Kidney Qi Pill) D. Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) E. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) 3. Mrs. Liu, female, age 65, describes a pain and obscure swelling in her left knee. There is also soreness in the lower back accompanied by tinnitus. Her tongue is pale with a thin white coating; the pulse is deep and weak. Which of the following patterns best describes this case? A. Kidney and liver deficiency B. Qi and blood deficiency C. Kidney deficiency and marrow consumption D. Cold-dampness stasis obstruction E. Blood stasis obstruction 4. Mrs. Xian, female, age 78, complains of a pain in her knee. She had a few treatments, but her pain has only gotten worse. Now she has serious pain, especially at night. She presents with a dark complexion. Her tongue is purple and dim with stasis spots and maculae at the edge, with an engorged sublingual vein. Her pulse is choppy and wiry. Which of the following patterns best explains the cause of the pain? A. Cold-dampness stasis obstruction

B. Blood stasis obstruction C. Yang deficiency due to cold congealing D. Kidney and liver deficiency E. Kidney deficiency and marrow consumption 5. Mr. Wu, male, age 77, presents with a pain on the right hip that he reports has been there for six months. He can think of no reason for this pain. The pain is better after massage. He had been diagnosed by X-ray with a hip osteophyte. Signs and symptoms include pain that comes and goes, and a limited range of motion. His tongue is bright red with a scanty coating; the pulse is thready. Which of the following formulas is most suitable? A. Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) B. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) C. Yòu Guī Wán (Right-Restoring Pill) and Juān Bì Tāng (Impediment-Alleviating Decoction) D. Zuŏ Guī Wán (Left-Restoring Pill) E. Bŭ Yáng Huán Wй Tāng (Yang-Supplementing and Five-Returning Decoction) 6. Mrs. Guan, female, age 64, complains of a pain in her lower back which she has felt for over a month. Movement is difficult, the pain is aggravated by cold and relieved with warmth. The tongue is purple with a greasy white coating; her pulse is wiry.

Which of the following formulas would best address the lower back pain? A. Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) B. Zuŏ Guī Wán (Left-Restoring Pill) C. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) D. Sì Wù Tāng (Four Substances Decoction) E. Yòu Guī Wán (Right-Restoring Pill) and Juān Bì Tāng (Impediment-Alleviating Decoction) 7. Mr. Chen, male, age 68, complains about a pain in the left knee that has been there for one year, though it has been worse over the past three days. The knee’s range of motion is limited. The tongue is dim red with a thin white coating; his pulse is choppy. Which of the following points should be chosen in addition to local points? A. SP 10 (xuè hăi) B. ST 34 (liáng qiū) C. ST 36 (zú sān lĭ) D. GB 34 (yáng líng quán) E. BL 17 (gé shù) 8. Ms. Guo, female, age 76, reports that for two years she has suffered from pain and swelling in her knee at night, especially when the weather is cold. The swelling and pain are temporarily relieved after a hot compress.

The X-ray has showed hyperosteogeny and narrowing of vertebral foramen. Two weeks ago, the pain was aggravated and normal movement was impaired. Which of the following formulas are indicated? A. Yòu Guī Wán (Right-Restoring Pill) and Juān Bì Tāng (Impediment-Alleviating Decoction) B. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) C. Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) D. Zuŏ Guī Wán (Left-Restoring Pill) E. Gān Jiāng Líng Zhú Tāng (Licorice, Dried Ginger, Poria, and Atractylodes Macrocephala Decoction) Answers 1. C 2. A 3. C 4. B 5. D 6. E 7. E 8. A

SECTION II Pain of the Head and Face 7. Eye Pain ANCIENT THEORIES AND MODERN INSIGHTS Red, swollen, painful eyes, or “seasonal epidemic red eyes” refers to an eye condition caused by contracting pestilent qi. This condition is marked by sudden redness in the sclera of the eyes, and spotty, patchy bleeding. This condition most likely involves both eyes, and it tends to be highly contagious. Western medicine would refer to this condition as epidemic hemorrhagic conjunctivitis. Acupuncture treatment mainly focuses on scattering wind and dissipating heat, and draining heat and resolving toxins. Acupuncture is applicable, but moxibustion is contraindicated because of this pathology’s toxic-heat nature. The drainage technique is applied in these cases.

ETIOLOGY AND PATHOMECHANISMS This disease is caused by two conditions: A sudden contraction of pestilent qi, whereby wind heat injures the vessels of the eye. Accumulated heat toxin in the lung and stomach, whereby the metalphase overcontrols wood. Heat invades the liver channel, which then leads the heat to the eyes as toxic-heat.

COMMON CLINICAL PATTERNS Early stage pestilent qi: Manifests as a burning sensation in the affected eye, sensitivity to light, tearing, slight redness of the eye lid, redness in the sclera, spotty and/or patchy bleeding, fever, headache, and a stuffy nose. The tongue is red with a thin yellow coating; the pulse is floating and rapid. Intense heat toxin: Manifests as a burning sensation and pain in the affected eye, a red swollen eye lid and sclera, profuse bleeding, thirst, irritability, constipation, and dark urine. The tongue is red with a burnt yellow coating; the pulse is rapid.

THERAPEUTICS Chinese Medicinals 1. Early Stage Pestilent Qi Formula: Modified Qū Fēng Sàn Rè Yĭn Zĭ (Wind-Expelling HeatDissipating Drink) Ingredients: lián qiào (Fructus Forsythiae), niú bàng zĭ (Fructus Arctii), qiāng huó (Rhizoma et Radix Notopterygii), bò he (Herba Menthae), dà huáng (Radix et Rhizoma Rhei), chì sháo (Radix Paeoniae Rubra), fáng fēng (Radix Saposhnikoviae), dāng guī wěi (Radix Angelicae Sinensis Extremitas), shān zhī zĭ (Fructus Gardeniae), chuān xiōng (Rhizoma Chuanxiong), gān căo (Radix et Rhizoma Glycyrrhizae) 2. Intense Heat Toxin Formula: Modified Pŭ Jì Xiāo Dú Yĭn (Universal Relief ToxinRemoving Beverage) Ingredients: huáng lián (Rhizoma Coptidis), huáng qín (Radix Scutellariae), gān căo, xuán shēn (Radix Scrophulariae), bò he (Herba MenthaeMedicinal), chái hú (Radix Bupleuri), jié gĕng (Radix Platycodonis), lián qiào, băn lán gēn (Radix Isatidis), chén pí (Pericarpium Citri Reticulatae), mă bó (Lasiosphaera seu Calvatia), niú bàng zĭ, jiāng cán (Bombyx Batryticatus), shēng má (Rhizoma Cimicifugae), rén shēn (Radix et Rhizoma Ginseng)

Acupuncture and Moxibustion Treatment

1. Local Points Use points around the eyes, BL 2 (cuán zhú), GB 1 (tóng zĭ liáo), tài yáng (EX-HN5). 2. Distal Points LI 4 (hé gŭ) and LV 3 (tài chōng) regulate qi of the yangming channel, scatter wind, discharge heat, descend liver fire and benefit the eyes. 3. Point Selection Based on Pattern Differentiation (1) Wind-heat: GB 20 (fēng chí), and LI 11 (qū chí) (2) Heat toxin: DU 14 (dà zhuī), GB 43 (xiá xī), and LV 2 (xíng jiān) One may also employ point-bleeding, 1-2 times daily.

CASE STUDY I Mr. Wang, age 20. Initial Visit: January 1st, 2000 Chief Complaint: Red, swollen painful eyes for three days. History: Red, swollen, painful eyes with sensitivity to light for three days without known cause. No significant relief after using eye-drops or medication. Signs and Symptoms: Red, swollen painful eyes, moderate congestion of the conjunctivae, sensitivity to light, increased tearing which was aggravated by facing the wind, scanty dark urine. The tongue is red-tipped with a yellow greasy coating. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc. No past history of allergies to drugs or foods. Physical Examination: The patient was normally developed, wellnourished, and slightly thin. Conjunctivae were inflamed. His skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). The bilateral respiratory movements were symmetrical, resonant percussion sound (normal). Heart rate was 70 bpm and regular, no pathological murmur at any valve area. Flat abdomen, liver and spleen non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Laboratory Examination: Eye secretion smear showed a white blood cell count of 15 × 109/L. Pattern Differentiation

Patient had red, painful swollen eyes with tearing when facing the wind, dark urine, and a red-tipped tongue with a greasy yellow coating. All of these indicate an upward disturbance of wind-heat or pestilent qi. Diagnosis TCM pattern: Wind-heat Clinical Treatment Principles: Scatter wind and cleat heat Formula: Modified Qū Fēng Sàn Rè Yĭn Zĭ (Wind-Expelling HeatDissipating Drink) [驱风散热饮⼦加减]

The above formula is used to make three doses. One decocted dose taken each day. [Formula Analysis] Lián qiào, niú bàng zĭ, qiāng huó, fáng fēng, and bò he scatter wind and dissipate heat.

Chì sháo, and dāng guī wěi serve as assistants to invigorate the blood and unblock the channels. Dà huáng and zhī zĭ clear heat and purge fire. Chuān xiōng serves as an envoy to guide the medicinals to the head. Gān căo harmonizes all formula medicinals. All formula medicinals work together to scatter wind, dissipate heat, clear the liver and invigorate blood.

Acupuncture Standard acupoints: BL 1 (jīng míng), tài yáng (EX-HN5), LV 3 (tài chōng), LI 4 (hégŭ), LV 2 (xíng jiān) Auricular points: Eye (yăn), Eye 1 (mù yī), Eye 2 (mù èr), Liver (gān) Method: Needle the points once per day. After qi was obtained, all needles were retained for 20 to 30 min. Techniques: The drainage method used at all points except BL 1 (jīng míng). Wángbù liú xíng (Semen Vaccariae) were also applied to auricular points. Further Consultation The first day after treatment, the redness, swelling and pain in the eyes were greatly relieved. After a second treatment, he was cured.

CASE STUDY II (ACUPUNCTURE, Zheng Kuishan) Miss Zheng, age 8. Chief Complaint: Redness, swelling and pain in the right eye for one day. History: Redness, swelling and pain in the right eye as well as tearing, sensitivity to lights, and difficulty opening the eye during school on the day prior. Examination: Severe bulbar conjunctival congestion. The tongue was red, and the pulse was rapid and floating. Diagnosis Red, swollen painful eye due to both wind-heat and heat in the blood Clinical Treatment Principles: Scatter wind, drain heat, disperse swelling and stop pain Points: DU 23 (shàng xīng), BL 2 (cuán zhú), LI 4 (hé gŭ), yú yāo (EX-HN4), GB 1 (tóngzĭ liáo) Techniques: Point-bleeding Note Bleeding at DU 23 (shàng xīng), BL 2 (cuán zhú), and yú yāo (EXHN4) to clear heat and disperse swelling. Apply drainage at LI 4 (hé gŭ) to scatter wind and drain heat, and the even method at GB 1 (tóng zĭ liáo).

COMMENTARY AND DISCUSSION While the treatment protocols for infected eyes in this chapter does not include the use of BL 1 (jīng míng) or ST 1 (chéng qì), these points do come up from time to time in the typical acupuncture practice. I was always squeamish about needling BL 1 (jīngmíng), even though it was often used in the Bells Palsy Department of the Yunnan Province TCM Hospital where I spent some time. I was always relieved to know that there is a thick layer of fat surrounding the eyeball which is where needles were to be inserted. However, I always had a fear of poking the orbit and causing a perforation that would cause it to leak its optic humor and deflate like a tire with a hole. In reality, the sclera, which surrounds the entire eye, is quite tough, more like leather than a cooked egg white, which my fears imagined. I recently had the opportunity to treat a patient who had something of a bottle cap sutured to the back of the eye in order to address a choroidal melanoma, a malignant tumor that was treated by applying radiation directly to the tumor, hence the attachment of the apparatus to hold the radioactive iodine rods in place behind the tumor. This surgical procedure let me know just how robust the sclera really is. The take-home message here is that even if you do poke the eyeball with a needle, it will not deflate or leak uncontrollably. There may be bleeding, and the sclera can turn red, not unlike a “black eye” but the trauma is superficial and will not cause any long-term damage to the eye or vision, assuming that the needle prick is no more aggressive than one would normally use while cautiously inserting a needle into these points.

STUDY QUESTIONS 1. Why was the drainage method used in the first case? 2. In addition to acupuncture and Chinese medicinal treatment, what precautions should be taken in the first case? 3. Which of the following medical approaches is best for the treatment of red, swollen painful eyes? A. Acupuncture followed by moxibustion B. Moxibustion followed by acupuncture C. Acupuncture together with moxibustion D. Moxibustion only without acupuncture E. Acupuncture and bleeding 4. Which of the following points are used to treat red, swollen, painful eyes due to invasion of external wind-heat? A. LI 4 (hé gŭ), LV 3 (tài chōng) B. GB 43 (xiá xī), LV 2 (xíng jiān) C. GB 20 (fēng chí), LI 11 (qū chí) D. GB 20 (fēng chí), LV 3 (tài chōng) E. GB 43 (xiá xī), LI 11 (qū chí) 5. Which of the following points are used to treat red, swollen, painful eyes due to heat toxin? A. LI 4 (hé gŭ), LV 3 (tài chōng)

B. GB 43 (xiá xī), LV 2 (xíng jiān) C. GB 20 (fēng chí), LI 11 (qū chí) D. GB 20 (fēng chí), LV 3 (tài chōng) E. GB 43 (xiá xī), LI 11 (qū chí) 6. Which of the following points are NOT used to treat red, swollen painful eyes? A. GB 1 (tóng zĭ liáo) B. tài yáng (EX-HN5) C. GB 20 (fēng chí) D. LI 4 (hé gŭ) E. LV 3 (tài chōng) 7. Which of the following points are NOT bled to treat red, swollen, painful eyes? A. GB 1 (tóng zĭ liáo) B. tài yáng (EX-HN5) C. BL 2 (cuán zhú) D. LV 3 (tài chōng) E. GB 20 (fēng chí) Answers 1. The pattern differentiation of this case was the upward disturbance of wind heat, an excess syndrome, thus drainage was applied.

2. This is an acute contagious disease frequently encountered in ophthalmology departments that can easily spread through the population. As such, eye hygiene is very important during the acute phase. 3. E 4. C 5. B 6. C 7. E

8. Toothache ANCIENT THEORIES AND MODERN INSIGHTS Toothache is a symptom most commonly seen in oral disease. Toothache can be caused by cavities, gingivitis, periodontitis, root infection, periodontal abscess, or simply due to tooth sensitivity. Toothache can also be triggered or aggravated by cold, heat, sour, sweets, etc. Toothache is categorized in TCM as “tooth root exposure” and “bone canal-wind”. The hand yangming large intestine channel enters the lower teeth, while the foot yangming stomach channel enters the upper. The kidney dominates the teeth and teeth are the surplus of the kidney, so toothache may be also caused by flaring up of deficiency fire due to patterns of kidney yin deficiency.

ETIOLOGY AND PATHOMECHANISMS Causes of toothache include the following scenarios: external wind invades the channels and collaterals and then accumulates in the yangming channel and transforms into fire; the fire pathogen then flares up through the channels and leads to toothache. Or, poor oral hygiene or excessive consumption of sweet, fatty, and salty foods leads to heat accumulation in the stomach and subsequent flaming upward of stomach fire. Wind, fire and toxins can also invade the body directly and affect the teeth. Finally, internal deficiency-type fire can also flame upward to scorch the teeth and gums. This disease has three contributing factors: Wind-fire: Latent fire in the yangming merges with a wind-heat pathogen. The wind-fire then flares up and results in toothache. Wind-cold: Wind-cold can enter the teeth and cause a toothache. Kidney yin deficiency: Deficiency fire flames upward and leads to looseness and dull pain of the teeth.

COMMON CLINICAL PATTERNS Wind-fire: Manifestations include toothache with red, swollen painful gums, pain that is alleviated by cold and aggravated by wind and heat, fever, aversion to cold, and thirst. The tongue is red with a dry white coating; the pulse is floating and rapid. Stomach fire: Manifestations include severe toothache, red swollen gums, discharge of pus, bleeding, pain that refers to the chin and face, headache, thirst, foul breath, and constipation. The tongue is red with a yellow coating; the pulse is slippery and rapid. Yin deficiency fire: Manifestations include low-grade, dull pain in the teeth, mild redness and swelling of the gums, atrophy of gums with long duration of disease, and loose teeth, accompanied by irritability, insomnia, and dizziness. The tongue is red; the pulse is thready and rapid.

THERAPEUTICS Chinese Medicinals 1. Toothache Due to Wind-fire Formula: Bò Hé Lián Qiào Fāng (Mint and Forsythia Formula) Ingredients: jīn yín huā (Flos Lonicerae Japonicae), lián qiào (Fructus Forsythiae), zhú yè (Folium Phyllostachydis Henonis), lü˘ dòu yī (Testa Glycinis), zhī mŭ (Rhizoma Anemarrhenae), shēng dì (Radix Rehmanniae), bò he (Herba MenthaeMedicinal) (added later), niú bàng zĭ (Fructus Arctii) 2. Toothache Due to Stomach Fire Formula: Qīng Wèi Săn (Stomach-Heat-Clearing Powder) Ingredients: huáng lián (Rhizoma Coptidis), shēng shí gāo (raw Gypsum Fibrosum) (decocted first), mŭ dān pí (Cortex Moutan), shēng dì, dāng guī (Radix Angelicae Sinensis), shēng má (Rhizoma Cimicifugae) 3. Toothache Due to Deficiency Fire Formula: Modified Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill) Ingredients: shú dì huáng (Radix Rehmanniae Praeparata), shān zhū yú (Fructus Corni), shān yào (Rhizoma Dioscoreae), zé xiè (Rhizoma Alismatis) fú líng (Poria), mŭdān pí, zhī mŭ, huáng băi (Cortex Phellodendri Chinensis), gŏu jĭ (Rhizoma Cibotii) ★ Key Medicinal

The Grand Compendium of Materia Medica (Bĕn Căo Gāng Mù, 本草 纲⽬) states, “shígāo is also called xì lĭ shí (literally: fine-texture stone) or hán shuĭ shí (Glauberitum). It is used to treat chills and fever due to wind invasion, has functions of releasing the muscle layer and promoting sweat, quenching thirst, relieving dry tongue, and stopping headaches and toothaches,... it is an effective medicinal for removing pestilence and reducing fever.” Toothache is a symptom of heat, and shí gāo has a very cold thermal property, so symptoms of toothache can be managed effectively by “using cold to subdue heat”.

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels The hand yangming large intestine channel enters the lower teeth and the foot yangming stomach channel enters the upper teeth, so points on these two channels are commonly selected: LI 4 (hé gŭ), LI 2 (èr jiān), ST 6 (jiá chē), ST 7 (xià guān), ST 44 (nèitíng). 2. Point Selection Based on Pattern Differentiation Add SJ 5 (wài guān) and GB 20 (fēng chí) for toothache due to windfire, ST 44 (nèi tíng) and LI 2 (èr jiān) for stomach fire, or KI 3 (tài xī) and LV 2 (xíng jiān) for yin deficiency patterns. 3. Auricular Acupuncture Select upper jaw (shàng hé), lower jaw (xià hé), shen men (shén mén), upper apex of tragus (shàng píng jiān), and toothache point (yá tòng diăn). 2-3 points are used at each treatment and given strong stimulation. Needles are retained for 20-30 min.

CASE STUDY I Mr. Yuan, age 35. Chief Complaint: Right upper toothache for three days. History: Mr. Yuan had dry stools, thirst and a bitter taste in the mouth over the past few days. His right upper toothache began three days ago, and the pain worsened the day prior to his examination. He was afraid of chewing foods. He took painkillers and NSAIDs, but didn’t have any relief. He hadn’t had a bowel movement for three days. He had foul breath, poor appetite and yellow urine. Signs and Symptoms: A red tongue body with a dry yellow coating, a slippery and wiry pulse. Pattern Differentiation Main features in this case: severe toothache arising with thirst, foul breath, yellow urine, constipation, fever and a dry yellow tongue coating. The stomach is treated for acute toothaches with foul breath, yellow urine and constipation. Pattern differentiation: yangming heat accumulation, obstruction of the channels and collaterals (causing pain). Diagnosis Toothache due to stomach fire Clinical Treatment

This is a case of toothache due to fire accumulating in the stomach and flaming upward to attack the teeth. Accompanying symptoms include swollen gums, foul breath, constipation and a slippery and wiry pulse. In addition to acupuncture and Chinese medicinal treatment, the patient should avoid spicy foods. Watching the diet is indispensible for effective treatment of this condition. Principles: Clear stomach heat, cool blood and stop pain Formula: Qīng Wèi Săn (Stomach-Heat-Clearing Powder) [清胃散]

Decocted with water as one divided dose, taken twice daily. [Formula Analysis] Huáng lián drains heart and stomach fire. Dāng guī harmonizes the blood. Shēng dì and mŭ dān pí cool the blood, and nourish yin to subdue yang. Shēng shí gāo strongly drains yangming heat. Shēng má lifts the clear yang of the stomach which stimulates the descent of heat (by promoting the ascent of coolness) to address the swelling and pain.

Acupuncture Treatment principles: Clear heat and drain fire, unblock the channels and stop pain Points: ST 44 (nèi tíng), ST 25 (tiān shū), ST 7 (xià guān) and ST 6 (jiá chē) Techniques: The above points were needled with drainage. The needles were retained for 30 min and manipulated once during the treatment. The patient felt pain relief after one acupuncture treatment and was able to eat after going home. He had one bowel movement the next morning after which he felt much better. He had a second treatment the next day, and the toothache was cured after three acupuncture treatments.

CASE STUDY II (ACUPUNCTURE) Ms. Li, age 45. Chief Complaint: Dull pain in the lower teeth for two days. History: Ms Li had dull, intermittent pain in her lower teeth for two days. No foul breath, no bleeding or swelling of the gums, sensations of the teeth being loose, frequent dizziness, and soreness of the lower back. The tongue was red; the pulse was thready. Diagnosis Toothache due to deficiency-fire Clinical Treatment Principles: Nourish yin, clear heat, descend fire and stop pain Points: ST 6 (jiá chē), ST 7 (xià guān), LI 4 (hé gŭ), ST 44 (nèi tíng), KI 3 (tài xī), and KI 6 (zhào hăi) with the even method Techniques: Electro-stimulation was added to ST 6 (jiá chē), ST7 (xià guān), LI 4 (hé gŭ) or LI 2 (èr jiān) after qi arrival. A dense wave was chosen and the points were strongly stimulated for 20-30 min.

COMMENTARY AND DISCUSSION I generally have a problem when those with limited clinical TCM experience or inadequate understanding Chinese differential diagnosis or protocols generally advocate for the use of Western treatments. That being said, there are many instances of dental infections with extreme pain that do not present as a clear pattern of disharmony, in which case I would not hesitate to refer out to the friendly local dentist. However, if I had a case of toothache in my office that also had clear and unambiguous indications of stomach heat or any of the patterns described in this chapter, I would not hesitate to use the formulas and point prescriptions listed here.

STUDY QUESTIONS 1. What is the presenting pattern in the first toothache case? 2. How does one differentiate between toothache and trigeminal neuralgia? 3. Which of the following points do NOT treat toothache? A. tài yáng (EX-HN5) B. ST 7 (xià guān) C. ST 6 (jiá chē) D. ST 44 (nèi tíng) E. LI 4 (hé gŭ) 4. Bleeding can be applied to which of the following points to treat toothache? A. LU 11 (shào shāng) B. LU 5 (chĭ zé) C. LU 10 (yú jì) D. BL 12 (fēng mén) E. ST 44 (nèi tíng) 5. Which of the following therapeutic methods is most applicable for toothache due to excess fire? A. Using both acupuncture and moxibustion B. Using only acupuncture but no moxibustion

C. Using only moxibustion but no acupuncture D. Tui na massage techniques E. Using bloodletting with tri-edged needle 6. The points on the hand and foot yangming channel are used frequently in the treatment of toothaches. Which of the following statements best explains this? A. The hand yangming channel of the large intestine enters the lower teeth B. The foot yangming channel of the stomach enters the lower teeth C. The hand yangming channel of the large intestine enters the upper teeth D. The foot yangming channel of the stomach enters both jaws E. The foot yangming channel of the stomach is effective for extinguishing wind Answers 1. Analysis of the main features of this case: toothache due to fire accumulating in the stomach flaming upward and attacking the teeth accompanied by swollen gums, foul breath, constipation and a slippery pulse. Differentiation: heat accumulation in the stomach, obstruction of the channels and collaterals. Pattern: toothache due to stomach fire. 2. Toothache is constant, and caused by inflammation or a cavity; it is aggravated by cold or heat, and is often worse at night. Trigeminal

neuralgia is sporadic and with severe pain in the area innervated by the trigeminal nerve. Unique symptoms include sudden and severe electric shock-like, lacerating or stabbing pains in the areas where the trigeminal nerve dominates (such as the forehead, cheeks, upper and lower lips, etc.). The pain lasts from a few seconds to minutes and then stops. Trigeminal neuralgia usually only occurs on one side of the face, but may occur on both sides too, and is more likely seen in people over age 40. 3. A 4. E 5. B 6. A

9. Sore Throat ANCIENT THEORIES AND MODERN INSIGHTS A sore throat is a common symptom related to disorders of the mouth, throat and larynx. It is also named “throat bi”, whose characteristics include a red swollen and painful throat that may induce difficulty in swallowing. It is associated with acute tonsillitis, pharyngitis, simplex laryngitis and abscess around the tonsil. Anatomically, the throat is followed by the esophagus, which then connects to the stomach; the larynx is followed by the trachea which then connects to the lungs. The epiglottis has the shape of a flower petal, being wider above and narrower below, and is located behind the hyoid bone. It rises while breathing and drops when swallowing to allow for passage of either food or air. There are two tonsils which are located one on each side visible in the back of the throat. The uvula, which is also called “emperor’s bell” and “little tongue” in Chinese (and the “punching bag” in American culture) is a little protrusion from the soft palate which recedes when opening the mouth. The tonsils, uvula, and the root of the tongue form the passageway to the throat, which then divides the local area into the “interior passage” and

“exterior passage”.

ETIOLOGY AND PATHOMECHANISMS External Causes This condition has an acute onset with red and swollen tissues, pain in the throat and difficulty in swallowing, also often accompanied by symptoms of an upper respiratory infection such as fever, cough, and poor appetite. Wind-heat: Wind-heat attacks the patient while his/her constitution is weak. It usually enters the body through the mouth and nose, and affects the lungs, resulting in dysfunction of lungs’ dispersion and descending functions, with an accumulation of heat-toxin in the throat. Wind-cold: Wind-cold attacks the body through the skin or lungs. The throat is the passageway to the lungs. Cold can impede the flow of wei qi or “defensive yang”in the throat, giving rise to soreness.

Internal Causes The onset of the disease mainly involves four organs: the lung, spleen, stomach and kidney. Lung: Sore throat often follows damage to the lung yin due to febrile disease; the throat is then poorly moistened and eventually scorched by deficiency fire. Kidney: Sore throat is also caused by kidney yin deficiency and deficiency fire scorching the throat; such kidney yin deficiency is often caused by over-exertion.

Spleen and stomach: Both organs are easily injured by excessive mental work, abnormal diet, or chronic diseases. Deficiency of the spleen and stomach results in impaired transformation thus leading to a lack of essence from food and drink; the throat in turn is under-nourished and throat bi pain follows.

COMMON CLINICAL PATTERNS Wind-heat: Red painful throat, difficulty in swallowing, cough, chills and fever, headache, a floating rapid pulse. Excess heat in the lung and stomach: Dry throat, thirst, constipation, yellow urine, a red tongue with a yellow coating, a surging pulse. Kidney yin deficiency: Mildly swollen, dark red throat, mild pain, or painful when swallowing, mild heat signs, worse in the evening.

THERAPEUTICS Chinese Medicinals 1. External Contraction (1) Wind-heat Formula: Shū Fēng Qīng Rè Tāng (Wind-Coursing Heat-Clearing Decoction) Ingredients: jīng jiè (Herba Schizonepetae), fáng fēng (Radix Saposhnikoviae), jīnyín huā (Flos Lonicerae Japonicae), lián qiào (Fructus Forsythiae), huáng qín (Radix Scutellariae), chì sháo (Radix Paeoniae Rubra), xuán shēn (Radix Scrophulariae), zhèbèi mŭ (Bulbus Fritillariae Thunbergii), tiān huā fĕn (Radix Trichosanthis), sāng bái pí (Cortex Mori) (2) Wind-cold Formula: Liù Wèi Tāng (Six-Ingredient Decoction) Ingredients: jīng jiè, fáng fēng, bò he (Herba Menthae), dà huáng (Radix et Rhizoma Rhei), chì sháo, jié gĕng (Radix Platycodonis), gān căo (Radix et Rhizoma Glycyrrhizae), jiāng cán (Bombyx Batryticatus) 2. Excess Heat in the Lung and Stomach Formula: Qīng Yān Lì Gé Tāng (Throat-Clearing DiaphragmDisinhibiting Decoction) Ingredients: jīng jiè, fáng fēng, bò he, jīn yín huā, lián qiào, zhī zĭ (Fructus Gardeniae), huáng qín, huáng lián (Rhizoma Coptidis), jié gĕng, gān căo, niú bàng zĭ (Fructus Arctii), xuán shēn

3. Lung Yin Deficiency Formula: Yăng Yīn Qīng Fèi Tāng (Yin-Nourishing Lung-Clearing Decoction) Ingredients: xuán shēn, bái sháo (Radix Paeoniae Alba), mài dōng (Radix Ophiopogonis), shēng dì (Radix Rehmanniae), bò he, bèi mŭ (Bulbus Fritillaria), mŭ dānpí (Cortex Moutan), shēng gān căo (Radix et Rhizoma Glycyrrhizae) 4. Kidney Yin Deficiency Formula: Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill) Ingredients: shān zhū yú (Fructus Corni), shān yào (Rhizoma Dioscoreae), shú dìhuáng (Radix Rehmanniae Praeparata), zé xiè (Rhizoma Alismatis), fú líng (Poria), mŭdān pí 5. Spleen and Stomach Deficiency Formula: Bŭ Zhōng Yì Qì Tāng (Center-Supplementing Qi-Boosting Decoction) Ingredients: huáng qí (Radix Astragali), rén shēn (Radix et Rhizoma Ginseng), bái zhú (Rhizoma Atractylodis Macrocephalae), zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle), dāng guī (Radix Angelicae Sinensis), jú pí (Pericarpium Citri Reticulatae), shēng má (Rhizoma Cimicifugae), chái hú (Radix Bupleuri) 6. Spleen and Kidney Yang Deficiency Formula: Fù Zĭ Lĭ Zhōng Wán (Aconite Center-Regulating Pill) Ingredients: rén shēn, bái zhú, gān jiāng (Rhizoma Zingiberis), fù zĭ (Radix Aconiti Lateralis Praeparata), gān căo

7. Accumulation of Phlegm and Blood Stasis Formula: Bèi Mŭ Guā Lóu Săn (Fritillary Bulb and Trichosanthes Fruit Powder) Ingredients: bèi mŭ (Bulbus Fritillaria), guā lóu (Fructus Trichosanthis), jú hóng (Exocarpium Citri Rubrum), jié gĕng, gān căo

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Points on the lung and stomach channels are often selected for excess patterns. (2) Points on the kidney channel are selected for deficiency patterns. 2. Point Selection According to Location (1) Local points: Frequently used points include SI 17 (tiān róng), RN 22 (tiān tū), and LI 18 (fú tū) (2) Points on the upper extremities Hand taiyin lung channel: LU 7 (liè quē), LU 5 (chĭ zé), LU 11 (shào shāng) Hand yangming large intestine channel: LI 11 (qū chí) (3) Points on the lower extremities Foot shaoyin kidney channel: KI 3 (tài xī), KI 6 (zhào hăi) 3. Point Selection Based on Pattern Differentiation (1) Excess heat patterns: Select points on the hand taiyin, and the hand and foot yangming channels.

Main points: LU 11 (shào shāng), LI 4 (hé gŭ), LU 5 (chĭ zé), SI 17 (tiān róng), LU 7 (lièquē), KI 6 (zhào hăi) Supplementary points: For wind-heat, add LI 11 (qū chí) and SJ 5 (wài guān). For excess heat in the lung and stomach, add ST 45 (lì duì) and LU 10 (yú jì). Technique: Needle all points with drainage. (2) Yin deficiency patterns: Select points on the foot shaoyin channel. Main points: KI 3 (tài xī), KI 6 (zhào hăi) and LU 10 (yú jì) Supplementary points: For fever at night, add SP 6 (sān yīn jiāo) and KI 7 (fù liū). Techniques: Needle KI 3 (tài xī), KI 6 (zhào hăi), SP 6 (sān yīn jiāo) and KI 7 (fù liū) with supplementation, and LU 10 (yú jì) with drainage. (3) Modifications LU 5 (chĭ zé), SJ 5 (wài guān) and LU 11 (shào shāng) are added to cases with accumulation of wind-heat in the lungs to disperse wind and clear heat. ST 44 (nèi tíng) and LI 11 (qū chí) are added for exuberant heat in the stomach to clear and drain heat. KI 3 (tài xī), KI 1 (yŏng quán) and SP 6 (sān yīn jiāo) are added for yin deficiency with exuberant fire to nourish yin and descend fire. RN 22 (tiān tū) and ashi points lateral to the Adam’s apple are added for swollen sore throat to reduce swelling and stop pain. KI 7 (fù liū) and LI 18 (fú tū) are added to moisten the throat and relieve hoarseness.

KI 6 (zhào hăi) and LU 7 (liè quē) are added to moisten the throat and relieve hoarseness. LI 11 (qū chí) and SJ 6 (zhī gōu) are added for constipation to clear heat and unblock the bowels.

CASE STUDY I Ms. Shen, age 14. Chief Complaint: Sore throat accompanied with fever for seven days. History: The patient was diagnosed as having the common cold with acute laryngitis. She was given chlortetracycline, antipyretic analgesic tablets and had fever drainage injections. She had a low-grade fever in the morning which got worse in the afternoon. Her temperature varied from 99.6 to 102.7°F (37.6-39.3℃). She had fever, sweats, dry and painful throat, difficulty swallowing and a poor appetite. Her tongue had a white tongue coating and red tip; her pulse was rapid. Physical Examination: The patient was malnourished and had a flushed face, dull spirit, fatigue, congested throat, enlarged tonsils with purulent discharge, free range of motion of joints, normal abdominal sounds. Heart rate was 96 bpm. Auxiliary Examination: Routine blood test: white blood cell 5.25×109/L, neutrophil 65%, lymphocyte 34%, eosinophil 1%; hemoglobin 14.1g, red blood cell count 4.15×1012/L, erythrocyte sedimentation rate 32 mm/h. Chest X-ray: No abnormal findings. Throat swab culture: Staphylococcus aureus and hemolytic streptococcus were found. Pattern Differentiation The key indications in Ms. Shen’s pathology involved a low-grade fever in the morning that became worse in the afternoon. She also had fever, sweats, dry and painful throat, difficulty swallowing and a poor appetite. Her tongue had a white coating and red tip; her pulse was rapid.

This patient had a yin deficiency-type constitution, where external wind had invaded the exterior then entered the interior where it transformed into heat and then accumulated in the throat. The location of the disease was the lungs, and the condition manifested as an excess pattern. Diagnosis TCM pattern: Wind-heat invading the exterior Clinical Treatment Principles: Nourish yin, clear heat, eliminate toxins and benefit the throat Formula: Shū Fēng Qīng Rè Tāng (Wind-Coursing Heat-Clearing Decoction) [疏风清热汤]

3 doses. One decocted dose per day. [Formula Analysis] Jīng jiè and fáng fēng disperse wind and release exterior. Jīn yín huā, lián qiào, huáng qín and chì sháo clear heat and eliminate toxins.

Xuán shēn, zhè bèi mŭ, tiān huā fĕn and sāng bái pí clear the lungs and resolve phlegm.

Acupuncture Main points: LU 11 (shào shāng), LI 1 (shāng yáng), ST 6 (jiá chē), GB 20 (fēng chí), DU 14 (dà zhuī), SJ 17 (yì fēng), LI 4 (hé gŭ) Method: After obtaining qi, all needles were retained for 20-30 min. 10 visits serve as one course of treatment. Techniques: LU 11 (shào shāng) and LI 1 (shāng yáng) were bled. Cooling and drainage techniques were applied to ST 6 (jiá chē), GB 20 (fēng chí), DU 14 (dà zhuī) and SJ 17 (yì fēng). The following day, SJ 17 (yì fēng), ST 6 (jiá chē) and LI 4 (hé gŭ) were needled with cooling and drainage, and KI 6 (zhào hăi) was needled with the even method. Further Consultation Her temperature dropped to 100.4°F (37.8℃) and the sore throat was relieved after the first treatment. After three consecutive daily treatments, all symptoms disappeared and her temperature dropped to 97.1°F (36.2℃). The throat and tonsils returned to normal and the patient was discharged from the hospital.

CASE STUDY II (ACUPUNCTURE) Mr. Zhao, age 29. Chief Complaint: Swollen, sore throat for two days. History: The patient had a mild dry sore throat last night after having visited the countryside. Today he has a swollen, sore throat, and difficulty swallowing, accompanied by fever, headache, sweating, and slight productive cough. The tongue is red with a thin slightly yellow coating; the pulse is floating and rapid. Laryngoscopy: Congestion and swelling of pharyngeal mucosa, lateral pharyngeal redness and swelling, no enlargement of either tonsil. Diagnosis Swollen and sore throat due to accumulation of wind-heat in the lungs Clinical Treatment Principles: Dispel wind, clear heat, reduce swelling and stop pain Points: SI 17 (tiān róng), LU 7 (liè quē), KI 6 (zhào hăi), LI 4 (hé gŭ), LU 5 (chĭ zé), LU 11 (shào shāng), SJ 5 (wài guān) Techniques: Bleeding was applied to LU 11 (shào shāng), drainage to LI 4 (hé gŭ) and LU 5 (chĭ zé), and the even method on the rest of the points; all needles were retained for 30 min. To strengthen the therapeutic effect, treatment was performed once a day for five days.

COMMENTARY AND DISCUSSION The authors have described internal causes for sore throat to be “mainly” due to the kidney, lung, and spleen and stomach. However, it should be noted that both the liver and heart channels pass also through the throat. Should you encounter a sore throat patient with a pattern that conforms better to a liver or heart disharmony, one should consider the possibility that the sore throat is arising from either of these organs, as well as those described previously in this chapter.

STUDY QUESTIONS 1. Which channel was mainly affected in the first case? 2. Which points were used to drain heat on the second day of treatment in the first case? 3. Which of the following points can be added to the basic point prescription to treat sore throat due to heat in the lung and stomach? A. LU 10 (yú jì) and ST 44 (nèi tíng) B. LU 5 (chĭ zé), SJ 5 (wài guān) and LU 11 (shào shāng) C. KI 3 (tài xī), KI 1 (yŏng quán) and SP 6 (sān yīn jiāo) D. LU 11 (shào shāng), KI 3 (tài xī) and LI 11 (qū chí) E. LU 7 (liè quē), BL 62 (shēn mài) and SP 6 (sān yīn jiāo) 4. Which of the following points is NOT among the basic points to treat sore throat? A. LU 7 (liè quē) B. SI 17 (tiān róng) C. KI 6 (zhào hăi) D. SJ 5 (wài guān) E. LI 4 (hé gŭ) 5. Which of the following points make up a basic point prescription to treat swollen, sore throat? A. LU 7 (liè quē), SP 4 (gōng sūn)

B. LU 7 (liè quē), KI 6 (zhào hăi) C. PC 6 (nèi guān), KI 6 (zhào hăi) D. SI 3 (hòu xī), KI 6 (zhào hăi) E. LU 7 (liè quē), BL 62 (shēn mài) 6. Which of the following is the indication for the prescription composed of LU 7 (lièquē), KI 6 (zhào hăi), LU 10 (yú jì), and KI 3 (tài xī)? A. Swollen, sore throat due to yin deficiency with exuberant fire B. Chronic pharyngitis due to insufficiency of lung yin C. Chronic pharyngitis due to phlegm-blood stasis D. Swollen, sore throat due to accumulation of wind-heat in the lungs E. Chronic pharyngitis due to kidney yin deficiency Answers 1. The hand taiyin lung channel 2. SJ 17 (yì fēng), ST 6 (jiá chē) and LI 4 (hé gŭ) 3. A 4. D 5. B 6. B

10. Headache ANCIENT THEORIES AND MODERN INSIGHTS Headache is a common subjective symptom presenting in clinical practice, occurring independently or as secondary to other diseases. The headaches discussed in this section arise from external factors such as the six pathogenic factors (abnormal climatic factors), lifestyle factors such as dietary or reproductive habits, or internal damage of the zang-fu organs. The head contains the “sea of marrow”, thus headaches arising with other indications of kidney deficiency may be treated by supplementing the essence, which is the precursor to marrow. Channel theory describes the head as the “confluence of all yang channels” and so focusing acupuncture therapies on yang channels to drain excess is a common approach to treatment. The head is also known as the “house of clear yang”. As such, when we see a lack of qi or yang lifting to the head, headaches may ensue. A lack of clear yang rising also implies a lack of turbid yin descending, so these headaches not only arise with fatigue, but can also include a heavy sensation in the head. Finally, it is said that the qi and blood of the five viscera and six bowels all converge in the head. This statement reminds the practitioner that any deficiency condition can give rise to headache.

ETIOLOGY AND PATHOMECHANISMS External Causes Among the external causes, headache most often results from windpathogens. Pathogenic wind, being the leading pathogenic factor of all diseases, often attacks the human body as a seasonal illness. Wind is usually accompanied by cold, heat, or dampness. Wind-cold: When wind-cold attacks the exterior, cold congeals and contracts which leads to blood stagnation. Patients with wind-cold will then develop a headache arising from the neck and shoulders where wind is said to enter the body. This is evidenced by the many point names on the nape that include the word “wind” (fēng, 风). Wind-cold headaches are accompanied by an aversion to cold with chills or shivering. Wind-heat: Heat rises, so pathogenic wind-heat will often affect the upper parts of the body. This mostly takes place in the head where the pathogenic factors stagnate in the channels, which then causes headache pain. Wind-heat patients will also present with feverishness. Wind-dampness: When wind attacks the exterior, it is often accompanied by dampness which clouds the head and obstructs the rising of clear yang, thus leading to heaviness and pain in the head. If the dampness penetrates to obstruct the middle jiao, clear yang fails to rise and turbid yin fails to descend, which can also give rise to a heavy-feeling headache. Dampness is a yin pathogen; it can thus damage yang qi, impair the free movement of qi, and confound the brain. As clear yang fails to ascend, headache ensues.

Internal Causes Headaches due to internal damage have a close relationship with three zang organs: the liver, spleen and the kidney. Liver: Headaches arise due to stagnation of qi and blood in the head, and pathogenic factors arising from the liver can cause this stagnation. Liver yin deficiency can give rise to hyperactivity of liver yang, leading to heat and/or wind rising to the head where it then prevents the free-flow of qi and blood. Liver qi stagnation can transform into fire, which then rises and causes stagnation in the head. Spleen: there are two key pathogenic mechanisms; the first due to excess, and the second due to deficiency. When the spleen fails to transport and transform (perhaps due to dietary indiscretion), the outcome is internal phlegm-turbidity which prevents the clear yang from rising and the turbid yin from descending. With this lack of clear yang and excess of turbid yin, qi and blood is stagnated with the outcome being a heavy-feeling headache. When there is a deficiency in the spleen, it cannot properly transform and generate enough qi to lift the clear yang and blood to nourish the brain, which results in a dull and often chronic headache. Kidney: Headaches can arise following sexual overindulgence, which consumes kidney essence and leads to deficiency in the sea of marrow. This gives rise to a lack of nourishment for the brain, causing a headache that feels empty and is obviously aggravated by sexual activity. Internal cold arises from kidney yang deficiency, in which case the clear yang fails to diffuse upward thus leading to another lack of yang nourishing the head. Insufficient kidney yin can fail to nourish the liver, which can lead to

internal wind rising to the head where it then causes qi stagnation and headache.

Other Causes Patients with chronic illness or traumatic injury can develop blood stagnation in the channels and collaterals. Because “stagnation causes pain”, these patients too can complain of headaches.

COMMON CLINICAL PATTERNS The most commonly encountered clinical patterns can be categorized into external contraction and internal damage. External contraction patterns include wind-cold, wind-heat, and wind-dampness; internal damage patterns involve the liver yang, blood deficiency, phlegm-turbidity, kidney deficiency, and blood stasis.

Pattern Differentiation 1. Differentiation Based on Channel Theory Yangming headache: Forehead headache with pain of the supraorbital ridge, which can be caused by sinusitis or diseases of the nose, eyes, or upper teeth. Shaoyang headache: Unilateral headache, often temporal, including pain caused by ear diseases. Taiyang headache: Occipital headache, including pain arising from a stiff neck or cervical spondylosis. Jueyin headache: Parietal and vertex headaches, including those arising from hypertension. Unilateral and frontal headache (yangming and shaoyang channels): Pain at the forehead and sides of the head. Global headache: Headache of the whole head, with the exact location difficult to distinguish. 2. Differentiation Based on Patterns

(Exterior) Cold: Headache associated with external wind-cold contraction; the location of pain favors the taiyang channel, including the neck and shoulders. Heat: Headache associated with feverishness. Liver yang rising: Aggravated by stress or the menstrual cycle; the pain often follows the shaoyang channel trajectory. Phlegm-dampness: Usually a frontal headache, often associated with a sensation of heaviness. Deficiency: Associated with other signs and symptoms of deficiency.

THERAPEUTICS Chinese Medicinals 1. External Contraction (1) Wind-cold Formula: Chuān Xiōng Chá Tiáo Săn (Tea-Mix and Chuanxiong Powder) Key ingredients: chuān xiōng (Rhizoma Chuanxiong), fáng fēng (Radix Saposhnikoviae), jīng jiè (Herba Schizonepetae), or găo běn (Rhizoma Ligustici) (2) Wind-heat Formula: Jú Huā Chá Tiáo Săn (Tea-Mix and Chrysanthemum Powder) Key ingredients: chuān xiōng, màn jīng zĭ (Fructus Viticis), jú huā (Flos Chrysanthemi), jiāng cán (Bombyx Batryticatus), chán tuì (Periostracum Cicadae) (3) Wind-dampness Formula: Qiāng Huó Shèng Shī Tāng (Notopterygium DampnessDrying Decoction) Key ingredients: chuān xiōng, qiāng huó (Rhizoma et Radix Notopterygii), jiāng cán 2. Internal Disharmonies

(1) Liver yang rising Formula: Tiān Má Gōu Téng Tāng (Gastrodia and Uncaria Decoction) Key ingredients: tiān má (Rhizoma Gastrodiae), gōu téng (Ramulus Uncariae Cum Uncis) (2) Liver qi stagnation with heat Formula: Jiā Wèi Xiāo Yáo Săn (Supplemented Free Wanderer Powder) Key additions: jú huā, gōu téng, chuān xiōng, shí jué míng (Concha Haliotidis) (3) Liver blood deficiency Formula: Sì Wù Tāng (Four Substances Decoction) Key ingredient: chuān xiōng (4) Phlegm-turbidity Formula: Bàn Xià Bái Zhú Tiān Má Tāng (Pinellia, Atractylodes Macrocephala and Gastrodia Decoction) Key additions: chuān xiōng, màn jīng zĭ, bái jí lí (Fructus Tribuli) (5) Kidney yin deficiency Formula: Zuŏ Guī Yĭn (Left-Restoring Beverage) (6) Kidney yang deficiency Formula: Yòu Guī Yĭn (Right-Restoring Beverage) (7) Kidney qi deficiency Formula: Jīn Guì Shèn Qì Wán (Golden Cabinet’s Kidney Qi Pill)

(8) Blood stasis Formula: Tōng Qiào Huó Xuè Tāng (Orifice-Unblocking BloodMoving Decoction) ★ Key Medicinal Chuān xiōng (Rhizoma Chuanxiong) is used for many kinds of headaches. Movement of blood is crucial in the treatment of headache, and chuān xiōng is remarkably effective in this regard. It should also be noted that chuān xiōng is a medicinal that guides blood upward to the head and outward to the skin. In this regard it works much like the acrid chái hú (Radix Bupleuri), which enters the gallbladder. However, because of its warm dispersing qualities, chuān xiōng should be used with caution in cases of liver yang rising, liver fire, and yin deficiency. ★ Medicinals for Headaches Based on Channels Affected

● Taiyang (occipital): găo běn, chuān xiōng, gé gēn (Radix Puerariae Lobatae)

● Yangming (frontal): bái zhĭ (Radix Angelicae Dahuricae), gé gēn, chuān xiōng

● Shaoyang (temporal): chái hú, màn jīng zĭ, chuān xiōng ● Jueyin (vertex): wú zhū yú (Fructus Evodiae) and chuān xiōng Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Select mainly yang channel points. (2) Among all of the yang channels, the taiyang channel is most important as it dominates the scalp.

(3) Points chosen can include both hand and foot yang channels. 2. Point Selection According to Location (1) Local points

● Yangming: BL 2 (cuán zhú), DU 23 (shàng xīng), DU 24 (shén tíng), GB 19 (năokōng)

● Taiyang: GB 20 (fēng chí), DU 16 (fēng fŭ) ● Jueyin: DU 22 (xìn huì), DU 23 (shàng xīng), DU 24 (shén tíng) ● Shaoyang: GB 20 (fēng chí), GB 19 (năo kōng) and tài yáng (EXHN5) (2) Hand and foot yang channel points (below the wrists and ankles), selected according to the theory of root and branch: LI 4 (hé gŭ), SI 3 (hòu xī), LI 5 (yáng xī), BL 62 (shēn mài), BL 60 (kūn lún) and ST 41 (jiĕ xī). (3) Yang channels points on the lower limbs: In cases of a spleen deficiency, select ST 36 (zú sān lĭ) to supplement qi and blood. 3. Point Selection Based on Pattern Differentiation (1) Cold patterns For headache caused by exterior wind-cold, select points from the following channels:

● Taiyang channel points on the head local to the pain, because taiyang is the most superficial of the six-channel system where wind first attacks

● Points on the back of the neck, also where wind enters ● Points on the lung and large intestine channels

The lung is the “tender organ”; it opens to the exterior, thus making it uniquely susceptible to exterior pathogenic attack. The large intestine channel stands in an interior-exterior relationship with the lung channel. Frequently used points include DU 16 (fēng fŭ), GB 20 (fēng chí), BL 12 (fēng mén), DU 20 (băi huì), GB 14 (yáng bái), tài yáng (EX-HN5), BL 11 (dà zhù), LU 7 (liè quē) and LI 4 (hé gŭ). For internal cold patterns, select BL 23 (shèn shù), RN 5 (shí mén), RN 6 (qì hăi) and ST 36 (zú sān lĭ); moxibustion is applicable. (2) Heat patterns Select upper points, distal points, and those on the lateral sides, near the elbows and knees, as well as yangming channel points. The yangming channel has “more qi and more blood” thus being a convenient location through which heat can be dispersed. Representative points include DU 15 (yă mén), LI 4 (hé gŭ), LI 11 (qū chí), and shí xuān (EX-UE11). (3) Liver yang excess For headaches caused by liver qi counterflow, select points on the liver and gallbladder channels, and also head points local to the pain. (4) Phlegm-dampness Select ST 40 (fēng lóng), RN 12 (zhōng wăn) and SP 4 (gōng sūn) to fortify the spleen, harmonize the stomach, dissolve phlegm and drain dampness. (5) Deficiency patterns Select supplementing points such as RN 12 (zhōng wăn), RN 6 (qì hăi), RN 4 (guānyuán), BL 23 (shèn shù), KI 3 (tài xī), DU 20 (băi huì), ST 36 (zú sān lĭ), etc. Manipulate the needles frequently and add moxibustion.

When treating according to the channel affected, select mainly yang channel points, favoring the taiyang channel due to its wide distribution on the surface of the scalp. Also emphasize points on the yang channels of the hand and the foot because all yang channels meet at the head. Tài yáng (EX-UE5) is a commonly chosen extra point. When it comes to acupuncture techniques, the drainage method is more often employed than supplementing methods because the yang channels meet at the head, and because yang-organs prefer to be empty rather than full; thus the yang-organs and channels tend to suffer from excess rather than deficiency. To assist in improving efficacy, practitioners should also be sensitive to needle insertion direction, the breath of the patient, and the arrival of qi. Moxibustion provides a good clinical outcome for pain symptoms caused by cold patterns, deficiency patterns, or related dysfunctions. Collateral bloodletting therapy can be used on points of the head, at the far ends of limbs, or at locations where vessels are engorged and apparent; the bleeding amount should be in accordance with the location. Some points will produce more blood than others.

CASE STUDY I Ms. Liu, age 24. Initial Visit: September 2nd, 2009 Chief Complaint: Persistent headache for two months, aggravated for the three days before arriving at the clinic. History: Ms. Liu was a university student, preparing for her postgraduate entrance exams. She complained of frequent distending headaches over the prior two months. The headache pain was temporal (bilateral), and occipital. Three days before her first office visit, she was depressed by her poor grades on the practice examination. At that time, she reported that her headache got worse with a severe distending-type pain. This discomfort spread over her entire head and was accompanied by flank pain. She had taken some headache medicine, but it did not provide much relief. Acupuncture and moxibustion treatment was also prescribed. Signs and Symptoms: The patient reported a headache with dizziness and heaviness. Symptoms also included an obvious tenderness to palpation at GB 20 (fēng chí), neck stiffness, vexation and agitation, unstable emotions, insomnia, mental fatigue, poor appetite, distending pain in the breasts, and thin unformed stools. The tongue was red with a thin yellow coating, and her pulse was wiry and deficient. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or foods. Menstrual, Marital and Childbearing History: Menarche at age 13, menstrual cycle 28-30 days, menstrual period 4-5 days, mild red menses,

the last menstrual period arrived August 24th, 2009. Physical Examination: The patient was a lean female, well-developed and moderately nourished, her skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, with resonant percussion sounds (normal). Heart rate was 96 bpm and regular, with no pathological murmur at any valve area. Flat abdomen, liver and spleen non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Laboratory Examination: Red blood cell count: 3 × 1012/L, platelet count: 90 × 109/L. Pattern Differentiation The key indications in Ms. Liu’s pathology are: Complaint: Headache aggravated by depression and emotional stress. Quality: Severe distending head pain. Location: Discomfort spreading over the whole head. Concurrent symptoms: Dizziness and heaviness. Palpation: Obvious tenderness at GB 20 (fēng chí) and neck stiffness. The pulse was wiry and deficient. Inquiry: Vexation and agitation, easily angered, insomnia, mental fatigue, poor appetite, distending breast pain, thin unformed stools. Observation: A red tongue with thin yellow coating. The patient studied obsessively and suffered from too much mental stress, thus the liver failed to govern the free-flow of qi giving rise to liver

qi stagnation and an excessive state of the wood-phase. Liver-wood then overacted on spleen-earth thus undermining the spleen’s functions of transportation and transformation to cause her poor appetite and headache due to a lack of clear yang rising. Once the spleen could not adequately generate enough qi and blood, the heart came to lack nourishment, resulting in insomnia, vexation and agitation, and mental fatigue. The lack of blood allowed for liver wind to rise and cause the spastic muscles in the neck. Hence, the location of Ms. Liu’s disease was in the liver and spleen, and the presenting pattern in this case was identified as a deficiency-excess complex. Diagnosis Headache due to liver qi invading the spleen Clinical Treatment This case was categorized as headache caused by excessive mental and emotional stress. The treatment strategy was to soothe and calm the liver to resolve constraint, nourish blood and fortify the spleen, and unblock the collaterals to relieve pain. In addition to acupuncture and Chinese medicine treatment, it is also necessary to advise the patient to take some exercise, regulate her mental activity, and to adjust her attitude so as to maintain a good mood. Principles: Soothe the liver, resolve constraint, nourish blood and fortify the spleen Formula: Modified Xiāo Yáo Săn (Free Wanderer Powder) [逍遥散加减]

Three doses. One decocted dose a day. [Formula Analysis] Chái hú, the chief medicinal, acts to soothe the liver and resolve constraint to promote the free flow of liver qi. Dāng guī is sweet, acrid, bitter and warm; it acts to nourish and invigorate blood. Bái sháo is sour, bitter and slightly cold; it nourishes blood and retains yin, softens the liver and relieves pain. As a pair, they can supplement and regulate the liver and harmonize blood. Sufficient liver blood is required for smooth liver function. These medicinals both act as deputies within the formula. Bái zhú, fú líng and gān căo boost qi, fortify the spleen, and supplement spleen-earth to fend off attack from liver-wood; in this way, sufficient qi and blood can be produced. These three medicinals act as assistants. Bò he disperses obstructed qi and out-thrusts heat from constraint in the liver channel. Wèi jiāng acts to warm, activate and harmonize the middle. These two medicinals are also assistants.

Gān căo, harmonizing all formulas medicinals, is also considered as an envoy in this formula. This formula is famous for regulating the liver and nourishing blood. When adding in hóng huā and chuān xiōng, the formula moves qi and activates blood; it is said: “there is no pain after unblocking the channels and collaterals”.

Acupuncture Main points: DU 20 (băi huì), sì shén cōng (EX-HN1), tài yáng (EXHN5), GB 20 (fēngchí), HT 7 (shén mén) Supplementary points: GB 19 (năo kōng), cervical jia ji points (C3C7), BL 18 (gānshù), BL 20 (pí shù), SP 6 (sān yīn jiāo), ST 36 (zú sān lĭ), LI 4 (hé gŭ), LV 3 (tài chōng) Method: Choose 3 main points and 4-5 supplementary points per day, changing points every other day. After obtaining qi, the needles were retained for 20-30 min. Ten days constitutes one course of treatment. Techniques: Drainage was applied at GB 20 (fēng chí), LV 3 (tài chōng) and BL 18 (gān shù). Warm-needle moxibustion was applied at ST 36 (zú sān lĭ), and BL 20 (pí shù) was needled with supplementation. The even method was used at all other points. Treat once every other day, electro-stimulation is also applicable in this case. Further Consultation After five treatments, her headache was relieved, but she received five more treatments to complete an entire course. When she returned for further

consultation, she appeared to be in high spirits, full of energy and with a positive state of mind. Commentary The actual cause of this headache embraces two potential causes, those being internal wind and lack of clear yang rising. Ultimately, both may be correct. The fact that her pulse was deficient and the headache felt heavy speaks of clear yang not rising. However, the distending headache that arose after her poor test results suggests a liver disharmony that generated wind, leading to spasms in her neck and the temporal headaches (both following the foot shaoyang trajectory, a channel associated with internal wind). Sometimes it can be difficult to decide which came first, or if both disharmonies are feeding off of each other. I believe that what Prof. Hu is describing in this case is how an excessive wood-phase caused deficient earth. This led to a deficiency of blood which created an environment more conducive to the rising of liver wind. I note also the advice that Ms. Liu was given to “remain in a good mood”. This kind of advice is extremely sensitive to cultural context and a simple statement such as this may not adequately address the needs of the Western patient population. It may be enough to inform the patient that stress is aggravating her condition, but we may need to also provide some examples of those things that can generate a better flow of liver qi. This may include anything suitable to her lifestyle and stage in life such as exercise, mindful breathing, etc. “Remaining in a good mood” is certainly a prescription that can address Ms. Liu’s headaches, but the more deeply well-being is explored, the more deeply Ms. Liu can live a satisfying life.

CASE STUDY II (ACUPUNCTURE, Zheng Kuishan) Mr. Liang, age 34. Chief Complaint: Headache on the right side for over two years. History: Mr. Liang initially noticed a one-sided headache after an argument with his mother-in-law two years prior. Since then, the headache has recurred whenever he was angry or in bad mood. The headache extended from the right side retroauricular region to the right side of the forehead. He described the intensity as severe and intolerable. The severe pain often lasted for 2-4 hours before dissipating. After a headache, he often experienced vexation, dizziness, fatigue and hypersomnolence. Examination: A red tongue with a thin white coating, a wiry pulse. Diagnosis Headache due to ascendant hyperactivity of liver yang Clinical Treatment Principles: Soothe the liver, direct counterflow downward, clear heat, extinguish wind, nourish yin and subdue yang, rectify qi and relieve pain Points: GB 20 (fēng chí), DU 20 (băi huì), ST 8 (tóu wéi) (right), GB 5 (xuán lú), tàiyáng (EX-HN5), LV 2 (xíng jiān), KI 6 (zhào hăi) [Analysis] DU 20 (băi huì), ST 8 (tóu wéi) (right), GB 5 (xuán lú), tài yáng (EXHN5) are local points used to relieve pain by dredging the channels,

unblocking the collaterals, moving qi and activating blood. LV 2 (xíng jiān), as the ying-spring point of the liver channel, acts to direct qi downward, clear liver heat, drain fire and clear the head and eyes. KI 6 (zhào hăi) is needled with supplementation to nourish yin and subdue yang. Techniques: GB 20 (fēng chí) was manipulated with the drainage bilaterally, guiding the needling sensation to the forehead for 2 min, without needle retention. Drainage was applied at DU 20 (băi huì), ST 8 (tóu wéi) (right), GB 5 (xuán lú), tàiyáng (EX-HN5) and LV 2 (xíng jiān). LV 2 (xíng jiān) needling guided the sensation to the toe, and KI 6 (zhào hăi) was needled with supplementation such that the needling sensation radiated to the sole and toe. Other than GB 20 (fēng chí), all needles were retained for 30 min, after which all pain was relieved. To reinforce the effects, treatment was performed once a day for five consecutive days. There was no relapse reported at a six-month follow-up.

STUDY QUESTIONS 1. In the first case, why was ST 36 (zú sān lĭ) chosen and manipulated with warm-needle moxibustion? 2. In the first case, what advice can the practitioner provide Ms. Liu to prevent her from returning with the same problem? 3. Based on the location of Ms. Liu’s headache, which channels were affected? Answers 1. The patient presented with mental fatigue, poor appetite, thin unformed stools, and a deficient pulse, all of which are manifestations of spleen deficiency. ST 36 (zúsān lĭ) was thus used to supplement deficiency while promoting the movement of qi and blood to remove pain. 2. Communicate that stress reduction is the ultimate solution to her headaches. 3. The shaoyang and taiyang channels.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mr. Hu, age 52, presented with a prolonged headache described as having a stabbing quality in a fixed location. Other signs and symptoms included a purple tongue with a thin and white coating, and a thready and choppy pulse. Which of the following treatment principles should be used? A. Scatter wind and vent pathogens B. Dispel wind and overcome dampness C. Invigorate blood and unblock the orifices D. Calm the liver and subdue yang E. Warm the channels and dissipate cold 2. Mr. Liu, age 70, described a heavy pain in his head. He presented with heavy bodily sensations, poor appetite and digestion, chest oppression, difficult urination, and thin unformed stools. His tongue had a greasy white coating, and the pulse was soggy. To which of the following patterns does Mr. Liu’s headache belong? A. Wind-cold B. Wind-dampness

C. Damp-turbidity D. Blood deficiency E. Wind-heat 3. Which of the following formulas is indicated given Mr. Liu’s pattern? A. Chuān Xiōng Chá Tiáo Săn (Tea-Mix and Chuanxiong Powder) B. Bàn Xià Bái Zhú Tiān Má Tāng (Pinellia, Atractylodes Macrocephala and Gastrodia Decoction) C. Tōng Qiào Huó Xuè Tāng (Orifice-Unblocking Blood-Moving Decoction) D. Qiāng Huó Shèng Shī Tāng (Notopterygium Dampness-Drying Decoction) E. Tiān Má Gōu Téng Tāng (Gastrodia and Uncaria Decoction) 4. Ms. Yu, age 26, complained of a headache two weeks after giving birth to her child. At that time, she received treatment for a wind-cold attack, but with no change to her headache. Now, in addition to her headache she also feels dizzy from time to time and has palpitations and restlessness. Her symptoms are worse after work. She also presents with shortness of breath, spontaneous sweating, fear of wind, and a pale white face. There was a pale tongue with a thin white coating, and a deep thready pulse. Which of the following formulas would you choose first? A. Bŭ Zhōng Yì Qì Tāng (Center-Supplementing Qi-Boosting Decoction)

B. Bā Zhēn Tāng (Eight-Gem Decoction) C. Yòu Guī Wán (Right-Restoring Pill) D. Xiāo Yáo Săn (Free Wanderer Powder) E. Fù Yuán Huó Xuè Tāng (Original Qi-Restoring Blood-Moving Decoction) 5. Ms. Wang, age 25, complained of a headache that is worse after her day at work. Other signs and symptoms included dizziness, palpitations, insomnia, pale face, mental fatigue and lack of strength. There was a pale tongue with a thin white coating, and a weak thready pulse. Which of the following treatment principles would be best? A. Nourish yin, calm the liver, subdue yang and extinguish wind B. Nourish yin, fortify the kidney, supplement essence and boost marrow C. Scatter wind-cold and relieve pain D. Enrich yin, nourish blood, unblock the collaterals and relieve pain E. Dry dampness, fortify the spleen, transform phlegm and downbear counterflow 6. Mr. Chen, age 50, presented with a distending unilateral headache accompanied by dizziness, vexation, quick anger, insomnia, bitter taste in the mouth, facial flush and flank pain. There was a red tongue with a yellow coating, and a wiry rapid pulse. Which of the following patterns is presented in this case? A. Wind-heat B. Liver yang

C. Wind-cold D. Blood deficiency E. Damp-turbidity 7. Mr. Xu, age 61, complained of frequent headaches arising from neck and back tension that was aggravated by exposure to wind. Other signs and symptoms included aversion to wind and fear of cold, with no pronounced thirst. The tongue had a thin white coating, and there was a tight floating pulse. Which of the following are the best principles of treatment for this case? A. Scatter wind, clear heat and harmonize the collaterals B. Dispel wind, overcome dampness and unblock the orifices C. Calm the liver, subdue yang and extinguish wind D. Scatter wind, dissipate cold and relieve pain E. Dry dampness, fortify the spleen and dissolve phlegm Answers 1. C 2. C 3. B 4. B 5. D 6. B

7. D

11. Facial Pain (Trigeminal Neuralgia) ANCIENT THEORIES AND MODERN INSIGHTS Facial pain is the disease characterized by radiating or burning pain in the area of the eyes and cheeks. In TCM, this is called “facial wind pain” or “cheek pain”. It tends to affect the right side more than the left, people over age forty, and women. Pain around the eyes is usually a disorder of the foot taiyang channel, while pain in the upper and lower jaw is caused by the hand and foot yangming and hand taiyang channels. Facial pain may be diagnosed as trigeminal neuralgia in Western medicine. The trigeminal nerve includes the ophthalmic, maxillary and mandibular branches. In clinic, the maxillary and mandibular branches are often affected together.

ETIOLOGY AND PATHOMECHANISMS External Causes Wind-cold: Exterior wind-cold invades the yangming and taiyang channels in the face. Because the nature of cold is to contract, the qi and blood within these channels is obstructed, leading to facial pain. Wind-heat toxin: Wind-heat and toxic pathogens attack the face and enter the channels, thus obstructing the flow of qi and blood, resulting in pain.

Internal Causes Qi stagnation and blood stasis: Trauma, emotional disorders, or chronic diseases impair the flow of qi and blood, resulting in pain.

COMMON CLINICAL PATTERNS Common patterns found in clinical practice include: wind-cold, windheat, and qi and blood stagnation. Wind-cold: Short-lived but with severe cutting-type pain in the face that is induced or aggravated by cold. The local area prefers warmth and is averse to cold. There is no thirst, and the tongue coating is thin and white; the pulse is floating and tight. Wind-heat: Short-lived burning sensation or cutting-type pain that is aggravated by heat and slightly alleviated by coolness. There is a red complexion with possible fever, aversion to wind, a dry sensation in the mouth, and sore throat. The tongue is red at the tip and margins, with a thin yellow coating; the pulse is floating and rapid. Qi stagnation and blood stasis: Short-lived but severe pain that arises quite suddenly, attacking bilaterally like lightning, with facial muscle spasms in severe cases. The tongue body is dark purple with a thin white coating; the pulse is wiry, tight and choppy.

THERAPEUTICS Chinese Medicinals 1. Wind-cold Formula: Modified Chuān Xiōng Chá Tiáo Săn (Tea-Mix and Chuanxiong Powder) Ingredients: chuān xiōng (Rhizoma Chuanxiong), bái zhĭ (Radix Angelicae Dahuricae), găo bĕn (Rhizoma Ligustici), qiāng huó (Rhizoma et Radix Notopterygii), xì xīn (Radix et Rhizoma Asari), jīng jiè (Herba Schizonepetae), fáng fēng (Radix Saposhnikoviae) 2. Wind-heat Formula: Modified Xiōng Zhĭ Shí Gāo Tāng (Chuanxiong, Angelica Root and Gypsum Decoction) Ingredients: jú huā (Flos Chrysanthemi), sāng yè (Folium Mori), bò he (Herba Menthae), màn jīng zĭ (Fructus Viticis), chuān xiōng, bái zhĭ, qiāng huó, shēng shí gāo (Gypsum Fibrosum) 3. Qi Stagnation and Blood Stasis Formula: Modified Tōng Qiào Huó Xuè Tāng (Orifice-Unblocking Blood-Moving Decoction) Ingredients: chì sháo (Radix Paeoniae Rubra), chuān xiōng, táo rén (Semen Persicae), hóng huā (Flos Carthami), lăo cōng (old cōng bái) (Bulbus Allii Fistulosi), shè xiāng (Moschus), xì xīn, fáng fēng

Acupuncture and Moxibustion Treatment

1. Point Selection According to Location of Pain Pain of the ophthalmic branch of the facial nerve: tài yáng (EX-HN5), BL 2 (cuánzhú), ST 8 (tóu wéi), GB 14 (yáng bái), LI 4 (hé gŭ), ST 41 (jiĕ xī) Pain of the maxillary branch: LI 20 (yíng xiāng), SI 18 (quán liáo), ST 7 (xià guān), ST 2 (sì bái), LI 4 (hé gŭ), ST 44 (nèi tíng) Pain of the mandibular branch: GB 2 (tīng huì), ST 7 (xià guān), ST 4 (dì cāng), RN 24 (chéng jiāng), ST 6 (jiá chē), SJ 17 (yì fēng) 2. Point Selection Based on Pattern Differentiation (1) Wind-cold: Add LU 7 (liè quē) to dispel wind and cold. Moxibustion is applicable. (2) Wind-heat: Add LI 11 (qū chí) to disperse heat and SJ 5 (wài guān) to release the exterior. (3) Qi stagnation and blood stasis: Add PC 6 (nèi guān) and SP 6 (sān yīn jiāo) to regulate liver blood.

CASE STUDY I Ms. Li, age 45. Initial Visit: May 2nd, 2008 Chief Complaint: Sudden pain on the right side of the face for six months which had been steadily worsening over the past three months. History: The patient became emotionally upset about six months ago; at that time, she recalls having a sudden facial spasm. In the beginning, the pain only occurred once or twice each month for 1-2 min each time. The pain was described as being cut with a knife. After taking phenytoin sodium (an antiepileptic), the pain was addressed for two months. Signs and Symptoms: Over the past three months, the pain would arise 7-8 times per week and last 5-6 min. At the onset of the pain, the patient could not chew, brush her teeth or wash her face. After taking another dose of phenytoin sodium, the analgesic benefits failed to appear. He tongue was dark red with stasis spots and a yellow coating; the pulse was wiry. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis or tuberculosis, no past history of allergies to drugs or foods. Menstrual, Marital and Childbearing History: Menarche at age 12, menstrual cycle 28-30 days, menstrual period 4-5 days with, large quantities of red blood with clots, the last menstrual period arrived April 21st, 2008. Physical Examination: The patient was well-developed and moderately nourished with a slightly thin body, her skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were

symmetrical, resonant percussion sounds (normal). Heart rate was 70 bpm and regular, no pathological murmur at any valve area. Flat abdomen, liver and spleen non-palpable, no deformity of the spine or limbs, no edema in the lower limbs. Laboratory Examination: RBC 3.0 × 1012/L, PLT 90 × 109/L. Pattern Differentiation The main keys to the diagnosis of this patient: half a year ago she suffered from anger and rage which gave rise to a sudden facial spasm, the tongue body is dark red with stasis spots and a yellow coating, and the pulse is wiry. The extreme emotion caused qi and blood stagnation that obstructed the channels and collaterals in the face and caused pain. Diagnosis Facial pain due to qi stagnation and blood stasis Treatment Principles: Move qi and invigorate blood Formula: Modified Tōng Qiào Huó Xuè Tāng (Orifice-Unblocking Blood-Moving Decoction) [通窍活⾎汤加减]

Three doses. One dose per day. [Formula Analysis] In this formula, chì sháo, chuān xiōng, táo rén, and hóng huā have the functions of invigorating the blood and dispel stasis. Shè xiāng helps the medicinals that move blood to reach the location of the pain. Its aromatic nature makes it very activating. Lăo cōng helps to diffuse qi to and move blood in the head and face. Zhĭ qiào moves qi, and fáng fēng dispels wind.

Acupuncture Treatment principles: Dispel wind and unblock the collaterals to stop pain Main points: BL 2 (cuán zhú), ST 2 (sì bái), ST 7 (xià guān), LI 4 (hé gŭ), ST 44 (nèitíng), LV 3 (tài chōng), PC 6 (nèi guān), SP 6 (sān yīn jiāo) Techniques: Drainage needling techniques were employed with strong stimulation on the distal points; for the points on the face, deep penetration with retention is best. After needling until the arrival of qi, retain the needles for 20-30 min. Ten treatments is one course of treatment. Electrostimulation is applicable.

[Analysis] BL 2 (cuán zhú), ST 2 (sì bái), ST 7(xià guān) and LI 4 (hé gŭ) free the channels and collaterals in the affected region. LI 4 (hé gŭ) is the yuan-source point and treats diseases on the face and around the mouth, and is commonly used with LV 3 (tài chōng), a point combination known as the “four gates”. LV 3 and LI 4 expel wind, open the collaterals and alleviate pain. ST 44 (nèi tíng) purges heat from the yangming channel. PC 6 (nèi guān) and SP 6 (sān yīn jiāo) move blood and dissolve stasis. Further Consultation After the first treatment, the pain got more intense and more frequent. After a one day break from acupuncture, treatments were applied daily. After four treatments, the pain was less intense with fewer attacks. After ten treatments, the pain was thoroughly alleviated without any recurrence for the following year. Note Trigeminal neuralgia is a stubborn disease and hard to treat, although acupuncture does produce an analgesic effect to stop the pain. It is appropriate to select distal points and to use very strong stimulation. For the points on the face, the deep needling with long needle retention is most often employed. The intensity of the manipulation depends on the level of pain tolerance in the patient.

CASE STUDY II (ACUPUNCTURE, Zheng Kuishan) Mrs. Zhang, age 50. Initial Visit: December, 1961 History: The patient had a toothache in March of 1960 which was aggravated whenever she ate cold or hot food. This pain radiated to the right side of her nostril and face. The pain was persistent and greatly influenced her eating and sleeping. The patient also reported feeling dizzy, a burning sensation in the face, and rib-side pain. Her face was red. She had been diagnosed as having trigeminal neuralgia in one hospital. Their treatment of pulling out teeth and prescribing an herbal decoction did not provide relief. Additionally, new symptoms appeared such as pain of the forehead that referred to the side of the head, with tension of the scalp. When the pain was most severe, she felt nauseated and feverish. There was chest fullness with difficulty in taking a deep breath, irritability, a bitter taste, poor sleep, and dry stools. Her tongue had visible cracks on the surface, with a white greasy coating; the pulse was wiry. Diagnosis Facial pain due to liver overacting on the stomach, wind-heat attacking upward Clinical Treatment Principles: Dispel wind, clear heat, regulate liver and stomach Points: GB 20 (fēng chí), DU 20 (băi huì), ST 8 (tóu wéi), tài yáng (EX-HN5), LI 4 (hé gŭ)

Techniques: Cooling and drainage manipulation was applied with needle retention for 20-30 min. Each treatment took place every other day. After three treatments, the symptoms had been relieved. At that time, points were changed to ST 8 (tóu wéi), RN 12 (zhōng wăn), ST 25 (tiānshū), and ST 36 (zú sān lĭ), needled with even supplementation and drainage. After ten treatments, all symptoms had vanished. Her follow-up visit on July 15th showed no recurrence. Note The affected region and characteristics of trigeminal neuralgia are similar to that of “facial pain” in TCM, which is persistent and hard to treat. Selecting points based on “treating the channel on which the pain is located” and “where there is sensitivity, there is a point”, the main points used for the facial pain included ST 7 (xià guān), tàiyáng (EX-HN5), ST 6 (jiá chē) and SI 18 (quán liáo). Some patients will feel that symptoms get worse after the first acupuncture treatment. Generally, it is unnecessary to stop treatment, but do apply the following procedures: (1) Use fewer points on the face but with more distal points. (2) Increase the density level of the electro-stimulation and the duration of needle retention if the patient can endure it.

COMMENTARY AND DISCUSSION One case study in this chapter describes the use of the so-called “four gates” or LV 3 (tài chōng) and LI 4 (hé gй) needled bilaterally. These four points are commonly used to address liver qi stagnation, but why? There are a few commentaries regarding this point combination, one notes that in both the hand and foot, we are essentially needling the exact same point. If the big toe was a thumb, or the thumb was more like a toe, it would be easier to see. In any case, it is clear that the points used in the “four gates” are the same point but on the hand and foot. However, another narrative on the use of these points describes the relationship of wood to metal. Of course, metal controls wood, and liver qi stagnation commonly presents as an excess condition. As such, strengthening the metal’s ability to control the wood makes a lot of sense. In the case of the “four gates”, we are using the yuan-source point on the yin-wood channel (liver) teamed up with the yuan-source point of the yang-metal channel (large intestine). So, we’re needling the yuan-source points that make up the controlling relationship between metal and wood. This leads to a sedation of the wood-phase which thus addresses liver qi stagnation due to excess. Furthermore, why do we use the yuan-source point of the yang-metal channel [LI 4, (hé gй) ] instead of the yuan-source point of the yin-metal channel [LU 9, (tàiyuān)]? I can only offer up this answer from Beijing University of TCM Prof. Tiende Yang who says that when we use the yang channel to control the yin (large intestine to control the liver) it is done with

love, but when using the yin-metal lung channel to control the liver, it is too harsh.

STUDY QUESTIONS 1. In the first case of facial pain, why were LI 4 (hé gŭ) and LV 3 (tài chōng) selected? 2. In the first case what other therapies can be applied in addition to needling? 3. What diseases should be considered for differential diagnosis in the first case? 4. For the wind-cold pattern of facial pain, which of the following points would be added the usual point prescription? A. LU 7 (liè quē) B. PC 6 (nèi guān) C. LI 11 (qū chí) D. LV 3 (tài chōng) E. ST 44 (nèi tíng) 5. For the wind-heat pattern of facial pain, which of the following points would be added to the usual point prescription? A. LU 7 (liè quē) B. PC 6 (nèi guān) C. LI 11 (qū chí) D. LV 3 (tài chōng) E. ST 44 (nèi tíng)

6. For pain of the ophthalmic branch of the trigeminal nerve, which of the following points would be added to the usual point prescription? A. SI 18 (quán liáo) B. ST 6 (jiá chē) C. SJ 17 (yì fēng) D. LI 20 (yíng xiāng) E. GB 14 (yáng bái) 7. For pain in the maxillary branch of the trigeminal nerve, which of the following points would be added to the usual point prescription? A. SI 18 (quán liáo) B. ST 6 (jiá chē) C. RN 24 (chéng jiāng) D. LI 20 (yíng xiāng) E. SJ 23 (sī zhú kōng) Answers 1. LI 4 (hé gŭ) is a yuan-source point that treats diseases of the face and around the mouth. This point is often used with LV 3 (tài chōng). This combination is known as the four gates, which acts to expel wind, open the collaterals and alleviate pain. 2. Ear acupuncture, point injection therapy, intradermal needling, cupping followed by collateral bleeding, moxibustion, and electrostimulation are all applicable.

3. Differential diagnosis for this disease includes toothache, trigeminal neuralgia and glossopharyngeal neuralgia. 4. A 5. C 6. E 7. A

SECTION III Pain of the Neck, Shoulders,and Upper Limb 12. Thoracic Outlet Syndrome(Neck and Shoulder Pain) ANCIENT THEORIES AND MODERN INSIGHTS Thoracic outlet syndrome refers to a group of symptoms and signs resulting from compression of the brachial plexus, subclavian arteries and veins due to abnormal changes in the superior thoracic outlet. Symptoms and signs include frigid upper extremities with weakness and/or dull pain in the shoulder, arm or hands. There may be difficulty in elevating the upper extremities above the head, etc. This disease is categorized in TCM as “bi syndrome” or “neckshoulder pain”. The pathomechanism of this disorder involves qi and blood deficiency at its root with wind, cold, dampness, or blood stasis as branches. This disease often occurs in females between twenty and forty years of age with a slim shape. Manifestations often include pain in the neck and shoulder with abnormal sensations and numbness along the medial aspect of the affected

upper limb, mainly following the distribution area of the ulnar nerve. A palpable mass is often felt in the supraclavicular fossa that causes radiating pain with pressure. Weakness, intolerance to cold and a pale hand color appear in the affected upper limb with a weak or imperceptible pulse in the radial artery.

ETIOLOGY AND PATHOMECHANISMS External Causes Wind-cold-dampness: Invasion of wind-cold-dampness results in impairment of the local qi and blood flow. Blood stasis: Sudden straining or long-term weight-bearing generate traumatic injury to the tendons and vessels, which results in blood stasis.

Internal Causes Qi and blood deficiency: When the blood vessels lack nourishment, or the tendons and muscles lack warmth and moisture, the circulation of blood is compromised which results in pain, intolerance to cold, and a bluish arm color.

COMMON CLINICAL PATTERNS Cold-dampness: Pain accompanied with cold and heavy sensations in the subclavian fossa and upper extremity, aggravated by cold and alleviated by warmth. The tongue is pale with a greasy white coating; the pulse is floating and slippery. Blood stasis: Subclavian fossa and upper extremity pain that can be unbearable, aggravated by movement, and much worse at night; accompanied by a local mass, weakness or imperceptibility of the radial pulse, and a purplish arm color. The tongue is dark with a white coating; the pulse is thready or choppy. Qi and blood deficiency: Pain in the subclavian fossa and upper extremity with local numbness, emaciation and weakness of the muscles; accompanied by a pale complexion, fatigue, no desire to talk, palpitations, and shortness of breath. The tongue is pale with a thin white coating; the pulse is thready or weak.

THERAPEUTICS Chinese Medicinals 1. Cold-dampness Formula: Guì Zhī Jiā Gé Gēn Tāng (Cinnamon Twig Decoction Plus Pueraria) Ingredients: guì zhī (Ramulus Cinnamomi), gé gēn (Radix Puerariae Lobatae), báisháo (Radix Paeoniae Alba), zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle), shēng jiāng (Rhizoma Zingiberis Recens), dà zăo (Fructus Jujubae) 2. Blood Stasis Formula: Tōng Qiào Huó Xuè Tāng (Orifice-Unblocking BloodMoving Decoction) Ingredients: táo rén (Semen Persicae), hóng huā (Flos Carthami), chì sháo (Radix Paeoniae Rubra), chuān xiōng (Rhizoma Chuanxiong), shè xiāng (Moschus), cōng bái (Bulbus Allii Fistulosi), shēng jiāng, dà zăo, huáng jiŭ (Aureum Vinum) 3. Qi and Blood Deficiency Formula: Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and FiveReturning Decoction) Ingredients: huáng qí (Radix Astragali), táo rén, hóng huā, chì sháo, chuān xiōng, dāngguī (Radix Angelicae Sinensis), dì lóng (Pheretima)

Acupuncture and Moxibustion Treatment

1. Local Points LI 18 (fú tū), LU 1 (zhōng fŭ), LI 17 (tiān dĭng), ST 12 (quē pén), HT 1 (jí quán), SI 8 (xiăohăi), HT 3 (shào hăi), HT 7 (shén mén), GB 21 (jiān jĭng), LI 11 (qū chí) 2. Point Selection Based on Pattern Differentiation (1) Cold-dampness Select GB 20 (fēng chí), DU 16 (fēng fŭ) and LI 4 (hé gŭ) to scatter wind and disperse cold. Select ST 36 (zú sān lĭ) and SP 9 (yīn líng quán) to strengthen the spleen and resolve dampness. Moxibustion may be used at local points. (2) Blood stasis Select SP 10 (xuè hăi) and BL 17 (gé shù) and needle with drainage to invigorate blood and resolve blood stasis. Bleed BL 40 (wĕi zhōng) with a tri-edged needle to invigorate blood and resolve blood stasis. (3) Qi and blood deficiency Select ST 36 (zú sān lĭ), RN 6 (qì hăi) and BL 40 (wĕi zhōng) and needle with supplementation to supplement qi and blood. Select BL 21 (wèi shù), BL 20 (pí shù) and BL 18 (gān shù) and needle with supplementation to promote qi and blood, supplement spleen and stomach, and nourish liver blood. Moxibustion may be added to local points with point selection based on pattern differentiation.

CASE STUDY I Ms. Li, age 33. Initial Visit: June 10th, 2007 Chief Complaint: The patient has had sensations of pain and cold in the right arm for one week. This pain is aggravated by elevating the arm, which is naturally very difficult for the patient. History: The patient felt soreness, pain, heaviness and cold sensations in the right arm upon awakening in the morning seven days ago after her shoulder and arms were exposed to cold at night. The condition could be alleviated by a local heat compress. Soreness, pain and heaviness of the right arm became progressively worse such that the patient observed increasing difficulty in elevating her arm and shorter periods of time in which she could carry heavy objects. She also began to drop things from her right hand. Thoracic outlet syndrome was diagnosed at a local hospital and surgery was suggested. The patient sought conservative treatment and was seen in the acupuncture department. Signs and Symptoms: Soreness, pain and heaviness of the right arm accompanied by cold sensations, inability of the right arm to elevate consistently beyond a 90° angle, dropping involuntarily after being elevated for one minute. The forearm and fingers were cold to the touch. The tongue was pale with a white greasy wet coating; the pulse was wiry and slippery. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or foods.

Menstrual, Marital and Childbearing History: Menarche at age 13, menstrual cycle 28-30 days, menstrual period 5-7 days; her spouse and son are healthy. Physical Examination: The patient was normally developed, wellnourished and trim in stature, her skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). The supraclavicular area on the affected side was swollen with local tenderness. The bilateral respiratory movements were symmetrical, resonant percussion sounds (normal). Heart rate was 80 bpm and regular, no pathological murmur at any valve area. Flat, soft abdomen, liver and spleen were non-palpable, vagina and anus were not checked. Chest-protruding test and upper extremity excessive abduction test: (+). Pattern Differentiation Main features of this case: patient had soreness, pain, heaviness and cold sensations in the right arm with exposure to cold that worsened progressively, and the forearm and fingers were cold to the touch. Invasion of pathogenic cold-damp in the arm and shoulder led to impediment of qi and blood movement in the local area, thus causing symptoms and signs such as soreness, pain, heaviness and cold sensations. The location of the disease was the shoulder and arm; pattern differentiation suggested an excess syndrome. Diagnosis Cold-damp bi syndrome Clinical Treatment

The patient was attacked by cold-dampness, so the treatment should mainly disperse cold and eliminate dampness. In addition to acupuncture and medicinal treatment, the patient should be ordered to avoid bearing weight with right upper extremity, to rest, and also to keep affected area warm. Principles: Disperse cold and eliminate dampness, warm and unblock the channels Formula: Modified Guì Zhī Jiā Gé Gēn Tāng (Cinnamon Twig Decoction Plus Pueraria) [桂枝加葛根汤加减]

Three doses. One decocted dose a day. [Formula Analysis] Guì zhī disperses cold and releases the muscle layer, warms and unblocks the channels. Gé gēn lifts yang and releases the exterior, relaxes tendons and unblocks channels, lifts fluids and stops spasms. Cāng zhú disperses pathogens and removes dampness. These three herbs serve as the chief medicinals.

Sāng zhī disperses wind, cold and dampness, and the twigs guide the effect to the extremities. Jiāng huáng warms the channels and stops pain. Yán hú suŏ invigorates the blood, moves qi and stops pain. Chuān xiōng moves qi and invigorates the blood, and guides medicinals upward. All assist the chief medicinals in warming the channels and dispersing cold, moving qi and invigorating the blood. These four herbs serve as deputy medicinals. Bái sháo is sour and works with the sweet medicinals to generate yin, relieve spasm and stop pain. Zhì gān căo harmonizes the action of all the herbs. These two herbs compose Sháo Yào Gān Căo Tāng (Peony and Licorice Decoction), also serving as assistant and envoy medicinals.

Acupuncture Main points: LI 18 (fú tū), LU 1 (zhōng fŭ), LI 17 (tiān dĭng), ST 12 (quē pén), HT 1 (jíquán), SI 8 (xiăo hăi ), HT 3 (shào hăi), HT 7 (shén mén), GB 21 (jiān jĭng), LI 11 (qū chí), GB 34 (yáng líng quán) Supplementary points: GB 20 (fēng chí), DU 16 (fēng fŭ), LI 4 (hé gŭ), ST 36 (zú sānlĭ), SP 9 (yīn líng quán) Method: Acupuncture treatments were performed every other day. 10 treatments constitute one course of treatment. Techniques: Drainage was applied at GB 20 (fēng chí), DU 16 (fēng fŭ) and ST 12 (quēpén), warming-needle moxibustion and supplementation techniques were applied to ST 36 (zú sān lĭ) and SP 9 (yīn líng quán), and the even method at all other points. Cupping may be used at LU 1 (zhōng fŭ) and GB 21 (jiān jĭng) following acupuncture, and infra-red TDP may be applied to warm the local

area. Further Consultation Ms. Li felt much relief in the arm immediately after the first treatment. After seven treatments, her symptoms and signs were relieved significantly, the upper right extremity had a free range of motion, and she had no difficulty in carrying heavy objects. She was cured after one course of treatment.

CASE STUDY II (ACUPUNCTURE, Song Ruying) Mr. Su, age 58. Chief Complaint: Pain in the left arm after exposure to cold rain. History: The patient had pain in the left arm after exposure to cold rain. Constant pain moved from the shoulder to the arm that was severe enough to affect his sleep. There was limited extension and elevation which caused difficulty putting on clothes; there was no relief following application of a topical patch for pain due to cold. Physical Examination: Limited extension and elevation with pain when moving the shoulder and arm. He had a pale complexion. His tongue was pale without coating, and the pulse was wiry and moderate. Diagnosis TCM pattern: Cold-dampness invading the channels and collaterals Clinical Treatment LI 18 (fú tū) was selected and the tip of a 1 cun 28 gauge needle was directed toward the cervical vertebrae to a depth of about 5 fen (the cervical artery is located beneath this point, so deep insertion is forbidden). The needle was removed after electrical and numb sensations extended to the hand. Methods: Treat once a day. After five treatments, the pain was reduced by more than half. Further Consultation

After seven treatments, there was no pain in the shoulder and the arm’s normal range of motion was restored. A one-year follow-up found no recurrence. Note The hand yangming large intestine channel runs through the shoulder and arm, so LI 18 (fú tū) was selected to unblock the channels and collaterals and regulate the qi and blood. The Song to Elucidate Mysteries (Biāo Yōu Fù, 标幽赋) states, “rapid arrival of qi leads to an immediate effect, slow arrival of qi delivers no effect”. It has been proven by years of practice that therapeutic effects and needling sensations are closely related, so only when an optimal needling sensation is produced can a satisfactory therapeutic effect be achieved.

COMMENTARY AND DISCUSSION The Song to Elucidate Mysteries wrote that “rapid arrival of qi leads to an immediate effect, slow arrival of qi delivers no effect”. This statement certainly does explain the Chinese and Korean acupuncture styles that assume “no pain, no gain”; however, there are some patients who will simply not return for a second acupuncture treatment if the first is too painful. As practitioners, we need to balance the comfort of the patient with our intended therapeutic outcomes. More importantly, I have found that very light needling also has its benefits. I even tested this out with a few patients that may have had three or four complaints. I would very lightly insert needles at points that would address all but one of the complaints, not telling the patients. The next time I saw them, I would get positive feedback on three of their complaints, but not the fourth that I ignored. After I tried this a few times, I pretty much came to the conclusion that superficial needling, which I refer to as “guide tube depth insertion” most certainly has its benefits. Western medicine recognizes that there are different nerve tracks that end up in different areas of the brain. Light touch sensation follows one nerve track, nerves that innervate the fascia is another nerve track, the neurohormonal responses that arise from positive human interactions represent a third. There are many ways to stimulate pain-relieving mechanisms in the human body. Dé qì needling sensations that produce dull achy feelings do have their place; however, we need to also address the patients’ need for a comfortable

treatment while addressing their pain via any and all mechanisms or nerve tracts available.

STUDY QUESTIONS 1. What are the benefits of cupping at LU 1 (zhōng fŭ) and GB 21 (jiān jĭng) in the first case? 2. In the first case, what advice should be expressed to Ms. Li to assist the medicinal treatment? 3. Why was GB 34 (yáng líng quán) used in the first case? 4. In which of the following age groups does thoracic outlet syndrome most often occur in females? A. Ages 20-30 B. Ages 30-40 C. Ages 40-50 D. Ages 20-40 E. Ages 30-50 5. To treat thoracic outlet syndrome due to obstruction of blood stasis, in addition to points selected regularly for acupuncture, bleeding may be applied to which of the following points? A. DU 14 (dà zhuī) B. BL 40 (wĕi zhōng) C. LI 11 (qū chí) D. LU 5 (chĭ zé) E. LV 3 (tài chōng)

Answers 1. The front-mu point of the lung channel LU 1 (zhōng fŭ) was used to regulate the lung qi, disperse cold, eliminate dampness and promote the circulation of the local qi and blood, while cupping was applied to GB 21 (jiān jĭng) to reduce swelling and stop pain. 2. The patient should be advised to limit the movements of the affected shoulder and weight bearing, and also to keep the local area warm. 3. GB 34 (yáng líng quán) is located on the foot shaoyang gallbladder channel and is also the influential point of the tendons, it acts to relax the sinews, calm spasm and alleviate pain. 4. D 5. B

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment; use the following exercises to test your overall understanding of the condition. 1. Ms. Gao, age 33, felt pain and discomfort in the right shoulder and arm after exposure to rain. The pain referred to ST 12 (quē pén) and responded favorably to the application of heat. She had a pale tongue with a greasy white coating; her pulse was wiry. Which of the following patterns best describes the presenting pattern? A. Cold-dampness B. Wind-cold C. Deficiency of qi and blood D. Phlegm-blood stasis E. Blood stasis 2. Ms. Shun, age 28, complains of pain in the subclavian fossa and upper extremities. She presents with emaciation, a pale complexion, fatigue, no desire to talk, palpitations, and shortness of breath. The tongue is pale with a thin white coating; her pulse is thready and weak. Which of the following formulas should be used? A. Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction)

B. Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction) C. Guì Zhī Jiā Gé Gēn Tāng (Cinnamon Twig Decoction Plus Pueraria) D. Sì Wù Tāng (Four Substances Decoction) E. Juān Bì Tāng (Impediment-Alleviating Decoction) 3. Ms. Tu, age 30, presented with pain in the subclavian fossa and upper extremities. The pain was severe, aggravated by movement, and worse at night. A mass was palpable in the supraclavicular fossa with pain and swelling in the arm and forearm. Her tongue was dim with a white coating; the pulse was choppy. With which of the following is the presenting pattern? A. Cold-dampness B. Wind-cold C. Deficiency of qi and blood D. Phlegm-blood stasis E. Blood stasis 4. Ms. Peng, age 25, had pain and discomfort in the supraclavicular fossa after exposure to cold. The pain referred to the right shoulder and arm, and responded favorably to warmth but unfavorably to cold. It did not respond to an over-thecounter topical warming patch. She also presented with a bluish tongue with a wet white coating, and a wiry pulse. Which of the following formulas should be prescribed based on the pattern differentiation of traditional Chinese medicine?

A. Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) B. Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction) C. Guì Zhī Jiā Gé Gēn Tāng (Cinnamon Twig Decoction Plus Pueraria) D. Sì Wù Tāng (Four Substances Decoction) E. Juān Bì Tāng (Impediment-Alleviating Decoction) 5. Ms. Jin, age 40, presents with pain in the subclavian fossa and upper extremities with emaciation, a pale complexion, fatigue, no desire to talk, palpitations, and shortness of breath. She has a small, pale tongue with a thin white coating; her pulse was thready and weak. Which of the following is the presenting pattern? A. Cold-dampness B. Wind-cold C. Deficiency of qi and blood D. Phlegm-blood stasis obstructing channels E. Blood stasis Answers 1. A 2. B 3. E 4. C

5. C

13. Cervical Spondylosis (Neck Bi) ANCIENT THEORIES AND MODERN INSIGHTS Cervical spondylosis is the general name for symptoms and physical signs caused by degenerative changes of the cervical intervertebral discs which lead to instability and compression of nearby tissues. TCM views this condition as “neck bi syndrome”, with the main external causes including external pathogens, trauma, and improper neck movement leading to impaired flow of qi and blood in the channels and collaterals of the neck. Internal causes include insufficiency of kidney and liver, impairment of qi and blood, deficiency of the du vessel, malnourishment of tendons and bones, and blockage of the channels and collaterals. Cervical spondylosis patterns often involve the liver and kidney, the du vessel, and the hand and foot taiyang channels.

ETIOLOGY AND PATHOMECHANISMS External Causes Invasion of wind, cold and dampness are the main external causes. Wind, cold and dampness: Wind, cold and dampness invade the body and obstruct the channels and collaterals of the neck.

Internal Causes Insufficiency of the liver and kidney leads to a malnourishment of the tendons and bones, the most common internal cause of cervical spondylosis. Kidney: Because the kidney governs bones and produces marrow, insufficiencies of kidney qi or kidney essence would bring about malnourishment of the bone marrow. The kidney stores essential yin and yang; thus yin deficiency can cause bone marrow malnourishment and degeneration, while yang deficiency can undermine the warmth and function of the bones, resulting in degeneration of the cervical discs. Liver: Because the liver stores blood and governs the tendons, insufficiency of qi and blood leads to malnourishment of tendons and bones which contributes to degenerative changes of the cervical discs.

Others Causes Trauma or injury, strain or other damage to tissues causes static blood interiorly, while stagnation of qi and blood leads to blockage in the

collaterals. The obstruction of qi and blood contributes to degenerative changes of the cervical discs.

COMMON CLINICAL PATTERNS The most commonly encountered clinical patterns include stagnation of windcold-dampness, qi stagnation and blood stasis, phlegm and dampness obstructing the collaterals, insufficiency of liver and kidney, and deficiency of qi and blood.

Pattern Differentiation 1. Differentiation Based on Patterns Stagnation of wind-cold-dampness: Migrating pain and numbness in the neck, shoulder and arms, heaviness of the head, stiffness and inflexible movement of the neck, aversion to cold and wind. The tongue is slightly red with a thin white coating; the pulse is wiry and tight. Qi stagnation and blood stasis: Stabbing pain with a fixed location on the neck, shoulder and arms, accompanied with numbness. The tongue body is dim; the pulse is wiry. Phlegm and dampness obstructing the collaterals: Stiff pain in the head and neck accompanied by vertigo, dim vision, and dizziness, or a sensation of the head being wrapped tightly, numbness of the four limbs, poor appetite and digestion. The tongue is dim with a thick greasy coating; the pulse is wiry and slippery. Insufficiency of liver and kidney: Shoulder and neck discomfort accompanied by dizziness and headache, deafness, tinnitus, insomnia, excessive dreaming, numbness of the limbs, reddish complexion and eyes. The tongue is red with a scanty coating; the pulse is wiry.

Deficiency of qi and blood: Dizziness and dim vision, pale complexion, palpitations, shortness of breath, fatigue and lassitude. The tongue is pale with a scanty coating; the pulse is thin and weak. 2. Differentiation Based on Western Medicine Neck-type: Soreness and distending pain in the neck radiating down to the back and shoulders, disturbance in motor activities of the cervical spine. Nerve root-type: Transient or persistent dull or severe pain in the occipital region of the head and neck, shoulders and back, numbness of the fingers. Vertebral artery-type: Dizziness aggravated by changing the position of the head and neck, with occipital or neck pain. Sympathetic nerve-type: Headache or migraine, irregular heartbeat, abnormal blood pressure. Spinal cord-type: Weak limbs with bound sensations, inability to make fine movements, abnormal sensations in the upper limbs.

THERAPEUTICS Chinese Medicinals 1. Stagnation of Wind-Cold-Dampness Formula: Modified Guì Zhī Jiā Gé Gēn Tāng (Cinnamon Twig Decoction Plus Pueraria) and Qiāng Huó Shèng Shī Tāng (Notopterygium Dampness-Drying Decoction) Ingredients: guì zhī (Ramulus Cinnamomi), gé gēn (Radix Puerariae Lobatae), qiāng huó (Rhizoma et Radix Notopterygii), sāng zhī (Ramulus Mori), bái sháo (Radix Paeoniae Alba) 2. Qi Stagnation and Blood Stasis Formula: Tōng Qiào Huó Xuè Tāng (Orifice-Unblocking BloodMoving Decoction) Ingredients: chì sháo (Radix Paeoniae Rubra), chuān xiōng (Rhizoma Chuanxiong), hóng huā (Flos Carthami), táo rén (Semen Persicae), gé gēn, fáng fēng (Radix Saposhnikoviae), bái zhĭ (Radix Angelicae Dahuricae) 3. Phlegm and Dampness Obstructing the Collaterals Formula: Bàn Xià Bái Zhú Tiān Má Tāng (Pinellia, Atractylodes Macrocephala and Gastrodia Decoction) Ingredients: bàn xià (Rhizoma Pinelliae), bái zhú (Rhizoma Atractylodis Macrocephalae), tiān má (Rhizoma Gastrodiae), gé gēn, fú líng (Poria) 4. Insufficiency of Liver and Kidney

Formula: Zuŏ Guī Wán (Left-Restoring Pill) and Yáng Hé Tāng (Harmonious Yang Decoction) Ingredients: dāng guī (Radix Angelicae Sinensis), jī xuè téng (Caulis Spatholobi), gé gēn, cí shí (Magnetitum), shí chāng pú (Rhizoma Acori Tatarinowii), chì sháo, gŏu qĭzĭ (Fructus Lycii), shēng dì (Radix Rehmanniae), dān shēn (Radix et Rhizoma Salviae Miltiorrhizae) 5. Deficiency of Qi and Blood Formula: Modified Jiā Wèi Shèng Yù Tāng (Supplemented Sagacious Cure Decoction) Ingredients: huáng qí (Radix Astragali), chái hú (Radix Bupleuri), bái sháo, gé gēn, gŏu qĭ zĭ, chuān xiōng, fáng fēng, dāng guī, jú huā (Flos Chrysanthemi) ★ Key Medicinal Gé gēn is the first and foremost medicinal for a painful and stiff neck, especially for pain due to wind-cold-dampness invasion. It acts to induce sweating, relieve the muscles, unblock channels and collaterals, and invigorate blood while clearing heating and generating fluids. Because smooth circulation of qi and blood in the cervical region is the key to treating pain in this area, gé gēn is especially important. Gégēn is sweet and pungent in flavor, and cool in property.

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Points on the yang channels are the mostly valued for their efficacy.

(2) The ancients considered the onset of this disease as mainly caused by stagnation of qi and blood of the channels and collaterals; therefore, distal point selection based on the route of channels and collaterals passing through the affected area are emphasized. (3) Points on the du vessel and hand and foot taiyang channels. 2. Point Selection According to Location (1) Local points on the head, neck and upper back

● Pain in the head and neck region: jiā jĭ (EX-B2) on the neck, GB 20 (fēng chí), DU 16 (fēng fŭ), DU 14 (dà zhuī), DU 19 (hòu dĭng)

● Pain in the upper back: DU 14 (dà zhuī), GB 21 (jiān jĭng), SI 15 (jiān zhōng shù), SI 14 (jiān wài shù) (2) Hand and foot taiyang channels According to the theory of root and branch as well as origins and junctions, SI 3 (hòuxī), LI 4 (hé gŭ), LI 10 (shŏu sān lĭ), SJ 5 (wài guān), LI 5 (yáng xī), GB 60 (kūn lún), GB 39 (xuán zhōng), KI 3 (tài xī), ST 36 (zú sān lĭ) and GB 40 (wĕi zhōng) are often selected. 3. Point Selection Based on Pattern Differentiation (1) Stagnation of wind-cold-dampness When cervical pain and stiffness is found to be caused by an invasion of windcold-dampness, the following points are selected:

● Points on the du vessel, taiyang and shaoyang channels of the neck. Because the taiyang channel is the most exterior of all the six channels and thus affected first when wind invades the body.

● Points on the posterior aspect of the neck. Because this is the location where wind typically enters the body.

● Points on the large intestine channel. As this channel is internallyexternally related to the lung channel. The lung, as canopy of the body, is the internal organ most susceptible to external pathogens. Moxibustion is applicable on all of the above points. (2) Qi stagnation and blood stasis Points on the cervical region, du vessel and yang channels are most often selected, such as jiā jĭ (EX-B2), GB 20 (fēng chí), DU 14 (dà zhuī), LI 10 (shŏu sān lĭ), LI 4 (hé gŭ), SI 3 (hòu xī), BL 17 (gé shù), and LV 3 (tài chōng). (3) Phlegm and dampness obstructing the collaterals Local points along with points that invigorate the spleen and harmonize the stomach are most often selected, such as jiā jĭ (EX-B2), GB 20 (fēng chí), DU 20 (băi huì), ST 36 (zú sān lĭ ), SP 6 (sān yīn jiāo), SP 9 (yīn líng quán), and ST 40 (fēng lóng). (4) Insufficiency of liver and kidney Jiā jĭ (EX-B2), GB 20 (fēng chí), DU 16 (fēng fŭ), DU 20 (băi huì), KI 3 (tài xī), BL 18 (gānshù), BL 23 (shèn shù), ST 36 (zú sān lĭ), and SP 6 (sān yīn jiāo) are selected. (5) Deficiency of qi and blood Jiā jĭ (EX-B2), BL 17 (gé shù), BL 18 (gān shù), BL 23 (shèn shù), ST 36 (zú sān lĭ), KI 3 (tàixī), and DU 14 (dà zhuī) are selected. Yang-channel points and local points on the neck are most commonly selected. Along with points on the taiyang and yangming channels and jiā jĭ

(EX-B2) points, the shaoyang channel point GB 20 (fēng chí) is considered as most important. When employing needling techniques, drainage is used more than supplementation. The direction of needling, the patient’s respiration and qiobtaining techniques both should be taken into consideration. Moxibustion is effective in curing neck bi due to cold or deficiency. Bleeding therapy is usually applied at painful points of the head and neck. The optimum therapeutic quantity of bleeding is based on the patient’s constitution and the presenting condition. 4. Treatment According to (Western Medicine) Types (1) Neck-type Point selection: DU 16 (fēng fŭ), DU 14 (dà zhuī), DU 20 (băi huì), yìn táng (EX-HN3), tài yáng (EX-HN5), DU 13 (táo dào), BL 12 (fēng mén), jiā jĭ (EX-B2) Techniques: The patient is treated while sitting upright. Select five to eight of the above points and apply drainage techniques. When needling DU 16 (fēng fŭ), pay attention to the safe insertion angle of the needle. Warming needle or cupping with bleeding can be employed. Treat every other day. (2) Nerve-root type Point selection: DU 14 (dà zhuī), GB 20 (fēng chí), LI 10 (shŏu sān lĭ), LI 4 (hé gŭ), LU 5 (chĭ zé), LI 15 (jiān yú), SI 3 (hòu xī), SI 7 (zhī zhèng), SJ 10 (tiān jĭng), PC 3 (qū zé), jiājĭ (EX-B2), DU 12 (shēn zhù), BL 60 (kūn lún), GB 40 (wĕi zhōng), LU 7 (liè quē), SJ 5 (wàiguān)

Techniques: The patient is treated in a sitting position. From the points above, select five to eight for each treatment, and apply drainage. Optionally, use cupping with bleeding. Treat every other day. (3) Vertebral artery-type Point selection: DU 20 (băi huì), GB 20 (fēng chí), jiā jĭ (EX-B2), BL 11 (dà zhù), tàiyáng (EX-HN5), DU 9 (zhì yáng), SP 10 (xuè hăi), BL 63 (jīn mén), BL 18 (gān shù), BL 23 (shèn shù), RN 6 (qì hăi), RN 4 (guān yuán) Techniques: Select five to eight of the above points and apply supplementation, optionally with moxibustion after needling. Treat daily or every other day. (4) Sympathetic nerve-type Point selection: DU 20 (băi huì), DU 16 (fēng fŭ), jĭng băi láo (EXHN15), jiā jĭ (EX-B2), DU 10 (líng tái), PC 6 (nèi guān), PC 8 (láo gōng), HT 6 (yīn xì), LI 11 (qū chí), SI 6 (yănglăo), ST 36 (zú sān lĭ ), SP 6 (sān yīn jiāo) Auricular points: shen men (shén mén), sympathetic (jiāo găn), neck (jĭng), heart (xīn), spleen (pí), liver (gān), adrenal gland (shèn shàng xiàn), subcortex (pí zhì xià) Techniques: Select five to eight of the above points and use supplementation techniques. Electro-stimulation can be used by connecting points on the same side (left or right of the spine), or by connecting one point on the du vessel to two points beside it. Retain the needles for 30-40 min, and then apply press-seeds to the auricular points. Treat once daily. (5) Spinal cord-type

Point selection: Jiā jĭ (EX-B2), DU 14 (dà zhuī), DU 10 (líng tái), LU 6 (kŏng zuì), HT 5 (tōng lĭ), GB 40 (wĕi zhōng), ST 38 (tiáo kŏu), GB 39 (xuán zhōng), GB 20 (fēng chí), jĭng băiláo (EX-HN15), BL 11 (dà zhù), GB 34 (yáng líng quán), ST 36 (zú sān lĭ), BL 18 (gān shù), BL 23 (shèn shù) Techniques: Select five to eight of the above points for electrostimulation, including two or three jiā jĭ (EX-B2) points on the neck (for cervical vertebrae with osteoproliferation). After qi arrival, each point is linked to a pulse current for 20-30 min. Treat once daily.

CASE STUDY I Ms. Li, age 45. Initial Visit: March 28th, 2008 Chief Complaint: Right cervical pain for six months, worse over the past three days. History: The patient, a busy collage teacher, often works at a desk and computer for long periods of time. Over the past six months, she frequently felt pain in her neck after work. This pain was accompanied by vertigo and nausea, and alleviated by resting. She explained that her cervical pain and inflexibility was induced by working overtime and grading papers for the week prior. At that time, the pain was accompanied by vertigo and nausea. Her pain was not relieved by taking oral painkillers, after which she came to visit us. Signs and Symptoms: Cervical pain accompanied by dizziness, difficulty in neck rotation, obvious tenderness lateral to the cervical vertebrae, depression, insomnia, chest distress and palpitations. Her tongue was pale pink with a thin yellow coating; the pulse was wiry and weak. Past History: Patient denied diabetes, history of high blood pressure, hepatitis, tuberculosis or other history of infectious disease or allergies caused by food or drugs. Menstrual, Marital and Childbearing History: Menarche at age 12, menstrual cycle between 28 and 30 days, lasting from 4-5 days. Menses are typically scanty in quantity and red in color. Physical Examination: Blood pressure 120/78 mmHg, heart rate 73 bpm and regular, no pathological murmur at any valve area. Muscles on the

cervical region were in spasm and thus confined rotation or movement of the neck. There was sensitivity to palpation lateral to the spinous processes of C3 through C5. Auxiliary Examination: X-ray showed loss of normal curvature, protrusion of C3 through C6 joints, narrowing of intervertebral spaces from C3 to C5, and diminishing intervertebral foramen. Pattern Differentiation The diagnostically significant features include: exhaustion from work, cervical pain accompanied by vertigo, chest distress and palpitations. The tongue was red with a thin yellow coating, and her pulse was wiry and weak. In this case there is a complex pattern of deficiency and excess as related to the liver, spleen and kidney. Diagnosis TCM pattern: Stagnation of qi and blood with blood deficiency Clinical Treatment This case was caused by over-exertion, a weak constitution and obstruction of the channels and collaterals of the neck leading to cervical pain and stiffness. Treatment should invigorate and nourish blood, unblock the collaterals and relieve pain. Apart from acupuncture and moxibustion, the patient was advised to alter her living habits by doing exercises for her neck while avoiding excessive shaking, avoiding exposure to wind and cold, rectifying improper posture while at the computer, alternating work with rest using better time management, and adjusting the height of her sleeping pillow.

Principles: Invigorate and supplement blood, unblock the collaterals to relieve pain Formula: Modified Tōng Qiào Huó Xuè Tāng (Orifice-Unblocking Blood-Moving Decoction) [通窍活⾎汤加减]

The patient was prescribed three doses; each dose lasted two days. [Formula Analysis] Gé gēn, as chief medicinal, acts to unblock the channels and collaterals. The assistant medicinals xuán hú suŏ, chuān xiōng, hóng huā, bái zhĭ, dāng guī, sān qī, bái sháo, bái zhú and gŏu qĭ all serve to invigorate or nourish the blood and open the collaterals to relieve pain.

Acupuncture Main points: GB 20 (fēng chí), cervical jia ji points (C3-C7), BL 10 (tiān zhù), DU 14 (dà zhuī) Supplementary points: BL 17 (gé shù), BL 20 (pí shù), BL 18 (gān shù), BL 23 (shènshù), SP 6 (sān yīn jiāo), ST 36 (zú sān lĭ), KI 3 (tài xī)

Method: Select three of the main points and four or five supplementary points each day, alternating points on a daily basis. After qi was obtained, all needles were retained for 20-30 min. One course of treatment lasted ten sessions. Techniques: Needle GB 20 (fēng chí), jiā jĭ (EX-B2) and DU 14 (dà zhuī) with drainage, needle SP 6 (sān yīn jiāo) and KI 3 (tài xī) with supplementation. Warming-needle moxibustion was applied to ST 36 (zú sān lĭ), and then successive flash-cupping or warming-needle moxibustion was applied to back-shu points. Further Consultation After five sessions, the patient felt that her neck had relaxed significantly, and that her pain was somewhat alleviated. Nonetheless, after one full course of treatment, the patient felt fresh with energy, vigor and good cheer.

CASE STUDY II (ACUPUNCTURE, Tian CongHuo) Ms. Fan, age 47. Chief Complaint: Neck stiffness for two months. History: Two months ago, the patient felt stiff pain in her neck without vertigo or radiating pain. She found it difficult to bend or rotate her head or neck. She suffered from dry eyes and poor sleep. Otherwise, she was vigorous and had a normal diet, urination and defecation. Her tongue was pale pink with a thin white coating; her pulse was wiry and thin. Auxiliary Examinations: X-ray showed slight spinal hyperplasia. Diagnosis WM diagnosis: Cervical spondylosis TCM diagnosis: Bi syndrome due to cold obstruction, qi stagnation and blood stasis Clinical Treatment Principles: Invigorate blood, remove stasis, disperse cold to relieve pain Points: GB 20 (fēng chí), DU 16 (fēng fŭ), cervical jia ji points (C3C7), GB 21 (jiānjĭng), BL 10 (tiān zhù), SI 11 (tiān zōng), GB 12 (wán gŭ), DU 14 (dà zhuī) Techniques: Needle GB 20 (fēng chí), DU 16 (fēng fŭ), cervical jia ji points (C3-C7), GB 21 (jiān jĭng), BL 10 (tiān zhù), SI 11 (tiān zōng), GB

12 (wán gŭ). Apply cupping and bleeding to DU 14 (dà zhuī). When needling GB 20 (fēng chí), DU 16 (fēng fŭ) and BL 10 (tiān zhù), pay attention to insertion angle and depth. Further Consultation After two sessions, the patient’s symptoms were obviously alleviated, but she still felt coldness of her neck and shoulders. Warm-needle therapy was then applied to GB 20 (fēng chí), ashi points, cervical jia ji points (C3C7), GB 21 (jiān jĭng), BL 10 (tiānzhù), SI 11 (tiān zōng), GB 12 (wán gŭ), BL 23 (shèn shù), GB 34 (yáng líng quán), ST 36 (zúsān lĭ) and DU 14 (dà zhuī). Additionally, she was prescribed Xuè Fŭ Zhú Yū Kŏu Fú Yè (Blood Mansion Stasis-Expelling Oral Liquid) 10 ml, 3 times daily. Note In this case, points such as GB 21 (jiān jĭng), BL 10 (tiān zhù), and SI 11 (tiān zōng) were selected as local points, while GB 20 (fēng chí) and DU 16 (fēng fŭ) are the main points for expelling wind. GB 20 (fēng chí) is also a crossing point of the shaoyang channel and yangwei vessel, often used with DU 14 (dà zhuī) to relieve the exterior and dispel cold. cervical jia ji points (C3-C7) act to unblock the channels and collaterals. Distal points such as BL 23 (shèn shù), GB 34 (yáng líng quán) and ST 36 (zú sān lĭ) were selected to regulate the internal organs, promote circulation of qi and blood, and dredge the channels and collaterals. ST 36 (zú sān lĭ) invigorates yang qi and supplements qi and blood. Moxibustion applied to any local area acts to warm and move qi, eliminate phlegm and relieve pain, while also helping to disperse and dispel wind. Bleeding and cupping therapy at DU 14 (dà zhuī) purges pathogens outward and dissipates stasis to promote regeneration. Chinese medicinals

could also be used to enhance the point functions of invigorating blood and eliminating stasis. For increased efficacy and pain reduction, acupuncture, moxibustion and Chinese medicinals were used together in this case.

COMMENTARY AND DISCUSSION Some acupuncturists in the Western world believe that Chinese medicine has become watered-down or otherwise adulterated by Western medicine. Modern medical terminology appears in this chapter along with a number of differential diagnoses expressed as “nerve root-type” or “vertebral artery-type” neck pain. In fact, the very name of this chapter favors the Western term “cervical spondylosis”over “neck bi”, as the condition is referred to in TCM. In any event, it seems clear that even though biomedical terms are being used here, channel and zang-fu theories continue to inform the point selection for the various types. Regardless of the selected terminology, many different approaches can be applied to the organization of presenting signs and symptoms, with improved clinical outcomes as the ultimate goal. On the other side of this debate are those who say that channel theory or zang-fu differentiation are both relics of a pre-scientific past, and thus have no value or place in the modern medical system. Again, I favor the importance of “patient over paradigm”, so whatever works best for our patients is ultimately the best approach. If consistently better results are achieved using channel theories, or nerve theories, you should favor those in your practice. Chinese medicine has always been a big tent with room for many theories and treatment principles. Those who want to define the tent too narrowly often lose sight of the purpose of our work, which is always to benefit our patients.

STUDY QUESTIONS 1. In the first case, why was a painful and stiff neck treated with warmneedling moxibustion on ST 36 (zú sān lĭ), and flash-cupping or warmneedling moxibustion on back-shu points? 2. In the first case, in addition to the use of acupuncture and Chinese medicinals, what lifestyle changes should this patient make? 3. In the first case, which channels were primarily affected? Answers 1. The disease in this case was caused by over-exertion at work, and the patient showed manifestations of blood deficiency and blood stasis including dizziness, a pale tongue with a thin yellow coating, and a weak wiry pulse. Warm-needling moxibustion on ST 36 (zú sān lĭ), flash-cupping, and warm-needling moxibustion on back-shu points were therefore applied to supplement qi and blood. 2. The patient was advised to avoid excessive shaking of her head and neck, to avoid exposure to wind and cold, to maintain an ergonomic posture while working, and to adjust her sleeping pillow height. 3. Foot taiyang channel, du vessel.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Ms. Zhao, age 43, felt a fixed stabbing pain on her shoulder and upper arm accompanied by numbness. Which of the following formulas is the best choice? A. Hŭ Qián Wán (Hidden Tiger Pill) B. Qiāng Huó Shèng Shī Tāng (Notopterygium Dampness-Drying Decoction) C. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) D. Tōng Qiào Huó Xuè Tāng (Orifice-Unblocking Blood-Moving Decoction) E. Bàn Xià Bái Zhú Tiān Má Tāng (Pinellia, Atractylodes Macrocephala and Gastrodia Decoction) 2. Mr. Liu, age 65, recently began to suffer from frequent stiff pain in the head and neck. This pain was accompanied by vertigo, numbness of the four limbs, and indigestion. His tongue was pink with a thick greasy coating, and the pulse was wiry and slippery. Which of the following are the best treatment principles? A. Invigorate blood and dissolve stasis

B. Reduce phlegm and dispel dampness C. Invigorate blood and unblock orifices D. Supplement liver and kidney E. Warm the channels and dissipate cold 3. Mr. Wang, age 68, had suffered from years of cervical spondylosis. Thus, he often felt neck and shoulder discomfort accompanied by vertigo, tinnitus, insomnia, somnolence, and numbness of his limbs. His tongue was red and dry, and his pulse was wiry. Which of the following is the presenting pattern? A. Retention of wind-cold B. Retention of wind-dampness C. Obstruction of turbid phlegm D. Deficiency of liver and kidney E. Blockage of static blood 4. Mr. Chen, age 48, felt pain, stiffness and inflexibility in his neck accompanied by migrating pain and numbness in his upper limbs; he also feared cold and wind. His tongue was pink with a thin white coating, and his pulse was wiry and tight. Which of the following formulas would be the best choice? A. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) B. Hŭ Qián Wán (Hidden Tiger Pill)

C. Bàn Xià Bái Zhú Tiān Má Tāng (Pinellia, Atractylodes Macrocephala and Gastrodia Decoction) D. Guì Zhī Jiā Gé Gēn Tāng (Cinnamon Twig Decoction Plus Pueraria) E. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) 5. Mr. Lan, age 46, felt distending pain in his neck which radiated to the shoulder and back. He was diagnosed with neck-type cervical spondylosis. Which of the following groups of points should be used for treatment? A. DU 16 (fēng fŭ), DU 14 (dà zhuī), cervical jia ji points (C3-C7) B. GB 20 (fēng chí), LI 10 (shŏu sān lĭ), LI 4 (hé gŭ), C. LU 5 (chĭ zé), LI 15 (jiān yú), SI 3 (hòu xī) D. SI 7 (zhī zhèng), SJ 10 (tiān jĭng), PC 3 (qū zé) E. LI 15 (jiān yú), SI 3 (hòu xī), PC 3 (qū zé) 6. Ms. He, age 65, complained of stiffness and pain in her neck accompanied by vertigo and numbness of the limbs. Her tongue had a thick greasy coating, and the pulse was wiry and slippery. Besides the local points, which of the following point groups could be employed? A. ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo) B. GB 34 (yáng líng quán), ST 40 (fēng lóng) C. ST 36 (zú sān lĭ), GB 34 (yáng líng quán)

D. GB 60 (kūn lún), ST 36 (zú sān lĭ) E. SP 6 (sān yīn jiāo), GB 34 (yáng líng quán) 7. Mr. Liao, age 53, reported frequent pain in his neck accompanied by vertigo. He had a pale complexion, numbness of the four limbs and lassitude. His tongue was pale with a scanty coating, and his pulse was thin and weak. In addition to the local points, which of the following groups of points could be employed for treatment? A. BL 18 (gān shù), BL 23 (shèn shù), ST 36 (zú sān lĭ) B. ST 36 (zú sān lĭ), GB 34 (yáng líng quán), GB 40 (wĕi zhōng) C. BL 23 (shèn shù), GB 40 (wĕi zhōng), GB 39 (xuán zhōng) D. BL 23 (shèn shù), GB 39 (xuán zhōng), GB 41 (zú lín qì) E. ST 36 (zú sān lĭ), GB 39 (xuán zhōng), GB 41 (zú lín qì) 8. Mr. Li, age 46, complained of neck and shoulder discomfort. His pain was accompanied by vertigo, tinnitus, insomnia, dream-disturbed sleep, numb limbs, a flushed face and red eyes. His tongue was red with a scanty coating, and his pulse was wiry. In addition to the local points, which of the following groups of points could be also used in treatment? A. KI 3 (tài xī), BL 18 (gān shù), BL 23 (shèn shù) B. BL 23 (shèn shù), ST 36 (zú sān lĭ), GB 41 (zú lín qì) C. ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo), GB 41 (zú lín qì) D. ST 36 (zú sān lĭ), GB 41 (zú lín qì), KI 3 (tài xī)

E. KI 3 (tài xī), GB 39 (xuán zhōng), GB 41 (zú lín qì) Answers 1. D 2. B 3. D 4. D 5. A 6. B 7. A 8. A

14. Stiff Neck (Torticollis) ANCIENT THEORIES AND MODERN INSIGHTS Stiff neck, also called “torticollis” or “wryneck” is a common condition that often attacks young people, mostly in winter and spring. Stiff neck is usually noticed first thing in the morning when the patient notices aching pain at the nape and back with limited neck range of motion, which suggests that stiff neck has a close relationship with the pillow and sleeping position. According to traditional Chinese medicine, stiff neck is usually caused by improper sleeping position or uncomfortable pillow height which leads to a disharmony of qi and blood in the neck characterized by spasms and tightness affecting the channels. Stiff neck can also be caused by neck sprain or wind-cold attacking the nape and back, giving rise to disharmony of local channel-qi. The condition described in this chapter can be defined biomedically as any of the following conditions: painful stiff neck and nape, limited movement of the neck due to muscle strain, neck muscle rheumatism, contusions due to excessive neck twisting, cervical degeneration, loss of synovial fluids, subluxation of the cervical bones, and myofascitis.

ETIOLOGY AND PATHOMECHANISMS External Causes Muscle sprain: Due to improper sleeping position at night, prolonged hyperflexion of the head and neck, or an uncomfortable pillow which puts the head and neck into a state of either hyperextension or hyperflexion. Any of these situations can cause muscular tension in the neck that leads to disharmony and stiffness of the local channel sinews, inhibited flow of qi and blood, local pain and discomfort, and obvious limited range of motion. Wind-cold: Can cause muscle tightness and tension, specifically in the upper back and neck. Even exposure to a cold breeze on the back of the neck can generate this condition, as can catching a cold, especially while sleeping. Cold constricts, which causes qi and blood stagnation in the channels and collaterals which generates neck stiffness, pain and a limited range of motion.

Internal Causes Weak constitution: One who is constitutionally deficient runs a greater risk of a spastic wind-cold attack. Aside from that, the general lack of nourishment of qi and blood to the structures of the neck can give rise to a muscle sprain or strain.

Pattern Differentiation 1. Differentiation Based on Channels

● Du mai and taiyang channel patterns: The pain occurs at the nape and back, with obvious tenderness on these body parts.

● Shaoyang channel pattern: The pain radiates from the neck to the arm, the neck unable to turn far enough to look backwards, with obvious tenderness on the lateral aspects of the neck. 2. Differentiation Based on Patterns

● Wind-cold attacking the channels and collaterals: Aching pain in the nape and neck with a possible history of exposure to cold weather or drafts, an aversion to wind and fear of cold.

● Qi stagnation and blood stasis: Aching pain in the nape and neck with a history of trauma to the neck or nape. Pain may be severe.

THERAPEUTICS Chinese Medicinals 1. Wind-cold Attacking the Channels and Collaterals Formula: Fáng Fēng Tāng (Ledebouriella Decoction) Ingredients: fáng fēng (Radix Saposhnikoviae), má huáng (Herba Ephedrae), guì zhī (Ramulus Cinnamomi), gé gēn (Radix Puerariae Lobatae), dāng guī (Radix Angelicae Sinensis), fú líng (Poria), shēng jiāng (Rhizoma Zingiberis Recens), dà zăo (Fructus Jujubae), gān căo (Radix et Rhizoma Glycyrrhizae) 2. Qi Stagnation and Blood Stasis Formula: Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) Ingredients: dāng guī (Radix Angelicae Sinensis), shēng dì (Radix Rehmanniae), táo rén (Semen Persicae), hóng huā (Flos Carthami), zhĭ qiào (Fructus Aurantii), gān căo, chì sháo (Radix Paeoniae Rubra), chái hú (Radix Bupleuri), chuān xiōng (Rhizoma Chuanxiong), niú xī (Radix Achyranthis Bidentatae), jié gĕng (Radix Platycodonis)

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Tenderness at the nape and back: select points on the du vessel and taiyang channel.

(2) Tenderness at the lateral aspects of the neck: select points on the shaoyang channel. 2. Point Selection According to Location (1) Local points Main points: DU 14 (dà zhuī), lào zhĕn (落枕) Taiyang channel: BL 10 (tiān zhù), SI 14 (jiān wài shù) Shaoyang channel: GB 20 (fēng chí), GB 21 (jiān jĭng) (2) Upper limbs: SI 3 (hòu xī), SI 2 (qián gŭ), SI 1 (shào zé) (3) Lower limbs: GB 39 (xuán zhōng), BL 60 (kūn lún) 3. Point Selection According to Syndrome (1) Wind-cold attacking the exterior: DU 14 (dà zhuī), BL 12 (fēng mén) and GB 20 (fēng chí) to dispel wind and dissipate cold, BL 10 (tiān zhù) to move qi and relieve pain. (2) Qi stagnation and blood stasis Pain radiating to the shoulder: SI 13 (qū yuán) and GB 21 (jiān jĭng) to unblock the channels and quicken the collaterals. Pain of the upper back: BL 11 (dà zhù) governs the bone, moves qi, and dissipates masses, SI 14 (jiān wài shù) and SI 11 (tiān zōng) promote the movement of local qi. Aversion to cold with headache: Taiyang is the most exterior of the six channels, and the channel most affected by exterior wind-cold. LI 4 (hé gŭ) and SJ 5 (wài guān) are both commonly used to release the exterior. They can also be used for stiff neck due to external wind-cold, by moving qi and dissolving stasis in the taiyang.

Limited range of motion: BL 60 (kūn lún) to address neck rigidity, LU 7 (liè quē) for pain in the neck and throat, and SI 7 (zhī zhèng) to move the qi in the channels and collaterals that pass through the neck.

CASE STUDY I Mr. Liu, age 29. Chief Complaint: Pain of the right side of the neck with limited movement for over 20 days. History: Three weeks prior, Mr. Liu woke up with a pinching tightness on the right side of his neck which prevented him from looking far to either side. Even coughing or spitting aggravated this pain. He tried several acupuncture and tui na treatments, but the pain didn’t improve. Two weeks ago, the pain worsened and began to radiate into his back and chest, with pulling pain and muscle spasms on the right-side nape and back. There was also chest oppression and depression. Next, he tried traditional Chinese herbal medicines and also ten more tui na treatments. He applied Wanhua oil externally and found that the pain improved a little, but his neck remained stiff which prevented him from looking backwards or bowing. His tongue had a thin white coating; the pulse was wiry and tight. Past History: No past history of trauma or disease to the cervical or thoracic spines. Physical Examination: The patient was well-developed and showed no signs of malnutrition, slightly lean, his skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, resonant percussion sounds. Heart rate was 68 bpm and regular, with no pathological murmur at any valve area. Flat abdomen, liver and spleen were non-palpable. There was no deformity of the spine or four limbs, and no edema in the lower limbs.

Auxiliary Examination: CT scan showed the cervical curvature slightly straightened, with no other obvious abnormities. Pattern Differentiation Improper sleeping position and/or wind-cold attacking the exterior gave rise to disharmony between ying and wei qi. This led to blockage of channel-qi and thus generated the stiff neck. The location of the disease was in the taiyang channel. His pulse was wiry and tight, and his tongue coating was thin and white. Both of these signs indicate wind-cold attacking the collaterals. Because the taiyang channel-qi failed to diffuse, the principle of treatment is to dispel wind-cold and diffuse the collaterals. The location was at the exterior, and the presenting pattern was excess in nature. Diagnosis Stiff neck due to wind-cold attacking the exterior Clinical Treatment In this case, an improper sleeping position or wind-cold attacking the exterior gave rise to a disharmony between ying and wei qi and blockage of channel-qi, which then caused the stiff neck. Principles: Dispel wind and dissipate cold, dispel pathogens and diffuse the collaterals Formula: Jiŭ Wèi Qìāng Huó Tāng (Nine Ingredients Notopterygium Decoction) [九味羌活汤]

[Formula Analysis] Qiāng huó dissipates cold and releases the exterior, dispels wind and promotes joint movement. Fáng fēng dispels wind and dries dampness; it also guides the formula to the taiyang channel. Gé gēn clears interior heat and releases wind from the muscles, especially that of the neck and shoulders. Guì zhī assists the wei-yang, unblocks the channels and collaterals, releases the muscles and diffuses the exterior. Bái sháo boosts yin and astringes ying. Dāng guī supplements and invigorates the blood, regulates the channels and relieves pain, while shēn jīn căo, bái máo téng and sī guā luò dredge the channels and quicken the collaterals.

Acupuncture Main points: Lào zhĕn (落枕), SI 3 (hòu xī), BL 60 (kūn lún) Supplementary points: DU 14 (dà zhuī), GB 20 (fēng chí)

Method: Treatments took place once daily, one course of treatment lasted 10 days. Moxibustion was optionally utilized as well. Techniques: After qi was obtained, the needles were rotated for 2 min using the even method, then retained for 30 min with rotation applied every 10 min. Further Consultation After one course of treatment (ten acupuncture treatments), the pain at the right nape and back was nearly gone; the patient could now look to the sides, backwards, and bow his head with no discomfort.

CASE STUDY II (ACUPUNCTURE, Yang Yongxuan) Ms. Liu, age 34. Chief Complaint: Stiffness and pain in the head and nape with limited range of motion since the day before her first visit. History: Ms. Liu was very busy the afternoon she suddenly felt stiffness and pain at the head and nape which made it difficult to rotate her head. The pain was relieved slightly after neck rotation movements and self-massage, but this morning the symptoms were even worse. At the time of her visit, her neck and nape were stiff and painful, she was unable to bow her head or look around. Her tongue was pink with a thin white coating; the pulse was wiry. Physical Examination: Obvious tenderness in the local muscles without redness or swelling. Diagnose Stiff neck due to muscle strain Clinical Treatment Principles: Relax the sinews and quicken the collaterals, move qi and relieve pain. Utilize acupuncture and moxibustion concurrently with the draining method. Points: DU 14 (dà zhuī), lào zhĕn (落枕), SI 3 (hòu xī), GB 39 (xuán zhōng), ashi points

Techniques: Needle DU 14 (dà zhuī) with the drainage method and the other points with the even method. Moreover, apply moxibustion on DU 14 (dà zhuī), làozhĕn (落枕) and ashi points. After withdrawing the needles at adjacent points, retain the needles at the distal points; during manipulation, ask the patient to rotate the head and neck. Results: The patient was cured immediately after the treatment.

COMMENTARY AND DISCUSSION The use of gé gēn (Radix Puerariae Lobatae) has been highly valued since the days of Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) (ca. 200 CE) for the treatment of stiff and painful neck due to wind-cold. Many Western patients complain of neck and shoulder tension, but often without any particular indication of an exterior attack. In these cases, using gé gēn as a guiding medicinal can prove successful when adding it to a formula that addresses a pattern arising from emotional stress. For example, gé gēn can be used to guide Xiāo Yáo Săn (Free Wanderer Powder) to the jaw in the treatment of stress-induced temporomandibular joint and muscle disorders (TMJ disorders) or inability for the mouth to open and close smoothly due to muscle spasms when the pattern involves internal wind arising from qi stagnation with heat. Xiāo Yáo Săn or other wind-extinguishing formulas can use gé gēn to guide the formula effects to the stomach channel (which dominates the jaw region), where the wind-extinguishing effects (and perhaps gé gēn as well) will help to relax the jaw muscles.

STUDY QUESTIONS 1. When we treat stiff neck of the du vessel and taiyang pattern, which group of points should we add to the main points? A. GB 20 (fēng chí), GB 31 (fēng shì), GB 21 (jiān jĭng) B. GB 21 (jiān jĭng), SI 14 (jiān wài shù), GB 31 (fēng shì) C. SI 14 (jiān wài shù), DU 16 (fēng fŭ), BL 10 (tiān zhù) D. GB 31 (fēng shì), GB 20 (fēng chí), DU 16 (fēng fŭ) E. DU 16 (fēng fŭ), GB 21 (jiān jĭng), GB 20 (fēng chí) 2. Which of the following points is NOT known to treat stiff neck? A. SI 3 (hòu xī) B. GB 39 (xuán zhōng) C. Ashi point D. BL 40 (wĕi zhōng) E. Lào zhĕn (落枕) 3. Which of the following points is NOT recommended for cupping? A. DU 14 (dà zhuī) B. GB 21 (jiān jĭng) C. SI 14 (jiān wài shù) D. Ashi point E. GB 20 (fēng chí)

4. Which of the following treatment is the best choice for stiff neck? A. Acupuncture and moxibustion B. Acupuncture without moxibustion C. Moxibustion without acupuncture D. Cupping E. Point bloodletting 5. Which of the following are the main points for stiff neck? A. LU 9 (tài yuān), LI 15 (jiān yú) B. SI 14 (jiān wài shù ), DU 14 (dà zhuī) C. GB 39 (xuán zhōng ), ashi point D. GB 20 (fēng chí ), GB 21 (jiān jĭng) E. DU 14 (dà zhuī), LI 4 (hé gŭ) Answers 1. C 2. D 3. E 4. A 5. C

15. Shoulder Pain ANCIENT THEORIES AND MODERN INSIGHTS Shoulder pain is a common condition mainly characterized by pain with a limited range of motion in the shoulder. It is also known in Chinese as wй shí jiān (fiftyyear shoulder), dòng jié jiān (frozen shoulder), jiān níng zhèng (shoulder coagulation disorder), and lòu jiān fēng (wind-leaking shoulder), named for the sensation that some patients describe as a cool wind blowing out of the shoulder. In TCM, all of these conditions belong to the category of “shoulder bi syndrome”. The internal pathomechanism of shoulder pain begins with deficiencies of wei, qi, ying, or blood. When wind, cold or dampness enters the interior, it invades to the depth of the tendons and bones while obstructing the channels and collaterals. The obstruction ultimately stagnates the qi and blood, which causes pain. This condition can be induced or aggravated by traumatic injury, or by sleeping only one side, which compresses the sinews and gradually results in an obstruction of qi and blood and the formation of shoulder bi. As shoulder pain persists, the afflicted part becomes swollen and stiff with a limited range of motion. Shoulder pain is more of a problem in those around age fifty, with the left shoulder more commonly affected than the right. Shoulder pain affects women three times more often than men.

ETIOLOGY AND PATHOMECHANISMS External Causes Wind, cold and dampness: Because of a pre-existing deficiency of qi and blood, there follows an insecurity of exterior wei. Following an invasion of pathogenic wind, cold and dampness, obstruction of the channels and collaterals results in pain. Musculoskeletal injury: Sleeping on only one side of the body compresses the sinews and gradually results in obstruction of qi and blood and the formation of shoulder bi. Local tissue injury can also generate shoulder pain.

Internal Causes Deficiency of qi and blood: Around age 50, deficiencies of qi and blood typically appear where the tendons and sinews are not properly nourished; this often results in a lingering low-grade pain.

Pattern Differentiation 1. Differentiation Based on Channel Theory Taiyin pattern: Pain at the anterior aspect of the shoulder (roughly in the area dominated by the hand taiyin lung channel) which is aggravated by shoulder extension (when the arm is stretched backwards as if accepting a baton in a relay race). Yangming pattern: Pain around LI 15 (jiān yú) with tenderness along the anterior portion of the deltoid muscle which is aggravated when the shoulder is in internal rotation (as in the movement necessary to place one’s palm on their chest). Shaoyang pattern: Pain around SJ 14 (jiān liáo) at the lateral aspect of the shoulder with tenderness in the deltoid muscle which is aggravated when the arm is in abduction (as in the movement that children will use to mimic an airplane’s wings). Taiyang pattern: Pain around SI 9 (jiān zhēn) and SI 10 (nào shù) at the posterior aspect of the shoulder which is aggravated when the shoulder is adducted (such as when the right hand is placed on the left hip). 2. Differentiation Based on Patterns Deficiency of qi and blood: Pain and soreness in the shoulder, worse after work or when fatigued. Weak constitution, a tired expression, and a pale complexion accompanied by palpitations, insomnia, and weakness of the four limbs. The tongue is pale with a white or scanty coating; the pulse is thready and weak.

Cold-dampness obstructing the collaterals: Pain of the whole shoulder aggravated by windy or cold weather and relieved by warmth. The patient is averse to wind and cold, or feels a sensation of heaviness in the shoulder. The tongue is pale with a white or greasy coating; the pulse is soggy or thready. Qi stagnation and blood stasis: Usually a stabbing pain in the shoulder of fixed location that is worse with pressure and at night. There is a dull complexion, and a purplish or dim tongue body, potentially with purple dots. The pulse is thready, choppy, or wiry and choppy.

THERAPEUTICS Chinese Medicinals 1. Deficiency of Qi and Blood Formula: Huáng Qí Guì Zhī Wŭ Wù Tāng (Astragalus and Cinnamon Twig Five Substances Decoction) Ingredients: huáng qí (Radix Astragali), guì zhī (Ramulus Cinnamomi), sháo yào (Radix Paeoniae), shēng jiāng (Rhizoma Zingiberis Recens), dà zăo (Fructus Jujubae), sāng zhī (Ramulus Mori), dāng guī (Radix Angelicae Sinensis) 2. Cold-dampness Obstructing the Collaterals Formula: Má Guì Wēn Jīng Tāng (Channel-Warming Decoction with Ephedra and Cinnamon twig) Ingredients: má huáng (Herba Ephedrae), guì zhī, hóng huā (Flos Carthami), xìxīn (Radix et Rhizoma Asari), táo rén (Semen Persicae), bái zhĭ (Radix Angelicae Dahuricae), chì sháo (Radix Paeoniae Rubra), zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle), sāng zhī 3. Qi Stagnation with Blood Stasis Formula: Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) Ingredients: táo rén, hóng huā, dāng guī (Radix Angelicae Sinensis), mò yào (Myrrha), wŭ líng zhī (Faeces Trogopterori), niú xī (Radix Achyranthis Bidentatae), dì lóng (Pheretima), chuān xiōng (Rhizoma

Chuanxiong), xiāng fù (Rhizoma Cyperi), qín jiāo (Radix Gentianae Macrophyllae), qiāng huó (Rhizoma et Radix Notopterygii), sāng zhī, zhì gān căo ★ Key Medicinal Sāng zhī, which guides the medicinal effects to the arm and fingers, is a key medicinal for frozen shoulder. The thermal nature of sāng zhī is neutral, the flavor is bitter, and functions include dispelling wind-dampness, promoting joint function, unblocking the channels and quickening the collaterals. The classics suggest that one “treat disease of the extremities by using an herb shaped like a limb”. Sāng zhī, being a branch, thus acts to strengthen and guide the effects of the formula to the upper limbs.

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels and Location (1) Local points Hand taiyin: LU 3 (tiān fŭ), LU 4 (xiá bái) Hand yangming: LI 15 (jiān yú), LI 14 (bì nào) Hand shaoyang: SJ 14 (jiān liáo), SJ 13 (nào huì) Hand taiyang: SI 9 (jiān zhēn), SI 10 (nào shù), SI 11 (tiān zōng) Extra point: Jiān qián (肩前, Shoulder Front) (2) Distal points Hand taiyin: LU 5 (chĭ zé), LU 10 (yú jì) Hand yangming: LI 11 (qū chí), LI 10 (shŏu sān lĭ), LI 4 (hé gŭ) Hand shaoyang: SJ 2 (yè mén), SJ 5 (wài guān)

Hand taiyang: SI 4 (wàn gŭ), SI 3 (hòu xī) Empirical points: Zhōng píng (中平, Central Balance), threading technique from ST 38 (tiáo kŏu) to BL 57 (chéng shān) Specific point: GB 34 (yáng líng quán) 2. Point Selection Based on Pattern Differentiation (1) Deficiency of qi and blood: ST 36 (zú sān lĭ), SP 10 (xuè hăi), BL 20 (pí shù), BL 21 (wèi shù) (2) Cold-dampness obstructing the collaterals: DU 9 (zhì yáng), DU 14 (dà zhuī), SP 9 (yīn líng quán) (3) Qi stagnation and blood stasis: LV 3 (tài chōng), BL 17 (gé shù) Shoulder pain, as a disease, is considered to exist in the channel sinews, so GB 34 (yáng líng quán) can be selected because it is the influential point of the sinews. Zhōngpíng (中平, Central Balance) is another effective empirical point. Through-needling from ST 38 (tiáo kŏu) to BL 57 (chéng shān) is also a common clinical procedure. As to the acupuncture techniques employed, in order to supplement deficiency or drain excess appropriately we need to follow correct pattern differentiation. The techniques for needling local points include penetrating puncture, multi-needle acupuncture (e.g. valley union needling, joint needling and triple needling). These methods all benefit the circulation of the local channel-qi and blood. [See editor’scommentary below for more on these techniques.] Moxibustion can be applied for patterns of cold-dampness obstructing the collaterals and deficiency of qi and blood. Moxibustion warms and unblocks the channels and collaterals, expels cold and dampness, and

reinforces upright qi. For patterns of qi stagnation and blood stasis, fireneedling or tri-edged needling can be followed by bleeding or bleedingcupping. Because the muscle around the shoulder is thick, we can apply retention cupping for longer periods of time to expel dampness, or flashcupping to warm and unblock the channels, invigorate blood and dissolve stasis. Commentary Some special techniques were described earlier in this chapter which may require further explanation:

● Valley union needling is not associated with point LI 4 (hé gŭ) (Union Valley), but rather is a specific needling technique applied to regions with thick muscles. Needling is perpendicular and relatively deep; then the needle is withdrawn enough to reposition its angle without removing it from the point. Then re-insert the needle obliquely, first to one side and then to the other. In addition to treating obstructive problems, this technique can also regulate the spleen, as the spleen governs the flesh. This method is only applied to areas where the muscle (flesh) is thick.

● Joint needling is to needle the tendons around a joint to treat obstructive disorders.

● Triple needling is also translated as “ranked needling”. Three needles are inserted in a row, with the center needle going in first and with subsequent needles on either side. This technique is used to treat deep obstructive disease over a small region.

CASE STUDY I Mr. Li, age 56. Initial Visit: October, 2009 Chief Complaint: Pain in the left shoulder for one month, with limited range of motion for two weeks. History: The patient was exposed to cold at night a month before, and the next morning he felt soreness, heaviness and pain in the left shoulder. He treated himself with some pain-killers and an analgesic plaster for traumatic injury and rheumatism, but the symptoms were not relieved. The pain had gotten worse over the past week. Mr. Li noted that the pain was aggravated by cold and relieved by warmth. The night before the patient arrived, he was awakened by the pain which also caused difficulty in reaching backwards. Signs and Symptoms: Pain in the left shoulder, limited movement when reaching backwards (shoulder extension), normal appetite, sleep, urine and stools. His tongue was pale with a thick white coating; the pulse was wiry. Past History: The patient had suffered from type II diabetes for two years, and took Metformin tablets 500 mg once daily. No history of hypertension, infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or foods. Menstrual, Marital and Childbearing History: Married with two children, spouse and children were healthy. Physical Examination: The patient was well-developed and moderately nourished, his skin and sclera showed no indication of jaundice, no palpable

superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, with resonant percussion sounds. Heart rate was 70 bpm and regular, no pathological murmur at any valve area. Flat abdomen, liver and spleen were nonpalpable, no deformity of the spine or four limbs, no edema in the lower limbs. Orthopedic Examination: Extensive tenderness in the left shoulder, worst in the adhesion area of the long head tendon of the biceps and below the coracoids. Limitation of movement: flexion 70°, abduction 60°, extension 15°. The tongue was pale with a thick white coating, and the pulse was wiry. Auxiliary Examination: Blood routine test showed no abnormity. Xray of the shoulder showed no fracture or spurs. Pattern Differentiation The patient suffered from shoulder pain caused by a wind-cold invasion. The wind-cold invaded the shoulder and blocked the channel and collaterals which then resulted in pain. As such, the pain was aggravated by cold and relieved by warmth. Tenderness indicated blockage of the local channel and collateral. The pale tongue with a thick white coating and the wiry pulse suggested an obstruction of cold-dampness. Diagnosis TCM pattern: Cold-dampness obstructing the collaterals Clinical Treatment Principles: Dissipate cold and dispel dampness, warm the channel to relieve pain

Formula: Modified Má Guì Wēn Jīng Tāng (Ephedra and Cinnamon Twig Channel-Warming Decoction) [麻桂温经汤加减]

Seven doses. One decocted dose per day. [Formula Analysis] Má huáng and guì zhī are the chief medicinals, acting to expel windcold and warm the channels and collaterals. Deputy medicinals include xì xīn and bái zhĭ to expel dampness and relieve pain, yán hú suŏ to dissipate cold to relieve pain, bái sháo to relax tension and relieve pain, and bái zhú and yì yĭ rén to fortify the spleen and eliminate dampness. Assistant medicinals include huáng qí to boost qi, warm yang and fortify the spleen, shēng jiāng to expel wind-cold, and sāng zhī, which guides the effects of the formula directly to the shoulder.

Gān căo harmonizes all formula ingredients, and combines with bái sháo to relax spasms. Gān căo with bái sháo can be referenced as Sháo Yào Gān Căo Tāng (Peony and Licorice Decoction) as described in the Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论).

Acupuncture Main points: LI 15 (jiān yú), SJ 14 (jiān liáo), jiān qián (肩前, Shoulder Front), LI 14 (bìnào), LI 11 (qū chí), GB 34 (yáng líng quán), zhōng píng (中平, Central Balance) Supplementary points: SJ 5 (wài guān), DU 14 (dà zhuī), SP 9 (yīn líng quán) Method: Three main points and two supplementary points were chosen each day, with points changed every other day. After qi was obtained, the needles were retained for 20-30 min. Ten daily treatments constitute one treatment course. Techniques: Apply filiform needle therapy at LI 15 (jiān yú), SJ 14 (jiān liáo), jiānqián (肩前, Shoulder Front), LI 14 (bì nào) and LI 11 (qū chí). Use warming-needle moxibustion at two points chosen from among LI 15 (jiān yú), SJ 14 (jiān liáo), jiān qián(肩前, Shoulder Front), and LI 14 (bì nào). Apply deep needling at GB 34 (yáng líng quán), or threading from GB 34 (yáng língquán) to SP 9 (yīn líng quán). Needle with the even method at zhōng píng (中平, Central Balance) and SJ 5 (wài guān). Apply cupping at the painful areas of the shoulders for 5 min after needles have been withdrawn, and mild moxibustion at DU 14 (dà zhuī)

until the skin appears flushed. Further Consultation After seven treatments, the pain was much relieved and the patient was able to lift his affected arm. After another 15 treatments, the pain was gone with no limited range of motion. Wind-cold-dampness invasion was the cause of the disease, so the treatment principles are to dissipate cold and dispel dampness while warming the channels to relieve pain. In addition to the acupuncture and medicinal treatments, the patient was instructed to keep the shoulder warm and to do functional exercises.

CASE STUDY II (ACUPUNCTURE, Lu Shouyan) Ms. Bao, 55 years old. Initial Visit: August 21th, 1963 Chief Complaint: Pain in the left shoulder with difficulty lifting the arm for over one year. Signs and Symptoms: Left shoulder pain with limited range of motion, numbness in the fingers, and a sensation of cold soreness in the shoulder and lower back. The pulse was thready and soft, and the tongue coating was thin and glossy. Pattern Differentiation The patient was over 49, and as such, qi and blood had declined in the chong and ren vessels, thus leading to a general deficiency in the vessels and collaterals. In addition, the ying was unable to moisten and nourish, while the wei lost its ability to defend against exterior pathogens; the resulting was disharmony between ying and wei with insecurity of the exterior. So when exterior wind invaded, the left shoulder felt a cold pain with stiffness and numbness of the fingers, also accompanied by soreness in the lower back. The pain had lasted for more than a year. The cause of the disease was an exterior invasion due to interior deficiency, so the treatment principle was to harmonize ying and wei while diffusing pathogens from the collaterals. Clinical Treatment Points: LI 15 (jiān yú), SJ 14 (jiān liáo), SI 9 (jiān zhēn), LI 16 (jù gŭ), LI 14 (bì nào), LI 11 (qū chí), LI 4 (hé gŭ), BL 23 (shèn shù) (bilateral)

Techniques: The draining needling technique was applied to LI 15 (jiān yú), SJ 14 (jiān liáo), SI 9 (jiān zhēn), LI 16 (jù gŭ), LI 14 (bì nào), LI 11 (qū chí) and LI 4 (hégŭ), and the supplementation needling technique was applied to BL 23 (shèn shù). The “valley union” needling technique was applied below the point LI 15 (jiān yú). Warmn-eedling and cupping were also applied to the local points on the shoulder. Further Consultation Second Visit September 20th After eight treatments, there was increased range of motion; however, the movement of revolving backwards had not improved, and tenderness remained at point jiān shù (肩俞, Shoulder Transport). Lumbar pain had also improved. Points: LI 15 (jiān yú), SJ 14 (jiān liáo), jiān shù (肩俞, Shoulder Transport) (empirical point, see below), LI 14 (bì nào), LI 11 (qū chí), LI 4 (hé gŭ), BL 23 (shèn shù) (bilateral) Techniques: Drainage was applied to LI 15 (jiān yú), SJ 14 (jiān liáo), jiān shù (肩俞, Shoulder Transport), LI 14 (bì nào), LI 11 (qū chí) and LI 4 (hé gŭ). Supplementation was applied to BL 23 (shèn shù). Triple needling was used at jiān shù (肩俞, Shoulder Transport). Warm-needling and cupping were applied to local points on the shoulder. Third Visit September 27th With continued acupuncture treatments, channel-qi was regulated and ying and wei were harmonized. The patient recovered fully with no

apparent limitation of movement. Comments Dr. Lu’s bi treatment principle involves the combining of local and distal points along the channel. Needle rotation was employed for supplementation and drainage. Because the disease was located in the muscles and sinews, valley union-needling and triple-needling methods were applied. Warm-needling was added because the channel was blocked due to cold bi. Valley union-needling, triple-needling and cupping are also often used for treating tenderness. When the symptom of limited armraising exists, cupping on the shoulder can be applied (2-3 cups maximum). Jiān shù (肩俞, Shoulder Transport) is an empirical point for frozen shoulder, which is located at the midpoint between LI 15 (jiān yú) and LU 2 (yún mén). Another empirical point for frozen shoulder is jiān nèi shù (肩内 俞, Shoulder Inner Transport), located one cun below the jiān shù (肩俞, Shoulder Transport). These two points are effective for pain at the medial aspect of the shoulder and arm accompanied by a limited ability to lift the arm upward.

STUDY QUESTIONS 1. According to pattern differentiation of channel and collaterals, which channel was affected in the first case? 2. Why was mild moxibustion applied to DU 14 (dà zhuī) in the first case? 3. In the first case, what instructions should the patient be given for home selfcare? 4. Which point can be threaded to BL 57 (chéng shān) in the treatment of shoulder pain? A. GB 34 (yáng líng quán) B. SP 9 (yīn líng quán) C. ST 38 (tiáo kŏu) D. ST 40 (fēng lóng) E. GB 39 (xuán zhōng) 5. A modern empirical point for treating frozen shoulder is: A. Zhōng píng (中平, Central Balance) B. Hè dĭng (EX-LE2) C. Tài yáng (EX-UE5) D. ST 38 (tiáo kŏu) E. SI 3 (hòu xī) Answers

1. The patient had pain in the left shoulder with limited range of motion when stretching backwards (shoulder extension). The physical examination showed extensive tenderness in the left shoulder, all found along the trajectory of the hand yangming channel. Differentiation indicates a yangming channel pattern. 2. DU 14 (dà zhuī) is the intersecting point of the du vessel and all three yang channels of the hand and foot. Mild moxibustion can supplement wei qi while warming and unblocking the channels and collaterals. This method treats the root deficiency of wei and qi. 3. The patient should be advised to keep the shoulder warm, and also encouraged to perform moderate physical exercise to aid their recovery. 4. C 5. A

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mr. Zheng, age 54, complains of pain of the anterior aspect of the left shoulder. There is limited range of motion when stretching his arm backwards (shoulder extension). Which of the following channels are affected? A. Yangming channel B. Taiyang channel C. Shaoyang channel D. Taiyin channel E. Shaoyin channel 2. Ms. Mai, age 56, reports pain in her left shoulder for three days. She treated herself with analgesic plaster for trauma and rheumatism, but with no improvement. Symptoms include pain in the left shoulder accompanied by a sensation of heaviness. The affected local area prefers warmth and is averse to cold. X-ray of the shoulder showed no fracture nor bone spurs. Which of the following formulas should she be prescribed? A. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction)

B. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) C. Juān Bì Tāng (Impediment-Alleviating Decoction) D. Má Guì Wēn Jīng Tāng (Ephedra and Cinnamon Twig ChannelWarming Decoction) E. Huáng Qí Guì Zhī Wŭ Wù Tāng (Astragalus and Cinnamon Twig Five Substances Decoction) 3. Mr. Wu, age 55, experienced pain in his shoulder for the past six months. The pain was pricking in nature, and worse at night. Mr. Wu woke up often because of the pain. Tight hard tendons are palpable in the painful area. Which of the following patterns apply to Mr. Wu’s case? A. Cold-dampness obstructing the collaterals B. Qi stagnation and blood stasis C. Deficiency of kidney and liver D. Deficiency of qi and blood E. Phlegm and stasis obstructing the collaterals 4. Ms. He, age 49, complained of pain around the shoulder for “a long time”. Her pain was worse after work or when fatigued. Her complexion was pale yellow. She also claimed to have regular heart palpitations, shortness of breath, insomnia and a poor appetite. According to TCM differentiation, which of the following formulas should be prescribed?

A. Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction) B. Bā Zhēn Tāng (Eight-Gem Decoction) C. Huáng Qí Guì Zhī Wŭ Wù Tāng (Astragalus and Cinnamon Twig Five Substances Decoction) D. Juān Bì Tāng (Impediment-Alleviating Decoction) E. Má Guì Wēn Jīng Tāng (Ephedra and Cinnamon Twig ChannelWarming Decoction) 5. Ms. Wei reports severe pain in her shoulder for six months with limited range of motion when raising her arm (abduction) or stretching the arm backwards (shoulder extension). The pain is worse at night. Her tongue shows stasis spots along the ridge of the tongue tip, and there is a blue and swollen sublingual vein. The pulse is deep and choppy. Which of the following formulas should be selected? A. Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) B. Juān Bì Tāng (Impediment-Alleviating Decoction) C. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) D. Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction) E. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) Answers

1. A 2. D 3. B 4. C 5. E

16. Brachial Plexus Neuralgia(Arm Pain) ANCIENT THEORIES AND MODERN INSIGHTS Brachial plexus neuralgia refers to pain of different intensities with chronic or acute pain in the shoulders or upper limb, caused by a primary or secondary affection of the nerve root, cord or trunk of the brachial plexus. Brachial plexus comprises the anterior branches of the nerve roots from C5 to T1 and in some cases T2, which provide both sensory and motor innervations in the upper limb. This kind of pain often becomes aggravated at night or with upper limb movement. Brachial plexus neuralgia (hereafter referred to as “arm pain”) is classified into two types, primary or secondary. Clinically, the latter is more common. In Chinese medicine, arm pain falls under the category of “bi syndrome”, with common causes including stagnation of qi and blood due to contraction of external wind, cold and dampness, phlegm and dampness obstructing the channels and collaterals, and stagnation of blood in the channels and collaterals due to trauma. Arm pain is associated closely with the spleen, the kidney, and the three yang channels of the hand.

ETIOLOGY AND PATHOMECHANISMS External Causes Contraction of external wind, cold and dampness leading to pain due to stagnation of qi and blood as well as blockage of the channels and collaterals. Wind, cold and dampness: As a yang-pathogen, pathogenic wind is capable of rapidly penetrating the channels. Riding on the penetrating qualities of wind, cold can concurrently invade the interior, where it tends to constrict and contract. Dampness is a yin-pathogen that tends to heaviness, thus giving rise to pain with a sensation of heaviness. The combination of external wind, cold and dampness are thus inclined to obstruct the channels and collaterals, and with that blockage, pain occurs. Invasion of damp-heat: Pathogenic factors that enter the channels usually stagnate and transform into heat. When this happens, the painful area is swollen, red and perhaps warm to the touch.

Internal Causes Internal causes of arm pain include insufficiency of upright qi or a deficiency of qi and blood which results in pain due to malnourishment; or spleen or kidney weakness creates susceptibility to invasion of wind, cold and dampness which results in stagnation of qi and blood as well as obstruction of the channels and collaterals with pain. Onset of arm pain due to internal deficiency is most closely related to the spleen and kidney.

Spleen deficiency: Deficiency weakens the transformation function of the spleen, resulting in a deficiency of qi and blood which gives rise to pain due to malnourishment. Another pathomechanism is that any dysfunction due to spleen deficiency is inclined to cause internal stagnation of dampness such that when the external and internal dampness combine together, obstruction of channels and collaterals occurs with pain. Kidney deficiency: Deficiency of kidney yang gives rise to pain mainly caused by internal cold. Conversely, constitutional yang hyperactivity or internal heat due to yin deficiency can easily allow for exteriorly-contracted pathogens to transform into heat which leads to pain. Damp-heat: With the spleen deficiency generating dampness and a kidney disharmony causing internal heat, a condition of damp-heat obstructing the channels can arise. Unaddressed dampness can also stagnate and generate heat, even in the absence of heat rising from the kidneys.

Others Causes Trauma or surgical error can also result in pain due to obstruction of the collaterals. In short, upright qi insufficiency is the main internal cause of arm pain, while exteriorly-contracted wind, cold and dampness are the key external causes. Any combination of these conditions can give rise to obstruction of the channels and collaterals, ultimately leading to stagnation of qi and blood and pain.

COMMON CLINICAL PATTERNS The most common clinical patterns are obstruction of wind and dampness, invasion of cold and dampness, obstruction of collaterals due to static blood, invasion of damp-heat, and deficiency of qi and blood.

Pattern Differentiation 1. Differentiation Based on Channel Theory (1) Yangming channel: Pain mainly located in the thumb, the radial side of the forearm, or in the upper arm along the trajectory of the hand yangming channel. (2) Taiyang channel: Pain mainly located in the little finger, the ulnar side of the forearm, or in the upper arm along the trajectory of the taiyang hand channel. (3) Shaoyang channel: Pain mainly located in the middle or ring finger, or along the trajectory of the hand shaoyang through the forearm and upper arm. 2. Differentiation Based on Patterns (1) Obstruction of wind and dampness: Pain in the shoulder and arm with an uncertain location, alternating chills and fever. The tongue has a thin white sometimes greasy coating; the pulse is superficial, slippery, or moderate. (2) Invasion of cold and dampness: Severe pain in the shoulder and arm that is alleviated by warmth and aggravated by cold, limited range of motion, the skin neither red nor warm. The tongue has a thin white or sometimes greasy coating; the pulse is wiry and tight, or slippery and moderate. (3) Obstruction of collaterals due to static blood: Stabbing pain in the shoulder and arm with a fixed location, or swelling and numbness of the

skin and muscles. The tongue is dark; the pulse is wiry and tight. (4) Invasion of damp-heat: Pain in the shoulder and arm with a burning sensation, slightly alleviated by cooling, often accompanied by thirst and fever. The tongue coating is yellow and dry; the pulse is slippery and rapid. (5) Deficiency of blood and qi Signs and symptoms: Continuous low-grade pain in the shoulder and arm, numbness and weakness in the four limbs, aching heavy joints and emaciation. The tongue is pale with a thin white or slightly yellow coating; the pulse is deep and moderately weak. 3. Differentiation Based on Western Medical Theory According to differences in pathogen and location, arm pain involves two types： (1) Nerve root pain of the brachial plexus: Patients with a history of cervical spondylosis or prolapsed intervertebral discs are at greater risk for this kind of arm pain. It may be induced by sprain and strain of the neck muscles, or by an attack of cold. The onset is acute, the course prolonged, and the disease recurrent. The nature of the pain can be dull, stabbing, or burning, and it tends to radiate to the neck, shoulder, arm and fingers. It is worse at night, and intensifies when moving the head and neck, coughing, or sneezing. It is occasionally accompanied by other neurological dysfunction such as numbness and weakness. (2) Nerve trunk pain of the brachial plexus: It is usually initiated by brachial plexus neuritis or thoracic outlet syndrome, with obvious tenderness at the trunks of the brachial plexus triggered when extending or raising the upper limb. The strength of the upper limb on the affected side is weakened, with tendon reflexes active at the early stage. If the sensitive

area is pressed or needled, the finger (of the patient) may feel numbness, stabbing pain, or sharp burning pain, and the ulnar side of the forearm may feel numbness, tingling, cold, or some other abnormal sensation. In some cases, paresthesia is accompanied by movement disorder or other sensory disturbances.

THERAPEUTICS Chinese Medicinals 1. Obstruction of Wind-dampness Formula: Modified Fáng Fēng Tāng (Ledebouriella Decoction) Ingredients: guì zhī (Ramulus Cinnamomi), fáng fēng (Radix Saposhnikoviae), qín jiāo (Radix Gentianae Macrophyllae), qiāng huó (Rhizoma et Radix Notopterygii), dāng guī (Radix Angelicae Sinensis), wēi líng xiān (Radix et Rhizoma Clematidis), shēngmá huáng (Herba Ephedrae Cruda), fáng jĭ (Radix Stephaniae Tetrandrae), sāng zhī (Ramulus Mori), yì yĭ rén (Semen Coicis) 2. Invasion of Cold-dampness Formula: Modified Wū Tóu Tāng (Aconite Main Tuber Decoction) Ingredients: lù lù tōng (Fructus Liquidambaris), shēng huáng qí (raw Radix Astragali), guì zhī, xì xīn (Radix et Rhizoma Asari), zhì chuān wū (Radix Aconiti Praeparata), shēng má huáng, bái sháo (Radix Paeoniae Alba), gān căo (Radix et Rhizoma Glycyrrhizae), jī xuè téng (Caulis Spatholobi), xī xiān căo (Herba Siegesbeckiae) 3. Obstruction of Channels Due to Static Blood Formula: Modified Shēn Tòng Zhú Yū Tāng (Generalized Pain StasisExpelling Decoction) Ingredients: chì sháo (Radix Paeoniae Rubra), chuān xiōng (Rhizoma Chuanxiong), hóng huā (Flos Carthami), táo rén (Semen Persicae), gé gēn

(Radix Puerariae Lobatae), sāng zhī, qiāng huó, xī xiān căo, zhì chuān wū, guì zhī 4. Invasion of Damp-heat Formula: Modified Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) Ingredients: shēng shí gāo (Gypsum Fibrosum), rĕn dōng téng (Caulis Lonicerae Japonicae), zhī mŭ (Rhizoma Anemarrhenae), gān căo, guì zhī, hán shuĭ shí (Glauberitum), zhī zĭ (Fructus Gardeniae), lián qiào (Fructus Forsythiae), sāng zhī 5. Deficiency of Qi and Blood Formula: Modified Qì Xuè Bìng Bŭ Róng Jīn Tāng (Qi and BloodSupplementing Sinew-Nourishing Decoction) Ingredients: fú líng (Poria), sāng zhī, qiāng huó, yì yĭ rén, xī xiān căo, huáng jīng (Rhizoma Polygonati), gŏu jĭ (Rhizoma Cibotii), xù duàn (Radix Dipsaci), bā jĭ tiān (Radix Morindae Officinalis), bái zhú (Rhizoma Atractylodis Macrocephalae), qīng hāo (Herba Artemisiae Annuae) ★ Key Medicinals Guì zhī and sāng zhī are the first and foremost medicinals for pain of the upper limb. Guì zhī is pungent and sweet in flavor, warm in thermal property, and enters the heart, lung and bladder channels. It dispels wind and cold, warms the channels and unblocks the collaterals to relieve pain. Sāng zhī is bitter and neutral, and enters the liver channel. It dispels wind and unblocks the collaterals, and lubricates the joints so as to treat paralysis or pain, especially of the upper limb.

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Points on the yang channels are favored. (2) Of all the yang channels, the taiyang channel is most important, especially the hand taiyang small intestine channel. (3) Points on the yang channels of the hand and foot can be used together. 2. Point Selection According to Location (1) Local and ashi points

● Yangming: LI 17 (tiān dĭng), LI 14 (bì nào), LI 11 (qū chí), LI 10 (shŏu sān lĭ), LI 4 (hégŭ), LU 7 (liè quē)

● Taiyang: SI 15 (jiān zhōng shù), SI 11 (tiān zōng), BL 13 (fèi shù), SI 9 (jiān zhēn), SI 8 (xiăo hăi), SI 7 (zhī zhèng), SI 6 (yăng lăo), SI 3 (hòu xī)

● Shaoyang: GB 20 (fēng chí), SJ 5 (wài guān), SJ 3 (zhōng zhŭ), PC 3 (qū zé), PC 6 (nèiguān), PC 7 (dà líng) (2) Points on lower limbs and back: With deficiency of qi and blood, select ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo), BL 20 (pí shù), and BL 23 (shèn shù). 3. Point Selection Based on Pattern Differentiation (1) Obstruction of wind-dampness

● Taiyang: SI 15 (jiān zhōng shù), SI 11 (tiān zōng), BL 13 (fèi shù) ● Points on neck: GB 20 (fēng chí)

● Points on the three hand yang channels: frequently selected points as mentioned above.

● Additional points to move qi, invigorate blood and disperse wind: BL 12 (fēngmén), BL 17 (gé shù), BL 18 (gān shù) (2) Invasion of cold-dampness: Add BL 23 (shèn shù) and RN 4 (guān yuán) to common points such as SI 15 (jiān zhōng shù), SI 11 (tiān zōng), BL 13 (fèi shù), GB 20 (fēng chí), and points on the three hand yang channels. (3) Deficiency of qi and blood: Add BL 17 (gé shù) and SP 10 (xuè hăi) to SI 15 (jiānzhōng shù), SI 11 (tiān zōng), BL 13 (fèi shù), GB 20 (fēng chí), and points on the three hand yang channels. (4) Invasion of damp-heat: Add DU 14 (dà zhuī) and LI 11 (qū chí) to SI 15 (jiānzhōng shù), SI 11 (tiān zōng), BL 13 (fèi shù), GB 20 (fēng chí), and points on the three hand yang channels. (5) Obstruction of channels due to static blood: Add RN 6 (qì hăi), RN 4 (guānyuán), BL 20 (pí shù), ST 36 (zú sān lĭ) and SP 6 (sān yīn jiāo) to common points such as SI 15 (jiān zhōng shù), SI 11 (tiān zōng), BL 13 (fèi shù), GB 20 (fēng chí), and points on the three hand yang channels. In acupuncture practice, drainage techniques are more commonly used than supplementation methods. For those in severe pain, apply drainage with lifting, thrusting, and rotation. For moderate pain, use the even method. For pain accompanied by a cold sensation or numbness, warmingneedles or moxibustion should be employed to warm the channels. Cutaneous needle-tapping (such as with a seven-star or plum blossom needle) and collateral bleeding are used to treat pain due to heat bi. 4. Treatment According to Channel Differentiation

(1) Yangming channel Point selection: ashi points, LI 17 (tiān dĭng), LI 14 (bì nào), LI 11 (qū chí), LI 10 (shŏusān lĭ), LI 4 (hé gŭ), LU 7 (liè quē) (2) Shaoyang channel Point selection: ashi points, GB 20 (fēng chí), SJ 5 (wài guān), SJ 3 (zhōng zhŭ), PC 3 (qūzé), PC 6 (nèi guān), PC 7 (dà líng) (3) Taiyang channel Point selection: ashi points, SI 15 (jiān zhōng shù), SI 11 (tiān zōng), BL 13 (fèi shù), SI 9 (jiān zhēn), SI 8 (xiăo hăi), SI 7 (zhī zhèng), SI 6 (yăng lăo), SI 3 (hòu xī) Protocol: Needle all points with drainage; the degree of stimulation used depends on the severity of pain. For greater pain, apply greater stimulation with lifting, thrusting, and rotation. 5. Treatment in Accordance with Affected Nerve (1) Nerve root pain of the brachial plexus Point selection: ashi points, GB 20 (fēng chí), SJ 5 (wài guān), SI 15 (jiān zhōng shù), SI 11 (tiān zōng), SI 6 (yăng lăo), SI 3 (hòu xī), LI 10 (shŏu sān lĭ) (2) Nerve trunk pain of the brachial plexus Point selection: ashi points, SJ 5 (wài guān), SI 6 (yăng lăo), SI 3 (hòu xī), LI 10 (shŏusān lĭ), LI 4 (hé gŭ), LU 7 (liè quē) Method: Electro-stimulation is employed after the arrival of qi, with the intensity of stimulation slowly increasing from moderate to intense.

CASE STUDY I Ms. Wu, age 45. Initial Visit: March 20th, 2008 Chief Complaint: Left arm pain for two weeks, worse over the past three days. History: Over the prior two weeks, the patient worked at a computer for long hours. Her main symptoms included aching and distending pain in the right arm, with sore muscles in the forearm and numbness in the thumb. Chinese medicinals, drugs, and physical therapy were all ineffective. Three days ago, the weather changed and she caught a cold which aggravated her pain severely enough to impact her quality of sleep at night. Acupuncture and moxibustion therapy was then suggested. Signs and Symptoms: Aching and distending pain of the right arm, mainly with muscular soreness on the radial side of the forearm and numbness in the thumb. There was obvious tenderness at GB 20 (fēng chí). The patient reported stiffness in the muscles of the right cervical region and trapezius that was relieved by warmth and aggravated by cold. The skin in the affected region was neither red nor warm to the touch. Her tongue was pale with a thin white coating, and her pulse was wiry and tight. Past History: The patient denied having diabetes or hypertension, or any history of infectious diseases such as hepatitis and tuberculosis, or allergies caused by drug and food. The patient did describe a medical history of cervical spondylosis. Menstrual History: Menarche at age 13. Her menstrual cycle averaged 28 to 30 days, with 3 to 5 days of scanty red menses. LMP: March 10th,

2008. Physical Examination: The patient was well-developed and moderately nourished. Bilateral respiratory movements were symmetrical, with resonant percussion sounds. Heart rate was 73 bpm and regular, with no pathological murmur at any valve area. Flat abdomen, liver and spleen were non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Pattern Differentiation According to the presenting signs and symptoms in this case, an internal deficiency of qi and blood was aggravated by overwork, and the channel affected was the yangming large intestine channel. The external cause was wind-cold invasion, an excess pathology leading to obstruction of the channels and collaterals. This case thus shows a complex pattern of mixed deficiency and excess. Diagnosis TCM pattern: Deficiency of qi and blood, invasion of wind-cold Clinical Treatment This case was caused by a qi and blood deficiency due to overwork, which was then complicated by an attack of wind-cold. Correct treatment should dispel wind, disperse cold, nourish blood and unblock the collaterals. Apart from acupuncture and moxibustion, the patient was also advised observe balanced periods of work and rest, and to exercise appropriately during work breaks. Principles: Dispel wind, disperse cold, nourish blood and unblock the collaterals to relieve pain

Formula: Modified Wū Tóu Tāng (Aconite Main Tuber Decoction) [乌头汤加减]

Three doses were prescribed, one dose lasting for two days. [Formula Analysis] Guì zhī and zhì chuān wū dispel wind, disperse cold and warm the channels. Sāng zhī, qiāng huó, xī xiān căo, qín jiāo invigorate blood, dredge stagnation, unblock the channels and relieve numbness. Bái sháo and gān căo relieve spasm and pain. Bái zhú, fú líng, shēng huáng qí and huáng jīng supplement qi and blood to invigorate the sinews.

Acupuncture

Main points: GB 20 (fēng chí), SI 11 (tiān zōng), GB 21 (jiān jĭng) Supplementary points: RN 4 (guān yuán), BL 20 (pí shù), SP 6 (sān yīn jiāo), ST 36 (zúsān lĭ), LI 4 (hé gŭ), LI 11 (qū chí), LI 10 (shŏu sān lĭ) Method: Three main points and four or five supplementary points were selected for each daily treatment. After qi was obtained, all needles were retained for 20-30 min. One course of treatment included ten sessions. Techniques: Warm-needle moxibustion was applied to GB 20 (fēng chí), SI 11 (tiān zōng), GB 21 (jiān jĭng), ST 36 (zú sān lĭ) and SP 6 (sān yīn jiāo), and drainage was applied to LI 4 (hé gŭ), LI 11 (qū chí) and LI 10 (shŏu sān lĭ). Moxibustion and flash cupping were used at BL 20 (pí shù) and RN 4 (guān yuán), with slide cupping applied to the rigid muscles of the neck. Further Consultation After two treatments, the patient felt that her pain was greatly alleviated. Nonetheless, the therapeutic method was continued until three doses of the formula and two courses of acupuncture and moxibustion treatment had been given, after which all pain was resolved.

CASE STUDY II (ACUPUNCTURE, Zheng Kuishan) Mr. Qu, age 28. Chief Complaint: Progressively worsening numbness in the right forearm over 20 days. History: A cold sensation in the right arm was first noticed 20 days ago. Since then, numbness has progressed from the fingers to the forearm. The patient was unable to hold objects. A Western medicine diagnosis of neuritis was made in a hospital where vitamins, electro-stimulation and thermal therapy had little effect. Examination: A red tongue with a white coating, the pulse was wiry and tight. Diagnosis Limb bi syndrome due to cold-dampness obstructing the channels and collaterals Clinical Treatment Principles: Warm and unblock the channels and collaterals, move qi and invigorate blood Points: SI 11 (tiān zōng), LI 11 (qū chí), SJ 5 (wài guān), shí xuān (EX-UE11) Techniques: With the patient in a prone position, SI 11 (tiān zōng) on the affected side was needled first to unblock the channels by conducting the qi sensation to the shoulder and arm. As the needle tip felt impulses and

the patient experienced needling sensation, the needle was rotated for one min to hold the qi. The needling sensation passed from the shoulder joint through the upper limb and all the way to the palm, and a sense of warmth was felt along the channels. The needles were then retained for 20 min. At the same time, LI 11 (qū chí), SJ 5 (wài guān) were manipulated on the affected side with rotation and supplementation. Finally, shí xuān (EXUE11) was bled on the affected side. Further Consultation After one treatment, the patient felt that his pain was greatly alleviated. He was given the same treatment once a day for three days, after which he was recovered. Note Numbness can be caused by obstruction of the channels and collaterals, and stagnation of qi and blood due to cold-dampness in the channels. The small intestine hand taiyang channel runs though the upper limb and controls its functions. SI 11 (tiān zōng) is needled with warming and supplementation techniques to enable channel-qi of the upper limb to move freely. From the perspective of nerves and channels, oblique needling on SI 11 (tiān zōng) toward the armpit to a certain depth would stimulate nerves in this location, regulate their sensitivity, relax the muscles of the upper limb and promote blood circulation, thus improving nutrition (qi and blood) to the nerves and other tissues. LI 11 (qū chí), shí xuān (EX-UE11) and SJ 5 (wài guān) were added to relieve numbness and other localized symptoms, working in concert with SI

11 (tiān zōng). This approach also works very well when applied to other upper limb syndromes of pain, tremors, or spasms.

COMMENTARY AND DISCUSSION Guì zhī (Ramulus Cinnamomi) and sāng zhī (Ramulus Mori) are both key medicinals for treatment of arm pain. It is interesting to note the doctrine of signatures at play with both medicinals, as both represent the “arm” of the tree in their natural function as branches. Herbs that are branches said to have a natural affinity for the “branches” of the human body, which are the arms in this case. When choosing between sāng zhī and guì zhī in the clinic, first consider their properties of cold, hot, warmth, or coolness. Because sāng zhī is neutral, it is best applied for disharmonies or constitutions that are warm or hot in nature, whereas guì zhī is best applied for cases involving cold, or in those patients with cold or cool constitutions. It should be noted that arm pain be as benign as simple pain from an improper sleeping position, or it could serve as a “red flag” symptom that points to a more serious condition such as a stroke or myocardial infarction. As such, the responsible practitioner will rule out these conditions first and refer to an emergency room as needed.

STUDY QUESTIONS 1. In the first case, why was the upper limb pain treated with moxibustion and cupping at BL 20 (pí shù) and RN 4 (guān yuán)? Why was warming-needle moxibustion applied to ST 36 (zú sān lĭ) and SP 6 (sān yīn jiāo)? 2. For the first case, in addition to acupuncture and Chinese medicine, what other measures should be considered? 3. In the first case, which channels were affected? Answers 1. The patient was insufficient in qi and blood due to overwork. Thus, BL 20 (píshù) and RN 4 (guān yuán) were selected for moxibustion and cupping. ST 36 (zú sān lĭ) and SP 6 (sān yīn jiāo) were treated with warmneedle moxibustion so as to nourish qi and blood, supplement blood and invigorate the tendons. Moxibustion immediately followed by cupping tends to invigorate and warm the qi and blood to relieve pain. 2. The causes of this case are complex. Therefore, the pathogenic factor should be first clearly distinguished before treatment. The patient was also advised to take enough time away from the computer to allow for more complete relaxation of the muscles on the affected side of the body. 3. Mostly the yangming large intestine channel, with the taiyang channel of secondary importance.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Ms. Wan, age 53, began to feel pain in her arm and shoulder two days ago. The pain was alleviated by warmth and aggravated by cold. She had difficulty in bending and stretching her arm and shoulder. The tongue coating was thin and whitish, and her pulse was wiry and tight. Which of the following formulas is the best choice? A. Modified Wū Tóu Tāng (Aconite Main Tuber Decoction) B. Modified Qiāng Huó Shèng Shī Tāng (Notopterygium DampnessDrying Decoction) C. Modified Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) D. Modified Fáng Fēng Tāng (Ledebouriella Decoction) E. Modified Yì Yĭ Rén Tāng (Coix Decoction) 2. Mr. Zhang, age 65, felt a stabbing pain in his upper limb that was fixed in location. His tongue was dark, and his pulse was wiry and tight. Which of the following treatment principles are most correct? A. Invigorate blood and dissolve stasis B. Drain dampness and unblock the collaterals

C. Warm cold and dry dampness D. Supplement liver and kidney E. Warm the channels and dissipate cold 3. Ms. Wang, age 58, felt moderate but continuous pain and numbness in the arm and shoulder for the past two months. Accompanying symptoms included weakness in the limbs, and general emaciation. Her tongue was pale with a thin white coating, and her pulse was deep, moderate and deficient. Which of the following patterns best describe the cause of her pain? A. Retention of wind-cold B. Retention of wind-dampness C. Obstruction of turbid phlegm D. Obstruction of damp-heat E. Deficiency of qi and blood 4. Thinking about Ms. Wang as described above, in addition to the main points, which of the following groups of supplementary points could also be employed? A. BL 23 (shèn shù), GB 39 (xuán zhōng), GB 41 (zú lín qì), SP 6 (sān yīn jiāo) B. ST 36 (zú sān lĭ), GB 34 (yáng líng quán), BL 40 (wĕi zhōng), GB 41 (zú lín qì) C. BL 23 (shèn shù), BL 40 (wĕi zhōng), GB 39 (xuán zhōng), GB 41 (zú lín qì)

D. ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo), BL 20 (pí shù), BL 23 (shèn shù) E. ST 36 (zú sān lĭ), GB 39 (xuán zhōng), GB 41 (zú lín qì), BL 40 (wĕi zhōng) 5. Mr. Li, age 58, has cervical spondylosis. After catching a cold, he felt a stabbing pain radiating from his neck into his shoulder, arm and hand. The pain was worse at night or when moving his head and neck. His pain was diagnosed as arising from the root of the brachial plexus. In addition to ashi points, which of the following groups are the main points for his treatment? A. GB 20 (fēng chí), SJ 5 (wài guān), SI 3 (hòu xī), LI 10 (shŏu sān lĭ) B. GB 20 (fēng chí), LU 5 (chĭ zé), LI 10 (shŏu sān lĭ), LI 4 (hé gŭ) C. LU 5 (chĭ zé), LI 15 (jiān yú), SI 3 (hòu xī), LI 4 (hé gŭ) D. SI 7 (zhī zhèng), SJ 10 (tiān jĭng), PC 3 (qū zé), LI 4 (hé gŭ) E. LI 15 (jiān yú), SI 3 (hòu xī), PC 3 (qū zé), LI 4 (hé gŭ) 6. Mr. Liu, age 56, felt pain in his arm and shoulder accompanied by a burning sensation. The pain was relieved slightly by cooling. He also reported fever and thirst. His tongue coating was yellowish and dry, and his pulse was slippery and rapid. In addition to the main points, which of the following groups of supplementary points could be added? A. DU 16 (fēng fŭ), cervical jia ji points (C3-C7) B. GB 20 (fēng chí), LI 4 (hé gŭ) C. DU 14 (dà zhuī), LI 11 (qū chí),

D. SJ 10 (tiān jĭng), PC 3 (qū zé), E. SI 3 (hòu xī), PC 3 (qū zé) 7. Ms. He, age 65, felt pain in her arm and shoulder, mostly in the thumb and radial side of the forearm. In addition to ashi points and the main points, which of the following groups of points could also be applied? A. SJ 5 (wài guān), SI 3 (hòu xī), ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo) B. LI 14 (bì nào), LI 11 (qū chí), LI 10 (shŏu sān lĭ), LU 7 (liè quē) C. SI 7 (zhī zhèng), SJ 10 (tiān jĭng), PC 3 (qū zé), ST 36 (zú sān lĭ) D. SI 7 (zhī zhèng), SJ 10 (tiān jĭng), GB 60 (kūn lún), ST 36 (zú sān lĭ) E. PC 3 (qū zé), LI 4 (hé gŭ), SP 6 (sān yīn jiāo), GB 34 (yáng líng quán) 8. Mrs. Li, age 46, felt pain in her arm and shoulder but was unable to provide an exact location. Now and then, she also suffered from chills and fever. Her tongue coating was thin and white, and her pulse was superficial. Which of the following is the best formula for this case? A. Modified Wū Tóu Tāng (Aconite Main Tuber Decoction) B. Modified Shēn Tòng Zhú Yū Tāng (Generalized Pain StasisExpelling Decoction) C. Modified Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig) D. Modified Fáng Fēng Tāng (Ledebouriella Decoction)

E. Modified Yì Yĭ Rén Tāng (Coix Decoction) Answers 1. A 2. A 3. E 4. D 5. A 6. C 7. B 8. D

17. Lateral Epicondylitis(Elbow Pain) ANCIENT THEORIES AND MODERN INSIGHTS Lateral epicondylitis, commonly called “tennis elbow”, is marked by pain at the lateral aspect of the elbow joint. There is localized tenderness that is aggravated by clenching a fist or by extending and pronating the forearm, but little abnormality is observed in appearance. In TCM, lateral epicondylitis is referred to as “impairment of tendons” or “elbow pain”. In the past, either acupuncture or moxibustion was generally applied to certain acupoints independently. However, a more diversified approach is now employed in that acupuncture, moxibustion, bleeding and cupping are often applied concurrently.

ETIOLOGY AND PATHOMECHANISMS External Causes Cold-dampness: Overstrain, excessive sweating, or disharmony of ying and wei can allow cold-dampness to attack the channels around the elbow, which then obstructs the flow of qi and blood. Static blood: Strenuous activities involving pronation or extension of the forearm can impair the channels and result in blood stasis and stagnation of channel-qi and hence, pain in the elbow.

Internal Causes Accumulation of damp-heat: Damp-heat is accumulated in the spleen, stomach, liver and gallbladder in the middle jiao. Dampness, a turbid and sticky pathogen, blocks qi movement. When integrated with a pathogenic heat, dampness and heat will commingle, resulting in local redness, swelling, heaviness and pain. Deficiency of qi and blood: When qi and blood is insufficient, blood fails to nourish the tendons, leading to elbow pain.

Pattern Differentiation 1. Differentiation Based on Channel Theory Hand yangming channel sinews: Tenderness along the lateral aspect of the elbow joint (around the humeral lateral epicondyle). Hand taiyang channel sinews: Tenderness along the medial aspect of the elbow joint (around the humeral medial epicondyle). Hand shaoyang channel sinews: Tenderness on the ulnar olecranon. 2. Differentiation Based on Patterns Cold-dampness invading the exterior: Diffuse pain alleviated by warmth, aggravated by strain, inability to rotate the elbow or pick up objects. There is a thin white tongue coating; the pulse is floating. Stagnation of qi and blood: History of a strenuous event that precipitated severe stabbing pain that radiates to the forearm and wrist, difficulty in holding or grabbing objects. There is a thin white tongue coating; the pulse is wiry and tight. Accumulation of damp-heat: Redness, swelling, heaviness and pain in the elbow, fever without perspiration or desire to drink. There is a pale tongue with a yellow greasy coating; the pulse is moderate. Deficiency of qi and blood: Elbow pain, inability to grasp objects; also associated with vertigo and dizziness, lethargy and shortness of breath. There is a pale tongue with a scanty coating; the pulse is weak and thready.

THERAPEUTICS Chinese Medicinals 1. External Pathogens Invading the Exterior (1) Cold-dampness Formula: Wū Tóu Tāng (Aconite Main Tuber Decoction) Ingredients: chuān wū (Radix Aconiti), má huáng (Herba Ephedrae), sháo yào (Radix Paeoniae), huáng qí (Radix Astragali), gān căo (Radix et Rhizoma Glycyrrhizae) (2) Stagnation of qi and blood Formula: Fù Yuán Huó Xuè Tāng (Original Qi-Restoring and BloodMoving Decoction) Ingredients: dà huáng (Radix et Rhizoma Rhei) (prepared with wine), chái hú (Radix Bupleuri), táo rén (Semen Persicae), hóng huā (Flos Carthami), dāng guī (Radix Angelicae Sinensis), chuān shān jiă (Squama Manitis), guā lóu gēn (Radix Trichosanthis), gān căo (Radix et Rhizoma Glycyrrhizae) 2. Internal Disharmonies (1) Damp-heat accumulation Formula: Yì Yĭ Rén Tāng (Coix Decoction) Ingredients: yì yĭ rén (Semen Coicis), cāng zhú (Rhizoma Atractylodis), qiāng huó (Rhizoma et Radix Notopterygii), dú huó (Radix Angelicae Pubescentis), má huáng (Herba Ephedrae), guì zhī (Ramulus

Cinnamomi), fáng fēng (Radix Saposhnikoviae), zhì chuān wū (Radix Aconiti Praeparata), dāng guī, chuān xiōng (Rhizoma Chuanxiong), shēng jiāng (Rhizoma Zingiberis Recens), gān căo (2) Deficiency of qi and blood Formula: Bŭ Xuè Róng Jīn Wán (Blood-Supplementing SinewEnhancing Pill) Ingredients: ròu cōng róng (Herba Cistanches), niú xī (Radix Achyranthis Bidentatae), tiān má (Rhizoma Gastrodiae), mù guā (Fructus Chaenomelis), lù róng (Cornu Cervi Pantotrichum), shú dì huáng (Radix Rehmanniae Praeparata), tù sī zĭ (Semen Cuscutae), wŭ wèi zĭ (Fructus Schisandrae Chinensis)

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels The lateral aspect of the elbow is the area dominated by the three yang channels of the hand; thus the main acupoints for this disease are located in the muscles along the three yang channels of the hand. 2. Point Selection According to Location (1) Frequently used local points include:

● Hand yangming channel: LI 11 (qū chí), LI 12 (zhŏu liáo), LI 10 (shŏu sān lĭ), LI 13 (shŏu wŭ lĭ)

● Hand shaoyang channel: SJ 10 (tiān jĭng) ● Hand taiyang channel: SI 8 (xiăo hăi), SI 7 (zhī zhèng), SI 3 (hòu xī) (2) Points on the back: BL 18 (gān shù), BL 23 (shèn shù)

(3) Points on the lower limbs: ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo) 3. Point Selection Based on Pattern Differentiation (1) Cold-dampness: Choose points on the hand yangming channel such as LI 12 (zhŏu liáo) and LI 10 (shŏu sān lĭ) to regulate qi and blood, unblock the channels and quicken the collaterals. LU 5 (chĭ zé), as the hesea point of the hand taiyin channel, acts to dispel cold and eliminate dampness. (2) Stagnation of qi and blood: LU 5 (chĭ zé) and LI 4 (hé gŭ) move qi, dredge the channels and clear heat induced by static blood. (3) Accumulation of damp-heat: ST 40 (fēng lóng), RN 12 (zhōng wăn), ST 44 (nèitíng), SP 6 (sān yīn jiāo), ST 36 (zú sān lĭ), SP 9 (yīn líng quán) harmonize the stomach, fortify the spleen and regulate fluid metabolism. SP 9 (yīn líng quán), as the he-sea point of spleen channel, acts to fortify the spleen to eliminate dampness. (4) Deficiency of qi and blood: BL 18 (gān shù), BL 23 (shèn shù) supplement the liver and kidney, ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo), LI 10 (shŏu sān lĭ) supplement the spleen and stomach. (5) Modifications

● For limited pronation range of motion, add LI 8 (xià lián). ● For limited supination range of motion, add LU 5 (chĭ zé). ● For pain on the medial aspect of the elbow, add HT 3 (shào hăi). ● For pain at the olecranon, add SJ 10 (tiān jĭng).

CASE STUDY I Mr. Cai, age 57. Chief Complaint: Right elbow pain for over one year. History: Right elbow aching pain and discomfort due to his physical work which began more than a year prior; since then his pain has gradually gotten worse. The pain was aggravated by grasping heavy objects and accompanied by limited flexion, extension and pronation of the elbow, with an inability to firmly grasp objects, and tenderness on the elbow. The application of heat relieves pain and improves range of motion. His tongue coating was thin and greasy; the pulse was wiry and thready. Physical Examination: The patient was a lean male, well-developed and appropriately nourished, his skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, resonant percussion sounds (normal). Heart rate was 68 bpm and regular, no pathological murmur at any valve area. Flat abdomen, liver and spleen were non-palpable, no deformity of the spine or four limbs, no redness on the right elbow, obvious tenderness on the lateral epicondyle, no edema in the lower limbs. Auxiliary Examination: X-ray imaging showed no abnormality of the elbow. Pattern Differentiation Main features: the patient had stagnant qi and blood due to strain of the sinews and invasion of wind-cold to the collaterals, as evidenced by how

heat provided some pain relief. His limited pronation range of motion was caused by the impairment of the hand shaoyang channel sinews, the weakness in grabbing and tenderness at the olecranon were induced by qi stagnation in the channels and collaterals, and the wiry and thready pulse with a thin greasy tongue coating indicated wind-cold blocking the channels and collaterals. The main treatment principles here are to diffuse qi, activate blood and dispel cold. The location of the disease was the superficial level of his muscles, and the presenting pattern is predominantly excess in nature. Diagnosis Elbow pain due to wind-cold invasion Clinical Treatment Principles: Diffuse qi and activate blood, dissipate cold Formula: Wū Tóu Tāng (Aconite Main Tuber Decoction) [乌头汤]

[Formula Analysis] Chuān wū and má huáng act as the chief medicinals to warm the channels, dissipate cold, free the collaterals and alleviate pain. Sháo yào and gān căo when used together act to relieve spasm and pain.

Huáng qí boosts qi to consolidate the exterior, benefit the blood and unblock bi.

Acupuncture Main points: LI 11 (qū chí), LI 12 (zhŏu liáo), LI 10 (shŏu sān lĭ), LI 13 (shŏu wŭ lĭ) Method: After qi was obtained, all needles were retained for 20-30 min. One course of treatment consisted of ten sessions. Techniques: The valley union needling was applied to the main points with a twirling drainage technique. After the needles were withdrawn, moxibustion on ginger was employed for three to five cones. Electrostimulation was occasionally used with a dense wave at a frequency of 30 Hz, with intensity as high as the patient could endure.

External Therapy Formula: Yang’s empirical formula for fumigation and washing Ingredients:

[Formula Analysis] Raw xiāng fù rectifies qi and resolve constraint, unblock the channels and relieve pain Wēi líng xiān dispels wind and eliminates dampness, unblocks the collaterals and relieves pain

Tòu gŭ căo dispels wind and eliminates dampness, invigorates blood and relieves swelling and pain Bò he scatters wind and clears heat Usage: Decoct the above herbs with water. Steam and wash the local areas with the warm decoction, 3-4 times daily. Further Consultation After one treatment, the elbow pain improved, and the disease was cured after a total of four treatments. This case was caused by strain of the tendons and invasion of wind-cold in the collaterals, so bò he (Herba Menthae) was also added to scatter and dissipate wind and to stimulate movement of qi. Should the patient complain of a local burning sensation, kŭ shēn (Radix Sophorae Flavescentis) and sāng zhī (Ramulus Mori) could be added to clear heat; in cases of severe pain that refuses to pressure, hóng huā (Flos Carthami) and táo rén (Semen Persicae) could be added to invigorate blood and dissolve stasis; with a local cold sensation, fú píng (Herba Spirodelae) and shēng jiāng (Rhizoma Zingiberis Recens) could be added to dissipate cold. The medicinals used for topical washes should also be chosen in according to the presenting pattern. The formula for fumigation and washing applied in this case is an empirical formula from Dr. Yang, which has showed good effects during his 60 years’ clinical practice.

CASE STUDY II (ACUPUNCTURE, Yang Yongxuan) Ms. Dang, age 32. Chief Complaint: Right elbow pain for six months. History: The patient noticed fatigue and discomfort in her right elbow six months prior. As she continued to work, the pain became gradually worse. By the time of her visit, the pain was accompanied by weakness in grasping objects, and aggravated by clenching her fist or pronating the forearms such as when wringing out a towel. She had limited pronation of the elbow. Her tongue was slightly red with a thin coating, the pulse was thready. Physical Examination: A fixed but sensitive tender point on the humeral articulation. Diagnosis Elbow pain due to qi stagnation and static blood Clinical Treatment Principles: Relax the sinews, quicken the blood, free the collaterals and alleviate pain Points: LI 11 (qū chí), LI 12 (zhŏu liáo), LI 10 (shŏu sān lĭ), LI 13 (shŏu wŭ lĭ), ashi points, LI 8 (xià lián) Techniques: Regular needling was applied to points on the hand yangming channel. Deep needling or tri-edged needling was used on ashi

points. The needles were retained for 20-30 min. Moxibustion or cupping on tender areas was also applicable.

CASE STUDY III Editor’s Case Summary Mr. Grande, age 57. Chief Complaint: Right elbow pain for over one year. History: Right elbow aching pain and discomfort aggravated when playing tennis, which was an important pastime both for the patient’s personal enjoyment as well as business. Physical Examination: The patient was a lean African-Hispanic male, well-developed and appropriately nourished, there was sensitivity to pressure on the right lateral epicondyle. His tongue was red with a thick yellow coating, and the pulse was wiry and excessive. His eyes were bloodshot with a slight yellow film (perhaps an early stage of damp-heat pterygium) with a slight exophthalmia. During the intake consultation, the patient seemed restless and impatient with the many questions that did not directly involve the musculoskeletal system or his elbow. As such, questions devoted to his internal environment were passed over and therapy began instead with acupuncture points local to the effected elbow. Pattern Differentiation Repetitive stresses of tennis playing caused qi and blood stagnation in the channels and collaterals. While the patient’s signs and symptoms also supported a damp-heat and diagnosis as indicative of his internal disharmony, the fact that playing tennis was the only aggravating factor for his pain pointed to qi and blood stagnation more than the damp-heat.

Still, many of his signs and symptoms pointed to damp-heat in the liver including the slight exophthalmia, yellow film over sclera (suggesting damp-heat), restlessness and impatience; red tongue body with a thick yellow tongue coating; and an excessive (wide, forceful and long) pulse that was also wiry. Diagnosis TCM pattern: Qi and blood stagnation superficially with damp-heat in the liver internally Clinical Treatment Principles: Diffuse qi and activate blood, dry dampness and clear heat from the liver Formula: Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction)

Acupuncture Main points: LI 11 (qū chí), LI 12 (zhŏu liáo), LI 10 (shŏu sān lĭ), LI 13 (shŏu wŭ lĭ) Method: After qi was obtained, the needles were retained for 20-30 min. Further Consultation After one weekly treatment, the elbow pain improved for a day. After two weekly treatments, the pain improved for three days, and after four weekly treatments, the pain had abated such that he could play tennis painfree. The herbal treatment of his damp-heat in the liver was terminated when his elbow pain went away.

Follow-up ten years later: the next time I had the opportunity to work with the patient, he was under the care of an attendant and confined to a wheelchair due to a stroke that he had suffered six months prior. He had a bleeding type stroke roughly in his motor cortex on the right side. He had been outfitted with stent from the right side motor cortex area to his jugular vein. Treatment employed scalp acupuncture and herbs. Again, his signs and symptoms pointed to the use of Lóng Dăn Xiè Gān Tāng, and this formula was prescribed. He came in for another four scalp acupuncture treatments favoring the motor line on the right side (skipping over the area dominated by the stent to prevent damaging this device). Six months after a stroke is a bit late to take on scalp acupuncture therapy, but there was little else for the patient to do and so we tried four treatments with little improvement to his condition. While an intervention with no improvement doesn’t make for a very inspiring case study, I bring it up to recognize how his damp-heat and liver yang rising condition was discovered while being treated ten years prior for his “tennis elbow”. He didn’t see the need for internal medicine and so the herbal medicines were not taken for a long enough time to see improvement. The key issue here is that liver yang rising was very likely the cause of his stroke. If he had taken the Lóng Dăn Xiè Gān Tāng until that liver yang rising and damp-heat in the liver had been cleared, perhaps he wouldn’t have had his stroke ten years later. While Lóng Dăn Xiè Gān Tāng is considered a formula to clear damp-heat from the liver, the king herb and some of the assistants are defined as effective for liver yang rising such as lóng dăn căo (Radix et Rhizoma Gentianae).

It is impossible for me to know for sure if taking his herbs would have prevented his stroke, but it is a very intriguing thought that ten years prior to his stroke, the underlying cause was already manifesting in his medical presentation.

COMMENTARY AND DISUSSION In Case Study I, the inclusion of má huáng (Herba Ephedrae) in Wū Tóu Tāng (Aconite Main Tuber Decoction) is an interesting non-wheezing application of this medicinal. Its use in this formula remains for wind-cold as in the functions of Má HuángTāng (Ephedra Decoction) but not so much to treat the lung-organ, rather it is employed to effect the superficial layers where pathogenic factors can enter the body. Rather than being used for asthma or wheezing, its pungent-dispersing nature is applied here to treat wind-cold attacking the channels and collaterals. It would be more easy to explain this function of má huáng as applied to lateral epicondylitis if it were considered to be a lung or bladder channel pathology; however, because both of these channels have an intimate relationship with the skin over the entire body, má huáng has beneficial effects in releasing the exterior in cases of musculoskeletal pain due to wind-cold.

STUDY QUESTIONS 1. In the first case, apart from combination therapy of acupuncture and Chinese medicinals, what advice can be given help the patient heal more quickly? 2. Combined with the basic points, which of the following could be used to treat limited supination due to lateral epicondylitis? A. LI 8 (xià lián) B. HT 3 (shào hăi) C. LU 5 (chĭ zé) D. SJ 10 (tiān jĭng) E. Ashi points 3. Combined with the basic points, which of the following points could be used to treat the limited pronation due to lateral epicondylitis? A. LI 8 (xià lián) B. HT 3 (shào hăi) C. LU 5 (chĭ zé) D. SJ 10 (tiān jĭng) E. Ashi points 4. Combined with the basic points, which of the following points could be used to treat the pain on the medial side of forearm due to lateral epicondylitis?

A. LI 8 (xià lián) B. HT 3 (shào hăi) C. LU 5 (chĭ zé) D. SJ 10 (tiān jĭng) E. Ashi points 5. Combined with the basic points, which of the following points could be used to treat the pain at the tip of the olecranon due to lateral epicondylitis? A. LI 8 (xià lián) B. HT 3 (shào hăi) C. LU 5 (chĭ zé) D. SJ 10 (tiān jĭng) E. Ashi points 6. Which of the following are not among the basic points to treat lateral epicondylitis? A. LI 11 (qū chí) B. LI 12 (zhŏu liáo) C. LI 10 (shŏu sān lĭ) D.LI 13 (shŏu wŭ lĭ) E. PC 6 (nèi guān) Answers

1. Over the course of treatment, avoid drastic exertion of the elbow. In case of another acute attack, learn to use the elbow joint gently and carefully. In case of a long course of this disease, tui na massage combined with some movement therapies should be employed for rehabilitation. The patient should also keep the elbow area warm and protected from wind or cold. 2. C 3. A 4. B 5. D 6. E

SECTION IV Pain of the Chest and Abdomen 18. Chest Bi and Heart Pain ANCIENT THEORIES AND MODERN INSIGHTS Chest bi and heart pain is a condition primarily characterized by pain over the left side of the patient’s chest or around RN 17 (dàn zhōng) caused by a spasm or obstruction of the heart vessel. In mild cases, chest bi manifests as a feeling of pressure in the chest with slightly difficult breathing as if choking. In severe cases that are called “heart pain”, the patient will present with a sudden pain that feels like pricking, burning, or twisting in the chest; the pain is accompanied by a pale complexion, profuse sweating and cold extremities. Acupuncture and moxibustion treatment focuses on promoting the flow of qi, unblocking yang, dispelling blood stasis and stopping pain. Both acupuncture and moxibustion are used with both drainage and supplementation methods, as appropriate to the patient’s constitution. This disease generally presents as a deficiency pattern with excess branch manifestations.

Based on its clinical characteristics, this disease is closely related to coronary heart disease and angina pectoris in Western medicine. The term “heart vessel” comes up frequently in this chapter, and while this is a TCM term, it is reasonable to apply this to the biomedical term “coronary artery” or other arteries that nourish the myocardium.

ETIOLOGY AND PATHOMECHANISMS Internal cold: Constitutional yang deficiency gives rise to an invasion of pathogenic cold, which congeals internally and causes qi stagnation, obstruction of chest yang and the development of chest bi. Improper diet: Improper diet such as excessive consumption of fatty or sweet foods injures the spleen and stomach, which leads to a failure of transportation and transformation where internal dampness is created and phlegm is produced. Dampness and phlegm then attack upward and affect the clear area of the chest and heart. As they impede and obstruct the heart yang, the chest yang fails to spread, the flow of qi is impeded, and the heart vessel becomes obstructed. Emotional stress: Worry and over-thinking impairs the spleen leading to a failure of transportation and transformation that leads to body fluids congealing into phlegm, while depression and anger injure the liver to cause stagnation of liver qi which can transform into fire. Fire scorches the body fluids, which transforms them into phlegm. Both phlegm obstruction and qi stagnation can impair blood flow and cause obstructions in the channels and collaterals; qi stagnation with blood stasis or phlegm obstruction with blood stasis then results in the stagnation of chest yang. Mental overstrain impairing the spleen: Excess mental strain impairs the spleen and leads to transportation and transformation failure that affects the spleen’s ability to produce qi and blood; the heart vessel is thus deprived of nourishment, leading to spasms and pain. Deficiency due to aging: This pattern is obviously seen in the elderly where kidney qi, essence and blood have gradually declined. When kidney

yang is deficient, it is unable to activate and warm the five zang organs, leading to insufficient heart qi or inactive heart yang. The heart vessel is deprived of warmth and become obstructed, thus chest bi develops. The etiology and pathomechanisms of this disease were summarized in GoldenMirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴), which states that chest bi arises from yang insufficiency with yin abundance. In other words, there is insufficiency of yang qi in the upper jiao and yin-cold in the lower jiao; such patterns are characterized by root deficiency with excess manifestations as the branch.

COMMON CLINICAL PATTERNS Patterns frequently encountered in clinic include: heart blood stagnation, qi stagnation in the chest, obstruction of phlegm-turbidity, cold congealing in the heart vessel, deficiency of both qi and yin, yin deficiency of both heart and kidney, and yang deficiency of both heart and kidney. Heart blood stagnation: Sporadic pain in the heart or chest which feels as if something is being pricked or twisted. It is fixed in location, worse at night and accompanied by chest tightness and palpitations. There is a dark lusterless complexion with a purple or dark tongue, possibly with purple spots and blue or purple vessels beneath. The pulse is deep, choppy or knotted. Qi stagnation in the chest: Frequent sighing, pain is easily triggered or aggravated by emotional stress and alleviated by belching or passing gas. The tongue coating is thin or thin and greasy, and the pulse is thready and/or wiry. Obstruction of phlegm-turbidity: Chest oppression or a sensation of pressure on the chest, shortness of breath and panting, heavy sensations in the extremities, a full sensation of fullness in the epigastric area, profuse sputum, and a sticky feeling in the mouth. The patient is often overweight with a turbid greasy tongue coating and a slippery pulse. Cold congealing in the heart vessel: Sudden heart pain that feels like something is being twisted. The pain refers to the back and is accompanied by shortness of breath, inability to lie flat, and intolerance to cold. There is a white tongue coating, and a deep and tight or deep thready pulse.

Deficiency of qi and yin: Dull pain in the heart and chest, palpitations, and shortness of breath accompanied by fatigue, a soft voice, a bright pale complexion, and frequently induced sweating. The tongue is slightly red, and the pulse is deficient, thready, moderate or knotted. Heart and kidney yin deficiency: Dull pain in the heart and chest that is chronic and hard to cure with palpitations, night sweats, irritability, insomnia, soreness and weakness in the lower back and knees, tinnitus, dizziness, shortness of breath, and fatigue. The tongue is red with scanty coating, and the pulse is rapid and thready. Heart and kidney yang deficiency: Chest oppression, shortness of breath, pain aggravated by exposure to cold, heart pain that refers to the back, intolerance of cold, cold extremities, panting with exertion, palpitations, sweating, inability to lie flat, soreness in the lower back, fatigue, a puffy face, and edema in legs. The tongue is pale and swollen with a white coating, and the pulse is deep and thready or faint and barely perceptible.

THERAPEUTICS Chinese Medicinals 1. Heart Blood Stagnation Formula: Modified Xuè Fŭ Zhú Yū Tāng (Blood Mansion StasisExpelling Decoction) Ingredients: dāng guī (Radix Angelicae Sinensis), shēng dì (Radix Rehmanniae), táo rén (Semen Persicae), hóng huā (Flos Carthami), zhĭ qiào (Fructus Aurantii), chìsháo (Radix Paeoniae Rubra), gān căo (Radix et Rhizoma Glycyrrhizae), chái hú (Radix Bupleuri), chuān xiōng (Rhizoma Chuanxiong), jié gĕng (Radix Platycodonis), niú xī (Radix Achyranthis Bidentatae) 2. Qi Stagnation in the Chest Formula: Modified Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder) Ingredients: chái hú, chén pí (Pericarpium Citri Reticulatae), chuān xiōng, zhĭ qiào, chì sháo, gān căo, xiāng fù (Rhizoma Cyperi) 3. Phlegm-turbidity Obstruction Formula: Modified Guā Lóu Xiè Bái Bàn Xià Tāng (Trichosanthes, Chinese Chive and Pinellia Decoction) and Dí Tán Tāng (Phlegm-Flushing Decoction) Ingredients: guā lóu (Fructus Trichosanthis), xiè bái (Bulbus Allii Macrostemi), bànxià (Rhizoma Pinelliae), dăn nán xīng (Arisaema cum

Bile), zhú rú (Caulis Bambusae in Taenia), rén shēn (Radix et Rhizoma Ginseng), fú líng (Poria), gān căo, shí chāng pú (Rhizoma Acori Tatarinowii), chén pí, zhĭ shí (Fructus Aurantii Immaturus) 4. Cold Congealing in the Heart Vessel Formula: Modified Zhĭ Shí Xiè Bái Guì Zhī Tāng (Immature Bitter Orange, Chinese Chive and Cinnamon Twig Decoction) and Dāng Guī Sì Nì Tāng (Chinese Angelica Frigid Extremities Decoction) Ingredients: guì zhī (Ramulus Cinnamomi), xì xīn (Radix et Rhizoma Asari), xièbái, guā lóu, dāng guī (Radix Angelicae Sinensis), sháo yào (Radix Paeoniae), gān căo, zhĭshí, hòu pò (Cortex Magnoliae Officinalis), dà zăo (Fructus Jujubae) 5. Deficiency of Qi and Yin Formula: Modified Shēng Mài Săn (Pulse-Engendering Powder) and Rén Shēn YăngRóng Tāng (Ginseng Supporting and Nourishing Decoction) Ingredients: rén shēn (Radix et Rhizoma Ginseng), huáng qí (Radix Astragali), gāncăo, ròu guì (Cortex Cinnamomi), mài dōng (Radix Ophiopogonis), yù zhú (Rhizoma Polygonati Odorati), wŭ wèi zĭ (Fructus Schisandrae Chinensis), dān shēn (Radix et Rhizoma Salviae Miltiorrhizae), dāng guī 6. Heart and Kidney Yin Deficiency Formula: Modified Tiān Wáng Bŭ Xīn Dān (Celestial Emperor HeartSupplementing Elixir) and Zhì Gān Căo Tāng (Honey-Fried Licorice Decoction) Ingredients: shēng dì (Radix Rehmanniae), xuán shēn (Radix Scrophulariae), màidōng, tiān dōng (Radix Asparagi), rén shēn, zhì gān căo

(Radix et Rhizoma Glycyrrhizae Praeparata cum Melle), fú líng, băi zĭ rén (Semen Platycladi), suān zăo rén (Semen Ziziphi Spinosae), wŭ wèi zĭ, yuăn zhì (Radix Polygalae), dān shēn, dāng guī, sháo yào, ējiāo (Colla Corii Asini) 7. Heart and Kidney Yang Deficiency Formula: Modified Shēn Fù Tāng (Ginseng and Aconite Decoction) and Yòu GuīYĭn (Right-Restoring Beverage) Ingredients: rén shēn, fù zĭ (Radix Aconiti Lateralis Praeparata), ròu guì, zhì gān căo, shú dì (Radix Rehmanniae Praeparata), shān zhū yú (Fructus Corni), xiān líng pí (Herba Epimedii), bŭ gŭ zhī (Fructus Psoraleae)

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels Hand jueyin and hand shaoyin channel points such as PC 6 (nèi guān), HT 6 (yīn xì), PC 4 (xì mén), and RN 17 (dàn zhōng) 2. Point Selection Based on Pattern Differentiation (1) Qi stagnation and blood stasis: LV 3 (tài chōng), SP 10 (xuè hăi) (2) Cold congealing: RN 8 (shén què), DU 9 (zhì yáng) (3) Turbid phlegm obstructing the collaterals: ST 40 (fēng lóng), RN 12 (zhōng wăn) (4) Yang qi deficiency: BL 15 (xīn shù), DU 9 (zhì yáng) Techniques: Apply transverse insertion at RN 17 (dàn zhōng) pointing downward toward the naval, and regular needling at other points. Electro-

stimulation is applicable, and moxibustion can be used for cases of cold congealing or yang qi deficiency. Acupoint Injection: PC 6 (nèi guān), PC 4 (xì mén), BL 15 (xīn shù), BL 14 (jué yīnshù), ST 36 (zú sān lĭ). Select two points and administer Fù Fāng Dān Shēn Zhù ShùYè (Compound Danshen Injection) or Chuān Xiōng Qíng Zhù Shù Yè (Ligustrazine Injection), 0.5-1 ml per point.

CASE STUDY I Mr. Zhang, age 65. Initial Visit: December 15th, 2006 Chief Complaint: Brief, sporadic pain in the left chest that attacked repeatedly for four years, aggravated for one month and accompanied by shortness of breath. History: The patient had pain in the left chest after over-exerting himself four years prior. The pain was sporadic, usually lasting for several seconds to a couple of minutes; rest or sublingual nitroglycerine could provide relief. He was diagnosed with angina pectoris after an ECG and pertinent exams in the hospital. During the most recent month, the pain returned again because of over-exertion. The chest pain attacked frequently and was worsened or triggered four to five times a day by increasingly milder movements. The attacks were accompanied by shortness of breath, panting and an inability to lie flat. Signs and Symptoms: An oppressive sensation and pain in the heart area that felt like choking and referred to the back with shortness of breath, fatigue, heavy limbs, dizziness, thirst with a desire to drink, and disturbed sleep. Urination and bowel movements were normal. The tongue was dark purple with a greasy white slippery coating, and the pulse was slippery. Past History: Hyperlipidemia for 12 years, overweight, smoked a pack of cigarettes each day for 30 years. Physical Examination: BP 120/80 mmHg, overweight, unable to lay flat, distended jugular vein, respiratory sounds in both lungs were clear with no rales heard, the heart area was not enlarged, heart rate was 90 bpm and

irregular, with no pathological murmur at any valve area. Liver and spleen were non-palpable, and no edema was observed in the lower limbs. Laboratory Examination: Blood Lipid: TG 7.8 mmol/L, CHOL 12.6 mmol/L, HDL 3.6 mmol/L. ECG: ST segment depression and flat T-waves in leads II, III and aVF. Pattern Differentiation The main features of the patient include obesity, a history of hyperlipidemia, and sporadic pain in the left chest induced by over-exertion for four years, aggravated over the past month and accompanied by shortness of breath. The chest pain was attacking more frequently with the pain increasing. The patient was obese and qi deficient. The spleen qi was deficient and thus failed to transport and transform, leading to phlegm-turbidity accumulation. Phlegm-turbidity obstructed the heart vessel, chest yang failed to spread, and flow of qi was not free, so chest oppression and pain that felt like choking occurred. The heart channel and its branch run to both shoulders and travel though the back-shu points, so as phlegm-turbidity accumulated and obstructed the heart channel, the pain thus referred to the back. Obstruction of the spleen by phlegm-turbidity with failure in transporting and transforming led to the sensation of heaviness in the limbs. Qi deficiency of the heart and spleen deprived the spirit of nourishment, so shortness of breath and fatigue were experienced. Spleen qi was deficient and phlegm-turbidity was accumulated, thus there presented a dark purple tongue with a greasy white slippery coating, and a slippery pulse. The disease location in this case was the heart and spleen, and the presenting pattern was qi deficiency leading to phlegm-turbidity. The root

condition was deficient in nature, but the branch manifestations were excess. Diagnosis TCM pattern: Qi deficiency of heart and spleen with phlegm-turbidity obstruction Clinical Treatment The root was deficiency, and the branch manifestations were excess. The branch pathomechanism was obstruction of the heart vessel from phlegm-turbidity, failure of chest yang to spread, and impediment of qi flow. According to the treatment principle, “in urgent conditions, treat the branch”, treatment should first focus on the phlegm-turbidity. After the excess manifestation was removed, the root deficiency was addressed. Lipid-lowering medication was combined with anti-angina pectoris treatments during acute attacks. Principles: Eliminate phlegm, direct turbidity downward, spread the chest qi and dissipate binds Formula: Guā Lóu Xiè Bái Bàn Xià Tāng (Trichosanthes, Chinese Chive and Pinellia Decoction) [瓜蒌薤⽩半夏汤]

Three doses. One decocted dose a day. [Formula Analysis] Guā lóu soothe the chest, dissipates binds and resolves phlegm. Xiè bái is pungent and warm, unblocks yang, dissipates binds, resolves phlegm and descends qi, and bàn xià resolves phlegm and descends rebellious qi. Guā Lóu Xiè Bái Bàn Xià Tāng is a main treatment formula for chest bi due to phlegm-turbidity obstruction. Táo rén, hóng huā, chuān xiōng, dān shēn and yù jīn were added to invigorate blood, resolve blood stasis and unblock the collaterals. Chén pí, and fú líng strengthen the spleen, resolve phlegm and unblock the collaterals. Pungent and warm guì zhī unblocks chest yang and quickens the collaterals.

Acupuncture

Main points: PC 6 (nèi guān), RN 17 (dàn zhōng), BL 15 (xīn shù), BL 14 (jué yīn shù), HT 7 (shén mén) Supplementary points: PC 5 (jiān shĭ), PC 4 (xì mén), ST 18 (rŭ gēn), LI 11 (qū chí), LV 3 (tài chōng), SP 6 (sān yīn jiāo), ST 40 (fēng lóng), ST 36 (zú sān lĭ) Method: Two main points and two or three supplementary points were selected for each daily treatment, and alternated every other day. After qi was obtained, the needles were retained for 20-30 min. One course of treatment lasted 10 days. Techniques: Drainage technique was applied during attacks of chest pain, and the even method at other times. Further Consultation After two weeks of treatment, the attacks were reduced to 1-2 times per day, the chest pain and shortness of breath were relieved significantly, and tolerance to activity was increased. At the time of the current review, the patient had chest oppression and dull pain that came and went, palpitations, irritability, fatigue, shortness of breath, occasional dizziness, dry mouth, a red tongue with a greasy yellow coating, and a deep slippery pulse. As the therapy progressed, the chest pain was relieved, which indicated that the excess branch had been relieved, but root deficiency of qi and yin persisted. The remaining branch manifestations mainly involved phlegm-heat. Principles: Supplement qi, nourish yin, clear heat and resolve phlegm

Formula: Shēng Mài Săn (Pulse-Engendering Powder) and Wēn Dăn Tāng (Gallbladder-Warming Decoction) [⽣脉散合温胆汤]

[Formula Analysis] Rén shēn, huáng qí, and bái zhú strengthen the spleen and supplement qi to aid the source of transformation and transportation and to augment heart qi. Mài dōng and shā shēn nourish yin and supplement blood thus “adding water to move the boat” in order to unblock the heart channel. Zhĭ shí, zhú rú, bàn xià and chén pí clear heat, resolve phlegm and unblock the collaterals.

CASE STUDY II (ACUPUNCTURE, Jin Bo-hua) Mrs. Wang, age 46. Chief Complaint: Chest oppression and shortness of breath for more than six months. History: Chest oppression, shortness of breath and sporadic prickling pain in the left chest area after she got angry with family member six months prior. An insufficient flow of blood to the coronary artery was diagnosed. The condition was addressed with both Chinese medicinal and Western drug treatment. Other signs and symptoms that had arisen included palpitations, lassitude, fatigue, a bright pale complexion, cold extremities, intolerance to cold, spontaneous sweating, frequent heart pain, profuse urination, and loose stools. The tongue was pale tongue with a white coating; the pulse was deep, moderate, knotted, and intermittent. Diagnosis Chest bi due to inactive chest yang, blockage of the heart vessel Clinical Treatment Principles: Warm and supplement heart yang, unblock the heart vessel and invigorate blood Points: RN 17 (dàn zhōng), RN 15 (jiū wĕi), RN 12 (zhōng wăn), PC 6 (nèi guān), HT 5 (tōng lĭ), ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo) Method: Needle ST 36 (zú sān lĭ) and SP 6 (sān yīn jiāo) with supplementation, drainage at RN 17 (dàn zhōng) and RN 15 (jiū wĕi), and the even method at all other points.

Note RN 17 (dàn zhōng) and RN 15 (jiū wĕi) move qi, invigorate blood, soothe the chest unblock the collaterals, and invigorate the heart yang. PC 6 (nèi guān) and HT 5 (tōnglĭ) invigorate blood, unblock the collaterals and stop pain. The patient was weak for a long time, presenting manifestations of qi and blood deficiency with splenic failure of transformation, so RN 12 (zhōng wăn) and ST 36 (zú sān lĭ) were selected to supplement qi and blood and to regulate the spleen and stomach. SP 6 (sān yīn jiāo) aids in invigorating blood and resolving blood stasis.

COMMENTARY AND DISCUSSION This chapter addresses many different causes for pain in the chest, and does not assume a life-threatening condition like the “true heart pain” as discussed in the chapter on angina pectoris. However, some chest bi patterns can ultimately give rise to the more dangerous “true heart pain”. In either case, practitioners are encouraged to operate within their scope of practice, within their comfort level, and with the welfare of the patient first and foremost in mind. In some cases, this may include a referral to a cardiologist or emergency room. Be honest with yourself and your patients. In the West, some providers and patients harbor an anti-modern medicine prejudice that can get in the way of providing your patients with the care they need when they need it, no matter where it is provided.

STUDY QUESTIONS 1. What is the prognosis of the first case? 2. In the first case, what were the manifestations of qi and yin deficiency at the follow-up? 3. What cautions should be taken regarding nursing in the first case? Answers 1. This case presented a disease with a relatively long course which tended to attack repeatedly; the condition had been aggravated in the most recent month, indicating further development that could lead to more severe heart vessel blockage. Severe complications such as myocardial infarction or heart failure may occur, so caution should be taken. 2. Qi deficiency was indicated by such manifestations as panting, fatigue, shortness of breath, palpitations, dizziness, chest oppression and a dull pain; yin deficiency was indicated by palpitations, irritability, dry mouth, and a red tongue. 3. Heart pain is often induced by excessive eating, mood swings, exposure to cold, overwork, over-exertion, etc. Thus the patient with chest bi and heart pain should watch their diet and mainly consume light, easily digestible foods while avoiding fatty, sweet, and salty foods. They shouldn’t eat large meals, but rather have frequent light meals. Clothes should be changed according to weather changes, especially to avoid cold exposure. The patient should avoid emotional excesses of rage, joy or sadness and avoid mood swings, remain optimistic, balance work and rest, exercise moderately, and avoid overwork or exertion. Heart pain can be induced by

exertion during defecation in patients with constipation, so caution should be taken. During an attack of heart pain, one should stay calm and take rest immediately.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mr. Liu, age 65, reports repeated attacks of chest pain for two months. Now, he has severe heart and chest pain that feels as if he was being pricked or twisted. The pain is fixed in location, worse at night, and lasts for about 10 min each time. The heart pain refers to the back and shoulder, and is accompanied by chest oppression without ever feeling completely relieved over the past two months. The condition was aggravated by anger. He has a purple tongue with purple spots and enlarged purple vessels beneath, and a thin coating. The pulse is choppy. Which of the following formulas would you choose first? A. Guā Lóu Xiè Bái Bàn Xià Tāng (Trichosanthes, Chinese Chive and Pinellia Decoction) B. Shēn Fù Tāng (Ginseng and Aconite Decoction) and Yòu Guī Yĭn (Right-Restoring Beverage) C. Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) D. Tiān Wáng Bŭ Xīn Dān Tāng (Celestial Emperor HeartSupplementing Elixir) E. Guā Lóu Xiè Bái Bái Jiŭ Tāng (Trichosanthes, Chinese Chive and White Wine Decoction)

2. Mr. Zhang, age 63, reports repeated attacks of chest oppression and pain for over five years. Now, he has frequent attacks of heart and chest pain, burning pain or oppressive pain, palpitations, five-center heat, dry mouth, night sweats, tidal fever sensation in the face. There is a dry red tongue with a scanty coating, and an intermittent thready pulse. Which of the following formulas would you choose first? A. Shēng Mài Săn (Pulse-Engendering Powder) B. Tiān Wáng Bŭ Xīn Dān (Celestial Emperor Heart-Supplementing Elixir) C. Rén Shēn Yăng Róng Tāng (Ginseng Supporting and Nourishing Decoction) D. Yòu Guī Yĭn (Right-Restoring Beverage) E. Shēn Fù Tāng (Ginseng and Aconite Decoction) 3. Ms. Li, age 61, reports an oppressive and heavy sensation in the chest with slight heart pain over the past two weeks. Other indications include obesity, sensations of heaviness in the body, profuse sputum, shortness of breath triggered or aggravated by cloudy or rainy weather, fatigue, poor appetite, loose stools, a sticky sensation in the mouth, nausea, and spitting up sputum. There is a greasy white tongue coating, and the pulse is slippery. Which of the following formulas would you choose first? A. Guā Lóu Xiè Bái Bàn Xià Tāng (Trichosanthes, Chinese Chive and Pinellia Decoction) B. Zhĭ Shí Xiè Bái Guì Zhī Tāng (Immature Bitter Orange, Chinese Chive and Cinnamon Twig Decoction)

C. Guā Lóu Xiè Bái Bái Jiŭ Tāng (Trichosanthes, Chinese Chive and White Wine Decoction) D. Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) E. Rén Shēn Yăng Róng Tāng (Ginseng Supporting and Nourishing Decoction) 4. Mr. Wu, age 71, reported severe left chest pain that had lasted for three hours and radiated to the left shoulder. It was induced by overwork and accompanied by palpitations, shortness of breath, spontaneous sweating worsened by exertion, lassitude, intolerance to cold, a pale complexion, cold extremities, and edema. He has a pale swollen tongue with a greasy coating, and the pulse is deep, thready and slow. Which of the following are the best principles of treatment for this case? A. Supplement qi and warm yang, invigorate blood and unblock the collaterals B. Spread and unblock chest yang, dissipate cold and resolve turbidity C. Supplement heart qi, invigorate blood and resolve blood stasis D. Supplement qi and nourish yin, invigorate blood and resolve blood stasis E. Unblock yang and drain turbidity, resolve phlegm and dissipate binds 5. Ms. Liu, age 58, presents with repeated attacks of chest oppression and pain for two years. Over the past week, there has also been some slight heart pain. She presents with obesity, sensations of heaviness throughout the whole body, profuse sputum, shortness of breath, fatigue, poor appetite,

loose stools, a sticky sensation in the mouth, nausea, and spitting of sputum. There is a slippery white tongue coating, and the pulse is slippery. Which of the following are the best principles of treatment for this case? A. Unblock yang with warm-pungent medicinals, open bi and dissipate cold B. Regulate qi, invigorate blood, unblock the collaterals and stop pain C. Unblock yang, drain turbidity, resolve phlegm and dissipate binds D. Clear the lung, resolve phlegm, regulate qi and stop pain E. Supplement heart and spleen, unblock yang and stop pain 6. Ms. Wu, age 64, presents with chest oppression, shortness of breath, palpitations and pain, spontaneous sweating aggravated by exertion, lassitude, intolerance to cold, pale complexion, cold extremities, and edema. His tongue is pale and swollen with a greasy coating, and the pulse is thready, deep and slow. Which of the following formulas would you choose first? A. Guā Lóu Xiè Bái Bàn Xià Tāng (Trichosanthes, Chinese Chive and Pinellia Decoction) B. Shēn Fù Tāng (Ginseng and Aconite Decoction) C. Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder) D. Shēng Mài Săn (Pulse-Engendering Powder) E. Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) 7. Ms. Yang, age 54, complains of periodic chest oppression and dull pain over the past two weeks. Other indications include palpitations,

shortness of breath, fatigue, a lusterless complexion, dizziness, symptoms aggravated by fatigue. The tongue is red, and the pulse is knotted and intermittent. Which of the following formulas would you choose first? A. Zuŏ Guī Yĭn (Left-Restoring Beverage) B. Shēn Fù Tāng (Ginseng and Aconite Decoction) C. Yòu Guī Yĭn (Right-Restoring Beverage) D. Shēng Mài Săn (Pulse-Engendering Powder) and Rén Shēn Yăng Róng Tāng (Ginseng Supporting and Nourishing Decoction) E. Guā Lóu Xiè Bái Bàn Xià Tāng (Trichosanthes, Chinese Chive and Pinellia Decoction) and Dān Shēn Yĭn (Salvia Beverage) 8. Mr. He presents with chronic chest bi, palpitations, shortness of breath, and an inability to lie flat; his symptoms are aggravated by exertion. There is also edema of the extremities, intolerance to cold, cold limbs, and scanty urine. The tongue is pale with a white slippery coating, and the pulse is deep and thready. Which of the following formulas would you choose first? A. Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) B. Yòu Guī Yĭn (Right-Restoring Beverage) C. Zuŏ Guī Yĭn (Left-Restoring Beverage) D. Shēng Mài Săn (Pulse-Engendering Powder) E. Zhēn Wŭ Tāng (True Warrior Decoction) Answers

1. C 2. B 3. A 4. A 5. C 6. B 7. D 8. E

19. Angina Pectoris ANCIENT THEORIES AND MODERN INSIGHTS Angina pectoris is manifested mainly as a sudden pressing pain in the left chest, accompanied by palpitations, chest tightness and shortness of breath. The syndrome is caused by insufficient blood supply from the coronary artery with sudden transient ischemia and hypoxia of the cardiac muscle. Various kinds of heart disease can cause angina pectoris such as coronary heart disease, severe aortic stenosis or aortic incompetence and hypertrophic cardiomyopathy. Angina pectoris was recognized early in TCM. It is written in The SpiritualPivot: Syncope (Líng Shū: Jué Bìng,灵枢·厥病) syncope chapter that “true heart pain manifests with blue joints of the hands and feet and severe chest pain; the patient died the next morning when the disease occurred the evening prior, or the patient died in the evening when the disease occurred in the morning”. In TCM, this disease belongs to chest bi, heart pain, syncope heart pain, and true heart pain.

ETIOLOGY AND PATHOMECHANISMS External Causes Cold invasion: The patient has a yang deficiency-type constitution such that overexertion causes distress of the chest yang where yin-cold attacks and occupies the position of the yang. When the weather changes, the cold congeals and qi stagnates, leading to chest yang obstruction, disturbance of qi movement, and contraction or blockage of the heart vessels, all of which result in angina pectoris.

Internal Causes Improper diet: The patient consumes excessive fatty foods or alcohol. The spleen is impaired and fails to transform, and damp-heat accumulates. The middle jiao is constrained, internal heat scorches the fluids and phlegm is formed. Over time, poor spleen function leads to the formation of turbid phlegm which further obstructs the vessels and qi movement. The heart vessel contracts or becomes blocked, resulting in angina pectoris. Internal damage due to emotional disorders: Anger damages the liver which then loses its function to regulate the qi flow, which leads to qi stagnation. The stagnant qi transforms into fire and scorches fluids into phlegm. Another cause of phlegm is when a constrained liver invades the spleen and the spleen qi fails to ascend and descend normally. The functions of transportation and transformation of the spleen are inhibited, and the accumulated dampness is thus transformed into phlegm. Qi stagnation, stasis or phlegm can all obstruct the blood movement, block the vessels,

and inhibit the movement of the chest yang and qi. Then the heart vessels contract or are blocked, resulting in angina pectoris. Kidney yang deficiency: Because of a weak constitution, old age or overstrain from excessive work or sex, the kidney is damaged and as time passes, the kidney qi further declines. The kidney is the foundation of the (prenatal) constitution. The kidney qi warms, generates and transforms the five viscera and six bowels. A deficiency of kidney yang leads to a spleen and heart yang deficiency and thus a systemic loss of warming, nourishment and promotion. The chest yang and qi movement is inhibited, and angina pectoris is the outcome.

COMMON CLINICAL PATTERNS Cold congealing: Chest pain that radiates to the back, aggravated by cold and relieved by warmth. There is a pale complexion and cold limbs. The tongue is pale with a thin white coating; the pulse is wiry and tight, or deep and slow. Phlegm-damp obstruction: Chest tightness, fullness and pain in the chest. Typically presents with an obese body type with a sense of heaviness in the body and limbs, a sticky sensation and a bland taste in the mouth, phlegm in the throat, a poor appetite, and abdominal distention. The tongue body is dim or purple with a turbid greasy coating; the pulse is deep and slippery. Qi stagnation and blood stasis: Stabbing pain in the chest at a fixed location, with pain worse at night. There is a dark complexion with purple lips and nails. The tongue body is dim or purple with stasis spots; the pulse is choppy, knotted or intermittent. Debilitation of yang qi: Chest tightness with shortness of breath, chest pain radiating to the back, cold body and limbs, a sore and weak lower back, pale white facial complexion, and purple or pale lips and nails. The tongue is pale with teeth marks and a moist glossy thin white coating; the pulse is deep and thready, deep and weak, or faint.

THERAPEUTICS Chinese Medicinals 1. Cold Congealing Formula: Guā Lóu Xiè Bái Bái Jiŭ Tāng (Trichosanthes, Chinese Chive and White Wine Decoction) with zhĭ shí (Fructus Aurantii Immaturus), guì zhī (Ramulus Cinnamomi), fù zĭ (Radix Aconiti Lateralis Praeparata), dān shēn (Radix et Rhizoma Salviae Miltiorrhizae), tán xiāng (Lignum Santali Albi) Ingredients: guā lóu (Fructus Trichosanthis), xiè bái (Bulbus Allii Macrostemi), zhĭshí (Fructus Aurantii Immaturus), guì zhī (Ramulus Cinnamomi), fù zĭ (Radix Aconiti Lateralis Praeparata), dān shēn (Radix et Rhizoma Salviae Miltiorrhizae), tán xiāng (Lignum Santali Albi) 2. Phlegm-damp Obstruction Formula: Guā Lóu Xiè Bái Bàn Xià Tāng (Trichosanthes, Chinese Chive and Pinellia Decoction) Ingredients: guā lóu, xiè bái, bàn xià (Rhizoma Pinelliae) 3. Qi Stagnation and Blood Stasis Formula: Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) Ingredients: dāng guī (Radix Angelicae Sinensis), chì sháo (Radix Paeoniae Rubra), chuān xiōng (Rhizoma Chuanxiong), táo rén (Semen

Persicae), hóng huā (Flos Carthami), niú xī (Radix Achyranthis Bidentatae), chái hú (Radix Bupleuri), shēng dì (Radix Rehmanniae) 4. Debilitation of Yang Qi Formula: Shēn Fù Tāng (Ginseng and Aconite Decoction) combined with Yòu GuīYĭn (Right-Restoring Beverage) (ròu guì (Cortex Cinnamomi) is replaced by guì zhī in this version of the formula) Ingredients: rén shēn (Radix et Rhizoma Ginseng), fù zĭ (Radix Aconiti Lateralis Praeparata), guì zhī (Ramulus Cinnamomi), shú dì (Radix Rehmanniae Praeparata), shān zhū yú (Fructus Corni), gŏu qĭ zĭ (Fructus Lycii), dù zhòng (Cortex Eucommiae)

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) According to zang-fu and channel pattern differentiation, the points on the hand shaoyin heart channel and hand jueyin pericardium channel are favored. During the period of disease onset, correlated front-mu points should be selected. For individuals with a weak constitution, associated back-shu points should also be selected between acute attacks. (2) According to the theory of “the channel treats those diseases that arise along the trajectory of that channel”, points on ren vessel can be selected (as the ren vessel passes through the middle of the chest). 2. Point Selection According to Location (1) Local points: Frequently used points include: RN 17 (dàn zhōng), RN 14 (jù quē) (acute period), BL 15 (xīn shù), BL 14 (jué yīn shù) (during remission), PC 1 (tiān chí), PC 2 (tiān quán), HT 1 (jí quán).

(2) Hand shaoyin and jueyin channel points (below the elbows): Frequently used points include: PC 4 (xì mén), HT 6 (yīn xì) (acute period), HT 7 (shén mén), PC 7 (dàlíng) (during remission), PC 6 (nèi guān). (3) Points in the lower limbs: According to the theory of confluence points on the eight extraordinary vessels, points SP 4 (gōng sūn) and PC 6 (nèi guān) can be needled together to treat chest bi. 3. Point Selection Based on Pattern Differentiation (1) Cold congealing: RN 8 (shén què), RN 4 (guān yuán) (2) Phlegm-damp obstruction: RN 12 (zhōng wăn), ST 40 (fēng lóng) (3) Qi stagnation and blood stasis: LV 3 (tài chōng), BL 17 (gé shù) (4) Debilitation of yang qi: BL 23 (shèn shù), BL 20 (pí shù), DU 4 (mìng mén) Techniques: When it comes to needling techniques, the drainage method is most often used, but for the patient with a weak constitution, supplementation should be applied. Moxibustion can be applied to treat cold or deficiency patterns, also effective for patterns of cold congealing or yang qi debilitation. During the disease onset period, treatment is performed twice a day; in remission, treatment is given every other day.

CASE STUDY I Mr. Shi, age 47. Initial Visit: May 7th, 1973 Chief Complaint: Lingering pain behind the sternum for five years, which was suddenly aggravated a day prior to the visit. History: In 1968, the patient was found to have high blood pressure from a health screening. He sometimes had palpitations and chest tightness. In 1970, he had severe pain behind his sternum (mostly on the left side) which radiated to the left shoulder and back, accompanied by shortness of breath, a pale complexion and excessive sweating. He was diagnosed with “coronary heart disease” from both provincial and local hospitals. Over the next three years, he was treated with both Western and Chinese medicines and showed improvement. However, the angina pectoris continued to attack intermittently for 15-30 min each time. The attacks were caused by emotional stimuli, and the symptoms were similar to as before. Signs and Symptoms: Severe pain behind the sternum (left side) which radiated to the left shoulder and back, accompanied by shortness of breath, a pale complexion and excessive sweating. The tongue was dim purple, and the pulse was deep and thready. Past History: Hypertension for five years, no history of diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or foods. Physical Examination: HP 160/90 mmHg, HR 70 bpm. The patient was a lean male, well-developed and moderately nourished, his skin and sclera showed no indication of jaundice, no palpable superficial lymph

nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, resonant percussion sounds (normal). Heart rate was 70 bpm and regular, no pathological murmur at any valve area. Flat abdomen, liver and spleen were non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Auxiliary Examination: ECG showed ST segment depression. Pattern Differentiation The key indications in the pathology are: history of hypertension for five years, angina pectoris for three years. The symptoms recurred intermittently. The patient had heart qi and blood disharmony and chest yang obstruction. This time, the disease was triggered by emotional stimuli where the liver failed to ensure the free flow of qi and worsened the qi stagnation. The inhibited qi movement and obstruction of heart blood led to severe pain behind the sternum which radiated to the left shoulder and back. There was also shortness of breath, a pale complexion and excessive sweating. The tongue was dim purple, and the pulse was deep and thready. The disease location was the heart and liver. The presenting pattern was a deficiency-excess complex. Diagnosis Chest bi due to qi stagnation and blood stasis Clinical Treatment The root of the disease was chest yang obstruction, and the branch was constrained liver qi. So the treatment principle here was to warm and unblock the heart yang, promote qi movement and relieve pain. In addition to the Chinese medicinal and acupuncture treatments, psychological

consultation should be provided to help the patient maintain a good mood and reduce stress. Principles: Warm and unblock heart yang, promote qi movement and relieve pain Formula: Modified Guā Lóu Xiè Bái Bái Jiŭ Tāng (Trichosanthes, Chinese Chive and White Wine Decoction) [瓜蒌薤⽩⽩酒汤加减]

Seven doses. One decocted dose a day. [Formula Analysis] Guā lóu opens the chest and dissipates masses, and xiè bái unblocks yang and dissolves bi. These two medicinals act together to unblock the yang qi of the chest and dissolve the stagnation in the upper jiao. Chinese white wine supports the therapeutic effect with a light and rising nature. Zhĭ shí and guì zhī descend qi and disperse pĭ (localized sensation of blockage in the chest or abdomen, with or without palpable lumps, painless upon pressure). When combined with guā lóu and xiè bái, the four

medicinals act together to relieve chest tightness, dissipate masses, descend qi and eliminate fullness. Bàn xià and hòu pò dissolve phlegm and direct turbidity downwards, which also promotes the dissolving of masses. Dāng guī harmonizes and nourishes the blood, and when combined with guì zhī also acts to warm and unblock ying qi. Chuān xiōng moves qi and invigorates the blood, while mù xiāng and yù jīn relieve chest tightness and disperse masses. This formula treats chest bi by diffusing and unblocking yang qi, regulating qi movement and nourishing heart blood.

Acupuncture Points: RN 17 (dàn zhōng), PC 6 (nèi guān) Techniques: A needle was inserted obliquely 15° downward at RN 17 (dàn zhōng) to a depth of 0.5-0.8 cun. PC 6 (nèi guān) was needled perpendicularly to 0.5-1 cun. After the arrival of qi, rotation was applied. The chest pain was relieved after five minutes of manipulation. Further Consultation This treatment was successfully applied to immediately relieve the pain of angina pectoris attacks until the patient was fully recovered in 1975. On August 7th, 1976, the patient was reexamined. The BP was 130/85 mmHg, ECG showed normal ST segment. The angina pectoris has never attacked again.

CASE STUDY II (ACUPUNCTURE, Li Chuanjie) Mrs. Liu, age 36. Chief Complaint: Intermittent precordial pain for six months. History: The patient had suffered from intermittent precordial pain for six months accompanied by chest tightness, palpitations, shortness of breath during activity, and loose stools. Physical Examination: His tongue was pale with a thin white coating, and the pulse was deep and thready. Diagnosis Angina pectoris due to heart yang deficiency Clinical Treatment Principles: Boost qi and promote heart function, invigorate heart yang Points: RN 17 (dàn zhōng), PC 6 (nèi guān), BL 14 (jué yīn shù), RN 6 (qì hăi), ST 36 (zúsān lĭ) Techniques: A needle was inserted obliquely 15° downward at RN 17 (dàn zhōng) to a depth of 0.5-0.8 cun. PC 6 (nèi guān) was needled perpendicularly to 0.5-1 cun. BL 14 (jué yīn shù) was needled obliquely to 0.5-0.8 cun. RN 6 (qì hăi) was needled perpendicularly to 0.5-0.8 cun, and ST 36 (zú sān lĭ) to 0.5-1 cun. After arrival of qi, rotation was applied until the pain was relieved or disappeared. Note

During the remission period, back-shu points and supplementing points such as RN 6 (qì hăi) and ST 36 (zú sān lĭ) were applied to reduce the frequency of attack, relieve symptoms, and to help normalize ECG findings.

COMMENTARY AND DISCUSSION There are many potential causes of chest pain. One of those causes is called “chest bi” as addressed in a separate chapter. Another cause of chest pain is the so-called “true heart pain”, which is the singular focus of this chapter. Based on the description of “true heart pain” as it originally appeared in TheSpiritual Pivot (Líng Shū, 灵枢), this condition appears to be identical with myocardial infarction as described in Western medicine. According to the Spiritual Pivot: Syncope (Líng Shū: Jué Bìng, 灵枢·厥病), “In true heart pain, the hands and feet turn bluegreen up to the joints, and the heart pain is severe. If it occurs at dawn, death ensues in the evening; if it occurs in the evening, death ensues at dawn.” (Wiseman, Ye, PDCM 1998) A note on the “Chinese white wine” as mentioned in this chapter. White wine in China is closer to hard liquor than it is to the white wine that we in the West might enjoy with a fish dinner. Therapeutic uses for white wine as described in this chapter should be read with this in mind.

STUDY QUESTIONS 1. Why were RN 17 (dàn zhōng) and PC 6 (nèi guān) chosen in the first case? 2. In addition to Chinese medicinals and acupuncture treatments, what lifestyle advice should be provided to the patient in the first case? Answers 1. RN 17 (dàn zhōng) is a local point, the front-mu point of the pericardium channel, and the influential point of qi. Its function is to move qi, unblock the collaterals, and relax chest tightness to relieve pain. PC 6 (nèi guān) is on the pericardium channel, connecting with the yinwei vessel. Its function is to relieve chest tightness, regulate qi, invigorate blood and unblock the collaterals. The combination of these two points moves qi, unblocks yang, dissolves stasis and relieves pain in the chest. 2. The patient should pay attention to diet and lifestyle. The diet should be light, avoiding fatty and heavy foods. Tobacco and alcohol are forbidden. The patient should always keep warm, and of course maintain a good mood free from emotional distress or pressure.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mr. Sun, age 49, reported a stabbing chest pain with a fixed location that was worse at night. It was accompanied by panting, palpitations, and excessive sweating. He found it impossible to lie down horizontally. His complexion was dark, with purple lips and nails. His tongue was purple with stasis spots, and the pulse was choppy. What is the presenting pattern in this case? A. Cold congealing and qi stagnation B. Cold congealing C. Qi stagnation and blood stasis D. Phlegm-dampness obstruction E. Debilitation of yang qi 2. Mr. Jia, age 52, reported chest pain which radiated to the back, accompanied by asthma. The pain was aggravated by cold and relieved by warmth. The patient could not lie down. He had a pale complexion and cold limbs. His tongue was pale with a thin white coating, and the pulse was deep and slow. What is the presenting pattern in this case? A. Cold congealing and qi stagnation

B. Cold congealing C. Qi stagnation and blood stasis D. Phlegm-damp obstruction E. Debilitation of yang qi 3. Mr. Xie, age 72, reported chest tightness, shortness of breath, chest pain radiating to the back, palpitations, asthma, and an inability to lie down. The body and four extremities were cold, and his lower back was sore and weak. The tongue was pale with teeth marks and a thin and moist coating, and the pulse was deep and faint. What is the presenting pattern in this case? A. Cold congealing and qi stagnation B. Cold congealing C. Qi stagnation and blood stasis D. Phlegm-damp obstruction E. Debilitation of yang qi 4. Mrs. Liu, age 48, reported chest tightness, with fullness and heart pain radiating to the back. This was accompanied by panting, phlegm in the throat, and inability to lie down. Patient was clearly obese, and reported a sticky sensation and bland taste in her mouth, poor appetite, and abdominal distention. The tongue body was dim purple with a turbid greasy coating, and the pulse was deep and slippery. What is the presenting pattern in this case? A. Cold congealing and qi stagnation B. Cold congealing

C. Qi stagnation and blood stasis D. Phlegm-damp obstruction E. Debilitation of yang qi Answers 1. C 2. B 3. E 4. D

20. Stomachache ANCIENT THEORIES AND MODERN INSIGHTS Stomachache is also known in TCM as “pain in the stomach cavity”, which is the most common subjective symptom of gastrointestinal disease. Stomachache as described in this chapter is caused by external pathogens invading the stomach, food damage, emotional disorders and spleenstomach weakness. Any of these conditions can give rise to frequent pain in the stomach or epigastric region. Chinese Medicine considers the spleen and stomach to be the foundation of the acquired constitution. The five zang organs all receive qi from the stomach, thus the stomach qi should be taken into consideration when treating any zang-fu organ disease. In order to avoid damaging the stomach qi during treatment, we must avoid overuse of acrid or bitter medicinals, purgatives, or medicinals that guide out stagnation. According to ancient theory, the stomach, spleen, and liver channels as well as the ren vessel all pass through the abdomen and are thus closely related to the stomach. The stomach is inter-related with the liver and spleen both physiologically and pathologically, thus we often choose acupoints on the stomach, spleen, and liver channels and the ren vessel. The stomach governs intake and decomposition of food and drink. Stomach qi governs descent; therefore, RN 12 (zhōng wăn) and ST 36 (zú

sān lĭ) are often needled with drainage to regulate qi, harmonize the stomach and relieve pain. Both internal and external pathogens can cause disorders of intake and decomposition as well as impairing the normal descending of stomach qi; either of these conditions can give rise to stomachache. If the stomach qi rises upward instead of descending downward, symptoms can arise such as stomach pain, poor appetite, vomiting, epigastric upset, acid regurgitation, hiccups, belching, and rib-side pain.

ETIOLOGY AND PATHOMECHANISMS External Causes External pathogens that invade the stomach include cold, heat, and dampness. Cold invading the stomach: As a yin-pathogen, cold tends to stagnation and contraction. The cold-pathogen directly attacks the stomach, leading to congealing cold and qi stagnation with resulting pain. Stomachache due to cold usually presents with excruciatingly painful spasms in the epigastric region. Damp-heat in the spleen and stomach: According to the physiological characteristics of the spleen and stomach, the spleen is considered as “damp-earth”, while the stomach is called “dry-earth”. Hence, the spleen easily suffers from dampness while the stomach easily suffers from dryness. The spleen prefers dryness and is averse to dampness, whereas the stomach prefers dampness and is averse to dryness. Thus the spleen tends to suffer from dampness, while the stomach tends to suffer from dryness. Dryness is a yang-pathogen. Any aggravation of dryness causes heat. The combination of stomach-heat and spleen-dampness generates damp-heat, which blocks qi and leads to stagnation of stomach qi, and the stagnation causes pain. Stomachache caused by damp-heat is often accompanied by heartburn, epigastric upset and acid regurgitation.

Internal causes

Stomachache due to internal damage is closely related with the liver and spleen. Liver: When the liver is constrained, the liver qi fails to flow normally. When the wood-phase is in excess it over-controls the earth-phase, leading to a lack of harmonious qi flow in the stomach. Once the stomach qi is stagnated, stomachache arises. Spleen-stomach: Deficiency cold of the middle jiao fails to warm and nourish the stomach; or the consumption of stomach yin fails to nourish the stomach, which also gives rise to stomachache that is typically low-grade and chronic. Furthermore, dietary irregularities can generate food stagnation with distending pain, foul belching and the sensation of food stuck in the stomach.

Other causes Long-term qi stagnation may causes blood stasis or stagnation in the collaterals that leads to stomach pain. This long-term stasis in the collaterals can also cause stomach bleeding. As described above, the most commonly encountered external patterns are cold invading the stomach, and spleen-stomach damp-heat. The most commonly encountered internal patterns include: food stagnation, liver qi invading the stomach (wood-earth disharmony), spleen-stomach deficiencycold, insufficiency of stomach yin, and blood stasis in the stomach.

COMMON CLINICAL PATTERNS External pathogen invading the stomach: Severe stomachache with fixed pain, worse with pressure, and induced or aggravated by cold or hot and dry foods (in the case of a heat-pathogen). Food stagnation: Stomachache often accompanied by belching and acid regurgitation. Liver qi invading the stomach: Mainly distending and migratory stomach pain, often induced by emotional stress. Blood stasis retention in the stomach: The pain is chronic in nature, stabbing in quality, fixed in character, and aggravated by pressure. Spleen and stomach deficiency-cold: Chronic dull pain relieved by warmth and pressure, and induced or aggravated by hunger, fatigue, exposure to cold weather, and raw or frozen foods. Insufficiency of stomach yin: Lingering burning pain in the stomach, hunger with a poor appetite.

THERAPEUTICS Chinese Medicinals 1. External Pathogens Invading the Stomach (1) Cold invading the stomach Formula: Liáng Fù Wán (Lesser Galangal and Cyperus Pill) Ingredients: gāo liáng jiāng (Rhizoma Alpiniae Officinarum), xiāng fù (Rhizoma Cyperi) (vinegar processed) (2) Spleen-stomach damp-heat Formula: Qīng Zhōng Tāng (Center-Clearing Decoction) Ingredients: huáng lián (Rhizoma Coptidis), zhī zĭ (Fructus Gardeniae), zhì bànxià (Rhizoma Pinelliae Praeparatum), fú líng (Poria), bái dòu kòu (Fructus Amomi Kravanh), chén pí (Pericarpium Citri Reticulatae), gān căo (Radix et Rhizoma Glycyrrhizae) 2. Internal Disharmony (1) Food stagnation Formula: Băo Hé Wán (Harmony-Preserving Pill) Ingredients: shén qū (Massa Medicata Fermentata), shān zhā (Fructus Crataegi), mài yá (Fructus Hordei Germinatus), lái fú zĭ (Semen Raphani), fú líng, bàn xià (Rhizoma Pinelliae), chén pí, lián qiào (Fructus Forsythiae) (2) Liver qi invading the stomach Formula: Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder)

Ingredients: chái hú (Radix Bupleuri), sháo yào (Radix Paeoniae), chuān xiōng (Rhizoma Chuanxiong), yù jīn (Radix Curcumae), xiāng fù (Rhizoma Cyperi), chénpí, zhĭ qiào (Fructus Aurantii), fó shŏu (Fructus Citri Sarcodactylis), gān căo (Radix et Rhizoma Glycyrrhizae) (3) Spleen-stomach deficiency-cold Formula: Huáng Qí Jiàn Zhōng Tāng (Astragalus Center-Fortifying Decoction) Ingredients: huáng qí (Radix Astragali), guì zhī (Ramulus Cinnamomi), shēng jiāng (Rhizoma Zingiberis Recens), sháo yào (Radix Paeoniae), zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle), yí táng (Saccharum Granorum), dà zăo (Fructus Jujubae) (4) Stomach yin insufficiency Formula: Yì Wèi Tāng (Stomach-Boosting Decoction) combined with Sháo Yào GānCăo Tāng (Peony and Licorice Decoction) Ingredients: shā shēn (Radix Adenophorae seu Glehniae), mài dōng (Radix Ophiopogonis), shēng dì (Radix Rehmanniae), yù zhú (Rhizoma Polygonati Odorati), sháo yào, gān căo (Radix et Rhizoma Glycyrrhizae) (5) Blood stasis retention in the stomach Formula: Shī Xiào Săn (Sudden Smile Powder) combined with Dān Shēn Yĭn (Salvia Beverage) Ingredients: pú huáng (Pollen Typhae), wŭ líng zhī (Faeces Trogopterori), dān shēn (Radix et Rhizoma Salviae Miltiorrhizae), tán xiāng (Lignum Santali Albi), shā rén (Fructus Amomi) ★ Key Medicinal

Yuán hú (yán hú suŏ) (Rhizoma Corydalis) is the first choice for stomachache. Any disharmony of the stomach can prevent the stomach qi from descending. When that stomach qi is blocked, stagnation ensues, and stagnation causes pain. Yuán hú is bitter and warm. It enters the liver, spleen and heart channels, and has the function of invigorating blood, moving qi and relieving pain. It can move both the “qi in the blood” and the “blood in the qi”. However, its nature is warm, so it should be used with caution in cases of spleen-stomach damp-heat or stomach yin insufficiency.

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Ren vessel points: RN 12 (zhōng wăn), RN 6 (qì hăi), RN 4 (guān yuán), RN 10 (xiàwăn ), RN 14 (jù quē) (2) Spleen and stomach points: SP 4 (gōng sūn), SP 5 (shāng qiū), SP 2 (dà dū), SP 3 (tàibái), SP 36 (zú sān lĭ), ST 18 (rŭ gēn) (3) Back-shu points: BL 17 (gé shù), BL 21 (wèi shù), BL 20 (pí shù), BL 23 (shèn shù) (4) Points on the foot shaoyin kidney and foot jueyin liver channels: KI 5 (shuĭ quán), KI 10 (yīn gŭ), KI 21 (yōu mén), LV 13 (zhāng mén), LV 14 (qī mén) 2. Point Selection Based on Location (1) Local points: RN 12 (zhōng wăn), RN 14 (jù quē), RN 10 (xià wăn) (2) Distal points: SP 4 (gōng sūn), SP 2 (dà dū), SP 3 (tài bái), KI 3 (tài xī), KI 5 (shuĭquán), KI 6 (zhào hăi), LV 1 (dà dūn), LV 2 (xíng jiān), LV 3 (tài chōng)

(3) Related back-shu points: BL 17 (gé shù), BL 21 (wèi shù), BL 20 (pí shù), BL 23 (shènshù) (4) ST 36 (zú sān lĭ) is the he-sea point of the stomach, and PC 6 (nèi guān) is a confluence point of the eight extraordinary vessels. They are often used for stomach issues. 3. Point Selection According to Pattern (1) Cold invading the stomach: Select points local to the stomach and on the abdomen, as well as distal points on the spleen and stomach channel such as RN 12 (zhōng wăn), LV 13 (zhāng mén), RN 6 (qì hăi ), PC 6 (nèi guān), SP 4 (gōng sūn), ST 36 (zúsān lĭ), and BL 17 (gé shù). Moxibustion on abdominal points acts to supplement the kidney, boost qi, strengthen yang and dispel cold. (2) Food stagnation: Choose points local to the stomach to promote digestion, as well as distal points on the spleen and stomach channels such as RN 10 (xià wăn), RN 12 (zhōng wăn), SP 4 (gōng sūn), ST 41 (jiĕ xī), and ST 36 (zú sān lĭ). (3) Liver qi invading the stomach: Select points on the chest, lower abdomen and related back-shu points such as LV 13 (zhāng mén), LV 14 (qī mén), RN 12 (zhōng wăn), LU 1 (zhōng fŭ), RN 6 (qì hăi), RN 4 (guān yuán), RN 3 (zhōng jí), KI 14 (sì măn), RN 7 (yīnjiāo), RN 5 (shí mén), ST 25 (tiān shū), KI 13 (qì xué), and BL 20 (pí shù). (4) Blood stasis retention in the stomach: Select points local to the stomach, xi-cleft points, back-shu points and front-mu points of the spleen and stomach channel such as RN 12 (zhōng wăn), BL 17 (gé shù), SP 10 (xuè hăi), ST 34 (liáng qiū).

(5) Spleen-stomach deficiency-cold: Select spleen-stomach points such as SP 5 (shāng qìū) and ST 36 (zú sān lĭ), and RN 6 (qì hăi). As for coldpain, deficiency cold and qi stagnation pain, add RN 4 (guān yuán) and RN 3 (zhōng jí) with moxibustion to supplement original qi, nourish the kidney and strengthen yang. This is particularly effective for long-term spleenstomach deficiency patterns, which often damage the kidney over time. (6) Stomach yin insufficiency: For heartburn, also employ the five transport points on the spleen and stomach channels such as SP 4 (gōng sūn), SP 6 (sān yīn jiāo), PC 6 (nèiguān), and BL 20 (pí shù). For all stomachache patterns, we generally select points local to the stomach, distal points on the spleen and stomach channels, and other related points (such as back-shu points, eight confluence points, etc.). For excesstype pain, needle with drainage; for deficiency pain, apply supplementation. Moxibustion warms yang and promote qi flow, and is therefore widely applied in the treatment of stomachache due to cold pain, deficiency, qi stagnation and food stagnation. For blood stasis in the stomach, bleeding methods are also commonly employed.

CASE STUDY I Mr. Tian, age 55. Initial Visit: July 12th, 2003 Chief Complaint: Epigastric pain for five years. History: Over the past five years, the patient has felt a constant pain in the stomach which was aggravated by anger, alcohol, or overeating of acidic or spicy foods. The pain was accompanied by belching and acid regurgitation which were relieved after taking an over-the-counter herbal remedy called Kuaiweiping pills. Two weeks before visiting our clinic, he felt distending pain in the stomach which was aggravated by work stress. This distention spread to his flanks and was so painful that he could not sleep from 1 to 3 a.m. each night. Other symptoms included chest oppression and frequent sighing, frequent belching, nausea, poor appetite and digestion, and constipation. His tongue was red at the sides and tip, and the pulse was wiry. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or foods. Physical Examination: PR 80 beats/min, RR 18 times/min, BP 160/88 mmHg. The patient was a lean male, well-developed and moderately nourished. His skin and sclera showed no indication of jaundice; there were no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, with resonant percussion sounds (normal). Heart rate was regular, no pathological murmur at any valve area. Flat abdomen, liver and spleen were

non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Laboratory Examination: Upper GI endoscopy showed: chronic superficial gastritis, helicobacter pylori examination (+). Pattern Differentiation The key indications in the pathology are: distending pain in the stomach spreading to the flanks that is aggravated by emotional stress. The severe distending pain causes insomnia from 1 to 3 a.m. every night, the time period associated with the liver. The patient was depressed due to work stress, which disturbed the function of the liver governing the free flow of qi; the liver qi invaded the stomach, which then failed to descend, leading to distending pain in the stomach that radiated to the flanks. Other symptoms of qi stagnation and liver qi invading the stomach include chest oppression and frequent sighing, frequent belching, nausea, poor appetite and digestion, and constipation. The location of disharmony was the liver and stomach, manifesting as an excess pattern. Diagnosis TCM pattern: Liver qi invading the stomach Clinical Treatment In this case, the stomachache was caused by emotional stress, thus the treatment strategy was to soothe the liver, regulate qi, and harmonize the stomach to relieve pain. In addition to acupuncture treatment and the medicinal formula, the patient is advised to regulate his mood, reduce stress, exercise, and to eat a light and healthy diet.

Principles: Soothe the liver, regulate qi, harmonize the stomach and relieve pain Formula: Modified Chái Hú Shū Gān Săn (Bupleurum LiverSoothing Powder) [柴胡疏肝散加减]

Three doses. One decocted dose per day. [Formula Analysis] Chái hú acts to soothe the liver, resolve constraint, and regulate the liver qi. Bái sháo is sour, bitter and cold, acting to nourish blood, soften the liver and relax the body to relieve pain. When bái sháo and chái hú are used together, they supplement and harmonize the liver, promote qi movement, and harmonize blood. Chái hú is the chief medicinal, and bái sháo serves as deputy. Zhĭ qìào, chuān xiōng, xiāng fù, chén pí and xuán hú act to regulate qi flow to harmonize the stomach and relieve pain. All serve as assistants. Gān căo harmonizes all formula medicinals, and acts as envoy. Xuán fù huā is used to direct counterflow (rebellious stomach qi) downward.

This formula effectively harmonizes liver and spleen, soothes the liver, unblocks the blood vessels, and harmonizes the stomach to relieve pain.

Acupuncture Main points: RN 12 (zhōng wăn), PC 6 (nèi guān), ST 36 (zú sān lĭ), SP 4 (gōng sūn) Supplementary points: LV 3 (tài chōng), LV 13 (zhāng mén), LV 14 (qī mén), ST 25 (tiān shū), GB 34 (yáng líng quán), RN 6 (qì hăi), BL 20 (pí shù), BL 21(wèi shù), KI 14 (sìmăn) Method: Choose 3 main points and 2-3 supplementary points, changing points every other day. After qi was obtained, the needles were retained for 20 to 30 min. Ten daily treatments constitute one course. Techniques: Firstly LV 3 (tài chōng) was needled bilaterally. After qi was obtained, rotation and drainage was applied for one minute, repeated every 10 minutes. ST 36 (zú sān lĭ), RN 6 (qì hăi), BL 20 (pí shù) and BL 21(wèi shù) were needled with the even method, all other points with drainage. Further Consultation After five treatments, the symptoms were greatly relieved. After another two months, he reported no additional symptoms, and biomedical tests showed no pathology.

CASE STUDY II (ACUPUNCTURE, Cheng Zinong) Mr. Yan, age 29. Chief Complaint: Epigastric pain for over seven years. History: Mr. Yan complained of stomach pain seven years prior, at that time his condition was diagnosed as “duodenal bulb ulcer”. However, the prescribed Western medicine did not improve his condition. The stomachache reoccurred from time to time, usually an hour or two after dinner. The pain was dull and fixed, improved with pressure or hot drink. He had a good appetite without nausea or vomiting, and with normal urine and stools. Physical Examination: The patient had a withered and yellow complexion. His tongue was red at the tip with a little yellow coating in the middle, and his pulse was deficient and wiry. Diagnosis Stomachache due to stomach cold Clinical Treatment Principles: Warm the middle jiao and dispel cold, move qi and relieve pain Points: RN 12 (zhōng wăn), RN 6 (qì hăi), PC 6 (nèi guān), SP 4 (gōng sūn), ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo) Techniques: Manipulate with supplementation or the even method, apply moxibustion to RN 12 (zhōng wăn).

After the first acupuncture treatment, the patient said his stomachache was relieved. After one course of ten treatments, his pain was relieved. Note In this case, the spleen and stomach were damaged simultaneously and the middle yang was insufficient, causing stomach disharmony. RN 12 (zhōng wăn), as the front-mu point of the stomach, is used to warm yang, dispel cold and harmonize the stomach. ST 36 (zú sān lĭ), as the lower hesea point of the foot yangming stomach channel, is combined with SP 6 (sān yīn jiāo) on the foot taiyin spleen channel to harmonize the stomach and strengthen the spleen. SP 4 (gōng sūn) is the luoconnecting point of the foot taiyin spleen channel which connects to the foot-yangming stomach channel, also paired with PC 6 (nèi guān) (the confluent point of the yinwei channel). Together, SP 4 (gōng sūn) and PC 6 (nèi guān) open the chest, move qi and harmonize the stomach. Combined, all points act to harmonize stomach qi thus leading to healthy middle jiao transportation functions to ease the stomachache.

COMMENTARY AND DISCUSSION “Stomach qi governs descent; we therefore often use the drainage method”. This instruction by the author of this book provides us with some diagnostic insight as well. While we can never ignore presenting signs and symptoms, we can also make some assumptions based on the nature of the yangming channel (described as “more qi, more blood”). In practice, when it comes to the yangming-organ and channels, acupuncture and medicinal therapies are most often employed to drain excess. Generally speaking, the majority of stomach (or yangming) conditions seen in clinic will present as an excess condition.

STUDY QUESTIONS 1. In the first case the patient had stomachache, why was LV 3 (tài chōng) needled with drainage? 2. In addition to the acupuncture and the formula, what additional measures can be applied for the first case? Answers 1. Mr. Tian complained of distending pain in the stomach, and upon further inquiry, it became clear that the condition was due to liver qi attacking the stomach. LV3 (tài chōng) was selected because it is the yuansource point of the foot jueyin liver channel. Needle rotation with drainage was applied to soothe the liver, move qi and relieve pain. 2. It is necessary to advise the patient to reduce stress and maintain a good mood along with a light diet and moderate exercise.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mrs. Zhang, age 49, complained of stabbing or cutting pain in the stomach. For many years, she had this fixed pain which got worse after large meals, when pressed, and at night. Her tongue body was purple, and the pulse was choppy. Which of the following formulas is indicated? A. Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) B. Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) C. Shào Fù Zhú Yū Tāng (Lower Abdominal Stasis-Expelling Decoction) D. Sháo Yào Gān Căo Tāng (Peony and Licorice Decoction) E. Shī Xiào Săn (Sudden Smile Powder) mixed with Dān Shēn Yĭn (Salvia Beverage) 2. Mrs. Zhao, age 47, had a burning pain in her stomach. She seemed somewhat angry and reported having a poor appetite, thirst with a desire to drink, five-center heat, and dry and hard stools. Her tongue body was red and dry, and the pulse was thready and rapid. Which of the following formulas is indicated?

A. Xiāng Sū Săn (Cyperus and Perilla Powder) mixed with Liáng Fù Wán (Lesser Galangal and Cyperus Pill) B. Yī Guàn Jiān (Effective Integration Decoction) mixed with Sháo Yào Gān Căo Tāng (Peony and Licorice Decoction) C. Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder) D. Qīng Zhōng Tāng (Center-Clearing Decoction) E. Băo Hé Wán (Harmony-Preserving Pill) 3. Mr. Cai, age 62, complains of a chronic stomachache for the past 30 years. He describes it as a constant dull pain that is aggravated when hungry and relieved by eating. The pain prefers warmth and pressure and is usually induced or aggravated by fatigue or cold. Other symptoms include mental fatigue and poor appetite, cold hands and feet; thin, loose, unformed stools. His tongue is pale with a white coating, and the pulse is deficient and slow. Which of the following treatment principles should be applied? A. Dissolve stasis, unblock collaterals, regulate qi and harmonize the stomach B. Clear and eliminate damp-heat, regulate qi and harmonize the stomach C. Warm the middle jiao, strengthen the spleen, harmonize the stomach and relieve pain D. Soothe the liver, resolve constraint, regulate qi and relieve pain E. Warm the stomach, dispel cold, move qi and relieve pain 4. Mr. Liu, age 25, felt distending pain in the stomach after dinner which was averse to pressure. Other symptoms included belching and acid

regurgitation, and vomiting of foul undigested food. The pain was relieved by vomiting. He also had excessive flatulence, a poor appetite, and hesitant stools. The tongue coating was thick and greasy, and his pulse was slippery. Which of the following formulas is the best choice? A. Dà Chéng Qì Tāng (Major Purgative Decoction) B. Xiăo Chéng Qì Tāng (Minor Purgative Decoction) C. Huò Xiāng Zhèng Qì Săn (Agastache Qi-Correcting Powder) D. Bàn Xià Xiè Xīn Wán (Pinellia Heart-Draining Pill) E. Băo Hé Wán (Harmony-Preserving Pill) 5. A patient complains of stomachache, which sometimes takes on a burning pain. He also reports a sticky sensation or bitter taste in the mouth, thirst without a desire to drink, yellow urine, and hesitant stools. The tongue coating is yellow and greasy, and the pulse is slippery and rapid. Which pattern is causing the stomachache? A. Damp-heat blocking the middle jiao B. Blood stasis retention in the stomach C. Deficiency cold in the spleen and stomach D. Liver qi invading the stomach E. Indigestion due to food stagnation 6. Mr. Liu, age 50, complained of repeated dull stomachaches for nearly 20 years. His symptoms could be aggravated for two days by eating cold food; however, the pain would be relieved after eating a large warm meal. Mr. Liu found that the stomachache would improve with pressure and a hot compress.

Which of the following formulas is the best choice? A. Băo Hé Wán (Harmony-Preserving Pill) B. Xiāng Sū Săn (Cyperus and Perilla Powder) mixed with Liáng Fù Wán (Lesser Galangal and Cyperus Pill) C. Huà Gān Jiān (Liver-Transforming Brew) D. Fù Guì Lĭ Zhōng Wán (Aconite and Cinnamon Center-Regulating Pill) E. Xiāng Shā Liù Jūn Zĭ Tāng (Costusroot and Amomum Six Gentlemen Decoction) 7. Mrs. Wang, age 40, suffered from a stomachache for the last four days which has spread to her flanks. We find her belching frequently during intake. The tongue coating is thin and white, the pulse is wiry. What is the presenting pattern? A. Damp-heat blocking the middle jiao B. Liver qi invading the stomach C. Blood stasis retention in the stomach D. Cold invading the stomach E. Indigestion due to food stagnation 8. Mr. Zhou, age 18, had a stomachache after overeating the day before. He reports belching, acid regurgitation, and hesitant stools. The tongue coating is thick and greasy. Which of the following treatment principles is best for this case?

A. Warm the middle jiao, supplement the spleen, harmonize the stomach and relieve pain B. Clear and eliminate damp-heat, regulate qi and harmonize the stomach C. Eliminate stasis, unblock the collaterals, regulate qi and harmonize the stomach D. Promote digestion and remove stagnation, harmonize the stomach and relieve pain E. Warm the stomach and dispel cold, move qi and relieve pain Answers 1. E 2. B 3. C 4. E 5. A 6. B 7. B 8. D

21. Abdominal Pain ANCIENT THEORIES AND MODERN INSIGHTS Abdominal pain is considered clinically as a gastrointestinal disorder marked by pain that arises anywhere below the ribs and above the pubic bone. The abdominal pain discussed in this section arises from external factors, dietary factors, mental factors or internal damage, which may occur during any season. Any number of disharmonies can cause an inhibited flow of qi, which is the common cause for abdominal pain; thus the cause of qi stagnation is where the practitioner must focus. Etiologies include invasion of external pathogens, dietary indiscretions, emotional disorders, traumatic injuries, and deficiencies of qi, blood or yang. Any of these can cause an inhibited flow of qi, blood stasis in the channels, or malnourishment of zang-fu organs and channels. The main disease mechanism is pain caused by stagnation, and as such, the general treatment approach is to regulate the qi of the zang-fu organs to relieve spasm and pain. Based on the traditional channel theory, points are chosen from those channels that pass through the abdomen. These include the hand and foot yangming channels, the foot shaoyang channel, the three yin channels of the foot, and the chong vessel, ren vessel and dai vessel. Clinically favored are points on the foot yangming stomach channel, the foot taiyin spleen channel, and the ren vessel.

The occurrence and remission of abdominal pain is associated with aggravating factors such as diet, emotions, cold weather, fatigue and so on. Abdominal pain can arise repeatedly, and is commonly associated with belching, flatulence, and abnormal stools.

ETIOLOGY AND PATHOMECHANISMS External Causes Externally-contracted pathogenic factors can attack the abdomen to cause pain. Among the six external causes, abdominal pain most often results from pathogenic cold. Less common causes include summerheat and damp-heat. Wind-cold: When wind-cold attacks the abdomen, cold congeals and gives rise to qi stagnation which causes pain. Patients with wind-cold abdominal pain also often suffer with vomiting and diarrhea. Damp-heat: There are a few scenarios that can give rise to damp-heat, including a direct attack. Summer-heat or cold constraint can transform into heat and attack the intestines, which then disturbs intestinal qi movement. Any disturbance in the intestines can generate dampness, and along with internal heat, the flow of qi is compromised thus resulting in abdominal pain. Patients with damp-heat from external causes often present with fever as well.

Internal Causes Abdominal pain due to internal damage has a close relationship with poor dietary choices, emotional stress, or a congenital deficiency of yang. Food damage: Many dietary problems can damage the spleen and stomach and lead to an obstructed flow of qi through the fu organs (stomach and intestines) which ultimately leads to abdominal pain. Overeating or eating foods that are difficult to digest can cause retention of food and drink

(or “food stagnation”). Foods that are greasy or excessively sweet are more likely to cause food stagnation. Unhygienic diets of raw foods that have become infected by bacteria are a common cause of damp-heat diarrhea (yellow, explosive, strong odor, burns the anus). Cold-dampness accumulating in the interior due to eating cold or excessive amounts of raw food can cause abdominal pain due to cold. Disorder of emotion or “stress”: A number of emotions including depression and anger cause a disturbance in the flow of qi, sometimes putting the liver into a state of excess where it then attacks the spleen, leading to inhibited qi flow in the abdomen. Excessive worry or anxiety can also impair the spleen, which then generates more dampness. Any of these can further cause qi stagnation and blood stasis in the zang-fu organs, channels and collaterals, resulting in abdominal pain. Congenital deficiency of yang: Chronic diseases or congenital factors can lead to kidney yang deficiency. Kidney yang deficiency leads to spleen yang deficiency, as well as the overconsumption of cold or raw foods which can easily damage the spleen yang. Any of these scenarios can result in failure to nourish the zang-fu and channels along with the creation of yincold, cold retention and qi stagnation, all of which result in abdominal pain.

Other Causes Patients with abdominal pain can also present with a history of: Traumatic injury causing damage and stagnation in the collaterals. Abdominal surgery causing injury to the blood collaterals. Qi stagnation impairing blood movement, leading to pain.

Chronic disease of the channels that pass through the abdomen causing degeneration and pain. Commonly encountered abdominal pain patterns include pathogenic cold obstructing the interior, stagnation of damp-heat, food accumulation, liver constraint and qi stagnation, middle jiao deficiency-cold, and blood stasis.

PATTERN DIFFERENTIATION 1. Differentiation Based on Patterns Cold obstructing the interior: Abrupt abdominal pain caused by exteriorly-contracted cold. The pain is worse when exposed to cold, and relieved by warmth. Stagnation of damp-heat: Abdominal pain associated with a thirst and a desire to drink; the tongue coating is yellow greasy or yellow dry. Food accumulation: Distending pain in the abdomen, belching with a foul odor, acid regurgitation, pain relieved after vomiting or diarrhea. The condition often occurs after overeating. Liver constraint and qi stagnation: Pain below the ribs, but usually not on the midline, but off to either side or the flanks. The pain is relieved by belching or passing gas, and aggravated by anger. Frequent sighing is common. Middle jiao deficiency-cold: Recurrent dull pain with a preference for warmth and pressure on the abdomen. Internal retention of static blood: Stabbing pain in a fixed location, often associated with a history of injury or abdominal surgery; recovery is often slow. 2. Differentiation Based on Pain Location Upper abdominal pain: Pain limited to the region above the naval, often caused by disharmony of the spleen-stomach and intestines.

Flank and lesser abdominal pain: Unilateral or lateral flank pain, pain of the abdomen below the navel (on either side). The pain is often associated with the foot jueyin liver channel and the large intestine. Lower abdominal pain: Pain below the navel, always associated with the kidney and bladder. Abdominal pain around the navel: Associated with the spleen and stomach channels, sometimes caused by intestinal parasites.

THERAPEUTICS Chinese Medicinals 1. External Contraction (1) Internal cold Formula: Liáng Fù Wán (Lesser Galangal and Cyperus Pill) and Zhèng Qì TiānXiāng Săn (Qi-Correcting Lindera and Cyperus Powder) Ingredients: gāo liáng jiāng (Rhizoma Alpiniae Officinarum), gān jiāng (Rhizoma Zingiberis), zĭ sū (Folium Perillae), wū yào (Radix Linderae), xiāng fù (Rhizoma Cyperi), chén pí (Pericarpium Citri Reticulatae) (2) Damp-heat Formula: Dà Chéng Qì Tāng (Major Purgative Decoction) Ingredients: dà huáng (Radix et Rhizoma Rhei), máng xiāo (Natrii Sulfas), hòu pò (Cortex Magnoliae Officinalis), zhĭ shí (Fructus Aurantii Immaturus) 2. Internal Disharmony (1) Food stagnation Formula: Zhĭ Shí Dăo Zhì Wán (Immature Bitter Orange StagnationMoving Pill) Ingredients: dà huáng, zhĭ shí, shén qū (Massa Medicata Fermentata), huáng qín (Radix Scutellariae), huáng lián (Rhizoma Coptidis), zé xiè

(Rhizoma Alismatis), bái zhú (Rhizoma Atractylodis Macrocephalae), fú líng (Poria) (2) Liver constraint and qi stagnation Formula: Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder) Ingredients: chái hú (Radix Bupleuri), zhĭ qiào (Fructus Aurantii), xiāng fù, chénpí, sháo yào (Radix Paeoniae), gān căo (Radix et Rhizoma Glycyrrhizae), chuān xiōng (Rhizoma Chuanxiong) (3) Middle jiao deficiency-cold Formula: Xiăo Jiăn Zhōng Tāng (Minor Center-Fortifying Decoction) Ingredients: guì zhī (Ramulus Cinnamomi), shēng jiāng (Rhizoma Zingiberis Recens), yí táng (Saccharum Granorum), dà zăo (Fructus Jujubae), sháo yào, zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle) (4) Blood stasis Formula: Shào Fù Zhú Yū Tāng (Lesser Abdominal Stasis-Expelling Decoction) Ingredients: táo rén (Semen Persicae), hóng huā (Flos Carthami), niú xī (Radix Achyranthis Bidentatae), chuān xiōng, chì sháo (Radix Paeoniae Rubra), dāng guī (Radix Angelicae Sinensis), shēng dì (Radix Rehmanniae), gān căo, chái hú, zhĭ qiào, jié gěng (Radix Platycodonis) ★ Guiding Medicinals for Abdominal Pain Foot yangming and shaoyang channels (pain in the upper abdomen): bái zhĭ (Radix Angelicae Dahuricae), bái sháo (Radix Paeoniae Alba), shēng má (Rhizoma Cimicifugae)

Foot jueyin and hand yangming (pain in the flank and lesser abdomen): qīng pí (Pericarpium Citri Reticulatae Viride), chuān xiōng Foot shaoyin (pain in the lower abdomen): găo běn (Rhizoma Ligustici), ròu guì (Cortex Cinnamomi)

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Favor points on the ren vessel, foot yangming, foot taiyin and foot jueyin channels. (2) Based on channel theory, choose points on the spleen and stomach channels, ren vessel, liver and gallbladder channels, and pericardium channel. Commonly used points include: ST 36 (zú sān lĭ), ST 25 (tiān shū), RN 12 (zhōng wăn), RN 4 (guān yuán), RN 6 (qì hăi), SP 6 (sān yīn jiāo), PC 6 (nèi guān) and LV 3 (tài chōng). ST 36 (zú sān lĭ) is a key point for abdominal pain based on the experiential adage that states “ST 36 (zúsān lĭ) can cure abdominal disease”. (3) Back-shu points on the foot taiyang bladder channel such as BL 20 (pí shù), BL 21 (wèi shù), BL 25 (dà cháng shù), and BL 23 (shèn shù) may be also included. 2. Point Selection According to Location (1) Local points: Frequently used points include:

● All abdominal pain: RN 12 (zhōng wăn), RN 10 (xià wăn) ● Flank or lesser abdominal pain: LV 14 (qī mén), LV 13 (zhāng mén) ● Lower abdomen pain (below the naval): RN 4 (guān yuán), RN 6 (qì hăi)

● Abdominal pain around the naval: RN 8 (shén què), ST 25 (tiān shū) RN 12 (zhōng wăn) is located above the naval; it is a convergence point of the zang-fu organs and also the front-mu point of the stomach. ST 25 (tiān shū) is located lateral to the naval and is the front-mu point of large intestine. RN 4 (guān yuán) is located below the naval and is the front-mu point of the small intestine. Any kind of abdominal pain can benefit from these points which act to regulate the fu-organ qi. (2) Foot yangming stomach channel below the knee: Common points include ST 36 (zú sān lĭ), ST 37 (shàng jù xū), ST 39 (xià jù xū), and GB 34 (yáng líng quán). Selection of these points is consistent with the theory that states, “the lower he-sea points of the six fu-organs can treat fu-organ diseases”. (3) Shaoyang and jueyin channel points on the upper limbs: Points on the hand shaoyang sanjiao channel and the hand jueyin pericardium channel such as SJ 6 (zhīgōu), SJ 5 (wài guān) and PC 6 (nèi guān) are selected because the sanjiao channel passes through the diaphragm. 3. Point Selection Based on Pattern Differentiation (1) Cold obstructing the interior: For this pattern, select from the following points:

● RN 8 (shén què), RN 6 (qì hăi), RN 4 (guān yuán). Because these points are located on the abdomen, moxibustion is used in conjunction with the needles to warm the middle and dissipate cold.

● SP 4 (gōng sūn) is the luo-connecting point of the foot taiyin spleen channel, and one of eight confluence points, also connected to the chong vessel. It can fortify the spleen, boost the stomach, regulate the chong vessel and disperse pĭ (bloating).

(2) Stagnation of damp-heat: Select SP 9 (yīn líng quán), LI 11 (qū chí) and ST 44 (nèitíng) to discharge heat and dredge the bowels. (3) Food stagnation: Select RN 10 (xià wăn) and lĭ nèi tíng (Inner Court, ⾥内庭) to promote digestion and guide out stagnation. (4) Liver constraint and qi stagnation: Select LV 14 (qī mén), LV 3 (tài chōng), LV 2 (xíng jiān) and GB 34 (yáng líng quán) to soothe the liver and regulate qi. (5) Middle jiao deficiency-cold: Select LV 13 (zhāng mén), RN 6 (qì hăi), BL 20 (píshù) and BL 23 (shèn shù) to supplement yang and warm the middle; moxibustion is recommended. (6) Internal retention of blood stasis: Select SP 8 (dì jī), SP 10 (xuè hăi), SP 6 (sān yīnjiāo), and LV 8 (qū quán) to invigorate blood, eliminate stasis, quicken the collaterals and relieve pain. When treating according to the channel affected, select points mainly from the ren vessel, foot yangming channel, and foot and hand shaoyang channels. Moxibustion and warm-needling are most effective for patterns of cold obstructing the interior or middle jiao deficiency-cold. Moxibustion on salt is used on RN 8 (shénquè).

CASE STUDY I Male, age 6. Initial Visit: April 21st, 2000 Chief Complaint: Abdominal pain around the navel for five years. History: The patient was weak when born. He had abdominal pain around the navel as far back as he and his parents can remember. Despite many kinds of treatments, he never fully recovered. Signs and Symptoms: Dull pain around his navel, radiating bilaterally to the rib-sides. He liked the feeling of pressure and warmth. His appetite, urine and stools were normal. The tongue was pale with a thin white coating, and the pulse was thready and deep. Past History: The child had dysentery at age one, which had developed to febrile convulsion. Physical Examination: The patient was listless, his face was pale. His lungs and heart were normal. Laboratory Examination: No pathological findings. Pattern Differentiation The child suffered from dysentery at age one, which was not wellcontrolled and had developed to febrile convulsion. Therefore, the child’s spleen became deficient and cold, with cold generated in the middle jiao presenting with dull pain around the navel. Because it was deficient and cold in nature, he liked the feeling of pressure and warmth. Over time, the cold accumulated and caused qi stagnation, causing the pain to radiate to the rib-sides. The deficient spleen and stomach failed to produce sufficient

qi and blood to nourish the tongue, so it appeared pale with a thin white coating. The thready deep pulse was indicative of deficiency and a deep internal disease location. Diagnosis Abdominal pain due to deficiency cold of the spleen and stomach Clinical Treatment The treatment strategy was to warm the middle, fortify the spleen, move qi and harmonize the middle. In additional to acupuncture and Chinese medicinal therapy, lifestyle should also be attended to as a necessary part of treatment. Principles: Warm the middle, fortify the spleen, move qi and harmonize the middle Formula: Modified Xiāng Shā Yăng Wèi Wán (Costusroot and Amomum Stomach-Nourishing Pill) [⾹砂养胃丸加减]

One decocted dose a day. [Formula Analysis] Hóng táng, the chief medicinal, is warm and sweet, acting to fortify the spleen, warm the stomach, relieve pain and harmonize the middle.

Bái kòu rén and shā rén are acrid and warm, enter the spleen and stomach channels, eliminate dampness, move qi, harmonize the middle and stop vomiting. Both serve as deputy medicinals. Shēng jiāng and mù xiāng are acrid and warm, acting to dispel cold, harmonize the middle and aromatically regulate the qi of the sanjiao to relieve pain. Both serving as assistant medicinals, they mainly address the stagnation of qi which leads to the abdominal pain. This formula is famous for regulating the liver and nourishing blood. With added hóng huā and chuān xiōng, the formula moves qi and activates blood, consistent with the ancient adage, “there is no pain after unblocking the channels and collaterals”.

Acupuncture Main points: ST 36 (zú sān lĭ), ST 25 (tiān shū) Supplementary points: Points of the du vessel on the back, hua tuo jia ji points (from T1 to L5) Method: Choose from the main and supplementary points for each daily treatment. Techniques: Needle ST 36 (zú sān lĭ) and ST 25 (tiān shū) with supplementation; apply plum-blossom needling at du vessel points and hua tuo jia ji points (from T1 to L5) until the skin is slightly red. Further Consultation After taking seven doses of the prescribed formula and receiving three acupuncture treatments, the abdominal pain was relieved. To prevent recurrence, the parents were advised to avoid raw, frozen or chilled foods.

CASE STUDY II (ACUPUNCTURE, Si-tu Ling) Mr. Yan, age 27. Initial Visit: July 22nd, 1983 Chief Complaint: Abrupt colicky abdominal pain. History: On the day that the pain arose, Mr. Yan had labored outside on a hot day. After he drank some ice water after supper, there arose an abrupt colicky abdominal pain that included a choking feeling. When he first arrived at our office, he was doubled-over with his arms clutched around his abdomen. Physical Examination: Bluish complexion, sweating, obvious tenderness on the upper abdomen, no rebound tenderness. His skin was cold moist, and the heart rate was 82 bpm, with no abnormities of the lungs. His tongue was red with a yellow coating, and the pulse was thready and rapid. Diagnosis Abdominal pain due to excess summerheat-damp Clinical Treatment Principles: Disperse summerheat-damp, unblock the collaterals and suppress pain Points: shí xuān (EX-UE11), PC 6 (nèi guān), SP 4 (gōng sūn) Techniques: PC 6 (nèi guān) and SP 4 (gōng sūn) were manipulated with drainage; however, this treatment did not produce a positive outcome. So, the next treatment began with the shí xuān (EX-UE11). While needling the shí xuān (EX-UE11), point-bleeding was done to produce enough blood

to fill a bean. After this, the pain disappeared and the patient was able to walk home full of happiness. Note This case was due to excess summerheat-damp with sand foulness (痧 秽), but aggravated by the cold drink which then gave rise to the colicky pain. As the pathogens penetrated into the blood level, only bloodletting therapy could achieve a good effect.

CASE STUDY III Editor’s Case Summary Diana, female, age 49. Initial Visit: May 5th, 2012 Chief Complaint: The patient complained of lower left quadrant (LLQ) abdominal pain that has occurred over the prior five months. The pain was initially described as fixed in location, at approximately her left-side SP 15 (dà héng). History: The patient was a hard worker who put her heart and soul into her business. When things began to blossom for her, the pains arose as did her self-employed responsibilities. Signs and Symptoms: In addition to her LLQ abdominal pain, the patient also reported bloating with significant discomfort, sometimes causing her to stop her daily activities and lie down. After passing gas (with little to no odor passed) most of the bloating and pain would be reduced immediately. Physical Examination: Her liver was unremarkable, however ultrasound examination discovered a slight splenomegaly. Colonoscopy discovered a slight diverticulosis. Endoscopy was unremarkable. The leftside front-mu point of the Stomach was sensitive. Laboratory Examination: Pancreatic enzyme levels in the blood were slightly elevated. Diagnosis Abdominal pain due to liver blood stagnation Clinical Treatment

The pain was initially described as fixed in location, and perhaps at the time it was. Other diagnostically significant findings included the slight diverticulosis, which when more severe could cause constipation. Because the stomach’s mu point was sensitive, it was thought that the problem was likely located in the large intestine, which is closely related to the stomach via the yangming relationship. As such, to control blood stagnation and constipation, a blend of Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) and Tiáo Wèi Chéng Qì Tāng (Stomach-Regulating and Purgative Decoction) was used. Principles: Resolve blood stagnation and promote defecation Formula: Modified Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) and Tiáo Wèi Chéng Qì Tāng (Stomach-Regulating and Purgative Decoction) [桃红四物汤合调胃承⽓汤加减]

Note Because there was more blood stagnation evident than constipation, the steamed version of dà huáng (Radix et Rhizoma Rhei) was used to lessen its purgative functions and strengthen its blood moving properties.

This formula produced some benefits early on but the bloating and pain soon returned, after which time, the patient began to describe the pain as referring to just below the ribs on the left side, roughly equivalent to her left point LV 14 (qī mén). The pains also migrated to the left flank. Further Consultation At this time, it became evident that her pain was more related to a stagnation of qi than blood, though targeting the liver remained the correct organ. Her second formula included some of the same blood moving treatment principles, but additionally those that regulated the flow of liver qi. Other added herbs addressed the underlying deficiency of both the spleen and liver. Her new formula included:

[Formula Analysis] Dāng guī, bái sháo, chì sháo and dān shēn 15g moved the blood.

Chuān liàn zĭ and yán hú suŏ address the hypochondriac pain due to deficiency. Zhĭ qiào and xiāng fù promote liver qi circulation Bái zhú and chén pí address her bloating by drying damp and tonifying spleen qi. Zhì gān căo, shēng jiāng and dà zăo 3g are the so-called “three candies” that promote the stomach qì to address the underlying deficiency. After taking this formula for about one month, the symptoms began to abate. After two months they were mostly gone, and after three months the formula was changed to shift the emphasis away from the lower left quadrant pain, and bloating because those symptoms had been addressed. The new formula focused exclusively on the deficiency of qi and blood.

COMMENTARY AND DISCUSSION The specific odors arising with flatulence are a tremendously valuable as a diagnostic tool when differentiating patterns that can give rise to abdominal pain. Flatulence due to qi stagnation: large in quantity but with mild or no odor. This kind of gas passage can be quite noisy. Flatulence due to qi deficiency: medium in quantity and smells like normal feces. Not all gas suggests deficiency, so it is considered normal to have a little gas of this sort every day. Flatulence due to damp-heat: The gas is small in quantity but strong in odor, it may be wet, or burn the anus. This can also arise from food stagnation, but in either case, it is damp-heat by the time it leaves the body. Flatulence due to cold-dampness: the gas is said to smell like raw beef and is sometimes accompanied by wetness.

STUDY QUESTIONS 1. The first case was about abdominal pain, why were points on the du vessel and hua tuo jia ji points (T1-L5) chosen? 2. For the first case, what else can be done in addition to the acupuncture and Chinese medicinal treatment? 3. Based on the location of abdominal pain, which channels were affected in the first case? Answers 1. The patient had been deficient since birth. His pulse was thready and deep after a chronic illness. Thus, this case was associated with a deficiency of blood and qi, so plum-blossom needling was used at du vessel points on the back and also at hua tuo jiaji points (T1-L5) to regulate the zang-fu, harmonize the qi and blood, promote upright qi, unblock the channels and quicken the collaterals. 2. Regulate the diet as necessary to prevent recurrence. 3. The yangming and taiyin channels (spleen and stomach, essentially).

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mrs. Lin, age 49, complains of abdominal pain with a fixed location. Other signs and symptoms include a dim purple tongue body, and a thready and choppy pulse. Which of the following formulas would be your first choice? A. Táo Hé Chéng Qì Tāng (Peach Kernel Qi-Guiding Decoction) B. Shào Fй Zhú Yū Tāng (Lesser Abdominal Stasis-Expelling Decoction) C. Shī Xiào Săn (Sudden Smile Powder) and Dān Shēn Yĭn (Salvia Beverage) D. Dà Huáng Mй Dān Pí Tāng (Rhubarb and Moutan Decoction) E. Fù Yuán Huó Xuè Tāng (Original Qi-Restoring and Blood-Moving Decoction) 2. A male, age 5, complained of abrupt abdominal pain after drinking ice water; the pain was intense and caused the boy to double over in pain. The pain was relieved by warmth. Other signs and symptoms included aversion to cold, cold hands and feet, slight loss of taste, no thirst, clear copious urine, and normal stools. The tongue coating was thin white, and the pulse was deep and tight.

Which of the following treatment principles should be used? A. Dispel cold, warm the interior, regulate qi and relieve pain B. Promote digestion, eliminate stagnation, regulate qi and relieve pain C. Soothe the liver, resolve constraint, regulate qi and relieve pain D. Warm the middle, supplement deficiency, relieve spasm and pain E. Unblock the bowels, discharge heat, move qi and remove food stagnation 3. Mrs. Zhang, age 45, complained of gas pain in the abdomen that was aggravated by anger and relieved by belching. Her tongue had a thin coating, and the pulse was thready. Which of the following diagnoses best explains the abdominal pain? A. Damp-heat in the liver and bladder B. Disharmony of liver and spleen C. Binding constraint of liver qi D. Ascending counterflow of stomach qi E. Blood stasis obstructing in the interior 4. Mr. Huang, age 56, complains of a dull and recurrent abdominal pain. The pain is better with warmth and pressure. Other symptoms include a cold body and thin loose stools. His tongue was pale with a white coating, and the pulse was thready and deep. Which of the following formulas would be your first choice? A. Bй Zhōng Yì Qì Tāng (Center-Supplementing Qi-Boosting Decoction)

B. Fù Zĭ Jīng Mĭ Tāng (Aconite and Rice Decoction) C. Băo Hé Wán (Harmony-Preserving Pill) D. Xiăo Jiàn Zhōng Tāng (Minor Center-Fortifying Decoction) E. Sì Nì Tāng (Frigid Extremities Decoction) 5. A male, age 12, complained of a gas and abdominal pain. His symptoms included belching with a foul odor, vomiting of acid, and an aversion to food. The pain precedes a bout of diarrhea, after which the pain is relieved. Which of the following formulas would you select first? A. Zhĭ Shí Dăo Zhì Wán (Immature Bitter Orange Stagnation-Moving Pill) B. Xiăo Chéng Qì Tāng (Minor Purgative Decoction) C. Dà Chéng Qì Tāng (Major Purgative Decoction) D. Zhĭ Zhú Wán (Immature Bitter Orange and Atractylodes Macrocephala Pill) E. Xiăo Jiàn Zhōng Tāng (Minor Center-Fortifying Decoction) 6. Mrs. Wang, age 25, complained of abdominal pain that was aggravated by pressure. There was incomplete passage of stools, and dark scanty urine. Her tongue was red with a greasy yellow coating. Which of the following diagnoses is correct? A. Cold obstructing the interior B. Stagnation of damp-heat C. Middle jiao deficiency-cold

D. Blood stasis and qi stagnation E. Food stagnation 7. Male, age 3, cried loudly due to abdominal gas after each meal. The pain was aggravated by pressure. Other symptoms included belching with a foul odor, acid regurgitation, aversion to food, and abdominal pain that was relieved after the passage of diarrhea. The tongue coating was thick and greasy, and the pulse was slippery. Which of the following diagnosis best describes the abdominal pain? A. Cold obstructing the interior B. Stagnation of damp-heat C. Middle jiao deficiency-cold D. Blood stasis and qi stagnation E. Food stagnation 8. Mrs. Cui, age 31, presents with abdominal pain and gas. The pain arises with diarrhea and is aggravated by anger; it is relieved by belching or after the passage of diarrhea. The tongue coating is thin white, and her pulse is wiry. Which of the following treatment principles should be used? A. Dispel cold, warm the interior, regulate qi and relieve pain B. Promote digestion, eliminate stagnation, regulate qi and relieve pain C. Unblock the bowels, discharge heat, move qi and remove food stagnation D. Warm the middle, supplement deficiency, relieve spasm and pain

E. Soothe the liver, resolve constraint, regulate qi and relieve pain Answers 1. B 2. A 3. C 4. D 5. A 6. B 7. E 8. E

22. Flank Pain ANCIENT THEORIES AND MODERN INSIGHTS Flank pain can arise on one or both sides. The foot jueyin liver channel and the foot shaoyang gallbladder channel traverse the flanks, and such, flank pain is mainly caused by disorders of the liver and gallbladder, although sometimes related to diseases of the spleen and the stomach. The pathogenesis of flank pain involves the blockage of channels of the flank region due to either excess pathogenic factors such as qi stagnation, blood stasis and damp-heat, and also malnourishment of the channels of the flank region. Acupuncture treatment principles include soothing the liver, promoting gallbladder function, and moving qi to relieve pain, generally needled with the drainage method; the even method is used in patterns of liver yin deficiency.

ETIOLOGY AND PATHOMECHANISMS External Causes Externally contracted damp-heat: External damp-heat enters the body and causes binding constraint in the shaoyang channel leading to a qi movement disorder. The liver and gallbladder are unable to maintain the free-flow of qi, from which flank pain arises.

Internal Causes Emotional dissatisfaction: When the liver is injured by an emotional disorder or anger, it may fail to govern the free-flow of qi. This can result in qi stagnation and collateral obstruction, from which flank pain with liver constraint appears. Food damage: Dietary irregularities or overconsumption of fat and sweets can give rise to internal damp-heat. Damp-heat retention in the liver and gallbladder may undermine the liver and gallbladder’s function of maintaining the free flow of liver qi, after which the flank pain appears. Overwork, sexual activity or long-term illness: These can all cause depletion of essence and blood, further leading to liver yin deficiency. When the liver or the liver collaterals are malnourished, spasms and flank pain can arise.

Other Causes Local trauma or overexertion: Traumatic injury or overexertion can give rise to injury and obstruction of the collaterals of the flank region,

blood stasis retention, and finally flank pain. The most common flank pain patterns encountered in the clinic are liver constraint and qi stagnation, damp-heat in the liver and gallbladder, blood stasis blocking the collaterals, and malnourishment of the liver collateral.

COMMON CLINICAL PATTERNS Liver constraint and qi stagnation: Distending and migratory pain in the chest and flank aggravated or alleviated by emotion changes, relieved after belching or passing gas. The tongue coating is thin white; the pulse is wiry. Damp-heat in the liver and gallbladder: Distending pain and burning pain of the flank region, a bitter taste in the mouth, a sticky sensation in the mouth, chest oppression, poor appetite and digestion, nausea and vomiting, dark urine, incomplete defecation. The tongue has a greasy yellow coating; the pulse is wiry and slippery. Blood stasis blocking the collaterals: Stabbing pain of the flank region with a fixed location, worse with pressure, much worse at night, and fixed masses with clear borders in the rib-side region in some cases. The tongue is dark purple; the pulse is deep and choppy. Malnourishment of the liver collateral: Dull pain in the flank region aggravated by exertion, dry mouth and throat, vexing heat in the heart. The tongue is red with scanty coating; the pulse is wiry and rapid.

THERAPEUTICS Chinese Medicinals 1. Liver Constraint and Qi Stagnation Formula: Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder) Ingredients: chái hú (Radix Bupleuri), zhĭ qiào (Fructus Aurantii), xiāng fù (Rhizoma Cyperi), chuān liàn zĭ (Fructus Toosendan), bái sháo (Radix Paeoniae Alba), chuānxiōng (Rhizoma Chuanxiong), yù jīn (Radix Curcumae), gān căo (Radix et Rhizoma Glycyrrhizae) 2. Damp-Heat in the Liver and Gallbladder Formula: Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction) Ingredients: lóng dăn căo (Radix et Rhizoma Gentianae), shān zhī zĭ (Fructus Gardeniae), huáng qín (Radix Scutellariae), chuān liàn zĭ (Fructus Toosendan), zhĭ qiào (Fructus Aurantii), yán hú suŏ (Rhizoma Corydalis), zé xiè (Rhizoma Alismatis), chē qián zĭ (Semen Plantaginis) 3. Blood Stasis Blocking the Collateral Formula: Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) or FùYuán Huó Xuè Tāng (Original Qi-Restoring and BloodMoving Decoction) Ingredients: dāng guī (Radix Angelicae Sinensis), chuān xiōng, hé táo rén (Semen Juglandis), hóng huā (Flos Carthami), chái hú, zhĭ qiào, zhì xiāng fù (Rhizoma Cyperi Praeparatum), chuān liàn zĭ, yù jīn (Radix

Curcumae), wŭ líng zhī (Faeces Trogopterori), yán hú suŏ, sān qī (Radix et Rhizoma Notoginseng) 4. Malnourishment of the Liver Collateral Formula: Yī Guàn Jiān (Effective Integration Decoction) Ingredients: shēng dì (Radix Rehmanniae), gŏu qĭ zĭ (Fructus Lycii), huáng jīng (Rhizoma Polygonati), shā shēn (Radix Adenophorae seu Glehniae), mài dōng (Radix Ophiopogonis), dāng guī, bái sháo (Radix Paeoniae Alba), zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle), chuān liàn zĭ, yán hú suŏ

Acupuncture and Moxibustion Treatment 1. Point Selection Based on Channels and Location (1) Select liver channel points on the flank and ren vessel points on the middle abdomen. Points commonly used include LV 13 (zhāng mén), LV 14 (qī mén), and RN 12 (zhōng wăn). (2) Select points on the liver, gallbladder, spleen, stomach, and bladder channels on the lower limbs. Points commonly used include GB 34 (yáng líng quán), GB 40 (qiūxū), GB 44 (zú qiào yīn), LV 2 (xíng jiān), ST 36 (zú sān lĭ), SP 4 (gōng sūn), and BL 40 (wĕizhōng). (3) Select points on the sanjiao and pericardium channels on the upper limbs. Points include SJ 6 (zhī gōu), SJ 5 (wài guān), and PC 6 (nèi guān). (4) Select points on the mid-back such as BL 18 (gān shù) and BL 17 (gé shù), and ashi points on the back. In terms of channels, this disease benefits from points selected on the liver, gallbladder, urinary bladder, spleen, stomach, sanjiao, and

pericardium channels and the ren vessel. 2. Point Selection Based on Pattern Differentiation (1) Cold pain: Select points related to the spleen, stomach, and kidney on the flanks, abdomen and back-shu points, such as LV 13 (zhāng mén), LV 14 (qī mén), and RN 12 (zhōng wăn). (2) Heat pain: Select points that clear the heat from the affected zangfu organs such as the liver, gallbladder and sanjiao. (3) Deficiency pain: Select points that fortify the spleen and strengthen the kidney. (4) Qi stagnation pain: Select local points on the flank region, as well as SJ 6 (zhī gōu) and BL 40 (wĕi zhōng) (5) Stasis pain: Needle the surface of the skin local to the obvious blue vessels as well as points on the related channels and collaterals. (6) Phlegm-dampness pain: Select points that fortify the spleen and transform phlegm-damp. (7) Indigestion pain: Select points that fortify the spleen and harmonize the stomach. (8) Anger and constraint pain: Select points on the liver and gallbladder channels to soothe the liver and resolve constraint.

CASE STUDY I Ms. Zhang, age 42. Initial Visit: May 2nd, 2004 Chief Complaint: Pain at both flanks for three months, worse over the past 48 hours. History: The patient initially felt pain in his flanks after quarrelling with a neighbor three months ago. She took Xiāo Yáo Săn (Free Wanderer Powder), but it was only somewhat effective. Signs and Symptoms: Distending and migratory pain of both flanks, chest oppression, epigastric bloating, frequent belching, easily angered, vexation and agitation. Her tongue had a thin coating, and the pulse was wiry. Past History: No history of hypertension or diabetes; no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or food. Menstrual, Marital and Childbearing History: Menarche age 14, menstrual cycle 27-28 days, menstrual period 3-5 days, scanty red menses. The last menstrual date was April 27th, 2004. Physical Examination: The patient was a lean female, well-developed and moderately nourished. Her skin and sclera showed no indication of jaundice. There was no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, with resonant percussion sounds (normal). Heart rate was 70 bpm and regular, with no pathological murmur at any valve area. Flat, soft

abdomen, liver and spleen were non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Laboratory Examination: Erythrocytes: 2.8 × 1012/L; platelets: 88 × 109/L. Pattern Differentiation After quarreling with a neighbor, the patient felt pain at the flanks, and then developed frequent belching, irritability and restlessness. The tongue coating was thin; her pulse was wiry. The presenting pattern here is liver constraint and qi stagnation with stasis obstructing the channel and collaterals. The liver is the disease location. Diagnosis TCM pattern: Liver constraint and qi stagnation Pattern Differentiation Treatment should focus on soothing the liver, resolving constraint and regulating qi movement. Instructing the patient to regulate how they think and to maintain a positive emotion is also an indispensable part of treatment. Principles: Soothe the liver and regulate qi Formula: Modified Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder) [柴胡疏肝散加减]

Three doses. One decocted dose per day. [Formula Analysis] This formula is modified from Sì Nì Săn (Frigid Extremities Powder) by removing zhĭ shí and adding chén pí, zhĭ qiào, chuān xiōng, and xiāng fù to strengthen the functions of soothing the liver, moving qi, invigorating blood and relieving pain. Using this formula, the liver qi and blood in the channels should regain free-flow, thus relieving her pain and all other symptoms.

Acupuncture Points: LV 14 (qī mén), LV 3 (tài chōng), GB 34 (yáng líng quán), SJ 6 (zhī gōu) Method: After qi was obtained, the needles were retained for 20-30 min. One treatment per day, ten treatments constitute one course. Techniques: Drainage needling was applied. Further Consultation The patient was cured after just two treatments.

CASE STUDY II (ACUPUNCTURE, Wang Leting) Ms. Liu, age 28. Chief Complaint: Pain on the right flank for two days. History: After a quarrel with her boyfriend, the patient felt distending pain on the right flank with chest oppression, a bitter taste in the mouth and a poor appetite. Physical Examination: The tongue was red with a thin white coating; her pulse was wiry. Diagnosis Flank pain due to liver constraint and qi stagnation Clinical Treatment Principles: Soothe the liver and resolve constraint Points: SJ 6 (zhī gōu), LV 14 (qī mén), GB 34 (yáng líng quán) Techniques: Drainage needling was employed. Note LV 14 (qī mén), the front-mu point of the liver, was used to soothe the liver and unblock the collaterals. As the shaoyang channels pass through the flanks, SJ 6 (zhīgōu) and GB 34 (yáng líng quán) were used to regulate the channel-qi of the shaoyang channels and relieve pain.

COMMENTARY AND DISCUSSION Most of the patterns described in this chapter associate flank pain with the jueyin liver channel and the shaoyang gallbladder channel. It is interesting to note the often-used duì yào (herb combination) of bái sháo (Radix Paeoniae Alba) and chái hú (Radix Bupleuri). Together, these two medicinals enter the liver and gallbladder to facilitate the flow of qi in the flanks, and yet when looking at their properties, they are opposites in many regards. Bái sháo is sour, which directs qi inward, whereas chái hú is pungent, which directs qi outward and upward. Bái sháo emolliates and moistens the liver to help it perform its functions of ensuring the free-flow of qi, while chái hú is drying, and activating, also used with caution in cases of yin deficiency as it is said to “plunder the yin”. I think of this as how a sponge is useless until it is wet. Because it is a yin-organ, the liver tends to deficiency, while the yangorgans tend to become excess. Bái sháo nourishes the liver blood to address that deficiency, while chái hú spreads the liver qi to address the excess of stagnation. The balanced use of these two medicinals is an important part of the medicinal treatment of flank pain as well as other excess/deficiency symptoms that arise from or give rise to qi stagnation.

STUDY QUESTIONS 1. Why was drainage needling applied in the first case? 2. To which channels is flank region pain related in the first case? 3. Which of the following represent the basic therapeutic principles for flank pain? A. Soothe the liver, boost qi and relieve pain B. Clear heat, drain dampness and relieve pain C. Dispel stasis, unblock collaterals and relieve pain D. Nourish yin, soften the liver and relieve pain E. Soothe the liver, harmonize the collaterals and relieve pain 4. Which one of the following items is NOT the characteristic of flank pain due to liver constraint and qi stagnation? A. Distending pain at the flank B. Migratory pain C. Pain that is aggravated at night D. Chest oppression and belching E. Pain aggravated by emotion 5. Which one of the following signs and symptoms is NOT the characteristic of flank pain due to liver-gallbladder damp-heat? A. Burning pain at the flank B. Bitter sticky sensation in the mouth

C. Dark yellow urine D. Red tongue with little coating E. Wiry, slippery and rapid pulse 6. Which one of the following signs and symptoms is NOT the characteristic of flank pain due to blood stasis blocking the collaterals? A. Stabbing pain at the flank B. Oppression and distended pain in the chest C. Fixed pain D. Pain aggravated at night E. Dark purple tongue 7. Which one of the following options is NOT the characteristic of flank pain due to malnourishment of the liver collaterals? A. Burning pain at the flank B. Permanent dull pain C. Pain aggravated when fatigued D. Red tongue with scanty coating E. Vertigo and dizzy vision Answers 1. The presenting pattern differentiation in this case was liver constraint and qi stagnation, which is an excess pattern, thus drainage needling techniques were used. 2. The liver and gallbladder channels.

3. E 4. C 5. D 6. B 7. A

23. Dysmenorrhea ANCIENT THEORIES AND MODERN INSIGHTS Dysmenorrhea is abdominal pain associated with menstruation, commonly affecting the lower abdomen and radiating to the lumbosacral region. In acute cases, the pain and cramping can become severe enough to cause fainting. Dysmenorrhea can be classified into two types: primary and secondary. Primary dysmenorrhea pertains to functional dysmenorrhea without any obvious disease of the reproductive organs as determined by a gynecological examination. Secondary dysmenorrhea refers to conditions secondary to diseases of the reproductive organs. In this section we focus on primary dysmenorrhea. In Chinese medicine, the occurrence of dysmenorrhea is closely related to periodic physiological changes of the chong and ren vessels, as well as the uterus. Chong and ren vessel disharmonies often arise from an invasion of pathogenic factors that lead to chong and ren vessel obstruction or congealing cold in the channels, either of which can inhibit the free movement of qi and blood and block the circulation of menses. “Stagnation causes pain”, so the treatment principles for dysmenorrhea generally include either warming the channels to dissipate cold, or eliminating blood stasis to stop pain. Acupuncture techniques favor the reducing method optionally with moxibustion.

When the uterus or the chong and ren vessels are not adequately nourished, pain from deficiency can also arise, because “deficiency causes pain”. In this case, we should regulate and supplement the chong and ren vessels with acupuncture techniques that employ the supplementing method, optionally with moxibustion.

ETIOLOGY AND PATHOMECHANISMS Qi stagnation and blood stasis: If the patient suffers from chronic depression or is constantly affected by negative emotions, the liver qi can bind, constrain, and stagnate. When the premenstrual or menstrual period arrives, the uterus and the chong and ren vessels are full of qi and blood which then stagnates. “Stagnation causes pain”, and is then called dysmenorrhea. Congealing cold in the uterus: This can arise from a constitutional yang deficiency, chronic exposure to damp environments, an excessively cold diet, or exposure to rain or swimming in cold water during menstruation. Any of these scenarios can lead to internal yin-cold exuberance. The cold-pathogen causes constriction and contraction which undermines the blood circulation, causing the pain of dysmenorrhea. Qi and blood deficiency: Qi and blood fails to be generated due to deficiency of the spleen and stomach. When blood is excreted as menses during menstruation, the sea of blood tends to empty, leading to inadequate nourishment for the chong and ren vessels as well as the uterus. The deficiency of blood then leads to pain. Deficiency of the liver and kidney: This condition also ultimately results in a deficiency of blood with inability to nourish the uterus and subsequent dysmenorrhea. Kidney essence and liver blood share an intertransformational relationship whereby essence can transform into liver blood when needed, and liver blood can transform into essence when needed. A deficiency of either liver blood or kidney essence can ultimately

turn into a lack of blood in the chong and ren vessels, leading to pain in the uterus. The four patterns above are the most commonly encountered in the clinic.

PATTERN DIFFERENTIATION The correct differentiation of dysmenorrhea patterns requires recognition of signs and symptoms of cold, heat, deficiency and excess. When these symptoms appear, the nature of the pain, its location, and its degree further define the presenting pattern. Also important are the qualities of the period, including the quantity, color and viscosity of the menses, the accompanying symptoms, the appearance of the tongue, the pulse qualities, and the constitution of the body. Generally speaking, pain that occurs before or during menstruation pertains to an excess pattern, while pain that arises afterwards pertains to a deficiency pattern. Pain that is worse with pressure suggests excess, while pain that is relieved by pressure suggests deficiency. Pain that is aggravated by heat pertains to a heat pattern, while pain that is relieved by heat suggests a cold pattern. If the sense of bloating is greater than the pain, this belongs to qi stagnation. If the pain is greater than the bloating, this suggests dysmenorrhea due to blood stasis. If the pain occurs in the lesser abdomen and arises with breast distention, the location of the disease lies in the liver. If the pain involves the lumbosacral region and arises with dizziness and tinnitus, the kidney is usually involved. Qi stagnation and blood stasis: Bloating with stabbing pain, distending pain of the chest and breast, and inhibited menstruation with dark purple clots in the menses. There may be dark stasis spots on the tongue; the pulse is choppy. Congealing cold in the uterus: Cold-type pain which is relieved by warmth. The tongue coating is white, the pulse is tight.

Qi and blood deficiency: Pain and a heavy feeling in the abdomen, pale menses, headache, palpitations. The tongue is pale; the pulse is thready. Deficiency of liver and kidney: Persistent dull pain along with low back pain, tinnitus, and pale thin or watery menses. The tongue is pale; the pulse is deep and thready.

THERAPEUTICS Chinese Medicinals Chinese medicinal formulas should be given during the week prior to the menstrual period. For stubborn or chronic conditions, however, medicinals should be prescribed for the entire month. In addition to a formula that addresses the root pattern, we can also add medicinals that directly relieve pain. Individual medicinals chosen for their analgesic qualities can be mixed and matched, depending on the presenting pattern and the base formula used. Individual medicinals for dysmenorrhea due to cold include: ài yè (Folium Artemisiae Argyi), xiăo huí xiāng (Fructus Foeniculi), páo jiāng (Rhizoma Zingiberis Praeparatum), ròu guì (Cortex Cinnamomi), wū yào (Radix Linderae), and wú zhū yú (Fructus Evodiae). Medicinals for qi stagnation include: xiāng fù (Rhizoma Cyperi), chuān liàn zĭ (Fructus Toosendan), and yán hú suŏ (Rhizoma Corydalis). Medicinals for blood stagnation pain include: chuān xiōng (Rhizoma Chuanxiong), rŭ xiāng (Olibanum), mò yào (Myrrha), sān qī (aka tián qī) (Radix et Rhizoma Notoginseng) and pú huáng (Pollen Typhae). 1. Qi Stagnation and Blood Stasis Formula: Gé Xià Zhú Yū Tāng (Expelling Stasis Below the Diaphragm Decoction) Ingredients: chuān xiōng, dāng guī (Radix Angelicae Sinensis), chì sháo (Radix Paeoniae Rubra), hóng huā (Flos Carthami), zhĭ qiào (Fructus

Aurantii), yán hú suŏ, wŭlíng zhī (Faeces Trogopterori), mŭ dān pí (Cortex Moutan), wū yào, xiāng fù, gān căo (Radix et Rhizoma Glycyrrhizae) 2. Congealing Cold in the Uterus (1) Yang deficiency and internal cold Formula: Wēn Jīng Tāng (Channel-Warming Decoction) Ingredients: wú zhū yú, chuān xiōng, dāng guī, chì sháo, rén shēn (Radix et Rhizoma Ginseng), shēng jiāng (Rhizoma Zingiberis Recens), bàn xià (Rhizoma Pinelliae), mŭ dān pí, guì zhī (Ramulus Cinnamomi), zhì fù zĭ (Radix Aconiti Lateralis Praeparata), ài yè, xiăo huí xiāng, gān căo (2) Stagnation of cold and dampness Formula: Shào Fù Zhú Yū Tāng (Lesser Abdominal Stasis-Expelling Decoction) Ingredients: xiăo huí xiāng, gān jiāng (Rhizoma Zingiberis), yán hú suŏ, mò yào, dāngguī, chuān xiōng, ròu guì, chì sháo, pú huáng, wŭ líng zhī 3. Qi and Blood Deficiency Formula: Shèng Yù Tāng (Sagacious Cure Decoction) Ingredients: rén shēn, huáng qí (Radix Astragali), dāng guī, chuān xiōng, shú dì huáng (Radix Rehmanniae Praeparata), shēng dì huáng (Radix Rehmanniae) 4. Deficiency of Liver and Kidney Formula: Dāng Guī Dì Huáng Yĭn (Chinese Angelica and Rehmannia Beverage)

Ingredients: dāng guī, shú dì huáng (Radix Rehmanniae Praeparata), huái shānyào (Rhizoma Dioscoreae), dù zhòng (Cortex Eucommiae), niú xī (Radix Achyranthis Bidentatae), shān zhū yú (Fructus Corni), zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle)

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels and Location (1) Local points on the ren vessel and stomach channels (on the abdomen): RN 4 (guān yuán), RN 3 (zhōng jí), RN 6 (qì hăi), RN 7 (yīn jiāo), ST 25 (tiān shū), ST 28 (shuĭdào), ST 29 (guī lái), and ST 30 (qì chōng). (2) Spleen, stomach and kidney channel points (on the lower limbs): SP 4 (gōngsūn), SP 6 (sān yīn jiāo), ST 36 (zú sān lĭ), ST 37 (shàng jù xū), ST 38 (tiáo kŏu), KI 3 (tài xī), KI 6 (zhào hăi), and KI 8 (jiāo xìn). The channels associated with these points all pass through the lower abdomen. 2. Point Selection Based on Pattern Differentiation (1) Qi stagnation and blood stasis: LV 3 (tài chōng) and SP 10 (xuè hăi). (2) Congealing cold and blood stasis: RN 4 (guān yuán) and ST 29 (guī lái). Moxibustion is especially applicable in all cases involving cold. (3) Qi and blood deficiency: SP 10 (xuè hăi) and RN 6 (qì hăi). (4) Deficiency of kidney qi: BL 23 (shèn shù) and KI 3 (tài xī). (5) For stagnation pain which tends to worsen before menstruation: ST 25 (tiānshū), RN 7 (yīn jiāo), RN 4 (guān yuán), RN 6 (qì hăi), SP 6 (sān yīn jiāo) and LV 1 (dàdūn).

(6) For deficiency pain which tends to worsen after menstruation: SP 6 (sān yīnjiāo) and RN 4 (guān yuán). When the pain is acute, electro-stimulation can be used. Treatment is performed 1-2 times each day during the disease onset period, and once daily or once every other day during remission, beginning a week before the period.

CASE STUDY I Ms. Shi, age 26. Initial Visit: December 16th, 2008 Chief Complaint: Cold pain in the lower abdomen for one day. History: Ms. Shi was caught in a rain storm during her menstrual period three months ago. Since then, she has had abdominal pain appearing before or during her period. She was then referred for acupuncture and moxibustion treatment. Signs and Symptoms: The patient reported that during her latest menstrual period that commenced on December 15th, she experienced a cold pain in her lower abdomen which was aggravated by pressure and relieved by warmth. The menses was scanty with purple clots. The patient had a fear of cold, cold hands and feet, and a pale bluish complexion. Her tongue was dim purple with a white coating; the pulse was deep and thready. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or foods. Menstrual, Marital and Childbearing History: Menarche at age 13, menstrual cycle 28-30 days, menstrual period 4-5 days, profuse purple menses with clots. Abdominal pain occurs just before and during menstruation. Physical Examination: The patient was a lean female, well-developed and moderately nourished, her skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention,

hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, with resonant percussion sounds (normal). Heart rate was 70 bpm and regular, with no pathological murmur at any valve area. Flat abdomen, liver and spleen were non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Laboratory Examination: Red blood cell count: 3 × 1012/L, platelet count: 90 × 109/L. Pattern Differentiation Key indications: the patient felt abdominal pain after she had been caught in a rain. Pathogenic cold and dampness entered the channels and ultimately invaded the chong and ren vessels and the uterus. The cold blocked the movement of menses, thus generating lower abdominal coldtype pain during menstruation. The blood stagnation caused by cold led to scanty purple menses with clots. Other indications of cold include pain relieved by warmth, a white tongue coating, a purple tongue body, and a deep thready pulse, all of which suggested internal cold and dampness leading to qi stagnation and blood stasis. Hence, the cause of disease was cold stagnation and blood stasis in the uterus and channels. Diagnosis TCM pattern: Stagnation of cold and dampness Clinical Treatment In this case, the patient should be advised to avoid exposure to rain, wind and cold, and swimming in cold water. She also should avoid raw,

cold or oily foods. She was also encouraged to limit strenuous exercise and heavy physical labor during her period. Principles: Warm the channels and dissipate cold, dissolve stasis to relieve pain Formula: Modified Shào Fù Zhú Yū Tāng (Lesser Abdominal StasisExpelling Decoction) [少腹逐瘀汤加减]

Three doses. One decocted dose per day. [Formula Analysis] Ròu guì, gān jiāng and xiăo huí xiāng warm the channels and dissipate cold, unblock the lower jiao, and dissipate cold in the lower abdomen and uterus. Yán hú suŏ acts to move qi and dissolve blood stasis, disperse swelling and relieve pain. Used together, pú huáng and wŭ líng zhī comprise the formula Shī Xiào Săn (Sudden Smile Powder), which acts to invigorate blood, dissolve stasis, dissipate masses and relieve pain. Pú huáng is used in its raw form

when invigorating blood and dissolving stasis , while dry-fried wŭ líng zhī can relieve pain without injuring stomach qi. Dāng guī invigorates and nourishes the blood. Chuān xiōng can promote movement of the qi in the blood, and when used with chìsháo, they together act to invigorate the blood, move qi, dissolve stasis and regulate menstruation. This formula is commonly used for gynecological diseases that benefit from activating the blood, dissolving stasis and warming the channels to eliminate pain.

Acupuncture Main points: RN 4 (guān yuán), SP 6 (sān yīn jiāo), SP 8 (dì jī), ST 28 (shuĭ dào), shí qīzhuī (EX-B8) Method: After qi was obtained, all needles were retained for 20-30 min. Treatments were provided one or two times per day during the acute stage, beginning three days before the period. Techniques: Needle rotation was used at RN 4 (guān yuán) to guide the needling sensation downwards. Moxibustion was applied at points on the lower abdomen. Further Consultation After three courses of treatment, the dysmenorrhea was relieved.

CASE STUDY II (ACUPUNCTURE, Jin Bo-hua) Mrs. Suo, age 37. Chief Complaint: Abdominal pain during menstruation for over ten years. History: Mrs. Suo initially had abdominal pain during menstruation ten years prior to her arrival in our clinic. The pain became unbearable after pregnancy, with dusky purple menses, but without clots. The dull pain persists over ten days around menstruation, peaking in intensity during her menstruation. She prefers warmth, is averse to cold, and found the symptoms relieved by pressure. There is also aching pain of the lower back, fatigue, poor appetite, vertigo, insomnia, palpitations and shortness of breath. Physical Examination: Pale tongue with a thin white coating. Her pulse was deep and thready, plus wiry and rapid on the left side. Diagnosis Dysmenorrhea due to deficiency of qi and blood Clinical Treatment Principles: Supplement and nourish qi and blood, warm and regulate the chong and ren vessels, fortify the spleen and nourish the kidney. Points: BL 23 (shèn shù), DU 4 (mìng mén), DU 9 (zhì yáng), RN 12 (zhōng wăn), RN 6 (qì hăi), RN 4 (guān yuán), ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo)

Techniques: Apply moxibustion to DU 4 (mìng mén) and RN 4 (guān yuán) every other day, and needle all other points with supplementation. After one course of treatment (ten treatments), all symptoms had disappeared and her spirit was improved. The patient was asked to return for treatment one week before menstruation. After three courses of treatment, the patient was cured. There was no relapse at a two-year follow-up. Note The selected points all act to supplement qi and blood, while moxibustion acts to warm the channels and relieve pain.

COMMENTARY AND DISCUSSION Swimming in cold water during menstruation is listed in this chapter as an etiological factor for dysmenorrhea. This certainly does sound like a quaint Chinese take on things, but in areas where surfing or other water sports are popular, a qian of prevention is most certainly worth a jin of relief. Menstruation can cause a temporary deficiency of qi and blood in many women. During this time, the body is more easily invaded by pathogenic factors, which includes the cold from the water. As such, swimming or engaging in activities that bring one into direct contact with water can allow for the invasion of cold into the uterus, where it may remain dormant until the next period, which can then be extremely painful. This pain would naturally be alleviated by warmth and/or addressed by the protocols described in this chapter. The importance of points on the spleen channel arises from two unique mechanisms. The first is the trajectory of the spleen channel as it rises up the lower abdomen with points on the spleen channel being local to the pain of dysmenorrhea. The other benefit of using points on the spleen channel is due to its important relationship with the chong vessel. Because of the chong vessel designation as the “sea of blood”, it is implicated in many disharmonies of menstruation. The spleen is called the root and source of the chong vessel, and not surprisingly, the master point for the chong vessel is located on the spleen channel at SP 4 (gōng sūn). The chong vessel and the spleen channel further overlap in that they are both sources of the body’s blood, and that

they both rule blood and/or menstruation. As such, imbalances in the spleen or chong vessel are common causes for bēng lòu, or menstrual “flooding and spotting”. So, as you use the points on the spleen channel in the treatment of menstrual pain thanks to the trajectory of the channel, remember that many spleen points also benefit the chong vessel and its influence on menstrual function.

STUDY QUESTIONS 1. Why was moxibustion used in the first case? 2. In the first case, why was point shí qī zhuī (EX-B8) selected? 3. For dysmenorrhea caused by qi stagnation and blood stasis, which of the following point-pairings is most suitable? A. ST 36 (zú sān lĭ) and BL 20 (pí shù) B. LV 3 (tài chōng) and BL 20 (pí shù) C. BL 17 (gé shù) and BL 20 (pí shù) D. SP 6 (sān yīn jiāo) and RN 4 (guān yuán) E. DU 4 (mìng mén) and KI 3 (tài xī) 4. Which of the following points is NOT used to treat dysmenorrhea caused by stagnation of cold and dampness? A. ST 28 (shuĭ dào) B. SP 8 (dì jī) C. RN 4 (guān yuán) D. LI 4 (hé gŭ) E. SP 6 (sān yīn jiāo) Answers 1. The patient was diagnosed with stagnation of cold and dampness. Moxibustion on the abdomen warms the channels and dissipates cold to relieve pain.

2. Shí qī zhuī (EX-B8) is an empirical point for dysmenorrhea located below the spinous process of the fifth lumbar vertebrae. Acupuncture or tui na massage applied to this point can relieve the pain of dysmenorrhea. 3. B 4. D

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Ms. Liu, age 27, complains of a cold pain in the lower abdomen during or after menstruation. Pressure and heat both bring some relief. The menses is scanty and pale purple, and her urine is clear and copious. The tongue is pale and enlarged with a moist white coating, and her pulse is deep. Which of the following formulas would be your first choice? A. Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill) B. Yòu Guī Wán (Right-Restoring Pill) C. Zuŏ Guī Wán (Left-Restoring Pill) D. Wēn Jīng Tāng (Channel-Warming Decoction) E. Èr Zhì Wán (Double Supreme Pill) 2. Ms. Yu, age 22, complains of distending pain during menstruation. The pain resists pressure and refers to the chest and flanks. She also reports scanty menstrual flow with clotted purple menses. The pain eases following the passing of the blood clots. The tongue body is dim with a thin white coating, and the pulse is wiry. Which of the following is the best choice of formula?

A. Gé Xià Zhú Yū Tāng (Expelling Stasis Below the Diaphragm Decoction) B. Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) C. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) D. Xiāo Yáo Săn (Free Wanderer Powder) E. Fù Yuán Huó Xuè Tāng (Original Qi-Restoring and Blood-Moving Decoction) 3. Ms. Wang, age 46, presents with a persistent dull pain for one or two days after her menstrual period. Her menses are pale, thin and scanty. There is soreness and pain in the low back as well as occasional afternoon fevers and tinnitus. Which of the following formulas is the best choice? A. Dāng Guī Dì Huáng Yĭn (Chinese Angelica and Rehmannia Beverage) B. Xiāo Yáo Săn (Free Wanderer Powder) C. Yòu Guī Wán (Right-Restoring Pill) D. Fù Yuán Huó Xuè Tāng (Original Qi-Restoring and Blood-Moving Decoction) E. Jīn Guì Shèn Qì Wán (Golden Cabinet’s Kidney Qi Pill) Answers 1. D 2. A

3. A

24. Renal Colic (Kidney Stones) ANCIENT THEORIES AND MODERN INSIGHTS Renal colic is a kind of pain caused by kidney stones, characterized by sudden acute pain of the lower back or lateral regions of the abdomen. The pain radiates upward or downward along the ureter, and is accompanied by varying degrees of painful and bloody urination. According to TCM, renal colic belongs to the categories of “low back pain”, “stone strangury”, “sand strangury” and “blood strangury”.

ETIOLOGY AND PATHOMECHANISMS Damp-heat in the lower jiao: Improper diet that is excessively fat, sweet, spicy, or alcoholic impairs the qi of the spleen and stomach. The spleen fails in its function to transport and thus damp-heat and fire-toxin accumulate internally. The nature of dampness is to flow downward. So as damp-heat descends to the lower jiao and scorches the urine, the resulting impurity forms stones to cause renal colic. Deficiency of kidney qi: Because of a congenital insufficiency or poor nourishment of the acquired constitution, the upright qi is consumed and depleted. When the condition becomes chronic, the qi depletion combined with blood stasis causes stone formation and renal colic.

COMMON CLINICAL PATTERNS Damp-heat in the lower jiao: Turbid dark urine and hematuria or stones accompanied by continuous, dribbling urination. The tongue body is red with a yellow or greasy coating; the pulse is wiry, tight, or rapid. Deficiency of kidney qi: Forceless and hesitant urination, sometimes flowing outward only as drops, accompanied by fatigue. The tongue body is pale with a thin white or yellow coating; the pulse is wiry and tight.

THERAPEUTICS Chinese Medicinals 1. Damp-heat in the Lower Jiao Formula: Shí Wéi Săn (Pyrrosia Leaf Powder) Ingredients: jīn qián căo (Herba Lysimachiae), chē qián zĭ (Semen Plantaginis), shíwéi (Folium Pyrrosiae), hăi jīn shā (Spora Lygodii), biăn xù (Herba Polygoni Avicularis), dà huáng (Radix et Rhizoma Rhei), gān căo (Radix et Rhizoma Glycyrrhizae) 2. Deficiency of Kidney Qi Formula: Yòu Guī Yĭn (Right-Restoring Beverage) Ingredients: shú dì (Radix Rehmanniae Praeparata), niú xī (Radix Achyranthis Bidentatae), bái zhú (Rhizoma Atractylodis Macrocephalae), gŏu qĭ (Fructus Lycii), jīnèi jīn (Endothelium Corneum Gigeriae Galli), shān zhū yú (Fructus Corni), dù zhòng (Cortex Eucommiae), ròu guì (Cortex Cinnamomi)

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels Select front-mu and back-shu points of the kidney and bladder channels. Frequently used points: RN 3 (zhōng jí), GB 25 (jīng mén), BL 23 (shèn shù), and BL 28 (páng guāng shù).

2. Point Selection Based on Pattern Differentiation (1) Damp-heat in the lower jiao: SP 6 (sān yīn jiāo), RN 2 (qū gŭ), SP 9 (yīn líng quán) (2) Deficiency of kidney qi: DU 4 (mìng mén), RN 6 (qì hăi), RN 4 (guān yuán) Techniques: Drainage methods are applied in patterns of lower jiao damp-heat. For kidney qi deficiency patterns, use supplementation or the even method; moxibustion is also applicable.

CASE STUDY I Mr. Qiu, age 40. Initial Visit: February 11th, 1974 Chief Complaint: Urinary difficulties including pain and hematuria for two years. History: The patient had suffered from difficult painful urination with bloody urine for two years. He was diagnosed with renal and ureteral stones in a hospital. At 11 pm, he had acute gripping pain of the kidney region, so he came to our clinic for further treatment. Signs and Symptoms: Sudden pain in the right kidney radiating to the right abdomen and inner thigh, continuous dribbling urination with blood. His tongue was red with a yellow coating; the pulse was wiry and tight. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis or tuberculosis, no past history of allergies to drugs or foods. Physical Examination: The patient was a lean male, well-developed and moderately nourished. His skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical with resonant percussion sounds (normal). Heart rate was 70 bpm and regular, with no pathological murmur at any valve area. Flat abdomen, liver and spleen non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Pattern Differentiation

The key indications of this patient are: painful and bloody urine for two years. As damp-heat accumulated in the lower jiao, the impurity of the urine formed into stones which obstructed qi movement and resulted in acute pain of the kidney region. The stones impaired the vessels and led to hematuria with continuous dribbling urination. The tongue body was red with a yellow coating; the pulse was wiry and tight. The signs and symptoms suggest a pattern of excess and heat. Diagnosis TCM pattern: Damp-heat pouring downward Clinical Treatment The patient suffered from an internal accumulation of damp-heat which transformed into stones resulting in colic pain. The treatment principles here are to clear heat, drain dampness, relieve strangury and stop pain. In addition to Chinese medicinal and acupuncture treatments, the patient should be advised to drink great quantities of water and to do sports which involve running and jumping to help discharge the stones. Principles: Clear heat, promote urination, relieve strangury and stop pain Formula: Modified Shí Wéi Săn (Pyrrosia Leaf Powder) [⽯韦散加减]

[Formula Analysis] Shí wéi, hăi jīn shā, jīn qián căo, chē qián zĭ and biăn xù promote urination and discharge stones. Dà huáng clears damp-heat. Xiăo jì, ŏu jié and bái máo gēn stop bleeding. Gān căo harmonizes all formula medicinals.

Acupuncture Points: Ashi points, BL 23 (shèn shù), GB 25 (jīng mén) Techniques: Needle BL 23 (shèn shù) and GB 25 (jīng mén) perpendicularly to 1-2 cun, apply lifting and thrusting or scraping methods. The insertion depth of ashi points on the abdomen should be no deeper than to penetrate the abdominal membrane, mild lifting and thrusting or scraping is also applied. All points should be manipulated until the pain is relieved. Needles are retained for 1-2 hrs with manipulation applied every 10-20 min. Further Consultation After two treatments, the patient discharged a wheat kernel-sized stone, after which his symptoms were greatly relieved.

CASE STUDY II (ACUPUNCTURE, Wang Zhiyi) Mr. Yan, age 54. Chief Complaint: Left low back pain and sudden abdominal pain in the left lower quadrant. History: The patient came to our clinic on Feb 25th, 1984. His lower back and abdominal pain was accompanied by nausea, and frequent urgent urination. He had a pale complexion and tenderness in the lower left quadrant of the abdomen. The pain was sensitive to percussion of the left kidney region. The tongue was pale with a thin white coating; the pulse was deep and thready. Diagnosis WM diagnosis: Renal colic Clinical Treatment Principles: Relax spasm and stop pain Points: KI 3 (tài xī), PC 6 (nèi guān). Both points needled bilaterally. Techniques: Moderate to intense stimulation was applied at KI 3 (tài xī) to generate a feeling of distention and numbness radiating from the ankle to the foot. The needles were retained for 30-90 min, and manipulated repeatedly. Note

KI 3 (tài xī) is the yuan-source point of the foot shaoyin kidney channel. It acts to harmonize interior and exterior, transport between the upper and lower, and regulate the flow of original qi from the kidney. KI 3 (tài xī) can treat acute or chronic kidney patterns of excess or deficiency. PC 6 (nèi guān) is the luo-connecting point of the hand jueyin pericardium channel, which connects to the yinwei vessel. The yinwei vessel connects with the foot taiyin, shaoyin and jueyin channels and also to the ren vessel and yangming channels. All of these channels pass through the chest, abdomen and flanks, thus PC 6 (nèi guān) can treat diseases of the chest, abdomen and flank.

COMMENTARY AND DISCUSSION The damp-heat etiology for kidney stones and the renal colic that ensues should come as no surprise to those accustomed with treating kidney stone or gall stones. However, cases associated with kidney qi deficiency and blood stasis are less commonly encountered in modern-era books on Chinese internal medicine. It is widely assumed in TCM that age leads to kidney deficiency; however, a more modern CM theory strongly associates aging with blood stagnation. This particular diagnosis of kidney qi deficiency plus blood stagnation may thus prove a popular approach for a modern aging population who do not otherwise show signs and symptoms of damp-heat. The pale tongue body, as a sign of kidney qi deficiency may also be a pink, but with little brightness or spirit. This color can thus be described as dusky or dim, and is commonly found in cases of blood stagnation.

STUDY QUESTIONS 1. In the first case of renal colic, why were BL 23 (shèn shù) and GB 25 (jīng mén) selected? 2. In addition to medicinal and acupuncture treatments, what else should be provided to the patient in the first case? Answers 1. BL 23 (shèn shù) is the back-shu point of the kidney and GB 25 (jīng mén) is the front-mu point of the kidney. Combining back-shu and front-mu points is a method for treating disease in a given organ. 2. During treatment, the patient should be instructed to drink a great deal of water, and also to do sports that involve running or jumping to help discharge the stones.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mr. Huang, age 47, had dark urine which came out in hesitant drops with blood and stones. The tongue body was red with a yellow greasy coating; his pulse was wiry. Which of the following is the most applicable formula? A. Shí Wéi Săn (Pyrrosia Leaf Powder) B. Yòu Guī Yĭn (Right-Restoring Beverage) C. Zuŏ Guī Yĭn (Left-Restoring Beverage) D. Zhú Yè Shí Gāo Tāng (Lophatherum and Gypsum Decoction) E. Wĕi Jìng Tāng (Phragmites Stem Decoction) 2. Mr. Gao, age 52, has a weak urine stream that was little more than hesitant dripping. Other observations include weak respiration and mental fatigue. The tongue body is pale with a thin yellow coating; his pulse is tight and wiry. Which of the following formulas is indicated? A. Shí Wéi Săn (Pyrrosia Leaf Powder) B. Yòu Guī Yĭn (Right-Restoring Beverage) C. Zuŏ Guī Yĭn (Left-Restoring Beverage)

D. Zhú Yè Shí Gāo Tāng (Lophatherum and Gypsum Decoction) E. Wĕi Jìng Tāng (Phragmites Stem Decoction) Answers 1. A 2. B

25. Gallbladder Pain ANCIENT THEORIES AND MODERN INSIGHTS Gallbladder pain is a common acute syndrome which manifests as colicky pain in the upper right quadrant; the pain may come and go quickly, or it may be continuous. Gallbladder pain occurs secondary to biliary tract diseases including cholecystitis, cholangitis, cholelithiasis, and biliary ascariasis. There are early records of gallbladder pain in TCM. Regarding the gallbladder channel, the Spiritual Pivot: Channel Vessels (Líng Shū: Jīng Mài, 灵枢·经脉) states, “…when this channel is diseased, the patient has a bitter taste in the mouth, frequent sighing, flank pain and an inability to rotate the torso”. In TCM, the various kinds of gallbladder pain belong to “flank pain”.

ETIOLOGY AND PATHOMECHANISMS Binding constraint of liver qi: Constrain of the liver undermines the free-flow of liver qi, whereby it blocks collaterals and leads to flank pain. The liver qi constraint arises from emotional disorders such as sorrow or anger. Dietary irregularities: Excessive intake of fatty, sweet or heavy foods impairs the spleen and stomach. When the spleen and stomach fail to transport, damp-heat and fire-toxins accumulate internally. Furthermore, accumulated phlegm-damp transforms to heat and eventually congeals into stones. Parasite movement: Parasites enter the biliary tract causing gallbladder pain.

COMMON CLINICAL PATTERNS Qi stagnation of the liver and gallbladder: Gallbladder pain is often triggered by emotional stimuli, and is accompanied by chest tightness, sighing, nausea, vomiting, poor appetite, vexation and irritability. The tongue coating is thin and white; the pulse is wiry and tight. Damp-heat of the liver and gallbladder: Gallbladder pain in the upper right quadrant accompanied by fever and chills, a bitter taste in the mouth, dry throat, nausea and vomiting; there may be jaundice of the eyes, body and urine, constipation, and cold sweats. The tongue coating is greasy and yellow; the pulse is wiry and rapid. Parasite movement: Sudden severe drilling-type pain in the upper right quadrant with aversion to pressure, vexation, fever and chills, nausea and vomiting, vomiting of worms, and poor appetite. The tongue coating is thick and white; the pulse is wiry and tight.

THERAPEUTICS Chinese Medicinals 1. Qi Stagnation of the Liver and Gallbladder Formula: Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder) Ingredients: chái hú (Radix Bupleuri), xiāng fù (Rhizoma Cyperi), chén pí (Pericarpium Citri Reticulatae), zhĭ qiào (Fructus Aurantii), chuān xiōng (Rhizoma Chuanxiong), bái sháo (Radix Paeoniae Alba), gān căo (Radix et Rhizoma Glycyrrhizae) 2. Damp-heat of the Liver and Gallbladder Formula: Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction) Ingredients: lóng dăn căo (Radix et Rhizoma Gentianae), huáng qín (Radix Scutellariae), zhī zĭ (Fructus Gardeniae), chē qián zĭ (Semen Plantaginis), zé xiè (Rhizoma Alismatis), mù tōng (Caulis Akebiae), shēng dì (Radix Rehmanniae), dāng guī (Radix Angelicae Sinensis), chái hú, gān căo 3. Parasite Movement Formula: Wū Méi Wán (Mume Pill) Ingredients: wū méi (Fructus Mume), xì xīn (Radix et Rhizoma Asari), gān jiāng (Rhizoma Zingiberis), huáng lián (Rhizoma Coptidis), dāng guī, fù zĭ (Radix Aconiti Lateralis Praeparata), shŭ jiāo (Pericarpium Zanthoxyli), guì zhī (Ramulus Cinnamomi), rén shēn (Radix et Rhizoma Ginseng), huáng băi (Cortex Phellodendri Chinensis)

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels Select points on the foot shaoyang gallbladder channel, foot jueyin liver channel and associated front-mu and back-shu points because these organs’ channels dominate the rib-sides and flanks. 2. Point Selection According to Location (1) Local points: RN 12 (zhōng wăn), GB 24 (rì yuè), BL 18 (gān shù), BL 19 (dăn shù) (2) Points on the lower limbs: GB 36 (wài qiū), GB 34 (yáng líng quán), dăn náng (EX-LE6), ST 36 (zú sān lĭ) 3. Point Selection Based on Pattern Differentiation (1) Qi stagnation of the liver and gallbladder: LV 3 (tài chōng), GB 43 (xiá xī) (2) Damp-heat of the liver and gallbladder: SP 6 (sān yīn jiāo), SP 9 (yīn líng quán) (3) Parasite movement: bái chóng wō (Hundred Worm Nest,百⾍窝), LI 20 (yíngxiāng) Techniques: Oblique insertion is applied to GB 24 (rì yuè) laterally along the intercostal space. Use oblique insertion at BL 18 (gān shù) and BL 19 (dăn shù) downwards or toward the spine, and normal needling for all other points. Use strong manipulation with longer needle retention time (1-2 hours according to the state of the illness). Intermittent needle stimulation should be applied to maintain the needling sensation. Treatment

is performed twice a day during the disease onset period, and once every other day during remission.

CASE STUDY I Ms. Zhu, age 65. Initial Visit: November 27th, 1969 Chief Complaint: Recurrent right rib and stomach pain for over 20 years, worse for the three days prior to intake. History: The patient complained of recurrent right rib and stomach pain for over 20 years. She was diagnosed with a gallstone at a local hospital. It recurred 3 days previously. Signs and Symptoms: The patient had paroxysmal colicky pain in the right upper abdomen, with a high fever (T 39.5℃). She was bent over with her arms protecting the abdomen. Other signs and symptoms included yellow discoloration of the skin and sclera, bitter taste in the mouth, dry throat, cold sweats, nausea and vomiting, and constipation. The tongue coating was greasy and yellow, and the pulse was wiry and rapid. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or food. Menstrual, Marital and Childbearing History: Menarche at age 13, menstrual cycle 28-30 days, menstrual period 4-5 days, slightly red menses, the last menstrual period arrived in 1959. Physical Examination: T 39.5℃ (103.1°F), HR 70 bpm. The patient was a lean female, well-developed and moderately nourished. Her skin and sclera showed jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, with resonant percussion sounds (normal). Heart rate

was 70 bpm and regular, with no pathological murmur at any valve area. Muscular tension in the right upper abdomen, tenderness and rebound tenderness, Murphy’s sign (+), no deformity of the spine or four limbs, no edema in the lower limbs. Pattern Differentiation The key indications of this patient include: recurrent long-term right rib and stomach pain with fever. Physical examination showed muscular tension in the right upper abdomen, tenderness and rebound tenderness, Murphy’s sign (+). Other relevant signs and symptoms included yellow discoloration of the skin and sclera, a bitter taste in the mouth, dry throat, cold sweats, nausea and vomiting, and constipation. The tongue coating was greasy yellow, and the pulse was wiry and rapid. The long-term stagnated damp-heat accumulated and transformed into stones which blocked the biliary tract and caused pain. The bile overflowed from the biliary tract. The disease location was the liver and gallbladder, manifesting as an excess pattern. Diagnosis TCM pattern: Damp-heat of the liver and gallbladder Clinical Treatment The treatment principles here are to clear the liver, promote gallbladder function, move qi, relieve pain, drain dampness and reduce jaundice. The treatment consisted of Chinese medicinals and acupuncture. The patient was advised to maintain a light diet, eat less fat, and to avoid heavy and sweet foods. Alcohol was forbidden. The patient was also advised to maintain a good mood.

Principles: Clear the liver, drain dampness and eliminate jaundice Formula: Modified Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction) [龙胆泻肝汤加减]

[Formula Analysis] Lóng dăn căo is bitter and cold, it drains excess fire of the liver and gallbladder, and clears damp-heat from the lower jiao. Lóng dăn căo is the chief medicinal. Huáng qín and zhī zĭ are bitter and cold, acting to clear heat and drain fire together with lóng dăn căo. These two medicinals serve as deputies. Zé xiè, mù tōng and chē qián zĭ clear heat, drain dampness, and lead damp-heat outward through the waterways. Yīn chén and hŭ zhàng clear damp-heat and eliminate jaundice. Shēng dì and dāng guī enrich yin and nourish the blood, thus treating the root. Chái hú guides the medicinal effects to the liver and gallbladder.

Gān căo harmonizes all formula medicinals. In summary, this formula combination acts to drain while supplementing and clear while enriching by clearing heat and fire and eliminating damp-turbidity.

Acupuncture Points: Tender points in the right upper abdomen, GB 24 (rì yuè) (right side), GB 34 (yáng líng quán) (bilaterally), LI 4 (hé gŭ), jing-well points Method: The acupuncture needles were retained for 1-2 hours until the gallbladder pain disappeared or was relieved with the manipulation of the needles. Treatment was performed once a day. Techniques: The patient lay supine with the lower limbs bent at 45°. Oblique needling with rotation was applied to a depth of 0.5-0.8 cun at the tender points and at GB 24 (rì yuè). Needling was applied to 1.5-3 cun at GB 34 (yáng líng quán) with lifting, thrusting and rotation. Needling was applied to 0.5-1 cun at LI 4 (hé gŭ) with rotation. Bleeding with a tri-edged needle was applied to the twelve jing-well points. Further Consultation After one acupuncture treatment, the pain disappeared and all other symptoms were relieved. The patient then discharged a stone of 1.5 cm × 2 cm × 2 cm. After three treatments, the patient was fully recovered.

CASE STUDY II (ACUPUNCTURE, Zhang Qing-nian) Mr. Wang, age 49, office worker. Chief Complaint: Right flank pain and distention below the xiphoid process for six months. History: In November of 1984, the patient suffered a bout of sudden severe pain of the right flank and was diagnosed with acute cholecystitis. The ultrasound examination showed cholecystitis and a gallstone. This time he had right flank pain with distention below the xiphoid process, accompanied by nausea, vomiting, mild diarrhea, and poor appetite. There was a dim tongue body with a thin white coating; the pulse was wiry and slippery. Diagnosis Gallbladder pain due to liver constraint and qi stagnation Clinical Treatment Principles: Soothe the liver, resolve constraint, regulate qi and relieve pain Points: GB 24 (rì yuè) (right side), BL 19 (dăn shù) (right side), GB 34 (yáng língquán) (right side) Techniques: Oblique needling was applied to a depth of 0.8 cun at BL 19 (dăn shù). Perpendicular insertion was applied to 1.5 cun at GB 24 (rì yuè), and 1.5-2 cun at GB 34 (yáng líng quán). Lifting and thrusting with drainage was applied for one minute. Needle sensation transmission was

directed from BL 19 (dăn shù) to the upper right quadrant or the area of the liver and gallbladder, from GB 24 (rì yuè) to below the xiphoid process, and from GB 34 (yáng líng quán) along the gallbladder channel to the upper right quadrant. Note Acupuncture is effective at treating gallbladder pain, especially for the acute, short-term type without severe complications. However, it is important to first correctly determine the cause.

COMMENTARY AND DISCUSSION Many patients with chronic gallbladder pain have their gallbladders surgically removed. This tends to address the acute pain, but not the precursor to the gallbladder pain, which is often liver qi stagnation. As we know, liver qi stagnation can give rise to widely divergent signs and symptoms, though they all tend to be aggravated by emotional stress or by the menstrual cycle. I once treated a woman with diarrhea which appeared to be stressinduced, so I addressed it with the usual formulas ranging from Xiāo Yáo Săn (Free Wanderer Powder) to Tòng Xiè Yào Fāng (Important Formula for Painful Diarrhea). However there was little improvement as would be expected. I then considered two other treatment principles. First, assuming diarrhea due to spleen qi deficiency, Shēn Líng Bái Zhú Săn (Ginseng, Poria and Atractylodes Macrocephalae Powder) was prescribed. Later, because the thickly coated tongue reflected an excess condition, I tried Băo Hé Wán (Harmony-Preserving Pill). Around the time that I began to use digestives, I learned that this patient had previously had her gallbladder removed. This bit of news came a little bit late, and after we had begun to apply a third treatment principle, she had grown impatient and I never saw her again. However, she was a good example of how much more you can learn from patients who don’t respond well to therapies compared with those who do respond well. The take-home message is for stubborn diarrhea due to chronic qi stagnation, add “gallbladder removal” to the list of questions one should ask at intake.

From the Western standpoint, the lack of the gallbladder means that for a certain period of time after having the organ removed, fats are not emulsified well, which gives rise to “steatorrhea” or fatty, white, floating, loose stools. In many cases, the body compensates for the lack of emulsifying bile entering the duodenum, and the stools can firm up over time; however, the unique unilateral presentation of her tongue coating was consistent with food stagnation likely caused initially by qi stagnation, but also likely aggravated by the removal of the gallbladder.

STUDY QUESTIONS

● For the first case, in addition to the Chinese medicinal and acupuncture treatments, what should the patient be advised? Answers The diet should be light. Fatty, heavy and sweet foods should be avoided, and alcohol is forbidden. Additionally, the patient is encouraged to maintain a good mood.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mrs. Lin, age 45, had flank pain that was often triggered by emotional stimuli. Other symptoms include chest tightness, sighing, nausea and vomiting, poor appetite, vexation and irritability. The tongue coating is thin white, and her pulse is wiry and tight. Which of the following is the best choice of formula? A. Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder) B. Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction) C. Wū Méi Wán (Mume Pill) D. Xiăo Chái Hú Tāng (Minor Bupleurum Decoction) E. Dà Chái Hú Tāng (Major Bupleurum Decoction) 2. Mr. Xie, age 50, complains of pain in the upper right quadrant, accompanied by chills and fever, a bitter taste in the mouth, dry mouth, sighing, nausea and vomiting, constipation, cold sweats, and jaundice of the eyes, body and urine. The tongue coating is greasy yellow, and his pulse is wiry and rapid. Which of the following is the best choice of formula? A. Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder)

B. Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction) C. Wū Méi Wán (Mume Pill) D. Xiăo Chái Hú Tāng (Minor Bupleurum Decoction) E. Dà Chái Hú Tāng (Major Bupleurum Decoction) 3. Mr. Hu, age 40, came to the clinic complaining of a sudden severe drilling pain in his upper right quadrant with aversion to pressure, vexation, chills and fever, nausea and vomiting, vomiting of worms, and poor appetite. The tongue coating is thin white, and his pulse is wiry and tight. Which of the following formulas will best address the pain? A. Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder) B. Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction) C. Wū Méi Wán (Mume Pill) D. Xiăo Chái Hú Tāng (Minor Bupleurum Decoction) E. Dà Chái Hú Tāng (Major Bupleurum Decoction) Answers 1. A 2. B 3. C

26. Lower Back Pain ANCIENT THEORIES AND MODERN INSIGHTS Lower back pain manifests mainly with subjective symptoms such as lumbar pain on or around the spine or waist. The causes of the disease may be complex. Contraction of external pathogens, tissue trauma and internal damage can all cause lower back pain. This chapter focuses mainly on lower back pain caused by external pathogens, deficiency, tissue trauma, and excessive sexual activity. The lower back is known as the “house of the kidneys”, nourished by the essential qi of the kidney. There is an interior-exterior relationship between the kidney and bladder, where the bladder channel travels along the side of the spine and connects to the kidneys. The du vessel also runs along the spine. The main pathomechanism of lower back pain involves blockage or malnourishment of the channels, collaterals, and channel sinews in the local area. The internal root of lower back pain is kidney deficiency, which is a form of internal damage, so it follows that the treatment principle in such cases is to supplement the kidney and nourish essence to strengthen the lower back. The branches of lower back pain include manifestations of excess dampness, wind-cold, damp-heat, and blood stasis. The treatment principles for the associated patterns of excess involve expelling external pathogens and quickening blood within the collaterals. Methods employed

include dissipating cold, eliminating dampness, clearing heat, regulating qi and eliminating stasis. If the presenting pattern is a deficiency-excess complex, simultaneous supplementing and draining strategies should be considered.

ETIOLOGY AND PATHOMECHANISMS External Causes When external wind-cold-dampness or damp-heat invade the body, because of its heavy, sticky and sinking nature, dampness is most likely to obstruct the channels and collaterals of the lower back, resulting in locally inhibited qi and blood which ultimately gives rise to pain. Among the external causes, dampness is typically of great importance. Cold-dampness: When cold-dampness invades, cold damages yang, causing yang qi deficiency affecting the local channels and collaterals. The heavy, sticky and sinking nature of dampness constrains the channels and collaterals in the lower back region leading to contraction and spasms of the muscles and sinews, and ultimately pain. Lower back pain caused by colddampness is often accompanied by cold-type pain and sensations of heaviness. Damp-heat: When damp-heat invades the body, the internal heat damages yin while the dampness damages yang. The sticky and stagnant nature of damp-heat blocks the channels and collaterals while constraining qi and blood. Lower back pain caused by damp-heat is often accompanied with heat-type pain.

Internal Causes About 80% of lower back pain cases are associated patterns of deficiency, with internal damage generally involving kidney deficiency.

Kidney: Lower back pain arises from constitutional deficiencies, fatigue, chronic disease, advanced age, or a history of excessive sexual activity. Due to a loss of essence, kidney-essence fails to nourish the channels and collaterals of the lower back.

Other Causes When the patient moves improperly, this can cause a sudden sprain. Other causes of local tissue trauma include knocks and falls, contusions or chronic diseases. When the movement of qi in the lower back is blocked, blood stagnates within the collaterals resulting in local pain. The most common clinical patterns are cold-dampness, damp-heat, blood stasis and kidney deficiency.

PATTERN DIFFERENTIATION 1. Differentiation Based on Channel Theory Foot taiyang: Pain is located lateral to the spine. Du vessel: Pain is centered on the spine. Mixed syndrome: Pain affects the entire lower back, but the exact location is not clear. 2. Differentiation Based on Patterns Cold-dampness: The patient has a history of cold exposure to the lower back. The lower back pain feels cold and is accompanied by heaviness. The patient has difficulty in rotating the lower back and symptoms get worse gradually, sometimes radiating to the lower limbs. The symptoms are not always relieved after rest or lying down, and become aggravated when the weather is cloudy, rainy, or after exposure to cold. Warmth often brings some relief. Damp-heat: Pain in the lower back accompanied by sensations of heaviness or warmth. The pain is aggravated during hot and humid days, and relieved by movement or coolness. Blood stasis: The patient generally has a history of injury in the lower back region. The symptoms are worse first thing in the morning, and aggravated by fatigue or after sitting for a long time. The location of the pain is fixed, aggravated by pressure, and the muscles along the two sides of the spine are stiff. The patient may feel distention or stinging-type pain

which is relieved during the day and worse at night, or consistent pain without relief. Kidney deficiency: Dull pain with soreness and weakness of the lower back, generally chronic in nature. This pain is aggravated by fatigue and relieved after rest, pressure or massage. The pattern can be subdivided into kidney yang and kidney yin deficiency-types and accompanied by symptoms or signs of general yang or yin deficiency.

THERAPEUTICS Chinese Medicinals 1. Cold-dampness Formula: Gān Jiāng Líng Zhú Tāng (Licorice, Dried Ginger, Poria, and White Atractylodes Decoction) Ingredients: gān jiāng (Rhizoma Zingiberis), gān căo (Radix et Rhizoma Glycyrrhizae), dīng xiāng (Flos Caryophylli), cāng zhú (Rhizoma Atractylodis), bái zhú (Rhizoma Atractylodis Macrocephalae), jú hóng (Exocarpium Citri Rubrum), fú líng (Poria) 2. Damp-heat Formula: Jiā Wèi Èr Miào Săn (Supplemented Two Mysterious Powder) Ingredients: huáng băi (Cortex Phellodendri Chinensis), cāng zhú (Rhizoma Atractylodis), fáng jĭ (Radix Stephaniae Tetrandrae), bì xiè (Rhizoma Dioscoreae Hypoglaucae), dāng guī (Radix Angelicae Sinensis), niú xī (Radix Achyranthis Bidentatae), guī băn (Plastrum Testudinis) 3. Blood Stasis Formula: Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) Ingredients: dāng guī, chuān xiōng (Rhizoma Chuanxiong), táo rén (Semen Persicae), hóng huā (Flos Carthami), mò yào (Myrrha), wŭ líng zhī

(Faeces Trogopterori), dì lóng (Pheretima), xiāng fù (Rhizoma Cyperi), niú xī 4. Kidney Yin Deficiency Formula: Zuŏ Guī Wán (Left-Restoring Pill) Ingredients: shú dì huáng (Radix Rehmanniae Praeparata), gŏu qĭ zĭ (Fructus Lycii), shān zhū yú (Fructus Corni), guī băn, tù sī zĭ (Semen Cuscutae), lù jiăo jiāo (Colla Cornus Cervi), niú xī 5. Kidney Yang Deficiency Formula: Yòu Guī Wán (Right-Restoring Pill) Ingredients: shú dì huáng, shān yào (Rhizoma Dioscoreae), shān zhū yú, gŏu qĭ zĭ, dùzhòng (Cortex Eucommiae), tù sī zĭ, dāng guī ★ Key Medicinal Niú xī is a commonly used channel envoy medicinal in the treatment of lower back pain. The thermal nature of niú xī is neutral, its flavor is bitter and sour, and it enters the liver and kidney channels. The function of raw huái niú xī (Radix Achyranthis Bidentatae) is to invigorate blood and dissolve stasis while also guiding blood downward. Processed huái niú xī supplements liver and kidney, and strengthens the sinews and bones.

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Favor foot taiyang channel points. (2) Additional points on the du vessel. 2. Point Selection According to Location

(1) Local points and ashi points

● Foot taiyang: BL 23 (shèn shù), BL 25 (dà cháng shù), BL 52 (zhì shì), local hua tuo jiaji points

● Du vessel: DU 3 (yāo yáng guān), DU 4 (mìng mén) (2) Hand and foot yang channel points (points on the forearm and lower leg): SI 3 (hòu xī), BL 40 (wĕi zhōng), and BL 60 (kūn lún), according to the theory of “hand-foot same-name channels”. 3. Point Selection Based on Pattern Differentiation (1) Cold-dampness: Select points from the lower back area on the foot taiyang channel and du vessel, and ashi points; also select points on the nape and limbs such as DU 14 (dà zhuī), BL 40 (wĕi zhōng), and BL 60 (kūn lún). (2) Damp-heat: In addition to local points, select points such as LI 11 (qū chí), DU 14 (dà zhuī) and SP 9 (yīn líng quán) to clear heat and drain dampness. (3) Blood stasis: Select local points to unblock the collaterals and relieve pain, and also apply cupping following collateral bloodletting on channel points such as BL 17 (géshù) and SP 10 (xuè hăi) to invigorate blood and eliminate stasis. (4) Kidney deficiency patterns

● Kidney yin deficiency: Needle BL 23 (shèn shù) and BL 52 (zhì shì) with supplementation to enrich yin and nourish the kidney.

● Kidney yang deficiency: Needle BL 23 (shèn shù) and DU 4 (mìng mén) to supplement the kidney and strengthen the lower back. Moxibustion is also recommended.

Taiyang channel points are most often selected, according to the affected channel, along with points on the du vessel and ashi points. Overall, the needling methods should emphasize drainage over supplementation, with special attention given to needling direction, breathing of the patient and de qi (arrival of qi). Moxibustion is usually applied for cold or deficiency patterns. Cupping following collateral bleeding is commonly applied at points on the lower back area, or near joints or superficial veins. The amount of blood that is let is decided according to location; small veins produce less blood while those larger will flow more freely. For example, the amount of bleeding at joints on the extremities should be less than points on the trunk or waist.

CASE STUDY I Mr. Xu, age 48. Initial Visit: September 20th, 2003 Chief Complaint: Chronic lower back pain for three years, aggravated over the past two weeks. History: The patient had suffered from chronic lower back pain for three years. The pain was aggravated by excessive work and relieved by pressure or massage. Due to his hectic schedule, he had not sought out medical attention previously, but over the last two weeks, his lower back pain had become more severe. Signs and Symptoms: Pain and soreness in the lower back, weak breathing, lack of strength, powerless legs and knees, cold hands and feet, frequent nighttime urination, a pale complexion. The tongue was pale and enlarged with teeth marks and a thin white coating; the pulse was deep and thready. Past History: Unremarkable Physical Examination: BT 36.7℃, RR 17 times/min, PR 72 beats/min, BP 160/90 mmHg Laboratory Examination: Urine routine test: protein (++), red blood cell (++)/Hp, granular cast 1-3/LP. Blood routine test: red blood cell count 3.6×1012/L, hemoglobin 120 g/L. Blood urea nitrogen 6.8 mmol/L, serum creatinine 100 μmol/L, blood uric acid 416 μmol/L, blood sugar (empty stomach) 5.5 mmol/L, plasma-albumin 38 g/L, globulin 25 g/L. B-mode ultrasound: normal kidney size, blurred structure. Pattern Differentiation

The patient is middle-aged and overworked, and has suffered from for lower back pain for three years. This led to a loss of kidney essence with subsequent malnourishment of the sinews and lower back pain. The lower back is the house of the kidney, and the kidney governs the marrow. If the essential qi of the kidney is deficient, the lower back and spine lose nourishment which leads to lower back soreness and weakness. Excessive work consumes qi, so the symptoms got worse when the patient was overworked. The kidney stores essence, and when it becomes deficient, the kidney function of securing and containing urine is compromised, the outcome being frequent urination at night. Deficient yang fails to warm and nourish the four extremities, so the patient’s hands and feet are cold. Other signs of yang deficiency include a pale complexion, a pale enlarged tongue with teeth marks, and a deep thready pulse. The location of the disease is in the kidney, and the presenting pattern primarily involves deficiency. Diagnosis Lower back pain due to kidney yang deficiency Clinical Treatment The treatment principles are to warm and supplement kidney yang, unblock the collaterals and relieve pain. In addition to acupuncture and Chinese medicinal treatment, the patient should maintain balanced periods of work and rest, perform moderate exercise, watch his diet and cultivate harmonious emotions. Principles: Warm and supplement kidney yang Formula: Modified Yòu Guī Wán (Right-Restoring Pill)

[右归丸加减]

Three doses. One decocted dose a day. [Formula Analysis] The chief medicinals, shú fù zĭ and ròu guì act to supplement original yang in the kidney, warm the interior, and dispel cold. The deputy medicinals, shú dì huáng, shān zhū yú, shān yào and gŏu qĭ zĭ nourish yin and supplement the kidney, liver, spleen, essence and marrow. They act on the “yang within yin”. Tù sī zĭ and dù zhòng serve as assistants to supplement the liver and kidney and strengthen the lower back and knees. Dāng guī nourishes and harmonizes blood, and fú líng fortifies the spleen. These four medicinals assist the kidney-supplementing medicinals to nourish essence and blood. Huái niú xī is a commonly used medicinal for lower back pain. Its thermal nature is neutral, and the flavor is bitter and sour. Huái niú xī enters the liver and kidney channels. Processed huái niú xī supplements liver and kidney, strengthens the sinews and bones, and guides the effects of the formula to the lower back.

This formula mainly benefits the liver, spleen and kidney by restoring original yang and acting on the “yang within yin”.

Acupuncture Main points: BL 23 (shèn shù), DU 3 (yāo yáng guān), BL 25 (dà cháng shù), BL 40 (wĕizhōng) Supplementary points: DU 4 (mìng mén), hua tuo jia ji points (L1-L5), yāo yăn (EXB7), ashi points, BL 60 (kūn lún), ST 36 (zú sān lĭ), SI 3 (hòu xī), DU 26 (shuĭ gōu, or rénzhōng), DU 14 (dà zhuī ) Method: Choose 3 main points and 3-4 supplementary points for each treatment given every other day. After qi was obtained, the needles were retained for 20-30 min. Ten treatments (over 20 days) constitute one treatment course. Techniques: Combined acupuncture and moxibustion was used. Supplementation methods were employed on the points of the lower back, the even method on all other points. Warm-needle moxibustion was added to ST 36 (zú sān lĭ). Further Consultation After one course of treatment, the lower back pain was greatly relieved. The patient received two more treatment courses, after which he was fully recovered.

CASE STUDY II (ACUPUNCTURE, Cheng Xinnong) Mr. Li, age 29. Chief Complaint: Lower back pain for two months. History: The patient complained of a dull pain in his lower back. The pain would vary from slight to intense. The pain radiated to the sacrum. The urine was dark and frequent. Physical Examination: A dark complexion, a dim purple tongue with teeth marks and a white coating, a slippery pulse also deficient at the chĭ position. Diagnosis Lower back pain due to cold-dampness invasion Clinical Treatment Principles: Supplement kidney qi, expel cold-dampness, unblock the channels Points: BL 23 (shèn shù), DU 3 (yāo yáng guān), DU 4 (mìng mén), BL 54 (zhì biān), BL 40 (wĕi zhōng), BL 58 (fēi yáng), ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo), KI 3 (tài xī) Techniques: Apply moxibustion to BL 23 (shèn shù) and DU 3 (yāo yáng guān). Needle DU 4 (mìng mén), ST 36 (zú sān lĭ) and KI 3 (tài xī) with supplementation; use the even method for all other points.

After four treatments, the pain was greatly relieved. However, the patient still reported a sensation of heaviness at the sacrum. After a total of ten treatments, the patient was fully recovered. Note The lower back is the house of the kidney. When kidney qi is deficient and cold-dampness invasion disturbs the circulation of qi and blood, lower back pain may result. The kidney dominates the lower orifices and has an interior-exterior relationship with the bladder, so when kidney qi deficiency leads to bladder qi deficiency, the bladder function of qi transformation declines and urination becomes frequent. Qi transformation can be thought of as the biomedical equivalent to the reuptake of fluids in the kidneys. When the reuptake is compromised, frequent urination is the outcome.

COMMENTARY AND DISCUSSION One cause of lower back pain described in this chapter is excessive sexual activity, a topic of some obsession among Western patients. We often want to provide our male patients with important information that can prevent lower back pain, but we also don’t want to inflame the individual’s sensitivities surrounding their sexuality. Conversely, some individuals who are more obsessed with sexuality may take kidney yang-supplementing medicinals even when they are not needed, which is certainly inadvisable. However, there is a reasonably gentle way to draw the line with what can be considered “excessive sex”. Providing specific numbers per week or month for sexual activity as provided in the Chinese medical classics may lack any real-world value in Western culture; a more acceptable solution would be to suggest that if one’s breathing capacity or lower back pain is aggravated by sexual activity, one should simply moderate that behavior. Furthermore, when a male patient comes in complaining of lower back pain that is aggravated by sex, we cannot necessarily assume that the problem is always kidney deficiency. Upon further questioning with one male patient, it became clear that it was not excessive ejaculation that was causing his pain, but rather aggravated tissue trauma secondary to the exotic sexual positions that he was exploring with his yoga-partner.

STUDY QUESTIONS 1. Why was ST 36 (zú sān lĭ) chosen in the first case, and why was it treated with warm-needle moxibustion? 2. In addition to acupuncture and Chinese medicine, what lifestyle changes should be initiated for the first case? 3. On which channels did this lower back pain arise? Answers 1. The patient had symptoms of weak breathing, lack of strength, a pale tongue and a deficient pulse, all manifestations of qi deficiency. ST 36 (zú sān lĭ) was thus treated with warm-needle moxibustion to supplement and promote the movement of qi and blood to relieve pain. 2. Overworking was a causative factor in this case, and as such, the patient should be provided tools to deal with work stress, or at least be advised to pay attention to the relationship between excessive work and his lower back pain. 3. Du vessel and foot taiyang channel

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mr. Wei, age 50, has worked in a job that required heavy lifting for 20 years. Over the past two years, he has reported discomfort in the lower back, especially after work or sitting for extended periods. Examinations: stiffness in the muscles of the lower back, tenderness, no radiating pain to the lower legs. There is a dim tongue with a thin white coating, and a wiry pulse. What is the presenting pattern? A. Blood stasis B. Kidney deficiency C. Cold-dampness D. Damp-heat E. Internal damage 2. Ms. He, age 50, had chronic lower back pain which varied from mild to severe. It was aggravated by over-exertion. She did not like cold weather. Her four extremities were cold and her urine was clear and copious. Her tongue was pale with a white coating, and the pulse was thin. Which of the following is the best formula choice for this case? A. Sì Miào Wán (Wonderfully Effective Four Pill)

B. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) C. Zuŏ Guī Wán (Left-Restoring Pill) D. Yòu Guī Wán (Right-Restoring Pill) E. Gān Jiāng Líng Zhú Tāng (Licorice, Dried Ginger, Poria, and White Atractylodes Decoction) 3. Ms. Zhang, age 35, had lower back pain with a heavy hot sensation. Her condition was aggravated by cloudy or hot humid weather during the summer. She also reported fatigue and sensations of heaviness in the body. The tongue had a yellow greasy coating, and her pulse was wiry and rapid. Which of the following are the best treatment principles for this case? A. Clear heat, eliminate phlegm, relax the sinews and unblock the collaterals B. Clear heat, drain dampness, relax the sinews and relieve pain C. Promote urination, reduce swelling, relax the sinews and unblock the collaterals D. Invigorate blood, dissolve stasis, unblock the collaterals and relieve pain E. Fortify the spleen and percolate dampness, relax the sinews and relieve pain 4. Ms. Fang, age 49, reported cold pain in the lower back and hip, as if she were wearing a heavy weight around her waist. She had a limited range of motion when attempting to rotate to the left or right. The symptoms were aggravated when the weather was rainy or cloudy. Her tongue was pale with a white greasy coating, and the pulse was deep, slow and moderate.

What is the presenting pattern? A. Blood stasis B. Kidney deficiency C. Cold-dampness D. Damp-heat E. Internal damage 5. Ms. Hu, age 53, had chronic dull pain in her lower back for two years, accompanied by soreness and lack of strength. She also reported vexation, insomnia, dry mouth and throat. Her tongue was red with thin cracks and a scanty coating, and the pulse was thin, rapid and wiry. Which of the following are the correct principles of treatment? A. Expel cold, percolate dampness, warm the collaterals and relive pain B. Clear heat, drain dampness, relax the sinews and relieve pain C. Promote urination, reduce swelling, relax the sinews and unblock the collaterals D. Invigorate blood, dissolve stasis, unblock the collaterals and relieve pain E. Nourish kidney yin and sinews 6. Mr. Li, age 64, injured his lower back playing sports a few days ago. He had limited range of motion with difficulties in stretching or turning his body over. He also needed help to lie down. He also reported a history of lower back injuries. The tongue was dim red with a thin white coating, and the pulse was wiry, tight and rapid.

Which of the following is the best formula choice for this case? A. Sì Miào Wán (Wonderfully Effective Four Pill) B. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) C. Zuŏ Guī Wán (Left-Restoring Pill) D. Yòu Guī Wán (Right-Restoring Pill) E. Gān Jiāng Líng Zhú Tāng (Licorice, Dried Ginger, Poria, and White Atractylodes Decoction) 7. Mr. Zhang, age 69, reported cold pain in the lower back for 50 years. During wartime 50 years ago, he lived (literally) underground for a long time where he first noticed his lower back pain. During the years since, his symptoms varied from mild to severe. His pain was aggravated by fatigue or whenever the weather was windy or rainy. His lower back is most sensitive at the level of the 4th and 5th lumbar vertebrae, although X-ray imaging showed no structural anomalies. Over the past six months, the pain had become severe. The patient could no longer stand up. His tongue was pale with a white coating, and the pulse was deep and slow. Which of the following are the most appropriate treatment principles? A. Expel cold, percolate dampness, warm the collaterals and relieve pain B. Clear heat, drain dampness, relax the sinews and relieve pain C. Promote urination, relax the sinews and unblock the collaterals

D. Invigorate blood, eliminate stasis, unblock the collaterals and relieve pain E. Clear heat, resolve phlegm, relax the sinews and unblock the collaterals 8. Mr. Yu, age 47, had chronic dull pain in her lower back for many years, accompanied by soreness and lack of strength. He seemed restless even though he reported trouble sleeping. Other indications included dry mouth and throat, hot flashes in the face, and a feverish feeling in the palms and soles. The tongue was red with a scanty coating, and his pulse was wiry, thin and rapid. Which of the following formulas is the best choice for this case? A. Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill) B. Yòu Guī Wán (Right-Restoring Pill) C. Hé Chē Dà Zào Wán (Placenta Great Creation Pill) D. Qīng Gŭ Săn (Bone-Clearing Powder) E. Zuŏ Guī Wán (Left-Restoring Pill) Answers 1. A 2. D 3. B 4. C 5. E 6. B

7. A 8. E

SECTION V Pain of the Lower Limb 27. Piriformis Syndrome ANCIENT THEORIES AND MODERN INSIGHTS Piriformis syndrome refers to the pain that arises from impingement or irritation to the sciatic nerve by the piriformis muscle. Causes of piriformis syndrome include excessive hip internal or external rotation, adduction or abduction, injury, edema, spasm, or hypertrophy of the piriformis muscle. In TCM, piriformis syndrome falls under the category of “bi syndrome” or simply referred to as “lumbus and lower limb pain”. According to TCM theory, trauma or chronic strain can result in stagnation of qi and blood with impairment of the sinews and channels. External contraction of wind, cold or dampness can result in pain due to obstruction of the sinews and channels, while insufficiency of the liver and kidney lead to malnourishment of the sinews and bones. Any such impairment of the sinews and channels can lead to piriformis syndrome.

ETIOLOGY AND PATHOMECHANISMS External Causes Acute sprain or contusion: Trauma impairs the flow of qi and blood in the channels and collaterals, leading to stagnation of qi and blood with subsequent blockage of the channels and collaterals which results in pain. Wind, cold, and dampness and heat: Those who suffer from acute sprain or chronic strain tend to have increased susceptibility to external contractions of wind, cold, dampness or heat. As yin-pathogens, cold tends to congeal, while dampness has a sticky nature. As these pathogens combine, subsequent blockage of the channels and collaterals results in pain.

Internal Causes The onset of this disease is associated closely with chronic exhaustion or a deficiency of the kidney. Kidney: Caused by excessive sexual activity consuming kidney essence which leads to a deficiency in the sea of marrow, or interior cold due to the decline of kidney yang, or insufficiency of kidney yin. Those with kidney deficiency may easily contract external wind, cold and dampness which in turn impair the kidney yang, often giving rise to chronic diseases. Because the patient with kidney deficiency is susceptible to external wind, cold and dampness, the disease is generally marked by a root deficiency pattern with excess branch manifestations.

COMMON CLINICAL PATTERNS The most commonly encountered patterns in clinic are obstruction of wind-cold-dampness, stagnation of qi and blood, accumulation of dampheat, and deficiency of liver and kidney.

PATTERN DIFFERENTIATION 1. Differentiation Based on Channel Theory Shaoyang channel: Sciatic and femoral pain that is aggravated by pressure and with a fixed location, palpable muscle spasms or cords on the buttock, difficult flexion of the affected lower limb, with pain radiating from the buttock down the lateral aspect of the leg along the trajectory of the gallbladder channel. Taiyang channel: Sciatic and femoral pain aggravated by pressure and with a fixed location, palpable muscle spasms or cords on the buttock, difficulty flexion of the affected lower limb, with pain radiating from the buttock down the posterior aspect of the leg along the trajectory of the bladder channel. 2. Differentiation Based on Patterns Obstruction of wind-cold-dampness: Cold pain and heavy sensations in the hip and leg, inflexibility when turning the body, and spasm of the affected lower limb aggravated by cold or sudden changes of weather. The tongue coating is white and greasy; the pulse is deep and slow. Stagnation of qi and blood: Severe pain at a fixed location that is aggravated by pressure, exertion or coughing, palpable muscle spasms or cords on the buttock, difficult flexion of the affected lower limb with pain radiating from the buttock down the posterior and lateral aspects of the leg. The tongue body is purple and dark with stasis spots; the pulse is wiry and choppy.

Accumulation of damp-heat: Burning pain in the hip and thigh, heavy sensations of the joints, leg weakness, thirst without a desire to drink, and dark or deep-yellow urine. The tongue is red with a greasy yellow coating; the pulse is slippery and rapid. Deficiency of liver and kidney: Recurrent dull or aching pain or heaviness of the hip and thigh that is aggravated by exertion and improves with pressure, or lethargy of the hip and thigh with an atrophy of the muscles. Those who have yang deficiency may also have a lusterless facial complexion, cold hands and feet, a pale tongue, and a deep and thin pulse; those with yin deficiency may show redness on the cheeks, five-center heat, a red tongue, and a rapid thready and wiry pulse.

THERAPEUTICS Chinese Medicinals 1. Obstruction of Wind-cold-dampness Formula: Zhì Lí Zhuàng Jī Zōng Hé Zhēng Fāng (Piriformis Syndrome Decoction) Ingredients: jī xuè téng (Caulis Spatholobi), dù zhòng(Cortex Eucommiae), chuānniú xī (Radix Cyathulae), gŏu jĭ (Rhizoma Cibotii), má huáng (Herba Ephedrae), guì zhī (Ramulus Cinnamomi), xì xīn (Radix et Rhizoma Asari), hóng huā (Flos Carthami), táorén (Semen Persicae), dú huó (Radix Angelicae Pubescentis), dì lóng (Pheretima), báisháo (Radix Paeoniae Alba), dāng guī (Radix Angelicae Sinensis) 2. Stagnation of Qi and Blood Formula: Modified Shēn Jīn Tāng (Tendon-Relaxing Decoction) Ingredients: gé gēn (Radix Puerariae Lobatae), dà zăo (Fructus Jujubae), zhì mò yào (Myrrha Praeparata), jī xuè téng, yán hú suŏ (Rhizoma Corydalis), guì zhī, chuān shān jiă (Squama Manitis), gān căo (Radix et Rhizoma Glycyrrhizae), chuān niú xī, dāng guī, báisháo, zhì rŭ xiāng (Olibanum praeparatum), tōng căo (Medulla Tetrapanacis) 3. Damp-heat Accumulation Formula: Modified Qīng Lì Huó Luò Tāng (Heat-Clearing DampnessDraining Channel-Activating Decoction)

Ingredients: jiāo zhī zĭ (Fructus Gardeniae Praeparatus), dú huó (Radix Angelicae Pubescentis), hóng huā, chuān niú xī, hŭ zhàng (Rhizoma Polygoni Cuspidati), huáng băi (Cortex Phellodendri Chinensis), dān shēn (Radix et Rhizoma Salviae Miltiorrhizae), rĕn dōng téng (Caulis Lonicerae Japonicae), zhì yuán hú (Rhizoma Corydalis praeparatum), lóng dăn căo (Radix et Rhizoma Gentianae), zé xiè (Rhizoma Alismatis), chì sháo (Radix Paeoniae Rubra), dì lóng 4. Deficiency of the Liver and Kidney Formula: Modified Qīng Lì Huó Luò Tāng (Heat-Clearing DampnessDraining Channel-Activating Decoction) Ingredients: chì sháo, dān shēn, rĕn dōng téng, zhì yuán hú, chuān niú xī, dú huó, dì lóng, hóng huā, zhì chuān wū (Radix Aconiti Praeparata), zhì căo wū (Radix Aconiti Kusnezoffii Praeparata), chuān xiōng (Rhizoma Chuanxiong), xù duàn (Radix Dipsaci), jiāng cán (Bombyx Batryticatus), dù zhòng (Cortex Eucommiae), wŭ jiā pí (Cortex Acanthopanacis) ★ Key Medicinals Niú xī (Radix Achyranthis Bidentatae) is the first and foremost medicinal for pain of the hip and thigh. It is bitter and sour in flavor, neutral in thermal property, and enters the kidney channel. Thus, it has the function not only of supplementing the liver and kidney, and strengthening the sinews and bones, but also of promoting blood circulation, guiding the blood flow downward, and unblocking the blood vessels to benefit the joints. Since it is apt to go downward, it is used for weakness or pain of the lower limbs. Due to its strong function of invigorating blood and dissolving stasis, niúxī is contraindicated in patients who are pregnant or prone to heavy menstrual flow.

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Points on the du vessel and the three yang channels of the foot. (2) Points on the foot shaoyang and taiyang channels. (3) Main points include BL 54 (zhì biān), GB 30 (huán tiào), and ashi points. 2. Point Selection According to Location (1) Local points

● Hip: GB 30 (huán tiào), BL 54 (zhì biān), BL 36 (chéng fú) ● Knee: GB 34 (yáng líng quán), BL 40 (wĕi zhōng) ● Leg and ankle: BL 57 (chéng shān), BL 60 (kūn lún), GB 39 (xuán zhōng) (2) Ashi points (3) Points on the lumbus: BL 23 (shèn shù), DU 4 (mìng mén), DU 3 (yāo yáng guān) 3. Point Selection Based on Pattern Differentiation (1) Obstruction of wind-cold-dampness

● BL 54 (zhì biān), GB 30 (huán tiào), and ashi points are chosen as the main points, while supplementary points include GB 34 (yáng líng quán), BL 40 (wĕi zhōng), LB 57 (chéng shān), BL 60 (kūn lún), and GB 39 (xuán zhōng).

● Ashi points and points in the lumbus.

● With predominant wind, add BL 12 (fēng mén) and GB 31 (fēng shì); with predominant dampness, add SP 6 (sān yīn jiāo) and SP 9 (yīn líng quán); with predominant cold, apply moxibustion to GB 39 (xuán zhōng), BL 23 (shèn shù) and DU 4 (mìng mén). (2) Stagnation of qi and blood: GB 30 (huán tiào), ashi points, BL 54 (zhì biān), GB 34 (yáng líng quán), BL 40 (wĕi zhōng), BL 57 (chéng shān), BL 60 (kūn lún), GB 39 (xuánzhōng), SP 10 (xuè hăi) and BL 17 (gé shù). (3) Accumulation of damp-heat: Points on the du vessel and three yang channels of the foot include GB 30 (huán tiào), BL 54 (zhì biān), GB 34 (yáng líng quán), BL 40 (wĕizhōng), BL 57 (chéng shān), BL 60 (kūn lún), GB 39 (xuán zhōng), and ashi points. (4) Deficiency of liver and kidney: GB 30 (huán tiào), BL 54 (zhì biān), GB 34 (yánglíng quán), BL 40 (wĕi zhōng), BL 57 (chéng shān), BL 60 (kūn lún), GB 39 (xuán zhōng), and ashi points. Moxibustion can be applied to BL 23 (shèn shù), DU 4 (mìng mén), and DU 3 (yāo yáng guān). At the beginning stage of treatment, apply gentle rather than strong stimulation, while during the later stage, a combination of moxibustion and acupoint injection is applicable. 4. Treatment in Accordance with Channel Differentiation (1) Shaoyang channel Point selection: GB 30 (huán tiào), BL 54 (zhì biān), GB 34 (yáng líng quán), ST 36 (zúsān lĭ), GB 31 (fēng shì), GB 33 (xī yáng guān), GB 38 (yáng fŭ), GB 39 (xuán zhōng), GB 41 (zú lín qì) (2) Taiyang channel

Point selection: BL 54 (zhì biān), BL 36 (chéng fú), GB 30 (huán tiào), BL 23 (shèn shù), BL 37 (yīn mén), BL 40 (wĕi zhōng), BL 57 (chéng shān), BL 60 (kūn lún) Method: Gentle rather than strong manipulation is advised at the beginning stage of treatment. In the later stages, the stimulation can be intensified.

CASE STUDY I Ms. Lei, age 42. Initial Visit: December 3rd, 2006 Chief Complaint: Left hip pain for two weeks, worse over the past three days. History: After a long drive where the patient had to repeatedly use her left foot to operate her car’s clutch, she developed a distending pain on the left side of her hip which was relieved after resting. After driving for a long time three days ago, her pain was aggravated, accompanied with inflexibility of her left hip joint. The suffering was not relieved by oral analgetics or by topical plaster therapy. Signs and Symptoms: Stiffness, pain and inflexibility of the left hip joint. Physical Examination: The patient showed no obvious tenderness on the lower back, but she had definite tenderness on the left piriformis muscle radiating down the posterolateral aspect of the thigh and leg, with limited internal rotation or adduction. Obvious pain was detected before 45° in the straight leg raise test, with slight relief after 60°. Her tongue was slightly red with a thin white coating; her pulse was wiry and tight. Past History: The patient denied any history of diabetes, hypertension, hepatitis, tuberculosis, other infectious diseases, or allergies caused by food or medications. Menstrual History: Menarche at age 13. The menstrual circle ranged from 28-30 days, with a duration of 4-5 days with a scanty red flow. Her last period arrived 10 days prior.

Physical Examination: Heart rate 73 bpm and regular, no pathological murmur at any valve area, flat abdomen, liver and spleen non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Pattern Differentiation The main features of the patient: stiffness, pain and inflexibility of the left hip joint, definite tenderness on the left piriformis muscle radiating down the posterolateral side of the thigh and leg, limited internal rotation or adduction. The straight leg elevation test revealed obvious pain before 45° with slight relief after 60°. Because of left lower limb exertion over the past two weeks, the patient damaged her hip muscles which led to impairment of the channels and collaterals, stagnation of qi and blood, obstruction within the channels, and blockage of the collaterals. The disease arises from the liver and spleen, and is considered a complex pattern of deficiency and excess. Diagnosis TCM pattern: Blood stasis Clinical Treatment Over-exertion injured the hip muscles, leading to impairment of the channels and collaterals, stagnation of qi and blood, obstruction in the channels, and blockage of the collaterals. Correct treatment should invigorate blood, eliminate stasis, and unblock the collaterals to relieve pain. Apart from acupuncture and moxibustion, the patient is also advised to move her lower limbs properly, and to engage in functional exercises of the hip muscles. Principles: Invigorate blood, eliminate stasis, unblock the collaterals

Formula: Modified Shēn Jīn Tāng (Tendon-Relaxing Decoction) [伸筋汤加减]

The patient was prescribed three doses, one dose for two days. [Formula Analysis] As the chief medicinal, dāng guī acts to nourish and invigorate blood, eliminate static blood and nourish the sinews. Chuān xiōng and hóng huā serve as minister medicinals to invigorate blood and eliminate stasis. Mŭ dān pí and bái sháo nourish and invigorate the blood, relax the sinews and relieve pain. Xù duàn, dù zhòng, wŭ jiā pí, and jī xuè téng supplement the liver and kidney, strengthen sinew and bone, and unblock channels and collaterals to relieve pain, while niú xī invigorates blood and guides it downward.

Gān căo, as the envoy medicinal, harmonizes the actions of all formula medicinals.

Acupuncture Main points: BL 54 (zhì biān), GB 30 (huán tiào), BL 36 (chéng fú), ashi points Supplementary points: GB 34 (yáng líng quán), BL 40 (wĕi zhōng), GB 39 (xuánzhōng), BL 57 (chéng shān), SP 10 (xuè hăi), BL 23 (shèn shù), ST 36 (zú sān lĭ) Method: Three main points and four to five supplementary points were chosen for each daily treatment. After qi was obtained, the needles were retained for 20-30 min. One course of treatment consisted of five sessions. Techniques: Points were needled with even supplementation and drainage, with warm-needle moxibustion at ST 36 (zú sān lĭ). Moxibustion or TDP lamp therapy was also applicable. Treatments took place once daily. Further Consultation After five treatments, the patient reported that her pain was greatly alleviated, so she stopped taking the medicinal decoction. She continued for five more acupuncture treatments, after which she was pain-free.

CASE STUDY II (ACUPUNCTURE, Huang Ding-jian) Ms. Dang, age 59. Chief Complaint: Right hip joint pain for the past three days, worse over the past 24 hrs. History: The patient complained of a sudden pulling pain on her right hip joint, radiating to the lateral aspect of her knee. She also had difficulty in twisting her body around, but she denied traumatic injury. She topically applied a medicinal wine by herself at home, but there was little beneficial effect. Her sleep was disturbed due to the pain. Her appetite and stools were normal. The tongue was red with a white coating, the pulse was wiry. Diagnosis Hip bi syndrome (piriformis syndrome) Clinical Treatment Principles: Free the collaterals and alleviate pain Points: Ashi points, BL 54 (zhì biān), GB 34 (yáng líng quán), and BL 40 (wĕi zhōng) (all on the right side). Techniques: On the first day, massage therapy was applied to the reactive points on the piriformis muscle for 10 min. BL 54 (zhì biān) was then needled, rubbed with a topical medicinal liniment, and then warmed with a TDP lamp for 30 min. The pain was greatly relieved the next day. For the second treatment, ashi points were needled with electrostimulation followed by a medicinal liniment and TDP. Additional points

included BL 54 (zhìbiān), GB 34 (yáng líng quán) and BL 40 (wĕi zhōng). She was given treatment every other day. After ten sessions she was recovered with full movement of her hip and leg. No recurrence was noted at a one-year follow-up. Note To effectively treat this disease, therapeutic massage should be employed. At the beginning, manipulation should be relatively gentle in order to avoid worsening of the local injury; later on, it should be strengthened to relax spasm and break up any adhesions. Acupuncture, medicinal liniments and a TDP lamp can all be employed to relieve local muscular spasm and pain by invigorating blood, eliminating stasis and unblocking the collaterals.

COMMENTARY AND DISCUSSION The following piriformis stretching exercise can be very effective, and can be performed by the patient at home: (1) Lie flat on the back (2) Raise the leg of the affected side (3) Keeping the leg fully extended (or “straight”), let it drop at a 90°angle to its opposite side. So, if you are raising your right leg, let it drop down to the floor on your left side, pointing to your left. This will stretch the piriformis muscle. If you were lying on a clock, your head would be at 12, your left foot at 6, and your right foot at 3. (4) To modulate the pain that this stretch may aggravate, go slowly and bend the knee if needed. Allow enough pain during the piriformis stretch that one can relax into. However, with too much pain, the muscle will tighten up as a guarding response, which is therapeutically counterproductive.

STUDY QUESTIONS 1. In addition to acupuncture and Chinese medicinals, what other therapies should be considered for the first case? 2. Regarding the location of the first piriformis syndrome case, which channels were affected? Answers 1. The patient is also advised to drive her car more ergonomically, as well as to perform piriformis-stretching exercises. 2. The pain was described as being located in the “posterolateral” aspect of the thigh and lower leg. The “posterior” part is the foot taiyang channel, while the “lateral”aspect suggests the foot shaoyang channel.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Ms. Sun, age 63, reported severe pain in her hip and thigh; the pain was fixed, sensitive to pressure, and aggravated by coughing. She had palpable tendons in spasm, and reported that she couldn’t bend or stretch her lower limb. Her tongue was purple and dark with purple spots, and her pulse was wiry. Which of the following formulas is the best choice in this case? A. Hŭ Qián Wán (Hidden Tiger Pill) B. Qiāng Huó Shèng Shī Tāng (Notopterygium Dampness-Drying Decoction) C. Modified Qīng Lì Huó Luò Tāng (Heat-Clearing DampnessDraining Channel-Activating Decoction) D. Modified Shēn Jīn Tāng (Tendon-Relaxing Decoction) E. Modified Èr Miào Săn (Two Mysterious Powder) 2. Mr. Zhang, age 52, felt burning pain, heaviness and weakness in his hip and thigh three days prior. He had thirst with no desire to drink, and dark yellow urine. His tongue was red with a yellow greasy coating, and his pulse was slippery and rapid. Which of the following are the correct treatment principles?

A. Invigorate blood and dissolve stasis B. Dispel wind and overcome dampness C. Clear heat and drain dampness D. Supplement liver and kidney E. Warm the channels and dissipate cold 3. Mr. Wang, age 68, suffered from chronic dull pain, heaviness, and weakness in his hip and thigh, which was aggravated by hard physical work; he reported that massage helped. His limbs were cold to the touch. His tongue was pale, and his pulse was deep and thin. Which of the following is the presenting pattern? A. Retention of wind-cold B. Retention of wind-dampness C. Obstruction of turbid phlegm D. Deficiency of liver and kidney E. Blockage of static blood 4. Mr. Liu, age 48, felt severe pain in his hip and thigh recently; the pain was fixed and sensitive to pressure. He had palpable spastic tendons and was unable to bend or stretch his lower limb. The pain radiated from his hip down the lateral side of his leg. Which of the following channels is affected? A. Taiyang channel of foot B. Shaoyang channel of foot C. Yangming channel of foot

D. Taiyang channel of hand E. Yangming channel of hand 5. Ms. He, age 46, reported severe pain in her hip and thigh; the pain was fixed and sensitive to pressure. She had palpable spastic tendons. Which of the following are the main points for treatment? A. BL 54 (zhì biān), GB 30 (huán tiào), ashi point B. BL 54 (zhì biān), BL 60 (kūn lún), GB 34 (yáng líng quán) C. GB 41 (zú lín qì), GB 39 (xuán zhōng), GB 34 (yáng líng quán) D. BL 54 (zhì biān), BL 40 (wĕi zhōng), BL 57 (chéng shān) E. BL 36 (chéng fú), BL 60 (kūn lún), GB 34 (yáng líng quán) 6. Ms. Zhou, age 65, reported a recent onset of cold pain, heaviness, and inflexibility of her hip and thigh that was aggravated by cold weather. Her tongue coating was white, and her pulse was deep and slow. In addition to the main points, which of the following point groupings could moxibustion be applied? A. GB 39 (xuán zhōng), BL 60 (kūn lún), GB 34 (yáng líng quán) B. BL 36 (chéng fú), BL 60 (kūn lún), GB 34 (yáng líng quán) C. BL 36 (chéng fú), GB 30 (huán tiào), GB 34 (yáng líng quán) D. BL 40 (wĕi zhōng), BL 60 (kūn lún), GB 34 (yáng líng quán) E. GB 39 (xuán zhōng), BL 23 (shèn shù), DU 4 (mìng mén) 7. Mr. Chen, age 50, felt severe fixed pain on his hip and thigh recently. He had palpable spastic tendons and couldn’t bend or stretch his

lower limb. The pain radiated from his hip down the posterior aspect of the leg. Which of the following channels is affected? A. Foot taiyang channel B. Foot shaoyang channel C. Foot yangming channel D. Hand taiyang channel E. Hand yangming channel 8. Mr. Zhang, age 68, suffered from recurrent dull pain in his hip and thigh which was aggravated by physical labor and improved by massage. Other signs included muscle atrophy, a lusterless complexion, and cold limbs. His tongue was pale, and his pulse was deep and thin. In addition to the main points, which of the following point groupings could be treated with moxibustion? A. BL 40 (wĕi zhōng), GB 39 (xuán zhōng), GB 41 (zú lín qì) B. BL 23 (shèn shù), DU 4 (mìng mén), DU 3 (yāo yáng guān) C. BL 40 (wĕi zhōng), SP 6 (sān yīn jiāo), GB 41 (zú lín qì) D. BL 40 (wĕi zhōng), ST 36 (zú sān lĭ), GB 41 (zú lín qì) E. BL 40 (wĕi zhōng), GB 39 (xuán zhōng), GB 41 (zú lín qì) Answers 1. D 2. C

3. D 4. B 5. A 6. E 7. A 8. B

28. Sciatica ANCIENT THEORIES AND MODERN INSIGHTS Sciatica refers to pain that appears along the sciatic nerve pathway, and includes pain in the lower back, hip, thigh, calf and foot. In TCM, sciatica falls under the category of “bi syndrome” or simply “lower limb pain”. The main symptoms include aching, numbness, and heavy sensations in the lower limbs as well as difficulty in flexion of the muscles, tendons, bones, and joints of the lower limbs. Articular swelling can also arise in some cases. There are both distinctions and similarities between this syndrome in TCM and the Western medical condition of “sciatic nerve pain”. Sciatica is often caused by external pathogens of wind, cold, dampness or heat that attack the lower limbs of the body and lead to obstruction of the channels and collaterals. Other common causes include deficiency of the liver and kidney which makes the body susceptible to external pathogens, especially in the lower parts of the body, the inability to dispel pathogens due to chronic illness, the invasion of external pathogens due to an unhealthy lifestyle, and finally, chronic illnesses that result in pain due to internal dampness, or blood or phlegm stagnation. In this last scenario, both internal and external pathogens combine to obstruct the channels and collaterals, thus causing unsmooth circulation of qi and blood that results in sciatic nerve pain.

Sciatica is associated closely with liver and kidney organs, and the foot taiyang and shaoyang channels.

ETIOLOGY AND PATHOMECHANISMS External Causes Cold-dampness: Cold-dampness invades at the lower back usually where there is a pre-existing deficiency. The resulting blockage of channelqi leads to pain that affects the lower limb of one side, also with numbness and limited range of motion. Damp-heat: There are a variety of potential sources for damp-heat, including exterior invasion of damp-heat, stasis of turbid-dampness transforming into internal heat, or a direct accumulation of damp-heat within the body. Once the damp-heat is created, it can enter the taiyang or shaoyang channels of the foot, attack the lower back when the body is weak, and ultimately lead to obstruction of channel-qi with sciatic nerve pain.

Internal Causes Because of a weak constitution, or qi and blood deficiency, the body can easily suffer from an invasion of external pathogens; chronic illness too can give rise to the inability for the body to expel pathogens which allows them to penetrate into and linger on the tendons and bones, leading to “bi syndrome”.

Others Causes Sciatica can be brought on by a number of lifestyle factors including living in a cold environment for too long, exposure to wind while sleeping,

lingering in the wind and rain, and entering water after sweating. Another cause for sciatica that corresponds more closely with nerve impingement syndrome is a lumbar sprain or contusion. Trauma can impair the sinews and channels, resulting in qi and blood stasis with blockage of the channels and collaterals.

COMMON CLINICAL PATTERNS The most common clinical patterns are cold-dampness, blood stasis, damp-heat accumulation, and deficiency of liver and kidney.

PATTERN DIFFERENTIATION 1. Differentiation Based on Channel Theory Foot shaoyang channel: Radiating pain of the lower limb that favors the lateral side of the thigh, leg and foot, following the trajectory of the gallbladder channel. Foot taiyang channel: Radiating pain of the lower limb that favors the posterior aspect of the thigh, leg and foot, following the trajectory of the bladder channel. 2. Differentiation Based on Patterns Cold-dampness: Radiating pain and heavy sensations in the lower limbs that is alleviated by warmth, and aggravated by cold or rainy weather; accompanied by cold limbs, a pale swollen tongue with a white coating, and a slippery pulse. Blood stasis: Those with tissue trauma or prolonged lumbar and femoral pain are most likely to develop this pattern with indications such as stabbing pains with difficulty in bending and turning the waist, especially at night. The tongue is purple or dark with dark stasis spots, and the pulse is choppy. Damp-heat accumulation: Burning pain in the waist and lower limbs, difficulty in twisting the waist with a heavy sensation, and thirst without a desire to drink. The tongue is red with a yellow greasy coating; the pulse is slippery and rapid.

Deficiency of liver and kidney: Low-grade sciatic nerve pain that lingers and recurs, pain of the low back and lower limbs, dizziness, tinnitus, fatigue aggravated by labor, and a weak pulse. 3. Differentiation Based on Neuroanatomy Nerve root-type: Located at the root of the spinal nerve in the spinal canal, the pain radiates from the lumbus to the buttocks along the posterior aspect of the thigh, the posterolateral aspect of the leg, and the lateral aspect of the dorsum of the foot; obvious aggravation of pain is caused by pressing or tapping on the lumbosacral levels of the spine. Nerve trunk-type: Located along the sciatic nerve outside of the spinal canal, without obvious lower back pain; the pain often begins in the buttocks and then follows the usual trajectory of the sciatic nerve. This is also called “piriformis syndrome”, whereby the piriformis muscle irritates the sciatic nerve as it passes through the buttocks.

THERAPEUTICS Chinese Medicinals 1. Cold-dampness Formula: Modified Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) Ingredients: dú huó (Radix Angelicae Pubescentis), jì shēng (Herba Taxilli), niú xī (Radix Achyranthis Bidentatae), xì xīn (Radix et Rhizoma Asari), fángfēng (Radix Saposhnikoviae), qín jiāo (Radix Gentianae Macrophyllae), dù zhòng (Cortex Eucommiae), ròu guì (Cortex Cinnamomi), fú líng (Poria), rén shēn (Radix et Rhizoma Ginseng), gān căo (Radix et Rhizoma Glycyrrhizae), chuān xiōng (Rhizoma Chuanxiong), dāng guī (Radix Angelicae Sinensis), shú dì huáng (Radix Rehmanniae Praeparata), bái sháo (Radix Paeoniae Alba), plus: wēi líng xiān (Radix et Rhizoma Clematidis), mù guā (Fructus Chaenomelis) 2. Blood Stasis Formula: Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) Ingredients: niú xī, wēi líng xiān, qín jiāo, chuān xiōng, táo rén (Semen Persicae), gāncăo (Radix et Rhizoma Glycyrrhizae), qiāng huó (Rhizoma et Radix Notopterygii), mòyào (Myrrha), dāng guī, wŭ líng zhī (Faeces Trogopterori), xiāng fù (Rhizoma Cyperi), dìlóng (Pheretima), hóng huā (Flos Carthami), plus shēn jīn căo (Herba Lycopodii) 3. Damp-heat accumulation

Formula: Jiā Wèi Èr Miào Săn (Supplemented Two Mysterious Powder) Ingredients: huáng băi (Cortex Phellodendri Chinensis), cāng zhú (Rhizoma Atractylodis), xù duàn (Radix Dipsaci), tŭ fú líng (Rhizoma Smilacis Glabrae), chuānniú xī (Radix Cyathulae), yì yĭ rén (Semen Coicis), mù guā, wēi líng xiān 4. Deficiency of Liver and Kidney Formula: Hŭ Qián Wán (Hidden Tiger Pill) Ingredients: huáng qí (Radix Astragali), chuān niú xī, wŭ jiā pí (Cortex Acanthopanacis), dù zhòng, gŏu qĭ zĭ (Fructus Lycii), gŏu jĭ (Rhizoma Cibotii), xù duàn, bā jĭ tiān (Radix Morindae Officinalis), huáng băi, guī băn (Plastrum Testudinis), zhī mŭ (Rhizoma Anemarrhenae), shú dì huáng (Radix Rehmanniae Praeparata), bái sháo (Radix Paeoniae Alba), hŭ gŭ (Os Tigridis) (replaced with legal substitution), suŏ yáng (Herba Cynomorii), gān jiāng (Rhizoma Zingiberis), chén pí (Pericarpium Citri Reticulatae) ★ Key Medicinals Niú xī is the first and foremost medicinal for paralysis and pain of the lower limb. It is bitter and sour in flavor, neutral in thermal property, and acts upon the liver and kidney channels. It supplements the liver and kidney, strengthens the sinews and bones, promotes blood circulation, guides blood downward, and unblocks the blood vessels to nourish the joints. Since it tends to descend, it is often used for paralysis or pain in the lower limbs. Due to its blood-invigorating and stasis-dissolving effects, niúxī is contraindicated in those who are pregnant or having a heavy menstrual period.

Acupuncture and moxibustion treatment 1. Point Selection According to Channels (1) Points on the du vessel and the three foot yang channels. (2) Points on the foot shaoyang and taiyang channels. (3) The key point is GB 30 (huán tiào). 2. Point Selection According to Location (1) Local points located around the joints on the foot yang channels

● Hip: GB 30 (huán tiào) ● Knee: GB 34 (yáng líng quán), BL 40 (wĕi zhōng), GB 33 (xī yáng guān)

● Ankle: BL 60 (kūn lún), GB 41 (zú lín qì), GB 39 (xuán zhōng) ● Metatarsus and toe: GB 43 (xiá xī) (2) Ashi points (3) Lumbus: Hua tuo jia ji points (L1-L5), and DU 3 (yāo yáng guān) 3. Point Selection Based on Pattern Differentiation (1) Cold-dampness

● Ashi points on the lower limb, especially on the taiyang and shaoyang channels of the foot. The taiyang channel is the most exterior of the six channels and the body area where wind-pathogens most easily attack, but, the shaoyang channel is also sensitive to wind by virtue of its wood-nature. As such, GB 30 (huán tiào) is the key point, with supplementary points including GB 34 (yáng líng quán), BL 40 (wĕi

zhōng), BL 54 (zhì biān), BL 60 (kūn lún), GB 41 (zú lín qì), GB 39 (xuánzhōng), etc.

● Lumbar points such as hua tuo jia ji points (L1-L5) and DU 3 (yāo yáng guān).

● With predominant wind, add BL 12 (fēng mén) and GB 31 (fēng shì); with predominant dampness, add SP 6 (sān yīn jiāo) and LV 6 (zhōng dū); with predominant cold, apply moxibustion on GB 39 (xuán zhōng) and DU 4 (mìngmén). (2) Damp-heat accumulation: Select points on du vessel and the three foot yang channels such as GB 30 (huán tiào), hua tuo jia ji points (L1-L5), BL 54 (zhì biān), GB 34 (yáng líng quán), BL 40 (wĕi zhōng), BL 60 (kūn lún), GB 41 (zú lín qì), GB 39 (xuánzhōng), GB 37 (guāng míng), and ST 38 (tiáo kŏu). (3) Blood stasis: In addition to points on du vessel and the three foot yang channels, add SP 10 (xuè hăi) and BL 17 (gé shù). (4) Deficiency of liver and kidney: In addition to points on du vessel and the three foot yang channels, apply moxibustion to BL 23 (shèn shù), ST 36 (zú sān lĭ), GB 37 (guāngmíng), and ST 41 (jiĕ xī). When needling GB 30 (huán tiào), BL 40 (wĕi zhōng), and GB 34 (yáng líng quán), the patient should feel an electric sensation or aching and distention conducted down along the entire lower limb; a needling sensation that extends to the toe is optimum, while sensation limited to the local area predicts poor efficacy. A sensation that radiates toward the lower abdomen or genitals predicts no efficacy at all; in this case, the needling direction should be changed. For the treatment of cold or deficiency patterns, moxibustion should also be employed.

4. Treatment in Accordance with Channel Differentiation (1) Foot taiyang channel Point selection: Hua tuo jia ji points (L3-L5), DU 3 (yāo yáng guān), GB 30 (huántiào), GB 34 (yáng líng quán), BL 54 (zhì biān), BL 36 (chéng fú), BL 37 (yīn mén), BL 40 (wĕizhōng), BL 57 (chéng shān), BL 60 (kūn lún) (2) Foot shaoyang channel Point selection: BL 32 (cì liáo), GB 30 (huán tiào), GB 34 (yáng líng quán), ST 36 (zúsān lĭ), GB 31 (fēng shì), GB 33 (xī yáng guān), GB 38 (yáng fŭ), GB 39 (xuán zhōng), GB 41 (zú lín qì). Techniques: Each point is needled with drainage by lifting and thrusting with rotation. Downward propagation of the needling sensation from the lumbar region along the foot taiyang and shaoyang channels predicts good efficacy. 5. Treatment in Accordance with Type of Illness (1) Nerve root-type Point selection: Hua tuo jia ji points (L4, L5), GB 34 (yáng líng quán), BL 40 (wĕizhōng), GB 30 (huán tiào), ashi points (2) Nerve trunk-type Point selection: BL 54 (zhì biān), GB 34 (yáng líng quán), BL 40 (wĕi zhōng), GB 30 (huán tiào), ashi points

CASE STUDY I Ms. Liu, age 53. Initial Visit: September 28th, 2006 Chief Complaint: Pain in the right leg for two years, worse over the past five days. History: The patient is a housewife. She sprained her lower back two years ago, which was followed by pain in the right leg. The pain arose recurrently and was aggravated by activity. Five days ago, a day of hiking aggravated her pain. The pain was not relieved by oral analgetics, so she chose to visit us. Signs and Symptoms: Distending pain in the right lower limb accompanied by lumbar pain. She had obvious tenderness at GB 30 (huán tiào). She also reported aching pain in the lower back and knee, dizziness, and tinnitus. Her pain improved with massage. Her tongue was slightly red with a thin white coating; the pulse was wiry and weak. Past History: The patient denied diabetes, hypertension, hepatitis, tuberculosis or other infectious diseases. She also denied any history of allergies to drugs or foods. Menstrual History: Menarche at age 13. Menstrual cycle of 28-30 days, with a duration of 3-4 days, and scant red menses. Physical Examination: BP 120/73mmHg. Heart rate 75bpm and regular, no pathological murmur at any valve area. Pain in the lumbar and sciatic regions intensified at 30°(+) in a straight leg elevation test. CT reveals mild intervertebral disc protrusion from L3 to S1. Pattern Differentiation

The main features of the patient: a sprained lower back from two years ago caused stagnation of qi and blood in the lower back and leg. Blood stasis caused obstruction in the channels and collaterals with pain. Additionally, she was over age 50 and presenting with insufficiency of the liver and kidney; malnourishment of the sinews and bones also aggravated the pain. There was distending pain in her right leg, aching pain of the lower back and knee, dizziness, and tinnitus. The pain improved with massage but was aggravated by exertion. Her tongue was slightly red with a thin white coating; her pulse was wiry and weak. The pattern is a mixture of deficiency and excess with the lower back and leg mainly affected, and the liver and kidney as the involved organs. Diagnosis TCM pattern: Blood stasis with deficiency of liver and kidney Clinical Treatment According to the presenting pattern, treatment should supplement liver and kidney, strengthening sinews and bone, invigorate blood and eliminate stasis to relieve pain. Apart from acupuncture and moxibustion, lifestyle changes are also considered as indispensible in this treatment. Changes include avoidance of overstrain and dressing warm in cold weather. Principles: Supplement liver and kidney, strengthen sinew and bone, invigorate blood, eliminate stasis Formula: Modified Shēn Tòng Zhú Yū Tāng (Generalized Pain StasisExpelling Decoction) [身痛逐瘀汤加减]

The patient was prescribed seven doses; one dose lasting two days. [Formula Analysis] As the chief medicinal, niú xī acts to supplement the liver and kidney, strengthen the sinews and bones, invigorate blood, direct blood downwards, and free the collaterals. Bái sháo, dù zhòng, xù duàn, gŭ suì bŭ, wŭ jiā pí, and huáng qí assist by supplementing liver and kidney, strengthening sinew and bone while nourishing and invigorating the blood. Wēi líng xiān, qín jiāo, rŭ xiāng, mò yào, dān shēn, shēn jīn căo, jī xuè téng and sān qī break up blood stasis, move qi, and unblock the collaterals to stop pain. These medicinals all serve as ministers. Gān căo, serves as envoy, and harmonizes all formula medicinals.

Acupuncture Main points: GB 30 (huán tiào), BL 54 (zhì biān), GB 34 (yáng líng quán), BL 40 (wĕizhōng), GB 39 (xuán zhōng) Supplementary points: BL 23 (shèn shù), ST 36 (zú sān lĭ), BL 18 (gān shù), BL 20 (píshù), BL 25 (dà cháng shù) Method: 3-4 main points and 4-5 supplementary points were selected. After qi was obtained, the needles were retained for 20-30 min. One course of treatment lasted ten sessions. Techniques: Apply needling with even supplementation and drainage on the main points. TDP lamp can also be employed. Warming-needle moxibustion was applied to ST 36 (zú sān lĭ), and flash-cupping on the back-shu points. Treatment took place every two days. Further Consultation After three treatments, the patient felt that her pain was greatly alleviated. Nonetheless, treatment was continued for ten sessions; when the sciatic nerve pain resolved, flexibility of the waist and leg was also recovered.

CASE STUDY II (ACUPUNCTURE, Tian Conghuo) Ms. Zhang, age 50. Chief Complaint: Pain in the left leg originating in the waist for one year. Aching pain has been aggravated for ten days. History: A year ago the patient developed numbness and pain along the lateral aspect of her left leg after lifting some heavy objects. The pain was alleviated by massage and she did not take any medicine. The pain, with a fixed location, was worse at night and aggravated by sudden weather changes. Ten days ago, the patient experienced numbness along the lateral aspect of her left leg with aching pain and coldness of the lumbus along with edema of the lower limb. Her tongue was dim with a yellowish coating and stasis spots; the pulse was deep, wiry and thready. Diagnosis WM diagnosis: Sciatica TCM diagnosis: Bi syndrome due to insufficiency of qi and blood with blood stasis Clinical Treatment Principles: Supplement qi and blood, invigorate blood and eliminate stasis, open the collaterals to relieve pain Acupoints: Hua tuo jia ji points (L3, L4), BL 32 (cì liáo), GB 30 (huán tiào), GB 34 (yánglíng quán), ST 36 (zú sān lĭ), GB 31 (fēng shì), SP 6 (sān yīn jiāo). Also apply cupping and warming of the lumbus with a TDP lamp.

Formula

Decocted in water, taken twice daily. Method: After needling points on her leg and lower back, the pain was relieved, swelling eliminated, but the numbness and coldness remained. Therefore, we followed up with points BL 23 (shèn shù), RN 6 (qì hăi), RN 12 (zhōngwăn), RN 4 (guān yuán), GB 30 (huán tiào), GB 34 (yáng líng quán), SP 10 (xuè hăi), GB 31 (fēng shì) and SP 6 (sān yīn jiāo). Medicinal formulas were continued. After treatment for two months, the patient was completely recovered. Note This case’s sciatic nerve pain was caused after heavy lifting that damaged the sinews and collaterals, resulting in a blockage of qi and blood with subsequent blood stasis. Thus, the pain emerged with a fixed location that got worse at night. The 52-year-old patient also showed some

hypofunction of the organs which lead to an insufficient production and transformation of qi and blood. Deficient qi and blood failed to warm the channels and collaterals, which lead to the sensations of coldness and pain at some locations. ST 36 (zú sān lĭ) and SP 6 (sān yīn jiāo) were employed to supplement the spleen and stomach and to regulate the qi and blood. Points on the ren vessel were needled, alternating between RN 6 (qì hăi), RN 12 (zhōng wăn), and RN4 (guān yuán), all of which are main points for invigorating qi and enriching blood by regulating the postnatal qi. SP 10 (xuè hăi) and GB 31 (fēng shì) act to disperse cold, dispel wind and promote the circulation of qi and blood. Most of the other points were selected along the related channels in order to unblock the channels and collaterals to relieve pain. Furthermore, the herbal formula acts to supplement qi and nourish blood, invigorate blood and dissolve stasis, and unblock the collaterals to relieve pain.

COMMENTARY AND DISCUSSION According to Western medicine, there are two key causes for sciatica, those involving a nerve impingement close to the spine, and a nerve impingement in the piriformis muscle (see the chapter Piriformis Syndrome). For those closer to the spine, diagnostic imaging will often reveal disc herniation. In many cases however, the surgical treatment that addresses the herniation and presumed nerve impingement proves unsuccessful at pain relief. In these cases it is reasonable to assume that whatever the cause of the sciatic nerve pain, it was not due to the only structural issue that diagnostic imaging could locate. It is not my intention to suggest that surgery does not have its place; however, it may be prudent to consider soft tissue impingements that can easily be addressed by massage or acupuncture, or even Chinese medicinals as described in this chapter before going to the time, expense, and risks of back surgery. Even seasoned TCM practitioners often fall into the trap of assuming that all sciatica must have a musculoskeletal etiology, and ignoring for instance, pain that is aggravated by cold and damp weather (which would obviously point to a cold-dampness bi syndrome). It can be difficult to let go of the limited mechanisms of Western medicine, but when considering the risks and costs of surgery, it is essential that we also consider the long history of therapeutic successes available through TCM before suggesting surgery or habit-forming drugs for pain relief.

STUDY QUESTIONS 1. In the first case, why was distending pain of the leg treated with flash-cupping on points BL 23 (shèn shù), BL 18 (gān shù), BL 20 (pí shù), and BL 25 (dà cháng shù)? 2. In addition to acupuncture and Chinese medicinal formulas for treatment, what lifestyle changes should be suggested? Answers 1. The patient had a history of lower back injury followed by blockage of the channels and collaterals with blood stasis. As she aged, deficiency of liver and kidney occurred, leading to malnourishment of the sinews and bones. Flash-cupping on BL 23 (shèn shù), BL 18 (gān shù), BL 20 (pí shù), and BL 25 (dà cháng shù) acts to supplement the liver and kidney while also promoting the movement of qi and blood to eliminate blood stasis and relieve pain. 2. The patient is advised to avoid overstrain, to dress warmly, and to protect her body from cold.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Ms. Liu, age 63, reported radiating pain down her lower limb that was aggravated by cold and alleviated by warmth. She felt heavy and cold sensations in her limbs. The tongue was pale and enlarged with a white coating, and the pulse was slippery. Which of the following is the best choice of treatment formula? A. Hŭ Qián Wán (Hidden Tiger Pill) B. Qiāng Huó Shèng Shī Tāng (Notopterygium Dampness-Drying Decoction) C. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) D. Bā Zhēn Tāng (Eight-Gem Decoction) E. Jiā Wèi Èr Miào Săn (Supplemented Two Mysterious Powder) 2. Mr. Zhang, age 42, complained of a prolonged stabbing pain in his lower back and leg that was worse at night. His tongue was dim purple with stasis spots, and his pulse was choppy. Which of the following treatment principles apply in this case? A. Invigorate blood and eliminate stasis

B. Dispel wind and overcome dampness C. Invigorate blood and unblock the orifices D. Supplement liver and kidney E. Warm the channels and dissipate cold 3. Mr. Wang, age 68, suffered from recurrent lumbar pain radiating to the posterior lateral side of the lower limb. He also reported distending pain at the lower back and knee, vertigo, tinnitus and fatigue, all of which were aggravated by physical labor. His pulse was weak. Which of the following is the presenting pattern? A. Retention of wind-cold B. Retention of wind-dampness C. Obstruction of turbid phlegm D. Deficiency of liver and kidney E. Blockage of static blood 4. Mr. Liu, age 48, experienced burning pain in his lower limb. He also reported heaviness and inflexibility in his waist, and thirst without a desire to drink. His tongue was red with a yellow greasy coating, and his pulse was slippery and rapid. Which of the following is the best choice of treatment formula? A. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) B. Hŭ Qián Wán (Hidden Tiger Pill) C. Jiā Wèi Èr Miào Săn (Supplemented Two Mysterious Powder)

D. Qiāng Huó Shèng Shī Tāng (Notopterygium Dampness-Drying Decoction) E. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) 5. Mr. Zhang, age 46, had pain in his lower limb, radiating from the buttock down to the calf. In addition to ashi points, which of the following groups of points also should be needled? A. GB 30 (huán tiào), GB 34 (yáng líng quán), BL 23 (shèn shù) B. BL 54 (zhì biān), GB 60 (kūn lún), GB 34 (yáng líng quán) C. GB 41 (zú lín qì), GB 39(xuán zhōng), GB 34 (yáng líng quán) D. BL 54 (zhì biān), BL 40 (wĕi zhōng), GB 57 (chéng shān) E. BL 36 (chéng fú), GB 60 (kūn lún), GB 34 (yáng líng quán) 6. Ms. He, age 65, felt pain in her lower limb, radiating from the buttock down the posterior aspect of the leg. The pain was alleviated by warmth. She had cold limbs. Her tongue was pale and enlarged with a white coating, and her pulse was deficient. Apart from the main points such as ashi, GB 30 (huán tiào), BL 54 (zhì biān), BL 40 (wĕizhōng), GB 57 (chéng shān), which of the following groups should also be treated with moxibustion? A. GB 39 (xuán zhōng), DU 4 (mìng mén) B. GB 60 (kūn lún), GB 34 (yáng líng quán) C. GB 30 (huán tiào), GB 34 (yáng líng quán) D. GB 60 (kūn lún), GB 34 (yáng líng quán) E. GB 41 (zú lín qì), GB 34 (yáng líng quán)

7. Mr. Zheng, age 50, suffered from pain from the bottom of the hip along the distribution area of the sciatic nerve; there was no pain in the lower back. He was therefore diagnosed with nerve trunk-type sciatica. Which of the following groups of points should be selected? A. BL 54 (zhì biān), GB 34 (yáng líng quán), BL 40 (wĕi zhōng) B. GB 30 (huán tiào), GB 34 (yáng líng quán), BL 23 (shèn shù) C. GB 30 (huán tiào), BL 40 (wĕi zhōng), GB 39 (xuán zhōng) D. BL 40 (wĕi zhōng), GB 39 (xuán zhōng), GB 41 (zú lín qì) E. GB 30 (huán tiào), GB 39 (xuán zhōng), GB 41 (zú lín qì) 8. Mr. Wu, age 66, was an athlete during his youth. After the age of 60, he frequently suffered from lumbar pain which radiated down the lower limb. He now has distending pain of the lumbus and knee, vertigo, tinnitus and fatigue, all of which were aggravated by physical labor. His pulse is weak. In addition to the main points, which of the following point pairings should be treated with moxibustion? A. GB 39 (xuán zhōng), GB 41 (zú lín qì) B. BL 23 (shèn shù), ST 36 (zú sān lĭ) C. SP 6 (sān yīn jiāo), GB 41 (zú lín qì) D. ST 36 (zú sān lĭ), GB 41 (zú lín qì) E. GB 39 (xuán zhōng), GB 41 (zú lín qì) Answers 1. C

2. A 3. D 4. C 5. D 6. A 7. A 8. B

29. Ankle Sprain ANCIENT THEORIES AND MODERN INSIGHTS Ankle sprain refers to ligament injuries of the ankle joint, most often caused by strenuous exercise, or traumatic injury. Following injury to the sinews and joints, qi and blood congests locally. In this section we discuss two types of injuries: sprain of the medial ankle and sprain of the lateral ankle. According to the principles of “eliminating old stagnation” and “removing blood excess”, the main treatment approach is to invigorate blood to relieve pain while dispelling stasis to eliminate swelling. The channels and collaterals pertain to the zang-fu organs and connect the limbs, nourishing the zang-fu organs interiorly and moistening the interstices exteriorly in order to maintain normal physiological function. Therefore, once the ankle is injured, there will be obvious swelling and pain at the ankle to the extent that the ankle cannot bear weight.

ETIOLOGY AND PATHOMECHANISMS Ankle sprain is most likely to result from trauma or an abrupt torsion of the ankle joint which injures the local sinews. The damage to the vessels and collaterals causes bruising. Static blood obstructs the qi pathway, fresh blood cannot arrive, blood stasis blocks the vessels and collaterals, and stagnation causes pain; the resulting stagnation and constraint manifests as swollen tissues. The location of this disease is in the sinews and joints, and the nature of the condition is excess. The clinical pattern is qi and blood obstruction.

COMMON CLINICAL PATTERN Qi and blood obstruction: Qi and blood obstructs the joints, with stagnation that causes pain and local swelling of the injured joint with obvious bruising.

THERAPEUTICS Chinese Medicinals 1. Acute Stage Treatment principles: Invigorate blood, dissolve stasis, eliminate swelling and relieve pain Formula: Shū Jīn Huó Xuè Tāng (Sinew-Soothing Blood-Quickening Decoction) Ingredients: qiāng huó (Rhizoma et Radix Notopterygii), fáng fēng (Radix Saposhnikoviae), jīng jiè (Herba Schizonepetae), dú huó (Radix Angelicae Pubescentis), dāng guī (Radix Angelicae Sinensis), xù duàn (Radix Dipsaci), qīng pí (Pericarpium Citri Reticulatae Viride), niú xī (Radix Achyranthis Bidentatae), wŭ jiā pí (Cortex Acanthopanacis), dù zhòng (Cortex Eucommiae), hóng huā (Flos Carthami), zhĭ qiào (Fructus Aurantii) 2. Chronic Stage Treatment principles: Nourish liver and kidney, strengthen tendon and bone, invigorate blood and strengthen the sinews Formula: Bŭ Shèn Zhuàng Jīn Tāng (Kidney-Supplementing SinewStrengthening Decoction) Ingredients: shú dì huáng (Radix Rehmanniae Praeparata), dāng guī, niú xī, shān zhūyú (Fructus Corni), xù duàn, dù zhòng, bái sháo (Radix Paeoniae Alba), qīng pí, wŭ jiā pí

Acupuncture and Moxibustion Treatment This disease occurs due to trauma which obstructs the sinews and vessels leading to limited joint movement. The first step is to clearly differentiate the channels affected, then selecting points along those channels along with local points. 1. Point Selection According to Channels (1) Foot yangming stomach channel: ST 36 (zú sān lĭ) (2) Foot taiyang bladder channel: BL 60 (kūn lún) (3) Foot shaoyang gallbladder channel: GB 39 (xuán zhōng) 2. Point Selection According to Location (1) Sprain of lateral aspect of the ankle: GB 34 (yáng líng quán), BL 62 (shēn mài), BL 60 (kūn lún), GB 40 (qiū xū), ashi points (2) Sprain of medial aspect of the ankle: SP 6 (sān yīn jiāo), KI 3 (tài xī), KI 6 (zhàohăi), SP 5 (shāng qiū), ashi points 3. Point Selection According to Cross-Joint Treatment (Ipsilateral) Select points around the wrist on the same side as the injured ankle. 4. Point Selection According to Cross Joint Treatment (Contralateral) Select points around the wrist on the opposite side as the injured ankle. When needling the wrist, after the qi is obtained, raise the force of lifting, thrusting and twirling gradually so as to increase the needling sensation. Meanwhile, ask the patient to do some walking or revolving exercises with the injured ankle. Manipulate needles with the drainage method.

Editorial Note During the acute phase, it may be difficult to directly needle the affected ankle due to its sensitivity. In these cases, needling the wrist on either side is of great benefit. Naturally, if the lateral malleolus is injured, points adjacent to the styloid process of the unla would be indicated. In the case of the medial malleolus, points adjacent to the styloid process of the radius would be chosen. The use of wrist points to treat the ankle is based on the concept that the entire body can be thought of as a microsystem, not just a portion such as the ear or the scalp, but the entire body. In this case, treating the wrist corresponds to the ankle. In particular, points can be further mapped to paired points on the hand/foot channel. An example would be taiyang channel points at the wrist crease such as SI 4 (wàngŭ) and SI 5 (yáng gŭ) that can address pain at BL 62 (shēn mài) and BL 60 (kūn lún) respectively.

CASE STUDY I Mr. Li, age 28. Initial Visit: July 5th, 2009 Chief Complaint: Right ankle sprain occurring two days prior. History: The patient lost his footing while jogging on a rough road two days prior, and his right ankle twisted inward. After taking some medicine and massaging the area with safflower oil, he experienced swelling and pain at the right ankle which prevented him from walking. Signs and Symptoms: The patient reported swelling and pain at the right ankle with no other discomfort. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or foods. Personal History: The patient was married, his spouse was healthy. No history of drinking or smoking. Physical Examination: The patient was a lean male, well-developed and nourished. His skin and sclera showed no sign of jaundice, there were no palpable superficial lymph nodes, nor jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical, with resonant percussion sounds (normal). Heart rate was 70 bpm and regular, no pathological murmur at any valve area. Flat abdomen, liver and spleen were non-palpable, no deformity of the spine or four limbs, the right ankle was locally swollen with bruising. There was tenderness inferior and anterior to the lateral malleolus, the skin of the area was warmer to the touch than the opposite side. No edema was evident in the lower limbs.

Auxiliary Examination: X-ray showed no fracture or dislocation. Pattern Differentiation The key indications in Mr. Li’s pathology are: 1) Complaint: right ankle sprain that arose when running on a rough and uneven surface. 2) Location: right ankle. 3) Concurrent symptoms: regional swelling with bruising. 4) Palpation: tenderness inferior and anterior to the lateral malleolus, high local skin temperature. 5) Examination: no fracture or dislocation according to X-ray. Hence, the etiology of disease was the sudden excessive twisting of the ankle that led to injury of the local sinews. The vessels and collaterals were damaged, which caused bruising; static blood obstructed the qi pathway and blood stasis prevented fresh blood from entering the area, and static blood blocked the vessels and collaterals. The stagnation caused pain and an inability of qi and blood to circulate locally, which also resulted in swelling. Diagnosis Ankle sprain due to qi and blood obstruction, sinew blockage, joint dysfunction Clinical Treatment Principles: Invigorate blood, dissolve stasis, dispel swelling and relieve pain

Formula: Modified Shū Jīn Huó Xuè Tāng (Sinew-Soothing BloodQuickening Decoction) [舒筋活⾎汤加减]

Decocted in water, one dose a day. [Formula Analysis] Dāng guī is the chief medicinal which acts to nourish and invigorate the blood, dissolve stasis and relieve pain. Chì sháo invigorates blood and dissolves stasis, assisting the chief medicinal. Wŭ jiā pí, wēi líng xiān and yì yĭ rén dispel wind, eliminate dampness and relieve pain. Xù duàn, sāng jì shēng and gŭ suì bŭ supplement liver and kidney, and strengthen the sinew and bone. All medicinals work together to invigorate blood, dissolve stasis, dispel swelling and relieve pain.

Acupuncture

Main points: GB 34 (yáng líng quán), BL 62 (shēn mài), BL 60 (kūn lún), GB 40 (qiūxū), ST 36 (zú sān lĭ), ashi points Method: Needles were inserted perpendicularly and manipulated until qi was obtained, then retained for 20 min. One course of treatment lasted ten days. Techniques: The even method was used at BL 62 (shēn mài), BL 60 (kūn lún) and GB 40 (qiū xū). For ST 36 (zú sān lĭ) and GB 34 (yáng líng quán), apply rotation and lifting and thrusting to increase the needling sensation, leading it downwards to the ankle. Follow with electrostimulation and heat with a TDP lamp. Further Consultation After three days, the swelling and pain eased significantly with his ankle movement improved. One week later, the swelling and pain was completely relieved, with activities of the ankle and walking returning to normal.

CASE STUDY II (ACUPUNCTURE, Yang Zhanlin) Mr. Li, age 48. Initial Visit: July 18th, 1988 Chief Complaint: Sprain of the right ankle, injured one day prior. History: The patient sprained his right ankle playing ping-pong the afternoon prior to his visit. His right ankle was swollen and painful. A coworker immediately massaged the injured ankle for him, but the pain and swelling increased that night and affected his sleep. The right leg was swollen from below the knee to the inner ankle, and he could not walk normally. Physical Examination: Bruising and swelling was visible surrounding the right internal malleolus. Also evident was edema along his right tibia. KI 3 (tài xī) and LV 4 (zhōng fēng) of the left foot were especially tender and sensitive to pressure. His tongue was red and dim with a white coating, the pulse was wiry and tight. Diagnosis Right ankle sprain due to qi and blood obstruction Clinical Treatment Principles: Invigorate blood, dissolve stasis, dispel swelling and relieve pain Points: LV 1 (dà dūn), SP 1 (yĭn bái), HT 5 (tōng lĭ), PC 7 (dà líng) Techniques: First, Mr. Li’s feet were bled at LV 1 (dà dūn), SP 1 (yĭn bái) and the point one fen proximal to the toenail of the middle toe. He was

then needled at HT 5 (tōng lĭ) and PC 7 (dà líng). After qi was obtained, the drainage method was used. After rotating the needles for about ten minutes, the patient felt warmth in the ankle, after which the needles were retained for an additional ten minutes. Swelling of inner ankle and leg gradually faded, and the limited range of motion recovered significantly upon withdrawing the needles. Comments It is written in Formulas for Universal Relief: Orthopedics and Traumatology Chapter (PŭJì Fāng: Zhé Shāng Mén) that “If trauma disturbs the sinews and collaterals, the pathway for blood circulation is blocked; the stasis and constraint fail to dispel and thus turns into swelling with pain. Dissolve the stasis, soothe the flow of qi and blood, and then the patient will recover”. Therefore, acupuncture and bleeding can be applied concurrently to dissolve stasis and promote healing.

STUDY QUESTIONS 1. What was the significance of the acupuncture point prescription in the first case? 2. Which other methods can be used for treatment in addition to acupuncture and Chinese medicinals for the first case? 3. What additional precautions should be exercised in the treatment of ankle sprain for the first case? 4. Which of the following formulas should be chosen when there is red, hot and swollen pain due to a sprained ankle? A. Shū Jīn Huó Xuè Tāng (Sinew-Soothing Blood-Quickening Decoction) B. Bŭ Shèn Zhuàng Jīn Tāng (Kidney-Supplementing SinewStrengthening Decoction) C. Xiān Fāng Huó Mìng Yĭn (Immortal Formula Life-Giving Beverage) D. Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe Decoction) E. Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) 5. The selection of SP 5 (shāng qiū) for ankle sprain belongs to which of the following point selection methods? A. Point selection according to pattern B. Point selection according to location

C. Point selection according to channels D. Point selection according to cross-joint treatment 6. Which one of the following treatment principles is NOT for ankle sprain? A. Invigorate blood and dissolve stasis B. Dispel swelling and relieve pain C. Regulate sinews and unblock collaterals D. Invigorate blood and strengthen sinews E. Cleat heat and drain dampness Answers 1. BL 60 (kūn lún) is the jing-river point of the foot taiyang bladder channel, thus it can unblock the collaterals and relieve pain. GB 40 (qiū xū) is the yuan-source point of the foot shaoyang gallbladder channel. BL 62 (shēn mài) is an eight confluence point, and connects with the yangqiao vessel, thus it can regulate yin and yang, move qi and invigorate blood, relax the sinews and quicken the collaterals. GB 34 (yáng líng quán) is the influential point of the sinews. ST 36 (zú sān lĭ) regulates the middle jiao, rectifies qi, removes stagnation and unblocks the collaterals. Ashi points reflect diseases of the collaterals on the body surface. All of these points used together act to soothe and unblock the qi and blood, thus relieving pain and eliminating swelling. 2. Therapeutic manipulations such as tui na for tendon injury can be applied. Additionally, bleeding may be employed to dispel stasis and promote healing.

3. Rule out or address fractures or dislocation before treatment of the tendon sprain. Keep the joint warm after any tui na manipulation. 4. A 5. B 6. E

30. Heel Pain ANCIENT THEORIES AND MODERN INSIGHTS Heel pain usually affects people from the ages of 40-60. In TCM, this disease belongs to bi syndrome. The internal causes are liver and kidney deficiency due to chronic illness, and sinew or bone overstrain in the local area of the heel. Heel pain can also become aggravated by exterior wind, cold and dampness. There is a theory in TCM that teaches “a given channel treats diseases that arise along that channel’s trajectory”. As such, heel pain has a close relationship with the foot shaoyin kidney channel. According to channel theory, the foot shaoyin kidney channel governs the heel. The foot shaoyin kidney channel originates from the inferior aspect of the little toe and proceeds diagonally to the center of the ball of the foot. It runs posterior to the inner malleolus and enters the heel. One channel diverges from KI 4 (dà zhōng), running from inner malleolus through the heel and to the exterior of the foot, where it connects with the foot taiyang channel. The kidney stores essence, governs bone and generates marrow. Heel pain syndrome is often related to patterns of kidney deficiency. The foot taiyang channel diverges from BL 58 (fēi yáng), which is located 7 cun superior to the exterior malleolus; it then connects with the foot shaoyin channel. Because of the interior-exterior relationship between the kidney and bladder, heel pain is also attributed to the bladder channel.

ETIOLOGY AND PATHOMECHANISMS External Causes Wind, cold and dampness: With qi deficiency, pathogens may accumulate inside the body. Pathogenic wind, cold and dampness can invade the body and remain within the sinews and bones, causing stasis and obstruction which ultimately leads to pain.

Internal Causes Kidney deficiency: Kidney qi deficiency arises in the patient with a congenitally deficient constitution or other deficiencies. The kidney governs bone, so when the kidney is deficient, the yin-essence fails to nourish the bones, resulting in heel pain. Qi stagnation and blood stasis: A deficiency of qi and blood often appears among the elderly. The heel is constantly hitting the ground, so the circulation of qi and blood can be easily obstructed. When there is obstruction of qi and blood, there is pain. If the heel suffers trauma, qi stagnation and blood stasis can result along with localized obstructions of the channels and collaterals. If external pathogens also invade, the heel pain would be due to both external and internal causes.

COMMON CLINICAL PATTERNS Liver and kidney deficiency: Old age or a weak constitution, dull pain in the heel, and difficulty in walking, soreness and weakness in the lower back and knees, and tinnitus or hearing impairment. The tongue is red with a scanty coating; the pulse is thin and rapid. Qi stagnation and blood stasis: History of tissue trauma, stabbing pains in the heel with a fixed location accompanied by limited range of motion in the ankle and difficulty in walking. The tongue is red or dim with a thin coating; the pulse is wiry and tight. Cold-damp obstruction: Caused by invasion of wind-cold manifesting with heaviness in the lower limbs, and heel pain relieved by warmth and aggravated by cold. The tongue is purple or dim; the pulse is deep and slow.

THERAPEUTICS Chinese Medicinals 1. Liver and Kidney Deficiency Formula: Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill) Ingredients: shú dì huáng (Radix Rehmanniae Praeparata), shān yào (Rhizoma Dioscoreae), shān zhū yú (Fructus Corni), fú líng (Poria), zé xiè (Rhizoma Alismatis), mŭdān pí (Cortex Moutan), huái niú xī (Radix Achyranthis Bidentatae), yán hú suŏ (Rhizoma Corydalis), mù guā (Fructus Chaenomelis) 2. Qi Stagnation and Blood Stasis Formula: Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) Ingredients: táo rén (Semen Persicae), hóng huā (Flos Carthami), shēng dì (Radix Rehmanniae), dāng guī (Radix Angelicae Sinensis), bái sháo (Radix Paeoniae Alba), chuān niú xī (Radix Cyathulae), yán hú suŏ, mù guā 3. Cold-damp Obstruction Formula: Wū Tóu Tāng (Aconite Main Tuber Decoction) Ingredients: wū tóu (Radix Aconiti), má huáng (Herba Ephedrae), sháo yào (Radix Paeoniae), gān căo (Radix et Rhizoma Glycyrrhizae), huáng qí (Radix Astragali), chuānniú xī ★ Key Medicinal

Niú xī (Radix Achyranthis Bidentatae) is an effective medicinal for diseases of the lower extremities. It has a neutral thermal nature, and its flavor is bitter, sweet and sour. Niú xī invigorates blood and unblocks the channels, nourishes liver and kidney, strengthens sinew and bone, and guides fire downward. It is commonly used for local injury with kidney deficiency symptoms such as soreness and weakness in the lower back and knees. In clinic, there are two types of niú xī used: chuān niú xī and huái niúxī. Huái niú xī is used more for nourishing liver and kidney and strengthening the lower back and knees, whereas chuān niú xī is used more for unblocking the channels, quickening the collaterals, dispelling wind and eliminating dampness. The two medicinals should be selected according to pattern differentiation, or even combined if necessary.

Acupuncture and Moxibustion Treatment 1. Point Selection According to Channels (1) Favor points on the foot shaoyin kidney channel. (2) Select foot taiyang bladder channel points. 2. Point Selection According to Location Ashi points, KI 3 (tài xī), BL 60 (kūn lún), BL 62 (shēn mài), KI 6 (zhào hăi), KI 4 (dàzhōng), GB 39 (xuán zhōng). 3. Point Selection Based on Pattern Differentiation (1) Liver and kidney deficiency: Select BL 18 (gān shù) and BL 23 (shèn shù) to supplement liver and kidney, and KI 7 (fù liū) to nourish kidney yin.

(2) Qi stagnation and blood stasis: Select LI 4 (hé gŭ) and LV 3 (tài chōng) to move qi and invigorate blood. As the influential point of blood, BL 17 (gé shù) is selected to invigorate the blood and dissolve stasis. (3) Obstruction of cold-dampness: Select SP 6 (sān yīn jiāo), SP 9 (yīn líng quán), and DU 14 (dà zhuī). Techniques: Perpendicular needling should be applied at KI 3 (tài xī) and BL 60 (kūn lún), and deep needling in the direction of the heel at BL 62 (shēn mài), KI 6 (zhàohăi) and KI 4 (dà zhōng). Multiple-needle puncture plus moxibustion can be applied at ashi points. Needle LI 4 (hé gŭ) and LV 3 (tài chōng) with drainage, and apply even supplementation and drainage at BL 17 (gé shù). Use warming-needle moxibustion at SP 6 (sān yīn jiāo), SP 9 (yīn líng quán), and DU 14 (dà zhuī). For ashi points, multiple-needle puncture can be applied such as tripleneedling, surround-needling, and joint-needling. If the pattern is qi stagnation and blood stasis, bleeding with a tri-edged needle can be applied to eliminate chronic stagnation; if the pattern is obstruction of colddampness and routine acupuncture and moxibustion methods are not effective, bleeding with a red-hot needle can be applied.

CASE STUDY I Mr. Liao, age 65. Initial Visit: December 5th, 2008 Chief Complaint: Recurring pain in the bottom of the right foot for six months which had flared up for two days prior to intake. History: Six months ago, the patient injured his right foot by slipping on a rock. There was no obvious bruising on the foot at that time. He received treatment in a local clinic and felt better. However, five days before the office visit, the foot began to hurt again after a lengthy walk. The pain was stabbing in quality and worse at night. He had received some treatments in another hospital, but his pain was not relieved. Signs and Symptoms: The bottom of the right foot was painful with obvious tenderness, but without redness or swelling. The pain was severe and interrupted the patient’s sleep, but appetite, urination and stools were normal. His tongue was pink with a thin white coating, and the pulse was wiry and tight. Past History: No history of hypertension or diabetes, no history of infectious disease such as hepatitis, tuberculosis, etc., no past history of allergies to drugs or foods. Menstrual, Marital and Childbearing History: Married with one son, the spouse and the son were healthy. Physical Examination: The patient was a lean male, well-developed and moderately nourished, his skin and sclera showed no indication of jaundice, no palpable superficial lymph nodes, no jugular vein distention, hepatojugular reflux (-). Bilateral respiratory movements were symmetrical,

with resonant percussion sounds (normal). Heart rate was 80 bpm and regular, with no pathological murmur at any valve area. Flat abdomen, liver and spleen were non-palpable, no deformity of the spine or four limbs, no edema in the lower limbs. Auxiliary Examination: X-ray of the foot showed no abnormality. Pattern Differentiation The patient had a foot injury which was treated six months before, but five days ago he had experienced severe stabbing pains after a long walk. The pain was worse at night. His tongue was pink with a thin white coating, and the pulse was wiry and tight. The patient had a history of foot injury, so there was impairment of the qi, blood, sinew and bone, resulting in stasis. After a long walk, the repetitive movement triggered the chronic stagnation to cause qi stagnation and blood stasis. Diagnosis TCM pattern: Qi stagnation and blood stasis Clinical Treatment This case was diagnosed by the quality of pain, which pointed to local qi stagnation and blood stasis. The treatment strategy then was to move qi, relax the sinews, eliminate stasis and relieve pain. To avoid further stimulation of the heel, the patient was also advised to rest in bed while the pain was acute, and also to exercise the toes in order to promote circulation of local qi and blood. Principles: Move qi, relax the sinews, eliminate stasis and relieve pain

Formula: Modified Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) [桃红四物汤加减]

Three doses. One decocted dose a day. [Formula Analysis] The chief medicinals táo rén and hóng huā act to invigorate blood and dissolve stasis. Dāng guī is sweet, acrid, bitter and warm, acting to nourish and invigorate blood. Bái sháo is sour, bitter, and slightly cold, acting to nourish blood, retain yin, soften the liver and relieve pain. Chuān xiōng moves qi, invigorates blood and dissolves stasis, assisting the chief medicinals. Niú xī guides blood downwards, while shēng dì enriches yin and nourishes the blood. These medicinals are all deputies. Shān zhā invigorates blood, yán hú suŏ and pú huáng eliminate stasis and relieve pain, ròu guì assists yang and transforms qi, thus benefiting qi and blood regulation. These four act as assistant medicinals.

Zhì gān căo harmonizes all of formula medicinals, also acting as an envoy.

Acupuncture Main points: KI 3 (tài xī), BL 60 (kūn lún), BL 62 (shēn mài), KI 6 (zhào hăi), KI 4 (dàzhōng), GB 39 (xuán zhōng), ashi points Supplementary points: LI 4 (hé gŭ), LV 3 (tài chōng), BL 17 (gé shù), SP 10 (xuè hăi), RN 6 (qì hăi), RN 17 (dàn zhōng) Method: 3-4 main points (including ashi points) and 2-3 supplementary points are needled each day, with points changed every other day. After qi was obtained, all needles were retained for 30 min. One course of treatment lasted ten days. Techniques: Penetrating puncture was applied at KI 3 (tài xī) and BL 60 (kūn lún). Deep needling in the direction of the heel was used at BL 62 (shēn mài), K I6 (zhào hăi) and KI 4 (dà zhōng). Multiple-needle puncturing or bleeding with a tri-edged needle was applied to ashi points. LI 4 (hé gŭ) and LV 3 (tài chōng) were needled with even supplementation and drainage. Treatment was given every other day, sometimes utilizing electrostimulation. Further Consultation After seven acupuncture treatments along with the formula prescription, his pain was relieved. The patient had no limitation of walking and felt only slight pain when running or jumping. To avoid the weightbearing stress of the heel, the patient was advised to avoid extreme sports for three months.

CASE STUDY II (ACUPUNCTURE, He Pu-ren) Mr. Li, age 53. Chief Complaint: Heel pain in both feet for over a year. The pain in the left foot was more severe than the right. Walking and movement had become difficult. History: Mr. Li had heel pain in both feet for over one year. In recent months, the pain become severe, and his heels were slightly swollen. Movement had become difficult, and sometimes his heels were so painful that he could not even touch them to the ground. He had gone to a hospital for X-ray exams which showed no bony spurs in either heel. So rather than receiving treatment, he was advised to wear cushions in his shoes. He followed this advice, but the symptoms were still not relieved. Finally he was recommended for acupuncture treatment. Physical Examination: Normal complexion, slightly swollen heels with tenderness. The tongue coating was thin and white, and the pulse was wiry and thready. Diagnosis Heel pain due to kidney qi deficiency, aggravated by excessive walking. The deficiency condition led to a lack of qi and blood for nourishing the sinews and bone. Clinical Treatment Principles: Supplement kidney qi, warm and unblock the channels and collaterals, harmonize qi and blood

Acupuncture: Bleeding with fire-needling on KI 3 (tài xī), BL 60 (kūn lún) and ashi points. Fire-needling can promote yang qi, harmonize qi and blood, and nourish sinews and bone. As stagnated qi and blood are dispelled, the channels and collaterals become unblocked. The patient fully recovered after 20 treatments.

COMMENTARY AND DISCUSSION Heel pain can often be described in neurological terms as affecting one nerve or another, depending on the distribution of the pain. In these cases, electro-stimulation applied to major points on either side of the nerve can prove valuable in the pain clinic. The goal of electro-stimulation is to over-accommodate the nerve such that it becomes numb to pain. When you lightly rub a portion of skin, any portion, over and over for 30 seconds, it can become numb due to the nerve’s accommodation to the constant stimulation. Accommodation in this sense refers to the nerve’s tendency to ignore signal that is constant. The nervous system is mostly focused on things that stick out, that are unusual. When we apply an electrical signal that the nerve interprets as pain, it will begin to filter out that signal focusing instead on those signals that are not constant. Because the signal that the electro-stimulation unit produces is not truly painful, the patient experiences only a tapping sensation, but the body gets used to it and filters out the pain arising from the selected nerve. This is essentially the treatment principle used in China for surgical anesthesia as well.

STUDY QUESTIONS 1. In the first case, why were KI 3 (tài xī), KI 6 (zhào hăi) and GB 39 (xuán zhōng) chosen? 2. In the first case, why was the bleeding with a tri-edged needle applied to ashi points? 3. Why were BL 17 (gé shù), SP 10 (xuè hăi), RN 6 (qì hăi) and RN 17 (dàn zhōng) chosen in the first case? What was the treatment principle? Answers 1. KI 3 (tài xī) is the yuan-source point of the foot shaoyin kidney channel. The kidney channel enters the heel. KI 3 (tài xī) is combined with KI 6 (zhào hăi) to strengthen sinew and bone, diffuse bi and relieve pain. GB 39 (xuán zhōng) is the influential point of marrow which can supplement marrow and strengthen bone, unblock the channels and quicken the collaterals. 2. The heel pain was caused by stasis long after an injury. Basic Questions:Explanation of Acupuncture (Sù Wèn: Zhēn Jiĕ, 素问·针解) states: “Eliminate prolonged stagnation because there is extravascularized blood inside”. Thus, the method of bleeding was applied to dispel stasis and promote regeneration. 3. RN 17 (dàn zhōng) is the influential point of qi. BL17 (gé shù) is the influential point of blood. SP 10 (xuè hăi) and RN 6 (qì hăi) are the sea of qi and blood. All of these points move qi, invigorate blood, and regulate qi and blood circulation.

CASE SCENARIOS The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition. 1. Mr. Wang, age 51, had a needling-type pain in his heel. The heel could not be touched, and he found it difficult to even move his foot. The pain was aggravated at night, and relieved when warmed. His complexion was dark. The tongue body was dark red with purple along the rim and at the tip, and his pulse was wiry and choppy. Which of the following is the best treatment principle for Mr. Wang? A. Disperse cold and dampness B. Warm and unblock channels and collaterals C. Disperse wind and dampness D. Warm the channel and relieve pain E. Dissolve blood stasis and relieve pain 2. Mr. Li, age 55, a farmer, had heel pain for two days. Two days ago while he was working outdoors barefoot, he felt a severe cold-type pain. Soon after, he developed heel pain with tightness in the lower leg and toes. The heel pain improved with warmth, and was aggravated by exposure to cold. As a rule, the patient was averse to cold, so this wasn’t anything new. His appetite, sleep, and stools were normal, and urination was copious. The tongue body was pale with a thin white coating, and his pulse was deep.

Which of the following would be the best treatment formula? A. Sì Nì Tāng (Frigid Extremities Decoction) B. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction) C. Yòu Guī Wán (Right-Restoring Pill) D. Wū Tóu Tāng (Aconite Main Tuber Decoction) E. Gān Jiāng Líng Zhú Tāng (Licorice, Dried Ginger, Poria, and White Atractylodes Decoction) 3. Mrs. Yan, age 58, had heel pain for many years. The pain was dull in quality, and oscillated from mild and severe. This pain was accompanied by soreness and weakness in the lower back and knees and tinnitus. His tongue was pink and with no coating, and the pulse was thin and weak. Which of the following patterns best applies in this case? A. Liver and kidney deficiency B. Cold-dampness obstruction C. Qi and blood deficiency D. Qi stagnation and blood stasis E. Vigorous fire due to yin deficiency 4. Which of the following would be the best formula based on the case above? A. Mài Wèi Dì Huáng Wán (Ophiopogon and Rehmannia Pill) B. Bŭ Xuè Róng Jīn Wán (Blood-Supplementing Sinew-Enhancing Pill)

C. Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill) D. Gān Jiāng Líng Zhú Tāng (Licorice, Dried Ginger, Poria, and White Atractylodes Decoction) E. Yòu Guī Wán (Right-Restoring Pill) Answers 1. E 2. D 3. A 4. C

Appendix I:Pinyin-English Formula Cross Reference

Appendix II: List of Cited Sources