Recently I found myself “eavesdropping” on an online conversation between two professors at NCNM, namely Roger Batchelor and Ed Neal, on the subject of the Pericardium in the Classics. What came out of it was more than a little enlightening and inspired me to talk about the Pericardium a bit this week.

The essential point of the discussion was as follows: what we call Pericardium in the modern Chinese medicine disciplines is referred to as (quoting Ed’s translation here) “Mai vessel of the heart encircling luo vessel (network), following the hand (upper) Jue Yin six confirmation terrain, relating to the function whose (domain of responsibility) is the heart.” Usually this is shortened to Xin Bao, or Heart Wrapper or Heart Encirclement. Usually this is assumed to equal the Western anatomical structure of the pericardium, the membrane that protects the heart. However, what Roger and Ed pointed out is that in it’s discussion of the function of the Xin Bao, which is always the important thing to the Classical Chinese mind, it has almost nothing to do with the pericardium whatsoever and instead equates much more closely to the coronary artery network. This, to my mind, answers a boatload of questions about what the Hand Jueyin (and the not-particularly-easy-to-understand Jueyin as a whole) actually does.

First, for our TCM readers, let me clarify a misconception that seems to be prevalent: contrary to what we learn in school, Jueyin does not refer to a seldom seen and horrifying state where the patient is vomiting roundworms (something that the average Westerner can’t fathom) and occurring just before spectacular death.  Rather, Jueyin, which deals with-amongst other things-the Heart and Pericardium organs, is the “closure” of Yin, the function that causes Yin to shrink and decrease so that it may change properly into Yang. The Liver stores the Blood and supplies said Blood throughout the body. The Heart moves the Blood, but how does the Blood get there? Via the Jueyin network. The Liver feeds blood to the Heart via the Pericardium/Xin Bao. How much more sense does this process make if the Xin Bao is really the coronary artery network?

Also notice that the representative  true Jueyin formula, Dang Gui Si Ni Tang, is a Blood-oriented formula. If Dang Gui is the Emperor herb, you can bet the house that Blood is the primary issue at stake, especially given the construction of the rest of the formula: Gui Zhi to invigorate the Blood, Tong Cao to decrease vascular rigidity, Xi Xin to warm the Blood as it reaches the Lungs, Sheng Jiang to bolster Taiyin function in the construction of Blood and Da Zao and Zhi Gan Cao to supply material to the Blood and Yang to the Heart when used with Gui Zhi and Sheng Jiang. Blood, Blood, and more Blood. If the Xin Bao was just the wrapper of the Heart (something that always mystified me) this wouldn’t make a great deal of sense. However, if it instead is equated  with a) the coronary artery system that is responsible for feeding Blood directly to the heart and b) a more formless and function-oriented idea of the system of channels, Luo networks, etc. that encircle the Heart and supply it with Yin and material fuel, suddenly both Xin Bao and Jueyin make a lot more sense. Also if you consider that the Kidneys have to provide the ultimate Yin Water that nourish and protect everything in the upper Jiao from the overwhelming Imperial Fire of the Heart, it makes complete sense that this Yin would travel up through its child Wood (meaning the Yin Wood network of the Liver, but which the Chong Mai adds its influence to) and onto Wood’s child Fire (being the Xin Bao and Heart).

Let’s also look at the Xin Bao/Pericardium from psychological perspectives. The Pericardium is normally seen as the Heart protector, a point of view I agree with fully. However, I think in the context of viewing Xin Bao as a network instead of reducing it to just one physical entity (as is our modern wont) the protective membrane of the pericardium is only a small part of the story. In the primary lineage I have been trained in (Leon Hammer’s Contemporary Oriental Medicine which, despite the name, is actually very classically informed) as the Heart pulse begins to tighten there is both a restriction of circulation into the Heart proper as well as a decrease in communication with the outside world. The patient is often quite far into nervous exhaustion and is beginning to close off and isolate himself emotionally from society, loved ones, possibly also even himself, especially if a Slippery quality is also found. The tighter the pulse gets the more the constriction develops on every plane, introducing emotional rigidity (frequently accompanied by the “character armor” of muscular rigidity) and impeded circulation in the chest, frequently with sharp pains over the heart. It’s much easier to see this constriction mirrored by a constriction of the arteries that feed the Heart rather than what amounts to a lubricated bag somehow constricting.

I would also add in a comment from Arnaud Versluys on this subject in a lecture where he stated that the Heart’s job is to primarily serve as a container for the Shen and that in fact the Pericardium-which is also represented by the entirety of the vascular network-does the actual beating, “squeezing the heart” as it were. Again, the coronary artery network theory really works well.

So what does this mean practically? To begin with, this really clarifies the (manifold) uses for the Pericardium channel in acupuncture. Given the usage of Pc-4 for treating acute myocardial infarction, we can see its power over the physical structure of the Heart and its Vessels. However, we can also see the benefits of providing nourishment to the Heart via the combination of K-22, Pc-1, and Pc-2 using the Exit and Entry points of the Kidney and Pericardium channels to bring the Yin influence of Water to the Fire networks, essentially mimicking the natural activity of the Jueyin. This combination is very useful for patients whose Imperial Fire is beginning to run amok causing insomnia, flight of thought, anxiety, and other symptoms.

This does however raise interesting questions about the true function of Pericardium-oriented herbs such as Zhi Mu, which is frequently used to cool down and protect the Heart and Pericardium, relieving cases of delerium as well as less serious psychological difficulties along the same spectrum.

I would love to hear from our more experienced practitioners on this subject in the comments section.

Regarding the Pericardium

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I have another great guest post for Deepest Health readers.  This time, please welcome Rob Blackburn and enjoy his article on the Hara as used in Shiatsu diagnosis and treatment.  It may help to get another angle on the abdomen in Asian medicine, a great companion to Kumiko’s fine article on the subject.

Quickly, by way of a personal update: School has, indeed, become very intense and I’m still adjusting – but we’ll be back to “regular” content soon.  Regardless, I’m sure you all agree that these guest posts are of top quality – thanks so much to all of my guest authors.  Please feel free to leave comments, the authors will hopefully be monitoring their posts and replying.

Eric

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Introducing the Hara

Before going too deeply into Hara Diagnosis and Treatment (or Ampuku) it is important to clearly define what we mean by “Hara”. Hara is a Japanese word that broadly refers to the area below the ribs and the sternum all the way to just above the pubic bone.

In Shiatsu, I think it is safe to say that Hara Diagnosis is a cornerstone of any treatment. In my school, and as far as I know most schools of Zen Shiatsu we are taught three different maps for Hara Diagnosis. The first and most commonly used is the Zen Shiatsu map. The second is the less specific, Five Element Map, and the last is a very broad map based around Ren points. I shall concentrate mostly on the Zen Shiatsu Map here with some reference to the Five Element Map, as it is what I am most familiar with in practice.

The Zen Shiatsu Map was developed by a man called Shizuto Masunaga (1925- 1981) who is largely responsible, along with his student Wataru Ohashi, for popularizing Shiatsu in the Western world. It is clear that Masunaga had very solid basis in the classics but as far as I can tell the Zen Shiatsu Map was largely his own creation along with 12 Extra meridians that he intuited during his career.  The Zen Shiatsu Map Divides up the Hara into Organ Specific areas for the 12 Major Meridians  The Zen map above is from my own notes.

The five Element map, on the other hand, more broadly divides the Hara up into the Respective Element areas, the middle three of which correlate with the Zen Map. 

Palpating and Diagnosing the Hara

The method for palpating the abdomen can follow a specific routine. First, generally ‘baby walking’ or ‘palming’ the whole Hara using steady whole hand pressure to get a good idea if the general qualities of the Hara (hard or soft, tense or relaxed, along with quality of the breath) and so too an overview of the person being treated. Then the practitioner can be more specific, using one, or both of the maps.

The Zen Shiatsu Map can even be palpated in a particular order to make learning it easier and to ensure all areas are covered with equal pressure. The Hara is usually palpated with the fingers of the hand held together whilst moving in a smooth rhythmic fashion.

The idea is to feel for areas of Kyo or Jitsu  (broadly equivalent to Excess and Deficiency in Chinese Medicine and worthy of a post all to themselves). This is where the Zen of the Diagnosis really comes in. The practitioner must ‘listen’ intently through their hands to any energetic qualities that may arise or become apparent, all the while being careful not the confuse physiological land marks with things of energetic significance (food in the intestines for example.) The practitioner must also be remain slightly uninvolved in order that whatever is to become apparent does so and is not disturbed by the practitioners movements. I liken this to dipping your hand in a still, dark pool to feel the currents without disturbing the surface and being distracted by the ripples.

The act of diagnosing in this way throws up an interesting problem, which is this; as soon as the practitioner interacts with the client in this way they are treating them. Hence the oft repeated saying “diagnosis is treatment, treatment is diagnosis.” But, this can lead to confusion as the more the Practitioner palpates the more likely they are to change what they are perceiving. The skill is to get a clear overview of the two Channels that will form the basis of the treatment, the most “Kyo” (or empty) channel and the most “Jitsu” (or full) Channel without going to far into treatment and risking muddying the waters. Obviously these are often novice pitfalls and the master would not even in some cases need to make physical contact with the patient in order to make a diagnosis.

The Hara is a powerful diagnostic tool and much like the tongue it tells an honest picture of the patients energetic make-up. The skill is to be sure of what you are looking at!  For example, the area around and below the ribs can be tight and full feeling due to Liver Ki Stagnation, which often makes this area tight. This could be mistaken for a Heart jitsu diagnosis, as the Fire diagnostic area is situated just below the Xiphoid Process and extending down towards the Umbilicus.  Similarly, it could mislead as the Stomach Bo (Mu) Point is in a similar area and could feel jitsu as a result. The key to resolving these problems is to ensure that even a comprehensive and telling Diagnostic tool such as the Hara is not taken in isolation but is compared with other Pillars of Diagnosis for a rounded picture.

Treating the Hara

Treating the Hara can be profoundly satisfying and yield on the spot results. You can provide treatment directly to areas affected by different patterns.
As mentioned previously, Liver Ki Stagnation can affect the epigastrium and respond very well to dynamic Ampuku techniques especially when the Stagnation effects the digestion and breathing.

In fact many digestive issues can be eased with Ampuku, yet the seemingly obvious act of massaging the abdomen seems quite an alien concept here in the West! Maybe this is because the Abdomen is such a sensitive Yin area of the body and is literally and often figuratively the core of a person’s being.
Finally, another great yet simple treatment that can be administered through the Hara is simply laying a hand on the lower Hara in the water diagnostic area, below the umbilicus around Ren 5 and 6. By following the recipients breath with the hand the Practitioner can effect a calming effect on the mind which can be like a guided meditation, or if the breath is followed more deeply with pressure being applied gradually with the hand, can have a tonifying effect on the Kidney.

This is where Shiatsu really comes into its own.  The practitioner can directly “remind” a body of a mental state and direct breath to the abdomen just through placing the hand on the Hara in a mindful way. This technique simultaneously activates the Triple Heater Bo (Mu) Point and the Sea of Qi point whilst reminding the recipient of their Dantien. In this way it is possible to give the person a sense of gravity and centeredness.

I could write a lot more about this fascinating subject. As it stands, I intended to go into my own experience but I ended up writing a brief overview of the subject instead! I am still a student so feel free to comment and correct me where you see fit.

Rob

Hurrah for Hara! Shiatsu diagnosis and treatment

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This is a guest post from recent National College of Natural Medicine (NCNM) graduate, Kumiko Shirai.  She is a fine herbalist already and obviously has an expertise in the (almost) lost art of abdominal diagnosis.  I have seen this work in action and can attest to its amazing effectiveness!  Please enjoy the article.  There are more guest articles to come! -Eric

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Japanese abdominal diagnosis, known as fukushin 腹診 is an art form of medical practice that is virtually lost in modern practice of Chinese medicine. There are two major schools and types of abdominal diagnosis, Nanjing and Shanghan Lun schools, which separates into the Japanese schools of acupuncture and the schools of herbalism respectively. There are many modern books written on acupuncture style of abdominal diagnosis, which is also referred to as hara diagnosis, however books written on herbal prescription style of fukushin are difficult to find.

In the studies of Japanese style of herbal prescriptions, kampo, 漢方 which is mostly based on Han Dynasty formulas from the classical texts of the Shanghan Lun and the Jingui Yaolue, one can find many abdominal patterns and findings for almost every formula. It appears, though it is not certain, that Zhang Zhongjing used abdominal palpation as part of his diagnostic tools.  And there are many Japanese scholars who have elaborated and perfected their practices of fukushin for the purpose of herbal prescriptions based on Zhang Zhongjing’s classical texts.

The concept and significance of the abdomen are different in Japan from what exists in Western cultures. It was not too long ago that Japanese people commonly said, “I am going to go see a doctor to get my abdomen examined.” In Japanese culture, the abdomen or hara is central.  Alternatively, the nervous system and mind seem to be central in Western cultures.  But, when we think about it, the Japanese idea makes a lot of sense.  The abdomen is physically a central part of the body, containing many of the vital organs.  Japanese people also believe that hara is the seat of the soul, where self-consciousness is anchored. On the other hand, from pathological sense, the abdomen is where people hold emotional stress, affecting their digestive problems as well as other physical discomforts. For this reason, in Japanese medicine,  the hara becomes a pivotal part of the body during the examination, diagnosis, and treatment.

In fukushin, abdominal patterns are named after herbal formulas such as “Xiao Chaihu Tang pattern” or “sho” in Japanese, which already gives a diagnosis and a treatment plan.  On the other hand, in the Nanjing school of abdominal diagnosis, abdominal patterns are named after theoretical diagnostic concepts such as  “Liver qi overacting on Spleen”.  The difference between Nanjing style of theoretical approach versus Shanghang Lun style of clinical approach is interesting in that it shifted the clinical practice of kampo in Japanese medical history. One of the most influential Japanese scholars, Todo Yoshimasu (1702-1773), emphasized mastering clinical skills rather than understanding theories. He claimed that “proof is always more convincing than logic,” accentuating the importance of the practice of palpation, and to treat what is obvious by carefully examining the abdomen. For this reason, Todo inspired many practitioners to practice palpation during the examination. However, Japanese scholars did not ignore fundamental theories of Chinese medicine completely, and fukushin is still very much based on theory as well.

In order to give an herbal formula based on abdominal diagnosis, one must understand the architecture of the formulas first. There are eight therapeutic methods in the study of herbal prescriptions, however, it is important to break up each method into further smaller groups, understanding the function of the pivotal herb or herbs in each formula. The key herb in a formula may not always be the emperor of the formula, though often times it is. For example, in the purging method, there can be different causes for accumulation in the middle burner hence requiring different approaches and treatment plans. While Dahuang (in Da Chengqi Tang) treats fullness caused by middle burner accumulation due to qi stagnation causing heat, Mangxiao (in Tiaowei Chengqi Tang) treats accumulation of the middle burner due to dryness of the intestines, and Taoren and Mudanpi (in Dahuang Mudanpi Tang) treat fullness by breaking up blood stasis, hence moving both qi and blood. As a consequence, these three formulas, which share a common category of method, will have different abdominal patterns and imply different treatment plans.

In closing, I want to emphasize that examining a person’s center is not only theoretically appropriate but also clinically helpful in the process of assessment, diagnosis and finally planning a treatment. Hence, Chinese medicine practitioners, are encouraged to cherish the art form of practicing this medicine by observing and touching each patient and interpreting such information as holographic representation of the body.

Kumiko

The Art of Palpating the Abdomen for the Purpose of Prescribing Chinese herbal formulas

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I have a special treat for you.  Deepest Health’s first podcast interview!   I am honored to offer this interview of Brandt Stickley talking about his practice and teaching of Contemporary Pulse Diagnosis, his work with Dr. Leon Hammer, his understanding of Classical Chinese Medicine and more.  Near the end of the podcast, Brandt and I discuss a number of topics that refer to our upcoming project here on Deepest Health.

As a first try at a long-distance podcast interview, we didn’t do a bad job – but I recognize that the recording quality doesn’t do the content justice!  I do hope you enjoy it.  Note:  I have higher quality recording equipment on the way and hope you will stick with me while my skills and knowledge increase!  Thanks again.

Note: I will not be doing my normal Friday summary podcast – I’m going to wait to do another one until I get my new sound equipment, which should arrive around August 13.  I hope you will enjoy the new sound!

Some important links to sites and books discussed in the podcast:

1. Dragon Rises.org : site containing articles, links and information about seminars pertaining to Contemporary Pulse Diagnosis
2. Dragon Rises College of Oriental Medicine
3. Dr. Leon Hammer’s two most well-known books (affiliate links – if you buy through them, Deepest Health gets a small percentage of the sale – thanks!) :

Dragon Rises, Red Bird Flies
Chinese Pulse Diagnosis: A Contemporary Approach (Revised Edition)

Click below to play the podcast:

Deepest Health Chinese Medicine Podcast Episode 5 : Interview with Brandt Stickley

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I’d like to go back over Fall term 2007 and distill what I feel to be the essence of what I learned in each course or clinic shift. It’s really fascinating to me how full of importance every single class turns out to be, regardless of my feeling of any one class at the onset. Over time this has taught me to be utterly open to the content of every course, the offerings of every teacher.

At NCNM, we begin our clinical education working in the Chinese herbal medicinary, and then graduate to Observation shifts, finally moving on to Internship the summer of our third year. Observation shifts are well named – mostly you watch. To some this may sound boring, but it is anything but. Trying to follow the doctor’s reasoning, observing the minute action of fingers on the pulse, the flashes of understanding as the patient reveals some seemingly minor detail… it’s all so valuable. We are able to take the pulse and look at the tongue, and with some doctors we are able to ask questions of our own. Some doctors have students remove needles or do some of the less intrusive therapies, like indirect moxibustion. During the “down time” when patients are lying with their needles inserted, some doctors will teach in quite a formal way, others simply take questions, still others like to joke around and get to know their students. We are in Observation for two years, beginning in the second year.

This term, I had the distinct pleasure of being one of four students on Arnaud Versluy’s Observation II shift. I have been on three other observation shifts so far, all of them were wonderful learning experiences and each so unique! However, Arnaud’s shift was a different animal altogether. I’m not sure if this is just because of something inherent in Arnaud or if it is because of my deep resonance with his basic medical philosophy and enjoyment of our interactions – either way, I learned so much on this shift I wish I could repeat it for my remaining Observation shifts!

Pulse taking

All of our doctors use the pulse in their diagnosis, but none so far have done so in such detail as Arnaud did this term. This may be due to the fact that he is a scholar and clinician in the Shang Han Lun tradition and in this school the pulse is emphasized. We began to learn a whole Shang Han Lun based pulse system, but really had to piece things together for ourselves. I believe he reveals more about this system in his mentorship tutorial, which is a fourth year opportunity. From what I can tell, the system has similarities to that espoused in the Nan Jing especially in terms of pulse positions and incorporates a system of formula differentiation as distilled from the Shang Han Lun text. The idea is to learn the pulses and their correspondences so well that as soon as you feel a pulse, you prescribe a formula without much question. There are, of course, exceptions to this rule – but our trust in the pulse should be above our trust in the patient’s ability to fully articulate their pathological process.

This makes sense to me, above all, because of my own experience as a patient. It is rare that I can tell a doctor “what’s wrong” and while I can sometimes articulate very strange, and very diagnostically helpful symptoms – most of the time, I just don’t feel right. :D

We also learned some basic pulse taking mechanics. It’s funny, because for all that we learned pulse qualities and the history of the view of pulse positions – we never learned “how to take a pulse” in any systematic way. Sometimes these basics get lost in the shuffle, I suppose. Arnaud gave us those basics on shift and I can tell you that my ability to learn from each pulse I take increased immeasurably.

Modular character of classical formulas

Arnaud is a formula guy, first and foremost. His point selections are intriguing, but it is in the realm of formulas that his brilliance is clearest to see. The easiest way to get him to talk a blue streak was to ask an insightful, but simple, question about a particular formula or formula modification. I’m sad to say that I probably didn’t take enough advantage of this resource – but when I did, the results were both deep and broad.

What I learned most was that the nature of classical (or canonical, as he likes to say) Chinese herbal formulas are exceedingly modular. What this means is that if you take half a dozen of the most used Shang Han formulas you will see numerous overlaps that make it simple to combine formulas without adding too many ingredients or making the formula too big. This creates an extremely wide therapeutic output with just a small number of different herbs. It also means that the dosages and combinations in classical formulas are EXTREMELY tight. If there are 9 grams of Gui Zhi and 9 grams of Bai Shao in a formula, changing one of those dosages to 6 grams produces an entirely different effect. So, the practice of willy nilly modifying formulas based on wanting “a little more of this and a little less of that” probably isn’t a great idea.

Thinking about formulas this way has completely changed the way I study them. Instead of looking at formulas in relative isolation or placed in arbitrary categories (as found in most formula text books) I look at formulas as in relationship with one another. All of the formulas that contain a similar ratio of two herbs are going to be related in some deep way. This allows me to more fully understand the function of the formulas and be more effective with them in clinic. Practically, whenever I learn a new formula, I spend some time searching for related formulas usually using electronic resources I have created myself. Then I read all I can about these related formulas, particularly anything included in the Classical texts. I seek to comprehend the similarities and differences. In some cases, I have also looked at all formulas with a particular two or three herb combination, regardless of dosage. This is also instructive.

Learning to ask good questions

As I’ve already mentioned, we usually got the most out of shift when we were brave enough to ask bold, yet succinct, questions. I tend not to speak up in academic group situations. Because of the rambling and pointless nature of some questions asked in many classes (Chinese medicine or not) I tend to wait until I have a truly important, well-informed and brief question to ask of a professor before I’m willing to put myself out there. However, I know that this policy has probably negatively impacted my educational experience in some small ways. My academic relationship with Arnaud is helping me to get better at quickly coming up with relevant and insightful questions. I hope this skill continues to develop.

In sum, my term with Dr. Versluys was quite enriching. I’d be interested to hear the stories of other people, even in other schools, about their early clinical experiences. Any disasters? Any moments of earth-shattering insight? Let us know in the comments. If you’re interested in hearing more about my experiences in medical school, be sure to subscribe to this blog via RSS feed or via email.

Eric

Term in review part I : On shift with Arnaud Versluys

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