The 2nd edition ofThe Practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbsdescribe
1,997 381 49MB
English Pages 1210 pages: illustrations [1528] Year 2007;2005
Table of contents :
Front Cover......Page 1
The Practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs......Page 3
Copyright Page......Page 4
Foreword......Page 5
ACKNOWLEDGEMENTS......Page 7
PREFACE TO THE SECOND EDITION......Page 9
NOTE ON THE TRANSLATION OF CHINESE MEDICAL TERMS......Page 15
CHAPTER 1. HEADACHES......Page 21
AETIOLOGY......Page 22
CHANNELS......Page 26
PATHOLOGY......Page 30
DIAGNOSIS......Page 32
TREATMENT STRATEGIES AND PRINCIPLES OF POINT SELECTION......Page 37
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 39
MODERN CHINESE LITERATURE......Page 72
CLINICAL TRIALS......Page 75
WESTERN DIFFERENTIAL DIAGNOSIS OF HEADACHES......Page 79
PROGNOSIS AND PREVENTION......Page 83
END NOTES......Page 84
CHAPTER 2. DIZZINESS......Page 85
PATHOLOGY......Page 86
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 87
MODERN CHINESE LITERATURE......Page 93
WESTERN DIFFERENTIATION......Page 94
END NOTES......Page 95
CHAPTER 3. BREATHLESSNESS (CHUAN)......Page 97
AETIOLOGY......Page 98
PATHOLOGY......Page 99
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 101
PROGNOSIS AND PREVENTION......Page 116
WESTERN DIFFERENTIAL DIAGNOSIS......Page 117
END NOTES......Page 119
CHAPTER 4. WHEEZING (XIAO)......Page 121
PATHOLOGY......Page 122
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 123
MODERN CHINESE LITERATURE......Page 129
PROGNOSIS AND PREVENTION......Page 130
WESTERN DIFFERENTIATION......Page 131
END NOTES......Page 132
CHAPTER 5. ALLERGIC ASTHMA (ATOPIC ECZEMA)......Page 133
ALLERGIC ASTHMA IN WESTERN MEDICINE......Page 135
CONNECTIONS AND DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN......Page 145
A NEW THEORY OF ASTHMA......Page 150
IN BETWEEN ATTACKS......Page 161
THE LIVER AND ASTHMA......Page 165
ATOPIC ECZEMA......Page 167
MODERN CHINESE LITERATURE......Page 173
CLINICAL TRIALS......Page 181
CASE HISTORIES......Page 184
PROGNOSIS AND PREVENTION......Page 191
WESTERN DRUG THERAPY......Page 192
END NOTES......Page 194
ALLERGIC RHINITIS IN WESTERN MEDICINE......Page 197
THE CHINESE THEORY OF BI YUAN......Page 199
DIFFERENCES BETWEEN ALLERGIC RHINITIS AND BI YUAN......Page 201
A NEW THEORY OF ALLERGIC RHINITIS......Page 202
TREATMENT OF ALLERGIC RHINITIS......Page 204
CLINICAL TRIALS......Page 212
CASE HISTORIES......Page 217
END NOTES......Page 219
CHAPTER 7. SINUSITIS (NASAL POLYPS)......Page 221
AETIOLOGY AND PATHOLOGY......Page 222
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 223
CLINICAL TRIALS......Page 230
CHINESE MEDICINE TREATMENT......Page 231
END NOTES......Page 233
CHAPTER 8. COUGH......Page 235
AETIOLOGY......Page 236
PATHOLOGY......Page 237
ACUPUNCTURE IN COUGH......Page 239
DIAGNOSIS......Page 240
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 241
ACUTE......Page 242
ACUTE EXTERIOR......Page 243
ACUTE INTERIOR......Page 246
CHRONIC FULL......Page 249
CHRONIC EMPTY......Page 253
MODERN CHINESE LITERATURE......Page 256
CLINICAL TRIALS......Page 259
WESTERN DIFFERENTIATION......Page 260
END NOTES......Page 262
NATURE OF THE MIND (SHEN) IN CHINESE MEDICINE......Page 263
THE FIVE MENTAL-SPIRITUAL ASPECTS......Page 267
END NOTES......Page 295
CHAPTER 10. THE EMOTIONS......Page 297
THE EMOTIONS......Page 302
THE PATHOLOGY OF QI AND MINISTER FIRE IN EMOTIONAL PROBLEMS......Page 318
END NOTES......Page 330
CHAPTER 11. AETIOLOGY OF MENTALEMOTIONAL PROBLEMS......Page 331
CONSTITUTION......Page 332
DIET......Page 336
DRUGS......Page 337
PREVENTION OF MENTALEMOTIONAL PROBLEMS......Page 339
END NOTES......Page 340
COMPLEXION......Page 341
EYES......Page 343
PULSE......Page 344
TONGUE......Page 346
END NOTES......Page 351
CHAPTER 13. DEPRESSION......Page 353
DEFINITION AND WESTERN MEDICINE’S VIEW......Page 354
PATHOLOGY OF DEPRESSION IN CHINESE MEDICINE......Page 355
AETIOLOGY......Page 360
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 362
ACUPUNCTURE POINTS FOR DEPRESSION......Page 378
HERBS FOR DEPRESSION......Page 384
MODERN CHINESE LITERATURE......Page 386
CLINICAL TRIALS......Page 390
CASE HISTORIES......Page 395
PATIENTS’ STATISTICS......Page 402
END NOTES......Page 403
ANXIETY IN WESTERN MEDICINE......Page 405
ANXIETY IN CHINESE MEDICINE......Page 407
AETIOLOGY......Page 410
PATHOLOGY AND TREATMENT PRINCIPLES......Page 411
ACUPUNCTURE TREATMENT OF ANXIETY......Page 415
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 417
CASE HISTORIES......Page 424
END NOTES......Page 426
CHAPTER 15. INSOMNIA (SOMNOLENCE, POOR MEMORY)......Page 427
AETIOLOGY......Page 429
PATHOLOGY......Page 431
DIAGNOSIS......Page 433
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 434
MODERN CHINESE LITERATURE......Page 448
CLINICAL TRIALS......Page 451
PATIENTS’ STATISTICS......Page 453
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 454
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 458
END NOTES......Page 460
CHAPTER 16. PATTERNS IN MENTALEMOTIONAL PROBLEMS AND THEIR TREATMENT WITH HERBAL MEDICINE AND ACUPUNCTURE......Page 461
THE EFFECT OF MENTAL-EMOTIONAL PROBLEMS ON QI, BLOOD, YIN AND PATHOGENIC FACTORS......Page 462
MIND OBSTRUCTED, UNSETTLED, WEAKENED......Page 467
MIND OBSTRUCTED......Page 470
MIND UNSETTLED......Page 482
MIND WEAKENED......Page 498
END NOTES......Page 511
AETIOLOGY......Page 513
PATHOLOGY......Page 514
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 516
MODERN CHINESE LITERATURE......Page 524
END NOTES......Page 525
CHAPTER 18. GOITRE (HYPOTHYROIDISM, HYPERTHYROIDISM)......Page 527
AETIOLOGY......Page 529
PATHOLOGY......Page 530
DIAGNOSIS......Page 531
GENERAL TREATMENT INDICATIONS......Page 532
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 534
GOITRE IN WESTERN MEDICINE......Page 539
PATHOLOGY......Page 541
CLINICAL MANIFESTATIONS......Page 542
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 543
PATHOLOGY......Page 546
CLINICAL MANIFESTATIONS......Page 547
HYPERTHYROIDISM IN CHINESE MEDICINE: A REVIEW OF CHINESE LITERATURE......Page 548
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 553
CASE HISTORIES......Page 557
MODERN CHINESE LITERATURE......Page 559
END NOTES......Page 560
CHAPTER 19. HYPERTENSION......Page 561
HYPERTENSION IN WESTERN MEDICINE......Page 562
HYPERTENSION IN CHINESE MEDICINE......Page 567
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 577
MODERN CHINESE LITERATURE......Page 589
CASE HISTORIES......Page 590
PATIENTS’ STATISTICS......Page 592
CLINICAL TRIALS......Page 593
END NOTES......Page 597
CHAPTER 20. TIREDNESS......Page 599
AETIOLOGY......Page 601
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 606
PATHOLOGY......Page 604
EMPTY......Page 607
FULL......Page 623
PATIENTS’ STATISTICS......Page 637
WESTERN DIFFERENTIAL DIAGNOSIS......Page 638
END NOTES......Page 639
CHAPTER 21. CHEST PAINFUL OBSTRUCTION SYNDROME......Page 641
AETIOLOGY......Page 642
PATHOLOGY......Page 643
DIFFERENTIAL DIAGNOSIS......Page 646
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 647
PROGNOSIS AND PREVENTION......Page 661
MODERN CHINESE LITERATURE......Page 662
CLINICAL TRIALS......Page 674
WESTERN DIFFERENTIAL DIAGNOSIS......Page 679
END NOTES......Page 681
CHAPTER 22. EPIGASTRIC PAIN......Page 683
AETIOLOGY......Page 684
PATHOLOGY......Page 688
DIAGNOSIS......Page 689
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 691
MODERN CHINESE LITERATURE......Page 712
CLINICAL TRIALS......Page 716
WESTERN DIFFERENTIAL DIAGNOSIS......Page 720
END NOTES......Page 721
CHAPTER 23. NAUSEA AND VOMITING......Page 723
AETIOLOGY......Page 724
PATHOLOGY......Page 725
DIAGNOSIS......Page 726
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 727
CLINICAL TRIALS......Page 735
END NOTES......Page 736
CHAPTER 24. GASTRO-OESOPHAGEAL REFLUX DISEASE......Page 737
GASTRO-OESOPHAGEAL REFLUX DISEASE IN CHINESE MEDICINE......Page 739
AETIOLOGY OF GASTROOESOPHAGEAL REFLUX DISEASE......Page 740
PATHOLOGY OF GASTROOESOPHAGEAL REFLUX DISEASE......Page 741
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 743
END NOTES......Page 747
CHAPTER 25. MOUTH ULCERS......Page 749
MOUTH ULCERS IN CHINESE MEDICINE......Page 750
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 755
MODERN CHINESE LITERATURE......Page 761
END NOTES......Page 763
CHAPTER 26. HYPOCHONDRIAL PAIN (GALL BLADDER STONES)......Page 765
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 766
WESTERN DIFFERENTIATION......Page 770
IDENTIFICATION OF PATTERNS......Page 771
TREATMENT......Page 772
MODERN CHINESE LITERATURE......Page 773
END NOTES......Page 776
CHAPTER 27. ABDOMINAL PAIN......Page 777
AETIOLOGY AND PATHOLOGY......Page 778
DIAGNOSIS......Page 779
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 782
PATIENTS’ STATISTICS......Page 796
PROGNOSIS AND PREVENTION......Page 797
WESTERN DIFFERENTIATION......Page 798
END NOTES......Page 799
CHAPTER 28. ABDOMINAL MASSES......Page 801
PATHOLOGY......Page 802
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 803
MODERN CHINESE LITERATURE......Page 812
PROGNOSIS AND PREVENTION......Page 817
END NOTES......Page 818
AETIOLOGY AND PATHOLOGY......Page 819
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 821
MODERN CHINESE LITERATURE......Page 830
WESTERN DIFFERENTIATION......Page 835
END NOTES......Page 836
CHAPTER 30. CONSTIPATION......Page 837
AETIOLOGY......Page 838
PATHOLOGY......Page 839
DIAGNOSIS......Page 841
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 842
MODERN CHINESE LITERATURE......Page 853
WESTERN DIFFERENTIATION......Page 854
END NOTES......Page 855
CHAPTER 31. URINARY SYNDROME (URINARY CALCULI)......Page 857
PATHOLOGY......Page 859
OVERVIEW OF PATTERNS......Page 861
AETIOLOGY......Page 864
DIAGNOSIS......Page 865
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 867
MODERN CHINESE LITERATURE......Page 883
PATIENTS’ STATISTICS......Page 887
WESTERN DIFFERENTIATION......Page 888
CLINICAL TRIALS......Page 889
AETIOLOGY......Page 891
TREATMENT......Page 892
END NOTES......Page 894
CHAPTER 32. ENURESIS AND INCONTINENCE (BLOOD IN THE URINE)......Page 895
PATHOLOGY......Page 896
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 897
PROGNOSIS......Page 904
MODERN CHINESE LITERATURE......Page 905
END NOTES......Page 908
CHAPTER 33. URINARY RETENTION......Page 909
PATHOLOGY......Page 910
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 911
END NOTES......Page 915
CHAPTER 34. INTERSTITIAL CYSTITIS......Page 917
INTERSTITIAL CYSTITIS IN CHINESE MEDICINE......Page 918
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 919
PROGNOSIS AND PREVENTION......Page 923
THE PROSTATE AND BENIGN PROSTATIC HYPERPLASIA IN WESTERN MEDICINE......Page 925
THE PROSTATE IN CHINESE MEDICINE......Page 927
PATHOLOGY OF BENIGN PROSTATIC HYPERPLASIA IN CHINESE MEDICINE......Page 930
TREATMENT STRATEGIES......Page 932
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 934
MODERN CHINESE LITERATURE......Page 938
END NOTES......Page 943
CHRONIC PROSTATITIS IN WESTERN MEDICINE......Page 945
CHRONIC PROSTATITIS IN CHINESE MEDICINE......Page 947
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 949
MODERN CHINESE LITERATURE......Page 957
CLINICAL TRIALS......Page 961
END NOTES......Page 963
CHAPTER 37. OEDEMA (NEPHRITIS)......Page 965
AETIOLOGY......Page 966
PATHOLOGY......Page 967
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 970
MODERN CHINESE LITERATURE......Page 981
AETIOLOGY AND PATHOLOGY......Page 982
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 983
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 987
END NOTES......Page 992
CHAPTER 38. PAINFUL OBSTRUCTION SYNDROME (RHEUMATOID ARTHRITIS)......Page 993
AETIOLOGY......Page 997
PATHOLOGY......Page 999
IDENTIFICATION OF PATTERNS......Page 1000
TREATMENT PRINCIPLES......Page 1003
ACUPUNCTURE TREATMENT......Page 1004
HERBAL THERAPY......Page 1013
TREATMENT OF SPECIFIC PARTS OF THE BODY......Page 1025
PROGNOSIS AND PREVENTION......Page 1041
MODERN CHINESE LITERATURE......Page 1043
CLINICAL TRIALS......Page 1050
WESTERN DIFFERENTIATION......Page 1053
AETIOLOGY......Page 1059
PATHOLOGY AND TREATMENT PRINCIPLES......Page 1060
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1062
CLINICAL TRIALS......Page 1070
END NOTES......Page 1072
CHAPTER 39. LOWER BACKACHE AND SCIATICA......Page 1075
AETIOLOGY......Page 1078
PATHOLOGY......Page 1079
DIAGNOSIS......Page 1081
IDENTIFICATION OF PATTERNS AND HERBAL TREATMENT......Page 1084
ACUPUNCTURE TREATMENT OF LOWER BACKACHE......Page 1087
TREATMENT OF SCIATICA......Page 1094
PATIENTS’ STATISTICS......Page 1098
PROGNOSIS AND PREVENTION......Page 1099
CLINICAL TRIALS......Page 1100
WESTERN DIFFERENTIATION......Page 1107
END NOTES......Page 1110
CHAPTER 40. FIBROMYALGIA......Page 1111
FIBROMYALGIA IN WESTERN MEDICINE......Page 1112
FIBROMYALGIA IN CHINESE MEDICINE......Page 1117
AETIOLOGY OF FIBROMYALGIA IN CHINESE MEDICINE......Page 1125
PATHOLOGY OF FIBROMYALGIA IN CHINESE MEDICINE......Page 1126
TREATMENT PRINCIPLES AND STRATEGY......Page 1128
ACUPUNCTURE IN THE TREATMENT OF FIBROMYALGIA......Page 1131
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1135
COMPARISON OF MYOFASCIAL PAIN SYNDROME, FIBROMYALGIA AND POSTVIRAL FATIGUE SYNDROME......Page 1143
END NOTES......Page 1145
CHAPTER 41. CHRONIC FATIGUE SYNDROME......Page 1147
CHRONIC FATIGUE SYNDROME IN WESTERN MEDICINE......Page 1148
CHRONIC FATIGUE SYNDROME IN CHINESE MEDICINE......Page 1153
AETIOLOGY......Page 1165
PATHOLOGY AND TREATMENT PRINCIPLES......Page 1166
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1168
PATIENTS’ STATISTICS......Page 1188
END NOTES......Page 1189
CHAPTER 42. PARKINSON’S DISEASE......Page 1191
PATHOLOGY......Page 1192
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1194
PROGNOSIS AND PREVENTION......Page 1202
MODERN CHINESE LITERATURE......Page 1203
CLINICAL TRIALS......Page 1207
END NOTES......Page 1209
CHAPTER 43. WIND-STROKE......Page 1211
AETIOLOGY......Page 1212
PATHOLOGY......Page 1213
IDENTIFICATION OF PATTERNS......Page 1214
TREATMENT......Page 1217
ATTACK OF THE CHANNELS ALONE......Page 1219
PATTERNS IN THE SEQUELAE STAGE......Page 1227
OTHER METHODS OF TREATMENT......Page 1230
MODERN CHINESE LITERATURE......Page 1231
END NOTES......Page 1238
AETIOLOGY......Page 1239
PATHOLOGY......Page 1241
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1242
MODERN CHINESE LITERATURE......Page 1251
PROGNOSIS AND WESTERN DIFFERENTIATION......Page 1254
END NOTES......Page 1255
CHAPTER 45. MULTIPLE SCLEROSIS......Page 1257
AETIOLOGY......Page 1259
PATHOLOGY......Page 1260
ACUPUNCTURE TREATMENT......Page 1261
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1263
PROGNOSIS......Page 1270
END NOTES......Page 1272
CHAPTER 46. BLEEDING......Page 1275
AETIOLOGY......Page 1276
PATHOLOGY......Page 1277
TREATMENT PRINCIPLES......Page 1279
COUGHING BLOOD......Page 1284
BLOOD IN THE STOOLS......Page 1288
BLOOD IN THE URINE......Page 1291
BLEEDING UNDER THE SKIN......Page 1296
BLEEDING GUMS......Page 1298
MODERN CHINESE LITERATURE......Page 1300
END NOTES......Page 1302
CHAPTER 47. ERECTILE DYSFUNCTION......Page 1303
ERECTILE DYSFUNCTION IN CHINESE MEDICINE......Page 1305
AETIOLOGY OF ERECTILE DYSFUNCTION IN CHINESE MEDICINE......Page 1313
PATHOLOGY OF ERECTILE DYSFUNCTION IN CHINESE MEDICINE......Page 1314
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1316
MODERN CHINESE LITERATURE......Page 1326
CLINICAL TRIALS......Page 1330
INTRODUCTION......Page 1333
AETIOLOGY AND PATHOLOGY......Page 1336
IDENTIFICATION OF PATTERNS AND TREATMENT......Page 1341
PROGNOSIS AND PREVENTION......Page 1356
END NOTES......Page 1357
GREATER YANG STAGE......Page 1359
LESSER YIN STAGE......Page 1360
TERMINAL YIN STAGE......Page 1361
DEFENSIVE-QI LEVEL......Page 1363
QI LEVEL......Page 1364
BLOOD LEVEL......Page 1365
MIDDLE BURNER......Page 1367
LOWER BURNER......Page 1368
Appendix 4: PRESCRIPTIONS......Page 1369
EMPIRICAL PRESCRIPTIONS......Page 1444
Appendix 5: ACUPUNCTURE POINTS FOR MENTAL-EMOTIONAL PROBLEMS......Page 1455
ENGLISH–PINYIN GLOSSARY OF CHINESE TERMS......Page 1467
BIBLIOGRAPHY......Page 1483
CHRONOLOGY OF CHINESE DYNASTIES......Page 1487
INDEX......Page 1489
Color Plate Section......Page 1522
To Sammi
Commissioning Editors: Karen Morley, Claire Wilson Development Editor: Kerry McGechie Project Manager: Emma Riley Designer: Charles Gray
The Practice of Chinese
Medicine
The Treatment of Diseases with Acupuncture and Chinese Herbs SECOND
EDITION
Giovanni Maciocia CAc (Nanjing) Acupuncturist and Medical Herbalist, UK Visiting Associated Professor, Nanjing University of Traditional Chinese Medicine Foreword by Steve Clavey, Ph.D., B.Ac., M.B.Ac.C. Illustrators: Michael Courtney and Richard Morris
Edinburgh • London • New York • Oxford • Philadelphia • St Louis • Sydney • Toronto • 2008
Am imprint of Elsevier Limited © Giovanni Maciocia 1994 © Giovanni Maciocia 2008 The right of Giovanni Maciocia to be identified as author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899, USA: phone (+1) 215 239 3804, fax (+1) 215 239 3805, or e-mail [email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com) by selecting ‘Support and Contact’ and then ‘Copyright and Permission’. First edition 1994 Second edition 2008 ISBN: 978-0-443-07490-5 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress
Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Author assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher
Printed in Europe
Foreword
I feel particularly honoured to be asked to pen the Foreword to the second edition of Giovanni Maciocia’s groundbreaking work, The Practice of Chinese Medicine, because – over 30 years ago – it was Giovanni himself who encouraged me to take up the study of Chinese medicine. Six years later, after leaving Taiwan, again it was Giovanni who enabled me to study in mainland China. He recalls neither of these, to me, life-changing impacts; they were simply part of what he does: surveying, cultivating, propagating. What makes his works so popular? Their clarity and system. They are easy to read, using clear everyday English, and are set out in such a way that a busy student, or an even busier clinician, can find the answers needed quickly and efficiently. Another factor in their popularity is the reflection of the cultural context we all of us outside of China share, i.e. working in societies shaped by the dominant paradigm of Western medicine, so that often the presenting complaint is not what the patients themselves feel, but rather a label applied through that paradigm. This is where The Practice of Chinese Medicine excels, providing a clear interface between the Western medicine understanding of a disease entity and the Chinese medicine view and handling of the same patient. In this, the second edition, there are over 14 new chapters, including a much expanded and in-depth discussion of the psyche in Chinese medicine, with new full chapters on anxiety, depression, chronic fatigue, nausea/vomiting, acid reflux, mouth ulcers, hypertension, prostatic enlargement, interstitial cystitis, thyroid conditions, erectile dysfunction, and more. There is also notable expansion of existing chapters, such as the differentiation and treatment of nasal polyps within the chapter on sinusitis. The chapters on gynaecology, now covered in a specialized text of their own, have not been carried over from the first edition.
This book is about Nei Ke – internal medicine – which is the guts of any general practice. From Zhang Zhong-Jing to Xu Shu-Wei, Li Gao to Cheng Guo-Peng – to name some of the taller trees in our forest – there have been many different ways of organizing the description of what happens after a patient sits down in front of you and says: “I don’t feel good.” Giovanni has gone to great lengths to develop as useful a way as possible for Westerners to access the current Chinese medicine understanding of what works best in each condition. Where that understanding is insufficient, he has brought his extensive clinical experience to bear in filling in the gaps and presenting us with his conclusions. Chinese medicine as a clinical discipline welcomes innovation, creativity; demands it, in fact. As a student, you may need to memorize for exams. When beginning clinic you may need to begin by memorizing a list of patterns for each condition, and their treatments. But though you may start with a list, you should not end up that way, but rather learn to be able to enter into a living understanding of the pathological mechanisms operating in your patients, and in the environment and society around you both. New theory, therefore, should not be a big surprise – we should all be producing it. Giovanni has invested his clinical heart and soul in the pages of this book, and the reader who really wishes to bring this book to life will meet him half way. Work to understand the mechanisms that create the various conditions in your patients, in your context, and try out the tools that are provided here, in the second edition of The Practice of Chinese Medicine. Steven Clavey Winter Solstice 2007 Melbourne
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ACKNOWLEDGEMENTS
My first trip to China, where I attended my first acupuncture course at the Nanjing University of Traditional Chinese Medicine in 1980, was an important milestone in my professional development. My first teacher there was Dr Su Xin Ming, who played an important role in the development of my acupuncture skills. I am indebted to him for the patient way in which he communicated his skills to me. I am grateful to Dr Zhou Zhong Ying of the Nanjing University of Chinese Medicine for teaching me his knowledge and skills in diagnosis and herbal medicine. I am indebted to Fi Lyburn for her exceptional attention to detail in checking the manuscript for consistency and generally helping with editing. Sylvie Perera gave me valuable help with checking the manuscript throughout, and for that I am grateful.
Becky Clarke helped me with compiling the statistics of patients from my practice with great skill. I am grateful to Suzanne Turner for her help with research and editing. Dr J.D. Van Buren was my very first teacher 35 years ago; from him, I learned the importance of diagnosis and especially of pulse diagnosis. I owe him a debt of gratitude for being my first source of inspiration in Chinese medicine. Finally, I would like to thank Karen Morley, Kerry McGechie and Claire Wilson of Elsevier for their professionalism and support. Giovanni Maciocia Amersham, 2006
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PREFACE TO THE SECOND EDITION
It is now 12 years since the first edition of The Practice of Chinese Medicine was published. That first edition was intended to be the companion volume to The Foundations of Chinese Medicine, setting out the application of the theory of Chinese medicine to the treatment of specific diseases with both acupuncture and Chinese herbs. The theory of allergic asthma and allergic rhinitis presented in this book is entirely new. Of course, this is far from perfect and will need constant revision according to our clinical experience and research, and I have added new references compared with those in the first edition. The theory of chronic fatigue syndrome, similarly new, is based on my clinical experience, although the concepts of residual pathogenic factor and Latent Heat on which it is based are very old. New too is the theory of multiple sclerosis, but this is mostly based on the pathology and symptomatology of Atrophy Syndrome. The chapter on tiredness is based on the old symptom of Xu-Lao, which means “exhaustion”, but I have departed from the traditional approach in so far as I include the Full causes of tiredness, something that is not done in the Chinese discussion of Xu-Lao. With this second edition, the following are the major changes or additions. • The text has been revised throughout, expanding the Chinese sources. • Many new patterns have been added to each disease. • New formulae have been added to many patterns. • I have added a section on modern Chinese literature to many chapters whenever applicable. • I have added new case histories. • I have added clinical trials. • I have added patients’ statistics from my own practice whenever possible.
• The discussion of mental-emotional problems has been greatly expanded (from one to eight chapters). • I have added the discussion of diseases not previously discussed. The new diseases added to this second edition are: • depression (Chapter 13) • anxiety (Chapter 14) • goitre (Chapter 18) • hypertension (Chapter 19) • nausea and vomiting (Chapter 23) • acid reflux (Chapter 24) • mouth ulcers (Chapter 25) • urinary retention (Chapter 33) • interstitial cystitis (Chapter 34) • benign prostatic hyperplasia (Chapter 35) • prostatitis (Chapter 36) • fibromyalgia (Chapter 40) • erectile dysfunction (Chapter 47). As in the first edition of this book, most of the “diseases” discussed are diseases only in the context of Chinese medicine. For example, epigastric pain is not a “disease” but a symptom in Western medicine; in Chinese medicine, it is a disease (bing) of internal medicine. However, in some cases, I discuss the treatment of Western-defined diseases (e.g. Parkinson’s disease or multiple sclerosis). Although Chinese medicine treats each individual as a whole rather than treating the “diseases” from which that patient is suffering, and explores the patterns of disharmony, lifestyle, environment, family situation, emotional life, diet, sexual habits, work routine and exercise, it is still important to discuss the treatment of individual diseases because treatment techniques vary enormously; for example, the treatment of Wind-stroke calls for specific techniques and approaches that are quite different from those used for, say, insomnia. The use of these techniques is not in
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Preface to the Second Edition
contradiction with whatever other approach or philosophy a particular practitioner may follow, and I therefore hope that this textbook can be of use to practitioners of many different orientations. Another important reason for discussing individual diseases is their particular and specific pathology and aetiology: it is only by understanding the distinctive pathology and aetiology that we can advise the patient on lifestyle, work, emotional life, sexual habits, diet and exercise. Educating the patient in these areas is as important as the treatment imparted, as it gives the patient responsibility for his or her own health and so can prevent recurrence of the problem. An addition in this second edition compared with the first are extracts from articles in modern Chinese medicine journals. Some of these are purely theoretical, discussing interesting aspects of the theory of Chinese medicine; some are reports of clinical trials. Many of these are without a control and many do not reach the standards of proper randomized controlled clinical trials. However, I do not report such articles so much for the value of their clinical trials but to gain from the experience of doctors in the treatment of various conditions. In other words, although some of the trials may be flawed, it is in many cases interesting to learn about the treatment principle and formulae adopted. Many articles report the experience of famous modern doctors of Chinese medicine (lao zhong yi). I have removed all references to modern Chinese patent remedies because of concerns about the quality controls applied, the presence of banned or toxic substances and, sometimes, the inclusion of Western drugs within a herbal remedy. The reader should note that some herbal prescriptions may contain substances that are illegal in certain countries. This could be either because they are toxic (such as Zhu Sha Cinnabaris) or because they are of animal origin from protected species; in some countries, all substances of animal or mineral origin are banned. The mention of such herbal formulae in this book does not signify an endorsement of the use of banned substances, and readers are strongly advised to enquire about the laws governing the use of certain herbs or substances in their country. Each practitioner should therefore satisfy himself or herself as to the suitability of a particular prescription. At the time of writing, all animal and mineral
products are illegal in the European Union, although each country applies the law differently. I have decided to leave the traditional formulae as they are to give the reader an idea of the action of the formula. It is only when we know the original ingredients of a formula that we can make proper substitutions based on the action of the herb or substance we intend to replace. For example, if we want to replace Gui Ban Plastrium Testudinis within a formula, we know that we can approximate its action by using the combination of Huang Jing Rhizoma Polygonati and Gou Qi Zi Fructus Lycii chinensis. I have listed some suggested herbal substitutions in Appendix 6. As for the name of the herbs, I have changed these and followed the names used in Bensky, Clavey and Stöger’s Materia Medica (third edition). The acupuncture points indicated for each pattern are not formulae but only the possible points from which the practitioner can choose when determining an acupuncture treatment. There are a few exceptions, and these are indicated as “general prescription” or “ancient prescription”. The herbal treatment of each disease is based on several modern Chinese textbooks and integrated with the treatment found in ancient classics (see Bibliography). The main modern textbook followed was that used in all colleges of Chinese Medicine in China, i.e. Internal Medicine in Chinese Medicine (Zhong Yi Nei Ke Xue) by Zhang Bo Yu (1986). I should make some comments on the dosages of the herbal prescriptions. The dosages shown are mostly those from modern and old Chinese books. In my practice, I use much lower dosages and these are reflected in the case histories, the average for each herb being about 4 g for dried herbs. I find that these reduced dosages work very well. As for the mode of administration of the herbs, I use both decoctions and concentrated powders; I tend to use decoctions for some gynaecological problems, such as endometriosis, and for skin diseases. In my practice in England, the patients’ compliance with decoctions is very high indeed (about 95%), and even most children manage to take decoctions (albeit disguised in a variety of ways). In children under 3, the decoction can be substantially diluted and given throughout the day. In children over 3, honey can be added to the decoction. Strictly speaking, the addition of honey alters the taste of the decoction and brings in honey’s own properties, but in practice I think it is
Preface to the Second Edition
better for a child to take the herbs with honey than not to take them at all. Other ways of coaxing children to take decoctions include offering them a biscuit (cookie) or a favourite drink immediately after they have swallowed the mixture. However, I find that one of the best ways of getting children over 3 to take a decoction is by involving them in the dispensing of the herbs: the child is fascinated by the different shapes, textures and smells of the herbs and loves helping to dispense the herbs and putting them in the bags. Involving a young patient in this way ensures that when the child drinks the decoction, it is not an alien preparation but something the child relates to – the actual herbs he or she helped to dispense. This method is of course timeconsuming for the practitioner, but it is also great fun. All the case histories are drawn from my own practice, and the reader is invited to study them, as they show how prescriptions are adapted to the individual’s particular disharmony and also how acupuncture points are chosen and combined. Each chapter includes the Western differentiation of the symptom discussed (e.g. the possible causes of headaches in Western medicine). Of course, this is not intended to be a replacement of a good book on Western clinical medicine (some are mentioned in the bibliography); it is simply meant to provide the practitioner in a clinical setting with a quick checklist of the possible Western causes of that particular symptom. This is important because we should know when to refer a patient to a Western medical doctor or specialist for a further diagnosis. For example, a patient
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may come to us complaining of urinary difficulty, and we should know when to suspect a prostate carcinoma. The second reason for familiarizing ourselves with the Western differentiation of symptoms is prognosis. Although Chinese medicine is excellent at providing not only a diagnosis but also a reasonable prognosis by carefully examining symptoms, signs, tongue and pulse, in many cases the prognosis depends also on the Western diagnosis. For example, it makes a big difference to prognosis whether tingling in a limb is caused by a “simple” Liver-Blood deficiency or by the beginning of multiple sclerosis. I have removed the three gynaecological diseases of painful periods, menorrhagia and premenstrual syndrome, because these are now discussed in my gynaecology book. Finally, I have eliminated the appendix on the principles of combination of acupuncture points, as this is now in my book The Channels of Acupuncture (2006). I have added an appendix (Appendix 5) listing the points commonly used for mental-emotional problems according to my experience. As for terminology and names of diseases, I have changed two names compared with the first edition. I now call Lin disease “Urinary Syndrome” rather than “Painful Urinary Disease”, as this condition does not always involve pain. I have changed the name myalgic encephalomyelitis to chronic fatigue syndrome. Giovanni Maciocia Amersham, 2006
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NOTE ON THE TRANSLATION OF CHINESE MEDICAL TERMS
The terminology used in this book generally follows that used in the second edition of Foundations of Chinese Medicine, Obstetrics and Gynaecology in Chinese Medicine and Diagnosis in Chinese Medicine. As in those books, I have opted for translating all Chinese medical terms with the exception of Yin, Yang, Qi and cun (a unit of measurement). I have also continued using initial capitals for the terms that are specific to Chinese medicine. For example, “Blood” indicates one of the vital substances of Chinese medicine, whereas “blood” denotes the liquid flowing in the blood vessels (e.g. “In Blood deficiency, the menstrual blood may be pale.”). I use initial capitals also for all pulse qualities and for pathological colours and shapes of the tongue body. This system has served readers of my previous books well. As most teachers (including myself) use Chinese terms when lecturing (e.g. Yuan Qi rather than Original Qi), I have given each term in Pinyin whenever it is introduced for the first time. One change I have introduced in this book (as in the second edition of Foundations of Chinese Medicine) is to use the Pinyin terms more often throughout the text and at least once in each chapter when the Chinese term is first introduced. I have done this to reduce the frequency with which the reader may need to consult the glossary. I made the choice of translating all Chinese terms (with the exceptions indicated above) mostly for reasons of style: I believe that a well-written English text reads better than one peppered with Chinese terms in Pinyin. Leaving Chinese terms in Pinyin is probably the easiest option, but this is not ideal also because a single Pinyin word can often have more than one meaning; for example, jing can mean “channels”, “periods”, “Essence” or “shock”, while shen can mean “Kidneys”, “Mind” or “Spirit”. I am conscious of the fact that there is no such thing as a “right” translation of a Chinese medicine term,
and my terminology is not proposed in this spirit; in fact, Chinese medicine terms are essentially impossible to translate. The greatest difficulty in translating Chinese terms is probably that a term has many facets and different meanings in different contexts, thus it would be impossible for one translation to be “right” in every situation and every context. For example, the term Jue ( ) has many different meanings; a translation can illustrate only one aspect of a multifaceted term. In fact, Jue can mean a state of collapse with unconsciousness, coldness of hands and feet, or a critical situation of retention of urine. In other contexts, it has other meanings, for example Jue qi ( ), a condition of chaotic Qi; Jue Xin Tong ( ), a condition of violent chest pain with cold hands; and Jue Yin Zheng ( ), the Terminal Yin pattern within the Six Stage identification of patterns characterized by Heat above and Cold below. Many sinologists concur that Chinese philosophical terms are essentially impossible to translate and that, the moment we translate them, we distort them with a worldview that is not Chinese. Ames is particularly clear about the intrinsic distortion of Chinese concepts when they are translated. He gives examples of Chinese terms that are distorted when translated, such as Tian (“Heaven”), You-Wu (“Being” and “Nonbeing”), Dao (“Way”), Xing (“human nature”), Ren (“benevolence”), Li (“Principle”), and Qi (“primal substance”).1 Ames is particularly forceful in rejecting a single, one to one translation of a Chinese term into a Western one in the introduction of his book Focusing the Familiar (a translation of the Confucian text Zhong Yong).2 Ames says:3 Our Western languages are substance-oriented and are therefore most relevant to the descriptions of a world defined by discreteness, objectivity and permanence. Such
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languages are ill disposed to describe and interpret a world, such as that of the Chinese, that is primarily characterized by continuity, process and becoming. Ames then gives some examples of what he considers to be serious mistranslations of Chinese philosophical terms. The important thing is that these are not “mistranslations” because the terms are “wrong” but because of the intrinsic difference between Chinese and Western thinking and therefore the inherent inability of Western terms to convey Chinese philosophical ideas. Ames says:4 For example, You and Wu have often been uncritically rendered as “Being” and “Non-being”. Influential translators, until quite recently, have rendered wu xing as “Five Elements”. Xing is still most often translated as “nature”. All these translations promote the fixed and univocal characterizations of objects or essences emergent from a language rooted in a substantialist perspective [our Western languages]. Ames continues by saying that the use of a “substances language” (i.e. a Western language) to translate Chinese insights into a world of process and change has led to seriously inappropriate interpretations of the Chinese sensibility. Ames asserts that it is the very difference between Chinese and Western philosophy that makes translation of Chinese terms virtually impossible. He says:5 In the classical traditions of the West, being takes precedence over becoming and thus becoming is ultimately unreal. Whatever becomes is realized by achieving its end – that is, coming into being. In the Chinese world, becoming takes precedence over being. ‘Being’ is interpreted as a transitory state marked by further transition. Ames then says:6 The Chinese world is a phenomenal world of continuity, becoming and change. In such a world there is no final discreteness. Things cannot be understood as objects. Without this notion of objectivity, there can only be the flux of passing circumstances in which things dissolve into the flux and flow. A processive language precludes the assumption that objects serve as references of linguistic expressions. The precise referential language of denotation and description is to be replaced by a language of “deference” in which meanings both allude to and defer to one another in a shifting field of significance. A referential language [Western language] characterizes an event, object, or
state of affairs through an act of naming meant to indicate a particular thing. On the other hand, the language of deference [Chinese] does not employ proper names simply as indicators of particular individuals or things, but invokes hints, suggestions, or allusions to indicate foci in a field of meanings. As an example of this intrinsic impossibility of translating a Chinese philosophical term into a Western language, Ames then cites Steve Owen’s reluctance in translating shi as “poem”. Owen says:7 If we translate “shi” as “poem”, it is merely for the sake of convenience. “Shi” is not a “poem”: “shi” is not a thing made in the same way one makes a bed, a painting or a shoe. A “shi” can be worked on, polished and crafted; but that has nothing to do with what a “shi” fundamentally ‘is’ ... “Shi” is not the “object” of its writer: it is the writer, the outside of an inside. Ames says that in classical Chinese philosophical texts, allusive and connotatively rich language is more highly prized than clarity, precision and argumentative rigor. This rather dramatic contrast between Chinese and Western languages with respect to the issue of clarity presents the translator of Chinese philosophical texts with a peculiar burden. For the Chinese, the opposite of clarity is not confusion but something like vagueness. Vague ideas are really determinable in the sense that a variety of meanings are associated with them. Each Chinese term constitutes a field of meanings that may be focused by any of a number of its meanings. Ames says that in the translation of Chinese texts we must avoid what Whitehead called “the Fallacy of the Perfect Dictionary”. By this, he means the assumption that there exists a complete semantic repository of terms of which we may adequately characterize the variety and depth of our experience and that, ideally, one may seek a one to one correspondence between word and meaning. These ideas could not be more apt to illustrate the problems in translating Chinese medicine terms. Of course we must strive for precision and consistency, but to think that there is a one to one, “right” correspondence between a Chinese medicine idea and a Western term is a misunderstanding of the very essence of Chinese medicine. For example, to say that the only “right” translation of Chong Mai is “Thoroughfare Vessel” makes us fall into the trap of what Whitehead calls the “Fallacy of
Note on the Translation of Chinese Medical Terms
the Perfect Dictionary”. Of course, Chong Mai can be translated as “Thoroughfare Vessel”, but that is only one of its meanings and it is absolutely impossible for a single Western term to convey the richness of ideas behind the word Chong Mai (which I translate as “Penetrating Vessel”); to think that we can reduce a rich Chinese medicine idea to a single, one to one term in a Western language reveals, in my opinion, a misunderstanding of the very essence of Chinese medicine. Ames makes this point very forcefully. He says:8 The Fallacy of the Perfect Dictionary is largely a consequence of our analytical bias towards univocity. We would suggest that this bias does not serve us well when approaching Chinese texts. Not only is there the continued possibility of novel experiences requiring appeal to novel terminologies, but also there is seldom, if ever, a simple, one-to-one translation of Chinese terms into Western languages. The allusiveness of the classical Chinese language is hardly conducive to univocal translations. We would contend that, in translating Chinese texts into Western languages, it is most unproductive to seek a single equivalent for a Chinese character. In fact, rather than trying to avoid ambiguity by a dogged use of formally stipulated terms, the translator might have to concede that characters often require a cluster of words to do justice to their range of meanings – all of which are suggested in any given rendering of the character. In fact, any attempt to employ univocal translations of Chinese terms justified by appeal to the criteria of clarity or univocity often reduces philosophical insight to nonsense and poetry to doggerel. Such an approach to translation serves only to numb Western readers to the provocative significance harboured within the richly vague and allusive language of the Chinese texts. As an example of the multiplicity of meanings of a Chinese term and therefore of the fact that it is perfectly legitimate to translate a single Chinese idea into more than one term according to different contexts, Ames says that he translates the term zhong (“centre” or “central”) in the title of the Confucian text sometimes as “focus”, sometimes as “focusing” and other times as “equilibrium”. Other times, he even translates it as “centre” or “impartiality”. He says strongly:9 The Chinese language is not logocentric. Words do not name essences. Rather, they indicate always-transitory processes and events. It is important therefore to stress the gerundative character of the language. The language of process is vague, allusive and suggestive.
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According to Ames, in the field of philosophy, two terms particularly stand out as being influenced by a Western thinking when translated, i.e. Tian (“Heaven”) and Ren (“benevolence”). Ames says:10 When we translate Tian as “Heaven”, like it or not, we invoke in the Western reader a notion of transcendent creator Deity, along with the language of soul, sin and afterlife ... When we translate Ren as “benevolence”, we psychologize and make altruistic a term which originally had a radically different range of sociological connotations. Being altruistic for example, implies being selfless in the service of others. But this “self-sacrifice” implicitly entails a notion of “self” which exists independently of others and that can be surrendered – a notion of self which we believe is alien to the world of the Analects [of Confucius]: indeed, such a reading [of the term ren] transforms what is fundamentally a strategy for self-realization into one of selfabnegation.10 With regard to Chinese medicine, the term Xue (“Blood”) is a good example of the above-mentioned problem reported by Ames. When we translate the word Xue as “Blood”, we immediately alter its essential character and give it a Western medical connotation; in fact, in Chinese medicine, Xue is itself actually a form of Qi and one that is closely bound with Nutritive Qi (Ying Qi). Indeed, the term mai appearing in the Yellow Emperor’s Classic of Internal Medicine is often ambiguous, as it sometimes clearly refers to the acupuncture channels and other times to the blood vessels. After highlighting the problems in translating Chinese terms, Ames confirms that a single Chinese term may have different meaning in different contexts. For example, the term shen in some cases means “human spirituality”, in others it means “divinity”.11 As he considers only the philosophical meanings of the word shen, we could actually add many others in the context of Chinese medicine, for example “mind”, “spirit” and “lustre” (in the context of diagnosis). Ames then surveys the options that are presented to a translator and seems to favour simply transliterating the Chinese terms and leaves them untranslated. He says:12 To some, this approach may appear to be simply the laziest way out of a difficult problem. But “ritual” has a narrowly circumscribed set of meanings in English, and Li an importantly different and less circumscribed set. Just as no
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Indological scholar would look for an English equivalent for “karma”, “dharma” and so on, perhaps it is time to do the same for classical Chinese, the homonymity of the language notwithstanding. Hall confirms that a single Chinese term may have a plurality of meanings. He says:13 The Chinese have traditionally affirmed as the ground of their intellectual and institutional harmony the recognition of the co-presence of a plurality of significances with which any given term might easily resonate. Finally, another sinologist, Yung Sik Kim, discusses the difficulty presented by the plurality of meanings of a single Chinese term. He says:14 I have adopted the policy of sticking to one English translation for a particular Chinese word whenever possible ... Of course, exceptions cannot be avoided altogether. I have had to resort to different translations for such characters as “xin” which means both “heart” and “mind”; “tian” , both “heaven” and “sky”. In another passage, Yung Sik Kim affirms that transliteration of a Chinese term with a plurality of meanings is the only alternative:15 The term “li” is difficult to define. It is difficult even to translate because there is no single word in Western languages that covers all facets of what “li” meant to the traditional Chinese mind. The existence of many translations for the term, which often leaves transliteration as the only viable option, bespeaks the difficulty. Although a diversity of translation of Chinese terms may present its problems, these are easily overcome if an author explains the translation in a glossary and, most importantly, explains the meaning of a given Chinese term in its context (in our case, Chinese medicine). In my books, I have chosen to translate all Chinese medicine terms rather than using Pinyin purely for reasons of style as a sentence written half in English and half in Pinyin is often awkward. Moreover, if we use Pinyin terms in writing, it could be argued that we should be consistent and use Pinyin terms for all Chinese medicine terms, and this would not make for very clear reading. Consider the following sentence: “To treat Pi-Yang Xu, we adopt the zhi fa of bu pi and wen Yang” (“To treat Spleen-Yang deficiency, we adopt the treatment principle of tonifying the Spleen and warming Yang”).
Moreover, the problem arises only in the written form as, in my experience, most lecturers in colleges throughout the Western world normally prefer using Pinyin terms rather than their counterparts in English (or any other Western languages). Thus a lecturer will refer to Kidney-Jing rather than Kidney-Essence. Indeed, when I myself lecture, I generally use the Pinyin terms rather than their English translation. Again, most lecturers use a pragmatic approach, translating some terms into English (such as “treatment principle” instead of zhi fa) and leaving others in Pinyin such as Yuan Qi or Chong Mai. When I lecture, I always try to give the participants an idea of the meaning of a particular Chinese character and its significance and application in Chinese medicine. Indeed, the use of Pinyin when lecturing renders Chinese medicine truly international, as I can lecture in the Czech Republic and mention Jing, Yang Qiao Mai, Wei Qi, etc. knowing that I will be understood by everyone. A diversity of translation of Chinese terms may even have a positive aspect, as each author may highlight a particular facet of a Chinese term so that diversity actually enriches our understanding of Chinese medicine. If someone translates Zong Qi as “Initial Qi”, for example, we learn something about that author’s view and understanding of Zong Qi; the translation cannot be branded as “wrong” (I translate this term as “Gathering Qi”). Another example: if someone translates yang qiao mai as “Yang Motility Vessel”, the translation captures one aspect of this vessel’s nature; again, this could not be defined as wrong (I translate the name of this vessel as “Yang Stepping Vessel”). Trying to impose a standard, “right” translation of Chinese medicine terms may lead to suppression of healthy debate; I therefore hope that readers will continue to benefit from the diversity of translation of Chinese medical terms and draw inspiration from the rich heritage of Chinese medicine that it represents. I firmly believe that the future lies not in trying to establish a rigid, embalmed, fossilized, “right” terminology based on single, one to one translations of Chinese ideas. Indeed, I believe that this is a potentially dangerous trend, as it would, in my opinion, lead students and practitioners away from the richness of Chinese language and richness of meanings of Chinese medicine ideas. The adoption of a standardized, “approved” terminology of Chinese medical terms may indeed, in time, divorce students and practitioners
Note on the Translation of Chinese Medical Terms
from the essence of Chinese medicine. If an “official”, standardized translation of Chinese terms took hold, then students would be less inclined to study the Chinese terms to explore their meaning. Moreover, imposing an “approved” terminology in English betrays an Anglocentric worldview; to be consistent, we should then have an “approved” terminology in every major language of the world. It seems to me much better to try to understand the spirit and the essence of Chinese medicine by studying its characters and their clinical significance and using Pinyin transliteration whenever appropriate. Trying to fossilize Chinese medicine terms into an imposed terminology goes against the very essence of the Chinese language which, as Ames says, is not logocentric and in which words do not name essences; rather, they indicate always-transitory processes and events. The language of process is vague, allusive and suggestive. Because Chinese language is a language of process, the question arises also whether practising Chinese medicine actually helps the understanding of Chinese medical terminology; in my opinion, in many cases it does. For example, I feel that clinical experience helps us to understand the nature of the Chong Mai (Penetrating Vessel) and therefore helps us to understand the term Chong in a “knowing practice” way (as Farquhar defines it)16 rather than a theoretical way. Of course, a translator of Chinese books should strive for precision and consistency, but we must accept that there is a rich multiplicity of meanings for any given idea of Chinese medicine. The Chong Mai is a good example of this multiplicity, as the term chong could be translated as “throroughfare”, “strategic crossroads”, “to penetrate”, “to rush”, “to rush upwards”, “to charge”, “activity”, “movement” and “free passage”. Which of these translations is “correct”? They are all correct, as they all convey an idea of the nature and function of the Chong Mai. I therefore think that the future of teaching Chinese medicine lies not in trying to impose the straightjacket of a rigid terminology of the rich ideas of Chinese medicine, but in teaching students more and more Chinese characters, explaining the richness of meanings associated with them in the context of Chinese medicine. I myself would not like my own terminology to be “adopted” as the “correct” or “official” one; I would rather see colleges teaching more and more Chinese to their students by illustrating the rich meanings of
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Chinese medicine terms. As mentioned above, my main motive for translating all terms is purely for reasons of style in an English language textbook; when I lecture, I generally use Pinyin terms but, most of all, I show the students the Chinese characters and try to convey their meaning in the context of Chinese medicine. Finally, I would like to explain my continued translation of Wu Xing as “Five Elements”. The term “Five Elements” has been used by most Western practitioners of Chinese medicine for a long time (also in French and other European languages). Some authors consider this to be a misunderstanding of the meaning of the Chinese term Wu Xing perpetuated over the years. Wu means “five” and Xing means “movement”, “process”, “to go”, “conduct” or “behaviour”. Most authors therefore think that the word Xing cannot indicate “element” as a basic constituent of Nature, as was supposedly intended in ancient Greek philosophy. This is, in my opinion, only partly true, because the elements, as they were conceived by various Greek philosophers over the centuries, were not always considered “basic constituents” of Nature or “passive motionless fundamental substances”.17 Some Greek philosophers conceived the elements as dynamic qualities of Nature in a way similar to Chinese philosophy. For example, Aristotle gave a definite dynamic interpretation to the four elements and called them “primary form” (prota somata). He said:18 Earth and Fire are opposites also due to the opposition of the respective qualities with which they are revealed to our senses: Fire is hot, Earth is cold. Besides the fundamental opposition of hot and cold, there is another one, i.e. that of dry and wet: hence the four possible combinations of hot-dry [Fire], hot-wet [Air], cold-dry [Earth] and coldwet [Water] ... the elements can mix with each other and can even transform into one another ... thus Earth, which is cold and dry, can generate Water if wetness replaces dryness. To Aristotle, therefore, the four elements became the four basic qualities of natural phenomena, classified as combinations of four qualities: hot, cold, dry and wet. As is apparent from the above statement, the Aristotelian elements could even transform into one another and generate each other. This interpretation is very similar to the Chinese one, in which the elements are qualities of Nature. Furthermore, it is interesting to note the similarity
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with the Chinese theory of Yin-Yang: the four Aristotelian elements derive from the interaction of the basic Yin-Yang qualities of cold-hot and dry-wet. Thus it is not entirely true to say that the Greek elements were conceived only as the basic constituents of matter, the “building blocks” of Nature, which would make the use of the word “element” wrong to indicate xing. Furthermore, the word “elements” does not necessarily imply that; it does so only in its modern chemical interpretation. In conclusion, for the above reasons I have kept the word “element” as a translation of the Chinese word xing. According to Wang, the term “Five Elements” could be translated in a number of ways, for example “agents”, “entities”, “goings”, “conduct”, “doings”, “forces”, “activities” and “stages of change”.19 Recently, the term “Five Phases” is gaining acceptance, but some sinologists disagree with this translation and propose returning to ‘Five Elements”, Friedrich and Lackner, for example, suggest restoring the term “elements”.20 Graham uses the term “Five Processes”.21 I would probably agree that “processes” is the best translation of Wu Xing. In fact, the book Shang Shu, written during the Western Zhou dynasty (1000–771 BC) said:22 The Five Elements are Water, Fire, Wood, Metal and Earth. Water moistens downwards; Fire flares upwards; Wood can be bent and straightened; Metal can be moulded and can harden; Earth allows sowing, growing and reaping. Some sinologists (e.g. Needham and Fung Yu Lan) still use the term “element”. Fung Yu Lan suggests that a possible translation of wu xing could be “Five Activities” or “Five Agents”.23 Although the term “five phases” has gained some acceptance as a translation of “wu xing”, I find this term restrictive, because it clearly refers to only one aspect of the Five Elements, i.e. phases of a (seasonal) cycle.
A glossary with Pinyin terms, Chinese characters and English translation appears at the end of the book. I have included both a Pinyin–English and an English–Pinyin glossary.
END NOTES 1. Ames RT, Rosemont H 1998 The Analects of Confucius – a Philosophical Translation. Ballantine Publishing Group, New York, p. 311. 2. Ames RT, Hall DL 2001 Focusing the Familiar – a Translation and Philosophical Interpretation of the Zhong Yong. University of Hawai’i Press, Honolulu, pp. 6–16. 3. Ibid., p. 6. 4. Ibid., p. 6. 5. Ibid., p. 10. 6. Ibid., p. 10. 7. Ibid., p. 13. 8. Ibid., p. 16. 9. Ibid., p. 16. 10. Ames RT. The Analects of Confucius, p. 312. 11. Ibid., p. 313. 12. Ibid., p. 314. 13. Hall DL, Ames RT 1998 Thinking from the Han. State University of New York Press, New York, p. 4. 14. Yung Sik Kim 2000 The Natural Philosophy of Chu Hsi. American Philosophical Society, Philadelphia, p. 11. 15. Ibid., p. 19. 16. Farquhar J 1994 Knowing Practice – the Clinical Encounter of Chinese Medicine. Westview Press, Boulder, USA. 17. Needham J 1977 Science and Civilization in China, vol. 2. Cambridge University Press, Cambridge, p. 244. 18. Lamanna EP 1967 Storia della Filosofia [History of Philosophy], vol. 1. Le Monnier, Florence, pp. 220–221. 19. Wang Ai He 1999 Cosmology and Political Culture in Early China. Cambridge University Press, Cambridge, p. 3. 20. Friedrich M, Lackner M 1983–1985. Once again: the concept of Wu Xing. Early China 9–10: 218–219. 21. Graham AC 1986 Yin-Yang and the Nature of Correlative Thinking. Institute of East Asian Philosophies, Singapore, pp. 42–66 and 70–92. 22. Shang Shu (c.659 BC) cited in 1975 Shi Yong Zhong Yi Xue [Practical Chinese Medicine]. Beijing Publishing House, Beijing, p. 32. The book Shang Shu is placed by some in the early Zhou dynasty (hence c.1000 BC), but the prevalent opinion is that is was written sometime between 659 BC and 627 BC. 23. Fung Yu Lan 1966 A Short History of Chinese Philosophy. Free Press, New York, p. 131.
CHAPTER 1
HEADACHES
Wind-Dampness 22 Liver-Yang rising 23 Liver-Fire 32 Liver-Wind 34 Liver-Qi stagnation 35 Stagnation of Cold in the Liver channel 36 Dampness 37 Turbid Phlegm 40 Turbid Phlegm-Wind 42 Liver-Yang rising with Phlegm in the head 42 Retention of food 43 Stasis of Blood 44 Stomach-Heat 47 Qi deficiency 47 Blood deficiency 48 Kidney deficiency 49
AETIOLOGY 2 Constitutional deficiency 2 Emotional stress 3 Overwork 4 Excessive sexual activity 4 Irregular diet 5 Trauma 5 Childbirth 6 External pathogenic factors 6 CHANNELS
6
PATHOLOGY 10 Excess of Yang 10 Deficiency of Yang 11 Excess of Yin 11 Deficiency of Yin 11
MODERN CHINESE LITERATURE DIAGNOSIS 12 Diagnosis according to channels 12 Diagnosis according to type of pain 15 Diagnosis according to amelioration and aggravation 16
CLINICAL TRIALS 55 Acupuncture 55 Herbal medicine 58 PATIENTS’ STATISTICS
TREATMENT STRATEGIES AND PRINCIPLES OF POINT SELECTION 17 Treating the Root or the Manifestation 18 Point selection 18 IDENTIFICATION OF PATTERNS AND TREATMENT Wind-Cold 20 Wind-Heat 21
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WESTERN DIFFERENTIAL DIAGNOSIS OF HEADACHES Intracranial 60 Cranial 62 Extracranial 62
19 PROGNOSIS AND PREVENTION
63
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2
The Practice of Chinese Medicine
EXTERIOR • Wind-Cold • Wind-Heat • Wind-Dampness INTERIOR Full • Liver-Yang rising • Liver-Fire • Liver-Wind • Liver-Qi stagnation • Stagnation of Cold in the Liver channel • Dampness • Turbid Phlegm • Turbid Phlegm-Wind • Liver-Yang rising with Phlegm in the head • Retention of Food • Stasis of Blood • Stomach-Heat Empty • Qi deficiency • Blood deficiency • Kidney deficiency
AETIOLOGY Any of the causes of disease normally considered in Chinese medicine can play a part in the aetiology of headaches. The main aetiological factors discussed are as follows. • Constitutional deficiency • Emotional stress — Anger — Worry — Sadness and grief — Fear — Shock — Pensiveness — Guilt — Shame • Overwork • Excessive sexual activity • Irregular diet • Trauma • Childbirth • External pathogenic factors
Constitutional deficiency The constitutional body condition inherited from our parents depends on three factors:
HEADACHES Headache is one of the most common symptoms encountered in clinical practice. There are few people who have never experienced a headache at some time or other of their life. The discussion of the treatment of headaches will include that of migraine and will be based on the following headings. • • • • • • • • • • •
Aetiology Channels Pathology Diagnosis Treatment strategies and principles of point selection Identification of patterns and treatment Modern Chinese literature Clinical trials Patients’ statistics Western differential diagnosis of headaches Prognosis and prevention
1. the parents’ health in general 2. the parents’ health at the time of conception 3. the conditions of the mother’s pregnancy. Any of these factors can affect the body condition and become a cause of headaches later in life. Persistent and recurrent headaches that start in childhood (usually between about 7 and 10) strongly indicate the presence of a constitutional factor of disease. If the parents’ Qi and Essence are weak, the resulting PreHeaven Essence of the child will also be weak; similarly, if the child is conceived when one or both parents are in later life. This can result in headaches deriving from a Kidney or Liver deficiency starting during childhood. A hereditary Kidney or Liver weakness manifests with enuresis or frequent urination, lack of vitality, dull headaches, and frequently myopia. Even though the parents’ general health may be good, if it is poor at the time of the child’s conception (perhaps through overwork, excessive sexual activity, excessive consumption of alcohol, or use of certain medications or drugs such as cannabis or cocaine), this
Headaches
will result in the child’s having a weak constitution and in the possibility of suffering from headaches. In this case, the weakness will affect not the Kidneys or Liver but any of the other organs, i.e. Spleen, Lungs or Heart, depending on the particular condition that is negatively affecting the parents’ health. For example, if the parents’ health is poor from overwork at the time of the child’s conception, this may be a cause of hereditary Spleen weakness in the child. The excessive consumption of alcohol or the use of drugs or certain medicines may cause a hereditary weakness of the child’s Heart or Lungs. A hereditary Spleen weakness in a child may manifest with poor muscle tone, physical weakness, digestive problems, and in severe cases Child Nutritional Impairment (Gan). In this case, the headaches will be on the forehead and be related to food intake. A hereditary Lung weakness in a child may manifest with a tendency to catching colds and respiratory infections, whooping cough, asthma, eczema, pale complexion, a thin chest, and a pulse in both Front positions that when felt is more medial and running upwards towards the thumb (Fig. 1.1). A hereditary Heart weakness in a child may manifest with dream-disturbed sleep, nervousness, and a relatively deep midline crack on the tongue. Young children (under 3) may wake up crying at night. In such cases, the headaches are usually on the forehead or in the whole head. The condition of the mother during the pregnancy can affect the fetus. For example, an accident to the mother can cause headaches for the child. A shock during pregnancy can also cause a child to suffer head-
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aches deriving from Heart deficiency. This will also manifest with a bluish tinge on the child’s forehead and chin.
Emotional stress Emotional causes of disease are, of course, extremely frequent causes of headaches.
Anger Many different emotions fall under the broad term of “anger” in Chinese medicine. Among them are frustration, resentment and pent-up grudges. All these emotions may cause the rising of Liver-Yang or LiverFire. Among the emotional causes of headaches, anger, in the broad sense intended above, is the most common one. It will give rise to headaches from LiverYang rising or Liver-Fire blazing. These headaches are typically situated on the Gall Bladder channel on the temple or side of the head. Please note, however, that the rising of Liver-Yang is not always due to anger (see below); it may also be caused by worry.
Worry Worrying excessively knots Qi, in particular Lung- and Heart-Qi. This is often an indirect cause of headaches, as the deficiency of Lung-Qi (Metal in the Five-Element model) may allow Liver-Yang to rise (Wood in the FiveElement model) and cause headaches. Worry may also be a direct cause of headaches, which are usually situated on the forehead or the top of the head and are dull in character. Please note that, like anger, worry may also lead to Liver-Yang rising and it may therefore be a direct cause of headaches.
Sadness and grief Sadness and grief deplete Qi; in time, this may lead to the depletion of Blood and to Blood deficiency. This may cause headaches of a deficient nature from Blood deficiency. In turn, Blood deficiency may, in the long run, lead to the rising of Liver-Yang, which may cause headaches. This situation is more likely to occur in women.
Fear Figure 1.1 Pulse picture in hereditary Lung weakness.
A chronic state of anxiety and fear depletes the Kidneys and causes headaches either directly from Kidney
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The Practice of Chinese Medicine
deficiency (in this case affecting the whole head) or indirectly when the Kidney deficiency leads to the rising of Liver-Yang.
Shock Shock “suspends” Qi and it affects Heart-, Lung- and Spleen-Qi. It will usually cause headaches affecting the whole head.
Pensiveness “Pensiveness” encompasses several different emotions including brooding, thinking too much, nostalgic thinking of the past and also excessive mental work. Excessive mental activity is a frequent cause of chronic headaches in children. Although this may seem strange at first, it does occur frequently when a bright child attends an academically demanding school with high parental expectations. This sets a pattern early in life of long hours of mental work and concentration combined with the worry over the need to do well, which leads to severe headaches or migraine. The long hours of reading by himself or herself (and nowadays working at a computer monitor) strain the child’s eyes and lead to headaches.
Guilt Guilt is a pervasive emotion in Western patients that is missing from Chinese medicine books. A feeling of guilt may be due to the transgression of social or religious taboos or from having done something “wrong” that is later regretted. However, a feeling of guilt may also be innate and not related to any specific action. This latter feeling is indeed the most destructive one. It is important to distinguish the subjective sense of guilt from its objective counterparts. For example, a person may be found guilty in a court of law, without feeling guilty; in a religious context, a person may deem himself or herself to be guilty in front of God but still not feel guilty; someone may be guilty of doing something reprehensible but still not feel guilty. It is therefore the feeling of guilt that is all important. Guilt is a “dark” emotion with no redemption; it is a much “darker” emotion than shame. Guilt can have different effects in different people. First of all, it may lead to Qi stagnation: it affects any organ, especially the Lungs, Heart, Liver and Kidneys. Due to its “dark”, “stagnating” character, it causes Blood stasis easily and quickly. This Blood stasis may be
in any part of the body and any organ but occurs particularly in the Lungs, Heart, Spleen and Liver. When Blood stasis deriving from guilt affects the Upper Burner (through the Lung and/or Heart channels), it may cause headaches.
Shame Shame is a common emotion in Western patients. It may be caused by feeling ashamed of one’s behaviour but, more commonly, shame is an inborn feeling due to one’s upbringing: a feeling of worthlessness, the absence of a feeling of self-worth. Shame is directed inwards; it is self-accusation. The feeling that one has to hide is an important aspect of shame. One feels judged all the time. Shame is directed inwards and it therefore makes Qi stagnate but also possibly sink. Indeed, sinking of Qi is a very common result of shame; Dampness also frequently accompanies shame. When one feels shame, one feels “dirty”, and “dirty” is characteristic of Dampness. When Dampness deriving from shame settles in the head, it may give rise to chronic headaches.
Overwork Working too long hours without adequate rest weakens Spleen-Qi and, in the long run, Kidney-Yin. This is the most common cause of Yin deficiency in Western industrial societies. The deficiency of Kidney-Yin will give rise to headaches in the whole head, or it will lead to Liver-Yang rising and causing migraine-type headaches on one side of the head on the Gall Bladder channel.
Excessive sexual activity This is a common cause of headaches, particularly in men. Under normal circumstances, the temporary loss of Kidney-Essence resulting from sexual activity is quickly restored and so sexual activity will not lead to disease. When sexual activity is too frequent, however, there is no time for the Kidney-Essence to be restored, and this results in deficiency of Kidney energy (either Yin or Yang, depending on the constitution of the person). An old Daoist saying declares: “Sleeping alone is better than taking 100 tonics”! Men are more affected by excessive sexual activity than are women. Too many childbirths in too short a
Headaches
time weaken the uterus and the Kidneys in women. This is an important cause of depletion of KidneyEssence in women, somewhat equivalent to excessive sexual activity in men (see below). Equally, excessive loss of blood due to chronic menorrhagia over many years in women also depletes the Kidneys. By depleting the Kidneys, excessive sexual activity is a frequent cause of headaches either on the occiput or the whole head. Indeed, if someone experiences a headache and dizziness following sexual intercourse, it is a certain sign that the particular level of sexual activity is excessive and it should be moderated. It is of course impossible to define what is “excessive” sexual activity, as this is entirely relative and depends on the person’s constitution and strength of Essence.1
Irregular diet Diet has a direct and profound influence on the aetiology of headaches. Dietary irregularities may cause headaches by affecting different organs. First of all, not eating enough in itself will obviously cause headaches from general deficiency of Qi and Blood usually occurring on the top of the head. This situation occurs when people follow too strict a diet, adhering to rigid “rules” and consequently lacking essential nourishment. On the other extreme, overeating obstructs StomachQi and weakens the Spleen, leading to headaches on the forehead, which are usually sharp in character. Excessive consumption of hot-energy foods such as curries, spices, pepper (black, white or red), red meat and alcohol causes Liver-Fire and/or Stomach-Heat. Liver-Fire will result in lateral headaches and StomachHeat in frontal headaches, both of which are sharp in character. The excessive consumption of Damp-producing foods affects the Spleen and leads to Dampness, which may cause dull headaches on the forehead and a typical feeling of heaviness in the head. Damp-producing foods include all greasy foods, fried foods, milk, cheese, butter, cream, ice cream, bananas, peanuts, sweets and white sugar. Too much salt in the diet will cause a Kidney deficiency and may result in dull headaches in the whole head or on the occiput. A diet based on tinned or processed foods is often heavy in salt, because this is added to many such foods: bacon, sausages, cereals, tinned soups, smoked fish and many others.
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An excessive consumption of sour foods affects the Liver and is also a frequent cause of headaches. Sour foods include yoghurt, grapefruit and its juice, cooking apples, pickles, vinegar, spinach, rhubarb, gooseberries and redcurrants. The way in which food is eaten also influences the energy of the internal organs. Eating too quickly or while discussing work leads to retention of food in the Stomach and to sharp headaches on the forehead. Eating irregularly or too late at night induces a deficiency of Stomach-Yin and may cause dull headaches on the forehead (see also Chapter 22, Epigastric pain). It should be remembered that the principles of Chinese diet were developed over 2000 years ago. They do not take into account modern discoveries about food and, most of all, do not consider the role of chemicals in food. Food has never been subjected to so much chemical manipulation as in the past 30 years or so. As far as headaches are concerned, they can be very much affected by chemicals in food. For example, it is well known that monosodium glutamate (found in Chinese restaurant food) can cause headaches. The possibility of a sensitivity to certain chemicals should therefore always be kept in mind when investigating the aetiology of headaches. Finally, certain foods we consume are not found in a Chinese diet at all, and for this reason are not even mentioned in books on diet. Cocoa (and chocolate) and coffee are a case in point. Both of these can aggravate headaches or precipitate a migraine attack. In particular, an excessive consumption of coffee is a frequent cause of chronic headaches in our society and, in my experience, any chronic headache sufferer always benefits greatly from not drinking coffee at all.2
Trauma Severe accidents and falls that affect the head can cause stasis of Blood in a particular area of the head. This is a frequent cause of chronic headache. If the headaches a patient suffers always occur in the same part of the head and particularly in a small area, then the possibility of an old trauma to the head should be considered. The patient may not be aware of or remember an old fall or accident and not relate it to the headaches. A single large purple spot near the tip of the tongue may indicate an old trauma in the head region.
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The Practice of Chinese Medicine
In particular, a trauma to the head may not cause headaches immediately after it, but these can start years later when a new cause of disease intervenes. For example, a child may fall on the head and be mildly concussed. Many years later, he or she may experience emotional problems related to anger or frustration, which cause Liver-Yang to rise. In such a case, the headache from Liver-Yang rising will settle in the area of the head where the old trauma occurred and will always affect such an area.
Childbirth Too many childbirths too close together weaken the Liver, Kidneys and Directing Vessel (Ren Mai) in a woman. A deficiency of the Liver and Kidneys can give rise to Empty-type headaches from Kidney-Essence not reaching the head; the deficiency of Liver and Kidneys may also induce Liver-Yang to rise and therefore cause headaches of this type. It is important to remember that miscarriages also count as “childbirth” as far as causes of disease are concerned. A miscarriage is as depleting as childbirth; in fact, some Chinese doctors even say that miscarriages are more depleting than childbirth. This is because, first of all, there may be more blood loss in a miscarriage than in childbirth; second, after a miscarriage there is an abrupt alteration of the hormone levels; third, a miscarriage (especially a late one) is emotionally very distressing and the mother often has deep feelings of loss and even failure.
External pathogenic factors The main external pathogenic factors that cause headaches are Wind and Dampness. Wind affects the top part of the body and is a very frequent cause of acute headaches, which may arise independently without other symptoms or may occur together with the symptoms of invasion of Wind-Cold. External Wind also affects the neck muscles, causing a pronounced stiffness. Wind is normally a cause of acute headaches, but repeated invasions of Wind may give rise to chronic headaches and stiffness of the neck and shoulders (called Head-Wind). External Dampness can also affect the head even though this particular pathogenic factor normally invades the lower part of the body. However, acute invasions of Dampness easily affect the Middle Burner; from here, Dampness may rise to the head and prevent
SUMMARY AETIOLOGY Constitutional deficiency Emotional stress — Anger — Worry — Sadness and grief — Fear — Shock — Pensiveness — Guilt — Shame Overwork Excessive sexual activity Irregular diet — Not eating enough — Overeating — Excessive consumption of hot-energy foods (curries, spices, pepper, red meat and alcohol) — Excessive consumption of Damp-producing foods (greasy foods, fried foods, milk, cheese, butter, cream, ice cream, bananas, peanuts, sweets and white sugar) — Too much salt — Excessive consumption of sour foods (yoghurt, grapefruit and its juice, cooking apples, pickles, vinegar, spinach, rhubarb, gooseberries, redcurrants) — Irregular eating habits — Chemicals in food — Cocoa (and chocolate) and coffee Trauma Childbirth External pathogenic factors
the clear Yang from reaching the head and clearing the head’s orifices.
CHANNELS A thorough knowledge of the channels flowing through the head is essential for the acupuncture treatment of headaches. When treating headaches, we must always look at their pathology from two different perspectives, i.e. from the perspective of Internal
Headaches
Organs’ disharmony and from that of the channels involved. Superficially, the head contains only Yang channels, as the Yang channels of the arm end in the head and those of the feet start there. This means that the head is an area of concentration of Yang Qi; for this reason, in ancient times it was compared with Heaven and it was also sometimes called the “Palace of Yang”. The Correct Seal of Medical Circles says:3
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Large Intestine Stomach
The head is like Heaven [being at the top]: the clear Qi of the three Yang channels [Greater Yang, Lesser Yang and Bright Yang] and the six Yang organs as well as the Blood and Essence of the three Yin channels [Greater Yin, Lesser Yin and Terminal Yin] and the five Yin organs, all reach it. It is affected by the six external pathogenic climates as well as by internal pathogenic factors. As the Arm Yang channels end on the face and flow into the Leg Yang channels that start on the face, the Yang channels (of Arm and Leg) could really be looked on as one channel in which there is no interruption between the arm and leg section (i.e. Large IntestineStomach, Small Intestine-Bladder and Triple BurnerGall Bladder). Indeed, this is one way in which the channels are paired, i.e. Bright Yang (Large Intestine and Stomach), Greater Yang (Small Intestine and Bladder) and Lesser Yang (Triple Burner and Gall Bladder). This means that often distal points of the arm and leg channels have very similar actions and are almost interchangeable, for example L.I.-4 Hegu and ST-44 Neiting, and T.B.-2 Yemen and G.B.-43 Xiaxi. Figure 1.2 shows the Large Intestine and Stomach channels to illustrate this principle. Thus, the connection between Yang channels on the face is more direct than that between Yin channels in the chest (the Yin channels of the arm start in the chest and those of the leg end there).
! The Yang channels communicate directly and superficially on the face (e.g. L.I.-20 Yingxiang and ST-1 Chengqi, S.I.-19 Tinggong and BL-1 Jingming, and T.B.-23 Sizhukong and G.B.-1 Tongziliao). Therefore, often distal points of the arm and leg channels have very similar actions and are almost interchangeable (e.g. L.I.-4 Hegu and ST-44 Neiting, S.I.-3 Houxi and BL-65 Shugu, T.B.-2 Yemen and G.B.-43 Xiaxi).
Figure 1.2 Large Intestine and Stomach channels as one continuous channel.
The head is the highest part of the body not only anatomically but also energetically according to the flow of Qi in the 12 channels. It is, in fact, the area of maximum potential of energy in the circulation of Qi in the channels. Qi circulates in the channels because
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The Practice of Chinese Medicine
there is a difference of energy potential between the chest and the head. If we consider the first four channels, for example, we see that Qi starts at the chest area in the Lung channel; this is the area of minimum potential of energy. In order to understand this, we can visualize a certain amount of water at the bottom of a hill, where its potential of producing energy is minimal. If we slowly carry this water up the hill, gradually its potential of producing energy will increase, as we know. When the water reaches the top of the hill, its potential of producing (hydroelectric) energy will be maximum (Fig. 1.3). The bottom of the hill corresponds to the chest, halfway up the hill corresponds to the hands (or feet), and the top of the hill corresponds to the head. Thus, from the Lung channel in the chest, Qi starts to move upwards towards the head. At the fingertips, Qi changes polarity, i.e. it flows from the Yin Lung channel to the Yang Large Intestine channel, but it is still flowing towards the head and its potential is increasing. When it reaches the head, the potential is at its maximum, and it then starts decreasing as it flows towards the
feet. At the feet, Qi changes polarity, i.e. it flows from the Yang Stomach channel to the Yin Spleen channel, but its potential is still decreasing as it flows towards the chest area, the area of minimum potential energy. Figures 1.4 and 1.5 illustrate the concept of potential energy in the flow of Qi from the chest (area of minimum potential energy) to the hands (area of average potential energy), to the head (area of maximum potential energy), to the feet (area of average potential energy) and back to the chest (area of minimum potential energy). When it reaches the chest, the potential is minimum (the water has reached the bottom of the hill again). The Qi from the Spleen channel then connects internally with the Heart channel and a new four-channel cycle starts in exactly the same way. The cycle of Qi in the first four channels can be seen in Figure 1.6, and Figure 1.7 shows the circulation of Qi in the 12 channels. The implication of all this is that the head is the area of maximum potential of Qi and therefore intrinsically prone to rising of energy (or pathogenic factors) to the top; for example, the rising of Liver-Yang, Liver-Fire,
Maximum potential energy
Minimum potential energy
Figure 1.3 Potential energy in Qi circulation. (From Maciocia G 2006 The Channels of Acupuncture. Churchill Livingstone, Edinburgh.)
Headaches
How a hydroelectric plant works
Maximum potential energy (Head)
HEAD Arm Yang
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Dam built across steep-sided river valley
LI HAND
Turbine passages
Leg Yang ST LU Arm Yin
Generators CHEST
Reservoir Turbines
Minimum potential energy (Chest)
SP Leg Yin FEET
River
Figure 1.4 Potential energy and the circulation of Qi.
Leg Yang
LI
ST FEET
LU
Face
Toes
Chest
Average potential energy
SP
Arm Yin
Fingers
YIN
HAND
Chest
YANG
HEAD Arm Yang
Maximum potential energy
Leg Yin CHEST
Minimum potential energy
Lungs
Large Intestine
Stomach
Spleen
Figure 1.5 Potential energy and the circulation of Qi. Bright Yang Greater Yin
Liver-Wind or Heart-Fire. Conversely, clear Yang Qi failing to rise to the top may lead to the obstruction of the head by Phlegm or Dampness. The head is also the area of concentration of Yang energy, as all the Yang channels directly meet and join up in the head. In fact, as far as the superficial pathways are concerned, only Yang channels reach the head. For this reason, the head is variously called “the confluence of Yang”, “the Palace of Yang” or “the Palace of clear Yang”.4 However, Yin Qi obviously also reaches the head but only internally. Of the Yin channels, only the Heart and Liver reach the head internally (deep pathway). All the other Yin channels reach the head indirectly
Figure 1.6 The circulation of Qi in the first four channels.
via their divergent channels, as each Yin divergent channel merges with its related Yang divergent channel at the neck area (Fig. 1.8). Therefore, the divergent channels are an important way in which Yin Qi reaches the head (as all Yin divergent channels eventually merge with the corresponding Yang divergent channel in the neck area). Figure 1.9 summarizes the channels reaching the head. Thus both the clear Yang from the Yang organs and the pure essences from the Yin organs reach the head.
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The Practice of Chinese Medicine Fingers
Face
Toes
Chest
Fingers
Face
Toes
Chest
Fingers
Face
Toes
Chest
YIN
YANG
Chest
LU
L.I.
ST
SP
HE
Bright Yang Greater Yin Figure 1.7 The circulation of Qi in the 12 channels.
Neck area
Yang main channel
Neck
S.I.
Yin main channel Limb
Limb Yang main channel
KL
P
T.B.
G.B.
Greater Yang
Lesser Yang
Lesser Yin
Terminal Yin
Yang main channel Yang divergent channel
Yang divergent channel
BL
Yin divergent channel
Arm Yang channels
Yin main (Heart and Liver)
HEAD Palace of Yang
Yang divergent
LIV
Leg Yang channels
Yin divergent
Figure 1.9 Channels reaching the head. Yin main channel
Figure 1.8 Connection between Yin and Yang divergent channels.
As far as headaches are concerned, the two Yang channels that are most frequently involved are the Gall Bladder and Bladder. Of the Yin channels, the two most frequently involved are the Liver and Kidneys.
PATHOLOGY As the head is an area of concentration of Yang Qi, the pathology of headaches can be reduced to four very simple and basic conditions of Excess Yang, Deficiency of Yang, Excess of Yin and Deficiency of Yin. Examples of Excess of Yang are Liver-Yang rising and Liver-Fire; examples of Deficiency of Yang are
Stomach-Qi deficiency, Kidney-Yang deficiency and Spleen-Qi deficiency; examples of Excess of Yin are Dampness and Phlegm; and examples of Deficiency of Yin are Liver-Blood deficiency and Kidney-Yin deficiency.
Excess of Yang “Excess of Yang” has two different meanings: it may indicate an actual Excess of Yang Qi in the head (such as in Liver-Fire) or an excessive rising of Yang to the head (as in Liver-Yang rising). It is important not to confuse these two separate conditions. In fact, the difference between Liver-Fire and LiverYang rising is a good illustration of this difference. With Liver-Fire, there is an actual Excess of Yang, i.e. Fire (Full Heat). This manifests with a red face, a feeling of heat in the face, intense thirst, a bitter taste in the
Headaches
mouth and irritability. This is a condition of Full Heat that must be drained with bitter-cold herbs. Liver-Fire is a type of Full Heat, and it has the tendency to dry the body fluids, it may cause bleeding and it strongly affects the Mind. Liver-Yang rising, by contrast, is not a condition of Full Heat but simply an imbalance of Qi with Qi and Yang rising excessively towards the head. Although there are a few symptoms of Heat due to the rise of Yang to the head (red face), it is neither a Full condition nor a condition of Full Heat. There is a very important difference between the herbal treatment of Liver-Fire and that of Liver-Yang rising: while the former is treated by draining Fire with bitter-cold herbs (e.g. Huang Qin Radix Scutellariae and Long Dan Cao Radix Gentianae), the latter is treated by subduing Yang using herbs that sink Qi (e.g. Shi Jue Ming Concha Haliotidis and Mu Li Concha Ostreae).
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Excess of Yin As we have seen, although Yin Qi does reach the head indirectly through the divergent channels, superficially there are only Yang channels on the head. This is not coincidental, as clear Yang Qi needs to rise to the head to brighten the orifices. Accumulation of Excess Yin in the head will have the effect of preventing the rising of clear Yang and will therefore lead to clouding of the orifices. “Clouding of the orifices” will result in blurred vision, dizziness, a blocked nose, a sticky taste, tinnitus and a feeling of muzziness (fuzziness) and heaviness of the head. The two most common pathogenic factors that lead to an Excess of Yin in the head are Dampness and Phlegm. The headache from Excess of Yin is dull but intense.
Deficiency of Yin CLINICAL NOTE Liver-Fire is a condition of Full Heat (thirst, bitter taste, feeling of heat, red face, red eyes, dark urine, dry stools); Liver-Yang rising is purely an imbalance between Yin and Yang with excessive rising of Yang Qi to the head. The headaches from Excess of Yang are therefore due to a stagnation of Yang Qi in the head: Qi cannot circulate and this causes head pain. The headache from Excess of Yang is by definition intense and usually throbbing.
As the head is an area of confluence of Yang channels, the rise of clear Yang to the head necessarily occurs, so deficiency of Yin is not a common cause of headaches. However, as Blood is part of Yin, a deficiency of Blood, which is a relatively common cause of headaches, is also a type of deficiency of Yin. A deficiency of Liver- or Heart-Blood is a common cause of headaches. Other examples of deficiency of Yin leading to headaches are deficiency of Kidney-Yin or of Kidney-Essence. The headache from Yin deficiency is dull and mild.
Deficiency of Yang
SUMMARY
With deficiency of Yang, there is the opposite situation, i.e. not enough clear Yang reaches the head. Under normal circumstances, clear Yang Qi flows up to the head, brightening the orifices of the head (ears, nose, mouth, eyes and the Mind). The rising of clear Yang to the head is also very important to the constant clearing of potential Yin pathogenic factors from the head. The physiological rise of clear Yang to the head is facilitated by the fact that, superficially, the head contains only Yang channels. The most common examples of deficient Yang not rising to the head are Stomach-Qi or Kidney-Yang not reaching the head. Stomach-Qi deficiency will cause a frontal headache, while KidneyYang will cause an occipital headache. The headache from Deficiency is by definition dull and mild.
PATHOLOGY Excess of Yang — Liver-Yang rising, Liver-Fire — Intense and usually throbbing Deficiency of Yang — Deficiency of Stomach-Qi (frontal) or Kidney-Yang (occipital) — Dull and mild Excess of Yin — Dampness and Phlegm — Dull but intense Deficiency of Yin — Deficiency of Liver- or Heart-Blood, deficiency of Yin or Kidney-Essence — Dull and mild
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The Practice of Chinese Medicine
DIAGNOSIS Headaches can be diagnosed from two perspectives: either from the point of view of channels or from that of Internal Organs. Both of these are equally relevant in clinical practice, particularly from the acupuncturist’s perspective. I will discuss the main diagnostic pointers from three viewpoints: 1. diagnosis according to channels 2. diagnosis according to type of pain 3. diagnosis according to amelioration and aggravation. The diagnosis according to the Internal Organs will be discussed under the heading, Identification of patterns and treatment.
Diagnosis according to channels Medical Talk from the Deserted Cottage says:5 The Greater Yang type of headache affects the occiput, the Bright Yang type affects the forehead, the Lesser Yang type affects the sides of the head ... the Terminal Yin type affects the top of the head ... the Greater and Lesser Yin do not ascend to the head, but Phlegm can prevent Qi from descending and the pure Yang from ascending freely to the head. This classification provides useful guidelines in clinical practice for a quick identification of the channel involved in a given type of headache (Fig. 1.10). However, this is only a broad guideline that first of all needs to be further refined, and second needs to be integrated with the identification of patterns of the
Internal Organs. For example, a headache on the top of the head often involves the Terminal Yin channel, i.e. the Liver channel; it can be due to either Liver-Yang rising or Liver-Blood deficiency. Furthermore, a headache on the top of the head may also be due to deficient Qi’s and/or Blood’s being unable to reach the head and may not necessarily reflect a Liver channel involvement at all. A further analysis of the channels affecting various head areas in headaches is as follows.
Top of the head The Liver channel reaches the top of the head internally and is the most frequent cause of headache there (Fig. 1.11). A headache on top of the head is most often due to deficient Liver-Blood’s being unable to reach the area. This headache, which will be dull in character, will improve if the patient lies down. In a few cases, a headache in this area may be due to Liver-Yang rising, in which case it will be sharp in character. There are also other causes of headache in this area not related to the Liver channel, such as deficient Qi’s and/or Blood’s being unable to reach the top of the head, or Heart-Blood deficiency. A headache on the top of the head only should not be confused with one that affects this area but that starts at the base of the occiput and works its way up. This type of headache is due to the Bladder channel.
Sides of the head This area corresponds to the Gall Bladder channel, and a headache here is most frequently due to Liver-Yang
Terminal Yin
Bright Yang Lesser Yang
Greater Yang
Figure 1.10 Headache areas.
Headaches
Figure 1.11 Liver-channel headache area.
Figure 1.12 Sides of the head area.
rising, Liver-Fire or Liver-Wind (Fig. 1.12). Such a headache is sharp and throbbing in character.
One side only This area also corresponds to the Gall Bladder channel, and a headache here is also due either to Liver-Yang rising or to Liver-Fire. It is said in Chinese medicine that a headache on the left side is more likely to result from a Deficiency and one on the right side to result from an Excess, but this rule is by no means completely reliable.
Temples This area also corresponds to the Gall Bladder channel, and such a headache most frequently affects one side only. This headache is usually due to Liver-Fire, LiverYang or Liver-Wind rising and is throbbing in character (Fig. 1.13).
Behind the eyes This is a very frequent location for migraine. The headache is due to Liver-Blood deficiency if the pain is dull, or to Liver-Yang rising if the pain is sharp and severe.
Figure 1.13 Temple area.
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The Practice of Chinese Medicine
Forehead Headaches in this area are usually related to the Stomach. If the pain is dull, they indicate Stomach deficiency; if it is sharp, Stomach-Heat. A very frequent cause of frontal headaches is the retention in the head of either Dampness or Phlegm, preventing the clear Yang from ascending to the head to brighten the sense orifices. For this reason, this type of headache is associated with a heavy sensation of the head, a muzzy (fuzzy) feeling of the head, and a lack of concentration. If Phlegm is causing the headache, the person will also experience dizziness and blurred vision. In a few cases, frontal headaches can be due to a residual pathogenic factor, such as external Wind that has not been expelled after an invasion of exterior Wind-Cold or Wind-Heat.
Back of the head (occiput) Chronic headaches in this area are usually due to a Kidney deficiency manifesting on the Bladder channel. Acute headaches here are due to invasion of external Wind (usually Wind-Cold) and form a typical feature of the Greater Yang pattern within the SixStage pattern identification (see Appendix 1). This type of headache is accompanied by great stiffness at the back of the neck. In a few cases, occipital headache can be associated with a Bladder pattern, such as Damp Heat in the Bladder, in which case the pain will be sharp.
Whole head Chronic headaches in this area are due to Kidney-Yin or Kidney-Essence deficiency. The Kidney-Essence nourishes the brain, and when it is deficient the brain lacks nourishment. This can give rise to dull headaches in the whole head accompanied by a feeling of emptiness of the head. Acute headaches affecting the whole head are due to invasion of external Wind (which can be either Wind-Cold or Wind-Heat). These are severe and sharp in character, sometimes accompanied by a pulling sensation. Thus there is generally a correlation between the pattern related to a specific type of headache and the channel involved. For example, the pattern of LiverYang rising will give rise to headaches on the Gall Bladder channel, while the pattern of Kidney deficiency will cause headaches on the Bladder channel. However,
there can be exceptions. This happens in situations when more than one pattern is involved. For example, a person may suffer from a chronic Kidney deficiency leading to the rising of Liver-Yang. If the Kidney deficiency is very long-standing and the Bladder channel on the head is affected, it is possible for headaches of the Liver-Yang type (i.e. very sharp and throbbing in character) to manifest on the Bladder channel on the occiput. It should also be remembered that headaches frequently occur in different parts of the head at different times. This is not unusual and is simply due to the coexistence of two different patterns causing headaches. For example, Liver-Blood deficiency can give rise to Liver-Yang rising. In this case, a person may suffer from dull headaches on top of the head reflecting the Liver-Blood deficiency, occasionally changing into sharp and throbbing headaches on one or other temple, reflecting the Liver-Yang rising. If the area of the headache changes all the time and the headache is experienced in different parts of the head at different times, it either indicates the presence of Liver-Wind, in which case the pain will be accompanied by a pulling sensation, or the presence of Phlegm, in which case the pain will be accompanied by a heavy sensation of the head.
SUMMARY DIAGNOSIS ACCORDING TO CHANNELS Top of the head — Deficiency of Liver-Blood — Deficiency of Qi and Blood — Heart-Blood deficiency Sides of the head — Liver-Yang rising — Liver-Fire — Liver-Wind One side only — Liver-Yang rising — Liver-Fire Temples — Liver-Yang rising — Liver-Fire — Liver-Wind Behind the eyes — Liver-Blood deficiency (dull) — Liver-Yang rising (sharp)
Headaches
Forehead — Stomach deficiency (dull) — Stomach-Heat (sharp) — Dampness or Phlegm — Residual pathogenic factor, such as external Wind Back of the head (occiput) — Kidney deficiency (chronic) — Invasion of external Wind (acute) — Bladder pattern (e.g. Damp Heat in the Bladder) Whole head — Kidney-Yin or Kidney-Essence deficiency (chronic) — Invasion of external Wind (acute)
Diagnosis according to type of pain
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Distending pain This is a typical Chinese expression that will be seldom used by Western patients (or at least in Anglo-Saxon languages). The most frequently recurrent expressions regarding this type of pain are “throbbing”, “bursting” and “pulsating”, all of which correspond to “distending”. This sensation is typical of a Liver-related headache, which could be from Liver-Yang or Liver-Fire. However, a distending pain can also be due to exterior Wind-Heat, in which case it will affect the whole head, whereas in the case of Liver-Yang or LiverFire it will most probably affect one or both sides of the head.
Stiff A pronounced stiffness of the occiput usually indicates an invasion of exterior Wind-Cold. A chronic headache with stiffness of the top of the shoulders and neck usually indicates Liver-Yang rising.
From the Eight-Principle perspective, a dull ache generally indicates an Empty condition, while a sharp pain indicates a Full condition. A sudden onset tends to indicate an exterior invasion, while a gradual onset tends to indicate an interior one. Empty conditions causing dull headaches include deficiency of Qi and/or Blood, Liver-Blood deficiency and Kidney deficiency. Full conditions include Liver-Yang rising, Liver-Fire blazing, Liver-Wind, Phlegm, stasis of Blood and Stomach-Heat.
Pulling
Dull
A sensation of emptiness of the brain indicates deficiency of Kidney (Yin or Yang).
A dull headache is due to one of the deficiencies outlined above.
A pulling type of sensation indicates internal LiverWind.
Stabbing, boring This sensation is very intense and fixed in one place, and it indicates Blood stasis. It occurs only in chronic headaches. A description also used in this context is “splitting headache”.
Feeling of emptiness
Feeling of heaviness
We can summarize the different types of headache according to patterns.
This is characteristic when Dampness or Phlegm obstructs the head and prevents the clear Yang Qi from ascending to the head and the turbid Yin Qi from descending. The head typically feels heavy, muzzy and as if it were wrapped in a cloth. The person would also find it difficult to concentrate and think, especially in the morning. Both Dampness and Phlegm may cause the above sensations, but Phlegm is more obstructive and it clouds the “orifices” and sense organs, causing dizziness and blurred vision. These last two symptoms distinguish between headaches caused by Phlegm and those caused by Dampness in the head.
• Wind-Cold: severe occipital with pronounced stiffness. • Wind-Heat: severe, distending, in the whole head. • Wind-Dampness: feeling of heaviness, as if the head were wrapped in a cloth. • Liver-Yang, Liver-Fire: distending. • Liver-Wind: pulling. • Stasis of Blood: stabbing, splitting, boring. • Phlegm: heavy sensation, as if the head were wrapped in a cloth; dizziness. • Dampness: heavy sensation, as if the head were wrapped in a cloth. • Qi-Blood deficiency: dull. • Kidney deficiency: feeling of emptiness.
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The Practice of Chinese Medicine
SUMMARY DIAGNOSIS ACCORDING TO TYPE OF PAIN Dull: Deficiency. Feeling of heaviness: Dampness or Phlegm. Distending pain: Liver-Yang or Liver-Fire, also exterior Wind-Heat. Stiff: exterior Wind-Cold; if chronic, Liver-Yang rising. Pulling: internal Liver-Wind. Stabbing, boring: Blood stasis. Feeling of emptiness: deficiency of Kidneys (Yin or Yang). — Wind-Cold: severe occipital with pronounced stiffness. — Wind-Heat: severe, distending, in the whole head. — Wind-Dampness: feeling of heaviness, as if the head were wrapped in a cloth. — Liver-Yang, Liver-Fire: distending. — Liver-Wind: pulling. — Stasis of Blood: stabbing, splitting, boring. — Phlegm: heavy sensation, as if the head were wrapped in a cloth; dizziness. — Dampness: heavy sensation, as if the head were wrapped in a cloth. — Qi-Blood deficiency: dull. — Kidney deficiency: feeling of emptiness.
Headaches that improve with rest and lying down are due to deficiency of Qi or Blood, while headaches that worsen lying down are due to Dampness or Phlegm.
Weather Headaches that get worse with heat may be due to Liver-Yang or Liver-Fire rising, while headaches that get worse with cold may be due to deficiency of Yang. If they worsen with damp weather, it is a clear indication that they are due to Dampness or Phlegm. A headache that improves temporarily with the application of cold (e.g. cold water) may be due to Liver-Yang or Liver-Fire.
Emotions Headaches that worsen with anger are due to LiverYang or Liver-Fire. Headaches that get worse when the person suddenly relaxes (the typical weekend headache) are due to Liver-Yang rising. Headaches that worsen with a sudden excitement may be due to LiverYang rising.
Sexual activity Chronic headaches that are aggravated after sexual activity (culminating in ejaculation for men or orgasm for women) clearly indicate a deficiency of the Kidneys. In rare cases, headaches may be ameliorated by sexual activity, which indicates Liver-Fire.
Food
Diagnosis according to amelioration and aggravation The factors that make a headache better or worse may give an indication of the condition causing the headache.
Time of day Chronic headaches that are worse in daytime indicate either deficiency of Qi/Yang or Dampness. Chronic headaches that are worse in the evening or at night indicate deficiency of Blood or Yin (which may be causing Yang rising).
Activity/rest Headaches that get worse with activity are due to deficiency of Qi or Blood, while headaches that improve with light exercise may be due to Liver-Yang rising or Phlegm.
Barring the vast subject of intolerance of certain foods, headaches that get worse after eating indicate Dampness, Phlegm, Retention of Food or Stomach-Heat. Headaches that get better with eating indicate deficiency of Qi or Blood. Headaches that are aggravated by the consumption of sour foods (such as oranges, grapefruit and vinegar) are due to Liver-Yang rising.
Posture If a headache improves when the patient is lying down, it is due to a Deficiency; if it worsens when lying down (and improves when sitting), it is due to an Excess. For example, severe headaches from Liver-Yang rising are usually eased if the patient sits up; such a patient dislikes lying down.
Menstruation Many types of headache are closely affected by the menstrual function. Headaches that precede the onset
Headaches
of the period are usually due to Liver-Yang rising or Liver-Qi stagnation. If they worsen during the period, they may be due to Liver-Fire or stasis of Blood. If they occur towards the end of the period, they indicate Blood deficiency.
Pressure If the person dislikes pressure on the part of the head where the headache occurs, it indicates an Excess condition. Conversely, if the headache improves with pressure, it indicates a Deficiency condition.
SUMMARY DIAGNOSIS ACCORDING TO AMELIORATION AND AGGRAVATION Time of day — Worse in daytime: deficiency of Qi/Yang or Dampness. — Worse in the evening or at night: deficiency of Blood or Yin. Activity or rest — Worse with activity: deficiency of Qi or Blood. — Better with light exercise: Liver-Yang rising or Phlegm. — Better with rest and lying down: deficiency of Qi or Blood. — Worse lying down: Dampness or Phlegm. Weather — Worse with heat: Liver-Yang or Liver-Fire rising. — Worse with cold: deficiency of Yang. — Worse with damp weather: Dampness or Phlegm. — Better with the application of cold: LiverYang or Liver-Fire. Emotions — Worse with anger: Liver-Yang or Liver-Fire. — Worse on relaxation: Liver-Yang rising. — Worse with a sudden excitement: Liver-Yang rising. Sexual activity — Worse after sexual activity: deficiency of the Kidneys. — Better after sexual activity: Liver-Fire. Food — Worse after eating: Dampness, Phlegm, Retention of Food or Stomach-Heat.
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— Better from eating: deficiency of Qi or Blood. — Worse with the consumption of sour foods: Liver-Yang rising. Posture — Better on lying down: Deficiency. — Worse when lying down: Excess. Menstruation — Worse before the period: Liver-Yang rising or Liver-Qi stagnation. — Worse during the period: Liver-Fire or stasis of Blood. — Worse after the period: Blood deficiency. Pressure — Worse on pressure: Excess condition. — Better with pressure: Deficiency condition.
TREATMENT STRATEGIES AND PRINCIPLES OF POINT SELECTION When identifying patterns for the treatment of headaches, the first differentiation to make is between exterior and interior headaches. From an EightPrinciple perspective, exterior headaches are of Excesstype by definition. Within the interior headaches, it is important to differentiate between Deficiency type and Excess type. Zhang Jie Bin in his Classic of Categories says that all headaches are simply due to either too much or too little Qi in the head: the former is an Excess-type headache, the latter a Deficiency-type. He says: “When the head is painful, it indicates a deficiency below and an excess above ... When Qi cannot ascend, the head aches ... when Qi does not ascend, the brain is empty.”6 In many cases of chronic headache, there is a condition of simultaneous Deficiency and Excess. For example, Liver-Yang rising (a Full condition in itself) may derive from Liver-Blood deficiency (an Empty condition); Phlegm (a Full condition) may derive from Spleen-Qi deficiency (an Empty condition). The Full or Empty character of a condition is also related to the question of Root (Ben) and Manifestation (Biao). For example, Liver-Blood deficiency may be the Root that leads to Liver-Yang rising (the Manifestation), or Spleen-Qi deficiency may be the Root that gives rise to Phlegm (the Manifestation). In such cases, the question arises whether we should treat the Root only, the Manifestation only or both.
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The Practice of Chinese Medicine
Treating the Root or the Manifestation The question of treating the Root or the Manifestation is particularly important in the case of headaches. There are three possible courses of action.
Treating both the Root and the Manifestation This is the most common approach. In most cases, it is possible and necessary to deal with both the Root and the Manifestation simultaneously. For example, if a headache is due to a rising of Liver-Yang that derives from Kidney-Yin deficiency, the most obvious course of action is to tonify the Kidneys and subdue Liver-Yang simultaneously. However, even if both Root and Manifestation are treated at the same time, it is often necessary to place the emphasis on one rather than the other. If the headaches are very severe and recur very frequently, it may be necessary to concentrate one’s attention on treating the Manifestation rather than the Root. In the example given above, if the headaches caused by LiverYang rising are very severe and frequent, it would be important to direct one’s attention to treating the Manifestation first, i.e. subduing Liver-Yang. On the other hand, if the Manifestation is not causing very severe headaches, then it might be sufficient to give primary importance to treatment of the Root. For example, if a person suffers from mild headaches from Qi deficiency, one would concentrate on treating the Root, i.e. tonifying Qi.
Treating the Manifestation first, the Root second This approach is necessary when the headaches caused by the Manifestation are extremely severe and so frequent as to impede any form of normal life. For example, if the headaches from Liver-Yang are of such intensity and frequency, one would concentrate one’s attention first on treating the Manifestation only, i.e. subduing Liver-Yang. Once the severity and the frequency of the headaches have been reduced, then one can start treating the Root too.
Treating the Root only This is possible when the headaches are mild and infrequent. These headaches are usually deficient in nature, for example mild headaches from Qi or Blood
deficiency. In these cases, it might be enough to concentrate simply on tonifying Qi or Blood so that the headaches will gradually disappear.
Point selection In the treatment of headaches, it is essential to combine local with distal points. The more chronic or intense the headache, the more local points are required. Local points are also especially required when a chronic headache appears always in the same spot. This indicates a local stasis of Blood, which always calls for the use of local points to disperse it. Generally speaking, both distal and local points are chosen according to the pattern and the channel involved. However, the primary aim of distal points is to treat the pattern, while that of local points is to treat the channel involved. For example, a Liver-Yang headache nearly always manifests on the Gall Bladder channel. We might therefore choose as distal points LIV-3 Taichong according to the pattern and G.B.-43 Xiaxi according to the channel. A model of the principles governing the selection of points is illustrated in Figure 1.14. Local points are mostly chosen according to the channel involved. For example, for headaches on the Gall Bladder channel, one might choose G.B.-6 Xuanli as a local point. Some local points may be chosen according to the location of the headache irrespective of the pattern. Examples are as follows. • Frontal headache: Du-23 Shangxing and G.B.-14 Yangbai. • Headache on vertex: Du-20 Baihui and Du-21 Qianding. • Occipital headache: BL-10 Tianzhu, Du-19 Houding. • Temporal headache: G.B.-8 Shuaihu and Taiyang.
DISTAL POINTS
Pattern
Channel
LOCAL POINTS
Pattern
Channel
Figure 1.14 Principles governing selection of points in headaches.
Headaches
However, local points may also be chosen according to the pattern. In the example above, if the headache on the Gall Bladder channel is caused by Liver-Yang rising, in addition to points on the Gall Bladder channel we might also use Du-20 Baihui, as the internal pathway of the Liver channel reaches up to that point. Figure 1.15 illustrates the principles governing the selection of points for headaches using the Gall Bladder channel in headaches from Liver-Yang rising as an example. The following are the main distal and local points according to channel involved:
Gall Bladder channel This may cause headaches in many different parts of the head: the sides of the head, temples, unilateral forehead (on G.B.-14 Yangbai) or lateral occiput (on G.B.-20 Fengchi).
Distal points G.B.-43 Xiaxi, T.B.-5 Waiguan.
Local points G.B.-4 Hanyan, G.B.-5 Xuanlu, G.B.-6 Xuanli, G.B.-8 Shuaigu, G.B.-9 Tianchong, G.B.-14 Yangbai and G.B.-20 Fengchi, according to the location of the headache.
Bladder channel This may cause headaches on the occiput.
Distal points BL-60 Kunlun.
DISTAL POINTS
Pattern
Channel
LOCAL POINTS
Pattern
Channel
Local points BL-10 Tianzhu.
Stomach channel This causes headaches on the forehead.
Distal points ST-44 Neiting, L.I.-4 Hegu.
Local points ST-8 Touwei. The same principles apply to herbal therapy. The “local” herbs, i.e. those that specifically affect the head, are chosen according to the channel involved (but to a certain extent also according to the pattern), and the “distal” herbs, i.e. those that treat the condition causing the headaches, are chosen according to the pattern. For example, in frontal headaches from LiverQi stagnation and Spleen deficiency, Bai Zhi Radix Angelicae dahuricae can be selected as a “local” herb to affect the forehead, while the Xiao Yao San Free and Easy Wanderer Powder could be selected as the main prescription to deal with the pattern causing the headaches, i.e. stagnation of Liver-Qi. “Local” herbs for different parts of the head are as follows. • Greater Yang area (occiput): Qiang Huo Rhizoma seu Radix Notopterygii. • Lesser Yang area (sides of the head, Gall Bladder channel): Chuan Xiong Rhizoma Chuanxiong and Chai Hu Radix Bupleuri. • Bright Yang area (forehead): Bai Zhi Radix Angelicae dahuricae. • Terminal Yin area (vertex): Tian Ma Rhizoma Gastrodiae and Wu Zhu Yu Fructus Evodiae. • Lesser Yin channels (inside head): Xi Xin Herba Asari.
IDENTIFICATION OF PATTERNS AND TREATMENT The patterns discussed are the following.
LIV–3, LIV–8
G.B.–43
G.B.–20
G.B.–6, Taiyang
Figure 1.15 Selection of points for headache on Gall Bladder channel in the temple from Liver-Yang rising and Liver-Blood deficiency.
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EXTERIOR • Wind-Cold • Wind-Heat • Wind-Dampness
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The Practice of Chinese Medicine
INTERIOR Full • Liver-Yang rising • Liver-Fire • Liver-Wind • Liver-Qi stagnation • Stagnation of Cold in the Liver channel • Dampness • Turbid Phlegm • Turbid Phlegm-Wind • Liver-Yang rising with Phlegm in the head • Retention of Food • Stasis of Blood • Stomach-Heat Empty • Qi deficiency • Blood deficiency • Kidney deficiency
Wind-Cold External Wind-Cold invades the Greater Yang channels first and manifests with a headache and stiffness on the occiput, where these channels flow. Cold contracts and tightens the sinews and slows down the circulation of Defensive Qi, hence the typical feeling of stiffness at the back of the neck. This headache is obviously of acute onset and can be very severe but it will last only a short time, i.e. for as long as the Wind-Cold is on the Exterior. Once the pathogenic factor penetrates the Interior, this type of headache goes. There are exceptions, however, as in a few cases when the external Wind-Cold is not expelled it can settle in the muscles and give rise to chronic headaches. In acute cases, apart from the headache, there would also be generalized aches of the whole body, as the exterior Wind-Cold obstructs the free circulation of Defensive Qi in the muscles. Other symptoms and signs include aversion to cold, shivers, possibly a fever, stiff and achy shoulders, absence of thirst, some breathlessness, cough, sneezing, a runny nose with a white discharge or a blocked nose, pale urine and a Floating-Tight pulse.
Treatment principle Release the Exterior, expel Wind, scatter Cold, remove obstruction from the channels.
Acupuncture General prescription: LU-7 Lieque, G.B.-20 Fengchi, Du16 Fengfu, BL-10 Tianzhu. All with reducing method.
Explanation The above points have been selected for their action in expelling Wind-Cold, with particular reference to the headache deriving from Wind-Cold. Several other points might have been chosen to release the Exterior without a specific action on headaches, such as, for example, BL-12 Fengmen and BL-13 Feishu (see also Chapter 48, Common cold and influenza). • LU-7 is the main point to release the Exterior and expel Wind-Cold by stimulating the diffusing and descending of Lung-Qi. In addition, it especially affects the head and relieves headaches. For this reason, it can be used for headaches from WindCold, Wind-Heat and also Turbid Phlegm. • G.B.-20 expels Wind from the head. • Du-16 expels Wind from the head and treats the Greater Yang channel area. • BL-10 is used as a local point pertaining to the Greater Yang channel area, which is usually affected in invasion of Wind-Cold.
Other points • Du-20 Baihui can be used if the headache is not specifically on the occiput but affects the whole head. • S.I.-3 Houxi eliminates Wind and affects the Greater Yang area. • S.I.-3 and BL-62 Shenmai in combination open the Governing Vessel, eliminate Wind and affect the Greater Yang area. • BL-67 Zhiyin and BL-66 Tonggu can be selected to affect the Greater Yang area if the headache is on the occiput. They are the Well point and Spring point, respectively, and as such are good in Full patterns to eliminate pathogenic factors. Also, being at the tip of the foot, they will affect the head, according to the principle that points at one end of the body affect the opposite end. • BL-60 Kunlun is used if the headache also affects the lower part of the neck and the top of the shoulders. • Du-8 Jinsuo eliminates both interior and exterior Wind and relaxes the muscles and tendons of the top of the shoulders, as its name implies (“Sinew spasm”).
Headaches
Herbal therapy CHUAN XIONG CHA TIAO SAN Chuanxiong-Green Tea Regulating Powder
Herbal therapy Prescription CHUAN XIONG CHA TIAO SAN Chuanxiong-Green Tea Regulating Powder
Explanation
Three Treasures remedy Expel Wind-Cold
Prescription
This prescription is aimed at treating specifically the headache deriving from Wind-Cold, rather than releasing the Exterior, although it also has that effect. Green tea is an integral part of the prescription, which clears upwards towards the eyes and through the head, thus relieving the headache. Moreover, it is cool and thus will balance out the majority of the other herbs, which are quite warm.
Modifications • If there are pronounced symptoms and signs of invasion of the Defensive-Qi portion by Wind-Cold (such as sneezing, cough and breathlessness), then Ma Huang Tang Ephedra Decoction can be used with suitable additions to affect the headache.
Herbs Several herbs can be considered. We can classify them according to the area affected, i.e. Greater Yang, Lesser Yang or Bright Yang. These herbs are as follows. • Greater Yang: Du Huo Radix Angelicae pubescentis, Qiang Huo Rhizoma seu Radix Notopterygii and Gao Ben Rhizoma Ligustici. • Lesser Yang: Chai Hu Radix Bupleuri, Huang Qin Radix Scutellariae and Qing Hao Herba Artemisiae annuae. • Bright Yang: Sheng Ma Rhizoma Cimicifugae, Ge Gen Radix Puerariae and Bai Zhi Radix Angelicae dahuricae.
Three Treasures remedy Expel Wind-Cold Expel Wind-Cold releases the Exterior and expels Wind-Cold.
SUMMARY WIND-COLD General prescription: LU-7 Lieque, G.B.-20 Fengchi, Du-16 Fengfu, BL-10 Tianzhu. All with reducing method.
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Wind-Heat External Wind-Heat obstructs the clear orifices in the head and leads to a headache that is felt inside the head and is distending in character. It can be very severe and cause the head to feel as if it were “cracking” open. This headache, like that from Wind-Cold, also has an acute onset and can last only while the pathogenic factor is in the Exterior. Other symptoms and signs include aversion to cold, shivers, fever, slight thirst, runny nose with a yellow discharge, a sore throat, possibly swollen tonsils, red eyes, slightly dark urine, slightly red sides or tip of the tongue and Floating-Rapid pulse. The aversion to cold and shivers would be less pronounced than in WindCold and the fever would be higher.
Treatment principle Release the Exterior, clear Heat, expel Wind and remove obstruction from the channels.
Acupuncture General prescription: L.I.-4 Hegu, G.B.-20 Fengchi, Du-16 Fengfu, Du-14 Dazhui, T.B.-5 Waiguan. All with reducing method.
Explanation • L.I.-4 releases the Exterior, expels Wind-Heat, and is a special point to affect the head and face. • G.B.-20 and Du-16 expel Wind from the head. • Du-14 expels Wind, clears Heat and relieves headache. • T.B.-5 expels Wind-Heat and relieves headache.
Other points • Du-20 Baihui expels Wind and relieves headache. It is particularly used if the headache affects the whole head.
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The Practice of Chinese Medicine
• L.I.-11 Quchi expels Wind-Heat and is used if the symptoms and signs of Heat are pronounced. • T.B.-16 Tianyou expels Wind-Heat and, in particular, relieves headache.
Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction
Explanation This is the main prescription to expel Wind-Heat in mild cases. If headache is the predominant symptom, the prescription would have to be adapted by adding some herbs specific for headaches out of those listed below under Herbs.
SUMMARY WIND-HEAT General prescription: L.I.-4 Hegu, G.B.-20 Fengchi, Du-16 Fengfu, Du-14 Dazhui, T.B.-5 Waiguan. All with reducing method. Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Prescription JU HUA CHA TIAO SAN Chrysanthemum-Green Tea Regulating Powder Three Treasures remedy Expel Wind-Heat
Prescription JU HUA CHA TIAO SAN Chrysanthemum-Green Tea Regulating Powder
Explanation This prescription combines the Chuan Xiong Cha Tiao San Chuanxiong-Green Tea Regulating Powder as a whole, which expels Wind-Cold, with two herbs, Ju Hua Flos Chrysanthemi and Jiang Can Bombyx batryticatus, that expel Wind-Heat and are specific for headache.
Herbs • Man Jing Zi Fructus Viticis expels Wind-Heat and is specific for headaches. • Ge Gen Radix Puerariae, which expels Wind-Heat and releases the muscles and sinews, is specific to relieve the ache and stiffness of the neck and shoulders from invasion of exterior Wind. • Bo He Herba Menthae haplocalycis and Ju Hua Flos Chrysanthemi expel Wind-Heat. They are light and aromatic and affect the head specifically. They also relieve headaches from Liver-Yang rising. Ju Hua, in addition, specifically affects the eyes and would therefore be indicated when the headache is situated around the eyes or if the eyes are red.
Wind-Dampness This is a type of Wind-Cold but is combined with Dampness. External Dampness obstructs the clear orifices of the head and gives rise to a headache with a typical feeling of heaviness. The head feels muzzy (fuzzy), as if it were wrapped in a cloth, a sensation that is aggravated by damp weather. Because Dampness prevents the clear Yang from reaching the head and brightening the orifices, and the turbid Yin from descending, the patient feels muzzy with a heavy head, poor concentration and heavy eyes. Other symptoms and signs include aversion to cold, shivers, possibly a fever, a sensation of oppression in the chest and epigastrium, a feeling of heaviness of the whole body, a runny nose with a white discharge, a sticky tongue coating and a Floating-Slippery pulse. This is an acute pattern that gives rise to acute headaches; however, they may become chronic if the Dampness settles in the head and is not expelled. It is relatively frequent in children.
Treatment principle Release the Exterior, expel Wind, resolve Dampness and remove obstruction from the channels.
Acupuncture Three Treasures remedy Expel Wind-Heat Expel Wind-Heat releases the Exterior and expels Wind-Heat.
General prescription: LU-7 Lieque, L.I.-6 Pianli, SP-6 Sanyinjiao, ST-8 Touwei, Du-23 Shangxing. Reducing method on all points.
Headaches
Explanation • LU-7 releases the Exterior and stimulates the Lungs’ diffusing and descending of fluids. It will therefore simultaneously expel Wind and resolve exterior Dampness. It is also a specific point for headaches. • L.I.-6 releases the Exterior and also stimulates the Lungs’ descending of fluids from the Upper Burner. It is the Connecting point of the Large Intestine Connecting channel that flows up to the jaw and ear and thus relieves any headache in this region. • SP-6 resolves Dampness. • ST-8 is the main local point on the head to resolve Dampness affecting the head, and is specific for dull headaches with a feeling of the head being wrapped in a cloth. • Du-23 relieves headaches on the forehead and the eyes.
Herbal therapy Prescription QIANG HUO SHENG SHI TANG Notopterygium Dispelling Dampness Decoction
Explanation This formula is specific to expel external WindDampness causing a headache.
Herbs • Bai Zhi Radix Angelicae dahuricae expels Wind from the head and face and is specific for headaches of this type. • Huo Xiang Herba Pogostemonis is a fragrant herb that resolves exterior Dampness. It is aromatic and light and therefore affects the head. • Cang Zhu Rhizoma Atractylodis is also a fragrant herb that resolves Dampness and is particularly indicated for headaches.
SUMMARY WIND-DAMPNESS General prescription: LU-7 Lieque, L.I.-6 Pianli, SP-6 Sanyinjiao, ST-8 Touwei, Du-23 Shangxing. Reducing method on all points.
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Herbal therapy Prescription QIANG HUO SHENG SHI TANG Notopterygium Dispelling Dampness Decoction
The four organs that are most directly involved in the pathogenesis of headaches are the Spleen, Stomach, Liver and Kidneys. The aetiology and pathology of interior headaches are represented in Figure 1.16.
Liver-Yang rising This is probably the most common of all interior headaches. It arises when the Yang of the Liver “rebels” upwards, creating an excess of Yang in the head. Although it is in the nature of Liver-Qi and Liver-Yang to flow freely upwards, in pathological circumstances this movement can be excessive and give rise to headaches. As we have seen, the Liver main channel is one of only two (together with the Heart channel) to flow internally to the head; all other Yin channels reach the head via their respective divergent channels. The most frequent cause of this type of headache is emotional. Anger (whether it is manifested or repressed), frustration or resentment over a long period of time can cause the excessive rising of LiverYang. However, in my opinion, worry may also cause Liver-Yang to rise. Liver-Yang rising is usually due to one of four situations: 1. 2. 3. 4.
Liver-Blood deficiency Liver-Yin deficiency Liver- and Kidney-Yin deficiency Liver/Kidney-Yin and Kidney-Yang deficiency (Fig. 1.17).
Liver-Blood deficiency is a common cause of the rising of Liver-Yang. Blood is part of Yin and is stored in the Liver. The Blood of the Liver roots and anchors the Yang of the Liver. Hence if Liver-Blood is deficient, Liver-Yang may “escape” upwards to disturb the head. Liver-Yin deficiency is practically the same as LiverBlood deficiency. One of the main signs that distinguishes between the two conditions is the dryness of the eyes in Liver-Yin deficiency. The Liver and Kidneys share a common root, and a deficiency of one often affects the other. Liver-Blood
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The Practice of Chinese Medicine
Heart Lungs Liver
Emotions
Qi STAGNATION
BLOOD STASIS
Blood-deficiency headache
Trauma
YIN DEFICIENCY
Blood deficiency
Spleen
DEFICIENCY
LIVER-FIRE rising
Liver-Fire headache
Damages Yin, Yang rises
PHLEGM clouds orrifices
Phlegm headache
Blood fails to nourish head
FIRE
Liver-Fire rising headache
Kidney-Yin fails to nourish Liver-Yin
Diet
Blood-stasis headache
Heredity
Qi deficiency Clear Yang cannot ascend
Qi-deficiency headache
Kidneys
DEFICIENCY
Kidney-deficiency headache
Figure 1.16 Aetiology and pathology of interior headaches.
deficiency may in the long run fail to nourish the Kidney-Essence, which may become deficient. Conversely, a deficient Kidney-Essence may fail to produce Blood and lead to Liver-Blood deficiency. Both Blood and Essence pertain to Yin, and Liver- and Kidney-Yin deficiency thus lead to the excessive rising of LiverYang. In a few cases, Liver-Yang rising may also derive from Kidney-Yang deficiency. Although this appears to be a paradox, the Kidneys are the source of all the Yin and Yang energies in the human body. There is a close interaction between the Yin and the Yang of the Kidneys, and the two cannot be separated. Thus, it is not uncommon for deficiency of both Kidney-Yin and Kidney-Yang to occur simultaneously. Of course, the deficiency of Yin and Yang within the Kidneys is never in a 50/50 proportion, and one or the
Liver-Yang rising
Liver Blood Xu
Liver-Yin Xu
Liver-and Kidney-Yin Xu
Figure 1.17 Causes of Liver-Yang rising.
Liver-Yin and KidneyYin-Yang Xu
Headaches
other is predominant. The tongue-body colour always shows the predominant deficiency: if it is Pale, it indicates a predominance of Kidney-Yang deficiency, and if it is without coating, it indicates a predominance of Kidney-Yin deficiency. When Kidney-Yang is deficient over a long period of time, it can induce a lesser deficiency of Kidney-Yin that, in turn, may lead to Liver-Yang rising. This explains how a person may have several symptoms and signs of Kidney-Yang deficiency (such as frequent-pale urination, chilliness, a Pale-Swollen tongue and a Deep and Slow pulse), only one symptom of Kidney-Yin deficiency (such as night sweating), and some symptoms of Liver-Yang rising (such as headaches, irritability and dizziness). The headache from Liver-Yang rising is intense, severe, throbbing or distending in character. Some patients also describe it as “pulsating”, “pounding” or “bursting”. It usually affects either or both sides of the head along the Gall Bladder channel, or the temple or eyebrow. Frequently, it is felt behind one or both eyes (Fig. 1.18). It may also occur on a small area around the point G.B.-14 Yangbai.
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The headache from Liver-Yang rising is frequently accompanied by nausea or vomiting. These are due to Liver-Qi invading the Stomach and preventing Stomach-Qi from descending. In a few cases, it is also accompanied by diarrhoea due to Liver-Qi invading the Spleen and impairing its transformation and transportation activity. The Liver-Yang headache is usually eased by sitting up, and a patient will often prefer to be propped up by several pillows when lying in bed. Other common symptoms with headaches from Liver-Yang are visual disturbances. The person may see flashing lights or auras, or the vision may be blurred. This type of headache is often called the “weekend headache”. When someone works excessively long hours and is under considerable tension during the week, the condition of Liver-Yang may be masked, but once he or she abruptly stops work at weekends, the inactivity makes Liver-Yang flare upwards to cause the headache. Other manifestations of Liver-Yang rising include dizziness, tinnitus, deafness, a dry throat, insomnia, irritability and a Wiry pulse. The pulse may be Wiry only on the left side or even only on the left Middle position. It is important to realize that the tongue appearance varies depending on whether the headache stems from Liver-Blood or Kidney/Liver-Yin deficiency. If it stems from Liver-Blood deficiency, the tongue body may be Pale and Thin, whereas if it stems from Kidney/LiverYin deficiency the tongue body will be without coating. Finally, in the few cases in which Liver-Yang rising derives from Kidney-Yang deficiency, the tongue body will be Pale and Swollen and the pulse Deep and Slow.
Treatment principle Pacify the Liver, subdue rebellious Yang, nourish LiverBlood or Liver-Yin and/or Kidney-Yin as appropriate.
Acupuncture General prescription: LIV-3 Taichong, LIV-8 Ququan, SP-6 Sanyinjiao, T.B.-5 Waiguan, G.B.-20 Fengchi, Taiyang extra point. • In case of Liver and Kidney Yin deficiency, add KI-3 Taixi.
Figure 1.18 Areas of Liver-Yang headache.
Reducing method on LIV-3, T.B.-5 and G.B.-20, reinforcing method on LIV-8, SP-6 and KI-3. Even method on Taiyang. If the condition is very chronic,
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The Practice of Chinese Medicine
even method can be applied to the points that are normally reduced.
Explanation • LIV-3 is the main distal point to pacify the Liver and subdue Yang rising. It is also the main distal point for this type of headache. It should be needled at an appropriate depth (at least 0.5 cun) and usually reduced. In acute cases, it should be rather vigorously reduced or at least manipulated repeatedly at intervals during the treatment; for example, four or five times during 20 minutes. For very severe acute headaches when the pulse is extremely Wiry, the needles should be left in a fairly long time, i.e. longer than 20 minutes, up to 1 hour. Many of the patients with this type of headache dislike lying down during an acute attack and should therefore be treated propped up in a comfortable position. The more chronic the condition, the less one needs to reduce this point, and in very chronic cases it is enough to apply manipulation with even method. • LIV-3 will affect a Liver-Yang headache no matter where the headache is situated. • LIV-8 is reinforced to nourish Liver-Blood and/or Liver-Yin. Liver-Yang rising always derives from a deficiency of Liver-Blood (or Liver-Yin) and/or Kidney-Yin. It is therefore necessary to use points to nourish Liver-Blood and/or tonify Kidney-Yin. • SP-6 is reinforced to nourish Liver-Blood. Being the meeting point of Liver, Spleen and Kidney channels, it will also help to pacify the Liver. It also calms the Mind and helps to promote sleep. This is important in chronic headaches because if the person does not sleep well, it will be much more difficult to cure the headaches. • T.B.-5 is reduced to subdue Liver-Yang and affect the side of the head. The use of this point is based on the relationship existing between the Triple Burner and Gall Bladder channels, both pertaining to the Lesser Yang channel system. The relationship between Yang hand and foot channels is very close indeed, because they meet superficially on the head region and merge into one another. For this reason, in practice they are almost interchangeable. In this case, T.B.-5 is chosen to affect the Lesser Yang area (which includes the Gall Bladder channel area) on
the head where the Liver-Yang headache usually occurs. But why do we choose the Triple Burner instead of the Gall Bladder channel, and why T.B.-5 in preference to other points on that channel? If a choice exists between Yang hand or foot channels (as it normally does) to affect their commoninfluence area, the hand-channel points have a more moderate effect than those of the foot channels. Thus T.B.-5 has a milder effect than, say, G.B.-43. The choice between Yang hand- or footchannel points can therefore be guided by the severity of the symptoms; in severe cases, Yang foot-channel points will be used. Of course, both hand- and foot-channel points can be used simultaneously for an even stronger effect. T.B.-5 is used in preference to other points on this channel because it is the Connecting (Luo) point and, as such, it is especially suited to treat channel problems. This point is therefore used not so much to subdue Liver-Yang at internal organ level, but to pacify rebellious Yang within the Lesser Yang channels area. Specifically, T.B.-5 will affect headaches in the temple area. • G.B.-20 is used as an adjacent point to subdue Liver-Yang. It subdues Liver-Yang and Liver-Wind and is specific for headaches from these two causes. It will also relax the muscles of the upper neck and brighten the eyes, both of which actions will help chronic headaches. This point is needled at least 0.5 cun deep with the needles pointed towards the opposite eye. This direction can, however, be changed and the needle directed towards the eye on the same side in order to treat a unilateral headache on that side. This point, contrary to points situated further up the neck and skull, can be manipulated with reducing method. It can be needled with the patient lying down and reached without the patient having to sit up. • Taiyang is an extra point on the temple. It is specific to subdue Liver-Yang when it causes temporal headaches. It is used only if the headache is situated on the temple, otherwise different local points are selected. It is manipulated with even method.
Other points Many other points can be used according to the location of the headache.
Headaches
Distal points • P-6 Neiguan is used as a distal point for various reasons. First of all, the Pericardium channel is connected to the Liver channel within the Terminal Yin. P-6 will therefore indirectly help to subdue Liver-Yang and calm the Mind (Shen) and Ethereal Soul (Hun) at the same time. P-6 is also the Connecting point of the Pericardium channel, and it therefore connects with the Triple Burner channel. For this reason, it affects the Triple Burner channel on the head and can contribute to subduing Liver-Yang rising, affecting the Lesser Yang channels. For this effect, P-6 can be combined with Yangchi T.B.-4. This combination is very effective for headaches on the Lesser Yang channel area (i.e. temples, sides of the head and lateral side of the neck), especially in women. Finally, a condition of Liver-Yang rising is frequently associated with stress and a highly strung disposition. P-6 will help to harmonize the Liver and calm the Mind and Ethereal Soul, especially in women. • LU-7 Lieque is a special point for headaches. It is not specific for Liver-Yang headaches, but it can be used here for three reasons. First of all, it will affect any type of headache, and second, it can tonify the Lungs when the deficiency of Lung-Qi is contributing to the rebellious rising of Liver-Yang. In Five-Element terms, this corresponds to “Metal failing to control Wood”. This situation is quite common and is reflected in the pulse, the right Front position being very weak and the left Middle position very Wiry. Often, there may be no other symptoms or signs of Lung deficiency apart from the pulse. Third, LU-7 stimulates the descending of Qi from the head, and it will therefore indirectly help to subdue Liver-Yang. • G.B.-43 Xiaxi is the Spring point of the Gall Bladder channel. As such, it is used in Full patterns to eliminate pathogenic factors. In this case, it can be used to subdue Liver-Yang and remove obstructions from the Gall Bladder channel in the head. Being on the foot, it can treat the opposite end, i.e. the head. Specifically, it will affect the temple and eye area. Local points • G.B.-4 Hanyan, G.B.-5 Xuanlu and G.B.-6 Xuanli are all very important local points for headaches on
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the Gall Bladder channel on the side of the head deriving from Liver-Yang rising. They are needled horizontally (i.e. just under the skin with the needle at an angle of about 15 degrees), usually pointing backwards. These local points should always be used at some time during the course of treatment, especially if the headache is very chronic and always appearing in that particular area (Fig. 1.19). • G.B.-8 Shuaigu is an effective local point for headaches around the ear area and the upper part of the lateral side of the neck. It is needled horizontally backwards. • G.B.-9 Tianchong is a very important local point for headaches on the sides of the head. In addition, it also has a general effect in calming the Mind and Ethereal Soul and subduing Liver-Yang. This point would be chosen when the person is very tense and is troubled by long-standing emotional problems. • G.B.-13 Benshen is used when the headache is on one side of the forehead, usually around G.B.-14. Besides subduing Liver-Yang, G.B.-13 has a powerful effect in calming the Mind and Ethereal Soul and helping sleep. The difference between G.B.-9 and G.B.-13 is that the former is used for emotional problems deriving from feelings of
G.B.-4 G.B.-5 G.B.-9
G.B.-8
G.B.-6
Figure 1.19 Local Gall Bladder points on the head.
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•
•
•
•
•
The Practice of Chinese Medicine
resentment and frustration, while the latter is better for calming the Mind when the person is extremely tense and cannot sleep. G.B.-14 Yangbai is simply used when the headache is situated around this point. Some headaches from Liver-Yang rising are situated on the forehead on one side around this point, and it feels like a nail being driven in. G.B.-21 Jianjing is used as an adjacent point when the top of the shoulders are very tense and stiff, as so often happens in those who suffer from chronic headaches. The repeated use of this point is very good for relaxing the neck muscles. BL-2 Zanzhu is used when the headache occurs around the eyes, or on the forehead extending down to the eyes. Yuyao, an extra point in the middle of the eyebrow, can be used when the headache occurs around or behind the eyes, especially when Liver-Yang rising stems from Liver-Blood deficiency. G.B.-1 Tongziliao is used when the headache occurs around the temples and outer corners of the eyes.
Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction
Explanation The main difference between this prescription and the previous one is that the latter nourishes the Yin more and is therefore suitable when there is a pronounced deficiency of Liver- and Kidney-Yin. Note that Dai Zhe Shi is not suitable for long-term use and is contraindicated in pregnancy. It could be eliminated from this prescription or replaced with Zhen Zhu Mu Concha Margatiriferae usta, which is a sinking substance that also subdues Liver-Yang.
Prescription LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction
Explanation This formula subdues Liver-Yang, nourishes Yin and resolves Phlegm. Its Yin-nourishing effect is mild.
Ancient formulae
Modifications
• General formula for headaches: Du-20 Baihui, Du-23 Shanxing, Du-16 Fengfu, G.B.-20 Fengchi, BL-2 Sizhukong, S.I.-8 Xiaohai, L.I.-5 Yangxi, S.I.-3 Houxi, L.I.-4 Hegu, S.I.-4 Wangu, P-9 Zhongchong, T.B.-3 Zhongzhu, BL-60 Kunlun, G.B.-34 Yanglingquan (Great Compendium of Acupuncture).7 • For headache from Liver-Yang rising: Du-20 Baihui, Du-21 Qianting, Du-24 Shenting, Du-23 Shangxing, T.B.-23 Sizhukong, G.B.-20 Fengchi, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei (Great Compendium of Acupuncture).8 • For headache on vertex: Du-23 Shangxing, Du-20 Baihui, L.I.-4 Hegu.9
• If Liver-Yang rising stems from Liver-Blood deficiency, Si Wu Tang Four Substances Decoction could be added to any of the above prescriptions. • If it stems from Liver-Yin deficiency, Yi Guan Jian One Linking Decoction could be added. • If it stems from Kidney-Yin deficiency, Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill or Zuo Gui Wan Restoring the Left [Kidney] Pill could be added.
Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction
Explanation This prescription is very widely used for headaches from Liver-Yang rising. It subdues Liver-Yang and tonifies the Liver and Kidneys.
Herbs • Tian Ma Rhizoma Gastrodiae is the herb for LiverYang headache. It subdues Liver-Yang and LiverWind and specifically treats headaches. • Gou Teng Ramulus cum Uncis Uncariae also subdues Liver-Yang and Liver-Wind and treats headaches. In addition, and in contrast to Tian Ma, it is cool and clears Liver-Heat. • Bai Ji Li Fructus Tribuli subdues Liver-Yang and Liver-Wind and is specific for headaches, especially if situated around the eyes. It is warm, bitter and pungent and therefore to be used with caution in Yin deficiency. • Ju Hua Flos Chrysanthemi subdues Liver-Yang and is one of the most frequently used herbs for this
Headaches
•
•
•
•
•
•
•
type of headache, especially if located around the eyes. It is frequently added to other prescriptions for headaches from other causes simply to direct the prescription to the head. Shi Jue Ming Concha Haliotidis subdues Liver-Yang and Liver-Wind and is specific for headaches. It is also cold and it therefore clears Liver-Fire. Ling Yang Jiao Cornu Saigae tataricae subdues LiverWind and Liver-Yang and can be used for chronic headaches. Bai Shao Radix Paeoniae alba harmonizes the Liver and is a very important herb for pain from many different Liver disharmonies. It not only promotes the smooth flow of Liver-Qi, but also subdues LiverYang and hence it can be used for headaches. It generally soothes and harmonizes (as it also nourishes Blood and Yin) and therefore stops pain, especially in combination with Gan Cao. Gan Cao Radix Glycyrrhizae uralensis, besides its other functions, can be used for chronic headaches from Liver-Yang because it is sweet in nature. The sweet flavour harmonizes and pacifies the Liver and therefore contributes to stopping pain, especially in combination with Bai Shao. The Simple Questions in Chapter 22 says: “For pain of Liver origin, [herbs with] sweet taste should be used to pacify the Liver.”10 Long Gu Mastodi Ossis fossilia sinks Liver-Yang, calms the Mind and settles the Ethereal Soul. It also nourishes Yin. Mu Li Concha Ostreae sinks Liver-Yang, calms the Mind, settles the Ethereal Soul and is suitable to treat Liver-Yang headaches. Like Long Gu, it also nourishes Yin. Suan Zao Ren Semen Ziziphi spinosae is an important addition to prescriptions for headaches from Liver-Yang. It subdues Liver-Yang and is particularly indicated for Liver-Yang headaches, as it enters the Liver and Gall Bladder channel. It also allays the irritability typical of Liver-Yang rising and is excellent for calming the Mind and settling the Ethereal Soul. Furthermore, if a person suffering from chronic headaches does not sleep well, this will definitely hinder the treatment. This herb is therefore important as it promotes sleep.
Three Treasures remedy Bend Bamboo Bend Bamboo subdues Liver-Yang and nourishes Liver-Blood. It was formulated specifically
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to treat this type of chronic headache, especially in women.
SUMMARY LIVER-YANG RISING General prescription: LIV-3 Taichong, LIV-8 Ququan, SP-6 Sanyinjiao, T.B.-5 Waiguan, G.B.-20 Fengchi, Taiyang extra point. In case of Liver and Kidney Yin deficiency, add KI-3 Taixi. Reducing method on LIV-3, T.B.-5 and G.B.-20, reinforcing method on LIV-8, SP-6 and KI-3. Even method on Taiyang. If the condition is very chronic, even method can be applied to the points that are normally reduced. Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction Prescription LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction Three Treasures remedy Bend Bamboo
Case history A 32-year-old woman had been suffering from migraine for the past 8 years. The headaches occurred on the top of the head and behind the eyes. They started with a dull pain and increased in intensity to a severe character, accompanied by nausea, vomiting and diarrhoea. They were better lying down. By the time she sought treatment, they occurred almost every day. Her tongue was Pale and Thin, and her pulse was Weak on the right side and slightly Wiry on the left. Diagnosis Liver-Yang rising stemming from LiverBlood deficiency. The Liver-Blood deficiency is apparent
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The Practice of Chinese Medicine
from the Pale and Thin tongue and Weak pulse. The dullness of some of the headaches and the fact that they are improved by lying down indicates that they are due to a deficiency, in this case of LiverBlood. The location of the headaches on top of the head also indicates Liver-Blood deficiency. Liver-Yang rising accounts for the more severe headaches and the vomiting and diarrhoea, due to Liver-Qi invading Stomach and Spleen, preventing Stomach-Qi from descending (vomiting) and Spleen-Qi from ascending (diarrhoea). Treatment principle Nourish Liver-Blood and subdue Liver-Yang. In this case, although the severe headaches are due to Liver-Yang rising, the pattern is still primarily one of deficiency, as evidenced by the tongue. For this reason, the treatment was aimed primarily at nourishing Liver-Blood. Acupuncture Points The main points used were P-6 Neiguan, T.B.-4 Yangchi, ST-36 Zusanli, LIV-8 Ququan, SP-6 Sanyinjiao and LIV-3 Taichong. The first two points were used with even method, LIV-3 was reduced and all the others were reinforced. Warming needle was applied to ST-36. Explanation • P-6 was used to regulate Liver-Blood, calm the Mind and settle the Ethereal Soul. • T.B.-4 was used in conjunction with Neiguan P-6 as a combination of Connecting and Source point. This combination strengthens the effect of P-6, while it also regulates the Lesser Yang channels. In addition, Yangchi T.B.-4 has a general tonifying effect. • ST-36 and SP-6 were used to nourish Blood. • LIV-8 was used to nourish Liver-Blood. • LIV-3 was used to subdue Liver-Yang. Herbal therapy Prescription The prescription used was a variation of Si Wu Tang Four Substances Decoction to nourish Liver-Blood. This prescription was chosen in preference to one of those to subdue Liver-Yang, because the condition was deemed to be primarily one of deficiency (of Liver-Blood). Herbs were added to subdue Liver-Yang. The prescription used was:
• • • • • • • •
Dang Gui Radix Angelicae sinensis 9 g Bai Shao Radix Paeoniae alba 6 g Chuan Xiong Rhizoma Chuanxiong 6 g Shu Di Huang Radix Rehmanniae preparata 6 g Shi Jue Ming Concha Haliotidis 9 g Gou Teng Ramulus cum Uncis Uncariae 6 g Man Jing Zi Fructus Viticis 4 g Ju Hua Flos Chrysanthemi 3 g
Explanation • The first four herbs are the Si Wu Tang Four Substances Decoction to nourish Liver-Blood. • Shi Jue Ming, Ju Hua and Gou Teng were added to subdue Liver-Yang. • Man Jing Zi was added to treat the headaches. This patient had a remarkable improvement after only one treatment, and her headache more or less went after three acupuncture treatments and three courses of 10 decoctions each.
Case history A 35-year-old woman had been suffering from migraine since the age of 14. The headaches got much worse when she reached 16, then got slightly better. They had been worse for the previous 6 years (i.e. since the age of about 28). The headaches occurred once a week and were therefore not related to her menstrual cycle. They were throbbing in character and were accompanied by dizziness, vision disturbance and floaters. The headaches on the right side of the head were of a different character from the ones on the left. Those on the right side were more intense, sharper, shorter and made her vomit. The ache on the left side was duller, longer, lingering and caused only nausea. In addition to these two types of headache, her head also felt heavy and muzzy as if filled with cotton wool. Her periods were normal, and she did not complain of anything else apart from insomnia. Her tongue was Red on the sides, Swollen and had a sticky coating. Her pulse was Wiry-Slippery. Diagnosis This case history is an interesting illustration of several principles of Chinese medicine. First, it is a good illustration of the life cycles (7 years for women and 8 for men). In fact, her headaches started
Headaches
when she was 14, got better when she was 21 and worse when she was 28. Interestingly, she sought treatment when she reached 35. The headache occurring on her right side is clearly from Liver-Yang rising: it is throbbing in character, involves visual disturbance and vomiting, and is intense. Although she had no symptoms of it apart from insomnia, I deduced that Liver-Yang rising stemmed from Blood deficiency. The headache on the left side was typical of Phlegm: dull, lingering, with nausea. This was confirmed also by the general heavy and muzzy feeling of the head and the Slippery pulse. This contrast between the headache on the right and the left is also a good illustration of the general principle of Chinese medicine that headaches on the right reflect a more Full condition. Indeed, this case history is a very good example of chronic headaches from the combination of LiverYang rising with Phlegm, which is very common in practice. Finally, when a condition varies clearly with the life cycles, I often attribute that to a Kidney deficiency, as I think it was the case in this patient. Treatment principle I adopted the treatment principle of subduing Liver-Yang and resolving Phlegm primarily. I did not concentrate on nourishing Blood or tonifying the Kidneys. However, this patient had been referred to me by a colleague, and I asked her to nourish Blood and tonify the Kidneys with acupuncture. I prescribed a variation of Ban Xia Bai Zhu Tian Ma Tang Pinellia-Atractylodes-Gastrodia Decoction (replacing Tian Ma with Gou Teng). Herbal therapy Prescription • Ban Xia Rhizoma Pinelliae preparatum 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6g • Gou Teng Ramulus cum Uncis Uncariae 9 g • Fu Ling Poria 6 g • Ju Hua Flos Chrysanthemi 6 g • Bai Ji Li Fructus Tribuli 6 g • Qiang Huo Rhizoma seu Radix Notopterygii 3 g • Man Jing Zi Fructus Viticis 4.5 g • Tu Si Zi Semen Cuscutae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Yuan Zhi Radix Polygalae 6 g
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• Shi Chang Pu Rhizoma Acori tatarinowii 6 g • Suan Zao Ren Semen Ziziphi spinosae 6 g Explanation • Ban Xia, Bai Zhu and Fu Ling resolve Phlegm. • Gou Teng, Ju Hua, Bai Ji Li, Qiang Huo and Man Jing Zi subdue Liver-Yang. • Tu Si Zi tonifies the Kidneys. • Dang Gui nourishes Blood. • Yuan Zhi and Suan Zao Ren calm the Mind and promote sleep. • Shi Chang Pu opens the Mind’s orifices which helps to eliminate Phlegm from the head. This patient has been treated for about 6 months at the time of writing with variations of the above formula. She is improving both in the frequency and the intensity of the headaches.
Case history A 31-year-old woman had been suffering from headaches from the age of 14. The headaches were better during a pregnancy and worse after childbirth. The headaches occurred more often on the left side and were generally dull but occasionally sharp. She said that she felt like “a pressure in the head”, “like the head wanted to explode” and a “muzzy pressure”. Her tongue was Swollen and had a sticky coating. Her pulse was Slippery and slightly Wiry on the left. Diagnosis This case history is a very good illustration of the fact that, in my opinion, pregnancy is not automatically a cause of disease (as many Chinese books say); far from it; frequently a woman’s condition improves during pregnancy. In this case, her headaches disappeared during pregnancy and returned after childbirth. When this happens, I attribute that to a Kidney deficiency (which improves during pregnancy and is aggravated after childbirth). Her headaches are clearly due to Phlegm (muzziness, dullness, Slippery pulse, Swollen tongue) and Liver-Yang rising (sharp, pressure in head, Wiry pulse). Herbal therapy Prescription I used a variation of Ban Xia Bai Zhu Tian Ma Tang Pinellia-Atractylodes-Gastrodia Decoction:
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• • • • • • • • • • • •
The Practice of Chinese Medicine
Ban Xia Rhizoma Pinelliae preparatum 6 g Bai Zhu Rhizoma Atractylodis macrocephalae 6 g Gou Teng Ramulus cum Uncis Uncariae 6 g Gua Lou Fructus Trichosanthis 6 g Fu Ling Poria 9 g Chen Pi Pericarpium Citri reticulatae 3 g Shi Chang Pu Rhizoma Acori tatarinowii 6 g Bai Zhi Radix Angelicae dahuricae 3 g Tu Si Zi Semen Cuscutae 6 g Gou Qi Zi Fructus Lycii chinensis 6 g Ju Hua Flos Chrysanthemi 6 g Man Jing Zi Fructus Viticis 4.5 g
Explanation • Ban Xia, Bai Zhu, Gua Lou, Fu Ling and Chen Pi resolve Phlegm. • Shi Chang Pu and Bai Zhu open the Mind’s orifices, which helps to resolve Phlegm from the head. • Tu Si Zi and Gou Qi Zi tonify the Kidneys. • Gou Teng, Ju Hua and Man Jing Zi subdue LiverYang.
Liver-Fire
Acupuncture General prescription: LIV-2 Xingjian, SP-6 Sanyinjiao, T.B.-5 Waiguan, G.B.-38 Yangfu, G.B.-20 Fengchi, Taiyang extra point. Distal points with reducing method, local points with even method.
Explanation • LIV-2 is the main distal point to clear Liver-Fire. Being the Spring point, it clears Heat. • SP-6 is used to nourish Yin, to prevent injury of Yin from Liver-Fire. • T.B.-5 is used as a distal point affecting the Lesser Yang channels. See the explanation given for this point under Liver-Yang rising. • G.B.-38 clears Liver- and Gall Bladder-Fire and treats unilateral headaches, especially if situated around an eye. It is especially good for very chronic migraine. • G.B.-20 expels Wind from the head and subdues Liver-Fire. See the explanation given under LiverYang rising. • Taiyang: see the explanation given under Liver-Yang rising.
Liver-Fire differs from Liver-Yang in so far as it is characterized by the presence of an actual pathogenic factor, i.e. Fire. Liver-Yang is characterized by an imbalance between Yin and Yang, without any actual pathogenic factor. Many of the symptoms and signs of Liver-Yang rising are seen in Liver-Fire too. These are dizziness, tinnitus, deafness, irritability, headache, a dry throat, insomnia and a Wiry pulse. In addition to these, Liver-Fire is characterized by thirst, a bitter taste, scanty-dark urine, constipation with dry stools, red eyes and a Red tongue with yellow coating. Liver-Fire is a purely Excess pattern, while Liver-Yang rising is a combined Excess-Deficiency pattern. The headache from Liver-Fire is similar in nature to that from Liver-Yang, being throbbing, distending, pulsating or bursting. It is, however, even more intense, tends to be more fixed in one place, and is more frequently accompanied by nausea or vomiting. This pattern is not a frequent cause of chronic headaches, and it is more common either in the elderly or in children.
Other points
Treatment principle
This formula is specific to drain Liver-Fire. Please note that it contains Mu Tong, which should be omitted because its use is illegal.
Pacify the Liver, drain Fire, subdue rebellious Liver-Qi, calm the Mind.
• G.B.-43 Xiaxi: being the Spring point, it clears Gall Bladder-Heat and is suitable if the headache is located around or behind one eye. • G.B.-44 Qiaoyin clears Gall Bladder-Heat and is suitable if the headache is located on the side of the head. • L.I.-11 Quchi is used if there are pronounced signs of Heat, such as thirst, a bitter taste, a feeling of heat, a Deep-Red tongue body with yellow coating and a Rapid pulse. • All the local points mentioned under Liver-Yang rising are equally applicable in the treatment of Liver-Fire headaches.
Herbal therapy Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction
Explanation
Headaches
Herbs • Long Dan Cao Radix Gentianae is the main herb to clear Liver-Fire. It is especially suited to the treatment of headaches, as it acts on the area around the ears and eyes. • Xia Ku Cao Spica Prunellae clears Liver-Fire and affects the head. • Jue Ming Zi Semen Cassiae clears Liver-Fire and affects the eyes. It is therefore suitable for Liver-Fire headaches around one eye.
Three Treasures remedy Drain Fire Drain Fire is a variation of Long Dan Xie Gan Tang and it drains Liver-Fire.
SUMMARY LIVER-FIRE General prescription: LIV-2 Xingjian, SP-6 Sanyinjiao, T.B.-5 Waiguan, G.B.-38 Yangfu, G.B.20 Fengchi, Taiyang extra point. Distal points with reducing method, local points with even method. Herbal therapy Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction Three Treasures remedy Drain Fire
Case history A 33-year-old woman had been suffering from chronic migraine for several years. The headaches were frequent and intense and occurred over the right eye. They were throbbing in character and aggravated by lying down. They were accompanied by nausea, a feeling of heat, thirst and a bitter taste. The headaches improved during pregnancy and worsened after childbirth. The periods were regular and normal, but she experienced premenstrual tension manifesting with irritability, mood swings and weeping. She had also been suffering from alopecia at 7, 14 and 21 years of age when the hair suddenly fell out in clumps and then regrew each time. In the past, she had suffered from severe depression.
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Her pulse was Wiry and her tongue was slightly Red, dry, rather peeled in the centre, with cracks in the central area. Diagnosis The present condition is one of Liver-Fire rising causing the migraine. This is evidenced by the Red and dry tongue, Wiry pulse, and the feeling of heat, thirst and bitter taste. Had the tongue not been dry and Red and had there been no thirst and bitter taste, the diagnosis would have been Liver-Yang rising. In this case, the Liver-Fire was beginning to injure the Yin of the Stomach, as evidenced by the centre of the tongue being slightly peeled and cracked. She must have been suffering from Liver-Qi stagnation as well preceding the development of LiverFire, as shown by the previous period of depression and premenstrual tension. The alopecia was due to Liver-Wind (which develops from Liver-Fire). When the hair falls out suddenly and in clumps, it indicates Liver-Wind. It is interesting that the alopecia occurred regularly at 7-year intervals (7, 14 and 21), coinciding exactly with a girl’s development cycles described in the first chapter of the Simple Questions. The fact that the migraine improved during pregnancy and worsened after childbirth indicates a Kidney deficiency, but this is the only sign of it in this case. Treatment principle Clear Liver-Fire, subdue LiverWind, nourish Stomach- and Kidney-Yin, calm the Mind and settle the Ethereal Soul. Treatment This patient was treated with acupuncture only and the main points used were T.B.-5 Waiguan, P-6 Neiguan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, LIV-2 Xingjian. Other points used at other times included Ren-12 Zhongwan, LU-7 Lieque and KI-6 Zhaohai in combination, G.B.-43 Xiaxi, KI-9 Zhubin, G.B.-20 Fengchi, Yuyao and G.B.-1 Tongziliao. Explanation • T.B.-5 was used on the right side as a distal point to affect the Lesser Yang channels where the headaches manifested. • P-6 was used on the left side (to balance T.B.-5) to regulate the Liver (by virtue of the connection between Pericardium and Liver within the Terminal Yin) and to calm the Mind and settle the Ethereal
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•
•
• • •
• • • • •
The Practice of Chinese Medicine
Soul. The combination of these two points for chronic headaches on the Lesser Yang channels from either Liver-Yang or Liver-Fire rising is very effective in treating the headache area, regulating the Liver and calming the Mind. In addition, T.B.-5 will regulate the Gall Bladder and P-6 will regulate the Liver. Because the Triple Burner pertains to the Lesser Yang, which is the “hinge” of the Yang channels, and the Pericardium pertains to the Terminal Yin, which is the “hinge” of the Yin channels, these two points will also regulate Yin and Yang, Defensive and Nutritive Qi, the Exterior and Interior, and Yin- and Yang-Linking Vessels. ST-36 and SP-6 were used to tonify Stomach-Yin. SP-6, in addition, will also regulate the Liver and calm the Mind. KI-3 was used to nourish the Kidneys and LiverYin. Although in this case it is Liver-Fire that is injuring Yin (and not the other way round), it is still important to nourish the Kidneys because Liver and Kidneys have a “common source”, and tonifying the Kidney points will help to regulate the Liver. LIV-2 was used with reducing method to clear Liver-Fire. Ren-12 was used to nourish Stomach-Yin. LU-7 and KI-6 in combination open the Directing Vessel. This was done to nourish the Kidneys and regulate the Uterus. G.B.-43 was used with reducing method to clear the Gall Bladder channel, where the headaches occurred. KI-9 was used to nourish the Kidneys and calm the Mind. This point has a powerful calming action. G.B.-20 was used as an adjacent point to subdue Liver-Fire and Liver-Wind. Yuyao is the extra point in the middle of the eyebrow and was used as a local point. G.B.-1 was also used as a local point to clear the Gall Bladder channel.
Liver-Wind The headache from Liver-Wind is pulling in character and affects the whole head rather than the sides. It is accompanied by severe giddiness. Other possible manifestations include a slight shaking of the head, numbness, or tremor of a limb. The pulse and tongue will vary according to whether the Liver-Wind derives from Liver-Fire, from LiverBlood deficiency or from Liver-Yin deficiency.
This is not a common pattern in chronic headaches, and it occurs only in the elderly.
Treatment principle Pacify the Liver, extinguish Wind.
Acupuncture General prescription: LIV-3 Taichong, SP-6 Sanyinjiao, G.B.-20 Fengchi, Du-16 Fengfu, Du-20 Baihui. Reducing method, except on SP-6, which should be reinforced.
Explanation • LIV-3 subdues Liver-Wind. • SP-6 is tonified to nourish Yin and Blood, which is always necessary in order to subdue internal Wind. • G.B.-20 subdues Wind (both internal and external). • Du-16 and Du-20 subdue internal Wind and relieve headache.
Other points • S.I.-3 Houxi and BL-62 Shenmai in combination open the Governing Vessel and subdue internal Wind agitating within it and causing headaches. In men, these two points can be used on their own, while in women they are best combined with the points to open the Directing Vessel, i.e. LU-7 Lieque and KI-6 Zhaohai. Any of the local points mentioned for the Liver-Yang type of headache can be used for the Liver-Wind type too.
Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction
Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction Both these prescriptions have been discussed under Liver-Yang rising.
Herbs • Bai Ji Li Fructus Tribuli extinguishes internal Wind and treats headaches, especially around the eyes. • Di Long Pheretima subdues internal Wind and is used for chronic headaches of this type, especially in old people.
Headaches
• Quan Xie Scorpio is used for severe and chronic headaches from internal Wind.
SUMMARY LIVER-WIND General prescription: LIV-3 Taichong, SP-6 Sanyinjiao, G.B.-20 Fengchi, Du-16 Fengfu, Du-20 Baihui. Reducing method, except on SP-6, which should be reinforced. Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction
Liver-Qi stagnation This type of headache usually occurs on the forehead or temples. It is frequently associated with a Stomach disharmony, such as retention of food in the Stomach. The type of ache resembles that from Stomach deficiency, but it is more intense. It is not, however, throbbing like that from Liver-Yang rising. Another characteristic of it is that it moves from one side to the other. The headache from Liver-Qi stagnation is typically caused by anxiety and stress and is a common type of headache in young and middle-aged patients. Other manifestations include hypochondrial pain or distension, nervous tension, poor digestion, belching, flatulence, abdominal distension, small-bitty stools, sighing and a Wiry pulse.
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Explanation • LIV-3 pacifies the Liver and eliminates stagnation. It is chosen out of all other Liver-channel points because it is the best point to affect the head. • G.B.-34 relieves stagnation of Liver-Qi. In combination with Du-24, it eliminates stagnation of Liver-Qi in the head. • L.I.-4 is chosen because it will combine with LIV-3 to eliminate stagnation of Liver-Qi in the head. It also calms the Mind, which is important because stagnation of Liver-Qi is normally caused by emotional problems. • ST-36 is used because the headache is caused by the influence of Liver-Qi stagnation on the Stomach channel in the head. • Du-24 and Taiyang in combination with G.B.-34 relieve stagnation of Liver-Qi in the head. Additionally Du-24 also calms the Mind.
Other points • LIV-14 Qimen can be added to help in eliminating stagnation of Liver-Qi. • Yintang is an extra point that can be used as a local point for headaches on the forehead. It also calms the Mind and promotes sleep.
Herbal therapy Prescription XIAO YAO SAN Free and Easy Wanderer Powder
Explanation This formula pacifies the Liver, moves Qi and eliminates stagnation. In order to treat headaches from Liver-Qi stagnation, it should be modified with the addition of herbs to subdue Liver-Yang, such as Gou Teng Ramulus cum cis Uncariae and Ju Hua Flos Chrysanthemi.
Treatment principle
Herbs
Pacify the Liver, eliminate stagnation, calm the Mind and settle the Ethereal Soul.
• Mu Xiang Radix Aucklandiae moves Qi in the Stomach, Spleen, Intestines and Gall Bladder. Because it enters the Gall Bladder, it can relieve headaches from Liver-Qi stagnation. • Ju Hua Flos Chrysanthemi subdues Liver-Yang and can be added as a symptomatic herb to relieve the headache. • Sang Ye Folium Mori has the same function as Ju Hua.
Acupuncture General prescription: LIV-3 Taichong, G.B.-34 Yanglingquan, L.I.-4 Hegu, ST-36 Zusanli, Du-24 Shenting, Taiyang. LIV-3, G.B.-34 and L.I.-4 with reducing method. ST-36 with reinforcing method and the local points with even method.
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The Practice of Chinese Medicine
• Zhi Shi Fructus Aurantii immaturus moves Qi and makes Qi descend. For this reason, it is a suitable addition to treat headaches from Liver-Qi stagnation. • Yan Hu Suo Rhizoma Corydalis moves Qi and Blood of Stomach and Liver and is particularly good for stopping pain. • Chen Xiang Lignum Aquilariae resinatum moves Qi and has a strong effect in subduing rebellious Qi. For this reason, it is suitable to treat headaches.
Women’s Treasure remedy Freeing the Moon Freeing the Moon pacifies the Liver, moves Qi, eliminates stagnation, calms the Mind and nourishes Liver-Blood. It is a variation of Xiao Yao San. Although it is in the Women’s Treasure range, it can be prescribed for men.
Acupuncture General prescription: LIV-3 Taichong, Du-20 Baihui. Reducing method on LIV-3 followed by application of moxa on the needle. Even method on Du-20.
Explanation • LIV-3 pacifies the Liver and subdues rebellious Liver-Qi, and is an important distal point for headaches from Liver disharmonies. • Du-20 is needled as a local point to disperse the stagnation of Liver-Qi in the vertex.
Herbal therapy Prescription WU ZHU YU TANG Evodia Decoction
Explanation
SUMMARY LIVER-QI STAGNATION
This formula is specific to expel Cold from the Liver channel.
General prescription: LIV-3 Taichong, G.B.-34 Yanglingquan, L.I.-4 Hegu, ST-36 Zusanli, Du-24 Shenting, Taiyang. LIV-3, G.B.-34 and L.I.-4 with reducing method. ST-36 with reinforcing method and the local points with even method.
Prescription
Herbal therapy Prescription XIAO YAO SAN Free and Easy Wanderer Powder
This formula subdues Yang, expels Cold and enters the Liver channel.
Women’s Treasure remedy Freeing the Moon
Stagnation of Cold in the Liver channel This is quite a rare type of headache. Caused by Cold in the Liver channel rebelling upwards to reach the head, it is called “Terminal-Yin headache”. The ache is intense and is experienced at the top of the head. It is associated with a feeling of cold, vomiting, cold limbs and a Wiry pulse. This pattern is a rare cause of headaches.
Treatment principle Pacify and warm the Liver, expel Cold, subdue rebellious Qi.
CHEN XIANG JIANG QI SAN Aquilaria Subduing Qi Powder
Explanation
Herbs • Chuan Xiong Rhizoma Chuanxiong enters the Liver and treats headaches. • Dang Gui Radix Angelicae sinensis enters the Liver channel. • Rou Gui Cortex Cinnamomi is very warm and expels Cold. • Gui Zhi Ramulus Cinnamomi cassiae is warming and enters the channels and blood vessels.
SUMMARY STAGNATION OF COLD IN THE LIVER CHANNEL General prescription: LIV-3 Taichong, Du-20 Baihui. Reducing method on LIV-3 followed by application of moxa on the needle. Even method on Du-20.
Headaches
Herbal therapy Prescription WU ZHU YU TANG Evodia Decoction Prescription CHEN XIANG JIANG QI SAN Aquilaria Subduing Qi Powder
Case history A 38-year-old man had been suffering from migraine headaches for the past 5 years. The headaches occurred over the whole head and were dull but intense in character. They were better lying down, worse from stress and worse from exposure to light. They were accompanied by nausea, vomiting without bringing up much food, and a feeling of cold. He also experienced some hypochondrial pain extending to the back, elicited by intake of fatty foods. He was also prone to belching and constipation. His tongue was of a normal colour and was Swollen with a dirty coating. His pulse was Wiry and Slow. Diagnosis The headaches were clearly due to stagnation of Cold in the Liver channel, as evidenced by the feeling of cold, the location of the headache, the dry vomiting and the Wiry-Slow pulse. The hypochondrial pain, belching and constipation were due to stagnation of Liver-Qi. In addition, there was also Spleen-Qi deficiency with accumulation of Phlegm, as indicated by the Swollen tongue and dirty coating. Treatment principle In this case, it is necessary to move Liver-Qi and eliminate Cold. Acupuncture Points The main points used were LU-7 Lieque, ST-40 Fenglong, G.B.-34 Yanglingquan and LIV-3 Taichong. The first two points were used with even method, and the latter two with reducing method. Moxa was used on LIV-3. In order to reduce the number of needles and create a balanced and dynamic combi-
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nation of points, LU-7 was used on the right side, ST-40 on the left side, G.B.-34 on the right side and LIV-3 on the left. The sides could have been inverted too, but the above was worked out so that by using G.B.-34 on the right side one treated the hypochondrial pain that was on the right side. Explanation • LU-7 was used to facilitate the flow of clear Qi up to the head. • ST-40 was used to tonify the Spleen and eliminate Phlegm. • G.B.-34 was used to move Liver-Qi and eliminate stagnation. • LIV-3 was used to move Liver-Qi and moxa was used on it to expel Cold from the Liver channel. Herbal therapy Prescription The prescription used was a variation of Wu Zhu Yu Tang Evodia Decoction: • • • • • • • •
Wu Zhu Yu Fructus Evodiae 3 g Dang Shen Radix Codonopsis 6 g Sheng Jiang Rhizoma Zingiberis recens 3 slices Gan Cao Radix Glycyrrhizae uralensis 3 g Gui Zhi Ramulus Cinnamomi cassiae 3 g Chen Pi Pericarpium Citri reticulatae 3 g Yin Chen Hao Herba Artemisiae scopariae 3 g Da Zao Fructus Jujubae 3 dates
Explanation • Wu Zhu Yu, Dang Shen, Sheng Jiang and Da Zao are all part of the Wu Zhu Yu Tang. • Gui Zhi was added to help to expel Cold. It also enters the blood vessels and channels and would therefore help the headaches. • Chen Pi was added to help to eliminate Phlegm. • Yin Chen Hao was added as a messenger herb to direct the prescription to the Liver channel. • Gan Cao was added to harmonize the prescription. This man’s headache stopped completely after 3 months.
Dampness Internal Dampness is a very frequent cause of headaches, particularly in damp countries such as the British Isles. Dampness is heavy in nature, so it has a natural tendency to settle in the Lower Burner, but
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The Practice of Chinese Medicine
it can affect the head too. In chronic cases, when Dampness obstructs the Middle Burner, prevents Stomach-Qi from descending and interferes with the normal movement of Qi in the Middle, this long-term stagnation of Dampness in the Middle leads to the obstruction gradually spreading upwards as well and filling the head. Once in the head, Dampness prevents the clear Yang from ascending to brighten the sense orifices and the turbid Yin from descending away from the head. The result is that the sense orifices are clouded by Dampness. This causes a dull headache: the head feels as if it were wrapped in a cloth or stuffed with cotton wool; there is also a sensation of heaviness there, and thinking is difficult. These symptoms are worse in the mornings. The headache may affect the whole head, or it may be on the forehead only. In a few cases, the Dampness may be affecting the Gall Bladder channel, in which case the headaches would occur on the temples or sides of the head. Other symptoms include persistent catarrh, sometimes sinusitis, nausea, lack of appetite, a feeling of fullness of the chest and epigastrium, a thick-sticky tongue coating and a Slippery pulse. If the Dampness is very chronic and the Spleen very deficient, the pulse may be Soggy, i.e. it feels Slippery but weak and soft and it is slightly Floating, especially on the right Middle position. Internal Dampness arises from a deficiency of Spleen-Qi failing to transform and transport fluids, which accumulate into Dampness. It can also derive from retention of external Dampness over a long period of time.
• L.I.-4 can eliminate pathogenic factors from the face and forehead area, and it also regulates the ascending and descending of Qi. • LU-7 is specific for headaches and is used to stimulate the ascending of clear Yang to the head. • Ren-12 and BL-20 are used to tonify the Spleen to eliminate Dampness. • ST-8 is the main local point to eliminate Dampness from the head and is specific for this type of headache.
Treatment principle
Explanation
Resolve Dampness, stimulate the ascending of clear Yang, tonify Stomach and Spleen.
This formula eliminates Dampness from the head and the top part of the body.
Acupuncture
Prescription
General prescription: SP-3 Taibai, L.I.-4 Hegu, LU-7 Lieque, Ren-12 Zhongwan, BL-20 Pishu, ST-8 Touwei. Reducing method on SP-3 and L.I.-4; reinforcing method on LU-7, Ren-12 and BL-20; even method on ST-8.
YIN CHEN WU LING SAN Artemisia scoparia Five “Ling” Powder
Explanation • SP-3 is a general point to eliminate Dampness in any part of the body. Being towards the extremity of the channel, it specifically affects the head.
Other points • Du-20 Baihui is used if the headache is accompanied by a marked cloudiness of the head. It stimulates the ascending of clear Yang to the head. • Du-24 Shenting can be used as a local point to eliminate Dampness from the forehead. • Du-23 Shangxing can be used if the headache is located around the eyes. • Yintang can be used as a local point if the headache is located on the forehead. • SP-6 Sanyinjiao and SP-9 Yinlingquan can be used as distal points to eliminate Dampness. • BL-21 Weishu can be added to strengthen the Stomach and Spleen to eliminate Dampness. It is especially good if the person suffers from chronic tiredness.
Herbal therapy Prescription QIANG HUO SHENG SHI TANG Notopterygium Dispelling Dampness Decoction
Explanation A variation of Wu Ling San Five Ling Powder, this formula is suitable for headaches from Dampness affecting the Gall Bladder rather than the Stomach and Spleen. It is used for more intense headaches on the temples or at the sides of the head rather than the forehead, which the previous formula addresses.
Headaches
It should be noted that there is nothing in these two prescriptions to strengthen the Spleen. For chronic headaches from Dampness, these prescriptions should be integrated with another to tonify the Spleen (e.g. Si Jun Zi Tang Four Gentlemen Decoction). In severe cases, the prescriptions could be used on their own first to eliminate Dampness, and then adapted with the addition of some herbs to tonify the Spleen (such as Bai Zhu Rhizoma Atractylodis macrocephalae).
SUMMARY DAMPNESS General prescription: SP-3 Taibai, L.I.-4 Hegu, LU-7 Lieque, Ren-12 Zhongwan, BL-20 Pishu, ST-8 Touwei. Reducing method on SP-3 and L.I.-4, even method on ST-8, reinforcing method on LU-7, BL-20 and Ren-12. Herbal therapy Prescription QIANG HUO SHENG SHI TANG Notopterygium Dispelling Dampness Decoction Prescription YIN CHEN WU LING SAN Artemisia scoparia Five “Ling” Powder
Case history A 52-year-old woman had been suffering from headaches for the past 3 years. The headaches occurred mostly on the forehead and in the face but also on the top of the head. They started after a fast and were worse in daytime. They were accompanied by a feeling of muzziness of the head. There was no dizziness. She had also been suffering from chronic catarrh and rhinitis for the past 25 years. She had a chronic ache in the lower back and her urination was too frequent. She felt tired. The bowels were constipated, not having a movement every day. When she did have a movement, it was sometimes loose. She felt generally cold. The Pulse was Deep and Weak on the whole, and slightly Slippery on the right side. Her tongue was Pale and Swollen with a sticky-yellow coating. The diagnosis was Spleen- and Kidney-Yang deficiency leading to Dampness obstructing the head. The headaches had all the typical features
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of Dampness: they were dull in character, with a feeling of muzziness of the head, and occurred mostly on the forehead. The absence of dizziness indicates Dampness as opposed to Phlegm. The presence of Dampness is confirmed by the chronic catarrh and rhinitis, the slippery quality of the pulse and the sticky tongue coating. The Kidney-Yang deficiency is indicated by the ache in the lower back, frequent urination, cold feeling and the Deep pulse, while the SpleenYang deficiency is indicated by the tiredness, the cold feeling, the Weak pulse and the Pale tongue. The constipation is due to deficient Kidney-Yang’s being unable to move the stools; this is confirmed by the fact that the stools were not dry and indeed were sometimes loose. It is interesting that the headaches should start after a fast. She had obviously suffered from Dampness for a long time, as evidenced by the chronic catarrh and rhinitis. Being on a fast weakened the Spleen, which became even more unable to transform and transport and therefore led to more Dampness. A person with Spleen deficiency should only fast under very controlled conditions and lead up to the fast by very gradually reducing the quantity of food eaten. Similarly, one should break the fast very gradually. Only if done under these conditions can a fast be beneficial. The treatment was based on both acupuncture and herbal therapy. Treatment principle Tonify Spleen- and KidneyYang and resolve Dampness. Acupuncture Points The main points used were LU-7 Lieque, L.I.-4 Hegu, Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai and KI-7 Fuliu. LU-7, L.I.-4 and SP-3 were needled with even method, while the others were needled with reinforcing method. Moxa was used on ST-36 and KI-7. Other points used included Ren-9 Shuifen, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu, ST-8 Touwei. Explanation • LU-7 and L.I.-4 were used to open the channels of the head and face and remove obstructions. They also stimulate the rising of clear Yang to the head.
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The Practice of Chinese Medicine
• Ren-12, ST-36 and BL-20 were used to tonify the Spleen. • BL-23 and KI-7 were used to tonify the Kidneys. • SP-3, SP-6 and Ren-9 were used to resolve Dampness. • ST-8 was used as a local point. It is the best local point to resolve Dampness in the head.
Phlegm is a common cause of chronic headaches in young and middle-aged patients.
Herbal therapy Prescription The prescription was based on a variation of Qiang Huo Sheng Shi Tang with the addition of:
General prescription: ST-40 Fenglong, L.I.-4 Hegu, LU-7 Lieque, ST-8 Touwei, Du-20 Baihui. Reducing method on ST-40 and L.I.-4, reinforcing method on LU-7, even method on ST-8 and Du-20.
• • • • • •
Explanation
Huo Xiang Herba Pogostemonis 3 g Pei Lan Herba Eupatorii 3 g Chen Pi Pericarpium Citri reticulatae 3 g Bai Zhu Rhizoma Atractylodis macrocephalae 6 g Du Zhong Cortex Eucommiae ulmoidis 6 g Cang Zhu Rhizoma Atractylodis 3 g
Explanation • Huo Xiang and Pei Lan were added as fragrant herbs to resolve Dampness. Being fragrant and light, these herbs also affect the head and face and relieve headache. • Cang Zhu is another fragrant herb to resolve Dampness and it is frequently used for headaches. • Chen Pi was added to help to resolve Dampness and move Qi. Moving Qi is nearly always necessary to help to resolve Dampness. • Bai Zhu was added to tonify the Spleen. • Du Zhong was used to tonify Kidney-Yang. Being slightly pungent, it would also help to relieve the backache. This patient’s headaches were cured after 6 months’ treatment.
Turbid Phlegm Phlegm is similar to Dampness in nature, and it also derives from deficiency of Spleen-Qi. The headache from Phlegm is similar to that from Dampness, i.e. it is dull and is accompanied by a feeling of heaviness and muzziness (fuzziness). However, Phlegm is more obstructive than Dampness and it clouds the sense orifices more. This results in blurred vision and dizziness, which are not present with Dampness. Other manifestations include sputum on the chest, a feeling of oppression of the chest, a Swollen tongue with a sticky coating and a Slippery pulse.
Treatment principle Resolve Phlegm, harmonize the Middle.
Acupuncture
• ST-40 is the main point to resolve Phlegm. • L.I.-4 is used as a distal point to eliminate pathogenic factors from the face and head. It also regulates the ascending and descending of Qi. • LU-7 is used as a distal point to stimulate the ascending of clear Yang to the head. • ST-8 is a local point for headaches from Phlegm (or Dampness). • Du-20 is used to stimulate the ascending of clear Yang to the head.
Other points • ST-36 Zusanli can be added as a distal point to tonify the Spleen and resolve Phlegm. It is important to use it if the person feels very tired. • SP-6 Sanyinjiao eliminates Dampness and helps to resolve Phlegm. • SP-3 Taibai eliminates Dampness and helps to resolve Phlegm. Being at the extremity of the channel, it affects the head. • L.I.-11 Quchi can be used if the Phlegm is associated with Heat. • Du-23 Shangxing can be used as a local point, especially if the eyes are affected. • Yintang can be used as a local point if the headache is on the forehead.
Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction
Explanation Ban Xia resolves Phlegm, makes Qi descend and stops vomiting. Tian Ma extinguishes internal Wind and
Headaches
stops headaches. These two herbs are the emperor herbs, one to resolve Phlegm, the other to subdue Wind. Thus, they treat Wind-Phlegm causing headache and dizziness. Li Dong Yuan in the Discussion on Stomach and Spleen says: “Headaches due to Phlegm cannot be treated without Ban Xia and headaches with dizziness due to Wind cannot be treated without Tian Ma.”11 Even though this prescription is actually for WindPhlegm, it is the prescription of choice because it includes Tian Ma, which is an important herb for headaches.
Herbs • Dan Nan Xing Rhizoma Arisaematis preparatum is a warm herb to resolve Phlegm and subdue internal Wind and is therefore suitable to treat headaches of this type. It is particularly suitable if the headaches move from one side to the other. • Bai Fu Zi Rhizoma Typhonii preparatum is another warm herb to resolve Phlegm and could be added particularly if Phlegm is associated with Cold and is difficult to eliminate. • Jiang Can Bombyx batryticatus subdues Wind and treats headaches. It is particularly useful in cases of very chronic headaches from Wind-Phlegm in old people.
Three Treasures remedy Clear Yang Clear Yang is a variation of Ban Xia Bai Zhu Tian Ma Tang to treat headaches from a combination of Phlegm and Liver-Yang rising.
SUMMARY TURBID PHLEGM General prescription: ST-40 Fenglong, L.I.-4 Hegu, LU-7 Lieque, ST-8 Touwei, Du-20 Baihui. Reducing method on ST-40 and L.I.-4, reinforcing method on LU-7, even method on ST-8 and Du-20. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction Three Treasures remedy Clear Yang
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Case history A man of 48 had been suffering from headaches for 10 years. The headaches occurred around the forehead and were dull in character. They were accompanied by a feeling of cloudiness, heaviness and dizziness. He also suffered from extreme tiredness and a lack of sexual drive. He felt cold easily. His pulse was Deep and Slippery and his tongue was Pale with swollen sides and a very thick-sticky yellow coating. Diagnosis The headaches were clearly caused by Turbid Phlegm obstructing the head orifices and preventing the clear Yang from rising. This caused the typical feeling of cloudiness, heaviness and dizziness. Dizziness, in particular, distinguishes it from Dampness. The Phlegm arose from a background of Spleen-Yang deficiency (Pale tongue with swollen sides, Deep pulse, feeling cold, tiredness and lack of sexual drive). Lack of sexual drive is not always due to Kidney deficiency; in this case, in fact, it was due to Spleen deficiency. Treatment principle In this case, due to the chronic nature of the condition, attention was directed at treating both the Root (Ben) and the Manifestation (Biao) simultaneously. This involved both tonifying the body’s Qi and eliminating the pathogenic factors (in this case Phlegm). This patient was treated with acupuncture only. Acupuncture Points The main points used were Ren-12 Zhongwan, ST-8 Touwei, LU-7 Lieque, L.I.-4 Hegu, ST-36 Zusanli, BL-20 Pishu, ST-40 Fenglong and SP-3 Taibai. ST-8 and ST-40 were needled with even method, while all the other points were needled with reinforcing method. Explanation • Ren-12, ST-36, BL-20 and SP-3 were reinforced to tonify the Spleen. Moxa was used on ST-36 to tonify Spleen-Yang. • LU-7 and L.I.-4 were used to stimulate the rising of clear Yang to the head and open the head orifices. • ST-8 is the main local point for headaches from Phlegm or Dampness. • ST-40 was used with even method to resolve Phlegm.
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Turbid Phlegm-Wind This pattern is similar to the previous one, and it simply corresponds to a combined condition of Phlegm and internal Wind. It is only seen in old people and may indicate the likelihood of Wind-stroke.
Treatment principle Resolve Phlegm, extinguish Wind, pacify the Liver.
Acupuncture General prescription: ST-40 Fenglong, L.I.-4 Hegu, LIV-3 Taichong, S.I.-3 Houxi, BL-62 Shenmai, ST-8 Touwei, Du-20 Baihui, G.B.-20 Fengchi. Reducing method on ST-40, L.I.-4, LIV-3 and G.B.-20, even method on S.I.-3, BL-62, ST-8 and Du-20.
one to subdue Liver-Wind such as Tian Ma Gou Teng Yin Gastrodia-Uncaria Decoction or Zhen Gan Xi Feng Tang Pacifying the Liver and Extinguishing Wind Decoction.
Herbs • Di Long Pheretima subdues Wind and removes obstructions from the channels. It is particularly useful for chronic Wind-Phlegm in old people. All the other herbs mentioned for the Turbid-Phlegm type are also indicated.
Three Treasures remedy Clear Yang Clear Yang is a variation of Ban Xia Bai Zhu Tian Ma Tang to treat headaches from a combination of Phlegm and Liver-Yang rising.
Explanation • ST-40, L.I.-4, ST-8, and Du-20: the use of these points has already been explained under the Phlegm-type headache. • LIV-3 extinguishes Wind and is an important point to relieve this type of headache. In combination with L.I.-4, it extinguishes Wind from the face and head. • S.I.-3 and BL-62 in combination open the Governing Vessel and extinguish Wind. In particular, by opening the Governing Vessel they will also relieve the headache. • G.B.-20 extinguishes Wind and relieves headaches.
SUMMARY
Other points
Three Treasures remedy Clear Yang
• G.B.-39 Xuanzhong extinguishes internal Wind and will relieve headaches of this type along the Gall Bladder channel. • Du-16 Fengfu extinguishes internal Wind and removes obstructions from the Governing Vessel. All the other points mentioned under the Turbid-Phlegm type are applicable to the Wind-Phlegm type too.
Herbal therapy Prescription The same prescription as for the Turbid-Phlegm type is applicable, i.e. Ban Xia Bai Zhu Tian Ma Tang (PinelliaAtractylodes-Gastrodia Decoction). Substances that extinguish internal Wind such as Quan Xie Scorpio and Jiang Can Bombyx batryticatus should be added. Alternatively, this prescription can be integrated with
TURBID PHLEGM-WIND General prescription: ST-40 Fenglong, L.I.-4 Hegu, LIV-3 Taichong, S.I.-3 Houxi, BL-62 Shenmai, ST-8 Touwei, Du-20 Baihui, G.B.-20 Fengchi. Reducing method on ST-40, L.I.-4, LIV-3 and G.B.-20, even method on S.I.-3, BL-62, ST-8 and Du-20. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction
Liver-Yang rising with Phlegm in the head Clinical manifestations Chronic headaches, frequent “background” dull headaches with muzziness of the head punctuated by occasional, severe attack of throbbing headaches, dizziness, vertigo, tinnitus, irritability, propensity to outbursts of anger, headache, a feeling of heaviness and muzziness (fuzziness) of the head as if it were full of cotton wool, blurred vision, difficulty in thinking and concentrating (especially in the morning), a feeling of oppression of the chest, nausea, poor appetite, a sticky taste.
Headaches
Tongue: Swollen with a sticky coating. Pulse: Slippery-Wiry. This is a common combination of patterns causing chronic headaches. As Liver-Yang rises, it carries Phlegm with it, aggravating the feeling of dizziness.
Treatment principle Subdue Liver-Yang, nourish the Kidneys, resolve Phlegm, tonify the Spleen, extinguish Wind if necessary.
Acupuncture Points LIV-3 Taichong, G.B.-20 Fengchi, Du-16 Fengfu, LIV-8 Ququan, KI-3 Taixi, L.I.-4 Hegu, ST-40 Fenglong, Ren-9 Shuifen, SP-9 Yinlingquan, ST-8 Touwei, Ren-12 Zhongwan, BL-20 Pishu. Ren-12, BL-20, LIV-8 and KI-3 with reinforcing method, the others with even method.
Explanation • LIV-3, G.B.-20 and Du-16 subdue Liver-Yang. • LIV-8 and KI-3 nourish the Liver and Kidneys. • L.I.-4 regulates the ascending and descending of Qi to and from the head. • ST-40, Ren-9 and SP-9 resolve Phlegm. • ST-8 resolves Phlegm from the head. • Ren-12 and BL-20 tonify the Spleen to resolve Phlegm.
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SUMMARY LIVER-YANG RISING WITH PHLEGM IN THE HEAD Points LIV-3 Taichong, G.B.-20 Fengchi, Du-16 Fengfu, LIV-8 Ququan, KI-3 Taixi, L.I.-4 Hegu, ST-40 Fenglong, Ren-9 Shuifen, SP-9 Yinlingquan, ST-8 Touwei, Ren-12 Zhongwan, BL-20 Pishu. Ren-12, BL-20, LIV-8 and KI-3 with reinforcing method; the others with even method. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction Three Treasures remedy Clear Yang
Retention of food
Prescription
This type of headache is experienced on the forehead and can be intense. It is obviously related to food intake and it will be aggravated by eating. It is frequently encountered as an acute headache after a dietary indiscretion. Other manifestations include a feeling of fullness of the epigastrium, sour regurgitation, belching, foul breath, a thick-sticky tongue coating and a Slippery pulse. This is not a common pattern seen in chronic headaches. It is more common in children.
BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction
Treatment principle
Explanation
Resolve retention of food, stimulate the descending of Stomach-Qi, promote digestion, harmonize the Middle.
Herbal therapy
This formula subdues Liver-Yang, extinguishes LiverWind and resolves Phlegm.
Modifications
Acupuncture
• In cases of Liver-Wind, add Di Long Pheretima, Quan Xie Scorpio or Jiang Can Bombyx batryticatus.
General prescription: Ren-10 Xiawan, ST-21 Liangmen, P-6 Neiguan, ST-34 Liangqiu, ST-45 Lidui, L.I.-4 Hegu, ST-8 Touwei. Even method on Ren-10, ST-21 and ST-8, reducing method on the others.
Three Treasures remedy
Explanation
Clear Yang Clear Yang is a variation of Ban Xia Bai Zhu Tian Ma Tang to treat headaches from a combination of Phlegm and Liver-Yang rising.
• Ren-10 stimulates the descending of Stomach-Qi and the movement of food downwards from the Stomach.
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• ST-21 resolves stagnant food and stops epigastric pain. • P-6 stimulates the descending of Stomach-Qi. • ST-34 relieves retention of food and stops pain. • ST-45 relieves retention of food. It is also chosen here as, being at the extremity of the channel, it will affect the head. • L.I.-4 is chosen to clear obstruction from the face and head. • ST-8 is chosen as a local point for Stomach-channel problems manifesting on the head.
Other points • ST-44 Neiting can be chosen as a distal point to eliminate obstructions from the Stomach, especially if the retention of food is associated with Heat. Being near the extremity of the channel, it will also affect the head. • SP-4 Gongsun relieves retention of food. • Ren-13 Shangwan is used if there are marked symptoms of ascending Stomach-Qi such as belching, sour regurgitation, nausea or vomiting. • ST-36 Zusanli is used if the retention of food is associated with a deficient condition of the Stomach. • ST-40 Fenglong is used if the retention of food is severe and long-standing and the tongue has a very thick and sticky coating.
Herbal therapy Prescription BAO HE WAN Preserving and Harmonizing Pill
Explanation This formula promotes digestion and resolves retention of food. Shan Zha resolves retention of food from meat and fatty foods. Shen Qu resolves retention of food from alcohol and fermented foods and Lai Fu Zi from cereals.
Prescription XIANG SHA ZHI ZHU WAN Aucklandia-Amomum-Citrus-Atractylodes Pill
Explanation This prescription is used in preference to the previous one if there are pronounced symptoms of rebellious Stomach-Qi such as belching, nausea, or vomiting.
Herbs • Da Huang Radix et Rhizoma Rhei is used if retention of food is accompanied by constipation. • Huo Xiang Herba Pogostemonis can be used to transform Dampness in the Middle. Being light and aromatic, it will help headaches from retention of food. • Cang Zhu Rhizoma Atractylodis is an aromatic herb to transform Dampness and it relieves headaches. • Zi Su Ye Folium Perillae harmonizes the Middle. It is a floating herb and will relieve headaches from retention of food. • Fang Feng Radix Saposhnikoviae expels Wind and Dampness. It is a floating herb and is used for headaches. • Bo He Herba Menthae haplocalycis clears the head, is light and aromatic and would therefore help to relieve this type of headache, especially if retention of food is accompanied by Heat.
SUMMARY RETENTION OF FOOD General prescription: Ren-10 Xiawan, ST-21 Liangmen, P-6 Neiguan, ST-34 Liangqiu, ST-45 Lidui, L.I.-4 Hegu, ST-8 Touwei. Even method on Ren-10, ST-21 and ST-8, reducing method on the others. Herbal therapy Prescription BAO HE WAN Preserving and Harmonizing Pill Prescription XIANG SHA ZHI ZHU WAN Aucklandia-Amomum-Citrus-Atractylodes Pill
Stasis of Blood This type of pattern is seen only in very chronic headaches. Stasis of Blood results from long-standing stagnation of Liver-Qi. Headaches may also often derive from local stasis of Blood in the head, caused by trauma. This may be due to an old fall or accident, often one that the person has forgotten about. If a headache always occurs on the same spot without fail, stasis of Blood from trauma should be suspected.
Headaches
The headache from stasis of Blood is very severe and intense. It is stabbing or boring in character and patients will often describe it as a “nail being driven into the head”. It is fixed in its location. This headache is more common in old people or in women with stasis of Blood associated with deficiency and dryness of Blood. Other manifestations include dark complexion, hypochondrial or abdominal pain and, in women, painful periods with dark-clotted blood. The pulse will be Firm, Wiry or Choppy and the tongue will be Purple. In case of a past accident to the head, the pulse may be very Weak on the Front position of both left and right sides and the tongue may have a purple spot on the tip while the rest of the tongue body is normal in colour. This is due to the fact that the tongue body reflects, apart from the internal organs, areas of the body. Thus the tip of the tongue corresponds to the head and an isolated purple spot there may indicate a past trauma to the head, while a normal colour of the rest of the tongue indicates that there is not a generalized stasis of Blood.
Treatment principle Invigorate Blood, open the orifices.
Acupuncture General prescription: L.I.-11 Quchi, L.I.-4 Hegu, SP-6 Sanyinjiao, LIV-3 Taichong, Ah Shi points. Reducing or even method on all points.
Explanation • L.I.-11, besides cooling Blood, also invigorates Blood and benefits sinews. • L.I.-4 in combination with LIV-3 expels pathogenic factors from the head and invigorates Blood. • SP-6 invigorates Blood. • LIV-3 invigorates Blood and alleviates headaches. • Ah Shi points on the head are an important and essential part of the treatment. The choice of local points is made simply according to the location of the headaches and a clear differentiation of the channel involved.
Other points • T.B.-5 Waiguan invigorates Qi and is especially indicated for headaches on the side of the head. • SP-10 Xuehai is used if there is general stasis of Blood.
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• BL-18 Ganshu is indicated if there are marked symptoms of Liver-Blood stasis. • BL-2 Zanzhu for stasis of Blood in the eye. • Taiyang for stasis of Blood in the temples. • T.B.-18 Qimai for stasis of Blood in the occiput. • Sishencong, extra point, for stasis of Blood on the vertex. It should be emphasized that stasis of Blood does not arise independently but may stem from various conditions, such as Qi stagnation, Blood deficiency, Blood-Heat, internal Cold and Qi deficiency. The treatment should obviously be aimed at treating the condition underlying the stasis of Blood.
Herbal therapy Prescription TONG QIAO HUO XUE TANG Opening the Orifices and Invigorating Blood Decoction
Explanation This formula invigorates Blood specifically in the head. This prescription is specific for headaches from stasis of Blood and is applicable for chronic headaches, especially but not exclusively in old people with a dark complexion. It is also suitable for women with Blood that is deficient, dry and stagnant and for children suffering from Child Nutritional Impairment (Gan disease).
Prescription TAO HONG SI WU TANG Persica-Carthamus Four Substances Decoction
Explanation This formula invigorates Blood in general. To treat headaches, it should be modified with the addition of herbs that reach the head.
Herbs • Chuan Xiong Rhizoma Chuanxiong invigorates Blood and, more specifically, the Qi portion of Blood, and is an important herb for headaches. • Hong Hua Flos Carthami tinctorii invigorates Blood and, being a flower and very light, it has a floating movement and affects the top part of the body. • San Qi Radix Notoginseng invigorates Blood (besides stopping bleeding) and is frequently used for
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chronic headaches, especially in combination with Tian Ma Rhizoma Gastrodiae. • Yan Hu Suo Rhizoma Corydalis invigorates Qi and Blood and is a major herb to stop pain.
Three Treasures remedy Red Stirring Red Stirring is a variation of Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction that invigorates Blood in the Upper Burner. It can be used to treat headaches from Blood stasis.
SUMMARY STASIS OF BLOOD General prescription: L.I.-11 Quchi, L.I.-4 Hegu, SP-6 Sanyinjiao, LIV-3 Taichong, Ah Shi points. Reducing or even method on all points. Herbal therapy Prescription TONG QIAO HUO XUE TANG Opening the Orifices and Invigorating Blood Decoction Prescription TAO HONG SI WU TANG Persica-Carthamus Four Substances Decoction Three Treasures remedy Red Stirring
Case history A 31-year-old woman had been suffering from chronic headaches since her childhood. The headaches occurred on either side of the head (along the Gall Bladder channel) and settling behind either eyeball. The pain was severe and stabbing in nature and was accompanied by vomiting and diarrhoea. Her periods were scanty. Her tongue was Pale and slightly Bluish-Purple, with darkswollen veins underneath it. Her pulse was Deep and Minute. Diagnosis This pattern presents a combination of Liver-Yang rising and stasis of Blood in the head. The headaches occurring along the Gall Bladder channel are a manifestation of Liver-Yang rising. The vomiting and diarrhoea are due to Liver-Qi stagnation invading
Stomach and Spleen, preventing the former from descending (hence vomiting) and the latter from ascending (hence diarrhoea). In this case, Liver-Yang rising derives from deficiency of Blood, as evidenced by the scanty periods, Pale tongue and Minute pulse. In addition, the long-standing headaches led to stasis of Blood in the head, hence the stabbing nature of the pain and the Bluish-Purple tongue with darkdistended veins underneath. Treatment principle In this case, it is possible to treat both the Root (deficiency of Liver-Blood) and the Manifestation (stasis of Blood in the head and rising of Liver-Yang). It is therefore necessary to nourish LiverBlood, invigorate Blood and subdue Liver-Yang. Acupuncture Points The main points used were T.B.-5 Waiguan, P-6 Neiguan, Ren-4 Guanyuan, LIV-8 Ququan, LIV-3 Taichong, SP-6 Sanyinjiao, G.B.-1 Tongziliao and SP10 Xuehai. Ren-4, LIV-8 and SP-6 were needled with reinforcing method to nourish Liver-Blood. The other points were needled with even method to invigorate Blood and subdue Liver-Yang. Explanation • Ren-4, LIV-8 and SP-6 were reinforced to nourish Liver-Blood. • T.B.-5 was chosen as a distal point to affect the Gall Bladder channel on the head and subdue LiverYang. • P-6 was chosen to invigorate Blood in the head. • G.B.-1 was chosen as a local point to invigorate Blood in the head. • LIV-3 subdues Liver-Yang. • SP-10 invigorates Blood. Herbal therapy Prescription The prescription chosen was a variation of Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction mentioned above. The only variations made to this prescription were increasing the dosage of Chuan Xiong Rhizoma Chuanxiong and the addition of Tian Ma Rhizoma Gastrodiae to subdue Liver-Yang.
Headaches
This patient was completely cured of her headaches in 1 year. Acupuncture was administered once a month, and she took the herbal decoction for 6 months, although with occasional breaks during that time.
Stomach-Heat This type of headache occurs on the forehead and can be acute or chronic. If it appears in the course of a febrile disease, it corresponds to the Bright-Yang stage within the Six-Stage patterns of diseases caused by exterior Cold. The Bright-Yang stage is characterized by Heat in the Stomach, which may cause intense headache on the forehead. Other symptoms include profuse sweating, intense thirst, fever and an OverflowingRapid pulse. In chronic cases, this type of headache is due to a long-standing condition of Stomach-Heat. The usual cause is the excessive consumption of hot-energy foods such as meat, spices, fried foods and alcohol. It is intense and is felt across the forehead. The headache may be brought about by eating foods that are too hot or simply by overeating. Other manifestations include thirst with desire to drink cold water, dry stools, possibly epigastric pain, a thick-yellow tongue coating and a Slippery and Overflowing pulse on the right Middle position. This is not a common type of headache.
Treatment principle Clear Heat, clear the Stomach, subdue rebellious Qi.
Acupuncture General prescription: ST-44 Neiting, L.I.-4 Hegu, Yintang extra point. Reducing method on ST-44 and L.I.-4 and even method on Yintang.
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• Du-23 Shangxing can be used as a local point to affect the forehead and eyes. • ST-8 Touwei can be used as a local point for headaches on the forehead.
Herbal therapy Prescription QING WEI SAN Clearing the Stomach Powder
Explanation This formula clears Stomach-Heat.
Herbs • Shi Gao Gypsum fibrosum clears Stomach-Heat at the Qi level. • Zhi Mu Radix Anemarrhenae clears Stomach-Heat and nourishes Yin. • Zhu Ye Folium Phyllostachys nigrae clears StomachHeat, especially when manifesting in the face region. • Lu Gen Rhizoma Phragmitis clears Stomach-Heat and promotes fluids. It is especially indicated if thirst is pronounced. It is light and floating and will therefore affect the head.
SUMMARY STOMACH-HEAT General prescription: ST-44 Neiting, L.I.-4 Hegu, Yintang extra point. Reducing method on ST-44 and L.I.-4 and even method on Yintang. Herbal therapy Prescription QING WEI SAN Clearing the Stomach Powder
Explanation • ST-44 is the main point to clear Stomach-Heat. Also, being towards the lower extremity of the channel, it will affect the other end, i.e. the head. • L.I.-4 clears Heat and affects the head and forehead. • Yintang is used as a local point for headaches on the forehead.
Other points • ST-34 Liangqiu is the Accumulation (Xi) point of the Stomach channel and, as such, it stops pain.
Qi deficiency This headache is due to deficient Qi failing to ascend to the head to brighten the orifices. It can be due to deficiency of Qi of the Stomach, Spleen, Lungs or Heart. It may manifest in the whole head or frequently on the forehead only, especially when it is due to Stomach-Qi deficiency. This headache comes in bouts. Dull in nature, it is alleviated by rest and aggravated by excessive work.
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It is also eased by lying down and is worse in the mornings. Other manifestations include poor appetite, tiredness, loose stools, slight breathlessness and an Empty pulse. In case of Heart-Qi deficiency, there would also be some slight palpitations and breathlessness on exertion. The Simple Questions in Chapter 18 says that in headaches from deficiency of Qi of the Heart or Lungs, the Front position pulse (of both right and left) can feel Short, i.e. not quite reaching the top of the pulse position.12 This is not a common type of chronic headache; usually the one from Blood or Yin deficiency is more common.
Treatment principle Tonify and raise Qi.
Acupuncture General prescription: ST-36 Zusanli, Ren-6 Qihai, SP-6 Sanyinjiao, Du-20 Baihui. All with reinforcing method. Du-20 with direct moxibustion.
Explanation • ST-36 and SP-6 in combination strongly tonify Qi. • Ren-6 tonifies and raises Qi. • Du-20 raises Yang.
Other points • L.I.-4 Hegu, when reinforced in combination with ST-36, can tonify and raise Qi. For this reason, it would be particularly indicated if the headache is on the forehead, because this is the area affected by this point. • BL-7 Tongtian can be used as a local point to raise Qi, especially if there is some deficiency of the Kidneys. • BL-20 Pishu can be used to tonify and raise Qi, because this is a function of Spleen-Qi.
Three Treasures remedy Tonify Qi and Ease the Muscles Tonify Qi and Ease the Muscles tonifies and lifts Qi and it promotes the ascending of clear Yang to the Head. It is therefore suitable to treat headaches from Qi deficiency. It is a variation of Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction.
SUMMARY QI DEFICIENCY General prescription: ST-36 Zusanli, Ren-6 Qihai, SP-6 Sanyinjiao, Du-20 Baihui. All with reinforcing method. Du-20 with direct moxibustion. Herbal therapy Prescription BU ZHONG YI QI TANG Tonifying the Centre and Benefiting Qi Decoction
Blood deficiency This headache is due to deficient Blood failing to reach the head and nourish the brain. It is slightly more severe in nature than the Qi-deficiency headache. It typically affects the top of the head, but it may also affect the forehead and is related to Blood deficiency of the Liver or Heart. It is often worse in the afternoon or evening and is accompanied by poor memory and lack of concentration. In women, it often occurs at the end of the period, as the temporary blood loss aggravates the Blood deficiency. This headache is also better lying down. This type of headache is more common in women.
Treatment principle Nourish Blood, tonify and raise Qi.
Herbal therapy
Acupuncture
Prescription BU ZHONG YI QI TANG Tonifying the Centre and Benefiting Qi Decoction
General prescription: ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, LIV-8 Ququan, Ren-4 Guanyuan, Du-20 Baihui, HE-5 Tongli. Tonifying method on all points.
Explanation
Explanation
This formula tonifies and lifts Qi; as it lifts Qi, it promotes the ascending of clear Yang to the head to brighten the orifices.
• ST-36, SP-6 and BL-20 nourish Blood and tonify Qi. • LIV-8 nourishes Liver-Blood. • Ren-4 nourishes Blood.
Headaches
• Du-20 raises Qi. • HE-5 nourishes Heart-Blood. It is necessary to tonify Heart-Blood, as deficient Heart-Blood not reaching the head is often a feature of this type of headache.
Other points • BL-20 Pishu and BL-18 Ganshu in combination nourish Liver-Blood. • Yuyao is indicated as a local point if the headaches occur behind the eyes.
Herbal therapy Prescription BA ZHEN TANG Eight Precious Decoction
Explanation This formula tonifies Qi and nourishes Blood.
Prescription
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Women’s Treasure remedy Precious Sea Precious Sea tonifies Qi and nourishes Blood; it is a variation of Ba Zhen Tang Eight Precious Decoction.
SUMMARY BLOOD DEFICIENCY General prescription: ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, LIV-8 Ququan, Ren-4 Guanyuan, Du-20 Baihui, HE-5 Tongli. Tonifying method on all points. Herbal therapy Prescription BA ZHEN TANG Eight Precious Decoction Prescription SHI QUAN DA BU TANG Ten Complete Great Tonification Decoction Three Treasures remedy Precious Sea
SHI QUAN DA BU TANG Ten Complete Great Tonification Decoction
Explanation
Kidney deficiency
This formula tonifies Qi and nourishes Blood. It also lifts Qi and therefore promotes the ascending of clear Yang to the head to brighten the orifices and relieve headaches.
This headache is due to deficient Kidney-Essence failing to reach the head and nourish the brain. It may manifest with deficiency of Kidney-Yin or KidneyYang, as the Essence has both a Yin and a Yang aspect. The headache is experienced inside the brain. It does not occur in any specific place and is accompanied by dizziness and a feeling of emptiness of the brain. When the Kidney deficiency affects the Bladder channel, the headache may also occur on the occiput. The headache from Kidney-Yang deficiency is somewhat milder and more similar to that from Qi deficiency, while that from Kidney-Yin deficiency is more severe and feels deeper in the head. In both cases, the headache may occur after sexual activity. Other manifestations depend on whether there is a deficiency of Kidney-Yin or Kidney-Yang. In case of Kidney-Yin deficiency, there will be night sweating, scanty urination, dizziness, tinnitus, soreness of the lower back, slight constipation, a tongue without coating and a Floating-Empty pulse. In case of Kidney-Yang deficiency, there will be a feeling of cold, soreness of the lower back and knees,
Herbs • Sang Ji Sheng Herba Taxilli nourishes Liver-Blood. • Shou Wu Radix Polygoni multiflori preparata nourishes Blood and is particularly indicated in chronic cases of Blood deficiency with manifestations of dryness (e.g. dry skin, dry hair and dry eyes). • Gou Qi Zi Fructus Lycii chinensis nourishes Blood and benefits the eyes. It is therefore particularly indicated if the headaches occur behind the eyes. • Long Yan Rou Arillus Longan nourishes Blood and promotes sleep. It is therefore indicated if the Blood deficiency causes insomnia. • Chuan Xiong Rhizoma Chuanxiong is already included in the above two prescriptions, but its dosage could be increased because it is an important and specific herb for headaches.
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abundant-pale urination, a Pale tongue and a Deep and Weak pulse.
Kidney-Yang Deficiency
Treatment principle Tonify the Kidneys, nourish Marrow.
YOU GUI WAN Restoring the Right [Kidney] Pill
Acupuncture
Explanation
General prescription: KI-3 Taixi, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui, G.B.-19 Naokong. For Kidney-Yin deficiency: Ren-4 Guanyuan. For Kidney-Yang deficiency: BL-23 Shenshu. All points should be reinforced. Moxa can be used on KI-3 unless there are pronounced symptoms of Empty Heat. In case of Kidney-Yang deficiency, moxa must be used on BL-23. Direct moxa can also be used on Du-20.
This formula tonifies and warms Kidney-Yang.
Explanation • KI-3 tonifies both Kidney-Yin and Kidney-Yang and the Original Qi. • ST-36 and SP-6 tonify Qi and Blood, which will help to tonify Yin. SP-6 also tonifies Yin. • Du-20 attracts Qi up towards the head and nourishes Marrow. • G.B.-19 attracts Kidney-Essence up to the brain, fills Marrow, and is a specific local point for headache from Kidney deficiency. Its name means “brain emptiness”. • Ren-4 nourishes Kidney-Yin. • BL-23 tonifies Kidney-Yang.
Other points • BL-60 Kunlun can be used as a distal point to affect the Bladder channel, especially if the headaches are along this channel on the occiput. • BL-10 Tianzhu can be used as an adjacent point if the headaches occur on the Bladder channel on the occiput. • BL-7 Tongtian can be used as a local point. • Du-17 Naohu can be used as an adjacent point to nourish Marrow.
Ancient formula Du-23 Shangxing, G.B.-20 Fengchi, G.B.-19 Naokong, BL-10 Tianzhu, HE-3 Shaohai (Great Compendium of Acupuncture).13
Prescription
Prescription JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill
Explanation This prescription consists of the Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill, which nourishes KidneyYin, with the addition of Fu Zi and Gui Zhi, which strongly tonify and warm Kidney-Yang and tonify the Fire of the Gate of Life.
Three Treasures remedy Strengthen the Root Strengthen the Root tonifies Kidney-Yang. It is a variation of You Gui Wan and it is less warming than the original prescription.
Kidney-Yin Deficiency Prescription ZUO GUI WAN Restoring the Left [Kidney] Pill
Explanation This formula nourishes Kidney-Yin.
Prescription LIU WEI DI HUANG WAN Six-Ingredient Rehmannia Pill
Explanation This formula nourishes Kidney-Yin.
Prescription QI JU DI HUANG WAN Lycium-Chrysanthemum-Rehmannia Pill
Herbal therapy The difference in treatment between Kidney-Yin and Kidney-Yang deficiency is more marked in herbal medicine than it is in acupuncture.
Explanation This formula is a variation of Liu Wei Di Huang Wan specifically to treat headaches.
Headaches
Herbs • Hei Zhi Ma Semen Sesami negrum nourishes Liverand Kidney-Yin and it extinguishes Wind. It is specific for headaches from Liver- and Kidney-Yin deficiency. • Du Huo Radix Angelicae pubescentis expels WindDampness and enters the Bladder channel of the back. It is indicated for headaches from deficiency of Kidney-Yang. • Qiang Huo Rhizoma seu Radix Notopterygii expels Wind-Dampness and enters the Bladder channel of the shoulders and neck. It is indicated for headaches from deficiency of Kidney-Yang. • Du Zhong Radix Eucommiae ulmoidis tonifies the Kidneys and expels Wind-Dampness from the Bladder channel. It is indicated for headaches from deficiency of Kidney-Yang. • Yu Zhu Rhizoma Polygonati odorati nourishes Stomach-Yin. In addition, it extinguishes Wind and softens and relaxes the sinews. It would therefore help headaches from deficiency of Kidney-Yin. • Sang Ji Sheng Herba Taxilli nourishes Liver and Kidneys and expels Wind-Dampness. It is indicated for headaches from Kidney and Liver Yin deficiency.
Three Treasures remedy Nourish the Root Nourish the Root nourishes KidneyYin. It is a variation of Zuo Gui Wan.
SUMMARY KIDNEY DEFICIENCY General prescription: KI-3 Taixi, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui, G.B.-19 Naokong. For Kidney-Yin deficiency: Ren-4 Guanyuan. For Kidney-Yang deficiency: BL-23 Shenshu. All points should be reinforced. Moxa can be used on KI-3, unless there are pronounced symptoms of Empty Heat. In case of Kidney-Yang deficiency, moxa must be used on BL-23. Direct moxa can also be used on Du-20. Herbal therapy The difference in treatment between Kidney-Yin and Kidney-Yang deficiency is more marked in herbal medicine than it is in acupuncture.
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KIDNEY-YANG DEFICIENCY Prescription YOU GUI WAN Restoring the Right [Kidney] Pill Prescription JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill Three Treasures remedy Strengthen the Root KIDNEY-YIN DEFICIENCY Prescription ZUO GUI WAN Restoring the Left [Kidney] Pill Prescription LIU WEI DI HUANG WAN Six-Ingredient Rehmannia Pill Prescription QI JU DI HUANG WAN Lycium-Chrysanthemum-Rehmannia Pill Three Treasures remedy Nourish the Root
Case history A woman of 45 complained of persistent headaches on the back of the neck and head, extending over the top of the head to the eyes. She also suffered from lower backache. She had been experiencing these symptoms for 2 years since she had had a kidney infection. She had been diagnosed as having pyelonephritis and was put on antibiotics. She also had a tendency to constipation, and the urine was scanty and dark at times. She sweated at night on most nights. Her tongue was slightly Red with a yellow coating that was thick on the root and rather rootless in the centre. Her pulse was Fine and very slightly Wiry in both Rear positions. Diagnosis The headaches were of a Deficiency nature and were caused by Kidney-Yin deficiency. They clearly occurred along the Bladder channel. Her main condition was one of Kidney-Yin deficiency (lower backache, night sweating, dark-scanty urine, constipation, Fine pulse and Red tongue) with Damp Heat in the Bladder (thick-yellow coating on the
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The Practice of Chinese Medicine
root of the tongue, slightly Wiry pulse on both Rear positions). In addition, there was also some StomachYin deficiency (slightly rootless tongue coating). Treatment principle First resolve Damp Heat from the Bladder, then nourish Kidney-Yin. Acupuncture Points The main points used initially were LU-7 Lieque and KI-6 Zhaohai (Directing Vessel), SP-6 Sanyinjiao and SP-9 Yinlingquan. Later on (after a few weeks), other points were added such as Ren-12 Zhongwan, ST-36 Zusanli, BL-10 Tianzhu, BL-60 Kunlun and KI-3 Taixi. Explanation • LU-7 Lieque and KI-6 Zhaohai open the Directing Vessel and nourish Kidney-Yin. • SP-6 Sanyinjiao and SP-9 Yinlingquan resolve Damp Heat in the Lower Burner. • Ren-12 Zhongwan and ST-36 Zusanli were used to nourish Stomach-Yin. • BL-10 Tianzhu was used as a local point to relieve the headaches along the Bladder channel. • BL-60 Kunlun was used as a distal point to open the Bladder channel and relieve the headaches. • KI-3 Taixi was used to nourish Kidney-Yin. Herbal therapy Prescription Two prescriptions were used. Applying the principle of treating the Manifestation before the Root in this case, a variation of Ba Zheng San Eight Upright Powder was used first for a few weeks to resolve Damp Heat in the Bladder. This was followed by a variation of the Zhi Bo Ba Wei Wan AnemarrhenaPhellodendron Eight-Ingredient Pill to nourish KidneyYin and resolve Damp Heat simultaneously. The variation of the Eight Upright Powder used was: • • • • • • •
Che Qian Zi Semen Plantaginis 6 g Shan Zhi Zi Fructus Gardeniae 4 g Da Huang Radix et Rhizoma Rhei 3 g Bian Xu Herba Polygoni avicularis 4 g Fu Ling Poria 6 g Zhu Ling Polyporus 6 g Gui Zhi Ramulus Cinnamomi cassiae 2 g
• Yi Yi Ren Semen Coicis 6 g • Bai Zhu Radix Atractylodis macrocephalae 4 g The variation of the Anemarrhena-Phellodendron Eight-Ingredient Pill was: • • • • • • • • • • •
Zhi Mu Radix Anemarrhenae 3 g Huang Bo Cortex Phellodendri 6 g Shu Di Huang Radix Rehmanniae preparata 9 g Ze Xie Rhizoma Alismatis 3 g Shan Yao Rhizoma Dioscoreae 6 g Fu Ling Poria 6 g Shan Zhu Yu Fructus Corni 4 g Mu Dan Pi Cortex Moutan 3 g Bai Zhu Radix Atractylodis macrocephalae 6 g Dang Shen Radix Codonopsis 6 g Sang Ji Sheng Herba Taxilli 6 g
Explanation The first prescription was used to resolve Damp Heat from the Lower Burner. Qu Mai Herba Dianthi, Hua Shi Talcum, Deng Xin Cao Medulla Junci and Gan Cao Radix Glycyrrhizae uralensis were omitted, as there was no burning on urination. Fu Ling Poria, Zhu Ling Polyporus and Yi Yi Ren Semen Coicis were added to help to eliminate Dampness. Bai Zhu Rhizoma Atractylodis macrocephalae was added to tonify the Spleen and help drain Dampness. The second prescription was used to nourish KidneyYin and simultaneously eliminate Damp Heat from the Lower Burner. To this was added Bai Zhu Rhizoma Atractylodis macrocephalae and Dang Shen Radix Codonopsis to tonify the Spleen, and Sang Ji Sheng Herba Taxilli to nourish Liver and Kidney and expel Wind-Dampness. This last herb would help to stop the back pains. This patient achieved a complete improvement of her condition after 6 months of treatment.
MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 23, No. 4, 1993, p. 214. Wang Da Quan, “Experience in the treatment of headaches.” In this article, Dr Wang reports his clinical experience with case histories on the treatment of headaches from
Headaches
five patterns, i.e. Dampness, Knotted Heat in the Liver and Gall Bladder, Qi and Blood stagnation, Kidney deficiency and Blood deficiency with Heat.
Dampness A 73-year-old man had been suffering from headaches accompanied by a feeling of fullness and heaviness; he felt as if “the cavities of his brain were obstructed”. His pulse was Deep, Short and Wiry; his tongue was Pale with a thick-sticky coating. Dr Wang diagnosed obstruction of the head by Dampness and adopted the treatment principle tonifying the Heart and Spleen, resolving Dampness and eliminating obstructions from the Connecting (Luo) channels. The formula used was as follows: • • • • • • • • • • • • • •
Tai Zi Shen Radix Pseudostellariae 25 g Mai Men Dong Radix Ophiopogonis 15 g Wu Wei Zi Fructus Schisandrae 10 g Dan Shen Radix Salviae milthiorrizae 15 g Tan Xiang Lignum Santali albi 10 g Sha Ren Fructus Amomi 10 g Bing Lang Semen Arecae catechu 10 g Cao Guo Fructus Tsaoko 10 g Hou Po Cortex Magnoliae officinalis 10 g Bai Shao Radix Paeoniae alba 25 g Zhi Mu Radix Anemarrhenae 10 g Tian Ma Rhizoma Gastrodiae 10 g Shi Chang Pu Rhizoma Acori tatarinowii 10 g Dan Nan Xing Rhizoma Arisaematis preparatum 10 g • Chi Shao Radix Paeoniae rubra 10 g • Chuan Xiong Rhizoma Chuanxiong 10 g • Bai Ji Li Fructus Tribuli 10 g
Liver and Gall Bladder Knotted Heat A 49-year-old woman had been suffering from throbbing, bilateral headaches. She also suffered from insomnia, dizziness, bitter taste, and propensity to outbursts of anger. Her pulse was Wiry and Rapid and her tongue was Red and without coating. Dr Wang diagnosed Blood deficiency with Heat in the Liver and Gall Bladder. He therefore adopted the treatment principle of nourishing Blood and clearing Heat in the Liver and Gall Bladder. The formula used was as follows: • Dan Shen Radix Salviae milthiorrizae 30 g • Bai Shao Radix Paeoniae alba 15 g
• • • • • • • • • • • • •
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Sheng Di Huang Radix Rehmanniae 15 g Han Lian Cao Herba Ecliptae 15 g Xia Ku Cao Spica Prunellae 25 g Ju Hua Flos Chrysanthemi 15 g Chuan Niu Xi Radix Cyathulae 15 g Gou Teng Ramulus cum Uncis Uncariae 15 g Shan Yao Rhizoma Dioscoreae 20 g Long Gu Mastodi Ossis fossilia 15 g Mu Li Concha Ostreae 15 g Bai Zi Ren Semen Biotae 12 g Ye Jiao Teng Caulis Polygoni multiflori 21 g Tian Ma Rhizoma Gastrodiae 10 g Bai Ji Li Fructus Tribuli 15 g
Qi and Blood stagnation A 36-year-old woman had been suffering from stabbing headaches on the temples. She also suffered from dizziness and her menstrual blood was dark with clots. Her pulse was Wiry but Empty and her tongue was Red. Dr Wang diagnosed Qi deficiency and Blood stasis and adopted the treatment principle of tonifying Qi and invigorating Blood. The formula used was as follows: • • • • • • • • • • • • • • • • •
Tai Zi Shen Radix Pseudostellariae 25 g Mai Men Dong Radix Ophiopogonis 15 g Wu Wei Zi Fructus Schisandrae 10 g Dang Gui Radix Angelicae sinensis 10 g Sheng Di Huang Radix Rehmanniae 15 g Tao Ren Semen Persicae 10 g Hong Hua Flos Carthami tinctorii 10 g Chi Shao Radix Paeoniae rubra 15 g Chuan Niu Xi Radix Cyathulae 15 g Chai Hu Radix Bupleuri 10 g Chuan Xiong Rhizoma Chuanxiong 10 g Jie Geng Radix Platycodi 10 g Zhi Ke Fructus Aurantii 10 g Mu Dan Pi Cortex Moutan 10 g Bai He Bulbus Lilii 10 g Ye Jiao Teng Caulis Polygoni multiflori 25 g Gan Cao Radix Glycyrrhizae uralensis 10 g
Kidney deficiency A 9-year-old boy had been suffering from dull headaches that were aggravated at night. He also complained of restlessness and a diminished capacity for study. His pulse was Short and Choppy and his tongue was dark with a thin coating.
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The Practice of Chinese Medicine
Dr Wang diagnosed a congenital deficiency of the Kidneys with an invasion of Wind in the Greater Yang channels. He adopted the treatment principle of tonifying the Kidneys, removing obstructions from the Governing Vessel, expelling Wind and invigorating the Connecting (Luo) channels. The formula used was as follows: • • • • • • • • • • • • • • •
Rou Gui Cortex Cinnamomi 2 g Fu Zi Radix Aconiti lateralis preparata 6 g Shou Wu Radix Polygoni multiflori preparata 25 g Shan Zhu Yu Fructus Corni 10 g Shan Yao Rhizoma Dioscoreae 25 g Fu Ling Poria 15 g Mu Dan Pi Cortex Moutan 10 g Ze Xie Rhizoma Alismatis 10 g Tian Hua Fen Radix Trichosanthis 15 g Gui Zhi Ramulus Cinnamomi cassiae 8 g Gen Gen Radix Puerariae 15 g Chen Pi Pericarpium Citri reticulatae 10 g Fang Feng Radix Saposhnikoviae 10 g Qiang Huo Rhizoma seu Radix Notopterygii 10 g Bai Zhi Radix Angelicae dahuricae 10 g
Blood deficiency with Knotted Heat A 52-year-old woman had been suffering from headaches with a feeling of heaviness and distension and dizziness. Her pulse was Wiry and Fine and her tongue was dark-Red and dry. Dr Wang diagnosed Blood deficiency of the Heart and Liver with Heat flaring upwards and clouding the head’s orifices. The formula used was a variation of Si Wu Tang Four Substances Decoction. • • • • • • • • • • • • • • • • •
Dang Gui Radix Angelicae sinensis 10 g Chuan Xiong Rhizoma Chuanxiong 12 g Bai Shao Radix Paeoniae alba 25 g Sheng Di Huang Radix Rehmanniae 15 g Tai Zi Shen Radix Pseudostellariae 15 g Wu Wei Zi Fructus Schisandrae 10 g Mai Men Dong Radix Ophiopogonis 15 g Shou Wu Radix Polygoni multiflori preparata 10 g Chai Hu Radix Bupleuri 10 g Huang Qin Radix Scutellariae 10 g Mu Dan Pi Cortex Moutan 15 g Shan Yao Rhizoma Dioscoreae 15 g Shan Zhu Yu Fructus Corni 15 g Long Gu Mastodi Ossis fossilia 15 g Mu Li Concha Ostreae 15 g Chuan Niu Xi Radix Cyathulae 15 g Gan Cao Radix Glycyrrhizae uralensis 10 g
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 37, No. 1, 1996, p. 57. Zhao Fu Guo, “The use of Chuan Xiong in the treatment of headaches.” Dr Zhao presents an interesting overview of the use of Chuan Xiong Rhizoma Chuanxiong in the treatment of headaches according to his clinical experience. Dr Zhao says that Chuan Xiong is pungent, warm and scattering, and it reaches the top part of the body. It moves Qi and invigorates Blood, it fragrantly opens the orifices, it expels Wind, it stops pain, and it reaches the head and face. Suitably combined with other herbs, it is the herb of choice to treat headaches. Combined with Jing Jie Herba Schizonepetae, Fang Feng Radix Saposhnikoviae, Qiang Huo Rhizoma seu Radix Notopterygii, Bai Zhi Radix Angelicae dahuricae, Xi Xin Herba Asari and Bo He Herba Menthae haplocalycis, it treats headaches from Wind-Cold. Combined with Ju Hua Flos Chrysanthemi, Shi Gao Gypsum fibrosum and Jiang Can Bombyx batryticatus, Chuan Xiong treats headaches from Wind-Heat. Combined with Tao Ren Semen Persicae, Hong Hua Flos Carthami tinctorii and Chi Shao Radix Paeoniae rubra, it treats headaches from Blood stasis. Dr Zhao reports that Zhu Dan Xi (1282–1358) says “In headaches must use Chuan Xiong” (this saying rhymes in Chinese as “Tou tong bi yong Chuan Xiong”). Dr Zhao adjusts the dosage of Chuan Xiong according to the condition treated. When used to expel Wind from the Great Yang channels, the dosage used is small, i.e. from 6 to 10 g per day. If using it for headaches from Blood stasis, Dr Zhao uses from 30 to 40 g per day. Interestingly, Dr Zhao advises against using Chuan Xiong in headaches from Liver-Yang rising, internal Wind and Phlegm-Heat. Also, as a general rule, Dr Zhao prefers using Chuan Xiong in Cold patterns and not in Heat patterns.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 35, No. 4, 1994, p. 222. Han Jin Cheng, “Clinical experience in the treatment of stubborn headaches with Chuan Xiong and Dan Shen.” The article describes how 68 patients suffering from chronic, stubborn headaches were treated with herbal medicine. There were 42 men and 26 women. The oldest patient was 72 and the youngest 30. The duration of the headaches ranged from 2 months to 34 years.
Headaches
The patients were treated with a decoction containing Chuan Xiong Rhizoma Chuanxiong and Dan Shen Radix Salviae miltiorrhizae in high doses (30–50 g and 40–60 g, respectively). The decoction was administered daily for 14 days. The decoction was modified according to pattern and channels involved. If there was Blood stasis, Tao Ren Semen Persicae, Hong Hua Flos Carthami tinctorii and Chi Shao Radix Paeoniae rubra were added. For headaches from Liver-Yang rising, Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus cum Uncis Uncariae and Shi Jue Ming Concha Haliotidis were added. For headaches from Kidney deficiency, Shan Zhu Yu Fructus Corni, Gou Qi Zi Fructus Lycii chinensis and Gui Ban Plastrium Testudinis were added. For headaches from Blood deficiency, Dang Gui Radix Angelicae sinensis, Bai Shao Radix Paeoniae alba and Huang Qi Radix Astragali were added. For headaches from Phlegm, Hou Po Cortex Magnoliae officinalis, Cang Zhu Rhizoma Atractylodis and Fu Ling Poria were added. Other modifications were carried out according to channel involved as follows: • Front of head, Bright Yang channels: Bai Zhi Radix Angelicae dahuricae • Sides of head, Lesser Yang channels: Chai Hu Radix Bupleuri • Vertex, Terminal Yin channels: Wu Zhu Yu Fructus Evodiae • Back of head, Greater Yang channels: Qiang Huo Rhizoma seu Radix Notopterygii • Greater Yin channels: Cang Zhu Rhizoma Atractylodis • Lesser Yin channels: Xi Xin Herba Asari. The results were as follows: • Headache attacks reduced in frequency and were much less intense: 35 (51.4%) • Headaches reduced in frequency and intensity: 28 (41.1%) • No improvement: 5 (7.5%)
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the treatment of headaches from physical trauma. The rationale of this use is based on the fact that physical trauma to the head causes local Blood stasis and this decoction treats Blood stasis in the Upper Burner.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 32, No. 1, 1991, p. 13. Wang Shao Hua, “The treatment of infrequently seen liver diseases.” Dr Wang reports case histories of infrequently seen Liver-related problems. One of these was the occurrence of headaches after sexual activity in a 45-yearold man following hepatitis. Apart from complaining of headaches following sexual activity, this man also suffered from dizziness, dry eyes, dry mouth and throat, bitter taste, insomnia, hot palms. His tongue was Red and his pulse Fine and Rapid. Dr Wang diagnosed Liver-Yang rising and followed the treatment principle of subduing Yang and nourishing Yin. He used a variation of Yi Yin Jian One Yin Decoction plus Zuo Gui Yin Restoring the Left [Kidney] Decoction as follows: • • • • • • • • • • •
Sheng Di Huang Radix Rehmanniae 15 g Shu Di Huang Radix Rehmanniae preparata 15 g Shi Jue Ming Concha Haliotidis 15 g Bai Shao Radix Paeoniae alba 12 g Gou Qi Zi Fructus Lycii chinensis 12 g Shan Zhu Yu Fructus Corni 10 g Tu Si Zi Semen Cuscutae 10 g Xia Ku Cao Spica Prunellae 10 g Gou Teng Ramulus cum Uncis Uncariae 10 g Di Gu Pi Cortex Lycii 10 g Gan Cao Radix Glycyrrhizae uralensis 3 g
CLINICAL TRIALS Acupuncture
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 27, No. 7, 1986, p. 41.
Comparison of pharmacological treatment versus acupuncture treatment for migraine without aura
Wang Yi Quan, “The treatment of headaches from trauma with Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction.”
Journal of Traditional Chinese Medicine 2000 September, Vol. 20, No. 3, pp. 231–240. Liguori A, Petti F, Bangrazi A, Camaioni D, Guccione G, Pitari GM, Bianchi A, Nicoletti WE Istituto Paracelso, Italian Center for Non Conventional Medicines, Rome, Italy
In this article, Dr Wang reports the use of Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction in
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The Practice of Chinese Medicine
Objective To determine the effects of acupuncture treatment for migraine versus conventional drug therapy.
Method One hundred and twenty patients affected by migraine without aura were randomly divided into acupuncture group (AG) and conventional drug therapy group (CDTG) and treated at four public health centres. For the AG group, acupuncture was applied to the following points: ST-8 Touwei, G.B.-5 Xuanlu, G.B-20 Fengchi, Du-14 Dazhui and LU-7 Lieque (all treated with the reducing method). Clinical results were evaluated 6 and 12 months after the beginning of treatment.
Results In AG, the occurrence of migraine attacks dropped from 9823 (in the 12-month period prior to treatment) to 1990 after 6 months and 1590 after 1 year. The total absence from work amounted to 1120 working days per year, with a total cost (private and social costs) of 96,410 euros. In CDTG, the occurrence of migraine attacks dropped from 8405 before treatment to 3927 after 6 months and 3084 after 1 year. The total absence from work amounted to 1404 working days per year, with a total cost of 137,694 euros.
Conclusion Acupuncture proved more effective than conventional drug therapy in the treatment of migraine without aura.
Acupuncture versus placebo versus sumatriptan for early treatment of migraine attacks: a randomized controlled trial Journal of International Medicine 2003 February, Vol. 253, No. 2, pp. 181–188. Melchart D, Thormaehlen J, Hager S, Liao J, Linde K, Weidenhammer W.
(one specialized in traditional Chinese medicine and one in the treatment of headache). A total of 179 migraine sufferers participated experiencing the first symptoms of a developing migraine attack. The interventions were traditional Chinese acupuncture, sumatriptan (6 mg subcutaneously) or placebo injection. The main outcome measure was the number of patients in whom a full migraine attack (defined as severe migraine headache) within 48 h was prevented. In patients who developed a migraine attack despite early treatment, acupuncture and sumatriptan were applied a second time, while patients initially randomized to placebo received sumatriptan.
Results A full migraine attack was prevented in 21 of 60 (35%) patients receiving acupuncture, 21 of 58 (36%) patients receiving sumatriptan and 11 of 61 (18%) patients receiving placebo. Response to the second intervention in patients who developed a full attack was better with sumatriptan (17/31 patients who received sumatriptan twice and 37/46 patients who had had placebo first) than with acupuncture (4/31). The number of patients reporting side effects was 14 in the acupuncture group, 23 in the sumatriptan group and 10 in the placebo group.
Conclusion In this trial, acupuncture and sumatriptan were more effective than a placebo injection in the early treatment of an acute migraine attack. When an attack could not be prevented, sumatriptan was more effective than acupuncture at relieving headache.
Acupuncture versus metoprolol in migraine prophylaxis: a randomized trial of trigger point inactivation Journal of Internal Medicine 1994 May, Vol. 235, Issue 5, pp. 451–456. Hesse J, Møgelvang B, Simonsen H
Objective
Objective
To investigate whether acupuncture is superior to placebo and equivalent to sumatriptan for the early treatment of an acute migraine attack.
To compare the effects of dry needling of myofascial trigger points in the neck region compared with metoprolol in migraine prophylaxis.
Method
Method
A randomized, partly double-blind (sumatriptan versus placebo) trial took place in two hospitals in Germany
This was a randomized, group comparative study. Patients, investigator and statistician were blinded as
Headaches
to treatment, and the therapist was blinded as to results. It took place at an outpatient pain clinic in the northern Copenhagen area. Patients were referred by general practitioners or responded to newspaper advertisements. Included were patients with a history of migraine with or without aura for at least 2 years. Excluded were persons with contraindications against treatment with beta blockers, chronic pain syndromes, pregnancy or previous experience with acupuncture or beta-blocking agents. A total of 85 patients were included; 77 completed the study. After a 4-week run-in period, patients were allocated to a 17-week regimen either with acupuncture and placebo tablets or with placebo stimulation and metoprolol 100 mg daily.
Results Both groups exhibited significant reduction in attack frequency. No difference was found between the groups regarding frequency or duration of attacks, but there was a significant difference in global rating of attacks in favour of metoprolol.
Conclusion Trigger point inactivation by dry needling is a valuable supplement to the list of migraine prophylactic tools, being equipotent to metoprolol in the influence on frequency and duration (but not severity) of attacks, and superior in terms of negative side effects.
Changes of cerebrovascular response to visual stimulation in migraine sufferers after repetitive sessions of somatosensory stimulation (acupuncture): a pilot study Headache 2004 January, Vol. 44, Issue 1, pp. 95–101. Backer M, Hammes M, Sander D, Funke D, Deppe M, Tolle TR, Dobos GJ Department of Internal Medicine V, Kliniken Essen Mitte, Germany
Objective To evaluate the effect of repetitive somatosensory stimulation (acupuncture) on cerebrovascular response in migraine sufferers by functional transcranial Doppler.
Method Ten migraine sufferers and 10 control subjects participated. Changes of cerebral blood flow velocity in the right posterior and left middle cerebral arteries were
57
measured by functional transcranial Doppler during visual stimulation (flickering light over 57 seconds) in 10 sufferers before and after 10 acupuncture sessions. The same stimulation paradigm was performed in 10 control subjects. Cerebral blood flow velocity data were analysed with a previously validated technique based on automated stimulus-related averaging. To evaluate the clinical effect of the treatment, a headache diary monitored the frequency and intensity of the migraine attacks. A positive treatment effect was defined as a reduction of at least 50% in the attack frequency or the mean headache intensity (or both).
Results Before treatment, migraine sufferers showed overshooting cerebral blood flow velocity changes at the beginning and at the end of the stimulation and a delayed decline to baseline compared with control subjects. After treatment, this response pattern was significantly diminished in those who benefited from treatment (six). Those who did not benefit from treatment (four) showed a significantly more marked alteration of the cerebral blood flow velocity pattern.
Conclusion Data indicate that repetitive somatosensory stimulation (acupuncture) might positively influence the abnormal cerebrovascular response in sufferers. In a subgroup of migraine sufferers, however, the dysfunction of the cerebrovascular system might deteriorate under the treatment.
Acupuncture of chronic headache disorders in primary care: randomised controlled trial and economic analysis Health Technology Assessment 2004 November, Vol. 8, Issue 48, pp. 1–35. Vickers AJ, Rees RW, Zollman CE, McCarney R, Smith CM, Ellis N, Fisher P, Van Haselen R, Wonderling D, Grieve R Integrative Medicine Service, Biostatistics Service, Memorial Sloan-Kettering Cancer Center, New York, USA
Objective To determine the effects of a policy of using acupuncture, compared with a policy of avoiding acupuncture, on headache in primary care patients with chronic headache disorders. The effects of acupuncture on
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medication use, quality of life, resource use and days off sick in this population, and the cost-effectiveness of acupuncture were also examined.
Method This was a randomized, controlled trial involving 401 patients with chronic headache, predominantly migraine, at general practices in England and Wales. Patients were randomly allocated to receive up to 12 acupuncture treatments over 3 months or to a control intervention offering usual care. Headache score, 36-Item Short-Form Health Survey (SF-36) health status, and use of medication were assessed at baseline (start of the trial), 3, and 12 months. Use of resources was assessed every 3 months.
Results Headache score at 12 months, the primary end point, was lower in the acupuncture group: 34% reduction from baseline compared with that of the controls, who had a 16% reduction from baseline. Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year. SF-36 data favoured acupuncture, although differences reached significance only for physical role functioning, energy, and change in health. Compared with controls, acupuncture patients used 15% less medication, made 25% fewer visits to general practitioners and took 15% fewer days off sick.
Conclusion Acupuncture leads to persisting, clinically relevant benefits for primary care patients with chronic headache, particularly migraine. It is relatively cost-effective compared with a number of other interventions provided by the UK National Health Service.
Herbal medicine Clinical and experimental study on treatment of migraine with Shu Tian Ning granule Zhongguo Zhong Xi Yi Jie He Za Zhi Zhong Guo Zhong Xi Yi Jie He Za Zhi [Chinese Journal of Integrated Traditional and Western Medicine] 2002 August, Vol. 8, pp. 581–583. Hu ZQ, Song LG, Mei T Department of Neurology, Affiliated Hospital of Shandong University of TCM, Jinan
Objective To explore the cause and pathogenesis of migraine based on traditional Chinese medicine theory and modern research to seek for new thinking and effective drugs in treating migraine.
Methods Ninety patients with migraine were divided into three groups, the treated group treated with Shu Tian Ning Granule 9 g three times a day; the control A group treated with composite Yang Jiao capsule, five capsules each time, three times a day; and the control B group treated with flunarizine hydrochloride capsule, 5 mg, once a day. The treatment lasted for 28 days to observe the degree, lasting time and frequency of pain attack, and the headache index was calculated. Transcranial Doppler examination, serum beta-evoked potential (beta-EP) and neuropeptide Y (NPY) determination were also performed before and after treatment. In the experimental study, effect of treatment of cerebral NPY and beta-EP were tested in Sprague Dawley rats with chronic pain in the treated or the control groups.
Results In the treated group, the markedly effective rate was 56.67% and the total effective rate was 90.00%; significant difference was shown in comparison with those in the control B group (P < 0.05), but with no difference in comparison with those in the control A group. Cerebral beta-EP level was raised and plasma NPY level was lowered in all the three treated groups. Compared with the normal saline group, there was significant difference (P < 0.05 or P < 0.01).
Conclusion Shu Tian Ning Granule could improve the cerebrovascular function effectively, raise plasma beta-EP level, lower plasma NPY level and alleviate vascular tension in patients with migraine.
Effect of new Zheng Tian pill on expression of whole blood platelet membrane adhesion molecules in patients of migraine Zhong Guo Zhong Xi Yi Jie He Za Zhi [Chinese Journal of Integrated Traditional and Western Medicine] 2001 November, Vol. 21, Issue 11, pp. 822–824. Zhu CQ, Xie W, Chan BT
Headaches
Objective To investigate the effect of New Zheng Tian Pill (NZTP) on expression of whole blood platelet membrane adhesion molecules (PMAM) in patients of migraine.
Methods Sixty-eight patients were divided into two groups, the 35 patients in the treated group treated by NZTP orally and the 33 patients in the control group treated by Fuguiqin Capsule, with a therapeutic course of 30 days for both groups. Changes of PMAM glycoprotein IIb/ IIIa (CD41) and P-selectin (CD62P) were observed by flow cytometry and compared with those in healthy persons.
Results The markedly effective rate and total effective rate in the treated group were higher than those in the control group (P < 0.05 and P < 0.01, respectively). The PMAM expression was also higher in patients, both at onset stage and intermittent stage, than in healthy persons (P < 0.01). NZTP treatment could reduce their increased expression significantly (P < 0.01).
Conclusion NZTP could reduce the PMAM expression and inhibit the activation of platelet.
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This shows that the overwhelming majority of patients were between 31 and 60. As for Full and Empty, the distribution was as follows. • Purely Empty condition: 18 (10%) • Purely Full condition: 37 (22%) • Mixed Full-Empty condition: 116 (68%) This shows that the overwhelming majority of patients suffered from a mixed Full-Empty condition and also that more patients suffered from a purely Full than a purely Empty condition. The logical conclusion is that very few headaches are due to a purely Empty condition. As for patterns, a very large percentage of patients suffered from either Liver-Yang rising or Phlegm. In fact, 88 patients (51%) suffered from Liver-Yang rising and 35 (20%) from Phlegm. Therefore, Liver-Yang rising is by far the most common pattern found in patients suffering from chronic headaches. Liver-Yang rising and Phlegm together account for 71% of chronic headaches. There was also a large percentage of patients suffering from Empty conditions and especially Liver-Blood or Kidney deficiency; this makes sense, as a Liver-Blood or Kidney deficiency is very frequently the backround for the rising of Liver-Yang. In fact, 51 patients (30%) suffered from Liver-Blood deficiency and 74 patients (44%) suffered from a Kidney deficiency (which can be a Kidney-Yang, Kidney-Yin or mixed Kidney-Yin/ Kidney-Yang deficiency).
PATIENTS’ STATISTICS I have compiled some statistics on 171 patients suffering from headaches from my practice. There were 130 women (76%) and 41 (24%) men. As the overall percentage of women in my practice is 67%, this shows that more women than men suffer from headaches (in my practice). The age distribution was as follows. • • • • • • • • •
1–10: 3 (2%) 11–20: 10 (6%) 21–30: 17 (10%) 31–40: 42 (24%) 41–50: 48 (28%) 51–60: 36 (21%) 61–70: 14 (8%) 71–80: 0 (0) 81–90: 1 (1%)
WESTERN DIFFERENTIAL DIAGNOSIS OF HEADACHES The main causes of headaches in Western medicine may be summarized as follows (Fig. 1.20). Intracranial: • Inflammatory — Meningitis • Non-inflammatory — Vascular: migraine, cerebral haemorrhage — Neoplastic: cerebral tumour — Hypertensive: essential hypertension, secondary hypertension (glomerulonephritis) Cranial: • Sinusitis, otitis media
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The Practice of Chinese Medicine INFLAMMATORY: meningitis VASCULAR: migraine, cerebral haemorrhage
Intracranial NON-INFLAMMATORY: meningitis
NEOPLASTIC: cerebral tumour
HYPERTENSIVE: essential hypertension, secondary hypertension (nephritis) Cranial
Extracranial
Sinusitis, otitis
Glaucoma, cervical spondylosis, trigeminal neuralgia
Figure 1.20 Synopsis of causes of headache.
Extracranial: • Glaucoma, cervical spondylosis, trigeminal neuralgia
Figure 1.21 illustrates the areas influenced by the cranial nerves.
Intracranial The intracranial causes of headaches may be inflammatory or non-inflammatory. The latter may be vascular, neoplastic or hypertensive.
The main manifestations are a severe headache, fever, vomiting, neck rigidity and, in severe cases, mental confusion. Brudzinski’s sign is positive: with the patient supine and the chest held firmly to the bed, try to flex the neck. In meningitis, this procedure causes involuntary flexion of the hips (Fig. 1.22). The diagnosis of headache from meningitis is obvious from its acute onset, the age of the patient, the fever and the neck rigidity. The headache is generalized, radiating to the neck (Fig. 1.23).
Non-inflammatory
Inflammatory
Vascular
Meningitis This is an inflammation of the meninges occurring during a febrile disease. It strikes infants, children or young adults. Two-thirds of cases occur before the age of 5. Meningitis often starts during a viral infection such as influenza or a bacterial infection such as a respiratory or an ear infection.
Migraine This is the most frequent cause of recurrent headaches. It consists of an initial constriction of the head arteries (giving rise to prodromal symptoms) followed by vasodilatation and distension of the vessels
TR 1 C2 TR 2 TR 3 C3 C4
Figure 1.21 Cranial nerves.
Figure 1.22 Brudzinski’s sign.
Headaches
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become progressively worse in terms of frequency, duration and intensity and are accompanied by vertigo, vomiting and intellectual impairment, a cerebral tumour should be suspected. The headache eventually becomes continuous (Fig. 1.25). The grasp reflex may be observed: if an object is put on the palm of the hand between thumb and index finger, the patient will automatically grasp it. This reflex action is present only on the side opposite to the location of the tumour.
Hypertensive Figure 1.23 Location of headache in meningitis.
(which causes a throbbing pain). The main manifestations are a unilateral, severe and throbbing pain, photophobia, nausea and possibly vomiting. The attacks are precipitated by stress; by consumption of cheese, chocolate, red wine; and by the contraceptive pill. The headache is located around the eye, radiating to the side of the head; it is unilateral or bilateral (Fig. 1.24). Cerebral (subarachnoid) haemorrhage This is more frequent in men over 40. The main manifestations are an intense head pain, neck rigidity and vomiting followed by loss of consciousness.
Essential hypertension This indicates a persistent high blood pressure without an apparent cause. It occurs in persons between 40 and 70. The main manifestations are a vertical (on top of the head) or occipital headache, occipital stiffness, giddiness, tinnitus, irritability and, in a few cases, epistaxis. The main sign is, of course, a raised diastolic and/or systolic blood pressure. However, it is not at all uncommon for a patient with raised blood pressure not to show any of the above symptoms. The headache from hypertension can occur either on the top of the head or on the occiput and is accompanied by a pronounced stiffness of the neck muscles (Fig. 1.26).
Cerebral tumour This is an uncommon cause of headache, but if a person develops headaches that
Secondary hypertension This a raised blood pressure secondary to other factors, the most frequent of them being chronic glomerulonephritis (see Chapter 37, on oedema). The main manifestations, apart from raised blood pressure and a headache, are aching in the loins, tiredness, oedema and albuminuria.
Figure 1.24 Location of headache in migraine.
Figure 1.25 Location of headache in brain tumour.
Neoplastic
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Frontal sinus
Ethmoidal sinus Maxillary sinus
Figure 1.26 Location of headache in hypertension.
Cranial
Figure 1.27 Location of headache in sinusitis.
Sinusitis This is a common complaint in industrialized countries. It is characterized by inflammation of the sinuses. The headache from sinusitis is easily distinguished from that from other causes, as it is clearly located on the face in correspondence with the frontal, ethmoidal or maxillary sinuses (Fig. 1.27). Other manifestations include a runny nose, a postnasal discharge and a characteristic feeling of muzziness of the face.
Otitis media This may be a cause of headache in a small child. Very often, the child may not be able to distinguish the source of pain and may complain of a “headache” when he or she has an earache. The diagnosis is fairly obvious, as this type of headache will occur in a small child during a febrile disease and there may be a discharge from the ear (Fig. 1.28).
Figure 1.28 Location of headache in otitis media.
Extracranial Glaucoma This consists of a raised intraocular fluid pressure. It is rare before middle age. It may cause a headache around or behind the eyes, which is easily mistaken for migraine. It is usually worse in the evening and is accompanied by the patient’s seeing haloes around lights and by blurred vision (Fig. 1.29).
Figure 1.29 Location of headache in glaucoma.
Headaches
Cervical spondylosis This term includes arthritis of the cervical spine or cervical disc degeneration. This causes an occipital headache with ache extending to the top of the shoulders and neck (Fig. 1.30). There is marked tenderness on pressure on the neck and shoulder muscles. X-rays of the cervical spine usually show a narrowing of the intervertebral spaces and osteophyte formation.
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Mandibular branch Maxillary branch Ophthalmic branch
Trigeminal neuralgia This is an inflammation of one or more of the three trigeminal nerves (which are part of the cranial nerves). It is usually seen in the elderly. The pain is unilateral and it is usually very intense, lasting for a short time. The pain can occur on the forehead and eye, cheek or temple and jaw according to the nerve involved (Fig. 1.31). Finally, a word should be said about Western medication for headaches. Of all the various drugs used for migraine, ergotamine tartrate (Cafergot) is, in my opinion, the most detrimental one. Not only does it produce side effects such as nausea and tingling of the limbs, but I think its long-term use only makes the headaches more frequent. This occurs for two reasons: first of all, ergotamine tartrate (with a chemical structure somewhat similar to LSD) is a powerful vasoconstrictor (this stops the acute headache), but vasoconstriction is inevitably followed by vasodilatation, which is going to cause the next headache. Second, most preparations of ergotamine tartrate also include caffeine, which is
Figure 1.31 Location of trigeminal neuralgia.
also a vasoconstrictor, but, as for ergotamine, vasoconstriction is only followed by a worse vasodilatation. The role of caffeine in headaches has already been discussed in this chapter (see also note 2). For these reasons, I always advise patients who take this medication to come off it if at all possible. There is no danger in stopping this drug abruptly.
PROGNOSIS AND PREVENTION
Figure 1.30 Location of headache in cervical spondylosis.
Both acupuncture and Chinese herbs are extremely effective for headaches and migraine. Results, however, are not necessarily achieved always quickly. Obviously, the longer a person has been suffering from headaches, the longer it will take to treat him or her. Very often, we see patients who have been suffering from headaches for 20 years or more; in these cases, the treatment will necessarily take many months or even over a year. The three most difficult types of headache to treat are those from Phlegm, Wind-Phlegm and stasis of Blood.
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As for prevention, this follows logically from what was said about aetiology. A person who is prone to headaches or someone who has been successfully treated for headaches should refrain from excessive sexual activity and overwork. He or she should have enough rest and sleep and should avoid eating sour foods (as defined above in this chapter) and drinking coffee. If a person is suffering from a deficiency, he or she should have enough rest, and especially lie down for a short time after lunch. If a person has been successfully treated for headaches from Liver-Yang, Liver-Fire, Liver-Qi stagnation or Liver-Wind, he or she should pay attention to their emotional state and avoid getting angry.
END NOTES 1. For a more detailed discussion of this subject, see Maciocia G 2005 The Foundations of Chinese Medicine, 2nd edn. Elsevier, London. 2. Harrie JR 1970 Caffeine and headache. Journal of the American Medical Association 213: 628. An article in this journal states that caffeine is one of the more frequent causes of chronic headaches.
3. Wu Zhan Ren, Yu Zhi Gao 1987 Yi Lin Zheng Yin [The Correct Seal of Medical Circles]. Jiangsu Science Publishing House, Nanjing, p. 142. The Correct Seal of Medical Circles was written by Ma Zhao Sheng and first published in 1605. 4. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, Chapter 17, p. 98. First published c.100 BC. 5. Lu Yi Hua 1897 Leng Hu Yi Hua [Medical Talk from the Deserted Cottage] cited in 1981 Nei Ke Bian Bing Yu Bian Zheng [Differentiation of Diseases and Patterns in Internal Medicine]. Heilongjiang People’s Publishing House, p. 331. 6. 1982 Lei Jing [Classic of Categories]. People’s Health Publishing House, Beijing, p. 325. The Classic of Categories was written by Zhang Jie Bin (also called Zhang Jing Yue) and first published in 1624. 7. Heilongjiang Province National Medical Research Group 1984 Zhen Jiu Da Cheng Jiao Shi [An Explanation of the Great Compendium of Acupuncture]. People’s Health Publishing House, Beijing, p. 1091. The Great Compendium of Acupuncture was written by Yang Ji Zhou and first published in 1601. 8. Ibid., p. 1091. 9. Ibid., p. 1091. 10. Simple Questions, p. 141. 11. 1976 Pi Wei Lun [Discussion on Stomach and Spleen]. People’s Publishing House, Beijing, p. 362. The Discussion on Stomach and Spleen was written by Li Dong Yuan and first published in 1249. 12. Simple Questions, p. 111. 13. An Explanation of the Great Compendium of Acupuncture, p. 1091.
CHAPTER 2
DIZZINESS
AETIOLOGY 66 Emotional strain 66 Overwork and excessive sexual activity Irregular diet 66 PATHOLOGY
66
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IDENTIFICATION OF PATTERNS AND TREATMENT 67 Liver-Yang, Liver-Fire or Liver-Wind rising 67 Turbid Phlegm in the head 69 Liver-Yang rising with Phlegm in the head 70 Qi and Blood deficiency 71 Kidney-Essence deficiency 71 MODERN CHINESE LITERATURE WESTERN DIFFERENTIATION Ear 74 Eighth cranial nerve 75 Brainstem 75
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INTERIOR Full • Liver-Yang, Liver-Fire and Liver-Wind rising • Turbid Phlegm in the head • Liver-Yang rising with Phlegm in the head Empty • Qi and Blood deficiency • Kidney-Essence deficiency
DIZZINESS Dizziness in Chinese medicine is called Xuan Yun. Xuan means “blurred vision”, while Yun means “dizziness.”
This symptom may range from a very slight dizziness, sometimes only on changing posture, to very severe vertigo with loss of balance, when everything around the patient seems to be spinning. The term “dizziness” also includes the very common sensation of “muzziness” or “fuzziness”, a heavy feeling as if the head was full of cotton wool and, linked to this, an inability to think properly and to concentrate. In English, I shall call the symptom Xuan Yun “dizziness”; I shall use “vertigo” to indicate a stronger sensation of dizziness to the point of losing balance. The first reference to dizziness occurs in the Yellow Emperor’s Classic of Internal Medicine, which links it to various patterns. The Simple Questions in Chapter 74 relates it to Liver-Wind: “Wind causes dizziness and it pertains to the Liver.”1 The Spiritual Axis in Chapter 28 attributes dizziness to Qi not reaching the head: “When the Qi of the Upper Burner is deficient, the brain is not full [this causes] dizziness and blurred vision.”2 In Chapter 33, it relates it to deficiency of the Sea of Marrow: “When the Sea of Marrow is deficient there is dizziness.”3 Zhu Dan Xi in Essential Methods of Dan Xi (1347) relates dizziness to Phlegm and goes as far as saying “There is no dizziness without Phlegm.”4 He therefore advocates resolving Phlegm as the main method of treating dizziness. As we shall see, Phlegm is a very common cause of dizziness in the elderly. Zhang Jing Yue, on the other hand, in his book The Complete Book of Jing Yue (1624), relates dizziness to Deficiency and says: “Deficiency above causes dizziness” and “There is no dizziness without Deficiency.”5 He therefore recommends tonifying as the main method to treat dizziness. The differentiation and treatment of dizziness together with those of Headaches can be used as a guideline to treat hypertension.
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The discussion of Dizziness will be conducted according to the following topics. • • • • •
Aetiology Pathology Identification of patterns and treatment Modern Chinese literature Western differentiation
AETIOLOGY Emotional strain Anger, frustration, resentment, bottled-up hatred and any other emotion that affects the Liver may cause Liver-Yang to rise. This is a common cause of dizziness of the Full type. On the other hand, prolonged stagnation of Qi from emotional strain often gives rise to Fire, in this case Liver-Fire, which may also cause dizziness. Moreover, Liver-Fire may generate Wind, which causes even more intense dizziness to the point of loss of balance.
Overwork or excessive sexual activity Overwork and/or excessive sexual activity (in men) over many years without adequate rest weakens the Kidneys. These fail to generate enough Marrow to nourish the brain, and dizziness results. This is dizziness of the Empty type.
Irregular diet Excessive consumption of greasy foods or dairy products or simply irregular eating may weaken the Spleen and lead to Dampness and Phlegm. When this is associated with a deficiency of Qi in the Upper Burner, the clear Qi cannot rise to the head and Turbid Phlegm stagnates there, giving rise to dizziness, blurred vision and a sensation of muzziness (fuzziness) and heaviness of the head.
PATHOLOGY The most important pathological distinction to be made in dizziness is that between Deficiency and Excess. The sensation of dizziness quite simply arises either because not enough Qi reaches the head (Deficiency type) or because a pathogenic factor in the head prevents the clear Yang from reaching the head (Excess type). The main deficiencies that give rise to dizziness are those of Qi and Blood or Kidney-Essence. The main pathogenic factors causing dizziness are Liver-Yang, Liver-Fire, Liver-Wind and Phlegm. In the elderly, Blood stasis may also contribute to causing dizziness. This happens especially in elderly people suffering from arteriosclerosis. Therefore, if there are any signs of Blood stasis (such as a Purple tongue or dark and distended sublingual veins), it is important to modify the prescription used to invigorate Blood and “penetrate” the blood vessels (see second article from a modern Chinese journal mentioned below). Dizziness deriving from a deficiency is slight and is associated with blurred vision. It may occur only on change of posture. When caused by a Full condition, dizziness is more severe, in serious cases causing loss of balance. When Phlegm is the cause of dizziness, it is associated with blurred vision and a sensation of heaviness and muzziness (fuzziness) in the head, together with an inability to concentrate. Figure 2.1 summarizes the aetiology and pathology of Dizziness.
EMOTIONAL STRESS
Liver-Yang rising
LIV-Wind
Qi stagnation
Liver-Fire
OVERWORK
Kidney deficiency
IRREGULAR DIET
Phlegm
SUMMARY
Cannot nourish Sea of Marrow
DIZZINESS
AETIOLOGY Emotional strain Overwork or excessive sexual activity Irregular diet
Obstructs the Brain and prevents SpleenYang from rising
Figure 2.1 Aetiology and pathology of Dizziness.
Dizziness
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SUMMARY
Treatment principles
PATHOLOGY
Liver-Yang rising Subdue Liver-Yang, nourish LiverYin or Liver-Blood and Kidney-Yin if necessary.
Empty — Qi and Blood deficiency — Deficiency of Kidney-Essence Full — Liver-Yang rising — Liver-Fire — Liver-Wind — Phlegm
IDENTIFICATION OF PATTERNS AND TREATMENT There are five main patterns causing dizziness: Full • Liver-Yang, Liver-Fire or Liver-Wind rising • Turbid Phlegm in the head • Liver-Yang rising with Phlegm in the head Empty • Qi and Blood deficiency • Kidney-Essence deficiency
Liver-Fire Drain Liver-Fire. Liver-Wind Extinguish Liver-Wind.
Acupuncture Points LIV-3 Taichong, G.B.-20 Fengchi, T.B.-5 Waiguan, Du-16 Fengfu, S.I.-3 Houxi, LIV-2 Xingjian, P-6 Neiguan, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi. Reducing method on all points, except LIV-8 and KI-3 which should be reinforced.
Explanation • LIV-3 and G.B.-20 subdue Liver-Yang and extinguish Liver-Wind. G.B.-20 is specific for dizziness. • T.B.-5 helps to subdue Liver-Yang. • Du-16 and S.I.-3 extinguish Liver-Wind. • LIV-2 drains Liver-Fire. • P-6 indirectly helps to subdue Liver-Yang, calms the Mind and settles the Ethereal Soul. • LIV-8 and SP-6 nourish Liver-Blood. • KI-3 nourishes Kidney-Yin.
Herbal therapy
Liver-Yang, Liver-Fire or Liver-Wind rising Clinical manifestations Liver-Yang Quite severe dizziness, tinnitus, red face, irritability, propensity to outbursts of anger, headache. Tongue: slightly Red sides. Pulse: Wiry. Liver-Fire Red face, thirst, bitter taste, dry stools, scanty dark urine. Tongue: Red with dry-yellow coating. Pulse: Rapid-Wiry-Full. Liver-Wind More severe dizziness, vertigo and loss of balance, tremors. Pulse: Wiry. The pattern of Liver-Yang as a cause of dizziness is the most common of the above three patterns. LiverFire is the least common and Liver-Wind occurs usually only in the elderly.
Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction
Explanation This formula, which has already been explained in the chapter on headaches (Chapter 1), subdues Liver-Yang and nourishes Liver and Kidneys. It is widely used for dizziness from Liver-Yang or Liver-Wind rising.
Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction
Explanation The main difference between this prescription and the previous one is that the latter nourishes the Yin more and is therefore suitable when there is a pronounced deficiency of Liver- and Kidney-Yin. Note that Dai Zhe Shi Haematitum is not suitable for long-term use and is contraindicated in pregnancy. It could be eliminated
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from this prescription or replaced with Zhen Zhu Mu Concha Margatiriferae usta, which is also a sinking substance that subdues Liver-Yang. This formula also extinguishes Liver-Wind.
Prescription LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction
Explanation This formula subdues Liver-Yang, nourishes Yin and resolves Phlegm. Its Yin-nourishing effect is mild.
Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction
Explanation This formula is specific to drain Liver-Fire. Please note that the original formula quoted here contains Mu Tong, which must now be omitted because its use is no longer legal.
Modifications • If there are symptoms and signs of Liver-Fire (indicated above), either add Long Dan Cao Radix Gentianae or use Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction instead, adding Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus cum Uncis Uncariae and Shi Jue Ming Concha Haliotidis. • If there is Liver-Wind, add Di Long Pheretima, Zhen Zhu Mu Concha Margatiriferae usta and Mu Li Concha Ostreae.
Three Treasures remedy Bend Bamboo Bend Bamboo subdues Liver-Yang and nourishes Liver-Blood.
SUMMARY LIVER-YANG, LIVER-FIRE OR LIVER-WIND RISING Points LIV-3 Taichong, G.B.-20 Fengchi, T.B.-5 Waiguan, Du-16 Fengfu, S.I.-3 Houxi, LIV-2 Xingjian, P-6 Neiguan, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi. Reducing method on all points, except LIV-8 and KI-3, which should be reinforced.
Herbal therapy Prescription TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction Prescription ZHEN GAN XI FENG TANG Pacifying the Liver and Extinguishing Wind Decoction Prescription LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction Three Treasures remedy Bend Bamboo
Case history A 70-year-old man had been suffering from vertigo for several years. He was very unsteady on his feet and often used a shopping trolley to steady himself while walking. His blood pressure was raised and he occasionally had blurred vision. His nails were very dry and withered, his complexion was dark and his skin dry. His tongue was Reddish-Purple with a thin yellow coating in the centre but no coating elsewhere. The tongue was also Stiff and dry. His pulse was very Full and Wiry. Diagnosis His condition was clearly due to Liver-Yang rising with an underlying deficiency of Liver-Yin. The vertigo was due to Liver-Yang rising, which was also reflected in the pulse quality, while Liver-Yin deficiency was evidenced by the blurred vision, the dry skin, the dry and withered nails and the Stiff tongue. Treatment principle The principle of treatment adopted was therefore to nourish Liver-Yin and subdue Liver-Yang. Acupuncture Points The main points used were G.B.-20 Fengchi, T.B.-5 Waiguan, L.I.-4 Hegu and LIV-3 Taichong with even
Dizziness
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method and LIV-8 Ququan, SP-6 Sanyinjiao and KI-3 with reinforcing method.
SP-3, BL-20 and BL-21. Reducing or even method on the others.
Explanation • G.B.-20 subdues Liver-Yang and relieves dizziness. • T.B.-5 subdues Liver-Yang. • L.I.-4, together with LIV-3, subdues Liver-Yang from the head. • LIV-3 subdues Liver-Yang and Liver-Wind. • LIV-8, SP-6 and KI-3 nourish Liver-Yin.
Explanation
Herbal therapy No herbs were prescribed but only the patent remedy Jiang Ya Wan Lowering [Blood] Pressure Pill, which subdues Liver-Yang and LiverWind and nourishes Liver- and Kidney-Yin.
• Ren-12, ST-36, SP-3, BL-20 and BL-21 tonify Stomach and Spleen to resolve Phlegm. • Ren-9, SP-9, ST-40 and ST-41 resolve Dampness and Phlegm. • L.I.-4 is used to affect the Stomach channels in the face and regulate the ascending of clear Yang and descending of turbid Qi. • ST-8 is a local point specific to resolve Phlegm from the head. • Du-20 facilitates the rising of clear Yang to the head.
After six treatments, his blood pressure became normal and his dizziness was much relieved.
Herbal therapy
Turbid Phlegm in the head
BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction
Clinical manifestations Dizziness, a feeling of heaviness and muzziness (fuzziness) of the head as if it were full of cotton wool, blurred vision, difficulty in thinking and concentrating especially in the morning, a feeling of oppression of the chest, nausea, poor appetite, a sticky taste. Tongue: Swollen with a sticky coating. Pulse: Slippery. This condition is due to Phlegm obstructing the head so that the clear Yang cannot rise to it and turbid Qi cannot descend. The above manifestations are purely those due to Phlegm. Obviously, the more chronic the condition, the more there will be manifestations of Spleen deficiency. This is probably the most common pattern causing chronic dizziness.
Treatment principle Dry Dampness, resolve Phlegm, strengthen the Spleen and harmonize the Stomach.
Acupuncture Points Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, BL-21 Weishu, Ren-9 Shuifen, SP-9 Yinlingquan, ST-40 Fenglong, ST-41 Jiexi, L.I.-4 Hegu, ST-8 Touwei, Du-20 Baihui. Reinforcing method on Ren-12, ST-36,
Prescription
Explanation This formula, which has already been explained in the chapter on headaches (Chapter 1), is specific to resolve Phlegm from the head.
Modifications • To enhance this formula’s resolving Phlegm effect, add Shi Chang Pu Rhizoma Acori tatarinowii to open the orifices and help the descending of turbid Qi. • If there is a pronounced feeling of nausea, add Zhu Ru Caulis Bambusae in Taeniam. • If there is a feeling of fullness in the epigastrium, add Bai Dou Kou Fructus Amomi rotundus and Sha Ren Fructus Amomi. • If there is Phlegm and Heat (mental restlessness, headache, bitter taste and a Rapid-Wiry pulse), add Zhu Ru Caulis Bambusae in Taeniam, Gua Lou Fructus Trichosanthis and Huang Qin Radix Scutellariae and remove Bai Zhu. Alternatively, use Wen Dan Tang Warming the Gall-Bladder Decoction, especially if the tongue has a Stomach crack in the centre with a rough-yellow coating inside it and the tongue-body is Red. If this formula is used, add Huang Qin Radix Scutellariae, Huang Lian Rhizoma Coptidis and Shi Chang Pu Rhizoma Acori tatarinowii to it.
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SUMMARY TURBID PHLEGM IN THE HEAD Points Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, BL-21 Weishu, Ren-9 Shuifen, SP-9 Yinlingquan, ST-40 Fenglong, ST-41 Jiexi, L.I.-4 Hegu, ST-8 Touwei, Du-20 Baihui. Reinforcing method on Ren-12, ST-36, SP-3, BL-20 and BL-21. Reducing or even method on the others. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction
Liver-Yang rising with Phlegm in the head Clinical manifestations Severe dizziness, vertigo, tinnitus, irritability, propensity to outbursts of anger, headache, a feeling of heaviness and muzziness (fuzziness) of the head as if it were full of cotton wool, blurred vision, difficulty in thinking and concentrating (especially in the morning), a feeling of oppression of the chest, nausea, poor appetite, a sticky taste. If there is Liver-Wind: tremor of a limb. Tongue: Swollen with a sticky coating. Pulse: Slippery-Wiry. This is a common combination of patterns causing severe dizziness in the elderly. As Liver-Yang rises, it carries Phlegm with it, aggravating the feeling of dizziness. This is also a common cause of chronic headaches.
Treatment principle Subdue Liver-Yang, nourish the Kidneys, resolve Phlegm, tonify the Spleen, extinguish Wind if necessary.
Acupuncture Points LIV-3 Taichong, G.B.-20 Fengchi, Du-16 Fengfu, LIV-8 Ququan, KI-3 Taixi, L.I.-4 Hegu, ST-40 Fenglong, Ren-9 Shuifen, SP-9 Yinlingquan, ST-8 Touwei, Ren-12 Zhongwan, BL-20 Pishu. Ren-12, BL-20, LIV-8 and KI-3 with reinforcing method, the others with even method.
Explanation • LIV-3, G.B.-20 and Du-16 subdue Liver-Yang and extinguish Liver-Wind. • LIV-8 and KI-3 nourish the Liver and Kidneys. • L.I.-4 regulates the ascending and descending of Qi to and from the head. • ST-40, Ren-9 and SP-9 resolve Phlegm. • ST-8 resolves Phlegm from the head. • Ren-12 and BL-20 tonify the Spleen to resolve Phlegm.
Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction
Explanation This formula subdues Liver-Yang, extinguishes LiverWind and resolves Phlegm.
Modifications • In cases of Liver-Wind, add Di Long Pheretima, Quan Xie Scorpio or Jiang Can Bombyx batryticatus.
Three Treasures remedy Clear Yang Clear Yang is a variation of Ban Xia Bai Zhu Tian Ma Tang to treat headaches from a combination of Phlegm and Liver-Yang rising.
SUMMARY LIVER-YANG RISING WITH PHLEGM IN THE HEAD Points LIV-3 Taichong, G.B.-20 Fengchi, Du-16 Fengfu, LIV-8 Ququan, KI-3 Taixi, L.I.-4 Hegu, ST-40 Fenglong, Ren-9 Shuifen, SP-9 Yinlingquan, ST-8 Touwei, Ren-12 Zhongwan, BL-20 Pishu. Ren-12, BL-20, LIV-8 and KI-3 with reinforcing method, the others with even method. Herbal therapy Prescription BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction Three Treasures remedy Clear Yang
Dizziness
Qi and Blood deficiency Clinical manifestations Slight dizziness, sometimes only on change of posture, tiredness, dull-pale face, poor memory, insomnia, palpitations, depression, poor appetite. Tongue: Pale and Thin. Pulse: Choppy or Fine. This is essentially a deficiency of Spleen- and HeartBlood. This is usually a cause of mild dizziness in younger patients and more in women.
Treatment principle Tonify Qi and nourish Blood, strengthen Stomach and Spleen.
Acupuncture Points ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, Ren-6 Qihai, BL-15 Xinshu. Reinforcing method. Moxa should be used.
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• If there are symptoms of Cold and epigastric pain, add Gui Zhi Ramulus Cinnamomi cassiae and Bai Shao Radix Paeoniae alba. • If Blood deficiency is pronounced, add Shu Di Huang Radix Rehmanniae preparata. • If Qi deficiency is more pronounced, remove Dang Gui and Long Yan Rou and increase the dosage of Huang Qi. Alternatively, use Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction instead.
SUMMARY QI AND BLOOD DEFICIENCY Points ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, Ren-6 Qihai, BL-15 Xinshu. Reinforcing method. Moxa should be used. Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction
Explanation • ST-36, SP-6, Ren-12, BL-20 and BL-21 strengthen the Stomach and Spleen and nourish Blood. • Du-20 facilitates the rising of clear Qi to the head and relieves dizziness. • Ren-6 tonifies Qi in general. • BL-15 nourishes Heart-Blood.
Herbal therapy Prescription GUI PI TANG Tonifying the Spleen Decoction
Explanation This formula tonifies Qi and Blood, strengthens the Spleen and Heart, and nourishes the brain.
Modifications • If a deficiency of Stomach and Spleen in making Blood is more pronounced than a deficiency of Liver-Blood, reduce the dosage of Dang Gui, increase that of Mu Xiang and add Fu Ling Poria, Yi Yi Ren Semen Coicis and Sha Ren Fructus Amomi.
Kidney-Essence deficiency Clinical manifestations Persistent dizziness with a feeling of emptiness in the brain, tinnitus, depression, exhaustion, waking up during the night, poor memory, sore back and knees. Tongue: Pale if Yang deficiency, without coating if Yin deficiency. Pulse: Deep and Weak if Yang deficiency, FloatingEmpty if Yin deficiency. This is essentially a deficiency of Kidney-Essence; the Essence is failing to nourish Marrow and the brain. This results in a deficiency of the Sea of Marrow, one of the main symptoms of which is dizziness. As the Essence has both a Yin and a Yang aspect, its deficiency may manifest with symptoms of either Kidney-Yang or Kidney-Yin deficiency. This is a common cause of mild dizziness in middleaged and elderly patients.
Treatment principle Tonify Kidney-Yang or nourish Kidney-Yin, strengthen the Essence and nourish the Sea of Marrow.
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The Practice of Chinese Medicine
Acupuncture
Explanation
Points
This formula, which has already been explained in the chapter on headaches (Chapter 1), tonifies KidneyYang. In particular, Lu Jiao Jiao nourishes Marrow.
Ren-4 Guanyuan, KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, S.I.-3 Houxi and BL-62 Shenmai, Du-16 Fengfu, Du-17 Naohu, Du-20 Baihui, G.B.-39 Xuanzhong. Reinforcing method. Use moxa in Kidney-Yang deficiency.
Three Treasures remedies Nourish the Root or Strengthen the Root Nourish the Root nourishes Kidney-Yin, while Strengthen the Root tonifies Kidney-Yang.
Explanation • Ren-4, KI-3, BL-23 and BL-52 strengthen KidneyYang or Yin (depending on whether moxa is used or not) and nourish the Essence. • S.I.-3 and BL-62 (better for Kidney-Yang deficiency) strengthen the Governing Vessel and nourish Marrow and the brain. • Du-16 and Du-20 are points of the Sea of Marrow according to Chapter 33 of the Spiritual Axis.6 They stimulate the rising of Qi to the brain and nourish Marrow. • Du-17, called “Brain Window”, nourishes Marrow and relieves giddiness. • G.B.-39 is the Gathering (Hui) point of Marrow and therefore nourishes Marrow and relieves dizziness from Kidney deficiency.
Herbal therapy Prescription
SUMMARY KIDNEY-ESSENCE DEFICIENCY Points Ren-4 Guanyuan, KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, S.I.-3 Houxi and BL-62 Shenmai, Du-16 Fengfu, Du-17 Naohu, Du-20 Baihui, G.B.-39 Xuanzhong. Reinforcing method. Use moxa in Kidney-Yang deficiency. Herbal therapy Prescription ZUO GUI WAN Restoring the Left [Kidney] Pill Prescription YOU GUI WAN Restoring the Right [Kidney] Pill Three Treasures remedies Nourish the Root or Strengthen the Root
ZUO GUI WAN Restoring the Left [Kidney] Pill
Explanation This formula, which has already been explained in the chapter on headaches (Chapter 1), tonifies Kidney-Yin and nourishes the Essence and Marrow. In particular, Lu Jiao and Lu Jiao Jiao (see below) nourish Marrow and the brain. It is especially suited to women.
Modifications • If there are symptoms of Empty Heat, add Zhi Mu Radix Anemarrhenae and Huang Bo Cortex Phellodendri.
Prescription YOU GUI WAN Restoring the Right [Kidney] Pill
Case history A 31-year-old man had been suffering from severe dizziness, slight deafness and tinnitus for 1 year. His condition had been diagnosed as Ménière’s disease. He sometimes sweated at night and felt generally exhausted. He had had a previous bout of dizziness 10 years earlier. He also suffered from headaches of a throbbing character on the temples, when his eyes would flicker. His tongue was slightly Red and the coating was too thin. His pulse was Empty on the deep level and Wiry on both Rear positions. Diagnosis This is a clear case of Kidney-Yin deficiency (night-sweating, exhaustion, tongue without enough coating, pulse Empty on the deep level) and LiverYang rising (throbbing headache, flickering eyes, Wiry
Dizziness
pulse). Thus this is a combined condition of Deficiency (of Kidney-Yin) and Excess (Liver-Yang rising). The dizziness and tinnitus can be accounted for both by Kidney-Yin deficiency and by Liver-Yang rising. Treatment principle Nourish Kidney-Yin and subdue Liver-Yang. Herbal therapy Prescription This patient, who had been referred to me by his acupuncturist, sought herbal treatment. The formula used was a variation of Liu Wei Di Huang Wan SixIngredient Rehmannia Pill. • • • • • • • • • •
Shu Di Huang Radix Rehmanniae preparata 9 g Shan Yao Rhizoma Dioscoreae 6 g Shan Zhu Yu Fructus Corni 4.5 g Ze Xie Rhizoma Alismatis 4 g Mu Dan Pi Cortex Moutan 4 g Fu Ling Poria 4.5 g Shi Jue Ming Concha Haliotidis 12 g Gou Teng Ramulus cum Uncis Uncariae 6 g Tian Ma Rhizoma Gastrodiae 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g
Explanation • The first six herbs constitute the Liu Wei Di Huang Wan, which nourishes Kidney-Yin. • Shi Jue Ming, Gou Teng and Tian Ma subdue LiverYang. • Zhi Gan Cao harmonizes.
MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 24, No. 7, 1983. Liu Zhi Ming, “Differentiation and treatment of dizziness.” Dr Liu considers that the three main patterns causing dizziness are Liver-Wind and Heat, deficient SpleenQi not rising to the head and deficiency of the Sea of Marrow.
Liver-Yang rising, Liver-Wind and Heat Dr Liu says that Liver-Yang rising or Liver-Wind may cause dizziness; in both cases, they stem from a
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deficiency of the Liver- and/or Kidney-Yin. An example of a prescription he uses is as follows. • • • • • • • • • • • •
Gou Teng Ramulus cum Uncis Uncariae 9 g Ju Hua Flos Chrysanthemi 9 g Huang Qin Radix Scutellariae 9 g Bai Shao Radix Paeoniae alba 9 g Fu Ling Poria 12 g Ze Xie Rhizoma Alismatis 12 g Xuan Shen Radix Scrophulariae 12 g Sheng Di Huang Radix Rehmanniae 15 g Shi Chang Pu Rhizoma Acori tatarinowii 6 g Yuan Zhi Radix Polygalae 4.5 g Zhen Zhu Mu Concha Margatiriferae usta 24 g Shi Jue Ming Concha Haliotidis 24 g
In cases of Liver-Fire, Dr Liu uses a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction as follows: • • • • • • • • • • • • •
Long Dan Cao Radix Gentianae 9 g Huang Qin Radix Scutellariae 9 g Shan Zhi Zi Fructus Gardeniae 9 g Chai Hu Radix Bupleuri 9 g Ju Hua Flos Chrysanthemi 9 g Bai Shao Radix Paeoniae alba 9 g Shi Chang Pu Rhizoma Acori tatarinowii 9 g Yuan Zhi Radix Polygalae 6 g Fu Ling Poria 12 g Ze Xie Rhizoma Alismatis 12 g Tai Zi Shen Radix Pseudostellariae 12 g Ge Gen Radix Puerariae 12 g Gan Cao Radix Glycyrrhizae uralensis 6 g
Deficient Qi not rising to the head Dr Liu considers that deficient Qi’s not rising to the head is an important cause of dizziness. This is mostly deficient Spleen-Qi. Dr Liu quotes Chapter 28 of the Spiritual Axis: “When the rising Qi is deficient, the brain cannot be filled, and there is tinnitus, the head feels like it is spinning and there is blurred vision.”7 An example of a prescription used by Dr Liu is as follows: • • • • • • • • •
Dang Shen Radix Codonopsis 12 g Huang Qi Radix Astragali 12 g Bai Zhu Rhizoma Atractylodis macrocephalae 6 g Ge Gen Radix Puerariae 9 g Dang Gui Radix Angelicae sinensis 9 g Chen Pi Pericarpium Citri reticulatae 9 g Suan Zao Ren Semen Ziziphi spinosae 9 g Fu Shen Sclerotium Poriae pararadicis 9 g Gan Cao Radix Glycyrrhizae uralensis 6 g
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The Practice of Chinese Medicine
Deficiency of the Sea of Marrow The Kidney-Essence fills the Sea of Marrow that forms the Brain. Chapter 33 of the Spiritual Axis mentions the symptoms caused by a deficiency of the Sea of Marrow: “When the Sea of Marrow is deficient, there is dizziness, tinnitus, blurred vision, weak legs and a desire to lie down.”8 For dizziness deriving from a deficiency of the Kidneys and of the Sea of Marrow, Dr Liu recommends tonifying the Kidneys (Yin or Yang). An example of a prescription used is as follows: • • • • • • • • • • • •
Shu Di Huang Radix Rehmanniae preparata 15 g Dang Gui Radix Angelicae sinensis 12 g Bai Shao Radix Paeoniae alba 9 g E Jiao Colla Corii Asini 12 g Xu Duan Radix Dipsaci 12 g Sang Ji Sheng Herba Taxilli 12 g Dang Shen Radix Codonopsis 12 g Huang Qi Radix Astragali 12 g Suan Zao Ren Semen Ziziphi spinosae 9 g Fu Ling Poria 12 g Zhen Zhu Mu Concha Margatiriferae usta 24 g Gan Cao Radix Glycyrrhizae uralensis 6 g
In cases of Kidney-Yang deficiency, Dr Liu uses the following prescription: • • • • • • • • • •
Fu Zi Radix Aconiti lateralis preparata 9 g Rou Gui Cortex Cinnamomi 4.5 g Shu Di Huang Radix Rehmanniae preparata 18 g Shan Zhu Yu Fructus Corni 15 g Ba Ji Tian Radix Morindae officinalis 12 g Fu Ling Poria 12g Yuan Zhi Radix Polygalae 6 g Shi Chang Pu Rhizoma Acori tatarinowii 9 g Huang Qi Radix Astragali 15 g Dang Gui Radix Angelicae sinensis 9 g
patients were 22 men and 10 women ranging in age from 48 to 72 with an average age of 63.5 years. Dr Chai considers that the invigorating of Blood in the elderly suffering from dizziness is an important treatment principle. The formula used was the following: • • • • • • • • • • • •
Tao Ren Semen Persicae 6 g Hong Hua Flos Carthami tinctorii 6 g Ban Xia Rhizoma Pinelliae preparatum 6 g Chen Pi Pericarpium Citri reticulatae 6 g Chuan Xiong Rhizoma Chuanxiong 9 g Shi Chang Pu Rhizoma Acori tatarinowii 9 g Dan Shen Radix Salviae miltiorrhizae 12 g Chi Shao Radix Paeoniae rubra 12 g Chuan Niu Xi Radix Cyathulae 12 g Di Long Pheretima 12 g Bai Zhu Rhizoma Atractylodis macrocephalae 12 g Ji Xue Teng Caulis Spatholobi 20 g The results of the treatment were as follows.
• Cured: 15 cases (46.88%) • Improved: 14 cases (43.75%) • No results: 3 cases (9.38%) This article highlights the importance of the invigorating of Blood to treat dizziness in the elderly.
WESTERN DIFFERENTIATION The causes of vertigo in Western medicine may be classified according to its site. The sites may be: • ear • eighth cranial nerve • brainstem.
Ear Journal of Nanjing University of Traditional Chinese Medicine, Vol. 13, No. 3, 1997. Chai Xiao Kang, “The treatment of dizziness from arteriosclerosis with Invigorating Blood and Penetrating the Blood Vessels Decoction.” Dr Chai reports on the treatment of 32 patients suffering from dizziness related to arteriosclerosis. The
Causes in the ear include wax, otitis media, acute labyrinthitis, Ménière’s disease and postural vertigo. The two most common causes of severe vertigo are acute labyrinthitis and Ménière’s disease.
Acute labyrinthitis This occurs during an acute febrile disease such as influenza. The sense of whirling that the patient develops has a sudden onset. Nausea and vomiting may occur. The patient has to lie flat, and the slightest movement brings on the vertigo. The symptoms
Dizziness
gradually subside and disappear in 3–6 weeks. There is no accompanying tinnitus or hearing loss.
Ménière’s disease This is characterized by recurring bouts of sudden vertigo, tinnitus and deafness. In the intervals between bouts, the patient has complete freedom from vertigo but the tinnitus and deafness continue.
Eighth cranial nerve This can be affected by acute meningitis, trauma and tumours. Damage to the eighth nerve produces vertigo, nystagmus (involuntary rapid movement of the eyeball) and hearing loss.
Brainstem This can be affected by infections (encephalitis, meningitis), trauma, thrombosis of the posteroinferior cerebellar artery and multiple sclerosis.
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Damage to the brainstem causes vertigo and nystagmus but no hearing loss. Transient vertigo may be caused by a vascular spasm.
END NOTES 1. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 538. First published c.100 BC. 2. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 68. First published c.100 BC. 3. Ibid., p. 72. 4. Zhu Dan Xi 1347 Dan Xi Xin Fa [Essential Methods of Dan Xi] cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue [Internal Medicine in Chinese Medicine]. Shanghai Science Publishing House, Shanghai, p. 204. 5. 1986 Jing Yue Quan Shu [Complete Book of Jing Yue]. Shanghai Science Publishing House, Shanghai, p. 320. The Complete Book of Jing Yue was written by Zhang Jing Yue and first published in 1624. 6. Spiritual Axis, p. 73. 7. Ibid., p. 68. 8. Ibid., p. 73.
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CHAPTER 3
BREATHLESSNESS (CHUAN)
AETIOLOGY 78 External pathogenic factors 78 Irregular diet 79 Emotional problems 79 Overwork, chronic illness 79 PATHOLOGY
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IDENTIFICATION OF PATTERNS AND TREATMENT 81 Wind-Cold invading the Lungs 82 Wind-Cold on the Exterior, Phlegm-Fluids in the Interior 83 Cold on the Exterior, Heat in the Interior 84 Phlegm-Heat in the Lungs 84 Turbid Phlegm in the Lungs 85 Lung-Qi Obstructed 86 Liver-Fire invading the Lungs 86 Lung-Qi deficiency 88 Lung-Yin deficiency 88 Lung and Kidney deficiency 89 Lung- and Kidney-Yin deficiency 92 Lung- and Kidney-Yang deficiency, Fluids overflowing to Heart and Lungs 94 Lung-, Heart- and Kidney-Yang deficiency, Fluids overflowing to the Heart 94 PROGNOSIS AND PREVENTION Diet 97 Life habits 97 Preventive treatment 97
Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung and Kidney deficiency • Lung- and Kidney-Yin deficiency • Lung- and Kidney-Yang deficiency, Fluids overflowing to Heart and Lungs • Lung-, Heart- and Kidney-Yang deficiency, Fluids overflowing to the Heart
BREATHLESSNESS (CHUAN)
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WESTERN DIFFERENTIAL DIAGNOSIS Causes in Lungs 97 Causes in Heart 99 General causes 99
Full • Wind-Cold invading the Lungs • Wind-Cold on the Exterior, Phlegm-Fluids in the Interior • Cold on the Exterior, Heat in the Interior • Phlegm-Heat in the Lungs • Turbid Phlegm in the Lungs • Lung-Qi Obstructed • Liver-Fire invading the Lungs
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Breathlessness was called Chuan in Chinese Medicine. Chuan means “to pant”. The symptoms and signs of breathlessness have been described in the Yellow Emperor’s Classic of Internal Medicine. In fact, the Simple Questions says in Chapter 22: “When the Lungs are diseased there is panting, cough, breathlessness, pain in the shoulders and back and sweating.”1 In Chapter 62, it says: “When Qi is in excess [in the chest] there is panting, cough and breathlessness; when Qi is deficient there is difficulty in breathing with shallow breath.”2 The Spiritual Axis in Chapter 20 says: “When pathogenic factors are in the Lungs, the skin is painful, there are feelings of heat and cold, panting, sweating, cough and pain in the shoulders.”3
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The Practice of Chinese Medicine
The Essential Prescriptions of the Golden Chest (AD 220) in Chapter 7 indicates “panting” as breathlessness at rest with inability to lie down. Also included is a “sound in the throat like a moorhen”.4 Thus, the term “panting” in Chinese medicine includes difficulty in breathing, breathing with an open mouth, lifting of the shoulders when breathing and inability to lie down. This could be an acute or chronic state. The discussion of breathlessness will be conducted according to the following topics. • • • • •
Aetiology Pathology Identification of patterns and treatment Prognosis and prevention Western differential diagnosis
AETIOLOGY External pathogenic factors Invasion of Wind-Cold or Wind-Heat is an important causative factor of breathlessness in many ways. First of all, both can cause acute breathlessness. External Wind obstructs the Lungs and prevents the diffusing and descending of Qi; this results in an accumulation of Qi in the chest and brings breathlessness. Second, an invasion of Wind-Cold or Wind-Heat can trigger off an acute attack in patients suffering from chronic breathlessness. Third, external Wind in itself is a frequent initial cause for the beginning of what eventually becomes chronic breathlessness. This is especially true in children. If a child suffers from an invasion of WindCold or Wind-Heat (or from repeated invasions) and the pathogen is not expelled properly (either through lack of treatment or through repeated treatment with antibiotics), the external pathogenic factor turns into Phlegm (with or without Heat) and it lodges itself in the Interior; there, it continuously obstructs the descending of Lung-Qi, causing chronic breathlessness. This is called residual pathogenic factor and it is a very common cause of chronic breathlessness in both adults and children. A residual pathogenic factor may be formed at the exterior stage of an invasion of Wind or when the Wind has become interior, usually turning itself into Heat (Fig. 3.1). When exterior Wind invades the body,
WIND
Expelled completely
WEI LEVEL
RESIDUAL PATHOGENIC FACTOR
Complete recovery
QI LEVEL
RESIDUAL PATHOGENIC FACTOR
YING-BLOOD LEVEL Figure 3.1 Formation of residual pathogenic factor.
it frequently upsets the ascending and descending of Spleen- and Stomach-Qi. This is even more likely to happen at the interior stage. For this reason, a residual pathogenic factor very frequently manifests with Dampness or Phlegm (Fig. 3.2). A frequent consequence of an invasion of Wind is interior Lung-Heat or Phlegm-Heat. Wind-Heat has a strong tendency to create interior Heat from its early stages by its drying action. Wind-Cold too, can turn into Heat once in the Interior. If there is a pre-existing condition of Lung-Heat, Wind-Cold can “lock” the
EXTERIOR PATHOGENIC FACTOR
Not expelled
RESIDUAL PATHOGENIC FACTOR
DAMPNESS/PHLEGM Disrupts ascending of SP-Qi and descending of ST-Qi INTERIOR PATHOGENIC FACTOR
Not cleared
DAMPNESS/PHLEGM Disrupts ascending of SP-Qi and descending of ST-Qi
RESIDUAL PATHOGENIC FACTOR Figure 3.2 Formation of Dampness and Phlegm in residual pathogenic factor.
Breathlessness (Chuan)
Heat in the Lungs, giving rise to breathlessness. As Lung-Qi fails to descend, fluids cannot be transformed and they accumulate into Phlegm. Phlegm, of course, becomes a cause of breathlessness in itself, as it further obstructs the descending of Lung-Qi in the chest. Phlegm-Heat in the Interior also obstructs the ascending of Spleen-Qi and the descending of StomachQi so that fluids cannot be transformed properly. This further contributes to forming Phlegm or Dampness and to making the condition chronic. For these reasons, Dampness or Phlegm is a very common result of any acute disease that becomes protracted. The possibility of the development of breathlessness from repeated invasions of external Wind (which occurs especially but not exclusively in children) is a further reason to treat all such invasions seriously and actively expel the pathogenic factor while it is still on the Exterior.
Irregular diet The excessive consumption of fats, dairy foods, sweets, sugar and raw-cold foods impairs the transformation and transportation of food essences and fluids by the Spleen. As fluids are not transformed, this eventually leads to the formation of Phlegm, which settles in the Lungs. In the Lungs, Phlegm obstructs the descending of Qi and causes breathlessness. This is an extremely common aetiological factor of breathlessness in Western societies, especially due to the excessive consumption of dairy foods such as milk, cheese, butter and cream.
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Overwork, chronic illness Overwork over a long period of time weakens KidneyYin. A deficiency of Kidney-Yin leads to the impairment of various Kidney functions, in this case that of receiving Qi. Thus the deficient Kidneys cannot receive and grasp Qi, which rebels upwards and obstructs the descending of Lung-Qi. This leads to a situation of Excess above and Deficiency below and therefore chronic breathlessness. Physical overexertion over a long period of time, or standing for too long, weakens Kidney-Yang, which then cannot receive Qi and hold it down. This leads to chronic breathlessness in exactly the same way as outlined above. Thus a Kidney deficiency (whether of Yin or Yang) is nearly always present in chronic breathlessness. For this reason, Ye Tian Shi (1667–1746) said of breathlessness: “If the Lungs are the cause, it is of the Excess type; if the Kidneys are the cause, it is of the Deficiency type.”5 A chronic deficiency of Lung-Qi or Lung-Yin such as one following an external invasion of Wind prevents Lung-Qi from descending and therefore leads to chronic cough and breathlessness.
SUMMARY AETIOLOGY External pathogenic factors Irregular diet Emotional problems Overwork, chronic illness
Emotional problems Worry, pensiveness or brooding over a long period of time weakens the Lung and Spleen. Lung-Qi becomes obstructed and this leads to breathlessness. Spleen-Qi is weakened and fluids are not transformed properly, and this leads to Phlegm, which is a contributing factor in chronic breathlessness. Anger, frustration, irritation or resentment over a long period of time causes Liver-Yang or Liver-Fire to rise. Rising, it can invade the Lungs and obstruct the descending of Lung-Qi. In Five-Element terms, this is called “Wood insulting Metal”. It is a fairly common cause of breathlessness, particularly in tense young people or children who are in a stressful family situation.
PATHOLOGY As outlined above, the causes of breathlessness primarily centre on the Lungs, Spleen and Kidneys. The Lungs, which govern Qi, are always involved, as in breathlessness Lung-Qi fails to descend. This failure to descend occurs when Lung-Qi is obstructed by exterior Wind or by Phlegm, or when it is deficient. The Kidneys are the root of Qi; they receive Qi and hold it down. Lungs and Kidney work in coordination for proper breathing as Lung-Qi descends to the Kidneys and the Kidneys hold it down. The Lungs control exhalation and the Kidney inhalation. Thus, in chronic breathlessness a difficulty in inhalation indicates
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The Practice of Chinese Medicine
Assists the descending of LU-Qi
LUNGS Lung-Qi not descending
BREATHLESSNESS
SPLEEN Spleen-Qi Xu leading to
LIVER
LUNGS
Phlegm
KIDNEYS Assists the ascending of LIV-Qi
Kidneys not receiving Qi Figure 3.3 The roles of Lungs, Spleen and Kidneys in the pathology of breathlessness.
Kidney deficiency, while a difficulty in exhalation points to a Lung deficiency. Although the pattern of Kidneys not receiving Qi, which is typical of chronic breathlessness, is a Yang-deficiency pattern, both Kidney-Yin and Kidney-Yang deficiency can lead to chronic breathlessness. Other organs are involved in breathlessness too. A deficiency of the Spleen leads to the formation of Phlegm, which obstructs the descending of Lung-Qi. Phlegm is often present, especially in bronchitic breathlessness (Fig. 3.3). Liver-Yang or Liver-Fire rising can impair the descending of Lung-Qi and lead to chronic breathlessness. This happens also because the Qi of the Lungs and the Qi of the Liver are coordinated: Liver-Qi ascends and Lung-Qi descends and the proper ascending/ descending is ensured by both organs functioning well. It should be pointed out that the ascending of Liver-Qi to the Lungs is physiological (Fig. 3.4). In pathology, when Liver-Qi is excessive and rebels upwards, it may prevent Lung-Qi from descending, causing breathlessness (Fig. 3.5). In very chronic cases in old people, the Heart may also be involved in two ways. First of all, the Heart vessels fill the lungs and Lung-Qi moves Blood. If LungQi is deficient, Blood is not moved and it stagnates in the lungs. This leads to right-heart failure due to retention of fluids in the lungs. Second, Kidney-Yang is the basis for Heart-Yang. When Kidney-Yang is deficient, the Fire of the Gate of
Figure 3.4 The coordination of Liver-Qi and Lung-Qi.
Rebellious Liver-Qi prevents the descending of Lung-Qi LUNGS
– LIVER
+ Figure 3.5 Rebellious Liver-Qi affecting the descending of Lung-Qi.
Life (Ming Men) fails to warm the Heart; fluids are not transformed and they accumulate in the Lungs and Heart. This is manifested with a profuse expectoration of white, watery, dilute and frothy sputum. There will also be a pronounced feeling of oppression of the chest and palpitations. It is called “Kidney-Yang deficient with Water overflowing to Lungs and Heart”. In even more chronic cases, the deficient Heart-Yang fails to move Blood in the chest and the stagnant fluids in the chest further obstruct Blood. This leads to stasis of Blood in the chest with symptoms of chest pain, cyanotic lips, dark nails and a Purple tongue. Thus, we can summarize the aetiology and pathology of chronic breathlessness with a diagram (Fig. 3.6).
Breathlessness (Chuan)
Invasion of exterior Wind
Overwork – Fatigue Excess sex – Constitution
LUNG-QI DEFICIENCY
KIDNEY DEFICIENCY
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Lung-Qi not descending Qi not transforming Water Kidney not holding Qi
HEART-QI DEFICIENT
CHRONIC ASTHMA Diet
Emotional problems
SPLEEN DEFICIENCY
LIVER-YANG LIVER-FIRE
Phlegm obstructs Lungs Qi not moving Blood
HEART-BLOOD STAGNANT
Liver-Yang or Liver-Fire rebelling towards the Lungs
Figure 3.6 Aetiology and pathology of breathlessness.
SUMMARY PATHOLOGY The causes of breathlessness centre on the Lungs, Spleen and Kidneys primarily. In breathlessness, Lung-Qi fails to descend. In chronic breathlessness, a difficulty in inhalation indicates Kidney deficiency. A deficiency of the Spleen leads to the formation of Phlegm, which obstructs the descending of Lung-Qi. Liver-Yang or Liver-Fire rising can impair the descending of Lung-Qi and lead to chronic breathlessness. If Lung-Qi is deficient, Blood is not moved and it stagnates in the lungs. This leads to rightheart failure due to retention of fluids in the lungs. When Kidney-Yang is deficient, Heart-Yang becomes deficient; fluids are not transformed and accumulate in the Lungs and Heart.
IDENTIFICATION OF PATTERNS AND TREATMENT For the treatment of breathlessness, it is most important to differentiate Excess from Deficiency. In Excess-type of breathlessness, breathing is shallow and long, the person exhales quickly with a loud noise, there are loud wheezing sounds, there may be a cough
and the pulse is Slippery or Tight and Full. In Deficiencytype of breathlessness, breathing is short and rapid, the person inhales quickly with a low noise and the pulse is Weak. The Complete Book of Jing Yue (1624) says:6 In Excess-breathlessness breathing is long, there is a feeling of oppression of the chest, the breathing sounds are loud, the person cannot hold the breath in and breathes out quickly. In Deficiency-breathlessness breathing is short, the person is flustered, Qi is weak, breathing sounds are weak, breathing is interrupted and is worse on exertion. For the treatment of Excess conditions, one concentrates on treating the Manifestation and on expelling pathogenic factors. For the treatment of Deficiency cases, one concentrates on treating the Root and tonifying the body’s Qi. For example, in breathlessness from Phlegm-Heat (the Manifestation), even though it is a Spleen deficiency (the Root) that leads to Phlegm, the first priority is to resolve Phlegm and clear Heat rather than tonifying the Spleen. On the other hand, in chronic breathlessness from deficiency of Lungs and Kidneys (the Root), the primary task is to tonify Lungs and Kidneys and only secondarily relieve breathlessness and possibly resolve Phlegm (the Manifestation). The patterns analysed will be: Full • Wind-Cold invading the Lungs • Wind-Cold on the Exterior, Phlegm-Fluids in the Interior
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• • • • •
The Practice of Chinese Medicine
Cold on the Exterior, Heat in the Interior Phlegm-Heat in the Lungs Turbid Phlegm in the Lungs Lung-Qi Obstructed Liver-Fire invading the Lungs
Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung and Kidney deficiency • Lung- and Kidney-Yin deficiency • Lung- and Kidney-Yang deficiency, Fluids overflowing to Heart and Lungs • Lung-, Heart- and Kidney-Yang deficiency, Fluids overflowing to the Heart
• LU-6, Accumulation point, is used for acute Lung patterns and it stops breathlessness. • BL-12 and BL-13 with cupping release the Exterior and restore the diffusing and descending of LungQi. Moxa can be applied after needling and cupping if Cold is predominant. • Dingchuan (0.5 cun lateral to Du-14 Dazhui) stops acute breathlessness.
Herbal therapy Prescription MA HUANG TANG Ephedra Decoction
Explanation
Wind-Cold invading the Lungs Clinical manifestations Aversion to cold, shivering, fever, cough, breathlessness, a feeling of oppression of the chest, thin-white mucus, headache, no sweating. Pulse: Floating-Tight. External Wind-Cold invades the Lung’s Defensive-Qi energetic layer and it impairs the diffusing and descending of Lung-Qi; this causes the breathlessness and cough. This situation corresponds either to an acute attack of breathlessness or an acute exacerbation of chronic breathlessness. At this acute stage, the treatment must always be aimed at releasing the Exterior and expelling Wind-Cold even in chronic breathlessness.
Treatment principle Release the Exterior, restore the diffusing and descending of Lung-Qi, expel Wind-Cold.
This is the decoction to release the Exterior and expel Wind-Cold. It has a strong scattering effect and it makes Lung-Qi diffuse and descend. It is particularly indicated for acute breathlessness. This prescription has a definite warm energy and, in order to use it, one should be absolutely certain that the pathogenic factor is Wind-Cold rather than WindHeat.
Modifications • In case of Cold-Phlegm in the Lungs, add Ban Xia Rhizoma Pinelliae preparatum, Chen Pi Pericarpium Citri reticulatae, Su Zi Fructus Perillae, Zi Wan Radix Asteris and Bai Qian Rhizoma Cynanchi stauntonii.
Prescription GUI ZHI JIA HOU PO XING ZI TANG Cinnamomum Decoction plus Magnolia and Prunus
Acupuncture
Explanation
Points
This prescription releases the Exterior by harmonizing Defensive and Nutritive Qi; it relieves fullness of the chest and stops breathlessness. Use this formula if the patient is sweating (which indicates the prevalence of Wind over Cold in invasions of Wind-Cold).
LU-7 Lieque, LU-6 Kongzui, BL-12 Fengmen, BL-13 Feishu, Dingchuan extra-point. All with reducing method, cupping on BL-12 and BL-13. Direct moxa with cones is applicable to BL-12 after needling and cupping.
Explanation • LU-7 releases the Exterior, expels Wind-Cold and restores the diffusing and descending of Lung-Qi.
Three Treasures remedy Expel Wind-Cold Expel Wind-Cold releases the Exterior, expels Wind-Cold and restores the descending and diffusing of Lung-Qi.
Breathlessness (Chuan)
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SUMMARY
Treatment principle
WIND-COLD INVADING THE LUNGS
Release the Exterior, expel Wind-Cold, restore the descending of Lung-Qi, resolve Phlegm.
Points LU-7 Lieque, LU-6 Kongzui, BL-12 Fengmen, BL-13 Feishu, Dingchuan extra-point. All with reducing method, cupping on BL-12 and BL-13. Direct moxa with cones is applicable to BL-12 after needling and cupping. Herbal therapy Prescription MA HUANG TANG Ephedra Decoction Prescription GUI ZHI JIA HOU PO XING ZI TANG Cinnamomum Decoction plus Magnolia and Prunus Three Treasures remedy Expel Wind-Cold
Acupuncture Points LU-7 Lieque, LU-6 Kongzui, LU-5 Chize, BL-12 Fengmen, BL-13 Feishu, Dingchuan extra-point, P-6 Neiguan, ST-40 Fenglong, Ren-22 Tiantu. All with reducing or even method.
Explanation • • • • • • • •
LU-7 releases the Exterior and expels Wind-Cold. LU-6, Accumulation point, relieves breathlessness. LU-5 resolves Phlegm from the Lungs. BL-12 and BL-13 with cupping (with or without needling) release the Exterior. Dingchuan stops acute breathlessness. P-6 opens the chest, relieves a feeling of oppression of the chest and helps breathing. ST-40 resolves Phlegm and opens the chest. Ren-22 stimulates the descending of Lung-Qi and resolves Phlegm.
Wind-Cold on the Exterior, PhlegmFluids in the Interior
Herbal therapy
Clinical manifestations
XIAO QING LONG TANG Small Green Dragon Decoction
Aversion to cold, fever, shivering, headache, no sweating, breathlessness, cough with profuse white-watery sputum, difficulty in lying down, swelling of the limbs. Tongue: sticky-white coating. Pulse: Floating. This corresponds to an invasion of exterior WindCold in a person with a pre-existing condition of Phlegm-Fluids in the Interior. It is a situation of an acute exacerbation of chronic breathlessness. PhlegmFluids usually occur only in the elderly. Besides the typical symptoms and signs of exterior invasion (aversion to cold, shivering, fever, headache, no sweating and Floating pulse), there are symptoms of retention of Phlegm-Fluids in the Interior, i.e. breathlessness, cough with expectoration of profuse white-watery sputum and sticky tongue coating. The swelling of the limbs is due to Phlegm-Fluids retained subcutaneously. The person finds it difficult to lie down because of the Phlegm-Fluids stagnating in the chest.
Prescription
Explanation This decoction simultaneously releases the Exterior and resolves Phlegm-Fluids in the Interior.
SUMMARY WIND-COLD ON THE EXTERIOR, PHLEGMFLUIDS IN THE INTERIOR Points LU-7 Lieque, LU-6 Kongzui, LU-5 Chize, BL-12 Fengmen, BL-13 Feishu, Dingchuan extra-point, P-6 Neiguan, ST-40 Fenglong, Ren-22 Tiantu. All with reducing or even method. Herbal therapy Prescription XIAO QING LONG TANG Small Green Dragon Decoction
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Cold on the Exterior, Heat in the Interior Clinical manifestations
Explanation This formula is specific to release the Exterior and expel Wind-Cold and to clear interior Heat.
Breathlessness, distension or pain in the chest, coarse breathing, runny nose, cough, vomiting of sticky phlegm, feeling of heat, cold limbs, irritability, aches, thirst. Tongue: Red, coating white or yellow. Pulse: Slippery-Rapid. This corresponds to the second stage of an invasion of Wind-Cold, when Wind-Cold is still on the Exterior but interior Heat has already formed. Alternatively, it could occur in an invasion of Wind-Cold in a person with a pre-existing condition of interior Heat. It can therefore be either an acute attack of breathlessness or an acute exacerbation of chronic breathlessness precipitated by an invasion of Wind-Cold on a background of interior Lung-Heat. There are some symptoms of Cold on the Exterior, such as cold limbs, aches and runny nose, and some of interior Heat (of the Lungs), such as irritability, feeling of heat, coarse breathing, thirst, Rapid pulse and Red tongue.
Modifications
Treatment principle
Phlegm-Heat in the Lungs
Clear Heat, restore the descending of Lung-Qi.
Clinical manifestations
Acupuncture Points LU-7 Lieque, LU-6 Kongzui, LU-10 Yuji, LU-5 Chize, LU-1 Zhongfu, L.I.-11 Quchi. Reducing or even method.
Explanation • • • •
LU-7 restores the descending of Lung-Qi. LU-6 relieves acute breathlessness. LU-10 and LU-5 clear Lung-Heat. LU-1, Front-Collecting point, clears Lung-Heat, relieves fullness of the chest and stops breathlessness. • L.I.-11 clears Heat.
Herbal therapy Prescription MA XING SHI GAN TANG Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction
• In case of profuse phlegm, add Huang Qin Radix Scutellariae, Sang Bai Pi Cortex Mori and Gua Lou Fructus Trichosanthis.
SUMMARY COLD ON THE EXTERIOR, HEAT IN THE INTERIOR Points LU-7 Lieque, LU-6 Kongzui, LU-10 Yuji, LU-5 Chize, LU-1 Zhongfu, L.I.-11 Quchi. Reducing or even method. Herbal therapy Prescription MA XING SHI GAN TANG Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction
Cough, breathlessness, pain in the chest, profuse stickyyellow or blood-tinged sputum, irritability, a feeling of oppression in the chest, feeling of heat, sweating, thirst, red face, dry throat, dark urine, constipation. Tongue: Red with sticky-yellow coating. Pulse: Slippery-Rapid. This corresponds to the stage following an invasion of Wind-Cold or Wind-Heat, when the pathogenic factor turns into Heat and it settles in the Lungs. All the symptoms point to Lung-Heat. This pattern occurs often after an invasion of Wind when the pathogenic factor changes into Heat, penetrates the Interior and combines with Phlegm. In such cases, it is the cause of acute breathlessness. Phlegm-Heat in the Lungs is also a very common residual pathogenic factor in the Lungs in chronic breathlessness. It occurs at any age from childhood to old age.
Treatment principle Clear Heat, resolve Phlegm, clear the Lungs.
Breathlessness (Chuan)
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Acupuncture
Turbid Phlegm in the Lungs
Points
Clinical manifestations
LU-5 Chize, LU-1 Zhongfu, L.I.-11 Quchi, ST-40 Fenglong, Du-14 Dazhui. Reducing method, no moxa.
Breathlessness, difficulty in breathing out, a feeling of oppression and fullness of the chest, cough with profuse sticky-white sputum, vomiting or nausea, sticky taste, no thirst. Tongue: Swollen body, thick-sticky-white coating. Pulse: Slippery-Full. This condition is characterized by retention of Damp-Phlegm in the Lungs. Damp-Phlegm severely obstructs the descending of Lung-Qi, resulting in cough and breathlessness. Phlegm also impairs the circulation of Qi in the chest, thus causing a feeling of oppression and fullness of the chest and nausea or vomiting (as it also prevents the descending of Stomach-Qi).
Explanation • LU-5 clears Lung-Heat. • LU-1 clears Lung-Heat and relieves fullness and pain in the chest. • L.I.-11 clears Heat. • ST-40 resolves Phlegm. • Du-14 clears Heat.
Herbal therapy Prescription SANG BAI PI TANG Cortex Mori Decoction
Treatment principle Resolve Phlegm, restore the descending of Lung-Qi.
Explanation This formula clears Lung-Heat, resolves Phlegm and restores the descending of Lung-Qi.
Modifications • In case of high fever, add Shi Gao Gypsum fibrosum and Zhi Mu Radix Anemarrhenae. • In case of profuse phlegm, add Hai Ge Ke Concha Meretricis seu Cyclinae. • In case of intense thirst, add Tian Hua Fen Radix Trichosanthis. • In case of severe breathlessness with inability to lie down and sticky phlegm, add Da Huang Radix et Rhizoma Rhei and Mang Xiao Natrii Sulfas. • If phlegm tastes of bile, add Yu Xing Cao Herba Houttuniae, Dong Gua Zi Semen Benincasae, Yi Yi Ren Semen Coicis and Lu Gen Rhizoma Phragmitis.
SUMMARY
Acupuncture Points LU-5 Chize, LU-7 Lieque, LU-1 Zhongfu, P-6 Neiguan, ST-40 Fenglong, SP-6 Sanyinjiao, Ren-9 Shuifen, BL13 Feishu, BL-20 Pishu. Reducing or even method, except on BL-20 which should be reinforced.
Explanation • LU-5 and LU-7 expel Damp-Phlegm from the Lungs and restore the descending of Lung-Qi. • LU-1 relieves the feeling of oppression of the chest. • P-6 relieves fullness of the chest, stops nausea or vomiting and opens the chest, facilitating the expulsion of Phlegm. • ST-40, SP-6 and Ren-9 resolve Phlegm. • BL-13 stimulates the descending of Lung-Qi. • BL-20 tonifies the Spleen to resolve Phlegm.
PHLEGM-HEAT IN THE LUNGS
Herbal therapy
Points LU-5 Chize, LU-1 Zhongfu, L.I.-11 Quchi, ST-40 Fenglong, Du-14 Dazhui. Reducing method, no moxa.
Prescription
Herbal therapy Prescription SANG BAI PI TANG Cortex Mori Decoction
ER CHEN TANG plus SAN ZI YANG QIN TANG Two Old Decoction plus Three-Seed Nourishing the Parents Decoction
Explanation Er Chen Tang Two Old Decoction resolves Damp-Phlegm. San Zi Yang Qin Tang Three-Seed Nourishing the Parents Decoction was especially formulated to treat old people
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who have chronic Damp-Phlegm in the chest (hence its name).
Acupuncture
Modifications
LIV-3 Taichong, LIV-14 Qimen, SP-4 Gongsun and P-6 Neiguan, LU-1 Zhongfu, Ren-17 Shanzhong, LU-7 Lieque, HE-7 Shenmen, ST-40 Fenglong. All with even method.
• In case of severe breathlessness, other herbs which make Lung-Qi descend, such as Xing Ren Semen Armeniacae, should be added. • In case of profuse phlegm, add Cang Zhu Rhizoma Atractylodis and Hou Po Cortex Magnoliae officinalis.
SUMMARY TURBID PHLEGM IN THE LUNGS Points LU-5 Chize, LU-7 Lieque, LU-1 Zhongfu, P-6 Neiguan, ST-40 Fenglong, SP-6 Sanyinjiao, Ren-9 Shuifen, BL-13 Feishu, BL-20 Pishu. Reducing or even method, except on BL-20 which should be reinforced. Herbal therapy Prescription ER CHEN TANG plus SAN ZI YANG QIN TANG Two Old Decoction plus Three-Seed Nourishing the Parents Decoction
Points
Explanation • LIV-3 and LIV-14 soothe the Liver and relieve stagnation. LIV-14, in particular, will relieve stagnation of Qi in the chest. • SP-4 and P-6 in combination, open the Penetrating Vessel (Chong Mai), free the chest and subdue rebellious Qi in the chest. • LU-1, Ren-17 and LU-7 restore the descending of Lung-Qi, free the chest and relieve fullness. • HE-7 calms the Mind. • ST-40 is used to resolve Qi-Phlegm.
Herbal therapy Prescription WU MO YIN ZI Five Powders Decoction
Explanation
Lung-Qi Obstructed Clinical manifestations
This formula is specific to restore the descending of Lung-Qi when this is obstructed by rebellious Liver-Qi. It also calms the Mind.
Sudden attacks of breathlessness precipitated by emotional problems, no wheezing sounds, feeling of suffocation or constriction in the throat, a feeling of oppression or pain in the chest, palpitations, restless sleep. Tongue: Red sides. Pulse: Wiry. This condition is due to stagnant Liver-Qi rebelling upwards towards the chest. Rebellious Liver-Qi impairs the descending of Lung-Qi and causes breathlessness. This is typically caused by emotional problems, and the attacks are brought on by some stressful situation. The feeling of constriction or suffocation in the throat is due to stagnation of Liver-Qi and obstruction of the throat by Qi-Phlegm, i.e. a very rarefied type of Phlegm to the point of being nearly like Qi.
Liver-Fire invading the Lungs
Treatment principle
Clinical manifestations
Soothe the Liver, move Qi, restore the descending of Lung-Qi, calm the Mind, settle the Ethereal Soul.
Attacks of breathlessness precipitated by emotional stress, a feeling of oppression of the chest, chest pain,
SUMMARY LUNG-QI OBSTRUCTED Points LIV-3 Taichong, LIV-14 Qimen, SP-4 Gongsun and P-6 Neiguan, LU-1 Zhongfu, Ren-17 Shanzhong, LU-7 Lieque, HE-7 Shenmen, ST-40 Fenglong. All with even method. Herbal therapy Prescription WU MO YIN ZI Five Powders Decoction
Breathlessness (Chuan)
dream-disturbed sleep, short temper, thirst, bitter taste, dark urine, constipation, headache, red eyes and face. Tongue: Red, redder and swollen on the sides, yellow coating. Pulse: Wiry and Rapid. This condition includes aspects of the previous one, i.e. rebellious Liver-Qi invading the chest and obstructing the descending of Lung-Qi. In this case, however, it is Liver-Fire that carries Liver-Qi upwards towards the chest. From a Five-Element perspective, it corresponds to Wood “insulting” Metal (i.e. reverse Controlling cycle). Because Fire dries up the body fluids, there is thirst, dark urine and constipation. Fire also affects the Mind causing dream-disturbed sleep. This type of breathlessness is more common and may be seen in nervous, highly-strung children.
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Three Treasures remedy Drain Fire Drain Fire drains Liver-Fire.
SUMMARY LIVER-FIRE INVADING THE LUNGS Points LIV-2 Xingjian, LIV-14 Qimen, LU-7 Lieque, Ren-17 Shanzhong, LU-1 Zhongfu, BL-18 Ganshu, BL-13 Feishu. Reducing or even method. Herbal therapy Prescription LONG DAN XIE GAN TANG Variation Gentiana Draining the Liver Decoction Variation Three Treasures remedy Drain Fire
Treatment principle Soothe the Liver, drain Fire, restore the descending of Lung-Qi, calm the Mind, settle the Ethereal Soul.
Acupuncture Points LIV-2 Xingjian, LIV-14 Qimen, LU-7 Lieque, Ren-17 Shanzhong, LU-1 Zhongfu, BL-18 Ganshu, BL-13 Feishu. Reducing or even method.
Explanation • LIV-2 drains Liver-Fire. • LIV-14 soothes the Liver and relieves stagnation of Qi in the chest and ribs. • LU-7, Ren-17 and BL-13 restore the descending of Lung-Qi. • LU-1 relieves fullness and pain in the chest. • BL-18 drains Liver-Fire.
Herbal therapy Prescription LONG DAN XIE GAN TANG Variation Gentiana Draining the Liver Decoction Variation
Explanation This is a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction that drains Liver-Fire. Sang Bai Pi Cortex Mori, Di Gu Pi Cortex Lycii and Su Zi Fructus Perillae restore the descending of Lung-Qi and clear Heat in the chest.
Case history A 33-year-old woman had been suffering from breathlessness for the previous 2 years. She found it difficult to breathe out, and her attacks were elicited by emotional stress. She also easily felt thirsty and occasionally experienced a bitter taste in her mouth. She frequently had headaches of a throbbing nature on her temples, and she generally felt wound-up and frustrated. She also easily felt hot and occasionally had palpitations. Her pulse was Wiry and her tongue was Red with redder sides and tip, with a shallow midline Heart crack. The sides also had red points. Diagnosis This was a very clear case of breathlessness due to Liver-Fire rebelling upwards towards the chest and obstructing the Lungs. It was also clearly due to emotional tensions mostly to do with her relationship with her father. Although Liver-Fire was the main problem, there was also some Heart-Fire, as shown by the shallow Heart crack, red tip of the tongue and palpitations. Treatment She was treated with herbs only with the following variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction. • Long Dan Cao Radix Gentianae 6 g • Huang Qin Radix Scutellariae 4 g • Shan Zhi Zi Fructus Gardeniae 4 g
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• • • • • • • •
The Practice of Chinese Medicine
Ze Xie Rhizoma Alismatis 6 g Sheng Di Huang Radix Rehmanniae 6 g Chai Hu Radix Bupleuri 6 g Suan Zao Ren Semen Ziziphi spinosae 6 g He Huan Pi Cortex Albiziae 6 g Hou Po Cortex Magnoliae officinalis 3 g Su Zi Fructus Perillae 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g
This is almost like the original decoction with the addition of Suan Zao Ren Semen Ziziphi spinosae and He Huan Pi Cortex Albiziae to calm the Mind, and Hou Po Cortex Magnoliae officinalis to relieve fullness of the chest and also to calm the Mind. The treatment stopped her breathlessness and helped her to calm down and achieve a more balanced emotional life.
Lung-Qi deficiency Clinical manifestations Shortness of breath, weak lung sounds, slight rattling sound in the throat, sweating, chilliness, pale face, weak voice, expectoration of scanty phlegm. Tongue: Pale. Pulse: Weak, especially on the right Front position.
• ST-36 tonifies Stomach and Spleen and this helps the Lungs according to the principle of “strengthening Earth to tonify Metal”.
Herbal therapy Prescription BU FEI TANG Tonifying the Lungs Decoction
Explanation This formula tonifies Lung-Qi and restores the descending of Lung-Qi.
SUMMARY LUNG-QI DEFICIENCY Points LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, Ren-6 Qihai, ST-36 Zusanli. Reinforcing method. Herbal therapy Prescription BU FEI TANG Tonifying the Lungs Decoction
Treatment principle
Lung-Yin deficiency
Tonify the Lungs, strengthen Qi, restore the descending of Lung-Qi.
Clinical manifestations
Acupuncture Points LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, Ren-6 Qihai, ST-36 Zusanli. Reinforcing method.
Explanation • LU-7 and LU-9 tonify the Lungs and restore the descending of Lung-Qi. • BL-13 and Du-12 tonify Lung-Qi. Direct moxa can be used. • Ren-12 and Ren-6 tonify Qi in general and they are also concentration points along the Lung channel, which starts over Ren-12 and flows down to Ren-6 before coursing back upwards.
Shortness of breath, chronic breathlessness, sweating at night, dry throat, dry cough with scanty sputum, malar flush. Tongue: dry and without coating, Red body if there is Empty Heat. Pulse: Floating-Empty or Fine, Rapid and Weak in the right Front position. Lung-Yin deficiency can occur in combination with Lung-Qi deficiency. Yin deficiency is more common in old people. Only in very advanced cases would the tongue be completely without coating. In other cases, it could have a rootless coating or lack a coating only in the front part.
Treatment principle Nourish Lung-Yin and restore the descending of Lung-Qi.
Breathlessness (Chuan)
Acupuncture Points LU-9 Taiyuan, LU-7 Lieque and KI-6 Zhaohai in combination, BL-43 Gaohuangshu, Ren-4 Guanyuan, BL-13 Feishu, Du-12 Shenzhu. Reinforcing method.
Explanation • LU-9 tonifies Lung-Yin. • LU-7 and KI-6 open the Directing Vessel, nourish Yin, restore the descending of Lung-Qi and benefit the throat. The combination of these two points is excellent in cases of chronic breathlessness from Lung-Yin deficiency or both Lung- and Kidney-Yin deficiency. • BL-43 nourishes Lung-Yin and is particularly effective in very chronic diseases. • Ren-4 nourishes Yin in general and strengthens the Kidney’s grasping of Qi. • BL-13 and Du-12 tonify Lung-Qi.
Herbal therapy Prescription SHENG MAI SAN Generating the Pulse Powder
Explanation This is the best prescription to tonify Lung-Yin. However, in cases of chronic breathlessness, herbs that restore the descending of Lung-Qi, such as Xing Ren Semen Armeniacae or Su Zi Fructus Perillae, should be added. Alternatively, this prescription could simply be combined with the previous one. They would combine particularly well also because they have two herbs in common (Ren Shen Radix Ginseng and Wu Wei Zi Fructus Schisandrae).
SUMMARY LUNG-YIN DEFICIENCY Points LU-9 Taiyuan, LU-7 Lieque and KI-6 Zhaohai in combination, BL-43 Gaohuangshu, Ren-4 Guanyuan, BL-13 Feishu, Du-12 Shenzhu. Reinforcing method.
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Herbal therapy Prescription SHENG MAI SAN Generating the Pulse Powder
Lung and Kidney deficiency Clinical manifestations Chronic breathlessness, attacks brought on by exertion, difficulty in inhalation, loss of weight, depression, oedema of ankles, cold limbs, lower backache, dizziness, weak knees. Tongue: Pale, Swollen. Pulse: Deep, Weak, Slow. This condition corresponds to Yang deficiency of both Lungs and Kidneys, with the Kidneys unable to grasp Qi. It results in the situation that is described in Chinese medicine as “Fullness above and Emptiness below”, i.e. deficiency of the Kidneys with relative Fullness in the Lungs. This pattern is due to Kidney-Yang deficiency, hence the oedema of ankles, cold limbs, weak knees, dizziness, depression, Pale and Swollen tongue, and Deep and Weak pulse. As Kidneys control inhalation, typically the patient would find it more difficult to breathe in.
Treatment principle Tonify and warm the Kidneys, stimulate the descending of Lung-Qi.
Acupuncture Points BL-23 Shenshu, BL-13 Feishu, Du-4 Mingmen, KI-7 Fuliu, KI-25 Shencang, KI-3 Taixi, LU-7 Lieque. Reinforcing method, moxa.
Explanation • BL-23 and KI-7 tonify Kidney-Yang. • Du-4 tonifies the Fire of the Gate of Life (Ming Men). Used with moxa, it strongly tonifies Yang. • KI-25 is an important local point to relieve fullness of the chest and breathlessness caused by Kidney deficiency. • KI-3, source point, tonifies the Kidneys. • LU-7 stimulates the descending of Lung-Qi.
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The Practice of Chinese Medicine
Herbal therapy
Three Treasures remedy
Prescription
Clear Qi Clear Qi is a variation of Su Zi Jiang Qi Tang and it tonifies Kidney-Yang and restores the descending of Lung-Qi in chronic breathlessness.
JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill
Explanation
SUMMARY
This is the classic formula to tonify and warm KidneyYang, derived from Zhang’s Discussion of Cold-induced Diseases of the Han dynasty. Later versions of this formula replace Gui Zhi Ramulus Cinnamomi cassiae with Rou Gui Cortex Cinnamomi.
LUNG AND KIDNEY DEFICIENCY
Modifications • When used for chronic Kidney-breathlessness, some herbs which promote the descending of Lung-Qi should be added, such as Su Zi Fructus Perillae or Xing Ren Semen Armeniacae.
Prescription
Points BL-23 Shenshu, BL-13 Feishu, Du-4 Mingmen, KI-7 Fuliu, KI-25 Shencang, KI-3 Taixi, LU-7 Lieque. Reinforcing method, moxa. Herbal therapy Prescription JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill Prescription SHEN GE SAN Ginseng-Gecko Powder
SHEN GE SAN Ginseng-Gecko Powder
Prescription SU ZI JIANG QI TANG Perilla Seed Lowering Qi Decoction
Explanation
Three Treasures remedy Clear Qi
This formula is specific to tonify the Kidney’s receiving of Qi in chronic breathlessness from Kidney-Yang deficiency. It can be used when the symptoms of Yang deficiency are not very pronounced.
Prescription SU ZI JIANG QI TANG Perilla Seed Lowering Qi Decoction
Explanation This prescription differs from the previous two in that it deals with both the “Emptiness below” and the “Fullness above”. It is therefore better indicated when there is pronounced fullness of the chest with expectoration of white phlegm and cough. It deals with both the Manifestation (accumulation of Qi in the Lungs) and the Root (deficiency of the Kidneys).
Modifications • If Qi rebels upwards and there is a feeling of movement under the umbilicus, add Chen Xiang Lignum Aquilariae resinatum.
Case history A 48-year-old woman had been suffering from breathlessness for the previous 10 years. She found it difficult to breathe in and the condition was worse at night. The breathlessness seemed to have started after her being caught in a dust storm in the Middle East, following which she contracted bronchopneumonia. She had had pneumonia previously as a child. She had also experienced fluid retention in the abdomen and ankles for the previous 10 years. She was often constipated and felt cold, especially in the legs. Her pulse was Fine and Deep and particularly Weak in both Rear positions. Her tongue was Pale and Swollen and had a sticky-white coating (Plate 3.1). Diagnosis This is a clear condition of breathlessness from Lung- and Kidney-Yang deficiency. She obviously had had a weakness in the Lungs since childhood
Breathlessness (Chuan)
deriving from the pneumonia, later aggravated by the bronchopneumonia 10 years before. Because of her age, the Kidney energy started to decline and, combining with the Lung deficiency, triggered off the onset of her breathlessness. The Kidney-Yang deficiency is confirmed by the fluid retention, the constipation, the cold feeling of the legs and the very Weak pulse on both Rear positions. Treatment This lady was treated with both acupuncture and herbs. The acupuncture treatment was very simple, basically aimed at tonifying the Lungs and Kidneys with ST-36 Zusanli, SP-6 Sanyinjiao, BL-13 Feishu, Du-12 Shenzhu and BL-23 Shenshu. In addition to these points, the Directing Vessel opening points were used every time, i.e. LU-7 Lieque on the right and KI-6 Zhaohai on the left to tonify Lungs and Kidneys. The herbal prescription used was a variation of Su Zi Jiang Qi Tang Perilla Seed Lowering Qi Decoction. • • • • • • • •
Su Zi Semen Perillae 6 g Fa Ban Xia Rhizoma Pinelliae preparatum 6 g Qian Hu Radix Peucedani 4 g Hou Po Cortex Magnoliae officinalis 4 g Rou Gui Cortex Cinnamomi 1.5 g Dang Gui Radix Angelicae sinensis 6 g Rou Cong Rong Herba Cistanches 6 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g
The combination of acupuncture and Chinese herbs produced an immediate improvement, which then continued steadily until most of her symptoms were relieved after a few months.
Case history A 42-year-old lady had suffered from breathlessness since the age of 7. It had got worse since moving to an old and dusty house 13 years previously. She found it difficult to breathe in, and the condition was worse at night and worse from exposure to cold or dust. She also suffered from lower backache and dizziness. She had borne two children and her breathlessness had been better during both pregnancies. She felt cold easily and her ankles often swelled up. As a 6-month-old baby, she had contracted whooping cough that lasted for a long time.
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Her pulse was Deep and Weak, especially on both Rear positions (Kidneys). Her tongue was Red, Stiff and had a shallow Stomach crack with a yellow coating (Plate 3.2). Diagnosis The breathlessness was due to a deficiency of the Yang of both Lungs and Kidneys. Originally, it may have been due to a Lung deficiency only, following the weakening of the Lungs from whooping cough. Later on, the onset of Kidney deficiency contributed to the breathlessness. Difficulty in breathing in, feeling cold, backache, swollen ankles, dizziness and Weak pulse on Rear positions all indicated Kidney (Yang) deficiency. The fact that she got better during the pregnancies also pointed to a Kidney deficiency. However, the tongue pointed to another coexisting condition of Heat and Phlegm. The deficient Lung and Kidneys failing to transform fluids led to the formation of Phlegm, which further aggravated the breathlessness. After a long time, Phlegm easily leads to the formation of Heat. Thus, this case shows a clear combination of Deficiency (of Lungs and Kidneys) and Excess (Phlegm-Heat in the Lungs) and of Cold (from Kidney-Yang deficiency) and Heat (in the Lungs). The Root is the deficiency of Lung- and Kidney-Yang, while the Phlegm-Heat in the Lungs is the Manifestation. Treatment Because this is an internal condition, we can treat both the Root and the Manifestation simultaneously, i.e. tonifying Lung- and Kidney-Yang, restoring the descending of Lung-Qi and resolving Phlegm and clearing Heat. As the pathogenic factor is internal, we can simultaneously tonify the body’s Qi (i.e. Lung- and Kidney-Yang) and expel the pathogenic factor (i.e. Phlegm-Heat). She was treated with acupuncture only using the following points at various times during 12 months of treatment: • Ren-12 Zhongwan, Ren-9 Shuifen and ST-40 Fenglong were used to resolve Phlegm. In addition, ST-40, in combination with P-6 Neiguan, opens the chest and helps breathing. • P-6 Neiguan was used to open the chest and alleviate breathlessness. • Directing Vessel (i.e. LU-7 Lieque on the right and KI-6 Zhaohai on the left) was used several times to restore the descending of Lung-Qi and stimulate the Kidney’s grasping of Qi. This
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extraordinary vessel is very important for the treatment of chronic breathlessness from Lung and Kidney deficiency. • BL-13 Feishu, BL-20 Pishu and BL-23 Shenshu were used to tonify and warm Lungs, Spleen and Kidneys with needles and moxa. • LU-5 Chize was used to clear Heat and resolve Phlegm from the Lungs. • KI-7 Fuliu and SP-6 Sanyinjiao were used to tonify Spleen- and Kidney-Yang and resolve oedema. Needles and moxa were used. This patient’s attacks of breathlessness drastically decreased in intensity and frequency over a 12-month period of treatment.
Case history A 39-year-old woman had suffered from breathlessness since the age of 4. She found it difficult to breathe in, sweated easily in the daytime and usually felt cold. She tired easily and also suffered from what was diagnosed as allergic rhinitis. Her nose was almost always running (white mucus), and she frequently sneezed when exposed to dust and to dogs or cats. She also had myomas in the uterus, which occasionally caused bleeding in between periods. The blood was not dark and there were no clots. Her pulse was generally Weak and her tongue was Pale, with swollen edges (of the Spleen-type), a dirty coating all over and two deep transversal cracks in the Lung area. Diagnosis This breathlessness is also due to Lungand Kidney-Yang deficiency. It started in childhood with a Lung deficiency most probably due to repeated invasions of Wind not treated properly (see two transversal Lung cracks). It later affected the Kidneys, as well as becoming unable to grasp Qi. The Spleen is also deficient as evidenced by the tiredness, the swelling on the edges of the tongue and the Weak pulse. Symptoms of Lung deficiency are the breathlessness and the daytime sweating. The difficulty in breathing in is due to Kidney deficiency. Besides this, there is also Phlegm deriving from the deficiency of Spleen, Lungs and Kidneys. The Phlegm can be observed in the swelling of the tongue, the dirty tongue coating and the myomas in the uterus (these could also be
due to stasis of Blood, but this was not the case in this instance as the blood was not dark with clots). Treatment In this case, as in the previous one, the condition is internal and we can treat both the Root (deficiency of Yang of the Spleen, Lungs and Kidneys) and the Manifestation (Phlegm). On the one hand, one can tonify the body’s Qi, and on the other one can resolve Phlegm. This woman was treated with acupuncture only with the following selection of points over a period of 8 months. • Directing Vessel (i.e. LU-7 Lieque on the right and KI-6 Zhaohai on the left). This combination of points opens the Directing Vessel, restores the descending of Lung-Qi and stimulates the grasping of Qi by the Kidneys. • Ren-12 Zhongwan, Ren-9 Shuifen and ST-40 Fenglong to resolve Phlegm. • ST-36 Zusanli and BL-20 Pishu with needles and moxa to warm and tonify the Spleen. • BL-13 Feishu and Du-12 Shenzhu to tonify and warm the Lungs. • BL-23 Shenshu and KI-7 Fuliu to tonify and warm the Kidneys. • L.I.-20 Yingxiang to expel Wind and stop sneezing.
Lung- and Kidney-Yin deficiency Clinical manifestations Chronic breathlessness, difficulty in breathing in, dry throat, dry cough, night sweating, malar flush. Tongue: without coating, cracks in Lung area, dry, Red body if there is Empty Heat. Pulse: Floating-Empty. Generally speaking, the Kidney’s grasping Qi is a Yang function. However, when Kidney-Yin is deficient, it also fails to grasp Qi, leading to breathlessness.
Treatment principle Nourish Yin, strengthen Lung and Kidneys, restore the descending of Lung-Qi.
Acupuncture Points LU-9 Taiyuan, Ren-17 Shanzhong, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, Ren-4 Guanyuan, KI-3
Breathlessness (Chuan)
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SUMMARY
Taixi, LU-7 Lieque and KI-6 Zhaohai in combination, KI-25 Shencang. All with reinforcing method except KI-25, which should be needled with even method.
LUNG- AND KIDNEY-YIN DEFICIENCY Points LU-9 Taiyuan, Ren-17 Shanzhong, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, Ren-4 Guanyuan, KI-3 Taixi, LU-7 Lieque and KI-6 Zhaohai in combination, KI-25 Shencang. All with reinforcing method except KI-25 which should be needled with even method.
Explanation • LU-9 and Ren-17 tonify the Lungs and promote the descending of Lung-Qi. • ST-36 and Ren-12 strengthen Earth to reinforce Metal. • SP-6 and Ren-4 nourish Yin. • KI-3 nourishes the Kidneys. • LU-7 and KI-6 nourish Kidney-Yin, restore the descending of Lung-Qi, and benefit the throat. They open the Directing Vessel and are ideal for this type of breathlessness. • KI-25 is a local point to stimulate the Kidney’s grasping of Qi in chronic breathlessness from Kidney deficiency.
Herbal therapy Prescription BA XIAN CHANG SHOU WAN Eight Immortals Longevity Pill Prescription EMPIRICAL PRESCRIPTION BY DR DONG JIAN HUA8
Herbal therapy Prescription BA XIAN CHANG SHOU WAN Eight Immortals Longevity Pill
Explanation This is the main formula for deficiency of both Lungand Kidney-Yin. It is a variation of Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill (which nourishes Liver- and Kidney-Yin), with the addition of Mai Men Dong Radix Ophiopogonis and Wu Wei Zi Fructus Schisandrae to nourish Lung-Yin and absorb leakages (such as night sweating).
Modifications • To treat chronic breathlessness, one or two herbs to stimulate the descending of Lung-Qi should be added, as indicated for the previous prescriptions. • In the case of symptoms of rising Yang (such as dizziness and headaches), add Long Gu Mastodi Ossis fossilia and Mu Li Concha Ostreae.
Prescription EMPIRICAL PRESCRIPTION BY Dr Dong Jian Hua7
Explanation This formula tonifies both Kidney-Yin and KidneyYang as well as Lung-Yin; it promotes the descending of Lung-Qi and stops breathlessness.
Case history A 43-year-old man had complained of hay fever and breathlessness for the past 18 years. He found it difficult to breathe in and often sweated at night. His lower back was sore and he suffered from slight tinnitus in one ear. His throat was dry. His pulse was slightly Floating-Empty in general and Weak in the right Front position. His tongue was slightly Red, with rootless coating, and dry. Diagnosis This man’s breathlessness was due to Lungand Kidney-Yin deficiency. The Lung-Yin deficiency is evident from the dry throat and the rootless coating on the tongue. The Kidney-Yin deficiency caused the backache, tinnitus, difficulty in breathing in, night sweating and Floating-Empty pulse. Treatment A variation of Ba Xian Chang Shou Wan Eight Immortals Longevity Pill was used. • • • • • • • •
Shu Di Huang Radix Rehmanniae preparata 12 g Shan Zhu Yu Fructus Corni 4 g Shan Yao Rhizoma Dioscoreae 6 g Ze Xie Rhizoma Alismatis 4 g Mu Dan Pi Cortex Moutan 4 g Fu Ling Poria 6 g Mai Men Dong Radix Ophiopogonis 6 g Wu Wei Zi Fructus Schisandrae 4 g
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• Xing Ren Semen Armeniacae 4 g • Su Zi Semen Perillae 6 g • Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g
Herbal therapy
Lung- and Kidney-Yang deficiency, Fluids overflowing to Heart and Lungs
Explanation
Clinical manifestations Chronic breathlessness, cough with expectoration of white-watery sputum, a feeling of oppression of the chest, palpitations, oedema, scanty urination, chilliness. Tongue: Pale, Swollen, wet. Pulse: Deep-Weak-Slow. This condition is due to deficiency of Yang of Lung and Kidneys, leading to the accumulation of PhlegmFluids in the Lungs and Heart. The expectoration of white-watery sputum is typical of Phlegm-Fluids.
Prescription ZHEN WU TANG Variation True Warrior Decoction Variation
This formula tonifies and warms Spleen- and KidneyYang, restores the descending of Lung-Qi and resolves Phlegm-Fluids.
Modifications • In cases of Heart-Yang deficiency as well, with Phlegm-Fluids in the Heart leading to stasis of Blood (purple face, cyanotic lips, dark nails, Purple tongue), add Dan Shen Radix Salviae miltiorrhizae, Hong Hua Flos Carthami tinctorii, Tao Ren Semen Persicae and Chuan Xiong Rhizoma Chuanxiong.
Treatment principle
SUMMARY
Tonify and warm Lung and Kidneys, resolve PhlegmFluids, stimulate the descending of Lung-Qi.
LUNG- AND KIDNEY-YANG DEFICIENCY, FLUIDS OVERFLOWING TO HEART AND LUNGS
Acupuncture Points LU-7 Lieque, L.I.-6 Pianli, Ren-17 Shanzhong, Ren-12 Zhongwan, Ren-9 Shuifen, KI-7 Fuliu, Ren-6 Qihai, SP-6 Sanyinjiao, ST-40 Fenglong, P-6 Neiguan, BL-20 Pishu, BL-23 Shenshu, BL-22 Sanjiaoshu, BL-13 Feishu, BL-15 Xinshu. All with reinforcing method except for LU-7, L.I.-6 and Ren-9, which should be needled with even method. Moxa.
Explanation • LU-7, L.I.-6 and Ren-17 stimulate the descending of Lung-Qi and open the Lung Water passages to resolve oedema. • Ren-12, Ren-9 and Ren-6 tonify Qi and resolve oedema. • KI-7 and SP-6 tonify the Kidneys and resolve oedema. • ST-40 resolves Phlegm. • P-6 opens the chest, thus relieving the feeling of oppression of the chest, and tonifies Heart-Yang. • BL-20, BL-23 and BL-22 tonify Spleen- and KidneyYang and stimulate the transformation of fluids in the Lower Burner to resolve oedema. • BL-13 and BL-15 tonify Lung- and Heart-Yang.
Points LU-7 Lieque, L.I.-6 Pianli, Ren-17 Shanzhong, Ren-12 Zhongwan, Ren-9 Shuifen, KI-7 Fuliu, Ren-6 Qihai, SP-6 Sanyinjiao, ST-40 Fenglong, P-6 Neiguan, BL-20 Pishu, BL-23 Shenshu, BL-22 Sanjiaoshu, BL-13 Feishu, BL-15 Xinshu. All with reinforcing method except for LU-7, L.I.-6 and Ren-9 which should be needled with even method. Moxa. Herbal therapy Prescription ZHEN WU TANG Variation True Warrior Decoction Variation
Lung-, Heart- and Kidney-Yang deficiency, Fluids overflowing to the Heart Clinical manifestations Chronic breathlessness, a feeling of oppression and pain of the chest, nausea, cyanotic lips, purple face and nails, expectoration of white-watery sputum, difficulty in lying down, oedema, chilliness, lower backache, weak knees, scanty but pale urine.
Breathlessness (Chuan)
Tongue: Bluish-Purple and Swollen. Pulse: Deep-Slow-Knotted. This condition only occurs in old people suffering from chronic breathlessness. It is characterized by deficiency of Yang of Lungs, Kidneys and Heart leading to the formation of Phlegm-Fluids (manifesting with white-watery expectoration). These overflow to the Lungs and Heart. In the Lungs, they further impair the descending of Lung-Qi and aggravate the breathlessness. In the Heart, they obstruct the circulation of Blood in the chest, leading to pain in the chest and cyanotic colour of face, nails, lips and tongue. The deficiency of Kidney-Yang causes backache, weak knees and scanty urination.
Treatment principle Tonify and warm Lungs, Heart and Kidneys, resolve Phlegm, restore the descending of Lung-Qi, invigorate Blood and eliminate stasis.
Acupuncture Points LU-7 Lieque, L.I.-6 Pianli, Ren-17 Shanzhong, Ren-12 Zhongwan, Ren-9 Shuifen, KI-7 Fuliu, Ren-6 Qihai, SP-6 Sanyinjiao, ST-40 Fenglong, P-6 Neiguan, BL-20 Pishu, BL-23 Shenshu, BL-22 Sanjiaoshu, BL-13 Feishu, BL-15 Xinshu, BL-17 Geshu, SP-10 Xuehai. Reinforcing method except on LU-7, L.I.-6, Ren-9, SP-6 and ST-40, which should be needled with even method. Moxa.
Explanation • LU-7, L.I.-6 and Ren-17 stimulate the descending of Lung-Qi and open the Lung’s Water passages to resolve oedema. • Ren-12, Ren-9 and Ren-6 tonify Qi and resolve oedema. • KI-7 and SP-6 tonify the Kidneys and resolve oedema. • ST-40 resolves Phlegm. • P-6 opens the chest thus relieving the feeling of oppression and tonifies Heart-Yang. • BL-20, BL-23 and BL-22 tonify Spleen- and KidneyYang and stimulate the transformation of fluids in the Lower Burner to resolve oedema. • BL-13 and BL-15 tonify Lung- and Heart-Yang. • BL-17 and SP-10 move Blood and eliminate stasis.
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Herbal therapy Prescription LING GUI ZHU GAN TANG, LING GAN WU WEI JIANG XIN TANG and ZHEN WU TANG Variation Poria-Cinnamomum-Atractylodes-Glycyrrhiza Decoction, Poria-Glycyrrhiza-Schisandra-Zingiber-Asarum Decoction and True Warrior Decoction Variation
Explanation Although this is a variation of three prescriptions, there is quite an overlap of ingredients among the three prescriptions so that the total ingredients are not too many. The first prescription, Ling Gui Zhu Gan Tang (Poria-Cinnamomum-Atractylodes-Glycyrrhiza Decoction), tonifies Spleen-Yang and resolves PhlegmFluids in the chest. It alleviates nausea, a feeling of oppression of the chest and breathlessness. The second prescription, Ling Gan Wu Wei Jiang Xin Tang (Poria-Glycyrrhiza-Schisandra-Zingiber-Asarum Decoction), warms the Lungs, resolves Phlegm-Fluids and relieves breathlessness and a feeling of oppression of the chest. The third prescription, used for the previous pattern, tonifies Spleen- and Kidney-Yang and resolves oedema. To these three prescriptions were added Chuan Xiong Rhizoma Chuanxiong and Dan Shen Radix Salviae miltiorrhizae to move Blood in the chest and eliminate stasis, and Sang Bai Pi Cortex Mori and Su Zi Fructus Perillae to restore the descending of Lung-Qi.
SUMMARY LUNG-, HEART- AND KIDNEY-YANG DEFICIENCY, FLUIDS OVERFLOWING TO THE HEART Points LU-7 Lieque, L.I.-6 Pianli, Ren-17 Shanzhong, Ren-12 Zhongwan, Ren-9 Shuifen, KI-7 Fuliu, Ren-6 Qihai, SP-6 Sanyinjiao, ST-40 Fenglong, P-6 Neiguan, BL-20 Pishu, BL-23 Shenshu, BL-22 Sanjiaoshu, BL-13 Feishu, BL-15 Xinshu, BL-17 Geshu, SP-10 Xuehai. Reinforcing method except on LU-7, L.I.-6, Ren-9, SP-6 and ST-40, which should be needled with even method. Moxa.
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Herbal therapy Prescription LING GUI ZHU GAN TANG, LING GAN WU WEI JIANG XIN TANG and ZHEN WU TANG Variation Poria-Cinnamomum-Atractylodes-Glycyrrhiza Decoction, Poria-Glycyrrhiza-Schisandra-ZingiberAsarum Decoction and True Warrior Decoction Variation
• • • • • • • •
Gan Jiang Rhizoma Zingiberis 1.5 g Fu Zi Radix Aconiti lateralis preparata 3 g Bai Shao Radix Paeoniae alba 6 g Dan Shen Radix Salviae miltiorrhizae 4 g Chuan Xiong Rhizoma Chuanxiong 4 g Sang Bai Pi Cortex Mori 6 g Su Zi Fructus Perillae 6 g Xing Ren Semen Armeniacae 4 g
PROGNOSIS AND PREVENTION Case history A 75-year-old woman suffered from breathlessness for 40 years. The breathlessness started after double pneumonia and collapse of a lung. She was treated with prednisolone for many years. She found it difficult to breathe in or out, had a sensation of oppression of the chest and slight nausea. Her lips were slightly cyanotic and she expectorated white-watery sputum. She easily felt cold and her back and knees ached. Occasionally she felt palpitations. Her tongue was very Pale but also Bluish on the sides (chest area) and very Swollen. Her pulse was Deep, Weak and Slow. It was particularly Weak on both Rear positions. Diagnosis This condition is due to extreme deficiency of Yang of the Lungs, Heart, Spleen and Kidneys, leading to Phlegm-Fluids in the Lungs and Heart. Treatment Because of her age and the prolonged use of prednisolone, her condition could be only improved, not cured. She was treated with herbal medicine using a variation of Ling Gui Zhu Gan Tang, Ling Gan Wu Wei Jiang Xin Tang and Zhen Wu Tang (Poria-Ramulus Cinnamomum-Atractylodes-Glycyrrhiza Decoction, Poria-Glycyrrhiza-Schisandra-ZingiberAsarum Decoction and True Warrior Decoction). • • • •
Fu Ling Poria 10 g Gui Zhi Ramulus Cinnamomi cassiae 3 g Bai Zhu Rhizoma Atractylodis macrocephalae 9 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 3 g • Wu Wei Zi Fructus Schisandrae 4 g
Both acupuncture and herbal medicine are effective in treating breathlessness. The kind of results obtained depends on the duration of the disease and the condition of the patient. Generally speaking, acute patterns respond very quickly while chronic conditions obviously respond slowly. For example, the first three patterns described, i.e. Wind-Cold invading the Lungs, Wind-Cold on the Exterior, Phlegm-Fluids in the Interior and Cold on the Exterior, Heat in the Interior are acute conditions and should therefore respond to treatment in a few sessions with a combination of acupuncture and herbs. The other Excess patterns of Phlegm-Heat in the Lungs, Turbid Phlegm in the Lungs, Lung-Qi Obstructed and Liver-Fire invading the Lungs will take longer to treat – between a few weeks and a few months, depending on the severity of the condition. The one of these four patterns that is most difficult to treat is that of Turbid Phlegm in the Lungs. Of the Deficiency patterns, the most difficult to treat is that of Lung-, Heart- and Kidney-Yang Deficiency. This is a very chronic condition that occurs only in old people and is characterized by the presence of PhlegmFluids affecting both Heart and Lungs. Phlegm-Fluids are a type of Phlegm that is always very difficult to treat. As for the relative importance of acupuncture and herbs, in general herbs are necessary whenever there is Phlegm, as they are better than acupuncture at resolving Phlegm. Acupuncture on its own gives particularly good results in the two Liver-related patterns, i.e. Lung-Qi Obstructed and Liver-Fire insulting the Lungs. As for prevention, after a successful treatment it is important to take certain preventive measures so that the breathlessness will not recur.
Breathlessness (Chuan)
Diet A person who has been successfully treated for breathlessness should abstain from eating dairy foods (milk, cheese, butter, cream, yoghurt, ice cream) because these tend to form Phlegm, which easily settles in the Lungs and obstructs breathing. For the same reason, greasy and fried foods should be kept to a minimum. It is also best to advise the patient not to eat too much fresh fruit and raw vegetables. Although in moderation these foods are beneficial, in excess they also tend to form Phlegm and injure Yang. This advice is particularly important for those patients whose breathlessness was caused by deficiency of Yang.
Life habits Persons who suffer from breathlessness should take great care in protecting themselves adequately from wind and cold. All too often, the dictates of fashion are not conducive to sensible dressing. Patients who have been suffering from breathlessness should especially take care to protect the upper back and chest.
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• Gan Sui Radix Euphorbiae Kansui • She Xiang Moschus • Yan Hu Suo Rhizoma Corydalis Grind these herbs (She Xiang can be omitted, as it is very expensive) into a powder in a coffee grinder, add ginger juice and honey, shape into tiny pieces (about the size of an “O”), place on a plaster and stick this on the acupuncture points. Keep the plasters on not longer than 2 hours, as the herbs are blistering. Patients who are prone to Lung-Qi deficiency could take a course of Yu Ping Feng San Jade Wind Screen Powder towards the end of August of each year. Patients who are prone to Kidney deficiency can take the patent remedy Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill (or Herbal Sentinel-Yang in the Three Treasures range) during the winter months. In case of Kidney-Yin deficiency, they should take Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill instead (or Herbal Sentinel-Yin in the Three Treasures range).
WESTERN DIFFERENTIAL DIAGNOSIS Preventive treatment Both moxa and herbs can be used to prevent a recurrence of breathlessness. Indirect moxibustion with garlic can be applied in the summertime at 10-day intervals on the following three groups of points. • First group: — extra-point Bai Lao (on the occiput 1 cun below the hairline and 1 cun from the midline) — BL-13 Feishu — BL-43 Gaohuangshu • Second group: — Du-14 Dazhui — BL-12 Fengmen — BL-20 Pishu • Third group: — BL-11 Dashu — BL-13 Feishu — BL-23 Shenshu A herbal plaster can also be applied on the same three groups of points at the same interval in summertime. The herbs used for the plaster are: • Bai Jie Zi Semen Sinapis albae • Xi Xin Herba Asari
Dyspnoea (breathlessness) can have many different causes in Western medicine. However, apart from general causes such as anaemia, they all relate either to the lungs or the heart. In fact, breathlessness can arise either from a disease of the lungs themselves (such as asthma, bronchitis or emphysema) or from a heart disease affecting the lungs (such as left ventricular heart failure). The most common causes of chronic breathlessness have been summarized with a diagram (Fig. 3.7).
Causes in Lungs Asthma This consists of the constriction of the bronchi on exhalation. It may arise during childhood in atopic individuals, i.e. those who easily form antibodies to commonly encountered allergens such as house dust, pollen or house dust mites. Such patients often suffer from other allergic diseases such as allergic rhinitis or atopic eczema. This is called early-onset or extrinsic asthma and will be discussed in a separate chapter (Chapter 5). In other cases, it starts in later life in nonatopic individuals and is called late-onset or intrinsic
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DYSPNOEA HEART
Left heart failure
GENERAL
Anaemia
Figure 3.7 Causes of breathlessness in Western medicine.
asthma. This type of asthma is not due to an allergic reaction. In both types, the main manifestations are breathlessness on exertion and wheezing and coughing, which may be worse at night.
Chronic bronchitis This is due to narrowing of the bronchioles by mucus and oedema of mucous membranes within the lungs. It is this narrowing that causes the breathlessness. This condition occurs in middle-aged or elderly people, and the main distinguishing sign to differentiate it from asthma is a chronic productive cough with abundant expectoration. It also differs from asthma in so far as the breathlessness is often worse in the morning (rather than at night, as in asthma). Another feature of this condition is the propensity to frequent chest infections.
With time, chronic bronchitis may lead to emphysema, i.e. over-distension of the alveoli.
Emphysema This condition is due to a permanent and irreversible over-distension of the alveoli. It frequently develops from chronic bronchitis, as explained above. After years of over-distension, an increasing proportion of the alveolar wall disintegrates with progressive obliteration of the vascular bed of the lungs. This is the most common cause of right ventricular heart failure, which, in itself, also causes breathlessness. The main clinical features are breathlessness first on exertion and, with time, also at rest. In severe cases, the breathlessness is constant, the chest movements are limited, the breath sounds inaudible and there may be cyanosis. Emphysema can be clearly differentiated from asthma, as the breathlessness is constant, whereas in asthma it comes in bouts. It can be differentiated from chronic bronchitis, as there is no cough or abundant sputum. The differentiation between asthma, chronic bronchitis and emphysema is important for prognosis, as the first two react well to acupuncture and herbal treatment, while emphysema reacts less so (Table 3.1).
Bronchial carcinoma This is statistically the most common of all carcinomas, and it accounts for 40% of all male deaths from malignant disease. The main clinical manifestations are a cough, with scanty sputum that may be blood-tinged, chest pain and breathlessness, although this may appear only in quite late stages.
Table 3.1 Comparison of asthma, chronic bronchitis and emphysema Asthma
Chronic bronchitis
Emphysema
Frequency
Bouts of dyspnoea
Bouts of dyspnoea with chest infections
Constant dyspnoea
Time
Worse at night
Worse in the morning
All the time
Allergies
Yes
No
No
Sputum
No
Yes
Yes
Breathlessness (Chuan)
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Table 3.2 Synopsis of causes of breathlessness Disease
Pathology
Symptoms
Signs
Asthma
Bronchospasm
Bouts of dyspnoea
Wheezing sound
Chronic bronchitis
Narrowing of bronchi by mucus
Dyspnoea, stuffiness of chest
Cough with abundant sputum
Emphysema
Distension of alveoli
Constant dyspnoea
Thin chest
Carcinoma of bronchi
Tumour obstructing bronchi
Chest pain, cough, dyspnoea, tiredness, poor appetite
Blood-tinged sputum, weight loss
Left heart failure
Blood accumulating in lungs and pulmonary veins
Dyspnoea on exertion, gasping for breath, palpitations, giddiness, nausea, vomiting
Watery-frothy sputum, intervals of apnoea lasting 20–30 seconds, pulsus alternans
Anaemia
Reduced red blood cells
Dyspnoea, tiredness
Pallor
Causes in Heart
General causes
Left heart failure
Anaemia
When the left ventricle of the heart loses strength of contraction, blood accumulates behind the left ventricle in the pulmonary veins and lungs. The resulting pulmonary congestion reduces the supply of oxygen to the alveoli and causes breathlessness. Left ventricular failure may be caused by:
Breathlessness on exertion is a feature of anaemia. The causes of breathlessness are summarized in Table 3.2.
• • • •
cardiac infarction aortic disease mitral incompetence essential hypertension.
The patient is severely breathless on exertion and has to sit up in bed to breathe, gasping for breath. He or she may wake up suddenly and feel hot. The breathlessness gets progressively worse until it is constant. There may also be a cough at night with watery-frothy sputum, palpitations, giddiness, nausea, vomiting, diarrhoea and abdominal pain. The phenomenon of pulsus alternans may be heard on the sphygmomanometer: at the upper limit, only half the heartbeats come through, but when the pressure is lowered by 10 mmHg or more all the beats become audible. For example, at 180 mmHg the pulse rate may appear to be 50, while at 160 mmHg it is 100.
END NOTES 1. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 147. First published c.100 BC. 2. Ibid., p. 336. 3. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 55. First published c.100 BC. 4. He Ren 1979 Jin Gui Yao Lue Tong Su Jiang Hua [A Popular Guide to the Essential Prescriptions of the Golden Chest]. Shanghai Science Publishing House, Shanghai, p. 46. The Essential Prescriptions of the Golden Chest was written by Zhang Zhong Jing and first published c.AD 220. 5. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue [Internal Medicine]. Shanghai Science Publishing House, Shanghai, p. 66. 6. 1986 Jing Yue Quan Shu [Complete Book of Jing Yue]. Shanghai Science Publishing House, Shanghai, p. 345. The Complete Book of Jing Yue was written by Zhang Jing Yue and first published in 1624. 7. Tian Hai He 1990 [Dr Dong Jian Hua’s Experience in Treating Asthma]. Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi ) 31(6): 18. 8. Ibid., p. 18.
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CHAPTER 4
WHEEZING (XIAO)
AETIOLOGY 102 External pathogenic factors Irregular diet 102 Weak body condition 102 PATHOLOGY
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IDENTIFICATION OF PATTERNS AND TREATMENT Cold Phlegm 103 Hot Phlegm 104 Lung deficiency 105 Spleen deficiency 106 Kidney deficiency 108 MODERN CHINESE LITERATURE
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PROGNOSIS AND PREVENTION
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WESTERN DIFFERENTIATION Acute bronchitis 111 Chronic bronchitis 111 Asthma 111
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ACUTE PHASE • Cold Phlegm • Hot Phlegm CHRONIC PHASE • Lung deficiency • Spleen deficiency • Kidney deficiency
WHEEZING (XIAO) Xiao indicates a wheezing sound that may resemble that of whistling, snoring or sawing. It is usually accompanied by breathlessness and an inability to breathe when lying down.
The Essential Prescriptions of the Golden Chest by Dr Zhang Zhong Jing was the first book to refer to wheezing: “For cough with a moor-hen sound in the throat, use Belamcanda-Ephedra Decoction.”1 The “moorhen sound in the throat” is wheezing. In later times, wheezing was also variously described as “hidden Yin”, “sip cough”, “howling wheezing” and “snoring wheezing”. In subsequent dynasties, the symptoms of wheezing (Xiao) and breathlessness (Chuan) were not clearly differentiated. Dr Zhu Dan Xi (1281–1358) was the first to use the term Xiao-Chuan and considered it due to Phlegm. He therefore indicated that the main principle of treatment was to tonify the body’s Qi and, in acute cases, expel pathogenic factors. The book Orthodox Medical Record (1515) by Dr Yu Tuan distinguishes between Wheezing (Xiao) and Breathlessness (Chuan) for the first time:2 Wheezing is named after its sound, Breathlessness after the breath. If breathing is rapid and there is a sound in the throat like a moor-hen, it is Wheezing [Xiao]; if breathing is rapid continuously and there is breathlessness, it is called Breathlessness [Chuan]. The Case Reports for Clinical Practice (1766) by Dr Ye Gui differentiates the two conditions by saying:3 If the pathogenic factor is expelled, breathlessness [Chuan] stops and will never return. In wheezing [Xiao], the pathogenic factor is hidden in the Interior and in the Lungs, it is sometimes active and sometimes quiescent, and there are frequent episodes over many years. Doctors of subsequent dynasties reverted to considering Wheezing and Breathlessness as one condition. In modern China they are also considered together, and modern books usually say that they may correspond to the two separate conditions of “bronchial asthma”
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or “asthmatic bronchitis” (chronic bronchitis leading to breathlessness). There are different types of asthma, and they may be summarized in three groups. 1. Allergic (or atopic) asthma, which starts in early childhood and is often associated with eczema; this will be discussed in a separate chapter (Chapter 5). 2. Asthma that starts early during childhood after repeated invasions of external Wind leading to chest infections. This is customarily due to chronic retention of a residual pathogenic factor (usually Phlegm). 3. Asthma that starts later in life as a consequence of repeated invasions of exterior Wind, irregular diet, emotional strain, overwork and excessive sexual activity. This is may be due to a combination of factors, such as chronic retention of a residual pathogenic factor (usually Phlegm) together with lifestyle factors that lead to Phlegm. The symptom of “Wheezing” discussed in this chapter corresponds to numbers 2 and 3 above. The discussion of Wheezing will be conducted according to the following topics. • • • • • •
Aetiology Pathology Identification of patterns and treatment Modern Chinese literature Prognosis and prevention Western differentiation
AETIOLOGY External pathogenic factors External Wind-Cold or Wind-Heat may invade the body, penetrate deeper and settle in the Lungs. Here the pathogenic factor obstructs Lung-Qi, which then cannot transform fluids, and the fluids accumulate into Phlegm.
Irregular diet The excessive consumption of cold, sour, or sweetgreasy foods injures the Spleen so that it cannot transform and transport food essences properly. When this happens, Phlegm forms; it accumulates in the
Lungs, obstructs Lung-Qi and causes wheezing. Old books distinguished between “food-wheezing”, “sugarwheezing” and “sour-wheezing” according to the particular type of food responsible.
Weak body condition A weakened body condition after a long illness (which in children may happen after measles or whooping cough) may deplete Lung-Qi and Spleen-Qi. When this happens, fluids are not transformed properly and Phlegm forms. If the Yin of the body is depleted, Empty Heat arises; this evaporates and condenses fluids into Phlegm.
PATHOLOGY The main pathological factor in Wheezing is “hidden Phlegm” stored in the Lungs. The upwards movement of Phlegm propelled by rebellious Qi narrows the airways and causes wheezing. The Supplement to Diagnosis and Treatment (1687) by Li Yong Cui says:4 Chronic wheezing and breathlessness are due to: 1) obstruction of Qi in the Interior; 2) an attack of an exterior pathogenic factor; 3) sticky Phlegm in the diaphragm. These three factors combine to obstruct the Qi passages and when breath is forced out there is a wheezing sound. Factors that may trigger the upwards movement of rebellious Qi and Phlegm are weather changes, diet, emotional stress and overwork. Phlegm may be cold or hot. Cold Phlegm may derive from frequent exposure to cold, which injures the Lungs, or from excessive consumption of cold foods, which injure Spleen-Yang. Cold Phlegm is more likely to be stirred by external pathogenic factors. It both derives from and causes Yang deficiency. Hot Phlegm may derive from excessive consumption of sour, sweet or greasy foods. Yin deficiency may contribute to forming Phlegm-Heat. In chronic cases, Cold Phlegm injures Spleen-Yang while Hot Phlegm injures Lung-Yin. The disease becomes therefore characterized by a combination of Fullness (Phlegm) and Emptiness (of the Lungs, Spleen or Kidneys). Deficient Lungs, Spleen and Kidney may in turn all lead to Phlegm. In particular, if KidneyYang is deficient there will be Cold Phlegm; if KidneyYin is deficient there will be Phlegm-Heat.
Wheezing (Xiao)
In severe and prolonged cases, when the deficient Lungs fail to control the blood vessels and harmonize the channels, Heart-Blood cannot circulate properly, the Fire of the Gate of Life (Ming Men) cannot rise to the Heart and this causes a deficiency of Heart-Yang.
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Treatment principle Warm the Lungs, scatter Cold, resolve Phlegm, relieve breathlessness.
Acupuncture Points
IDENTIFICATION OF PATTERNS AND TREATMENT In order to apply the correct principle of treatment, a clear distinction must be made between the acute and chronic phases. In general, one follows the principle of treating the Manifestation during the acute phase and the Root during the chronic phase. This means that in the acute phase one must expel pathogenic factors, resolve Phlegm and restore the descending of Lung-Qi. During the chronic phase, attention should be turned to tonifying the body’s Qi, particularly of the Lungs, Spleen or Kidneys. In some chronic cases, it may be necessary to treat both Manifestation and Root simultaneously. The patterns discussed are as follows. Acute phase • Cold Phlegm • Hot Phlegm Chronic phase • Lung deficiency • Spleen deficiency • Kidney deficiency Treatment of the acute phase includes not only treatment during the actual acute attack but also treatment during a period of time when attacks are frequent. The main differentiation to be made is that between Cold Phlegm and Hot Phlegm and the main principle of treatment is to resolve Phlegm and restore the descending of Lung-Qi.
Cold Phlegm Clinical manifestations Rapid breathing, wheezing, a feeling of fullness and oppression of the chest, cough, scanty phlegm, a bluishwhite complexion, no thirst, or a desire for warm drinks, feeling cold, worse in cold weather. Tongue: Swollen with a sticky-white coating. Pulse: Tight and Slippery.
LU-7 Lieque, BL-13 Feishu, LU-1 Zhongfu, LU-6 Kongzui, Ren-22 Tiantu, Ren-17 Shanzhong, ST-40 Fenglong, P-6 Neiguan. All with reducing or even method. Moxa is applicable.
Explanation • LU-7, BL-13 and LU-1 restore the descending of Lung-Qi and stop wheezing. • LU-6, Accumulation point, stops wheezing and breathlessness in acute cases. • Ren-22 restores the descending of Lung-Qi and resolves Phlegm. • Ren-17 moves Qi in the chest and affects the Lung channel. With direct moxa, it can dispel Cold from the Lungs. • ST-40 and P-6 open the chest, relieve breathlessness and resolve Phlegm.
Herbal therapy Prescription SHE GAN MA HUANG TANG Belamcanda-Ephedra Decoction
Explanation This formula is specific to stop wheezing and breathlessness from Cold Phlegm.
Modifications • If there are symptoms of exterior Cold and internal Phlegm-Fluids, use Xiao Qing Long Tang Small Green Dragon Decoction instead. • In a chronic case with Yang deficiency and frequent attacks of wheezing that sounds like low snoring, breathing not rapid, watery sputum, a dull-pale complexion, cold sweating, a Deep pulse and a Pale tongue, one must treat both the Manifestation and the Root simultaneously. One must resolve Phlegm and restore the descending of Lung-Qi on one hand, and tonify Kidney-Yang on the other hand. This therapeutic aim may be achieved by using Su Zi Jiang Qi Tang Perilla Seed Lowering Qi Decoction. Add to this formula Dang Shen Radix Codonopsis
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and Hu Tao Rou Semen Juglandis to tonify Spleen and Kidneys, and Chen Xiang Lignum Aquilariae to restore the descending of Lung-Qi. • In cases of very severe symptoms of Yang deficiency (such as severe chilliness and a very Pale and wet tongue), add Fu Zi Radix Aconiti carmichaeli preparata.
SUMMARY COLD PHLEGM Points LU-7 Lieque, BL-13 Feishu, LU-1 Zhongfu, LU-6 Kongzui, Ren-22 Tiantu, Ren-17 Shanzhong, ST-40 Fenglong, P-6 Neiguan. All with reducing or even method. Moxa is applicable. Herbal therapy Prescription SHE GAN MA HUANG TANG Belamcanda-Ephedra Decoction
Hot Phlegm Clinical manifestations Wheezing with a loud noise, breathlessness, distended chest, cough, yellow-sticky sputum, irritability, sweating, a red face, a bitter taste, thirst, a feeling of heat. Tongue: Red with a yellow-sticky coating. Pulse: Slippery-Rapid.
Treatment principle Clear Heat, restore the descending of Lung-Qi, resolve Phlegm, stop wheezing.
• LU-1 and BL-13, Front-Collecting and BackTransporting point respectively, clear Lung-Heat and restore the descending of Lung-Qi, especially in acute cases. • L.I.-11 clears Heat. • P-5 and ST-40 resolve Phlegm and open the chest. • Ren-22 resolves Phlegm, restores the descending of Lung-Qi and benefits the throat.
Herbal therapy Prescription DING CHUAN TANG Stopping Breathlessness Decoction
Explanation This formula is specific for wheezing from Hot Phlegm.
Modifications • If there are simultaneous symptoms of exterior Cold and Hot Phlegm, add Gui Zhi Ramulus Cinnamomi cassiae and Sheng Jiang Rhizoma Zingiberis officinalis recens. • If there are symptoms of Fire (as opposed to Heat), such as constipation, dark urine, dry stools, dry mouth and a dry-yellow tongue coating, add Da Huang Rhizoma Rhei and Mang Xiao Mirabilitum. • If there is vomiting of sticky-yellow phlegm, add Zhi Mu Radix Anemarrhenae, Hai Ge Ke Concha Cyclinae sinensis and She Gan Rhizoma Belamcandae. • If Heat has injured the Yin, add Mai Men Dong Tang Ophiopogon Decoction. • If Phlegm is the main problem without any clearcut hot or cold symptom, use San Zi Yang Qin Tang Three-Seed Nourishing the Parents Decoction.
Acupuncture
SUMMARY
Points
HOT PHLEGM
LU-5 Chize, LU-10 Yuji, LU-6 Kongzui, LU-1 Zhongfu, BL-13 Feishu, L.I.-11 Quchi, P-5 Jianshi, ST-40 Fenglong, Ren-22 Tiantu. All with even or reducing method.
Points LU-5 Chize, LU-10 Yuji, LU-6 Kongzui, LU-1 Zhongfu, BL-13 Feishu, L.I.-11 Quchi, P-5 Jianshi, ST-40 Fenglong, Ren-22 Tiantu. All with even or reducing method.
Explanation • LU-5 resolves Phlegm-Heat from the Lungs. • LU-10 clears Lung-Heat. • LU-6, Accumulation point, stops wheezing and breathlessness in acute cases.
Herbal therapy Prescription DING CHUAN TANG Stopping Breathlessness Decoction
Wheezing (Xiao)
Case history A 58-year-old man had been suffering from asthma for 6 years. At the time of consultation, the asthma was very severe, with frequent attacks every day. He was using a Ventolin inhaler, Becloforte (corticosteroid) spray and corticosteroids orally. His chest felt extremely tight and he could not lie down. He was prone to chest infections, developing expectoration of yellow sputum. He also experienced epigastric fullness and distension. His tongue was slightly Red, with swollen edges (of the Spleen-type) and a sticky coating (Plate 4.1). His pulse was Rapid, Full and Slippery. Diagnosis This is non-allergic late-onset asthma from Hot Phlegm against a background of Spleen deficiency. Treatment principle Because the attacks are severe and frequent, this is treated as an acute case, and attention must be turned to treating the Manifestation, i.e. resolve Phlegm, clear Heat and restore the descending of Lung-Qi.
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gradually reduced and discontinued after 3 months. As he started to improve, after 3 months the treatment included some tonification of the Spleen (with Ren-12 Zhongwan, BL-20 Pishu and ST-36 Zusanli) and the use of the patent remedy Ping Chuan Wan Calming Breathlessness Pill, which tonifies Spleen and Kidneys and restores the descending of Lung-Qi. During the chronic phase, the main priority is to tonify Lungs, Spleen, or Kidneys.
Lung deficiency Clinical manifestations Sweating, chilliness, propensity to catching colds, sneezing, a runny nose, shortness of breath, slight wheezing with a low sound, a slight cough. Tongue: Pale. Pulse: Weak.
Treatment principle Tonify the Lungs and consolidate the Exterior.
Acupuncture
Treatment This patient was treated with acupuncture only. He had to be treated every other day initially, followed by a gradual spacing-out of treatments. The main points used were as follows.
Points
• SP-4 Gongsun and P-6 Neiguan open the Penetrating Vessel, relax the chest and subdue rebellious Stomach-Qi. The Lung and Stomach channels are closely connected and rebellious Stomach-Qi will adversely affect Lung-Qi. • LU-5 Chize, LU-7 Lieque and LU-6 Kongzui restore the descending of Lung-Qi. LU-6, Accumulation point, is specific for acute cases. LU-5 also clears Phlegm from the Lungs. • LU-1 Zhongfu and BL-13 Feishu, Front-Collecting and Back-Transporting points, respectively, clear Lung-Heat and restore the descending of Lung-Qi. • ST-40 Fenglong and SP-6 Sanyinjiao resolve Phlegm. ST-40 also opens the chest and eases breathing. • Dingchuan, extra point 0.5 cun lateral to Du-14 Dazhui, is an empirical point for acute asthma.
Explanation
With treatment on alternate days, he started to improve gradually. The treatment was slowed down by his use of oral corticosteroids. However, these were
Modifications
LU-9 Taiyuan, ST-36 Zusanli, Ren-6 Qihai, BL-13 Feishu, Du-12 Shenzhu, LU-7 Lieque. All with reinforcing method.
• LU-9, BL-13 and Du-12 tonify Lung-Qi and consolidate the Exterior. • ST-36 and Ren-6 tonify Qi in general. • LU-7 restores the descending of Lung-Qi and stops wheezing and cough.
Herbal therapy Prescription YU PING FENG SAN Jade Wind Screen Powder
Explanation This formula tonifies Lung-Qi and consolidates the Exterior.
• If there are Cold symptoms, add Gui Zhi Ramulus Cinnamomi cassiae, Bai Shao Radix Paeoniae alba,
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Sheng Jiang Rhizoma Zingiberis officinalis recens and Da Zao Fructus Jujubae. • If there is both Qi and Yin deficiency, add Sheng Mai San Generating the Pulse Decoction.
Three Treasures remedy Herbal Sentinel Herbal Sentinel tonifies Lung-Qi and Kidney-Qi and consolidates the Exterior. There are two versions: Herbal Sentinel-Yang for patients with a tendency to Yang deficiency and Herbal Sentinel-Yin for those with a tendency to Yin deficiency.
SUMMARY LUNG DEFICIENCY Points LU-9 Taiyuan, ST-36 Zusanli, Ren-6 Qihai, BL-13 Feishu, Du-12 Shenzhu, LU-7 Lieque. All with reinforcing method. Herbal therapy Prescription YU PING FENG SAN Jade Wind Screen Powder Three Treasures remedy Herbal Sentinel
Spleen deficiency Clinical manifestations Slight wheezing that has a low sound, poor appetite, slight abdominal distension, intolerance to certain foods, tiredness, shortness of breath, dislike of speaking, desire to lie down, weariness. Tongue: Pale. Pulse: Weak.
Treatment principle Tonify the Spleen and resolve Phlegm.
Acupuncture
Explanation • ST-36, SP-3, BL-20, BL-21 and Ren-12 tonify Stomach and Spleen. • ST-40 resolves Phlegm. • LU-7 restores the descending of Lung-Qi. • LU-9 and BL-13 tonify Lung-Qi. • Ren-6 tonifies Qi in general.
Herbal therapy Prescription LIU JUN ZI TANG Six Gentlemen Decoction
Explanation This formula tonifies Spleen-Qi and mildly resolves Dampness.
Modifications • If there are pronounced symptoms of Cold, add Gui Zhi Ramulus Cinnamomi cassiae and Gan Jiang Rhizoma Zingiberis officinalis.
Three Treasures remedy Prosperous Earth Prosperous Earth tonifies the Spleen and mildly resolves Dampness; it is a variation of Liu Jun Zi Tang Six Gentlemen Decoction.
SUMMARY SPLEEN DEFICIENCY Points ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, BL-21 Weishu, Ren-12 Zhongwan, ST-40 Fenglong, LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Ren-6 Qihai. All with reinforcing method. Moxa is applicable. Herbal therapy Prescription LIU JUN ZI TANG Six Gentlemen Decoction Three Treasures remedy Prosperous Earth
Points ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, BL-21 Weishu, Ren-12 Zhongwan, ST-40 Fenglong, LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Ren-6 Qihai. All with reinforcing method. Moxa is applicable.
Case history A 45-year-old woman had been suffering from asthma for 8 years since she stopped smoking.
Wheezing (Xiao)
She found it difficult to breathe in and had a constant nasal discharge. She constantly felt catarrh in her throat and chest and sometimes coughed up some sticky-yellow phlegm. She often experienced a feeling of oppression of the chest and slight nausea. She was slightly deaf in one ear and her urine was rather pale. She often complained of bad digestion, slight thirst and acid regurgitation. She frequently had hiccups for long periods of time. She was overweight, particularly around her stomach and abdomen. Her tongue body was of a normal colour although slightly Purple on the sides (chest area), was very Swollen, and had a Stomach crack in the middle with a rough, dirty-yellow coating in it (Plate 4.2). Her pulse was definitely Slippery on the whole and slightly Weak on the right side. Diagnosis This is a clear case of retention of Phlegm-Heat with a background of Spleen deficiency. The symptoms of Phlegm-Heat are expectoration of sticky-yellow phlegm, nasal discharge, feeling of oppression of the chest, nausea, overweight body, Swollen tongue and Slippery pulse. Although this is Phlegm-Heat because the mucus is yellow, the Heat is only slight and the predominant aspect is the Phlegm rather than Heat. There is also a slight, secondary Kidney-Yang deficiency as shown by the slight deafness and pale urine. A third pathological condition is the retention of Phlegm-Heat in the Stomach, as shown by the acid regurgitation, bad digestion and Stomach crack with rough, yellow coating inside it. The presence of Phlegm-Heat induced Stomach-Qi to rebel upwards, causing frequent hiccups. The rebelling upwards of Stomach-Qi contributed to the asthma. The fact that her asthma started after stopping smoking is puzzling but interesting. One possible explanation could be that the conditions to cause asthma were already present but tobacco, which has a hot and drying energy, constantly dried up Phlegm, thus delaying the onset of the disease. A sudden cessation of smoking means that the drying action of tobacco is abruptly withdrawn and Phlegm therefore overflows profusely. Treatment principle Because this is a chronic condition, the treatment principle is to treat Root and Manifestation simultaneously, i.e. tonify the body’s
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Qi and expel pathogenic factors. Treating the Root involves primarily tonifying Spleen-Qi and secondarily tonifying Kidney-Yang. Treating the Manifestation involves resolving Phlegm from the Lungs, restoring the descending of Lung-Qi, resolving Phlegm-Heat from the Stomach and subduing rebellious Stomach-Qi. Acupuncture This patient was treated with both acupuncture and herbs. The acupuncture treatment was focused on tonifying the Spleen, restoring the descending of Lung-Qi and subduing Stomach-Qi. Points The main points used at various times were: • SP-4 Gongsun on the left and P-6 Neiguan on the right, to open the Penetrating Vessel and subdue rebellious Stomach-Qi. The Lung and Stomach channels are closely connected, and Qi rebelling upwards in one channel easily affects the other. It was therefore important in this case to subdue Stomach-Qi as well as stimulate the descending of Lung-Qi. The Penetrating Vessel is excellent to subdue rebellious Stomach-Qi, especially in overweight people. • ST-40 Fenglong to resolve Phlegm and open the chest. • Ren-12 Zhongwan, BL-20 Pishu and Ren-9 Shuifen to tonify the Spleen and resolve Phlegm. • LU-7 Lieque, Ren-22 Tiantu and LU-5 Chize to restore the descending of Lung-Qi. • BL-23 Shenshu and KI-7 Fuliu to tonify Kidney-Yang. Herbal therapy Prescription Because acupuncture was aimed at treating the Root by tonifying the Spleen and Kidneys, the herbs were used mainly to treat the Manifestation, i.e. to resolve Phlegm, as they are better than acupuncture at doing this. The main formula used was a variation of Wen Dan Tang Warming the Gall-Bladder Decoction, which resolves Phlegm-Heat from both Lungs and Stomach. • • • • • •
Zhu Ru Caulis Bambusae in Taeniam 6 g Zhi Shi Fructus Aurantii immaturus 6 g Ban Xia Rhizoma Pinelliae preparatum 6 g Fu Ling Poria 6 g Chen Pi Pericarpium Citri reticulatae 4 g Sheng Jiang Rhizoma Zingiberis officinalis recens 3 slices
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• • • •
The Practice of Chinese Medicine
Da Zao Fructus Jujubae 3 dates Xing Ren Semen Armeniacae 4 g Su Zi Fructus Perillae 6 g Hou Po Cortex Magnoliae officinalis 4 g
Explanation • The first seven herbs constitute the Wen Dan Tang, which resolves Phlegm-Heat. • Xing Ren and Su Zi restore the descending of Lung-Qi. • Hou Po moves Qi and relieves fullness and oppression of the chest. As the treatment progressed and she improved, a few herbs to strengthen the Spleen were added, such as Bai Zhu Rhizoma Atractylodis macrocephalae, and the dosage of Fu Ling Poria was increased. This patient achieved great improvement in 9 months of treatment.
Kidney deficiency Clinical manifestations Shortness of breath, slight wheezing that has a low sound, greater difficulty in breathing in, absentmindedness, poor memory, tinnitus, weakness and soreness of the lower back, breathlessness on exertion. Kidney-Yang deficiency: chilliness, Pale tongue, DeepWeak pulse. Kidney-Yin deficiency: feeling of heat, Red tongue without coating, Floating-Empty pulse.
Treatment principle Tonify the Kidneys, strengthen the Kidney’s grasping of Qi.
Acupuncture
Herbal therapy Prescription Kidney-Yang deficiency JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill
Explanation This formula tonifies and warms Kidney-Yang.
Modifications • For severe Yang deficiency, add Bu Gu Zhi Fructus Psoraleae and Lu Jiao Cornu Cervi. • To strengthen the Kidney’s grasping of Qi, add Hu Tao Rou Semen Juglandis.
Three Treasures remedy Herbal Sentinel-Yang Herbal Sentinel-Yang tonifies Lung- and Kidney-Yang.
Prescription Kidney-Yin deficiency MAI WEI DI HUANG WAN (BA XIAN CHANG SHOU WAN) Ophiopogon-Schisandra-Rehmannia Pill (Eight Immortals Longevity Pill)
Explanation This formula nourishes Kidney- and Lung-Yin.
Modifications • To strengthen the Kidney’s grasping of Qi, add Hu Tao Rou Semen Juglandis.
Three Treasures remedy Herbal Sentinel-Yin Herbal Sentinel-Yin tonifies the Lungs and Kidneys in people with a tendency to Yin deficiency.
Points KI-3 Taixi, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-23 Shenshu, BL-13 Feishu, Du-12 Shenzhu, KI-25 Shencang. All with reinforcing method. Use moxa for Kidney-Yang deficiency.
Explanation • KI-3, SP-6, Ren-4 and BL-23 tonify the Kidneys. • BL-13 and Du-12 strengthen the Lungs. • KI-25 is an important local point to relieve wheezing due to a Kidney deficiency.
SUMMARY KIDNEY Points KI-3 Taixi, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-23 Shenshu, BL-13 Feishu, Du-12 Shenzhu, KI-25 Shencang. All with reinforcing method. Use moxa for Kidney-Yang deficiency.
Wheezing (Xiao)
Herbal therapy Prescription Kidney-Yang deficiency JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill Three Treasures remedy Herbal Sentinel-Yang Prescription Kidney-Yin deficiency MAI WEI DI HUANG WAN (BA XIAN CHANG SHOU WAN) Ophiopogon-Schisandra-Rehmannia Pill (Eight Immortals Longevity Pill) Three Treasures remedy Herbal Sentinel-Yin
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Points The main points used were: • BL-23 Shenshu, Ren-4 Guanyuan and KI-3 Taixi, with moxa, to tonify Kidney-Yang. • LU-7 Lieque on the right and KI-6 Zhaohai on the left, to open the Directing Vessel, tonify the Kidneys and restore the descending of Lung-Qi. • LU-5 Chize and Ren-22 Tiantu to restore the descending of Lung-Qi. • BL-20 Pishu and Ren-12 Zhongwan to tonify the Spleen. • ST-40 Fenglong and SP-6 Sanyinjiao to resolve Phlegm. • P-6 Neiguan to open the chest and relieve breathlessness. This patient was treated every 2 weeks (as she lived quite far away) for 18 months, after which time there was an improvement of about 80% in her condition and she experienced only occasional breathlessness.
Case history
MODERN CHINESE LITERATURE
A 42-year-old woman had been suffering from asthma for 10 years. It started after the birth of her second child. She experienced a feeling of oppression of the chest and sometimes coughed up some yellow phlegm. She also suffered from lower backache and often felt dizzy. Occasionally, she experienced tinnitus and her urine was pale and frequent. She felt very tired. Her tongue was slightly Pale but with a yellow coating and her pulse was Deep and Weak, especially on both Kidney positions.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 25, No. 8, 1984, p. 8.
Diagnosis This is a clear case of asthma from deficiency of Kidney-Yang, with the Kidneys not grasping Qi. There is also some Phlegm-Heat (yellow sputum and yellow tongue coating) but it is not significant. Treatment principle The treatment principle must therefore be aimed primarily at strengthening KidneyYang and secondarily at tonifying the Spleen and resolving Phlegm. Acupuncture This patient was treated only with acupuncture.
Dong Shu Liu, “Experience in the differentiation and treatment of wheezing (Xiao).” Dr Dong considers Wheezing always due to “hidden Phlegm” in the bronchi, which accounts for the wheezing sound on exhalation. He considers the disease due to repeated invasions of external pathogenic factors that become interior. Phlegm obstructs the airways and causes cough, wheezing and breathlessness. In treatment, one must resolve Phlegm and restore the diffusing and descending of Lung-Qi. For Cold Wheezing (from Cold Phlegm), Dr Dong uses a variation of Xiao Qing Long Tang Small Green Dragon Decoction as follows. • • • • • • • •
Ma Huang Herba Ephedrae 4.5 g Gui Zhi Ramulus Cinnamomi cassiae 3 g Bai Shao Radix Paeoniae alba 9 g Gan Jiang Rhizoma Zingiberis 2.4 g Wu Wei Zi Fructus Schisandrae 3 g Xi Xin Herba Asari 2.4 g Ban Xia Rhizoma Pinelliae preparatum 9 g Chen Pi Pericarpium Citri reticulatae 4.5 g
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• Xing Ren Semen Armeniacae 9 g • Hou Po Cortex Magnoliae officinalis 3 g • E Guan Shi Balanophyllia 9 g For Hot Wheezing (from Hot Phlegm) Dr Dong uses a variation of Ma Xing Shi Gan Tang Ephedra-PrunusGypsum-Glycyrrhiza Decoction. • • • • • • • • • • • •
Ma Huang Herba Ephedrae 4.5 g Xing Ren Semen Armeniacae 9 g Shi Gao Gypsum fibrosum 30 g Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6g Gua Lou Fructus Trichosanthis 12 g Huang Qin Radix Scutellariae 9 g Sang Bai Pi Cortex Mori 9 g Di Gu Pi Cortex Lycii 12 g Zhi Shi Fructus Aurantii immaturus 6 g Dan Nan Xing Rhizoma Arisaematis preparatum 9 g Chuan Bei Mu Bulbus Fritillariae cirrhosae 9 g Lu Gen Rhizoma Phragmitis 30 g
Dr Dong considers Ma Huang Herba Ephedrae to be the most important herb in the treatment of Wheezing. He combines it with Gui Zhi Ramulus Cinnamomi cassiae for Cold Wheezing and with Shi Gao Gypsum fibrosum for Hot Wheezing. In addition to this basic combination, he uses herbs to restore the descending of Lung-Qi and herbs that resolve Phlegm (as in the two formulae above).
PROGNOSIS AND PREVENTION Apart from obvious reference to tongue and pulse, the prognosis in the symptom of Wheezing must be based on a Western differentiation. The main conditions that give rise to wheezing are acute and chronic bronchitis and asthma (see below) and the prognosis varies considerably in each of these diseases. Acute bronchitis is the easiest to treat and it normally manifests with symptoms of Hot Phlegm, as described above. It corresponds to the Qi level (affecting the Lungs) within the Four-Level identification of patterns. The treatment of this condition is discussed in further detail in the chapter on common cold and influenza (Chapter 48). Generally speaking, this condition responds extremely well to acupuncture and Chinese herbs, which should bring about an improvement within days, and it is not usually necessary to resort to
antibiotics. These damage Stomach-Yin and often lead to a residual Heat in the Lungs, which predisposes the patient to further invasions of Wind. When such a vicious circle of exterior invasions of Wind, chest infections, antibiotics, residual Heat in the Lungs and further invasions of Wind takes hold, wheezing may become chronic. Chronic bronchitis also responds extremely well to acupuncture and Chinese herbs but it will obviously take much longer to treat. The length of treatment will depend on the age of the patient and the duration and severity of the disease, but it will certainly take months rather than weeks. Chronic bronchitis should be treated by attending to the Root and Manifestation simultaneously, i.e. tonify the body’s Qi and expel pathogenic factors. Tonifying the body’s Qi will involve tonifying the Lungs, Spleen or Kidneys, or a combination of these, and expelling pathogenic factors will involve resolving Phlegm and either scattering Cold or clearing Heat, depending on whether there is Hot Phlegm or Cold Phlegm. The differentiation and treatment of this condition are discussed in further detail in the chapters on cough (Chapter 8) and common cold and influenza (Chapter 48). The prognosis of asthma depends on the age of the patient and the type of asthma. Early-onset, allergic asthma that is associated with eczema is the most difficult to treat, because it stems from an inborn deficiency of the Lung and Kidney’s Defensive-Qi systems (see Chapter 5). From a Western point of view, it is due to an inborn excessive level of immunoglobulin E antibodies. The treatment of this condition will certainly take several months and, depending on the severity, even years. Non-allergic, early-onset asthma is easier to treat, especially in children. In most cases, treatment should not take more than a few weeks. This condition is due to repeated invasions of Wind leading to retention of Phlegm in the Lungs, which obstructs the dispersing and descending of Lung-Qi. The foremost principle of treatment in children is to resolve Phlegm, restore the descending of Lung-Qi and relieve stagnation of food. Retention of food is very common in children, and the stagnation in the Middle Burner predisposes the child to retention of Phlegm in the Upper Burner. It is thus beneficial to relieve stagnation of food with digestive herbs such as Mai Ya Fructus Hordei vulgaris germinatus, Gu Ya Fructus Oryzae sativae germinatus, Lai Fu Zi Semen Raphani sativi, Shan Zha Fructus Crataegi, Shen Qu
Wheezing (Xiao)
Massa Fermentata Medicinalis and Ji Nei Jin Endothelium Corneum gigeraiae galli. Late-onset asthma in adults stands somewhat in between the previous two types in terms of prognosis: it is easier to treat than allergic asthma but more difficult than non-allergic early-onset asthma in children. Late-onset asthma in adults is usually characterized by a deficiency of Lungs, Spleen or Kidneys, or a combination of these, and retention of Phlegm. The treatment principle is therefore based on treating the Root (i.e. tonifying the body’s Qi) and the Manifestation simultaneously (i.e. resolving Phlegm and restoring the descending of Lung-Qi). The treatment will take several months at least. In some cases, asthma is caused by Liver-Qi stagnation or Liver-Fire (from emotional strain) obstructing the descending of LungQi. This type of asthma is usually easier to treat and is discussed in Chapter 5. As for prevention, this also differs according to the condition causing wheezing. Acute bronchitis cannot really be prevented as it is due to an invasion of exterior Wind. The main way of preventing chronic bronchitis is to avoid the set of circumstances leading to the vicious circle outlined above. This means that any acute invasion of Wind should never be underestimated and should be treated promptly, preferably avoiding antibiotics. The patient should also avoid dairy products and greasy foods, which facilitate the formation of Phlegm. He or she should also regulate his or her eating habits so that meals are taken at regular times. As for asthma, preventive measures for allergic asthma will be described in the chapter on asthma (Chapter 5), and these apply to other types of asthma as well.
WESTERN DIFFERENTIATION A wheezing sound is a sign of bronchiolar narrowing by spasm, oedema of the epithelium, retained mucus, or all three acting together. Wheezes are therefore like musical sounds produced by the rapid passage of air through a narrowed bronchus. Wheezes appear in obstructive lung diseases. They usually occur on exhalation but may also appear on inhalation. The state of bronchiolar narrowing on
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expiration can be diagnosed by measuring the maximum volume of air that can be blown out in a second. This is called forced expiratory volume and is a way of assessing the respiratory disability in diseases such as asthma, emphysema or chronic bronchitis. If a peak flow meter is not available, a simpler test can be carried out by asking the patient to blow out a lighted match without pursing the lips. A patient who is unable to do so and wheezes audibly in the attempt is suffering from obstructive airway disease. Another way of eliciting a wheeze is to press on the sternum while the patient breathes out. A wheeze is called polyphonic when it is composed of different sounds with different pitches all starting and stopping at the same time, and monophonic when it is composed of single sounds each with its own pitch.
Acute bronchitis This is an inflammation of the trachea and bronchi caused by various pyogenic organisms, such as Streptococcus pneumoniae, Haemophilus influenzae or Staphylococcus pyogenes. The main clinical manifestations include a cough that is productive of mucoid, viscid sputum in the beginning then becoming more copious and purulent, breathlessness, wheezing, a feeling of tightness of the chest, fever and leucocytosis. A persistent, single, monophonic wheeze may indicate obstruction of a bronchus by tumour. The main conditions that may cause wheezing are acute and chronic bronchitis and asthma.
Chronic bronchitis This condition is characterized by repeated attacks of cough during winter, gradually increasing in frequency until the cough becomes almost constant. Other manifestations include wheezing, tightness of the chest, tenacious, mucoid, purulent sputum and breathlessness.
Asthma The pathology and clinical manifestations of this disease will be described in detail in the chapter on allergic asthma (Chapter 5).
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END NOTES 1. Duan Guang Zhou et al. 1986 Jin Gui Yao Lue Shou Ce [A Manual of the Essential Prescriptions of the Golden Chest]. Science Publishing House, p. 21. The Essential Prescriptions of the Golden Chest was written by Zhang Zhong Jing and first published c.AD 220.
2. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue [Internal Medicine in Chinese Medicine]. Shanghai Science Publishing House, Shanghai, p. 59. 3. Ibid., p. 59. 4. Ibid., p. 59.
CHAPTER 5
ALLERGIC ASTHMA (ATOPIC ECZEMA) ALLERGIC ASTHMA IN WESTERN MEDICINE Pathology 115 Aetiology 118 Clinical features 123 Differential diagnosis 123
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CONNECTIONS AND DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN 125 Aetiology 125 Pathology 126 Identification of patterns and treatment 129 Late-onset, non-allergic asthma 130 A NEW THEORY OF ASTHMA 130 Aetiology and pathology 130 Identification of patterns and treatment THE LIVER AND ASTHMA 145 Liver-Qi stagnant, insulting the Lungs Liver-Fire insulting the Lungs 146 Liver-Yin deficiency 147
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145
ATOPIC ECZEMA 147 Acute eczema 150 Chronic eczema 152 External treatment 153 MODERN CHINESE LITERATURE
ATOPIC ECZEMA Acute eczema • Wind-Heat • Damp Heat
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PATIENTS’ STATISTICS
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PROGNOSIS AND PREVENTION
In between attacks • Lung-Qi deficiency • Lung-Qi and Lung-Yin deficiency • Lung-Qi and Kidney-Yang deficiency (with predominance of the latter) • Lung-Qi and Kidney-Yang deficiency (with predominance of the former) • Lung-Qi and Kidney-Yang deficiency with pronounced Cold • Lung-Yin and Stomach-Yin deficiency with Dryness and some Empty Heat • Lung-Yin deficiency, no Dryness and no Empty Heat • Lung- and Kidney-Yin deficiency • Lung-Qi and Kidney-Yang deficiency with internal Cold THE LIVER AND ASTHMA • Liver-Qi stagnant, insulting the Lungs • Liver-Fire insulting the Lungs • Liver-Yin deficiency
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CLINICAL TRIALS 161 Acupuncture 161 Herbal medicine 162 CASE HISTORIES
ALLERGIC ASTHMA During attacks • Wind-Cold (without sweating) • Wind-Cold (with sweating) • Wind-Heat
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WESTERN DRUG THERAPY 172 Antiallergic drugs (mast cell stabilizers) Bronchodilators 173 Corticosteroids 173 Leukotriene antagonists 173
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Chronic eczema • Wind-Heat (with Blood deficiency) • Damp Heat
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ALLERGIC ASTHMA (ATOPIC ECZEMA) This chapter is dedicated to the discussion of allergic asthma and especially that in children and young people. Asthma is a general term that may refer to quite different diseases and, in my practice, I make a distinction between allergic and non-allergic asthma. I make this distinction because I believe that the Chinese theory of Xiao (Wheezing, Chapter 4) and Chuan (Breathlessness, Chapter 3) can be used to treat non-allergic asthma but not allergic asthma. I believe the aetiology and pathology of allergic asthma to be different from those of Xiao and Chuan. Also, I find that the theory of Xiao and Chuan does not explain the pathology of atopy and the association between allergic asthma and atopic eczema. In this, I differ from all modern Chinese books, which translate Xiao-Chuan as “asthma” (without specifying whether they are describing allergic or non-allergic asthma). A reader who disagrees with my views on allergic asthma may refer to Chapters 3 and 4 on Breathlessness and Wheezing instead for the treatment of asthma. The discussion of allergic asthma will be conducted according to the following topics. • Allergic asthma in Western medicine • Connections and differences between early-onset, allergic asthma and Xiao-Chuan • A new theory of asthma • The Liver and asthma • Atopic eczema • Modern Chinese literature • Clinical trials • Case histories • Patients’ statistics • Prognosis and prevention • Western drug therapy In this chapter, I will concentrate on the treatment of allergic asthma (also called early-onset or extrinsic asthma) in atopic individuals. The incidence of allergic asthma (and of eczema, which is associated with it) has steadily increased in industrialized countries in the past decades, and both morbidity and mortality are increasing. In the UK, 12% of children are diagnosed with asthma. There is no doubt that the incidence of asthma is increasing. For example, in the UK, it affected from 2% to 4% of children in 1979, and 12% in 1996; in South Wales, asthma in children doubled in 15 years; in Aberdeen between 1964 and 1989 the diagnosis of asthma increased 21⁄2 times.1
In the USA, 20 million people (of whom 5 million are children) are estimated to suffer from asthma.2 There are 20 million outpatient visits per year and 500 000 hospitalizations per year.3 In a study conducted in Scotland, it was found that in 1972–6 the incidence of asthma and allergic rhinitis in adults was 3% and 5.8%, respectively; in 1996, they were 8.2% and 19.9%, respectively. Therefore in 20 years the incidence of asthma nearly trebled and that of allergic rhinitis more than trebled.4
! In the UK, 12% of children are diagnosed with asthma. In the UK, the incidence of asthma went from between 2% and 4% of children in 1979 to 12% in 1996. In South Wales, asthma in children doubled in 15 years. In Aberdeen between 1964 and 1989, diagnosed asthma increased 21⁄2 times. In the USA, 20 million people (of whom 5 million are children) are estimated to suffer from asthma. In the USA, there are 20 million outpatient visits per year and 500 000 hospitalizations per year. In Scotland, in 20 years the incidence of asthma nearly trebled and that of allergic rhinitis more than trebled.
Despite the introduction of several new drugs for the treatment of asthma, severe asthma is still by far the most common chronic debilitating disease in childhood and its mortality rate has not declined. Indeed, some think that the long-term use of some antiasthma drugs, such as bronchodilators, may be detrimental and may even have increased the mortality rate from this disease, which, in the USA, has increased by 45% in the past 10 years. All b2 agonists cause cardiac dysrhythmia. In the UK, there was an upsurge in deaths from asthma in the 1960s following the introduction of pressurized aerosols for the relief of asthma over the counter. As the sales went up, so did the deaths.5 New Zealand experienced a fourfold increase in asthma deaths in the 1980s over a period of 5 years.6 This was also attributed to the introduction of b2 agonists. In the
Allergic asthma (atopic eczema)
USA also, the mortality rate from asthma has been in constant increase from 1979. From 1978 through 1989, asthma mortality increased, with a near doubling in the mortality rates in both non-white and white people.7
BIAN BING
Gastric ulcer
! In New Zealand, there was a fourfold increase in asthma deaths in the 1980s over a period of 5 years. In the USA from 1978 through 1989, asthma mortality increased, with a near doubling in the mortality rates in both non-white and white people.
Because allergic asthma is a modern disease, when formulating a pathology and treatment of allergic asthma the question arises: to which Chinese disease category does allergic asthma correspond? The theoretical framework of Chinese medicine and its approach to treatment focus on symptoms rather than diseases. For example, textbooks of Chinese internal medicine discuss the treatment of “Epigastric Pain”, “Chest Pain”, “Constipation”, etc.; these are “diseases” in Chinese medicine, although they are only symptoms in Western medicine. Western internal medicine, on the contrary, discusses only the treatment of recognized “diseases” such as “stomach ulcer”, “coronary heart disease,” “diverticulitis”, etc. We generally treat specific Western diseases by referring to a corresponding Chinese symptom. For example, in order to treat a person with a stomach ulcer, we can clearly use the differentiation and treatment of “Epigastric Pain” in Chinese medicine; this is called “identifying the disease” (Bian Bing) in Chinese medicine. In some cases, the correspondence is less obvious. For example, in order to differentiate and treat hypertension, we generally need to refer to the differentiation and treatment of “Headache” and “Dizziness” in Chinese medicine (Fig. 5.1). Allergic asthma is a well-defined disease with very specific and characteristic aetiology and pathology. In order to diagnose and treat it properly with Chinese medicine, we must identify the symptom to which it most closely corresponds in the Chinese framework. All textbooks of Chinese medicine, whether Chinese or Western, say that asthma corresponds to the symptom of Xiao-Chuan as defined in Chinese medicine. The
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‘‘Epigastric pain’’
‘‘Headaches’’ Hypertension ‘‘Dizziness’’
Allergic asthma
‘?’
In other words, is it legitimate to make a Chinese Bian Bing on the basis of Western diagnosis? Figure 5.1 Identification of the disease in Chinese medicine.
reason for this is probably also semantic, as the Chinese word for “asthma” is xiao-chuan and, in terminology, there is no way of distinguishing between allergic asthma and chronic breathlessness from other causes. I propose that: • Xiao (Wheezing) and Chuan (Breathlessness) are two separate symptoms • allergic asthma does not correspond to either of them (although it is somewhat closer to Xiao than to Chuan), and the identification of patterns and treatment of Xiao or Chuan cannot be applied to allergic asthma. In order to ascertain the correspondence and differences between Xiao-Chuan and asthma, we have to discuss the three following aspects: 1. the pathology and aetiology of allergic asthma in Western medicine 2. the connections and differences between XiaoChuan and allergic asthma 3. a new theory of allergic asthma in Chinese medicine.
ALLERGIC ASTHMA IN WESTERN MEDICINE Pathology The symptoms and signs of allergic asthma evolve from three basic characteristics that underlie the disease
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and its exacerbations: airway obstruction, airway hyper-responsiveness and airway inflammation. The pathology of asthma is characterized by a partial and temporary obstruction of airflow in the airways (Fig. 5.2). Bronchial narrowing in asthma can be caused by three main factors: mucus in the bronchi, swelling of the internal layers of the bronchi and contraction of the muscles lying in the walls of the bronchi, which leads to constriction of the air passages (“bronchospasm”).8 The bronchial narrowing interferes with ventilation and raises the resistance to airflow in the bronchi. This is more marked on exhalation, and it causes air to be trapped in the lungs. The narrowed bronchi can no longer be effectively cleared of mucus by coughing. Contraction of the bronchial muscles may be the sole factor causing airway narrowing in allergic asthma. As we shall see later, from the Chinese point of view the contraction of bronchial muscles is due to Wind. However, the narrowing of the airways is more often due also to the other two factors cited above, i.e. mucus production and swelling of the inner layers.9 In allergic asthma, the bronchospasm is caused by an allergic reaction due to immune hypersensitivity. This is also called anaphylactic or type 1 reaction. Only immunoglobulin (Ig) E (reaginic) antibodies produce type 1 reactions. As these antibodies adhere strongly to tissues (and particularly to mast cells in the tissues), they are often called tissue-sensitizing antibodies. Anaphylactic crises in asthma are caused by an antigen– antibody reaction on the surface of the mast cells in the bronchi. This activates a series of enzymes, which leads to the release of certain chemical substances from the mast cells, such as histamine, serotonin, bradykinin AIRWAY IN ASTHMA
NORMAL AIRWAY
and prostaglandins. The IgE-dependent release of mastcell products not only provokes acute bronchospasm but also contributes to the development of the latephase asthmatic reaction (Fig. 5.3). Immunoglobulin G antibodies account for 73% of immunoglobulin antibodies in serum, and they can prevent IgE-mediated allergic reactions; on the other hand, the level of IgE antibodies in serum is under genetic control. IgG antibodies are the only antibodies that are transported across the placenta to reach the fetal circulation. This factor is quite significant in explaining the aetiology of allergic asthma from a Chinese medical perspective, as will be discussed later. Bronchospasm from an allergic reaction, however, is only one aspect of the pathology of asthma, chronic inflammation of the bronchial mucosa being another (Fig. 5.4). The allergic reaction in the mast cells of the bronchi causes inflammation of the airways. Inflammation causes a swelling of the inner layers of the airways, reducing their lumen. The inflamed lining then
Antigen
Antibody:
Tissue-fixed IgE Mast cells
Muscle
Tight muscles Lining
Swollen lining
Histamine, serotonin, bradykinin
Prostaglandins
Contraction of plain muscles Accumulation of eosinophils Bronchospasm Epithelial damage (late phase) Mucus Figure 5.2 Airway obstruction in asthma.
Asthma Figure 5.3 Pathology of allergic asthma.
Allergic asthma (atopic eczema)
Histamine
MAST CELLS
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• Smooth muscle contraction • Acute symptoms • Episodic wheeze
Prostaglandins IgE production Beta lymphocytes
ALLERGEN
T lymphocytes
• Inflammation • Chronic wheeze • Bronchial hyper-responsiveness
Eosinophils
Figure 5.4 Allergic and inflammatory processes in allergic asthma.
produces a mucus that further narrows the airways (Fig. 5.5). We can see therefore (as will be emphasized below) that the mucus in allergic asthma is the result rather than the cause of the pathology. The chemical mediators responsible for allergic inflammation in asthma are histamine, prostaglandins and leukotrienes manufactured by the mast cells. Eosinophils are scavenger cells that are attracted to the airways in allergic inflammation; they break up and they themselves release complex proteins and chemicals that aggravate the inflammation.
We can distinguish an early and a late inflammatory reaction, and in the interval between these two phases eosinophils crowd the airways; it is at this time that the airways become increasingly irritable and increasingly reactive to histamine.10 Lymphocytes also become activated in an allergic inflammatory reaction. They encourage more eosinophils to move into the inflamed airways and they themselves release chemicals that aggravate the inflammation; such chemicals are collectively known as cytokines.11
EARLY ALLERGIC REACTION
NORMAL AIRWAY
LATE ALLERGIC REACTION
Cytokines Histamine
Prostaglandins Leukotrienes
Allergen
Mast cell Figure 5.5 Narrowing of lumen of airways from inflammation in asthma.
Eosinophils
Lymphocytes
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The mucosa is inflamed and oedematous, and there are infiltrating inflammatory cells. There is an excess of eosinophils that lead to destruction of epithelial cells with consequent exposure of irritant receptors on the basement membrane. This, in turn, leads to an increase in bronchial responsiveness from allergic stimulation.12 Inflammatory molecules called leukotrienes are one of several substances that are released by mast cells during an asthma attack, and it is leukotrienes that are primarily responsible for the bronchoconstriction. In chronic, more severe cases of asthma, general bronchial hyper-reactivity is largely caused by eosinophils, which are attracted into the bronchioles by leukotrienes; the eosinophils themselves then also produce leukotrienes. Thus, leukotrienes seem to be critical both in triggering acute asthma attacks and in causing longer term hypersensitivity of the airways in chronic asthma. Cysteinyl-leukotrienes are concerned primarily with eosinophil- and mast cell-induced bronchoconstriction in asthma. They bind to highly selective receptors on bronchial smooth muscle and other airway tissue.
SUMMARY PATHOLOGY OF ALLERGIC ASTHMA IN WESTERN MEDICINE Airway obstruction, airway hyperresponsiveness and airway inflammation. Partial and temporary obstruction of airflow in the airways. Bronchial narrowing caused by three main factors: mucus in the bronchi, swelling of the internal layers of the bronchi and contraction of the muscles lying in the walls of the bronchi, which leads to constriction of the air passages (“bronchospasm”). In allergic asthma, the bronchospasm is caused by an allergic reaction due to immune hypersensitivity. This is also called anaphylactic or type 1 reaction from IgE (reaginic) antibodies. Anaphylactic crises in asthma are caused by an antigen–antibody reaction on the surface of the mast cells in the bronchi. This activates a series of enzymes, which leads to the release of certain chemical substances
from the mast cells, such as histamine, serotonin, bradykinin and prostaglandins. The IgE-dependent release of mast cell products not only provokes acute bronchospasm but also contributes to the development of the late-phase asthmatic reaction. The allergic reaction in the mast cells of the bronchi causes inflammation of the airways. Inflammation causes a swelling of the inner layers of the airways, reducing their lumen. The inflamed lining then produces a mucus that further narrows the airways. The chemical mediators responsible for allergic inflammation in asthma are histamine, prostaglandins and leukotrienes manufactured by the mast cells. We can distinguish an early and a late inflammatory reaction, and in the interval between these two phases eosinophils crowd the airways; it is at this time that the airways become increasingly irritable and increasingly reactive to histamine. The mucosa is inflamed and oedematous, and there are infiltrating inflammatory cells. There is an excess of eosinophils that lead to destruction of epithelial cells with consequent exposure of irritant receptors on the basement membrane. This, in turn, leads to an increase in bronchial responsiveness from allergic stimulation. Inflammatory molecules called leukotrienes are released by mast cells during an asthma attack, and it is leukotrienes that are primarily responsible for the bronchoconstriction.
Aetiology There are two types of asthma: the early-onset type, which is also called extrinsic or allergic asthma, and the late-onset type, which is also called intrinsic asthma. Our discussion will concentrate mostly on the allergic, early-onset type of asthma.
Early-onset asthma As the names imply, the early-onset asthma usually starts during childhood, while the late-onset asthma
Allergic asthma (atopic eczema)
starts later on in life. However, it is important to note that not all cases of early-onset asthma are due to atopy. On the other hand, not all cases of late-onset asthma are intrinsic, i.e. non-allergic; although it is not a common occurrence, allergic asthma may occasionally start late in life. Indeed, in children, many cases of non-allergic asthma are caused by retention of a residual pathogenic factor (usually Phlegm) following repeated invasions of external Wind. Moreover, many children are often wrongly diagnosed with asthma when they have bronchiolitis (see below). Early-onset asthma has the following characteristics: • it starts during early childhood • it appears to run in families • it is often associated with eczema from birth; individuals who suffer from this type of asthma have wealing skin reactions to common allergens • they also have antibodies in their serum that could be transferred to the skin of non-sensitized people to cause the same wealing skin reactions (Fig. 5.6).
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In patients with allergic asthma, inhalation challenge with an antigen produces an immediate bronchoconstriction, reaching a maximum in 20 minutes. This early asthmatic response is almost identical in time course to the weal reaction. This would show that the primary aetiological factor of allergic asthma is indeed the allergic reaction rather than the inflammation process that follows the allergic reaction. The main thrust of the therapeutic medical intervention is based on the use of anti-inflammatory drugs (cortisone), and one cannot help wondering how much of this approach is research-driven and how much drug-driven. Indeed, there are authors who place the stress on bronchoconstriction as opposed to inflammation as the main cause of asthma. In fact, chemical mediators of inflammatory response are present in the normal lung and do not cause bronchoconstriction; this seems to prove that inflammation is not the primary cause of asthma, while allergy is.13 The same authors also observe that normal subjects demonstrate a plateau of bronchoconstriction following histamine provocation no matter how high the dose. By contrast, asthmatics do not have such a plateau, and they obviously lack the
Family history usually positive “Allergic shiner” may be present
History of eczema in childhood
Attacks related to specific antigens Favourable response to hypersensitization
Pollen
Foods
Drugs Dust Dander
IgE-associated Skin tests usually positive
Figure 5.6 Characteristics of allergic, early-onset asthma.
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protective mechanism of healthy subjects that prevents excessive bronchoconstriction.14 Macklem thinks that the loss of plateau with resulting unrestricted bronchoconstriction cannot be explained by excessive smooth muscle excitation by neural or humoral mediators.15 He thinks therefore that the objective of asthma therapy must be to restore the plateau; as we shall see below, from the Chinese perspective, I believe this means to tonify the Lungs and Kidneys. Macklem also thinks that airway smooth muscle hypertrophy is the main culprit in producing unlimited bronchoconstriction.16 As a result, the author expresses his doubts about steroid therapy, as this has no effect on airway smooth muscles. As we shall see below, I relate the smooth muscle spasm to “Wind” from the point of view of Chinese medicine. CLINICAL NOTE Some authors place the stress on bronchoconstriction as opposed to inflammation as the main cause of asthma. Chemical mediators of inflammatory response are present in the normal lung and do not cause bronchoconstriction; this seems to prove that inflammation is not the primary cause of asthma, while allergy is. Asthmatics do not have a plateau to bronchoconstriction following histamine challenge. The loss of plateau with resulting unrestricted bronchoconstriction cannot be explained by excessive smooth muscle excitation by neural or humoral mediators. Macklem thinks that airway smooth muscle hypertrophy is the main culprit in producing unlimited bronchoconstriction. As a result, Macklem expresses his doubts about steroid therapy, as this has no effect on airway smooth muscles. Individuals who suffer from allergic asthma with the above characteristics are called “atopic”, and they have levels of IgE immunoglobulins up to six times higher than those found in patients suffering from non-atopic asthma. Atopic individuals have a hereditary predisposition to anaphylactic (or type 1) reactions.
Many different allergens are implicated, but the main ones are faecal particles of house dust mites, pollen, fungal spores, feathers, animal dander and cats’ saliva. Once the mast cells have been primed by exposure to
these allergens and high levels of IgE immunoglobulins adhere to them, they also become hypersensitive to other non-specific allergens, such as smoke, tobacco smoke, petrol fumes, dust, atmospheric pollutants and perfumes. Occasionally, an allergic reaction in the bronchi can be elicited by ingested allergens from food such as shellfish, fish, eggs, milk, yeast or wheat, which reach the bronchi via the bloodstream. Viruses may also act as allergens, and that is why an attack of allergic asthma may be triggered in a child by a viral infection, the most common ones being respiratory syncytial virus and the influenza virus.17 As for the increased incidence of atopy, it is difficult to pinpoint one or two of its causes. However, several hypotheses have been advanced. One is the hygiene hypothesis, i.e. that the increased incidence of atopy may be due to the lack of infections in childhood (itself due to immunizations).18 At birth, infants destined to become allergic have impaired production of interferon-g by their circulating T lymphocytes. A possible explanation of the protective effects of exposure to bacteria in early life, when sensitization occurs, is their action in increasing production of interferon-g. This concept has given rise to the hygiene hypothesis, in which changes to infant diets, early use of antibiotics and reduced exposure to bacterial products predispose to the persistence of TH2 responses in childhood.19 This hypothesis seems to be confirmed by a study conducted on children attending anthroposophic schools. Parents following an anthroposophic lifestyle generally do not vaccinate their children, they tend to minimize use of antibiotics and consume fermented dairy products with lactobacilli. In Sweden, 295 children attending anthroposophic schools were compared with 380 children of the same age attending normal schools. At the Steiner (Waldorf) schools, 52% of the children had had antibiotics in the past, compared with 90% in normal schools, respectively; 18% and 93% of children had had combined immmunizations against measles, mumps and rubella (61% of children in Steiner schools had had measles). Foods containing lactobacilli were consumed by 63% of children at Steiner schools, compared with 4.5% of children from the control schools. Prevalence of atopy was lower in children from anthroposophic families than in children from other families.20 In a study conducted in Guinea-Bissau, it was found that exposure to measles infection protected against the development of atopy in African children.21 The
Allergic asthma (atopic eczema)
study also found that those who had been breastfed for more than 1 year were less likely to have a positive skin test to house dust mites. The clean living conditions of Western societies, by reducing the incidence of infection, may weigh the balance toward the TH2 phenotype and predispose to asthma.22 Another study also showed a possible correlation between the use of antibiotics during infancy and the development of asthma in the first year of life. This study concluded that exposure to at least one course of antibiotics in the first year of life appears to be a risk factor for the development of childhood asthma. It also formed the hypothesis that growing up in a more hygienic environment with less microbial exposure may increase atopic immune responses and, thus, the development of asthma.23 Although this study makes a correlation between the use of antibiotics in infancy and atopic asthma and therefore the so-called hygiene theory, I personally suspect that some of the cases of “asthma” in children referred to in the study are probably not “asthma” but cases of cough from retained Phlegm in the Lungs and therefore not atopic. It should be noted here that asthma that starts during early childhood is not necessarily atopic asthma. In other words, an early onset is not the only criterion for defining asthma as “allergic” or “atopic”. The familial incidence, its connection with eczema and the typical wealing skin reactions on inhalation of allergens are other important features necessary to diagnose atopic asthma. There are cases of asthma starting in early childhood without an allergic basis. This happens especially when a small child suffers from an upper respiratory infection (invasion of Wind-Cold or Wind-Heat), which is either not treated properly or treated with antibiotics. If Wind is not expelled properly, it lodges itself in the Lungs and impairs the diffusing and descending of Lung-Qi, resulting in breathlessness and Phlegm. On the other hand, the presence of Wind and Phlegm in the Lungs predisposes the child to further invasions of external Wind, which make the situation worse. Thus, a vicious cycle sets in: the child is progressively weakened and more prone to invasions of external Wind, and the breathlessness gets gradually worse. Therefore, many cases of what is essentially retention of residual pathogenic factor (as Phlegm) following repeated invasions of Wind in small children are diag-
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nosed as “asthma” and they are treated with cortisone inhalers. In my opinion, “asthma” is also often wrongly diagnosed in small children who are actually suffering from bronchiolitis (see below). The symptoms of bronchiolitis, a viral infection, closely mimic those of asthma.
Case history A 2-year-old boy had developed a fever, wheezing and breathlessness a few days after suffering an acute upper respiratory infection. He also suffered from a cough with expectoration of yellow sputum. From the Chinese perspective, this is a clear case of Phlegm-Heat at the Qi Level following an invasion of Wind at the Defensive-Qi (Wei) Level. The fever and aversion to heat indicate the presence of interior Heat at the Qi Level. From the Western perspective too, the fever indicates an infection (bacterial or viral). Surprisingly, the child was diagnosed with “asthma” and given cortisone inhalers. Most probably, the child had bronchiolitis or a viral infection from syncytial virus. This chapter, however, will concentrate primarily on discussing the typical allergic asthma, as non-allergic asthma can be diagnosed and treated mostly according to the guidelines given for Wheezing (Chapter 4).
Late-onset asthma Late-onset asthma, also called intrinsic asthma, normally starts later in life and is due to bronchial hyper-reactivity. In this case, there is no familial history of asthma and no eczema. Late-onset asthma occurs in non-atopic individuals and, although in some cases it may be triggered by certain allergens, it does not present all the typical traits of atopic asthma. In other cases, it would appear that external allergens play no part in the aetiology of this disease (Fig. 5.7). Some authors give a general guideline to differentiate extrinsic from intrinsic asthma based on the age of onset: when asthma begins before 30, the cause is allergy unless proven otherwise; when it begins after 40, the cause is not allergy unless proven otherwise.24 The diagnosis of asthma is done on the basis of lung function tests (forced expiratory volume, FEV), peak flow charts (peak expiratory flow rate, PEFR), exercise
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Family history usually negative
No history of eczema in childhood
Attacks related to infections, exercise and other stimuli Unfavourable response to hypersensitization
Skin tests usually negative
Not IgE-associated
Figure 5.7 Characteristics of non-allergic, late-onset asthma.
tests, histamine provocation tests and skin tests (inhalation of an allergen that produces large weals on the skin also triggers off asthma). Sputum and blood tests are done to exclude bronchitis, as large numbers of eosinophils in the sputum point to bronchitis. X-rays have no diagnostic value in asthma, as they show no particular feature in this disease.
SUMMARY AETIOLOGY OF ALLERGIC ASTHMA Two types of asthma: the early-onset type, which is also called extrinsic or allergic asthma, and the late-onset type, which is also called intrinsic asthma. Early-onset asthma has the following characteristics: — it starts during early childhood — it appears to run in families — it is often associated with eczema from birth
— individuals who suffer from this type of asthma have wealing skin reactions to common allergens. In patients with allergic asthma, inhalation challenge with an antigen produces an immediate bronchoconstriction, reaching a maximum in 20 minutes. There are some who place the stress on bronchoconstriction rather than inflammation as the main cause of asthma. Individuals who suffer from allergic asthma with the above characteristics are called “atopic”, and they have levels of IgE immunoglobulins up to six times higher than those found in patients suffering from nonatopic asthma. Many different allergens are implicated, but the main ones are faecal particles of house dust mites, pollen, fungal spores, feathers, animal dander and cats’ saliva.
Allergic asthma (atopic eczema)
Viruses may also act as allergens, and that is why an attack of allergic asthma may be triggered in a child by a viral infection, the most common ones being respiratory syncytial virus and the influenza virus. A study showed a possible correlation between the use of antibiotics during infancy and the development of asthma in the first year of life. This study concluded that exposure to at least one course of antibiotics in the first year of life appears to be a risk factor for the development of childhood asthma. Late-onset asthma, also called intrinsic asthma, normally starts later in life and is due to bronchial hyper-reactivity. In this case, there is no familial history of asthma and no eczema. Late-onset asthma occurs in non-atopic individuals.
Clinical features Asthma is characterized by wheezing attacks with shortness of breath, which are usually worse at night. Sometimes there is a dry cough, which is also worse at night. The onset is sudden and is preceded by tightness of the chest. The dyspnoea and wheezing occur mainly
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on exhalation with fixing of the shoulder girdle. The patient likes to sit up. It is in the very nature of asthma that it occurs in paroxysms, i.e. it comes and goes. Indeed, some chest specialists say it is not so much the symptoms themselves (tightness of the chest and wheezing) that enable us to diagnose asthma (these symptoms are present in other chest diseases) as the circumstances under which they occur.25
Differential diagnosis Patients with asthma can have similar symptoms to those suffering from airflow limitation deriving from chronic bronchitis and emphysema. Table 5.1 illustrates the features of asthma, chronic bronchitis and emphysema.
Chronic bronchitis This disease is characterized by hypertrophy of mucussecreting glands in the bronchial tree. In advanced cases, the bronchi themselves are inflamed and there is pus with infection. The clinical features include breathlessness and a cough on most days. There is also wheezing, and the cough is productive of abundant sputum. This may become purulent from time to time, indicating a bacterial infection that often supervenes in chronic bronchitis.
Table 5.1 Differentiation of asthma, chronic bronchitis and emphysema Asthma
Chronic bronchitis
Emphysema
Pathology
Bronchospasm
Narrowing of bronchi by mucus
Distension of alveoli and/or bronchioles
Signs
Wheezing
Productive cough with profuse sputum
Thin chest
Symptoms
Bouts of dyspnoea
Dyspnoea, stuffiness of the chest
Constant dyspnoea
Frequency
Bouts of dyspnoea
Bouts of dyspnoea with chest infections
Constant dyspnoea
Time
Worse at night
Worse in the morning
All the time
Allergies
Yes
No
No
Sputum
No
Yes, abundant
Yes
Eczema
Yes
No
No
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Some specialists refer to “wheezy bronchitis” in young children, i.e. a bronchitis from a viral infection with concurrent wheezing. From the perspective of Chinese medicine, bronchitis is due to an invasion of external Wind that then penetrates into the Interior, giving rise to Phlegm-Heat in the Lungs. There is the tendency among doctors and chest specialists to treat such wheezy bronchitis as asthma. For example, one text states: “Good reasons were put forward why these children should be called asthmatics rather than be labelled as wheezy bronchitics.”26 From the point of view of Chinese medicine, this is regrettable, as it condemns young children to long-term use of cortisone inhalers when their bronchitis could be cleared by the use of acupuncture and Chinese herbs. There is also the increasing tendency by doctors and consultants to consider all cases of nocturnal cough as asthma. For example:27 There is the quite common presentation of asthma especially in pre-school children as coughing alone without any wheezing. A careful analysis of the circumstances under which the coughing occurs will reveal that it follows the same pattern as that described for wheezing. Thus the coughing will be most obvious during the night, on awakening in the morning and after exercise. There is an unfortunate tendency for these children to be regarded as “bronchitic” and to be treated with antibiotics. This is a wrong approach: they are asthmatic and they should be treated as such. There are only a few voices against this approach, and some doctors consider asthma in young children to be over-diagnosed. For example, Dr M. Rudolph says: “There are clearly groups of infants and young children who develop wheezing in association with viral infections yet who subsequently have normal lung function and do not develop asthma.”28 The over-diagnosis of asthma is an important potential disadvantage of aggressive early use of inhaled corticosteroids in young children. It may well be that some children with nocturnal cough are asthmatic but, in my experience, very many of them simply suffer from a residual pathogenic factor in the Lungs (which is usually Heat or Phlegm-Heat) following repeated invasions of external Wind.
Emphysema This disease is characterized by distension and damage of bronchioles and/or alveoli. There is breathlessness on exertion and wheezing that is almost constant.
Bronchiectasis This disease is characterized by dilatation of the bronchi with production of large amounts of sputum. There are recurrent episodes of fever or pneumonia. It may develop from pneumonia or whooping cough.
Bronchiolitis The respiratory syncytial virus is probably the most successful of all viruses, causing annual epidemics of respiratory illness throughout the world.29 In temperate climates, these epidemics last from 3 to 5 months, peaking in midwinter. The annual epidemics are remarkably consistent in timing across continents and from year to year. The virus was first isolated nearly 50 years ago from chimpanzees, but it quickly became apparent that this was the virus largely responsible for the annual epidemics of respiratory illness observed in young infants. Between 0.5% and 2% of all infants are admitted to hospital with airways obstruction due to respiratory syncytial virus infection, and it remains the commonest reason for hospitalization in infancy.30 The majority of those admitted to hospital are diagnosed as having “acute bronchiolitis”, and it has been known for many decades that such infants experience increased levels of recurrent respiratory symptoms in subsequent years.31 The most common form of lower respiratory tract illness noted in infants is “acute bronchiolitis”.32 The majority of paediatricians in the UK, Australia and parts of Europe will use this term to refer to patients showing signs of viral upper respiratory tract viral infection together with lower respiratory tract inflammation characterized by widespread crepitations. These infants may wheeze at some point during the acute illness. The term “acute bronchiolitis” in North America and other parts of Europe is frequently used to describe infants with their first wheezing episode associated with a viral upper respiratory tract infection. The main symptoms of bronchiolitis are wheezing, lung hyperexpansion and hypoxia. During a 17-year study period in the USA, there were 1.65 million hospitalizations for bronchiolitis.33 It is virtually impossible to distinguish between the symptoms of bronchiolitis and asthma in children under 1.34
Allergic asthma (atopic eczema)
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CONNECTIONS AND DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN
eaten in China. Intolerance to milk is an important aetiological factor in allergic asthma.
Let us start by analysing the gaps in the Chinese view of Xiao-Chuan in relation to early-onset, allergic asthma. We will look at the three areas of aetiology, pathology and differentiation/treatment.
Overwork and excessive sexual activity as mentioned in the theory of Xiao-Chuan are clearly not an aetiological factor in children with asthma, although they may play a part in adults with late-onset asthma.
Aetiology It will be remembered that the main aetiological factors mentioned in the theory of Wheezing (Xiao) and Breathlessness (Chuan) are: • • • •
external pathogenic factors diet emotional problems fatigue, chronic illness and excessive sexual activity.
Let us now examine each of these aetiological factors in relation to allergic asthma and also any gaps in the traditional aetiology of Xiao-Chuan.
Atopy A fundamental gap in the traditional theory of XiaoChuan is that it has no concept of allergy and atopy as an aetiological factor in asthma, although early-onset asthma is so clearly related to an allergic immune hypersensitivity. A few modern Chinese books briefly refer to the allergic nature of asthma, but they still apply the theory of Xiao-Chuan for its treatment.
External pathogenic factors Most books say that asthma attacks are elicited by invasion of external pathogenic factors such as WindCold or Wind-Heat. While this is true in some cases, it is certainly not true in all.
Diet The theory of Xiao-Chuan mentions the excessive consumption of sour, greasy or cold foods as an aetiological factor. While this is certainly true in late-onset asthma, it cannot be true when asthma starts in early childhood. Very few children, if any, are likely to eat such foods in excess. Dairy foods, which certainly are a possible aetiological factor in asthma, are not mentioned in the aetiology of Xiao-Chuan simply because they are not
Overwork and excessive sexual activity
Emotional stress Emotional stress such as worry, brooding and pensiveness mentioned in the theory of Xiao-Chuan is certainly not an aetiological factor in very young children with early-onset asthma. Of course, children may be subject to emotional stress from early age but not in the same sense as adults.
Weak body condition One of the aetiological factors of Xiao-Chuan which does apply to early-onset, allergic asthma is a weak body condition. In young children, this may be caused by a severe attack of measles, whooping cough, or pneumonia.
SUMMARY DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN AETIOLOGY The theory of Xiao-Chuan has no concept of allergy and atopy as an aetiological factor in asthma. Most books say that asthma attacks are elicited by invasion of external pathogenic factors such as Wind-Cold or Wind-Heat. While this is true in some cases, it is certainly not true in all. The theory of Xiao-Chuan mentions the excessive consumption of sour, greasy or cold foods as an aetiological factor. This cannot be true when asthma starts in early childhood, as very few children, if any, are likely to eat such foods in excess. Dairy foods, which certainly are a possible aetiological factor in asthma, are not mentioned in the aetiology of Xiao-Chuan simply because they are not eaten in China. Intolerance to milk is an important aetiological factor in allergic asthma.
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Overwork and excessive sexual activity as mentioned in the theory of Xiao-Chuan are clearly not an aetiological factor in children with asthma. Emotional stress such as worry, brooding and pensiveness mentioned in the theory of XiaoChuan is certainly not an aetiological factor in very young children with early-onset asthma.
Pathology The following are what I perceive to be the gaps in the traditional pathology of Xiao-Chuan in relation to allergic asthma.
Phlegm not the main pathogenic factor in allergic asthma Phlegm is central to the pathology of both Xiao and Chuan. In both conditions, wheezing and breathlessness are caused by Phlegm obstructing the airways. The wheezing sound is due to rebellious Qi ascending along the airways obstructed by Phlegm. In my opinion and according to my experience, however, Phlegm is not the main pathogenic factor in allergic asthma. In this disease, wheezing and breathlessness are due to narrowing of the airways from bronchospasm following an allergic reaction. The narrowed bronchi cannot be properly cleared of mucus by coughing. Seen from this point of view, Phlegm is therefore the result rather than the cause of the condition (see also below).
! Phlegm is not the main pathogenic factor in allergic asthma; wheezing and breathlessness are due to bronchospasm following a type 1 allergic reaction.
The old Chinese doctors had to attribute narrowing of the airways to Phlegm, as they could not know the mechanism of bronchoconstriction from parasympathetic stimulation. Interestingly, old Western medicine also attributed asthma to obstruction of the airways by mucus. John Miller wrote in 1769: “The superfluous serum, which ought to be thrown out by
expiration, is accumulated and the organs of respiration are weakened.”35 Robert Bree (1807) saw asthma as “an extraordinary effort to get rid of some peccant and irritating matter existing in the air tubes”.36 Other doctors, however, understood as early as 1868 that wheezing and breathlessness in asthma were due to bronchospasm rather than obstruction from phlegm and that this was the result rather than the cause of asthma. Dr Henry Hyde Salter in fact said: “The fact is, Dr Bree mistook the effect [i.e. phlegm] for the cause.”37 As far back as 1786, some doctors perceived the allergic nature of asthma even though they could not explain it fully. Dr William Withering (who pioneered the use of foxglove extract to treat congestive cardiac failure) wrote in 1786 that asthma might be cured by the patient’s living in large rooms from which curtains and feather beds had been removed.38 Two other elements that are not consistent with Phlegm being the main factor in asthma are the tongue and the pulse. If Phlegm were the main pathological factor in asthma, then the tongue should be Swollen with a sticky coating and the pulse Slippery. This is very often not the case. In early-onset asthma, the tongue is not usually Swollen (it is often Thin) and the pulse not Slippery (it is often Tight). Interestingly, a study in China in atopic children found a correlation between a geographic tongue (indicating Yin deficiency) with an atopic constitution and raised levels of IgE.39 Moreover, the author related the atopic constitution to a Kidney deficiency. Beaven also reports a correlation between a geographic tongue and a history of allergic rhinitis, allergic asthma and atopic eczema.40 Another factor that rules out Phlegm as a pathogenic factor in asthma is the fact that, in between attacks, an asthmatic person is often quite normal. Indeed, there are some athletes who are asthmatic. If Phlegm obstructs the Lungs, however, wheezing and breathlessness are constant and they persist until Phlegm is completely eliminated. Thus Dr Ye Gui in Case Reports for Clinical Practice (1766) correctly says:41 If the pathogenic factor is expelled, breathlessness [Chuan] stops and will never return. In wheezing [Xiao], the pathogenic factor is hidden in the Interior and in the Lungs, it is sometimes active and sometimes quiescent, and there are frequent episodes over many years. This confirms that Phlegm is the main causative factor in Breathlessness (Chuan): once Phlegm is eliminated,
Allergic asthma (atopic eczema)
the breathlessness goes completely. In Wheezing (Xiao), which is closer to asthma, the pathogenic factor is hidden in the Lungs and it becomes active in bouts causing asthma attacks. CLINICAL NOTE Although I do not consider Phlegm to be the main pathogenic factor in allergic asthma, I do use ST-40 Fenglong frequently to treat this disease not because of its action in resolving Phlegm but its other actions. In fact, ST-40:
subdues rebellious Qi opens and relaxes the chest in combination with LU-7 Lieque and P-6 Neiguan, it stimulates the descending of Lung-Qi.
“Wind” as the main pathogenic factor in allergic asthma It is interesting that Dr Gui states that the pathogenic factor in Wheezing (Xiao) is “sometimes active and sometimes quiescent”. In my view, the intermittent nature of the pathogenic factor confirms that Wind rather than Phlegm is the main pathogenic factor in allergic asthma, as it is in the nature of Wind to come and go and change rapidly (see below) whereas Phlegm would not have this intermittent nature. The contraction of the bronchial muscles by itself may be the sole cause of airway narrowing; such a contraction may be attributed to “Wind” in Chinese medicine, as it manifests with the symptoms of Wind, i.e. Wind contracts, it may come and go and changes rapidly. This explains why an asthmatic breathes well in between attacks. It is in the very nature of asthma that it occurs in paroxysms, i.e. it comes and goes. Indeed, some chest specialists say it is not so much the symptoms themselves (tightness of the chest and wheezing) that enable us to diagnose asthma (these symptoms occur in other chest diseases) as the circumstances under which they occur.42 In asthma, it is characteristic that they occur in paroxysms; this is due to the nature of Wind that comes and goes. Another characteristic of allergic asthma that points to Wind as a cause of disease is the fact that, although the asthmatic does become breathless during exercise, much more importantly, he or she becomes even more breathless after exercise has ended. The progressive
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paroxysm of tightness, coughing and wheezing following exercise reaches a peak within a few minutes and may last for half an hour. Virtually no other type of chest disease is associated with symptoms that get worse immediately after exercise.43 Of course, in chronic asthma, other factors account for the narrowing of the airways, i.e. a swelling of the lining of the airways and the presence of mucus; the more chronic the asthma, the more these two factors play a role in the narrowing of the airways. The mucus that forms in the airways in allergic asthma, however, is a consequence of the inflammatory reaction, which itself is a consequence of the allergic reaction. Therefore, we can say that mucus is more the result than the cause of allergic asthma. It is also interesting to note that there is a difference between the type of mucus in chronic bronchitis and that in asthma. In chronic bronchitis, there is a reduction of serous acini; in asthma, the normal serous– mucous acinar ration is intact. The plugs in asthma have a non-mucous component. What is the pathogenic factor in allergic asthma then? Basically, it is Wind: not exterior Wind invading the Lung’s Defensive-Qi portion, nor interior Wind (which pertains to the Liver), but a kind of chronic (exterior) Wind lodged in the bronchi and periodically leading to bronchospasm. The attacks are elicited by exposure to allergens, viruses or cold weather or by emotional stress. The nature of this “Wind” as a pathogenic factor in asthma will be expanded on shortly.
! “Wind” in the bronchi is the main pathogenic factor in asthma, as it: contracts (causing bronchospasm) comes and goes (accounting for the paroxysmal nature of asthma) is non-substantial (does not show up on X-rays) changes rapidly (accounting for normality in between attacks). It is also interesting that X-rays have no diagnostic value in asthma. This seems to confirm that Wind, and not Phlegm, is the main pathogenic factor in asthma. Wind is a non-substantial pathogenic factor and, as such, it naturally would not show on an X-ray whereas Phlegm, a substantial pathogenic factor, would.
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Although there is excessive mucus production in the airways in allergic asthma as a result of the inflammatory process, this is more the result rather than the cause of the pathology. Of course, in a person with early-onset asthma, after many years, in adulthood, the pathology becomes more complicated and other factors, including Phlegm, may play a role. This happens under the influence of several aetiological factors, such as overwork, emotional stress, excessive sexual activity and irregular diet, all factors which are not present in childhood. The more chronic the asthma, the more Phlegm there is.
Case history A 42-year-old woman had been suffering from allergic asthma since childhood. The asthma had got better during adolescence, but after she was about 32 it worsened. At that time, the asthma started after an episode of influenza that then turned into bronchitis. She had three courses of antibiotics but was left with a cough productive of profuse sputum, wheezing, and breathlessness. She was prescribed inhalers of steroids (Pulmicort) and b2 agonists (Bricanyl). All these symptoms seem to point clearly to a late-onset, intrinsic, non-allergic type of asthma. However, there were other factors that pointed also to an early-onset, extrinsic, allergic type of asthma, i.e. the period of allergic asthma during childhood, the onset of asthma attacks on exposure to dust, high levels of IgE and the fact that she also suffered from allergic rhinitis. This case history is given here as a clear example of a case of asthma that is a mixture of allergic and non-allergic: in her case, although the asthma was originally of the allergic type she did also have Phlegm. This case is reported here to illustrate this combination; the treatment administered is described under Case histories.
Atopic eczema not discussed with allergic asthma in the theory of Xiao-Chuan The pathology of Xiao-Chuan does not contemplate infantile eczema, which so often accompanies or precedes early-onset asthma. And yet the connection between eczema and early-onset, allergic asthma is very close and clinically extremely frequent. Chinese
medical theory can easily explain this connection via the Lungs, which are involved in breathing and control the skin. Strangely, this connection between Lungs and skin does not seem to be used in the diagnosis and treatment of infantile eczema. The connection between asthma and eczema is also easily observed in the wealing reaction occurring on the skin of atopic individuals from inhalation of allergens.
SUMMARY DIFFERENCES BETWEEN EARLY-ONSET ALLERGIC ASTHMA AND XIAO-CHUAN PATHOLOGY Phlegm is central to the pathology of both Xiao and Chuan. Phlegm is not the main pathogenic factor in allergic asthma. In allergic asthma, wheezing and breathlessness are due to narrowing of the airways from bronchospasm following an allergic reaction. The narrowed bronchi cannot be properly cleared of mucus by coughing. Phlegm is therefore the result rather than the cause of the condition. In early-onset asthma, the tongue is not usually Swollen (it is often Thin) and the pulse not Slippery (it is often Tight), therefore pulse and tongue do not show Phlegm. Another factor that rules out Phlegm as a pathogenic factor in asthma is the fact that, in between attacks, an asthmatic person is often quite normal. Indeed, there are some athletes who are asthmatic. If Phlegm obstructs the Lungs, however, wheezing and breathlessness are constant and they persist until Phlegm is completely eliminated. The intermittent nature of the pathogenic factor confirms that this is Wind rather than Phlegm, as it is in the nature of Wind to come and go and change rapidly (see below) whereas Phlegm would not have this intermittent nature. In chronic asthma, other factors account for the narrowing of the airways, i.e. a swelling of the lining of the airways and the presence of mucus; the more chronic the asthma, the more
Allergic asthma (atopic eczema)
these two factors play a role in the narrowing of the airways. The mucus that forms in the airways in allergic asthma is a consequence of the inflammatory reaction, which itself is a consequence of the allergic reaction. Therefore, we can say that mucus is more the result than the cause of allergic asthma. The pathogenic factor in allergic asthma is Wind: not exterior Wind as such invading the Lungs, nor interior Wind, but a kind of chronic (exterior) Wind lodged in the bronchi and periodically leading to bronchospasm. The attacks are elicited by exposure to allergens or cold weather or by emotional stress. The pathology of Xiao-Chuan does not contemplate infantile eczema, which so often accompanies or precedes early-onset asthma. And yet the connection between eczema and early-onset, allergic asthma is very close and clinically extremely frequent.
Identification of patterns and treatment In order to discuss the differences and connections between asthma and Xiao-Chuan, it is better to deal with Xiao and Chuan separately.
Xiao It will be remembered that the main patterns in Xiao are as follows. • During attacks: — Cold Phlegm — Hot Phlegm • In between attacks — Lung deficiency — Spleen deficiency — Kidney deficiency Points to note are as follows. • The differentiation of treatment during or in between attacks is important and is used in the treatment of asthma. • The distinction between Cold Phlegm and Hot Phlegm is useful in the treatment of allergic
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asthma to differentiate between two basic types with Cold or Heat even though there is no Phlegm.
Chuan It will be remembered that the main patterns in Chuan are as follows. • Full: — Invasion of Wind-Cold — Wind-Cold on Exterior, Phlegm-Fluids in Interior — Cold on Exterior, Heat in Interior — Phlegm-Heat in Lungs — Turbid Phlegm in Lungs — Lung-Qi obstructed • Empty: — Lung deficiency — Kidney deficiency Points to note are as follows. • External Wind-Cold can trigger off an acute attack of asthma. From a Western point of view too, it is well known that viral infections can trigger off allergic asthma in sensitized individuals.44 Furthermore, activation of mast cells causing bronchoconstriction may be elicited not only by allergens but also by exercise, cold air and hyperventilation.45 An invasion of external Wind that is not expelled properly or that is suppressed with antibiotics may also cause the beginning of asthma in non-atopic children. • Exterior Wind-Cold with interior Phlegm-Fluids usually occurs only in adults, as Phlegm-Fluid is a chronic condition that develops only over many years. It therefore cannot explain allergic asthma in children. • The pattern of Cold on the Exterior and Heat in the Interior corresponds not to asthma but to an acute chest infection. • The pattern of Phlegm-Heat in the Lungs corresponds not to asthma but to acute bronchitis, pneumonia or febrile episodes of bronchiectasis. • The pattern of Turbid Phlegm corresponds not to asthma but to a severe chest infection with sepsis. • The pattern of Lung-Qi Obstructed corresponds to an acute attack of asthma in adults from emotional stress affecting the Liver. It does not correspond to early-onset asthma.
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• Chuan from Lung deficiency corresponds to chronic asthma. • Chuan from Kidney deficiency corresponds to asthma or emphysema in old people, not to earlyonset asthma.
Late-onset, non-allergic asthma Late-onset asthma is not allergic and occurs without eczema. As its name implies, it starts later in life, usually during the thirties or forties. For the treatment of this disease, the theory of XiaoChuan can be applied. Late-onset asthma is characterized more often by Spleen deficiency manifesting with a Swollen tongue.
A NEW THEORY OF ASTHMA Because, as we have seen, the theory of Xiao-Chuan is not adequate to diagnose and treat allergic asthma (and eczema), we must attempt to develop a new theory of allergic asthma in Chinese medicine. It should be stressed here that the following is by no means a definitive new theory of asthma and that it will need much refining and revising according to clinical experience. This discussion will concentrate on the diagnosis and treatment of early-onset asthma, also called extrinsic or allergic asthma; the discussion will also centre primarily on the clinical manifestations of allergic asthma in children as opposed to adults. One of the reasons why the theory of Xiao-Chuan does not precisely apply to asthma is simply that allergic asthma probably did not exist in ancient China. Even in modern times, it is relatively rare in China and the Far East, and its incidence is far higher in Western countries. The development of allergic asthma must obviously be related to Western lifestyle, as the incidence of allergic asthma in Chinese people who live in the West and adopt a Western lifestyle is the same as for Westerners.46
Lung and Kidney’s Defensive-Qi systems deficiency The Kidneys and the Defensive Qi The Lungs spread Defensive Qi (Wei Qi) to skin and muscles, and the Kidneys are the root of the Defensive Qi. Defensive Qi is Yang in nature and it warms skin and muscles. Kidney-Yang is the source of all Yang energies of the body; it is in this sense that it is the root of Defensive Qi. Chapter 18 of the Spiritual Axis says: “Nutritive Qi emerges from the Middle Burner and Defensive Qi from the Lower Burner.”47 The Kidneys are paired with the Bladder, and KidneyYang provides Qi to the Bladder for its transformation of fluids. In the process of this transformation, some clear part of the fluids flows upwards along the Bladder channel in the back to the skin and muscles, where they mingle with Defensive Qi. This is another indirect way in which Kidney-Yang is the root of Defensive Qi (Fig. 5.8). Besides this, both the Bladder channel and the Governing Vessel (Du Mai), which spread Defensive Qi all over the back in the Greater Yang area, are connected to the Kidneys. It will be remembered that the Governing Vessel starts from the Kidneys themselves. Furthermore, the Spiritual Axis in Chapter 71 says:48 The Defensive Qi flows in the Yang in daytime and in the Yin at night-time, starting from the muscles portion of the Kidney channel, flowing to the five Yin and six Yang organs.
GREATER YANG AREA
Clear fluids from Kidneys
Spread Defensive Qi
Du Mai
Aetiology and pathology Two main factors play a role in the pathogenesis of asthma: the first is a deficiency of both Lung and Kidney’s Defensive-Qi systems, and the other is Wind. The former accounts for the Root of the disease, the latter for its Manifestation.
Bladder channel
KIDNEYS Figure 5.8 The Kidneys, Bladder channel, Governing Vessel and Defensive Qi.
Allergic asthma (atopic eczema) Defensive-Qi vessels
Kidney
Figure 5.9 Defensive-Qi vessels arising out of the kidneys according to Wang Qing Ren.
Interestingly, the Correction of Errors in Medicine (1831) by Wang Qing Ren has diagrams showing “DefensiveQi-gathering vessels” emerging from the Kidneys.49 Thus, resistance to pathogenic factors (which include allergens) is dependent not only on the Lungs but to a great extent also on the Kidneys (Fig. 5.9).
Kidney deficiency and allergic asthma The type of Kidney deficiency involved in allergic asthma is a deficiency of only one aspect of the Kidney functions, i.e. in connection with Defensive Qi. It could be called deficiency of the Kidney’s Defensive-Qi system, which is similar to the Lung’s Defensive-Qi system. This Kidney deficiency involves only this aspect of its functions, and therefore not many other symptoms and signs are present. For example, a child or teenager with allergic asthma would not have dizziness, deafness, tinnitus, backache, weak knees or night sweating.
! The type of Kidney deficiency involved in allergic asthma is a deficiency of only one aspect of the Kidney functions, i.e. in connection with Defensive Qi. It could be called deficiency of the Kidney’s Defensive-Qi system, which is similar to the Lung’s Defensive-Qi system. The traditional theories of Wheezing (Xiao) and Breathlessness (Chuan) both contemplate a Kidney deficiency as a factor in asthma, but only for its late
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stages in chronic cases. In allergic asthma, on the contrary, there is a deficiency of the Kidney DefensiveQi system from the beginning. In children also, prolonged wheezing and cough may induce a Kidney deficiency, which is therefore the consequence of a Lung pathology; in atopic asthma, however, a Kidney deficiency is the cause of the condition and it is present from the onset of the disease – it also the cause for chronic Wind to be lodged in the chest. It is interesting to note that atopic asthma often improves during pregnancy.50 During pregnancy, allergic asthma improves in a third of women, is aggravated in another third, and is unaffected in the rest.51 I personally relate both an improvement and an aggravation of a symptom during pregnancy to a Kidney deficiency: in the first instance, the Kidney deficiency is actually improved by the pregnancy, and in the latter instance it is aggravated. The fact that pregnancy improves or aggravates allergic asthma in two-thirds of women seems to show that a Kidney deficiency is at the root of allergic asthma. This confirms the involvement of the Kidneys in atopic asthma as a Kidney deficiency sometimes improves during pregnancy. A longitudinal cohort study of 1861 children born to women recruited during pregnancy and followed up at 5 years study in the USA showed that low maternal intake of vitamin E during pregnancy is associated with an increased risk of developing allergic asthma.52 This would confirm that the aetiology of allergic asthma is an inborn deficiency of the Kidneys.
The Kidneys and the immune system Thus, the immune hyper-reactivity that is the basis of allergic asthma is due to a deficiency of both Lung and Kidney’s Defensive-Qi systems. The Kidneys influence the immune system not only through the connection between Kidney-Yang and Defensive Qi but also because the Kidney-Essence, through the Governing (Du), Penetrating (Chong) and Directing (Ren) Vessels, is partly responsible for protection from external pathogenic factors. Interestingly, Li Shi Zhen says in his Study of the Eight Extraordinary Vessels:53 when the Qi of the channels overflows, it flows into the extraordinary vessels, where it is turned into irrigation, warming the organs internally and irrigating the space between skin and muscles externally.
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The fact that the Qi of the channels overflowing into the Extraordinary Vessels goes to irrigate the space between skin and muscles confirms that the Kidneys (through the Extraordinary Vessels) play a role in the protection from pathogenic factors and in the circulation of Defensive Qi in this space. Western physiology confirms this role of the Kidneys in the immune defences, because all cells involved in the immune response are derived from a common stem cell in the marrow (which is a product of the KidneyEssence). This is illustrated in Figure 5.10. Also, low levels of cortisol (secreted by the adrenal cortex) alter the immune function to allow an exaggerated allergic response. A Chinese study comparing the effect of Xiao Qing Long Tang Small Green Dragon Decoction versus Kidney tonics for atopic asthma showed that the Kidney tonics had a better effect and that they reduced the levels of IgE.54 There are a few modern Chinese doctors who place the stress on tonifying the Kidneys in asthma. For example, Dr Zhang Jing Lei believes that in order to treat the inflammation process, the atopy and the bronchoconstriction, it is necessary to nourish Kidney-Yin.55 Dr Shen Zi Yin thinks that tonifying the Kidneys is necessary not only from the perspective of Chinese medicine but also from that of Western medicine. Interestingly, he says that using herbs with a sweet and
Marrow stem cell
Lymphoid progenitor cells
B lymphocytes
Myeloid progenitor cells
Thymus
T lymphocytes
• Macrophages • Monocytes • Eosinophils • Neutrophils • Mast cells
Figure 5.10 Marrow stem cells and immune system cells.
sour taste stabilizes the cell membranes and therefore has a stabilizing effect on the mast cells in the bronchi.56 Dr Shen also says that tonifying the Kidneys (and especially Kidney-Yang) in asthma has the effect of regulating immunity by regulating the T-cells and reducing the levels of IgE.
Aetiology of the deficiency of the Lung and Kidney’s Defensive-Qi systems in allergic asthma How does a deficiency of the Kidney’s Defensive-Qi system arise? It may derive from: • hereditary constitutional weakness • problems to the mother during pregnancy, such as a shock, smoking, drinking alcohol or using drugs • problems at childbirth, such as fetal distress, induction and premature cutting of the umbilical cord • immunizations. Points to note are as follows. • Bronchial hyper-reactivity is hereditary, as studies on twins have shown: hyper-reactivity is higher in monozygote than in dizygote twins.57 Some authors think that heredity is the most important factor in the bronchial hyper-reactivity displayed by asthmatics.58 • It has been shown that maternal smoking during pregnancy may result in increased levels of IgE antibodies in the cord blood of the newborn baby.59 Some drugs taken during pregnancy have also been shown to predispose infants to atopic disease. For example, a double-blind placebo control study showed that children exposed in utero to betaadrenergic receptor-blocking drugs taken for toxicosis of pregnancy had elevated IgE levels in the cord blood and developed clinical allergy during the first 4 years of life – significantly more often than the children of placebo-treated control mothers.60 • Apart from a constitutional Kidney Defensive-Qi system weakness, which may be hereditary or developed in utero as in the above two points, the period of time during the actual birth has a bearing on the development of the Lung and Kidney’s Defensive-Qi systems. Studies have shown that stress during the neonatal period may increase the risk of development of allergy later in life.61
Allergic asthma (atopic eczema)
• In particular, premature severing of the umbilical cord may interrupt the vital flow of hormones and immune cells from the placenta to the offspring and the excretion of waste products from the baby to the placenta. As mentioned earlier, IgG immunoglobulins, which prevent IgE-mediated allergic reactions, are the only immunoglobulins that are transported across the placenta to reach the fetal circulation. It is therefore possible that a premature severance of the umbilical cord may lead to a deficiency of IgG immunoglobulins in the baby and therefore a predisposition to IgE-mediated allergic reactions later in life. In fact, levels of IgE antibodies are already higher at birth in infants who later develop atopic disease.62 As IgE antibodies do not cross the placental barrier, they must be of fetal origin. Their elevated levels therefore suggest a spontaneous antibody formation that is not efficiently suppressed by the IgG immunoglobulins (Fig. 5.11). Umbilical cord blood is rich in some kind of stem cells found in bone marrow, and it has been used instead of bone marrow transplant.63 There is an interesting connection here with the traditional Chinese use of placenta and umbilical cord for the treatment of asthma in children.
Placenta
IgG
IgE (do not cross the placental barrier)
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In modern China, some doctors inject placenta extract in the points LU-6 Kongzui, ST-40 Fenglong and BL-23 Shenshu to treat allergic asthma. This seems to confirm that an interruption in the twoway flow of hormones, immune cells and wastes between the placenta and the baby during childbirth is one of the causes of a deficiency of the Kidney’s Defensive-Qi system. Dr Kiiko Matsumoto also attributes allergies and asthma to the premature severing of the umbilical cord.64 Finally, the very last development of lungs and kidneys takes place in the birth canal and babies delivered by caesarean section show a higher incidence of allergic asthma. It is not surprising that the time in the womb plays such an important role in our constitution. Indeed, in ancient China, an individual’s life was divided either into “Nine Stars” or into “12 Branches”. In the first instance, the time in the womb accounted for Three Stars and, in the second, for Four Branches. In both cases, therefore, the time in the womb accounts for one-third of our life; this shows the importance of the formative time in the womb for our constitution (Fig. 5.12). • Immunizations may sometimes trigger off atopic asthma and/or eczema in susceptible individuals. Animal studies have demonstrated that pertussis bacteria induce IgE antibody formation. It is therefore possible that pertussis immunization may induce excessive levels of IgE antibodies; this effect would be enhanced if immunization is given during the pollen season.65 Some have suggested that the increasing incidence of asthma may be due to vaccinations, primarily to whole cell pertussis vaccine. Some
LIFESPAN
9 Stars 3 Placenta IgG
6
9
IgE++ 12 Branches 4
8
12
Time in the womb Figure 5.11 The effect of premature cutting of the umbilical cord.
Figure 5.12 The importance of the time in the womb in an individual’s life.
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have hypothesized that vaccines might change the balance of immunity towards allergic responses either directly (that is, caused by the immune responses to the vaccine) or indirectly (by altering the balance of immune responses to infections in infancy). The first study suggesting a possible association between vaccination and asthma was conducted in children born in 1977 in Christchurch, New Zealand.66 In this study, there was no evidence of asthma during 5–10 years of follow-up among 23 children who received neither pertussis vaccine nor oral polio vaccine, whereas asthma developed in more than 20% of 1184 children who had been vaccinated. A study of 1934 patients observed from birth to age 12 in a general medical practice in the UK found that children given an older form of pertussis vaccine (whole cell vaccine) were 40% more likely to develop asthma than unvaccinated children.67 An indirect mechanism by which vaccines might affect the tendency to develop allergies, perhaps including asthma, would be by preventing infections in childhood, causing an imbalance in immune responses later in life. More recent data, however, do not support the theory that specific vaccines or the number of vaccines administered lead to an increased risk of childhood asthma. For example, one large study involving 167 240 children from four large health maintenance organizations in Washington, Oregon and California found no increased risk of developing childhood asthma associated with vaccines against diphtheria, tetanus, whole cell pertussis, measles, mumps or rubella and with oral polio vaccine.68 It has also been reported that general anaesthesia in infants may be associated with later development of respiratory tract allergy.69 Breastfed infants may also be sensitized by minute amounts of foreign proteins (such as from cow’s milk, eggs and fish) present in the maternal milk. Studies have shown that atopic dermatitis was significantly lower in the babies of mothers avoiding the above foods during the first 6 months of breastfeeding.70 Other studies have also shown that the incidence of asthma in children under 6 is higher in children who were introduced to milk other than breast milk before 4 months of age.71
Deficiency of the Lung and Kidney’s Defensive-Qi systems and atopic eczema The deficiency of the Lung and Kidney’s Defensive-Qi systems may also play a role in the pathogenesis of eczema in babies and very young children. The relationship between the Lungs and skin is well known in Chinese medicine and yet, as mentioned above, it is seldom used to explain the linkage between asthma and atopic eczema in children. The Kidneys also influence the skin. The Lungs influence the skin, as they spread Defensive Qi and fluids to the skin and control the pores. The Kidneys control the condition and lustre of the skin. The same deficiency of the Kidney’s Defensive-Qi system that leads to IgE-mediated allergic asthma causes eczema lesions on the skin. From a Chinese perspective, the Kidneys fail to nourish the skin, leading to either Wind-Heat or Damp Heat. Furthermore, there is a close relationship between the Kidney-Essence and the Lung’s Corporeal Soul (Po). The Corporeal Soul is closely linked to the Essence and is described in Chapter 8 of the Spiritual Axis as the “exiting and entering of the Essence”.72 The Corporeal Soul derives from the mother and arises soon after the Prenatal Essence of a newly conceived being is formed. It could be described as the manifestation of the Essence in the sphere of sensations and feelings. The Corporeal Soul provides movement to the Essence, i.e. it brings the Essence into play in all physiological processes of the body. The Corporeal Soul is the closest to the Essence and, as such, is responsible for the first physiological processes after birth (Fig. 5.13). Zhang Jie Bin says: “In the beginning of life ears, eyes and Heart perceive, hands and feet move and breathing starts: all this is due to the sharpness of the Corporeal Soul.”73 He also says: “The Corporeal Soul can move and do things and [when it is active] pain and itching can be felt.” This shows that the Corporeal Soul is responsible for sensations and itching and is therefore closely related to the skin through which such sensations are experienced. This explains the somatic expression on the skin of emotional tensions that affect the Corporeal Soul via the Mind and the connection between Corporeal Soul, Lungs and skin. The relationship between Corporeal Soul and Essence may therefore explain the eruption of atopic eczema and asthma in babies. From the Chinese point of view, eczema in babies is due to the surfacing of Toxic Heat from the uterus; it is therefore closely linked with the
Allergic asthma (atopic eczema) HEREDITY ATOPIC CONSTITUTION (Excess IgE)
KIDNEYS
ESSENCE ‘‘Po is entering/exiting of Jing’’
Nourish, moisten
Allergy
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Eczema SKIN
CORPOREAL SOUL
LUNGS
Moisten skin Spread Defensive Qi EXTRAORDINARY VESSEL
Asthma
(Originate from Kidneys) Figure 5.13 Relationship between Kidneys and skin.
Prenatal Essence of the baby. Because the Essence is related to the Corporeal Soul, which manifests on the skin (itching and pain), the Toxic Heat from the uterus erupts on the baby’s skin in the form of eczema. Asthma can be explained in the same way, as the deficient Essence of the baby fails to root its Corporeal Soul and therefore its Lungs.
SUMMARY LUNG AND KIDNEY’S DEFENSIVE-QI SYSTEMS DEFICIENCY The Lungs spread Defensive Qi (Wei Qi) to skin and muscles, and the Kidneys are the root of the Defensive Qi. The Kidneys are paired with the Bladder, and Kidney-Yang provides Qi to the Bladder for its transformation of fluids. In the process of this transformation, some clear part of the fluids flows upwards along the Bladder channel in the back to the skin and muscles, where they mingle with Defensive Qi. Both the Bladder channel and the Governing Vessel (Du Mai), which spread Defensive Qi all over the back in the Greater Yang area, are connected to the Kidneys. The type of deficiency involved in allergic asthma is a deficiency of only one aspect of the Kidney functions, i.e. in connection with Defensive Qi. It could be called deficiency of
the Kidney’s Defensive-Qi system, similar to the Lung’s Defensive-Qi system. This Kidney deficiency involves only this aspect of its functions, and therefore not many other symptoms and signs are present. The immune hyper-reactivity that is the basis of allergic asthma is due to a deficiency of both Lung and Kidney’s Defensive-Qi systems. The Kidneys influence the immune system not only through the connection between Kidney-Yang and Defensive Qi but also because the KidneyEssence, through the Governing (Du), Penetrating (Chong) and Directing (Ren) Vessels, is partly responsible for protection from external pathogenic factors. A deficiency of the Kidney’s Defensive-Qi system arises from: — hereditary constitutional weakness — problems to the mother during pregnancy, such as a shock, smoking, drinking alcohol or using drugs — problems at childbirth, such as fetal distress, induction and premature cutting of the umbilical cord — immunizations. The deficiency of the Lung and Kidney’s Defensive-Qi systems may also play a role in the pathogenesis of eczema in babies and very young children.
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Wind as the main pathogenic factor in asthma Having discussed the role of the Lung and Kidney’s Defensive-Qi systems as the Root in asthma, we can now turn our attention to Wind as the main Manifestation of this disease. Some of the characteristics of Wind explain its effect on the bronchi and asthma. In fact, Wind contracts, it comes and goes in bouts, and it causes spasm. A modern doctor, Dr Hu Lie of the Pharmacology Department of the Nanjing University of Chinese Medicine, calls allergic asthma “Chest Wind” (Xiong Feng). Wind is the main pathogenic factor in asthma, not in the sense of an invasion of external Wind but as a kind of chronic external Wind locked in the bronchi. The Lungs are the most exterior of the Yin organs, as they control the skin. The bronchial mucosa could be seen as an extension of the skin. Thus, just as Wind invades the skin, it may invade the bronchi, lodge itself there and cause bronchospasm (Fig. 5.14). Even from a Western point of view, animal studies suggest that the pathological features of skin and pulmonary actions are very similar.74 According to some authors, the wheezing, breathlessness, cough, expectoration and tightness of the chest are not typical diagnostic signs of asthma. They believe that the most important symptom is a history of recurrent bouts of asthma, often triggered by exogenous factors such as allergens, irritants, physical effort or viral infections. As the symptoms of asthma are typically episodic, the physical examination is often normal not only when the patient is asymptomatic but sometimes even during a period of frequent attacks.75 This would seem to show that the main pathogenic factor
“WIND” Contracts Comes and goes
Bronchospasm
in asthma is something non-substantial like Wind; if it were Phlegm, the physical examination would not be normal. This can happen only against a background of deficiency of the Lung and Kidney’s Defensive-Qi systems, which allows Wind to lodge in the bronchi for a long time. Thus, asthma is characterized by Wind, a nonsubstantial pathogenic factor. This may explain how X-rays have no diagnostic value in asthma, as they may show phlegm but not “Wind”, and also how in asthmatic children or young people the tongue is nearly always not Swollen and the pulse not Slippery as one would expect were Phlegm the main pathogenic factor; instead, the tongue is often Thin and the pulse Tight. The Chinese idea of Wind may be compared with the Western concept of allergens. The inhalation of dust, faecal matter from house dust mites, pollen and animal dander could be compared with invasion of “Wind” as conceived in Chinese medicine (Fig. 5.15). In fact, the Chinese character for Wind includes the radical for “insect” or “worm”, i.e. comparable with allergens and germs carried by the wind. Thus, the main problem in asthma is a deficiency of the Lung and Kidney’s Defensive-Qi systems, which allows Wind to penetrate and lodge itself in the bronchi, causing bouts of bronchospasm. When Dr Ye Gui (1766) said, as mentioned above, that in breathlessness [Chuan] if the pathogenic factor [Phlegm] is expelled it will never return. In wheezing [Xiao] the pathogenic factor is hidden in the Interior and in the Lungs and there are frequent episodes over the years he correctly highlighted the difference between wheezing (Xiao) and breathlessness (Chuan). Breathlessness is due to Phlegm, and once this is resolved the condition is cured permanently. Allergic asthma is due to Wind in the bronchi causing periodic
Bouts of wheezing
Insect, (chong) worm
Figure 5.14 Effect of Wind on bronchi.
Figure 5.15 Chinese character for “Wind”.
Allergic asthma (atopic eczema)
bouts of wheezing. The reason this is difficult to expel is not that it is particularly deep in the Interior but that it is linked to a deficiency of the Lung and Kidney’s Defensive-Qi systems. Until this deficiency is addressed, the Wind cannot be expelled. Another phenomenon that points to Wind rather than Phlegm as the main pathogenic factor in asthma is the remarkable effectiveness of acupuncture in stopping an acute asthma attack. This is because Wind is a non-substantial pathogenic factor and, as such, more responsive to acupuncture treatment. When Phlegm is the main pathogenic factor as in chronic bronchitis, acupuncture has only a limited efficacy in relieving breathlessness in the short term, as it obviously takes a long time to resolve Phlegm. Another interesting detail that points to Wind as the main pathogenic factor in allergic asthma is that asthma attacks are often preceded by itching on the neck and/or upper back: itching is often due to Wind, even more so when it is confined to the upper part of the body.76 Interestingly, there are some modern Chinese doctors who have similar ideas about allergic asthma, i.e. that its Root is a deficiency of the Kidneys and its Manifestation is due to Wind. For example, Dr Chen Jin treated 106 asthmatic children with a decoction of Chinese herbs that tonified the Lungs, expelled Wind and restored the descending of Lung-Qi (Ma Huang Herba Ephedrae, Xing Ren Semen Armeniacae, Ban Xia Rhizoma Pinelliae preparatum, Chen Pi Pericarpium Citri reticulatae, Fu Ling Poria, Bai Zhu Rhizoma Atractylodis macrocephalae, Fang Feng Radix Saposhnikoviae, Wu Wei Zi Fructus Schisandrae, Tai Zi Shen Radix Pseudostellariae, Dang Gui Radix Angelicae sinensis, Shu Di Huang Radix Rehmanniae preparata, Zi He Che Placenta hominis, Dong Chong Xia Cao Cordyceps).77 In the discussion of the treatment, Dr Chen explains that a deficiency of the Kidneys is the Root of asthma in children; he also notes that this is contrary to traditional theory, according to which a deficiency of the Kidneys plays a role only in chronic asthma in adults. In Dr Chen’s opinion, in children a deficiency of the Kidneys plays a role in asthma from the beginning. He also says that asthma in children is triggered by Wind (hence the presence of Fang Feng Radix Saposhnikoviae in his formula). Another modern Chinese doctor, Dr He Shu Huai, maintains (as I do) that the main pathogenic factor in asthma is not Phlegm but “Wind”. Dr He says that
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allergic asthma is due to the invasion of allergens, and he compares these with the Chinese concept of “Wind”. Interestingly, in contrast to most other modern Chinese doctors, Dr He understands the correlation between allergic rhinitis and allergic asthma as being two manifestations of the same disease. He says that when allergens settle in the nose they cause allergic rhinitis (with sneezing and itchy nose), and when they settle in the bronchi they cause allergic asthma. Dr He also says that the episodic nature of allergic asthma reflects the characteristic of Wind coming and going quickly and having rapid onset. Moreover, Dr He also thinks (as I do) that the bronchospasm that causes narrowing of the airways in asthma is also a manifestation of Wind as this contracts.78 Dr Wu Ying He recommends the use of insect substances for the treatment of acute asthma. This is based on the principle that insects extinguish Wind. The insects he adds to a formula according to pattern identification are Jiang Can Bombyx batryticatus, Chan Tui Periostracum Cicadae, Di Long Pheretima and Quan Xie Scorpio.79
SUMMARY WIND AS THE MAIN PATHOGENIC FACTOR IN ASTHMA Wind contracts, it comes and goes in bouts, and it causes spasm. Wind is the main pathogenic factor in asthma, not in the sense of an invasion of external Wind but as a kind of chronic external Wind locked in the bronchi. The Chinese idea of Wind may be compared with the Western concept of allergens. The inhalation of dust, faecal matter from house dust mites, pollen and animal dander could be compared with invasion of “Wind” as conceived in Chinese medicine. Allergic asthma is due to Wind in the bronchi causing periodic bouts of wheezing. Asthma attacks are often preceded by itching of the neck and/or upper back: itching is often due to Wind, even more so when it is confined to the upper part of the body.
As for late-onset asthma, although this is usually not allergic, its pathology is similar, with the Root being the
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deficiency of Lungs and Kidneys but the Manifestation being Phlegm in the Lungs. The aetiology is different because the Kidney deficiency is induced by overwork, excessive sexual activity and a natural decline of Kidney-Qi in middle age, rather than being congenital. Thus the Kidneys are affected not from birth but by lifestyle. Many patients with late-onset asthma, especially men, often find the condition worse after sexual activity. In late-onset asthma, a Spleen deficiency, caused by irregular diet, is often present, and this accounts for the presence of Phlegm, which manifests with a Swollen tongue. Late-onset asthma is also characterized by a more frequent involvement of the Liver, caused by emotional stress, in the pathogenesis of the condition. Table 5.2 summarizes the differences between earlyonset and late-onset asthma.
Identification of patterns and treatment The differentiation made in Wheezing (Chapter 4) between treatment during attacks and treatment in between attacks is applicable to asthma. The differentiation made in Breathlessness (Chapter 3) between Deficiency and Excess conditions is not applicable to asthma, because this is always characterized by both a Deficiency (of the Lung and Kidney’s Defensive-Qi systems) and an Excess (Wind). The main patterns seen in allergic asthma are as follows. • During attacks: — Wind-Cold — Wind-Heat
• In between attacks: — Deficiency of Lung and Kidney’s Defensive-Qi systems and Wind in the Lungs There are three approaches to the treatment principle of asthma, as follows. 1. During an actual attack: treat the Manifestation (Biao) only, i.e. expel Wind and restore the descending of Lung-Qi. 2. In a period of time when attacks are frequent: treat primarily the Manifestation, i.e. expel Wind and restore the descending of Lung-Qi but treat also the Root (Ben), i.e. tonify the Lung and Kidney’s Defensive-Qi systems. 3. In a period of time when attacks are infrequent: treat primarily the Root, i.e. tonify the Lung and Kidney’s Defensive-Qi systems but, as a secondary aim, also expel Wind and restore the descending of Lung-Qi. In the treatment of asthma, especially acute cases, it is important also to calm the Mind. This is a useful principle of treatment, as acute asthma is due to bronchospasm from overstimulation of the parasympathetic nervous system. The herbs and acupuncture points which “calm the Mind” also have a regulating effect on the nervous system. For example, the point Du-24 Shenting, which calms the Mind, is widely used to calm asthma.
DURING ATTACKS The treatments discussed below apply not only to the actual acute attack but also to a period of time when attacks are frequent.
Table 5.2 Comparison between early-onset and late-onset asthma Early-onset, allergic, extrinsic asthma
Late-onset, non-allergic, intrinsic asthma
Root
Deficiency of Lung and Kidney’s Defensive-Qi systems
Deficiency of Lungs, Spleen and Kidneys
Manifestation
Wind
Phlegm
Aetiology
Congenital
Overwork, excessive sexual activity, irregular diet, old age
Patterns
–
Liver patterns often involved
Allergic asthma (atopic eczema)
The two patterns of Wind-Cold and Wind-Heat may correspond to an asthma attack elicited by an actual invasion of Wind with all its relevant symptoms, or to a picture of symptoms and signs due to a pre-existing Wind in the bronchi that is mimicking an invasion of Wind. If there were an actual invasion of Wind, there would be aversion to cold, shivering and possibly fever. The pulse would be Floating. The patterns described below, however, presume an acute attack of asthma manifesting with certain symptoms of Wind but without an actual invasion of external Wind. Even if there is not an actual invasion of external Wind, the treatment principle is to “release the Exterior”, as herbs that release the Exterior also expel Wind from the Lungs in allergic asthma. The patterns occurring during attacks discussed will be: • Wind-Cold (without sweating) • Wind-Cold (with sweating) • Wind-Heat.
Wind-Cold (without sweating) Clinical manifestations Sudden wheezing and breathlessness with difficulty in breathing out, no sweating, tightness of the chest, pale face, feeling cold, sneezing, cough, no thirst, attack elicited by cold weather, stiffness of shoulders and neck. Pulse: Tight. Treatment principle Release the Exterior, expel Wind-Cold, restore the descending of Lung-Qi, calm the Mind.
Acupuncture Points Extra point Dingchuan, BL-12 Fengmen, BL-13 Feishu, Ren-22 Tiantu, LU-7 Lieque, LU-6 Kongzui, HE-7 Shenmen, Ren-15 Jiuwei, G.B.-20 Fengchi, G.B.21 Jianjing. Reducing method. Cupping is applicable to BL-12 and BL-13. Explanation • Dingchuan stops acute asthma. • BL-12 expels Wind. • BL-13, Ren-22 and LU-7 restore the descending of Lung-Qi. • LU-6, Accumulation point, stops acute asthma. • HE-7 and Ren-15 calm the Mind. HE-7 also makes Qi descend and Ren-15 relieves fullness in the chest.
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• G.B.-20 and G.B.-21 relax the neck and shoulders, which is important to drop the shoulder girdle and help breathing. G.B.-21 also makes Qi descend.
Herbal therapy Prescription MA HUANG TANG Ephedra Decoction Explanation This is the standard formula for WindCold and the Greater Yang stage of the Six Stages from the Discussion of Cold-induced Diseases. Prescription HUA GAI SAN Glorious Lid Decoction Explanation This formula is better for asthma, as it has a stronger Qi-descending effect. Modifications • For acute asthma, increase the dosage of Su Zi Fructus Perillae and add Xuan Fu Hua Flos Inulae to restore the descending of Lung-Qi. • If there is an actual invasion of exterior Wind-Cold, add Fang Feng Radix Saposhnikoviae and Jing Jie Herba Schizonepetae.
SUMMARY WIND-COLD (WITHOUT SWEATING) Points Extra point Dingchuan, BL-12 Fengmen, BL-13 Feishu, Ren-22 Tiantu, LU-7 Lieque, LU-6 Kongzui, HE-7 Shenmen, Ren-15 Jiuwei, G.B.-20 Fengchi, G.B.-21 Jianjing. Reducing method. Cupping is applicable to BL-12 and BL-13. Herbal therapy Prescription MA HUANG TANG Ephedra Decoction Prescription HUA GAI SAN Glorious Lid Decoction
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Wind-Cold (with sweating) Clinical manifestations Slight sweating, asthma attack with breathlessness and wheezing, less noisy than previous case, not so much chilliness, a feeling of tightness of the chest, pale face. Pulse: Tight-Slow. Treatment principle Release the Exterior, harmonize Nutritive and Defensive Qi, restore the descending of Lung-Qi, calm the Mind.
Acupuncture Points Extra point Dingchuan, BL-12 Fengmen, BL-13 Feishu, Ren-22 Tiantu, LU-6 Konzui, ST-36 Zusanli, SP-6 Sanyinjiao, HE-7 Shenmen, Ren-15 Jiuwei. Reducing method except for ST-36 and SP-6, which should be needled with even method to harmonize Nutritive and Defensive Qi. Cupping is applicable on BL-12. Explanation • Dingchuan stops acute asthma. • BL-12 and BL-13 expel Wind and restore the diffusing and descending of Lung-Qi. • Ren-22 restores the descending of Lung-Qi and stops asthma. • LU-6, Accumulation point, stops acute asthma. • ST-36 and SP-6 harmonize Nutritive and Defensive Qi. • HE-7 and Ren-15 calm the Mind. HE-7 also restores the descending of Qi as Heart-Qi, similarly to Lung-Qi, also has a descending movement. The descending of Heart-Qi will also help breathing. Ren-15 also relieves fullness in the chest.
Herbal therapy Prescription GUI ZHI JIA HOU PO XING ZI TANG Cinnamomum Decoction plus Magnolia and Prunus Explanation The first five herbs constitute the Gui Zhi Tang Ramulus Cinnamomi Decoction, which is the standard decoction for expelling Wind-Cold by harmonizing Nutritive and Defensive Qi. It is used instead of Ma Huang Tang Ephedra Decoction when the patient is sweating slightly, which indicates a deficiency of Nutritive-Qi.
Modifications • If there is an acute invasion of external Wind-Cold, add Fang Feng Radix Saposhnikoviae and Jing Jie Herba Schizonepetae. • To strengthen the descending of Lung-Qi, add Su Zi Fructus Perillae and Xuan Fu Hua Flos Inulae. • If some symptoms of interior Heat are just beginning, add Shi Gao Gypsum fibrosum.
SUMMARY WIND-COLD (WITH SWEATING) Points Extra point Dingchuan, BL-12 Fengmen, BL-13 Feishu, Ren-22 Tiantu, LU-6 Konzui, ST-36 Zusanli, SP-6 Sanyinjiao, HE-7 Shenmen, Ren-15 Jiuwei. Reducing method except for ST-36 and SP-6, which should be needled with even method to harmonize Nutritive and Defensive Qi. Cupping is applicable on BL-12. Herbal therapy Prescription GUI ZHI JIA HOU PO XING ZI TANG Cinnamomum Decoction plus Magnolia and Prunus
Wind-Heat Clinical manifestations Fever and aversion to cold (if true exterior invasion, otherwise feeling of heat), headache, tightness of the chest, loud wheezing, barking cough, asthma, slight thirst. Tongue: Red sides towards the front. Pulse: Rapid. Treatment principle Release the Exterior, restore the descending of Lung-Qi, expel Wind-Heat, calm asthma, calm the Mind.
Acupuncture Points LU-5 Chize, LU-7 Lieque, LU-1 Zhongfu, BL-13 Feishu, LU-6 Kongzui, LU-11 Shaoshang, Dingchuan, HE-7 Shenmen, Ren-15 Jiuwei. Reducing method, no moxa. Explanation • LU-5 clears Lung-Heat. • LU-7, LU-1 and BL-13 restore the descending of Lung-Qi.
Allergic asthma (atopic eczema)
• • • •
LU-6, Accumulation point, stops acute asthma. LU-11 expels Wind-Heat and eases the throat. Dingchuan stops acute asthma. HE-7 and Ren-15 calm the Mind and open the chest.
Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Explanation This formula expels Wind-Heat and restores the descending of Lung-Qi. Prescription DING CHUAN TANG Stopping Breathlessness Decoction Explanation This formula is stronger than the previous one and it is used if Heat is more prevalent. It also has a stronger effect in calming asthma. Modifications • A small dose of Ma Huang may be added, even if it is hot, in order to calm asthma. • If there is pronounced irritability, increase the dosage of Huang Qin Radix Scutellariae and add Dan Dou Chi Semen Sojae preparatum. • If symptoms of interior Heat are beginning, add Shi Gao Gypsum fibrosum.
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CLINICAL NOTE Acupuncture is important in acute attacks of asthma, as it is usually very effective. As for herbal medicine, some doctors use a small dose of Ma Huang Herba Ephedrae for its adrenergic properties even if there are some Heat signs. Ma Huang yields many different alkaloids, among which are ephedrine and psi ephedrine. Ephedrine is alpha-adrenergic and psi ephedrine is betaadrenergic. An alpha-adrenergic effect produces vasoconstriction and a rise in the blood pressure, while a beta-adrenergic effect induces dilatation of the bronchi and increases the respiration rate and cardiac output and rate. The balance of alkaloids in the natural plant is such that none of the undesirable effects of the isolated alkaloids has been observed from administration of Ephedra itself. For this reason, many doctors use a small dose of Ma Huang in any acute asthma attack. Ma Huang may be combined with many different herbs for different situations. Some of the herbs with which it is combined are listed below.
Cold: Gui Zhi Ramulus Cinnamomi cassiae Heat: Shi Gao Gypsum fibrosum Lung-Heat: Sang Bai Pi Cortex Mori Rebellious Qi: Xing Ren Semen Armeniacae Phlegm: She Gan Rhizoma Belamcandae Stagnation of Qi in the chest: Hou Po Cortex Magnoliae officinalis
Qi deficiency: Dang Shen Radix Codonopsis Kidney deficiency: Shu Di Huang Radix Rehmanniae preparata
Lung-Yin deficiency: Bei Sha Shen Radix Glehniae
SUMMARY WIND-HEAT Points LU-5 Chize, LU-7 Lieque, LU-1 Zhongfu, BL-13 Feishu, LU-6 Kongzui, LU-11 Shaoshang, Dingchuan, HE-7 Shenmen, Ren-15 Jiuwei. Reducing method, no moxa. Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Prescription DING CHUAN TANG Stopping Breathlessness Decoction
or Wu Wei Zi Fructus Schisandrae
Kidney-Yang deficiency: Fu Zi Radix Aconiti lateralis preparata
IN BETWEEN ATTACKS This refers to periods of time when asthma attacks are very infrequent or when the asthma is controlled by the occasional use of inhalers. At this stage, some asthma attacks are typically elicited by exposure to cats, dogs, pollen or dust, causing wheezing, breathlessness and tightness of the chest. If the patient is using inhalers, there is no conflict with Chinese herbs or acupuncture and these can be used concurrently. Indeed, the frequency with which the patient needs to use the inhalers can be a very useful benchmark to gauge the efficacy of the treatment.
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The priority of treatment in between attacks is to treat the Root, i.e. tonify the Lung and Kidney’s Defensive-Qi systems. At the same time, the Manifestation (i.e. Wind in the bronchi obstructing the descending of Lung-Qi) should not be overlooked, so that each formula should always include some herbs to expel Wind and make Lung-Qi descend. Within the scope of Lung and Kidney deficiency, there may be many variations, with different degrees of deficiency between Lung and Kidneys and, within the Kidneys, between deficiency of Yang or of Yin. Some Chinese doctors treat chronic asthma in between attacks simply by tonifying Lung, Spleen or Kidneys or a combination of these with the addition of small doses of Ma Huang Herba Ephedrae and Xing Ren Semen Armeniacae.80 This runs contrary to traditional theory, according to which Ma Huang should be used strictly for Full conditions because it has a scattering effect. However, in small doses (3 g) and combined with tonics, it can be used in chronic Deficiency-asthma for its strong adrenergic properties. Furthermore, in order to decrease its scattering effect, one could use honeytoasted Ma Huang. Some doctors also use Dan Shen Radix Salviae miltiorrhizae in chronic cases of asthma to invigorate Blood in the chest. Interestingly, modern research shows that Dan Shen reduces levels of the IgE immunoglobulins that are responsible for the antigen–antibody reaction that triggers an asthma attack.81 The following formulae are all aimed at tonifying the Lung and Kidney’s Defensive-Qi systems, with several variations to account for varying involvement of Lungs or Kidneys and deficiency of Yin or Yang. All the formulae without exception should be modified with the following aims in mind. 1. Tonify the Kidney’s Defensive-Qi system with such herbs as Tu Si Zi Semen Cuscutae, Xu Duan Radix Dipsaci, Du Zhong Cortex Eucommiae ulmoidis, Bu Gu Zhi Fructus Psoraleae, Hu Tao Rou Semen Juglandis or Shu Di Huang Radix Rehmanniae preparata. A small dose of a KidneyYang-tonic herb may be added, even in Yin deficiency, in order to bolster the Kidney’s Defensive-Qi system. 2. Stimulate the descending of Lung-Qi and expel Wind with such herbs as Xing Ren Semen Armeniacae, Su Zi Fructus Perillae, Xuan Fu Hua Flos Inulae and Fang Feng Radix Saposhnikoviae.
3. Use herbs that have an antiallergy effect, such as Dan Shen Radix Salviae miltiorrhizae, Wu Wei Zi Fructus Schisandrae and Wu Mei Fructus Mume. The above modifications apply to all the following formulae and will therefore not be repeated in each case. For each formula, the pattern and clinical manifestations will be given. These are in addition to the pattern and clinical manifestations of deficiency of Lung and Kidney’s Defensive-Qi systems present in all cases and that are essentially asthma, wheezing, tightness of the chest and, in some cases, eczema.
Acupuncture The four aims of treatment with acupuncture are: 1. to tonify the Lung and Kidney’s Defensive-Qi systems 2. to restore the descending of Lung-Qi 3. to calm the Mind 4. in late-onset asthma, there is also the necessity to tonify the Spleen. The points to use for the above aims are: 1. BL-23 Shenshu, Ren-4 Guanyuan, KI-13 Qixue, BL-52 Zhishi, Ren-8 Shenque with moxa cones on salt, KI-16 Huangshu, LU-9 Taiyuan, Du-12 Shenzhu and BL-13 Feishu to tonify Lung and Kidney’s Defensive-Qi systems. 2. LU-7 Lieque, LU-5 Chize, Ren-17 Shanzhong and BL-13 Feishu to restore the descending of Lung-Qi. 3. Du-24 Shenting, HE-7 Shenmen, DU-19 Houding and Ren-15 Jiuwei to calm the Mind. 4. ST-36 Zusanli, ST-40 Fenglong, Ren-12 Zhongwan, BL-20 Pishu and BL-21 Weishu to tonify the Spleen. The patterns discussed under the various formulae in this section are: • Lung-Qi deficiency • Lung-Qi and Lung-Yin deficiency • Lung-Qi and Kidney-Yang deficiency with predominance of the latter • Lung-Qi and Kidney-Yang deficiency with predominance of the former • Lung-Qi and Kidney-Yang deficiency with pronounced Cold
Allergic asthma (atopic eczema)
• Lung-Yin and Stomach-Yin deficiency with Dryness and some Empty Heat • Lung-Yin deficiency, no Dryness and no Empty Heat • Lung- and Kidney-Yin deficiency • Lung-Qi and Kidney-Yang deficiency with internal Cold
Lung-Qi deficiency Clinical manifestations Sweating, pale face, weak voice, prone to catching colds, sneezing, runny nose, shortness of breath, attacks of asthma elicited by pollen or dust, allergic rhinitis. Pulse: Empty.
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Lung-Qi and Kidney-Yang deficiency (with predominance of the former) Clinical manifestations Daytime sweating, infrequent attacks of asthma, chilliness, backache, frequent-pale urination, pale face, tiredness. Tongue: Pale. Pulse: Deep-Weak.
Prescription REN SHEN HU TAO TANG Ginseng-Juglans Decoction
Lung-Qi and Kidney-Yang deficiency with pronounced Cold
Prescription
Clinical manifestations
YU PING FENG SAN Jade Wind Screen Powder
Infrequent attacks of asthma elicited by exposure to cold, wheezing, chilliness, frequent-pale urination, tiredness, depression. Tongue: Pale, wet. Pulse: Deep-Weak-Slow.
Lung-Qi and Lung-Yin deficiency Clinical manifestations Attacks of asthma at night, tightness of the chest, wheezing, dry cough, dry throat, weak voice, night sweating, tiredness, prone to catching colds, pale face, palpitations. Tongue: dry, slightly Red in the Lung area. Pulse: Floating-Empty.
Prescription DING CHUAN SAN Stopping Breathlessness Powder
Lung-Yin and Stomach-Yin deficiency with dryness and some Empty Heat Clinical manifestations
Prescription SHENG MAI SAN Generating the Pulse Powder
Mild attacks of asthma at night, dry cough, dry throat, breathlessness on exertion, slight night sweating. Tongue: Red, without coating in the front part. Pulse: Floating-Empty on the right Front position.
Lung-Qi and Kidney-Yang deficiency (with predominance of the latter)
Prescription
Clinical manifestations Asthma attacks worse at night, tightness of the chest, chilliness, oedema of the face, tiredness, backache, depression, husky voice. Tongue: Pale. Pulse: Weak-Deep-Slow.
Prescription REN SHEN GE JIE SAN Ginseng-Gecko Powder
SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction This formula is also suitable to treat either late-onset asthma with Lung-Yin deficiency or asthma attacks from injury of Lung-Yin in children after a febrile Warm disease.
Lung-Yin deficiency, no dryness and no Empty Heat Clinical manifestations Same as above but with fewer symptoms of Dryness.
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Prescription MAI MEN DONG TANG Ophiopogon Decoction
Modifications • If the asthma attacks are relatively frequent, add Xuan Fu Hua Flos Inulae and Sang Bai Pi Cortex Mori to restore the descending of Lung-Qi.
Lung- and Kidney-Yin deficiency Clinical manifestations Chronic asthma with infrequent attacks that usually occur at night, wheezing, breathlessness on exertion, dry throat, night sweating, backache, tinnitus, dry cough, five-palm heat. Tongue: Red and without coating in the front part. Pulse: Floating-Empty.
Prescription BAI HE GU JIN TANG Lilium Consolidating Metal Decoction
Lung-Qi and Kidney-Yang deficiency with internal Cold Clinical manifestations Chronic asthma with infrequent attacks occurring mostly in daytime, chilliness, wheezing, backache, frequent-pale urination, oedema of ankles. Tongue: Pale, wet. Pulse: Deep-Weak-Slow.
Prescription SU ZI JIANG QI TANG Perilla Seed Lowering Qi Decoction
LU-7 Lieque, LU-5 Chize, Ren-17 Shanzhong and BL-13 Feishu to restore the descending of Lung-Qi. Du-24 Shenting, HE-7 Shenmen, DU-19 Houding and Ren-15 Jiuwei to calm the Mind. ST-36 Zusanli, ST-40 Fenglong, Ren-12 Zhongwan, BL-20 Pishu and BL-21 Weishu to tonify the Spleen. Herbal therapy LUNG-QI DEFICIENCY Prescription YU PING FENG SAN Jade Wind Screen Powder LUNG-QI AND LUNG-YIN DEFICIENCY Prescription SHENG MAI SAN Generating the Pulse Powder LUNG-QI AND KIDNEY-YANG DEFICIENCY (WITH PREDOMINANCE OF THE LATTER) Prescription REN SHEN GE JIE SAN Ginseng-Gecko Powder LUNG-QI AND KIDNEY-YANG DEFICIENCY (WITH PREDOMINANCE OF THE FORMER) Prescription REN SHEN HU TAO TANG Ginseng-Juglans Decoction LUNG-QI AND KIDNEY-YANG DEFICIENCY WITH PRONOUNCED COLD Prescription DING CHUAN SAN Stopping Breathlessness Powder
TONIFY THE LUNG AND KIDNEY’S DEFENSIVE-QI SYSTEMS
LUNG-YIN AND STOMACH-YIN DEFICIENCY WITH DRYNESS AND SOME EMPTY HEAT Prescription SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction
Acupuncture BL-23 Shenshu, Ren-4 Guanyuan, KI-13 Qixue, BL-52 Zhishi, Ren-8 Shenque with moxa cones on salt, KI-16 Huangshu, LU-9 Taiyuan, Du-12 Shenzhu and BL-13 Feishu to tonify Lung and Kidney’s Defensive-Qi systems.
LUNG-YIN DEFICIENCY, NO DRYNESS AND NO EMPTY HEAT Prescription MAI MEN DONG TANG Ophiopogon Decoction
SUMMARY
Allergic asthma (atopic eczema)
LUNG- AND KIDNEY-YIN DEFICIENCY Prescription BAI HE GU JIN TANG Lilium Consolidating Metal Decoction LUNG-QI AND KIDNEY-YANG DEFICIENCY WITH INTERNAL COLD Prescription SU ZI JIANG QI TANG Perilla Seed Lowering Qi Decoction
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HE
LIV
SP Stagnant Liver-Qi
Deficient KidneyYin ‘‘draws’’ from Kidneys (Mother)
Liver-Fire
KI
LU Deficient KidneyYin ‘‘draws’’ from Lungs (Mother)
THE LIVER AND ASTHMA The Liver is also involved in the pathogenesis of asthma, especially in the late-onset type. In early-onset asthma, emotional stress affecting the Liver can often be a triggering factor for an attack. The Liver can play a role in the pathology of asthma in three possible ways. 1. Stagnant Liver-Qi may rebel upwards in the chest and obstruct the descending of Lung-Qi. From a Five-Element perspective, this is called “Wood insulting Metal”. 2. Liver-Fire may also rebel upwards in the chest and similarly obstruct the descending of Lung-Qi. This is also called “Wood insulting Metal”. In addition, Liver-Fire may dry up the Lung fluids. 3. Deficient Liver-Yin may fail to nourish the Kidneys, and this may lead to the Kidneys’ not grasping it. Furthermore, a deficiency of Kidney-Yin may lead to dryness in the Lungs (Fig. 5.16). Stagnant Liver-Qi derives from emotional problems such as repressed anger, frustration and resentment over a long period of time. After some years, stagnant Liver-Qi may easily turn to Liver-Fire. Liver-Yin deficiency may also derive from emotional problems such as sadness. In addition, in women it may be induced by childbirth and overwork. The three main Liver patterns affecting asthma are therefore: 1. Liver-Qi stagnant, insulting the Lungs 2. Liver-Fire insulting the Lungs 3. Liver-Yin deficiency.
Figure 5.16 The Liver in asthma.
Liver-Qi stagnant, insulting the Lungs Clinical manifestations Asthma attacks elicited by emotional stress, a feeling of oppression and distension of the chest and hypochondrium. Tongue: the tongue body may not change in colour except in long-standing cases, when the sides might be Red. Pulse: Wiry.
Treatment principle Soothe the Liver, regulate Qi, restore the descending of Lung-Qi, calm the mind.
Acupuncture Points SP-4 Gongsun, P-6 Neiguan, LIV-14 Qimen, G.B.-34 Yanglingquan, Ren-17 Shanzhong, BL-18 Ganshu with reducing or even method. These points are in addition to those mentioned above for the various types of deficiency of Lung and Kidney’s Defensive-Qi systems.
Explanation • SP-4 and P-6, in combination, open the Penetrating Vessel (Chong Mai), relieve fullness in the chest and subdue rebellious Qi in the chest. In addition, P-6 calms the Mind and indirectly moves Liver-Qi, as the Pericardium and Liver channels are connected within the Terminal Yin channels.
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• LIV-14 and BL-18, as Front-Collecting and BackTransporting points of the Liver respectively, move Liver-Qi. • G.B.-34 moves Liver-Qi. • Ren-17 moves Qi in the chest and restores the descending of Lung-Qi.
Herbal therapy Prescription CHEN XIANG JIANG QI SAN Aquilaria Subduing Qi Powder
hypochondrial and chest fullness and distension, bitter taste, thirst. Tongue: Red with redder sides and yellow coating. Pulse: Wiry-Rapid.
Treatment principle Clear the Liver, drain Fire, subdue rebellious Qi, restore the descending of Lung-Qi and calm the Mind.
Acupuncture Points
This formula soothes the Liver, moves Qi and restores the descending of Lung-Qi.
LIV-2 Xingjian, LIV-14 Qimen, BL-18 Ganshu, P-6 Neiguan, LU-7 Lieque. Reducing or even method. These points are to be used in addition to those mentioned previously for the various patterns of asthma.
Modifications
Explanation
• In cases in which Liver-Qi stagnation plays a role in asthma, any of the formulae mentioned above for deficiency of the Lung and Kidney’s Defensive-Qi systems can be modified with the addition of herbs such as Qing Pi Pericarpium Citri reticulatae viride, Mu Xiang Radix Aucklandiae, Yu Jin Radix Curcumae, Zhi Ke Fructus Aurantii and He Huan Pi Cortex Albiziae.
• LIV-2 is the main point to drain Liver-Fire. • LIV-14 and BL-18 clear Liver-Heat and move Liver-Qi. • P-6 regulates the Liver, opens the chest, eases breathing and calms the Mind. • LU-7 restores the descending of Lung-Qi.
Explanation
Herbal therapy Prescription
SUMMARY LIVER-QI STAGNANT, INSULTING THE LUNGS Points SP-4 Gongsun, P-6 Neiguan, LIV-14 Qimen, G.B.-34 Yanglingquan, Ren-17 Shanzhong, BL-18 Ganshu with reducing or even method. These points are in addition to those mentioned above for the various types of deficiency of Lung and Kidney’s Defensive-Qi systems. Herbal therapy Prescription CHEN XIANG JIANG QI SAN Aquilaria Subduing Qi Powder
LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction
Explanation This is the most important formula to drain Liver-Fire.
Modifications • When this formula is used for Liver-Fire insulting the Lungs in asthma, one needs to add some herbs to restore the descending of Lung-Qi, such as Xuan Fu Hua Flos Inulae, Xing Ren Semen Armeniacae and Su Zi Fructus Perillae.
Prescription EMPIRICAL PRESCRIPTION82
Modifications
Liver-Fire insulting the Lungs Clinical manifestations Loud wheezing, attacks of asthma elicited by emotional strain, irritability, propensity to outbursts of anger,
• If one were to use one of the formulae for deficiency of the Lung and Kidney’s Defensive-Qi systems mentioned above, then herbs to clear LiverFire should be added (e.g. Long Dan Cao Radix Gentianae).
Allergic asthma (atopic eczema)
SUMMARY
Herbal therapy
LIVER-FIRE INSULTING THE LUNGS
Prescription
Points LIV-2 Xingjian, LIV-14 Qimen, BL-18 Ganshu, P-6 Neiguan, LU-7 Lieque. Reducing or even method. These points are to be used in addition to those mentioned previously for the various patterns of asthma.
YI GUAN JIAN One Linking Decoction
Herbal therapy Prescription LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction Prescription EMPIRICAL PRESCRIPTION
Liver-Yin deficiency Clinical manifestations Infrequent asthma attacks at night, dry throat, dry cough, blurred vision, dry eyes, hypochondrial and chest distension. Floating-Empty pulse and Red tongue without coating.
Treatment principle Nourish Liver-Yin, move Liver-Qi, restore the descending of Lung-Qi and calm the Mind.
Acupuncture Points LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, P-6 Neiguan and SP-4 Gongsun. Reinforcing method. These points are used in addition to the ones previously mentioned for deficiency of the Lung and Kidney’s Defensive-Qi systems.
Explanation • LIV-8 and Ren-4 nourish Liver-Yin. • SP-6 and KI-3 nourish Kidney-Yin, which helps to nourish Liver-Yin. • P-6 and SP-4 open the Yin Linking vessel (Yin Wei Mai), nourish Liver-Blood, open the chest and calm the Mind.
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Explanation This formula nourishes Liver-Yin.
Modifications • When used for chronic asthma, herbs to restore the descending of Lung-Qi should be added, such as Xuan Fu Hua Flos Inulae, Xing Ren Semen Armeniacae and Su Zi Fructus Perillae. • If one were to use one of the formulae for deficiency of the Lung and Kidney’s Defensive-Qi systems, then some herbs to nourish Liver-Yin should be added, such as Sheng Di Huang Radix Rehmanniae, Gou Qi Zi Fructus Lycii chinensis, Nu Zhen Zi Fructus Ligustri lucidi and Sang Ji Sheng Herba Taxilli.
SUMMARY LIVER-YIN DEFICIENCY Points LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, P-6 Neiguan and SP-4 Gongsun. Reinforcing method. These points are used in addition to the ones previously mentioned for deficiency of the Lung and Kidney’s Defensive-Qi systems. Herbal therapy Prescription YI GUAN JIAN One Linking Decoction
ATOPIC ECZEMA Eczema from a very early age or even from birth often accompanies or precedes the development of allergic asthma. The two conditions of eczema and asthma have the same allergic root, as is easily demonstrated by the wealing skin reactions occurring on inhalation of allergens in individuals suffering from extrinsic asthma.
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From the point of view of Chinese pathology, eczema is also due to an inborn deficiency of the Lung and Kidney’s Defensive-Qi systems. The relationship between the Lungs and skin is well known and yet, when discussing the pathology of skin diseases, Chinese books always seem to stress more the role of Blood (and Liver) in connection with the skin. In the case of atopic eczema and asthma, the connection between the Lungs and the skin could not be clearer. These two symptoms are very clearly related, and often one will appear as the other improves. For example, often eczema appears first at a very early age or even from birth, to be followed later by asthma when the child is about 4 or 5 years old. This pattern is more likely to occur if the eczema is suppressed with the application of cortisone creams. The reverse may also occur when asthma appears first and then apparently improves only to be followed by eczema. The relationship between skin diseases and the Lungs can also be observed in the action of many of the herbs that are used to expel Wind in skin diseases. The same herbs that expel Wind from the skin in eczema or rashes also stimulate the diffusing and descending of Lung-Qi in exterior conditions. The following are some examples, with their action on the skin given in brackets. • Fang Feng Radix Saposhnikoviae (expels WindDampness) • Jing Jie Herba Schizonepetae (expels Wind) • Chan Tui Periostracum Cicadae (expels Wind-Heat) • Ge Gen Radix Puerariae (expresses rashes) • Ma Huang Herba Ephedrae (expels Wind-Cold) • Bai Zhi Radix Angelicae dahuricae (expresses pus from skin) • Cang Er Zi Fructus Xanthii (expels Wind) • Bo He Herba Menthae haplocalycis (expresses rashes) • Niu Bang Zi Fructus Arctii (expresses rashes, reduces erythema) • Fu Ping Herba Spirodelae (expresses rashes) • Sheng Ma Rhizoma Cimicifugae (expresses rashes) There are also other herbs that act on the Lungs and affect the skin. • Bei Sha Shen Radix Glehniae, which tonifies LungYin, is used frequently for chronic skin diseases, especially if there is dryness.
• Wu Wei Zi Fructus Schisandrae, which tonifies LungYin and promotes the Lung’s fluids, is also used frequently for chronic skin diseases with dryness. • Sang Bai Pi Cortex Mori, which restores the descending of Lung-Qi and resolves Phlegm-Heat from the Lungs, is used in chronic skin diseases with Damp Heat. Thus, there is a very close relationship between the Lungs, and in particular the Lung’s Defensive-Qi system, and the skin. The Kidneys also play a role in the pathogenesis of eczema. First of all, while the Lungs control the skin in the sense of being linked to its pores, the Kidneys nourish and moisten the skin. Second, as mentioned before, the Kidney-Essence is closely bound with the Corporeal Soul (Po) of the Lungs, which manifests on the skin and which is responsible for sensations of itching and pain on the skin. An inborn defect of the Kidney-Essence, such as occurs in atopic asthma and eczema, can therefore affect the Corporeal Soul and the skin. Third, the Extraordinary Vessels, especially the Penetrating (Chong) and Directing (Ren) Vessels, nourish the skin through a network of secondary vessels all over the body. Because these two vessels arise from the Kidneys and spread the Kidney-Essence to the skin, they provide a further link between the Kidneys and the skin. Li Shi Zhen, in his work A Study of the Eight Extraordinary Vessels (1578), says: “when the Qi of the channels overflows, it flows into the extraordinary vessels, where it is turned into irrigation, warming the organs internally and irrigating the space between skin and muscles externally.”83 The Penetrating Vessel also moistens the skin. The Spiritual Axis in Chapter 65 says: “if the Blood [of the Penetrating Vessel] is abundant, the skin is moist.”84 Skin pigmentation also depends on the Extraordinary Vessels. That is why darker pigmentation is concentrated along the pathway of the Extraordinary Vessels (Directing and Penetrating Vessels) such as the genitals and the midline between pubis and umbilicus and nipples. In fact, the pigmentation on the midline between pubis and umbilicus (Directing Vessel) often becomes darker during pregnancy.85 Another example of the relationship between Kidneys and skin is the development of nephritis from a blood infection deriving from a skin disease.
Allergic asthma (atopic eczema)
CLINICAL NOTE The Kidneys and the skin The Kidneys nourish and moisten the skin. The Kidney-Essence is closely bound with the Corporeal Soul (Po) of the Lungs, which manifests on the skin and which is responsible for sensations of itching and pain on the skin. An inborn defect of the Kidney-Essence, such as occurs in atopic asthma and eczema, can affect the Corporeal Soul and the skin. The Extraordinary Vessels (arising from the Kidneys and spreading the Kidney-Essence to the skin), especially the Penetrating (Chong) and Directing (Ren) Vessels, nourish the skin through a network of secondary vessels all over the body. Li Shi Zhen: “when the Qi of the channels overflows, it flows into the extraordinary vessels, where it is turned into irrigation, warming the organs internally and irrigating the space between skin and muscles externally.” The Penetrating Vessel moistens the skin. Skin pigmentation depends on the Extraordinary Vessels. Nephritis from a blood infection may derive from a skin disease.
There are two basic types of eczema in babies, one characterized by Wind-Heat (called “dry fetus”) and the other characterized by Damp Heat (called “damp fetus”). They are both due to a deficiency of Lung and Kidney’s Defensive-Qi systems but with varying degrees of involvement of the Lungs or Kidneys. The Wind-Heat type is more due to the Lungs, while the Damp Heat type is more related to the Kidneys. As for the treatment, the aim depends on whether the asthma or the eczema is the predominant problem. If asthma is the predominant problem, one would simply use one of the formulae indicated above and add some herbs to treat the eczema according to type. • Wind-Heat: — Jing Jie Herba Schizonepetae — Chan Tui Periostracum Cicadae — Bo He Herba Menthae haplocalycis — Bai Xian Pi Cortex Dictamni • Damp Heat: — Fang Feng Radix Saposhnikoviae — Bai Xian Pi Cortex Dictamni — Ge Gen Radix Puerariae — Bai Zhi Radix Angelicae dahuricae
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— Niu Bang Zi Fructus Arctii — Sheng Ma Rhizoma Cimicifugae All these herbs are suitable for babies or young children. Eczema from Wind-Heat is characterized by skin lesions that are very dry, red and itchy, with the itchiness being spread all over the body and moving from place to place. Eczema from Damp Heat is characterized by skin lesions that are moist, oozing fluid, red and itchy, with the itchiness being more confined to specific parts of the body, often the forearm and lower leg. However, please remember that in eczema there is always Dampness, even in the “dry” type; in fact, the typical skin puffiness seen in eczema is a manifestation of Dampness. CLINICAL NOTE Wind-Heat eczema Dry, red and itchy skin lesions, with the itchiness being spread all over the body and moving from place to place. Damp Heat eczema Moist, oozing fluid, red and itchy skin lesions, with the itchiness being more confined to specific parts of the body, often the forearm and lower leg.
! Remember that in eczema there is always Dampness, even in the “dry” type; in fact, the typical skin puffiness seen in eczema is a manifestation of Dampness. Table 5.3 summarizes the differences between Wind-Heat and Damp Heat in eczema. If eczema is the main problem but the patient suffers also from asthma, then one must use one of the following formulae and modify it with the addition of herbs to restore the descending of Lung-Qi, such as Su Zi Fructus Perillae, Xing Ren Semen Armeniacae, Sang Bai Pi Cortex Mori, Pi Pa Ye Folium Eriobotryae, or Xuan Fu Hua Flos Inulae. In particular, Pi Pa Ye and Sang Bai Pi are suitable to restore the descending of Lung-Qi and they also clear Damp Heat from the skin. In babies and young children, I often use a variation of Chu Shi Wei Ling Tang Eliminating Dampness Stomach “Ling” Decoction, which is aimed primarily at
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Table 5.3 Comparison between Wind-Heat and Damp Heat types of eczema Wind-Heat (Dry fetus)
Damp Heat (Damp fetus)
Organ
Lungs
Kidneys
Clinical manifestations
Dry skin lesions, red, itchy, itchiness all over and moving from place to place
Moist skin lesions, oozing fluid, itchy, itchiness confined to specific parts (usually limbs)
Herbs
Jing Jie, Chan Tui, Bo He, Bai Xian Pi
Fang Feng, Bai Xian Pi, Ge Gen, Bai Zhi, Niu Bang Zi, Sheng Ma
eliminating Dampness. I modify it with the addition of herbs with the following aims: • To expel Wind: Jing Jie Herba Schizonepetae or Chan Tui Periostracum Cicadae. • To tonify the Lung’s Defensive-Qi system: Bei Sha Shen Radix Glehniae and Mai Men Dong Radix Ophiopogonis. • To tonify the Kidney’s Defensive-Qi system: Tu Si Zi Semen Cuscutae. • Antiallergy herbs: Dan Shen Radix Salviae miltiorrhizae, Wu Wei Zi Fructus Schisandrae.
Acute eczema Wind-Heat
• HE-8 and HE-7 stop itching, and one of these points is used if this symptom is pronounced. • Zhiyangxue, extra point, stops itching. It is situated 2 cun directly above L.I.-11 Quchi on the Large Intestine channel. • LU-7 and KI-6, in combination, open the Directing Vessel (Ren Mai), tonify the Lung and Kidney’s Defensive-Qi systems, nourish the Essence and benefit the skin. These points are used in women. In men, use LU-9 and KI-3 to tonify the Lung and Kidney’s Defensive-Qi systems and benefit the skin. • Sifeng, extra point, can be pricked in infants for acute Wind-Heat. It is located in the cracks of the fingers.
Acupuncture
Herbal therapy
Points T.B.-6 Zhigou, G.B.-31 Fengshi, BL-12 Fengmen, L.I.-11 Quchi, L.I.-4 Hegu, Du-14 Dazhui, SP-10 Xuehai, SP-6 Sanyinjiao, LIV-2 Xingjian, HE-8 Shaofu, HE-7 Shenmen, Zhiyangxue extra point, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, Sifeng. Reducing method on all points except SP-6, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa.
Prescription XIAO FENG SAN Clearing Wind Powder
Explanation • T.B.-6 and G.B.-31 are the main points to expel Wind-Heat from the skin. • BL-12 helps to expel Wind. • L.I.-11 and L.I.-4 expel Wind-Heat and cool Blood. • Du-14 is used if Heat is pronounced. • SP-10 and SP-6 cool and nourish Blood. This is necessary according to the principle of “harmonizing Blood in order to expel Wind”. • LIV-2 is used if there are signs of Liver-Heat. It also helps to expel Wind.
Explanation This formula expels Wind-Heat, clears Heat, cools Blood and nourishes Blood. It is specific for acute skin diseases from Wind-Heat. Modifications • In very chronic conditions, there may be a pronounced deficiency and dryness of the Blood. In these cases, the herbs that resolve Dampness (Ku Shen, Cang Zhu) can be eliminated or reduced in dosage, and the herbs that nourish Blood (Sheng Di Huang Radix Rehmanniae and Dang Gui Radix Angelicae sinensis) should be increased in dosage. Furthermore, Shou Wu Radix Polygoni multiflori preparata should be added.
Allergic asthma (atopic eczema)
SUMMARY ACUTE ECZEMA – WIND-HEAT Points T.B.-6 Zhigou, G.B.-31 Fengshi, BL-12 Fengmen, L.I.-11 Quchi, L.I.-4 Hegu, Du-14 Dazhui, SP-10 Xuehai, SP-6 Sanyinjiao, LIV-2 Xingjian, HE-8 Shaofu, HE-7 Shenmen, Zhiyangxue extra point, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, Sifeng. Reducing method on all points except SP-6, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa.
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tonify the Lung and Kidney’s Defensive-Qi systems and benefit the skin. • Sifeng, in infants, expels Damp Heat.
Herbal therapy Prescription BI XIE SHEN SHI TANG Dioscorea Draining Dampness Decoction Explanation This formula drains Damp Heat from the Lower Burner and the skin. Prescription CHU SHI WEI LING TANG Eliminating Dampness Stomach “Ling” Decoction
Herbal therapy Prescription XIAO FENG SAN Clearing Wind Powder
Explanation This formula drains Damp Heat and clears Heat. Compared with the previous formula, the emphasis is slightly more on Heat and on Dampness.
Damp Heat Acupuncture Points L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Du-14 Dazhui, SP-10 Xuehai, Ren-12 Zhongwan, BL-20 Pishu, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, Sifeng. Reducing method except on Ren-12, BL-20, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa. Explanation • L.I.-11, SP-9 and SP-6 resolve Damp Heat. • Du-14 and SP-10 clear Heat and cool Blood. • Ren-12 and BL-20 tonify the Spleen to resolve Dampness. • LU-7 and KI-6, in combination, are used in women to open the Directing Vessel, tonify the Lung and Kidney’s Defensive-Qi systems, nourish the Essence and benefit the skin. In men, use LU-9 and KI-3 to
Prescription QING RE SHEN SHI TANG Clearing Heat and Draining Dampness Decoction Explanation This formula drains Damp Heat, clears Heat, cools Blood and expels Toxic Heat. These three formulae for acute eczema may be differentiated in Table 5.4.
SUMMARY ACUTE ECZEMA – DAMP HEAT Points L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Du-14 Dazhui, SP-10 Xuehai, Ren-12 Zhongwan, BL-20 Pishu, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, Sifeng. Reducing method
Table 5.4 Differentiation of acute eczema formulae Bi Xie Shen Shi Tang
Chu Shi Wei Ling Tang
Qing Re Shen Shi Tang
Action
Drain Damp Heat via urine
Drain Damp Heat via urine and relieve epigastric fullness
Drain Damp Heat and resolve Toxic Heat
Skin
Moist-red skin lesions
Moist-red skin lesions, eczema more on legs
Pustular-red skin lesions
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except on Ren-12, BL-20, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa. Herbal therapy Prescription BI XIE SHEN SHI TANG Dioscorea Draining Dampness Decoction Prescription CHU SHI WEI LING TANG Eliminating Dampness Stomach “Ling” Decoction Prescription QING RE SHEN SHI TANG Clearing Heat and Draining Dampness Decoction
Chronic eczema Wind-Heat (with Blood deficiency) Acupuncture Points T.B.-6 Zhigou, G.B.-31 Fengshi, BL-12 Fengmen, L.I.-11 Quchi, L.I.-4 Hegu, Du-14 Dazhui, SP-10 Xuehai, SP-6 Sanyinjiao, LIV-2 Xingjian, HE-8 Shaofu, Zhiyangxue extra point, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, ST-36 Zusanli, BL-17 Geshu, LIV-8 Ququan, Ren-4 Guanyuan. Even method on all points except SP-6, LU-7, KI-6, LU-9, KI-3, ST-36, BL-17, LIV-8 and Ren-4, which should be reinforced. No moxa.
Kidney’s Defensive-Qi systems, nourish the Essence and benefit the skin. In men, use LU-9 and KI-3 to tonify the Lung and Kidney’s Defensive-Qi systems and benefit the skin. • ST-36 and BL-17 nourish Blood. • LIV-8 and Ren-4 are reinforced if there are symptoms of Liver-Blood deficiency.
Herbal therapy Prescription YANG XUE DING FENG TANG Nourishing Blood and Clearing Wind Decoction Explanation This formula is for chronic eczema from Wind-Heat in the Blood affecting the skin against a background of Blood deficiency. The skin lesions are not very red and the skin is very dry and itchy. Prescription XIAO FENG CHONG JI Clearing Wind Decoction Explanation This formula is for a more complex condition than the previous one. It is for chronic eczema from both Wind-Heat and some Damp Heat against a background of Blood deficiency with some Blood-Heat. The skin lesions are quite red, not too itchy, dry but frequently turning moist.
SUMMARY Explanation • T.B.-6 and G.B.-31 are the main points to expel Wind-Heat from the skin. • BL-12 helps to expel Wind. • L.I.-11 and L.I.-4 expel Wind-Heat and cool Blood. • Du-14 is used if Heat is pronounced. • SP-10 and SP-6 cool and nourish Blood. This is necessary according to the principle of “harmonizing Blood in order to expel Wind”. • LIV-2 is used if there are signs of Liver-Heat. It also helps to expel Wind. • HE-8 stops itching and is used if itching is pronounced. • Zhiyangxue, extra point, stops itching. It is situated 2 cun directly above L.I.-11 on the Large Intestine channel. • LU-7 and KI-6, in combination, are used in women to open the Directing Vessel, tonify the Lung and
CHRONIC ECZEMA – WIND-HEAT (WITH BLOOD DEFICIENCY) Points T.B.-6 Zhigou, G.B.-31 Fengshi, BL-12 Fengmen, L.I.-11 Quchi, L.I.-4 Hegu, Du-14 Dazhui, SP-10 Xuehai, SP-6 Sanyinjiao, LIV-2 Xingjian, HE-8 Shaofu, Zhiyangxue extra point, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi, ST-36 Zusanli, BL-17 Geshu, LIV-8 Ququan, Ren-4 Guanyuan. Even method on all points except SP-6, LU-7, KI-6, LU-9, KI-3, ST-36, BL-17, LIV-8 and Ren-4, which should be reinforced. No moxa. Herbal therapy Prescription YANG XUE DING FENG TANG Nourishing Blood and Clearing Wind Decoction
Allergic asthma (atopic eczema)
Prescription XIAO FENG CHONG JI Clearing Wind Decoction
LU-9 and KI-3, which should be reinforced. No moxa. Herbal therapy Prescription SAN FENG CHU SHI TANG Scattering Wind and Eliminating Dampness Decoction
Damp Heat Acupuncture Points L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Du-14 Dazhui, SP-10 Xuehai, Zhiyangxue, Ren-12 Zhongwan, BL-20 Pishu, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi. Reducing method except on Ren-12, BL-20, LU-7, KI-6, LU-9 and KI-3, which should be reinforced. No moxa. Explanation • L.I.-11, SP-9 and SP-6 resolve Damp Heat. • Du-14 and SP-10 clear Heat and cool Blood. • Zhiyangxue, extra point located 2 cun above L.I.-11, stops itching. • Ren-12 and BL-20 tonify the Spleen to resolve Dampness. • LU-7 and KI-6, in combination, are used in women to open the Directing Vessel, tonify the Lung and Kidney’s Defensive-Qi systems, nourish the Essence and benefit the skin. In men, use LU-9 and KI-3 to tonify the Lung and Kidney’s Defensive-Qi systems and benefit the skin.
Herbal therapy
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External treatment The application of herbs externally is very beneficial for chronic eczema. The herbs may be boiled in the usual way but with a much larger quantity of water and then strained. The resulting liquid may then be poured in a shallow bath. Let the patient bathe in this water. A common formula for external use is as follows. • • • • • •
Da Huang Radix et Rhizoma Rhei Huang Qin Radix Scutellariae Huang Bo Cortex Phellodendri Ku Shen Radix Sophorae flavescentis Ju Hua Flos Chrysanthemi Zi Hua Di Ding Herba Violae
MODERN CHINESE LITERATURE
Prescription SAN FENG CHU SHI TANG Scattering Wind and Eliminating Dampness Decoction
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 36, No. 11, 1995, p. 666.
Explanation This formula is for chronic eczema from Damp Heat with dark lesions usually in a limited area oozing fluid and with a thick-rough skin.
Chen Jin and Luo Guan Liang, “The treatment of paediatric asthma by simultaneously tonifying and expelling.”
SUMMARY CHRONIC ECZEMA – DAMP HEAT Points L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Du-14 Dazhui, SP-10 Xuehai, Zhiyangxue, Ren-12 Zhongwan, BL-20 Pishu, LU-7 Lieque and KI-6 Zhaohai, LU-9 Taiyuan, KI-3 Taixi. Reducing method except on Ren-12, BL-20, LU-7, KI-6,
The authors treated 156 children with asthma, of whom 106 received treatment with Chinese herbs and 50 were in a control group treated with Western medication. Of the 106 children in the treatment group, 81% were under 3. The asthma was elicited by invasion of external Wind in 86% of cases, by diet in 26%, by exercise in 19%, and by distress in 7.4%. In 71.7% of cases, there was a deficiency of Prenatal Qi. One hundred per cent of the children displayed wheezing, breathlessness and cough; 96% had Phlegm;
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64% had a Kidney deficiency; 70% had Lung-Yin deficiency; 63% a Spleen deficiency; 9% Blood stasis; and 7% Lung-Yang deficiency. The formula used was as follows. • • • • • • • • • • • • •
Ma Huang Herba Ephedrae Xing Ren Semen Armeniacae Ban Xia Rhizoma Pinelliae preparatum Chen Pi Pericarpium Citri reticulatae Fu Ling Poria Bai Zhu Rhizoma Atractylodis macrocephalae Fang Feng Radix Saposhnikoviae Wu Wei Zi Fructus Schisandrae Tai Zi Shen Radix Pseudostellariae Dang Gui Radix Angelicae sinensis Shu Di Huang Radix Rehmanniae preparata Zi He Che Placenta hominis Dong Chong Xia Cao Cordyceps
The children in the control group were treated with Tranilast, an antiallergy medication. The total of positive results in the treatment group was 90.6% and that in the control group 66.7%. In the discussion, the authors say that external Wind can trigger asthma attacks only when there is Phlegm in the Lungs and a deficiency of the Kidneys. Contrary to traditional theory, according to which a deficiency of the Kidneys is a factor in chronic asthma in adults in the late stages of the disease, they say that in children a deficiency of the Kidneys is present from the beginning and is at the root of the disease. They make a correlation between the Kidney deficiency and an insufficiency of the adrenal cortex.
Dr He says that allergic asthma is due to the invasion of allergens, and he compares these to the Chinese concept of “Wind”. Interestingly, in contrast to most other modern Chinese doctors, Dr He understands the correlation between allergic rhinitis and allergic asthma as being two manifestations of the same disease. He says that when allergens settle in the nose they cause allergic rhinitis (with sneezing and itchiness), and when they settle in the bronchi they cause allergic asthma. Dr He says, in addition, that the episodic nature of allergic asthma reflects the characteristic of Wind in coming and going quickly and having rapid onset. Moreover, Dr He also thinks (as I do) that the bronchospasm that causes narrowing of the airways in asthma is also a manifestation of Wind as this contracts. Dr He recommends using two main points to expel Wind in asthma: G.B.-20 Fengchi and LU-7 Lieque. In the same article, Dr Shao Jing Ming says that the three most important points to treat asthma are BL-12 Fengmen, BL-13 Feishu and Du-14 Dazhui. The other points he uses according to clinical manifestations are as follows. • Cough with sputum: LU-5 Chize, LU-9 Taiyuan. • Profuse phlegm: Ren-12 Zhongwan, ST-36 Zusanli. • Phlegm in the throat: Ren-22 Tiantu, Ren-17 Shanzhong. • Better with rest and worse with exercise: Ren-4 Guanyuan, BL-23 Shenshu and KI-3 Taixi. • Palpitations: BL-14 Jueyinshu and BL-15 Xinshu.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 26, No. 5, 1985, p. 47.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 29, No. 1, 1988, pp. 5–11.
Shao Jing Ming, “Clinical observation on the treatment of 111 cases of asthma with acupuncture.”
He Shu Huai, “Patterns and treatment of asthma.”
Dr Shao Jing Ming treated 111 cases of asthma with acupuncture. The three main points were BL-12 Fengmen, BL-13 Feishu and Du-14 Dazhui. Other points according to clinical manifestations were as follows.
This article is a collection of clinical experiences of modern Chinese doctors. Dr He Shu Huai stands out as having a theory of asthma that is different from the traditional theory. In fact, Dr He maintains (as I do) that the main pathogenic factor in asthma is not Phlegm but “Wind”. Dr He uses the quotation marks for “Wind” because he says (as I do) that in type it differs slightly from Wind as usually considered in Chinese medicine.
• Cough with sputum: LU-5 Chize, LU-9 Taiyuan. • Profuse phlegm: Ren-12 Zhongwan, ST-36 Zusanli. • Phlegm in the throat: Ren-22 Tiantu, Ren-17 Shanzhong. Of 111 patients, 48 (43.2%) reported a large improvement in symptoms, 61 (54.9%) a noticeable improvement, and 2 (1.8%) no improvement.
Allergic asthma (atopic eczema)
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 39, No. 2, 1998, pp. 99–100. Zhang Jing Lei, “The treatment of bronchial asthma with Chinese medicine.” Dr Zhang Jing Lei treated 764 patients with bronchial asthma, of whom 600 were in the treatment group (with Chinese herbs) and 164 in the control group treated with Western medication (bronchodilators, cortisone and histamine). There were 410 men and 354 women. The youngest patient was 18 and the oldest 65, with the average age being 42 years. The prescription used is not fully disclosed in the article but is based on tonification of the Kidneys with the main ingredients given as follows. • • • • • •
Sheng Di Huang Radix Rehmanniae Shu Di Huang Radix Rehmanniae preparata Mai Men Dong Radix Ophiopogonis Ren Shen Radix Ginseng Wu Wei Zi Fructus Schisandrae Ci Shi Magnetitum
Dr Zhang believes that in order to treat the inflammation process, the atopy and the bronchoconstriction, it is necessary to nourish Kidney-Yin.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 40, No. 3, 1999, pp. 139–40. Wang Xing Juan, “The experience of Dr Shen Zi Yin in the treatment of asthma.” Dr Wang Xing Juan reports the experience of Dr Shen Zi Yin in the treatment of asthma. Dr Wang considers that the two main treatment methods for asthma are to restore the descending and diffusing of Lung-Qi and to tonify the Kidneys. To restore the descending and diffusing of Lung-Qi, Dr Shen uses formulae such as Ma Huang Tang Ephedra Decoction, San Ao Tang Three Break Decoction, Xiao Qing Long Tang Small Green Dragon Decoction or Ma Xing Shi Gan Tang Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction. Dr Shen thinks that tonifying the Kidneys is necessary not only from the perspective of Chinese medicine but also from that of Western medicine. Interestingly,
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he says that using herbs with a sweet and sour taste stabilizes the cell membranes and therefore has a stabilizing effect on the mast cells in the bronchi. Dr Shen also says that tonifying the Kidneys (and especially Kidney-Yang) in asthma has the effect of regulating immunity by regulating the T-cells and reducing the levels of IgE.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 31, No. 1, 1990, p. 57. Hu Jin Sheng, “Needle manipulation for asthma.” Dr Hu Jin Sheng discusses the needle manipulation for points to stop asthma. For the extra point Dingquan, he recommends inserting the needle obliquely towards Du-14 Dazhui to the depth of 1.5 cun. The needling sensation should radiate to the chest and it should be retained for 30 minutes. It should be reduced with rotation technique. The point LU-10 Yuji should be needled perpendicularly to the depth of 0.7 cun, and it should be retained for 30 minutes. It should be reduced with rotation technique. The point Du-14 Dazhui should be needled to a depth of 1.3 cun, and the patient should experience a distending and heaviness sensation.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 42, No. 3, 2001, p. 185. Cui Hong Sheng, “Differences between cough and asthma.” Dr Cui Hong Sheng discusses the differences between the Chinese disease entities of “Cough” and “Asthma”. Dr Cui has a theory of allergic asthma that differs from the traditional one and that is close to my theory of asthma. He says that in allergic asthma there is a deficiency of Liver-Blood and a dryness of Blood leading to Wind. The Wind travels upwards and causes wheezing. Dr Cui says that the treatment principle for allergic asthma is to soothe the Liver and restore the descending of Lung-Qi, together with the administration of herbs that have an antiallergy effect. The formula he uses is as follows.
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• Wu Mei Fructus Mume 15 g (antiallergy effect) • Wu Wei Zi Fructus Schisandrae 6 g (antiallergy effect) • Chai Hu Radix Bupleuri 10 g • Fang Feng Radix Saposhnikoviae 6 g • Bai Shao Radix Paeoniae alba 10 g • Bei Sha Shen Radix Glehniae 10 g • Sang Ye Folium Mori 10 g • Sang Bai Pi Cortex Mori 10 g • Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6 g
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 36, No. 4, 1995, p. 242. Wang Zhi Ying, “Research on the treatment of asthma by invigorating blood and eliminating stasis.” Dr Wang Zhi Ying’s ideas on the treatment of asthma differ from the traditional ones. To treat asthma, in fact, he uses the method of invigorating Blood. He bases his view on two factors. First, he says that in asthma, the failure of Lung-Qi to descend also causes some Qi stagnation. As Qi is the mother of Blood, this Qi stagnation frequently leads to Blood stasis. Second, as in Phlegm there is asthma, Phlegm often harbours stasis of Blood because of the interaction between Fluids and Blood; in fact, Phlegm and Blood stasis are two pathogenic factors that aggravate each other. The formulae Dr Wang uses are Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction, Fu Yuan Huo Xue Tang Restoring the Source and Invigorating Blood Decoction and Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 39, No. 7, 1998, p. 398. Zhang Cheng, “A case of asthma treated with large doses of Shu Di Huang Radix Rehmanniae preparata.” Dr Zhang Cheng reports the treatment of asthma by using large doses of Shu Di Huang Radix Rehmanniae preparata (30–60 g) within a prescription. He says that Shu Di Huang nourishes Kidney-Yin, tonifies the Original Qi and strengthens the Kidney’s receiving of Qi. The formula he uses is as follows.
• • • • • • • • • • • •
Shu Di Huang Radix Rehmanniae preparata Dang Gui Radix Angelicae sinensis Yin Yang Huo Herba Epimidii Bu Gu Zhi Fructus Psoraleae Wu Wei Zi Fructus Schisandrae Bai Zhu Rhizoma Atractylodis macrocephalae Qian Shi Semen Euryales Xing Ren Semen Armeniacae Zi Wan Radix Asteris Sang Bai Pi Cortex Mori Dan Shen Radix Salviae miltiorrhizae Tao Ren Semen Persicae
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 39, No. 7, 1998, p. 396. Wu Ying He, “The treatment of acute bronchial asthma according to pattern identification and with the addition of insect substances to extinguish Wind.” Dr Wu Ying He recommends the use of insect substances for the treatment of acute asthma. This is based on the principle that insects extinguish Wind. The insects he adds to a formula according to pattern identification are Jiang Can Bombyx batryticatus, Chan Tui Periostracum Cicadae, Di Long Pheretima and Quan Xie Scorpio.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 28, No. 12, 1987, p. 37. Shi Guang Yu, “Dr Shao Jing Ming’s experience on the acupuncture treatment of asthma.” Dr Shao Jing Ming is an expert in the treatment of asthma with acupuncture. The three main points he uses are BL-12 Fengmen, BL-13 Feishu and Du-14 Dazhui. The combination of these three points for asthma is described as the “Three Points, Five Needles, One Cupping” (because cupping is applied to Du-14 Dazhui). He inserts Du-14 to the depth of 1 cun and rotates it to obtain deqi; he inserts BL-12 and BL-13 to the depth of 5-8 fen. He uses rotation for an even manipulation. He retains the needles for 20 minutes in adults but only 2–3 minutes in children. Other points he uses according to clinical manifestations are as follows.
Allergic asthma (atopic eczema)
• External invasion of Wind: L.I.-4 Hegu and LU-7 Lieque. • Cough with sputum: LU-5 Chize, LU-9 Taiyuan. • Profuse phlegm: Ren-12 Zhongwan, ST-36 Zusanli. • Phlegm in the throat: Ren-22 Tiantu, Ren-17 Shanzhong. • Better with rest and worse with exercise: Ren-4 Guanyuan, BL-23 Shenshu and KI-3 Taixi.
Journal of the Nanjing University of Traditional Chinese Medicine (Nan Jing Zhong Yi Yao Da Xue Xue Bao), Vol. 12, No. 2, 1996, p. 53. Qiu Li Sheng, “The treatment of children’s allergic asthma with the method of expelling Wind and penetrating the Connecting channels.” Dr Qiu Li Sheng reports the treatment of 38 children suffering from allergic asthma. In one of a few Chinese articles that discusses allergic asthma specifically, Dr Qiu adopted the method of expelling Wind and removing obstructions from the Connecting channels with herbs such as Fang Feng Radix Saposhnikoviae, Chan Tui Periostracum Cicadae, Gou Teng Ramulus cum Uncis Uncariae, Wu Shao She Zaocys and Si Gua Luo Fructus Retinervus Luffae. The other treatment methods used in addition to the above include restoring the descending of Lung-Qi, resolving Phlegm and nourishing Lung-Yin.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 38, No. 6, 1997, p. 340. Hu Jin Sheng, “The treatment of allergic asthma with acupuncture.” Dr Hu Jin Sheng discusses the treatment of allergic asthma with acupuncture. He distinguishes two main patterns in allergic asthma: Qi deficiency with Blood stasis and Lung and Kidney deficiency. The main points he uses fall into two groups. They are divided as follows. 1. Du-20 Baihui, Du-23 Shangxing, Yintang, BL-7 Tongtian, L.I.-20 Yingxiang, LU-1 Zhongfu, L.I.-4 Hegu, Ren-17 Shanzhong, P-6 Neiguan, ST-36 Zusanli, SP-6 Sanyinjiao. 2. Du-14 Dazhui, Dingchuan, Chuanxi, G.B.-20 Fengchi, BL-13 Feishu, BL-17 Geshu, BL-20 Pishu, BL-23 Shenshu, BL-25 Dachangshu.
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The points used by Dr Hu are interesting, as they are quite different from the ones used by other modern doctors. The first group includes many points from the Governing Vessel (Du Mai) and, surprisingly, BL-7 Tongtian (on the head). The inclusion of Du-20 Baihui is also surprising, as this point lifts Qi (something that one would not want to do in asthma when Qi needs to descend). The second group includes points that expel Wind and points that tonify the Lungs and Kidneys. This is interesting from my perspective, as it would confirm my theory of Wind being the main pathogenic factor and a deficiency of Lungs and Kidneys the underlying condition in allergic asthma. Dr Hu’s explanation of the points is as follows. • Du-20 lifts the deficient Qi. • Du-23, Yintang and L.I.-20 open the Lung’s orifices to make Qi descend. • BL-7, as the name Tongtian implies (according to Dr Hu), “makes Lung-Qi penetrate (Tong) to Heaven (Tian)” and promotes the exchange and communication between Lung-Qi and air. • LU-1, Front-Collecting point of the Lungs, regulates the Lungs and promotes the descending of Lung-Qi. • L.I.-4, Source (Yuan) point of the Large Intestine, helps Lung-Qi to descend thanks to the exterior–interior relationship between Large Intestine and Lung channels. • Ren-17 and P-6 regulate the Qi Mechanism (Qi Ji). • ST-36 and SP-6 tonify Stomach and Spleen which will help to tonify the Lungs (Earth being the mother of Metal). • Du-14 is a meeting point of all Yang channels (Dr Hu does not say how exactly this helps asthma). • Dingchuan (0.5 cun lateral to Du-14) and Chuanxi (1 cun lateral to Du-14) are empirical points for asthma. • G.B.-20 expels Wind. • BL-13, BL-20 and BL-23 tonify Lungs, Spleen and Kidneys. • BL-17 regulates Blood: invigorating Blood will help to move Qi. Dr Hu adds other points according to clinical manifestations as follows. • Qi deficiency: Ren-6 Qihai and SP-10 Xuehai to tonify Qi and Blood. • Lung and Kidney deficiency: KI-3 Taixi, LU-9 Taiyuan.
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• Cough, chest pain: KI-26 Yuzhong and KI-27 Shufu. • Profuse phlegm, itchy throat: ST-40 Fenglong, Ren-22 Tiantu, Zengyin (literally “increase voice”, 1 cun lateral to the tip of the laryngeal prominence). • Digestive symptoms: Ren-12 Zhongwan, ST-25 Tianshu. • Oedema of upper limbs: L.I.-6 Pianli and LU-7 Lieque. • Oedema of lower limbs: SP-9 Yinlingquan, SP-6 Sanyinjiao, SP-5 Shangqiu. Dr Hu recommends using the above two groups of points four times a week initially, twice for each group. After 3 weeks, reduce the treatment to three times a week using the first group twice and the second group once. After 4 weeks, reduce the frequency to twice a week, once for each group. Use even method after obtaining the needling sensation and needle Dingquan to a depth of 1–1.2 cun.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 29, No. 2, 1988, pp. 38–39. Hu Wen Hao, “Clinical observation of 39 cases of allergic asthma treated with acupuncture and Chinese herbs.” Dr Hu Wen Hao discusses the treatment of 39 cases of allergic asthma with acupuncture and Chinese herbs. The formula used was Er Ma Si Ren Tang Two Hemp Four Seeds Decoction. The main acupuncture points used were Dingchuan, ST-40 Fenglong, BL-23 Shenshu, LU-6 Kongzui, ST-36 Zusanli. Dr Hu explains that if Phlegm predominates, Dingchuan and LU-6 should be the main points; if there is Phlegm and Kidney deficiency, ST-40, ST-36 and BL-23 should be the main points.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 33, No. 8, 1992, p. 55. Shen Zhuang Fa, “The treatment of Wheezing (Xiao) by restoring the diffusing and descending of Qi, by rectifying Qi and by benefiting Qi.” Dr Shen Zhuang Fa discusses the treatment principles for asthma (Xiao). He says that in asthma there is stagnation of Qi in the Interior, invasion of external Wind (eliciting acute attacks) and accumulation of
Phlegm in the diaphragm. The organs involved are Lungs, Spleen and Kidneys. Dr Shen explains that in asthma there is a failure of the diffusing and descending of Lung-Qi, leading to the formation of Phlegm; the Spleen is deficient and cannot transform and transport, so fluids accumulate into Dampness and Phlegm; the deficient Kidneys fail to hold and receive Qi, so this rebels upwards towards the Lungs. Therefore the treatment methods must be based on stimulating the diffusing of Lung-Qi and the descending of Lung-Qi (which will help to resolve Phlegm) and on rectifying Qi (i.e. promote its flow in the right direction). In between attacks, one must tonify Qi of the Lungs, Spleen and Kidneys. The formulae used by Dr Shen are as follows. • To stimulate the diffusing of Lung-Qi (for Phlegm in the Lungs): She Gan Ma Huang Tang BelamcandaEphedra Decoction. • To stimulate the descending of Lung-Qi (for PhlegmHeat in the Lungs): Ding Chuan Tang Stopping Breathlessness Decoction. • To rectify Qi (for Phlegm and Qi deficiency): Su Zi Jiang Qi Tang Perilla Seed Lowering Qi Decoction. • To benefit Qi (for chronic stage with deficiency of Lungs and Spleen): Yu Ping Feng San Jade Screen Powder. • To stimulate the reception of Qi (for deficient Kidneys not holding Qi): You Gui Wan Restoring the Right [Kidney] Pill plus Shen Ge San Ginseng-Gecko Powder.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 24, No. 5, 1983, p. 33. Huo Guo Shang, “The effect of tonifying the Kidneys in asthma on serum levels of IgE and T cells.” Dr Hu Guo Shang conducted a study to test the effect of tonifying the Kidneys on serum levels of IgE and T-cells in patients suffering from allergic asthma. Interestingly, rather than testing Chinese medicine against Western medicine or a placebo, the study tested the effect of herbs that tonify the Kidneys against the formula Xiao Qing Long Tang Small Green Dragon Decoction, which eliminates Cold Phlegm from the Lungs. In the treatment group (taking Kidney tonics), there were 60 patients, 38 men and 22 women, with the median age of 32 and the average duration of the
Allergic asthma (atopic eczema)
disease was 22 years. In the control group (taking Xiao Qing Long Tang), there were 36 patients, 21 men and 15 women, with the median age of 29 and the average duration of the disease was 26 years. The Kidney-tonic prescription tonified Kidney-Yang and included the following herbs. • • • • • • •
Fu Zi Radix Aconiti lateralis preparata Sheng Di Huang Radix Rehmanniae Shu Di Huang Radix Rehmanniae preparata Shan Yao Rhizoma Dioscoreae Xian Ling Pi Herba Epimidii Bu Gu Zhi Fructus Psoraleae Tu Si Zi Semen Cuscutae
The control group took Xiao Qing Long Tang. After 1 year of therapy, the effective rate in the group taking Kidney tonics was 75%, while that in the control group was 19.5%. The levels of IgE in serum in the treatment group decreased from 97.74 to 94.99, while those in the control group increased from 115.15 to 147.43. The study also found that tonifying the Kidneys will not treat the Manifestation (Biao) in asthma, but the treatment works best if administered in the summer to prevent attacks in winter. This article is particularly interesting in light of my theory of allergic asthma, as it confirms that the high levels of IgE in atopic individuals are connected to a Kidney deficiency and that tonifying the Kidneys will induce a decrease in the levels of IgE (and therefore treat the underlying cause of atopy). In view of my theory, it is also significant that tonification of the Kidneys was compared with resolving Phlegm (with Xiao Qing Long Tang) and that this treatment method produced worse results.
Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 3, No. 5, 1983, p. 7. Ding Yi Dan, “Preliminary research on effect of relieving asthma by needling BL-13, BL-12 and Du-14.” Dr Ding Yi Dan treated 124 patients suffering from asthma with acupuncture on the points BL-13 Feishu, BL-12 Fengmen and Du-14 Dazhui. The results were compared with those of a control group who had no treatment. The FEV, forced vital capacity and PEFR were monitored before and after treatment, and the results
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in the control group showed that the lung function is improved by acupuncture (P < 0.001). Interestingly, the study also compared the effect of acupuncture with moxibustion to that of acupuncture with cupping, and the results showed that the former method gives better results. The points used were BL-13 Feishu, BL-12 Fengmen and Du-14 Dazhui, the first two needled at a depth of 0.8 fen and the third at a depth of 1.3 cun; the needles were retained for 20 minutes.
Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 2, No. 5, 1982, p. 13. Li Zhi Ming, “Observations on the treatment of 182 cases of asthma with scarring moxibustion.” Dr Li Zhi Ming treated 182 asthmatic patients with scarring moxibustion. This article is reported here even though it is unlikely that we could use such a method on Western patients. However, ordinary moxibustion would also have an effect. The points used were selected according to the organ involved as follows. • Lungs: Du-14 Dazhui 5–7 cones, BL-13 Feishu 5–7 cones, Ren-17 Shanzhong 3–5 cones. • Spleen: Du-14 Dazhui 5–7 cones, BL-13 Feishu 5–7 cones, BL-43 Gaohuangshu 5–7 cones, Ren12 Zhongwan 7–9 cones. • Kidneys: Du-14 Dazhui 5–7 cones, BL-13 Feishu 5–7 cones, BL-43 Gaohuangshu 5–7 cones, Ren-6 Qihai 5–9 cones, BL-23 Shenshu 5–9 cones. Dr Li reports that 12.1% of patients were cured, 8.2% reported a clear improvement, 56.6% an improvement, and 23.1% no improvement.
Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 20, No. 3, 2000, p. 155. Chen Ming, “Preliminary study on the relationship between acupuncture in different solar terms and changes in pulmonary function in asthma.” Dr Chen Ming treated 43 patients with asthma by giving them acupuncture during specific solar terms
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and compared the results to those in 24 patients who were not treated according to solar terms. The solar terms are 24 periods of 2 weeks each in a year, beginning from the first day of the Chinese New Year (which would fall on a different date of the Western calendar each year). The solar terms during which the treatment was administered were as follows. • • • •
Spring equinox (4th solar term) Summer solstice (10th solar term) Autumn equinox (16th solar term) Winter solstice (22nd solar term)
The points used were Du-14 Dazhui and BL-13 Feishu with moxibustion on ginger juice. A small plaster with Chinese herbs was also applied on the points during the solar term. The herbs were Bai Jie Zi Semen Sinapis albae, Gan Sui Radix Euphorbiae Kansui, Xi Xin Herba Asari and Yan Hu Suo Rhizoma Corydalis. The FEV was measured in each patient in each group, and the patients treated according to the solar terms registered a greater improvement than those who did not.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 30, No. 5, 1989, pp. 35–36. Zhu Sheng Chao, “Clinical observation on the prevention of cough and breathlessness in children with massage in the summer.” Dr Zhu recommends a massage treatment for children suffering from asthma to be given in summertime. This treatment consists of three massage techniqes: 1. massaging the ring finger from the base towards the tip 100 times 2. kneading LU-5 Chize 50 times 3. kneading LU-10 Yuji 100 times.
Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 20, No. 2, 2000, p. 75. Wu Jian Ming, “Research on the treatment of 260 cases of allergic asthma with moxibustion.” Dr Wu treated 260 patients with allergic asthma, 148 men and 112 women, with ages ranging from 6 to 75. The shortest duration of the disease was 6 months and the longest 60 years. The patients were divided into two groups of two patterns, one with manifestations of Cold, the other with manifestations of Heat. The treatment consisted of the application of indirect moxibustion to the points Du-14 Dazhui, BL-13 Feishu, BL-17 Geshu, BL-23 Shenshu, Ren-22 Tiantu, Ren-17 Shanzhong, and KI-1 Yongquan. Treatment was given in the summer with one application of moxibustion every 10 days, three times constituting a course. Moxibustion was applied with moxa cones after placing a herbal poultice on the acupuncture points. The herbal prescription for external application with moxibustion included Yan Hu Suo Rhizoma Corydalis, Xi Xin Herba Asari, Gan Sui Radix Euphorbiae Kansui, Bai Jie Zi Semen Sinapis albae and Fang Feng Radix Saposhnikoviae. The results were differentiated according to the Cold and Heat group as shown in the table. Predictably, the results were better in the Cold group.
Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 20, No. 2, 2000, p. 109. Zhang Zhi Guo et al., “Experience on the treatment of asthma with plum-blossom tapping and cupping in Algeria.” Dr Zhang and others treated 125 cases of asthma with an interesting combination of treatment. They used
Pattern
No. of patients
Cure
Good
Results Satisfactory
None
Cure rate (%)
Cold
144
28 (19.5%)
56 (38.9%)
46 (31.9%)
14 (9.7%)
90.3%
Heat
60
5 (8.3%)
12 (20%)
30 (50%)
13 (21.7%)
78.3%
Not determined
56
11 (19.7%)
18 (32.1%)
18 (32.1%)
9 (16.1%)
83.9%
Allergic asthma (atopic eczema)
plum-blossom tapping on points on the chest and cupping on points of the upper back. The area that was tapped with the plum-blossom hammer was from Ren-22 Tiantu to Ren-15 Jiuwei, along the Directing Vessel (Ren Mai). The area of the back that was cupped was along the Governing Vessel (Du Mai) from Du-14 Dazhui to Du-8 Jinsuo.
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IL-8 rose significantly. Additionally the in vitro lymphocyte proliferation rate increased significantly and the eosinophils decreased from 4.4% to 3.3% after acupuncture. In the control group, these variables showed no significant changes apart from an increase in CD4+ cells.
Conclusion
Acupuncture
The results imply that asthma patients benefit from acupuncture treatment given in addition to conventional therapy. Furthermore, acupuncture performed in accordance with the principles of TCM showed significant immunomodulatory effects.
Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study
Effect of acupuncture or acupressure on quality of life of patients with chronic obstructive asthma: a pilot study
Journal of Alternative and Complementary Medicine 2000 December, Vol. 6, Issue 6, pp. 519–525. Joos S, Schott C, Zou H, Daniel V, Martin E, Brinkhaus B Department of Anaesthetics, University of Heidelberg, Germany
Journal of Alternative and Complementary Medicine 2003 October, Vol. 9, Issue 5, pp. 659–670. Maa SH, Sun MF, Hsu KH, Hung TJ, Chen HC, Yu CT, Wang CH, Lin HC School of Nursing, Chang Gung University, Tao-Yuan, Taiwan
CLINICAL TRIALS
Objective To investigate the immunological effects of Chinese acupuncture in a randomized controlled study of patients with allergic asthma.
Method The effects of acupuncture treatment given according to the rules of traditional Chinese medicine (TCM group, n = 20) were compared with those of acupuncture treatment using points not specific for asthma (control group, n = 18). All patients were treated 12 times for 30 minutes over 4 weeks. Besides the documentation of the patients’ general well-being, several immunological parameters (eosinophils, lymphocyte subpopulations, cytokines, in vitro lymphocyte proliferation) were determined in the peripheral blood before and after acupuncture treatment.
Results In the TCM group, significantly more patients indicated an improvement in general well-being (79% in the TCM group versus 47% in the control group) after acupuncture treatment. Moreover, in the TCM group the CD3+ and CD4+ cells increased significantly after acupuncture. There were also significant changes in cytokine concentrations: IL-6 and IL-10 fell, whereas
Objective To determine the contribution of acupuncture or acupressure to the improvement of quality of life of adults with chronic obstructive asthma.
Method This randomized study involved 8 weeks of treatment at Chang Gung Memorial Hospital (Tao-Yuan, Taiwan) and was conducted between March 1997 and September 1998. Forty-one patients with chronic obstructive asthma were enrolled. Patients were randomly assigned to receive acupuncture in addition to standard care (n = 11), acupressure and standard care (n = 17) or standard care alone (n = 13). Twenty acupuncture treatments were administered, and self-administered acupressure was performed daily for 8 weeks. Sixminute walking, the Dyspnea Visual Analogue Scale, the modified Borg scale, St George’s Respiratory Questionnaire (SGRQ) and the Bronchitis Emphysema Symptom Checklist (BESC) were used at the beginning and end of the 8 weeks of treatment.
Results The total SGRQ score of acupuncture subjects showed an average 18.5-fold improvement; the improvement for
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the acupressure subjects was 6.57-fold. Additionally, for patients who received acupressure, the irritability domain score determined by the BESC exhibited an 11.8-fold improvement after adjustment for covariables. The other variables did not differ from those of the controls.
Conclusion Patients with clinically stable, chronic obstructive asthma experienced clinically significant improvements in quality of life when their standard care was supplemented with acupuncture or acupressure.
Herbal medicine Effect of Yi Qi Bu Shen Huo Xue (benefiting Qi, tonifying the Kidneys and invigorating Blood) herbs in treating childhood asthma and on levels of nitric oxide, endothelin-1 and serum endothelial cells Chinese Journal of Integrated Traditional and Western Medicine 2001 September, Vol. 21, Issue 9, pp. 667–669. Kong LF, Guo LH, Zheng XY
Objective To observe the therapeutic effect of Yi Qi Bu Shen Huo Xue herbs (YQBSHX, the Chinese herbs for supplementing Qi, tonifying Kidney and activating blood circulation) on childhood asthma, looking particularly at its effect on the serum levels of nitric oxide (NO), endothelin-1 (ET-1) and circulating endothelial cells (CEC).
Method Two hundred children with asthma were divided into two groups, the YQBSHX and the control group, and their serum levels of NO, ET-1 and CEC were detected in acute and remission stage, respectively. Twenty patients in each group were followed up for 1 year to observe the frequency of asthma attack and the changes in ET-1, NO and CEC levels.
Results Serum levels of ET-1, NO and CEC in patients of acute stage were obviously raised. After treatment, the above-mentioned criteria in the YQBSHX group were significantly lower than those in the control group. The
frequency of attack in the YQBSHX group was markedly reduced.
Conclusion The YQBSHX herbs could reduce ET-1, NO and CEC levels in children with asthma, lessen the frequency of attack, and therefore elevate the cure rate of childhood asthma.
Evaluation of efficacy of traditional Chinese medicines in the treatment of childhood bronchial asthma: clinical trial, immunological tests and animal study Paediatric Allergy and Immunology 1996, Vol. 7, Issue 3, pp. 130–140. Hsieh KH, Chuang CY, Cheng CH, Hsiao WC, Chou CC, Su KC, Wang JY, Yang CH, Liu WJ, Wang JS, Chou CT, Kao ST, Lue KH, Shen JJ, Tsay JJ, Huang MT, Tang RB, Chang BT, Lan JL, Chang CK, Lin JG, Shih TY
Objective To evaluate the efficacy of traditional Chinese medicines in the treatment of childhood bronchial asthma.
Method A multicentre, double-blind and placebo-controlled study was conducted to evaluate the clinical efficacy in terms of symptom score, medication score, morning and evening PEFRs, and changes of immunoregulatory function, such as distribution of lymphocyte subsets and in vivo and in vitro production of lymphokines (interferon-g and interleukin-4) and inflammatory mediators (histamine, prostaglandin E2 [PGE2] and leukotriene C4 [LTC4]). Furthermore, the protective effect of traditional Chinese medicine on the late asthmatic reaction was evaluated by using asthmatic guinea pigs. Three hundred and three asthmatic children were classified by Chinese doctors, according to a standardized questionnaire designed on the basis of basic logic of Chinese medicine, into three groups of specific constitution (groups A, B and C). Group A consisted of 32 herb A-treated patients and 34 placebotreated; group B, 74 herb B-treated and 64 placebotreated; and group C, 55 herb C-treated and 44 placebo-treated. The study period was 6 months.
Results • Both the treatment group and the placebo group showed an improvement in all clinical parameters,
Allergic asthma (atopic eczema)
• • •
•
thus demonstrating a placebo effect. However, the improvement was usually greater in the former than the latter, although only the difference in PEFR was significant. Herb A could increase total T-cells and decrease B cells. Herbs A and B enhanced production of PGE2 but not LTC4, interferon-g and interleukin-4. There was a general tendency for in vivo and in vitro production of histamine to decrease at the end of the study in both the treatment group and the placebo group; however, the decrease was significantly greater in the former than in the latter. In asthmatic guinea pigs, 10 days’ pretreatment with Chinese herbs could reverse the decrease of sGaw, suppress eosinophilia in bronchoalveolar lavage fluid, prevent the eosinophil infiltration of airways, increase PGE2 production and decrease LTC4 production in serum and bronchoalveolar lavage fluid. The decreased production of histamine and LTC4 and the increased production of PGE2 that were found in both asthmatic children and asthmatic guinea pigs, as well as the prevention of occurrence of late asthmatic reaction by suppressing eosinophil infiltration of airways and preserving airway conductance that was observed in asthmatic guinea pigs after allergen challenge, might be used to account partly for the effectiveness.
Conclusion Thus, traditional Chinese medicines did show a certain degree of clinical efficacy.
The potential use of Chinese herbal medicines in treating allergic asthma Annals of Allergy, Asthma and Immunology 2004 August, Vol. 93, Issue 2, Suppl. 1, pp. 35–44. Li XM, Zhang TF, Sampson H, Zou ZM, Beyer K, Wen MC, Schofield B Department of Paediatrics, Mount Sinai School of Medicine, New York, USA
Objective To discuss the potential use of the Chinese herbal formula MSSM-002 in treating asthma based on its effects on a murine model of allergic asthma, immunoregulatory actions on TH2 cells in vitro and the means of standardization for herbal formula quality control.
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Data sources Information presented at the 2002 American College of Allergy, Asthma and Immunology (ACAAI) Annual Scientific Meeting International Symposium on Complementary Alternative Medicine in San Antonio, Texas.
Study selection All presentations from the ACAAI meeting that discussed MSSM-002 were considered for this review.
Results The Chinese herbal formula MSSM-002 suppressed airway hyper-reactivity and eosinophilic inflammation in a murine model of allergic asthma. These effects were comparable with dexamethasone but were not accompanied by the suppression of TH1 responses seen with dexamethasone. In vitro studies demonstrated that MSSM-002 significantly decreased antigen-induced TH2 cytokine secretion by murine TH2-polarized splenocytes and human mucosal TH2 cell lines, which in contrast to dexamethasone did not cause apoptosis and was not cytotoxic but was associated with decreased GATA-3 expression. Chromatographic fingerprints of MSSM-002 and evaluation of in vivo actions showed that the quality of several batches of MSSM-002 was consistent.
Conclusion MSSM-002 has a therapeutic effect on allergic asthma and immunoregulatory actions on established TH2 cells and may prove to be of potential clinical benefit to asthma patients.
Experimental study on prevention and treatment of bronchial asthma by compound Chinese herbal monomer recipe Zhong Guo Zhong Xi Yi Jie He Za Zhi [Chinese Journal of Integrated Traditional and Western Medicine] 2004 August, Vol. 24, Issue 8, pp. 717–721. Dong JC, Ni J, Gong ZH Institute of Pulmonary and Atopic Diseases by Integrative Chinese and Western Medicine, Huashan Hospital, Fudan University, Shanghai
Objective To observe the effect of compound Chinese herbal monomer (CHM) recipe, consisting of ligustrazin
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(3.75 mg/kg μ d), baicalin (7.5 mg/kg μ d) and ginkgolide (2 mg/kg μ d), on airway atopic inflammation and hyper-responsiveness in asthma.
Method Model guinea pigs with asthma were randomly divided into three groups: the model group, the CHM group and the cromolyn sodium (CS) group. They were treated by atomizing inhalation with normal saline, CHM and CS, respectively. The eosinophil count and eosinophil cation protein in blood and bronchial alveolar lavage fluid (BALF) and the total cell count in BALF were measured and compared. The effect of treatment on the airway hyper-responsiveness and pathology among groups was also compared.
Results The CHM showed significant inhibition of blood eosinophil count and BALF and total cell count in BALF, showing significant differences compared with those in the model group. The level of eosinophil cation protein was not different in the various groups. Airway responsiveness determination showed that CHM has significant inhibitory action on it. And the pathology of airway inflammation in the CHM group was significantly milder than that in the model group.
Conclusion The compound inhalation liquid consisting of ligustrazin, baicalin and ginkgolide affects the antiasthmatic airway atopic inflammation and decreases the airway hyper-responsiveness, suggesting that components of compound CHM recipe could inhibit the multiple pathogenetic asthmatic inflammation from different angles and on multiple targets so as to cure asthma effectively.
CASE HISTORIES Case history A 35-year-old woman had been suffering from eczema since she was 3 months old. Over the years, she used all sorts of steroid creams. She had three children and, during each of her gestations, her eczema was always worse in the
first 3 months of pregnancy, better in the last 6 months and worse after childbirth. It was mostly on the limbs and face (around her mouth). It consisted of papules (red spots) that were very itchy. They then turned into pustules and oozed a liquid. She had also been suffering from asthma since the age of 3 after pneumonia. Her wheezing attacks were triggered by dust, house dust mites, animals’ fur, dairy products and shellfish. She also suffered from hay fever (seasonal allergic rhinitis). She occasionally had mild tinnitus. Her pulse was unremarkable, only slightly Weak on the right Front and the left Rear positions. Her tongue was also unremarkable, with slightly Swollen sides (Plate 5.1). This is a good example of how the tongue is often unremarkable in patients with atopic asthma, seemingly confirming that Wind and not Phlegm is the main pathological feature of asthma. Diagnosis Asthma, seasonal allergic rhinitis and eczema from Lung and Kidney’s Defensive-Qi systems deficiency from birth. Kidney-Essence affecting the Lung-Corporeal Soul that, in turn, affected the skin. The Kidney deficiency is also clearly shown by the aggravation during the first 3 months of pregnancy, amelioration in the last 6 months and again aggravation after childbirth. The relatively normal pulse and tongue show that the Kidney deficiency involves only the Kidney Defensive-Qi system and not other aspects of the Kidney functions. The eczema is of the chronic Damp Heat type. The eliciting of asthma attacks from certain foods points to Large Intestine-Heat. Treatment principle Her main problem at the time of consultation was the eczema rather than the asthma, the attacks of which were quite infrequent. The principle of treatment adopted was therefore to clear Wind in the skin, resolve Damp Heat, cool Blood, tonify the Lung and Kidney’s Defensive-Qi systems and stimulate the descending of Lung-Qi. Herbal therapy Prescription The prescriptions chosen were those for chronic Damp Heat, with some variations to tonify the Kidney’s Defensive-Qi system. The formula was a variation of
Allergic asthma (atopic eczema)
San Feng Chu Shi Tang Scattering Wind and Eliminating Dampness Decoction and Chu Shi Wei Ling Tang Eliminating Dampness Stomach “Ling” Decoction, with the addition of herbs to tonify the Lung and Kidney’s Defensive-Qi systems and to stimulate the descending of Lung-Qi. • • • • • • • • • • • • • • • • • •
Huang Bo Cortex Phellodendri 4 g Cang Zhu Rhizoma Atractylodis 4 g Fang Feng Radix Saposhnikoviae 4 g Bai Xian Pi Cortex Dictamni 6 g She Chuang Zi Semen Cnidii 4 g Zhu Ling Polyporus 4 g Fu Ling Poria 6 g Yi Yi Ren Semen Coicis 9 g Chen Pi Pericarpium Citri reticulatae 3 g Ze Xie Rhizoma Alismatis 4 g Shou Wu Radix Polygoni multiflori preparata 9 g Sheng Di Huang Radix Rehmanniae 9 g Tu Si Zi Semen Cuscutae 6 g Bu Gu Zhi Fructus Psoraleae 4 g Mai Men Dong Radix Ophiopogonis 6 g Bai He Bulbus Lilii 6 g Sang Bai Pi Cortex Mori 4 g Gan Cao Radix Glycyrrhizae uralensis 3 g
Explanation • Huang Bo and Cang Zhu resolve Damp Heat. • Fang Feng resolves Dampness and expels Wind. • Bai Xian Pi and She Chuang Zi expel Wind and resolve Dampness and Toxic Heat. They are both very important herbs for skin diseases. • Zhu Ling, Fu Ling, Yi Yi Ren, Chen Pi and Ze Xie drain Dampness via urination. • Shou Wu and Sheng Di nourish and cool Blood. • Tu Si Zi and Bu Gu Zhi tonify the Kidney’s DefensiveQi system. • Mai Dong and Bai He tonify the Lung’s DefensiveQi system and will also help to regenerate new skin. • Sang Bai Pi restores the descending of Lung-Qi and also helps the skin. • Gan Cao harmonizes. Acupuncture Points LU-7 Lieque and KI-6 Zhaohai, KI-16 Huangshu, KI-3 Taixi, BL-23 Shenshu, L.I.-11 Quchi, SP-10 Xuehai, SP-9 Yinlingquan, BL-13 Feishu, DU-12 Shenzhu.
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Explanation • LU-7 and KI-6 tonify Lung and Kidneys, benefit the Essence and the Corporeal Soul, nourish the skin and stimulate the descending of Lung-Qi. • KI-16, KI-3 and BL-23 tonify the Kidney’s DefensiveQi system. In particular, KI-16 also benefits the Essence and therefore acts at a deep level to correct the inborn deficiency of the Kidney’s Defensive-Qi system. In a way, it is the acupuncture equivalent of the herbal use of placenta and umbilical cord for asthma. • L.I.-11 and SP-10 cool Blood and clear Heat from the skin. • SP-9 resolves Damp Heat. • BL-13 and Du-12 tonify the Lung’s Defensive-Qi system. After 9 months’ treatment, mostly with herbal medicine and infrequent sessions of acupuncture treatment, this woman’s eczema cleared up almost completely.
Case history A 19-year-old woman had been suffering from eczema and asthma since the age of 2. At the time of consultation, both the eczema and asthma were still very bad. She had to use Ventolin and Becotide every day for her asthma and had used steroid creams in the past for her eczema. Her asthma attacks were elicited by exposure to cats and house dust mites. She also sweated at night, and her bowels opened only every other day. Apart from this, she had no other symptoms. She was very thin and shy. Her skin was very dry, red and itchy. The pulse and tongue were unremarkable, as they often are in atopic asthma. Diagnosis This is a very typical case of atopic asthma and eczema from deficiency of the Lung and Kidney’s Defensive-Qi systems in a highly allergic individual. There is some Lung-Yin deficiency as shown by the night sweating and constipation. Treatment principle Tonify the Lung and Kidney’s Defensive-Qi systems, nourish Lung-Yin, nourish Blood, moisten the skin, clear Wind from the skin and expel Wind from the chest. She had only herbal therapy and the formula used initially was as follows.
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• • • • • • • • • • • • • • • • •
The Practice of Chinese Medicine
Mai Men Dong Radix Ophiopogonis 6 g Bai He Bulbus Lilii 6 g Su Zi Fructus Perillae 4 g Xing Ren Semen Armeniacae 4 g Fang Feng Radix Saposhnikoviae 4 g Tu Si Zi Semen Cuscutae 6 g Du Zhong Cortex Eucommiae ulmoidis 4 g Nu Zhen Zi Fructus Ligustri lucidi 4 g Shou Wu Radix Polygoni multiflori preparata 9g Dang Gui Radix Angelicae sinensis 6 g Bai Xian Pi Cortex Dictamni 6 g Chan Tui Periostracum Cicadae 4 g Nan Sha Shen Radix Adenophorae 4 g Huo Ma Ren Semen Cannabis 4 g Hei Zhi Ma Semen Sesami negrum 6 g Hong Hua Flos Carthami tinctorii 3 g Gan Cao Radix Glycyrrhizae uralensis 3 g
Explanation • Mai Dong and Bai He nourish Lung-Yin and tonify the Lung’s Defensive-Qi system. • Su Zi and Xing Ren restore the descending of LungYin. • Fang Feng expels Wind from the chest. • Tu Si Zi and Du Zhong tonify the Kidney’s DefensiveQi system. • Nu Zhen Zi, Shou Wu and Dang Gui nourish Blood and the skin. • Bai Xian Pi and Chan Tui clear Wind-Heat from the skin. • Nan Sha Shen, Huo Ma Ren and Hei Zhi Ma moisten the skin and promote the bowel movements. • Hong Hua moves Blood and, being a light petal, has a floating movement and therefore carries the other herbs towards the surface, i.e. the skin. • Gan Cao harmonizes and detoxifies. This patient is still being treated and the eczema and asthma are gradually improving.
Case history A 23-year old woman had been suffering from asthma since she was 4 years old. She used Ventolin and Becotide. Her asthma attacks were elicited by exposure to dogs, cats and house dust mites. She also suffered mildly from eczema only when exposed to inhaled or ingested allergens. She usually felt tired, her lower back ached and her
bowels opened only every 2 or 3 days. Her sleep was not good, with her waking up frequently during the night. Her periods lasted 7–8 days and she suffered from premenstrual tension. Her pulse was slightly Weak in the left Rear position and slightly Wiry in the left Middle position. Her tongue was Red on the sides and tip. Diagnosis This is again a clear case of Lung and Kidney’s Defensive-Qi systems being deficient from birth. There are, however, other factors, notably some Liver-Yang rising (red sides of the tongue and premenstrual tension) and some Kidney-Yin deficiency (constipation, backache and insomnia). Treatment principle The principle of treatment was to tonify the Lung and Kidney’s Defensive-Qi systems, nourish Kidney-Yin, restore the descending of LungQi, expel Wind and subdue Liver-Yang. Herbal therapy Prescription The formula used was a variation of Bai He Gu Jin Tang Lilium Consolidating Metal Decoction. • • • • • • • • • • • • • •
Bai He Bulbus Lilii 15 g Mai Men Dong Radix Ophiopogonis 9 g Shu Di Huang Radix Rehmanniae preparata 9 g Dang Gui Radix Angelicae sinensis 6 g Bai Shao Radix Paeoniae alba 9 g Jie Geng Radix Platycodi 6 g Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g Fang Feng Radix Saposhnikoviae 4 g Tu Si Zi Semen Cuscutae 6 g Bu Gu Zhi Fructus Psoraleae 4 g Xing Ren Semen Armeniacae 3 g Su Zi Fructus Perillae 4 g Suan Zao Ren Semen Ziziphi spinosae 4 g Gan Cao Radix Glycyrrhizae uralensis 3 g
Explanation • Bai He and Mai Dong nourish Lung-Yin and tonify the Lung’s Defensive-Qi system. • Shu Di tonifies the Kidney’s function of grasping Qi. • Dang Gui, Bai Shao and Suan Zao Ren harmonize the Liver, subdue Liver-Yang and calm the Mind. • Jie Geng, Chuan Bei Mu, Xing Ren and Su Zi restore the descending of Lung-Qi and calm asthma. • Fang Feng expels Wind.
Allergic asthma (atopic eczema)
• Tu Si Zi and Bu Gu Zhi tonify the Kidney’s DefensiveQi system. • Gan Cao harmonizes.
Case history A 30-year-old woman had been suffering from eczema and asthma since birth. She used Ventolin and Becloforte inhalers every day and also took Phyllocontin tablets. As a baby, she was given steroids for the asthma, but these made the eczema worse. She used cortisone creams for her eczema from the age of 7. The eczema seemed to clear during her school years but returned with a vengeance at around 20. When she came for treatment, it was extremely bad. It covered practically the whole body and was worse on her face, chest and limbs. The skin was very red, very dry, thick, coarse and itchy. Although the skin was dry, the eczema lesions would also weep occasionally. She also suffered from seasonal allergic rhinitis (hay fever) and her mouth often felt dry. There were no other obvious symptoms and signs, and her urine and stools were normal. Her tongue was slightly Pale, Thin and dry. Her pulse was Weak, Choppy and both Rear positions (Kidneys) were particularly Weak. Diagnosis This is also a clear case of inborn deficiency of Lung and Kidney’s Defensive-Qi systems. The pulse confirms the Kidney weakness. Because of the long duration of the illness, there is also some Blood deficiency (as the Kidneys also contribute to making Blood) that, leading to the development of Wind-Heat in the skin, aggravates the eczema. The Blood deficiency is clearly shown by the tongue being Pale, Thin and dry. The eczema is primarily of the Wind-Heat type, although there is some Damp Heat as well because it is sometimes weepy. Treatment principle Because the eczema was by far the most distressing problem at the time, attention was turned to treating it first. The aim of treatment was to tonify the Lung and Kidney’s Defensive-Qi systems, expel Wind from the chest, nourish Blood, clear Wind-Heat from the skin and restore the descending of Lung-Qi. The formula used was a variation of Yang Xue Ding Feng Tang Nourishing Blood and Clearing Wind Decoction.
• • • • • • • • • • • • • • • •
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Sheng Di Huang Radix Rehmanniae 12 g Dang Gui Radix Angelicae sinensis 9 g Shou Wu Radix Polygoni multiflori preparata 9 g Tian Men Dong Radix Asparagi 9 g Mai Men Dong Radix Ophiopogonis 6 g Chi Shao Radix Paeoniae rubra 6 g Mu Dan Pi Cortex Moutan 4 g Shan Zhi Zi Fructus Gardeniae 4 g Chan Tui Periostracum Cicadae 6 g Jing Jie Herba Schizonepetae 4 g Fang Feng Radix Saposhnikoviae 4 g Tu Si Zi Semen Cuscutae 6 g Bu Gu Zhi Fructus Psoraleae 4 g Xing Ren Semen Armeniacae 4 g Su Zi Fructus Perillae 4 g Gan Cao Radix Glycyrrhizae uralensis 4 g
Explanation • Sheng Di Huang, Dang Gui and Shou Wu nourish Blood. Sheng Di also cools Blood. • Tian Dong and Mai Dong nourish Yin to help to nourish Blood and they moisten; Mai Dong also tonifies the Lungs. They also tonify the Lung’s Defensive-Qi system. • Chi Shao, Dan Pi and Zhi Zi clear Heat and cool Blood to help to clear Heat from the skin. • Chan Tui and Jing Jie clear Wind-Heat from the skin. • Fang Feng expels Wind from the chest. • Tu Si Zi and Bu Gu Zhi tonify the Kidney’s DefensiveQi system. • Xing Ren and Su Zi restore the descending of Lung-Qi. • Gan Cao harmonizes and detoxifies. This patient is slowly improving and the treatment is still in progress.
Case history A 28-year-old woman had been suffering from asthma since she was 7 years old. The attacks were worse at night and were elicited by exposure to cold, dogs, cats or horses. She had to resort to using a Ventolin inhaler every day. She also suffered from seasonal allergic rhinitis (hay fever). She generally felt cold and her hands and feet were cold. Her tongue was slightly Pale and her pulse was Slow and Weak, especially on the right Rear position.
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Diagnosis This is yet another case of deficiency of the Lung and Kidney’s Defensive-Qi system on a background of Kidney-Yang deficiency, as is very clear from the general cold feeling, the Pale tongue and the Weak pulse on the right Rear position. Treatment principle The principle of treatment was to tonify the Lung and Kidney’s Defensive-Qi systems, strengthen Kidney-Yang, expel Wind and restore the descending of Lung-Qi. The formula used was a variation of Su Zi Jiang Qi Tang Perilla Seed Lowering Qi Decoction. • • • • • • • • • • •
Su Zi Fructus Perillae 9 g Zi Su Ye Folium Perillae 5 leaves Ban Xia Rhizoma Pinelliae preparatum 9 g Hou Po Cortex Magnoliae officinalis 6 g Fang Feng Radix Saposhnikoviae 4 g Rou Gui Cortex Cinnamomi 3 g Dang Gui Radix Angelicae sinensis 6 g Tu Si Zi Semen Cuscutae 6 g Xu Duan Radix Dipsaci 4 g Sheng Jiang Rhizoma Zingiberis recens 2 slices Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 6 g • Da Zao Fructus Jujubae 1 date Explanation • Su Zi and Su Ye restore the descending of Lung-Qi. • Ban Xia and Hou Po subdue rebellious Qi and relieve fullness in the chest. • Fang Feng expels Wind from the chest. • Rou Gui and Dang Gui tonify Kidney-Yang and the Liver to strengthen the Lower Burner. • Tu Si Zi and Xu Duan tonify the Kidney’s DefensiveQi system and strengthen Kidney-Yang. • Sheng Jiang, Gan Cao and Da Zao harmonize.
Case history A 40-year-old woman had been suffering from asthma since her early twenties. The attacks started following a deep emotional trauma. She used Ventolin and Becotide inhalers four times a day. At the time of consultation, she was also on corticorsteroids orally (prednisolone). She was not seemingly allergic to any substance, nor did she suffer from allergic rhinitis.
In addition to asthma, she also had a lot of catarrh with a profuse, sticky-yellow nasal discharge. She said that when under stress she became very tense and weak, her hands became cold and she felt unable to cope. She also complained of premenstrual tension and hypochondrial and abdominal distension. Her tongue was Red, redder on the sides and tip with a yellow coating. Her pulse was Wiry on the left side. Diagnosis This asthma is not allergic but of the lateonset type, and it is very clearly related to a Liver disharmony. Stagnation of Liver-Qi, over a long period of time, has turned into Liver-Fire, and this has obstructed the descending of Lung-Qi in the chest, giving rise to asthma. The presence of Liver-Fire is obvious from the Red tongue body with redder sides. The thick-yellow nasal discharge is a case of rhinorrhoea (Bi Yuan) from Liver- and Gall Bladder-Fire rising to the nose. Treatment principle Move Liver-Qi, clear Liver-Fire, restore the descending of Lung-Qi, calm the Mind and settle the Ethereal Soul. Herbal therapy Prescription This patient was treated only with herbs. The formula chosen was a variation of Si Ni San Four Rebellious Powder, which moves Liver-Qi, and Xie Bai San Draining Whiteness Powder, which clears Lung-Heat and restores the descending of Lung-Qi. Si Ni San was chosen because it was Liver-Qi stagnation that led to Liver-Fire. The method to be adopted therefore is not to drain Liver-Fire with bitter and cold herbs, but to clear Liver-Fire with pungent herbs that open Qi and bitter herbs that drain. A further reason for choosing Si Ni San was that the patient had cold hands when under emotional strain, one of the symptoms of this formula. The formula used was as follows. • • • • •
Chai Hu Radix Bupleuri 6 g Bai Shao Radix Paeoniae alba 9 g Gan Cao Radix Glycyrrhizae uralensis 4.5 g Zhi Shi Fructus Aurantii immaturus 6 g Hou Po Cortex Magnoliae officinalis 4.5 g
Allergic asthma (atopic eczema)
• • • • • • •
Shan Zhi Zi Fructus Gardeniae 4 g Sang Bai Pi Cortex Mori 6 g Di Gu Pi Cortex Lycii 4 g Su Zi Fructus Perillae 6 g Xing Ren Semen Armeniacae 6 g Suan Zao Ren Semen Ziziphi spinosae 4 g Yuan Zhi Radix Polygalae 4 g
Explanation • Chai Hu, Bai Shao, Gan Cao and Zhi Shi constitute the Si Ni San, which moves Liver-Qi and calms the Mind. • Hou Po, a pungent herb, was added to help to move Qi and open the chest. It will therefore help breathing and has also a good calming effect on the Mind. • Shan Zhi Zi, a bitter herb to clear, was added to clear Liver-Fire. • Sang Bai Pi and Di Gu Pi constitute the Xie Bai San, which clears Lung-Heat and restores the descending of Lung-Qi. • Su Zi and Xing Ren restore the descending of LungQi and relieve asthma. • Suan Zao Ren and Yuan Zhi calm the Mind and settle the Ethereal Soul. This patient was treated with this basic formula, with some variations along the way, and she reacted very well, reaching almost a complete cure after 9 months.
Case history A 33-year-old man had been suffering from asthma since he was 1. He got better during his teenage years but then worse again from 20 onwards. His asthma attacks were brought on by exposure to dust, house dust mites and cats. He had to resort to using a Ventolin inhaler every day. Apart from his asthma, he had hardly any other symptoms. He had to urinate at night. His tongue-body colour was nearly normal and only very slightly Pale, its body was Swollen, and there was a Stomach crack (Plate 5.2). His pulse was slightly Weak on the right side. Diagnosis This is another case of deficiency of the Lung and Kidney’s Defensive-Qi systems, especially of the Lung’s. In addition, there was a deficiency of the Stomach and Spleen, as evidenced by the Weak pulse
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on the right, the Stomach crack on the tongue and the Swollen tongue body. Treatment principle Tonify the Lung and Kidney’s Defensive-Qi systems and strengthen the Spleen. Herbal therapy Prescription This patient was treated only with herbs, and the formula used was a variation of Ren Shen Ge Jie San Ginseng-Gecko Powder. • Ge Jie Gecko 4 g (as a powder) • Zhi Gan Cao Radix Glycyrrhizae uralensis preparata 4 g • Ren Shen Radix Ginseng 6 g • Fu Ling Poria 6 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g • Sang Bai Pi Cortex Mori 6 g • Xing Ren Semen Armeniacae 9 g • Huang Qi Radix Astragali 6 g • Mai Men Dong Radix Ophiopogonis 3 g Explanation This formula tonifies the Lung and Kidney’s DefensiveQi systems, strengthens the Spleen and restores the descending of Lung-Qi. • The first seven herbs constitute the original prescription. • Zhi Mu was eliminated from the original formula, as there are no signs of Heat. • Huang Qi and Mai Dong were added to tonify the Lung’s Defensive-Qi system further. This patient is still being treated, and he is gradually reducing the use of his inhaler.
Case history A 42-year-old woman had been suffering from allergic asthma since childhood. The asthma had got better during adolescence, but it had then got worse when she was about 32. At that time, the asthma started after an episode of influenza that then turned into bronchitis. She had three courses of antibiotics but was left with a cough productive of profuse sputum, wheezing, and breathlessness. She was prescribed inhalers of steroids (Pulmicort) and b2 agonists (Bricanyl).
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All these symptoms seem to point clearly to a late-onset, intrinsic, non-allergic type of asthma. However, there were other factors that pointed also to an early-onset, extrinsic, allergic type of asthma, i.e. the period of allergic asthma during childhood, the onset of asthma attacks on exposure to dust, high levels of IgE and the fact that she also suffered from allergic rhinitis. This case history is a clear example of a case of asthma that is a mixture of allergic and nonallergic; in her case, although the asthma was originally of the allergic type, she did also have Phlegm. Her pulse was Tight in general and Weak on the left Rear position; her tongue was slightly Pale and Bluish-Purple. Diagnosis This is a clear example of asthma that started as an early-onset, allergic one and became combined with a late-onset one. The main pathology was Phlegm in the Lungs (Swollen tongue, Slippery pulse and expectoration of mucus), a deficiency of the Lung and Kidneys’ Defensive-Qi systems with Wind and Phlegm in the Lungs. There was also a Spleen deficiency, which contributed to the formation of Phlegm. Treatment principle Treat the Root by tonifying the Lung and Kidneys’ Defensive-Qi systems and the Spleen, expel Wind from the bronchi, resolve Phlegm. She was treated only with acupuncture. Although she would have benefited from herbal treatment, she specifically declined it. Acupuncture Points The treatment was carried out over several years and is still ongoing. The acupuncture points were selected from the following: LU-7 Lieque and KI-6 Zhaohai (Directing Vessel’s opening points), Ren-4 Guanyuan, KI-13 Qixue, SP-6 Sanyinjiao, KI-7 Fuliu, BL-23 Shenshu, Ren-12 Zhongwan, BL-20 Pishu, BL-13 Feishu, LU-5 Chize and ST-40 Fenglong. Explanation • LU-7 and KI-6 open the Directing Vessel (Ren Mai), which tonifies Lungs and Kidneys. • Ren-4, KI-13, SP-6, KI-7 and BL-23 tonify the Kidneys. • Ren-12 and BL-20 tonify the Spleen.
• BL-13 tonifies the Lungs. • LU-5 and ST-40 restore the descending of Lung-Qi, open the chest and resolve Phlegm from the Lungs.
Case history A 65-year-old man had been suffering from asthma since early childhood after a bout of bronchitis. The asthma improved when he became 17. There was no allergy, no familial incidence, no eczema and no allergic rhinitis. Three years before his consultation with me, he had a cold that went to the chest and caused bronchitis. He was treated with antibiotics. After that, his asthma worsened considerably and he was put on a steroid inhaler and a bronchodilator inhaler. He suffered from wheezing, breathlessness and cough with expectoration of mucus. His blood pressure was raised, for which he took a diuretic. His pulse was Full, Slippery and Wiry. His tongue was Red, Swollen and without a coating. Diagnosis This is a clear example of asthma that had an early onset but was not allergic. The main pathology was Phlegm in the Lungs (Swollen tongue, Slippery pulse, expectoration of mucus) and deficiency of Lung- and Kidney-Yin (tongue without coating) with Empty Heat (Red tongue). Treatment principle Resolve Phlegm, nourish Lungand Kidney-Yin, restore the descending of Lung-Qi. Herbal therapy Prescription This patient was treated only with herbs, and the formula used was a variation of Wen Dan Tang Warming the Gall Bladder Decoction. • • • • • • • • • •
Zhu Ru Caulis Bambusae in Taeniam Ban Xia Rhizoma Pinelliae preparatum Chen Pi Pericarpium Citri reticulatae Fu Ling Poria Zhi Shi Fructus Aurantii immaturus Su Zi Fructus Perillae Sang Bai Pi Cortex Mori Xing Ren Semen Armeniacae Kuan Dong Hua Flos Farfarae Mai Men Dong Radix Ophiopogonis
Allergic asthma (atopic eczema)
• Xi Yang Shen Radix Panacis quinquefolii • Huang Qin Radix Scutellariae This patient’s symptoms improved remarkably after only 3 weeks of therapy. His breathing was much easier and he was able to reduce the use of his medication. He is still under treatment at the time of writing and improving steadily.
PATIENTS’ STATISTICS These statistics are based on a population of 93 patients from my practice. The age distribution was as follows. • • • • • • • • •
0–10: 10 (11%) 11–20: 11 (12%) 21–30: 17 (18%) 31–40: 23 (25%) 41–50: 18 (19%) 51–60: 7 (8%) 61–70: 3 (3%) 71–80: 3 (3%) 81–90: 1 (1%)
There were 41 male and 52 female patients. Please note that, although at first sight this would seem to show that more women than men suffer from asthma, this is not so. In fact, the total percentage of women in my practice is 67% against 34% of men. As in the above statistics 55% are women, this is below the average of 67%. This would therefore indicate that more men than women suffer from asthma. Of course, this is a statistic from my practice reflecting conditions in the UK and the situation might well be different in other countries. Of the 93 patients with asthma, a third (31) also had eczema, which shows the strong association between allergic asthma and eczema. As readers will know from reading this chapter, I relate allergic asthma to a deficiency of the Lung and Kidney’s Defensive-Qi systems. In this statistic, 62% of patients had such a deficiency, which indicates that 62% of asthma patients suffer from early-onset, allergic asthma. I relate the pathology of late-onset, non-allergic asthma to Phlegm, as the traditional theory of asthma (Xiao-Chuan) does. Thirty-nine per cent of patients had Phlegm, which means that about that percentage of patients suffered from late-onset, non-allergic asthma. I say “about”. because some middle-aged or elderly patients with allergic asthma may also develop Phlegm.
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The percentage of patients with Phlegm (39%) correlated almost exactly with that of patients with a Slippery pulse (30%). The pulse qualities by quality were as follows. • • • • • • • •
Wiry: 14 (16%) Slippery: 26 (30%) Tight: 8 (9%) Empty: 12 (14%) Weak: 46 (52%) Deep: 14 (16%) Slow: 4 (5%) Rapid: 4 (5%)
If we consider the Empty and Weak pulses together, the percentage of patients with a weak-type of pulse (66%) correlates almost exactly with the percentage of patients suffering from a deficiency of the Lung and Kidney’s Defensive-Qi systems (62%).
PROGNOSIS AND PREVENTION The treatment of allergic asthma will necessarily take a long time, because the disease is always based, as we have seen, on an inborn deficiency of Lung and Kidney’s Defensive-Qi systems. In most cases, the treatment may need many months if not years to produce lasting results. Both acupuncture and Chinese herbs are equally effective in combination or independently. If children can be treated fairly early after the development of the disease, the course of treatment will be much shorter. If the patient is on bronchodilator inhalers (such as Ventolin), it is not necessary to make a conscious effort to stop them, as the need to use them will automatically decrease as the treatment progresses. As for oral steroids, it is much better if the patient can reduce them very gradually as soon as possible, as they have many side effects, the main one being that of inducing a deficiency of the Kidneys in the long run. As allergic asthma is based on a deficiency of the Kidney’s Defensive-Qi system, oral steroids, although affording relief in the short run, can only make it worse in the long run. If asthma is accompanied by eczema and the patient is using steroid creams, these should be stopped. This means, and the patient should be warned, that the eczema may temporarily become worse. This aggravation can and should be counteracted, however, by the use of herbs externally as described above. To do
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this is important to gain the patient’s confidence in the treatment. After successfully treating a patient with asthma, it is important to take preventive measures to avoid its recurrence. Adults should be advised to have enough rest and avoid excessive sexual activity. Children (or rather their parents) should be advised to avoid eating excessive amounts of dairy foods, sweets and greasy-fried foods. They should also take great care to avoid exposure to cold and wind without proper clothing. Both adults and children should be treated immediately at the first signs of invasion of external Wind, because this may easily precipitate an attack of asthma in susceptible individuals. If there is eczema, they should never eat shellfish such as shrimps, prawns, crab and lobster. They should also avoid eating spinach and mushrooms, dairy products, fried-greasy foods, spicy foods and alcohol.
Herbal therapy Certain herbal formulae may also be given, especially during the early autumn. “Autumn” is meant here as autumn according to the Chinese calendar in which equinoxes and solstices mark not the beginning but roughly the middle of each season. Thus early autumn would be towards the end of August. The following are some of the formulae used.
Prescription • • • • • • •
Ren Shen Radix Ginseng 60 g Ge Jie Gecko 2 geckos Ma Huang Herba Ephedrae 30 g Xing Ren Semen Armeniacae 100 g Gan Cao Radix Glycyrrhizae uralensis 50 g Sheng Jiang Rhizoma Zingiberis recens 60 g Hong Zao Fructus Jujubae 120 g
These are the proportions to make roughly 500 g of powder. Grind the above ingredients very finely in a coffee grinder and give one teaspoonful a day to be swallowed with hot water after a meal. Alternatively, and even better, one can buy the concentrated powders of the above herbs (in equal parts), mix them together, and take one teaspoonful a day dissolved in hot water.
Prescription (for external use) • Bai Jie Zi Semen Sinapsis albae 12 g
• • • •
Yan Hu Suo Rhizoma Corydalis 12 g Xi Xin Herba Asari 21 g Gan Sui Radix Euphorbiae Kansui 12 g She Xiang Moschus 0.15 g
Grind the above herbs into a fine powder, mix with fresh ginger juice, shape into small cones and apply with plaster on the following points: BL-13 Feishu, BL-43 Gaohuangshu and DU-14 Dazhui. Remove after 2 hours. Apply two or three times in August for the reason explained above. She Xiang can be omitted from the above formula, as it is both illegal and expensive.
Acupuncture Points Reinforce the following points with moxa (unless there is Yin deficiency): • BL-13 Feishu, DU-12 Shenzhu and BL-43 Gaohuangshu to strengthen the Lung’s DefensiveQi system. Use these points in late August. • BL-23 Shenshu, Ren-4 Guanyuan and KI-16 Huangshu to strengthen the Kidney’s Defensive-Qi system. Use these points in late October.
WESTERN DRUG THERAPY Because most asthmatic patients whom we treat are bound to be on some kind of medication, it is important to understand the medications’ mode of action and how they affect our treatment. The four main approaches to drug treatment of asthma in Western medicine are: 1. 2. 3. 4.
antiallergic drugs bronchodilators corticosteroids leukotriene antagonists.
Each of these drugs acts on a certain stage of the pathological process that leads to asthma.
Antiallergic drugs (mast cell stabilizers) These act by stabilizing the mast cells in the bronchi and reducing their sensitivity to allergen stimulation. They are used only as a prophylactic in the prevention and not the treatment of asthma. They seem to be more effective in children than in adults.
Allergic asthma (atopic eczema)
They do not affect the treatment with acupuncture or herbs and do not produce any appreciable change in the pulse or tongue. The most common brand names of this class of drug in the USA and UK are cromolyn inhaler (Intal inhaler) and nedocromil oral inhalation (Tilade).
Bronchodilators These act by stimulating the adrenergic receptors in the sympathethic nerves to the bronchi and thus causing bronchodilation. The most widely used ones are the b2-adrenoceptor stimulants, as they are more selective and produce fewer side effects than adrenaline (epinephrine) or theophylline (which stimulate both alpha- and beta-adrenoceptors). Even these, however, have side effects and, in particular, they may stimulate the heart, producing tachycardia. Some authors point out that bronchial hyperreactivity is not decreased with the use of b2 agonists, and that their effect runs out rapidly within 3–4 weeks of ceasing to use them. According to these authors, when side effects are taken into account, mast cell stabilizers are therapeutically superior to b2 agonists or anti-inflammatory agents.86 From the point of view of Chinese diagnosis, selective bronchodilators such as salbutamol (Ventolin) do not affect the tongue, although they may make the Heart pulse slightly Overflowing. Other brochodilators, such as isoprenaline (Iso-Autohaler) and orciprenaline (Alupent) have more side effects on the heart and, besides making the Heart pulse Overflowing, they may also make the tip of the tongue red. The use of bronchodilator inhalers may be integrated with acupuncture and herbal therapy. Indeed, they may provide a useful benchmark of the efficacy of our treatment as the patient gradually reduces the frequency of use of inhalers. The most common brands of this type of drug (USA and UK) are: • salmeterol (Serevent) • albuterol (Ventolin, Proventil) • salbutamol (Ventolin).
beclometasone. When given orally, they produce many more side effects. From a Chinese perspective, they produce Heat and weaken the Kidneys. They definitely affect the tongue, making it Red and Swollen. They also affect the pulse, as the Kidney position becomes Weak and the pulse is generally more Rapid than normal. Although they can be combined with acupuncture and herbal therapy, corticosteroids slow down the effects of our treatment somewhat. In the course of our treatment, it is necessary to tonify the Kidneys even more by using points such as BL-23 Shenshu and herbs such as Shu Di Huang Radix Rehmanniae preparata and Sheng Di Huang Radix Rehmanniae. The mode and site of action of the above three drugs may be summarized in two diagrams (Figs 5.17 and 5.18).
Leukotriene antagonists Inflammatory molecules called leukotrienes are one of several substances that are released by mast cells during an asthma attack, and it is leukotrienes that are primarily responsible for the bronchoconstriction. A new class of antiasthma drugs has been designed to interfere with the activity of leukotrienes. Both leukotriene synthesis inhibitors and cysteinylAllergen
Mast cells
These act by reducing bronchial mucosal inflammation and hypersecretion of mucus. They are given either orally, such as prednisolone, or by inhalation, such as
Cromoglicate (Intal)
Histamine Bronchospasm
Corticosteroids
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Incomplete clearing of mucus inflammation
Salbutamol (Ventolin)
Corticosteroids
Figure 5.17 Mode and site of action of antiallergy agents, bronchodilators and corticosteroids.
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Avoidance
ALLERGENS 3. 4.
DSCG (Intal)
MAST CELLS
5. 6. 7. 8. 9. 10. 11. 12.
EOSINOPHILS
13.
MEDIATOR AND CYTOKINASE RELEASE
Blockers
Steroids
14. 15. 16. 17.
INFLAMMATION
18. 19. 20. 21.
Bronchodilators
BRONCHOSPASM
TISSUE SWELLING
AIRWAY MUCUS
Figure 5.18 Mode and site of action of antiallergy agents, bronchodilators and corticosteroids.
leukotriene receptor antagonists have recently been shown to protect asthmatic patients against asthma attacks, but they are not useful as “rescue” remedies once an attack has already started. These drugs act by preventing leukotriene release from mast cells or by blocking the specific leukotriene receptors on bronchial tissues, thus preventing bronchoconstriction, mucus secretion and oedema. These drugs also reduce the influx of eosinophils, thus limiting inflammatory damage in the airways. These oral, nonsteroidal, anti-inflammatory drugs reduce the incidence of acute asthma attacks when taken regularly. The most common brand names of this class of drug in both the UK and USA are montelukast (Singulair) and zafirlukast (Accolate).
END NOTES 1. Lane DJ 1996 Asthma: the Facts, 3rd edn. Oxford University Press, Oxford, p. 123. 2. National Institutes of Health. Who is at risk for asthma? Online.
22. 23.
24. 25. 26. 27. 28. 29.
30.
31.
32. 33. 34. 35. 36. 37. 38.
39.
40. 41.
Available: http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/ Asthma_WhoIsAtRisk.html Centers for Disease Control and Prevention. Online. Available: http://www.cdc.gov Upton MN et al. 2000 Intergenerational 20-year trends in the prevalence of asthma and hay fever in adults. British Medical Journal 321: 88–92. Ibid., p. 131. Ibid., pp. 131–132. Arrighi HM 1995 US asthma mortality: 1941 to 1989. Annals of Allergy, Asthma and Immunology 74(4): 321–326. Asthma: the Facts, p. 26. Ibid., p. 27. Ibid., p. 68. Ibid., p. 68. Kay AB 1989 Allergy and Asthma. Blackwell Scientific Publications, Oxford, p. 153. Macklem PT 1992 The importance of excessive bronchoconstriction in asthma. Giornale Italiano di Allergologia e Immunologia Clinica 2(5): 276. Ibid., p. 276. Ibid., p. 279. Ibid., p. 280. Middleton E et al. 1991 Treatise of Allergology, Italian edition. Momento Medico, Salerno, p. 205. Voelker R 2000 The hygiene hypothesis. JAMA 283(10):1282. Holgate ST 2000 Allergic disorders. British Medical Journal 320: 231–234. Alm JS et al. 1999 Atopy in children of families with an anthroposophic lifestyle. The Lancet 353(9163): 1485–1488. Shaheen SO et al. 1996 Measles and atopy in Guinea-Bissau. The Lancet 347(9018): 1792–1796. William OCM, Moffatt M 1997 Asthma – an epidemic in the absence of infection? Science 275(5296): 41. Marra F et al. 2006 Does antibiotic exposure during infancy lead to development of asthma? A systematic review and metaanalysis. Chest 129: 610–618. Asthma: the Facts, p. 94. Ibid., p. 32. Ibid., p. 77. Ibid., p. 96. Strube G, Rudolph M 2000 Should steroids be the first line treatment for asthma? British Medical Journal 320: 47–49. Gilchrist S, Torok TJ, Gary HE Jr et al. 1994 National surveillance for respiratory syncytial virus, United States, 1985–1990. Journal of Infectious Diseases 170: 986–990. Everard ML 1998 Respiratory syncytial virus bronchiolitis and pneumonia. In: Taussig L, Landau L (eds) Textbook of Paediatric Respiratory Medicine. Mosby, St Louis, pp. 580–595. Wittig HJ, Glaser J 1959 The relationship between bronchiolitis and childhood asthma: a follow-up study of 100 cases of bronchiolitis. Journal of Allergy 30: 19–23. Johnston SL 1998 Viruses and asthma. Allergy 53: 922–932. Shay DK et al. 1999 Bronchiolitis-associated hospitalizations among US children, 1980–1996. JAMA 282(15):1440–1446. Treatise of Allergology, p. 207. Mygind N et al. 1990 Rhinitis and Asthma. Munksgaard, Lund, p. 10. Ibid., p. 10. Ibid., p. 10. Ibid., p. 14. Dr. Withering also advocated “coffee made very strong” as the prime reliever of asthma. This is in accordance with the modern use of sympathomimetic agents to promote bronchodilation. Caffeine is a xanthine with sympathomimetic effects. Bao Jing 1992 [Patterns and treatment of children with geographic tongue]. Journal of Chinese Medicine (Zhong Yi Za Zhi ) 33(4): 40–41. Beaven DW, Brooks SE 1988 Colour Atlas of the Tongue in Clinical Diagnosis. Wolfe, London, p. 117. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue
Allergic asthma (atopic eczema)
42. 43. 44. 45. 46. 47. 48. 49. 50. 51.
52.
53.
54.
55.
56. 57. 58. 59. 60. 61. 62. 63.
64. 65.
[Internal Medicine in Internal Medicine]. Shanghai Science Publishing House, Shanghai, p. 59. Asthma: the Facts, p. 32. Ibid., p. 33. Allergy and Asthma, p. 104. Ibid., p. 159. Kumar PJ, Clark ML 1987 Clinical Medicine. Baillière Tindall, London, p. 586. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 52. First published c.100 BC. Ibid., p. 126. Andrews BJ 1991 Wang Qingren and the history of Chinese anatomy. Journal of Chinese Medicine 36: 31. Rhinitis and Asthma, p. 252. National Heart, Lung, and Blood Institute, National Institutes of Health 1992 International report on the diagnosis and treatment of asthma. Giornale Italiano di Allergologia erectile dysfunction Immunologia Clinica 2: 260. Devereux G, Turner SW, Craig LCA et al. 2006 Low maternal vitamin E intake during pregnancy is associated with asthma in 5-year-old children. American Journal of Respiratory and Critical Care Medicine 174: 499–507. Wang Luo Zhen 1985 Qi Jing Ba Mai Kao Jiao Zhu [A Compilation of the Study of the Eight Extraordinary Vessels]. Shanghai Science Publishing House, Shanghai, p. 1. The Study of the Eight Extraordinary Vessels was written by Li Shi Zhen and first published in 1578. Hu Guo Rang et al. 1983 [The influence of the method of tonifying the kidneys on serum IgE and T-cell levels in patients with asthma]. Journal of Chinese Medicine 5: 33. Zhang Jing Lei 1985 Clinical observation on the treatment of 111 cases of asthma with acupuncture. Journal of Chinese Medicine 26(5): 47. Wang Xing Juan 1999 The experience of Dr Shen Zi Yin in the treatment of asthma. Journal of Chinese Medicine 40(3): 139–140. Treatise of Allergology, p. 205. Ibid., p. 205. Ibid., p. 113. Allergy and Asthma, p. 107. Ibid., p. 114. Rhinitis and Asthma, p. 102. Kline RM, Bertolone S 1998 Umbilical cord blood transplantation: providing a donor for everyone needing a bone marrow transplant? Southern Medical Journal 91(9): 821–828. Kiiko Matsumoto 1990 Presentation at Pacific Symposium of Oriental Medicine. Rhinitis and Asthma, p. 112.
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66. Kemp T, Pearce N, Fitzharris P et al. 1997 Is infant immunization a risk factor for childhood asthma or allergy? Epidemiology 8: 678–680. 67. Farooqi IS, Hopkin JM 1998 Early childhood infection and atopic disorder. Thorax 53: 927–932. 68. DeStefano F, Gu D, Kramarz P et al. 2002 Childhood vaccinations and risk of asthma. Pediatric Infectious Disease Journal 21(6): 498–504. 69. Allergy and Asthma, p. 107. 70. Ibid., p. 108. 71. Oddy W et al. 1999 Association between breast feeding and asthma in 6-year-old children: findings of a prospective birth cohort study. British Medical Journal 319: 815–819. 72. Spiritual Axis, p. 23. 73. 1982 Lei Jing [Classic of Categories]. People’s Health Publishing House, Beijing, p. 63. The Classic of Categories was written by Zhang Jie Bin and first published in 1624. 74. Allergy and Asthma, p. 162. 75. National Heart, Lung, and Blood Institute, National Institutes of Health 1992 International report on the diagnosis and treatment of asthma. Giornale Italiano di Allergologia erectile dysfunction Immunologia Clinica 2: 215–216. 76. Treatise of Allergology, p. 208. 77. Chen Jin 1995 [The treatment of paediatric asthma with combined tonifying and eliminating method]. Journal of Chinese Medicine 36(11): 666–667. 78. He Shu Huai 1988 [Patterns and treatment of asthma]. Journal of Chinese Medicine 29(1): 5–11. 79. Wu Ying He 1998 [The treatment of acute bronchial asthma according to pattern identification and with the addition of insect substances to extinguish wind]. Journal of Chinese Medicine 39(7): 396. 80. Shi Zi Guang 1988 Dang Dai Ming Yi Lin Zheng Jing Hua [Essential Clinical Experience of Famous Modern Doctors – Asthma]. Ancient Chinese Medical Texts Publishing House, p. 96. 81. Journal of Chinese Medicine 32(12): 4. 82. Essential Clinical Experience of Famous Modern Doctors, p. 180. 83. A Compilation of the Study of the Eight Extraordinary Vessels, p. 1. 84. Spiritual Axis, p. 120. 85. De Giacomo E 1991 Rivista Italiana di Medicina Tradizionale Cinese (Italian Journal of Chinese Medicine) 3: 10. 86. Novembre E et al. 1994 Terapia Antinfiammatoria dell’Asma: quale Farmaco prima? In: Proceedings of the International Meeting of Allergology and Clinical Immunology Paediatric Perspectives, February 1994, pp. 207–208.
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CHAPTER 6
ALLERGIC RHINITIS
ALLERGIC RHINITIS IN WESTERN MEDICINE Aetiology 178 Pathology 178 THE CHINESE THEORY OF BI YUAN Aetiology 179 Pathology 180
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DIFFERENCES BETWEEN ALLERGIC RHINITIS AND BI YUAN 181 Differences between allergic rhinitis and Bi Yuan 181 The Chinese theory of Bi Qiu (“stuffy nose”) 181 A NEW THEORY OF ALLERGIC RHINITIS Aetiology 182 Pathology 182 TREATMENT OF ALLERGIC RHINITIS Seasonal allergic rhinitis 184 Perennial allergic rhinitis 188 MODERN CHINESE LITERATURE
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The approach to the diagnosis and treatment of allergic rhinitis presents similar problems to that of asthma. Because “allergic rhinitis” is a disease defined according to Western medicine, we need to establish which symptom it might correspond to in the Chinese medical literature. Most books, both Chinese and English language ones, correlate allergic rhinitis to the Chinese symptom of Bi Yuan , which literally means “nose pool”. We need first to ascertain whether there is such a correspondence and whether the theory of Bi Yuan may be used to differentiate and diagnose allergic rhinitis. As for asthma, we shall therefore discuss the following topics. • • • •
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CLINICAL TRIALS 192 Acupuncture 192 Acupuncture and herbal medicine Herbal medicine 195
ALLERGIC RHINITIS
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Allergic rhinitis in Western medicine The theory of Bi Yuan in Chinese medicine Differences between allergic rhinitis and Bi Yuan A new theory of allergic rhinitis in Chinese medicine
Allergic rhinitis will be discussed according to the following topics.
SEASONAL ALLERGIC RHINITIS Treatment of the Manifestation • Wind-Cold • Wind-Heat
• • • • • • • •
Treatment of the Root • Deficiency of Lung and Kidney’s Defensive-Qi systems and the Governing Vessel
ALLERGIC RHINITIS IN WESTERN MEDICINE
PERENNIAL ALLERGIC RHINITIS Simultaneous treatment of the Manifestation and Root
The main clinical manifestations of allergic rhinitis are nasal congestion, a watery nasal discharge and sneezing. In a few cases, it affects the eyes and the
CASE HISTORIES
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Allergic rhinitis in Western medicine The Chinese theory of Bi Yuan Differences between allergic rhinitis and Bi Yuan A new theory of allergic rhinitis Treatment of allergic rhinitis Modern Chinese literature Clinical trials Case histories
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conjunctiva may become red and itchy. In 20% of cases, there is also asthma in conjunction with the rhinitis.
Aetiology Allergic rhinitis is due to an antigen–antibody reaction in the nasal mucosa. If the antigens responsible are only pollen particles, then it is called seasonal allergic rhinitis (hay fever). If the antigens are dust, house dust mites’ faecal matter, fungal spores and animal dander, it is called perennial allergic rhinitis. As for furry animals such as dogs and cats, the most allergenic substances are protein from their skin, urine and saliva. In perennial rhinitis, the nose becomes more reactive to non-specific stimuli such as cigarette smoke, petrol fumes, perfumes and, in the case of acupuncturists, moxa smoke.
Pathology Allergic rhinitis develops as a result of the interaction between the inhaled allergen and adjacent molecules
IgE
High levels of IgE in atopic individuals attached to mast cells in respiratory tract
of immunoglobulin (Ig) E antibodies. These adhere to the surface of the mast cells that line the nasal epithelium with the first exposure to the offending allergen (Fig. 6.1). After the first exposure, the mast cells are “primed”, i.e. high levels of IgE antibodies adhere to their surface. With subsequent exposure to allergens, the IgE antibodies provoke an “explosion” in the mast cells, with the massive release of histamine. Histamine itself causes an increase in permeability of the epithelium, allowing allergens to reach IgE-primed mast cells. Sneezing results from overstimulation of the afferent nerve endings and starts within minutes of the allergens entering the nose. This is followed by a greatly increased nasal secretion and eventually nasal blockage about 15–20 minutes after contact with the allergen. This pathological process is similar to that of asthma, the main difference being that histamine plays a more important role in the development of allergic rhinitis than of asthma. In fact, antihistamines are effective for allergic rhinitis but are of little value for asthma.
Pollen grains
Protein leaches out of pollen grains and binds IgE antibodies on to mast cells
Figure 6.1 Allergic reaction in allergic rhinitis.
Histamine, prostaglandins
Linkage of IgE on to mast cells sparks off ‘’explosion‘’ in them. Histamine and prostaglandins (among others) leak from the cells. These cause sneezing, congestion and itching.
Allergic Rhinitis
A higher number of mast cells are present in the nasal mucosa of individuals with rhinitis, and they probably increase as allergen stimulation continues. This accounts for the increasing responsiveness of the nose to lower amounts of allergens. The grossly swollen mucosa in allergic rhinitis may obstruct drainage from the sinuses, causing sinusitis in half the patients. Thus, infection of the paranasal sinuses is a frequent complication and consequence of allergic rhinitis (Fig. 6.2). This is an important point to remember when discussing the differences between allergic rhinitis and Bi Yuan. Some individuals may also lose the sense of taste and smell. The antigen–antibody reaction is illustrated in Figure 6.1, in which the allergen in question is pollen granules. The Western treatment of allergic rhinitis relies mostly on the use of antihistamine agents. These work by preventing histamine from reaching its site of action, i.e. the H1-receptors, and hence they are called H1-receptor blockers. Side effects include sedation, dizziness, fatigue, insomnia, nervousness and gastrointestinal disturbances. Failure to respond to antihistamines is due to the fact that active substances other than histamine are released in allergic states. Steroids by nasal inhalation are also used for allergic rhinitis; these do not seem to have the same general, systemic effect of oral steroids.
Infection in paranasal sinuses Nasal cavity Swollen mucosa prevents drainage from sinuses
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SUMMARY ALLERGIC RHINITIS IN WESTERN MEDICINE Aetiology Allergic rhinitis is due to an antigen–antibody reaction in the nasal mucosa. If the antigens responsible are only pollen particles, then it is called seasonal allergic rhinitis (hay fever). If the antigens are dust, house dust mites’ faecal matter, fungal spores and animal dander, it is called perennial allergic rhinitis. Pathology Allergic rhinitis develops as a result of the interaction between the inhaled allergen and adjacent molecules of IgE antibodies. After the first exposure, the mast cells are “primed”, i.e. high levels of IgE antibodies adhere to their surface. With subsequent exposure to allergens, the IgE antibodies provoke an “explosion” in the mast cells, with the massive release of histamine. Sneezing results from overstimulation of the afferent nerve endings and starts within minutes of the allergens entering the nose. The grossly swollen mucosa in allergic rhinitis may obstruct drainage from the sinuses, causing sinusitis in half the patients. The Western treatment of allergic rhinitis relies mostly on the use of antihistamine agents.
THE CHINESE THEORY OF BI YUAN The main clinical manifestations usually mentioned in connection with Bi Yuan are a purulent nasal discharge with a foul smell, a stuffed nose, a runny nose, headache and sneezing.
Aetiology
Figure 6.2 Sinusitis secondary to allergic rhinitis.
Bi Yuan is due to repeated invasions of Wind-Cold in the Lung channel that are not treated properly. After some time, Cold turns into Heat, the Lung cannot diffuse and descend Qi and local stagnation of Qi and Blood develops in the nose. All these factors lead to nasal discharge. The Gall Bladder channel carries Heat upwards to the brain, and as the Governing Vessel also
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flows into the brain and the nose, this therefore causes a purulent yellow nasal discharge. In Chinese medicine, this condition was in fact also called “brain flooding” or “brain discharge”.
Stomach- and Spleen-Heat
Pathology
Qi and Blood stagnation
Thus two channels and organs are involved: Lungs and Gall Bladder. After several years, the Spleen will usually also become involved, and a Spleen deficiency leading to Dampness further aggravates the condition. The Manifestation of this condition consists of symptoms of Wind-Cold or Wind-Heat. The Root of the condition is a deficiency of the Lung in diffusing and descending Qi and, in some cases, Gall Bladder-Heat. The treatment is variously aimed at expelling WindCold, clearing Gall Bladder-Heat or clearing SpleenHeat, according to the pattern involved. The main patterns encountered in Bi Yuan are:
White or yellow, purulent, sticky nasal discharge, headaches, nasal mucosa swollen and red, hypertrophy of nasal mucosa, Purple tongue, Wiry or Choppy pulse.
• • • • •
Lung invaded by Wind-Cold Lung invaded by Wind-Heat Liver- and Gall Bladder-Heat Lung-Heat Stomach- and Spleen-Heat.
In chronic conditions, there may be any of the above patterns of Heat plus one of the following patterns: • Qi and Blood stagnation • Liver- and Kidney-Yin deficiency • Lung- and Spleen-Qi deficiency.
Lung invaded by Wind-Cold Stuffed nose, runny nose with clear mucus, slight headache, sneezing.
Lung invaded by Wind-Heat Sneezing, stuffed nose, runny nose with thick-yellow discharge, itchy nose and throat, redness and swelling around the nose, itchy eyes.
Liver- and Gall Bladder-Heat Dry nose, runny nose with yellow-sticky-purulent and foul-smelling discharge, diminished sense of smell, bitter taste, dry throat, headache.
Lung-Heat Stuffed nose, runny nose with yellow foul-smelling discharge that may contain blood, dry mouth, feeling of heat.
Stuffed nose, runny nose with yellow foul-smelling discharge, diminished sense of smell, feeling of heaviness of the head, headache, bitter and sticky taste.
Liver- and Kidney-Yin deficiency Runny but scanty nasal discharge, diminished sense of smell, headache experienced inside the skull, dizziness, tinnitus, night sweating, poor memory, lower backache, atrophy of nasal mucosa, tongue without coating, Floating-Empty pulse.
Lung- and Spleen-Qi deficiency White-watery nasal discharge without smell, varying in amount, nasal obstruction, diminished sense of smell, feeling of heaviness of the head, headache, inflamed nasal mucosa, hypertrophy of nasal mucosa, tiredness, poor appetite, loose stools, spontaneous sweating, weak voice, Pale tongue, Weak pulse.
SUMMARY THE CHINESE THEORY OF BI YUAN Clinical manifestations: a purulent nasal discharge with a foul smell, a stuffed nose, a runny nose, headache and sneezing. Aetiology and pathology Bi Yuan due to repeated invasions of WindCold in the Lung channel. Cold turns into Heat, the Lung cannot diffuse and descend Qi and local stagnation of Qi and Blood develops in the nose. The Gall Bladder channel carries Heat upwards to the brain, and this causes a purulent yellow nasal discharge. The Manifestation consists of symptoms of Wind-Cold or Wind-Heat. The Root of the condition is a deficiency of the Lung in diffusing and descending Qi and, in some cases, Gall Bladder-Heat. The main patterns encountered in Bi Yuan are: — Lung invaded by Wind-Cold
Allergic Rhinitis
— Lung invaded by Wind-Heat — Liver- and Gall Bladder-Heat — Lung-Heat — Stomach- and Spleen-Heat.
BI YUAN
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Sinusitis
BI QIU Allergic rhinitis
DIFFERENCES BETWEEN ALLERGIC RHINITIS AND BI YUAN I shall explore first the differences between allergic rhinitis and Bi Yuan and then the Chinese theory of Bi Qiu (“stuffy nose”).
Differences between allergic rhinitis and Bi Yuan The use of the theory of Bi Yuan to treat allergic rhinitis presents several problems. The theory of Bi Yuan presents no clear explanation of the allergic nature of rhinitis and no explanation of its aetiology. Some of the patterns described in Bi Yuan are not allergic rhinitis but sinusitis. In fact, all of them, except for Lung invaded by Wind-Cold, include runny nose with a yellow, sticky, purulent and foul-smelling discharge. This is very clearly a symptom of sinusitis, not rhinitis, as it is the infection of the sinuses, not rhinitis, that produces the yellow and purulent discharge.
The Chinese theory of Bi Qiu (“stuffy nose”) All modern Chinese books equate allergic rhinitis to Bi Yuan, but this disease corresponds more to sinusitis rather than to allergic rhinitis. There is, in fact, an ancient Chinese disease entity called Bi Qiu that actually corresponds more closely to allergic rhinitis. Bi Qiu means “stuffy nose”, and it is characterized by a profuse, thin, clear nasal discharge, stuffed nose and sneezing. Another Chinese disease category that may correspond to allergic rhinitis is called Qiu Ti , which may be translated as “stuffy nose and sneezing” (Fig. 6.3). The only exception is the modern book A New General Outline of Chinese Medicine by the Guangzhou Army Health Department, which attributes the pathology of
QIU TI Figure 6.3 Sinusitis and allergic rhinitis in Chinese medicine.
allergic rhinitis to a Kidney deficiency and a deficiency of the Governing Vessel (as I do). The book also says specifically:1 The Kidneys control sneezing. The Governing Vessel flows to the upper lip. Sneezing, stuffed nose, runny nose with a watery, clear nasal discharge is due to a deficiency of the Kidneys and of the Governing Vessel. Itchy nose is due to Wind. This book mentions four patterns for allergic rhinitis, two clearly “borrowed” from the theory of Bi Yuan and two different ones that are a deficiency of the Kidneys and of the Governing Vessel and a deficiency of the Spleen with Dampness. Bi Qiu (“stuffy nose”) is characterized by itchy nose, sneezing, profuse, white-watery nasal discharge and stuffy nose. On examination, the nasal mucosa is swollen but not inflamed. The patterns of Bi Qiu are: • Lung-Qi deficiency and weakness of the Defensive Qi • Spleen-Qi deficiency • Kidney-Yang deficiency and weakness of the Governing Vessel • Qi deficiency and Blood stasis.
Lung-Qi deficiency and weakness of the Defensive Qi Itchy nose, sneezing, white-watery nasal discharge, swollen nasal mucosa, itchy throat, cough, elicited by Wind, propensity to catching colds, spontaneous sweating, Pale tongue, Empty pulse.
Prescription WEN FEI ZHI LIU DAN plus GUI ZHI TANG Warming the Lungs and Stopping Discharge Pill plus Ramulus Cinnamomi Decoction
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Spleen-Qi deficiency Chronic attacks, sneezing, white-watery nasal discharge, stuffy nose, white nasal mucosa, feeling of heaviness of the head, tiredness, poor appetite, loose stools, Pale tongue, Weak pulse.
Prescription BU ZHONG YI QI TANG plus QIANG HUO SHENG SHI TANG Tonifying the Centre and Benefiting Qi Decoction plus Notopterygium Dispelling Dampness Decoction
Kidney-Yang deficiency and weakness of the Governing Vessel Chronic condition, sneezing, white-watery nasal discharge, worse in winter, stuffy nose, diminished sense of smell, white nasal mucosa, dizziness, tinnitus, lower backache, chilliness, cold feet, Pale tongue, Weak and Deep pulse.
Prescription JIN GUI SHEN QUI WAN plus MA HUANG FU ZI XI XIN TANG Golden Chest Kidney-Qi Pill plus Ephedra-AconitumAsarum Decoction
Qi deficiency and Blood stasis Chronic condition, sneezing, white-watery nasal discharge, white nasal mucosa, swollen nose, polyps, headache, Purple tongue, Wiry or Choppy pulse.
Prescription WEN FEI HUA YU TANG Warming the Lungs and Eliminating Stasis Decoction
SUMMARY DIFFERENCES BETWEEN ALLERGIC RHINITIS AND BI YUAN The theory of Bi Yuan presents no clear explanation of the allergic nature of rhinitis and no explanation of its aetiology. All the patterns described in Bi Yuan (with the exception of Lung invaded by Wind-Cold) are not allergic rhinitis but sinusitis. The ancient Chinese disease entity called Bi Qiu corresponds more closely to allergic rhinitis.
A NEW THEORY OF ALLERGIC RHINITIS Allergic rhinitis is due to an over-reactivity of the immune system to certain allergens. Like asthma, this is due, from the Chinese point of view, to a deficiency of the Lung and Kidney’s Defensive-Qi systems, a deficiency of the Governing Vessel combined with retention of chronic Wind in the nose.
Aetiology The deficiency of Lung and Kidney’s Defensive-Qi systems is either hereditary or due to problems during the pregnancy or childbirth. The aetiological factors are exactly the same as for asthma (see Chapter 5). Repeated invasions of Wind that are not treated properly, combined with a pre-existing deficiency of Lung and Kidney’s Defensive-Qi systems, lead to the retention of what could be described as chronic Wind in the nose, similar to what happens in asthma when Wind is retained in the chest.
Pathology Allergic rhinitis is therefore characterized by two factors: a deficiency of Lung and Kidney’s Defensive-Qi systems and retention of Wind in the nose. As mentioned for asthma, a deficiency of the Kidney’s Defensive-Qi system involves only this particular aspect of its function and not others. One would not expect therefore to see symptoms such as tinnitus, dizziness, night sweating, and weak back and legs. Even more than asthma, a Kidney deficiency is involved in the pathology of allergic rhinitis. This is so because, in allergic rhinitis, the Kidneys are involved not only in the Root of the disease but also in the Manifestation through the Governing Vessel (Fig. 6.4). The Governing Vessel emerges from between the Kidneys and flows up the spine to the top of the head and then down to the nose and lips. It is therefore the channel connection between the Kidneys and the nose. For this reason, the Kidneys are responsible not only for breathing, due to their function of grasping Qi, but also sneezing. Sneezing itself is also directly linked to the Kidneys and not necessarily due only to Wind. Chapter 23 of the Simple Questions says: “The Kidneys control sneezing.”2 Chapter 64 of the Simple Questions discusses the consequences of inserting a needle into
Allergic Rhinitis Governing Vessel Deficiency of Governing Vessel Deficiency of Lung and Kidney’s DefensiveQi systems Wind
Frontal sinus Olfactory bulb Sphenoidal sinus Pharyngeal tonsil
Nasopharynx
Cartilage Nasal bone Nasal cavity Lip muscle Tongue Figure 6.4 The influence of the Governing Vessel on the nose in allergic rhinitis.
an organ and, for the kidneys, it says: “If we pierce the kidneys, this will cause sneezing and death will ensue within 6 days.”3 Thus the hyper-reactivity of the immune response of allergic rhinitis is due to a deficiency of the Kidney’s Defensive-Qi system and the Governing Vessel. With regard to the role of the Governing Vessel in allergic rhinitis, it is interesting that many of the herbs that Li Shi Zhen connected with this vessel are expelling-Wind herbs that act on the nose. These herbs are Fang Feng Radix Saposhnikoviae, Cang Er Zi Fructus Xanthii, Jing Jie Herba Schizonepetae, Qiang Huo Rhizoma seu Radix Notopterygii, Xi Xin Herba Asari and Gao Ben Rhizoma Ligustici.4 The symptoms and signs of allergic rhinitis are those of Wind-Cold, as the nasal discharge is always white and watery. This indicates a deficiency of Defensive Qi, which is spread by the Lungs but has its root in the Kidneys.5 Thus, although some books do refer to a Kidney deficiency as the Root of allergic rhinitis, the Kidneys are responsible not only for the Root of this disease (because of the deficiency of the Kidney’s Defensive-Qi system), but also for the Manifestation through their direct connection with the Defensive Qi and sneezing and with the Governing Vessel (which flows through the nose). Allergic rhinitis often starts in early childhood, but it may also start later in life, with a progressive decline of Kidney-Qi or perhaps with a decline of Kidney-Qi connected to the beginning of sexual activity. In fact, in men over 40 suffering from allergic rhinitis there is often a direct connection between sexual activity
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and an attack of rhinitis. Thus, although rhinitis is obviously a much less severe disease than asthma, when compared with it, it indicates a more severe deficiency of the Kidneys. As for the difference between seasonal and perennial allergic rhinitis (hay fever), the latter simply occurs when there is a more severe Kidney deficiency. Obviously, in patients aged 50 or over the pathology will be complicated by other factors, the most common of which is a Spleen deficiency, which produces more mucus and therefore a runny nose. Also, allergic rhinitis causes a congestion of the nasal mucosa, which may prevent proper drainage from the sinuses; this may lead to a secondary sinus infection complicating the clinical manifestations, as the patient will display the symptoms of both allergic rhinitis and of sinusitis. As for the Manifestation, the main pathogenic factor is Wind invading the Lung channel in the nose. However, this is due not only to repeated invasions of Wind, as in the theory of Bi Yuan, but primarily to the inherent deficiency of the Kidney’s Defensive-Qi system and Governing Vessel in the nose, which mimics symptoms of invasion of Wind-Cold. As mentioned above, sneezing itself is also directly due to the Kidneys and not necessarily only to Wind.
SUMMARY A NEW THEORY OF ALLERGIC RHINITIS Aetiology Deficiency of Lung and Kidney’s Defensive-Qi systems. Chronic “Wind” in the nose. Pathology Deficiency of Lung and Kidney’s Defensive-Qi systems (Ben) and retention of Wind in the nose (Biao). The Kidneys are involved not only in the Root of the disease but also in the Manifestation through the Governing Vessel. Sneezing is linked to the Kidneys. The symptoms and signs of allergic rhinitis are those of Wind-Cold, as the nasal discharge is always white and watery. Deficiency of Defensive Qi. The Kidneys are responsible not only for the Root of this disease but also for the Manifestation through their direct connection
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with the Defensive Qi and sneezing and with the Governing Vessel. Allergic rhinitis causes a congestion of the nasal mucosa, which may lead to a secondary sinus infection. The Manifestation of Wind invading the Lung channel in the nose is due not only to repeated invasions of Wind, but primarily to the inherent deficiency of the Kidney’s Defensive-Qi system and Governing Vessel in the nose.
TREATMENT OF ALLERGIC RHINITIS As for treatment, it is important to distinguish seasonal from perennial rhinitis. In seasonal rhinitis, we should apply different principles of treatment according to the season. In perennial rhinitis, the principle of treatment is irrespective of the season. The discussion of the treatment will therefore be structured in the following way. Seasonal allergic rhinitis: • Treatment of the Manifestation — Wind-Cold — Wind-Heat • Treatment of the Root — Deficiency of Lung and Kidney’s Defensive-Qi systems and the Governing Vessel Perennial allergic rhinitis: • Simultaneous treatment of the Manifestation and Root
Seasonal allergic rhinitis In seasonal rhinitis, one must adapt the treatment according to the season. During the pollen season, attention is directed at treating the Manifestation, i.e. expelling Wind-Cold or Wind-Heat. Outside the summer season, attention is directed at treating the Root, i.e. tonifying the Lung and Kidney’s Defensive-Qi systems and strengthening the Governing Vessel.
TREATMENT OF THE MANIFESTATION Wind-Cold Clinical manifestations Sneezing, profuse runny nose with white-watery discharge, pale complexion, stuffed nose, slight headache, no thirst.
Treatment principle Expel Wind-Cold and restore the diffusing and descending of Lung-Qi.
Acupuncture Points BL-12 Fengmen, BL-13 Feishu, LU-7 Lieque, L.I.-20 Yingxiang, Bitong, Du-23 Shangxing, G.B.-20 Fengchi, Yintang. Reducing or even method. Cupping is applicable on BL-12 and BL-13. Explanation • BL-12, BL-13 and LU-7 restore the diffusing and descending of Lung-Qi and expel Wind. BL-12 is particularly effective with cupping. • L.I.-20, Bitong and Yintang are local points to expel Wind from the nose and to stop itching and sneezing. • Du-23 and G.B.-20 are adjacent points to expel Wind from the head. Du-23, in particular, expels Wind from the nose and stops nasal discharge.
Herbal therapy Prescription XIAO QING LONG TANG Small Green Dragon Decoction Modifications • In case of very itchy and runny nose, add Xin Yi Hua Flos Magnoliae, Cang Er Zi Fructus Xanthii and Bai Zhi Radix Angelicae dahuricae. Prescription CANG ER ZI SAN Xanthium Powder Explanation This formula is applicable if sneezing rather than runny nose is the main problem. As it is composed of only four herbs, it may also be added as a unit to other formulae when sneezing is a predominant problem. Prescription MA HUANG TANG Ephedra Decoction Explanation This formula is used if there are pronounced symptoms of Wind-Cold, such as chilliness, absence of sweating and a Floating-Tight pulse.
Allergic Rhinitis
Prescription GUI ZHI TANG Ramulus Cinnamomi Decoction Explanation This formula is used if there are symptoms of WindCold with slight sweating. Prescription TONG XUAN LI FEI TANG Penetrating, Diffusing and Regulating the Lungs Decoction
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Prescription TONG XUAN LI FEI TANG Penetrating, Diffusing and Regulating the Lungs Decoction Prescription JIA WEI XIANG SU SAN New Cyperus-Perilla Powder
Wind-Heat
Explanation This formula is used if there is a profuse discharge from the nose, sneezing, a cough and possibly a headache.
Clinical manifestation Sneezing, runny nose with white and watery discharge, itchy throat, itchy-red eyes, slight thirst.
Prescription JIA WEI XIANG SU SAN New Cyperus-Perilla Powder
Treatment principle Expel Wind, clear Heat, restore the dispersing and descending of Lung-Qi.
Explanation This prescription is used if there is stiffness of the shoulders, a headache and sneezing. It is suitable for a more chronic condition that has led to stagnation of Qi and Blood in the head and shoulders.
Points BL-12 Fengmen, BL-13 Feishu, L.I.-4 Hegu, L.I.-11 Quchi, L.I.-20 Yingxiang, Bitong, Yintang, G.B.-20 Fengchi. Reducing or even method. Cupping is applicable on BL-12 and BL-13.
SUMMARY WIND-COLD Points BL-12 Fengmen, BL-13 Feishu, LU-7 Lieque, L.I.-20 Yingxiang, Bitong, Du-23 Shangxing, G.B.-20 Fengchi, Yintang. Reducing or even method. Cupping is applicable on BL-12 and BL-13. Herbal therapy Prescription XIAO QING LONG TANG Small Green Dragon Decoction Prescription CANG ER ZI SAN Xanthium Powder Prescription MA HUANG TANG Ephedra Decoction Prescription GUI ZHI TANG Ramulus Cinnamomi Decoction
Acupuncture
Explanation • BL-12 and BL-13 restore the dispersing and descending of Lung-Qi. • L.I.-4 and L.I.-11 expel Wind and clear Heat. • L.I.-20, Bitong and Yintang are local points to expel Wind from the nose. • G.B.-20 expels Wind.
Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Explanation This is a general formula for WindHeat, especially affecting the throat and causing itchy throat and a cough. Modifications • If there is pronounced sneezing, add Cang Er Zi Fructus Xanthii, Xin Yi Hua Flos Magnoliae and Bai Zhi Radix Angelicae dahuricae. Prescription CHAI GE JIE JI TANG Bupleurum-Pueraria Relaxing the Tendons Decoction
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Explanation This formula is used for sneezing with symptoms of Wind-Heat and some interior Heat. Three Treasures remedy To treat the Manifestation of allergic rhinitis, I use the remedy Jade Screen. In case of seasonal allergic rhinitis, I use Jade Screen during the hay fever season in a relatively high dose, i.e. 9 tablets a day or more (for adults). Jade Screen can be taken both for the manifestations of Wind-Cold and Wind-Heat.
SUMMARY WIND-HEAT Points BL-12 Fengmen, BL-13 Feishu, L.I.-4 Hegu, L.I.-11 Quchi, L.I.-20 Yingxiang, Bitong, Yintang. Reducing or even method. Cupping is applicable on BL-12 and BL-13. Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction Prescription CHAI GE JIE JI TANG Bupleurum-Pueraria Relaxing the Tendons Decoction Three Treasures remedy Jade Screen
Treatment of the Root In seasonal rhinitis, attention should be directed at treating the Root of the disease at any time outside the pollen season. The best time to do it is actually towards the end of the summer and beginning of Autumn, i.e. August, September and October. In treating the Root, the aim is to tonify the Lung and Kidney’s Defensive-Qi systems and strengthen the Governing Vessel. As the rhinitis is seasonal, there is no need to treat the Manifestation. Herbs that strengthen the Governing Vessel include Lu Rong Cornu Cervi pantotrichum, Lu Jiao Cornu Cervi, Lu Jiao Jiao Gelatinum Cornu Cervi and Gui Ban Plastrium Testudinis. Lu Rong, Lu Jiao and Lu Jiao Jiao are particularly important to treat allergic rhinitis, as they tonify Kidney-Yang without creating too much
Heat, strengthen the Governing Vessel and bolster the Lung and Kidney’s Defensive-Qi systems. By entering the Governing Vessel and tonifying the Kidneys, they treat both the Root and the Manifestation of the disease. Lu Jiao Jiao is particularly applicable to women, as it additionally nourishes Blood. Lu Rong, in particular, strengthens the Governing Vessel, tonifies Yang without drying, nourishes the Essence and Marrow and strengthens tendons and bones. In other words, it strengthens both the Yin and Yang aspects of the Governing Vessel and of the Essence. Gui Ban nourishes the Directing Vessel and is particularly used in women, in combination with Lu Jiao or Lu Jiao Jiao, to strengthen both Governing and Directing Vessels. With acupuncture in women, this is achieved by using the opening and coupled points of both the Governing and Directing Vessels. Thus, in a woman, one would needle S.I.-3 Houxi on the right, BL-62 Shenmai on the left, LU-7 Lieque on the left and KI-6 Zhaohai on the right in this order. Li Shi Zhen indicates the following herbs for the Governing Vessel.6 • • • • • • • • • •
Rou Gui Cortex Cinnamomi Gui Zhi Ramulus Cinnamomi cassiae Fu Zi Radix Aconiti lateralis preparata Du Huo Radix Angelicae pubescentis Qiang Huo Rhizoma seu Radix Notopterygii Fang Feng Radix Saposhnikoviae Jing Jie Herba Schizonepetae Xi Xin Herba Asari Gao Ben Rhizoma Ligustici Cang Er Zi Fructus Xanthii
The first three herbs tonify the Original Qi (Yuan Qi), from which the Governing Vessel originates, and strengthen the Fire of the Gate of Life. Du Huo strengthens the back and expels Wind-Dampness from the lower back. All the other herbs affect the Governing Vessel in its upper part along the nose. In fact, all these herbs expel Wind from the nose and restore the dispersing of Lung-Qi.
Deficiency of Lung and Kidney’s Defensive-Qi systems and the Governing Vessel Clinical manifestations Pale complexion, weak back, propensity to catching colds, Pale tongue, WeakDeep pulse.
Allergic Rhinitis
Treatment principle Tonify the Lung and Kidney’s Defensive-Qi systems and strengthen the Governing Vessel.
Acupuncture Points Du-4 Mingmen, Ren-4 Guanyuan with moxa, BL-23 Shenshu, KI-3 Taixi, BL-13 Feishu, Du-12 Shenzhu, Du-24 Shenting, Du-23 Shangxing, G.B.-20 Fengchi, Du-14 Dazhui with moxa, S.I.-3 Houxi and BL-62 Shenmai (in women combined with LU-7 Lieque and KI-6 Zhaohai). Reinforcing method, except on the head points which should be needled with even method. Explanation • Du-4 and Ren-4, in combination with moxa, strengthen the Governing Vessel. Ren-4 is used because the internal pathway of the Governing Vessel actually runs along the front midline of the body under the Directing Vessel. The use of Du-4 and Ren-4, therefore, tonifies both the Yang and the Yin aspects of the Governing Vessel. • BL-23, KI-3, BL-13 and Du-12 tonify the Lung and Kidney’s Defensive-Qi systems. • Du-24 and Du-23 expel Wind from the nose, strengthen the Governing Vessel locally and stop nasal discharge. • G.B.-20 is an adjacent point to expel Wind. In order to affect the nose, it should be needled with the tip of the needle pointing towards the nostril of the same side. • Du-14 with moxa strengthens the Governing Vessel in its upper part. • S.I.-3 and BL-62 open the Governing Vessel. The points are crossed over with S.I.-3 on the left side for men and right for women and BL-62 on the right side for men and left for women. In women, it is preferable to combine the Governing Vessel with the Directing Vessel; one would therefore needle S.I.-3 on the right, BL-62 on the left, LU-7 on the left and KI-6 on the right.
Herbal therapy Prescription YI DU YANG YUAN TANG Benefiting the Governing Vessel and Nourishing the Original Qi Decoction
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Modifications • If there are pronounced symptoms of Cold and deficiency of Kidney-Yang, add Rou Gui Cortex Cinnamomi. • If there is a propensity to catching colds, add Huang Qi Radix Astragali, Bai Zhu Rhizoma Atractylodis macrocephalae and Fang Feng Radix Saposhnikoviae. • If there is a nasal discharge and a sticky tongue coating, add Bai Zhu Rhizoma Atractylodis macrocephalae, Ban Xia Rhizoma Pinelliae preparatum and Fu Ling Poria. The above formula is particularly suited to allergic rhinitis, as it tonifies the Lung and Kidney’s DefensiveQi systems, strengthens the Governing Vessel and nourishes the Essence. However, any Kidney-Yangtonifying formula may be used modified with the addition of the following ingredients. • Herbs that strengthen the Governing Vessel: Lu Rong Cornu Cervi pantotrichum, Lu Jiao Cornu Cervi or Lu Jiao Jiao Gelatinum Cornu Cervi in women. • Herbs that nourish the Essence and Marrow: Gui Ban Plastrium Testudinis, Tu Si Zi Semen Cuscutae, Gou Qi Zi Fructus Lycii chinensis or Wu Wei Zi Fructus Schisandrae. • Herbs to tonify the Lung’s Defensive-Qi system: Huang Qi Radix Astragali, Mai Men Dong Radix Ophiopogonis and Bei Sha Shen Radix Glehniae. If necessary, add small doses of one or two cold herbs to prevent overheating from the hot herbs that tonify Kidney-Yang, for example Zhi Mu Radix Anemarrhenae and Huang Bo Cortex Phellodendri. In women, it is necessary to strengthen the Directing as well as the Governing Vessel with such herbs as Sheng Di Huang Radix Rehmanniae, Gui Ban Plastrium Testudinis, Bie Jia Carapax Trionycis or E Jiao Colla Corii Asini. Although allergic rhinitis in itself indicates a deficiency of Lung and Kidney’s Defensive-Qi systems, especially in people over 40, this may be combined with a Kidney-Yin deficiency. In such cases, it is better to start from a prescription to nourish Kidney-Yin such as Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill and modify it with the addition of herbs to tonify Lung and Kidney’s Defensive-Qi systems and strengthen the Governing Vessel, as indicated above.
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Finally, if there are symptoms and signs of Spleen deficiency, simply add Bai Zhu Rhizoma Atractylodis macrocephalae, Huang Qi Radix Astragali and Fu Ling Poria. Many other formulae can be used according to the patient’s body condition, and these are illustrated below when discussing the treatment of perennial rhinitis.
Treatment principle Tonify the Lung and Kidney’s Defensive-Qi systems, strengthen the Governing Vessel, consolidate the Exterior and expel Wind.
Acupuncture Points
Three Treasures remedies To treat the Root in seasonal allergic rhinitis, I use the remedy Herbal Sentinel, of which there are two variants: Herbal Sentinel-Yang for patients with a tendency to Yang deficiency and Herbal Sentinel-Yin for patients with a tendency to Yin deficiency. I generally prescribe Herbal Sentinel during autumn and winter, with the dosage of 4–6 tablets a day (for adults).
• BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, ST-36 Zusanli, LU-7 Lieque, LU-9 Taiyuan, with reinforcing method, to tonify the Lung’s Defensive-Qi system. • L.I.-4 Hegu, L.I.-20 Yingxiang, Bitong, Du-23 Shangxing, with even method, to expel Wind from the nose. • All other Kidney and Governing Vessel as indicated above for treatment of the Root of seasonal rhinitis.
SUMMARY DEFICIENCY OF LUNG AND KIDNEY’S DEFENSIVE-QI SYSTEMS AND THE GOVERNING VESSEL Points Du-4 Mingmen, Ren-4 Guanyuan with moxa, BL-23 Shenshu, KI-3 Taixi, BL-13 Feishu, Du-12 Shenzhu, Du-24 Shenting, Du-23 Shangxing, G.B.-20 Fengchi, Du-14 Dazhui with moxa, S.I.-3 Houxi and BL-62 Shenmai (in women combined with LU-7 Lieque and KI-6 Zhaohai). Reinforcing method, except on the head points, which should be needled with even method. Herbal therapy Prescription YI DU YANG YUAN TANG Benefiting the Governing Vessel and Nourishing the Original Qi Decoction. Three Treasures remedy Herbal Sentinel
Perennial allergic rhinitis SIMULTANEOUS TREATMENT OF THE MANIFESTATION AND ROOT To treat perennial rhinitis, one must treat both the Root and the Manifestation simultaneously because the symptoms are evident the whole year round.
Herbal therapy There are many suitable formulae, and they should all be modified with the addition of the following types of herb. • Herbs to tonify the Lung and Kidney’s Defensive-Qi systems: Du Zhong Cortex Eucommiae ulmoidis, Xu Duan Radix Dipsaci or Bu Gu Zhi Fructus Psoralelae. • Herbs that strengthen the Governing Vessel: Lu Rong Cornu Cervi pantotrichum, Lu Jiao Cornu Cervi or Lu Jiao Jiao Gelatinum Cornu Cervi in women. • Herbs to tonify the Lung’s Defensive-Qi system: Huang Qi Radix Astragali, Mai Men Dong Radix Ophiopogonis and Bei Sha Shen Radix Glehniae. • Herbs that expel Wind from the nose and stop nasal discharge: Fang Feng Radix Saposhnikoviae, Jing Jie Herba Schizonepetae, Cang Er Zi Fructus Xanthii, Xin Yi Hua Flos Magnoliae and Xi Xin Herba Asari. • Herbs that nourish the Essence and Marrow: Gui Ban Plastrium Testudinis, Tu Si Zi Semen Cuscutae, Gou Qi Zi Fructus Lycii chinensis or Wu Wei Zi Fructus Schisandrae. If necessary, add small doses of one or two cold herbs to prevent overheating from the hot herbs that tonify Kidney-Yang, for example Zhi Mu Radix Anemarrhenae and Huang Bo Cortex Phellodendri. The comments made above on the treatment of the Root of seasonal allergic rhinitis apply also to the treatment of perennial rhinitis.
Allergic Rhinitis
• In women, it is necessary to strengthen the Directing as well as the Governing Vessel with such herbs as Sheng Di Huang Radix Rehmanniae, Gui Ban Plastrium Testudinis, Bie Jia Carapax Trionycis or E Jiao Colla Corii Asini. • If there is a background of Kidney-Yin deficiency or a deficiency of both Kidney-Yang and KidneyYin, it is better to start from a prescription to nourish Kidney-Yin such as Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill or Zuo Gui Wan Restoring the Left [Kidney] Pill and modify it with the addition of herbs to tonify Lung and Kidney’s Defensive-Qi systems and strengthen the Governing Vessel, as indicated above. • If there are symptoms and signs of Spleen deficiency, simply add Bai Zhu Rhizoma Atractylodis macrocephalae, Huang Qi Radix Astragali and Fu Ling Poria.
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Prescription JIA JIAN YU ZHU TANG Variation of Polygonatum Decoction
Explanation This formula is used if there is a background of Stomach-Yin deficiency.
Prescription WU JI SAN Five Accumulations Powder
Explanation This formula is suitable for very chronic allergic rhinitis with Spleen- and Stomach-Yang deficiency and some stasis of Blood. It is particularly suitable for women.
Prescription Prescription YU PING FENG SAN Jade Wind Screen Powder
Explanation This is a very simple and effective formula to tonify Lung-Qi and consolidate the Exterior.
GUI ZHI REN SHEN TANG Ramulus Cinnamomi-Ginseng Decoction
Explanation This prescription is for deficiency of Lung- and SpleenYang with Phlegm and profuse runny nose with very watery and white discharge.
Prescription Prescription SHEN SU YIN Ginseng-Perilla Decoction
Explanation This formula is suitable if there is some Spleen deficiency as well and Phlegm with a profuse nasal discharge.
Prescription REN SHEN BAI DU SAN Ginseng Expelling Poison Powder
MA HUANG FU ZI XI XIN TANG Ephedra-Aconitum-Asarum Decoction
Explanation This formula is suitable if there is severe Kidney-Yang deficiency and internal Cold with profuse white-watery discharge from the nose. It may be used as a unit added to other prescriptions for Yang deficiency. In this case, much smaller doses should be used; for example, reduced by two-thirds.
Prescription ZAI ZAO SAN Renewal Powder
Explanation
Explanation
This prescription is suitable if there is some Spleen deficiency with Phlegm and pronounced stiffness of the muscles of the top of the shoulders and neck.
This formula is for deficiency of Yang of the Spleen, Lungs and Kidneys with a profuse nasal discharge and sweating.
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Prescription
SUMMARY
YI DU YANG YUAN TANG Benefiting the Governing Vessel and Nourishing the Original Qi Decoction
SIMULTANEOUS TREATMENT OF THE MANIFESTATION AND ROOT
Explanation This formula strengthens the Governing Vessel and tonifies the Kidney’s Defensive-Qi system. It has already been discussed above in connection with treatment of the Root of seasonal rhinitis.
Modifications These modifications apply to all the above formulae. • If there is profuse sneezing and nasal discharge, add Fang Feng Radix Saposhnikoviae, Cang Er Zi Fructus Xanthii and Xi Xin Herba Asari. This last herb is used in a small dose such as 1.5 g. • If there is profuse nasal discharge, add Bai Zhi Radix Angelicae dahuricae, Xi Xin Herba Asari and Gan Jiang Rhizoma Zingiberis. • If there are symptoms of Wind-Heat, use Ju Hua Flos Chrysanthemi and Chan Tui Periostracum Cicadae. • If there are headaches, add Ju Hua Flos Chrysanthemi, Ge Gen Radix Puerariae and Man Jing Zi Fructus Viticis. • If there is sweating, use Gui Zhi Tang Ramulus Cinnamomi Decoction. • If there is Spleen deficiency and Phlegm, add Bai Zhu Rhizoma Atractylodis macrocephalae, Fu Ling Poria and Ban Xia Rhizoma Pinelliae preparatum.
Three Treasures remedies In perennial allergic rhinitis, I treat both the Root and the Manifestation simultaneously. To treat the Root, I prescribe Herbal Sentinel (Herbal Sentinel-Yang for those with a tendency to Yang deficiency and Herbal Sentinel-Yin for those with a tendency to Yin deficiency). To treat the Manifestation, I prescribe Jade Screen. Generally speaking, when I use two remedies I ask the patient to take them at different times of the day. Thus, if I was using Herbal Sentinel-Yang I would prescribe that to be taken in the morning and Jade Screen in the afternoon. If I was using Herbal Sentinel-Yin I would prescribe that to be taken in the afternoon and Jade Screen in the morning.
Points BL-13 Feishu, Du-12 Shenzhu, Ren-12 Zhongwan, ST-36 Zusanli, LU-7 Lieque, LU-9 Taiyuan, with reinforcing method, to tonify the Lung’s Defensive-Qi system. L.I.-4 Hegu, L.I.-20 Yingxiang, Bitong, Du-23 Shangxing, with even method, to expel Wind from the nose. All other Kidney and Governing Vessel as indicated above for treatment of the Root of seasonal rhinitis. Herbal therapy Prescription YU PING FENG SAN Jade Wind Screen Powder Prescription SHEN SU YIN Ginseng-Perilla Decoction Prescription REN SHEN BAI DU SAN Ginseng Expelling Poison Powder Prescription JIA JIAN YU ZHU TANG Variation of Polygonatum Decoction Prescription WU JI SAN Five Accumulations Powder Prescription GUI ZHI REN SHEN TANG Ramulus Cinnamomi-Ginseng Decoction Prescription MA HUANG FU ZI XI XIN TANG Ephedra-Aconitum-Asarum Decoction Prescription ZAI ZAO SAN Renewal Powder Prescription YI DU YANG YUAN TANG Benefiting the Governing Vessel and Nourishing the Original Qi Decoction Three Treasures remedies Herbal Sentinel and Jade Screen
Allergic Rhinitis
During the season
Treat Biao with Jade Screen
Outside the season
Treat Ben with Herbal Sentinel
SEASONAL
Treat Biao with Jade Screen and Ben with Herbal Sentinel
PERENNIAL
Figure 6.5 Protocol for treatment of allergic rhinitis with the Three Treasures remedies.
Figure 6.5 summarizes the protocol for the use of the Three Treasures remedies for allergic rhinitis.
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control group were treated with the formula Xiao Qing Long Tang Small Green Dragon Decoction. The results were as shown in the table.
Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 18, No. 8, 1998, p. 453 Chen Yong Hong, “Clinical study on bleeding therapy for 31 cases of allergic rhinitis.” This study compared the effect of bleeding therapy on serum IgE in patients with allergic rhinitis compared with a control group taking Chinese herbal medicine, a placebo control group and a healthy control group. The bleeding therapy was applied to L.I.-20 Yinxiang, Bitong, Yintang, L.I.-4 Hegu and L.I.-11 Quchi. Results showed that bleeding of the acupuncture points reduced serum IgE levels.
MODERN CHINESE LITERATURE Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 18, No. 8, 1998, p. 477.
Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 18, No. 9, 1998, p. 533.
Wang Jia Tai, “Clinical observation on the treatment of 152 cases of allergic rhinitis with the application of herbal paste on acupuncture points.”
Wei Xia Ri, “Treatment of 36 cases of perennial allergic rhinitis with scarring moxibustion.” Dr Wei treated 51 cases of perennial allergic rhinitis, of which the treatment group of 36 was treated with scarring moxibustion and the control group of 15 was treated with herbal medicine. For the treatment group, he used four groups of points: 1. 2. 3. 4.
Du-14 Dazhui, Du-23 Shangxing, Naohu BL-13 Feishu, BL-20 Pishu Ren-4 Guanyuan, Du-4 Mingmen BL-58 Feiyang, BL-67 Zhiyin.
The points from each group were treated in succession at intervals of 4 days. The patients in the
This study treated 188 patients suffering from allergic rhinitis, 152 in the treatment group and 36 in the control group. The treatment group received acupuncture (with the application of a herbal paste on acupuncture points) and the control group received antihistamine. In the treatment group, there were 66 men and 86 women; the youngest patient was 3 and the oldest 72. The shortest duration of the disease was 1 week and the longest 26 years. Two herbal pastes were used, one for Cold patterns and the other for Heat patterns. The one for Cold
Group
No.
Cure
Marked results
Some results
No results
Moxibustion
36
19 (52.8%)
6 (16.7%)
8 (22.2%)
3 (8.3%)
Control
15
3 (20%)
4 (26.7%)
3 (20%)
5 (33.3%)
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patterns consisted of Bai Jie Zi Semen Sinapis albae, Xi Xin Herba Asari, Yan Hu Suo Rhizoma Corydalis and Rou Gui Cortex Cinnamomi. The paste for the Heat group consisted of Xu Chang Qing, Xin Yi Hua Flos Magnoliae, Cang Er Zi Fructus Xanthii, Chen Xiang Lignum Aquilariae resinatum and Huang Qin Radix Scutellariae. The points to which the paste was applied are in the abdomen, and they are found by drawing an imaginary circle with its centre in the umbilicus and a radius of 5 cm. There are four points at North, South, East and West and four more at North-West, NorthEast, South-East and South-West. The paste was left in place for 24 hours if the skin of the patient showed no allergic reaction; if it showed an allergic reaction, it was left in place for 8 hours. This procedure was carried out once every 10 days for three times in total. Before the application of the paste, the points BL-13 Feishu, BL-15 Xinshu and BL-17 Geshu were needled. The results were as shown in the table.
The authors report that 41 (78.8%) patients showed marked improvement, 9 (17.3%) some improvement and 2 (3.9%) no improvement.
Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu), Vol. 18, No. 12, 1998, p. 739.
Objective
Acupuncture A double-blind, randomized, placebocontrolled trial of acupuncture for the treatment of childhood persistent allergic rhinitis Paediatrics 2004 November, Vol. 5, Issue 114, pp. 1242–1247. Ng DK, Chow PY, Ming SP, Hong SH, Lau S, Tse D, Kwong WK, Wong MF, Wong WH, Fu YM, Kwok KL, Li H, Ho JC Department of Paediatrics, Kwong Wah Hospital, Kowloon, Hong Kong
To compare active acupuncture with sham acupuncture for the treatment of persistent allergic rhinitis among children.
Acupuncture Department of Zhejiang Province Hospital, “Clinical observation on the treatment of 52 cases of allergic rhinitis with acupuncture.”
Method
Fifty-two patients suffering from allergic rhinitis were treated with acupuncture. There were 29 men and 23 women; the youngest patient was 11 and the oldest 59. The main points used were L.I.-20 Yingxiang, Yintang, L.I.-4 Hegu and ST-36 Zusanli. Other points were selected according to patterns. • Wind-Cold: BL-12 Fengmen, G.B.-20 Fengchi • Spleen deficiency: BL-13 Feishu and BL-20 Pishu • Kidney deficiency: BL-23 Shenshu, Du-23 Shangxing
CLINICAL TRIALS
Subjects with persistent allergic rhinitis were recruited from the paediatric outpatient clinic. They were randomized to receive either active acupuncture or sham acupuncture. Main outcome measures included daily rhinitis scores, symptom-free days, visual analogue scale scores for immediate effects of acupuncture, daily relief medication scores, blood eosinophil counts, serum IgE levels, nasal eosinophil counts, patients’ and parents’ preferences for treatment modalities, and adverse effects. Eighty-five patients were recruited from the paediatric outpatient clinic at Kwong Wah Hospital, in Hong Kong. Thirteen patients withdrew before randomization, 35 patients (mean age 11.7 ± 3.2 years)
Group
No.
Marked results
Some results
No results
Percentage
Treatment
152
121 (79.6%)
21 (13.8)
10 (6.6)
93.4%
36
8 (22.2%)
Control
24 (66.7%)
4 (11.1)
88.9%
Allergic Rhinitis
were randomized to receive active acupuncture for 8 weeks, and 37 patients (mean age 11 ± 3.8 years) were randomized to receive sham acupuncture for 8 weeks. Acupuncture was performed twice per week for both groups. Both the assessing paediatricians and the patients were blinded.
Results There were significantly lower daily rhinitis scores and more symptom-free days for the group receiving active acupuncture, during both the treatment and the follow-up periods. The visual analogue scale scores for immediate improvement after acupuncture were also significantly better for the active acupuncture group. There was no significant difference in the following outcome measures between the active and sham acupuncture groups: daily relief medication scores, blood eosinophil counts, serum IgE levels and nasal eosinophil counts, except for the IgE levels before and 2 months after acupuncture in the sham acupuncture group. No severe adverse effects were encountered. Numbness, headache and dizziness were found in both the active and sham acupuncture groups, with no difference in incidence, and the effects were self-limiting.
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Method Cytokine levels were determined before and after treatment in 30 healthy volunteers (group A) and 90 chronic allergic rhinitis patients (group B) with an increased plasma IL-10 level. Group B was then divided into three subgroups: 30 patients treated with real acupuncture (group B1), 30 patients treated with sham acupuncture (group B2) and 30 non-treated patients (group B3).
Results The allergic subjects of group B1, compared with controls, showed a significant reduction of IL-10 after a specific treatment with acupuncture. On the other hand, in those patients treated with sham acupuncture (group B2) as well as in non-treated patients (group B3), the IL-10 values remained high and unchanged. There was a statistically significant change in IL-2 values at 24 hours after real acupuncture (groups A and B1); however, the values remained within normal ranges. The IL-6 did not change after therapy.
Conclusion Acupuncture treatment can reduce plasmatic level of IL-10 in chronic allergic rhinitis.
Conclusion This study showed that active acupuncture was more effective than sham acupuncture in decreasing the symptom scores for persistent allergic rhinitis and increasing the symptom-free days. No serious adverse effect was identified. A large-scale study is required to confirm the safety of acupuncture for children.
Study on cytokines IL-2, IL-6, IL-10 in patients of chronic allergic rhinitis treated with acupuncture Journal of Traditional Chinese Medicine 2002 June, Vol. 22, Issue 2, pp. 104–111. Petti FB, Liguori A, Ippoliti F Paracelso Institute, Body Corporate of Italian Ministry of Health, Chair of Social Medicine, School of Medicine La Sapienza University, Rome, Italy
Objective To observe the plasmatic concentration of interleukin (IL)-6, IL-10 and IL-2 in patients suffering from chronic allergic rhinitis before and after acupuncture therapy.
The effect of acupuncture on allergic rhinitis: a randomized controlled clinical trial American Journal of Chinese Medicine 2004, Vol. 32, Issue 1, pp. 105–115. Magnusson AL, Svensson RE, Leirvik C, Gunnarsson RK Bollebygd’s Primary Health Care Centre, Bollebygd, Sweden
Objective To evaluate the effect of acupuncture on allergic rhinitis.
Method This study compared active versus sham acupuncture in 40 consecutive patients with a history of allergic rhinitis and a positive skin test. Patients were randomized and assessed prior to treatment and then reassessed after 12 months. Improvements in symptoms using visual analogue scales, reduction in skin test reactions and levels of specific IgE were used to compare the effect of treatment.
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Results For one allergen, mugwort, a greater reduction in levels of specific IgE (P = 0.019, 0.039) and skin test reaction (P = 0.004) was seen in the group receiving active acupuncture compared with the group receiving sham acupuncture. However, this finding might be an artefact. No differences in clinical symptoms were seen between active versus sham acupuncture.
acupuncture treatment group. No side effects were observed for both groups.
Conclusion The results indicate that acupuncture is an effective and safe alternative treatment for the management of seasonal allergic rhinitis.
Conclusion
Acupuncture and herbal medicine
The effect of acupuncture on allergic rhinitis should be further evaluated in larger randomized studies.
Acupuncture and Chinese herbal medicine in the treatment of patients with seasonal allergic rhinitis: a randomized-controlled clinical trial
Effect of acupuncture in the treatment of seasonal allergic rhinitis: a randomized controlled clinical trial American Journal of Chinese Medicine 2002, Vol. 30, Issue 1, pp. 1–11. Xue CC, English R, Zhang JJ, Da Costa C, Li CG The Chinese Medicine Unit, RMIT University, Victoria, Australia
Objective
Allergy 2004 September, Vol. 59, Issue 9, pp. 953–960. Brinkhaus B, Hummelsberger J, Kohnen R, Seufert J, Hempen CH, Leonhardy H, Nogel R, Joos S, Hahn E, Schuppan D Department of Medicine I, Friedrich-AlexanderUniversity of Erlangen-Nuremberg, Erlangen, Germany
Objective
To evaluate the efficacy and safety of acupuncture in the treatment of seasonal allergic rhinitis.
The aim of this study was to determine whether traditional Chinese therapy is efficacious in patients suffering from seasonal allergic rhinitis.
Method
Method
A two-phase crossover single-blind clinical trial was adopted. Thirty subjects were randomly assigned to two groups with 17 and 13 subjects, respectively. They were treated with real or sham acupuncture three times per week for 4 consecutive weeks and then a crossover of treatments for a further 4 weeks without a wash-out period. The administration of real acupuncture treatment was guided by a syndrome differentiation according to Chinese medicine theory. Subjects were assessed by various criteria before, during and after the treatments. Outcome measures included subjective symptom scores using a five-point scale, relief medication scores and adverse effect records. Twenty-six subjects completed the study.
Fifty-two patients between the ages of 20 and 58 who had typical symptoms of seasonal allergic rhinitis were assigned randomly and in a blinded fashion to:
Results There was a significant improvement in five-point scale (nasal and non-nasal symptoms) in the real group compared with the sham group. No significant differences were shown in relief medication scores between the real acupuncture treatment group and the sham
• an active treatment group that received a semistandardized treatment of acupuncture and Chinese herbal medicine • a control group that received acupuncture applied to non-acupuncture points in addition to a nonspecific Chinese herbal formula. All patients received acupuncture treatment once per week and the respective Chinese herbal formula as a decoction three times daily for a total of 6 weeks. Assessments were performed before, during, and 1 week after treatment. The change in severity of hay fever symptoms was the primary outcome measured on a visual analogue scale. Each patient received a total of six acupuncture sessions once a week. Chinese herbal medicine was taken three times a day over a period of 6 weeks. The protocol used is shown in the table.
Allergic Rhinitis
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Protocol for study on allergic rhinitis Points
Herbal formula
Every patient
L.I.-4 Hegu, L.I.-20 Yingxiang. G.B.-20 Fengchi, LU-7 Lieque, LIV-3 Taichong
Jing Jie Herba Schizonepetae, Ju Hua Flos Chrysanthemi, Jue Ming Zi Semen Cassiae, Che Qian Zi Semen Plantaginis, Bai Ji Li Fructus Tribuli
Wind-Heat in Lungs
L.I.-11 Quchi
Bo He Herba Menthae haplocalycis, Sang Ye Folium Mori, Fu Ping Herba Spirodelae, Bai Shao Radix Paeoniae alba
Liver-Heat and Liver-Fire
L.I.-11 Quchi, G.B.-37 Guangming, G.B.-42 Diwuhui, T.B.-5 Waiguan
Lian Qiao Fructus Forsythiae, Shan Zhi Zi Fructus Gardeniae, Chi Shao Radix Paeoniae rubra, Sheng Di Huang Radix Rehmanniae
Lung-Yin deficiency
LU-5 Chize
Mai Men Dong Radix Ophiopogonis, Bei Sha Shen Radix Glehniae
Cold in Lungs
BL-12 Fengmen, BL-13 Feishu
Xi Xin Herba Asari, Bai Zhi Radix Angelicae dahuricae
Spleen-Qi deficiency
ST-36 Zusanli, T.B.-6 Zhigou, LU-9 Taiyuan, Yintang
Huang Qi Radix Astragali, Fu Ling Poria, Dang Shen Radix Codonopsis, Bai Zhu Rhizoma Atractylodis macrocephalae, Gan Cao Radix Glycyrrhizae uralensis
Results Compared with patients in the control group, patients in the active treatment group showed a significant after treatment improvement on the visual analogue scale and Rhinitis Quality of Life Questionnaire. Improvement on the Global Assessment of Change Scale was noted in 85% of active treatment group participants versus 40% in the control group. No differences between the two groups could be detected with the Allergic Rhinitis Symptom Questionnaire. Both treatments were well tolerated.
Conclusion The results of this study suggest that traditional Chinese therapy may be an efficacious and safe treatment option for patients with seasonal allergic rhinitis.
Herbal medicine The Chinese herbal formulation Bi Min in management of perennial allergic rhinitis: a randomized, double-blind, placebo-controlled, 12-week clinical trial Annals of Allergy, Asthma and Immunology 2002 May, Vol. 88, Issue 5, pp. 478–487.
Hu G, Walls RS, Bass D, Ramon B, Grayson D, Jones M, Gebski V Department of Medicine, University of Sydney, Australia
Objective The aim of this study was to test the effects of the Chinese herbal formulation Bi Min in patients with moderate to severe perennial allergic rhinitis.
Method In a randomized, double-blind, placebo-controlled clinical trial, 58 patients were randomized to receive either Bi Min capsules (n = 26) or placebo (n = 32) in doses of five capsules twice a day for 12 weeks. Main outcomes were measured by changes in symptom diaries, quality of life scores, patients’ evaluations of improvement on visual analogue scores, and physicians’ overall evaluation. Total serum IgE was measured in all patients without knowledge of which group they were in. After 1 year, a randomized, double-blind, dose– response study was performed with 22 patients who had previously received placebo.
Results The trial outcomes evaluated by four instruments showed a statistically significant improvement in some
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of the symptoms of allergic rhinitis, whereas others exhibited a positive trend that did not reach statistical significance. A follow-up 1 year after completion of the trial suggested that the benefit of the treatment persisted. A pilot dose–response study showed both half and full strengths were effective. Total serum IgE was reduced after the herbal treatment.
Conclusion The results suggest that the Bi Min formulation is effective in the treatment of perennial allergic rhinitis. Its mode of action is unknown.
Decreased serum IgE level, decreased IFN-gamma and IL-5 but increased IL-10 production, and suppressed cyclooxygenase 2 mRNA expression in patients with perennial allergic rhinitis after treatment with a new mixed formula of Chinese herbs International Immunopharmacology 2001 June, Vol. 1, Issue 6, pp. 1173–1182. Yang SH, Hong CY, Yu CL Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
Objective
Clinical and experimental study for allergic rhinitis with treatment of Bi Min Kang mixture Chinese Journal of Integrated Traditional and Western Medicine 1997 February, Vol. 17, Issue 2, pp. 70–72. Bao L, Sun QW, Hu L
Objective To observe the efficacy of Bi Min Kang in treating allergic rhinitis.
Method One hundred and sixty-four cases of allergic rhinitis were treated with the Chinese medicine Bi Min Kang mixture, mainly consisting of the Kazak folk herb Artemisia rupestris L. Fifty-two cases of allergic rhinitis were treated as the control with the patent medicine Bi Yan Kang.
Results The total effective rates in both groups were 93.9% and 69.2%, respectively. After stopping the medications, the recurrence rates were 46.8% and 87.1%. Bi Min Kang was better than Bi Yan Kang in short or long term of effectiveness. Pharmacological study demonstrated that Bi Min Kang played a significant role in resisting histamine, inhibiting allergic reaction type 1 and stabilizing the cell membrane of mastocytes.
Conclusion Bi Min Kang mixture is an effective drug in treating allergic rhinitis.
To evaluate the effects of Chinese herbs on patients with perennial allergic rhinitis.
Method A new mixed formula of Chinese herbs containing Xin Yi San (Magnolia Powder) plus Xiao Qing Long Tang (Small Green Dragon Decoction) plus Xiang Sha Liu Jun Zi Tang (Aucklandia-Amomum Six Gentlemen Decoction) by the weight of 9 plus 3 plus 3 g/day was prescribed for the treatment of patients with perennial allergic rhinitis for 3 months. The patients were classified into high and low IgE groups according to the titre of serum total IgE (> 200 KIU/L in high IgE versus < 200 KIU/L in low IgE) and the presence of house dust mite-specific IgE.
Results The nasal symptomatic score in the high IgE group was significantly improved from 7.19 ± 0.18 before treatment to 2.67 ± 0.37 after treatment. In addition, the serum total and house dust mite-specific IgE levels were also decreased after treatment. For elucidating the working mechanism of the mixed formula, the TH1 (interferon-g) and TH2 (IL-4, IL-5, IL-10 and IL-13) cytokine production by phytohemagglutinin-stimulated mononuclear cells (2 μ 106 cells/mL) and cyclooxygenase type 2 (COX-2) mRNA expression in LPS or IL-13-stimulated PMN were compared before and after 3 months of treatment. It was found that the mixed formula treatment significantly enhanced IL-10 but decreased interferon-g and IL-5 production by phytohemagglutinin-stimulated mononuclear cells. The IL-5 production was also decreased by phytohemagglutinin-stimulated lymphocyte. In addition,
Allergic Rhinitis
the COX-2 mRNA expression in stimulated PMN was significantly suppressed after treatment.
Conclusion These results suggest that the new mixed formula treatment is beneficial to the patients with perennial allergic rhinitis via modulating the function of lymphocytes and neutrophils.
Treatment for seasonal allergic rhinitis by Chinese herbal medicine: a randomized placebo controlled trial Alternative Therapies Health Medicine 2003 September– October, Vol. 9, Issue 5, pp. 80–87. Xue CC, Thien FC, Zhang JJ, Da Costa C, Li CG RMIT Chinese Medicine Research Group, RMIT University, Bundoora West Campus, Bundoora, Australia
Objective To evaluate the efficacy of a Chinese herbal formulation for the treatment of seasonal allergic rhinitis.
Method A randomized, double-blind, placebo-controlled trial was adopted at RMIT Chinese Medicine Clinic. Fiftyfive patients with seasonal allergic rhinitis took part (active 28, placebo 27). A Chinese herbal medicine extract capsule containing 18 herbs or a placebo was given daily for 8 weeks. The primary measure of efficacy was a change in the severity of nasal and nonnasal symptoms using a five-point scale measured by both patients and the practitioner. The secondary measure was the change in score for the domains measured in the Rhinoconjunctivitis and Rhinitis Quality of Life Questionnaire (RRQLQ) assessed by patients.
Results Forty-nine patients completed the study (active 24, placebo 25). After 8 weeks, the severity of nasal symptoms and non-nasal symptoms was significantly less in the active treatment group than in the control group, for both measurements made by patients and those by the practitioner. Comparison of active and placebo treatment groups RRQLQ scores also indicated significant beneficial effects of treatment. Intention to treat analyses of categorical items showed that moderate to marked improvement rates were 60.7%
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and 29.6% for active and placebo groups, respectively. Eleven patients reported mild adverse events, including one withdrawal from the trial.
Conclusion This Chinese herbal medicine formulation appears to offer symptomatic relief and improvement of quality of life for some patients with seasonal allergic rhinitis.
CASE HISTORIES Case history A 33-year-old woman had been suffering from allergic rhinitis since the age of 18. She sneezed and her nose ran (white-watery discharge) when exposed to dust, cats and dogs. She also sneezed and “came out in blotches” on drinking tea, coffee, wine, spirits or eating certain foods (such as cheese, butter, chocolate, fats and spices). She suffered from frequent urination, and her need to urinate sometimes became urgent. She described it as “cystitis”, but there was no burning and the urine was pale. This symptom had started only a few months previously. She had also been suffering from backache for the previous 6 years. Her pulse was Weak and Deep, and both Rear positions were Weak. Her tongue was Pale and slightly bluish, with teeth marks and a yellow coating on the root. Diagnosis Perennial rhinitis from deficiency of Lung and Kidney’s Defensive-Qi systems, particularly Kidneys and specifically Kidney-Yang (hence the backache, frequent-urgent urination and Pale-Bluish tongue). The fact that she also sneezed on eating certain foods indicates that there was some Heat in the Large Intestine (hence the yellow tongue coating on the root). She obviously had a Lung and Kidney’s DefensiveQi systems deficiency from birth; the backache and frequent urination appeared later with the physiological decline of Kidney-Qi. Treatment Because this is perennial rhinitis, one must treat both Root and Manifestation simultaneously with a formula that tonifies Kidney-Yang. However,
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this patient was treated primarily with acupuncture using: • LU-7 Lieque and KI-6 Zhaohai to open the Directing Vessel and tonify Lungs and Kidneys • ST-36 Zusanli and SP-6 Sanyinjiao to tonify Qi in general • BL-23 Shenshu, KI-7 Fuliu, Ren-4 Guanyuan and KI-16 Huangshu to tonify Kidney-Yang and the Kidney-Essence • BL-13 Feishu and Du-12 Shenzhu to tonify the Lung’s Defensive-Qi system • SP-9 Yinlingquan and BL-25 Dachangshu to clear Large Intestine-Heat • Du-23 Shangxing and L.I.-20 Yingxiang to expel Wind from the nose. Additionally, she was given the patent remedy Quan Lu Wan Whole-Deer Pill. The combination of acupuncture and this patent remedy produced a complete cure of her condition.
• • • • • • •
Bu Gu Zhi Fructus Psoralelae 6 g Lu Jiao Jiao Gelatinum Cornu Cervi 4 g Wu Wei Zi Fructus Schisandrae 3 g Zhi Mu Radix Anemarrhenae 3 g Fang Feng Radix Saposhnikoviae 4 g Chan Tui Periostracum Cicadae 4 g Bai Xian Pi Cortex Dictamni 6 g
Explanation • Gui Ban and Shu Di Huang nourish the KidneyEssence and strengthen the Directing Vessel. • Bu Gu Zhi and Lu Jiao Jiao tonify the Kidney’s Defensive-Qi system and strengthen the Governing Vessel. • Wu Wei Zi tonifies the Lung’s Defensive-Qi system. • Zhi Mu clears Heat. • Fang Feng, Chan Tui and Bai Xian Pi clear WindHeat from the skin. This formula and subsequent variations produced a considerable improvement over 6 months.
Case history
Case history
A 25-year-old woman had been suffering from hay fever (seasonal allergic rhinitis) for as long as she could remember. During the summer season, she sneezed and had itchy eyes and throat. She also suffered from eczema at the sides of her nose and on her chin. The eruptions were papulelike (red spots) at first, and they then turned dry and flaky some weeks later. The spots were red and itchy and worse with exposure to the sun. Her pulse was only slightly Weak, and the left Rear position was weaker. Her tongue had a normal colour with a slightly sticky coating.
A 44-year-old man had suffered from seasonal rhinitis since the age of 22. The main manifestations were sneezing, sensitive eyes and a runny nose with a white-watery discharge (except in the morning, when it was thick-yellow). His pulse was only slightly Weak, and the left Rear position was weaker. His tongue was Pale and Swollen.
Diagnosis Seasonal rhinitis from deficiency of Lung and Kidney’s Defensive-Qi systems. Eczema from same cause. Treatment The aim of the treatment is to tonify Lung and Kidney’s Defensive-Qi systems and clear WindHeat from the Lung’s Defensive-Qi system (skin). The formula chosen was a variation of Yi Du Yang Yuan Tang Benefiting the Governing Vessel and Nourishing the Original Qi Decoction. • Gui Ban Plastrium Testudinis 15 g • Shu Di Huang Radix Rehmanniae preparata 9 g
Diagnosis Seasonal rhinitis from Lung and Kidney’s Defensive-Qi systems deficiency. The Pale and Swollen tongue also indicates a deficiency of Spleen-Yang, which often occurs in such cases after 40. The stickyyellow mucus in the mornings indicates that the sinuses have been affected due to swelling of the nasal mucosa preventing proper drainage. Treatment The main aim (outside the season) is to tonify Lung and Kidney’s Defensive-Qi systems and Spleen-Yang. The formula used was a variation of Yi Du Yang Yuan Tang Benefiting the Governing Vessel and Nourishing the Original Qi Decoction. • Gui Ban Plastrium Testudinis 15 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Bu Gu Zhi Fructus Psoralelae 6 g
Allergic Rhinitis
• • • • • • •
Lu Jiao Cornu Cervi 9 g Wu Wei Zi Fructus Schisandrae 3 g Zhi Mu Radix Anemarrhenae 3 g Huang Qi Radix Astragali 9 g Fang Feng Radix Saposhnikoviae 4 g Bai Zhu Rhizoma Atractylodis macrocephalae 6 g Fu Ling Poria 6 g
Explanation • Gui Ban and Shu Di Huang nourish the KidneyEssence. • Bu Gu Zhi and Lu Jiao tonify the Kidney’s DefensiveQi system and strengthen the Governing Vessel. • Wu Wei Zi and Huang Qi tonify the Lung’s DefensiveQi system. • Zhi Mu clears Heat. • Fang Feng expels Wind from the nose. • Bai Zhu and Fu Ling tonify the Spleen and drain Dampness. This formula produced an improvement after a short time. The patient is still under treatment.
Case history A 37-year-old woman had been suffering from seasonal allergic rhinitis (hay fever) for 11 years. The problem started after the birth of her first child. She was Chinese and came to England from Singapore 3 years before the birth of her fist child. She had a second child 2 years after the first, and the allergic rhinitis was better during the pregnancy. Her symptoms were the usual ones: sneezing, runny nose with watery nasal discharge, itchy eyes. She was also occasionally slightly wheezy. She also suffered from lower backache and tinnitus. Her tongue was Pale, Swollen and with a sticky coating. Her pulse was Soggy, i.e. Weak but slightly Slippery. It was particularly Weak on the Kidney positions. Diagnosis As explained above, I relate the Root of allergic rhinitis to a deficiency of the Lung and Kidney’s
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Defensive-Qi systems. Her symptoms of Kidney-Yang deficiency were the lower backache, the tinnitus, the Pale tongue and the Weak pulse. The onset of the allergic rhinitis after childbirth is also related to a Kidney deficiency; the fact that the rhinitis got better during the second pregnancy also confirms this. I think that the Kidneys can become not only weaker during a pregnancy but also stronger, therefore I relate both an aggravation or an amelioration of a symptom during pregnancy to a Kidney deficiency. In her case, however, the allergic rhinitis has a slightly different and more complex pathology than the one outlined in this chapter. Her tongue and pulse also show a Spleen deficiency and Phlegm; the Phlegm plays a role in the pathology of allergic rhinitis in her case. I think that the change in diet from a Chinese to a Western diet when she moved from Singapore to England contributed to the formation of Phlegm. I report this case history mostly for its interesting aspect of the onset of allergic rhinitis after childbirth and amelioration during pregnancy. It is far too early to report any reaction, as the treatment was only just started at the time of writing.
END NOTES 1. Guangzhou Army Health Department 1974 Xin Bian Zhong Yi Xue Gai Yao [A New General Outline of Chinese Medicine]. People’s Health Publishing House, Beijing, p. 676. 2. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 150. First published c.100 BC. 3. Ibid., p. 355. 4. Wang Luo Zhen 1985 Qi Jing Ba Mai Kao Jiao Zhu [A Compilation of the Study of the Eight Extraordinary Vessels]. Shanghai Science Publishing House, Shanghai, p. 89. The Study of the Eight Extraordinary Vessels was written by Li Shi Zhen and first published in 1578. 5. Another interesting connection between the Kidneys and rhinitis could be observed in the use by some Chinese doctors of injection of cortisone in the point BL-12 Fengmen with far fewer side effects than in a systemic administration of cortisone. If we view cortisone as a kind of “Kidney tonic”, it would make sense to inject it in the point BL-12, which expels Wind and spreads Defensive Qi in the Exterior. 6. A Compilation of the Study of the Eight Extraordinary Vessels, p. 89.
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CHAPTER 7
SINUSITIS (NASAL POLYPS)
SINUSITIS 202 AETIOLOGY AND PATHOLOGY Repeated invasions of Wind Diet 203
202 202
IDENTIFICATION OF PATTERNS AND TREATMENT Wind-Heat 205 Lung-Heat 205 Liver- and Gall Bladder-Fire 206 Stomach and Spleen Damp Heat 207 Qi and Blood stagnation 207 Lung- and Spleen-Qi deficiency 208 Liver- and Kidney-Yin deficiency 209 MODERN CHINESE LITERATURE
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210
CLINICAL TRIALS 210 Acupuncture 210 PROGNOSIS
211
NASAL POLYPS 211 CHINESE MEDICINE TREATMENT 211 Lung-Heat with stagnation 212 Damp Phlegm with stasis 212 Lung- and Spleen-Qi deficiency with Damp Phlegm 213
NASAL POLYPS • Lung-Heat with stagnation • Damp Phlegm with stasis • Lung- and Spleen-Qi deficiency with Damp Phlegm
SINUSITIS (NASAL POLYPS) The sinuses are mucosa-lined cavities in the skull communicating with the nasal cavities. There are four pairs of sinuses, i.e. the ethmoidal, frontal, maxillary and sphenoidal sinuses. The frontal and maxillary sinuses, especially the latter ones, are more prone to infection and inflammation. Figures 7.1 and 7.2 show the location of frontal and maxillary sinuses in relation to nasal cavities, while Figure 7.3 shows for clinical examination the areas overlying such sinuses. The condition of sinusitis broadly corresponds to the old Chinese medical category of Bi Yuan, which literally means “nose pool”. As we have seen in the chapter on allergic rhinitis, the differentiation and treatment of Bi Yuan are often used to diagnose and
SINUSITIS Full • Wind-Heat • Lung-Heat • Liver- and Gall Bladder-Fire • Stomach and Spleen Damp Heat • Qi and Blood stagnation
Frontal sinus Sphenoidal sinus Bony position of nasal septum
Empty • Lung- and Spleen-Qi deficiency • Liver- and Kidney-Yin deficiency
Hard palate Figure 7.1 Frontal and sphenoidal sinuses.
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Orbit Nasal cavity Maxillary sinus
Figure 7.2 Maxillary sinuses (cross-section, anterior view).
Frontal sinus
Maxillary sinus
and into the palate by the pituitary gland; but I shall prove that the structure of these parts is such that neither is possible. It is interesting to note that, when seen from the viewpoint of Chinese medicine, the assumption that nasal discharges originate from the brain is obviously anatomically wrong but physiologically possible, because the Gall Bladder channel flows through the brain. In Chinese medicine, Heat in the brain affects the Governing Vessel and flows down to the nose and sinuses. The main symptoms of sinusitis are a purulent, yellow nasal discharge from the front and the back of the nose (into the throat), a stuffy nose, a frontal headache, facial pain and a feeling of muzziness (fuzziness) and heaviness of the head. There may be local tenderness over the maxillary or frontal sinuses. The discussion of sinusitis will be done according to the following topics. Sinusitis • Aetiology and pathology • Identification of patterns and treatment • Modern Chinese literature • Clinical trials • Prognosis Nasal polyps • Chinese medicine treatment
Figure 7.3 Location of frontal and maxillary sinuses.
SINUSITIS treat allergic rhinitis, which is a mistake, because Bi Yuan corresponds more closely to sinusitis. Bi Yuan is sometimes also called Nao Lou, which means “brain discharge”, because the profuse and purulent discharge from the nose was considered to come from the brain. Interestingly, Hippocrates and his disciples also thought that the evil humour (of sinusitis) arose in the brain and from there descended into the nasal cavities.1 It was not until 1672 that Richard Lower demonstrated in his book De Catarrhis that it was anatomically impossible for respiratory catarrh to originate in the brain:2 Since the opinion has generally persisted amongst learned doctors everywhere that catarrh ... comes from the cerebrum I shall ... attempt to prove the contrary. People claim that the fluid collected in the ventricles of the brain oozes down into the nostrils solely by the cribriform plate,
AETIOLOGY AND PATHOLOGY Repeated invasions of Wind Repeated invasions of external Wind, whether WindHeat or Wind-Cold (but more frequently Wind-Heat), impair the diffusing and descending of Lung-Qi in the nasal passages so that fluids stagnate in the nose and sinuses. The long-term stagnation of fluids leads to Phlegm and Heat, which manifest with a yellow, purulent nasal discharge. Repeated invasions of external Wind are the main cause of sinusitis, especially when the person does not take care or have extra rest during such invasions. From a Western medical perspective, infections from the common cold or influenza viruses frequently cause secondary infections in the sinuses, especially the
Sinusitis (Nasal Polyps)
maxillary sinuses. For anatomical reasons, sinus infection is liable to become chronic. In fact, the openings through which the maxillary sinuses communicate with the nasal cavities are narrow, and inflammatory oedema of the mucosa lining them often prevents adequate drainage of the infected sinuses. As a result, resolution of sinus infection is often slow and incomplete so that, when the next viral infection from the common cold or influenza occurs, the already infected and inflamed sinuses will be affected again. Thus, repeated infections by the common cold or influenza viruses will lead to chronic sinusitis.
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nasal passages so that fluids stagnate in the nose and sinuses. Infections from the common cold or influenza viruses frequently cause secondary infections in the sinuses, especially the maxillary sinuses. Repeated infections by the common cold or influenza viruses will lead to chronic sinusitis. Diet Excessive consumption of greasy-hot foods leading to Phlegm and Heat.
Diet Excessive consumption of greasy-hot foods leading to Phlegm and Heat may predispose one to sinusitis. This type of food may lead to the formation of Damp Heat in the Stomach and Spleen, which may be carried upwards to the sinuses via the Stomach channel. However, this can be only a predisposing factor in the development of sinusitis, the repeated invasions of Wind being the necessary condition. It is important to understand clearly the difference between the clinical manifestations of allergic rhinitis and of sinusitis. In allergic rhinitis, the nasal discharge is clear, runny and profuse. In sinusitis, the nasal discharge is thick, sticky and yellow. CLINICAL NOTE In allergic rhinitis, the nasal discharge is clear, runny and profuse. In sinusitis, the nasal discharge is thick, sticky and yellow. In some cases, the congestion of the nasal mucosa that occurs in allergic rhinitis may prevent proper drainage from the sinuses and lead to a secondary sinusitis. If the patient has a clear history of reaction to allergens (sneezing and runny nose) and the nasal discharge is sometimes clear and runny and sometimes thick and yellow, we know that the sinusitis is secondary to allergic rhinitis.
SUMMARY AETIOLOGY AND PATHOLOGY Repeated invasions of Wind Repeated invasions of external Wind impair the diffusing and descending of Lung-Qi in the
IDENTIFICATION OF PATTERNS AND TREATMENT The patterns discussed will be: • • • • • • •
Wind-Heat Lung-Heat Liver- and Gall Bladder-Fire Stomach and Spleen Damp Heat Qi and Blood stagnation Lung- and Spleen-Qi deficiency Liver- and Kidney-Yin deficiency
It should be remembered that all the above patterns are of the Excess type, and the formulae used are aimed at expelling pathogenic factors. However, in chronic cases, there is always an underlying deficiency, especially of the Spleen, which needs to be addressed. In such cases, all the formulae indicated below need to be modified with the addition of Spleen-Qi tonic herbs such as Bai Zhu Rhizoma Atractylodis macrocephalae, Dang Shen Radix Codonopsis or Huang Qi Radix Astragali. With acupuncture, the points indicated below will have to be integrated by the addition of points to tonify the Spleen such as ST-36 Zusanli and BL-20 Pishu. The above patterns should be clearly classified according to Full-Empty and Acute-Chronic conditions. The Empty patterns appear only in chronic conditions, while some of the Full patterns may appear in acute or chronic conditions. The classification of the above patterns according to Full and Empty is as follows. Full • Wind-Heat • Lung-Heat • Liver- and Gall Bladder-Fire
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• Stomach and Spleen Damp Heat • Qi and Blood stagnation
Table 7.1 Full-Empty and Acute-Chronic classification of sinusitis patterns
Empty • Lung- and Spleen-Qi deficiency • Liver- and Kidney-Yin deficiency The classification of the above patterns according to Acute and Chronic is as follows (Fig. 7.4 and Table 7.1). Acute • Wind-Heat • Lung-Heat • Liver- and Gall Bladder-Fire • Stomach and Spleen Damp Heat
Full
Empty
Acute
Wind-Heat Lung-Heat Liver- and Gall BladderFire Stomach and Spleen Damp Heat
–
Chronic
Lung-Heat Liver- and Gall BladderFire Stomach and Spleen Damp Heat Qi and Blood stagnation
Lung- and Spleen-Qi deficiency Liver- and Kidney-Yin deficiency
Chronic • Lung- and Spleen-Qi deficiency • Liver- and Kidney-Yin deficiency • Qi and Blood stagnation
the same name. The main herb to use from this category is Shi Chang Pu Rhizoma Acori tatarinowii. However, there are herbs from other categories that also open the nose and sinus orifices and these are:
Both acute and chronic • Lung-Heat • Liver- and Gall Bladder-Fire • Stomach and Spleen Damp Heat As for treatment, although not “officially” one of the four orifices of the face, the sinuses should be considered like an “orifice” (assimilated to those of the nose). In sinusitis, there is always an obstruction of the orifices of the nose and sinuses. The implication of this in treatment is that we should use the method of “opening the orifices” by using some herbs from the category with
• • • • •
Bai Zhi Radix Angelicae dahuricae Xin Yi Hua Flos Magnoliae Cang Er Zi Fructus Xanthii Xi Xin Herba Asari Cong Bai Bulbus Allii fistulosi.
As for acupuncture points, the main points that act on the sinuses are as follows (Fig. 7.5).
ST-8 FULL Acute
EMPTY
Du-23
WIND-HEAT BL-2 LUNG-HEAT
Acute or chronic
LIVER- AND GALL BLADDER-FIRE STOMACH AND SPLEEN DAMP HEAT
Chronic
QI AND BLOOD STAGNATION
Yintang
Ethmoid sinus
Bitong L.I.-20
Maxillary sinus
LUNG- AND SPLEENQI DEFICIENCY LIVER- AND KIDNEYYIN DEFICIENCY
Figure 7.4 Full-Empty and Acute-Chronic classification of sinusitis patterns.
Frontal sinus
Distal points: LU-7, L.I.-4, ST-44 Figure 7.5 Points for sinusitis.
Sinusitis (Nasal Polyps)
Local • ST-8 Touwei • Du-23 Shangxing • BL-2 Zanzhu • Yintang • Bitong • L.I.-20 Yingxiang Distal • LU-7 Lieque • L.I.-4 Hegu • ST-44 Neiting
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Explanation This formula expels Wind-Heat, opens the nasal orifice, separates turbid from clear and restores the descending of Lung-Qi.
Prescription EMPIRICAL PRESCRIPTION (No. 2)
Explanation This formula has a stronger effect than the previous one in clearing Damp Heat and Toxic Heat and is therefore used when there is a profuse sticky-yellow or purulent nasal discharge.
Wind-Heat Clinical manifestations
SUMMARY
Stuffed nose, yellow-sticky or purulent nasal discharge, headache, diminished sense of smell, aversion to cold and fever. Tongue: Red sides and/or front. Pulse: Floating-Rapid. This corresponds to an acute attack of sinusitis following an invasion of Wind-Heat.
WIND-HEAT Points L.I.-11 Quchi, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Bitong, Du-23 Shangxing, BL-12 Fengmen. Reducing method.
Treatment principle
Herbal therapy Prescription EMPIRICAL PRESCRIPTION (No. 1)
Release the Exterior, expel Wind-Heat and restore the dispersing and descending of Lung-Qi.
Prescription EMPIRICAL PRESCRIPTION (No. 2)
Acupuncture Points L.I.-11 Quchi, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Bitong, Du-23 Shangxing, BL-12 Fengmen. Reducing method.
Explanation • L.I.-11 expels Wind-Heat and clears Heat. • L.I.-4 expels Wind-Heat and clears the nose. • L.I.-20, BL-2 and Bitong (extra point) expel Wind and clear the nose and sinuses. • Du-23 opens the nose and expels Wind. It should be needled horizontally forwards. • BL-12, with cupping, expels Wind.
Herbal therapy Prescription EMPIRICAL PRESCRIPTION (No. 1)
Lung-Heat Clinical manifestations Sticky-yellow or purulent nasal discharge, tenderness over maxillary sinuses, flushed face, feeling of heat, thirst, headache. Tongue: Red with sticky-yellow coating. Pulse: Slippery and Full, although possibly only on the right Front position. This is a condition of chronic sinusitis when repeated invasions of Wind-Heat have impaired the diffusing and descending function of the Lungs so that fluids stagnate in the sinuses and give rise to PhlegmHeat.
Treatment principle Restore the diffusing and descending of Lung-Qi, clear Lung-Heat.
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Acupuncture Points L.I.-11 Quchi, L.I.-4 Hegu, LU-10 Yuji, LU-7 Lieque, L.I.-20 Yingxiang, BL-2 Zanzhu, Bitong, Du-14 Dazhui. Reducing method.
Explanation • • • •
L.I.-11 clears Heat. L.I.-4 opens the nose. LU-10 clears Lung-Heat and opens the nose. LU-7 restores the dispersing and descending of Lung-Qi. • L.I.-20, BL-2 and Bitong open the nose and expel Wind. • Du-14 is added if the symptoms of Heat are pronounced.
Herbal therapy Prescription XIN YI QING FEI YIN Magnolia Clearing the Lungs Decoction
Explanation This formula clears Lung-Heat and resolves Toxic Heat.
SUMMARY LUNG-HEAT Points L.I.-11 Quchi, L.I.-4 Hegu, LU-10 Yuji, LU-7 Lieque, L.I.-20 Yingxiang, BL-2 Zanzhu, Bitong, Du-14 Dazhui. Reducing method. Herbal therapy Prescription XIN YI QING FEI YIN Magnolia Clearing the Lungs Decoction
This condition is due to Liver- and Gall Bladder-Fire rising to the nose and the brain. Fire condenses the fluids in the nose and leads to Phlegm-Heat. The Gall Bladder channel flows through the brain, and Gall Bladder-Fire causes what is considered to be a discharge of purulent fluid from the brain. Although this pattern is always mentioned in Chinese books, in my experience, it is not a common cause of sinusitis.
Treatment principle Drain Liver- and Gall Bladder-Fire, restore the descending of Lung-Qi.
Acupuncture Points LIV-2 Xingjian, G.B.-43 Xiaxi, LU-7 Lieque, L.I.-4 Hegu, Bitong, BL-2 Zanzhu, G.B.-15 Toulinqi. Reducing method.
Explanation • • • • • •
LIV-2 drains Liver-Fire. G.B.-43 drains Gall Bladder-Fire. LU-7 restores the descending of Lung-Qi. L.I.-4 and Bitong open the nose and the sinuses. BL-2 opens the frontal sinuses. G.B.-15 is a local point to clear the Gall Bladder channel. It affects the eyes and the sinuses.
Herbal therapy Prescription QING GAN TOU DING TANG Clearing the Liver and Penetrating the Crown (of the head) Decoction
Explanation This formula subdues Liver-Yang, drains Liver-Fire and cools Blood.
Liver- and Gall Bladder-Fire
Prescription
Clinical manifestations
LONG DAN BI YUAN FANG Gentiana “Nose Pool” Formula
Yellow-purulent nasal discharge, bloodshot eyes, red face, headache on temples and cheeks, dizziness, a bitter taste, dry stools, irritability. Tongue: Red with redder sides, sticky-yellow coating. Pulse: Wiry, Slippery and Rapid.
Explanation This formula drains Liver-Fire, resolves Toxic Heat and opens the sinuses.
Sinusitis (Nasal Polyps)
SUMMARY LIVER- AND GALL BLADDER-FIRE Points LIV-2 Xingjian, G.B.-43 Xiaxi, LU-7 Lieque, L.I.-4 Hegu, Bitong, BL-2 Zanzhu, G.B.-15 Toulinqi. Reducing method. Herbal therapy Prescription QING GAN TOU DING TANG Clearing the Liver and Penetrating the Crown (of the head) Decoction Prescription LONG DAN BI YUAN FANG Gentiana “Nose Pool” Formula
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• Ren-13 harmonizes the Stomach and regulates the Upper Burner. • Bitong and BL-2 open the nose and the sinuses.
Herbal therapy Prescription CANG ER BI DOU YAN FANG Xanthium Sinusitis Formula
Explanation This formula resolves Dampness, clears Heat, harmonizes the Stomach and opens the sinuses. It is specific to treat sinusitis.
Modifications • If there is Stomach-Fire with constipation or dry stools, add Da Huang Rhizoma Rhei.
Stomach and Spleen Damp Heat Clinical manifestations Sticky-yellow nasal discharge, red cheeks, thirst, dry lips, impaired sense of smell, a feeling of heaviness and muzziness of the head, a frontal headache, a sticky taste, a feeling of oppression of the chest and epigastrium. Tongue: sticky-yellow coating in the centre. Pulse: Slippery. This pattern is a common cause of chronic sinusitis. It is common also in children.
Treatment principle Clear Heat, resolve Dampness, harmonize the Stomach, tonify the Spleen.
Acupuncture Points Ren-12 Zhongwan, BL-20 Pishu, Ren-9 Shuifen, SP-9 Yinlingquan, BL-22 Sanjiaoshu, L.I.-11 Quchi, L.I.-4 Hegu, Ren-13 Shangwan, Bitong, BL-2 Zanzhu. Even method, except on the first two points, which should be reinforced.
Explanation • Ren-12 and BL-20 tonify the Spleen to resolve Dampness. • Ren-9, SP-9 and BL-22 resolve Dampness. • L.I.-11 resolves Damp Heat. • L.I.-4 opens the nose and harmonizes the Stomach.
Three Treasures remedy Welcome Fragrance Welcome Fragrance is a variation of the above formula, and it resolves Dampness and clears Heat from the sinuses. It is specific for acute or chronic sinusitis.
SUMMARY STOMACH AND SPLEEN DAMP HEAT Points Ren-12 Zhongwan, BL-20 Pishu, Ren-9 Shuifen, SP-9 Yinlingquan, BL-22 Sanjiaoshu, L.I.-11 Quchi, L.I.-4 Hegu, Ren-13 Shangwan, Bitong, BL-2 Zanzhu. Even method, except on the first two points, which should be reinforced. Herbal therapy Prescription CANG ER BI DOU YAN FANG Xanthium Sinusitis Formula Three Treasures remedy Welcome Fragrance
Qi and Blood stagnation Clinical manifestations Sticky, white or yellow nasal discharge, headache, facial pain that may be worse at night, nasal mucosa inflamed and hypertrophied, polyps.
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Tongue: Purple. Pulse: Wiry or Firm. This pattern is seen in sinusitis only in very chronic conditions in middle-aged people.
Treatment principle Invigorate Blood, eliminate stasis, move Qi.
Acupuncture
LIV-3 Taichong, SP-10 Xuehai. All with even method. Herbal therapy Prescription TONG QIAO HUO XUE TANG plus CANG ER ZI SAN Opening the Orifices and Invigorating Blood Decoction plus Xanthium Powder
Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, P-6 Neiguan, LIV-3 Taichong, SP-10 Xuehai. All with even method.
Explanation • LU-7 and L.I.-4 regulate the ascending and descending of Qi in the head and therefore help to open the orifices. • L.I.-20, BL-2 and Yintang are local points to open the sinuses and relieve inflammation. • ST-8 is a local point to open the orifices of the head. • P-6 invigorates Blood and eliminates stasis in the Upper Burner. • LIV-3 and SP-10 invigorate Blood and eliminate stasis.
Herbal therapy
Lung- and Spleen-Qi deficiency Clinical manifestations White-sticky nasal discharge without smell, stuffy nose, diminished sense of smell, feeling of heaviness of the head, facial pain, inflamed and hypertrophied nasal mucosa, polyps, tiredness, poor appetite, loose stools, weak voice, propensity to catching colds. Tongue: Pale. Pulse: Weak.
Treatment principle Tonify Lung- and Spleen-Qi, resolve Dampness, open the sinuses.
Prescription TONG QIAO HUO XUE TANG plus CANG ER ZI SAN Opening the Orifices and Invigorating Blood Decoction plus Xanthium Powder
Explanation These two formulae together invigorate Blood, eliminate stasis and open the orifices specifically from the head and therefore also the sinuses. Please note that the first formula contains She Xiang Moschus, which should be omitted (as its use is illegal) and replaced with Shi Chang Pu Rhizoma Acori tatarinowii.
SUMMARY QI AND BLOOD STAGNATION Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, P-6 Neiguan,
Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-13 Feishu. The first six points with even method, the rest with reinforcing method.
Explanation • LU-7 and L.I.-4 regulate the ascending and descending of Qi in the head and therefore help to open the orifices. • L.I.-20, BL-2 and Yintang are local points to open the sinuses and relieve inflammation. • ST-8 is a local point to open the orifices of the head. • ST-36, SP-6, Ren-12 and BL-20 tonify Spleen-Qi. Ren-12 also tonifies Lung-Qi. • BL-13 tonifies Lung-Qi.
Sinusitis (Nasal Polyps)
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Herbal therapy
Liver- and Kidney-Yin deficiency
Prescription
Clinical manifestations
SHEN LING BAI ZHU SAN Ginseng-Poria-Atractylodes Powder
Runny but scanty nasal discharge, diminished sense of smell, headaches felt inside the skull, dizziness, tinnitus, lower backache, night-sweating, inflamed nasal mucosa but not hypertrophied. Tongue: without coating. Pulse: Floating-Empty.
Explanation This formula tonifies Lung- and Spleen-Qi and resolves Dampness. To treat chronic sinusitis, it should be adapted according to the modifications listed below.
Modifications • Stuffy nose: Bai Zhi Radix Angelicae dahuricae and Xin Yi Hua Flos Magnoliae. • Feeling of heaviness of the head, facial pain: Ge Gen Radix Puerariae and Xi Xin Herba Asari. • Inflamed mucosa: Dang Gui Radix Angelicae sinensis and Chuan Xiong Rhizoma Chuanxiong. • Propensity to catching cold, sinusitis elicited by exposure to wind: Huang Qi Radix Astragali and Fang Feng Radix Saposhnikoviae. • Damp Heat, sticky-yellow nasal discharge: Che Qian Zi Semen Plantaginis and Huang Lian Rhizoma Coptidis.
Three Treasures remedies Central Mansion plus Welcome Fragrance Central Mansion tonifies Lung- and Spleen-Qi and resolves Dampness; it is a variation of Shen Ling Bai Zhu San Ginseng-Poria-Atractylodes Powder. Welcome Fragrance resolves Damp Heat from the sinuses.
SUMMARY LUNG- AND SPLEEN-QI DEFICIENCY Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-13 Feishu. The first six points with even method, the rest with reinforcing method. Herbal therapy Prescription SHEN LING BAI ZHU SAN Ginseng-Poria-Atractylodes Powder Three Treasures remedies Central Mansion plus Welcome Fragrance
Treatment principle Nourish Liver- and Kidney-Yin, open the sinuses.
Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, Ren-4 Guanyuan, SP-6 Sanyinjiao, LIV-8 Ququan, KI-3 Taixi. All with even method, except the last four points, which should be reinforced.
Explanation • LU-7 and L.I.-4 regulate the ascending and descending of Qi in the head and therefore help to open the orifices. • L.I.-20, BL-2 and Yintang are local points to open the sinuses and relieve inflammation. • ST-8 is a local point to open the orifices of the head. • Ren-4, SP-6, LIV-8 and KI-3 nourish Liver- and Kidney-Yin.
Herbal therapy Prescription QI JU DI HUANG WAN Variation Lycium-Chrysanthemum-Rehmannia Pill Variation
Explanation This formula nourishes Liver- and Kidney-Yin and opens the sinuses.
SUMMARY LIVER- AND KIDNEY-YIN DEFICIENCY Points LU-7 Lieque, L.I.-4 Hegu, L.I.-20 Yingxiang, BL-2 Zanzhu, Yintang, ST-8 Touwei, Ren-4 Guanyuan,
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SP-6 Sanyinjiao, LIV-8 Ququan, KI-3 Taixi. All with even method, except the last four points, which should be reinforced. Herbal therapy Prescription QI JU DI HUANG WAN Variation Lycium-Chrysanthemum-Rehmannia Pill Variation
CLINICAL TRIALS Acupuncture Comparison of traditional Chinese acupuncture, minimal acupuncture at non-acupoints and conventional treatment for chronic sinusitis Complementary Therapies in Medicine 2005 March, Vol. 13, Issue 1, pp. 4–10. Rossberg E, Larsson PG, Birkeflet O, Soholt LE, Stavem K Balder-Klinikken, Oslo, Norway
MODERN CHINESE LITERATURE
Objective
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 27, No. 6, 1986, pp. 34–35.
To compare traditional Chinese acupuncture, minimal acupuncture at non-acupoints and conventional treatment for chronic sinusitis.
Tan Hui Zhen, “Clinical analysis of 100 cases of chronic sinusitis treated with Chinese herbs.”
Method
Dr Tan Hui Zhen treated 100 patients suffering from chronic sinusitis; there were 57 men and 43 women. The youngest patient was 12 and the oldest 56. The formula used was as follows. • • • • • • • • • • • • • • •
Pu Gong Ying Herba Taraxaci 12 g Ju Hua Flos Chrysanthemi 12 g Huang Qin Radix Scutellariae 15 g Yu Xing Cao Herba Houttuniae 15 g Bai Jiang Cao Herba Patriniae 15 g Ban Lan Gen Radix Isatis seu Baphicacanthis 10 g Bai Zhi Radix Angelicae dahuricae 15 g Xin Yi Hua Flos Magnoliae 15 g Cang Er Zi Fructus Xanthii 10 g Man Jing Zi Fructus Viticis 10 g Chi Shao Radix Paeoniae rubra 10 g Chuan Xiong Rhizoma Chuanxiong 6 g Jie Geng Radix Platycodi 10 g Gao Ben Rhizoma Ligustici 6 g Gan Cao Radix Glycyrrhizae uralensis 3 g
The treatment principle behind this formula is to resolve Toxic Heat, invigorate Blood and open the nasal and sinosal orifices. The results were as follows. • Good results: 71 cases (71%) • Some results: 23 cases (23%) • No results: 6 cases (6%)
A three-armed, single-blind, randomized controlled study was adopted at an outpatient specialist clinic. Sixty-five patients with symptoms of sinusitis for more than 3 months and signs of sinusitis on computed tomography were recruited. Patients were randomized to one of three trial groups: 1. 2–4 weeks of medication with antibiotics, corticosteroids, 0.9% sodium chloride solution and local decongestants (n = 21) 2. 10 treatments with traditional Chinese acupuncture (n = 25) 3. 10 treatments with minimal acupuncture at nonacupoints (n = 19). Change in sinus soft tissue swelling on computed tomography, symptoms of sinusitis, and health-related quality of life, using the two component summary scales of the Short Form-36 and a rating scale, were observed.
Results In the conventional treatment group, sinus soft tissue swelling was reduced over 4 weeks and health-related quality of life improved over 12 weeks. Pairwise comparisons of changes in total symptom score between the groups showed signs of a difference between conventional medication and sham over 4 weeks.
Conclusion Sinus soft tissue swelling was reduced in the conventional treatment group over 4 weeks and health-related
Sinusitis (Nasal Polyps)
quality of life improved over 12 weeks. Only a nonsignificant difference in symptom score change over 4 and 12 weeks was shown between conventional medication and traditional Chinese acupuncture.
The effects of acupuncture on thermal sensitivity and the clinical perception of pain in patients with sinusitis Ear, Nose, and Throat Journal 1988, Vol. 67, Issue 8, pp. 565–566, 571–572. Lundeberg T, Laurell G, Thomas M
Objective This study was carried out to determine the effects of acupuncture on thermal sensitivity and the clinical perception of pain in patients with sinusitis.
Method Thirty-five patients with sinusitis and 12 healthy subjects took part. Patients received acupuncture with manual stimulation, 2-Hz electroacupuncture, 80-Hz electroacupuncture or two different modes of placebo.
Results The intensity of pain was reduced in 13 out of the 21 patients receiving active stimulations, but in only 4 out of 14 patients receiving placebo treatments. Thresholds for the perceptions of cold, warm and heat sensations did not differ significantly between painful and non-painful skin areas in patients or between patients and healthy controls. Despite the finding that 17 of the 35 patients had a definite reduction in the intensity of sinus pain, no significant changes in thermal sensitivity were noted in any of these test groups.
Heat. The most likely deficiencies are those of Lung-Qi and Stomach- and Spleen-Qi. If both acupuncture and herbal medicine are used, it is possible to use acupuncture to tonify any underlying deficiency and herbal medicine to clear pathogenic factors (Heat, Damp Heat or Toxic Heat).
NASAL POLYPS Small nasal polyps usually cause few problems, but larger ones can affect breathing and diminish the sense of smell. Sometimes they may cause dull headaches or snoring (Fig. 7.6). Nasal polyps result from inflammation of the nasal mucosa. Signs and symptoms include: • • • • • •
runny nose persistent stuffiness chronic sinus infections diminished sense of smell dull headaches snoring.
Polyps are treated either with nasal corticosteroid sprays or with surgery; however, when excised they frequently return.
CHINESE MEDICINE TREATMENT Polyps are usually associated with the condition of Bi Yuan in Chinese medicine. The patterns appearing in polyps are: • Lung-Heat with stagnation • Damp Phlegm with stasis
Conclusion These results indicate that acupuncture may be effective for reducing the pain felt by patients suffering from sinusitis, but further trials are needed. Nasal polyps
PROGNOSIS Sinusitis is a stubborn, chronic disease that requires long-term treatment. The more obvious the signs of Toxic Heat, the longer it will take to treat. It is important to attend to any underlying deficiency as well as clearing Heat, resolving Damp Heat or Toxic
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Figure 7.6 Nasal polyps.
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• Lung- and Spleen-Qi deficiency with Damp Phlegm.
Lung-Heat with stagnation Clinical manifestations
Herbal therapy Prescription HUANG QIN QING FEI YIN plus CANG ER ZI SAN Scutellaria Clearing the Lungs Decoction plus Xanthium Powder
Red, shiny, soft and slippery polyps, diminished sense of smell, yellow-sticky nasal discharge, headache. Tongue: Red with yellow coating. Pulse: Overflowing-Rapid.
Treatment principle Clear Lung-Heat, invigorate Blood, open the nose and sinuses.
Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, LU-5 Chize, L.I.-11 Quchi, BL-2 Zanzhu, ST-8 Touwei, Bitong, P-6 Neiguan. All with even method.
Explanation • • • •
LU-7 and L.I.-4 open the nose and sinuses. LU-5 clears Lung-Heat. L.I.-11 clears Heat. BL-2, ST-8 and Bitong are local points to open the nose and sinuses. • P-6 invigorates Blood in the Upper Burner.
Herbal therapy
Damp Phlegm with stasis Clinical manifestations White-sticky, shiny, soft polyps, diminished sense of smell, white, sticky or runny nasal discharge, headache, feeling of heaviness of the head, a feeling of oppression of the chest, expectoration of sputum. Tongue: Swollen, sticky coating. Pulse: Slippery.
Treatment principle Resolve Phlegm, soften hardness, dissolve nodules.
Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei, Bitong, Ren-12 Zhongwan, Ren-9 Shuifen, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-40 Fenglong. All with even method.
Prescription
Explanation
HUANG QIN QING FEI YIN plus CANG ER ZI SAN Scutellaria Clearing the Lungs Decoction plus Xanthium Powder
• LU-7 and L.I.-4 open the nose and sinuses. • BL-2, ST-8 and Bitong are local points to open the nose and sinuses. • Ren-12, Ren-9, SP-6, SP-9 and ST-40 resolve Phlegm.
Explanation These two formulae together clear Lung-Heat, open the nose and sinuses and invigorate Blood.
Herbal therapy
SUMMARY
Prescription
LUNG-HEAT WITH STAGNATION
DAO TAN TANG plus CANG ER ZI SAN Conducting Phlegm Decoction plus Xanthium Powder
Points LU-7 Lieque, L.I.-4 Hegu, LU-5 Chize, L.I.-11 Quchi, BL-2 Zanzhu, ST-8 Touwei, Bitong, P-6 Neiguan. All with even method.
Explanation These two formulae together resolve Phlegm and dissolve nodules from the nose and sinuses.
Sinusitis (Nasal Polyps)
SUMMARY DAMP-PHLEGM WITH STASIS Points LU-7 Lieque, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei, Bitong, Ren-12 Zhongwan, Ren-9 Shuifen, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-40 Fenglong. All with even method. Herbal therapy Prescription DAO TAN TANG plus CANG ER ZI SAN Conducting Phlegm Decoction plus Xanthium Powder
Lung- and Spleen-Qi deficiency with Damp Phlegm Clinical manifestations White, shiny polyps which return after surgery, diminished sense of smell, runny or sticky nasal discharge, a feeling of oppression of the chest, expectoration of sputum, tiredness, loose stools, poor appetite, weak voice, propensity to catching colds. Tongue: Pale, Swollen, sticky coating. Pulse: Weak and slightly Slippery or Soggy.
Treatment principle Tonify Lung- and Spleen-Qi, resolve Phlegm, dissolve nodules.
Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei, Bitong, Ren-9 Shuifen, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-40 Fenglong, Ren-12 Zhongwan, ST36 Zusanli, BL-20 Pishu, LU-9 Taiyuan, BL-13 Feishu. All with even method, except the last five points, which should be needled with reinforcing method.
Explanation • LU-7 and L.I.-4 open the nose and sinuses. • BL-2, ST-8 and Bitong are local points to open the nose and sinuses.
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• Ren-9, SP-6, SP-9 and ST-40 resolve Phlegm. • Ren-12, ST-36 and BL-20 tonify Spleen-Qi. • LU-9 Taiyuan and BL-13 Feishu tonify Lung-Qi.
Herbal therapy Prescription BU ZHONG YI QI TANG plus ER CHEN TANG Tonifying the Centre and Benefiting Qi Decoction plus Two Old Decoction
Modifications • Stuffy nose, diminished sense of smell: Bai Zhi Radix Angelicae dahuricae, Xin Yi Hua Flos Magnoliae, Shi Chang Pu Rhizoma Acori tatarinowii. • Stubborn polyps resistant to treatment: Jiang Can Bombyx batryticatus.
SUMMARY LUNG- AND SPLEEN-QI DEFICIENCY WITH DAMP PHLEGM Points LU-7 Lieque, L.I.-4 Hegu, BL-2 Zanzhu, ST-8 Touwei, Bitong, Ren-9 Shuifen, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-40 Fenglong, Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, LU-9 Taiyuan, BL-13 Feishu. All with even method, except the last five points, which should be needled with reinforcing method. Herbal therapy Prescription BU ZHONG YI QI TANG plus ER CHEN TANG Tonifying the Centre and Benefiting Qi Decoction plus Two Old Decoction
END NOTES 1. Mygind N et al. 1990 Rhinitis and Asthma: Similarities and Differences. Munksgaard, Lund, p. 10. 2. Ibid., p. 10.
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CHAPTER 8
COUGH
AETIOLOGY 216 External pathogenic factors Emotional stress 217 Diet 217 Chronic illness 217 PATHOLOGY
Phlegm-Heat in the Lungs 230 Phlegm-Fluids in the Lungs 231 Liver-Fire insulting the Lungs 232 CHRONIC EMPTY 233 Lung-Qi Deficiency 233 Lung-Yin Deficiency 234 Lung-Dryness 234
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ACUPUNCTURE IN COUGH
219
MODERN CHINESE LITERATURE
DIAGNOSIS 220 Sound 220 Time of day 220 Sputum 221 IDENTIFICATION OF PATTERNS AND TREATMENT ACUTE 222 ACUTE EXTERIOR 223 Invasion of Wind-Cold 223 Invasion of Wind-Heat 224 Invasion of Wind-Dryness 225 ACUTE INTERIOR 226 Lung-Heat 226 Lung Phlegm-Heat 227 CHRONIC 229 CHRONIC FULL 229 Damp Phlegm in the Lungs 229
ACUTE Exterior • Invasion of Wind-Cold • Invasion of Wind-Heat • Invasion of Wind-Dryness Interior • Lung-Heat • Lung Phlegm-Heat
236
CLINICAL TRIALS 239 Herbal medicine 239 PROGNOSIS 221
240
WESTERN DIFFERENTIATION 240 Tracheitis 240 Acute bronchitis 240 Chronic bronchitis 241 Whooping cough 241 Pleurisy 241 Pneumonia 241 Carcinoma of the bronchi 241 Tuberculosis of the lungs 241 Bronchiectasis 241 Heart disease 241
CHRONIC Full • Damp Phlegm in the Lungs • Phlegm-Heat in the Lungs • Phlegm-Fluids in the Lungs • Liver-Fire insulting the Lungs Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung-Dryness
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COUGH Cough is mentioned in the Yellow Emperor’s Classic, in which a whole chapter is dedicated to it. The two characters of its Chinese name, Ke Sou, originally referred to two different types of cough. Ke denotes a cough that makes a noise but is without phlegm; this indicates injury of the Lungs. Sou denotes a cough with phlegm but that does not make a noise; this indicates that the Spleen is obstructed by Phlegm. Ke-Sou therefore denotes a cough that is both noisy and phlegmridden due to injury of the Lungs and Spleen from Phlegm. CLINICAL NOTE Ke: cough that makes a noise but is without phlegm. Sou: cough with phlegm but without making a noise.
Chapter 23 of the Simple Questions relates different sounds to different organs, and it says: “Diseases of Qi manifest ... in the Lungs with cough.”1 Chapter 38 of the Simple Questions, which is entirely dedicated to cough, says that coughing does not depend only on the Lungs but may be caused by each of the five Yin organs:2 Lung-cough [is accompanied by] breathlessness and spitting of blood; Heart-cough by pain in the heart region and a feeling of an obstruction in the throat; Livercough by hypochondrial fullness and pain ... Kidneycough by backache ... Spleen-cough by right hypochondrial pain ... It then goes on to say that when cough is prolonged it may transmit from the Yin organs to their related Yang organs:3 When the cough of the five Yin organs persists for a long time, it will be transmitted to the six Yang organs. If a Spleen-cough persists for a long time, it will transmit to the Stomach ... [causing] vomiting on coughing ... If a Livercough persists for a long time, it will transmit to the Gall Bladder ... [causing] coughing of bile. If a Lung-cough persists for a long time, it will transmit to the Large Intestine ... [causing] bowel incontinence on coughing. If a Heart-cough persists for a long time, it will transmit to the Small Intestine ... [causing] flatulence on coughing. If a Kidney-cough persists for a long time, it will transmit to
the Bladder ... [causing] incontinence of urine on coughing. Any chronic cough will affect the Triple Burner ... [causing] cough with abdominal fullness and no desire to eat or drink. The same chapter clearly attributes cough to a combination of invasion of an external pathogenic factor and improper diet:4 The skin is in relation with the Lungs; when an external pathogenic factor [Wind-Cold] invades the skin, it progresses to the Lungs. When cold food and drinks enter the Stomach, they go upwards to the Lungs via the Lung channel [which starts in the Middle Burner] and give rise to Cold in the Lungs. The combination of exterior and interior Cold causes cough in the Lungs. The chapter on cough ends by giving indications for treatment:5 For cough of the Yin organs, needle the [Back] Transporting (Shu) points; for cough of the Yang organs, needle the Sea (He) points; for cough with oedema, needle the River (Jing) points. The Complete Book of Jing Yue (1624) distinguishes between cough caused by invasion of an external pathogenic factor and cough due to an internal disharmony.6 The discussion of cough will be conducted according to the following topics. • • • • • • • •
Aetiology Pathology Diagnosis Identification of patterns and treatment Modern Chinese literature Clinical trials Prognosis Western differentiation
AETIOLOGY External pathogenic factors External Wind is the main cause of exterior coughs. Wind penetrates the skin and the Defensive-Qi portion, which is controlled by the Lungs. It therefore impairs the descending of Lung-Qi and causes a cough. This is an exterior type of cough that, with proper treatment, disappears rather quickly without any consequences.
Cough
Wind combines with other pathogenic factors, and the most likely to cause a cough are Wind-Cold, WindHeat and Wind-Dryness. Wind-Cold invades the skin and the Defensive-Qi portion, impairing the descending of Lung-Qi and thus causing a cough, usually with a white nasal discharge. Wind-Heat enters via the nose and mouth and affects the throat. It causes a cough by invading the Lung channel in the throat and preventing the descending of Lung-Qi. The cough caused by Wind-Heat is of a drier type than that caused by Wind-Cold. Wind-Dryness, rare in the British Isles but rather prevalent in the American South-West, also invades the Lung channel in the throat and causes a very dry and ticklish cough. Besides impairing the descending of Lung-Qi, Wind-Dryness also dries up the Lung’s fluids and the resulting cough is more persistent than that caused by Wind-Cold or Wind-Heat.
Emotional stress Worry is a frequent emotional cause of cough. It affects the Lungs directly and it knots Qi, preventing the descending of Lung-Qi. The resulting type of cough is dry and irritating. Sadness and grief deplete Lung-Qi, and they may cause a Deficiency-type cough as the deficient Lung-Qi fails to descend. Prolonged anger, frustration or resentment lead to stagnation of Liver-Qi and, over a long period of time, to Liver-Fire. This may invade the Lungs and prevent the descending of Lung-Qi, causing a cough.
Diet Excessive consumption of sweets, greasy foods and dairy foods may lead to the formation of Phlegm, which settles in the Lungs and prevents Lung-Qi from descending. This causes a cough with profuse expectoration. Excessive consumption of hot foods, alcohol and fried-greasy foods leads to the formation of Heat and Phlegm. Phlegm settles in the Lungs and impairs the descending of Lung-Qi, while Heat dries up the Lung fluids. Both these processes cause coughing. Excessive consumption of cold and raw foods such as salads and fruit impairs the transformation of fluids and may lead to Phlegm, which settles in the Lungs.
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Chronic illness A chronic illness affecting the Lungs weakens Lung-Qi and/or Lung-Yin. The deficient Lung-Qi fails to descend and causes a chronic cough of the Empty type.
SUMMARY AETIOLOGY External pathogenic factors Emotional stress — Worry — Sadness and grief — Anger, frustration or resentment Diet — Excessive consumption of sweets, greasy foods and dairy foods, leading to Phlegm — Excessive consumption of hot foods, alcohol and fried-greasy foods, leading to Heat and Phlegm — Excessive consumption of cold and raw foods, leading to Phlegm Chronic illness
PATHOLOGY As indicated above, the Chinese term for “cough”, Ke Sou, is composed of two parts, each being a distinct symptom. The Su Wen Bing Ji Qi Zu Bao Ming Ji says:7 Ke refers to a cough without sputum, in which case one uses pungent-sweet herbs to moisten the Lungs; Sou refers to cough with sputum, in which case one must resolve Phlegm and restore the descending of Lung-Qi. The Jin Gui Gou Xuan gives the treatment principles for various types of cough as follows:8 For Wind-Cold, open the space between skin and muscles and use Er Chen Tang plus Ma Huang, Xing Ren and Jie Geng; for Fire, drain Fire, clear the Lungs and resolve Phlegm; for Deficiency, use Si Wu Tang plus Zhu Li and Jiang Ye [ginger juice]. Cough that is worse in daytime is due to StomachFire: use Zhe Bei Mu and Shi Gao to drain Stomach-Fire. Cough that is worse in the evening is due to Yin deficiency: use Si Wu Tang plus Zhi Mu and Huang Bo. The pathology of cough is always characterized by Lung-Qi failing to descend. This may happen either because the Lungs are obstructed by an exterior or
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interior pathogenic factor (Full type), or because LungQi (or Lung-Yin) is deficient and fails to descend properly (Empty type). Pathogenic factors in the Lungs that impair the descending of Qi include external Wind, Heat, Phlegm, stagnation of Qi and Liver-Fire. In such cases when Qi fails to descend because of a pathogenic factor, it is said to be “rebelling upwards”. All the old classics convey this idea of cough being caused by rebellious Qi. The Simple Questions in Chapter 10 says: “Cough consists of Qi rebelling upwards.”9 The Essential Prescriptions of the Golden Chest by Zhang Zhong Jing says: “Cough is due to Qi rebelling upwards.”10 The implication is that, in order to treat cough, one must restore the descending of Lung-Qi and subdue rebellious Qi. In Chinese, subduing rebellious Qi and making Qi flow in the correct direction is called shun, a term that is used in opposition to ni, which means “rebellious”. The Yi Xue Zheng Chuan says: “To treat cough, one must first resolve Phlegm; to resolve Phlegm, one must rectify [shun] Qi.”11 The Yi Tong Zheng Mai Quan Shu confirms this when it says: “To treat cough one must resolve Phlegm; to resolve Phlegm, one must make Qi descend.”12 External coughs are by definition of the Full type. Interior coughs may be of the Deficiency or Excess type, and the main pathology in the Excess type is Phlegm or Fire. Phlegm combines with Heat or Cold, and Fire may be of the Excess or Deficiency type.
Thus coughs may be classified in various ways. Using Fullness and Emptiness as parameters, we may classify them as follows (Fig. 8.1). FULL Exterior • Wind-Cold • Wind-Heat • Wind-Dryness Interior • Damp Phlegm • Phlegm-Heat • Fire • Phlegm-Fluids EMPTY • Lung-Qi deficiency • Lung-Yin deficiency Using Exterior and Interior as parameters, we may classify coughs as follows (Fig. 8.2). EXTERIOR • Wind-Cold • Wind-Heat • Wind-Dryness INTERIOR Full • Damp Phlegm • Phlegm-Heat Wind-Cold EXTERIOR
Wind-Heat Wind-Dryness
FULL Damp Phlegm INTERIOR
Phlegm-Heat Fire
COUGH
Phlegm-Fluids Lung-Qi deficiency EMPTY Lung-Yin deficiency Figure 8.1 Classification of cough according to Full and Empty.
Cough
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Wind-Cold EXTERIOR
Wind-Heat Wind-Dryness Damp Phlegm
COUGH Phlegm-Heat FULL
Fire Phlegm-Fluids
INTERIOR Lung-Qi deficiency EMPTY Lung-Yin deficiency Figure 8.2 Classification of cough according to Exterior and Interior.
• Fire • Phlegm-Fluids Empty • Lung-Qi deficiency • Lung-Yin deficiency However, I prefer to classify coughs as acute or chronic, because this factor is clinically more significant. In fact, when presented with a patient with a cough the first thing to ascertain is whether the cough is acute or chronic. Once this has been ascertained, one needs to establish whether the cough is external or internal. Acute coughs may be external or internal but are always of the Full type, while chronic coughs are always internal and they may be either of the Full or the Empty type. Many of the old classics also stress the classification of cough according to acute and chronic. For example, the Yi Xue Ru Men classifies cough according to acute and chronic, each of them with or without Phlegm:13 If an acute cough manifests with Phlegm, it is due to exterior invasion and the treatment principle is to release the Exterior and eliminate the pathogenic factor. If an acute cough manifests without Phlegm, it is due to Fire and the treatment principle is to drain Fire. The Ming Yi Za Zhu also recommends distinguishing between acute and chronic cough. It says:14
Acute cough may be due to invasion of Wind-Cold, in which case one must scatter the pathogenic factor; to Fire, in which case one must drain Fire; or to Damp Heat, in which case one must resolve Dampness. Chronic cough may be due to Deficiency or to stagnation: in Deficiency one must tonify Qi or nourish Blood; in stagnation, one must eliminate stagnation. The Za Bing Yuan Liu says:15 Cough should be classified according to acute/chronic and Full/Empty. In acute cough, the Lungs are obstructed by a pathogenic factor. This may be Wind, in which case one must release the Exterior; Cold, in which case one must scatter; Heat, in which case one must clear; Fire, in which case one must drain; Dampness, in which case one must resolve Dampness; Phlegm, in which case one must resolve Phlegm. The train of thought and the guideline for interrogation of the patient may be represented with a diagram (Fig. 8.3).
ACUPUNCTURE IN COUGH As we have seen, most Chinese books place the emphasis on resolving Phlegm as a treatment method for cough. It is important to understand that all these books give this recommendation primarily from the
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The Practice of Chinese Medicine Hot (Wind-Heat) EXTERNAL Cold (Wind-Cold) ACUTE With Phlegm INTERNAL
Hot Without Phlegm
COUGH Hot FULL Cold CHRONIC Qi EMPTY
With Empty Heat Yin Without Empty Heat
Figure 8.3 Classification of cough and guideline for interrogation.
perspective of herbal medicine. If we use only acupuncture, our thinking must be somewhat different. Of course we can resolve Phlegm with acupuncture, but it is important to understand that acupuncture’s way of achieving this differs from that of herbal medicine. Herbal medicine resolves Phlegm with herbal drugs that actually dry up Phlegm; herbs that resolve Phlegm are generally pungent and drying (e.g. Ban Xia Rhizoma Pinelliae preparatum, Dan Nan Xing Rhizoma Arisaematis preparatum). How can acupuncture resolve Phlegm? It can do so only by regulating Qi, i.e. restoring the correct ascending/descending and entering/exiting of Qi in the Qi Mechanism. It follows therefore, that, when giving acupuncture, we must pay attention to regulating the flow of Qi rather than attributing a “Phlegm-resolving action” to specific points (e.g. ST-40 Fenglong). In other words, as acupuncturists, we must think more of Qi flow than “actions” of a particular point (e.g. “ST-40 resolves Phlegm”). Indeed, how does ST-40 “resolve Phlegm”? It does so specifically because it subdues rebellious Qi in the chest and makes Qi descend. Moreover, by regulating the ascending/descending of Stomach-Qi, it also affects Spleen-Qi: the regulating of the flow of Qi in these two
organs results in their transporting and transforming fluids in the correct way and therefore indirectly “resolves Phlegm”.
DIAGNOSIS Cough can be diagnosed according to its sound, the time of occurrence and the character of any sputum.
Sound As a general rule, a weak-sounding cough indicates Deficiency while a loud cough indicates Excess. A barking cough denotes Heat while a loose, rattling cough indicates the presence of Phlegm.
Time of day A cough that occurs only in the late afternoon or evening indicates Yin deficiency. A cough that is worse in the morning is usually due to Phlegm.
Cough
Sputum A cough without sputum indicates either Deficiency or Heat. If there is abundant sputum, it is due to Phlegm. A yellow sputum denotes Heat, while white sputum denotes Cold. White sputum may be sticky or dilute; if it is sticky, it indicates the prevalence of Dampness and Phlegm over Cold, while if it is dilute it indicates the prevalence of Cold over Dampness or Phlegm (Fig. 8.4). Blood-tinged sputum indicates either Full or Empty Heat. Greenish sputum indicates Heat, while white, very watery and frothy sputum indicates Phlegm-Fluids.
IDENTIFICATION OF PATTERNS AND TREATMENT As mentioned above, I shall classify coughs into acute or chronic. Acute cases are usually characterized by Fullness, while chronic cases may be of the Full or Empty type. Fullness and Emptiness, however, often combine. Zhang Jing Yue says in the Complete Book of Jing Yue (1624):16 Coughs of external origin are very frequent [and are characterized by] some Deficiency within the Fullness,
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hence one must tonify somewhat as well as expelling [pathogenic factors]. In coughs of internal origin, there is some Fullness within Emptiness, hence one must clear and moisten simultaneously. The patterns discussed are the following. ACUTE Exterior • Invasion of Wind-Cold • Invasion of Wind-Heat • Invasion of Wind-Dryness Interior • Lung-Heat • Lung Phlegm-Heat CHRONIC Full • Damp Phlegm in the Lungs • Phlegm-Heat in the Lungs • Phlegm-Fluids in the Lungs • Liver-Fire insulting the Lungs Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung-Dryness
Deficiency WITHOUT SPUTUM
STICKY
+Dampness –Cold
DILUTE
+Cold –Dampness
Heat COUGH WHITE ABUNDANT SPUTUM
Cold WATERYFROTHY
PHLEGM
YELLOW
Heat Full Heat
BLOODTINGED Empty Heat GREENISH Figure 8.4 Diagnosis of cough.
Heat
PhlegmFluids
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ACUTE By acute is meant a cough of a few days’ or, at most, a few weeks’ duration. The most important fact to establish when seeing a patient suffering from acute cough is whether the cough is external or internal. All acute coughs are originally due to invasion of external Wind, but the external pathogenic factor may become internal in only a few days while the cough is still at the acute stage. The identification of patterns according to the Four Levels provides the clinical framework for the symptomatology of invasions of external Wind turning into interior Heat. For example, within the Four Levels patterns, invasion of exterior Wind-Heat may cause a cough (together with shivering, fever, aversion to cold, body aches and a Floating-Rapid pulse). If the exterior Wind penetrates into the Interior, it gives rise to the pattern of Lung-Heat with a barking cough (together with high fever, thirst, sweating and a Big pulse). Although the patterns of the Four Levels initially start with an invasion of Wind-Heat, Wind-Cold may also turn into interior Heat in the Lungs so that, at that stage, the identification of patterns according to the Four Levels may be used also for invasions of WindCold. Acute Lung-Heat with cough in the course of a febrile disease may therefore derive either from WindHeat or Wind-Cold, although the former is more likely (Fig. 8.5). Thus, when presented with a patient with acute cough, the crucial distinction must be made between exterior or interior cough. Apart from many other
symptoms, this differentiation may be made very simply on the basis of the patient’s feelings of cold or heat. If the patient shivers and feels aversion to cold, and this feeling is not alleviated by wrapping up, it indicates an exterior pattern, i.e. the pathogenic factor is still on the Exterior. If the patient feels aversion to heat and is generally hot, very thirsty and restless, it indicates an interior pattern of Heat, i.e. the pathogenic factor is in the Interior and it has turned into Heat. In such a case, the presence of cough, breathlessness, some chest pain and possibly flaring of the alae nasi indicate the location of Heat in the Lungs. After establishing from its character whether a cough is exterior or interior, we must differentiate the pattern further in each case. If it is exterior, we must ascertain whether it is Wind-Cold or Wind-Heat. If it is interior, it is due to Lung-Heat and we must ascertain whether there is just Lung-Heat or Lung Phlegm-Heat (see Fig. 8.6). For a description of the Six-Stage and Four-Level patterns, see Appendices 1 and 2. The acute patterns to be discussed are as follows. Exterior • Invasion of Wind-Cold • Invasion of Wind-Heat • Invasion of Wind-Dryness Interior • Lung-Heat • Lung Phlegm-Heat WEI – Acute, exterior cough from Wind-Heat QI – Acute, interior cough from Lung-Heat YING
WIND-HEAT
4 Levels
BLOOD
COLD-HEAT
6 Stages
TAI YANG – Acute, exterior cough from Wind-Cold
EXTERIOR WIND
YANG MING SHAO YANG TAI YIN SHAO YIN JUE YIN Figure 8.5 Invasions of Wind in the Four Levels patterns.
Cough
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Hot (Wind-Heat) EXTERNAL Cold (Wind-Cold)
ACUTE COUGH
With Phlegm INTERNAL
Hot Without Phlegm
Figure 8.6 Patterns in acute cough.
ACUTE EXTERIOR Invasion of Wind-Cold Clinical manifestations Cough, slight breathlessness, sneezing, runny nose with white discharge, aversion to cold, shivers, no temperature or one that is only slightly raised, no sweating, body aches, stiff neck, headache and pale urine. Tongue: there may be no evident change. Pulse: Floating-Tight. This is the typical pattern of invasion of Wind-Cold with prevalence of Cold. It corresponds to the Greater Yang pattern with prevalence of Cold within the Six Stages (see Appendix 1). It is a common pattern in acute cough.
Treatment principle Release the Exterior, restore the diffusing and descending of Lung-Qi, expel Wind, scatter Cold by promoting sweating and stop cough.
• L.I.-4 (reduced) and KI-7 (reinforced), in combination, promote sweating to release the Exterior. • LU-6, Accumulation point, stops acute cough.
Herbal therapy Prescription MA HUANG TANG Ephedra Decoction
Explanation This formula expels Wind, scatters Cold, promotes sweating, releases the Exterior, restores the diffusing and descending of Lung-Qi and stops cough and breathlessness.
Modifications • To enhance the antitussive effect, add Kuan Dong Hua Flos Farfarae, especially treated with honey, and increase the dosage of Xing Ren.
Prescription
Acupuncture Points LU-7 Lieque, BL-12 Fengmen, BL-13 Feishu, L.I.-4 Hegu, KI-7 Fuliu, LU-6 Kongzui. Reducing method; cupping is applicable on BL-12 and BL-13.
Explanation • LU-7 releases the Exterior, restores the descending of Lung-Qi and stops cough. • BL-12 expels exterior Wind and releases the Exterior. It is very effective with cupping. • BL-13 releases the Exterior, restores the descending of Lung-Qi and stops cough. Cupping is also applicable on this point.
SAN AO TANG and ZHI SOU SAN Three Break Decoction and Stopping Cough Powder
Explanation These two formulae together release the Exterior, expel Wind, scatter Cold, restore the descending of Lung-Qi and stop cough.
Modifications • If there is a lot of sputum, stuffiness of the chest and a sticky tongue coating (signs of Phlegm), add Ban Xia Rhizoma Pinelliae preparatum, Hou Po Cortex Magnoliae officinalis and Fu Ling Poria. • If there are Heat signs such as thirst and red sides of the tongue, add Shi Gao Gypsum fibrosum, San
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Bai Pi Cortex Mori and Huang Qin Radix Scutellariae.
Prescription XING SU SAN Variation Armeniaca-Perilla Powder Variation
Explanation This formula releases the Exterior, expels Wind-Cold, restores the descending of Lung-Qi and stops cough.
SUMMARY INVASION OF WIND-COLD Points LU-7 Lieque, BL-12 Fengmen, BL-13 Feishu, L.I.-4 Hegu, KI-7 Fuliu, LU-6 Kongzui. Reducing method; cupping is applicable on BL-12 and BL-13. Herbal therapy Prescription MA HUANG TANG Ephedra Decoction Prescription SAN AO TANG and ZHI SOU SAN Three Break Decoction and Stopping Cough Powder Prescription XING SU SAN Variation Armeniaca-Perilla Powder Variation
Invasion of Wind-Heat Clinical manifestations Dry cough with a tickling sensation in the throat, aversion to cold, shivers, fever, sore throat, slight sweating, body aches, headache, runny nose with yellow discharge, sneezing, slight thirst and slightly dark urine. Tongue: slightly Red sides and/or front part. Pulse: Floating-Rapid. This is a common pattern in acute cough, especially in children.
Acupuncture Points LU-7 Lieque, L.I.-4 Hegu, BL-12 Fengmen, BL-13 Feishu, L.I.-11 Quchi, LU-11 Shaoshang, Du-14 Dazhui, LU-6 Kongzui. All with reducing method; cupping is applicable to BL-12 and BL-13.
Explanation • LU-7 and BL-13 release the Exterior, expel Wind, restore the descending of Lung-Qi and stop cough. • L.I.-4 expels Wind-Heat. • BL-12 releases the Exterior. • L.I.-11 expels Wind-Heat. • LU-11 expels Wind-Heat and is used if the throat is sore and the tonsils are swollen. • Du-14 is used if symptoms of Heat are pronounced. • LU-6, Accumulation point, stops acute cough.
Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction
Explanation This formula releases the Exterior and expels WindHeat. Sang Ye and Xing Ren, in particular, restore the descending of Lung-Qi and stop cough.
Modifications • In case of pronounced Heat signs, add Huang Qin Radix Scutellariae and Zhi Mu Radix Anemarrhenae. • In case of very sore throat and hoarse voice, add She Gan Rhizoma Belamcandae and Chi Shao Radix Paeoniae rubra. • If Heat has begun to injure the Lung fluids, causing dry mouth and throat, add Nan Sha Shen Radix Adenophorae and Tian Hua Fen Radix Trichosanthis.
Prescription SANG JU YIN Variation Morus-Chrysanthemum Decoction Variation
Treatment principle
Explanation
Release the Exterior, expel Wind, clear Heat, restore the descending of Lung-Qi and stop cough.
This formula releases the Exterior, expels Wind-Heat, restores the descending of Lung-Qi, stops cough and
Cough
resolves Phlegm. Compared with the previous formula, it has a more marked Phlegm-resolving effect.
SUMMARY INVASION OF WIND-HEAT Points LU-7 Lieque, L.I.-4 Hegu, BL-12 Fengmen, BL-13 Feishu, L.I.-11 Quchi, LU-11 Shaoshang, Du-14 Dazhui, LU-6 Kongzui. All with reducing method; cupping is applicable to BL-12 and BL-13. Herbal therapy Prescription SANG JU YIN Morus-Chrysanthemum Decoction. Prescription SANG JU YIN Variation Morus-Chrysanthemum Decoction Variation
Invasion of Wind-Dryness Clinical manifestations Dry and ticklish cough, dry-itchy-sore throat, sore sensation in the upper chest (trachea), dry lips, dry mouth, stuffy nose, headache, slight aversion to cold, mild shivers. Tongue: slightly Red sides and/or front part. Pulse: Floating.
Treatment principle Release the Exterior, restore the descending of LungQi, promote fluids and stop cough.
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• KI-6 promotes fluids and benefits and moistens the throat. • SP-6 promotes fluids.
Herbal therapy Prescription SANG XING TANG Morus-Prunus Decoction
Explanation This formula restores the descending of Lung-Qi, stops cough and promotes fluids.
Modifications • If the fluids have been severely injured, add Mai Men Dong Radix Ophiopogonis and Yu Zhu Rhizoma Polygonati odorati. • If symptoms of Heat are pronounced, add Shi Gao Gypsum fibrosum and Zhi Mu Radix Anemarrhenae. • If there is coughing of scanty, blood-flecked sputum, add Bai Mao Gen Rhizoma Imperatae.
Prescription XING SU SAN Prunus-Perilla Leaf Powder
Explanation This formula is used if Dryness is accompanied by symptoms of Wind-Cold (normally it is accompanied by Wind-Heat). It restores the descending of Lung-Qi, stops cough, expels Wind-Cold and promotes fluids.
SUMMARY INVASION OF WIND-DRYNESS
Acupuncture Points LU-7 Lieque, LU-9 Taiyuan, Ren-12 Zhongwan, KI-6 Zhaohai, SP-6 Sanyinjiao. All with reinforcing method except for LU-7 which should be needled with reducing method.
Explanation • LU-7 releases the Exterior and restores the descending of Lung-Qi to stop cough. • LU-9 nourishes the Lung’s fluids. • Ren-12, the point marking the beginning of the Lung channel’s internal pathway, promotes fluids.
Points LU-7 Lieque, LU-9 Taiyuan, Ren-12 Zhongwan, KI-6 Zhaohai, SP-6 Sanyinjiao. All with reinforcing method except for LU-7, which should be needled with reducing method. Herbal therapy Prescription SANG XING TANG Morus-Prunus Decoction Prescription XING SU SAN Prunus-Perilla Leaf Powder
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Case history A 41-year-old man had contracted an upper respiratory infection while holidaying in the Rocky Mountains in summertime. At the time, this manifested with symptoms of Wind-Heat and Dryness, i.e. aversion to cold, a slight temperature, a dry cough, a dry and itchy sensation of the throat and a headache. He came for treatment on his return from his holiday when he still had a dry, persistent and ticklish cough that was keeping him awake at night. Diagnosis This was originally an attack of WindHeat-Dryness that had then dried up the Lung’s fluids and left him with some Dryness. Treatment The principle of treatment adopted was to moisten the Lungs, promote fluids and restore the descending of Lung-Qi. Although this was not an Exterior pattern any longer, I used a variation of Sang Xing Tang Morus-Prunus Decoction, as this prescription does not contain many herbs that release the Exterior. The variation used was as follows. • • • • • • • • • •
Sang Ye Folium Mori 6 g Xing Ren Semen Armeniacae 6 g Dan Dou Chi Semen Sojae preparatum 4 g Shan Zhi Zi Fructus Gardeniae 3 g Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g Nan Sha Shen Radix Adenophorae 6 g Li Pi Pericarpium Fructi Pyri 6 g Tian Hua Fen Radix Trichosanthis 6 g Yu Zhu Rhizoma Polygonati odorati 6 g Kuan Dong Hua (honey-treated) Flos Farfarae 9 g
Explanation • Sang Ye and Xing Ren are the two main herbs to restore the descending of Lung-Qi. • Dan Dou Chi and Zhi Zi clear any residual Heat. Their dosage was reduced, as there was no sign of much Heat left; they were left in, however, to prevent any residual Heat forming. • Zhe Bei Mu helps to restore the descending of Lung-Qi and stop cough. • Sha Shen, Li Pi, Tian Hua Fen and Yu Zhu promote fluids and moisten the Lungs and throat. • Kuan Dong Hua restores the descending of Lung-Qi and stops cough. Its antitussive effect is enhanced by toasting with honey.
Only three doses of this decoction were enough to stop the cough completely.
ACUTE INTERIOR Lung-Heat Clinical manifestations Barking cough, chest pain, breathlessness, fever, thirst, sweating, flaring of alae nasi, restlessness and a feeling of heat. Tongue: Red with yellow coating. Pulse: Rapid and Overflowing. This corresponds to the pattern “Heat in the diaphragm” within the Qi Level of the Four-Level identification of patterns. This pattern is seen only in acute coughs following an invasion of Wind when the pathogenic factor has turned into Heat and penetrated the Interior.
Treatment principle Clear Lung-Heat, restore the descending of Lung-Qi and stop cough.
Acupuncture Points LU-5 Chize, LU-1 Zhongfu, Du-14 Dazhui, LU-6 Kongzui and L.I.-11 Quchi. Reducing method.
Explanation • LU-5 clears Lung-Heat and restores the descending of Lung-Qi. • LU-1 clears Lung-Heat and treats acute patterns of the Lungs. • Du-14 clears Heat. • LU-6, Accumulation point, treats acute patterns of the Lungs and stops cough. • L.I.-11 clears Heat.
Herbal therapy Prescription MA XING SHI GAN TANG Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction
Explanation This formula restores the descending of Lung-Qi, stops cough, clears Heat and stops breathlessness.
Cough
Modifications • To enhance the antitussive effect of the formula, add Sang Bai Pi Cortex Mori, Pi Pa Ye Folium Eriobotryae and Kuan Dong Hua Flos Farfarae. • To enhance the Lung-clearing effect, add Huang Qin Radix Scutellariae.
SUMMARY LUNG-HEAT Points LU-5 Chize, LU-1 Zhongfu, Du-14 Dazhui, LU-6 Kongzui and L.I.-11 Quchi. Reducing method. Herbal therapy Prescription MA XING SHI GAN TANG Ephedra-Armeniaca-Gypsum-Glycyrrhiza Decoction
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SP-15 Daheng. All with reducing method except Ren-12, which should be reinforced.
Explanation • LU-5 expels Phlegm and clears Heat from the Lungs. • LU-1 and LU-6, Front-Collecting point and Accumulation point, respectively, are used for acute cases; they clear Lung-Heat and stop cough. • Ren-12, Ren-9, ST-40 and SP-6 resolve Phlegm. • Du-14 and L.I.-11 clear Heat. • T.B.-6 and SP-15 clear Heat and move downwards.
Herbal therapy Prescription QING QI HUA TAN TANG Clearing Qi and Resolving Phlegm Decoction
Explanation
Lung Phlegm-Heat Clinical manifestations Barking cough with expectoration of profuse-stickyyellow sputum, fever, restlessness, thirst, feeling of heat and a sensation of oppression in the chest. Tongue: Red with a sticky-yellow coating. Pulse: Rapid and Slippery. This corresponds to Lung-Heat at the Qi Level within the Four-Level identification of patterns, but with the presence of Phlegm in addition to Heat. Wind-Heat easily leads to Phlegm, because it quickly dries up the body fluids, which condense, forming Phlegm. This is a very common pattern in acute cough. It occurs when an external pathogenic factor turns into Heat, penetrates the Interior and combines with Phlegm.
This formula resolves Phlegm, clears Lung-Heat, restores the descending of Lung-Qi, stops cough.
Prescription XIAO XIAN XIONG TANG Small Sinking [Qi of the] Chest Decoction
Explanation This formula clears Heat, makes Qi descend and stops cough. The main difference between these two formulae is that the former is better at resolving Phlegm (and therefore used for profuse expectoration), while the latter is better to make Qi descend in the chest (and therefore used for a feeling of oppression in the chest).
Prescription
Treatment principle
GUN TAN WAN Chasing-away Phlegm Pill
Clear Lung-Heat, resolve Phlegm, restore the descending of Lung-Qi and stop cough.
Explanation
Acupuncture Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, LU-6 Kongzui, Du-14 Dazhui, L.I.-11 Quchi, T.B.-6 Sanyangluo and
This formula drains Fire by moving downwards, resolves Phlegm and stops cough. This is a strong formula for Lung-Fire as opposed to Lung-Heat. Although Heat and Fire are the same in nature, there are differences between them, the main one being that Heat is more superficial and less intense than Fire. This distinction is not very significant or important in
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acupuncture, but it is crucial when herbal medicine is used. For Heat, one uses pungent-cold herbs (such as Shi Gao Gypsum fibrosum) to clear it by pushing it outwards. Fire is more intense and is knotted deep inside in the Interior of the body; one therefore drains it with bitter-cold herbs (such as Huang Qin Radix Scutellariae or Long Dan Cao Radix Gentianae) and, if the stools are dry, with moving-downward herbs such as Da Huang Radix et Rhizoma Rhei. Some of the clinical manifestations of Heat and Fire overlap, such as a feeling of heat, thirst, sweating, a red face, a Red tongue and a Rapid pulse. Fire, however, is more drying, affects the Mind more and may cause bleeding. Thus, in addition to the above manifestations, Fire also causes mental restlessness, dark urine, dry stools, very dry tongue coating, a bitter taste, dry mouth and a deeper pulse. In this case, there is Lung-Fire as opposed to LungHeat, and the manifestations would be a barking cough with profuse yellow-purulent or blood-flecked expectoration, fever, constipation or dry stools, dark urine, a red face, dry mouth, mental restlessness, a Red tongue with a thick-dry-yellow or dark brown or even black coating and a Deep-Full and Rapid pulse. In such a case, clearing Heat is not enough; we need to drain Fire by moving downwards, which is what this formula does.
Modifications • To enhance the antitussive effect, add Kuan Dong Hua Flos Farfarae, Sang Bai Pi Cortex Mori and Xing Ren Semen Armeniacae.
SUMMARY LUNG PHLEGM-HEAT Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, LU-6 Kongzui, Du-14 Dazhui, L.I.-11 Quchi, T.B.-6 Sanyangluo and SP-15 Daheng. All with reducing method except Ren-12, which should be reinforced. Herbal therapy Prescription QING QI HUA TAN TANG Clearing Qi and Resolving Phlegm Decoction
Prescription XIAO XIAN XIONG TANG Small Sinking [Qi of the] Chest Decoction Prescription GUN TAN WAN Chasing-away Phlegm Pill
Case history A 2-year-old girl had contracted an upper respiratory infection, which had been treated with antibiotics. Her mother took her to me for treatment about 1 week into the antibiotic treatment, as she was not getting better. Although the initial temperature had gone, she now had a barking cough productive of yellow sputum; she also wheezed slightly, was restless and slept badly. Her tongue had a sticky-yellow coating and was Red in the front part. Diagnosis This is a typical example of progression of an external pathogenic factor into the Interior due to treatment with antibiotics (see also Chapter 48). The pathogenic factor is now interior Phlegm-Heat obstructing the Lungs. Treatment The treatment’s aim was to resolve Phlegm, clear Lung-Heat, restore the descending of Lung-Qi and stop cough and wheezing. She was treated only with herbal decoctions, and the one used was a variation of Qing Qi Hua Tan Tang Clearing Qi and Resolving Phlegm Decoction. • Dan Nan Xing Rhizoma Arisaematis preparatum 3g • Gua Lou Fructus Trichosanthis 6 g • Huang Qin Radix Scutellariae 4 g • Shan Zhi Shi Fructus Aurantii immaturus 3 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g • Xing Ren Semen Armeniacae 4 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Su Zi Fructus Perillae 4 g • Sang Bai Pi Cortex Radicis Mori albae 4 g • Kuan Dong Hua (honey-treated) Flos Farfarae 6g
Cough
Explanation • The first eight herbs constitute the Qing Qi Hua Tan Tang, which resolves Phlegm and clears Lung-Heat. • Su Zi and Sang Bai Pi were added to restore the descending of Lung-Qi. • Kuan Dong Hua, especially good when honeytreated, restores the descending of Lung-Qi and stops cough. The decoction was given to the little girl well diluted with water and mixed with some honey in small amounts throughout the day. She improved completely after 1 week. Her treatment was followed up with a decoction to tonify the Spleen and resolve Phlegm (the Liu Jun Zi Tang Six Gentlemen Decoction) in order to prevent any recurrence.
CHRONIC Chronic cough may be of the Full or Empty type. The main patterns are as follows. Full • Damp Phlegm • Phlegm-Heat • Phlegm-Fluids • Liver-Fire Empty • Lung-Qi deficiency • Lung-Yin deficiency • Lung-Dryness The pathology of chronic coughs is characterized by involvement of other organs besides the Lungs. The organs involved for each pattern are as follows. • Damp Phlegm: Spleen-Qi or Spleen-Yang deficiency, Kidney-Yang deficiency • Phlegm-Heat: Spleen-Qi deficiency • Phlegm-Fluids: Spleen- and Kidney-Yang deficiency • Liver-Fire insulting the Lungs: Liver-Fire • Lung-Qi deficiency: Spleen-Qi deficiency • Lung-Yin deficiency: Kidney-Yin deficiency • Lung-Dryness: Stomach-Yin deficiency Thus, the pattern of Lung-Qi deficiency will be nearly always accompanied by Spleen-Qi deficiency, while that of Lung-Yin deficiency will be nearly always accompanied by Stomach- and/or Kidney-Yin deficiency.
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CHRONIC FULL Damp Phlegm in the Lungs Clinical manifestations Repeated attacks of cough, profuse expectoration of white-sticky sputum, breathlessness, worse in the mornings and after eating, a feeling of oppression in the chest, a feeling of fullness of the epigastrium, nausea, poor appetite, tiredness, a feeling of heaviness, loose stools. Tongue: Pale or normal, Swollen, sticky-thick-white coating. Pulse: Slippery. This is a common pattern seen in chronic cough, especially in middle-aged and elderly patients.
Treatment principle Dry Dampness, resolve Phlegm, tonify the Spleen, restore the descending of Lung-Qi and stop cough.
Acupuncture Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu. Reinforcing method on ST-36, Ren-12 and BL-20, reducing or even method on the others. Moxa is applicable.
Explanation • LU-5 resolves Phlegm from the Lungs and restores the descending of Lung-Qi. • LU-1 restores the descending of Lung-Qi. • Ren-12, BL-20 and ST-36 tonify the Spleen to resolve Phlegm. • Ren-9, ST-40 and SP-6 resolve Dampness and Phlegm. • BL-13, Back-Transporting point, is used for chronic patterns to restore the descending of Lung-Qi.
Herbal therapy Prescription ER CHEN TANG and SAN ZI YANG QIN TANG Two Old Decoction and Three-Seed Nourishing the Parents Decoction
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Explanation
Phlegm-Heat in the Lungs
These two formulae together resolve Damp Phlegm or Cold Phlegm, restore the descending of Lung-Qi and stop cough. This pattern nearly always occurs against a background of Spleen-Qi or Spleen-Yang deficiency. In such cases, it is necessary to add some Spleen tonics such as Bai Zhu Rhizoma Atractylodis macrocephalae and, if there is Spleen-Yang deficiency, Gan Jiang Rhizoma Zingiberis.
Clinical manifestations
Modifications • To enhance the antitussive effect, add Kuan Dong Hua Flos Farfarae and Xing Ren Semen Armeniacae. • In cases of pronounced Dampness, add Cang Zhu Rhizoma Atractylodis and Hou Po Cortex Magnoliae officinalis. • If there are symptoms of Cold Phlegm (see above), add Gan Jiang Rhizoma Zingiberis and Xi Xin Herba Asari. • If there is a pronounced deficiency of the Spleen, add Bai Zhu Rhizoma Atractylodis macrocephalae and Dang Shen Radix Codonopsis. • After the Phlegm has been successfully resolved, use the Liu Jun Zi Tang Six Gentlemen Decoction to consolidate the results by strengthening the Spleen. • If the attacks of cough are elicited by frequent colds, add Huang Qi Radix Astragali and Fang Feng Radix Saposhnikoviae.
SUMMARY DAMP PHLEGM IN THE LUNGS Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu. Reinforcing method on ST-36, Ren-12 and BL-20, reducing or even method on the others. Moxa is applicable. Herbal therapy Prescription ER CHEN TANG and SAN ZI YANG QIN TANG Two Old Decoction and Three-Seed Nourishing the Parents Decoction
Repeated attacks of a barking cough with profuse expectoration of yellow or blood-flecked purulent sputum, breathlessness, rattling sound in the throat, a feeling of oppression in the chest, red face, feeling of heat, dry mouth, thirst, tiredness, loose stools. Tongue: Red, Swollen, with a sticky-yellow coating. Pulse: Slippery and Rapid. This condition is similar to Phlegm-Heat cough at the acute stage. It differs from it insofar as it is a chronic condition occurring against a background of Spleen deficiency (hence the tiredness and loose stools). In chronic cases, it occurs when there is a residual Phlegm-Heat in the Lungs; this is a very common cause of chronic cough at all ages from childhood to old age.
Treatment principle Clear Heat, resolve Phlegm, restore the descending of Lung-Qi, stop cough, tonify the Spleen.
Acupuncture Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu, Du-14 Dazhui and L.I.-11 Quchi. Reinforce Ren-12, BL-20, and ST-36; reduce all the others. No moxa.
Explanation • Du-14 and L.I.-11 clear Heat. • All the other points are the same as for Damp Phlegm and have already been explained.
Herbal therapy Prescription QING JIN HUA TAN TANG Clearing Metal and Resolving Phlegm Decoction
Explanation This formula clears Lung-Heat, resolves Phlegm-Heat in the Lungs and restores the descending of Lung-Qi.
Modifications • As there is nearly always a Spleen deficiency that produces Phlegm, add Bai Zhu Rhizoma Atractylodis macrocephalae and Dang Shen Radix Codonopsis.
Cough
• If there is purulent sputum, add Dan Nan Xing Rhizoma Arisaematis preparatum, Yi Yi Ren Semen Coicis and Dong Gua Ren Semen Benincasae. • If there is a pronounced feeling of oppression of the chest and constipation, add Da Huang Radix et Rhizoma Rhei. • If the Heat part of Phlegm-Heat has begun to injure fluids, add Nan Sha Shen Radix Adenophorae, Tian Men Dong Radix Asparagi and Tian Hua Fen Radix Trichosanthis.
SUMMARY PHLEGM-HEAT IN THE LUNGS Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu, Du-14 Dazhui and L.I.-11 Quchi. Reinforce Ren-12, BL-20, and ST-36; reduce all the others. No moxa. Herbal therapy Prescription QING JIN HUA TAN TANG Clearing Metal and Resolving Phlegm Decoction
Case history An 80-year-old woman had been suffering from a persistent cough for 5 years. The cough was productive of scanty-sticky yellow sputum, and she experienced a feeling of oppression of the chest. Her health was otherwise very good; she was a keen practitioner and teacher of yoga. Her body was thin and her skin was dry. Her pulse was slightly Floating-Empty in general and slightly Slippery on the Lung position. Her tongue was Red, dry, and without coating in the front part (Plate 8.1). Diagnosis This is a case of retention of Phlegm-Heat in the Lungs occurring against a background of LungYin deficiency. The Phlegm-Heat is indicated by the sticky-yellow sputum and Slippery pulse quality on the Lung position, while the Lung-Yin deficiency is apparent from the thin body, the dry skin, the FloatingEmpty pulse and the Red tongue without coating in the front part (Lung area).
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Treatment The treatment principle adopted was to resolve Phlegm, clear Heat, nourish Lung-Yin and clear Lung Empty Heat. She was treated with herbs only, and the decoction used was a variation of Qing Jin Hua Tan Tang Clearing Metal and Resolving Phlegm Decoction. • • • • • • • • • • • • • •
Huang Qin Radix Scutellariae 6 g Shan Zhi Zi Fructus Gardeniae 4 g Zhi Mu Radix Anemarrhenae 6 g Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g Gua Lou Fructus Trichosanthis 9 g Sang Bai Pi Cortex Mori 4 g Chen Pi Pericarpium Citri reticulatae 4.5 g Fu Ling Poria 6 g Jie Geng Radix Platycodi 5 g Mai Men Dong Radix Ophiopogonis 6 g Gan Cao Radix Glycyrrhizae uralensis 3 g Tian Men Dong Radix Asparagi 6 g Kuan Dong Hua (honey-treated) Flos Farfarae 9 g Di Gu Pi Cortex Lycii 4 g
Explanation The original formula was used in its entirety, because it corresponds well to the treatment aim of resolving Phlegm, clearing Heat and restoring the descending of Lung-Qi. • Tian Men Dong was added to nourish Lung-Yin. • Kuan Dong Hua was added to restore the descending of Lung-Qi and stop cough. • Di Gu Pi was added to clear Lung Empty Heat. This patient made a complete recovery after 3 months of taking herbal decoctions along lines similar to the one above.
Phlegm-Fluids in the Lungs Clinical manifestations Cough with a low sound and expectoration of whitewatery-dilute sputum, a feeling of cold, a feeling of oppression in the chest, tiredness, poor appetite and low spirits. Tongue: Pale, Swollen, with a sticky-white coating. Pulse: Soggy. This is not a common pattern seen in chronic cough; it usually occurs only in the elderly.
Treatment principle Drain Dampness, resolve Phlegm, scatter Cold, tonify the Spleen and Kidneys and stop cough.
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Acupuncture
SUMMARY
Points
PHLEGM-FLUIDS IN THE LUNGS
LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, SP-9 Yinlingquan, KI-7 Fuliu, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu, Du-4 Mingmen, BL-23 Shenshu, BL-22 Sanjiaoshu. Reinforcing method on ST-36, Ren-12, BL-20, Du-4 and BL-23, reducing or even method on the others. Moxa is applicable.
Points LU-5 Chize, LU-1 Zhongfu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6 Sanyinjiao, SP-9 Yinlingquan, KI-7 Fuliu, BL-20 Pishu, ST-36 Zusanli, BL-13 Feishu, Du-4 Mingmen, BL-23 Shenshu, BL-22 Sanjiaoshu. Reinforcing method on ST-36, Ren-12, BL-20, Du-4 and BL-23, reducing or even method on the others. Moxa is applicable.
Explanation With acupuncture, the treatment of Phlegm-Fluids is not very different from that of Damp Phlegm outlined above. • Du-4 and BL-23 are reinforced with moxa if there is a Kidney-Yang deficiency. • BL-22 is reduced to promote the transformation of fluids and therefore resolve Phlegm. • All the other points have been explained under Damp Phlegm.
Herbal therapy Prescription LING GAN WU WEI JIANG XIN TANG Poria-Glycyrrhiza-Schisandra-Zingiber-Asarum Decoction
Liver-Fire insulting the Lungs Clinical manifestations
Herbal therapy Prescription LING GAN WU WEI JIANG XIN TANG Poria-Glycyrrhiza-Schisandra-Zingiber-Asarum Decoction
Explanation This formula resolves Cold Phlegm and Phlegm-Fluids.
Modifications • This condition is very chronic and occurs against a background of Spleen-Yang deficiency and often Kidney-Yang deficiency. In such cases one should add herbs to tonify Spleen- and Kidney-Yang, such as Bai Zhu Rhizoma Atractylodis macrocephalae, Huang Qi Radix Astragali, Yin Yang Huo Herba Epimidii and Du Zhong Cortex Eucommiae ulmoidis. • If there are very pronounced symptoms of Cold, add Fu Zi Radix Aconiti lateralis preparata. However, in such a case, one must be absolutely sure that there is no Heat anywhere in the body, as the three herbs Gan Jiang, Xi Xin and Fu Zi are very hot, pungent and scattering. Please note that the use of Fu Zi is illegal in Europe. • To enhance the antitussive effect, add Su Zi Fructus Perillae, Xuan Fu Hua Flos Inulae and Xing Ren Semen Armeniacae.
Sudden bouts of cough, a red face often elicited by emotional stress, dry throat, a feeling of phlegm in the throat, expectoration of scanty phlegm, hypochondrial distension and pain, pain on coughing, bitter taste, dark urine, dry stools, irritability and a dry mouth. Tongue: Red with redder sides, dry-yellow coating. Pulse: Wiry and Rapid. This is not a common pattern seen in chronic cough.
Treatment principle Clear the Lungs, drain Liver-Fire, restore the descending of Lung-Qi and stop cough.
Acupuncture Points LIV-2 Xingjian, G.B.-34 Yanglingquan, L.I.-11 Quchi, LU-5 Chize, LU-1 Zhongfu, Ren-17 Shanzhong, G.B.-21 Jianjing. All with reducing or even method.
Explanation • LIV-2 drains Liver-Fire. • G.B.-34 pacifies the Liver and eliminates stagnation from the hypochondrial region and chest. • L.I.-11 clears Heat. • LU-5 and LU-1 clear Lung-Heat and restore the descending of Lung-Qi.
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• Ren-17 subdues rebellious Qi in the chest and restores the descending of Lung-Qi. • G.B.-21 subdues rebellious Qi and makes Qi descend.
CHRONIC EMPTY
Herbal therapy
Slight cough with low sound, no phlegm, spontaneous sweating, propensity to catching cold, weak voice, tiredness and pale face. Tongue: Pale. Pulse: Empty.
Prescription XIE BAI SAN and DAI GE SAN Draining Whiteness Powder and Indigo-Concha Cyclinae Powder
Explanation
Lung-Qi Deficiency Clinical manifestations
Treatment principle Tonify Lung-Qi and restore the descending of Lung-Qi.
These two formulae together clear Lung-Heat, drain Liver-Fire, restore the descending of Lung-Qi and stop cough.
Acupuncture
Modifications
Points
• If symptoms of Heat are pronounced, add Shan Zhi Zi Fructus Gardeniae and Mu Dan Pi Cortex Moutan. • If there is a lot of Phlegm and severe cough, add Zhu Ru Caulis Bambusae in Taeniam, Su Zi Fructus Perillae and Pi Pa Ye Folium Eriobotryae. • If there is severe cough and other symptoms of rebellious Qi (such as fullness of the chest), add Shan Zhi Shi Fructus Aurantii immaturus and Xuan Fu Hua Flos Inulae. • If there is chest pain, add Yu Jin Radix Curcumae. • If Fire has begun to injure fluids, add Nan Sha Shen Radix Adenophorae, Mai Men Dong Radix Ophiopogonis and Tian Hua Fen Radix Trichosanthis.
LU-9 Taiyuan, BL-13 Feishu, LU-7 Lieque, BL-43 Gaohuangshu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao. Reinforcing method; moxa is applicable.
SUMMARY LIVER-FIRE INSULTING THE LUNGS Points LIV-2 Xingjian, G.B.-34 Yanglingquan, L.I.-11 Quchi, LU-5 Chize, LU-1 Zhongfu, Ren-17 Shanzhong, G.B.-21 Jianjing. All with reducing or even method. Herbal therapy Prescription XIE BAI SAN and DAI GE SAN Draining Whiteness Powder and Indigo-Concha Cyclinae Powder
Explanation • LU-9 and BL-13 tonify Lung-Qi and stop cough. • LU-7 restores the descending of Lung-Qi. • BL-43 nourishes Lung-Yin and is specific for chronic Lung problems. • Ren-12, ST-36 and SP-6 tonify both Spleen and Lungs (since the Lung channel starts in the Middle Burner).
Herbal therapy Prescription BU FEI TANG Tonifying the Lungs Decoction
Explanation This formula tonifies Lung-Qi, restores the descending of Lung-Qi and stops cough.
Modifications • If there is Spleen-Qi deficiency, add Bai Zhu Rhizoma Atractylodis macrocephalae. • If there is Kidney-Yang deficiency, add Xu Duan Radix Dipsaci and Hu Tao Rou Semen Juglandis.
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SUMMARY
Herbal therapy
LUNG-QI DEFICIENCY
Prescription
Points LU-9 Taiyuan, BL-13 Feishu, LU-7 Lieque, BL-43 Gaohuangshu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao. Reinforcing method; moxa is applicable.
SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction
Herbal therapy Prescription BU FEI TANG Tonifying the Lungs Decoction
Lung-Yin Deficiency Clinical manifestations Dry cough in short bursts and with a low sound, scanty phlegm or none, blood-flecked sputum, dry throat, feeling of heat in the evening, night sweating, thin body, extreme tiredness. Tongue: without coating, dry, Lung cracks. If there is Empty Heat, the body is Red. Pulse: Floating-Empty.
Treatment principle Nourish Lung-Yin, moisten the Lungs, clear Empty Heat if necessary, restore the descending of Lung-Qi and stop cough.
Acupuncture Points LU-9 Taiyuan, LU-10 Yuji, Ren-12 Zhongwan, LU-1 Zhongfu, ST-36 Zusanli, SP-6 Sanyinjiao, LU-7 Lieque and KI-6 Zhaohai. All with reinforcing method except for LU-10, which should be reduced. No moxa.
Explanation • LU-9 and LU-1 nourish Lung-Yin. • LU-10 clears Lung Empty Heat. • Ren-12, ST-36 and SP-6 tonify the Spleen to nourish the Lungs. • LU-7 and KI-6 in combination open the Directing Vessel (Ren Mai), benefit the throat, nourish LungYin, restore the descending of Lung-Qi and stop cough from Lung-Yin deficiency.
Explanation This formula nourishes Lung-Yin, clears Empty Heat, restores the descending of Lung-Qi and stops cough.
Modifications • To enhance the antitussive effect, add Zhe Bei Mu Bulbus Fritillariae thunbergii and Xing Ren Semen Armeniacae. • If there are pronounced symptoms of Empty Heat in the Lungs, add Di Gu Pi Cortex Lycii and Qing Hao Herba Artemisiae annuae. • If there is sweating at night, add Wu Mei Fructus Mume and Fu Xiao Mai Fructus Tritici levis. • If there is some scanty yellow sputum, add Hai Ge Ke Concha Meretricis seu Cyclinae and Huang Qin Radix Scutellariae. • If there is blood in the sputum, add charred Shan Zhi Zi Fructus Gardeniae, Mu Dan Pi Cortex Moutan and Bai Mao Gen Rhizoma Imperatae.
SUMMARY LUNG-YIN DEFICIENCY Points LU-9 Taiyuan, LU-10 Yuji, Ren-12 Zhongwan, LU-1 Zhongfu, ST-36 Zusanli, SP-6 Sanyinjiao, LU-7 Lieque and KI-6 Zhaohai. All with reinforcing method except for LU-10, which should be reduced. No moxa. Herbal therapy Prescription SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction
Lung-Dryness Clinical manifestations Dry cough with a low sound, dry throat and mouth. Tongue: Dry. Pulse: Floating-Empty.
Cough
This is a condition of Dryness of the Lungs and, although it does not show all the symptoms of Yin deficiency, it is a state that often precedes Yin deficiency. It frequently occurs in people with a predisposition to Lung deficiency who, through their work, need to use their voice a lot (such as teachers). In such cases, it is usually associated with a deficiency of Stomach-Yin because the Stomach is the origin of fluids. This pattern may also arise following an invasion of Wind-Heat that dries the Lung’s fluids and leads to Dryness with some residual Heat or Phlegm-Heat in the Lungs. It is manifested with a very dry and ticklish cough immediately following an invasion of WindHeat. The cough is very persistent and is worse at night.
Treatment principle Moisten the Lungs, restore the descending of Lung-Qi and stop cough.
Acupuncture
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Modifications • To enhance the antitussive effect, add Sang Bai Pi Cortex Mori and Zi Wan Radix Asteris.
Prescription QING ZAO JIU FEI TANG Clearing Dryness and Rescuing the Lungs Decoction
Explanation This formula, which is for Dryness and residual Heat in the Lungs following an invasion of Wind-Heat, restores the descending of Lung-Qi, stops cough, clears Lung-Heat and nourishes and moistens Lung-Yin. The cough is usually dry without phlegm, although it may be dry with the occasional, difficult expectoration of scanty phlegm.
Prescription BEI MU GUA LOU SAN Fritillaria-Trichosanthes Powder
Points
Explanation
LU-9 Taiyuan, LU-10 Yuji, Ren-12 Zhongwan, LU-1 Zhongfu, ST-36 Zusanli, SP-6 Sanyinjiao, LU-7 Lieque and KI-6 Zhaohai. All with reinforcing method except for LU-10, which should be reduced. No moxa.
This formula restores the descending of Lung-Qi, stops cough and resolves Phlegm-Heat. It is also for Dryness and residual Heat in the Lungs following an invasion of Wind-Heat, but with the addition of some Phlegm. The cough is therefore dry but with some scanty and sticky phlegm that is difficult to expectorate. This situation arises because of WindHeat, which, on the one hand, may dry up fluids leading to Dryness or, on the other hand, condenses fluids into Phlegm.
Explanation These points are the same as for Lung-Yin deficiency and have already been explained above.
Herbal therapy Prescription SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction
Explanation This formula has already been explained above.
Prescription SHENG MAI SAN Generating the Pulse Powder
Explanation This formula tonifies Lung-Qi, generates fluids and nourishes Lung-Yin.
SUMMARY LUNG-DRYNESS Points LU-9 Taiyuan, LU-10 Yuji, Ren-12 Zhongwan, LU-1 Zhongfu, ST-36 Zusanli, SP-6 Sanyinjiao, LU-7 Lieque and KI-6 Zhaohai. All with reinforcing method except for LU-10, which should be reduced. No moxa. Herbal therapy Prescription SHA SHEN MAI DONG TANG Glehnia-Ophiopogon Decoction
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Prescription SHENG MAI SAN Generating the Pulse Powder
KI SP
Prescription QING ZAO JIU FEI TANG Clearing Dryness and Rescuing the Lungs Decoction Prescription BEI MU GUA LOU SAN Fritillaria-Trichosanthes Powder
MODERN CHINESE LITERATURE Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 30, No. 5, 1999, pp. 35–36. Zhu Sheng Chao, “Clinical observation on the prevention of cough and breathlessness in children with massage in the summer.” This article explores the clinical effect of giving children preventive treatment in the summer to prevent cough and breathlessness in the winter. Dr Zhu treated 112 children (73 boys and 39 girls), of whom 35 were aged between 1 and 3, 59 between 3 and 7, and 18 between 7 and 12. To prevent their developing a cough of external origin in winter, treatment was given in the summer based on the “Three Tonifications”, “Two Kneadings” and “One Pressure”. The “Three Tonifications” are tonification of the Spleen, Lungs and Kidneys. These three organs are tonified by massaging the thumb, fourth finger and fifth finger. To tonify the Spleen, the thumb is massaged with a stroking movement on the radial side from the tip towards the wrist. To tonify the Lungs, the ring finger is massaged with a stroking movement on the radial side from the tip towards the palm. To tonify the Kidneys, the little finger is massaged with a stroking movement on the radial side from the tip towards the palm (Fig. 8.7). Each of the fingers is stroked 100 times.
Figure 8.7 Paediatric massage to prevent cough in winter.
The “Two Kneadings” are kneading of Ren-17 Shanzhong (50 times) and BL-13 Feishu (100 times). The “One Pressure” consists of pinching-pulling over the spine from the coccyx to Du-14 Dazhui and in kneading BL-13 Feishu, BL-20 Pishu and BL-21 Weishu 10 times each. For chronic cough in children, Dr Zhu recommends three techniques: 1. massaging the areas of the “Eight Trigrams” in the palm of the hand 50 times (Fig. 8.8) 2. massaging the radial side of the thumb from LU10 Yuji to LU-11 Shaoshang 100 times (Fig. 8.9). The latter technique is called the “Three Gates”. 3. massaging BL-23 Shenshu.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 41, No. 10, 2000, p. 637. Hong Hai Zhou, “Treat stasis for night cough.” Dr Hong says that coughing at night is due to deficient Yang and Excess of Yin. More specifically, it is due to Lung-Qi not descending, Qi and Blood not being regulated, Cold stagnating in the Interior and Blood stasis.
Cough
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LU-10 5
6
4
7 8
3
2
1
Figure 8.9 “Three Gates” massage for children.
Figure 8.8 “Eight Trigrams” massage for children.
Dr Hong therefore advocates invigorating Blood and eliminating stasis for night cough. He considers Dang Gui Radix Angelicae sinensis to be the main herb for this aim, together with Hong Hua Flos Carthami tinctorii and Tao Ren Semen Persicae.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 36, No. 7, 1995, p. 409. Shi Xin De and An Bao Hua, “284 cases of cough from Lung-Heat treated with Qing Jin Zhi Ke Tang.” Dr Shi and Dr An report on the treatment of 284 patients with acute cough from Lung-Heat. There were 161 men and 123 women; the youngest patient was 2.5 and the oldest 42. The formula used was Qing Jin Zhi Ke Tang Clearing Metal and Stopping Cough Decoction. • • • • • • •
Jin Yin Hua Flos Lonicerae japonicae 10 g Chai Hu Radix Bupleuri 10 g Huang Qin Radix Scutellariae 12 g Shi Gao Gypsum fibrosum 20 g Da Huang Radix et Rhizoma Rhei 6 g Sang Bai Pi Cortex Mori 12 g Xing Ren Semen Armeniacae 10 g
• • • • • • • •
Jie Geng Radix Platycodi 10 g Ma Huang (fried with honey) Herba Ephedrae 3 g Lu Gen Rhizoma Phragmitis 12 g Mai Men Dong Radix Ophiopogonis 10 g Sheng Di Huang Radix Rehmanniae 10 g Ju Hua Flos Chrysanthemi 10 g Bo He Herba Menthae haplocalycis 6 g Gan Cao Radix Glycyrrhizae uralensis 6 g
This formula should be modified according to clinical manifestations. • Headache, stuffy nose, sore throat: add Ban Lan Gen Radix Isatis seu Baphicacanthis, Ma Bo Lasiosphaera/ Calvatia, Shan Dou Gen Radix Sophorae tonkinensis. • Aversion to cold, wheezing: add Xuan Shen Radix Scrophulariae, Ma Bo Lasiosphaera/Calvatia, Zhe Bei Mu Bulbus Fritillariae thunbergii. • Dry throat, no phlegm or scanty phlegm: add Bei Sha Shen Radix Glehniae, Li Pi (pear skin), Shan Zhi Zi Fructus Gardeniae, Zhe Bei Mu Bulbus Fritillariae thunbergii. • Thirst, profuse yellow phlegm: add Chi Shao Radix Paeoniae rubra, Gua Lou Fructus Trichosanthis, Yu Jin Radix Curcumae, Xuan Shen Radix Scrophulariae. • Mental restlessness, thirst: add Bei Sha Shen Radix Glehniae, Xuan Shen Radix Scrophulariae, Tian Hua Fen Radix Trichosanthis. • Lesser Yang pattern: add Shi Gao Gypsum fibrosum, Ban Xia Rhizoma Pinelliae preparatum, Bai Bu Radix Stemonae.
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Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 42, No. 9, 2001, p. 568. Bo Li Ye et al, “The treatment of cough of external origin in children with the method of restoring the diffusing of Lung-Qi and penetrating the Yang Organs.” This is an interesting article reporting a clinical trial that did not involve the comparison of Chinese medicine with a placebo or a Western drug but that of two different Chinese methods of treatment. The authors explain that, in the treatment of cough from external origin, one normally uses the method of restoring the diffusing of Lung-Qi with pungent and clearing herbs that make Qi diffuse and descend. They think that, in children, it is necessary also to “penetrate the Yang Organs”, which means moving Qi downwards by stimulating the bowel movement with Da Huang Radix et Rhizoma Rhei. The rationale behind the use of Da Huang to stimulate the bowel movement and “penetrate the Yang Organs” is based on the exterior–interior relationship between the Large Intestine and Lungs. The unblocking of the Large Intestine means that Lung-Qi can descend and therefore alleviate cough. The authors treated 130 children suffering from cough of external origin and a control group of 70 children. In the treatment group, there were 62 boys and 68 girls; 99 were aged between 2 and 10, and 31 between 11 and 15. The formula used for the treatment and control groups was the same, i.e. Ma Xing Shi Gan Tang EphedraArmeniaca-Gypsum-Glycyrrhiza Decoction, except that the decoction in the treatment group contained Da Huang Radix et Rhizoma Rhei and that in the control group it did not. If the children suffered from constipation, Da Huang was added towards the end of boiling the decoction (this increases its downwards movement and stimulates the bowel movement more); if they did not suffer from constipation, Da Huang was boiled together with the other herbs. The results in the treatment group were as follows. • Cured within 1–3 days: 118 (90.8%) • Cured within 4–6 days: 10 (7.7%) • Cured in over 7 days: 2 (1.5%)
In the control group, the results were as follows. • Cured within 1–3 days: 48 (69.1%) • Cured within 4–6 days: 19 (27.1%) • Cured in over 7 days: 3 (3.8%) Statistically, P < 0.01.
Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 42, No. 9, 1994, p. 524. Su Yun Fang, “The experience of Dr Jiang Shi Ying in the treatment of cough from autumn Dryness with the method of moistening.” In an account of the experience of a famous contemporary doctor in the treatment of dry cough caused by autumn dryness, Dr Su reports three different formulae: one for dryness affecting the Lungs and the Upper Burner, one for Dryness affecting the Lungs and one for Dryness affecting the Lungs with Lung-Qi deficiency. The formula for Dryness affecting the Lungs and the Upper Burner (dry eyes and mouth) is as follows. • • • • • • • •
Sang Ye Folium Mori 10 g Ju Hua Flos Chrysanthemi 12 g Lian Qiao Fructus Forsythiae 10 g Chan Tui Periostracum Cicadae 6 g Jie Geng Radix Platycodi 12 g Zhu Ye Folium Phyllostachys nigrae 10 g Ku Ding Cha Folium Ilecis cornutae 10 g Lai Fu Zi Semen Raphani 10 g The formula for Dryness in the Lungs is as follows.
• • • • • • • • • •
Sang Ye Folium Mori 12 g Bei Sha Shen Radix Glehniae 12 g Mai Men Dong Radix Ophiopogonis 10 g Xing Ren Semen Armeniacae 10 g Zi Wan Radix Asteris 10 g Kuan Dong Hua Flos Farfarae 10 g Pi Pa Ye Folium Eriobotryae 10 g Bai Bu Radix Stemonae 12 g Chen Pi Pericarpium Citri reticulatae 6 g Jie Geng Radix Platycodi 6 g
The formula for Dryness in the Lungs with Lung-Qi deficiency is as follows. • Xi Yang Shen Radix Panacis quinquefolii 12 g • Bei Sha Shen Radix Glehniae 10 g
Cough
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asthma and in 82% with non-bronchial asthma conditions. Bakumondo-to was more effective in reducing cough sensitivity to capsaicin in bronchial asthma than in non-bronchial asthma conditions. While Bakumondo-to did not significantly reduce the sputum eosinophil count, its effectiveness in suppressing cough was greatest in patients whose sputum eosinophil count was less than or equal to 2%. It remains to be established whether Bakumondo-to inhibits eosinophil activation.
Herbal medicine
Conclusion
• • • • • • •
Mai Men Dong Radix Ophiopogonis 12 g Lu Gen Rhizoma Phragmitis 10 g Xing Ren Semen Armeniacae 6 g Zi Wan Radix Asteris 10 g Kuan Dong Hua Flos Farfarae 10 g Bai Bu Radix Stemonae 10 g Sang Ye Folium Mori 10 g
The effects of Bakumondo-to (Mai Men Dong Tang Ophiopogon Decoction) on asthmatic and non-asthmatic patients with increased cough sensitivity
The results suggest that Bakumondo-to is an effective therapeutic preparation for cough hypersensitivity accompanying chronic cough disease, especially in cases of severe allergic inflammation.
Nihon Kokyuki Gakkai Zasshi [Japanese Respiratory Journal] 2004 January, Vol. 42, Issue 1, pp. 49–55. Watanabe N, Gang C, Fukuda T Department of Pulmonary Medicine and Clinical Immunology, Dokkyo University School of Medicine, Tochigi, Japan
Treatment of acute bronchiolitis with Chinese herbs
Objective
Objective
This study was conducted to investigate the effect of Bakumondo-to (Mai Men Dong Tang) on cough sensitivity in patients with bronchial asthma and nonasthmatic (non-bronchial asthma) conditions. The effect on respiratory tract inflammation was also examined.
To evaluate the effect of the Chinese herb Huang Lian (Rhizoma Coptidis) on acute bronchiolitis.
Method Twenty-one bronchial asthma and 22 non-bronchial asthma subjects whose cough threshold for capsaicin was less than 3.9 mM were examined. Solutions of 1000, 500, 250, 125, 62.5, 31.2, 15.6, 7.80, 3.90, 1.95, 0.98, and 0.49 mM were prepared. Cough thresholds to a concentration of inhaled capsaicin solution causing five or more coughs was measured before treatment and after 2 months or more of treatment with Bakumondo-to (9 g/day, TJ-29). The number of eosinophils in the peripheral blood, the sputum eosinophil ratio, and the eosinophil cationic protein level in the serum were also measured before and after treatment.
Results Bakumondo-to significantly improved the cough threshold value in 76% of patients with bronchial
Archives of Disease in Childhood 1993 April, Vol. 68, Issue 4, pp. 468–471. Kong XT, Fang HT, Jiang GQ, Zhai SZ, O’Connell DL, Brewster DR
Method In a randomized single-blind trial, children with acute bronchiolitis and serological evidence of recent respiratory syncytial virus infection were studied in a tertiary hospital in Harbin, China. The 96 children were randomized into three treatment groups: herbs, herbs with antibiotics and antibiotics alone. The herbs were prepared by the medical school pharmacy and administered daily by intravenous infusion for 7 days.
Results The main outcomes, assessed blindly, were symptomatic improvement in cough, fever, wheezing, chest signs and duration of stay in hospital. The mean duration of symptoms from the start of treatment was 6.2 (ranging from 5.6 to 6.9) days in the two groups treated with herbs, compared with 8.6 (ranging from 7.5 to 9.8) days in the group treated with antibiotics alone. The mean reductions in duration of clinical manifestations for treatment with antibiotics alone compared with herbs were from 3.1 to 1.5 days for fever, 9.1 to
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6.1 days for cough, 6.5 to 4.1 days for wheezing and 7.2 to 4.9 days for chest crackles. No adverse effect of Huang Lian herbal treatment was detected.
Conclusion In conclusion, this study confirms that Huang Lian is safe and effective and warrants further study.
Cochrane Database Systemic Review 2005 Wu T, Chen X, Duan X, Juan N, Liu G, Qiao J, Wang Q, Wei J, Zhen J, Zhou L Chinese Cochrane Centre, Chinese Evidence-Based Medicine Centre and Regional Clinical Epidemiology Resource and Training Centre, China
Objective This review aimed to summarize the existing evidence on the comparative effectiveness and safety of Chinese medicinal herbs for treating uncomplicated acute bronchitis.
Search strategy The search included the Cochrane Central Register of Controlled Trials (the Cochrane Library Issue 1, 2005), which includes the Cochrane Acute Respiratory Infections Group’s specialized register; the Chinese Cochrane Centre’s Controlled Trials Register (up to December 2004); Medline (1966 to March week 1, 2005); Embase (1988 to December 2004); and the Chinese Biomedical Database (1980 to December 2004).
were beneficial in terms of relief of signs and symptoms. Thirteen trials analysed the data on physician global assessment of improvement at follow-up. Nine of 13 trials showed that Chinese herbs were superior to routine treatment, and the other four trials showed a similar effect to routine treatment. In general, Chinese herbs appeared beneficial. Only one trial reported on adverse effects during treatment.
PROGNOSIS Both acupuncture and Chinese herbs give excellent results in the treatment of cough. Obviously acute cough, whether it is external or internal, is easier and quicker to treat. Coughs from acute respiratory infections can be cleared in a few days at the Defensive-Qi or Qi level, and it is not necessary to take antibiotics, which often only lead to residual Heat or Phlegm-Heat. Chronic coughs are also relatively easy to treat; the most difficult one is that from Lung-Yin deficiency, which may take some months to clear. Of all the patterns appearing with a chronic cough, Chinese herbs give better results in the patterns of Damp Phlegm, Phlegm-Heat, Phlegm-Fluids and Lung-Yin deficiency.
WESTERN DIFFERENTIATION
Selection criteria
The following are the main causes of cough from the perspective of Western medicine.
Randomized controlled trials comparing Chinese medicinal herbs with placebo, antibiotics or other Western medicines for the treatment of uncomplicated acute bronchitis.
Tracheitis
Data collection and analysis At least two authors extracted data and assessed trial quality.
Main results Four trials reported the time to improvement of cough, fever and rales associated with bronchitis and showed that patients treated with Chinese herbs had a shorter duration of signs and symptoms. Two trials reported the proportion of patients with improved signs and symptoms at follow-up and showed that Chinese herbs
This usually occurs following an invasion of WindHeat (upper respiratory infection). The cough is harsh and painful, and the throat and trachea feel very raw and sore. It is usually worse at night. From a Chinese perspective, this broadly corresponds to Lung-Dryness following an invasion of Wind-Heat.
Acute bronchitis This usually follows an upper respiratory infection, and the cough is loose with expectoration of yellow, green or purulent sputum. The temperature and pulse are raised.
Cough
From the point of view of Chinese medicine, this broadly corresponds to the Qi level with Phlegm-Heat in the Lungs.
Chronic bronchitis This is usually the consequence of repeated bouts of acute bronchitis. It is more frequent in smokers over 40. The cough is productive of white, yellow or bloodflecked sputum. From a Chinese perspective, this corresponds to either Damp Phlegm or Phlegm-Heat in the Lungs on a background of Spleen deficiency.
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is high, the patient is flushed, the pulse and the breathing are rapid. There may also be movement in the alae nasi. From the Chinese point of view, it corresponds to Lung-Heat at the Qi level.
Carcinoma of the bronchi The most common cancer of all, this occurs most often in men between 40 and 55. It is characterized by a dry cough, breathlessness and a deep-seated thoracic pain. There may be some scanty, blood-flecked sputum. The patient is weak and debilitated and lacks appetite. From the Chinese point of view, it corresponds, in its late stage, to Lung-Yin deficiency.
Whooping cough This occurs in children, mostly under 5. It starts like an ordinary cold with a cough. After a week, the characteristic “whoop” appears. The cough comes in bouts that are worse at night and are very distressing. The coughing bouts often end in vomiting. The child is flushed or cyanosed and looks frightened. Chinese medicine can alleviate the symptoms and shorten the course of this disease, but it requires very many treatments given every day. In the beginning stage, it corresponds to invasion of Wind-Heat; in the middle stage to Lung-Heat; and in the recovery stage to Stomach- and Lung-Yin deficiency, possibly with some residual Heat.
Pleurisy This consists of inflammation of the pleura, usually occurring after an upper respiratory infection. The cough is unproductive and distressingly painful. There is also chest pain and the temperature is raised. From the point of view of Chinese medicine, it corresponds to Lung Phlegm-Heat at the Qi level.
Pneumonia This consists of inflammation of the lung alveoli. It may begin abruptly with shivering, a headache, a high temperature and breathlessness. The cough is short and unproductive at first. It then develops scanty sputum, which is viscid, rust-coloured and bloodflecked. Pneumonia is nearly always accompanied by pleurisy, which causes chest pain. The temperature
Tuberculosis of the lungs This is an uncommon disease, but it is on the increase in both the UK and the USA. It is more frequent between the ages of 15 and 45. The cough is dry or with a scanty, blood-flecked sputum. There is also a chest pain, breathlessness and night sweating. The patient is very tired and debilitated and may have a low-grade fever in the afternoons. From the Chinese point of view, this condition is typical of Lung-Yin deficiency with Empty Heat.
Bronchiectasis This consists of permanent dilatation of bronchi and/or bronchioles. The alveoli become distended and filled with mucus. The cough occurs more in the mornings and is productive of large amounts of sputum, which is purulent and has a fruity odour. The breath is offensive after a bout of coughing. During acute episodes, there is a temperature. From the point of view of Chinese medicine, it may broadly correspond to the pattern of Turbid Phlegm in the Lungs in Breathlessness (Chuan).
Heart disease In the elderly, cough may also occur with heart disease. A cough at night that is productive of a very watery, white and frothy sputum may indicate impending left ventricular failure. On the other hand, left ventricular failure may also cause pulmonary
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embolism manifesting with a sudden, severe chest pain with dyspnoea and followed by a cough with bloodstained sputum.
END NOTES 1. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 150. First published c.100 BC. 2. Ibid., p. 215. 3. Ibid., pp. 215–216. 4. Ibid., p. 214. 5. Ibid., p. 216. 6. 1986 Jing Yue Quan Shu [Complete Book of Jing Yue]. Shanghai Science Publishing House, Shanghai, p. 336. The Complete Book of Jing Yue was written by Zhang Jing Yue and first published in 1624.
7. Zhou Chao Fan 2000 Li Dai Zhong Yi Zhi Ze Jing Hua [Essential Chinese Medicine Treatment Principles in Successive Dynasties]. Chinese Herbal Medicine Publishing House, Beijing, p. 285. 8. Ibid., p. 285. 9. Simple Questions, p. 74. 10. 1981 Jin Gui Yao Lue Fang Xin Jie [A New Explanation of the Essential Prescriptions of the Golden Chest]. Zhejiang Scientific Publishing House, Zhejiang, p. 56. The Essential Prescriptions of the Golden Chest was written by Zhang Zhong Jing and first published c.AD 220. 11. Ibid., p. 285. 12. Ibid., p. 287. 13. Essential Chinese Medicine Treatment Principles in Successive Dynasties, p. 286. 14. Ibid., p. 286. 15. Ibid., p. 291. 16. Complete Book of Jing Yue, p. 336.
CHAPTER 9
THE PSYCHE IN CHINESE MEDICINE NATURE OF THE MIND (SHEN) IN CHINESE MEDICINE THE FIVE MENTAL-SPIRITUAL ASPECTS The Ethereal Soul (Hun) 248 The Corporeal Soul (Po) 264 The Intellect (Yi) 272 The Will-Power (Zhi) 274
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THE PSYCHE IN CHINESE MEDICINE A discussion of the treatment of mental and emotional problems is not possible without first exploring the concept of the mind and spirit in Chinese medicine. It is only by understanding the concept of mind and spirit in Chinese culture that we can truly grasp how to treat psychological and emotional problems with acupuncture and Chinese herbs. We must be careful not to interpret the Chinese concepts of “mind” and “spirit” in terms of Western (and often Christian) concepts of “mind” and “spirit”. The discussion of the treatment of mental-emotional problems will be centred on the following subjects. • The nature of the psyche in Chinese medicine (Chapter 9) • The five mental-spiritual aspects of a human being (Chapter 9) • The effect of the emotions on the Mind and Spirit (Chapter 10) • Aetiology of mental-emotional problems (Chapter 11) • Diagnostic signs in mental-emotional problems (Chapter 12) • Acupuncture in the treatment of mental-emotional problems (Appendix 5) • Pathology and treatment of depression (Chapter 13)
• Pathology and treatment of anxiety (Chapter 14) • Pathology and treatment of insomnia (Chapter 15) • Patterns in mental-emotional problems and their treatment with herbal medicine and acupuncture (Chapter 16) The discussion of the psyche in Chinese medicine in the present chapter will be conducted according to the following topics. • Nature of the Mind (Shen) in Chinese medicine • The five mental-spiritual aspects
NATURE OF THE MIND (SHEN) IN CHINESE MEDICINE The Mind (Shen) is one of the vital substances of the body. It is the most subtle and non-material type of Qi. Most authors translate the word Shen as “spirit”; for reasons that will be clearer as the discussion progresses, I prefer to translate Shen of the Heart as “Mind” rather than as “Spirit”. I translate as “Spirit” the complex of all five mental-spiritual aspects of a human being, i.e. the Ethereal Soul (Hun), the Corporeal Soul (Po), the Intellect (Yi), the Will-Power (Zhi) and the Mind (Shen) itself. All sinologists who write about the Confucian and neo-Confucian philosophers of the Song and Ming dynasty translate “School of Xin” as “School of Mind”, i.e. they translate the word “Xin” (meaning Heart) as “Mind”. The word Shen is used in the Yellow Emperor’s Classic of Internal Medicine with many different meanings. The two main meanings that concern us are the following. 1. Shen indicates the activity of thinking, consciousness, self-identity, insight and memory, all of which depend on the Heart. I translate this as “Mind”.
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2. Shen indicates the complex of all five mentalspiritual aspects of a human being, i.e. the Mind itself of the Heart, the Ethereal Soul (Hun) of the Liver, the Corporeal Soul (Po) of the Lungs, the Intellect (Yi) of the Spleen and the Will-Power (Zhi) of the Kidneys. I translate this as “Spirit”. There is another meaning to the word Shen that is frequently mentioned in relation to diagnosis. In this context, the word shen indicates an undefinable and subtle quality of “life”, “flourishing” or “lustre”, which can be observed in health. This quality can be observed in the complexion, the eyes, the tongue and the pulse, as will be explained in Chapter 12.
The Mind (Shen) The Chinese character for Shen is composed of two parts. The one on the left, called shi , indicates “influx from heaven; auspicious or inauspicious signs by which the will of Heaven is known to mankind”; this character is itself composed of two horizontal lines at the top, indicating what is above, high and therefore Heaven, and three vertical lines representing what is hanging from Heaven, i.e. the sun, the moon and the stars, the mutations of which reveal to people transcendent things. The right part of the character is the word shen , meaning “to state, to express, to explain, to stretch, to extend”. As we shall see later, the quality of “extending” has an important psychological implication in the life of the Mind (Shen). This part of the character, called shen, is also phonetic, i.e. it gives the word its sound (“shen”). The seal writing shows two hands stretching a rope and hence the idea of stretching, expansion (Fig. 9.1). The combination is probably phonetic, but the idea of spirit may have some connection with an increased or extended spiritual revelation.
! The Chinese character for Shen (Mind) conveys two ideas: “spiritual manifestation” and “to extend”, “to stretch”. It is therefore a pure and subtle Vital Substance that “extends” outwards towards the environment and mediates the relationship between the individual and the environment.
What then is the Chinese view of the Mind? As explained above, the Mind, like other vital substances, is a form of Qi; in fact, it is the most subtle and nonmaterial type of Qi. One of the most important characteristics of Chinese medicine is the close integration of body and Mind, which is highlighted by the integration of the three Vital Substances of Essence (Jing), Qi and Mind (Shen), called the “Three Treasures”. The Essence is the origin and biological basis of the Mind. The Spiritual Axis in Chapter 8 says: “Life comes about through the Essence; when the two Essences [of mother and father] unite, they form the Mind.”1 Zhang Jie Bin says: “The two Essences, one Yin, one Yang, unite ... to form life; the Essences of mother and father unite to form the Mind.”2 See Figure 9.2. Therefore the Mind of a newly conceived being comes from the Prenatal Essences of its mother and father. After birth, its Prenatal Essence is stored in the Kidneys and provides the biological foundation for the Mind. The life and Mind of a newly born baby, however, also
Essence of mother
Essence of father
MIND (Shen) Figure 9.1 Ancient Chinese script for shi.
Figure 9.2 Union of Essences to form Mind.
The Psyche in Chinese Medicine
depend on the nourishment from its own Postnatal Essence. The Spiritual Axis in Chapter 30 says:3 When the Stomach and Intestines are coordinated, the five Yin organs are peaceful, Blood is harmonized and mental activity is stable. The Mind derives from the refined essence of water and food.
will tend to weaken the Essence either when it is combined with overwork and/or excessive sexual activity or when the Fire generated by long-term emotional tensions injures Yin and Essence. CLINICAL NOTE The Three Treasures The Essence (Jing), Qi and Mind (Shen) interact with and influence each other in both directions, i.e. from the Essence to Qi and the Mind, and from the Mind to Qi and to Essence.
Thus the Mind draws its biological basis and nourishment from the Prenatal Essence stored in the Kidneys and the Postnatal Essence produced by Lungs, Stomach and Spleen. Hence the Three Treasures (Fig. 9.3): Mind (Shen) = Heart Qi = Lungs-Stomach-Spleen Essence (Jing) = Kidneys. These Three Treasures represent three different states of condensation or aggregation of Qi, the Essence being the densest, Qi more rarefied, and the Mind the most subtle and non-material. The activity of the Mind relies on the Essence and Qi as its fundamental basis. Hence the Essence is said to be the “foundation of the body and the root of the Mind”. Thus if Essence and Qi are strong and flourishing, the Mind will be happy, balanced and alert. If Essence and Qi are depleted, the Mind will suffer and may become unhappy, depressed, anxious or clouded. Zhang Jie Bin says: “If the Essence is strong, Qi flourishes; if Qi flourishes, the Mind is whole.”4 However, the state of the Mind also affects Qi and Essence. If the Mind is disturbed by emotional stress, becoming unhappy, depressed, anxious, or unstable, it will definitely affect Qi and/or the Essence. In most cases, it will affect Qi first, because all emotional stress upsets the normal functioning of Qi. Emotional stress
MIND
QI
ESSENCE
Heart
Lungs-Stomach-Spleen
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Of all the organs, the Mind is most closely related to the Heart, which is said to be the “residence” of the Mind. The Simple Questions in Chapter 8 says: “The Heart is the Monarch and it governs the Mind ...”5 The Spiritual Axis in Chapter 71 says: “The Heart is the Monarch of the five Yin organs and six Yang organs, and it is the residence of the Mind.”6 The “Mind” residing in the Heart or Heart-Mind is responsible for many different mental activities, including: • • • • • • • • • •
thinking memory consciousness insight emotional life cognition sleep intelligence wisdom ideas.
In addition to these, the Mind of the Heart is also responsible for hearing, sight, touch, taste and smell. Of course, many of the above activities are also carried out by other organs, and there often is an overlap between the functions of various organs. For example, although the Mind is mainly responsible for memory, the Spleen and Kidneys (and therefore Intellect and Will-Power) also play a role. CLINICAL NOTE In order to stimulate the thinking function that is associated with the Heart, I use the points HE-5 Tongli and BL-15 Xinshu.
Kidneys
Figure 9.3 The Three Treasures (Essence, Qi, Mind).
Let us now briefly look at the above functions in more detail.
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Thinking depends on the Mind. If the Mind is strong, thinking will be clear. If the Mind is weak or disturbed, thinking will be slow and dull. The Chinese characters for “thought” (yi), “to think” (xiang) and “pensiveness” (si) all have the character for “heart” as their radical. Memory has two different meanings. On the one hand, it indicates the capacity of memorizing data when one is studying or working. On the other hand, it refers to the ability to remember past events. Both of these depend on the Mind and therefore the Heart, although also on the Spleen and Kidneys. Consciousness indicates the totality of thoughts and perceptions as well as the state of being conscious. In the first sense, the Mind is responsible for the recognition of thoughts, perceptions and feelings. In the latter sense, when the Mind is clear, we are conscious; if the Mind is obfuscated or suddenly depleted, we lose consciousness. Insight indicates our capacity of self-knowledge, self-recognition and identity of self. The Mind of the Heart is responsible for our identity of self as individuals. This is lost in serious mental illness such as schizophrenia. Emotional life refers to the perception and feeling of emotional stimuli. With regard to emotions, only the Mind (and therefore the Heart) can “feel” them. Of course, emotions definitely affect all the other organs too, but it is only the Mind that actually recognizes, feels and assesses them. For example, anger affects the Liver, but the Liver cannot feel it because it does not house the Mind. Only the Heart can feel it, because it houses the Mind, which is responsible for insight. When one feels sad, angry or worried, it is the Mind of the Heart that feels these emotions. It is for this reason that all emotions eventually affect the Heart (in addition to other specific organs), and it is in this sense that the Heart is the “emperor” of all the other organs.
CLINICAL NOTE Only the Mind (and therefore the Heart) can “feel” the emotions. Each emotion affects one or more organs, but it is only the Mind that actually recognizes, feels and assesses them. It is for this reason that all emotions eventually affect the Heart (in addition to other specific organs), and it is in this sense that the Heart is the “emperor” of all the other organs.
As emotions usually tend to cause some Heat, it is for this reason that a red tip of the tongue is such a common sign as all emotions affect the Heart. The best point to use when the Heart is affected by emotional stress is HE-7 Shenmen.
Cognition indicates the activity of the Mind in perceiving and conceiving, in reaction to stimuli. Sleep is dependent on the state of the Mind. If the Mind is calm and balanced, a person sleeps well. If the Mind is restless, the person sleeps badly. However, the Ethereal Soul is also responsible for sleep. Intelligence also depends on the Heart and the Mind. A strong Heart and Mind will make a person intelligent and bright. A weak Heart and Mind will render a person slow and dull. It should be remembered, however, that the Essence, and therefore heredity, plays a role in determining a person’s intelligence. Wisdom derives from a strong Heart and a healthy Mind. As the Mind is responsible for knowing and perceiving, it also gives us the sagacity to apply this knowledge critically and wisely. Ideas are another function of the Mind. The Heart and Mind are responsible for our ideas, our projects and the dreams that give our lives purpose. Thus, if the Heart is strong and the Mind healthy, a person can think clearly, memory is good, the state of consciousness and insight are sharp, the cognition is clear, sleep is sound, intelligence is bright, the emotional life is balanced, ideas flow easily and he or she acts wisely. If the Heart is affected and the Mind weak or disturbed, a person is unable to think clearly, memory is poor, the consciousness is clouded, insight is poor, sleep is restless, the emotional life is unbalanced, intelligence is lacking, ideas are muddled and he or she acts unwisely. Finally, the Mind of the Heart performs the very important function of coordinating and integrating the various parts of our mental-emotional life into an individual whole; this is probably its most important characteristic and function. It is really in this sense that the Heart is the “emperor” or “monarch” of the other organs. Most of the above functions of the Mind are attributed to the brain in Western medicine. During the course of development of Chinese medicine too, there have been doctors who attributed mental func-
The Psyche in Chinese Medicine
tions to the brain rather than the Heart; in particular, Sun Si Miao of the Tang dynasty, Zhao You Qin of the Yuan dynasty, Li Shi Zhen of the Ming dynasty and especially Wang Qing Ren of the Qing dynasty. As the Heart controls all mental activities of the Mind and is responsible for insight and cognition, which other organs do not have, this is another reason that it is the “emperor” of all the other organs. For this reason, the Heart is also called the “root of life”, as in Chapter 9 of the Simple Questions: “The Heart is the root of life and the origin of mental life ...”7 Apart from the above mental functions, the Mind also plays a role in the senses of sight, hearing, smell, taste and touch. The eyes and sight are obviously related to the Liver, especially Liver-Blood, and the Ethereal Soul. The book The Essence of Medical Classics on the Convergence of Chinese and Western Medicine (1892) says: “When the Ethereal Soul swims to the eyes, they can see.”8 However, although the eyes rely on the nourishment from LiverBlood, blood flows to the eyes through blood vessels that are under the control of the Heart. On the other hand, the Mind “gathers” the Ethereal Soul and, in this way, it has an influence on sight. The Simple Questions says in Chapter 10: “Blood vessels influence the eyes.”9 In fact, the Simple Questions also lists excessive use of the eyes as harmful to the blood vessels and Heart. It says in Chapter 23: “Excessive use of the eyes injures Blood [i.e. the Heart].”10 Ren Ying Qiu in Theories of Chinese Medicine Doctors says: “The Heart governs the Mind ... sight is a manifestation of the activity of the Mind.”11 Wang Ken Tang in Standards of Diagnosis and Treatment (1602) says: “The eye is an orifice of the Liver ... but a function of the Heart.”12 From the point of view of channels, both the Heart Main and Connecting (Luo) channels flow to the eye. Hearing depends on the Kidneys, but the Heart also has an influence on it in so far as it brings Qi and Blood to the ears. The Simple Questions in Chapter 4 says: “The colour of the Southern direction is red; it is related to the Heart, which opens into the ears ...”13 Some types of tinnitus are due to Heart-Qi being deficient and not reaching the ears. The sense of smell is also dependent on the Heart and Mind besides the Lungs. The Simple Questions in Chapter 11 says: “The five odours enter the nose and are stored by Lungs and Heart; if Lungs and Heart are diseased, the nose cannot smell.”14 The sense of taste naturally depends on the Heart and Mind, as the tongue is an offshoot of the Heart.
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The sense of touch is also dependent on the Heart and Mind, as this is responsible for the cognition and organization of external stimuli sensations. To sum up, all sensations of sight, hearing, smell, taste and touch depend on the Mind in much the same way as they depend on the brain in Western medicine. Therefore, the Mind (Shen) of the Heart is the Qi that allows the following: • forms life from the union of the Essence of the parents (but life needs also the Corporeal and Ethereal Souls) • allows the individual to be conscious of his or her self • permits the cohesion of various parts of our psyche and emotions • defines us as individuals • feels and assesses the emotions • is responsible for perceptions and senses • is responsible for thinking, memory, intelligence, wisdom, ideas • determines consciousness • allows insight and identity of self • is responsible for perception and cognition • determines sleep • governs the five senses (sight, hearing, smelling, taste, touch).
SUMMARY THE MIND (SHEN) The Mind is the most subtle and refined Vital Substance of the Three Treasures, i.e. Essence (Jing), Qi and Mind (Shen). The Essence, Qi and Mind interact with and influence each other. The Mind is responsible for thinking, memory, consciousness, insight, emotional life, cognition, sleep, intelligence, wisdom and ideation. The Mind is responsible for self-consciousness and the integration of various parts of our psyche.
THE FIVE MENTAL-SPIRITUAL ASPECTS As we have just seen, the Mind, and therefore the Heart, plays a pivotal and leading role in all mental
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activities. Yu Chang in Principles of Medical Practice (1658) says clearly: “The Mind [Shen] of the Heart gathers and unites the Ethereal Soul [Hun] and the Corporeal Soul [Po] and it combines the Intellect [Yi] and the Will-Power [Zhi].”15 However, all other organs also play roles in mental, emotional and spiritual activities, very often overlapping with that of the Heart. In particular, the Yin organs are more directly responsible for mental activities. Each Yin organ “houses” a particular mental-spiritual aspect of a human being. These are: • • • • •
Mind (Shen) – Heart Ethereal Soul (Hun) – Liver Corporeal Soul (Po) – Lungs Intellect (Yi) – Spleen Will-Power (Zhi) – Kidneys.
The Simple Questions in Chapter 23 says: “The Heart houses the Mind, the Lungs house the Corporeal Soul, the Liver houses the Ethereal Soul, the Spleen houses the Intellect and the Kidneys house the Will-Power.”16 In Chapter 9 it says:17 The Heart is the root of life and the origin of the Mind ... the Lungs are the root of Qi and the dwelling of the Corporeal Soul ... the Kidneys are the root of sealed storage [Essence] and the dwelling of Will-Power ... the Liver is the root of harmonization and the residence of the Ethereal Soul. The commentary to Chapter 23 of the Simple Questions, also based on passages from the Spiritual Axis, says:18 The Mind is a transformation of Essence and Qi; both Essences [i.e. the Prenatal and Postnatal Essences] contribute to forming the Mind. The Corporeal Soul is the assistant of the Essence and Qi; it is close to Essence but it moves in and out. The Ethereal Soul complements the Mind and Qi; it is close to the Mind but it comes and goes. The Intellect corresponds to memory; it is the memory that depends on the Heart. The Will-Power is like a purposeful and focused mind; the Kidneys store Essence ... and through the Will-Power they can fulfil our destiny. These five aspects together form the “Spirit”, which is also called Shen or sometimes the “Five Shen” in the old classics. The five Yin organs are the residences of Shen, i.e. the Spirit, and they are sometimes also called the “Five-Shen residences”, as in Chapter 9 of the Simple Questions.19 As indicated above, I use the term “Mind” to indicate the Shen that resides in the Heart and is responsible
for thinking, consciousness, self-identity, insight and memory, and the term “Spirit” to denote the Shen as the complex of all five mental-spiritual aspects of a human being, i.e. the Mind itself of the Heart, the Ethereal Soul (Hun) of the Liver, the Corporeal Soul (Po) of the Lungs, the Intellect (Yi) of the Spleen and the Will-Power (Zhi) of the Kidneys (Fig. 9.4). The five Yin organs are the physiological basis of the Spirit. The indissoluble relationship between them is well known to any practitioner of Chinese medicine. The state of Qi and Blood of each organ can influence the Mind or Spirit and, conversely, alterations of the Mind or Spirit will affect one or more of the internal organs. We can now discuss the five mental-spiritual aspects one by one.
The Ethereal Soul (Hun) The Ethereal Soul broadly corresponds to our Western concept of “soul”. According to ancient Chinese beliefs, it enters the body shortly after birth. Ethereal in nature, after death it survives the body and flows back to “Heaven” (Tian); this is the ancient Chinese concept of “Heaven”, i.e. a state of subtle and non-material energies and beings, and has therefore nothing to do with the Western and Christian concept of “Heaven”. The Ethereal Soul can be described as “that part of the Soul [as opposed to Corporeal Soul] that at death leaves the body, carrying with it an appearance of physical form.”20
Shen of Heart
= MIND
SHEN HUN
YI = SPIRIT ZHI
PO
Figure 9.4 The two meanings of Shen.
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The Chinese character for Ethereal Soul is:
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a dead person, but it is Yang and ethereal in nature and essentially harmless, i.e. it is not one of the evil spirits (hence the presence of the “cloud” radical).
This is composed of the following parts: = clouds = spirit, ghost. The ancient form of this last radical is shown in Figure 9.5; it means a head without a body. This form is itself composed of two parts (Fig. 9.6), meaning a swirling movement. This ancient radical therefore depicts the bodiless head of a dead person flowing to Heaven in a swirling movement or swimming in the realm of spirits and ghosts. The combination of the two characters for “cloud” and “spirit” in the character for Ethereal Soul conveys the idea of its nature; it is like a “ghost” or the spirit of
Old character for gui
Figure 9.5 Old Chinese character for gui.
Head of dead person without a body
Swirling movement of the spirit of dead person in the realm of spirits
Figure 9.6 Parts of old Chinese character for gui.
! The Chinese character for Ethereal Soul (Hun) contains the radical for gui, i.e “ghost, spirit, demon”. This immediately conveys the idea that the Ethereal Soul is a “dark”, subterranean part of our psyche with its own independent existence. There are three types of Ethereal Soul: a vegetative one (called Shuang Ling or “Clear Spirit”) common to plants, animals and human beings; an animal one (called Tai Guang or “Brilliant Light”) common to animals and human beings; and a human one (called You Jing or “Dark Essence”), which is present only in human beings (Fig. 9.7). Zhang Jie Bin in the Classic of Categories says: “The Mind and Ethereal Soul are Yang ... the Ethereal Soul follows the Mind; if the Mind is unconscious, the Ethereal Soul is swept away.”21 It also says: “The Mind corresponds to Yang within Yang, the Ethereal Soul corresponds to Yin within Yang.”22 The Spiritual Axis in Chapter 8 says: “The Ethereal Soul is the coming and going of the Mind.”23 See Figure 9.8. The concept of Ethereal Soul is closely linked to ancient Chinese beliefs in spirits, ghosts and demons. According to these beliefs, spirits, ghosts and demons are spirit-like creatures who preserve a physical appearance after death and wander in the world of spirit. Some are good and some are evil. In the times prior to the Warring States period (476–221 BC), such spirits were considered to be the main cause of disease. Since the Warring States period, a belief in naturalistic causes of disease (such as weather) gradually came to the fore; however, the belief in spirits has never really disappeared, even to the present day. What is the Ethereal Soul then and what does it do? An analysis of the Chinese character depicting the Ethereal Soul is essential to gain an understanding and a feeling for what it is. The presence of the radical for gui within its character immediately tells us that the Ethereal Soul has a somewhat “dark” nature; in ancient Greek philosophy, we would say it has a “Dionysian” nature. It pertains to a “subterranean” world that is different from the world of the Mind.
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Vegetative Ethereal Soul Shuang Ling (‘‘Clear Spirit’’)
Animal Ethereal Soul Tai Guang (‘‘Brilliant Light’’)
Human Ethereal Soul You Jing (‘‘Dark Essence’’)
Figure 9.7 The three Ethereal Souls.
ETHEREAL SOUL (Hun)
MIND (Shen)
‘‘Coming and going’’ of Ethereal Soul Figure 9.8 Relationship between Ethereal Soul and Mind.
The Ethereal Soul is the gui, i.e. the “dark”, intuitive, non-rational side of human nature; Yang in character, it enters and exits through the nose and communicates with Heaven. The gui in the character hun for the “Ethereal Soul” has also another important meaning. The fact that the Ethereal Soul has the nature of gui means that it has an independent existence from the Mind (Shen). The Ethereal Soul has its own life and
“agenda” over which the Mind has no say; the interaction and integration of the Mind with the Ethereal Soul is the basis for our rich psychic life. Unlike the Ethereal Soul, the other two mentalspiritual aspects of Intellect (Yi of the Spleen) and WillPower (Zhi of the Kidneys) do not have an independent existence but could be said to be part of the Mind (Shen) of the Heart. As we shall see below, the character for “Corporeal Soul” (Po) also contains the character for gui; like the Ethereal Soul, the Corporeal Soul also has its own independent existence, although on a physical level. Thus, the Ethereal Soul has its own separate existence from the Mind on a psychic level and the Corporeal Soul on a physical level. The Chinese character for Ethereal Soul should be compared and contrasted with that for the Mind (Shen). The radical gui in the character for “Ethereal Soul” is a ghost or spirit; it is “dark” and leads its own independent existence from that of the Mind. The character shen, by contrast, indicates the influx from Heaven – something pure, spiritual. The Ethereal Soul can be described as that part of the soul (as opposed to Corporeal Soul) that at death leaves the body, carrying with it an appearance of physical form. From this point of view, therefore, the soul has an independent existence just like in the ancient Greek–Roman civilization and during the Middle Ages. At death, the Ethereal Soul survives the body and returns to “Heaven”; the Corporeal Soul dies with the body and returns to Earth and the Mind is simply extinguished. It is interesting to note that, when describing the changes occurring at death, Chinese books say that the Ethereal Soul and not the Mind (Shen) returns to “Heaven”; this would seem to confirm that the Shen has indeed the nature of Mind rather than “Spirit”. Figure 9.9 uses the image of a cigarette to convey the different destinies of the Ethereal Soul, Corporeal Soul and Mind at death: the cigarette itself is the Mind (Shen), the smoke is the Ethereal Soul, the ashes the Corporeal Soul and the tobacco the Essence (Jing). As the cigarette is extinguished, the Ethereal Soul survives and goes to “Heaven” in the form of smoke, the Corporeal Soul dies with the body and returns to Earth in the form of ashes, the Mind is extinguished (the cigarette itself) and the Essence is used up (in the form of tobacco).
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Smoke going up to ‘‘Heaven’’ is Hun
Cigarette is Shen Tobacco is the Essence that is used up
Ashes going down to Earth are Po
Figure 9.9 Comparison between Ethereal Soul, Mind, Corporeal Soul and Essence represented by a cigarette.
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that, through this ceremony, the baby was assigned his or her place in the family and society. The Ethereal Soul corresponds to our individuality, but an individuality within the family and society. When describing the Ethereal Soul, the theme of “movement”, “swirling”, “wandering” is ever present. As we have seen above, the old form of the Chinese radical within the word Hun depicts the swirling movement of the soul of a dead person in the realm of spirit. The Ethereal Soul provides movement to the psyche in many ways: movement of the soul out of the body as in dreaming, movement out of one’s everyday life as in life dreams and ideas, movement towards the others in human relationships, movement in terms of plans and projects. CLINICAL NOTE The Ethereal Soul provides movement to the psyche in many ways: movement of the soul out of the body as in dreaming, movement out of one’s everyday life as in life dreams and ideas, movement towards the others in human relationships, movement in terms of plans, projects, ideas, life dreams, inspiration, creativity. The best point to stimulate the coming and going of the Ethereal Soul is G.B.-40 Qiuxu together with BL-47 Hunmen.
! At death, the Ethereal Soul survives the body and returns to “Heaven”, the Corporeal Soul dies with the body and returns to Earth and the Mind is simply extinguished.
According to ancient Chinese beliefs, the Ethereal Soul was imparted by the father 3 days after birth during a naming ceremony, i.e. the baby was given a name and the father “imparted” the Ethereal Soul to him or her. The fact that the Ethereal Soul is imparted by the father after birth is significant, as it is symbolic of the social, relational nature of the Ethereal Soul (as opposed to the Corporeal Soul). The Ethereal Soul is responsible for relationships and our relating to other people in the family and society. The ceremony during which the father imparted the Ethereal Soul and the name to the baby 3 days after birth is therefore symbolic of the fact
To sum up, the Ethereal Soul is basically another level of consciousness, different from the Mind but closely related to it. It is a part of the psyche that is not rational like the Mind (Shen) but is responsible for intuition, inspiration, ideas, life dreams, artistic inspiration; it is also responsible for the “movement” of our psyche towards the environment and other people in relationships.
CLINICAL NOTE The Ethereal Soul is another level of consciousness, different from the Mind but closely related to it. It is a part of the psyche that is not rational like the Mind (Shen) but is responsible for intuition, inspiration, ideas, life dreams, artistic inspiration; it is also responsible for the “movement” of our psyche towards the environment and other people in relationships. The point BL-47 Hunmen regulates the movement of the Ethereal Soul.
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The Ethereal Soul is rooted in the Liver and in particular Liver-Yin (which includes Liver-Blood). If Liver-Yin or Liver-Blood is depleted, the Ethereal Soul is deprived of its residence and becomes rootless. This can result in insomnia. The Ethereal Soul, deprived of its residence, wanders without aim. At death, the Ethereal Soul survives and goes to “Heaven” while the Corporeal Soul dies and returns to Earth. The nature and functions of the Ethereal Soul can be summarized under seven headings as follows. 1. 2. 3. 4. 5. 6. 7.
Sleep and dreaming Mental activities Balance of emotions Eyes and sight Courage Planning Relationship with the Mind
Dreams constitute the wandering of the Ethereal Soul in the Nine Heavens and Nine Earths. When one wakes up, one feels obscure and confused [because] one is constrained by the Corporeal Soul.
The Ethereal Soul influences sleep and dreaming. The length and quality of sleep are related to the state of the Ethereal Soul. If this is well rooted in the Liver (Liver-Blood or Liver-Yin), sleep is normal and sound and without too many dreams. If Liver-Yin or LiverBlood is deficient, the Ethereal Soul is deprived of its residence and wanders off at night, causing a restless sleep with many tiring dreams (Fig. 9.10). Sleep disturbances related to excessive dreaming are particularly related to the Ethereal Soul. As it is in the nature of the Ethereal Soul to “wander”, at night it wanders, giving rise to dreams. Tang Zong Hai says: “At night during sleep, the Ethereal Soul returns to the
Liver-Blood Liver-Yin
ETHEREAL SOUL
Liver-Blood Liver-Yin deficient
Ethereal Soul Ethereal Soul rooted in Liver unrooted in Liver Figure 9.10 Ethereal Soul and sleep.
In the daytime, the Ethereal Soul is in the eyes and at night in the Liver. When it is in the eyes, we can see; when it is in the Liver, we dream. It also says:26
Sleep and dreaming
ETHEREAL SOUL
Liver; if the Ethereal Soul is not peaceful, there are a lot of dreams.”24 The length and quality of sleep are also related to the state of the Ethereal Soul. If this is well rooted in the Liver (Liver-Blood or Liver-Yin), sleep is normal and sound, without too many dreams. If Liver-Yin or LiverBlood is deficient, the Ethereal Soul is deprived of its residence and wanders off at night, causing a restless sleep with many tiring dreams. The Secret of the Golden Flower in Chapter 2 says:25
Insomnia
Chinese books do not define “excessive dreaming”. In my experience, dreaming can be defined as excessive either when they are nightmares or when one has unpleasant or anxiety-causing dreams the whole night, waking up exhausted. In such cases, it is necessary to nourish Liver-Yin with sour and absorbing herbs such as Mu Li Concha Ostreae, Long Chi Fossilia Dentis Mastodi, Suan Zao Ren Semen Ziziphi spinosae or Bai Shao Radix Paeoniae alba. There is an interesting correlation between the astringent and absorbing quality of such herbs on a physical level and their use in calming the Mind and “absorbing” the Ethereal Soul to draw it back into the Liver. CLINICAL NOTE In order to nourish Liver-Blood and anchor the Ethereal Soul into the Liver, I use (with reinforcing method) LIV-8 Ququan, Ren-4 Guanyuan and SP-6 Sanyinjiao.
If Liver-Yin is very depleted, at times the Ethereal Soul may even leave the body temporarily at night during or just before sleep. Those who suffer from severe deficiency of Yin may experience a floating sensation in the few moments just before falling asleep; this is said to be due to the “floating” of the Ethereal Soul not rooted in Yin.
The Psyche in Chinese Medicine
Of course, the length and quality of sleep also depend on the state of Heart-Blood, and there is an overlap between the influence of Heart-Blood and Liver-Blood on sleep. Besides dreaming at night, the Ethereal Soul influences dreaming in a broad sense, i.e. the dreams, aims and projects of our life. When one has a life “dream”, this is dependent on the activity of the Ethereal Soul. The Ethereal Soul is therefore also responsible for “dreaming” in a positive sense, i.e. having a sense of purpose in life and “dreams” in the sense of goals. As we shall see later, the lack of a sense of direction and purpose and the absence of dreams and goals in one’s life is an important feature of depression, and it is due to a lack of “movement” of the Ethereal Soul. Thus, the Ethereal Soul influences dreaming at night and “life dreams” in our awake state. When the Ethereal Soul is in the eyes, we have external visualization; when it is in the Liver, we have internal visualization as in dreams or life dreams. Finally, the Ethereal Soul is also responsible for daydreaming. Zhang Jie Bin says in the Classic of Categories: “Absent-mindedness as if in a trance is due to the Ethereal Soul wandering outside its residence.”27 Thus if Liver-Blood or Liver-Yin is deficient, the Ethereal Soul wanders off in a daydream and the person has no clear sense of direction in life. The Ethereal Soul may even leave the body temporarily; some Chinese idiomatic expressions confirm this. For example, fan hun (literally “Hun returning”) means “to come back to life”, as after being in a trance during which the soul leaves the body. Hun fei po san (literally “hun flying, po scattered”) means “to be scared out of one’s wits” or also “to be struck dumb”, for example by love.
SUMMARY THE ETHEREAL SOUL, SLEEP AND DREAMING The Ethereal Soul is responsible for sound sleep and a normal amount of dreaming. When the Ethereal Soul flows to the eyes in daytime, we can see; when it flows to the eyes at night, we dream. If the Ethereal Soul is not rooted in Liver-Blood and Liver-Yin, it may wander too much and we have too many dreams or unpleasant dreams.
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Mental activities The Ethereal Soul assists the Mind in its mental activities. The Five-Channel Righteousness, a text from the Tang dynasty, says: “Knowledge is dependent on the sharpness of the Ethereal Soul.”28 The Ethereal Soul provides the Mind, which is responsible for rational thinking, with intuition and inspiration. It also gives the Mind “movement” in the sense that it allows the Mind the capacity of self-insight and introspection as well as the ability to project outwards and relate to other people. This capacity for movement and outward projection is closely related to the Liver-Qi quality of quick and free movement. It will be remembered that the words “movement,” “coming and going,” “swimming” are often used in connection with the Ethereal Soul. For example, as mentioned above, the Ethereal Soul is the “coming and going of the Mind” or “when the Ethereal Soul swims to the eyes, they can see”. It is interesting to compare this quality of the Ethereal Soul, on an ethereal level, with the swirling movement of a spirit depicted in its old character and, on a physical level, with the smooth flow of Liver-Qi. The Ethereal Soul is always described as the “coming and going of the Mind (Shen)” (sui Shen wang lai wei zhi Hun) or, to put it differently, “what follows the Mind in its coming and going is the Ethereal Soul”. On a psychic level, this means that the Ethereal Soul provides the Mind with “movement” in the sense of intuition, inspiration, movement towards others in relationships, creativity, dreaming (in the sense of life dreams), planning, imagination, projects, symbols, and archetypes. The Ethereal Soul gives the Mind the necessary psychic tension of Wood. The Mind without the Ethereal Soul would be like a powerful computer without software. CLINICAL NOTE On a psychic level, the Ethereal Soul provides the Mind with “movement” in the sense of intuition, inspiration, movement towards others in relationships, creativity, dreaming (in the sense of life dreams), planning, imagination, projects, symbols, and archetypes. The Ethereal Soul gives the Mind the necessary psychic tension of Wood. In order to stimulate the movement of the Ethereal Soul, I use BL-47 Hunmen and G.B.-40 Qiuxu.
The relationship between the Mind, responsible for rational thinking (but also our emotional life), and the
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Ethereal Soul, responsible for intuition and inspiration, is somewhat similar to the relationship between Athena and Dionysus in Greek mythology. In fact, Athena is the Goddess of reason and wisdom while Dionysus is the God of mystery religions, ecstasy, personal delivery from the daily world through spiritual intoxication, and initiation into secret rites. A delightful illustration on an ancient Greek vase depicts Dionysus pushing Athena, who is sitting on a swing (Fig. 9.11). This illustrates the necessary coordination and integration of the rational side of the psyche (symbolized by Athena) with the “dark”, inspirational and non-rational side (symbolized by Dionysus). This Greek painting is a good illustration of the “movement” that the Ethereal Soul imparts to the Mind, symbolized by the pushing movement of the swing by Dionysus.
SUMMARY MENTAL ACTIVITIES OF ETHEREAL SOUL The Ethereal Soul contributes to the mental activities of the Mind (Shen) by providing it with ideas, intuition, images and creativity. This activity of the Ethereal Soul depends on its “coming and going”.
Balance of emotions The Ethereal Soul is responsible for maintaining a normal balance between excitation and restraint of the emotional life, under the leadership of the Heart and
the Mind. Emotions are a normal part of our mental life: we all experience anger, sadness, worry, or fear on occasions in the course of our life, and these do not normally lead to disease. The Ethereal Soul, being responsible for the more intuitive and subconscious part of the Mind, plays a role in keeping an emotional balance and, most of all, prevents the emotions from becoming excessive and therefore turning into causes of disease. This regulatory function of the Ethereal Soul is closely related to the balance between Liver-Blood (the Yin part of the Liver) and Liver-Qi (the Yang part of the Liver). Liver-Blood and Liver-Qi need to be harmonized, and Liver-Blood must root Liver-Qi to prevent it from becoming stagnant or rebelling upwards. On a mentalemotional level, Liver-Blood needs to root the Ethereal Soul, thus allowing a balanced and happy emotional life. This is one of the meanings, on a mental level, of the Liver being a “regulating and harmonizing” organ (Fig. 9.12). Chapter 9 of the Simple Questions says: “The Liver has a regulating function [literally. the root of stopping extremes], it houses the Ethereal Soul ...”29 If Liver-Blood is deficient, there will be fear and anxiety; if Liver-Yang is in excess, there will be anger. The Spiritual Axis in Chapter 8 says: “If the Liver is deficient, there will be fear; if it is in excess, there will be anger.”30 Tang Zong Hai in the Discussion on Blood Patterns says: “If Liver-Blood is deficient, Fire agitates the Ethereal Soul, resulting in nocturnal emissions with dreams.”31 The free flow of Liver-Qi is the physical counterpart of the “coming and going” of the Ethereal Soul; this “coming and going” should be regulated and balanced. If it is deficient (as in Liver-Qi stagnation), the person is depressed and not in touch with his or her emotions; if it is excessive (as in Liver-Yang rising or Liver-Fire),
Movement of Ethereal Soul
LIVER-QI LIVERBLOOD Figure 9.11 Comparison between the relationship between Ethereal Soul and Mind with that between Dionysus and Athena.
Roots the Ethereal Soul Figure 9.12 Relationship between Liver-Qi and Liver-Blood and the Ethereal Soul.
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Deficient: depression Excessive: ‘‘mania’’, agitation, anger, emotional LIVER-QI LIVERBLOOD Deficient: insomnia, anxiety, fear Figure 9.13 Pathological states of the relationship between Liver-Qi and Liver-Blood.
the person may be agitated, angry, too emotional or slightly manic (Fig. 9.13). CLINICAL NOTE The free flow of Liver-Qi is the physical counterpart of the “coming and going” of the Ethereal Soul; this “coming and going” should be regulated and balanced. If it is deficient (as in Liver-Qi stagnation), the person is depressed and not in touch with his or her emotions; if it is excessive (as in Liver-Yang rising or Liver-Fire), the person may be agitated, angry, too emotional or slightly manic. The best points to regulate and balance the coming and going of the Ethereal Soul are LIV-3 Taichong and BL-47 Hunmen.
These two opposing emotional states characterized by a hyperactive Liver-Qi (with excessive “coming and going” of the Ethereal Soul) or a stagnant Liver-Qi (with insufficient “coming and going” of the Ethereal Soul) are described in the Simple Questions as “Fullness” and “Emptiness” of the Mind (Shen). Chapter 62 of the Simple Questions says:32 What are the symptoms of Fullness and Emptiness of the Mind [Shen]? When the Mind is in Excess, the person laughs uncontrollably; when the Mind is Deficient, the person is sad.
SUMMARY THE ETHEREAL SOUL’S BALANCE OF EMOTIONS The Ethereal Soul is responsible for maintaining a normal balance between
excitation and restraint of the emotional life, under the leadership of the Heart and the Mind. On an emotional level, Liver-Blood needs to root the Ethereal Soul, thus allowing a balanced and happy emotional life. The free flow of Liver-Qi is the physical counterpart of the “coming and going” of the Ethereal Soul; this “coming and going” should be regulated and balanced. If it is deficient (as in Liver-Qi stagnation), the person is depressed and not in touch with his or her emotions; if it is excessive (as in Liver-Yang rising or Liver-Fire), the person may be agitated, angry, too emotional or slightly manic.
Eyes and sight The Ethereal Soul relates to the eyes and sight. Tang Zong Hai says: “When the Ethereal Soul wanders to the eyes, they can see.”33 The Secret of the Golden Flower in Chapter 2 says:34 In the daytime, the Ethereal Soul is in the eyes and at night in the Liver. When it is in the eyes, we can see; when it is in the Liver, we dream. Apart from physical sight, the Ethereal Soul also gives us “vision” in life, i.e. the capacity to have life dreams, projects and creativity. CLINICAL NOTE The best points to influence the Ethereal Soul and sight are G.B.-37 Guangming, LIV-2 Xingjian and BL-18 Ganshu.
This connection with the eyes can easily be related to the rooting of the Ethereal Soul in Liver-Blood, as this nourishes the eyes. On a psychic level, the Ethereal Soul gives us “vision” and insight. At night, the Ethereal Soul makes us “see” when we dream. Thus, the Ethereal Soul is responsible for vision in three ways: physical sight, “seeing” at night in the form of dreams and “vision” in life (Fig. 9.14).
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On a physical level
SIGHT
At night
DREAMS
On a psychic level
VISION, INSIGHT
Figure 9.14 The three influences of the Ethereal Soul on “seeing”.
SUMMARY THE ETHEREAL SOUL, EYES AND SIGHT The Ethereal Soul relates to the eyes and sight. In the daytime, the Ethereal Soul is in the eyes and at night in the Liver. When it is in the eyes, we can see; when it is in the Liver, we dream. On a psychic level, the Ethereal Soul gives us “vision” and insight.
CLINICAL NOTE In order to stimulate the “courage” of the Ethereal Soul, I use the point G.B.-40 Qiuxu.
The quality of courage and resoluteness is also dependent on the strength of Gall Bladder-Qi.
SUMMARY THE ETHEREAL SOUL AND COURAGE
Courage The Ethereal Soul is related to courage or cowardice, and for this reason the Liver is sometimes called the “resolute organ”. Tang Zong Hai says: “When the Ethereal Soul is not strong, the person is timid.”35 The “strength” of the Ethereal Soul in this connection derives mainly from Liver-Blood. If Liver-Blood is abundant, the person is fearless and is able to face up to life’s difficulties without being easily discouraged. Just as in disease Liver-Yang easily flares upwards causing anger, in health the same type of mental energy deriving from Liver-Blood can give a person courage and resoluteness. If Liver-Blood is deficient and the Ethereal Soul is dithering, the person lacks courage and resolve, cannot face up to difficulties or make decisions and is easily discouraged. A vague feeling of fear at night before falling asleep is also due to a lack of rooting of the Ethereal Soul.
The Ethereal Soul is related to courage or cowardice, and for this reason the Liver is sometimes called the “resolute organ”. If Liver-Blood is abundant, the person is fearless and is able to face up to life’s difficulties with an indomitable spirit; if Liver-Blood is deficient and the Ethereal Soul is dithering, the person lacks courage and resolve, cannot face up to difficulties or making decisions and is easily discouraged.
Planning The Ethereal Soul influences our capacity for planning our life and giving it a sense of direction. A lack of direction in life and a sense of spiritual confusion may be compared with the aimless wandering of the Ethereal Soul; such a sense of lack of direction and plans is due to the insufficient “coming and going” of the Ethereal Soul.
The Psyche in Chinese Medicine
If the Liver is flourishing, the Ethereal Soul is firmly rooted and can help us to plan our life with vision, wisdom and creativity. If Liver-Blood and Liver-Qi are deficient, the Ethereal Soul does not “come and go” enough and we lack a sense of direction and vision in life.
SUMMARY THE ETHEREAL SOUL AND PLANNING The Ethereal Soul influences our capacity for planning our life and giving it a sense of direction. If the Liver is flourishing, the Ethereal Soul is firmly rooted and can help us to plan our life with vision, wisdom and creativity; if LiverBlood and Liver-Qi are deficient, the Ethereal Soul does not “come and go” enough and we lack a sense of direction and vision in life.
Relationship with the Mind It is important to consider the relationship between the Mind (Shen) and the Ethereal Soul (Hun). Both Yang in nature, they are closely connected to each other and both partake in all the mental activities of a human being. We have already seen that the Ethereal Soul is described as the “coming and going” of the Mind. This means that, through the Ethereal Soul, the Mind can project outwards to the external world and to other people and can also turn inwards to receive the intuition, inspiration, dreams and images deriving from the unconscious. Thus if Liver-Blood is abundant and the Ethereal Soul firm, there will be a healthy flow from it to the Mind, providing it with inspiration, creativity and plans. The perfect relationship between the Mind and the Ethereal Soul is one in which the latter provides the former with “movement”, manifesting with aims, intuition, creativity, ideas, life dreams, plans, etc.; on the other hand, the Mind provides control and integration to the Ethereal Soul. This means that the Mind must exercise some form of “control” over the material coming from the Ethereal Soul. Figure 9.15 illustrates the ideal relationship between the Mind and the Ethereal Soul, in which the movement of the Ethereal Soul is normal and the control and integration of the Mind is also normal.
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SHEN
Gives movement ideas, inspiration, intuition, creativity
Controls, integrates
HUN Figure 9.15 Normal relationship between Ethereal Soul and Mind.
Being the source of ideas and life dreams for the Mind, the Ethereal Soul may be compared with a sea; the Ethereal Soul’s world is a subterranean world, an undifferentiated sea, and it is also the world of gui. The Ethereal Soul is the gui of the Mind’s emotionalspiritual life. The Mind can only cope with one idea at a time originating from the Ethereal Soul, and it must therefore exercise some form of control over the material coming from the Ethereal Soul. It must also integrate the material deriving from the Ethereal Soul in the general psyche life. If the Mind is strong and the Ethereal Soul properly “gathered”, there will be harmony between the two and the person has calm vision, insight and wisdom. If the Ethereal Soul does not “come and go” enough, it may lack movement and inspiration and the person may be depressed, without aim or life dreams. The Ethereal Soul may be restrained in its movement either by itself or because the Mind is over-controlling it. This happens, for example, in people who are rigid in their views and repressed. Figure 9.16 illustrates the
SHEN
SHEN
HUN
HUN
Hun coming and going not enough (control by Shen normal) = depression Figure 9.16 Deficient movement of the Ethereal Soul.
Shen over-controls = depression
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two situations when the “coming and going” of the Ethereal Soul is restrained either by itself (on the right side) or because the Mind is over-controlling it (on the left side). If the Mind is weak and fails to restrain and control the Ethereal Soul, it may be too restless and its “movement” excessive, only bringing confusion and chaos to the Mind, making the person scattered, unsettled and slightly manic. This can be observed in some people who are always full of ideas, dreams and projects, none of which ever comes to fruition because of the chaotic state of the Mind, which is therefore unable to restrain the Ethereal Soul. Figure 9.17 illustrates the two situations when the “coming and going” of the Ethereal Soul is excessive either by itself (on the left side) or because the Mind does not control it enough (on the right side). If the Mind is weak or if the Ethereal Soul “comes and goes” too much, contents breaking through from the Ethereal Soul cannot be integrated by the Mind. The Mind should integrate the Ethereal Soul so that images, symbols and dreams coming from it can be assimilated. For the conscious Mind, this means bringing together two disparate ways of seeing the world: the conscious and rational one (of the Mind) and the entirely different one in which the Ethereal Soul holds sway. If not, the Mind may be flooded by the contents of the Ethereal Soul with risk of obstruction of the Mind and, in serious cases, psychosis.
! The key words that describe the function of the Mind in relation to the Ethereal Soul are control and integration. As I have mentioned the terms “manic” and “mania” a few times in connection with the situation when the Ethereal Soul is not restrained by the Mind and its “coming and going” is excessive, I should define what I mean by this term. In psychiatric terms, signs and symptoms of mania (or a manic episode) include:36 • • • •
increased energy, activity and restlessness excessively “high”, overly good, euphoric mood extreme irritability racing thoughts and talking very fast, jumping from one idea to another
SHEN
SHEN
HUN
HUN
Hun coming and going too much = ‘‘mania’’
Hun coming and going too much (Shen not controlling Hun) = ‘‘mania’’ Figure 9.17 Excessive movement of the Ethereal Soul.
• • • • • • • • • •
distractibility, inability to concentrate well little sleep needed unrealistic beliefs in one’s abilities and powers poor judgement spending sprees a lasting period of behaviour that is different from usual increased sexual drive abuse of drugs, particularly cocaine, alcohol and sleeping medications provocative, intrusive or aggressive behaviour denial that anything is wrong.
The important thing to realize is that mania and manic behaviour can occur in many degrees of severity, i.e. the border between “mental illness” and “normality” is not a clear-cut separation between the two but there is a broad area of behaviours that, while not normal, do not constitute “mental illness”. In other words, in its milder forms, “mania” and “manic behaviour” are relatively common. Whenever the “coming and going” of the Ethereal Soul is excessive, there is the possibility of “manic” behaviour. CLINICAL NOTE Mania and manic behaviour can occur in many degrees of severity, i.e. the border between “mental illness” and “normality” is not a clear-cut separation between the two but there is a broad area of behaviours that, while not normal, do not constitute “mental illness”. In other words, in its milder forms, “mania” and “manic behaviour” are relatively common. Whenever the “coming and going” of the Ethereal Soul is excessive, there is the possibility of “manic” behaviour.
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My own criteria for diagnosing mild “mania” (i.e. in normal people who are not mentally ill) are as follows: • • • • • • • • • • •
mental restlessness, agitation hyperactivity working and being active at night spending a lot having many projects simultaneously, none of which comes to fruition mental confusion obsessive thoughts laughing a lot talking a lot propensity to taking risks often artistic.
In order to give the reader a feel for the actions of the Ethereal Soul, I have listed six things (Fig. 9.18): 1. 2. 3. 4. 5. 6.
children artistic inspiration dreams sleepwalking guided daydreams coma.
Children are a good example of the activity of the Ethereal Soul. In small children, the Mind (Shen) is
Figure 9.18 Six illustrations of the activity of the Ethereal Soul.
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“immature” and therefore does not control and restrain the Ethereal Soul, a situation that, while pathological in adults, is perfectly normal in children. The result is that, from the age of about 2 to about 7, children live in the world of the Ethereal Soul, a world of wild imagination and fantasy where inanimate objects come to life. Behaviours that are normal in children would be considered mental illness in adults. After the age of about 7, the Mind (Shen) is more mature and starts to control and restrain the Ethereal Soul. Artistic inspiration is another good example of the activity of the Ethereal Soul. Artistic inspiration (at least in Western art) derives from the Ethereal Soul, not the Mind. The Ethereal Soul is the source from which springs forth creativity and inspiration. The same psychic energy that, in pathological conditions, leads to manic behaviour is also responsible for artistic inspiration. In fact, this is the result of the “coming and going” of the Ethereal Soul; it is the Ethereal Soul that is the source of artistic images coming forth in an artist. It is interesting to note that, among the artistic community, there is a disproportionate incidence of bipolar disorder compared with in the general population.37 Dreams derive from the wandering of the Ethereal Soul at night: when the Ethereal Soul goes to the eyes
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in daytime, we see; when it goes to the eyes at night, we dream. It is interesting that most dreaming takes place during the rapid eye movement (REM) periods of sleep. It could be argued that the REM is due to the Ethereal Soul going to the eyes at night! It is also interesting to note that we suffer more from dream- than from sleepdeprivation. In sleepwalking, the Mind is inactive but the Ethereal Soul is active: the Ethereal Soul wanders at night and leads to sleepwalking. In fact, the point BL-47 Hunmen (the Door of the Hun) was used for sleepwalking. Guided daydreams are a technique used in psychotherapy whereby the therapist sets a certain scene for the client who is asked to imagine himself or herself in that scene and to proceed as if in a dream. The aim of this exercise is to bypass the critical analysis of the Mind and bring forth psychological material from the Ethereal Soul as happens in dreams. Jung described this technique:38 We learn to sit and simply observe a fragment of a dream without any attempt to guide, control or interfere with it. The aim is to allow the image to come to life of its own autonomous psychic energy [= Ethereal Soul], our ego [= Mind] letting go of all expectations, presuppositions, or interpretations. After a certain period of practice and initial coaching by the therapist, this inner image will start to move in some way and our observing ego [Mind] learns to participate in the story very much like a dream. In coma, the Mind is completely devoid of residence and it therefore cannot function at all, and yet the person is not dead. This means that there are other mental aspects at play, and these are the Ethereal Soul and the Corporeal Soul. In fact, for death to occur, not only must the Mind die, but the Ethereal Soul must leave the body and the Corporeal Soul return to Earth. Finally, drawing from Buddhist and Jungian ideas, the Mind could be said to be the individual Mind, and the Ethereal Soul the link between the individual and Universal Mind. This can be represented with a diagram (Fig. 9.19). The Universal Mind is the repository of images, archetypes, symbols and ideas belonging to the collective unconscious in Jungian psychology. These often manifest to our Mind as myths, symbols and dreams. They come into our consciousness (individual Mind) via the Ethereal Soul, because this belongs to the world of image and ideas. Thus the Ethereal Soul is the vehicle
UNIVERSAL MIND (collective unconscious)
HUN
MIND
HUN
Archetypes, images, symbols, ideas
MIND
Figure 9.19 The relationship between Ethereal Soul and Mind from Buddhist and Jungian viewpoint.
through which images, ideas and symbols from the Universal Mind (or collective unconscious) emerge into our individual Mind (conscious). This shows the vital importance of the Ethereal Soul for our mental and spiritual life. Without the Ethereal Soul, our mental and spiritual life would be quite sterile and deprived of images, ideas and dreams. If the Liver is strong and the Ethereal Soul firm and flowing harmoniously, ideas and images from the Universal Mind will flow freely and the mental and spiritual state will be happy, creative and fruitful. If the “coming and going” of the Ethereal Soul is insufficient, the individual Mind will be cut off from the Universal Mind and will be unhappy, confused, isolated, aimless, sterile and without dreams (Fig. 9.20). On the other hand, if the Mind is clouded and cannot exercise its proper control over the Ethereal Soul,
UNIVERSAL MIND (collective unconscious)
HUN
MIND
Hun lacks ‘‘movement’’, Mind cut off from Universal Mind (unconscious) Archetypes, images, symbols, ideas
HUN
MIND
Figure 9.20 Deficient movement of the Ethereal Soul and its relation with Universal Unconscious.
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Conscious UNIVERSAL MIND (collective unconscious)
HUN
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SHEN
MIND
Hun ‘‘going’’ too much, Mind cannot cope with material from Universal Mind (unconscious) Archetypes, images, symbols, ideas
Unconscious HUN
HUN
MIND
Figure 9.21 Excessive movement of the Ethereal Soul and its relation with Universal Unconscious.
contents breaking through from the Ethereal Soul cannot be integrated by it (Fig. 9.21). It is important for the Mind to assume an integrating position towards the Ethereal Soul so that images, symbols and dreams coming from it can be assimilated. If not, the Mind may be flooded by the contents of the Ethereal Soul with risk of obstruction of the Mind and, in serious cases, psychosis. According to Jung, the unconscious is compensatory to consciousness. He said: “The psyche is a self-regulating system that maintains itself in equilibrium ... Every process that goes too far immediately and inevitably calls forth a compensatory activity.”39 This compensatory relationship between the unconscious and consciousness resembles the balancing relationship between the Ethereal Soul and the Mind. The Mind discriminates and differentiates, whereas the Ethereal Soul is like an undifferentiated sea that flows around, under and above the Mind, eroding certain parts and depositing fresh ones. The psyche as a whole, i.e. the sum total of Mind, Ethereal Soul, Corporeal Soul, Intellect and Will-Power, contains all possibilities, whereas the Mind can only work with one possibility at a time (Fig. 9.22). Figure 9.22 shows many arrows from the Ethereal Soul to the Mind (indicating the material in the form of ideas coming from the Ethereal Soul) but only one arrow coming out of the Mind. It is no wonder that in myths and fairy tales the unconscious is often symbolized by the sea. The Ethereal Soul is an underwater world, and a total immersion of the Mind in it means insanity (Fig. 9.23). In Figure 9.23, the Mind is totally enclosed by the
Figure 9.22 Comparison of the relationship between the Ethereal Soul and Mind with that between the unconscious and the conscious.
SHEN
Mental illness
HUN Figure 9.23 Total absorption of the Mind within the Ethereal Soul in mental illness.
Ethereal Soul; this image is used to depict mental illness. In myths and fairy tales, the unconscious is often symbolized by the sea; in Christian mythology too, baptism and the parting of the waters by God use water and the sea as a spiritual symbol. The Ethereal Soul is an underwater world, and a total immersion of the Mind in it means insanity. The Ethereal Soul is like an ocean that is the source of archetypes, symbols, ideas, images; the Mind draws from this sea through the intermediary of the Ethereal Soul. The material coming forth is controlled and integrated by the Mind, one at a time (hence the key words “control” and “integration” expressing the Mind’s function in relation to the Ethereal Soul). The relationship between the Mind and the Ethereal Soul is all about expansion (stimulation of “coming and going” of the Hun) and contraction (restraint of coming and going of Ethereal Soul) in our psychic life. Shen and gui can be interpreted as the two opposing states of expansion (shen) and contraction (gui) in our psychic life (Figs 9.24 and 9.25).
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‘
MIND
Ethereal Soul
Expansion (‘‘shen’’)
MIND
Ethereal Soul
Contraction (‘‘gui’’) Figure 9.24 Expansion and contraction of the Ethereal Soul.
Shen
Expansion
Gui
Figure 9.25 Shen and gui as expansion and contraction.
Expansion and contraction in our psychic life are two normal, physiological states that alternate naturally. When we feel “up”, we are in an extrovert mood, we feel like going out and we are active; then we are in a state of expansion and the Ethereal Soul is “coming and going” normally. When we feel “down”, we are in an introvert mood, we do not feel like going out and we feel passive; then we are in a state of contraction and the Ethereal Soul’s “coming and going” is restrained.40 The proper alternation of expansion (stimulation of the coming and going of the Ethereal Soul) and contraction (restraint of the coming and going of the Ethereal Soul) in our psychic life allows for a healthy and normal psychic life. Chinese herbal medicine reflects this polarity of expansion and contraction in our psychic life as, within the category of herbs that calm the Mind, some are pungent and stimulate expansion (and therefore the coming and going of the Ethereal Soul), while others are sour and astringent and stimulate contraction (and therefore restrain the coming and going of the Ethereal Soul).
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The two important herbs Yuan Zhi Radix Polygalae and Suan Zao Ren Semen Ziziphi spinosae are representative of this polarity of expansion and contraction. The actions of these two herbs are described below. • Yuan Zhi Radix Polygalae: pungent, bitter, warm, dispersing and draining, resolves Phlegm, opens the Heart orifices = stimulates expansion, i.e. coming and going of Ethereal Soul. • Suan Zao Ren Semen Ziziphi spinosae: sour, sweet, astringent, promotes sleep, anchors Ethereal Soul = stimulates contraction, i.e. restraint of coming and going of Ethereal Soul. In terms of patterns, what are the patterns that arise from the Ethereal Soul “coming and going” too much or too little? The coming and going of the Ethereal Soul may become excessive either from Full conditions of Heat or Fire or from Empty conditions with a deficiency of Liver-Blood and/or Liver-Yin. In case of Full conditions with Heat or Fire, these agitate the Ethereal Soul and stimulate its coming and going excessively; in the case of deficiency of Liver-Blood and/or LiverYin, these fail to anchor the Ethereal Soul so that this becomes agitated and its coming and going becomes excessive. Although the end result is the same, the symptoms and signs of the Ethereal Soul coming and going too much from Full or Empty conditions will be different. Excessive coming and going of the Ethereal Soul results in “manic behaviour” as described above. The coming and going of the Ethereal Soul may become deficient under three conditions. Liver-Qi stagnation, Liver-Blood and Liver-Qi deficiency, and deficiency of Yang of the Spleen and Kidneys may all impair the coming and going of the Ethereal Soul and result in depression. I should explain the pattern of Liver-Qi deficiency in more detail. Although we are often told that “Liver-Qi cannot be deficient”, this is not quite true. Deficiency of Liver-Qi does exist and it manifests primarily in the psychic sphere with depression. As we know, every organ’s Qi should flow in a proper, correct direction, for example Stomach-Qi descends and Spleen-Qi ascends. Liver-Qi should flow in all directions; this is the manifestation of the free flow of Liver-Qi. However, the normal, correct flow of Liver-Qi is also ascending; its ascending movement is coordinated with the descending of Lung-Qi. Where does Liver-Qi ascend to? One important aspect of its ascending movement is the ascension of Liver-Qi towards the Heart and the Mind (Shen). The
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Ascends Provides ‘‘movement’’ of Ethereal Soul LIVER-QI Figure 9.26 Ascending movement of Liver-Qi in relation to the movement of the Ethereal Soul.
ascending of Liver-Qi towards the Mind is an important way in which the Ethereal Soul stimulates the “coming and going” of the Mind (Fig. 9.26). A deficiency of Liver-Qi always implies a failure of Liver-Qi to ascend to the Mind and therefore results in depression. What are the symptoms of Liver-Qi deficiency? First, they include all the symptoms of Liver-Blood deficiency (blurred vision, tingling of limbs, dry hair and skin); second, they include symptoms such as sighing, tiredness and depression. The patterns manifesting in excessive or insufficient movement of the Ethereal Soul are listed below. Ethereal Soul coming and going too much (“manic” behaviour): • Heat or Fire • Phlegm-Fire • Liver-Blood and/or Liver-Yin deficiency Ethereal Soul coming and going too little (depression): • Liver-Qi stagnation • Liver-Blood and Liver-Qi deficiency • Spleen- and Kidney-Yang deficiency
SUMMARY RELATIONSHIP BETWEEN MIND AND ETHEREAL SOUL The Ethereal Soul is the “coming and going” of the Mind. Through the Ethereal Soul, the Mind can project outwards to the external world and to other people and can also turn inwards to receive the intuition, inspiration, dreams and images deriving from the unconscious.
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The Ethereal Soul provides the Mind with “movement”, manifesting with aims, intuition, creativity, ideas, life dreams, plans, etc.; on the other hand, the Mind provides control and integration to the Ethereal Soul. If the Ethereal Soul does not “come and go” enough, it may lack movement and inspiration and the person may be depressed, without aim or life dreams. If the Mind is weak and fails to restrain and control the Ethereal Soul, this may be too restless and its “movement” excessive and only bring confusion and chaos to the Mind, making the person scattered, unsettled and slightly manic. The nature and activity of the Ethereal Soul may be observed in six areas, i.e. children’s fantasy, artistic inspiration, dreams, sleepwalking, guided daydreams and coma. The patterns that arise from the Ethereal Soul “coming and going” too much are Full conditions of Heat or Fire or Empty conditions with a deficiency of Liver-Blood and/or LiverYin; the patterns that arise from the Ethereal Soul coming and going too little are Liver-Qi stagnation, Liver-Blood and Liver-Qi deficiency and deficiency of Yang of the Spleen and Kidneys.
SUMMARY THE ETHEREAL SOUL The Ethereal Soul enters the body 3 days after birth; at death, it survives the body and returns to “Heaven”. It resides in the Liver and is anchored in LiverBlood and Liver-Yin. It is responsible for: — sleep and dreaming — mental activities in association with the Mind (Shen) — emotional balance — sight — courage — planning — giving the Mind “movement” in the sense of ideas, vision, plans, life dreams, intuition, creativity.
The Corporeal Soul (Po) The Corporeal Soul (Po) resides in the Lungs and is the physical counterpart of the Ethereal Soul. Its Chinese character is composed of two parts: one (on the right) is the radical gui, which means “spirit” or “ghost”. the other (on the left) is the radical for bai (or bo), meaning “white”. The character for Corporeal Soul is Po:
This is composed of the radical gui for “spirit” or “ghost”:
and the character for “white”:
The radical for “white” in the character for Po can have several interpretations. The bai (or bo) meaning “white” within the character is related to the light of the waxing moon, but it is also phonetic, i.e. it gives the character the sound po. The association with the waxing moon (Yin) is in keeping with the association of the Corporeal Soul with Yin (as opposed to the Ethereal Soul that is Yang) and the dark forces of gui. The connection between the Corporeal Soul and the moon is also related to the fact that this physical soul comes into being on the third day after conception, analogous to the thin crescent on the third day of the rising moon. Finally, the association with the colour white somewhat tempers the radical for the dark gui and it conveys the idea that the Corporeal Soul, although related to gui, is a human, physical soul. See Figure 9.27. Hence there is a connection between the Corporeal Soul and the embryonic lunar light (Yin) as opposed to
Corporeal Soul
Entering and exiting Essence
Movement
GUI Figure 9.27 Gui within the Corporeal Soul.
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the hot (Yang) sun light of the Ethereal Soul. In fact, in ancient times the Corporeal Soul was also called “Moon-Po”. As the waxing moon is in the West, one can therefore build the following correspondence:
As we shall see below, the Corporeal Soul is in relation with gui. Confucius said: “Qi is the fullness of the Shen; the Corporeal Soul is the fullness of gui.”43 He Shang Gong said:44
WEST – WHITE – METAL – CORPOREAL SOUL – LUNGS.
The turbid and humid five flavours from bones, flesh, blood, vessels and the six passions ... these gui are called Corporeal Soul. This is Yin in character and enters and exits through the mouth and communicates with Earth.
The Corporeal Soul can be defined as “that part of the Soul [as opposed to the Ethereal Soul] which is indissolubly attached to the body and goes down to Earth with it at death.”41 It is closely linked to the body and could be described as the somatic expression of the Soul, or conversely, the organizational principle of the body. The Corporeal Soul is active from conception and it shapes the body. It could be also described as the organization of the organism and the coordinating force of all physiological processes. Zhang Jie Bin says:42 In the beginning of an individual’s life, the body is formed; the spirit of the body is the Corporeal Soul. When the Corporeal Soul is in the Interior, there is [enough] Yang Qi. At death, unlike the Ethereal Soul, the Corporeal Soul dies with the body, but it is thought to adhere to the corpse for some time, especially the bones, before returning to Earth. This explains the importance of looking after the bones of the dead in ancient Chinese culture. Some years after death, relatives of the dead used to clean the bones of the skeleton carefully and place them in neat bundles. There are seven types of Corporeal Soul: the five senses, the limbs and the Corporeal Soul as a whole. The link between the five senses and the Corporeal Soul will be explained shortly. As we have seen for the Ethereal Soul, the ancient character for gui conveys the idea of movement, an expression of the swirling movement of the bodiless head of a dead person in the realm of spirits. The Ethereal Soul is responsible for movement in a psychic sense. The movement related to the Corporeal Soul is a physical movement of this soul in all physiological processes of the body. Also, the Corporeal Soul gives the body the capacity of movement, agility, balance and coordination of movements. The Ethereal Soul is described as “coming and going” of the Mind while the Corporeal Soul is described as the “entering and exiting” of the Essence (see below).
The discussion of the Corporeal Soul will be done according to the following topics. • • • • • • • • • •
The Corporeal Soul and the Essence (Jing) Infancy Senses Emotions Physiological activity Breathing Corporeal Soul and individual life Corporeal Soul and gui The Corporeal Soul and the anus Relationship between Corporeal Soul and Ethereal Soul
The Corporeal Soul and the Essence (Jing) The Corporeal Soul is closely linked to the Essence (Jing) and is described in Chapter 8 of the Spiritual Axis as the “exiting and entering of Essence”.45 The Corporeal Soul derives from the mother and arises at conception (in theory 3 days after conception) soon after the Prenatal Essence of a newly conceived being is formed. Thus the Corporeal Soul, closely linked to Essence, is the first to come into being after conception. Both Essence and Corporeal Soul represent the organizational principles of life that shape the body from conception (the Extraordinary Vessels are the channels through which this happens). “Entering and exiting” implies an Interior and Exterior, i.e. a separation of the individual from the environment. It also implies a vertical movement, as ru (to enter) evokes “roots” and chu (to exit) evokes “branches”. Thus the centripetal, separating, materializing of the Corporeal Soul (see below) also depends on the vertical exiting and entering of the Essence (Fig. 9.28). The Corporeal Soul could be described as the manifestation of the Essence in the sphere of sensations and feelings. Just as the Ethereal Soul provides psychic movement to the Mind (“coming and going of the Mind”),
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Whole body
Essence
Corporeal Soul
Deficiency of Kidney’s Defensive-Qi system
Deficiency of Lung’s Defensive-Qi system
Skin (atopic eczema)
Figure 9.29 The Corporeal Soul and atopic eczema. Entering
Corporeal Soul
Exiting
Essence (Jing) Figure 9.28 The entering and exiting of the Essence.
the Corporeal Soul provides physical movement to the Essence, i.e. it brings the Essence into play in all physiological processes of the body. Without the Corporeal Soul, the Essence would be an inert, albeit precious, vital substance. The Corporeal Soul is the closest to the Essence and is the intermediary between it and the other vital substances of the body. In fact, Zhang Jie Bin in the Classic of Categories says: “If the Essence is exhausted, the Corporeal Soul declines, Qi is scattered and the Ethereal Soul swims without a residence.”46 CLINICAL NOTE Through the Corporeal Soul, the Essence (Jing) of the Kidneys plays a role in all physiological processes. This is further confirmation that the Essence, although a precious, partly inherited and constitutional Essence, does not simply “reside” in the Lower Dan Tian. Through the Corporeal Soul, it “enters and exits” in all parts of the body, playing a role in all physiological activities. The implication of this is that, when nourishing the Essence (through tonification of the Kidneys), it is better to also strengthen the Corporeal Soul (through tonification of the Lungs). This may be an explanation why the opening points of the Directing Vessel (Ren Mai), the best vessel to nourish the Essence, are one on the Lung and the other on the Kidney channel (LU-7 Lieque and KI-6 Zhaohai).
The relationship between Corporeal Soul and Essence also explains the eruption of atopic eczema and asthma in babies. From the Chinese point of view, eczema in
babies is due to the surfacing of Toxic Heat from the uterus; it is therefore closely linked with the Prenatal Essence of the baby (Fig. 9.29). Because the Essence is related to the Corporeal Soul that manifests on the skin (with itching and pain), the Toxic Heat from the Uterus erupts on the baby’s skin in the form of eczema.
CLINICAL NOTE As I interpret the pathology of atopic eczema as being due to a deficiency of the Lung and Kidney’s Defensive-Qi systems, when using herbal medicine in children I modify the classic formulae with the addition of Tu Si Zi Semen Cuscutae and Mai Men Dong Radix Ophiopogonis to tonify the Kidneys and the Lungs, respectively (and therefore the Essence and the Corporeal Soul).
Asthma can be explained in the same way, as the deficient Essence of the baby fails to root its Corporeal Soul and therefore its Lungs. During gestation, the fetus is “all Corporeal Soul and Essence” and is nourished by the Corporeal Soul of the mother (Fig. 9.30). This is of clinical importance, as we are inclined to think that it is the Kidneys of the mother that nourish the fetus; this is certainly so, but the Lungs and Corporeal Soul of the mother also play an important role in nourishing the fetus. The connection between Corporeal Soul and fetal life is very ancient: Granet calls the Corporeal Soul the “soul of blood”. The fetus depends on the mother’s Corporeal Soul, Blood and Essence for its nourishment. By giving rise to the human form during gestation, the Corporeal Soul has a centripetal, separating, materializing, aggregating movement. As it separates, it aggregates and it materializes into a separate existence in the fetus. As this separation is expressed by the skin (which separates the being from the world), there is a further connection between the Corporeal Soul, the skin and the Lungs.
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sensations and it is nourished by the mother’s Corporeal Soul through breast feeding and touching.
Mother’s Corporeal Soul
Nourishes
Essence/Corporeal Soul
Figure 9.30 The Corporeal Soul during pregnancy.
This separating power of the Corporeal Soul allies itself with the centripetal forces of gui, which are constantly fragmenting and which, eventually, become the germ of death. With regard to the fragmenting of the Corporeal Soul and of gui, there is a resonance between the word gui and kuai (formed by the radical for gui with “earth” in front), which means “pieces”. The Corporeal Soul is therefore linked to a “thirst for existence”, centripetal, materializing life force, aggregating into a separate existence.
Infancy Being the closest to the Essence, the Corporeal Soul is responsible for the first physiological processes after birth. Zhang Jie Bin says: “In the beginning of life, ears, eyes and Heart perceive, hands and feet move and breathing starts; all this is due to the sharpness of the Corporeal Soul.”47 It is said that, in the first month of life especially, the baby is “all Corporeal Soul”. As it resides in the Lungs, the Corporeal Soul is responsible for touch and skin
CLINICAL NOTE In the first month of life, the baby is “all Corporeal Soul”, i.e. its life revolves around its Corporeal Soul (breast feeding, touch from the mother) and its Corporeal Soul is nourished by the mother’s Corporeal Soul.
Senses Later in life, the Corporeal Soul gives us the capacity of sensation, feeling, hearing and sight. When the Corporeal Soul is flourishing, ears and eyes are keen and can register. The decline of hearing and sight in old people is due to a weakening of the Corporeal Soul. We often attribute the decline of sensory acuity in the elderly to the decline of the Kidneys and of the Essence; this may certainly be so, but the influence of the Corporeal Soul in this decline should not be underestimated. Zhang Jie Bin says: “The Corporeal Soul can move and do things and [when it is active] pain and itching can be felt.”48 This shows that the Corporeal Soul is responsible for sensations and itching and is therefore closely related to the skin through which such sensations are experienced. This explains the somatic expression on the skin of emotional tension that affects the Corporeal Soul and the connection between the Corporeal Soul, Lungs and skin (Fig. 9.31). The Corporeal Soul, being closely related to the body, is the first to be affected when needles are inserted; the almost immediate feeling of relaxation following the insertion of needles is due to the unwinding of the Corporeal Soul. Through it, the Mind, Ethereal Soul, Intellect and Will-Power are all affected.
Emotions The Corporeal Soul is also related to weeping and crying. Just as the Corporeal Soul makes us feel pain on
Emotions
Corporeal Soul
Skin
Figure 9.31 The Corporeal Soul, emotions and the skin.
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a physical level, it also makes us cry and weep when subject to grief and sadness. Especially unexpressed grief constricts the Corporeal Soul and gives rise to accumulations. Emotional stress (especially worry, pensiveness, grief and sadness) “constricts” the Corporeal Soul and causes Lung-Qi stagnation in the chest. Lung-Qi stagnation affects the breasts and may give rise to the formation of lumps.
Physiological activity Some modern doctors consider the Corporeal Soul the “basic regulatory activity of all physiological functions of the body”.49 In this sense, it is the manifestation of the Lung’s function of regulating all physiological activities. Chapter 8 of the Simple Questions says: “The Lungs are like a Prime Minister in charge of regulation.”50 This description of the Lungs’ function in the Simple Questions should be seen in context. In fact, the sentence preceding the above concerning the function of the Heart says: “The Heart is like the Emperor, in charge of the Spirit (Shen Ming).”51 Thus, the Heart is compared to an Emperor and the Lungs to a Prime Minister assisting the Emperor.52 This relationship is an expression of the close relationship between Qi and Blood. The Lungs govern Qi and the Heart governs Blood; Qi is the “commander of Blood” (it moves Blood) and Blood is the “mother of Qi”. Qi and Blood assist and depend on each other, hence the comparison of the relationship between the Heart and Lungs to that between an Emperor and his Prime Minister. After saying that the Lungs are like a Prime Minister, the Simple Questions says that the Lungs are in charge of “regulation”. This means that, just as the Prime Minister regulates all administrative functions, the Lungs help to regulate all physiological activities in every organ and every part of the body, just as the Prime Minister’s office controls and directs the administrative functions of all government departments. The Lungs regulate all physiological activities in various ways: • by governing Qi • by controlling all channels and blood vessels • by governing breathing. As Qi is the basis for all physiological activities, the Lungs, by governing Qi, are naturally in charge of all physiological activities. This regulation function is
dependent also on the Lungs’ action in moving Qi around the body. Thus, the Corporeal Soul is the expression of the Lungs’ regulatory function in all physiological processes; the Corporeal Soul is the physical soul that makes this regulation possible.
Breathing Residing in the Lungs, the Corporeal Soul is closely linked to breathing. Breathing can be seen as the pulsating of the Corporeal Soul. Meditation makes use of the link between breathing and the Corporeal Soul. By concentrating on the breathing, someone who is meditating quietens the Corporeal Soul, the Mind becomes still and empty, and through this the Ethereal Soul becomes open and gets in touch with the Universal Mind.
Corporeal Soul and individual life The Corporeal Soul is related to our life as individuals, while the Ethereal Soul is responsible for our relations with other people and the world. From this point of view, there is an important difference between the Ethereal Soul and the Corporeal Soul. As we have seen, the Ethereal Soul is imparted by the father 3 days after birth; this shows that it is a soul that is socially constructed, a soul that lets us take and identify our place in the family and society. As we know, the Ethereal Soul is responsible for the “movement” of our psyche towards other people and the world in general. By contrast, the Corporeal Soul is a physical, individual soul that is formed soon after conception; it is the “blind” force of a soul whose only function is the regulation of physical activity and of the life force itself. However, that is not to say of course, that the Corporeal Soul is not affected by our emotional life. Emotional stress certainly always affects the Corporeal Soul, but the Corporeal Soul does not control our emotional life in the same way that the Mind and Ethereal Soul do.
The Corporeal Soul and the gui Beyond its nature of “spirit” or “ghost”, gui can have a very interesting psychological interpretation. Gui is like a “dark” force of the psyche, which gives the Ethereal and Corporeal Souls its imprint; in fact, as we have seen, the Chinese characters for these two souls contain the radical gui. Apart from other implications,
The Psyche in Chinese Medicine
this tells us that these two souls have their own existence independent from that of the Mind; they are “dark” forces of the psyche, one on a psychic level, the other on a physical level (Fig. 9.32). The gui within the Ethereal Soul gives it movement on a psychic level (coming and going of the Mind), which, as we have seen, generates ideas, intuition, creativity; the gui within the Corporeal Soul gives it movement on a physical level (entering and exiting of the Essence) in all the body’s physiological processes. Thus, the gui within the Corporeal Soul is the “dark” force that animates it in carrying out its function of promoting all physiological processes and of bringing the Essence into play in all parts of the body. There is a close connection between Corporeal Soul and gui intended in the sense of a contracting, centripetal, fragmenting, materializing force (Fig. 9.33). As mentioned above, He Shang Gong says: “The five turbid and humid flavours form bones, muscles,
Ethereal Soul
Coming and going MIND
Entering and exiting
Essence
Figure 9.32 The gui, the Ethereal Soul and the Corporeal Soul.
Qi
Corporeal Soul
is fullness of
blood, vessels and the six passions ... these gui are called Corporeal Soul.”53 In other words, one can say that the Corporeal Soul represents the forces of gui in the human sphere.
The Corporeal Soul and the anus Because of the relationship between the Corporeal Soul and the Lungs and of that between these and the Large Intestine, the anus is sometimes called po men, the “door of the Po”, as in Chapter 11 of the Simple Questions: “The door of the Po [anus] is the messenger for the five viscera and it drains off water and food without storing them for too long.”54 In fact, the point BL-42 Pohu (the “Window of the Po”) was indicated for incontinence of both urine and faeces from fright.
Relationship between Corporeal Soul and Ethereal Soul Because the Ethereal Soul and Corporeal Soul are two aspects of the soul, it is interesting to compare and contrast their various characteristics and functions (Table 9.1). Most of these are derived from Zhang Jie Bin’s Classic of Categories.55 As can be seen from Table 9.1, the Ethereal Soul is involved in problems occurring at night (although not exclusively), and the Corporeal Soul in problems occurring in daytime. The Discussion on Blood Patterns (1884) by Tang Zong Hai says:56
Gui
Corporeal Soul
269
MIND (Shen)
is fullness of
Figure 9.33 Qi, Mind, Corporeal Soul and gui.
GUI
Restlessness at night with excessive dreaming is due to an unsettled Ethereal Soul; this is Yang, and if at night it has no resting place the person is restless and dreams a lot. Restlessness in the daytime and a clouded Mind are due to an unsettled Corporeal Soul; this is Yin, and if Yin is deficient in daytime restlessness and mental confusion result. The Ethereal Soul pertains to the realm of Image and the Corporeal Soul to that of Form. This can be represented with a diagram (Fig. 9.34). The Ethereal Soul is ethereal, and is last to arrive (after birth) and first to go (after death); the Corporeal Soul is physical, and is the first to arrive (at conception) and the last to go after death (it lingers in the bones). According to Granet, the Ethereal Soul corresponds to the higher aspect of personality, to the personal name through which each person takes his or her social and family place; the Ethereal Soul conferred one one’s individuality.
The Practice of Chinese Medicine
Corporeal Soul
Is the “coming and going” of the Mind
Is the “entering and exiting” of the Essence
Pertains to the Mind
Pertains to the body
Is the Qi of the Mind
Is the spirit of the body
Follows the changes of Qi
Follows the changes of the body
Is Yang and moves
Is Yin and quiescent
Creates action with movement
Creates action without movement
Related to the Mind: when Qi gathers, the Ethereal Soul gathers
Related to the Essence: when this gathers, the Corporeal Soul gathers
At birth, the Ethereal Soul joins with the Corporeal Soul
At birth, the Corporeal Soul restrains the Ethereal Soul
At death, it swims away and returns to Heaven
At death, it dissolves and returns to Earth
Is bright and lights the Corporeal Soul
Is dark and roots the Ethereal Soul
Is like a fire: the more things you add, the more it burns
Is like a mirror: it shines but holds only a reflection (of the Ethereal Soul)
Represents the movement of the Mind outwardly
Represents the movement of the Essence inwardly
Is rooted in Blood and Yin
Is connected to Qi and Yang
Disharmony causes problems with sleep at night
Disharmony causes problems in daytime
Disharmony causes lack of direction and inspiration, confusion
Disharmony causes lack of vigour and vitality
It is the link with the Universal Mind
It is purely individual
Corresponds to full moon
Corresponds to new moon
MIND (Heart)
ETHEREAL SOUL (Liver)
CORPOREAL SOUL (Lungs)
ESSENCE (Kidneys)
en er gy
Ethereal Soul
Image
bo dy ,v igo ur,
Table 9.1 Comparison of Ethereal Soul and Corporeal Soul
mi nd ,s ou l, s pir it
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Form
Figure 9.34 The realms of Image and Form and the Ethereal and Corporeal Souls.
The Huai Nan Zi says: “The Ethereal Soul derives from Heavenly Qi, the Corporeal Soul from Earthly Qi.”57 The Wu Xing Da Yi says: “The Corporeal Soul is like the envelope, the Ethereal Soul is the source of Life’s Qi.”58 These statements highlight the nature of the Corporeal Soul as the centripetal, materializing, separating force that produces Form and the body, hence it is like an “envelope” separating the body from the world. Hence the Corporeal Soul is constraining, contracting, centripetal; this constraining, separating and fragmenting movement eventually ends in death. By contrast, the Ethereal Soul is expansive, it is constantly moving towards the world; hence it is expansive, centrifugal. The Ethereal Soul is the source of Life’s Qi, it is centrifugal, and it has an outward movement and goes towards life. The Ethereal Soul is called the “Essence of Life’s Qi” and the Corporeal Soul the “Abode of Death’s Qi”. The connection of the Corporeal Soul with death is due to the fact that it is separating, constraining, fragmenting and contracting and it dies with the body (Fig. 9.35). The Secret of the Golden Flower says: “The Corporeal Soul partakes of the nature of darkness. It is the energy of the heavy and turbid. The Ethereal Soul loves life; the Corporeal Soul seeks death.”59 The Wu Xing Da Yi says:60 The Qi of the Ethereal Soul is the fullness [perfection] of Shen, the Qi of the Corporeal Soul is the fullness [perfection] of Gui. Human life includes death. At death, one returns to Earth; that is called Gui.
The Psyche in Chinese Medicine
Ethereal Soul
271
Warm Qi of Hun rising Expansive centrifugal ‘‘Essence of Life’s Qi’’
Corporeal Soul
Contracting, centripetal ‘‘Abode of Death’s Qi’’ Cold Po returning to Earth
Figure 9.37 Ethereal Soul rising and Corporeal Soul falling at death.
Figure 9.35 Expansive and contracting movements of Ethereal Soul and Corporeal Soul.
Zhu Xi said: Qi belongs to the Ethereal Soul, and the body is governed by the Corporeal Soul. The Ethereal Soul is the spirit of Yang, and the Corporeal Soul is the spirit of Yin. When a person is about to die, the warm Qi leaves him or her and rises. This is called the Ethereal Soul rising. The lower part of the body gradually becomes cold. This is called the Corporeal Soul falling.
Po falling
Warm Qi of Hun rising
See Figures 9.36–9.40. In ancient China, the dead were temporarily buried in the corner of the house where seeds were kept. This allowed the substance of the dead to penetrate the Earth in the house. The body of the dead decomposed in the corner where seeds were kept to symbolize the sprouting of new life from the seeds. In the same place
YANG ‘‘Essence of Life’s Qi’’
HUN
SHEN
Figure 9.38 Rising of Ethereal Soul and falling of Corporeal Soul.
HUN YIN ‘‘Abode of Death’s Qi’’
PO
GUI
PO
GUI
Figure 9.36 Ethereal Soul, Corporeal Soul, Mind and Gui.
Figure 9.39 Gui in Ethereal Soul and Corporeal Soul.
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The Practice of Chinese Medicine HUN YI
ZHI
SHEN
ETHEREAL SOUL – YANG – MIND (SHEN) – CENTRIFUGAL – “ESSENCE OF LIFE’S QI”
PO 6 passions
5 natures Ethereal Soul
Corporeal Soul
GUI
Figure 9.40 Ethereal Soul and Corporeal Soul as the gui of the five natures and six passions.
was the marital bed, where new lives are conceived. As the Corporeal Soul returned to Earth after death, this allowed people to imagine that a new life sprouted from the Earth in the house and from the dead ancestors as if the baby had taken the substance of the ancestors. The bodiless gui were hovering around the marital bed waiting for a new incarnation. This continuity between dead and living allowed people to believe in an unbroken family lineage, in an eternal family substance like the Earth. A death did not diminish this family substance and a birth did not increase it. The family was formed of two parallel communities: the living (with their individualities in the Corporeal Soul) and the dead. The Ethereal Soul’s “coming and going” gives “horizontality” to life; the Corporeal Soul’s “entering and exiting” gives “verticality” to life (Fig. 9.41). “Horizontality” means that the Ethereal Soul is constantly exploring the bounds of consciousness into the world of ideas, creativity, art, exploration, dreams, etc. “Verticality” means that the Corporeal Soul is constantly materializing into the body in the spheres of senses, feelings, etc. From what we have said about the Ethereal Soul and the Corporeal Soul, we can build the following sets of correspondences:
Going
CORPOREAL SOUL – YIN – GUI – CENTRIPETAL – “ABODE OF DEATH’S QI” CLINICAL NOTE Given the connection between the Corporeal Soul and death, it is interesting to note the association with death among the indications of three points related to the Lungs (and therefore Corporeal Soul).
BL-13 Feishu: “suicidal” Du-12 Shenzhu: “desire to kill people” BL-42 Pohu: “three corpses flowing”.
SUMMARY THE CORPOREAL SOUL It is a physical soul that resides in the Lungs. It is formed 3 days after conception. It is closely related to the Essence (Jing). It is the “entering and exiting” of Essence, bringing this into play in all physiological processes. During infancy, the baby’s life revolves entirely around the Corporeal Soul. The Corporeal Soul is responsible for acuity of the sense organs. The Corporeal Soul is affected by all emotions, especially pensiveness, worry, grief and sadness. The Corporeal Soul is responsible for all physiological processes; it is the “soul” that animates all physiological activities. The Corporeal Soul is responsible for breathing. The Corporeal Soul is closely linked to gui as a centripetal, materializing, fragmenting force. The anus is related to the Corporeal Soul.
PO HUN
Shen
Entering
Exiting Jing
Coming Horizontal movement
Vertical movement
Figure 9.41 Verticality of Corporeal Soul and horizontality of Ethereal Soul.
The Intellect (Yi) The Chinese character for Intellect is Yi , which can mean “idea”. I have chosen to translate this as “Intellect”, as it is very close to the Mind (Shen) of the Heart. The Intellect (Yi) resides in the Spleen and is responsible for applied thinking, studying, memorizing, focusing, concentrating and generating ideas.
The Psyche in Chinese Medicine
The Postnatal Qi and Blood are the physiological basis for the Intellect. Thus if the Spleen is strong, thinking will be clear, memory good and the capacity for concentrating, studying and generating ideas will also be good. If the Spleen is weak, the Intellect will be dull, thinking will be slow, memory poor and the capacity for studying, concentrating and focusing will all be weak. In the sphere of thinking, remembering and memorizing, there is considerable overlap between the Intellect (Yi of Spleen), the Mind (Shen of Heart) and the Will-Power (Zhi of Kidneys). The main differentiating factor is that the Spleen is specifically responsible for memorizing data in the course of one’s work or study (Fig. 9.42). For example, it is not uncommon for someone to have a brilliant memory in his or her field of study or research (a function of the Spleen) and yet be quite forgetful in daily life (a function of the Heart and Kidneys). The Heart and Kidneys also naturally contribute to this function, but they are also responsible for the memory of past events, whether recent or long past. In particular, the overlap between the Intellect and the Mind in thinking activity is very close, so much so that the Spiritual Axis says in Chapter 8: “The Heart function of recollecting is called Intellect.”61 In turn, the memorizing function of the Intellect is so closely related to the Will-Power (Zhi of the Kidneys) that the same chapter continues: “The storing [of data] of the Intellect is called Will-Power [Zhi].”62 It should be noted here that I translate the mental aspect of the Kidneys
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Zhi as Will-Power, although it also has the meaning of “memory” or “mind”. Another aspect of the Intellect of the Spleen is the generation of ideas (Fig. 9.43). We have seen above, that the Ethereal Soul also generates ideas, plans, projects, etc. The “ideas” generated by the Spleen differ from those deriving from the Ethereal Soul. The Ethereal Soul is responsible for “ideas” more in the sense of intuition, inspiration and creativity; these are broad ideas also in the sense of vision. The Intellect is responsible for “ideas” more in the sense of specific ideas in a given field. For example, the “idea” that allows us to carry out a repair job successfully derives from the Intellect of the Spleen; by contrast, the “idea” that gives us vision and creativity derives from the Ethereal Soul of the Liver. Ideas
INTELLECT (Spleen)
Memorizing, concentration, focusing
Figure 9.43 The Intellect as source of memorization and ideas.
SUMMARY THE INTELLECT (YI)
MIND (Heart)
Memory
Memory of events
INTELLECT (Spleen) Memorizing, concentrating, studying
Memory of events
ZHI (Kidneys)
Figure 9.42 Relationship of Mind, Intellect and Will-Power with memory.
The Intellect (Yi) resides in the Spleen and is responsible for applied thinking, studying, memorizing, focusing, concentrating and generating ideas. The Postnatal Qi and Blood are the physiological basis for the Intellect. In the sphere of thinking, remembering and memorizing, there is considerable overlap between the Intellect (Yi of Spleen), the Mind (Shen of Heart) and the Will-Power (Zhi of Kidneys). The main differentiating factor is that the Spleen is specifically responsible for memorizing data in the course of one’s work or study. The Intellect of the Spleen is also responsible for the generation of ideas.
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The Will-Power (Zhi) The word Zhi
has at least three meanings:
1. it indicates “memory” 2. it means “will-power “ (Fig. 9.44) 3. it is sometimes used to indicate the “five Zhi”, i.e. the five mental aspects Mind, Ethereal Soul, Corporeal Soul, Intellect and Will-Power itself. So as to avoid confusion between “Mind” (of the Heart), “Intellect” (of the Spleen) and “Memory” (of the Kidneys), I translate “Zhi” as Will-Power, bearing in mind that it also includes the meaning of “memory” and capacity of memorizing and recollecting. In this sense, the Kidneys influence our capacity for memorizing and storing data. Some of the ancient doctors even said that the Intellect (of the Spleen) and the memory (of the Kidneys) are almost the same thing, except that the Intellect is responsible for memorizing in the course of studying and the memory of the Kidneys is responsible for the storing of data over the long term. Tang Zong Hai says: “Memory [Zhi] indicates Intellect with a capacity for storing [data].”63 In the second and clinically more important sense, the Kidneys house Will-Power, which indicates drive, determination, single-mindedness in the pursuit of goals, enthusiasm and motivation. Zhang Jie Bin says in the Classic of Categories: “When one thinks of something, decides on it and then acts on it, this is called WillPower [Zhi].”64 The implication of this passage is that thinking of something (an “idea”) derives from the Ethereal Soul or the Intellect depending on the kind of idea, making a decision depends on the Liver and Gall Bladder (and the Ethereal Soul), and acting on it depends on the drive provided by the Will-Power (Zhi) of the Kidneys. Thus, if the Kidneys are strong, the Will-Power is strong and the person will have drive, enthusiasm, motivation and determination in the pursuit of goals. If the Kidneys are depleted and the Will-Power weakened, the person will lack drive and initiative,
Memory
ZHI (Kidneys)
Figure 9.44 Zhi as “memory” and “will-power”.
Will-Power
will be easily discouraged and swayed from his or her aims. A deficiency of the Kidneys and Will-Power is an important aspect of chronic depression. CLINICAL NOTE I always tonify the Kidneys in order to strengthen the Will-Power in depression, even in the absence of a specific Kidney pattern. To do so, I reinforce BL-23 Shenshu and BL-52 Zhishi.
The Will-Power (Zhi) must be coordinated with the Mind (Shen), just as on a physiological level the Kidneys and Heart must communicate (Fig. 9.45). The Will-Power gives Mind drive and determination in the pursuit of its goals, and the Mind directs and harnesses the Will-Power. If the Mind is clear in its aims and plans and the Will-Power is strong, then the person will have the drive to pursue goals. Thus it is necessary for both Will-Power and Mind to be strong. The Mind may be clear in its objectives, but if the Will-Power is weak the person will have no drive to realize such objectives. Conversely, the Will-Power may be strong, but if the Mind is confused the force of WillPower will only become destructive. Although not a pathology, a good example of this second situation may be seen in toddlers who have a strong Will-Power (the age at which they always say “No!”) but an immature Mind (Shen). A similar situation in adults transforms the normal drive and determination of Will-Power (Zhi) into recklessness and excessive risk taking.
MIND (Heart)
Directs and harnesses Will-Power
Gives the Mind drive and determination
WILL-POWER (Kidneys)
Figure 9.45 Relationship between Will-Power (Zhi) and Mind.
The Psyche in Chinese Medicine
SUMMARY THE WILL-POWER (ZHI) The word Zhi has at least three meanings: 1. it indicates “memory” 2. it means “will-power” 3. it is sometimes used to indicate the “five Zhi”, i.e. the five mental aspects Mind, Ethereal Soul, Corporeal Soul, Intellect and Will-Power itself. In the sense of Zhi as memory, the Kidneys influence our capacity for memorizing and storing data. In the second sense of Zhi as will-power, the Kidneys house Will-Power, which indicates drive, determination, enthusiasm, motivation and single-mindedness in the pursuit of goals. A deficiency of the Kidneys and Will-Power is an important aspect of chronic depression. The Will-Power (Zhi) must be coordinated with the Mind (Shen). The Will-Power is the basis for the Mind, and the Mind directs the Will-Power. If the Mind is clear in its aims and plans and the Will-Power is strong, then the person will have the drive to pursue goals. Thus it is necessary for both Will-Power and Mind to be strong.
END NOTES 1. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Publishing House, Beijing, p. 23. First published c.100 BC. 2. 1982 Lei Jing [Classic of Categories]. People’s Health Publishing House, Beijing, p. 49. The Classic of Categories was written by Zhang Jie Bin and first published in 1624. 3. Spiritual Axis, p. 71. 4. Classic of Categories, p. 63. 5. 1979 Huang Di Nei Jing Su Wen [The Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. People’s Health Publishing House, Beijing, p. 58. First published c.100 BC. 6. Spiritual Axis, p. 128. 7. Simple Questions, p. 67. 8. Tang Zong Hai 1892 Zhong Xi Hui Tong Yi Jing Jing Yi [The Essence of Medical Classics on the Convergence of Chinese and Western Medicine], cited in Wang Ke Qin 1988 Zhong Yi Shen Zhu Xue Shuo [Theory of the Mind in Chinese Medicine]. Ancient Chinese Medical Texts Publishing House, p. 22. 9. Simple Questions, p. 72. 10. Ibid., p. 154. 11. Ren Ying Qiu 1985 Zhong Yi Ge Jia Xue Shuo [Theories of Chinese Medicine Doctors], cited in Theory of the Mind in Chinese Medicine, p. 22. 12. Wang Ken Tang 1602 Zheng Zhi Zhun Sheng [Standards of Diagnosis and Treatment], cited in Theory of the Mind in Chinese Medicine, p. 22. 13. Simple Questions, p. 26.
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14. Ibid., p. 78. 15. Yu Chang 1658 Yi Men Fa Lu [Principles of Medical Practice], cited in Theory of the Mind in Chinese Medicine, p. 39. 16. Simple Questions, p. 153. 17. Ibid., pp. 67–68. 18. Ibid., p. 153. 19. Ibid., p. 63. 20. Giles H 1912 Chinese–English Dictionary. Kelly & Walsh, Shanghai, p. 650. 21. Classic of Categories, p. 50. 22. Ibid, p. 50. 23. Spiritual Axis, p. 23. 24. 1979 Xue Zheng Lun [Discussion on Blood Patterns]. People’s Health Publishing House, Beijing, p. 29. The Discussion on Blood Patterns was written by Tang Zong Hai and first published in 1884. 25. Wilhelm R (translator) 1962 The Secret of the Golden Flower. Harcourt, Brace & World, New York, p. 26. 26. Ibid., p. 26. 27. Classic of Categories, p. 50. 28. Kong Ying Da Wu Jing Zheng Yi [Five-Channel Righteousness], cited in Theory of the Mind in Chinese Medicine, p. 37. 29. Simple Questions, p. 68. 30. Spiritual Axis, p. 24. 31. Discussion on Blood Patterns, p. 29. 32. Simple Questions, p. 335. 33. The Essence of the Convergence between Chinese and Western Medicine, cited in Theory of the Mind in Chinese Medicine, p. 36. 34. The Secret of the Golden Flower, p. 26. 35. Ibid., p. 36. 36. National Institute of Mental Health. Online. Available: http://www.nimh.nih.gov 37. Redfield Jamison K 1993 Touched with Fire – Manic-Depressive Illness and the Artistic Temperament. Free Press, New York. 38. Jung CG 1961 Modern Man in Search of a Soul. Routledge & Kegan Paul, London. 39. Modern Man in Search of a Soul. 40. Many pieces of classical music display such alternation of expansion and contraction, none more than Beethoven’s. Very many of Beethoven’s works are characterized by musical phrases of intense, deep, romantic feeling (“expansion”) to be followed quickly by phrases of turbulent and dark passion (“contraction”). The best example of such an alternation of feelings is Beethoven’s Violin Sonata no. 5 (the “Spring” Sonata). 41. Giles H 1912 Chinese–English Dictionary, p. 1144. 42. Classic of Categories, p. 63. 43. Eyssalet J-M 1990 Le Secret de la Maison des Ancêtres. Guy Trédaniel Editeur, Paris, p. 30. 44. Ibid., p. 31. 45. Spiritual Axis, p. 23. 46. Classic of Categories, p. 63. 47. Ibid., p. 63. 48. Ibid., p. 63. 49. Zhao You Chen 1979 Liao Ning Zhong Yi [Chinese Medicine of Liao Ning], no. 5, p. 24. 50. Simple Questions, p. 58. 51. Ibid., p. 58. 52. In order to understand the clinical significance of the Lungs being like a Prime Minister, we should see this statement in the context of the social and political situation of ancient China. In modern, Western societies, the Prime Minister has primarily political responsibility, and the administration of government is delegated to government departments (or the Civil Service in Britain). In ancient China, society was administered very tightly by a central, pyramidal bureaucracy with the Prime Minister at its apex; the Prime Minister, therefore, was the head of all government departments administering the country. It is in this context that the functions of the Lungs should be seen. 53. Le Secret de la Maison des Ancêtres, p. 31.
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54. 55. 56. 57. 58. 59. 60.
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Simple Questions, p. 77. Classic of Categories, pp. 63–64. Discussion on Blood Patterns, p. 236. Le Secret de la Maison des Ancêtres, p. 441. Ibid., p. 441. The Secret of the Golden Flower, p. 28. Ibid., p. 453.
61. Spiritual Axis, p. 23. 62. Ibid, p. 23. 63. The Essence of Medical Classics on the Convergence of Chinese and Western Medicine, cited in the Theory of the Mind in Chinese Medicine, p. 38. 64. Classic of Categories, p. 50.
CHAPTER 10
THE EMOTIONS
THE EMOTIONS 282 Anger 282 Joy 285 Worry 287 Pensiveness 288 Sadness and grief 290 Fear 291 Shock 292 Love 293 Craving 294 Guilt 295 Shame 297 THE PATHOLOGY OF QI AND MINISTER FIRE IN EMOTIONAL PROBLEMS 298 The effect of emotions on the body’s Qi 298 The pathology of the Minister Fire in emotional problems 303
THE EMOTIONS Le coeur a ses raisons que la Raison ne connait point. (“The heart has its reasons that Reason does not know”.) Pascal, Pensées The Chinese term for what we translate as “emotion” is qing ; this is composed of the radical for “heart” on the left and another component on the right (qing) that is partly phonetic and partly conveying the idea of “green” of growing plants.
! The Chinese word for “emotion” (qing) contains the radical for “heart” on the left and that for “green” on the right.
The word “emotion” itself is not, in my opinion, a good term to indicate the Chinese view of the “emotional” causes of disease. The word “emotion” derives from Latin, and it refers to “e-movere”, i.e. to “move out”; it is used to indicate any feeling of the mind “moving outwards” or “being moved”, as distinct from the cognitive or volitional states of consciousness. In this sense, the term “emotion” may refer to any feeling, such as fear, joy, hope, surprise, desire, aversion, pleasure and pain; it is therefore not entirely suitable as a term denoting the emotions as intended in Chinese medicine. In fact, emotions are considered in Chinese medicine as causes of disease, and some of the emotions just mentioned (e.g. surprise) are not causes of disease. It is interesting to note that the word used to indicate a suffering of the mind (as they are in Chinese medicine) originally was “passion” rather than “emotion”. The word “passion” derives from the Latin verb “patire”, which means “to suffer”, and it would therefore be a better translation of the Chinese word “qing” in the context of emotions as causes of disease. The word “emotion” replaced “passion” in the time between Descartes and Rousseau, i.e. between 1650 and 1750 (as the former used the word “passion” and the latter the word “emotion”). Thus, the word “passion” would convey the idea of mental suffering better than “emotion” also because it implies the idea of something that is “suffered”, something that we are subject to. Indeed, feelings such as sadness, fear, anger become causes of disease when they take over our mind – when we no longer possess them but they “possess” us. Indeed, the Chinese expression most Chinese books use to describe the “stimulation” or “excitation” produced by the emotions is ci ji , in which “ji” contains the radical for “water” and means to “swash, surge” as a wave does, i.e. it denotes the surge of emotions like a wave that carries us away.
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The Practice of Chinese Medicine
Emotions are mental stimuli that influence our affective life. Under normal circumstances, they are not a cause of disease. Hardly any human being can avoid being angry, sad, aggrieved, worried or afraid at some time in his or her life. For example, the death of a relative provokes a very natural feeling of grief. Emotions become causes of disease only when they are either long-lasting or very intense. It is only when we are in a particular emotional state for a long time (months or years) that they become a cause of disease; for example, if a particular family or work situation makes us angry and frustrated in an ongoing way, this will affect the Liver and cause an internal disharmony. In a few cases, emotions can become a cause of disease in a very short time if they are intense enough: shock is the best example of such a situation. CLINICAL NOTE Emotions become causes of disease only when they are either long-lasting or very intense.
Each emotion stems from a psychic field that pertains to the relevant Yin organ. This, in fact, explains why a certain emotion affects a specific organ: that particular organ already produces a certain psychic energy with specific characteristics that, when subject to emotional stimuli, responds to or “resonates” with a particular emotion; for example, an external stimulus resonates with the Liver’s psychic energy, giving rise to anger (Fig. 10.1). Thus emotions are not something that comes from outside the internal organs to attack them; the internal organs already have a Emotion
LIVER Mental energy
psychic energy that turns into a negative emotion only when triggered by certain external circumstances. For example, why does anger affect the Liver? If one considers the Liver’s characteristics of free-going, easy and quick movement, with a tendency for its Qi to rise, its correspondence to Spring when the powerful Yang energy bursts outwards and upwards and its correspondence to Wood with its expansive movement, it is easy to understand that the Liver would be affected by anger. This emotion, with its quick outbursts, the rising of blood to the head that one feels when very angry, the destructive, expansive quality of rage, mimics, on an affective level, the characteristics of the Liver and Wood outlined above. The same psychic and affective qualities of the Liver that may give rise to anger and resentment over many years under normal circumstances are also harnessed and used for creative activities. The healthy counterpart of emotions will be considered further when each emotion is discussed in detail. In Chinese medicine, emotions (intended as causes of disease) are mental stimuli that disturb the Mind (Shen), Ethereal Soul (Hun) and Corporeal Soul (Po) and, through these, they alter the balance of the Internal Organs and the harmony of Qi and Blood. For this reason, emotional stress is an internal cause of disease that injures the Internal Organs directly. On the other hand, and this is a very important feature of Chinese medicine, the state of the Internal Organs affects our emotional state. For example, if Liver-Blood is deficient (perhaps from dietary factors) and causes Liver-Yang to rise, this may cause a person to become irritable all the time. Conversely, if a person is constantly angry about a certain situation or with a particular person, this may cause Liver-Yang to rise. The Spiritual Axis in Chapter 8 clearly illustrates the reciprocal relationship between the emotions and the Internal Organs. It says:1 The Heart’s fear, anxiety and pensiveness injure the Mind (Shen) ... the Spleen’s worry injures the Intellect (Yi) ... the Liver’s sadness and shock injure the Ethereal Soul (Hun) ... the Lung’s excessive joy injures the Corporeal Soul (Po) ... the Kidney’s anger injures the Will-Power (Zhi). On the other hand, further on it says:2
External stimuli Figure 10.1 Conversion of organ’s mental energy into “emotion”.
If Liver-Blood is deficient, there is fear; if it is in excess, there is anger ... if Heart-Qi is deficient, there is sadness; if it is in excess, there is manic behaviour.
The Emotions
These two passages clearly show that, on the one hand, emotional stress injures the Internal Organs and, on the other hand, disharmony of the Internal Organs causes emotional imbalance. The emotions taken into consideration in Chinese medicine have varied over the years. From a Five-Element perspective, the Yellow Emperor’s Classic considered five emotions, each one affecting a specific Yin organ: • • • • •
anger affects the Liver joy affects the Heart pensiveness affects the Spleen worry affects the Lungs fear affects the Kidneys.
SUMMARY THE EMOTIONS AND THE FIVE ELEMENTS WOOD – ANGER – LIVER FIRE – JOY – HEART EARTH – PENSIVENESS – SPLEEN METAL – WORRY – LUNGS FEAR – WATER – KIDNEYS
Although each emotion affects a particular Yin organ selectively, the relationship between a given emotion and a particular organ should not be interpreted too rigidly. Each emotion can and does affect more than one organ, and often in a pattern that does not follow that of the Five Elements. This will be explained more in detail below. Passages of the Spiritual Axis and Simple Questions confirm Dr Zhang’s ideas. For example, with regard to excess joy, Chapter 8 of the Spiritual Axis says: “Excess joy of the Lungs injures the Corporeal Soul, and this may cause manic behaviour.”3 With regard to anger, Chapter 23 of the Simple Questions says: “When the Gall Bladder is diseased, there is anger.”4 Chapter 62 of the Simple Questions says: “When Blood rushes upwards and Qi downwards, the Heart is harassed and may cause anger.”5 Chapter 8 of the Spiritual Axis says: “Anger affecting the Kidneys injures the Will-Power [Zhi].”6 With regard to pensiveness, Chapter 39 of the Simple Questions says: “Pensiveness makes the Heart [Qi] accumulate, causing the Mind to stagnate; the Upright Qi settles and does not move, and therefore Qi stagnates.”7 With regard to worry, Chapter 23 of the Simple Questions says: “When Qi rushes upwards, it affects the
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Liver, causing worry.”8 Chapter 8 of the Spiritual Axis says: “Worry of the Spleen injures the Intellect.”9 With regard to fear, Chapter 4 of the Spiritual Axis says: “Worry and fear injure the Heart.”10 Chapter 62 of the Simple Questions says: “When Blood [of the Liver] is deficient, there is fear.”11 Chapter 19 of the Simple Questions says: “Fear makes Spleen-Qi stagnate.”12 Chapter 23 of the Simple Questions says: “When Stomach-Qi rebels upwards, there is vomiting and fear.”13 Chapter 8 of the Spiritual Axis deals with the mental effect of the emotions in quite some detail. It says:14 The method of needling should first of all be rooted in the Mind (Shen). Blood, blood vessels, Nutritive Qi (Ying Qi), Qi and the spirit (Jingshen) are stored in the five Yin Organs. When they are out of harmony due to the emotions, the Essence (Jing) is lost, the Ethereal Soul [Hun] and Corporeal Soul [Po] are scattered, the Will-Power (Zhi) and Intellect (Yi) are chaotic and the person lacks wisdom and reflection: why is that? Heaven bestows us Virtue (De), Earth bestows us Qi. When Virtue flows and Qi pulsates, there is life. When the two Essences [of mother and father] unite, the Mind comes into being. What follows the Mind in its coming and going is the Ethereal Soul, what follows the Essence in its entering and exiting is the Corporeal Soul. The Heart directs mental activities; it houses memory that is called Intellect (Yi); the storing [of data] of the Intellect is called Will-Power [or Memory, Zhi]; WillPower generates pensiveness; pensiveness (si ) generates reflection (lu ). Thus the wise nourish life (yang sheng) by following the four seasons, adapting to cold and heat, moderating joy and anger, regulating Yin and Yang and thus will enjoy long life. Fear, pensiveness and worry injure the Mind and Spirit. When the Spirit is injured, fear may run wild. When sadness agitates inside, it injures life. Joy scatters the Spirit out of its residence. Worry obstructs Qi so that it stagnates. Anger causes loss of self-control. Fear sweeps the Spirit away. Fright and pensiveness of the Heart injure the Spirit. Worry of the Spleen injures the Intellect. Sadness of the Liver injures the Ethereal Soul, which may cause manic behaviour and mental confusion; there is contraction of the sinews, the hypochondrium cannot be raised, the hair withers. The joy of the Lungs injures the Corporeal Soul; when the Corporeal Soul is injured, there is manic behaviour and the Yin cannot reside, the skin becomes like heated leather, the hair withers. Anger of the Kidneys injures the Will-Power; when the Will-Power is injured, it affects the memory and one does not remember what they said, there is lower backache and inability to bend or extend the back,
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the hair withers. Fear injures the Essence; this injures the bones. Thus, the five Yin Organs that store the Essence should not be injured; if they are, Yin deficiency results and from this, Qi deficiency. Therefore when needling one should observe the patient in order to know the condition of the Essence, Mind, Ethereal Soul, Corporeal Soul, and whether they have been preserved or not. The Liver stores Blood and Blood houses the Ethereal Soul: when Liver-Qi is deficient, there is fear; when full, anger. The Spleen stores nourishment, and this houses the Intellect: when Spleen-Qi is deficient, the four limbs are weak and there is an imbalance in the five Yin Organs; when full, there is abdominal distension and menstrual and urinary problems. The Heart stores the blood vessels, and these house the Mind: when Heart-Qi is deficient, there is sadness; when full, incessant laughter. The Lungs store Qi, and this houses the Corporeal Soul: when Lung-Qi is deficient, there is nasal obstruction; when full, breathlessness and a feeling of tightness of the chest. The Kidneys store the Essence, and this houses Will-Power: when Kidney-Qi is deficient, there is collapse; when full, distension and the five Yin Organs are not at peace. See Figure 10.2. An interesting aspect of the above passage from the Spiritual Axis is the sentence: “Heaven bestows us Virtue
(De), Earth bestows us Qi. When Virtue flows and Qi pulsates, there is life.” These two sentences show very clearly the Confucian influence on Chinese medicine, i.e. the idea that “Heaven bestows Virtue”; the term used for “Virtue” [de ] is a typical Confucian term indicating the qualities of the Confucian sage, and the translation as “virtue” is inevitably inadequate. This is discussed more fully below. Chapter 5 of the Simple Questions says:15 Anger injures the Liver, sadness counteracts anger ... joy injures the Heart, fear counteracts joy ... pensiveness injures the Spleen, anger counteracts pensiveness ... worry injures the Lungs, joy counteracts worry ... fear injures the Kidneys, pensiveness counteracts fear. An interesting feature of this passage is that each emotion is said to counteract another along the Controlling Sequence of the Five Elements (Fig. 10.3). For example, fear pertains to the Kidneys and Water, Water controls Fire (Heart), the emotion related to the Heart is joy, hence fear counteracts joy. This thinking presents some interesting ideas that are certainly true in practice, for example that “anger counteracts pensiveness”. Thus, according to this scheme, emotions counteract each other as follows (Fig. 10.3):
Empty = fear LIVER
Blood
HUN Full = anger Empty = sadness
HEART
Blood Vessels
SHEN Full = laughter Empty = weak limbs, Five-Zang disorder
SPLEEN
Nourishment
YI Full = distension, menstrual-urinary disorders Empty = nasal obstruction
LUNGS
Qi
PO Full = breathlessness Empty = collapse
KIDNEYS
Essence
ZHI Full = distension, Five-Zang disorder
Figure 10.2 Effect of Internal Organs disharmony on emotional state according to Chapter 8 of the Spiritual Axis.
The Emotions Joy fire
Anger wood
6. shock 7. sadness 8. fear (wei Pensiveness earth
Fear Sadness water metal Figure 10.3 Emotions counteracting each other along the Controlling Sequence of the Five Elements.
• • • • •
anger counteracts pensiveness joy counteracts sadness pensiveness counteracts fear sadness counteracts anger fear counteracts joy.
However, the above five emotions are not by any means the only emotions discussed in the Yellow Emperor’s Classic. In other passages, sadness and shock are added, giving seven emotions as follows: 1. 2. 3. 4. 5. 6. 7.
anger affects the Liver joy affects the Heart worry affects the Lungs and Spleen pensiveness affects the Spleen sadness affects the Lungs and Heart fear affects the Kidneys shock affects the Kidneys and Heart.
Zhang Jie Bin actually mentions eight emotions in his Classic of Categories.16 These are: 1. 2. 3. 4. 5.
excess joy anger pensiveness worry fright (kong
)
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)
Besides the above emotions, I shall also discuss some emotions that are not usually mentioned in modern Chinese books but were mentioned in the ancient ones. Moreover, I am also going to discuss some emotions that are never mentioned in Chinese books, modern or ancient. Indeed, the list of emotions that are not discussed in Chinese books is very long, and the following are some examples: • • • • • • • • • • • • • • • • • • • • •
pride shame guilt envy contempt resentment angst despair hopelessness frustration hatred rejection (being rejected) indignation humiliation regret remorse self-contempt self-hatred self-love (narcissism) spite vanity.
Besides the usual seven emotions, some Chinese doctors considered other emotions, such as grief, love, hatred and desire. Grief would naturally be akin to sadness. “Love” here means not normal love, such as that of a mother towards her child or that between two lovers, but rather the condition when love becomes an obsession or when it is misdirected, as when a person loves someone who persistently hurts them. Hatred is a common negative emotion that would be akin to anger. “Desire” means excessive craving. The inclusion of this as a cause of disease reflects the Daoist, Confucianist and Buddhist influence on Chinese medicine, as all three major Chinese religions/philosophies considered excessive desire as the root of many emotional problems.
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Indeed, according to Buddhist thought, desire is the ultimate cause of disease, i.e. clinging to external objects or other people and to life itself. Indeed, from a Buddhist perspective, it is the very “craving” for the warmth of a womb by a soul in the Bardo state (the state in between death and life) that brings our existence into being. This excessive craving, which is one aspect of the emotion of “joy” in Chinese medicine, causes the Minister Fire to blaze upwards and harass the Mind. Finally, two emotions that are common in Western patients but not mentioned in Chinese books are guilt and shame. Thus, the list of emotions could be expanded as follows, and these are the emotions I will discuss: • anger (including frustration and resentment) affects the Liver • joy affects the Heart • worry affects the Lungs and Spleen • pensiveness affects the Spleen • sadness and grief affect the Lungs and Heart • fear affects the Kidneys • shock affects the Kidneys and Heart • love affects the Heart • craving affects the Heart • guilt affects the Kidneys and Heart • shame affects the Heart and Spleen.
• craving • guilt • shame.
Anger The term “anger”, perhaps more than any other emotion, should be interpreted broadly to include several other allied emotional states, such as resentment, repressed anger, feeling aggrieved, frustration, irritation, rage, indignation, animosity or bitterness. If they persist for a long time, any of these emotional states can affect the Liver, causing stagnation of LiverQi, stasis of Liver-Blood, rising of Liver-Yang or blazing of Liver-Fire. Anger (intended in the broad sense outlined above) usually makes Qi rise, and many of the symptoms and signs will manifest in the head and neck, such as headaches, tinnitus, dizziness, red blotches on the front part of the neck, a red face, thirst, a bitter taste and a Red tongue with red sides (Fig. 10.4). Chapter 8 of the Spiritual Axis says: “Anger causes loss of self-control.”17 The Simple Questions in Chapter 39 says: “Anger makes Qi rise and causes vomiting of blood and diarrhoea.”18 It causes vomiting of blood because it
Dizziness, tinnitus, dry throat, shouting, blurred vision
I shall first discuss the effects of emotions on Qi in general and then discuss each emotion individually. The discussion of the emotions will be carried out according to the following topics. • The Emotions • The pathology of Qi and Minister Fire in emotional problems
Tense shoulders
THE EMOTIONS As mentioned above, the emotions discussed are: • • • • • • • •
anger joy worry pensiveness sadness and grief fear shock love
Wiry pulse
Figure 10.4 Clinical picture of anger.
The Emotions
makes Liver-Qi and Liver-Fire rise, and diarrhoea because it induces Liver-Qi to invade the Spleen. Chapter 3 of the Simple Questions says: “Severe anger severs the body and Qi, Blood stagnates in the upper part and the person may suffer from syncope.”19 The effect of anger on the Liver depends, on the one hand, on the person’s reaction to the emotional stimulus and, on the other hand, on other concurrent factors. If the anger is bottled up, it will cause stagnation of Liver-Qi, whereas if it is expressed it will cause Liver-Yang rising or Liver-Fire blazing (Fig. 10.5). In a woman, stagnation of Liver-Qi may easily lead to stasis of Liver-Blood. If the person also suffers from some Kidney-Yin deficiency (perhaps from overwork), then he or she will develop Liver-Yang rising. If, on the other hand, the person has a tendency to Heat (perhaps from excessive consumption of hot foods), then he or she will tend to develop Liver-Fire blazing. Anger does not always manifest outwardly with outbursts of anger, irritability, shouting, red face, etc. Some individuals may carry anger inside them for years without ever manifesting it. In particular, longstanding depression may be due to repressed anger or resentment. Because the person is very depressed, he or she may look very subdued and pale, walk slowly and speak with a low voice, all signs which one would associate with a depletion of Qi and Blood deriving from sadness or grief. However, when anger rather than sadness is the cause of disease, the pulse and tongue will clearly show it: the pulse will be Full and Wiry, and
Liver-Yang rising
Liver
Liver-Qi stagnation
Heart
ANGER
Intestines Figure 10.5 Effects of anger.
Stomach
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the tongue will be Red with redder sides and with a dry yellow coating. This type of depression is most probably due to long-standing resentment often harboured towards a member of that person’s family. In some cases, anger disguises other emotions, such as guilt. Some people may harbour guilt inside for many years and may be unable or unwilling to recognize it; they may then use anger as a mask for their guilt. Moreover, there are some families in which every member is perpetually angry; this happens more in Mediterranean countries such as Italy, Spain or Greece. In these families, anger is used as a mask to hide other emotions such as guilt, fear, dislike of being controlled, weakness or inferiority complex. When this is the case, it is important to be aware of this situation, as one needs to treat not the anger but the underlying psychological and emotional condition. In some cases, anger can affect organs other than the Liver, especially the Stomach. This can be due to stagnant Liver-Qi invading the Stomach. Such a condition is more likely to occur if one gets angry at mealtimes, which may happen if family meals become occasions for regular rows. It also happens when there is a pre-existing weakness of the Stomach, in which case the anger may affect only the Stomach without even affecting the Liver. If one regularly gets angry an hour or two after meals, then the anger will affect the Intestines rather than the Stomach. This happens, for example, when one goes straight back to a stressful and frustrating job after lunch. In this case, stagnant Liver-Qi invades the Intestines and causes abdominal pain, distension and alternation of constipation with diarrhoea. Finally, anger, like all other emotions, also affects the Heart. This is particularly prone to be affected by anger also because, from a Five-Element perspective, the Liver is the mother of the Heart and often Liver-Fire is transmitted to the Heart, giving rise to Heart-Fire. Anger makes the Heart full with blood rushing to it. With time, this leads to Blood-Heat affecting the Heart and therefore the Mind. Anger tends to affect the Heart, particularly when the person does a lot of jogging, hurrying or exercising. Thus, anger may cause either stagnation of Liver-Qi or Liver-Yang rising. When advising patients on how to deal with their anger, we should note that if anger has caused stagnation of Liver-Qi – expressing the anger may be helpful. However, if anger has given rise to Liver-Yang rising, expressing it will not usually help; it
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is too late, and expressing the anger forcefully may only make Liver-Yang rise even more. In my opinion, anger is overemphasized as an emotional cause of disease in Chinese books. I feel that this is very much due to the Confucian influence on Chinese medicine. A very important aspect of Confucianism is the emphasis laid on social harmony, which, according to them, begins with family harmony, which, in turn, is based on the rigid respect of family hierarchy. For example, the younger brother obeys the older brother, the sister obeys the brother, all the children obey the parents and the wife obeys the husband. When every member of the family and society takes his or her proper place and role in the family and social hierarchy, then familial, social and political harmony reigns. Figure 10.6 summarizes the effects of anger and the organs affected by it.
! In my opinion, anger is overemphasized as an emotional cause of disease in Chinese books.
It is easy to see that the emotion that most threatens the established order is anger, because this emotion may lead people to rebel. Given the Confucian influence on Chinese medicine, I believe it is for this reason that anger plays such a predominant role among the emotional causes of disease. Anger makes Qi “rebel”, i.e. go in the wrong direction, and it is interesting to note that the Chinese character for “rebellious” Qi is ni , which means “rebellious”,
Liver-Yang rising
Qi rising
Liver-Qi stagnation Heart-Qi stagnation
ANGER Qi stagnation
Stomach-Qi stagnation Intestine-Qi stagnation
Figure 10.6 Summary of effects of anger.
“contrary”, “to counter”, “to disobey”, “to defy”, “to go against”; it is easy to see the “social” nature of this pathological movement of Qi. Indeed, the opposite of ni is shun , which, in Chinese medicine, denotes Qi going the right, proper way; again, it is easy to see the social implication of this term, which means “to conform”, “in the same direction as”, “to obey”, “to yield to”, “to act in submission to”. With regard to Liver-Qi stagnation and anger, there are two issues to consider. First, anger is, in my opinion, over-diagnosed as an emotional cause of disease (see case history below). Second, Qi stagnation does not derive always necessarily from anger, and it therefore may affect organs other than the Liver; in emotional problems, Qi stagnation may affect especially the Lungs, Heart and Spleen. It follows that when we diagnose Qi stagnation in a patient we should not assume that it is necessarily due to Liver-Qi stagnation and to anger: worry, sadness, grief and guilt may all cause Qi stagnation in the Lungs and/or Heart. The patterns o