Classical Point Combinations and |
Clusters of Points in |
Acupuncture Therapy |
Shmuel Halevi Ph.D
This work will present the thesis that, both clinically and theoretically, point-combinations in acupuncture therapy and especially classical point combinations, constitute the most reliable form of treatment in Chinese acupuncture.
We shall try to demonstrate as many such combinations as possible, dealing with their logic, i.e. theoretical foundations within the framework of Chinese medical philosophy and other aspects such as:
• Analysis of each point in regard to its place in the prescription.
• Comparison of certain point-combinations to herbal formulae used to treat the same patterns of disharmony.
• When possible, comparison of each point in the formula with a specific herb used for the same energetic action.
• Relevant and real case histories demonstrating the efficacy of a specific point combination.
• Technical data of importance in utilizing POINT COMBINATIONs like:
1. Needle manipulation of various points in the combination (i.e.strengthening, reducing, dispersing, heating, etc.).
2. Sequence of needling procedure.
3. Other techniques of stimulation like: moxibustion, pressure, cupping, lectro-acupuncture and more.
In addition, we shall examine a few major methods of formula composition existent in Chinese medicine for ages. These methods are very important to our thesis as they form the theoretical basis from which many of the point-combinations have evolved.
Another important facet of this subject is the tendency of students and practitioners alike, to regard point-combinations as formulae for treatment. In this work, we shall show that point-combinations are not formulae and that they serve only as solid "brick constructions" so to speak for a good formula. A comprehensive formula has to be formulated entirely on diagnosis.
CONSTRUCTION
This work consists of the following chapters:
A. Point-combinations general rules.
B. The various laws for combining points.
C. Formula building in acupuncture therapy utilizing POINT COMBINATIONs.
D. Survey of popular and effective point combinations .
DETAILING
CHAPTER A - This chapter discusses the nature of point combinations in general terms and will demonstrate the general principles of their existence.
CHAPTER B - Chapter B discusses in detail the various laws and principles from which the art of combining points has evolved.
CHAPTER C - In this chapter, we discuss the difference between treatment formulae and point combinations . There are a few examples of the way in which a treatment formula is constructed, utilizing one or more point combinations.
CHAPTEL D - This is the last and the lengthiest chapter in which we have surveyed 18 effective point combinations, each of which includes the parameters that we have mentioned above.
REMARKS
The assumption of this work is that the reader is completely familiar with the concepts, philosophy and terminology of Traditional Chinese Medicine (T.C.M.).
Therefore, basic concepts such as: Qi, Blood, Yin, Wind, Heat and the like, have not been discussed or explained.
Some of the ideas presented in this work, particularly those dealing with the practical aspects of T.C.M., have no roots other than the clinical experience accumulated by me during my years of practice and my personal observation. Nevertheless, in most cases, there is a numbered reference throughout the paper, pointing to a bibliography at the end of the work.
CHAPTER A
POINT COMBINATION GENERAL RULES
A point combination in Chinese medicine is a term used to describe a well known collection of acupuncture points from two up to, usually, no more than five or six points. Generally, this collection of points has a long history of clinical use based both on theoretical foundations and experience.
Since most of T.C.M. (Traditional Chinese Medicine from now onward) clinical means, herbs and acupuncture alike, have evolved from solid theoretical ground, it is not surprising that almost all classical point-combinations are the result of logical reasoning of the same valid principles. Moreover, the fact that so many classical combinations have survived throughout the ages (and we are speaking of some thousands of years) (1), and have proven themselves clinically successful, only emphasizes and reaffirms the stability and truthfulness of these theoretical principles.
Basically a point combination, or point cluster (which is a different thing) (2), is supposed to have a very specific energetic impact on the body, thus enhancing the effectiveness of the whole treatment of which it is a part.
In order to illustrate this idea more clearly, here are a few examples:
A. A nasal congestion and/or sinus infection is supposed to clog the Yang Ming meridian system in the region of the nasal cavities and forehead. There is an age old point combination dealing with this phenomenon, based on the points: Hequ (LI 4), Ouchi (LI 11) and YIngx1ang (LI 20). These three points together, which belong to the Shou Yang Ming system, if punctured in the above mentioned sequence, have a pushing, obstruction clearing action on the meridian thus, resolving the stagnation in the affected region.
B. Another example, which is based on the principle Shu Mu combinations, will show an effect directed toward a specific internal organ in the body. For instance the points: Feishu (B 13) and Zhongfu (L 1), which serve as the Back Shu (associated) point of the Lung organ and the Front Mu (alarm) point of the Lung organ, deal successfully with problems such as asthma, painful breathing, pulmonary bleeding etc. These problems need a soothing, calming and harmonizing action which this combination can provide.
Yet, other combinations are capable of even more fantastic effects. There are combinations based on more complex principles, which are capable of multi system overall effects. Such a combination is Liehchueh (L 7) and Zhaohai (K 6).
These two form the Master and Coupled points of an extra meridian the Jen Mai. As such, they have a vast influence over the organs and functions in the domain of this vessel. This may include the breathing, digestive and sexual-urinary systems; it may also include fluid metabolism in general, as well as hormonal imbalances affecting the uterus (3).
Besides "opening" the Jen Mai by activating its Master and Coupled points, these two points bind the mutual assistance function of the Lung and Kidney systems (4).
Liehchueh activates the downward flow of the lung energy, thus setting in motion the lung's activities such as breathing properly, dispersing extra fluid from the body (perspiration, urine, etc.), sending extra fluid to the kidney and eliminating phlegm (5). Zhaohai, in response, causes an upward movement by activating kidney functions associated with Yin (water, phlegm metabolism) (6), thus harmonizing the activities in the Kidney's domain, such as sexual urinary functions. In addition, as mentioned above, these two points form the link between the Lung and the kidney, by aiding the kidney to "grasp" lung Qi (which descends), and preventing it from "rebelling" upward (i.e. dyspnoea, asthma) (7).
In these three examples we can see that point-combinations may have a local effect on a meridian, on an internal organ, on a specific disease focus in the body as well as on general functions or activities of various systems in the body.
It is, therefore, of primary importance to make a proper diagnosis which will enable the practitioner to choose the proper point combination in order to assist the treatment formula in the desired way. Still, it will be difficult to choose the proper point combination just by memorizing them all. A profound comprehension of the logic which lies behind each combination is needed.
This brings us back to the "laws" of acupuncture and to its very core the theories of Yin Yang, Five elements, Tsang Fu etc.
Only by a thorough understanding of these principles can one understand or even memorize the manifold point-combinations and then apply them correctly.
back to top of page
CHAPTER B
THE VARIOUS LAWS OF POINT COMBINATION
1. The Shu Mu Law (8)
This technique of point combination is based on two specific point groupings, one on the front of the body and one on the back, i.e., the Associated and Alarm points. The concept is that both sets have a direct influence on the organ with which they are associated, like Feishu (B 13) and Zhongfu (L 1) on the lung, or Pishsu (B 20) and Zhangmen (LIV 13) on the spleen etc. Furthermore, if each point alone has a strong influence on its organ, combining it with its vis a vis point, will boost its effect and enhance the therapy.
Clinical experience has shown that this combination principle usually has a better effect in Shi conditions when a sedating and soothing action is needed. It is used less in Xu conditions where other techniques are applied. Both Shu and Mu points are chosen when an internal organ is afflicted thus,
combining these two points together has a strong effect on the organ, most frequently, a sedating one.
The principle of Shu Mu is based on an even more basic law, the law of "opposites".
2. The Law of the Opposites
The use of the "law of opposites" suggests that a disease located in one part of the body should be treated on the opposite part. For Instance, a disease located in the right part of the body should be treated on the left side. A disease located in the back should be treated in the front and vice versa. A disease located in the upper part should be treated in the lower part of the body and so on.
Practical examples of this law is treating Weizhong (B 54) for back pain (lower upper), or treating Hegu (LI 4) left for a toothache in the right mandible, etc.
An extension of this law gave birth to many sets of point combination, using two effective points from each of the opposites. Thus, in the case of lower back pain, the use of the point below Weizhong (B 54), is happily "married" with the most effective point in the upper part, i.e. Shenshu (B 23). These two points together form the very basis for any lumbago treatment, taking advantage of the law of opposites.
3. Combining Yin Channel Points with Yang Channel Points
This law is another example of how Chinese thinking makes use of the philosophy of duality or rather, contrasting and complementary phenomena such as Yin Yang etc.
The Comprehensive Text of Shanghai College states:
"As we know, the primary Yang channels are connected to the primary Yin channels in a Yin/Yang relationship. By combining a point on a Yang channel with another on its paired Yin channel, the cumulative effect is greater than needling either point separately. Examples: combining S 36 (Zusanli) on the stomach channel (Yang) with SP 4 (Gongsun) on the spleen channel (Yin) for stomach disease. Or, combining L 9 (Taiyuan) on the lung channel (Yin) with LI 4 (Hequ) on the large intestine channel (Yang) for coughing. The most well known combinations of this kind are between the Source points on the channel primarily affected by a disease, and the Connecting point on the channel paired with the first, in the Yin Yang relationship. In this combination the Source point is called the "host" and the Connecting point the "guest"."(p.58).
This principle of combining points has created renowned combinations such as Hegu (LI 4) with Liehchueh (L 7) for upper respiratory tract ailments. Taichong (LIV 3) with Guangming (G37) for eye disorders, Taiyuan (L 9) with Pianli (LI 6) for cough from phlegm aetiology, etc.
The idea behind this form of combination is to divert excess energy from the diseased organ to its parallel Yin/Yang related channel. Thus, by puncturing the "host" point which is a Source point, one directly drains an overactive organ (Source points are in close relation with their organ (9)). The stimulation of the Luo point of the parallel meridian ensures that the excess Qi would thus leave by the closest possible gate. (Luo points form a passage between two Yin/Yang meridians). (10)
4. Master and Coupled Points of Extra Meridians
The master and coupled points of the eight extra meridians form eight pairs of points each attributed to one extra meridian. Each pair is said to "open" its extra meridian, thus enabling it to absorb extra energy like a "sea" or "reservoir" of energy. (11)
Two techniques exist by which these combinations are used. one way stimulates the two master points and then the two coupled points. The second advocates puncturing right master point and left coupled point in women and vice versa in men. (12)
Many of the eight pairs have been found so successful in clinical practice that they are often used with no regard to their original assignment as master and coupled points of an extra meridian. A good example would be the pair Neiguan (P 6) and Gongsun (SP 4). This couple with the addition of Zusanli (ST 36) form the best point combination to treat morning sickness or any nausea, of different etiologies.
Another couple: Liehchueh (L 7) and Shaohai (K 6) which is also used quite frequently, has already been discussed in the previous chapter.
More of these couples will be discussed later in our last chapter.
5. Combining Local with Distant Points
This is a general law for combining points in acupuncture. The law takes advantage of the experience gained from the use of various points and binds together effective points in the vicinity of the disease, with other effective points from distant parts of the body.
It has been found, for instance, that Ligou (LIV 5) is an effective point in treating maladies of the external sex organs (by virtue of its task as a Luo point of the meridian that encircles these organs). Zhongi (CV 3) is also an effective point for treating such problems (13). Thus, binding the two together, one close to the disease focus, and one from afar, makes a good combination in any formula for this purpose.
This law also has a deep root in the concept of "Root and Branch" and "Origin and End".
This concept is an ancient observation that all primary meridians have reciprocal relationships between points situated on the upper and lower reaches of the body, respectively.
Thus, the bladder meridian has its root area in the vicinity of Fuyang (B 59) and branch area around Jingming (B 1).
Or, the spleen channel makes its root around Sanyiniiao (SP 6) and its branch in Pishu (B 20) as well as Lianchuan (CV-23). (Acupuncture A Comprehensive Text, p. 61).
6. One Point Above. Two Points Below
An extension of the previous law this extraordinary law achieves wonders in acute processes, if applied correctly.
This law makes use of the previous law: "combining local with distant points", with two additions. One is that all the points should be on the same meridian segment (i.e. Shaoyang, Yangming, Taiyin etc.). The second, emphasizes that only one needle should be planted near the disease, while far from it two needles. This may, at first, sound bizarre, but the logic is clear.
Taking, once more, the example of sinusitis, the point-combination which is the outcome of this law would be: Hegu (LI 4), Yingxiang (LI 20), Zusanly (ST 36), Nelting (ST 44).
Hegu, as the strongest point in the hand Yangming, will set the whole Yang Ming energy in motion. Yingxiang serves as the local point to cause a dispersion effect in the area and Zusanli, together with Neiting, are "the two points below". These two points below provide a strong stimulation to the other end of the meridian accelerating its energy and flow while eliminating the stagnation in its upper part.
This same law formulates another very important point-combination, used to effect Dampness elimination from the intestines (purgation of the intestines).
The combination is: Tianshu (ST 25), Zusanli (ST 36), Shangjuxu (ST 37)and Xiajuxu (ST 39).
Tianshu is the local strong point for the intestines (the Mu point of the colon), the other three points being situated on the same stomach meridian and creating the weight to cause a strong downward flow of the stomach meridian energy (15).
7. Empirical Point combinations
There are dozens of point-combinations in acupuncture which have emerged through sheer clinical
experience. Every practitioner, who has spent a considerable length of time in clinical work, has probably noticed that some points yield better results when combined with certain other points.
It is only logical that after so many generations of accumulated experience in the field of acupuncture, such empirical combinations have become the inheritance of the majority of practitioners.
In comparison with the other forms of point-combinations that have so far been detailed, this form lacks their theoretical background in most cases.
Nevertheless, clinical success is after all the ultimate judge and thus, these combinations have earned their position in clinical work.
Here are a few examples of point-combinations whose source is entirely empirical:
• The addition of Sibai (ST 2) to the combination of Dannangxue (extra), Tianshsu (ST 25) and Guanyuan (CV 4), have a great soothing effect on biliary ascariasis. Manipulating Sibai in a sedative fashion, usually eliminates the very sharp pain which this illness causes (16). There is no theoretical explanation for this phenomenon.
• Hegu (LI 4) on the opposite side, combined with Liangqiu(ST 34) on the affected side, is a quick relief for strained muscles or tendons of the knee joint (usually due to a sport injury). In order to obtain the full effect of this combination, one should first puncture Hegu, at an oblique angle towards the metacarpal bones, two Cun deep, and then manipulate Liangqiu to cause numbness or distension around the knee (17).
• Shaoze (SI 1) has an undeniable influence on the breasts. Hence, all breast diseases, including agalactia (lack of milk), are treated with the aid of this point. When combining Taiyang (extra) to Shaoze (SI 1), we make an effective point combination for swollen breasts. This formula's source is also classical (Song of the Jade Dragon Ca. 1500) (18).
It is worthwhile mentioning, in this connection, that many empirical combinations include extra points, and there are a few that are composed entirely of extra points.
The reason for this is clear. Since extra points themselves have originated from clinical experience, and in many cases as Ahshi points, they lack the theoretical basis that most of the meridians' points have.
It is no wonder then, that many empirical combinations include extra points, for they too have originated from clinical observation.
Example No. 3 (above) may illustrate this phenomenon, or this very popular combination:
Yintang (extra), Shenmen (H 7), Sanyinjiao (SP 6).
This formula is often used to calm the mind, especially in cases of insomnia (19), or mental anxiety.
Shenmen and SanyinJiao harmonize Fire and Water elements, or heart and kidney functions, while Yintang places an emphasis on calming the mind. Thus, an extra point (Yintang) contributes to the principal effect of the two meridian points, with its empirically found soothing properties.
8. Point Clusters
A point cluster is a grouping of a few points in the same area of the body, whose mutual effect on this area is beneficial.
In many cases, these clusters are formed from extra points like Sishencong on the vertex or from Ahshi points (tender points) in the vicinity of the disease focus.
An example of a point cluster would be "Three needles at the ankle". I.e. Kunlun (B 60), Jiexi (ST 41), Taixi (K 3). This cluster serves as a local treatment to disperse any blood stagnation caused by trauma in the ankle joint, or paraplegia (20).
Another "Three needles at the ankle" serves the same purpose, and is a combination of three different points: Qiuxu (G 40), Jiexi (ST 41), and Shangqiu (SP 5). This is indeed a very effective trio for a sprained ankle, etc.
The majority of the point clusters, though not all of them, are concerned with localized influence. Making use of the T.C.M. principle that any pain, swelling etc. is caused by stagnant energy or blood, or both, (21) the use of powerful local points in conjunction, is supposed to resolve this stagnation, and dislodge the barrier.
Needless to mention, the utilization of such a combination would need a special dispersing technique, one that would enhance the flow of energy in the region, and disperse blood or fluid from the joint.
Other point clusters serve the same purpose as regular point combinations, i.e. to cause any pre-calculated therapeutic effect, with the difference, as we mentioned above, that they are located in close vicinity.
The articulations of the body, such as: shoulder joint, ankle, knee or elbow joint, are considered the most vulnerable parts of the body, in relation to the smooth flow of Qi (22). Rheumatic pain which is caused by weather Influences, according to T.C.M. thinking, is usually lodged in the joints, thus hindering the smooth flow of Qi.
It is not surprising, therefore, that many clusters of points have originated in the vicinity of the joints for the purpose of removing the stagnant pernicious influence that has lodged there.
Such clusters are the "three ankle points" that we have already mentioned or "the three shoulder points" and the "three knee points", some of which will be discussed later.
9. Balancing and Mutual Assistance
This very traditional principle of Chinese medicine is responsible for dozens of point combinations, which have been formulated over the millennia.
The idea of balancing is, after all, the core of Chinese thought, originating from the basic conception of Yin and Yang (23).
All phenomena in our body can actually be attributed to Yin and Yang, and its balanced or imbalanced state.
Without pondering too deeply upon this subject's philosophy, which is beyond the scope of this work, it is sufficient to say that the balancing of Yin and Yang, Hot and Cold, Shi and Xu, is the ultimate goal of Chinese medicine (24).
Therefore, besides the various rules of point-combinations that we have summarized above, there is the principle of balancing Yin and Yang activities, which dictates what points to use in each case of imbalance.
One of the most frequently encountered imbalances in clinical practice is that of the elements of Fire and Water. Most often symptoms such as heart palpitations, insomnia, dream disturbed sleep, anxiety etc., are the outcome of this imbalance. According to the poetic and imaginative Chinese physiology, kidney Water is insufficient and unable to control heart Fire, which blazes upward.
This may cause palpitations and a restless heart, as well as a disturbed Shen (spirit), since Shen resides in the heart organ.
To rectify this, the Chinese have originated many combinations, formulated from points having the ability to restrain or dredge the heart activity on the one hand, and to strengthen or supplement kidney Water, on the other.
Such combinations are:
1. Shenmen (H 7) and Sanyinjiao (SP 6)
2. Tongli (H 5) and Dazhong (K 4)
3. Tongli (H 5) and Zhaohai (K 6). (26)
Another frequently encountered balancing method is to harmonize activities, either of organs or of functions. This is also based on the concept of deficiency or excess of specific activities. A good illustration for this would be the combination of Hequ (LI 4) and Fuliu (K 7).
This combination is used primarily to treat cases of either excessive or lack of perspiration.
In case of excessive perspiration, Wei Qi is deficient, so Hegu has to be tonified in order to fortify the protective abilities of Wei Qi. (Please note that Wei Qi is responsible for the tonus of the sweat pores, thus controlling perspiration). At the same time Fuliu has to be reduced, since its activities are closely linked to "water" movements in the body.
In the case of the absence of perspiration, one should use these very points, only with reversed manipulation. For example: Hegu sedated, in order to release tightness of the sweat pores which are controlled by Wei Qi. Fuliu tonified, in order to increase "Water" movement In the body (27).
Another principle of point combination, which was included under this heading, is the principle of mutual assistance.
In the same way that herbs are frequently chosen to assist and strengthen each other’s action, so are points, by this principle of combination.
This method is often relevant in cases where the elimination of a pathogenic factor is needed, much like herbal treatment.
For instance, where the elimination of a Wind Heat factor in the head region is needed (i.e. tonsillitis), Hegu (LI 4) is of major importance. To strengthen its action we shall most probably choose Quchi (LI 11), a point quite powerful by itself, for eliminating Wind Heat. Clinical observaton has verified, that this couple of points has a much better impact on the head region than each of them alone (28).
By the same logic, Sanyinjiao (SP 6) and Yinlingquan (SP-9) are often combined together, for the purpose of eliminating Damp Heat pathogen from the Lower Burner.
SanyinJIao is indicated, among many other qualities, to resolve Damp and Damp Heat from the Lower Burner, mostly by facilitating urination (29). Yinlingquan is also indicated to resolve Damp and Damp Heat from the Lower Jiao, and it treats: edema, ascites, retention of urine, urinary tract infection, diarrhea, etc. (30).
Again, clinical experience has shown that putting together these two points, enhances the therapeutic effect of each of them, and this combination has become a valuable asset of Traditional Chinese medicine (31).
CHAPTER C
FORMULA BUILDING IN ACUPUNCTURE THERAPY, UTILIZING
POINT COMBINATIONS
1. Diagnosis
Diagnosis is of prime importance in T.C.M. Actually, it is impossible to construct a treatment formula, unless one has reached a sound diagnosis.
Knowing that, in ancient times the Chinese developed a unique diagnostic skill, based on procedures that matched their medical doctrine.
Remaining faithful to their basic concept that via the meridians' system, the inside of the body can be perceived by the outside of the body, most diagnostic procedure was based on techniques of how to best decipher these outside signs.
Thus, the famous four methods of diagnosis emerged. These four methods are:
• I. Looking
• II. Listening and smelling (which is the same word in Chinese)
• III. Asking
• IV. Touching (32)
Without giving a fully detailed description of each of these steps of diagnosis, suffice it to say that they consist of:
• Looking especially at the tongue shape, colors and fur.
• Listening - to the pitch of voice, or cough (moaning or groaning and other sounds) whether loud or low, labored breathing such as wheezing etc.
• Asking which is an interrogation of specifities of the patient's complaints, and especially some pointed questions, unique to T.C.M.
• Touching especially the art of taking the pulse, but also the palpation of the abdomen or of some special acupuncture points.
After these procedures have been performed, the practitioner has to form a diagnosis, based on the eight principles of T.C.M. These principles are:
Yin or Yang (1+2)
Hot or Cold (3+4)
Shi or Xu (5+6)
Internal or External (7+8)
In addition, the information gathered so far must include the site of disease (whether the spleen, colon, or any of the meridians) and, of no less importance, the cause of the disease.
All these details and knowledge have a strong impact on the planned treatment, as well as on the prognosis.
When all of this information has been collected and processed into a logical and workable diagnosis, then we must determine our treatment approach. This approach is based entirely on diagnosis. Thus if we have diagnosed a simple case of a Wind Heat condition, the approach would be: the elimination of Wind Heat and restoring normal balance. Or, in a more complicated case, where our diagnosis leads us to a conclusion of disharmony of stomach and spleen and a kidney Yin deficiency, our approach should be to tonify spleen Qi and sedate stomach Fire, while placing an emphasis on strengthening kidney Yin.
At this stage, the practitioner must assess whether Stomach Fire is more severe than the deficiency condition of the kidneys, and this conclusion must lead him either to put an emphasis on sedating the stomach, or on tonifying Kidney Yin and Spleen Qi.
It is no less important to educate the patient as to how to behave in the future, enabling him to keep his reharmonized state of health intact. This education cannot be of value unless the real cause of disease has been grasped by the practitioner.
When a specific approach has been determined, as we have illustrated above, our next step is to choose a specific technique for the treatment.
A specific technique may actually be comprised of several techniques, with one goal: to induce a general effect on the patient, in order to achieve the aims of the approach.
A technique may be a tonifying technique, based on choosing points that usually tonify. It may use moxa, in order to enhance the tonifying effect, and it should apply certain needle manipulations that cause an effective tonification.
A technique may need to disperse stagnant blood that causes pain, swelling and immobility. Therefore dispersion techniques should be adopted such as: drawing blood with a cup, or, again, certain needle manipulations like: "needling one point in four different directions" (33), etc.
While discussing the technique, we must also bear in mind that at this stage, we have to set the course of the whole treatment. We have to decide whether we treat the Ben first, or the Biao (i.e. the symptoms, or the cause), or we have to decide whether we treat an externally inflicted disease, before we treat an internal imbalance or, sometimes, vice versa. In the same manner, we shall have to decide whether to treat the Shi condition or the Xu condition first and make many other difficult decisions.
As a rule, all these decisions, and others, will be the outcome of a careful assessment of our patient's condition, which will dictate the treatment technique, its impetus, its rhythm, and above all the treatment formula.
Building the treatment formula is really the climax of the practitioner's intellectual ability. By composing the formula, the practitioner's diagnostic skills, as well as his thorough memorization of points, combinations and actions, will come to full realization.
There are many methods and approaches as to how to construct a formula. Some of these approaches even contradict each other. Some approaches state that any formula should have close points, medium points and distant points (34), in order to have a full effect.
Some approaches advocate the use of the Five Elements school, as the basis for any treatment. Other approaches recommend prescriptions by the new China T.C.M. approach.
There are even practitioners who are trained to build a treatment formula that will match their patient's astrological map, and some that use the famous I Ching trigrams hexagrams and to construct a formula.
The methods are numerous, and differ entirely. However, the China T.C.M. stream is the main, and this is the method that yields the best results, according to Chinese researchers (35).
The T.C.M. method of formula building relies most of all on empiricism. It relies also on strong foundations of sound traditional medical theories. Its main theoretical source is syndrome differentiation according to the Tzang Fu system, but, nevertheless, it adopts any treatment procedure that has proven itself valuable throughout the ages.
It is no wonder that a method that relies most of all on clinical experience, will use as many point-combinations as does this method.
We have already shown that point-combinations have both theoretical and empirical background as their backbone.
Thus, we can rarely find a treatment formula that does not include, at least, one practical points combination. In order to illustrate this assumption, the following is a casually chosen list of treatment formulae, for various complaints in which I have marked the point combinations:
I. Ganshu (B 18), Qimen (LIV 14), Danshu (G 24), Changman (LIV 13). This is a formula for infectious hepatitis, combined by two pairs of point-combinations according to the Shu Mu principle.
II. For acute enteritis: Tianshsu (ST 25) with Shangjuxu (ST-37). This combination is one point above and one point below, on the same meridian.
III. For bronchitis: Chitze (L 5), Hegu (LI 4) and Liehchueh (L 7). In this formula, Hegu and Liehchueh form the "Host Guest" relationship combination.
IV. Ermen (T 21), Tinggong (SI 19), Tinghui (GB 2), Yifeng (T17), Waiguan (T 5) and Chungzhu (T 3), is a recommended formula to treat deafness. Ermen, Tinggong, Tinghui and Yifeng, make a cluster of points for ear problems.
V. For rectal prolapse we may choose Paihui (GV 20), Changqiang (GV 1), Zusauli (ST 36), Sanyinjiao (SP 6), Qihai (CV 6) and Shenchueh (CV 8) the last two points, and probably Paihul too, with moxa. Paihu, Qihai and Shenchueh together make a very strong point combination that powerfully raises Yang Qi thereby elevating prolapsed organs, like the rectum. This combination is based on the mutual assistance principle (see previous chapter, paragraph No. 9).
Changqiang and Paihui is another combination in this formula, built on the principle of "one point above, one point below," on the same meridian. While puncturing both ends of the meridian, we balance its activities, and if it is on an extra meridian, like the Du Mo meridian, by doing so we drain its excess energy (36, 37).
VI. For the treatment of palpitations caused by ventricular septal defect with symptoms such as: general weakness and shortness of breath, the following formula may be utilized (38):
Neiguan (P 6), Shenmen (H 7), Tanzhong (CV 17), Zusanli (ST 36), Qihai (CV 6), Sanyinjiao (SP 6), Shaohal (K 6), Jueyinshu (B 14), Xinshu (B 15), Keshu (B 17).
In this formula, several classical point-combinations were used, in order to bring about the desired effect. This is obviously a case that needs a direct effect on the main symptom, palpitations, while not neglecting the rest of the problem which is Qi and blood deficiency.
The points Neiguan, Shenmen and Tanzhong serve as a well known combination to relax the heart, calm the Shen and "open the chest". ("Open the chest" is a Chinese metaphor used to describe functions such as: to improve blood circulation between heart and lungs, or to relax symptoms such as sensations of fullness or congestion and tightness in the chest).
Jueyinshu and again, Tanzhong, is another combination which uses the principle of Shu Mu. In this case, adding mutual assistance to the previous combination to enhance heart circulation.
Zusanli, SanyinJiao and Qihai constitute an even more frequently used combination whose goal is to tonify the Qi and eliminate lassitude. In this case, it also has another task of helping in creation of blood, since "Qi is the mother of blood" (39. Tonifying the Qi will help produce new blood.
But, this excellent formula creator has made another important link and added Shaohai and Sanyinjiao to the formula. This pair have a mutual assistance effect on the general Yin Qi. Since blood is Yin, it is important to tonify both Qi and Yin, in order to supplement blood.
The last combination in this formula is Sanyinjiao, Xinshu and Keshu. This is also a blood strengthening combination (based on Keshu which is the associated point of blood), only it puts an impetus on the heart's blood. We have to bear in mind that according to Chinese physiology, blood is also formed in the Tanzhong area with the aid of the heart.
From the few examples above, we can see that treatment formulae may vary considerably from one another. A formula may contain, or even be composed of one point combination and it may have as many as four or even more point combinations.
In any case, the purpose of including these combinations so deliberately in the formula, is to ensure that certain influences shall be exerted as decisively and promptly as possible. Since many of the point-combinations have proved themselves most valuable in clinical work, it is obvious that one should use these combinations while composing a treatment scheme.
Thus, besides taking advantage of the use of already clinically proven combinations and giving our formula a solid basis, there is also a benefit in utilizing pre-made segments for the formula, liberating us from the necessity to build them by ourselves.
back to top of page
CHAPTER D
SURVEY OF POPULAR AND EFFECTIVE POINT COMBINATIONS
Foreword to this chapter
Most of the combinations in this chapter have been taken from the book: ACUPUNCTURE A COMPREHENSIVE TEXT, by the SHANGHAI COLLEGE OF TRADITIONAL CHINESE MEDICINE.
The majority of the combinations form the backbone of the clinical knowledge of every practicing acupuncturist and as such, they should certainly not be expected to be innovations or rare information. Moreover, the eighteen point-combinations analyzed here, are only a drop in the ocean when compared with the myriad combinations which have evolved throughout the history of T.C.M.
However, the aim of this analysis is to understand the principles by which a point combination has been formed, as well as its clinical value and application.
The functions of the various points in the following combinations as well as their classical indications and qualities, were taken from two main sources:
1. The same COMPREHENSIVE TEXT (see above).
2. THE ACTIONS OF ACUPUNCTURE POINTS by Peter Deadman which was published in several
parts in the JOURNAL OF CHINESE MEDICINE.
The rest of the material, including the analysis of each point, the theoretical background of the combination, the practical application and the comparison with a herbal prescription, were all taken from my own clinical experience and personal observation, unless otherwise stated.
Needless to say, all the case histories in this chapter are of persons treated by me in my practice.
The source for all information presented here regarding herbs, including herbal prescriptions, is the book: CHINESE HERBAL MEDICINE MATERIA MEDICA of Eastland Press, by Dan Bensky et al. However, comparison of the point-combinations with the herbal prescriptions in this chapter, is mine alone.
-------------------------------------------
back to top of page
1. SANYINJIAO (SP 6), GUANYUAN (CV 4), QIHAI (CV 6).
Main effect and clinical purpose
This point combination is commonly used as a general tonic for Qi and Blood. It is therefore frequently used in cases of severe lassitude, anemia, impotence, spermatorrhea and the like.
Because of this point combination's main effect, it is used with a tonifying manipulation and/or moxa.
Point discussion
Sanyinjiao (SP 6) is the point of intersection of the liver, spleen and kidney meridians and functions to regulate and tonify the Oi in these channels. It also has a strong effect on the reproductive, as well as on the urinary systems and is therefore used to regulate Yin Qi either to tonify, or drain. Sanyinjiao belongs to the spleen meridian and has a great influence on all the functions of the spleen organ. That includes: regulating the digestive system, improving appetite, creation of blood and elimination of Dampness (40).
Guanyuan (CV 4) The meaning of Guanyuan is "the passage for the Source Qi". This is the point of intersection of the three Yin channels of the leg on the Conception Vessel (41).
Needling this point tonifies the Yuan Qi which is the prenatal Qi. It therefore strengthens the kidneys and actually the whole body. Due to its location, it is primarily used to tonify Yin Qi but it can be used to tonify Yang Qi as well. It is hardly ever used to sedate. Qihai (CV 6) is also located on the Conception Vessel, Ren Mai. Its name implies that it controls the sea of Qi which lies exactly on this spot, known as the "Lower Dan tien". Qihai is therefore used to regulate Qi, especially post natal Qi (42) and strengthen kidney Qi, Yin and Yang in general.
Combining Guanyuan and Qihai has a strong strengthening effect on the Qi of the whole body. These points together stimulate pre and post natal Qi and the kidneys. Adding Sanyinjiao to these two, gives a further impetus to creation of Yin and blood, improved liver and spleen functioning, thus making the best tonifying point-combination.
There is another similar point combination that uses Zusanli (ST 36) instead of Sanyinjiao (SP 6). The difference between these two is that the latter is used mainly for general strengthening purposes, with an emphasis on digestive irregularities, blood and general stamina. The previous combination has a more uro genital bias.
Needling sequence, manipulation and stimulation
For purposes of general strengthening of Qi, one generally punctures in this order: Guanyuan, Qihai and then Sanyinjiao. But, if our aim is to strengthen Yin Qi, or treat the uro-genital system, Sanyinjiao precedes the other two points.
As we have stated before, the goal of this combination is primarily to tonify. In order to do so, we must use a tonifying manipulation, i.e. penetrate the point gently in three stages. While manipulating, we need to push into the point more strongly than when withdrawing the needle.
Often we may utilize the "Burning the Mountain" technique. In this technique the needle is first inserted to a superficial level and is then advanced to a middle and finally to a deep level. At each level the needle is forcefully thrust, and gently raised, nine times. Then, the needle is left in the superficial level. This manipulation is repeated until the patient experiences a warm or burning sensation.
It is also very common to use moxa on these points, either direct moxa, or "warm needling". Moxa is used mainly in cold/deficient diseases.
Herbal eguivalent
It is adequate to compare the use of Guanyuan and Qihai to radix Panax Ginseng. This herb is mainly used in severe Qi deficiencies or even collapse. It is also known to tonify the Yuan Qi and both Yin and Yang Qi.
We can also find similarities between Angelica Sinensis, Dan Gui and the actions of Sanyinjiao. This herb, too, is used to tonify the blood and treat uro-genital disorders. Along with this, Dang Gui is also used for abdominal pain, constipation, Damp Bi etc., for all of which Sanyinjiao is also useful.
Case history
Mr. A.M. of Arab origin, age 27, occupation: building worker, married for two years.
Complaint infertility, spermatorrhea especially at night and premature ejaculation.
Diagnostic features
1. Red face, cold feet.
2. Feels generally fine, except sometimes dribbling urine.
3. Pulse slippery, big.
4. Tongue pale, soft
5. Abdominal tenderness under umbilicus and right hypochondriac region.
Diagnosis
1. Weakness and looseness of the "gate of sperm" ("Ming Men"), due to excessive sexual intercourse and hard physical labor.
2. Excitement of Heart Fire.
Treatment
1. Sanyinjiao (SP 6), Gyanyuan (CV 4), Qihai (CV 6) and Taling (P 7).
2. Refrain from sexual intercourse until spermatorrhea subsides.
Explanation
Sanyinjiao, Guanyuan and Qihai together tonify the Yuan Qi thus enlivening the sperm and strengthening the Ming Men. Taling is used to decrease Heart Fire and thereby helps the patient control his sexual enthusiasm. Taling was punctured against the flow of Qi, i.e. needle pointed proximally, in order to cause sedation.
Results
After two sessions the spermatorrhea ceased. After three months the patient’s wife became pregnant.
2. HEGU (LI 4), YINGXIANG (LI 20), ZUSANLI (ST 36), NEITING (ST 44), XIANGU (ST 43) [43].
Main effect and clinical purpose
This is a point combination based on the law "one point above two points below" (see previous chapter). Its purpose is to clear obstruction from the Yang Ming system, mainly sinusitis.
It has a clear sedating effect and is therefore used for excess patterns characterized by Heat and Dampness.
Point discussion
Hegu is one of the most frequently used acupuncture points. It is the strongest point on the hand Yangming channel and is often used for all complaints of the head.
It is used to eliminate Wind heat or Wind cold. Hegu is an analgesic point and it relieves pain. It is anti-phlogistic, anti-pyretic and used for all inflammatory processes in the head region.
Yingxiang is the last point of the hand Yangming channel. Its indications are for all diseases of the nose and to dispel Wind heat from the nasal cavities. It is also an intersection point between the large intestine and stomach meridians.
Zusanli is also one of the most frequently used points in acupuncture. It is the most powerful point on the stomach meridian and is used for all digestive complaints. In this context it is used to eliminate Dampness and Heat from the Yangming channel. Zusanli may be either tonified or sedated, depending on the nature of the disharmony.
Thus, among its manifold activities, it may be used to eliminate Wind and Dampness, to regulate circulation of Qi and blood, to tonify weakness and promote anti pathogenic Qi.
Neiting is a point of choice in the treatment of excess patterns in the stomach or stomach meridian. It is mainly used to reduce Heat in the channel or in organs under control of this channel. This includes the nasal cavities, the upper teeth and gums, the stomach and intestines. Its indications are also to regulate Qi and relieve pain.
Xiangu is indicated mainly for facial edema, for pain and elimination of Wind. Sinusitis is characterized as a Wind Heat disease and it causes accumulation of fluid (Dampness) in the face due to a Heat stagnation.
As we have explained in the previous chapter, this type of combination places an emphasis on regulating the Qi in the channel, making it flow more vigorously in the proper direction, by utilizing more points situated on the desired direction.
Therefore, points Zusanli, Neiting and Xiangu provide a heavier weight than Hegu and Yingxiang, in order to promote the flow of Qi in their direction. This invigoration of Qi is said to clear the obstruction (sinusitis) where the hand Yangming and leg Yangming meet (the nasal area).
It is worthwhile mentioning that all of these points have a clear Dampness and Heat clearing functioning among their other qualities.
Needling sequence. manipulation and stimulation
The needling sequence is of major importance in this combination. Since the whole idea is to propel the energy along the meridian in the desired direction, we have to stimulate the points in the appropriate order. By needling these points in succession, we propagate both the needle sensation and the effect towards the oriented direction.
The fact that Neiting is needled before Xiangu is because Neiting is a stronger point than Xiangu and therefore plays a more important role in the "see saw" balance of the combination.
The points are naturally manipulated in a reducing, or sedating technique. This may be either the anti clockwise rotation of the needles, or pull thrust maneuvering.
When an excessive hot condition is observed, it is possible to perform the "Cooling the Sky" technique. By this technique the needle is inserted rapidly to the desired depth and then forcefully raised up a fraction, then gently inserted again. This manipulation is repeated six times. The procedure is repeated at three different levels, from the deepest to the most superficial position, until the patient senses coolness. This is exactly the opposite procedure to "burning the mountain" which was described under the previous combination (44).
As a rule, for sedation purposes the needle manipulation requires stronger movements by the practitioner, with larger amplitude and angles than the tonifying manipulations. On shallow surfaces it is often sufficient to point the needle tip along or against the energy stream, in order to tonify or sedate, respectively.
Case history
Mrs. S.A., age 40, has suffered from chronic sinusitis for 12 years. She had some 4 5 acute incidents each year, for which various antibiotics had been prescribed. Twice she had undergone nasal operations and sinus pumping without long term satisfactory results.
She came to see me three years ago, suffering an acute attack which did not respond to antibiotic remedies. She had a low fever, felt very weak and sick and had unbearable pain around the supra-orbital area, especially of her left eye. Mrs. S.A. had a purulent yellow, foul smelling nasal discharge, dry mouth and constipation.
Both her pulse and tongue indicated an excessive Damp-Heat condition. Her pulse was also weak and indicated her general weakness.
Mrs. S. received six treatments. The prescription was built from the above combination, with the addition of Zanshu (B 2). Zanshu was manipulated by a dispersion technique, i.e. was punctured in three directions one after the other, and then was left intact.
Zanshu was chosen due to its local effect, in order to disperse the purulent liquid around the eyes' orbit.
After two treatments Mrs. S. experienced significant relief and after the fifth appointment she proclaimed that she was free of all symptoms. Hence, she was given another treatment to consolidate the effect and the treatment was terminated.
During the last three years Mrs. S. suffered one more attack which responded to treatment in the same fashion.
3. JIANYU (LI 15), JIANEILING (EXTRA), JIANLIAO (T 14)
Main effect and clinical purpose
The combination above is a point cluster of the shoulder. It is frequently used to disperse stagnation in the shoulder joint and to facilitate the flow of Qi there.
The cluster is usually effective in cold stagnation of the shoulder or Damp Bi (cases of frozen shoulder, perifocal inflammation of the shoulder joint etc.). It may also be of value for traumatic pain from sports or accidents.
Point discussion
Jianyu in Chinese "shoulder bone", is the main point for all shoulder diseases. Its indications are:
• to eliminate Wind
• to remove obstruction from the Jingluo, and promote
circulation of Qi and blood.
• to soothe the Joints, relieve pain and scatter Bi.
Jianyu is either punctured deeply, with the arm abducted, towards Jiquan (H 1), for inflammation of the joint bones, or along the deltoid muscle, for Damp or cold Bi, affecting the muscles and tendons.
It is often cauterized with moxa, by all the variations: direct (scarring) moxibustion, the warm needle technique and moxa on ginger. These techniques are applied for Cold, or Damp-Cold induced problems. For the "frozen shoulder" syndrome, Cold penetrating to the bone level, one may use the "Fire needle" technique. By this technique a long needle is heated by fire, and immediately introduced into the deep level of Jianyu, then withdrawn. This technique was already mentioned in the "Ling Shu” and the Ming dynasty physician, Wu Hegao, recommended it for Cold Bi of the shoulder.
In any case, utilization of moxa or heat at this point, accelerates the flow of Qi, disperses the cold and damp stagnations and returns the joint and muscles to normal functioning. However, it is imperative to stress that any shoulder inflammation exhibiting heat condition, (i.e. febrile Bi) should not be treated with moxa which can undoubtedly aggravate the condition.
Jianneiling is an extra point situated exactly between Jianyu and the top of the anterior axillary crease.
Its indications are the same as Jianyu’s.
Jianliao "Shoulder Seam" in Chinese, also has exactly the same indications as Jianyu. It is more often used for pain located on the posterior aspect of the shoulder, on the route of the Sanjiao channel.
Needling these three points together affects the shoulder from three different angles and causes an acceleration of the Qi that passes through this joint. The various methods of stimulation, when properly applied, deal with the cause and nature of the stagnation accordingly.
Needling sequence, manipulation and stimulation
The needling sequence in this combination is usually related to the site of the pain. If the pain is in the anterior part of the shoulder, Jianneiling is usually needled first, and then the other two. If the whole shoulder is painful, Jianyu is needled first, as the strongest point of the trio.
Besides moxa stimulation, of which we have already spoken, the "cupping" treatment over these points is also frequently used.
Cupping is generally applied on spots where we need to enhance circulation of Qi and Blood and is widely used in China and in T.C.M. clinics.
Also electrical stimulation of these points is often applied, as shoulder problems usually involve pain. Electrical stimulation is usually applied with a dense disperse wave, for periods of 10 20 minutes. Cupping is usually applied after needling the points, or over the needles, also for 15 20 minutes.
When the "warm needle" technique is utilized, only one needle of the trio is generally cauterized with moxa. It is usually the needle that is situated in the most painful site of the shoulder. This is a small variation of a technique called Qici which was already mentioned in the Nei Jing (45).
Another technique which is often used to disperse stagnation of Qi and Blood and to resolve pain quickly, is called "Huici", and has also been mentioned in the Nei Jing.
By this method a 1.5 inch needle is inserted and manipulated until "Deqi" is obtained. The needle is then raised and redirected to the left or right, and manipulated again for 3 minutes. The needle is then raised and redirected toward another direction and manipulated once again. It is then raised to a superficial level and left intact.
Case history
Mrs. D.B., a teacher by profession, was born in 1951. On April 18, 1990 she consulted me, complaining of severe pain in her right shoulder which hindered her sleep and disabled her right hand preventing almost any movement.
X ray examination at "Rambam" Hospital in Haifa revealed excessive calcium deposits in the shoulder joint, hence she had been advised to undergo the calcium pumping operation, as well as steroid injections to the affected joint.
Mrs. D. was reluctant for such "adventures" as she expressed it, and since she had had a previous successful experience in my clinic for another problem, she made an appointment.
An examination by means of Chinese medicine brought me to the diagnosis of a Cold Bi condition in the shoulder, and kidney hypo-functioning (Kidney Yang Xu).
The main signs were:
1. Fear of cold in general and especially a need for warmth around both shoulders.
2. Pallid face and lips.
3. Pale, wet tongue, with a thin white fur.
4. Thin, soft and deep pulse, weak on third position.
The only sign which did not match the diagnosis entirely, was the pulse, which should have been tighter. Nevertheless, I interpreted the thin pulse as a sign of a Blood Xu to some extent due to her kidney Yang Xu condition which prevented her from a proper creation of blood. The relative weakness and depth of the pulse was due to her kidney weakness.
The prescription for treatment was:
Right side: Tiaokou (ST 38), Jianyu (LI 15), Jianliao (T 14), Jianneiling.
Both: Taixi (K 3), Shenshu (B 23).
Tiaokou is an excellent empirical point for acute shoulder pain. It was inserted toward Chengshan (B 57) and manipulated for 5 minutes (46).
on Jianyu I burnt four moxa balls on top of the needle, in every treatment session.
The three cluster points of the shoulder were manipulated by the dispersal "Huici” pattern (see above). This was done prior to the application of moxa, and in order to disperse the stagnant Cold which lodged in the area.
Taixi and Shenshu were chosen to stimulate and reinforce kidney Yang. In order to ensure a full impact on kidney Yang, three moxa balls were burnt over the left Shenshu needle.
Since all the Yang go to the left and all the Yin to the right, Shenshu left is also considered to belong to Yang, and was given an extra stimulation there.
Mrs. D. experienced significant pain relief following the first session and could sleep the whole night through. After the second and third treatments her condition improved even more and on the fourth, the treatment was performed without moxa.
After the fourth treatment her condition worsened, probably due to a cold change in the weather.
Five more treatments were required to establish a full recovery, all of them with moxa.
4. FENGCHI (G 20), TAIYANG (EXTRA), XINJIAN (LIV 2), YANGLINGCHUAN (G 34)
Main effect and clinical purpose
This point combination works primarily on the liver and gallbladder channels and has a strong Yang, or Fire reducing action, as well as Wind clearing, especially liver Wind from the head.
As a result of these properties, the combination is widely used to treat hypertension of liver Yang, or liver Fire origin. It may also treat headaches, migraine, or pressure behind the eye (glaucoma) stemming from the same etiology.
Point discussion
Fengchi is an important point, situated on the gallbladder meridian, below the occipital bone. It is involved in almost every formula that treats headaches, especially of a Shi nature. The point is indicated to eliminate Wind (external, or an internal liver Wind), to pacify the liver and reduce Yang Qi, to clear the mind, brighten the eyes, to benefit the ears and to reduce heat.
Fengchi is usually punctured toward the eyeball of the opposite site, with care not to point the tip upward, the direction of the medulla oblongata.
Since its use is most often indicated to calm hyperactive Yang or sedate Wind, it is manipulated to sedate by a leftward twirling, or forcefully withdrawing and gently thrusting back.
Fengchi is often combined with Hegu (LI 4) for various headaches and this is a basic combination for headaches. Hegu has a strong effect on the face, forehead and the anterior half of the head, whereas Fengchl has the same effect on the posterior half. Both points therefore, circulate the Qi and Blood of the whole head and disperse Wind and stagnation.
Taiyang is an extra point situated on both temples. Its indications are also to disperse Wind and Heat from the head and eyes. It is often used for migraine headaches, red and painful eyes, fever or high blood pressure.
Taiyang has a close relationship to the Gallbladder meridian, firstly because of its location, as well as its functioning.
It is punctured up to a depth of one cun perpendicularly and it is often pricked with a triangular needle to release a few drops of blood. This is usually done in acute conditions, involving pain, heat, severe inflammation, etc.
Xinjian also has similar properties. It is widely used to reduce liver Fire, but it is located on the other end of the body, i.e. the foot.
Besides draining the excessive liver Fire, Xinjian is also said to spread the stagnant Qi of the liver. This is usually a heat stagnation, which is one of seven stagnations that exist in classical Chinese medicine: stagnations of Qi, Blood, Dampness, Cold, Heat, Phlegm and Food (47).
This stagnation of heat often involves the blood too, as it causes the blood to coagulate. Since blood and heat both have a close physiologic link with the concept of liver in T.C.M., it is not surprising that hypertension in its most common etiology, is treated via the liver or Gall meridians. Xinjian therefore, is an important point for this disorder, as it treats both heat and stagnation.
Yanglinchuan also has the ability to cool liver heat, as well as to clear dampness. It regulates and benefits the liver and gallbladder and strengthens the tendons, sinews and bones.
After analyzing each point in the combination, it is clear that this point combination is built on the concept of mutual assistance. Actually, all the mentioned above points have the quality of lowering Yang, and subduing liver Fire.
The most frequently encountered etiology for high blood pressure in T.C.M. is hyperactive liver Yang. This pattern usually involves symptoms such as: headache, glaucoma, red eyes and face, dizziness, tinnitus, etc., all of which are very common in the modern concept of hypertension.
According to Chinese medical philosophy, when the liver lacks Yin Qi (due to a kidney deficiency, most often), or blood (due to spleen deficiency), or its Qi stagnates due to other causes, it creates heat. Heat tends to climb up, or float to the head region, via the gallbladder meridian, which is the liver coupled meridian, or via the internal branch of the liver meridian itself. The heat rushes up the blood, thus creating the hypertension as well as the accompanying symptoms.
Needling sequence. manipulation and stimulation
The needling sequence in this combination is from above downward, in order to lower or bring down liver Yang.
It is therefore necessary to use the head points first, in order to sedate liver Fire or Wind in the head region, then Xinjian which is more important for this purpose and finally Yanglingchuan.
Manipulation of the needles is effected to sedate liver Yang and therefore, the amplitude and strength should be as high as the patient can tolerate. Nevertheless, care must be taken in cases having a fragile constitution, or a pattern which includes a Xu condition, at the same time. In this case the practitioner must assess which is predominant, the Shi or the Xu condition and stimulate accordingly. It is also advised, in any case, not to be too vigorous with the manipulation at the first session.
As we have stated before, in cases which involve an acute head or eye pain, with inflammation or Fire signs, it is possible to bleed Taiyang and release a few drops of blood with the prysmatic needle.
Herbal equivalent
The effect of this point combination may be compared to the use of Spica Prunella Vulgaris (Xia Ku Cao), together with Flos. Chrysanthemi Morifoli (Ju Hua).
The first herb is cold in nature and acrid and is used to clear the liver and brighten the eyes. Very much like Taiyang and Xinjian. The latter herb is slightly cold and bitter and is used to disperse Wind and clear heat. It therefore clears Wind-Heat in the liver channel and pacifies the liver and relieves headache, dizziness, red and painful eyes, etc. Its action resembles that of Fengchi.
The two herbs together are therefore classically used for headache, dizziness, vertigo, painful and red eyes and high blood pressure.
Case history
Mr. G., age 46 a businessman, has suffered for the past eight years from hypertension and occipital headaches. During this period he has regularly taken hypotensive drugs (50 mg Convertin), which have adversely affected his sexual abilities. With the drugs, his blood pressure was 140/110 Hg.
Mr. G. had a shiny red face, red eyes and darkish lips. He spoke loudly and was very talkative.
Examination of the tongue revealed red rims, and a slippery yellow coating.
His pulse was moderate and first and second positions of his right hand were Shi.
It was apparent that Mr. G. had an excess heat condition. The problem was whether it was of liver Yang origin, or stomach Fire. As neither of these possibilities involved other symptoms, it was decided to clear the heat from the Yangming system through a combination renowned for this purpose. The combination is: Quchi (LI 11), Zusauli (ST 36) Neiting (ST 44).
Actually, the Yangming channel was chosen to operate upon because of the pulse, which showed predominance on the right Guan position.
A few treatments were carried out by this method, but the patient showed no improvement.
The diagnosis was then reconsidered, and changed to hyperactive liver Yang. The pulse abnormality was thence interpreted as an overactivity of the right liver channel, rather than both channels, a fact which has shown itself on the right hand pulse.
The formula for treatment was thus changed to the following: Fengchi (G 20), Taiyang, Xinjian (LIV 2), Yanglingchuan (G 34), Qimen (LIV 14) on the right side only, and Fuliu (K 7).
All points, except Qimen and Fuliu, were sedated in a broad angle twirling and raise thrust manipulation. Qimen was manipulated in an even manner, in order to regulate liver Qi and Fuliu was tonified so as to tonify kidney Yin.
After the first treatment, Mr. G’s blood-pressure decreased to 140/100 Hg. and after five more treatments to 140/90 Hg. He was advised not to take any more hypotensive drugs, advice which he accepted readily, and his blood pressure remains stable.
Since Mr. G. was not prone to anger, he was only advised to regulate his diet, to exclude Yang nourishing foods (coffee, sea food, fried food, pepper, alcohol, etc.) and to tend his business in a more relaxed manner.
5. QUCHI (LI 11), XUEHAI (SP 10), WAIGUAN (T 5)
Main effect and clinical purpose
The above point combination is widely used to treat skin disorders, mainly characterized by heat and Wind of either internal or external origin.
These disorders include allergic skin reactions, various types of eczema, rash, hives, and other conditions.
With added points like Yinlingchuan (SP 9), or Sanyinjiao (SP 6), it may also treat skin conditions in which Dampness exists, i.e. weeping eczema, furunculosis, etc.
Point discussion
Quchi is the most effective point for skin diseases, especially those characterized by wind and heat. Its traditional functions are:
1. Eliminates Wind and exterior conditions.
2. Cools heat and alleviates Dampness.
3. Regulates the Blood.
Quchi is situated on the large intestine meridian, a meridian most of whose functions deal with exterior conditions or with the outer layers of the body, such as: skin, muscles, etc.
As its most pronounced function is to eliminate heat and therefore it is used in cases of fever, and since it is very influential at the skin level, Quchi also removes heat from the skin. By removing heat from the skin, it improves Ching I (fluid) circulation at the cellular level, thus facilitating skin nutrition.
Quchi is also an important point to clear heat from the blood. We know that the large intestine meridian carries the largest amount of blood in comparison with other meridians, as it belongs to the Yangming system. As a result of this fact, Quchi is able to act directly on the blood, regulate it and drain excess heat therefrom.
In this regard, we should bear in mind that many skin diseases are the result of "heat entering the blood level", according to T.C.M. theory. The heat in the blood concept may be paralleled to the western concept of toxins in the blood. This phenomenon of toxins is of a hot energetic nature, often manifesting itself as red skin eruptions of various kinds. In its most extreme variation it is defined even in T.C.M as “Fire-toxin”. This definition is often attributed to the western medical diseases such as furunculosis, purulent abscesses and the like.
Xuehai "Sea of blood" in Chinese, is situated on the spleen meridian. The Spleen governs the circulation of blood (i.e. keeps the blood in the blood vessels) and governs the volume of blood, as it stimulates its creation. Xuehai therefore, is the point which serves to regulate and invigorate blood circulation, on behalf of the spleen. In its indications Xuehai is said to harmonize blood and Ying Qi (the nourishing Qi) and to cool heat. In accordance with these qualities Xuehai is used to tonify blood, improve its circulation and drain excessive heat from it.
Waiguan is used in this prescription for its quality to relieve exterior and hot conditions. It is called the "Outer Gate" in Chinese and thus serves as a gate keeper against exogenous pernicious influences.
Traditional Chinese Medicine teaches that in order to control wind, the blood must be first regulated. Wind subsides by itself when normal blood flow is restored, i.e., it is expelled naturally when it has nothing to cling to.
“The use of Xuehai and Waiguan for invigorating the blood and dispersing the wind, combined with Quchi for clearing the heat, is an important combination of points for treating the itching due to stagnation of Wind and Heat in the skin." (48).
Needling sequence, manipulation and stimulation
The needling sequence in this combination is from the upper limb to the lower limb. This follows the general acupuncture rules accordingly:
1. Generally apply needles first to the upper parts of the body and then to the lower parts.
2. First apply to points situated on the back and then on the abdomen.
3. Apply needles first to the left side and then to the right side.
Manipulations of the needles are, in most cases, in order to disperse wind and heat, which are Shi conditions. In any case, Xuehai may sometimes be tonified, when the blood is xu, or dry, or more often, be manipulated evenly so as to tonify the blood and at the same time drain the pathogenic heat.
In very acute conditions it is possible to bleed these points with the triangular needle, but it should not be done too often, as it might damage both Qi and Blood.
Herbal equivalent
The functions of Xuehai are very similar, in many aspects, to those of Radix Rehmainia Glutinosa (Sheng Di Huang).
This herb has these properties:
1. Clears heat and cools the blood.
2. Indicated for cases of hemorrhage, where heat has penetrated the blood level (in cases like excessive menstruation and premature menstruation, for which Xuehai is also indicated).
3. Nourishes the Yin and the blood.
The whole point combination may be compared to a classical herbal prescription that has about the same properties. it includes:
1. Periostracum Cicade (Chan Tui)
2. Herba Mentha (Bo He)
3. Radix Rehmania Glutinose (Sheng Di Huang)
Chan Tui and Bo He belong to the cooling herbs that relieve exterior conditions. Therefore their main activity is to disperse wind and clear heat.
Both of them are also used to speed recovery in measles, as they are said to encourage rashes to rise to the surface.
Sheng Di Huang, as mentioned above, acts on the blood level. By tonifying the blood it assists in dispersing Wind conditions and by cooling the blood it removes the basis for any skin hot conditions.
Case history
Miss O.S., age 9, has suffered for one month from a pruritic rash on her right costal surface, anteriorly and posteriorly.
Various allergic examinations did not reveal any special sensitivity and local application of ointments had not improved her condition.
Questioning revealed that the rash had appeared suddenly and that it was very itchy.
Observation showed that the rash consisted of tiny red points, giving the impression of sand on the skin. It also showed a red rimmed tongue with a very thin white moss.
The diagnosis was an externally contracted Wind-Heat, affecting the liver/gallbladder meridians. (Wind-Rash, in Chinese).
The fact that the rash appeared only on the surface of the right rib cage, along with the red rimmed tongue, pointed to the involvement of the liver and gall meridians. The sudden appearance of the disease, together with its red color, plus the thin white coating of the tongue, indicated an externally contracted Wind-Heat.
The formula chosen for treatment was: Quchi (LI 11), Xuehai (SP 10), Waignau (T 5), Talchong (LIV 3), Sanyinjiao (SP 6).
Taichong and Sanyinjiao were added to the prescription in order to resolve stagnation of the liver and hasten the recovery. This is another well known point combination, used to promote the function of the liver and spread Liver Qi.
After two treatments which were carried out on two consecutive days, there was no itchiness at all and the rash had significantly diminished.
After the fifth treatment the problem was entirely resolved.
6. NEIGUAN (P 6), TALING (P 7), LIEHCHUEH (L 7)
Main effect and clinical purpose
This point cluster helps facilitate the flow of Qi and blood to the palm and fingers. It is used in cases of Metacarpal Tunnel Syndrome, where Qi and Blood are blocked in the matacorpal joint tunnel and the symptoms exhibit numbness, pain and weakness of the fingers.
Point discussion
Neiguan is the most important point on the pericardium channel. It is mainly used to treat chest or abdominal problems and its functions spread from regulating the stomach activities, to improving blood circulation in the heart.
One of its manifold characteristics is to regulate the Qi. The fact that it belongs to the pericardium liver system, the Chueh Yin energetic segment, suggests that it is also closely linked with blood circulation problems. (In fact some authors call the pericardium meridian "Circulation Sex meridian") (49).
As a tribute to its anatomical location near the metacarpal tunnel, it influences Qi and blood circulation in this area. Due to its major role in improving blood circulation in general, Neiguan has a double effect on this area: one merely as a local effect and the second as an influence on systemic circulation in the whole body.
Another unique characteristic of Neiguan is that contributing to its anatomical location above the medial nerve of the arm, it is very easy to propagate the needle sensation as far as the finger tips. As Metacarpal Tunnel Syndrome usually exhibits numbness of the middle finger, or even of the other fingers too, we can manipulate Neiguan to transmit a clear sensation to those fingers, thus facilitating the flow of Qi and blood up to the desired foremost target.
Taling has much the same characteristics as Neiguan, with one advantage over the latter. Its location is exactly above the metacarpal bones and joint, a fact which makes Taling a barrier point for this area. Its needle sensation is also most often felt through to the finger tips, and puncturing this point has a direct effect on the joint tunnel itself. Taling has a more cooling effect than Neiguan. It is a point often used to clear Heart Fire and resolve heat in the meridian or the organ. In many cases Metacarpal Tunnel Syndrome also exhibits heat symptoms due to the pressure of the stagnation there. The use of Taling is very beneficial for such a condition.
Liehchueh is the Luo point, or connecting point of the lung meridian. The connecting channel of the lung, after leaving the main lung channel at point Liehchueh, travels to the large intestine meridian and connects with it at point Pianli (LI 6). Another branch follows the lung meridian into the palm and spreads there through the thenar eminence.
Due to its course, Liehchueh is also used for wrist joint problems or abnormalities of the palm, such as: pain, hot palms, eczematous or numb palms.
Liehchueh needs to be punctured with the tip of the needle pointed toward the thumb, for maladies of the palm. The needle sensation must follow the route of the lung meridian or to spread into the palm.
In this point combination we can see that besides its quality as a point cluster, there is a combination of two points, Taling and Neiguan, whereby each enhances the action of the other. Thus, there is the principle of mutual assistance as well as the facilitation of the normal flow of Qi and blood that any point cluster would achieve.
Needling sequence, manipulation and stimulation
The order of needling these points is from Neiguan to Taling, so as to follow the ordinary flow of Qi in this meridian. These are also the more significant points of the trio and the pericardium meridian is more significant than the lung meridian for this prescription’s purpose. Liehchueh is punctured last.
As was hinted above, after Deqi has been obtained, needles must be pointed towards the palm and manipulated in dispersion so as to cause needle sensation to travel downwards toward the fingers.
In Metacarpal Tunnel Syndrome, where specific heat signs are absent, it is recommended to apply moxa stimulation on the points after needling.
In severe cases, direct moxibustion is usually applied and scars are formed. In less severe conditions it is possible to lay the moxa cones, the size of beans, on a thin layer of fresh ginger (Sheng Jiang). The layer is punctured through, in order to allow the heat to penetrate easily and the cones are placed one after the other, until the whole area becomes red.
Another technique advocates the use of white pepper mixed with flour to make a paste and spread over the point. The thickness of the layer should be 0.1 inch, and a hole is made in the center.
A moxa cone is set upon it and ignited. This method is indicated usually for numbness and stiffnss, and is most suitable for the Metacarpal Tunnel Syndrome (50).
Case history
Mrs. O.T., age 35, is the owner of a goat farm and she is also the mother of case history number 5 ( see above).
A year and a half prior to her first visit to my clinic, she began experiencing numbness along the anterior medial aspect of her right arm, extending towards her fingers. It was more pronounced at night, while sleeping. Later, she experienced pain when numbness reached its climax. In the last few weeks she started having the same phenomena, though to a much milder extent, in her left hand too.
Routine checks at Nahariya Hospital revealed no signs on her cervical vertebrae, where they had projected their suspicion. The diagnosis given was of a Metacarpal Tunnel Syndrome and she was advised to undergo an operation.
On questioning, Mrs. O.T. revealed that sometimes when she awakens in the morning, she senses a sharp prick in her heart region, experiencing difficulty in breathing deeply, for a while. The sensation then disappears.
Questioning also revealed that she is in the habit of milking her goats for many hours and that she rides a motorcycle in the fields. Observation revealed a red tipped tongue with red points and red rims. She also had peeled areas. Her right palm was dry and eczematous, she said that she had been told that it was a fungal infection, but it did not respond to medications. I diagnosed her condition as follows:
1. A pre existing state of slight heat stagnation of the pericardium which gave rise to the shape of the tongue, to the stabbing pain in the chest, and to disturbances along the pericardium meridian.
2. Hard labor of milking had strained the brachial muscles, especially the flexor group. This strain had impeded the flow of Qi and blood to the palm and had laid an extra burden on the pericardium channel.
3. Due to impeded flow of Qi and blood to the palm, the palm became dry, undernourished and had developed the eczema.
The reason for aggravated numbness at night, was that rest hindered the flow of Qi and blood even more due to lack of movement or activity, thus making the numb sensation more pronounced.
The treatment was constructed from the three cluster points, plus Tanzhong (CV 17). Tanzhong was utilized to build the formula due to its task as the Mu point for the pericardium. It has a strong influence on blood circulation and is said to propel Qi in the Upper Burner, thus enhancing blood formation and Qi and blood circulation (51).
By choosing Tanzhang, I dealt with the local carpal stagnation, as well as assisting from afar by viewing the local problem in its holistic background.
After needling Neiguan I applied seven moxa cones on the point, using a layer of a paste made from flour and white pepper underneath.
After seven treatments over a two weeks period, Mrs. O.T. improved by 90% as she proclaimed.
About one year later she came to me again, saying she was afraid that her previous symptoms were returning. She was then given four more treatments, after which she felt better again.
7. JIANYU (LI 15), OUCHI (LI 11), HEGU (LI 4)
Main effect and clinical purpose
This frequently used point combination has been devised in accord with the principle of choosing points on the same meridian, for mutual assistance.
It is used in many different problems of the arm, involving the shoulder, arm, hand and fingers.
Its main use, however, is to invigorate the flow of Qi and blood in the upper limb, for problems such as painful Bi syndrome of different etiologies, or paralysis.
The fact that all these points are situated only on the large intestine meridian and not on one or more of the other five meridians of the arm, is because this meridian is known to have the richest supply of Qi and blood (together with its Yangming counterpart, the stomach meridian).
The Nei Jing states: "When treating flaccidity of the limbs (Wei syndrome), use points only from Yangming" (52).
Point discussion
As stated above, all the three points are situated on the large intestine meridian and are considered important points. The title of important points is usually given to those points which have a broad spectrum of activity and that play a major role in many formulae.
All three have in their indications qualities such as: invigorating Qi and blood circulation, removing obstruction from the Jing Luo, relieving pain, scattering Bi and the like.
By choosing these three points, we combine their abilities to assist each other and to have a mutual impact on the disease, which is far better than any one of them alone.
The fact that all the three are situated on the same meridian, enables each point's sensation to travel to the next point and thus propagate the needle sensation along the whole limb. When needle sensation is propagated, so is Qi and thereafter blood.
There is a saying in T.C.M. that "Acupuncture is only effective when the Qi reaches the affected area". Many contemporary researchers have verified this concept. They also found a significant correlation between the degree of induced propagated needle sensation, and therapeutic success (53).
As we have mentioned above, the Nei Jing has recommended the use of the Yangming system for diseases characterized by flaccidity, numbness and hypertrophical features. The fact that the Yangming has been recommended for such tasks is due to its abundance of Qi, and especially blood.
Recent researchers in China have verified for instance, that the use of these points in a C.V.A. sequelae, like hemiplegia, has no substitute. The reasons are those mentioned above. Hemiplegia, as an example, is a paralysis of half of the body, caused by blood stasis (or hemorrhage) in the brain. This stagnation has caused a Qi and blood circulatory impediment and in fact a real blockage in half of the body, usually longitudinally.
Thus, these three points (among other points), are manipulated to invigorate the blocked circulation and return the limb to its normal function.
By the same token, these points help eliminate pain caused by a Xu condition like paralysis, or a Shi condition such as painful obstruction of the joints. The only difference is in the technique of stimulation and in the combination of other points within the formula.
Needling sequence. manipulation and stimulation
The needling sequence in this combination is usually performed in accordance with the nature of the disease. In Xu conditions, when paralysis, numbness or weakness of the arm and fingers exists, the needling sequence is applied from Jianyu to Hegu. This is done in order to drive the Qi sensation toward the fingers which, in most cases, are in a worse condition.
In painful Shi conditions Hegu is most often punctured first due to its generalized analgesic effect, followed by the rest of the points. It is, nevertheless, possible to start with Jianyu, especially if there is a marked stagnation there.
In the conditions of paralysis or atrophied muscles, the stimulation is by tonification. The method of tonification varies, but in most cases it is a strong tonification for two reasons:
A. The paralytic state of the limb does not allow a satisfactory Deqi sensation in many cases, if the manipulation is too weak.
B. This is a severe condition which generally will not respond satisfactorily to a mild stimulation. In this context we may compare the amount of stimulation, or degree of needle manipulation, to a measured dose in medication or a herbal formula. In severe conditions the dose will generally be increased. The difference however, between acupuncture and other remedies, is that only a well experienced practitioner is able to develop the "touch" or sensitivity for the right amount of manual stimulation. In orally taken remedies the dosage is measurable and recommended in the formula.
In many cases of Xu conditions, especially the most severe or those in which cold is a part of the condition, the preferred type of tonification is the "Burning the Mountain" (54) technique, which was discussed under case number 1 in this chapter.
Xu conditions of the upper limb are very often treated with moxa too. The warm needle technique is highly recommended, as it warms the channel, tonifies the Qi and accelerates its flow.
Massage techniques, Tui Na with warming and activating oils and ointments, are also very popular and widely used. The massage is carried along the limb meridians, with rubbing and pinching, and scraping movements, pressing on the acupressure points and activating Qi and Blood.
For such conditions also the plum blossom, seven star hammer needle is applied by tapping it along the meridians, until the whole route is reddened.
In Shi conditions, such as painful Bi of the shoulder, elbow, carpal and phalangeal joints, the needle technique is in sedation and dispersion. The needle is inserted against the energy stream of the channel or manipulated in sedating procedures, or in the HuiCi technique which was described earlier in this work.
Cupping is also applicable, as it drains excess and disperses stagnation. Also electro-acupuncture is possible, usually combining two points from the trio in a disperse wave.
Case history
Mr. G., age 63, a barber by profession, left handed, had, a month before he came to see me, a marked decrease in the power of his left hand, fingers and leg.
He had a sudden decrease of mental acuity, of his usual sense of humor, as well as physical abilities of hand and leg. Mr. G. had to cease working in his barber shop, since he was left handed.
A week before coming to me, he suddenly felt very unwell and almost lost consciousness. He could not speak properly, and suffered a staggering headache. He was taken to Nahariya Hospital where he underwent a C.T. scan of the head. The diagnosis was a cerebro vascular infarct in his right brain lobe.
Upon examination it was obvious that he had significant difficulty in moving his left fingers freely and his gait was a little clumsy. His tongue was big, red and peeled. The pulse was moderate and big at the Cun and Guan positions. Mr. G. confessed to a long history of moderate hypertension.
My diagnosis was a basic Shi condition of liver Yang, complicated by a Xu condition, after the brain damage had occurred.
The treatment principle was, therefore, to invigorate the flow of Qi and blood in his left hand and leg, subdue liver Yang and invigorate the blood circulation in general.
The points chosen for these purposes were:
Jianyu (LI 15), Ouchi (LI 11), Hegu (LI 4), Baxie (extra), Biguan (ST 31), Zusanli (ST 36) all in the left side only and, Taichong (LIV 3), Sanyinjiao (SP 6), Xuehai (SP 10) bilaterally.
Jianyu, Ouchi and Hegu were manipulated in a strong tonification. Baxie, are eight points situated between the knuckles of the fingers. These were stimulated in order to facilitate the flow of Qi and blood in the fingers.
Biguan and Zusanli are a combination of two points on the leg Yangming channel, and the principle of their choice and use is exactly the same as for the three Yangming points of the arm.
Taichong and Xuehai act on the blood level, in general. Taichong reduces liver Yang and improves blood circulation by facilitating liver Qi and Xuehai’s role in blood disorders has already been discussed in case Number 5 of this chapter.
Mr. G. felt mental improvement after the first treatment. Following this treatment he never again experienced any episode of losing consciousness or difficulty in speaking. After the third treatment, which took place during the same week, his leg returned to normal and he had lost his clumsy gait.
After the seventh treatment his hand and fingers regained their normal flexibility and strength.
Mr. G. was advised to come once a month for a check up for his liver Yang and was consulted about his way of life for the same purpose.
8. SHAOZE (SI 1), TANZHONG (CV 17), RUGEN (ST 18)
Main effect and clinical purpose
This point combination was mentioned in the "Great Compendium of Acupuncture and Moxibustian" (Zhenjiu Dacheng) written in 1601 in China during the Ming Dynasty by Yang Jizhow (55).
Since those ancient times the relevance of the combination has not diminished and its validity serves us today equally well.
The combination is suitable for all breast diseases, especially those of a Shi nature. It is used with great efficacy in cases of breast abscess, mastitis, benign tumors of the breast and the like. This same formula is also utilized in mastosis or agalactia (insufficient lactation) which are primarily Xu conditions.
Point discussion
Shaoze is the Well point of the samll intestine meridian and its main indications show:
1. Disperses Wind and Heat.
2. Facilitates the flow of milk in the breast.
Its first indication, which is in accord with its role as a Well point, makes it useful in acute conditions of febrile diseases, coma etc.
Its second indication points to its soothing effect on the breast.
The breast is where milk is originates and is produced in the female body. It is anatomically located in the Upper Burner, where blood is also produced. Milk, according to Chinese medical theory, is made of seven parts blood and one part Qi (56). The mechanism of milk production in the female body, is closely related to the functioning of the Chong Mai (the extra meridian which is also called the Sea of Blood) and which traverses the breasts (57).
The Stomach meridian also traverses the breasts and this meridian too, as we know, is very rich in blood, thus both meridians nourish the breasts.
The close location of the breasts to the lungs and lung meridian, permits the access of Qi from the air to the blood of the breasts. Thus the intermingling of Qi and blood in the proper amounts, make the formation of milk possible.
Still, in order not to accumulate and become stagnant, milk needs a harmonizer which will activate and supervise its flow. For this purpose liver Qi is responsible, for two reasons:
• This is the main task of liver Qi in the whole body, as the liver is responsible for the free flow of Qi anywhere in the body.
• The liver meridian itself traverses the breasts.
Milk flow, therefore, is very dependent on the free flowing of liver Qi, in the same manner as blood flow (like menstrual flow) is also dependent on liver Qi. (Nei Jing: “Qi is the ruler of Blood").
When liver Qi stagnates due to emotional problems, then blood and/or milk tends to stagnate too. In nursing mothers, this stagnation causes heat (due to the pressure) and then mastitis, breast abscesses, etc.
Shaoze, both due to its milk flow facilitating quality, as well as its heat dispersing quality, is a first choice point for such problems.
Tanzhong was partially discussed in this paper under case history number 6. It is the master point of the Upper Burner, and the Mu point of the pericardium. Its stimulation sets in motion the Upper Burner Qi, in order to eliminate stagnation in the Upper Burner. It thus helps facilitate the function of the lungs, aids in dispersion of phlegm in the chest in cases of asthma, facilitates the flow of heart Qi and resolves angina pectoris, circulates the Qi of the breasts and eliminates stagnation there.
In accord with these qualities, Tanzhong was selected for this combination.
In cases of agalactia due to a Xu pattern, Tanzhong is stimulated with moxa, to tonify the activities of the Upper- Burner for milk production.
Rugen is situated in the fifth inter-costal space, directly below the nipple. Due to its location in the vicinity of the breast and to its belonging to the stomach meridian, its function is to regulate the breast. Rugen, therefore, assists either by tonification in Xu conditions or by sedation in Shi conditions of the breast.
The combination, as we can see, was based on the principle of joining points which can assist each other by influencing the same organ. Shaoze and Rugen are specific points fox breast problems, while Tanzhong is the most powerful point in the vicinity of the breast. Tanzhong has some systemic influences in addition as we have seen above, influences that help regulate breast functioning through general physiological functioning.
Needling sequence. manipulation and stimulation
Usually, Shaoze is first punctured so as to direct the influence of the treatment to the breast. Then Tanzhong is stimulated due to its prime importance and then Rugen.
Shaoze is punctured 1 2 fen deep, slantingly, in the direction of the wrist.
Tanzhong is punctured either pointed upward or downward, until Deqi is obtained. When this is done, the needle is lifted to the skin level and redirected towards the diseased breast. Manipulation of the needle is then performed by twirling and lift thrusting movements, allowing the sensation to project to the breast. In cases of abscesses or mastitis, it is imperative that needle sensation should project inside the diseased breast.
If both breasts are diseased, the same procedure is applied to the other breast as well.
In Xu conditions of the Upper-Burner leading to agalactia, the use of moxa is very beneficial. It is possible to apply direct moxibustion, taking proper care not to cause a scald. It is possible to warm the point with a moxa stick or by indirect moxibustion on a thin ginger layer.
It is forbidden to stimulate Tanzhong with electricity, or cupping, as it may have an adverse effect upon the heart. Actually there are some texts that forbid the stimulation of this point even by acupuncture, and recommend only the use of moxa (Points of Chinese Acupuncture by Dr. J. Lavier, or Chinese Acupuncture by Dr. Wu Wei Ping for instance). In any case, contemporary experience in China strongly advocates acupuncture in this point, plus moxibustion.
With Rugen, the procedure of needling is the same as with Tanzhong. After obtaining the Qi the needle is directed proximally toward the breast and then manipulated.
Herbal equivalent
This point combination, especially when performed in order to soothe Shi patterns, resembles a herbal prescription generally used to treat the same disorders.
1. Pericarpium Citri Reticulata (Qing Pi)
2. Semen Vaccaria (Wang Bu Liu Xing)
3. Radix Salvia Miltihorriza (Dan Shen)
This herbal prescription is used to treat pain and swelling of the breasts, palpable masses or lumps in the breasts, due to congealed blood or constrained Qi.
It is also used to promote lactation. Much like the point-combination, it is a basic prescription, on which other herbs are usually added according to the various necessities of any specific case.
Qing Pi is a major herb to regulate the free flow of liver Qi. It reduces Qi accumulations due to constrained liver Qi in the breasts and therefore alleviates pain and distension.
Dan Shen invigorates blood flow and breaks up congealed blood. It may be used also for palpable masses in the chest, cysts and lumps. Dan Shen also clears heat and may be used therefore to treat breast abscess due to heat stagnation.
Wang Bu Liu Xing, with its qualities regarding the breasts, may be adequately compared to point Shaoze. It also promotes lactation and treats breast abscesses and swellings. The meridians it enters are those of the stomach and liver, exactly the same meridians that play such a large role in breast physiology.
This formula, when tonifying herbs such as radix Astragali (Huang Qi) are added to, may be used to treat agalactia due to Qi Xu conditions which have led to constrained Qi.
On the other hand, when herbs like Taraxacum (Pu Gong Ying) are added, it may treat breast abscesses, due to fire and poison origin and constrained liver Qi.
Case history
Miss K., age 27, a stage actress by profession, complained of a large abscess on her left breast. A month prior to that, she had another abscess on her right thigh, on the path of the liver meridian near Yinlian (LIV 11).
She was treated at that time with antibiotics which caused the former abscess to disappear and the new one to appear on her left breast. The antibiotics, she proclaimed, had made her very weak, lethargic, and depressed.
On arrival at my clinic, she had a fever and suffered great pain in her left breast, a pain that radiated along the pericardium channel of her left arm.
The abscess was large, situated under her left nipple, inflamed and resembled a second red, big nipple.
Miss K.'s pulse was moderate and choppy, deep and weak. The Cun position on both sides was very choppy.
Her tongue was red purple with even redder rims. The inside of her eyelids showed a red shaded line on the upper part of the lids a blood stasis indication.
In reply to my question as to whether she had had any problems with her liver, she said that she had suffered a severe jaundice five years earlier.
Thus, in accordance with all the symptoms and signs, I diagnosed Miss K. as suffering from liver heat stagnation, affecting the meridian. The abscess on her left breast was of the Fire Poison category and also involved blood stagnation. This blood involvement had caused the fever and the involvement of the pericardium channel. The pericardium channel is in continuum with the liver channel, as a partner in the Chueh Yin segment.
The formula for treatment was devised as follows:
Left side: Shaoze (SI 1), Tanzhong (CV 17), Rugen (ST 18), Zulinqi (G 41), Waiguan (T 5)
Both sides:Quchi (LI 11), Zusanli (ST 36).
This formula was actually constructed from three well known point combinations.
on the first combination there is no need to elaborate, it is sufficient to say that in this case all the criteria existed in order to utilize this combination.
Zulinqi and Waiguan are the Master and Coupled points of Dai Mai the Girdle Vessel. This extra meridian harmonizes liver and gallbladder activities and its areas of influence are the waist, ribs and chest and the head. Dai Mai, as an extra-meridian, absorbs excess energy from the liver and gall channels and adjusts their functioning. Moreover, Zulinqi is indicated for liver Qi stagnation affecting the breast and that includes mastitis and abscess.
Waiguan, in addition to its role as the coupled point of the Dai Mai, is the Luo point of the hand Triple Burner (San Jiao) meridian. Its coupled (Yin-Yang) meridian is the pericardium meridian. Puncturing Waiguan may be thus used to divert excess from the pericardium and to adjust its functioning. All this is due to the Luo points' role as a "tap" that may be used to balance two coupled (Yin Yang) meridians.
Quchi and Zusanli, both situated on the Yangming segment of channels, drain excess heat, relieve fever and invigorate and regulate the blood. They are therefore widely used in hypertension due to excess heat a fact which has already been discussed in this paper.
The first session lasted thirty minutes, in which Tanzhong and Zulinqi were manipulated every ten minutes. The patient experienced a "sucking" sensation traveling from Tanzhong to the abscess. Following the treatment, she experienced the same "sucking" sensation plus pain along her left arm, for about six hours.
After six hours the abscess burst open and a great deal of pus and blood were discharged. Afterwards, she experienced a sudden relief. The pain subsided almost completely, as did the fever and the depression.
Miss K. came for six consecutive treatments thereafter, following which her breast healed completely.
Miss K. came to me a year later for a different problem and while examining her I noticed that her breast did not bear even the slightest mark of the episode she had undergone.
9. HEGU (LI 4), TIANTU (CV 22), FUTU (LI 18)
Main effect and clinical purpose
The point combination above is mainly used to treat conditions in which phlegm has accumulated in the region of the throat, giving rise to problems such as: hoarse voice, asthma with a sensation of blocked throat, lumps in the throat, goiter etc.
Point discussion
Hegu is a point which possesses many qualities, some of which have been discussed in various parts of this work and especially under cases numbers 2 and 7.
Hegu was chosen in this point combination due to its key role in the large intestine meridian which makes its route through the neck and throat.
We have already discussed the invigorating quality of Hegu, which, when stimulated, sets in motion and invigorates the flow of Qi in this channel, thus clearing any blockages along its route. In case number 2, for example, the point was utilized to unblock stagnation in the area of the nasal sinuses. Here, the point serves to resolve phlegm, or Phlegm-Fire, or Damp Phlegm in the region of the throat, conditions that may cause, if untreated, grave problems in that area.
Due to Hegu’s other qualities it may be used just as well for externally contracted dampness that has transformed into phlegm, or an internally originated Phlegm.
We already know that Hegu is a first choice point for externally contracted situations. That may include in fact all the patterns. Wind, Heat, Cold, Dampness, plus any combinations of them. Internally, Hegu is the Yuan point of the large intestine, therefore in close relation with the organ itself. The large bowel is responsible for eliminating toxins and waste through the lower orifice and thereby, Hegu plays an important role. Moreover, Hegu also belongs to the Yang Ming system and thereby, exerts an influence over the stomach too. Since we know that the stomach/spleen malfunctioning is responsible for phlegm creation, we can imagine how Hegu may have an influence on the internal origins of phlegm.
Tiantu is probably the most important symptomatic point in the case of asthma. It is located in the base of the throat and forms the barrier between the trunk and the head region.
In this area, people sometimes feel a sensation as if "something" is stuck in their throat, a sensation metaphorically related to as "plum seed" in Chinese. This sensation is typical of the formation of phlegm accumulations in the throat.
Since phlegm has a dense energy, or "dirty" energy, it is stuck in the narrow passages of the throat and blocks liver Qi, or the "Clear Yang" of stomach Qi from ascending to nourish the brain (58).
Stimulation of Tiantu disperses the phlegm in this area and facilitates both the ascent of Qi to the head and the absorption of air Qi in the lungs.
Tiantu is also indicated when Fire exists in the throat. Fire may present on its own, but in the throat region it is usually combined with phlegm, creating the phenomenon of Phlegm Fire. Phlegm Fire exists in cases of throat cancer, abscess, acute goiter, etc.
Futu is also a point on the large intestine meridian and is located on both sides of the neck. It is combined with Hegu which is on the other end of the meridian, forming the bond of one point in the vicinity of the diseased organ and one distant point.
Futu’s traditional indications are:
Coughing and wheezing, excessive mucous, difficulty in swallowing, hoarse voice, and "duck like" sounds in the throat.
It is therefore in mutual assistance with Hegu on the same meridian and with Tiantu in the vicinity of the focus of the disease.
Needling sequence, manipulation and stimulation
As with other conditions which are basically Shi, needling is initiated with distant points and continued with close points (59).
Hegu is stimulated in sedation in order to invigorate the flow of Qi In the meridian and to disperse phlegm in the throat. Then, Futu is punctured, to make a continuum with Hegu and take advantage of the propagated Qi that Hegu has transmitted upward.
Tiantu is lastly utilized to produce its effect on the whole area.
In Taiwan I have watched practitioners using the "warm needle" technique on Hegu in this context, when there were no heat signs. The idea behind this is that the Nei Jing states that in cases of abundant dampness "warm needle" technique is superior (60).
The logic is that the heated needle conveys warmth through the point to the meridian. This warmth helps dissipate the phlegm by drying it.
I have occasionally used this technique myself with very good results.
Futu, in cases of goiter or neck lumps, is sometimes stimulated with indirect moxibustion over a layer of ginger. This is applied after the point has been needled and the needle is withdrawn right afterwards.
In cases of lumps in the vicinity of Futu, it is often seen that the lump itself is pierced rather deeply, to follow right afterwards with the indirect moxibustion procedure.
Regarding Tiantu there are two main possibilities. The first is to insert the needle parallel to the sternum posteriorly, until Deqi is obtained and then to withdraw it. The second is to do likewise, but suspend the needle until the whole treatment is terminated.
Herbal equivalent
A herbal formula consisted of the following herbs:
1. Thallus Algae (Kun Bu)
2. Herba Saragassi (Hai Zao)
3. Radix Cynanchi Stautoni (Bai Qian)
is very similar in action to the above mentioned point combination.
Kun Bu and Hai Zao assist each other in dissipating phlegm nodules in the neck region or they are used together to treat goiter. Their nature is cold and salty and they clear heat and reduce phlegm.
Bai Qian is very similar in action to point Futu and probably Tiantu as well. It is used to treat phlegm conditions in the throat and to redirect rebellious lung Qi, which means asthmatic conditions.
Its traditional indications also mention that Bai Qian is effective in treating "gurgling sounds” in the throat" which is a sign of accumulation of Damp-Phlegm,.
This indication in particular reminds us of the classical indication of the point Futu which we have mentioned above, that it treats: "sounds in throat like a duck".
Case history
Miss S., age 26, also a stage actress and a close friend of Miss K. from case history number 9, was diagnosed five years before as having a benign tumor on her vocal cords.
She exhibited symptoms of hoarse voice, a fact that was not at all unwelcome in her profession and a constant sensation of mucous in her throat.
She had an odorless vaginal discharge, occasional stomachache and not very frequently also nausea.
All four methods of Chinese diagnosis revealed a state of lung and spleen Qi Xu as a basis for formation of phlegm and the obstruction of her throat by phlegm.
Her pulse was thin, soggy and weak, especially on right Cun and Guan positions.
Her tongue body was slightly flabby and covered with a thick, white, transparent and slippery coating.
Changmen (LIV 13) on the left side was tender but very ticklish, and Zhongwan (CV 12) was very tender as well.
Miss S. was a ten year smoker and used to smoke at least 20 cigarettes a day.
The principle of treatment was to eliminate phlegm in the throat and to tonify spleen and lung Qi.
I therefore chose the following points for treatment:
Hegu (LI 4), Futu (LI 18), Tiantu (CV 22), Panglianquan (extra), Liehchueh (L 7), Fenglong (ST 40)
Since there were no heat signs despite the fact that Miss S. was quite a smoker, Hegu was acted on by the warm needle technique.
Panglianqua