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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After posting an earlier post discussing the first of my five maxims, a request came up to present the rest of them. Never one to shy from a good request, today I’d like to present Reynolds’ Second Maxim, which is “Don’t hear horses and think zebras” which could also be phrased “Thou shalt not overcomplicate!”

“This will be the seventh time we have destroyed Zion…”

I remember going to the movies to see “The Matrix Reloaded” during the course of which a neat and tidy story which everyone was familiar with was exploded into about a million little subplots and alternate storylines with a new cast of characters that became hard to keep track of and events and motivations that didn’t make a great deal of sense. That and some sort of rave/orgy. Upon leaving the theater, my girlfriend at the time turned to me and said “Uhh…that was needlessly complicated.” This I feel is an excellent example of the typical state we frequently find ourselves in, especially once herbs enter the picture.

I feel that this concept is heavily tied in to my first maxim (“What are the symptoms?”) in that you don’t want to make the mistake that many physicians have made throughout history, East and West, which is deciding what a great idea a particular path of treatment would be and  implementing it without bothering to first find out if it’s a good idea.

Not women, THIS woman

This very much applies to the TCM habit of protocol-making, where, in the example of one very popular protocol, a treatment method including both points and formulas is decided upon depending on what week of her menstrual cycle a woman is currently in. If it’s week one, she gets Formula A and Point Protocol A. Week two is Formula B and Point Protocol B and so on. Now at first glance this seems like it could be a great idea, as it appears to take into account the fact that a woman is likely to be in a slightly different physiological state depending on what week of her cycle is in. However, it fails to take into account the only thing that matters, which is the condition of the patient before you. It’s very easy to get caught up in thinking of things in broad strokes, the nature of women, the resonance between this or that herb and female physiology, lab results, and a million other things when in fact the only question of importance is still “what are the symptoms?” All information regarding symbology, tendencies, studies, typical clinical solutions, etc. is only of value insofar as it can be translated into a specific and accurate treatment for the individual. What works on “women” is of little use as we are interested in what works for this woman, whose specific menstrual complaints may have very little to do with Spleen Qi Deficiency, Blood Deficiency, etc. and may instead come from sources as varied as emotional trauma, overexercise, or acute stress.

Now this is not to say that I don’t use protocols, which would be the furthest thing from the truth. Technically, as long as we are  borrowing from someone else to match a situation, that’s a protocol. I just do my best to a) use the most powerful and effective protocols and b) only use protocols that are very strongly indicated for the case in question. The truth of the matter is that I tend to avoid overcomplication by using the most simple, direct, elegant, profound, and well…broad protocols we’ve ever had the privilege of being handed, which lie in the work of Zhang Zhong Jing.

Now those of you who attended NCNM have likely not experienced what those of us who are classic-minded but came through TCM schools have, so please try to put yourself in our shoes a bit. My particular experience frequently involved the presenting of a case to a supervisor who, especially the Chinese ones, would roll their eyes at my Shang Han Lun-based approach and instead begin rattling off piles of points, truckloads of herbs with dosages set to numbers gained via some inexplicable method that had more to do with cooking than herbology in my opinion, and sent off to make the patient better instead of doing whatever craziness I had been working on, despite the fact that 10 times out of 10 I could point to textual support in the Shang Han Lun or Jin Gui Yao Lue for what it was I was trying to accomplish. This to me is the ultimate overcomplication and unfortunately this “whatchagot” method of making formulas out of single herbs (or dui yao pairs amongst the more enlightened) is the hallmark of TCM herbology’s gross ineffectiveness.

An Example

I’ll give the following example which is, admittedly, a straw man, but one that will hopefully illustrate what I’m going on about to the non-TCM trained set. I can assure you that I have seen this very approach many times by TCM herbalists, even very experienced ones. Suppose a patient presents with the following: sore throat, somewhat mild all-over pain that is especially strong in head and back, fever, chills, yellow phlegm in chest and sinuses, headache in occipital, parietal, and frontal regions, coughing, sneezing, nasal drip, nausea, irritability. Tongue has thick white coat. Standout pulse qualities are floating and moderate at left cun position and slightly deep and tight at left guan position. I will present three different ways of dealing with this case:

Method #1: The completely wrong way: Diagnosis: Wind-Heat Treatment: Yin Qiao San, or failing that Chuan Xin Lian Pian + Bi Yan Pian. Rationale: , YQS is primary formula for early stage Wind-Heat. CXLP is extremely antiviral and antibacterial, BYP is good for runny nose and sneezing.

Method #2: The needlessly complicated way: Diagnosis: Wind-Cold invasion turning into Heat. Treatment: Make the following symptom-based custom formula (with rationale):

Lian Qiao + Jin Yin Hua: Good for Wind-Heat, clears Heat, reduce fever, soothes sore throat
Yan Hu Suo: #1 herb for pain
Du Huo+Ji Sheng: #1 combination for back pain
Gao Ben: relieves head pain, back pain, also good vs wind
Ban Lan Gen: clears Lung Heat, antiviral/antibacterial
Lu Gen: clears Heat Phlegm from Lungs
Jing Jie + Fang Feng=expel Wind
Niu Bang Zi: relieves cough, clears toxicity
Bo He: releases exterior, clears Heat, relieves irritability
Sha Ren: nausea
Gan Cao: clears Heat, harmonizes formula

Method #3: The right way : Diagnosis: Combined Taiyang-Shaoyang syndrome Treatment: Xiao Chai Hu Tang modifed as follows (as listed in the original SHL text):

Chai Hu
Huang Qin
Ban Xia
Gan Jiang
Zhi Gan Cao
Wu Wei Zi
Gui Zhi
Gua Lou Shi

Rationale: These are the modifications given by Zhang Zhong Jing to match this very situation. Even if you didn’t know these, by having a working knowledge of the SHL/JGYL you would know enough of the approach to work this out for yourself. There’s no fishing around for herbs to match up vs symptoms and having to guess which option is better than another, its all there already. The problem is primarily blockage in the Shaoyang network with some accompanying Taiyang symptoms. Xiao Chai Hu Tang is the primary formula for resolving this type of blockage with a couple modifications made to assist. Note that the point of this formula is to unblock Shaoyang, unblock Taiyang, unbind the chest, drain damp, strengthen Taiyin and that all curative actions are based out of that without having to make the World’s Biggest Formula in an attempt to solve a relatively simple problem that was solved (and written down) a couple thousand years ago. As Arnaud Versluys says, “there’s really no reason to re-invent hot water every time you need to cook something.”

Even in the case of chronic disease, the approach remains the same: choose the correct root that most accurately fits the situation and modify to match specifics. It also helps to have reliable information to draw from, which is of course why I insist that Zhang Zhong Jing’s work must be the toolbox that all Chinese herbology reaches into when it needs a tool. Before you start thinking “Ok, I’m going to take this formula and mix it with that formula and then add these herbs and then refer them to that doctor for this therapy and…” first see if there is a simple solution to the problem, as is so often the case. Don’t be afraid ti mix and match with formulas, herbs, modalities, etc. but make sure it’s necessary first.

I’m sure I will expound upon this at a later date but for now I hope this gets you thinking in the right direction.

Overcomplicating Things

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Let’s conclude this series on strategy in Chinese medicine with our final two points.

Treating Erratically

Martin Luther once said that Mankind is like a drunkard who upon falling off his horse on one side overcompensates and promptly falls off the other side. In Chinese medicine, the opposite of sticking with the same protocol no matter the situation is constantly changing what you’re doing. Now, I want to draw an important distinction here. The speed with which you have to make adjustments will depend on many factors, especially the modality being used. The very nature of acupuncture is such that you’re both creating and reacting to changes in the patient’s energy field, which by its nature is subtle. This just naturally leads to treatments in most cases being completely different from week to week in a lot of patients.

In the case of herbs however, what you don’t want to do with a chronic case if you can possibly help it is to leap from formula to formula. If you have legitimately resolved a layer of the condition and are ready to move to the next thing, that’s one thing. What you don’t want to do however is “Ok this week I think I’ll give you You Gui Wan because last week I gave you Si Jun Zi Tang and the week before I gave you Xiao Yao Wan, so I feel like we’re covering all the bases.” As I have heard Heiner Fruehauf eloquently state, you have to have the courage to decide on a base formula that adequately meets the conditions and then stick with it long term by regularly alternating a small amount of the ingredients.

That said, I don’t want to discourage anyone from having the courage to take a well-calculated risk when they aren’t 100% sure of the outcome. Let’s be honest, not many of us are completely sure about exactly what’s going to happen every time they hand their patient a bottle. I certainly am not. In fact, I find myself white-knuckling the patient’s chart, re-re-checking my conclusion long after they’ve gone home more than I care to admit. Its part of the Chinese medicine experience in our age, in my opinion.

In short, treat what you see and not according to pre-conceived notions if you can possibly help it. When in doubt, remember Reynolds’ First Maxim!

Too Many Doctors Spoil the Case

A huge problem in Chinese medicine-and one not easily resolved-that you will run into with many of your patients is the fact that you are only one of a small army of medical practitioners that they are currently seeing, and often the last one to the party, so to speak. You will often find yourself having to cope with not only the patient’s original condition, but also the added side effects and pulse-obscuring properties of drugs given to them by their team of MDs, the pile of supplements procured from their local health food store, their ill-advised Medifast diet/candida cleanse/detox protocol, their equally ill-advised weight room habit, their Reiki practitioner, their support group, and oh yes, their OTHER acupuncturist. Different doctors I’ve talked to have had different things to say on this subject. Dr. Leon Hammer has said that he typically suggests that if the patient would like to try these other methods that perhaps they come back after having first exhausted their possibilities. A famous Taiwanese doctor that a couple of my friends learned under is reputed to have refused treatment to patients who were currently under the care of someone else. How you handle this is your business of course, but suffice it to say that the more factors there are in the treater equation the more difficult it’s going to be to get anywhere with the case.

In America at least, most of the people who seek us out are in a high degree of physical and energetic chaos. The nature of our societal demands such as our crazy “rest is for the weak” work ethic, our fetishization of requiring the absolute best of the best of everything we come into contact with, keeping up with not just the Joneses anymore but the rich, famous, and Hollywood-employed as well, our terrible diets, our masochistic exercise programs, our sense of entitlement and lack of tradition, our rejection of the old and glorification of the young, our out and out INSANITY in every corner of our existence produces a patient who is coming apart at the seams on their best day. The introduction of any more chaos whatsoever into this picture can cause nothing but further catastrophe. It is absolutely not surprising that our most common “big” diseases are cancer and autoimmune conditions. We are chaos personified, the absolute opposite of peaceful growth and progression like the seasons. Nearly every patient that walks through our doors will be in this state and it would be well to keep in mind.

Also worth noting is that the primary problem in the chaotic state is that the very Yin and Yang of our beings is separating and with that separation comes greater and greater vulnerability to more disastrous diseases of every sphere. In my opinion, this separation begins at the level of the Gui Zhi Tang-type Taiyang invasion (note that Gui Zhi Tang’s most famous characteristic is that of “harmonizing Ying and Wei” which is nothing less than putting Yin and Yang back into contact with each other) and ends in death. Everything else along that continuum is some degree of separation of Yin and Yang and needs to be accounted for thusly. I fervently recommend that anyone not intimately familiar with this concept read the following article by Dr. Hammer entitled,” Towards a Unified Theory of Chronic Disease with Regard to the Separation of Yin and Yang and ‘The Qi is Wild.”

How do these two topics relate to timing and momentum? Simple. If you’re trying to walk to Albuquerque you’ll never get there if you walk toward Portland for a day, then San Diego for a day, then Atlanta for two days. You also won’t get there if you ask directions from everyone you meet and they all tell you something different. Timing and momentum is doing the right things at the right time consistently. Cure doesn’t happen without it.

That concludes this series. I hope you’ve gotten something useful out of it. If you’d like to go back and read the previous segments, here they are again:

http://deepesthealth.com/2010/strategy-in-chinese-medicine-timing-and-momentum-pt-1/

http://deepesthealth.com/2010/strategy-in-chinese-medicine-timing-and-momentum-pt-2/

http://deepesthealth.com/2010/strategy-in-chinese-medicine-timing-and-momentum-pt-3/

Strategy in Chinese Medicine, pt 4: Timing and Momentum

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You will remember not too long ago when Mitesh, a student at NCNM, released some very interesting information about an experiment he was doing concerning the flavors of Chinese herbs, their combinations, and their impact on human physiology.  Well, he completed a continuation of the project for this latest term project and has consented to let me share his findings with all of you.

I want to apologize for the formatting – I’m actually on vacation and have limited time to put this together.  Sometimes, copying and pasting from other programs (like Microsoft Word) can be pretty tricky.  Hopefully, it will still be readable.

I’ll also have another student project to share sometime soon.  It’s one student’s multi-disciplinary exploration of the energetics of Chaihu – I think you’ll find it to be very interesting.  Enjoy!

—

Purpose of Experiment

This experiment is a continuation of last term’s experiment in which I combined Chinese herb flavors to see if a particular effect arose. For example, did Sweet and Pungent create an inner sensation which I would call Yang Qi? Using the Tang Ye Jing herb flavor assignments, I would combine Ren Shen, the sweet archetypal herb, with Gui Zhi, the pungent archetypal herb, assess the inner experience and see if it converged on something I would consider Yang Qi. This proved to be true.

Table 1: Tang Ye Jing Primary and Secondary Flavors

I continued this Chinese herb paring for Sweet and Sour, whose outcome, according to my teachers, should be the creation of fluids. This too proved true.

I further investigated the other two pairing with Sweet, that being Bitter and Salty. I then attempted to create descriptive markers to note the inner experience after which I then attempted to attribute my best Chinese Medicine term to the experiences.

The flavor combination testing was preceded with a calibration effort in which I poetically described the effect of the archetypal herb flavors. This allowed me to then have an authentic experience of what was meant to be Sour or Pungent.

Furthermore, I then take the a combination of primary and secondary flavors and see if the single herb would also have the same effect as the combined archtypal herbs. Therefore, would the herb with a primary flavor of Sweet and secondary flavor of Pungent, Gan Cao, create Yang Qi? And would the herb with a primary flavor of Pungent and Secondary flavor of Sweet, Sheng Jiang, create  Yang Qi as well? This proved not to be true for this case and there was no convergence is experience between any combination o f archetypal herb flavors and single herb with matching primary and secondary flavors. As such, I decided to drop this portion of the experiment and only proceed with testing of archetypal herb flavor combinations.

Background Information

The Tang Ye Jing assigns organs to flavors differently than the NeiJing. The Tang Ye Jing assigns flavors based upon shared gesture. The NeiJing assigns flavors based upon contrary gestures. For example, the Lung has a natural gesture of contraction, that akin to Metal and Fall. Therefore then NeiJing would assign Pungent to the Lung because its gesture is dispersive. Therefore, it would counteract the over-contractive pathology of the Lung. However, the Tang Ye Jing would assign the flavor of Sour to the Lung because they share the same gesture.

Another way of describing this difference is what is referred to as Tǐ Yòng體用, translated as body and use. Tǐ shows bones next to a ritual vessel. Yòng shows either a target with an arrow through it or bronze ritual tripod vessel. The Tang Ye Jing assignments focus on Tǐ whereas the NeiJing assignments focus on Yòng.

Table 2: Flavors and Organs according to Tang Ye Jing and NeiJing SuWen

Unknown to me at the time of the conception of the experiment, a line in Chapter Five of the SuWen states:

酸苦涌泄為陰
Suān kǔ yǒng xiè wèi yīn
Sour and bitter gush and leak forth yin

Originally I hadn’t tasted this flavor combination, but this time it was on the docket. Knowing that results like this were possible, I proceeded with a little more caution than when all the combinations had Sweet as a flavor.

Table 3: Two Flavor Combinations

In the future I would like to investigate triple, quadruple and all five flavors. A list in the appendix shows the possible combinations.

Methods and Design

The real question is if there was a convergence of experiences amongst herbs on a subjective level.  As mentioned previously, a primary baseline of subjective experience harmonized to the Tang Ye Jing flavors was done with the primary flavors from Table 2 above.

There was 6 oz of each herb decocted in 16 oz of water and gently boiled to a 8 oz reduction. They were ingested slowly savoring the experience. Each tasting lasted about 20 to 30 minutes for the full effect and about 10 minutes between tasting to clear the experience…

–

During the next portion of this article – Mitesh will reveal the results of this, his latest experiment.  Look for it coming this week!

An Exploration into Chinese herb flavor combinations – continued!

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The past two weeks we’ve been discussing timing as it pertains to acupuncture and herbology. Let’s now tackle momentum.

As you may recall, the quote we have been referencing from the Art of War is this:

“When a falcon strike breaks the body of its prey, it is because of timing. When torrential water tosses boulders, it is because of momentum.”

What Sun Zi is talking about here is the accomplishing of something difficult, moving mountains as it were. In Chinese medicine this can be compared to dealing with difficult and intractable cases, the likes of which unfortunately are rapidly increasing in number here in the U.S. These cases are often created by incorrect or ineffectual treatment of a condition that is made orders of magnitude more complicated by the failed treatment itself. Here I’m talking about things like disease suppression, medication side effects, and the results of surgery, all things that most of our patients will have experienced in spades before they ever walk through our doors as their “last hope”. Leaving aside for now the problems of what to attack and how (something I’ll cover at a later date), let’s now assume that we have intervened in some way and had some sort of positive effect on the patient. This is where momentum comes in.

Consecutive intervention

The process is almost always going to be the same for deciding on treatment: gather the symptoms, look at the whole picture, make a decision. The next time the patient comes in this decision-making process has to be repeated. Even if the decision is to continue the treatment from the previous session, you’re still having to make the call of “what do they need me to do right now?” The time-honored TCM school clinic technique of “I did these points last week and they feel better so I’m just gonna do them again” is just not going to fly unless a proper examination reveals that yes, that combination of points is appropriate here. This is the primary component of establishing momentum, doing the right thing at the right time, repeated.

Uprooting

Borrowing from the Chinese martial art Taijiquan: in Taijiquan, a primary goal is to “uproot” your opponent (meaning, remove their structural stability) so that you can basically do whatever you want with them. My teacher’s teacher once compared this to a job he used to work at a loading dock in a harbor in Taiwan moving giant barrels from ship to land and vice versa. By themselves, the barrels were absolutely impossible for even 2-3 people to move. Yet, if you uprooted it by tilting it up onto its edge a bit you could now sort of roll it by yourself to wherever you needed it to go.

Treating chronic disease is very much like this. Your first task is to make enough initial headway against the condition that now it starts responding to what you want to do, which I can tell you is not always the easiest thing in the world. However, once you finally achieve that uprooting, now you have to keep it uprooted so that you can keep pushing it where you want it to go, like the aforementioned barrels. Explaining what to do to achieve this would take its own series, and really is the sum of all other treatment knowledge you are able to bring to bear. So instead I will tell you what not to do, otherwise known as a group of pitfalls that will effectively kill whatever momentum you have built. Note that some of these pitfalls will be of your doing and some will be of your patients’ doing. It’s part of your job to make clear to them what needs to happen in order for the desired result to be achieved, meaning achieving health.

Pitfall #1-Failing to modify

Something that is abundantly clear in Western medicine that somehow we in Chinese medicine lose sight of is the idea of habituation. A short explanation of this phenomenon is this: when the exact same treatment-of any kind-is repeated enough, the body or the agents of disease will adapt to it making the treatment no longer effective. This can actually be viewed from a couple different viewpoints. One is that the patient is rarely in the exact same situation two visits in a row (“you can never step in the same river twice”), especially where acupuncture is concerned. Another is that if you are dealing with an intelligent pathogenic agent (virus, bacteria, spirochete, etc.) if you continually show it the same attack it will eventually adapt, making the attack ineffective. Think MRSA.

This is fairly easy to deal with in acupuncture, as you can throw in subtle variations to the treatment that meet the patient exactly where they are at that moment in very specific detail. With herbs it’s more difficult as in these types of cases you’ll need the same formula for months at a time. The key to this then is having a good enough grasp of your root formulas and also of the nature of your individual herbs so that you can switch in and out appropriate substitutions that still get you where you want to go. Now obviously, no two herbs are a perfect trade for each other as even different parts of the same plant behave very differently and have very different properties. In the context of a carefully modified formula, however, the structure that is not changed will help keep what has been changed moving in the right direction.

This concept is most vitally important for cases where there is an organism on the other end that is being dealt with as part of the process (like Lyme Disease for instance), but this also holds true for other deep diseases, though you may not need to rotate as often. In a fast-reacting case (like Lyme) I generally look to rotate ingredients every three weeks or so. I usually look to rotate major (and powerful) components of the base formula I’m using that I’m confident I can get a good trade for. So if the base formula is Gui Zhi Tang, I would have the option to rotate just about any ingredient in the formula. Rou Gui for Gui Zhi, Gan Jiang or Pao Jiang for Sheng Jiang, Chi Shao for Bai Shao, Gan Cao for Zhi Gan Cao. In this particular case I would probably only rotate two ingredients (unless I had a very good reason for doing otherwise-always a caveat!) and try to stick to the soul of the formula by changing Gui Zhi less frequently than the other ingredients. Obviously this applies to any formula that you could use long-term. Note that in some cases (and with some patients) you’ll need to rotate more frequently or more creatively, with other cases you can get away with longer waits. Your mileage will vary.

If you fall into the pitfall of failing to modify you will certainly see the case stall out, which can mean not only a simply stalling of progress but can frequently be the first step into a quick regression depending on what else is going on in the patient’s life. You want to avoid this at all costs.

Next week we’ll discuss the pitfalls of Treating Erratically and Too Many Doctors Spoil the Case.

Strategy in Chinese Medicine: Timing and Momentum, pt. 3

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Last week we began by exploring the concept of timing in acupuncture. This week we’ll move on to herbs.

Timing in Herbology

Timing is equally important in herbology, as knowing where in the system the disease currently is will dictate what formula you prescribe and what modifications have to be made (I discuss this in an upcoming free PDF entitled “Beginners Guide to Acute Respiratory Disease”).

For this, the Six Conformation model used by Zhang Zhongjing (called the Six Channel Model in TCM) is without question the most powerful tool we have at our disposal, telling us where the disharmony is, what its nature is, and what principles are required to fix it.  This applies in acute as well as chronic cases. For example – If the problem is diagnosed as a Cold invasion of the channels of Taiyang we know several things at once:

1. We know that since the invasion has penetrated into the channel that the surface is open, which removes the need for the pure surface opening action of Ma Huang Tang.
2. We know that Taiyang is a Yang conformation. Therefore, our efforts are going to be centered on expelling the Cold pathogen and that if resolved correctly there won’t be any long term consequences of the invasion having taken place (as opposed to an invasion of the Yin conformations which tends to leave the need for a significant cleanup operation after being resolved).
3. We know that according to the Five Phase (or Five Element) model Taiyang is associated with Cold Water of the North. Taiyang invasions tend to be accompanied by all over muscular aches of varying degrees (depending on the situation). If we envision the Taiyang channels (UB/SI) as being rivers of cold water coming down from the mountains to nourish the plains (read about Mt. Kailash for the ultimate example of this) we can see that when those rivers get more cold, they freeze over and stop flowing. The Chinese characters for pain 疼痛 (teng tong) indicate a state of cold and of obstruction of movement, much like the frozen river analogy. This tells us that we need to “melt the ice” by warming up the channels and re-establishing uninterrupted flow.

The formula that answers all of these requirements is Gui Zhi Tang. If given on time (meaning before the pathogen passes on to, say, the Shaoyang level) the patient will recover quickly. Aside from the diagnostic timing, however, the Shang Han Lun tells us about another necessary element of timing.  An all important feature of timing and momentum in Chinese herbalism is the method and length of time to apply treatment.

The text that introduces Gui Zhi Tang makes very clear that the formula must be prescribed under very specific conditions. One of them is the instruction to give the decoction to the patient warm, then have them bundle up to await sweating. However it also makes very clear that once the patient sweats the formula must be stopped immediately.

The danger here (one that I have seen happen many times and have even experienced personally) is that the patient over-sweats and suffers damage to their Yang Qi, thus creating a different or more complex condition that now has to be treated.  In a Gui Zhi Tang type situation, over-sweating can lead to a combined Taiyang-Shaoyin condition of external invasion with underlying Yang deficiency (needing a formula such as Gui Zhi Jia Fu Zi Tang).

Strength and Focus

The other side of this is the question of strength and focus. A principle that Heiner Fruehauf often points out is that you must have not only the right formula with the right herbs, but also of sufficient quality and enough of them.

A practice of a lot of TCM-trained herbalists (including those from China and even those who have been in practice since the early days of the PRC) is one of adjusting downward individual herb dosages in formulas for the purposes of safety or according to someones weight. This is especially true for Shang Han Lun formulas, which seem overly aggressive in comparison with modern “gentle” formulas.

TCM herbalists will take a formula like the aforementioned Gui Zhi Tang and begin stripping it of its curative power by ratcheting downward the dosages of the warming herbs Gui Zhi and Sheng Jiang by as much as half, then playing around with the amounts of Da Zao, Bai Shao, and Zhi Gan Cao according to some paradigm known only to themselves. The result is the equivalent of cooking a complex dish in the kitchen while randomly choosing ingredient amounts and never tasting the results. This results in a grossly ineffective formula (I’ll save a critique of the practice of ingredient carpet-bombing for another time).

Native Dosage

An absolute fact in Chinese herbology is that each herb we use behaves differently in both different dosages and different ratios within each formula. Each herb also has what I think of as a “native dosage”, meaning the amount that you are most likely to see it prescribed at effectively. For example, Gui Zhi at 9g, Chai Hu at 24g, Ban Xia at 12g, etc. Going away from these amounts (without very good reason) usually translates into outright failure in my experience. If you need Gui Zhi Tang, you also need Gui Zhi at 9g. If you need Xiao Chai Hu Tang, you need Chai Hu at 24g. Going away from this is a good way to not be successful vs. the condition you are treating.

When you change the dosage of herbs you change the functional emphasis of that herb within its formula. The best example of this principle in my opinion is with Fu Zi. Fu Zi in most TCM clinics-if used at all-is used at a very low dosage, usually in the range of 3-6g. The fear is that because Fu Zi is so “toxic” that more than a small amount will give the patient headaches, nosebleeds, hot flashes, etc.

Paradoxically, Fu Zi in this small amount causes its energy to rush outward to the exterior and to the head, causing the very situation that they were trying to avoid in the first place. However, once the dosage crosses a certain line (around 18g in my experience) its entire behavior changes. Now instead of warming the Yang and sending it rushing outward and upward, it grabs the Yang qi of the body and causes it to descend into storage (the lower Dantian in Qigong parlance) where it is now able to recharge. Rather than feeling hyperactive, patients on the receiving end of recharge formulas like Qian Yang Dan (in which I usually use 30g of Fu Zi) have the overwhelming urge to go to sleep, which is exactly the aim of the formula.

Ratio

Finally, one must account for the ratios of herbs in formulas. In the Shang Han Lun there is an army of formulas that are essentially Gui Zhi Tang with one ingredient changed in some way. This small shift significantly changes the impact of the formula.

For example, if in the case of Gui Zhi Tang you increase Gui Zhi to 15g you now have the formula Gui Zhi Jia Gui Tang.  Now, instead of treating a case of the common cold, the formula treats the anxiety disorder known as Running Piglet Syndrome. The increased Gui Zhi stokes the Fire of the Heart.  The Heart, in turn, is now able to descend and overcome the amassed cold in the Lower Jiao.  This amassed cold was what the patient’s Yang qi was counterflowing away from -  causing the Running Piglet sensation.  Problem solved.

Another example starting with Gui Zhi Tang.   If we remove Bai Shao altogether we get the formula Gui Zhi Qu Shao Yao Tang, which treats conditions of fullness in the chest and skipping pulse.  These symptoms  point toward Upper Jiao blockage as well as deficiency of the Heart itself. Removal of sour flavored Bai Shao also removes the formulas restraints on the Wood energy of the body (due to Bai Shao’s affinity with Metal and Metal’s husband-wife relationship with Wood).  Wood is now more  able to feed the Fire energy (due to Mother-Son relationship) and release the body’s Earth energy (again, husband-wife relationship) which makes up half the Middle Jiao!

Formula Strength

There is also the question of amount of herbs taken. Zhang Zhong Jing was very clear on the necessary amounts to be taken for all of the formulas in his book, as well as specific preparation instructions. A close inspection of the Shang Han Lun’s preparatory methods reveals formulas that are orders of magnitude more concentrated than their modern descendants, using significantly less water both at the start of decocting as well as the final dose.

In both individual herb dosages as well as the total amount to be taken, these formulas were very much built upon the idea of the right intervention at the right time and in concentrated strength. It’s no good to just try and push a boulder any old way in hopes that it will move. You have to push at the right spot (the fulcrum) and use sufficient force  in order to accomplish the task.

The point here is that as herbalists we absolutely must know what our herbs do inside and out, right down to the effects of differing amounts. This will prevent the useless (and potentially dangerous in the hands of the over-enthusiastic) practice of trying to assign random amounts and percentages to our formula components.

Next week we’ll begin tackling the issue of momentum.

Strategy in Chinese Medicine: Timing and Momentum, pt. 2

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“When a falcon strike breaks the body of its prey, it is because of timing. When torrential water tosses boulders, it is because of momentum.”

Timing

In the current culture of TCM, the evidence-based protocol is king. A hypothetical example: “On 6-14/09 Patient K. was diagnosed with asthma. UB-13, UB-23, Ding Chuan, and Lu-9 were needled with reinforcing method for 30 minutes. Treatment was repeated daily for 7 days. Upon re-evaluation patient’s spirometer performance increased 15%. Therefore, this protocol is useful in treating asthma. ” This is how case studies are presented to us in our primary textbooks. This is also the primary research method in Chinese TCM hospitals presently, thus making it the perceived superior method of research and treatment amongst the standardized professional Chinese medicine community in the West.

However, this method has an ocean of problems, chiefly that it doesn’t work very well when replicated in clinic. Leaving alone for now the problem of misunderstanding what particular points/methods/herbs/formulas really do, it also neglects the necessity of meeting the patient exactly where they are at that very moment. This is what I mean by timing.

No matter how effective a formula or protocol has been in the past, if applied to the wrong situation it will not only not be effective, it may actually make the situation worse.

The importance of accurate diagnosis cannot be overstated. As a clinician, it’s the heart of your job to figure exactly what is going on with the patient in front of you at that moment, work out specifically what needs to be done, and apply it correctly. It’s no good giving a patient Gui Zhi Tang because they have a “Wind-Cold Invasion” when in fact the disease has moved on to a deeper level and the patient now needs Xiao Chai Hu Tang. You may have been needling St-36 and Sp-3 for the past three visits and seeing improvement in the patient’s digestive condition, but continuing to needle it would be a huge mistake if this week they’re having back spasms and can’t walk.

Timing in Acupuncture

The image of a falcon crashing into its prey from a steep dive at a hundred miles per hour is an accurate description of how effective doing the exact right thing at the exact right time is. However if we imagine the situation from the reverse angle, we can imagine the falcon arriving at the wrong time and completely missing its intended target. As the Lingshu says: “At the moment the energy arrives, [the physician] does not stray even by a hair; and if he is unaware of it, no results are produced. Therefore it is necessary to discern the arriving and departing movements of energy in order to intervene in time. The mediocre physician ignores this rule; the skilled physician respects it.”

This is a good time to clear up a common misconception among acupuncturists about this “arrival of energy”, usually referred to as De Qi. The commonly held belief is that De Qi is when the patient experiences a jolt or shocking sensation. This is held to be the sign that things are working and that now the patient should be left to relax with needles in for twenty minutes or so in order to allow the Ying Qi to make a full circuit through the body.

What the text is actually referring to when it talks about the arrival of Qi is the moment of regulation, the specific and clearly perceivable moment when the channel imbalance has been corrected. The higher level of perceiving this moment of regulation relies upon the acupuncturists ability to experience the unseen energy of the patient, a subject I don’t feel currently qualified to address. However the lower method (one that can be used by everyone fairly easily) is to monitor the state of channel balance via the Renying-Cunkuo pulse method where the very moment of balance can be felt by comparing the strength of the pulse at Renying St-9 and Cunkuo Lu-9 while needling the affected channels.  The timing for this is so delicate and vital that the Lingshu says: “When needling, if the energy does not arrive, the number of needles is insignificant. If the energy arrives, stop needling.”

This timing is important not only for good results, but also for avoiding bad ones. You can imagine the falcon missing its target so badly that it crashes into the ground face-first. This is a very real possibility in everything we do. Contrary to popular belief, the Lingshu makes very clear many times throughout its text that the patient can be significantly harmed by incorrect acupuncture technique. To wit:

“Needling presents two risks:

1. Not removing the needle once it has reached the affected zone, which may cause the loss of Jing
2. Removing the needle as soon as it reaches the affected zone, which may cause the Xie Qi to return.

The loss of Jing exacerbates the illness with nervous exhaustion, and the return of Xie Qi is the origin of abscesses and ulcerations.”

Our primary concerns for harming the patient in our schooling are things like puncturing the pleura, the peritoneum, or an organ. However, the Lingshu rarely talks about physical damage due to incorrect needling and instead frequently cites examples of energetically-caused damage from doing the wrong thing at the wrong time, including different forms of insanity and even death. Clearly, the acupuncture needle is a powerful tool, one that must be treated with the same respect as a sharp knife or sword.

My point here isn’t to scare people, but rather to insist that if we are going to use any tool in the pursuit of altering the health of  another person for a fee it’s our responsibility to be very very good at what we do and to not mistakenly believe that we can get away with following a protocol cookbook. Our practice of a natural and holistic medicine in no way lessens our responsibility to practice safely and effectively to the utmost of our abilities and the ability of our medicine. Acupuncture is capable of a lot, and the Neijing repeatedly talks about it in the context of treating very serious illness. However, it only works when you do it correctly.

Next week in this column we’ll discuss timing in herbology. If you want to talk more, please leave a comment or drop by the Deepest Health Community Forum.

See you Wednesday.

Strategy in Chinese Medicine: Timing and Momentum, pt. 1

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Quite some time ago, before the changes that are currently sweeping Deepest Health, I promised that I would discuss an “herb learning method” and eventually develop it into a course of some kind.  Well, those wheels are turning again.  You can already get a basic report about the first stages of the method by signing up for our newsletter.

Over the next couple of weeks, I’ll unpack some more advanced pieces of the method – including some application.  We’re getting closer to the point where I can release a fuller version of the method.

First, I want to refresh your memory with some basic background material.  I think about herbs in a similar way as I think about people.  They have names, faces, general personalities.  They have families, friends, favorite activities.  They like certain climates and not others.  They have jobs and hobbies.  If you really want to get to know a person – you are going to have to access a broad slice of their life.  The same is true of herbs.

What happens when we understand a person more deeply?

Well, for one, you reap great personal benefits from these kinds of relationships. It’s a personal benefit – close human friendships can be the difference between having a long, happy life and a shorter, more stressful one.  I honestly think the same is true of my relationships with herbs.  Certainly it’s a different kind of relationship, but it does have that kind of benefit.  It is, of course, also beneficial for your patients.  When you understand the herbs deeply – you prescribe with more accuracy and shooting for a deeper level of pathology.  You’re a better practitioner, in short.

In the Family

Those of you who have a significant other know that you learn quite a bit about that person by hanging out with their family.  The same is true of herbs, though certainly for different reasons.  I’m not talking ONLY about plant families from a Western botanical perspective, though I’m including that as well.  To learn the family life of an herb deeply you need to look into:

1. Western botanical herb family
2. TCM herb category
3. Shennong Bencao Jing herbal class
4. Related to #3, a family based on the broad “plant/animal/mineral” distinction and the specific part within it

Let’s look at these in turn, using an example – the seldom mentioned herb Xuan Fu Hua / Inula / 旋覆花.

Western botanical information

Inula (either japonica or brittanica) is a member of the Asteraceae family – a family it shares with sunflowers, goldenrod, dandelions among many others. It is a largely herbaceous family, without trees or significant  numbers of climbing and vining plants.  Now, I should note right now that I’m not a botanist, and while I do have a science background, this kind of information always sort of baffled me.  That’s why I’m so happy to be an herbalist – it gives me an excuse to learn this information as deeply as I please.

Now there is a ton of information we can find out about the species itself, and that’s definitely part of the method.  But here, we are largely concerned with the group that the plant is associated with – its family.  One interesting thing about this group of plants is that what looks like a single flower (the yellow mass in the middle) is actually a packed together bunch of little flowers – a composite flower head.

There is a ton of information we could get into with this family – but one of the most simple and common observations is how these flowers look much like a representation of the sun.  Sunflowers, dandelions and many of the members of this family all have a sunny disposition and thrive in sunny locales.

What does this tell us about Xuanfuhua?

Well – the association with the sun can certainly get us thinking.  There must be some kind 0f Yang affiliation, perhaps a Fire association.  Now, in some cases, the information we get from family is going to seem to contradict what we commonly know about the herb, or simply seem irrelevant.  I’m going to suggest that this is almost never the case.

In Xuanfuhua’s case, we don’t need to dig too far to help us find some confirmation for this information.  In the Tang Ye Jing, Xuanfuhua is considered to be the “fire herb of the fire class.”  In other words, it is the ultimate exemplar of fire within the 25 herbs mentioned in this text.  For those of you who aren’t familiar with this text, we’ll discuss it in more detail in the future.

So, in my opinion, we need to think about Xuanfuhua a little differently in light of this information.  While it is commonly thought of as an herb that deals with phlegm and counterflow, perhaps we understand this function in a slightly different way knowing of it’s strong sun, Yang and Fire associations.  Perhaps we even start to expand our understanding of the herb – can you think of some unique uses, or some more advanced understanding, that might transform the way you use this herb in clinical practice?

We don’t have space in this short article to go through the example with each of the four family categories above, but I will provide a brief description of each…

TCM herb category

This is a family of another kind – an affinity group bound by basic effect.  Now, there’s information to be gained by diving deeply into the TCM category, but here we’re looking at the similarities in herbs within that family.  It can also be instructive if we find differences.  That tells us something about the herb, but also something about the ultimate utility of this method of categorization.

Shennong Bencao Jing herbal class

Now, obviously, this is only going to work for herbs that are actually contained in this text.  However, I think it’s pretty interesting to look at which herbs are put together within the SNBCJ.  This goes both for the categorization of upper, middle and lower class herbs as well as the various plant, mineral and animal classifications.  As an early record, perhaps more influenced by the Shamanic traditions in use at the time, the SNBCJ categorizes herbs in a different way than, say, TCM categories.

Layperson family classification

Is the herb animal, plant or mineral?  Within that categorization, what part of the plant (or whatever) is the herb in question?  In the case of Xuanfuhua, we are discussing the flower of an herbaceous plant.  What can we say about flowers, in general?  These are the kind of questions we ask as we examine this “family.”

Join me next week as we unpack another piece of this relational herb learning method.  Thanks for reading.

The relational method of learning Chinese herbs : herb families

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