Summary, Speculation, Suggestions
The best speculations available to us about the origins of acupuncture point to the likelihood that needles were used to lance boils and to let out blood from areas where veins looked distended and/or darkened. The technique was broadened to let out various "evils" including evil spirits, thus allowing the internal resources to rebuild. Such treatments were thought of as one time interventions. Dou Hanqing (ca. 1230 A.D.), in his discussion of acupuncture techniques, quoted the famous phrase (1): "Take a piercing stone-needle and apply it outside to remove the evil and support the true." Referring to the stone needles, he noted that they could "expel disease and cure evil-there is nothing it can not heal."
As the concepts of disease causation developed, needles were also used to let out wind, cold, heat, damp, or other pathological factors that had invaded from the environment into the body, often thought to gain access through the pores. The treatments were still intended to be short and quick, but there were added considerations about how, when, and where to needle. Dou Hanqing wrote:
The Way of the Doctor-if he can clearly understand the principle of using the needle-is to swiftly eliminate pain as if it were plucked out by the hand. And to shatter blockages releasing them far and wide, as dissolving ice. As soon as the mystery of this is accomplished, you eliminate the problems of early deaths and mistaken treatments.
This medical art developed considerably into what comes down to us as modern acupuncture based on the concept that one can regulate the body functions through insertion of the needles, not just let things out and immediately get rid of a disease. The Lingshu (2) is the text that points to the situation that was evolving from the original concept. In the third scroll, it says:
The unskilled physician grasps only the form when he uses the techniques of acupuncture. The superior physician understands the spirit: his understanding of man includes both the blood and qi, whether there is excess or deficiency, whether he should tonify or disperse. The spirit and the guest, the primary and the evil, meet. The spirit is the primary qi, the guest is the evil qi. "Located at the door" means that the evil qi pursues the primary qi at those places where it comes out and enters. Don't just stare at disease! Begin by knowing the evil and the primary qi, and which channels are diseased….The unskilled physician only guards the gates….The superior physician knows the subtleties; he understands how to handle qi….
The "form" that the unskilled physician grasps is the inserting of needles into points on the body, relying only on places of obvious obstruction or the doorways where pathogens can exit. The superior physician first diagnoses the various conditions of qi, such as deficiency and excess, and adjusts his needling accordingly. The "evil" is like a guest or invader in the body; the unskilled physician only stands at the doorway trying to block the entrance of an evil qi or open the door to let it out. The superior physician tracks down the location of the evil qi in the channels and escorts it to the door. The spirit or "primary qi" is the normal qi of the body, which the superior physician can coax into action to help get rid of the pathogenic guest. The disease is not just something stared at, looked at in a cursory manner; rather, it is to be understood and properly handled.
Over the centuries, considerable effort was applied to determining what points could alleviate spirit disorders, not solely by serving as a door (spirit gate), but also by adjusting the healthy qi to overcome the perverse qi. The result of these efforts is a focus on points at the head, on the wrists, and on the feet and lower part of the legs. I would like to propose that treating this set of points (to be detailed later) corresponds with the Daoist (Taoist) wandering in the wooded mountain trails. That is, acupuncture partly serves the role as an in-office version of a trek through the woods.
In walking along these trails, especially with the limited quality of shoes available to them, the Daoists had their feet and ankles and calves thoroughly and vigorously massaged by the irregular surfaces. At the same time, their eyes, ears, and nostrils were filled with the sensory stimuli of nature: sky, trees, mountains, waters, animals, and so on. While enjoying the beauty, fragrance, and sound of their surroundings, these wanderers also had to stay attentive-whether for dangerous terrain or dangerous animals. Thus, their nervous systems were entirely alert. In climbing they would sometimes grasp at branches and stones; for their meals they would be plucking various fruits and making food out of the natural materials they encountered, thus working their hands and wrists. Today, many people turn instead to half hour sessions of foot reflexology or rotating specially designed Chinese balls in the hands for a few minutes, or getting acupuncture for 20-40 minutes to stimulate the qi flow; but then they do not at the same time encounter nature by sensation, so it is a lesser benefit, it is less holistic. When the practitioner decorates his office with Chinese nature paintings and even with the charts showing the flow patterns of the meridians, the patient gets a small glimpse of the desirable encounter; with the fragrance of moxa and the sounds of a small fountain or gentle traditional Chinese music, the patient has a sensory experience completely different from what is typically found in a modern medical office.
Thus, it is proposed, at one level, that the Chinese medicine practitioner is standing in for a nature hike! In saying this, I am not proposing that people who follow the Daoist path regularly (being out in nature for hours rather than 30 minutes, and doing so daily rather than once a week) don't sometimes suffer from shen disorders. Nor do I suggest that all shen disorders might be resolved by Daoist wandering on rocky paths through forested mountains. However, when practitioners of Chinese medicine refer to the concept of the body as a microcosm for the universe (as the macrocosm), they are agreeing to the idea that what goes on within the body needs to be attuned to the world outside, and that is the natural world. Such correspondence between the inner and outer worlds comes about by interacting with nature. The acupuncturist directs the patient's attention to the "Tao which is great."
Continuing the quotation from Dou Hanqing, with some slight editing of the translation to make the point more evident:
What was hidden from your view, can now be distinguished-you are able to understand secrets from the ancient books of the past. What was hidden was the underlying pattern-to perceive it is to begin to explain it. Understanding the patterns means enlightenment. The pattern, illuminated and revealed by those who came before, easily throws its light upon you later scholars.
What are these patterns? He described the flow of qi and blood in the body this way: "Traveling in ditches or collecting pools, or else running like a stream in a valley, along different pathways. The pathways here are the tracks. Among the points on the vessels some are called, ditches, pools, streams, valleys-just as each is in a different position along the track or pathway." That is, the interior of the body is like nature, and when examining the body, one is looking for how its natural function has been disturbed-hoping to restore it. The Daoists provided a model for healthy function, which is contained in the concept of Xiao Yao. A hidden secret is that the needling of patients can mimic the Xiao Yao. This is not the only way to practice acupuncture, but it is one of the ways.
There can be little doubt that the earliest determination of medicinal properties of herbs had to do with immediate effects of consuming them. In most cases, these were things to be avoided, such as herbs causing vomiting or diarrhea. However, the effects were utilized for healing-much as ancient acupuncture was-to let out evils from the body. In such cases, they would typically be taken once or twice, with the expectation that the disease would change markedly, preferably in the direction of resolution. The standard methods of therapy mentioned in the Shanghan Lun (3) were types of purging: vomiting, laxation, and perspiration. They were frequently mentioned in the context of being used wrongly (like the acupuncturists who only relied on opening the door to let out evil). What was then introduced in that text was a more sophisticated analysis of disorders and more complex therapies that involved locating the problem within certain part of the body and addressing it with methods of tonifying or dispersing or even harmonizing, usually with only a few days of treatment.
There also developed a different concept that some medicinal substances could be taken routinely over a long period to protect health and gain long life or immortality. Unfortunately, many of these remedies were not really based on experience of positive outcomes, but on theories that had been worked out by a few individuals. Some of the substances they advocated did not stand the test of time. Alchemists, believing in the ability to transform the body in a way that would correspond to chemical transformations, became involved in using a number of toxic substances. One of the results of the toxicity was loss of body weight, a change that may today seem beneficial in terms of the problem of obesity, but was actually part of the harm done to a person through such things as heavy metal poisoning. To this day, we read of Chinese herbs that had this effect (causing the body weight to decline), often without realizing that this attribution is not necessarily a positive one. Sometimes this weight loss effect was attributed to herbs that are non-toxic (such as ginseng), but the herb didn't have that effect; instead, it was simply included as a listed property because that herb was considered to be one that could contribute to gaining immortality.
Over time, herb therapies have gone through a variety of changes, especially as they have come to us in the West. Some herbs that are especially potent in effect, but also potentially causing serious side effects, have been dropped from the treatments in recent times. These are replaced, in actual practice, by drugs that also have potent effects and potential for side-effects, but are better studied and better controlled than the natural substances. For the non-toxic agents, there is a tendency to use very high doses in China (e.g., 120 grams or more in decoction for a one day dose), and these high doses may contribute common nutrients, such as vitamins and minerals, as well as any chemical constituents that are active. In that sense, they serve a function similar to eating nutritious foods or consuming dietary supplements made with components such as vitamins, minerals, and amino acids. Numerous Chinese investigations into the herbal remedies have been based on determining the quantity of such things as trace minerals and amino acids to help explain their effects. Some of the substances used for treating shen disorders, such as oyster shell and dragon bone and wheat, may have part of their value explained by the presence of calcium compounds and B-vitamins, things that are as easily attained by consuming certain foods or supplements (the Chinese diet lacked calcium rich dairy products and relied on milled rice which lacked vitamin B). It is understood that such minerals and vitamins can have a positive influence on the function of the brain and nervous system for persons who suffer deficiencies.
In addition to providing what we might consider ordinary nutritional benefits, many of the herbs may have indirect therapeutic effects on shen disorders. For example, a person who has poor blood sugar regulation may experience difficulty with mental concentration when blood sugar is either high or low; herbs that regulate blood sugar may stabilize the mental condition without having a direct impact on the brain.
At this time, it is difficult to know what ingredients are truly effective in treating shen disorders. Some herbs have been shown, through laboratory testing, to affect neurotransmitters, such as acetylcholine or serotonin, and some clinical trials have demonstrated improvements in patient conditions (e.g., depression, insomnia, memory, response time). The herbs that are most frequently employed have a variety of different active components, though there may be a prevalence of steroidal glycosides among several of the commonly used herbs. The question of which ingredients are active and their mechanism for various effects on the brain and mind is an area that requires further investigation. China has had a limited investment in researching herbal effects on shen disorders, partly for political reasons and partly because of the great difficulty involved in assessing the effects.
I would like to present a protocol of acupuncture and herbs corresponding to the analysis presented in this booklet that would lead directly to rapid improvement in most patients. This might be considered a system of treatment that involves some relatively simple choices. By contrast, according to a large component of the Chinese medical literature, one should undertake an extensive diagnostic overview, determine a pattern of dysfunction, and treat accordingly, utilizing therapies that are both traditionally recognized and also influenced by personal training and clinical experience. Is there a way to offer something that is true to both these intentions? I believe there may be. On the one hand, we have the complete Chinese medical system, with hundreds of acupuncture points and hundreds of herbs, which provides for meeting the demands of the methodology called differential diagnosis and treatment. One can hardly dispense with all of that. On the other hand, numerous practitioners, some of them revered for their competency, have observed that there are certain acupuncture point sets that can be used reliably for many patients, or have utilized a small number of herbal prescriptions to help patients with diverse conditions. The potential value of such an approach based on trustworthy regimens is that it allows many people to benefit even when the practitioner is not in a position to provide full differential diagnosis and treatment.. Even in modern medicine, where we have very detailed analyses that lead to much finer differentiation of diseases than in Chinese medicine, we still sometimes find some central therapeutic approaches that are relied upon over and over. As a prime example, a relatively safe anti-inflammatory can have the potential to alleviate a wide range of conditions, both acute and chronic. In fact, aspirin is one such compound, and this substance is now produced at an estimated rate of 24 million pounds per year. One can similarly think of treatments for mental disorders, such as Prozac (fluoxetine), for which the U.S. alone used 1.2 billion dosages in one year.
The 20th century acupuncturist Wang Leting (4) had described an acupuncture protocol, called "Old Ten Needles" for gastrointestinal diseases which can also be chosen and used for other diseases. It was pointed out that "Generally speaking, the Old Ten Needles can be selected for all kinds of gastrointestinal diseases regardless of whether they are vacuous [deficient] or replete [excess], cold or hot." In a similar manner, certain herbal formulas are very broadly used, often for gastrointestinal disorders and then additionally for other conditions, of which Guipi Tang is a good example mentioned in Chapter 8.
For shen disorders, I propose the following structures for basic treatment using acupuncture and herbs, which can be further modified according to the practitioner's decisions
At least two points are selected along the centerline of the head to the neck, thus on the GV vessel (including extra point yintang). These points run from GV-14 through GV-26. Starting at GV-14, the back of the head points are selected for strengthening yang and for treating disorders that physically affect the brain. Reaching the top of the head, one regulates the yang and treats disorders that are primarily affecting the function of the brain, such as with insomnia and memory. Moving to the front of the head, one treats points to remove excess and to calm agitation. Points along either side of the center line may be used additionally, such as sishencong or fengqi (GB-20).
Two or more points are selected on the forearm or hand, the most common choices are PC-6 (or adjacent points PC-5 or PC-7) and HT-7. These points can be treated to enhance the function and nourishment of the heart while draining excess from the head; LI-4, at the hand, is an example of a point that is especially used for draining.
One or two points are selected on the lower leg or foot. The points may be used for draining excess (e.g., LV-2 or LV-3) or for tonifying (e.g., KI-3 and SP-6); sometimes points slightly higher on the calf are used, such as ST-40 (for draining) or ST-36 (for tonifying) For tonification therapy, one may also include the use of points in the waist area, such as CV-4 or CV-6, GV-4, or BL-23. If such tonification is not required, then the points at the head, hand/wrist, and foot/lower leg are sufficient.
The combination of head points and points at all the extremities (bilateral upper and lower limbs) produces a pattern of effects that is notable; it may be described as a stabilizing pattern. This protocol can be seen to be contained within the treatments of most of the clinical reports listed in Chapter 5, but the authors do not describe their treatments as following this general pattern, rather, the set of points is simply laid out and some comments may be provided about the value of individual points or, occasionally, the value of a certain combination of two points.
There is a traditional concept of treating "one point above, with two points below," but, in this case, the recommendation is to treat points above as specifically referring to the head (and neck) and points at the extremities (with emphasis on the distal areas) are the ones below. It is also possible to recommend an order to applying the needles. This begins with needling the top of the head (such as GV-20), which is often less painful than other points and has a calming effect; then any additional points in the head/neck area are treated. After that, the hands/wrists are needled, and this will have the effect of giving a greater stimulus to the brain. Finally the feet are needled in order to complete the circuit of circulation from the extremities to the head.
A purpose of this needling order is to clear the movement of qi in the head region first, removing any blockages and calming agitation. Next, the flow of qi and blood to the head region from the arms allows for a stronger sensation. Finally, the distal points at the lower body help regulate the gross circulation of qi throughout the body. This approach is particularly relevant to disorders that are considered to affect the brain, mind, and spirit. The exception is where the patient experiences an obvious nervousness that would be attributed to liver qi excess, in which case the use of the lower body points (e.g., LV-3, LV-2) might be the starting point; then the head and finally the arms might be treated.
Except when using the bladder meridian or governing vessel points at the back, this treatment can be applied with the patient lying in the comfortable face-up position. If needling the back of the head points such as GV-14, 15, or 16, or GB-20, the patient may be seated so long as attention is paid to the rare possibility of fainting.
Herbal therapeutics for shen disorders often present a certain limited set of herbs repeatedly. These basic herbs are summarized in the following table:
|Qi tonics to raise the clear yang||ginseng, astragalus||Licorice is often included; mild tonics, such as longan or jujube might be added. Codonopsis can be used in place of ginseng as a spleen tonic, but it lacks the shen calming effects.|
|Damp-clearing herbs||hoelen, atractylodes||Pinellia and citrus added for greater fluid accumulation or obvious phlegm; alpinia may be used to invigorate stomach/spleen function.|
|Blood nourishing herbs||tang-kuei, peony||Rehmannia is also used, especially for older patients.|
|Spirit calming herbs||zizyphus, biota||Albizzia bark or flower used for depression; oyster shell and dragon bone or dragon teeth used for fright and agitation.|
|Phlegm-mist clearing herbs||acorus, polygala||Arisaema, curcuma, and bamboo are used additionally for severe cases; platycodon may be included, especially where there is obvious sputum accumulation.|
|Qi regulating herbs||bupleurum, plus one or more of: citrus, chih-shih, chih-ko, saussurea, magnolia bark||Cyperus is sometimes used for depression; lindera might be used in place of bupleurum for weak constitution patients.|
|Heat clearing herbs||coptis, gardenia||Moutan is sometimes used for heat in the blood.|
|Yin nourishing herbs||ophiopogon, rehmannia, cornus||Scrophularia and/or lily might be used additionally; these herbs are for yin deficiency agitation with insomnia and night sweating; lily helps drain damp and treats neurosis.|
|Kidney essence replenishing herbs||ho-shou-wu, tortoise shell, lycium, cuscuta||These herbs are particularly used with older patients.|
|Blood vitalizing herbs||salvia, red peony, cnidium, persica, carthamus||Blood stasis syndromes tend to occur in cases with long duration and in elderly patients.|
Key formulations mentioned in the previous chapters are Guipi Tang, Tianwang Buxin Dan, and Jiawei Xiaoyao San. A practitioner using these formulations, or others relying primarily on the herbs listed in the above table, will be working in a manner consistent with most Chinese medicine experts in China. The herbs for resolving phlegm or phlegm-mist and for vitalizing blood may need to be added to these basic combinations.
In the modern circumstances, it is common for people to approach practitioners involved with Chinese medicine only after a disorder has been present for some time and has not resolved either on its own or with standard medical approaches. In Western society in particular, many people suffer from certain disorders of excess (due, largely, to dietary excess) and stagnation (due, largely, to sedentary life style). Because of the chronic nature of the problems, the excess and stagnation cause or occur simultaneously with certain deficiencies, particularly in the function and proper nourishment of the viscera. Therefore, it is almost always the case that patients will benefit from the therapeutic principles including clearing excess (e.g., getting rid of damp and phlegm and heat), dispersing stagnation (vitalizing circulation of qi, blood, and fluids), and tonification (e.g., nourishing qi and yin).
For the herbs to be effective, it is important to avoid using too many ingredients at once. Many patients prefer taking a small quantity of herb materials (today, many people consume herbal tablets, capsules, or pills, rather than heavy decoctions), so in order to get a large enough dosage of the key ingredients, only a few items ought to be used. As examples, Guipi Tang has 12 ingredients and Tianwang Buxin Dan has 13; and most of the treatments described have no more than 16 ingredients. Sometimes, two formulas are combined to produce a therapy, such as using a kidney nourishing prescription (e.g., Zuogui Wan) and a formula for resolving phlegm accumulation (e.g., Banxia Baizhu Tianma Tang); each of these formulas had 8 ingredients, for a total of 16. Although most of the treatment strategies outlined in the table above may appear attractive for addressing a patient's needs, the therapy should usually focus on only a few of them. As necessary, the therapy can be changed over time as some conditions improve and others then become the target of concern.
An important part of the protocol, as revealed in the previous chapters, is to drain fluids. In cases with obvious moisture accumulation, the herbs hoelen and atractylodes are especially desired, possibly in the context of using spleen qi tonics to enhance the moisture dispersing action attributed to the spleen organ system. As the fluid is transformed to phlegm-fluid due to stagnation, herbs such as pinellia and citrus, magnolia bark, or alpinia may be added. If the disorder displays signs of phlegm-mist, then acorus and polygala become important (for severe cases, arisaema and bamboo are added) and one should consider the possibility of blood stasis occurring at the same time (salvia is a favored herb). In the case where yin deficiency is present, lily may be used to drain fluid without damaging yin.
To sum up, ancient Chinese therapeutics were originally quite coarse in nature (big needles and lances, herbs with strong, even toxic, action) and used briefly to affect a change. Later, the system was refined so that more subtle adjustments could be made. These subtle effects may be seen, in some sense, as a replacement for components of lifestyle-such as walking through mountain paths and eating a nutritious diet-that were recommended by Chinese philosophers who thought along the same lines as the early medical scholars.
In addition to any specific action that might be attained via acupuncture and herbs, it is the interaction of the physician with the patient that is critical. Chinese medicine offers what for many appears to be a positive intervention, which contrasts with what is seen as a negative intervention of modern medicine. The impression about the positive or negative impact of a style of treatment (i.e., Western or Eastern) is often a matter of interpretation, but the contrasting views provide for an opening in the relationship. The doctor who offers Chinese medical therapy has at his disposal the Chinese conceptual framework about health. That acupuncture and herbs tie into a larger picture, namely the interaction of the patient with the world outside them and, in particular, the spiritual part of their being, may be important for many people, a key to changing their health.
This is not to say that the Western world can't offer essentially the same thing as does the Asian culture in terms of this holistic view. It is only that doctors and patients in the Western world have fallen into a pattern of thinking and acting that some find unsatisfactory. The patient presents a disorder and the doctor presents a treatment-typically drugs and/or surgery-but there isn't much time to go into other aspects of a person's health or the concerns have become sufficiently routine ("lose weight, stop smoking") that they are quickly passed over. In fact, the Western doctor must reserve his or her time for the technical aspects of diagnosis and medical intervention.
Theoretically, the Western doctor ought to be able to rely on the person's church (or other religious organization) to take care of the spiritual matters that are important to healing. The person's family ought to help with maintenance of a healthy pattern of behavior, including diet and exercise. The culture that a person lives within is supposed to help provide healthy mental and physical activities; and the medical literature put into layman's terms (popular format) is supposed to tell people what are generally understood to be healthy or unhealthy practices. But, we find today in our society many people isolated from their spiritual tradition, from their family, from the better side of their culture, and skeptical of the general health care teachings (searching instead through various alternatives), so that they are left without good health and have limited hope. They are looking for something else to fill the gaps.
Chinese medicine offers an alternative that seems attractive to some. It has the spirituality of Daoism, for example, that actually fits well with the uncertainties of the modern times, and offers the natural concepts of yin and yang and five elements that fill a void left by too much technological information about the chemical make-up of the body and the environment. China has a unique dietary approach (such as attributing cold and hot or yin and yang properties to foods and herbs) and the physical culture of taiji quan and qi gong (that strikes many far more harmonious than running and weight lifting). The Far East has the therapeutics of acupuncture which seems both mysterious and effective, and it has what is perceived as a more potent form of herbalism than is available in the West (and this perception may be justified because of the greater reliance on herb therapy).
In order to tap into and gain the most from the Chinese system, its components should not be taken in isolation. There are cases where acupuncture and/or herbs are simply provided as the sole remedies, without going into a broader context, and this can be appropriate for injuries or infections. However, for those with shen disorders, where the mental function, the emotions, and the spirit are all involved, a focus on techniques of needling and herb prescribing herbs may be too narrow. For that reason, this booklet begins with an introduction to the underlying concept of the shen and its disorders in relation to how a person lives.